trauma, Uncategorized

Trauma as a Disorder: a fundamental error

The word trauma is now bandied around as though it is the next great solution to the mental health crisis we are facing in western society. There seems to be this idea that trauma is that the basis of all mental health problems, that it is our response to intolerable circumstances that produce our distress. Now to some extent that may well be true and certainly people develop distress in response to adverse circumstances. They also develop mental distress in response to environments that are toxic. These environments can take many forms including workplace, home, social, war, famine, and so on. Human beings are incredibly successful at making life as difficult as possible for other human beings in order to further their own selfish ends. Human beings are also incredibly good at making the best of difficult circumstances, but more of that later.

In the last 50 years or so psychiatrist and psychologists have explored many aspects of diagnoses such as post traumatic stress disorder and adjustment disorder but, in my opinion they have started from the wrong premise. Many people are now observing that a person’s reaction to trauma is a normal natural bodily response and what the medical profession consider to be symptoms (see my lecture at (https://stream.liv.ac.uk/a9r9u78k ) are the body’s natural and normal response to threat. These are not disorders, attempting to treat these natural body responses as symptoms, with medications is akin to treating a fully functional liver to the response it produces to a toxin such as alcohol or some more dangerous poison. The word disorder is creating the wrong professional response to our reactions to trauma. There is a real attempt by the professional to “fix” the person. First of all, as I observed above most trauma reactions are normal and while distressing are related to the paradox that is being a Homo sapiens sapiens.

I have explained my view of this paradox in a metaphor called “the horse and rider”. That metaphor goes something like this:
Antonio Damasio in his book “Descartes’ Error” describes very clearly and lucidly the unfortunate case of Phineas Gage, who suffered a very serious brain injury when a 3 ½ foot long, 1/2 inch diameter steel bar was explosively pushed through his left cheekbone piercing the base of the skull and exiting through the top of his head. The crucial thing about Gage’s story for the therapist is not the physical injury, but the profound change in personality and behaviour that took place following the insult to his brain. Gage changed from a highly competent railway engineer, making complex and highly responsible decisions on a daily basis to a boorish ill tempered, ill-mannered man who made consistently bad decisions for the rest of his life. Damasio makes careful and considered analysis of the medical notes provided by Harlow, the physician who tended to him, and the subsequent knowledge of Gage’s life story and makes the observation that Gage had become, “a child in his intellectual capacity and manifestations, he has the animal passions of a strongman… The strongest admonitions from Harlow himself failed to return our survivor to good behaviour”.

There can be little clearer description of the disconnection between a well formed intellect and a powerful emotional basis. Gage’s most unfortunate accident and miserable subsequent life gives us a clue to the power and importance of the bond between the prefrontal cortex, the limbic system and primitive brain, a bond that I describe in terms of a horse and a rider. It is this bond that seems to me be helpful for understanding how and why human beings behave the way they do.

Jonathan Haidt provided me with the idea of the rider and horse from his book, “the righteous mind: why good people are divided by politics and religion”. He states quite explicitly that he “chose an elephant rather than a horse because elephants are so much bigger – and smarter – than horses.” In my opinion this part of the human brain has not developed to be smarter, but merely to be more successful in survival. It is the development of the rider (prefrontal cortex, PFC) that created smartness, though as we see the world over, having a prefrontal cortex does not necessarily make us wise!

