Posts tagged trauma
Posts tagged trauma
Recent years have seen an influx of numerous studies providing an undeniable link between childhood/ chronic trauma and psychotic states. Although many researchers (i.e., Richard Bentall, Anthony Morrison, John Read) have been publishing and speaking at events around the world discussing the implications of this link, they are still largely ignored by mainstream practitioners, researchers, and even those with lived experience. While this may be partially due to an understandable (but not necessarily defensible) tendency to deny the existence of trauma, in general, there are also certainly many political, ideological, and financial reasons for this as well.
Many have called for the trauma and psychosis fields to join forces. So many valuable findings have come out of the trauma field that could inform practitioners and lay people alike in understanding how one might come to be so overwhelmingly distressed and behave in such seemingly strange ways (see Read, Fosse, Moskowitz, & Perry, 2014, for an informative overview of how trauma affects our bodies). Studies looking at how the non-disordered brain adapts to chronic stress, how cumulative adverse events affect how people perceive and react to the world around them, and how many creative ways people come up with to defend against their own awareness of their distress all can help others to understand the un-understandable. More importantly, the trauma field has shown time and again how trauma-informed care can help a person slowly heal from horrid life experiences.
Yet, the trauma and dissociation field often goes to great lengths in an apparent effort to draw a decisive line in the sand between “real” trauma “disorders” and “schizophrenia.” This largely is done by insinuating that “dissociation” is trauma-based and explains the bizarre behaviors of so many distressed individuals labeled with “borderline” or “dissociative identity disorder”, while some cognitive or brain-diseased factor contributes to “real” psychosis. Somebody with “schizophrenia” may have experienced trauma, but it is largely irrelevant to the present distress. Is this true? Is there any actual evidence for this beyond ideology? It may be helpful to look at the overlap and separation between “dissociation” and “psychosis” to get a better understanding.
Brief History of Trauma Research
Over 100 years ago, Pierre Janet became the first major figure to identify and treat the vast array of the effects of trauma. In fact, he considered almost all “psychopathology” to be the result of childhood trauma and dissociation (Janet, 1919/25). Under the large umbrella term of “hysteria”, Janet identified the following symptoms: hallucinations in all senses, fugue states, amnesia, extreme suggestibility, an odd disposition, nightmares, psychosomatic and conversion symptoms, reenactments, flashbacks, paranoia, subjective experiences of possession, motor agitation, mutism, catatonia, thought disorder (or disorganized speech), and/or double personalities (Janet, 1907/1965). He believed that treatment consisted of a phase-based approach involving stabilization, trauma processing, and recovery. Fatefully, Janet’s use of hypnosis provided the main basis for his eventual expulsion from the psychiatric community. He responded to his exile by pointing out that the medical establishment denied the existence of trauma and its effects, to the point of focusing too much on the physiological and biological domain.
For the next 8 decades or so, the mental health field became more and more narrow in its focus on and recognition of trauma to the point of neglecting it completely in the more biological domains. It was not until the late1970′s, when a massive influx of veterans gained political clout and women began to speak out and be heard, that trauma was once again recognized as a major factor in extreme emotional distress. This also was the time when the DSM became psychiatry’s new bible; and so, while trauma was once again recognized, it was also separated into narrowly defined disorders that included PTSD, adjustment disorders, and dissociative disorders (including multiple personality disorder, as it was then known). It was then that the modern-day lines were drawn.
So what are people talking about when they speak of “dissociation”? Well, not too many people agree on this. It also appears as though the more professionals attempt to come to a consensus on what this term means, the more they do so in an effort to delineate it from any possible association with “psychosis”; their attempts to define dissociation are done by disassociating.
Wikipedia defines dissociation (in the broad sense) as: “an act of disuniting or separating a complex object into parts.” I do not believe that many mental health professionals, particularly dissociation researchers, would entirely disagree with this definition. Rather, it is the interpretation of this meaning that is a hotly debated topic within psychiatry (a general term I use to describe the entirety of the mental health field). In general, it may be used to describe a process, a multitude of symptoms, specific disorders, a division of the personality (or lack of integration), and/or a psychic defense. Many believe that it refers to disconnection from one’s thoughts, feelings, environment, self, others, etc. The term is also used to refer to a process of entering a trance-like state or extreme detachment. Most agree that dissociation lies on a continuum from “everyday dissociation” (i.e., losing track of time while driving, becoming absorbed in a book) to severe dysfunctional dissociation (i.e., “multiple personalities”). Lately, it appears as though trauma researchers and practitioners are interpreting dissociation as solely meaning a separation of identity states or ego functioning that is based in trauma and is clearly understandable (i.e., not psychosis).
