WHAT IS POST TRAUMATIC STRESS DISORDER AND THE APPROPRIATE RESPONSE TO IT?
An overview of the work of
Dr. Judith Herman Lewis
By Jim Spencley.
Introduction: PTSD is not malingering, dependency, avoidance of responsibility, attention seeking or any of a number of ways of discounting and not believing the sufferer - it is a normal response to abnormal situations.
Post-Traumatic Stress Disorder (PTSD) is a relatively new diagnosis of a condition which has always been part of the human experience. This diagnosis first appeared in the fourth edition of the official bible of the American Psychiatric Association - The Diagnostic and Statistical Manual (DSM-IV). Because of the identicy of symptoms of various previous diagnosis applied to different histories, but all sharing some form of traumatic experience, the American Psychiatric Association brought together service providers who had worked with traumatized people from many different social settings, including, political violence, hostage victims, combat veterans, accident victims and victims of domestic and sexual violation.
Dr. Judith Herman Lewis was on this committee. She is now a professor of psychiatry at Harvard's Medical School, head of Cambridge's Center for the Treatment of Trauma and a chief trauma consultant for The United States' Departments of Defense and Veterans Affairs. In short she is currently considered to be a pre-eminent authourity on trauma, treatment and recovery.
What follows are from of her work. The first is a summary of the introduction her book Trauma and Recovery (copy enclosed herein) and the second is a synopsis of her work, taken from the book, and various articles and interviews with her. I AN OVERVIEW OF THE SOCIAL RELATIONS OF PTSD (A summary of the introduction of the textbook Trauma and Recovery) The study of psychological trauma does not languish for lack of interest; in fact it has an abundant, and rich tradition but also a curious history - one of episodic amnesia. Periodically in the past century, similar lines of inquiry have been taken up, abruptly abandoned and forgotten only to be periodically rediscovered and reclaimed much later. This intermittent amnesia is not the result of the ordinary changes in fashion that affect any intellectual pursuit rather; the subject provokes such intense controversy that it periodically becomes anathema.
To study psychological trauma means bearing witness to horrible events. It means to come face to face both with human vulnerability in the natural world and with the capacity for evil in human nature. When the events are natural disasters or "acts of God," those who bear witness sympathize readily with the victim. But when the traumatic events are of human design those who bear witness are led into realms of the unthinkable and caught in the conflict between victim and perpetrator.
In this conflict it is morally impossible to remain neutral and the observer is forced to take sides. Consequentially the study of psychological trauma founders on fundamental questions of belief. Certain violations of the social compact are too terrible to utter aloud and the ordinary response to such atrocities is to banish them from consciousness: this is the meaning of the word unspeakable. Atrocities, however, refuse to be buried because remembering and telling the truth about such events are the prerequisites both for the restoration of the social order and for the healing of individual victims. Consequently, equally as powerful as the imperative to deny is the imperative that denial does not work. This conflict between the will to deny horrible events and the will to proclaim them aloud is the central dialectic of psychological trauma to which perpetrators, victims and witnesses are all subject.
In order to escape accountability for his crimes the perpetrator does everything in his power to promote forgetting. Secrecy and silence are the perpetrator's first line of defense. If secrecy fails, the perpetrator attacks to make sure that no one listens. To this end, he marshals and impressive array of arguments, from the most blatant denial to the most sophisticated and elegant rationalizations. After every atrocity one can expect to hear the same predictable apologies: it never happened; the victim lies; the victim exaggerates; the victim brought it upon them self; and in any case it is time to forget the past and move on. The more powerful the perpetrator, the greater is his prerogative to name and define reality, and the more completely his arguments prevail. Ranging from the effects of a single overwhelming event to the more complicated effects of prolonged and repeated abuse there is a spectrum of traumatic disorders.
However, people who have endured horrible events suffer predictable psychological harm. The dialectic of trauma (the imperatives of silence and speaking out) is internalized in victims and evident in their psychological distress symptoms. It results in the protean, dramatic, and often bizarre symptoms of hysteria which Freud recognized a century ago as disguised communications about abuse. It gives rise to complicated, sometimes uncanny alterations of consciousness which George Orwell, one of the committed truth-tellers of our century, called "doublethink,"" and which mental health professionals, searching for a calm precise language call "dissociation." This is most apparent in the way traumatized people alternate between feeling numb and reliving the event.
