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Welcome to Therapy Tuesday, Smashboard's fortnightly podcast for people looking to have conversations about mental health from a feminist perspective. I am Noopur, founder, Smashboard and joining me today is Dr. Debbi Kutner. We are going to be talking about trauma and triggers, about c-PTSD and about how to support loved ones who live with the condition or also the kind of support we can expect from our own entourage when we are living with c-PTSD.
Dr Debbi Kutner is joining me from her home in Florida. She is a mental health counsellor with a PhD in Health Psychology. Health psychology basically focuses on how different layers like biology, psychology, cultural, social, and environmental factors influence health and wellness. Thank you so much for doing this session with me Deb.
Question 1: Firstly, I want to acknowledge that this is a difficult time for mental health care workers, as well. In fact, this show is generally hosted by Ruchita who has also been working very hard and it's primarily to give her a break that you and I are doing this together, Deb. So, thank you for doing what you do because it is very important work. Secondly, tell me how are you doing and whether the worst is really over in terms of what the pandemic has done to people's mental health?
Dr Debbi Kutner: You are VERY kind to ask, Noopur. To be honest, some days I feel like I’m taking a cortisol bath with anxiety bubbles! I’m in the human condition with my clients. We are having a shared feeling of trauma, a shared emotion of feeling uncertainty, and though we might each experience various shades of stress, I think it’s important to say to ourselves: I am not alone in this.
And here’s the truth, none of us are experts on how to make sense of this pandemic EXCEPT to follow a path of self-compassion; to allow ourselves to bear witness to what’s happening in the world; and to know that our only control is in our moment-to-moment responses, We shouldn’t always need to put on a brave face when we feel distressed, or pretend that this is all somehow okay, because we are expected to be resilient. We really need to gently give ourselves permission to say whatever it is we are feeling. This is a moment of suffering and trauma. And again, I am reminded that this IS what it feels like when we struggle. I DO love that so many of us are nurturing our resilience, but I also feel like there’s an increasing sense of exhaustion. Resilience fatigue. And you know, resilience is a finite source. For SO many of us, the mantra is: push through; chin up; no time to be sad, angry, or frustrated. So basically, just suck it up. And I, for one, just want to have my moments of emotional messiness, create some art whenever I can, and sip my glass of whisky in the evening. I want everyone to know that we are not falling short just because we need a "time out" from being resilient.
I really think our singular responsibility, right now, is to acknowledge this reality, but also to do our best to stay connected to others; and to stay connected to ourselves. It’s NOT easy; there is nothing easy about it. And there is no right or wrong way; no simple technique.
I actually remember, at the height of lockdown in early 2020, walking to the grocery store in the city of Philadelphia, where I was born and raised, and the storefronts were boarded up, the streets were eerily empty, and people’s homes became their workplace, school, playground, refuge, and also a really frustrating place of confinement. And so many people I spoke to doubted if life would return to normal, and many of my colleagues speculated, me included, if the post pandemic world would lead to a mental health avalanche. And I think, with all the research I’ve been reading, and the people I’ve been counseling during this past year, that there is a percentage of us that isn’t going to feel a sense of normal for a long time after the majority of us do, because the pandemic has triggered, or worsened, other mental health issues. But if we view emerging from this pandemic as post traumatic growth, there is an opportunity for us to rise from this experience with a deeper sense of purpose and meaning. The growth can be that we just might become a kinder, more open, more self-reflective, and more self-compassionate person. Without trauma, and I do NOT say this to mean that we should all experience deep pain, but without pain, I don’t think that immense growth can actually take place in the same way. Pain can be an ally if we let it.
Question 2: Pain can be ally if we let it.. Deb, it’s interesting that you say that esp. since we are talking about trauma and triggers and about c-PTSD today… I thought the best thing would be to really understand from you what c-PTSD is first. To get done with the slightly technical part first. A lot of people do know about PTSD as something that occurs after a single incident or an experience that shocks a person into trauma Natural disaster, a violent encounter, an accident…. is c-PTSD different from PTSD?
Dr Debbi Kutner: Great question and many people don’t even know there is a term complex post-traumatic stress disorder, or c-PTSD. Complex PTSD is slightly different than PTSD.
When we talk about PTSD, we are really talking about a single event. When we talk about complex PTSD, we are referring to a series of events, or even one prolonged event. While PTSD might occur after an incident like an accident, or a natural disaster, or a single episode of sexual assault or other violent encounter, like you mentioned, complex PTSD can include sexually, physically, emotionally, or verbally abusive behaviours. So complex PTSD is a term specifically used to capture the profound and often disabling arc of psychological harm experienced by chronic trauma. I want to differentiate between males and females for just a moment. Violence, and its aftermath, is a transient experience for most men. On the flip side, violence against women is likely to be prolonged. Repeated. And that’s probably a significant reason why the lifetime prevalence of PTSD for women is doubled.
