Coping With Trauma

Extracts from Coping With Trauma: A Guide to Self-Understanding, by Jon G. Allen.
(Once again, footnote references in the original have been omitted.)

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Given the broad array of problems, symptoms, and disorders associated with traumatic experience, it should come as no surprise that virtually all major forms of treatment are applicable. Because of the complexity of trauma-related disturbances, the many forms of trauma, and inherent differences among individuals, treatment must be tailored to each individual's needs and situation. Individual psychotherapy is usually the primary form of treatment for trauma-related problems. But persons who have been severely traumatized and who have chronic symptoms often need a combination of treatment approaches over an extended period of time.

This chapter offers an overview of major treatment approaches, emphasizing issues pertinent to trauma. First, a preliminary matter is addressed: establishing safety....

Judith Herman rightly declares: "The first task of recovery is to establish the survivor's safety. This task takes precedence over all other, for no other therapeutic work can possibly succeed if safety has not been adequately secured." I reiterate a few of the main points from her chapter on safety in Traum and Recovery -- a chapter I consider required reading for all who are in treatment for trauma. A paramount issue in the beginning of treatment, safety remains crucial throughout. Above all, progress in treatment depends on putting an end to ongoing trauma -- incest, battering, or any other form of abuse. Safety cannot be predicated on others' declarations that they will no longer inflict harm; rather, "it must be based on the self-protective capability of the victim."

Safety includes not only protection from the maltreatment of others but also protection from self-harm. Many persons who have been severely traumatized continue to feel endangered by their own self-destructive impulses. This vulnerability reaches the extreme in dissociative identity disorder when the individual feels terrorized by dissociated suicidal states. Short of endangerment from abuse at the hands of others or oneself, Herman emphasizes caring for basic needs: finding safe living quarters, eating and sleeping properly, obtaining needed medical care, and providing for financial security. Another crucial component of safety is a social support network -- the wider the better. This network may include friends, lovers, trusted family members, self-help groups, and mental health professionals. The process of establishing safety as a foundation for treatment is not easy; Herman likens it to preparing to run a marathon....

The price of establishing safety can be extrememly high. Many individuals face the dilemma of being economically dependent on persons (parents, spouses, or lovers) who continue to inflict trauma. Herman eloquently describes the magnitude of these costs:

"Creating a safe environment required the patient to make major changes in her life. It entailed difficult choices and sacrifices. This patient discovered, as many others have done, that she could not recover until she took charge of the material circumstances of her life. Without freedom, there can be no safety and no recovery, but freedom is often achieved at great cost. In order to gain their freedom, survivors may have to give up almost everything else. Battered women may lose their homes, their friends, and their livelihood. Survivors of childhood abuse may lose their families. Political refugees may lose their homes and their homeland. Rarely are the dimensions of this sacrifice fully recognized."
(Pages 235-237)

The universal prescription for trauma: Talk about it. To whom? To any trusted person who will listen -- the sooner the better. This universal prescription works best in conjunction with single-blow traumas, such as a natural disaster, an assault or a rape. Even then, it is not always easy to "just talk about it." Talking about it may bring back the feelings of terror or rage engendered by the trauma. Shame may get in the way. As you begin to think or speak about it, self-protective dissociation may block the memory.

It's not always easy for others to listen, even when they are caring and eager to help. Trauma can be abhorrent. Listening to another person's horrific stories of trauma can itself be traumatizing. It can threaten the listener's sense of safety and security. Friends may urge you to "just get your mind off it" so that they do not have to think about it. You may need to impress on them the importance of your need for someone to listen. But the listener's feelings of fear and outrage can also interfere with his or her capacity to listen. A woman who has been raped may find that every time she tries to discuss it with her husband, he becomes so embroiled in his wish to kill the rapist that he can hardly pay attention to her feelings. In such cases, trying to talk about the trauma can make it worse, not better.

