The Grief That Dare Not Speak It’s Name*

*Title borrowed from a series of articles by Sandra L. Bloom, M.D., published in the Psychotherapy Review in September, October, and December of 2000. I highly recommend the series.

#MentalHealthAwarenessMonth #RelationalTraumaReaction #RTR #ComplexTrauma #cPTSD #Depression #Retraumatized #IFS #InternalFamilySystemsTherapy #CBT #REBT

Prologue

I wrote and updated this piece to raise awareness of a mental health condition that I believe to be too common, relational trauma reaction (RTR). RTR is more commonly referred to as complex post-traumatic stress disorder (cPTSD).

cPTSD is an accepted diagnosis under the World Health Organization's (WHO's) International Classification of Diseases 11th Revision (ICD-11). The symptoms of RTR/cPTSD are summarized in this download from the Out of the Storm Online Community. However, the American Psychiatric Association (APA) declined to include cPTSD in its Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5®).

Matthew Friedman, executive director of the National Center for PTSD and chair of the relevant DSM subcommittee wrote [to the task force that had proposed the inclusion of cPTSD] 'The consensus was that no new diagnosis was required to fill a "missing diagnostic niche." […] The notion that early childhood adverse experiences lead to substantial developmental disruptions is more clinical intuition than a research-based fact. This statement is commonly made but cannot be backed up by prospective studies.' (The Body Keeps the Score, van der Kolk, Bessel A., 2014)

This was despite the submission of a significant number of prospective studies backing up the existence and prevalence of cPTSD to the APA along with the proposal.

Unfortunately, based on my experience, it appears that RTR/cPTSD is rarely recognized, let alone properly diagnosed. Many in the mental health establishment appear to uncritically accept the American Psychiatric Association's position that there is no evidence that adverse childhood experiences, including abject neglect, extended emotional abuse, or even repeated sexual abuse, cause psychological problems for adult survivors.

Furthermore, it appears to be difficult, if not impossible, to obtain effective treatment for RTR outside of urban areas because of the mental health establishment's flawed infatuation with Cognitive Behavioral Therapy (CBT). If you wish to understand why I believe that CBT is not the panacea that it is widely promoted to be, please read my PSYC 101 Paper, Implications of Recent Research in Social Psychology and Neuroscience for a Comprehensive Theory of Emotion, or read the book A Major Critique of REBT: Revealing the many errors in the foundations of Rational Emotive Behaviour Therapy, by Dr. Jim Byrnes.

Warning:

Below is a cautionary tale. It is only my own personal experience and my own personal opinion, as a layman, developed over the course of that experience.

If my mental health falls into the category of TMI for you, then please stop reading here.

Exposure to RTR/cPTSD

I am a survivor of relational trauma that continued over a period of three decades. Relational trauma is still more commonly referred to as complex trauma. I have a history of significant episodes of depression that extends back to at least my sophomore year of high school, probably to my seventh-grade year. I have a constellation of symptoms that are most often labeled as complex PTSD (cPTSD), but are now described more appropriately by some as relational trauma reaction (RTR).

My mother (may she rest in peace) had a life-long mental illness that went effectively untreated. My trauma resulted from the acute and chronic emotional abuse that she inflicted on all those close to her due to her illness. I was first traumatized sometime in my early childhood and then repeatedly traumatized until my mother disowned me in early 1988 when I was thirty-one (31). She rejected me because I tried to establish boundaries in our relationship to protect my wife and my children from her illness. We never spoke again and we were in the same room only once during the final 26 years of her 81-year life. That was at my father's memorial service in 2006.

I experienced emotional abuse at my mother's hands throughout my relationship with her. These episodes came both very early & often. While I don't remember the early stuff, I do recall witnessing what I now recognize as emotional abuse of my sisters and my father by my mother. At our first Thanksgiving dinner with my family as a couple, my wife (then-girlfriend, soon-to-be fiancé) remembers my mother chasing my then 17-year-old sister around the house with a spatula, trying to beat her for showing up late for dinner. I have searched my memory and am unable to recall anything of the incident, but I have no doubt that it happened. My failure to recall comes not from the fact that it was absolutely typical, but because it undoubtedly evoked an emotional flashback.

