Book Review-Critical Incident Stress Management, 2e

While sufficiently discredited by research, many first responding organizations continue to use Critical Incident Stress Management (CISM) as a part of their strategy for employee wellness, particularly after a big event or a mass casualty.  I’ve not made it a secret that I think CISM is harmful (which is consistent with research).  I most thoroughly discussed some of the problems in my review of Opening Up.  One could easily wonder why I read this book.  The answer has to do with intentionally trying to give it a chance – to extract some of the good things from the approaches.  I found a few nuggets, but it was hard to find the things that are good and should be a part of any trauma response program.

Take Two

Before I continue, I should say that I read another book about CISM, titled CISM: Group Crisis Intervention, that was so bad I couldn’t find enough to write a separate review for it.  I share this here to reinforce the statement that I’m trying to find value.

Emotional First Aid

Crisis intervention is sometimes considered emotional first aid.  The analogy breaks down pretty quickly.  The direct quote from the book is, “Urgent and acute emotional ‘first aid’ designed to stabilize and reduce symptoms of distress, while assisting the person in crisis to return to a state of adaptive functioning.”  The problematic part of this statement is the “in crisis to return to a state of adaptive functioning.”  It’s problematic, because it treats the person as if they’re misbehaving machine that just must be patched up long enough to get through the crisis.  It ignores the ways that we know humans respond.

Certainly, for a non-zero number of people, they’ll encounter a crisis, and they’ll be unable to continue.  However, this is a rare case in general and particularly in the first responder communities where CISM is still used.  It’s more likely that our automatic defenses will kick in – at least in the short term.

As humans, we have the ability to compartmentalize trauma so that we can remain functional by temporarily blocking out information related to the trauma.  (See Trauma Therapy and Clinical Practice.)  If that fails, the second-line defense of detachment makes it seem as if the trauma didn’t happen to us – or to the people we care the most about.  It’s like we’re watching from above or outside of the situation.  (See In an Unspoken Voice.)

At some point, either when our defenses have been exhausted, or a relative degree of safety is encountered, we’ll attempt to process the trauma and convert it from an implicit memory to an explicit memory.  This happens mostly during REM sleep.  (See Trauma and Memory for more.)

So, fundamentally, the premise that we’re patching someone up in situ (in the crisis or in the moment) is inconsistent with how we operate as humans (in most cases).

Immediacy, Proximity, and Expectancy

Everly and Mitchell refer back to a 1947 book, titled War Stress and Neurotic Illness.  They explain that the authors believe the key to crisis response are immediacy, proximity, and expectancy.  The problem is that the three of these are expressions of a single belief that the person will be supported.  In The Psychology of Hope, Rick Snyder explains the need for willpower and waypower for the cognitive process of hope.  However, when you consider Richard Lazarus’ work in Emotion and Adaptation or Lisa Feldman Barrett’s work in How Emotions Are Made, one realizes that there are expectations of how support will be received by others that influence the way that events are processed.

In short, the authors of War Stress and Neurotic Illness can be forgiven for not recognizing their articulation is about external expectancies of support.  In reviewing the subsequent research, it should be obvious that it’s about the belief that help will be provided.

Mandates

Everly and Mitchell claim that the US Air Force required “CISM-oriented” crisis response programs on all bases, but the cited AF144 153 doesn’t actually say this.  It does indicate that the Air Force needs to be able to care for personnel involved in a crisis – but that’s different.  They similarly claim that the US Coast Guard requires CISM teams via Commandant Instruction 1754.3.  It actually says they need to support personnel when they encounter stress – but it doesn’t specify the program or approach.

I think that’s part of my challenge with CISM: the statements are almost – but not quite – true.

Pennebaker

James Pennebaker has been kind enough to answer some questions about his work after my review of his book, Opening Up.  Everly and Mitchell refer to his work as the authority. That’s why the disconnect between what CISM is and what he recommends is so striking to me.  Pennebaker’s work calls out the need to develop a narrative in a safe way.  Specifically, his research showed a written narrative that could be destroyed without anyone seeing it was best.  This has no place in CISM as defined.

In personal communications with Pennebaker, he expressed some level of surprise that CISM was still in use after the research that had been done that indicated some degree of hazard.

The Core Components

Table 1.2 of the book is reproduced below, as it is the most succinct version of the overall program.

INTERVENTION	TIMING	ACTIVATION	GOALS	FORMAT
1. Pre-crisis preparation	Pre-crisis phase	Anticipation of crisis	Set expectations. Improve coping.	Groups/orgs.
2. Individual crisis intervention (1:1)	Anytime. Anywhere.	Symptom driven.	Symptom mitigation. Return to function, if possible. Referral, if needed. Stress management	Individuals
Large Groups: 3a. Demobilization & Staff Consult (rescuers); 3b. Group Info. Briefing for schools, businesses, and large civilian groups	Shift disengagement; or anytime post crisis	Event driven.	To inform, and consult. To allow for psychological decompression. Stress management.	Large groups. Organizations
4. Defusing	Post-crisis (within 12 hrs.)	Usually symptom driven	Symptom mitigation. Possible closure. Triage.	Small groups.
5. Critical Incident Stress Debriefing (CISD)	Post-crisis 1 to 10 days; At 3-4 weeks for mass disasters	Usually symptom driven. Can be event driven.	Facilitate psychological closure. Symptom mitigation. Triage.	Small groups.
Systems: 6a. Family CISM; 6b. Organizational Consultation	Anytime.	Either symptom driven or event driven.	Foster support, communications. Symptom mitigation. Closure, if possible. Referral, if needed.	Families. Organizations.
7. Follow-Up; Referral	Anytime	Usually symptom driven.	Assess mental status. Access higher level of care.	Individual. Family.

