Raspberry Hill - Where Love Grows
Emotionally Focused Therapy Online
Bessel van der Kolk wrote about trauma: “One does not have to be a combat soldier, or visit a refugee camp in Syria or the Congo to encounter trauma. Trauma happens to us, our friends, our families and our neighbours. Research by the Centers for Disease Control and Prevention has shown that one in five Americans was sexually molested as a child; one in four was beaten by a parent to a point of a mark being left on their body; and one in three couples engages in physical violence. A quarter of us grew up with alcoholic relatives, and one out of eight witnessed their mother become a victim of domestic violence.” (Bessel van der Kolk, 2015 p. 1)
The ACE study (ACE = Adverse Childhood Experiences) has shown how massive the consequences of childhood trauma are. This is a study that examined over 17,000 adults in the US population regarding childhood trauma and its aftermath. The results of the ACE study are more than clear: There is a direct connection between childhood trauma and later health in adulthood – both mentally and physically. The more traumatisation those affected have experienced in their childhood, the greater the negative impact on their health. For example, if you have three childhood traumas, the risk of attempting suicide is already five times higher. If there are four or more traumas, the risk increases eight to nine times (see Bessel van der Kolk, 2015, Chapter 11).
It is therefore not surprising that in EFT we also have trauma survivors in our sessions. Sue Johnson (2019, p. 177) aptly described the reality in which some of our clients live: “It is not surprising then that a central reality of so many trauma survivor’s adult relationships is that it is often exceedingly difficult for a partner to properly read a survivor’s attachment signals and so to respond in a caring way. These signals are mostly distorted by defensive aggression or numbing and so are continually missed. This response then induces more panic and despair in the survivor, as well as alienation and distress in the other partner. A survivor needs more support from a partner and is also less able to ask for it in an effective way. Survivors of childhood abuse are much more likely to exhibit a fearful avoidant attachment style (Shaver & Clarke, 1994; Alexander, 1993). The emotional switches from extreme vulnerability and need to extreme avoidance and cutoff typical of this style are experienced as crazy making by partners, who then lose the ability to be empathic.”
On the diagnosis of trauma
Traumas received little attention in psychotherapy for most of the last century. The introduction of PTSD into psychiatric classifications in 1980 made extensive scientific studies of this diagnosis possible (van der Kolk, 2009). Sue Johnson writes in Emotionally Focused Couple Therapy with Trauma Survivors – Strengthening Attachment Bonds (The Guilford Press, 2002, p. 19): “For a formal diagnosis of PTSD, one intrusive, three avoidance / numbing, and two hyperarousal symptoms are necessary. However, many of the problems arising from trauma are relatively unrecognized in this formulation. It is also rare for PTSD to appear alone. Trauma itself, and the secondary difficulties that arise in coping with trauma symptoms, make the occurrence of additional problems such a major depression extremely likely. Feminist conceptualizations of trauma are critical of the narrowness of the range of experiences considered traumatic on the basis of DSM criteria. The point to evidence that traumatic events are not “uncommon,” as suggested in the DSM. In the lives of many women and children, they are more like everyday occurrences.”
Van der Kolk and others argued already years ago that post-traumatic stress disorder (PTSD) does not cover all consequences of severe and complex trauma in childhood and suggest a developmental trauma disorder (van der Kolk, 2009). With the introduction of Complex Post Traumatic Stress Disorder (C-PTSD), the ICD-11 takes an important step in this direction. According to ICD-11, the complex form of PTSD arises from prolonged traumatic events consisting of multiple or repetitive traumas. These are usually events from which it is difficult or impossible to escape (e.g. continued domestic violence, repeated sexual or physical abuse in childhood). A C-PTSD is characterized by the PTSD core symptoms (reliving, avoidance and feeling of threat) as well as other symptoms, summarized as disorders of self-organization. These are defined as:
- problems in affect regulation;
- beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and
- difficulties in sustaining relationships and in feeling close to others.
All 3 problems of self-organization must be present for the diagnosis of C-PTSD. They can be so salient that the 3 core symptoms of PTSD are difficult to discern (Gysi, 2021). Examples given by Jan Gysi (2021) are clients who experienced sudden anger and physical violence from their father, who experienced emotional neglect and sexual violence in childhood or who grew up with parents who were alcohol dependent and who suffered from untreated chronic schizophrenia.
An idea of the extent of PTSD and C-PTSD among adults gives a study among the adult population of the United States (Cloitre et al, 2019). A total of 7.2% of the sample met the criteria for PTSD or C-PTSD, and the prevalence rates were 3.4% for PTSD and 3.8% for C-PTSD. Women met the criteria for PTSD and C-PTSD more often than men. Numbers we see confirmed in our work as EFT therapists.
