The document discusses psychological trauma and injury. It proposes that trauma results from experiences of loss, disaster/tragedy, or betrayal, which damage one's sense of self-worth. Unresolved trauma can lead to symptoms of depression, anxiety, guilt, anger, and shame as protective behaviors to regain control. Over time, symptoms may become rigid coping habits or ways to control others and avoid responsibility. The document advocates understanding depression and anxiety not as conditions but as meaningful belief structures arising from trauma.

1. There is no greater privilege, then to share in the suffering of another!

2. Disclaimer
Given the number of counseling approaches there is no shortage of opinion on how best to view the basic constructs within our field.
The ideas presented herein are simply those that assist me in my work and in my understanding of human motivation and pathology.
They are also a form of homage to Robert Sherman and Richard Belson, two remarkable clinicians that have greatly shaped our
understanding of power and its role in psychological injury and the intergenerational transmission of trauma.
Background
We were substance abuse counselors, since the mid-1970’s, when we began our training with Dr. Robert Sherman in 1980 and
continued until his retirement and relocation from New York City in 1992. Bob (Robert) was an AAMFT Clinical Supervisor, author,
co-founder of Adlerian Family Therapy, a long-time Fellow at the North American Society of Adlerian Psychology, and Chair of the
Department of Marriage and Family Therapy Programs at Queens College which he founded and where I served on faculty in 1986
and 1987. This remarkable, 12-year mentorship included small-group instruction with noted Adlerians Kurt Adler (1980), Bernard H.
Shulman (1980), Harold Mosak (1980-1981) and Larry Zuckerman (1982-1983), as well as a unique series of live-practice seminars
with Maurizio Andolfi (1981), Adia Shumsky (1982), Carlos Sluski (1983), Murray Bowen (1984), James Framo (1985), Bunny Duhl
(1986), Monica McGoldrick (1987), Carl Whitaker (1988), Jay Haley (1989), Salvador Minuchin (1990 and 1991) and Peggy Papp
(1992). In March 1991, we undertook a two-day intensive with Patricia and Salvador Minuchin. Throughout these years, and since,
Bob has remained enormously influential, promoting counseling and psychotherapy and guiding the training of hundreds of advanced
practitioners in clinical methods and practice. I am very grateful to continue to regard him as a friend and mentor.
In 1990, a small group of us began a two-year, 30-session externship with Dr. Richard Belson, Director of the (Strategic) Family
Therapy Institute of Long Island. This innovative, live-supervision practicum employed a team-therapy approach to treating chronic,
highly intractable problems. At the time, Richard was collaborating with Jay Haley and Cloe Madanes at the Family Therapy Institute
of Washington, D.C. (1980 to 1990), on faculty at the Adelphi School of Social Work, and serving on the editorial board of the Journal
of Strategic and Systemic Therapies (1981 to 1993). He is most noted for his work on forgiveness, revenge, and various methods for
undermining passive-aggression and power-plays. To this day, I have yet to witness a more brilliant and creative tactician.
The following notes stem from their perspectives.
_______________________ . ________________________
Demetrios Peratsakis, MSEd, SDSAS, LPC, ACS, Western Tidewater Community Services Board; 2020
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3. 3
There exists an extensive body of literature on the causes and treatment of trauma.
As such, the ideas presented herein are simply those that assist me in my work and in my
understanding of human motivation and pathology.
Please also note that this PowerPoint is an abridged version of
a more extensive training, available upon request.
YouTube version: https://youtu.be/Qsx4xZbk3Ug

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Hardships and disappointments are a natural part of life.
When gauged as deeply distressing or disturbing experiences
we refer to them as psychological injury or trauma.
The actual injury is damage to one’s sense of self-worth, an estimation of trust in one’s
own capabilities as well as in the safety and security of one’s relationships.
Trauma fosters guilt, anger and shame, and because of its social implications may harbor
blame and resentment toward others. Its results are cumulative.
Unresolved, it results in depression and anxiety.

5. Accidents, Natural Disaster, Illness, Injury
1. Accidental Physical Injury
2. Fire
3. Industrial Accident
4. Work Accident
5. Invasive Medical Procedures
6. Injury or Illness
7. Motor Vehicle Accident
8. Natural Disaster
9. Property Loss
Threat or Harm to Others
1. Death of a Loved One
2. Injury or Illness of a Loved One
3. Threat to a Loved One
4. Witness to Violence
5. Suicide of a loved one
Threat or Harm to Self
1. Adult Sexual Assault
2. Captivity
3. Childhood Sexual Abuse
4. Combat & Military Sexual Trauma
5. Communal Rejection (Scapegoating, Shunning)
6. Cults and Entrapment
7. Domestic Violence
8. Physical Assault
9. Rape
10. Robbery
11. Sexual Harassment
12. Threat of Physical Violence
13. Torture
14. Victim of Crime
15. Victim of Violence
16. Witnessing Traumatic Event
A broad spectrum of events can lead to trauma and complications in mood,
thought and in one’s own sense of self and beingness in the world

