Chapter 27:
Understanding Severe Traumatization©
BY LIZABETH ROAMER AND
LESLIE LEBOWITZ

Emotional, physical or psychological traumatic experiences, particularly chronic and/or severe, early traumas, often leave long lasting psychological consequences in their wake. This traumatic legacy takes many forms: Trauma survivors can react dramatically to undetectable or slight provocation, or respond to recollected images of horror in their heads that others can't see, rather than their external environment. Some survivors of trauma may appear emotionally callous, detached, and distrustful of others, or express rage and apparently undue aggression, but show little or no remorse. People who have been traumatized may also display extreme, fluctuating emotions, and may alternate between extreme dependency and marked disconnection in their relationships with others. They may display little regard for their own or others' safety and well-being. When these behaviors are not interpreted in the context of the person's past trauma, they appear disagreeable or odd at best, and reprehensible at worst. The shame and secrecy surrounding traumatic experience compounds this predicament, with individuals rarely disclosing the histories which would provide meaning and context for their actions. A traumatic experience may so profoundly alter an individual's feelings, thoughts and reactions, forming and shaping the person's personality and way of relating to the world, that even a distant past event can dramatically influence present day experience and behavior.

Traumatic experiences, particularly when they are prolonged, severe and happen during childhood, disrupt basic human emotional, cognitive, and physiological processes, resulting in pervasive, far-reaching consequences. However, in spite of the broad reach of traumatic injury, it is often difficult to identify and understand the traumatic origins of the problems many victims have. In this article, we aim to provide a context in which to understand those individuals for whom the wake of trauma has led to destructive, debilitating actions and reactions. We first provide an overview of the definition of a potentially traumatizing event and its effects, then we discuss the particular risks of chronic childhood trauma which are pertinent to this discussion. The bulk of the paper is devoted to describing how traumatic experience can disrupt the optimal functioning of our cognitive, physiological and emotional systems. We conclude with a brief overview of some of the potential long-term effects of traumatic experiences most relevant to our understanding of destructive behavior, focusing particularly on hypersensitivity and reactivity, and conscious and unconscious efforts to avoid traumatic memories and feelings. Placing a client in the context outlined here may help seemingly inexplicable actions become understandable.

What is a traumatic experience?

According to the Diagnostic and Statistical Manual for Psychiatric Disorders criteria for Post-Traumatic Stress Disorder, a potentially traumatizing event is one in which an "individual experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others" (see DSM-IV, APA, 1994). The DSM criteria also specify a subjective response that is characterized by fear, helplessness, and/or horror. Research and clinical observation indicate that the range of events falling under this classification (e.g., physical or sexual assault/abuse; witnessing violence to others; sudden, unexpected death of a loved one; severe physical and emotional neglect) evoke several characteristic responses from the individual: a) the experience of extreme, overwhelming emotions (e.g., terror, helplessness, horror, rage, shame); b) heightened, sustained physiological arousal; and c) the shattering and/or distortion of basic beliefs and assumptions that are necessary for us to function optimally in the world (e.g., that there is some safety and predictability in the world, that the self has some power and worth, that some people are good and trustworthy).

To be traumatized is, by definition, to have the untenable happen; a victim is left with the almost insurmountable task of making sense of and coping with something that is overwhelming, beyond comprehension, inherently unacceptable. For example, a boy who watched his mother being beaten and raped experiences debilitating fear, along with incapacitating shame and guilt at not having rescued her (even in the case where any effort on his part would have been futile). He may be left with a profound sense of danger and lack of meaning in the world, along with a malignant sense of self, that may preclude his ability to form mutually satisfying relationships, find meaningful work. The potentially devastating impact of trauma cannot be overemphasized.

The nature and course of post-trauma response is of course varied and complex, shaped by a host of factors (e.g., severity and frequency of traumatic exposure, age of victimization, level and nature of pre-trauma functioning, and characteristics of the recovery environment [Green, Wilson, & Lindy, 1985). Certainly many victims are fortunate enough to have the internal and external resources (e.g., emotional support, effective coping skills, a history of positive relationships) necessary to cope with horrible events in such a way that their adjustment is relatively smooth, resulting in few, if any, long- term negative effects. Others, however, are not so lucky due to characteristics of the events themselves, their developmental history, or the environment in which they struggle to cope with these experiences. Often traumatic histories are compounded by additional stressors (e.g., poverty, oppression) and the occurrence of additional traumatizing events, significantly reducing the possibility of successful recovery.

We will focus here on the kinds of lingering, debilitating difficulties some victims experience in order to provide a context for understanding and empathizing with people whose traumatic histories have shaped and altered their lives in destructive ways. (see Herman, 1997; van der Kolk, McFarlane, & Weisaeth, 1996, for more extensive discussions of the range of post- traumatic sequelae and factors of risk and resiliency). Although we include in our discussion those characteristics which fall under the diagnostic category of post-traumatic stress disorder (PTSD), we describe here a broader array of damage and dysfunction that is often associated with severe traumatization and is not adequately described by the diagnostic category of PTSD.

When the victim is a child.

