Imposter syndrome can feel like standing outside a life that should belong to you, sensing that the version others see is only a careful performance. For some people, that feeling is not just doubt before a big moment. It is a quiet, persistent question about whether the self they show the world is the whole truth.

Imposter syndrome
Inner critic
Authentic self
Therapy support

In this blog

	The door that was always yours
	Why imposter syndrome misses the point
	How this pattern begins
	How therapy helps with imposter syndrome

The Door That Was Always Yours

The writer Franz Kafka told a story about a man who waits his whole life in front of a door. At the very end of his life, he is told that this door was always meant only for him. He never walked through. He simply did not know it was his.

This is the quiet sadness of the “as-if” pattern. The real self has been there all along, waiting. While the person performs an elaborate show about not needing it.

Key insight

The feeling of being a fraud may be less about failure and more about a self that learned to hide in order to stay connected, accepted, or safe.

Why Imposter Syndrome Misses the Point

The term imposter syndrome is useful. But it is also a little thin. It names the feeling without explaining where it comes from.

For many people, this goes beyond nerves before a speech. It is a steady, low feeling of unreality. Like moving through life as an actor who has not quite learned the script. A quiet suspicion that the version of you the world sees, capable, likeable, put-together, is a construction, and that underneath, there is not much there at all.

Researchers often use the term impostor phenomenon rather than a formal diagnosis. That distinction matters: the experience can be painful and disruptive, but it does not mean something is wrong with you.

In depth psychology this is called the “as-if” personality. This term describes a person who performs the motions of living, rather than truly living them. Moving as if they belong. As if they feel. As if they know who they are.

Imposter Syndrome and the Mask We Wear

We all wear masks. This is not a sickness. It is part of being human.

The persona is the name for the face we show the world. You speak differently at work than at home. You act differently with your boss than with your best friend. This is normal. This is healthy.

However, for some people, the mask did not stay a mask. It became the whole face. The performance became the person. Underneath, the real self, the true self, sat quietly in the dark. Waiting.

When the inner critic is loud

If the voice inside keeps saying you are not good enough, GoodTherapy’s article on self-compassion and the inner critic can offer another way to relate to that voice.

How This Pattern Begins

This usually starts in childhood.

Children are smart. They learn fast what is safe and what is not. If you grew up in a home where being too loud, too emotional, or too needy was met with coldness, you learned to adapt. You learned to become what the world needed you to be.

A child who learns that being real feels dangerous will build another self. A safer self. One that earns love by being agreeable, capable, and easy to manage.

The true self does not disappear. It hides. And it waits.

The adult who grew from that child often carries great skill on the outside. But there is a strange hollowness on the inside. They have mastered the performance. They just cannot quite remember who was there before the curtain went up.

If the roots of this pattern are connected to chronic stress, neglect, or trauma, it may help to read about how complex trauma can change a person’s sense of self. A trauma-informed approach emphasizes safety, trust, choice, and collaboration, principles also described by SAMHSA.

Do You Recognize Yourself Here?

Here are some signs that you may be living in the “as-if” pattern:

	The perpetual understudy. No matter how much you achieve, success still feels like a lucky mistake. You are waiting for someone to realize they got it wrong.
	Exhausting adaptability. You are very good at reading a room and giving people what they want. Secretly, it drains you completely.
	Not knowing what you want. When someone asks what you want, not what you should want, not what would please others, your mind goes strangely blank.
	The glass wall feeling. You are present in conversations and relationships. Yet not quite there. You narrate your own life rather than live it.
	Needing praise but fearing closeness. You crave recognition. But you believe that if someone looked too closely, they would find you out.
	A relentless inner critic. A voice in your head that never stops: not good enough. Not real enough. Not deserving enough.

These experiences are not random. They are the logical result of a self that learned to hide in order to survive.

What Happened to the Hidden Parts

Here is something most people do not know. When we push parts of ourselves away, those parts do not simply vanish.

These hidden parts become the shadow. The shadow holds everything we have pushed out of sight, our anger, our grief, our strongest wants. All the parts of us that felt too dangerous to show. Often, buried alongside the anger and grief, are creativity, vitality, and passion. The parts of the self that got pushed away were not only the “bad” parts. They were the alive parts. The ones that felt too much, wanted too boldly, or loved too fiercely for the world around them at the time.

The shadow does not disappear just because we ignore it. It finds other ways to come out. Sudden bursts of emotion. Strange dreams. A vague feeling that something is wrong, but you cannot name it.

A gentle try-this-now exercise

Without forcing an answer, ask yourself: What part of me has been waiting to be noticed?

Write one sentence beginning with, “A part of me wants…” Then stop. You do not need to explain, justify, or fix the answer today.

How Therapy Helps with Imposter Syndrome

Therapy is about finding the door that was always yours and finally walking through it.

The good news: the “as-if” pattern is not permanent. People find their way back to themselves. Not all at once. Slowly. Surprisingly. Often with great relief. Psychotherapy can offer a structured relationship where thoughts, emotions, body cues, and patterns can be explored with support.

1	Learning to be seen. In therapy, you practice letting someone witness your real self, your doubt, your anger, your need. When that person does not leave or punish you for it, something inside relaxes. Being real begins to feel safe.
2	Meeting your shadow. Not acting out buried feelings but getting to know them. What emotions have you been managing instead of feeling? What would you be like if you stopped performing?
3	Coming back to the body. The “as-if” pattern often means living so much in the constructed self that the body goes quiet. Body-aware work can reconnect you to sensations you stopped noticing long ago.
4	Working with dreams. Dreams speak the language of the unconscious. They show you, in image and story, exactly what your waking mind is too busy, or too scared, to look at directly.

Early research on interventions for the impostor phenomenon suggests that approaches such as reflection, self-compassion, and supportive therapeutic work can be useful, though more rigorous research is still needed.

Finding support

If this pattern feels familiar, you do not have to figure it out alone. You can search for a therapist or read GoodTherapy’s guide on how to find the right therapist.

Your Sensitivity Is a Strength

The very sensitivity that made the mask necessary is also one of your greatest strengths.

People who learned to read environments carefully, who sense what others need, who adapt with skill and care, these people have a rare and deep empathy. They understand others in ways that most people never will.

You Do Not Have to Keep Performing

The feeling of being a fraud, of moving through life behind a carefully built face, has roots. And those roots can be gently, bravely explored. Therapy offers exactly this kind of space. To help you find your way back to what was always right about you and let it take up space in the world.

A next step that does not require performing

You can begin with one honest sentence in a safe relationship. If therapy feels like the right place for that, GoodTherapy can help you find a therapist who fits your needs.

Frequently Asked Questions

Direct answers about imposter syndrome, self-doubt, therapy, and the inner critic.

Q: Is imposter syndrome a diagnosis? +

A: No. Imposter syndrome is a common way of naming feelings of fraudulence and self-doubt, but it is not a formal mental health diagnosis. The feeling can still be distressing and worth exploring with support.

Q: Why do I feel like a fraud even when I am capable? +

A: Sometimes the self that performs well is not the same self that feels seen. If you learned to earn safety, praise, or closeness by adapting, success may feel disconnected from who you are inside.

Q: Can therapy help with imposter syndrome? +

A: Therapy can help many people explore the roots of self-doubt, practice being seen more honestly, and build a safer relationship with parts of themselves they learned to hide. It is not a quick fix, but it can be a steady place to begin.

Q: What can I do when the inner critic gets loud? +

A: Try naming the critic as one part of you, not the whole truth of you. A simple sentence such as, “A part of me is afraid I will be found out,” can create enough space to respond with curiosity instead of attack.

