integrative trauma therapy: for complex experiences
Unresolved trauma — a wound — is common for most human beings. Trauma-focused work is essential to heal and move forward.
Trauma manifests in a wide variety of symptoms, from chronic fatigue, anxiety, and burnout to relationship problems and financial woes. Individuals who have experienced trauma become trapped in their trauma responses because they’re trapped in the (emotional, physical, and relational) memories of their traumatic experience(s). This means that the individual is reliving the experience over and over again, either cognitively (remembering the events or beliefs associated to it) or emotionally (remembering how they felt back then in their bodies or in the relational experience). As a result, their brains and bodies respond as if they were still in that situation, leading to the ongoing trauma response (PTSD, C-PTSD). These feelings can be triggered easier in the present than we would expect.
Our work together in trauma-focused therapy is to create safety and steadiness inside, gently get to know the ways trauma affects your life and lessen the charge and intensity of traumatic memory. When guided thoughtfully, you can address it, move through it, and learn how to apply the lessons of healing and recovery to your life, work, and relationships. Eventually, if you stay the course, you’ll develop a more peaceful experience of living and flourish.
Each therapy experience for the treatment and resolution of traumatic experiences is unique, Michael offers AEDP, AEDP Parts Work, IFS, and Attachment-focused EMDR as pure experiences of each therapy as well as blended, for effectiveness.
Explore Trauma Therapy with Michael here
making sense of trauma and our reactions
Traumatic experiences are, by their very definition, frightening and overwhelming. Trauma literally means "wound, injury, or shock.” People differ in what they find traumatic. However, some events are so stressful that most people would find them traumatic. In the past many people believed that only physical harm or danger caused trauma. We now know that emotionally stressful events can cause trauma, particularly during childhood and in the absence of caring supports. Trauma may begin as acute stress from an actual or perceived life-threatening experience or as the end product of cumulative stress. Both types of stress can seriously impair a person’s ability to function with resilience and ease.
And if you have experienced trauma, the world can feel like a threatening place to survive, close relationships can feel complicated, and a belief that you are not enough or unlovable can linger. If this describes you, it is not your fault and you have not failed. You can recover.
If you were harmed, especially during childhood, it’s only natural that traumatic experiences would leave you untrusting or confused about what constitutes a safe environment or a loving, safe relationship. Fear and lack of safety might compel you to continuously scan your environment for potential threats. You may have relied on strategies to survive, such as dissociation, a protective mechanism that disconnects you from threatening experiences and from emotion and our bodies in the present. You’re not broken. You were put into situations where you had to disconnect from parts of yourself to survive. You were and are doing the best you with the situation you’ve experienced.
One way to think about relational trauma, PTSD, complex trauma/C-PTSD is as conditions where someone’s gotten trapped in a trauma response. Trauma responses are defense mechanisms against danger, whether that danger is real or only perceived. It’s important to note that trauma responses are natural and (usually) healthy responses to danger—however, in the case of complex trauma, a person may perceive everything — people, places, experiences — as dangerous and respond accordingly.
the body + trauma: telling the story without words
When trauma has been recurrent or we are young and vulnerable or have inadequate support, we can be left with intense emotional and physical responses that “tell our story” without words and (sometimes) without the knowledge that we are re-experiencing events and feelings from long ago. Emotional suffering and relationship difficulties are common when you’ve experienced trauma.
Some forms of emotional suffering show up as:
self-criticism
difficulty sleeping or concentrating;
physical pain or muscle tension;
sudden or intense irritability, anger, or edginess;
a sense of dread or sudden bouts of panic;
avoidance of certain people, places, and things that remind you of past bad experiences;
dissociation: numb or detached some or much of the time
tumultuous relationships;
difficulty connecting to others;
intimacy or sexual issues;
recurrent dreams or disturbing and intrusive images; thoughts or flashbacks;
or feeling “shattered” or broken inside.
