Exposure Therapy Less Effective For Shame Based Responses To Trauma?

[Sandstone]

My T suggested last week that responses to trauma are focussed mainly around either Fear or Shame. Fear based responses are similar to phobias, in that they can be reduced by graduated exposure. That is the basis of many of the standard PTSD treatments - exposure by telling or visualising the story, with interruptions to ensure the exposure doesn't become overwhelming.

However she said that for Shame based responses, any level of exposure can simply reinforce the response instead of reducing it. I've started to read around this a bit , and there seems to be some evidence to support the idea. I'll aim to post a bit of my reading later

For me it makes sense on a logical and an experienced level. An innocuous example - I overcame my fear of going to the field where I walked the dog by standing where I could see the field and staying till my panic subsided, then standing at the edge of the field and so on. Yet I couldn't make that technique work for going to my allotment on the same field, perhaps because my fear was based around the shame of having an imperfect allotment.

Does anyone recognise this?

 

[watundah]

Kind of. My social anxiety continues to dissolve with each positive encounter. Pretty black and white.

However, the dark tarry mass that I carry from the 18 years of familial abuse is much tougher to crawl out of. Deeply entrenched at a psychic level. This is the nuts and bolts of it. Makes the social anxiety seem easy (and I never thought I'd say that! )

 

[shimmerz]

You rock @stenni. Thank you so much. Do you happen to know how someone identifies a shame based response as opposed to a shame based response? I get what you are saying about shame being re-instilled through exposure therapy and wonder how shame can be worked on. I did a bunch of work with EFT on shame and that seemed to help.

 

[Anarchy]

Stenni, I've forgotten whether you have had early / developmental trauma?
If the trauma / neglect / rejection is from about five or six months from conception, when the amygdala begins to function - to probably about 3 years of age, perhaps more.

Then, according to Bowlby's attachment theory, your emotions probably never "regulated".

The only way that I'm aware of to achieve that regulation in later life, appears to be right side training with neurofeedback, coupled with therapy.

Exposure just strengthens the fear circuits by exercising them.

DBT skills teach how to accept and to some extent manage the dysregulation, but don't address the underlying extreme fear responses from the amygdala, and it appears to be fear that underpins the shame (and rage if you get it too).

 

[Sandstone]

Do you happen to know how someone identifies a shame based response as opposed to a shame based response?

The only bit I recall from reading was that shame based responses have fewer flashback/re-experiencing symptoms.

This bit from the British Journal of Psychiatry ( found at http://bjp.rcpsych.org/content/177/2/144 ) suggests that it relates to what has been destroyed - either an inner or an external sense of security

"For such individuals, it seems likely that something about the traumatic experience affected their sense of themselves: the way they think about themselves, and about others in relationships with them. Their symptoms seem to express less about the shattering of external security by fear, and more about a fragmentation of an inner sense of security."

and

"they describe experiences of ruminating on what went wrong, how they failed, their sense of hopelessness and helplessness, and other self-directed cognitions such as guilt. The painful thoughts and feelings seem to be less to do with fear of death, and more to do with the loss of an inner sense of self-confidence and esteem."


In A Casebook of Cognitive Therapy for Traumatic Stress Reactions (ed. Nick Grey) Deborah A Lee writes that using a process of logic hits a dead end, because we can't move beyond the belief we are bad, faulty, broken just because we are that way. We can't move beyond believing we are perceived as disgusting, and we see ourselves that way too. That certainly resonates with my experience - my inner certainty the "It's all my fault" and "I have no right to exist" feel shame based. Perfectly described by watundah

much tougher to crawl out of. Deeply entrenched at a psychic level

Lee then says that because we feel so unworthy we can't develop self-comapssion or self -care: instead we invalidate or minimise our distress. That also sounds like me, In fact I can hear many things I've written here and said to T.

@Anarchy You seem to be saying that fear is the source of shame. So do you think that they are both manifestations of the same thing? And hence taht they both need managing in the same way?

 

[Anarchy]

I think shame has its roots in fear - but if you have early traumas or neglect (sorry that I cant remember), that fear may well be fear of abandonment, and from what I've picked up in my reading, all that exposure would do is reinforce it.

This is the best that I've found so far on early trauma, and it is good. Although the approach is considered "alternative" (probably because it doesn't have the multi billion marketing budgets of big pharmaceutical companies to push it), It does have very well respected believers, the foreword is by van der Kolk, and there's an endorsement from Marsha Linehan: http://www.bookdepository.com/Neuro...elopmental-Trauma-Sebern-Fisher/9780393707861

 

[Friday]

I've found exposure therapy equally effective with both. Conversely, done wrong, exposure therapy can also definitely reinforce both.

There's another piece, however. In my experience, the first part of exposure therapy deals almost exclusively with the nervous system response. For past shames? I need action in addition to exposure therapy. I need to be able to put things right, on my terms, in the present & future... To not feel the shame of the past all over it. "Dares. The art of a successful recovery." That's the second part.

For myself:

Action kills fear... In the moment.
Action kills shame... In the past. By building a new present.

Now... I happen to nearly always add that piece to things I'm ET'ing that are fear or rage based, in addition to shame based.

To use a made up example... If I'm touchy about bikes? I will ET everything that bothers me about the damn bike. And then? I either ride the sucker and get freaking good at it, or I will cheerfully set it on fire and ride a horse/ car/ etc. from now in. I have a new present, and a new future, that only includes a bike of I choose.