I do clearly recall experiencing several emotional flashbacks that left me absolutely frozen and in a state of fear of my own mother which bordered on abject terror. I now also recognize several other flavors of emotional flashbacks which, while less extreme, are much more common and long-lasting.

Treatment Summary

I have now seen four different therapists and three psychiatrists for treatment. I do not believe that the first three therapists were competent to treat RTR at the time that they treated me, despite their diplomas, their licenses, their other credentials, and their clinical experience. Only my fourth (and very likely final) therapist demonstrated a useful understanding of relational trauma. Nonetheless, despite 15 months of therapy with him, I still struggle with the symptoms of RTR every day.

Therapist One—Kaiser Permanente LMFT

I saw my first therapist, a Kaiser Permanente LMFT, a total of four times in 2008 for libido issues which he apparently diagnosed as a symptom of depression. I was 51 at that time. He assigned the reading of the first four chapters of Dr. David Burns' Feeling Good Handbook and turned me loose. I read it, and having learned a little bit of CBT, I generated a spreadsheet implementation of the Anxiety Inventory & Depression Checklist and a word processing implementation of the Mood Log from Burns' book. I used those a handful of times over the next several weeks and the symptoms that led me to therapy abated for a while. This extremely brief therapeutic interlude didn't help me to understand my condition, nor was it an authentic attempt to do so.

My symptoms more than likely subsided over the summer of 2008, not from doing a few CBT worksheets, but because I was working as hard at my job as I ever have in my life and had been for nearly three years. Within four or five months I would be burnt out for the second time in my career. I know now that I have always used overwork, overeating, dissociation, and avoidance as mechanisms for coping with overwhelming shame and fear despite the fact that they are often ineffective and have unwanted side effects of their own.

Medical Issue

Skip ahead nine years. On the evening of Thursday, October 12, 2017, I boarded an airplane in Phoenix to return home from a business trip. To all indications, my back was normal as I did so. Ninety minutes later, I woke up as we approached Bakersfield with mild, but burning, pain in my lower back. Sixty minutes after leaving Bakersfield in my car, I was home. By that time, the pain had become so debilitating that I needed help to get out of my car. Over the next five days, I saw four different doctors for my worsening back pain. On the sixth day, I had my wife take me to the emergency room. After they were unable to find the cause of the pain, they transferred me to Adventist Health Bakersfield by ambulance in the early hours of the next morning. At 5:00 pm on Saturday, October 21, I spent 30 minutes lying flat on my back on the hard table of an MRI scanner experiencing the most excruciating pain of my life. That MRI scan revealed that an abscess around my lumbar spine was the source of my back pain. That abscess would eventually be found to be the result of a systemic MRSA infection.

Two and a half hours after I came out of the MRI scanner, I was wheeled into emergency surgery to clean out the abscess. I had separate hallucinatory experiences before and after the five-and-a-half-hour Saturday-night/Sunday-morning surgery. Prior to the surgery, I experienced an illusion that the extended conversation between my neurosurgeon, my wife, and myself, during which I would eventually and reluctantly consent to the surgery, was happening during an episode of The Orville and somehow concerned a "satellite that was not a moon." (Perhaps because my neurosurgeon bears a slight resemblance to Victor Garber, who played an admiral on The Orville.) When I came out of anesthesia at 5:30 the next morning, I had a brief illusion that my doctor and an ICU nurse at my bedside were actually cartoon characters. A few days later, I had a follow-up surgery on my right hand to remove a small MRSA abscess there.

My mood and behavior in the immediate aftermath of the back surgery were very atypical for me. My neurosurgeon was initially gravely concerned about the stability of my lumbar spine due to the extensive soft-tissue damage that the MRSA infection had caused. In the first few days post-surgery he would not venture a forecast of the degree of function that I would recover or even whether I would walk again. Despite this, not only did I not become depressed, I was intensely grateful for the assistance provided to me by the various doctors, nurses, physical therapists, and other specialists through five weeks of hospital and skilled nursing convalescence and then through the home health care and physical therapy that continued until June 2018. During this time, I took pains to learn the names of everyone involved in my care and to personally thank them for their help in my recovery. I had never before felt such intense gratitude.