If you or someone you care for identifies with these emotional and physical experiences, they may be experiencing a reaction to trauma.
what is complex trauma?
Complex Trauma describes a series of traumatic experiences that goes beyond a one-time incident. Complex Trauma tends to:
be repeated or ongoing;
be difficult or impossible to escape from;
occur within a personal relationship;
begin in childhood, so that it affects a child’s development; and
be covered up, kept secret or denied.
Complex Trauma Takes Many Forms and Combinations:
lived in an unpredictable, inconsistent, scary, chaotic, overwhelming or complicated home with parents, caregivers or individuals with untreated addiction, mental health or problematic personality issues;
experienced traumatic early caregiving like physical or emotional neglect or abandonment, intrusive, overbearing parenting styles or other daily, unescapable persistent early attachment ruptures;
consistently felt both frightened by and drawn to those who cared for you;
experienced multiple, prolonged, or chronic events, such as childhood sexual, physical, psychological or emotional abuse;
experienced a persistent feeling that you did not belong, felt "other" or bullied at home, at work, at school, and/or in your community;
witnessed or experienced acts of violence, an accident, a natural disaster, a life-threatening medical illness, or the death of a loved one, often with little or no support.
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This is a really important important question.
The 10 most common forms of trauma fall into three categories: physical/emotional abuse, neglect and household dysfunction. They generally include the following:
Physical abuse
Sexual abuse
Emotional abuse
Physical neglect
Emotional neglect
Mental illness
Divorce
Substance abuse
Violence against your mother
Mental illness
Having a relative who has been sent to jail or prison
With that said, trauma is a person’s emotional response to a distressing experience. Few people can go through life without encountering some kind of trauma. Unlike ordinary hardships, traumatic events tend to be sudden and unpredictable, involve a serious threat to life—like bodily injury, death or psychological annihilation —and feel beyond a person’s control.
Most important, events are traumatic to the degree that they undermine a person's sense of safety in the world and create a sense that catastrophe could strike at any time. Parental loss in childhood, auto accidents, physical violence, sexual assault, military combat experiences, the unexpected loss of a loved one are commonly traumatic events.
Trauma is a deeply disturbing event that infringes upon an individual’s sense of control and may reduce their capacity to integrate the situation or circumstances into their current reality. When most people think about trauma, they tend to think about those who have been exposed to war, combat, natural disasters, physical or sexual abuse, terrorism, and catastrophic accidents. These are some of the most profound negative, overwhelming experiences one can endure. However, a person does not have to undergo an overtly distressing event for it to affect them. An accumulation of smaller or less pronounced events can still be traumatic, but in the small 't' form.
How a situation impacts a person is largely dependent on predisposing factors, such as the individual’s past experiences, beliefs, perceptions, expectations, level of distress tolerance, values and more. For example, not all military service members who have engaged in combat are diagnosed with PTSD or develop post-trauma symptoms. Whether one develops trauma-reaction symptoms or not can be due to a multitude of reasons, some of which include the predisposing factors described above, in addition to the individual’s ability to process their experience without the presence of significant avoidance.
The DSM-5 defines a PTSD trauma as any situation where one’s life or bodily integrity is threatened; these are typically large ‘T’ traumas.
While small ‘t’ traumas for the most part would not lead to the development of pure PTSD symptoms, it is possible that a person can develop some trauma response symptoms. In other words, the person may experience increased distress, mood changes, relationships difficulties, social, generalized or panic anxiety symptoms, loss of sense of self, spiritual connection or general emptiness and/or decreased quality of life.
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Acute trauma reflects intense distress in the immediate aftermath of a one-time event and the reaction is of short duration. Common examples include a car crash, physical or sexual assault, or the sudden death of a loved one. EMDR is particularly helpful for acute trauma.
Chronic trauma can arise from harmful events that are repeated or prolonged. It can develop in response to persistent bullying, emotional or physical neglect, abuse (emotional, physical, or sexual), and domestic violence.
