Inpatient Trauma Care is in Crisis

Since Beauty After Bruises’ inception, we have been speaking to the dire need for more specialized, trauma-competent care for survivors with Complex PTSD and Dissociative Disorders. Not only a need for more therapists, psychiatrists, medical doctors, and healthcare services at large, but most critically, inpatient care. We were distressed by the lack of inpatient trauma units available back then, but following so many recent, rather sudden closures, it is no longer alarmist to say: This is a crisis.

So, what on earth is happening? Why are these units closing? And, what do we do from here if we’re to have any hope of keeping our complex trauma survivors alive?

Hopefully, this in-depth look can shed some light on a rather complex problem - starting with how grave the situation we were already in many years ago truly was.

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Though there are thousands of psychiatric hospitals, facilities, and individual units across the United States, there are now less than five who are equipped to treat the nuanced, highly specialized needs of survivors with Complex PTSD and Dissociative Disorders. Devastatingly, we have had to sit back and watch in horror as some of the leading mainstays in trauma and dissociation closed their doors one-by-one. Others have downsized, greatly limited who they accept (based on patients’ location or level of care needed), changed leadership (and thusly, the structure and quality of their programs), or merged units with other psychiatric populations. This is unacceptable, worrying, and - truthfully - dangerous for all survivors in critical need.

WhY A specialized TRAUMA UNIT?

It may be easy to assume that survivors can go to any unit, or at least the next best thing - particularly if their life depends on it. But, 'just going somewhere else' often isn’t a safe or viable option; it may even jeopardize their lives further. Even units claiming they “are trauma-informed,” “see patients with DID,” “have a trauma track,” or simply “treat PTSD” are rarely, in fact, trauma-competent. We know it is possible to leave even the highest-rated inpatient programs with more trauma than the day you arrived, but when missteps and failures happen in the care of those who erroneously think themselves equipped to process trauma, bring child parts out of flashback, or talk time-disoriented alters down from active safety crises, the consequences can be fatal. They already have been. Intellectually knowing ways trauma can affect a mind and body versus having the skills, training, staff, environment, safety protocols, infrastructure, and detailed curricula to treat or engage with a traumatized patient are very, very different things. This distinction exponentiates when caring for survivors with Dissociative Identity Disorder or who have organized perpetrator groups still active in their lives.

Other psychiatric units and residential programs unintentionally place complex trauma patients in danger when they do not have specialized treatment teams, properly-trained unit staff, quiet and low-trigger atmospheres (separate from other psychiatric populations), and/or locked units capable of handling both safety threats from outside the building as well as dissociative or wandering patients inside the building. It requires a very nuanced education to, first, correctly identify, and then safely engage with a survivor who is in crisis versus a flashback, switching between self-states, having an immediate safety threat, or experiencing a medical emergency. These are all delicate concerns of life and death, particularly when patients are already coming onto the unit at a critical low, with their symptoms and safety impulses most unmanaged. This is not merely the difference between a 3- or 4-star review.

Unfortunately, because there are no other options, many survivors are sent to these other locations. Or, they’re left to roll the dice in gen-psych in hopes of either stabilizing in 3 days or - at the very least - adjusting necessary medications and quickly returning to their outpatient therapists. Rarely is any true therapy or treatment provided here, only attempts at acute stabilization. Other survivors are forced to come up with tens of thousands of dollars to try a more trauma-centered residential program. But, many of these locations run into the very same trouble as those above — particularly their inability to take on clients struggling with critical safety issues, behavioral outbursts, or co-occurring eating disorders, substance abuse, or medical illness. While not being a locked unit can offer survivors more freedom, it also means staff are unable to prevent elopement and are woefully under-equipped for any external safety threats, intruders, or even belligerent visitors. This not only jeopardizes the life and wellbeing of the patient that these nefarious folks may be after, but also the lives of everyone else in the program, staff included.

It should also be noted that this sincerely tragic and heartbreaking state of affairs is not limited to the United States. This is a global crisis. Most countries have exactly zero trauma units. Some have one or two, though often of questionable caliber. Healthcare systems set aside, most nations encounter these very same complications internationally. It is unacceptable that, right as we are all becoming more trauma-aware and trauma-educated than we’ve ever been, this is when doors begin closing left and right. So, what is happening? And why is it happening? Let’s examine.

WHY ARE TRAUMA UNITS CLOSING EN MASSE?

Unfortunately, like most things in life - particularly healthcare - it is multifactorial. With so many moving parts, people, institutions, dollar signs, and powers that be, it’s tough to summarize such a complex issue. That doesn’t mean we shouldn’t try to at least identify all we can discern, otherwise we delay working on the elements within our means of influence. It is not hyperbolic to say survivors will die each day we fail to understand and, most importantly, begin to rectify this crisis.

An incomplete list of known reasons:

• Hospital budget cuts. The simplest answer will always be money. And, when it comes to hospital systems, trauma units are often the easiest to cut when they need to trim margins - even if the program is in high demand, always full, and has a waitlist a mile long. They are usually the most niche focus in the entire hospital. They are also hard to advocate for amongst suits who have no knowledge of trauma or dissociation broadly, let alone how widespread it actually is.
  
  Moreover, in order to be an effective and therapeutic environment, they are kept small (usually amassing no more than 15-20 patients in a particularly large program) and thus, they become easy to excise. Expansion - be it to serve more survivors desperately waiting at home, or to prove its profitability to a hospital - isn’t truly viable. It drastically compromises the quality of care, patient atmosphere, and overall safety of everyone when too many struggling and dissociative survivors are congregated in one space.
  

