In this post, I discuss principles around a difficult but common therapeutic situation. Many people live on the assumption that “nothing terrible could happen to me.” Trauma can crash through that denial with the knowledge that bad things can and do happen. This discussion is about lasting consequences.
A therapist writes: “My client is a trauma survivor who had inadequate support as a child, was physically bullied by an older brother, and, at 17, was sent to a program for troubled adolescents, which has since been shut down for sadistic practices. While there, he was made to feel powerless and denied access to parents or any other means of reporting his abuse. Ultimately he aged out of the system at 18. Now in his 30s, in a therapy focused on trauma, he complains that he can’t sleep and feels compelled to check doors and closets to make sure an intruder has not entered his home. On exploration, he feels 100% that he could absolutely not survive another assault, but is unable to be 100% certain of preventing that possibility. The lack of certainty leaves him in a constant state of fear and hypervigilance, which wakes him up after 2-3 hours of sleep. He has tried all kinds of self-soothing techniques and sleep medications without success.”
How irrational fears are not irrational
The therapist has done a good job of clarifying why this client is in a constant state of arousal. His emotional brain requires certainty where certainty is not possible. Let’s take a common example, fear of flying. We all know that the likelihood of a plane crash is very low, and that flying is statistically safer than traveling by car. And we know that missing out on air travel can exact a cost in quality of life. The key to this common fear is that the emotional mind, formed by evolution, is binary in its processing. Falling from the sky is unthinkable. It’s the same as our client’s feeling that one more assault would not be emotionally survivable. The client is demanding a level of certainty that, as his intellect knows, reality cannot provide. Life doesn’t negotiate. Therefore, it is a matter of logic that remaining fully vigilant 24/7 is a necessity, not an option.
The absolute psychic imperative
Let's look at three stages of cognitive development. From birth, the mind reacts to adverse events but, lacking the ability to represent them symbolically, cannot anticipate or predict what might happen. Somewhere around age two, with further brain maturation, mental concepts begin to become available in words or some other symbolic form. As in the examples above, processing is binary. On the level of symbolic thinking, bad things must not happen and the things one desires are a requirement. Simultaneously, pre-symbolic, "analog" processing is still present and there, the child's range of emotional expression tells us that good and bad, pain and pleasure do have degrees of intensity. The two systems of cognition coexist. What happens next is that associations between the two systems begin to form. The child begins to learn from experience that the unthinkable may not be so terrible. Presumably, connections are built that allow pre-symbolic experience to modulate symbolic absolutes.
An early example is disagreement with the primary caregiver. As I have often written, the resulting temper tantrum is where the learning takes place. Children ideally learn, incrementally, that disagreeing with Mom is not the absolute end of their loving relationship.
If we think of other adverse events, skinned knees, bumped heads, things lost, wishes not fulfilled, these begin as dreaded unknowns. The first impulse is denial, and when that fails, intense distress is likely. It is through experience, along with with understanding and support received from others, that the child learns, a bit at a time, that these things can be survived. If, for some reason, that learning has not taken place, then the default remains in place that certain experiences must never happen. And that is where the absolute psychic imperative collides with reality, especially where the likelihood of an adverse event is low but not zero.
In adults, this absolute logic as part of the black and white thinking that is characteristic of the non-conscious emotional mind. We can personify it as the thinking of an inner child. However we describe it, healthy development calls for the mind’s absolutes to be modified by the impact of experience. When binary thinking persists in adults, healing in therapy takes the same pathway as the learning of childhood. What makes this possible is the support and safety found in a context of human connection. Without a safe interpersonal context, learning is blocked and the mind remains in its original default world of absolutes.
Fortunately, unlike the client described here, many individuals have been able to internalize a robust sense of positive connection early in life. This may be the basis of much of what we call resilience. With such an internalized sense of "basic trust," learning that specific adverse events are survivable can take place spontaneously or with a minimum of outside support.
