Good Overview of PTSD

My Career was based on the belief that all Mental Health Issues / Illnesses were trauma based - hence my use of  the Trauma Model of Care - so out of the core feature of emotional trauma comes PTSD aka all mental illnesses. Posttraumatic Stress Disorder WHAT IS POSTRAUMATIC STRESS DISORDER or PTSD? PTSD is an anxiety disorder that involves a very specific reaction following exposure to an extremely traumatic event or stressor (e.g., a serious injury to oneself, witnessing an act of violence, hearing about something horrible that has happened to someone you are close to). Data from a number of studies indicates that between 51 and 89 percent of adults are exposed to at least one potentially traumatizing event in their lifetime. An immediate stress reaction (including many of the symptoms of PTSD) that disrupts daily functioning for a short time is a normal response to a traumatic event. How a person copes with his or her immediate reaction to the trauma, as well as other psychological and biological factors appear to contribute to the risk of developing more prolonged difficulties, including full blown PTSD. The prevalence rates of PTSD vary depending on the study reviewed. In one study, the lifetime prevalence rate of PTSD was 8%. OFFICIAL CRITERIA FOR PTSD Exposure to a Trauma – The person has been exposed to a trauma, in which he or she has experienced or witnessed an event involving the threat of death, serious injury, or a threat to the physical well-being of oneself or others. Note that only physical threats count in the definition of a trauma in PTSD. Situations that represent a psychological threat (e.g., a divorce, being criticized by a loved one, being teased) are not considered traumas in the definition of PTSD, even though they may lead to difficulties for the individual. A Response of Fear, Helplessness, or Horror – The immediate response to the trauma is one of fear, helplessness or horror (in children, it may be a response involving disorganized behavior or agitation). So, if an individual’s response to the trauma is one primarily of sadness or loss rather than fear (this is often the case following the death of a loved one who was ill), PTSD would likely not be diagnosed. Symptoms of Re-Experiencing the Trauma – The individual persistently re-experiences the event in at least one of the following ways: 1. Recurrent and disturbing memories, images, and thoughts about the trauma. 2. Recurrent and disturbing dreams or nightmares about the trauma. 3. Acting or feeling as if the trauma was occurring again (these experiences are often called flashbacks). This may include hallucinations (e.g., seeing things or hearing voices that were present during the trauma, even though they are not really there currently), misinterpreting things that are heard or seen (e.g., being convinced that the sound of fireworks in the distance is actually the sound of gunfire). 4. Becoming emotionally upset upon being exposed to reminders of the trauma, including physical sensations that were present during the trauma or situational reminders (e.g., the street where the trauma occurred, the anniversary of the trauma). 5. Becoming physically aroused (e.g., breathless, heart racing) upon being exposed to reminders of the trauma, including physical sensations that were present during the trauma or situational reminders (e.g., the street where the trauma occurred, the anniversary of the trauma). Symptoms of Avoidance and Emotional Numbing – The individual avoids triggers and reminders of the trauma, or experiences a sense of emotional numbing, as indicated by at least three of the following features: 1. Avoiding thoughts, feelings, or conversations that remind the individual of the trauma. 2. Avoiding activities, places or people that remind the individual of the trauma. 3. An inability to remember important aspects of the trauma. 4. A lack of interest or participation in significant activities, such as socializing, work, and hobbies. 5. Feeling detached or different from others. 6. An inability to enjoy things or to experience positive emotions (e.g., feeling “flat”). 7. A sense that one’s future will be shortened. For example, it may be difficult to imagine having a career, getting married, having children, or having a normal life span. Symptoms of Increased Arousal and Vigilance – The individual has symptoms of arousal and vigilance that were not present before the trauma, as indicated by at least two of the following features: 1. Difficulty falling or staying asleep. 2. Feeling irritable and grumpy, or experiencing outbursts of anger and temper tantrums. 3. Difficulty concentrating. 4. Hypervigilance (e.g., always being on guard, looking over one’s shoulder while walking down the street, etc.) 5. Becoming startled very easily (e.g., jumping when the telephone rings). The problem must last at least one month for a diagnosis of PTSD to be assigned. The individual’s fear, anxiety, avoidance, or other PTSD symptoms cause significant distress (i.e., it bothers the person that he or she has the symptoms) or significant interference in the person’s day-to-day life. For example, the difficulties may make it difficult for the person to perform important tasks at work, meet new friends, attend classes, or interact with others. WHAT IS ACUTE STRESS DISORDER? Like PTSD, acute stress disorder is an anxiety disorder that involves a very specific reaction following exposure to a traumatic event or stressor (e.g., a serious injury to oneself, witnessing an act of violence, hearing about something horrible that has happened to someone you are close to). However, the duration of acute stress disorder is shorter than that for PTSD. For a diagnosis of acute stress disorder, the full range of symptoms must be present for at least two days and no more than four weeks. If the symptoms persist for longer than four weeks, a diagnosis of PTSD should be considered. It is normal to have some symptoms following a trauma and a diagnosis of acute stress disorder is given only if all the necessary features are present. OFFICIAL CRITERIA FOR ACUTE STRESS DISORDER Exposure to a Trauma – The person has been exposed to a trauma, in which he or she has experienced or witnessed an event involving the threat of death, serious injury, or a threat to the physical well-being of oneself or others. Note that only physical threats count in the definition of a trauma in acute stress disorder. Situations that represent a psychological threat (e.g., a divorce, being criticized by a loved one, being teased) are not considered traumas in the definition of acute stress disorder, even though they may lead to difficulties for the individual. A Response of Fear, Helplessness, or Horror – The immediate response to the trauma is one of fear, helplessness or horror (in children, it may be a response involving disorganized behavior or agitation). So, if an individual’s response to the trauma is one primarily of sadness or loss rather than fear (this is often the case following the death of a loved one who was ill), acute stress disorder would likely not be diagnosed. Symptoms of Dissociation or Decreased Awareness – During or after the trauma, the individual experiences at least three of the following features: 1. A feeling of emotional numbness (a lack of emotional response), or feeling detached. 2. Reduced awareness of surroundings (e.g., feeling “in a daze”). 3. Feelings of unreality (e.g., feeling detached from one’s surroundings, perceptual changes, such as one’s surroundings seeming dream-like). 4. Depersonalization (i.e., feeling detached from one’s body or self). 5. Inability to remember one or more important aspects of the trauma. Symptoms of Re-Experiencing – The individual persistently re-experiences the event in at least one of the following ways: 1. Recurrent and disturbing memories, images, and thoughts about the trauma. 2. Recurrent and disturbing dreams or nightmares about the trauma. 3. Acting or feeling as if the trauma was occurring again (these experiences are often called flashbacks). This may include hallucinations (e.g., seeing things or hearing voices that were present during the trauma, even though they are not really there currently), misinterpreting things that are heard or seen (e.g., being convinced that the sound of fireworks in the distance is actually the sound of gunfire). 4. Becoming emotionally upset upon being exposed to reminders of the trauma, including physical sensations that were present during the trauma or situational reminders (e.g., the street where the trauma occurred, the anniversary of the trauma). Avoidance of thoughts, feelings, conversations, activities, places, or people that remind the individual of the trauma. Significant symptoms of anxiety or arousal (e.g., difficulty sleeping, feeling irritable, poor concentration, hypervigilance, being easily startled, feeling restless or unable to sit still). The problem lasts at least two days and no more than four weeks, and it begins within four weeks of experiencing the traumatic event. The individual’s fear, anxiety, avoidance, or other acute stress disorder symptoms cause significant distress (i.e., it bothers the person that he or she has the symptoms) or significant interference in the person’s day-to-day life (e.g., work, school, social functioning). For example, the symptoms may make it difficult to get much needed help, or to tell family members or the authorities about the trauma. It must be established that the acute stress disorder symptoms are not being caused by a medical condition (e.g., thyroid condition, diabetes, heart condition) or by a drug or substance (e.g., cocaine use, caffeine, withdrawal from alcohol). In addition, they cannot simply be due to a worsening of another psychological problem. EXAMPLES OF TRAUMAS THAT CAN LEAD TO PTSD or ACUTE STRESS DISORDER • military combat • violent personal assault (e.g., sexual assault, physical attack, mugging, robbery) • being kidnapped or taken hostage • torture • incarceration as a prisoner of war or in a concentration camp • natural disaster (earthquake, fire, tornado, hurricane) • terrorist attack • severe automobile accident • severe accident at work or in the home • sexual abuse during childhood • sexual assault or abuse • being diagnosed with a life-threatening illness • unexpectedly observing serious injury or unnatural death of another person EFFECTIVE TREATMENTS FOR PTSD and ACUTE STRESS DISORDER Biological treatments (i.e., medications), psychological treatments, and their combination, have been found to be effective for treatment of PTSD and related problems. Biological Treatments A number of medications have been shown to be useful for treating PTSD. The most common of these are the antidepressants (see list below), particularly the SSRIs. In addition, mood stabilizers such as divalproex (Depakote) may be used in cases where a person experiences only a partial response to an antidepressant. The addition of a mood stabilizer (along with an antidepressant) is also recommended for particular PTSD symptoms, such as marked irritability or anger. In addition to antidepressants and mood stabilizers, anti-anxiety medications such as alprazolam (Xanax), clonazepam (Klonapin or Rivotril), and lorazepam (Ativan) may be useful on a short term basis. Caution should be used with these medications, due to the potential for dependence. Type of Medication Generic Name Brand Name Citalopram Celexa SSRI Antidepressant Fluoxetine Prozac Fluvoxamine Luvox Paroxetine Paxil Sertraline Zoloft Tricyclic Antidepressant Amitriptyline Elavil Imipramine Tofranil Other Antidepressant Nefazodone Serzone Venlafaxine Effexor Medications are warranted particularly when symptoms are significant and daily functioning is severely impaired, the person has severe insomnia, an additional psychiatric condition (e.g., depression) is present, or if significant symptoms are still present following psychological treatment. Among medications, selective serotonin reuptake inhibitors (SSRIs) have the most data supporting them. These medications are most effective for PTSD in nonveterans. When symptoms have lasted less than three months (acute PTSD) it is generally recommended that medication be continued for 6 to 12 months. When symptoms have lasted more than three months (chronic PTSD) it is generally recommended that medication be continued for one to two years. Longer treatment may be required if significant symptoms are still present. The decision of whether to take medication for PTSD, and which medication to take should be based on the individual’s past treatment history, the individual’s medical history, possible interactions between the medication and other drugs that person may be taking, potential side effects, and any other relevant factors. Psychological Treatments The psychological treatment shown to be most effective for PTSD is cognitive behavior therapy (CBT). CBT for PTSD involves a number of useful strategies including: Psychoeducation – includes a number of components: information about common reactions to trauma (e.g., that it is normal to be upset and have distressing symptoms shortly after a trauma); emotional support and reassurance to help relieve irrational feelings of guilt; encouragement to seek support from family and friends by talking about the trauma and associated feelings; education for the family about the importance of listening and being tolerant of the individual’s emotional reactions and need to retell the event. Anxiety Management – involves teaching skills to help manage the symptoms of PTSD including relaxation and breathing retraining, positive self-talk, and assertiveness training. Cognitive Therapy – involves identifying anxious thoughts (e.g., guilty thoughts about the trauma, exaggerated thoughts about danger) and replacing them with more realistic thoughts. For example, if an individual has the thought “I will never be safe again, the world is a very dangerous place,” cognitive therapy would focus on helping the individual to consider evidence for and against the belief. Exposure to Trauma Cues and Feared Situations – involves confronting feared situations or triggers repeatedly, in a gradual way, until fear is extinguished. For example, a person who is avoiding driving after being in a very severe car accident is encouraged to drive again, beginning in easier situations (e.g., light traffic) and gradually progressing to more difficult situations (e.g., heavy traffic, night, in the rain). Exposure to Trauma Memories – involves confronting trauma memories repeatedly until they are no longer associated with extreme distress. This strategy is combined with anxiety management strategies and cognitive therapy. For children, play therapy is often used to treat PTSD. Topics are addressed in an indirect manner using games to facilitate processing of traumatic memories. Controversial Psychological Treatments for PTSD and Related Problems Eye Movement Desensitization and Reprocessing (EMDR) – EMDR is a therapy that was developed in the late 1980s by psychologist, Francine Shapiro. It involves bringing to mind an image of a traumatic event while visually tracking a therapist’s finger as it moves back and forth in front of the patient’s visual field. A number of variations on this treatment have been developed, including tracking a light moving back and forth, or listening to tones alternating from one ear to the other. Research on EMDR suggests that it does lead to a reduction in PTSD symptoms, though it is no more effective than other forms of CBT. Interestingly, the eye movements and other forms of sensory stimulation appear to have nothing to do with the effectiveness of EMDR. Critics of EMDR have argued persuasively that the main reason EMDR works is the exposure to the traumatic image. In other words, EMDR is thought to be no more than “dressed up” form of imaginal exposure. Critical Incidence Stress Debriefing (CISD) – CISD is a procedure that is often used with groups of individuals within one to three days of having experienced a trauma (e.g., a natural disaster, accident, terrorist attack, etc.). The treatment encourages trauma victims to share their thoughts and experiences, and the therapist discusses thoughts and emotional reactions that the individuals are likely to experience. Participants are typically encouraged to stay with the procedure. The strategies listed here are similar to those listed earlier in the section on psychoeducation for PTSD. The difference is that in CISD, all trauma victims are exposed to the treatment, not just those who develop PTSD or other adjustment problems. The data on CISD are mixed, but generally not supportive of the procedure. Some studies have shown the people having undergone CISD following a trauma are no better off than people who did not receive this treatment. Furthermore, a few studies have actually shown that people who undergo CISD are functioning more poorly later on, relative to those who have not undergone the procedure. Critics of CISD have recommended against using this procedure for all trauma victims. Instead, they encourage professionals to help victims with their basic needs (e.g., contacting insurance companies, etc.), provide support, and allow them to discuss the trauma only if they want to. More intensive treatment should be reserved for people who are still experiencing anxiety symptoms some time after the trauma has passed. Combined Treatments There is a lack of research comparing CBT to medications or examining the combination of these approaches for treating PTSD. In other anxiety disorders, CBT, medications, and combined treatments are often similar in effectiveness across groups of individuals, although any one person may respond better to one of these approaches than to the other treatments. For most anxiety disorders, the effects of CBT tend to be more long lasting than the effects of medication. In other words, once treatment has stopped, anxious individuals who have been treated with CBT are less likely to experience a return of their symptoms than are individuals who have been treated with medication. In light of these findings, CBT may be the best approach initially. For individuals who do not respond to CBT, adding an SSRI is a reasonable next step in treatment. More research is needed before recommendations regarding the relative and combined effectiveness of medications and CBT can be made with confidence. DID YOU KNOW ...? • PTSD is generally more severe or long-lasting when the trauma is of human design (e.g., torture, terrorist attack) vs. a natural disaster (e.g., earthquake) • The chance of developing PTSD increases as the severity, duration, and physical proximity to the trauma increases. Other factors that increase the risk for developing PTSD include history of previous trauma and negative reactions from friends and family. • When the duration of PTSD symptoms is less than three months it is termed acute. If the duration of PTSD symptoms is three months or more it is termed chronic. • Although symptoms of PTSD usually begin within the first three months after the trauma, there may be a delay of months or even years before symptoms appear. Delayed onset of PTSD is said to have occurred when the symptoms begin at least six months after the trauma. • PTSD is related to increased rates of major depressive disorder, substance-related disorders, and other anxiety disorders. • Research on individuals at-risk for the development of PTSD has found the highest rates of onset (30 to 50%) in survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide. • PTSD can occur at any age, including childhood. • Individuals with PTSD often report painful feelings of guilt about surviving when others did not or about things they had to do to survive. SUGGESTED READINGS Readings for Consumers 1. Allen, J.G. & Allen J.A. (1999). Coping with trauma: A guide to self-understanding. New York, NY: American Psychiatric Press. 2. Foa, E.B., Davidson, J.R.T., Frances, A., & Ross, R. (1999). Expert consensus treatment guidelines for posttraumatic stress disorder: A guide for patients and families. Journal of Clinical Psychiatry, 60, 1-8. 3. Herman, J.L. (1997). Trauma and recovery. Basic Books 4. Matsakis, A. (1996). I can’t get over it: A handbook for trauma survivors, Second Edition. Oakland, CA: New Harbinger Publications. 5. Matsakis, A. (1998). Trust after trauma: A guide to relationships for survivors and those who love them. Oakland, CA: New Harbinger Publications. 6. Matsakis, A. (1999). Survivor guilt. Oakland, CA: New Harbinger Publications. 7. Rosenbloom, D., Williams, M.B. & Watkins, B.E. (1999). Life After Trauma: A Workbook for Healing. New York, NY: Guilford Press. 8. Rothbaum, B.O., & Foa, E.B. (2000). Reclaiming your life after rape: A cognitive-behavioral therapy for PTSD. San Antonio, TX: The Psychological Corporation. 9. Williams, M.B., Poijula, S., & Nurmi, L.A. (2002). The PTSD workbook. Oakland, CA: New Harbinger Publications Readings for Professionals 1. Bryant, R.A., & Harvey, A.G. (2000). Acute stress disorder: A handbook of theory, assessment, and treatment. Washington, DC: American Psychological Association. 2. Carlson, E.B. (1997). Trauma assessments: A clinician’s guide. New York, NY: Guilford Publications. 3. Foa, E.B., Keane, T.M., & Friedman, M.J. (2000). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. New York, NY: Guilford Publications. 4. Foa, E.B., & Rothbaum, B.O. (1998). Treating the trauma of rape: Cognitive behavioral therapy for PTSD. New York, NY: Guilford Press. 5. Foy, D.W. (Ed.) (1992). Treating PTSD: Cognitive behavioral strategies. New York, NY: Guilford Press. 6. Litz, B.T., Miller, M.W., Ruef, A.M., & McTeague, L.M. (2002). Exposure to trauma in adults. In. M.M. Antony and D.H. Barlow (Eds.) Handbook of assessment and treatment planning for psychological disorders. New York, NY: Guilford Press. 7. Meichenbaum, D. (1994). A clinical handbook/practical therapist manual for assessing and treating adults with post-traumatic stress disorder (PTSD). Waterloo, ON: Institute Press. 8. Najavits, L.M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: Guilford. 9. Resick, P.A., & Calhoun, K.S. (2001). Post-traumatic stress disorder. In D.H. Barlow, (Ed.), Clinical handbook of psychological disorders, third edition. New York: Guilford Press. 10. Resick, P.A., & Schnicke, M.K. (1996). Cognitive processing therapy for rape victims: A treatment manual. Newbury Park, CA: Sage Publications. 11. Wilson, J.P., Friedman, M.J., & Lindy, J.D. (Eds.) (2001). Treating psychological trauma and PTSD. New York: Guilford. 12. Wilson, J.P., & Keane, T.M. (Eds.) (1997). Assessing psychological trauma and PTSD. New York, NY: Guilford Publications. 13. Yule, W. (Ed.) (1999). Post-traumatic stress disorders: Concepts and therapy. New York: Wiley.

