Treating Trauma

There are three types of “bad memories”.

A. Resolved bad memories
These memories bring up only a mild emotional response when they are recalled. Sometime in the past, since the time of this event, you have allowed yourself to feel the appropriate and proportionate emotional responses that would be natural to feel regarding this event, such as grief, sadness, anger, fear or shame. You have accepted the fact that this incident has occurred in your life and you have incorporated it into your identity.

B. Unresolved bad memories
These memories bring up distressing feelings when they are recalled. You feel emotional when you think about these events, and you have avoided thinking about them. You have not yet felt the appropriate emotions that go with the event, have numbed or avoided the memories, have not accepted the fact that it is true in your life, and/or have not fully understood what happened or its effect on you. You may have developed dysfunctional life strategies to avoid similar events or attempted to resolve what happened through other events (for example, make up for it).

C. Traumatic memories
These memories make you feel disoriented (out of it) when they are recalled or triggered by something similar. The memories are fragmented and nonverbal (usually more related to the physical senses such as a visual image). These memories include the PTSD symptoms of hyper-arousal – persistent expectation of danger, intrusion –indelible imprint of the traumatic moment, and constriction –numbing response of surrender. This is described below.

The psychiatric definition of trauma is "an event outside normal human experience." “Traumatic events are extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life. Unlike commonplace misfortunes, traumatic events generally involve threats to life or bodily integrity, or a close personal encounter with violence and death. They confront human beings with the extremities of helplessness and terror, and evoke the responses of catastrophe.” (Herman, p.33.)

The common denominators of psychological trauma are feelings of “intense fear, helplessness, loss of control, and threat of annihilation.”

Psychological trauma is an affliction of the powerless….Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning. Note that children are more susceptible to experiencing trauma because they have less power to handle difficult events.

Traumatic events cannot/should not be compared by level of horror.

However, traumatic events are increased in intensity by: surprise, being trapped, duration of trauma lasts to point of exhaustion, physical violation or injury, exposure to extreme violence, witnessing a grotesque death, other elements that inspire helplessness and terror.

A. Some instances of one-time trauma:

• natural disasters (earthquake, flood, hurricane, etc)

• rape

• assault

• muggings

• robbery

• accidents (automobile, airplane, train, etc)

• fires

B. Some instances of prolonged trauma:

• physical or sexual abuse as a child or spouse

• extreme emotional abuse (abandonment, control, verbal abuse, isolation, etc.)

• war

• life in a prison camp

• life as a refugee

• hostage situations

• life in a concentration camp

• life in some religious cults

A. Emotional (feelings)

• Shock (which includes numbed emotions, questioning of perceptions, memory disturbances)

• Denial (which helps reduce terror, helplessness, fear of dying or fear being abandoned to manageable levels)

• Confusion and disorientation

• Numbness

• Panic

• Weeping

• Extreme anxiety and insecurity

• Inflexibility

• Dissociation, feelings of unreality

B. Cognitive (thinking)

• Disbelief (another protective device)

• Disorientation and confusion

• Difficulty thinking and concentrating

• Unwanted thoughts (traumatic memories may intrude on everyday living and in dreams, leaving you feeling out of control).

• Perceptual problems

• The world may seem unsafe, unsteady, unpredictable, and unfair

• Traumatic memories (intense, clear, vivid images)

• Forgetfulness

C. Hyper-arousal (sensitivity, state of alert)

• Trouble sleeping

• Trouble concentrating

• Heightened vigilance

• Easily startled

• Being wary

• Sudden tears or anger or panic

• Increased alertness and anxiety

D. Body

• Gastrointestinal symptoms

• Headaches

• Allergy symptoms

• Menstrual problems

E. The inevitable review

Trauma survivors spend a lot of time thinking about what they could have done differently. The truth is you couldn't have done it differently. The body takes over in a crisis (fight, flight or freeze). The important thing is not what you did, it's that you survived.

The immediate effects of prolonged trauma are the same as for a one-time trauma, only they recur with each new wave of traumatic experience. The long-term effects include Post-traumatic Stress Disorder, Complex Post-traumatic stress disorder, and a variety of mental and physical illnesses.