Now while I can understand his reasoning about the elephant being bigger and smarter, it is more difficult for people to associate themselves with an elephant and understand what it might be like to ride one. Nor is the elephant renowned for its skittishness and ability to be spooked by the smallest things. I prefer the horse as it is a very threatminded creature that spooks easily, lives in the here and now and reacts quickly when threatened with anger or fear and these reactions are also characteristic of human beings in danger or under stress.
He goes on to say,
“automatic processes run the human mind, just as they have been running animal minds for 500 million years, so they’re very good at what they do, like software that has been improved through thousands of product cycles. When human beings evolved the capacity for language and reasoning at some point in the last million years, the brain did not rewire itself to hand over the reins to a new and experienced charioteer. Rather, the rider (language-based reasoning) evolved because it did something useful for the elephant.
The rider can do several useful things. It can see further into the future (because we can examine alternative scenarios in our heads) and therefore it can help the elephant make better decisions in the present. It can, learn new skills and master new technologies, which can be deployed to help the elephant reach its goals and sidestep disasters. And, most important, the rider acts as a spokesman for the elephant, even though it doesn’t necessarily know what the elephant is really thinking…. Once human beings developed language and began to use it to gossip about each other, became extremely valuable for elephants to carry around on their backs a full-time public relations firm.”

Haidt also makes another very important point when he said that he stopped thinking about emotion versus cognition and started thinking about intuition versus reasoning. To me, his allusion to intuition is a reference to what most people might call “gut feeling”. An automatic emotional response driven by millions of years of successful evolution that enables the creature experiencing it to have a better chance of survival.

The horse and the rider metaphor is important as it recognises those times when people are struggling with anxiety and depression. Let me explain: the people I work with (mostly trauma) often complain of not feeling like themselves anymore. Questions like, “why am I like this?” or statements like, “I don’t feel in control of myself any more” are frequent, confusion about not being “me” anymore is often expressed.

I provide the horse and rider analogy in these sort of terms:
Do you remember a time before all this began when you were well? What were you like? Sometimes the person is able to describe themselves, at times when they were feeling competent and together, feeling comfortable inside their own skin, knowing who they are and being able to behave in ways that makes sense to them. Sometimes I have to encourage them to describe how they were with prompts and detailed questions about what their life was like before they started to struggle with their misery. Then I describe the horse as emotional, physically powerful, threatminded, spooking at the smallest things, scared or angry, wanting to hide away from “danger” and generally avoidant. Many people recognise themselves but say that it is not them and that they don’t understand why they are now like this.

I then describe the rider as the rational, logical and pragmatic person who is sat on the back of the horse. When the person is well and enjoying life the horse and rider work well together, the join between them is seamless and both are happy and comfortable with their role in the person’s life. Indeed, together as horse and rider they could win the Grand National (or perhaps that should be the “Grand Notional!”).

However, when the person becomes stressed, depressed, traumatised, bullied, suffers loss or some other setback in life the control tends to move from a balanced point between the horse and rider to a point where the horse is slightly more dominant and thus the characteristics of the horse begin to take over and the person becomes more avoidant in many aspects of their life. They may feel reluctant and anxious about going to work, seeing friends, spending time with intimates, the horse is driving a loss of confidence in the person’s abilities simply through its desire to avoid situations that may involve risk (no matter how small) of any kind. The rider begins to feel a sense of loss of control as this reluctance to engage is experienced. The immediate consequence of this is a sense of feeling out of control and the rider tries to grip the horse more tightly, which as every horse rider knows, makes the horse go faster, creating a vicious circle.

It is difficult to know which comes first, the horse taking more control to avoid the fear or the rider feeling out of control and losing confidence. Either way the result is that the horse transmits its fear to the rider and the rider transmits their loss of confidence in themselves to the horse creating a feedback loop in which the rider is clinging to the horse tighter and tighter making the horse go faster and faster (panic attacks).

Like most ways of helping ourselves to manage our psychological processes, the answer is simple but not easy. Relaxing on the back of a runaway horse would not be easy, trying to let go and allow yourself to be overwhelmed by your anxiety is not easy either but very necessary for a change of behaviour.

Fortunately, there are another ways of taking control back from the horse; by the use of reason and also by taking control through breathing. The rider is a very new phenomenon in terms of evolution. The rider only appeared a few hundred thousand years ago but in that short period of time since then it has transformed its environment, from one of almost constant physical threat to a rather benign environment in which the vast majority of threats are intellectual and not physical. Unfortunately, the horse continues to respond to any threat and can only respond in one way which is a profoundly physical response arousal and preparation to run or fight.