Take the Next Step

You do not have to keep performing your way through self-doubt alone. Support can help you understand what the mask has protected and what your real self may need now.

Find a Therapist Near You >

About the Author Amanda Frudakis-Ruckel Licensed Clinical Social Worker, TCTSY-F Amanda Frudakis-Ruckel, LCSW, TCTSY-F, is a licensed clinical social worker and psychotherapist practicing in New Jersey and New York. She trained clinically at Memorial Sloan Kettering, Weill Cornell Medicine, and through New York City’s Mental Health Service Corps, and holds a Master’s in Social Work from Fordham University. Her practice, Person to Person Psychotherapy, specializes in trauma, identity, life transitions, grief, and existential anxiety. She draws on existential, humanistic, and narrative frameworks and is a certified Trauma Center Trauma Sensitive Yoga facilitator. View Profile >

When we talk about attachment wounds in therapy, most people think of early childhood dynamics, moments when caregivers couldn’t show up consistently, or times when love felt conditional. But for many queer and trans people, Attachment-Focused EMDR healing addresses challenges magnified by something larger than family: society itself.

For people struggling with trauma, anxiety, or depression, the journey to healing requires understanding which trauma therapy approaches actually work. Many begin with well-meaning but inadequate advice: “Just think positive thoughts,” “Try meditation,” or “Practice positive affirmations.” While these approaches have value in general wellness, they fall short when addressing the complex neurobiological impact of trauma.

If you’ve tried meditation, positive affirmations, Reiki, yoga, or other wellness practices but still feel stuck, drained, or triggered by past experiences, you’re not alone. Understanding why these methods fail and discovering evidence-based trauma therapy approaches that actually work can transform your healing journey.

The Science Behind Why Positive Affirmations Fail for Trauma

Research reveals a fundamental flaw in how positive affirmations are typically used for trauma recovery. Positive affirmations jump directly from negative feelings to positive ones without addressing the underlying trauma. For a positive affirmation to take hold, its negative counterpart must first be neutralized or desensitized.

This means whatever makes the feeling negative needs to lose its emotional power first. Only then, by adding a positive affirmation to a neutral state, can that positive feeling hold lasting power.

For example, if someone goes from “I am unsafe” to “I am safe,” the safety cannot truly take hold unless the unsafe feeling first loses its emotional charge. The person must no longer be bothered by the original trauma trigger.

The Neurobiological Reality of Trauma

As Bessel van der Kolk, MD, explains in The Body Keeps the Score, trauma’s impact exists in the survival part of the brain, which doesn’t return to baseline after the threat ends. Through brain imaging technology, we can visualize how traumatized individuals struggle to process ordinary, non-threatening information, making it difficult to fully engage in daily life.

Trauma affects the entire human organism; thinking, feeling, relationships, and bodily functions. Survivors often experience:

• Chronic feeling of being unsafe in their bodies
• Visceral warning signs and bodily sensations
• Frozen traumatic images, sounds, or smells in the brain
• Difficulty with emotional regulation
• Recurring patterns and triggers

Why Alternative Therapy Approaches Fall Short for Trauma Healing

Meditation and Mindfulness

While meditation can provide temporary relief and general wellness benefits, it doesn’t specifically resolve underlying trauma issues. Meditation helps manage symptoms but rarely addresses the root cause of traumatic stress stored in the body.

Reiki and Energy Work

Reiki can identify where negative emotions are felt in the body, such as the chest, neck, or legs. However, most energy healing modalities lack specialized tools to actually remove trauma and negative emotions stuck in the body.

Exercise and Yoga

Physical activity and yoga benefit both body and mind and can help clear mental fog. However, when someone has experienced traumatic events like car accidents, painful divorces, or other overwhelming experiences, the negative sensory memories can become frozen in the brain. No amount of yoga or exercise alone can unfreeze those traumatic imprints.

Evidence-Based Trauma Therapy Approaches That Actually Work

Trauma-Focused Therapy Approaches (TF-CBT)

Research demonstrates that TF-CBT effectively reduces symptoms of depression, anxiety, and PTSD. This approach combines:

• Psychoeducation about trauma’s effects
• Coping skills development
• Trauma narrative processing
• Cognitive restructuring of trauma-related beliefs
• Post-treatment planning and relapse prevention

Eye Movement Desensitization and Reprocessing (EMDR)

EMDR helps process traumatic memories without requiring extensive verbal processing, making it particularly effective for those who find talk therapy challenging or re-traumatizing.

Emotion-Focused Therapy (EFT)

EFT helps clients build emotional regulation skills and learn healthy responses to difficult emotions. This approach is particularly effective for complex trauma survivors.

Body-Based Trauma Therapy Approaches

These therapies recognize that trauma lives in the body and focus on:

• Resensitizing the nervous system to safety
• Completing interrupted fight-or-flight responses
• Restoring a felt sense of control and empowerment
• Processing trauma through body awareness rather than just talk

Find Specialized Trauma Support

If you recognize yourself in this description, feeling stuck despite trying positive approaches, experiencing unexplained anxiety, or finding that the same patterns keep recurring, it may be time to seek specialized trauma support.

Ready to explore evidence-based trauma therapy approaches? Browse our comprehensive directory of trauma-informed therapists who specialize in approaches that actually resolve trauma at its root rather than just managing symptoms.

How Professional Trauma Therapy Approaches Differ from General Counseling

The Tracing Process

Effective trauma therapy approaches often involve tracing current difficulties back to their origins. On average, it takes less than a minute for trained trauma specialists to identify the connection between today’s struggles and past experiences. This linking process clarifies differences between past and present, helping clear current issues successfully.

Specialized Treatment Methods

Talk therapy alone often isn’t enough to heal trauma. Since trauma keeps people stuck in the past, talking about traumatic experiences can sometimes worsen distress. The good news is that specialized treatment methods can resolve trauma with little or no talking required.

Addressing the Unconscious

If you wonder why you feel anxious for no apparent reason at 2 a.m., rest assured there’s always an unconscious cause. Trauma therapy approaches help uncover and resolve these hidden triggers that keep you stuck in survival mode.

Understanding Different Trauma Therapy Approaches and Timelines

The length of trauma therapy approaches depends on several factors:

• How many issues you wish to resolve
• How deeply traumas are embedded in the unconscious
• Your personal healing capacity and resources
• The therapeutic approach used

It’s important to note that there are major traumas (like accidents) and smaller ones (like conflicts with loved ones). The process to resolve them is essentially the same, though the timeline may vary.

FAQ: Common Questions About Modern Trauma Therapy Approaches

Q: How do I know if I need specialized trauma therapy approaches versus regular counseling? A: If you experience recurring patterns, unexplained anxiety, emotional numbness, intrusive thoughts, or feel stuck despite trying positive approaches, trauma-informed therapy approaches may be more appropriate than general counseling.

Q: Will trauma therapy approaches make me feel worse initially? A: Quality trauma therapy approaches prioritize your safety and emotional capacity. While processing can bring up difficult feelings, skilled trauma therapists use techniques to prevent overwhelming or re-traumatizing clients.

Q: How long do trauma therapy approaches typically take? A: The timeline varies based on individual factors, but many people notice significant improvements within 3-6 months of consistent trauma-informed therapy. Complex trauma may require longer treatment.

Q: Can trauma therapy approaches work if I don’t remember my trauma clearly? A: Yes. Many effective trauma therapy approaches work with whatever memory or body sensations you have, regardless of detail or clarity. Your body holds the memory even when your mind doesn’t.

