Liz Long Rottman
Transcript
Liz Long Rottman: Today we are going to talk about common misunderstandings about CPTSD. We’re going to use a hypothetical client with CPTSD and medically unexplained symptoms. I work a lot with folks with medically unexplained symptoms, which just means that we have symptoms that the medical field has not diagnosed. It doesn’t mean that it’s all in our head. It just means that there could be some element of that, but we need to be very careful because it may actually be pointing to something that needs physical attention.
Liz Long Rottman: So, this client was convinced they were doing therapy wrong because they had gone through a number of programs that told them if they could change their thoughts and foster a positive mood that their medically unexplained symptoms would go away. This is actually something I hear a lot from clients who have gone through some of the more mainstream chronic illness and pain management approaches. And I don’t know if that’s because this is actually what is being taught or if clients tend to misunderstand what is being said. I’m not really sure what’s happening there. So anyway, I’ve had several people come to me terrified that if they don’t get it right that they’ll never heal or feel good again.
Liz Long Rottman: And they develop this almost superstitious relationship with their own thoughts and feelings. If I think the wrong thing, my body will punish me. Some of you may have seen this with manifestation culture that people believe that if they are not feeling 100% tiptop spick and span all the time that they will never achieve their dreams by means of the law of attraction. So, it’s a similar kind of issue just applied to medical symptoms. So, it’s kind of a magical thinking pattern: bad thoughts equal it means that I’m going to stay sick forever. So, this is a direct reaction to “just change your thoughts” messaging from psychology and the chronic illness management worlds, cognitive psychology and the chronic illness management worlds.
Liz Long Rottman: And I’m not saying that these chronic illness approaches are not helpful or correct, but it seems to me that they’re at times being delivered in ways that people misunderstand them. All right, that’s the premise of our story, and we’ll come back to that. So now I’m just going to list off some of the common misunderstandings about CPTSD that I’ve seen the most because there are a ton. So CPTSD isn’t just worse PTSD is nervous system reactivity to triggers.
Liz Long Rottman: So, let’s say somebody has a trauma where there’s a really loud noise involved and now anytime it’s a fireworks holiday, they get a little on edge. With CPTSD, and I don’t want to minimize PTSD either, maybe they become quite symptomatic. So, CPTSD fundamentally shapes our identity. So with PTSD, there’s the personality before the trauma and then there’s the trauma and then there’s the symptoms after the trauma. People with PTSD often can access that personality from before the event.
Liz Long Rottman: People with CPTSD typically—the traumas began before identity formation and so the identity is based on the trauma. CPTSD can also be developed later in life and one of the things that occurs even when it’s later in life is there is a shift in the identity. You can think about somebody who gets kind of pulled into a cult. They are shaped by that group to lose their old identity and relationship is very important with CPTSD. So the term “emotional dysregulation” is too light. These activated states completely bypass conscious control.
Liz Long Rottman: The person is not able to track that they are now—their symptoms can feel all-encompassing like they are the truth, and often that means it feels like the abuse is happening right now even if there’s none of that going on at all or the emergency’s happening right now even though none of that’s going on at all. All right. Number three, flashbacks don’t include the sensation of remembering. This is an artifact of—this is a consequence of the activity of the amygdala and the hippocampus.
Liz Long Rottman: The hippocampus is where we record our movie memories. And the amygdala—it’s very small. It’s the little fear area in the brain. That little fear area overwhelms many systems. But one of the things it does is it shuts down the hippocampus and we stop recording the movie memory. So when the trauma is big enough or it’s early enough that the person is very vulnerable—young child—they may not create a recording of the memory but the body and the amygdala records that memory and so when a trigger happens they don’t know that they are remembering but their body acts as though they are remembering and the event or events or that environment is happening right now.
Liz Long Rottman: So that’s a very challenging aspect of CPTSD. It’s what makes it feel like a hall of mirrors. So CPTSD—this is number four—does not respond well to standard PTSD treatment. Exposure therapy is really important. Things like Sensorimotor Psychotherapy, Somatic Experiencing, these are—you can think of them actually all as new wave exposure therapy approaches in some way. This is not like the old school really kind of putting the—making the person confront the thing and there’s a lot of fear and it’s really dramatic.
