Today I am proud to bring to you John Briere, Ph.D., Associate Professor of Psychiatry and Psychology at the Keck School of Medicine, University of Southern California, and Director of the Psychological Trauma Program at Los Angeles County-USC Medical Center. He is past president of the International Society for Traumatic Stress Studies, and recipient of ISTSS’s Robert S. Laufer Memorial Award for Outstanding Scientific Achievement. John has authored a number of books, including Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment, Psychological Assessment of Adult Posttraumatic States: Phenomenology, Diagnosis, and Measurement, and Therapy for Adults Molested As Children: Beyond Survival, Second Edition. He lectures frequently on the intersection between trauma, therapy, and mindfulness.
Today, John talks with us about trauma, and how he uses mindfulness to address it. Some of the work in this interview is from John’s latest book-in-progress tentatively entitled Beyond Suffering: Trauma, Psychology, and Mindfulness in the Western World.
Elisha: The word “trauma” seems to mean different things to different people. In your mind, what is psychological trauma?
John: Psychological trauma refers to an event that is life-threatening or likely to cause injury, that produces feelings of terror, horror, or helplessness. I would define it more broadly to include threats to psychological integrity, including major losses, events that were very upsetting but did not include fear of death or injury, and early and severe childhood neglect.
On another level, trauma refers to the inevitable pain that arises as we interact with the world. When we encounter an event or loss that hurts us enough, it pushes us into an emergency state, and can activate thoughts, perspectives, and behaviors that, paradoxically, add to suffering. We may feel so “bad” that we end up thinking that we are bad, we may blame ourselves for what happened, and expect it to happen again. We may feel anger of such magnitude that we to want to “get even” with someone, although hurting people rarely works out for us (or them). And, in our pain, we may do whatever we can to feel less overwhelmed. We may use alcohol or drugs, distracting behaviors, dissociation, or denial. Or we may withdraw from the world, pull into ourselves, and stay there. All these reactions are perfectly understandable.
Unfortunately, both Western and Buddhist psychology tell us that attempts to avoid pain often increase suffering. The momentary good news may be that we feel less overwhelmed when we avoid or externalize painful experience; the bad news is that our solutions to pain may keep us from recovering, by shutting us down just when we need to open up and process what has happened to us. An unfortunate aspect of psychological trauma is that, in order to move out of pain, we have to sit with pain, even if we may prefer the seeming protection of deadened emotions and reduced awareness. The journey of the trauma survivor can sometimes require great bravery — to approach rather than avoid, to reach out when isolation seems like a better idea.
Elisha: Why would you consider using mindfulness to work with trauma?
John: Mindfulness is a learnable set of skills, involving ongoing, moment-by-moment focused awareness and openness to the here-and-now, without judgment and with acceptance. It is, in some sense, the polar opposite of avoidance. Mindfulness can be a useful component of trauma therapy in several ways: the therapist can be mindful, which will increase her compassion and empathic attunement toward the client; she can communicate non-judgment, and acceptance, which the client may then internalize; and the client can learn mindfulness during treatment. In the latter case, the individual may develop mindfulness skills outside of meditation (for example, in Dialectical Behavior Therapy), or he or she can learn to meditate, which often teaches mindfulness. I think the latter can be more helpful, since, in addition to mindfulness, meditation more directly teaches us equanimity — for example how to sit with and tolerate difficult states, like anxiety or anger, while entering a more settled and objective state of mind.
Elisha: If you were sitting across the table from someone who has recently experienced a traumatic event, how would you use mindfulness as an approach to work with their trauma?
John: Well, it would depend on how recently the traumatic event had occurred. We have learned that in the immediate aftermath of trauma, often the most helpful thing we can do is to offer safety and support, facilitate connection with loved ones, and perhaps assist in accessing social, psychological, and medical resources. Initially, the individual may be too overwhelmed to engage in formal psychotherapy, let alone learn mindfulness.
The therapist, of course, will gain from mindfulness during this period, whether working at the scene of a mass casualty event or with a rape victim. Witnessing the psychological pain associated with immediate trauma can be impactful for the therapist, and we need all the help we can get at such times.
When enough time has passed, mindfulness-based interventions might be quite helpful to the traumatized person. Whether taught as specific skills, or in the context of meditation, mindfulness can stimulate the client’s growing realization that his or her thoughts are only thoughts, and his or her feelings, are only feelings — not necessarily information on the actual state of his or her posttraumatic reality. As this process develops, the client may be able to discern the transient nature of even very compelling cognitive and emotional processes, and discover that many strong emotional reactions, intrusive experiences, and problematic beliefs are not “real”: they arise from the past, not the present. As she or he becomes more aware that these are triggered, historic phenomena, the client’s capacity to observe them without getting stuck in them typically grows.
Because mindfulness allows us to stay present in pain, it supports the mind’s ability to process painful aspects of the past. Over time, repeated exposure to painful memories in the context of acceptance and nonjudgment causes those memories to lose much of their sting; a process we sometimes call desensitization or habituation. Of course, the process of allowing painful experience to enter one’s consciousness (in the words of one teacher, to “invite your fear to tea”) can produce distress. It is the therapist’s task at such times to keep the work from being overwhelming, while, at the same time, helping the client to see that such upsetting intrusions are memories, recordings from the past, that do not necessarily have much relevance to the current moment beyond their distracting and delusive qualities.
So, we might help this person to learn to meditate, and/or we might encourage ongoing mindfulness during psychotherapy, so that trauma can be processed before it engenders additional suffering. We might also refer this person to books, CDs, or DVDs that teach mindfulness. Some popular Western teachers, for example, Jon Kabat-Zinn, Pema Chödrön, Tara Brach, and Jack Kornfield are very good at teaching mindfulness techniques, but also more existential ideas about the nature of things as it relates to painful experience. In my experience, such resources are helpful to many people, from torture victims to child abuse survivors, combat vets, and psychotherapists struggling with the emotional effects of their occupation. Trauma survivors seem to take to mindfulness — perhaps because Buddhism arose as a solution to suffering, and many of those exposed to trauma grapple with enormous suffering every day.
Sitting across from a traumatized person, I would try to listen as completely as I could, hopefully conveying acceptance, positive regard, and compassion for where the person finds herself. I would attempt this knowing that we share similar predicaments; both of us subject to times of suffering and both of us trying to do the best we can. I hope my attitude and behavior would highlight the bravery of this person, given her decision to engage such pain when it might seem much easier to avoid it.
Thank you so much, John, for a fantastic interview!
As always, please share your thoughts, stories and questions below. Your interaction provides a living wisdom for us all to benefit from.