What is Trauma?
Paper commissioned by RENATE Europe, for presentation to RENATE members attending training on "Trafficking and Trauma: Care for the Carers,’’Freising, Germany. 30 April – 4 May, 2018."
Prepared by Joana Terezieva, Psychoanalytical Psychotherapist.

What is Trauma?

The Etymology of the English word trauma is from the ancient Greek word τραῦμᾰ, which means wound (hurt; injury). While it is easy in a way, to imagine how our body could be wounded or injured, when speaking of trauma we should imagine how certain events could wound the mind and emotions. What does it mean? We know that traumatic events may have both physical and emotional aspects, for example, a car incident and the sudden loss of someone we love. Both events may cause strong traumatic reactions and symptoms such as depression, fear, numbness, irritability, anger, sleep and eating disturbances, inertia, memory lapse, distraction, compulsion, substance abuse, isolation, avoidance, social withdrawal, flashbacks, nightmares, and more. Symptoms and signs of trauma may be physical, emotional, cognitive, and behavioral. Additionally, symptoms of re-experiencing the trauma through flashbacks, nightmares, intrusive thoughts, sudden emotional or physical flooding are acknowledged. This is because the trauma is affecting one’s body, mind, emotions and social life.

Conversely, it has become quite common to speak of the “traumatized institution”. As is well known, trauma reactions to abuse are displayed not only by the individuals affected but also in the systems involved such as schools, communities, associations, clubs and other institutions. However, this formulation can be misunderstood to mean that the institutions affected are likewise to be defined as victims. For the process between institution and victim it is decisive, first of all, that the representatives of the institution assume responsibility for their own failure − so that they certainly do not define themselves as victims, but admit their systemic membership of the offenders’ side. But, on the other hand, clearing up a case of abuse is always connected with experience that is also extremely painful for the institution. For example, Canisius-Kolleg: the rector assumes responsibility. But, in fact, the others who belong to the same institution, namely its employees, children, youths, parents, and former members, are treated as liable as well. When, on January 28, 2010, the Berliner Morgenpost published my letter to those former students abused in the 1970s and 1980s, the children and youths at Canisius-Kolleg ran through the city’s streets and saw the picture of their school under headlines such as “School of Horror”, “School of Abuse” emblazoned across the newspaper kiosks. That hurts, and is experienced in the “System” as unjust, yet it must be accepted if one is to face the truth.

Dictionaries define trauma as (1) a deeply distressing or disturbing experience or (2) a severe emotional shock and pain caused by an extremely upsetting experience. Wikipedia gives the following definition of psychological trauma: ‘a type of damage to the mind that occurs as a result of a severely distressing event. Trauma is often the result of an overwhelming amount of stress that exceeds one's ability to cope, or integrate the emotions involved with that experience.’

It is essential to understand that responses to traumatic events are unique to each person. The same event may be experienced in an extremely stressful way by one person and as something not that dramatic by another person. Take divorce for example, and events that are always traumatizing e.g. war, which cause both physical and emotional violence. Equally important to recognize is the fact that some of us may recover faster and easier compared to others, surviving the same traumatic event, despite of its nature. How does it possible?

In her paper, Understanding Trauma, a Psychoanalytical Approach(2002)Caroline Garland, a Consultant Clinical Psychologist at the Tavistock Clinic and a member of The British Psychoanalytical Society, links trauma with the capacity of the individual “to take care of what he feels to be his own well-being”. The concept behind this statement is very psychoanalytical, based on the ideas of Freud (1920), who gives metaphoric examples of brain, enveloped with a protective skin (as the body is), described as an “outcome of the development in the brain of a highly selective sensitivity to external stimuli”.

A short and simple explanation to this theory is that in order to function well, the mind needs to operate with a selectivity function so that certain stimuli are blocked and the mind is kept safe from being overwhelmed. This developmental process begins in early childhood where the selectivity function of the baby is initiated and developed by the mother/primer caregiver. The mother keeps the child from overstimulation by knowing what her child is capable of managing at certain times. Adults manage this by themselves through the level of their personal autonomy. Nevertheless, some adults may behave in a risky manner, often placing themselves in jeopardy, as if they are constantly looking for problems.

