00:01
There are wounds from trauma
that people experience,
whether they experienced it
as a child, as an infant,
as a young person, as an adult,
or as an older senior person.
00:17
So we think about trauma
in two ways.
00:20
There can be that
"capital-T" trauma,
which is something like 9/11.
00:26
Some horrific event.
00:29
That occurs and makes us think
that we're going to die.
00:33
Or there can be the
"small-T" traumas,
the traumas that happen day,
after day, after day,
like bullying.
00:43
Like, the effects of racism.
00:50
Like having to deal
with a mental illness,
and not being able to get
the help you need,
and having people look at you
in a different way.
01:01
So, we want to understand that
when we have those kind of wounds,
our body wants to protect us.
01:14
And so it does,
either escaping
or it defends us.
01:21
So, if we can't escape,
and we can't defend,
and I'd like you
to think about children
who are dependent
on their adult caretakers,
they can't escape, nor
can they defend themselves.
01:39
So, when those two responses
are unavailable,
that active defense mechanism
becomes passive.
01:50
It becomes the freeze, submit,
because otherwise, I might die.
02:00
What happens in those moments,
if we cannot defend ourselves,
is that our brain,
because it is so complex,
it starts fragmenting things.
02:13
We don't want to think
that we gave in
to the uncle,
who sexually assaulted us,
at the age of four.
02:23
We have to go to Christmas
every year
and he's there.
02:28
And so what our brain does,
is it fragments it.
02:33
And it helps us to dissociate
or step outside of ourselves,
and be able to say that happened
to her, it didn't happen to me.
02:44
Frequently,
when you're talking to a person
who has had to have
that submit response to trauma,
you will find
that they have dissociation.
02:56
And we see the dissociation.
02:59
We see the person
as they are talking,
where my uncle
would walk into the room,
and I would see his silhouette
in the doorway.
03:14
And you have to say to the person,
"Are you still here with me?
Because I'm Dr. Marshall, and you're
in my office, and you're safe here."
Are you with me?
Because they have now
dissociated on me.
03:27
They've left intellectually
and emotionally my office,
and they are now that four-year-old
lying in the bed,
seeing that silhouette,
as clear as if it was happening
in the moment.
03:40
So, we know that the instinctive
physical body reaction
is going to be that
fight or flight.
03:48
But when that's unresolved,
when we run away, or we put up
a fight against someone,
sometimes our body memorizes,
that terrible moment,
and we have actual physical impulses
that remain memorized in our body,
even though it's not experienced.
04:17
So, what does that mean?
That means that when we are
hoping to defend ourself,
we might internalize,
what if?
What if
I was able to do this?
What if
I was able to do that?
Even though we're not
able to actually engage
in that self defense,
that what if sense,
remains in our body
because every cell in your body
responds.
04:48
If you've ever been sitting
in a nice quiet place
and someone drops a tray of food
and you jump.
04:56
It's not just your head
that's jumping.
04:58
It's every cell in your body
is reacting
to the crash of that
tray on the floor.
05:06
And it may be minutes later
that you start feeling
that your heart slows down.
05:14
So, sometimes,
that moment of,
what if I get up?
and what if I stand up,
and I shout out?
or I call my mother?
Sometimes that happens in a moment,
and we become reactivated.
05:33
Our autonomic nervous system
becomes activated anew.
05:38
Our heart starts beating
really fast.
05:41
We start sweating.
05:43
We have pupillary changes,
getting ready for the attack.
05:47
Our mouth dries up.
05:50
We might start trembling,
a sense of panic comes over us.
05:56
And we know that there are
overwhelming odds
that we cannot do this.
06:02
This is reactivation.
This can happen at any time.
06:06
As I was saying
with that one patient
who starts telling me
about her uncle,
she's in my office,
she's safe in my office.
06:15
And yet,
in that moment,
her whole autonomic nervous system
was becoming reactivated.
06:23
Survivors of trauma have symptoms.
06:26
They recall a feeling,
or they stopped talking.
06:32
They may have depression.
06:35
They may have irritability.
06:38
They may have loss of interest
in doing any of the things
that they want to do.
06:45
They may find that
they can concentrate.
06:49
A sense of numbness
comes over them.
06:53
Maybe they feel unreal,
or out of their body.
06:55
Like they're watching
something happen to themselves,
even though they know
what's actually happening to them.
07:04
When we ask people,
"Well, what about the next
three years or five years?
What do you see?"
There's a loss of a sense of
what the future might hold for them.