This study also showed that attachment relationships are an important variable in the emergence of C-PTSD. Childhood sexual and physical abuse committed by a parent or caregiver was particularly strongly associated with the risk of C-PTSD when compared to other traumas in a multivariate context. In contrast, childhood sexual assault that was not committed by parents or caregivers was linked to PTSD.
Working with people who suffer from trauma can challenge therapists. Clinical experience has shown that they tend to benefit from trauma informed therapy. Victims of abuse and neglect in childhood often develop a wide range of age-related psychopathologies with various psychological comorbidities.
Trauma & EFT
EFT is based on attachment theory and combines systemic and experiential interventions. It is non-pathologizing. Clients who are trapped in restricted patterns of neuroception, emotion-regulation and reactivity, did survive with them. These patterns arose out of the need to deal with attachment insecurity or danger, in order to provide the most possible security, the most degree of protection or even the survival and simultaneously feeling the human wired-in need to depend on primary attachment figures.
In EFT, we frame symptoms as part of an internal and relational cycle and an expression of emotion regulation strategies and their often lasting consequences. If trauma exists, we explicitly talk with our clients about it in EFT, because it represents an extra challenge in the client’s life. Naming trauma provides orientation and a first piece of security; it often creates meaning for our clients and an understanding of their dysregulated emotional states – the “this makes sense effect” is part of the de-escalation process in Stage 1 of EFT. Trauma dragons are part of the cycle. The EFT therapist focuses on framing symptoms as consequences of traumatic experiences from an attachment perspective. She is a temporary attachment figure to accompany her clients in making corrective emotional experiences with herself and relevant others.
In EFT we formulate contraindications and requirements as:
Contraindications are (Yolanda von Hockauf, Training-Handout, 2020):
- Psychosis: requires medical intervention
- Suicidality: requires stabilization intervention
- Engaged in ongoing substance use disorder: requires treatment
- Antisocial personality disorder, etc.: ability to self-reflect and take ownership lacking
- Clients are capable to engage in the therapeutic process, to gradually focus and to feel safe enough in the space we create as therapists.
- Clients get task alliance with our focus on attachment and emotion regulation.
- Clients reach their emotional experience and learn to name it within the therapeutic process – even if slowly.
- We as therapists are capable and feel safe to work with this client.
Even in the absence of contraindications and when the requirements are met, working with trauma is common in our daily work as EFT therapists in all 3 modalities, EFT, EFIT and EFFT.
Trauma is an overwhelming, uncontrollable experience that can happen to anyone at any age. The experience perceived as life-threatening for oneself or others triggers helplessness and intense fear that exceeds the window of tolerance for stress. Pat Ogden describes the experience of trauma as “Unsafe in our own skin” (Pat Ogden, 2015). Trauma can be caused by experiencing or witnessing sexual, physical, emotional abuse or neglect, sudden or unexpected loss of an attachment figure, war experience, medical treatment, natural disasters, etc. Also transgenerational transmission of trauma is receiving increasing attention.
However, the event itself is not the trauma, but how a person reacts to it.
Trauma is the coupling of fear + being alone + immobilization in the autonomic nervous system.
– this is how Peter Levine describes it, who, like Sue Johnson, also links to the research of Stephen Porges and the Polyvagal Theory. At the centre of traumatic stress lies the breakdown of the ability to regulate internal states of the autonomic nervous system. Sensations, emotions, cognitions cannot be associated. They become dissociated, fragmented. Without conscious awareness, our ANS is constantly examining the environment to determine how safe it is for us, and it sets priorities for adaptive behaviour that are not cognitive in nature. Triggers can cause responses of fight, flight, freeze – and related to C-PTSD the so-called fawn response.
Via neuroception, the ANS decides for protection and survival. If we are able to protect ourselves successfully in the event of imminent danger by fleeing or fighting, the organism usually regains its natural balance afterwards. Whether and who is by our side plays a decisive role here and, if necessary, helps us to integrate and co-regulate the overwhelming experience. An additional decisive factor is whether the source of danger is “neutral” or our attachment figure itself.
Reports of treatments of the 9/11 survivors as part of their trauma therapy showed that the severity of trauma had to do with whether or not trustworthy people were emotionally present in moments after the overwhelming, life-threatening experience.
If trauma occurred in childhood, was persistent or occurred in important developmental phases, and is left untreated, the conditions of the ANS can become chronic. The system is “stuck” in survival mode. If a defensive behavior was successful, it is registered as effective, and this increases the probability that it will be used in a future threat situations. If it particularly affects the life phase before and of birth and the first three years of life, Peter Levine, the developer of Somatic Experiencing, speaks of „Global High Intensity Activation“ (GHIA) of the ANS. The system does not learn to regulate naturally. Trauma thus results in a lasting break in connectedness. The survival response system can be chronically activated, leading to long-term feelings of alarm and danger, a tendency to flee or fight under stress, or paralyzing feelings, extreme vulnerability and exhaustion, the inability to protect oneself (Janina Fisher, www.janinafisher.com).
