4

Getting Triggered

Suddenly In Defense or Survival Mode

When triggers hit, they’re usually unexpected and beyond your control.

And what usually happens next, right after the trigger: You react with old ‘defenses’ or ‘survival strategies’ that are no longer helpful or healthy (if they ever were), and that only make things worse.

Some simple examples of triggers and the ‘conditioned responses’ they unleash:

  • Someone criticizes something you’ve said or done, and you instantly get defensive and angry, then verbally go on the attack.
  • Someone criticizes something you’ve said or done, and you instantly feel crushed and defeated, then go silent and try to ‘disappear.’
  • Walking into your childhood home, your body suddenly tenses up and your eyes scan for threats.

The Nature of Triggers

Triggers can be totally obvious, like someone touching you sexually when you don’t want or expect it, or someone threatening you or clearly trying to take advantage of you.

Triggers can be obvious or subtle, in our awareness or not.

Or they can be subtle, like someone making a mildly sarcastic comment that reminds you of mean and shaming things a parent used to say, or someone giving you a look that seems to have some contempt in it.

Triggers aren’t always about other people and what they say or do. They can be something like a faint smell of alcohol (that used to be on the breath of an abuser). They could be the shape of a man’s moustache, a style of clothing, a wallpaper pattern, or the sound of a slamming door. They can be an ‘anniversary’ date of a traumatic event like an abuse experience or someone’s death.

What are triggers for a particular man depends on his unique experiences of being vulnerable and hurt in his life, and the unique details of the situations in which those experiences occurred.

The trigger is always real. By definition, a trigger is something that reminds you of something bad or hurtful from your past. It ‘triggers’ an association or memory in your brain.

But sometimes you are imagining that what’s happening now is actually like what happened back then, when in reality it’s hardly similar at all, or it just reminds you because you’re feeling vulnerable in a way you did when that bad thing happened in the past.

Just as triggers range from obvious to subtle, sometimes we’re aware of them and sometimes we’re not. Your body may suddenly freak out with a racing heart and feeling of panic, but you have no idea what set off that reaction. You may suddenly feel enraged in a slightly tense conversation, but be unable to point to anything in particular that made you angry. Sometimes you can figure it out later (for example in therapy), and sometimes not.

Also, though we may not realize that we just got triggered, or why, it can be obvious to someone who knows us well, like a partner, friend, or therapist. When you feel comfortable doing so, with someone you really trust, it can be very helpful to talk over situations where you seemed to over-react.

Triggers that involve other people’s behavior are often connected to ways that we repeat unhealthy relationship patterns learned in childhood. Things that other people do – especially people close to us and especially in situations of conflict – remind us of hurtful things done to us in the past. Then we respond as if we’re defending ourselves against those old vulnerabilities, hurts, or traumas.

But our responses usually just trigger vulnerable feelings in the other person, as well as their own old self-defense patterns, and we both end up repeating the unhealthy relationship patterns we that fear and don’t want in our lives.

As noted above, other common triggers include ‘anniversaries,’ that is, dates or holidays that remind you, at some level, of traumatic experiences, of how your family wasn’t and isn’t so happy and loving, etc.

Triggers’ Power and Effects

The power of a trigger depends on how closely it resembles a past situation or relationship, how painful or traumatic that situation or relationships was, and the state of your body and brain when the triggering happens.

Reactions can be big and fast, or creep up on you slowly.

If you’re feeling very calm and safe, the reaction will be much less than if you’re feeling anxious and afraid. If you’re feeling little support or trust in a relationship, your reactions to triggering behaviors by the other person will be much greater.

A trigger can bring out feelings, memories, thoughts, and behaviors.

Other people might have no idea that you’ve been triggered, but you could be struggling with terrible memories in your head. Or you could suddenly have all kinds of negative thoughts and beliefs about the other person and/or yourself, like, ‘I never should have trusted her,’ ‘Every woman will stab you in the heart,’ ‘What a loser I am,’ etc.

Reactions to triggers can be very dramatic and rapid, like lashing out at someone who says the wrong thing or looks at you the wrong way. In these cases, your brain has entered a ‘fight or flight’ state and the part of your brain that you need to think clearly, to remember your values and what’s important to you, and to reflect on your own behavior, is effectively shut down.

But responses to triggers can also creep up on you, playing out over hours and days, and get worse over time.

You may find yourself depressed and retreating from any contact with friends, or drinking a lot more every night, or smoking way more cigarettes than usual. You may find youself getting lost in TV, videogames, or pornography. Days later you may wonder, ‘Woah, how did I get back into this?’

