Trauma and resilience specialist, Dr Christine Gibson joins fx Medicine ambassador, Dr Michelle Woolhouse, to discuss the role of trauma in clinical practice; how this may manifest for patients, and how healthcare practitioners can empower patients working through trauma.
Michelle and Christine unpack the evolution of trauma in practice, looking to the research and sharing their own clinical experience in supporting patients with trauma. Together they provide hope to those impacted by trauma, with the idea that trauma can be effectively managed, and that coping mechanisms serve a beneficial psychological and physiological purpose.
Christine provides a myriad of research and evidence-based tools, to equip the healthcare practitioner with the knowledge and practical skill to provide support, normalise and unpack the complex issue of trauma, and provide hope for patients.
This podcast is a must listen for anyone who works in the trauma space.
COVERED IN THIS EPISODE
(00:26) Welcoming Dr Christine Gibson
(01:56) What is trauma
(06:01) The adverse childhood events study
(14:02) The physiological impacts of trauma and polyvagal theory
(19:21) The ventral vagus system
(21:30) Survival adaptations
(24:20) The physiology of trauma
(31:01) Dr Gibson’s personal trauma story and how it shapes her practice
(37:18) Trauma management for practitioners, practical tools and strategies
(49:47) Post trauma growth
(52:28) Thanking Dr Gibson and final remarks
KEY TAKEAWAYS
- The three stages of healing:
1) Establishing safety: using somatic skills to calm and balance the nervous system
2) Trauma processing: re-imprinting amygdala associations to the traumatic event
3) Resourcing: Who are you now? How do you identify, separate from your trauma?
- Somatic skills and tools to utilise in clinical practice:
- The ventral vagal nervous system involves the vagus nerve, and has a direct role in the innervation of the face, and our tone of voice. It directly relates to our window of tolerance and sympathetic tone.
- By reducing sympathetic tone, we can bring ourselves out of fight or flight.
- The ACE study demonstrated the significant role of trauma in the manifestation of mental health or chronic disease, including diabetes, cancer, depression and substance abuse in adults.
- Sympathetic nervous system dominance can increase pain severity and one’s perception of pain.
Resources discussed and further reading
DR CHRISTINE GIBSON
| Dr Gibson’s website |
RESOURCES AND RESEARCH
| The Modern Trauma Toolkit |
| The Adverse Childhood Events Study |
| Lissa Rankin’s Ted talk |
| Eric Gentry |
| Russ Harris – acceptance commitment therapy |
TRANSCRIPT
Michelle: Welcome to fx Medicine, bringing you the latest in evidence-based, integrative, functional and complementary medicine. I'm Dr Michelle Woolhouse. fx Medicine acknowledges the Traditional Custodians of country throughout Australia where we live and work and the connections to land, sea, and community. We pay our respects to the elders, past and present, and extend this respect to all aboriginal and Torres Strait Islander people today.
For many decades, modern science believed that the damage to the brain was permanent. Since the discovery of neuroplasticity, the science of the transformational power of the brain has been nothing short of mind-blowing, mind-blowing in the sense that we now know the past traumas from childhood, natural disasters to dramatic negative events that have impacted a person's nervous systems can be healed.
Let me introduce you to my colleague and trauma-specialist physician, Dr Christy Gibson. Dr Christy is a TEDx speaker, author, and vocal advocate for equitable social medicine, and her latest book, The Modern Trauma Toolkit, is an accessible and practical read into the science of trauma and the evidence-based techniques that can help us all to heal and grow from past, challenging events. Welcome to the show, Dr Christy.
Christy: Oh, I'm so glad to be here, Michelle.
Michelle: Okay, so I wanted to start with a pretty obvious question, what is trauma and why has there been such a change in the way we look at past traumas in both mental and physical health?
Christy: So, honestly I had to take a long time before I could truly understand this myself. I had thought with the DSM, the big book of psychiatry, that trauma was very specific events as outlined in their definition of PTSD. And what I now understand is that trauma is not related to a specific event. Trauma is something that happens in the individual body. So, you can come out of a family and have three kids who grew up in the same environment, and one will have experienced complex trauma from that environment and the others might not.
So, I feel like what would help people to understand is that trauma is a response, and it will be different in every person, and you can have trauma related to relationships and trauma related to events or experiences. And different people will experience those things in different ways.
Michelle: Because there's a new concept that I wanted to, kind of, introduce to all of us, which is that trauma big T and trauma little t. Does that help you... Is that a good distinction in your opinion? And why is it so important?
Christy: Yeah, it's a really good question. I'm not 100% convinced that big T and little t trauma is always helpful for people because it is so subjective. And I think there's been a bit of a backlash around the word trauma saying that people are overusing it like, "Oh, my gosh, this coffee was terrible. It was so traumatic." Well, no, your coffee is fine.
