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Friedrich Nietzsche said “That which does not kill us makes us stronger.” Trauma consists of reactions to an overwhelming danger or an inescapable chronic threat which, particularly if it happens in childhood or adolescence while the brain is still developing, is an equal opportunity destroyer of that brain. So, unless he meant to include an intervening step of treatment, Nietzsche was wrong. Many traumatized people lead lives truncated by substance abuse and/or constant drama and disappointments, inability to learn from experience, and suicide. Mammals do not fly away in the face of danger; they have no wings (except for bats and a few flying squirrels). They instead are hard-wired to seek safety by running to a secure attachment figure. When the perpetrator is also that figure, it poses an insoluble problem to our brain: I must run away from danger toward my attachment figure, who is also the danger I must run away from. The consequences of this situation, if chronic, are frequently referred to as “complex trauma” or toxic stress, because their impact on the brain is pervasive and encompasses neurobiological and structural alterations. Of note is the fact that the amygdala, our threat detector, sends signals to the hypothalamic-pituitary-adrenal system that releases hormones including cortisol and adrenaline to deal with stress, which increase heart rate, blood pressure and breathing to put us in “fight or flight” mode. Our prefrontal cortex then evaluates and makes executive decisions. I jumped at a loud noise, my amygdala gets me on my feet, but then my prefrontal cortex informs that it was the wind slamming the door. I can continue reading my book. However, when the stress is unpredictable, inescapable and chronic as it is in childhood maltreatment, the amygdala remains on overdrive, growing structurally larger, while executive functions fail to develop fully, making learning and problem-solving more difficult, in a downward spiral. Traumatized people thus may perceive others as more hostile than they are, and over-react to even minor stresses. 

A residential substance abuse or dual diagnosis treatment setting provides great opportunities to offer a multi-pronged, stage-wise, team approach. The person initially is detoxed and stabilized, and further psychiatric interventions may also be necessary with medications such as SSRI’s and/or beta-blockers which may be helpful in containing anxiety sufficiently to benefit from therapeutic work. Next, there is a thorough psychological evaluation of how the patient fares in the “here and now.” Thankfully, we have valid and reliable measures to assess the symptoms of trauma, even if the person is unable to talk about what happened to them, recently or in childhood. Traumatized people often do not remember the details of how they grew up, either because their memories are deeply repressed or dissociated and they constructed a mythologized history; or because what happened occurred prior to language acquisition and they literally have no words, no coherent narrative or chronology, just images and sensations; or because they mislabel or diminish their childhood abuse under the guise that it was “no big deal.” Comprehensive assessment helps in determining the next steps.

In all cases, it is essential that the therapist make the person feel safe and in control of the work so that she doesn’t feel she “submits” to therapy as she submitted to the perpetrators in the past, while at the same time taking care not to collude with the typical avoidance symptomatic of trauma under the guise that the person is “not ready.” I met many patients who never worked on their trauma(s) in spite of multiple attempts at therapy. Any therapy hinges on the therapeutic alliance and the building of trust. However, most people with complex trauma have deep ambivalence about trusting anyone, particularly someone purporting to be helping them. After all, didn’t Uncle Joe say the same and then he molested me? Or Mommy, and then she beat me?  Hence, the very therapeutic setting may set a person into a traumatic response which can take on many forms- from fighting and finding “proof” that the therapist is incompetent, uncaring or scared- to becoming strikingly compliant, and simply dissociating in session.

Thankfully, the field has developed many “evidence-based” therapeutic approaches to trauma well beyond “talk therapy.”  In plain English, this means interventions that have scientifically showed statistically significant differences when compared with previously standard treatment. These approaches, such as trauma-informed CBT (TI-CBT), EMDR, DBT, mindfulness, somatic experiencing, sensorimotor therapy etc. are very effective- alone or in combination. However, the process matters more than the tools we employ. It is of no use to do “trauma work” unless and until the person can learn to be grounded, quiet her amygdala and get her executive functions online. It matters more to be attentive moment to moment to what the person might be talking about, and to the intensity of the emotions described about a particular incident recounted. It matters more to help the person locate the emotion in her body, a new concept for many who learned to cut off their bodies when they were 5 years old and Uncle Joe was over them. It matters to teach the person to breathe deeply and notice their breath as a way to switch in session from the sympathetic to the parasympathetic side of the autonomic nervous system, a most empowering process. The “entry point” matters little and can be the recounting of a spat which happened the day before with a friend. It does not have to be historical, and in fact, history may only come bit by bit as the person learns to identify and differentiate emotions belonging to the present from those emerging from the past but “triggered” by a current event. The goal of therapy is to gain the ability to leave the past in the past and live fully present, in the present moment. For a traumatized person whose brain has been altered, this is a great challenge indeed.

References Provided Upon Request

Dr. Nicole Gilbert is a licensed clinical psychologist who has practiced in Los Angeles, California for over 25 years. Her specializations include treatment addiction and dual disorders, attachment and trauma. She is currently Clinical Director at the Trauma and Beyond Psychological Center in Sherman Oaks, California.

Dr. Gilbert was educated in Switzerland, France and the United States and is competent to conduct therapy in French and English. She earned a Bachelor of Science in Psychology from the University of Washington, and her doctorate at the California Graduate Institute (now The Chicago School).  She did her dissertation in cooperation with the Yale Psychiatric Institute on intergenerational patterns of attachment. www.traumaandbeyondcenter.com     

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