Trauma

The Boil-Down: Attachment can be viewed as the single most important factor in the development of human (or other mammalian) life. Were you fed nourishing, unspoiled, unpoisoned food when you needed it? Were you able to sleep safely and comfortably? Were you able to trust all adults in your space to watch over you, to tell you and show you that you had value, that you belonged, that you could learn capable skills to get things done? Were you shown strategies for delaying your own self-centered wants and impulses? Were you reassured that you were okay as a person after you made mistakes--but strongly encouraged to account for those mistakes? Were you protected from physical, sexual, and emotional harm? The benefits of safe, secure attachments to our people and our environment increase the chances that our brains will grow to a healthy, optimally-developed state. Interruptions and complications to healthy attachment qualify as psychological trauma. Trauma can be viewed as the single most prevalent and deleterious (and yet fully recoverable) type of adverse event in human development. Neglecting to grieve our traumatic attachments is connected to most mental or emotional problems, and many physical problems, in modern adulthood. But seriously, does trauma really have anything to do with conditions like depression or generalized anxiety disorder? Over 40,000 clinical hours into my career, I provide an informed answer below.

The Details: In the 1950s, John Bowlby developed his attachment theory, suggesting that the comfort and care of a secure emotional bond with a parent was key in the healthy development of a child. Bowlby was interested in factors contributing to separation anxiety in young children. In the 1970s, Mary Ainsworth expanded significantly on Bowlby's theory with her research observations. Bringing new groundbreaking insight into the effects of attachment on child behavior, Ainsworth established three of four observed attachment styles in humans: secure, anxious-ambivalent insecure, and avoidant insecure (disorganized insecure was added in 1986 by Main and Solomon).

Attachment theory has been widely criticized (Fitzgerald, 2020; Aaron, 2016 are only a couple of examples). Without assuming any expertise on attachment theory per se, I note two of the bigger criticisms: that attachment theorists assumed the child to be a "blank slate," with genes having nothing to do with the development of emotions and behavior; and that clinicians subscribing to attachment theory overemphasized the "crucible" of the therapeutic relationship as the main factor in being able to change (save?) a client, adjust attachment style, etc. (which places the therapeutic relationship on the previously described PVR triangle). Much like the theories endorsed by the critics from traditional psychology and psychiatry, attachment theory held errors of logic and scholarship that made it reductionistic; moreover, its assumptions were sometimes difficult to replicate in social science, which is bound to draw rejection from the "fraternity" in the field. But the pioneers of attachment theory were onto something that proved very effective in treating mental health conditions. A secure dyadic space, made evident in part by Porges' "coregulated state" between therapist and client, is a common factor in virtually all effective mental health therapies, according to well-established research (Brown, 2018).

In 2001, Colin Ross published his book titled The Trauma Model. This work asserted that psychological trauma was the basis for the vast majority of "mental illness" symptoms, and that resolving attachment grief leading to trauma was the key to significant recovery from these symptoms and the disorders they comprise. In the process of articulating the groundwork of his integrated theory, Ross drew on attachment theory and systems theory, also emphasizing that in order for genetics to impact mental illness, an environmental event is required to "turn on" the affecting gene or gene cluster. He also convincingly discredited one of the fundamental underpinnings of modern psychiatry, findings from the Finnish twin study. Supplanting other errors of logic and scholarship in the field, Ross also cited his own research (which now has been soundly replicated) establishing dissociative identity disorder (DID) as a valid, bonafide mental health disorder. His efforts, which include calling out psychiatrists for iatrogenesis against cormorbid patients (those diagnosable with multiple "Axis I" mental disorders, as many as ten diagnosable in common psychiatric inpatients, who tend to respond poorly to psychiatry's staple intervention of pharmacotherapy), have been apparent justification for his ideas being dismissed by psychiatric field leaders and their siccophants, and his reputation discredited. But the research and writings of Colin Ross confirm and expand upon my philosophical and professional thoughts of the past two decades.

