Category Archives: ptsd

December 15, 2015 · 6:30 am

So, you want to support trauma recovery?


In recent years I have witnessed significant growth in public discussions of posttraumatic stress (PTS) and trauma. This is a good thing. We want to care well for victims of natural disasters and political and ethnic conflict. We want to care well for ex-combatants. While we work to stop the worldwide disaster of child sexual abuse and domestic violence we also want to care well for those we couldn’t protect.

What do I need to know to be able to help?

When we want to help solve a problem we look for solutions. Students in my counseling and global trauma programs see the problem (individuals and communities experiencing trauma symptoms) and come looking for solutions. They want to know which intervention strategies will be most effective in reducing or eliminating the problem of PTSD. It is a good thing to be skilled; skilled in diagnostics as well as treatment application.

However, knowledge and skills are not enough. Yes, a helper will necessarily need to know how to listen to trauma stories, how to speak and how to be silent. A helper will need to know him or herself in such a way as to recognize blind spots and other factors that may hinder the capacity to walk with a survivor. But even more importantly, the helper will need to recognize, and participate in the following trajectory of memorializing trauma while moving to recovery.¹

The trajectory of memory and recovery

  • The [trauma] Event took place: One must speak.

Having experienced trauma (the Event), speaking of trauma is a necessity if recovery is to take place. How one speaks and what is spoken will differ from person to person (thus, NEVER force someone to speak beyond what they want to speak). But whatever is spoken always leads back (explicitly or implicitly) to the Event. Nothing can be spoken without the Event in view. And resolution is really not possible. How does one resolve a genocide? A sexual assault. Rather, there is before…and after. The victim, as Brown says, “does not have the privilege of such a resolution…again and again” (p. 23). We listeners cannot fully understand, but we can listen and repeat what we have heard.

  • The Event defies description: One cannot speak.

When speaking, victims soon realize, “having tried to speak, they discover that attempts to speak of this Event are doomed” (p. 23). Brown notes that this places the messenger and listener into a double bind. It cannot be adequately spoken and understood. Normal language cannot do justice to what was experienced. If not, then the  trauma would cease to be evil, horrific and devastating but normal and inconsequential. The double bind is this: to not speak is a betrayal of the experience and to speak is a betrayal since words will always fail to do justice to what has been experienced.

Words must minimize the event to some extent. Consider 6 million Jews slaughtered or 1 million Rwandans. It is easy to speak those facts but in doing so we must minimize what those numbers mean. We cannot imagine unless we are there.

If we are going to recover and if we are going to support that recovery, we must sit with the fact that we cannot make sense of trauma. The human attempt to do so is normal…but impossible. Helpers need to avoid all attempts to answer the question of why even as we acknowledge that is is always on our lips.

  • The Event suggests an alternative: One could choose silence.

It must be recognized that victims can choose silence. In fact, silence can heighten our understanding of the unspeakableness of trauma. This is a silence that is chosen in an effort to highlight what is also being told. Consider Beethoven’s 5th symphony that has a rest just after the first four notes (dit dit dit dah [rest]). As Brown points out, the rest accentuates what has just been “spoken.”

One could (ought?) also to choose silence when descriptions of trauma will be used to critique the character of the victim. Too often when tales of trauma are told, listeners look for ways to minimize or explain away the events. “It wasn’t that bad…he didn’t mean it…it could have been worse…you’re fine now.” So, in light of these common experiences, victims and helpers have to wrestle with how and when to be silent.

But of course, silence may be the right choice for victims, it never is for observers. As Brown so starkly puts it,

Silence is no virtue; it is vice twice-compounded: indifference toward the victims, complicity with the executioners. (p. 36)

  • The Event precludes silence: One must become a messenger.

…speech betrays so we must forswear speech, but silence also betrays so we must forsake silence. (p. 36)

Per Wiesel and Brown survival by itself is insufficient. Survival must include testimony to those who live. They call it being a messenger from the dead to (and for) the living. The messenger’s job is to disturb and to awaken those who would rather not see or know of the trauma. Truth must be brought to light and wrongs ought to be acknowledged without explanations or reasons given. These things happened, period.

