Folks, most of you know I made a move from Directing the Graduate School of Counseling at Biblical Seminary to a new job at the American Bible Society. BTS is now advertising for my replacement: GSOC Director Ad 9-17 FINAL. Please share this and pray that they find the right person capable of leading the counseling programs into their next area of growth. The MA counseling program, if I can say so myself, is top-notch and a rare find for those seeking both licensure and biblical-theological depth.
What kind of messages about mental health diagnoses and medications do you receive in your community? What do you hear about these in the church? Silence? Warm embrace? Implicit or explicit rejection?
Mike Emlet, a former family practice physician and now counselor, has written a small book to introduce readers to a nuanced and biblical take on the value of diagnoses and medications. Descriptions and Prescriptions: A Biblical Perspective on Psychiatric Diagnoses & Medications (New Growth Press, 2017) comprises 22 short chapters exploring the pros and cons of both arenas for those who are “too cold” or “too warm” towards the use of mental health diagnoses and medications.
In the first section Mike explores some of the weaknesses of the current DSM (psychiatric diagnostic system). Those who are “too cold” and who think the system is fraught with problems may find themselves saying “yes, exactly.” But rather than just stop there, he begins to articulate implications for ministry responses—how to go deep to understand the person behind the diagnosis. There is much the pastor or counselor can learn.
One key point is made here and in later chapters: we live in bodies and Scripture takes this seriously. So learn about the symptoms a person experiences.
So, you might think this book is negative on the value of diagnoses. It is not. Chapter 9 begins to describe the potential value of diagnoses, especially to those who tend to see mental health problems ONLY as spiritual and ONLY or usually involving just the will. If there is one thing the reader should get from this chapter is that humility is in order. If you don’t put much stock in diagnoses you likely don’t put much stock in published research exploring symptom clusters. As an example, Mike briefly discusses the multivariate experiences of those with obsessions and compulsions. This little window into the problem of OCD should remind us that we must work hard to understand the many subtle forms of obsessional thinking and consider how best to describe and care for the person suffering with them.
On the final page of chapter 9, Mike takes on one crucial criticism—that since you can’t see structural differences in the brain that implicate a particular diagnosis then the diagnosis isn’t real. From his point of view, this is a simplistic understanding of biology and diagnoses.
The second section explores the challenges and benefits of psychiatric medications. Mike gives a very brief overview of the categories of medications and how they work (what we know and what we don’t know). He summarizes the research as indicating a modest positive effect, though also showing that other means are quite effective (placebo and counseling). Such results show us that there are a range of helpful responses. While it is true that medications for anxiety and depression aren’t cures and aren’t without their side effects, it is important to remember that the individual in front of you may in fact benefit immensely. Thus it is good to remember that we don’t offer advice to others based on population statistics. Rather wisdom is in order for this particular person.
In probably the best part of the book, Mike walks the reader through a wisdom approach to the use of medications—walking the tightrope as he suggests. Too much suffering and too little suffering can be hazardous to our spiritual health. We can make idols out of medications or out of not taking them. Medications aren’t good or bad on their own. It is how we approach them that matters.
He makes this statement nearing the end of the book,
“I hope you have seen that there is not a clear-cut “right” or “wrong” answer. There is no universal “rule” that we can apply to all people at all times. There is no simple algorithm. Rather, the use of these medications is a wisdom issue, to be addressed individually with those we counsel. There will always be a mix of pros and cons, costs and benefits to carefully consider.” (p. 87)
This answer may frustrate those who want a clear-cut “this is right/wrong” response. However, counselors are not umpires calling what is “fair” or “foul.” Instead we are walking with and helping others look for relief (what can I do to make the moment better?) and look for acceptance (what is God up to in my life?). Sometimes relief means medications, other times it means examining thoughts, habits, perceptions, etc. Sometimes acceptance means pursuing other goals beyond symptom relief, other times it means understanding accepting that God has, in his providence, allowed them to have a body that needs external supports.