When talking through the trauma with others is not possible, you may need to turn to a psychotherapist. A psychotherapist not only can provide help with symptoms but also can help with the process of talking about the trauma. As Judith Herman puts it, the psychotherapist's role is to bear witness. Not that it's easy for the psychotherapist. Psychotherapists can also feel horrified and outraged. But their training, experience, and professional role afford a degree of objectivity that provides a safeguard against their becoming so distressed that they, too, cannot listen....
(Pages 237-238)

Trust forms the foundation of a positive relationship with a psychotherapist, as does a feeling of being accepted by the therapist. The feeling of trust should be based on your perception that your psychotherapist is trustworthy, reliable, and trying to be helpful. For a good alliance, your psychotherapist must indeed be trustworthy and capable of providing help. Obtaining a referral from a reliable source and checking out your psychotherapist's reputation can help provide a foundation for the alliance. But ultimately you must make a judgment on the basis of your own experience with the psychotherapist. It is important to find a good match; a psychotherapist whom someone else finds helpful may not necessarily be best for you.

A good therapeutic alliance also includes active collaboration. In psychotherapy research at The Menninger Clinic, we have defined the patient's collaborative role as making active use of the psychotherapy as a resource for constructive change. You should feel that you and your psychotherapist are working together toward common goals. You should be an active participant in the process. Probably every patient in psychotherapy wishes she or he could just be "cured" by the psychotherapist. Who wouldn't? Psychotherapists I know work very hard. But their patients must work even harder. Your psychotherapist should not be working harder than you are. You are the major contributor to the success of your therapy. Your psychotherapist's job is to provide the guidance and support you need to do your hard work. Talking about trauma is hard work. Coping with trauma is hard work. Like any other hard work, it can't be done continuously. You need breaks; you need rest; you need respite. But the ultimate outcome depends on your persistence -- over the long haul, if need be.
(Page 239)

Psychoterhapy is not a cure by love -- emotional or physical. Rather than belatedly attempting to provide the level of attachment and mothering that was missing at the time of trauma, your psychotherapist can help you mourn that lack of mothering, comforting, and affection. No amount of psychotherapy can entirely redress that loss....

You might think of psychotherapy as a stepping stone to other relationships in which your natural and healthy needs for intimacy and physical comforting can be met. As Bowlby stated, the need for attachments, for a secure base, and for comforting -- including touch -- is lifelong. Optimally, psychotherapy is but a way station that fosters a capacity to depend on others even more deeply and intimately.
(Page 246)

Fortunately, while legions of psychologists and others have studied the various forms of distress that befall us, a few have worked to understand positive emotion. We should be devoting at least as much energy to learning about feeling good as we do to learning about feeling bad.

It is easy to appreciate the biological significance of "negative emotions" like fear and anger. Fight and flight can save our skins. But positive emotion is just as biologically necessary. While pain and negative emotions tell us what to steer clear of, positive feelings tell us what to head for. Positive feelings go with activities that satisfy our basic needs, such as hunger, thirst, and sex. Positive feelings go with activities that lead to growth, development, mastery, and accomplishment. Positive feelings also accompany the healthy forms of relatedness. Neurophysiologist Jean-Didier Vincent puts it plainly: "This choice [between pleasure and pain] helps the species to adapt. What is good for it causes pleasure and what is bad causes displeasure." Our brains come with billions of possible connections, and we have to hook them up on the basis of our experience. Good feelings are a guide: Hook this up! Do it again!

Unless you know what it feels like to feel good, you don't know how to get there. As a start, you must learn to identify your positive feelings. Look for them. Notice them. Pay attention to them. Then you can use various methods to cultivate them. Make them a more prominent part of your experience. Make good experience a habit, a daily routine. Ultimately, you can gain a sense of choice and feeedom about your feelings. You can learn to change unnecessary distress -- to bring it within more tolerable bounds and to shift into more positive experience. Beware, however, that you cannot necessarily change quickly from negative to positive feelings. Anxiety, fear, and anger create a blast of transmitters that remain in circulation -- in the brain and in the rest of the body -- sometimes for a long while. The switch can be turned on in an instant but it can be turned off only gradually.
(Pages 270-271)