Trauma has profound and lifelong physical and psychological effects on its survivors. It can damage the mind, the brain, and stunt development. What exactly is trauma? How does it affect us individually and as a society? And how can trauma survivors recover from these experiences? Maria Armoudian speaks with Charles Figley, Richard Chefetz, and Daniel Siegel.
Richard Chefetz is a Psychiatrist in Washington D.C. He is the author of Intensive Psychotherapy for Persistent Dissociative Processes: The Fear of Feeling Real.
Daniel Siegel is a Professor of Psychiatry at UCLA. He is an expert in clinical psychiatry and is the author of The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are.
This interview has been edited for clarity and length
Maria Armoudian: Maybe the most important place to start would be what exactly do we mean when we talk about types of trauma? What does qualify as trauma? What does not? And are there degrees? Dan Siegal?
Daniel Siegel: Well it is a great question and the word trauma sometimes is used to mean very small things, you know, ‘That was very traumatic when you told me you didn’t like my vanilla ice cream that I made for you’. And other people use trauma that is sometimes called trauma with a capital ‘T’, you know things that can be experienced where there is a sense of life being threatened whether it be yourself or others, and you can feel out of control and feel very helpless so it can be extremely terrifying. So, the word trauma usually in psychiatric terms is when we mean more the latter, where it is something quite serious often life-threatening and when it is unresolved can mean when we really had a hard time coping. And that can become an important element looking at what the clinical implications are having experienced what is called a ‘traumatic event’ and whether it leads to post-traumatic stress or not.
MA: So it really is about feeling that your life is threatened and the sense of being helpless and terrified. Would you say those were the qualifying factors?
DS: Those are very important factors, absolutely.
MA: Anything you would add Rich Chefetz?
Richard Chefetz: I am glad you are starting here because I think the topic is actually somewhat controversial from my perspective. I don’t disagree with anything that Dan is saying, but there is an additional perspective and that is trying to understand why it is that in the study of drive-by schoolyard shootings children who are not at school the day of the shooting come back and develop PTSD? What’s that about? In science it is often so much more interesting to try to understand things that don’t make sense and to struggle with those. So where I have come out in trying to figure this out, is that our current definitions of traumatic experience are based on what I call the ‘size of the bang’. What if we defined trauma as represented by the change in a person, so a change in the development of their mind, the trajectory of it, or the functioning of it. And it is a messy kind of way to proceed because it is going to be unique for each person, but there is something about it that is attractive for me because I see a lot of people who have trauma histories, and their histories have similarities but also a lot of differences. But how they are as human beings, that is really for me the measure of the trauma.
MA: Charles Figley you have worked with veterans and that might be an interesting place to look for this as well. Obviously, veterans often go through very traumatic experiences, but some have the response and some don’t it seems and this relates a little bit to what Rich is saying. Why is it that some people develop, say, PTSD while others do not?
Charles Figley: The whole notion of conceptualising trauma and looking for variations, we have been doing this for a very long time. We have had concepts related to trauma and traumatic injury as long as there have been human beings, basically. You can trace it back to descriptions of battles many centuries ago. I think the point is when looking at the military you have a wide variety of stressors and you also have a wide variety of reactions, and what we are now recognising is meaning is the most important thing, and that is what is related to what we were talking about before. So a trauma is similar to the extent of the characteristics, but it has huge variations in terms of the individual. For example, the notion of the drive-by shooting and a child comes to school and develops PTSD, I think it is a profound and important question but we have had the concept of compassion fatigue, vicarious trauma, secondary traumatic stress reactions for some time as well as post-traumatic growth. I mean this area has been thoroughly studied, we have ways to go still, but there is a lot of variations here. But I think there is quite a bit that we know and that we could base our research on.
MA: Where does meaning-making come in to this?