Question 3: I think it’s very important what you are saying here about the prevalence of PTSD being doubled for women and how men experience most of their violence as transient whereas for women it’s something that lasts longer and it's something that a lot of women have to live with. I would like our listeners to understand how this disorder or disturbance affects a person, what they are feeling and experiencing in their day to day lives, and why that makes it difficult for them work with people, to generally relate to other people whether it's close relationships or any other kind of relationships.
Dr Debbi Kutner: So, here’s some additional layers to complex PTSD. First, there’s a change in self-concept, like the foundational question of “who am I?” after experiencing trauma. Then there are difficulties with emotional regulation, which is the ability to manage the intensity and duration of those negative emotions. How a person once coped with everyday stress might very well not work after trauma. Coping skills need to be relearned; sort of rewiring the brain for healing, because you may also have a hard time feeling safe. Just being able to self-sooth, to calm, to feel peaceful. New strategies need to be adopted and practiced.
The emotion regulation center AND the thinking center in our brain are under-activated after trauma, sort of like dimming the lights, while our fear center is painfully bright. Lit. Up. It’s overactivated, like we’re constantly in a fear response mode: fight, flight, or freeze. So, on a daily basis, you might operate on a frequency of chronic stress, fear, frustration, impatience, hyper-vigilance, and a lack of concentration.
Another serious challenge is chronic sleep loss, because sleep can be really elusive. Nightmares and other disturbances totally disrupt the sleep cycle. Then there are everyday triggers, which can really take a person by surprise. And those triggers might begin these often vivid, really frightening, and unwanted recollections OF those traumatic experiences. It can feel totally paralyzing in the moment. Also, it can really impair relationships with other people, because trauma can create disorganized attachment patterns.
So, in counseling, we really need to be mindful to address all of those things, which are on the spectrum for everyone who goes through complex trauma.
Question 4: Coming to the word "trigger" now. It’s a word that is often used by people very casually. Personally, as someone who has lived through triggers, I know that they are extremely painful episodes, they feel very threatening, and can cause upheaval for a number of days. A lot of people use word "trigger" also for things that make them very angry or very upset. Which I find problematic. But then some people could also be living with all kinds of trauma- because of systemic oppression, or intergenerational trauma because their families were uprooted, or children died in their families, or they are battling poverty or chronic illness. Are all these people living with c-PTSD? And do they experience triggers in the same way as say, somebody who has faced sexual abuse, has been raped or has experienced a generally very abusive relationship, emotionally abusive relationship? I don't mean to create any hierarchy here but I do want to understand what "being triggered" and "living with trauma" mean and how the diagnosis of c-PTSD could perhaps be something different.
Dr Debbi Kutner: Let’s start at the beginning by looking at human development as a lifelong process; so, in early childhood, then beyond, through middle childhood, adolescence and youth, it’s about focusing on all the things that nurture growing into a cognitively complex, mature, and competent person. And that’s not one thing. It’s physical, cognitive, social and emotional competencies intersecting so a person can fully engage in relationships and in the world. So, our development is the product of complex nuanced transactions between individual action, our genetic makeup, biological and physiological maturation processes, and external forces. I don’t view any one thing as deterministic, and I don’t believe there is a one size fits all to experiencing trauma. And like I said before, trauma can cause an array of emotional health issues that affect development. So, it becomes a developmental cascade. There’s a dynamic relationship between human development and the changing nature of these other influences over the course of time. These become crucial to development, because exposure to adversity can have different effects, and at different stages of life. And multiple adversities over time can have cumulative effects. Now let’s talk about triggers. It’s really anything that can remind a person of past trauma that causes distress. But I don’t want this to be confused with just being uncomfortable. For people with a history of trauma, being around anything that reminds them of the traumatic experience can bring that trauma back to the surface, as if it’s being experienced again. While using the word “trigger” is more commonly related to people living with PTSD or complex PTSD, it’s important to remember that these diagnoses are the umbrella terms that describes a dysfunctional reaction to trauma.
Question 5: And now to what I think is the most important question. How can we help someone who tells us that they are living with trauma or that they are triggered? What about communication between 2 people whose symptoms of c-PTSD are very activated at the same time? Can they help each other?
Dr Debbi Kutner: I think the first important thing to help someone feeling triggered is to validate them. Don’t question their feelings, or try to have that person rationalize emotions, because their fear response is activated. And you can’t shame, critique, or minimize another person’s emotional response to a trigger and expect that person to feel peaceful. So, it’s really important be gentle, because a person feeling triggered needs to be approached with care and empathy. I think two people who have suffered trauma can be very affirming for each other. It’s that bridge of understanding. They can help each other in the positive meaning making process, in growth post trauma, or what’s referred to as PTG, which is post traumatic growth, and ultimately in the transformation of their experience.