So, I think it's the overuse of the word trauma is sometimes equated with the little t trauma, but I worry that we sometimes downplay the role of things like microaggressions like racism, fatphobia, transphobia. I mean, that's the core of your being when people are harming your identity. And I think we do tend to downplay the kinds of small, daily events that can really add up and cause a significant trauma response in lots of people.
So, unless a patient in front of me is saying to me, "Well, this was something quite mild, and I feel like it was a 2 out of 10 or a 3 out of 10..." We use these scores, and we call it subjective units of distress. So, some of my patients are really familiar, and they'll give me a number, but I'm really careful not to presume that something is major or minor until I'm told that that's how it's landing for them.
And then the amazing thing is, once you're actually processing trauma, you can bring a really big big T trauma like something that starts out as a 9 or a 10, and you can finish that session and have it down at a 2 or a 3. And that's what I did not understand as a physician was that complex trauma and trauma are not things that you're locked into forever and ever. There's many, many techniques, and skills, and tools, and treatments that can turn it into a small t.
Michelle: Yeah, and I think your book explains that so beautifully. You go through really the background of trauma, some of the, kind of, historical aspects to it, and really bring breadth to that. But also there's so much positivity in your book. You talk us through so many of the different skills and applications that really give the reader a huge amount of hope.
But I wanted to talk to you about explaining the adverse childhood events study that really, in my view as a fellow GP, really started off this whole new language around trauma and its impact on not only mental health, which we, kind of, probably in an observational sense, intuitively understood, but also how it impacts physical health as well. So, can you explain how the ACE study came about and what it showed?
Christy: I'm so glad you're asking this. The funny thing, Dr Michelle, that you do not know is I actually completed my doctorate. It's a doctorate of professional studies by public works a week ago, and my external examiner's asked me this exact question during my oral bypass.
Michelle: Yay.
Christy: So, it's so funny you're asking it right now. I'm ready for this question...
Michelle: Yay.
Christy: ...because what I said in my doctorate was this study should have changed everything we thought we knew about clinical medicine.
Michelle: Everything.
Christy: And it just surprises me on a daily basis that it didn't.
Michelle: Yes.
Christy: So, it's Vincent Felitti. He was an internal medicine physician in California, and he was working at a weight loss clinic. And what he noted was that so many of the people who would have a success story and they would lose a bunch of weight, they would gain it back invariably. And he accidentally elicited a history of childhood sexual abuse from one of the patients. He wasn't meaning to ask the question in the way that he did, but what he asked and what he uncovered was quite a shock to him.
And so he asked her a little bit more detail and, "Well, how much does this... This event that happened to you as a child, how does this play into what's going on with your weight?" and he got an earful. The weight felt protective. The weight was keeping her safe. It made her feel invisible. It was literally a protective layer, and she wasn't feeling like she was as sexual with the weight that she had. And of course there's a lot of fatphobia in our society that was playing into the social construct, but it mattered how she perceived it.
So, what he did is he asked Kaiser Permanente, or this big medical healthcare provider, if he could do a study. And they've managed to recruit 10,000 people...
Michelle: It's extraordinary.
Christy: ...within the KP network. And he selected very carefully certain possible adverse childhood experiences, so that is the word ACE, adverse childhood experiences, and he was not intending to cover all of the possible things that can happen to children. He just wanted to get a public health survey of how often big events happened. And so he was looking at childhood abuse, childhood neglect, and not getting their needs met. So, he spoke about poverty. He talked about specific events that might happen, so a parent that goes to jail. But, again, he didn't cover every single possible experience.
But what he did find knocked his socks off. So, the ACEs study proved that for the particular 10 things that he asked of this 10,000 population, they had an exponential increase in every single mental health or social health outcome that was measured, so things like diabetes, cancer to depression, substance use, to poverty, to having a child at a young age. Every single outcome that they measured had an exponential increase with every increase in your ACE score. And we've never seen anything like that in medicine before.
Michelle: It's extraordinary.
Christy: And it really should have meant that trauma-informed education infiltrated every single medical school and every single health practitioner.
Michelle: Across the... Yeah.
Christy: And that's why I'm so passionate about it.
Michelle: No, I mean, I agree with you. When I first came across the ACE survey and the results of it, it really I guess presented me with an understanding of what I had already intuitively witnessed. Particularly, I remember a patient who had had about three or four car accidents, and so she had terrible whiplash, and all of that kind of stuff. And when you looked at her adverse childhood events, they were extraordinary. And even going on to, sort of, see things like car accidents, which obviously is we see that as bad luck and often they weren't her fault. But just the world, kind of, ending up to being that way and things like back pain and immune deficiencies, etc., and how you deal with chronic pain comes into it as well. So, for me, it really did change the way that I viewed every single patient that walked in my door, and it really gave an underpinning of trauma-informed care across the breadth of practice.