Without going into details, you’ll notice that many of the timeframes are inconsistent with what we know about how trauma is processed and what we need to do to recover.  In fact, it appears that some of these interventions can interfere with normal processing – making things worse.

What people need is to know they’re supported.  What can happen is these CISM interventions can feel more intrusive than supportive.  (For more on supportive environments, see Servant Leadership, and The Fearless Organization.)

Research

It’s normal for me to review the research that underpins books.  Sometimes, I’m so intrigued by an author’s summary of an article that I must read it to get the details.  Normally, this process isn’t that complicated.  However, for this book, it was.  In some cases, like Pennebaker’s work mentioned above, the book said nearly opposite of what the study said.  In other cases, I found that the articles being referenced were retracted.  In still others, I couldn’t find the article at all.  While this can happen to even the best researchers, the breadth and volume of the challenges I found gave me reason to pause and wonder what was going on.

Trauma Informed

By the very nature of a crisis response, we must expect psychological trauma involvement.  It’s possible for someone to navigate a crisis without psychological trauma – or lasting trauma.  However, the principles of trauma-informed care apply whether the person is impacted by a trauma or not.  (See Restoring Sanctuary for trauma-informed care.)

CISM correctly identifies that sometimes telling a person in crisis what to do is the wrong thing – because they need to be given a sense of control.  Telling the person what to do is certainly appropriate if someone is at eminent risk that they don’t understand, and you need immediate reaction.  However, in most cases, the best response is to try to create choice and options.

Evidence

In the end, CISM has some “evidence” that indicates a positive response.  The problem is that the evidence is very weak “sentiment” type research rather than results research (which is admittedly hard).  It reminded me of the “smile sheets” that Kirkpatrick rails against in the education market.  (See How People Learn.)  On balance, I think people like CISM because it makes them feel better – but it’s not clear that it makes them better.  It’s still worth learning about Critical Incident Stress Management.

Book Review-Transforming Trauma: The Path to Hope and Healing

Sometimes, you can agree with the goal and even some of the foundational premises of an author without accepting their extension into a place where there’s no empirical support.  That’s where I am with Transforming Trauma: The Path to Hope and Healing.  Much like The HeartMath Solution, there are extensions that simply don’t follow the evidence we have.  Despite this, there are some good things about the book, what it shares, and how it can help  It just leaves a lot to the reader to ensure that what they’re reading is supported by science – or at least not invalidated by it.

Meditation

I’m not going to take away the documented benefits of meditation.  I wholeheartedly support and agree with them.  (See Altered Traits and Happiness for two examples of solid foundations for meditation.)  That being said, James Gordon’s assertion that “MEDITATION IS THE antidote to trauma” (capitalization original) is overstated.  To understand why, we need to understand what the research does and does not say.  James Pennebaker’s work shows the need to develop a narrative around trauma.  (See Opening Up.)  While meditation can activate the parasympathetic system and downregulate someone to a point of being able to address the trauma, it does not in and of itself neutralize the trauma.  (See Emotional Intelligence and Reducing Secondary Traumatic Stress for more on the parasympathetic system.)

Gordon claims that “if you meditate regularly, the tone of your vagus nerve – its level of functioning – increases.”  However, the referenced article doesn’t make such broad claims.  Instead, it surveys mechanisms of meditation and references the relaxation and anti-inflammatory properties.  This is a bit of tautology, because the vagus nerve is the parasympathetic system’s key driver – towards relaxation (or, shorthand, “rest and digest”).  Similarly, anti-inflammatory is often a shortcut for saying a reduction in cortisol.  (See Why Zebras Don’t Get Ulcers for more on stress, inflammation, and cortisol.)  In short, there’s no support for the statement made – even if it’s generally a good thing.

Gordon also claims, “Much of the research on meditation has been done with people who meditate for forty minutes a day or more.”  Here, the problem is that he’s isolated one measure – and not the one that’s arguably the most important.  Much of the initial research was done with people who have extensive experience with meditation and showed dramatic effects.  Altered Traits shares some of the more recent and much more transient work.  Even short sessions over a few weeks can make an impact.  So, there is research, and it’s the kind that’s important to people trying to recover right now.

Why is this important?  It’s important, because we need to recognize that you don’t need to maintain meditation over the remainder of your life.  There’s no singular prescription for a kind of meditation that’s necessary.  The fact that you’re able to focus on something or nothing seems to be the key.

Fear of Emotions

Gordon correctly identifies that many people are afraid of their emotions.  They fear that if they allow emotions, they’ll appear weak – or that the emotions will get the better of them, and they’ll be unable to control themselves.  They feel as if they’re Bruce Banner who only needs to be provoked to become The Hulk.  One of the ways that we can heal from trauma is accepting ourselves and, particularly, our emotions about the trauma.

Hypervigilance

A common compensation by those who’ve been traumatized is hypervigilance.  That is, they can’t accept any threat ever impacting them again.  They pursue strategies to avoid stressful or risky situations.  They’re constantly on the lookout for the next potential problem.

Often, this leads to a need to control everything they can.  The reasoning, even if unconscious, is that if it’s under control, then it’s not a threat.  This can be the case – but it may not be.

