WHY FOCUS ON TRAUMA?
Trauma is a special interest of mine, as it so intimately related with just about any health problem we can imagine. There are major 'Big T' traumas such as loss of life and limb or abusive relationships, and there are also smaller and more subtle 'little t' traumas. This may be when we were spoken to harshly by our grade 3 teacher, or when as an infant our mum inadvertently left us to cry. Then there is collective trauma, which extends to our parents, ancestors, societies, culture and countries. Often invisible, this leads to widespread emotional repression and plays out in poverty and violence across the planet. Therefore trauma healing is relevant to all of us, whether we have a mental health 'diagnosis' or we are simply willing to do the inner work needed to help our planet heal.
Most people with trauma-related problems have experienced multiple traumas, which is what we call complex trauma. This describes exposure to multiple traumas as well as the huge impacts of such exposure, which can make us truly feel as if our life is in ruins. Although we may think it is simply another label to describe mental illness, the acceptance of this label in mainstream healthcare, I believe, has the capacity to revolutionize how we understand and treat ill health. To this end, complex post traumatic stress disorder (CPTSD) is now recognized by the ICD - the global classification of mental health disorders.
The single most important thing I didn’t learn in medical school was about the impact of adverse childhood experiences, also known as ACEs. Everyday as GPs we see smokers, drinkers, drug addicts and morbidly obese people, not to mention those whose lives are crippled by depression, anxiety, uncontrolled anger or chronic pain. I continue to learn how these addictions and emotional patterns are imperfect solutions to the toxic imprints of adverse childhood experiences, or of traumatic memories in general - both individual and collective. These toxic imprints, which we now know can go as far back as the womb and even our ancestors, set up brain pathways and 'body memories' which persist into adulthood. The sad truth is this is really common, with 1 in 4 Australian adults now experiencing the impact childhood trauma.
The extent of this problem and supporting research is recounted in a poignant Ted Talk by paediatrician Dr Nadine Burke Harris: How Childhood Trauma Affects Health across a Lifetime.
The good news, however, is the we can heal. Yes, WE CAN HEAL! On a community level, we need special investment in early childhood education and early intervention for those at risk, as beautifully described by Dr Harris in the video above. We can also learn how we are not separate from the collective trauma that affects our community, and discover how collective healing is possible.
On an individual level, we need urgent education of health practitioners in trauma-informed care and urgent research into methods which are most effective in healing early attachment wounds, as well as a growing body of passionate practitioners to translate this into action. To this end I am inspired by the work of the Blue Knot Foundation, and I urge you to peruse the resources they offer. I especially recommend you read their fact sheet about recovering from complex trauma.
My medical practice radically changed when I was able to understand the role of complex trauma and learn methods to help people move past their struggles – it became more real, more heartful, more courageous and more effective. No more hiding behind diagnostic labels, protocols or time constraints, as I attempted to plunge in to the true reality of what affected people’s lives and allow them to be my teachers.
FOR HEALTH PROFESSIONALS
After a typical day at work at my semi-rural integrative GP clinic, I would often ask myself what more I could do to help all these people that seemed stuck in chronic ill health - both mental health and physical health. Gradually I began to realise the mammoth impact of Adverse Childhood Expereinces (ACEs), or Adverse Life Experiences in general. There were those whose health was never the same after a life changing event like being mugged on the street. There were others who had completely blanked out many years of abuse, which held the key to understanding a variety of symptoms and behaviours. There were others still who recalled a vague sense of feeling unloved or unwanted for as long as they can remember. My research showed that I was not alone in suspecting how common this scenario was. The scale of this problem is highlighted in this 2017 systematic review published in the Lancet, and eloquently described in the 2012 book Scared Sick - The Role of Childhood Trauma in Adult Disease.
What, then, can we do about this in our day to day clinical work?
