Back From the Brink: A Family Guide to Overcoming Traumatic Stress, by Don R. Catherall, Ph.D.
Table of Contents | Introduction | Afterword
Chapter 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12
back to EmotionalSafety.net
previous | next
1
A
BROKEN LIFE
Traumatization and How It
Happens
William served a year as an infantryman in Vietnam. Like many men who see heavy combat, William experienced a number of traumatic events. He lost several close friends, he was nearly killed several times, and on one occasion he was certain he was going to die. But he did make it home, and once there he tried to put Vietnam behind him. He went to college on the G.I. bill, but he didn't perform well; his concentration was poor and he couldn't apply himself to his studies. He was preoccupied with Vietnam; memories of the carnage kept coming back to him. He had some success at forgetting Vietnam during the day, but at night it invaded his dreams. In fact, it was hard to sleep because of recurring nightmares. He was trying to live his life as though his experiences in Vietnam were nothing but history and therefore had no further effect upon him.
Socially, he couldn't fit in with the other students, and he lived a very isolated life. He worked at jobs that required a minimum of dealing with people. He lived alone in a dilapidated house outside town and spent less and less time interacting with the other students at the university. He'd hunted as a boy, and now he kept weapons in his house and spent long hours cleaning them. The only social life he had was occasionally visiting bars in the area, where he sometimes found himself talking to strangers about his experiences in Vietnam. Still, he somehow kept up his grades and got by.
After about a year of this life, however, he started drinking too much, and his performance and his attendance at school fell off. Finally, he gave up on school and went to work full time as a security guard. But he lost that job because of frequent absences. After that, he drifted for several years, holding a series of jobs. Eventually, he wound up at a commune where everyone was into natural foods, yoga, meditation, and other health‑oriented pursuits. He found that they accepted him as long as he did his share of the work. Over a period of months, he stopped drinking and became a valued member of the commune.
William stayed at the commune for over five years. During that time he talked to people about his experience in Vietnam. More than once, he got upset as he recalled some of the things that most disturbed him. But the commune accepted him‑they wanted to understand what he'd been through. This gave William a sanctuary where he could examine what had happened to him and come to terms with the emotional turmoil with which he'd been struggling. Slowly, the turmoil subsided. As he regained his ability to apply himself to projects, he apprenticed himself to two members of the commune who taught him carpentry. Eventually, he fell in love and got married, and he and his wife left the commune and moved to a city. Today William is a master carpenter and a devoted family man.
William's story is not uncommon. Many Vietnam veterans came home and discovered that they couldn't fit into the world they had left. They tried to resume the business of living the best they could. Some were lucky enough to find a niche where they fit, but others were not so lucky. William's story is one of the successful ones: During his five years on the commune, he lived a life that allowed him to feel accepted and understood while he negotiated the painful process of healing from his traumatization.
Many of William's fellow veterans had similar problems, such as drinking and having trouble with relationships and holding a job. But when they sought help, their problems were usually seen as the result of basic character flaws, and they were viewed as misfits. The people around these men didn't recognize that they were reeling from the effects of their war experiences.
Lynn was a middle‑aged professional woman who lived alone in a large city. She enjoyed her career and put a lot of energy into it, gaining positions of authority and status. She led an active social life and maintained many friendships and interests. Frequently she got together with family and friends and attended cultural events and played sports. She liked the city and had never been afraid of living there. All this changed, however, after she was mugged.
Although the mugging lasted only a few seconds, Lynn fought back and nearly got herself hurt very badly. After it was over, Lynn tried to forget it and go on with her life as if everything were normal again, but she found that she was now afraid of many things. She didn't go out much, and she lost contact with many of her friends. She stopped participating in sports and attending cultural events. Work was no longer satisfying to her. Preoccupied with what had happened to her, she often relived the mugging in her mind, always wary of it happening again. She found it increasingly difficult to sleep, and she started drinking to help her sleep.