Q: Is it normal to feel resistant to trauma therapy approaches? A: Absolutely. Resistance often indicates your protective system is working. A skilled trauma therapist will work with your resistance compassionately and help you move at a pace that feels safe.

Building Trust and Connection in Healing

Above all, trust and connection between therapist and client are essential for trauma recovery. This therapeutic relationship becomes the foundation for healing because, ultimately, you’ll be working toward the same goals: your healing, growth, and freedom from trauma’s grip.

When choosing a trauma therapist, look for someone who:

• Specializes in trauma-informed approaches
• Creates a sense of safety and trust
• Respects your pace and autonomy
• Uses evidence-based methods
• Understands trauma’s impact on the nervous system

Moving Forward: Your Investment in Healing

Imagine for a moment that you could resolve your trauma symptoms and ease your physical stress responses in the most effective and efficient way possible. How would that change your life? What becomes possible when you’re no longer held hostage by past experiences?

Quality trauma therapy approaches aren’t just an expense, they’re an investment in reclaiming your life, relationships, and peace of mind.

Remember, healing is possible. With the right therapeutic approach and support, you can move from surviving to truly thriving.

Additional Resources

• Read More:
  • Understanding Different Trauma Therapy Approaches
  • Complex Trauma and Emotion-Focused Therapy
  • The Three Phases of Trauma Healing
• External Resources:
  • National Center for PTSD – Treatment Options
  • International Society for Traumatic Stress Studies

My journey from the disciplined ranks of a US Army combat engineer to a bastion of support for those battling internal wars has been both enlightening and deeply personal. This path, paved with both my own experiences and those of the individuals I’ve had the honor to help, underscores a critical yet often overlooked side of veteran care: the silent, unseen wounds of PTSD and complex trauma. Through this article, I aim to delve into the transformative potential of trauma-informed care, advocating for a shift from merely enduring survival to embracing a thriving existence, especially for veterans confronting the specter of suicidal ideation. 

Unveiling PTSD and Complex Trauma 

PTSD and complex trauma are more than clinical terms; they are lived realities for countless veterans, embodying the enduring aftermath of combat and service. Unlike physical injuries, which are visible and quantifiable, these mental health challenges lurk unseen, their symptoms echoing the tumult of past traumas. Veterans may find themselves in the grip of intense flashbacks, plagued by insomnia, or wrestling with an incessant sense of alertness that transforms even the most mundane environments into potential threats. Such manifestations are not merely remnants of their service but pervasive influences that color every side of their daily lives. 

The journey of understanding these conditions is akin to navigating a labyrinth, where each turn reveals new challenges and complexities. PTSD, traditionally associated with a singular traumatic event, can sometimes overshadow the nuanced and compounded nature of complex trauma, which arises from prolonged exposure to distressing experiences. This distinction is crucial in tailoring interventions and support systems that acknowledge the depth and breadth of the trauma experienced by veterans. 

The Silent Battle Within: A Closer Look 

Beyond the clinical symptoms lies a more profound struggle—a battle for identity, meaning, and connection. Many veterans, accustomed to the camaraderie and purpose found within the military, find themselves adrift in civilian life, where their experiences seem alien and incomprehensible to those around them. This disconnection fosters a sense of isolation, worsening the symptoms of PTSD and complex trauma and, tragically, steering some toward suicidal ideation. 

The story of “John” (a pseudonym to protect confidentiality) is illustrative of this struggle. A veteran of multiple deployments, John’s return home was marked not by peace but by a relentless battle with his memories and a pervasive sense of dislocation. In our sessions, it became clear that John’s journey to healing needed more than just coping strategies; it demanded a redefinition of his relationship with his past and a rekindling of hope for his future. Through a concerted approach grounded in trauma-informed care, we embarked on this journey together, navigating the intricacies of his experiences with empathy and patience. 

Trauma-Informed Care: A Beacon of Hope 

The essence of trauma-informed care lies in its acknowledgment of trauma as a pervasive element that influences the physical, emotional, and psychological well-being of individuals. This approach shifts the paradigm from pathology to understanding, emphasizing the need for safety, choice, collaboration, trustworthiness, and empowerment in the therapeutic process. It challenges us to see beyond the symptoms, to recognize the person grappling with the trauma, and to tailor our interventions in a manner that is respectful, informed, and healing centered. 

For veterans like John, and indeed for many others, trauma-informed care offers a pathway out of the darkness. It is not a quick fix but a journey—a process of rebuilding trust, redefining self-worth, and rediscovering purpose. By integrating principles of safety and empowerment, we create a therapeutic environment where veterans can explore their traumas without fear of judgment, where their stories are heard and validated, and where healing begins with understanding. 

Expanding the Narrative: Education, Advocacy, and Community Engagement 

The journey from service to support does not end with individual therapy; it extends into the realms of education, advocacy, and community engagement. It is about broadening the narrative around veterans’ mental health, challenging stigmas, and fostering a society that recognizes the sacrifices of its veterans not just in words but in actions. By educating healthcare professionals, policymakers, and the public about the realities of PTSD and complex trauma, we can build more robust support systems that reflect our collective gratitude and responsibility towards those who have served. 

In Conclusion 

The transition from surviving to thriving is more than a personal journey for veterans; it is a societal imperative. As we continue to explore and advocate for trauma-informed care, we not only aid in the healing of our veterans but also enrich our collective human experience. The scars of service, though unseen, are indelible markers of sacrifice and resilience. By acknowledging these wounds, by offering our understanding, empathy, and support, we honor the entirety of the veteran experience, fostering a community where healing is not just possible but embraced. 

by Bren Michelle Chasse, Licensed Marriage and Family Therapist

Healing from Trauma Does Not Hinge on a Survivor’s Ability to Forgive

Forgiveness is an evolutionary phenomenon that, historically, has been a necessary part to building and sustaining community (Tooby & Cosmides, 2005)). In early times, it allowed groups to minimize conflict and helped support, foster, and preserve cooperation so that groups could function effectively, thrive, and achieve the goals necessary for their survival. In short, group members needed each other, a fact which didn’t change when a wrong had been done. They had to learn to deal with wrongs and stay alive. Over time, the concept of forgiveness has transformed into a modern-day virtue. Many consider forgiveness to be the moral high ground. There are even mental health providers who believe forgiveness to be the holy grail of healing, identifying it as a necessary therapeutic objective or clinical goal (Luskin, 2003). I am not one of them. 

A Deeper Look at Forgiveness and Trauma

Research has shown that, in general, people practice forgiveness more readily within their tribe or primary support group, while more likely to withhold forgiveness from those outside their group (McAuliffe & Dunham, 2016). However, this research depends on an assumption of high-functioning group dynamics. Not every relationship we experience in our lives (or even within our own family systems) falls into this category. It is simply inappropriate to generalize and apply a forgiveness model evenly across the board to all relationships. Relationships, by definition, are nuanced and very complex—and so is the experience of trauma.  

Additionally, not all transgressions are created equal. For example, I may be able to forgive a close friend who lied to me but find myself unwilling or unable to forgive the same friend if they were to assault me. A one-size-fits-all approach to healing simply doesn’t work! More specifically, the forgiveness model, when applied equally across domains, is fundamentally flawed. It fails to account for context, attachment style, cultural implications, personal moral values, organic individual differences, past experiences (including prior trauma exposure), and the depth and breadth of the transgression.  

Force-Fed Forgiveness?

