Managing Abandonment Depression in Complex PTSD By Pete Walker, M.A. Psychotherapy, M.A. Psychotherapy
Here is a map of the layering of defensive reactions to the underlying feelings of abandonment typically found in Complex PTSD. This territory is best viewed through unwinding the dynamics of emotional flashbacks. Flashbacks are at the deepest level painful layers of reactions - physiological, emotional, cognitive, and behavioral - to the reemerging despair of the childhood abandonment depression. One very common flashback-scenario occurs as follows: Internal or external perceptions of possible abandonment trigger fear and shame, which then activates panicky Inner Critic cognitions, which in turn launches an adrenalized fight, flight, freeze or fawn trauma response (subsequently referred to as the 4F's). The 4F's correlate respectively with narcissistic, obsessive-compulsive, dissociative or codependent defensive reactions.
Here is an example of the layered processes of an emotional flashback. A complex PTSD sufferer wakes up feeling depressed. Because childhood experience has conditioned her to believe that she is unworthy and unacceptable in this state, she quickly becomes anxious and ashamed. This in turn activates her Inner Critic to goad her with perfectionistic and endangering messages. The critic clamors: "No wonder no one likes you. Get your lazy, worthless ass going or you'll end up as a wretched bag lady on the street"! Retraumatized by her own inner voice, she then launches into her most habitual 4F behavior. She lashes out at the nearest person as she becomes irritable, controlling and pushy (Fight/ Narcissistic) - or she launches into busy productivity driven by negative, perfectionistic and catastrophic thinking (Flight/Obsessive-Compulsive)- or she flips on the TV and becomes dissociated, spaced out and sleepy (Freeze/ Dissociative)- or she focuses immediately on solving someone's else's problem and becomes servile, self-abnegating and ingratiating (Fawn/Codependent). Unfortunately this dynamic also commonly operates in reverse, creating perpetual motion cycles of internal trauma as 4F acting out also gives the critic endless material for self-hating criticism, which in turn amps up fear and shame and finally compounds the abandonment depression with a non-stop experience of self-abandonment. Here is a diagram of these dynamics: Triggered ABANDONMENT DEPRESSION -- FEAR&SHAME --INNER CRITIC Activation: (Perfectionism & Endangerment) -- 4F's: (Fight, Flight, Freeze or Fawn Response). Especially noteworthy here is how the inner critic can interact with fear and shame in a particular vicious and escalating cycle.
This article describes a treatment approach that decreases retraumatizing reactivity to the internal affects of the abandonment depression. It guides the client to meet abandonment feelings equanimously by staying somatically present to the physical sensations of depression and fear. This in turn promotes the ability to feel through abandonment experiences without launching into inner critic drasticizing and 4F acting out. R.D. Laing once stated that: "The only pain that can be avoided is the pain that comes from trying to avoid unavoidable pain". In my experience resisting unavoidable encounters with depression and fear accounts for more than the lion's share of the PTSD client's pain.
The etiology of a self-abandoning response to depression. Chronic emotional abandonment is one of the worst things that can happen to a child. It naturally makes her feel and appear deadened and depressed. Functional parents respond to a child's depression with concern and comfort; abandoning parents respond to it with anger, disgust and further abandonment, which in turn create the fear, shame and despair that become characteristic of the abandonment depression. A child who is never comforted when she is depressed has no model for developing a self-comforting response to her own depression. Without a nurturing connection with a caretaker, she may flounder for long periods of time in a depression that can devolve into The Failure to Thrive Syndrome. In my experience failure to thrive is not an all-or-none phenomenon, but rather a continuum that begins with excessive depression and ends in the most severe cases with death.
