Session 196: Understanding Complex PTSD

Session 196: Understanding Complex PTSD

Dr. Joy: Hey, y’all! Thanks so much for joining me for Session 196 of the Therapy for Black Girls podcast. While many of us may be familiar with post-traumatic stress disorder or PTSD, you might be less familiar with complex post-traumatic stress disorder or CPTSD. To help us understand the differences between the two and to provide some context for CPTSD, today I'm joined by Dr. Janelle Peifer.

Dr. Peifer is a licensed clinical psychologist, assistant professor, and researcher committed to working alongside a vast diversity of clients as they navigate their lives. She owns two private practices: Peifer Psychology and Onward and Outward Psychotherapy in downtown Decatur, Georgia. Dr. Peifer focuses on providing identity and trauma-informed therapy during the perinatal period and believes in low barrier solutions-focused therapy rooted in evidence-based practices.

Dr. Peifer and I discussed some of the causes of CPTSD, how it impacts interpersonal relationships, how we often overlook experiences as traumatic, an example of what this might look like based on the Duke of Hastings from Bridgerton, and she shares some of her favorite resources for you to dig in a little further. If there's something that resonates with you while enjoying our conversation, please share with us on social media using the hashtag #TBGinSession. Here's our conversation.

Dr. Joy: Thank you so much for joining us today, Dr. Peifer.

Dr. Peifer: Of course. Thank you for having me.

Dr. Joy: Absolutely, I am really intrigued by your work, I think it's so important. Much of your work focuses on emerging adults’ identity formation and trauma and resilience, and we are going to be talking a lot today about the difference between PTSD and CPTSD, which is complex post-traumatic stress disorder. And I'd love for you to kind of just start by telling us what are the differences between the two.

Dr. Peifer: Oh, yes. When we're thinking about PTSD, especially as it's diagnosed in the DSM-5 which is kind of our Bible for diagnoses, PTSD tends to refer to a single incident that's called like an index trauma, and especially simple PTSD might look like that. When we're looking at complex PTSD, the major difference is that it is the experience of repeated trauma that can happen over time, over years. It's not this like single isolated event, but it's the experience of ongoing trauma, abuse, experiences of lack of safety, that then can show up with CPTSD or that complex PTSD.

Dr. Joy: So there does not need to be one activating event and then multiple stressors after; it can just be accumulation of stressors and traumatic experiences?

Dr. Peifer: Exactly, exactly.

Dr. Joy: Got it. And can you talk a little bit more about like some of the nuances between these? Like how might you be able to differentiate in terms of the diagnosis?

Dr. Peifer: Oh, yes. When it comes to complex PTSD, often what I've seen in my experiences is that people have been misdiagnosed because they often take for granted that their ongoing experiences–the life experiences that they had, the place where they grew up, the abuse that they might have experienced–they don't think of that as trauma. They're just like that was just my childhood or that was just my life. And so oftentimes it can get missed in therapy or even in school settings, other settings. People are just not labeling it for what it is.

When we're thinking about really distinguishing between PTSD and complex PTSD, being able to pick up on some of the things that will show up, that can give you a sign that it CPTSD is those “being pulled back into memories” feeling, like you're stuck in loops. Like the early experiences that you've had, some of the trauma that you experienced kind of keeps you in these cycles that you can't quite break out of. Noticing kind of being on edge, hyper vigilant, really independent and feeling like you can't really trust or rely on other people. Having these beliefs about yourself and the world around you.

Sometimes it shows up as agitation, anger, irritability and sometimes we even see it, too, where people have a hard time accessing their emotions. Like this ongoing experience of having to be alert to keep yourself safe when you're in this emotionally or physically unsafe position for a long period of time. Sometimes people will have trouble feeling and being able to convey their emotions. Those are all kind of hints that you can pull together if you're looking for CPTSD and really trying to label it correctly.

Dr. Joy: It's interesting that you mention, Dr. Peifer, that it’s often misdiagnosed because I'm thinking back now to my own training, and CPTSD is a fairly newer terminology. Like I don't remember getting any training in my grad program about CPTSD, so I would imagine that lots of therapists have not done any research or really know very much about CPTSD, which is why they may be missing it.

Dr. Peifer: Oh, exactly. In my experience, I did not get training on being able to identify or even the sort of therapies that are appropriate for CPTSD. It's something that's getting more attention, especially as we think about racial trauma as a potential complex PTSD. CPTSD diagnosis didn't even make it into the DSM-5, so it's not surprising that the field is still sort of catching up at being able to identify it and then knowing what to do.

Dr. Joy: Mm hmm. Of course, of course. You mentioned earlier, before we started recording, that in your work you are seeing this kind of being represented more in your client load in terms of black women presenting with CPTSD presentations. And now you're mentioning the whole racial trauma which we know, especially in this last year, lots of people have been experiencing or re-experiencing some of these racially traumatic experiences. Can you say a little bit more about that and what it might look like? Like if I'm listening to the podcast right now, how might I know that this may be something that I'm struggling with?