The messenger (and the helper) do not just speak truth to the rest of humanity but also to God. Like Job, like Jeremiah, like David, we contend with God through our questions and our laments. In the Christian world we tend to try to speak for God. But what if our time was spent raising our questions and our complaints to God? Such complaints do not have to be about our anger but rather because we cannot make sense of both the senseless–God and evil in the world.

  • The Event suggests a certain kind of messenger: A teller of tales.

If trauma presses the messengers (victim and helper) to speak and yet makes in next to impossible to effectively communicate what has happened, then the telling will have to be done in analogies. Brown suggests that storytelling is one way to bring victim and listener together. Consider how Nathan uses story to confront David. Such a story, per Brown, bridges two worlds and uses one (the story) to challenge or confront the other. Confrontations may be as direct as Nathan (You are that man!) but just as frequently these “confrontations” are affective and subtle. This is what happens when you find yourself crying during a movie that has tugged on your heart in ways you never expected. The story enables you to connect with feelings and experiences that may have just moments before, been distant and protected.

Why tell stories? Not just to have a feeling (Brown calls that merely an indulgence). Tell stories to change people; to call to action; to demand acknowledgement of injustice and movement to right wrongs.

A final thought: standing on sacred ground

This trajectory (struggle to voice, necessity of silence, becoming messengers and storytellers to call the world to action) does not often happen in a linear fashion. Rather, it happens in fits and starts; in quiet and rageful voices. But if you see evidences of someone attempting to speak about a trauma you are witnessing the Spirit speaking,

Likewise the Spirit helps us in our weakness. For we do not know what to pray for as we ought, but the Spirit himself intercedes for us with groanings too deep for words. 27 And he who searches hearts knows what is the mind of the Spirit, because the Spirit intercedes for the saints according to the will of God. (Rom 8:26-7)

When you see those groanings be silent. You are standing on sacred ground.

___

¹This trajectory of remembering trauma and becoming a messenger can be found in Robert McAfee Brown’s Elie Wiesel: Messenger to all Humanity, Rev ed. This book is a kind of commentary on Wiesel’s work and so this trajectory intersperses Wiesel’s quotes and thoughts with the authors. These five points are made by Brown on pages 20-49 in much greater clarity and artistry than I can in this space.

 

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March 24, 2015 · 1:40 pm

What does recovery look like after traumatic experiences


After trauma, what does recovery look like? Is it possible to “move on?” How can you when you can never unsee or unremember what happened to you? 

Is it possible to experience joy rather than emotional pain when remembering past or ongoing hurts? If so, just what does that look and feel like for the victim? What can be expected if I am “healed”? Can I be free from the typical experience of trauma (e.g., Hopelessness, despair, anxiety, confusion, shame, anger, loss of identity, feeling stuck but the demand to act as if the trauma did not take place, and spiritual angst over the goodness and love of God)?

As Diane Langberg has so aptly reminded us, “Trauma is the mission field of this century.” Around the world there is much openness to talk about the impact of trauma and to use spiritual practices as part of the recovery process. In Christian language, we talk about healing the wounds of the heart and one of the best programs out there is the Trauma Healing Institute’s, Healing the Wounds of Trauma. This program is based on the strong Christian belief that God, through the work of the Holy Spirit and the Scriptures,  is in the business of healing wounded hearts. At the heart of this belief sits two important passages:

Isa 61:1-4 The Spirit of the Lord Yahweh is upon me, because Yahweh has anointed me, he has sent me to bring good news to the oppressed, to bind up the brokenhearted, to proclaim release to the captives and liberation to those who are bound, to proclaim the year of Yahweh’s favor, and our God’s day of vengeance, to comfort all those in mourning, to give for those in mourning in Zion, to give them a head wrap instead of ashes, the oil of joy instead of mourning, a garment of praise instead of a faint spirit. 