• Expertise comes at a price. The caliber of trauma professionals required to adequately staff a trauma unit - from the doctors, therapists, social workers, nurses, and accessory therapy leaders, to the round-the-clock mental health workers - is extremely high. They need and expect to be paid accordingly for their expertise, hours of training, and broader qualifications obtained to work there. As they should. Few to no other psychiatric units in any medical center carry this amount of professional weight, nor do they require this much funding to support.
  

• Training. Related to but separate from above, the amount of training focused on the nuances of trauma and dissociation that day-to-day unit staff must receive - as well as the hospital-wide art, music, occupational, movement, and/or psychodrama therapists; the medical directors, doctors, and pharmacists; and the RNs, unit nurses, residents, social workers, and other specialized positions - in order to safely aid this population, takes time. And quality instruction. And those things cost money. But each staff member that enters a trauma unit, no matter how briefly, needs to understand the differences that this floor maintains in terms of environment, patient rules, and detailed safety protocols that likely don’t exist on the other units.
  
  Float staff often require a crash course. Medical doctors, coverage psychiatrists, and rotating nurses need to be taught about dissociation, switching, and the shifting brain chemistry that patients with DID can experience, which may affect their medications and/or medical health. Outside-unit staff called in for emergency health or behavioral codes need careful instruction on the rules surrounding physical touch and chemical/physical restraint, as well as how patient engagement and deescalation work differently here. (And, to be fair, these should be hospital-wide policies, not solely applied to the trauma unit, but we can’t fix all of psychiatric care here at once!)
  
  Above all, the daily unit staff need to be fully educated on PTSD, triggers, dissociative disorders, switching, flashbacks, grounding, child parts, emotion dysregulation, internal communication, and safety safety safety. To not only recognize, but mitigate and/or teach, these things to patients who will need to learn how to do these things for themselves when they leave. It takes time—often shadowing for weeks. It takes dedication. Patience. Compassion. Loyal, focused staff. All of which are not only dollar signs to a hospital, but just hard to come by in general. Because…
  

• Inpatient crisis-care is grueling and painful. Staffing a trauma unit is hard. There was already a steep imbalance of trauma-competent or even -aware professionals versus the number of survivors in need since the beginning of time. But, inpatient care is emotionally and mentally intense. These brave souls see patients at their absolute worst, at a time their symptoms are the most unmanaged, emotions most dysregulated, and safety concerns most grave. The latter alone can be internally frightening. They are people - with big, warm, compassionate hearts. It’s a requisite for this work. They hear, on repeat, the worst crimes of all humanity, against the most precious of innocents this world has: children. And, they do it for years. It is hard on a mind.
  
  Burnout, vicarious and secondary trauma, or consciously opting to dedicate just a few years to this work before stepping down to outpatient care are all very common. The folks with these unique qualifications, talents, and now the one-on-one experience can find it more lucrative and rewarding to either start their own practices, join a collective that offers adjunctive trauma therapies, or step down to a day program so that they can help survivors integrate what they’re learning into their day-to-day lives. So, not only is staffing a trauma unit hard from the jump, retaining the staff you’ve built there is even harder.
  

• Healthcare worker burnout: 2020-edition. We are currently amidst a period of mass global trauma. Healthcare worker burnout in all fields and practices is occurring at such an accelerated rate it’s impossible to plug the leak. As clinicians and HCWs from other specialties leave (or have passed on themselves), those remaining must step in for them to fill the gaps. They are then spread even thinner, begin to burn out, and leave—rinse, repeat. Trauma populations just happened to be so much more vulnerable to this to begin with.
  
  Having your own active trauma, on top of your clients’ past trauma, on top of their fresh and ongoing trauma is…a lot. Units are just unable to cope right now; and, as they have thinned out, not only did the quality of programs decline, but more severely, so has their safety. Patients leaving more traumatized than they came in, or suffering catastrophic lapses in safety whilst there (or immediately upon discharge), aren’t things we can risk. Compromising unit integrity can cost lives. It’s a snowball effect that compromises everyone involved and only ends in disaster. Closure, or program reduction-and-refocus, is the only ethical choice.
  

• Lack of awareness that dedicated trauma programs exist at all. The consequences this unfamiliarity to complex trauma care brings are twofold. First, most training psychologists and psychiatrists don’t even know trauma disorders are a specialty they could pursue. This makes them even less familiar with the option of completing their post-doctoral fellowship (or comparable residency) on a specialized trauma disorders unit. Second, the treating therapists of survivors are largely unaware that dedicated treatment centers exist for their patients in crisis to go. Combined, this creates an impossible equation. It not only increases the disparity between the number of survivors in need to the number of treatment providers available, but also makes it impossible to accurately measure the scope of their need. Reliable figures to represent the demand for trauma care are impossible to gather so long as clinicians aren’t attempting to admit their patients to programs they don’t know exist. Even waitlists fail to illustrate just how many are going without acute, crisis care. We, inevitably, are losing far more patients than we can possibly know.
  
  Additionally, while ignorance to trauma and dissociation is prevalent in all of healthcare, those who are already in the field are too often unaware of what separates a “trauma unit” from any other program. Trauma disorders programs are as different from an adult general psychiatric or even dual-diagnosis unit as, say, an eating disorder or adolescent program would be to each of those. Not only from the staffing, rules, and unit atmosphere, but in the work that is done there. Daily schedules are filled to the brim - including things like educational groups on coping skills; the incorporation of DBT, CBT, and sensorimotor tools; broader psychoeducation on trauma, child development, and medication management; processing groups to share heavy emotions, struggles with safety, sexuality and intimacy concerns, the challenges of comorbid addictions and/or compulsive behaviors, as well as even walking through trauma narratives; expressive therapies to work with one’s inner child and/or parts inside, connecting with your body safely, or creatively depicting important emotions; as well as an abundance of relapse prevention-based groups. Individual therapy may be 3-5 times a week and psychiatry is usually daily. It is hard, intense, grueling work. Stays are often 2-3 weeks at minimum but can easily become months depending on the program and level of care needed. These units do more than just stabilize patients; leaving prematurely can be quite dangerous, which is, of course, why they stay longer.
  