Unfortunately, I’ve found in my practice that many clients have a history of being force-fed (through various sources) the value and importance of always forgiving. Consider the Lord’s Prayer, which requires we stand humbly before God and ask, “Forgive our trespasses…” and challenges us to “…forgive those that trespass against us.” The pressure to forgive is often applied by those we hold in high regard. When family members, advisors, mentors, close friends, or spiritual leaders insist on this, many clients feeling gaslit, shamed, and forced to betray themselves by placing the needs of their perpetrator above their own. 

Healing from trauma requires a focus on the self — not on the needs of another. When we claim that forgiveness is a necessary component of healing, we tell survivors that they cannot be whole again unless they extend forgiveness even to those who have committed the most physically and psychologically violent acts imaginable. 

Making Change Happen

As a society and as therapists, we must begin to change the language and conversation around forgiveness. If we don’t, we maintain the status quo and risk becoming part of the problem. The language we use, especially when we are in a position of power, really matters. 

We have to change the way we think about this topic as well. An unwillingness to forgive does not directly translate to anger, aggression, seeking revenge, or a refusal to move on, nor does it necessarily equate to a dysfunctional response to trauma. In many cases, survivors simply don’t relate to the concept of forgiveness. The healing journey focuses on creating and enforcing healthy boundaries, refusing to hold toxic secrets, learning to prioritize their own physical and emotional needs, and healing the younger parts of themselves that still feel stuck in the trauma of their past. If forgiveness isn’t part of a survivor’s healing journey, it doesn’t mean there’s something wrong. 

Be True to Yourself as You Heal

Let me be clear — for those that find forgiveness to be a healing part of your journey, I encourage you to embrace it. If you don’t relate to that, or if you feel forgiveness is a barrier to your healing, I encourage you to honor that. What I am arguing is that not everyone who experiences trauma will benefit from sharing physical, emotional, or psychological space with the person who has harmed them. Forgiveness is not necessarily a required stop along the path toward healing. Simply put, how you heal is up to you!

References

Luskin, F. (2003).  Forgive for good: A proven prescription for health and happiness. Harper One.

McAuliffe, K. & Dunham, Y. (2016). Group bias in cooperative norm enforcement. Philosophical Transactions of The Royal Society B Biological Sciences, 371(1686). doi https://doi.org/10.1111/j.1467-9221.2008.00688.x

Tooby, J. & Cosmides, L. (2005). Conceptual foundations of evolutionary psychology, in Handbook of Evolutionary Psychology, ed. Buss, D. M. Wiley, 5-67.

Understanding Intergenerational Trauma: An Introduction for Clinicians

January 8, 2021 • By Dr. Fabiana Franco, PhD, DAAETS

by Dr. Fabiana Franco, PhD, DAEETS
Simple trauma describes a single, circumscribed traumatic event (such as an assault). Complex trauma occurs when a person experiences a series of repeated traumatic events or when new, unique traumatic incidents occur such as natural disasters. Complex trauma early in life can damage multiple aspects of the child’s development. Complex trauma may involve entire families in incidents of violence, addiction, or poverty. (1)

Historical Trauma

Historical trauma refers to traumatic experiences or events that are shared by a group of people within a society, or even by an entire community, ethnic, or national group. Historical trauma meets three criteria: widespread effects, collective suffering, and malicious intent (2). Historical Trauma Response (HTR) can manifest as substance abuse, suicidal thoughts, depression, anxiety, low self-esteem, anger, violence, and difficulty in emotional regulation (3)

Intergenerational Trauma

Intergenerational trauma (sometimes referred to as trans- or multigenerational trauma) is defined as trauma that gets passed down from those who directly experience an incident to subsequent generations. Intergenerational trauma may begin with a traumatic event affecting an individual, traumatic events affecting multiple family members, or collective trauma affecting larger community, cultural, racial, ethnic, or other groups/populations (historical trauma). Those affected by intergenerational trauma might experience symptoms similar to that of post-traumatic stress disorder (PTSD), including hypervigilance, anxiety, and mood dysregulation.

Intergenerational trauma was first identified among the children of Holocaust survivors (4), but recent research has identified intergenerational trauma among other groups such as indigenous populations in North America and Australia (3)(5). In 1988, one study showed that children of Holocaust survivors were overrepresented in psychiatric referrals by 300% (6). The subjects were selected based on having at least one parent or grandparent who was a survivor.

Parenting as an Explanation for the Phenomenon of Intergenerational Trauma

While the existence of intergenerational trauma is well documented in multiple studies across several cultures, the mechanisms of transmission of intergenerational trauma remain unclear.

Trauma’s Effects on Parents

Parents may transmit inborn genetic vulnerabilities triggered by their own traumatic experience or via parenting styles that have been impacted by their trauma (7). Trauma survivors face many challenges when they are parents, including difficulty bonding to and creating healthy emotional attachments with their children. Yael Danieli categorized four adaptation styles amongst the families of survivors: Numb, Victim, Fighters, and Those Who Made It. Survivors who become numb seek silence by self-isolating, have a very low tolerance for stimulation of any kind, and are minimally involved in raising their children. Victims fear and distrust the outside world, try to remain inconspicuous, and are frequently depressed and quarrelsome. Fighters focus on succeeding at all costs and retaining an armor of strength, making them intolerant of weakness or self-pity. Those Who Made It are characterized by their pursuit of socio-economic success but also by the ways in which they intentionally distance themselves both from their experience of trauma and from other survivors (8).

Effects on Children

Children experience and understand the world primarily through direct caregivers and are, therefore, profoundly affected by their parents’ modeling. Children both mimic their parents’ behaviors and learn to navigate future relationships based on how they learned to relate to their parents. Enduring coping mechanisms due to the effects of trauma may be forged out of efforts to avoid and/or “fix” a parent’s abusive behavior, anger, depression, neglect, or other problematic behaviors.

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The Great Famine in Ukraine of 1932-1933 and Intergenerational Trauma 

The Holodomor (derived from the Ukrainian “to kill by starvation”‘) is also known as the Famine-Genocide in Ukraine, the Terror-Famine, the Great Famine, or the Ukrainian Genocide of 1932–33. It resulted from deliberate actions on the part of the authorities in Soviet Ukraine who, under the direction of Joseph Stalin, sought to force collectivization on the ethnic Ukrainian peasant population. This resulted in the deaths of millions (11).

In 2010, Brent Bezo conducted a pilot study to understand the generational impact of the Holodomor. Bezo interviewed 45 people from three generations of 15 Ukrainian families. The first generation survived through the Holodomor: the second and third generations were their children and grandchildren.

The study revealed that the coping mechanisms that the direct survivors had developed during the genocide were retained in the family system and passed down to their children and grandchildren. They described living in “survival mode,” including difficulty trusting people, a food-scarcity mentality, low self-worth, hoarding, social hostility, and risky health behaviors (10).

Aboriginal Communities in Canada and Intergenerational Trauma 

Aboriginal communities in Canada suffered from sustained trauma. For generations, Canada tried to forcibly assimilate Aboriginal people by placing them in residential schools, removing children from their families, and generally attempting to eradicate their culture and traditions (5).

The effects of this prolonged trauma have impacted First Nations groups on individual and collective levels, including markedly high rates of depression and self-destructive behaviors compared to the non-Aboriginal population. One of the challenges for mental health professionals working with community members is to understand the effects of intergenerational trauma on their clients, including a well-earned mistrust in the ministries of outsiders.

