Back From the Brink: A Family Guide to Overcoming Traumatic Stress, by Don R. Catherall, Ph.D.
Table of Contents | Introduction | Afterword
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2
STILL
STAGGERING FROM
THE BLOW
Living with a Trauma
There's no single description for what life is like
for all individuals with PTSD. Because of the many possible levels of
traumatization, the symptoms vary considerably. For some, life becomes a boring,
meaningless pursuit, with no emotional ups and downs, nothing to get excited
about. For others, it is a perpetual struggle, and threats are everywhere.
They are constantly uptight and on their guard, anticipating trouble at times
when others would be relaxed. For still others, life becomes a big drag;
they're depressed, and they slog through their days isolated from the rest of
the world.
But despite all the differences, certain common
themes weave through the experience of everyone who has a trauma disorder. If
you or a loved one has been traumatized, you should be able to recognize these
themes.
When a traumatization persists for more than a few
weeks, it begins to become a whole way of life, and everything that matters to
you is affected. It's not just the intrusive thoughts, it's the life you're
leading as well, particularly the way you feel about yourself and where you
belong in the world of people. The effects of the trauma itself—what I call the
initial trauma—can be viewed separately from the changes in your relationships
with other people (the relational trauma). Initial
trauma refers to the direct effects of the trauma on your thoughts and
emotions—the reexperiencing, the avoidance/emotional numbing, and the
hyperarousal. Relational trauma refers
to the changes in your relationships and the way in which you view yourself,
which is influenced by your relationships. This disruption of your social world
is reflected in your symptoms of alienation and your difficulty with
relationships. Let's look at one of the examples from Chapter 1 in order to get
a feel for the basic difference between the symptoms of the initial and
relational traumas.
Randy, the policeman who was traumatized on his high
stress job, had both kinds of symptoms. The shakes and fearfulness he
experienced when he put on his uniform were symptoms of the initial trauma;
they were a direct physical reaction to the memory of his trauma and his fear
of encountering similar events. But Randy also developed symptoms of
relational trauma. His friendships with other policemen declined, and he
became isolated. He valued their friendship and saw his isolation as evidence
that he was worthless. As his feelings about himself suffered, he became
irritable and difficult to be around—which put considerable stress on his
relationship with his wife.
Randy's shakes and anxiety were set off by a
reminder of his initial trauma—his uniform. But his alienation, his lowered
self‑esteem, and his difficulty with intimacy were not directly related
to his traumatic job. Rather, they reflected a breakdown in his relationships
with other people and how he felt about himself. These symptoms were manifestations
of his relational trauma.
The development of a trauma disorder begins with the
experience of a trauma, whether it is a single event—such as an accident or
natural disaster—or a series of highly stressful events, such as wartime duty
or an abusive relationship. At the time of the event, you are so emotionally
overwhelmed that you are unable to fully integrate your experience of it. At
the time of the event, if you were to allow yourself to experience its full
emotional impact, you'd be immobilized by the intensity of the emotions. And
during a disaster, you cannot allow yourself to "fall apart"; you
must control your feelings and maintain composure in order to take appropriate
action. Similarly, you dare not give in to your feelings of outrage in an
abusive relationship, or you could provoke further abuse. Even if there is no
immediate, obvious danger, you tend to avoid letting yourself be overcome by
extremely intense emotions. Consequently, you protect your functioning by
shutting down your ability to have a spontaneous emotional reaction.
Overwhelming Emotion
Many people don't fully appreciate the notion of
truly overwhelming emotion. But if I may offer a graphic example: Imagine a
situation where you witness a human being at the moment of being badly hurt or
killed. Perhaps you see an auto accident, even live coverage of a catastrophe
on television. Your feeling at this moment is overpowering; you may feel
suddenly sick at your stomach. For an instant, you are under the sway of a
traumatic emotion, the unthinkable anxiety that comes from helplessness in the
face of something terrible happening to a human being. These emotions are
overwhelming. Now imagine that you live with that overwhelming feeling just
under the surface all the time. That is how it can feel to live with
traumatization.
If you have undergone such a trauma, it's likely
that you shut down significant parts of your spontaneous emotional reaction to
the event, and perhaps even to the memory of it. You may have recalled the
event as you were reading just now, started to feel that terrible feeling, and
quickly shut down the overwhelming emotion so that the memory could be viewed
dispassionately.
A couple of years ago, I witnessed a dog being hit
by a high‑speed car at a park. A number of bystanders saw the tragedy as
well. I saw the dog run out in front of the car, and I was helpless to do
anything to stop what I knew was about to happen. Afterward, all the bystanders
were in a bit of a daze; everyone had stopped in their tracks and stood still
for a moment, as if in shock. The memory of the impact came back to me several
times over the next few days. This was an example of a traumatic emotion, the
overwhelming helplessness and the horror that I and, I'm sure, many other
people felt when that dog was hit.
Emotional Numbing
When you shut down your spontaneous emotional reaction
because it is too overwhelming, part of your personality shuts down as well.
You lose touch with the part of your own emotional makeup. You're able to
function, but you're emotionally numb. And this numbness isn't restricted to
the emotions surrounding trauma. It can become a way of life, a new part of
your personality. This is particularly true if you've been repeatedly exposed
to trauma. You quickly learn to numb out and insulate yourself from the effects
of the continued exposure. Abused children grow up learning to numb out at a
moment's notice, and by the time they're adults, emotional numbing is a way of
life.
The price you pay for emotional numbing is to lose
touch with the part of yourself that makes you feel alive inside. A deadness
replaces the core of your emotional nature, and as this happens, you lose your
ability to feel awe, wonder, and rapture. Many people who are emotionally numb
pursue perilous life‑styles to try to recapture those feelings. As one
man described it, "I have such a jaded view of the world that nothing
excites me or feels really important to me—the only thing that gets me up is
living on the edge."
