“When neither resistance nor escape is possible, the human system of self-defense becomes overwhelmed and disorganized. Each component of the ordinary response to danger, having lost its utility, tends to persist in an altered and exaggerated state long after the actual danger is over.”
(Herman, 1992, p. 92)
“[Abused children] will need to have the potential to mobilize an intense flight-fight response and to react aggressively to challenge without hesitation … [These survival responses] markedly augment the individual’s capacity to rapidly and dramatically shift into an intense aggressive state when threatened by danger or loss.”
(Teicher et al., 2002, p. 18)
Surviving trauma, going on each day as if nothing has happened, coping with both the normal challenges of daily life and the abnormal challenges of traumatogenic environments—all tax an individual’s belief in safety and erode the determination to live. Feeling helpless, overwhelmed, inadequate, vulnerable, terrified, and alone, the lived experience is that there is nowhere to turn, nowhere to hide, no one to help. The only resources upon which each individual can draw reside in the body: disconnection, numbing, dissociation, neurochemicals such as adrenaline and endorphins, and the animal defense survival responses of fight, flight, freeze, submit, and attach for survival. These are “desperate times requiring desperate measures.”
It is not surprising that trauma and self-destructive behavior go hand-in-hand. “Road rage,” sexual compulsivity, the inability to anticipate danger and take self-protective measures, indifference to normal safety concerns, inability to leave dangerous situations or relationships—all are congruent with past experiences of being treated as an object whose welfare doesn’t matter, whose life has no purpose other than to be used. It is no wonder that the prospect of death can be comforting as an alternative to entrapment, not surprising that wishing to die rather than live with such pain could be procedurally learned as a way of surviving. There is scientific support for this hypothesis as well as clinical evidence. Suicidal ideation, threats of suicide, and suicide attempts have all been statistically correlated with a diagnosis of PTSD, as have substance abuse, eating disorders, and self-injury (Khoury et al., 2007; Krysinska & Lester, 2010; Min et al., 2007). Even after repeated treatments for these symptoms and disorders, rates of relapse are extremely high among those with trauma histories (Najavits, 2002), suggesting that these different forms of addictive behavior have a complex inter-relationship with the effects of traumatic experience. How can we understand the coexistence in one individual of a strong will to live and an equally intense longing to die at one and the same time?
Surviving trauma requires immense determination to keep on “keeping on” while simultaneously taxing an individual’s belief in safety and eroding the wish to live. Having to cope both with the normal challenges of daily life and the abnormal challenges of traumatogenic environments is a heavy load for any human being to bear, much less a child. Having a sense that there is relief in sight; an exit plan, a parachute, or a “Get Out of Jail Free” card, brings a glimmer of hope or lessening of helplessness: “There is something I can do.” When we are very young, the only resources upon which we can draw reside in the body: disconnection, numbing, dissociation, our body’s neurochemicals (adrenaline, endorphins, cortisol), and animal defenses of freeze, total submission, or cry for help. By the teenage years, there are more options afforded us by a more physically powerful body and rapidly developing brain. As we develop during puberty, the animal defense survival responses of fight and flight become effective actions rather than the wishes and fantasies of a small child.
Whether trapped under enduring conditions of threat or triggered by everyday stimuli, and whether we are three, thirteen, or thirty, the felt sense is that these are desperate moments requiring desperate measures to survive. The choice of “desperate measure” is only limited by our circumstances and our bodies. The sympathetic nervous system mobilizes the body to defend itself in the face of threat, but when fighting and fleeing are too dangerous, the body instinctively inhibits action by freezing or redirecting the impulse. We punch the wall; imagine ourselves crashing into a telephone pole; throw something; punch or bite ourselves. Immediately, there is a felt sense of control—just as we might feel when we duck for cover, get away, or push back the attacker.
Self-destructive behavior thus has its origin in the experience of feeling terrified of annihilation, isolated and abandoned, helpless against overwhelming emotions, and filled with despair and hopelessness. Whether these states are reactions to threat and violence or repeatedly triggered implicit memories, they feel equally true (and therefore equally frightening) now. To further amplify the desperation, manifestations of vulnerability feel unsafe, too. Emotions and emotional expression rarely result in greater safety for child victims and more often provoke intensified violence—to the point that many traumatized individuals become more afraid of their feelings than afraid for their lives.
The fact that the normal sensations and emotions resulting from any adverse event are experienced as threatening, not liberating, is something important for therapists to keep in mind. In the effort to help clients acknowledge their feelings, rather than shutting down or acting out, therapists often forget that these emotions were once a source of danger and are now connected to implicit memories of overwhelm, threat, or humiliation. When clients learn instead to associate emotions that feel overwhelming or unsafe to a young child part of the self, the relationship to the feeling is altered. The client can feel the emotion still, but perceiving it as a child part’s feelings reduces its threat, reduces the client’s sense of vulnerability. It is OK for a child to feel ashamed or lonely or sad. It is even understandable that the child’s vulnerability triggers fight and flight parts. The client’s job is to mindfully notice the emotions as communications from a child part, to name them as “the little one’s sadness” or “the little boy’s fear,” and inhibit the automatic tendency to identify with the fight or flight part and act on their impulses.