So, the capacity to respond to traumatic events very much depends on the individual’s autonomy and mental functioning. However, as Garland says, “some events will overwhelm that capacity, will knock out ordinary functioning and throw the individual into extreme disarray”(ibid). What the individual actually perceives is that the world, as he knows it, is gone. A traumatic event is sudden. It shatters the belief that the world is a safe and predictable place.

It is fundamental at this juncture, to state that in order to function well and to be confident and mentally stable, one needs to rely on the predictability of the world. The Sun rises in the east and sets in the west; My daughter is waiting for me at home; I will always find something to eat; People are predominantly good; It is safe to fly in airplanes, etc. Of course, there always could be doubts and fears that something wrong or bad will happen. The degree to which these fears affect us is indicative of our mental state. Some people are most vulnerable. Some people engage strong defensive mechanisms to prevent themselves from being overwhelmed or worried (e.g. when someone denies bad news but eventually accept such bad news when he/she is already prepared to manage the news, because they are now emotionally stronger).

3. Split in the Institution

We need to know the world and to be able to make sense of events in it. People have always engaged in rationalizing events, we feel safer and relaxed when we know the reason. Why did this happen? Why did it happen to me? In contrast, it is painful, disturbing, maddening when we do not know the answers. It is crucial that things make sense, positive sense. Trauma does not make positive sense. It is always the question “why me”? A quotation from Garland’s paper is very relevant here:
…a traumatic event is one which, for a particular individual, breaks through or overrides the discriminatory, filtering process, and overrides any temporary denial … of the damage. The mind is flooded with a kind and degree of stimulation that is far more than it can make sense of or manage. … There is a massive disruption in functioning …. It is a breakdown of an established way of going about one’s life, of established beliefs about the predictability of the world, of established mental structures, of an established defensive organization (ibid).

While trying to make sense and to extract meaning from traumatic events, some people could find themselves trapped in repetitive situations: they may be fixated on talking about the event, or revisiting the place where the traumatic event occurred, or even literally trying to repeat the event, either from the position of the victim or the perpetrator.

Trauma affects the inner world of the survivor. The damage is perceived internally although the experience is external. The trauma may also stoke inner fears, such as the feeling “I knew this would happen”. It may feel as if one’s worst fears come true in reality, if, for example the survivor were threatened. This greatly affects the ego and the mental functioning.

In his famous publication Inhibition, Symptoms and anxiety (1926) Sigmund Freud wrote that X once traumatized, the ego can no longer afford to believe, in single anxiety (fear) in any situation resembling the life-threatening trauma (…). After being traumatized, one’s capacity for belief in warnings is empty, and the threatening situation is perceived as equal to reality. No warning, this is it!

The higher our inner anxiety is, the weaker our capacity to manage and overcome trauma. The capacity to sustain or to recover from trauma correlates to one’s confidence. This means that our early lives and the level of our cognitive and mental development predetermines our capacity to respond to sudden distressing experiences. This is why children, raised in institutional care-there are many in Bulgaria and Romania- easily and increasingly become victims of violence, including human trafficking. Their individual autonomy is weak. Due to severe deprivation during their early years, the lack of constant caregiving and the weakness of the primary care they may have received, their developmental process may not have been strong and their social and emotional wellbeing is more likely to be seriously affected.

Contemporary research in neuroscience reveals that a child’s brain develops in relation to other people. This finding was crucial to proving basic ideas of relational theories. It was in the 19th century when Donald Winnicott, a famous British pediatrician and psychoanalyst, suggested that the developmental process of the child’s mind corelates to the child’s environment, which in early childhood is created by the mother/primer caregiver.

In her recent book, Keeping Your Child in Mind, (2011), pediatrician Claudia Gold, interested in children’s mental health, gives a wonderful, accessible overview of the most recent neuroscientific research related to brain development of infants.
A part of the brain called medial prefrontal cortex (MPC) is primarily responsible for emotional regulation. When a person have a well-developed MPC, he experiences a sense of emotional balance. He can feel things strongly, without being thrown in to chaos.

Claudia Gold describes the important role played by the amygdala and the insula (both parts of the MPC) in emotional control. Furthermore, Gold stressed the fact that MPC development starts from the second month of life, continuing through to one’s twenties. Her primary concept, supported with ample research and her own clinical practice, is that interacting with the child emotionally the mother literally promotes the growth of her baby’s brain, helping to wire it with a secure sense of self. Furthermore Gold suggests that the first step to help a child, a teenager or a parent (client) is understanding. Like the mother who looks after her crying baby and telling him with no words: “I understand your emotion”.

