Book Review – Life After Trauma: A Workbook for Healing by Dena Rosenbloom, Ph.D. and Mary Beth Williams, Ph.D. (2nd Edition) 2010, The Guilford Press.

It is difficult to find workbooks for trauma survivors that are as well thought out as Life After Trauma by Drs. Rosenbloom and Williams. I usually approach workbooks or curriculums for support groups with some trepidation, fearful that the book will promote the telling of one’s trauma story or engaging in reconciliation with the abuser. Life After Trauma quickly dispelled my fears and I found it to be very sensitive in its approach and development of safety for the trauma survivor.
The workbook is primarily for use by an individual but could easily be adapted for group work. However, the ability to take the book at one’s own pace makes it particularly valuable for someone who may feel a need to move through the book thoughtfully and take breaks as needed. I would recommend that anyone who wishes to work with this book use it an excellent adjunct to individual therapy with a therapist who has specialized training in working with trauma survivors.
I was particularly impressed with the book’s progression from recognizing and coping with triggers to understanding reactions to trauma, ending with strategies on how to develop safe and secure relationships and heal for the long term. There are regular check-ins throughout the workbook that provide breathers and the opportunity for the survivor to assess whether or not she/he is able to move on.
The authors appear to use cognitive behavioral trauma- focused therapy techniques to develop strategies for survivors to use in addressing beliefs about the abuse or traumatic event. A strength based approach assists survivors in understanding how trauma has affected their self esteem and how they can gain value, esteem, power, and intimacy in their lives.
The appendix offers valuable information for trauma survivors on how to choose a doctor or other health practitioner and plan for appointments. It also has an excellent bibliography of books, articles and websites. Suggestions for find a therapist for trauma is also included along with a section on how mental health professionals can use the workbook with a warning to non-trauma specialists to not evoke or examine traumatic memories.
Dena Rosenbloom, Ph.D. is a clinical psychologist in Glastonbury, CT and Mary Beth Williams, Ph.D. is an LCSW working in private practice in Warrenton, VA. Dr. Williams is widely published and is an instructor for the Office for Victims of Crime at the U.S. Department of Justice.

Trauma and Shame

Trauma victims, particularly those who experienced traumatic events in childhood, are often reluctant to talk about what happened to them for a variety of reasons. Keeping the secrets buried are often due to a deep sense of shame. Because of the intense personal nature of interpersonal violence, victims are often left believing that there is something horribly wrong with them that caused the event to occur and this shame remains within them for years.


Shame and guilt are two separate emotions. Guilt is feeling bad about something that you did. Shame is feeling bad about who you are. Perpetrators are experts at manipulating the victim into believing that the traumatic act was because of whom she/he is and that if they were any different it wouldn’t have happened. The perpetrator’s accusations could range from “you were so beautiful and innocent I just had to have you” to “if you hadn’t been in that place, wearing that particular clothing, being who you are I wouldn't have done what I did." The victim is left feeling as if the violence occurred because of who they are rather than who the perpetrator is.

Shame is common in young children. In early childhood, the brain has not developed the capacity to logically understand the actions of others. Children are unable to think through events to have an understanding of their victimization. Their thinking is very ego-centric, resulting in a belief that “if I was just smart enough, strong enough, pretty enough” bad things would not happen to me and people would love me. This accounts for the prevalence of super heroes in our culture and the rising amount of children’s literature containing young people with special powers to fight evil while grownups are either bystanders or enemies.

Shame is perpetuated when there is little support after the traumatic event. This could be due to the family’s desire to keep a secret or the belief that one must be strong and maintain a good public image of the family unit at the cost of the individual.

I was told the story of a woman who as a five year old girl was taken to her grandfather’s funeral without being told ahead of time the nature of the occasion. She was led to the coffin and held up to see her grandfather for the last time. She told me that she remembered feeling something break inside of her and she immediately became afraid. When she tried to talk to her family about the fear she suddenly felt she was told to keep quiet and judged for her feelings. She grew up believing that fear was something that you avoided and, if you felt any fear you hid it for the sake of the family’s image. She said that she has grown to associate this fear with funerals, although she has no difficulty with death. Her fear appears to be based in the belief that she will do something that will cause others to be angry with her.

Intense shame can lead to isolation, use of drugs and alcohol to numb the pain, and developing survival skills to get needs met. These may be seen as negative by others, but may be productive in many ways. The woman above told me that she learned that when she was afraid in the middle of the night, she could wake up her baby sister and make her cry so that their mother would come and rock the baby. Then the young girl would be able to go to sleep to the sound of her mother rocking her sister. Telling her mother that she was afraid was too scary and meant she would have to let her mother know she was afraid, a cause of great shame in her family.
A lot of survivors do things that seem unproductive in their attempt to keep their secrets because of the shame it involves. To let someone know your secrets sets you up to be re-victimized if that person sees you for who you think you are. This possibly translates into “imposter syndrome,” an overwhelming self doubt that results in a fear that others will find out who you really are.  This can lead to disorganization, procrastination, and possible under achievement or over achievement.  It is all about keeping the secret/s. 

It all comes back to remembering how trauma occurs in relationship and the healing occurs in relationship (Judith Herman).  It takes finding a safe relationship in which a person can release their secrets and discover the truth within their story for healing to take place.  Once this sense of shame is lifted, the person is more empowered to move forward knowing that they are not responsible for what happened to them and can take control of their life. 

Surviving the Holidays

The holidays are often a difficult time for trauma survivors. Family activities, while joyous times for some people, are often difficult reminders of the past and can cause distress. For some survivors, the holidays are anniversaries of traumatic experiences. For other survivors, it may mean being in the presence of the sexual perpetrator or the abuser.

Survivors may not always be aware of how they are being triggered or may feel guilt and shame for not being able to rise to the same level of excitement and anticipation that others feel during this period. Even if they seem to have recovered well from past trauma, they may begin to have more problems with sleeping, over or under eating, increased anxiety, and a sense of impending disaster.

Here are some tips to help survivors manage stress during this time:

1. Have an exit strategy. Some survivors are able to say “no” when expected to attend family gatherings where a perpetrator may be present. A sense of obligation to other family members may make it difficult to stay away. If someone is planning to attend a family gathering where a perpetrator is present, it is good to limit the amount of time spent in the situation. Arriving late, having one’s own form of transportation, having an agreement with another family member to assist in maintaining distance are all possibilities.

2. Good self care. With all the stress of the holiday season, immune systems become compromised. Illness and fatigue can increase susceptibility to triggers and make it more difficult to manage reactions and heightened emotional vulnerability. High intakes of sugar through this time can also reduce the ability to combat infection, increasing vulnerability. Any activities that increase a sense of well being such as support groups, mindfulness activities, exercise, and creative projects can help fight off depression.

3. Support. Isolation is often a strategy for managing this time of year that can end up being very unproductive. Existing support groups or informal support of understanding friends may help alleviate some of the loneliness that occurs during the holidays.

4.  Limit alcohol intake.  Alcohol is a depressant and can also affect the immune system.  It also decreases inhibitions and affect sleep patterns which can then lead to increased vulnerability to the effects of trauma or additional trauma. 

Moderation in consumption of food, alcohol, and activity can be a very valuable for surviving the holidays.

