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PTSD. Episode 4. When Trauma Leaves A Scar · Inside The Consulting Room - Understanding the Child Behind the Behaviour

• 0:03
  SPEAKER_00: Hello, this is Kim Lee, child and adolescent psychotherapist, and this is the series on post-traumatic stress disorder and post-traumatic stress reactions in children and young people.
• 0:17
  SPEAKER_00: Before I begin, the motivation for this series has not only to do with my clinical experience of working with patients who are clearly suffering following a single or multiple traumatic episodes.
• 0:39
  SPEAKER_00: I think it's really important to communicate once again how as adults we have a responsibility to not just take behavior at face value.
• 0:56
  SPEAKER_00: More and more I see people who are wanting me to do something which I don't do, and they ask me to give them or their children tools and strategies to deal with the problems that they have, and those are most often to do with emotional dysregulation.
• 1:20
  SPEAKER_00: And at one level, I I can understand why people want this because they want the behavior to stop.
• 1:28
  SPEAKER_00: But I am instantly compelled to say, well, yes, whilst we can pay attention to the behavior because it's problematic, if we don't explore and identify what's driving it, then we do the child a disservice, and actually, whatever tools and strategies may be developed, the behavior will maybe lessen, but whatever's driving it will simply find expression in another way.
• 2:03
  SPEAKER_00: So I think this is why I don't really consider CBT, a cognitive behavioral therapy, as necessarily a useful approach for children and young people.
• 2:16
  SPEAKER_00: And there might be some people for whom that works, and that's fine.
• 2:20
  SPEAKER_00: But my stance is about trying to identify the deeper understanding, because if we can pay attention to that, we are doing long-term good.
• 2:33
  SPEAKER_00: And helping parents to see that, and many do really means that in their parenting and in my role as a clinician, if we work together, the child, and if we can include the school as well where possible, the child becomes the focus for an approach that is much more likely to repair causes.
• 3:01
  SPEAKER_00: Now, in this episode, I want to look at the notion of the wounds that are created by traumatic events.
• 3:17
  SPEAKER_00: And I think really the focus here is the wounds that relate to or caused by traumatic events don't automatically heal.
• 3:30
  SPEAKER_00: And so what happens is that they heal badly, and every wound tells a story, and every story deserves to be expressed so that it has the chance to heal properly.
• 3:48
  SPEAKER_00: As I've said before, trauma isn't just what simply has happened to a child, it's them it's what the mind was forced to carry subsequently.
• 3:58
  SPEAKER_00: Now, in medicine, trauma refers to physical injury when the body is wounded, and doctors know that the proper treatment is essential because wounds, if they're ignored, don't really heal that well.
• 4:14
  SPEAKER_00: And I think something remarkably similar happens with psychological trauma or wounds.
• 4:22
  SPEAKER_00: Imagine a deep cut into the skin.
• 4:24
  SPEAKER_00: And if the wound is cleaned and protected, the body gradually repairs itself naturally, the tissue closes and the healing begins.
• 4:34
  SPEAKER_00: But if the wound is neglected, something different is likely to occur.
• 4:40
  SPEAKER_00: Although the body still attempts to heal, but the tissue may form a scar tissue.
• 4:49
  SPEAKER_00: And scar tissue is the body's attempt to repair damage, yet it's not the same as the original tissue.
• 4:56
  SPEAKER_00: So it might be tighter, more sensitive, sometimes painful when touched.
• 5:02
  SPEAKER_00: Now, in my view, psychological scar tissue works in a remarkably similar way.
• 5:09
  SPEAKER_00: Because when overwhelming experiences are not processed, the mind still attempts to adapt.
• 5:16
  SPEAKER_00: But the healing may be incomplete because the central nervous system may remain sensitive to certain situations, sounds, experiences, and that's because these touch the psychological scar.
• 5:33
  SPEAKER_00: And when that happens, the nervous system reacts.
• 5:36
  SPEAKER_00: At its very simplest, we have reactions as adults, which we might say, oh, that's because, or every time I come into contact with, or you know, I feel something, I do something, I and these, I mean, I might I might perhaps rather than say scar, these could just be minor abrasion, abrasions.
• 5:58
  SPEAKER_00: Nonetheless, it could have happened years ago, but here in the present, something touches it and there's a reaction.
• 6:05
  SPEAKER_00: Well, with significant trauma, that reaction is very much louder.
• 6:11
  SPEAKER_00: A 13-year-old girl who was referred to me had grown up in a household where arguments between adults frequently escalated into shouting and things becoming broken, doors slamming.
• 6:26
  SPEAKER_00: And over time she became extremely sensitive to raised voices.
