December 28, 2018
The Trauma Response:
Re-Thinking Diagnosis When Trauma is Present
Survivors of trauma often experience symptoms related to their trauma that are parallel to many of the diagnostic criteria of other DSM disorders, including what are often labeled “Personality Disorders”. What often happens though is these symptoms get labeled as the primary diagnosis and we end up trying to cure the flu by ridding ourselves of a fever. This can lead to mediocre improvement and more labels, such as “client resistance” or “treatment resistant depression/ anxiety/ etc…” However, the depression is not resistant to treatment if it is the wrong treatment. A car is not resistant to repair if it is not being repaired in the right way.
If we can start looking at symptomatic behavior as a trauma response we will be able to use this information to guide treatment and get better treatment outcomes. I have seen and experienced this first hand. Trauma is an injury to the Mind, Body, and Brain and as a result we are going to see psychological, biological, social, and spiritual impacts that won’t respond to traditional therapeutic interventions (e.g. talk therapy or psychiatric medication). Getting informed on the different types of trauma and understanding symptoms from a framework of a trauma response (when it is part of their developmental history) will bring more effective results and less shame for the individual.
What is Trauma?
Asking people if they have trauma is not enough. I often find most people don’t even know they have trauma, which is understandable; the nature of trauma makes us want to repel from it, forget it, and dissociate from it. Additionally, trauma survivors usually have taken to minimizing their pain to help them survive. They don’t always identify their experiences as traumatic; or if they do they always think someone else has had it worse. I vividly remember one session where a client told me about some of the worst trauma I had ever heard and they quickly followed it up with “but I don’t know why I’m complaining, other people have it worse than me.”
Acknowledging pain was a weakness and served them no good. Also, what happened is not always a good judge of assessing if it’s trauma. Trauma is more about our perception of what happened and the imprint it leaves. Some people get in car accidents and are fine, some can’t drive. Generally speaking, when there is a sense of loss of control, powerlessness, an inability to escape, and a sense we won’t survive, we will have a trauma response.
Additionally, there is a theme of wounding that comes with trauma; “Archetypal Wounding” as Dr. Mario Martinez calls it. The primary wounds being Abandonment (actual or the feeling of it), Betrayal (feeling injured or tricked), and Shame (feeling rejected, humiliated, and pathetic). If these experiences can’t be “shaken off” then the trauma is unresolved, and the world is experienced with a different nervous system— as if we’re navigating the world trying to run from the bear we escaped 15 years ago. If our nervous system doesn’t think we’re safe it’s going to mobilize biological and psychological defenses to protect us.
When most people hear the word trauma they think PTSD, war, murder, etc…which is trauma, but only one category of trauma. I call this “Shock” trauma. It is overt, often intentional, and it literally shocks us. War, near death experiences, sexual abuse, physical abuse, emotional abuse, neglect, witnessing abuse, lack of basic needs like food and shelter, and even complicated early childhood medical complications are examples of this.
In a study by the National Institute of Health, they found that out of 587 adults with substance abuse or addiction, 70% had a history of shock trauma. Most qualified for PTSD. Unresolved Shock trauma can be intrusive and debilitating, often haunting people as if it was recent many many years after it has passed.
The other category I see frequently is Relational Trauma. Relational trauma is trickier. It’s subtle, covert, and often unintentional. It is rooted in our early attachment experiences with our parents. Relational trauma is where we feel others can’t help us, we feel misunderstood, out of place, and like we don’t belong in the world. Ideally we want to feel understood, accepted, validated, honored, and celebrated. We first want to feel this in the context of our caregivers, then our peers, and that sets the stage for our intimate relationships.
Healthy attachment is the foundation to our resilience and ability to navigate Shock trauma (every person I see with Shock trauma has Relational trauma). While with Shock trauma it is easy to see how it impacts our nervous system, it is important to know Relational trauma does so as well. We are one of the few mammals born completely helpless and we rely on our caregivers to survive in the world. If something threatens our relationship with them (not feeling good enough, smart enough, pretty enough, athletic enough, tough enough, etc…) our body interprets it as a threat to our survival similarly as an event that is overtly painful. Both Shock and Relational trauma deeply embed in us negative ways of seeing ourselves and the world; this is referred to as our Internal Working Model. If this is disrupted it can leave long lasting imprints.