© Randi E. McCabe, PhD and Martin M. Antony PhD This material is provided courtesy of PsychDirect, a public education website of the Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, CANADA. While it may be printed for personal use, written permission of the author is reqyuired for any other purpose.Contact PsychDirect for more information.

Healing the Inner Child

Mental Health –Inner Child  Healing - How to begin

"Recovery involves bringing to consciousness those beliefs and attitudes in our subconscious that are causing our dysfunctional reactions so that we can reprogram our ego defenses to allow us to live a healthy, fulfilling life instead of just surviving.  So that we can own our power to make choices for ourselves about our beliefs and values instead of unconsciously reacting to the old tapes.  Recovery is consciousness rising.  It is en-light-en-ment - bringing the dysfunctional attitudes and beliefs out of the darkness of our subconscious into the Light of consciousness.

On an emotional level the dance of Recovery is owning and honoring the emotional wounds so that we can release the grief energy - the pain, rage, terror, and shame that is driving us. 

That shame is toxic and is not ours - it never was!  We did nothing to be ashamed of - we were just little kids.  Just as our parents were little kids when they were wounded and shamed, and their parents before them, etc., etc.  This is shame about being human that has been passed down from generation to generation.

There is no blame here, there are no bad guys, only wounded souls and broken hearts and scrambled minds."

(Quotations in this color are from Codependence: The Dance of Wounded Souls)

Inner child work is in one way detective work.  We have a mystery to solve.  Why have I have I been attracted to the type of people that I have been in relationship with in my life?  Why do I react in certain ways in certain situations?  Where did my behavior patterns come from?  Why do I sometimes feel so: helpless; lonely; desperate; scared; angry; suicidal; etc.

Just starting to ask these types of questions, is the first step in the healing process.  It is healthy to start wondering about the cause and effect dynamics in our life. 

In our codependence, we reacted to life out of a black and white, right and wrong, belief paradigm that taught us that is was shameful and bad to be wrong, to make mistakes, to be imperfect - to be human.  We formed our core relationship with our self and with life in early childhood based on the messages we got, the emotional trauma we suffered, and the role modeling of the adults around us.  As we grew up, we built our relationship with self, other people, and life on the foundation we formed in early childhood.

When we were 5, we were already reacting to life out of the emotional trauma of earlier ages.  We adapted defenses to try to protect ourselves and to get our survival needs met.  The defenses adapted at 5 due to the trauma suffered at earlier ages led to further trauma when we were 7 that then caused us to adjust our defenses that led to wounding at 9, etc., etc., etc.

Toxic shame is the belief that there is something inherently wrong with who we are, with our being.  Guilt is "I made a mistake, I did something wrong."  Toxic shame is:  "I am a mistake. There is something wrong with me."

It is very important to start “awakening to the Truth” (Basic Goodness) that there is nothing inherently wrong with our being - it is our relationship with our self and with life that is dysfunctional.  And that relationship was formed in early childhood.

The way that one begins inner child healing is simply to become aware. 

To become aware that the governing principle in life is cause and effect.

To become aware that our relationship with our self is dysfunctional.

To become aware that we have the power to change our relationship with our self.

To become aware that we were programmed with false beliefs about the purpose and nature of life in early childhood - and that we can change that programming.

To become aware that we have emotional wounds from childhood that it is possible to get in touch with and heal enough to stop them from dictating how we are living our life today. 

That is the purpose of inner child healing - to stop letting our experiences of the past dictate how we respond to life today.  It cannot be done without revisiting our childhood.

We need to become aware, to raise our consciousness.  To create a new level of consciousness for ourselves that allows us to observe ourselves. The Past Present Linkage. We have to Back to Go Forward

It is vitally important to start observing ourselves - our reactions, our feelings, our thoughts - from a detached witness place that is not shaming.