When Trauma is not Acknowledged – Learning From the Armenian Genocide

Mental health professionals are often unfamiliar with the history of those they seek to treat. Unrecognized and, therefore, unacknowledged traumatic events, such as family trauma or childhood trauma will go on to pose unique challenges for both client and clinician.

Trauma Denied

The Armenian Genocide, during which the Ottoman Turkish Empire massacred 1.5 million Armenians in 1915, is an example of historical trauma that has often been either minimized or denied outright. In fact, the mass murder of Armenians, Assyrian, Greek, and other Christian and religious minority populations of the Ottoman Empire between 1914 and 1923 has yet to be acknowledged as a genocide by the Turkish government (11). It can be especially challenging to cope with an injury while you are still fighting for its acknowledgment a century after it was inflicted. Additionally, due to this lack of formal recognition, Armenian survivors find it difficult to trust non-Armenian mental health professionals with their history and pain (12).

Coping: Family Closeness

Dagirmanjian suggested narrative therapy as a treatment with Armenians (12). Narrative therapy allows survivors to embody and settle into their perception and view of themselves (11). Another important key to working with Armenians is understanding the way Armenians value family closeness. This trait has sometimes been misunderstood and even considered unhealthy by Western clinicians who have been trained to approach family therapy with the goal of promoting individuation (12). In general, it is crucial for the mental health professional to understand the cultural context of the person suffering from trauma, including intergenerational trauma, to provide the most effective and sensitive treatment.

When Trauma Attacks the Core of a Person’s Identity 

Systematic attacks on a person or group’s identity, such as the Holocaust or the Aboriginal experience, are particularly damaging because identity and tradition are essential to perceived meaning in life. Victor Frankl, in his book, Man’s Search for Meaning, describes the imperative for people to feel securely connected to meaning in their life: without specific meaning, it is literally impossible to live (13).

In approaching survivors of historical trauma in which the intent was not only to inflict pain or kill but to demean and, ultimately, erase the identity of an entire people, the therapist must be aware that recovery requires the restoration of morale, identity, and purpose.

Culturally-Mindful Interventions

In Canada’s Aboriginal communities, intergenerational trauma treatment is complicated due to high substance use (which is itself likely a sequela of historical trauma). A valuable 2015 study (14) demonstrated the importance of blending Aboriginal and Western healing methods to treat intergenerational trauma when it was associated with substance use disorder among Aboriginal people in Canada (14). A vital element in this approach is reclaiming and recovering Aboriginal identity, including traditions, philosophies, and practices, and adapting them to current circumstances and needs. Programs that enhanced identity through cultural affiliations, increased cultural awareness through healing circles and family involvement, and were strongly influenced by traditional Aboriginal spirituality contributed significantly to decreases in substance use, domestic violence (which are often associated with substance use), and an overall increase in individual and communal healing (14).

The Role of Epigenetics in Intergenerational Transmission of Trauma 

Maternal stress and trauma are associated with health consequences for both mother and child, including low birth weight, fetal growth, and preterm delivery (15). The effect of maternal stress and trauma translate into additional risks for the infant later in life, including hypertension, heart disease, Type II diabetes mellitus, and even cancer (16).

Epigenetics refers to the study of heritable changes in gene expression in response to behavioral and environmental factors that do not change the underlying DNA sequence. In other words, epigenetics is the study of inherited changes in phenotypical properties without a difference in the inherited genetic makeup. Recent studies demonstrate that traumatic events can induce genetic changes in the parents, which may then be transmitted to their children with adverse effects (17).

In 2005, a study conducted to better understand the relationship between the PTSD symptoms of women exposed to the World Trade Center collapse on September 11, 2001, and their infant children’s cortisol levels found lower cortisol levels both in the mothers and their babies (18). Cortisol is a hormone released through the adrenal gland which helps regulate stress response. These findings speak to the importance of factoring epigenetic effects into our evolving understanding of how posttraumatic effects may be transmitted across generations (18).

Take Away Lessons for Mental Health Professionals Treating Intergenerational Trauma 

Intergenerational trauma may be transmitted through parenting behaviors, changes in gene expression, and/or other pathways that we have yet to understand fully. These may be biological, social, psychological, and/or a mixture of all three. As we trace these modes of transmission, practitioners will be better able to match interventions to specific factors that either propagate traumatic effects across generations or mitigate against their transmission. Different sources of intergenerational trauma will likely require different approaches. Innovative treatments for multigenerational trauma that borrow from indigenous cultures, acknowledge historical trauma, connect to group identity, and support survivors in finding meaning and purpose in their experience and that of their family and people are already providing practical tools for practitioners and point the way towards future progress for future generations.

References

(1) Courtois, C. A. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychological Trauma: Theory, Research, Practice, and Policy, S(1), 86-100. Accessed August 24, 2017.

(2) O’Neill L, Fraser T, Kitchenham A, McDonald V (June 2018). “Hidden Burdens: a Review of Intergenerational, Historical and Complex Trauma, Implications for Indigenous Families”. Journal of Child & Adolescent Trauma. 11 (2): 173–186.

(3) Maria Yellow Horse Brave Heart “The historical trauma response among natives and its relationship to substance abuse: A Lakota illustration.” Journal of Psychoactive Drugs 35(1).

(4) Fossion P, Rejas MC, Servais L, Pelc I, Hirsch S (2003). “Family approach with grandchildren of Holocaust survivors”. American Journal of Psychotherapy. 57 (4): 519–27.

(5) Aguiar, W. & Halseth, R. (2015). Aboriginal peoples and Historic Trauma: The processes of intergenerational transmission. Prince George, BC: National Collaborating Centre for Aboriginal Health.

(6) Sigal, J. J., Dinicola, V. F., & Buonvino, M. (1988). Grandchildren of Survivors: Can Negative Effects of Prolonged Exposure to Excessive Stress be Observed Two Generations Later? The Canadian Journal of Psychiatry, 33(3), 207–212.

(7) Bowers, M. E., & Yehuda, R. (2016). Intergenerational Transmission of Stress in Humans. Neuropsychopharmacology: official publication of the American College of Neuropsychopharmacology, 41(1), 232–244.

(8) Danieli, Y. (1981). Differing adaptational styles in families of survivors of the Nazi Holocaust: Some implications for treatment. Children Today, 10: 6-10.

(9) Werth, Nicolas. 2007. “La grande famine ukrainienne de 1932–1933.” In La terreur et le désarroi: Staline et son système, edited by N. Werth. Paris. ISBN 2-262-02462-6. p. 132.

(10) DeAngelis, T. (2019, February). The legacy of trauma. Monitor on Psychology, 50(2). http://www.apa.org/monitor/2019/02/legacy-trauma

(11) Mangassarian, Selina L. (2016). 100 Years of Trauma: the Armenian Genocide and Intergenerational Cultural Trauma, Journal of Aggression, Maltreatment & Trauma, 25:4, 371-381

(12) Dagirmanjian, S. (2005). Armenian families. In G. McGoldrick & N. Garcia-Preto (Eds.), Ethnicity and family therapy (pp. 437–450). New York, NY: Guilford.

(13) Frankl, V. E. (1984). Man’s search for meaning: An introduction to logotherapy. New York: Simon & Schuster.

(14) Marsh, T.N., Coholic, D., Cote-Meek, S. et al. Blending Aboriginal and Western healing methods to treat intergenerational trauma with substance use disorder in Aboriginal peoples who live in Northeastern Ontario, Canada. Harm Reduct J 12, 14 (2015).

(15) Dunkel-Schetter, C, Wadhwa, P, & Stanton, AL. (2000). Stress and reproduction: Introduction to the special section. Health Psychol; 19(6): 507-509.