Book Recommendation: Great first text for those who either over-estimate the value of mental health diagnoses or medications or those who minimize their value. Author leans to a conservative approach and probably spends more time speaking to those who might over-value medications. Yet, he also repeatedly affirms that biblical counseling must take seriously the fact that humans are embodied souls and that diagnoses and medications have value, albeit limited value. Great text to start the conversation and lead to deeper study about our responses to suffering, especially for beginning pastoral counselors and lay helpers.
This morning I was reading a journal article in the latest issue of Psychological Trauma: Theory, Research, Practice & Policy (vol 9:3, special issue on South Africa). In discussing rape of women in the context of South Africa, the authors report
In a recent study, 17% of the South African women agreed that rape usually results from what a woman says or does. (p. 310)
Does this number seem high or low to you?
While 17% do not make up the majority of women, it is not a small number either. Without being able to see the original study, I had the following questions:
- 17% of South African women agree that rape usually is the result of female behavior. How many more believe that it is sometimes true?
- What are the numbers for what men believe about the problem of rape?
Lest we think that this is just a problem in less evolved countries (note: that perception is offensive and false), we have the same
conversation debate here in the US about whether a woman is responsible for what happens to her if she drinks too much at a party or wears the wrong sort of clothing.
What is behind rape?¹
Rape by men requires two factors: aggression and arousal. First, the rapist is aggressive and uncaring about the experience of the other, willing to take what they want by physical, verbal, or psychological force. Often (though not always) the rapist experiences anger, both during and after the rape. And second, the male must be sexually aroused in order to rape. Normally, one would think that aggression and anger would extinguish arousal but this is not the case for those who engage in rape.
What enables this pairing? Several factors are clearly involved:
- Obsession. When someone is obsessed with sex or power or anything at all it has a tendency to shape a person and to increase self-focus and shape beliefs about what others think and want. Wants become needs become demands. “I want” becomes “I’m deserve.” This is even true for those rapes that appear un-premeditated.
- Fantasy. Coupled with obsession, a person must then begin to fantasize about getting the obsession. They may find ways to normalize what they want (e.g., the other person wants it in their fantasy). No one rapes without having practiced in their mind.
- Objectification. Others only exist as opportunities to solve the obsession. They don’t have feelings. They don’t have needs. They don’t matter. The best example of this in Scripture is Amnon’s rape of Tamar (2 Samuel 13).
- Blame-shifting. The victim wanted it, asked for it, deserved it. Alcohol was the cause. They didn’t know it was wrong. They couldn’t help it. Any number of excuses may be at work to shift blame. In order to avoid the crushing weight of a stricken conscience, one would have to find a means to shift blame or deny reality.
Is there a culture of rape?
If a significant portion of a population believes either that victims of rape are responsible for the crime or that perpetrators are unable to stop themselves, then where do those beliefs come from? Culture can support these beliefs, either in an active or passive manner. Mostly commonly we see passive means at work. For example,
- Failing to investigate he said/she said crimes and thereby failing to bring justice supports rape
- Responding first to victims about their culpability
- Promoting violence in media towards victims as normal and acceptable
Who is responsible for rape?
While we can say that sexual violence is multi-factorial (learning, culture, history, habits, opportunity, etc.) it is wrong to say that the victim has brought it on. In fact, a naked individual actually asking to be violated cannot succeed unless there is someone willing to respond. Drunken, flirty, scantily dressed women cannot cause rape (once again, a terrible perception that most victims fit these descriptors). Thus, the only one responsible for a rape is the one doing that act.
For Christians, this should be a no-brainer:
Luke 6:45. A good man brings good things out of the good stored up in his heart, and an evil man brings evil things out of the evil stored up in his heart. For the mouth speaks what the heart is full of.
2 Cor 5:10. For we must all appear before the judgment seat of Christ, so that each of us may receive what is due us for the things done while in the body, whether good or bad.
What can we do?
Simple acts are best.
- Notice and correct all “explanations” about causes of rape that do not put the blame solely on the perpetrator.²
- Notice and speak up about messages from the larger culture that make light of violence, especially sexual violence. In fact one special area is the sexual abuse of teen boys by female teachers. This is all to commonly treated as a win for the boy. It is not.