  So. How do we prove the value and necessity of trauma units when far too many have never even heard of their existence? How do you staff an entire unit, and fill it with the survivors desperately needing to be there, if you don’t even know it's an option?  …sadly, it’s become almost too accurate to say they don’t actually exist and aren’t an option.
  

• Pioneers of trauma hospitalization are retiring. Most of the leading trauma units began in the 80s-90s, with the pioneers of trauma and dissociation research as we know them at the helm. They built their programs from the ground up, trained those under them for decades, and remained in leadership until very recently. It’s now time to retire, step down, or focus solely on education. When they leave, finding quality leadership to fill their shoes can be a messy, disruptive, chaotic transition. While some found balance, others didn’t at all. Even those who seemed to at first lost what they had over time. And, when there’s disruption at the top, it seeps into everything beneath it - like syrup soaked through a pancake stack. That’s when patients suffer. And, when patients begin to suffer instead of heal, that’s when you’re failing oath number one of any good medical practice: Do No Harm.
  

• Ever-evolving fields create change and conflict. The true understanding of trauma and dissociation is not only a relatively new, ever-evolving landscape, but the preferred treatment models are steeply in flux. The various treatment facilities we’ve had often disagreed with one another, had different modalities, rules, groups, and patient atmospheres. But, that was largely a good thing, because patients could then choose the model that was working best for them through the guidance of their outpatient teams. That’s the benefit of having so very many locations.
  
  Patients aren’t a monolith. And certainly not those with dissociative disorders. But, when that disagreement is occurring internally, within one program, and they’re unable to settle on best practice or a modality, things break down. Programs unravel. Staff leave. Patients are failed. You know the tune by now.
  

• Long stays, long waitlists, long everything. Trauma units are most effective when they don’t merely stabilize a patient and send them on their way, but instead supply them with a modest amount of treatment. First: robust tools, coping skills, trauma education. For some, a diagnosis at all. Many learn for the very first time, only whilst hospitalized, that they even have any trauma at all, that they dissociate, or that they possess an entire OSDD/DID system within them. It can be a HUGE, life-altering shock—one that requires a delicate, gentle hand to help them digest and process it through. Others need a safe place they can go to work through a piece of trauma content that has continually destabilized them outpatient. This, too, requires great care and - above all - time.
  
  Stays can become quite long. There is little turnover compared to other units. Their waitlists are often so long that those in crisis can’t actually get in when they need it. They’re forced to go elsewhere - even if it’s an eating disorder, substance abuse, or other subspecialty program that includes some trauma care. This isn’t ideal for anyone, but hospital systems don’t like it either. Insurance companies above all don’t like it. Patients can’t afford it when they’re either cut-off too soon or before they can get in at all. The model just isn’t sustainable.
  
  Doctors and therapists don’t want to have up fight so hard just to keep their patients there. Accepting a pro-bono or halved rate to save a client’s life gets messy when you’re doing so repeatedly. Reimbursements dwindle. Many would rather just….frankly? Not fuss with it. Their time, patience and fight could be put in elsewhere for the benefit of survivors. It’s just one more reason we need MORE units, not less. But, since that didn’t occur, the strain on those already here was inevitable. Breakdown follows.
  

• Bad apples. Simply put? We’d be remiss to not acknowledge this very plain reality. Awful people exist everywhere. That sadly includes trauma care, be they leadership or unit staff. Sometimes they come as wolves in sheep’s clothing, others are merely ignorant but still harm all they touch. All it takes is one or two morally grey folks to step onto a unit before everything starts turning toxic. Y’know, “spoil the whole bunch” and all. Some units fell victim to this early and disintegrated, others later on. It became particularly evident in some locations when patients were coming out with horrid experiences by the handfuls. The consequences of this are just so much higher with already-traumatized clients. Therapists would avoid or warn against them. Eyes widen at their name. It, heartbreakingly, happens and was the downfall of some, just as it can be the downfall of any.

There are so many more spokes to this wheel that, while a disappointingly honest thought to end on, we could no doubt list more and more for hours to come. But, our fingers are admittedly tired, hearts just aching with pain, and whole selves yearning for solutions or a light to crack through the darkness just as much as you are. So, let’s take a moment to consider a few ways we can begin to turn this around. Breathe. Find fresh air.

What can we do to change this?

No action in this crisis is too small or insignificant. Whether you yourself are a survivor/patient, or instead are a clinician, concerned loved one, donor, legislator, or just a stranger with a heart, there are things we can do. And, we hope you share your own ideas below because we are in this together and thrive when we unite in collaboration, not independence.

An also-incomplete list of actions you - no, we - can take:

• Spread the message. Educate. Inform! Share this grim reality, and all the knowledge therein, with everyone you can. Help it find the hands of those in a position to make some real movement. Make noise, kick and scream, get attention. Be seen. Refuse to be overlooked. There are, no doubt, those whom this directly affects that don’t even know how dark things have gotten—how few resources they’ll have should they find themselves in crisis. Much of the world is most certainly not aware how bad it has always been. Each person it reaches is a chance for change, a flicker of hope. When we all shine at once, we burn brighter and are impossible to ignore. Go light your world.
  

