Post-Traumatic Stress Disorder
by Dr. Daniel A. Bochner
Psychologists are always talking about “inner conflicts.” Why is that?
Well, certainly “inner conflicts” can't have anything to do with a disorder
that arises due to trauma. Right?... Nooooo, wrooonng!!! Post-traumatic
stress disorder (also known as PTSD) is, believe it or not, also caused by an
inner conflict. The inner conflict of PTSD, however, is not borne from a
troubled past or conflicted feelings about right and wrong. Those kinds of
issues can exacerbate PTSD, sure, but they are not what causes it. PTSD is
actually caused by a conflict between two essential biological imperatives.
These imperatives are at the core of health and development. The first is the
avoidance of pain. The second is the integration of experience.
It should come as no surprise that we avoid pain. It is obvious that we
humans, just like all animals, survive largely because we do avoid pain.
Most organisms move away from physical pain instinctively. The instinctual
first cry of birth is an impulse to have some kind of tension or discomfort
soothed, whether it be the actual pain of being born, the first pangs of
hunger, or the first experience of terror. We then move on to cry for
comfort of all kinds, which is not just avoiding pain, but is also deeply
involved in connecting to others. And of course, from the earliest ages,
although we might reach out to touch the glowing embers of the fire or the
red hot burner on the stove, our first burn teaches us a clear respect for
anything with a yellow, red, or orange glow.
Trauma is, by definition, out of the ordinary, extremely painful,
experience. Sometimes severe physical pain is involved, but often the most
horrendously damaging aspects of a traumatic experience involve the impact
it has on others whom we love or for whom we feel responsible, or our
feeling that we might be to blame for the trauma. Emotional pain is
somewhat different than physical pain. Nevertheless, the impact of
emotional pain is every bit as powerful as physical pain in traumatic
experiences. Just like any other kinds of pain, it is natural that we avoid all
the different kinds of pain involved in trauma, including both the physical
and the emotional aspects. Avoiding emotional pain is at the core of PTSD.
The second primary factor involved in PTSD, the integration of our
ongoing experience, is just as essential for living as the avoidance of pain.
Life has little meaning without the ability to remember what we've been
through, or who we know, or where we've been. Our earliest experiences,
perhaps by design, are especially difficult to integrate. Maybe that is one of
the reasons that being born is not especially traumatic (from the viewpoint
that it is not recalled repeatedly with horror). At that point we have not yet
integrated any of our experiences. As we develop, however, our ability to
recognize our closest caregivers, to know how best to get their attention, and
to steer clear of physically painful objects grows in importance. Soon, our
understanding of everything we perceive gets organized for the specific
purpose of helping us manage our ongoing functioning in the most efficient
manner possible.
Trauma is especially chaotic experience that defies logical
understanding and thus is especially difficult to integrate. Although we
typically expect to be able to avoid disasters, traumatic experience brings into
question our ability to avoid accidents or painful experience. Thus, we don't
want to integrate traumatic experience because doing so requires us to admit
that we might be in danger that is unavoidable. Not only are many accidents
unavoidable, but we also would like to remain in denial about how true it is
that we are taking chances on a daily basis. Our desire to deny the
possibility of danger, even when it might be avoidable, makes it difficult to
integrate trauma in that doing so requires us to realize how dangerous things
are. When we're making ourselves vulnerable in some way, we're typically
in denial of the danger we're in. For example, we operate motor vehicles so
frequently that we forget how ludicrous it is to believe that it's safe to hurtle
ourselves at 60 mph in a metal box on wheels, and to expect our vehicle will
never malfunction, and to expect that we ourselves will never malfunction,
and to expect that all the other drivers will follow all the rules.
In spite of how safe we'd like to think we can make ourselves, when
something does go wrong, the results can be horrifying. We likely blame
many circumstances and perhaps we blame others we don't know. We can
blame ourselves as if our ability to avoid disasters should be flawless. Any
loss of material possessions, a loss of the feeling of safety, or God forbid,
loss of life or limb, can seem utterly incomprehensible. Although traumatic
events should be integrated into our understanding of life, maybe even more
than other experiences since they could help us learn better what to avoid,
these events defy logic, seem to make little sense, and hurt us so deeply and
personally, that such events are often not remembered at all (even when
head injury is not involved). Our desire to avoid the pain of trauma often
actually makes us forget the incident entirely.
More than anything else, really, it's the severity of the emotional terror
that makes it impossible to integrate a trauma into our ongoing experience.
Our emotions go into turmoil over the trauma, and the pain is so bad that we
just can't bring ourselves to think about it. Yet we can't help it. Our minds
do want to make sense of the event. Flashes of the event thus push
themselves into our consciousness, begging for recognition. Although we do
not want to think about the trauma, the trauma will not leave us alone
because it must be integrated. We do need to understand what went wrong
and how similar disasters might be avoided. If we cannot get such an
understanding, we're likely to feel we're damned to experiencing the same
trauma again and again. That is the essence of PTSD. The traumatic
experience is both impossible to remember or integrate, and impossible to
forget or avoid.