Lynn was traumatized by her experience. Fortunately, she is a strong woman. Her life continues, and she does not appear to be in a state of shock like some people who've been traumatized. Most of the people she works with don't know what she has been through. But inside, she feels different from everyone else. She is no longer involved with people as she once was; she feels very vulnerable around others. Despite the progress she has made, she hasn't reached the point of feeling carefree again.
There are many similarities between William and Lynn. They were both traumatized by a near‑death experience, despite the difference in magnitude. William was exposed to death almost daily for a year; Lynn had one brief‑but intimate‑brush with it. And they were affected in very similar ways: Both were traumatized, and both suffered from PTSD.
We all start out life totally dependent upon our caretakers to keep us alive and free of hurt, whether physical or emotional. In order to function independently, we slowly develop and learn to take care of ourselves. But a core feeling of extreme vulnerability stays with us, usually buried deep inside our memories. We learn to protect ourselves from feeling vulnerable by increasing our control over our environment and by convincing ourselves that we're safe.
Sometimes we aren't really as safe as we wish we were, so we fool ourselves by developing illusions of security. These illusions allow us to contend with the daily tasks of life without being constantly overwhelmed by anxiety about our underlying fragility. Periodically, however, things happen that remind us that we're not really as safe as we would like to think. We get hurt: Our bodies are torn, bones get broken, we get burned, or someone makes us feel unloved, uncared for, or worthless.
We've all experienced events that threaten our sense of safety. Those who are fortunate profited from those traumatic experiences. They developed strength of character, they learned that they could survive and that they could recover from fearful experiences. In effect, they became less controlled by their fears. But those less fortunate became more controlled by those fears. Perhaps they learned that they weren't as strong or as secure as they believed. They began to live in fear of more trauma, and their range of choices in life narrowed as a result.
Some traumas are immense, while others are relatively minor‑but all can be traumatizing. We expect an accident victim who has lost a limb to be traumatized, but we don't expect it from the bystander who only witnessed the accident. Yet traumas that appear to be minor can produce severe consequences, and sometimes those that seem to be major don't produce the catastrophic effects upon the individual that one would expect.
As I outlined in the introduction, our response to traumatic events is determined by five factors, including: (1) the nature of the event, (2) the meaning we give it, (3) our unique personality, (4) our coping style (this includes the way we learned to deal with past trauma), and (5) the nature of the response we get from others following our traumatic experiences.
The greatest difficulty we have in identifying traumatization is that we don't always know the meaning that a particular event has had for an individual. If you are traumatized and other people don't recognize what has happened to you, then you are less likely to recognize it yourself. You may live alone with it, with no opportunity to share your grief with others, or to talk about it and examine what it has done to you. It can be hard to recognize when someone has been traumatized because people are often exposed to trauma without being traumatized. We're accustomed to the idea that traumas are part of life, and that most of us deal with them at one time or another.
Throughout history, individuals have been psychologically damaged as a result of their exposure to traumas. Stories of these individuals appear in our literature, our histories, and our cultural myths. One of the most common themes is the lone survivor of a cataclysm, such as a battle, a sunken ship, a disease, or another natural disaster that devastated a community. He is a tragic figure, generally unable to experience joy and haunted by the memory of what happened. Often, he lives a kind of death trip, pushing his own luck until fate causes him to rejoin his lost companions through his own death. In other cases, the survivor devotes his life to serving or possibly avenging his comrades. Many of the heroes of popular literature are such survivors, like the Lone Ranger and the Phantom, who devote their lives to helping others.
Captain Ahab, the whaler in Herman Melville's famous novel Moby‑Dick, is a survivor who endangers others in his headlong rush to test fate and seek revenge. But ultimately, he rejoins his lost comrades‑a common outcome in stories about lone survivors. Some survivors seek to repeat their trauma; in a sense, they're trying to master it. And sometimes they feel so guilty about surviving when others didn't that they repeat the trauma in order to satisfy their guilt, and they continue to repeat it until fate finally catches up with them.