Post-Traumatic Stress Disorder (PTSD) is the name given to a cluster of symptoms often seen in trauma survivors. These symptoms are considered normal for the first 6 weeks following a trauma. If they persist beyond that, help is suggested for recovery. The more severe the trauma, the longer these symptoms will last. In cases of major and/or repeated trauma, strong reactions may continue for years.

Symptoms of PTSD include:

1. Hyper-arousal: permanent alert

• Increased heart rate

• Increased blood pressure

• Startles easily, especially unexpected stimuli

• Reacts irritably to small provocations. Explosively aggressive behavior of traumatized men = disorganized fight/flight

• Aggressive, controlling behavior (insistence on getting your way)

• Sleeps poorly – arousal persists during sleep causing sleep disturbances

• Nightmares

• Psychosomatic complaints

• Generalized anxiety

• Specific fears

• Constant state of alert for danger vs. relaxed attention

• Intense reaction to specific stimuli associated with traumatic event

• Can’t tune out repetitive stimuli

2. Intrusion of the memory into everyday life

• Relive the event as though it were continually recurring in the present

• Memories are different. Not verbal, linear or assimilated into ongoing life story.

• Frozen, wordless quality

• Lack verbal narrative and context

• Often a particular set of images crystallizes the experience

• Traumatic dreams

• Fragments

• Repeated identical dreams

• Experienced as if occurring in the present

• Violent reactions to external stimuli during dreams

• Reenactment of trauma in play, repetitive, grim, obsessive, monotonous (Children)

• Recreation of the moment of terror (literally or in disguised form)

3. Constriction (state of surrender when completely powerless)

• Internal escape by altering state of consciousness

• “freeze” mode

• Numbing, detached calm

• Events become disconnected from their ordinary meanings

• Perceptions numb or distorted

• Time sense may be slow motion

• May observe event from outside body

• Experience it as a bad dream

• Feeling of indifference, emotional detachment, profound passivity

• Detached states of consciousness (like hypnotic trance)

• Dissociation through alcohol or narcotics

• Limits of activities

• Limits of emotional capacity

• May feel a part of them has died

• Depression

• Suicidal thoughts /attempts

• Survivor’s guilt

The simple answer, of course, is trauma. But it's more complicated than that. During a traumatic experience, you adapt and choose new approaches that are survival oriented for the situation you're in (such as fight, flight or freeze). The problem comes after the trauma, when those approaches and response are no longer helpful in normal life. Recovery involves recognizing what responses are and aren't functional, and getting rid of the ones that hurt you. In effect, trauma reprograms your reactions very quickly; recovery is a kind of process of deprogramming.

Biologic Theories for PTSD

The amygdala, a structure in the brain, is part of the limbic system that is involved in the expression of emotion, especially fear, autonomic reactions (e.g., increased heart rate and blood pressure, the startle response), and emotional memory. Dysfunction in this structure may produce symptoms of PTSD.

Overwhelming trauma can cause changes in brain function that produce symptoms of PTSD: hyperarousal, numbing, sleep disturbance, irritability, intrusive emotions and memories, flashbacks, outbursts, and memory impairment.

The body responds to stress and trauma by releasing several stress hormones (e.g., norepinephrine, epinephrine). When a person is subjected to repeated or severe trauma, the physiological stress response becomes hyperactive and hyperarousal and intrusive symptoms of PTSD develop.

There also may be a biological component to numbing and other dissociative symptoms of PTSD. Some studies show that when people who have been exposed to prolonged or repeated trauma are exposed to any stimulus reminiscent of the trauma, the brain releases opiates (e.g., endorphins, enkephalins) that can produce emotional non-responsiveness, or numbing, and amnesia.

Serotonin depletion may result from repeated exposure to severe stress and trauma, which may be a factor in the development of irritability and violent or angry outbursts in people with PTSD.

Risk factors for PTSD include previous trauma; a predisposing mental health condition; the type and severity of the traumatic event; and lack of adequate and competent support for the person after the trauma. However, PTSD can develop in people who do not possess any of these risk factors.

Pre-trauma Risk Factors
The psychological history of a person may include risk factors for developing PTSD after a traumatic event, such as Borderline Personality and Dependent Personality Disorders, low self-esteem, or previous trauma.

