When someone asks, “How are you today?”it can be a casual, ritualistic way of informally initiating a conversation. Sometimes, it’s much less, as when we meet an acquaintance on the street and they ask us this question without actually stopping for our answer. But what if the question’s for real—what if it actually matters?

I often encounter this situation at the beginning of a counseling session, where I usually ask my client “How are you doing?” It is not unusual for people to have a lot to say in response. It is somewhat less common, but hardly unusual, for the person I’m with to reply “I don’t know.” Often, that is simply the truth.

This can be a problem, since, as I’ve written before, “people come to therapy because of their feelings. Put simply, they’re having feelings they don’t like, in quantities they can’t handle. They can’t fix the problem, and they’re fed up. So, this is why in the beginning of therapy it can be so useful to enlarge one’s awareness of feelings.” In truth, developing an increased awareness of one’s feelings has a broad range of immediate and potential benefits.

More than this, as UCLA’s Daniel Siegel points out, in the context of child development, and by implication in the context of trauma-focused psychotherapy intended to remediate the developmental damage done by neglectful and/or abusive parenting, “the experience of expressing one’s emotional state and having others perceive and respond to those signals appears to be of vital importance in the development of the brain.”

Affect, feeling, andemotion become useful concepts

In my early journey as a therapist, I came to discover that I was no better informed about the actual nature of “feelings” than the average non-therapist. I wasn’t particularly aware of this until I encountered the work of psychologist Silvan Tomkins, recounted by Donald Nathanson in his 1994 book, Shame and Pride: Affect, Sex and the Birth of Self. This new knowledge changed my sense of human feelings. My ability to read both my own and other people’s feelings radically changed, and much for the better. Richard Kluft, a name surely familiar to any therapist working with dissociative disorders, recently wrote in Shelter from the Storm, of how his own encounter with Nathanson’s account of Tomkins’ affect model “dramatically improved” his effectiveness as a trauma therapist. That was precisely my own experience.

In brief, Nathanson took a rather difficult body of work by Tomkins and repackaged it in accessible and fully coherent form. A fundamental idea crucial to the entire book is the affect-feeling-emotion distinction. Its usefulness is hard to overestimate.

Perceptions, affects, and feelings

Perceptions, affects, and feelings – the Affect System model of S. Tomkins – figure copyright 2014 Tom Cloyd – licensing

Nathanson describes “affect” as the neural energy that comes out of the middle part of our brain when our perceptions lead to a realization that something important is happening. It need not seem “important” at all. Most often it is actually rather a small thing and we generally don’t even notice.

For example, we may want another sip of our coffee, so we reach for the cup. Prior to that action, we had to perceive the desire for more coffee and then cause our middle brain to produce energy, directed to our lower brain, which actually gets our muscles to move. We do this sort of thing all the time, while giving it little or no notice. It is important to note the initial affect which starts this whole response sequence is an automatic response. It cannot directly be caused or controlled by our will.

To restate, the energy that initially comes out of our middle brain and gets the body to move is called “affect.” Should we become aware of it, we call it “feeling.” But most affects never make it into consciousness. They just do their job and then vanish. Those that do become “feelings,” however, tend to matter. They affect (unintended and unavoidable pun) our consciousness, for one thing. That alone can change what we do next.

It will be valuable to look at the individual feelings a bit more carefully, but before we turn to that, what of emotions? Although commonly used as a synonym for “feelings,” Nathanson suggests that these are actually best thought of as feelings-in-context, and often more than one feeling is involved in an “emotion.” For example, complex things like “exhilaration” can mean very different things to different people. To one person it might be the feelings of interest and enjoyment experienced when they get an “A” on a paper in school, while to another it’s the excitement, plus a little anxiety, experienced when heading out in the early morning on their horse to check the cattle in the north pasture, after a major snow storm. Emotions are strongly embedded in personal history.

Feelings are fundamental, but few in number

There are probably hundreds of words for different sorts of feelings, but don’t be fooled. When Tomkins studied facial expressions in relation to subjective experiences in a wide range of contexts, he saw that there were only nine basic feelings which people experience. All have accompanying facial expressions which give them away. While the jury is still out on whether or not he got this simple list essentially correct, many people think he did. I can say that his analysis has proven profoundly useful to me and my clients over the years. I suspect it will serve you well also, if you’ll learn it.

Tomkins found that we have three types of feelings—two positive feelings, one neutral, and six negative feelings. Here is his list of the nine fundamental feelings his qualitative research delineated, with a brief description of each. Most are described as a continuum, running from low to high levels of the feeling. (I use the terms affect and feeling interchangeably below, although strictly they are not equivalent, as previously explained.)

Positive feelings

Interest–excitement: We experience this when our focus on anything becomes more intense. Body movement usually ceases, and our face is usually “blank.”

Enjoyment–joy: Interestingly, we experience this when our brain quiets down, when brain activity reduces. We typically smile.

Neutral feeling

Surprise–startle: This briefest of the feelings happens when we experience an extremely sudden major increase in stimulation. It can be combined or followed with another feeling, negative or positive in tone, but is itself neither. Its primary effect is to remove from our brain and mind (consciousness) whatever we were feeling before the “surprise” occurred. It thus assists us to achieve a quick change in feelings. Typically, we open our eyes, and often our mouth, wide.

Negative feelings

Fear–terror: This is triggered by any incoming information that is overwhelming in nature. Our brain seems to experience this as inherently threatening. Its range is large, from minor anxiety to complete panic.

Distress–anguish: We experience this when we detect that something amiss or missing. It has a large range, from rather minor to completely agonizing. “Grief” is somewhere in the middle.

Anger–rage: This occurs when we experience the highest levels of brain stimulation. A stimulation source, which may initially cause mere distress, if prolonged can ultimately cause anger. Its primary function is to increase both problem awareness and any response it leads to. It appears always to be secondary to the perception of a threat (which will produce fear), and thus is part of our fundamentally important fight or flight response.

Dissmell: This affect (Tomkins created its name) is simply triggered by a bad smell. It warns of noxious substances, and can act to limit hunger. Dissmell and disgust (see below) may or may not operate independently of each other in various situations. (Off all the affects, this one seems to be the most specialized and least useful to know about.)