Dr. Peifer: That's a good question. When we're thinking, particularly in the work that I do, which tends to be with black women, we're able to reflect on what your early experiences were. And one of the things that I've noticed is that black women... and this is talking in broad terms, of course. Like there's a lot of different nuance there but there is the experience when you're actually asked to reflect on what your childhood was and what you experienced, that you kind of take it as it is. You're just like, that's what, you know, what happened, happened.

I might have been exposed to some difficulty, I might have experienced racism, I might have experienced constantly having to prove myself, I might have experienced emotional abuse or verbal abuse, I might have been exposed to violence or a lot of instability, but that was what it was. And when it comes to the experiences of these ongoing trauma, one of the things that we know is that the more you avoid and the more that you don't actually encounter and deal with and sort of really dive into being able to explore that with support, the more that it's going to continue to impact you in ways that you may or may not even realize.

So when I'm working with my clients particularly, and they're talking about sort of feeling numb or feeling like there is this disconnect between themselves and their identity, like there’s a little bit of like what I think of as fragmentation, that can be a sign that there's things to explore about ongoing experiences of strain. And you hit the nail on the head when you talk about this year in particular. The dual like simultaneous traumas of the pandemic and especially the disproportionate impact that it's had on black and brown communities, that's a complex trauma.

Like the anticipation of death and being exposed to the threat of death and those that you love and in yourself, that's an experience of trauma. And then if you layer on top of it this racial justice reckoning that we're having and just the absolute horror of this last year, of what we went through as a nation and as black folks, then you have that other layer. So it can activate some of that childhood stuff that you might have not addressed and then you kind of have this perfect storm of just really feeling out of control, feeling overwhelmed and having some of those complex PTSD reactions or trauma reactions.

Dr. Joy: Mm hmm. Yeah, and I think that that is frequently what happens when people have these reactions that they feel like are stronger than what they “typically would be.” So you kind of find yourself crying uncontrollably or you're feeling super isolated and you're not quite sure where it's coming from, because it doesn't feel proportional to the activating event. Then I think it is typically a good suggestion to kind of dig into some childhood stuff to see if something from there is being reactivated.

Dr. Peifer: Oh, yes, I feel I like that was perfectly said. Because I often think for me when I'm with a client and they describe a reaction that's outsized to the activating event, where they're like, “I completely, I was furious, or I was sobbing, or I just like...” And it was something that shouldn't have activated a response to that strongly, that's a good sign of let's dig deep and see what's underneath that.

Dr. Joy: Mm hmm. Dr. Peifer, I would love to go back because I think we talk a lot about childhood experiences, but I don't know that we always are clear about what kinds of things we're looking for in childhood. What are some of these early childhood experiences that we're talking about that might lead to a later kind of CPTSD response?

Dr. Peifer: Oh, yeah. There's a wide range and I often think about a good place to start are what we call adverse childhood experiences or ACEs. There was a big research study that brought together these ACEs that can happen in childhood, and they can range from verbal or emotional abuse–which might be like being yelled at, screamed at, being really denigrated by somebody. Really harsh verbal treatment, being shut down, being cursed at. Some people take for granted, “You know, that's just how my family talks.” That can be, for a child, an experience of emotional or verbal abuse.

And that might also include being in an environment that felt unsafe so if you were in a neighborhood or had experiences where you were exposed to violence or where you felt like you couldn't walk around safely, that can be an adverse childhood experience or one of those ACEs. And then it can also range to things like physical abuse, the things that people more traditionally think about like physical abuse, sexual abuse, somebody who inappropriately touched you or had experiences of sexual assault. And then we have the experiences of neglect as well. So if you didn't have adults who were looking out for you or who were keeping you safe, that experience of having to really take care of yourself, those could all be traumatic childhood experiences and ones that we might not always think of as a trauma.

Dr. Joy: Mm hmm. Yeah, especially I think the neglect piece. Because I think that there are some things that people kind of readily accept as neglect. Like if you have been left home for weekends at a time with no adult supervision or something like that, I think we can kind of say, yes, that feels neglectful. But I think that there are ways that neglect shows up in smaller ways that we sometimes miss. Yeah.

Dr. Peifer: Mm hmm, yes. Well, when I'm working with folks, too, one of the things that I try to make clear is that most of my clients really can understand what their parents or their family struggled with. So being able to label something as trauma doesn't mean that you're saying that your parent or your caregiver was a bad person or that they were doing it purposefully. Oftentimes people are protective of those childhood experiences because they're like, my mom didn't have a choice. You know, she was in a situation where she had to work those multiple jobs, because otherwise there wasn't going to be food on the table.

One of the things that I do is that, especially, I'm not in the business of trying to disrespect or say that people's families or their caregiving environments were trying to hurt them. Oftentimes, people do it unintentionally or it was based on circumstances and societal factors that are beyond the control of the people. So being able to like label and name it doesn't mean that you're saying that the people who you loved or the people who you have these complex relationships with weren't doing the best they could with what they had.

