Colin A. Ross, M.D. joins us to discuss PTSD as a future-oriented survival strategy. See the full video and transcription below:
Inspiration Series: PTSD as Future-Oriented Survival Strategy
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Welcome to May 1st, the start of Mental Health Awareness month. And what better way to start Mental Health Awareness month than to have a conversation and presentation by Dr. Colin Ross on trauma attachment dissociation and EMDR.
I’d like to say just a few words before we begin. First of all, thank you, and each and every one of you, who are joining us today. Thank you so much for the work that you are doing out there especially in light of COVID-19. The social distancing, with 30 million Americans out of work, with trauma happening day in and day out given all these new set of rules we have to live with. Now more than ever you are so important to society, so important. The work that you’re doing to help people suffering from addiction mental health disorders. So we really appreciate what you’re doing.
I would like to give a little shout out to the Gateway staff. Our staff, probably unlike many staff out there, are doing everything they can to treat people today inpatient treatment. We have three of our nurses at our Springfield location in their latest “COVID garb”, and we have the “Heroes Work Here” artwork from the patients at our Aurora facility. So, we can’t thank the Gateway staff who are on the front lines enough for the work that they are doing. The role that they are playing in helping people battling with addiction, trauma, and mental health issues. We are so proud of our team, thank you so much.
So, a couple things to go over very quickly. You have some web controls at your disposal. Also, there will be a chance to ask questions. You are all muted now, but at the end we will take questions from Colin. We will save a few minutes at the end. If you have any questions, please just type it in the questions bar and we will get them at the end of the presentation.
Some of you, perhaps, are here not only to hear the wonderful words and wisdom from Colin Ross, but to collect “CE’s”. After the presentation you’ll receive an evaluation form, and once you fill that evaluation form out, please send it back to us and we will send you a certificate.
Alright, I would very much like to thank our sponsors. First and foremost, the Higher Thought Institute. They are an incredible organization offering continuing education workshops, conferences around the country, and webinars. They had a conference scheduled here in Chicago this April. Unfortunately, it was postponed due to COVID. They have a Webinar series starting up in May. Paul Ortman is the founder of that organization and started the Summit for Clinical Excellence, as some of you may have gone to a couple of those conferences. So, they are providing us our CE’s for this segment and providing Colin Ross for us today.
Got to give a shout out to the Beacon House, our sister company out in Monterey Peninsula. Although I know we have some Beacon House people out there watching the presentation. It’s an incredible, intimate, 22-bed addiction facility. It’s so beautiful, a Victorian-style mansion. It’s probably the oldest treatment center in California, they’re going on 60 years. And TJ Woodward is gonna be speaking next week, next Friday, he’s going to talk on conscious recovery, and he is affiliated with the Beacon House.
Alright, Gateway Foundation. I guess I should introduce myself. I’m Keith Arnold, the chief marketing officer for Gateway Foundation. I’m proud to be associated with this organization we have 14 facilities around the state of Illinois as well, covering inpatient treatment with raw management, partial hospitalization, intensive outpatient, outpatient living and we have specialty programs at some of our sites including our woman and trauma program, “Her Story”, that utilizes EMDR and is located in Carbondale, which is Southern Illinois. All of our programs utilize 9 evidence-based practices, and they include trauma-informed care “Seeking Safety”. We’re proud to be a member of Illinois’ treatment community and partnering with many of the other organizations, hospitals, and treatment centers out there.
Obviously, Colin Ross Institute. We’re proud to have them here and Colin here. Founded in 1995 by Dr. Colin Ross. This institute is internationally recognized for their delivery of their trauma model of psychopathology. Dr. Ross is with us today and he is an incredible man. I’ve gotten to know him over the last 20 years. The contributions to this field are amazing, and what he’s been able to give to us. I can’t imagine that there’s anybody in this audience who hasn’t read at least one of Colin Ross’s 34 books. I’ll just say a few more words about him. He’s internationally renowned, clinician-researcher, author and lecturer in the field of dissociation and trauma-related disorders. He has authored 34 books, and over 230 professional papers. He is a past president of the international society for the study of trauma and dissociation. He has appeared in numerous television documentaries and has published essays, aphorisms, poetry, short stories, and screenplays. So, Dr. Colin Ross, thank you so much for joining us today and we are very excited to be hearing from you.
Are you there?
I’m here, but I don’t look like I’m switched over to my slides yet.
I’m going to share the controls so in just a moment, you will have full access to everything.
That’s very helpful because I’m a control freak.
All right here you go, they’re coming over to you.
Ok let me just share my screen and we should be good.
Awesome, I’m going to mute myself.
Ok let me pull up my slides. Let me start. Ok, there we are.
So you’re seeing my slides the way you’re supposed to?
Well that’s all I have to say so I can take questions now (pause). Oh wait a minute, I think there are some slides after this one.
So, PTSD is a future-oriented survival strategy. That’s my topic today. And this is basically an idea that I’ve come up with. There’s no evidence for it, you can’t find any literature on it. But hopefully you’ll find some literature soon because I have a paper under review. But I’ve actually been having quite a bit of troubling getting this paper published. And the responses have been kind of two-fold. One is certain crabby people who claim to be scientists and they say, “Where’s the evidence?” point being there is no evidence, it’s an idea. And then there are people who say “Oh, this just doesn’t make any sense”. So there seems to be some kind of concept floating in the field that having a theory or a hypothesis or an idea is a bad thing. Beats me, I’m not sure why.
Trauma Education Essentials I’ll just mention real briefly. It’s a company I formed with my daughter who is a psychiatrist in Toronto. And we also provide webinars, so you can go to the website and check it out. And if you sign up for the free monthly newsletter, my daughter writes a really good, useful book review every month with a trauma-related theme. And there’s also some handouts and documents there.
This is my contact information if you have any reason you want to contact me or if you have a question, that’s where you go.
So, I’m going to start with a history of PTSD. I walk through DSM 3, 4, 5, and talk about things I think are missing from the concept of PTSD. And then I’ll get into a couple of core concepts, underlying this idea that it’s a future-oriented survival study. And talk about that a bit, get into case examples. And that’s basically the plan of action.
So the history of PTSD goes back approximately one billion years since trauma is involved in all of life on the planet for all forms of life. In terms of the human race, depending on your view of evolution, it’s probably been around in human beings for hundreds of thousands or a million years or something. And obviously there’s nothing new here. But it didn’t really have any official name until late in the 19th century. So this is how railway spine and people were working on the railroad whose pretty heavy construction job causes a lot of injuries. So people who have PTSD were said to have a railway spine. Then when we get to first and second world wars the name changes to shell shock battle fatigue. And it really becomes PTSD for the first time, at least on this planet, in 1980 with DSM 3 in 1980. And, a little quick summary on the historical background with that: so most of the people who were in the community that got PTSD to DSM 3 were working in the VA system with Vietnam vets. So therefore the picture of PTSD was very much combat driven. Didn’t have to be combat, could be civilian. But a BIG scary life-threatening event where you might actually die or have a serious physical injury. That was basically the type of event that caused PTSD. And then you have an immediate reaction of powerless fear, terror, helplessness. And then, it has to last a month, so for a month or longer, you would have all the hyperarousal symptoms: physiological and psychological and then the numbing shutdown symptoms. That was the basic picture of PTSD and you would fluctuate back and forth from what I call the “up pull” of PTSD which is sympathetic systems going triple-overtime: flashback, nightmares, all that. Hyperarousal heart rate up, scanning looking for danger. And then you have what I call the “down pull”. So I look at PTSD as a kind of bipolar trauma disorder in a sense. The down pull being social withdrawal, numbing, disengagement, some variable amount of amnesia.