Disgust: With dissmell, disgust can also act to limit the hunger, but it is much more generalized and significant. Its effect extends from food to anything we perceive as unwanted, undesirable, or toxic, and primarily functions to limit our contact with whatever provokes the affect.

Shame–humiliation: A critically important affect which only works in relation to other feelings, primarily acting at least to partially inhibit positive feeling.

The importance of shame

The last affect described—shame—is critically important in trauma-focused psychotherapy, as Kluft and many others have noted. Shame’s primary function of inhibiting positive responses plays a crucial role in a child’s developing sense of self in relation to environment. It occurs commonly and appropriately when they encounter reality-based limits to their narcissistic fantasies about having what they want, when they want it. It also plays a crucial role in learning the structure of social relations, as they gradually learn that they must make room for others in their life, else they will experience serious limitations to the social rewards available to them.

Shame responses and shame-induction thus become primary means of social control, points out neuropsychologist Louis Cozolino, but when too much shame occurs (either self-generated or induced by others), over-control results. This has been referred to as “toxic shame”—the feeling not that you have done something bad but that you are bad, worthless, shameful, etc. I prefer to define toxic shame simply as any learned shame response which does not serve to promote your well-being as normal, healthy, appropriate shame does. With this fundamental distinction in hand, it becomes obvious that toxic shame is rather common, and that in the population of individuals living with enduring psychological trauma injuries, it is chronic and endemic. It must be given serious attention and corrected, if a healthy sense of self is to develop.

As Cozolino puts it so well: “Children left in a shamed state for long periods of time may develop permanently dysregulated autonomic functioning.” This will predispose them to “developmental psychopathology related to affect regulation and identity.”..

The fundamental functions of feelings

Why do we have affects (and feelings) at all? Tomkins offers a remarkable answer: they have evolved as a solution to the problem of the brain’s needing to limit the stimuli to which it attends, in order to function at all. Our sensory nervous system responds involuntarily to a wide range of stimuli. Most of it has little value. The particular sorts of stimuli we do respond to—with the generation of an affect—is that which actually matters to our survival. The rest we can usually safely ignore. Thus, our affect-production-system is seen to function as a kind of environmental filter, limiting the actual work our brain must do.

Siegel agrees that feelings are a signal of an encounter with something important. They are the beginning of meaning-making in the brain. Much more than that, the regulation of the affect-feeling-emotion dynamic in the brain “. . . creates the experience of the self.” Feelings thus may be seen as the beginning of a complex coordination of brain systems which produce meaning, conscious experience, sense of self, and action. Consciousness of affect, as feelings, has a very particular advantage and function: “it has value for our survival as a social species,” says Siegel, for it gives us “an increase in the flexibility of our response to the environment,” which is most especially important in social contexts.

Understanding now the great importance of feelings, and some of the benefits of improved awareness of feelings, please consider the self assessment (and training) procedure I am about to describe. Its use will dramatically improve your awareness of your own feelings, and increase your ability to read those of other people as well.

Self-assessment of feelings—how to do it carefully and thoughtfully

The procedure I will show you is very simple. For some readers, however, it may appear too objective, too “sciencey.” Others will feel uncomfortable with the slow, thoughtful way it must be used. Do not be side-tracked by such initial impressions. This procedure has done good things for many people I have worked with, and it will almost surely benefit anyone who uses it in good faith.

Here’s what I can all but promise you: If you will just try out what I suggest here, you will discover feelings you have of which you had no awareness whatsoever. This will increase your self-knowledge, and therefore your choice options in your life. That’s not a meager payoff for a few moments of your time. Furthermore, while you can choose to deliberately use this procedure to immediately improve your self-knowledge, you will find that just practicing it a few times over several days will also have distinct benefit enduring benefit, as you become more alert to this important dimension of human experience. Whether or not you continue to use this procedure after that is entirely your choice.

The self-assessment process

In order to get a more accurate awareness of what you are actually feeling in present time, we will use two tactics.

Selective focus: we will consider 7 of Tomkins’ 9 affects one at a time, omitting surprise (too brief to matter) and dissmell (too limited to highly specific situation to matter much of the time).

self-assessment scaling tool (Wolpe, 1969), known as the Subjective Units of Discomfort (SUD) score, widely used in one of the major models of trauma psychotherapy (EMDR).

The SUD scale score

The SUD (Subjective Units of Distress) is a linear scale ranging from 0 to 10. Each extreme of the scale (0 and 10) is verbally described (anchored) for the individual using the tool. They then locate their discomfort or disturbance level on the scale to establish a disturbance level score.

Adopted by Francine Shapiro as the prime tool for assessing initial disturbance levels and subsequent reduction of these levels in the protocol for EMDR therapy (Eye Movement Desensitization and Reprocessing), the SUD scale score has been found to correlate significantly with autonomic indices of anxiety (i.e., heart rate and hand temperature). Later researchers confirmed the validity of the SUD score in relation to current or state anxiety. Finally, in the only study so far of the use of the SUD score in a psychotherapy context, a group of researchers led by EMDR expert Daeho Kim found that “the initial score of the SUDS at the first session was significantly correlated with the patient’s level of depression, the state anxiety, and distress from the impact of events” as measured by several other standard assessment tools.

Obtaining your feeling level scores using the SUD scale

This scale, which has this structure -

0 —- 1 —- 2 —- 3 —- 4 —- 5 —- 6 —- 7 —- 8 —- 9 —- 10

can be easily and quickly drawn out on a sheet of paper. This simple device will entirely suffice for all uses.

For self-assessment of the 7 feelings most likely to be relevant in present time, take them one at a time. The question to be answered is:

“How much of this feeling do I have at present?”

Using Interest-excitement as an example, tell yourself the following (this is to “anchor” the scale extremes), right before determining your score. This is important, so don’t skip it.

“0 means I’m feeling no Interest-excitement at all”

“10 means as much Interest-excitement as I could possibly feel.”