6. Common Signs and Symptoms of Psychological Trauma
Cognitive/Behavioral:
 Intrusive thoughts, images, smells and sounds of the event
 Nightmares
 Disorientation, confusion, loss of memory or ability to concentrate
 Mood swings, especially fear, sadness and anger
 Avoidance or lack of interest in activities or places that trigger memories
 Social isolation and withdrawal
Physical:
 Fatigue and exhaustion
 Tachycardia; irritable or edgy, nervous or easily startled
 Insomnia or difficulty sleeping; loss of appetite of eating problems
 Sexual dysfunction
 Hypervigilance; preoccupation with safety, danger or risk
Psychological:
 Feeling overwhelmed or fearful; feeling anxious, vulnerable and unsafe; panic attacks
 Ritualized behavior, obsessive and compulsive behaviors; rumination
 Depression or detachment from others
 Failure or self-defeating behavior
 Blaming, shaming or feelings of guilt
 Anger
Untreated Psychological Trauma, may include
 Addiction, Alcoholism or Substance abuse
 Sexual problems or dysfunctions
 Distrust/Issues with intimacy, closeness or trust
 Hostility or rage
 Combativeness, pervasive irritability or social withdrawal
 Self-destructive behaviors including self-injury and suicide
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7. Anxiety and Depression --including such varied forms of expression as dread, worry, hesitation, remorse, grief,
and despair, are affective conditions fueled by guilt and shame, two highly corrosive, negative estimations of
the self. Because guilt and shame are rooted in the opinion of others, a corresponding sense of anger or
resentment occurs, and worsens whenever there is a perception of injustice or critique.
The ensuing Guilt, Anger and Shame (GASh) corkscrew into repetitive cycles called rumination. This may
deepen into feelings of worthlessness, hopelessness, and suppressed rage expressed as depression and anxiety.
The root of emotional pain is the hurt caused by any of the many kinds of trauma, most simply categorized as
either a loss, disaster, or betrayal. Unresolved, the ensuing damage, or psychological injury, is a degree of harm
to one’s perceived sense of self in relation to others --their self-esteem or sense of self-worth. This mars their
desire to trust and to be intimate and causes them to feel dis-empowered and less capable.
Symptoms may develop as a means to gain or re-gain control and to stabilize and reorganize the individual and
their relationship system. As such, they accumulate meaning and power or the ability to influence outcome.
Over time, the behaviors may concretize into established transactional patterns or habits that we call symptoms.
These become rigid and resistant to change.
As counselors, our main concern is when these conditions fulfill some important function or method of coping.
In particular, we are concerned when they become power-struggles or serve as a means of controlling or
punishing others or as a method of excusing or avoiding responsibility for change.
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8.  Hurt or harm from experiencing a disaster, suffering a loss, or becoming the victim of the breach of a
sacred trust (betrayal) creates a psychological injury. This is what we call trauma.
 The injury, or trauma, is damage to one’s sense of self-worth, one’s self-esteem or estimation of self in
regard to the cumulative opinion of others, one’s past, and one’s idealized self.
 Anger arises at the perceived injustice of others (or the world).
 Symptoms emerge as protective, safe-guarding behavior that help reassert control and safe-guard or
shield the individual and their relationship system from further injury or harm.
 The most common symptoms are depression and anxiety, which carry strong evolutionary advantage.
This is a very different way of understanding depression and anxiety. Instead of thinking of them as
conditions that befall the individual, this viewpoint regards them as constructive belief structures that
generate psychological as well as somatic changes.
 Depression and Anxiety are identical emotional experiences; their temporal frame differs. Depression
(bad/sad) is past-oriented, whereas anxiety (fear/dread) is a foreboding of events as yet to come.
 Depression and Anxiety are fueled by Guilt, Anger and Shame (GASh).
 Left unresolved, Anxiety and Depression may become a means of avoiding risk of further injury. In
some instances, it may be used to deflect blame, control others, punish others, or avoid the
responsibility to change.
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9. A Simpler Model for Understanding Psychological Injury