We all have an inner critic, (Super-Ego) a critical parent voice that beats us up with shame, judgment, and fear.  The critical parent voice developed to try to control our emotions and our behaviors because we got the message there was something wrong with us and that our survival would be threatened if we did, said, or felt the "wrong" things.

Self- Love – Self- Hate

It is vital to start learning how to not give power to that critical shaming voice.  We need to start observing ourselves with compassion.  This is almost impossible at the beginning of the inner child healing process - having compassion for our self, being loving to our self, is the hardest thing for us to do.  Love others as we love ourselves.

So, we need to start observing ourselves from at least a more neutral perspective.  Become a scientific observer, a detective - the Sherlock Holmes of your own inner process as it were. We need to go on ‘Dig’ – We have to make conscious the Unconscious

We need to start being that detective, observing ourselves and asking ourselves where that reaction / thought / feeling is coming from.  Why am I feeling this way?  What does this remind me of from my past?  How old do I feel right now?  How old did I act when that happened?

One of the amazing things about this process is that as one starts to become more aware of our own reactions, we also start to become more aware of others.  We start seeing when the people in our lives are reacting like a little kid, or adolescent, or teenager, or whatever.  The more we become aware of their reactions, the easier it becomes to stop taking their behavior personally - which then makes it easier to detach from our own reactions and observe ourselves. The Self- Observing Self

It is an amazing, miraculous process that can help us to change our relationship with our self, with other people, and with life.  Becoming more aware, becoming conscious of a new way of looking at ourselves and life is the beginning of a process of learning to forgive and Love our self. Through Self-Awareness

A detective always looks at cause and effect.  By becoming a detective, solving the mystery of why we have lived our lives as we have, we can start to free ourselves from our past.  By doing the inner child healing, we can start to learn how to really be alive instead of just surviving and enduring.

Inner Child Healing - Why do it?

"We are set up to be emotionally dysfunctional by our role models, both parental and societal.  We are taught to repress and distort our own emotional process.  We are trained to be emotionally dishonest when we are children.

This emotional repression and dishonesty causes society to be emotionally dysfunctional.  Additionally, urban based civilization has completely disregarded natural laws and natural cycles such as the human developmental process.  There is no integration into our culture of the natural human developmental process.

As just one blatant example of this, consider how most so called primitive or aboriginal societies react to the onset of puberty.  When a girl starts menstruating, ceremonies are held to celebrate her womanhood - to honor her coming into her power, to honor her miraculous gift of being able to conceive.  Boys go through training and initiation rites to help them make the transition from boyhood to manhood. Example Outward Bound. Look at what we have in our society: junior high school - a bunch of scared, insecure kids who torture each other out of their confusion and fear, and join gangs to try to find an identity.

This lack of integration of the natural human growth process causes trauma.  At each stage of the developmental process we were traumatized because of the emotionally repressive, spiritually hostile environment into which we were born.  We went into the next stage incomplete and then were retraumatized, were wounded again." We can return to the beginning through Infinite Regression

(Quotations in this color are from Codependence: The Dance of Wounded Souls)

For all of the so called progress of our modern societies, we still are far behind most aboriginal cultures in terms of respect for individual rights and dignity in some kind of balance with the good of the whole.  (I am speaking here of tribal aboriginal societies - not urbanized ones.)  Nowhere is this more evident in terms of our relationship to our children.

Modern civilizations - both Eastern and Western - are no more than a generation or two removed from the belief that children were property.  This, of course, goes hand in hand with the belief that women were property.  The idea that children have rights, individuality, and dignity is relatively new in modern society.  The predominant and underlying belief, as it has been manifested in the treatment of children, has been that children are extensions of, and tools to be used by, their parents.

A very telling insight into the basic beliefs underlying Western attitudes towards children is shared by inner child pioneer Alice Miller in her book The Drama of The Gifted Child.  She shares how the 19th Century German Philosophers who laid the groundwork for modern psychology, emphasized the importance of stamping out a child's "exuberance."  In other words, a child's spirit must be crushed in order to control them.

Children are to be seen and not heard.  Spare the rod and spoil the child.

It is only in very recent history, that our society has even recognized child abuse as a crime instead of an inherent right of the parent.  The concept of healthy parenting as a skill to be learned is very new in society.

Any society that does not respect and honor individual human dignity is going to be a society that does not meet the essential needs of its members.  Patriarchal societies, that demean and degrade women and children, are dysfunctional in their essence.

We form our core relationship with our self and with life - and of course with other people - in early childhood in reaction to the messages we get from the way we are treated and the role modeling of the other people in our lives.  We then have no training or initiation ceremonies, no culturally approved grieving process, to help us let go of the old programming and learn a different relationship with our self and life.  So, we build upon the foundation laid in early childhood.

As adults, we react to the programming of our childhood. To contend that our childhood emotional wounds have not affected our adult lives is ridiculous.  To think that our early programming has not influenced the way we have lived is to be in denial to an extreme.

Because societies standards for what constitutes success are dysfunctional, many people can be pointed out who "have risen above" their past to be a success.  It is those people, who are supposedly successful, that are running the world.  How good a job do you think they are doing?

It is our world leaders, reacting out of the fear and insecurity of their inner children, and the dysfunctional belief systems underlying civilization, who give us war and poverty, billionaires and homelessness.

My book, Codependence: The Dance of Wounded Souls, evolved out of a talk that I first did in 1991.  In the talk, I stated that I would like to one day make up a bumper sticker that said "Work for World Peace, Heal Your Inner Child."  I did have these bumper stickers printed when I published my book.  It is, I believe, an essential Truth.  We will never have world peace, or a civilized society which is based upon respect and dignity - to say nothing of Love - unless we can heal our relationships with ourselves enough to learn to Love and respect our self.

We cannot Love our neighbor as our self, as long as we are judging and comparing our self to them in order to feel good about our self.  We cannot have a society that meets the essential emotional and spiritual needs of its members as long as we are reacting to life in alignment with rules of interaction that we learned in junior high school.

We are all connected - not separate.  We all have worth and deserved to be treated with dignity and respect - instead of earning societies version of worth by stepping on and over our fellow humans, to say nothing of destroying the planet we live on.

It is through healing our inner child wounds that we can learn to respect and Love our self so that we can know how to treat others with respect and Love.  It is through healing our inner children that we can save our planet and evolve into a society that does meet the essential needs of its members.

Inner child healing is not some fad or pop psychology.  Inner child healing is the only way to empower ourselves to stop living life in reaction to the past. Reactive vs. Proactive. We have been ignoring history and repeating it for centuries.  If we are going to have a chance to reverse the self destructive patterns of human kind, it is going to come from individuals healing self.  By healing our inner child wounds, we can change the world.

Infinite Regression - "It is through having the courage and willingness to revisit the emotional "dark night of the soul" that was our childhood, that we can start to understand on a gut level why we have lived our lives as we have.

It is when we start understanding the cause and effect relationship between what happened to the child that we were, and the effect it had on the adult we became, that we can truly start to forgive ourselves. It is only when we start understanding on an emotional level, on a gut level, that we were powerless to do anything any differently than we did that we can truly start to Love ourselves. 

The hardest thing for any of us to do is to have compassion for ourselves.  As children we felt responsible for the things that happened to us.  We blamed ourselves for the things that were done to us and for the deprivations we suffered. There is nothing more powerful in this transformational process than being able to go back to that child who still exists within us and say, "It wasn't your fault.  You didn't do anything wrong, you were just a little kid.""  Healing of Guilt and Shame

"As long as we are judging and shaming ourselves we are giving power to the disease. We are feeding the monster that is devouring us
. 
We need to take responsibility without taking the blame. We need to own and honor the feelings without being a victim of them. 

We need to rescue and nurture and Love our inner children - and STOP them from controlling our lives. STOP them from driving the bus!  Children are not supposed to drive; they are not supposed to be in control. 

The Child will become the Father of the Man

And they are not supposed to be abused and abandoned. We have been doing it backwards. We abandoned and abused our inner children. Locked them in a dark place within us. And at the same time let the children drive the bus - let the children's wounds dictate our lives." 

Our parents were our higher powers.  We were not capable of understanding that they might have problems that had nothing to do with us.  So it felt like it was our fault. 

We formed our relationship with ourselves and life in early childhood.  We learned about love from people who were not capable of loving in a healthy way because of their unhealed childhood wounds.  Our core / earliest relationship with our self were formed from the feeling that something is wrong and it must be me.  At the core of our being is a little kid who believes that he/she is unworthy and unlovable.  That was the foundation that we built our concept of "self" on. 

Children are master manipulators. That is their job - to survive in whatever way works.  So we adapted defense systems to protect our broken hearts and wounded spirits.  The 4 year old learned to throw tantrums, or be real quiet, or help clean the house, or protect the younger siblings, or be cute and funny, etc.  Then we got to be 7 or 8 and started being able to understand cause and effect and use reason and logic - and we changed our defense systems to fit the circumstances.  Then we reach puberty and didn't have a clue what was happening to us, and no healthy adults to help us understand, so we adapted our defense systems to protect our vulnerability.  And then we were teenagers and our job was to start becoming independent and prepare ourselves to be adults so we changed our defense systems once again.

Robert choose “quietism to cope and survive.

It is not only dysfunctional; it is ridiculous to maintain that what happened in our childhood did not affect our adult life.  We have layer upon layer of denial, emotional dishonesty, buried trauma, unfulfilled needs, etc., etc.  Our hearts were broken, our spirit's wounded, our minds programmed dysfunctional.  The choices we have made as adults were made in reaction to our childhood wounds / programming - our lives have been dictated by our wounded inner children. 

(History, politics, "success" or lack of "success," in our dysfunctional society/civilizations can always be made clearer by looking at the childhoods of the individuals involved.  History has been, and is being, made by immature, scared, angry, hurt individuals who were/are reacting to their childhood wounds and programming - reacting to the little child inside who feels unworthy and unlovable.) 

It is very important to realize that we are not an integrated whole being - to ourselves.  Our self concept is fractured into a multitude of pieces.  In some instances we feel powerful and strong, in others weak and helpless - that is because different parts of us are reacting to different stimuli (different "buttons" are being pushed.)  The parts of us that feel weak, helpless, needy, etc. are not bad or wrong - what is being felt is perfect for the reality that was experienced by the part of our self that is reacting (perfect for then - but it has very little to do with what is happening in the now).  It is very important to start having compassion for that wounded part of ourselves.

It is by owning our wounds that we can start taking the power away from the wounded part of us.  When we suppress the feelings, feel ashamed about our reactions, do not own that part of our being, then we give it power.  It is the feelings that we are hiding from that dictate our behavior, that fuel obsession and compulsion. 

Codependence is a disease of extremes. 

Those of us who were horrified and deeply wounded by a perpetrator in childhood - and were never going to be like that parent - adapted a more passive defense system to avoid confrontation and "hurting others."  The more passive type of codependent defense system leads to a dominant pattern of being the victim.

Those of us who were disgusted by, and ashamed of, the victim parent in childhood and vowed never to be like that role model, adapted a more aggressive defense system.  So we go charging through life being the bull in the china shop - being the perpetrator who blames other people for not allowing us to be in control.   The perpetrator that feels like a victim of other people not doing things "right" - which is what forces us to bulldoze our way through life. 

And, of course, some of us go first one way and then the other.  (We all have our own personal spectrum of extremes that we swing between - sometimes being the victim, sometimes being the perpetrator.  Being a passive victim is perpetrating on those around us.)