Christy: Yeah, you absolutely nailed it. I think that understanding trauma responses as it relates to pain responses is so important, and so few of us really put all of that together physiologically. But of course it makes sense that, if your amygdalas are firing because they're anticipating further threat, that they're also going to be scanning the internal environment looking for signs of danger. So, putting it all together has really changed the way that I conceive of perception and the way that people are experiencing the world and experiencing their body.
Michelle: Mm, and also, I think the impact of it coming from childhood often means that it's very normalised for a person because they don't know any different. Consciously they don't know how a person would experience the world in any other way because they've been doing it for such a long time as opposed to something like a more classic PTSD where you may have had a serious car accident or something very instantaneous and very life-threatening as an adult is a different kind of I guess subjective experience for the person because of that childhood element.
Christy: And I do believe that the same pathways around the traumatic responses of fight, flight, and freeze can get locked in at any stage, but these foundational beliefs that we lay down in childhood like, do we have a secure attachment with a caregiver? Do we believe that the world is a safe place? Do we believe that we can trust people? Do we believe we are good? Because one of the things that really shocked me to understand is that it's safer for a kid to believe that there's something fundamentally wrong with them and they aren't good enough to explain abuse or neglect rather than to believe that their caregiver isn't capable. And it's safer for the kid to believe there's something wrong with them.
And it is really hard to shift a foundational belief that was laid down for self-preservation, even if it is so harmful in the greater scheme of things. So, I just find it so fascinating, and I love sharing with people... So, you mentioned my book, The Modern Trauma Toolkit, but it actually started on TikTok. Six months before I got the book deal, I joined TikTok and I started sharing these kinds of insights that I was having with this general audience and people just loved it. They really appreciate learning these kinds of things, and the things that I thought, wow, this is such a game-changer for healthcare and mental health, and I love having these conversations on social media, too.
Michelle: Yeah, that's awesome. I wanted to take you back to some of the different biological underpinnings because I think it's really important that people understand that there's actually a physiological impact from long-term trauma or experiences from childhood in so much as we can, kind of, describe the neurobiological impact.
So, Stephen Porges, who is a research scientist, came up with polyvagal theory and, again, a little bit like the ACE study back all those decades ago, has been a real game-changer in the semantics, and the understanding, and almost the simplicity of looking at the various, different response. I know you feel that there is some limitations to this theory, but can you explain to us what polyvagal theory is and how you interpret the findings from that?
Christy: I'm so glad you asked this. I do believe that, in the clinical world, there has been a backlash against polyvagal theory because it wasn't perfect. So, it's still being formed, and that's, kind of, what I like about Stephen. I just really appreciate that the more he learns and studies, the more the theory changes.
So, there was some evolutionary aspects that he had initially claimed that he's backtracked on. And then he was saying that the dorsal vagal system or the vagus nerve that wanders from the lower brain and travels through the chest and abdominal cavity, initially, he said that that was creating bradycardia or slowing the system down. And now it's looking more physiologically like that system is just tempering the sympathetic drive. So, he has changed the theory to evolve with the more that we've learned about physiology.
But in my mind, polyvagal theory is one of the most clinically relevant paradigms that really shifted not just my therapy practice but also just the way that I think of my interaction with people. So, I don't just do clinical work now, I actually run a training program called Safer Spaces Training where we do workplace-based training around psychological first aid and trauma-informed spaces. And people love learning this because anybody who works with the general public, certainly clinicians and caregivers, we're constantly running into fight, flight, and freeze and sometimes we feel it ourselves. And to understand concepts like polyvagal theory... And I can explain it to your listeners in a more clinical language, but I also love explaining this to laypeople to say, "This is how your body is showing up."
So, everybody's first instinct, this is all mammals, we have a fight or flight, which is a movement-based or sympathetic-based response to danger. And so we all first move into fight or flight, and we try to use our movement to get away from the problem. So, evolutionarily, we would have been running away from a predator or a natural disaster. And it doesn't always work for us to run away from or fight off our problems in modern times, so it just really locked us into...
Michelle: Running away from your boss.
Christy: ...a high sympathetic tone. Yeah, exactly. But it means we're tense, we're restless, we've got a racing mind, our muscles are more toned. The people I work with, with complex trauma, they look like they run marathons because their body is always getting them to be ready to outrun their problem. And I wish they could.
And so people think, "Oh, sympathetic, that means you're in this state of agitation and restlessness." Well, no, you use your sympathetic system when you're making dinner, when you're going for... a jog. You use your sympathetic body all the time, it's just when that body is in overwhelm, too much sympathetic tone is what creates that fight and flight response. So, this really ties well into Dan Siegel's window of tolerance, where if you can bring that sympathetic tone down to a level where you are coping and managing everything in front of you and it's not too much, then you've got sympathetic in the window of tolerance, and you're no longer in fight and flight.