Sadness and Fear

Gordon states, “Sadness and fear are similar.”  Unfortunately, most respected scientists wouldn’t agree with him.  Richard Lazarus explains how fear works in Emotion and Adaptation – and it’s not about sadness.  While Lisa Feldman Barrett doesn’t agree with much that Paul Ekman says, neither believe that fear and sadness are similar in the way that Gordon states.  (For Barrett, see How Emotions Are Made; for Ekman, see Telling Lies and Emotional Awareness.)

Triggers

Triggers are those things that lead people back to their trauma experience.  Gordon states, “TRIGGERS ARE EVENTS – words, actions, or perceptions – that in some way resemble a past trauma and reawaken it.”  The problem is that triggers don’t need to resemble the original event – they only need to remind people of the event.  Even very odd connections work to drag people back to their trauma.  Sometimes these connections aren’t (and can’t be made) conscious.

What’s important to realize is that triggers are a part of the amplification process.  We see trauma get worse over time, because triggers cause their own traumas (by hyperactivation) that pile on to the original trauma and can exacerbate the problem.

The First Time Nobody Tried to Fix Me

It’s an odd thing.  It’s what happens when you listen – just to listen.  The person that you’re with feels different.  They’re so used to people listening so they can respond that when someone listens with the full intent of simply understanding someone else, it’s special and different.  One of the spontaneous things that happens is that people recognize “it’s the first time that nobody tried to fix me.”  It’s the sort of thing that one would expect to hear when the other person has been trained in Motivational Interviewing.  It could happen if someone experienced Dialectical Behavioral Therapy (DBT).  (See Cognitive Behavioral Treatment of Borderline Personality Disorder.)

The Impact of Positive and Negative Responses

At some level, those responding to others who have experienced trauma believe that there’s nothing they can do to undo the trauma that happened.  That’s true – but the important thing isn’t the trauma that has happened, it’s what is going to happen.  Stories proliferate, like the one told in Transforming Trauma of a woman who was raped by her mentor and minister.  The tragedy was that the way the system responded to her invalidated both her and the event – and led to forty years of needless suffering.

Trauma-informed responses can mean the difference between a hard period and a hard life.  Obviously, we hope that every interaction is supportive and leads to less suffering – but that is tragically rare.

Keeping Pain from the Center

In the midst of a conversation about keeping gratitude journals, a conversation emerged about using gratitude journals as a technique for keeping pain from becoming the center of life.  Gratitude journals, however, have some mixed evidence.  Their use in acute cases, where people can’t understand what to be grateful for, is certainly warranted.  (See Flourish, Hardwiring Happiness, Happiness, Positive Psychotherapy, and Happier?.)

However, I’m cautious about long-term use of gratitude journaling, because it becomes another task that people need to do – instead of providing positive effects.

Meaning and Purpose

Referring to Viktor Frankl, the book ends with a recommendation to find your meaning and purpose.  (See Man’s Search for Meaning and also Simon Sinek’s Start with Why.)  While it’s sound advice, there’s no guidance on how to do it.  That can be frustrating as you recognize that you need to find your meaning but also are painfully aware that you don’t know how.  Trauma sometimes closes people off from themselves, as is explained by the Internal Family Systems model in No Bad Parts.  Sometimes, to find our meaning, we must first be freed from the weight of trauma, and it’s only then that we can achieve Transforming Trauma.

Book Review-Brainspotting: The Revolutionary New Therapy for Rapid and Effective Change

It started with a wobble and pause.  Practicing a variant of EMDR, David Grand crossed the visual field of a patient, when her eyes wobbled, then locked – and Grand felt as if his hand was locked in the place where the patient was looking.  Thus were the beginnings of what he calls Brainspotting: The Revolutionary New Therapy for Rapid and Effective Change.  Conceptually Grand explains that, “Where you look affects how you feel.”

Roots

Before we can get to the heart of the Brainspotting approach, it is necessary to explain its roots.  One of these roots is EMDR – eye-movement desensitization and reprocessing.  EMDR is a validated therapy approach.  The other component is Somatic Experiencing, Peter Levine’s approach, as explained in In an Unspoken Voice.  While Somatic Experiencing has less empirical support, it’s generally regarded as promising.

EMDR is primarily focused on lateral eye movements, but other approaches, including hand tapping and audio stimulation, are used to trigger rapid coordination between the right and left hemispheres of the brain.

Somatic Experiencing is based on the concept that, during traumatic events, there’s energy released that our human brains thwart the release of.  This happens when we suppress fighting or fleeing.  When we freeze, Levine posits that we store that energy and fail to release it.  He cites the reactions of animals as they recover from being frozen by a threat.  Many, if not most, animals “shake it off” when they unfreeze, but humans don’t have this response.  This is placed in the broader experience of recognizing and relating to our bodies (thus somatic).  This is inclusive of acknowledging unpleasant sensations in the past or current.

From these two therapies, Grand created what he called “Natural Flow EMDR.”  His previous book on this technique published 11 days before the tragic 9/11 attacks.  As a result of the attacks, there was an influx of patients with trauma experience.  (Grand is based in New York.)

Outside and Inside

The initial discovery required that the therapist observe a disturbance in the eyes of the patient.  This is what Grand calls “outside window spotting.”  That is, someone outside of the person is triggering and identifying the “brainspot.”  The converse is when the person guides themselves and detects something as they sweep their eyes.