Please feel free to add any other ideas you may have in the comment section below.

Forgiveness and Recovery from Trauma

I recently had a discussion with a few advocates on the idea of forgiveness and its place in healing the effects of trauma. I have had a few incidences in my work over the years to discuss this with both survivors and advocates and thought that it would be meaningful to generate some more thoughts on the subject.


The idea of forgiving the perpetrator for many survivors is an abhorrent idea. When presented with the idea in a support group curriculum or self-help book a survivor may have many responses. “Why would I forgive him? He hasn’t apologized!” “If I forgive him, that means I have to let him in my life again?” “What? Forgive? That would mean I would have to condone what happened? I can’t do that. First you tell me it was wrong and now I have to forgive?” “I must be a horrible person if I can’t forgive.”

Healing from trauma is a process and so is forgiveness. The process of recovery from trauma has many stages and forgiveness is only a part of one of those stages. Forgiveness may also be something that occurs further along in the healing, after there has been separation from the perpetrator and more manageability of one’s life and emotions.

In Trauma and Recovery, psychiatrist Judith Herman (1997) defines trauma as a disease of disconnection. In her book she describes a three-stage model for recovery – safety, remembrance and mourning, and reconnection.

Early in recovery a survivor is primarily working on issues regarding safety. Forgiving the abuser can often feel unsafe. It may feel as if a crack is being opened in a door that the survivor is working very hard to keep shut. If she is still experiencing feelings of love toward the abuser she may feel that forgiveness would increase her vulnerability and decrease her safety. During this early stage, controlling the environment, both internally and externally, is the most important task. Being able to establish appropriate boundaries with everyone in her life is a part of this task and forgiveness may blur that boundary. This stage is focused on the present and lasts as long as necessary for the survivor to develop skills to reduce the impact of triggers, alleviate anxiety and depression, and negotiate safety in the greater world.

During the remembrance and mourning stage the women is stabilized and begins to focus on the past. She often begins to acknowledge her losses and mourns the loss of the relationship or the dreams that were associated with her relationship. She is using the skills learned in the first stage to self-soothe while she comes to term with the impact of the trauma on the life she thought she would have. It is during this time that she may need to start to forgive herself – not for the abuse – but for what she may perceive her role to have been in the trauma. Many survivors carry a sense of guilt and shame in regards to their abuse and how they may have handled the situation. Hopefully, she will be able to recognize that she did the best she could under the circumstances and can now move on, stronger in knowing that she survived.

If forgiveness of the perpetrator is going take place, it is probably during the third stage – reconnection. This reconnection refers to developing a new self and creating a new future. It does not mean reconnecting with the perpetrator. Forgiveness is often described as a state of “letting go,” a process of releasing the past and moving forward into the future with a light load. It is not an action toward the abuser, but is rather an internal process of living life without resentments, anger or indignation. It is the recognition that until we “let go” the abuser still has power over us. Forgiveness is really not about what it does for the other person, but what it does for the survivor. The perpetrator never needs to know.

Forgiveness is also an action that cannot be forced onto the survivor. It is not to be a prescribed or demanded expectation. This is a process that the survivor comes to of her own choosing and in her own time. She will be able to let go of the past when she feels safe stepping into the future.

New Resource Added to Valuable Links - Stop the Storm

I would like to introduce you to  the blog http://stopthestorm.wordpress.com/ It is a wonderful resource.  This blog is written by a 59 year old survivor of childhood maltreatment who is also a cancer survivor.  She has done extensive research on trauma and how it has affected her ability to be in the world.  She does an excellent job of describing her responses to triggers and how trauma has influenced her relationships.  I highly recommend that you check it out.

Effects of Maltreatment on Brain Development

There have been a few requests lately for more information on how trauma affects a child’s brain and the child’s ability to form attachments and learn. The following is a summary of an article, Understanding the Effects of Maltreatment on Brain Development, published by the US Department of Health and Human Services’ Child Welfare Information Gateway www.childwelfare.gov/pubs/issue_briefs/brain_development

Thanks to the relatively recently developments in the study of brain development including functional magnetic resonance imaging, there is now evidence to show that brain function is altered significantly. “…genetics predisposes us to develop in certain ways. But our experiences, including our interaction with other people have a significant impact on how our predispositions are expressed. In fact, research now shows that many capacities thought to be fixed at birth are actually dependent on a sequence of experiences combine with heredity. (Shonkoff and Phillips, 2000).”

An infant is born with almost all of the brain neurons that it will ever have. As the brain developed in the fetus these neurons began to specialize, developing specific tasks for the lifespan of the person. This development continues after birth and on into adulthood. The first regions to develop are those concerned with bodily functions and maintaining life. “But the majority of brain growth and development takes place after birth, especially higher brain regions involved in regulating emotions, language and abstract thought. Each region manages its assigned functions through complex processes that involved chemical messengers (Perry, 2000a).”

Plasticity is the term used to describe the brain’s ability to change in response to stimulation. This is dependent on the stage of development and the specific region of the brain that is affected. The part of the brain that is “wired” to respond to the human voice or facial expression anticipates the exposure and when this does not happen, the brain will discard these pathways. The brain will discard pathways that are not being used and develop other pathways that are needed for survival.

There are sensitive periods for the development of certain capabilities. “For example, infants have the genetic predisposition to form strong attachments to their caregivers. But if a child’s caregivers are unresponsive or threatening, and the attachment process is disrupted, the child’s ability to form any healthy relationships during his or her life may be impaired )Perry, 2001a).

Babies are born with implicit memory which means they have a perception of the environment that can be recalled in unconscious ways (responding to the sound of mother’s voice). Explicit memory is tied to language development and provides children around the age of 2 with the ability to talk about themselves in the past or future or in different places or circumstances. However, children who have been abused or suffered other trauma may not be able to retain the explicit memories that they need to be able to tell about their trauma. Instead, they will experience the implicit memories such as bodily or emotional sensations that manifest as nightmares, flashbacks or other uncontrollable reactions.

Children can learn to tolerate moderate stress and greater amount of stress can be tolerated if he/she has a positive relationship with an adult caregiver. However, without this positive interaction in significant amounts at critical periods, the brain can be altered by the toxic stress. Specific effects depend on the age of the child, whether the trauma was one-time or chronic, the identity of the abuser, and whether there is a dependable nurturing adults present, the type and severity of the abuse, the intervention, and how long the maltreatment lasted.

“Altered brain development in children who have been maltreated may be the result of their brains adapting to their negative environment. If a child lives in a threatening, chaotic world, the child’s brain may be hyperalert for danger because survival may depend on it. But if this environment persists, and the child’s brain is focused on developing and strengthening its strategies for survival, other strategies may not develop as fully. The result may be a child who has difficulty functioning with a world of kindness, nurturing, and stimulation.”

Children who are exposed to long term and severe abuse, either emotional or physical/sexual, will develop responses such as a persistent fear response, hyperarousal, dissociation and disrupted attachment (inability to form relationships). The neural pathways have formed these responses as a means of surviving the impact of the trauma. However, these responses also result in increased susceptibility to stress, excessive help-seeking and dependency or excessive social isolation, and the inability to regulate emotions. The effects are cumulative and can lead to life long difficulties in interpersonal relationships.

