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Full Title: What My Bones Know
A Memoir of Healing from Complex Trauma
Author(s): Stephanie Foo
Publishing / Edition: Ballantine Books, 2022

Click here for the Table of Contents of the book


Content Review

Warning: The following is not to be considered advice, medical, psychological, or otherwise.

First, an important message...

If you are in the middle a crisis (e.g.: contemplating suicide), then please get help. And despite the intensity of the pain that you might be feeling right now, please reconsider. There is hope for healing!

Likewise, it is important that you are NOT in any immediate physical danger. Those circumstances must be taken care of to some extent before attempting to do anything else. Get to a safe place.



I am so glad that Stephanie had the courage to share her story. The events of her childhood that are covered within Part 1 of the book could be very upsetting to read, whether or not one has personally experienced similar trials. The book itself opens up with an "author's note" that is essentially a warning. To quote a small part of it:
...I know that trauma books can be triggering and painful to read. I've struggled through a number of them myself. But I felt that it was necessary for me to share my abusive childhood in order for the reader to understand where I'm coming from...
I am not going to repeat her story and I will try to be considerate in how I express this. However, the topic of complex trauma and its treatment is going to be an inherent part of this article...

Generally, I find it a bit strange for one person to "review" another's memoir. Everyone's experiences are unique and cannot be compared. I appreciate the colorful descriptions that she uses throughout her writing though. For example, while they were both borne of hardship, she contrasts the stoicism and sense of duty of her older Malaysian relatives with her own rugged self-sufficiency as a young, first-generation U.S. immigrant in the following way:
...They had shown that suffering was the heart of strength. I was not capable of that decorum. I was a meteor, a ball of whirling knives, an American girl who walked with her pistols blazing. And I paid the price for it...
In addition to the vivid imagery, there is some sarcastic humour and cursing throughout as well. I merely highlight those points to give one a flavor for how much of the text reads.

Another thing that I appreciate about the book is how she goes through the details of her own healing journey, briefly describing the various treatments that she tried, and just as importantly, noting various ways in which the current practice of medicine has failed her. I will elaborate upon these aspects in particular. I hope to provide a little bit of support to those who are going through immense suffering, and to help remedy some of the shortcomings of medicine by exploring avenues for further research. Please take everything that I say with a grain of salt...



Now, for a few rough personal definitions:

• "Trauma" is severe mental-emotional and/or physical distress. Any experience which induces it can be referred to as being "traumatic" in nature.

• "Post-Traumatic Stress Disorder" (or PTSD) is when a specific traumatic experience within a person's past conditions their body to react in a destructive way whenever an assocation is drawn between that experience and their current circumstances.

• "Complex Post-Traumatic Stress Disorder" (or C-PTSD) is when a person's survival instincts are reconditioned by multiple traumatic experiences repeated over a long period of time. In turn, the body tends to react destructively when attempting to handle situations outside of those traumatic experiences.

C-PTSD is usually more pervasive than PTSD in its effects because the trauma that lies at its root is spread out in its duration, with many events triggering it. In Stephanie's case, it arose because her mother was physically and verbally abusive towards her throughout the majority of her childhood, while her father continued to neglect her throughout her adolescence.

Please do not get too caught up within the labels. We simply want to highlight the fact that, whatever their cause, traumatic experiences can sometimes overwhelm a person's nervous system to the point where cause and effect can get mixed up.

In general, there is not always a linear, 1-to-1 correspondence between cause and effect. For example, what seems to be a single effect could actually have an entire cluster of causes. Therefore:

1. The experience of C-PTSD itself could have multiple contributing factors underlying it.

And inversely...

2. Sometimes, many things are helping to sustain our individual sense of stability.

Both of these are "systems" in that they can only be understood and addressed holistically. In order to heal, one must have the latter support system in place as one takes care of each aspect of the former.

