Trauma and Couple Therapy

Trauma and couple therapy is a specialized area of counseling that emphasizes how individuals can grow and heal within the context of their relationships, especially when trauma is part of the picture. 

While childhood trauma can shape a person’s ability to emotionally connect, communicate with, and trust others (MacIntosh, 2019), individuals who have experienced trauma also possess incredible adaptability and strength. Survivors who form relationships may encounter some difficulties with communication or intimacy, however, these challenges can also be considered as opportunities for growth and deeper understanding (MacIntosh, 2016).

Those who have experienced childhood trauma may face emotional regulation difficulties. In some instances, survivors may feel the urge to withdraw or shut down when emotions become intense. However, this is a natural coping mechanism rooted in past experiences. When they work on developing skills to better regulate emotions, couples can start to view their relationship as a space for healing, compassion, and emotional connection. Rather than seeing emotional moments as obstacles, they can become opportunities for building empathy and mutual support.

With the help of a skilled therapist, individuals can understand how past trauma influences current relationship dynamics and can tap into their inherent strengths and resilience, deepen their bond, and create a loving, safe environment (Platt and Freyd, 2015). If you and your partner are navigating the impact of individual or shared trauma in your relationship, therapy can help you both build the skills to regulate emotions, manage conflict, deepen intimacy, and restore connection in all aspects of your partnership.

References

Godbout, N., Runtz, M. G., MacIntosh, H. B., & Briere, J. (2013). Childhood trauma and couple relationships. Integrating Science and Practice, 3(2), 14–17.

MacIntosh, H.B. (2019). Developmental Couple Therapy for Complex Trauma. Taylor & Francis.

MacIntosh, H. B. (2016). Dyadic traumatic reenactment: An integration of repetition and enactment into the understanding of negative interaction cycles in childhood trauma survivors and their partners in couple therapy. Clinical Social Work, 45(4), 345–353. 

Platt, M. G., & Freyd, J. J. (2015). Betray my trust, shame on me: Shame, dissociation, fear, and betrayal trauma. Psychological Trauma: Theory, Research, Practice, and Policy, 7(4), 398.

Elizabeth Waite, M.A. is a Registered Psychotherapist at the Centre for Interpersonal Relationships (CFIR) working under the clinical supervision of Dr. Jean Kim, C.Psych. and Dr. Heather MacIntosh, C.Psych. Elizabeth provides therapy to adult individuals and couples and has training and interest in treating couples who have an individual or shared history of childhood trauma. She also has experience treating eating disorders and issues relating to anxiety, depression, grief and loss.

When faced with a challenging or traumatic life experience, many clients often expect that “getting over it” is the goal. These instances, particularly those that are traumatic in nature, reshape how our brains process events, emotions, and relationships. Ongoing and fruitless attempts to reduce symptoms may in fact worsen one’s distress (Harris, 2006). While problem-solving strategies are highly adaptive in the outside world, they are not always applicable within our internal psychological worlds. The more time and energy we spend trying to rid of these negative experiences, the more we may suffer in the long term. Alternatively, compassionate healing recognizes that recovery is a process rather than a destination. Instead of erasing the past, clients are guided towards creating safety, self-understanding, and growth (Harris, 2006).

Though it’s natural for our initial response to distress to be “I want this to go away,” some clients benefit from altering that relationship with difficult thoughts and feelings. Though they are uncomfortable, they are approached with compassion and curiosity rather than the perspective that they are something to “get over.” We experience some form of distress on a daily basis, so allowing room for unpleasant feelings, sensations, and urges to come and go without struggling with them actually helps in reducing their frequency or severity (Harris, 2006). Once we can separate ourselves from our thoughts, we are able to see them as passing events rather than absolute truths. By this perspective, healing happens not by “getting over it,” but my embracing what is, while striving for what can be.

Erin Rehmann, M.A., is a therapist and psychometrist at CFIR. She is supervised by Dr. Mard Becard, C.Psych. Erin provides individual psychotherapy to individual adults with a wide presentation of mental health difficulties, specializing in anxiety, depression, self-esteem challenges, trauma, and emotional dysregulation. She utilizes an integrative and collaborative approach, primarily using person-centred, cognitive behavioural, and acceptance and commitment therapy. Erin also provides psychological assessments to adults with Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder. 

