Free resource available here (filmed October 2013). (Overlook that maniacal looking pose from the image below)
Tag Archives: PTSD
David Davies, part of the staff of “Fresh Air” on NPR, has conducted an 35 minute interview with David Morris, a journalist who was embedded in a unit in Iraq and who suffers from PTSD resulting from an explosion he survived. David has written a book, The Evil Hours: A Biography Of Post-Traumatic Stress Disorder. If you want to better understand the experience of PTSD and its impact on a person, you should listen to this show (or read the transcript). For therapists, Morris discusses his experiences with Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). He also describes the use of propranolol when repeating trauma stories.
Here’s a couple of my take-aways:
- PTSD is a disease of time.
“…in some ways, PTSD is a disease of time. And a lot of people – PTSD is many things, but one of the things it is a failure to live fully in the present. And I think what happens a lot of times with traumatic – survivors of trauma is they have these compulsive returns to awful events, and they are unable to live in the now.”
- The best treatment never removes all symptoms of PTSD
“The best we can do is work to contain the pain. Draw a line around it. Name it. Domesticate it, and try to transform what lays on the other side of that line into a kind of knowledge, a knowledge of the mechanics of loss that might be put to use for future generations.”
- Honest reflections of the impact of PE and CPT (and why so many dropout from PE treatment)
- Honest admission about the most common “treatment” of PTSD–alcohol (and evidence why so many end up abusing it!)
- War traumatizes far too many but rape is 5x more traumatizing
[in discussing how helplessness/lack of control is a significant factor in the development of PTSD] “Yeah, the helplessness is one of the main predictors of who’s going to end up with PTSD and who doesn’t. And the idea that you have absolutely no control over your environment is very hard for people to deal with because, you know, you are basically completely helpless and unable to control your destiny and your survival….and that’s one thing I discovered in the book is I thought – you know, we sort of assume that PTSD is sort of the realm of soldiers and veterans, when in fact, the most common and most toxic form of trauma is rape.
…a soldier may have some control over his or her environment. They have a weapon with them; they can move; they can take cover. But oftentimes in the cases of rape, the victim is completely overwhelmed and trapped and cornered. And from the moment the attack begins, they are rendered almost completely helpless, which is interesting. And you see that in the diagnosable rates of who gets PTSD and who doesn’t. Rape survivors tend to have it almost 50 percent of the time, whereas your average war veteran – particularly for Iraq and Afghanistan veterans – the rate of PTSD diagnosis is more around 10 to 12 percent. So a rape victim – rape is, in a manner of speaking, five times more traumatic than combat.”
For those who have not suffered a chronic trauma reaction it can sometimes be hard to understand how a victimized person gets situations where re-victimization can happen. Wouldn’t one trauma at the hands of another cause you to be vigilant against any subsequent danger?
You might think so, but here’s how it happens in simplistic terms:
- Interpersonal Trauma leads to confusion, self-doubt (and hatred), loss of voice.
- Vigilance against one kind of victimization leads to making decisions to give up other values/interests to avoid the trauma
- That decision (or impulse) leads to opportunity for exploitation
Still doesn’t make sense? Consider how a societal trauma preps a community or country for re-victimization. Dave Zirin writes about the use of “Shock Doctrine” in his 2014 book, Brazil’s Dance with the Devil: The World Cup, the Olympics, and the Fight for Democracy. Shock doctrine is opportunist moves by governments interested in taking advantage of a traumatized population
Left to their own devices, people tend to vote for things that make their lives better, like sharing wealth and resources and ensuring quality health care and education for all. Nobody wins elections by promising to turn the country into a sweatshop zone. So in order to put neoliberal policies in place, the world’s elite need a strategy—some clever sleight of hand to get what they want before anyone can object. Enter the shock doctrine
The idea is simple: people who are traumatized are more likely to agree to authoritarian measures, to suspending democracy, to doing whatever it takes. The trauma can be unexpected, like a natural disaster or a terrorist attack, or planned, like a massive budget cuts or a military coup—anything that
‘puts the entire population into a state of collective shock. The falling bombs, the bursts of terror, the pounding winds serve to soften up whole societies much as the blaring music and blows in the torture cells soften up prisoners. Like the terrorized prisoner who gives up the names of comrades and renounces his faith, shocked societies often give up the things they would otherwise fiercely protect…’
While people are reeling, trying to figure out how to survive, corporations and the corporationist state walk through the open door and take what they please.” (p 73-4)
Zirin illustrates this by pointing to countries who take privacy rights or freedom of speech from citizens in the name of protecting the people (state) from outside attack. Or corporations who find ways to take land from poor citizens after a natural disaster—to use for their own benefit.
My point is not to attack political ideologies, corporations, or governments. Rather it is to show that trauma sets us up to give up rights and boundaries more easily in order to avoid a terror. That same willingness is more easily exploited by one who sees the vulnerability. The authority will protect us we think. But if the authority is only interested in its own protection, the victim is prone to re-victimization.