If nobody agrees on what it means, then why do we really care? Because the political implications and resulting effects on treatment options are directly related to how one interprets this meaning. We can see by looking at the DSM how this might work…
DSM and all its Fancy Terms
Akin to many religions throughout time, psychiatry makes up many technical terms and then create circular and eccentric definitions to confuse lay people into believing that mental health issues can only be dealt with by an educated professional. Putting this political maneuvering aside, I would like to focus for a moment on key terms related to the topic at hand: trauma, dissociation, dissociative symptoms, psychosis, psychotic symptoms, dissociative disorders, and schizophrenia.
Trauma: Trauma is technically defined as an event that provokes death-related fears in an individual. It is also agreed upon that trauma is defined by the person’s response to such an event, rather than the event itself. But, what of the child whose parents are cold and over-protective? Or the child who is “only” bullied verbally? Or the child who is chronically invalidated? Or poverty? Or the person in existential crisis? Are these not a form of “trauma”? Certainly, they are shown to be chronically stressful which, physiologically, is not any different than “trauma” defined in the DSM-sense. Although it is understood that trauma is subjective, the DSM insists on narrowly defining it anyways.
Dissociation: As stated previously, very few professionals in psychiatry agree on what this term means. Instead of just saying “absorption”, “feeling unreal”, “feeling one’s surroundings are not real”, “lack of integrated sense of self”, or “detachment” (all considered in different circles as varied forms of dissociation), scholars instead argue over its meaning until it has no meaning at all. Often, it is an ideological term that is used to say “trauma” vs. “not trauma”, whether this is explicitly acknowledged or not. Therefore, when one’s “symptoms” are considered non-dissociative, the assumption generally tends to be that they also are not trauma-based.
Dissociative symptoms: Although dissociative symptoms are acknowledged as existing in a multitude of different DSM categories, they mostly are usurped by the dissociative disorder classifications. In this case, as I will discuss in a moment, dissociative symptoms often seem to take on the meaning of “not psychotic” rather than having any distinct meaning in and of themselves.
Psychosis: Psychosis is another technical term with no precise meaning. It tends to refer to a state in which a person appears to not be aware of or in touch with consensual reality. This can be for 5 minutes or 5 years, but the term itself is non-time specific. In practice, it tends to be used when the professional comes to a point where they say “I don’t understand you or agree with your interpretation of reality.”
Psychotic symptoms: Most people tend to think that psychotic symptoms clearly refer to things such as hearing voices, seeing visions, having strange beliefs, or disorganized thinking/speech. However, “psychotic symptoms” specifically refers to symptoms of psychosis. What is psychosis? Having psychotic symptoms. If you don’t have psychosis, then you may have “psychotic-like” symptoms or “quasi-” insert what you like here. What makes these symptoms psychotic-like instead of truly psychotic? Whether or not your therapist understands you.
Dissociative disorders: While there are 5 dissociative disorders, the one that is most intertwined with the idea of psychosis is dissociative identity disorder (DID). People who might meet the criteria for DID often experience what is inarguably the core of the term “dissociation”; namely, having a fragmented sense of self. In addition, they also experience periods where they cannot remember large gaps of time. This amnesia is certainly not an experience that is universal to many or even most individuals suffering extreme states; however, the other experiences common in DID are definitely non-specific to this classification. These include: hallucinations in all senses, incoherence, bizarre beliefs, impaired reality testing, lack of awareness of the present moment, paranoia, and paranormal experiences. However, these are reframed as: hearing voices of an “alter”, body memories, flashbacks, intrusions of trauma and/or “alters”, beliefs attributed to “alters”, not being grounded, and hypervigilence. These words do not necessarily indicate any difference in the lived-experience, but rather a difference in how psychiatry interprets the experience. And who wouldn’t rather say “I have body memories and intrusions” then “I have hallucinations and delusions”?