Then place your finger on the approximate middle of the scale, and begin slowly sliding it back and forth. You are searching for the place on the scale that just FEELS right. Keep scanning back and forth until your finger comes to rest. An approximate score is just fine. Read the resulting score and record it. If the score is much above zero at all—say 2 to 3 or more, see if you can determine what’s on your mind that might be provoking the feeling. Make a note of that, if anything comes to mind, then go on to the next feeling, continuing until all 7 have been assessed.

Making sense of your scores

I have done this process with a large number of people and with myself a number of times. It doesn’t take long, and the results are usually informative and even surprising. To discover feelings for which you had no prior awareness of at all well illustrates that, much of the time, we are having affects which never rise to the level of conscious feelings. In certain situations knowing about this can be of great value.

Pondering what is provoking these feelings can lead to increased awareness of what’s really going on in your life. Contrastingly, you can use this process to probe your affects in relation to some distinct focus—say a potential new job, or a possible new friend or intimacy partner.

Knowing all of your feelings and their levels can give you a much clearer picture of yourself, add much to the meaning of your experience, and help you make better decisions.

What to do next

You can explore this whole topic further by looking at my 2003 article titled, “Feelings: Deepening Self-Awareness in the Early Stages of Psychotherapy.”. You can go into it more deeply in Vernon Kelly’s 2009 article, “A Primer of Affect Psychology.” Finally, you can explore it in considerable depth with Nathanson’s fascinating 1994 book.

To acquire greater facility in simply making use of what you now know about the different human affects, the best thing to do is to simply observe people and practice detecting their affects, from their facial expressions. A shopping mall can be a superb place to do this—or any other place where you can simply sit and watch people. Over the next several weeks and months, do several more self assessments of the 7 feelings, to continue your developing awareness of your own affect processes.

Skill comes from practice, so the more you make these fundamental discriminations, the more easily and quickly you will be able to “read” your own and others’ feelings. Increasing your ability to do this will add much richness to your life and your social interactions.

_________________

Want to know more? Check out the following resources:

Healing the Shame That Binds You, John Bradshaw (1988).  Deerfield Beach, Fla: Health Communications.

A validity study of the subjective unit of discomfort (SUD) score,” David M. Kaplan and others (1995) in Measurement and Evaluation in Counseling and Development, Volume 27 (Number 4), pp 195 – 199.

A Primer of Affect Psychology,” Vernon C. Kelly, Jr. (2009).  

Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development,  Allan N. Schore (1994).  L. Erlbaum Associates.

Autonomic correlates of the subjective anxiety scale,” Thyer, B. A., Papsdorf, J. D., Davis, R., & Vallecorsa, S. (1984). Journal of Behavior Therapy and Experimental Psychiatry, Volume 15 (Number 1), pp 3 – 7.

TraumaRecoveryReviewPt2

 

Having looked at Babette Rothschild’s presentation of basic awareness, focus on present time and place, correct sequencing of recovery tasks (symptom management before all else), and flashback management, in part one of this two-part review, we now turn to the issues of shame, patience, physical activity, and constructive re-thinking. Each has unique challenges and rewards to offer. As before, my format here is both book review and a discussion of key concepts in the context of my own clinical experience.

5: Forgiving yourself and confronting your shame with the truth

I suspect this will be the toughest part of the book for many readers. However, it’s apparent to me that therapy is about non-avoidance, and good symptom management cannot happen without admitting to the symptoms. Shame is one of the central and toughest consequences and an ongoing symptoms of psychological trauma, especially of chronic trauma or neglect (which is likely more traumatizing than abuse, in the opinion of many therapists).

It has always been an odd fact, in my professional experience, that traumatized people take unusual degrees of responsibility for their trauma. Then they feel awful about themselves—shame. Trauma plus shame—that’s a true “double whammy” if there ever was one.

The false attribution of responsibility that people traumatized at any age will exhibit is a complex thing. Part of it is pure misunderstanding due to faulty thinking, and part is surely a desperate attempt to fight off the perception of a world gone mad by giving yourself some control in that world. For whatever reason it happens, it’s clear to me that such false attribution leads to toxic shame and guilt.

There is significant detail in this chapter that cannot be taken up here—essential neuropsychology, one of Rothschild’s special strengths. Basically, she asks that you acknowledge how your brain actually functions when threatened. Only some of what happens when we are threatened is a response to conscious thought at the time of the threat. The rest, the automatic part, cannot, by definition, be our fault—a new idea for many people. Yet, it is essential that we get real about our actual accountability at the time of our trauma. Why? Because our sense of accountability is intimately connected to our shame.

Shame is ubiquitous,  essential to mental health, toxic, and life-saving – complex, in a word. Her treatment of it is extended and worth serious investment. In many ways, this is the heart of the book— twice as long as any of several of the other sections. It’s a critically important subject, and I’m convinced that her thoughts and suggestions will more than reward your time.

6: Avoiding overwhelm by thinking small

This relatively brief section of the book focuses on possibly the simplest of her “key” ideas. It’s one I find myself emphasizing in clinical work over and over: the Great Wall of China was built stone by stone, and your recovery will be accomplished in a similar manner. Focusing less on the wall and more on the stone in front of you will be the most productive approach. Put even more simply—successful recovery work is about process more than objective. “Are we there yet?” You’ll know when you are, and it’ll happen because you just kept on walking, so I tend to stress that we focus on that next step.

Impatience for progress and for the accomplishment of healing is so very easy to understand. Who in their right mind wants to suffer one minute longer than necessary? Yet, we do well to recall the children we’ve seen who ran before they could walk, with predictable results!  Regrettably, there are external forces supporting the notion of a “quick fix”—from insurance companies who expect it all to happen in 6–12 sessions to Internet purveyors of all sorts of simplistic, folkloric, and simply wrong-headed “miracle” cures, invariably presented without a shred of legitimate treatment validation research.

“Over the years I have noticed that the vast majority of supervision and consultation problems presented to me are solved simply by reducing the size of the steps being attempted.” (p. 103) Amen to that! The problem, I’ve always thought, is that we tend to get overly goal-focused, and it just seems reasonable that large steps—speed—will get us there sooner.