Emotional numbing is one of the most important survival
mechanisms available to people who have been traumatized. Without it, they
would quickly succumb to the overwhelming emotions. It's a critical adaptation
to extreme circumstances. But it becomes maladaptive when it persists after the
traumatic situation is over. And this is what happens when people develop
PTSD. They continue to numb themselves, even though the threatening situation
is over.
One of the things that I hear most consistently from
Vietnam vets is that they developed an insensitivity to the horror and tragedy
going on around them. They (and I) learned to numb out and pass through the
experiences with deadened feelings, unaffected by things that would normally
horrify them. For some, the numbing happened suddenly—in the aftermath of a
particularly shattering traumatic experience. For others, it developed more
slowly, often invisibly, until the realization of their deadened reactions
dawned upon them. For many this emotional numbing was clearly a reaction to a
specific trauma. But for others, it was an adaptation to living with the
constant stress of life in Vietnam.
Virtually all the Vietnam veterans I've talked to
describe this experience—not just the combat troops, but the nurses,
administrative personnel, and others. There were many sources of extreme stress
in Vietnam—combat is only the most obvious. One of the most stress‑producing
jobs was working with Graves Registration and dealing with the mangled bodies
of the men killed in combat. This produced a very high number of traumatized
individuals who never saw a shot fired.
If you are a trauma survivor, the more you rely upon
numbing to deaden the potentially overwhelming emotions associated with your
memories, the more you lose touch with your ability to spontaneously experience
many kinds of emotion. It's important that you be able to experience a wide
range of emotions—you need them in order to deal with life. Your emotions
notify you when you should be careful in dangerous situations; they bond you to
others and provide you with the motivation to strive in the face of adversity.
You're handicapped without them.
In a sense, your ability to spontaneously experience
your emotions is locked away with your memories of the horrifying trauma. In
order to unlock those spontaneous emotions, you must release those memories.
Until they're released, your ability to spontaneously experience the full
range of emotions will remain stunted. Yet unlocking your traumatic memories
also restimulates the cycle of fear and the mechanisms that protected you from
experiencing the overwhelming emotions in the first place—the mechanisms that
shut down your emotions.
Reexperiencing the Trauma
Your autobiographical memories are more than just
recollections of what has happened to you. They're composed of the intense
sensations, thoughts, and feelings you experienced at the time of the event.
Normally, the immediate sensory impressions fade as the memory of the event is
consolidated and stored into a different mode of memory called declarative
memory. In that form of memory, the immediate experiences are transformed into
a symbolic form, primarily language. However, this transformation and long-term
storage process cannot occur when an individual is in a highly aroused state of
fear. Our capacity to perform the sophisticated mental gyrations involved in
the establishment of declarative memory is largely unavailable to us when we
are in a state of fear. Instead, we are focused exclusively on the source of
the fear and thinking only about what we must do to escape.
As long as our recollections of a traumatic event
send us back into an intense fear state, we are unable to transform the
memories into declarative memory. Whenever we access our memories of the
trauma, we encounter the sensorimotor experiences that we experienced at the
time of the initial trauma and we feel as though it is happening again. This
sends us back into the fear state and we continue to be unable to transform the
memory. In effect, we are caught in a vicious cycle in which the fearful
memories cannot be transformed because they continue to produce the fear which
impedes our ability to transform them.
Triggers
Since the images recorded in your memory are linked
to the sensory perceptions you experienced at the time of the trauma, each of
your five senses—sight, hearing, smell, touch, taste—can participate in helping
you recover a memory. You encounter a sensory reminder, and you suddenly
recall the memory. Have you ever smelled a rose? How about vomit? (Sorry, I'm
trying to make a point.) Did I get a reaction? Did you shudder, wrinkle your nose,
or groan? If so, why do you think you reacted that way? You reacted not just to
the word vomit but to all the sensory impressions you have tied up
with that word—and I suggested you recall the smell. In just this way,
traumatic memories are triggered by sensory impressions.
Vietnam vets frequently react to the sound of
helicopters, which they associate with Vietnam. They usually react to the
helicopter sound by becoming vigilant. They scan the sky until they locate the
source, and only then do they relax. Similarly, many women who were molested as
children react to the weight of a man upon them during sex. Women who have been
molested often feel claustrophobic and panicked, compelled to remove the
person's weight and feel unrestrained before they can relax. For each,
recalling buried memories brings back some of the associated emotions.
Living with the Trauma
Most traumatized people live lives that are deadened
by emotional numbing and periodically disrupted by the intrusion of disturbing
memories and emotions related to the primary trauma. They seldom feel good;
they feel either numb or not so good. If you have intrusive memories and emotional
numbing but they don't seriously interfere with your life, chances are that you
keep your traumatic memories effectively bottled up or that you pursue a life‑style
that allows you to control your symptoms. Such life‑styles can include
being a hermit and withdrawing from society, relying on alcohol or drugs to
remain numb, living a sensation‑seeking life to overcome the deadness
inside, or making a career out of reliving the trauma.
The sensation‑seeker pursues high adventure or
takes extreme risks and lives like a sort of adrenaline addict, always seeking
excitement highs. The person who makes a career out of reliving the trauma
usually works in an area that requires the same skills as those used to
survive the primary trauma, such as the combat veteran who becomes a policeman,
fireman, or emergency medical worker. Obviously, some of these life‑styles are more adaptive than others. If you've
been traumatized, such adaptations can make it easier to keep an emotional
distance from your traumatic memories. You'll probably be more able to recall
the memories while, at the same time, you remain relatively numb to the
overwhelming emotions associated with them.
