The Cumulative Nature of Trauma (using a Semi-Truck Metaphor)

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May 8, 2018 | Brian Gong, LMHC

I was recently at an EMDR conference in Massachusetts where a presenter used the fantastic metaphor of a tractor trailer full of packages when describing the cumulative nature of debilitating, unresolved traumatic memories.  As an individual (the truck) goes through life, they often encounter difficult experiences that are not properly dealt with or processed and these are placed into the person’s “trailer” where they are put away and not to be discussed again.  These traumas, or “packages”, all come in different shapes and sizes with some being small and seemingly innocuous while others larger and more profound.  Some people with long histories of trauma and neglect even have tandem trailers, back-to-back mobile storage units all full of burdensome material packed away and not to be thought of or bothered with as they go through life.  Sometimes the engine struggles a bit more than normal when going up a hill or after carrying too large of a load for a while.  Until one day they pick up a package that is too large to throw in the back and everything comes spilling out…

Unfortunately I see this as a all-too-common occurrence, with individuals accumulating layer after layer of traumatic material over the years.  Often a recent traumatic event serves as the “straw that broke the camel’s back” and an individual’s past spills out into the present, and they are suddenly left to face years of old stuff.  This is true for many of Parkland shooting victims that I have been treating who have prior histories of trauma.  Old memories, previously kept at bay and wrapped up tightly in little boxes that were stored on the shelf never to be seen or thought about again, have surfaced as a result of going through the school shooting and now they are facing the psychological brunt of it all.

Some are more prone to layers of traumatic exposure as a result of their careers.  First responders see horrific things on a daily and often hourly basis through their normal tasks as police officers, EMT’s, firefighters, etc.  They collect numerous packages every day to be placed in their trailers lest they stop to dwell on the past and allow it to hinder their ability to perform their duties.  Others, for example those who may have childhood trauma and neglect, and find themselves in abusive relationships as adults continue to load up their trailers as well.

There are well-known concepts in trauma therapy such as kindling and sensitization that describe an individual’s progressively-increasing reactivity over time to reminders and repeated exposure to traumatic events.  We know that a history of past trauma is a risk factor for the development of PTSD, and it is not hard to imagine the impact it has to a person’s system when their trailer is too full of burdensome packages.  So what can a person do to lighten the load?

Working with a skilled trauma therapist can help to clear away layers of traumatic material from the past so that a person can be in optimal functioning and not weighed down by old stuff showing up in the present.  There are therapies, such as EMDR, that can help the brain process old, dysfunctionally-stored trauma memories which often leads to significant improvements in overall functioning and quality of life.  How full is your trailer?

What Politicians could Learn from the Recovery Community

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May 2, 2018 | Brian Gong, LMHC

As I watch the news these days I continue to become disheartened at what I see from various politicians on both sides of the aisle.  Their behavior is often disgraceful and certainly not good role modeling for the youth of today.  I reflect on what it takes for an addict to be successful in recovery, what principles they need to incorporate into every fiber of their lives in order to maintain abstinence from whatever compulsive behavior they used to engage in, and I truly believe that these politicians can learn a lot from the recovery community.

Taking personal responsibility.  Recovery is all about taking responsibility for one’s actions.  It is a common occurrence for those in active addiction to avoid recognizing their part in things and to blame others for their problems in life.  If you cannot own your failures, you will not be able to own your successes.  The externalization of blame comes at a cost for the individual addict in that he or she is deprived of this valuable lesson and opportunity for growth.  Living with the victim mentality is a curse unbeknownst to many people prior to recovery, and they find that to become clean and sober they will need to change this dynamic significantly.  In the 4th step of Alcoholics Anonymous and other 12 Step groups, individuals must take a personal inventory and examine their role in things.  All too often politicians will avoid simply saying that they messed up or that they made a mistake, all the while finding some outside reason for their follies.  Perhaps the finger pointing is designed to avoid a juicy soundbite for their political opponents or to prevent some form of legal liability, or simply because their fragile egos cannot tolerate the fact that they screwed up somehow.  It reminds me of Donald Trump constantly blaming the previous administration for current problems, or his microphone failing during a poor debate performance, and so on (democrats are not immune to this problem either).  How refreshing would it be for politicians to show some humility and just take some basic responsibility for the choices they make?

Honesty.  People in the program will refer to the term “rigorous honesty” when characterizing the level of their need to be honest with themselves and others.  As an addict’s life is inherently fraught with dishonesty toward others in order to hide their problem, and with themselves through minimization and denial, entering into successful recovery naturally requires a major change in this department.  Yet in the political world there seems to be a normalization of lying as a means to avoid scrutiny or accountability, or to garner further support for one’s political goals.  I am not naïve to believe that dishonesty only recently entered into the world of politics, yet it seems to be much more prevalent these days.  Would the world be a better place if politicians were more honest?