Harris, R. (2006). Overview of ACT: A brief introduction to Acceptance and Commitment Therapy. Retrieved from https://static1.squarespace.com/static/509ad2ede4b011ec832812ed/t/5b896b1870a6ad36f8841834/1535732505180/Russ+Harris+-+Overview+of+ACT.pdf

Trauma occurs when the stress of a situation overcomes our ability to cope, and mindfulness can help us process this while better allowing us to regulate emotionally (Larsen et al., 2021). A key concept related to this is the idea of a window of tolerance (Siegel, 1999). Our window of tolerance is where we can still cope with what is happening, maintain regulation of our nervous system in a way that allows us to be grounded in the present, and behave in ways that serve our values and outcome goals. When dysregulated, we can move in two directions; towards a state of complete shutdown and disconnection with the world or towards an activated state of anxious thought and overwhelming fear that leads to a desire to fight or flee from a perceived threat. The state of shutdown can be seen in individuals who, when overwhelmed, move into feelings of hopelessness and helplessness and appear depressed or withdrawn from the world, unable to connect with others. When individuals move in the other direction, their anxiety propels them to attack others or run away from difficult situations to protect their sense of self and feeling of safety.

With mindfulness, we can identify the cues from our bodies and emotions to determine when we are about to move away from our window of tolerance. Mindfulness also provides various tools and strategies to help us move back toward the window of tolerance through awareness and non-judgment.

An example of a mindfulness-based practice I use with clients in a state of fight or flight is three-part yogic breath, in which awareness is drawn to feeling the rise of the lower, mid and upper regions of the abdomen as they expand. By placing the palms together with just the middle fingers touching while the others are separated, we can begin to notice if each of the regions of the abdomen is rising on the inhale. This awareness can foster a focus on the breath that can draw an individual back toward their window of tolerance. Over time, they can be encouraged to lengthen their exhalation relative to their inhalation, facilitating this movement from anxiety towards balance.

Conversely, when a client is moving towards emotional shutdown, mindfulness can be used to bring them back to their window of tolerance. A simple technique is to ask the client to allow their inhale to be slightly longer than their inhale. For those who find these overwhelming, gentle, rhythmic movements like gently rubbing a stone or rolling their shoulders up, back, and down continuously can help return the client’s basic level towards their window.

Mindfulness approaches can be integrated into any therapeutic modality but are integral to approaches such as mindfulness-based Cognitive Behavioural Therapy and Acceptance and Commitment Therapy. Our therapists at the CFIR can help you learn how to build mindfulness skills to process trauma and emotionally regulate it.

Mr. Jeffery Driscoll, B.SC., B.Ed., is a counsellor at the Centre for Interpersonal Relationships (CFIR) supervised by Dr. Ashwin Mehra, C.Psych, Psychologist. Mr. Driscoll is registered as both a teacher in Ontario and a yoga instructor and provides integrated therapy through a mindfulness lens to adults and seniors. Given his years of experience in yoga and education, he is skilled at helping individuals navigate life transitions or find greater career or relationship meaning and joy. He works with individuals who are experiencing a wide range of psychological, relationship and career difficulties relating to grief, life changes, aging, mood disorders, trauma, sexuality, sleep disturbances and interpersonal conflicts. He integrates mindfulness with Cognitive-behavioral therapy (CBT), Acceptance and Commitment Therapy (ACT), Dialectical Behavioural Therapy (DBT), Emotion-Focused Therapy (EFT), Existentialist, Systemic, Adlerian and Psycho-dynamic therapy.

Reference

Larsen KL, Stanley EA. Leaders’ Windows of Tolerance for Affect Arousal-and Their Effects on Political Decision-making During COVID-19. Front Psychol. 2021 Oct 26;12:749715. doi: 10.3389/fpsyg.2021.749715. PMID: 34764917; PMCID: PMC8575779.

Siegel, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. Guilford Press.

By Davey Chafe, MA, RP(Q)

Too often emotions are dismissed as weakness or as something that clouds our judgment from more “rational” thinking. However, emotions are very important for effective communication and give us vital information about our environments and the people within them. For example, if someone wrongs us or mistreats us and we become angry, it signals that we may need firmer boundaries with this person. In the same way, if we suffer a loss and feel sadness and grief, it may signal for closeness and support from people around us.