Dr. Joy: Mm hmm. So maybe we can get into this a little bit when we talk about like how you might work with a client struggling with CPTSD, but I think I've seen this come up when people then try to have these conversations with their parents. Maybe they have been in therapy and have learned, wow, like, that was a much bigger deal than I thought or I didn't know that that impacted me in this way. And then a part of the work they want to do is to go back and have this conversation with their parents and it doesn't often go well. Because that defensiveness, like you mentioned, typically rises up.

Dr. Peifer: Yep, we can definitely dive into that; just let me know when.

Dr. Joy: Okay, we’ll put a pin in that so we can come back. But I'm really glad that you brought up the ACE scores because I was thinking as you were talking, like I wonder if there is some correlation between CPTSD and the adverse childhood experiences scores. And so are the ACE surveys something that you might use to kind of make this diagnosis of CPTSD?

Dr. Peifer: Oh, yes, definitely. I think being able to pull some of that ACE information can be really helpful and I've increasingly moved. So there is a screening tool you can use for ACEs and I've moved to doing that conversationally and as part of the work. And as part of what we call like that first appointment that you have with a therapist (where they're doing an intake and they're asking you questions and they’re learning about what's bringing you in to therapy) I fold in ACEs as a part of that to be able to have it as a nuanced conversation. And I found that that's been way more effective than when I’d, in the past, just gave that survey. And so that is one way to pull some information, is to go through and look at those different ACE scores.

Dr. Joy: Why do you think it’s been more effective for you to give it conversationally, as opposed to like just giving the worksheet?

Dr. Peifer: Oh, yeah. Firstly, I think that being able to talk about your experiences, your childhood experiences with another human being, can feel more validating, feel more supported. And I think that from the time that you start your intake and assessment, you're starting your therapeutic work. So you want to set a tone that I'm not going to leave you to explore these things on your own. Like this is something that we're going to be doing together, we're going to be doing it at your pace, I'm not going to rush you, I'm not gonna force you to do anything that you're not ready to do yet. So it’s able to set that tone from the beginning and it gives me the ability to pick up on when we're doing too much too fast.

If you're going through it and you're like, “Yep, this happened to me, this happened to me, this happened to me, this happened to me,” that can feel pretty overwhelming or you could even just shut down. Like you start to just do it and then turn off your emotions. So it's helpful if we're doing it conversationally because I can pick up on that.

And then as well, I think that it gives me the ability to ask more questions in the moment. Rather than having somebody do this ACEs and then have to come back and go back through and expand on it, we can really just then much more fluently go into more detail as feels right in the moment. And be able to come back and bookmark things that we can get to at a slower pace as we're building trust, as we're building skills, as we're building the relationship. So I feel like that's been much more effective, now that I've shifted to doing it that way.

Dr. Joy: Mm hmm. Yeah, and it made me think about your earlier comment that sometimes we don't always label childhood experiences as traumatic. So depending on how the question is asked, I might say like, no, I didn't have any childhood trauma. But then when you ask it with all of this context, then we can easily identify it as such.

Dr. Peifer: Exactly, exactly. And even still, I still think a lot of people think of trauma as something that's for veterans, like in a war zone. I mean, so when people hear the word trauma, they're like, “Whoa, that's a big word. Like, I don't know if I would call that a trauma.” And so even when I'm working with my clients, we don't necessarily use the word trauma. We might get to a point where people self-identify that way and they're able to say, yeah, this was a trauma and I understand what that means. But for many people, there are other ways that they think about it and then there are other ways that they label, and that's legit. Like we can use the language that resonates with you and fit it into a model that can offer the support that you need. So, yeah, being able to use language that actually resonates with the client makes a difference, too.

Dr. Joy: Mm hmm. Yeah. Thank you so much for that, Dr. Peifer. You've already mentioned some of these early childhood experiences. And the Harvard Center on the Developing Child has done research studies showing that from pregnancy through early childhood, all of the environments in which children live and learn and the quality of their relationships with adults and caregivers, have a significant impact on these cognitive emotional and social development. Which is kind of what you've talked about.

I’d love for you to just talk a little bit more about your work with the GPS, the Global Pathways Study. Talk about how this is disproportionate in black communities, black and brown communities, because we know so much of the world is really kind of set up to be against us even from birth. I would just love to hear about your work with that study and how maybe some of that has been illuminated there.

Dr. Peifer: Oh, yes. I always like to start by saying that I try to really take an asset-based approach or like a strength-based approach in my research that’s also very much so honest and contextualized in the different barriers that people of color, black people face. And so one of the things when we look at adverse childhood experiences, the research really demonstrates that blacks (like you said) from infancy are more likely to have these higher ACE scores and have more of these adverse childhood experiences.

Now, as a researcher, what I'm interested in is why. Then as soon as you kind of dig under the surface of that and you start to ask what's behind that question, you start to see the intersection with racism and institutions and systems. So a lot of the ACE scores are tied to things like socioeconomic status and poverty. If you have a group that has been historically marginalized and has less access to resources and is more likely to be in poverty, then you're going to be in a situation where there is going to be higher exposure to violence in the community, less access to resources and support, and you're going to have more of those adverse experiences. It’s just going to happen.

