Reprinted from the Illinois Society for Clinical Social Work Newsletter, Summer 2008, pp.12-15.
Preface to the Article (excerpt from ISCSW Newsletter)
In November 2006, Jeff Levy presented a Sunday Morning Seminar for the Illinois Society of Clinical Social Work (ISCSW) on “Clinical Practice with LGBT Survivors of Childhood Trauma.” Following the presentation, Jeff was asked to write an article for the Newsletter describing the content of his presentation. The article Jeff submitted discussed not only the content of the workshop, but also included his experience of the process of the workshop. ISCSW declined to print his article out of concern that it would offend those who attended the workshop, as well as the general ISCSW membership. Jeff and ISCSW representatives had numerous conversations, and the decision not to print his article was upheld. After having been a member of ISCSW for many years, Jeff did not renew his membership.
In December 2007, ISCSW reached out to Jeff once again, realizing that there had been no closure. This discussion centered on issues of safety versus comfort, and the extent to which what some perceive as safe may not feel safe for others. All agreed that Jeff’s article raised uncomfortable issues and challenged ISCSW around its own cultural competence in work with LGBT individuals and their families. After much discussion, Jeff clarified points in his original article, and ISCSW would now like to print it.
The current ISCSW President, Ruth Sterlin, and the rest of the Board would like to extend an apology to Jeff for hot having followed up with acknowledgements about Jeff’s presentation, which he did as a volunteer, in following newsletters and for hot having sent him a letter of thanks. We truly hope that all of our time earnestly spent in trying to understand each other can serve as a platform to launch future open discussions and better understanding of our work with diverse populations. Jeff Levy’s article appears below.
Trauma, The Body, and LGBT Survivors
Much of my clinical work has focused on individuals dealing with histories of complex trauma. As a social worker who is also gay, I have become particularly interested in the intersection of stigmatized identities: how trauma begets stigma begets trauma. A great deal of my clinical work in the past ten years has focused on lesbian, gay, bisexual and transgender (LGBT) survivors of childhood trauma. And, as I become more trauma informed, I have begun to understand the neurophysiological impact of trauma—the necessity of non-talk/non-verbal therapeutic interventions. Most recently, I presented a workshop on this topic at the ISCSW Sunday Morning Seminar Series. Unexpectedly, this presentation provided an opportunity to be personally reminded of the importance of my work. A brief description of one of my clients will help clarify.
Steve, a gay man in his late thirties, has been talking about his frustration with the circumstances of his current relationship. He’s in love with a gay attorney who is from Venezuela and in the United States on a student visa. They have been together for over two years and hope to plan a life together. Unless something miraculous happens, however, his partner will be forced to return to Venezuela in June. It’s uncertain whether he will ever be able to return to this country. Steve is devastated by this potential loss. Moreover, he feels powerlessness, shame, invisibility, and a sense of physical immobilization. He has repeated to me many times: “If I were heterosexual and my partner was a woman, we could be married and remain together in this country.” I think to myself: “Yes, that’s absolutely true.”
On the surface, one might wonder how this vignette relates to working with LGBT survivors of childhood trauma. And it might also be unclear how this even remotely touches upon the impact of trauma on the body. This story, however, is a powerful example of how complex and overlapping traumas impact cognition, affect, and somatosensory responses.
My client is also a survivor of multiple episodes of childhood trauma. In fact, he was initially referred to me so that he might participate in a group I was facilitating for gay male survivors of childhood sexual abuse. He completed this 35-week group and chose to continue to see me for individual therapy. Steve had shared that he knew he was “different” from the time he was a little boy, and that somehow this “difference” was bad/shameful/wrong and had to be kept a secret from all those around him. When the abuse occurred between the ages of eight and thirteen, he realized that this experience, too, was bad/shameful/wrong and could not be shared with anyone. Both of these traumas were to be kept a secret.