This afternoon I will be speaking at Chelten Church on the topic of “Making the Church A Safe Place for Victims of Trauma.” This 3 hour continuing education seminar (co-sponsored by Biblical Seminary who provides the NBCC approved CEs) will focus primarily on trauma resulting from child sexual abuse. However, other forms of sexual violence and traumas (domestic violence, military trauma) will get a bit of attention as well. If you can’t make it or wish to see what I am talking about, you can download and see the slides: Making the Church A Safe Place For Victims.
Tomorrow, Mary DeMuth will speak on a topic similar to her book. Her talk is entitled, “Unmarked Marriage.” I suspect the conference organizers will take walk-ins!
July 11, 2014.
We ended the Community of Practice at noon and said our goodbyes. The morning consisted of a short devotional comparing the good and the false shepherd described in John 10. We explored how helpers may end up becoming “hirelings” due to burn-out and
loss of vision. After the devotional, our tables each became case consultations with caregivers discussing their hard cases and receiving encouragement, support, prayer, and a bit of advice. In a number of instances, caregivers brought up the issue of those who have mixed parentage (Hutu/Tutsi) and the struggle to deal with their identity. I and others have noted that this group has been far more vocal talking about the different “tribes” where previous groups have rarely even mentioned these groupings. It makes me wonder whether this is unique to this group or whether there is something going on in the country that makes it okay to discuss identity.
After our goodbyes, we traveled south for 2 hours to the university town of Butare. Butare is the home of the National University. First stop in Butare consisted of an ice cream at Sweet Dreams just down the road from the Shalom Guest house where we are staying (known internationally as the project with the female drumming corp). Our purpose here is to meet with Anglican Bishop Nathan Gasatura and some of the pastors/leaders of his diocese to discuss the trauma recovery needs. Bishop Nathan has been a friend and attended some of our previous training. Diane spoke a bit about “talking, tears, and time” and the process of healing through trauma. We had a good dialogue where one question was raised, how can a Hutu counselor help a Tutsi victim (or vice versa)? I was thankful that Baraka Paulette, the new president of the new Rwandan Association of Christian Counselors, was present as she answered in a very beautiful way, putting all at ease. Though our time was short, we squeezed in a bit of singing and dancing in the cathedral.
Before our meeting, a few of us purchased locally roasted inexpensive Rwandan coffee and an espresso at Café Connexion across the street from the cathedral and guesthouse. This cafe was not something most would venture into in the United States. It contained dingy walls, a couch and a couple of stuffed chairs, a shelf full of brown bags of coffee, a large coffee roaster and the center of the room was a small desk with an espresso machine. Yet, this was possibly the best coffee I tasted on the trip. [the return trip the next morning and bag of coffee brought home and now gone supports this opinion!] After dinner, many of us walked down the dimly lit main street in the dark passing the university. It was good to walk and good to deepen relationships with fellow GTRI mates.
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.
July 8, 2014
Tuesday. Yesterday was a deep dive into Rwanda for GTRI students. They heard directly from Rwandan caregivers and spent time trying to weigh the genocide and its ongoing impact. Today we begin meeting and interacting with trauma healing and recovery caregivers in a conference setting. At a local hotel about 100 Rwandans gathered to kick off the Bible Society’s trauma healing community of practice and the inauguration of the Rwandan Association of Christian Counselors. The purpose of this meeting was to introduce both projects to the public and to invite the media and dignitaries to be present. The Rev. Emmanuel Kayijuka game some opening remarks and an Anglican Bishop offered a brief bible study of John 4:1-3, the woman at the well. He pointed out that she was likely a prostitute and an abused woman, abused by men, by society and desperate. Why else gather water at noon. He also pointed out that after her healing, she became a woman on a mission of healing, seeking social contact for the purpose of evangelism. After these reflections, Dr. Jean Mutabaruka presented a paper looking at the relationship between trauma, PTSD, and complicated grief. He pointed to 12 types of trauma in Rwanda, including sexual/physical/emotional abuse, witnessing violence, discrimination, poverty, etc. At the end, he raised a few general questions regarding the management of the mourning period/process each year.
After the professor finished, both Diane Langberg and I made a few brief remarks in response. Dr. Harriet Hill presented an overview of trauma healing project, in Rwanda and around the world. She showed the latest trailer of a documentary (much about the Congo project) about bible based trauma healing slated to be aired on ABC network this fall. Fun to see people I know in this trailer. David from the Rwandan Bible Society reviewed the progress to date: 2,918 trained people using Healing Wounds of Trauma material. Many of these are able to train others while the rest are better able to care for themselves.
The second half of the day included a presentation by Baraka Paulette Unwingeneye about the efforts thus far to form the Rwandan Association of Christian Counselors. This group of counselors and caregivers have been meeting with us since 2011 and are ready to be birthed. As Baraka said it, it may be like an elephant’s gestation, but now we are near the final month. We had presentations from Narcisse about the needed documents to be filed to make the association official, myself about the benefits and processes to form an associations. Then, those in attendance voted in a president, vice-president, secretary, treasurer, advisors, and conflict managers. This may not sound very moving, but I assure it was!
