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Grief, Interrupted: PTSD in the time of Tsunami and War
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Grief, Interrupted: PTSD in the time of Tsunami and War
Mark Dombeck, Ph.D.

The turn of the year confronts us with unfolding traumas on massive scales – one each of the natural disaster (the tsunami tidal-waves in Asia and India) and man-made disaster (the ongoing Iraq war) varieties, and any number of smaller (or simply less well reported) disasters. I use the word 'traumatic' carefully here. These events are traumatic in many senses, but perhaps most especially in the psychological sense as they generally fall "outside the range of human experience" in that they involve situations that most people do not typically experience in the course of a civilian life, evoke sustained terror and involve the acute threat of death or actual death of others. These are overpowering events capable quite literally of blowing someone's mind. With so much trauma floating around, it seems like a good time to discuss the traumatic stress disorders and what they tell us about how human beings relate to overloading, overwhelming events.

Change, Grief and Loss

To understand what traumatic reactions are about, you have to start with how people are set up to respond to change. Change has been called the one constant, and is an inevitable part of life. People spend most of their lives trying to manage change – to slow it's pace or make it come faster than the universe wants to dole it out. Some change is good for people – it allows for progress and growth - but whether for the positive or the negative, change stresses and tests us.

People must adapt psychologically when faced with change. This can be an easy or difficult task depending on whether change happens slowly or fast, in small increments or all at once, and whether the change is personally meaningful or not. The sharper and faster things change, the less change is expected, and the more personally meaningful are the things that have changed, the greater the stress that is experienced. Getting a flat tire is not too terribly stressful a change to endure, but the death of a parent is a very large and very stressful loss.

Significant and stressful life changes often cause people to grieve. Or, another way of saying this is that grief is a process through which psychological adaptation to significant life change occurs. Various models outlining the stages people pass through while grieving have been proposed. The famous Dr. Kubler-Ross (of “On Death and Dying” fame) proposed, “Denial, Anger, Bargaining, Depression and then finally Acceptance as a predictable progression. A model more dear to my own experience, proposed by psychiatrist Mardi Horowitz suggested that Outcry followed by a back-and-forth motion through Denial and Intrusion (of painful memories), and then a process of Working Through occurred prior to Completion of grief.

Traumatic Stress and the Shattering of the “Just” World.

When we are grieving, what we are doing (to put it coldly and clinically) is updating an out-of-date mental picture or model of the world so that it can once again closely match with our experience of reality. For example, we grieve when someone close to us dies. In the process of that grief, we come to terms with the fact that our loved one is dead.

The notion that we have a 'model of the world' that must be updated when significant change occurs is key to understanding trauma. Though change can occur in an instant, it is not possible for us to grieve in an instant. This is because we are not fundamentally in touch with the 'real' world where objects collide purely according to the laws of physics. Rather, we live in a sort of model-world of our own construction inhabited by feelings and attachments. The formation of this model is a lifelong project starting shortly after conception. It occurs slowly and incrementally and in the background so that we never notice that it is there. The model of the world in our heads becomes the unquestioned foundation on which we make sense out of new situations and people. Though this model of the world allows us to predict with good accuracy what will happen next, it is not the same thing as the world itself. When our model ceases to conform to reality (because the world itself has changed) we generally attempt to ignore the changes (denial), and when that doesn't work out, we freak (e.g., emotional outburst).

Long ago a psychologist by the name of Lerner coined the term “Just Word Hypothesis” to describe a feature of this model-world in our heads, which is that it generally gets constructed in such a way that the world appears to us to be stable, orderly, law-abiding and just (as in justice), with a reason and rhyme present behind each thing that occurs. The thing is though that the actual world is not always stable, orderly, law-abiding and just. Sometimes it is unstable, chaotic and downright criminal.

It's not really that the world is disorderly – rather it is statistical in nature. Most of the time life is relatively orderly, and then every now and then things happen that are rare, and not easy to anticipate (a massive “500” year flood, an earthquake, a tsunami, a meteor slamming into earth, the overthrow of the government, etc.). Such unpredictable events conflict strongly with our just world hypotheses, and tend to make us feel crazy uncomfortable on the inside. We adapt as well as we can, but sometimes events we experience are so powerful as to make adaptation very difficult indeed.

Traumatic events are precisely those events that shatter people's world models; their just world hypotheses. People exposed to events with the potential to induce trauma (such as untimely violent death or maiming, torture, combat, rape, etc.) lose the foundation upon which beliefs and understandings vital to their well-being (such as their ability to conceive of the world as a place which is good, plentiful, abundant, nurturing) rest. Without this foundation, the world becomes a fundamentally more chaotic, capricious and terrifying place, and the task of grieving becomes exponentially more difficult.

