The Truth About Trauma: CBT Is Not Enough

I reflect on childhood trauma and it's association to chronic anxiety, including factors like sensory processing sensitivity (SPS). I discuss how cognitive and metacognitive therapies can be combined with medication like Trintellix, to great effect, but n

I read Trauma the Invisible Epidemic and Feeling Great looking for a solution to the problem of my distorted thinking. The first is about how widespread trauma is and what it does to us, and the second is about the formula of success that Dr. Burns developed over years of clinical practice. I read them with the conviction that finding a way to control my thinking would control my anxiety as well. This confidence was partially right. I did need to address both my trauma and my distorted thinking.

Recently a woman told me about a situation she experienced in which someone she was close to was severely traumatized by an event they both experienced, but she was not. She did not really know why she was not effected. The psychiatrist involved in assisting after the event explained that some people are more resilient because of temperament or life experience, and that trauma tends to occur around threats that a person is sensitized to, usually from previous trauma or pain.

Trauma Sensitization

In "Trauma and Recovery: The Aftermath of Violence--from Domestic Abuse to Political Terror" Judith Lewis Herman discusses the psychological impact of trauma, including the concept of trauma sensitization. She explains how traumatic experiences can shape an individual's psychological responses over time.

Trauma sensitization is when a person becomes more susceptible to experiencing traumatic reactions or distress due to their history of past traumatic experiences. People who previously encountered trauma may find themselves more affected by subsequent traumatic events or even events that might not be traumatic for others.

Are some people more susceptible to sensitization like some people are easier to hypnotize that others? Yes, the evidence suggest this is true.

A 2018 study found that, "...Sensory Processing Sensitivity (SPS) is distinct from ASD, SZ and PTSD in that in response to social and emotional stimuli, SPS differentially engages brain regions involved in reward processing, memory, physiological homeostasis, self-other processing, empathy and awareness." The authors concluded that, " this serves species survival via deep integration and memory for environmental and social information that may subserve well-being and cooperation." That deep integration and memory can lead to a heightened and persistent sensitivity to the differential engagement. (https://royalsocietypublishing.org/doi/full/10.1098/rstb.2017.0161)

There is also preliminary work on the connection between Sensory Processing Sensitivity (SPS) and trauma sensitivity. Here are just two recent articles:

https://www.sciencedirect.com/science/article/abs/pii/S0191886921006577

https://link.springer.com/article/10.1186/s12888-021-03532-4

This research suggests that people with SPS may reinforce a response to traumatic events over time, leading to a psychological disorder in adulthood. While this may not explain the high level of resistance I experienced with CBT, (see this blog post) it seems to be a big part of it. Many years of reinforced responses shaped the way I think about some social and emotional stimuli, AND that thinking is deeply integrated. Perhaps, just perhaps, my life of differentially engaged brain regions for self-other processing, empathy, and awareness is not something I should dismiss?

Distorted Thinking

My Psychiatrist and therapist both told me the source of my suffering was distorted thinking. Not surprisingly I chose to trust this diagnosis over friends and family who said I had a lack of willpower or grit, or that I needed to develop thicker skin. Thick skin has been the dominant prescription my whole life. As if a leathery emotional barrier could be developed by anyone who set their mind to it. Obviously some people think it can. I am not sure that thick skin is something I want, or if protective clothing, metaphorically speaking, is more like what I'm seeking.

As far as I can tell what people mean by thick skin is the ability to ignore or be unaffected by insults, put downs, and other social aggression. Or the ability to face situations that would be emotionally upsetting by turning down the intensity of the feelings. A colleague I worked with called it professional detachment. I can see the value of that for surgeons cutting into someone, or soldiers shooting at other humans. But does it make sense outside of these extreme situations?

Schema therapy was very effective for me in 2013. But attempting to use it 8 years later to address a new bout of anxiety was not effective. My therapist persisted in his conviction, stating that it was a long road to change distorted thinking, especially if you didn't believe it is distorted. Our worked ended with him reminding me to remember that I slipped into my schema under stress. I needed to constantly remind myself that my narratives and perspectives were often distorted and unhelpful, or at the very least, constraining.