• Support and raise awareness of trauma- and dissociation-dedicated organizations, like ours. Survivors won’t stop being in critical need just because there are few places for them to turn. And the public will still need reliable, accessible places to go to expand their education on trauma. We need to have a more robust supply of resources to offer everyone, to ensure they can get at least enough, even if it’s not everything they need or deserve. For our survivors who are able to access therapy, we need to guarantee they get to attend regularly, and don’t reach crisis points. For those who inevitably require inpatient care, we need to assiduously secure what is still available to them. We are only able to supply that with the aid of others. We must be the bridge to safety that’s been knocked down for them elsewhere. [Some organizations/efforts you may wish to direct your support can be found here and here.]
  

• Contact to your local hospitals. Write, call, message, whatever is accessible to you - or do all the above! Explain the need for them to open a specialized trauma unit or day program in your area. Share the high demand, vital urgency, and how complex trauma care differs from the needs of a general psychiatric population. Urge them to consult leaders in the field and work together to build quality programs. Make them aware of how their whole hospital benefits from becoming trauma-informed.
  

• Contact your community leaders, legislators, change-makers. Make them aware of the actions we need to see locally and nationally in regards to all mental health services, trauma care, and access to healthcare in its entirety. Ask them to support programs that keep folks out of crisis. Ask them to fund hospitals, mental health programs, training services that create more professionals and nonprofits who are making a difference in the lives of trauma survivors. Ask them to amplify and remedy this current trauma care crisis.
  

• Vote. Be counted. Seek elections at all levels, from the smallest and most local, to the largest, most national. Seat those who will help move the needle for all mental health care - in schools, hospitals, communities, states, countries. Prioritize the needs of complex trauma survivors who are being sorely neglected.
  

• Congregate together. Therapists, nurses, psychiatrists, mental health workers, everyone who’s ever had a dream to open up a unit or day program. Find one another and see if it’s something you might actually be able to bring to life together. What may have always been a private pipe dream on your own could actually materialize when you have an entire crew of passionate hearts with you, ones who are no longer willing to wait. Consult organizations like ours, ISSTD, An Infinite Mind, Blue Knot, and more to help design centers that will best serve our precious communities.
  

• Start small. While we need more inpatient units, and quickly, prevention is the best medicine. There are countless services that trauma survivors need but are missing that can keep them out of crisis. “Simple” things like: reliable food, utilities, transportation to appointments and sessions, community, friendship, sober activities or accountability partners, safe housing, consistent phone or internet access, medical devices, help filling out forms, some laughter in their day, etc. See where you can lend a hand or support. If you can’t do it yourself, reach out to those who may be able. Generate noise there as well. Let people know who is in need.
  

• Keep your spirits up and eyes on the goal. We know this is painfully crushing and feels rather dismal. It is extremely easy to become demoralized beyond belief or the ability to be effective. But we can’t get lost in the overwhelming sense of futility. Make sure to actively engage in self-care. Friendship. Community. Goal-setting. Active movements forward. Reflection at the progress. Gratitude. Hope-restoration. Do things that instill your faith in humanity or at least in yourself. Don’t let that dazzling spark, the one that was so invested in change that you made it all the way to the end of this article, fade out. You’re made of the brilliant stuff.

So, lets do this. Together.

You are not alone and we won’t leave anyone behind. We refuse to.

We have the ability to redirect this ship, and if there is one thing that survivors have in abundance, it’s determination, grit, and FIGHT. But you’ve never had an entire army of the same on your side. Uniting together as one front, charging ahead—that is one helluva force. One that those in our way could never have seen nor imagined. So, let’s press onward. Advance. It’s time to claim what’s yours. …ours. What we as survivors and those dedicated to them have always needed and deserved: Protection. Safety. Hope.

MORE POSTS YOU MAY FIND HELPFUL:

  ✧  Grounding 101: 101 Grounding Techniques
  ✧  Distraction 101: 101 Distraction Tools
  ✧  Flashbacks 101: 4 Tools to Cope with Flashbacks
✧ Self-Care 101: 101 Self-Care Tools
  ✧  Nighttime 101 and Nighttime 201: Sleep Strategies for Complex PTSD
✧ Color Breathing 101: How to Calm Overwhelming Emotions and Physical Pain
  ✧  Imagery 101: Healing Pool and Healing Light
  ✧  DID Myths: Dispelling Common Misconceptions about Dissociative Identity Disorder
  ✧  Did You Know?: 8 Things We Should All Know about C-PTSD and DID
  ✧  Trauma and Attachment: 3-Part Series on Attachment Theory with Jade Miller
 
  ❖  Article Index  ❖

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The BASK Model of Trauma Memory

In previous articles, we have talked a fair bit about flashbacks, particularly offering several tools and strategies to manage them. We have also discussed the more specific and unique phenomena of Emotional Flashbacks and Body Memories — all in the hopes of providing a few ways to work through them! But, we haven’t taken a proper detour into the mechanism behind all flashbacks, to really solidify the ways traumatic memory gets stored differently from regular, unfractionated, safe memory. To do this, we look to something called The BASK Model of dissociation and memory.

When a traumatic event occurs, for many folks, strong dissociation steps in as a means of self-protection. It helps compartmentalize the experience, or cast parts of it far outside of conscious thought, where it cannot be reached. It would be too distressing to be fresh on your mind, or even easily-accessible, when you're trying to go to work or are just making dinner. But, memories are made up of a vast, colorful array of mental, physical, emotional, and sensory experiences! Simplistically, we recognize them in four main categories: Behavior, Affect, Sensory, and Knowledge (BASK). We break down each of these further in the graphics below.

Let’s break those down a little further!

• Behavior — What was the action in this memory? What did you physically do - or feel the overwhelming compulsion to do - with your body? Hide, flinch, run away, attack, duck/cover, stop speaking, yell, isolate, use self-destructive behaviors, go to a certain place, turn to stone, etc?

