How to help someone with PTSD

How to Help Patients With Sexual Abuse

On today’s episode of the podcast, I interview Ginger Simonton, a PhD student finishing her dissertation. We will cover her in-depth research on alleviating the symptomology of childhood sexual abuse.

We will specifically be talking about the link between women who have been sexually abused, never given a chance to heal, and how it has affected their mental and physical health, and programs that can benefit them.

What is childhood sexual abuse?

“The CDC defines the act of CSA as “inducing or coercing a child to engage in sexual acts” that include “fondling, penetration, and exposing a child to other sexual activities” (2017).”

The facts:

  • 88% of sexual abuse cases happen with someone the child knows (Finkelhor, Ormrod, Turner, & Hamby, 2005)

  • 20-30% of women experience some form of sexual abuse before they reach 18 years old (Pereda et al., 2009; Stoltenborgh, Van Ijzendoorn, Euser, Bakermans-Kranenburg, 2011; Bolen & Scannapieco, 1999; Holmes & Slap, 1998; Finkelhor, 1994)

  • 20-40% of survivors have no adverse effects later in life (resilience is the norm) (Paras, Murad, Chen, Goranson, Sattler, Colbenson, Elamin, Seime, Prokop, & Zirakzadeh, 2009)

How does it affect health?

Statistics show that 20-40% of survivors have no negative effects later in life. This is dependent on the response of caregivers. If someone was supported, protected, validated and responded to in a therapeutic way, the child has a higher chance of resiliency, which occurs through secure attachment. If the child has secure attachment, they can usually move forward with their lives.

What Simonton’s study shows is that women who were silenced, shamed or not given a voice to resolve those childhood sexual trauma issues have more mental and physical health issues than normal. If a woman was in a multi-dimensionally unstable family—drug use, no structural stability, alcoholism, revictimization—they are less likely to have resiliency.

Bodily representations of chronic stress:

Women who experienced childhood sexual abuse that was never recognized by a loving caregiver demonstrate biopsychosocial health problems both in childhood and later on in life. Sexual abuse causes intensive stress, and there are many subsequent health issues that stem from it.

What we see is the body begin to break down in the face of cortisol and other stress-related hormones that are released over years of unresolved trauma. One of the first indicators that drives them to seek medical help is usually a physical ailment. Often the patient experiences a few health issues, and ends up medicating the physical things, but the underlying cause is never treated.

These show up in many different ways, but there are some predominant issues such as:

  • Migraines

  • Bladder problems

  • Hypertension

  • Anxiety

  • PTSD

  • Depression

  • Chronic fatigue

  • TMJ

  • Irritable bowel

  • Fibromialgia

  • Non-epileptic seizures

  • Diabetes (chronic stress makes it more difficult to control)

If your patient does have a chronic illness, that does not mean they have experienced childhood sexual trauma. However, if they are retaining stress from childhood sexual abuse, they are more likely to develop comorbid mental and physical health issues later on.

Helping patients who have experienced sexual abuse

Because we are meaning-making creatures, we assign values to situations in our lives. If something good happens, we assign positive meanings to it—we are good people, we are highly valued, we are loved, etc. If something bad happens, we assign meaning to it—we are gross, we are worthless, we are disgusting. As we internalize these beliefs, we begin to act according to those meanings in ways that further damage our bodies and minds.

So how do we help our patients revisit the meaning they’ve assigned to these traumatic experiences? Simonton’s research shows different programs and therapies that can help patients cope with the trauma and relief their symptomology.

Ask them their story

It’s important for a patient to feel they are revealing their story slowly and gradually if that’s what makes them most comfortable. Simply asking for them to tell their story, then helping them unpack the information if they mention sexual abuse, is the best way to go about it.


Don’t lead the witness

Some therapists who have been sexually abused themselves, or who are particularly drawn to sexual abuse victims, can tend to transfer other patient’s experiences and make conclusions about patients who maybe have not experienced sexual abuse. If this is the case, the therapist can sometimes “lead the witness” by suggesting and leading the patient to believe they have experienced this when they have not.

Get the right team around them

It takes a good team to help someone recover from the trauma of sexual abuse. A good friend and family support group, plus therapists and internal medicine doctors (if the patient is on medications for their comorbid physical ailments) will all bolster the patient’s healing process. As a therapist, try to work with the patient’s internal medicine doctor to get a complete picture of the patient’s whole health. That way, as the patient heals, their medication can be managed accordingly.

Family involvement is critical to patients improving quality of life. Women who had a partner or sibling did much better and received the fullest benefit of having someone with them for home care and help. Also, someone with a spiritual base or community demonstrated higher health quality of life throughout intake and therapy.