So that was PTSD. And PTSD was in the section of DSM 3 called “anxiety disorders”, and the reason it was there is because there’s a lot of fear and anxiety type symptoms in PTSD, unquestionable. The problem was that trauma when you traumatize a mammal, you’re going to activate mammalian defense response systems. So that’s your basic fight, flight, and freeze. And if you attack, corner, threaten, attack, corner, threaten a mammal, including a human being, especially a child who’s trapped, powerless, can’t escape, your body will automatically go into fight mode. But if the aggressor is a grizzly bear and you’re trapped in a corner that’s not going to work, so then you’ll go into flight mode, which gazelle and deer specialize in. But if you’re a trapped little kid or a trapped mammal so you can’t fight, you’ll never win. If you try to fight, you’ll get it worse. If you try to run you’ll just aggravate the assailant. Which, I’ve heard this in a scenario a zillion ties from women who have been sexually assaulted. “He was too big, he was too strong, I couldn’t fight, I couldn’t run aware, he was either physically overpowering me or had a weapon” and so the only option that’s left is freeze. And people come and they commonly think that if they freeze, they did nothing. Therefore it’s all their fault, they deserved it, they should have done this, they could have done that. Which I’ll come back to.
So fight, flight and freeze are core elements of trauma survival. But in the DSM 3, it was mostly focused on the fear, anxiety, flight part of things. And, this is kind of like the barest mention of anger and really the barest mention of any kind of freeze or dissociative symptom. I’ll come back to dissociation in a second. So that was the picture in DSM 3.
The problem was we started having drug studies by drug companies who are trying to get FDA approval for medications to treat PTSD in the post-DSM 3 and the early post-DSM 4 period. And one of the big studies that got one of the SSRI’s approved by the FDA for PTSD, a large chunk of the people in the study were women, and their trauma was childhood sexual abuse. So it didn’t fit the combat, military, guns, and explosion bottle. And some childhood sexual abuse, there’s a big strong scary adult pedophile and there is physical danger and threat to your integrity or body and there can be a bodily injury. But also a lot of the time with sexual abuse it’s kind of more seductive, kinder, gentler, this is our special secret princess kind of perpetrator. So it just doesn’t fit the combat model of trauma. So, a couple of thousand years behind schedule, the American Psychiatric Association kind of caught on to this, and in DSM 4, there’s a couple of modifications. There was still the anxiety disorders section, and it was in there with OCD, Panic disorder, social phobia, etc., a generalized anxiety disorder. But the definition of the vent got a little broader. So, it didn’t have to be an immediate threat to the bodily integrity of your life. But otherwise, it more or less stayed pretty much the same.
Then in between DSM 4 and DSM 5, some leading people in the field were publishing papers and arguing that in DSM 5, PTSD should be moved out of the anxiety disorders into a section called “fear circuitry disorders”. So it was still fear fear fear fear, and it was going to be called fear circuitry disorders basically so the guys in the committee could look like really smart scientists who talk about brain circuits.
Ok, but what about fight and freeze? They’re still kind of basically left out of the picture. And they didn’t win, so it didn’t become fear circuitry disorders. But what did happen to DSM 5, was PTSD was moved out of that section into its own section called trauma and stress-related disorders. SO it was no longer an anxiety disorder. So, ok we’ll just forget about that. It’s not an anxiety disorder anymore it’s a trauma disorder. Also, OCD was moved out of its little spot in anxiety disorders into its own section. So it’s no longer an anxiety disorder either. It’s obsessive-compulsive and related disorders.
So it’s all these shift around that are really more political, ideological, theoretical, then based on any actual science that proves that we should move PTSD out of the anxiety disorders section. It’s just the peculiarities of the whole process which I’ll get to more in a second. But there were several kinds of fairly significant changes in DSM 5.
Jumping back into the past again. As you see I am modeling the signs and symptoms of attention deficit disorder here by jumping around back to DSM 4.
Back in DSM 4, Bessel Van Der Kolk actually got field trial money. So field trials are research that’s done in preparation for the next edition of the manual. And he came up with this disorder of extreme stress not otherwise specified. He had all kinds of data for it. It’s basically the same as complex PTSD. Complex PTSD is going to be, well it is in, it’s going to be in ICD-11, but it isn’t in DSM 5, and it’s basically the majority of cases of PTSD in the world that meet criteria for complex PTSD. Which is PTSD, depression, anger, alcohol substance abuse, relationship problems. And that’s what we see all the time clinically. So DSM 3, 4, 5 PTSD is only one slice of the pie of all of the symptoms people get when they get acutely traumatized and especially when they get chronically traumatized as children. But nevertheless, Bessel Van Der Kolk lost the war and disorders of extreme stress did not get into the manual DSM 4.
So for DSM 5 he thought “Ok, I’ll see if I can get it in through the child and adolescent people as developmental trauma disorder” which is basically complex PTSD of childhood. Nope. Shut out. Didn’t happen. And one of the comments he got in the DSM 4 era was “we can’t allow Des Nos into the manual because it would destroy the whole foundation of the DSM system which is the separate disorders in separate sections. Because it’s basically a whole pile of disorders that are all part of one disorder. One umbrella diagnosis.
But, there was a little secret Trojan horse maneuver. Because when you look into the criteria of DSM 5, they’re now much broader. They look much more like Des Nos, or complex PTSD than the DSM 4 area. Because they now include more emphasis on anger, irritability, and depression. And they’ve got little words in there talking about negative mood, negative condition, negative view and past, present, or future self. And that’s good. And now for the first time there’s also a dissociative subtype of PTSD. So the idea that the dissociative disorders are over here in the dissociative disorders section, PTSD is in the anxiety disorders, but now it’s in the post-traumatic and stressor-related disorders. But nevertheless, that’s two separate sections because they’re separate disorders.
It’s always been true that there’s tons of dissociation in PTSD. But, without actually officially admitting to it, it’s been begrudgingly acknowledged by the APA that dissociation is a component. But how big a component? Well in the research that resulted in the dissociative subtype of PTSD getting into DSM 5, a measure was used that only asked about depersonalization and derealization, out of all the types of dissociative symptoms. So, therefore, the dissociative subtype is defined by the presence of depersonalization and derealization symptoms and all the other criteria for PTSD and the dissociative subtype depend on the research study, but it bounces around between 7-15% of all the cases of PTSD have the dissociative subtype. So, you know it’s interesting but it’s kind of small. It’s not really the main focus in the PTSD world.