When that system gets locked on for a really long time is when we tip into the dorsal vagal, which is you have energetically exhausted your sympathetic tone and then the existing trauma response that you have left is freeze and the whole system just shuts down. So, in the animal kingdom, this would be playing dead and hoping the predator goes away, playing possum or sticking your head in the sand and just really not attuning to what's around you.
So, in a patient, this would look like not getting out of bed, not getting off the couch or, from a clinician's perspective, not being compliant with the treatment plan. And I think it's really helped me be way more compassionate with patients to think, are you actually not doing this stuff or are you in freeze? And they're almost always in freeze.
Michelle: Yeah, and the ventral vagal, which is the other component of it, explain that to us because that's a really important aspect of how we do connect with people. And that can also give us some clues as well in the clinical classroom.
Christy: Absolutely. And this is why I think every human should be learning this stuff.
Michelle: Yes, I agree.
Christy: I really wanted to write The Modern Trauma Toolkit in an accessible way because I thought this is useful for teachers and it's useful for parents. And the ventral vagal system is the vagus nerve that is innervating the face, so it's cranial nerve X. So, when we've studied the different nerves that are working through the head and neck, it's one of the basic ones that we study.
And what Dr Porges hypothesised was that cranial nerve X was involved in the vagus nerve response that exists when you're in your window of tolerance, when you are feeling safe, and feeling connected, and feeling like you are co-regulating with others. So, self-regulating is how we individually bring our body back into that window, and co-regulating is when we're doing that with others.
And so what Stephen noticed was a large part of that ventral vagus system is related to our facial expression and our tone of voice. So, vocal prosody is really important or the singsong nature that's kind of up and down, almost maternal sounding, very soothing, very calming way that we can speak. And it's something that we would naturally do when we're doing therapy. We naturally do it with a baby or a puppy. But this is the way that humans show up when we feel safe. And so it's interesting because facial expression and tone of voice isn't something we think about. It's almost like a reflex, but it is how we show up when we feel safe.
Michelle: It's really beautiful to understand because I know later on in your book, you actually talk a lot about how we can use the ventral vagal to create safety as well.
Michelle: But I loved also, just at the start of the book, really laying down this foundation to understand some of... And this is inverted commas. And I know we're on a podcast but just imagine my little fingers, kind of, doing inverted commas here. But sometimes survival adaptations actually result in what are kind of nonsensical outcomes such as drug addiction, or self-harm, or risk-taking behaviours, for example. And you look at that from a biological perspective, and I loved one of your lines. You say, "We handle stress biologically." What do you mean by that? And what can we learn from some of these less sensical behavioural responses?
Christy: And I'm going to frame it a little bit differently. So, I totally understand what you're saying, and this is what we're taught in medicine and as practitioners, but I actually conceive of these behaviours as adaptive and not maladaptive. So, it makes sense to me, and I work in an addiction clinic as a trauma therapist. It makes sense to me that people use drugs because they are trying to achieve a different nervous system state. So, if their nervous system is locked into fight and flight and they find that uncomfortable or dysregulating, it makes sense that they're going to take a narcotic and numb or dissociate that really uncomfortable feeling that they've been having.
So, I always explain to people that their survival strategies make sense. And rather than saying that we need to change these, we need to say, "Well, are they working for you? And do we need to replace them with something different?" So, this is what I love about somatic skills is because we actually have so much more agency over our nervous system responses than we're led to believe. And a lot of this is just innate, natural human biological abilities and capacities. And we don't learn any of these skills. And this is one of the reasons why I wanted to put so many skills in The Modern Trauma Toolkit, things like tapping and havening and tremoring, is because until you have a better strategy to regulate your nervous system, you're going to use the things that you've learned. So, whether that's substance use, whether that's overwork, which is the socially acceptable way to regulate and dissociate.
So, we're really good at staying busy and staying distracted and maybe we doomscroll social media. So, there are lots of different ways that we regulate our nervous system, and there's so many more ways that are out there and people just don't learn those.
Michelle: Yeah, I know. You go through these in lots of almost descriptive but, kind of, storytelling ways, which I really liked because I think that these concepts are just so different to how we grew up and how we were educated through the medical education system. So, things like intrusive thoughts, and avoidance symptoms, and depressive symptoms and, kind of, go through in a story-like way of why something may occur. So, let's just take something like depressive symptoms. From your clinical skill and from your understanding of the physiology of trauma, what could, say, depressive symptoms represent?
Christy: Well, this is like a blanket statement without having a person in front of me and saying this is an individual thing. So, I want to be clear that this is more like a macro or a larger picture view of the kinds of things that I think we need to consider as clinicians. And that if a person is exhibiting depressive symptoms, one of the possibilities is that they have depression. And I think the chemical theory of depression as being a lack of serotonin, we're starting to question that. This is what I was taught in medical school, but we're starting to get research trials, and neuroimaging, and actual functional scans that are demonstrating that there might be some holes in that theory.