While we come to Rwanda for serious matters, not everything has to be intense. As our day was ending, we quickly changed from our conference clothes to go out for a bit of shopping: the Simba market for coffee and tea, and another market selling typical Rwandan traditional items (clothes, woven bowls, banana leaf art. I looked and looked for a blue African traditional shirt but came up empty.
This marks our last night at Solace. Tomorrow we move on to the conference proper about 50 minutes or so south in Muhanga (Southern Province). Though we are about to begin the training in earnest, I think I am beginning to relax. A year’s worth of planning is now well under way. Despite a few surprises and schedule changes, most everything is working as planned. No problems with transportation, food, water, housing. Meetings planned have more or less happened.
In just a few days I will be off to Uganda and then on to Rwanda to do some training with trauma healing workers in both country’s bible societies. In addition, a group of students from our Global Trauma Recovery Institute will join me in Rwanda to learn more about how to help without hurting. In light of this trip, I penned a few thoughts for those who have a heart to do something about the massive trauma needs around the world. Here’s a preview:
Trauma is a hot topic these days. We live in a world where we are aware of terrible traumas happening around the globe in real time. We hear and see tsunamis unfolding, towns being flooded when dikes are breached, mass shootings, bodies strewn about due to ethnic conflict, houses destroyed by errant bombs, and gender violence in almost every corner of the world. While humanitarian efforts to respond to the physical needs of those in trouble are not new, there is a recent push to have charity workers become “trauma informed” so they can also address spiritual and psychological distress.
Trauma is a hot topic not just because we have more evidence of it happening in real time. It is hot because we have better information about the impact of violence and abuse on the human brain, on human interactions, and on the fabric of a society (Mollica, 2006).
Christian counselors, many of whom want to provide cups of cold water to the hurting masses, undoubtedly wish to use their skills to bring hope, healing and recovery to traumatized peoples around the world. But just where should they start?
You can read the rest of my thoughts over at our faculty blog site.
Many who suffer from PTSD or other traumatic reactions also experience chronic nightmares. It is bad enough to have to deal with intrusive memories and triggers during the day but being robbed of peaceful sleep can send you over the edge, both in terms of physical and emotional health. Christian counselors may be tempted to ignore these nightmares (how can you stop something you have little control over?) or overly spiritualize the content of the dream.
But we ought not neglect the problem of nightmares. It is well-known that reductions in quality of sleep make all mental illnesses worse. Nightmare sufferers understandably avoid sleep but of course this creates a vicious cycle of insomnia, anxiety, and increased avoidance strategies.
There are two intervention options (among many) that appear to have fairly robust positive data indicating helpfulness. (For detailed descriptions of these two and others including the analyses of value, see this pdf): Prazosin (medication) and Imagery Rehearsal Therapy (IRT).
Prazosin is an anti-hypertensive (alpha blocker) that may work on the problem of too much norepinephrine in PTSD patients. It seems to improve sleep length and REM time. Interestingly, beta blockers have been found to increase nightmares rather than reduce them. I am no physician and so cannot evaluate the value of this medication for clients but would encourage clients with chronic, severe and re-occurring nightmares to talk with their doctor about whether Prazosin might work for them. The studies I have reviewed primarily examined the value of this medication for veterans with extreme nightmare problems. The most significant downside to medication treatment is that it only works when the medication is taken. Stop the medication, the nightmares may come back. However, some relief may be beneficial and thus the medication then has value.
Imagery Rehearsal Therapy (IRT) is a short-term therapy that does not work on the actual content of the traumatic experience or attempt to treat PTSD. Instead, it treats nightmares as a primary sleep disorder problem. There are variations on IRT but most versions last between 4 and 6 sessions and may be delivered in individual or group formats. Sessions include education about the nature of nightmares, sleep hygiene protocols, and the imagery replacement protocol. While some of the IR protocols are done imaginally, others ask nightmare sufferers to (a) write down the details of the distressing nightmare, and (b) write a new ending to the nightmare. As Bret Moore and Barry Krakow describe, the therapist does not dictate the new outcome of the revised dream but encourage the sufferer to “change the nightmare anyway you wish” (Psychological Trauma, v. 2, 2010). The nightmare sufferer then rehearses (multiple times) the new ending and is instructed to ignore the old nightmare.
Sound goofy? How is it that a person can just decide to have a different dream? However, the evidence that this therapy works is quite robust. Numerous studies with veterans and civilians indicates it is effective in reducing unwanted nightmares. Most treatment protocols suggest starting with nightmares with content unrelated to actual traumatic events.
Thus, Christian counselors ought to review these two treatments and consider learning the IRT protocol to bring relief to chronic nightmare sufferers.
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.