(16) Barker, D. J. P. (1998). Mothers, babies and health in later life (2nd ed,). Edinburgh: Churchill Livingstone.

(17) Yehuda R, Bierer LM (2009). The relevance of epigenetics to PTSD: implications for the DSM-V. J Trauma Stress 22: 427–434.

(18) Yehuda, Rachel, Mulherin Engel, Stephanie, Brand, Sarah R., Seckl, Jonathan, Marcus, Sue M., Berkowitz, Gertrud S., Transgenerational Effects of Posttraumatic Stress Disorder in Babies of Mothers Exposed to the World Trade Center Attacks during Pregnancy, The Journal of Clinical Endocrinology & Metabolism, Volume 90, Issue 7, 1 July 2005, Pages 4115–4118.

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Many might assume that the intergenerational transmission of trauma from parent to child occurs through abuse or neglect, but this is not always the case.

Trauma can also be passed on through changes in gene expression. This is known as the epigenetic transmission of trauma. Epigenetics is understood as changes in gene function that are heritable and not associated with changes in one’s DNA sequence (Dupont, Armant, & Brenner, 2009). It is thought that epigenetic changes can occur as a result of extreme stress, such as in the case of parents with histories of trauma.

Heritability of Trauma

Research with children of Holocaust survivors has indicated that children can inherit the traumatic memories of their parents. The evidence is so compelling that some have argued children can inherit the unconscious minds of their parents. Some children of Holocaust survivors have even been known to have genocide-themed nightmares. Although it can be argued the children receive Holocaust imagery through shared stories and narratives, it does not explain their increased vulnerability to stress-related diagnoses such as complex trauma (C-PTSD) and posttraumatic stress (PTSD).

While may be more difficult to prove the inheritance of traumatic memories, we do know that psychological stress can affect gene expression patterns via the nervous system.

While may be more difficult to prove the inheritance of traumatic memories, we do know that psychological stress can affect gene expression patterns via the nervous system. It may be that the disposition to develop PTSD and C-PTSD is passed down through an epigenetic route (Kellermann, 2013).

When Symptoms Occur Without a History of Trauma

It is important to understand that trauma can be inherited independently of difficult family circumstances. A child can develop anxiety, depression, or other stress-related issues such as PTSD as a result of an inherited vulnerability rather than direct trauma.

Research has shown that secure mother-child attachment is key for childhood development (Meins, Bureau, & Fernyhough, 2018). A recent study shows that “good-enough” parenting is adequate for a child to develop a secure attachment to its mother. What this means is that perfect parenting is not required for the child to grow up securely attached, a state that is associated with the best outcomes for mental health (Lehigh University, 2019).

The research has two sides. On one, the research shows us that we do not require perfect parenting and a stress-free environment to be secure and healthy. The flip side of this research is that some children will inherit trauma even with a gentle upbringing. In these cases, a child can inherit symptoms of trauma, including nightmares and anxiety, even without being exposed to trauma.

Can Epigenetic Changes Lead to Positive Outcomes?

While the news that trauma can be passed down despite good parenting may sound disheartening, epigenetics also creates changes in a positive way as well. When we have good nutrition and are raised in a nurturing and loving environment, over generations, epigenetic changes can also occur for the better. Researchers investigating epigenetics in animal models have found that rat pups with mothers who lick and groom them often are more likely to grow up to be calm, while pups who are not groomed frequently by their mothers may grow up to be anxious (Kirkpatrick, 2017).

What we know from epigenetic research as it relates to the intergenerational transmission of trauma is that we can have at least some influence on our children’s ability to be calm and resilient to stress. By providing a loving and nurturing environment for them, we can diminish the intensity of inherited trauma. Each succeeding generation can whittle away at the effects of trauma through consistent nurturing and loving parenting. Trauma does not have to continue from one generation to the next.

References:

1. Dupont, C., Armant, D. R., & Brenner, C. A. (2009). Epigenetics: Definition, mechanisms and clinical perspective. Seminars in Reproductive Medicine, 27(5), 351-357. doi: 10.1055/s-0029-1237423
2. Kellermann, N. P. (2013). Epigenetic transmission of Holocaust trauma: Can nightmares be inherited?. The Israel Journal of Psychiatry and Related Sciences, 50(1), 33-39. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24029109
3. Kirkpatrick, B. (2017, December 12). Cuddling can leave positive epigenetic traces on your baby’s DNA. Retrieved from https://www.whatisepigenetics.com/cuddling-can-leave-positive-epigenetic-traces-babys-dna
4. Lehigh University. (2019, May 8). ‘Good enough’ parenting is good enough, study finds. ScienceDaily. Retrieved from https://www.sciencedaily.com/releases/2019/05/190508134511.htm
5. Meins, E., Bureau, J. F., & Fernyhough, C. (2018). Mother–child attachment from infancy to the preschool years: Predicting security and stability. Child Development, 89(3), 1,022-1,038. doi: 10.1111/cdev.12778

Posttraumatic stress (PTSD) and complex posttraumatic stress (C-PTSD) are related but distinct from each other. C-PTSD is thought to be an enhanced version of PTSD. C-PTSD is, in turn, related to borderline personality (BPD).

Ongoing Interpersonal Trauma and C-PTSD

PTSD is usually caused by a single traumatic event (or a series of traumatic events) that result in a real or imagined threat to one’s life or bodily integrity. Events that could cause PTSD include exposure to war, a terrorist attack, physical or sexual assault, or even the threat of such attacks. C-PTSD is different in that it’s typically caused by ongoing trauma which is often interpersonal in nature. C-PTSD tends to be associated with continued trauma that occurs at a young age. Children who grow up in neglectful or abusive environments may go on to develop C-PTSD (Giourou et al., 2018).

Borderline Personality and Ongoing Interpersonal Trauma

Borderline personality is also connected to ongoing interpersonal trauma during childhood. Researchers have linked exposure to chronic fear and stress as a child, as well as suffering from physical, sexual, and/or emotional abuse as a child, to the development of BPD. Growing up with a parent who had a serious mental health issue is also a risk factor for the development of BPD.

BPD and C-PTSD share an association with maltreatment in childhood, and up to 71% of individuals who experience BPD report severe abuse in childhood.

BPD is a serious issue characterized by a constellation of emotional, social, cognitive, and behavioral dysregulation. The most notable features of BPD are difficulty managing emotions, impulsivity, identity problems, and dysfunctional interpersonal relationships (Hecht, Cicchetti, Rogosch, & Crick, 2014).

Common Characteristics of C-PTSD and BPD

BPD and C-PTSD share an association with maltreatment in childhood, and up to 71% of individuals who experience BPD report severe abuse in childhood. BPD and C-PTSD also share symptoms. Overlapping symptoms relate to the areas of emotion processing and regulation, security in relationships, and self-concept (Ford & Courtois, 2014).

Some common symptoms of BPD and C-PTSD include:

Emotion processing and regulation difficulties

People with BPD and C-PTSD are known to have difficulties managing and regulating emotions. When experiencing uncomfortable emotions such as anger, fear, or sadness, the person may have difficulty controlling the intensity and duration of the emotion. It can be very hard to “let things go” and return to a neutral or uplifted mood once they’ve been thrown off balance.