Tolerance of others.  There seems to be so much nasty conflict and personal attacking of opponents when disagreeing on various policy points.  The closed-mindedness and lack of consideration for others’ perspectives continues to polarize the political world and deteriorate the ability for things to actually get done in Washington.  “Love and tolerance of others is our code” in Alcoholics Anonymous.  The recovery community is extremely diverse in demographics.  Go to any meeting and you’ll see people of various ages, genders, races, sexual orientations, socioeconomic status, etc.  But they all focus on the fact that they have a common problem and common solution.  If politicians were to focus more on commonalities and things shared as equal citizens of the same country, could they perhaps work better together with more compromise and effectiveness?

Being Others-Centered.  The final concept I’ll mention of selfishness and self-centeredness is important for recovering addicts and alcoholics, as survival and success depend upon changing this old ego-centric way of seeing the world and devoting their lives to service and helping others.  Addiction is a disease of selfishness, and the individual in active addiction often has tremendous difficulty putting others’ needs ahead of their own.  What they are desiring or feeling in the moment often becomes most important in the world, and major changes subsequently need to happen when engaging in the recovery process.  Politicians are elected to serve their constituents and government employees tasked with spending taxpayer dollars appropriately.  It is quite unfortunate when elected officials seem in it for their own personal gain or when corrupt government agency heads spend Americans’ money on lavish personal expenses.  Wouldn’t it be nice for those working in the public sector to be working for the people instead of themselves?

Clearly no one in the recovery community is perfect or a saint, and not all politicians are corrupt and problematic.  But generally-speaking, I believe that the principles practiced every day by members of the recovery community could really help those running the government to be more effective leaders, better role models for our kids, and overall more decent human beings.

“How do I know if I need trauma therapy?”  A common question from Parkland shooting survivors

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April 24, 2018 | Brian Gong, LMHC

After consulting with numerous people directly and indirectly affected by the shooting at Stoneman Douglas High School in Parkland, FL, a common question has been raised around whether or not to seek treatment for psychological trauma.  This question involving the need for treatment following traumatic exposure has come not only from teachers, staff, students, and families, but also from therapists and school officials making assessments and referrals.  Due to the clear importance this has for the welfare of individual victims as well as the Parkland community as a whole, I will attempt to answer the question below.

A number of mental health professionals have been assertive in their position that a victim’s post-traumatic stress symptoms are normal and that we don’t want to shame them by suggesting they go to therapy, thereby sending the message that there is something wrong with them.  I agree that these symptoms are very normal reactions to a very intense and overwhelming situation and that it is important for individuals to understand this.  The process of normalization needs to occur as well as education on what they can expect to experience going forward.  What about those who say that “grieving the death(s) of loved ones is a process and that nature should just take its course over time without trying to push clients toward more-rapid healing”?  I partially-agree, however would point out the difference in this situation for many – that there is a loss and a trauma.  This can perhaps be described by one expert as ‘complicated grieving’ (Kessler, 2017) and ‘traumatic grief’ by others (Shear & Smith-Caroff, 2002).  I wonder if the grieving process could even begin if an individual’s brain and body are still stuck in the trauma and in perpetual fight or flight.  I have also been hearing people spread the unfortunate misconception that PTSD is a lifelong condition and that one must just learn to live with it.  This notion is far outdated and creates an inaccurate and misinformed belief in society that perpetuates suffering.  The truth is that PTSD is a very treatable condition and symptoms can be reduced significantly or even eliminated altogether and people can return to the state they were prior to the traumatic event.  If there are safe and effective, evidenced-based, early interventions that can clear away the traumatic memories and reduce an individual’s disturbing symptoms quickly, then shouldn’t these be provided without delay?

Over time, most people with traumatic stress symptoms immediately following an event will have a spontaneous remission of symptoms without any psychological treatment at all.  Only about a third of individuals go on to develop the full criteria for the diagnosis of PTSD (van der Kolk et al., 2007).  However, this does not mean that two-thirds of individuals are left unscathed.  Many won’t progress to the full PTSD diagnosis but may still have  debilitating traits, while others who don’t have any of the common PTSD reactions such as hypervigilance, flashbacks, etc. may go down a different road and develop substance use disorders and addictions, mood disorders, and panic attacks.  It is widely accepted that numerous psychopathological conditions have origins based on trauma.

