Saturday, 30 June 2012

Backing up the Bus

When treating post traumatic symptoms, we often reach points where we find we have over-reached therapeutically and have to “back up the bus” and slow the pace.  But there are some circumstances when we not only have to back the bus up, but actually back it up into the depot and start from the beginning.

What I’m referring to are clients who experienced severe or long term trauma and have developed Complex Post Traumatic Stress.  In many cases when children have suffered extended child abuse or child sexual abuse, their sense of self has been either extremely distorted or even annihilated.

Many therapies that address post traumatic stress, such as EMDR, TIR, TF-CBT and others use what is known as a “trauma narrative” - this is basically having the affected person tell the story of their traumatic experience or experiences, often repeatedly starting with small doses in the safe setting of the therapy room, and working toward sharing the entire story in a support group or with trusted loved ones.  By doing this, they desensitize their trauma memories and are able to integrate the experience into their life story.  Though the memories will always remain, they won’t have the life-altering emotional power they once had.  But there are some individuals for whom the trauma narrative is too much to endure - they simply cannot “tell their story” without being retraumatized.  This is quite common among those who experienced early childhood trauma - their trauma may have interrupted and distorted their developing sense of self.

Without a healthy sense of self, a person’s resiliency and ability to regulate emotions is drastically compromised or even absent.  They are unable to turn away from the trauma narrative and retreat into their safe place during therapy and are left in a state of extreme distress that they are unable to escape from on their own.  Such clients may turn to other means to break this loop of traumatic stress through drug or alcohol dependence, self-injury, physical acting out, or suicide.

As therapists we must be cognitive of where our clients are at with their sense of self before proceeding with any trauma focused therapy, and we always must begin with breathing, relaxation, and mindfulness learning and practice for our clients so they will be equipped to deal with the distressing process of revisiting their traumatic memories.

Another aspect we must be aware of is the strength of ego-states created as a defensive strategy during early childhood trauma.  Dr. Bessel van der Kolk - a leading clinician in post traumatic stress and its treatment since the 1970s - recently stated that a child experiencing ongoing trauma, such as sexual abuse, will develop multiple ego-states in order to survive, such as; one who can go to school and get good grades; one who can foster friendships and play, and; one who is a sexual slave to her abuser.  These are not to be confused with the distinctly separate personalities sometimes found in Dissociative Identity Disorder [once referred to as multiple personality disorder].  Instead, these ego-states allow a child to function in the various roles that make up their life.

The creator of the ego-state model, Dr. Eric Berne, recognized that when a childhood ego-state remains strong - such as van der Kolk’s example of being a sexual slave to an abuser - the adult may find themselves shifting into that ego-state when triggered by stimulus that reminds them of their trauma.  It is obvious that for a person struggling with Complex PTSD created by early childhood trauma who also has a strong ego-state associated with it still present, the use of a trauma narrative will not only be ineffective, it could retraumatize by taking them back to that place where their trauma originated.

For these clients, we must first work toward integrating those ego-states, starting with breathing, relaxation, and mindful meditation to help them be firmly rooted and “Be Here Now”.  We can then help them examine those ego-states and integrate them into their life story so their sense of self is no longer fragmented, but are all parts of the continuous evolution toward being a whole person.

Only once that sense of self is strong, can we employ the trauma narrative and help them move forward.

Aaron D. McClelland, RPCc

Sunday, 24 June 2012

The Long and Arduous Road toward Trauma Awareness

Near the close of the 19th century, Sigmund Freud began documenting memories of childhood sexual abuse in many of his patients.  He wrote three papers on how these sometimes repressed memories resulted in “hysterical symptoms” or “obsessional neurosis”. This discovery could have launched the study and treatment of Post Traumatic Stress nearly a hundred years before it finally came to the notice of psychologists and therapists.  But that was not to be.

Why Freud’s early discoveries and theories were suppressed is one of the deep dark legends of the mental health field.  The parents of Freud’s patients who disclosed child sexual abuse at the hands of their parents and other family members, were Freud’s peers and patrons.  As soon as Freud began to speak publicly of the devastating and long lasting effects that sexual abuse had on their children, those peers and patrons convinced Freud that to continue in this manner could destroy his career.  So Freud took the expedient course to save his career and reversed his stand on this “hysteria”.

To place himself in good standing in his community, Freud  reversed his position by labeling these child sexual abuse victims as false accusers and claimed that memories of incestuous experiences were remnants of childhood desires to be sexually seduced by their parents.  He created the “Oedipus complex” to explain this phenomenon [other practitioners used Oedipus for males and created the title “Electra complex” for females] So in effect, Freud and his followers blamed the victim.  And because children are quick to learn, a shroud of silence descended over the topic of child sexual abuse that continues to silence many victims to this day.

Since that time, generations of therapists were taught that children were “resilient” that no matter what we did to them, they would “bounce back”.  And the ones who didn’t “bounce back” – well, they arrived at their addictions, anxiety, depression, aggression, self-injury, or suicide, through other flaws in their character.