• Affect — What were your emotions in this moment - even those stifled or shut-off? Were you sad, afraid, angry, worried, calm, disgusted, helpless, ashamed, enraged, suspicious, defeated, conflicted, intimidated, or even entirely numb or apathetic? Try to discern them from what you feel about the moment today.

• Sensory — What were the sensations in your body? Racing heart, physical pain, thirst, trouble breathing, chills, numbness, clenched jaw, dizzy, sweaty palms, nauseous, muscle tension, off-balance/spinning, intoxicated, exhaustion, etc? Were you smelling anything in particular? Hearing specific things? Keys, footsteps, loud bangs, painful silence, whispering, creaking in a floor or door, cars, extreme weather, music, etc? Did you have any tastes? External feelings against your skin?

• Knowledge — What were you intellectually aware of at the moment (the who, what, when, where, how)? The narrative, information, sequence of events? Additionally, what were your thoughts at the time? Even those that you later found out to be incorrect? What did you believe was happening or think to yourself as this moment was occurring?

During the unconscious process of putting thick dissociative barriers around this extremely sensitive material, some of those pieces scatter apart into far corners of the mind. They may each be fully detached from one another or linked up in unique, and sometimes perplexing, combinations. We know that a defining trait of PTSD, and one of its criterion for diagnosis, is "re-experiencing". When we push anything out of our awareness long enough (like when we stuff our feelings or pretend they don't exist for awhile) - but particularly if we've had to traumatically dissociate it away - it is likely to be intrusively thrust upon us against our will at some point. ...aaand typically when we're most vulnerable, least expect it, and it's the most inconvenient!

When we look to the BASK Model, and some of the unusual pairings that traumatic information can become linked, you can see how having them suddenly surface and come alive in your body without other important contextual pieces, can be deeply disorienting. It is understandably confusing, sometimes quite scary, and often easier to explain away by a hundred other things. You can now understand how this can manifest in symptoms like Body Memories (S + sometimes B), Emotional Flashbacks (A), or the ability to recount your trauma to someone without a single emotion or attachment to it in the world (K without A, and sometimes no B or S, either). Conversely, you may have every single indicator of a deeply terrifying event - it’s erupting in your thoughts, your skin, your emotions - and you know a trauma has to be there by context clues alone, but you’ve got zero intellectual awareness of what it is or where it's coming from (B+A+S). These scenarios only magnify in complexity when they’re become additionally scattered amongst parts of self in DID and OSDD systems.

The goal of traumatic processing is to find and link - or integrate - all these pieces to one another into one full, complete memory, then further integrate them into your self-concept, your narrative, the story of your life. If you're missing any vital pieces, not only are they still likely to revisit intrusively, but you may be drawing incomplete or inaccurate conclusions about the very trauma itself or what it means in the broader context of your life. You may believe a certain person in your life is much safer or more helpful than they really are; that you "didn't even react" when you maybe did so in a very powerful way; that you're at fault, when you unequivocally were not; that what occurred never hurt or 'wasn't that bad', when it very much did and absolutely was; that you felt fine, content, or enjoyment, when you really felt anger, disgust, or betrayal. The truth may completely reshape how you see yourself and everything around you. There is so much to be gleaned from these pieces coming together, and you deserve to know them in full, even though they're painful and difficult.

You also deserve to have control over your mind - no longer at its mercy when it throws these things at you when your guard’s at its lowest. Until then, we hope the some of the tools we have offered elsewhere can help to mitigate some of their effects (such as Flashbacks 101, Healing Pool/Light, Color Breathing, or Imagery with Dials), and additionally arm you with a different kind of strength and control over your symptoms.

Let's help take that power back!

MORE POSTS YOU MAY FIND HELPFUL:

  ✧  Grounding 101: 101 Grounding Techniques
  ✧  Distraction 101: 101 Distraction Tools
  ✧  Flashbacks 101: 4 Tools to Cope with Flashbacks
✧ Self-Care 101: 101 Self-Care Tools
  ✧  Nighttime 101 and Nighttime 201: Sleep Strategies for Complex PTSD
✧ Color Breathing 101: How to Calm Overwhelming Emotions and Physical Pain
  ✧  Imagery 101: Healing Pool and Healing Light
  ✧  DID Myths: Dispelling Common Misconceptions about Dissociative Identity Disorder
  ✧  Did You Know?: 8 Things We Should All Know about C-PTSD and DID
  ✧  Trauma and Attachment: 3-Part Series on Attachment Theory with Jade Miller
 
  ❖  Article Index  ❖

FIND US ON SOCIAL MEDIA:

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Dissociation and Survival vs. Living: A Survivor's Story

 

A CSA Survivor's Relationship with Dissociation, Survival and Living:

     
    "There are many things I wish I could help people understand about childhood trauma; this just happens to be one I hear very little about. Like many survivors, I struggle to hear sentiments like, "Oh my! I'm so so glad that's over now and you got through it!", "I can't believe you got out of that alive. I couldn't even do that now! I'd give up," or "At least you know your worst days are behind you. You know you can conquer anything!". Even resources and groups for trauma survivors, as well as therapists and clinicians, can share quips like "You survived the abuse, you're going to survive the recovery!". While these things intend to uplift or highlight our strength, they all categorically deny the fundamental mechanism that allowed us to survive in the first place, and why adulthood is the real hard part: dissociation.

    Make no mistake, those of us who endured trauma as children are courageously strong. We were forced to be tougher than most; and, by nature or necessity, we became resilient, creative and sharp. But Little Me didn't even experience the bulk of the trauma back then. I wasn't connected to the physical pain or sheer terror; I wasn't incapacitated by shame, disgust or uncleanliness; I wasn't aware of the immorality, nor was I having a crisis of conscience. I also didn't even know who was hurting me for much of my childhood - parts of my mind did, but not me. Little Me wasn't facing the anger or the blistering sting of betrayal from those I loved most hurting me in such inhumane ways. I wasn't yet aware this was abnormal or something that could make me feel alien or 'different' from my peers. I was numb, I was hyperfocused on the things I could control, and I was even made to feel special or self-confident in certain areas very early on. While some of that confidence dwindled over time and I became more aware of my unhappiness and "irrational" fears, none of that compares to what you imagine a tortured child feels — let alone what I was about to feel later in life.

