Sanctuary for the Abused
Sunday, May 30, 2021
CHILDHOOD STRESS AND EMOTIONAL ABUSE ADD UP TO ILLNESS LATER IN LIFE
If you saw Laura walking down the New York City street where she lives today, you’d see a well-dressed 46-year-old woman with auburn hair and green eyes, who exudes a sense of ‘I matter here.’ She looks entirely in charge of her life, but behind Laura’s confident demeanour lies a history of trauma: a bipolar mother who vacillated between braiding her daughter’s hair and peppering her with insults, and a father who moved out-of-state with his wife-to-be when Laura was 15 years old.
She recalls a family trip to the Grand Canyon when she was 10. In a photo taken that day, Laura and her parents sit on a bench, sporting tourist whites. ‘Anyone looking at us would have assumed that we were a normal, loving family.’ But as they put on fake smiles for the camera, Laura’s mother suddenly pinched her daughter’s midriff and told her to stop ‘staring off into space’. A second pinch: ‘No wonder you’re turning into a butterball, you ate so much cheesecake last night you’re hanging over your shorts!’ If you look hard at Laura’s face in the photograph, you can see that she’s not squinting at the Arizona sun, but holding back tears.
After her father left the family, he sent cards and money, but called less and less. Meanwhile, her mother’s untreated bipolar disorder worsened. Sometimes, Laura says: ‘My mom would go on a vitriolic diatribe about my dad until spittle foamed on her chin. I’d stand there, trying not to hear her as she went on and on, my whole body shaking inside.’ Laura never invited friends over, for fear they’d find out her secret: her mom ‘wasn’t like other moms’.
Some 30 years later, Laura says: ‘In many ways, no matter where I go or what I do, I’m still in my mother’s house.’ Today, ‘If a car swerves into my lane, a grocery store clerk is rude, my husband and I argue, or my boss calls me in to talk over a problem, I feel something flip over inside. It’s like there’s a match standing inside too near a flame, and with the smallest breeze, it ignites.’
To see Laura, you’d never know that she is ‘always shaking a little, only invisibly, deep down in my cells’.
Her sense that something is wrong inside is mirrored by her physical health. During a routine exam, Laura’s doctor discovered that Laura was suffering from dilated cardiomyopathy and would require a cardioverter defibrillator to keep her heart pumping. The two-inch scar from her surgery only hints at the more severe scars she hides from her childhood.
For as long as John can remember, he says, his parents’ marriage was deeply troubled, as was his relationship with his father. ‘I consider myself to have been raised by my mom and her mom. I longed to feel a deeper connection with my dad, but it just wasn’t there. He couldn’t extend himself in that way.’ John’s poor relationship with his father was due, in large part, to his father’s reactivity and need for control. For instance, if John’s father said that the capital of New York was New York City, there was just no use telling him that it was Albany.
As John got older, it seemed wrong to him that his father ‘was constantly pointing out all the mistakes that my brother and I made, without acknowledging any of his own’. His father relentlessly criticised his mother, who was ‘kinder and more confident’. Aged 12, John began to interject himself into the fights between his parents. He remembers one Christmas Eve, when he found his father with his hands around his mother’s neck and had to separate them. ‘I was always trying to be the adult between them,’ John says.
John is now a boyish 40, with warm hazel eyes and a wide, affable grin. But beneath his easy, open demeanour, he struggles with an array of chronic illnesses. By the time he was 33, his blood pressure was shockingly high; he began to experience bouts of stabbing stomach pain and diarrhoea and often had blood in his stool; he struggled from headaches almost daily. By 34, he’d developed chronic fatigue, and was so wiped out that he sometimes struggled to make it through an entire workday.
John’s relationships, like his body, were never completely healthy. He ended a year‑long romance with a woman he deeply loved because he felt riddled with anxiety around her normal, ‘happy family’. He just didn’t know how to fit in. ‘She wanted to help,’ he says, ‘but instead of telling her how insecure I was around her, I told her I wasn’t in love with her.’ Bleeding from his inflamed intestines, exhausted by chronic fatigue, debilitated and distracted by pounding headaches, often struggling with work, and unable to feel comfortable in a relationship, John was stuck in a universe of pain and solitude, and he couldn’t get out.
Laura’s and John’s life stories illustrate the physical price we can pay, as adults, for trauma that took place 10, 20, even 30 years ago. New findings in neuroscience, psychology and immunology tell us that the adversity we face during childhood has farther-reaching consequences than we might ever have imagined. Today, in labs across the country, neuroscientists are peering into the once-inscrutable brain-body connection, and breaking down, on a biochemical level, exactly how the stress we experience during childhood and adolescence catches up with us when we are adults, altering our bodies, our cells, and even our DNA.
Emotional stress in adult life affects us on a physical level in quantifiable, life-altering ways. We all know that when we are stressed, chemicals and hormones can flush our body and increase levels of inflammation. That’s why stressful events in adult life are correlated with the likelihood of getting a cold or having a heart attack.