Over time, we learn how to listen to, and trust these emotional cues to help us navigate our worlds. However, if we experience traumatic events that we have difficulty coping with, it is not uncommon for people to develop negative changes in mood which can include distorted views of the self (e.g., self-blame and criticism), persistent negative emotional states (e.g., fear, horror, anger, guilt, or shame), feeling detached from others, and inability to experience positive emotions, such as happiness, satisfaction, or even loving feelings (American Psychiatric Association, 2022). These emotional disturbances can be present even without a diagnosis of PTSD or other trauma-related disorders. When this happens, people will often develop a negative relationship with their emotions, often leading to ignoring, avoiding, or no longer trusting their feelings.

Not feeling our emotions can lead to unhelpful coping strategies over time that allow us to “escape” the severe, negative emotions that can come with experiences of trauma. Unfortunately, avoiding these feelings can often result in new or worsening symptoms as our underlying emotions will look for new outlets. The energy from these emotions may manifest as symptoms such as anxiety, outbursts of anger, feeling low or depressed, dissociation, or substance use to avoid these negative feeling states. This is where therapy can help.

The hard part of this work is facing the feelings we have been avoiding, sometimes for years. If these feelings are not acknowledged and worked through, the emotional signals continue to go unheard, and we will continue to experience symptoms. Therapy can help by creating a safe place to begin unpacking and exploring these feelings through building safety and stability in our bodies and then learning to develop a relationship with our feelings again. As we process traumatic events and memories in a safe and productive way, it allows us to get back in touch with our bodies, our emotions, and the meaningful roles and relationships in our lives.

Davey Chafe, M.A., R.P. (Qualifying), is a Clinical Psychology Resident at CFIR in the final year of his PhD at York University and works with both individuals and couples in therapy. Throughout Davey’s clinical training, he has gained experience in a broad range of settings. He has worked with Emotion Focused Therapy for individuals and couples and Dialectical Behavioural Therapy for couples through York University, CBT for Mood and Anxiety at Brampton Civic Hospital, and with individuals and groups treating PTSD, mood disorders, and anxiety through community trauma initiatives. In addition to clinical work, Davey has been involved in psychotherapy research for over 10 years and has published in peer-reviewed journals and attended international conferences to present his clinical work. He is currently being supervised by Dr. Dino Zuccarini, C.Psych, Dr. Lila Hakim, C.Psych, and Dr. Aleks Milosevic, C.Psych.

REGULATING NERVOUS SYSTEM RESPONSES TO TRAUMA

Please see blog post: PART I: TRAUMA AND THE NERVOUS SYSTEM prior to reading this post

There are many different ways to regulate our nervous system. Body-based or somatic approaches are accessible and can create lasting changes to our feelings, thoughts, and behaviours. 

HYPERAROUSAL:

1. Hand on heart: 
   • place your hand on your heart and start to notice the gentle contact between your hand and your chest. Notice the weight of your hand on your chest.
   • Notice the temperature (e.g., warm or cold)
   • Notice any sensations (e.g., tingly, spacious, energized, airy)
   • Notice if the sensation starts to spread
   • Notice your breathing 
   • Deep breathing
2. Deep breathing:
   • Inhale for 4 counts; hold for 4 counts; exhale 8 counts
   • *try: inhaling through your noise and exhaling through your mouth (making an “O” shape with your mouth)
3. Belly breathing:
   • Place your hand on your belly
   • Inhale for 4 and actively expand your stomach
   • Hold for 4 
   • Exhale for 8 and collapse your stomach 

HYPORAROUSAL:

1. Posture change: 
   • Elongate your spine (*imaging your spine being pulled up to the top of your head)
   • Pull your shoulder back 
   • Gently push your chest out 
   • Take a few breaths here
2. Breathing:
   • Inhale for 8 counts; hold for 4 counts; exhale for 4 counts
3. Grounding through contact:
   • Stand up and notice your feet on the floor; elongate your spine and start to peddle your feet to apply more weight to one foot at a time; notice activation of muscles in your legs and glutes; bring attention to sensations (e.g., pressure, energized) and temperatures in your feet.  

