Treating Complex Trauma

A Relational Blueprint for Collaboration and Change

Mary Jo Barrett, Linda Stone Fish

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781136345784
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

In Treating Complex Trauma, renowned clinicians Mary Jo Barrett and Linda Stone Fish present the Collaborative Change Model (CCM), a clinically evaluated model that facilitates client and practitioner collaboration and provides invaluable tools for clients struggling with the impact and effects of complex trauma. A practical guide, Treating Complex Trauma organizes clinical theory, outcome research, and decades of experiential wisdom into a manageable blueprint for treatment. With an emphasis on relationships, the model helps clients move from survival mindstates to engaged mindstates, and as a sequential and organized model, the CCM can be used by helping professionals in a wide array of disciplines and settings. Utilization of the CCM in collaboration with clients and other trauma-informed practitioners helps prevent the re-traumatization of clients and the compassion fatigue of the practitioner so that they can work together to build a hopeful and meaningful vision of the future.

Part I

Creating a Context for the Journey of Change

one

Complex Trauma

The Individual

Humans are wired to anticipate and react to all of the various elements in our environment that pose a threat. This is a survival instinct and is stored in the part of the brain that we share with all animals. Our brain is triune—that is, it is divided into three sections, the brainstem, the limbic system, and the cortex. The part of the brain that we share with our reptilian cousins is the brainstem and it manages our impulses and controls our states of arousal. “Working in concert with the evaluative processes of both the limbic and the higher cortical regions, the brainstem is the arbiter of whether we respond to threats either by mobilizing our energy for combat or for flight, or by freezing in helplessness, collapsing in the face of an overwhelming situation” (Siegel, 2010a, pp. 16–17). When we experience threat or danger, our amygdala is activated, we are wired to fight the danger, flee from it, or freeze in a protective nature. This physiology is reactive and protective. When we react to threat from the brainstem, it is an automatic reaction that has survival functions.

Our autonomic nervous system has two branches, the sympathetic and the parasympathetic nervous systems. The sympathetic nervous system is activated under moments of threat and stress and helps to protect us from potential danger by getting us ready to fight or run. The amygdala, part of our sympathetic nervous system, remembers threat and responds. Our bodies are amazing instruments programmed for exquisite—survival—positive functioning. For example, our heart rates increase and blood flows toward the muscles to ready a protective response or a run for our lives. Our mouths feel dry because our saliva dries up, since our bodies know that we are probably not planning on eating anytime soon. Our skin temperature drops since we are using resources that we might normally use to keep our bodies warm and our pupils dilate so we can see our target more clearly. In other words, we are pumped. We are not thoughtful, we are not calm, nor are we relaxed. We are ready for danger. This survival physiology has kept the species alive for a very long time. The image of what danger looks like has changed over time and is different for every single individual. What is threatening to one person is absolutely not necessarily threatening to another. Consequently, all of our modes of fight, flight, and freeze are different and have evolved over time depending on the contexts in which we live.

Porges (2001) coined the term “neuroception” to explain how the nervous system detects threat and danger without our conscious awareness. His polyvagal theory (2001, 2003) explains that there are three basic stages that occur which are activated phylogenetically and subconsciously. Acute threat triggers the vagal nerve. When we feel safe, the evolved branch of the vagal nerve is activated and we are calm and able to engage socially and access support when we are threatened. When we feel threatened and unsafe, we are mobilized toward fight or flight. When both those branches fail, we rely on the unmyelinated visceral vagus, which renders us immobile (Porges, 2001).

Levine (2010) states: “When acutely threatened, we mobilize vast energies to protect and defend ourselves. We duck, dodge, twist, stiffen and retract. Our muscles contract to fight or flee. However, if our actions are ineffective, we freeze or collapse.” This is very important in our understanding of trauma and the key to the trauma cycle. What Levine recognizes in this simple and brilliant statement is actually our phylogenetic response to complex trauma. The parasympathetic reaction drives the body toward action. When you are faced with a traumatic event that you cannot fight or escape from, your body enters lockdown mode. To observe this primitive response in action, watch a herd of animals being chased by a predator. The predator targets a vulnerable animal, stalks and then gives chase. When death is inevitable, the prey clearly drops into lockdown mode. This lockdown or locked in experience has been called tonic immobility or animal hypnosis by ethologists (e.g., Burghardt, 1990) and is starting to be studied in humans as well.

The primitive and protective reaction of freezing, collapsing, or playing dead (many names describing the same activity) is, for animals that face being eaten, apparently to reduce the experienced pain of their death, or perhaps to encourage the predator to leave without attacking. When we talk to clients who have been threatened and cannot escape, many describe this experience. This protective function is known as dissociation. Although the dissociative process may be an evolutionarily adaptive response to unmanageable stress, it becomes maladaptive when incorporated into a person’s functioning as a result of the repeated assaults (and psychic escapes) inherent in complex trauma. An understanding of how this process functions maladaptively allows us to assist clients in transitioning from a survival mindstate to an engaged mindstate that is more aware, wiser, more present, and more attuned to self and other.