Awareness and Learning = Freedom and Control

Basically, if you’re reacting to someone or something much more intensely than seems to make sense, then the situation has triggered something deeper and older in your brain. You’re not reacting to what’s actually happening in the here and now, and you’re certainly not acting freely.

You can change how you respond to triggers.

Instead, you’re feeling and acting, however consciously or unconsciously, as if you’re ‘back there’ in that old painful or traumatic experience, on autopilot and enslaved by old conditioning.

Fortunately, it’s entirely possible to greatly increase your awareness of your own unique triggers, and of what happens in your mind and body when particular things trigger you. With that foundation of awareness and understanding in place, you can learn how to avoid simply responding as you always did in the past, and instead respond in new and much more healthy ways.

In this way, you can free yourself from deeply ingrained conditioning, actually rewiring your brain to respond in new and much healthier ways to the inevitable triggers we all encounter in our lives and relationships.

For many men, understanding and reconditioning their responses to triggers will require, or be greatly speeded up, by help from a therapist or counselor. There are also self-help resources available, including those mentioned under Additional Resources below.

Expert Views

Aphrodite Matsakis

Due to the way traumatic memories are stored, when something arises in the present that reminds you of a past event, you may feel the feelings associated with the past event…. We call the present-day events triggers, because they trigger the emotions associated with the trauma….

You may be unaware of certain triggers, because you have amnesia about the traumatic events and so can not relate present-day sights, smells, actions, feelings, and people to those involved in your trauma. Often trauma survivors do not know why they react so negatively or intensely to certain situations. It may seem that the situation does not warrant such an extreme reaction, yet there may be a perfectly logical reason for such a reaction if the situation is in some way similar to the trauma…

Having triggers, or reacting to them, does not mean you are crazy or defective. However, when you are blind to what you are feeling and why you are feeling it, you may be driven to act in ways that do not serve you well. The purpose of this chapter is to help you become more aware of your triggers and to help you to manage your reactions to them

Elizabeth Vermilyea

A stress response can trigger avoidance in the form of denial, dissociation, bingeing, substance abuse, self-harm, and other behaviors in an effort to get rid of feelings. These avoidance behaviors, in turn, can trigger stress responses inside because they are reminders of old efforts to deal with painful feelings. The stronger the response, the stronger the impulses to avoid. The effort spent avoiding leaves little energy to manage day-to-day life, and the result is increased stress responses that increase impulses to avoid. What a mess!

Fortunately, self-regulation skills can help you to tolerate (sit with) and control intense feeling states that have led to avoidance or dissociation in the past. You can learn to feel and control the intensity of your emotions to reduce avoidance.

0

Dissociative Disorders

 Dissociative Disorders: (A Medical Perspective)

As society has become increasingly aware of the prevalence of child abuse, trauma or neglect and its serious consequences, there has been an explosion of information on posttraumatic and dissociative disorders resulting from abuse or trauma in childhood. Since most clinicians learned little about childhood trauma and its aftereffects in their training, many are struggling to build their knowledge base and clinical skills to effectively treat survivors and their families.

Understanding dissociation and its relationship to trauma is basic to understanding the posttraumatic and dissociative disorders. Dissociation is the disconnection from full awareness of self, time, and/or external circumstances. It is a complex neuropsychological process. Dissociation exists along a continuum from normal everyday experiences to disorders that interfere with everyday functioning. Common examples of normal dissociation are highway hypnosis (a trance-like feeling that develops as the miles go by), “getting lost” in a book or a movie so that one loses a sense of passing time and surroundings, and daydreaming.

Researchers and clinicians believe that dissociation is a common, naturally occurring defense against childhood trauma. Children tend to dissociate more readily than adults. Faced with overwhelming abuse, it is not surprising that children would psychologically flee (dissociate) from full awareness of their experience. Dissociation may become a defensive pattern that persists into adulthood and can result in a full-fledged dissociative disorder.

The essential feature of dissociative disorders is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. If the disturbance occurs primarily in memory, Dissociative Amnesia or Fugue (APA, 1994) results; important personal events cannot be recalled. Dissociative Amnesia with acute loss of memory may result from wartime trauma, a severe accident, or rape. Dissociative Fugue is indicated by not only loss of memory, but also travel to a new location and the assumption of a new identity. Posttraumatic Stress Disorder (PTSD), although not officially a dissociative disorder (it is classified as an anxiety disorder), can be thought of as part of the dissociative spectrum. In PTSD, recall/re-experiencing of the trauma (flashbacks) alternates with numbing (detachment or dissociation), and avoidance. Atypical dissociative disorders are classified as Dissociative Disorders Not Otherwise Specified (DDNOS). If the disturbance occurs primarily in identity with parts of the self assuming separate identities, the resulting disorder is Dissociative Identity Disorder (DID), formerly called Multiple Personality Disorder.