Unresolved trauma (Shock or Relational) can be very injuring at a biological, psychological, and social level. The psychological imprints from trauma result in lingering negative beliefs (I’m not good enough, I’m not safe, I’m damaged etc…) and the biological imprints are a nervous system that continues to think it’s not safe so it stays fluctuating between states of Fight, Flight, and Freeze. These responses to trauma are often what get labeled as diagnoses.
If our bodies are stuck in a state of Fight/ Flight we will see symptoms that mirror disorders such as ADHD, ODD, Anxiety, Intermittent Explosive Disorder, and Panic disorders. If we are stuck on a state of Freeze/ Collapse/ Despair we see symptoms that mirror Depression, Dissociation, Alexithymia, and Bipolar. Since our nervous system is woven into the fabric of our bodies and is connected to all our organs, if this response persists over years we start to see somatic issues. Gastrointestinal issues, autoimmune disorders, chronic pain disorders, chronic migraines, and much more (refer to the ACES study for more on this) are common issues for people with prolonged and unresolved trauma.
Unfortunately, these “symptoms” start to become the main focus of treatment rather than the source of them: trauma. Further complicating this, talk therapy does not take the right approach to resolve these issues. Don’t get me wrong, talk therapy is useful and I still do lots of it. It can help a great deal but it does not resolve trauma, especially at a physiological level. It is not talk therapy’s fault; it has more to do with how the brain processes trauma.
Bottom-Up vs. Top Down
The brain is always scanning for danger and takes in sensory information and immediately sends a signal to the body via the Vagus nerve creating a Sensation (tightness). This sensation sends a signal to the brain triggering an Emotion (fear). This triggers a Thought (I’m going to die) and this thought triggers a Behavior (Fight/ Flee/ Freeze). This is called a “bottom-up” response. Talk therapy tries to take a “top-down” approach to resolving this; change your thoughts and behavior. While this helps with tools and stabilization it does not go deep enough.
To effectively resolve the trauma imprints (not just improve symptoms) treatment needs to include bottom-up body-based approaches such as The Comprehensive Resource Model (my personal favorite), EMDR, Somatic Experiencing, Yoga, and Brainspotting to name a few. When the right treatment is applied I see rapid changes at a deep level, releasing deeply rooted negative cognitions and bringing the body to a place of ease and rest. More often than not their “diagnosis” subsides as well. Sometimes resolving the trauma does help clarify if someone has actual bi-polar or depression but until the trauma is resolved effectively it becomes difficult to tell.
Implementing this framework and understanding the many shades of trauma, how the brain and body work together, how trauma impacts our Mind, Body, and Brain, and knowing what modalities are out there is crucial if we are going to reduce the suicide rates, decrease the prevalence of addiction, reduce mass shootings, and raise healthier children.
References & Suggested Reading:
Adverse Childhood Experiences Study: www.cdc.gov/violenceprevention/acestudy/about.html
Attachment in Psychotherapy: Wallin, David
The Body Keeps The Score: Kolk van der, Bessel
The Polyvagal Theory: Porges, Steven
Trauma and the Body: Ogden, Minton, & Pain
About the Author
Curtis Buzanski, LMFT, LAADC, is a licensed marriage and family therapist and advanced addiction counselor. He has worked in the substance abuse field since 1998, shortly after entering recovery himself, and the mental health field since 2009 when he began his Masters program at the University of San Francisco. He has a private practice in the Fair Oaks area where he primarily treats substance abuse, trauma, and other mental health issues. Utilizing EMDR and The Comprehensive Resource Model, Curtis has a special interest in treating Complex PTSD, Attachment Disorders, and Dissociative Disorders. In addition to his private practice, Curtis has taught graduate level courses in the Counseling Psychology program at The University of San Francisco and offers trainings to the community and consultation to programs and clinics.