On Trauma: A Conversation with Dr. Virginia Demos page 2

Can you say more about what’s it like on the inside for people with trauma? What do they feel like and think like? Well, as I say, they are very hard on themselves, and they feel totally alone in the world. This recovery of traumatic memories is a slow gradual process, and it often starts with a fragment of something, a sensation in the body, a sudden panic, or finding them selves crouched somewhere. Ever so slowly they begin to piece together these events. And again and again they may say, “This can’t be true. I must be making this up.” Or, “I can’t stand it.” And yet it feels so real; some part of them knows it all happened. As the traumatic memories become more real, they struggle with why they didn’t tell anyone at the time it was happening, or with a feeling that they colluded in the abuse somehow. Or they become enraged that others did not intervene, or seemed blind to what was happening. They may try again to convince themselves that maybe it wasn’t so bad. But the terror they have now remembered and felt is an unwelcome reminder that it was indeed awful. They have to slowly accept how terrified and helpless they were as children, and to re-experience the basic conflict they have struggled with, namely that they often both love and hate the person who hurt them so badly. This conflict just tears the mind apart. How could they have been so duped? How can they ever love and trust again?

And how does that manifest?
They’re often surprised by any kindness. They can’t believe it is genuine or that anyone can take them seriously. They don’t expect anyone to care about them or to believe their story, even if they know what happened. Their trust has been sorely violated and they have been deeply hurt, so they have had to hide their needs and vulnerabilities deep inside of themselves. So it can feel very risky and frightening for them to trust the therapist initially and to let that person know what might be going on inside of them. They have had to learn to control the contents of their minds, so they often have sleep problems. That is, they can’t let themselves dream. They may sleep for two hours and then wake up before REM sleep happens. Or they get into a day/night reversal, staying up all night, and only sleeping during the day, when it feels safer. They control the contents of their consciousness as well, so they have difficulty allowing themselves to think about something that might be deeply upsetting. They don’t expect anyone to stay with them through a painful experience; indeed they may expect to be criticized, rejected or abandoned if they express their distress or needs, so they may initially isolate when they are suffering the most, or punish themselves for having such troubles.

It sounds like one of the hallmarks of trauma is its obscurity —its hidden-ness. How do you work with that as a clinician?It is true, sometimes the abuse is not evident right away even when it is quite clear that it occurred. But when we see the array of difficulties I’ve discussed —substance abuse, self-harm, eating disorders, disassociation, and so on —we know there’s some deep trouble somewhere. We take a very thorough personal history and family history, and we also do psychological testing, that includes projective testing, as part of a thorough five or six week evaluation. We look in the family history for traumatic events, especially what’s been chronic and unacknowledged across generations. For example, we may see a third generation Holocaust survivor where the family trauma has never been processed, leaving the child with an unnamed anxiety. We look for possible dislocations or unprocessed losses in the family history, and how the family has dealt with such difficulties or events, so we can begin to get a sense of the kind of trouble that may have been unprocessed in the family and the ways it may have affected our patient.

As all of this data gathering is going on, the patient is also manifesting some of their trouble in the community, and is slowly building an alliance with the therapist, to whom they begin to reveal a little more about themselves, and how they’ve bifurcated their world. Sometimes they protect their family, or the abuser, saying everything was fine, but that they just have all these terrible problems. But often this doesn’t add up. They may continue to protect the abuser for a while, until they begin to believe that the medical and nursing staff take their trouble and their story seriously, and what they have experienced might actually have happened. There may be a lot of resistance for them to see that it is all real because they don’t want it to be true, or they fear it will damage the family or the abuser in some way. Abuse can come from many quarters – a neighbor, a teacher, a stranger, a doctor, a peer, clergy, a grandfather, or older cousin or sibling, or a parent. If the family does not believe the child’s story, or has been involved in abusing the patient, this can lead to a rupture in the treatment. The family may actually pull the patient out of treatment. But other families are ready and willing to work on what has happened, and we then provide family therapy.