Another contributor to self-destructive behavior in traumatized individuals is the absence of ways to soothe or regulate intense, autonomically driven feelings and sensations. The ability to self-soothe is directly related to consistent early experiences of soothing that condition the nervous system to settle and recalibrate until the child is in an “optimally aroused” state (Ogden & Fisher, 2015). Under conditions of inadequate early attachment followed by traumatic threat, our clients’ nervous systems learn habits of sympathetic hyperarousal to drive hypervigilence and readiness for action or habits of parasympathetic hypoarousal to ensure inaction and numbing (Ogden et al., 2006). Lacking the ability to self-regulate, overwhelmed by apparently dangerous emotions and sensations, the child’s felt sense is, “I can’t survive these feelings—if I can’t make them stop, I will explode into a million pieces—I will die.” The result: both ordinary and autonomically exacerbated emotional reactions come to feel unbearable, intolerable, and life-threatening. On the other hand, the dangers associated with high-risk behavior seem “unreal.” The client is used to surviving life threat by dissociating or minimizing the danger in order to “keep on keeping on.” Dying is not what the client fears. The client fears his or her own feelings. What feels dangerous is the implicit memory: “I can’t tolerate these emotions by myself—if no one can help me, I will die—I have to do something.”
The most common error made by professionals and lay people alike in understanding high-risk behavior is the automatic assumption that self-harm, suicidality, eating disorders, and substance abuse are destruction-seeking, rather than relief-seeking. If we assume that self-harm induces pain, then we interpret it as masochism or self-punishment or a cry for help. If we assume that suicidal ideation reflects a conscious intention to die, we will interpret it as a life-threat or a scream for help. And if we do, we will miss the core issue in self-harm: the pursuit of mastery over unbearable feelings or relief-seeking.
At the heart of all self-destructive behavior is a simple fact: hurting the body, starving it, planning its annihilation, or compulsively engaging in addictive behavior result in welcome relief from physical and emotional pain. Ironically, based on its physiological effects, high-risk behavior seems to be an ingenious attempt to cope with pain, or to live through it, in the only ways the client knows how. If we can validate that clients currently have no better way of self-soothing, if we can acknowledge why self-harm or suicidal ideation and self-destructive behavior have been successful in bringing relief—albeit in a paradoxical way—we have the opportunity to develop a collaborative relationship with the client (and the fight or flight parts) in facing the challenges of relief-seeking. Rather than reacting immediately to suicidal ideation, active addiction, or self-harm as a safety concern, the therapist should begin by communicating curiosity: what problem might this be a solution for? What triggered this impulse? What is it the client is hoping for as a result of the action? Has he or she found relief in this way previously?
Providing psychoeducation about why these behaviors are so effective in regulating unbearable states mitigates client shame and secrecy. Describing the range of positive intentions that might underlie a self-destructive impulse makes it all the more likely that clients will volunteer their doubts and fears about achieving relief in these ways, rather than trying to convince the therapist that addictive or unsafe behavior is their only or best option.
Historically, treatments for unsafe behavior have often polarized client and therapist: the therapist’s goal of reducing self-injury or preventing suicide is often in conflict with the client’s need to hold on to the one kind of relief that can be counted upon to work. Or the therapist’s agenda of “safety first” might evoke an interpersonal struggle by putting the therapist in a policing role. In this treatment model, my first priority is to help the client attend to the internal struggle: what feelings are activating fight and flight parts to such desperate measures? Which parts want to die? Which are trying to help? And which want to live? Are any of them frightened by the fight part’s capacity for violence? Do the child parts see the fight part as a rescuer or are they afraid of being killed?
To effectively treat unsafe and addictive behavior, therapist and client must be able to share the intra-personal dilemma: if self-harming, eating disordered, or addictive behavior is the only means of managing what feels like life-threatening emotional arousal, how else does the client tolerate the pain? How do therapists encourage clients to acquire or make use of the skills, resources, or treatments that are healthier options when “ordinary measures” are slower and less effective than the desperate measures? When the client’s internal experience is a sense of life-or-death urgency? Historically, the treatment approaches for trauma-related self-harm, addictive behavior, eating disorders, or suicidality have primarily addressed abstinence and safety as behavioral goals, only to discover that trauma-related triggers and an inadequate window of tolerance consistently undermine the client’s attempts at stability. To understand the complex inter-relationship between trauma and unsafe, addictive behaviors requires comprehension of the effects of these behaviors on the body and how they facilitate relief and regulation.
Child abuse and neglect, torture, domestic violence, and many other categories of trauma share a common characteristic: the victim’s body, mind, and emotions have been exploited by others, either to gratify their needs, exert control, or provide an outlet for release of tension (Miller, 1994). It is not surprising that children whose bodies have been used in this way might later become adults who instinctively use their own bodies to relieve tension or act out impulses. They have been deprived of the normal experiences of tension relief (i.e., the soothing of secure attachment), while the abuse has relegated the body to no more than a vehicle for releasing tension, with no other real value.