10. All trauma results in pain.
The source of the injury, however, can greatly effect the type of psychological damage that occurs.
The death of a loved one, devastation through flood or accident, and infidelity or abuse, all differ
greatly because of the nature of the injury and its associated meaning.
The next slide denotes three categories of psychological injury:
Loss, Tragedy/Disaster and Betrayal.
While there may be other ways to group trauma, doing so based on the source of the injury
helps the clinician to better understand the kind of injury that has occurred
as well as the most likely path for clinical intervention.
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11. Tragedy/Disaster
An event causing great suffering, hardship,
destruction or distress, such as a serious
accident, crime, or natural catastrophe.
Loss
Ambiguous loss, loss of a loved one, loss of
prestige, a prized possession, a familiar way of
being, one’s health, or one’s goal.
Betrayal (breach of trust)
The breach of the trust agreement in
friendship and love, including abuse, neglect,
incest, infidelity and sexual affairs.
• Impact: sense of Vulnerability
• Emotional experience: Fear (Dread)
• Preoccupation: Avoidance (Safety-Needs)
• Impact: sense of Emptiness
• Emotional experience: Grief
• Preoccupation: Replacement
• Impact: sense of Treachery (Power
Struggle or Conflict)
• Distinguishing Feature: Anger; Rage
• Preoccupation: Revenge
OftenOverlap
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Source of Injury Psychological Impact

12. The next slide depicts an illustration for understanding
the development of complex depression over time. Since we don’t truly know
how depression forms, this is simply a working model.
All psychological injury results in a complex belief structure that includes hurt and
despondency over the event. Typically, guilt and shame surface as the individual evaluates
their own role in the occurrence or in their ability to remain safe.
If others failed to adequately protect the individual, perpetrated the harm, or were critical in
their assessment of the individual’s performance, anger and resentment will emerge.
When dread of reinjury or a sense of vulnerability persists, the individual
will also develop anxiety and foreboding.
Depression can evolve into a chronic syndrome characterized by feelings of
worthlessness and discouragement, but also of suppressed anger and rage.
.
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13. The Development of Depression and Rage
Trauma: Disaster; Loss; Betrayal (including abuse, neglect, incest and affairs)
Anger
Guilt
Shame Anxiety/Dread
Sadness
DepressionRage
Primary Emotion/Initial Reaction:
Complex Emotion/Over Time:
Sense of Discouragement and Worthlessness
Fear
Demetrios Peratsakis, LPC, ACS © March 2016
Anger, sadness and fear are natural responses to psychological injury. They result in feelings of depression and anxiety, which are fueled by thoughts of guilt and
shame. Anger, which can provide a faulty sense of power, is an attempt to counter-act the feelings of guilt and shame; to retain the anger, the harm or emotional
pain must be continually reactivated (rumination) in the form of self-pity or blame. This can result in feelings of helplessness and worthlessness or the desire to
over-power, punish or seek revenge. Unresolved, the effects of trauma are cumulative and typically erode confidence in self and trust and intimacy with others.
Treatment considerations for Depression and Anxiety:
1. Resolve conflict and disengage and redirect the power-play; practice enacting new ways of behaving and interacting. Challenge the meaning and the power of
the depression and its symptoms; examine how it avoids responsibility and how it controls others.
2. Tap underlying feelings of anger; seek acknowledgement and de-escalation; examine betrayal and work on revenge, forgiveness and redemption.
3. Bridge emotional cut-offs; fill loss; connect to meaningful activity and relationships; develop a sense of purpose and rekindle spiritual being-ness.
4. Consider medication for mood stabilization and safety or suicide planning, as needed. Look to self-care and general health.
OverlappingandCyclicEmotionalStrands
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14. The next few slides show a very interesting relationship
between Anxiety and Depression.
Anxiety, is fear, dread and foreboding; Depression, sadness, sorrow and despair.
It is suggested that it makes clinical sense to regard them as one and the same,
with the only difference being the temporal frame of reference.
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15. 15

16. Depression
Feeling sad, bad, hopeless or worthless. Experiencing guilt
or shame over conduct or actions.
Common depression signs and symptoms include:
 Persistent sad, anxious, or "empty" mood
 Feelings of hopelessness, pessimism
 Feelings of guilt, worthlessness, helplessness
 Loss of interest or pleasure in hobbies and activities that
were once enjoyed, including sex
 Decreased energy, fatigue, being "slowed down“
 Difficulty remembering, making decisions
 Insomnia, early-morning awakening, or oversleeping
 Appetite and/or weight loss, or overeating and weight
gain
 Thoughts of death or suicide; suicide attempts
 Restlessness, irritability
 Persistent physical symptoms that do not respond to
treatment, such as headaches, digestive disorders, and
chronic pain
Anxiety
Fear, dread or foreboding; a state of uneasiness,
apprehension, uncertainty, and fear resulting from
anticipation of a realistic or fantasized threatening event
future uncertainties or situation, often impairing physical
and psychological functioning
Common anxiety signs and symptoms include:
 Feeling nervous, restless or worried
 Having a sense of impending danger, panic or doom
 Increased heart rate/Breathing rapidly (hyperventilation)
 Sweating, trembling, feeling weak or tired
 Trouble concentrating/thinking anything other than the
present worry
 Having trouble sleeping
 Experiencing gastrointestinal (GI) problems
 Having difficulty controlling worry
 Having the urge to avoid things that trigger anxiety
Past Events Future Events
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18.  Anxiety = is fear and foreboding (tension; distress) due to a perceived sense of vulnerability, especially
with a preoccupation and concern over the potential reoccurrence of harm (dread).
 Depression = feelings of sadness and hurt from experiencing a disaster, suffering a significant loss or
becoming the victim of betrayal by a trusted or loved one.
 Both include feelings of Anger that is fueled by Guilt and Shame.
 Anxiety is future-oriented, a preoccupation with something yet to come; Depression, with conditions that
currently exist or events that have already happened.
Anger
Sadness
- Demetrios Peratsakis, LPC, ACS
Guilt
Shame