Thus the symptoms of traumatized people simultaneously call attention to the existence of an unspeakable secret and deflect attention from it. Because the traumatic syndromes have basic features in common, the recovery process also follows a common pathway. The fundamental stages of recovery are establishing safety, reconstructing the trauma story, and restoring the connection between survivors and their community.
However people who have survived atrocities often tell their stories in a highly emotional, contradictory, and fragmented manner which undermines their credibility and thereby serves the twin imperatives of truth-telling and secrecy. When the victim is already devalued (a woman, a child, a psychiatric patient, etc.), they may find that the most traumatic events of their life take place outside the realm of socially validated reality. Her experience becomes unspeakable. When the truth is finally recognized, survivors can begin their recovery. But far too often secrecy prevails and the story of the traumatic event surfaces not as a verbal narrative but as a symptom. Because denial, repression and dissociation operate on social as well as an individual level witnesses as well as victims are subject to the dialectic of trauma. It is difficult for an observer to remain clearheaded and calm, to see more than a few fragments of the picture at one time, to retain all the pieces, and to fit them together. It is even more difficult to find a language that conveys fully and persuasively what one has seen.
Those who attempt to describe the atrocities that they have witnessed also risk their own credibility. To speak publicly about one's knowledge of atrocities is to invite the stigma that attaches to victims. It is very tempting to take the side of the perpetrator. All the perpetrator asks is that the bystander do nothing. He appeals to the universal desire to see, hear and speak no evil.
The victim, on the contrary, asks the bystander to share the burden of pain and demands action, engagement and remembering. The perpetrator's arguments prove irresistible when the bystander faces them in isolation. Without a supportive social environment, the bystander usually succumbs to the temptation to look the other way. The study of psychological trauma must constantly contend with this tendency to discredit and render the victim invisible. Throughout the history of the field, dispute has raged over whether patients with post traumatic conditions are entitled to care and respect or deserving of contempt, whether they are genuinely suffering or malingering, whether their histories are true or false and, if false, whether imagined or maliciously fabricated.
In spite of a vast literature documenting the phenomena of psychological trauma, debate still centers on the basic question of whether these phenomena are credible. We find the two sides face to face; on one side the victims who perhaps wish to forget but cannot, and on the other all those with strong, often unconscious motives who very intensely both wish to forget and succeed in doing so. The contrast...is frequently very painful for both sides. The weakest one ... remains the losing party in this silent and unequal dialogue.
" II SYNOPSIS The History of Research into PTSD Periods of active investigation of trauma have alternated with periods of oblivion this is because the history of psychological insight is related to the ferment of the times. The paying of attention, the selection of what it is that we're going to consider interesting and significant in human behavior and how we name it is formed by the social and political context that we're embedded in. That's particularly true about the emotions related to power and control, the emotions related to one's place in society, one's place in the family, and the emotions of shame, of resentment, of pride, of a sense of legitimacy or illegitimacy
Three forms of trauma have come to light over the past century, and each time, the investigation of that trauma has flourished in affiliation with a political movement. In the first instance, Freud's work and that of others on hysteria came at a political moment in French history when there was a brief inclination to consider 'hysteria' as a possible manifestation of the isolated, politically powerless lives led by most Western women (an interpretation later dismissed in favor of Freudian reductionism). The second form of trauma to be studied was "shell shock" or combat neurosis, which became an issue in England and the United States after the First World War and which reached a peak after the Vietnam War.
Here the political context was the growth of an antiwar movement and a re-thinking of the effects of armed combat in the modern world The most recent type of trauma to achieve widespread public awareness was sexual and domestic violence, spotlighted by the feminist movement as well as modern political advocacy to secure the human rights and protection of children. Trauma vs. Fear Traumatic experiences must be distinguished from fear inducing ones (no matter how threatening the latter may be) by one crucial difference. Fear is a complex biological, integrated system of reactions to danger, encompassing both body and mind which we share with other animals.
A threat initially arouses the sympathetic nervous system, causing the person in danger to feel an adrenalin rush and go into a state of alert. In this state our attention becomes concentrated on the immediate situation, our ordinary perceptions of such things as hunger, fatigue, pain, etc., may alter such that we are able to disregard them and we feel intense feelings of fear and anger. These changes in arousal, attention, perception, and emotion are normal, adaptive reactions which mobilize the threatened person for strenuous action, either in battle or in flight.
