Coping with Trauma

Jon G. Allen, PhD¹
Senior Staff Psychologist with The Menninger Clinic

Like many other psychiatric problems, trauma is not only profoundly distressing but also bewildering—to patients, their family members and, at times, even mental health professionals. Such trauma-related problems as flashbacks, nightmares, dissociative states, deliberate self-harm, and reenactments of past traumatic patterns in current relationships are alarming and disruptive. Persons in close relationships with traumatized patients—including their therapists—are exposed to emotional contagion and vicarious trauma. Secure and stable relationships are the foundation for healing; yet these trauma-related problems undermine attachments, often creating a vicious circle of spiraling distress wherein the traumatized person feels increasingly alienated from sources of support—and further traumatized.

Understanding provides a platform for treatment and for hope. Illness can be treated and managed; functioning and relationships can be improved. For more than a decade, we at The Menninger Clinic have been refining psychoeducational programs for trauma, through which patients, their family members, and the professional staff have been educated. These programs, often conducted in a seminar-like atmosphere, capitalize on a synergy: as clinicians educate patients, patients educate clinicians; in the process, our collective knowledge grows.

Of course, clinicians and patients alike benefit from burgeoning scientific knowledge in the field of trauma. In addition to making use of accruing findings in the field at large, we have been incorporating emerging concepts from the Menninger Child and Family Program’s research on attachment and trauma, inspired by British psychologist and psychoanalyst Peter Fonagy’s pioneering work on the role of mentalizing—awareness of mental states in oneself and others—in resilience. This ongoing research in developmental psychopathology and related theoretical advances are playing a central role in the evolving treatment philosophy of The Clinic.

This manuscript is a précis of the second edition of Coping with Trauma: Hope through understanding, published by American Psychiatric Publishing. This book, developed from the psychoeducational program, provides a comprehensive overview of trauma and its treatment. It is addressed to patients, their family members, and mental health professionals. Each section of this article provides a précis of the corresponding chapter of the book.

In tandem with Coping with Trauma, Lisa Lewis, Kay Kelly, and I have published a more concise book, Restoring Hope and Trust: An illustrated guide to mastering trauma, published by the Sidran Institute Press. This book is based on a condensed version of the psychoeducational course developed for patients in the Menninger Professionals in Crisis program. Suggested readings are included with this article; more comprehensive references can be found in Coping with Trauma.

Part I. Foundations

1. Trauma

Trauma refers to persistent negative effects of experiencing extremely stressful events. These negative effects may include psychiatric disorders, such as depression and posttraumatic stress disorder, as well as psychological and interpersonal problems more generally (e.g., distrust and resentment).

Potentially traumatic events include objective features (e.g., an event as someone else might witness it, such as having a gun pointed at you) and subjective experience (i.e., your emotional experience, such as feeling helpless and terrified that you’re about to be killed). Not all exposure to potentially traumatic events results in persistent negative effects. We believe that trauma can be prevented, for example, by having emotional support and comforting that restores a sense of safety and helps you make sense of the frightening events. Conversely, we think that the core of traumatizing events is feeling afraid and alone.

Potentially traumatic events range from single incidents (e.g., a car accident) to repeated stress (e.g., combat trauma). We can distinguish among three levels of interpersonal involvement in potentially traumatic events: impersonal (e.g., a tornado), interpersonal (e.g., an assault), and attachment trauma (i.e., trauma in attachment relationships, such as childhood maltreatment or battering relationships in adulthood). We believe that greater interpersonal involvement contributes to trauma.

Attachment trauma includes physical abuse, sexual abuse, antipathy (rejection), psychological abuse (cruelty), emotional neglect (lack of responsiveness to emotional states), and physical neglect (lack of supervision and failure to provide for basic needs). Attachment trauma in childhood may be especially problematic, because it can influence the course of psychological, social, and physiological development.

Many patients struggling with trauma suffer from stress pileup, an accumulation of traumatic stress over the lifetime. Despite a history of childhood trauma, many persons function very well for long periods. Yet a pileup of stress in adulthood—on top of the vulnerability resulting from childhood trauma—becomes the last straw. For example, adulthood stress can lead to depression, sometimes coupled with substance abuse, and then memories of earlier trauma may come to the forefront in the form of posttraumatic stress disorder.

Keeping the idea of stress pileup in mind, coping with trauma entails (1) learning to regulate emotional distress more effectively and (2) minimizing exposure to further stress to the extent humanly possible. Both of these strategies entail caring for yourself over your lifetime so as to maximize your functioning and to minimize your vulnerability to recurrence of trauma-related illnesses.