2 Cor 4: 16-18 Therefore we do not lose heart, but even if our outer person is being destroyed, yet our inner person is being renewed day after day. For our momentary light affliction is producing in us an eternal weight of glory beyond all measure and proportion, because we are not looking at what is seen, but what is not seen. For what is seen is temporary, but what is not seen is eternal.  

These two beautiful passages present a picture of recovery. Good news, release, favor, comfort, joy and beauty in place of mourning and oppression. Renewal in the face of affliction. But what does this mean in real life? Does a “double portion” instead of shame feel like to a victim of sexual trauma? What does renewal and release feel like after a natural disaster? 

Prognosis for Complete Recovery?

If you suffer a serious knee injury requiring surgery, you will need time for rehabilitation. But rehab does not necessarily mean you will recover the full range of motion you once had, or that  your knee will be entirely pain free when you are finished with physical therapy. Your prognosis for recovery depends on many factors such as age, extent of injury, physical health prior to the accident, and availability of quality care. Even with the best care provided to top athletes, recovery may not lead to return to top form. For example, an Olympic skier may be able to ski again but not at a quality that allows for competitive skiing. 

What about the prognosis for spiritual and emotional recovery? Of course, just as in the knee injury example, the answer must be “it depends.” Still, considering the two passages above, words like liberation, joy, release, and renewal shape our imagination for recovery. Do we imagine complete recovery to top spiritual and emotional form, without pain and limitation? It appears to me that we sometimes imagine emotional and spiritual healing without taking consideration the reality of broken bodies and a fallen world. We are not guaranteed a pain free life or faith without distressing questions. In fact, Paul’s beautiful words in 2 Corinthians bear this out. afflicted in every way, persecuted, perplexed, persecuted, struck down, always carrying around death, burdened, groaning and more. Yes, he also says not crushed, not despairing, not destroyed, but alive. But both must be considered together at the same time if we are indeed to imagine our prognosis. Recovery means comfort and lament, joy in mourning, perplexed while trusting, dying yet alive. 

Sprouts of Justice and Recovery?

Isaiah describes sprouts of justice and righteousness beginning in the recovery of the oppressed (Isa 61:11). As a gardener, I see sprouts as the beginning of hope. After planting seeds, the tiny sprouts give me hope for a later harvest but that hope is still tempered with the knowledge of the challenge of getting sprouts to develop into fruited plants. I have to be vigilant about bugs, weeds, and drought. I need to cultivate and fertilize or my sprouts will not turn into much. And even if I do everything right, the seed may be weak or the weather may mean I only have spindly or stunted plants that cannot bear much fruit. Yet, the sight of sprouts brings the hope that empowers us to keep at the gardening work. 

So, what are these sprouts of justice and recovery that victims of trauma may first see that encourage hope and further empowerment? Consider some of these: 

  • Capacity to Name Truth and Justice

Recovery begins when oppressed people find words to name injustices done to self and other. For example, a victim of domestic violence may become well aware of the subtle signs of verbal and emotional coercion, long before any physical violence. They become the canary in the mine, aware of poison that others may not yet sense. 

As this capacity grows beyond a mere sprout, the person may be able to speak the truth aloud, even with courage to say it to leaders. 

As naming capacity grows, it moves from awareness of personal risk to capacity to notice and care for the injustices others experience

  • Accepting weaknesses without hopelessness

Part of recovery requires honest reflection of the damage done. Signs of recovery include the ability to recognize limitations and working within capacity without self-hatred (though there may be lament for losses of previously held abilities). When we truly accept the “new normal” we then can stop evaluating daily life from the perspective of who we used to be

As we accept our limits, we can then begin to see the opportunities we do have even within our limitations

  • Identify resilience and new capacities in the midst of struggle

There may be new capacities we never observed before (e.g., the capacity to speak up to power, the ability to withstand rejection, increased empathy for the pain of others). We now notice these resiliences and growth as they stand on their own

Though we will not call the suffering good, we will be able to identify blessings that we have received in spite of and as a result of the trauma experienced 

