This weekend I attended an international trauma studies conference in Miami, Florida, where some of the leading researchers and clinicians in the field of trauma gathered to share their innovative projects and findings. I was excited to hear about the ongoing work to bring trauma-informed practices to individuals around the world and also, admittedly, to present some of my own work while having an excuse to visit my home state. Although there were many worthwhile moments (Miami really is quite beautiful at this time of year), overall I left feeling paradoxically hopeful, saddened, inspired, and a bit dumbfounded.
Four days of panels and papers dedicated to the field of trauma, hundreds of individual presentations, and a huge gathering of some of the most compassionate, dedicated, and marginalized professionals in the mental health field provided quite the learning opportunity. Some of the more interesting material presented (in my personal opinion) showed:
- That 1/3 of women experience childbirth as traumatic (Beck, 2009) with 10-20% reporting a traumatic stress response (Beck et al., 2011; Rojas, 2014)
- How domestic violence can result in transgenerational changes in DNA in the children of the victimized parent even if the child never witnesses this violence(Schauer, 2014)
- That childhood adversity (a term that circumvents the argument of defining “trauma”), including stress, poverty, socioeconomic status, education, parental stress, and diet is directly related, in a dose-response relationship with later physical and mental health (Schauer, 2014) and that when enough cumulative adverse events are experienced 100% (yes, 100%) of individuals will develop a “mental illness” (I guess there is finally “evidence” to the common sense notion that we all have our breaking point)
- The effects of childhood trauma are unique and more complex when compared to single event, adult trauma, including dramatic alterations and difficulties in interpersonal relationships (van der Kolk, Ford, Spinazzola, 2014)
- How DNA damage in response to traumatic stress (Schauer, 2014) can actually be healed through PSYCHOTHERAPY (Morath, et al., 2014)
- How prevention of “mental illness” can nearly completely be heeded through interventions at the parental and systemic levels to reduce child abuse, discrimination, and poverty (Schauer, 2014; van der Kolk, Ford, Spinazzola, 2014)
- A dominating focus on brain and gene correlates of traumatic responses and the healing effects of trauma-informed therapy (biological difference does NOT mean healing has to be in the form of biology!)
- How primary care giver attachment disruption is MORE likely to result in a traumatic and psychopathological response than physical and/or sexual abuse (with the combination having the worst results; van der Kolk, Ford, Spinazzola, 2014)
- How the diagnosis of PTSD is very limited and does not capture the effects of disrupted childhood development and interpersonal trauma and…
- The necessity of “human/child/woman’s rights [to be] at the core of counseling and therapy” (Schauer & Schauer, 2010).
One study after another was presented on “trauma-related disorders” and their associated treatments, yet there was not a single mention of schizophrenia or its related diagnoses. Four days of trauma discussion and the topic of psychosis was nowhere to be found. That is, of course, until I brought up the subject during a panel discussion on dissociation.
The focus of this particular panel was a broad attempt to integrate different perspectives and findings on dissociation. Very interesting research was presented, for instance: evidence shows that psychological trauma results in alterations of consciousness in the domains of time, thought, body, and emotion (Thompson & Zahavi, 2007; Frewen & Lanius, 2014). According to this research, as the levels of dissociation increase, a person is more likely to experience identity fragmentation and flashbacks/reliving (time), voice-hearing and confusion (thought), depersonalization (body), and numbing/compartmentalization (emotion). Additional research showed how trauma effects the brain and makes one more likely to become addicted to alcohol or benzodiazapines at a neurochemical level (too technical for me to fully understand; Kudler, Lanius, D’Andrea, & Rasmusson, 2014) and the association of specific genes related to PTSD and dissociation. There also was a lengthy discussion about how experiencing multiple traumas (unlike a single trauma) results in a shutting down response rather than hyperarousal and increased physiological activity. This includes: loss of emotion, loss of memory and language, shutting off of cognitive processing, deactivation of the brain, loss of physical sensation, social disengagement, miscommunication, and social withdrawal (McTeague, et al., 2010).
As I was listening, I found even my own ideas being broadened and put into question. More specifically, one of the longest standing agreed-upon ideas is that “negative symptoms” of “schizophrenia” are something separate from trauma and are non-dissociative. I must admit, I too have thought this, though likely for different reasons than many. Personally, I believe that so-called negative symptoms are usually a result of the long-term effects of neuroleptic drugs and hopelessness; they are, most often, iatrogenic. I have not changed my mind on this, but I realize now that just because it may be iatrogenic or drug-induced, that does not mean that it is not also dissociative. What I really was struck by were the findings showing how the higher one scores on measures of “dissociation,” the more the entire psychological and physiological systems shut down. For instance, those with scores indicating high levels of dissociation are far more likely than other traumatized individuals to have a decreased startle response, decreased sweating, decreased heart rate, decreased vision, decreased attention, decreased verbal response, and increased numbness.