2. Attachment

Close emotional bonds characterize attachment relationships. The prototype of attachment is mother-infant bonding. Attachment relationships provide a safe haven (promoting a feeling of security when you’re distressed) and a secure base (fostering confidence in being able to actively explore the wider world). Although attachment begins developing in the first year of life, we all need secure attachment relationships throughout life.

Besides providing a safe haven and secure base, attachment relationships have another crucial function: they promote the development of the ability to mentalize, that is, to make sense of mental states (such as desires, feelings, and beliefs) in oneself and others. Mentalizing is essential for self-awareness and healthy relationships.

Attachment plays a key role in trauma for two reasons: (1) an attachment relationship can restore the feeling of safety when you’ve been through a potentially traumatic event and (2) attachment relationships can be a source of significant trauma.

Based on research with infants, four patterns of attachment have been distinguished. Secure attachment, like basic trust, entails a sense of confidence that an attachment figure will be responsive when needed in times of distress. If you have felt hurt or let down, you may develop insecure patterns of attachment. The avoidant pattern involves refraining from relying on others to meet attachment needs, trying to take care of yourself entirely by yourself. The ambivalent pattern involves an emotionally stormy pattern of clinging to attachment figures while expressing frustration and resentment. Childhood trauma also may lead to a more severely insecure pattern of disorganized attachment, characterized by fear of attachment relationships and inability to develop a workable strategy for interacting with attachment figures.

Although the basic need for secure attachment is lifelong, attachment relationships undergo many changes over the course of development. Although the foundations of attachment are established early in life with primary caregivers, attachment may develop in relationships with a wide range of other persons: siblings, grandparents, members of the extended family, peers, teachers, counselors, friends, co-workers, romantic partners, and professionals. We also can form significant attachments with pets. Attachment always allows room for change and growth. Persons who have been traumatized in attachment relationships rarely give up on attachment relationships; despite trauma, most persons are able to establish and maintain some network of relatively secure attachments.

Part II. Effects of Trauma

3. Emotion

It’s natural to avoid emotional distress, but this natural strategy may backfire: having blocked your emotions, you can be blindsided by intense emotional upheavals. Thus it’s best to take the opposite approach, cultivating emotions, increasing your awareness of your feelings so as to regulate them before they get out of hand. And emotions are adaptive. As the fight-or-flight response illustrates, emotions such as anger and fear are adaptive: they are fast; they are informative; and they are motivating—they can save your skin.

Emotions are packages, consisting of cognitive appraisals (interpretations of the implications of a situation for your wellbeing as well as interpretations of your ability to cope), physiological responses (e.g., providing energy for coping), adaptive actions (e.g., running), and expressions (e.g., communicative facial and vocal expressions). In addition, emotions include conscious feelings that provide information about our emotional state.

Fear and related emotions (anxiety, panic) play a major role in trauma, and fear illustrates a crucial fact: you can become conditioned to respond automatically with fear to stimuli associated with traumatic experiences, and these triggers can evoke fear responses in a fraction of a second—far faster than you can think. Thus you may not be able to prevent fear from erupting, but you can learn quickly to regulate your fear once you do feel it, so it does not escalate into panic or terror. You can also lower your general arousal level by such means as routine relaxation and exercise, as well as by learning to diminish your anxiety sensitivity—fear of fear.

Anger illustrates how the same emotion can be beneficial and harmful. Benign anger provides fuel for self-protection, for example, fostering assertiveness. Outrage is another helpful form of anger in relation to trauma. But anger can be destructive when it reaches extreme intensity (e.g., rage) or when it smolders and undermines your wellbeing and relationships (hostility, hate, and vengeful feelings). Many persons believe it’s always best to move from resentment to forgiveness, but this is a complicated matter for which there are no pat prescriptions.

Shame involves pervasively negative feelings about the self (e.g., feeling incompetent, damaged, unlovable) whereas guilt relates to feelings about specific actions that have harmed other persons. Shame and guilt feelings tend to perpetuate trauma, and working with these feelings is an important part of trauma treatment. Often these feelings stem from childlike perspectives on trauma that can be rethought from an adulthood perspective. The antidote to shame is pride, and the antidotes to guilt are making reparation and self-forgiveness.

Cultivating awareness of painful emotions allows you to implement coping strategies before their intensity escalates to unmanageable levels.

4. Memory

Trauma poses two main challenges: (1) you may be haunted by intrusive memories of traumatic events, and (2) you may be unsure about the accuracy of these memories. Thus it’s important to understand something about the nature of memory when you’re struggling with traumatic memories.

Researchers distinguish between implicit memory (conditioned emotional responses) and explicit memory (conscious remembering). Trauma includes both conditioned responses and explicit, personal-event memories, that is, memories of specific events in our past. We also construct an autobiographical narrative—a life story—based on personal-event memories, what we have been told about our past, and what we infer happened to us.