Another common literary figure of traumatization is the individual who has lost her sense of herself as a person. She is seen as helpless, drifting in the sway of forces greater than herself. Lorena, who is kidnapped and traumatized by renegades in Larry McMurtry's novel Lonesome Dove, is unable to care for herself and must live apart from other people while she rediscovers her connection to civilized people. Newt, the little girl in the 1986 movie Aliens, is similarly unable to relate to people after surviving the devastation of the aliens. Both Lorena and Newt are able to recover their connections to other people only after one caring person persists in trying to reach out and understand them.
Our culture is full of images of traumatization. We see them in novels, movies, on television‑even in comic books. It's the victim who is still in a state of shock long after the traumatic event, who can't describe the horror of what he has experienced though it is evident in his frozen expression. It's the soldier who can only stutter in answer to the assaultive questioning of General Patton. It's the cold, singleminded heroine who has witnessed a villain kill her family. But are these cultural images truly representative of what trauma victims are like? The answer is‑not entirely. These images are dramatic, and such cases do exist. But many, many more people have been traumatized who don't stand out in these exaggerated ways‑even though they bear much in common with these cultural stereotypes.
Randy was a policeman. He worked in the inner city with a special unit that dealt with violent situations. He never fired his weapon, but he was often in confrontations with people who had weapons. He was stabbed and hurt physically several times; he saw a number of citizens hurt badly and was often exposed to the aftermath of violent death. Unlike many of his colleagues, however, Randy didn't resort to drinking or drugs‑he kept all the tremendous stress of his work inside. His partner committed suicide, but Randy still showed no overt signs of problems. However, one day several months after his partner's death, as Randy got ready to go to work, he put his uniform on, started shaking, and couldn't stop. In fact, over the next several weeks, Randy discovered that he couldn't even put on his uniform without getting the shakes.
Randy spent two more years trying to be a policeman. He was hospitalized for various physical ailments, went through a number of treatments, and was given a variety of leaves and light‑duty assignments. But he never fully resumed his old job. His life fell apart; his marriage nearly failed, and he began to lose respect for himself. Randy was traumatized not by a single event, but by the gradual accumulation of stressful exposure to trauma.
Robert, the highly successful owner of an export business, lived in an expensive home filled with the objects of his greatest passion, art. One night, he awoke with the house in flames. He escaped unharmed, but his home was totally destroyed. His insurance wasn't adequate to replace even a tenth of the priceless art he had lost. Robert had never lived in fear‑he had always had that basic feeling of security that most of us carry through our daily lives. But ever since the fire, his life hasn't been the same, and he feels as though it never will be. Each day has become difficult, something to be gotten through, not to anticipate with excitement, the way it used to be.
Robert no longer feels remotely secure. In fact, he is all too aware of how vulnerable he is, and how vulnerable everything he has is. Robert has been traumatized. His art was the greatest source of pleasure in his life, but now he is reluctant to acquire more of it. He is too aware of the ease with which it can be taken from him.
Cynthia grew up in a dysfunctional family. Her father drank and became very moralistic and demanding when he was drunk. Over several years, he came into her room at night and molested her. Cynthia tried to tell her mother, but her mother discouraged her and said that Cynthia was exaggerating. So Cynthia learned to keep it to herself.
Cynthia's molestation went on for about four years, until she was eight. But for years after that, she continued to live in fear of her father coming into her room at night. She often dreamed that it was still happening. Eventually, the nightmares died down, and Cynthia became involved in school activities. She was popular in high school, although she didn't date much. She got married before she finished college and had a daughter of her own when she was twenty‑six.
Around that time, her world began to fall apart. It became nearly impossible for her to have sex with her husband. In fact, getting physically close to him at all was disturbing to her. She found herself fearful and distrustful of him, even though there was no rational reason for her to feel that way. She found herself thinking more about her father and how he had abused her and ignored her feelings. In fits of rage that she directed at her husband, comparisons with her father would come up. And she began to have nightmares again, mostly of men chasing her and threatening her. Her sleep deteriorated and she looked haggard. She became depressed.