Schizophrenia: The category of schizophrenia, and all its sister disorders, is one that is assumed to be a largely biological, genetic brain disease. What differentiates it from DID? No one seems to be able to define where this distinction lies, but those in the dissociative disorder field will state that the difference is based on the existence of “delusions” and/or “thought disorder”. A delusion, of course, is a belief that society deems unacceptable. Yet, nobody seems to be able to explain where the line is separating a delusion from an acceptable belief. More specifically, nobody will explain what the difference is between believing “I have a bunch of people living inside of my body who are not me” (DID) and “I am God” (psychotic). But questionnaires that measure dissociation use this very distinction to say whether one has dissociation or not. And then they say “delusions are not related to dissociation” because they just ruled out dissociation by the fact that a person did not endorse an interpretation of their experience that the questionnaire makers deemed dissociative.
“Thought disorder” has been convincingly described by Richard Bentall as a problem in communication, rather than an indication of any true cognitive impairment (Bentall, 2003). Yet, the theory adopted by mainstream psychiatry remains that “thought disorder” is a neurological disease. And so, if one is considered to have DID, any indication of thought disorder is instead interpreted as “intrusions” or “rapid-switching” of altered identity states. Only those with “real” psychosis have a “real” thought disorder.
On the other hand, psychosis researchers solve the problem by simply saying DID just does not exist. People who present with altered identity states and memory problems (not attributed to an actual neurological problem) are considered as just “borderline” or “attention-seeking”. I honestly cannot think of much that is worse than experiencing such emotional turmoil and distress to the point of a break-down and then being told I am making it up for attention. But, then, of course, that is just my perspective.
In spite of these ideological battles, studies still have shown that individuals meeting criteria for schizophrenia endorse a greater level of dissociative symptoms than any other clinical group, discounting PTSD and dissociative disorders (Ross, Heber, Norton, & Anderson, 1989). Approximately two-thirds of individuals diagnosed with DID who are hospitalized also meet structured interview criteria for schizophrenia or schizoaffective disorder (Ross, 2007), 25-50% of anybody diagnosed with DID has received a previous diagnosis of schizophrenia (Ross & Keyes, 2004), and approximately 60% of those diagnosed with schizophrenia meet criteria for a dissociative disorder (Ross & Keyes, 2004). Up to 20% of individuals diagnosed with DID have been found to exhibit communication styles indicative of thought disorder (Putnam, Guroff, Silberman, Barban, & Post, 1986), and levels of dissociation are highly correlated with thought disorder (Allen, Coyne, & Console, 1997). Bizarre explanations for anomalous experiences are not rare in those diagnosed with DID; indeed, one study discovered that 41% of individuals diagnosed with DID have been found to believe they were possessed by demons, and 36% experienced possession by some other outer power or force not attributed to part of the self (Ross, 2011). In addition, the original concept of ‘schizophrenia’ (as it was discussed by Kurt Schneider, Eugen Bleuler, Harry Stack Sullivan, and Harold Searles) appears to emphasize presentations indicative of a dissociative disorder.
On the other hand, it has been found that dissociatively detached individuals are not necessarily chronically psychotic and can function at a high level (Allen et al., 1997). Individuals diagnosed with DID are often able to maintain reality testing despite experiencing “psychotic” phenomena (Howell, 2008). Another difference is that persons diagnosed with DID also report higher levels of dissociation, and more child, angry, persecutory, and commenting voices (Dorahy et al., 2009; Laddis & Dell, 2012). They also generally report a higher rate of more severe childhood trauma than any other clinical group (Putnam et al., 1986).
What Does This all Mean???
It is often purported that “delusions” and “schizophrenia” are not dissociative, when using the narrow definition of dissociation; when dissociation means dis-integration of identity. I would argue that when one is so distressed so as to be labeled as having delusions or schizophrenia, the person has experienced such a high level of dissociation so as to have a completely shattered identity; dis-integration to the point of disintegrated oblivion. But, this is not acknowledged as dissociative, and so then is considered somehow something completely different and separate.
I do not believe it is possible to separate psychosis and dissociation; to me this is like attempting to separate a headache and a fever when I have the flu. Where does the headache begin and the fever end? And should I focus on “treating” my headache, fever, or maybe the virus that infected me and is creating an interconnected process of events in my body? While psychosis and dissociation are not the same thing, I believe that one does not have psychosis without dissociation or dissociation without psychosis. Often the difference simply boils down to: who can frame things the way that the professional wants to hear or agrees with.