In simple terms, we need to see our clients from the perspective of 'trauma-informed care' - we can then ask the question, 'What happened to you?' instead of 'What's wrong with you?' I see a disconcerting number of patients coming back from specialist visits of hospital stays disillusioned or even re-traumatised. With true empathy and understanding, we can build trusting, empowering and healing relationships, and even share a message of hope that trauma survivors can heal with appropriate treatment and support.
I urge all health practitioners, especially GPs, to peruse the 2012 Practice Guidelines for the Treatment of Complex Trauma and Trauma informed Care, published by the Blue Knot Foundation, which have been formally endorsed by the RACGP. They have also put together a fact sheet specifically for GPs.
Since 2012, the range of treatment possibilities for Complex Trauma has expanded to include many ‘new’ approaches and practices which may have much to contribute - detailed in the 2019 Practice Guidelines for Clinical Treatment of Complex Trauma. These guidelines acknowledge the limitations and over-optimistic claims of traditional 'evidence-based' treatments such as CBT (Cognitive Behaviour Therapy). New and emerging approaches include 'energy psychology' methods such as EFT (Emotional Freedom Techniques), CRM (Comprehensive Resource Model), brainspotting, EMDR, MDMA-assisted therapy and neurofeedback, as well as 'right-brained' oriented therapies like art therapy, sandplay, creative dance, equine therapy and drumming. As a therapist we are called to integrate these diverse interventions within a phased treatment model, while also attuning to the impact of dissociation - our client’s 'internal diversity'.
For those of us offering therapy, the Blue Knot Foundation have also published Complementary Guidelines which spell out the differences between standard counselling and complex trauma therapy, as well as competencies we need to work towards. In my own clinical work I resonate with the knowing that the many of these clients have an impaired 'felt sense' of safety, a high level of dissociation and a pervasive sense of shame, often going back as far as early childhood.
Here I have listed some of the essential points from the original guidelines about the reality of complex trauma, which I feel as health professionals we all need to know:
Over the last two decades research has established a substantive evidence base in relation to trauma. However a huge gap still exists between evidence about the effects of trauma on individuals and possibilities for recovery, as well as in the treatments which enable sustained recovery.
Repeated interpersonal trauma resulting from adverse childhood events (`complex’ trauma) is not only more common, but far more prevalent than currently acknowledged. The effects of complex (cumulative, underlying) trauma are pervasive, and if unresolved, negatively impact mental and physical health across the lifespan.
When unresolved, complex trauma causes ongoing problems, not only for those who experience it, but for their children and society as a whole - with enormous costs.
People impacted by trauma present to multiple services over a long period of time; care is fragmented with poor referral and follow-up pathways, and then a `merry go round’ of unintegrated care risks re-traumatisation.
Research shows that the impacts of even severe early trauma can be resolved, and its negative inter-generational effects can be intercepted - people can and do recover and their children can do well, and mental health and human service delivery need to reflect current research insights to support this.
THE SCIENCE OF TRAUMA
The brain is initially `sculpted’ by parent-child interactions, and particularly by the emotional (`attachment’) relationship. Attunement of the right brain of the care-giver to the right-brain of the infant is crucial to this process, affecting the child's capacity to connect both with self and others.
The right brain is dominant in the early years of life, and linked to pre-verbal experience. Such experience is unconscious, stored in implicit (rather than explicit, conscious) memory, and is unwittingly activated by subsequent life experiences.
Adverse and traumatic experience, particularly in the context of infancy and childhood, is deeply disruptive of the developing brain. Early onset trauma requires a shift from a `learning’ brain to a `survival’ brain.
The subjective dimensions of trauma can now be objectively correlated in brain activity, including changes in neurotransmitter activity and operation.
Attachment styles generated in early care-giving relationships (`secure’, `insecure-avoidant’, `insecure-ambivalent’ and `disorganised’) are longstanding. They are also transmitted to the next generation via subsequent parent-child relationships. However, neuroplasticity also means that trauma survivers can heal, as the brain is capable of change in structure and function.