Memory is not like a video recorder; it’s a construction. For example, our memories are influenced by what we believe or imagine might have happened. By and large, the gist of our autobiographical memory is accurate, although we are liable to mix up many details. Persons with a history of repeated trauma beginning in childhood—like everyone else—may have an amalgam of memories that vary widely in accuracy, potentially ranging from mainly true to mainly false.

Flashbacks are intrusive personal event memories that entail a painful sense of reliving the traumatic event. Intrusive memories also occur in sleep in the form of nightmares. There is no simple way to prevent flashbacks and nightmares; the whole of trauma treatment may be required. Yet we emphasize the importance of grounding techniques that focus your attention on current reality so as to reinforce the difference between the present and the past. Examples are feeling your body in the chair, naming objects in the room, getting up and walking around, splashing cold water on your face, holding ice, or talking to someone.

The goal of trauma treatment is to be able to remember rather than relive trauma. This entails being able to have the trauma in mind rather than putting it out of mind. Constructing a meaningful autobiographical narrative that will enable you to make sense of your history and your symptoms is a crucial part of trauma treatment. It’s important to cultivate positive memories alongside painful memories. If you’re struggling with the problem of accuracy, you may need to do some detective work and to live with some degree of not knowing. Others, including therapists, cannot tell you what to believe; you must decide.

If you’ve undergone extensive trauma, it may not make any sense to try to remember or recount everything. It’s crucial not to focus your life all around trauma. The main agenda of healing and thriving should always be in the forefront. You should feel free to forget. You should feel free to let sleeping dogs lie. It’s crucial to learn from the past, but the goal is to make the most of the present and the future.

5. Self

We can distinguish two aspects of the self: (1) the “I” or self as active agent and (2) the “me” or self-concept—how you think and feel about yourself. Importantly, the me has a strong impact on the I: how you feel about yourself influences who you become. For example, if you think of yourself as weak and vulnerable, you may be reinforcing avoidant and timid behavior. If you think of yourself as capable, you may be more inclined to develop your strengths.

Both the “I” and the “me” can be influenced by trauma. Traumatic events are overpowering and render you helpless. Repeated trauma can undermine your feeling of agency (the “I”)—your sense of power and influence. In addition, trauma can undermine your sense of self-worth (the “me”), leading you to feel as if you are bad, worthless, or even evil. Healing from trauma entails strengthening your sense of agency—empowering yourself—and enhancing your sense of self-worth.

Every person is extremely complex, and every self-concept is potentially based on a complex mixture of good, bad, and indifferent characteristics. Persons who are traumatized and depressed often focus on the negative as if this negates all the positive. To a degree, our self-concept mirrors how others regard us, and being treated in contradictory ways (e.g., loved and hated) can promote confusion in the sense of self. Improving self-worth entails establishing accepting relationships, concentrating on a more balanced view of the complex self, and improving your functioning so as to have a greater basis for a positive view.

You are not only conscious (aware) but also self-conscious (self-aware). This dual aspect to consciousness enables you to form a relationship with yourself. The relationship you have with yourself, like your self-concept, may mirror relationships you have with others. Feeling hated by others can translate into hating yourself. Healing from trauma requires accepting yourself, an important part of which is being attentive and open to your feelings—listening to yourself. Accepting yourself and tolerating your various feelings puts you in a stronger position to criticize yourself constructively—something you also need to be able to do to improve yourself. But you can go beyond self-acceptance. Also important is feeling compassion for yourself, that is, a feeling of sympathy for the suffering you’ve endured. Compassion for yourself promotes self-care. Ideally, you can develop loving feelings for yourself, a sense of bonding with yourself that promotes your strength and vitality.

6. Relationships

On the basis of interactions we have with other persons, we develop internal working models of relationships that provide patterns for our relationships. Secure attachment relationships are a primary source of positive working models. Examples of problematic relationship models stemming from trauma include isolation from others, yearning for closeness and affection, fearfulness of others, dependency on others, feeling victimized by others, being controlling of others, and being aggressive toward others.

It’s not uncommon for persons with a history of attachment trauma to find themselves reenacting traumatic patterns in later relationships. Such reenactments can contribute significantly to your general level of stress as well as serving as triggers that remind you of previous trauma. Thus reenactments can stimulate reexperiencing symptoms. An example of a pattern of reenactment is the following cycle: feeling isolated, longing for rescue, feeling let down or abused, retreating into isolation, and feeling alone and neglected.

