Overcoming childhood toxic stress: biography of a wounded healer
Journal of Psychiatry Reform Vol 10 #13
Associate Clinical Professor, Psychiatrist, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA. [email protected]
The analyst must go on learning endlessly… It is his/her own hurt that gives the measure of his/her power to heal. This, and nothing else, is the meaning of the Greek Myth of the wounded physician (healer).”
Physicians must go on learning not only CME but how their own life experiences, especially traumatic ones, have shaped their identity, coping mechanisms and vulnerabilities. Paradoxically, once one owns his or her vulnerabilities, the scars become a superpower. But this process can take years, decades, or a lifetime.
The shattered self, the pulverized glass or mirror of the spirit after childhood trauma might facilitate some degree of compartmentalization, hence making a medical student able to disconnect from the emotional aspects of illness and death. Sooner or later, the student, resident or attending might find himself or herself traumatized by a superior who shamed them, a supervisor who committed a micro-aggression based on gender, race etc. Or the healer might be triggered, and eventually experience burnout, an occupational hazard often blamed on inadequacy of the physician. In order to be an effective but also fulfilled healer and person, it is important to acknowledge all these traumatic events that landed on the trajectory of the physician, and try to reframe this as positively or as constructively as possible. Examples of questions facilitating such a process include:
- What stress have you experienced and overcome?
- What helped you cope with the situations?
- What stresses are still impacting you to this day?
- Do you know where you are stuck? (anger, shame, unresolved grief, constant reminders…)
The knowledge about the ACE (adverse childhood experiences) study, published in 1998, is starting to finally become widespread among health care professionals, leading many to do a self-screen. Even without knowing the exact questionnaire, simply revisiting childhood and determining if there was any abuse or family dysfunction, and assigning each type a score of 1 can give an idea of the level of risk of developing chronic conditions such as diabetes, hypertension, depression, substance use disorder. Trauma affects the whole person and potentially all body systems. Another way to review one’s past is to ask oneself: “Were my emotional needs met as a child?” If the answer is no, then, what were the barriers (or types of ACE)? Another way to screen for ACEs is to look for anything in the patient’s past or one’s own that could have interfered with secure attachment, such as divorce, physical abuse etc.
Therefore, it might be easier to screen with a more general question, especially since not all types of childhood trauma are included in the questionnaire (for instance, bullying was not part of it in the initial study, even though it can be severe enough to lead the victim to commit suicide).
What do we do if we have a high score (1-3 if there are associated medical conditions, or 4 or more with or without medical conditions)? It doesn’t have to be a death sentence. Healing is possible. And it starts with self-compassion, which is distinct from empathy. Among doctors, there is a significant number of “empaths”, or highly sensitive people with a strong ability to feel other people’s emotions to the point of absorbing the experience, as if it were happening to them. Because it involves brain structures that are part of the stress response systems (such as the amygdala), such resonance with the pain of others can lead to sadness, stress, fear, or emotional exhaustion. When the point of burnout is reached, we should refer to it as “empathy fatigue”, and not “compassion fatigue”, because compassion, as opposed to empathy, is energizing and associated with positive emotions. It involves the reward centers and is unlimited. How do we shift our mind from empathetic to compassionate? We need some distance or detachment while remaining attentive to others’ suffering, and meditation or mindfulness practices help accomplish that. Matthieu Ricard used a beautiful metaphor to convey this: “When altruistic love passes through the prism of empathy, it becomes compassion.”
And how do we find or express love? It starts with the well we all have within. The love for ourselves. It means embracing our whole being, flaws and all. It means accepting the emotions without judgment. Like Tim Desmond wrote, we have to nurture our unpleasant emotions “as if they were a screaming infant.”
Body scan, a common technique to achieve a meditative state, helps develop self-awareness by paying attention to pain and symptoms which can be an expression of unprocessed trauma. The body is like the stationery where the wound-words land. The body is a messenger, a parchment. The body remembers, it speaks and cries through illnesses. The body never lies. Therefore, we should trust our body. The other question for the doctor writing his own case report, biography or memoirs is: what is my medical history? Do I have or did I once develop conditions associated with chronic inflammation, one of the core mechanisms of the long term impact of unprocessed trauma?