This was information that I have read and seen in numerous different academic and clinical contexts, but this particular study showed a dose-response relationship; in other words, the more one endorsed “dissociation,” the more one also experienced these other phenomena. This seems logical to me, so my mind naturally followed the continuum to its end point. At the most extreme, I would think that such experiences, when deeply entrenched and long-standing, would appear catatonic to the outsider (this has also been explored by others, e.g., Moskowitz, 2004). But, step back from this a couple of notches, and these demonstrated phenomena sound an awful lot like lack of motivation, flat affect, monotone speech, blank looks, and lack of interest in the world (i.e., negative symptoms).
So, I got a little excited, thinking perhaps I was wrong and there was going to be some discussion of trauma, dissociation, and at least psychotic symptoms, if not “schizophrenia.” In fact, the word “schizophrenia” came up a couple of times, but only in dismissive passing and without elaboration. Thus, I dared to speak up. Since the topic was on integrating different perspectives on dissociation, I asked the entire panel to define what dissociation is to each of them. I explained that the presentation took for granted that we all know what “dissociation” is, but that I have found in my research and more informal discussions regarding dissociation and so-called schizophrenia, that the definition of dissociation changes and changes again in an apparent effort to make sure it never gets confused with schizophrenia. So, I asked the panel of experts (several of whom I was quite familiar with due to their “expert” status in this area) to define dissociation. Simple, right?
Suddenly and immediately the tension in the room became so palpable that I actually thought I might be physically ill. The panel appeared to be speechless and awkward laughter ensued, as if nobody knew quite what to do with my question. The first response was partially in jest, where one speaker stated: “You have to define it for yourself.” After this initial tension-breaking response, that I believe might have a had a little too much truth behind it, the panel became a bit more serious. The first panelist to respond stated that there is dissension within this very small group of thinkers (dissociation researchers) who are already marginalized, and that there is often argument over “who owns the definition of dissociation.” She was a kind woman and explicitly offered me solidarity (which I quite appreciated in that moment), yet she never attempted to provide a definition of dissociation. The next person responded by describing how important it is to recognize there is a clear distinction between dissociation and schizophrenia.
She went on to explain how “bizarre” delusions are different from dissociation and are unequivocally not related to trauma. So, at least in this case, the answer to “what is dissociation” was quite literally “not schizophrenia.” The next panel member started talking about something so completely unrelated to my question that I am not entirely sure what she was talking about. Though, in all fairness, I may have been so taken aback by the previous response that I just was incapable of hearing what she was saying. The last person, who originally told me to define dissociation for myself, was the only one who attempted to answer my question. He spoke of the idea of dissociation being a vertical split (unlike suppression or repression where someone “stuffs it down”) in the psyche of emotions, self, and experience, which, on a side note, I happen to agree with. He then quickly added that he saw little difference between psychosis and dissociation as he hastily handed off the microphone to the next question-asker (preventing any argument with his controversial statement). And people wonder why I have given up on using the term “dissociation.”
Interestingly, the next couple of comments indirectly came back to my own, in swift passing, like: “I’d like to ask X, but also want to say that there is evidence that psychosis is related to trauma, and my question is X.” It was so strange, and the way people seemed to be afraid to really discuss this topic kind of blew my mind. To speak of trauma and schizophrenia in this environment felt like what probably happens when a man verbalizes that his wife has gained weight…it is something you just don’t do.
Now, I know that there are many financial interests that make the topic of trauma and psychosis a sure-fired way to drive a stake into the heart of one’s career (I wonder every day when that stake might find mine). But, this was something different. This was emotional, and coming from a group of professionals who have spent their careers fighting “the system” to get trauma-informed care more widely disseminated. These folks really are, for the most part, some pretty amazing people. There were so many stories of those who have spent their careers (with very little pay, I might add) helping refugees to get out of camps, foster children to gain a positive sense of self and attachment, and homeless individuals to get off the streets and find hope and purpose, all through healing trauma and recognizing the tragic consequences of cumulative stress. I do not believe for one moment that money is at the root of this clearly highly charged topic, at least not with this group of professionals. Yet, there definitely is something.
I can’t help but wonder how far we, as a human race, might come if we were to accept diversity in all of its forms, accept that suffering manifests differently for everyone, and stop attaching political weight to what is and is not acceptable ways of being human. One of the most famous trauma researchers in the world said to me several years ago, when I confronted him with this very topic: “Sometimes you have to choose between being honest and being effective.” The sad thing is, I think he was right. And, the experience at this conference seemed to prove that statement. I cannot be an effective clinician if I cannot graduate; I cannot be an effective researcher if I cannot get support or collaboration; I cannot be an effective advocate if people won’t listen; and yet, it is just in my nature to be honest. Even after all of this, and knowing the risks to myself, I still feel the right thing to do is to put the truth out there for others to read. Perhaps this is because I do not view this issue as a simple career-based, intellectual, theoretical issue; this is, fundamentally, a civil rights issue with far-reaching consequences. How am I supposed to be silent on that? And when people tell me I am exaggerating by comparing this subject with civil rights issues from the past, I need only to point to the interactions such as that described here. Talking about trauma, dissociation, and psychosis is akin to talking about race in the Deep South, the Israel-Palestinian conflict with vested parties on either side, or homosexuality with Catholic priests.