One particularly troubling pattern of relating is traumatic bonding. On the surface, it seems puzzling that a person would cling to a relationship that is frightening and injurious. Attachment theory helps explain this pattern. Fear prompts us to seek attachments: the more frightened you are, the tighter you cling. If you’re afraid and have no other source of support, you’re driven to cling to the available attachment figure—even if this person frightens and hurts you. It’s this conflict between need and fear that leads to disorganized attachment. Learning self-protection and finding other secure attachments is the pathway out of traumatic bonding.

The vast majority of persons with a history of trauma in attachment relationships in childhood are able to develop some relatively secure attachments in adulthood. A network of supportive relationships is ideal, because different persons can meet different needs and it’s best not to unduly burden any single relationship. Potential domains of relationships include friendships, romantic relationships, family relationships, work and school relationships, relationships with professionals, and more informal social contacts.

Developing a capacity for self-dependence balances autonomy with connection. Being self-dependent does not mean that you need not rely on others for security and comfort but rather that you can be alone and manage your distress on your own for some period of time until you are able to make contact. Put succinctly, self-dependence is the capacity to bridge the gap between separation and reunion.

7. Illness

Exposure to stress causes physiological changes in the brain and the body. In the short run, these changes are adaptive, because they enable the brain and body to cope with challenge. When the stress extreme and prolonged, as would be the case with repeated traumatic stress, the physiological changes can be persistent and maladaptive. Thus psychological trauma can create physical illnesses.

Research on brain changes in the aftermath of traumatic stress documents the physical basis of posttraumatic symptoms. While it’s alarming that traumatic stress can lead to brain impairment, recent research also shows that these brain changes can be reversible with treatment and psychological healing.

When you’re struggling with trauma, you may be urged just to “Put the past behind you,” to “Move on,” or to “Get over it!” Yet trauma-related disorders are illnesses: you cannot recover by a mere act of will. Recovering takes many acts of will over a long period of time and is likely to require considerable professional help. And trauma-related illnesses tend to be recurrent, such that prevention—taking care of yourself over the long haul—is extremely important. In this sense, trauma-related illnesses are analogous to hypertension or diabetes.

Repeated uncontrollable stress can sensitize the sympathetic nervous system (the fight-or-flight system). Sensitization is the opposite of desensitization. Ideally, when you’re exposed to an anxiety-provoking situation repeatedly, you become calmer about it—usually when you approach the situation in gradual, graded steps (e.g., giving speeches to increasingly large audiences). In the face of overwhelming stress, however, the opposite can happen; you can become more reactive to stress rather than less so. This is the “last straw” effect: a small stressor can set off a large reaction if your nervous system is sensitized. You may be criticized for “making mountains out of molehills.” But your nervous system, geared up for danger, has learned to do this rapidly and automatically. And there is a real mountain of trauma in the past that is stored in your nervous system. Thus part of recovering from trauma is desensitizing yourself by coming to terms with the trauma and learning emotion-regulation strategies.

In addition to trauma-related symptoms, chronic stress can result in generalized ill health. Not just the nervous system but also all other organ systems may be affected (e.g., you may experience headaches, gastrointestinal symptoms, sexual dysfunction, pain, fatigue, shortness of breath, and so forth). Again, these are signs of real, stress-related physical illness, even if they cannot be diagnosed and treated as specific diseases. It’s crucial not to dismiss these symptoms as “all in your head” and thereby fail to obtain routine medical monitoring and treatment. Yet the physical basis of traumatic stress underscores the importance of your aiming for positive physical health: sleeping well, eating properly, exercising, and refraining from substance abuse.

Part III. Trauma-Related Psychiatric Disorders

8. Depression

Depression is perhaps the most common trauma-related problem. Darwin observed that fear is the most depressing of the emotions. Recurrent, trauma-related fear is extremely stressful. Depression is the result of sustained unresolvable stress. It is a physical as well as a mental illness.

Although an episode of depression may be triggered by an acute stressor (e.g., a loss or failure), depression is often the culmination of stress pileup that accumulates over the lifetime. Genetic factors and prenatal stress can render you vulnerable to responding to later stress with depression. Other early stressors that can contribute to a later vulnerability to depression include maternal depression in infancy, childhood loss and trauma, adolescent depression, and substance abuse. These risk factors can set the psychological and physiological stage for a greater tendency to respond to adulthood stress—including traumatic stress—with depression.