Even when Post Traumatic Stress Disorder was added to the Diagnostic and Statistical Manual of Mental Disorders in 1980, one main criteria for the diagnosis was that the victim’s life had to have been in danger.  It is only recently that clinicians have recognized that if it “feels” like your life is in danger, then it was in danger.  The emotional part of our brain [the limbic system] that keeps us safe and organizes our memories, isn’t capable of reason.  The amygdala – the almond sized guardian of our safety in the core of our brain cannot tell the difference between a real or imagined danger, nor a current traumatic experience or a memory of a traumatic experience in the form of a nightmare or a flashback.

In my practice and my years working with at-risk and high-risk youth I have come upon so many children and youth who were medicated for multiple diagnoses; ADHD - Attention Deficit Hyperactivity Disorder, RAD - Reactive Attachment Disorder, ODD - Oppositional Defiance Disorder, OCD - Obsessive Compulsive Disorder, MDD Major Depressive Disorder, and other clinical “alphabet” disorders.  But what my colleagues and I found over and over, was that under all of these sets of symptoms, lay unresolved childhood trauma.  Once we understood that trauma was the wellspring of the behaviours we saw in these children and adolescents, it all began to make sense.

ADHD – The child can’t focus.  How can they focus when all they can think about is the memories of their abuse?  How can they focus when they are living in a dangerous and threatening world?

RAD – How can a child form healthy attachments to adults when it was an adult who hurt them in the first place?

ODD – Can you blame a child for opposing the will of adults when the last time they submitted to that will they were sexually or physically abused?

OCD – Of course they obsess over rituals, they are desperate to have some form of control over their lives.

MDD - Who wouldn’t be depressed by the memory of abuse?

And what we found was, if we looked past the multiple diagnoses and treated the Post Traumatic Stress, the symptoms of all those disorders faded or vanished completely.

Thankfully, we are now moving away from the old model of multiple diagnosis and prescription drugs to treat symptoms alone and are looking deeper to explore and treat the underlying trauma.  Therapists have known this for years and now small pockets of the medical community is finally joining us in that movement toward mental health through the use of fMRI [Functional Magnetic Resonance Imaging] to see inside the brains of patients in order to tailor therapeutic approaches to treat the lingering effects of trauma. Once we see how deeply rooted the trauma is within the brain, we can provide a therapy that begins where the patient is at.

Aaron D. McClelland, RPCc

Wednesday, 13 June 2012

Memorializing and Trauma Recovery

Memorial offerings removed from grave markers in our local cemetery.

A recent incident in the community where I live really brought home the trauma that many experience at the death of a loved one and how the grieving process is not widely understood or acknowledged by officials who caretake cemeteries.

Our community has three cemeteries, the newest of these is the only one where new internments can be accepted.  There is a municipal cemetery bylaw that limits memorial offerings placed on grave markers to cut flowers only.  However, in the history of this cemetery, this bylaw has never been enforced and the only items removed were ones that interfered with grounds maintenance crews doing their job.  Memorial offerings placed on the grave markers or in the four inch flower receptacles on each concrete grave base were left undisturbed.

Recently, municipal staff made the decision to hold a “clean-up” and posted two advertisements in the local newspaper advising the public that they would be enforcing the bylaw and of the planned clean-up - very few people noticed the ads.  During the clean-up, maintenance staff removed every memorial offering and made judgement calls on what they considered worth keeping and what to discard.  The items they kept were placed in on the ground in a works yard so people could retrieve them.  Items they deemed worthless or were accidentally broken during the clean-up were sent to the municipal landfill.

The public’s response was immediate and profound.  Municipal Council was inundated with phone calls, letters were written to the editor of local newspapers, people appeared before Council to voice their anger and sorrow.

To their credit, the Mayor and Council were as shocked and outraged by this action by Municipal staff as the public was and most offered sincere apologies for their staff’s actions.

Losing a loved one can be a truly traumatic experience for many - and I am speaking of clinical trauma, the same shock to the mind and body that combat soldiers, abuse, or rape survivors experience.  The initial experience of those who have a loved one die can be identical to the symptoms of Acute Traumatic Stress Disorder; numbing; detachment; derealization; continued re-experiencing of the event through thoughts, dreams, and flashbacks; avoidance of any stimulation that reminds them of the event; symptoms of anxiety.  If Acute Truamatic Stress is not therapeutically addressed, it can - in many cases - become Post Traumatic Stress Disorder after 30 days.

The stages and process of grief have been well documented by such notable clinicians as psychiatrist Elisabeth K├╝bler-Ross, M.D. who categorized the 5 stages of the grieving process; 
  1. Denial
  2. Anger
  3. Bargaining
  4. Depression
  5. Acceptance

It is the fifth stage - Acceptance - that is the most important for an individual to navigate through successfully to be able to integrate the trauma of losing someone they love, reorganize, and move forward in life.