The only way we can be whole is to own all of the parts of ourselves.  By owning all the parts we can then have choices about how we respond to life.  By denying, hiding, and suppressing parts of ourselves we doom ourselves to live life in reaction. 

A technique I have found very valuable in this healing process is to relate to the different wounded parts of our self as different ages of the inner child.  These different ages of the child may be literally tied to an event that happened at that age - i.e. when I was 7 I tried to commit suicide. Or the age of the child might be a symbolic designator for a pattern of abuse/deprivation that occurred throughout our childhood - i.e. the 9 year old within me feels completely emotionally isolated and desperately needy/lonely, a condition which was true for most of my childhood and not tied to any specific incident (that I know of) that happened when I was 9.

By searching out, getting acquainted with, owning the feelings of, and building a relationship with, these different emotional wounds/ages of the inner child, we can start being a loving parent to ourselves instead of an abusive one.  We can have boundaries with ourselves that allow us to:  take responsibility for being a co-creator of our life (grow up); protect our inner children from the perpetrator within/critical parent (be loving to ourselves); stop letting our childhood wounds control our life (take loving action for ourselves); and own the Truth of who we really are (Spiritual Beings) so that we can open up to receive the Love and Joy we deserve.

It is impossible to truly love the adult that we are without owning the child that we were.  In order to do that we need to detach from our inner process (and stop the disease from abusing us) so that we can have some objectivity and discernment that will allow us to have compassion for our own childhood wounds.  Then we need to grieve those wounds and own our right to be angry about what happened to us in childhood - so that we can truly know in our gut that it wasn't our fault - we were just innocent little kids.

Feeling the Feelings

"Attempting to suppress emotions is dysfunctional; it does not work.  Emotions are energy:  E-motion = energy in motion.  It is supposed to be in motion, it was meant to flow. 

Emotions have a purpose, a very good reason to be - even those emotions that feel uncomfortable.  Fear is a warning; anger is for protection, tears are for cleansing and releasing.  These are not negative emotional responses!  We were taught to react negatively to them.  It is our reaction that is dysfunctional and negative, not the emotion."

"The way to stop reacting out of our inner children is to release the stored emotional energy from our childhoods by doing the grief work that will heal our wounds.  The only effective, long term way to clear our emotional process - to clear the inner channel to Truth which exists in all of us - is to grieve the wounds which we suffered as children.  The most important single tool, the tool which is vital to changing behavior patterns and attitudes in this healing transformation, is the grief process.  The process of grieving.

We are all carrying around repressed pain, terror, shame, and rage energy from our childhoods, whether it was twenty years ago or fifty years ago.  We have this grief energy within us even if we came from a relatively healthy family, because this society is emotionally dishonest and dysfunctional."

Emotions are energy that is manifested in our bodies.  They exist below the neck.  They are not thoughts (although attitudes set up our emotional reactions.)  In order to do the emotional healing it is vital to start paying attention to where energy is manifesting in our bodies.  Where is there tension, tightness?  Could that "indigestion" really be some feelings?  Are those "butterflies" in my stomach telling me something emotionally?

When I am working with someone and they start having some feelings coming up, the first thing I have to tell them is to keep breathing.  Most of us have learned a variety of ways to control our emotions and one of them is to stop breathing and close our throats.  That is because grief in the form of sadness accumulates in our upper chest and breathing into it helps some of it to escape - so we learned to stop breathing at those moments when we start getting emotional, when our voice starts breaking.

Western civilization has for many years been way out of balance towards the left brain way of thinking - concrete, rational, what you see is all there is (this was in reaction to earlier times of being out of balance the other way, towards superstition and ignorance.)  Because emotional energy can not be seen or measured or weighed ("The x-ray shows you've got 5 pounds of grief in there.") emotions were discounted and devalued.  This has started to change somewhat in recent years but most of us grew up in a society that taught us that being too emotional was a bad thing that we should avoid.  (Certain cultures / subcultures give more permission for emotions but those are usually out of balance to the other extreme of allowing the emotions to rule - the goal is balance: between mental and emotional, between intuitive and rational.)

Emotions are a vital part of our being for several reasons. 

1. Because it is energy and energy cannot just disappear.  The emotional energy generated by the circumstances of our childhood and early life does not go away just because we were forced to deny it.  It is still trapped in our body - in a pressurized, explosive state, as a result of being suppressed.  If we don't learn how to release it in a healthy way it will explode outward or implode back in on us.  Eventually it will transform into some other form - such as cancer. 

2.  As long as we have pockets of pressurized emotional energy that we have to avoid dealing with - those emotional wounds will run our lives.  We use food, cigarettes, alcohol and drugs, work, religion, exercise, meditation, television, etc., to help us keep suppressing that energy.  To help us keep ourselves focused on something else, anything else, besides the emotional wounds that terrify us.  The emotional wounds are what because obsession and compulsion are what the "critical parent" voice works so hard to keep us from dealing with.

3.  Our emotions tell us who we are - our Soul communicates with us through emotional energy vibrations.  Truth is an emotional energy vibrational communication from our Soul on the Spiritual Plane to our being/spirit/soul on this physical plane - it is something that we feel in our heart/our gut, something that resonates within us. 

Our problem has been that because of our unhealed childhood wounds it has been very difficult to tell the difference between an intuitive emotional Truth and the emotional truth that comes from our childhood wounds.  When one of our buttons is pushed and we react out of the insecure, scared little kid inside of us (or the angry/rage filled kid, or the powerless/helpless kid, etc.) then we are reacting to what our emotional truth was when we were 5 or 9 or 14 - not to what is happening now.  Since we have been doing that all of our lives, we learned not to trust our emotional reactions (and got the message not to trust them in a variety of ways when we were kids.)

 4. We are attracted to people that feel familiar on an energetic level - which means (until we start clearing our emotional process) people that emotionally / vibrationally feel like our parents did when we were very little kids.  At a certain point in my process I realized that if I met a woman who felt like my soul mate, that the chances were pretty huge that she was one more unavailable woman that fit my pattern of being attracted to someone who would reinforce the message that I wasn't good enough, that I was unlovable.  Until we start releasing the hurt, sadness, rage, shame, terror - the emotional grief energy - from our childhoods we will keep having dysfunctional relationships.

I became willing to do the emotional healing in the summer of 1987 when I set myself up to be abandoned on my birthday one more time.  I called a counselor that I had been told was good with the emotional work.  It turned our that he was in the middle of moving to Hawaii and wasn't doing counseling anymore.  But he said I could come over and talk to him as he packed.

I don't remember anything that he said to me that day - what I do remember is that as I sat in his house watching him pack I had a feeling, and a visual image, that I had just opened Pandora's Box - the monsters were loose now and I would never be able shut that box again.

Doing the grief work is absolutely terrifying.  The word I came up with to describe how I felt was terrify***ingfying.  It felt like if I ever really owned the pain, I would end up crying in a rubber room for the rest of my life.  That if I ever really owned the rage, I would just go up and down the street shooting people.  That is not what happened.  The Spirit guided me through the process and gave me the resources I needed to release great quantities of that pent up, pressurized emotional energy.  To release enough to start learning who I really am, to start seeing my path more clearly, and to start forgiving myself and learning about love. 

I still need to do the grieving/energy release work from time to time.  There is still a hole in my soul - a seemingly bottomless abyss of wish-to-die-pain, shame, and unbearable suffering.   But it is a much smaller hole and I don't have to visit it very often. 

The wounds don't go away.  They have less power to dictate my life as I heal.  I needed to own that wounded part of me in order to start getting to know, and have compassion for, me.  I also needed to learn to have a balance because we can't live in those feelings.  We need to own them and honor them in order to own and honor ourselves - but then we need to learn to have internal boundaries that will allow us to find some balance in our life, allow us to trust the process and our Higher Power. 

We are on a Spiritual journey - and the Force is with us.  It will help and guide us as we face the terror of owning how painful our human experience has been.  The more we are able to feel and release the feelings / emotional energy, the more clearly we can tune into the emotional energy that is Truth - and Love, Light, Joy, Beauty - coming from The Source Energy.

Learning to Love our self

"Codependence is an emotional and behavioral defense system which was adopted by our egos in order to meet our need to survive as a child.  Because we had no tools for reprogramming our egos and healing our emotional wounds (culturally approved grieving, training and initiation rites, healthy role models, etc.), the effect is that as an adult we keep reacting to the programming of our childhood and do not get our needs met - our emotional, mental, Spiritual, or physical needs.  Codependence allows us to survive physically but causes us to feel empty and dead inside.  Codependence is a defense system that causes us to wound ourselves."

"We need to take the shame and judgment out of the process on a personal level.  It is vitally important to stop listening and giving power to that critical place within us that tells us that we are bad and wrong and shameful.

That "critical parent" voice in our head is the disease lying to us. . . .Again the Critical Super-Ego This healing is a long gradual process - the goal is progress, not perfection.  What we are learning about is unconditional Love.  Unconditional Love means no judgment, no shame."

"We need to start observing ourselves and stop judging ourselves.  Any time we judge and shame ourselves, we are feeding back into the disease; we are jumping back into the squirrel cage."

(Quotations in this color are from Codependence: The Dance of Wounded Souls)

Codependence is a dysfunctional defense system that was built in reaction to feeling unlovable and unworthy - because our parents were wounded codependents who didn't know how to love themselves.  We grew up in environments that were emotionally dishonest, spiritually hostile, and shame based.  Our relationship with ourselves (and all the different parts of our self: emotions, gender, spirit, etc.) got twisted and distorted in order to survive in our particular dysfunctional environment.

We got to an age where we were supposed to be an adult and we started acting like we knew what we were doing.  We went around pretending to be adult at the same time we were reacting to the programming that we got growing up.  We tried to do everything "right" or rebelled and went against what we had been taught was "right."  Either way we weren't living our life through choice, we were living it in reaction. Illness is Reactive – Health is proactive

In order to start being loving to ourselves we need to change our relationship with our self - and with all the wounded parts of our self.   The way which I have found works the best in starting to love ourselves is through having internal boundaries.

Learning to have internal boundaries is a dynamic process that involves three distinctly different, but intimately interconnected spheres of work.  The purpose of the work is to change our ego-programming - to change our relationship with ourselves by changing our emotional/behavioral defense system into something that works to open us up to receive love, instead of sabotaging ourselves because of our deep belief that we don't deserve love. 

(I need to make the point here that Codependence and recovery are both multi-leveled, multi-dimensional phenomena. What we are trying to achieve is integration and balance on different levels. In regard to our relationship with us this involves two major dimensions: the horizontal and the vertical. In this context the horizontal is about being human and relating to other humans and our environment. The vertical is Spiritual, about our relationship to a Higher Power, to the Universal Source. If we cannot conceive of a God/Goddess Force that loves us then it makes it virtually impossible to love to ourselves. So a Spiritual Awakening is absolutely vital to the process in my opinion. Changing our relationship with ourselves on the horizontal level is both a necessary element in and possible because we are working on, integrating Spiritual Truth into our inner process.)

These three spheres are:

1.  Detachment

2.  Inner Child Healing

3.  Grieving

Because Codependence is a reactive phenomena it is vital to start being able to detach from our own process in order to have some choice in changing our reactions.  We need to start observing our selves from the witness perspective instead of from the perspective of the judge. 

We all observe ourselves - have a place of watching ourselves as if from outside, or perched somewhere inside, observing our own behavior.  Because of our childhoods we learned to judge ourselves from that witness perspective, the "critical parent" voice. 