Question 6: I also want to talk to you a little bit about medication, Deb because there is a lot of stigma attached to taking anti-depressants or medication that is anti-anxiety. Among your own patients, have you seen a difference between those who do take anti-depressants or anti-anxiety meds and those who don't?
Dr Debbi Kutner: In my experience, people stick with a treatment plan that makes sense to them. If a doctor hasn’t thoroughly explained medication, and the client doesn’t understand how that medication might help, then the client isn’t going to be open to incorporating it into treatment. I think of medication as a helper. It’s more like something that helps dissipate that layer of inner fog and supports the healing work. But medication is not a cure-all. For anxiety and depressive disorders, talk therapy, antidepressant and anti-anxiety medications have all been shown to be helpful. Yet research also shows that psychotherapy is more effective than medication, and that adding medication doesn’t significantly improve outcomes.
Question 7: I think it’s very interesting that you say that medication is a kind of helper. I can say that some of the people that I have spoken to who are on medication and I myself have taken anti-anxiety medication before and I feel that it's something that gives you a break that you need to sort of get started on the other kind of healing that you have to work on. I really like that you call medicines a “helper” and there’s also the placebo effect we shouldn’t rule out. Anyway moving on, a lot of times we hear people accusing those living with c-PTSD of "using" their triggers to have their way (which I am sure happens but I also know that sometimes the slightest mention or request to people to consider your triggers either spirals off into a mental health Olympics or is perceived as an assault). How can we navigate through all this with mindfulness?
Dr Debbi Kutner: Mindfulness is self-care. And I love to talk about self-care, self-compassion, and practicing loving kindness. My clients all know these are my favorite words! In my practice, it’s the trifecta of healing. I think what self-compassion and mindfulness can’t do, however, and this is what I try to explain in therapy, is that they can’t make life’s challenges smaller. So being mindful and self-compassionate is not going to change any shit going on out there. BUT what they CAN do is make US bigger in relation to those challenges that we’re facing.
We really need to honor OUR emotional responses within our own experiences. So, what I’m really saying is that it’s important to make room for all that complex PTSD brings. We tend to judge our feelings and categorize them: right; wrong; good; bad. And there isn’t any correct way to heal…or emerge from trauma…or deal with anxiety…with pain…with loss…with suffering. What is “right” or “good” means how it feels the most peaceful within. That’s different for each of us. It’s giving ourselves permission to be in the present moment without judging the present moment. It’s part of our habit…this go-to self-critical place…to judge who we are in our experiences. And when we’re having a good experience, especially in the healing process, we may try REALLY hard to hold that tightly, to clutch it because we want to keep feeling it. Like: I can’t let go of this calm because I’m afraid to lose it…because the pain will be there...and that doesn’t feel safe. So, we become anxious about the experience ending. But this grasping prevents us from fully being mindful…from fully being present…in the moment…with that feeling of empowerment and peace. On the flip side, if we label an experience as bad, we often try to run away from it, protest it, or ruminate about it until we are emotionally exhausted. We forget that the experience is temporary, and we become afraid that the pain won’t subside, it won’t ebb, and so once again, we lose our connection to the present experience. When practicing viewing experiences with a non-judgmental mind (and I mean YOU…and ME…in our own experience)…we sit with whatever we are feeling…whatever we are experiencing in that moment…not viewing it as good or bad…not judging it…or judging ourselves…on any binary point…but just as it is…knowing that we can float between all points. Acceptance is in NO way any form of complacency. We can gently acknowledge our pain and still actively BE in the healing process.
Question 8: What are some of the things that people living with c-PTSD need to do to make those around them aware of how they might sometimes (over) react to things and how can they communicate to people what they need from them in such situations to sort of feel safe and to act in ways that don't hurt anyone?
Dr Debbi Kutner: I think disclosing that you have complex PTSD to people in your life, especially those in your sacred circle, is really important, because people who love you can be the very best source of support. And we know that social support has been found to be incredibly beneficial for people with complex PTSD. Also, telling others about your diagnosis can be a very stressful thing to do. I think in order to make others aware of what complex PTSD looks like for you, it’s important that you understand the diagnosis yourself. Knowledge is power, right? So much of mental health issues are misunderstood, so I say: edify yourself first. Because when you begin to tell others about what you need, they just might have a few questions. And if there is something you are uncomfortable talking about, it’s perfectly okay to say: “I'm sorry, but I’m just not ready to talk about that yet”. If you don’t know or remember the answer to a question, it might be super helpful if you can direct that person to an informative resource on complex PTSD; maybe a resource that you found personally helpful.