We will come back to this idea later on.

Nowadays psychotherapist find it is increasingly important to be kept informed about the neuroscientific findings in order to be able to understand and usefully treat their patients. Of course, this is not that easy, as neurology is complicated. Helpfully they are initiatives of multidisciplinary teams who seem to have been working hard to find a way to link psychotherapy with neuroscience and devise publications equally addressing both types of professionals. A wonderful example is the book The Psychotherapist’s Essential Guide to the Brain, (Dahlitz, 2017), which I am going to refer to now, attempting to present the brain and its functions.

According to a well-known model of the human brain, the brain comprises three main parts: The reptilian complex (the primitive part), The Limbic system and The neo-cortex.

The reptilian complex is fully developed at birth and is responsible for our basic bodily functions such as heart rate, breathing, body temperature and spatial orientation.
It is important to recognize that the function of the primitive brain will take precedence over other brain activity. For example, if you try to hold your breath, you will find that as carbon dioxide builds up in your bloodstream, this primitive part of your brain is going to want to take over and make you breathe again.

While the neo-cortex is our “smart brain”, responsible for all higher–order conscious activity such as language, imagination, abstract thinking. The limbic system is our emotional brain. It is a collection of brain structures located in the middle of the brain.
(…) We could think of it as a center for emotional responsiveness, motivation, memory, formation and integration, olfaction and the mechanism designed to keep us safe. Key areas of interest to psychotherapy are the hippocampus, the amygdala and the hypothalamus.
The amygdala is like an early-warning system, with the motto “safety first” – put that safety plan into effect before consulting the executive brain (the new cortex). Picture yourself jumping out of the way of a snake–like object before closer examination reveals it to be just a garden hose in the grass. This is very important first response, because if it were left to the prefrontal cortex to initiate, for example, a leap out of the way of a bus you had inadvertently stopped in front of, than it might be too late: the evaluation system is too slow. The amygdala makes very fast, albeit not always accurate, evaluations and has a fast track from the thalamus through the hypothalamus that can initiate a stress response to forestall impending doom. The hippocampus plays an equally important role by encoding events in time and space them from short-term to long-term memory.
Of particular interested to therapists is the case where the limbic system gets the cues wrong: where there is no danger in actuality, but the body is thrown into stress response anyway. From chronic low-grade stress to full-blow panic attacks, a maladaptive limbic system could be the key to what is troubling your client.
……
The amygdala forms part of the limbic system. It is most commonly recognized as the emotional processing center that receives incoming sensory information and processes it for an emotional response. The response may be a defense to a perceived threat (…). The amygdala learns how to respond to various stimuli based on the its reference to implicit memory and makes decisions on how to initiate an emotional reaction to such stimuli. The emotional memory learned and utilized by the amygdala is episodic-autobiographical memory that can be notably implicit or unconscious, in contrast with explicit or declarative memory processed by the hippocampus.
The left and right amygdala have separate memory systems, but they work together to evaluate incoming information and process an emotional response, encoding, storing and retrieving memories that are associated with certain cues in the environment. The right amygdala is more strongly associated with negative emotions such as fear and sadness, whereas the left amygdala has been associated with both positive and negative emotional responses.
The amygdala has an attentional role, focusing our attention on the most important stimuli in the environment. It helps us define a stimulus and primes our immediate response, for example in recognizing a dangerous stimulus and initiating a stress response. (….) when the amygdala perceives a threat, it initiates a response to keep us safe from that threat, although this may not be the most adaptive response.
Hypersensitivity and over activity of the amygdala are at the core of anxiety – based disorders such as generalized anxiety disorder, phobias, PTSD, and other limbic-driven states that inhibit positive, rational responses to stressors. Down-regulating amygdala reactivity (…) is of primary importance when treating clients suffering from fear-driven conditions. Cognitive therapeutic techniques are of little value to someone who cannot function cognitively, so a bottom-up approach should be employed. Creating of environment of safety and calm becomes the first step in helping the client regulate their amygdala reactivity (Dahlitz,2017).