I think that there's this intersection between like what happens societally and then what happens in families and in these individual microcosms. And so, similarly, what also ends up happening is what we call intergenerational trauma. Oftentimes, we learn how to parent by how we were parented. You don't sign up and take a course, you don't get a degree in parenting; you often use the models that you had around you. So, unintentionally, some people perpetuate the same experiences that they had as children. They didn't know any better.

They might use spanking or corporal punishment because that's how they were taught that you keep children's behavior in line. They might rely on the tools that they saw their caregivers have. So then you have that second piece of like this intergenerational passing down of trauma, particularly if people didn't understand or work through the trauma that they experienced. It can show up in your parenting, too, all that pain can show up in your parenting.

And then there's this third piece (and this is where I feel like you, Dr. Joy, are making a huge difference), the access to really culturally-informed and attuned mental health care that understands and is able to appropriately address this complex trauma. Because it is so tied in with some of the most intimate aspects of our experiences of being human. Like our childhood, how we were parented, our identity, our sense of self, our relationships.

You really need somebody who you're working with therapeutically, or even the people who are developing the interventions and the research, to develop the appropriate therapies. To understand culture and to really focus on how does all of this fit in and express in different ways? How can I make sure that this is an approach that's going to work for this human being who's going to be informed by who they are, their complex different layers of identity? So with the GPS, that's work that I do like during this period of emerging identity, is what we call it with college students. And so we're really watching and looking at growth and change over time in college students and the different experiences that shape who they are, and trauma is one of those experiences that can shape who we are.

Dr. Joy: Mm hmm. I'd love to hear more about your work with college students, like what prompted you to study that group in particular?

Dr. Peifer: With my work with my college students, I have two branches of research. The work that I do with college students, I got interested in because I see higher education as one space that can change the world. You have this environment where we know that people are exposed to more diversity than they've ever experienced before. It tends to be in the college experience, you are exposed to new ideas, new people. I mean, you also have this space where people are searching for and trying to determine what role they're going to play in the world.

And so I see the higher ed experience as this time where we can really shaped the future leaders and citizens of the world. And that it's really important to understand: what are those experiences that help them develop empathy, that help them develop self-awareness, that shape the way that they think about others, about the groups that they choose to engage with? The cultural competence that they develop.

So that's why I really gravitated towards this work (because I'm a professor as well as a therapist) when I saw that these college years, that these young people just come in and they are hungry and just like open in ways that oftentimes is really rare. It's like a very rare period of time where you're forming your identity, you're forming who you're going to be. And so, as a researcher, I'm really interested in that process.

Dr. Joy: Yeah, I mean, having a background in college student mental health, I definitely echo what you're saying. And I think it is also prime for them to be kind of unlearning (maybe) some of the things that were harmful from their childhood, and so you see a lot of that happening in this period, too.

Dr. Peifer: Oh, yes, definitely. And when you're in this environment, I feel like... It can happen in different spaces as well, it's not just in higher education. Like during this period of time, people might experience it as they're working, as they're part of technical school. It's really this period where, in America at least, you're moving away from your family and you have this ability to reflect on what aspects of my upbringing do I want to hold on to? Which ones are foundational to me and which parts might I want to work through or move away from? You're having conversations with different people. And it is the space where you're like, the way that I saw the world where I came from is only one way of billions of different ways. So you really have this eye opening moment where you're like, oh, yeah, like that was my experience, but that's not the only experience out there.

Dr. Joy: Mm hmm. We'll be back with more from Dr. Peifer, right after the break.

[BREAK]

Dr. Joy: I would love to get into now, Dr. Peifer... you and I both watch Bridgerton, correct?

Dr. Peifer: Yes.

Dr. Joy: Yeah, that was one of my New Year’s holiday, kind of binge watch, I think like a lot of people. And so I think we can kind of clearly see illustrated some of the things that you've talked about, with the Duke of Hastings. We see this very tenuous relationship he's had with his father, his mother died in childbirth. And so I would just love to hear if you were able to kind of identify some of the behaviors that he does display in his relationship with Daphne, and how that maybe is consistent with a CPTSD framework.

Dr. Peifer: Yes. I think that there's a lot there that can sort of be signals for that complex PTSD. And like you said, sometimes that shaping trauma can be grief or a loss that that child might not even necessarily remember. So some of the things that really showed up that seemed clear was the profound decision about your relationships, especially romantic relationships. Our early childhood experiences are pretty attached to how we engage with our romantic partners, what we call attachment. Like your early childhood attachment can really shape how you then later engage with your partners and romantic relationships.