The "six dimensional model" of Pete Walker, a psychotherapist and survivor of C-PTSD, captures this well:

This image is based on the one on the cover of his book/audiobook, Holistically Treating Complex PTSD: A Six-Dimensional Approach.

He lists out some of the destructive tendencies that can be induced by the experience of C-PTSD and what they can be constructively transformed into. More broadly, we are aiming for an "embodied" and coherent sense of "Self" that is helpfully "attuned" to all aspects of one's inner and outer life. In other words, we have an awareness of our own needs and are able to effectively engage with a larger social context. An insightful visualization of this has been created by the psychologist Catherine Cook-Cottone:

This image is based on one within an article on her website, Embodied Self-Regulation.

Of course, all of this is often easier said than done. What might work for one person may not work for another, or must be approached in a different way. Further, we might have to personally operate within various constraints that can limit our access to things like psychotherapy, nutritious food, or other resources that could help facilitate healing.



We will start off by exploring some of the more challenging and confusing Physiological aspects that can be associated with C-PTSD, using Stephanie's comments as a launch pad...

Diet and Lifestyle-Related Factors

In Chapter 14, Stephanie describes how the psychologist Lisa Feldman Barrett encouraged her to try to get the nutrition, exercise, and sleep that her body needs, so that she would not be "running at a deficit". Lisa further explains that trauma has a tendency to induce intense reactions to such deficits. This led Stephanie to adopt many healthy habits, such as:

• No longer drinking alcohol or smoking cigarettes
• Eating more vegetables and drinking more water
• Taking up regular fitness classes, three times a week
• Getting eight hours of sleep every night

While these changes helped her to feel physically stronger, she still struggled with a kind of mental-emotional exhaustion. Trying to sustain a healthy lifestyle can be beneficial to our overall well-being, so long as it is kept within certain reasonable limits. At the same time, diet and mental-emotional health can interact in many ways that are not yet well understood.

A good example of this is "schizophrenia". Some research into nutrition (e.g.: the work of Dr. Carl Pfeiffer), would seem to indicate that excesses / deficiencies of particular vitamins and minerals may cause or exacerbate its symptoms. And a relatively recent study has shown that a ketogenic diet may help to allievate those same symptoms.

The field of "Integrative Psychiatry" tries to balance out these different aspects of treatment:

This image is based on one on the Integrative Psychiatry Centers website.

Psychiatric Drug Side-Effects

Unfortunately, the practice of medicine can be a bit reductive sometimes, to the point where these interactions are not even considered. For example, "mental illness" of any kind might be interpreted as simply a "biochemical imbalance" that must be treated soley with psychiatric medications like Selective Serotonin Reuptake Inhibitors (or SSRIs, more commonly known as "antidepressants").

In Chapter 36, Stephanie notes the following. To quote:
...I spent a good amount of time reading about how SSRIs were far from a one-stop fix for PTSD, depression, and anxiety. I have many friends for whom medication has been critical in order to sleep, work, get through the day. And if meds work for you, take them. More power to you! But for millions of people, meds can be unhelpful - or even make their conditions worse...
What does one do when the "cure" is worse than the "illness"? There seems to be a significant lack of awareness when it comes to how psychiatric medications can have adverse effects. A helpful introduction to this topic is Adele Framer's article, What I have learnt from helping thousands of people taper off antidepressants and other psychotropic medications [from the special Discontinuing Psychotropic Medication issue of the Therapeutic Advances in Psychopharmacology journal].

Adele suffered from Post-Acute Withdraw Symptoms (PAWS), severe reactions that arise when someone suddenly stops the use of a drug. In Adele's case, it was not an illicit or addictive substance. It was an antidepressant that was prescribed to her by her doctor. She started an online community, SurvivingAntidepressants, to help other people overcome similar challenges.

Why was this necessary? A person usually cannot stop taking a drug "cold turkey". In order to minimize adverse effects, they must take a small percentage of their previous dose over a period of time, all while paying close attention to how they are physically, emotionally, and mentally responding to that change. This is known as "hyperbolic tapering". The use of multiple medications ("polypharmacy") and nutritional supplements can make the situation much more complex to deal with as well.