In both cases, there’s a catch.  The catch is that the person must be “activated.”  If they’re in a place of complete calm, they won’t be able to discover their brainspots.  It’s a common thing for therapists and researchers to “prime” individuals so that they’re more receptive, so the idea that someone is activated isn’t particularly different or concerning.  However, there is a careful balance to be struck.  If someone is too activated, they’ll be unable to work through an issue – and if they’re not activated enough, the brainspots will likely not surface.

The Problems

There are a few problems with Brainspotting as a technique.  First, the research on the technique is still very weak.  The studies have low power, and the designs are subject to substantial therapist influence.  It’s not been shown to be harmful – but the research is weak at best.  This is normal for emerging approaches but with a 10 year history of Brainspotting, one would expect for more robust research support.

More than that, some of the assumptions that Grand makes are not well accepted either.  For instance, while talking about blinking, he claims, “aspects of the brain are timeless, and so they experience this shutdown of visual input as a significant pause.”  The research on flow indicates that time calculation in the brain is very complex, and it happens across multiple centers.  (See Flow, Finding Flow, and The Rise of Superman.)  We know that the ability to process time is quite frequently taken offline temporarily.  Flow, in fact, is remarkable in the fact that changing blood flows in the brain takes the ability to maintain a sense of time offline.

Additionally, we know that the brain is constantly filling in details that are missing.  Incognito powerfully shows what happens when your brain needs to fill in information, because one eye is covered and there is a hole in the remaining visual field where the retina attaches to the optic nerve.  We also know that the rods and cones of the eyes have a slight retention of the previously recorded image – particularly when there is no new input.  In short, the brain is in a constant mode of filling in information, so the milliseconds of time during the obscuring part of a blink aren’t significant in any particular way.

Holding Space

Like many therapies, Brainspotting proposes that we hold space for people.  That is, we create feelings of safety – as much as is possible – and we accept them for who they are and for what has happened.  This is an important aspect of healing that is often absent in our daily lives.  It’s rare to hear people acknowledge their traumas, too – without trying to one-up the person sharing.

It can be that some of the moderate effects that are seen with Brainspotting are the effects of creating safety and validating the person for who they are.

Three Dimensional

A key divergence from the basis of EMDR is Grand’s discovery that the places where people could look and discover an issue are three dimensional.  It’s more than the lateral movement prescribed in EMDR (x-axis).  He introduced vertical (y-axis) movement as well with reportedly good results.  Finally, Brainspotting has evolved to include a depth or z-axis dimension.  There may be a trauma connection to this space, but it’s hard to say.  It could be that exposing trauma can be done by concentrating on a point and can be resolved with cognition.  If it is, then we should all start Brainspotting.

Book Review-The End of Trauma: How the New Science of Resilience Is Changing How We Think About PTSD

Trauma has a double meaning.  It can mean the physical impact of an event – or it can mean the psychological impact.  The End of Trauma: How the New Science of Resilience Is Changing How We Think About PTSD is focused on psychological trauma – but compares and contrasts it with how we heal physically.

Post-traumatic Stress Disorder (PTSD)

Before the DSM-III in 1980, the idea of psychological trauma had struggled to find acceptance.  From the initial conditions, which were quite narrow (“outside the range of usual human experience and that would be markedly distressing to almost anyone”), to the broader acceptance of multiple kinds of trauma today, we have transformed our understanding.  We know that everyone experiences events differently, and what may be trauma for one may not be trauma for another.  More broadly, however, we recognize that, of those who experience trauma, not all of them – or even many of them – will experience PTSD.

Some are frustrated by the “disorder” part of PTSD.  They’d prefer to call it a “syndrome” – a set of co-occurring symptoms.  However, the distinction with disorder is that it has a negative impact on peoples’ lives – on their ability to function.  Many who struggle with PTSD would freely acknowledge that it has an impact on their lives – and not a positive one.  However, important to the conversation is the understanding that people can recover from PTSD – if not completely at least partially.  Our goal should be to encourage the best outcomes, but that takes more than “just getting over it.”

Resilience

Crawford Stanley “Buzz” Holling first began using the word “resilience” to describe how forests and other ecological systems manage to endure.  He explained that the instability in the system was what allowed it to stay alive.  Unfortunately for Buzz, the word has been coopted by everyone who wants to sell a wellness course based on little (if any) research.  Everyone wants to talk about how they make students “resilient” with an obvious lack of understanding of the word.  (You’ll notice we avoid the word in our Extinguish Burnout work.)

The more contemporary definition of resilience is a return to the previous state.  The problem here is that the way that things were will never be again.  Heracles said that no man steps in the same river twice, for he’s not the same man, and it’s not the same river.  In Antifragile, Nassim Taleb explains how we can use adversity to grow.  Robert Sapolsky in Why Zebras Don’t Get Ulcers forms a similar conclusion but takes it further, arguing stress is necessary for our survival.  Rich Tedeschi explains how growth is possible after trauma – and what seems to lead to it.  (See Transformed by Trauma and Posttraumatic Growth.)

Our innate ability to recover from trauma is ordinary magic.  It’s the thing that is both magical and expected.

Psychopathology

Just because you’re struggling with an event that was temporarily overwhelming to you doesn’t mean there’s anything inherently wrong with you.  (One definition for psychological trauma is a temporarily overwhelming event.)  Sometimes, people over-pathologize normal responses.  In the absence of a serious loss, a sustained depressed mood might indicate a problem.  After the loss of a spouse, a child, or close friend, a period of depression is the normative response.