Does every trauma survivor get caught in this cycle
of dredging up and then numbing out memories? Not all of them—many people who
experience trauma never get caught in this vicious cycle. But every trauma
survivor can conceivably develop it, even after functioning well for many
years. People who aren't plagued by intrusive reexperiencing of a trauma are
those whose personalities are well suited
for ignoring disturbing emotions
while continuing to function well. But it is my opinion that no one locks up
the emotions associated with an extreme traumatic experience without paying a
price of at least some deadness inside. People who know such individuals
intimately report that there's something amiss in them, but they've learned to
leave the subject alone.
The relational trauma doesn't occur until sometime after the traumatic event. If you've been traumatized, at some point you realize that things have changed between you and others—you're no longer the same person you were before, and you can't enjoy yourself with others in the same way. In effect, the trauma has come back and traumatized you a second time. You must contend not only with the terrible event that happened to you, but with the person you've become as a result of it. You no longer feel that you are like others, and you've lost something in your sense of being connected with people. Living with your traumatization takes on a whole new dimension of loneliness. It's like discovering that you are defective and no longer a full‑fledged member of society.
Damaged Connection with Others
The concept that you are connected to other people may be harder to grasp than the concept of intrusive memories. Connectedness is a feeling that makes you comfortable with others, a sense of sharing something in common. You feel connected to people with whom you share membership in a group. This starts with your family and includes many other groups throughout your life: school, work, community, and country. This sense of belonging to a group allows you to open yourself up and be vulnerable with others.
In the case of a relational trauma, your feeling of
belonging to a group is affected in two ways. First, the symptoms of your
initial trauma make you feel that you're different from others, and second,
others react to you differently. In cases of severe traumatization, you feel
that you belong to no groups whatsoever because there is no one to whom you feel connected. In less severe cases, you may
feel you can relate to some restricted groups, such as your loved ones or your
fellow survivors.
Your strongest connections (to spouse, family, and
close friends) will be the last to go, but one thing is certain: the greater
the degree of your relational traumatization, the fewer groups you'll find to
which you feel you really belong.
Damaged Sense of Self
The other negative consequence of the relational
trauma is that your sense of self is affected. You've changed; you feel
different because you are different,
and you can tell that others see you as different. You have three changes to
deal with: your internal view of yourself, others' view of you, and your
loosened connection with others. These three changes adversely affect your
sense of self.
Sense of self
is a
psychological term that is used often but hard to define clearly. It's
sometimes used like the word identity to
mean who you are. I use it more to mean the core of your sense of being a
person. Your sense of self includes your sense of who you are, as well as what
kind of person you are and how worthwhile you are. Thus, you must have a basic
sense of self in order to have an identity, a self‑concept, and high self‑esteem.
If you're not accustomed to concepts like identity
and self‑esteem, this notion of a sense of self may be a bit murky to
you. Let's look at an example.
Lynn, the woman who was mugged in the large city,
had functioned very well prior to her mugging. She maintained an active social
life, a satisfying career, and numerous hobbies and interests. We could say
that she knew who and what she was, and that she felt connected to a variety of
people and groups of people. Basically, she had a satisfying life. But after
her traumatization, things changed. Her view of herself changed—and she saw
herself as much more vulnerable, not the strong person she used to be. She
became more anxious, stayed at home more, and was much more timid about taking
risks. She also believed that others saw her differently, because their
interactions with her changed. But since Lynn hadn't told most people about her
trauma, their changed behavior was not a result of viewing her as traumatized.
Rather, they were responding to the changes in her own behavior. Lynn was
living with considerable fear, which she tried to control by keeping it to
herself. This combination of fear and self‑control interfered with her
connection to others, and she began to feel increasingly alienated.
As a result of this alienation, Lynn's core feeling
about herself was affected. She lost much of her self‑esteem and became
plagued with doubts about who she really was. She was no longer able to enjoy
the activities that had previously made her life meaningful. The meaning she
lost was replaced by a preoccupation with simply getting through each day. We
can use many different concepts and labels to describe what Lynn was
experiencing; I prefer to say that her very sense of herself as a person was
shaken.
If your sense of self has been damaged, your feeling
of basic worth as a person, and your ability to soothe your own anxieties and
maintain control of your emotions, may fluctuate. You may feel that you're on
an emotional roller‑coaster, where your moods are swept about by
relatively minor events. Your basic sense of self may be so tenuous that it
falters in the face of any indication that you are not living up to your own or
others' expectations of you.
Most people who suffer from a damaged sense of self
do so because of events that occurred during their formative years in early
childhood. It is then that people generally develop the solid sense of self
that underlies their self‑esteem and emotional balance in later life. But
some people who have a solid sense of self lose it as a result of
traumatization. In either case, if your sense of self has been affected, you
must develop ways to control your emotions and regain your self‑esteem.
Coping with Relational Trauma
One way trauma survivors control their unstable emotions
is by using the emotional numbing that they used during the initial trauma.
This emotionally non-reactive state becomes the status quo for many trauma
survivors, who go through life shut down emotionally, never getting terribly
happy or terribly sad. But most of us cannot maintain emotional numbness all the
time; we find ourselves periodically overwhelmed by feelings that we can't
control. This can lead to sudden states of rage, tantrums over our frustration
and lack of control. For others, the lack of emotional control depresses them
and makes them feel helpless, and they get even more down.
Some people avoid directly experiencing their
emotions by developing physical problems that preoccupy and distract them.
Their feelings about their physical problems are often some of the same
feelings they have about their emotional trauma: They're depressed, anxious, or
enraged by their physical problems, just as they are about their trauma. For
example, Randy became preoccupied with his physical health and worried
constantly about it. He was concerned that he might have some fatal illness and
sought out many doctors. This was actually a displacement of his fear that he
might die on his dangerous job. But focusing on physical problems allowed him
to focus on physical cures; he could search for the doctor, the drug, or the
right technique. He could maintain the illusion that his feelings could be
instantly fixed if he could only find the right remedy.