The field? ET to get to the field. Gardening in the allotment to make it as you choose, to kill the shame.

This piece would be -in part- why many people who didn't fight back learn to fight. If they're smart, and most people are, they know that fighting won't save them next time. It's not about prevention. Protecting yourself is only the outward piece. It's about killing shame. Action killing shame. And every time they do defend themselves in the future? It kills the shame harder. Until there isn't any left. ((Dealing with the shame involved when you're a damn good fighter, and overpowered anyway, cause anyone can be? Different creature. Needs different action.))

It's about building self confidence.

Dispelling ghosts is one thing. Building self confidence is another.

I always have both built into my ET. It seems to me that many people stop halfway.

 

[Eleanor]

I would only add to the above (which seem quite sensible to me, but what do I know?) that there are two basic emotional response systems (prior to social learning) PANIC and FEAR that can "feel fearful."

I think shame has its roots in fear - but if you have early traumas or neglect (sorry that I cant remember), that fear may well be fear of abandonment, and from what I've picked up in my reading, all that exposure would do is reinforce it.

Fear of abandonment (which has no target - no clear and present danger that will attack you) is PANIC. Fear of the rustling in the bushes (that might be a tiger) or focusing on the barrel of the gun pointed at you is FEAR. FEAR makes the hair on the back of your neck stand up, it makes the blood go to your legs, it makes your guts clench, and has anesthetic properties. FEAR puts a bunch of adrenaline in your system in case you have to fight when RAGE (a different system) kicks in. PANIC, by contrast is more like we think about anxiety - it is whiney, skittish, scanning everywhere constantly, it looks to cling, it is about insecurity - because PANIC is about attachment. In childhood trauma they get closely associated and co-activated. Anyhow, what everyone else is saying makes sense to me because FEAR has an object and PANIC doesn't. So exposure wouldn't work for PANIC because PANIC is about absence, the absence of protection. What can exposure therapy be done with? Exposure therapy is good for desensitization, but you can't desensitize people from the need for attachment (well, maybe you can... but... seems like a really really bad idea to me.)

 

[Tinyflame]

Dear @Eleanor , then what does one do about panic? And also, for example I know as a child I felt panic with abandonment (only times I remember crying terribly/ panicing, especially as you said versus fear, never cried (even bad injuries, & never publically if I could help it, including family except for twice- thumb smashed & stuck in car door I eventually did, & one bite, & for a few seconds when I fell off a roof directly on my tailbone with a friend; deaths & leaving etc was privately) ). But now I feel panic without it, or already feel 'abandoned' (which is silly because I have no one to abandon me, maybe it's helplessness +/or hopelessness), +/or feel panic/ shock with non-abandonment interactions (there's almost something comforting about abandonment).Or an expectation to be & that it's right, true & best to be abandoned Seems hopeless.

(PS, Thanks to let me ask. And nice to 'see' you, hope you got your new house/ (reno's done?) eif I'm hopefully remembering correctly? Hope all is well. :hug: )

Think @stenni's post #5 has much truth in it. Good for you @stenni to persevere. :hug: :tup: I am pulling for you.

 

[Tinyflame]

I guess what I mean is (as it ties in to what @stenni said), that sometimes I feel abandoned (by others, though that's usually followed by feeling deserving of it), sometimes I don't. I guess there is (possibly) shame in feeling 'deserving' to be abandoned (different than the shame of trauma specific history).

Similarly, as @stenni said re: needs, I can only accept food/ water/ air (literally) qualifying as 'needs'. Ideally also shelter/ a home. (Also ideally water, a place to bathe, transportation= stuff for work, heat in the winter, lights/ Hydro).

 

[Sandstone]

n addition to exposure therapy. I need to be able to put things right, on my terms, in the present & future

Gardening in the allotment to make it as you choose, to kill the shame.

Doesn't this depend on whether there is actually anything wrong in the first place? It's possible that my allotment is actually completely acceptable (because my husband keeps it up), but my sense of shame and failure mean that only perfection, or at least the best allotment in town, would be non-shameful. Sadly, I know that if it was the best, I would them feel enormous guilt for distressing other allotment holders. It comes back to the underlying knowledge that I am unacceptable in almost every way.

Exposure therapy is good for desensitization, but you can't desensitize people from the need for attachment

And I suppose a breakdown is that attachment is what creates

a fragmentation of an inner sense of security.

And back we come to

we can't develop self-comapssion or self -care: instead we invalidate or minimise our distress

and I find myself shamed by even having any needs, just as @Junebug so clearly describes. I recall posting about why self care was so impossible, and that was way back in Feb 2013.

All this came up through a conversation in therapy about my ongoing inability to wear the bright colours I used to love, to use make up or wear any accessories. If I try, I quickly end up very disturbed, and on the occasion I persisted I was ready to destroy myself by the end of the day. I cannot deal with incongruence between how I feel inside and the lie I'm presenting externally. I shall be interested to hear later today what T has to say about dealing with shame-based responses.

 

[Anarchy]

guess there is (possibly) shame in feeling 'deserving' to be abandoned (different than the shame of trauma specific history).

Shame is the fear of not being acceptable to others - and hence they abandon us

It's the fear of abandonment that is driving the shame.