We can make a relatively direct link between trauma and depression by considering the fact that depression is often a response to oppression—being overpowered, intimidated, burdened, under a weight. Traumatic relationships are oppressive. The natural response to being threatened is to fight or to flee but, when you’re overpowered, fleeing is not possible and fighting back may result in your being hurt worse. One theory proposes that depression is an automatic response of submitting and giving up when you are overpowered. This response is self-protective because it automatically prevents you from engaging in a dangerous aggressive confrontation. Although depression may be adaptive in an overpowering relationship, depression also takes the form of learned helplessness, a pattern that can be carried on into later life when the situation is safe. Then it is maladaptive and new learning must occur.

It’s not uncommon for persons to require several months to recover from a major depressive episode. One reason recovery may be so slow is a set of catch-22s: all you need to do to recover is made difficult by the symptoms of depression. For example, being chronically stressed, you must rest and sleep well, but a typical symptom of depression is insomnia. Here are others: you must eat well but may have little appetite; you should be active and exercise but may have little energy; you should engage in enjoyable activity but may have little capacity for pleasure; you should think realistically but may be beset by automatic negative thoughts; you should socialize but may be tempted to withdraw and isolate; and, above all, you should be hopeful but you may feel hopeless. These catch 22s make it difficult to recover from depression but not impossible to do so. The vast majority of depressed persons recover. But it takes time. You’ll do best by setting small goals as well as by being patient with yourself, respecting the challenges of coping with the catch 22s. Ideally, you can feel some compassion for yourself in this struggle, rather than berating yourself for your slow progress.

9. Posttraumatic Stress Disorder (PTSD)

PTSD is aptly named: it’s a disorder that develops after traumatic stress. The hallmark of PTSD is reexperiencing the trauma in response to reminders. Reexperiencing symptoms include flashbacks and nightmares. PTSD adds insult to injury: experiencing extremely stressful events—bad enough in itself—induces an illness that renders sufferers vulnerable to reliving those experiences in their mind afterwards.

Reexperiencing symptoms reflect sensitization: small reminders—anything that leads to fear or helplessness—may evoke strong responses. Also, if the core of trauma is feeling frightened and alone, reexperiencing neglect can be as painful as reexperiencing abuse. We call sensitization and the reexperiencing symptoms the “90/10 response,” where 90% of the emotion is a response to the past and 10% is a response to the present. Thus learning to separate the present from the past is a major agenda in coping with trauma.

It’s natural to try to avoid stirring up painful traumatic memories. You may try not to remember, think about, or talk about the trauma, as well as avoiding situations that might remind you of trauma. In moderation, avoidance is adaptive. Yet avoidance can lead to significant impairment of functioning (e.g., if you’re extremely isolated socially), and it can prevent your coming to terms with the trauma. Thus avoidance can keep you stuck.

Current stress plays a key role in PTSD. Often the reminders of past trauma consist of conflicts in current close relationships. Many traumatized persons unwittingly reenact past traumatic patterns in current relationships. Thus it’s important to place major emphasis on working on current relationship conflicts as well as on diminishing other current stressors to the extent possible.

Repeated and severe stress, such as attachment trauma, may not just result in PTSD but rather can affect the whole personality—identity, relationships, and emotional responsiveness. Thus persons with a history of such trauma may meet criteria for personality disorders, such as borderline personality disorder. Some trauma specialists have raised concern that such diagnoses may seem like blaming the victim and have proposed instead that such trauma be diagnosed as complex PTSD, but this proposal was not adopted in the current diagnostic manual.

The formalization of the diagnosis of PTSD in 1980 in the aftermath of the Vietnam war has led to more than two decades of highly productive research that has documented the seriousness of trauma and its physical as well as psychological and social effects. This research has included the development of a wide range of effective treatment interventions. And research has also revealed that, in addition to the serious negative effects, many trauma survivors report posttraumatic growth in the form of enhanced strengths, connections with others, and spirituality. It’s important to recognize and cultivate whatever benefit may come from suffering.

10. Dissociative Disorders

Dissociation is an automatic, self-protective alteration of consciousness in the face of overwhelming stress, a form of mental flight. Although dissociation mentally removes you from painful experience, it can undermine your functioning when it develops into a habitual way of coping with anxiety or stress.

The most common form of dissociation is dissociative detachment: feeling disconnected from yourself or the outer world, for example, in a trance-like or dream-like state. Dissociative detachment can be contrasted with alert consciousness, being flexibly aware of what’s going on outside of you as well as inside of you. Mild detachment involves being very absorbed in something—a movie, a book, or a daydream. Being absorbed in one activity, you’re detached from all else (e.g., you might not even hear your name being called). Such absorption is healthy and necessary for creative activity. Problematic dissociative detachment involves feelings of unreality. Depersonalization involves feelings of unreality regarding your sense of self. You may feel you’re on autopilot, you’re an actor in a play, you’re disconnected from your body, or you’re observing yourself from outside of your body. Derealization involves a sense that the outer world is not real. You may feel as if other persons are actors in a play or as if you’re looking at the world through a tunnel. Extreme detachment involves feeling as if you’re gone, in the blackness, or in a void—completely unaware. Some persons can sit and stare for hours, not being aware of time passing. When you’re very detached, you may have trouble remembering what you’ve said or done; you have not encoded it well into memory and therefore cannot retrieve it.

