Monthly Archives: October 2013

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]