Well, that’s a little progress, but there’s a tiny, tiny little problem here. In DSM 3, and DSM 4, and DSM 5, there are the regular criteria. So there’s the flashbacks, the nightmares, the numbing shutdown, and there are also flashbacks. So who thinks that flashbacks are a minor symptom in PTSD? They’re obviously a core major symptom. What are they called in DSM 3, 4, and 5? Either dissociative flashback episodes or dissociative reactions, for example, flashbacks. Also in the criteria, just the regular general criteria, is dissociative amnesia. Inability to explain elements of the traumatic events that cannot be accounted for by ordinary forgetting.
So hold on a second. Now we’ve admitted there’s a dissociative subtype of PTSD, but we’ve restricted it to those respectable symptoms of depersonalization and derealization. And over here, nothing to do with dissociative PTSD, we’ve got dissociative amnesia and dissociative flashbacks in the criteria. So this makes absolutely no sense whatsoever. It’s completely irrational, unscientific, illogical. And what would happen if we said “Oh, we think that the dissociative subtype of PTSD should be defined by the full range of dissociating symptoms, of which two are dissociative flashback episodes and dissociative amnesia. So if flashbacks are part of the criteria for the dissociative subtype of PTSD, it would be almost everybody. So, PTSD would be dissociative PTSD, and non-dissociative PTSD would be a little subgroup, like maybe 5% or something.
So, this is the way it goes in the politics of American psychiatry. But, and I’ve written papers about this already, but hopefully in the future DSM 6, or 7 or 8, sometime, somebody in charge of the manual will go “Wait a minute, that doesn’t make sense. PTSD is fundamentally dissociative all of the time if we say that the amnesia and the flashbacks are dissociative”. And we now, though, we are improving. PTSD is expanding, getting closer and closer to complex PTSD as the basic common form.
But there’s another problem with the whole history of and the definition of PTSD. Which is, on the one hand this completely makes sense. You can’t have PTSD unless something bad happens. And it’s gonna be like, bad. So you can’t have PTSD because you didn’t like the cartoons on the TV or you stubbed your toe or you didn’t like the taste of the jello. It’s gotta be some kind of big event. So who would debate that. Why is that our problem?
It’s a problem because it misses out on half of reality. Because the population I work with and my inpatient trauma programs serve is complex childhood trauma and complex PTSD. And that means, basically, 95% have a dissociative disorder of some kind on structured interview, 97% have depression, 80% meet full criteria for PTSD, the rest are just sub-threshold. Two-thirds OCD, two-thirds panic disorder. 50-60% substance abuse, 50-60% borderline personality, 40% an eating disorder, 40& DSM 4 somatoform disorder of some kind. Lots of comorbidities. So this is the population I work with all the time. And bad things definitely happened, and the bad things definitely led to all sorts of mental health problems. Additions and all kinds of self-defeating disorders.
So what’s my beef? My beef is, half, not scientifically half, but “halfish” of the trouble that we treat is due to what didn’t happen. If you can’t have PTSD because something didn’t happen. I have combat PTSD because I never was deployed, it doesn’t make any sense. But actually, it makes total sense. Because half of the trouble is a failure of bonding, failure of nurturing, inadequate caretaking. Not because of physical or active abuse, emotional neglect and physical neglect. And that causes a whole lot of bad feelings. But instead of fear circuitry disorder hyperarousal, ignore adrenaline style symptoms. It’s a little quieter and it’s really sadness, loss, grief, small, scared, sad, lost, lonely child. So that hold I mentioned should be incorporated in the criteria for PTSD, it should be part of the treatment outcome literature, part of all the treatment protocols, but it isn’t- because you can’t have PTSD from something that never happened. So as you can see, I am unhappy with PTSD for a number of reasons. But it’s a heck of a lot better than having no PTSD.
Another little twist on the history here. And the basic theme is we buy into the concrete scientific reality of these DSM 5 disorders too much. And it’s good to take a step back and look at “Ok, does this make logical sense?” And then getting into the literature and data, how strong is the data? And also the history and the politics. So, I’ll go over this fairly quickly. We’ll get into kind of the main point here.
So I was on the DSM for dissociative disorders committee, and we had one in-person meeting, some conference call meetings, and a bunch of emails. And, there’s a cutoff. SO DSM 4 came out in 1994. So late 1993 was the cutoff point, no more revisions, no more changes. So we;re getting kind of close to the deadline, and we’re having a meeting, and two people involved in the committee and in the whole DSM process present us with this new disorder: Brief Reactive Dissociative Disorder. There’s no literature on it, it hadn’t been presented at conferences, and nobody on the committee had ever heard of it, because it was just invented or coined by these two guys. And basically what it was is you had a big traumatic event, and your immediate response is intense, severe, disabling, dissociative symptoms, and there’s a list of those. And if it lasts longer than a month it’s not brief reactive dissociative disorder anymore. And everybody went “well yeah that makes sense”. So it’s too severe and intense to be an adjustment disorder, it’s not brief psychotic disorder. So there’s nowhere to kind of fit these people into the system so that we can start recognizing it, figuring out what’s the treatment, doing the research, and not to mention get paid by a managed care company. So everybody goes “Ok, well I like that. And our turf just got bigger, hey!”.
But this is literally a process for every short interval of time. Somebody goes “Oh, wait a minute. What happens if brief dissociative disorder doesn’t go away in a month?” You can’t have brief reactive dissociative disorder for a year. Oh yeah, hm ok. We’ve got a solution. If it lasts longer than a month, we’ll change the diagnosis to Post Traumatic Stress Disorder. Which, you must have symptoms for one month before you can make that diagnosis. Oh okay, good, problem solved.
A little bit of time goes by. Oh hold on. This means you have a dissociative disorder for the first month, then all the sudden you wake up the next morning and you’ve got an anxiety disorder. Oh yeah that doesn’t really make sense. What do we do about that? Oh, we’ll move brief reactive dissociative disorder into the anxiety disorder section and put it beside PTSD. So now you’re not jumping through categories, phew!
Uh, oh. Wait a minute. Now we’ve got an anxiety disorder named brief reactive dissociative disorder. That doesn’t make sense. Solution? We’ll change the name to “acute stress disorder”. This is where acute stress disorder came from. It was just invited as a solution, it had no science or research behind it at all. A little bit more time goes by and somebody goes “Wait, acute stress disorder is defined by a list of dissociative symptoms. That doesn’t really make sense. So the final switcheroo was added on all of the other criteria for PTSD. Big traumatic event, now we have this list of symptoms, then we’ve got the hyperarousal, the numbing. So it looks exactly like PTSD, except it lasts less than a month.
This is the history of where acute stress disorder came from. It didn’t come from research or science at all. And this kind of politics, ideology jockeying around has a pretty big influence on the DSM system. So again, my advice is don’t buy into all of these categories being that solidly scientific.
Another problem with PTSD, as if I haven’t listened enough now, is it’s called Post Traumatic Stress Disorder. So the whole conceptualization in the literature is something bad happened in the past, now post-the trauma, you have symptoms. That’s why the name makes sense. And the entire literature on PTSD agrees on this. Something bad happened in the past, it’s causing problems in the present. End of discussion. Now I’m going to start explaining my objections to this conceptualization and why I think we need to change the name of PTSD.
So rather than calling PTSD PTSD, we should call it PTSD. Because PTSD is a better name for PTSD than PTSD if you see what I mean.
So just in case that wasn’t totally clear, it’s called post-traumatic stress disorder. But I think it could as easily be called “pre-traumatic stress disorder”, that is, it’s a disorder of the future. Which I’m going to explain.
