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

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