“Some of the specific long-term effects of abuse and neglect on the developing brain can include (Teicher, 2000): diminished growth in the left hemisphere, which may increase the risk for depression; irritability in the limbic system, setting the stage for the emergence of panic disorder or posttraumatic stress disorder; smaller growth in the hippocampus and limbic abnormalities (areas of emotions and memories in the brain), which can increase the risk for dissociative disorders and memory impairments; impairment in the connection between the two brain hemispheres, which has been linked to symptoms of attention-deficit/hyperactivity disorder.

The U.S. Department of Health and Human Services Children’s Bureau (2009) encourages professionals to promote five “protective factors” that can strengthen families, prevent abuse and neglect, and promote healthy brain development: nurturing and attachment, knowledge of parenting and of children and youth development, parental resilience, social connections, and concrete support for parents.

For additional information go to www.nhcadsv.org to access the recent publication, The Mental Health Needs of Children Exposed to Violence in their Homes.

Editorial Response to Glee Actresses Posing for GQ Magazine

This past week GQ magazine printed photos of Lea Michelle and Dianna Argon of the very popular FOX television series, Glee. These photos are part of the latest issue of GQ. The photos depicted Lea and Dianna as high school students in various states of undress or exposure. In most of the photos they were wearing parts of cheerleader uniforms (though I have never seen a cheerleader in pink spiked heels). In a couple of the photos, they pose with Corey Monteith, another actor on the television show, draped over him in sexualized positions. Corey is fully clothed in all photos and appears to be depicted as the character he plays on the television show.


I have searched and have yet to find a response to the photo shoot from anyone in the feminist or child abuse community. A statement by the Parents Television Council responded to the photos by stating "It is disturbing that GQ, which is explicitly written for adult men, is sexualizing the actresses who play high school-aged characters on 'Glee' in this way. It borders on pedophilia. By authorizing this kind of near-pornographic display, the creators of the program have established their intentions on the show's direction. And it isn't good for families.” GQ responded with "The Parents Television Council must not be watching much TV these days and should learn to divide reality from fantasy," Jim Nelson, editor-in-chief of GQ, said. "As often happens in Hollywood, these 'kids' are in their twenties. Cory Montieth's almost 30! I think they're old enough to do what they want."

I think that GQ is missing the point. I have few objections to Lea and Dianna posing for GQ or any other magazine if they are portraying adult women. The irresponsibility occurs when the photos depict them as high school students and, as in this case, very sexualized high school students.

Looking at GQ demographics we quickly find the age group, 25 to 34, makes up

38% of the readership while 29% of the readership belongs to the 35 to 49 years old

group. The 18 to 24 year olds make up 24% of the readership while the 50 to 64 year

old males make up only 8% and the 65+ age group makes up only 1%. 91% of the

readers are under 50 years of age. Over 36% of the male readers graduated college

while another 37% attended college. 64% of the males have an income of $50,000 or

more, 11% have an income of $40,000 or more, 8% at $30,000 or more and the

balance are the $20,000 or more at 7% and the $10,000 or more and the less than

$10,000 having 10% of the male readership between them. Clearly, the worldview of

GQ is through the eyes of a young, educated, and wealthy American male. (Media and Culture as Manifest in Male Individualism, Bozark, 2003)

My concern is how these American males are viewing adolescent girls. What Lea and Dianna and GQ magazine have done is to set up our teenage daughters and granddaughters up for continuing to be seen as objects of sexual desire for males over the age of 25. It doesn’t matter that Lea and Dianna are in their twenties, they were explicitly depicting adolescent girls in these photos.

Lea Michelle stated in an interview that she had been dealing with body issues and that she enjoyed being able to pose for these photos. She also stated she was surprised at what the photographers were able to talk her into doing. Her statement suggests that she was manipulated into some of the poses. I think that Lea could have taken a more responsible approach and 1) thought about how media had contributed to her issues regarding her body 2) been more pro-active and responsible for what was happening in the photo shoot. I would not be as concerned if she had been responsibly posing as the adult woman that she is, though I would still be concerned with how media presents women as objects and demands perfect bodies.

GQ’s response shows the ongoing irresponsibility of the media in regards to what it sells to its readers. By saying that the PTC is unable to separate fantasy from reality, it is showing that it does not understand that what it is selling to adult males is a fantasy of American teenage girls that sets them up for victimization in a number of ways.
I am an avid watcher of Glee. I find that its portrayal of the struggles of adolescence is spot on and it is willing to take on a number of controversial issues including teen pregnancy and homosexuality. The cast is talented and the musical numbers are entertaining and often inspiring. This recent incident with GQ, however, will now make me think even more about how media depicts teenagers. I will also use this as a teachable moment with my teenage granddaughters. If it is out there, it needs to be discussed.

Fetal Alcohol Spectrum Disorder and Complex Trauma

A couple of weeks ago I attended a day long workshop on Fetal Alcohol Spectrum Disorders (FASD) present by Dr. Susan Adubato Ph.D. and Dr. Mary DeJoseph of the New Jersey Regional FASD Diagnostic Centers. The following will give you a brief summary of what FASD is and then I will discuss how this effects the work we do with survivors who are using alcohol.

From the website http://www.fascenter.samhsa.gov/



What is FASD

FASD is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. Each year in the U.S., as many as 40,000 babies are born with an FASD. The cost to the nation for FAS alone is about $6 billion a year.

The term FASD

The term FASD refers to a spectrum of conditions that include fetal alcohol syndrome (FAS), fetal alcohol effects (FAE), alcohol-related neurodevelopmental disorder (ARND), and alcohol-related birth defects (ARBD). Although disorders within the spectrum can be diagnosed, the term FASD itself is not intended for use as a clinical diagnosis.

Fetal Alcohol Syndrome has been an evolving issue. Initially, from the 1950’s until the mid 90’s FAS was the term which applied to those children who were born with certain facial characteristics - thin upper lip with a small philtrum (the midline groove in the upper lip that runs from the top of the lip to the nose), low birth weight, small eye openings, and small head circumference. However, as neuroscience and the ability to study fetal development has advanced, it is now known that the physical characteristics of FAS do not need to be present for a child to be born with FASD. When and how much drinking occurred during fetal development influences what the effects will be.

The most serious symptoms of FASD are the invisible symptoms of neurological damage that results from prenatal exposure to alcohol. These include: attention deficits (with or without hyperactivity, memory deficits, difficulty with abstract concepts (math, time, money), poor problem solving skills, difficulty learning from consequences, poor judgment, immature behavior, poor impulse control. Adults with FASD have difficulty maintaining successful independence. They have trouble staying in school, keeping jobs, or sustaining healthy relationships. Without appropriate support services, these individuals have a high risk of developing secondary disabilities such as mental illness, getting into trouble with the law, abusing alcohol and other drugs, and unwanted pregnancies. Children and adults with FAS are also quite vulnerable to physical, sexual and emotional abuse (Teresa Kellerman of the FAS Community Resource Center 2005). This is very similar to the issues faced by persons with a history of complex trauma.

This presents a challenge. FASD is considered to be a birth defect that is organic in nature and needs to be treated differently than you would someone with complex trauma. How are we to know that difference? We more than likely don’t. However, there is the likelihood that we are working with survivors who have FASD in addition to dealing with trauma. Knowing the family history is the only way to know if it is possible and it can only be diagnosed by a doctor who specializes in FASD.