As I have mentioned, another problem created by a
damaged sense of self is difficulty in maintaining self‑esteem. If you
have an impaired ability to sustain self‑esteem, you tend to find less
and less lasting means of feeling all right. You may fill your life with work
or other accomplishments to feel good about yourself. As long as you're
producing, you can feel okay. Or you may surround yourself with people who make
you feel better about yourself, whether they are admirers or people toward whom
you feel superior. You may be unable to acknowledge your shortcomings and
become adept at blaming others. Or you may just accept a woeful view of
yourself—a loser image.
All these styles of dealing with flagging self‑esteem
are available to trauma survivors. Some, to be sure, are less available than
others. Because of their feelings of unconnectedness, for example, few trauma
survivors are able to maintain relationships with admirers. It's also more
difficult to fill their lives with accomplishments because of the other ways in
which their functioning is impaired. Consequently, they tend to immerse
themselves in work that doesn't involve too much contact with people, and/or
they develop a style of always blaming others for problems, and/or they become
increasingly depressed and dysfunctional.
Further Effects of Traumatization
If you have suffered an initial trauma, internally
you're struggling with several problems: your vulnerability to being
overwhelmed by emotions, the protective deadening you use to deal with them,
and pressure to revive and process the traumatic memories in order to recover
the ability to safely and spontaneously feel emotions. And if you have a
relational trauma, you're experiencing a loss of many of your good feelings
about yourself, having feelings of alienation and detachment from others, and
having difficulty in relationships. These are the central effects of
traumatization—but unfortunately, they aren't the whole story.
Damaged Worldview
Traumatization also changes the way you see the
world, including your view of yourself and your place in that world. Your
worldview is composed of all the attitudes, preconceptions, ideas, and
knowledge you have. In many respects, your worldview actually defines your
perceptions. In the phenomenon known as selective
perception, different people focus on different aspects of the same event.
A policeman and a clothing designer see entirely different things when they
survey a crowd of people. The policeman focuses on people's behavior, while the
designer focuses on people's appearance. So their experiences (and
recollections) of the same event are quite different. They are selectively
perceiving that part of the event to which they are most attuned.
Selective perception suggests that your biases and
attitudes also shape your perceptions. If you feel that people can't be
trusted, then you notice every minor indicator that people are not behaving in
trustworthy ways. When you read the newspaper, you catch every headline that
confirms your view, but you do not focus on headlines that might represent a
more optimistic view.
When you're traumatized, you're more attuned to dangers
than you used to be. It feels as if you have become a different person living
in a different world. When your worldview changes, in a very real sense, your
whole world changes.
One aspect of your altered worldview is the loss of
your illusions of security. You're suddenly aware of your vulnerability to
dangers that you had previously ignored. If you haven't been traumatized, you
may not realize how much you maintain illusions of security. But consider: You
drive a vehicle that weighs several thousand pounds, and its mechanical
reliability and your consequent safety are often in the hands of people you
don't even know. You pilot it along busy roads among thousands of other equally
heavy or even heavier vehicles, driven by a mass of humanity who have widely
different levels of driving skill and motivations to drive carefully.
Approximately thirty thousand people die on U.S. highways each year. An
enormous number of drivers are legally drunk while driving, particularly on Saturday
nights. And the majority of accidents occur within twenty-five miles of home.
You know what happens to human beings in bad auto accidents—they're so common
that you have probably seen accidents or their aftermath personally. Yet every
day, you blithely get into your car and zip off to the grocery store under the
illusion that you're as safe as if you were sitting on the sofa. Your illusions
of security allow you to cope with many of the common dangers of everyday life
without becoming preoccupied with them.
If you've been traumatized, however, you have a
different view of the world and its dangers. You find it difficult to maintain
illusions of security because you know what could potentially happen. You're no
longer able to maintain the belief that accidents, illnesses, and bad things
only happen to the "other guy" and never to you. We've all had our
illusions of security dim at times—we usually drive a little more safely after
viewing an accident. But when you've been traumatized, the dimming of those
illusions is no longer just temporary. Often, illusions of security are lost
altogether.
Each of us needs to find some meaning in our
existence, and we do it in many different ways. People find meaning through
religion, family, work, or even play. Some people find it by helping their
fellow man; others find it by providing the most enjoyment for themselves. But
somehow, everyone finds some reason to want to live and to want to live in a
certain way.
The meanings we find change as our lives change, but
usually those changes are gradual. There are occasional sudden shifts when we
make transitions through life stages, such as marriage and parenthood. For
those changes, social institutions—such as ceremonies and well‑defined
roles—help us make the adjustments. But traumatization causes a sudden
wrenching of our personal meanings for our lives. And unfortunately, fewer
social institutions tend to be available to help us negotiate that kind of
change.
If your life loses meaning, you're thrown into a
state of uncertainty. You're no longer sure what's important to you, and this
uncertainty interferes with your ability to pursue your goals. It is difficult
enough to attain a long‑term goal, such as getting a higher education or
maintaining a lifelong relationship. The secret to attaining such goals is to
tolerate the short‑term frustrations by keeping sight of the long‑term
payoff. But if the meaning in your life is lost, you may not be so sure that
there is any long‑term payoff. And when you lose that certainty, the
short‑term frustrations become too much for you to bear. So you give up
on your goal—be it a relationship, a project, a job, or a self‑improvement
program.
When Elizabeth was a nurse in Vietnam, she was exposed to tremendous amounts of trauma. She worked with men who were horribly maimed and saw hundreds of her patients die. But she felt that what she was doing was immensely important, worthwhile, and meaningful, so she was able to tolerate the daily stress. After she returned home from the war, she continued to pursue a meaningful life by teaching others and passing on some of the valuable knowledge she'd acquired. But then a close friend, another nurse from Vietnam, committed suicide. Suddenly, Elizabeth felt useless, that her life was meaningless, hollow. She felt she was not doing anything that justified her existence—and she responded to this by giving up her career.
