Processing trauma has become an essential aspect of psychotherapy as providers find the ubiquity of traumatized people in their practices. So-called trauma resolution therapies have also become important elements of therapists’ toolboxes, e.g. EMDR among others. But what does resolution of traumatic experiences really mean? Experience treating complex trauma strongly suggests that trauma processing means far more than desensitization of memory.
When therapists address specific traumatic content, successful resolution is often defined as an ability to consciously attend to the traumatic target without the same degree of disruption in arousal or dysphoric affect, and abatement of accompanying negative self-beliefs. After such apparent resolutions, there is often an expression of relief or even joy to be free of an historically psychological burden. This positive effect, at least of the reduction of dysphoria and negative self-meaning, may be long-lasting if not permanent with regard to that stimulus.
On the other hand, what if the resolved memory was seated in early childhood, and in effect, attenuated growth of exploring relational connections, interests, and innate talents? This could likely include a diminished sense of vitality or viability in relation to their world. If this person is a middle-aged adult, would they then feel free to explore what they had missed after a successfully processed resolution These questions would obviously depend on a multitude of factors, but the issue of the whole person’s treatment becomes paramount. If a therapist sees their role as resolving trauma, while the subsequent development of the self is left to the discretion of the patient who may or may not have the requisite supports or inclination to resume or repair developmental disruptions, is this brand of resolution really sufficient?
One of the hallmarks of traumatic experience is an attenuation of mental process (Van der Kolk & Van der Hart, 1989; Kira, I., Lewandowski, Somers, Chiodo, 2012). While the brain/mind is often capable of sidestepping such blockages functionally, affect and personal meanings remain hidden with unformulated (unconscious/dissociated) impact. In other words, there is peri-traumatic fixation of the feelings and meanings from that trauma that compel avoidant mechanisms while creating reenactments from the unresolved meanings and affects as well as a kind of internal pressure in the form of anxiety resulting from unacknowledged affects. This complex of internalized reactions and perplexing enactments have minimal, if not completely dissociated consciousness, compressed either with anxiety or shame-based deadened affect.
In fact, when treating people who are either very anxious or shut down, there is typically an avoidance of understanding what gives them discomfort. Therapists and authors often refer to this as affect intolerance or affect phobia. What is implied with these terms is that it is the feelings themselves that create overwhelm, possibly because the client, inexperienced with allowing awareness of feelings, lacks the skills to explore and tolerate emotions. If we look to affect theory to understand how affect becomes felt and finally transformed into emotion, this premise may not be correct.
According to affect theory, affects are hard-wired pre-conscious orientations of a finite number (Nathanson, 1994; Panksepp, 1998). These orientations are activated by any number of salient stimuli (external or internal) that require assessment by the brain. For the self to respond instructively to the incoming information the brain/body holds from the activated affect, the body gives off a signal that is consciously felt, commonly referred to as a “feeling.” Such feelings are then assessed comparatively by the cortex and other limbic structures from memorialized experiences that may have had similar feelings (LeDoux, 1998). There is also a concomitant assessment as to what stimulus activated this feeling. Once these assessments have been made, emotional meaning is achieved. Emotions are far more nuanced than affects or feelings, in fact infinitely so, such that language often fails to fully capture their unique experiences. Yet we attempt to create narratives for those felt meanings as we seek to make sense of our experiences.
But if our felt experiences lead to meanings that we cannot accept coherently, what do we do? For example, if a child is being assaulted maliciously by a caregiver they explicitly need, how can that child allow an affective process that leads them to that meaning? Dependency for a child is a necessity for survival (Bowlby & Holmes, 2012) and so the emotional impact of realizing a parent is not acting with love toward them cannot be tolerated. It is certainly true that extreme physical pain or terror may not be tolerable either, but it is also true that even our adult patients who experienced such abuse are typically unwilling to admit that abusive parents were in fact abusive. Frequently when we try to process such abuse, if remembered, it is easy to assume that the experience itself is the main reason for reticence and anxiety, when it is frequently the case that if consciousness is applied to the full meaning of the abuse, the emotional meaning of being unloved and thereby abandoned and betrayed, is the real impetus for avoidance of affect and feeling.
Spending therapeutic efforts to mitigate anxiety may be useful, but it does not mitigate the incoherence of meaning they cannot bear to know (Chefetz, 2015). Titration of feelings is thought to be essential for the patient to tolerate those feelings. Doing so also delays the realization of traumatic meanings beyond shame-based negative ones. In many cases of early childhood abuse, shame-based meanings help forestall realizations that are intolerable regarding a caregiver’s abuse. While titration of intense feelings may be important, and even necessary in the process of unfolding traumatic memories, the anxious arousal that often accompanies those intense feelings may be a harbinger of the intolerable meanings to come.
Techniques of somatic processing focus on the felt experiences of affects, but also on the various bodily tensions that form to block the sequence toward emotional meaning. According to some of these somatic theories of trauma (Ogden & Fisher, 2015), what is blocked in the body are self-protective instincts thwarted due to peri-traumatic disempowerment. While this is no doubt true in many cases, it is also true that when focusing on somatic processing, there is often a rhythm of affect-based feeling and anxiety-based tensions that serve to block the movement of the former.