Many PTSD survivors "thrived" very poorly, and perhaps at times lingered near the end of the continuum where they were close to death, if not physically, then psychologically. When a child is consistently abandoned, her developing superego eventually assumes totalitarian control of her psyche and carcinogenically morphs into a toxic Inner Critic. She is then driven to desperately seek connection and acceptance through the numerous processes of perfectionism and endangerment described in my article "Shrinking The Inner Critic in Complex PTSD" (see link for this article: Shrinking the Inner Critic). Her inner critic also typically becomes emotional perfectionistic, as it imitates her parent's contempt of her emotional pain about abandonment. The child learns to judge her dysphoric feelings as the cause of her abandonment.
Over time her affects are repressed, but not without contaminating her thinking processes. Unfelt fear, shame and depression are transmuted into thoughts and images so frightening, humiliating and despairing that they instantly trigger escapist 4F acting out. Eventually even the mildest hint of fear or depression, no matter how functional or appropriate, is automatically deemed as danger-ridden and overwhelming as the original abandonment. The capacity to self-nurturingly weather any experience of depression, no matter how mild, remains unrealized. The original experience of parental abandonment devolves into self-abandonment. The ability to stay supportively present to all of one's own inner experience gradually disappears.
We can gradually deconstruct the self-abandoning habit of reacting to depression with fear and shame, inner critic "freak out", and 4F acting out. The processes described in this article and my paper: "Managing Emotional Flashbacks in Complex PTSD"(see link for this article: 13 Steps for Managing Flashbacks) awaken the psyche's innate, developmentally arrested capacity to respond amelioratively to depression and the fear and shame that attaches to it. It is a long difficult journey however, for even without attachment trauma, feelings of fear and depression are difficult to accept and weather.
The normalcy of depression
We live in a culture that judges fear as despicable, and depression as an unpatriotic violation of the "pursuit of happiness". Taboos about depression even emanate from the psychological establishment, where some schools strip it of its status as a legitimate emotion - dismissing it simplistically as mere negative thinking, or as a dysfunctional state that results from the repression of less taboo emotions like sadness and anger. I believe we must learn to distinguish depressed thinking - which can be eliminated - from depressed feelings - which must sometimes be felt. Occasional feelings of enervation and anhedonia are normal and existential - part of the admission price to life. Moreover, depression is sometimes an invaluable harbinger of the need to slow down, to drop interiorly into a place that at least allows us to restore and recharge, and at best unfolds into our deepest intuitiveness. One recurring gift that typically comes cloaked in depression is an invitation to grow that necessitates relinquishing a formerly treasured job or relationship that has now become obsolete or moribund. Overreaction to depression essentially reinforces learned toxic shame. It reinforces the individual's notion that, when depressed, he is unworthy, defective and unlovable. Sadly this typically drives him deeper into abandonment-exacerbating isolation. Deep level recovery from childhood trauma requires a normalization of depression, a renunciation of the habit of reflexively reacting to it. Central to this is the development of a capacity to stay in one's body, to stay fully present to all internal experience, to stay acceptingly open to one's emotional, visceral and somatic experiences without 4F acting out. Renouncing this kind of self-abandonment is a journey that often feels frustratingly Sisyphean. It is a labor of self-love and a self-nurturing process of the highest order, but it can feel like an ordeal replete with unspectacular redundancy - with countless, menial experiences of noticing, naming and disidentifying from the unhelpful internal overreactions that depression triggers in us.
A relational approach to healing abandonment
I am a relational therapist, because I believe this journey requires reparative relational experience. Healing Complex PTSD and the attachment disorder that typically accompanies it is an interpersonal journey which needs to be initiated and shepherded by a therapist, partner or trusted friend who has the capacity to stay unreactively present to their own depression and the various affects that attach to it. When a therapist has this level of emotional intelligence, she can guide the client to gradually release the learned habit of automatic affect-rejection and overreaction. A key operation here appears to depend on the eye and ear contact of a bi-hemispheric brain process Daniel Siegel calls "the co-regulation of affect". Safe and empathic eye and voice connection with an individual with "good enough" emotional intelligence provides a working model and a "limbic resonance" to help her stay unreactively present to her depression and the fear that attaches to it. This, in turn, promotes the integration of right and left brain functioning - helping the client to feel and think simultaneously and egosyntonically. Moreover, as Susan Vaughan's book: The Talking Cure avers, such work appears to promote the development of the inner neural circuitry necessary to healthily manage and integrate depression and its attenuated affects.