The suicide of Elizabeth's friend made her question
almost everything she'd ever considered worth living for, and she "just
curled up emotionally and withdrew." She went from finding considerable
meaning in her life to questioning whether life was even worth living.
Elizabeth's story is a dramatic example of someone whose life loses meaning as
a result of traumatization. It also illustrates how finding meaning in work
allows a person to tolerate incredible levels of stress. She had successfully
coped with daily exposure to powerful trauma for many years.
Some people feel that they're in control of their
lives. They live where they live and do what they do because they've chosen to
do these things. Such people are said to have an internal locus o f control. They regard the basic control over
their lives as existing within themselves.
Other people have an external locus o f
control. They don't feel that they have much control over their own lives.
They believe that what happens to them is mostly the result of external events.
All they can do is go along with things, making the best of it all. People who
see themselves as having very little control over their lives are vulnerable to
depression if things go badly because they feel powerless to do anything about
it.
Traumatization can damage your feeling that you're
in control of your own life. Someone with an internal locus of control suddenly
has an external one. You can develop a sort of victim identity, in which you
always see yourself as a victim, the pawn of external events. Under such
circumstances, you may reason, why strive for more, why try to make things
better? It's all beyond your control anyway.
Clearly, this is a destructive attitude. In his book
Man's Search for Meaning, Victor
Frankl described his experience in the Nazi concentration camps. He noted that
some prisoners just gave up, and he could tell that they were going to die.
Frankl realized that the Nazis could control all the external events, but he
still had control over his attitude. Having this one piece of control gave him
the strength to maintain hope, to find meaning, and to keep sight of the long‑term
payoff of surviving. He recognized the importance of finding the meaning in
life, and because of it he was able to tolerate an enormously stressful
experience.
Avoidance
If you're besieged by intrusive memories, you live
in fear of being reminded of your trauma. All kinds of things can serve as
triggers, not only tangibles like Randy's uniform but intangibles like
situations and relationships. In fact, it seems that for a lot of trauma
survivors their strongest feelings rise to the surface when they experience
the intensity of a very close relationship. This intensity connects them with
the strong feelings associated with the trauma.
Some people are so sensitive to stimuli that remind
them of their trauma that they must retreat from all relationships and activity that involves other people in order
to avoid them. But what you avoid depends upon the stimuli to which you are
most vulnerable. A jungle combat vet might steer clear of thickly foliated
countryside, while a crime victim may avoid the urban jungle.
Lynn's mugging took place in a parking lot in a large city. It was dark but not terribly late, and there were other people around, but no one was close by at the moment of the attack. Lynn subsequently became sensitive to a number of reminders of her attack. She became very fearful about going out after dark, and she viewed parking lots as particularly dangerous. She learned to alter her shopping routines so as to not be in a parking lot after dark. She became highly attuned to the other people who were on the street when she was out. She learned to wait for a man to leave her office building so that she wouldn't have to walk to her car alone.
Clearly, many of Lynn's actions are realistic
precautions that anyone would take to avoid a mugging. But she was also
avoiding the anxiety that accompanied the memories of her attack. She became
afraid of the dark because she knew what kind of terrors can be encountered in
the dark. She was not really much safer in the daytime—it was simply that her
attack took place in the dark. So in addition to the realistic possibility of
another attack, darkness is linked to her feelings of helplessness and terror
from the first attack.
You may not realize how much your life has come to
center on avoiding reminders of your trauma. You may be steering clear of
reminders automatically, without thinking; you may believe that you've chosen
to live the way you do for reasons that have nothing to do with your
traumatization. You rationalize your behavior in order to explain it to yourself
and others. For example, a woman who has been raped and proceeds to find
something wrong with every man she goes out with may be looking for a way of
explaining why she can't let herself get close with a man. She rationalizes
that something is wrong with this one, and something else is wrong with that
one. But she ignores the fact that the very prospect of getting involved with a
man stirs up her fearful feelings from the rape. She doesn't trust any man but
instead of focusing on that, she focuses on the superficial shortcomings of
each one she comes across.
The longer your traumatization goes unresolved, the
more your entire life‑style becomes devoted to avoiding reminders of it.
At first, you may be aware of the reason that you get anxious around certain
situations, and you actively avoid them. But the longer it goes on, the more
you forget why the situation must be avoided, and you do it automatically.
Certainly, many situations will always be directly linked to the trauma, and
you know full well why you stay away from those situations. But there are many,
many more situations in which the link to the trauma is less obvious, yet you
learn to stay away from those as well.
Elizabeth left the field of nursing after her
friend's death opened up her feelings about the trauma she had experienced in
Vietnam. She says she just "lost interest in nursing" and told
herself that training others and performing relatively mild nursing work in
the States was just not as fulfilling as her work in the war. Years after she
left nursing, her husband underwent surgery, and she was exposed to the sights,
sounds, smells, and caretaking situations of nursing once more. She reacted to
these reminders of her trauma by becoming very uncomfortable. The experience of
dealing with her husband's surgery brought back many of the memories and
feelings that she had had in Vietnam. And she found herself avoiding the
hospital and becoming numb again when she had to deal with her husband's
physical needs.
Elizabeth had believed her decision to leave nursing
was unrelated to her traumatization. But twenty years after her trauma, nursing
still brought back traumatic memories. Therefore, her decision to leave her
profession was surely influenced by its power to remind her of her
traumatization.
Hyperarousal
Living in a state of heightened arousal from
traumatization means you go through life with your motor running all the time.
This ongoing state of arousal is reflected in a number of different symptoms,
the most common of which are sleep problems. You have trouble turning off long
enough to fall asleep, or you wake easily at night and have difficulty falling back
asleep.
