By Charlotte Jackson, MA, RCC
Imagine two scenarios: You have a client in the waiting room that has been identified as having an Axis II diagnosis of Borderline Personality Disorder. You have heard that ‘Borderline’ is short hand for difficult, irritating and demanding. How do you feel as you prepare yourself for your initial meeting? Warm? Apprehensive? Open? Cautious? Now what if you were told that another client waiting for you has had a long history of trauma, abuse, disruption and, as a result, struggles to cope? They are not intentionally difficult or divisive; they are just trying to stay afloat in a sea of their own internal chaos and dysregulation? Does your feeling toward meeting client #2 differ from meeting client #1? What if you were told that both clients are the same person? Research shows that while an abuse history alone is not a direct predictor of developing a personality disorder, of those diagnosed with personality disorders, 80% report significant adverse events in childhood (Hong, Lishner, & Liard, 2011). One study found that 91% of individuals with Borderline Personality Disorder reported having been abused, and 92% reported being neglected before the age of 18 (Zanarini et al, 1998).
Stigma
Personality Disorders are one of the last remaining bastions of acceptable stigmatization. Only months ago I heard a mental health professional dismiss a client experiencing flashbacks and dissociations as a ‘PD’ under her breath. Flashbacks, dissociations, affect dysregulation and relational instability are very real symptoms of trauma history. John Briere, Director of the Psychological Trauma Program in the Department of Psychiatry at the Los Angeles County + USC Medical Center posits that these symptoms are the body and mind’s attempts to heal trauma. Just as the body marshals its resources to fight infection, Briere proposes that the nervous system of the individual with unresolved trauma also marshals to rid the body and mind of the trauma through flashbacks and dissociation (Briere & Erhlich, 2002). Unfortunately, unless the individual has sufficient skills and safety to tolerate these attempts at self healing, they will end up being re-traumatized by the experiences.
Attachment
One essential component for successful relationship development and the ability to regulate emotional states is having an attentive attachment figure in the first years of life. While genetic material is available to be coded in the infant’s brain, Dr Dan Siegel, professor of psychiatry at UCLA, has discovered that more genetic material is found in the brain of a one year old than in a newborn. This is due to the presence of an attentive caregiver in the environment which triggers the continued growth of genetic material in the child’s brain. Allan Schore (2003) has reviewed evidence that the rearing environment has a direct effect on the development of brain structures and pathways involved in affect regulation.
Bessel Van Der Kolk, world-renowned psychiatrist researching trauma for over 40 years, has studied the influences of trauma on psychiatric treatment. Van Der Kolk (Andrea et al, 2012) cites a 2003 study by Grella and Joshi, in which it was seen that individuals with a trauma history were more likely to terminate therapy, fared poorer in substance use therapy if it was not trauma-focused and had a decreased response to medication therapies. Furthermore, in a 2006 study, Becker-Weidman noted that trauma-informed therapy improved outcomes, improved cortisol levels as well as improving attention, social, behavioural, cognitive and internalizing problems. So why don’t we all adopt a trauma-informed practice? Perhaps because we lack information and education around the pervasive symptomology associated with trauma and its treatment.
What is a trauma-informed practice?
Depathologizing and destigmatizing our clients is the first order of the day. The question to ask is not what is wrong with you, but rather, what happened to you? According to John Bowlby, psychologist, psychiatrist, and founder of attachment theory, if an attuned adult is not present to mirror back to an infant how to regulate and contain emotions and internal states, the child will lack the ability to control their feelings and thoughts and behaviours, which leads to massive disruption in relationships (Bretherton, 1992). The role of a therapist or health care provider supporting an individual lacking in an ability to self regulate is to become a ‘surrogate’ attachment figure, attuning, attending, validating and legitimizing. How do we do this? By listening, by being present, by validating what the client reports without dismissing or judging. As practitioners we can offer corrective experiences that heal trauma on a psychological and neurobiological level. We can support by not getting caught up in black and white/all or nothing thinking and instead validating their experience of emotional extremes. We can focus on strengths and capacities and validate current coping skills that may no longer serve them but have served to keep them alive.
Medication: what works and what doesn’t?