So we definitely see that. Like some of the difficulty with trust, some of that feeling of needing control, needing to feel like you're in control of situations, having difficulty with intimacy and (with) really being vulnerable and seen and known. We definitely saw that show up some in his relationship with Daphne. In other ways, there’s early experiences of the emotional abuse that he experienced with his father. So I know of the episode where you see the judgment and the rejection from his father (because of his stutter) as being a really powerful shaping experience that he made a very profound decision about not wanting to ever have children. Because, like we were talking about before, there seems to be some fear that he's going to pass down or engage in some of the same behaviors or that he's afraid of what intimacy looks like in that way.

But I think that one of the things that was really hard about Bridgerton, one of the things that ended up as I watched it more that was really hard for me to see, was that it kind of perpetuated the same trope that trauma can be resolved just by love. And even that the encounter of, you know, they didn't come to a space of like honestly talking about this trauma, that trauma together. I don't know, it’s like back in the day if they would have gone to couples therapy or something. But it was sort of re traumatizing in some sort of ways, the approach that Daphne took. I won't give spoilers for people who haven't seen it yet, but I do think that by the end I was left a little unsatisfied and a little bit kind of sad to see that it sort of took that same approach. That if you just love somebody enough, that resolves the trauma.

Dr. Joy: See, that was something that I had missed, Dr. Peifer, so I'm really glad that you brought that out. Can you say more about like that trope, but also what that work looks like to resolve the trauma?

Dr. Peifer: Yeah. I know that one of the things that young folks I hear are getting more emotional intelligence on are things like trauma bonding in relationships. And one of the very, sort of like, age old tropes that we see in romantic movies and even romantic comedies is this idea that there's somebody (particularly it tends to be a man) who has like this really traumatic history, and that if you hang in there and if you love and if you provide the support, that that's going to resolve and fix it.

Where you and I know in therapy that trauma resolution and trauma therapy is an ongoing process that's done and it's often done in individual work. That being able to work to identify your experiences of trauma, to develop the skills to emotionally regulate while you're talking about and being able to really explore that trauma, and oftentimes in a structured way. Like there are some specific types of therapy like prolonged exposure or cognitive processing therapy or EMDR that people do that are specific types of therapy, that they work with a trained specialized clinician over time to be able to learn skills to identify and address that trauma.

And that oftentimes when you are doing couples work, when you're engaging with that with your partner, you’re learning different ways that your experience of trauma, the experiences that you had growing up before you met your partner, are showing up. And different ways to engage with it that feels more adaptive, that feels more in line with the direction you want to move in as a couple. But oftentimes, that trauma work, you're doing individually. Another person can't do that work for you. They can't fix or heal that for you, no matter how much they might want to. So that was something that I noticed in Bridgerton that kind of, you know, gave me a little pause.

Dr. Joy: Mm hmm. You know, as you mention that, Dr. Peifer, I'm thinking about how even that tendency to think that you can love somebody through trauma may be a result of your own early childhood experiences. Like if I were just a good enough child or if I did this thing or if I was perfect, then mom wouldn't have struggled that way. And so how some of that even shows up in our adult relationships.

Dr. Peifer: Oh, exactly.

Dr. Joy: Can you say more? We kind of used the Duke of Hastings as an example but I’d love to kind of just go more broadly, thinking about what are some of the other ways that CPTSD shows up in our relationships with other people? Especially when you talked about like having difficulty even accessing some emotions, like some of that feels missing? How does that look in real life?

Dr. Peifer: Mm hmm. Yeah, when it comes down to trauma, it's root, it's the response that we have to protect ourselves. We have the central nervous system response when we experience a threat that's wired into our bodies, that puts us on the defensive to protect ourselves. You might be more alert if there is a tiger coming at you. You're gonna be on high alert, your hearts gonna be going fast, you're going to be paying attention to all of those different threats.

Now, the issue with trauma and after you've experienced this space of feeling unsafe, is that that reaction never quite turns off. You have that experience of never really being able to get out of gear, like you're more hyper vigilant. As we're thinking about how that might show up in relationships then as we’re thinking about in romantic relationships, where it often shows up is in conflict. Any time where you feel unsafe, you feel like there might be something that reminds you of a threat.

And again, it's like you said earlier, Dr. Joy, you might also notice that it's like kind of outsized to the threat at hand. You might have a question or a conflict that shows up about like trust. Like, where were you? Like, why didn't you call me back when I reached out? But your reaction feels really big, like you might get really angry, you might have a really hard time being able to name when you were feeling worried or sad without it exploding into a big fight. Like you don't have the tools to be able to deal with it in another way. You might also notice that you just shut down like what we often call the stonewalling, where whenever you feel that threat or whenever you feel that instability, that you just turn off the emotions and like you can't be accessed and you can't even access your own emotions. So that numbness, that withdrawal, might be a sign.

Another sign might be where you don't feel like you have the tools to be able to talk about it without getting really emotionally off-kilter, really dysregulated, so you kind of create this experience of just feeling out of control. And oftentimes people will say that they might experience that their partner also has trauma that's activated so it's just like fire on fire. You have like fuel on fire and it keeps on growing and then people aren't able to really get back to a space where they can connect and talk in these like feelings of security and safety and stability. So those are the things that can show up in romantic relationships.