When distressed, most children seek connections to others, preferably adults, for soothing, reassurance, or comfort. Those who experience neglect or abuse, however, quickly learn to avoid connection, rather than seek it, and to rely almost exclusively on their own resources. Because they cannot trust or depend on others for support, they instinctively seek relief in a variety of behaviors that share one common characteristic: none requires reliance on other human beings. Some clients learned as teenagers to use drugs and alcohol to numb; others discovered in early puberty that self-starvation or binging and purging allowed them to achieve a similar state of calm or “non-feeling.” Still others, often beginning when young children, develop a variety of relief-providing self-injurious behaviors: pinching, cutting, scratching, burning, hitting or punching, head-banging, and even blood-letting.
The biggest challenge in treating self-destructive behavior is how effective it is in producing relief—at least in the early stages before tolerance develops. Harm to the body (cutting, burning, hitting, ingestion of sharp objects) has the same effects as any injury or threat: first, the harm stimulates adrenaline production (resulting in increased energy, focus, feelings of power and control, and decreased emotional and body sensation), and then a heightened endorphin release, facilitating a relaxation/analgesic effect. Both responses occur quite quickly, providing almost instant relief for the client feeling terrified and overwhelmed by the level of intensity or the disconnection.
Although eating disorders have traditionally been conceptualized as resulting from a distorted body image or distorted sense of self, it is striking that their effects quite specifically address the hyperarousal-related symptoms of trauma. In eating disorders, relief can be achieved by under- or over-eating. For example, in anorexia, restricting food intake results in numbing of emotion and sensation while at the same time, due to the effects of ketosis, there is an increase in energy and feelings of well-being. Over-eating also results in numbing accompanied by relaxation, increased parasympathetic hypoarousal, disconnection from the body, spaciness, or drowsiness. Bulimia, too, in both the binging and purging phases, causes a reduction in hyperarousal and decreased pain sensitivity via activation of the dorsal vagal system (Faris et al., 2008), the same branch of the parasympathetic nervous system implicated in total collapse and feigned death survival responses. That bulimia is associated with a higher pain threshold compared to normal controls (Faris et al., 2008), presumably because of the numbing effects of both the binging and purging, may account for the increased number of young women being diagnosed with this disorder.
Both substance abuse and addictive behaviors also tend to result in quite specific effects on autonomic arousal—as reflected in the drug-related terms “uppers” and “downers.” Cocaine, speed, MDMA (Ecstasy), Ritalin and Adderall, crystal meth, and other stimulants are the drugs of choice when clients begin to feel “dead” or “empty” but can also be used to increase feelings of power and control or maintain arousal at a heightened level in clients who fear relaxation or confuse it with insufficient hypervigilance. Similarly, alcohol, marijuana, benzodiazepines, and opiods, such as heroin, oxycodone, and morphine, all down-regulate hyperarousal symptoms and overwhelming emotions, but they can also be used to help individuals maintain a chronic state of hypoarousal in which they can be sure of not feeling or sensing “too much.” Particularly in eating disorders and addictions, any sense of connection between the drug or behavior of choice and the trauma symptoms they treat has often long been lost. Habitually “using” or engaging in eating disordered behavior prevents the intrusion of feared emotions and sensations—until the client begins to develop tolerance and must restrict, binge and purge, or overeat more frequently or severely to induce the same effect. As clients develop tolerance, eating disorders often spiral out of control. Consistent with the split-brain research showing the tendency of the left brain to create rational arguments for right brain-driven irrational behavior, clients with eating and/or substance abuse disorders will have “stories” or rationales for their symptoms: for example, “I’d be as big as a house if I didn’t ___________.” But those stories do not account for the relief experienced as a result of eating disordered behavior. They do not explain the panic triggered by the effects of increased tolerance, and the desperate need to numb the feelings again, causing increased eating disordered or addictive behavior. It may be more than a coincidence that substance abuse, eating disorders, self-harm, and suicidal behavior typically begin in the years from 11 to 14—just at the height of a teenagers’ mounting internal conflicts between the drive for independence/individuation and the fear of abandonment and separation.
Most victims of trauma face some version of the same life-threatening dilemma: how to minimize the dangers facing them and maximize the relational resources that might afford protection while simultaneously avoiding vulnerability to those who might do them harm. To minimize danger, they must avoid antagonizing the predator; they must cultivate good will while simultaneously remaining guarded. For young children, this challenge is especially difficult due to their dependence on adults and the strength of their biological drive to attach or seek proximity. They need a solution that inhibits the attachment drive without increasing the risk of abuse or sacrificing any positive attention that might be available to them.
While her mother and I conferred about her emotionally disturbed older brother’s care, 2-year-old Anya ran in, tripped over a toy, and fell hard on her chin. She started to sob but made no eye contact or appeal to her mother for comfort, nor did her mother seem to notice her crying. Seemingly oblivious to either adult, Anya pulled herself up to a standing position and started to rock from foot to foot, quietly sobbing and rocking at the same time. In her own world now, her eyes unfocused, she kept rocking until she was calm and quiet.