Depression being one of the consequences of untreated trauma, insecure attachment or chronic inflammation, is more prevalent in women. Another essential inquiry for the doctor’s autobiography is to try to have a deep understanding and develop hypotheses about reasons explaining the gender difference instead of accepting this as a non-modifiable fact, as if women were defective. Although it is true that women are more victimized than men, and MDD is a form of chronic PTSD, there might be other mechanisms at play. Women are socialized to put others’ needs first. With time, there is an inevitable depletion of inner resources. There is also ongoing discrimination and inequality (power dynamics, lower pay, even for women physicians, compared to men). Depression can also be the consequence of turning anger inwards (women socialized to not express anger… it is seen as a strength in a man, but still labeled as aggression in women). Auto-immune disorders (which can be triggered or exacerbated by stress, and in turn perpetuate chronic inflammation) affect women more than men (75% of people receiving that category of diagnosis are women).
Similarly, I recall during medical school having learned that Black people were more at risk of developing hypertension. It was stated as a fact under epidemiology, again without any obvious attempt stated in the textbook to explain this difference based on race. But we know that Black people are still suffering from discrimination on top of transgenerational trauma. Additionally, Black people are disproportionately diagnosed with severe mental illness rather than trauma-related disorders. ACEs have been overlooked. Yet, we now know that ACEs can affect the telomere length. Is it easier to blame non-modifiable characteristics than injustice and inequalities? How can we shift the narrative?
To regain power and become a better advocate for ourselves and for the oppressed, it is important that the wounded healer views himself or herself as an overcomer. It might help to add answers to the following to your biography:
- What illnesses have you experienced? Are they correlated to prior toxic stress?
- What is the next chapter? Imagine, believe, and it can materialize (thoughts are our environment)
Have an ongoing self-care plan. Allow yourself to fall apart without beating yourself up. Just recognize that you are falling apart, and do it well! (being humorous or theatrical can help defuse a tense situation).
To reframe adversity as constructively as possible, one can think of the positive element in their trauma story, even during the most horrific event (“I had a friend who listened and believed me”). It helps put things into perspective. Other statements could sound like:
- “It taught me what love isn’t.”
- “I discovered resources I didn’t know I had.”
- “This made me realize that I am the sole responsible for my happiness.”
- “I can understand other people’s suffering better and help them.”
- “I survived this and I am here to tell the tale. Maybe my story will help others.”
- “Nothing that has happened to me has destroyed me.”
Moving out of one’s comfort zone to tolerate uncertainty can lead to post-traumatic growth. To quote André Gide, “One doesn’t discover new lands without consenting to lose sight of the shore for a very long time.”
Joy cultivation is a philosophy that catalyzes healing. It brings lightness of being, it is contagious and raises the vibration in our world. How can we harvest more joy or awe? First, practicing mindfulness is essential. The total awareness of what is happening -feeling, thinking, or nothing-, without judgment will increase the likelihood of noticing joy. Similarly, it is important to find, identify and create beauty. Gratitude helps enhancing the sense of joy and beauty. It helps accept the unknown, the ambiguity, the mysterious. Also, it is crucial to let go of the outcome, or the world of form, and instead aim to be a conduit for creativity and love. Celebrating the small stuff and emphasizing meaning can enhance joy. Finally, it is recommended to be around joyful and positive people!
Just like we feed our bodies three times per day, we should allocate three mindfulness activities to nourish our minds and soul. I encourage my patients to develop a “meditation menu”, which consists of a list of activities that bring joy and therefore increase the mindfulness index, such as walking in nature, journaling, playing (or learning to play) a musical instrument, storytelling with a prompt, writing a gratitude or joy list, repeat positive mantras, making a daily pledge to self to honor one’s gifts, moving your body (yoga, dancing), creating a sensory/memory bag with soothing objects to use in times of distress, and combine modalities as needed if there is lack of enthusiasm due to hedonic adaptation (for instance, meditation in group to pair mindfulness with socialization).
Throughout this wellness contract with oneself, it is essential to learn to set boundaries (physical, mental, material, emotional, temporal etc). If you experienced trauma but never let yourself heal, it is time to reclaim your body, beliefs, intuition, gifts, identity, freedom, power. It is time to be the conductor of the orchestra of your life, the CEO of your schedule.
Continue your autobiography to better identify and manage triggers and address blind spots; self-awareness and cohesive narrative will help consolidate recovery. Self-awareness is essential to break the cycle of traumatization. There are other important principles through this self-healing journey: self-care is HOLISTIC (and NOT selfish. Don’t let anybody tell you otherwise, and set boundaries with such abusive people). And only YOU can take care of YOU.
Your “case report” or autobiography will help you understand how the past affected you, shaped you, so you can choose the meaning of the experience and take the responsibility for your health and happiness. It will help you feel whole again. You will maybe start viewing your being not made of fragments but pieces of a puzzle that all fit well together to create a beautiful landscape. Or not as a broken glass anymore but as stained glass that can let in the most powerful light in the cathedral of your soul.