Having someone with the patient who can be there day in and day out leads to a much higher success rate than when they have isolated experiences with the therapist. What is difficult is when a person experiences positive change in their therapy, but goes back to a rigid family who relates mostly to the patient’s illness. Illness can even create a continuing underlying family rule of keeping the victim in her lower, negatively associated role.

This also helps the women establish a new relationship with whoever they bring to therapy with them in a sexual abuse program—it helps them re-relate to a person in a new healthy way. They are no longer just the victim, they can portray new goals for healing and see rapid growth alongside their partner, family or sibling.

Get them back in touch with their bodies

Many people who experience sexual abuse learn that their body is their enemy, a conduit of pain. They learn to dissociate to be able to survive, and that ability carries over into adulthood. Dissociation is a powerful tool that helps them be able to mentally “leave” their body so they can withstand physical pain or trauma.

One fascinating note Simonton made is that patients never recounted physical pain when they talked about their trauma. Their minds were so disconnected from their bodies that they had no memory of the physical consequences. Women who do this have been carrying this unchartered territory of pain in their physical bodies for so long that by the time they reach adulthood, they have to learn to reconnect with their bodies.

When we start to break the meaning apart to help patients begin to heal, we have to very delicately focus on what it means to reconnect their mind and body.

Getting patients refocused on their bodies and unearthing the resident trauma that is causing the stress-related illnesses will help them unlock their emotional and mental healing processes. They have an opportunity to discover that their body has a story to tell. By reconnecting to their bodies, they give it a voice to process its trauma.

How to listen well

There are a few things you can do to make sure your patient feels heard and validated when they open up about their sexual abuse. “Witnessing” is an important one. Some people who’ve experienced sexual abuse have stories that were never heard or validated.

When someone shares a trauma story and it is not validated (shame and silencing might have occurred with their family) it can re-damage the patient. When they share and feel validated, it can be a healing experience for them.

Asking them how it makes their body feel when they share about their experience is also important. It connects the somatic representations with the emotions and thoughts, which is important because these patients have most likely dissociated from their emotions and bodily sensations in general, but more so when they talk about their experiences.

How to listen, empathize and not take on the emotional repercussions of trauma

Hearing stories of trauma is difficult as an empathic therapist.

  • Make sure you practice what you preach—have your own therapist to help when you need it.

  • Find a colleague who also helps people through childhood sexual abuse and go speak to them about your feelings.

  • Determine a way you can take care of yourself when you get home from your work day. Create a space where you can enjoy your family, spirituality and recreation (including cardio and strength training).

  • Develop a treatment team of colleagues that works together to process through the difficult stories you are each hearing.

  • Ask fellow therapists how they feel—check in with your coworkers and fellow therapists to make sure you are each sustaining your own health.

What therapy techniques work best for the sexually abused?

  • EFT - Emotionally focused therapy for couples is an effective, research based spousal support therapy system. This teaches the spouses to be effective witnesses in the trauma story and is able to bring the support to inside of their home.

  • DBT - Dialectical behavioral therapy is incredibly helpful for people who are struggling with PTSD related to childhood sexual abuse.

  • Transference Focused Psychotherapy

  • Mentalization Based Psychotherapy

How can you tell what patients should be in regular, weekly therapy versus an intensive outpatient therapy for sexual abuse?

Many excellent outpatient therapists are doing a great job at treating patients who have experienced childhood sexual abuse. There are a few specific factors that could mean your patient would be better treated in a more intensive outpatient programs, such as:

  • If they are in a multi dimensionally unstable family where their health is being impaired. (AKA If they do not have a support system at home.)

  • If they are medically fragile because the body is beginning to break down.

    • Some outpatient programs have internal medicine staff to ensure the patients who are medically fragile are being physically supported.

  • If your patient doesn’t seem to be thriving or processing well, recommend them to an intensive outpatient program, with the idea that when they become more stable, they will titrate down to weekly therapy again.

  • If the patient is on so many medications, recreational drugs or alcohol that it puts them in a dissociative state where they are unable to concentrate and do deeper therapy work, an outpatient program might help support them while they come off of medications and process the difficulty of their trauma. (Many therapists don’t realize how much medications can dull the mind and make therapy very difficult.)

    • After a few weeks, some patients may need to be detoxed before they can fully process the emotional trauma.

During supportive forms of therapy, who should the patient bring with them to be a support?

The family is not always the most supportive group for the patient. There could be a partner or friend who is therapeutic and non-judgemental enough. However, it’s important to encourage the patient to bring someone they feel completely safe around. This person is supposed to help the patient grow and move forward, to make good choices outside of the therapy office. This person must have the best interest of the patient in mind, and not prefer the old maladaptive patterns the patient was in. They must support the patient in their growth and journey of health.

