by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way
One week after the mass shooting in Orlando, we are faced with the difficult work of managing the resulting trauma. Part of this management requires us to delineate between the presentation of trauma and other mental health struggles like depression, anxiety, or grief. Trauma, while appearing to have many overlapping symptoms with other conditions, truly operates in its own way, residing in a specific place in both the brain and the body. Many who are negotiating the stress and torment over what happened in Orlando are certainly feeling grief stricken and startled. This does not mean that everyone is traumatized as a result of it. However, for massacres and other attachment assaults, trauma is a common outcome, made better only by the proper and precise identification and subsequently well attuned treatment of it.
Trauma is not anxiety.
Anxiety is often associated with trauma; however, it is not the same as trauma itself. Anxiety is often experienced as a dysregulation in the flow of both adrenaline (the chemical that courses through us when in a flight mode) and cortisol (the chemical that runs through us when we are in a fight mode). Similar to depression, anxiety is highly based in the body and mind. The body feels nearly electrified, while the mind runs through an unmanageable volume of thoughts, which are typically described as worries. Sometimes the thoughts are obsessive and feel nearly impossible to get a hold of. When relief comes through experiencing a rational or soothing thought, another set of frightening thoughts often follows. Finding calm in a sea of anxiety is extremely difficult, given the heavy role that our limbic system plays in sustaining anxious states. Furthermore, when the body can no longer sustain anxious states, depression typically follows.
Trauma is not depression.
Although many people experience depression as a result of trauma, trauma and depression are two distinct psychological phenomena. The central signs of depression are a decrease in motivation, loss of interest in familiar and enjoyable activities, and an overwhelming feeling of hopelessness. Individuals who are depressed try to seek ways to self soothe, but they have difficulty identifying ways to do so. Many who feel depressed describe feeling as if their minds are blank and that it is hard to give words to their thought processes. Depression can almost feel flu-like, slowing the overall body and mind down. It is an extremely painful way to feel, because the road to relief feels paved with tasks that feel impossible, like exercise, social engagement, and talking openly.
Trauma is not grief.
Grief, the complex set of emotions that follow a loss, is typically experienced in stages. While these stages are not always linear, there is a somewhat predictable format to the grief experience. These stages are denial, anger, bargaining, depression, and acceptance. There is no set timeline for these stages, and some parts of the grieving process last much longer than others. Grief, most commonly characterized by sadness, is a completely natural part of attachment and loss. There is nothing wrong with grief. In fact, grief needs to be experienced in order for us to metabolize loss.
What is trauma?
The way that trauma is distinct from psychological processes mentioned above is that it is an assault on the body and the psyche. First, someone can experience a trauma and not become traumatized. The single biggest predictor of whether or not someone becomes traumatized by a trauma (a car accident, a murder, a robbery, an illness) is the presence of a secure attachment. Secure attachment, at any point in someone’s life, can act as a protective factor against someone becoming traumatized. Furthermore, becoming traumatized is not the same thing as developing PTSD or complex PTSD.
There are different levels at which trauma resides in us, the most superficial being called “traumatized” and the most penetrating level being characterized as complex trauma. PTSD lies somewhere in between. When someone is traumatized, this often means that they are in a hypervigilant state, marked by the presence of intrusive thoughts. But there is an awareness of the distinction between their sense of self and what happened to them. PTSD, more deep seated, does start to seep into one’s sense of self and causes tremendous levels of dysregulation, irritability, reoccurring images of the stressor, and leaves someone generally operating from a place of fight or flight. Most disturbing to one’s sense of self is complex PTSD. Complex PTSD suggests the presence of a prolonged trauma, extensive exposure to a stressful environment, extremely unpredictable attachment experiences, and a near inability to distinguish between one’s sense of who they are versus the trauma itself.
It is essential for us, clinically, to properly assess traumatization. This is because, without proper treatment, trauma begets trauma. The more unresolved that trauma is, the more malignantly it has an impact on our overall environments. Furthermore, psychological trauma results in a loss of faith in the order of the world, in the possibility of meaning making, and creates an unending inability to find safety within one’s own mind or relationships. Our lives feel completely unmanageable to us when we cannot find meaning, and this leaves us fleeing our own minds at almost any expense, including dissociation, rage, and possible psychosis.
The most valuable element of any treatment of trauma is that the trauma is named and that the client is believed. Taken from the shaken and traumatized client is a sense of their own truth, own believability, own sense of knowing. In our work, we must diligently attend to the work of helping our clients re-know their own truth, but reflecting back to them what we are hearing. We must also help to educate them on the fact that self-doubt is a hallmark of trauma, not evidence of the absence of it. Another task in our work with traumatized clients is to encourage, though in a well-paced manner, the telling and retelling of their stories. For some, this might be too difficult to handle, and that is okay. Others can tell small parts of their stories. For others, talking about issues or stories that resemble their own helps, too. The bottom line is to help the client to see the trauma as separate from their own sense of self.
Another central piece of our work with trauma is to remain as predictable and transparent in our work as possible. While we can not necessarily create perfectly secure attachments, the very nature of our ability to contain the rhythm of the clinical process can help someone to feel as if the world is less chaotic and fearful.
Trauma work requires engagement with intense affect. We cannot keep our emotions out of our work with trauma. Concurrently, we ought to tenderly offer a persistent and open invitation to the emotions of our clients -- the good, bad, and ugly.
While trauma work is clearly complicated and deserves complex attention and study, there are basic tenets that can create real and lasting change. Recognizing the way that trauma lives in the body and mind, the way it is distinct from other mental health issues (although there is tremendous overlap), and honoring the way it overwhelms or severs one’s mind from intolerable realities can start to pave a path toward relief.
Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. She provides more of her clinical perspective and tips for developing clinicians in her book, Real World Clinical Social Work: Find Your Voice and Find Your Way.