Although detailed discussion of the range of factors that impact traumatic recovery is beyond the scope of this paper, we highlight one of particular relevance: the age at which victimization occurs. Trauma that occurs during adulthood burdens an already formed personality. However, trauma that occurs during childhood often alters the very course of personality development (Herman, 1997). During childhood, we are just beginning to develop the capacities that help us function and thrive in the world: we are learning how to understand, manage, and regulate our emotional experience; we are developing our views of the world and ourselves; we are forming attachments and blueprints of relationships that will be the basis for all our future interpersonal relationships and the neural pathways and biochemical patterns of our brains are being established. Prolonged victimization and/or recurrent exposure to horrible, overwhelming events shape these emerging abilities in ways that profoundly impact the course of our future development. Such experiences may preclude the development of healthy ways of coping with our emotions, or functional views of the world, ourselves, and relationships, all deficits which will significantly affect every subsequent reaction and interaction we have. Researchers have even demonstrated that our brains will not adequately acquire capabilities we take for granted (e.g., being able to talk about our feelings, think before we act, regulate our impulses) if we do not receive the appropriate stimulation (warmth, attention, control over our environments) at certain critical periods of development (Perry, 1997).

Children are also more vulnerable to the negative effects of trauma because they have less power than adults and they are less able to find means of escaping, or even comprehending, a traumatic situation, leaving them more susceptible to feelings of helplessness, arguably the core traumatic emotion. Children who are abused within the family are placed in a particularly untenable position: the adults they must rely on to meet their basic physical and emotional needs have betrayed them. They are faced with dramatically conflicting imperatives: the powerful human drive to attach to a caregiver, to rely on someone, to bond, and the need to protect oneself from abuse and make sense of a situation which defies comprehension. How can this person I rely on, trust and love do such horrible things? How can someone who is supposed to love me treat me this way? The absence of satisfactory answers to these questions and/or their probable answers in the direction of self-blame profoundly shapes a child's sense of the world, relationships, and, perhaps most tragically, his/her own self-worth.

A naive observer might expect childhood events to be more easily forgotten, "put in the past," so the victim can "move on." However, there is evidence that, for many individuals, traumatic memories do not fade with the passage of time. For some they will become "integrated" and modified by subsequent experience and learning, thereby lessening their emotional intensity and functional impact. But, in the absence of these reparative and transformative processes, they will remain as emotionally vivid as the day they were experienced. Thus, managing a traumatic event involves coping not only with the event itself, but also with the endurance of that event inside oneself -- the intense feelings, graphic images, and life-altering thoughts that persist long after the event itself has passed. Because we are accustomed to the way non-traumatic memories gradually decrease in intensity and salience, we might minimize or underestimate the impact of a horror that does not dissipate over time. To understand the experience of a trauma survivor, we must imagine what it would feel like to continue to relive an unbearable event, with all of its concomitant horror, fear, and helplessness without our volition even years after the event is past.

The impact of traumatic experience on the individual.

Researchers and clinicians recognize that the psychological consequences of trauma affect multiple domains of functioning: emotional, cognitive, physiological. In each area, traumatic experience disrupts and dysregulates the delicate balance that allows each system to respond optimally to incoming information. These disruptions in intrapersonal processes reciprocally interact with the interpersonal ruptures that accompany traumatic experience (e.g., loss of trust in significant others, shame-induced isolation from others) with each deficit potentially exacerbating the others in an escalating cycle. Within this traumagenic internal and interpersonal context, some victims come to behave in ways that are self-destructive and/or destructive to others. We describe below how traumatic experience alters our thoughts and perceptions, our physiology, and our emotionality. We then discuss some of the long-term consequences of these experiences which helps explain the men and women whose lives have been negatively effected by traumatic experience.

Effects on Thoughts and Schemas

How we construct and organize our experience.

What each of us perceives as "real" in the world is actually a composite that is a product of our selective attention to information and our subjective interpretation of that information. In other words, we construct our reality - through the development of "schemas." Schemas are the enduring mental structures - mental maps - that help us make sense of the immense amount of information that continually confronts us. We develop these schemas at both conscious and unconscious, micro and macro, levels. Schemas guide us in areas that range from trivial and concrete tasks to the most meaningful questions about our sense of self and the world. For instance, when we encounter a new baby, our actions are guided by our schemas: If we have had extensive prior experience with babies who enjoy being tickled, we are likely to tickle this new baby; if the babies we know prefer gentler play, we may rock this baby and sing to it. Our reaction is more heavily based on our prior experience than on new information about this particular baby. Ideally, however, if this baby responds counter to our expectations, we will search out alternative strategies, and alter our schema. In this way, our expectations and knowledge base (our schemas) are molded by our experience, and our behavior is in turn guided by these schemas. These schemas guide our interpretation of (and reaction to) events in our environment, reducing the mental work involved in making assessments and decisions. However, this expediency brings with it the risk of misperception or distortion: if we expect the baby to like being tickled, we are considerably more likely to notice indications that s/he is enjoying this activity than we are to note any contradictory information, and we might never try out her favorite games if they are not represented in our schema. Our method of cognitive processing contains a danger within it: The most efficient, definitive way to process information is through rigid adherence to schemas. However, rigid, extreme schemas lead to rigid (and often maladaptive) ways of behaving. Rigid schemas are often inaccurate, distorted, or negative, all of which lead to problematic actions. For instance, a caretaker's schema that babies don't need to be played with at all would have profoundly detrimental consequences for the baby of that caretaker. On the other hand, overly flexible schemas wouldn't provide sufficiently clear and automatic guidelines for functioning.