Certainly not all those who experience altered identity states experience strange beliefs, voices, or incoherence, but most do. Not all those who experience extreme states also experience altered identity or memory loss, but some do. These experiences are not separate, even if they are different. Although one may appear more reality-based and “dissociative” while another may appear more out of touch with reality and incomprehensible, I believe both stem from the same underlying process of attempting to deal with overwhelming life experiences. And this is where “treatment” should be focused.
Of course, this belief comes with the caveat that some presentations of emotional distress (whether it is psychosis, depression, dissociation, or any other term or category one might like to think of) are dietary, biological, and/or neurologically based. These are not psychological or psychiatric problems, then, and should be dealt with in the medical realm. All individuals suffering from extreme states should evaluate their diet, exercise, and overall physical health; when these are shown to be a non-issue, however, it should be assumed that some difficulty with life has led to whatever the person is suffering through in the present rather than blaming a faulty brain or neurochemicals without any evidence to back up such assertions.
I do not have all the answers. But, I do ask why it is that mental health professionals do not start with just saying what they mean? We can talk about altered identity states, memory loss, feeling unreal, not knowing what is real or not, being terrified of others, etc. Mental health professionals can own the fact that “I do not understand this person” instead of taking this as equivocal evidence of some brain-diseased process of “psychosis.” Each of these experiences do not make a distinct disease. People are complex. People do not fit in nice, neat boxes. People suffer, and when they do this is not necessarily a disease. People adapt to unbearable life circumstances in a number of complex ways that cannot be categorized, no matter how much psychiatry insists that it can. And none of these labels can tell anybody much of anything about a person beyond the stereotypes and confirmation biases they elicit.
At the end of the day, extreme states and anomalous experiences are terrifying; they are terrifying to the people experiencing them and to all those around those people. Doctors are human beings (much as many might like to state otherwise) and they too often act out of that fear. Certainly, nobody wants to get labeled with being psychotic, and there is benevolence in the efforts of those who try to save many from being so doomed. Being recently labeled with “schizophrenia” appears to be enough to increase the likelihood somebody will commit suicide (Fleischhacker et. al, 2014).
Instead of trying to understand people through labeling and insisting on enforcement of an authoritarian dictation of what the experience “really” is, perhaps psychiatry can listen to those who have actually been there. The Hearing Voices Network has given us tools to work with voices and other anomalous experiences; the National Empowerment Center has given us tools on how to work with crises and extreme states; I am working to try to get first-person perspectives on how to work with altered identity states and memory loss; so many individuals (most famously Marsha Linehan) have given us tools on how to work with self-harm and suicidality.
Why does psychiatry then continue to insist on abiding by a broken and invalid system of disease mongering? Why do we not allow the experiencer to make sense of their experience through their own framework? Why must we be so evangelical and insist that they see things our way? There is NOTHING that truly, scientifically can say that one diagnosis is more “accurate” than another. All of these diagnoses are just checklists of behaviors- there is nothing that anybody “has” and until some biological test shows otherwise than nobody can claim that there is. What matters is being with a person in their world where they are at and understanding the MEANING behind the experience, not attempting to define the experience itself in a way that makes sense to us. This is nothing more than social control and perpetuation of the status quo, not science.
Even the most biologically-based medical doctor knows that treatment can only be effective when the underlying disease is recognized and addressed. In my opinion (and it is only that), the underlying “disease” is trauma, overwhelming emotions in reaction to an un-understandable and terrifying world, and/or fear of death/annihilation. If this is the issue, and logically then the issue that needs to be “treated”, then why do we spend so much time splitting hairs over differentiating what behaviors or beliefs belong in what technical categories? In the heart of the Hearing Voices Network, why are we not focusing all of our time on understanding what happened to the person, not what’s wrong with the person?
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Disclaimer: The views presented here are constructed from my biased interpretation of the vast literature associated with the various topics discussed. This is based on my on-going dissertation work as well as personal and clinical experiences that influence my views. In no way is any of this meant as a criticism towards any individual organization or researcher. I have a great appreciation for the work done in both the trauma and psychosis fields, and recognize that we all cling to views that help us make sense of the world. I just hope that one day we might be able to move past some of these partialities and work towards improving options for people who are in extreme distress without further traumatizing them in the process.
This article’s references can be found HERE.