But when children or teens face adversity and especially unpredictable stressors, they are left with deeper, longer‑lasting scars. When the young brain is thrust into stressful situations over and over again without warning, and stress hormones are repeatedly ramped up, small chemical markers, known as methyl groups, adhere to specific genes that regulate the activity of stress‑hormone receptors in the brain. These epigenetic changes hamper the body’s ability to turn off the stress response. In ideal circumstances, a child learns to respond to stress, and recover from it, learning resilience. But kids who’ve faced chronic, unpredictable stress undergo biological changes that cause their inflammatory stress response to stay activated.
Joan Kaufman, director of the Child and Adolescent Research and Education (CARE) programme at the Yale School of Medicine, recently analysed DNA in the saliva of happy, healthy children, and of children who had been taken from abusive or neglectful parents. The children who’d experienced chronic childhood stress showed epigenetic changes in almost 3,000 sites on their DNA, and on all 23 chromosomes – altering how appropriately they would be able to respond to and rebound from future stressors.
'Kids who’ve had early adversity have a drip of fight-or-flight hormones turned on every day – it’s as if there is no off switch
Likewise, Seth Pollak, professor of psychology and director of the Child Emotion Research Laboratory at the University of Wisconsin at Madison, uncovered startling genetic changes in children with a history of adversity and trauma. Pollak identified damage to a gene responsible for calming the stress response. 'This particular gene wasn’t working properly; the kids’ bodies weren’t able to reign in their heightened stress response.,’
Imagine for a moment that your body receives its stress hormones and chemicals through an IV drip that’s turned on high when needed and, when the crisis passes, it’s switched off again. You might think of kids whose brains have undergone epigenetic changes because of early adversity as having an inflammation-promoting drip of fight-or-flight hormones turned on every day – it’s as if there is no off switch.
Experiencing stress in childhood changes your set point of wellbeing for decades to come. In people such as Laura and John, the endocrine and immune systems are churning out a damaging and inflammatory cocktail of stress neurochemicals in response to even small stressors – an unexpected bill, a disagreement with their spouse, a car that swerves in front of them on the highway, a creak on the staircase – for the rest of their lives. They might find themselves overreacting to, and less able to recover from, the inevitable stressors of life. They’re always responding. And all the while, they’re unwittingly marinating in inflammatory chemicals, which sets the stage for full-throttle disease down the road, in the form of autoimmune disease, heart disease, cancer, fibromyalgia, chronic fatigue, fibroid tumours, irritable bowel syndrome, ulcers, migraines and asthma.
Scientists first came to understand the relationship between early chronic stress and later adult disease through the work of a dedicated physician in San Diego and a determined epidemiologist from the Centers for Disease Control and Prevention (CDC) in Atlanta. Together, during the 1980s and ’90s – the years when Laura and John were growing up – these two researchers began a paradigm-shifting public-health investigation known as the Adverse Childhood Experiences (ACE) Study.
In 1985, Vincent J Felitti, chief of a revolutionary preventive care initiative at the Kaiser Permanente Medical Care programme in San Diego, noticed a startling pattern in adult patients at an obesity clinic. A significant number were, with the support of Felitti and his nurses, successfully losing hundreds of pounds a year, a remarkable feat, only to withdraw from the programme despite weight-loss success. Felitti, determined to get to the bottom of the attrition rate, conducted face-to-face interviews with 286 patients. It turned out there was a common denominator. Many confided that they had suffered some sort of trauma, often sexual abuse, in their childhoods. To these patients, eating was a solution, not a problem: it soothed the anxiety and depression they had harboured for decades; their weight served as a shield against undesired attention, and they didn’t want to let it go.
Felitti’s interviews gave him a new way of looking at human health and well-being that other physicians just weren’t seeing. He presented his findings at a national obesity conference, arguing that ‘our intractable public health problems’ had root causes hidden ‘by shame, by secrecy, and by social taboos against exploring certain areas of life experience’. Felitti’s peers were quick to blast him. One even stood up in the audience and accused Felitti of offering ‘excuses’ for patients’ ‘failed lives’. Felitti, however, remained unfazed; he felt sure that he had stumbled upon a piece of information that would hold enormous import for the field of medicine.
After a colleague who attended that same conference suggested that he design a study with thousands of patients who suffered from a wide variety of diseases, not just obesity, Felitti joined forces with Robert Anda, a medical epidemiologist at the CDC who had, at the time, been researching the relationship between coronary heart disease and depression. Felitti and Anda took advantage of Kaiser Permanente’s vast patient cohort to set up a national epidemiology laboratory. Of the 26,000 patients they invited to take part in their study, more than 17,000 agreed
Anda and Felitti surveyed these 17,000 individuals on about 10 types of adversity, or adverse childhood experiences (ACEs), probing into patients’ childhood and adolescent histories. Questions included: ‘Was a biological parent ever lost to you through divorce, abandonment or other reason?’; ‘Did a parent or other adult in the household often swear at you, insult you, put you down or humiliate you?’; and ‘Was a household member depressed or mentally ill?’ Other questions looked at types of family dysfunction that included growing up with a parent who was an alcoholic or addicted to other substances; being physically or emotionally neglected; being sexually or physically abused; witnessing domestic violence; having a family member who was sent to prison; feeling that there was no one to provide protection; and feeling that one’s family didn’t look out for each other. For each category to which a patient responded ‘yes’, one point would be added to her ACE score, so an ACE score of 2 would indicate that she had suffered two adverse childhood experiences.