Almost invariably, I see individuals in trauma therapy as unaware of two crucial facts about speed: (a) the wreckage that results from going too fact can be serious—in some cases enough emotional overwhelm emerges that they quit therapy (I have seen this happen), and (b) the recovery process does accelerate, but you have to pass through the slow part to get to the fast part. The single most important immediate goal is to be as successful as possible at your present work. Crawl. Walk. Then run. All of us with experience in this domain of human activity will tell you: THIS is the quickest way to complete your recovery.

7: Improving mental resilience by exercising your body

It’s a paradox: at times you need to be still and just watch what’s happening. I would urge that this will deepen your awareness, and teach you that feelings are never fatal and do not necessarily reflect your present reality. Other times, the best thing to do is to move—decisively. I know this as well I as know anything: nothing straightens out a twisted mind quite like an immediate physical urgency. Partly for the sheer humor of it, but mostly because it really drives this point home, I’ve offered at times to put a match to a client’s pants cuff or skirt hem. I have yet for a single person to say that this would not pull them out of whatever hole they’ve fallen into at the moment!

But, there’s a better way (for which we can be grateful)—exercise. Unprocessed trauma memory tends to paralyze people. They simply move less, and even freeze for periods of time, as Rothschild is quick to point out. Part of this has to do with depression, and part is simply a reaction to severe fear. Accompanying this is a loss of body awareness, and, of course, this promotes a sense of dissociation. None of this is healthy or helpful.

However, I have repeatedly found that exercise will NOT be what you want to do. Immobility will seem much preferable. This is a great example of how misled we can be by our feelings. I address this in therapy just as Rothschild does—by fostering a thoughtful dialog. Exercise is THE antidote to immobility, is it not? And becoming more fit will make your body simply feel better (although if you haven’t experienced this you may not initially make sense of this assertion). Rothschild assures us that it tends also to normalize hormones, especially stress hormones, and this reduces the damaging physical aspects of active trauma memory. That’s a lot of payoff for a brisk walk of moderate duration, three times a week.

Relaxed muscles offer wonderful (if temporary) relief from anxiety and stress, yet many victims of psychological trauma simply can’t go directly into relaxation, by any means. There’s another way, and it’s virtually a sure thing: work your muscles. Tired muscles will relax. I’ve promoted this—and seen it work—for years. There’s an additional, hidden benefit here: the act of purposeful exercise tends to shift one’s focus—away from those awful “home movies” you look at, and think about too often, to something quite plain and simple: just huffing up that hill in front of you, or trying to get around the block where your in less than, say, 8 minutes.

Rothschild discloses in this chapter a little about her own experience with posttraumatic stress disorder (PTSD), because getting herself moving turned out to be crucial to her recovery. She emphasizes two things – one must take small steps, with exercise, and the activity you choose needs to fit you. Exercise options are quite varied. I have found that most traumatized women much prefer to stay indoors—one can do that with inexpensive free weights, or yoga, or a treadmill, or by enrolling in a group exercise class. Men seem to prefer to venture outdoors: biking, brisk walking, jogging can work well for them. Weight training is an excellent choice for both. I’ve never had a client initiate exercise who failed to report benefit, both immediate and long term. What you do is up to you. That you do something physical is the essential objective.

8: Improving your mood and feelings by changing your thinking

In my work, I have seen that there is a time for weeping, and a time for thinking, and they usually come in that order. While you may not yet have come to the time for thinking, it will come. Here’s why: the world really is largely what we tell ourselves it is, and at some point in our healing we must pay attention to our thinking, and words we speak to ourselves. For some people, this is an idea so radical as to seem absurd. For those to whom it is NOT absurd, this final section of the book is invaluable. As might be expected, there is a lot of thoughtfulness here. It is also a kind of summing up, as it references a number of skills addressed in the previous chapters.

You think – my life is over. I’m ruined. I’ll never be the same. But if you think about it and realize that nothing is really stopping you from being helpful to others, from being valuable to the world, and if you do that then your life is certainly NOT over. That realization of the impossibility of being worthless and valuable at the same time—this could be a lifesaver, and it all starts with a simple thought.

You think – I don’t know how to get started. I have no idea what to DO. Rothschild suggests you use mindfulness (skill #1) to become aware of what you WANT to do. Realize that if you survived (skill #2) you surely can do something as modest as finding a way to be valuable. You can begin with a very modest activity—a small step (skill #6). For example, offering to help a senior in your neighborhood with grocery shopping, or by walking their dog, or helping someone with yard care (skill #7). If you have underutilized maternal or paternal impulses, consider befriending any of the “lost” kids that always are to be found scattered about our neighborhoods. Some may need tutoring. Some may just need a ball-tossing companion. Once you start looking, your problem well may be winnowing your options and not a lack of them!

Summary: The multiple values of this book

Rothschild’s writing is direct and conversational, and peppered with interesting stories, some of which are about her. She doesn’t minimize the challenges of living with active trauma memory, much less those of navigating therapy, nor does she offer quick fixes. She does however, offer realistic activities and practices—skills which many people do in fact acquire, and ones quite likely to improve one’s quality of life—whether or not one is dealing with the after-effects of psychological trauma.

While clearly directed to those dealing first hand with trauma recovery (and their non-professional family and friends), there is so much good sense in these pages that it is certain that therapists as well, whether trauma specialists or not, would surely enjoy and benefit from reading this well-focused, practical manual.

The book has several brief appendices of significant value. She offers slightly over 3 pages of distinctly sage advice to therapists, all of which I would strongly emphasize. Her comments for those in therapy about how to evaluate progress, and what to expect as their traumatized nervous system heals is outstanding, as are her suggestions about how to manage one’s therapy and therapist. Finally, there’s an excellent brief section addressed to those who are not or cannot be in therapy and are working on their healing by themselves.

So much helpfulness—all in 174 pages. A remarkable achievement!

TraumaRecoveryReview8 Keys to Safe Trauma Recovery: Take-Charge Strategies to Empower Your Healing.
Babette Rothschild. 2010. W.W. Norton, New York.  174 pages.