In addition to these types of specific schemas regarding various situations and events, we develop more central schemas which encompass our perceptions and expectations of ourselves, the world, and other people. It is generally accepted that certain basic schemas allow us to function optimally in the world (Epstein, 1994; Janoff-Bullman, 1985; McCann & Pearlmann, 1990). In general, people need to have some sense of safety in the world and to feel they can rely on themselves and others to ensure that safety. Also, people need to have a sense of self-worth and to feel valued by those people they trust. Further, people need to believe in some type of order, meaning and fairness in the world, that things happen for a reason, that life is not totally capricious. These basic assumptions are what enable us to interact proactively, planfully, and positively in the world, develop relationships, care for ourselves and others, explore new places, and treat others fairly. For instance, because we believe that we can trust some people, we act in trusting ways with them, which increases the chances they will be deserving of this trust. In this way schemas are self-fulfilling prophecies.

How we process information that is inconsistent with our schemas.

We are often confronted with information that is inconsistent with our existing schemas, both our central, basic, schemas and our more specific, concrete schemas. When this occurs, one of two things must happen. Either we must alter the incoming information so it remains consistent with the schema, in which case our schema remains unchanged (referred to as assimilation), or we must modify our schema so that it encompasses the information at hand (accommodation). Referring back to our prior example of the baby: assimilation would be occurring if we interpret the babies' cries as squeals of glee so this event is consistent with our "babies like to be tickled" schema. Or, we might (more appropriately) accommodate the information that this baby is different by altering our schema to "some babies like to be tickled and this one does not." Our psychological equilibrium is in part maintained by our ability to balance these two processes of assimilation and accommodation so that our schemas grow and positively reflect reality but we also maintain a relatively consistent view of the world. In other words, we do best when we are able to establish and maintain flexible, positive schemas.

Clearly, our process of maintaining cognitive homeostasis is quite complex and multifaceted. We need to make meaning of our world, to understand it, to develop expectations and beliefs that will guide us and help us efficiently organize incoming information. However, if our beliefs are too rigid, definitive, negative, absolute, they will lead to distortions. We must interpret information in light of our schemas, yet at times we need to reassess our schemas in light of our experience. And we must generally maintain some faith in ourselves, the world, and others. However, if this faith is extreme, or overstated, it may lead to dangerous behaviors, or may be easily shattered. Traumatic experiences rupture this homeostasis at nearly every level.

How traumatic experience disrupts our cognitive equilibrium.

Our need to understand, comprehend, and make sense of experiences is dramatically heightened when events are emotional, overwhelming, unpredictable, and challenge our central, basic schemas. A trauma victim is confronted with experiences that cry out for comprehension, for schemas which will structure and order them, for some sense of meaning and purpose. Yet the overwhelmingly negative nature of traumatic events make them difficult to reconcile with positive, coherent, agentive views of self and others. Often, profound contradictions exist even within the event itself: a father is affectionate and loving, yet violates a child claiming it is her fault, then apologizes profusely and says how much he loves her. There is no simple construction of this event that can maintain positive core assumptions and adequately explain the entirety of the victim's experience.

Nonetheless, human beings need to maintain a coherent understanding of reality. The lack of clear positive answers in a traumatic situation drives the victim to develop or alter his/her schema to explain what is happening. It is important to note that this process is happening instantaneously, outside of awareness, while the victim is in a state of hyperarousal that interferes with any form of reasoned, analytic thought (as described below). In this state, the victim is vulnerable to embracing definitive, extreme, negative schemas which are consistent with what is happening (e.g., they are helpless, they are to blame, the world is unfair). Often a victim will embrace one negative belief, which will serve to protect several other positive beliefs. For instance, blaming yourself for what your father has done to you preserves your trust and faith in him. Once these beliefs have been adopted in a state of extreme emotion, they exert a powerful influence on subsequent behavior and adaptation. The rigid, extreme nature of these negative schemas interferes with the incorporation of new information, contributing to their maintenance.

In cases of chronic developmental trauma, more positive fundamental schemas (e.g., the world is safe, has meaning, people can be trusted) never even have the chance to develop. Instead the child, based on her/his experiences, may form primary beliefs that the world is unsafe, that people cannot be trusted, that fairness should not be expected, and that there is something fundamentally wrong with her/him, and that s/he has no future. How can this child form a meaningful, positive connection with another person when this is what s/he expects to find? How will s/he learn to follow the rules of society, when these rules apparently contain no justice or even predictability for her/him and when s/he can not imagine a future? These negative assumptions will color every future interaction, both in terms of what the survivor perceives (e.g., misconstruing helpful behavior as malevolently motivated), and how the survivor acts (e.g., hurting others before they can hurt him/her).