To be clear, the patients Felitti and Anda surveyed were not troubled or disadvantaged; the average patient was 57, and three-quarters had attended college. These were ‘successful’ men and women, mostly white, middle-class, with stable jobs and health benefits. Felitti and Anda expected their number of ‘yes’ answers to be fairly low.
The correlation between having a difficult childhood and facing illness as an adult offered a whole new lens through which we could view human health and disease
When the results came in, Felitti and Anda were shocked: 64 per cent of participants answered ‘yes’ to having encountered at least one category of early adversity, and 87 per cent of those patients also had additional adverse childhood experiences; 40 per cent had suffered two or more ACEs; 12.5 per cent had an ACE score greater than or equal to 4.
Felitti and Anda wanted to find out whether there was a correlation between the number of adverse childhood experiences an individual had faced, and the number and severity of illnesses and disorders she developed as an adult. The correlation proved so powerful that Anda was not only ‘stunned’, but deeply moved.
‘I wept,’ he says. ‘I saw how much people had suffered, and I wept.’
Felitti, too, was deeply affected. ‘Our findings exceeded anything we had conceived. The correlation between having a difficult childhood and facing illness as an adult offered a whole new lens through which we could view human health and disease.’
Here, says Felitti, ‘was the missing piece as to what was causing so much of our unspoken suffering as human beings’.
The number of adverse childhood experiences a patient had suffered could by and large predict the amount of medical care she would require in adulthood: the higher the ACE score, the higher the number of doctor’s appointments she’d had in the past year, and the more unexplained physical symptoms she’d reported.
People with an ACE score of 4 were twice as likely to be diagnosed with cancer than people who hadn’t faced any form of childhood adversity. For each point an individual had, her chance of being hospitalised with an autoimmune disease in adulthood rose 20 per cent. Someone with an ACE score of 4 was 460 per cent more likely to face depression than someone with a score of 0.
An ACE score of 6 or higher shortened an individual’s lifespan by almost 20 years.
Researchers wondered if those who encountered childhood adversity were also more likely to smoke, drink and overeat as a sort of coping strategy, and while that was sometimes the case, unhealthy habits didn’t wholly account for the correlation Felitti and Anda saw between adverse childhood experiences and later illness. For instance, those with ACE scores greater than or equal to 7 who didn’t drink or smoke, weren’t overweight or diabetic, and didn’t have high cholesterol still had a 360 per cent higher risk of heart disease than those with ACE scores of 0.
‘Time,’ says Felitti, ‘does not heal all wounds. One does not “just get over” something – not even 50 years later.’ Instead, he says: ‘Time conceals. And human beings convert traumatic emotional experiences in childhood into organic disease later in life.’
Often, these illnesses can be chronic and lifelong. Autoimmune disease. Heart disease. Chronic bowel disorders. Migraines. Persistent depression. Even today, doctors puzzle over these very conditions: why are they so prevalent; why are some patients more prone to them than others; and why are they so difficult to treat?
The more research that’s done, the more granular details emerge about the profound link between adverse experiences and adult disease. Scientists at Duke University in North Carolina, the University of California, San Francisco, and Brown University in Rhode Island have shown that childhood adversity damages us on a cellular level in ways that prematurely age our cells and affect our longevity. Adults who faced early life stress show greater erosion in what are known as telomeres – protective caps that sit on the ends of DNA strands to keep the DNA healthy and intact. As telomeres erode, we’re more likely to develop disease, and we age faster; as our telomeres age and expire, our cells expire and so, eventually, do we.
Researchers have also seen a correlation between specific types of adverse childhood experiences and a range of diseases. For instance, children whose parents die, or who face emotional or physical abuse, or experience childhood neglect, or witness marital discord between their parents are more likely to develop cardiovascular disease, lung disease, diabetes, headaches, multiple sclerosis and lupus as adults. Facing difficult circumstances in childhood increases six-fold your chances of having myalgic encephalomyelitis (chronic fatigue immune dysfunction syndrome or CFIDS) as an adult. Kids who lose a parent have triple the risk of depression in their lifetimes. Children whose parents divorce are twice as likely to suffer a stroke later down the line.
Laura and John’s stories illustrate that the past can tick away inside us for decades like a silent time bomb, until it sets off a cellular message that lets us know the body does not forget its history.
Something that happened to you when you were five or 15 can land you in the hospital 30 years later
John’s ACE score would be a 3: a parent often put him down; he witnessed his mother being harmed; and, clearly, his father suffered from an undiagnosed behaviour health disorder, perhaps narcissism or depression, or both.
Laura had an ACE score of 4.
Laura and John are hardly alone. Two-thirds of American adults are carrying wounds from childhood quietly into adulthood, with little or no idea of the extent to which these wounds affect their daily health and wellbeing. Something that happened to you when you were five or 15 can land you in the hospital 30 years later, whether that something was headline news, or happened quietly, without anyone else knowing it, in the living room of your childhood home.
