A Conversation Between Marla Caplan, LMFT, and Laurel Roberts-Meese, LMFT.
LRM: I’m very excited to talk today with my colleague Marla Caplan. We’ve worked together for a few years and she’s one of the people whose clinical judgment I trust the most. We’re going to talk about trauma, which is something we both specialize in. Welcome, Marla, and I’m excited to hear what you have to say.
MC: I’m excited to hear what comes out of my mouth.
LRM: Before we talk about trauma and how we work with it, it’s important to define what is trauma. People have all different ideas of what trauma is and what it looks like. Historically, there have been many definitions of what trauma is. The first diagnosis we had for trauma was “shellshock” and it was used exclusively for WW1 combat vets. We now know WW1 vets are not the only people who have experienced trauma. If someone asked you, “Hey Marla, what’s trauma?” what would you say?
MC: The first thing that comes up is that trauma is about the way a person responds to a series of events that feel threatening, that make the person feel like their life is in danger, or a loved one is in serious danger. It’s a feeling of threat that can be identified primarily by the symptoms that show up, a feeling that the world is an unsafe place, which often leads to hypervigilant behavior, constantly checking around oneself, checking to see if one is safe. Also persistent nightmares is often a feature, and flashbacks, which is one of the more well-known features.
LRM: And more extreme.
MC: Yeah. I think on the more subtle end of things, there’s a sense of doubt around self-worth, doubt around a person’s ability to a make a good estimate of what is real.
LRM: Or who to trust. I would agree with that. In our field there’s this saying that there’s “big T Trauma” which would be an acute trauma like a car accident. These kinds of big T Traumas are the kinds of traumas we see in first responders and combat veterans, or someone who witnesses or was a victim of a violent crime, or had a medical trauma. But there’s also what we call “little t trauma” which can be much more subtle. Little t trauma trends to not have the physiological hallmarks of flashbacks or a certain level of hyperarousal. It’s a more internalized negative view of the self or the world; either that you are inadequate or the world is unsafe. These little t traumas are often built over time, and they’re usually relational. What are your thoughts on relational trauma? It’s different than some people might think of trauma; we think of car accidents and all that.
MC: It makes a huge impact on the way the person approaches the world, and their stance and belief that they carry with them. I think what you’re talking about is that [the impact of trauma] can range from that chronic disregard that a child might experience in cases of neglect, to intimate partner violence, whether emotional, physical, or verbal. You’re right that both of those situations leaves a person with a lot of doubt around who they are, how valuable they are, and who they can trust.
LRM: And how safe the world is.
MC: Yeah. And it can show up in really subtle ways, like, is it okay to ask for what I need?
LRM: Absolutely. So now that we have a shared definition of trauma, how do we work with it? If someone were coming to us and saying “I think this thing I experienced was a trauma, I experienced it that way.” How do we work with them?
MC: Safety is the place to start. And trust. If a client doesn’t feel safe, and doesn’t trust that I’m not going to add to that sense of judgment, they’re not going to share with me, and if they’re not going to share with me, what are we doing?
MC: They need to feel safe enough to open up and to be honest, and to take a look at some of the hard stuff. That hard stuff is some of the first stuff to get buried. Digging it up can be painful. Necessary, but painful. Especially in a time like now where a lot of people are feeling unsafe in general, really gaining trust and creating a safe space, even if it’s over video, is the place to start.
LRM: My mind really went there to video [sessions] specifically because I think, on the one hand, [clients] don’t have the little extra person connection that happens in person, but they can also be in the comfort of their own home. They can have their dog with them, they can go get a snack or lay on their bed. They don’t have to go out to their car and pay for parking, etc, and then go home. They’re able to decompress and continue processing whatever comes up in the therapy session in the comfort of their own home, which can increase their feelings of safety.
MC: I think that’s absolutely true when a person lives alone, and it’s been problematic with couples, or for people who have relationships with boundaries that are less than ideal. That’s been something I’ve encountered where I’m working with a client and the client doesn’t feel like they can really tell me what’s going on, or they’re whispering, or they’re in their car outside because that’s the best they can do.
LRM: Yeah, there’s a double edge sword there. I’ve had experiences where people say they actually felt safer to talk about really uncomfortable, traumatic things because they were at home. But I also too have experienced when someone doesn’t have that privacy that creates the feeling of safety.
MC: Along with creating safety, the first thing to do is to establish resources. That’s really reviewing and, if need be, creating resources or skills or tools or places to go when things that to be a little too intense.