Another form of dissociation is compartmentalization. Some persons develop dissociative amnesia for frightening or stressful events; they’re blocked from consciousness but, with time and effort, can be remembered. Some persons experience fugues during which they lose their sense of identity and memory for their past and travel to another place—again, recovering their memory and sense of identity with time and effort. Dissociative identity disorder involves changes in sense of identity and engaging in uncharacteristic behavior (e.g., childlike or aggressive behavior) coupled with amnesia for behavior in dissociative states. Treatment of dissociative compartmentalization involves helping the individual to have the stressful memories and emotions in mind rather than having to compartmentalize them by amnesia.

PTSD and dissociation overlap, and some clinicians consider flashbacks to be a form of dissociation—they involve altered consciousness and detachment from current reality. Thus grounding techniques are helpful in coping with dissociation and PTSD symptoms. These techniques (e.g., holding ice, squeezing an object, walking around in the fresh air, talking to someone) draw your attention to current reality by heightening your sensory awareness.

11. Self-Destructiveness

Many persons struggling with intense, painful feelings stemming from trauma resort to forms of coping that backfire: they relieve tension in the short run, only to create additional stress in the long run. Examples are substance abuse and self-injurious behaviors. These behaviors are self-destructive in the sense that they undermine coping and damage relationships. Yet the aim is self-preservative in providing relief from unbearable emotional states.

Substance abuse illustrates coping that backfires. Substances like alcohol and cocaine alter painful feelings, such as anxiety and depression. These substances have potent effects on mood, and they are fast acting. Yet the spiral of intoxication and withdrawal ultimately intensifies anxiety and depression, and addiction develops as more of the substance is needed to regulate its own effects. Like depression, PTSD can contribute to substance abuse. Conversely, substance abuse can worsen PTSD symptoms and can also lead to PTSD indirectly by increasing the risk of incurring trauma (e.g., accidents in drunk driving).

Like substance abuse, bingeing, purging, and starving can be used to quell emotional distress. Like substance abuse, these forms of coping backfire. For example, although bingeing and purging may momentarily relieve tension, these behaviors create feelings of shame and guilt, which then contribute to a desire to binge and purge.

It’s especially hard for people to appreciate how deliberate self-harm (e.g., self-cutting) can relieve tension. Yet, for persons with PTSD, such behavior actually can be calming. Deliberate self-harm may or may not be associated with pain sensations. Some persons are analgesic, not feeling pain; others find it calming to deflect their attention away from emotional pain onto a tangible, physical sensation that they can control. This behavior is often seen to be manipulative—trying to “get attention.” But the main point is trying to relieve tension. Whether intended or not, self-harm has a communicative function: it shows in action what’s hard to express in words. Yet this form of communication is hard to receive. There’s a vicious circle: feelings of abandonment trigger self-harm, the behavior provokes alarm and anger in others, intensifying fears of abandonment, leading to more self-harm behavior.

Whereas substance abuse, eating disorders, and self-harm are intended to alter consciousness, suicidal behavior is intended to eliminate conscious pain, once and for all. More specifically, it is often intended as a permanent escape from self-awareness. It’s important to keep in mind that self-destructive and suicidal actions are borne out of unbearable emotional states, many of which entail a sense of painful aloneness. This combination of unbearable emotional pain and being alone may mirror earlier traumatic events—reflecting a 90/10 reaction. Thus self-destructive actions stem from a state of mind. States change. Self-awareness—mentalizing—during these states can enable you to alter them, most crucially by learning to reach out for support so as not to feel so alone.

Part IV. Healing

12. Emotion Regulation

It’s tempting to try to suppress and avoid painful emotions when you’ve been traumatized, but this tends to backfire because you can be blindsided by them. It’s better to cultivate emotional awareness so you can work with your emotions.

When you’re in a painful emotional state, you can learn to push the pause button, sitting with the painful emotion rather than immediately acting. This requires inhibiting your automatic pattern, giving yourself space for alternatives. It takes great effort. We call this process mentalizing emotionally: being aware of your mental state while you’re experiencing a strong emotion. There are three steps: identifying your feelings, modulating them (e.g., decreasing their intensity), and expressing them. Mentalizing emotionally enables you to (1) employ self-regulation techniques, (2) seek support from others, and (3) engage in active problem solving—first and foremost, working on interpersonal conflicts and reenactments that fuel posttraumatic symptoms.