In the case of the therapist’s client, it appears that parental neglect may have interfered with that internalization as well as with learning that bad things can be survived. Adding to that, his adolescent trauma left him with a strong feeling that he could never tolerate another instance of being made to feel powerless. Interestingly, I queried the therapist and learned that his client had another characteristic. When a romantic relationship didn’t work out, he was unable to accept the fact and would cling to unrealistic hopes that somehow a dead relationship might be rekindled. It appears that, in a very different realm, the feeling of loss of control was not something he had had the luxury of learning to accept.
Implications for psychotherapy
What principles might be helpful in dealing with this kind of hypervigilance? What I have suggested so far, is that, in this situation, the key to reclaiming one’s life is getting to where the psychic imperative is no longer absolute. Only then, might it be conceivable to give reality back its prerogative to produce the dreaded experience. Once a bad event can be held in the mind as unlikely but survivable, then hypervigilance is no longer necessary and sleep might become a relief instead of being associated with unacceptable vulnerability. Let's consider other kinds of dread due to trauma that might undergo a similar transformation in therapy.
- Endless tears: One dread that trauma can leave behind is the sense that the grief is so great it can never be metabolized. The presence of an attuned therapist can help in this processing.
- Self defense inhibited: Peter Levine points to the effects of blocked bodily movement that can stall any emotional resolution of trauma and needs to be brought to light in the course of therapy. Only with completion of the defensive bodily movement can the trauma begin to be worked through.
- Unspeakable terror: Another dread can be facing emotions of extreme fear. The work is similar to that of endless tears. Building a sense of safe and reliable connection can lead to bringing emotions to consciousness where they can be transformed from absolute to relative.
- Unfinished anger: As described in TIFT #50, a common source of dread that can block progress is anger that has not had a chance to run its course. The wish for revenge or retribution can delay getting past anger, giving false hope that settling the score will bring peace. Therapists can facilitate the process by validating the anger and, when appropriate, supporting legal remedies while helping the client arrive at a point where retribution or revenge is no longer seen as the source of inner hope.
- Identification with the aggressor: A very common result of trauma is internalization of attitudes towards the self as exhibited by a perpetrator. This is generally the source of the low self-esteem and inappropriate guilt that often accompany trauma. For the adult, a result is often a mixture of inadequate self-care along with opposite attempts to assert one’s value. This dynamic can interfere with processing of emotion by making healthy feelings seem illegitimate along with unconscious sabotage of self-affirming behavior, including seeking effective therapy. Therapists can help identify attitudes that are inappropriate and adoption of a healthier narrative and values. They can also help clients adopt self-affirming and more positive patterns of behavior. These changes can begin to override the old, inappropriate patterns.
- Trauma bonds: This is an example of weakening of an absolute using the same mechanism as learning to accept an adverse event. Unfortunately what is learned is feeling safe when one should not. Trusting those who are not trustworthy can lead to bad choices that perpetuate abuse and further reinforce negative attitudes towards the self. Therapists need to be patient as the capacity to seek out healthy relationships can be slow to evolve.
Confidence that an adverse event could be survived
Perhaps the greatest source of stress in humans is needing to control things we can't control. In the process of healing the many facets of trauma the client needs to develop a sense of safety and confidence sufficient to tolerate the (hopefully remote) possibility of yet another adverse event. That means an openness to risk. As stated above, humans essentially can’t take emotional risks without a context of safe connection, either internalized, external, or both when external support reinforces a shaky internal sense of safety.
When a safe sense of connectedness is present, we call it many things: Resilience, basic trust, secure attachment, or simply mental health. Sadly, some form of trauma or neglect may be the most common reason why an internalized sense of safe connectedness cannot be taken for granted. That is why trauma treatment requires special attention to earning trust by managing expectations and safeguarding the therapeutic relationship, not to mention expecting and working with bouts of mistrust.
Jeffery Smith MD
PS: Don’t forget to submit your most challenging clinical situations. Clients are welcome to contribute as well. We all have stuck points and I’d love to discuss principles that may be relevant and helpful for yours. Of course, this does not constitute advice to be taken literally, as I am not in a position to do a proper evaluation. Any ideas presented here should be taken only as food for thought.