Betsy de Thierry: Trauma Overview
A quick overview of the centrality of assessment and recognition of the levels of trauma
1 in 3 diagnosed mental health conditions in adulthood are known to directly relate to adverse childhood experiences (childhood trauma).
50% mental health problems established by age 14 and 75% by age 24.
In a society that often focuses on survival and management rather than recovery and post -traumatic growth, this overview aims to explore the possibility of working within a recovery framework.
Definition of trauma and recovery
It is recognised that ‘trauma is perhaps the most avoided, ignored, belittled, denied, misunderstood, and untreated cause of human suffering’ (Levine & Kline, 2007, p.3). Trauma could be defined as an event or repeated experience where the person felt terrified and powerless to defend themselves, and then were unable to process or make sense of the experience with a non judgemental, listening adult who could offer consistent comfort and reassurance.
Unprocessed trauma can lead to increased mental health difficulties during adulthood and a host of social problems
Unprocessed trauma can lead to increased mental health difficulties during adulthood and a host of social problems, such as drug use, school failure, anti-social behaviour etc. It can also lead to neuropsychiatric problems, such as post-traumatic stress disorder (PTSD), conduct disorders, and dissociative disorders, whilst unprocessed trauma can also lead to medical challenges, such as asthma and heart disease (Perry & Szalavitz, 2011). When childhood trauma is processed as a child in the context of a warm and genuine relationship, the impact is minimalized if not altogether transformed into greater resilience, thus changing the trajectory of a child’s life. This paper reflects on what it would take, financially, systemically and organisationally to raise the bar to think about trauma recovery as a focus that enables long- term transformation.
Trauma Informed Framework
The trauma informed movement has gathered pace in the last decade and the training that has swept across the UK has led to a general consensus that it is a healthy approach to hold. Arguably, the main facets of a trauma informed community are a belief that when trauma has taken place in relationships (both relationships that doesn’t meet all the needs of the child and relationships that have caused harm), then recovery needs to happen in relationships. Therefore relationships that are kind, nurturing, empathetic, compassionate facilitate healing, for both the children and young people who have experienced trauma and those caring for them who may now also be traumatised by the behaviour they have been exposed to. Another main facet is that all behaviour is communication and fear is the cause of the majority of disruptive or concerning behaviour. It is recognised that a basic understanding of the neuroscience of the threat response can enable empathy from adults rather than frustration, anger or authoritarian approaches. This empathy can then facilitate the nurturing responses that they need to help them become calm and feel safe. The trauma informed movement asserts that relationship is more powerful than medicine and when each person is recognised, we can each feel emotionally connected and validated as people with needs that they shouldn't be ashamed of. This reduces shame and enables growth and healthy communities to develop.
…and when each person is recognised, we can each feel emotionally connected and validated as people with needs that they shouldn't be ashamed of.
Trauma Recovery Focused Framework starts with Effective Assessment
We recognise that trauma can impact a person’s body, brain, memory, emotions, relationships, learning and behaviour. A step further on from a trauma informed approach is a trauma recovery focused framework. The distinction is the end goal being recovery from the long-term impact of the traumatic experience for the traumatised individual. In order to hold a trauma recovery focused approach, the first building block following the trauma informed facets would be the centrality of assessing the severity of the impact of the trauma.
‘Traumatic stress is caused by the exposure to or witnessing of an extreme and potentially life-threatening event. Traumatic exposure may be brief in duration (e.g. an accident), or involve prolonged, repeated exposure (e.g. sexual abuse), with the former being referred to as ‘Type I’ trauma and the latter as ‘Type II’ trauma (Terr, 1991). Knowledge of traumatic stress, how it develops, presents and affects the lives of those who suffer from it, may be the first step towards being able to interact positively with those affected by it. Heide and Solomon (1999) have defined an additional category as ‘Type III’ trauma, which they propose is the type of traumatic experience that occurs when an individual experiences multiple, pervasive, violent events beginning at an early age and continuing over a long period of time.’
de Thierry (2015).
Almost all Type III Trauma could be categorised as interpersonal trauma, which is thereby inseparable from attachment trauma and would now arguably be called ‘developmental trauma’ due to the trauma beginning in early infancy when the brain is most impacted due to the speed of neural growth under five years old. Allen articulates,
‘The most pernicious trauma is deliberately inflicted in a relationship where the traumatised individual is dependent – at worst, in a parent-child relationship.’
(Allen, 1995)
The trauma continuum needs to be considered together with the parenting or environmental capacity continuum (Figure 2), This continuum enables an exploration of how much support was and is available to the child or how complex their home environment was or is when the trauma occurred and their current context. We recognise that with many children and young people, when they are courageous enough to disclose any maltreatment, they can be faced with being told to be silent, shut up or worse still they are threatened so that they don’t tell anyone. These factors need to be a point of reflection so that an estimate of how severe the impact of trauma is likely to have been.
The questions that are used to reflect on the child’s level of trauma are these:
1. What traumatic experiences have they endured? Were they Type I,II or III?
2. What are their trauma symptoms past and present, internalised and externalised?
3. What is their current environment/ family setting like?
4. Who was their primary attachment in their first five years and what were they like? What key events happened in those years?
A sliding continuum enables professionals to discuss where the person sits on the continuum according to their experience and this would lead to a discussion about the most appropriate intervention that can be put in place. A single incident trauma could become a Trauma Type II due to the lack of empathy, care or nurture by the primary care givers. The more information there is, enables the professionals to grasp how deep the impact of the trauma is and this leads to being able to effectively plan a recovery treatment plan.