The adversity a child faces doesn’t have to be severe abuse in order to create deep biophysical changes that can lead to chronic health conditions in adulthood.
‘Our findings showed that the 10 different types of adversity we examined were almost equal in their damage,’ says Felitti. He and Anda found that no single ACE significantly trumped another. This was true even though some types, such as being sexually abused, are far worse in that society regards them as particularly shameful, and others, such as physical abuse, are more overt in their violence.
This makes sense if you think about how the stress response functions on an optimal level. You meet a bear in the woods, and your body floods with adrenaline and cortisol so that you can quickly decide whether to run in the opposite direction or stay and try to frighten the bear. After you deal with the crisis, you recover, your stress hormones abate, and you go home with a great story. For Laura and John, though, that feeling that the bear is still out there, somewhere, circling in the woods, stalking, and might strike again any day, anytime – that feeling never disappears.
There are a lot of bears out there. Chronic parental discord; enduring low-dose humiliation or blame and shame; chronic teasing; the quiet divorce between two secretly seething parents; a parent’s premature exit from a child’s life; the emotional scars of growing up with a hypercritical, unsteady, narcissistic, bipolar, alcoholic, addicted or depressed parent; physical or emotional abuse or neglect: these happen in all too many families. Although the details of individual adverse experiences differ from one home to another and from one neighbourhood to another, they are all precursors to the same organic chemical changes deep in the gray matter of the developing brain.
Every few decades, a groundbreaking psychosocial ‘theory of everything’ helps us to develop a new understanding of why we are the way we are – and how we got that way. In the early 20th century, the psychoanalyst Sigmund Freud transformed the landscape of psychology when he argued that the unconscious rules much of our waking life and dreams. Jungian theory taught, among other ideas, that we tend toward introversion or extroversion, which led the American educationalist Katharine Cook Briggs and her daughter Isabel Briggs Myers to develop a personality indicator. More recently, neuroscientists discovered that age ‘zero to three’ was a critical synaptic window for brain development, giving birth to Head Start and other preschool programmes. The correlation between childhood trauma, brain architecture and adult wellbeing is the newest, and perhaps our most important, psychobiological theory of everything.
Today’s research on adverse childhood experiences revolutionises how we see ourselves, our understanding of how we came to be the way we are, why we love the way we do, how we can better nurture our children, and how we can work to realise our potential.
To date, more than 1,500 studies founded on Felitti and Anda’s hallmark ACE research show that both physical and emotional suffering are rooted in the complex workings of the immune system, the body’s master operating control centre – and what happens to the brain during childhood sets the programming for how our immune systems will respond for the rest of our lives.
The unifying principle of this new theory of everything is this: your emotional biography becomes your physical biology, and together, they write much of the script for how you will live your life. Put another way: your early stories script your biology and your biology scripts the way your life will play out.
Unlike previous theories of everything, though, this one has been mind-bogglingly slow to change how we do medicine, according to Felitti. ‘Very few internists or medical schools are interested in embracing the added responsibility that this understanding imposes on them.’
With the ACE research now available, we might hope that physicians will begin to see patients as a holistic sum of their experiences and embrace the understanding that a stressor from long ago can be a health-risk time bomb that has exploded. Such a medical paradigm, which sees adverse childhood experiences as one of many key factors that can play a role in disease, could save many patients years in the healing process.
But seeing that connection takes a little time. It means asking patients to fill out the ACE questionnaire and delving into that patient’s history for insight into sources of both physical and emotional pain. As health-care budgets have become stretched, physicians spend less time interacting one-on-one with patients in their exam rooms; the average physician schedules patients back-to-back at 15-minute intervals.
Still, the cost of not intervening is far greater – not only in the loss of human health and wellbeing, but also in additional healthcare. According to the CDC, the total lifetime cost of child maltreatment in the US is $124 billion each year. The lifetime healthcare cost for each individual who experiences childhood maltreatment is estimated at $210,012 – comparable to other costly health conditions, such as having a stroke, which has a lifetime estimated cost of $159,846 per person, or type-2 diabetes, which is estimated to cost between $181,000 and $253,000.
Further hindering change is the fact that adult physical medicine and psychological medicine remain in separate silos. Utilising ACE research requires breaking down these long-standing divisions in healthcare between what is ‘physical’ and what is ‘mental’ or ‘emotional,’ and that’s hard to achieve. Physicians have been well-trained to deal only with what they can touch with their hands, see with their eyes, or view with microscopes or scans.
Just as physical wounds and bruises heal, just as we can regain our muscle tone, we can recover function in underconnected areas of the brain
However, now that we have scientific evidence that the brain is genetically modified by childhood experience, we can no longer draw that line in the sand. With hundreds of studies showing that childhood adversity hurts our mental and physical health, putting us at greater risk for learning disorders, cardiovascular disease, autoimmune disease, depression, obesity, suicide, substance abuse, failed relationships, violence, poor parenting and early death, we just can’t afford to make such distinctions.