In short, in fear we perceive danger; we startle, look around, do a quick appraisal of the situation and figure out what to. That is, fear is a response to danger in which there is some control, choice or way out even if it is only to either fight or flee. Traumatic experiences are those fight or flight doesn't work action is of no avail and this instills helplessness and terror. Post Traumatic Stress Disorder There are two degrees of PTSD, Simple (sPTSD) and Complex (cPTSD). Simple Post Traumatic Stress Disorder (sPTSD) The public at large is most familiar with sPTSD through such things as the Vietnam veterans, Bosnian civilians, witnesses to schoolyard shootings [and most recently 9-11]
Here the impact of a single or temporally discrete event in conditions of terror and helplessness results in trauma. Even so such experiences give rise to complicated, sometimes uncanny alterations of consciousness. When neither resistance nor escape is possible, the self-defense system becomes overwhelmed and disorganized. While we understand little about the psycho-biology it appears that some kind of biological rewiring seems to occur in people as well as animals. [Current research has shown that in animals which have been experimentally traumatized and in autopsies of humans who have died in violent incidents there are lesions in the amygdala, of the brain, believed to play a role in the processing of short-term memory into long term memory].
Traumatic events produce profound and lasting changes in physiological arousal, emotion, cognition and memory. After trauma each component of the ordinary response to danger (startle, alert, focused attention, non attendance to tertiary stimuli, anger, fear) these normally integrated functions become severed from each other, disconnected from their cause, take on a life of their own and persist in an altered and exaggerated state long after the actual danger is over. Thereafter the victim continues to respond to both specific reminders and to generally stressful and threatening situations as though this terrifying event were still occurring in the present.
Clinically speaking the triad of sPTSD is hyper-arousal, re-experiencing and numbing. Hyper-arousal is activation of the fear system. Re-experiencing is the reliving of the trauma through flashbacks and nightmares as if the event were still occurring. And, numbing/withdrawal (which is poorly understood) where there is a general loss of interest, a sense that things aren't real, amnesia for some, more, or all of the event and a sense in the aftermath that one is just not really oneself.
Complex Post Traumatic Stress Disorder (cPTSD) Complex Post Traumatic Stress Disorder (cPTSD) is more difficult and less understood (both socially and medically) than sPTSD. Unlike the later, which is the result of accident, conflict, or 'act of God,' cPTSD is caused by one's fellow humans. CPTSD results from: 1. prolonged and repeated trauma, 2. in situations of captivity and coercive control, 3. where the perpetrator isn't content to just have external compliance, but wants the victim to adopt and endorse his worldview. CPTSD occurs in situations of: · domestic violence (towards women, children and dependent adults where the cycle goes on and on) · sexual abuse · religious cults · prolonged hostage situations · concentration camps and political prisoners
In all these cases both the methods and the resultant mental processes they produce are the same. Oppression is oppression. Being the underdog is being the underdog. Being treated with contempt is being treated with contempt. Being treated violently is being treated violently. People do it and respond to it in the same ways. When you get right down to it, pain is pain. Complex Post Traumatic Stress Disorder is a normal response to very abnormal experience.
The 'singe cell family' of domestic abuse is not just the model for learning about the techniques of coercive control, torture and the transmission of this knowledge to the other contexts but the progenitor. That is, it is in isolated dysfunctional/abusive families that the spousal abuser, the pimp/child pornographer, the hostage taker, the political interrogator, etc., first experiences and learns these techniques and perhaps later develops them into a fine art. The abuse is done in the name of (not necessarily done by) the dominant authourity figure (primarily the father). The key elements in the development of cPTSD are: isolation; secrecy; splitting behaviour and betrayal (which destroy the relationships that would afford protection) withholding care and/ or affirmation or using or threatening to use care/affirmation as reward or punishment in order to undermine personal identity.
Fear is further increased by the polar extremes of fawning love, inconsistent capricious enforcement of petty rules and unpredictable outbursts of violence. And while violence is a universal method of terror perpetrators don't have to resort to it in order to cause trauma and it may be used infrequently, as a last resort. Apparent conventionality and normality are the most consistent features of perpetrators of this kind of terror. The general stereotypes of the 'ignorant blue collar worker,' the bottom-line alcoholic and drug user, the lurking insular psychopath, etc., are the remote exceptions not the rule.