People who have experienced previous trauma(s) are at higher risk for developing PTSD. Repeated exposure to trauma causes hyperactive release of stress hormones, which may increase symptoms of PTSD.

Trauma-Related Risk Factors
The severity, duration, proximity to (direct or witnessed), and type of traumatic event are the most significant risk factors for developing PTSD. Whether or not the event was perpetrated in a sadistic manner (e.g., torture, rape) occurred accidentally (e.g., fire), or occurred as an "act of God" can affect whether a person develops PTSD and whether the disorder is one-time, ongoing, or has a delayed onset of symptoms. A perceived lack of humane help or rescue may also fall into this category.

Post-trauma Risk Factors

Symptoms and duration of PTSD may be more severe if there is a lack of support from family and/or community following the trauma. For instance, a rape victim who either is blamed for the assault or not believed (e.g., in the case of rape by a family member) may be at greater risk for developing PTSD.

Healing begins when the survivor realizes that the trauma was real and had real effects on his/her life, not all of which are adaptive in terms of "ordinary" living.

Trauma creates overwhelming fear and leaves in its wake a feeling that the world is not a safe place. Many practitioners (Herman, Colodzin, Miller, Hybels-Steer, Dee) thus believe recovery begins with establishing a safe place, a situation within which the survivor can feel some sense of safety and predictability. This usually involves developing an honesty about and awareness of the fear. As the fear subsides, the survivor is able to focus on other feelings and symptoms, to recognize them, search them for meaning, and decide whether or not to act on them.

A combination of psychotherapy and medication is commonly used to treat PTSD. Psychotherapeutic treatments include the following:

Debriefing sessions are usually conducted as soon after the event as possible. A debriefing session typically involves a discussion of the event, the person's reaction to it, and coping strategies. Debriefing sessions are commonly used to help rescue personnel, groups of people who experience a violent attack, or community tragedy.

Psychotherapy (individual or group) is generally recommended in the treatment of PTSD. Survivor groups may be associated with or may refer group members to local community agencies that offer support for victims of rape, domestic violence, combat, natural disasters, and so on.

Eye movement desensitization and reprocessing (EMDR) is a specialized form of psychotherapy that is used primarily for treating PTSD and its associated conditions, including depression. EMDR typically is integrated into a conventional psychotherapy regimen and is not used alone to treat PTSD. It is a more rapid and permanent techniques for resolving trauma.

The theory behind EMDR is that stimulating the two hemispheres of the brain through eye movements or other senses helps the brain access the different aspects of a memory more easily in order to process the trauma.

Pharmacotherapy

The use of medication in addition to psychotherapy has been shown to be beneficial in the treatment of PTSD. Treatment is symptom related.

CPTSD is a diagnosis to describe the complicated results of trauma for persons who have had multiple or prolonged traumas in their lives. Judith Herman (Trauma and Recovery, c1992 by Basic Books) recommends the following diagnostic criteria for CPTSD.

1. A history of subjection to totalitarian control over a prolonged period (months to years). Examples include hostages, prisoners of war, concentration-camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organized sexual exploitation.

2. Alterations in affect regulation (emotional stability), including:

o persistent dysphoria (anxiety, irritation, unrest)

o chronic suicidal preoccupation

o self-injury

o explosive or extremely inhibited anger (may alternate)

o compulsive or extremely inhibited sexuality (may alternate)

3. Alterations in consciousness, including:

o Amnesia (inability to remember) for traumatic events

o passing dissociative episodes (temporarily feeling “out of it”)

o depersonalization/de-realization (not feeling in your body)

o reliving experiences, either in the form of intrusive post-traumatic stress disorder symptoms (see above) or in the form of ruminative preoccupation (thinking about it over and over, inability to stop thinking about it)

4. Alterations in self-perception, including:

o sense of helplessness or paralysis of initiative

o shame, guilt, and self-blame

o sense of defilement or stigma (such as feeling dirty, broken, ruined)

o sense of complete difference from others (may include sense of specialness, utter aloneness, belief no other person can understand, or nonhuman identity)