Complex trauma can arise from experiencing repeated or multiple traumatic events from which there is no possibility of escape. The sense of being trapped is a feature of the experience. These traumas are often experienced relationships.
Like other types of trauma, it can undermine a sense of safety in the world and beget hypervigilance, constant (and exhausting!) monitoring of the environment for the possibility of threat.
Insidious trauma refers to the daily incidents of marginalization, objectification, dehumanization, intimidation, et cetera that are experienced by members of groups targeted by racism, heterosexism, ageism, ableism, sexism, and other forms of oppression, and groups impacted by poverty.
Secondary or vicarious trauma arises from exposure to other people’s suffering and can strike those in professions that are called on to respond to injury and mayhem, notably physicians, first responders, and law enforcement. Over time, such individuals are at risk for compassion fatigue, whereby they avoid investing emotionally in other people in an attempt to protect themselves from experiencing distress.
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For shorthand, trauma’s are sorted into two categories: Large-T trauma and Small-t trauma.
A large-T trauma is distinguished as an extraordinary and significant event that leaves the individual feeling powerless and possessing little control in their environment. Such events could take the form of a natural disaster, terrorist attack, sexual assault, combat, a car or plane accident or emotional, physical, psychological and sexual abuse.
Helplessness is also a key factor of large ‘T’ traumas, and the extent of experienced helplessness is far beyond that of a small ‘t’ trauma. Large ‘T’ traumas are more readily identified by the experiencer, as well as those who have any familiarity with their pain and suffering.
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For shorthand, trauma’s are sorted into two categories: Large-T trauma and Small-t trauma.
Small ‘t’ traumas are events that exceed our capacity to cope and cause a disruption in emotional functioning. These distressing events are not inherently life or bodily-integrity threatening, but perhaps better described as emotionally-threatening due to the individual left feeling notable helplessness. Some examples include:
* Interpersonal conflict
* Infidelity
* Divorce
* Abrupt or extended relocation
* Legal trouble
* Financial worries or difficulty
Small ‘t’ traumas tend to be overlooked by the individual who has experienced the difficulty. This is sometimes due to the tendency to rationalize the experience as common and therefore cognitively shame oneself for any reaction that could be construed as an over-reaction or being “dramatic.” Other times, the individual does not recognize just how disturbed they are by the event or situation.
Perhaps surprisingly, sometimes these events are also overlooked or dismissed by a therapist. This usually does not happen due to the therapist lacking empathy, but rather it occurs due to a lack of understanding about the importance of these experiences for a person’s functioning.
One of the most overlooked aspects of small ‘t’ traumas is their accumulated effect.
While one small ‘t’ trauma may not lead to significant distress, multiple compounded small ‘t’ traumas, particularly in a short span of time, are more likely to lead to an increase in distress and trouble with emotional functioning. In fact, it is likely that the reason many individuals present for psychotherapy is due to an accumulation of small ‘t’ traumas. These traumas may have occurred over the course of one’s life or condensed in the recent past.
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Dissociative disorders or Dissociative adaptation are adaptive conditions that involve experiencing a loss of connection between thoughts, memories, feelings, surroundings, behavior and identity. They involve disruptions or breakdowns of memory, awareness, identity, or perception. These adaptive conditions are associated with Complex Trauma and include escape from reality. Managing everyday life can feel harder.
In the context of severe chronic abuse, the reliance on disassociation is adaptive, as it succeeds in reducing unbearable distress, and warding off the threat of extreme psychological overwhelm that is further damaging to the person’s sense of self and well-being.
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Research tends to show that dissociation stems from a combination of environmental and biological factors. The likelihood that a tendency to dissociate is inherited genetically is estimated to be zero (Simeon et al., 2001).