How do you handle the problem of so-called false memories?
That is a slippery issue. We work very hard not to lead our patients, but to follow their lead. Some memories turn out to be false, and when that happens we then focus on the dynamic issues involved in wanting to put forth such a story. This is difficult terrain and care and caution are essential. But when the memories are real, they tend to emerge very powerfully —in dreams, in dissociated memories, in vivid, terrified states that are hard to fake, and in a context that makes sense. So when the memories of real trauma start to emerge, they are quite compelling, extremely painful and confusing. It is very helpful for the person to be in a safe environment like a residential treatment center where other people can stay with them through the experience.

Neurologists tell us that the brain is biased toward fear. When something fearful has happened the brain hangs onto it, because in human evolutionary history it had been important to know what can hurt or kill you. The brain has two memory systems, the bodily memory system and the cognitive memory system. And trauma, particularly sexual or even physical trauma, is always remembered in the body, though it may or may not be remembered in the conscious mind. Flashbacks are traumatic memories characterized by vivid, terrified states that flood consciousness, so that it feels as if the trauma is happening right now, and the person loses the capacity to discriminate between remembering something from the past and something that is in the room happening to them in the present. We work very hard to help the person to keep one foot in the room with us, while they are remembering an event in the past. If they can hold onto the therapist or nurse in the present, they will be able to bring the experience into conscious memory with our help, and begin the process of tolerating the horror of the experience with somebody whom they trust is trying to help them through it and who believes what they’re saying.

What does it look like as people start to recover?
There is the slow gradual awareness that it was real. That’s the first part. And even then, with sexual abuse particularly, even when they know it happened, they first remember it as watching it happen from the ceiling looking down, so they still haven’t fully experienced that it happened to them, and to their body. This defense protects them from feeling the deep disgust, humiliation, and sense of contamination that all sexual violations entail. It can take another couple of years often to get to that place, knowing that not only did this happen, but this was me, and it’s in my body. Only then, when the body sensations, the detailed memories, the intense negative emotions and the conscious mind can all come together is there the beginning of a process of deep psychic integration. The integration ushers in the next stage of the work, which involves slowly beginning to grieve what happened to them. When a person gets to that point, they are almost home free, because by then they are finally accepting that this never should have happened, that they didn’t deserve it, and that they were deeply and badly hurt by someone they loved or trusted, and they were robbed of a carefree childhood, and of the many years spent in hiding from themselves and from the world. Abuse and trauma takes away the sense that there is any safety in the world, which is a horrible way to have to live.

The final stage is a very cautious, slow, opening up of hope for something different, namely to come out of hiding, and trusting that maybe, just maybe they can be safe in the world beyond the therapy. That can be a terrifying moment, because they have spent years protecting themselves, by not allowing themselves to hope for something, or to trust someone in an intimate relationship. This last phase can take more years and if they can get to that place, they begin to tell you even more about the way they had organized their mind — all the rules in their head, about what they could and couldn’t do, in an effort to control everything about their lives, because they had no control over the abuse. They can only get to this material after they’ve come through the worst of it, and become more aware of how these rules are now getting in their way. They can’t quite believe that they don’t still need them to be safe. For example, if someone developed an eating disorder, they may hang onto that ritual, because of some magical belief that it has been keeping them safe all this time, and they can’t believe that they’re strong enough to deal with the world without it. It takes more time and many experiences in the real world to feel “I have the inner resources that I need now to manage this,” and that when things go wrong it is not an indication that some catastrophe is about to happen.

Another thing about trauma is that it involves a sudden change. Something that’s good goes bad very quickly. So people with a trauma history become very cautious about things that go bad. The ordinary bumps of life can signal to someone with trauma that something catastrophic is about to happen. It takes a while to re-orient the brain, that this isn’t a sign of impending danger, that they don’t need to fear it, and that it is not a repetition of the past. At times their fear can still get the better of them, and for a brief period, they can become hyper-alert, jump at anything, and see many things as dangerous that most people don’t see as dangerous. The worst part is that this very fear can lead to new trauma. Many rape victims often get raped again; they feel they have a big sign on their forehead that says “victim.” The problem is that when they’re in that situation, they freeze and become helpless and cannot protect themselves or yell for help, so it can happen again.

But when they get to this last phase of the healing process, they can recover fairly quickly and move on. When they get far enough along with the integration and acceptance process, they can begin to trust that they are now able to be in the world. They can speak up and not freeze. They can take care of themselves and can begin to feel that they are safe enough.

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