The emotionally dishonest environments we were raised in taught us that it was not ok to feel our emotions or those only certain emotions were ok.  So we had to learn ways to control our emotions in order to survive.  We adapted the same tools that were used on us - guilt, shame, and fear (and saw in the role modeling of our parents how they reacted to life from shame and fear.)  This is where the critical parent gets born.  Its purpose is to try to keep our emotions and behavior under some sort of control so that we can get our survival needs met.

So the first boundary that we need to start setting internally is with the wounded / dysfunctional programmed part of our own mind.  We need to start saying no to the inner voices that are shaming and judgmental.  The disease comes from a black and white, right and wrong, perspective.  It speaks in absolutes: "You always screw up!"  "You will never be a success!" - These are lies. We don't always screw up. We may never be a success according to our parents or societies dysfunctional definition of success - but that is because our heart and soul do not resonate with those definitions, so that kind of success would be a betrayal of ourselves. We need to consciously change our definitions so that we can stop judging ourselves against someone else's screwed up value system.

We learned to relate to ourselves (and all the parts of our self - emotions, sexuality, etc.) and life from a critical place of believing that something was wrong with us - and in fear that we would be punished if we didn't do life "right."  Whatever we are doing or not doing the disease can always finds something to beat us up with.  I have 10 things on my "to do list" today, I get 9 of them done, the disease does not want me to give myself credit for what I have done but instead beats me up for the one I didn't get done.  Whenever life gets too good we get uncomfortable and the disease jumps right in with fear and shame messages.  The critical parent voice keeps us from relaxing and enjoying life, and from loving our self.  Dammed if you do, and dammed if you don’t

We need to own that we have the power to choose where to focus our mind. We can consciously start viewing ourselves from the "witness" perspective.   It is time to fire the judge - our critical parent - and choose to replace that judge with our Higher Self, who is a loving parent. We can then intervene in our own process to protect ourselves from the perpetrator within - the critical parent/disease voice.

(It is almost impossible to go from critical parent to compassionate loving parent in one step - so the first step often is to try to observe ourselves from a neutral position or a "scientific observer" perspective.) 

This is what enlightenment and consciousness raising are all about.  Owning our power to be a co-creator of our lives by changing our relationship with ourselves.  We can change the way we think.  We can change the way we respond to our own emotions. We need to detach from our wounded self in order to allow our Spiritual Self to guide us.  We are Unconditionally Loved.  The Spirit does not speak to us from judgment and shame. 

One of the visualizations that have helped me over the years is an image of a small control room in my brain.  This control room is full of dials and gauges and lights and sirens. In this control room are a bunch of Keebler-like elves whose job it is to make sure that I don't get too emotional for my own good.  Whenever I feel anything too strongly (including Joy, happiness, and self-love) the lights start flashing and the sirens start wailing and the elves go crazy running around trying to get things under control.  They start pushing some of the old survival buttons:  feeling too happy - drink; feeling too sad- eat sugar; feeling scared - get laid; or whatever.

To me, the process of recovery is about teaching those elves to chill out.  Reprogramming my ego-defenses to knowing that it is ok to feel the feelings.  That feeling and releasing the emotions is not only ok it is what will work best in allowing me to have my needs fulfilled. 

We need to change our relationship with ourselves and our own emotions in order to stop being at war with ourselves.  The first step to doing that is to detach from ourselves enough to start protecting ourselves from the perpetrator that lives within us.

Trauma Re-Enactment and Re-victimization of theSelf

    The Compulsion to Repeat the Trauma Re-enactment, Revictimization, and Masochism

              Bessel A.

              van der Kolk, MD*

           

During the formative years of contemporary psychiatry much attention was paid to

the continuing role of past traumatic experiences on the current lives of people. Charcot, Janet, and Freud all noted that fragmented memories of traumatic events

dominated the mental life of many of their patient and built their theories about the nature and treatment of psychopathology on this recognition. Janet thought

that traumatic memories of traumatic events persist as unassimilated fixed ideas that act as foci for the development of alternate states of consciousness, including dissociative phenomena, such as fugue states, amnesias, and chronic states of helplessness and depression. Unbidden memories of the trauma may return as physical sensations, horrific images or nightmares, behavioral reenactments, or a combination of these. Janet showed how traumatized individuals become fixated on the trauma: difficulties in assimilating subsequent experiences as well. It is "as if their personality development has stopped at a certain point and cannot expand anymore by the addition orassimilation of new elements." Freud independently came to similar conclusions. Initially, he thought all hysterical symptoms were caused by childhood sexual"seduction" of which unconscious memories were activated, when during adolescence, a person was exposed to situations reminiscent of the original trauma. The trauma permanently disturbed the capacity to deal with other challenges, and the victim who did not integrate the trauma was doomed to "repeat the repressed material as a contemporary experience in instead or . . . remembering it as something belonging to the past."

In this article, I will show how the trauma is repeated on behavioral, emotional, physiologic, and neuroendocrinologic levels, whose confluence explains the diversity of repetition phenomena. Many traumatized people expose themselves, seemingly compulsively, to situations reminiscent of the original trauma. These behavioral reenactments are rarely consciously understood to be related to earlier life experiences. This "repetition compulsion" has received surprisingly little systematic exploration during the 70 years since its discovery, though it is regularly described in the clinical literature. Freud thought that the aim of repetition was to gain mastery, but clinical experience has shown that this rarely happens; instead, repetition causes further suffering for the victims or for people in their surroundings. Children seem more vulnerable than adults to compulsive behavioral repetition and loss of conscious memory of the trauma.70,136. However, responses to projective tests show that adults, too, are liable to experience a large range of stimuli vaguely reminiscent of the trauma as a return of the trauma itself, and to react accordingly.39,42

BEHAVIORAL RE-ENACTMENT

In behavioral re-enactment of the trauma, the self may play the role of either victim or victimizer.

Harm to Others

Re-enactment of victimization is a major cause of violence. Criminals have often been physically or sexually abused as children. In a recent prospective study of 34 sexually abused boys, Burgess et al. found a link with drug abuse, juvenile delinquency, and criminal behavior only a few year later. Lewis has extensively studied the association between childhood abuse and subsequent victimization of others. Recently, she showed that of 14 juveniles condemned to death for murder in the United States in 1987, 12 had been brutally physically abused, and five had been sodomized by relatives. In a study of self-mutilating male criminals, Brach-y-Rita concluded that "the constellation of withdrawal, depressive reaction, hyperreactivity, stimulus-seeking behavior, impaired pain perception, and violent aggressive behavior directed at self or others may be the consequence of having been reared under conditions of maternal social deprivation. This constellation of symptoms is a common phenomenon among a member of environmentally deprived animals."

Self-destructiveness

Self-destructive acts are common in abused children. Green found that 41 per cent

of his sample of abused children engaged in head banging, biting, burning, and cutting. In a controlled, double-blind study on traumatic antecedents of borderline personality

disorder, we found a highly significant relationship between childhood sexual abuse and various kinds of self-harm later in life, particularly cutting and self-starving. Clinical reports also consistently show that self-mutilators have childhood histories of physical or sexual abuse, or repeated Surgery. Simpson and Porter found a significant association between self-mutilation and other forms of self-deprecation or self-destruction such as alcohol and drug abuse and eating disorders. They sum up the

conclusions of many students of this problem in stating that "self-destructive activities were not primarily related to conflict, guilt and superego pressure, but to

more primitive behavior patterns originating in painful encounters with hostile caretakers during the first years of life."

Revictimization

Revictimization is a consistent finding. Victims of rape are more likely to be raped and women who were physically or sexually abused, as children are more

likely to be abused as adults. Victims of child sexual abuse are at high risk of becoming prostitutes. Russell,  in a very careful study of the effects of incest on the life of women, found that few women made a conscious connection between their

childhood victimization and their drug abuse, prostitution, and suicide attempts. Whereas 38 per cent of a random sample of women reported incidents of rape or attempted

rape after age 14, 68 per cent of those with a childhood history of incest did. Twice as many women with a history of physical violence in their marriages (27 per cent), and

more than twice as many (53 per cent) reported unwanted sexual advances by an unrelated authority figure such as a teacher, clergyman, or therapist. Victims of

father-daughter incest were four times more likely than nonincest victims to be asked to pose for pornography.

SOCIAL ATTACHMENT AND THE TRAUMA RESPONSE

Human beings are strongly dependent on social support for a sense of safety, meaning, power, and control. Even our biologic maturation is strongly influenced by the nature of early attachment bonds. Traumatization occurs when both internal and external resources are inadequate to cope with external threat. Physical and emotional maturation, as well as innate variations in physiologic reactivity to perceived danger, play important roles in the capacity to deal with external threat. The presence of familiar caregivers also plays an important role in helping children modulate their physiologic arousal. In the absence of a caregiver, children experience extremes of under-and over arousal that are physiologically aversive and disorganizing. The availability of a caregiver who can be blindly trusted when their own resources are inadequate is very important in coping with threats. If the caregiver is rejecting and abusive, children are likely to become hyper aroused. When the persons who are supposed to be the sources of safety and nurturance become simultaneously the sources of danger against which protection is needed, children maneuver to re-establish some sense of safety. Instead of turning on their caregivers and thereby losing hope for protection, they blame themselves. They become fearfully and hungrily attached and anxiously obedient. Bowlby calls this "a pattern of behavior in which avoidance of them competes with his desire for proximity and care and in which angry behavior is apt to become prominent."

Studies by Bowlby and Ainsworth in humans, and by Harlow  in other primates, demonstrate the crucial role that a "safe base" plays for normal social and biologic development. As children mature, they continually acquire new cognitive schemata in which to frame current life experiences. These ever-expanding cognitive schemes decrease their reliance on the environment for soothing and increase their own capacity to modulate physiologic arousal in the face of threat. Thus, the cognitive preparedness (development) of an individual interacts with the degree of physiologic disorganization to determine the capacity for mental processing of potentially

traumatizing experiences.137,141

SEX DIFFERENCES

The frequency with which abused children repeat aggressive interactions has suggested to Green a link between the compulsion to repeat and identification with the aggressor,

which replaces fear and helplessness with a sense of omnipotence. There are significant sex differences in the way trauma victims incorporate the abuse experience. Studies by Carmen et al. and others indicate that abused men and boys tend to identify with the aggressor and later victimize others whereas abused women are prone to

become attached to abusive men who allow themselves and their offspring to be victimized further.

Reiker and colleagues have pointed out that confrontations with violence challenges one's most basic assumptions about the self as invulnerable and intrinsically worthy and about the world as orderly and just. After abuse, the victim's view of self and world can never be the same again: it must be reconstructed. to incorporate the abuse experience." Assuming responsibility for the abuse allows feelings of helplessness to be replaced with an illusion of control. Ironically, victims of rape who blame themselves have a better prognosis than those who do not assume this false responsibility: it allows the locus of control to remain internal and prevent helplessness. Children are even more likely to blame themselves: "The child needs to hold on to an image of the parent as good in order to deal with the intensity of fear and rage which is the effect of the tormenting experiences." Anger directed against the self or others is always a central problem in the life of people who have been violated. Reikers concludes that "this 'acting out' is seldom understood by either victims or clinicians as being a repetitive re-enactment of real events from the past."