Cynthia had escaped the effects of her trauma for years until the intimacy of family life brought back her feelings of being exploited and abused in a close relationship.
William, Lynn, Randy, Robert, and Cynthia have all been traumatized. What happened to each of them and what it means is different, yet they have many things in common. Each felt that his or her life had been turned upside‑down by an unforgettable event or series of events. These experiences stirred up massive emotions in them and left them with a general feeling that they were different from other people and that their lives were not nearly as secure as they had once believed. Each now lives with a feeling of uncertainty about the future, no longer confident that more traumatic things are not about to happen.
Each has pulled back from an old life, feeling somehow that he or she no longer fits in. Old pleasures have lost their meaning. All have struggled with feelings of anxiety and depression, and with physical problems, such as the shakes, sleep disorders, and digestive problems. William and Randy left their former professions where they had experienced the trauma. But Lynn and Robert continue to try to live their former lives, and most of the people they know have not noticed that they've changed. Cynthia's husband is aware that something is wrong, but he has difficulty linking her suspiciousness and anger to the molestation she experienced as a child.
The traumas that these individuals experienced were quite different—a physical attack, extended exposure to violence and fear, the sudden loss of a home and possessions, an abusive relationship with a father—yet all of them reacted in similar ways. The similarity of their reactions is what marks them all as traumatized. The precipitating event—the trauma—may be more or less severe in the eyes of an outsider, but we can only determine whether a person is traumatized by their reaction to an event. We can safely say that the more traumatic an event appears to be, the higher its magnitude and the greater the likelihood that the person will be traumatized by it. We also know that the more people are exposed to traumatic stresses, the greater the likelihood that they'll be traumatized. But the ultimate determination of whether a person has been traumatized lies in his or her reaction, not in the event itself.
Diagnostic labeling by mental health professionals is sometimes very rigid, and sometimes people whose symptoms do not warrant an official diagnosis may still require treatment. Professionals often have a sort of either/or thinking about certain psychological disorders: If an individual meets all the criteria, he has the disorder; if he doesn't meet all the criteria, then he doesn't have the disorder.
This either/or thinking applies to the diagnosis of traumatization, Post‑traumatic Stress Disorder (PTSD). It was acknowledged and added to the official manual of psychiatric diagnoses, the American Psychiatric Association's Diagnostic and Statistical Manual, only in the late 1970s. The DSM provides a list of criteria that must be met in order to warrant the diagnosis of PTSD. This diagnosis inevitably points the finger of causality every time it is used. Consequently, it has been the subject of a certain amount of controversy and may already be more of an either/or‑type diagnosis than we need. My feeling is that PTSD should not be viewed as an either/or phenomenon. I believe there is a continuum of traumatization; some people are mildly traumatized, while others are severely affected. You can't be a little bit pregnant, but you can be a little bit traumatized.
I am not the only mental health professional who feels this way. During the middle and late 1980s, one of the largest and most comprehensive research projects ever undertaken—the National Vietnam Veterans Readjustment Study—was performed to assess the extent of PTSD among Vietnam veterans. In order to go beyond the rigid criteria of the official DSM diagnosis, the study looked for "Partial PTSD" as well. This was the experimenters' way of assessing related traumatization problems that didn't meet the formal criteria of PTSD.
The Diagnosis of Post‑traumatic
Stress Disorder (PTSD)
The current (DSM IV) formal criteria for a PTSD diagnosis designate both specific elements associated with the traumatic event and specific symptoms following the event. Criterion A requires that the individual have (1) “experienced, witnessed, or been confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others” and (2) had a “response that involved intense fear, helplessness or horror”.
The person must then experience the following symptoms for a period of at least a month:
B. He must continue to reexperience the trauma through at least one of the following: intrusive memories, dreams, flashbacks, or through becoming intensely distressed or reacting physiologically when encountering reminders, including symbolic ones, of the traumatic event.