Liz Long Rottman: We want to do the exposure therapy but actually keep things pretty tame and boring if we can. So even doing something like EMDR without rapport when we have CPTSD is not going to work. The person with CPTSD will feel like you are doing something to them instead of doing something with them. And that quality of being joined and having someone do it with is an important reparative experience for someone with CPTSD. So before we start doing the bilateral stimulation or even certain somatic protocols, we need to make sure that the relationship is established and that ramp of the relationship might take a few months actually and it’s very important.
Liz Long Rottman: And if we don’t do that, not only is it not going to work as well, it could actually be damaging. Because for folks who have lived through CPTSD, having things done to you is often part of what caused the trauma in the first place. All right. Number five, the trauma is primarily through relationships. So most folks know attachment language these days who are interested in this stuff.
Liz Long Rottman: So that means all relationships are triggering, especially safe ones, ironically. And this isn’t always the case, but this is something I’ve noticed with a lot of folks living with CPTSD is they feel safe with relationships that are exploitative or not honoring of their boundaries or people who put them down or people who are hot and cold or neglectful. And it’s not because they feel truly safe. It’s because those relationships feel familiar. They feel like what they’re used to. And the CPTSD has been adapted to be in that type of relationship. It is not adapted for being in a safe relationship. Safe relationships can bring up feelings of the unknown. It can make the person with CPTSD feel like they’re out of their depth.
Liz Long Rottman: It can bring up cognitive dissonance. They can feel boring and flat. These are all things I’ve heard. Number six, dissociation isn’t zoning out. I’m sure we’ve all zoned out in the afternoon after doing your taxes or something like that and you start to feel a little floaty or your vision gets a little fuzzy, your brain wants to think about anything but taxes. That’s not what dissociation is. When the brain floods itself with neurotransmitters that are called endogenous opioids and cannabinoids. Endorphins are one of the neurotransmitters involved in this.
Liz Long Rottman: This is kind of like—I actually call it getting high on your own supply because your brain is flooding itself with its own drugs. So this can cause mild disconnection all the way to full personality fragmentation. So I didn’t talk about this in this video but this is where when you see somebody switching between subpersonalities or parts. We all have parts. We’re all multiple.
Liz Long Rottman: It’s not just folks with DID, but that’s relevant here. DID is an extreme version of that. So, when you see somebody switching between dissociative parts, this neurotransmitter flood is involved in that. So, it’s not just spacing out. It’s actually as though drugs have been introduced into the system. All right. Number seven, healing from CPTSD is not about changing your thoughts or your beliefs, believing you deserve love, doing positive affirmations. That’s a part of it. That’s not a bad thing to do. We certainly want to address the thoughts, the belief systems and so on.
Liz Long Rottman: We have to train the nervous system though to really move the needle on this because the thoughts are not caused by some confusion. The thoughts are really the icing on the cake of a whole experience, a whole nervous system event. So we have to train the nervous system to detect safety when it’s there versus just experiencing danger everywhere. And that we do primarily through somatic processes.
Liz Long Rottman: Yes—I pause because not everyone can start with somatic processes but again when they can’t start with somatic processes we start with a relationship and maybe we can do some Socratic dialoguing which is in that cognitive realm. All right, where are we at? One, two, three, four, five… Number eight. Boundaries require knowing where you end and others begin. So with CPTSD, that distinction was often never formed or as in the cult example, you were encouraged to get rid of your boundaries. So I do a lot of work with objects and I’m not in my office, so I don’t have a scarf, but I do have this cord here.
Liz Long Rottman: So, you can just grab whatever you have. You’re probably wondering why I’m not using my microphone. I don’t know. That’s why. So I would grab something like this cord and I would have the client lay it on the ground and we would actually physicalize some boundary work. And if you’re a therapist and you’ve never tried that, do it. It is very evocative and it’s extremely interesting how people respond to that. It’s not subtle. If you want to learn more how to use objects, you can get gestalt training. Physicalizing things in Sensorimotor Psychotherapy and Hakomi all use physicalizing. Those are the ones I’m aware of. All right, number nine, I think. So, there’s a real impact on physical health.