So I’m not saying that we get rid of the whole old perspective and substitute it and its survival strategy. I’m saying that this is another dimension that we should open up, think about, talk about, treat, take into account in therapy. So I’ll explain a little bit more, then we’ll get back to therapy and examples.
In my trauma model of therapy, it’s a subject of a series of treatment outcome studies that have been published in a book called “Trauma Model Therapy”. There’s some core, sort of principles or elements that we use all the time. And one is the Locus of Control Shift,
This idea, and now we’re talking about childhood trauma, how do kids think? And how kids think is, “I’m at the center of the world, the whole world revolves around me, and I’ve got this magical power to make things happen”. So it doesn’t matter what your IQ is, your race, your gender, your culture, that’s how kids process information. So they’re at the center of the world, they cause everything that happens, therefore in a big trauma family, they automatically conclude “I’m bad, I’m causing it, I deserve it, it’s my fault”. They shift the LOC, the control point, from inside the adults where it really is, to themselves. This is not a defense, it’s not an option. It happens automatically. It’s just because that’s the way kids process information.
How and why did I come up with this idea? From listening to the people who teach me over and over and over far more than any professional ever has ever taught me. These people are called patients, or clients. And what did I hear over and over and over? I’m bad (this is from adults talking about their childhoods), I caused it, I deserved it, I’m bad, it was my fault, I’m this I’m that, I’m no good. So it’s intense self-blame, self-hatred, then self punishment that follows from it. And I’m thinking to myself, “there must be something wrong with these people”. Who would ever buy this idea that any child ever deserved to be abused or neglected? So, these guys must have like really, really low IQs. Clearly not true, they have a whole range of IQs. So it has nothing to do with IQ, it didn’t have anything to do with gender. We have lots, not lots as in the majority, but we have a range of fully transgender people come in for our trauma programs now, and we have people that are intermediate and we have people that are all these different categories, so I’m very aware of that. But just explaining the principal, say it doesn’t have to do with gender, race, culture, or IQ.
So I noticed males and females, old people, young people, all different races, everybody had this locus control shift. That’s how I realized it’s not about gender, race, culture IQ. So why are they thinking like this? It’s so ridiculous. Then I thought “Ah, this is magical child thinking that’s still running the show, running the words that come out of the person’s mouth, their behavior towards themselves, how they feel about themselves, their physiological state, their relationship patterns…”. So this is the locus control shift, and it leads to very entrenched self-blame. But it has a very protective function. So I also figured out, I am puzzled as to “ok so that’s just childhood thinking, get over it already you’re a grown-up” (I never actually had that attitude). But I am intellectually wondering “Why are people holding on to it so tight? Why aren’t they getting over it?”
Well, then I started to see that there’s a payoff. So we have a little girl who’s four years old. Not huge trauma, dad moves out. So what’s the reality? She’s powerless, helpless, trapped, overwhelmed, a whole bunch of loss. There’s nothing she can do to fix the situation. Her future just collapsed, she’s lost one of her primary caretakers. Now, the number of caretakers is 50% reduced and it’s a scary world out there. But she’s this four-year-old sociologist who’s working on a PhD in Sociology. She’s examining her field data, her field data are: Daddy doesn’t live here anymore.
It’s good to have field data, but you have to have a hypothesis- a theory to explain your data. So why doesn’t daddy live here anymore? I got it! Daddy doesn’t live here anymore because I didn’t keep my bedroom tidy. Ridiculous, delusional, out of touch with reality. But this is a completely normal child using completely normal childhood cognitive processes and vocabulary to explain to herself what is going on in her world: Daddy doesn’t live here anymore because I didn’t keep my bedroom tidy. So she shifted the locus of control inside herself automatically.
Once that happens, it serves a secondary defense function. “Wait a minute, I’m not totally helpless, powerless, trapped, overwhelmed, I know what the problem is. I’ve got the problem totally contained inside of me. Daddy will see that I’m a good little girl, he’ll forgive me and he’ll move back in”
So the self-blame happens automatically, but it creates this illusion of power, control, and mastery, that protects you from the full impact of the core of the trauma which is: powerless, helpless, trapped, can’t escape it, can’t fix it. So that’s the locus of control shifter
Another core idea is that the problem is not the problem. This is trauma model therapy in general, not just for PTSD. And the attitude, the approach, is “I wanna know, what’s the person’s story?”. Where were they born? How did they grow up? What happened? What didn’t happen? Relationships? Work history? Current relationships?
And my assumption is, one of the symptoms, the social role, the errors of thinking, the self-destructive behaviors, the bad relationships- all of these things, which are symptoms of behaviors, have some sort of function or purpose. And the idea is that the presenting problem, which, let’s say it’s alcohol, so the person is heavy drinking, for real, for sure alcoholic. It doesn’t take long to figure out that the alcohol is not the basic problem, the alcohol is numbing yourself out, drowning your sorrows, not having to deal with, feel, know, think about all of the other stuff. And that’s kind of intuitively obvious with alcohol. I could get into a whole side talk about the effects of alcoholism that I’ve talked about. But scientifically it is a fact that the genetic contribution to schizophrenia, depression, alcoholism, eating disorders, is quite small and modest. Which is proven by the literature. One of my most recent books is about all that. It’s really survival stepping or strategy, with a big downside or price tag.
And so we just take that idea, which is basic family systems thinking. The identified patient is the teenager, who’s been acting out, parents know the problem, they want the problem fixed, but the family therapist’s job is to go “Ok, what is the context, the function, the purpose, of this bad behavior?” And the easy example is, “well, the parents are drifting apart towards divorce”. They don’t co-parent, they don’t co-anything. The only thing they have any joint passion on, or the only thing they work together as a team on is the bad behavior of the adolescent. Which therefore, is helping prevent divorce to keep the family together. It’s not that simple in real life but that’s the concept, the principle.
So then this leads to a very different intervention. Let’s say, take Johnny. Put him over on the mental health assembly line, give him therapy and meds. “Uh, it’s ok Johnny well thanks, nice to meet you. You don’t have to come anymore. The intervention is going to be marital therapy.” This is this revolutionary idea that sometimes, maybe it’s not the kid who’s the problem it’s actually the parents- it’s the parents who need treatment. It’s not easy to sell to the parents, but obviously true tons of times. So, it’s the same approach. Whether it’s symptoms of PTSD, hearing voices, depression, staying stuck in unhealthy relationships. I want to know- how did the person get to this point? And how is this some sort of attempt to survive? And what would they have to deal with, that they don’t want to deal with, if they stop the drinking, stop this stop that. And I say all of the time at treatment, “nobody in their right mind would want to feel that stuff, so it’s very understandable that you don’t, and you use all of these avoidance strategies, addictions and so on. But if everything was working really well, you wouldn’t be here. So something’s not working, something needs to be adjusted. Let’s figure out what that is”. So this is my general approach, which I then apply to the symptoms of PTSD.