Many patients end up in relationships that are similar to the dysfunction of their trauma. How do you encourage a patient to find or make a friend that is healthy and can support them?

  • Help the patient identify their feedback loops, through identifying their early narratives and early meaning-making experiences.

  • Start to make changes as to how the person sees themself so that they see themselves as worthy. This is the best way to have lasting effects on their relational patterns.

  • A victim is a victim because they have a perpetrator. If there is no longer a perpetrator because they’ve surrounded themselves with healthy people, the patient is able to shed the victim narrative.

From chronic pain to thriving

We have found that patients who receive therapy are able to reduce the negative biopsychosocial effects. They are getting back to school, getting new jobs or raises at work, setting new goals.

Some people get stuck and lose hope, they don’t see it’s possible. Eventually though, if they keep seeking help, they are able to have breakthroughs and change their lives.

If you’re interested in learning more, here are a few podcasts and articles about emotional trauma:

How to Treat Emotional Trauma

How to Fix Emotional Detachment

Emotional Shutdown - Understanding Polyvagal Theory

***If you have been sexually abused, or think you have been sexually abused, connect with a therapist who specializes in this.


How to Treat Emotional Trauma

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This week on the podcast I spoke with fellow therapist, Randy Stinnett Psy. D, about how trauma works, and how we can help our patients overcome it.  

What is trauma?

Emotional trauma comes from stress that is overwhelms a person’s neurological system. Some stress can be good and formative, or it can be bad and get stuck in the brain, causing someone deep emotional pain.

Think of climbing Mount Everest. Some people choose to do that, and it’s easily one of the most stressful situations you can put yourself in on purpose. That’s good stress if you have trained for years and are ready for it. If someone forced you to climb Mount Everest, it would register in the brain as a trauma.

Trauma is too big for the mind, brain, and nervous system to assimilate. It’s a memory, or experience, that gets stuck because the person believed it would result in their death, or at least serious injury.

The brain has several mechanisms to keep something stuck so that the person will remember it, and try to avoid getting hurt in the same way in the future. It is a survival instinct.

People commonly demonstrate symptoms of trauma when they’ve:

 

  • Experienced a sexual violation

  • Seen violence

  • Experienced violence or abuse

  • Been neglected—experienced the absence of something that they should have had.

  • Been in near death experiences like car accidents or war

People who have PTSD, or post traumatic stress disorder, have experienced a soul-level of brokenness, and even talking about the event, or having a memory of it, can bring it back with the same force that occured in the actual accident. They often have recurring nightmares, or repetitive symptoms that continue long after the event.

Typical PTSD symptoms alternate between chronic shut down and fight and flight

  • Fight and flight symptoms are:

    • Sweating, nightmares, flashbacks, anger, rage, panic, hypervigilance, tense muscles, painful knotted gut

  • Shut down symptoms are:

    • Dissociation, freezing, emotional detachment, voice trembling, difficulty getting words out, numbness, apathy, fear, helplessness, dizzy, empty, nausea

  • Moments in connection mode look like:

    • curiosity, exploration, relaxed and full breathing, feeling grounded, true smiles

 

Body movement and trauma

We’ve all heard the reference to Pavlov’s dogs—the bell rings and the dogs salivate because they know it is dinnertime. Pavlov discovered many more things than that dogs drool. Once, his lab was flooded with freezing water that nearly filled the cages of the dogs. When they were finally able to get the dogs free, the dogs interacted differently with the world around them. They seemed hopeless.

Humans work the same way.

PTSD rates were 16% for survivors of 911, and 33% for survivors of Hurricane Katrina. Why? Traumatologists speculate it was because during 911, survivors were running away from the catastrophe to save their lives. In Katrina, the victims were airlifted out and placed in gyms, for sometimes months at a time. Those in lower socioeconomic levels had no money, no home, and nowhere to go—they were trapped.

The body is designed to move away from danger, but if the body can’t move, trauma can set in.

 

Attachment based trauma

Having a negative attachment with parents often sets people up for later traumas in life to be a bigger assault on the nervous system and psychological functioning, than it would have been as a standalone event.

Patients who experience unhealthy attachments often struggle with emotional regulation and boundaries.  

Many people, as children, were not heard and mirrored in their emotions and experiences. When they discussed their problems with their parent, and it was met with disdain or shut down, the patient has most likely developed the idea that they have no voice. The stress was not contained and thus all the raw emotion is still there and unprocessed. This leads something to continue to be traumatic in the brain.  

This follows the same pattern as polyvagal theory. When we are in connection mode, we are open hearted and happy. When we feel stress, or lack of connection, our sympathetic nervous system kicks in and we switch into fight or flight mode. If that disconnection continues, our parathetic nervous system takes over and we go into full-on shutdown. When children are repeatedly ignored or abused, they switch in and out of shutdown mode, causing trauma.