Relationship issues

Those with BPD and C-PTSD often have relationship issues. Relationships may be unstable, insecure, and can often be traumatic or stressful for one or both partners. We start learning how relationships work in childhood. If our caregivers in childhood were neglectful or abusive, we tend to carry these learned perceptions of ourselves, such as “I’m bad, worthless, or not worthy of support,” into our adult relationships, as well as lessons about relationships, such as “They are unpredictable, unreliable, and sometimes dangerous.”

Individuals with BPD may have an especially difficult time trusting and relating to others. It is thought that because they may not have experienced empathy from their primary caregivers during childhood, they have developed limited abilities to see past their own emotional responses and understand how others may be feeling.

Adults with C-PTSD may also have difficulty with empathy and relationships, although it depends on the nature of the trauma and whether they had access to at least one caring adult during their childhood. We are all unique, and how we develop and respond to early trauma is variable and can depend on many different factors within the environment and the individual.

Self-concept

BPD and C-PTSD are both associated with impulsive behaviors and dissociation. People may behave in ways that are self-destructive and reckless. Unsafe sex, abuse of drugs and alcohol, and disregard for one’s own safety can occur.

Dissociation is highly prevalent in BPD, and it’s known to occur in PTSD as well (Krause-Utz & Elzinga, 2018). Dissociation can result in a feeling of being disconnected from oneself and the world. Especially during times where stress levels are high, dissociation can act as a defense mechanism where the sufferer feels detached from themselves and what’s happening around them. In certain cases, amnesia may result, as well as a feeling of “lost time.” Identity confusion can also occur, and the person may feel as though they don’t have a strong sense of self or that their identity seems to shift depending on the circumstances and the environment they find themselves in.

High levels of worry, sadness, and shame

Borderline personality and C-PTSD are associated with high levels of general distress. Many feel isolated and empty, as a significant portion of their symptoms can affect their relationships and connection with others. They may have high levels of shame and sometimes experience a feeling that they have been permanently damaged. This can lead to the desire to withdraw from others, as relationships are often a source of stress, insecurity, and/or conflict.

What If You Have Symptoms of Both C-PTSD and BPD?

Complex posttraumatic stress and BPD require treatment and support. If you are experiencing symptoms of C-PTSD and BPD, it can help to first receive an accurate assessment and diagnosis. It is important to understand that nobody is permanently damaged, and there are treatment approaches that have demonstrated effectiveness for both C-PTSD and BPD.

Therapy can help you develop strategies and techniques that allow you to better cope with stress and manage difficult emotions. Ongoing support from a therapist who understands what you are experiencing and where your feelings and symptoms are coming from can be enormously helpful for your healing journey. Find a therapist near me.

If you are struggling, it is important to reach out and take advantage of the support and options available. With treatment, you can not only feel better, but also avoid the negative consequences of behavioral and emotional symptoms. Feeling better and coping with stress can improve other areas of your life as well, such as how you function in professional and personal relationships.

References:

1. Ford, J. D., & Courtois, C. A. (2014, July 9). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1, 9. doi: 10.1186/2051-6673-1-9
2. Giourou, E., Skokou, M., Andrew, S. P., Alexopoulou, K., Gourzis, P., & Jelastopulu, E. (2018, March 22). Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? World Journal of Psychiatry, 8(1), 12-19. doi: 10.5498/wjp.v8.i1.12
3. Hecht, K. F., Cicchetti, D., Rogosch, F. A., & Crick, N. R. (2014). Borderline personality features in childhood: The role of subtype, developmental timing, and chronicity of child maltreatment. Development and Psychopathology, 26(3), 805-815. doi: 10.1017/S0954579414000406
4. Krause-Utz, A., & Elzinga, B. (2018). Current understanding of the neural mechanisms of dissociation in borderline personality disorder. Current Behavioral Neuroscience Reports, 5(1), 113-123. doi: 10.1007/s40473-018-0146-9
5. Luyten, P., Campbell, C., & Fonagy, P. (2019, May 7). Borderline personality disorder, complex trauma, and problems with self and identity: A social‐communicative approach. Journal of Personality. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/jopy.12483

Traumatic stress involves a threat to a person’s life or physical integrity. It can have a profound impact on the brain, nervous system, and peripheral bodily systems. The impact of trauma on our emotional and mental health is discussed at length in the literature. However, trauma’s impact on the peripheral body (the peripheral nervous system, as well as the muscles and internal organs it connects to) is less understood. Said impact is often not considered in primary health care or even a therapist’s office.

Physicians and therapists need to understand that trauma impacts more than emotional and mental health. While the mechanism is not fully understood, we know from large, population-based studies that traumatic stress is a factor in chronic diseases such as cardiovascular disease (CVD). An investigation that was conducted across diverse populations showed that people experiencing depression, posttraumatic stress disorder (PTSD), and anxiety are at an elevated risk of dying from cardiovascular disease.

How trauma affects the heart

Trauma is associated with behavioral factors that affect heart health and lead to an increased risk for CVD. Individuals with a history of trauma are more likely to:

• Begin smoking.
• Have low levels of physical activity.
• Abuse illicit substances and/or alcohol.
• Refuse to take medicines prescribed by doctors or follow doctors’ orders after a cardiac event.

In addition, evidence suggests there are biological effects of traumatic stress that occur independently of behavior. For example, individuals with past trauma show elevated biological markers of inflammation. In other words, traumatic stress increases inflammation in the body. In turn, inflammation has been shown to increase the risk of CVD. The effects of traumatic stress on inflammation and the subsequent link to CVD is likely to play a key role in the causal connection between trauma and CVD.

The effects of trauma on inflammation seem to hold over time. A study designed to assess trauma and inflammation looked at a sample of 1,021 individuals aged 40-90 years. Higher lifetime trauma exposure was linked to increased levels of biological markers of inflammation at baseline and after five years.

Complex trauma

Complex trauma and its related condition, Complex Posttraumatic Stress Disorder (C-PTSD), is different than PTSD. The cause of PTSD can be a one-time incident or group of incidents such as combat, a natural disaster, or a car accident. Meanwhile, complex trauma results from exposure to ongoing trauma over an extended period of time. Child abuse or neglect and ongoing interpersonal (relationship) trauma tend to meet the criteria for complex trauma.

The data suggest that taking steps to take better care of our bodies is extra important if we have a history of trauma. Prolonged trauma over the course of childhood results in a different cluster of symptoms and outcomes. It is sometimes more difficult to diagnose and treat. Clients with a history of prolonged trauma are exposed to elevated risk for CVD on multiple levels. Studies have found that the cumulative effects of prolonged trauma are associated with elevated levels of inflammation and have the most potent effects on one’s physical health.

What can be done today?

Studies show patients with CVD demonstrate higher biological markers of inflammation following acute mental stress as well as higher levels of circulating stress hormones. In addition to the ongoing physiological effects, childhood trauma exposure is also associated with unhealthy behaviors that further increase the risk of developing CVD.

In some cases, gaining a better understanding of how state-of-mind and health habits affect our bodies in a concrete way (such as cardiovascular risk) motivates us to make changes. The data suggest that taking steps to take better care of our bodies is extra important if we have a history of trauma. Similarly, taking steps to care for our mental health can mitigate the damage that PTSD and C-PTSD can inflict.

Therapeutic interventions are effective for PTSD and related symptoms. A trained professional can teach you strategies to deal with difficult emotions such as fear, worry, anger, and sadness. They can also help you with emotion regulation by providing the support necessary for healing.

Dealing with trauma needs to be a holistic venture, where the body, emotions, and mind are all addressed and nurtured. In addition to taking steps to improve physical health, individuals are also encouraged to seek therapy to protect their heart on every level possible.