Perpetrators of such abuse are extremely difficult to identify, until they are caught. They do not give warning signals. They do not perceive that anything is wrong with them, are convinced of their ultimate rightness, rationalize the abuse in heroic terms (i.e. for the good of...) and emphasize the deservedness of the victim - if only to bring them into line. They do not seek help and only rarely get into difficulties with the law. The profile of such abusers is that they are generally, charismatic, authoritarian, secretive, sometimes grandiose, and even paranoid. They seek out social and professional situations where their tyrannical behavior will be tolerated, condoned, or admired. They are exquisitely sensitive to the realities of power and to social norms. They are usually economically successful and involved in their communities. Their demeanor and status provide excellent camouflage, for few people believe that such extraordinary crimes can be committed by persons of such conventional appearance and position.
When exposed the public is shocked by how upstanding such people. Survivors of this kind of abuse have all the responses of sPTSD but only more so. Not only are there many more traumatic incidents where neither resistance nor escape is possible but the danger is in reality never over - Not only is the self-defense system overwhelmed and disorganized but repeatedly done so. As well, personal identity is repeatedly undermined through fawning love, capricious rules and violation or threats of violation - consequently there is no recourse a to previous sense of self to fall back on as is the case with sPTSD.
The disintegration of the components of physiological arousal, emotion, cognition, and memory such that and each function takes on a life of its own is much more intense with cPTSD. The sufferer doesn't 'merely' experience intense emotion without clear memory of the events or remember everything in detail but without emotion, their thinking processes are themselves fragmented. On the one hand they continually relive intense flashbacks of fragmented pieces of various incidents which are more real than the here and now (not just of a single event) with either all the terror intact or complete numbness.
And they experience intense anxiety and phobias unassociated with any present object. On the other hand they have an inability to remember discrete moments in current experience (fugues) and entire periods (up to years) are blocked from memory (long term amnesia) and not just of a single event. Relatedly, they often are aphasic - that is, their internal cognition remains intact but they are unable to take in new information and express their thoughts externally in meaningfully constructions. [It is akin to sitting in a concrete cell, communication with the outside world is imperative, a telephone is the only mode of communication with the outside world but there is a voice scrambler attached to it - what is said in either direction is undecipherable.] And, they experience 'pseudo' hallucinations - that is visual and auditory hallucinations with the awareness that they are hallucinations.
To make this response even more difficult to comprehend is the fact that under conditions of coercive control and captivity consciousness divides. We don't understand unitary consciousness very well consequently when people have double consciousness, double reality, it is more challenging. Survivors experience living in a double reality of the present and the past co-existing in mind they go back and forth between the two and it is not clear which is more real. Even with the amnesia, people will describe simultaneously knowing and not knowing what happened -remembering and not remembering simultaneously and when people get their memories back, they will often describe it as simultaneously re-living the experience and being outside of it as though it happened to somebody else.
Further they internalize and mentally co-exist with the perpetrator and the perpetrators way of seeing the world constantly unsure of which thoughts or feelings belong to them or the perpetrator. In this state of confusion and uncertainty they over-idealize the 'authourity' of the perpetrator and are in constant dialogue with him/her- either hopelessly trying to live up to unrealistic expectations or blaming themselves for not being able to do so - seeing oneself as bad, responsible for and deserving of what happened Weighted under these experiences the sufferer withdraws into isolation, paralysis, self-injury or explosive anger and frequent suicide attempts.
This is the realm of apparent hopelessness and despair Features of hope and recovery and the road back. Sufferers of PTSD demonstrate a remarkable resilience. If given the right circumstances they really do get better, make new lives for themselves and in so doing re-instill hope for other victims. Disintegration, in all probability at a biological level, of the normally integrated functions of fear, where those functions become dissociated from their source and take on a 'life of their own,' under conditions where the survival mechanisms of flight or flight are overwhelmed and no recourse is possible, is the defining cause of PTSD.
This disintegration extends beyond the biological and includes the perceptual, psychological and social realms. Such traumatic events destroy the sustaining bonds between individual and community. With cPTSD the destruction of these bonds and imposition of their interpretation of reality is the goal of the perpetrator and cause of the disorder. On the biological level, it is highly probable that both the symptomlogy (the continual reliving of the events, the isolation) and the continued imposition of the perpetrators world view do not allow the healing process to take place.