The research and clinical literature clearly and consistently indicate that different forms of interpersonal trauma have the potential to affect the core aspect of human functioning: attachment (Sue Johnson, 2002). Trauma survivors, when triggered, suffer from a variety of dysregulated states of the ANS. Trauma impacts many levels. Self-esteem can be shaped by helplessness, shame, self-blame and feeling-not-normal. The experience of attachment and emotion regulation, the ability to remember and perceive, the experience of the meaningfulness of life and the ability to mentalize can be impaired. (see Heather MacIntosh, 2019).
Sue Johnson and Leanne Campbell describe trauma as a continuum in their EFT + trauma training. They name the following factors:
- Non-interpersonal vs. Interpersonal
- Single vs. Multiple Exposures
- Proximity to the Event
- Shorter vs. Longer Duration
- Onset: earlier age or later age
- Support of Family/Caregiver vs. Less/No Support
- Attachment Security with someone vs. Insecure Attachment
- Transgenerational transmission or Not (added by Christine Weiß)
Co-regulation is the central task in primary attachment relationships. Without the experience of co-regulation, no trust is built and it becomes extremely difficult to preserve emotional balance. The ANS paths that support co-regulation are therefore neither trained nor strengthened. This can lead to a lonely vicious circle.
Deb Dana, who developed a psychotherapeutic approach based on Stephen Porges’ research, names co-regulation as a biological imperative – essential for human survival. John Bowlby laid the foundation for this in his attachment theory. Self-regulation is formed on the basis of ongoing experience of co-regulation. Co-regulation alone creates the felt sense of security. With trauma that is not integrated, a person is stuck in survival patterns – according to Stephen Porges – in the shutdown of the dorsal vagus and / or in the sympathetic arousal of flight and fight – or he oscillates between these two states and rarely finds the relaxed state of the ventral vagus, where we can experience emotional security and relational connectedness. Activating the ventral vagus system is the goal of co-regulation. It is the goal of secure attachment and the goal of EFT.
Science tells us today that secure attachment is critical to every aspect of health – mental, emotional, and physical. Loneliness increases blood pressure to the point where the risk of heart attack and stroke doubles. Research shows that relationship stress increases the risk of depression ten times. Trauma, by definition, is a loneliness risk. Partners struggle with the influence of trauma. EFT is an attachment-based approach in which co-regulation takes place and clients expand their felt-sense of security in relation to important others through corrective emotional experiences and learn to risk reaching and responding, allowing their negative internal working model of self and others to change. EFT can support trauma survivors to grow as a human, who feels saver in the world and reach their full potential.
- Campbell, Leanne, Johnson, Sue (2020), EFIT + Trauma – Handout.
- Cloitre et al. (2019), ICD-11 Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in the United States: A Population-Based Study, Journal of Traumatic Stress, 32, 833–842.
- Dana, Deb (2019), The Polyvagal Theory in Therapy: Engaging the Rhythm of Regulation (Norton Series on Interpersonal Neurobiology).
- Gysi Jan (2021), Diagnostik von Traumafolgestörungen: Multiaxiales Trauma-Dissoziations-Modell nach ICD-11.
- Johnson, Sue (2002, 2021), EFT with Trauma Survivors. Strengthening Attachment Bonds.
- Johnson, Sue (2019), Attachment Theory in Practice: Emotionally Focused Therapy (EFT) with Individuals, Couples, and Families.
- Levine, Peter (2010), In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness.
- Levine, Peter (1997), Waking the Tiger: Healing Trauma.
- Ogden, Pat, Fisher, Janina (2015), Sensorimotor Psychotherapy. Interventions for Trauma and Attachment.
- MacInstosh, Heather (2019), Developmental Couple Therapy for Complex Trauma.
- Porges, Stephen (2010), The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation.
- Rothschild, Babette (2002), The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment.
- Van der Kolk, Bessel (2009), Developmental Trauma Disorder Toward a rational diagnosis for children with complex trauma histories, Psychiatric Annals 35:5, May 2005, 401-408
- Van der Kolk, Bessel (2019), The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma.
- Johnson, Sue (2012), Emotionally Focused Therapy in Action, Psychotherapy.net
- Johnson, Sue (2017), Facing the Dragon Together. EFT with Traumatized Couples, ICEEFT
- Johnson, Sue (2019), Emotionally Focused Individual Therapy (EFIT) Working with Anxiety and Depression, ICEEFT
- Johnson, Sue & Leanne Campbell (2020), EFIT – Creating Core Change in Emotionally Focused Individual Therapy, ICEEFT
- Johnson, Sue & Leanne Campbell (2020), Escaping the Trauma Trap: Transforming Life-Long Trauma in EFT couple sessions, ICEEFT
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