Tag Archives: PTSD

What happens after a trauma may be the key in the formation of PTSD


Thanks to a friend I read this essay today about a possible way to model PTSD formation–by considering what does or does not happen in the trauma victim’s social environment after the trauma experience. The article discusses 2 different studies, one animal and the other human.

The animal study concludes that kidnapping a mother rat from her pups for more than 15 minutes will result in anxious activity upon reunification in the same cage where the trauma happened. Mother and pups will continue to be over-reactive well beyond the event. However, if mother and pups are reunited in a new environment, the trauma reactions (racing around, stepping on each other, aggressive behaviors) seem not to be present. Might it be that they have a shared job of exploring the new environment?

The human study points to the importance of having reunification symbols or rites of re-entry when bringing child soldiers back into the community. This appears to have value over just quietly pretending that nothing happened.

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Did God injure me? A great pastoral response


I am reading a version of a paper entitled, “Connecting horizons with Job: Pastoral care (in cooperation with professionals) in the trauma-coping process” by Egbert Brink. In one section he discusses pastoral care responses to the victim’s experience that God was the adversary (such as Job experienced). Mr. Brink cites Job 9:10-12, 9:16-17 where Job feels like God’s hand is the one who is doing the wounding. The victim that Mr. Brink is meeting with says,

Did God do this, did He wound me? My heart says yes, but my mind does not allow that answer….Again; did God wound me? Yes…Okay. That’s what Job feels, and I identify with Job. The next logical step is: what emotions do I have? … This is scary, but the step must be taken. It’s not until you say it, that the emotion can be set free. I can do it, I say: I am disappointed in God, and angry, I think. That last bit isn’t proper, but I can’t help it. Don’t take it too harshly. (p. 16)

Mr. Brink (or is it Dr? I do not know) provides this commentary,

…this is a special moment in trauma coping process…every traumatized person is faced with the question why God let it happen and did not protect him or her. The book of Job grants the necessary space to ask these probing life questions dealing with the mysteries of God. Faith in God’s omnipotence and goodness raises many questions in this context, but also provides space for them. Passionate complaints don’t immediately put God’s omnipotence in question but rather underline it.  (ibid, emphasis mine)

And then Mr. Brink says this,

The pastoral task, then, is not to stand in the way of the traumatized client with apologetics, as Job’s friends do. God does not need advocates to plead his case. (ibid, emphasis his)

I found the following Vimeo link (http://vimeo.com/48232843) of Mr. Brink giving a talk on this paper and pastoral case.

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Good trauma telling?


In preparation for the start of our introductory Global Trauma Recovery course here at Biblical I re-read Richard Mollica’s Healing Invisible Wounds book (see previous posts about the book here and here). Mollica reminds us that there is a healing way to tell one’s trauma story…and there are destructive forms of telling the story.

Destructive forms of storytelling?

Trauma victims do need to tell their story. They need to be heard. But some forms of telling do more damage than good. Signs that the telling may not be helpful?

  • Puts victim/teller into high emotions (reliving the experience versus telling about it)
  • Overwhelms the hearer (who then disconnects thereby leaving the victim feeling more alone)
  • Focuses solely on the trauma or trauma symptoms (e.g., the degradation, shame, etc. thus maximizing paralysis and minimizing survival skills, resiliencies, and other important parts of the person’s life)

Facets of healthy trauma telling?

Mollica suggests 4 facets of good story telling

  • Factual re-telling of trauma (however not every graphic detail)
  • Identifying the cultural significance of the trauma experience
  • Gaining existential or spiritual perspective (reframe from larger perspective on self and world)
  • Identifying the teller/listener relationship forming

Notice that the storytelling is not just about what happened. It is also about the significance, looking from God’s perspective (on self, other, world, etc.) and identifying new connections, skills, resiliencies, etc.

Mollica gives these questions for counselors, family, and pastors to help guide a better story. I find them very helpful if one accepts the caveat that they are not all asked in one sitting nor would we demand articulate answers from victims:

  1. What traumatic events have happened?
  2. How are your body and mind repairing the injuries sustained from those events?
  3. What have you done in your daily life to help yourself recover?
  4. What justice do you require from society to support your personal healing?

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The biological roots of PTSD…and resilience


Brain structures involved in dealing with fear...

Brain structures involved in dealing with fear and stress. (Photo credit: Wikipedia)

A good friend of mine pointed me to a recent Nature essay that describes the biological markers for PTSD and resilience–and provides some of the answer of why some seem to recover fairly quickly while others continue to struggle. Here’s a couple key quotes:

“Functional magnetic resonance imaging (fMRI), which tracks blood flow in the brain, has revealed that when people who have PTSD are reminded of the trauma, they tend to have an underactive prefrontal cortex and an overactive amygdala, another limbic brain region, which processes fear and emotion…”

“People who experience trauma but do not develop PTSD, on the other hand, show more activity in the prefrontal cortex.”