    That suffering is here now. Adulthood is when all of it breaks through and confronts you with a vengeance. No, the abuse is not "over", it is not "behind me", it is not "something I got through". As far as my mind and body are concerned, it is NOW. It is very alive and in full-effect. Each excruciating detail of physical pain, disgust, and revulsion; every tidal wave of anger at those who knew and did nothing; each immobilizing shockwave of new material that re-writes my entire life story from how I once knew it. THIS is when my survival is tested. I am hypervigiliant, terrified, exhausted, unsure if I'm even real. I exist in hollowing spaces of grief for Little Me and the life I should have had. ...lost in an endless state of confusion, horror, disbelief and dismay. It is all day. THIS is live trauma in my brain and body. THIS is my battleground, and I am fighting for my life NOW. As an adult, not as a child.

     Furthermore, the dissociative process not only contorts the timeline of when we experience our trauma, but dissociation as an independent symptom challenges life as an adult, too. (..even beyond the forgetfulness, memory gaps, driving troubles, safety, maintaining a job, etc.) One of the most critical elements in trauma recovery is establishing healthy relationships and improving our overall worldview. It's very hard to want to carry on when all you've known is the absolute worst of mankind. Being able to look around, connect, and believe the world is still good is vital to our sanity, safety and healing. But, dissociation challenges this. It can dull your senses, leave you numb to positive feelings, keep you at an emotional distance from love or affections shown to you. It can keep you trapped in a surreal in-between state of both the past and the present -- where you respond to what's happening today with the same emotional maturity you had as a child. Emotional flashbacks, unexpected triggers, and other sudden symptoms that crop up - particularly in intimate relationships or the more meaningful aspects of life - can complicate joy and frustrate those in your life. But most of all, no one wants to just "be alive", we want to LIVE. Fully and authentically, with all the vibrance and richness available to us. But, dissociation has a way of diluting and blurring the world - stripping it of its color and beauty. How do you hold onto a light that you can barely see, feel or trust is even there?

    Like most all means of sheer survival, dissociation has its pros and cons. Just like chemotherapy and emergency surgery, they can keep you alive, but there are risks. They're also unpleasant in the moment and, separate from the conditions that necessitate these interventions, they alone carry longterm consequences. But, without them, you wouldn't be here -- so it's a constant tug of war with perspective and gratitude. Dissociation is no different. It got me through. It saved my life. It gave Little Me a fighting chance. But it also made life after abuse so darn difficult. Because, I should feel free. The abuse has ended, I am safe. I should be dancing and singing and holding everything I love dear to my chest. But instead, now is when I fight. Now is when I stare down my trauma, my innocence, my perpetrators - all with adult intellect and understanding - and try to decide if this life is worth living and if I'm up for the task.

    It is worth it. And, I am up for the fight. I'm going to do this and will do it with grace and strength. But then, and only then, can you say I survived the impossible or that 'it's over now'. This is the battle. ..and not for just survival, but for life. To make this existence meaningful now. I get the autonomy of choice today, not just be along for the ride. I get to choose Life and choose Me each day. The fight is no longer to endure the day, just see the next one - or go through the motions while feeling trapped here - but instead to fill each one with things of meaning and substance. Things I GET to do.

    I get to discover texture and nuance, vibrance and stillness, range in opacity and brightness - all for the first time. I get to engage with the world like a child, but it's in my control and at my direction (..aaand with the cheat code of adult freedom!). There is so much to learn and discover, so much I've not tasted or touched, and I get to be excited by that prospect. Trust it. Grow from it. Share it with another. I am going to conquer this. The trauma, the feelings, the defeat, the difficult relationships, the dissociation. I will also remain appreciative of what dissociation made possible for me, despite its thorns. I want Young Me to get credit for surviving the horror. But I want Adult Me to get credit for not only surviving additional anguish, but for learning to LIVE, too.

 

 

MORE POSTS YOU MAY FIND HELPFUL:

  ✧  Grounding 101: 101 Grounding Techniques
  ✧  Distraction 101: 101 Distraction Tools
  ✧  Flashbacks 101: 4 Tools to Cope with Flashbacks
✧ Self-Care 101: 101 Self-Care Tools
  ✧  Nighttime 101 and Nighttime 201: Sleep Strategies for Complex PTSD
✧ Color Breathing 101: How to Calm Overwhelming Emotions and Physical Pain
  ✧  Imagery 101: Healing Pool and Healing Light
  ✧  DID Myths: Dispelling Common Misconceptions about Dissociative Identity Disorder
  ✧  Did You Know?: 8 Things We Should All Know about C-PTSD and DID
  ✧  Trauma and Attachment: 3-Part Series on Attachment Theory with Jade Miller
 
  ❖  Article Index  ❖

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An In-Depth Conversation with Elizabeth Vermilyea

   If you've worked in the field of trauma and dissociation for any amount of time, the name Elizabeth Vermilyea will likely be very familiar to you. For survivors new to their healing, you may not know her by name, but you've most certainly been using her tools and symptom management skills! In part due to her own humility and unassuming disposition, it's quite possible to be unaware of the impact of Elizabeth's work, despite having benefitted from it for years and years. If learning the detailed process of containment, modulation, healing pool/healing light imagery, or the more welcoming takes on internal communication, sounds familiar to you -- you have her to thank for that!