Guiding the client into somatic mindfulness
Therapists can teach clients the practice of "paying" non-reactive, self-accepting attention to their own affects. Behaviorally, this entails staying aware of, focused on and present to the somatic experience of the abandonment depression. Typically, this process is indirect at first because depression so commonly and instantly morphs into the hyperaroused sensations of fear. Early work then primarily involves staying present to the kinesthetic sensations of fear and noticing the psyche's penchant to dissociate or distract from them. Dissociation can be either the classical right brain distraction of spacing out into reverie, fantasy, TV/computer trance, fogginess or sleep - or it can be the left brain, cognitive dissociation of becoming distracted in obsessive thinking. Particularly nefarious here is the inner critic's penchant for dissociating from and reacting to depression and fear with toxic cognitions and reveries of endangerment and perfectionism. Over and over, the client needs to be guided to rescue himself from dissociation (left and/or right), and to gently bring his awareness back into fully feeling and experiencing the sensations of his fear and noticing his reactions to it. Sensations of fear may range from simple tension and muscular tightness anywhere in the body, especially the alimentary canal - to nauseous, jumpy, wired feelings and shocks of electrification - to shortness of breath, hyperventilation and diarrhea, when it is at its worst. Although these sensations typically feel unbearable at first, persistent focusing on them with non-judgmental, non-eschewing awareness eventually lessens and quiets them. Held non-reactively enough, they are seemingly dissolved, digested and integrated by awareness itself.
It is important to note here that this type of kinesthetic focusing often triggers memories and unworked through feelings of grief about the client's abuse and neglect in his original abandonment. This provides many invaluable opportunities to ameliorate PTSD by more fully grieving the losses of childhood. Therapists can also use the results of such explorations to foster the creation of an egosyntonic and self-compassionate narrative that deconstructs the shame and self-blame the PTSD client typically assigns to her suffering. I describe a safe, efficacious process for this type of grief work in my book: The Tao Of Fully Feeling: Harvesting Forgiveness Out of Blame. With considerable practice, the client eventually begins to exhume, from his fear, an awareness of the more elemental, underlying sensations of depression - sensations exceedingly subtle and barely perceptible at first. These sensations are initially as difficult to stay present to as they are to find. With guided ongoing practice however, focused attending also digests them as they are integrated into consciousness. As practice becomes more proficient, these feelings and sensations of depression sometimes morph into a sense of peace, relaxation and ease. Such relaxation can even, over time, open into a continuum of inner peace that may stretch from profound equanimity to that place of unsurpassable peace that various Eastern pundits describe as the Great Void or Sublime Nothingness.
Inner Somatic Work
Therapeutic gains in diminishing automatic self-abandonment in the face of fear or depression are augmented by individual introspective work. In my personal discovery of this skill, I spent over an hour a day in meditation with my awareness yo-yo vacillating between my body and my mind - between tense sensations of fear and the myriad disturbing mentations of my inner critic. These drasticizing thoughts and visualizations were my critic's outmoded historical interpretations that my feelings and sensations meant that I was in imminent danger of the abandonment of attack or neglect. My critic excoriated me incessantly to strive for safety through productivity and perfection. In the first year of this practice I frequently had to white-knuckle the handles on my chair to stay somatically present to my feelings - to break my adrenalin addiction, to stop myself from launching into my preferred 4F flight response. I had survived my childhood with ADHD-like busyness - with marathons of activity that kept me one step ahead of my fear- and shame-stained depression. Gradually as I used my focused awareness to digest my fear, I experientially discovered the rock bottom underlying core sensations of my abandonment depression itself. Over and over I focused on sensations of heaviness, swollenness, exhaustion, emptiness, hunger, longing, soreness, ache-iness, deadness. Sometimes these sensations were intense, but more often they were very subtle. With time I noticed how instantly my depression scared me and lead me to echo my parents' toxic shaming: "You're bad, worthless, useless, defective, ugly, despicable". Blessedly, with ongoing practice, I gradually learned to disidentify from the toxic vocabulary of the critic. I found myself more accurately naming these revisited childhood feelings: "Small, helpless, lonely, unsupported, unloved, needy" (as in profoundly unsuccessful in getting my needs for emotional comfort met).