My physical therapists were continually amazed that I had very little serious pain after such an invasive back surgery (a laminectomy). By the end of May 2018, I was back to riding gradually increasing distances on my road bike. When physical therapy ended in early June, I thought that I was basically fully recovered.

However, by mid-June 2018 my mental health was about to change abruptly for the worse. At that time, I experienced about ten days of serious back pain which overlapped my 40th Wedding Anniversary. This coincided with a slide into a major depressive episode. Even though my back improved by late June, the major depressive episode did not. In October 2018, I would have another seven days of serious back pain. However, I have had none since and am essentially fully recovered, at least physically.

[Earlier this year my research into ketamine diffusion therapy for depression led me to wonder whether or not I had been given ketamine as an anesthetic during the emergency laminectomy and whether or not that might explain the post-operative hallucinatory experience and the unprecedented intense feelings of gratitude post-surgery. I asked my primary care doctor to check my medical records for the day of the surgery. They show that I was given a different anesthetic. ]

Therapist Two—The Government Psychologist

By the beginning of July 2018 (I was then six weeks shy of 62), my depression was severe (not quite my most severe episode ever, but close). This mental health crisis forced me to go to therapy for the second time. Immediately after returning from the July 4th long holiday weekend, I called the Employee Assistance Program (EAP) Psychologist at my place of employment and I made an appointment. She was a Psy.D. Psychologist licensed by the State of California and employed by the U.S. Federal Government. I saw her 26 times between July 11, 2018, and May 1, 2019.

This government psychologist was relatively young. At one point, she identified herself to me as "a millennial." Notwithstanding that, she was (and I presume still is) an old-school, blank-slate therapist, though that is not how she promotes herself. Her blank-slate, psychoanalytic approach and extremely rigid personal boundaries began to create issues for me as early as September. I believe that this combination of traits in a therapist would be anti-therapeutic for any RTR/cPTSD sufferer. If you believe that you have active symptoms of RTR/cPTSD and have a therapist like this, I would advise you to walk away immediately, don't look back, and seek out a better therapist.

In September 2018, I had a visit with my primary care physician after having been released from the care of my neurosurgeon, infectious disease specialist, and cardiologist. At that visit, I told my primary care doc that I was in therapy for depression. He prescribed Lexapro (escitalopram), an SSRI antidepressant known to suppress libido. The government psychologist recommended that I seek a second opinion from a psychiatrist, as the psychiatrists with whom she worked in her private practice did not prescribe SSRI antidepressants for patients presenting with a preexisting libido problem.

In late September I had a screening appointment with a Kaiser psychiatrist who prescribed Effexor (venlafaxine), an SNRI antidepressant, along with trazodone for serious insomnia which had begun suddenly on the night following my third session with the government psychologist (August 7, 2018). The government psychologist thought that Effexor was a better choice. I took the Effexor for about a week, but it only worsened my insomnia. On top of that, the trazodone was completely ineffective for me, even after the Effexor was discontinued. On two occasions after discontinuing the Effexor, I took 300 mg of trazodone (three times the maximum prescribed dose). Even that was ineffective for me (I DO NOT RECOMMEND that you or anyone else exceed the prescribed dose of any medication, even though I did). Consequently, I have taken no prescription psychoactive medications since October 2018. I clashed with this first Kaiser psychiatrist I had seen in September, and I followed up with a second Kaiser psychiatrist until April 25, 2019.

I came within a whisker of terminating therapy with the government psychologist on several occasions beginning in October 2018. These events occurred approximately once every two months, with me coming closer & closer to terminating each time.

By early April 2019, after investing more than six hundred hours of work into improving my mental health over nine months, I had finally come to understand the root of my psychological issues. That root was the traumatic and repeated emotional abuse that I had experienced over the first 30+ years of my life. Notwithstanding this recent and hard-won understanding, things were again about to take a very serious turn for the worse.

During what would prove to be the penultimate session with the government psychologist on April 16, 2019 (more significantly to me, Tuesday of Holy Week), I discussed my understanding of my trauma with her. I don't know whether she rejected the existence of RTR/cPTSD, underestimated it, wasn't trained to recognize and treat it properly, or all of the above. I do know that I needed more from her as a therapist—more understanding ... more acceptance ... more compassion ... more empathy—than she was prepared to give. In any event, with a single sentence, a 13-word intervention related to my approach to my trauma, she concluded that discussion.