Whitney Reinhart, M.A., R.P., is a psychotherapist who provides psychological services to adults and couples experiencing a wide range of issues, with a special interest and expertise in trauma and relationships. She uses a variety of trauma-informed approaches, including sensorimotor psychotherapy, somatic experiencing, and parts-based therapies.  

When we experience threat, our nervous system reacts in the best possible way for that situation, either by fight, flight, freeze, submit, or cry for help. When we experience threatening situations or traumas where we aren’t able to mobilize and run to safety or fight back, we will freeze or submit. In freeze, we feel stuck; there is an internal sense of danger and threat, but we are unable to move or act. In submit, we collapse; everything goes offline, our muscles become flaccid, and breathing decreases. 

When we have unresolved trauma (chronic or acute; attachment-based or threat to body), we can go throughout our lives reliving the trauma through our nervous system – often leaving us in a chronic state of hyperarousal (fight, flight, freeze, attach) or hypoarousal (submit). In chronic hyperarousal, our nervous system is geared up and activated. For example, we might find ourselves feeling irritable and on edge (fight), using substances for relief, distancing from relationships (flight), relying heavily on others, clinging to avoid abandonment (attach/cry for help), feeling frozen and/or experiencing panic attacks and flashbacks (freeze). In chronic hypoarousal, our nervous system is shut down and numbed out, and can result in us feeling depressed, ashamed, disconnected, unable to think, and passive.  

If you identify with some of these internal experiences, therapy is a great step for understanding your nervous system responses, what you had to do to stay safe, and how to regulate your nervous system. 

Stay tuned for Part II on regulating your nervous system.

Whitney Reinhart, M.A., R.P., is a psychotherapist who provides psychological services to adults and couples experiencing a wide range of issues, with a special interest and expertise in trauma and relationships. She uses a variety of trauma-informed approaches, including sensorimotor psychotherapy, somatic experiencing, and parts-based approaches. 

Complex post-traumatic stress disorder (C-PTSD) is a relatively new diagnosis for understanding how past events can impact our mental health in the present. If you’re struggling with difficult symptoms, you might have wondered if they could be due to complex trauma. 

Complex trauma involves experiencing a series of events of a threatening or horrific nature, where escape is difficult or impossible. These events overwhelm an individual’s capacity to control or cope with the stressor. They can occur in childhood or adulthood, and could include (but aren’t limited to):

• Domestic violence
• Physical abuse
• Sexual abuse, harassment, or assault
• Neglect or abandonment
• Racial, cultural, religious, gender, or sexual identity-based oppression and violence
• Bullying
• Kidnapping
• Torture
• Human trafficking
• Genocide and other forms of organized violence

Those with complex trauma develop post-traumatic symptoms such as flashbacks, avoiding reminders of the events, and feeling constantly “on edge” or hypervigilant. But due to the prolonged and pervasive nature of the trauma, those with complex trauma develop additional symptoms that are important to recognize.

The first is trouble with affect regulation. This means they might have trouble calming down after a stressor or have strong emotional reactions. On the other end of the scale, they may often feel emotionally numb, or not able to experience positive emotions such as joy. 

Secondly, individuals with complex trauma struggle with negative self-concept. This means they often have strong beliefs that they are worthless, or a failure. They might feel intense guilt or shame in relation to these beliefs.

Finally, individuals with complex trauma often have issues in relationships with others. They might have trouble sustaining relationships and feeling closeness to other people. They might have short, intense relationships, or avoid relationships altogether.

Complex trauma often occurs across generations (sometimes referred to as intergenerational trauma), due to a lack of resolution of previous traumas and prejudice and discrimination that results in the oppression of entire families and groups.

Always consult with an experienced mental health professional if you believe that you may have complex trauma or another condition. Regardless of the cause of your symptoms, there are many treatment options available that can help you achieve your goals and feel better. 

Camille Labelle, BSci, is a therapist working at the Centre for Interpersonal Relationships (CFIR) under the supervision of Dr. Lila Hakim, C.Psych. They provide individual therapy to adults who have experienced single-incident or complex trauma or are seeking support for other mental health conditions such as anxiety or depression. They use an integrated approach including emotion-focused therapy (EFT) and cognitive behavioural therapy (CBT) to empower people to process their experiences, understand their reactions, and change their lives. 