THE SEPARATION REPONSE

Primates have evolved highly complex ways to maintain attachment bonds; they are intensely dependent on their caregivers at the start. In lower primates, his dependency

is principally expressed in physical contact, in humans this is supplemented by verbal communication. McLean suggests that language is an evolutionary development from the mammalian separation cry that induces caregivers to provide safety, nurturance, and social stimulation. Primates react to separation from attachment figures as if they were directly threatened. Thus, small children, unable to anticipate the future, experience separation anxiety as soon as they lose sight of their mothers. Bowlby has described the protest and despair phases of this response in great detail. As people mature, they develop an ever-enlarging repertoire of coping responses, but adults are still intensely dependent upon social support to prevent and overcome traumatization, and under threat they still may cry out for their mothers. Sudden, uncontrollable loss of attachment bonds is an essential element in the development of post-traumatic stress syndromes. On exposure to extreme terror, even mature people have protest and despair responses (anger and grief, intrusion and numbing) that make them turn toward the nearest available source of comfort to return to a state of both psychological and physiologic calm. Thus, severe external threat may result in renewed clinging. Because the attachment system is so important, mobilization of social supports is an important element in the treatment of post-traumatic stress disorder (PTSD).

INCREASED ATTACHMENT IN THE FACE OF DANGER

People in general, and children in particular, seek increased attachment in the face of external danger. Pain, fear, fatigue, and loss of loved ones and protectors all

evoke efforts to attract increased care and most cultures have rituals designed to provide it. When there is no access to ordinary sources of comfort, people may turn toward their tormentors. Adults as well as children may develop strong emotional ties with people who intermittently harass, beat, and threaten them. Hostages have put up bail for their captors, expressed a wish to marry them, or had sexual relations with them; 31 abused children often cling to their parents and resist being removed from the home;31,80 inmates of Nazi prison camps sometimes imitated their captors by sewing together clothing to copy SS uniforms.11 When Harlow observed this in nonhuman primates, he stated that "the immediate consequences of maternal rejection is the accentuation of proximity seeking on the part of the infant."114

Walker145 and Dutton and Painter31 have noted that the bond between batter and victim in abusive marriages resembles the bond between captor and hostage or cult leader and

follower. Social workers, police, and legal personnel are constantly frustrated by the strength of this bond. The woman's longing for the batterer soon prevails over memories of the terror, and she starts to make excuses for his behavior. This pattern is so common that women engaged in these sorts of relationships become the recipients of

intense anger for social service personnel. They are then called masochistic, and like other psychiatric terms, this can be employed pejoratively rather than conveying an

understanding of the underlying causes and treatment of the problem. Walker145 first applied ethnology to the study of traumatic bonding in such couples. A

central component is captivity, the lack of permeability, and the absence of outside support or influence.31,62,119,145 The victim organizes her life completely around pleasing her captor and his demands. As Dutton and Painter point out, "her compliance legitimates his demands, builds up a store of repressed anger and frustration on her part (which may surface in her goading him or fighting back during an actual argument, leading to escalating violence), and systematically eliminates opportunities for her to build up a supportive network which could eventually assist her in leaving the relationship."

Walker145 has clarified the operation of intermittent reinforcement paradigms in such

relationships, applying the animal model of punishment-indulgence patterns. In child abuse or spouse battering, this mechanism is accentuated by the extreme contrast of terror followed by submission and reconciliation. When such negative reinforcement occurs intermittently, the reinforced response consolidates the attachment between victim and victimizer. During the abuse, victims tend to dissociate emotionally with a sense of

disbelief that the incident is really happening. This is followed by the typical post-traumatic response of numbing and constriction, resulting in inactivity, depression,

self-blame, and feelings of helplessness. Walker145 describes the process as follows: "tension gradually builds" (during phase one), an explosive battering incident

occurs (during phase two), and a "calm, loving respite follows phase three). The violence allows intense emotional engagement and dramatic scenes of forgiveness,

reconciliation, and physical contact that restores the fantasy of fusion and symbiosis.87,140 Hence, there are two powerful sources of reinforcement: the "arousal-jag" or excitement before the violence and the peace of surrender afterwards, Both of these responses, placed at appropriate intervals, reinforce the traumatic bond between victim and abuser.31,145 To varying degrees, the memory of the battering incidents is state-dependent or dissociated, and thus only comes back in full force during renewed situations of terror. This interferes with good judgment about the relationship and allows longing for love an reconciliation to overcome realistic fears.

VULNERABILITY TO DEVELOP TRAUMATIC BONDING

At least four studies of family violence40, 48,63,132 have found a direct relationship between the severity of childhood physical abuse and later marital violence. Interestingly,

nonhuman primates subjected to early abuse and deprivation also are more likely to engage in violent relationships with their peers as adults.134 as in humans, males tend

To be hyper aggressive, and females fail to protect themselves and their offspring against danger. Neither sex develops the capacity for sustained peaceful social interactions.134

People who are exposed early to violence or neglect come to expect it as a

way of life. They see the chronic helplessness of their mothers and fathers' alternating outbursts of affection and violence; they learn that they themselves have no control.

As adults they hope to undo the past by love, competency, and exemplary behavior.46,87,145 When they fail they are likely to make sense out of this situation by blaming themselves. When they have little experience with nonviolent resolution of differences, partners in relationships alternate between expectations of perfect

Behavior leading to perfect harmony and a state of helplessness, in which all verbal communication seems futile. A return to earlier coping mechanisms, such as

self-blame, numbing (by means of emotional withdrawal or drugs or alcohol), and physical violence sets the stage for a repetition of the childhood trauma and "return of the

repressed."1,42,46,137

BIOLOGIC RESPONSES TO TRAUMATIZATION

Chronic physiologic hyper arousal to stimuli reminiscent of the trauma is a

cardinal feature of the trauma response, well documented in a large variety of traumatized individuals, including victims of child abuse, burns, rape, natural disasters, and

War.2, 78,84,107,133,142 Because of their decreased capacity to modulate physiologic arousal, which leads to reduced ability to utilize symbols and fantasy to cope with stress, they tend to experience later stresses as somatic states, rather than as specific events

that require specific means of coping.142 Thus, victims of trauma respond to contemporary stimuli as if the trauma had returned, without conscious awareness that past injury rather than current stress is the basis of their physiologic emergency responses. The hyper arousal interferes with their ability to make calm and rational

assessments and prevents resolution and integration of the trauma.142 They respond to threats as emergencies requiring action rather than thought.

Chronic hyper arousal in response to new challenges is also found in animals exposed to inescapable shock.5 In fact, this phenomenon drew our attention to the possibility of

using this animal model for the study of human traumatization.142 Human beings and other mammals are very similar biologically in respect to such relatively uncomplicated behaviors as fight, flight, and freeze responses. Exposure to inescapable aversive events

has widespread behavioral and physiologic effects on animals including (1) deficits in learning to escape novel adverse situations, (2) decreased motivation for learning

new options, (3) chronic subjective distress,94 and (4) increased tumor genesis and immunosuppression.143 All this is the result not of the shock itself but of a helplessness

syndrome that is a result of the lack of control that the animal has in terminating shock.

Several neurotransmitters have been shown to be affected by inescapably fearful experiences in animals; they have low resting cerebro-spinal fluid (CSF) norepinephrine, but under stress they respond with much higher elevations than other animals. Something has disturbed the organism’s capacity to modulate the extent of arousal.37, 95,115,116,142 Dysregulation of the serotonin system has been implicated in this.123, 139 Serotonin is thought to be the neurotransmitter most involved in modulating the actions of other neurotransmitters; 19 it has also been implicated in the fine tuning of emotional reactions, particularly arousal and aggression.18 Traumatization also causes

dysregulation of the endogenous opioid system in both animals and humans. We will discuss this phenomenon and how this could explain the clinical phenomenon of compulsive re-exposure to trauma.

STATE-DEPENDENT LEARNING

Both Janet74 and Freud observed that early memory traces could be activated by later events that cause partial reliving of earlier traumas in the form of affects states, anxiety, or re-enactments. Their patients generally had a poor memory for traumatic childhood events, until they were brought back, by means of hypnosis, to a state of mind similar to the one they were in at the time of the trauma. In the past few decades, these notions have

gained scientific confirmation with the discovery of state-dependent learning; for example what is learned under the influence of a particular drug tends to become

dissociated and seemingly lost until return of the state similar to the one in which the memory was stored. State dependency can be roughly related to arousal levels. For

example, state-dependent learning in humans is produced by both psycho stimulants and depressants: alcohol, marijuana, barbiturates, and amphetamines as well as other psychoactive agents.32 Reactivation of past learning is relatively automatic: contextual stimuli directly evoke memories without conscious awareness of the transition. The more similar are the contextual stimuli are to conditions prevailing at the time of the original

storage of memories, the more likely the probability of retrieval. Both internal states, such as particular affects, or external events reminiscent of earlier trauma

thus can trigger a return to feeling as if victims are back in their original traumatizing situation. Thus, battered women who otherwise behave competently may experience

themselves within the battering relationship like the terrified child they once were in a violent or alcoholic home.119 Similarly, war veterans may be asymptomatic until they become intimate with a partner and start reliving feelings of loss, grief, vulnerability, and revenge related to the death of a comrade on the battlefield but that are now incorrectly

attributed to some element of the current relationship. Disinhibition resulting from drugs or alcohol strongly facilitates the occurrence of such reliving experiences, which then may take the form of acting out violent or sexual traumatic episodes.107

During states of massive autonomic arousal, memories are laid down that powerfully influence later actions and interpretations of events. Long-term activation of memory

tracts is observed in animals exposed to a highly stressful stimulus.51,81 This pheromenon has been attributed to massive noradrenergic activity at the time of

the stress.129 In traumatized people, visual and motoric reliving experiences, nightmares,

flashbacks, and re-enactments are generally preceded by physiologic arousal.30 Activation of long-term augmented memory tracts may explain why current stress is

experienced as a return of the trauma.

"RETURN OF THE REPRESSED" OCCURS IN SITUATIONS OF THREAT

Under ordinary conditions, most previously traumatized individuals can adjust psychologically and socially. Studies have shown this to be true of victims of rape, 82 battered women, 63 and victims of child abuse.53 Nonhuman primates subjected

to extended periods of isolation may later become reasonably well integrated socially. However, they do not respond to stress in the same ways as their nontraumatized

peers. Studies in the Wisconsin primate laboratory have shown that, even after an initial good social adjustment, heightened emotional or physical arousal causes social

withdrawal or aggression.86 Even monkeys that recover in other respects tend to respond inappropriately to sexual arousal and misperceive social cues when threatened by a

dominant animal.4,95,101 Animals with a history of trauma also have much more intense catecholamine responses to stress85 and a blunted cortisol response.25

Stress causes a return to earlier behavior patterns throughout the animal kingdom. In experiments in mice, Mitchell and colleagues98, 99 found that arousal state

determines how an animal will react to stimuli. In a state of low arousal, animals tend to be curious and seek novelty. During high arousal, they are frightened, avoid

novelty, and perseverate in familiar behavior regardless of the outcome. Under ordinary circumstances, an animal will choose the more pleasant of two alternatives. When

hyper aroused, it will seek the familiar, regardless of the intrinsic rewards.99 Thus shocked animals returned to the box in which they were originally shocked,

in preference to less familiar locations not associated with punishment. Punished animals actually increased their exposure to shock as the trials continued.98 Mitchell

concluded that this perseveration is no associative, that is, if uncoupled from the usual rewards systems, animals seek optimal levels of arousal,10,122 and this mediates

patterns of alternation and perseveration. Because novel stimuli cause arousal, an animal in a state of high arousal will avoid even mildly novel stimuli even if it would

reduce exposure to pain.