- Engage in community discussion about the shame tactics used to blame victims for their situation.
¹Rape is not only committed by males against females. And there are many reasons why men rape and many contexts in which it happens. This post is not trying to speak to all the types of rapists nor all of the contexts where it happens. It is only focusing on the rape of women by men as that was the context of the initial article.
²There is a time to discuss with both perpetrators and victims about aspect of the situation that may have contributed. A rapist may need to explore how family history or personal abuse history contributed to their acting out. A victim may also need to explore some of their own choices that may have increased their vulnerability to being victimized. The challenge is knowing when. While avoiding these conversations can be unhelpful, having them too early can be deadly to the soul.
Over the years I have promoted the trauma healing curriculum run by the American Bible Society. Now that I am on the Mission Trauma Healing training team of the Bible Society, I will be letting you know of our upcoming local trainings. Whether or not you are local, you can always find out the trainings being offered around the world by us or our alliance partners here.
For those of you who might be new to the Healing the Wounds of Trauma curriculum, it is participatory/experiential healing group model where participants engage Scripture and trauma and explore a healing arc beginning with suffering, lamenting, grieving and talking to God about our pain. It is founded on mental health best practices by designed for lay leaders to learn and then pass on to others in a train-the-trainer fashion.
Currently the materials are contextualized and translated into 60 distinct languages with many more underway. Some 6,000 facilitators have been trained in the materials.
Why get trained? Here are some reasons:
- You want to better understand how to put faith and trauma recovery together in the same sentence
- You want to become equipped to lead others in a healing process
- You already know a lot about trauma but know that the needs are great enough that you want to have a part in raising up an army of well-trained helpers beginning the conversation about God and trauma
- You already completed the initial equipping training, have led a healing group and now want to come back for the advanced training to become certified as a training facilitator.
When is it? October 13-16 at Mother Boniface Spirituality Center in Northeast Philadelphia?
Details on cost and registration link? This link will get you to the details page and will give you the link to register. The price is ridiculously low for the training.
I just finished reading “In God’s House” by Ray Mouton. It is a terribly disturbing novel (barely one as it is thinly disguised from his real life) about the massive cover-up of pedophile priests in Louisiana in the early to mid 1980s. Like the Spotlight story in Boston more than 15 years later, those in positions of power in this story (or those who felt the loss of church integrity too much to lose) found ways to deny that a systemic problem existed. Some knew full well and denied the systemic cover-up and obstructed justice as often as they could. Others did not have the facts but chose to minimize the consequences when evidence was presented to them–frequently out of fear for bringing scandal to the church.
But before we get too self-righteous about the problem of child abusing priests, let’s consider how we respond when a system we love is accused of significant and systemic evil. Let me give you a couple of examples, beginning with the trivial
- The home run steroid era in baseball. If your favorite team had several players caught taking steroids. Would you acknowledge the problem and suggest that awards won by the team should be revoked…or would you point to the fact that all the teams (possibly true) had steroid users as well?
- The race and incarceration problem. African Americans are inordinately represented in prison populations despite being a smaller minority group in the United States. Of course the problem is complex. But can we agree that racial discrimination on a systemic level plays a large role?
Notice that both the trivial and the serious examples are complex and that multiple factors can be implicated in the problem. Notice also that not everyone involved in the incarceration issue are evidence of systemic problems. For example, there are good judges and biased judges. There are profiling police and upright police. There are wrongly accused and justly punished. And yet, we do have a serious problem of sending more Black men to prison than we do men of other races. Naming this problem does not condemn all involved in the justice system. But the problem still exists and reveals some systemic evil.
Is it possible to name a problem without going first to a defense (or attack of another’s position)? It seems this is our common first response when a system we love comes under fire.
Common System Defense Tactics
This week, after the events of Charlottesville and the debates over the statues of leaders of the Confederacy, we see some of these types of responses:
“Well, should we remove all statues, including Washington and Jefferson since they too are tainted?
“Can’t we celebrate the values we see in General Lee?”
“The other side’s extremists also bear some fault.”