Author of the book Animal Madness, TED Fellow Laurel Braitman shares 5 ways in which animals and humans suffer from similar mental illnesses. Anthropomorphism run amok? You decide.
A golden retriever chases his tail every morning for hours on end. In the evening he compulsively licks his paws till they’re bare and oozy. When he’s given Prozac, he calms down and stops injuring himself … After the death of her mate, a scarlet macaw plucks out every last one of her feathers and doesn’t stop until she’s befriended by a cockatoo … A tabby cat who grew listless and stopped eating after his favorite human went off to college is cheered by the arrival of the family’s new pet rabbit, whom he likes to follow around the house.
Is the dog obsessive-compulsive? The parrot struggling with trichotillomania? The cat, once depressed, now recovered?
Making sense of animal emotional states and behavior, especially when they are doing things that seem abnormal, has always involved a certain amount of projection. The diagnoses that many of these animals receive reflect shifting ideas about human mental health, since people use the concepts, language and diagnostic tools they are comfortable with to puzzle out what may be wrong with the animals around them.
This isn’t to say that the creatures aren’t suffering, but the labels we give to their suffering reflect not only our beliefs about animals’ capacity for emotional expression, but also our own, most popular, ideas about mental illness and recovery. Where, for example, earlier generations saw madness, homesickness and heartbreak in themselves and other animals, veterinarians and physicians now diagnose anxiety, impulse control and obsessive-compulsive disorders in humans, dogs, gorillas, whales and many animals in between.
Looking at instances of purported animal madness is like holding up a mirror to the history of mental illness in people. It’s not always flattering — but it’s always interesting. Here are five classic examples of animal insanity, as diagnosed by arguably the craziest creatures of all, humans:
Well into the 20th century, brokenheartedness was considered a potentially lethal medical problem that affected both humans and other animals alike, from jilted lovers who were thought to have died of shock after being left at the altar to loyal dogs that died immediately after their masters. In 1937, a German shepherd named Teddy stopped eating when his horse companion died; he stayed in the horse’s stall for three days until he died himself. These cases still pop up from time to time. In 2010, two elderly male otters that had been inseparable for 15 years died within an hour of each other at a New Zealand zoo. Only one had been ill; their keepers believed that the second otter died of a broken heart. In March 2011 another heartbreak story pinged around the web. A British soldier, Lance Corporal Tasker, was killed in a firefight in Helmand, Afghanistan. His dog, Theo, a Springer spaniel mix trained to sniff out explosives, watched the whole thing. Theo wasn’t injured in the firefight, but hours after Tasker died, she suffered a fatal seizure, brought on, according to witnesses, by stress and grief over the loss of her companion.
It wasn’t until Louis Pasteur successfully inoculated the first person against rabies in 1885 that people began to understand the disease as a matter of contagion. Before Pasteur, rabies symptoms were often seen as a form of insanity that could be passed between people and other animals. How and why animals could catch madness was a confusing business. Creatures could go mad from a lifetime of abuse, such as Smiles, the Central Park rhinoceros, who reportedly did so in 1903. Maddened horses, as they were known, could simply take off running, still attached to their carriages or dragging their riders behind, often with fatal consequences. Mad monkeys bit small children at the circus, and dogs could sometimes go mad with loneliness. Looking back, it’s likely that more than a few of these animals were not actually rabid. Instead, madness was a catch-all term for lots of different kinds of emotional suffering and other forms of insanity.
Obsessive-compulsive disorders are now relatively common diagnoses in humans and other animals. Many of these behaviors are actually healthy animal activities gone awry. People, mice and dogs, for example, can develop hand- or paw-washing habits that are so extreme as to keep them from playing, eating their meals, going on walks or sleeping. Parrots can develop feather-plucking compulsions that leave them bald as roasting chickens; rodents, cats, humans and other primates can compulsively pluck their hair to the point of baldness, a disorder known as trichotillomania. Other OCD spectrum behaviors, like rituals, can also be seen in nonhumans, as for instance this dog that spins every time he sees a car.
Some animals, like some people, develop extremely specific fears of particular things in their environment, such as escalators, the beeps of an electronic alarm clock, shadows, even toaster ovens. One of the most common phobias, at least in dogs, iscrippling fear of thunderstorms, but cats can develop fears too, like this one whose owners believe is scared of measuring spoons. Horses can develop fears of plastic bags or umbrellas, among many other things. Thankfully, both people and other animals can learn to overcome their phobias, often with a mixture of behavior therapy and training, time, and psychopharmaceutical drugs such as Valium or Xanax.