Psychosomatic Illnesses and Neuroplastic Symptoms

There are many situations in which significant health problems are caused by sources that are entirely unknown or quite obscure. For example, a disease like "pernicious anemia" could be hard to diagnose and look like a "mental illness" due to how it may affect the nervous system. In some instances, there are things that can be done to heal or to mitigate its symptoms (e.g.: folinic acid supplementation and Vitamin B12 injections).

The inverse can also be true: Trauma can induce the symptoms of an illness within the body without there being any evidence of an underlying physical cause. Those illnesses are generally referred to as "psychosomatic", with symptoms that are "neuroplastic" in nature. This does NOT mean that they are "imaginary". It means that, when the nervous system is under severe stress, it is capable of generating real physical problems throughout the body. That includes illnesses like Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS), Postural Orthostatic Tachycardia Syndrome (POTS), Dysautonomia, and so on.

It is important to keep in mind that the nervous system is NOT trying to make that person sick! It is trying to protect them from danger. The proper treatment must include a kind of "brain re-training" that calms the mind and allows the body to recognize when no threat is present. As their name suggests, neuroplastic symptoms tend to appear, move, or shift throughout the body in response to the amount of stress that a person is experiencing. Yet, psychosomatic illnesses are sometimes only distinguishable from illnesses caused by some kind of structural problem after thorough testing. Unfortunately, that is also why a person can go from doctor to doctor seeking relief, only to be repeatedly told that "nothing is wrong". If that sounds familiar, the work of Dr. Howard Schubiner is an excellent introduction to all of this.

Some illnesses, like the Endometriosis that Stephanie talks about in Chapter 36, can sometimes fall within this category of cause/treatment. She ended up managing the pain by doing Pelvic Floor Therapy and getting her IUD removed.

Social Impacts on Physical and Mental-Emotional Health

This connection between our mental-emotional experience and our physical health often links up to larger social dynamics in ways that are, again, little understood. At the end of Part 3 of the book (specifically Chapters 29 through 31), Stephanie spends quite a bit of time exploring how the intergenerational trauma experienced by the immigrant families within her childhood community was connected to various prejudices and historical events, such as war.

One of the most striking examples that I've come across is the so-called "resignation syndrome" experienced by refugee children in Sweden. To quote the article Agency, embodiment and enactment in psychosomatic theory and practice by Laurence J. Kirmayer and Ana Gómez-Carrillo:
...Since 2001, several hundred cases of refugee children have presented clinically with a syndrome characterised by depression and behavioural withdrawal that progresses to stupor and finally a state of apparent unconsciousness, with loss of pain response, requiring nasogastric tube feeding and intensive care. This condition, reported exclusively in Sweden, has been termed 'apathetic' or 'uppgivenheits syndrome' - literally, "given-up syndrome" but officially translated as "resignation syndrome". The disorder occurred among children whose families were stuck in "limbo" in the process of migration facing an uncertain outcome. Recovery could take months to years and appeared to be related to the restoration of hope to the family, often through receiving permanent residency...
The authors go on to point out how different groups interpreted the causes/effects of the illness in different ways, summarizing the various viewpoints within the following table:

Model Mechanism Clinical Social Political Locus of Agency
Medical Disorder affects biologically vulnerable individuals under certain circumstances Reinforces the role of the clinician and justifies intervention Strains social welfare systems that need to provide universal healthcare Often disregards sociopolitical dimensions of disease, at the same time doctors may be blamed for encouraging the phenomenon Paternalistic medical model that needs to protect the vulnerable individual, who is ill and dysfunctional; victims
Family Interactions in family system dynamics Justifies interventions to address family dynamics, may disempower parents Removes blame from wider system Focus on a certain kind of family rather than the wider sociopolitical forces at play Agency on family as a unit, ultimately parents or individuals
Psychological Effects of uncontrollability through models of learnt helplessness and hopelessness Clinical focus on individual and potential weakness, personality traits Removes blame from wider system Individuals considered problematic, potential consequences regarding immigration Agency on individual
Political Impact of political decisions governing the asylum process Politicises role of clinician, warns of iatrogenesis Public concerns over their vulnerability and welfare Pragmatic response at a system level may worsen long-term outcomes or add to iatrogenic mechanisms Agency on sociopolitical system
Cultural Symptoms reflect patients' cultural or religious background and that of the country to which they migrate May lead to disengagement, exoticisation, and call for experts to understand the phenomenon Risk of stigmatising, othering and reduced empathy. May potentiate discriminatory responses in combination with assumption of secondary gain More structural or intersectional concerns are hidden behind "cultural" issues, removes immediacy to act, be responsive On cultural group, cultural differences are highlighted, may lead to 'othering'
Intentional Intentional action (based on conscious decision) by family or the child Clinical interventions likely to make things worse Questions the authenticity and legitimacy of their claims, implies secondary gain and potentially malingering Criticism of failed empathy and compassion, contrasts with country's self-image as an international model for immigration/children's rights On individual or family as malingering for secondary gain purposes, children and families as untrustworthy 'others'

These types of considerations are important to be aware of when attempting to heal trauma on a collective level, such as within the context of peacemaking. The connections between trauma and physical health can stretch across space and time, influencing the circumstances of the individual as well. For example:

In Chapter 15, Stephanie noticed how difficult it is for someone to find a therapist who will both accept their insurance and who is willing to take them on as a "client". She also describes how it is necessary to get a specific "diagnosis" in order to receive treatment. With those types of systems in place, how many people stay sick because that is the only way that they will receive any kind of help?



Next, let's look more closely at how the Emotional and Cognitive aspects of ourselves interface with our surrounding Microsystem and Exosystem (i.e.: relationships with Family / Friends and Community)...

Stages / Phases of Treatment

Stephanie mentions Judith Herman's' book, Trauma and Recovery, as well as Gretchen Schmelzer's book, Journey Through Trauma. Both authors present a model of treatment and recovery from trauma as divided into distinct stages / phases:

Judith Herman's Model Gretchen Schmelzer's Model
Stage 1: Safety Phase 1: Preparation
Stage 2: Remembrance and Mourning Phase 2: Unintegration
Phase 3: Identification
Stage 3: Reconnection Phase 4: Integration
Phase 5: Consolidation
Stage 4: Social Healing

One might correlate the stages and phases between the two models slightly differently. Here, I've simply gone with what makes the most sense to me personally. Both are valuable. Since Judith Herman is the one who first developed the concept of "C-PTSD", the first three stages of her model seem to be the most prevalent within psychotherapy. This is often reflected within books about treatment, such as:

• Courtois, Christine, and Julian Ford. Treatment of Complex Trauma. Guilford Press, 2015.
• Gingrich, Heather. Restoring the Shattered Self. Second ed., InterVarsity Press, 2020.

Let's focus in on these models for a moment...

Preparing for Inner Work by Creating a Safe Space (Stage / Phase 1)

Although these models are not covered in the book, they are a useful framework for classifying various healing methods. They help us to know when, how, and why to use them! For example, in Chapter 20, Stephanie goes through several methods that could be considered "Stage 1" approaches:

• "Grounding" techniques, like when she counts all of the objects within the room that are the same color at the onset of a stressful situation

• Exercises that induce "somatic awareness", like when she took a Restorative Yoga class

• Mindfully eating, like when she tried to savour all of the flavors of her chicken wrap

All of these create an awareness of our body and our current environment that counteracts the tendency to "dissociate", or disconnect from our present experience. [Within the article, Handling Stress, Anxiety, and Trauma, we've mentioned several other methods that are similar, such as Trauma Release Exercises (TRE) and Trigger Point Therapy / self-massage.]