Dr. Ross describes psychological trauma as the result of experiences a child has when attachment figures do things unhealthy to the child's safe brain development (commissive trauma) or fail to do things healthy to the child's safe brain development (ommissive trauma). Even when this psychological danger is not life-threatening, it creates the condition described by Stephen Porges as "immobilization with fear" (because the child must remain attached to thrive, and therefore must not/cannot fight or flee, so she "freezes"), and it occasions a specific kind of cognitive shift within the victim. Referred to by Ross as the locus of control shift, this involuntary adjustment in cognition makes it possible for the child not to fight or flee from the attachment figure traumatizing her, by whitewashing the attachment figure and placing responsibility for the harm within the child. "This was my fault." Or "this happened to me because I am a bad girl; I can try harder to be a good girl, and this sort of thing won't happen to me." In the process, the child's powerlessness is exchanged for blame. She now feels as though there is something she can do about the attachment figure "not loving me right," but the transaction infects her with a self-deprecating myth. Trauma can be severe, or it can be subtle, but the result leaves the victim carrying an irrational belief that feels entirely true, and struggling to belief rational, positive cognitions about herself.

When I started reading the work of authors like Colin Ross, Bessel van der Kolk, and Richard Kluft, I was already on a journey to emancipate my professional self from a field-imposed mold that did not fit my clinical observations. The journey also aimed to improve my knowledge and skills as a clinician, because I was tired and frustrated from clients chronically dropping out of therapy with debilitating, unresolved symptoms. As a Licensed Mental Health Practitioner, I was required to get supervision from doctors on all my cases and their diagnoses. Based on the implied but unidentified/unspoken stance of the biomedical model, these doctors sometimes condescendingly, sometimes compassionately urged me to understand that the key to helping mentally ill patients was properly questioning them about their symptoms and their family history of mental illness, so that these patients could be properly labeled using the Diagnostic and Statistical Manual of Mental Disorders (the DSM; in water-cooler lingo, the "psychiatrist's bible"). Doing so would logically lead to the most appropriate treatment for a given patient's mental illness (they were invariably referring to pharmacotherapy--psychotropic medications). Whatever the intent of this clubhouse advice from these doctors, it left me unhelpfully trapped in a room with desperate people who were suffering from anxiety, mood disorders, post-traumatic stress, and debilitating family conflict.

Several other ideological points and fraternal folkways were implied by these supervisors, who occasionally were willing to show their "hole card" and more explicitly state their collective stance: a mental illness is an endogenous biological disease driven by a single gene that magically turns on a display of symptoms at some point in the mentally ill patient's life; the right medication is the only legitimate treatment for mental illness; oh by the way, many patients don't respond ideally to their medication, so additional medications often need to be added (in combinations that have never been systematically studied by the scientific community); when clients report a growing number of experiences which should be explored as possible side effects of the medications, it's customary to regard these as unavoidable fallout from an industry-accepted remedy, or mislabel them as simply more mental illness symptoms in a mentally ill patient whose condition is expected to decompensate as he ages; therapy or counseling is not a serious intervention for mental illness, and is to be reserved for the light or "worried-well" cases as a way to pad a psychiatrist's income and give lackeys like masters-prepared clinicians something to do; masters-prepared clinicians are not wise enough or well-trained enough to have a noteworthy impact on the lives of mental illness patients, but should be kept around to listen at length to the unpleasantries of the "mentally ill" experience, and to make sure patients are taking the medications their doctors so proficiently prescribed--especially if physician supervisors can skim a percentage of the counselors' income off the top. (Yep, that was one long sentence.)

One of the best things I ever did early in my career to make my practice effective for my clients was to be trained in Francine Shapiro's technical protocol Eye Movement Desensitization and Reprocessing (EMDR), which is rooted in her Adaptive Information Processing (AIP) theory. Not only did it provide consistent, enduring relief for cognitive turmoil, low self-concept, and emotional distress (and notable partial relief for the experience of physical pain), but Dr. Shapiro's place in the industry gave me hope and inspired me to think outside the psychiatric box. Her theory and logic were rejected, and her clinical method was ridiculed by the establishment. So she did the sound scientific trials which would require the boys at the country club to take serious notice of her work, and to declare her EMDR protocol as "probably efficacious"; they were only referring to PTSD at the time. I'll never forget going to hear a lecture by one of the great living cognitive trauma therapists; it made the good-ol'-boy politics really swim into focus for me when, after all of Dr. Shapiro's research was on the table and field leaders had begun to accept her work, this male guru pettily kept EMDR on a list of interventions which were not proven compared with cognitive-behavioral therapy (CBT)--his own pet intervention, with which I guess he perceived EMDR to be in competition. I have since clinically practiced both pure protocols for helping survivors of trauma. Both methods are useful, but EMDR has proven faster and more thorough, with a lower rate of attrition than CBT or its eventual offspring, trauma-focused cognitive-behavioral therapy (TF-CBT). Moments like the one during that lecture helped me realize that fraternal psychiatrists, psychologists, counselors and social workers would be too ensnared in groupthink and its ideology, errors of logic, and errors of scholarship to ever accept what I was discovering as an outpatient therapist.