Along with the generational abuse that occurs in families, we can now ascertain that the legacy of growing up in an alcoholic family may include FASD in addition to complex trauma. I have to admit that I find this information a little overwhelming. It explains why there appear to be some survivors who continue to have difficulty problem solving and making changes even when we provide support and empowerment. This may explain why some survivors have difficulty making decisions, processing information, and developing new healthy relationships long after the trauma has ended and they are living in a safe environment and not experiencing triggers or flashback.

I would be interested in hearing how you feel this information plays a part in the work that you do, your response to survivors with complex trauma who grew up in alcoholic families, and how you respond to pregnant women who are using alcohol.

According to the research, there is no safe amount or safe time during a pregnancy for a woman to drink alcohol. Many women have already incurred damage on the fetus even before they know they are pregnant. Does this information change your thinking in regards to choice when it comes to using alcohol, particular for women of childbearing age?

Contact me for more information or do a search for Fetal Alcohol Spectrum Disorder.

Where Does She Belong?

In this post I would like to address some of the comments that I have heard over the years in regards to opening shelter doors to women who have substance abuse and mental health issues.  I have tried not to editorialize in most of my blog posts, however, this post may stretch that boundary.  If you are a staff member or volunteer with a domestic violence program, I invite you to use this article as a way to generate discussion with other staff members.

During the 1990’s I worked with the YWCA in Norfolk, VA to implement the Women and Recovery program to provide shelter and transitional housing to victims of domestic violence who had substance abuse issues.  I also worked with the Virginia domestic violence coalition to provide training and technical assistance to other programs in the state to increase access for women with substance abuse issues.

At that time, many programs were screening women out of shelter based on when they had last had a drink or used drugs.  Some programs had a requirement of 24 hours of abstinence whereas others had a 30 day requirement.  My argument was that many staff in those programs would not be able to access shelter under those restrictions. 

My goal was to educate in regards to the safety needs of victims who were self medicating due to violence in their lives.  People started to realize that a woman was unable to get clean and sober while living with an abuser who was using her substance use as a means to control her and who tightened control if she tried to become sober.  We also understood how some systems of recovery further disempowered women and how much fear, stigma, and shame existed for women who used drugs.

There were staff members who stated their opposition and one executive director said to me “I do not want those type of women in my shelter.”  I responded with “you already do.  They just know that their safety and security is at risk if you find out so they do everything they can to hide it.”  In the same way that victims have had to hide money, keys, clothing and important paperwork from their abuser, victims with a drug or alcohol problem knew they needed to hide their use from shelter staff in order to remain safe.

I have seen shelters become more understanding of the use of alcohol and drugs to self medicate the effects of trauma in women who come into shelter.  Shelter staff are more willing to work with survivors to access recovery programs and provide plans to remain safe and sober.  They understand that without other resources and skills to manage anxiety, fear, and sleeplessness, the woman does not see another choice but to use.

The challenge now is to address the stigma and attitudes in regards to sheltering persons with severe mental illness.  The comments I hear now are – “She doesn’t belong here.  She is mentally ill.”  “Her primary issue is not domestic violence.  She doesn’t belong here.”  “She is scaring the other clients.  She doesn’t belong here.”

Where does a battered women who has a mental illness (that is more than likely a response to trauma)  belong?

The domestic violence movement has consistently seen that violence against women is perpetuated due to systems that fail to respond to the needs of battered women and their children.  The movement not only worked to develop programs that provided safety and shelter to women, but also worked to make changes in the institutions that were created to maintain public safety.  Over the years, the domestic violence movement has made institutional, society, and ideological changes that made it safer for women in their homes and made it safer for her to leave. 

What this means is that the women who used to seek shelter now have resources that provide safety without needing to leave their home or, if they do leave, they are able to live safely elsewhere. 

There are still failures in the systems, but now the systems actually exist and the number of women whose primary issue upon entrance to shelter is domestic violence is fewer.  Domestic violence may be a contributing factor but once safety needs are met, it is no longer the main issue.  The long term effects of trauma, whatever form they take, become the main issue along with housing, financial, and transportation needs. 

Because of the current crisis in the mental health system women have a more difficult time in accessing services to address their mental illness.  Women may also choose not to engage in the mental health system because it has not met her needs, overmedicated her, did not validate her trauma, and possibly re-victimized her or colluded with the abuser. 

So, again I ask – Where does she belong?

If the domestic violence movement has a history of keeping women safe while working to change or partner with systems, then she belongs with us.  In the same way that we have kept battered women safe while we worked with police officers, judges, and social services to develop laws to protect, we are called to protect battered women with mental illness while we work to promote collaboration and changes that can protect her and assist in her recovery from trauma.

By saying she doesn’t belong, we are re-victimizing her.  By recognizing she does belong with us due to the nature of her being a woman who has been abused, our goal becomes changing how we respond to ensure her safety, the safety of others in the program, and the safety of staff?  It takes education and willingness to move outside our comfort levels in order to meet her where she is and find ways to increase her choices.  If we don’t, what other choices does she have?

Cultural Influences and Response to Trauma

“A broad understanding of culture leads us to realize that ethnicity, gender identity and expression, spirituality, race, immigration status, and a host of other factors affect not just the experience of trauma but help-seeking behavior, treatment, and recovery.”

- National Child Traumatic Stress Network

As we broaden our service response to immigrants and refugees, victims of human trafficking, and children and grandchildren of persons who have experienced trauma in this country and others, it becomes apparent that the need for more information on how to respond to trauma survivors from a cultural perspective is crucial. Not only is it necessary to understand the trauma that has occurred within cultures, but it is also important to have an understanding that how cultures respond to trauma can impact the ability of a survivor to recover from complex trauma.

Culture is not limited to one’s ethnicity or birthplace, but also relates to age, disability, religion and spirituality, social class, sexual orientation, indigenous heritage, immigration or refugee status, and gender and sex.

Laura S. Brown, author of Cultural Competence in Trauma Therapy, states that being culturally competent involves being aware of our own personal relationship to each of the above identities and to be attentive to the phenomenon of dominant group privilege.

“Privilege lends power to one’s biases; if I am a lesbian biased against heterosexual people, I may suffer from being prejudiced but I lack the social power to declare all marriage between other-sexed persons illegal. The heterosexual person, biased against me has the privilege and power to legislate against me. Acknowledging one’s privilege can be a trust-engendering and relationship-building action in therapy (advocacy). Ignoring it or pretending that it does not matter will eventually undermine trust and endanger the working alliance of therapy (advocacy). Pg. 41

The ability of a person to recover from trauma is dependent on a number of factors. How culture views the traumatic event is one of the factors. A young woman raped on a college campus in this country faces many obstacles in her recovery but also has access to sexual assault crisis services and medical care. If she chooses to let her parents know of the event, she may or may not receive support. However, if she is living in a Middle Eastern or African country, there may be a possibility that the rape occurred as an act of war resulting in the loss of status for herself and her family and possibly her death at the hands of a family member.

In some Central American countries (and others) families have had sons and daughters “disappear” or killed by the government or people posing as authority. When they immigrate to this country they are often suspicious or frightened of anyone in a government agency or in authority because of this. If a social worker or advocate is unaware of this, they may see the fear as resistance or noncompliance.