C. He must persistently either (1) make efforts to avoid thoughts, feelings, or situational reminders associated with the trauma or (2) manifest a state of general numbed responsiveness. The numbing is reflected in things such as a loss of memory of important aspects of the trauma (perhaps a form of avoidance as well), loss of interest in activities once enjoyed, feelings of detachment from others, a restricted range of feelings, and a sense of a foreshortened future. The formal diagnosis requires a minimum of three separate symptoms.
D. He must show symptoms of a state of heightened arousal by having at least two of the following: sleep disorder, exaggerated startle response, a wary hypervigilant attitude, irritability or angry outbursts, and difficulties with concentration.
The symptoms must persist for more than a month (Criterion E) and the disorder must cause significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). These diagnostic criteria are altered somewhat when the traumatized individual is a child. The child’s response to the traumatic event may be expressed by disorganized or agitated behavior rather than the usual fear, helplessness or horror. Repetitive play portraying themes related to the event may take the place of intrusive recollections. Traumatic dreams of children may be simply frightening dreams with not recognizable tie to the trauma. Finally, children may reenact the trauma in their play or in other forms of behavior rather than the flashback experiences of adults.
As you can see, someone who has everything except the proper minimum number of symptoms in one of the categories wouldn't qualify for an official diagnosis of PTSD. But it seems absurd to suggest that such a person hasn't been traumatized. There are other symptoms that frequently accompany the syndrome but that are not viewed as specific criteria for the diagnosis. These include depression, survivor guilt (which I will explain in Chapter 2), and drug and alcohol abuse.
The five individuals I cited before all qualify for the DSM diagnosis of PTSD. But the following description is of a woman who doesn't qualify for the formal diagnosis. Still, I view her as another person who has been traumatized.
Dale had been married for over twelve years when she unexpectedly got pregnant ten years ago. At that time, she and her husband, Ed, were ambivalent about having a child, especially considering her age, and she couldn't decide whether she should have an abortion or proceed with a highrisk pregnancy. As her pregnancy progressed, it was getting close to the point where abortion wouldn't have been allowed. Finally, they decided to have the abortion, and her husband took her to a clinic where they knew no one. Immediately afterward, they left on a vacation. It proved to be disastrous. Without being able to say exactly why, they hated the place, the food‑everything they came in contact with.
The abortion seemed to become history, and their lives resumed. But in the years that ensued, they developed problems in their marriage. They found it increasingly difficult to maintain a sexual relationship. Nearly ten years after the abortion, during the course of their marital therapy with me, the incident came up once more. Dale and Ed had never openly discussed how they felt about their decision to abort Dale's pregnancy. But in therapy, their guilt, anger, and sadness were finally aired.
How someone responds to having an abortion depends upon the meaning of the experience to that individual. Those with strong convictions against abortion are certainly likely to be more upset and have more guilt. For Dale, it was very upsetting, and her symptoms resembled those of someone who had been traumatized. She didn't seem to reexperience the event, but she did become distressed on every anniversary of the trauma. She had no physical symptoms, but her memory of that period had definitely been impaired, and she had developed an amazing unconscious ability to avoid reminders of it.
As we discussed all this in therapy, it became evident that she had no recollection of significant portions of the experience. Indeed, it turned out that she had driven past the abortion clinic twice a day for ten years but never noticed it. When her husband told her where it was, she was completely surprised. And yet even after that realization, she continued to fail to notice it. It was clear to me that the abortion was a traumatic event for her, and that she remained affected in a variety of ways for many years afterward. The things I have to say about healing from a traumatization are quite applicable for Dale.
As you can see, "traumatic experiences" aren't limited to horrible car accidents, the death of a parent, or being mugged and raped. It isn't something that happens only to survivors of the Holocaust or to Vietnam veterans. Traumatization is defined by how upset and vulnerable an experience (or an accumulation of several experiences) has made a person feel, even if she "only" witnessed that horrible car accident or "only" went through a vicious divorce or the loss of a job, or a baby ten years ago. The first step in dealing with traumatization is to recognize the traumatic experiences in your life.