Traumatic stress disorders have been documented in a variety of animal species — from great ape veterans of pharmaceutical testing and elephants rescued from brutal circus training to canine veterans of armed conflict. How similar is PTSD in different animal species? It’s hard to know, but there are many shared symptoms, from changes in temperament and mood, difficulty sleeping and more sensitive startle responses to possible flashbacks of traumatizing events. In his book Second Nature,the ethologist Jonathan Balcombe shares an account of PTSD at the Fauna Sanctuary in Quebec, Canada, a refuge for chimps who’d been used in research. One afternoon, keepers loaded a shipment of materials onto a metal trolley they pushed past the enclosure of two chimps, Tom and Pablo. As soon as the chimps caught sight of it they let out frightened shrieks and became inconsolable. The staff later realized that the same brand of trolley, or one that looked like it, had been used to transport unconscious chimps to the surgery room at a research facility where Tom and Pablo had lived, and been experimented upon, two years earlier.
Laurel Braitman’s book, Animal Madness: How Anxious Dogs, Compulsive Parrots and Elephants in Recovery Help Us Understand Ourselves, is out now.
Since the posting on PsychCentral a year ago of the article called “Organizational Infidelity Amplifies Sexual Trauma” there has been a great deal of attention paid to the poor handling of sexual trauma by institutions such as universities, the military and the church. That article cited a study showing that victims of sexual trauma who also reported having a sense of institutional betrayal showed more severe symptoms of post-traumatic stress such as anxiety, sexual dysfunction and dissociation.
Recently there have been legislative efforts to impose guidelines in the handling of sexual assaults on campuses as well as efforts to find the best ways to address problems in the reporting, investigation and prosecution of sexual misconduct within the military, universities, and the church. These efforts were prompted by the low rate at which sexual assaults were reported and if reported the low rate at which those cases were acted upon. For example, although 20% of students were sexually assaulted at college, only 12% of the victims actually reported the assault. And although rape in the military had increase 50% over the previous year, only one in 100 was prosecuted.
Attempts to address institutional betrayal have focused on prevention, changing the institutional culture, structural changes in investigation and prosecution, adding necessary resources and policies for following up on reports, and the interface between the institution and law enforcement.
Institutional betrayal and family betrayal
Many factors play into a person’s response to trauma including some having to do with the psychology of the individual and their own history and resiliency. Being betrayed by your organization or institution seems to me to involve a number of other psychological layers all of which exacerbate the sexual trauma and make the recovery from it more difficult. All of these aspects have parallels to what happens or doesn’t happen in a family in which a child is abused or traumatized.
Safety and the failure to protect
It makes sense on the face of it that sexual trauma in a supposedly safe environment would be more traumatic. The expectation of protection and the betrayal of that expectation would add an element of traumatic stress. In the past I have done extensive work with families in which a child is abused by a family member. In the handling of such cases by the child protection agencies and by the law, the parent who fails to protect the child or even who knowingly exposes the child to abuse is seen as being abusive in their own right. The non-offending parent is supposed to be the caregiver, the protector. The violation of the expectation of security shakes the child’s or adult’s reality. Rocking the foundations of someone’s sense of reality is a highly traumatic form of mental abuse. When used in brainwashing it often involves committing unthinkable acts in front of the person in order to make then so mentally shaken that they become malleable. This is sometimes called “ritual abuse.”
So the contrast between what victims expect from the institution (safety from harm or exploitation) and what actually happens renders the person more shaken and less able to rely on their own mental processes to help them cope. It jars loose their sense of reality above and beyond the impact of the actual assault. For children in a family this kind of betrayal is an attachment injury or relational trauma which has lasting effects on emotional development.
Failure of support after the fact and complex PTSD
Among the key factors that affect how well a child can cope with a traumatic event of any kind is the response of the parent or caregiver, the way the child is handled after the event occurs. Other things being equal, the child who receives a lot of support, comforting, sympathy validation and help after a traumatic experience will bounce back faster and have fewer long terms effects. The child who is not appropriately comforted and validated will likely be more damaged.