19. The following slide illustrates the fundamental way to remedy trauma.
1. The guilt and shame must be reconciled
and their underlying (cognitive) distortions restructured.
2. The anger that accompanies the hurt must be validated and given voice.
As the therapist taps into the anger, the depression will lift.
The simple rule is: where there is depression, there is also anger.
(“Sad!” = “Mad!”.; to diminish the “Sad!”, tap into the “Mad!”)
3. Self-worth must be improved by increasing confidence and prestige through
social involvement that is purposeful and meaningful.
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20. - Demetrios Peratsakis, LPC, ACS © 2015
Sadness
Fear
Anger
Guilt
Shame
1
2
3
Depression and
Anxiety will lift
Work through
Guilt and
Shame
Tap into
underlying Anger
Empowerment
begins
Self-worth
Improves

21. While there are numerous strategies and interventions for repairing psychological injury,
the following tactics should be a part of any approach and treatment plan.
1. Medication can be a valuable tool for stabilizing the highs (anxiety) and lows (depression) in mood that
accompany the emotional pain of trauma. Be mindful, however, that because medication (and drug use) can
blunt the experience of pain, this may detract from the individuals willingness to seek counseling. When both
are employed, medication should augment, not serve as a substitute for, talk therapy.
2. Ending the source of the Damage, then Repairing it. Failure to thrive, domestic violence and other sources
of chronic demoralization must be addressed first. The simple rule is, 1) work to end the source of the injury,
2) while building up the self-esteem, and then 3) treat or repair the damage that’s been caused. Repair includes
working through the underlying guilt, shame and anger (GASh). Since some of the worst damage results from
betrayal, working to re-build trust in relationships and increasing social interest (care of others) is critical.
3. Building Self-worth: self-worth is tied to once estimation of self, their competencies and abilities, as well as
to their evaluation by others. Empower the individual through constructive “can-do” skill developments,
especially those that increase one’s sense of social competency and adulthood. Feeling able and “adult” has
protective value, makes one feel less vulnerable and more confident. These can be any form of achievement,
the more enduring the better. “Dooming the Client to Success” is important, so early endeavors should be
small, geared for success and reviewed for the possibility of failure or sabotage.
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22. 4. Revenge is important to the healing process. While immoral and illegal activities are counter-therapeutic and
should be discouraged, many forms of retribution are beneficial to recovery. Validate the desire for revenge,
give the underlying anger voice, and help the individual work through their own guilt and shame. A common
admonition is that “It’s O.K. to hope that he gets hit by a truck, so long as you’re not the one driving it”.
Naturally, the best form of revenge is to heal and move forward with life.
5. Forgiveness and Redemption: Forgiveness is transformational; for the perpetrator, as well as the victim.
While retribution and apologies may be helpful, genuine forgiveness is only made possible by genuine remorse.
6. Not all Depression is the Same. It’s helpful to think of depression as falling into one of three categories:
 Simple depression: the natural sadness and worry that accompanies disappointment and loss. Rarely will
this result in the need for counseling. The individual and their relationship system will heal the pain on
their own over time.
 Complex depression: An injury that results in a greater degree of pain that effects daily living, and is
accompanied by a pervasive sense of guilt and shame. An important feature of complex depression is that
the individual harbors unresolved resentment or rage. Untangling the hurt and voicing the anger are
important to resolving it.
 Depressives: Individuals, often adult children of chronic childhood abuse, can develop a “depression-
prone” or “depression-like” style of life that we call “depressive”. Depressives have learned from early on
to control and manipulate others through their depression. It’s a highly effective strategy for getting one’s
way without having to accept responsibility or blame. When you work with someone who you believe
“wants to, but can not”, you feel compassion; but when you work with someone that you sense “can do,
but will not”, you feel angry and resentful. Few syndromes pose a greater challenge to the therapist, for
these individuals can present as very demanding, passive aggressive, and manipulative. The key to success
is to check your own anger and to remember that the person is in dire need of compassion and love, the
very thing they fear and that their behavior is fashioned to guard against.
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23. For additional information or materials please contact me directly at
dperatsakis@wtcsb.org or dperatsakis@gmail.com