5. Alterations in perception of the perpetrator, including:

o preoccupation with relationship with perpetrator (includes preoccupation with revenge)

o unrealistic attribution of total power to perpetrator (caution: victim's assessment of power realities may be realistic)

o idealization or paradoxical gratitude

o sense of special or supernatural relationship

o acceptance of belief system or rationalizations of perpetrator

6. Alterations in relations with others, including:

o isolation and withdrawal

o disruption in intimate relationships

o repeated search for rescuer (may alternate with isolation and withdrawal)

o persistent distrust

o repeated failures of self-protection

7. Alterations in systems of meaning:

o loss of sustaining faith

o sense of hopelessness and despair

Crucial to helping someone survive trauma is realizing that you, too, are affected by the trauma, that deciding to help is a big commitment, and that you need helpers, too.

One of the best ways to help a traumatized person is simply to listen compassionately and actively, and make the person aware that you are willing to listen. Reassure the person that there are realistic ways to make it okay, that s/he can survive, that you are willing to help.

Help restore order and give them back a sense of control of their lives. Even if you have to act on their behalf to destabilize them, be sure to off as many choices as possible in the process of the details so they can regain a sense of power.

Offer practical assistance -- running errands, cooking, whatever needs to be done. Don't just ask; if you see that something needs doing, suggest that you do it. This is much more effective than simply saying, "If there's anything I can do..."

DO NOT criticize the person's reaction, minimize the trauma, suggest it was fate or God's doing, minimize the person's feelings, or say you know exactly how they feel (a very subtle way of minimizing feelings). Do not interfere with actions the person has chosen to take unless they are endangering self or others. If you think an action is too extreme, encourage the person to slow down and talk it through.

According to Herman and Miller, survivors of prolonged trauma must first create a safe place. Herman considers the remaining steps to be remembrance and mourning and reconnecting with the world, accepting the changes that the trauma has made in your life. Remembrance and mourning involves grieving both actualities and potentials that were lost; reconnection is a time of "I know I have myself" -- a time for seeing the positive changes wrought by the traumas, celebrating the survivor self, and reconnecting/deepening intimacy with others in ways that were not possible before.

Miller sees recovery in three stages, too: the outer, middle, and inner circles. The outer circle is a time for building safety and rapport and gathering basic information. Middle circle work involves focusing on current symptoms and how to handle them. Inner circle work, when trust is deepest, involves the sharing of shameful secrets and resolving the issues behind the trauma.

As miserable as it is to function with symptoms of PTSD, facing the memory in order to recover from it may also have risks. Before intentionally arousing memories, it is important that the person be currently stable with good support systems in place, good coping strategies in the present for handling stress (not self-destructive) and ideally have a faith in God to sustain him/her.

A therapeutic recalling of the event in order to recover should be done with great care in order to not re-traumatize the person by flooding their mind with the memory to such a degree that it causes the person to lose the ability to function in everyday life. This can be done either slowly and carefully over time while continuing to function, or quickly while taking a break from everyday life.

A. Managing the symptoms helps you regain a sense of control and safety for recovery.

o Many symptoms can be reduced and controlled simply by getting sufficient sleep and eating healthy, balanced meals.

o Nightmares can sometimes be controlled by use of a dream journal.

o Rage and flashbacks can be prevented or reduced by recognizing triggers and avoiding them. Triggers are environmental reminders of the event.

o Reducing your general stress level and finding self-soothing methods can also help.

o Depression and anxiety can sometimes be helped through medication (antidepressants, anxiolytics, mood stabilizers).

o Hyper-arousal can also be helped by medication, and older tricyclic antidepressants are frequently used for insomnia.

B. Soothing the stress and anxiety following a trauma is also important.

o Develop rituals which help create a sense of safety. For example, a going-tosleep ritual. Take a long, relaxing bath, put on comfortable clothing and light a candle by your bed. Turn off the other lights. Stretch slowly across your bed, feeling your movements, feeling the sheets. Slowly open a book (something positive or relaxing) and read a page, meditating on what is good. Blow out the candle and go to sleep.

o Take time off to relax or hide for a day. For example, hide under the covers and make a nest of pillows and blankets somewhere. Do whatever makes you feel refreshed and relaxed, even if it's just huddling in your nest with munchies for a few hours. Allow the anxiety to bleed away.

A. Safety

A trauma by nature is something you cannot control. Gaining control of your environment and even your own emotions is the first step to healing the trauma.