In the case of institutional betrayal– the experience of betrayal by the church, the school, the military– the failure after the fact is much like the betrayal by parents who fail to adequately support a child following a traumatic event. Adults, like children, may be better able to quickly recuperate following and event like sexual assault if they are able to go to someone in charge, be believed, get appropriate supports and be vindicated. If they are sent away or ignored and if the person who assaulted them is not held to account, their recovery is bound to be compromised and lead to symptoms akin to complex PTSD.
Of the two aspects of organizational betrayal, I am inclined to think that the failure after the fact may be potentially more damaging than the failure to prevent or protect in the first place. The healthy person can recover from trauma in the right context. We are all able to understand that there are people in the world who are up to no good. And as adults most people can even understand what it is like to be in a “culture” in which the norms are pretty rough, as long as the powers that be are willing to take a stand when a line is crossed. So although someone may be deeply shaken, they can also be very resilient if they get the right emotional supports at the right time. The failure to prevent a trauma can be understood and accepted, as long as the institution or organization does not look the other way or abandon the victim.
Trigger warning: This article is about sexual abuse. Please exercise caution in deciding whether, when, and where to read this piece. This advice isn’t going to apply to everyone, and I unfortunately can’t address every aspect of the healing process. I strongly recommend seeking personalized support if that’s an option for you.
Understandably, those who have experienced the dark side of sex can sometimes forget that sex does have the potential to be incredibly joyful and pleasurable.
I love being a sex therapist because I get to help people discover how much fun sex can be. Unfortunately, sex also has some really dark shadow sides. Human beings are capable of hurting each other in the most unimaginably awful ways. What’s even worse is how frequently abuse occurs. We’ve all heard the numbers — one in every three or four women will experience sexual abuse in her lifetime. I’ve worked with a lot of sexual abuse survivors.
Sexual abuse of any kind or degree has the potential to dramatically affect your sex life. Being sexually abused can lead to fearful response patterns, chronic pain conditions and health issues, a low or nonexistent sex drive, and a feeling of disconnect from your body. It can eradicate your ability to enjoy sex altogether.
Understandably, those who have experienced the dark side of sex can sometimes forget that sex does have the potential to be incredibly joyful and pleasurable. See if you can tap into even the slightest ounce of hope that you could develop a better relationship with your sex life. Think about possible goals. How do you want your sex life to be different from what it is now? What do you want sex or intimacy to feel like for you? Some of your goals may feel obvious, but the simple process of setting them can be an act of reasserting yourself.
One of the ways I start working with a new survivor is to talk about the messages that get sent to your body when you’re being sexually abused. The messages vary based on your particular situation, but many of the underlying themes are the same:
●You’re not in control
●Your desires aren’t important
●Sex is emotionally and/or physically painful
●You’re not safe
I see my job as helping women acknowledge the particular messages they received, and working on sending their bodies and minds a new and improved set of beliefs about sex. Here are four of the most common dynamics that I’ve seen, and what you can do to regain control of your sex life:
You may have developed triggers around sex.
Triggers are words, experiences, actions, sounds, gestures, or even smells that can send you into a heightened state of agitation. The effects of triggers can range from making you feel emotional to making you feel like you’re back in the abuse.
One of the most helpful things you can do is to start to identify your triggers. What makes you scared, nervous, upset, or uncomfortable? Is it when your partner touches a certain part of your body? Is it when you’re having sex in specific locations or positions? Is it a particular sexual act?
Once you identify some of your triggers, you can start taking active steps to avoid those situations. My clients have reported that even the act of brainstorming a game plan or declaring certain things off-limits helps them feel more in control. For example, you can tell your boyfriend, “it’s really important for me to be able to make eye contact with you during sex. Can you help support me with that?”
You can also identify a trigger in the moment, like reminding yourself that you tend to feel jittery when someone whispers in your ear. Being able to say to yourself, “OK, this is a trigger” takes away some of the intensity and helps you feel more present.
You may have learned to dissociate during sex.
Dissociation is the experience of feeling separate from your body. Many women report feeling dissociated during their abuse. You may have felt like you were floating up by the ceiling, standing right next to yourself, or far, far away. I tell my clients that dissociation is actually an amazing defense mechanism. Your psyche knew that it was unsafe to be in your body during the abuse, so it got the hell out of there. Unfortunately, dissociation persists long after the abuse is over, and makes it difficult to be present enough to enjoy having sex.
To start reversing your dissociative tendencies, first learn more about how you dissociate. Which triggers cause you to leave your body? Where do you go? What does it feel like to dissociate?