Attachment researchers who study disorganized attachment have described behavior like Anya’s beginning as early as age two, postulating that it reflects a solution to the challenge of experiencing simultaneous urges to seek proximity and impulses to distance or defend. Presumably wary of seeking proximity to their “frightened and frightening” caregivers when vulnerable or needy, these preschoolers begin to relate in ways that give them more control, termed the “controlling strategies” (Liotti, 2014). One group, described as “controlling-caregiving,” engages in parentified or “tend and befriend” behavior: charming, directing, entertaining, soothing, precociously independent, and offering approval and comfort to the parent. The other group of children, termed “controlling-punitive,” reacts to proximity in ways that are hostile, provocative, coercive, shaming, and sometimes aggressive or violent, putting them at risk for diagnoses of “oppositional-defiant disorder.” It appears from this research that when caregivers are neglectful, dangerous, or unavailable, safety becomes equated with the choice between appeasement or parentification, on the one hand, and hostility or distancing, on the other. Or proximity-seeking and distancing alternate in the same individual, each impulse driven by a different survival defense response: the attach or submit part’s using parentified behavior to gain greater control over closeness and the fight part’s use of hostile engagement to push others away at the same time. Because closeness and safety are intertwined when we are dependent for survival on caregivers, the implicit message is: “It isn’t safe to depend. It isn’t safe to get too close or to love those closest to you.” These patterns of attachment behavior persist into adulthood and when accompanied by structural dissociation, become increasingly sophisticated, polarized, and easily activated.
Structural dissociation facilitates negotiating unsafe attachment relationships: if the wish for closeness is held by an attach part, the ability to appease by a submit part, the need for distance by flight, the fear of attack by freeze, and the imperative to control the situation is instinctive for the fight part, then the individual has all the “ingredients” necessary to manage in a dangerous world. That each structurally dissociated part can operate somewhat independently of the others to pursue its goals creates an advantage. Quick, automatic transitions from hypervigilant to needy to distancing to robotic compliance facilitate defensive flexibility—important when you have easily provoked abusive caretakers. When perceiving trauma-related stimuli as dangerous increases the chances of avoiding trouble, and staying safe another day, this pattern is adaptive. But, once we are safe (i.e., no longer emotionally or physically dependent on abusive individuals), these defensive patterns are no longer useful. The parts still scan the environment for traumatic triggers salient to their aims and needs and react to each in their own characteristic ways. But their activation increases susceptibility to internal conflicts. The most threatening triggers every part will encounter are likely to be other human beings. Not only will angry, violent, aggressive individuals evoke strong defensive responses, so will authority figures, and even those to whom clients are closest: partners and spouses, therapists, family members, close friends, and love objects of all kinds. Tragically, those who might aid in the healing process are likely to be as triggering for the structurally dissociated parts as those who harmed them.
As these struggles inevitably lead to increasing polarization, the internal conflicts intensify. The attach part instinctively idealizes potential attachment figures (including the therapist), while the fight part is likely to become more guarded, hypervigilant, or hostile to those seeking closeness or whomever empathically fails the young parts by disappointing them, not “being there,” not caring for them, or having other priorities. Because the others in the client’s life believe they are in the company of an adult, not a child, even their most well-meaning and supportive efforts to “be there” can easily disappoint or hurt a young traumatized part’s feelings. What is well-meaning and supportive to an adult is very different than “well-meaning and supportive” to a child, as Jessica attests.
Jessica counted on her friends and their friends to help her during difficult times, and they tried to come through. But their practical offers of rides, help with finding a new job, or being treated to lunch didn’t register as “caring” to a 2-year-old attach part. She longed for a hug, for gaze-to-gaze contact, for someone who would hang on her every word, someone who wasn’t in a hurry to go somewhere after lunch. As these were not experiences generally offered to a 45-year-old woman, Jessica’s attach part was often left feeling hurt and disappointed. Complicating this situation was her fight part’s constant alertness to behavior that would wound the attach part or offend the fight part’s sense of fairness. Because Jessica’s parents had both been hypersensitive and hypercritical, the fight part’s alarms went off in the context of what her friends deemed very minor offenses. And once someone offended, the fight part remained hostile and vigilant for months or even years, refusing to allow Jessica to forgive and move on—or even to reassure the little part. Gradually, she became more and more isolated, unable to make new friends because the fight part inevitably found them “cold,” “narcissistic,” “mean,” or “not healthy enough” for her. But isolation did not solve the underlying attachment wound: the child part’s loneliness and rejection sensitivity only deepened, while the fight part’s hypervigilence increased in tandem.
Particularly as children enter puberty, begin to individuate, and become physically stronger, the fight and flight parts become more active. By age 15, adolescent parts are often physically capable of standing up to authority figures and exercising power and control over the vulnerability of younger parts (yearning, neediness, hurt, disappointment) that could potentially be exploited. It is not a coincidence that eating and substance abuse disorders tend to appear around ages 11 to 12 at a time when separation-individuation instincts require inhibition of the attachment drive but also at a time when the child’s physical strength and greater independence increase opportunities for disordered eating, self-harm, and access to substances. Sometimes this is also the stage at which a first suicide attempt takes place.