The costs of trauma are quite high not only for the individual victim but for their families and society as a whole.  If you know someone who has been traumatized you can witness in them the devastating suffering that is caused by post-traumatic stress (read last week’s post for more details on what the Parkland survivors are reporting).  And what about the secondary problems that arise from not sleeping well or having the difficulty concentration and attention that causes lost productivity and an inability to learn?  How can a traumatized mother or teacher perform the vital parenting and educating roles that require individuals to be calm and present?  What about the chronic re-experiencing of trauma that happens through self-victimization or when victims become perpetrators and create cycles of violence through the generations?  It reminds me of the sayings, “we repeat what we don’t repair” and “hurt people hurt people.”  Unresolved trauma can cause problems on a physical level as well (McFarlane, 2010).  Chronic stress on the HPA axis and autonomic nervous system creates a wear and tear on the body over time and can cause immunosuppression and a variety of other physiological concerns.  PTSD is associated with a variety of somatic complaints such as hypertension, unexplained physical pain, irritable bowel syndrome, chronic fatigue, hyperlipidemia, coronary heart disease, and obesity.  The implications for treatment (or not treatment) are clear.

Our knowledge about the cumulative nature of trauma suggests a great need to intervene early to prevent the layering effect of dysfunctionally-stored trauma memories and subsequent problems down the road.  If a trauma is left untreated, the processes of kindling and sensitization occurs where an individual has a progressively greater degree of reactivity over time through reminders of the event as well as repeated exposure to traumatic events.  In fact, many Parkland victims who have a history of prior, unresolved traumatic experiences are noticing that their past is starting to creep to the surface, no longer able to be contained and as if this was the “straw that broke the camel’s back”.

The truth is that there are safe, efficient and effective trauma treatments such as Eye-Movement Desensitization and Reprocessing (EMDR) that can effectively clear away debilitating unprocessed trauma memories thereby reducing or eliminating distressful symptoms and potentially preventing the development of PTSD or other mental health conditions.  If you notice your problems persisting after several days or weeks and are having a hard time sleeping, feeling jumpy and on-guard, difficulty controlling your emotions, anger and aggression, having disturbing intrusions (images, memories, body sensations, smells, sounds), a thin window of tolerance for ‘holding it together’, difficulty concentrating, or desperately trying to avoid even thinking of the event, my recommendation would be to talk with a professional who is trauma-informed and up-to-date on the current research and treatment guidelines and can talk with you about your symptoms.  There are several organizations that are providing pro bono therapy from quality clinicians and can provide appropriate assessment and recommendations.  If you’re experiencing difficulties following the Parkland shooting that have not subsided after a few days, it can’t hurt and can only help to consult with a professional who can ask the right questions and provide therapeutic options.  The Southeast Florida Trauma Recovery Network is available to help with pro bono EMDR therapy services (Please see next week’s post on EMDR as an evidence-based early intervention trauma treatment).  Working closely with us, the Professionals United for Parkland (PU4P) organization is also available and is providing a limited number of no-cost sessions to anyone impacted by the shooting.

 

Brian Gong is the co-founder and coordinator of the Southeast Florida Trauma Recovery Network (TRN) which is providing pro bono EMDR therapy to those individuals directly impacted by the Parkland shooting.  For more information or to request no-cost trauma therapy, please visit: www.southeastfloridatrn.org

 

Kessler, D. (2017, October). David Kessler on Grief and Grieving.  Presented at a continuing education workshop in Fort Lauderdale, FL.

McFarlane, A. C. (2010). The long-term costs of traumatic stress:  intertwined physical and psychological consequences. World Psychiatry9(1), 3–10.

Shear, K. M., & Smith-Caroff, K. (2002). Traumatic Loss and the Syndrome of Complicated Grief. PTSD Research Quarterly, 13(1).

Van der Kolk, B., McFarlane, A. C., & Weisæth, L. (2007). Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press.

Common Traumatic Stress Reactions in Parkland Shooting Survivors

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April 18, 2018 | Brian Gong, LMHC

The shooting at Marjory Stoneman Douglas High School on Valentine’s Day changed the lives of many forever in profound ways that others who were not there can only imagine.  Those who were in the 1200 building were forced to experience the terror of the incident firsthand and are likely to have experienced the greatest level of traumatization; however, others such as family members, students and staff who were in other parts of the campus, and many more were impacted significantly.  After all, the critical element that makes an event “traumatic” is the subjective assessment of how threatened and helpless one feels during the event (van der Kolk et al., 1996).

Members of the Southeast Florida Trauma Recovery Network (TRN) have had the honor of treating dozens of MSD students, teachers, and family members for post-traumatic stress and have observed a variety of common symptoms and reactions.  Of course, it is important to note that these are all normal reactions to an incredibly abnormal situation, so there is nothing to be ashamed of.  The body has a way of reacting with a mind of its own following an overwhelming, extraordinary event.