Once you start building up awareness of your dissociation patterns, you can start slowly building tolerance for being in your body. Focus on breathing slowly and deeply during intimate moments. Get up and shake out when you feel yourself starting to disconnect; movement can counteract the feelings of paralysis. You can also try touching your body, to remind you that you’re in your own skin. Put your hand on a part of your body that feels safe, and practice remaining present for increasing periods of time.
You may have learned to hate your body.
When you learn that your body is not a safe place to be, it’s hard to feel a lot of love for it. It takes a while to change your relationship with your body, but one way to start improving it is to try finding your body’s happy places and safe spaces. Perhaps you feel very present in your own skin after taking a walk on the beach, or maybe you feel safe and snuggly in your bed. Learn the things that feel good for your body, and do them on a regular basis.
You may have learned that you don’t have a choice when it comes to sex.
This is one of the biggest struggles for my clients. Even if your partner knows about the abuse, you may still find yourself feeling like you’re obligated to have sex with him. A lot of my clients report having a hard time saying no, either because they feel like they’re not allowed to, or because they never learned how to feel comfortable saying it.
The first step is to start getting in touch with your authentic desires. You have to stop forcing yourself to engage in sexual behaviors that you don’t actually want, and start sending yourself the message that your desires are important. You get to decide what you do and don’t want to do.
If you’re in a relationship, I suggest taking a temporary break from intercourse. This can be a difficult thing to ask your partner for, but it gives your body the opportunity to relax and start learning what it actually wants. You can also create a period of time where you get to do all of the sexual initiation. Knowing that all contact will be on your terms helps promote a sense of safety and agency.
Next, you’re going to want to practice getting more comfortable saying no. Try saying “no” more confidently in your life outside the bedroom. Reread the part of my first article where I discussed good rejection technique. Practice touching your body and trying to sense when it’s saying “no” or “yes” to touch.
When you start having sex again, it’s important to keep emphasizing your agency. Make the conscious decision about what you want to do in the moment, and use a little self-talk to remind yourself. For example, “I want to kiss him right now, so I am going to kiss him,” or, “I’m choosing to give a hand job because I want to bring my partner pleasure.”
Perhaps the single most important piece of advice I can give you is to be kind to yourself as you work towards rebuilding your sex life. You’ve gone through a horribly traumatic experience that no one should EVER have to go through. Take care of yourself as best you can.
Lack of research and exclusion of truly complex cases
Research for complex trauma and dissociation is severely underfunded relative to the numbers of individuals with these conditions. As such, there aren’t any randomized control trials that assess a specific protocol, like there are for other disorders. The few studies that claim to include survivors of complex trauma will include people who have been exposed to the traumatic events I described a couple of posts ago, but then exclude people who are suicidal, have self-harming behaviors, have comorbid disorders, have psychotic symptoms (people who are dissociative can appear to have psychotic symptoms) and/or have substance abuse. Since this describes individuals with dissociative disorders, the studies are excluding clients who have truly complex trauma. This study, for example, claims to study the efficacy of CBT and CPT, relatively short term evidence-based treatments for classic trauma. However, they exclude people with almost all of the symptoms listed above, so while the participants may have some features of complex trauma, they definitely don’t resemble the complex trauma clients that I work with, or that are described in case studies of extremely dissociative cases.
This study did show that when TF-CBT is adapted to be administered in a phase-based fashion (up to 30 sessions instead of 12, assessing for safety and stability throughout), it can be helpful in treating adolescents with complex trauma. Unfortunately, they say almost nothing about their participants except to note how difficult it is to assess youth for complex trauma, so we don’t know how severe their symptoms were when they started.
So what do we know?
What does exist are some case studies and a large, international prospective study by Bethany Brand that examines what practitioners are currently doing and assesses how that is working. The good news is that practitioners who take on complex trauma clients (the suicidal, self-harming, addicted, dissociative ones with disorganized attachment) are doing solid clinical work that is consistent with complex trauma treatment guidelines and are unequivocally helping clients get better.
What is currently recommended to treat complex trauma and dissociation is a three phase treatment approach. Incidentally, if you’re seeking a therapist for complex trauma a great way to find out if they know what they’re doing is to ask if they use this (or if they even know what it is).
Phase I- Safety and Coping
Phase II-Trauma Processing