According to Bessel Van Der Kolk, medication compliance is low with clients who have trauma histories when they are not prescribed in the context of trauma-informed care (2012). John Briere outlines the benefits and deficits of common psychiatric meds when treating individuals with trauma histories:
Selective serotonin reuptake inhibitors (SSRIs) have been shown in several studies to be effective in reducing the symptoms of posttraumatic stress. In addition, many trauma survivors suffer from co-morbid depression and anxiety that may also respond to treatment with SSRIs or other antidepressants. The use of anxiolytics (benzodiazepines such as Ativan or Klonopin) is somewhat controversial in the treatment of trauma victims. In acute trauma situations, such medications may be indicated for immediate symptom relief. In instances of more long-term posttraumatic distress, however, an attempt is made to avoid the chronic use of anxiolytics, as this class of medication can interfere with appropriate processing of traumatic material, in much the same way as recreational substance use can inhibit processing and encourage avoidance (pp 12, 2002)
The Ace Study
The Adverse Childhood Experience (ACE) study was a three year study (1995-1997) of over 17,000 individuals that links the long term effects of early trauma with its disruption on health, health risk behaviour, cognitive functioning and social problems (http://acestudy.org/). These are the individuals most likely to show up in medical clinics and hospitals for care. Understanding the correlation between trauma and the development of many of these health challenges can guide health care providers in offering more successful interventions with better outcomes for all.
Tips and Techniques
When I have presented workshops to health care professionals on trauma-informed care, care providers report that learning practical techniques has been very helpful. There are a number of strategies that facilitate the healing and integration of trauma. Some may seem so simple as to be dismissed as irrelevant. However, it is important to remember that the healing of trauma is incremental; trust, which is essential to a therapeutic relationship, takes time to develop.
- Validation. Invalidation is a hallmark of the traumatized individual’s history. Validate whatever parts of the clients story you can support. ‘It sounds like you have been through a lot’. ‘Anyone experiencing what you have would be struggling like you are’ ‘You did what you needed to do to survive’.
- Grounding/Containment Skills. Slow down the session. Ask permission to do some slow, deep breathing together. Encourage the client to feel their feet on the floor and/or their body in the chair to facilitate being present in the here and now. Speak out loud that they are ‘safe and secure’ in this moment.
- Hamburger method. When delivering feedback that might be difficult to receive, validate before and after. For example: ‘I’m glad you came in today. We can only spend 10 minutes together. How can we best use this time?’
- Motivational Interviewing Techniques. This approach helps clients identify goals for change while encouraging and developing a sense of empowerment in their capacity to change. This includes ‘rolling with resistance’, a strategy for not confronting resistance or challenging behaviour but learning to de-escalate and refocus attention.
We Need Support Too
Being the surrogate, corrective caregiver to individuals who have survived significantly disrupted attachment and consequent affect dysregulation can take a toll on us. Teams that work with traumatized populations successfully have lots of support. They are required to participate in supervision and peer support so everyone has a safe place in which to process and integrate the often moving and emotional work they do. Don’t go it alone.
Trauma-informed care is an ongoing process; it’s not something you implement and ignore, it’s about ongoing growth and change, for clients, for care providers and for organizations as a whole.
Charlotte Jackson is a Registered Clinical Counsellor working in Mental Health and Addictions. She welcomes your feedback or questions and can be reached at Charlotte.Jackson@vch.ca
References
Becker-Weidman, A. (2006). Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy. Child and Adolescent Social Work Journal, 23 (2), 146-171.
Andrea, W., Ford, J., Stolbach, B., Spinazzola, J., & van der Kolk, B. (2012). Understanding Interpersonal Trauma in Children: Why We Need A Developmentally Appropriate Trauma Diagnosis. American Journal of Orthopsychiatry, 82 (2), 187-200.
Bretherton, I. (1992). The Origins of Attachment Theory: John Bowlby and Mary Ainsworth. Developmental Psychology, 28 (5), 759-775.
Briere, J. Ph.D. – Overview of Psychological Trauma Clinic LAC/USC. (n.d.). John Briere, Ph.D. Retrieved from http://www.johnbriere.com/PTC_paper.htm
Grella, C.E. & Joshi, V. (2003). Treatment Processes and Outcomes Among Adolescents With a History of Abuse Who Are In Drug Treatment. Child Maltreatment, 8 (1), 7-18.
Hong, P, Lishner, D. & Ilardi, S. (2011). The Aftermath of Trauma: The Impact of Periceived and Anticipated Invalidation of Childhood Sexual Abuse on Borderline Symptomatology. Psychological Trauma: Theory, Research, Practice, and Policy, 3(4), 360-368.
Schore, Allan (2003). Effects of A Secure Attachment Relationship on Right Brain Development, Affect Regulation and Infant Mental Health. Infant Mental Health Journal, 22(1-2), 7-66.
Siegel, D. J., & Hartzell, M. (2003). In Parenting from the inside out: How a deeper self-understanding can help you raise children who thrive. New York: J.P. Tarcher/Putnam.
Zanarini (1998). Reported Pathological Childhood Experiences Associated With the Development of Borderline Personality Disorder. American Journal of Psychiatry, 154(8), 1101-6.