Most commonly, repetitive childhood physical and/or sexual abuse and other forms of trauma are associated with the development of dissociative disorders (e.g., Putnam, 1985). In the context of chronic, severe childhood trauma, dissociation can be considered adaptive because it reduces the overwhelming distress created by trauma. However, if dissociation continues to be used in adulthood, when the original danger no longer exists, it can be maladaptive. The dissociative adult may automatically disconnect from situations that are perceived as dangerous or threatening, without taking time to determine whether there is any real danger. This leaves the person “spaced out” in many situations in ordinary life, and unable to protect themselves in conditions of real danger.
Dissociation may also occur when there has been severe neglect or emotional abuse, even when there has been no overt physical or sexual abuse (Anderson & Alexander, 1996; West, Adam, Spreng, & Rose, 2001). Children may also become dissociative in families in which the parents are frightening, unpredictable, are dissociative themselves, or make highly contradictory communications (Blizard, 2001; Liotti, 1992, 1999a, b).
The development of dissociative disorders in adulthood appears to be related to the intensity of dissociation during the actual traumatic event(s); severe dissociation during the traumatic experience increases the likelihood of generalization of such mechanisms following the event(s). The experience of ongoing trauma in childhood significantly increases the likelihood of developing dissociative disorders in adulthood (International Society for the Study of Dissociation, 2002; Kisiel & Lyons, 2001; Martinez-Taboas & Guillermo, 2000; Nash, Hulsey, Sexton, Harralson & Lambert, 1993; Siegel, 2003; Simeon et al., 2001; Simeon, Guralnik, & Schmeidler, 2001; Spiegel & Cardeña, 1991).
https://www.isst-d.org
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Amnesia refers to the inability to recall important personal information that is so extensive that it is not due to ordinary forgetfulness. Most of the amnesias typical of dissociative disorders are not of the classic fugue variety, where people travel long distances, and suddenly become alert, disoriented as to where they are and how they got there.
Rather, the amnesias are often an important event that is forgotten, such as abuse, a troubling incident, or a block of time, from minutes to years. More typically, there are micro-amnesias where the discussion engaged in is not remembered, or the content of a conversation is forgotten from one moment to the next. Some people report that these kinds of experiences often leave them scrambling to figure out what was being discussed. Meanwhile, they try not to let the person with whom they are talking realize they haven’t a clue as to what was just said (Maldonado et al., 2002; Steinberg et al., 1993; Steinberg, 1995)
https://www.isst-d.org
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There are four main categories of dissociative disorders as defined in the DSM-5. The four dissociative disorders are: Dissociative Amnesia, Dissociative Fugue, Dissociative Identity Disorder, and Depersonalization Disorder (American Psychiatric Association, 2000; Frey, 2001; Spiegel & Cardeña, 1991).
DISSOCIATIVE AMNESIA is characterized by an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness. The amnesia must be too extensive to be characterized as typical forgetfulness and cannot be due to an organic disorder or DID (American Psychiatric Association, 2000; Frey, 2001; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg et al., 1993).
DISSOCIATIVE FUGUE is characterized by a sudden, unexpected travel away from home or one’s customary place of work, accompanied by an inability to recall one’s past and confusion about personal identity or the assumption of a new identity. Individual’s suffering from Dissociative Fugue appear “normal” to others. They are generally unaware of their memory loss/amnesia (American Psychiatric Association, 2000; Frey, 2001; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg et al., 1993).
DEPERSONALIZATION DISORDER is characterized by a persistent or recurrent feeling of being detached from one’s own mental processes or body. Individuals suffering from Depersonalization Disorder relate feeling as if they are watching their lives from outside of their bodies, similar to watching a movie (American Psychiatric Association, 2000; Frey, 2001; Guralnik, Schmeidler, & Simeon, 2000; Maldonado et al., 2002; Simeon et al., 2001; Spiegel & Cardeña, 1991). Individuals with Depersonalization Disorder often report problems with concentration, memory and perception (Guralnik et al., 2001). The depersonalization must occur independently of DID, substance abuse disorders and Schizophrenia (Steinberg et al., 1993).