Let’s get specific about some of these tactics which are responses we may go to first, before listening to the concerns of the other:
- Blame-shifting. Point out the sins/flaws of those pointing out the sins of the system.
- Sin-leveling. We’re all sinners so no one can point a finger. If every system is tainted, then no system gets to call out the sins of another system.
- Emphasizing the good. If a system has flaws, quickly point out the good it has done.
- Pointing out the exceptions. If an exception to the complaint exists, then point it out to invalidate the complaint.
- Taking the complaint to the extreme. If a system has flaws then take the complaint to the extreme to invalidate it. Example: Complaint: some statues need to come down. Response: So, I guess we need to remove all statues of those who stood for things we don’t like.
System Justification: An Explanation?
Aaron Kay and Justin Friesen discuss factors behind justifying a broken system in their 2011 paper, “On social stability and social change: Understanding when system justification does and does not occur.” They pinpoint 4 factors common in responses that justify maintaining status quo: system threat, system dependence, system inescapability, and low personal control. In other words, when a system I am connected to is threatened and I feel somewhat dependent on it, but it is a large system (e.g., a government or a religion), and I personally cannot make a change, then I’m likely to defend it. In the words of these and other authors, system justification is when “people are motivated to perceive existing social arrangements as just and legitimate” even if not always fair to all. (Kay et al, 2009, p 421).¹ “…Thus, when little can be done to change [a system that is unfair], people will likely be motivated to justify their system in an attempt to view it in a more legitimate, fair, and desirable light” (Kay et al, p. 422). Why would we do this? The authors say to reduce the sense of threat and anxiety that would come in acknowledging a sick system.
It wasn’t that long ago that our country was embroiled in controversy around big tobacco companies. After clear evidence of tobacco’s role in causing cancer, some still insisted that control of tobacco companies (especially their advertising) would harm the country. These companies paid billions in taxes, they employed hundreds of thousands of people and farmers needed to make a living. They gave generously to many important non-profits. And anyway, the product was legal and bought on a voluntary level.
In an interview in the New York Times Magazine in 1994, a lawyer for Philip Morris had this to say to his daughter regarding tobacco,
And I told her that a lot of people believe that cigarette smoking is addictive but I don’t believe it. And I told her the Surgeon General says some 40 million people have quit smoking on their own. But if she asked me about the health consequences, I would tell her that I certainly don’t think it’s safe to smoke. It’s a risk factor for lung cancer. For heart disease. But it’s a choice. We’re confronted with choices all the time. Still, I’d have to tell her that it might be a bad idea. I don’t know. But it might be.
The author of that essay (with extensive interviews of Philip Morris executives) did not conclude that they were morally bankrupt individuals. Instead, he concluded,
The best answer, which isn’t particularly satisfying, is that people in groups behave differently, and usually worse, than they do singly. In speaking with these Philip Morris executives, I felt the presence of the company within the person. In the end, I felt that I was speaking with more company than person, or perhaps to a person who could no longer distinguish between the two.
A Question and A Challenge
A question for each of us: Which “company” –system–are you so beholden to that you are inclined first to defend status quo? Your “companies” may include the NFL (the CTE problem), a political movement, a beloved pastor, a denomination, a school.
And a challenge: Be willing to discuss what is before moving on to what ought to be. Discuss the problems. Own them even if you have no power to change them. Then later you can have a discussion about what to do.
¹Kay, A. C., Gaucher, D., Peach, J. M., Laurin, K., Friesen, J., Zanna, M. P., & Spencer, S. J. (2009). Inequality, discrimination, and the power of the status quo: Direct evidence for a motivation to see the way things are as the way they should be. Journal Of Personality And Social Psychology, 97(3), 421-434.
I’m reading David Wood’s What Have We Done: The Moral Injury of Our Longest Wars (2016, Little, Brown and Company). David is a journalist and has experiences embedded in military operations in Iraq and Afghanistan. PTSD is well-known and discussed, especially in the context of war. If you have listened to the news, you know that many veterans struggle with it and struggle with return to civilian life. Suicide rates of current and former military members should grab your attention and tell you that we have a serious problem on our hands. If you have read further, you probably have heard about treatments such as Prolonged Exposure and Cognitive Processing Therapy being used by VA mental health practitioners.