Traumatic experiences are typically held in the mind/body as fixations, e.g., recursively intrusive in the mind/body, reenacted externally, generating specific sets of symptoms, and therefore blocking emotional meaning. As such, trauma processing aims to dissolve the fixated content such that processing can continue unimpeded. This would result in the natural affective-emotional meaning process to complete, at least in a conscious manner. It certainly can be argued that such meaning may exist dissociatively or in an otherwise unformulated state, which after sufficient processing would become realized. This would also give credibility to the notion of anxiety becoming more acute as affect-based feelings begin to push for conscious recognition owing to an unconscious dread of the unwanted and unformulated meaning. Could this be the real culprit of affect intolerance?
Trauma resolution techniques often measure a successful outcome as desensitization of the target which would presumably dissolve its fixation within the mind/body. Immediate realizations are often an initial relief from a sense of having been burdened by that fixation. However, consciousness of the many meanings, both from the time of the traumatic event and those evolving from a greater freedom to reflect, may take much more time and relational reflection than simply dissolution of that fixation. In fact, it is the dissolving of fixation that can allow meanings to be formulated. Therefore, it is the ongoing formulations of meaning that is the therapeutic outcome of trauma processing. Rather than relying on the release of fixation to result in spontaneous meaning making, it is the dyadic therapeutic relationship that examines and effects changes in meaning. When traumatic meanings are discovered and felt emotionally, there is typically a sense of loss and grief stemming from realizing betrayal. This processing of very intense emotions requires relational discourse and understanding.
This conclusion begs that processing of traumata is inclusive of a relationally based reformulation of self-derived meaning. Traumatic experiences are contextually meaningful, and once dissolved, have multiple “downstream” effects as a more highly nuanced sense of self emerges. To assume that dissolution of fixation is sufficient to process a sense of self is to ignore what it is to be truly human. As therapists we may believe that helping someone release certain fixations gives patients the freedom to individuate, even in lieu of developing a sense of who they are free to be. As mindful therapists, however, we must be cognizant of how meanings and a more complete sense of self develop beyond the so-called resolution of trauma.
To illustrate this point, consider the treatment of a middle-aged woman (pseudonym Lois) referring herself for treatment of unresolved grief from the death of her father when she was 12 years old. She presented as quite intelligent, married to the same man for 30 years, and with two adult children. She also complained of considerable anxiety, shame-based self-doubt, and depressed mood despite evidence of being highly verbal and with many interests. We decided to use EMDR to address poignant aspects of her father’s death from cancer that had been a short terminal illness of several months. Lois had never been directly informed of his illness, prognosis, or even of his death by her family, relying only on overheard conversations. Her relationship with him was the only enlivening relationship she had as a child, as her ebullient nature was discouraged by her mother. The loss of her father left her alone, afraid, and relationally deadened.
EMDR processing elicited considerable grief which was not unexpected but was quite difficult for her, especially as these feelings were not well received by her husband and children, much like her childhood experiences with her family of origin and extended family. As we continued to re-process her childhood experiences, she began to find herself expressing relational needs and desires with her adult siblings, husband, and children. She also began to realize the degree to which she had inhibited an intrinsic delight in relating to people and became angry at those who preferred her to be less expressive. It is important to note that there had been perhaps 6-10 EMDR sessions within a year’s time and that the majority of our sessions were devoted to what she was realizing about her life. She became aware that her interpersonal orientation had been shame based ever since the death of her father, enabling her to grieve the loss of herself.
Subsequent sessions helped her to fully realize the extent to which her sense of self had been deadened as she gradually expanded her relational life while working through the decades of dread she had felt to be witnessed as a viable person. There were many twists and turns in her psychotherapy as well as in her external life. While she was grateful for the EMDR which exposed and allowed her to express her grief, the dissolution of the omnipresent shame that kept her from experiencing that grief and from realizing betrayals by many people in her life, including her husband, was achieved in our therapeutic relationship.
Chronic deadening, especially when beginning in developmental years, utilizes chronic shame to hold in place. Relational processes are essential to its relief and repair, resulting in development of self. EMDR helped Lois access the affects that she could not experience by herself as a child which then lifted her defaulted subordination and accommodation in her adult relationships. This change was difficult and frightening for her, requiring an extensive relational psychotherapy, but also retrieved a sense of self she had lost for much of her life. The release of attenuated grief via EMDR was essential to allowing subsequent conscious processing of an attenuated sense of self which we have both observed to be a layered and developing trajectory for her that we mutually discover. Trauma resolution, therefore, is more of a release of fixated attenuation to one of ongoing and consciously relational process.
References
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Kira, I., Lewandowski, L., Somers, C. L., Yoon, J. S., & Chiodo, L. (2012). The effects of trauma types, cumulative trauma, and PTSD on IQ in two highly traumatized adolescent groups. Psychological Trauma: Theory, Research, Practice, and Policy, 4(1), 128. https://doi.org/10.1037/a0022121
LeDoux, J. E. (1998). The emotional brain: The mysterious underpinnings of emotional life. Simon and Schuster. https://doi.org/10.1176/ajp.155.4.570
Nathanson, D. L. (1994). Shame and pride: Affect, sex, and the birth of the self. WW Norton & Company. https://doi.org/10.1176/ajp.151.5.776
Ogden, P., & Fisher, J. Sensoriomotor psychotherapy: Interventions for trauma and attachment, New York 2015. https://doi.org/10.1037/e608922012-008
Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal emotions. Oxford university press. https://doi.org/10.1093/oso/9780195096736.001.0001
Van der Kolk, B. A., & Van der Hart, O. (1989). Pierre Janet and the breakdown of adaptation in psychological trauma. American Journal of Psychiatry, 146(12), 1530-1540. https://doi.org/10.1176/ajp.146.12.1530