Annette could remember the time she first dreamed of dying as a solution to her situation. She was 6 years old, her mother was away at work all day, and her stepfather’s abuse became increasingly cold, calculating, and sadistic. Every day, she would promise herself: “If you just get through today, you can die tomorrow.” Then she could breathe, knowing there was an end in sight. “If you just get through today, you can die tomorrow.” It was a promise that brought welcome relief and helped fortify her for what was to come. Even after her mother left her stepfather and the abuse stopped, the wish to die remained a “fail safe” solution each time she felt overwhelmed or abandoned. She made her first suicide attempt at age 14 after the end of a relationship with her first boyfriend: she downed a bottle of aspirin.
The paradox was that, initially, the wish to die had begun as a way to live through the abuse by exerting control: “I’ll only put up with this one more day.” That sense of control brought welcome relief each time she made that promise to herself. By age 14, however, just wishing wasn’t enough to bring relief anymore. “That’s why,” she said, “I had to do something. I had to feel that I could end it.” She was not relieved to be alive still nor was she disappointed. Once she’d taken the overdose, Annette felt a renewed sense of purpose: she did have a way out when she needed it. At the same time, she was cautious to avoid detection of her suicidality for fear of “being locked up.” This continued to be the pattern until Annette was in her 30s: something or someone would hurt or trigger the younger parts’ feelings, and the suicidal part would re-establish a sense of control by threatening suicide, self-harming, or taking non-lethal overdoses, often small enough just to render her unconscious for the night until she could wake up the next morning and go on about her life. Of more concern was her use of alcohol.
After a hospitalization following the first suicide attempt at age 14, Annette felt trapped and fearful. If she couldn’t control her impulses, she’d be locked up again, but if she gave up her suicidal longing, there would be no source of relief. She began to feel an internal battle. Her littlest part longed for someone to just love her and keep her safe, but that rendered her vulnerable to men looking for sex. Disappointment in not finding someone to care triggered the child’s grief, and although the suicidal part bought a little relief by scratching her arms, Annette worried that the scratches would be viewed as signs she wanted to die. On her fifteenth birthday, some friends brought a bottle of wine, and as she drank her first glass, she began to feel “normal.” The wine relaxed the tension and fearfulness, allowed her to laugh and smile at people’s jokes—and then they smiled back, filling her little part with hope that maybe they liked her after all.
Even after individuals are safe, trauma-related triggers interfere with differentiating what is safe now from what was dangerous then. Once her stepfather was gone, Annette was finally safe from harm, but she and her parts didn’t feel safe. Her little part still yearned for the safety of someone’s love and protection; her suicidal part still brought relief by promising to end it all; and her addict part had to increase her consumption of alcohol to regulate trauma-related implicit memories and their accompanying autonomic arousal. When boyfriends left or girlfriends disappointed her, the little part panicked, and Annette was flooded with hurt and desperation—requiring yet more wine. As the years went on, though, her once trusty chemical support began to fail her: to make the feelings go away, the flight part now had to drink to blackout. But when she blacked out, what happened next re-exacerbated the disturbing feelings instead of easing them. All too often, her nights out at the bar with her trendy young professional “family” of drinkers ended in blackout, and she would find herself in a stranger’s bed the next morning.
Self-destructive behavior stems from a “perfect storm” of variables: first, a trigger evokes trauma-related implicit memory. Second, the implicit memory’s association with danger activates the emergency stress response, inducing a sympathetic nervous system reaction and shutting down the prefrontal cortex, impairing the individual’s judgment and disempowering the normal life self. Now, parts with conflicting defensive responses have free rein to act on their survival instincts, leading to some action intended to bring relief—whether it is binging and purging, cutting, a suicide attempt, addictive behavior, or restricting food. For a short time, perhaps only minutes, clients report a temporary feeling of control or well-being that reinforces the connection between the aversive feelings, dysregulated arousal, and immediate need for an action that will bring “relief.” Because often there is little felt connection between the apparently benign or mildly distressing trigger, the hurt and sadness or shame of child parts, and the impulsive behavior of fight or flight parts, even the client does not understand his or her behavior except as a statement about the actions taken: “I want to kill myself.”
Stabilization of high-risk behavior requires addressing “the parts’ part,” a step not included even in newer, cutting edge treatments. Dialectical Behavior Therapy (DBT) addresses the skills needed by the normal life part to tolerate the dysregulated emotions of the traumatized parts but does not address fragmentation or how to differentiate the normal life self from the parts. Internal Family Systems (IFS) addresses the role of the parts but conceptualizes self-destructive behavior as an expression of “firefighter” parts trying to suppress vulnerable “exiles” (Schwartz, 2001). In IFS, the normal life self is thought to be a “manager” and its emphasis on functioning just another way to keep the exiles out of mind. In this model, the normal life self is a competent present-moment-oriented aspect of the individual able to provide social judgment and “top-down” behavior management but is also capable of curiosity, compassion, wisdom, courage, and calm. In IFS, those qualities (along with clarity, confidence, and commitment) are reserved for “self” or what I call “wise mind” or the “wise self.” Sensorimotor Psychotherapy (Ogden & Fisher, 2015) is the only treatment model for trauma other than Somatic Experiencing, that focuses on the contributions of autonomic dysregulation and animal defenses to post-traumatic stress disorders but lacks, as does IFS, specific interventions to address unsafe behavior. Each (IFS and Sensorimotor) encourages a mindful interest and curiosity in the habitual patterns rather than a solution-oriented approach to safety issues. In IFS, the therapist understands the firefighters as motivated to protect and defend the exiles. In Sensorimotor Psychotherapy, unsafe behavior is framed as a “survival response” to autonomic dysregulation.