This book, however, introduces readers to the concept of moral injury, a cousin to PTSD. While the features may look similar to PTSD, moral injury may better account for some of the experiences, especially where terror (the emotion, not behaviors) may not have been the main experience.
The book opens with a story of a Nik, a Marine whose position came under fire from a small boy with an assault rifle.
“According to the military’s exacting legal principles and rules, it was a justifiable kill, even laudable, an action taken against an enemy combatant in defense of Nik himself and his fellow marines. But now Nik is back home in civilian life, where killing a child violates the bedrock moral ideals we all hold. His action that day, righteous in combat, nonetheless is a bruise on his soul, a painful violation of the simple understanding of right and wrong that he and all of us carry subconsciously through life.
… At home strangers thank him for his service, and politicians celebrate him and other combat veterans as heroes. And Nik carries on his conscience a child’s death.” (8)
The author goes on to argue with illustration after illustration that to go to war is to suffer moral injury, to suffer the disconnect between deeply held values and the experiences during war. While it is easy to see moral injury in the forced choice to kill a child vs. save one’s own life, moral injury can also result from being sent on a fool’s errand–political reasons sent to war vs. need to protect or defend freedoms.
PTSD v. Moral Injury?
Post-traumatic stress disorder is biology. It is the body’s involuntary physical reaction as we relive the intense fear of a life-threatening event and the scalding emotional responses that follow: terror and a debilitating sense of helplessness. (15)
He goes on for paragraphs to depict the experience of PTSD and its cascade of symptoms–“fear-circuitry dysregulation.” But then listen to how he talks about Nik
…Nik doesn’t have PTSD. What Nik struggles with is not the involuntary recurrence of fear. He’s okay with the crowds at Walmart. He doesn’t startle at loud noises. In contrast with veterans who’ve experienced PTSD, Nik didn’t feel the pain of his moral injury at the moment of the incident…. [But] he is bothered by the memory of that Afghan boy and with questions about what he did that day. Like all of us, Nik had always thought of himself as a good person. But does a good person kill a child? …No, a good person doesn’t kill a child, therefore I must be a bad person. …The symptoms can be similar to those of PTSD: anxiety, depression, sleeplessness, anger. But sorrow, remorse, grief, shame, bitterness, and moral confusion–what is right?–signal moral injury while flashbacks, loss of memory, fear, and startle complex seem to characterize PTSD. (17)
PTSD has little to do with sin. It is a psychological wound caused by something done to you. Someone with PTSD is a victim. A moral injury is a self-accusation, prompted by something you did, something you failed to do, as well as something done to you. (18)
Guilt and shame are key characteristics. Not being able to save a buddy, making a quick decision that also included losses of civilian life, betrayal by leaders but being forced to carry out orders, or not being protected by buddies–all can create a moral injury. Add a mega dose of grief/loss from death and loss of companionship after the unit breaks up and you have a serious problem. (Don’t forget once home and safe, the loss of adrenaline, the loss of status, the replacement of dullness and the rebuilding of old relationships without your friends and without purpose will enhance all painful feelings including nagging guilt and shame.)
The lasting psychological, biological, spiritual, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations. (250)
Spiritual community interventions?
Despite their attractiveness, short-term interventions like CISD aren’t effective (chapter 6 details this). In addition, straight up attempts to challenge distorted thoughts are likely to fail. So, what might work? The book details some listening and validating activities by chaplains, including the burning of cards listing their “sins” as they leave the battlefront symbolizing their remorse and reception of God’s forgiveness. Talking about guilt, confessing failures and shame seem central. Note that confessing and validating do not necessarily mean that others agree that sins have been committed or that perceptions of self are accurate. They merely acknowledge the burden the veteran carries. Even the secular therapy models validate feelings of guilt while finding acceptance and forgiveness. Saying, “don’t blame yourself, you couldn’t help it” to Nik aren’t helpful. Finding a path that doesn’t blame or excuse (237) allows for a different path between all or nothing shame responses.