Stephanie goes into a brief "neurobiological" explanation as to why this works: Mindfulness quiets a cluster of brain centers that tend to ruminate upon memories of the past or imaginations about the present and future. It is known as the Default Mode Network (DMN). This quieting of the DMN actually corresponds to some spiritual states triggered by certain forms of prayer or meditation. The work of Gary Weber on the concept of "self-enquiry" or "ego-death" highlights this connection well.

In Chapter 22, Stephanie describes a "trip" that she had on psilocybin (i.e.: hallucinogenic mushrooms) while relaxing in a garden. She experiences a similar state for a relatively short period of time. It inspires her to focus on gratitude for both the things that bring her joy and the joy that she can provide to others.

Religious and drug-induced experiences aside, there is a collection of "Stage 1" techniques researched and developed specifically for the treatement of C-PTSD. They are referred to as the Finding Solid Ground program. As the name implies, they are intended to create the proper foundation for approaching "Stage 2" without getting re-traumatized and repeatedly struggling through crisis.

Another extremely helpful collection of techniques is Dialectical Behavior Therapy (DBT). [We've mentioned it before within the Relationship Difficulties article.] There are websites that go through each skill or that provide a free course on how to use them. If you want something shorter and more self-contained, there are several books that are very straightforward and practical introducitons to DBT, such as:

• Real Skills for Real Life by Shireen Rizvi and Jesse Finkelstein
• The Dialectical Behavior Therapy Skills Workbook by Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley

Remembrance as Unintegration of Destructive Beliefs and Identification of Constructive Learnings (Stage 2 / Phases 2 and 3)

Stephanie also describes her experiences with a form of therapy that would fall under the category of "Stage 2", Eye Movement Desensitization and Reprocessing (EMDR). During her EMDR treatments, she has some intense recollections of her childhood experiences that help her to be more compassionate towards herself.

The purpose of the "remembrance" and "mourning" that takes place in "Stage 2" approaches is to create a coherent narrative of one's life experience and to take the time to grieve whatever might have been lost in the process, such as one's own childhood.

It is important to cultivate a sense of self-compassion independently of one's ability to remember. It may not be possible, or even helpful, to recall "all" experiences. I appreciate how the therapist Tamara McClintock Greenberg puts it. To quote her book, Treating Complex Trauma:
...One of the major deprivations that occurs with repeated trauma is that it takes away our ability to have a tale to tell. Therapy can and should help [a person] develop this, but it's more realistic that part of the narrative involves a loss of coherence, the loss of a story...
However, just because an image does not come up mentally, does not necessarily mean that "nothing is there". For example:

In Chapter 20, Stephanie also mentions the concept of an "emotional flashback". One can be consciously aware that they are not in danger, while simultaneously, their body responds emotionally as if a past threat is present.

Some types of somatic psychotherapy could be considered "Stage 2" treatments in that they help one to process those kinds of feeling memories. But again, the only way to safely approach them is to have a set of "Stage 1" skills in place. Why?

Along with things like chronic pain, emotional flashbacks can induce a kind of aversion to somatic awareness. In other words, it can feel very unsafe to try to access dissociated parts of one's own body and mind. This is part of the reason why we are aiming for an "embodied" sense of "Self". There is no part of you that you should feel ashamed or uncomfortable to take "ownership" of. They all serve some useful function and can work together as one complementary whole. But only if we take the time to understand them and to patiently guide them.