Camouflaged Depression
Feelings of depression sometimes mimic gnawings of hunger, especially the emotions of abandonment which commonly masquerade as physiological sensations. Feeling very hungry a hour or two after a big meal is an almost certain signal of abandonment feelings and not real hunger. As much as this hunger appears to be about food, it is actually an emotional hunger - an emotional longing for safe, nurturing connection and for the satiation of abandonment. Even after a decade of practice, I still find it difficult to differentiate this type of attachment hunger from physical hunger. One, often, reliable clue is that the sensation of longing for the nourishment of attachment is usually in my small intestine, while physical hunger's locus is a little higher up in my stomach. (I believe the extreme longing for sex and/or love typical of sex and love addiction can similarly be an encounter with our abandonment depression, especially when no amount of affection or sexual attention from another seems to fill the void of longing).
On a parallel with false hunger, feeling tired is sometimes an emotional experience of the abandonment depression, and entirely unrelated to sleep deprivation - although over time the two can easily become confusingly intertwined. The emotional tiredness of not resting enough in the comfort of safe attachment and belonging, often masquerades as physiological tiredness. When our abandonment depression is unremediated, any kind of tiredness - emotional or physical - commonly triggers us into fear, which the inner critic translates into endangerment and imperfection, and the accompanying adrenalization launches us into one of the 4F responses.
Pseudo-Cyclothymia
It is a sad irony that reacting to emotional tiredness in this way can eventually exacerbate it into real physical exhaustion via a process I call the The Cyclothymic Two-Step. PTSD sufferers with a primary or secondary flight response frequently overreact to their tiredness with workaholic or busyholic action. They run so compulsively from their depression, that they eventually exhaust themselves physically, and at times become too depleted or sick to continue running. When this occurs, they collapse into an experience of abandonment so painful, that they re-launch desperately into "flight" speed at the first sign of replenished adrenalin. I have witnessed a number of such clients misdiagnose themselves as bipolar because of the extremes that ensue from desperately pursuing the adrenalin high and eschewing the abandonment low.
Adrenalization often becomes addictive because it self-medicates and counteracts the emotional tiredness that emanates from undigested and unworked through abandonment feelings. Especially noteworthy here is the endless and expensive journey that many survivors undergo trying to remedy emotional tiredness with physiologically-based medical treatments. Even worse, the short-lived (if any) improvements of such an approach increasingly augments the shame and self-hate of the sufferer over time: "What's wrong with me. I've changed everything in my diet and in my sleep and exercise schedule. I've seen every type of practitioner imaginable and I am still waking up feeling dead tired." It is a subtle, hard acquired skill, but learning to self-compassionately focus on the inexorable somatic experiences of sometimes feeling tired, bad, lonely, or depressed is the only way out of this cul-de-sac of self-destructive and unwarranted efforting. In this regard, the notable AA 12 Step acronym, HALT - Hungry, Angry, Lonely, Tired - can remind us to stop and pause introspectively to determine whether our abandonment depression has been triggered and needs the quiet, internal, self-compassionate attention described above.
We can sometimes gain motivation for this difficult work by seeing our depressed feelings as messages from our developmentally arrested child who is flashing back to his abandonment in hopes that his adult self will respond to him in a more comforting, compassionate and appropriate way.
Through such practice, clients can gradually achieve the healing that the Buddhists call separating necessary suffering (normal depression) from unnecessary suffering (the internal hopelessness, shame and fear, and the life-constricting acting out that ensues from unnecessary engagements with the critic and the 4F's).