And oftentimes, when I'm working with clients, they'll say that they notice the cycle just keeps on happening, like they keep on ending up in these relationships where the same thing keeps happening. And when people come to talk with me, they might be looking at the symptoms or what I often think of as the smoke and they're like, I don't know why this keeps happening. Why do I keep ending up with these really dysfunctional relationships? Where the fire might be something like from your childhood, it might be that trauma. And we can all day talk about how to look for different partners, how to accept love, but if we haven't resolved the underlying trauma, that underlying fire, then that smoke’s going to keep coming back and that feeling of that stuck in a cycle is going to keep happening.

Dr. Joy: Mm hmm. Yeah. Because as you're talking, I'm thinking if the only way you've known to react when you are feeling unsafe is to have these like huge reactions, you may not see them as huge. Maybe when I'm talking with you as my therapist, you can say like, “Oh, that reaction seems interesting, given what happened. Let's talk about it.” But in my life, I might just feel like, oh, this is just how I react. I think it's interesting that it’s only in therapy (or somebody else calling it out) do we even recognize that our reactions don't always match what has happened.

Dr. Peifer: Oh, exactly. And especially if the communities that you're a part of have normalized that because that's what they do. You might even say, yeah, nobody else has even told me that that is maybe outsized. I didn't have any alternatives, I didn't see anybody modeling different behavior.

Dr. Joy: Stay tuned for more of our conversation after the break.

[BREAK]

Dr. Joy: What would some of that work look like, Dr. Peifer? You know, because you've talked about like EMDR and other kinds of things and my understanding is that those therapies are more effective for like an actual event, like a car accident or something like that. Would something like that work on like these kind of childhood traumatic experiences?

Dr. Peifer: Yeah, I feel like this is where there's a huge gap in the field. I think that the more and deeper I go into this work, I feel like this is a gap. There's some work that's being done, there's like a complex PTSD workbook that has some helpful frameworks for people who are addressing and being able to identify complex PTSD. But really, when it comes to like the gold standard (evidence-based practices that we think about, like the cognitive processing, therapy, the prolonged exposure, all of those sorts of therapies that are considered like the gold standard for PTSD) like you said, they were designed for single events or index traumas. Which can be frustrating.

So what I found is that some of those therapies can be used, where you're identifying, you might be able to focus on one index trauma. But of course, it has themes that can be connected to other experiences that you had that could be traumatic as well. So you can kind of modify some of those to be more broad and encompassing. Some of the work as well will happen as a part of the therapeutic process, so being able to start to develop language for identifying different experiences that happened, being able to talk through them. There are some narrative therapies that can be helpful, being able to develop coping skills as you're exploring different experiences, and equipping clients with the skills to be able to deal with emotions that might come up and have alternative ways of processing.

You might be able to do things like mindfulness, meditation, those sorts of things can be helpful for complex PTSD. But again, I really feel like this is where there is a gap in the field, particularly when it comes to thinking about the experience of complex PTSD in a really identity and culturally informed way. Because that's somewhere, I think, work needs to be done. I'm gonna put on my list of things to research: developing evidence-based practice for complex PTSD for black women, on my to do list.

Dr. Joy: Yeah, because you know any time there's a gap in the general literature, then you know that we are even further pushed to the margins. So if there's not somebody kind of studying it overall, then there definitely is not the culturally-responsive treatments that would be most helpful for black women.

Dr. Peifer: Yeah. And I'm not saying there's not anything out. There's definitely people who are exploring this, but it's definitely (like you said) it's still younger in the field. We still have a really long way to go and I'm glad that we're having this conversation because, yeah, I think that there's still so much work we can do.

Dr. Joy: Mm hmm. I want to go back to our earlier point about like maybe having some of these difficult conversations with parents. Even if we use like the Duke of Hastings (since we talked about him earlier) if he were to want to have this conversation with his father about how some of his childhood experiences impacted him, or if any of us wanted to have a conversation with a parent about how early childhood experiences have impacted us: one, is this something that you would suggest? And then, two, how might you be able to navigate that, knowing some of the defensiveness that might come up from the parent?

Dr. Peifer: Yes. To answer that first question, is it something I would suggest? I think it really depends on the individual. Firstly, the most important thing is going to always be safety. Like there's some instances where being able to really talk to or confront the person who intentionally or unintentionally traumatized you, is not going to be physically safe or it isn't going to be emotionally safe. So that would be one of the first things that we explored. Is this going to do more harm or is it going to be something that has the potential for good? And I think that that really is a space where being able to explore that with your therapist can be really helpful. And being able to talk about what you're looking for and why, what the experience might be like, what you can expect, even going through things like role plays with your clinician can be really helpful. That would be the first thing that I would look for. Is this something that is safe for you to do emotionally and physically? And then that would then be a collaborative decision that you would make together with your therapist.