"THE COSTS OF PLEASURE AND THE BENEFITS OF PAIN'

 Solomon127 proposes an "opponent process theory of acquired motivation" to explain addictive behavior that originates in frightening or painful events. He points out that frequent exposure to stimuli, pleasant or unpleasant, may lead to habituation; the resulting withdrawal or abstinence state can take on a powerful life of its own and may become an effective source of motivation. In drug addiction, for example, the motivation changes from getting high (pleasure) to controlling a highly aversive withdrawal state. In contrast with drug taking, which initially is pleasant, many initially aversive stimuli, such as sauna bathing, marathon running, and parachute jumping, may also be

eventually perceived as highly rewarding by people who have repeatedly exposed themselves to these frightening or painful situations. Parachute jumpers, sauna bathers, and marathon runners all feel exhilaration and a sense of well being from the initially aversive activities. These new sources of pleasure become independent of the fear that was b necessary to produce them in the first place. Solomon concludes that certain behaviors can become highly pleasurable: "…if they are derived from aversive

processes they can provide a relatively enduring source of positive hedonic tone following the removal of the aversive reenforcer. Fear thus has its positive conquences."127

Solomon and colleagues have applied these observations to imprinting and social attachment. Their research showed that young animals responded with increasing distress to repeated separations.66 Habituation did not occur, and attachment in fact increased, provided that the imprinting object was presented at fairly regular intervals. Starr130 demonstrated that there is critical decay duration, the time that it takes for

the withdrawal response to the original stimulus to wear off. If the reinforcing stimulus of the imprinting or attachment object is presented at intervals greater than

the critical decay duration, increased attachment does not occur. However, animals earlier exposed to repeated separations are more vulnerable to increased distress upon

later separations: "repeated exposures to the imprinting object took less time and fewer exposures than did the original exposures." The strength of the imprinting eventually decays by disuse, but some residues of past experiences remain and facilitate the reactivation of the temporarily dormant system. Readdiction to nicotine and

opiates occurs much faster than the initial addiction. If Starr is correct, similar processes account for social attachment to aversive objects and thus "the law of social

attachment may be identical to the law of drug addiction."130

Solomon and coworkers established experimentally that animal and people become habituated to the original stimulus, whether it is morphine, parachute jumping or

marathon running, but the withdrawal syndromes that follow a large number of arousing events retain their integrity over time, and recur when the original stimuli are reintroduced.127 Thus, the positive reenforcer loses some of its power, but the negative

reinforcer gains power and lasts longer: parachute jumpers continued to feel exhilarated after jumping, even when they feel less year beforehand. Solomon hypothesized that

endorphins are secreted in response to certain environmental stresses and play a role in the opponent process. We have recently found evidence that supports this view.

ADDICTION TO TRAUMA

Some traumatized people remain preoccupied with the trauma at the expense of other life experiences137, 141 and continue to re-create it in some form for themselves or for

others. War veterans may enlist as mercenaries,128 victims of incest may become prostitutes,47,120,125 and victims of childhood physical abuse seemingly provoke subsequent abuse in foster families53 or become self-mutilators143a Still others identify

with the aggressor and do to others what was done to them.21,39 Clinically, these people

are observed to have a vague sense of apprehension, emptiness, boredom, and anxiety when not involved in activities reminiscent of the trauma. There is no evidence to support Freud's idea that repetition eventually leads to mastery and resolution. In fact, reliving the trauma repeatedly in psychotherapy may serve to re-enforce the preoccupation and fixation. Many observers of traumatic bonding have speculated that victims become addicted to their victimizers. Erschak33 asks why the batterer does not stop when injury and pain are apparent and why does the victim not leave? He answers, "they are addicted to each other and to abuse. The system, the interaction, the relation takes hold; the individuals are

as powerless as junkies."

ENDOGENOUS OPIATES AND ATTACHMENT

Thus Starr, 130 Solomon, 127 Erschak and others may be right in postulating that people can become physiologically addicted to each other. There is now considerable evidence that human attachment is, in part, mediated by the endogenous opiate system. Research in

non-human primates shows that social attachment is related to the development of core neurobiologic functions in the primate brain. Early disruption of the attachment bond

causes long-lasting psychobiologic changes that not only reduce the capacity to cope with subsequent social disruption but also disturb parenting processes and create similar vulnerability into the next generation. In recent years knowledge about the brain circuits involved in the maintenance of afflictive behavior are precisely those most richly endowed with opioid receptors.83 Behavioral studies show that the endogenous opioid system plays an important role in the maintenance of social attachment. According to

Panksepp and colleagues, the separation response in rats can be inhibited with doses of neuroactive agents to have yielded reliable behavioral effects. Minute injections of

morphine abolish both the separation cry in rate infants and the maternal response to it.100,103-105 Morphine-treated mothers (1 mg per kg) disregard male intruders, often

attempting no defense of their offspring at all. One mother permitted a male intruder to eat her pups.

Blocking of opioid receptors with naloxone causes increased huddling in nonhuman primates, where as activation of brain opioid systems can decrease gregariousness.34,104 Lack of care giving during the first few weeks of life decreases the number of opioid receptors in the cingulate gyrus in mice.13 Panksepp and colleagues have shown that the loss of social support decreases brain opioid activity and produces withdrawal symptoms; emotive circuits mediating loneliness-panic states are apparently activated or

disinhibited. Re-establishment of social contact may, among other neural changes, activate endogenous opioid systems, alleviating separation distress and strengthening social bonds.103 If brain opioid activity fulfills social needs, opioid blockade might be expected to influence such other forms of gratification as sex. Indeed, opioid systems interact with the brain systems that regulate sex-steroid secretion, 56 and naloxone facilitates sexual behavior in some mammals.49, 96

High levels of stress, 3 including social stress, 97 also activate opioid systems. Animals exposed to inescapable shock develop stress-induced analgesia (SIA) when

re-exposed to stress shortly afterward. This analgesic response is mediated by endogenous opioid and is readily reversible by the opioid receptor blocker naloxone.79 In humans elevations of enkephalins and plasma beta endorphins have been reported following a large variety of stressors.26, 28,73 In testing the generalizability of the phenomenon of SIA to people, we found that seven of eight Vietnam veterans with

PTSD showed a 30 percent reduction in perception of pain when viewing a movie depicting combat in Vietnam. This analgesia can be reversed with naloxone.107, 143b

This amount of analgesia produced by watching 15 minutes of a combat movie was equivalent to that which follows the injection of 8 mg. of morphine. We concluded that

Beecher9 was right when, after observing that wounded soldiers require less morphine, he speculated, "strong emotions can block pain" because of the release of endogenous

opioid. Our experiments show that even in people traumatized as adults, re-exposure to situations reminiscent of the trauma evokes as endogenous opioid response analogous to that of animals exposed to mild shock subsequent to inescapable shock. Thus, re-exposure to stress may have the same effect as the temporary application of exogenous opioids, providing a similar relief from anxiety.50

Field113 has suggested that normal play and exploratory activity in infants are dependent on the presence of a familiar attachment figure that modulates physiologic arousal by providing a balance between soothing and stimulation. She, Reite, 115,116 and others has shown that in the absence of the mother, infant experiences by psychological disorganizing extremes of under- and over arousal. This soothing and arousal may be mediated by alternate stimulation of different neurotransmitter systems, in which the endogenous opioid system is likely to play a role, especially in subjective experience of safety and soothing. Endogenous opioids decrease central noradrenergic activity, 6 and their activation may thus inhibit hyper arousal. Childhood abuse and neglect may cause

a long-term vulnerability to be hyper aroused, expressed on a social level as decreased ability to modulate strong affect states. "On a continuum from low to high physiologic

arousal there is an optimal level for every organism. The shape of an individual's optimal stimulation curve may depend on the level of stimulation received during early

experience."37 As a result, people who were neglected or abused as children may require much higher external stimulation of the endogenous opioid system for soothing than those whose endogenous opioids can be more easily activated by conditioned responses based on good early care giving experiences. These victimized people neutralize their hyper arousal by a variety of addictive behaviors including compulsive re-exposure to situations reminiscent of the trauma.

CHILDHOOD TRAUMA, ENDOGENOUS OPIOIDS, AND SELF-HARM

If recent animal research is any guide, people, particularly children, who have been exposed to severe, prolonged environmental stress will experience extraordinary

increases in both catecholamine and endogenous opioid responses to subsequent stress. The endogenous opioid response may produce both dependence and withdrawal phenomena resembling those of exogenous opioids. This could explain, in part, why childhood trauma is associated with subsequent self-destructive behavior. Depending on which stimuli have come to condition an opioid response, self-destructive behavior may include chronic involvement with abusive partners, sexual masochism, self-starvation,

and violence against self or others. In a recent study, we found that patients' reports of early childhood physical and sexual abuse were highly correlated with self-mutilation and self-starvation in adulthood.143a This controlled study supports numerous other clinical reports about the relationship between childhood abuse and self-destructive behavior.52, 106,118 In these people, self-mutilation is a common response to abandonment; it is accompanied by both analgesia and an altered state of consciousness, and it provides relief and return to normality. The pain, cutting, and burning are apparent attempts at "repairing the cohesiveness of the self in the face of overwhelming anxiety."35 This pattern is reminiscent of spouse abuse described by Walker: 145 "tension gradually builds, an explosive battering (self-mutilating) incident occurs, and a 'calm, loving respite' follows."

Bach-y-Rita7 studied men who were in prison because they habitually took out their frustrations on others violently. He found that they started to self-mutilate in prison when no external object of violence was available. Thus acts of violence that the perpetrator

regards as horrible may, in fact, produce somatic calm.

The evidence for involvement of the endogenous opioid system in self-mutilation is fairly good. A recent study found increased levels of metenkephalins in habitual

self-mutilators during the active stage of self-harm, but not 3 months later.27 Opioid receptor blockade has been found to decrease self-mutilation.60,117 The specific biologic factors that account for the relief felt by these traumatized people who habitually harm themselves or others are still unknown.

TREATMENT IMPLICATIONS

Compulsive repetition of the trauma usually is an unconscious process that, although it may provide a temporary sense of mastery or even pleasure, ultimately perpetuates chronic feelings of helplessness and a subjective sense of being bad and out of control. Gaining control over one's current life, rather than repeating trauma in action, mood, or somatic states, is the goal of treatment.

Although verbalizing the contextual elements of the trauma is the essence of treatment of acute post-traumatic stress, the essential elements of chronic post-traumatic reactions generally are retrieved with difficulty and often cannot be dealt with until reasonable control over current behavior can assure the safety of both the patient and those in the patient's immediate surroundings. Failure to approach trauma-related material very gradually leads to intensification of the affects and physiologic states related to the trauma, leading to increased repetitive phenomena. It is important to keep in mind that the only reason to uncover the trauma is to gain conscious control over the unbidden re-experience or re-enactments. Prior to unearthing the traumatic roots of current behavior, people need to gain reasonable control over the longstanding secondary defenses that were originally elaborated to defend against being overwhelmed by traumatic material such as alcohol and drug abuse and violence against self or others. The trauma can only be worked through after a secure bond is established with another person. The presence of an attachment figure provides people with the security necessary to explore their life experiences and to interrupt the inner or social isolation that keeps people stuck in repetitive patterns. Both the etiology and the cure of trauma-related psychological disturbance depend fundamentally on security of interpersonal attachments.