Living with persisting trauma memories is tough. Involuntarily triggered by events, or people, or places, or thoughts, or feelings . . . well, anything can be a trigger, actually . . . these intrusive, searing memories will turn one’s life inside out. Recovery from traumatic experience is tough as well, and achieving a sense of safety is essential to successful recovery. Rothschild’s brief, personable, and accessible book directly targets safe, successful recovery in a way that compels and convinces the reader. If trauma memories impact your life or that of someone you know or treat in a healthcare setting, you need this book. Because of the importance of this material, and because I want this to be a bit more than a mere review, I will be discussing this book in a two-part post. My format is both book review and a discussion of key concepts central to Rothschild’s book in the context of my own clinical experience.

People in trauma recovery can change the course of their recovery

Rothschild has herself recovered from posttraumatic stress disorder (PTSD), so her instructions will have special relevance to trauma victims—she’s “been there.” Her special focus is reducing the trauma of recovery itself. For many reasons, trauma psychotherapy too often is more painful than it has to be. As a therapist, I lay significant accountability for this at the feet of my peers. Many are still learning how to deal effectively with psychological trauma. Others believe they are doing well, but are using treatment models which not only are not research-validated but also are known not to be effective—such as group therapy, or old-style talk therapy. The idea of evidence-based psychotherapy has yet to reach all corners of the professional trauma-treatment world, with the result that therapy intended to resolve the effects of traumatic experience results in needless emotional, social, and financial pain more often than it should.

Personally, I deeply regret that many in my profession remain significantly uninformed about psychological trauma phenomena. However, there is little doubt that the situation is improving—at least for civilians. In the military? Well, take a number, then take your prescription to be filled, then take your pills . . . and I’m sorry to report that this is simply not a validated treatment for PTSD on any known planet. I’ll be blunt: our military health system needs more money from Congress, then they need to prioritize training people to properly treat trauma.

Regardless of your situation, Rothschild proposes that your life in relation to trauma memories can be dramatically improved by focusing on just eight specific skills. This proposition is not likely to overwhelm. What’s utterly wonderful is the eight skills she has chosen: not only are they highly varied, but each of them, in her account, appears to offer such benefit as to be essential. In truth, we ALL need these skills—that was my thought after examining this book. However, she emphasizes that for some people certain skills may be much more useful than others. Learning how YOU work and responding to your personal needs is the point, here.

There is a secret promise in this book: If you’re in therapy, your therapist’s skills are not something you can control, but YOU can get your own skills in better shape, and if you do there’s every reason to expect that this will seriously improve your chances of success in therapy. A simple idea, with the promise of an improved chance of a life-changing outcome. Want to know more? Keep reading.

1: Self-awareness (mindfulness)

I ask you to consider something simple, yet profound: To navigate any difficult terrain, you must be aware. You cannot respond to what you do not see. Because therapy is about YOU, that’s where your awareness must focus. While there has been a growing interest in mindfulness meditation as a practice of great relevance to psychotherapy, the fundamental skills needed by those in recovery from trauma don’t rise to the level of formal meditation. Rothschild asks us simply to develop body-awareness, feelings-awareness, and thought-awareness.

Body-awareness is basic. From the beginning, Rothschild emphasizes that we are not all the same, so it should make sense that what happens in one person’s body as a result of trauma may differ in important ways from the responses seen in another person. What does not differ is the simple fact that if you pay attention to how your body changes in different situations, you can better manage your life as you recover. Zombies inhabit dead bodies, but we really should not!

However, it may be more useful to you to focus on your mood (your overall level of energy and pleasure in life). Closely related to this are your feelings—which will change more dramatically and quickly than your mood. Both mood and feelings are affected by a wide range of things, and how this all connects for you can be important knowledge in your recovery

Thought-awareness is given little attention in her excursion into mindfulness. It receives much more in the book’s final section, as well as the section on flashbacks. For now, the notion is to notice where your thinking takes you—what images arise in your mind. From that content will arise feelings. If you don’t like the feelings, track them back to the thoughts and images which brought them about.

2: Time and place: Where are you? WHEN are you?

Trauma memories distract. As a result, Rothschild reminds us, you will repeatedly lose your orientation to place and time. The “posttraumatic” part of PTSD points to the fact that the trauma is over. You survived. And if you’re like most trauma survivors you’ll forget this again and again! As I routinely point out to my clients, one problem is that since all feelings are real, when you are having feelings in relation to triggered memories, you ARE in a real moment. It’s confusing: the memory is of THEN, but the feelings are NOW. Pretty tricky, yes?

To shift your focus to where and when you really are—here and now, will likely require persistent effort. You need reminders and repeated correction. I suggest that you get other people to assist you with this. You can also leave reminders stuck on your refrigerator. There a plenty of other simple things you can do, as well. Rothschild’s point is that recapturing your life after trauma means knowing where you actually are, and this is a question that can, and should, be addressed now.

It is assumed, in dealing with this issue, that the environment in which your trauma occurred is gone. It may not be. Rothschild recognizes this special problem, but addresses it in the next section of the book (pp. 48–48).  However, let me say plainly at this point: if you are still in a traumatizing situation (exposure to domestic violence threats is one of the most common such situations), your therapy will be especially likely to fail. You must come in out of the rain if you are to dry off. If you cannot, this next section, while important to all, will be especially relevant for you.

3: Focus on managing symptoms first, then consider the option of processing trauma memories

To fully recover from traumatic events, research has shown that confronting the memories of the events is essential. It is a realistic fact, however, that this is not possible for everyone, or at least not immediately possible. This is especially true for those challenged by Complex-PTSD or Dissociative Identity Disorder (DID). It can also be especially true for those whose PTSD began in childhood. The decision about whether or not to go forward with trauma memory processing is NOT an immediate decision in therapy—although some clients and therapists are unwisely in a hurry to get to that part of therapy.

As do a great many trauma therapists, Rothschild embraces a model of trauma treatment that is not new at all, and that means that it’s had a lot of testing on the front lines of trauma treatment. It requires that (a) good management of symptoms be achieved before going on to (b) confront trauma memory, and says that the final stage is (c) integration of your life into the larger world. What needs to be understood is that “good management of symptoms” takes exactly as long as it takes, and not less. For some people, this will be years. For others, 2–3 weeks will be sufficient. You must simply be honest with yourself about your situation, and not try to grow roses in three days.