DISSOCIATIVE IDENTITY DISORDER (previously known as Multiple Personality Disorder) is the most severe and chronic manifestation of dissociation, characterized by the presence of two or more distinct identities or personality states that recurrently take control of the individual’s behavior, accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. It is now recognized that these dissociated states are not fully-formed personalities, but rather represent a fragmented sense of identity. The amnesia typically associated with Dissociative Identity Disorder is asymmetrical, with different identity states remembering different aspects of autobiographical information. There is usually a host personality who identifies with the client’s real name. Typically, the host personality is not aware of the presence of other alters (American Psychiatric Association, 2000; Fine, 1999; Frey, 2001; Kluft, 1999; Kluft, Steinberg & Spitzer, 1988; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg et al., 1993). The different personalities may serve distinct roles in coping with problem areas. An average of 2 to 4 personalities/alters are present at diagnosis, with an average of 13 to 15 personalities emerging over the course of treatment (Coons, Bowman & Milstein, 1988; Maldonado et al., 2002). Environmental events usually trigger a sudden shifting from one personality to another (Maldonado et al., 2002).
DISSOCIATIVE DISORDER NOT OTHERWISE SPECIFIED (DDNOS): DDNOS includes dissociative presentations that do not meet the full criteria for any other dissociative disorder (American Psychiatric Association, 2000; Steinberg et al., 1993). In clinical practice, this appears to be the most commonly presented dissociative disorder, and may often be better characterized by Major Dissociative Disorder with partially dissociated self states (Dell, 2001).
https://www.isst-d.org
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Identity confusion is a sense of confusion about who a person is. An example of identity confusion is when a person sometimes feels a thrill while engaged in an activity (e.g., reckless driving, drug use) which at other times would be repugnant. Identity alteration is the sense of being markedly different from another part of oneself. This can be unnerving to clinicians. A person may shift into an alternate personality, become confused, and demand of the clinician, “Who the dickens are you, and what am I doing here?” In addition to these observable changes, the person may experience distortions in time, place, and situation. For example, in the course of an initial discovery of the experience of identity alteration, a person might incorrectly believe they were five years old, in their childhood home and not the therapist’s office, and expecting a deceased person whom they fear to appear at any moment (e.g., Fine, 1999; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg, 1995).
More frequently, subtler forms of identity alteration can be observed when a person uses different voice tones, range of language, or facial expressions. These may be associated with a change in the patient’s world view. For example, during a discussion about fear, a client may initially feel young, vulnerable, and frightened, followed by a sudden shift to feeling hostile and callous. The person may express confusion about their feelings and perceptions, or may have difficulty remembering what they have just said, even though they do not claim to be a different person or have a different name. The patient may be able to confirm the experience of identity alteration, but often the part of the self that presents for therapy is not aware of the existence of dissociated self-states. If identity alteration is suspected, it may be confirmed by observation of amnesia for behavior and distinct changes in affect, speech patterns, demeanor and body language, and relationship to the therapist. The therapist can gently help the patient become aware of these changes (e.g., Fine, 1999; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg, 1995).
https://www.isst-d.org
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When a person is asking whether or not they have DID, that is a question that is worthy of consultation. Some people are relieved to find that there is a diagnosis and an understandable model for their experiences. Some dissociative experiences may provoke considerable anxiety and bafflement, and it is important to be able to find an organizing concept that makes these experiences understandable.
The bottom line in all this is that it is our strong recommendation that this question (How do I know if I have DID?) be asked in the context of an ongoing psychotherapy. If you are in a psychotherapy, ask your therapist what they think. Ask them if they have enough experience with DID to feel comfortable in making the diagnosis. If they dont, ask them to get a consultation for you and for them.
There are a number of diagnostic tests, such as the Structured Clinical Interview for Dissociative Disorders (SCID-D), the Multidimensional Inventory of Dissociation (MID), and the Dissociative Disorders Interview Scale (DDIS), that are available and can be administered by a trained clinician.
https://www.isst-d.org