So, yes, there are some people who may benefit from the types of medical intervention that we were taught, and there are a subset of people who have depressive symptoms that make sense based on their painful past history. And so they might have a negative worldview and believe that things are not safe and have this, kind of, locked in sense of hopelessness and powerlessness because that's the way that the world has gone for them so far. They've had experiences of powerlessness. They've had very many reasons to believe that good things don't happen to them and, you know, the kinds of symptoms we might be screened for like anhedonia, this is the way that we don't look forward to things that we used to enjoy.
Well, it's pretty hard to convince a person even using traditional interventions like CBT, cognitive behavioural therapy, well, you just have to think differently if their life experience has not taught them those lessons. So, to try to offer up hope or a sense of agency is pretty hard to do if that person's foundational belief is tied up even in a preverbal way.
I think a lot of people have these subconscious foundational beliefs that aren't even necessarily accessible to them, and it's why I really love subconscious work and somatic work because sometimes people don't even have the language for those beliefs and they're just locked in. And it does not mean that they're not accessible, it doesn't mean that they can't be shifted, but we just have to be way more creative with how to get to them.
Michelle: Yeah, and I think also just the understanding of what is the physiological response from early trauma and for it to be a state of curiosity to, kind of, find out what is there rather than there's something defective with you and there's something that is inherently wrong or it's locked in and give people that sense of curiosity and exploration rather than, "Okay, let's find the flaws." Would you agree with that in terms of the framing of speaking to people about this kind of way of looking at how a body can be chronically fatigued or chronically impacted?
Christy: Absolutely. You totally nailed it there. I think it's probably the word they use the most in my practice is to be examining their thought patterns and our behaviour patterns with the lens of curiosity and compassion. And I think a lot of therapy has been predicated on there's something wrong with us. It's pathological. It's a disease. It's a disorder and an illness. What if it's not? What if it actually makes sense? What if it's actually a totally normal physiologic and practical response that is trying to solve a problem. It's trying to protect us.
And I think it's such a more fruitful way of looking at it, and, I mean, certainly clinical outcomes are vastly different with this one than it used to be before I had all these skills but also just a greater understanding that, if we look at it through the lens of compassion and say, "Why does it make sense that we've developed these survival strategies? And why does this foundational belief make sense based on your past history or even your ancestral history?" This is something we often don't talk about.
But I have worked in First Nations Health in both my family practice and in the places where I work. And I do work at the refugee clinic for the last five years now. So, one of the things that I've learned through experiencing different cultures, especially places where there's been colonial or neoliberal risk and harm that have been creating communities placed at risk, it makes sense that they have trauma in their bones, because there's been this epigenetic lack of safety that's been passed down. And so even though you might not have the words for it, if you've been born into a culture or a racialised community or into indigenous families, there's been trauma that you've inherited even before you were born. And that's not even talking about the trauma that happens to all of us during childbirth. There are these traumas that don't always have a language for, but we just carry them.
Michelle: Yeah. And it's such a good way to, kind of, recognise that with some people because it also connects us to our ancestors in many ways and makes sense that there is this, kind of, non-verbal transfer of information. I wanted to also talk to you about your personal trauma. It's a story that you talk about in the book and an event that happened in Nepal, which I read again last night actually, which sounded like an incredibly harrowing experience. How has that experience shaped the way you see trauma? Were you already interested in that trauma management or was that the spark that led you down this journey?
Christy: I think it was for a couple of reasons, and I'm hoping your listeners will give me some grace with my answer, because clinically, yes, I did experience some symptoms of post-traumatic stress, but I didn't have full PTSD but I definitely had some PTS. So, because I was caught in the earthquakes in 2015 by accident, I run a small nonprofit, Global Familymed Foundation, and we were doing some academic consulting in Patan, which is in the Kathmandu Valley. And Patan is a pretty old city. There's a lot of old buildings. There's a beautiful old town with lots of gorgeous shrines, many of them dissolved into dust during that earthquake. It was a very loud and shattering event. Many of the community were rendered homeless and lost family members, and the hospital where I was affiliated was just overrun with casualties and fortunately had an amazing triage system in place and did everything they could, even though there were cracks in the hospital foundation.
So, my TED Talk was very much about the lesson learned of hubris and feeling like, as a Western-trained doctor with all these letters behind my name, that I was going to be useful in this kind of event and I really wasn't. So, I was evacuated and then I experienced my own questioning of like, "Who am I in the world?" but also, "What's going on in my body?" because I evacuated to Singapore and I was in a very tall hotel. And every time that somebody would walk down the hallway or the garage door would open, I had this newfound sensitivity to the shaking of a building and it was nowhere near obviously the intensity of the earthquakes that I've experienced, but even just a small little tremor was really causing a lot of distress in my physical body.