In his current life, Steve knows that the “difference” he experienced as a little boy was around his attraction to other boys: that he was gay. He has struggled with wondering what his life would be like if he hadn’t been abused, if he was abused because he was gay, or if somehow the abuse “caused” his sexual orientation to solidify as same-gender attraction. He reports adolescence filled with running away from home, substance abuse, academic failures, and sexual acting out. Through therapy, he has begun to understand how these overlapping stigmatizing experiences influenced his vulnerability and that he attempted to survive in any way possible.
Steve’s current situation with his boyfriend has triggered an array of thoughts, feelings, sensations, and somatic reactions that he has not felt since the childhood sexual abuse. He wonders why these are arising so “suddenly” at this point in his life. Upon closer examination, there is no mystery why Steve is once again struggling.
The powerlessness Steve is currently feeling in his life is magnified by past life experiences; his powerlessness as a little boy struggling with being different magnifies his powerlessness around the sexual abuse he experienced (and vice versa). While Steve is employed by an international organization with offices around the world, he feels he cannot garner support for his relationship, ask about immigration resources, and seek information because he has not disclosed his sexual orientation at work and fears discrimination, shame, stigma, and ostracism. He feels he must maintain his secrets which, he says, are “smothering him.” He can’t sleep, experiences physical urges to run away, can’t focus, and says that he often feels “frozen.” In short, Steve is in a constant physiological state of perceived threat and he vacillates between hyper and hypo arousal-both of which may be dissociative. He slides along the flight-fight-freeze-collapse neurophysiological continuum of responses to trauma and, more frustratingly, he cognitively knows this is happening but cannot stop his responses.
Bruce Perry, M.D., Bessel van der Kolk, M.D., Pat Ogden, Ph.D. and other pioneers in the study of the brain’s response to trauma would find Steve’s responses to his current circumstances quite predictable. The brain, a use-dependent structure, grows and develops in response to the extent to which it (or parts of it) is used. Steve’s early and prolonged exposure to trauma, both in the form of the stigma/shame/secrecy of being gay and the stigma/shame/secrecy of the sexual abuse, has created a web of neural “circuitry” that invites responses, when triggered, that include increased heart rate, muscle contraction, increased respiration, visual acuity, and an urge to flee followed by an urge to fight. When overwhelmed further, Steve’s neural circuitry moves first to a place of immobilization (freezing) and finally to a place of collapse (powerlessness). There are parts of Steve’s brain-his amygdala in particular-that activates emotional responses of shame, fear, and rage. This array of somatosensory responses all occur with absolutely no cognitive “control” on Steve’s part. They are automatic and despite Steve’s intellectual understanding of his circumstances, he says he cannot change how he feels or what’s happening in his body.
What has become more and more clear in the treatment of complex trauma is the need for creative, expressive, and body-centered interventions to address trauma-related responses that are not mediated by the brain’s logic center (the neocortex). The same trauma pioneers mentioned above advocate for non-talk based interventions to assist people in metabolizing trauma that has been locked away in repetitive neural loops. While talk potentiates insight, insight is not “connected” to the parts of the brain that are continually reactivated by traumatic triggers-a fact supported through PET scan studies. Through intervention that focuses on somatosensory activation (art, music, movement, etc), stored traumatic responses can be physiologically metabolized and clients may begin to find more productive ways to manage what would otherwise have been re-traumatizing circumstances.
This theory is not, of course, only relevant for LGBT individuals impacted by trauma. It becomes more powerful, however, when we apply this theory to individuals who are managing multiple traumas and/or multiple stigmatized identities. When trauma is superimposed on an already traumatized/stigmatized identity, the imperative for neurophysiological “re-wiring” is magnified. Trauma exacerbates trauma and requires an informed, sensitive, and empathic understanding of the interrelated nature of overlapping/interrelated traumatizing experiences.
Of additional merit is a brief discussion of my experience presenting this information at an ISCSW Sunday Morning Seminar Series. While explaining the interrelated traumatic experience of being gay and also being a survivor of other childhood traumas, a small group of members from the audience asked questions or made comments which triggered many of my own feelings stigma, invisibility and shame that are inherently traumatic to LGBT individuals. These comments and questions fell into three main categories.