Polyvagal theory and attachment theory, and how they affect children (and adults too), are demonstrated best in the Still Face Experiment video (link to prior article I wrote on that experiment).

Attachment trauma is repeated trauma. It can occur in childhood, or any other time throughout our lives within relationships.

 

Notes to therapists on dealing with PTSD

Studies show that having an emotionally connected therapist, while someone is reprocessing their traumatic memories, can help heal the emotional damage of those memories.

Displaying emotional stability

Patients often superimpose all of their abusers onto their therapists. As therapists, we need to realize this, and stay steady during the entire course of therapy. Remaining calm, safe and empathic is one of the most healing things we can do for them.

It is a way of being, not just an action, or a reaction, towards our patients.

Receiving feedback

As therapists, it’s important to be able to receive feedback from our patients about what is working for them without it being an adversarial situation.

We must respond in a way that allows the patient to have their own voice. First, validate their emotional experience of the patient. Next, thank them for being honest with you. Ask for the whole story behind their feedback.

I am not saying this as some sort of technique, but rather this should come out of the belief that 1) their emotional experience is valid and needs a voice 2) it takes courage to voice any feedback and this is important for their growth and success.

When these things are truly believed, we are empathizing and thanking them, out of the core of our being, and not just as a technique.  

Where they were expecting rejection, you end up validating their experience. Finally, ask them how it feels, in the moment, to be heard and to be able to safely express their opinion. Allow them to experience a felt difference between you and their abusers. This provides a corrective emotional experience!

Know when to limit the stress

Understanding the different nervous system’s functions will help you know when enough is enough for your patient.

Study the symptoms of the activation of the somatic, autonomic, sympathetic, and parasympathetic nervous systems. This is imperative, and if you cannot slowly uncover the stressful situations in a way that the patient can manage it without engaging shutdown mode, you will end up doing more damage than good.

Emotional connection

One psychiatry resident asked my mentor, Dr. John D Tarr, if it was better to keep inpatient people at an emotional distance, so the patient would not get attached and want to continue to stay in the hospital. My mentor responded that we always want to be connected to our patients, to be empathic. When we feel they are getting attached and don’t want to leave, we need to open up that dialogue to how we can help them experience connection outside of the hospital.

Studies show that patients who feel connected to their doctor are more engaged in treatment—they go to therapy, take their medications, and continue their mental health journey.

Trauma-based memories are different from normal memories, like knowing what you ate for breakfast this morning. Trauma-based memory has a sensory aspect to it. They are stored in a different part of the brain than where we function for our daily, normal connection mode.

As therapists, when we access those memories with patients, the patient begins to switch to a different part of their mind, and demonstrate symptoms of trauma physically. They may tremble, sweat, and sometimes even their voice changes—it can be hard to get the words out, they whisper, they sound child-like.

To understand how people respond to trauma, we have to know that emotions have primacy, or first dibs, on our reactions. Our brain deems them more important than our executive functioning—our ability to reason and plan our lives’ daily tasks.  

If the patient is open to it and we have established a good, trusted attachment and connection, we will talk about their traumatic memories. If we do not have a connection in that way, I will not explore deep traumatic memories with them. It is more important to build a safe, secure relationship first.

Trauma gets stuck in the non-analytical parts of the brain—our emotions, creativity, experiences, art. It’s image-based, somatic (physical body), it’s non-verbal. Parts of the left hemisphere of the brain deals with logic, reasoning and language. To integrate this part of the brain, the patient will have to access the emotional parts and then put words to their experiences.   

In that conversation, these are some of the questions I will ask:

  • What did you see?

  • What did you feel emotionally?

  • What did your body experience?

  • What do you believe about yourself as a result?

Allow for freedom

Also, when we require our patients to do anything, even to stay for the whole hour of therapy if they do not want to, we are reinforcing the trapped feeling. Keep an open dialogue about what your patient is feeling throughout the therapy session.

If the patient is suicidal with a plan and intent, they likely need a safe place to get through the intense time. I will tell them, “My goal is to not keep you here indefinitely. We will come up with a plan to get you out of here, and for you to be healthy.”

In general, try to give your patients, especially the PTSD ones, choices. Create boundaries and give guidance, but allow them to have freedom in their choices.

Summary  

In this first discussion with Dr. Stinnett, I wanted to highlight some introductory understanding on trauma.  We discussed how trauma is stored differently in the brain and how the polyvagal theory is connected with this journey.  We highlighted the importance of emotion, connection and feedback. Please leave comments below on your thoughts regarding this blog and podcast!  

 

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