CF: The way perceive trauma working in this field since 1974 is that trauma happens as a result of us being confused. When something traumatic or something extraordinary happens, we do what everyone does: we ask what happened, what happened to me, why did this happen. Then we start looking back on specific events and wonder why they behaved the way they did, because sometimes, we’re talking about soldiers and other traumatized people, frequently they obsess over their own behaviour not just what was caused to them. But in addition to that the questions are ‘Why am I acting the way I have since that time?’ because typically people are shocked and it is extraordinary and they find themselves behaving in a particular way and much of that is really trying to understand exactly are they at risk – are they going crazy, that sort of thing. And then finally, ‘What if this happens again? Will I be okay, will I be able to survive?’ That’s one of the more fundamental things. But with the notion of meaning and meaning-based, it really is associated with your life experiences. Rarely does trauma happen independently. More often than not you could trace back to your childhood or some place in the past, traumatic memories and events that are forgotten or that haven’t been adequately processed and then another traumatic event happened recently and then much of that stuff comes back to your attention.
RC: I’d like to jump in with two things. One has to do with what I think everybody would agree is a studied outcome, and that is that the best predictor of PTSD developing after a traumatic event is peritraumatic dissociation – a depersonalisation experience. And I agree that meaning-making processes are essential in our discussion, but the presence of a disassociative response is not a thought-out process. It is an automatic non-conscious process. So I would like to add that.
MA: What is that exactly? I saw that in your work and I wanted to understand this disassociation like what exactly happens?
RC: De-personalisation for example is an activated disassociative process and it seems to be mediated neurobiologically at the temporoparietal junction in the brain. But the thing is about trauma response, if you look at Martin Teicher’s work for example, he is a neuroscience researcher in Boston and he published a paper in 2010 that looked at the neurodevelopmental delays that occurred in children who experienced only emotional abuse, bullying, ridicule and so on – no physical abuse, no sexual abuse – and the developmental delays were profound. And so the definition of trauma when we think of those kinds of things, you know, a lot of people wouldn’t think of ridicule as traumatic. So I wanted to add that because I think there is a lot of complexity here.
DS: I agree with that. When you build on what we are talking about, the meaning on one hand and looking at disassociation as a risk factor where a traumatic experience turned in to a negative sequela, which is an issue if we can we should try and tease that apart. I was teaching in Australia with Martin Teicher and we were talking about the fundamental process of developmental trauma which could be abuse, but it can also be neglect, it leads to impairment in the growth of integration in the brain. And what is really important about integration is the corpus callosum that links the differentiation of left and right to each other, integration in general is different things being linked. So the corpus callosum doesn’t grow as well, the hippocampus which links differentiated memory systems to each other and the prefrontal region which links various regions including the higher and lower areas of the brain, but in addition, the studies of what is called the connectome which are the more subtly differentiated regions of the brain and how those are linked together is massively lower in its interconnection.
Now the good news to say about that important negative finding is that there may be interventions that we can do that can actually either grow around these deficits or grow through them that have been established in the general population, not yet for trauma. But the issue about integration in the brain that is so crucial is that it looks like it is even a part of meaning-making and so Charles when you talk about meaning, I could not agree more. For a child the meaning of ridicule is the kind of assault on the essence of your life when it is from your attachment figure. And so when we talk about helplessness or a sense of death there is even the death of the psyche when you are in that kind of emotional abuse. Obviously physical abuse can feel threatening of your life as well and neglect of course is the same way. And so without meaning the brain is not integrated, but when you do create meaning there is reason to believe it actually involves integrating different areas of the brain as well as just relational integration where you are saying I can express what this event was and articulate it and someone will bear witness to it which I think is ultimately what psychotherapy is all about.
MA: Rick Chefetz, you have talked about shame in your work and how that is one of the hardest emotions to deal with and to help treat. Can you walk us through what shame is, it seems to be attached to this ridicule right? What is it, why is it so difficult to treat, what is going on in that dynamic?