Trauma-informed stabilization treatment (TIST) (Fisher, 2015) is a treatment model developed to stabilize severe self-destructive behavior unresponsive to conventional treatments. TIST was initially developed in the context of a paradigm shift in the State of Connecticut’s Young Adult Services, a division under the Department of Mental Health and Substance Abuse. In an attempt to help some of its most severe cases in the age range from 18 to 25, a daring decision was made to explore the impact of trauma-informed approaches, given that a high percentage of these chronically suicidal, self-destructive clients had histories of severe trauma. The patients for whom the program was first designed had been given many different diagnoses over years of mental health treatment in inpatient and residential settings. What they had in common was an early childhood history of trauma followed by symptoms of severe self-injury, suicidality, substance abuse, eating disorders, and aggression toward others, primarily staff. All of them had been hospitalized for more than six months and as long as 10 years. Their difficulties in benefiting from existing treatment models resulted from the lack of a method that could simultaneously address the separate components of their self-destructive behavior: its origins in their traumatic past, trauma-related triggering, loss of perspective and judgment due to cortical inhibition, and the degree of relief experienced as a result of the behavior. By using the structural dissociation model as the theoretical foundation for TIST, each separate variable contributing to unsafe actions in a client could be identified and each of the self-destructive impulses could be externalized and assigned to the appropriate part. That single intervention in and of itself immediately supported the clients’ identification with the going on with normal life self, loosening the identification with the suicidal and self-harming impulses. To ensure that the model was not perceived as shaming by clients, all aspects of self (including the suicidal part) are consistently described in terms of their positive contribution to survival.
When treatment models conceptualize self-destructive behavior as pathological, “borderline,” or manipulative, and judge inhibition of unsafe impulses as “healthy,” attention is diverted away from the underlying issue: the internal struggle between conflicting drives. Should the client seek relief in impulsive action or find a way to bear the pain and go forward? Successful treatment of any conflict requires acknowledgment of all sides or parties involved, not just those toward whom we are biased. Although on the surface it seems that the answer should be easy, it is not. With no hope or belief in the future, with emotional vulnerability intensified by autonomic activation and adrenaline-driven fight-flight impulses wanting discharge, it is hard for traumatized clients to believe that “keeping on keeping on” has much chance of success. To resolve the struggle, clients have to learn to trust that all their parts are committed to survival in different ways; that even their most intensely suicidal parts “want to die in order to live.”
“I feel suicidal” is an utterance that strikes fear in the heart of any therapist because it implies that the whole being of the client wants to die, that danger is imminent. The TIST model makes a different assumption. It assumes that the wish to suicide reflects the point of view or impulse of one part but not necessarily all. The question we must ask before jumping to any conclusion is: which “I” feels suicidal? The depressed part? A suicidal part? What triggered this part or parts? What is driving the impulse or feeling?
Once broken down into its component parts, the suicide threat might just mean, “My little part is really sad and disappointed, and the fight part is trying to prevent her from future rejection by threatening suicide.” Or it could mean that the suicidal part has been triggered by the child’s tears and frightens her to stop the tears. Or perhaps it means that the depressed part just wants to go to sleep and never wake up again. Each of these answers would require a different solution—which we cannot provide without gaining an understanding of the parts. In addition, TIST would ask: where is the normal life self? Why is he or she missing in action? What could the normal life part do to find out more about what is happening or to soothe distressed parts? Is the normal life self temporarily disempowered by the intense emotions and impulses of the child parts or the fight and flight parts? Or is the going on with normal life self just watching helplessly from a distance?
Most human beings would agree that criticism is not motivating; that suppressing or blocking feelings results in either depression or anger. Yet these are often the treatment approaches used with suicidal, self-destructive, eating disorder and addicted clients. The message is: these impulses or behaviors are wrong—they are dangerous—and we are going to help you stop engaging in them. To fight and flight parts, this approach is tantamount to waving a red flag at the proverbial bull. It alienates and polarizes the parts whose trust we most want to win, whose motives we want to understand. It can undermine a normal life self who is sincerely trying to work with treatment providers but keeps being told she or he is not trying hard enough—when in fact no amount of “trying” by the normal life self can stop parts driven by adrenaline and convinced that their only safety lies in action. In the TIST model, the intentions of a part are differentiated from its actions: what is the suicidal fight hoping to accomplish? How is it trying to protect the client? The following example describes the first client treated with the TIST model as it was first being developed in a state hospital setting. Katya illustrates how switching from a uni-consciousness model to a parts model and from a treatment method for borderline personality to a treatment approach for trauma could quickly change the treatment picture:
Katya had been hospitalized now for well over 2 years because of her unrelenting suicidality and self-injury, drug use, and violence toward staff. Although Katya recognized the role of her fight part once the new treatment model was described to her and validated its contribution to her survival, its determination seemed to increase with each unsafe event. Sometimes, Katya could unblend and differentiate herself from the fight part’s violent impulses by repeating as a mantra: “It’s just the fight part—it’s just the fight part—I don’t have to do what it says.” But sometimes the fight part hijacked her seemingly “behind her back,” and suddenly an act of aggressive or self-harming behavior would occur. Worried that the suicidal fight part was treading too close to the edge, I decided it was time that Katya and I found out what was driving it. I inquired, “Could you ask the suicidal part what it’s worried about if it pauses and takes some time to let you work on all this? What is the suicidal part afraid will happen if it stops trying to kill you?”