So this is kind of a series of progressions in my thinking over the past couple decades. If we talk about cutting, the main purpose of cutting is, most of the time- which most of the time is done in private, so it’s not attention-seeking, you’re not trying to manipulate anybody- most of the time, too much stimulation, too much hyperarousal, too much sympathetic system, you’re above your window of tolerance and you cut on yourself, and *relief*, you de-escalate way back down. So it makes the bad feelings go away, and then you don’t have to kill yourself to make it through the day. So cutting is actually an anti-suicide strategy. The small percentage, I can’t give you an exact number, like 5 to 10% of people maybe, of people with complex PTSD, the problem is the opposite. They’re too knocked out, too shut down. When they cut, they at least feel something. So they’re too far below their window of tolerance and they are bringing themselves up. But the majority of times they’re way up here, you know, way too much hyperarousal, and the cutting just brings it back down. So the cutting, certainly we want to treat that, we want the person to stop that behavior, but in order for them to stop cutting, we have to figure out what’s the purpose, context, function of the cutting. And then, basically, we’re going to help the person to learn better self-soothing, self-manageable skills, solve some external life problems. So now they have more tools in their tool box. Now it’s possible to say no to cutting, because you can cope in a healthier, more adaptive way, so we use that all the time.
So then, ok, how would that apply to PTSD? How could the symptoms of PTSD be the solution to some problem? And it was not obvious at all, it took a little while to figure it out. And the tricky party of it was to not make it seem like you were blaming the victim. And in the future-oriented paper, in one of the journals that rejected it, one of the reviewers was all irate because I seemed to be blaming the victim or saying that PTSD was not really a disorder- like it came from outer space. I don’t know, it had really nothing to do with my actual paper.
But nevertheless, you have to be sensitive and you have to frame it and say it and pace it in such a way that it doesn’t come across as blaming the victim. So, a woman who has been sexually assaulted or raped a week ago comes into the rape crisis center, and the intake person says “Well, you’re just having flashbacks to solve some other problem”. Sound like good therapy? Horrible therapy. So it’s all about timing, pacing, treatment alliance. All non specific things like good treatment alliance, unconditional positive regard, good work ethic, with the therapist goals matched to the client’s goals. All of those things are fundamental to all therapies. So it’s all about the delivery and the timing.
So how could it be true that the symptoms of PTSD are not the problem? That they’re the solution to the problem in the background. And this is still Post Traumatic Stress Disorder thinking, I haven’t gone to pre-traumatic stress disorder yet, and my own thinking. So, there is on book that was helpful on that.
I think it was ‘91 or ‘92, somewhere in there, Lenore Terr, who’s a child psychiatrist in the Bay Area, published a book called Too Scared to Cry, which was about the Chowchilla bus kidnapping (Chowchilla being the town in central California). It’s a normal day, all of the kids get on the bus, and everything is fine- until two guys commandeer the bus at gunpoint, force the driver to go to a gravel quarry, burry the driver and all of the kids under some gravel- and before they do that they say “if you dig out we’re going to be here and we’ll kill you”. So they were down there like 10+ hours in a school, now that’s pretty scary and traumatic. They finally dug out, the guys were gone- who were later arrested, served a whole bunch of time in jail, got released about 8 or 10 years ago, somewhere in that ballpark- so everybody was ok. Problem solved. So Lenore Terr started interviewing these kids going forward in time. A couple years later, five years later. What does she hear? “You know, Dr. Terr, I should have known. Every single day, Mary sits on the same seat on the bus. That day she was across the aisle. I should have known something was wrong, I shouldn’t have gotten on the bus”. Next kid “You know Dr. Terr, the newspaper boy (so this is the 70’s and there’s still newspaper boys around) put the paper on that side of the sidewalk, usually it’s on the other side. I should have known something was wrong, I shouldn’t have gotten on the bus”.
So this is all magical child thinking, because where Mary is sitting and where the newspaper is has zero predictive value in terms of coping with trauma. But, because they’re kids, they shifted the locus of control. “It’s my fault, I did something wrong, I should have known”. And she calls these red flags. So the red flags are the things that you missed leading up to the traumatic event. Whether its combat, rape, car accident, natural disaster. And it’s “I shoulda, coulda”. I should have known, I shouldn’t have gotten on the bus. If it’s a rape survivor- I shouldn’t have worn those shoes, I shouldn’t have had on that lipstick, I shouldn’t this shouldn’t that.
The problem is that, if the red flag is where the newspaper is, it has no predictive value. If the red flag was “probably shouldn’t have been walking around in the neighborhood by myself at midnight”, that’s not a red flag it’s an actual risk. And you can modify that objectively. So this is all magical child thinking. Ok, so it confers, like the locus control shift in general, it confers this illusion of power and mastery. I had the power, I had the control, I just didn’t pay attention enough. What did I miss last time? I better review the tape? … and then it happened.
So flashbacks are not just the brain on the fritz symptoms, they are an attempt to review the tape of the trauma and figure out what red flags you missed last time, so then you can take evasive action in the future. You messed up last time, “shoulda coulda shoulda coulda”, you’re not going to mess up next time now you know the red flags. Maybe I missed a couple, better review the tape one more time. SO flashbacks are really not just meaningless “brain on the fritz” neurotransmitter problems. They’re not just about the past, they’re about spotting and then repaving future trauma. And the real problem in the past, really underneath it is that the trauma was not predictable. You can check out where the newspaper is 100 times, you can wear lipstick not wear lipstick, you can go for a walk in the park, none of these things would have or could have impacted the trauma, because the real problem is that it was unpredictable, you couldn’t foresee it, you couldn’t protect yourself, couldn’t avoid it. And who wants to feel that feeling and know that? Nobody. Nobody in their right mind. So you don’t, so you hold on to the locus control shift and hold on to the illusion that at least you could have done something last time. But because you’re “stupid, wrong, slack, bad, no good” it messed up last time so it was your own stupid fault, but not in the future.
Ok, so now we’ve got our list of red flags, we’re good. Now we can relax. The red flags do you absolutely no good at all if you’re not hypervision scanning looking for danger, because then you’ll just miss them again like you did the last time because you’re such a- fill in the blank with all sorts of nasty self talk.
So let’s go back in evolution for a second. So there’s this group of gazelle’s out on the Savannah there. And some of them are, you know, chilled out guys. “Oh the grass is good, life is good”. Along comes a lion, takes out one of the group, “Oh well, stuff happens”. The other half of the group is all hyperarousal, adrenaline, fear-scanning, looking for danger. Next time the lion comes around, they’re gonna spot that, they’re going to run away, they’re going to survive, and the chilled guys are gonna get eaten again. So clearly, genes that make you more prone to kicking up into sympathetic overdrive, scanning for danger, having all the symptoms of PTSD- those genes are going to be selected for in evolution because they have survival value. So therefore, all mammals have survival value genes for fight, flight, and freeze. So, to me it’s just common sense, it’s basic logic, and it makes evolutionary sense, and it’s my theory it makes sense to me chronically- and it’s actually useful.