RC: Well that is a very important question and a very complex one, because when I talk about shame in psychotherapy, or you talk about it on the battlefield, there is the difference between the feeling that one has of acute shame, where you have a sense of you having done something that changes the meaning of who you are as a human being and your value, that is distinct from guilt which is about having done something and you regret what you have done but your value as a person doesn’t change. And there is a difference between that kind of acute shame, which is often easily reparable, and chronic shame which is much more typical of chronic abuse situations or scenes where there is repetitive violence. And one of the best ways I have found to think of how to understand shame is to think about the opposite. And often times people talk about pride as the opposite of shame and I think there is something to that, and yet pride is also connotatively about the kinds of things that we do and we are proud of what we did, which is much more on the pride-guilt axis if you will. So I have come to understand shame in regard to a state of chronic shame, the opposite of that is really a state of dignity. And I came to that appreciation in reading the work of Donna Hicks who was a conflict resolution expert at Harvard and defined shame as valuing the essence of all living beings while acknowledging one’s vulnerability.
MA: One of the things I really wanted to get to was how do we help people heal the trauma or the shame? And I know all three of you have worked in this area. So Dan earlier you talked about neuro-plasticity as well and I have seen that in your work. Perhaps that is the place to start.
DS: I think what we are speaking about is so important. When you think about shame and its developmental impact, one way to think about it in terms of treatment, is that it is very different from guilt. And developmentally, one way to think about it is this: If I am a baby and I am having these experiences when my inner emotions, my inner intensions, my inner experience of mind basically are not being tuned into by my parent, then at that moment of course there is a disconnect and I feel very isolated and alone. But if that is repeated and especially if it is associated with parental anger, then it can create this state of shame. The baby basically has a choice where they can say they had these inner experiences and needs that are not being fulfilled. And they have two choices here, they can either say ‘You know my mum is just a little distracted, she is probably having some difficulty with my father but in the end, it will be fine, I just to have to take care of my own needs and everything is fine’. Let’s say that is choice A. Or I choose choice B where I say ‘This feeling of not having my needs met is so painful that I can’t see that my parents are the source of this pain because I need to see them as my protectors or I will go insane’. And so rather than going insane I better come up with some kind of mental solution, which of course physiologically I could have a heaviness in my chest, nausea in my belly, turning away of my eye gaze, these physiological things that go along with shame. But the cognitive belief that I can get is that who I am at my core is defective, and so the reason my parents are not giving me what I need is that there is something wrong with me. And at least even though I am filled with shame I didn’t go insane because they as my parents are good. And as I grow, that state of shame is so painful, and obviously it’s not only painful in itself but it makes me feel so helpless because, unlike guilt, where I can change my behaviour because I don’t feel guilty anymore because I just don’t behave that way, there is nothing I can do to behave myself because myself is defective to the core. And so what we see in children and in adolescences and then adults of course is that the shame can go under the radar of our consciousness, and it leads to a whole complex of ways of behaving so that people for example put themselves in familiar situations of being with significant others who don’t meet their needs, or if things are going well they sabotage them because deep inside they feel they don’t deserve this good behavioural treatment. And so the healing of it is possible. And I find what is very helpful is not only an attuned relationship which is allowing the person to find something that is in conflict with the sense that they are effective but also psychoeducation where you are teaching them about this developmental pathway and acknowledging that, okay one aspect of them maybe feeling that shame, but it doesn’t have to be the totality of who they are. And as they go forward it is hard work but they can actually see that shame as just an understandable, developmental adaptation to a traumatic disconnect in their early childhood.
MA: Charles Figley what would you add?
CF: Well it is a different framework than I would typically use. But I think what all of us are trying to do is to help people understand their experiences, and definitely shame is frequently part of that. Certainly with the military, the notion of moral injury is often connected to shame to the extent that they said or did things that they regret significantly and this is the way things are among soldiers and Marines. I think the critical thing with regards to a sense of shame and how that is connected to trauma – and again this is related to anyone who thinks they have been traumatised – there are pockets of information that we don’t have because in part we are afraid to go there. We are afraid to revisit the scene for fear that we will discover that we have done things that were worse than what we had initially remembered. So a lot of it is the notion of being able to access that information and then hopefully come to a different conclusion. I’m not talking about psychotherapy, I am talking about people who try on their own to get over this traumatic experience. And they are urged to talk about it and when they talk about it, it is painful and it is painful in part because the people that they are talking to don’t get it, don’t understand it, so they shift from the insight and their own understanding of what took place to try to help other people understand what happened to them.