Science tells us that biology does not have to be destiny. ACEs can last a lifetime, but they don’t have to. Just as physical wounds and bruises heal, just as we can regain our muscle tone, we can recover function in underconnected areas of the brain. If anything, that’s the most important take-away from ACE research: the brain and body are never static; they are always in the process of becoming and changing.
Even if we have been set on high-reactive mode for decades or a lifetime, we can still dial it down. We can respond to life’s inevitable stressors more appropriately and shift away from an overactive inflammatory response. We can become neurobiologically resilient. We can turn bad epigenetics into good epigenetics and rescue ourselves. We have the capacity, within ourselves, to create better health. We might call this brave undertaking ‘the neurobiology of awakening’.
Today, scientists recognise a range of promising approaches to help create new neurons (known as neurogenesis), make new synaptic connections between those neurons (known as synaptogenesis), promote new patterns of thoughts and reactions, bring underconnected areas of the brain back online – and reset our stress response so that we decrease the inflammation that makes us ill.
You can find ways to start right where you are, no matter how deep your scars or how long ago they occurred. Many mind-body therapies not only help you to calm your thoughts and increase your emotional and physical wellbeing, but research suggests that they have the potential to reverse, on a biological level, the harmful impact of childhood adversity.
Recent studies indicate that individuals who practice mindfulness meditation and mindfulness-based stress reduction (MBSR) show an increase in gray matter in parts of the brain associated with managing stress, and experience shifts in genes that regulate their stress response and their levels of inflammatory hormones. Other research suggests that a process known as neurofeedback can help to regrow connections in the brain that were lost to adverse childhood experiences.
Meditation, mindfulness, neurofeedback, cognitive therapy, EMDR (eye movement desensitisation and reprocessing) therapy: these promising new avenues to healing can be part of any patient’s recovery plan, if only healthcare practitioners would begin to treat the whole patient – past, present and future, without making distinctions between physical and mental health – and encourage patients to explore all the treatment options available to them. The more we learn about the toxic impact of early stress, the better equipped we are to counter its effects, and help to uncover new strategies and modalities to come back to who it is we really are, and who it was we might have been had we not encountered childhood adversity in the first place.
SOURCE
This is an adapted and reprinted extract from ‘Childhood Disrupted: How Your Biography Becomes Your Biology, and How You Can Heal’ (Atria), by Donna Jackson Nakazawa. Copyright © Donna Jackson Nakazawa, 2015.
Labels: abuse, ACONs, adrenal fatigue, adult children of narcissists, autoimmune, brain development, CFIDS, emotionally abusive mothers, fibromyalgia, illness, migraine, ptsd, toxic parents, trauma, unhealthy, woundedness
Thursday, November 01, 2018
Managing Abandonment Depression in Complex PTSD (C-PTSD)
Here is a map of the layering of defensive reactions to the underlying feelings of abandonment typically found in Complex PTSD. This territory is best viewed through unwinding the dynamics of emotional flashbacks.
Flashbacks are at the deepest level painful layers of reactions - physiological, emotional, cognitive, and behavioral - to the reemerging despair of the childhood abandonment depression. One very common flashback-scenario occurs as follows: Internal or external perceptions of possible abandonment trigger fear and shame, which then activates panicky Inner Critic cognitions, which in turn launches an adrenalized fight, flight, freeze or fawn trauma response (subsequently referred to as the 4F's). The 4F's correlate respectively with narcissistic, obsessive-compulsive, or dissociative defensive reactions.
Flashbacks are at the deepest level painful layers of reactions - physiological, emotional, cognitive, and behavioral - to the reemerging despair of the childhood abandonment depression. One very common flashback-scenario occurs as follows: Internal or external perceptions of possible abandonment trigger fear and shame, which then activates panicky Inner Critic cognitions, which in turn launches an adrenalized fight, flight, freeze or fawn trauma response (subsequently referred to as the 4F's). The 4F's correlate respectively with narcissistic, obsessive-compulsive, or dissociative defensive reactions.
Here is an example of the layered processes of an emotional flashback. A complex PTSD sufferer wakes up feeling depressed. Because childhood experience has conditioned her to believe that she is unworthy and unacceptable in this state, she quickly becomes anxious and ashamed. This in turn activates her Inner Critic to goad her with perfectionistic and endangering messages. The critic clamors: "No wonder no one likes you. Get your lazy, worthless ass going or you'll end up as a wretched bag lady on the street"! Retraumatized by her own inner voice, she then launches into her most habitual 4F behavior. She lashes out at the nearest person as she becomes irritable, controlling and pushy (Fight/ Narcissistic) - or she launches into busy productivity driven by negative, perfectionistic and catastrophic thinking (Flight/Obsessive-Compulsive)- or she flips on the TV and becomes dissociated, spaced out and sleepy (Freeze/ Dissociative)- or she focuses immediately on solving someone's else's problem and becomes servile, self-abnegating and ingratiating (Fawn/Dependent). Unfortunately this dynamic also commonly operates in reverse, creating perpetual motion cycles of internal trauma as 4F acting out also gives the critic endless material for self-hating criticism, which in turn amps up fear and shame and finally compounds the abandonment depression with a non-stop experience of self-abandonment.