And you know, disclosure is really personal. You don’t need to tell everyone. And you definitely don’t need to say everything. For instance, you don’t need to speak about your specific trauma when you talk about your diagnosis. Share information with those people in your life that are actually going to be a support. People you trust. Those you have a close relationship with. Because it’s those people who can create a safe space for you.
When you understand the foundation of complex PTSD, then you can explain common symptoms and behaviors, what they look like for you, because again, no diagnosis is a “one size fits all”. You can also explain what triggers you have experienced before, whether it be people, certain situations, sounds, or memories. and what you need in order to feel safe. If there are certain coping skills that really help soothe your nervous system, then share what they are. It’s great to create some type of action plan. Like, if this happens to me, if I am experiencing these symptoms and behaving or reacting in a certain way, then you can do A, B, or C to gently address what’s happening and support me in that moment.
Question 9: Yes, that’s really important I mean also this A, B or C you can ask someone to do for you, you have to know what these have to be which brings us back to what said earlier the need to edify ourselves, to know what’s going on with us and perhaps read more about c-PTSD- there are amazing reference books that are out there and we can perhaps attach a list at the end of this podcast, I mean in the text that is available with the podcast. Going on to people who are in a difficult stage… Different people are at different stages of healing in their trauma, their c-PTSD. There is always a point when we haven't yet started to heal… the journey hasn’t started and that is when the pain that it all brings seem unbearable… where recovery almost seems impossible. What is the one thing you'd say to someone who finds themselves in that place today?
Dr Debbi Kutner: I would first say: you are much more than the wounds you carry.
But of course, I never have just one thing to say, because many of us who have experienced trauma and have PTSD or complex PTSD protest our anguish. And I think it’s a relief to just acknowledge our suffering as REAL. It’s so important to validate those feelings. So, I would probably also say something like: I know it seems sort of distant, before the waves of healing come, talking about self-compassion when you are in pain. I know it probably seems almost too simple. I've definitely asked myself: is this really the first step? Isn't there something more concrete to just make this pain stop? And self-kindness…especially when we are suffering…should be more instinctual...but it's not. It needs to be cultivated. Nurtured. Planted like seeds and grown. So self-compassion is a process. There is simplicity and complexity to that process.
It's much like how I would describe the healing process. Because as extensive as post-traumatic stress feels, there is also the expansiveness of post-traumatic growth. Recovery takes time. And yeah, it can feel so damn tiring. And from personal, and professional, experience with trauma, I think many of us would like the Universe to just stop for a moment. I know, in my greatest times of emotional pain, I wish things around me would just BE STILL. But everything keeps moving. And so do we. And so does the process of grieving what was lost. And…so does the process of becoming. Of unfolding. The process of reconnecting; of redefining our sense of identity. It's fluid; it's continual. The path is not linear. It's really like the ebb and flow of the tides…what healing can feel like…riding those waves into shore…and then feeling pulled back with force. There are times the waters are so choppy it feels like you can’t keep your head above the waves. Like you are drowning. And then…you find yourself in a moment of calmness…and you can take that breath. So, it’s really an organic cycle. Ebb tides are one half of this natural movement. And flow is the counterpart; the balance. There cannot exist one without the other. This IS healing.
Question 10: Is c-PTSD something one has to live with forever?
Dr Debbi Kutner: If we look at trauma as an impetus for a process of powerful meaning-making that can lead to positive outcomes, then we can hold hope in our healing.
This is a process of struggling with adversity. And as there is a deeper understanding about who we are after trauma, there can be an awakening of empowerment, where changes may surface that help us rise to a higher level of functioning than even existed prior to the trauma. Those are the positive changes when I talk about post-traumatic growth. For all that trauma can leave as a negative by-product, like complex PTSD, trauma can also lead to positive by-products; to emotional thriving; to stress-related growth.
And just for my last thought, let’s think of trauma as a past-oriented phenomenon and post-traumatic growth as a future-oriented phenomenon. And there are some therapists who are much more invested in the past; that’s their philosophical and practical orientation. There are other therapists who are much more future-oriented. But, you know, I’m a firm believer that the best way to come to terms with really shitty past experiences is to have a fucking reclamation of healing and growth. A reclamation of self. The aspiration during the journey is a balance between pain and release. Honor the pain and celebrate the release. Ebb and flow.
(Noopur Laughs): That’s a good note to end on- “fucking reclamation of healing and growth”. Yes. Honoring the pain and celebrating the release. That’s so important. Thank you so very much Deb.
You were listening to Dr. Debbi Kutner answering my questions on trauma, trigger, and c-PTSD. That’s all we have for you on this episode of Therapy Tuesday and this is Noopur signing off.
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