Liz Long Rottman: I can’t stress this enough. I think maybe in the therapy world I’m constantly surprised that folks aren’t aware of the—mind and the body are not separate. We like to blame Descartes, but I don’t think he really meant to cause the separation that occurred from his thinking. But yeah, it’s like your brain didn’t fall out of your head and just think thoughts somewhere outside of your body. The states that you feel in your body cause thoughts and thoughts that you think cause states in your body and thoughts and states can emerge spontaneously due to things out in your environment. And all of that impacts your health. We know—this has been proven for a long time.
Liz Long Rottman: And so what that means is trauma—it doesn’t cause dysautonomia, which is a type of autoimmune disorder. It doesn’t cause those things. But what it does do is it activates genetic vulnerabilities. So let’s say you have a genetic vulnerability to hives and you didn’t have the hives before you got sucked into the cult and now you have the worst hives ever all the time. And then when you’re feeling less stressed, you don’t have the hives. And then when you’re more stressed, you do. So that’s an example. All right, last one. You can’t communicate your needs because you don’t know what they are. Having needs and wants were punished or they were dangerous or you were shamed for having them.
Liz Long Rottman: So what people will often do, whether this is a childhood situation or an adult situation, is they start to distance themselves from their wants and needs. So it’s a lot easier to just not know because then I’m not under the threat that I might want or need something and then express that need and then be punished or humiliated for it. So people just get rid of those needs and wants. Usually people still know what their favorite flavor of ice cream is, whether or not they like Brussels sprouts, do you prefer snow or do you prefer the beach? So we can use those less evocative wants and needs to reestablish the relationship there. But yeah, that has gone offline.
Liz Long Rottman: Okay, so let’s go back to our story. So the client is monitoring their thoughts obsessively trying to catch the bad ones. Every symptom flare is evidence that they thought something wrong. They start to develop exhausting hypervigilance around their internal experience. It turns into this compulsion of just checking and checking and trying to reframe the thought. Everything they feel inside even like a hunger pang starts to cause a lot of worry. So this has created a flywheel that actually makes things worse. The self-monitoring creates—the symptoms increase the monitoring which increases the activation and so on and so forth.
Liz Long Rottman: So this is an example of a person who’s trying to think their way out of a nervous system problem. So where we can help clients shift is helping them understand that their thoughts are not causing the symptoms, that it’s their nervous system stuck in a pattern from back then. So often I see clients will have visible relief. I check in to see how that psychoeducation landed. But then a new fear comes. It’s like, but I have to be able to control something. My life feels so out of control. And the answer is you can. We just want to not do it through thought policing. We want to focus on something else.
Liz Long Rottman: So, we’re going to let the yucky thoughts be there. But what I can control is where I direct my attention. I’m not going to try to change the thought, but maybe I’m going to notice that it’s a nice day outside. Maybe I’m going to make a list of things that went well today. I prefer those to gratitude lists because gratitude is a little bit like forcing a feeling. But we can notice what went well today because that’s just true. For folks who are ready for this, they can start body-based work. They can track the sensations without judging them. They can use somatic resourcing—putting their legs up the wall or standing or dancing if they’re ready for that or going on a walk or breathing. And as they do this, they start to build their ability to detect when they’re safe because they are clearing out the noise when it is in fact safe.
Liz Long Rottman: And that opens their system to more nuance instead of just terror all the time. So, this client stopped trying to have the right thoughts. Their symptoms didn’t vanish, but their relationship to the symptoms changed. And they could actually rest instead of the constant internal surveillance. They could eat which of course helps a lot when you have chronic physical conditions or CPTSD or dysregulation of any kind. So out of that whole list, my main takeaway here is CPTSD isn’t a thinking problem that you can think your way out of.
Liz Long Rottman: Though it is important to notice your thoughts and work with those. It’s a nervous system stuck detecting danger everywhere, including when you’re in safety. Thought changing has its place, but it’s not the most important thing here. Body-based practices retrain our safety detection, and so therefore, it is essential. The “just think better thoughts” crowd has unfortunately created harm. No one meant to do that and I don’t know if it’s the philosophy itself or if it’s the way that it’s being delivered but people are now blaming themselves for nervous system states that they just can’t consciously control. Recovery isn’t about perfect thoughts. It’s about nervous system flexibility.