While Stephanie mentions it only briefly and somewhat critically within Chapter 34, Internal Family Systems (IFS) therapy provides a helpful framework for doing this. IFS broadly categorizes our various "parts" by what they do, referring to them as "Managers", "Firefighters", and "Exiles", respectively. A fantastic introduction is the article Boundaries for Your Soul by Alison Cook and Kimberly Miller. To quote:
Managers are protectors that strive to keep you emotionally safe and prevent more vulnerable parts of you from experiencing harm. They drive you to perform, produce, protect, and please. [...] While managers try to act preemptively, firefighters try to extinguish pain after it occurs. These impulsive parts indulge in a lot of whatever feels good, distracting and tricking you into believing you are handling life well. [...] Exiles are the distressed parts that your managers and firefighters are trying to protect. [...] Exiles have great need, and they have often yielded their power in counterproductive ways.
Treatment within IFS mainly consists of exploring these various parts and harmonizing them with one another through a transcendent "Self", the core aspect of our being that truly embodies "The 8 C's": Calmness, Curiosity, Compassion, Confidence, Courage, Clarity, Creativity, and Connectedness.

Reconnecting to Life through Integration and Consolidation of Constructive Learning (Stage 3 / Phases 4 and 5)

Stephanie's therapy sessions with Dr. Jacob Ham could be considered a "Stage 3" approach.

Beginning in Chapter 37, Stephanie describes how they are able to analyze recordings of their conversations together in order to gain a deeper awareness of what they were experiencing within each moment. Jacob repeatedly points out where she is mistaking her pain as wholly personal, pervasive, or permanent. He also provides alternative ways of responding to situations that foster connection rather than a sense of condemnation or punishment towards herself and other people.

This gives Stephanie greater clarity in how she habitually responds in her interactions with others outside of the context of therapy. Eventually, this becomes a way of living that positively impacts her marriage and other close relationships with family and friends.

There is an emphasis on the idea that healing is relational. Having a community of people who are also working through C-PTSD could help to facilitate that, so long as it doesn't degrade into the situation that Stephanie describes within Chapter 21 (i.e.: becoming overwhelmed by other people's trauma without personal healing taking place).

Stephanie gives a link to Pete Walker's 4F Model within the footnotes of Chapter 11. It is useful for showing how trauma can rewire our subconscious survival responses (i.e.: flight, fight, freeze, and fawn) in ways that might lead to self-sabotaging beliefs and behaviors.

One healing method that could be considered "Stage 3" in nature is Schema Therapy. In this context, a "schema" is "any broad organizing principle for making sense of one's life experience".

Schema Therapy describes how destructive schemas are formed when our fundamental needs are not met throughout our growth and development, such as in the case of childhood abuse, for example. Those types of schemas are referred to as "Early Maladaptive Schemas" (EMS). In turn, EMS can act as a filter for our perceptions and influence our self-image.

When combined with a strong emotion, an EMS can lead to automatic reactions that are unhelpful. Those reactions are called "Coping Styles". Coping Styles are related to our subconscious survival responses. The combination of an EMS and a Coping Style at any given moment is known as a "Mode". Understanding these Modes is a large part of treatment.

The model behind Schema Therapy might seem complex, but at its root, it is very simple:

We are trying to transform any destructive schemas into constructive ones, so that we can come up with healthier ways of coping with situations in life. This process is called "Reparenting".

Ideally, everyone's needs would be met in ways that foster a sense of security and safety, so that we instinctually develop the characteristics of "tenacity". This is rarely the case, even in the best of circumstances. We could all probably use some Reparenting.

Healing Cultural and Structural Violence (Stage 4)

We've already noted how the larger social context in which people are embedded has a significant impact on both the occurrence and the healing of trauma. Some interesting parallels can be drawn between how violence and infectious diseases spread. Let's explore some ways of understanding it and healing it...

Topics To Go (in no particular order):

+ Cover Intergroup Threat Theory parallels to 4F Model and how it shows up within our neurobiology
+ Describe Galtung's Triangle and the three different types of violence (Direct, Cultural, and Structural)
+ Elaborate on the concepts of moral disengagement and enemy images that perpetuate each form of violence



[In Progress...]


Related Resources

• Lease the eBook from Google Play $

• Being Well Podcast: Living with Complex PTSD

• Navigating Narcissism Podcast - Season 2, Episode 5: Confronting Complex PTSD with Stephanie Foo