Those 13 words upset the apple cart, causing my depression and anxiety symptoms (which had been very much improved) to flare-up over the Easter holy days, beginning during the Mass of the Lord's Supper on the evening of Holy Thursday, and reaching a crescendo from the night of Easter Monday through the morning of Easter Tuesday, April 22-23.

At about 6:30 AM on the morning of the 23rd, I submitted a written notification of revocation of my consent to treatment to the government psychologist through interoffice mail. Immediately thereafter, I filed an online application for retirement with the NASA Shared Services Center, accelerating the end of my career from September 30 to August 02, 2019. I did this solely to get away from her as quickly as possible.

The following day, I teleworked from home so I wouldn't have to be in the same building with her. She called me that afternoon, upon receiving my written notification, to suggest scheduling a termination session. By then I had reconsidered and was nearing completion of a 13-page letter to her detailing my experience of the previous seven days. I told her that, and we confirmed the previously scheduled May 1 session. I sent her the letter via secure email from home later that afternoon.

At my last consultation with the second Kaiser psychiatrist (April 25, 2019, Easter Thursday), we discussed my retirement plans and the fact that I would lose access to the government psychologist when I retired (then tentatively planned for the end of September; I had been putting off filing my retirement application as I considered a series of later and later dates). The psychiatrist referred me to a Kaiser psychologist because of the abrupt worsening of my symptoms over the previous week.

Finally, during the climactic session with the government psychologist on Wednesday, May 1, she reacted to my abrupt and serious symptoms using words that, over the next two days, stoked my feelings of shame to new heights. I believe she chose those words not only carefully and deliberately, but with premeditation and practice. These few sentences initiated the process of retraumatizing me. Consequently, on Monday, May 6, I sent her a written notification of revocation of my consent to treatment through interoffice mail for the second time.

Therapist Three

After terminating therapy with the government psychologist, I initially tried to get information from Kaiser Permanente that would allow me to select a therapist who was competent to treat someone who had experienced relational trauma and who was experienced in doing so. The mental health system simply does not support that, it is built around the arrogant assumption that any therapist can produce positive outcomes treating any patient. I am living proof of the falsity of that assumption.

When Kaiser Member Services refused to provide the information that I requested, I asked my Kaiser psychiatrist to help me find an appropriate psychologist. He responded that it was "all about the relationship with the therapist" and I should "just make an appointment with someone." I decided not to see him again at that point.

I very nearly ended therapy permanently after terminating my therapeutic relationship with the government psychologist and being denied help in finding someone new by my erstwhile psychiatrist. However, after a couple of weeks of intense and rapidly cycling emotional flashbacks, I asked my local Kaiser Mental Health Clinic to refer me to someone with appropriate qualifications and experience. They did refer me to an outside LMFT who was, in my judgment, no better qualified to help me than the first two therapists. I saw him 11 times between May 24 and September 27, 2019. By the end, he was spending as much of my time talking about his life as we were spending talking about my issues. He was minimally helpful at first, but by the end, therapy with him was obviously going nowhere.

At the end of the second week of June 2019, I permanently vacated my office at work and I teleworked from home for the remainder of my professional career. I went in to work on only six days over my final seven weeks, five of them during my final week.

During the three months between being retraumatized and retiring, I had more frequent and more intense symptoms than any others that I can ever recall. I was taking CBD and Oleamide during these traumatic final weeks at NASA, so I came to the conclusion that they were as ineffective for me as the prescription psychoactive drugs had been and I discontinued them.

Reading About cPTSD

After my retirement (August 3, 2019), my symptoms gradually faded from their incredible intensity and frequency. In the fall of 2019, a major step forward in my understanding of what is going on inside my head resulted from reading Pete Walker's book, Complex PTSD: From Surviving to Thriving. While Walker's book proved helpful, the 13th and final step on Walker's "13 Steps for Managing Flashbacks" is "Be patient with a slow recovery process." I am now 65, so I don't know how much of a slow recovery process I might actually have time for.