So this is the core thing I’m talking about here today. Let’s get back into some case examples. But before we do that, let’s cycle back into what is another purpose for the symptoms of PTSD. Which is kind of future-oriented but not totally. So, just to repeat, the future orientation doesn’t replace PTSD, it doesn’t replace all of the existing literature or techniques. It opens up another dimension that we should consider talking about- see how active it is, does it need attention? And therapies that I’m aware of so far do mention the future, so in EMDR there’s the future template, which is a component of EMDR. So basically what it is is that problems that happened in the past are causing symptoms in the present and are going to persist in the future. So you want to look at some future scenarios: What would you think? What would you feel? What would you do? And then it’s basically damage persisting into the future that you want to take care of in the present. There’s no survival function aspect to it. In DSM 4, which was dropped out in DSM 5, there’s a PTSD symptom of a force-shortened future. So that just meant the future crashed, was empty, dark, blank negative. Again, it’s about the future, but there wasn’t a future-oriented survival strategy.
So let’s just imagine that I’m correct here. That it’s not the whole story but it’s an important part of the story. Now we have somebody who is treatment-resistant- not getting anywhere not cooperating, so we either say that we’ve got to try medication number 17, or we’ve got a real problem here and they’re just not motivated, what can I do? Those are stereotypical reactions to the treatment-resistant case. So it’s kind of blaming the victim basically. It may not be a conscious choice, it may be a character defect, there’s all kinds of ways to make it sound politically palatable, but basically the treatment-resistant patient has either got something wrong with them biologically or something wrong with them psychologically- it’s not my fault.
Well first of all, I completely disagree with that approach in general. Instead of thinking it’s the clients fault, we ought to be thinking “maybe my treatment model sucks”, or maybe it doesn’t apply to everybody, maybe I don’t have the right techniques, or maybe I’m not understanding. That’s just sort of a general attitude, but here- somebody is not getting better, they’re not letting go of their symptoms, why? Well maybe it’s because we’re trying to take away their future-oriented survival strategy without even realizing that’s what we’re doing, and without replacing it with anything, or even talking about it.
So therefore, which is not based on any research, outcomes or evidence so far, the idea is- Ok, if you have somebody who’s had a single-car wreck and you do whatever you want to do: CBT, thought-field therapy, psychoanalytic psychotherapy, on and on and on. It’s relatively easy to treat most of the time, you get good resolution, you don’t have to worry about future orientation. But when you have complex PTSD, massive locus of control shift, all kinds of symptoms, and the person is stuck in resistance, not responding to antidepressants, not responding to prolonged exposure, standard CBT. Now it’s time to go “wait a minute, maybe this person is resistant because I haven’t talked about the future”. The powerlessness and helplessness of the future, if they don’t hold onto the symptoms.
Holding onto the symptoms; again, the problem is not the problem, the problem is, they’re not going to have coping strategies in their way of thinking if you just strip away the locus control shift, self-blame, symptoms. And I think that the self-blame, constantly, is driving- it’s the wind and the sails of the PTSD, continuing to maintain the symptoms. Because, since it was your stupid fault last time, you don’t deserve to have a good life, have any peace and quiet, have a good night’s sleep. So how are you going to make sure that you don’t? Well let’s keep the negative self-talk going, let’s keep the hyperarousal and the symptoms and the stress because you don’t deserve to get off that easy. Because you’re either just incompetent in general, dumb, or you don’t deserve it anyway because you’re a bad little girl, always have been- or bad big girl, or bad big boy.
But there’s one other little element I want to mention, until I cycle into case examples. And that is, I’m working with somebody, quite a long time ago actually, and clearly I wasn’t thinking, because I didn’t have the words and the complexities of PTSD in my mind- which was actually invented by Judith Herman a long time ago. But this woman is borderline, dissociative, depressed, etc. and I’m trying to work with her in this therapy group, and she’s just holding onto the symptoms and stuck. So I’m thinking, “What’s the deal here? What’s going on? What do I need to do?” So I say to her, with this blinding insight that I’m capable of “you seem to be holding onto the symptoms really hard, why are you doing that?” And so she explained. And this is how I learn. So I asked people why are you doing that? How is that helping you in anyway? What’s the purpose of that? How did you get onto this coping strategy, where did it come from? And they explain it to me, and then I write it in a book and I’m the expert- that’s literally how it works.
So why are you holding onto the symptoms so tight? Why don’t you let go? So she explains it to me: “That’s what my perpetrators have been telling me to do my whole life”. Let go of the symptoms, get past it. Well what do they actually mean? Don’t talk about it. Don’t cause any discomfort around here. Pretend it didn’t happen, it was no big deal, carry on, be quiet. So she explained to me, if she does that, she’s dishonoring, invalidating, betraying herself. So her symptoms of PTSD are her memorial to her trauma. “That’s what proved that they hurt me so bad. So if I get rid of the symptoms, first of all I have to adjust to being this person who doesn’t have a huge array of symptoms all the time, but basically I’ll be pretending it never happened. I’ll be dancing to the tune of my perpetrators, I’m not willing to do that, so I have to hold on to the symptoms.” To which I respond, “Wow, that really makes sense. Ok, absolutely that totally makes sense”. But maybe there’s another option. So your symptoms are basically the memorial to your trauma, maybe there’s a cooler memorial. Because when you hold onto your symptoms, you’re basically living your life in the shadow of the perpetrator. How you feel, your emotional state, your arousal state, how you think about yourself, relationships, the risks you take in life, they’re all dominated and controlled by what the perpetrator(s) did to you. What if you walked out of the shadow of the perpetrator and you were actually a recovered human being? Now that would be a cool memorial. And she goes “Oh,” and one of my favorite feedback lines from patients is “… I never looked at it that way before”. And it’s not “Oh, that’s an interesting intellectual idea here in my cortex” it’s that kind of “A-ha” moment. What we’ve done there is complete treatment resistance, holding onto the symptoms just because she’s a borderliner this and that. But we figured out that this is for very good reason, and there’s another option, there’s another way out of the maze. It doesn’t mean she’s cured by any means, but now the whole crack has opened up. Now it’s actually rational, it makes sense to make a commitment to letting go of the symptoms, which will take a lot of work. But before that, we weren’t even going to get started.
To me, this is the power of cognitive therapy, that is just kind of cracks open the door, lets a little light in, and then you get to work. With all kinds of different therapies- some bottom-up processing, some out-of-sensory, experiential, cognitive-behavioral, all of these things. The more tools in your toolbox, the better. So I’m not so much talking about the tools, I’m really talking about the perspective. If you do x-style of therapy for post-traumatic stress disorder, just do x- style of therapy for pre-traumatic stress disorder. It’s really more about changing the perspective than the tools of such.
And so then I think to myself, that’s something I have to keep in mind- that the symptoms are more of a memorial to the trauma. And then other people start explaining the same thing. If I cut on myself and I have scars all over, they’ll see how much they hurt me. And the ultimate is: “If I kill myself, then they’ll me sorry, then they’ll see how much they hurt me”. And my response is “it’s totally understandable that someone would feel that way, but let’s step back a bit. If somebody who’s a survivor of childhood abuse, like you are, like everybody in the group is, do we go ‘yay! Score one for the victims!’? No, the perpetrators just won another battle. And what are the perpetrators going to say? It’s highly unlikely that they’ll go “Oh gee, we’re so sorry, now we get it”. They’ll just go “Ah, it’s ok, she was always a nutcase, we’re not surprised she killed herself, we’re better off without her, thank goodness! Secret is safe now”. Are you sure you want to give that gift to the perpetrators? So I’m trying to physically activate “I hate the perpetrators, I’m angry at them” (the problem being they’re also family members so I also love them). But I’m trying to activate the fight part and get them to turn their anger into rebellion mode. “I’m not gonna do what they want, I’m not gonna follow that recipe anymore, I’m gonna take care of myself, I deserve it…” Reverse the locus control shift, get the fight energy going and steer it towards recovery.