LRM: Can you define what a resource is? In every field it means something different.
MC: A resource for someone might be something like having their dog, or working in the garden, listening to music, calling a friend.
MC: Oh yeah. Resources are activities in a lot of cases that make a person feel fortified.
LRM: Ideally people have at least one relationship that is a resource. A relationship that is positive, that is safe, that is trusting. It doesn’t have to be their partner – hopefully it is – but another place of safety in the world.
MC: And the way it shows up in session is getting a sense of what the client’s resources are so that I can redirect their attention if they can become escalated or deescalated to a point where their heart is racing and they’re starting to sweat, or they’re decompensating in the other direction and are spacing out. The level of arousal sometimes needs to increased or decreased so that things become more tolerable. If the person isn’t in a stable frame of mind, the work is not helpful. It will either not be integrated, or it can even be damaging.
LRM: Absolutely. If you don’t have that sense of safety, you should not be doing trauma therapy. You’re not there yet. The first stage of trauma therapy is building that trust and safety, and if that hasn’t been done, don’t proceed.
MC: And sometimes severe trauma clients come in and they don’t have good resources. They don’t have a partner or family they can rely on, they don’t have a dog, they haven’t figured out the things they can do to ground themselves. I like to work with guided imagery and help people find an imaginal space that feels good.
LRM: I also like to assemble a resource team of literal people in the person’s life or in the public eye that hopefully includes people close to them, but can also include positive, nurturing members of their community, or a grandmother who isn’t alive anymore but there’s a good memory of her. I also include people that client maybe hasn’t met, like a celebrity or politician. Michelle Obama and what she represents and the way she carries herself in the world – I’ve had people who didn’t have [a resource] close to them who would enlist Michelle Obama as a resource. When they were feeling like they had a really intense session and we’d processed some stuff, and then I’d say, “Let’s invite Michelle Obama in here and have her tell you what she thinks about that work you just did, and have her be with you while you’re transitioning back out [of the session.]” Ideally you have a real person in your life, or the memory of a real person in your life, but if you don’t, you can call on public figures, or spiritual figures, or even fictional or mythical people or creatures. They can be resources if you don’t have any in your life, and I think that’s really important.
MC: Similarly to the definition of trauma, “what is a resource” is really personal.
LRM: It is! There’s one that I remember someone telling me in graduate school, someone who was working a 12 Step program for sobriety, they were struggling with the “god” aspect and higher power aspect of 12 Step, and so they just replaced it with an image of Richard Gere, and that was enough for them – they just loved Richard Gere so much – that whenever they were talking about a higher power, they were imaging Richard Gere, and something clicked, and they were able to work their steps and maintain their sobriety. That wouldn’t work for most people, but it worked for that one person, and I thought it was such a creative way to implement a resource in a way that was really effective.
MC: Maybe a goal for that kind of work is figuring out how you can be your own resource. When you were talking about “higher power” I was thinking about Higher Self, and how that would be a real sign of progress of a client’s ability to really strengthen that relationship within themselves so they can be there [for themselves] when no one else is.
LRM: Yes! The part of you that is a good dog owner, the part of you that’s a good mom, the part of you that’s a nurturer and a responsible, loving caregiver; we all have some of that in ourselves, and if we can harness it and use that as a resource for ourselves, that’s incredibly powerful.
MC: Yeah; Can I mother myself in the way that my mother never did, but that I needed? Not you mom! I know my mom’s gonna see this and think, “What?! It’s always my fault!”
LRM: [Laughing] It’s more of the archetypal mother than the literal mother. You could have had a really great mother and still need mothering from yourself. Or parenting. I’m curious what you’re seeing happening now. We’re having this conversation about ten weeks into shelter-in-place, and I’m wondering if you’re seeing anything new and different, any spikes, or not, as people are sheltering in place and we’re dealing with a national trauma on top of whatever personal traumas we’re having.
MC: I’ve been surprised that a lot of my clients with higher levels of anxiety have been managing really well. People who deal with chronic anxiety and heightened states of arousal know how to manage, in a way.
LRM: It’s kind of normal. If things were totally great and calm they might be more alert because that doesn’t feel normal.
MC: And I think it gives some clients something to direct their anxiety toward.
LRM: A lightning rod.
MC: Yeah. And then in other cases, it’s been the ebb and flow that is life.