As noted in a post in January, I took a break from cognitive therapy because of the frustration I was feeling with not making progress. I didn't seem able to work my way out of that deeply integrated understanding of things. Instead I chose to practice Metacognitive Therapy. MCT combined with Dr. Burn's insights about resistance, and the drug Trintellix, have allowed me to "stay calm and carry on." This does not mean I am healed, have developed a thick skin, or have re-formed my thoughts.

Resistance

Dr. Burns talks about resistance on one of his podcasts. When I started listening to Feeling Great I was delighted to discover that the first thing he talks about is the difference between his first book and this one. It is what he has learned about resistance. In a curious synchronicity, I arrived at the book exactly when I had accepted my own resistance. I believed that my anxiety served a purpose, and was reasonable. I knew that just changing my thoughts was not enough.

The story of Maria in the first section of the book demonstrates the power of reducing resistance not by convincing us we are wrong, nor by showing how our thinking is flawed, but instead by acknowledging that anxiety and depression, while painful, come from beautiful, positive, awesome aspects of the who we are.

Because of this, I committed to working through the book and I figured if I dedicate 2 hours per weekend I could complete it is 8 or 10 weeks. During that time I would keep a daily journal and spend another 20 minutes or so a day completing the exercise of recording my negative thoughts, identifying the accompanying feelings, and reframing them. All together something like 40 hours of work per week. Not too bad a commitment if it works.

Too Hard

After the first two weeks of work, I began to dread the exercises. Not that they were not working, but deconstructing the thoughts of the day was contributing to my sense of futility and just how hard it was to change my way of reacting and thinking. The more I did the work, the more it showed me how much work I had to do. Changing patterns of thinking reinforced over 60 years is, well, really hard.

Too Easy

Trintellex on the other hand, stopped my ruminations within weeks. Not entirely or permanently, but subtly and profoundly. I started taking 10 mg and within two weeks was sleeping better, and my anxiety levels began to drop. Wanda noticed within a few weeks and told me I was no longer under a cloud. At first I didn't notice any downsides. I was coping with life better, and I just seemed more able to shrug things off. "She is having a bad day," I would say or, "That is outside of my control," and so on. I had been telling myself these things for a long time, but now, the emotional catch was gone, the disbelief was gone. Practicing the strategies I had learned over the years came so much easier now and were so much more effective.

So I gave up on the Feeling Great work and coasted on Trintellix. I told myself that, "perhaps I am now functioning as most people do," and it felt good to not be triggered by events and people. If people had a different opinion from me, I didn't see it as a threat, I just thought, "hunh, we sure see things differently."

After a few months of this, however, I noticed other differences. I didn't really care about what people thought, or even what they thought of me. I would initially be upset by an insult or judgement about me, a subtle put down or advice about what I should or shouldn't do. But then I would think, "oh well, it's their opinion. They can think what they think and it doesn't effect me." I congratulated myself on finally doing what I had tried to do for so long. But then I found myself noticing that I genuinely didn't care much about well, anything! I had become very blasé about everything. I had lost interest in doing the things I loved. I waded through my days like I was leaving a flooded house. An unruffled retreat. Don't step in a hole, don't lose your footing. Steady as she goes. I didn't get upset as much as I used to, though I did still get triggered by things. I thought about dying, but not with fear or sadness, it wasn't that I wanted to die, but I didn't seem to care much if I did. I just didn't seem to have much going on in my head. I felt anxiety and anger and other emotions, but they were muted in a cottony resignation.

Worst of all, where previously I had been very sensitive to the spiritual aspects of life, now I just felt spiritually in a coma. Meaning had gone out of things, I saw the goodness in people and also the selfish manipulative ways of people, but neither the goodness nor the selfishness seemed of much significance. It was what it was. Oh well, whatever.

As this awareness has grown, I was faced with a decision,

• Go off of Trintellix and return to old anxious me, but with deep satisfaction and joy in nature and creative activities.

• Stay on Trintellix, dull and uninterested, but functioning well in work, and handling the challenges of life.

• Stay on Trintellix and try to rekindle my passions, flow, and creativity.