As Rothschild puts it (p. 43), “the first goal of trauma recovery must be to improve your quality of life on a daily basis.” In focusing initially on symptom management and reduction, you will be working directly to achieve this goal. Know that improving your quality of life is a good and attainable goal for almost everyone. Furthermore, she suggests that the commonly accepted last stage of trauma therapy—re-integration back into the larger world—can be addressed as part of the goal of improving symptom management. This is especially relevant for those with any ongoing risk of trauma, but the real question is whether you ought to move on to the stage of trauma memory processing, and Rothschild’s book is particularly strong in its addressing of this question (pp. 48–56). The key idea is that it should be YOUR decision, made when you feel ready, if ever.

Rothschild’s final comment is worth emphasizing: the present is always more important than the past. If you have trauma symptoms but no memories (which occurs, for example, with trauma stored in implicit-memory, a topic she doesn’t take up), don’t go on fishing expeditions in your mind, and don’t let anyone lead you on one either. Focus instead on getting your present life to work.

4: Flashback management: You can do it

Intrusive noxious memories which provoke real and disturbing feelings in the present—these are flashbacks, and they are the cardinal symptom of posttraumatic stress and of PTSD. Trying to avoid them is also a key symptom of PTSD, and for good reason. Rothschild wants you to improve your skills both at avoiding them and at shutting them down when they occur – an excellent idea, and quite doable for many people.

We all talk to ourselves internally—part of this is imagined dialogs and part is our thoughts. She urges that you pay attention to your thought-talk. Often, for traumatized people, this talk does not reflect current reality. If you notice your thought-language, have a chance to make some changes. There’s a large difference between “I’m in danger of being assaulted again!” and “I was assaulted, in the past, and I still feel unsafe, but no one here is a real threat to me!” Present reality, and its essential safety, is only present in the second version.

You can make these corrections repeatedly in your flashback moments, and over time they will become more and more automatic. You need to do this because trauma causes impaired function in our middle brain—the part that creates new learning and a sense of present time. So, remind yourself, “I’m having a memory!” In this way, you can accomplish by intention what your brain is no longer able to do automatically.

A key part of this involves getting NEW sensory information into your brain: awareness of where you are NOW, and that things are NOT like they were in former times. Rothschild is right on target in stressing that traumatized people repeatedly get snatched out of present time by their symptoms. Fight back against this in the ways she suggests and you’ll see a reduction in your symptoms. A simple proposition with a major effect.

[Part 2 of this review will address dealing with forgiveness of self and with shame; avoiding overwhelm by thinking small; improving mental resilience by exercising your body; and improving your mood and feelings by changing your thinking. I will then offer a glimpse at research supporting the value of these skills.]

[revised 2013.11.20]

GuidelinesResearch on traumatic stress disorders grows more voluminous and complex almost daily. While this is a very good thing, it does present an ongoing problem for treatment professionals. How are they to confidently summarize current knowledge so as to be assured of providing state-of-the-art care? A parallel problem exists for consumers of psychotherapy services: how are they to know that the treatment they are getting is the best available?

Treatment guideline summary recommendations, traditionally issued from time to time by major governmental agencies and professional organizations, address this need well[1]. Now we have a new and important guideline publication to guide professionals and consumers alike—the Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder, published late this summer by the Australian Centre for Posttraumatic Mental Health (ACPMH), a non-profit corporation originally devoted to trauma issues of military veterans but now also including the civilian population in their scope of concern.

Overview

An “update, revision and expansion of the original Guidelines” (ACPHC, 2013a, p. 2) published in 2007, the most significant change in this new edition of the Guidelines is the inclusion of recommendations for children and adolescents. Conveniently, it is published in four separate documents: a primary detailed statement of the Guidelines (ACPHC, 2013a), an extensive and lengthy set of appendices (ACPHC, 2013b), a special summary statement focused on children (ACPHC, 2013d), and an overall summary statement (ACPHC, 2013c). All are available for download in PDF format, which may be easily subjected to full-text search using common software. (See References below for details and download links.)

These non-prescriptive (ACPHC, 3013a, p. 2) Guidelines are derived from a systematic review of relevant literature, focusing on 24 specific research questions given to reviewers (ACPHC, 2013b, pp. 25-26). Recommendations are qualified by a grading system developed by the Australian National Health and Medical Research Council  (ACPHC, 3013a, p. 2):

  • Grade A: Available evidence can be trusted to guide practice.
  • Grade B: Available evidence can be trusted to guide practice in most situations.
  • Grade C: Available evidence provides some support for recommendation(s) but care should be taken in its application.
  • Grade D: Available evidence is weak and recommendation(s) must be applied with caution.

In cases where there was no research evidence for a recommendation, Consensus Points (CP) were assigned, based on the consensus opinion of the reviewers if such evidence had been expected, and Good Practice Points (GPP) in cases where no such evidence was expected to exist and none was looked for.

Treatment recommendations

Significantly stronger evidence was found for recommendations for adults than for children. In addition, it is important to realize that “posttraumatic mental health problems manifest in many different ways, and that ASD and PTSD are only two of the issues encountered by health professionals when helping individuals affected by traumatic events” (ACPHC, 2013c, p. 4).

Overall recommendations may be succinctly summarized: Do not medicate potentially traumatized children; do not use “psychological debriefing” at all. For adults, medication should not be used in preference to psychotherapy; in those cases where medication is indicated, the preferred choice is selective serotonin reuptake inhibitor (SSRI) antidepressants.

The single strongest recommendation (Grade A) is for trauma-focused cognitive behavioral therapy (TF-CBT) or eye-movement desensitization and reprocessing (EMDR), with TF-CBT alone being the recommendation for children.

Psychological interventions for adults

  1. Individuals exposed to potentially traumatizing events should not be offered a psychological “de-briefing” intervention [Grade B].
  2. Individuals who are displaying symptoms consistent with Acute Stress Disorder (ASD) or Posttraumatic Stress Disorder (PTSD) in the four weeks after exposure to potentially traumatizing events should be considered for individual TF-CBT, if this is indicated by a thorough clinical assessment [Grade C].
  3. Individuals diagnosed with PTSD should be given TF-CBT or EMDR [Grade A] (ACPMH, 2013a, p. 3).