References

Ford, J. D. & Courtois, C. A. (2020). Treating Complex Post-Traumatic Stress Disorders in Adults, 2nd ed: Scientific Foundations and Therapeutic Models. New York, NY: The Guilford Press. 

World Health Organization. (2019). International Statistical Classification of Diseases and Related Health Problems (11th ed). https://www.icd.who.int/  

How we understand, feel, and behave interpersonally in adulthood stems from our experiences in our earliest relationships. As children, caregivers help us make sense of our experiences. They translate a physical reaction, such as crying, into a conscious feeling, thought, or desire. They do so by mirroring the child’s emotion, marking it with exaggerated facial, vocal, or gestural displays, and responding to it sensitively. They also put into words their own reactions, modeling ways to make sense of a child’s behaviours, and allowing the child to understand that people experience situations differently. These interactions foster what is called “mentalization”, which is the capacity to understand oneself and others in terms of possible thoughts, feelings, wishes, and desires. 

And what about children who did not benefit from such interactions with caregivers? In cases of child abuse and neglect, the child’s physical experiences are often ignored or met with anger, resentment, and irritation. These responses leave a child with the impossible task of processing his experience alone, therefore compromising the development of mentalization. It is not surprising that many adults having suffered maltreatment in childhood often encounter difficulties in their adult relationships. They may often feel hurt or angry in relationships as their understanding of others’ intentions or feelings is either lacking or inaccurate, leading to conclusions drawn by their own painful experiences in childhood. Therefore, behaviours such as withdrawing from a situation may be perceived as an intentional rejection, when, in fact, it may result from other intentions or needs. 

At CFIR, we can help you develop your mentalization skills by taking a step back from situations that trigger strong reactions. By learning how to think about how you feel and feel about how you think, we can support you to create stronger bonds in your relationship with others. 

Lorenzi, N., Campbell, C. & Fonagy, P. (2018). Mentalization and its role in processing trauma. In B. Huppertz (Ed) Approaches to psychic trauma: Theory and practice (p. 403-422). Rowman & Littlefield. 

Camille Bandola, B.Sc., is a counsellor at Centre for Interpersonal Relationships working under the supervision of Dr. Dino Zuccarini, C.Psych. She is currently in the fourth year of my doctoral program in Clinical Psychology at Université du Québec en Outaouais.

by: Dr. Dino Zuccarini, C.Psych.

Living and loving in the social margins of a heteronormative world can create complexity in the relationships of individuals from the LGBTQ+ community.  In our early years, recognition of being different than members of your family of origin and peers can create significant attachment and self fears. We all need a sense of acceptance, emotional validation, approval, and admiration if we are to develop a strong sense of self and connection to others. Individuals from LGBTQ+, in many instances, may face abandonment, rejection, punishment, and abuse just for being different. These types of traumatic experiences create fears and distrust in others, mainly when early attachment figures are the individuals who are the source of rejection, punishment, and abandonment. Rejection also fills individuals with a deep sense of shame that comes with deep feelings of unlovability, insignificance, and worthlessness.  

The internalization of these experiences can create difficulties when fears, shame, and past hurts limit the capacity to trust and connect others. The clinicians at CFIR work to build more secure, resilient identities and strengthen interpersonal relationships in the LGBTQ+.  They support you to unpack the emotional residue of early distress in attachment and/or with pears and the impact of this residue on your attachments.

by: Andrea Kapeleris Ph.D.

More common than you think! About 20-50% of children and teens who have experienced trauma meet the criteria for Post-Traumatic Stress Disorder (PTSD) and nearly 75% also experience depression and substance use (Elwood, Hahn, Olatunji, & Williams, 2009). Statistics also show that about 14% of people exposed to a major stressor go on to develop PTSD (Terhakopian, Sinaii, Engel, Schnurr, & Hoge, 2008), and women are about twice as likely as men to develop PTSD after a trauma (Kessler, Berglund, & Demler, 2005). Stressors can be one-time events that cause actual or threatened death or harm to yourself or a loved one (such as, a car accident, sexual assault, mugging, natural disaster), or they can include on-going negative and damaging experiences – such as, chronic stress resulting from military service, or childhood experiences in which there was repeated damage to the attachment relationship between you and your caregiver. These chronic experiences can shatter a child’s sense that the world is benign, the world is meaningful, and the self is worthy, and often results in avoidance coping and an increase in overall level of arousal and anxiety (Roth et al., 1997).