So, I got curious about it, and I started to research trauma responses at that time, but it wasn't until I started to do the research that I recognised, because I had already created a residency program in health equity and I've always worked in equity-deserving communities, they also tend to have higher rates of traumatic experience, especially folks who are using substances, who are unhoused, and then I put together every single person in my family practice were actually manifesting trauma responses and that the disease stages that I was trying to treat as a family doctor was actually pretty far downstream and I could move further upstream by managing trauma. And that's what changed everything for me.
Michelle: Yeah, that's amazing. I wanted to... Sometimes when you read a book and then a line just pops out at you, and the last couple of days, I read this one line that you wrote and you said, "Always move at the speed of trust." Can you tell us what you mean by that? Because I think I know what you mean by that, but I'd love to hear it from your words because I really think that that is such a critical message that we all need to heed.
Christy: I feel like one of the things we don't understand as clinicians sometimes is that the way that a person's nervous system is accessible to them allows so much self-healing. So, one of the first teachers I had was Dr Lissa Rankin, and she focused her TED Talk on the placebo effect. Well, I think she's done four TED Talks now, but the one that my friend sent me, when I was evacuated in Nepal, was Lissa's TED Talk about placebo.
And it really made me curious. Well, if the placebo effect works 30% to 40% of the time, how do we harness that? And so much of it is about being in your ventral vagal state, accessing your parasympathetic system so that the body can naturally self-heal, because we were designed to do that. We were designed with an amazing immune system that prevents autoimmune disease, and fights off infections, and deals with metaplasia before it becomes cancer. But if we're stuck in sympathetic tone all day, we don't actually allow that part of our self-healing to work, to function. So, so much of my curiosity was, how do I just give people experiences of parasympathetic state?
And moving at the speed of trust is just co-regulating enough to know when they're there. What does it look like for the person in front of you to be in ventral vagal? And moving at the speed of trust means that you're allowing them to pace it because people who've been through traumatic experiences don't often trust authority figures. And some of their trauma might be medical. I mean, traditional Western medicine is a leading cause of deaf and disability, and we certainly impart a lot of trauma. Even just having a surgery or being through anesthesia can be traumatic. So, I don't think we often recognise the role that we play as practitioners and the opportunities for that, like the opportunities for co-regulation and recognising in our own bodies and knowing what it's like to have a person in ventral vagal in the room with you.
Michelle: I think that's so beautiful, and it's such a good reminder because as Western medicine becomes more and more technical, some of the technological advances of modern medicine are quite phenomenal. It's almost been dehumanised in the process of that in many regards, particularly for some very sensitive patients. And my observation is that trauma management is an extremely sensitive opportunity. What kind of guardrails do you have for someone moving into this space or for practitioners? And are there some clues for lesser experienced practitioners to know when to appropriately refer?
Christy: Mm, so I think you also closed the loop on another important part of this question, which is the relationship being part of the healing modality. So, people can reparent these foundational beliefs and, as adults who have more conscious awareness and more self-actualisation, we can parent the parts of ourselves, so that's the language of Internal Family Systems that have these foundational beliefs and we can shift that.
And part of the therapeutic relationship is to create that window for reparenting and just modelling that. So, it's not that we are the parent of the client or the patient, but we're modelling compassion and self-compassion. And we're modeling the state that it needs to be, that the work is done in. So, unconditional positive regard.
And this gets to the work of Eric Gentry at the Arizona Trauma Institute. He's one of my favorite teachers that I've studied from. And I've studied with Gabor Maté, Bessel van der Kolk, all of the big names in trauma, I've tried to learn from a variety. One of the things I love about Eric is he's really practical. He'll say it doesn't really matter what trauma modality you study. You can learn the alphabet soup as I have, or you can learn one of any number of therapeutic modalities. The key is the relationship. It's all about attunement and how you're showing up in that consultation.
So, I will tell you that there are three stages of trauma healing according to Judith Herman's book, Trauma and Recovery. The first stage is establishing safety, and I call that noticing. So, what does interoception look like? How do you learn your own nervous system? How do you know when you're in ventral or dorsal vagal? And when you're in sympathetic state, how do you know when you're in your window of tolerance? And this is the first thing that I'll teach people to learn and then give them really practical tools to shift. So, establishing safety is just knowing that your nervous system state is something you have more agency over than you knew and giving them really practical exposure to that.
For this stage, I'll use a lot of somatic skills. So, I love Pat Ogden's Sensorimotor Psychotherapy. I'm a huge fan of havening which is creating delta and theta waves which calm the whole body down. So, in The Modern Trauma Toolkit, I have a whole chapter on havening, on tapping which is EFT or emotional freedom techniques, it's self-acupressure, and then I also have, on the QR code, some videos to teach people how to do this. You don't have to get certified to be able to have this as part of your daily routine. And in that daily routine, you're giving yourself a ventral vagal exposure and just returning your nervous system to a greater balance. And that's how you establish safety.