Of course, we need to understand that we are complex beings with complex histories and current social connections. We don’t only look at neural activity but with increasing understanding, we learn how experiences such as childhood trauma, poor social support influence brain activity.

Some worry that the discussion of biological features of PTSD will lead only to increasing chemical interventions (meds, surgeries, etc.). I do not believe this to be the case given that we are also learning about the ways that current relationships and psychotherapies are altering brain activity.

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Critical Incident Stress Debriefing: Does it work?


As someone who wants to advance faith-based global trauma recovery efforts, I am always on the prowl for effective interventions that could be sustainably used by local caregivers. However, it is always important to ask whether a popular or up-and-coming intervention has been fully vetted. Sadly, “does it work?” and “does it work here?” are often not fully answered before an intervention is promoted as the next best thing.

One of the most popular forms of immediate trauma intervention is called “Critical Incident Stress Debriefing,” a one time group intervention designed to forestall long-term trauma due to stressors. When you think of CISD, think of interventions with police or fire fighters or military after a traumatic experience.

But, does it work? This post here provides a helpful summary of the critique, even though it was published 2 years ago. As I read this I remembered an American Psychologist article on the same topic–but for the life of me I can’t find it. My recollection of this fantasy article is that these interventions seem to be helpful for about 50% of those who participate but that at this point it is not possible to tell which 50% will find it helpful. And further, a portion of the other 50% are actually harmed by it.

 

 

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Why is some trauma complex? A helpful distinction from Judith Herman


Counselors talk about trauma as if all traumas lead to traumatic reactions. They do not. Some people have significant distress from what might be considered slight traumatic experiences (surely an oxymoron!) while others appear not have any negative or ongoing reactions to very large distressing events.

There’s another problem. We sometimes talk as if all traumatic reactions are the same. This is also not the case. While the symptoms of posttraumatic stress disorder (PTSD) are well-known to many (i.e., intrusive re-experiencing of trauma experiences, emotional numbing and other attempts of avoiding memories or triggers, and hypervigilance), you can find counseling students and practitioners who are less aware of a cousin of PTSD: Complex Trauma.

Defining Complex Trauma

I’m reading Treating complex Traumatic Stress Disorders: An Evidence-Based Guide, edited by Christine Courtois and Julian Ford (Guilford Press, 2009). This is an excellent text if you are interested in exploring the symptoms, neurobiology, and treatment protocols for complex trauma. In the foreword, Judith Herman helps the reader clarify the main difference between regular and complex trauma

These days, when I teach about complex PTSD, I always begin with the social ecology of prolonged and repeated interpersonal trauma. There are two main points to grasp here. The first is that such trauma is always embedded in a social structure that permits the abuse and exploitation of a subordinate group… The second point is that such trauma is always relational. It takes place when the victim is in a state of captivity, under the control and domination of the perpetrator. (xiv, emphases mine).

For trauma to become complex one needs to experience the trauma at the hands of those who are most perceived to control a social unit (family, community, etc.). It needs to be repeated and woven into the fabric of distorted relationships. You can see that prolonged abuses experienced as a child prior to development of an understanding of the world and of the self would have more devastating impact than an unfortunate and distressing event that happens as an adult. If I experience a horrific accident and an unexpected attack by a stranger, I would not, usually, begin to feel unsafe amongst friends and family. I would likely continue to trust them even as I might not trust the larger community. However, if I experience repeated abuse by a teacher, a parent, a relative, a church leader as a young child, I do not have the prior experiences of safety to rely on and thus, I am likely to experience all of the symptoms of PTSD and then some more.

What More Symptoms?

Courtois and Ford give a cursory description of complex trauma on the first page of the book,

…involving traumatic stressors that (1) are repetitive or prolonged; (2) involve direct harm and/or neglect and abandonment by caregivers or ostensibly responsible adults; (3) occur at developmentally vulnerable times in the victim’s life, such as early childhood; and (4) have great potential to compromise severely a child’s development.

Adding to the typical symptoms of PTSD, complex trauma victims also struggle to regulate emotions, impulses, somatic experiences, consciousness, and evidence significant distortions in views of the self and others leading to difficulty forming trust relationships and finding meaning in life and faith.