It is very simple, but not easy, to change what we think to something that we desire, what is wanted, away from paying attention to that which is not wanted. We are threat-minded creatures we evolved to notice threat, for if we failed to notice threat it was more than possible, in prehistoric times, that we would die or be seriously injured, which amounted to the same thing. In today’s world threats are largely intellectual and they are unlikely to kill us. For example, losing a job or a relationship may be devastating emotionally and intellectually but it is not life-threatening. Yet even the idea of these things occurring produces significant levels of anxiety and stress and this is because the horse is reacting to what has been imagined, something that may or may not occur in the future. However, the horse, our primitive self, cannot take the chance that this is not real and thus responds in the only way it knows how through physical arousal in preparation for running or fighting.

It is our imagination that does so much damage and produces so many stress responses. Therefore, the logical and rational way to change this is to change the way we think and in order to do that we have to overcome millions of years of evolution that has produced very sophisticated survival machine upon which we self-aware creatures are now precariously sat. It is really important to begin to think about what is wanted and move towards the safety of a preferred future rather than try to run away from a perceived danger.

Zen has a famous statement that illustrates this clearly, “the difference between misery and happiness depends on what we pay attention to”.

This is where I part company with much of the approach being used in psychotherapy and psychology at the present time. I have seen so many papers, text books and lectures that suggest that going over and over the traumatic event – reliving, re-experiencing or exposure – is the treatment of choice. Indeed I had to sit through an excruciating set of videos from the Oxford trauma centre at one conference that had a poor woman sobbing because she was being exposed time after time to a video of wiper blades swishing on a windscreen as though this would help her with the road traffic collision she was involved in when it was raining!

Her poor horse was suffering the memory of the event without any adaptation and the only way the woman made a recovery was through her horse being numbed to the event. What makes this kind of therapy even more abusive is that that is the only thing she is now numbed to. If she were to have another collision with some other trigger that would then need some attention for desensitisation. The original intervention would have no impact on a new trauma at all. I and my colleagues work in a very different way.

“Trauma” is a small word for a huge topic and the example given above is an example of how even a simple trauma can be managed badly. Today the appetite for treating trauma from those in the psychology and psychotherapy professions has unleashed a whole new lexicon of words and phrases for all to conjure with and wonder what the meaning of there are.

Today there is a plethora of three letter acronyms being thrown into the trauma mix such as ACEs, (adverse childhood events), CSA (childhood sexual abuse). Professionals seem to delight in writing about these with detailed descriptions as though they have great knowledge about what they mean and more importantly what they mean to others.

When I first started working with people who were struggling with some kind of mental distress as a result of trauma a quarter of a century ago, like those professionals, I thought that I had the world by the tail as well and the perceived wisdom of the time was all I needed to be able to help people.
No doubt it was useful but it quickly became apparent that most of the time I was woefully ignorant of what the experiences of others really meant to them.

I have my own traumatic experiences from a young age and they no doubt inform my perception of the world of trauma is like, but could I empathise with another’s experience, no, definitely not.

What my experience of working with thousands of people over the years has taught me is quite the reverse. My own experiences are different to those of others, my understanding of them is different to others, my way of dealing with them is different to others. I have learned, sometimes painfully, that I cannot understand what another person’s experience means to them in any real or intimate sense. I am clear about what their experience means to me but that is no guarantee that what I understand about what has happened to them is the same as what they experienced and what they understand it means to them.