Part of the Acceptance stage is for the affected individual to be able to personally memorialize their lost loved-one.  For many, this memorialization must be more than purchasing a grave marker and holding a funeral - this is evidenced by the number of memorial offerings removed from our cemetery by municipal staff.  Each of those items were placed there by those who sought to memorialize their loved one on a personal and emotional level.  The psychological process of this memorializing is to relocate their loved one from within their own life story to their loved one’s grave, and accept that they are no longer alive.

The removal of those memorial offerings - putting it bluntly - retraumatized many of the people who placed them there.  The most moving example of this was one lady who had planted a miniature rose in the four inch receptacle of her husband’s grave marker and tended it weekly each Sunday after church for the past year.  This lady was still in the process of working through the Acceptance stage by doing this, and when she discovered to her horror that the rose had been pulled up by its roots and discarded, her trauma resurfaced.

The lady had the courage to attend the next Municipal Council meeting and address them during the public hearing portion.  As she spoke of her shock and distress of discovering that the miniature rose had been torn up by the roots and discarded, her emotions were as raw and intense as the day her husband died - her grieving process was not only interrupted, but reverted to a previous stage.  She was experiencing the trauma of her husband’s death once again.

I have urged our Mayor and Council to take the psychology of grief into consideration when examining the cemetery bylaws and district policy in the coming months.  Municipal staffs’ suggestion to landscape the cemetery by adding plantings of “colour” is all well and good, but will not replace the personal memorialization that helps people heal from the trauma of losing a loved one.

On a personal note; A well-tended cemetery - to me - appears sanitized and impersonal, but seeing the small memorial offerings left and tended on grave markers speaks of the love family members still hold for the significant people they have lost.

Aaron D. McClelland, RPCc

Sunday, 3 June 2012

Ancient Trauma, Ancient Treatment

We often hear alarming reports that mental health issues and disorders are on the rise in our modern, stressful world. Yet as a mental health practitioner, I do not believe there is an increase in mental health disorders, we’re simply getting better at recognizing them.

Mental health disorders have been with us throughout history, but until the rise of psychological research in the last 100 or so years, they were often misinterpreted. One such case in point can be found in the Bible;

Mark 5:5 -
“And always, night and day, he was in the mountains, and in the tombs, crying, and cutting himself with stones.”

In the chapters from which this quote is drawn, Jesus is said to have heard of this man and his troubled state and had sailed with his companions
“unto the other side of the sea, into the country of the Gadarenes” to visit him. When Jesus asked the man his name the man replied “My name is Legion: for we are many”.

Jesus is credited to have exorcised the
“devils” who had possessed the man and cured him, yet credited this miracle to the compassion he had brought to the man in the name of the Lord. The story concludes with the once afflicted man returning to his home in Decapolis where he published writings describing how Jesus had restored him to a normal life.

If we examine this story with a modern mental health point-of-view, the man’s symptoms suggest something other than demonic possession. First, spending his days and nights
“crying and cutting himself with stones” suggests that the man was continually overwhelmed with emotional distress and had resorted to self-injury to momentarily give him relief from these distressing emotions. This is now commonly referred to as Non-Suicidal Self-Injury and is to be included as a V-code anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. It often accompanies other anxiety, depressive, and post-traumatic disorders.

Persons who struggle with self-injury most commonly use it to regulate emotions that can be overwhelming or – on the other end of the scale – absent. For those who cannot cope with their negative emotional distress, self-injury serves to focus their feelings in an external way (As one person put it;
“To make my outside look and feel like my inside”) And for those who struggle with a dissociative disorder, there are times that they feel so disconnected from their own bodies and reality that they begin to doubt if they are still alive. Feeling the pain and seeing the blood of a self inflicted injury allows them to return to their body and feel real again.

The full diagnosis of the man in the country of the Gadarenes will never be known, but how he identified himself may provide a clue: When asked his name he replied
“My name is Legion, for we are many.” This suggests very strongly that the man suffered from what is now known as Dissociative Identity Disorder. (This condition used to be called “Multiple Personality Disorder” but that term is no longer used)

According to the American Psychiatric Association, Dissociative Identity Disorder is most frequently associated with severe physical and/or sexual abuse as a child. This coupled with recent surveys that indicate that upward of 85% of those who self-injure also disclosed physical or sexual abuse as children, it would fit that the man from the country of the Gadarenes had experienced some serious abuse as a child that left him with post-traumatic symptoms.

The other piece of this story that aligns with the modern evolution of mental health practice is the main
“cure” that Jesus spoke of; Compassion. I believe that Jesus did more than cast out devils to help this man from the country of Gadarenes – I believe he was the first person who accepted this man as he was, who listened and was present with him instead of trying to judge, imprison, correct, or shun him as others had done prior to his arrival.

The story may be ancient, but the principal message of seeking to understand and to treat with compassion is one that every mental health practitioner can learn from.

Aaron D. McClelland, RPCc