Stage 2 is trauma processing. So, if you're really wanting to become a practitioner who can cure PTSD, which I absolutely believe is possible for most people, then you're going to be learning a tool that is re-imprinting the amygdala associations to the event. So, what makes a memory traumatic as opposed to a neutral memory is that the amygdalas are going to store the associations. They're going to store the physical sensations, the emotions, and the context of the event in order to trigger you so that you avoid it in the future.
Michelle: Smart.
Christy: Triggers are adaptive, and so what we want to do is to change those associations. And I don't get into this in the book a lot because the book is really meant for the general public, for practitioners to learn how to establish safety, which is Phase 1. But two things that I love are accelerated resolution therapy. You can learn how to do this in three days, and it is the biggest gamechanger. It is phenomenal. People will leave the room when I do ART with them, and they'll say words like magic or giddy or surreal. And they'll, in that moment, know that they have rewired their brain. You can see it at work. It is the most amazing experience. Every time I get to do the therapy, it's intense, but I just feel so privileged to be able to do this for people because it is magical. I've since learned an advanced version of tapping called matrix reimprinting that can also be phenomenal to rewire foundational beliefs.
So, there's lots of different ways that we can approach it. I mean, we're taught the gold standards like prolonged exposure will do it, but there's nicer ways to do it. Prolonged exposure can take a long time, and it can be really uncomfortable for people to go through it. Whereas, Accelerated Resolution Therapy is pleasant. Oh, it's amazing. It's a more modern version of EMDR, or Eye Movement Desensitisation.
Michelle: Desensitisation, yeah.
Christy: And I love ART. I'm just trying to spread the word about ART. I just want every family doctor to have this tool in their toolkit.
Michelle: Yeah, that's fantastic. And what's the third stage of healing that you mentioned?
Christy: The third stage is resourcing, and it's basically, who are you now? If you are a human in the world who's not driven by their trauma responses, who do you want to be? And so, in that stage, I love... Russ Harris is an Australian practitioner who's done a lot of...
Michelle: Yeah, I know Russ.
Christy: ...acceptance commitment therapy, and I love his training programs, his videos. He's just awesome.
Michelle: Yeah, it's beautiful.
Christy: Another therapy I love at this stage is something called NARM, or the NeuroAffective Relational Model. It's out of California and Germany, actually. I think Lauren Teller's now moved to Europe. But Brad Kammer's the main trainer. I just did Level 2 of NARM last year, and it has blown my mind. A lot of my lens around survival strategies being adaptive comes from NARM, and it is a beautiful way of doing therapy.
So, I mean, I've thrown out the alphabet soup. I've mentioned Internal Family Systems, Accelerated Resolution. So, this is IFS, and ART, and ACT, and there's CBT. There's CBT, there's PE. There is the alphabet soup of therapies, and I just recommend every practitioner just get one skill for Stage 1, one for Phase 2, and one for Phase 3, and do that well.
So, I don't think everyone needs to learn the alphabet soup the way I did. I did it more because I love knowledge translation and getting the word out to practitioners and the general public. But if you just had one tool for each of those phases... And that's why I wrote a lot of those tools in my book is because, even though The Modern Trauma Toolkit was written for the layperson, every single practitioner is going to learn something in there, and that's why I studied as long as I did is because I was like, "Let's get the word out to the people."
I did not know that the body was capable of tremoring the way that a dog or a horse would shake off sympathetic tone until I started studying TRE or the Tension Releasing Exercises. And so I had to put it in the book and say, "Hey, did you know that you can actually shake off stress? I didn't and it's amazing."
Michelle: It's so cool how you've done it. And also just your book is so inclusive, but it also encompasses so many of these different ways of understanding because it really is a whole new landscape that can be so transformative for practitioners in this space, whether they do want to go into trauma management, but also for anyone holding space for a person, that position of safety and attunement with that person.
And I love Lissa Rankin's work around placebo as well, because a practitioner has the capacity to create such a state of healing within the four walls in which we work or maybe you might be an outside therapist. But there is just so much power in the human attunement aspect of things. And so then once that has occurred, then all of these magical tools can come into place. And I loved the kind of, "Who are you now?" because that's a really important aspect of healing because sometimes with trauma particularly, complex or long-term or it's stemming from childhood events, we often overidentify with our trauma.
And so really having a construct of saying, "Okay, well, who am I now? And what is that potentiality?" And also the practice that occurs from, "Now, I don't identify with my trauma, how do I relate? And what do I want to do? And how do I use my time?" There's so much potential and excitement through that whole experience, so I really love that resourcing part of it as well.