When hyperarousal severely interferes with sleeping,
a common "solution" is to develop an appetite for alcohol. But people
who drink to sleep tend to wake up early because the effect of the alcohol
begins to wear off. (Sometimes the early wakening is mistakenly seen as caused
by depression.) Such people habitually fail to get enough sleep, which
contributes to their lowered stress tolerance and ongoing state of fatigue.
And, of course, their dependence upon alcohol leads to further problems with
their health, relationships, and self-esteem.
Another way some people cope with sleep problems is
to work themselves into a state of exhaustion. They work at multiple jobs or
pursue leisure activities at a pace that is totally exhausting. This enables them
to literally "fall into bed" at the end of the day and fall asleep.
One Vietnam veteran who lived this way commented, "I'm never really
relaxed until I've exhausted every muscle in my body. I feel best when I burn
all over."
Other people pursue such "solutions" in
order to avoid dreaming about the trauma. Neither the drinker nor the
physically exhausted person recalls his dreams because he's too "out of
it" when he sleeps. Some people are so upset by their trauma dreams that
they exhaust themselves in order to be in a state where it's nearly impossible
to dream. If you have trauma dreams, you know they can be as bad as the trauma
itself. In your dreams, you're vulnerable to all the overwhelming feelings that
you suppressed at the time of the trauma.
The state of heightened arousal can also produce exaggerated startle response, which means that you're very touchy and easily startled. This is the scientific term for the old cliche from movies where the combat veteran dives for cover when he hears a car backfire or firecrackers go off. Obviously, the veteran's sensitivity to such noises is very adaptive when he is in combat, but it is out of place back in the peaceful environment of his hometown. But exaggerated startle response is not confined to combat veterans. It is a characteristic of many kinds of traumatized people who have concluded that the world isn't safe. They are constantly prepared for further trauma and jump when they encounter anything that might represent danger, especially loud noises.
The "fight‑or‑flight" response
is a physiological state that animals enter when they perceive danger. Within
seconds, the sympathetic branch of the autonomic nervous system is activated
and makes major changes in preparation for action. Certain functions shut down,
such as the flow of blood to the organs that are involved in digesting food,
and other functions step up, such as the flow of blood to muscles. Within
minutes, a second wave of change takes place as the adrenal glands release
epinephrine (formerly called adrenaline) into the bloodstream. The whole
process is similar to the battle station alarm sounded on a warship—everybody
leaves the mess hall and goes to the spot where they'll be most useful if there's
a battle. This is what happens with many trauma survivors; they are constantly
at their battle stations and prepared to fight or flee.
This state of heightened preparedness takes a
considerable toll on you. You're prone to become irritable and subject to angry
outbursts. You're like a football lineman in the final seconds of a close
game—it’s easy to jump offside because you're so keyed up to react quickly.
Indeed, a failure to react can lead to death in many traumatic situations. If
you're taken off guard, you're likely to be traumatized again. So you stay prepared,
and inevitably "jump offside" now and then.
There are other costs to maintaining a state of
always being prepared for disaster—physical costs. The warship that stays at
battle stations too long ends up with a bunch of hungry and fatigued men.
Likewise, your body isn't built to stay in the fight‑or‑flight
state for extended periods of time. You need to have your down
time—opportunities to rest, relax, and recharge your batteries. If you don't take these opportunities,
you can overtax your body and pay a physical price. Your immune system breaks
down, and you catch a virus. Your blood pressure builds, and you have a heart
attack. Your stomach produces excess acids, and you develop an ulcer. Your
muscles remain tense too long, and you get cramps, backaches, and headaches.
Your inner harmony deteriorates, and you become nervous and fidgety, uncertain
of yourself.
You can't maintain a constant state of fight‑or‑flight
arousal—your body chemistry won't allow it. But you can come close to it if you
maintain the vigilant attitude and constant preparedness for danger. If you
never feel that you're safe, you're likely to carry excessive arousal with you
even into your sleep. Thus, developing mechanisms—such as hobbies—for relaxing
and feeling safe are prime goals to overcoming excessive arousal.
Randy, the policeman who was traumatized by the
accumulation of stress on his job, was unable to relax. Early in his career, he
had been very active in sports, and he had found this to be a tremendous outlet
for the tensions he acquired on the job. But after his exposure to traumatic
stress had built to a certain pitch, he was unable to get the same level of
relief from sports. More than that, he developed a number of physical problems.
He worked harder than ever at the sports, but he started developing more
injuries. The injuries finally reached the point where he was unable to pursue
sports at all. Then other physical problems developed. He got headaches and was
sick more often. He developed anxiety symptoms and had several panic attacks in
which he went to emergency rooms fearing that he was having a heart attack (a
common form of panic or anxiety attack). It wasn't until several years after
he'd left the job that his physical problems subsided.
Other physiological symptoms can result from a preoccupation
with a physical problem that a traumatized person develops to divert attention
from intrusive memories. This preoccupation becomes an intrusion into your
normal life, much like the traumatic memories that the physical problem
displaces. The feelings you have about your physical problem are also similar
to the feelings you might have about your memories of the trauma, were you to
remember it directly. In this case, however, you attribute your anxiety and
preoccupation to your physical symptoms and thus see no connection between it
and the primary trauma.
Bill, as a marine in Vietnam, spent virtually all
his time on missions deep in enemy territory, commanding a small team of four
or five men. Their job was to spy on and ambush the enemy. His unit's survival
depended upon not being discovered because if they were, they were sure to be
outnumbered and would have little chance of escape. As leader, Bill worried
about his team's survival. During the forays into the jungle, he focused on the
task at hand and did his job well. Even so, when he was in the rear area
awaiting the next mission, he worried constantly about where his team would be
sent next. Bill didn't share these fears with anyone, feeling it was important
for him to appear calm in order to inspire his men with confidence. Bill
successfully led his team on more than fifty missions and never lost a man. He
returned home with only minor wounds.