California Board of Psychology Complaint 600-200-0002

After reading Walker's book, I decided that I should file a complaint against the government psychologist with the California Board of Psychology for re-traumatizing me, mostly in reaction to Walker's discussion of the importance of learning to both anger and grieve over your traumatic injury. I filed the complaint that would result in the Board opening case 600-2020-000002 just before Christmas, 2019.

The California Board of Psychology acknowledged receipt of my complaint on January 2, 2020, via an unsigned letter. On April 15, 2021, I received another unsigned letter from the Board (dated April 13, 2021) informing me that "the Board has determined that there was no evidence to establish a violation of the laws and regulations relating to the practice of psychology with regard to Dr. Prueitt's practice or conduct in this matter. Therefore, your complaint has been closed." Apparently, it is easier on the Board to afford complainants less dignity than is deserved by those who may have been damaged through the deliberate actions of its licensees.

Therapist Four

In July 2020, I concluded an extensive and fruitless search for an IFS therapist both in California and willing to accept the $90 per session that Kaiser allows. I elected to return to therapy with a fourth therapist who was not IFS trained because I felt I needed some support while trying to figure out how to employ IFS on my own. Even though he advertises IFS as a type of therapy that he provides, his approach to therapy "is through a CBT lens." However, I believed him to be a pragmatist, not a CBT/REBT true believer, as the government psychologist apparently was and undoubtedly still is.

Nonetheless, despite continuing therapy, my symptoms again increased in intensity and frequency through late 2020 and early 2021. I terminated therapy with the fourth therapist with his agreement in September 2021, primarily because my symptoms were not improving. These symptoms have interfered with my intention to try to implement IFS self-therapy using Jay Earley's book: Self Therapy: A Step-By-Step Guide to Creating Wholeness and Healing Your Inner Child Using IFS, A New, Cutting-Edge Psychotherapy; 2nd Edition.

The Aftermath

In IFS parlance, I haven't been able to "unblend from my protectors" sufficiently for my "self to heal my parts." (If you're not familiar with IFS, this may sound like psychobabble to you, it did to me as I started reading Schwartz and Sweezy's book. However, the more I read, the more I came to believe that the IFS model corresponds quite well to my own interior experience.)

Since retiring, I have completely cut off contact with all but three of my former NASA colleagues and I have only very minimal contact with the remaining three. I have destroyed or thrown away all of the memorabilia of my 18 years of employment by NASA. Most of the memorabilia went directly into the dumpster at the opposite end of the building from my office as I cleaned it out in the late spring of 2019. The few items that actually made the trip from my office to my home were disposed of with other household trash some time ago during a particularly strong emotional flashback. Reminders of that traumatic final few weeks at NASA have repeatedly and regularly triggered such painful flashbacks over the last two and a half years.

In the summer of 2021, I decided to resume a regimen of CBD. There are some indications that it is helpful. It appeared to reduce the intensity and perhaps the frequency of emotional flashbacks, but they still occurred several times a week and were still strong at times. Some time ago I scheduled another visit with a third Kaiser psychiatrist to check my options. I know that Kaiser provides ketamine infusion therapy for those with treatment-resistant depression in Northern California. They don't here in Southern California. Psychiatrist Number Three suggested Risperdal or Seroquel. I declined as the possible side effects seemed unacceptable. I have also since stopped taking CBD again due to the high cost.

In December 2021, I completed the first half of IFS Guide's IFS 12 Day Challenge. I dropped out after week one because I had difficulty being sufficiently "in self" to identify and work with a suitable part. However, using IFS techniques I asked my overwhelming exile part to give me space over Christmas and allow my core self to work. On the way to Missouri and back for Christmas, for the first time since the morning of April 18, 2019, I was able to pull myself back into the present moment while driving. For three weeks, I had no emotional flashbacks. They were also less frequent for a couple of weeks afterward. That is very modest progress, although I still have not ridden a solo bike ride since June 2020 and after three years of steady weight gain, I am at a new all-time high. Despite 28 months of therapy with three therapists between July 2018 and September 2021, my mental health is still far more fragile than it was on that warm October evening in Phoenix, more than four years ago, when I boarded a flight home.