Be Careful Not to Damage the Sprouts

For those who are not attempting the impossible, to “move on” from trauma and abuse, it is good to remember that sprouts are tender and can be easily damaged with too much interference. You may need to leave a few weeds you see near the fledgling plants so as not to disturb their roots or bruise the green shoots. How do we do this to the sprouts of recovery? We may unintentional limit growth by questioning why the person learning to speak the truth isn’t doing it in a even-tempered manner. Sadly, too often those in domestically violent marriages are told to stop being so dramatic and to calm down when they begin to speak about the truth of the violence they have experienced. Or, we can point out the sins of the victim as if somehow their responsive sins eliminate their right to speak up about the trauma they experienced. Or, we can hear someone accepting brokenness and accuse them of not trusting God for complete healing. 

Nurture recovery as you would a tender plant. It is a scandalous act of grace! By paying attention to safety needs, by bearing witness to trauma, by being willing to lament and to stay connected, we provide a greenhouse for such plants to grow into levels of recovery never before dreamed of. 

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August 12, 2014 · 12:11 pm

Brooks on journaling about emotions


Friend Jeff McMullen pointed out a recent David Brooks op ed in the New York Times. (Read it here). While I’m not sure I agree fully with his journaling/not journaling point he says something very important about the timing of writing one’s emotions after a traumatic event. He says,

When people examine themselves from too close, they often end up ruminating or oversimplifying. Rumination is like that middle-of-the-night thinking — when the rest of the world is hidden by darkness and the mind descends into a spiral of endless reaction to itself. People have repetitive thoughts, but don’t take action. Depressed ruminators end up making themselves more depressed.

Then later, this important distinction between immediate processing of emotions and later processing,

We are better self-perceivers if we can create distance and see the general contours of our emergent system selves — rather than trying to unpack constituent parts. This can be done in several ways.

First, you can distance yourself by time. A program called Critical Incident Stress Debriefing had victims of trauma write down their emotions right after the event. (The idea was they shouldn’t bottle up their feelings.) But people who did so suffered more post-traumatic stress and were more depressed in the ensuing weeks. Their intimate reflections impeded healing and froze the pain. But people who write about trauma later on can place a broader perspective on things. Their lives are improved by the exercise.

David points to some research that exists that suggest CISD is unhelpful for some participants. Some are made worse. Yet, narrating one’s trauma in the broader context of a life tend to see a reduction of symptoms. The difference seems to be whether the focus in on life or mostly on the trauma. Trauma in perspective is the goal. Just reviewing trauma may in fact strengthen the traumatic reaction rather than weaken it.

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June 28, 2014 · 5:15 am

Military trauma and traumatic brain injury: Challenges and Opportunities


Colleague and veteran Steve Smith has let me know about this web article regarding the state of PTSD/TBI injury among active duty military personnel. The essay points to some very startling numbers:

  • 59% report no improvement or worsened symptoms after undergoing treatment for PTSD and TBI
  • 30% dropped out before treatment was complete
  • A large portion of patients are on up to 10 meds at a time

The news item goes on to summarize presentations made a few days ago at the American Legion symposium on care for TBI and PTSD veterans. What makes this worth reading is that the actual slides from the presentations are provided in links at the end of the piece. I encourage you to go and read up. You can see what is being done using complementary treatments, the numbers of veterans with head injuries (interestingly, 80% are NOT received during combat) and/or PTSD, what services are available and what recommendations are made to DoD and the VA system to improve patient care.

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May 5, 2014 · 9:49 am

Does yoga decrease PTSD symptoms?


The lead article in the most recent issue of Journal of Traumatic Stress (27:2, 2014) presents a small randomized control trial pitting yoga interventions (12 sessions) against “assessment control” (i.e. assessment plus no treatment). The authors suggest this is the first randomized control trial for yoga interventions, something needed since there is significant anecdotal and quasi-research evidence that yoga reduces trauma symptoms. It is purported to work for several reasons: improved breath-control, improved mind-body awareness/mindfulness, and improved stress resiliency.

What did they find?