Pharmacological interventions for adults

  1. Drug treatments should not be used as a blanket intervention for groups of people exposed to potentially traumatizing events [Grade D].
  2. Drug treatments should not be routinely used for individuals with ASD and early PTSD (within first 4 weeks of symptom emergence) [Grade C].
  3. For PTSD, drug treatments should not be used as a first treatment, in preference to TF-CBT pr EMDR [Grade B].
  4. For PTSD, when drug treatments are considered, the first choice should be SSRI antidepressants [Grade C].
  5. SSRI antidepressants should be considered in situations where an individual has not benefited from trauma focused psychological therapy, or has pre-existing conditions (details are given) which interfere with participation in such therapy [GPP] (ACPMH, 2013a, p. 4).

Psychological interventions for children and adolescents

  1. Children exposed to a potentially traumatic event should not be offered “psychological debriefing” [Grade B].
  2. Children of at least school age who have PTSD should be considered for developmentally appropriate TF-CBT [Grade C].
  3. Children exposed to a potentially traumatic event, with symptoms of PTSD, when exposed to the same event, should be considered for a school-based TF-CBT intervention to reduce symptoms [Grade C] (ACPMH, 2013a, p. 4).

Pharmacological interventions for children and adolescents

  1. Pharmacotherapy should not be considered as a blanket therapy for groups of children exposed to a potentially traumatic event [Grade D].
  2. Pharmacotherapy should not be given preference over TF-CBT for children with PTSD [Grade D].
  3. Pharmacotherapy should not be routinely used as an adjunct to TF-CBT for children with PTSD [Grade D]  (ACPMH, 2013a, p. 4).

Development Process and publication formats

The Guidelines are presented very attractively at the ACPMH website, hosted by the University of Melbourne. Four groups are addressed at the website—children, adolescents, adults, and mental health professionals. This largely reflects the focus of the Guidelines (ACPHC, 2013a, p. 1):

“The Guidelines have been designed to be used by: a) the range of general and mental health practitioners planning and providing treatment across clinical settings; b) people affected by trauma making decisions about their treatment; and c) funding bodies making service purchasing decisions.”

The quickest access to this large and significant work is the Guidelines Summary (ACPHC, 2013c). The main Guideline statement (ACPHC, 2013a) will be the focus of professionals, and some consumers; it’s well organized and easy to read into. For children and professionals, there is a brief summary “practitioner guide” statement (ACPHC, 2013d). Finally, for scholars, researchers, and those who wish to examine the basis for these guidelines, there is a separately published very substantial set of Appendices.

Of likely interest to professionals, Appendix 2 offers documentation of the process by which the Guidelines were developed. Key concepts relevant to this process are defined. Of particular interest is this statement concerning limitations of this effort:

“The Guidelines are principally limited to forms of distress consistent with the constructs of ASD and PTSD. They do not seek to address the full range of possible responses to traumatic exposure, including those known as Complex PTSD or Disorders of Extreme Stress Not Otherwise Specified (DESNOS). The original Guidelines were limited to adults; however, the revised version will also include children and adolescents.” (p. 4)

Then, concerning the question of who should actually use the Guidelines:

“There is insufficient evidence available in either the research or clinical practice literature to allow an authoritative specification of competencies required for particular interventions, and so the individual practitioner should be guided by his or her own professional code of conduct with regard to this issue.” (p. 5)

As it was a specific charge given to the Working Group that their recommendations be based on “a systematic review of the literature” (p. 13), the overwhelming bulk of the Appendices document is devoted to Appendix 3, which is the “Evidence Report” commissioned by the ACPMH and undertaken by the Adelaide Health Technology Assessment group, University of Adelaide. Addressed are ASD and PTSD, people “exposed to trauma”, school based interventions, psychological interventions, psychopharmacology, exercise and physical therapies, combined interventions, comorbidities, and “child-specific questions”. Appendix 3 has also several potentially useful sub-appendices. Appendix 5 (p. 592ff) is a complete specification of the DSM-5 Diagnostic Criteria for PTSD.

Summary

This is clearly a serious effort to guide treatment practices. That it is NOT focused solely on a military population is significant, given that, contrary to general public perception, most people with traumatic stress disorders are civilians. The explicitness of recommendations provides well-focused guidance for professionals concerned with providing best-practices care. The extensive and thoroughly documented accounting of the literature review upon which the recommendations are based is a model of transparency well-articulated thoughtfulness.

I find this 2-year large-scale effort fully deserving of respect by both professionals and the general services-consuming population. A large number of contributors, specialists in their fields working closely with each other and with many check and balances, produced what is offered here. In all regards, this is a definitive statement of best-practices treatment for traumatic stress disorders (ASD and PTSD) at this point in time.

Note

1. I am assembling a fairly complete list of such guidelines, and expect to have it completed soon after this present review is published.

References

Australian Centre for Posttraumatic Mental Health. Acute Stress Disorder & Posttraumatic Stress Disorder in Children & Adolescents: A Practitioner’s Guide to Treatment. Melbourne, Victoria, Australia: ACPMH, 2013. (7 pp) [download: http://guidelines.acpmh.unimelb.edu.au/__data/assets/pdf_file/0011/851672/ACPMH_Child_Practitioner_Guide.pdf]

—. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder. Melbourne, Victoria, Australia: ACPMH, 2013a. (177 pp) [download: http://guidelines.acpmh.unimelb.edu.au/__data/assets/pdf_file/0008/851489/ACPMH_Full_ASD_PTSD_Guidelines.pdf]

—. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder – Appendices. Melbourne, Victoria, Australia: ACPMH, 2013b. (596 pp) [download: http://guidelines.acpmh.unimelb.edu.au/__data/assets/pdf_file/0010/851473/ACPMH_Full_Guidelines_Appendices.pdf]

—. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder: Guidelines Summary. Melbourne, Victoria, Australia: ACPMH, 2013c. (50 pp) [download: http://guidelines.acpmh.unimelb.edu.au/__data/assets/pdf_file/0011/851672/ACPMH_Child_Practitioner_Guide.pdf]

—. Australian Guidelines for the Treatment of Adults with Acute Stress Disorder & Posttraumatic Stress Disorder. Melbourne, Victoria, Australia: ACPMH, 2007.  Downloaded 2013.03.20 from http://www.acpmh.unimelb.edu.au/resources/resources-guidelines.html#1.