It seems that what spiritual mentors and Christian practitioners have to offer in light of these themes are central to recovery from moral injury.
The reality, says the author, our current therapies are only marginally helpful and sometimes harmful. Near the end of the book he concludes with this conviction,
True healing of veterans with war-related moral injuries will only come from community, however we and they define community–peers, neighborhoods, faith congregations, service organizations, individuals. That means it is up to us. (260)
And thus, YOU have a job to do.
Listen. I highly recommend you read his last chapter (“Listen” begins on page 261). He will tell you how to engage a conversation in order to learn. No matter your personal beliefs about war, this is something you can do. Don’t look for the government to do the job, be the one to listen and learn yourself. Be the one to bear witness, as silently as you can. Your presence (more than your words) will convey compassion, understanding, and God’s presence.
I write this from Uganda having just completed a Community of Practice conference hosted by the Ugandan Bible Society. This community of practice is for bible-based trauma healing facilitators and local mental and public health experts. I presented on an update to PTSD causes, effects, and treatment. We looked at the value of Scripture engagement around the topics of trauma, loss, and recovery as well as how it fits into the larger picture of trauma counseling.
Much of what we clinicians know and do for treatment for PTSD symptoms is based on partial research but a significant dose of “clinical judgment.” What is that? Well, it is treatment models that may have some empirical support but mostly formed over long-held assumptions in the field. One of those assumptions is that we may be able to prevent PTSD if we provide group or individual debriefing sessions soon after a traumatic experience. These debriefing sessions have been offered for decades to first responders, humanitarians, and missionaries after exposure to traumatic and tragic events. In recent years we have seen some evidence that some may not be helped but these sessions. In fact, some may even be harmed.
The evidence of possible harm is not new. Yet, debriefing is still offered indiscriminately. We find it hard to let go what seems to work. Today I was able to read a 2006 study published in the British Journal of Psychiatry (citation below). This bit of research compared emotional debriefing, educational only debriefing, and no treatment. This study of Dutch civilians who had experienced a single episode of trauma within the last two weeks found that all three groups (emotion oriented debriefing, education only, and no treatment) saw a decrease of symptoms at 2 and 6 weeks post intervention. There was no benefit from either form of debriefing found in this study.
In addition to no benefit, those individuals with high arounsal trauma symptoms who completed emotional debriefing showed higher rates of PTSD symptoms than the those with higher arousal who did nothing or only the educational oriented debriefing intervention. So, some forms of debriefing may actually worsen symptoms. Why? The authors surmise,
In previous studies it has been established that high degrees of arousal in the immediate aftermath of a traumatic event are associated with an increased risk for the development of PTSD, measured both by self-report (Carlier et al, 1997; Schell et al, 2004) and physiologically by means of heart rate response (Shalev et al, 1998; Bryant et al, 2000; Zatzick et al, 2005). Encouraging highly aroused trauma survivors to express their feeling and emotions concerning the trauma might activate the sympathetic nervous system to such a degree that successful encoding of the traumatic memory is disrupted. Moreover, during an emotional debriefing session negative appraisal of one’s sense of mastery may be promoted (Weisaeth, 2000). This is assumed to keep the hyperreactive individual in a state of high arousal which may cause symptoms of PTSD to escalate rather than resolve (McCleery & Harvey, 2004).
So, what should we do with this information? Nothing? No. But what we do should not harm, especially when we know some may be harmed. I suggest a few possible outcomes:
- Education about PTSD and trauma should continue. This study does not reveal harm for this intervention and given the relatively low trauma symptoms in this study (and the possibility some may have already been aware of what trauma is), education is likely to be helpful. Education is not only about trauma but also about good coping skills and activities. It does not focus on the events of the trauma experienced.
- Bible-based trauma healing begins not with a person’s story but looks at culture and common reactions. It normalizes pain and suffering and connects people to God and others. We do not yet have great empirical evidence (it is being collected) that such an intervention is helpful or harmful. But it appears that giving people permission to ask questions of their faith and to see that God encourages lament may still be helpful.