Christy: And I think it's important to recognise that sometimes people are too connected to their trauma responses. So, I'll see this a lot in refugees because they just haven't had a sense of safety for so long and a lot of the event traumas they've had are very extreme. So, I dealt with Yezidi communities for a while who'd been slaves of ISIS for two or three years. It was really horrific what they've been through, but I also feel that sometimes people underidentify with trauma. So, the trauma of medical training. My God, we deprive our body from...
Michelle: Oh, my God.
Christy: ...its human resources. We don't feed, or sleep, or go to the bathroom. We don't do the human things. We disconnect from the pain of what we're seeing in front of us. And I did hospital practice for 16 years, and you would tell people really bad news in one room, have a person who was palliative in the next room, dealing with complex multi-organ failure in the next room and just go from room to room without processing yourself the vicarious trauma of the suffering and the pain that you manage.
And this is because I now do medically assisted death, it's something I have to really consciously process for myself is because I'm constantly hearing stories of irredeemable suffering. But anybody who's a practitioner is hearing the stories and gaining this vicarious trauma, and we're often not good at recognising it in ourselves because we think, "Well, I'm resilient. I can cope with it." And it might add up and show up in very surprising ways.
The other thing that I think we underidentify is with the collective trauma. I mean, Australia has been hit really hard by the climate that's changing, and the whole world has been hit by this ongoing global pandemic. And I don't think that we recognise just how significantly these events are affecting the individual as well as the ecosystem.
Michelle: Yeah, absolutely. And it's really well said in the sense of we don't want to underdo and we don't want to overdo it. And this leads me to my last, kind of, question, because you so beautifully put in The Modern Trauma Toolkit, but actually your byline is nurture your post-traumatic growth with personalised solutions. So, what to you is post-trauma growth and what does that look like? And what would you love to see from a collective understanding in terms of the work that you and the education that you've been teaching?
Christy: Oh, I love the way you phrased that, Michelle. That was so rich. I think the impact on an individual level as practitioners is really significant. If we do have a greater understanding of trauma, the work we can do one-on-one is more upstream and more meaningful. But it's that collective that I really am hopeful for. So, this is why I started Safer Spaces Training, and why I love to give keynotes and just talk to the public about the possibilities, because we are not making significant dents in our polarisation in our response to climate and I think it is actually trauma.
If I think about why global leaders in industry and government and the people who can change policy are not doing enough, I think it's dissociation. I think they have completely cut off their day-to-day behaviours from the impact on, as Indigenous communities would say, the seven generations in front of us or even the very real impact that's happening to animals and living beings and the fact that generations ahead of us like Gen Z, they're saying, "I don't know that I want kids. Why would I bring kids into this world? It's pretty messed up the thing we're inheriting." These are your kids, people, key decision-makers.
For you to listen to Gen Z say things like this and to still maintain this dissociation, numbness, disconnection from the real pain that's being caused, it's trauma. And I feel very strongly that if we were to have more capacity to really examine the trauma that we're facing and learn different skills instead of fight and flight, which is causing war and inequity or freeze, which is just this, "It's not my problem. Someone else will deal with it." That would be what would wake up the collective.
Michelle: Oh, wow, Dr Christy, what a treat to have you here with us and help us explore all of these complex issues from how to identify it, what sometimes these survival adaptations could mean, exploring complex trauma and also giving us, I guess, a sense of personal integrity for our attunement and our role as practitioners as we explore all these complex issues but also most importantly hope in the sense of this post-traumatic growth.
Personally, I found it deeply moving. Your sensitivity and your wisdom is truly a gift and it is on every single page of your beautiful, beautiful book, so thank you so much for sharing with us all of your clinical expertise.
Christy: That was not just me, Dr Michelle. That was my beta readers. I had sensitivity readers that were mostly racialised, one was trans. And I just said to them, "We write this book over and over again together until it feels safe for everybody." And if I was going to embody the things that get people to post-traumatic growth, it was going to be nurturing and gentleness and compassion. And so really I'm so grateful that you recognised the effort that we put into everything that happened.
Michelle: Yes, it really is distinctive, and it's beautiful.
Christy: It was. It's like every single word was chosen with gentleness in mind.
Michelle: Mm, gorgeous. Thank you, thank you, thank you.
Christy: Well, thanks for your really wise and insightful questions. It was such as a delicious conversation.
Michelle: I could've gone on forever. I had so many more questions, so maybe we could do Part 2 sometime.
Christy: I am more than happy to. This was wonderful. I really enjoyed it.
Michelle: That's great. Thank you, everyone, for listening today. Don't forget that you can find all the show notes, transcripts, and other resources mentioned from today's episode on the fx Medicine website. I'm Dr Michelle Woolhouse and thanks for joining us. We'll see you next time.
Emma: This podcast is intended as healthcare practitioner education only. And it is not a substitute for medical advice, diagnosis, or treatment.
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