Disruptive, violent, stressful, and violating events that are not processed by the body and the mind become traumatic. When the body enters lockdown mode, the natural sympathetic nervous system response that activates reaction to danger is suppressed, and this activating urge is stored in the body (Levine, 2010). The body has a memory of its own and, when threatened by another perceived disruptive, violent, stressful, or violating event, will tend to act in ways that were protective at one time. The amygdala remembers. We refer to the result of this phylogenetic pattern of locking down as “acting from a survival mindstate” associated with a history of complex trauma. The survival mindstate is the result of a multitude of locking down reactions in the face of overwhelming persistent trauma. Van der Kolk, Van der Hart, and Marmar (1996) show that persistent trauma and the use of dissociation change the pathways between the amygdala and the hippocampus, disrupting the storage of memories and the individual’s capacity to cope.

Complex trauma occurs in environments replete with unmanageable stress. A history of complex trauma inevitably involves relationships with caregivers who failed to model, teach, support, and encourage constructive adaptive responses to stressful situations. Unmanageable stress is stress that the developing human (and we are always developing) cannot manage. A stressful event that we can manage is mediated by the sympathetic nervous system so that our body is mobilized to flee or fight and by our neocortex so that we are thoughtful about the best response. When an event is unmanageable, the unmyelinated dorsal vagal branch is activated (Porges, 2001), we go into lockdown mode, we are immobile, and we survive. The ways we survive in these unmanageable situations become our ways of coping. In this manner, over time, these immobilizing coping mechanisms become our typical survival skills.

Stan, for example, was repeatedly sexually abused by his older brother when he was a child. The abuse hurt him physically and when he complained of discomfort his brother told Stan he would tell their mother that Stan made him do it if he yelled out in pain. Stan coped with years of physical and psychic pain by numbing the pain, shutting down from his body, and not feeling any physical sensation. By adolescence he had perfected this coping style and felt dead inside. In moments of stress, for instance, when he fought with his parents and felt as though they were inflexible and he had no control, he found that he needed to burn himself and feel the pain of physical injury to cope with the stressful event in the present. Stan could not cope with discomfort and knew if he created physical pain, he could numb the discomfort because had had been doing it all his life. The coping mechanism of his childhood trauma became his survival skill when under stress.

Survival skills are fueled by the limbic area of our triune brain. The limbic system regulates the autonomic nervous system. So, when stressed and ready to fight or flight, the adrenal glands release cortisol, which puts our body on high alert. Unfortunately, in overwhelming stress, again, that stress that we cannot cope with, the cortisol levels can become toxic. “These high cortisol levels can also be toxic to the growing brain and interfere with proper growth and function of the neural tissue” (Siegel, 2010a, p. 18). While the limbic system helps us survive in dangerous situations, when we are no longer in danger we may be in overdrive and unable to turn off the high levels of cortisol distribution in our bodies. Porges (2003) and Badenoch (2011) state that when the vagal branch that connects us to calm and engaged states of mind or to fight or flight reactions are not functioning because of this overdrive situation, our immobility, trauma mindstate sets in and we survive.

Ledoux (1998) calls this the fear reaction system. As a result of relational trauma, our brains see threat when it is not there. The trauma creates a hyperactivation of the amygdala and impairs parts of the brain that help with inhibition and the capacity to integrate complex information. In other words, as a result of complex trauma, the brain has difficulty communicating with itself and actually perceiving complex information. The amygdala continually detects threat. Ledoux (1998) suggests that a traumatic response is one in which a stick always looks like a snake. Of course, it is adaptive for the brain to perceive danger in a situation that is dangerous, but complex trauma makes it difficult for someone to differentiate whether danger actually lurks. Complex trauma triggers a hyperaroused, hyperactive state that overperceives threat and hinders accurate integration of information. Without the ability to effectively perceive and process threatening stimuli, hyperaroused and hyperactive reactions are not helpful. They tend to be simplistic and rigid and isolative as opposed to integrative and complex. Furthermore, these survival mindstates may encourage behaviors which sabotage the development of constructive responses, including and especially the ability to use social support.

For example, when people offend others physically, sexually, emotionally, or verbally, this offending behavior may be conceptualized as emerging from people who are acting from a survival mindstate. A hyperaroused and hyperactive reaction to discomfort has the tendency to alert people to fight, flight, or freeze. The offenders are reacting to stressful events as if something about them is in danger. Their power, sense of control, and/or self-worth feel threatened. They are powerless, out of control, and they are in danger. Their fear is triggered and their traumatic history has not taught them to respond in an engaged mindstate to stressful events. Instead, stress is overgeneralized as danger, resulting in a misguided attempt to survive the perceived threat through aggressive behaviors supposed to address control and self-esteem needs.

In another example, a child who is sexually abused by an uncle protectively reacts with freezing and tonic immobility because she is too small and vulnerable and therefore unable to fight or run. This tonic immobility decreases her physical and emotional pain as she psychically disconnects and is no longer consciously present. She may or may not remember the event but her body remembers this state. With no one to help her cope with experiences that are too much for her to cope with alone, she develops trauma mindstate coping. Cortisol levels continue to rise and become toxic. This survival skill that helped her cope as a child, however, becomes maladaptive when she is under stress later on in life. Whenever in a stressful situation, then, even though she is no longer actually as vulnerable and incapable as she used to be, she perceives it as if it is a threat to her life and still reacts as if she is incapable of fighting or fleeing.