It’s not wrong to experience and express strong emotions in the presence of a traumatic event.  Some will argue that there are stages to traumatic response, perhaps aligned to those of Kubler-Ross’ On Death and Dying.  Regardless of the model in use, they accept the reality of strong emotions not being pathological but rather being normal.

The Deception of Recovery

Because clinicians necessarily only see those patients who have struggled to process and resolve their trauma, encountering someone who has processed their trauma well is so outside of their experience that they may believe that the person isn’t “really” okay.  This is a sampling error – or “what you see is all there is.”  (See Thinking, Fast and Slow for more.)  Like a black swan, just because it’s rare and you’ve not seen it doesn’t mean that it can’t happen.  (See The Black Swan for more.)

Certainly, I’ve personally observed people who wanted to portray to the world that they’re better than they really are.  I’ve also met people who were able to process and recover from traumas that others would have said weren’t recoverable from.  The point is that you can’t easily tell whether someone is being deceptive about their recovery – or whether it’s real.

Impact

In terms of normative recovery, the scale of the problem is often inversely related to the difficulty in processing it.  Natural disasters, generally, have some of the greatest impact to people and property – objectively speaking.  Technical disasters, while tragic, tend to impact fewer people.  Acts of intentional violence are even narrower still in their scope of objective impact.  However, it’s the intentional acts of violence that cause people the most difficulty to accept.

Our belief in the goodness of others is shaken by the acts of intentional violence.  We struggle, because we need to adjust our belief about the world.  One thing that may make it better is Mister Rogers’ mother’s appeal to look for the helpers.  (See Kindness and Wonder.)

Mindfulness and Resilience

There’s a lot of talk about mindfulness and how it leads to resilience.  The problem is that there isn’t research to say that.  There’s research to say that meditation matters – see Altered Traits, Happiness, and Emotional Awareness.)  Dialectical behavior therapy (DBT) is a proven therapy for the treatment of suicidality in borderline personality patients.  (See Cognitive Behavioral Treatment of Borderline Personality Disorder.)  That’s why a recent study at Kaiser Permanente raised eyebrows when it said that DBT wasn’t effective.

It takes a closer look to understand why.  First, DBT requires the balance between acceptance and the push for change.  It’s the fundamental “dialectical” that Marsha Linehan was speaking of.  Second, the study used only an online set of study materials for studying DBT, which, in my opinion, weren’t built with best practices for adult learning.  (See Efficiency in Learning for more.) Third, and importantly, of the 24 skills of DBT, only four skills were selected for training – all of which were mindfulness.

For me, it had no chance of being successful, because it failed to adhere to the spirit of DBT – but it also attempted to teach the part of DBT that isn’t individually supported by research.

Behavior and Personality Traits

The degree of agreement between behavior and personality traits won’t be a surprise to anyone who has seen Kurt Lewin’s work and his formula that behavior is a function of both person and environment.  (See A Dynamic Theory of Personality.)  Nor will it surprise anyone who has read Steven Reiss’ work about motivators in conflict.  (See Who Am I? and The Normal Personality.)

However, it tends to surprise people who believe in personality tests like CliftonStrengths (see Strengths Finder 2.0), the Enneagram (see Personality Types), or the Myers-Briggs Type Indicator (MBTI – see Quiet.)  In fact, entire books have been written about The Cult of Personality Testing.

Emotional Suppression and Reprocessing

Suppressing the emotion related to a trauma is a bad plan.  (See No Easy Answers, Assessment and Prediction of Suicide, and How Not to Kill Yourself.)  However, there’s not a ton of solid long-term research that proves that repression of emotions is bad as compared to expressing them – due in part to the difficulty of doing that kind of research.

However, there is research that says that if you have an option to change the situation or simply change how you feel about a negative situation, changing the situation is better.  While reprocessing events is almost always a positive experience, solving the real, tangible, underlying problem is more effective.  Said differently, it’s better to feed someone rather than help them to feel less hunger pain.

Flexibility and Environmentally Appropriate Skills

Flexibility is our ability to adapt to our environment and use skills that are tailored to the situation.  Using environmentally appropriate skills is the best strategy, because no one skill or set of skills is best in every situation.  Developing this flexibility is two components.  First is learning a set of skills and when they’re most likely to be useful.  Second is learning how to understand the environment so the most environmentally appropriate skill can be used.

Maybe by using the right skills at the right time, we can find The End of Trauma.

Book Review-What Happened to You?: Conversations on Trauma, Resilience, and Healing

It’s easy to assume that people who are famous and wealthy have had it good their entire lives, including now.  It’s harder to realize some of the awful tragedies that were wrought in their childhoods.  It’s harder to consider that they’re still humans who grew up with trauma that left scars.  What Happened to You?: Conversations on Trauma, Resilience, and Healing is a collection of writings and interactions between Oprah Winfrey and Bruce Perry.  It’s about increasing the understanding about the trauma that others have encountered to be able to understand their curious behaviors.

Oprah Winfrey

Born in Kosciusko, Mississippi, Oprah Winfrey has come a long way from the child of a one-time hookup between her mother and father.  She spent much of her formative years with her grandmother until her death, when she alternated between her mother and father.  From this unstable upbringing, she recalls the pervasive feeling of loneliness.