However, human needs are remarkably robust, and the basic human need to relate to others, to venture out into the world, even to value oneself, does not completely deteriorate in the context of these negative schemas. Unfortunately, this may only lead to further difficulties for a trauma survivor. The survivor is motivated to act in ways that are inconsistent with her/his negative schemas, and is therefore acting without the guidance of adaptive schemas. S/he is at risk then of forming a relationship with someone who is untrustworthy, because s/he hasn't formed a series of guidelines for determining whether someone should be trusted. Without this type of schema, signals of danger may easily be overlooked, increasing the risk of revictimization, further confirming negative schemas. Similarly, a survivor might find him/herself in a dangerous situation because his/her extreme view that every situation is fraught with danger precludes the ability to adequately assess and ensure relative levels of safety and self-protection. The survivor often oscillates between extremes in relation to his/her environment - at times acting like a daredevil, at other times being cautious and overly careful; at times indiscriminately seeking connection, at other times being isolative. The rigidity with which these schemas have developed, coupled with the physiological and emotional constraints discussed below, greatly interferes with the survivor's ability to find any middle ground in his/her cognitive construction of the world - each extreme drives the opposing extreme in an endless, self-perpetuating cycle. (e.g., the inevitable negative outcome when a survivor acts without consideration of safety confirms beliefs that the world is unsafe, further restricting subsequent behavior, increasing the need to finally break out of that constraint, etc.)

Effects on the Brain

How we maintain biological equilibrium.

Our brains involve multiple, intricate, interconnected systems designed to detect internal and external stimuli, identify and interpret them, integrate complex information coming from multiple sources, and motivate appropriate action. Contrary to common belief, the human brain is not a fixed, unchanging organ but rather develops and is shaped in an ongoing fashion by the environment. Each environmentally triggered physiological reaction causes a chain of events in the brain (e.g., release of neurotransmitters) as information is passed from one system to another (stimulating the release of other neurotransmitters). Elaborate checks and balances regulate these events in an effort to maintain homeostasis in the brain's chemistry; in this way the brain remains prepared to detect future new information and process it accordingly. For instance, upon detection of threatening information, catecholemines are immediately released, preparing the organism for quick unreflective responses of fighting or fleeing. Simultaneously, other regulatory neurotransmitters are released, in order to return the organism to baseline where it is prepared to carefully assess further incoming information. Higher cortical activity (thinking and reasoning) further helps to modulate and regulate the more primal fight or flight response. In this way we are able to quickly jump out of the way of a moving bus without first deliberating, yet shortly afterward are able to carefully look both ways, calculate the relative speed of oncoming traffic and therefore safely venture across the street. Once on the other side, we are able to reflect on this experience, learn from it, and therefore potentially avoid future dangers. The initial fight or flight response enables us to establish immediate safety; deliberation at that point would be fatal. However, the subsequent regulatory mechanisms are what enable us to continue functioning in the world, and to learn from our experience.

How traumatic experience disrupts our biological equilibrium.

Just as trauma overwhelms our natural cognitive regulatory systems, it can also short-circuit our biological regulation. Traumatic experience produces such a strong and overwhelming fight or flight response, that it compromises our brain's regulatory functions, with negative long-term consequences. Evolutionarily, it has been essential that the brain's responses to threats of harm are immediate and extreme. If a saber-tooth tiger approaches you, unless you immediately perceive the danger and are activated to run or fight, you will die. Dangerous events thus evoke powerful responses from our brain, sending massive amounts of neurotransmitters coursing through the structures of our brain, resulting in a cascade of hormones and resultant bodily sensations (rapid heart beat, sweating, increased blood pressure), attentional consequences (narrowing of attention, heightened awareness of threat cues, lack of attention to unrelated cues), and motoric responses (e.g., heightened ability to run or fight). For discrete dangers, this is quite functional, the individual is able to attend to the necessary information at hand, enact the appropriate behaviors to ensure survival and then return to baseline functioning.

However, chronic danger produces chronic activation of what was likely intended as a rapid response systems and the long-term consequences of these reactions can be damaging. Research has shown that chronic exposure to traumatic stress - to the hormones and neurochemicals that are released within us in reaction to it - impacts the brain's chemistry and physiology. Individuals with a history of chronic traumatic experiences exhibit increased levels of baseline arousal, heightened physiological reactivity to both trauma-relevant and neutral information, increased levels of catecholomines (e.g., adrenaline), dysregulation of regulatory neurotransmitters, and increased levels of neurochemicals (endogenous opioids) which may be associated with emotional numbing. These effects may even have a structural impact on the organs of the brain. For example, stress hormones may cause actual cell death in the hippocampus, an area of the brain that plays an important role in evaluation and consolidation of new information to be stored in memory (see van der Kolk, 1996, for a review of the biological effects of trauma).