Why, though? Why in an environment with deeply compassionate, outside-of-the-box thinkers does a simple question provoke such an emotional and heated reaction? Why does a conference dedicated solely to trauma not have one panel or poster that even mentions psychosis? I am not saying that there isn’t a strong possibility that my theoretical assertions (the inter-relatedness of psychosis and dissociation) are completely false; but why are they so certain that they are right? Why are my questions and ideas consistently, systematically shut down? Why are yours also? Why is it that the words of those with lived-experience are so easily dismissed?**
It’s easy to just say that these people are evil, or they only care about money or their careers, or that they cannot deal with more complex or difficult things. This just isn’t true. “Trauma-related disorders” include extreme levels of hyperarousal, dismissiveness, violence, fear, rage, suicide, and bizarre presentations of trauma-related events that often result in vicarious traumatization of the therapist; the professionals who dedicate their lives to working with trauma victims are rarely in it for the money, fame, or ease of simple work. Certainly there is plenty of evidence to show that supporting the status quo, defending the dominant ideology, and endorsement of stereotypes is the norm for most people so as to maintain a sense of solidarity and belief in a just world (Jost, Banaji, & Nosek, 2004; Lerner, & Miller, 1977). Maybe these trauma researchers, like all of us, are just afraid of the unknown. Or maybe instead, they are afraid of being like all of us.
**Note: If anybody thinks that they might be able to contribute to first-person perspectives on dissociation, contact me ([email protected])! You might be able to participate in my dissertation research on the treatment of severe dissociation.
* * * * *
Beck, C. T. (2009). Birth trauma and its sequelae. Journal of Trauma & Dissociation, 10, 189-203.
Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Posttraumatic stress disorder in new mothers: Results from a two-stage U. S. National Survey. Birth: Issues in Perinatal Care, 38(3), 216-227.
Frewen P., & Lanius, R. (2014). Healing the traumatized self. W. W. Norton
Jost, J. T., Banaji, M. R., & Nosek, B. A. (2004). A decade of system justification theory: Accumulated evidence of conscious and unconscious bolstering of the status quo. Political Psychology, 25(6), 881-919.
Kudler, H., Lanius, R., D’Andrea, W., & Rasmusson, A. (2014, November). Towards an integrated theory of dissociation. Panel presented at the 30th Annual Meeting of the International Society for Traumatic Stress Studies , Miami, FL.
Lerner, M. J., & Miller, D. T. (1977). Just world research and the attribution process: Looking back and ahead. Psychological Bulletin, 85, 1030-1051.
McTeague, L. M., Lang, P. J., Laplante, M. C., Cuthbert, B. N., Shumen, J. R., & Bradley, M. M. (2010). Aversive imagery in posttraumatic stress disorder: Trauma recurrence, comorbidity, and physiological reactivity. Biological Psychiatry, 67(4), 346-356.
Morath, J., Moreno-Villanueva, M., Hamuni, G., Kolassa, S., Ruf-Leuschner, M., Schauer, M., …& Kolassa, I. T. (2014). Effects of psychotherapy on DNA strand break accumulation originating from traumatic stress. Psychotherapy and Psychosomatics, 83, 289-297.
Moskowitz, A. (2004). “Scared stiff”: Catatonia as an evolutionary-based fear response. Psychological Review, 111, 984-1002.
Rojas, E. E. (2014). Childbirth as a traumatic event: Understanding risk factors. Poster presented at the 30th Annual Meeting of the International Society for Traumatic Stress Studies , Miami, FL.
Schauer, M. (2014, November). This is my story, I am. Keynote Address presented at the 30th Annual Meeting of the International Society for Traumatic Stress Studies, Miami, FL.
Schauer, M., & Schauer, E. (2010). Trauma-focused public mental health interventions: A paradigm shift in humanitarian assistance and aid work. In E. Martz (ed.), Trauma rehabilitation after war and conflict. New York: Springer.
Thompson, E., & Zahavi, D. (2007). Philosophical issues: Continental phenomenology. In P. D. Zelazo, M. Moscovitch, & E. Thompson (Eds.), The Cambridge handbook of consciousness. Cambridge University Press.
Van der Kolk, B., Ford, J., Spinazzola, J. (2014, November). Developmental Trauma Disorder (DTD) Field Trail Outcomes: III. Differential comorbidity of DTD and PTSD. In J. Ford (Chair), The Developmental Trauma Disorder (DTD) Field Trial: Scientific integrity and clinical utility of a developmentally-informed complex traumatic stress disorder for children. Symposium conducted at the 30th Annual Meeting of the International Society for Traumatic Stress Studies , Miami, FL.