Words are no substitute for experience and words limit understanding by creating meaning – their particular meaning for each one of us. Words certainly do not reflect experience. No matter hard we try any attempt to describe experience using language it is limited by the experiences of those involved in the verbal or written exchange. Wittgenstein makes this very clear by indicating in his book Tractatus, “The book will … draw a limit to thinking, or rather—not to thinking, but to the expression of thoughts …. The limit can … only be drawn in language and what lies on the other side of the limit will be simply nonsense”. https://plato.stanford.edu/entries/wittgenstein/#TracLogiPhil

In my opinion words and language can only provide “a shadow on the wall” when used to describe the experience of one to another. Therefore, it becomes imperative that we find a way to help people who have suffered trauma that does not involve placing our beliefs, ideas or models upon their experience. In order to do this I have learned, painfully at times, that I must defer to the wisdom of Socrates, the idol of the Cognitive Behavioural Therapist, who famously said, “I seem, then, in just this little thing to be wiser than this man at any rate, that what I do not know I do not think I know either.” https://en.m.wikipedia.org/wiki/I_know_that_I_know_nothing

This statement sums up my position neatly as I am a little wiser than than the person who thinks that they know something about another as I have now reached a position where I know that I can never know anything very much about the people with whom I have conversations about their experiences.

It is their knowledge of themselves that I and other like minded people who work in psychology and psychiatry mine for the nuggets of gold that is their ability to survive and cope with everything that has been thrown at them by their being in the world.

For I know that they have survived and coped simply because they are sat with me, whether in their home, my office, a café, or some other place where they chose to meet with me. My understanding of their pain is limited to what I can take from their words and body language, but I cannot assume that the images they paint by their communications in my imagination (following my interpretation) have any relation to what they experienced and how they understand what happened to them. All I can do is reflect back their words and ask helpful questions that may help them to gain insight into their own behaviours and thoughts. They are the ones who make the changes to their thinking, imagery and behaviours, not me. My job is to help them discover their own way through their maze of possibilities by providing space and opportunity to explore their own unique way of coming to terms with what happened to them in the past.

I am well known for using metaphor and analogy as attempts to express what I mean and I am going to offer one here to make a poor attempt at what I mean.

We all get injured through our lives, whether it is physical or mental injuries. When we are physically injured the wound heals naturally, though we have a much better chance of survival through the intersession of a doctor, nurse or paramedic. We can be given antibiotics to prevent infection from a wound, we can have broken bones reset, we can have medication that addresses deficits, for example insulin for diabetes but by and large our bodies do the healing from physical trauma by themselves. We quickly forget the pain and distress we experienced from an event that is understandable and explainable. (Something here about medicine and physical injury.)

However, mental trauma seems to be much more complicated and apparently not amenable to recovery these days without the intervention of an expert. That these events now stand out in our lives as worthy of attention by medical and psychological professionals is a tribute to how society and its lawmakers have contributed to making this aspect of the environment much safer. However, it does not mean that these behavioural responses by people who have experienced unusual and traumatic events are now the remit of the medical profession in the form of a disorder. These responses remain a normal and when thought about carefully, a logical response to an unpleasant experience.

Allen Frances makes the observation:
“Our brains and our social structures are adapted to deal with the toughest of circumstances-we are fully capable of finding solutions to most of life’s troubles without medical meddling, which often muddles the situation and makes it worse. As we drift evermore toward the wholesale medicalisation of normality, we lose touch with our strong self healing capacities-forgetting that most problems are not sickness…” (Frances 2013)

Since the “discovery”of ACEs and CSAs there has been a huge growth in the industry that appears to be now necessary to resolve them. Yet my argument would be that the industry is becoming self sustaining through a range of unhelpful interventions that, on occasion, are more likely to prolong distress than relieve it.

First of all trauma is, by definition, in the past. We cannot “treat” mental trauma in the present in the same way as we can treat a wound. Mental trauma relies upon memory for our experience of it and each time we remember it we experience it in a slightly different way. Memory is far from perfect, despite flashbacks being an apparent “video” of the event. But we know from so much research that traumatic memory is frequently incomplete and fragmented. Current theory for recovery suggests that we should “work through” what happened to us until we have come to terms with it. I have a serious set of questions for those professionals who subscribe to this approach:

1) how do you know the memory is accurate, that what you are working on bears any relationship to what happened, particularly if the event occurred a long time ago?

2) how do you know what is being worked on is key to any resolution?

3) how will you know the person has come to terms with whatever happened to them?