- We need assessment of the growing movement and art oriented responses to trauma. What do these non-talk therapies add to the prevention or intervention strategies?
- Debriefing or talking about a trauma that has just happened should focus less on replaying the details and more on current cognitive and affective impact with focus on resilience and boosting existing capacities. Brief assessment of arousal symptoms may well be warranted by those who promote processing trauma stories. This may be why NET, CPT and DBT oriented PE have lower drop-out rates than classic PE (prolonged exposure) therapy.
Citation: Emotional or educational debriefing after psychological trauma (Randomised controlled trial) by MARIT SIJBRANDIJ, MIRANDA OLFF, JOHANNES B. REITSMA, INGRID V. E. CARLIER and BERTHOLD P. R. GERSONS. In BRITISH JOURNAL OF PSYCHIATRY (2006), 189, 150-155. doi: 10.1192/bjp.bp.105.021121
Dissociating during trauma makes PTSD worse by increasing negative narratives about the self? Connecting recovery with rejecting these narratives
It is somewhat common for individuals to experiences a period of dissociation and/or perception of being frozen and unable to move during a traumatic experience. Dissociation is a catch-all word to describe experiences where a person is somehow disconnected from a portion of their senses making what is happening feel somehow unreal. Experiences can include emotional numbness, feeling events are not real, not feeling in one’s own body, or not remembering what just happened.
In the April issue of the Journal of Trauma Stress researchers discuss possible connections between experiencing dissociation during a trauma and increased negative beliefs about the self. Dissociation during a trauma is called “peri-traumatic dissociation.” It is already understood that peri-traumatic dissociation is a strong predictor of subsequent PTSD diagnosis.
This short study suggests that those who have dissociative experiences during trauma may be more likely to think negatively about themselves, both about their trauma experiences (e.g., I should have been able to stop it) and their present feelings about themselves (e.g., I’m unreliable). The researchers suggest that therapists ask clients about both forms of negative views of self if the client describes dissociative like symptoms during the trauma experience.
It would have been helpful if the researchers connected their work with that of shame experiences. We continue to try to understand why some people find some experiences more traumatizing and thus have greater difficulty finding recovery. It seems that shame is distinctly tied to chronic trauma and being stuck in negative self-talk narratives. It may be that those who struggle the most with negative self-talk (I should have been able to stop my abuser) experience the most shame. But I have yet to see anyone try to parse that out.
In my experience, negative attributions about the self are just about the hardest things for us to change. We may have developed these well-formed beliefs from failure experiences or we may have had them formed for us by our families. But whatever the cause, they are so very hard to let go. In fact, when others show kindness to our perceived uglyness, we tend to pull back, refusing to allow these parts to be acceptable.
What is it about letting go of our shame and accepting ourselves as normal, as valuable? How would you articulate the problem?
*Thompson-Hollands, J., Jun, J.J. & Sloan, D.M. (2017). The Association Between Peritraumatic Dissociation and PTSD Symptoms: The Mediating Role of Negative Beliefs About the Self. JTS, 30, 190-194.
Recently, I was interviewed for a podcast on the topic of anxiety by Walt Mueller and the good folks at the Center for Parent/Youth Understandings. You can listen here: https://cpyu.org/resource/episode-39-anxiety-with-dr-phil-monroe/
The current definition of PTSD requires an exposure to an intensely distressing event or events (either witnessed or told about in great detail) resulting in a pattern of intrusive re-experiencing, attempts to avoid such experiences and an ongoing negative cognitive/mood pattern. Such a diagnosis might be made after domestic and sexual violence, accidents, natural disasters, war, betrayal traumas, and even after hearing repeated stories of traumatic experiences to others (called secondary trauma).
Someone experiencing PTSD after life-threatening events might feel disconnected from family/friends, find it difficult to sleep, experience repeated nightmares, have difficulty not thinking about events during and after the traumatic experience, choose unhealthy coping patterns like alcohol abuse, or place themselves in situations where they re-enact parts of their trauma story.