• 6:31
  SPEAKER_00: And at school, when classmates argued loudly, or if the teacher was experienced as shouting, what if that teacher might not be?
• 6:44
  SPEAKER_00: This girl sometimes reacted with sudden anger or panic.
• 6:48
  SPEAKER_00: And teachers initially viewed this as overreacting, which I suppose you know is true, certainly a disproportionate response.
• 6:59
  SPEAKER_00: But what they were witnessing was a disproportionate traumatic response.
• 7:03
  SPEAKER_00: So you can't expect them to just automatically know that.
• 7:07
  SPEAKER_00: But what had happened was that the earlier experiences that had been sustained had left a psychological scar.
• 7:14
  SPEAKER_00: And whenever voices rose, her nervous system responded as though the danger had or was about to return.
• 7:24
  SPEAKER_00: So just as scar tissue protects injured skin, trauma responses are the mind's attempts to protect the individual from further harm.
• 7:36
  SPEAKER_00: And they may be evidenced through hyper-vigilance.
• 7:40
  SPEAKER_00: And something that I didn't say in the previous episode that needed to was the difference.
• 7:46
  SPEAKER_00: I referred to the difference between hyper-vigilance and hypo, and hyper being higher, hypo being lower.
• 7:56
  SPEAKER_00: Now, with hyper-vigilant behaviors, they're visible.
• 8:00
  SPEAKER_00: We can see the person is alert, over-alert, that they are easily agitated.
• 8:06
  SPEAKER_00: With hypo-vigilance, that is not the case.
• 8:09
  SPEAKER_00: We don't see those same behaviors.
• 8:11
  SPEAKER_00: Instead, we see something that may represent or may present as a kind of distancing, numbness, silence, even serenity, as one parent put it to me.
• 8:25
  SPEAKER_00: And you know, I'm I'm always reminded of that analogy of the swan gliding gracefully across the water, but the bit you don't see is the feet paddling furiously beneath.
• 8:38
  SPEAKER_00: And this is really important because just because the person is appearing calm doesn't mean that their set their central nervous system is calm.
• 8:52
  SPEAKER_00: In fact, it might be highly active, and exactly the same mechanisms and psychological or neurological activity is taking place, but it's finding it's finding expression through a kind of facade which the person has no control over.
• 9:11
  SPEAKER_00: And these are site, these are survival strategies, but the problem is that these strategies that once protected the child can later make ordinary life much more difficult.
• 9:23
  SPEAKER_00: There was a 12-year-old boy who had undergone a really frightening procedure in hospital in his childhood, and the procedure was unsuccessful, and so it meant readmission, uncertainty, and feeling highly vulnerable at the repeated invasive procedures that took place.
• 9:52
  SPEAKER_00: They were necessary, but we're talking about, you know, a small person.
• 9:56
  SPEAKER_00: And years later, during a school trip, the group on the trip walked, they went to a hospital, they walked through a hospital corridor, and almost immediately he became anxious and he wanted to run.
• 10:12
  SPEAKER_00: His breathing changed, his body tensed, and all that had happened was that he was back in the environment which had created the wounds, and the scar tissue that was left had been touched because the memory hadn't been fully healed or processed.
• 10:35
  SPEAKER_00: So post-traumatic stress disorder is often, and post-traumatic stress is often misunderstood.
• 10:43
  SPEAKER_00: People sometimes assume that it represents some kind of weakness.
• 10:49
  SPEAKER_00: And I I do hear things like but it happened this this is from adults, but say, you know, but that happened years ago.
• 10:59
  SPEAKER_00: And I I think yes, that's that's true.
• 11:05
  SPEAKER_00: So how come it hasn't healed?
• 11:09
  SPEAKER_00: Something's something's not right, something needs to be investigated because this child is stuck.
• 11:17
  SPEAKER_00: In reality, PTSD is in a class of its own.
• 11:24
  SPEAKER_00: It's the mind's attempt to live with an injury that hasn't yet healed.
• 11:29
  SPEAKER_00: And I'll say again, sometimes spontaneous recovery occurs, but more often than not, no, it doesn't.
• 11:36
  SPEAKER_00: It needs attention.
• 11:38
  SPEAKER_00: So the nervous system remains alert, sensitive, and reactive, which is telling us that the wound needs attention.
• 11:50
  SPEAKER_00: Just as physical wounds require care, as I said previously, psychological wounds require attention.
• 11:57
  SPEAKER_00: In relational psychotherapy, as I've said again, we provide a safe environment where the emotional, the child's emotional experience can be understood.
• 12:06
  SPEAKER_00: And this is interesting because quite often what I what I talk to patients about is the idea that they're made up of parts.
• 12:15
  SPEAKER_00: And sometimes the traumatized part is somewhere that they protect themselves from experiencing through symptomatic behaviors.