So, after chronic exposure to overwhelming, terrifying experiences, an individual's physiology may be altered so that they remain in a state of readiness to perceive threat and act immediately. These alterations may interfere with the brain's ability to process information completely by short-circuiting the balanced relationship between primal immediate responding and higher cortical reasoning and analyzing. Usually, information travels through an intricate network of brain cells (neurons) that begins by registering sensory information in the most "primitive" parts of the brain. It then continues through other parts of the brain -- such as the amygdala -- that assign an emotional tone to the information, and then threads its way into the most evolutionarily advanced part of the brain, the neocortex, where the information can be integrated with the brain's most complex forms of functioning such as the ability to reason and the ability to transform experience into language. In a state of arousal, this system is short-circuited in order to facilitate rapid response. Thus, in a crisis, sensory stimuli (such as hearing an angry tone of voice or seeing a hostile facial expression) immediately signal bodily responses that prepare for action, with little or no cortical mediation. This may compromise an individual's ability to control their reactions; it is through cortical activity that we reason, weigh options, and deliberate. When we remain in a constant physiological state of readiness, we are always ready to jump out of the way of the bus (even when it wasn't really going to hit us), but far less able to assess relative danger and determine a safe opportunity to make our way across the street. This over-reaction to threat can be easily triggered by reminders of a previous traumatic experience.

This reduction in cortical mediation yields pervasive psychological consequences. As described above, being confronted with a traumatic event provides an immense challenge to our meaning-making structures, our schemas. However, the depletion of cortical involvement significantly impedes our ability to negotiate such a challenge. Not surprising, then, that a trauma survivor has difficulty developing or maintaining the type of complex schematic structures that might provide meaning for the experience while still maintaining necessary positive assumptions. Lack of cortical mediation similarly interferes with the survivor's ability to regulate his/her emotional experience, as described below.

Effects on our Emotions

The function of emotions and emotional regulation.

Our emotional responses provide us with essential information about our environment that motivates our actions and helps us to function effectively in the world. Each emotion brings with it specific information and physiological reactions which guide our actions. Just as cognitive and physiological balance and flexibility is important for our well-being, so is emotional regulation. We need to be able to recognize our emotional responses, understand them, and modulate them. We want to be aware of our feelings, but not be compelled to action solely based on these feelings. The balance between amygdala responses and higher cortical reasoning described above is one of the ways that we achieve this regulation. Ideally, we experience our emotions, but analyze and interpret them before acting. Traumatic experiences typically evoke powerful, overwhelming feelings of fear, rage, helplessness, grief, guilt, shame and alienation (which can cause uncontrollable behavior). Moderate levels of these emotions occur in everyday life, and individuals are usually able to cope with them through a variety of processes which involve some combination of experiencing (enduring) them, expressing and/or sharing them, and understanding them until they gradually lessen and abate. The key here is balance. Denial and suppression of emotion is no more healthy than is complete abandonment to one's emotional state. In general, most people are able to maintain a state of emotional equilibrium in which they are responsive to events, but not overcome by them.

How traumatic experience disrupts our emotional regulation.

During a traumatic experience, emotions are so unbearably intense, intolerable, and overwhelming that they either deactivate or defy our normal coping strategies. For example, horror, fear, helplessness, shame, and despair that accompanies being raped by your favorite uncle outstrips normal regulatory responses. However, human beings don't just cease trying to respond effectively to their environment. Dramatic forms of emotional experiences instead invoke equally dramatic forms of emotional regulation, often outside of awareness. Rather than the typical vacillation between some degree of emotionality and some degree of regulation, resulting in an optimal balance between the two; traumatic affects usually result in extreme, absolute regulation and constriction, prompting an extreme vacillation between all-consuming emotionality, and disrupted, apparently absent emotion. Under ideal circumstances (i.e., normal bereavement) social mechanisms and support provide a way to move back and forth between these extremes, gradually processing the feelings and meanings of the event until they lessen in intensity and equilibrium is re-established. Trauma, however, is more extreme than a normal stressor and we have no established social processes to deal with it. Hence, more extreme strategies are often used and, more importantly, in the absence of meaningful social assistance, often maintained. The most serious consequences of traumatic experience come from the endurance of what are "intended" to be brief responses. Dissociation provides an excellent example of this.

Dissociation and emotional numbing.

During traumatic experiences, victims often report experiencing themselves as separate from their bodies, sometimes watching from above or from the corner of the room. In these descriptions, the victim becomes and observer and is no longer experiencing the emotions of the person who is in the process of being victimized. S/he can see everything that is happening, and may even know how the victim is feeling, but the act of dissociation protects him/her from actually experiencing the overwhelming emotion. This is a highly effective form of responding to unbearable feeling in the moment as it greatly reduces the intensity of emotion. However, recent studies indicate that these responses may have detrimental long-term psychological consequences and are an important predictor of subsequent post-traumatic symptomatology (see van der Kolk, van der Hart, & Marmar, 1996, for a review).

Another extreme emotional adaptation used by trauma victims is emotional "numbing." Victims commonly report feeling shocked or "numb" during victimization, particularly when it is chronic and prolonged. Some researchers have suggested that secretion of endogenous opioids may be associated with this response (van der Kolk, 1996). It is unclear whether reports of numbing indicate actual deficits in emotionality or if they instead indicate an overwhelming, undifferentiated response that the victim cannot identify or acknowledge, and so construes as numbing. Again, this numbing is an effective means of managing the initial traumatic impact since it lessens (although doesn't eliminate) emotional intensity. However, again numbing does not seem to lead to long-lasting relief and it can lead to long-term impairment.