Self-regulation techniques are generally ancient, ranging from relaxation and meditation to exercise—not to mention sleep. A recent invention is biofeedback: you can use physiological information (e.g., from a finger thermometer) to inform you about your level of relaxation so as to guide your efforts. All these techniques are simple but difficult: they require a great deal of patience and practice. One practitioner recommended trying meditation for a few years.

Self-regulation techniques can backfire. Techniques that involve turning your attention inward (relaxation, guided imagery, meditation) may lead to dissociation or intrusive traumatic memories. You may need to engage in relaxing activities (e.g., making or building things) that focus your attention outward. Exercise can backfire if physiological arousal (e.g., increased heart rate or labored breathing) reminds you of being in a traumatic situation.

Fortunately, there are so many ways of emotion regulation that you’re bound to find some that suit your needs and interests. Routine use of some combination of relaxation (or relaxing activity) and exercise is ideal for stress management. Developing skill enables you to use the techniques to relieve tension in a crunch, and routine practice can lower your overall level of stress and arousal.

An important component of regulating painful emotions is cultivating positive emotions. Positive emotional states facilitate flexible and creative thinking, and they also undo the physiological arousal from distressing emotions. There’s a wide range of positive emotions to cultivate: pleasure, interest, excitement, absorption, enjoyment, joy, contentment, pride, compassion, and love.

While there are many ways of regulating emotions by yourself (e.g., relaxation or exercise), keep in mind that a major form of emotion regulation is relying on other people—ideally, secure attachment relationships. The experience of someone who cares having your mind in mind—being mentalized—may be most crucial.

13. Treatment Approaches

We face a dilemma in treating trauma: reminders of trauma activate PTSD, and treating trauma evokes traumatic memories. Thus processing trauma—thinking, feeling, and talking about it—must be balanced with containment—social support, self-regulation, and a daily routine or structure. Many persons must spend a long time strengthening containment (relationships and self-regulation) before getting too deeply into processing.

A therapeutic alliance is crucial to success of any treatment approach. There are two components to the therapeutic alliance: a good relationship with your therapist (e.g., a sense of trust and acceptance) and active collaboration (a sense of working together on shared goals). Trauma in attachment relationships can make it difficult to form a therapeutic alliance, but one of the benefits of doing so is learning how to trust, confide, and work on fears and conflicts in relationships. Thus developing a solid relationship with a therapist can serve as a bridge to other trusting relationships.

The best-studied psychotherapies for trauma are cognitive-behavioral approaches. Dialectical behavior therapy includes helpful strategies for emotion regulation. Edna Foa’s exposure therapy entails (1) emotional engagement with the traumatic memories, (2) organizing a coherent narrative of the trauma, and (3) modifying core negative beliefs associated with the trauma, namely, that the world is dangerous or the self is bad and incompetent. Cognitive restructuring focuses specifically on negative beliefs. Eye Movement Desensitization and Reprocessing (EMDR) also involves bringing traumatic images to mind and altering negative beliefs about the trauma. These approaches have been systematically researched and shown to be effective for many persons. Psychodynamic therapy has been less well researched but is widely employed in treating complex trauma-related disorders. In general, many different approaches are equally effective; the challenge is to find the approach that best fits your individual needs and preferences. Whatever the specific technique, the crucial elements are: bringing the memories to mind, talking about them in a trusting relationship, and developing the capacities for containment that support this process. This approach promotes mentalizing, which, in turn, promotes resilience by enhancing emotion regulation and secure attachments.

Group therapy provides an opportunity not just for helpful feedback and supportive relationships but also for the experience of universality—recognizing that others have related experiences and you are not alone. Family therapy can help with relationship conflicts as well as providing education and support to other family members. Medication can be employed to help with symptoms and emotion regulation. Antidepressants (e.g., SSRI’s like Prozac and Zoloft) are employed in the treatment of PTSD as well as depression. Anti-anxiety agents, mood stabilizers, antipsychotic medications, and medication to help with sleeping on a short-term basis also may be employed.

14. Hope

We’re accustomed to thinking of traumatized persons as survivors rather than victims. Yet mere surviving is not enough: we must aspire to thrive. Even with the best of treatments, it is not possible to be certain of preventing recurrence of illness or suffering. Thus we might think in terms of thriving in the context of illness and suffering, while trying to minimize both.