He made the transition back into civilian life with
little difficulty, finishing college and starting a successful career in
business. For about fifteen years, he did not talk about his experience in
Vietnam. His life went along just fine, and he had no reason to feel that he'd
been traumatized.
Then he started to develop some minor physical symptoms—intestinal
problems, pain and weakness. His symptoms were not severe, but they were cause
for concern, and he was forced to give up his program of regular exercise. His
physicians couldn't explain the cause of the symptoms, so they admitted him to
the hospital to do extensive tests. They told him that they thought he had
cancer, but after several weeks, they concluded that he didn't. Yet still they
couldn't explain his symptoms. They told him to go home and not worry about it.
Needless to say, he continued to worry about it. In
fact, Bill became obsessed with his physical problems. It was less the amount
of pain or discomfort he experienced than the uncertainty about what the
symptoms represented. His life appeared unchanged to his work associates, but
inside he was distraught and constantly preoccupied with his “illness.”
In my view, Bill was once again experiencing the
traumatization of his wartime experience. The focus of his fear was the
uncertainty, similar to the uncertainty he had felt every time he took his team
into enemy territory, never knowing what they would encounter. His
psychological anxiety was displaced into physical symptoms.
It would be difficult to give Bill the official
diagnosis of PTSD because he didn't have the intrusive reexperiencing of
Vietnam. Or did he? We usually think of the reexperiencing as dreams,
flashbacks, or memories of the actual event. But Bill's traumatic stress was
related less to a single incident of combat than to his reliving the fear,
uncertainty, and constant threat of being discovered.
Such physiological reactions to stress can be
immense. I've seen these reactions in many different forms among Vietnam
veterans. The combat veterans who were in frequent battles had an outlet for
their fear—they could shoot back. But the men and women who were exposed to the
dangers of the war without the opportunity to shoot back had to find other outlets
for their stress and fear. The less free they were to talk about those
feelings, the more likely they were to develop physical problems such as
ulcers, headaches, intestinal problems, irritable bowel syndrome, tachycardia,
and other kinds of disorders. I'm not talking about hypochondriacs—people who
play up their minor physical symptoms. I'm talking about real physical
problems that develop as a result of living with stress and carrying great
tensions without adequate outlets.
We see the result of normal stress all around us—the
little aches and pains we all develop when life is too much for us. Think about
the difference between normal stressful events—such as the pace of modern
life—and traumatic events, and you begin to appreciate how deep the impact of
traumatic stress can go.
Fatigue and Depression
Living with an unrecovered case of traumatization is
very fatiguing; it can seem as if everything you do requires so much effort.
Since your psychological apparatus for dealing with stress is working overtime
dealing with the traumatization, you have few reserves to deal with other
stresses in your life. You can easily become fatigued, irritated, or withdrawn.
But whether you react by getting angry or depressed or by becoming more
emotionally numb, the daily stresses of life are harder to cope with than they
were before your traumatization.
Your fatigue is worse if you're in the midst of
struggling with intrusive memories; trying to control them drains your
psychological apparatus for dealing with stress. And your fatigue can be
disguised by the use of alcohol and other drugs, if you've turned to them for
help. Of course, that "solution" always creates new problems. (In
Chapter 9, we'll look at some better solutions for dealing with fatigue and
stress.)
Many people who have been traumatized are depressed.
They lose their zest for life and feel down all the time. Some of those people
are misdiagnosed. Their depression is obvious, so it's easy to miss their
traumatization because depression can mask many of its symptoms. Depression is
a natural reaction to traumatization, though not all people react this way, and
the two may or may not be related.
There is a diversity of professional opinion on the
reasons for depression. Depression has traditionally been understood to be a
reaction to disturbing life events, usually ones involving loss. But in recent
years, research has shown that many depressed people have a chemical disorder
that is probably inherited. The professionals who are most committed to this
biological view of depression support the use of antidepressant medications in
treating it. It's logical, they feel, to treat a chemical imbalance with
chemicals. Other professionals object to the standard use of antidepressants,
and some are opposed to ever using them, except in the
most severe circumstances. What this can mean to you is that your treatment can
vary radically depending upon the orientation of the professional you see.
(We'll discuss the issue of selecting a professional and the best form of
treatment in Chapter 12.) 1 would advise avoiding anyone who insists there's
only one way to treat your depression, whether it's always with drugs or always
without.
But for now let's look a little closer at the
symptom of depression itself. Depression is a mood disorder. We all experience
higher and lower moods, but depression is a low mood in which you feel the
blues, blah, or downright rotten. It can interfere with your memory, your
concentration, and your thinking processes. It can affect your physical
functioning. Some people are mildly depressed and have no physical symptoms.
But the more depressed you are, the more likely it is that you'll have physical
symptoms, such as slower reflexes, lower energy level, a decreased sex drive,
and sleeping problems. And of course, depression can affect your spirit: you
can have more negative thoughts, be more pessimistic, and have lower self‑esteem.
Additionally, depressed patients consistently complain that other people are
turned off by their depression and avoid them. Thus, being depressed can
resemble the alienation of the relational trauma and can magnify the relational
trauma.
Our understanding of depression has increased
significantly in recent years. As a result, we now recognize a range of
variations and types of depression. We've learned that many of the more clearly
biological forms of depression are related to chemical changes in the body
(such as a woman's menstrual cycle), the seasons of the year, or even the
amount of sunlight to which a person is exposed. But we also recognize the
power of non-biological, psychological factors such as the quality of
relationships or the anniversary of a significant loss. A reactive depression
is one that seems to be clearly a reaction to
an event in your life. The depression that accompanies a trauma disorder is
obviously reactive, but this doesn't necessarily mean you don't have a
biological depression as well.
If you were traumatized at a time when you were
alone, you probably don't have feelings about other people being hurt. But if
the trauma occurred in some kind of group situation, you may have feelings
about how you were affected in comparison to the other people involved. If
others were injured or killed, you may feel guilty that you survived and they
did not, or that they didn't fare as well as you did. We call this phenomenon survivor guilt.