But not everyone who has intrusive thoughts about a challenging situation, feels disconnected from their community (and previous self), drinks too much, or impulsively jumps back into danger have PTSD. Some of these same behaviors and experiences also show up in those who have left dangerous and all-consuming experiences and now do not know how to re-engage in regular life.
Consider these words of Dr. Steven Hatch, who spent time in Ebola clinics in Liberia at the height of the 2014 pandemic crisis in West Africa. He describes his experience after returning to his job at the University of Massachusetts.
To match the outside weather, my mood willingly turned dark. I withdrew from people, wandered about in a daze, and avoided public gatherings. When I did venture out, I carried myself in a completely different manner than I had before in my life.
The simple explanation was that I had post-traumatic stress disorder, and a few people, including some whose job it is to make such diagnoses, thought this to be true. (p. 239, Inferno)
He goes on to dispute his experience fighting Ebola as trauma. While difficult, he did not think it rose to the level of trauma experienced in war or even other more overwhelming Ebola clinics.
I could, however, recall the event [death of a toddler] in my mind without being emotionally overwhelmed, but also just as importantly I was able to still experience emotions about it, feeling appropriately somber. I just didn’t feel traumatized. (p 240)
So, what was his problem?
What I did share with many other volunteers was a sense that I didn’t belong in the States, for the work in West Africa was far from over. I desperately wanted to return, and almost within days of coming home I was trying to figure out how I could get back to an ETU [crisis Ebola center]. What I missed was the profound sense of purpose that such work had provided, and I slowly realized why people talked of “missing the war,” a phrase that always seemed discordant to my ears. You miss being in the midst of senseless butchery? Great. But I belatedly realized it was that purposefulness, the sense that you were doing something that was deeply and truly meaningful, that drove people back to such unstable situations. (p. 240-41)
There you have it. The seeming loss of crystal clarity or purpose in life can be very painful. When you are in an intense helping situation as Dr. Hatch was, every movement leads towards life or death. At the end of a day, you can count who lived and who died. No ambiguity. In addition, you are doing it with a team of people all committed to the same thing. You share the same vision, goal, and daily experience. You do not have to explain anything. And in these intense situations, you can have the kinds of intimacy not often experienced even in your immediate family. Also subtract mundane activities (grocery shopping, cleaning, taking care of children, etc.) that may not need to be done.
This is a recipe for distress upon return.
Return to regular life where you are expected to do these seemingly inconsequential activities AND where you have no one around to save AND no one who was present with your toughest experience…and you have a recipe for trouble. You may find it difficult to find joy in light of intrusive thoughts of recent emotionally intense experiences. You may long for a return to that sense of purpose and value. Because others do not understand and aren’t part of your “tribe” you may withdraw or find other ways to numb the pain.
Loss of identity and intensity may mimic trauma symptoms. They may be significant to need treatment. Military ending tours of duty, missionaries returning from field, humanitarians returning from doing crisis work, church planters leaving high stakes urban church plants, and trauma healing trainers returning from intense experiences may be at risk.
What can be done to prevent this distress?
- Probably nothing will take care of the problem. One could not go do intense work. Or one could become a crisis junkie. Neither are good options.
- But developing re-acclimation plans can help. Yes, training done before entering the intense experience will set the stage for healthy returns but post-tour of duty re-entry work is more important. The Army has develop protocols for re-entry by beginning the process even before leaving the “theatre.” Creating space for coming off the “high” giving time to process and following-up in the early days back can help. Involving family in the re-entry planning and building activities that can elevate family intimacy upon return will help immensely.
- Encouraging time and space to lament and process in group settings. This is where a therapist can help. Group process helps to put words to experiences and acknowledges impact on identity. This can also help re-connect with meaningful activities and experiences at home. One has to re-learn that meaning is not solely connected to intensity.
I have some very small personal experience with this. I’ve had intense experiences in international settings. When I have returned, I have sometimes found it hard to be at home when my head was still overseas. Being able to share with Kim and others helped. Practicing lament helped. Learning to be mindful of the present also helped me remember what has meaning and value in everyday life.