Frequently, I recommend that people talk to other people who have gone through similar kinds of experiences rather than immediately going to a therapist. Maybe because they have been in therapy they know that they need a therapist immediately. But more often than not, if you connect with those fellow survivors and are able to address those victim questions, invariably they will talk about things that they regret. And as a result of that, more often than not the people who are fellow survivors they offer alternative explanations or alternative conclusions. So shame is often constructed ourselves without anyone often helping us and so it requires us to kind of dismantle that, but I have found that talking to other people who understand what you went through is extraordinary helpful.
RC: There is a nice model from a psychiatrist in Chicago, Stevan Reine, who developed a cafe model for people with PTSD in Kosovo after the conflict there, because there is sort of an anti-psychiatric attitude in the population. And Stevan reasoned that since Kosovars like to go to coffee houses and talk that doing that would be a great way to help people get better. And it creates something that I want people to be able to know, and that is that very often when we have traumatic experiences we lose faith in people, we lose faith in people who hurt us, we lose faith in people who seem to not see us and make us invisible, and so people are the problem. But the thing is about healing from trauma is that people are also the solution, and it is in the relationship with an honest and attentive, faithful witness to the story that someone has to tell about their wounds, their hurts that the healing occurs. Across all forms of psychotherapy whether it is cognitive behavioural or psychoanalytic the common factor that predicts the best outcome of the treatment is the relationship with the therapist.
MA: I read about some of the methods that some of your colleagues are using, I think one of them is called [Eye Movement Desensitisation and Reprocessing], one was [Accelerated Experiential Dynamic Psychotherapy]. What are these means of trying to heal, Dan Siegel?
DS: They are quite distinct so I don’t think we have time to address both. But briefly in Diana Fosha’s work there is a focus on bringing emotion to the centre of the connection between the therapist and the client and then allowing that emotion to be articulated and then the relational emotion that is created to be a part of what goes on. She has done excellent clinical case descriptions of what happens. In EMDR, most clinicians know about it, and of course like any process there is a lot of discussion back and forth, debate and controversy. My experience having been trained in EMDR and being familiar with some of the research on EMDR which is pretty extensive, is that what you are doing is you are creating a setting with certain primes that are priming a person to talk about, for example, their awareness of an image of a traumatic experience, to be aware then of what is going on in the body, to then say with words what they hope will happen in the future. This is the kind of frame of mind that they are having in a negative way, what they hope a positive frame would be and that I think is extremely useful just by itself. I think it is a brilliant way of organising a therapeutic approach.
And then in addition, and this is probably the most controversial part is what is called bilateral stimulation. And I know there are publications written saying this doesn’t do anything, other publications say it is essential. In my own clinical work there are people that reach a certain stuck place in therapy and then doing bilateral stimulation whether it is with the eyes moving back and forth or there are these vibrating things you can hold in each hand, or tapping on the knees. There is a way of trying it out, and I have done this myself that is consistent with the reports, when you do it simultaneously you don’t get the powerful effects you do when it is alternating and if you do it on the same side you don’t get the same effects as when you alternate bilaterally. So I think there is something, I mean this is where the controversy is but I will just speak from direct personal experience as a therapist, there is something very powerful for certain clients, maybe not all patients, where offering this setup and this bilateral set of stimuli accelerates processing of traumatic material where the person doesn’t have to articulate everything they experience…I think there is an extreme amount of value to it actually.
MA: I wanted to ask about some of your concepts while you are talking about healing. Some of yours like the ‘Yes brain, no brain’, the ‘Mind site multiversity’, how do these fit in within the therapeutic model?