As a young therapist with a "golden retriever" personality, I tried really hard to make my physician and psychologist supervisors pleased and proud by learning and applying their wisdom about mental disorders. I utilized their thinking about how to approach therapy patients, shelving my enthusiasm for biopsychosocial principles (you know, the ideas about the body and mind being reciprocally connected, with environment as worthy a factor in illness and wellness as genetics) because they rarely said a word about such principles. I worked energetically with my clients, then reported back to the supervisors, who encouraged me to keep doing "good" work even though the clients were not improving.

Then I encountered some attitudes and decisions the supervisors were exhibiting but not explaining (their biomedical model didn't explain this stuff either), along with some private discoveries about by bosses' own clinical skills. The attitudes and behavior were about certain difficult clients: if clients presented with unpleasant personality features, or reports of hearing voices, losing time, doing things without remembering, having alter ego states inside them, escaping their symptoms by using illegal chemicals, or having chronic pain paired with a request for relief via prescription, at best you were supposed to listen gently and sincerely deliver canned answers, but then you were supposed to talk badly about them during clinical supervision. The middle-ground: talk badly about them in the break room with clinicians who don't see your clients--after all, the clients signed required agency-wide authorizations permitting us to talk about cases.

The above examples are laced with iatrogenesis (clinical presence or technique that actually harms the clients we have promised to help), but some professionals did not stop there. It was difficult to tell if those physicians and other licensed clinicians were even aware of their own internal states as they reacted to client conditions they seemed not to understand, or seemed threatened by. I had some supervisors refuse to sign off on cases that had dissociative identity disorder as a diagnosis, even historically (it's not as though a patient's diagnostic history can be rewritten), or cases in which I planned to use EMDR as an intervention--years after it was widely accepted as "efficacious." In the lowest of situations, my supervisors and/or peers suggested the only way to handle certain difficult clients was to get them off the caseload as soon as possible...or they sat in-session with those clients and told them they were imagining the symptoms and should "just get over" them, or making the symptoms up for attention (this is vary rarely the case; while clients who confabulate symptoms as part of factitious disorder have a consistently estimated prevalence of one percent in the inpatient clinical population, my bosses and peers were reacting this way with sometimes between five and ten percent of their outpatient clients). A handful of morally bankrupt doctors and therapists in my geographic area, whom I never met and whose identities I don't know, sexually abused adult and youth clients who ended up in my care; the clients voluntarily disclosed this but were afraid to give names. (Studies consistently indicate that between six and fifteen percent of psychiatrists, psychologists and therapists sexually exploit their clients--most often clients diagnosed with depression, dissociative identity disorder and/or borderline personality disorder) (Moreno, 2012). It was as though a segment of mental health clinicians, detectably connected by an invisible web of caste system rules and prohibitions, were acting out the PVR triangle with mental health clients exhibiting symptoms that, if they acknowledged and treated, could get the clinicians kicked out of the club. Their group iatrogenesis was victimizing the very people who desperately needed their wisdom and compassion. (Once I began openly treating "borderline," psychotic and DID patients with real therapy, the same iatrogenesis club quietly ostracized me.)

These attitudes and behaviors were not explained by any paradigm of therapy; they were just accepted in clinician culture...irrational subcultural social structure resulting from fear and conformity. Groupthink. Examples of what not to do if I was going to be an ethical therapist. I knew by their collective example what not to do. But what was I to do to help clients get better? I examined client charts at these agencies, hoping to read detailed examples of what my supervisors and peers did on a regular basis to help clients recover; this information would be in the session progress notes. What the notes revealed astounded me. Most session progress notes written by my supervisors and peers contained zero evidence of any intervention! Were they just listening for an hour and then saying, "see ya next week"? When interventions were documented, they referenced techniques like "taking a deep breath," "counting to ten," "journaling," "positive affirmations," and "muscle tension/relaxation" (e.g. flexing your right forearm for ten seconds and then releasing). While these tools of intervention can be helpful, to call them a comprehensive course of recovery treatment would be like calling four ounces of orange juice "a complete breakfast." These clients were coming to see licensed professionals with advanced degrees--two to four years of graduate school--and this is what they got from their educated listeners on a good day. I had heard and sometimes seen the outcomes in the patients named in the charts. They were not healing or even experiencing significant symptom relief.