First, feelings of invisibility: Examples included: “What is LGBT?” :What is transgender, anyway?” Many might believe that the that the initials that describe this population aren’t as important as understanding the actual words or the identity of being “lesbian, gay, bisexual, or transgender.” However, the language we use to understand the identity of our clients very much reflects the extent to which we can validate our clients’ current experience. If, as clinicians, we fail to understand or be aware of the way a group of people/segment of a group of people uses language to understand themselves, we may be, on some level, maintaining their invisibility.
Second, some of the questions felt dismissive of the impact of homophobia, heterosexism, and disdain for gender non-conforming behaviors. Examples of such questions/statements included: “What’s the big deal with girls playing softball? I don’t see how people have problems with this” and “Other people experience the same things-the same kinds of traumas or responses to traumas” (e.g. denying that there is something that must be understood as unique about the trauma of being LGBT).
The third group of questions appeared/seemed/felt more pathologizing in nature. I shared clips from a poignant film about a family’s struggle with the stigma/shame associated with their young son’s gender non-conforming behavior and the extreme physical abuse he endured by peers. The premise behind sharing the film was to demonstrate that trauma associated with being LGBT is primarily the result of the responses of others; that homophobia, heterosexism, and disdain for gender non-conforming behaviors are pathogenic for LGBT individuals. Rather than empathizing with this family’s struggle, and the painfully traumatic experiences of this little boy, these comments seemed to pathologize the relationship between the little boy and his mother, implying that the “real” problem with this boy was not society’s response to his gender non-conforming behavior. I felt the comments implied that the problem was about his relationship with his mother. This type of comment decontextualizes LGBT trauma as a larger social issue and maintains the view that gay and lesbian people have problems because of enmeshed relationships with their mothers and/or distant fathers; a theory long ago dismissed. A final comment from the audience recommended that families struggling with a gay/lesbian child and/or a gay/lesbian individual struggling with issues of sexual orientation might benefit by being referred to groups espousing reparative therapy (i.e. practitioners focusing on “curing” gay and lesbian individuals of the pathology of their sexual orientation). Not only has this approach to LGBT individuals proven ineffective, it is also acknowledged as unethical by almost all professional mental health associations and organizations.
I noticed my response to these comments. My heart raced. My breathing quickened. My muscles twitched. And I had an incredible urge to run from the room. Despite my desire to logically address questions and comments, I was overcome with old and familiar feelings of somehow being bad/wrong/shameful. I was quickly moving along the flight-fight-freeze-collapse continuum. I breathed deeply. I slowed myself down. I looked into the eyes of others in the room with whom I felt a connection, and I moved on. Without addressing what was happening in my body, however, I would have been stuck, paralyzed, overwhelmed, and powerless-much like my current client, Steve. And with Steve, I might intervene as I did with myself. I might ask him to become more aware of what is happening in his body. I might invite him to attend to the way his hands are moving and his foot is shaking. I might ask him to exaggerate the movements in his foot, to slow down his breathing, to change his position on the sofa. By offering Steve an opportunity to be safely present to his body’s responses, I might also be offering him an opportunity to process stored emotional and somatosensory reactions and, ultimately, to create new and more productive neurophysiological patterns.
My clinical work with trauma has evolved greatly over the past ten years. I have become further aware of the limits of talk and continue to be surprised by the power of movement, art, music, and other creative/expressive therapies. Furthermore, I have become acutely more aware of my own somatic reactions in a variety of contexts. While the responses to my workshop were overwhelmingly positive, the comments of some resonated deeply with much older somatic and affective responses to the stigma, isolation, invisibility, and shame associated with being gay in this culture. I share this experience to underscore the need to understand the impact of overlapping stigmatizing identities. I also share in order to invite all of us to understand how our own lack of information, intellectualized responses, and adherence to one way of understanding trauma might maintain the very traumatic responses we are attempting to address and, therefore, interfere with our clients ability to heal.