LRM: For the most part, I’m seeing most the people I work with are doing okay, and there’s the ebb and flow, there are some really hard weeks or hard days, of course, but the thing I’m seeing most is that I’m having to remind them that we’re also going through a national trauma on top of the stuff that we’re working on. They’re being really hard on themselves if a symptom or a behavior is getting worse, and I’m having to remind them that we’re also in the midst of a pandemic, so I think that some… I don’t like the word regression, but some little setback is pretty normal and to be expected. If you weren’t, that might actually be more cause for alarm, if you’re that disconnected, because we’re all sensitive, we’re all affected our environment and the emotional states of people we care about… So once safety has been established, and once you have your resource team, then what do you do? What’s that next phase of treatment, with the juicy stuff, what does that look like with you?
MC: For me it’s a lot of looking back at history and looking back at childhood, getting a sense of where the client is coming from and then slowly easing in, a little bit at a time, as much as is tolerable, dipping the toe into the water, approaching the traumatic event or events gently and cautiously. It’s a little bit like fear exposure; “can I touch this a little bit with someone who makes me feel safe?” just for a moment at a time, and then maybe we talk about something else for a while, until their tolerance gets bigger and bigger, and then maybe we can actually look right at it.
LRM: I just got this flash in my mind, maybe because I was thinking about Harry Potter earlier, but thinking about approaching it like a basilisk. You first look at it in a mirror, or just look at the shadow, and eventually get to the point where you could face it head on.
MC: Yes, and at a time and place where things are relatively stable.
LRM: So maybe not in the middle of a national health crisis. I’m taking a pause on doing that stage of direct trauma work, because I want them to be in a place of real stability, tons of resources, tons of safety, and if that’s not available, we’re not going to dip our toe in.
MC: A lot comes up that is disruptive. In some ways it’s meant to be disruptive, because disrupting stories a person has created around that event is a big part of the work. Retelling the story, and then disrupting that story to create a new one.
LRM: Something that’s been really integral to my work with trauma is approaching the event with an adult perspective; the perspective of an adult that feels safe, and has resources, and knows that six year old didn’t deserve to be hit or punished, or knows that the accident wasn’t their fault. We can so quickly go back to that space in our brain that believes that we deserved it, or that it was our fault, but when we can really maintain that healthy adult perspective and stay in that [adult] perspective as you process the memory, we begin forming new neural pathways, and that creates real healing. You can do that through talk therapy, and you can also do that through EMDR, which I’m trained in. I’ve done it both ways; I’ve done talk therapy to walk through a trauma while maintaining that healthy adult perspective, and I’ve also done the eye movement, bilateral stimulation, and both can work. It really depends on what the issue is, and your relationship with your therapist.
MC: What does the process look like when you do EMDR?
LRM: It’s an 8 stage process. If you’re familiar with it, you’re probably familiar with the part where you move your eyes back and forth, or the bilateral sound or hand pulsars. The first several phases really are around establishing safety and resourcing, so that’s the same. It’s very structured, but personal within the structure. You can’t do it the same way with each person; if that was the case we could just create an app, and I would not recommend using an app to process your trauma. So once we’ve resourced you and established what we’re going to be working on with EMDR, then I guide people through specific triggers and reminders of the trauma, whether it’s a physical sensation, or an image, or an audio clip, and we process that through, and I’ve seen some really incredible progress. I’ve seen people able to face people who have wronged them after many years, or who are able to drive again after not being able to after a car accident. I’ve seen some incredible resilience, which is why we do this work, right? Because we believe in the innate resilience of the human spirit. Anyway, if people are interested in working with you, how can they get in touch with you?
MC: The easiest way is my website.
LRM: And you do a free consultation to see if it’s a good fit.
MC: I’m happy to talk to anyone for 20-30 minutes to see if it feels right. Sometimes people want to bypass that step, and if so you can look through the website. It’s easy to fill out the intake form and set up an appointment.
LRM: And who do you love working with? Who’s a really good fit?
MC: I love working with creative people; artists, writers, makers, etc. People who like to take a look inside and are curious to see what’s in there. I’ve noticed over the last while I have a significant percentage of international clients, and I’m not sure why, but I tend to work with people from a variety of culture. Mostly women; I don’t know if that’s because more women come to therapy, or just with me.
LRM: Great. And if people are interested in working with me, I love working with driven young professionals. My website is laureltherapy.net or on Facebook. Marla, thank you so much for having this conversation, it was wonderful.