Phil Mollon Ph.D. DCEP
Stress Response and Cumulative Stress Syndromes
The understanding of stress and trauma is relatively recent. Contrary to common popular assumptions, Freud did not emphasise trauma - although he did write two papers on sexual abuse trauma in 1896. Most of his work focused on internally driven psychodynamic conflict. One of his contempories, the French Pierre Janet, did present a sophisticated model of traumatic stress, highly congruent with our modern understanding. However, it was not until the mid to late 80s - and indeed well into the 1990s - that the modern understanding became well-established. This modern perspective takes account of Post Traumatic Stress Disorder, in both its simple (e.g. single trauma) and complex developmental forms (e.g repeated interpersonal trauma in childhood), and also recognises the way in which recent adult traumas re-stimulate thematically related childhood traumas (and the defensive strategies associated with these).
A remarkably pioneering early book on traumatic stress was Stress Response Syndromes, by Dr Mardi Horowitz [Aronson 1978]. Horowitz is a psychiatrist and psychoanalyst - and the author of the widely used Impact of Events Scale. Horowitz described clearly the twin processes of denial/avoidance/numbing, on the one hand, and intrusive reliving or repeating trauma, on the other. He noted the following common themes in response to trauma:
- Fear of repetition
- Fear of merger with the victim
- Shame and rage over vulnerability
- Rage at the source
- Rage at those exempted
- Fear of loss of control of aggressive impulses
- Guilt/shame over aggressive impulses
- Guilt/shame over surviving
- Sadness over losses
The intrusive experiences can include the following:
•Illusions or pseudo-hallucinations
•Intrusive/repetitive thoughts, behaviours, images, emotions •Overgeneralisation of associations
•Inability to concentrate on other topics
•Confusion or thought disruption when thinking of trauma-related themes
•Labile or explosive entry into intense emotion
•Chronic fight-flight readiness, or exhaustion from arousal
•Search for lost persons/situations, compulsive repetitions
The avoidant experiences can include:
•Inability to appreciate significance of stimuli
•Amnesia (complete or partial)
•Inability to visualise memories
Depersonalisation and derealisation
Horowitz noted that the tendency to repeat and relive trauma (such as in dreams and behaviour, as well as intrusive recollections) puzzled Freud, particularly since it seemed incongruent with the Freudian hypothesis of dreams as disguised wish fulfilments. In his 1920 paper Beyond the Pleasure Principle, Freud was struck by the prevalence of traumatic neuroses following the world war, and was stimulated by this to speculate about the 'Death Instinct', as well as proposing a drive towards mastery of trauma that might play a role in what he described as the 'repetition compulsion'. Horowitz himself propose s a hypothesis of a 'completion tendency'. According to Horowitz, the human mind has an intrinsic ability to continue to process new information in order to bring up to date the inner schemata (or 'working models') of the self and the world – a continual revision of these relatively enduring structures of meaning. When trauma occurs, there is a discrepancy between the ‘news’ and the enduring, slowly changing, schemata. Repetition and processing of trauma will occur until completion of the revision of the internal ‘cognitive maps’.
How is trauma treated? There are a variety of approaches, but all effective treatments for trauma, in effect, follow the principles proposed by Edna Foa and colleagues:
1. Traumatic memories, and trauma-related affect and cognitions, must be activated
2. Trauma-discrepant information is provided - which might be as simple as 'I survived' or 'It is not happening now'.
The problem is that for many traumatised people, any contact with traumatic memories will be overwhelming and risk retraumatising and destabilising them. Moreover, traumatised people have often lost trust in self, in others, and the world in general. Danger is perceived everywhere, and nowhere and no-one are felt to be safe. Insensitive therapeutic approaches to trauma can result in intense fear and a worsening of the person's mental state.
The therapeutic challenge is
•To find ways of processing trauma and recovering a sense of safety, without retraumatizing the patient.
•To negotiate the therapeutic relationship when trust in others has been shattered
•To engage with the client’s belief that it is not safe to feel safe
•To facilitate modification in response in the body and brain, as well as the cognitive mind
Eye Movement Desensitisation and Reprocessing (EMDR), used with skill within a therapeutic relationship, can be an effective component of treatment for trauma - but must be used with great care.
The gentlest methods of treating trauma are based on energy psychology. These do not require intensive reliving of trauma. Although some distress may be experienced, this is usually relatively mild. Nevertheless, the person may feel very afraid of approaching their residues of trauma at all.
Cumulative stress syndromes
It is perhaps not as widely recognised as it could be that many common mental health problems are essentially the result of cumulative stress. Conditions such as depression, anxiety, feelings of being unable to cope, and generally experiencing a 'breakdown', are often the result of an accummulation of traumatic stress that the person has not been able to 'digest'. Before one traumatic or stressful experience is resolved, another has happened - often years of stress, of prolonged activation of fight-flight responses. This chronic high arousal exhausts a person's brain and body. Chronic fatigue may be one result. Cumulative stress may be exacerbated by the trait of perfectionism, which causes internal pressure to succeed when faced with difficult or repeated challenges. Just as a person may cope with repeated ingesting of toxic substances until his or her 'toxic threshold' is reached, so a person may cope well with traumatic stress until such point as their coping capacities are overwhelmed. It is at that point that one 'final straw', perhaps seemingly small in itself, triggers the collapse of the person's capacity to maintain their previous way of life and work.
In the case of these common 'cumulative stress syndromes', the therapeutic task is one of addressing the stress in the body and the brain, as well as the person's beliefs and protective strategies (such as avoidance) that he or she has developed in response to stress and trauma. Forcing a person to overcome their 'avoidance', or to substitute their characteristic thoughts by 'new cognitions' may provide a superficial and temporary recovery, but the underlying stress may remain in his or her system.
There are many ways of resolving stress in the body and brain. These can include yoga and meditation, acupuncture and acupressure, EMDR, and many forms of 'energy psychology'. The 'Healing Codes', developed by Alex Lloyd, is a relatively new and promising mode of energy psychology that seems excellent at steadily resolving the cumulative stress that has overwhelmed a person's capacity to cope. The 'Healing Codes' approach does not involve tapping, but uses the person's own fingers are suble energy trasmitters that are directed at four healing centres around the head/brain. I am sure we will, over the next few years, continue to discover many other modes of gently and effectively relieving stress, which engage not only the mind but the deeper parts of the brain and the body's physiology. Talking alone is less likely to address effectively these deeper neurobiological realms. The various energy psychology modalities are best incorporated into an overall therapeutic approach, such as Psychoanalytic Energy Psychotherapy [PEP]
NB The views expressed her are the personal perspectives of Phil Mollon. They are not a substitute for consultation with a licensed professional. If you have a mental health problem, please consult your doctor or other mental health professional.