This article was originally published on goodtherapy.org on June 5th, 2012
I believe one mistake I made early on in my career was viewing severe trauma or loss reaction through a filter of pathology. Please understand that I’m not of the mindset that undesirable behaviors can simply be made right by relabeling them as normal. However, I do believe viewing symptoms such as hypervigilance, reenactment (in most cases), avoidance, and even dissociation from a purely deficit-based lens does not accurately capture the purpose of these behaviors and removes the healthy human inclination driving each of these coping skills.
One does not need to meet the criteria for a posttraumatic stress diagnosis or any diagnosis for trauma to have a negative impact on one’s behaviors, decision making, or world view. Many of the symptoms present in an individual with a diagnosis are simply behaviors or experiences most folks would have, but the behaviors are carried out to an extreme in terms of both duration and intensity.
I make this point because, in working with clients who experience a severe trauma reaction, particularly adolescents, I find that causality and normalcy are a big deal. “ Why am I doing this?” and “Am I normal?” are make-or-break questions when it comes to engaging adolescent clients in the work, and how we answer these questions can either instill realistic hope or unrealistic expectations.
Drawing from Shapiro’s Adaptive Information Processing Model (regardless of what you think about eye movement desensitization and reprocessing, she nails it with this theory), a survivor may understand causality on a surface level. “I know my uncle abused me, but I feel it’s my fault” illustrates the disconnect survivors have between the evidence surrounding the trauma and their beliefs about what the trauma says about them.
Adolescents (depending on where they are developmentally) are already in the throes of attempting to formulate an identity. The code for their moral understanding of the world, their place in the world, and their purpose is being heavily edited and finalized. A trauma can have a devastating impact on this process, and while teens are resilient, this may be somewhat of a liability as what works is codified and what works now may not always work later. Generally, teens have a healthy distrust of folks they don’t know and are highly sensitive to how they are perceived and what an authority figure can do to them based on that perception. Because of these defense mechanisms, the material can remain a guarded secret until trust is developed. The trust connects to two primary areas and can take the form of, “Will this person get me?” and “Can this person help me?” For many adolescent victims of trauma, this is particularly true. Therapists can be complicit in keeping unproductive defenses in play if they spend too much time revisiting and retro-redirecting extreme behaviors that occurred between sessions.
One primary task of adolescence is to conform and be different—but “not in a creepy way,” as many of the adolescents I work with would say. This process of reconciliation becomes more complicated and can be potentially derailed when a trauma enters the picture because it provides teens with ample soil for distorted beliefs about themselves and those around them. The trauma can make them feel different in a “creepy” or “weird” way, and the belief many times is that their peers can see this weirdness.
The first step I find most useful in working with an adolescent survivor is to determine the purpose of each symptom. The question, “Why I am doing this?” has an answer, and it is critical for clients to understand that answer so they recognize the need they are trying to meet through their behaviors. In answering the question “Why am I doing this?” it is important to take the symptom back to the traumatic event and ask “At that time or at that point in my life, was this useful?” and “How was it useful?” The answer that typically follows is rational; many times the behavior came about because it was really the only way the client could have coped with the trauma, given the event and his or her developmental stage at the time. This process has a high potential of providing clients with an understanding that they are not acting this way because they are crazy; there is a purpose to the behavior, and it is related to a reality; it’s just an ineffective means to an end at this time.
Now to the question of “Am I normal ?” One of the best interventions I ever learned in relation to trauma work was this one question: “What would you say about a person who has experienced (state the client’s traumatic experiences) and was still able to do (state the client’s strengths concretely, avoid attributes)?” The narrative that the client produces is usually a powerful counter to the beliefs he or she has held about him- or herself as a result of the trauma. In my experience, there are very few instances where a client engages in the narrative and a demonstrable shift in his or her presentation does not occur. This also has the potential of changing a client’s view of the therapist from that of another adult the client shouldn’t trust to someone who has a substantial understanding of what he or she is experiencing and how it has affected him or her.
This task of normalizing behaviors by providing context and purpose is not a one-session deal—it is a constant theme when reviewing and practicing coping skills and is a significant part of exposure work. The value to normalization is that it increases the probability that clients will change their understanding of the events and the narratives they hold on to in describing these events to themselves. The process also provides a rational basis for why change is necessary and why they should trust you to help them.
Dialectical behavior therapy and mindfulness-based cognitive therapy interventions are logical prerequisites when providing interventions from this framework in preparation for exposure-type therapy or as a standalone. The reasons are obvious; both modalities focus on observation, acceptance, and regulation of thoughts in managing distress. They provide safe avenues for adolescents to manage maladaptive coping skills as they are nonjudgmental, and both de-emphasize pathology and expectations.
An adolescent’s faith tradition may be another complement to the work and a potential source of support (if one exists for that client). Although not on the same topic, my previous article on forgiveness and family work (Forgiveness in Family Therapy) speaks to the process of using this resource as the basis for interventions. Same logic, different context.