Though not addressed directly in the book, Oprah has spoken repeatedly about the sexual abuse and rape she experienced growing up and has worked tirelessly to prevent the harm to other children.  In addition to her personal experience with trauma, Oprah covered the issue of sexual abuse 217 times on her show.

Learning to Love

Children’s brains don’t create linear narrative memory before the age of about three, when the brain prunes connections and develops this capacity.  In theories about trauma, it’s believed that traumas encountered before this time can’t be recalled but are still somehow encoded in the child.  Conversely, it’s believed that supportive environments change the way that people experience the world.

Much has been made of attachment styles and the way that they change how people respond to different situations, including the “strange situation” test developed by Mary Ainsworth to test the theories of her mentor, John Bowlby.  (See Attached.)  There’s strong research indicating that children develop a greater ability to explore the world when they routinely encounter others that respond to their needs.  Those who encounter neglect or negative outcomes when they share their needs are classified with insecure attachment styles, which hold them back in their relationships for life.

The good news is that attachment styles, while initially set as an infant, are malleable.  If children encounter supportive, responsive relationships later in their life, their attachment style can shift towards more security and better outcomes.  (See Attachment in Adulthood.)

In essence, when children encounter love, they learn to love.  That love should come from parents but doesn’t always.

Repeating Patterns

One of the recurring tragedies of trauma is that, often, the person who was traumatized as a child replicates the pattern of abuse and trauma as an adult.  Because a child can’t see the difference between their experience and healthy or normal, they unwittingly replicate it.  Unconsciously, they may be trying to find a better outcome, like the son who became a doctor.  It wasn’t until much later that he would realize his mother was always kind to the doctor in ways she wasn’t kind to him.  He wondered if, unconsciously, he had chosen to become a doctor with the idea that he could finally get his mother to be nice to him.

Others aren’t so lucky in the way that they try to replicate what they experienced as children.  Women find mates who are controlling and abusive instead of supporting and caring.  Perhaps, at some level, they hope they can change their mates when they couldn’t change their situation as a child.

Reality is the Problem

Oprah recounts an interaction with Russell Brand, who wrote Recovery, when he said, “Reality is my problem, drugs and alcohol are my solution.”  If you’ve been abused or neglected as a child, your perspective of reality might be that it’s a painful place with nothing for you.  Instead, it’s a place where you can expect only to be hurt.  In these cases, like Brand’s, it makes sense that reality is a problem.  If you’re not hurting now, the perception is that you could be hurting at any moment.

There is a stigma about substance use disorder (SUD).  It’s believed that people who become addicted are bad.  Someone did something wrong.  However, as Dreamland, The Globalization of Addiction, and Chasing the Scream all explain, it’s not that.  It’s that they found life unlivable and sought an escape.  As Judith Harris Rich explains in No Two Alike and The Nurture Assumption, you can’t protect your children from everything.  They may experience hurts that you can’t protect them from.

Robert Putnam, in Our Kids, explains that some neighborhoods have better protections.  Some don’t support their children in ways that lead them to the greatest success.  It’s not about the kids.  It’s that the odds are better sometimes – and that there are no guarantees even with the best parents or in the best neighborhoods.

Stressing Growth

If too much stress is trauma and it’s not good for you, then one might think that no stress is the goal.  However, Nassim Taleb makes the point in Antifragile that we need stress.  Anders Ericsson makes the same point in Peak as he speaks about professionals at the peak if their profession.  Quiet Leadership speaks more generally about the need to have struggles for our growth.  While the idea of a stress-free life sounds good, a complete lack of stress leads to apathy, and that’s not good.

Event, Experience, and Effects

Trauma is defined by three Es: event, experience, and effects.  The event itself is easy to identify.  It’s the thing that happened from an objective point of view.

Experience is a bit different than the objective experience.  It includes how you initially assessed the event, including how it’s related to previous experiences, as well as what it felt like.  Effects are the down-stream impacts of the event.  If you’re in a car accident, there may be surgeries, physical therapy, or even permanent changes to your state of being.

Each of these plays a part in the impact of an event and whether it will be overwhelming and thus a trauma.  (See Trauma and Recovery.)

The ACE You Can’t Keep

It’s hard to not have heard about the adverse childhood experiences (ACEs) study.  The spooky results showed that there were lifelong effects to having experienced more traumatic events in childhood.  The more events, the worse your adult health.  Why Zebras Don’t Get Ulcers discusses it, as does Trauma: The Invisible Epidemic and It’s Not You, It’s What Happened to You.  Even How Children Succeed spoke of how ACEs impact children’s success (beyond health measures).

As a population health tool, the ACEs survey is useful.  As a clinical tool or to predict individual outcomes it’s not that useful.  It suffers from many of the same problems that Craig Bryan explains in Rethinking Suicide.  You just can’t make the statistics work like that.

Finding Flow

Perry explains that “flow” and being “in the zone” are partial dissociative states – that is, you start to disconnect from the reality around you.  The concept of flow was developed by Mihaly Csikszentmihalyi and is the subject of his books, Flow and Finding Flow.  Many have spoken about the power of flow, including Steven Kotler in The Rise of Superman.  Flow, in addition to its dissociative aspects, is a highly productive state and, that may be why Perry explains that people who can control when they go into flow have a gift.

I struggle with Perry’s focus on unescapable distress and pain as a trigger for flow, because it feels as if he’s speaking of dissociation but not the same state that Csikszentmihalyi is speaking of.  Csikszentmihalyi speaks of flow as a delicate balance between skills and challenge – a situation that isn’t present in the traumatic situations Perry is describing.