Here is a diagram of these dynamics:
Triggered ABANDONMENT DEPRESSION -- FEAR & SHAME -- INNER CRITIC Activation: (Perfectionism & Endangerment) -- 4F's: (Fight, Flight, Freeze or Fawn Response).
Here is a diagram of these dynamics:
Triggered ABANDONMENT DEPRESSION -- FEAR & SHAME -- INNER CRITIC Activation: (Perfectionism & Endangerment) -- 4F's: (Fight, Flight, Freeze or Fawn Response).
Especially noteworthy here is how the inner critic can interact with fear and shame in a particular vicious and escalating cycle.
This article describes a treatment approach that decreases retraumatizing reactivity to the internal affects of the abandonment depression. It guides the client to meet abandonment feelings equanimously by staying somatically present to the physical sensations of depression and fear. This in turn promotes the ability to feel through abandonment experiences without launching into inner critic drasticizing and 4F acting out. R.D. Laing once stated that: "The only pain that can be avoided is the pain that comes from trying to avoid unavoidable pain". In my experience resisting unavoidable encounters with depression and fear accounts for more than the lion's share of the PTSD client's pain.
The etiology of a self-abandoning response to depression. Chronic emotional abandonment is one of the worst things that can happen to a child. It naturally makes her feel and appear deadened and depressed. Functional parents respond to a child's depression with concern and comfort; abandoning parents respond to it with anger, disgust and further abandonment, which in turn create the fear, shame and despair that become characteristic of the abandonment depression. A child who is never comforted when she is depressed has no model for developing a self-comforting response to her own depression. Without a nurturing connection with a caretaker, she may flounder for long periods of time in a depression that can devolve into The Failure to Thrive Syndrome. In my experience failure to thrive is not an all-or-none phenomenon, but rather a continuum that begins with excessive depression and ends in the most severe cases with death. Many PTSD survivors "thrived" very poorly, and perhaps at times lingered near the end of the continuum where they were close to death, if not physically, then psychologically. When a child is consistently abandoned, her developing superego eventually assumes totalitarian control of her psyche and carcinogenically morphs into a toxic Inner Critic. She is then driven to desperately seek connection and acceptance through the numerous processes of perfectionism and endangerment described in my article "Shrinking The Inner Critic in Complex PTSD" (see link for this article: Shrinking the Inner Critic). Her inner critic also typically becomes emotional perfectionistic, as it imitates her parent's contempt of her emotional pain about abandonment. The child learns to judge her dysphoric feelings as the cause of her abandonment. Over time her affects are repressed, but not without contaminating her thinking processes. Unfelt fear, shame and depression are transmuted into thoughts and images so frightening, humiliating and despairing that they instantly trigger escapist 4F acting out. Eventually even the mildest hint of fear or depression, no matter how functional or appropriate, is automatically deemed as danger-ridden and overwhelming as the original abandonment. The capacity to self-nurturingly weather any experience of depression, no matter how mild, remains unrealized. The original experience of parental abandonment devolves into self-abandonment. The ability to stay supportively present to all of one's own inner experience gradually disappears.
We can gradually deconstruct the self-abandoning habit of reacting to depression with fear and shame, inner critic "freak out", and 4F acting out. The processes awaken the psyche's innate, developmentally arrested capacity to respond amelioratively to depression and the fear and shame that attaches to it. It is a long difficult journey however, for even without attachment trauma, feelings of fear and depression are difficult to accept and weather.
The normalcy of depression
We live in a culture that judges fear as despicable, and depression as an unpatriotic violation of the "pursuit of happiness". Taboos about depression even emanate from the psychological establishment, where some schools strip it of its status as a legitimate emotion - dismissing it simplistically as mere negative thinking, or as a dysfunctional state that results from the repression of less taboo emotions like sadness and anger. I believe we must learn to distinguish depressed thinking - which can be eliminated - from depressed feelings - which must sometimes be felt.
Occasional feelings of enervation and anhedonia are normal and existential - part of the admission price to life. Moreover, depression is sometimes an invaluable harbinger of the need to slow down, to drop interiorly into a place that at least allows us to restore and recharge, and at best unfolds into our deepest intuitiveness. One recurring gift that typically comes cloaked in depression is an invitation to grow that necessitates relinquishing a formerly treasured job or relationship that has now become obsolete or moribund. Overreaction to depression essentially reinforces learned toxic shame. It reinforces the individual's notion that, when depressed, he is unworthy, defective and unlovable. Sadly this typically drives him deeper into abandonment-exacerbating isolation. Deep level recovery from childhood trauma requires a normalization of depression, a renunciation of the habit of reflexively reacting to it. Central to this is the development of a capacity to stay in one's body, to stay fully present to all internal experience, to stay acceptingly open to one's emotional, visceral and somatic experiences without 4F acting out. Renouncing this kind of self-abandonment is a journey that often feels frustratingly Sisyphean. It is a labor of self-love and a self-nurturing process of the highest order, but it can feel like an ordeal replete with unspectacular redundancy - with countless, menial experiences of noticing, naming and disidentifying from the unhelpful internal overreactions that depression triggers in us.
