The feeling nobody cared was worse than the violence
“I’ve come to terms with the violence I experienced as a child. I don’t blame myself for that. I’m more haunted by the feeling that nobody cared about me and that I am somehow unlovable,” lamented Pamela in our first session. Pamela was now a 40-year old manager in her company who seemed functional at work, but after work she struggled with chronic suicidal ideation, chaotic relationships, and numerous health issues.
She had been diagnosed with fibromyalgia, post-traumatic stress disorder, recurrent major depression, and borderline personality disorder. She felt helpless and hopeless as if she was “broken and unfixable.” Everyone focused on her “behavior,” but nobody really explored how the heck years of severe childhood physical abuse may have impacted her brain, body, and ability to even know how to have a healthy relationship.
Pamela groaned, “I’m tired of talking about the trauma. I just want someone to love me and have a normal life.” How many times have you heard this from people who experienced childhood, developmental, or complex trauma?
In these cases, it’s not enough to reprocess the traumatic events themselves. As Pamela noted, it’s the attachment trauma- the feeling that nobody cared about me and I’m unlovable haunts a person more than the event in and of itself. And– it’s not just a psychological issue. When traumatic stressors are chronic and occur at critical stages of development, additional changes happen in the brain that interfere with a person’s ability to cope in general.
How chronic stress and trauma affect the brain and body
When a person experiences chronic stress, particularly stress that feels like a threat to one’s survival, the chronic release of stress hormones like adrenaline, norepinephrine, and cortisol begin to change how the brain organizes itself. Elevated levels of adrenaline and norepinephrine lead to generalized anxiety, irritability, aggression, and hypervigilance. Persistent surges of these excitatory neurochemicals increase blood pressure, damage blood vessels, and contribute to cardiovascular disease. High cortisol levels interfere with cognition and memory, suppress the immune system, and alter insulin responses, contributing to health conditions like diabetes, obesity, and even alcoholism.
Neurons in the amygdala become enhanced for sensing danger. Meanwhile, neurons in the hippocampus– an area of the brain involved in learning, memory, and new neuronal growth, atrophy, shrink, and even die off. Similarly, the pre-frontal cortex– the area where we reason, plan, and attempt to regulate emotions becomes thwarted by the chronic release of stress hormones. The thalamus has trouble filtering out irrelevant stimuli, leading to sensory overload and feellings of overwhelm from even routine activities like going to the grocery store.
Are we mislabeling the problem?
Unfortunately people with these issues are often labeled with treatment resistant depression and anxiety disorders, hypochondriasis, eating disorders, and worse– personality disorders. Extreme emotional outbursts and behaviors are often viewed as willful attempts to resist treatment and manipulate others. Chronic health complaints can be interpreted to be psychosomatic cries for attention or malingering attempts to get drugs. The medical model’s solution has been to medicate these patients’ symptoms into submission and set firm boundaries with their behaviors.
Granted, it’s difficult to stay calm and therapeutic when a client is cutting on themselves, raging at you for being two minutes late for a session, or insisting they have chronic pain even though doctors can’t find anything physically wrong with their body. But when we understand how chronic stress, trauma, and abuse reorganize the developing brain, these behaviors and somatic complaints begin to make sense. The brains of these clients aren’t trying to sabotage treatment or give you a hard time. They’re simply responding to the way they’ve been programmed to survive in a chaotic environment.
Relationships change the brain
So how do we help these clients? No matter what you hear from managed care companies or see in advertisements for the latest “evidenced-based” treatment, the evidence says that a strong therapeutic relationship is the key to effective therapy; regardless of the treatment method you use. Remember this on those days when you are doubting yourself as therapist. Your willingness to show up, be present, and listen compassionately to your clients is the best medicine you can give them. I realize empathic listening isn’t going to fix everything, but it is the basis for everything else we do.
Moreover, creating the conditions for secure attachment is what helps the brain begin to develop neural connections and pathways that may have been thwarted in childhood. Neuropsychologist and researcher Allan Schore (2012) asserts attuned responsiveness from another person helps our brains and nervous systems develop the neuropathways for emotional regulation and resilience– and this can happen later in life if you didn’t get it in your childhood. In other words, your attuned presence isn’t just a kind thing to offer, it’s a powerful brain changing tool.
We’re taught we need to teach clients emotional regulation skills, but the best way to regulate emotions is through a safe relationship with a safe person. Neuroscience suggests that human contact calms us down because it signals the hypothalamus to release oxytocin– a powerful hormone that inhibits fear responses, lifts our mood, and promotes trust and bonding with others. Simply holding the hand of a friend or even a total stranger during a stressful experience has been shown to attenuate emotional responses in the brain. (Coan et al., 2006).
But… it depends on the person’s attachment style
So, what do you when your best efforts to establish a secure therapeutic alliance aren’t working? Do you label the client as resistant? Do you assume you’re a “bad fit” and refer the client out to another therapist? Not necessarily. When you understand how to connect with various attachment styles, you can more easily develop rapport and avoid unnecessary frustration.
For instance, clients with an avoidant style are going to be reserved and will pull back if you push them to reveal deep emotions too quickly. Anxiously attached clients my idealize you in the first few sessions, then suddenly become angry if you have to reschedule and appointment or challenge their thinking. Clients with disorganized attachment my dissociate in your sessions, seem frightened or suspicious of you, or suddenly become enraged with you.
In upcoming articles, I’ll share tips for how to navigate these emotional defenses and securely connect with different attachment styles. It helps to remember that these attachment styles were adaptive responses that helped these clients survive complex trauma. Their behaviors may seem self-defeating to our rational brains, but for our client’s emotional brains, they still seem necessary for survival.
For more ideas about how to effectively work with complex trauma and different attachment styles, check out my book Rethinking Trauma Treatment: Attachment, Memory Reconsolidation and Resilience.