Both numbing and dissociation may first emerge during a traumatic experience, but they often remain as common emotional regulation strategies in the wake of trauma, interfering with survivors' recovery. Although both strategies originate in response to extreme emotions, they become habitual and are then elicited by a range of emotional experiences. A rape survivor may find that during a stressful conversation with his mother, he has "checked out" and is experiencing himself as across the room, not following much of the conversation. These responses leave the survivor unaware of his surroundings, unable to respond optimally to his environment (regulate his reactions), and ironically even more vulnerable to threat. Dissociation has been implicated in the prevalence of revictimization among rape survivors (Cloitre, Scarvalone, & Difede, 1997). Ironically, one lives through a horrible event in part by separating oneself from it, and, as a result, comes to easily dissociate from reality, increasing risk for more pain and suffering. These ways of responding also exacerbate one's sense of confusion and inability to make sense of events.

Habitual numbing and emotional constriction bring with them their own unique disruptions of recovery and adaptation. Particularly for male survivors, who are socialized to control and constrict virtually all emotional experiences except anger (Lisak, Hopper, & Song, 1996), overwhelming, dysregulated affect elicits repeated, constant efforts at constriction and concealment. Through a variety of processes that we are just beginning to explore (e.g., opioid mediation, chronic overarousal resulting in the depletion of emotional resources, detachment, isolation and alienation from others motivated by shame and fear [see Litz, 1992, for an extensive discussion]), trauma survivors often appear numb, remote, distant, or emotionally callous. While at a funeral of someone they know they loved, survivors will describe feeling empty, vacant, "knowing" they should feel sad but having no experience of that emotion. This disruption in natural emotional reactions alienates the survivor from his/her own feelings as well as from other people. Often other people will interpret these reactions as indicative of disinterest and callousness. A lifetime of trying to quell overwhelming emotions and maintain safety in a world perceived as dangerous may evoke an external presentation of callousness, but, underneath this exterior, a cauldron of intense, unmodulated, overwhelming feelings resides. This may explain why some defendants display no emotional response when they hear a jury sentence them to death; they have spent years practicing this form of emotional protection and can not help using it at this moment of profound stress and despair.

Disruptions in describing an emotional event.

One of our most effective ways of regulating an emotional experience is through language. As we describe an event, recall the emotions we felt at the time, and discuss the thoughts we were having, we are integrating this experience more fully, making meaning of it. We are also engaging those structures in the brain associated with regulation of emotion and behavior, enhancing the connections between the emotional memory and higher cortical processes. As we verbally examine our emotions, the feelings are simultaneously accorded a place in our conscious mental structure and tempered by the words we assign them. Describing our feelings also allows others to understand and validate our emotional experience, reducing the isolation that otherwise may exacerbate our emotional distress.

Unfortunately, traumatic events are not easily described for a variety of reasons. Description of these experiences is likely to evoke intolerably painful emotions and memories that the survivor has been trying desperately (both consciously and unconsciously) to avoid. Also, traumatic events often engender shame, due to the degradation and utter helplessness the individual was subject to during victimization as well as the social stigma of victimization. Shame interferes with interpersonal communication. Also, as discussed below, often the survivor will literally not have access to many elements of the experience, due to dissociation, biological factors (e.g., decreased cortical involvement, hippocampal cell death), and other trauma-related phenomena that interfere with the integration of memory. For men, whose gender socialization demands masculine virtues like emotional stoicism, power, and control, disclosures of traumatic experiences (and the inevitably associated emotionality) threaten their very gender identity, greatly reducing the likelihood of disclosure. Finally, trauma victims often accurately perceive that others do not want to hear about the horrible things they have lived through. They fear rejection, incredulity, and invalidation.

Disruptions in our storage
of emotional experience.

The intense emotions of traumatic experience also influence the storage of traumatic memories. When we experience an emotional event, we store a variety of information about this event in our minds. The sights, sounds, smells, tastes, feelings, sensations, meanings and interpretations of the event are all associated with each other and we are able to access each component when we are reminded of an event. However, traumatic experience overwhelms this process, disrupting attentional and organizational abilities, so that components are not efficiently integrated and stored in memory. Parts of the memory may be fragmented or separated so that the emotions are separate from the thoughts, the pictures separate from the words, parts of the event separate from each other, and the meaning of the event may be distorted or nonexistent. This process of fragmentation may serve to reduce the overwhelming nature of the event at the moment of storage. However, it interferes with our ability to make sense of and understand the event later, further interfering with the development of flexible, adaptive schemas. When something in the environment reminds the survivor of the experience (e.g., a smell, a voice), only a fragment of the experience may be recalled (e.g., the image of a face, a feeling of dread). The connections which would help understand these responses may be absent, leaving the survivor bewildered, frightened or angry, motivated by impulses s/he cannot understand. For example, a victim hears a male voice and experiences an overwhelming desire to strike out, with little awareness that this impulse is not being motivated by current experience, but is instead activated by unintegrated memories of the past. For instance, the voice might sound like his older brother's, who anally raped him repeatedly during childhood. However, his conscious experience might consist only of this impulse to harm, out of fear or self-protection. In the absence of the modulating effect of understanding the context of this impulse, i.e. accessing more elements of the memory in order to help identify the impulse as historical rather than current, he may act on his impulses (particularly given that his inhibitory abilities may not be fully developed due to development trauma) without any externally adequate cause.