In early February 2022, I found an IFS-trained therapist in Southern California who accepts Kaiser Permanente patients and I spent four months on her waitlist without getting any closer. I recently dropped off the list and have given up on ever finding a suitable therapist. Emotional flashbacks are less frequent, less intense, and shorter these days. However, this comes at the expense of increased emotional numbness. I do still have very rare tiny moments "in self," but they never last more than minutes. So apparently and in some respects, I am psychologically back to where I was four years ago. However, in other respects, both physically and psychologically, I am a lesser person today than I was in early October 2017. Consequently, it seems that all I can do is accept my state of brokenness as permanent.

Lessons Learned

As I mentioned above, I believe that CBT, and its direct progenitor therapy, REBT, are fatally flawed. However, CBT has been embraced by the medical and psychological establishment as a panacea. Both CBT and REBT are based on the ABC model of Albert Ellis, which posits that troublesome emotions result from irrational beliefs and are correctable by replacing those beliefs with rational ones. Ellis's theory and his ABC model are contradicted by recent research in both neuroscience and social psychology. (See my PSYC 101 research paper, Implications of Recent Research in Social Psychology and Neuroscience for a Comprehensive Theory of Emotion, or the book, A Major Critique of REBT: Revealing the many errors in the foundations of Rational Emotive Behaviour Therapy, by Dr. Jim Byrnes, for the detailed rationale supporting my belief that CBT and REBT are flawed.)

RTR (or cPTSD) is much more than an irrational belief. Two short passages from The Body Keeps the Score best explain this. First from page 48:

For a hundred years or more, every textbook of psychology and psychotherapy has advised that some method of talking about distressing feelings can resolve them. However, as we've seen, the experience of trauma itself gets in the way of being able to do that. No matter how much insight and understanding we develop, the rational brain is basically impotent to talk the emotional brain out of its own reality. I am continually impressed by how difficult it is for people who have gone through the unspeakable to convey the essence of their experience. It is so much easier for them to talk about what has been done to them?to tell a story of victimization and revenge?than to notice, feel, and put into words the reality of their internal experience.

(It is not lost on me that the narrative which you have just read is just such "a story of victimization and revenge.")

And from page 64:

Psychologists usually try to help people use insight and understanding to manage their behavior. However, neuroscience research shows that very few psychological problems are the result of defects in understanding; most originate in pressures from deeper regions in the brain that drive our perception and attention. When the alarm bell of the emotional brain keeps signaling that you are in danger, no amount of insight will silence it.

At the point in time immediately prior to my retraumatization, I had come to believe that it was possible for me to be a much better, much happier person. I had come to believe that I could live an emotional life that was much fuller and richer than I had ever experienced in the past. I had reached my own Mount Nebo; I had seen the promised land. Unfortunately, like Moses, I was denied entry. I was cast back into the emotionless wilderness, cramped, silent, and colorless, punctuated only by intense bouts of the anguish of shame and of profound brokenness, in which I have spent my life. While I now doubt that there is any way out of this wilderness for me, I yet hope that there may be for others.

My experience has also taught me that, contrary to the common understanding, faith is not a belief, it is an emotion, no different from love, hope, shame, guilt, or anger. When you are either overwhelmed by traumatic emotion or emotionally numbed to protect yourself from that traumatic overwhelm, you can't feel faith or the love of God any more than you can feel joy. I think that traumatic overwhelm, in particular, must be what has been described by believers as "the dark night of the soul." In those brief moments that I am "in self," I can again feel faith and the love of God. Psychologists describe this loss of faith resulting from emotional numbing as a shift in values. It is not, it is a form of isolation from your actual self that a "firefighter" part imposes to protect you from your pain. I have always been vaguely aware that my values are a constant aspect of my "self" rather than of my parts, even before I understood what my "self" was, and even though I struggle to live my values when I am not "in self."

Conclusion

If you have suffered prolonged emotional abuse, you deserve better care than I have received. I hope and pray that you can find a way to get it. I do recommend that you read (if you haven't already) Pete Walker's Complex PTSD, From Surviving to Thriving, and Bessel Van Der Kolk's The Body Keeps the Score. I also recommend that you try to find an IFS therapist, someone who truly understands what RTR/cPTSD is and who is clearly competent to help RTR/cPTSD sufferers overcome their traumatic psychic injuries and heal their wounds.

Best wishes. I pray for you.

Gary

My Life and Thoughts: Gary S. Martin

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