Loss of Innocence

I was doing a publisher-sponsored review of a book to provide feedback to the author about what could be improved upon.  One of the big flags for me was the continued use of the phrase and concept of “loss of innocence.”  The point I made is that only our first trauma deprives us of innocence.  The second through the thousandth still impacts us without necessarily displacing innocence.  After trauma, we’re different – but not just in the loss of innocence.

One of the words that I struggle with is “resilience”  At a literal level, it means a return to a prior state.  The thing is that, with humans, every trauma changes us.  Heracles said, “No man enters the same river twice.  He’s not the same man and it’s not the same river.”  It is the same with trauma.  Even when you’ve processed and recovered from the trauma, you’re still not the same.

Knowing

Oprah, as an adult, encountered a time when her mother was dying.  It was then that she wondered if the millions of television viewers knew her better than her own mother did.  The past loneliness that was endemic in her childhood hadn’t fully left her.  Instead, she still wondered if, even at the end of her life, her mother really knew her.

As people share their experiences today, for better or worse, we should continue to wonder What Happened to You?

Book Review-Trauma Focused ACT: A Practitioner’s Guide to Working with Mind, Body, and Emotion Using Acceptance and Commitment Therapy

ACT is the acronym for “acceptance and commitment therapy.”  It’s a therapy that’s evidence supported.  That’s a big deal.  Trauma Focused ACT: A Practitioner’s Guide to Working with Mind, Body, and Emotion Using Acceptance and Commitment Therapy is designed as a guide for using this proven technique with trauma patients.  The author, Russ Harris, offers a different book that’s more focused on the fundamentals of ACT without the specialization towards patients with trauma, but I chose this work because I wanted to see what could be done before a traumatic experience developed into a mental health problem.  How can we stop the trauma from eating away at a person?

Psychological Flexibility

Harris explains that the overarching goal of ACT is psychological flexibility.  He provides a four-part framework: be present, fully open to experience, allowing (thoughts and feelings), and value-guided.  While this is a fine framework, I’d suggest that the key is learning how to respond instead of reacting.  (See The Book of Joy for more.)  It’s about bringing more agency into our day-to-day living.  (See Conflict Resolved? For more about agency and its impact.)

Things change when you have a choice.  Without choice you have no personal agency.  You can have no sense that you have influence on your world and your future.  The truth is that we always have a choice to make about how we respond to situations.  There are cases when it’s not possible to change the circumstances but changing how we respond makes all the difference.

Trauma Focused

What makes trauma focused ACT different is the integration of trauma related components, including polyvagal theory, attachment theory, and inhibitory learning theory.  It’s about understanding the impacts of trauma on physical and mental health.  It’s being aware that working in general may trigger trauma reactions at any time.

Being trauma focused also means that we need to heal past hurts (see Hurtful, Hurt, Hurting), be present in the present (see Resilient), and build the future.  In The Time Paradox, Phillip Zimbardo explains that we each have different perspectives – or approaches to time.  What trauma-focused ACT seeks to do is to give us the flexibility to view time using different lenses.

Defusion and Fusion

The goal suggested by ACT is defusion (de-fusion) from our thoughts.  Instead of acting on them immediately, to “step back” and evaluate them.  This key factor gives us the agency in our response.  We can act as Neo in The Matrix, where we investigate thoughts outside of being hurt or disturbed by them.  (See also A Way of Being for more.)  By stepping back and evaluating our thoughts and emotions, we gain power over them.

The opposite, unhealthy view is to fuse our thoughts and beliefs.  We can believe that life sucks and is pointless.  (See the nihilist view in The Blank Slate.)  We can believe that the world is unsafe and evil.  (See The Marketing of Evil as an example.)  We can believe that people are untrustworthy.  (See The Lucifer Effect.)  We can even believe that we’re unworthy of love.  (See Compassion and Self-Hate.)

These fusions prevent us from seeing the opposite is also true.  There are parts of life that are pointless – and some amazing moments.  The world is, at times, unsafe.  Other times, it’s incredibly supportive and helpful.  People will betray us, but the decision to trust is worth it.  (See Trust => Vulnerability => Intimacy, Revisited for more.)  It’s even hard to see the amazing parts of ourselves when we’re consumed by a sense of unlovability and shame.  (See The Gifts of Imperfection for more.)

The book often uses the term “unhooking” to refer to the removal of automatic and complete views of truth.  Unhooking creates spaces for other ideas, thoughts, and approaches.

Avoidance

One of the key challenges with trauma – and the part that causes event escalation – is avoidance.  When we avoid the root of the problem, we’re forced to find larger and more complicated workarounds that ultimately consume more time and energy than directly addressing the problem.  Van Der Kolk in The Body Keeps the Score explains the value of short-term avoidance through compartmentalization and the long-term toll that compartmentalization can take.

One of the most important aspects of trauma-focused anything is in creating space where people feel safe enough to confront their trauma gradually instead of using avoidance tactics.

Listening

The starting point in any therapy – including ACT – is listening.  Before we can expect that someone will listen to us, they’ve got to believe that we understand at some level.  Motivational Interviewing is powerful in this respect.  It creates an intentional space for a therapeutic alliance to form.  (See The Heart and Soul of Change for more on therapeutic alliance.)

Despite the power of listening, it’s not necessary for someone to share their complete story with you in an initial conversation – after all, you are, in fact, a stranger.  Rather than insisting on hearing the story, the key is to create space where the other person can share their story if they desire to.  There’s no requirement or expectation – just an opportunity.