One mistake that is made by advocates/therapist/case managers is assuming the cultural identity of another person. Persons of mixed racial heritage are often identified with a group with whom they may not choose to belong or proudly identify as a member of a group that others may not recognize as a possibility. Gender identity is often confused with sex when gender identity pertains to gender roles and sex is the biological makeup. Sexual orientation is a biological response. Assumptions in regards to race, ethnicity, gender, sex and sexual orientation can lead to re-victimization of a trauma survivor.

The effects of trauma can be transmitted across generations. Children of holocaust and/or genocide survivors have grown up in a family that recognizes that their ethnicity/religion/tribal affiliations have made them the target of extremists. This can lead to either a denial of their family roots or an increase in affiliation in order to maintain the cultural identity of the victimized group.

The group’s experience in the greater world can also determine how they respond to help. If the predominant and privileged culture is descendant from the same culture that perpetuated the abuses, it may be difficult for a family to seek help outside of their own affiliation. One example of this is the American Native. Their desire to maintain services and affiliation within the tribe is a result of trying to preserve their culture and their distrust of the predominant (conquering) culture. Keeping in mind a group’s history as an oppressed people can help us understand their reluctance to seek services. This phenomenon is also reflected in populations of immigrants living together within communities. It is very important to them to maintain their cultural affiliation and maintain a sense of safety within their own communities.

Within seemingly homogeneous cultures can be a number of identities that respond to trauma differently. In New England, the Yankee culture has a strong identity with a belief in the idea of “pulling one’s self up by the boot straps” and moving on without a lot of discussion of the event. Rural populations respond differently than urban and within each of those, there may be subsets of identities that respond differently. It becomes increasing important to learn as much about a person’s identity and affiliations as possible in order to be aware of any implications due to racism, classism, poverty, sexism, ageism, homophobia, et.al. and, as said before, be aware of any privilege or oppression that exists because of your own identity.

As it is very difficult to discuss all of the implications in regards to cultural trauma and competencies I highly recommend Laura S. Brown’s book, Cultural Competence in Trauma Therapy, Beyond the Flashback (APA Publishing, 2008). Even if you are not a therapist, this book is an excellent resource for expanding your understanding of the influence of identity on a person or a group’s experience of trauma.

4th National Conference on Women, Addiction, and Recovery – Thriving in Changing Times, Chicago, July 26-28, 2010

I attended the 4th National Conference on Women, Addiction and Recovery in Chicago last week. There were approximately 700 people in attendance, mostly women, and the agenda was full and motivating. It was sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), Treatment Alternatives for Safe Communities (TASC, Inc.) and The ATTC Network. The focus of the conference was to support, engage, and motivate so that providers are able to continue to thrive in the changing environment and continue to provide excellent services to women and their children who are impacted by substance abuse. The following is a synopsis of the plenaries and the workshops that I attended.

The Honorable Pam S. Hyde, J.D. of SAMHSA and Carol McDaid of Capital Decisions presented open plenaries on the state of behavioral health and the future of the mental health and substance use disorders field post parity and health care reform. The major point was that mental health and substance abuse treatment coverage under health reform will be covered equal to medical coverage under all insurance plans. This will extend coverage for a number of people who were not covered before.

There was a video message from the Hon. Tammy Duckworth, M.A., Assistant Secretary for Public and Intergovernmental Affairs at the U.S. Department of Veterans Affairs. She noted that the number of women returning from Iraq and Afghanistan who have mental health and substance abuse disorders is increasing and their needs are complex, some having experienced sexual assault by fellow servicemen. The impact of their deployment on their families is also significant and the Ms. Duckworth expressed the commitment of the VA in providing the needed resources for these service members.

On Tuesday, Lisa Najavits, Ph.d., discussed Emerging Developments in Trauma and Addiction. She introduced the follow-up to her program, Seeking Safety, which will be coming out in the next year. It is called Seeking Change and moves beyond the areas addressed in Seeking Safety by helping the trauma survivor to address the actual traumatic events by moving through three steps – Establishing Safety in Body and Environment, Reconstruction of Trauma, Social Reconnection.

Francine Ward, J.D., presented her personal story of recovery. Francine was raised in poverty in South Bronx and eventually became a prostitute and addict in Las Vegas before being hit by a car when she was in her late 20s. She currently has over 31 years of sobriety and is a Georgetown University graduate and is practicing law. Her message is that recovery is possible if you are willing to do the foot work and if there is someone in your life that is willing to love you to the point where you can love yourself.

Gil Kerlikowske, M.A., President Obama’s Director of the White House Office on National Drug Control Policy discussed the White House’s commitment to family centered treatment as a major part of the office’s strategy to control drug use and trafficking in the United States. Mr. Kerlikowski has been visiting treatment programs throughout the country and listening to providers and consumers express their concerns and needs for more holistic means of addressing the issue.

On Wednesday morning, Jean Kilbourne, Ed.D, presented “Deadly Persuasion: Advertising, Addiction and Relationships.” In the same way that she has previously shown us in Killing Us Softly, Dr. Kilbourne was able to illustrate how advertisers use the psychology of addiction to target the 30% of people who drink 90% of the alcohol in this country. She noted that advertisers do not actually want people to drink responsibly because if everyone in this country drank what would be considered responsibly, then alcohol sales would decrease by 80%. Ads that show alcohol as sexy and desirable are playing into the addicts feelings that alcohol is their lover and friend. She also showed how advertising is directed to children in order to keep the number of consumers stable or growing. One shocking aspect that she discussed was how television and magazines basically sell the public as product, i.e. “if you advertise your beer in our magazine we can guarantee that you will have a certain number of readers who will see your ad and possibly buy your product.”

The workshops at this conference were well planned to provide time for lecture and discussion or to spend time with an expert in the field. On Monday, I attended a lecture on “Women, Addiction & Personality Disorders” given by Drs. Karen Dodge and Caterina Iapaolo of the Hanley Research Center in Florida. The premise was that substance abuse often presents with the same characteristics as a personality disorder and once the person becomes sober, the characteristics will diminish. They demonstrated this through case studies and research statistics. It was noted by many of the audience members that the same characteristics were reactions to trauma and that in each of the case studies trauma had occurred during the person’s childhood. The researchers had not made the same connection, but it was exciting to hear that the audience was well aware of trauma and its impact and were able to bring that information forward.

Lia Gaty, LCSW, from Iowa presented “Attachment Rhythms for Women in Trauma Recovery.” Through the use of emotionally engaging mirroring games she illustrated the rhythm of attachments through the states of attachment, disruption and repair.

Dr. Stephanie Covington, Dr. Sherri Green, and Niki Miller (of NH DOC) presented “A National Women’s Peer Recovery Support Initiative” and stressed the importance of gender responsive treatment programs that are trauma informed. The focus of the discussion was the increasing availability of peer support services. We discussed the development of a national leadership initiative that will train recovering women to be peer supports to women who are just becoming clean and sober. It was also discussed how this could be a great opportunity for domestic violence programs to have additional support for women in shelters. The domestic violence movement has had a long tradition of peer support and this can be expanded into enhancing services to trauma survivors with substance abuse issues.