Once the traumatic experiences have been located in time and place, a person can start making distinctions between current life stresses and past trauma and decrease the

impact of the trauma on present experience.137

Self-help organizations for people with addictions or with backgrounds that include childhood traumas or parental addictions have elaborated a model of treatment that

appears to address many of the core issues of repetitive traumatization. These groups provide people with both human attachments and a meaningful cognitive frame for dealing with the sense of helplessness that is central to these problems. They focus on the development of "serenity," which can be understood both as a state of automatic

stability and of being at peace with one's surroundings. These groups teach that the way to gain this serenity is by learning to trust, by surrendering, and by making contact

and developing interpersonal commitments. They provide a support network that attempts to avoid the barriers that people create to bolster their individual differences, and

they thus endeavor to circumvent the shame of being helpless and vulnerable that perpetuates social isolation. Shame and social isolation are thought to promote

regression to earlier states of anxious attachment and to addictive involvements. In these circles it is said that: "No pain is so devastating as the pain a person refuses to

face and no suffering is so lasting as suffering left unacknowledged."23 There is emphasis on living in the here and now, generally with the acknowledgement

that in contrast to victimized children, adults can learn to protect themselves and make a conscious choice about not engaging in relationships or behaviors that are known to be

harmful. The underlying assumption is that conclusions drawn from a child's perspective retain their power into adulthood until verbalized and examined. In a group

context, victims can learn that as children they were not responsible for the chaos, violence and despair surrounding them, but that as adults there are choices and

Consequences.23, 137

These groups also teach that in order to avoid repetition, one has to give up the behavior, drug, or person involved in the addiction. Acknowledging the addictive quality of the involvement is known as overcoming denial. Avoiding acknowledging the feelings promotes acting out. Traumatized people need to understand that

acknowledging feelings related to the trauma does not bring back the trauma itself, and its accompanying violence and helplessness. There must be emphasis on finding replacement activities and experiences that are more rewarding, successful and powerful in the immediate present. These may include being of help to victims of similar traumas as one's own.

Psychotropic medicines may be of help to decrease autonomic hype arousal and decrease all or none responses. Lithium, beta-blockers, and serotonin reuptake blockers such as

flouxetine, may be particularly helpful. By decreasing hyper arousal, one decreases the likelihood that current stress will be experienced as a recurrence of past trauma.

This facilitates finding solutions appropriate to the current stress rather than the past.139 The use of medications that affect the opioid system should be regarded as experimental and at this time needs to be avoided except in life-threatening cases.

In our last study on patients with borderline personality disorder Judith Herman and I (unpublished data, 1988) asked our self-mutilating subjects what had helped them most in

Overcoming the impact of their childhood traumas, including their self-mutilation. All subjects attributed their improvement to having found a safe therapeutic relationship

In which they had been able to explore the realities of their childhood experiences and their reactions to them. All subjects reported that they had been able to markedly decrease a variety of repetitive behaviors, including habitual self-harm, after they had established a relationship in which they felt safe to acknowledge the realities of both their past and their current lives.

SUMMARY

Trauma can be repeated on behavioral, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual

and social suffering. Anger directed against the self or others is always a central problem in the lives of people who have been violated and this is itself a repetitive re-enactment of real events from the past.

People need a "safe base" for normal social and biologic development. Traumatization occurs when both internal and external resources are inadequate to cope with external

threat. Uncontrolable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the

face of danger. Adults, as well as children, may develop strong emotional ties with people when intermittently harass, beat, and, threaten them. The persistence of these

attachment bonds leads to confusion of pain and love. Assaults lead to hyper arousal states for which the memory can be state-dependent or dissociated, and this memory only

returns fully during renewed terror. This interferes with good judgment about these relationships and allows longing for attachment to overcome realistic fears.

All primates subjected to early abuse and deprivation is vulnerable to engage in violent relationships with peers as adults. Males tend to be hyperagressive, and females fail

to protect themselves and their offspring against danger. Chronic physiologic hyper arousal persists, particularly to stimuli reminiscent of the trauma. Later stresses tend to be experienced as somatic states, rather than as specific events that require specific means of coping. Thus victims of trauma may respond to contemporary stimuli as a return of the trauma, without conscious awareness that past injury

rather than current stress is the basis of their physiologic emergency responses. Hyper arousal interferes with the ability to make rational assessments and prevents

resolution and integration of the trauma. Disturbances in the catecholamine, serotonin, and endogenous opioid systems have been implicated in this persistenence of

all-or-nothing responses.

People who have been exposed to highly stressful stimuli develop long-term potentiation of memory tracts that are reactivated at times of subsequent arousal. This activation

explains how current stress is experienced as a return of the trauma; it causes a return to earlier behavior patterns. Ordinarily, people will choose the most pleasant

of two alternatives. High arousal causes people to engage in familiar behavior, regardless of the rewards. As novel stimuli are anxiety provoking, under stress, previously

traumatized people tend return to familiar patterns, even if they cause pain.

The "opponent process theory of acquired motivation" explains how fear may become a pleasurable sensation and that "the laws of social attachment may be identical to those of drug addiction." Victims can become addicted to their victimizers; social contact may activate endogenous opioid systems, alleviating separation distress and strengthening

social bonds. High levels of social stress activate opioid systems as well. Vietnam veterans with PTSD show opioid-mediated reduction in pain perception after re-exposure to a traumatic stimulus. Thus re-exposure to stress can have the same effect as taking exogenous opioids, providing a similar relief from stress.

Childhood abuse and neglect enhance long-term hyperarousal and decreased modulation of strong affect states. Abused children may require much higher external stimulation to

affect the endogenous opioid system for soothing than when the biologic concomitants of comfort are easily activated by conditioned responses based on good early care giving

experiences. Victimized people may neutralize their hyperarousal by a variety of addictive behaviors, including compulsive re-exposure to victimization of self and others.

Gaining control over one's current life, rather than repeating trauma in action, mood, or somatic states, is the goal of treatment. The only reason to uncover traumatic material is to gain conscious control over unbidden re-experiences or re-enactments. The presence of strong attachments provides people with the security necessary to explore their life experiences and to interrupt the inner or social isolation that keeps them stuck in repetitive patterns. In contrast with victimized children, adults can learn to protect themselves and make conscious choices about not engaging in relationships or behaviors that are harmful.

REFERENCES

1. Ainsworth MDS: Infancy in

Uganda: Infant Care and the Growth of Attachment.

Baltimore, John Hopkins University Press, 1976

2.

American Psychiatric Association: Diagnosis and Statistical

Manual of Mental Disorders, Ed 3. Washington, DC,

American Psychiatric Association, 1980

3. Amir

S, Brown ZW, Amit Z. The role of endorphins in stress:

Evidence and speculations. Neurosci Biobehav Rev

4:77-86;1980

4.

Anderson CO, Mason WA: Competitive social strategies in

groups of deprived and experienced rhesus monkeys. Dev

Psychobiol 11:289-299, 1980

5.

Anisman HL, Ritch M, Sklar LS: Noradrenergic and

dopaminergic interactions escape behavior.

Psychopharmacology 74:263-268, 1981

6. Arbila

S, Langer SZ: Morphine and beta endorphin inhibit release

of noradrenaline from cerebral cortex but not of dopamine

from rat striatum. Nature 271:559-560, 1978

7.

Bach-y-Rita: Habitual violence and self-mutilation. Am J

Psychiatry 131:1018-1020, 1974

8. Becker

E: The Denial of Death. New York, The Free Press,

1973

9.

Beecher HK: Pain in men wounded in battle. Ann Surg

123:96-105

10. Berlyne DE:

Conflict Arousal in Curiosity. New York, McGraw-Hill,

1960

11. Bettelheim B:

Individual and mass behavior in extreme situations. J

Abnorm Soc Psychol 38:417-452, 1943

12. Blank AS: The

unconscious flashback to the war in Vietnam veterans.

In Sonnenberg SM, Blank AS, Talbot JA (eds): Stress

and Recovery of Vietmam Veterans. Washington, DC, American

Psychiatric Press, 1985

13. Bonnet KS,

Miller JS, Simon EJ: The effects of chronic opiate

treatment and social isolation on opiate receptors in the

rodent brain. In Kosterlitz HW (ed): Opiate and

Endogenous Opioid Peptides. Amsterdam, Elsevier, 1976

14. Bowlby J:

Attachment and Loss. Vol 1: Attachment. New York, Basic

Books, 1973

15. Bowby J:

Attachment and Loss. Vol 2: Separation. New York, Basic

Books, 1973

16. Bowby J:

Violence in the family as a disorder of the attachment and

caregiving systems. Am J Psychoanal 44:9-27, 1984

17. Brett EA,

Ostroff R: Imagery and posttraumatic stress disorder: An

overview. Am J Psychiatry 142:417-424, 1985

18. Brown GL, Ebert

ME, Boyer PF, et al: Aggression, suicide and serotonin:

Relationships to CSF amine metabolites. Am J Psychiatry

139:741-746, 1982

19. Bunney WE,

Garland BL: Lithium and its possible mode of action.

In Post RM, Ballenger JC (eds): Neurobiology of Mood

Disorders. Baltimore, Williams and Wilkins, 1984

20. Burgess AW,

Hartman CR, McCormack A: Abused to abuser: Antecedents of

socially deviant behavior. Am J Psychiatry 144:1431-1436,

1987

21. Burgstein A:

Posttraumatic flashbacks, dream disturbances and mental

imagery. J Clin Psychiatry 46:374-378, 1985

22. Carmen EH,

Reiker PP, Mills T: Victims of violence and psychiatric

illness. Am J Psychiatry 141:378-379, 1984

23. Cermak TL,

Brown S: Interactional group therapy with the adult

children of alcoholics. Int J Group Psychother 32:375-389,

1982

24. Cicchetti D:

The emergence of developmental psychopathology. Child Dev

55:1-7, 1984

25. Coe CL, Wiener

S, Rosenberg LT, et al: Endocrine and immune response tos

to separation and maternal loss in nonhuman primates.

In Reite M, Fields T (eds): The Psychobiology of

Attachment and Separation. Orlando, Academic Press,

1985

26. Cohen MR,

Pinchas M, et al: Stress induced plasma endorphin

immunoreactivity may predict postoperative morphine usage.

Psychiatry Res 6:7-12, 1982

27. Cold J, Allolio

B, Rees LH: Raised plasma metenkephalin in patients who

habitually mutilate themselves. Lancet 2:545-546,

1983

28. Colt EW,

Wardlaw SL, Frantz AG: The effect of running on plasma beta

endorphin. Life Sci 28:1637-1640, 1981

29. Cooper AM:

Masochism: In Glick RA, Meyers DI (eds): Current

Psychological Perspectives. Hillsdale, The Analytic Press,

1988

30. Delaney R,

Tussi D, Gold PE: Longterm potentiation as a

neurophysiological analog of memory. Pharmocol Biochem

Behav 18:137-139, 1983

31. Dutton D,

Painter SL: Traumatic bonding: The development of emotional

attachments in battered women and other relationships of

intermittent abuse. Victimology 6:139-155, 1981

32. Eich JE: The

cue-dependent nature of state dependent retrival. Memory

Cognition 8:157-168, 1980

33. Erschak GM: The

escalation and maintenance of spouse abuse: A cybernetic

model. Victimology 9:247-253, 1984

34. Fabre-Nys C,

Meller RE, Keverne EG: Opiate antogonists stimulate

affiliative behavior in monkeys. Pharmacol Biochem Behav

18:137-139, 1983

35. Ferenczi S:

Confusion of tongues between the adult and the child: The

language of tenderness and the language of passion.

In Ferenczi S: Problems and Methods of

Psychoanalysis. London, Hogarth Press, 1955

36. Field T:

Attachment of psychobiological attunement: Being on the

same wavelength. In Re