Survivor guilt was presented very well in the movie Ordinary People, in
which a teenager survives a boating accident in which his brother was killed.
Afterward, he is very troubled, and in the course of his psychotherapy, he
learns that it is because he feels guilty that he lived when his brother did
not. If you live with this kind of guilt, you may not be aware of it, or you
may be unaware of the degree to which it affects your daily life. You might be
living in a fashion that serves as your punishment. You may pursue self-destructive
behaviors such as drug abuse or fighting. Or you may deprive yourself of any
pleasures in life, work excessively, refuse to buy yourself nice things, or
not take proper care of yourself.
Survivor guilt is most clearly seen in situations
where the survivor experienced the same trauma as the person who died. Thus,
the survivor of an auto crash in which others were killed is obviously
vulnerable to developing survivor guilt. But survivor guilt also occurs in
situations where people were exposed to different traumatic events. One man who
survived a car crash developed survivor guilt a year later, when a close friend
was drowned in a rafting accident. He related the two events in his mind and
felt guilty that he lived when his friend didn't. Survivor guilt has been
reported by people who survived serious illnesses, then saw someone else
succumb to one. These people develop the illogical notion that their own
survival has been bought at the cost of another's loss.
Kirk went to Vietnam during the heavy fighting of
1968. He was a noncombatant with
an administrative job that prevented him from ever getting close to the
fighting. Nevertheless, he heard about the heavy casualties and felt some guilt
that he had such a safe position. After his tour of duty, he returned home and
left the service. A few weeks after his discharge, he ran into a high school
acquaintance who was also recently home from Vietnam and who had been involved
in heavy fighting. This man shared some of his experiences with Kirk,
particularly the letdown of his return to the States. The man was depressed and
clearly affected by his combat experience. Shortly after their conversation,
the combat veteran committed suicide. Subsequently, Kirk turned into a
workaholic who never found time for himself. He never spent money on himself
and always put himself down when talking with others.
When Kirk entered psychotherapy, he became aware of
how terribly guilty he felt. He believed he should have done something to
prevent the man's suicide and that "it simply wasn't fair" that he
himself had "sailed through his tour in Vietnam" while this other man
was exposed to extreme trauma. Kirk had survivor guilt (and many other symptoms
of PTSD), and he was traumatized by his friend's suicide.
There are many reasons why people respond to the
misfortunes of others by feeling guilty. Although Kirk felt guilty that he'd
avoided combat, he may have already had a tendency to feel guilty that he
learned in childhood. Nor is survivor guilt limited to those who avoided a
serious trauma that got someone else. Many people who have been badly injured
in accidents still feel guilty because someone else was badly injured or
killed. The fact that they paid an obvious physical price doesn't seem to
prevent survivor guilt in them.
Survivor guilt is rampant among Vietnam veterans who
were exposed to severe trauma. Men who survived lots of heavy combat often
extended their time in the combat zone or returned for additional tours because
they felt guilty for surviving. Because of the way the rotation system was set
up, the experienced troops always left less‑experienced men behind when
their tours ended. It's common for combat veterans to feel guilty about going
home and to worry about what happened to the less‑experienced men after
they left.
For most people who suffer from survivor guilt, the
underlying issue is not simply that they survived but that they feel relief
that they survived. Most people suffering from survivor guilt are not
consciously aware of this relief. Irrationally, you may even feel that you are
responsible, that you made some kind of bargain in which the other person was
damaged or killed instead of you. You end up feeling a sense of responsibility
for the other person's tragedy. It may sound illogical, but this kind of
reasoning is often used when people try to make sense of surviving when someone
else didn't. Many "deals" are made with God in situations where
people fear for their life or the life of a loved one.
Feeling responsible for another's tragedy can be a
way of avoiding the feelings of helplessness and lack of control that are part
of the primary trauma. It's a way of hanging on to an internal locus of
control, or even the illusion that you are invulnerable and can control
traumatic events. You're so powerful that not only were you able to save
yourself but you decided who to sacrifice in the process. As a result, although
you feel guilty about your responsibility for letting something happen to
someone else, you avoid feeling helpless.
Your guilt can also serve as an outlet for the
outrage you feel at your helplessness and lack of control. Most of us can't
stand feeling helpless and unable to control our world, so we get angry and
blame ourselves for letting terrible things happen. Feeling anger is
preferable to feeling that we really have no control over the terrible things
in our lives. This side of survivor guilt is very visible among people who
blame someone when something happens to a member of their family. The bearer
of the bad news often encounters anger from family members, as if the family
blames the messenger for the death.
When you have survivor guilt, you may also direct
your feelings of anger and blame toward yourself. It's common for war veterans
to be ambivalent about contacting the families of the friends they lost in the
war. They say they don't want to upset the families and remind them of their
loss. This is certainly a legitimate reason for ambivalence, but another reason
is often the veteran's own survivor guilt. He blames himself for his
companion's loss and anticipates that the family will blame him as well.
On the twentieth anniversary of the death of my best
friend in Vietnam, I tracked down his parents and contacted them. I had thought
about doing this many, many times before, but always found reasons to let it
go. When I finally did it, I was very tentative. I didn't want to force them to
talk about their loss if they didn't wish to revisit it. But I thought they
might want to talk to me, as I wanted to talk to them. When I called them, they
were receptive. But making that phone call was one of the hardest things I've
ever done. It was a healing experience for me, and I think it helped some with
my survivor guilt.
Survivor guilt is prevalent among the children of
trauma survivors, who often feel that they're somehow part of that
"deal" that their parents made with God. Children often feel that
they are to be the reward for which the parent survived. Such children can feel
a tremendous sense of responsibility. In a sense, it's as if they inherit their
parent's survivor guilt.