People can overuse the word trauma. I get it. Your butter falls on the floor - it's traumatic. You cut your finger on a nail, it's traumatic. Your dog growled at you- trauma. We don't want to look for trauma and treat something that is not there. However, as clinicians and informed clients, we need to be aware of it. This means accurate assessments and evaluations on the front end. One commonly used tool is called the "PCL checklist."
But in all seriousness, trauma is subjective to the person who experienced it and for those with lasting memories (in psychobabble we call it intrusive thoughts) that interfere with day to day life -- we must understand as behavioral health providers what is likely happening. Scaer does an amazing job looking comparing trauma survivors and whiplash victims both experiencing problems functioning that have no explained physical abnormality. To elaborate, Scaer is a neurologist who researched reporters having whiplash from motor vehicle accidents. During his work in the area, Scaer found that treating professionals believed victims were malingering symptoms to receive compensation from the accidents. However, after litigation proceedings and settlements were received, these victims still weren't getting much better and continued to report pain even when there was no further compensation possible. Scared couldn't see any neurological or physical abnormalities in these patients but believed there was still something going on.
Scaer states dedicates his first book to his english teacher who taught him that "the diagnostic truth lies more in the uninterrupted stories told in its entry by the patient than in a dozen diagnostic tests." This is not to say that diagnostic tests are not important. As clinicians, we need to administer tools to be able to see whether or not a person is getting better from the treatment they are receiving. Do not forget about the Rogerian importance of human connection and the basic dignity and respect your clients need in getting better. However, within this relationship, the untold stories are what are most important. Stories that may never have been safe enough to put words to before.
I recently attended a prolonged exposure workshop focusing on the treatment of post traumatic stress disorder that fits nicely with Scaer's hypothesis. I found myself relating back to this book I read a couple of years ago which introduced me to response of a brain to trauma.
In both PE and for Scaer, the premise that the brain separates from human awareness during or after a trauma and stays "stuck" is interesting. While some researchers refute Scaer's empirical backing, both theories seem to hold value and by integrating what we know about the brain we have found ways to treat PTSD and/or trauma that hold promising empirical support. Prolonged Exposure (which is a best-practice in the VA for trauma victims) is about accurately educating patients about the fight/flight/or freeze responses that occur during a trauma which is based in survival. We are wired to protect ourselves and our brains protect us from things that might just be too difficult to fully experience. Most people are familiar with the fight or flight but I believe that not many know about the impact of the other part. The freeze holds the key to understanding what is really going on.
In the animal kingdom and in other cultures, we can actually see the releasing of energy - sometimes shaking, crying, but nonetheless - energy right before a near death experience or after. Some animals detaching from their experiences during or following a trauma seem to shake, flutter, kick, etc. which releases the energy (ever heard of anyone say "play dead like a possum"?) The thing is, when this release of energy doesn't happen in humans naturally, the brain can become hard-wired and hijack a person into thinking that future events are as significant and fearful as the one they experienced during the trauma. In essence, the memory gets stuck and people come out of it with a range of symptoms like:
A) feeling emotionally numb
B) over reactive to things that weren't bothersome prior to the event
C) avoid people, places, and things because they no longer feel safe
D) experience agitation, loss of sleep, etc. which were not difficult for them prior to the trauma.
There are many other symptoms related to trauma that we have seen too. For purposes of this blog (and to avoid clinical jargon, I won't get into these and encourage you to google PTSD diagnostic criteria.)
What we do know is that the more a person avoids (the hallmark of post traumatic stress) - the more the brain is rewarded. It finds relief in avoiding and distracting. The brain likes it, it makes sense to a brain that has not been able to process an event. However, the more it avoids and is reinforced, the more things grow and the more anxiety that is present.
Part of trauma therapy (scary, right?) is about moving the person towards the situations they are avoiding through planning and tackling experiences in a systematic way. The term used for this is "in vivo" exposure. For example, if a person is afraid of airplane, we can't expect a person to jump on a plane to go to Hawaii tomorrow after this fear has been growing for a great deal of time. First steps might be to look at a picture of a plane for thirty seconds, to sit on a plane and get off immediately, etc... with a goal of eventually flying on the plane. You see, many people aren't as distressed after they have successfully moved toward what they are facing vs. escaping (what the brain really likes). All makes sense, right?
The second part is through imaginal work --- which means telling the story over and over in a safe spot until the brain recognizes it is safe to tell, put words and feelings to -- to experience the event as though you were again in it and able to cope (thus, getting "unstuck"). We are resilient human beings and we can and do great things. It takes bravery and patience. Homework assignments related to breathing and relaxation and some really cool applications (look up PE coach - it's free in the iPhone app store and there's one for android users too) are an important part of the protocol along with doing some work outside of the sessions. The more exposures to the fear in the mind, the better.
What's most important as a therapist to understand - is that there is a brain/body connection that happens in all we do. The problem is the problem and the people are not the problem. The good news is ---there's a medical explanation in the brain we know and you're not crazy. Finding ways to move towards the fear and looking at the ways we find meaning in our experiences is paramount. There are lots of ways to get better and PE is just one of them. However, one that shows excellent empirical research for individuals who continued to be bothered by their symptoms.
What is also true is that by understanding how our very "old" parts of the brain which are in our evolutionary core for protection and serve the flight/fight/or freeze responses try to protect us to avoid pain - they can also fool a person into believing that the fear is as intense as when a traumatic event happened and even grow in it's avoidance.
If you're a therapist or a client interested in learning more about Scaer, check it. It's worth a read and some thought.