Traumatically victimized people cannot recover in isolation. They need other people and they need to take action in affiliation with others. Elements of survival and recovery The means of recovery is by working back through these disintegrated elements and reintegrating through the social, personal and ultimately allowing the biological to heal. Those who have survived, who have recovered their sense of self, of worth, of humanity learn that the only way back from severe psychological trauma depends upon re-establishing connectedness with others.
The 3 interconnected conditions of recovery are: 1. providing a zone of safety with other victims and survivors 2. remembering and feeling 3. telling and listening to others (reconnect elements of this safety support for telling the story) This kind of work cannot be done by a single therapist. Nor can a therapist do this kind of therapeutic work alone. Therapists if they believe their clients have empathic reactions to what they hear. They have nightmares, fragmented thinking, visual flashes, etc., of the horror that they bear witness to.
When they are isolated they lose perspective, burn out, give in to despair and resort to attempting to manage or control behaviour. Further damage can be incurred when therapy attempts to control the symptoms of cPTSD. This is especially true when the victim is characterized as a person with problem behaviors who must experience aversive "treatments" as a "medical necessity," and when the perpetrator seems both pleasant and reasonable. Those who are without speech, whose ability to produce the needed words 'on demand' is unreliable, or whose words are discounted, are more vulnerable to experiences of intense frustration, helplessness, and entrapment in no-win situations.
Treatments, services, and living facilities which not only fail to help the person accomplish what they need to do, but make their quality of life contingent on their successful accomplishment of what someone else wishes them to do establish situations of intense threat from which neither victory nor escape are perceived as possible. As a common feature of post-traumatic stress syndrome is the flashback in which a person acts as if a memory is present reality, every time they are put in situations of such threat they recall their previous maltreatment and unless their panic and rage are recognized as a function of this stress, they are likely to be further stigmatized as 'impossible to serve' and subjected to more intensive aversive control thus aggravating the problem.
The experience of being hurt in the name of this kind of 'treatment' is no different than being hurt in familial, sexual and cult abuse. Consequently the emphasis must be on community, a community of therapists, victims and survivors. The solidarity of a group provides the strongest protection against terror and despair, and the strongest antidote to traumatic experience. Trauma isolates; the group recreates a sense of belonging. Trauma shames and stigmatizes; the group bears witness and affirms. The group provides a place where one's experience can be safely told without fear of invalidation, challenge or re-interpretation. A context of empathy allows a re-association of memory and feeling - a very painful process which may have to be done time and time again but which allows the victim to eventually affirm the reality and feel the appropriate emotions for the abuse and reconnect and learn to hear the pain of others (thus recognizing that they are not alone in their suffering).
Those who recover most successfully are those who discover some meaning in their experience that transcends the limits of their own personal tragedy. This is what it means to say that psychological insight cannot be separated from political insight and action. It means hearing other people's stories, it means mentoring in the context of a tragedy and working with others in social action such as joining organizations that change the laws about what the criminal justice system says is a violation of human rights.
New researchers lack a passionate intellectual and social commitment they do not see the essential interconnection between the biological, psychological, social, and political dimensions of trauma. The interesting questions lie in values but this is a murky confusing, emotionally laden area we don't understand and which is riddled with controversy. People write dissertations and apply for research money from drug companies who are seeking to get approval for their drugs for the treatment of Post-Traumatic Stress Disorder and if you want to get research funding, you probably should stay away from this murky, messy, social issue 'stuff.' You can just do a nice psycho-biological study and you can randomly assign people to eight sessions of cognitive behavioral therapy or eight sessions of a serotonin re-uptake inhibitor, or a combination of the two, or a placebo, and see what works best. But if you want to really figure out how the mind works or how society works, you have to look at the broader society and asking question about relationships of power authourity and sanctioned perception.
Ultimately if you're talking about horrible abuses of power, you're talking about the atrocious things that one person does to another person. Here you are dealing with very profound questions of human evil, human cruelty, human sadism and the abuse of power and authority. The antidote to that is the solidarity of resistance. Nobody can do that alone. Under conditions of abuse of power and authority much of what people say about relationships of sex, parenthood, society, authourity, etc., depends on what one thinks or has been told to think is legitimate to express - what ought to be said and felt as opposed to what one actually feels. That is unless one has a support system that says, "Forget what everybody else thinks you ought to be feeling, what you ought to be saying. Get down to it, tell the truth."