Often in training settings, it has become apparent that professionals in special schools or residential settings have not spent the time reflecting on what happened to the child and other such key questions but instead were speaking in terms of ‘what was wrong with’ the child and what was the ‘diagnosis made’. Without discussions that enable the professionals around the child to reflect on what happened to them, what is their behaviour showing us and what are their needs now, we cannot be recovery focused.
Behaviour and words showing us how severe the trauma
The crucial difference in behaviour from a person who has experienced a Type I or a Type II or III trauma is the way they use words. What we know of the brain, is that when any of us become frightened, we have an instinctive, natural, survival reaction that enables almost all the neural energy to be focused on the back brain or brain stem. Here the survival fight, flight and freeze reactions cause a host of other physiological movements.
Here the survival fight, flight and freeze reactions cause a host of other physiological movements.
One of those is the reduction in neural activity in the pre frontal cortex, which is responsible for thinking, being reasonable, reflective, rational and intelligent. This area of the brain is shut down so that our primitive, survival brain can ‘take over’ and automatically move us into a place to survive. This means that we see people fight, be aggressive, become agitated or run away when something has caused them to feel threatened. If they don’t fight or flight, they could freeze, which is a complex, internalised reaction that can cause long-term challenges to their physical and mental health. The other important factor in this instinctive reaction is that the broca’s area of the brain also goes ‘offline’ and speaking becomes difficult, apart from automatic language, which can be small talk or swearing! Therefore, when a child or young person, in the context of a warm and safe relationship, can use words to describe what happened to them and what it felt like, without too much effort, it is unlikely that they are describing Type II or III trauma experience. The impact on the person who experiences Type II or III trauma is primarily located in the subconscious and the body, not language. The person usually loses some of the memory of the trauma experience but the body and subconscious continue to behave as if they never forget. The traumatised person instinctively behaves in ways that show they are wired to survive certain threats, but may not be aware of what those threats are. Often a person who has experienced Type II or Type III trauma has NOT got a clear story or narrative of what has happened, even if they want to have one, due to level of overwhelm that has caused the memories and feelings to be pushed into the subconscious and a survival behaviour to ‘take over,’ defending their vulnerability. However, recovery does include an integrative narrative and a sense of understanding of what happened.
Different interventions and approaches for different levels of trauma
When the starting point for a group of multi disciplinary professionals is to reflect on the four questions around the trauma continuum, it enables a sharing of appropriate information that leads to an understanding of the persons behaviour. This can then further lead to clarity of what therapy or intervention is most suitable for a recovery approach. Type I trauma can be processed verbally, with counselling, with mentoring or with most one to one or even group work that enables an emotionally safe environment. They need to be able to feel safe enough to be able to reflect, speak and feel heard, cared for and the emotions they feel to be explored and validated. This is enough and can lead to recovery. Most current interventions, approaches or methods that are attachment focused or thinking focused or require verbal reflection are suitable for those who have been wounded in Type I trauma experiences.
However, the person who experiences Type II and Type III trauma, can often end up with memory, behaviour, emotion and thought that has become disconnected internally, leading to more explosive, irrational behaviour and the person feeling increased fear due to being so out of control. As such they often need more specialised help. Certainly if the person has experienced Type III, continual, multiple, repetitive trauma from an early age, the child or young person will not be able to recover in any short term, verbal or reflective type of approach. The impact of the trauma is now buried deep within the subconscious and enmeshed with different sensory experiences, which cause many different triggers that lead to behaviour that often makes no sense to the survivors themselves. No matter how eager the professional is to enable a person to reflect on what could have triggered the explosive behaviour, it is unlikely that they will be able to identify anything. If they sense that the professional ‘needs’ them to find a reason, they may often make up anything to appease them if they want to keep that positive relationship. This can lead to a common occurrence, which is that the child’s behaviour stabilises whilst they regularly have access to their preferred adult, but when that relationship becomes unavailable, their behaviour can escalate or become worse.
The kind of approaches that are unhelpful for Type II and Type III trauma are those which focus on self regulation rather than co regulation due to the dependency for regular, repetitive, nurturing support. Approaches that assume the person can reflect on their thoughts or behaviour is also counterproductive due to the probable shame and blame that is caused as these people realise that they are unable to due to the turmoil and confusion that is lurking in their subconscious. Some people who have experienced the horrors of coercive control or emotional abuse will be potentially more keen to work harder, become more disciplined and become exhausted, disappointed and depressed that they cannot do what seems to be so helpful to so many others.
The subconscious
The subconscious is a complex area. We describe it as a can of worms, but when trauma is present, the worms need to come out in the right order or depression and suicidal ideation can become a reality far too soon. This is why assessment is key and simplifying an understanding of trauma without clear boundaries and warnings regarding to childhood trauma can be catastrophic. No amount of thinking and ‘taking your thoughts captive’ will enable the subconscious to be restored and healed.
No amount of thinking and ‘taking your thoughts captive’ will enable the subconscious to be restored and healed.
Betsy de Thierry
MA Counselling and Psychotherapy.
www.betsytraininguk.co.uk for training and other free resources.
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Books by Betsy de Thierry on trauma:
Teaching The Child on the Trauma Continuum. 2015
The Simple Guide To Child Trauma 2016
The Simple Guide to Sensitive Boys 2017
The Simple Guide to Understanding Shame in Children 2018
The Simple Guide to Attachment Difficulties 2019
The Simple Guide to Complex Trauma and Dissociation 2020
©Betsy de Thierry