Even Katya was surprised by the answer. “The fight part says: ‘It’s the only way to push people away—they can’t hurt you if they can’t get close.’” In the hospital, she had developed close relationships to certain staff who would comfort her little parts, joke around with the adolescent parts, and connect to her normal life self. But the fight part had pushed away her family and successfully convinced her fiancé to end their engagement because he couldn’t tolerate the fear that she might die. Hearing the suicidal part’s agenda evoked panic in her attach part and worry in her normal life self: what about her wish to love and be loved? To marry and have children someday?
As I coached her, Katya asked the suicidal part: “What would you need from me to trust that I could handle these relationships that I want to have?” The suicidal part replied, “I would have to believe that you would be OK, that you couldn’t be devastated.” It would take many months for Katya to prove herself to the fight part and many more months to finally be approved for discharge from the state hospital.
Today, she lives on her own, with the love and companionship of her cat, the closest comfort to her attach part and the emotional center and regulator of any negative feelings. She is proud to have grown into the normal life she once dreamed about, a life that includes college classes as well as caring for herself, her apartment, and her cat. The fight part now trusts her to choose relationships well and to soothe parts that might feel hurt or rejected by others before their implicit memories are triggered and become overwhelming. She in turn trusts the fight part to discriminate when people are taking advantage of her or expecting too much. Now, with growing communication and collaboration, Katya can heed the fight part’s warnings and set boundaries before it reacts aggressively to potential threat. Her ability to comfort the attach part reduces the sense of aloneness and vulnerability, allowing the fight part to sit back and leave her to do her job.
By learning to “ask inside,” Katya learned how to dialogue with her fight part, rather than interpreting its behavior, until she finally discovered why it was so determined to lead her down a self-destructive path, even if that meant she was “incarcerated” on a locked ward in a state hospital. When the fight part acknowledged its primary purpose was to keep her safe from any attachment, even to her parents, the last few years suddenly made sense to her. Knowing how much she and her attach part yearned for closeness, she had immediately understood what she’d have to do to be free to live her life as she wished it to be, rather than the way her traumatic experiences had dictated that it be. Having almost died many times, it was clear that her fight part was unyielding and would ultimately have its way if she didn’t do something different.
Today, Katya is not reliant on anyone other than her cat for regulating her emotions and actions. She takes no psychiatric medications, no longer goes to therapy, and has been discharged from the Department of Mental Health system. The parts seem to feel safe with her, safe enough to allow her to set up a Facebook page to make contact with others and share her story of survival and redemption. When she first was assigned to the new “trauma program” I developed in the hospital, the pilot version of what has become the TIST approach, she immediately felt a sense of pride: she wasn’t sick; she had been harmed, and she was receiving special services as a result. With a basic understanding of trauma that helped her see her symptoms as logical and meaningful, she felt less unworthy. As a “trauma patient,” she was being treated as someone who deserved something more than medication, restraints, and injury-proof hospital rooms, someone who was intelligent and capable of participating in her own recovery. She kept repeating to her staff, “I needed a trauma program, and I finally got one—this is what I’ve needed all this time.”
The opportunity to change her relationship to her symptoms, to make meaning of them as a legacy of the trauma, and to externalize them as communications from her parts all helped Katya to “disidentify” or “unblend” from the parts, rather than continuing to interpret their actions and reactions as her own. She could begin to differentiate her willingness to work therapeutically as evidence of an intelligent, motivated normal life self and feel a greater alliance with the staff who wanted to help her, rather than “believing” the hypervigilant suspicions of her fight part or the desperate seeking of contact and validation coming from the attach part. As she identified with her normal life self, without a loss of compassion and loyalty to her young parts, they relaxed ever so slightly—enough that she was less often triggered and more often able to recognize when she was. This process of separating “whom she was meant to be” from the actions and reactions of the parts and learning to regulate their strong responses sufficiently so she could interrupt the fight part’s acting out took several years. It required a few of the staff who embraced the TIST model to repeatedly and consistently help her translate her emotions into parts language, connect the feelings and impulses to those parts, feel empathy toward them, and, trusting that this process would allow her to avoid acting on the fight part’s impulses, tolerate the risk that she might die before her team could help her learn how to help the parts.
As in Katya’s case, suicidal and self-destructive parts are typically activated by the distress of younger parts associated with the experience of traumatic attachment. In the TIST model, the major focus is not on inhibiting the impulses of the fight and flight parts. It is on anticipating and soothing the emotional activation of young, vulnerable parts before the fight and flight parts take action. First, clients are helped to recognize the signs and symptoms of distressed child parts because even before the client has the ability to “help” them, their appearance can be used to anticipate unsafe situations. The therapist must model mindful observation of “domino effects,” patterns in which triggered parts trigger other parts that trigger other parts that eventually trigger fight or flight.