Post Traumatic Stress Disorder

Trauma reactions have been occurring since human beings have been on this planet, but until recently they did not get much respect. There have been profound natural disasters throughout history, but they are by and large infrequent when measured in human time scales. The common ways that people have had their model-worlds shattered is through combat and war experience, or assault. Not surprisingly, the modern western concept of Post-Traumatic stress disorder is one that has evolved out of military medicine experiences, in the United States through the Veterans Affairs medical centers, and mostly in the 40 years since the Vietnam war.

Today, Post Traumatic Stress Disorder is recognized as a psychiatric disorder that can occur in the aftermath of trauma (combat derived or otherwise). Inside DSM it is categorized as an anxiety disorder (in the same family as panic disorder, generalized anxiety, phobia, etc.) but in its own subgrouping which it shares with its sibling, Acute Stress Disorder.

Both stress disorders occur in the wake of exposure to a truly traumatic stressor, and both disorders share the same profile of symptoms characterized by: 1) Intrusive thoughts and feelings concerning the trauma, 2) Avoidance of trauma reminders, and 3) heightened startle response and arousal (hyper-vigilance). The big difference between Acute and Post disorder types has to do with time: the 'acute' diagnosis is used for the first six months post trauma exposure, and the 'post' diagnosis is used thereafter. In practice, it all ends up PTSD.

PTSD is basically an overloaded dysfunctional grief process; one so severely overloaded that the normal grief process gets interrupted and hung up. It is a sort of delay of normal 'emotional digestion'.

In a normal grief process initial outcry and anger gives way to cycles of denial, disbelief and numbing, and intrusion (of painful loss-related memories), all of which ultimately work their way through to a new adjustment. Though painful, neither the denial nor the intrusion is overwhelming for too long. In contrast, PTSD involves re-experiencing of trauma related memories which never cease to be overwhelming and paralyzing. The traumatized person is unable to cope with the intrusive traumatic memories and is pushed towards extreme ways of avoiding them; drugs to dull the pain, prolonged avoidance of intimacy, etc. Working through does not occur because working through requires the ability to tolerate what has been lost, and in PTSD that ability to tolerate is precisely what is not possible.

For someone who has not endured a trauma, it is fundamentally hard to grasp why it is so difficult for PTSD sufferers to 'get over' their experience. PTSD sufferers do look like everyone else, so why the difficulty. The issue of why goes beyond the simple trauma memory, deep into physiology. The experience of trauma is fundamentally overwhelming. In a best case scenario, it is accompanied by the highest intensity output of outrage/fear/anxiety/overwhelm you can imagine – actually probably more than you can imagine if you haven't been traumatized. This outpouring of emotion is capable of altering the base arousal level of the body so that after the trauma experience, traumatized people are far jumpier and more anxious then they were originally. This is often a permanent alteration so far as I know; it doesn't much go back to 'normal', or if it does, it happens glacially.

There is another reason why traumatized people don't 'get better' easily and that is that they get into an avoidance loop. They rightly fear their trauma memories, do not wish to re-experience them, and run from them (or take steps to avoid them) whenever feasible. This sort of avoidance can be bad enough when people are in full command of their memories. It is worse when they are not - as in the case of trauma-related dissociation.

In severe trauma cases, a phenomena called dissociation can occur. Dissociation is a sort of coping mechanism that helps some people to manage shocking or stressful events by altering the way that memory about those events gets processed. Dissociated memories are cut off from other memories and cannot be easily retrieved via normal recall. Dissociation is related to hypnosis. It is responsible for some cases of amnesia, and (when it is severe and has occurred in childhood) for 'multiple personality' cases. You'd think that someone who dissociated during a trauma would be better off than someone who didn't, but it isn't the case. Dissociated traumatic memories are still capable of intruding into consciousness (via dreams and other back doors), but they are harder to find and face down than normal trauma memories and therefore harder to treat. When dissociation is present at the time of trauma, the danger of a difficult-to-resolve avoidance loop occurring is heightened.

Between repetitive and intrusive re-experiencing of trauma memories, avoidance loops dissociation and hyper-arousal, traumatized people can have a very difficult time living their lives post-trauma. Typically, they are frazzled all the time. Some of them have anger or emotion regulation problems. Some of them seek solace inside a bottle of alcohol, or in a heroin needle. Some of them end up killing themselves. A fair number of them have difficulty continuing to work normally and to maintain or develop intimate relationships. If the trauma occurs when someone is young and still forming, they may become developmentally or socially 'stuck' in some fashion, making it more difficult for them to thrive as adults.