So there are many ways in which it’s true in the symptoms of PTSD that the problem is not the problem, one being this future-oriented aspect. So let me just prove a couple of cases here. And Keither is going to alert me as to whether or not you guys have questions.
There’s many sub-sub-sub groups of people that I’ve worked with. If we just divide into civilian and military trauma. One of my books is called Self Blame and Suicidal Ideation in Combat Veterans- it’s basically a locus control shift analysis. And there’s different scenarios, it’s basically an IED blew up, could be a firefight, could be this could be that. But very typically the scenario is- I’ve worked with some Vietnam vets but not. Mostly Afghanistan, Iraq, etc.- big firefight going on, bullets zinging all over the place. Me and my buddy were hunkered down behind the vehicle and I told him to change positions with me so I could get a better look at what was going on. 30 seconds later, a sniper’s bullet came, hit him in the head and killed him.
It’s all my fault, I should have known, I shouldn’t have changed positions, and it wraps all the way up to literally “I’m a monster” or basically “I’m a war criminal” and “It’s my fault, I’m a murder. So I’ve put myself through a court marshall and I’ve sentenced myself to death,” equals I’m suicidal which is why they’re in the hospital, “and getting off too easy, I don’t deserve that. So I gotta keep myself on the planet, tormenting myself, threatening to kill myself, pointing out how I’m a murderer forever”. And so then we want to reverse the locus control shift, cognitive, some experiential, and some general process attacks. So, again, the more tools in the toolbox the better. But we want to reverse the locus control shift. “Oh I get it, but how do I work on reverse the locus control shift?” By doing quotes behavioral analysis. As this Canadian-born, raised, and educated guy who’s never been in the military, never been in combat, never had a friend die in combat, where do I get off telling these guys what’s up? I stepped outside the magical child thinking. Because I’m not in that trauma. I am able to be an, at least somewhat, rational, reasonable adult in my logical mind- whereas this guy is all in the magical childhood thinking locus control shift. So by getting him to look at himself through my mind, he can take a step back and go “Oh wait a minute, yeah let’s walk through it in detail here”
“So you’re in the combat situation, there are bullets flying all over the place. I was just watching season 3 episode 12 of Fauda”, which is a very intense program and really well done. It’s basically Israeli special forces guys who are also fluent in arabic going into Palestine, doing all types of missions, and it’s very powerful in showing PTSD because you get to know these guys, but it’s also very powerful in showing both sides. Because both sides are talking about “God’s on our side”, and all the human cost and the suffering and the anger and the revenge, back and forth. Very well made show, and it’s got a sniper in it. There are multiple snipers.
So I asked the guy, “Okay, why do armies have snipers anyway?”
“Because they’re highly effective and they have a lot of kills they rack up”
So it’s just a fact that snipers take guys out. Agreed. That’s why we have them, that’s why the enemy has them. So would you agree that not every single time that a US soldier dies in combat, it has to be another US servicemen’s fault. Sometimes it just happens. Ok, we agree on that. It’s kind of belaboring the obvious, but not really. Because in the magical child thinking, he’s not got a grip on all this stuff.
“Ok, so if you had known that the sniper’s bullet was going to come out at exactly that trajectory at exactly that time, what would you have done?”
“Well I would have changed my position, I would have ducked down, I would have gotten my buddy to duck down”.
“Right, so the fact that you didn’t do that is proof that you didn’t know, so the actual problem is not that you ‘coulda shoulda’ and it’s your fault. The actual problem is that there was nothing you could do about it, that it wasn’t foreseeable”.
Then I might go, “Well what’s wrong with all the other guys on your platoon? Why didn’t they take the sniper out?”
“Well they couldn’t, it was a big firefight, he was too far away in a little tiny opening”
“Okay, so you’re not blaming any of the other guys in your group, what’s the difference between you and them? You were as powerless, as overwhelmed as they were. Maybe, if you looked at yourself the way you looked at them, some of the self-blame would lift.” Because the problem is not the problem.
And so, that’s a military situation. And that’s just trying to get the guy to review it all and think “maybe I’m not a war criminal, maybe it wasn’t my fault, maybe I was doing the best I could, war just sucks”. So we let go of the self-blame self hatreds, therefore we’re looking at letting go of the self-punishment, equals letting go of the suicide.
So this is still similar to treatment for PTSD and suicide. Ok, so another guy that I worked with, special forces style. Easily could be a linebacker in the NFL- strong, tough, well-trained. And so I clarify with him, “If you’re on a mission, or let’s say we’re planning a mission, you’re the kind of guy we want to call on, right? I mean you’re tough, you’re on it, you’re in there, you get the job done, you’re back out”. Of course it’s completely true and he’s proud about that, no hesitation- completely true. “So you’re tough, strong, you can go into combat and take out all the scary stuff very efficiently. Most people would be frozen.”
“Yup that’s me.”
“Ok, so if you’re so tough, how come you’re scared to feel your feelings?”
So that’s me kind of opening a jar, trying to get the lid off of it so we can feel all the feelings, because we’ve got all this numb out, shut down, drinking, avoidance strategies. But the PTSD under there is very active and life is a mess and he’s suicidal because it’s his fault this, that and the other. But in this particular situation, this guy was assigned the job of transporting the commanding officer. So he’s got to get this guy on schedule. And this guy is kind of talkative and tends to be 5-10 minutes over and it’s gotta herd him, get him to the next appointment, take care of security, and keep an eye on things.
Simultaneously with that, he’s befriended a 10-12-year-old Afghan boy. Which is very common with troops over there. And so, this particular day, the commanding officer is 10 minutes late, he finally comes out of the meeting and my patient can’t interrupt- hops in the jeep and they’re going to the next place. Driving along the way , they get to this scene where there’s just been a big firefight, and there’s the 12-year-old boy lying dead on the ground. “It’s my fault, I’m a murderer, I killed him, I should have known.”
“Well if you had known, what would you have done?”
“I would have left the commanding officer, I don’t care. I would have taken out the bad guys.”
“Ok, so why didn’t you just burst into the meeting and get the commanding officer- ‘Hey jerk, time to go’?. Can’t do that, so the problem is not that it was your fault, the problem is that it was unforeseeable and helpless”. He was kind of getting it and kind of opening up, but still like a numbed out, shutdown tough guy. So this is the situation I give him:
“If you could go back to Afghanistan and talk to the boy’s mother, what would you want to say?” The flood gates opened. Tears, crying on my shoulder shaking.
“I just want to tell her I’m sorry”
So by taking over the locus of control and shifting the blame off, we get into the underlying grief, sadness and loss. The problem wasn’t that it was his fault, it’s that it wasn’t his fault, unpreventable. So this is just a general function of PTSD symptoms, but maybe in the future he might deserve forgiveness? Well not today and not tomorrow, so now we’ve got self hate hanging in the center of the locus control shift in order to stay away from the powerless, helpless underlying reality.