Occasional feelings of enervation and anhedonia are normal and existential - part of the admission price to life. Moreover, depression is sometimes an invaluable harbinger of the need to slow down, to drop interiorly into a place that at least allows us to restore and recharge, and at best unfolds into our deepest intuitiveness. One recurring gift that typically comes cloaked in depression is an invitation to grow that necessitates relinquishing a formerly treasured job or relationship that has now become obsolete or moribund. Overreaction to depression essentially reinforces learned toxic shame. It reinforces the individual's notion that, when depressed, he is unworthy, defective and unlovable. Sadly this typically drives him deeper into abandonment-exacerbating isolation. Deep level recovery from childhood trauma requires a normalization of depression, a renunciation of the habit of reflexively reacting to it. Central to this is the development of a capacity to stay in one's body, to stay fully present to all internal experience, to stay acceptingly open to one's emotional, visceral and somatic experiences without 4F acting out. Renouncing this kind of self-abandonment is a journey that often feels frustratingly Sisyphean. It is a labor of self-love and a self-nurturing process of the highest order, but it can feel like an ordeal replete with unspectacular redundancy - with countless, menial experiences of noticing, naming and disidentifying from the unhelpful internal overreactions that depression triggers in us.
A relational approach to healing abandonment
I am a relational therapist, because I believe this journey requires reparative relational experience. Healing Complex PTSD and the attachment disorder that typically accompanies it is an interpersonal journey which needs to be initiated and shepherded by a therapist, partner or trusted friend who has the capacity to stay unreactively present to their own depression and the various affects that attach to it. When a therapist has this level of emotional intelligence, she can guide the client to gradually release the learned habit of automatic affect-rejection and overreaction. A key operation here appears to depend on the eye and ear contact of a bi-hemispheric brain process Daniel Siegel calls "the co-regulation of affect". Safe and empathic eye and voice connection with an individual with "good enough" emotional intelligence provides a working model and a "limbic resonance" to help her stay unreactively present to her depression and the fear that attaches to it. This, in turn, promotes the integration of right and left brain functioning - helping the client to feel and think simultaneously and egosyntonically. Moreover, as Susan Vaughan's book: The Talking Cure avers, such work appears to promote the development of the inner neural circuitry necessary to healthily manage and integrate depression and its attenuated affects.
Guiding the client into somatic mindfulness
Therapists can teach clients the practice of "paying" non-reactive, self-accepting attention to their own affects. Behaviorally, this entails staying aware of, focused on and present to the somatic experience of the abandonment depression. Typically, this process is indirect at first because depression so commonly and instantly morphs into the hyperaroused sensations of fear. Early work then primarily involves staying present to the kinesthetic sensations of fear and noticing the psyche's penchant to dissociate or distract from them. Dissociation can be either the classical right brain distraction of spacing out into reverie, fantasy, TV/computer trance, fogginess or sleep - or it can be the left brain, cognitive dissociation of becoming distracted in obsessive thinking. Particularly nefarious here is the inner critic's penchant for dissociating from and reacting to depression and fear with toxic cognitions and reveries of endangerment and perfectionism. Over and over, the client needs to be guided to rescue himself from dissociation (left and/or right), and to gently bring his awareness back into fully feeling and experiencing the sensations of his fear and noticing his reactions to it. Sensations of fear may range from simple tension and muscular tightness anywhere in the body, especially the alimentary canal - to nauseous, jumpy, wired feelings and shocks of electrification - to shortness of breath, hyperventilation and diarrhea, when it is at its worst. Although these sensations typically feel unbearable at first, persistent focusing on them with non-judgmental, non-eschewing awareness eventually lessens and quiets them. Held non-reactively enough, they are seemingly dissolved, digested and integrated by awareness itself.
It is important to note here that this type of kinesthetic focusing often triggers memories and unworked through feelings of grief about the client's abuse and neglect in his original abandonment. This provides many invaluable opportunities to ameliorate PTSD by more fully grieving the losses of childhood. Therapists can also use the results of such explorations to foster the creation of an egosyntonic and self-compassionate narrative that deconstructs the shame and self-blame the PTSD client typically assigns to her suffering. I describe a safe, efficacious process for this type of grief work in my book: The Tao Of Fully Feeling: Harvesting Forgiveness Out of Blame. With considerable practice, the client eventually begins to exhume, from his fear, an awareness of the more elemental, underlying sensations of depression - sensations exceedingly subtle and barely perceptible at first. These sensations are initially as difficult to stay present to as they are to find. With guided ongoing practice however, focused attending also digests them as they are integrated into consciousness. As practice becomes more proficient, these feelings and sensations of depression sometimes morph into a sense of peace, relaxation and ease. Such relaxation can even, over time, open into a continuum of inner peace that may stretch from profound equanimity to that place of unsurpassable peace that various Eastern pundits describe as the Great Void or Sublime Nothingness.