Many MSD victims report the presence and interference of memory intrusions related to the shooting in the form of terrifying images, thoughts, feelings, body sensations, sounds and even smells.  When the experience of a trauma is overwhelming beyond the capacity of the brain to process, the traumatic memory becomes dysfunctionally stored in the right limbic system of the brain and not integrated and accepted as part of a person’s past, as a story of an event that occurred and is now over.  Instead, the past is relived as if the traumatic event were happening all over again.  This re-experiencing of the trauma is a hallmark feature of PTSD and often is triggered by some stimuli or reminder of the event. Many students and teachers talk about difficulty getting images out of their heads of the bodies and blood that they saw when being escorted out of the building by police.  One student had a major flashback when he was visiting a college and the fire alarm went off in the building he was in.  Another reported smelling smoke from her family cooking dinner and her mind suddenly went back to the smell of gunpowder that day.  One student described hearing screams of laughter from children playing nearby but had the instinctual feeling of being back at the school that day.  Others have an exaggerated startle response and feel jolted when commonplace things happen such as a door slamming, a book falling to the floor, or the clanking of some ordinary piece of metal.  Nightmares are common, of course.  The unprocessed and unresolved memories of that day continue to haunt them.

Many report a chronic state of hyperarousal, with difficulty sleeping and feeling “jumpy”, “twitchy”, “keyed up” or on edge all the time.  They are finding it impossible to relax and calm their nerves.  Understanding the psychobiology of trauma helps to explain these reactions.  When individuals experience a crisis, they go into fight or flight (or freeze) caused by the sympathetic nervous system increasing the release of adrenaline and other hormones (Solomon & Heide, 2005).  When the traumatic memory is triggered, the body continues to become flooded with these hormones leading to a constant state of physiological arousal.  This chronic stress can cause much distress and the suppression of the immune system.  Several students and teachers have reported taking weeks to get past their colds and other common ailments that normally would have taken only a few days.    These uncomfortable body sensations and feelings often lead to the process of avoidance where individuals try hard not to be reminded or even think of the event so as to prevent themselves from having to experience the pain over and over again.  They will often organize their entire lives around not having to feel these feelings thus leading to the problem getting worse as they’re not processing the event in any way and also start to withdraw from society and healthy social interactions.

Emotional dysregulation and negative cognitions are common.  Many are really struggling with the choice they made in not opening the door for people trapped in the hallway and suffering from tremendous amounts of guilt.  Despite knowing that keeping the door closed and locked is the protocol they were trained in to keep the students in the classrooms safe, the thought of “I should have done something different” continues to cause a lot of disturbance.  Many are analyzing their behavior and wishing they would have taken action to stop the perpetrator from continuing his wrath.  After all, it is way more tolerable for a person to believe they had some control in the situation as opposed to the truth – that they were utterly helpless.  Despite knowing that a person often loses control of their body during a crisis, students and teachers feel embarrassed and ashamed of how they reacted whether it be that they were making nervous jokes after the incident or that they were frozen in fear.  Many have intense levels of depression and anger.

Many report that during the shooting they believed it was all just a drill, that it wasn’t really happening or that they felt like they were in a fog the whole time.  This is likely an example of what is called dissociation which is a very common feature of psychological trauma and is the brain’s subconscious way of coping with the event by disconnecting in some way from the overwhelming reality of the situation.  Many are having trouble feeling grounded and present in the moment and find themselves feeling numb and detached.

I hear many express frustrations that they are having a hard time focusing, keeping up with class conversations and difficulty reading books and organizing their thinking.  Cognitive deficits are a prominent symptom of post-traumatic stress and include impairments in attention, concentration, and memory, planning, and problem-solving due to a hyperactivity in the limbic system, or the emotional center of the brain, and low activity in the prefrontal cortex (Hayes et al., 2012).   This causes clear implications in an institution such as a school where the primary focus is on learning.

These are just some of the common reactions I have noticed in working with numerous Parkland teachers, students, and family members.  And beyond these traumatic stress symptoms are the loss of friends and loved ones and a new harsh reality and reduction of one’s sense of safety in the world.  But there is hope.  With loving support as well as engagement in effective counseling with an experienced trauma therapy professional, the traumatic memory can be cleared away leading to reduction or even an elimination of symptoms described above.  Recovery can indeed happen, one step at a time.

 

Brian Gong is the co-founder and coordinator of the Southeast Florida Trauma Recovery Network which is providing pro bono EMDR therapy to those individuals directly impacted by the Parkland shooting.  For more information or to request no-cost trauma therapy, please visit: www.southeastfloridatrn.org

 

 

Hayes, J. P., VanElzakker, M. B., & Shim, L. M. (2012). Emotional and Cognitive Interactions in PTSD: A Review of Neurocognitive and Neuroimaging Studies.  Frontiers in Integrative Neuroscience, 9(2012).  Retrieved from https://doi.org/10.3389/fnint.2012.00089

Solomon, E. P., & Heide, K. (2005).  The Biology of Trauma: Implications for Treatment.  Journal of Interpersonal Violence, Jan 2005, pp. 51-60. doi: 10.1177/0886260504268119

Van der Kolk, B., McFarlane, A. C., & Weisæth, L. (2007). Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press.