   Elizabeth's workbook, "Growing Beyond Survival: A Self-Help Toolkit for Managing Traumatic Stress" truly revolutionized the way that trauma survivors could not only learn about their conditions, but explore a variety of tools to alleviate their suffering at the same time. An unintimidating and easy to understand look at complex trauma, it allowed survivors to really work at their own pace. Clinicians were also given a new language with which to explain coping skills to their clients, and most importantly, a chance to work on them together.  Elizabeth's message of educating with compassion and warmth, and always including survivors in the process, has remained steadfast throughout the years and is a lasting legacy on the community. Through her continued work in the field, she keeps the momentum of trauma education and care headed in the right direction -- always focused but empathic.

    It is our absolute honor and privilege to bring to you an in-depth interview with someone we admire and value so deeply. You'll get a chance to learn more about Elizabeth's personal journey, her experience weeding through the at-times tepid and contentious world of trauma, and also explore the past, present and future of trauma care! We sincerely hope you enjoy!

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Let’s start with some background for those who are being introduced to you for the first time.

・Where are you from/currently residing? Where did you attend school and what did you earn your degree in?
How long have you been practicing and in what capacity do you currently work with trauma survivors?

     I was born in Raleigh, NC, and I currently live in Napa, CA. I don’t like to focus on schools and degrees because I don’t think they tell us anything about who someone is. Suffice it to say, I’ve spent a great deal of time on my education, but I really learned the most from the people I’ve worked with over the years both as clients and colleagues. Currently I do not treat survivors, but I do train and consult with professionals and survivors alike. My consultation with survivors focuses on managing traumatic stress symptoms.

・What made you interested in pursuing trauma disorders? Did you always know you wanted to focus here, or was it something that found you?

     I like to say that I tripped and fell into this work, and then fell in love with it. I had intended to become an experimental psychologist. My first job out of college was at the Masters & Johnson Sexual Trauma program at River Oaks in Louisiana, and I got that job after sending out resumes everywhere I could. They were the ones who called back! It didn’t take long for me to realize that I wanted to make a career in the trauma field.

・When did you come to understand the full impact of complex childhood trauma vs. trauma as an adult? What was your introduction to dissociative disorders like?

     My work at River Oaks was my introduction to all of this. I remember going home one night in tears after having heard some horrific stories of abuse at the hands of a man’s parents. I found my mom and said, “Thank you for not abusing your power over me.” I realized how much that relationship means, how it can be twisted, how it can torment a child. Most of the clients in that program were diagnosed with a dissociative disorder, so I learned a great deal there. The program took a relational approach to the work, and I appreciated that. It wasn’t so hierarchical or tied to the strict medical model.

You began your work in this field over 25 years ago — a time where dissociative disorders were even more heavily stigmatized, disbelieved and could even be used to question the integrity of the very clinicians who supported their existence.

・What would you say the climate was like when you were first starting out? Did you face any particular challenges — clinically, interpersonally or even within yourself? 

     I started this work at the beginnings of what would become known as the recovered memory debate era, but I didn’t encounter much of that controversy until I moved to Baltimore and began working at Sheppard Pratt in their Trauma Disorders Program. Across town was Johns Hopkins and Paul McHugh who staunchly denied that recovered memories could be valid and that dissociation was real. The climate among those of us at Sheppard Pratt was one of dedication to the cause and to believing people. When I was starting out, the challenges I faced were related to understanding that horrible things are done to people, but that doesn’t mean the world is horrible. Holding those truths together is an important part of the work for all of us. More challenges came later when I began to chafe against the medical model and hierarchy in the treatment arena, and especially the “once a patient always a patient” mentality.

・When did you decide you wanted to write a book? And not just an informational or educational book but specifically a workbook for survivors?

     For several years I ran a PTSD Symptom Management group at Sheppard Pratt. I used to create worksheets because there weren’t any around that met the needs of the clients and my needs as a helper. Over time, I had a rather large portfolio of these worksheets. My colleagues and the clients started telling me I should write a book. So I began.

・Were there any unique obstacles to getting it published? Did you ever have any reluctance or hesitation, particularly given the atmosphere back then?

     Getting the book published was an incredibly serendipitous series of events. I was meeting with Esther Giller, the President and CEO of Sidran Institute, a publication company specializing in traumatic stress education and advocacy. Let me see if I can remember it the right way. She was looking for someone to come on board as a trainer for a Federal Grant project she was involved in. At the same time, she was looking for someone to produce a self-help symptom management book for a project being underwritten by the States of Maine and New York who were embarking on a massive training effort in their public mental health systems. This is a long story, but a good one.
     Survivors in the State of Maine had sued the state saying not only was the mental health treatment they received not helpful, but worse, it was hurtful. So the State handed down a consent decree that all state mental health personnel be trained in what is now called Trauma-Informed Care. This was the beginning! Esther had located professionals to create the material for training personnel (the good folks at TSI CAAP – Karen Saakvitne, Laurie Ann Pearlman, Beth Tabor-Lev, and Sarah Gamble – who wrote the Risking Connection Curriculum), and they also wanted material for the clients. That’s where I came in. I left Sheppard Pratt to take the training job at Sidran, and Sidran published the book, which was then distributed to survivors in the Maine and New York public health systems for free. I’m really proud of that.

Your workbook, whether you know it or not, truly revolutionized trauma care on the patient level. Worksheets were printed out on trauma units, weekly inpatient groups were held to teach your skills, your techniques and scripts became the go-to standard for coping with specific symptoms, and survivors in countries across the globe use your tools by name (sometimes not even knowing where they came from or having read your book)!

・Did you ever anticipate that your work would have such a profound impact or global reach, let alone become the foundational launchpad for which survivors worldwide would begin their trauma healing? 