On Tuesday morning I attended a workshop and facilitated discussion on “Racial/Gender Identity Development: Thriving in the Stages of Recovery.” Dr. Mary Henderson and Carolyn Ross of TASC led a lively discussion on the stages to developing racial and gender identity and how that influences a person’s recovery from drugs and alcohol. The audience was very diverse and the facilitators created a safe space for people to share from their own experience regarding how they and clients they have worked with have dealt with issues regarding race and gender identity.

On Tuesday afternoon I attended a tea with Dr. Stephanie Covington, author of A Women’s Way Through the 12 Steps” and four comprehensive, integrate, gender-responsive curricula that relate to the issues in the lives of women and girls, including trauma and substance abuse. She answered questions specific to curricula and more general questions regarding trauma informed care for women who are survivors of trauma. I found it validating to hear from other professionals about their concerns and their recognition that services have to be trauma informed in order to meet the needs of substance abusing women.

The conference was also very focused on providing a healthy environment for all attendees. On Tuesday evening, Joan Borysenko, a licensed psychologist, Harvard trained scientist and a pioneer in mind/body medicine led a work shop, “Revive: Creating Synergy in Mind, Body, Spirit and Work,” which gave participants to discuss what gives them joy, what stresses them out, and provided an opportunity to set goals for the future. All of this was done in an atmosphere that created a chance to meet new people and engage in lively conversation.

This conference is held every two years and it has not been decided where it will be held in 2012. It was encouraging and validating to see that trauma was a focus of a number of workshops and it is my hope that this will be expanded even more in the future. The conference planners also provided many opportunities to explore Chicago and continue discussions after hours.  I have posted links to various websites mentioned at the conference on this blog.

Adverse Childhood Experiences, Attachment and Resiliency

When talking about trauma, I am frequently asked about the effects of trauma on children, and if the damage can be reversed. The answer is not simple and a lot of factors contribute both to the effects of complex trauma on the child and to the ability to recover.

One of the first studies to address the effects of childhood trauma is the ACE – Adverse Childhood Experiences – study began in the 1980s and continues to this day. “The ACE Study is an ongoing collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente. Led by Co-principal Investigators Robert F. Anda, MD, MS, and Vincent J. Felitti, MD, the ACE Study is perhaps the largest scientific research study of its kind, analyzing the relationship between multiple categories of childhood trauma (ACEs), and health and behavioral outcomes later in life.” (http://www.acestudy.org/).

The study was initially begun to study obesity and weight loss. However, after finding many people regaining weight after a significant loss, the researchers began to search for clues into the reasons people began to use food, alcohol and drugs as coping mechanisms long after the weight issues were address. The researchers compiled a list of nine adverse childhood experiences and developed a point system which related to a person’s likelihood of having serious difficulties in adulthood. The nine ACEs are

1. Recurrent physical abuse
2. Recurrent emotional abuse
3. Contact sexual abuse
4. An alcohol and/or drug abuser in the household
5. An incarcerated household member
6. Someone who is chronically depressed, mentally ill, institutionalized, or suicidal
7. Mother is treated violently
8. One or no parents
9. Emotional or physical neglect

The more exposure to an ACE before the age of 18, the greater the likelihood of adverse affects as an adult. The research subjects were primarily from working class families and members of a HMO. In another ACE study that focused on childhood exposure to domestic violence, the authors found that individuals exposed to domestic violence in childhood had a two to six times greater chance of having experienced other childhood adversities. In addition, exposure to domestic violence in childhood was associated with a higher risk for self-reported alcoholism, illicit drug use, IV drug use and depression as an adult. (Felitti et al 1998, Dube et al 2001)

In addition to the extent of the history of trauma, another factor in resiliency and recovery is support and validation. This is best illustrated in the following stories:

Anna and her friend, Bridget, are seven years old, and playing outside after school one spring afternoon. Suddenly a car swerves around the corner and a gang of young men in the car start shooting at another group of men on the corner. One of the bullets hits Bridget and she is killed on the spot in front of Anna.

Anna’s family and community respond to the violence by supporting her and offering her additional counseling as needed. Her family recognizes her need for additional support and continues to check in with her on a regular basis. In addition, the community takes measure to ensure the safety of children in the neighborhood.

Sarah, also seven years old, walks five blocks to school each morning. Most mornings she is followed by a group of sixth graders who throw rocks at her, call her names, and grab at her clothing and backpack. When she tells her parents they call her a “baby’ and tell her to “toughen up” and “get over it.” The abuse continues for the full school year.

Of these two children, even given the severity of the incident, Anna is more likely to recover and have fewer symptoms of PTSD in the future. Sarah, however, will likely develop some symptoms and seek ways to escape from the emotions and fears that continue to plague her.

If the situations were reversed and Anna was not receiving validation and support, she may continue to experience nightmares and other repercussions of witnessing a traumatic death. If Sarah received support, validation, and advocacy from her parents, she may be able to recover from the effects of the abuse.

The brain is significantly affected by neglect and trauma in childhood. The following picture shows a brain of a normal three year old as compared to another three year old that has experienced extreme neglect. The brain development has been significantly impaired. The good news is that the brain has resiliency and can make positive gains once the child is placed in a home where he/she is validated, supported, and given the chance to develop positive attachments.

This relationship provides an enduring emotional bond and determines future relationships and self-regulation. It is a secure “container” that provides for basic needs and safety, and gives the freedom to explore and learn as opposed to being unavailable, lacking in safety and security. This relationship increases the child’s ability to develop trusting relationships and coping skills.

Studies on brain development have also revealed that the ability to dissociate during times of stress develops during childhood. Dissociation is the ability to psychically leave the situation and lose memory of the even. This may be due to the brain not having developed enough of the pre-frontal cortex (thinking brain) to be able to develop other skills. Dissociation may continue into adulthood.

In a future blog, I will address how cultural influences can shape a person’s viewpoint and ability to recover from complex trauma.

Domestic Violence, Trauma and Mental Health Conference Overview

On June 24, 2010 in Nashua, NH and June 25, 2010 in Meredith, NH, close to 250 members of the mental health professions and advocates from New Hampshire domestic violence and sexual assault programs met for the Mental Health, Trauma & Domestic Conference. Sponsored as a part of the Open Doors to Safety project of the NH Coalition Against Domestic and Sexual Violence, the goals of the conference included enhancing services of both mental health and DV/SA agencies to survivors with mental health issues, build a bridge between the two disciplines by using trauma theory as a common language, and start a collaborative process between existing services.

 Terri Pease, Linda Douglas, Carole Warshaw and Grace Mattern

Carole Warshaw M.D. and Terri Pease Ph.D. of the Domestic Violence and Mental Health Policy Initiative and the National Center on Domestic Violence, Trauma and Mental Health were the primary speakers for the conference and were sponsored by the National Network to End Domestic Violence (see links to the left). The following is my attempt to outline some of the topics that were discussed.

Why Address the Issues of Domestic Violence, Trauma and Mental Health?