The Dissociative Spectrum

The dissociative spectrum (Braun, 1988) extends from normal dissociation to poly-fragmented DID. All of the disorders are trauma-based, and symptoms result from the habitual dissociation of traumatic memories. For example, a rape victim with Dissociative Amnesia may have no conscious memory of the attack, yet experience depression, numbness, and distress resulting from environmental stimuli such as colors, odors, sounds, and images that recall the traumatic experience. The dissociated memory is alive and active–not forgotten, merely submerged (Tasman & Goldfinger, 1991). Major studies have confirmed the traumatic origin of DID (Putnam, 1989, and Ross, 1989), which arises before the age of 12 (and often before age 5) as a result of severe physical, sexual, and/or emotional abuse. Poly-fragmented DID (involving over 100 personality states) may be the result of sadistic abuse by multiple perpetrators over an extended period of time.

Although DID is a common disorder (perhaps as common as one in 100) (Ross, 1989), the combination of PTSD-DDNOS is the most frequent diagnosis in survivors of childhood abuse. These survivors experience the flashbacks and intrusion of trauma memories, sometimes not until years after the childhood abuse, with dissociative experiences of distancing, “trancing out”, feeling unreal, the ability to ignore pain, and feeling as if they were looking at the world through a fog.

The symptom profile of adults who were abuse as children includes posttraumatic and dissociative disorders combined with depression, anxiety syndromes, and addictions. These symptoms include (1) recurrent depression; (2) anxiety, panic, and phobias; (3) anger and rage; (4) low self-esteem, and feeling damaged and/or worthless; (5) shame; (6) somatic pain syndromes (7) self-destructive thoughts and/or behavior; (8) substance abuse; (9) eating disorders: bulimia, anorexia, and compulsive overeating; (10) relationship and intimacy difficulties; (11) sexual dysfunction, including addictions and avoidance; (12) time loss, memory gaps, and a sense of unreality; (13) flashbacks, intrusive thoughts and images of trauma; (14) hypervigilance; (15) sleep disturbances: nightmares, insomnia, and sleepwalking; and (16) alternative states of consciousness or personalities.

Diagnosis

The diagnosis of dissociative disorders starts with an awareness of the prevalence of childhood abuse and its relation to these clinical disorders with their complex symptomatology. A clinical interview, whether the client is male or female, should always include questions about significant childhood and adult trauma. The interview should include questions related to the above list of symptoms with a particular focus on dissociative experiences. Pertinent questions include those related to blackouts/time loss, disremembered behaviors, fugues, unexplained possessions, inexplicable changes in relationships, fluctuations in skills and knowledge, fragmentary recall of life history, spontaneous trances, enthrallment, spontaneous age regression, out-of-body experiences, and awareness of other parts of self (Loewenstein, 1991).

Structured diagnostic interviews such as the Dissociative Experiences Scale (DES) (Putnam, 1989), the Dissociative Disorders Interview Schedule (DDIS) (Ross, 1989), and the Structured Clinical Interview for Dissociative Disorders (SCID-D) (Steinberg, 1990) are now available for the assessment of dissociative disorders. This can result in more rapid and appropriate help for survivors. Dissociative disorders can also be diagnosed by the Diagnostic Drawing Series (DDS) (Mills & Cohen, 1993).

The diagnostic criteria for the diagnosis of DID are (1) the existence within the person of two or more distinct personalities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self, (2) at least two of these personality states recurrently take full control of the person’s behavior, (3) the inability to recall important personal information that is to extensive to be explained by ordinary forgetfulness, and (4) the disturbance is not due to the direct physiological effects of a substance (blackouts due to alcohol intoxication) or a general medical condition (APA, 1994). The clinician must, therefore, “meet” and observe the “switch process” between at least two personalities. The dissociative personality system usually includes a number of personality states (alter personalities) of varying ages (many are child alters) and of both sexes.

In the past, individuals with dissociative disorders were often in the mental health system for years before receiving an accurate diagnosis and appropriate treatment. As clinicians become more skilled in the identification and treatment dissociative disorders, there should no longer be such delay.

Treatment

The heart of the treatment of dissociative disorders is long-term psychodynamic/cognitive psychotherapy facilitated by hypnotherapy. It is not uncommon for survivors to need three to five years of intensive therapy work. Setting the frame for the trauma work is the most important part of therapy. One cannot do trauma work without some destabilization, so the therapy starts with assessment and stabilization before any abreactive work (revisiting the trauma).