References:

1. de Assis, M. A., de Mello, M. F., Scorza, F. A., Cadrobbi, M. P., Schooedl, A. F., de Silva, S. G., … & Arida, R. M. (2008). Evaluation of physical activity habits in patients with posttraumatic stress disorder. Clinics, 63(4), 473-478.
2. Feldner, M. T., Babson, K. A., & Zvolensky, M. J. (2007). Smoking, traumatic event exposure, and post-traumatic stress: A critical review of the empirical literature. Clinical Psychology Review, 27(1), 14-45.
3. Giourou, E., Skokou, M., Andrew, S. P., Alexopoulou, K., Gourzis, P., & Jelastopulu, E. (2018). Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma?. World Journal of Psychiatry, 8(1), 12-19.
4. Hendrickson, C. M., Neylan, T. C., Na, B., Regan, M., Zhang, Q., & Cohen, B. E. (2013). Lifetime trauma exposure and prospective cardiovascular events and all-cause mortality: findings from the Heart and Soul Study. Psychosomatic Medicine, 75(9), 849-855.
5. Kop, W. J., Weissman, N. J., Zhu, J., Bonsall, R. W., Doyle, M., Stretch, M. R., … & Tracy, R. P. (2008). Effects of acute mental stress and exercise on inflammatory markers in patients with coronary artery disease and healthy controls. The American Journal of Cardiology, 101(6), 767-773.
6. Kuhl, E. A., Fauerbach, J. A., Bush, D. E., & Ziegelstein, R. C. (2009). Relation of anxiety and adherence to risk-reducing recommendations following myocardial infarction. The American Journal of Cardiology, 103(12), 1629-1634.
7. Martens, E. J., de Jonge, P., Na, B., Cohen, B. E., Lett, H., & Whooley, M. A. (2010). Scared to death? Generalized anxiety disorder and cardiovascular events in patients with stable coronary heart disease: The Heart and Soul Study. Archives of General Psychiatry, 67(7), 750-758.
8. von Känel, R., Hepp, U., Kraemer, B., Traber, R., Keel, M., Mica, L., & Schnyder, U. (2007). Evidence for low-grade systemic proinflammatory activity in patients with posttraumatic stress disorder. Journal of Psychiatric Research, 41(9), 744-752.

Many of us develop emotion regulation skills naturally during childhood and as we mature into our adult years. We learn to down-regulate negative emotions such as anxiety or anger through constructive self-talk, distraction (if there’s nothing to be done about a distressing situation), or reaching out to a supportive person for help.

Complex trauma, as the name suggests is a more complex form of trauma that is caused by prolonged abuse and trauma (Herman, 1993). People who have experienced complex trauma or who grew up in an abusive or stressful environment often did not have the opportunity to learn emotion regulation. Abusive parents often increase negative emotional states in their child rather than offering helpful assistance.

For people with complex trauma, experiences of sadness, fear, or anger may be more intense and last longer. Ongoing negative emotions often seriously interfere with functioning and can cause distress in interpersonal relationships.

Fortunately, emotional regulation can be learned. Emotion-focused therapy (EFT) with a trained EFT therapist can help clients build skills for healthy responses to difficult emotions and learn ways to more effectively regulate their negative emotions.

What Is Emotion-Focused Therapy?

Emotion-focused therapy is an approach to psychotherapy that is based in the understanding that our emotions play a key role in who we are and how we function.

Our emotions are connected to our needs and behavior. Our feelings drive how we select goals and maintain the intensity of commitment to realizing our goals. Emotions inform our decision-making and play a central role in communicating our feelings and intentions to others.

Our emotions are connected to our needs and behavior. Our feelings drive how we select goals and maintain the intensity of commitment to realizing our goals.

Emotions also alert us to danger or unhealthy situations. In this way, they protect, guide, and motivate us. They also help us make sense of ourselves and the world around us (Greenberg, 2004).

Grounded in the theory that emotions are centrally important in human experience, EFT seeks to help clients identify, experience, make sense of, and flexibly manage emotions in order to bring about positive change and live vitally.

The Three Goals of Emotion-Focused Therapy

1. Increasing awareness of emotion: The first goal of EFT is to increase the client’s ability to identify and name their emotions. While this may seem straightforward, many people, especially those who experienced abuse in childhood or other forms of complex trauma, do not naturally identify emotions. For example, depression may not be felt as sadness or despair, but instead as fatigue or lethargy. Anxiety may manifest as another emotion such as irritability.
2. Enhancing emotional regulation: Emotional regulation may be thought of as the ability to control the intensity and duration of negative emotions as well as increase the experience of positive emotions.
3. Transforming emotion: It is possible to transform emotions by changing a maladaptive emotion into more positive feelings.

Cognitive reasoning and the desire to change an emotion are not sufficient to transform one’s emotions. An EFT-trained therapist can teach clients to identify and name emotions, to regulate emotions, and to learn emotion transformation skills.

Using EFT to Overcome Complex Trauma

If you have complex trauma, you may find you have difficulty with heightened and prolonged feelings of sadness, fear, or anxiety. You may be unable to trust people or expect good things to happen in your life. Anger and rage may well up over small upsets, and it may take a long time to calm down afterward.

Given the difficulties in building and maintaining trust, complex trauma sufferers often face serious or prolonged challenges with interpersonal relationships. It may be difficult for your partner to understand your intense emotional states. Additionally, you may have difficulty naming or explaining your feelings and reactions to your partner and even to yourself.

EFT treatment goals are naturally aligned with the needs of many individuals with complex trauma. The goals of EFT are to help the client to identify, regulate, and transform negative emotions as well as to address the core symptoms of their complex trauma.

EFT for complex trauma is empirically supported. One study designed to examine the effectiveness of EFT for adult survivors of childhood abuse (physical, emotional, and sexual abuse) found that those who received 20 weeks of EFT therapy achieved significant improvements with multiple symptoms. The results of EFT have also held up over time. Over nine months after EFT sessions ended, clients were still maintaining improvements gained during therapy (Paivio & Nieuwenhuis, 2001).

If You Have Complex Trauma, There Is Hope

If you have complex trauma, consider meeting with a therapist. A therapist trained in EFT can help you manage and understand your emotional experience. You can develop and maintain healthier and more durable relationships. Emotions do not have to be maladaptive; you can learn to transform your emotions. Difficult feelings can be changed into adaptive and positive states that will enable you to live a higher quality of life as well as improve your overall health and well-being.

References:

1. Ehring, T., Welboren, R., Morina, N., Wicherts, J. M., Freitag, J., & Emmelkamp, P. M. (2014). Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse. Clinical Psychology Review, 34(8), 645-657. doi: 10.1016/j.cpr.2014.10.004
2. Greenberg, L. S. (2004). Emotion-focused therapy. Clinical Psychology and Psychotherapy, 1(11), 3-16. doi: 10.1002/cpp.388
3. Herman, J. L. (1993). Posttraumatic stress disorder: DSM-IV and beyond. Washington D.C.: American Psychiatric Press.
4. Paivio, S. C. & Nieuwenhuis, J. A. (2001). Efficacy of emotion focused therapy for adult survivors of child abuse: A preliminary study. Journal of Traumatic Stress, 14(1), 115-133. doi: 10.1023/A:1007891716593
5. Pascual-Leone, A., Yeryomenko, N., Sawashima, T., & Warwar , S. (2017). Building emotional resilience over 14 sessions of emotion focused therapy: Micro-longitudinal analyses of productive emotional patterns. Psychotherapy Research. doi: 10.1080/10503307.2017.1315779