Back to the civilian world. So a woman is acutely suicidal, in her late twenties, and what is it that she’s got herself on death row for? When she was 16, she was dating a guy and they were drinking underage. He was with a motorcycle, they were all going in cars. So this guy came to the party on a motorcycle, drank too much, and she was going to get back on the motorcycle and drive to the next party, but her friend was nagging her and nagging her. And she said “Ok you get on the motorcycle and I’ll get in the car”. Less than a mile down the road, motorcycle accident, the guy and the girl both died.
She’s a murderer, it’s her fault. It’s exactly the same logic and rationale, it’s just civilians in a different situation. So virtually every time- I should have known, could have known. It’s civilian, it’s different gender, it’s a different form of trauma, but the underlying theme is the same. This is keeping the PTSD going, keeping the flashbacks, keeping the hyperarousal. So for me this is something that we should focus on and take into account.
Ok, what would happen if you didn’t have flashbacks, if you weren’t in hyperarousal if you weren’t scanning for danger? Well, the answer is going to be “this would happen, that would happen”.
One more military example. This guy I’m working with, he gave a guy under his command permission to go out on a motorcycle. Not on a mission, just for a ride, in what seemed to be a safe area. Hits an IEd and he dies. What’s my patient’s motto? “Nobody is ever going to die on my watch again.” Beautiful motto, who wouldn’t want that. Problem is he comes back home, and the people who aren’t going to die on his watch are his kids. Every night, in a safe neighborhood, he gets up and patrols the perimeter of his property armed. And he is very overprotective and constantly on them, and they’re like “Dad! Dad! Lighten up”. Basically, the goal of the treatment was “I think your threat assessment is off”. Basically, his patrol level was combat and the danger of his neighborhood was down here. It’s an overresponse and look at the price the kids are paying. It’s locus control, if you had known, you wouldn’t have let him go out.
So, how about some questions?
Thank you, Colin.
Q: The first question is “What is your take on the therapeutic relationship as a vessel for future-oriented coping?”
A: The therapy space is always the vessel for any healing that therapy has to offer. In therapy, all these nonspecific factors- good strong treatment relationship, good work ethic on both sides, accurate empathy and genuineness. That’s 50% of the power of therapy. Without that, nothing is going to happen.
Q: Can you speak to the recent addition of fawn within the mammalian defense mechanisms?
A: When you’re just simple folks like me and you have fight, flight and freeze, you can kind of keep track of everything. But turns out there’s more. So there’s fawning, submissiveness and you sit there like a limp bundle, all on the spectrum of responses. I see it more as managing the perpetrator strategy. In the sexual abuse sector, it’s more consenting. Many people have told me “It’s my fault because I initiated it, the worst thing at all is I experienced some type of arousal and pleasure. Or at least I like the attention”. Sometimes in forced survival you have to take the bad option, but when you have a choice, of course you’ll take the better option. Even if you have to deal with a lousy substitute, that’s not what you want to have happen.
Q; Hyperarousal is definitely seen in the example of a house fire. How can somebody be taught to decrease their hyperarousal when hearing fire trucks, for example?
A: That’s just a classic trigger. So for the combat guy it’s hearing a backfire. I would use the example. So you’ve been in the mental health system, apparently only women can be borderline. Even though men display the symptoms just as often it’s always women. So wait a minute, what if the guy is special forces or navy seal, tough style. He’s back 10 years later, in his backyard. Then all of the sudden a helicopter flies past, giant flashback, he dives under the hedge. Nobody goes, “Oh what a borderline hysteric”, they go “thank you for your service, Hero, you have PTSD”. But he’s clearly been triggered by a reminder of the trauma. But if your trauma is child abuse and Uncle Joe always wore a blue baseball cap when he came over, then all the sudden you walk past a guy in a blue baseball cap, all of the sudden you’re a hysterical woman who overreacts. It is a normal response to the past transposed onto a less-dangerous present. This is what PTSD is all about. One problem is the threat evaluation is off cognitively because the situation is not the same. So then we need to change our self-talk, talk ourselves down for that, work on our breathing, all these other coping strategies. And so, the first thing is to normalize. You’re not just some mentally ill personal with symptoms because your brain is wrecked and your genes are all messed up. This is an understandable reaction, it’s a trigger. Now let’s get to work on some of our coping tools. Some of it can also be memory work. The data seems to show that the amount of amnesia does not seem to affect how long you respond to prolonged exposure. You can memorize bits and pieces in order to normalize exposure. But people do want to tell the story, construct a trauma narrative. So just having another human being at the campfire listening to what the tiger did- it’s basic human nature.
Q: Can you give a case example for females with self-hatred evolving from unloving, neglectful family of origin, and in adulthood, choosing to stay in an unhealthy relationship, shifting locus of control?
A: That is a big long question but that goes to the core of what we do all the time. SO in the trauma program we have 90% women, 10% men. We have lots of people currently or previously in these relationships. And one of the core problems is the problem of attachment to the perpetrator. And the problem is, you get set up, you’re a mammal, you bond, you connect. But your caretakers are also your perpetrators. And you can’t stay in “I’m out of here” mode because you’re a dependent little kid. So this is the push, pull “I hate you don’t leave me attachment”. You push them away and okay you’re safe, but two seconds go by and it’s oh my god my caretakers are far. It’s cyclical. This borderline push-pull is the logical outcome of having primary caretakers who are your perpetrators. So you’ve got the illusion that it’s your fault, you’re bad, no one else would want you anyway. And what would you have to deal with if you didn’t go back to that person? If you did reverse the locus control shift and decided you didn’t deserve to be treated that way.
Q: Can you please walk through an example with repeated sexual assault and rape?
A: I assume this means more in teenage and adulthood. We see cases of some women, through adulthood, being raped several times. And it’s all locus control shift “It’s my fault”, “I’ve got a target on my forehead”, “I’m making it happen”. Pertaining to an adult. One thing is simple education. What would be your estimate- what percentage of female undergraduate college students are raped throughout their years of undergraduate studies? It’s 25%. So this is a very common problem, and our studies have been burying that secret forever. Do you think that all of those other women deserved to be assaulted? Why you? Why not them?
Then we look at all of the unhealthy risk-taking behaviors you seem to be doing, what are the relationships that you are getting into? We want to know the whole context. What is it inside you that’s keeping you in this pattern? What can you do to get out? Then we want to look at the inside. Which is all locus control shift, self-blame, attachment to the perpetrator. And then forgiving yourself for what’s not your fault to start with.
Thank you Colin, thank you so much for this presentation.
I would like to quickly go over, for our CE’s after this presentation you will be receiving an email with this evaluation form. Please fill that out and send it back, and you will get this nifty certificate from us.
Next week, we have TJ Woodward who is affiliated with the Beacon House speaking on creating a new narrative for conscious recovery. And we will have Dr. Rob Weiss on the fusion of substance use and sex addiction join us on May 15th.
We’d like to thank everybody again for joining us. Thank you so much for being with us today.
Gateway Foundation and Beacon House are open and accepting patients inpatient and virtual outpatient.
Thank you, everybody, have a great Friday and a great weekend and we appreciate you being a part of this here today. Take care now.