The long-term impact of traumatic experiences.

Traumatic experiences disrupt the basic human processes of emotion, cognition and physiology. When these disruptions are not counteracted by equally powerful positive experiences (e.g., exceptionally loving and supportive long-term relationships), the consequences are often extensive, and devastating. Reactive, extreme, dysregulated functioning interferes with the establishment of mutually satisfying relationships. Conversely, our ability to regulate our feelings and maintain adaptive schemas is predicated on a minimal level of positive interpersonal relationships. Interpersonal violence (particularly when it originates from primary attachment figures) disrupts both intrapersonal and interpersonal functioning, creating a debilitating cycle of biological, emotional, cognitive and relational effects. Our interpersonal relationships are the foundation for our membership in society. We comply with the guidelines of society because we can, and because of our sense of connection to the whole, our identity within the group. The disruption of basic regulatory abilities and the psychological foundations for this sense of belonging pose a two-pronged threat to our ability to conform to society's rules.

The traumatic legacy of pervasive dysregulation, alienation, despair, terror, rage, and self-hatred results in a host of devastating sequelae. Traumatic sequelae are far from static: efforts to minimize one set of difficulties elicit a host of new problems resulting in a constantly changing picture, reflecting the struggle to adapt. Trauma survivors commonly alternate between phases of over- and under-control, sometimes cycling within an hour, sometimes over a decade or a lifetime, reflecting the different demands of trauma (to avoid versus to make sense) Many aspects of survivors' actions are contradictory, further compounding their difficulty understanding themselves, and our difficulty understanding them. We highlight below two components of possible long-term reactions to trauma that may particularly account for participation in apparently inexplicable, destructive actions. They represent the two poles of the dialectic of the traumatic legacy: intrusive recollections and extreme, reactive emotionality versus endless, futile efforts to avoid and banish chronic, intolerable distress.

Reactivity and hypersensitivity to danger.

A survivor of severe trauma whose recovery has been thwarted lives in a state of constant readiness. High levels of arousal and hypervigilance, and schemas regarding the lack of safety in the world, combine to create a style of processing information that is exquisitely sensitive to the slightest indication of threat and often overlooks evidence of safety. Individuals may respond to benign cues with hostility, preparing to fight and protect themselves, and thus elicit hostile responses from others, exacerbating the situation. Heightened reactivity to trauma-related cues compounds the risks associated with this style of responding. A trauma survivor may be triggered and find him/herself in a state of alarm and readiness without understanding why, and may react impulsively, uncontrollably, at times violently and aggressively, because his/her reasoning ability is temporarily diminished and short-circuited. Violent actions are particularly likely, both because they are a natural response to feeling threatened, and because survivors are often raised in extremely violent environments, learning that such actions are appropriate ways of responding to conflict or danger. Traumatized men may be particularly at risk for violent, aggressive actions because anger is one of the few emotional outlets permitted by their gender socialization. Violent actions are also self-perpetuating, both because they elicit violent responses from others, confirming the perception of danger and need for self-protection, and because they temporarily alleviate the sense of helplessness and powerlessness that is so devastating for trauma survivors. The factors that typically inhibit violent behavior (ability to reason and weigh options, compassion for self and others, belief in a sense of justice and meaning in the world) are often disrupted among these survivors, so that a pattern of violence can easily be established and maintained.

Avoidance efforts which may mask traumatic symptoms.

One of the challenges to recognizing trauma-related difficulties is the fluctuating nature of symptoms and responses, and the range of behaviors that serve to mask the traumatic etiology of distress. The overwhelming, intense, horrible nature of trauma-related thoughts, feelings, and images motivates elaborate, complex efforts of avoidance (usually without conscious awareness of this goal). These effects are ultimately ineffective, except in masking the initial source of suffering. Even when survivors display what we have come to accept as the classic post-traumatic response -- being bombarded with intrusive recollections, avoiding any situation reminiscent of the trauma, chronically hyperaroused and irritable, detached and numb -- they experience periods of numbing and avoidance in which the traumatic source may not be evident and the survivor may appear to be depressed without any obvious cause.

Concealment of a traumatic history.

The most obvious example of efforts to quell the pain of the trauma is the avoidance or denial of a traumatic history. Discussing abusive experiences tends to activate the associated emotions, often at the same level of intensity with which they were first experienced. (Symptoms and distress commonly intensify initially upon disclosure, extensive resources are needed to facilitate this process [see Herman, 1997; Roth & Batson, 1997, for thorough discussion of the process of disclosure]). Often then, survivors don't disclose events and even deny them when asked directly. Sometimes this lack of disclosure is deliberate, mediated by shame and lack of trust. At other times, the survivor may not have sufficient conscious access to their trauma history to disclose, even if they might want to.

Alcohol and substance abuse.