Those interested in learning more about the current thinking on complex trauma conceptualization and treatment may find this book useful. Others may wish to check out the latest articles at www.traumacenter.org, one of the leading centers in the country focused on the problem of trauma.

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Healing Trauma in International Settings: AACC Seminar


Today, Carol King and myself will be presenting this PowerPoint show for our 1 hour breakout at this year’s AACC World Conference. Feel free to check out what we talk about by following the link.

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Sneak preview: Healing Trauma in International Settings (AACC seminar)


Cascade Atrium, Gaylord Opryland Resort & Conv...

Image via Wikipedia

Just completed preparing my breakout seminar for this year’s AACC World Conference at the beautiful but outlandishly expansive Opryland Hotel in Nashville (Sept 28-Oct 2). This time around I presenting with my colleague Carol King on “Healing Trauma in International Settings: Best Practices.” Carol has had some experience in Rwanda and Goma, DRC and will be with our group in October when we do trauma recovery training in Kigali. Come back to the blog on the 30th and you can see and download the slideshow we will do.

What will we be talking about? 3 main points:

  • Listen…don’t assume you already know trauma or treatment practices
  • Train…don’t do the interventions yourself (train local leaders)
  • Utilize…don’t reinvent the wheel (use existing models)

Now obviously we will be fleshing those points out. Our goal is to help prepare interested counselors to develop short and long-range intervention strategies that utilize the cultural and human resources of the people they will serve. The only way to do this well is to have a listening and collaborative/support role approach. To that end I will talk about hoe to build an effective area case map.  We end by reviewing a few models for trauma recovery (both Christian and secular).

Check back on the 30th for the full set of slides.

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Heal thyself? Do we have the capacity?


Those who follow the Christian faith wholeheartedly believe that God is the “great physician” and eschew the belief that humans heal themselves. As a result of this belief, Christians sometimes react rather strongly to humanistic language of “self-healing.”

But before you do, consider this: if we assume that God is indeed the creator of all things, then we must also assume he puts into place the many corrective features found in the body. The liver and kidneys remove toxins from the body; blood clots when we cut ourselves; we sneeze to get rid of irritants; we sleep to rejuvenate what has become run down. In better words, Richard Mollica says,

This force, called self-healing, is one of the human organism’s natural responses to psychological illness and injury. The elaborate process of self-repair is clearly seen in the way physical wounds heal. At the moment of injury, blood vessels contract to staunch bleeding. Chemical messengers pour into the tissue, signalling a multitude of specialized cells to begin the inflammation process. White blood cells migrate into the wound within twenty-four hours, killing bacteria and triggering a process of cleansing and tissue repair. A matrix of connective tissue collagen is then laid down, knitting together the ragged edges of the wound in a repair that may not be perfect but is highly functional. (p. 94)

He goes on to say,

The healing of the emotional wounds inflicted on mind and spirit by severe violence is also a natural process.

I find his writing on this subject rather helpful. Sometimes we look passively to God to resolve our traumas, as if it were entirely up to Him. Other times we either resist what we can do or attempt what is not healthy for us. Dr. Mollica (an MD) provides many examples in his book of how the body naturally tries to heal/respond to trauma (e.g., DHEA counteracts toxicity of too much cortisol), where the system goes wrong, and what we can do about it from a therapeutic standpoint.

Dr. Mollica is right in that our bodies are designed to respond well to traumatic experiences. However, I’m pretty sure he also agrees that we are not designed to do this unassisted. The community must participate in the process. We are social beings and thus our healing must be socially situated.

Two Toxins: Emotional Memory and Poor Storytelling

Part of the problem, says Dr. Mollica, is the emotional memory system. When we experience a trauma, our cortex forms declarative memories of the event. These are where we store the “facts” (where we were, what we felt, and how these events connect to previous experiences). But there is another memory system, one he calls “emotional memory” (p. 96). Declarative memory involves the cortex and hippocampus while emotional memory involves the amygdala.

The amygdala is the fear-response command center of the brain, and it does not wait around for the conscious mind, located in the cortex, to decide if a threat is real or not. The amygdala can activate an emergency response throughout the body within milliseconds by calling the stress-response system into play.  (p. 96)

Unfortunately, traumatic events can create emotional memories in the amygdala that keep on replaying and are difficult to extinguish over time. (p. 97)

Another toxin is the re-telling of the trauma story in a way that retraumatizes the victim. Dr. Mollica, in chapter 5, describes the problem of poor storytelling. Poor storytelling evokes only the trauma, the shame, the degradation experienced. Storytelling should cause us to form images in the teller and listener’s minds. These images need to symbolize the whole person/story and not only the most damaging details. The problem is we tend to tell stories that fixate on the intense emotions and thus elicit toxic emotions and maintain the experience that the trauma is still ongoing.