Seven years into this thirteen-year stint of being supervised by people who were doing virtually nothing pragmatically for their patients, and who were also expressing unhelpful or harmful attitudes toward difficult patients, I began to think outside the box. I could not ride out my career skating through hour after hour of therapy knowing that I wasn't helping my clients enough. When I approached mental health therapy the way I was being taught--with the idea that mental illnesses were not significantly recoverable conditions, and only psychotropic medications helped but they didn't help much and often came with insufferable side effects--people didn't get better.

Thanks to Francine Shapiro, I began cultivating an idea that had sat planted but unfertilized in the back of my mind: there must be another way to think about "mental illness," a way that would not resign people to a life of symptoms without much hope, a way that would not block their path to a comparatively full recovery. Constructivism, which I independently studied during graduate school, also catalyzed my thinking; it stated that there is no reality independent of the observer--your lens is going to profoundly influence what you end up seeing. This assertion invited me to join a person in their reality, to see, think about, and feel things the way my client was seeing, thinking about, and feeling things--instead of patronizing or placating, instead of silently doubting them or telling them they were wrong (even when they were describing delusions), instead of implying they were making up stories for escape or for attention. As I made this paradigmatic and pragmatic shift, something really encouraging happened; people from varying backgrounds with an assortment of disorders began to respond uniformly to treatment. When I began accepting clients' experiences as real, as genuine, as authentic, it validated their suffering and they began to get well. Really well.

In the process of rejecting the psychiatric establishment's mentality toward psychiatric patients as hysterically diseased with single-gene-driven and sometimes factitiously confabulated conditions, I expanded my options for believing in trauma as the driving force behind mental health conditions, and in the existence of more thoroughly effective interventions, seeking them, and learning them. Theorist's ideas are generally well-intended, but something about psychological theories (and perhaps theories in all disciplines) tends to make them a reductionistic final product. Psychodynamic theory, cognitive theory, social learning theory, behaviorism, and most others implied here but unnamed, seem to be launched, shared and practiced with unfortunate self-imposed limits. So I set out to develop a way of thinking about wellness and doing therapy which integrates effective concepts and methods from existing models to form a "supertherapy" (I've never considered a term like that until just now; I admit it sounds a bit sensational) of interwoven techniques producing healing emergent properties superior to when the techniques are used independently from their original, purist paradigms.

Integrated therapy is not to be confused with eclecticism, which draws upon various paradigms without conventions or rules dictating which paradigms to combine, or how to combine them. The phase-oriented trauma therapy I developed dictates which models and concepts to combine, which techniques to infuse, and when. Specifically, I have discovered that when a given (and usually effective) pure technique does not work with a particular client who is properly motivated, combining techniques into a hybridized tool which can be applied at the same point of intervention will suddenly work.

The conditions I treat--major depression, bipolar disorder, panic disorder, posttraumatic stress disorder, generalized anxiety disorder, agoraphobia and other phobias, dissociative identity disorder, sometimes schizophrenia or schizoaffective disorder, and unspecified lesser versions of all of these--are suffered by human beings who have a lot in common. They have dysregulated emotional states. They have troubling thoughts that they feel they can't stop thinking. (Oddly, psychiatry doesn't regard cognitions such as "I don't see the point in getting out of bed," "I can't take it anymore," or "what if my greatest fears come true?"--the cognitions of depression/PTSD, panic disorder, and generalized anxiety disorder--as "thought-disordered," but "the CIA is poisoning my oatmeal" qualifies. And by the way, it might not actually be the CIA, it might be a herbicide corporation.) They tend to rely on unhealthy escapes from suffering. They have social and family connections that harm them, triangulate them and fail to support them. And they almost invariably light up the boxes on any trauma screen checklist.

When I treated these human beings as hopelessly diseased by genetically-driven illnesses which might only modestly respond to the only respectable intervention--medications (except for those people who are just "making up" symptoms and stories of abuse; their sorry asses can just stop faking it and get a life any time they want, said the doctors), predictable outcomes happened. They all stayed "sick." After all, the definition of the practice of medicine is "slowing the progress of disease." But when I began treating mental health clients as wounded survivors capable of dramatic recovery from symptoms due to genuinely traumatic events, something wonderful happened. People began to stay engaged in their treatment long enough to unpack all their baggage and overcome their symptoms.