• Domestic violence can have serious mental health consequences and abuse and violence play a significant role in the development and exacerbation of existing mental health disorders. 
• Through the Adverse Childhood Experiences Study (Felitti et. al. 1998) it has been found that the great number of risks (physical, sexual, psychological abuse; witnessing violence toward parent, household members with substance abuse, suicide attempts or incarceration) encountered in childhood, the greater the likelihood of experiencing poor health, alcohol or drug abuse, or mental illness as an adult.  
• Batterer’s use MH issues to control their partners by control meds and/or treatment and undermining sanity. Often, since symptoms of trauma are misdiagnosed as mental illness, the batterer is able to use the symptoms against the victim by way of stigma, poverty, discrimination and institutionalization.

Issues of Collaboration: Concerns of DV Programs and Survivors

• Availability and Accessibility –  
• Linguistic and cultural appropriateness 
• Priorities, time and Cost 
• Transportation and Childcare 
• Abuser Control of Insurance 
• Service Quality 
• Choice of provider 
• Providers knowledge of DV 
• Trauma informed vs. trauma competent 
• Need for gender specific services 

Trauma Theory

Trauma theory normalizes the responses that humans experience when exposed to traumatic events. It reframes many symptoms of PTSD and borderline personality disorder as adaptations and survival strategies necessary for survival in a life of complex (ongoing) trauma. Trauma theory also integrates developmental, biological, emotional, cognitive, spiritual and relational domains and challenges both DV and MH providers to expand their skill base and build a broader response to survivors of trauma.

Carole Warshaw M.D. also presented information based on research in the field of neuroscience to explain how the brain and body reacts when experiencing trauma or reminders of the trauma. Similar information is presented in previous blog postings so I will not cover it here.

In order to increase the mental health clinicians’ knowledge of what domestic violence and sexual assault advocates do, I, Linda Douglas, gave a short presentation outlining the aspects of empowerment, advocacy and privilege. As advocacy and empowerment are discussed in other blog postings I will not review here. The issue of privilege and how it pertains to the survivors confidentiality will be covered at another time.

Carole and Terri provided a forum to discuss clinical implications for mental health clinicians. Issues regarding documentation, safety planning and the dynamics of power and control were discussed along with the counter transference, transference and the parallel process that occurs in the therapeutic relationship.

On both days a case was presented and participants were asked to work together to determine what services would be needed for a survivor who is experiencing domestic violence currently and has adaptive behaviors due to complex childhood trauma. It was during this time that domestic violence advocates and mental health clinicians were able to discuss what they can do in the context of their programs and also began to identify gaps in services in their area. Hopefully, steps were taken to continue to discuss collaboration within their communities, with mental health clinicians recognizing that DV/SA advocates are doing trauma informed work with survivors and that mental health services would be valuable in providing assistance to survivors who are dealing with the affects of complex trauma.

This post can in no way cover all the important aspects of this conference. If you desire any more information, please feel free to email me with your questions or make comments below. In addition, I have provided the following bibliography for your use.

•  Warshaw, C. Domestic Violence, Trauma and Mental Health. Encyclopedia on Interpersonal Violence. (C. Renzetti and J. Edleson (eds.). Sage. Thousand Oaks, CA. 2008
•  Warshaw, C., Brashler, P., and Gill, J. Mental health consequences of intimate partner violence. In C. Mitchell and D. Anglin (Eds.), Intimate partner violence: A health based perspective. New York:
• Oxford University Press (2009)
•  Warshaw, C., Brashler P. Mental Health Treatment for Survivors of Domestic Violence. In C. Mitchell and D. Anglin (Eds.), Intimate partner violence: A health based perspective. New York: Oxford University Press (2009)
•  Herman, JL. Trauma and recovery: The aftermath of violence: domestic abuse to political terror. New York: Basic Books; 1992.
•  Davies J, Lyon E, Monti-Catania D. Safety planning with battered women: Complex lives/Difficult choices. Thousand Oaks: Sage; 1998.
•  Markham DW. Mental illness and domestic violence: Implications for family law litigation. Journal of Poverty Law and Policy. 2003;May-June:23-35.
•   Clark C, Young MS, Jackson E, et al. Consumer perceptions of integrated trauma-informed services among women with co-occurring disorders. J Behav Health Serv Res. Jan 2008;35(1):71-90.

The Brain Talk II - Traumatic Memories

I have been doing a lot of reading lately on how the brain stores memories. Most of the information is written by scientists and psychologists/psychiatrists in the field of neuroscience and is not written for the lay person. In order to understand it myself, I have translated the information into metaphors and hope that this helps my readers understand how the brain handles traumatic memories.




There are two types of memory – explicit and implicit. Explicit memory is related to events that are easily related using language. It involves facts, descriptions, concepts and ideas. It is explicit memory that enables us to tell our life story, narrate events, put experiences into words, construct a chronology and extract a meaning (Rothschild

2000, 28-29). It is easily stored into the language centers of our brain and is easily recalled. It is as if we take the memory of the event and place it tidily in one file folder, in one file drawer, into one file cabinet.

Implicit memory involves automatic states within the brain and operates unconsciously. It is implicit memory that we use when we do something we have done many times before and we no longer need to think about the action it takes, such as walking, brushing our teeth, or riding a bicycle. There may be a bridge between the two types of memory if there is a need to make sense of the unconscious action, such as trying to identify why a certain body response occurs when a person is triggered by a reminder (conscious or unconscious) of a traumatic event.

Explicit memory is also dependent on when the event occurred in a person’s development. If the brain has not developed full language and narrative abilities it may only store the event in the areas of the brain responsible for the body’s responses to the trauma.

Here is my example – When I was a year and a half old I was toddling in my grandmother’s kitchen. Someone had placed a freshly brewed (boiled/percolated) cup of coffee within my reach on the kitchen counter. I caught my finger in the handle of the cup and the hot coffee spilled down my neck and chest, resulting in third degree burns. My throat started to close up and by the time we arrived at the hospital I need to have a breathing tube. I had numerous surgeries to repair that damage which required that I be wrapped up in bandages for about six months.

I have no explicit memory of the event. The language areas of my brain were not developed. I have no visual memory of the event. All I know of that day is what my mother told me. As an adult, she was able to store the event in an area of her brain that allowed her to develop a narrative.

I have implicit memories of the event. When I was five, my mother tried to get me to wear a red hooded sweatshirt that had a tight neck. I had a complete meltdown. She tried this twice over a period of a week and then connected that I was reacting to the sensations of feeling out of control and having something over my face. As I developed, I was able to make meaning of the body memories (implicit) and have reduced the effects. I no longer have intense responses to having something over my face and around my neck. I find it uncomfortable but am able to adjust accordingly.

Even after the language and meaning making centers of the brain are developed, when traumatic events occur, our brain is flooded with large amounts of chemicals. This chemical overload will shut down the areas of the brain responsible for the explicit memories and the memories are then stored in the areas that govern sight, smell, hearing, and other body sensations. These memories are fragmented and stored in multiple areas as if the memory was torn into hundreds of puzzle pieces, placed in multiple file folders, and tucked in various file drawers. The result is that the person is unable to recall the memory in chronological order and may even mix up memories from different events, much like finding unconnected puzzle pieces and Legos in the Monopoly and Clue game boxes. It is very difficult for the person to figure out where the piece actually belongs.

What results is a survivor who cannot tell her story in a way that makes sense to the police, court or advocate. The survivor may mix up different events, be unable to relate when the incident happened, who was there, or even have blocked out certain parts of the event. For law enforcement and lawyers, who require a cohesive, sequential narrative, this can be frustrating. This may even result in a survivor being re-victimized by a system that does not understand trauma.