Inner Somatic Work
Therapeutic gains in diminishing automatic self-abandonment in the face of fear or depression are augmented by individual introspective work. In my personal discovery of this skill, I spent over an hour a day in meditation with my awareness yo-yo vacillating between my body and my mind - between tense sensations of fear and the myriad disturbing mentations of my inner critic. These drasticizing thoughts and visualizations were my critic's outmoded historical interpretations that my feelings and sensations meant that I was in imminent danger of the abandonment of attack or neglect. My critic excoriated me incessantly to strive for safety through productivity and perfection. In the first year of this practice I frequently had to white-knuckle the handles on my chair to stay somatically present to my feelings - to break my adrenalin addiction, to stop myself from launching into my preferred 4F flight response. I had survived my childhood with ADHD-like busyness - with marathons of activity that kept me one step ahead of my fear- and shame-stained depression. Gradually as I used my focused awareness to digest my fear, I experientially discovered the rock bottom underlying core sensations of my abandonment depression itself. Over and over I focused on sensations of heaviness, swollenness, exhaustion, emptiness, hunger, longing, soreness, ache-iness, deadness. Sometimes these sensations were intense, but more often they were very subtle. With time I noticed how instantly my depression scared me and lead me to echo my parents' toxic shaming: "You're bad, worthless, useless, defective, ugly, despicable". Blessedly, with ongoing practice, I gradually learned to disidentify from the toxic vocabulary of the critic. I found myself more accurately naming these revisited childhood feelings: "Small, helpless, lonely, unsupported, unloved, needy" (as in profoundly unsuccessful in getting my needs for emotional comfort met).
Camouflaged Depression
Feelings of depression sometimes mimic gnawings of hunger, especially the emotions of abandonment which commonly masquerade as physiological sensations. Feeling very hungry a hour or two after a big meal is an almost certain signal of abandonment feelings and not real hunger. As much as this hunger appears to be about food, it is actually an emotional hunger - an emotional longing for safe, nurturing connection and for the satiation of abandonment. Even after a decade of practice, I still find it difficult to differentiate this type of attachment hunger from physical hunger. One, often, reliable clue is that the sensation of longing for the nourishment of attachment is usually in my small intestine, while physical hunger's locus is a little higher up in my stomach. (I believe the extreme longing for sex and/or love typical of sex and love addiction can similarly be an encounter with our abandonment depression, especially when no amount of affection or sexual attention from another seems to fill the void of longing).
On a parallel with false hunger, feeling tired is sometimes an emotional experience of the abandonment depression, and entirely unrelated to sleep deprivation - although over time the two can easily become confusingly intertwined. The emotional tiredness of not resting enough in the comfort of safe attachment and belonging, often masquerades as physiological tiredness. When our abandonment depression is unremediated, any kind of tiredness - emotional or physical - commonly triggers us into fear, which the inner critic translates into endangerment and imperfection, and the accompanying adrenalization launches us into one of the 4F responses.
Pseudo-Cyclothymia
It is a sad irony that reacting to emotional tiredness in this way can eventually exacerbate it into real physical exhaustion via a process I call the The Cyclothymic Two-Step. PTSD sufferers with a primary or secondary flight response frequently overreact to their tiredness with workaholic or busyholic action. They run so compulsively from their depression, that they eventually exhaust themselves physically, and at times become too depleted or sick to continue running. When this occurs, they collapse into an experience of abandonment so painful, that they re-launch desperately into "flight" speed at the first sign of replenished adrenalin. I have witnessed a number of such clients misdiagnose themselves as bipolar because of the extremes that ensue from desperately pursuing the adrenalin high and eschewing the abandonment low.
Adrenalization often becomes addictive because it self-medicates and counteracts the emotional tiredness that emanates from undigested and unworked through abandonment feelings. Especially noteworthy here is the endless and expensive journey that many survivors undergo trying to remedy emotional tiredness with physiologically-based medical treatments. Even worse, the short-lived (if any) improvements of such an approach increasingly augments the shame and self-hate of the sufferer over time: "What's wrong with me. I've changed everything in my diet and in my sleep and exercise schedule. I've seen every type of practitioner imaginable and I am still waking up feeling dead tired." It is a subtle, hard acquired skill, but learning to self-compassionately focus on the inexorable somatic experiences of sometimes feeling tired, bad, lonely, or depressed is the only way out of this cul-de-sac of self-destructive and unwarranted efforting. In this regard, the notable AA 12 Step acronym, HALT - Hungry, Angry, Lonely, Tired - can remind us to stop and pause introspectively to determine whether our abandonment depression has been triggered and needs the quiet, internal, self-compassionate attention described above.
We can sometimes gain motivation for this difficult work by seeing our depressed feelings as messages from our developmentally arrested child who is flashing back to his abandonment in hopes that his adult self will respond to him in a more comforting, compassionate and appropriate way.
Through such practice, clients can gradually achieve the healing that the Buddhists call separating necessary suffering (normal depression) from unnecessary suffering (the internal hopelessness, shame and fear, and the life-constricting acting out that ensues from unnecessary engagements with the critic and the 4F's).
Labels: abandonment, adrenal fatigue, adult children of narcissists, c-ptsd, complex ptsd, depression, shame, toxic guilt, trauma bonding