Dropping Anchor

When emotions start to become overwhelming, Harris recommends a technique he calls “dropping anchor,” which isn’t designed to control the overwhelming emotions but to stabilize a person until they subside.  It includes three key factors:

• A – Acknowledge your inner world.
• C – Connect with your body.
• E – Engage in what you’re doing.

This approach fully recognizes what’s going on in the current moment and allows the cognition or emotion to pass in its own time rather than trying to control it.

Normalization

Being different from others or abnormal has a powerful force behind it.  It’s one of the things that makes adolescence difficult.  Teenagers are caught between the need to be an individual and unique (see Childhood and Society) and the need to conform and to be a part of the group.  We’re social animals who have dominated the planet because of our ability to work together – and that requires, to some degree, that we’re like others.  (See The Righteous Mind.)

Normalization is, therefore, a powerful tool to help people work through trauma.  It’s a way of helping them understand they’re not alone.  It’s a way to help them understand that their feelings and thoughts are reasonable given what they’ve been through.  Too many people who have been through trauma are concerned about whether their thoughts are reasonable or not.

Getting Rid of Thoughts

One of the normal things is a desire to get rid of unwanted thoughts.  Paradoxically, the best way to combat unwanted thoughts is to allow them.  By trying to block them, we give them more attention and more power.  (See White Bears and Other Unwanted Thoughts.)  If we practice mindful or meditation techniques of observing and acknowledging the thought, it will go away on its own.  (See Altered Traits.)  The desire to get rid of unwanted thoughts paradoxically prohibits people from doing so.  It’s a Chinese finger trap of mental orientation.

Pain Signals

Painful thoughts and emotions contain valuable information.  (See Compelled to Control for more.)  It is hard to believe that in the moment.  But often times, when we look back at our lives, we can see that some of the times of deepest pain taught us something or changed the direction of our lives in ways that have been important and powerful for us.  (See Extreme Productivity for an example.)  ACT treats pain as an ally, not an enemy.

Here and Now

There’s an odd interaction that happens between the current moment – the here and now – and the desired future.  Sometimes, the future seems like it’s too far off or unlikely, and it becomes necessary to find strength in the here and now.  Of course, we’d all love to have the resolve to leave the marshmallow on the table for the promise of two, like the children in the Stanford preschool in The Marshmallow Test.  However, they knew that the delay had to come to an end.  At the very least, they’d get to leave with their parent at the end of the day.

Kotter, in Leading Change, makes the point that you need to build on small wins.  If you want to sustain an effort over the long-term, it’s necessary to receive reinforcement and support.  That means seeing some value in the current moment.

Adrift Without Values

Living a life when you don’t know what you value is like trying to pilot a boat without a rudder.  You can’t control where you’re going – and that’s frightening.  Too many people don’t have a sense for what they value.  Luckily, there are lots of ways to discover what’s important to you – what you value.  You can look towards Values in Action, Gallup’s CliftonStrengths, and other frameworks that help you discover your interests and values.  (Like the REISS Motivational Profile summarized in Who Am I?)

Harris explains that we all have values, but many of us don’t know what those values are.  I’d concur.  Too few people realize what’s important to them, and as a result, they’re not sure how to navigate after a trauma – or through life in general.

Adulting

Around here, we call it “adulting.”  That is, doing the thing you know is the right thing even when there are other things that we want to do.  It might be paying a bill instead of spending money on a night out, or it could be a hard but necessary conversation.  Adulting isn’t something that people want to do – but it can be the right thing to do.  The problem is that without a sense of what you value, it’s hard to know which hard things you need to do.  We value truthfulness even when it means upsetting another person.  In the end, we know it’s better, even if it’s not easy in the moment.

Planting a Tree

A Chinese proverb says that “The best time to plant a tree was twenty years ago; the second-best time is now.”  It’s a gentle reminder that you can’t change the past, you can only work with the present and remember the future gains.  Viewing time as a long arc allows you to accept that the first draft of anything is, as Earnest Hemmingway said, “shit.”  Ed Catmull in Creativity, Inc. explains a similar perspective of the first drafts of the Pixar movies that we have fallen in love with.  The process refines the idea.

Similarly, we set an initial set of values, and as we live them, we can adjust them.  The more we adjust, the more they’ll fit us perfectly.

More than the Trauma

One of the risks in working too much on trauma is that people will begin to see everything in their life as the trauma – or trauma-connected.  It’s important to recognize that everyone – even those who have survived the most horrific sustained traumas – is more than their trauma.  Humans are amazing, diverse individuals who cannot be reduced to a single dimension.

Compassionate to the Child

In cases of severe trauma, sometimes people find it difficult to be compassionate to themselves as they are today.  They reason that they’ve seen, done, and experienced too much.  They believe, incorrectly, that they’re beyond repair.  In these cases, it’s often possible to speak and interact compassionately with their younger selves – the person they were before all the traumas.  Gradually, they realize that they are still this same person.

Failure

Failure when helping people with trauma isn’t an option – it’s a fact.  What we know is that when we’re interacting with people who have been traumatized, we’re going to accidentally trigger them.  We’re going to say the “wrong” thing.  We’re going to be imperfect.  The good news is that we can still be helpful – in a non-clinical or clinical way – if we’re willing to step into the space and try.  We don’t have to be a therapist to learn more about Trauma Focused ACT.