The answer to the title question: yes, but not more than controls. Some improvement is noted in the Yoga intervention group: reduction of re-experiencing symptoms and reduction of hyperarousal symptoms. However, the same reductions are also noted in the assessment control group. You might wonder why. The authors suggest that the control group found benefit in tracking their symptoms each week. Thus, self-monitoring may help improve well-being, especially if the person also is accepting and normalizing symptom expression of PTSD. Thus, both groups may have received the same intervention: self-awareness, self-monitoring, and self-acceptance.

Now, this trial was rather small, just 38 in total. With a larger study, researchers might find more power to their intervention. Why keep trying? Yoga is (a) low-cost, (b) not particularly taxing from an emotional standpoint (thus few drop-outs when compared to something like Prolonged Exposure), and (c) something that helps sufferers stay attuned to their body.

 

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April 29, 2014 · 12:39 pm

Urban trauma or bad kids?


Psychiatrist Michael Lyles gives an excellent presentation on the nature of urban trauma at the 2014 ABS Community of Practice. He points out how much of what gets labeled as uncaring violence is better seen through the lens of urban trauma reactions. In addition, he discusses the response of the church. Not to be missed!

Michael Lyles – COP 2014 from American Bible Society on Vimeo.

After his presentation, Police chaplain and urban pastor Rev. Luis Centano gave this response regarding trauma in the city of Philadelphia.

Rev. Luis Centeno – COP 2014 from American Bible Society on Vimeo.

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March 19, 2014 · 10:11 am

Mapping urban domestic trauma


Our community of practice continues with a presentation by Michael Lyles, MD who presented on the problem of trauma in urban settings. [Watch his talk here] He pointed out how we often think about violence and the connection with trauma in international settings but fail to connect the two in American urban settings. We see angry young men and women who seem calloused and do not value life. Yet, often what is happening is that we have hypervigilant individuals who choose to manage their trauma reactions by being alert and on edge and ready to attack before being attacked. When you bring together poverty, violence and a traumatized population, you develop a chronically traumatized person, meeting most criteria for PTSD but never getting diagnosed.

One study mentioned a few statistics about violence prevalence. 55% of urban children have experienced sexual abuse (compare that to about 15% of US population); 39% have witnessed domestic violence. 27% experienced physical abuse.

To highlight the problem he pointed out a 2o12 Philly Magazine report on trauma in our city. Between 2001 and 2012, more than 18,000 people were shot. During that time some 3800 murders. He noted that suicide rates run about 20% and that number goes even higher when you include “academic suicide”–dropping out of life. In addition, he pointed to the connections between trauma and adrenal overload, hypertension, diabetes, and other physical illness. He also pointed to the scarring that takes place in the amygdala.

He noted a good book to consider: John Rich, MD (Drexel University) Wrong Place, Wrong Time: Trauma and Violence in Lives of Young Black Men.

He ended his presentation considering the role of “Chief Musician” as found in the Psalms. These are folks who listen to the story, don’t debate it, set it to words/music that are appropriate.

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March 18, 2014 · 12:29 pm

Mapping Global Trauma


This week I am participating in the American Bible Society sponsored Community of Practice for trauma healing interventionists. The audience represents many organizations, Exile International, Wycliffe, SIL, the Seed Company, Food for the Hungry, as well as many bible societies. Attendees come from places such as Sri Lanka, Nigeria, South Sudan, CAR, Rwanda, Uganda plus several more.

Today, we heard from successes and challenges in several specific areas. Then, Dr. Matthew Stanford (Baylor) gave us an overview of trauma around the world. When we look at armed conflict, we see much on the continent of Africa. Natural disasters take even more of the globe. Trafficking, HIV and sexual violence cover the rest. While some 50% of the US population are exposed to traumatic events, only about 8% will meet criteria for PTSD during their lifetime. In other parts of the world, 90% are exposed to trauma and 40% will meet criteria for PTSD during their lifetime. One of the challenges missionary/humanitarian efforts face is learning about the symptoms and impact of trauma on populations. Too often people either neglect trauma or only focus on a few symptoms. We can try to work on one problem (domestic violence) but without addressing the deeper roots of trauma, it is likely not to be very effective.