We cannot change the past no matter what we do with regard to the memory – no matter what discussions we have about the past we cannot resolve it, we can only come to terms with it. The key to working through trauma does not lie in the past, it lies in the present and future. Attitude and behaviour change does not take place as a result of change in the past but by changing our relationship with it. That change of relationship takes place in the present through recognition of how we coped with what happened to us, how we brought skills to the trauma that enabled us to survive – by noticing our own abilities and skills that brought us through that event or period in our lives. It does not depend on “justice”, “getting even” or even a “trust and reconciliation” conversation with another who was involved in our trauma.

Often, we have no contact with the event or people involved and if we do have contact, we have no way of changing their minds or what happened. Resolution comes through our recognition of our own qualities, regaining trust in ourselves, forgiving ourselves and letting go of an awful time in our lives. This change can only take place in the present and through that change impact on and alter our future to one closer to that which we desire.

Wishing that our past had been different or wishing we had behaved in a different way that would have changed the situation that produced the trauma places failure firmly within ourselves for those events. This produces guilt, fear and an inability to change. When we begin to notice how we survived whatever happened to us we can regain our autonomy, we can begin to celebrate our skills and qualities, we can begin to trust ourselves again and feel safer in our relationships with the world outside our heads.

The key is to begin to recognise those qualities that helped us to survive what ever happened to us, celebrate those qualities and use them to create the story of our survival rather than the story of our helplessness.

Eleanor Longden famously quotes, “don’t ask what is wrong with me, ask what happened to me”. While this is significantly more helpful and takes us in the right direction the real question should be, “So that’s what happened to you, what would you like to happen next?

Interventions in the form of questions that offer the potential for change; questions that help a person to think about how they would like to be; questions that help them to imagine and then take small steps towards a future that is desired, questions full of possibility for change, for growth and for many future that has never even been imagined let alone considered as possible.

The irony of this is that in order for people to develop the kind of futures they want we also have to create the kind of environments in which that could happen. Environments in which opportunity for all is possible and not dependent upon the expertise of others, whether they be therapists, social workers or politicians is upon each individual being able to access security and the knowledge of a safer future, so they don’t have to spend all their time managing threats, perceived or real in order to survive. Blaming the individual what is a natural bodily response and trying to medicate or therapy it away as though it is some kind of disorder fits beautifully into Einstein’s definition of madness, “doing the same thing over and over again and expecting a different result”.

I was sent a link the other day of a public health service idea of how adverse childhood events and child sexual abuse should be managed (https://www.google.co.uk/amp/s/acestoohigh.com/2017/05/01/england-and-wales-produce-new-animation-about-aces-resilience/amp/ ). It appalled me so much due to its negativity that I actually responded to it on Twitter. For all bar about three seconds of the animation (it was five minutes long) it systematically illustrated the assumptions of so many professionals that people who have suffered from ACEs and child sexual abuse will go on to repeat the cycle with their children and so on. As someone who suffered many adverse childhood events, the video incensed me and I am quite sure that there are thousands of people out there who also suffered and yet have gone on to achieve great things and have not abused their own children in any way. What made the video even worse was the profound assumption that for the most part it would be the “experts” who would put this defect right in each person and each child that had experienced adverse events.

It is time that the “experts” the professionals recognise the qualities and the abilities of the people that they work with and work with those rather than attempting to impose yet another model or protocol that has been designed in an academic institution based on research carried out using biased (WEIRD) samples gathered from the subjects available to the researchers. Research that is then further biased by the need for publication, whether for personal vanity for the demands of the academic institution.

It is time that the professions of psychiatry, psychology and psychotherapy took a good look at themselves and asked a fundamental question, “Who are the experts in the people we are working with, is it us or is it them?” Only this time we should reflect upon our answer.

References
Frances, A. (2013) Saving Normal, Harper Collins, London.
Haidt, Jonathan. (2013) The Righteous Mind: Why Good People are Divided by Politics and Religion. Penguin Books Ltd. Kindle Edition.

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