Symptoms of PTSD are Normal Reactions to a Non-Normal Experience

• Re-experiencing the event in a number of ways including, flashbacks, nightmares, or vivid memories that come to you unexpectedly 
• Avoiding any reminders of the event (people, places, or things associated with the event), and a feeling of numbness
• Increased feelings of anxiety or emotional arousal

Treating Trauma

Overstuffed Cupboard Metaphor

The mind is like a pantry cupboard. When a traumatic event occurs, it is as if very large and oddly shaped boxes were hurriedly stuffed into the pantry. Since there was no time to properly place the boxes in the pantry in an organized fashion, each time you open the pantry to get something you need, a box suddenly and unexpectedly falls on you – startling you and possibly hurting you! The same thing happens when our mind experiences trauma. Due to the sudden and overwhelming nature of the traumatic event, the mind doesn’t have the opportunity to process all of the emotions associated with it, and as a result, unpleasant memories or emotions may come to us when we least expect them too. For example, you may become startled by an unsettling memory or emotion when you are relaxing at home, watching TV, or spending time with friends. As a result, you may begin to avoid things you previously enjoyed. 

The purpose of therapy is to help you organize this pantry. We need to take each box out of the pantry slowly and carefully, examine its contents, and then place it in its proper place. Once all of the boxes are organized accordingly, you will be able to enter the pantry without fear, and will no longer need to avoid that part of your home. Similarly, the goal is to slowly process the trauma and place events and their accompanying emotions into sequential order. In this way, your mind will be able to integrate the trauma and make sense of it. You will be able to think more freely and move forward with your life. 

Fight or Flight mode

When we encounter a traumatic event (something that threatens our physical or psychological integrity) our bodies enter a process called the “Fight or Flight” mode. This mode is evolutionarily necessary and served an important purpose – in the times of cavemen and women when our ancestors were being chased by predators (e.g., a tiger) all of the resources in their bodies left the frontal cortex (the part of our brain used to reflect on our thoughts and feelings, and make decisions) and automatically went to their muscles (to prepare them to flee or fight the predator), and also went to pump up their heart rate, breathing, and overall adrenaline (again, to make it easier for them to flee or fight predators). In modern times, when we are faced with a trauma, our bodies go into ‘Fight or Flight’ mode in order to protect us. Later, any experiences, people, places, or things that remind us of the trauma stimulate our body to again go into this fight/flight mode in case we need to be protected again. Part of our work in therapy is to help your body and mind recognize that this threat occurred in the past and that you are no longer in danger. We foster this safety on many different levels:
1) Physiologically: We must help the physical body itself feel safe and come down from overarousal. This may partly be achieved through learning relaxation strategies or overcoming avoidance-coping strategies that maintain and intensify anxiety. 

2) Emotionally: We must help the mind itself feel safe and come down from overarousal. This is achieved through:
a) processing the trauma as described above in ‘the cupboard metaphor’; 
b) learning Emotion Regulation strategies

Emotion Regulation

Emotion regulation is a process of 1) identifying and increasing awareness of your feelings (e.g., what are the names/labels for the vague and sometimes uncomfortable sensations that happen inside?), and 2) ‘sitting with’ the sensations that go on inside and experiencing the waxing and waning of your feelings – all feelings do wax/wane, come and go – the only thing we can be certain of is change from moment to moment. Physiologically, our bodies experience of any emotion follows a bell-shaped curve (i.e., it must come down from its peak) – our bodies cannot maintain the high emotional arousal indefinitely – but sometimes, our feelings about our feelings (feeling angry that we are sad, for example) may intensify our original emotion. In therapy, we help to disentangle this, and in effect, help you to regulate your emotions. Importantly, we also begin to look at your feelings as an important signal that there is something inside that needs our attention

Read more about our Trauma Psychology & PTSD Treatment Service.