To this day, most of the time these clients graduate from therapy no longer meeting criteria for the conditions they came in with. Those on psychotropic medications often consult with their doctors and move forward on lower doses of fewer medications, or on no psychotropics at all. Imagine a person showing up at my office diagnosed with bipolar disorder and diagnosable with PTSD, somatization disorder, borderline personality disorder, and DID. Imagine that person persistently working on her trauma as often as twice a week for perhaps four years, and then discontinuing therapy with virtually no symptoms of a mood disorder, no symptoms of PTSD, no reaction to horrible memories, no longer losing time, not having unexplained physical symptoms or hearing dozens of voices in her head, but reaping the benefits of a half dozen career promotions, and finding a safe, supportive partner to marry.

Are there people out there suffering from disorders that seem to be driven solely by endogenous biological causes (genetics)? Yes. So many doctors and other professionals practice as though they believe the vast majority of their patients became "mentally ill" this way, and that trauma has little or nothing to do with "mental illness" symptoms, because 1) the biomedical model explains mental illness without mention of trauma; 2) their professional "fraternities," formal and informal, reinforce this thinking and punish ideas that threaten their omniscience or don't conform; and 3) these professionals do not thoroughly screen their patients and clients for trauma. In fact, when Dr. Vincent Felitti (known for co-developing the ACE Questionnaire about "adverse" traumatic childhood experiences) reviewed doctors' practices of interviewing their patients, a plurality of these physicians stated they were not screening their patients for these adverse experiences. Why? Because it was impolite to ask such questions! Causal research has since shown these questions as relevant to the well-being of even a general practitioner's patients, because the higher the ACE score, the more exponential the risk of myriad physical and mental/emotional conditions as people age.

If you suspect that this blog entry is overting doctors who treat psychiatric patients for years with untested polypharmacy practices (without making patients better); who misguide their patients and supervisees with errors of logic and scholarship; who overmedicate their patients with drug combinations never tested by research; and whose attitudes and behavior are harmful to their highly comorbid patients (SIX to FIFTEEN percent of the time sexually exploiting them)...you're absolutely right. But I am also painting a clear picture of so-called "mental illness" treatment and recovery based upon (as of this writing) twenty-seven years of clinical experience: when professionals regard psychiatric symptoms as trauma-driven, and join their clients in a reality based upon very real wounds, and then show them how to regulate themselves, let go of the pain of memories, and rejoin their world as survivors...then those clients recover.

What You Can Do: Trauma affects all human beings directly or indirectly. If you feel that trauma is not negatively impacting you, ask a trusted loved one and see if they agree. You likely have someone close to you who may be struggling with the aftereffects of trauma. Encourage them to reach out to a professional for help; it's best to seek out a well-reputed trauma therapist for the most efficient, thorough results. Don't be fooled by the overused industry buzz term "trauma-informed." Inquire about whether the therapist or clinic screens individuals for trauma history, and be willing to scrutinize whether they regard behavioral health symptoms as driven by trauma, and that resolving traumatic attachment grief (or generally desensitizing from traumatic events) is the key to recovery from most "mental illness" symptoms.

I am not a qualified expert in pharmacotherapy. My observations about the effectiveness of medications upon mental health conditions is based upon clinical experience (observation and client report) and my own consumption of scientific literature on the subject, but I am not a doctor. If you take prescribed medication that helps you with your behavioral health symptoms, good for you! If you're wondering whether medication would be right for you, ask a trusted doctor about it, AND read up on it. For side effects and long term effects, make sure you ask specific questions and do your homework by seeking information from trustworthy publications authored by reputable experts who are not abetted by the pharmaceutical industry

What can the reader do about these problems in the field of mental health? First of all, you can always report allegations of clinician misconduct to the state licensure board. Second, get a grasp of what counts as sound scientific/clinical research, and read up on the work of groundbreaking professionals in the field of psychological trauma, such as Francine Shapiro, Bessel van der Kolk, Colin Ross, Stephen Porges, Robert Kluft, and Alexander MacFarlane. When you see the validity in the clinical and scientific findings of these professionals, pass them on. Post them. Describe them to your friends and coworkers. Leave links or hard copies for your personal care physician or psychiatric prescriber to read. Encourage psychologists or counselors you know to look into it.

*The concept of trauma and other concepts preceding and to follow will be used in the Eyes Wide Open project to help the reader to identify the impact of previously "invisible" forces such as social tactics and other phenomena upon individuals and groups, see past those tactics, and gain a more effective understanding of events in the mind, the family, the government and other institutions, in the media and in politics.