Trauma can occur in a variety of forms, but these days there are two obvious sources of traumatization: the Iraq war, and the recent Indian Ocean tsunamis. Both of these events have shattered lives and families, killing randomly and indiscriminately. In the case of the war, soldiers have been placed into conditions of unrelenting stress and dangerousness wherein they have to kill or be killed. It is often not possible to tell with any certainty who is a threat and who is an innocent civilian. Inevitably, mistakes get made and innocents get killed. Soldiers get killed too, often in horrific, unimaginable, and completely unpredictable ways. It is not possible to predict whether today will be your last day on earth while operating in a combat zone. Without question, some reasonable minority percentage of the soldiers returning from the war will return with PTSD, or will develop war-related PTSD at some later time.

In the case of the recent tidal waves, the scale of the carnage is unimaginable. Entire villages have been erased, and well over 100,000 people are dead, many never to be recovered even to be buried. There was little or no warning before this disaster struck. In the affected countries, the trauma will be not merely personal, but rather has the potential to infect the entire culture for a generation or more.

Helping Traumatized People

PTSD is a story of interrupted grief. Traumatized people are stuck people, forever needing to avoid what no one could legitimately face without going 'mad'. You can't really avoid fears and expect that they'll go away, however. In general, the safest way out is usually through. This is to say, the way to overcome a feared memory is to carefully, and in a graduated and safe way, learn to tolerate it, in so doing, learning how to discriminate what is memory and what is present-day reality; that while the past may have been dangerous, the present is not. This much is true with regard to regular fear-disorders (phobias), and it is more or less true also for PTSD.

There is effective therapy for PTSD, but it is by no means a miracle cure. By this I mean to say that I know of no therapy capable of erasing the impact of trauma on a traumatized person. Memory is a one-way, input only process. Things go into memory and they don't go out (until Alzheimer's sets in, anyway). What can occur is this: Psychotherapy can help a traumatized person to break down dissociations, and to learn to react less severely to their trauma memories. Adjunctive medication therapy can help traumatized patients to experience less anxiety and to better manage their arousal. Relaxation therapies can similarly help patients to manage their stress.

Recovery from trauma works best when trauma exposure is recent, when the traumatized person accepts help from others, and when the traumatized person did not dissociate (space out) at the point of trauma.

One of the better psychotherapy approaches for helping traumatized people involves helping them break the cycle of avoidance and come to grips with what they have experienced through careful and systematic exposure to trauma memories. This is a very delicate process that really is best left to professionals and then only undertaken with a trusted therapist. The task is a balancing act. If the therapist doesn't push the patient at all, he or she ends up colluding with the patient's natural tendency to avoid trauma memories. If he or she pushes too hard, or doesn't provide an escape for a patient who becomes overwhelmed while thinking of the trauma, re-traumatization can occur. The therapist must also contain and support the pain of the patient by maintaining an authentic presence (“being real”) with the patient while the patient is discussing the trauma.

This sort of therapy is too delicate of a process to try at home and this is especially true if dissociation occurred at the time of trauma. You will not be doing anyone a favor by bringing up trauma subjects around PTSD patients without the explicit consent of that person to talk about those traumatic events. Even sincere efforts could easily backfire and result in negative outcomes (the patient might avoid working with a real therapist in the future, making it harder for them to get the help they need). This being said, it can be helpful for a traumatized person to be able to talk about what they have experienced if they can do it on their terms. If someone who has been traumatized wants to talk about it with you, and you are strong and caring and respectful enough to listen, that is a whole other thing.

Take-Home Message:

Trauma seems to be a simple fact of life in these troubled times. If you are confronted with traumatized people you should keep in mind the following facts: PTSD is a real psychiatric disorder that could happen to anyone. It is not a sign of weakness or moral failure. It occurs when the amount of trauma someone is exposed to is more than they can handle. It manifests as severe and crippling anxiety, emotional regulation problems, arousal, and avoidance. It is perpetuated by dissociation and avoidance behavior. It can be effectively treated but this treatment should be attempted by trained professionals only, as the techniques involved are delicate and take practice to get right. Effective therapy may involve medicine, psychotherapy, and relaxation oriented approaches. It is not a good idea to force a traumatized person to talk about what they have experienced. However, it is a good idea to recommend that they get professional help and perhaps even to assist them in accessing that help. The sooner someone is treated the better their outcome will tend to be.