Take this same child as a young adult woman and married to a young man with a temper. He has had too much to drink one night and wants to have sex. She is tired and is aware that she would prefer not to have sexual relations at that time. He pushes himself onto her and she collapses, limp, and in lockdown. She cannot move. She cannot tell him to stop and she cannot assert her position because her survival skill is activated and she is immobile. Her early reaction to imminent danger, useful when she was a child, is no longer useful and it ends up perpetuating her survival mindstate. If she were not in a trauma state of mind, her sympathetic nervous system would be activated and she could fight or flee. She would sense danger, recognize she was in a dangerous situation, have been taught how to modulate her arousal so she could thoughtfully respond, and/or remove herself from the situation. She could clearly and assertively tell her husband she was not going to have sex with him. If he persists and aggresses against her, she recognizes that she is in a dangerous relationship and has the cognitive and emotional resources to generate constructive alternatives.

Complex trauma changes the way our brains are organized (Perry, 1994, 2001). The brain reacts to persistent traumatic experiences in childhood and individual brain chemistry is altered because of these experiences. When children are in constant states of hyperarousal and/or dissociation, it alters their brain chemistry. There is some evidence that boys are more likely to use hyperarousal and girls to use dissociation (Perry, Pollard, Blakely, Baker, & Vigilante, 1995) and that these lead to externalizing and internalizing behaviors respectively in adulthood. Either way, the complex trauma response which may have previously assisted survival becomes a maladaptive state of being in adulthood. This is the survival mindstate.

People in a survival mindstate tend to react to signs of stress or discomfort as if each experience is traumatic; their coping response is thereby informed from a reactive state as opposed to a calm and engaged perspective. In other words, we use the two most basic parts of the triune brain, the brainstem and the limbic regions, and fail to include the cortex, which is the part of the brain that is useful in higher-level decision-making. Our understanding of interpersonal neurobiology (Cozolino, 2006, 2010; Schore, 2003; Siegel, 2007, 2010a) is helpful here. To make intelligent decisions, we require strong connections to the prefrontal region of our cortex. When in a trauma/survival mindstate, the neurons connected to that region are not firing. The prefrontal cortex is responsible for sophisticated, complicated functioning such as paying attention and managing our relationship with self and with others. It is what allows mindsight (Siegel, 2010a). When in a trauma mindstate, we are not engaging the cortex that helps us accurately map and engage the world and our responses to it.

Surviving dominated by a trauma mindstate prohibits us from optimal functioning in our daily lives. We have learned to react impulsively rather than respond thoughtfully. This concept is key to understanding the goals of trauma treatment. We want to help clients to respond to their own internal cues and to the cues of others. Frantic reactivity does not serve us well in most situations. Reactivity leads us to abuse ourselves and others, maintaining the cycle of complex trauma, re-traumatizing ourselves and/or others. Responding utilizing the amazing resources of an integrated, interconnected brain and body serves us much better. When we are reacting, we are not using all of our brain but only that part that experiences threat. Mindsight (Siegel, 2010a) is the term for a part of our brain function that we are not using when we are in a survival mindstate. As we stated above, our triune brain’s three regions are the brainstem, the limbic area, and the cortex. The cortex is the part of the brain that we share only with primates and is more evolved in humans; the prefrontal cortex only functions in humans. Mindsight, then, is the capacity to pay attention, to be in an engaged state of mind that is not possible to access if we rely only on reacting to threatening situations and our survival skills (see the user-friendly diagram of the brain in Appendix 1).

Pause and Ponder: Does the neurobiology summary make sense? Is it clear how our clients are homeostatic and in a trauma/survival mindstate? Do the “mindstate” concepts seem applicable to self and others? To produce change it is important that we believe that all humans are created with the capacity to grow and change. It is important, no matter what age or learning capacity of our clients, that we create methods of how to communicate these concepts. Take some time to explore and generate ideas of how to utilize and communicate these concepts to clients in our day-to-day practice.

Attachment and Complex Trauma

Children who experience trauma may be more dramatically affected by chronic hyperarousal than adults. Trauma in childhood occurs before the brain has developed normal modulation of arousal. One of the most essential functions of parenting is to provide children with external modulation for their internal states. To develop optimally, chil...

Table of contents

• Cover Page
• Half Title page
• Series Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Series Editor's Foreword
• Introduction
• Part I Creating a Context for the Journey of Change
• Part II Expanding Realities The Collaborative Change Model
• Appendix 1 User-Friendly Diagram of the Brain
• Appendix 2 Communication Skills
• Appendix 3 Vulnerability/Survivor Worksheet
• Appendix 4 Handout Explaining CCM
• Appendix 5 Sample No-Violence Contract
• Appendix 6 Vulnerability/Resource Handout
• Appendix 7 List of Evaluative Tools
• Index