As advocates our job becomes assisting the person in putting together the pieces of the puzzle. Being triggered by the telling of the event is a common occurrence. It helps if the advocate can find a safe, quiet place before a court hearing where the victim can tell her story as it comes to her. Once most of the pieces are the table, then both the victim and the advocate can attempt to put them in order. Trying to have the person tell the person in chronological order right at the start would be like trying to put a puzzle together starting at the upper left corner and moving to the right and then back to the left piece by piece. The process may actually take sorting, putting a group of pieces together, discarding the pieces from another puzzle, and then trying to put the picture together. There may still be some holes when all is done but the story is there.

Finding a way to explain this process to a survivor is also helpful. You can try to find your own metaphors and make this information more accessible. Trauma survivors are often frustrated and re-traumatized by the difficulties they experience when trying to remember and make meaning out of their experiences. By understanding what is happening and having a tool box of skills to use to manage the emotions and body sensations that arise out of being triggered a victim can move to being a survivor and will be more empowered as she is able to manage and make sense out of her memories.

The following are some suggestions from the Bristol Crisis Services for Women (UK) for managing triggers or body memories of trauma –

Grounding:
• stamp your feet, grind them around on the floor to remind yourself where you are now
• look around the room, noticing the colors, the people, the shapes of things
• listen to the sounds around you: the traffic, voices, the washing machine, etc.
• feel your body, the boundary of your skin, your clothes, the chair or floor supporting you
• have an elastic band to hand - you can 'ping' it against your wrist and feel it on your skin
• tell yourself that feeling is in the now, the things you are re-experiencing were in the past.


Take care of your breathing: breathe deeply down to your diaphragm; put your hand there (just above your navel) and breathe so that your hand gets pushed up and down.

Count slowly to 5 as you breathe. When we get scared we breathe too quickly and
shallowly and our body panics. This causes dizziness, shakiness and more panic.
Breathing slowly and deeply will stop the panic.

If you have lost a sense of where you end and the rest of the world begins, rub your body so you can feel its edges, the boundary of you. Wrap yourself in a blanket, feel it around you.

My Brain Talk

This is a short version of my “brain talk” that is part of most presentations I give on trauma.

The brain is an amazing organ. Every time I get ready to present about what happens within the brain during a trauma event I am in awe of how the brain really works to try and protect us from harm. However, when exposed to chronic trauma the brain eventually goes into overdrive and ends up wearing down both the brain mechanisms that are meant to protect and the physical body.

Imagine that you are driving through a residential neighborhood on a beautiful spring day. Suddenly, you see a soccer ball bounce into the middle of the street just a few car lengths ahead of you. What is the first thing that you do? I hope that you answered “I slam on the brake!”

Did you think about slamming on the brake? Did you consciously think to yourself “Hmmm, there is a ball. There may be a child somewhere behind it. I should put on the brake. Yes, I will put on the brake.” NO – you probably just slammed on the brake and thought about it afterward. That was your amygdale engaging.

The amygdale (the doing center of the brain) is a small kidney shaped piece inside of your brain that becomes flooded with cortisol and norepinephrine during times of extreme stress. The message is sent down the brain stem and spinal cord to whichever part of the body needs to act and completely bypasses the thinking part of the brain (the frontal cortex or forebrain). In lesser amounts cortisol improves cognition and attention and stimulates the front cortex (the part of the brain behind your forehead and above your eyes). However, in large amounts, the cortisol causes the frontal cortex to shut down and the amygdale does all the work. Once the danger is over (someone has held back the children and removed the ball from the street) the frontal cortex and the amygdale can go back to a normal state.

EMTs, military personnel, and other people talk about times when they didn’t think about how to respond but just went into automatic mode during times of danger and extreme stress. This is what happens to persons who are experiencing trauma in their lives and when the danger is chronic. The frontal cortex basically stops and says “I am not even going to stop and think about things any more because this person needs to be on constant alert and ready to act.”

This explains why survivors of trauma appear to always be on guard, hyper-vigilant, ready to fight or flee, and appear to be constantly afraid. This also is the reason why some people are not able to engage in a relationship with a provider. The person’s brain has gone into a default mode of constantly being prepared for danger. The survivor has probably had few experiences of being engaged in safe relationships and may not have grown up in an environment that leads to the ability to make choices other than those needed for survival. In fact, perpetrators were probably caretakers and had said that they were only doing what was good for the person or that they were just trying to help.

Another important point to know is that if the survivor grew up in an unsafe or hostile atmosphere he/she did not have the opportunity develop normally. Most or all of development was focused on maintaining safety and survival in the environment in which he/she grew up. Some of the behaviors we may observe may seem strange or counter-productive in a safe environment. However, in their environment, these behaviors were skills to maintain safety.

Here are two examples:

In the book, The Cellist of Sarajevo by Steven Galloway, the author describes how during the siege of Sarajevo in 1992, people in the city of Sarajevo had to change how they traveled about the city. There were snipers in the mountains around the city who were shooting at people as they crossed streets on their way to get water or bread. People would congregate on street corners to decide whether or not it was safe to cross. They would cross in large groups or one by one. They would often run in a zig-zag pattern in order to be a harder target to hit. If someone who grew up or lived in a war zone such as this for a long period of time, even when they moved to a safe place, they may continue to cross the street in the same manner. For them it is an ingrained survival skill. For observers it may seem strange or a means of attracting attention.

Another story is of a personal nature. When I was in sixth grade I was bullied by a boy in my class who was two years older than the rest of us. He always waited until the math teacher came into the class as he appeared to sense that she was timid and would not stop him. He would get out of his desk and roam around the room during the math hour. At some point, sometimes once a week and sometimes not for a week or so, he would come up behind me and drive the point of his elbow into the middle of my back. I eventually was able to talk to a school counselor and it stopped. The repercussions did not end there. When I went into seventh grade I was placed in a remedial math class.

Because I had been focused on the boy and his whereabouts and was in fear of his attack, I had not learned sixth grade math. Fortunately, because I was in a nurturing environment, had my feelings regarding the bullying validated, and the abuse had stopped I was eventually able to move quickly back up to a higher level math class within the first semester of seventh grade.

The other part of the story is what I know about the boy. He came from a family of about eight children and his parents were alcoholics and known to be violent. Since he was two years older than the rest of us it is evident that he had been held back and had difficulties learning. This was more than likely because he was focused on survival at home and not on learning at school. He did not graduate from high school. I can only speculate on what the rest of his life has been like.

This story took place forty years ago. These days he probably would have been diagnosed with some sort of conduct disorder and possibly attention deficit disorder. Underneath it all, though, was the ongoing trauma in his life and that he was probably in a default mode of survival which made it difficult for him to learn anything else. This is why we may know people who have street smarts, can read faces and emotions, and have difficulties in new environments because they are looking for danger and how to manage (usually considered “manipulation”) the systems in which they are involved.

I hope this helps explain what is happening in the brain of persons who have had ongoing trauma. In future posts, I will write about how attachment and nurturing can have an impact on children who have experienced trauma and also how culture can affect a person’s response to traumatic events.