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.,
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
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
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
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
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
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
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.
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.