Safe environment.
Safety is first established by taking care of the real practical needs of your body. You must seek out and establish a place that is no longer physically or emotionally harmful. This means food, clothing, rest and no longer being at risk of danger (if possible).

Safe people.
It also means that you find people around you who will care for your body and your heart. You need people who are safe to talk to about the event who will listen and care. You need people who will not judge you, minimize what you went through, or be scared/unwilling to hear about it.

Safe emotions.
Safety is also established by being able to think about how the event has affected your life without remembering it directly. One way to view your trauma objectively is to simply learn more about trauma itself (like reading these pages). This will help you feel normal in your responses and thus more in control of what is happening to you. This is an important step before directly thinking about or talking about your memory.

B. Remembrance and Mourning

1) Revisiting the Memory

Pacing.
Letting yourself remember the details of what happened is the most powerful portion of healing from a traumatic event. It is important to do this at a pace that is comfortable for you so that you do not get overwhelmed and retraumatized. Perhaps this means that you must remember your event one tiny bit at a time, giving yourself time in between to recover from the painful reality of what happened, to mourn the losses and to care for yourself. You need to pace your storytelling comfortably and feel in control of your emotions in the process (it is OK to cry, you just don’t want to feel out of control or overwhelmed).

Admitting what was real.
Another ingredient in recovery is to acknowledge that what happened was real. It happened to you in time and space. It was true. When events are so horrible that we believe they should not ever happen, it can be hard to allow ourselves to believe they do (especially to us). This is true for the person who went through the trauma as well as for those of us who hear about it. Listeners also want it to not be true, so they minimize it, deny it or avoid the painful details. Facing the truth is painful, but honesty is the path to recovery. Nothing has happened that you and God cannot face together. Remember, you already survived it!

To help you do this, you can ask yourself the following questions to help you to think about the memory safely and objectively.

• What label can you give the memory so that you can talk about more easily (for example, “the day with my brother”)?

• If you let yourself think about that memory today, how distressed (upset) does it make you feel? Score the intensity of your feelings from 0 to 10, 0 being no upset feelings at all, 10 being the most upset feelings you can imagine.

• How has this event affected your life?

o Does the memory itself intrude upon your life without you wanting it to? Examples: reliving the event, flashbacks, nightmares about it, etc.

o Do you find yourself in a frequent state of alert because of this event? Examples: always on edge, super tuned in to a similar type of danger, always watching out

o Have you limited the way you live your life because of this event? Examples: depression, avoiding people or activities, emotional numbing

o Do you overreact to present situations because of this event? Example: have emotions that are too big for what is currently happening

o Do you overcompensate in the present because of this event? Example: going extremely out of your way to avoid a similar situation

o Are you oversensitive in the present because of this event? Example: things that seem little to others bother you a lot

o Are there ways that you currently behave, think or feel that are a result of this event? Examples: not trusting people, avoiding confrontations, not speaking for yourself, not asking for help, etc.

Feel the feelings.
As the memory comes, allow yourself to feel the proportionate and appropriate emotions that go with the event (anger, confusion, loss, fear, sadness, humiliation, shock, horror, etc.). When a traumatic event is occurring, our brains shut off all of these emotions in order to help us respond at the time and survive. Recovery includes allowing yourself to feel these many feelings (often contradictory) and to slowly process each of them. Try not to judge yourself for having the feelings. Just let them come and they will leave when you have acknowledged them.

Feeling the feelings also includes the process of mourning. All trauma involves loss. In addition to the loss of people, objects, or places, less tangible losses may include the loss of safety, the loss of the world as we knew it, the loss of innocence, the loss of faith and trust, the loss of ideals we longed for, the loss of power or control, the loss of our hopes and expectations, etc. Sadness is appropriate for all loss, and incorporating the truth of our losses into our present lives is a process.

Connect with the person who went through it. This part of recovery is how you reconnect with all of the parts of you who went through the trauma. Traumas cause us to become disconnected (from ourselves, others, our own feelings, the event itself, the community, etc.). As you revisit the memory, try to see yourself in the situation. What did you do, think, or feel? What did you need or wish?

2) Sharing the experience.