After Matt, Rebecca Deng spoke of the experience of being a refugee (South Sudan) and coming to the US as a refugee. Some 42 million refugees worldwide. Some 25 million internally displaced (IDPs) on the continent of Africa. She told a bit of her story of loss and struggle even as she came to the US as an unaccompanied youth. She spoke this very important question

You can grow food, purify water, but who can clean the wounds of the heart?

We ended the morning session with a presentation from Bethany Haley of Exile International. Dr. Haley spoke about the impact of trauma on children. (Exile has work in the DRC and Uganda.) She reviewed the many sources of trauma (armed violence, sexual violence, trafficking, child labor, orphans, recruitment into armed gangs) and how it commonly impacts capacity to develop well and learn. We know that trauma changes brain structure and function. She pointed us to the work of Karyn Purvis at Texas Christian University who has done work on the effects of trauma on developing brains. In addition, she pointed us to Unicef materials available to teach about child trafficking around the world.

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February 14, 2014 · 11:34 am

Free Issue of Journal of Traumatic Stress


As a member of International Society of Traumatic Stress Studies (ISTSS), I am able to offer you a link to a free issue of their journal, Journal of Traumatic Stress.

Click this link for the February issue page with links to download individual articles.  Several essays relate to PTSD treatment for veterans, at least one essay re: child maltreatment in Uganda.

 

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December 3, 2013 · 7:15 pm

Is PTSD an internal problem causing social problems? Or the other way around?


I am finally getting around to read Ethan Watters’ polemic Crazy Like Us: The Globalization of American Psyche (Free Press, 2010). In this book he details the way America has exported not only its pharmaceuticals but have redefined mental health and disease. As the promotional material on the front cover says, the book “[uncovers] America’s role in homogenizing how the world defines wellness and healing.”

As I read the book, I find he is overly negative and pessimistic, even as he right points out some major bumbling when bringing Western mental health ideas to the world. And yet, consider this…

In chapter two he examines the way Western mental health providers flooded (bad pun but appropriate picture) Sri Lanka after the Tsunami to treat all the PTSD that would most definitely come to light. They “educated” the country about the symptoms of PTSD and trained caregivers and counselors to provide counseling interventions. When certain symptoms weren’t presenting widely, some helpers assumed victims must be living in denial.

Watters describes how one researcher began looking to see how Sri Lankans described symptoms of poor responses to trauma–instead of using a pre-determined set of symptoms. This researcher concluded that Sri Lankans experience trauma quite differently.

1. Sri Lankan PTSD symptoms were primarily physical in nature.

2. Sri Lankans did not identify anxiety, numbing, fear symptoms but rather identified isolation and loss of social connection as key to PTSD symptoms.

The root problem in PTSD? 

So, is PTSD internal or external? Intrapsychic or social? Most Westerners think of psychopathology in terms of the individual. A sick individual will likely find their social lives eroding and less supportive. It appears Sri Lankans think of pathology in terms of social connection which when broken results in some of the physical symptoms. So, does trauma cause psychological damage which in turn harms social networks…or does trauma harm social networks which in turn causes distress?

Your answer to this question likely reveals whether you see the world as a community or a group of individuals.  Or, your answer reveals whether you focus on universal human experiences or constructed human experiences.

One semi-helpful answer

My answer? Our minds, bodies, spirits and social networks are not disconnected. While distinct entities, we are far more connected than disconnected. To paraphrase the bible, if the eye is sick, the whole body is sick. Psychopathology does not reside only in one location, even if we can see it’s impact in one specific location (e.g., cells not functioning). We would not assume that seeing the destruction after a tornado would be all that is needed to find the cause of that same tornado. Whatever interventions we devise, we will not find a one-size-fits-all solution. For some, we will intervene first in the interior of their lives (medications, private counseling). For others, we will start with social reconnection.

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