07:13
There's a replacement
of hope for the future
with a kind of hopelessness.
07:20
They feel ashamed and worthless.
07:25
When you ask them about
memories of their childhood,
or memories of college,
little or no memories
will actually come up.
07:33
But they will tell you
about their nightmares,
or about their flashbacks
to a moment in time.
07:42
Meeting new people,
or trusting people
is very difficult.
07:47
They are hypervigilant.
07:48
They're always waiting
for the next thing to happen.
07:52
They have a very difficult time
trusting people.
07:57
We find that oftentimes, people
who go on with PTSD, chronic PTSD,
they find that they have
chronic pains.
08:05
They have back pains,
they have hip pains,
they have headaches,
shoulder pains, myalgias.
08:14
And they don't know
who they are anymore.
08:15
They have a loss of the sense
of, who am I?
We see generalized anxiety
all the time,
with panic attacks
that are not infrequent.
08:30
In order to cope with
all of these feelings,
this constellation of feelings,
they're more likely
to try and help themselves
cope through
maladaptive behaviors,
like substance abuse,
or through eating disorders.
08:48
Usually, there is
a high level of insomnia.
08:53
Also, when you're talking to them,
they will say,
"I am so overwhelmed.
08:58
My emotions are just
drowning me out."
And self-destructive behaviors like
drinking and driving, or smoking.
09:09
Because what does it
matter, anyway?
So, if we
take a minute now,
and we think about the symptoms
that emerge in PTSD,
this irritability, the depression,
the anxiety, the substance use.
09:27
Each one of these symptoms
actually can be a diagnosis
of a different mental illness.
09:36
When we see the constellation,
however, we need to take a moment,
we need to take a breath,
And we need to ask the patient,
"So tell me,
is there anyone in your life
who you are or were afraid of?"
And if they say, "Oh, yeah,
I'm really afraid of my mother.
10:01
Even now in her 90s,
she's is hell to live with."
And then you say to them,
"Is there anyone now or during your
lifetime you were ever afraid for?"
And they say,
"Oh, my sister. My mother
used to beat her senseless."
Well, you have now just
with two questions,
Who are you afraid of?
Who are you afraid for?
You've been able to identify
that there is the possibility
that this person presenting with
this constellation of symptoms,
actually is a survivor of trauma,
and needs to be treated for
post-traumatic stress disorder.
10:49
Trauma causes
disorganized attachment.
10:54
Especially if
this trauma is happening
as a person is a child or youth.
11:01
The person is continually
asking themselves,
is it really safe to be attached?
Is it safe to care about something?
Or someone?
So what do we think happens?
When a parent figure is creating
safety versus danger,
what do you think we might see?
If early attachments are safe.
If a child cries,
and the person taking care of them
comes in and comforts them,
that child learns
to trust being taken care of.
11:41
And as they grow and mature,
they're able to engage in
comfortable kinds of relationships,
because relationships are safe.
11:52
But when the adult caregiver
is constantly either
not taking care of them,
ignoring them,
when a child is crying,
and instead of being held
they're screamed at or perhaps hit,
that creates an internal struggle,
because that baby, that child
is yearning to be attached,
is needing as a human being,
to be held, to feel safe.
12:25
But at the same time is
learning that that is not safe.
12:29
To call another person
into its life,
is to call danger and pain
into its life.
12:39
With the parent or caregiver
that provides safety,
the adult grows up, learning
it's safe to be close to others.
12:48
And it's even safe to be by myself.
12:51
I'm okay. I am a complete and
worthy person that people can love.
12:59
I want to be close.
I don't want to be alone.
13:03
I like when people are around me.
13:06
And so, my impulse,
and my belief system says,
"It's okay to attach
to another person.
13:14
It's alright to be close.
13:16
I can trust other people
with my emotions in my heart."
But for that child
who knew only danger,
that child grows up with
the real story that they believe,
a schema that says,
it is not safe to be
connected to others.
13:37
It is unsafe to have
to depend on anybody else.
13:41
You better watch out.
Don't you trust anyone else?
And so that person when an
attachment starts to occur,
their impulse is
that fight or flight.
13:55
Get away from that closeness.
13:58
Don't allow people in
because you know
what's going to happen.
14:03
Remember, this is the idea
of the trauma being codified,
being codified so deep,
that we are not aware.
14:12
We're not thinking,
Oh, it's not safe to trust.
14:15
We just know if we have
been mistreated as babies,
our patients know,
don't let this nurse
get close to you
because as soon as you do,
it is a problem.