TraumaBlogEvery breath—a new beginning. And with every breath, we come home.

In this, my first post in this new blog, I want to tell you a little about how I got here, by way of introduction.

Over a period of some 15 years, I have found myself increasingly focused on trauma psychology and the psychotherapy of trauma. My professional life did not begin with that focus, but rather with a near total failure to recognize that the psychology of trauma—much less that of dissociation—mattered much. I will take responsibility for it, but I did have a lot of help in creating this failure of understanding.

Trauma process was anything but a focus of training in graduate school. We learned many useful things, but because there was so much to learn and so little time, we mostly opened doors and looked in; then rushed on. Even several years of internship, during graduate school and afterwards, barely informed me of what lay ahead.

Immediately after graduation, I began directing the admissions department of the major private psychiatric hospital in Portland, Oregon. In reality an internship of a different sort, it was indescribably valuable. I engaged with people in real trouble with their mental health. I can recall dealing with one person who had dissociative identity disorder (DID), and two or three who had posttraumatic stress disorder (PTSD). It was kind of exotic stuff, pretty much as I’d been led to believe in graduate school.

After two years of that I was ready for an increased clinical focus, and was hired to manage a branch office of a county mental health agency in eastern Washington State. As the senior clinician, I tended to get most of the really tough cases, and before long I realized that I simply didn’t know enough. A few of the people in my case load clearly qualified for PTSD diagnoses, while the majority appeared to have one flavor or another of depression, as well as various sorts of anxiety. Many of them were essentially chronic cases. Why couldn’t I do more with them? Why was I the only one bothered by my ineffectiveness?

Then I got my agency to pay for training in eye movement desensitization and processing (EMDR), a new approach to dealing with trauma, which we appeared to have a lot of in rural Washington. I learned a lot about PTSD in that training, came back to my case load to reassess every individual, and discovered that 85% of them had PTSD! I was stunned.

At that point I had a problem: I didn’t think I could share this revelation with my supervisor, because it was just too unexpected, too anomalous. As I began treating people with this new, trauma-focused approach, I saw immediate transformative results. They got better, and I got wiser.

Not only had I been clueless as to what was right under my nose, I had never been instructed in graduate school or by any of my clinical supervisors to routinely look much deeper than the symptoms and “the complaint” that my clients initially offered to me. That laissez-faire approach had clearly been failing my clients.

At this point, I finally confided in my supervisor. To my surprise, he accepted my finding of an 85 percent rate of PTSD in my case load. Why hadn’t he directed me to look for this, if he found my report to be unsurprising? It just wasn’t his focus. It wasn’t anyone’s focus. Still, it quickly became mine. It had to, as I had a fatal flaw: I actually wanted, above all else, to be effective with my clients.

I suggested to him that our entire agency needed to shift its service delivery model to this new orientation, get a lot more individuals trained in how to treat trauma disorders, and start insisting that virtually everyone get assessed for trauma-related disorders. He said that while it might be a good idea to do so, we had to give priority to a major paperwork-compliance problem we were working out with the state, which would take at least another eight months to resolve. We had new software to bring online, for one thing. Maybe we could address this over the next budget period, he proposed.

While that prospect might have worked for him, however, it certainly did not for me. I knew I was finished at the agency. Within 10 days or so, I gave my 30-day notice. I had to go where I could be far more responsive to the needs of my clients, and that meant private practice.

That was about 15 years ago. Since then, I’ve been learning, writing, and doing clinical work—all of which has increasingly been focused on trauma-related disorders. At the same time, my profession has also been continually learning, researching, writing, and working with such disorders. We now understand—those of us with this special focus—that merely having a relative who develops cancer can result in your acquiring PTSD. We understand that children can get a particularly challenging form of it (“complex PTSD”) merely from inadequate parenting. We understand that for the most part, dissociative identity disorder (DID) is advanced, severe PTSD with an early-childhood  onset.

What started out as a large fish has turned into a veritable whale. Is this a good thing? Well, it does have its critics, surely. However, little of what they say amounts to more than a protest about having to alter their basic paradigm for much of mental illness. When it turns out that much of substance abuse is connected to trauma in childhood; that one girl in 3–4 and one boy in 5–6 is sexually abused growing up; that while the mass media is fixated on soldiers with PTSD the reality is that, by more than 2 to 1, individuals with PTSD are neither male nor have any military background—how can this new paradigm be anything BUT a good thing? Solving the wrong problem is never helpful.

I now understand that what some of us know in my profession needs to be passed on more quickly to our peers. They need to understand that just as certain things in medicine (cancer, and obstetrics, for example) are clearly best dealt with by specialists, so it is with trauma disorders. They need to learn how to do better assessments, and then make appropriate referrals.

I also have found that misunderstandings about trauma are endemic in the general population, and that merely treating individual after individual in one’s office will not do much to address that problem. People aren’t getting treatment because they don’t know it’s possible, or they don’t know that their symptoms could well indicate a need for it. At a personal level, this is simply tragic, given the consequences of having to live year after year with PTSD or DID— consequences that touch not just the individual but their spouses, children, work associates, and friends.

So . . . what I want here is this: a chance to dialog with you about psychological trauma disorders, to pass on correct, current and useful information; to tell stories about people who been profoundly affected by trauma, and have found ways not just to manage their symptoms, but to recover from their disorder. I have some things to show you that you really should know about, if your life is touched by any of these disorders. What I want is simply a chance to say them.

One other thing. I’m here because the publisher of Mom Psych and I think essentially the same way about the critical importance of evidence-based psychology. Unless we resort to folkloric explanations and remedies, it’s all we have to push back the darkness. Fortunately, it’s a very powerful tool.

You deserve to know about all this. For the most part it’s good news, and it just keeps getting better. For many of you it will be life-changing information.

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