I decided it was important to make Terri aware of the relationship I was seeing between her suicidality and a disowned young part of her. Because I believe that timing and readiness are everything in psychotherapy, I had waited several months—until a moment when Terri expressed her own anxiety about the prospect of future crises: “My boss told me that if I’m hospitalized again, he can’t keep me on in my job. No matter how good I am at it. I don’t know what to do. I can’t tell him I’ll never make another suicide attempt!”
ME: “Hmmm … That is a problem, isn’t it? Maybe there is a way around this. I’m observing a pattern: have you ever noticed that the suicidal part only gets activated when your depressed 13-year-old is having a hard time? I know you try to ignore her so you can keep working, but I think being ignored just reminds her of never being seen—never feeling she mattered to anyone. It seems to me that the suicidal part deserves to be thanked for getting us to listen to the 13-year-old at last! I don’t think the suicidal part wants to die (or kill anyone), but it’s clearly stating that it won’t stand for her to be left alone to suffer.” At first, Terri pooh-poohed this theory and insisted she didn’t have parts, so it was irrelevant. I nonetheless continued to watch for signs of the 13-year-old’s deepening depressions so I could warn Terri that the suicidal part wouldn’t be far behind.
In this instance, the depressed part was a very accurate barometer for anticipating the sudden impulsive actions of the suicidal part, which almost always resulted in months of hospitalization. By intervening to help the 13-year-old by acknowledging her distress before a crisis ensued, suicide attempts could be more predictably warded off in time to prevent threats to her job and threat to life.
Often, depressed parts are the triggers for unsafe behavior. Sometimes, parts who communicate via flashbacks and memories are instigators of fight or flight parts: the body and emotional memories of young parts intrude upon the consciousness of the normal life self to communicate that they are afraid they’ll be hurt again, that no one will believe them, that they need protection. The somatic message that things are still unsafe might then trigger fight parts to protective action, for example, to end the risk of being hurt again forever. Ashamed parts are also triggering for the fight part, evoking a painful vulnerability that is intolerable to a part whose biological imperative is to gain control over the enemy. When the therapist can predict the risk ahead of time and help the client’s normal life self provide soothing and a sense of no longer being alone to the vulnerable parts, the risk of impulsive behavior diminishes dramatically. Clients are taught the Internal Dialogue Technique (see Appendix C) and asked to practice it in therapy sessions until their ability to regulate parts’ unbearable feelings grows sufficiently that they can use it independently of the therapist.
“No part left behind” is the motto clients are taught and the standard to which they are held. This standard challenges the survival strategy of self-alienation. As functional as the normal life self might be, he or she will not be allowed to abandon the parts responsible for survival. The ashamed part, the frightened part, the addicted or eating disordered flight part, or the suicidal, the angry, self-injurious or justice-seeking fight part: all deserve respect and compassion.
When clients are held to the “no part left behind” standard in therapy, the threat of abandonment, which for children is as frightening as the threat of annihilation, is lifted. The parts, hearing the therapist speak on their behalf, have a reparative experience: someone has heard them. The normal life self, I know, will also feel grateful later on as the parts’ attachment to him or her grows. Being loved by a small child feels pleasurable to both parties, as every parent knows. And when a mindful normal life self can interpret their implicit memories as “just a feeling” or “just a memory” and develop greater ability to soothe and regulate “their” responses, the parts begin to feel safer. Now a new, safer and more satisfying internal environment can be established.
In a world that feels safe or safer, traumatized clients can learn to use their capacity for inner communication to co-create a life they were “meant to have,” rather than living a life dictated by the trauma. Each part can play a valuable role after trauma. Not only do the parts offer survival defense responses but other important resources as well related to their specialized roles. The fight response, for example, provides increased energy, “grit” or determination, a “backbone,” refusal to give way, and the ability to guard our rights and privileges. As the client’s normal life self learns to ask the fight part to “give me courage to say No,” or “give me the strength to hold my ground,” there is a surge of energy or increased strength in the core or spine. The normal life part now has other resources for change and growth; the freeze part feels a bodily sense of being protected; the submit part is not freely “used” by others, and there is energy to counteract its depressive hypoarousal; the flight part doesn’t have to run for cover because the parts are safe “here now.”
Robert was a tall gaunt 70-year-old man, tormented since his early 20s by voices warning him that someone wanted to kill him. Having witnessed his mother beaten nearly to death by his abusive father, the fear of being killed was very familiar to him, and since he was a young boy, it could only be soothed by the longing for death. Only his devout Catholic faith prevented him from committing suicide, no matter how much he felt compelled to end his life.
After 2 years of helping him stay alive, I was in his hospital room to say goodbye as he faced death from end-stage cancer. His “wish” was at hand, and he was terrified. “All my life, I’ve longed to die—but now that I’m really dying, I’m scared—wanting to die gave me control—dying is taking it away.” In the 20 years since I said goodbye at his bedside, I’ve taken his wisdom with me: wanting to die is about taking control, not about wanting death.
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