Telling the story to someone else is also a crucial part of recovery. Saying it out loud makes it real. It breaks the isolation of experiencing the event alone. It breaks the shameful hold of secrecy and silence. It brings the memory out of its wordless quality and into something tangible that can be dealt with.

Telling the story to others also allows us to have feedback from others. They become witnesses of the truth. They can give feedback and clarity about the facts of the story. They can ask questions to help us connect with the event. They can validate our feelings and provide empathy. They help us know that we are not crazy. They provide companionship and support in the journey.

3) Rewriting the Memory

“Rewriting the memory” means incorporating all of the newly discovered truths of the story into our memories to be a more accurate picture of what happened. This part of the recovery process may include filling in missing information from outside sources. It may also be helpful to try to understand the event from the perspectives of others who were involved.

This part also includes recognizing the outcomes of the event. These may be positive or negative or both. Seeing God’s hand in the event is one of the most freeing aspects of all.

Rewriting the memory may also include correcting the lies we believe because of this event and replacing them with the truth.

To help you do this, look at the “Irrational Negative Beliefs” listed below. Do you have any negative thoughts about yourself that are related to this event? What is that thought.

Responsibility

o I don’t deserve love

o I am a bad person

o I am terrible

o I am worthless (Inadequate)

o I am shameful

o I am not lovable

o I am not good enough

o I deserve only bad things

o I am permanently damaged

o I am ugly (my body is hateful)

o I do not deserve …

o I am stupid (not smart enough)

o I am insignificant (unimportant)

o I am a disappointment

o I deserve to die

o I deserve to be miserable

o I am different (don’t belong)

o It’s my fault

o I should have known better

o I did something wrong

o I should have done something

o Safety/vulnerability

o I cannot be trusted

o I cannot trust myself

o I cannot trust my judgment

o I cannot trust anyone

o I cannot protect myself

o I am in danger

o It’s not OK to feel (show) my

emotions

o I cannot stand up for myself

o I cannot let it out

Control / Choices

o I am not in control

o I am powerless (helpless)

o I am weak

o I cannot get what I want

o I am a failure (will fail)

o I cannot succeed

o I have to be perfect (please

everyone)

o I cannot stand it

o I am inadequate

• If you checked one of these negative beliefs, what would you like to believe about yourself instead?

• Do you have any fears or concerns about bringing up this memory?

• If this negative event no longer affected your life, how do you imagine your life would change? Describe how you would be different if this memory were truly healed / resolved.

Lastly, rewriting the story may include envisioning the fact that God Himself was present at this event. This truth may require some spiritual wrestling (“How could a good God allow this to happen?”), but it is a journey worth taking. Only God can answer that question for you. Nevertheless, God is in control; God is all-present; God does love you; and God is good. Imagine the fact that God was there and ask Him to come into your memory of the event and take care of you.

C. Reconnection.
This last phase of recovery is a process of integrating the trauma into your present and future life. It’s allowing yourself to live again; to feel, hope, laugh and love again. Giving yourself permission to connect with yourself and others does not mean you have forgotten your trauma or minimized its importance. It is not a betrayal of what was. It is an acknowledgement that what happened was true, but it is not the only thing that has ever happened or will ever happen in your life. Life can go on and be lived well or possibly even better. You can move from “survive” to “thrive”.

Colodzin, B. (1993). How to Survive Trauma. Barrytown, New York: Station Hill Press.

Dee, E. (1993). War Against the Silence After Trauma: Unmasking and managing the stress of change. Sioux City, Iowa: Loess Hills Press.

Herman, J. L. (1992). Trauma and Recovery: The aftermath of violence -- from domestic abuse to political terror. New York: Basic Books.

Hybels-Steer, M. (1995). Aftermath: Survive and overcome trauma. New York: Fireside.

Louden, J. (1992). The Woman's Comfort Book: A self-nurturing guide for restoring balance in your life. San Francisco: HarperCollins.

Miller, D. (1994). Women Who Hurt Themselves: A book of hope and understanding. New York: Basic Books.

Shengold, L. (1989). Soul Murder:The effects of childhood abuse and deprivation. New York: Ballantine.

David Baldwin: www.trauma-pages.com www.emdria.org

www.mentalhealth.com,