What I learned

That was in September, and I decided to try the last one. Three months later and I have learned a few things:

1. I didn't realize how deeply I saw things till it was taken away from me. I used to spend hours looking at bugs and flowers and trees. I used to take great pleasure in simple things like walking in a summer breeze or listening to Vivaldi. When I read a description about being on Mescalin, I had a revelation. Here is the quote from Huxley from the Doors of Perception. "This was something I had seen before - seen that very morning, between the flowers and the furniture, when I looked down by chance, and went on passionately staring by choice, at my own crossed legs. Those folds in the trousers - what a labyrinth of endlessly significant complexity! And the texture of the gray flannel - how rich, how deeply, mysteriously sumptuous!"  It is perhaps a stretch to say that my life was like that before Trintellix, but not much of a stretch. As a person with SPS I took in a lot of information about the world around me, and felt both the wonder and horror of it. Huxley talked about seeing reality as it is. There is indeed great pleasure and joy in that, but also the flip-side.

2. The Effects of Trintellix have faded or I have been able to compensate. During my weeks off of work in the last three months I have had some of my old feelings of awe and tranquility. But the thought of returning to work has ignited a sense of taking on the difficult challenges that my work contains. I have that cottony feeling about it. I'm neither excited nor dreading it. I have instead a fragile resolve to bring my talents and best self to the challenges.

3. It might be tempting to say that work is the problem, but in fact that is not so. My work provides a lot of challenge and meaning for my life and without it I could easily slip into avoidance and isolation. I will have to face this problem eventually as I consider retirement in the next few years. Susan Cain's Quiet Life in 7 Steps was very liberating for me. One of the steps in about having projects. I will be planning projects to provide challenge and meaning both at work and afterwards.

4. Working with your thoughts is important, but only a piece of the story. This post by Dr. Kennedy points to a new idea for me, anxiety is not well treated by CBT.

After seeing this post I bought Dr. Kennedy's book. One of the most insightful contributions of Kennedy is a expansion on a quote from Gordon Neufeld, "All anxiety is separation anxiety." Kennedy suggests that anxiety is a pain from the past projected onto an imagined event in the future, and that the pain in the past is the pain of separation.

He also explains how children who are rewarded for not getting angry, or who are punished or shamed for getting angry never learn how to use the energy of anger to defend themselves and set boundaries.

"When you take a child's ability to be angry away from them" Kennedy says, "they feel helpless, move into victim mode, and progressively loose the ability to defend themselves. " This struck a cord with me. I remember that feeling of helplessness, from both being a victim, and from having my anger invalidated.

This confirms my long standing intuition that I needed to uncover and treat the source of my anxiety (childhood trauma and victim mentality), not just the result (flawed thinking). In my case the source was low level neglect from parents, harsh and insensitive teachers, and a general sense of being in a dangerous world communicated from parents who were themselves anxiety sufferers.

I believe now that a defining moment in my childhood was when my mother dragged me to school in grade 1, me crying and resisting for reasons I could not explain. Embarrassed by my fear and sensitivity, my mother lacked the knowledge or ability to offer comfort and support. I suspect she saw her own weakness and fear in me. I felt abandoned and began to believe that my survival was up to me alone. This belief was confirmed during years of schooling in which "skin-thickening" was prescribed. For grades 3 and 4 I had a teacher who left an indelible impression on me. She and her substitute teacher both showed remarkable distaste and intolerance of a sensitive boy like me, relegating me to the category of dunce and inattentive dreamer. Fortunately, I found teachers in high school and university who understood the value of a "sensitive soul."

Dr. Kennedy believes that a state of alarm often occurs when we face situations similar to the one's we initially found traumatic. For me, the school environment became associated with shame, especially the shame of failure. It has left me with a nuanced understanding of education. Parents and teachers of sensitive children must support and encourage them enough to create a sense of "not being alone" and being empowered, while at the same time not coddling them or enabling retreat and immobility.

If you are a sensitive person like me, and you had your own feeling separation from a parent, a sense of safety, or from yourself, then you will understand how important it is to identify that dynamic and begin the process of supporting and empowering your inner child, who still remains in you, traumatized and alone.

This will be part of my work in 2025. Caring for my inner child, and using techniques like those offered in the Anxiety Rx, to heal and move forward. One more crucial piece in my healing journey.