Many traumatized persons are plagued by the two poles of humiliation–sadness and despair on one side, and anger and revenge on the other. (p. 122)

Assisted Self-healing?

Mollica says, “A proper clinical approach to emotional memory avoids triggering the emotions stored in the amygdala and enables the cortex to assert conscious control over the recollection of traumatic events. (p. 97)

How do you do this? With the help of a storytelling coach, a person tells their story in a factual, direct, but not grotesque way that would cause the listener to turn away. Why does this matter? Because part of the healing process is to be heard, seen, and empathized with. Fixating on the most grotesque details only enhances the emotional memory system and pushes others away. Good storytelling still tells the truth but does so in a way that reconnects people with the world, enables them to feel sadness but in community with others, and helps them see that their lives are not solely defined by the traumatic events. Further, good storytelling points to larger values that are still held and not lost due to the evil done by others. Surely trauma does shape and change us. Recovery and healing to the point of living as if the event did not happen would be to live in a world of denial and self-deception. But good storytelling reminds us that we are not ONLY defined by and/or limited to being victims. And good storytelling reminds us of God’s sustaining power that is greater than those who can only destroy bodies.

Dr. Mollica summarizes this chapter this way,

Strong emotions comprise the traumatic memories that are imprinted in the survivor’s brain. One of the mind’s key tasks after trauma is to take these strong emotions and gradually reduce them over time through good storytelling. A poor storyteller tells a toxic trauma story, unhealthy to mind and body with its focus on facts and high expressed emotions. In our society situations that demonstrate this type of storytelling are common, including superficial, sensational media reporting of tragedies and debriefing therapy by misguided mental health workers. In contrast a good storyteller is able to express tragic emotions with the artfulness of a musician playing an instrument, engaging the listener’s interest and involvement. (p. 133)

I commend to you the book. He discusses both good and bad dreams, the role of “social instruments” of healing and a call to health. Very helpful book if you are interested in international trauma recovery.

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Can you change your nightmares?


Blogging has been much harder this fall with a busy teaching and traveling schedule. I’ve been doing a lot of reading and thinking about best practices to deal with trauma in international settings–specifically in the Great Lakes region of Africa. Diane Langberg and I have been consulting with a Christian organization to help develop those practices with a local, sustainable mindset.

One of the recent items I read had to do with attempts to address repetitive “posttraumatic nightmares.” Bret Moore and Barry Krakow published, “Imagery Rehearsal Therapy: An Emerging Treatment for Posttraumatic Nightmares in Veterans” in the September 2010 issue of Psychological Trauma: Theory, Research, Practice, and Policy (v. 2, 232-238).

Imagery Rehearsal Therapy (IRT) attempts to alter nightmares by changing the storyline of the nightmare. The authors view nightmares as learned behavior such as insomnia. The CBT style treatment entails

  1. education about the relationship between nightmares and insomnia.
  2. education about cognitive restructuring via imagery
  3. client selects a particularly disturbing nightmare (maybe not the most disturbing one first)
  4. Client then instructed to “change the nightmare anyway you wish” (notice they are not asked to make it positive or even less distressing)
  5. Client then rehearses (over sessions) the new dream through imagery techniques

Previous controlled studies indicate a reduction in nightmare frequency and intensity. This particular summary article reports that the evidence is there that veterans find it helpful even at 12 months post treatment with 4 sessions.

A couple of things to note. There may be some effect of desensitization from rehearsal of the initial dream (exposure therapy) though the exposure is brief. Also, the client does not spend time rehearsing the actual traumatic events in this therapy–only the nightmares.

Some thoughts:

  1. This treatment makes sense. Ever have a dream that seems to go on and on, or one that you go back to upon waking up in the middle of the night. Often we may find ourselves trying to make the dream turn out okay. This treatment uses our fully awake brains to rehearse something we want to think about.
  2. If nightmares are the result of a collection of anxieties then it stands to reason that repeating new thoughts and images will begin to make associations in the brain that might compete with the anxieties.
  3. Christian living emphasizes re-telling the truth to ourselves. Consider how OT authors remind readers of the Exodus or Paul reminds the Ephesian readers of their prior state (chapters 1-3). What we rehearse does have an impact on our brains.
  4. Finally, some of our nightmares seem written in indelible ink. Do you still have test anxiety nightmares 20 years after your last class? I do. But I feel differently about them now than I might have back when I was still worried about school. It may be that we begin to feel differently about the nightmares. The less we are bothered by them the more infrequent they will be.

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