So we avoid the pain by avoiding memories and thoughts about the
trauma. We attempt to avoid anything that reminds us of the trauma. Yet
reminders are everywhere. Colors, sounds, smells, and all sorts of familiar
everyday occurrences make us think and feel about the trauma. Anything
that could remind us of the trauma brings back a flood of thoughts and
memories. We busy ourselves so our mind can't possibly let thoughts or
feelings related to the trauma bother us. But as soon as our defenses are
down, when we're not so busy, thoughts push their way into our minds. Our
defenses are always down when we sleep, and nightmares related to the
trauma begin to plague us.
When we're supposed to be at our most relaxed, instead we find
ourselves in hyper-vigilant states, watching out for anything that might hurt
us. In fact, quite often, because we have not properly integrated our trauma
into our understanding of life, we start to generalize our traumatized state to
areas that are completely unrelated to the initial trauma. We start to be on
edge all the time. We can become hyper-vigilant to the point that we
become paranoid. Now, because we have not integrated our traumatic
experience, the trauma sneaks into our way of being in the world. We are
avoiding all sorts of things. We're irritable, tense, often paranoid and
angry. Now, because we have generalized our emotional state to all our
experiences, the trauma in effect, has us avoiding relationships altogether.
In spite of how much we love our loved ones, it's often our
relationships that suffer more than any other area of our lives. Those closest
to us are typically those who see us at our worst. Unfortunately, the anger
we feel about how unfair things are, or the anger that simply derives from
feeling so tense, is often aimed the most at those at home. Suspicion leads
to lack of trust. Simultaneously, the confusion of someone with PTSD often
leads to their need for immediate gratification. Family members rarely
understand the need of the afflicted family member to have some sense of
control which might permit them to feel things are not in complete chaos. In
short, trauma creates a complete mess, not just for the individual who
develops PTSD but also for his entire family.
It is also typical that a person with PTSD gets no treatment
whatsoever. Because they are paranoid and avoiding the pain of the trauma,
someone with PTSD often has no desire to visit a complete stranger for the
purpose of confronting their problems. It is far more likely that they will
become increasingly withdrawn and find various ways to escape even from
themselves. Substances or behaviors that help numb the pain of the trauma
are sought and often result in addictions. Anything is better than
experiencing the feelings and recalling the events of a serious trauma. When
the victim of PTSD does not seek help, their problems often fester within
their hearts and minds and dissolve their relationships, and all too often, the
trauma ruins their life.
There is hope, however. Treatment for trauma generally focuses on
helping people integrate the traumatic response in spite of the pain involved.
Talk therapies, hypnosis and EMDR (Eye Movement Desensitization
Reprocessing) help individuals combine the meanings they have derived from
the trauma, with their memories, emotions, and body feelings. It is
remarkable how often traumatized individuals have taken the trauma to
mean they are responsible for the pain of others, or have no one who cares
about them, or that they just have bad luck. Others will think the trauma
happened for a reason. If the trauma occurred at the hands of a loved one,
they'll think the trauma was related to their behavior or that it showed them
who they really are, or who they will always be. Treatments for PTSD help
people see how memory involving the trauma is associated with body
sensations as well as painful, but irrational, feelings.
In the absence of, or in addition to, interpersonal psychotherapy,
writing can provide huge relief (please see article, The Writing Cure).
Strangely, this simple tool can help a person get feelings, thoughts, and body
sensations out of one's mind and onto paper. The desire for integration in
the mind pushes thoughts and memories into consciousness almost as if
there's fear the the thoughts and memories will be forgotten. In fact, in the
case of PTSD, the mind is trying to forget that which must be remembered.
But when things are written down, the mind can start to work through the
complications of the trauma. An individual should specifically attempt to
remember every detail – everything said, all the colors and movement,
shading, textures, times of day, sensations, smells, tensions, stresses, tastes,
emotions. One can also try to remember the beliefs these feelings and
sensations bring them to and how the feelings make them view their role in
the world. When it seems there may not be any more to write, any other
thought evoked should also be written down. Writing makes the mind know
that what must be integrated has been acknowledged. As long as the
information is all written down, the mind often finds much less need to
repeat the experiences, almost as if the mind believes the trauma has been
integrated simply because it is written down.
Although trauma can be psychologically devastating, and can lead to a
short-circuit in normal functioning as painful memories are avoided and
integration of experience is prevented, it need not always be a completely life-
changing event. Treatments for trauma are very effective and are often
relatively accessible. In the absence of treatment, some individuals can treat
themselves with focused writing, or can find that expressing their feelings to
friends is not as unacceptable as they might have thought. There is great
hope for those with PTSD even though a lack of treatment can lead to a
lifetime of avoidance and withdrawal. With proper help, the splintered life of
the trauma victim can be rebuilt so that pain is no longer considered
impossible to face, and integration of experience can lead to a newly
integrated life. In recovery from trauma, the victim of PTSD puts life back
in perspective, opens up to new possibilities, and begins to develop new
relationships. With recovery, the traumatic experience is integrated and the
pain it inflicted, although remembered, is no longer overwhelming. Often,
then, the traumatic experience can be utilized in helping one relate to others
who have also experienced trauma, and can actually thus make a person a
more connected individual than ever. With treatment, once traumatic
memories are successfully integrated, what was once horrifically traumatizing
is reduced in intensity to a powerful learning experience, and that age-old
adage is often true, “what doesn't kill you, can make you stronger.”