DS: The overall model that I have been writing about for twenty-five years is coming from this field called interpersonal neurobiology. The framework basically takes all the fields of science combines them all into one and asks the question what is the mind and what is the healthy mind and then applies it for mental health practitioners, teachers, parents, organisations, all sorts of things. And at the route of it is seeing that the mind in part, beyond subjective experiences and consciousness and information processing, is a self-organising in body relational process that regulates the flow of energy and information. And then a healthy mind would be a mental process, a mind that is optimising self-organisation, and mathematics tells us that the way you do that is through differentiating and linking, which we are just going to call integration…And the exciting thing for us as mental health professionals, when you look at every disorder that has ever been studied so far including trauma, imperative integration has been found, and when you look at the studies of the connectome the number one predictor of wellbeing is how integrated your brain is, how interconnected the connectome is. What I do in my latest book is basically say ‘Here are the researched proven ways that can actually lead to the integration of your brain, meaning you grow your hippocampus, you grow your corpus colosseum, you grow the prefrontal cortex, you actually make the connectome more interconnected. These are the most research-proven ways on the planet and we as mental health professionals can actually do that whether a person has been traumatised or not we can provide these integrative mind training practices for ourselves, for our patients, and this is the wonderful state I think we are in that we can actually promote wellbeing not just reduce symptoms of a disorder but actually move towards these thriving states which are integrative states.
MA: Charles Figley what would you add? I know you have worked with families as well.
CF: You are asking about how would you frame or characterise these treatment approaches. They are all attempting to promote de-sensitization, to break the emotionality connected with a particular event. And from all of the research that has been done on what is the most effective, it seems like exposure is the active ingredient that accounts for the success in all of these treatment approaches. I know we have differences of opinion here but I am more of a behaviourist, a researcher focussing on stress in particular. It is certainly important in terms of neurointegration, I completely agree in that regard, but again I am working mostly with adults. We have just finished a project on torture trauma treatments, we are focussing now on racial trauma and ways of measuring and treating that.
MA: With regards to torture or human rights abuse victims what do you make of the idea of taking the abuser to court as a form of healing because of the agency it gives victims?
CF: I completely agree, we have known about this for a very long time. It also helps in preventing it. I was in South Africa when the Truth and Reconciliation Commission was doing its work, and it is not only the notion of taking the perpetrator to trial and holding them accountable but also for them to come forward and admit what they had done, to apologise specifically – that makes a tremendous amount of difference. The problem though is, if you set up a survivor expecting that and you get something different, it is a real setback, so it has to be orchestrated pretty effectively.
MA: I suppose there is also the risk of re-traumatisation through that process?
CF: Yes, there is the risk of that. It is not just a risk it is a probability. And that is one of the reasons why social workers worked with these testifiers and prepared them for that first, and went over the materials so they wouldn’t be at all surprised. The same way when survivors testify in court there is a re-traumatisation, but in the preparation for the testimony as well as the testimony and the outcome, it is well worth it.
MA: Dan Siegel what are your final thoughts on this?
DS: Well I am so happy that we have been able to get together and talk about these different approaches. You know, whether, you talk about de-sensitisation or expressing emotion, when you look at the brain’s contribution to this, the mind-brain relationship, those entities are not exactly the same. And when we look, for example, at meaning you could say it is a mental process but it involves our relationships and it involves our brain. So, for me as a clinician really trying to look at the deep mechanisms of healing, integration helps you with understanding desensitisation, integration helps you with understanding processes like why attachment is so important. And from a political view, as you are noting if you look at a society that doesn’t honour differences or doesn’t honour and support the marginalised people in that society, then what you are looking at is a society that itself is traumatising. People feel like they don’t have a sense of belonging, there’s a threat of death sometimes. I mean if you look at the deep structures of our human evolution, belonging is a matter of life and death. And so when we say people are marginalised, you know that feeling that you are not an accepted and empowered part of society and included, is a traumatic experience. I am at an event right now where the main theme, is the trauma and exclusion from a racial and gender and religious point of view. So yes, these are things you might not say somebody has a gun pointing at their head, but exclusion is a matter of life and death from our deep social nature. So I think integration, honouring differences and promoting linkages even applies at the political-societal level, so you can go from the brain to what happens in communities and our larger culture, and promoting integration then allows you to go across different modalities of treatment and different ways we can approach societal change and cultural evolution.
MA: Final thoughts Charles Figley?
CF: Just briefly we have to continue to keep the family in our thoughts. In particular, families get traumatised as well. If the trauma happens to one individual and they seek help and encouragement from family secondarily, the family experiences this. So when we think about a traumatised person we need to multiply that a bit to make sure that we include their supporters and family members.
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