Treatment of people who have survived trauma:

So, now that we are at least one step further along in our knowledge and, hopefully, understanding, of trauma and had a look at the most recent theories and findings, together with some really old ones, have made a link between psychoanalytically informed science together with neuroscience, the question now is ‘how to put this knowledge to good use?’ How can we relate theory to practice in our daily lives?

As Caroline Garland (ibid) wrote in the last part of her paper:

We need theory behind us for at least two reasons. First, we know that when survivors come for treatment, it is because the sympathy and support of family or friends or neighbors or colleagues has not, on its own, been enough to help repair the damage. (…) Second, when we listen to someone in deep distress because terrible things have happened to them, it can also be very distressing for the listener’’ (op cit).

Effective listening and empathy are primary requirements of all the helping and caring professions. However, in order to be helpful, we need to be able to listen without being overwhelmed ourselves. Nevertheless, it is not an easy task to listen to someone’s terrible, or even horrifying personal story. Empathy “involves, in part, imaginative identification with the speaker and with his or her experience.” There is also neurophysiology behind it. The Insula, which Claudia Gold identified as equal important part of the medial prefrontal cortex as the amygdala and the hypothalamus, is mediating the physical experience of empathy.

‘When experiencing empathy for another person, one often has a number of physical sensations such as a tightening in the chest and tingling in the skin,’’ Garland wrote (ibid).’

When a person is either doing something or watching another person doing something, the mirror neurons (a special set of neurons) code not only the action, but also the goal or intention of the action and plays an important role in interpreting the meaning of another person’s behavior. Together with the Insula, mirror neurons seem to play a critical role in attunement and the sense of being understood by another person.

Effective listening appears to be a very complex process, isn’t it? In addition, listening to traumatized persons is also challenging. As I mentioned earlier when talking about the brain development in infants in relation to their mother and made a parallel with the process between therapist and client, the feeling of being understood is of primary importance to the client.

This understanding goes beyond the simple meaning of the word. It requires that the person is seen and accepted as the way he is – with his entire personal story, all the suffering and all the flaws. Traumatized people have failed in their attempts to make sense of what has happened to them and to keep a positive sense of self. From their perspective according to Garland, ‘’the thing that happened to them, and is still happening inside them.’’ They failed to manage that feeling, to make sense of it, and this has changed their entire sense of self, the confidence about who they are, their positive belief in the world, their will to live. And they are looking for someone to help them, through holding and containing this mental process instead of them. As the mother who holds her child’s unbearable emotions provoked by things such as hunger, pain, etc., in her own mind, calming the child with words of understanding and confirmation, “I know you are hungry/afraid/in pain…”, until the moment when the child’s mind and brain are ready and the little one is capable of taking care of himself.

The survivor is looking for help to regain his or her equilibrium. If we want to understand this process in a way that is helpful, we must not to be overwhelmed ourselves. We have to sustain a complicate balance: to be open enough to the survivor’s experience to take in a real way his or her state, but steady enough not to be knocked off balance of it. (Garland, ibid).

It may take years of treatment, where the therapist may be feared or even hated by the survivor, until the survivor begins to trust him or her in a realistic way. The therapist’s role here is to follow the client instead of lead him.

Most importantly, it is not good to focus on the traumatic events. The process of treatment will move on through the relationship between the therapist and client, through the transference.

‘What is offered by the therapist is that particular way of understanding, in a setting that offers a new experience of containment. Attention to the transference will, bit by bit, help re-establish the capacity to think about the traumatic events and their significance without the patient is being overwhelmed by flashbacks. Unfortunately, not all individuals can be helped. Some, particularly those who were severe ill-treated in a brutal and sustained way in childhood, cannot tolerate the demands of the one-to-one treatment setting. This patient are often those most in need of treatment. Here, group therapy, or the loose but stable containment offered by district psychiatry or forensic service can be very helpful,’’ Garland (ibid).’

 

Bibliography:

1. Dahlitz, Matthew (2017). The Psychotherapist’s Essential Guide to the Brain.
2. Freud, Sigmund (1926). Inhibition, Symptoms and anxiety.
3. Garland, Caroline (2002). Understanding Trauma, a Psycho-Analytical Approach.
4. Gold, Claudia (2011). Keeping Your Child in Mind.