Today I will be presenting a one hour breakout at the 2017 AACC World Conference in Nashville, TN. If you are interested in seeing the slides, down them here.
Tag Archives: trauma
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.
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.
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.
As part of our staff meeting today we watched this video by Diane Langberg. It reviews the 3 stages of typical trauma recovery process plus focuses on the impact of the work on the counselor. Self-care is a common conversation these days. However, a few lines stuck out to me:
Unless we take care of ourselves, we will not be able to bear witness…. Vicarious trauma is not something done to us but a consequence of having empathy…. Evil and suffering also provide an opportunity to expose the weak places in [the counselor]…. Seek out the antidotes to the poison that you sit with…[these antidotes] are not just good coping mechanisms but part and parcel to living the life obedient to God.
What if you read the bible through the lens of trauma? Some are quite obvious–catastrophes are all throughout the bible. But are these stories of trauma in the bible merely keeping a record of it or attempts to deal with the trauma, to put the world back proper perspective after chaos?
Consider this 2015 video by Rev. Dr. Robert Schreiter entitled: Trauma in The Biblical Record. He gives some background about this newer way to read the bible through this lens and then ends with 3 examples. I’ve just ordered this book on the subject, but those wanting to jump ahead may wish to know about it as well.
A few years ago, Dr. Diane Langberg gave a talk about ongoing trauma experiences, when there is no “post” in the posttraumatic stress disorder. When there is no after trauma yet (e.g., ongoing domestic violence, living in a war zone, etc.), what kinds of help and hope might a survivor hold on to? Is there anything that can be done?
A few years ago, Dr. Diane Langberg presented on the topic of shame at the 2014 Community of Practice hosted by the American Bible Society. She describes the toxicity of shame as a distinct part of trauma, especially betrayal trauma. You will learn about the cognitive phase of shame, kinds of shame experienced and how the response to shame takes one of 4 common forms (i.e., withdraw, avoid, attack self, attack others).
Make sure you watch to the end as she shares some insights to how God understands and responds to our problem of shame. See how Jesus enters in to our shame.