Other efforts to modulate distress are less straightforward. Drugs or alcohol are often used as a form of self-medication in order to block post-traumatic symptoms. Even survivors who have maintained sobriety for decades now will confirm that the most effective, immediate way of diminishing traumatic feelings is through substance use. Given that dissociation and numbing are not completely effective, survivors often turn to these more efficient means of regulating their emotions and distracting themselves from their memories. Unfortunately, the benefits are temporary, and chronic substance use brings with it a host of other complicating difficulties, including decreased attention to safety and increases in mistaking behavior, again increasing the chances of further victimization. Social isolation, particularly from nonsubstance using family and friends, compounds feelings of alienation and self-loathing. The financial strain of drug use, coupled with inability to work (due to the entire post-traumatic constellation of responses) increases the likelihood of criminal behaviors.

Social isolation and disruptions in interpersonal relationships.

Many of the effects and long-term sequelae of traumatic experience we have discussed here disrupt the survivor's interpersonal relationships. Just as substance use initially diminishes distress but has a host of subsequent complications, isolation and interpersonal distance can be momentarily comforting for a trauma survivor. Victims have experienced horrendous degradation and pain at the hands of another person, they are strongly motivated to avoid interpersonal vulnerability and doing so somewhat enhances their sense of safety and protection. Feeling love or a sense of connection to someone else often serves as a traumatic reminder, evoking a host of conflicting, intolerable emotions. Isolation and/or rage protects them from this agony. However, the isolation and alienation further erodes their sense of self-worth, and they cannot banish the natural human need for connection and compassion. These conflicting needs and desires result in inconsistency in their relationships. Survivors may fluctuate between extreme, defiant independence, and equally profound dependence and reliance on others. Or they may insist that they have no need for anyone and consistently act in hostile ways that ensure others will keep their distance, yet unconsciously hope that someone will remain, withstand their constant testing, and show that they are in fact worthy of love. Working with survivors of extreme trauma requires immense patience and endurance. We need to accept that they cannot trust us and believe we are on their side, to do so would be to ignore the extensive experience predicting otherwise, and would make them intolerably vulnerable. However, tentative trust can be developed overtime, as long as we are consistent and forthright and show ourselves to be deserving of that trust.

Self-destructive, suicidal and homicidal impulses.

The most dramatic efforts to expel, diminish or expunge traumatic memories and feelings come in the form of self-destructive actions like burning or cutting oneself, and, even more dramatically, serious suicidal attempts. Acts of self-harm are often clinically understood as attempts to distract from psychological suffering, or to reconnect, through pain, with one's body after chronic, pervasive dissociation. The depth of suffering and dearth of self-regard necessary for self-inflicted pain to be experienced as a relief is monumental, and hard to understand for those fortunate enough never to have experienced it. Often this despair takes the form of an overwhelming desire to end the pain, and simply cease to exist. Sometimes, the rage toward those who have victimized becomes intertwined with profound self-loathing, so that homicidal and suicidal impulses become entangled, with the survivor feeling driven to do anything to stop the pain and suffering they experience, to quell their endless rage. Even homicide can sometimes be in part a self-destructive act. Often there is little regard for one's own well-being or concern that incarceration may follow. Also, sometimes homicidal impulses are motivated by a desire to kill what the survivor perceives as a part of him/herself represented in another person. Also, injuring or killing a loved one ultimately causes the survivor pain as well.

Conclusion

Clearly, we can only provide a snapshot here of how a devastating, severe traumatic history might effect an individual and lead them to behave in destructive, dangerous, criminal ways. Because traumatic events push us to the extremes, leading to profound contradictions in our views of ourselves and others, the legacy of trauma is a fluctuating, often inconsistent, extreme way of responding to the world. Fortunately, many survivors find people and inner strengths along the way that help them develop more positive forms of adaptation, never losing or gradually regaining the ability to regulate their responses, flexibly process information, and adaptively respond to their environments. For those who do not, the patterns described here can be self-perpetuating, with each iteration further diminishing the likelihood that alternative perspectives will be adopted, that more effective forms of regulating emotions will be established, that (perhaps most crucially) positive relationships will be established. The apparent incomprehensibility of many trauma survivors' reactions, coupled with the ways their reactions mask the source of their distress, interferes with our ability (along with their own) to understand their reactions and respond compassionately. By viewing their seemingly inexplicable actions in the context of post-traumatic adaptation, responses become understandable and meaningful, profoundly altering our perceptions of these individuals.

LIZABETH ROEMER

Department of Psychology
University of Massachusetts at Boston
100 Morrissey Blvd.
Boston, MA 02125
Tel: (617) 287-6358

LESLIE LEBOWITZ, PH.D.

388 Park Street
Boston, MA 02125
Tel: (617) 327-1081

Lizabeth Roemer is an Assistant Professor in the Department of Psychology at the University of Massachusetts at Boston. She holds a doctoral degree in clinical psychology from Pennsylvania State University and did her post-doctoral training at the National Center for Post-traumatic Stress Disorder - Behavioral Sciences Division. Her research and clinical work focuses on understanding and treating emotional numbing and other emotional disruptions associated with a traumatic history.

Leslie Lebowitz, who received her doctorate in clinical psychology from Duke University, is a clinical psychologist specializing in psychological trauma. Her research interests have focused on psychological response to violence and the ways in which gender and culture affect the meaning making process. In addition to treating victims of violence, she consults and conducts workshops and trainings on trauma and child abuse for legal and other professionals.

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