Since Aristotle, philosophers have strived to understand the basis of flourishing. Psychologists have identified three main ingredients of flourishing: intimacy (close caring relationships), generativity (investment in future generations, e.g., through teaching or creating products of lasting benefit) and spirituality (transcending the self, e.g., through love and reverence for something greater than the self). Only 20% of the population is flourishing; at the other end of the spectrum, about 20% are languishing—not psychiatrically ill, but leading lives lacking vital engagement in intimacy, generativity, and spirituality.

Coping with trauma requires hope. Connecting hope with achieving goals, psychologist, Rick Snyder, identified two key ingredients: (1) a feeling of agency and (2) pathways or plans for action. He dubbed these “willpower” and “waypower.” Optimism and hope are associated with flourishing, whereas depression tends to undermine hope. Persons who are feeling utterly hopeless may need to borrow hope from others who can hold out hope for them.

On a more existential level, the need for hope presupposes a tragic situation and extreme suffering. Hope is an existential stance: it does not lie in the facts of reality but the meaning we ascribe to reality. Maintaining hope is precious and difficult; that’s why hope is considered a virtue.

Evildoing inflicts profound trauma and poses one of the greatest challenges to maintaining hope. Philosopher Claudia Card defines evil as foreseeable intolerable harms produced by culpable wrongdoing. Evil deprives persons of basics needed to make life tolerable (e.g., emotional ties with other persons, freedom to make choices, and freedom from prolonged pain and fear). Diabolical evil corrupts traumatized persons by drawing them into evildoing. Most evil is not perpetrated by evil persons (e.g., sadists) but rather through indifference and negligence—failure to mentalize. Coping with trauma is making sense of evil, a problem that has preoccupied theologians and philosophers, as well as trauma sufferers—for ages.

Three factors are crucial for hope: finding meaning, developing a sense of benevolence in the world, and cultivating a feeling of self-worth. Benevolence is central. Menninger psychologist Paul Pruyser believed that hoping is based on the belief that there is some benevolent disposition toward oneself somewhere in the universe. One may find hope in a belief in God, in nature, or in other persons. Keep in mind that “somewhere in the universe” includes inside yourself. A benevolent disposition toward oneself from within oneself can play an important role in sustaining hope. This benevolent disposition would go hand in hand with secure attachment relationships.

For Further Reading

Allen, J. G. (2001). Traumatic relationships and serious mental disorders. Chichester, UK: John Wiley & Sons.

Allen JG: (2003). Mentalizing. Bulletin of the Menninger Clinic, 67, 87-108

Allen, J. G. (2005). Coping with trauma: Hope through understanding (Second Edition). Washington, DC: American Psychiatric Publishing.

Allen, J.G. (forthcoming). Coping with depression. American Psychiatric Publishing.

Allen JG, Bleiberg E, Haslam-Hopwood GTG (2003). Mentalizing as a compass for treatment. (White Paper). Houston, TX, The Menninger Clinic.

Allen, J.G., Munich, R.L., & Rogan, A. (2004). Agency in illness and recovery. (White Paper). Houston, TX, The Menninger Clinic.

Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York: Basic Books.

Card C (2002). The atrocity paradigm: A theory of evil. New York, Oxford University Press.

Fahrion SL, Norris PA (1990). Self-regulation of anxiety. Bulletin of the Menninger Clinic, 54, 217-231

Foa EB, Rothbaum BO (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York, Guilford, 1998

Fonagy P, Gergely G, Jurist EL, & Target, M. (2002). Affect regulation, mentalization, and the development of the self. New York, Other Press, 2002

Groopman, J. (2004). The anatomy of hope: How people prevail in the face of illness. New York: Random House.

Keyes CL, Haidt J. (Eds.) (2003). Flourishing: Positive psychology and the life well-lived. Washington, DC, American Psychological Association.

Lewis, L., Kelly, K. A., & Allen, J. G. (2004). Restoring hope and trust: An illustrated guide to mastering trauma. Baltimore, MD: Sidran Institute Press.

McEwen, B. S. (2002). The end of stress as we know it. Washington, DC: Joseph Henry Press.

Menninger KA (1987). Hope. Bulletin of the Menninger Clinic, 51, 447-462

Pruyser, P. W. (1987). Maintaining hope in adversity. Bulletin of the Menninger Clinic, 51, 463-474

Resick PA, & Schnicke MK (1993). Cognitive processing therapy for rape victims: A treatment manual. London: Sage.

Shapiro F (1995). Eye Movement Desensitization and Reprocessing: Basic principles, protocols, and procedures. New York: Guilford.

Snyder, C.R. (1994). The psychology of hope: You can get there from here. New York: Free Press.

Wagner AW, Linehan MM: Dissociative behavior, in Cognitive-behavioral therapies for trauma. Edited by Follette VM, Ruzek JI, Abueg FR. New York, Guilford, 1998, pp 191-225