But of course, for me, when I'm working with somebody who has trauma, one of the biggest pieces is empowerment. Like you're the expert on you. I can be there and say what might come up and what my concerns might be and make recommendations, but at the end of the day, trauma often takes power away from us, so I'm always really conscientious to try to be aware of that this is your choice. You have agency in it and I'll be there to process whatever happens–good, bad or ugly. Like, I'm going to still show up and we'll be able to still kind of work through whatever occurs. So that would definitely go into my recommendations. I know that was kind of a dodgy therapist response but... There was supposed to be maybe would I recommend doing that?

But the second piece of if you are in a place where you are able to have that conversation, I think you hit it earlier, Dr. Joy, when you said, “Don't be surprised if the person you're speaking to still doesn't have the skills to be able to hear what you're saying without defensiveness.” Oftentimes, the knee jerk response that humans experience when they hear something that they did that was hurtful or harmful, particularly for their child, that can bring up a lot of defensiveness. That can show up as anger, it can show up as avoidance, it can show up as minimization, deflecting, and those are all responses that are showing that, yeah, this is something that's heavy for you to hear and that you might automatically get defensive.

So this is a space where if the person is willing to do a facilitated conversation with a therapist, that could be helpful because they can provide some support to be able to help the other person use some active listening. Like where you're able to hear what the person is saying non- defensively, sit with some of the emotions that come up and be able to hold them without shutting down. Sometimes people just haven't yet developed the skills to be able to know how to respond and how to really listen to and make space for your experience.

But then on the flip side, some people have been able to do the work since their childhood, since that time, and they're able to hear what you're saying and to be able to talk about, okay, I hear this and make amends and figure out different ways of moving forward. I've definitely seen as people have talked with their families or caregivers or people in their life, there's a whole range of different ways that people respond. And the hope is that over time, they're able to hear what the person is coming back and telling them was their experience. Because that's something that can be extremely powerful and extremely validating and transformative, to be able to hear, yeah, that's what happened and I'm sorry. Like, that wasn't right, you didn't deserve that. And that can make a huge difference for someone.

Dr. Joy: Yeah. And I think that that is what people often hope is going to happen, is that they're going to have this conversation and somebody's gonna say, I'm so sorry. You know, I did the best I could at the time. And you definitely could get that experience but I think that happens most often when the parent has had some therapy or done some work on their own. Like, I think for most people, they hear this and they just hear “I was a bad parent” and so I think a part of this also has to be you really understanding what are you hoping to gain from having this conversation?

Dr. Peifer: Oh, yes. That's the more rare circumstance, where somebody has done all that work and they can hear it, they can apologize, and they can make space. That's probably rare because, like you said... I mean, I'm a mother myself and I was thinking of this morning I had to apologize to my son and that can feel really hard, especially when we're given this message as parents that we need to be perfect. So, yeah, anybody who is listening to this who is a parent who did have an experience where they felt like they didn't live in line with the values that they wanted for their child or that there's something that got in the way, I do think that that experience of being able to do your own work and being able to get that therapeutic support and then being able to really make space to apologize, can be transformative for a child.

But yeah, it is hard when we have this culture where it's like that's ancient history, move on, let go. Why are you bringing that all up again? Like, why do we have to keep talking about this? Like you know that I did the best that I could. Because it feels like an attack, when oftentimes the fact that somebody is coming back to have this conversation with you is a signal that they don't want to let go of the relationship. They want to stay in it. Why, otherwise, would they even go through the pain of going back down that road?

Dr. Joy: Right. Dr. Peifer, you just mentioned having to apologize to your little one, that's something that I actively try to do as well, and I know that a lot of your work is also with black couples who are kind of approaching parenthood or different transitions in their families. Can you talk a little bit about your work in terms of CPTSD and how that maybe helps you to help your clients to think about some of these things that might come up in parenting, or how they can respond to their own trauma? Because we know sometimes, like some of those things don't even get unshaken in us until we become parents or responsible for another person, so I’d love to hear just a little bit about what that looks like and some things for parents or parents-to-be to kind of be thinking about.

Dr. Peifer: Oh, yes, thinking about this. So when I'm working with folks, like to that transition of parenthood, because sometimes people are like how does identity and the transition to parenthood and trauma fit together? Because those are my areas of expertise, and I'm like, they're so tied together. They're so deeply tied together. Because we know that when we become parents, it is so all-encompassing and it really can bring up things for you that you didn't even know were there. And especially if you have experiences of trauma that you haven't been able to have the time to invest in exploring, it can pop up in ways that you weren't expecting.

An example would be if I'm working with a client who had experienced sexual abuse as a child and then they notice that they are very much so angry and protective and having a lot of... even emotionally or verbally abusive of their child when they get to the age that they were when they were sexually abused. And feeling really protective about how they are when they're around boys or making those sorts of things. So that's an example of, if you have this unresolved trauma because of what happened to you, it might pop up in your relationship with your child.