A careful assessment should cover the basic issues of history (what happened to you?), sense of self (how do you think/feel about yourself?), symptoms (e.g., depression, anxiety, hypervigilance, rage, flashbacks, intrusive memories, inner voices, amnesias, numbing, nightmares, recurrent dreams), safety (of self, to and from others), relationship difficulties, substance abuse, eating disorders, family history (family of origin and current), social support system, and medical status.

After gathering important information, the therapist and client should jointly develop a plan for stabilization (Turkus, 1991). Treatment modalities should be carefully considered. These include individual psychotherapy, group therapy, expressive therapies (art, poetry, movement, psychodrama, music), family therapy (current family), psychoeducation, and pharmacotherapy. Hospital treatment may be necessary in some cases for a comprehensive assessment and stabilization. The Empowerment Model (Turkus, Cohen, & Courtois, 1991) for the treatment of survivors of childhood abuse–which can be adapted to outpatient treatment–uses ego-enhancing, progressive treatment to encourage the highest level of function (“how to keep your life together while doing the work”). The use of sequenced treatment using the above modalities for safe expression and processing of painful material within the structure of a therapeutic community of connectedness with healthy boundaries is particularly effective. Group experiences are critical to all survivors if they are to overcome the secrecy, shame, and isolation of survivorship.

Stabilization may include contracts to ensure physical and emotional safety and discussion before any disclosure or confrontation related to the abuse, and to prevent any precipitous stop in therapy. Physician consultants should be selected for medical needs or psychopharmacologic treatment. Antidepressant and antianxiety medications can be helpful adjunctive treatment for survivors, but they should be viewed as adjunctive to the psychotherapy, not as an alternative to it.

Developing a cognitive framework is also an essential part of stabilization. This involves sorting out how an abused child thinks and feels, undoing damaging self-concepts, and learning about what is “normal”. Stabilization is a time to learn how to ask for help and build support networks. The stabilization stage may take a year or longer–as much time as is necessary for the patient to move safely into the next phase of treatment.

If the dissociative disorder is DID, stabilization involves the survivor’s acceptance of the diagnosis and commitment to treatment. Diagnosis is in itself a crisis, and much work must be done to reframe DID as a creative survival tool (which it is) rather than a disease or stigma. The treatment frame for DID includes developing acceptance and respect for each alter as a part of the internal system. Each alter must be treated equally, whether it presents as a delightful child or an angry persecutor. Mapping of the dissociative personality system is the next step, followed by the work of internal dialogue and cooperation between alters. This is the critical stage in DID therapy, one that must be in place before trauma work begins. Communication and cooperation among the alters facilitates the gathering of ego strength that stabilizes the internal system, hence the whole person.

Revisiting and reworking the trauma is the next stage. This may involve abreactions, which can release pain and allow dissociated trauma back into the normal memory track. An abreaction might be described as the vivid re-experiencing of a traumatic event accompanied by the release of related emotion and the recovery of repressed or dissociated aspects of that event (Steele & Colrain, 1990). The retrieval of traumatic memories should be staged with planned abreactions. Hypnosis, when facilitated by a trained professional, is extremely useful in abreactive work to safely contain the abreaction and release the painful emotions more quickly. Some survivors may only be able to do abreactive work on an inpatient basis in a safe and supportive environment. In any setting, the work must be paced and contained to prevent retraumatization and to give the client a feeling of mastery. This means that the speed of the work must be carefully monitored, and the release painful material must be thoughtfully managed and controlled, so as not to be overwhelming. An abreaction of a person diagnosed with DID may involve a number of different alters, who must all participate in the work. The reworking of the trauma involves sharing the abuse story, undoing unnecessary shame and guilt, doing some anger work, and grieving. Grief work pertains to both the abuse and abandonment and the damage to one’s life. Throughout this mid-level work, there is integration of memories and, in DID, alternate personalities; the substitution of adult methods of coping for dissociation; and the learning of new life skills.

This leads into the final phase of the therapy work. There is continued processing of traumatic memories and cognitive distortions, and further letting go of shame. At the end of the grieving process, creative energy is released. The survivor can reclaim self-worth and personal power and rebuild life after so much focus on healing. There are often important life choices to be made about vocation and relationships at this time, as well as solidifying gains from treatment.

This is challenging and satisfying work for both survivors and therapists. The journey is painful, but the rewards are great. Successfully working through the healing journey can significantly impact a survivor’s life and philosophy. Coming through this intense, self-reflective process might lead one to discover a desire to contribute to society in a variety of vital ways.

by Joan A. Turkus, M.D.