For the past 50 years, psychotherapy has taken a back seat to biomedical psychiatry, largely due to reliance on medications for the treatment of mental disorders. Yet clinical evidence increasingly points to chronic, unresolved traumatic stress as the source of many — if not most — mental disorders. Furthermore, longitudinal analyses show continued use of psychotropic medications is bad for the body, even causing chronic diseases. Granted, medications can stabilize a body wracked by recurrent distress, but such an approach is hardly a long-term cure. According to psychiatrist and trauma specialist Bessel Van der Kolk, “dramatic advances in pharmacotherapy have helped enormously to control some of the neurochemical abnormalities caused by trauma, but they obviously are not capable of correcting the imbalance.” To correct the “imbalance” often requires learning to inhabit one’s body and relationships in new ways.
Fortunately, the psychotherapeutic treatment of psychological trauma has advanced significantly the past several decades. In part, this is due to scientific discoveries of how the body and relationships naturally defend against traumatic stress. In particular, trauma-informed psychotherapies that draw from neuroscience and attachment studies are more holistic and scientifically based than ever before, although they often support the intuitions held by originators of psychotherapy such as Pierre Janet, Sigmund Freud, and C. G. Jung.
The neurobiology of trauma
Pierre Janet was the first to recognize how the body responds to present events as if past traumas were recurring — what today we call flashbacks. He observed patients
“continuing the action, or rather the attempt at action, which began when the [traumatic event] happened, and they exhaust themselves in these everlasting recommencements.”
Today we know the neurobiological reasons for flashbacks. Unlike narrative memories that seamlessly integrate
remembrances of the past — e.g., feelings, perceptions, thoughts, body sensations, beliefs — the memories associated with traumatic events largely remain unintegrated. This has to do with how the body has evolved to deal with threat. Thinking about a threat would slow down reaction time. Thus the frontal lobe — the so-called “thinking part” of the brain — effectively shuts down during perceived threats as energy and attention are directed towards survival responses. Consequently, a coherent narrative of the traumatic event is not created, inhibiting the past from becoming, well, the past.
These fragmented, often unconscious memories can be stimulated by even the subtlest reminders of past traumas. When this happens, the amygdala is also stimulated. The amygdala functions like the body’s alarm for the presence of danger, setting off survival responses even if no danger is present. The stock example of this process is the war veteran who hears a car backfire and automatically drops to the ground because his body “thinks” it hears gunfire. Today, sensorimotor psychotherapy, EMDR, and somatic experiencing are a few of the psychotherapeutic approaches that help release what Bessel van der Kolk described as “fixed action patterns” of the body that the trauma survivor would otherwise continually replay.
The significance of early life relationships
Sigmund Freud described psychoanalysis as “a cure through love.” Learning to trust love — and seeing oneself as lovable — remains one of the best possible outcomes of psychotherapy. Perhaps this is because even more debilitating than enduring something traumatizing is the pain of facing trauma and its aftereffects alone. Traumatic stress incubates in isolation and feeds on shame. Over time, survivors can lose trust not only in others, but also in their own minds as they defend against intrusive reminders of past traumatic events.
Common goals when starting therapy include gaining control over distressing emotions such as fear and anger, ending depression, creating better relationships, and functioning well at work. Traumatic stress and fragmentation are rarely seen as the root causes of suffering even though these experiences are often the neurobiological underpinnings of feelings of despair, distress, or impaired functioning. Furthermore, present difficulties are often the long-term outcome of adapting to maladaptive or traumatizing caregiving early in life.
Trauma-informed psychotherapies distinguish between two types of trauma:
- Big “T” trauma associated with fear-based events (i.e., overwhelming experiences that cannot be integrated)
- Little “t” trauma that results from maladaptive caregiving (i.e., cause emotional distress, but do not overwhelm)
Both can lead to mental disorders in later life as well as problems with intimacy. Connecting current problems to early relationships is difficult. It can be distressing to describe them as traumatic, or even maladaptive, when there are continued feelings of emotional dependency on parents or caregivers. Even so, research and clinical evidence reliably show the extent to which we have evolved for specific emotional experiences with caregivers. When these experiences were lacking, or if there was abuse, developing intimate relationships later in life can be particularly challenging. There can also be difficulties with consistently feeling confident, calm, and hopeful about one’s abilities.
Clinical psychologist Robert Karen described attachment theory as a “theory of love and its central place in human life.” According to attachment theory, one of the primary roles of the caregiver is to teach the child how to bond with others and regulate emotions. Emotions are the basis for intimacy and are also fundamental for understanding one’s own needs and desires. Furthermore, having the capacity to regulate emotions is vital for forming relationships and self-knowledge.
Studies conducted by Mary Ainsworth revealed mothers who provided secure attachments do the following:
- reflect sensitivity rather than misattune to emotional needs
- accept rather than reject the infant’s emotional needs
- cooperate with the infant rather than attempt to control and dominate
- appear emotionally available to the infant rather than remote
- adapt to the infant’s natural rhythms and emotional needs.
Challenges to developing secure attachment include:
- the caregiver frequently appears frightened, such as when intimate partner violence is occurring
- the caregiver is emotionally unavailable, such as when the caregiver is depressed
- the caregiver is frightening, which is how a caregiver is perceived when abusive
- the household is chaotic, keeping the caregiver from emotionally attending to the infant.
According to the CDC’s Adverse Childhood Experiences Study, two-thirds of US households have conditions that can damage the caregiver-infant bond. Adverse childhood experiences also increase the likelihood of later developing mental disorders. Of note, most people receive or seek mental health services after a period of isolation, which suggests difficulties trusting others or having safe people in their lives who could offer support.
The healing impact of relationships
Just as treatments for the body’s response to trauma have improved other the years, so has the “love cure” originating with Freud and others. Relationships involving the safe exchange of emotions may be the single most healing experience a person with a history of trauma can have. Yet such intimacy is a two-directional process, which challenges the idea that an effective therapist is a distant one. Early in psychotherapy’s history, C. G. Jung realized that psychotherapy heals when both therapist and client are equally invested in the relationship. He went so far as to claim, “unless both doctor and patient become a problem to each other, no solution is found.”
The idea of the therapist as “blank screen,” which Freud advocated, fails to fit the present-day understanding of the neurobiological effects of trauma or the nature of attachment. Instead, attachment theorists see healing occurring through the repeated experience of finding oneself in the mind of the therapist — and altering that image by genuinely impacting the therapist. Yet to have such an impact on another person means having a real relationship, albeit one in which the focus in psychotherapy is on the client. Clinical psychologist David Wallin wrote,
“psychotherapy ‘works’ by generating a relationship of secure attachment within which the patient’s mentalizing and affect regulating capacities can develop. … such a relationship must be an intersubjective one in which the patient comes to know him- or herself in the process of being known by another.”
I would venture to add the client comes to trust love through being loved.
Of course, therapy isn’t the only way to learn to trust love and trust loving oneself. We can begin to do this for ourselves and each other by prioritizing emotional safety and love in all our interactions. Sometimes this is as simple as asking ourselves, Is this emotionally safe for me/him/her/them? Is this loving?
© 2014 Laura K Kerr, PhD. All rights reserved.
Laura K. Kerr, PhD, IMFT is a mental health scholar and registered marriage & family therapist intern in the San Francisco Bay Area. For more information, visit her website.