Because you're doing work and you understand that connection, it can be really empowering because you're like, oh, right now I'm having a trauma response. Like this is coming up for me and I'm feeling really unsafe. My desire is to protect my child and what I'm doing is not helping. So being able to make that connection and being able to use your coping skills, being able to use the strategies that you've developed in therapy, you can make a different choice, you can engage with it in a different way. But yeah, as you're transitioning to parenthood, you're exhausted, you're under the stress and you're trying to learn to do something that you care about really, really deeply but that many of us, we're learning as we go.

And it's imperfect, so being able to... I really love working with couples about how can you be aware of how your childhood is going to shape how you show up with your child? And also the choices that you can make that are different. Like what choices do you want to make that are different and why? And beyond that, how would I actually go about doing it? So we do a lot of that work.

And also encouraging couples to be able to have conversations with each other because the more that you understand where your partner's coming from and why, the more that you're able to create this third space for your family. Where you're like, this is where I came from, this is where you came from and this is the third space that we're creating for our family. And the choices that we're making that are value-aligned, that are about who we want to be. And that that creating and sustaining that third space is an active process.

And it's even harder, I feel like, for black families because you're doing it in this space where you're trying to cultivate the family environment values–safety, security–in a world that's often adversarial. You're trying to do this against the current. That's where having that therapist, having that other person who's in your team, who's in your corner, who's helping you to navigate all of that, can be really helpful.

Dr. Joy: Mm hmm. Yeah, as you're talking about cultivating this third space, I'm thinking about how, for black parents, so much of that is out of our control. Having these conversations about how to protect your child against racist attacks and like what happens when somebody calls them the N word or something. So much of that, it feels like, are things that we have to kind of prepare for that other parents don't.

Dr. Peifer: Oh, yes. One of the things that I often hear is that parents feel like they have to toughen their child up. That from the space to trauma, you’re like the world is gonna traumatize you, the world is gonna hurt you, I am scared for you from the time that you're born, based on what you're up against. You need to be above reproach, you need to be on point all the time. Intentionally or unintentionally, that can even show up as us kind of perpetuating that trauma.

And where we know in the research, one of the things that I love about some of the research on black families, is that black families can be this protective buffer against things that are outside of your control. That racial socialization, that pride, that empathy, that warmth, that security and stability, it can't fix the whole world but it can create like this protective barrier around your child that they're going to carry with them. That secure identity, that secure attachment, that even in a world that's up against them, gives them an extra layer of protection. Not hardening them up. Like not trying to prepare them and almost like pre-traumatize them, but this idea that actually what we see is that those warm, supportive loving home environments actually best prepare people to deal with the harsh realities of the world.

Dr. Joy: Thank you so much for that, Dr. Peifer. I feel like we could dig so much deeper into that, but I do not want to take all of your time. So I would love for you to be able to just share with us maybe any helpful resources. You've already talked about the CPTSD workbook but are there other books or podcasts or things that you find yourself recommending pretty frequently?

Dr. Peifer: Oh, yes. If you have time to read or listen to audio books, I can recommend The Body Keeps the Score, that's kind of like a classic book about trauma. My Grandmother's Hands is another good one to be able to read or listen to, the Complex PTSD Workbook is good. But yeah, just doing some research and being able to even give a name to some of these things can be really helpful. So yeah, definitely reading about those adverse childhood experiences and the idea of post-traumatic growth and resilience as well, so thinking about this conversation as a two-sided coin. Because what we didn't get to dive into is that, yeah, there are ways that trauma, based on kind of the way we're able to engage with it, can inspire growth, resilience and continued flourishing in certain circumstances.

Dr. Joy; You may have to have a great follow up session related to that, so we can dig a little deeper into that one. Tell us where can we find you, Dr. Peifer? What is your website as well as any social media handles you'd like to share?

Dr. Peifer: Oh, this is a good question. My practice website is OnwardAndOutward.org, that's where my website is. I'm also on Therapy for Black Girls directory so you can find me there. And then in terms of social media, I think my Insta is @DrJanelleATL (for Atlanta) and I think I'm on Facebook as well. You can search me, you can find me.

Dr. Joy: Perfect. We'll include all of that in the show notes. Well, thank you so much for this, Dr. Peifer. It’s such a great conversation, such a wealth of resources, I really appreciate it.

Dr. Peifer: Oh, thank you for giving me a chance to talk about this. It’s something that I care deeply about and I really appreciate the chance to talk more about it.

Dr. Joy: Thank you. I'm so glad Dr. Peifer was able to join us for today's conversation. To learn more about her and to check out the resources she shared, be sure to visit the show notes at TherapyForBlackGirls.com/session196. And please text two sisters right now and tell them to check out the episode. Don't forget that if you're looking for a therapist in your area, you can check out our therapist directory at TherapyForBlackGirls.com/directory. And if you want to continue digging into this topic or just be in community with other sisters, come on over and join us in the newly formed Therapy for Black Girls Sister Circle.

Our community was formerly called the Yellow Couch Collective, but now it's called The Sister Circle. It's our cozy corner of the internet designed just for black women. You can join us at Community.TherapyForBlackGirls.com. Thank y’all so much for joining me again this week. I look forward to continuing this conversation with you all, real soon. Take good care.