     I am humbled beyond words by what you’re saying. I can tell you when I did the second edition I felt really good that there was still an interest in the book and that it was still useful thirteen years after the original publication. It’s mind boggling to think it has the impact you describe. I guess I have to take your word for it! I really felt I had arrived on the day a friend told me her book had been stolen! I replaced it for her, but for someone to steal it… it must be valuable!

・What has it meant to you seeing your work, and not just your book but your advocacy and education in all forms, fill such a massive void in the trauma community?

How does it feel knowing most has stood the test of time?

     Like most people dedicated to this work, I feel good about being able to educate, support, help, advocate, and hopefully change for the better the process of healing for trauma survivors. I know that every professional I am able to help will spread that exponentially outward, and that’s why I do it. I think it has stood the test of time because the material I focus on is universal and not subject to treatment trends. I want to offer something that can help everyone every time.

・What would you say is the biggest change you’ve noticed in the field of trauma since beginning your studies (ex. education, the approach to care, general attitudes toward trauma/dissociative disorders, etc)?

     The biggest change I’ve seen is the mainstreaming of trauma-informed care. There used to be a handful of treatment centers providing good treatment, and now, thanks to the Adverse Childhood Experiences (A.C.E.) study, there’s a deeper understanding of trauma as a public health issue. Even Oprah has got on board recently! I’ll be working with the Oregon Commission for the Blind next month because they want to better serve traumatized persons in their vocational rehabilitation programs. That’s huge! If you Google “Trauma Certificate Programs” you can find them all over the country. That’s amazing!

・What areas do you feel still need significant improvement? Is there anything you feel is almost missing entirely? What changes would you like to see be made in those areas?

     We need to improve the awareness, understanding, and addressing of the intersections of trauma with addiction and the criminal justice system. These intersections are at the heart of recidivism in both arenas. We have to keep showing agencies and organizations what’s in it for them and how trauma-informed practice can support and enhance their existing work. Essentially, we have to sell it.

・Do you have any colleagues or mentors that you really look up to or admire?

     Oh gosh, too many to name. I can tell you one person who had tremendous influence on me professionally. Her name was Andrea Karfgin, and she was a psychologist. She died several years ago, but she lives on in me. She taught me how to think about this work, how to understand really important dynamics in the work, and she guided me through tough lessons as a professional. I hesitate to mention other names for fear I’d forget someone. I worked with a number of survivors who were brave and trusting enough to let me into their inner worlds and allow me to walk with them into the wider world with more confidence, faith in themselves, and stronger boundaries toward life beyond survival. I’ve had many colleagues who were instrumental in shaping my professional development. I’ve had the privilege to work with some of the most respected people in the field and to have worked with the amazingly skillful lesser-known warriors for survivors. What I love is that I keep meeting people in the field who continue to inspire me and who keep me on track. I am so grateful that I get to do this work.

・What keeps you going after sitting face-to-face with some of the darkest, heaviest tragedies this world has had to know? What keeps you focused, rejuvenated or inspired?

     In the beginning I wrote a lot of songs to process what I was seeing, feeling, and understanding. I would play music for the clients in the evenings, sometimes songs about them and their struggles and strengths. That helped a lot. I keep a guitar in my office in case any of my staff need to sing the blues. Laughter is important and has always been a way for me to rejuvenate. We have to be able to laugh in the midst of awareness of such pain. I’m fortunate that people put up with my goofy humor. What helps most though is that with every workshop I do, I encounter people who believe, who want to help, and who are eager to learn how to be more effective in the work. It gives me such hope!

・·Do you have any advice to new, or even veteran, clinicians who are seeking to work with trauma patients?

     Do your own work. Get a good clinical supervisor. Make friends with countertransference. It will help you through so many confusing moments, and being able to notice it, understand it and use it to strengthen the relationship will be helpful and a huge protection when facing ethical dilemmas. Cultivate a good support system. Pay attention to and address signs of vicarious trauma, compassion fatigue and secondary traumatic stress. TAKE VACATIONS!

・What is the biggest thing you’ve learned from your patients, or other survivors, over the years? What have they taught you that books could not?

     I’ve learned that I can never give up on a person, never write them off, because people are more resilient that we imagine, and we never know when the moment of hope will come - the moment of immersive transformation that gives someone a reason and the will to continue. I’ve learned to trust people’s judgment about themselves. I’ve learned to be kinder. 

・If there was one thing you wish the world could understand about trauma survivors, or the clinicians that help them, what would it be?

   There is no “them.” There is only us.

❧     ❧     ❧

     Thank you, Elizabeth for your sincerity, your thoughtfulness, and your humble dedication to survivors everywhere.

    You can find more information about Elizabeth here on her website. You can also order the "Growing Beyond Survival" workbook here (or here). [Note: While the blue cover edition is still available on Amazon, the Second Edition (green cover) is the most up-to-date and has the most current perspective on trauma, so we of course recommend that one. The first is also no longer in print, but Amazon has held onto some copies.]  We cannot recommend this workbook highly enough. It has been the first recommendation on our Resource page, since the day it was made, for a reason!
 

 

MORE POSTS YOU MAY FIND HELPFUL:

  ✧  Grounding 101: 101 Grounding Techniques
  ✧  Flashbacks 101: 4 Tools to Cope with Flashbacks
  ✧  Nighttime 101 and Nighttime 201: Sleep Strategies for Complex PTSD
  ✧  Imagery 101: Healing Pool and Healing Light
  ✧  DID Myths: Dispelling Common Misconceptions about Dissociative Identity Disorder
  ✧  Did You Know?: 8 Things We Should All Know about C-PTSD and DID
  ✧  Trauma and Attachment: 3-Part Series on Attachment Theory with Jade Miller

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