• 12:26
  SPEAKER_00: And I suppose my task is to help them revisit gently and in stages that part of themselves.
• 12:36
  SPEAKER_00: But I have to do it in a way I have to help them to do it so that they don't get stuck in it and become reactivated.
• 12:46
  SPEAKER_00: Instead, what I do is I try and help them imagine visualizing that part from another part of themselves, a kind of observing part that can look and say, what do we see?
• 13:01
  SPEAKER_00: What do we remember?
• 13:03
  SPEAKER_00: And but doing so, remaining in the safe part of the self.
• 13:10
  SPEAKER_00: A lot of this work, we talk about parts work in psychotherapy, but it has to do with the idea that we're all made up of parts.
• 13:18
  SPEAKER_00: Some parts work incredibly well, some parts not so well, and some parts we don't want to have anything to do with because they're really difficult.
• 13:28
  SPEAKER_00: But working in this way enables the reduction of emotional sensitivity.
• 13:36
  SPEAKER_00: So it there's a decrease in reactivation.
• 13:41
  SPEAKER_00: The scar tissue becomes more touchable.
• 13:49
  SPEAKER_00: I'm reminded here of sometimes people who work in physiotherapy and other manual-related musculoskeletal treatments will talk about the breaking down of skull tissue because that is ultimately what's required in physical manipulation therapies.
• 14:12
  SPEAKER_00: Now, breaking down emotional scar tissue in a child as a consequence of post-traumatic stress is not something we we work towards.
• 14:25
  SPEAKER_00: The breaking down, it it sounds just a little bit too forceful.
• 14:30
  SPEAKER_00: I guess what we're doing is we're sort of unpicking it bit by bit, and we're trying to get the stuck parts that are tight to loosen up so that they can they can heal more naturally.
• 14:47
  SPEAKER_00: But this isn't something people can do on their own.
• 14:50
  SPEAKER_00: Think back to the Vietnam War vets, think about people, soldiers returning from Afghanistan, the Falklands, people who have endured constant threats to their survival.
• 15:04
  SPEAKER_00: Think about the symptoms and the behaviors that follow on.
• 15:09
  SPEAKER_00: Some years ago I worked with a boy from Cambodia, and I I worked as a consultant to Save the Children Fund, and I was very fortunate to be given the task of organizing the treatment programs for the Vietnamese boat children, and and that was an incredibly sad and invigorating kind of privilege.
• 15:44
  SPEAKER_00: These children had endured the most horrific journeys from their villages in South Vietnam to uh somewhere in the high seas where hopefully they'd be picked up by um a rescue vessel and then taken to uh what were called transit camps before finally going to whichever country could take them.
• 16:09
  SPEAKER_00: And I could say a very great deal about that, but that's um that's more the subject of a documentary rather than a podcast series.
• 16:18
  SPEAKER_00: But one boy in particular from Cambodia, because although they were principally Vietnamese children, there were some northern Chinese and some Cambodians as well.
• 16:31
  SPEAKER_00: And there were lots and lots of them, and they they came to or that they were housed by France, Australia, the US, the UK, and I think some other countries as well.
• 16:45
  SPEAKER_00: But this one boy was horribly traumatized, and he would walk into rooms sideways and with his back against the wall, constantly scanning and constantly alert to the potential danger, which is how he had survived when he had been captured by the Viet Cong, and he was something of a mascot.
• 17:21
  SPEAKER_00: And he his life was devoted to serving the Khmer Rouge, and the then subsequent the Viet Congorillas, absolutely awful, an incredibly young child who witnessed the most awful atrocities separated from his family, and he his psychological state was so fractured that he was unable to put into words what was going on inside, and it took a very, very long time of working with this boy to get him to a state where it was possible to speak, to recall, to demonstrate, and to start the process of recovery, which I was a part of.
• 18:16
  SPEAKER_00: So I suppose, in a sense, this is a reminder that the damage that can be done is considerable.
• 18:28
  SPEAKER_00: And although the damage that most children sustain may not be at this magnitude, damage is damage.
• 18:39
  SPEAKER_00: Physical wounds remind us that injuries require care, and without treatment the body may heal badly.
• 18:47
  SPEAKER_00: Psychological trauma teaches us something similar.
• 18:51
  SPEAKER_00: Because when emotional wounds are ignored, they don't disappear and they remain sensitive and reactive.
• 19:01
  SPEAKER_00: But when the wounds are recognized and attended to, the mind begins to do with help what it has always been capable of doing, and it heals.
• 19:13
  SPEAKER_00: Every wound tells a story, and every story needs to be heard and deserves the chance to heal.
• 19:20
  SPEAKER_00: Thank you for listening.