Archive for the ‘Trauma’ Category

In the first few paragraphs of his book “Angela’s Ashes” Frank McCourt comments: “When I look back on my childhood I wonder how I survived it all. It was, of course, a miserable childhood: the happy childhood is hardly worth your while. Worse than the ordinary miserable childhood is the miserable Irish childhood, and worse yet is the miserable Irish Catholic childhood.

People everywhere brag and whimper about the woes of their early years, but nothing can compare with the Irish version: the poverty; the shiftless loquacious alcoholic father; the pious defeated mother moaning by the fire; pompous priests; bullying schoolmasters; the English and the terrible things they did to us for eight hundred long years.”

Does a bad childhood (not only an Irish one) inevitably lead to problems in life? Not inevitably. Not everyone will demonstrate the effects of a bad childhood, but it does seem that many people do. And they do in surprising ways. We would expect a bad childhood to affect our psychological make-up and our ability to form relationships. Bad childhoods do this, but they appear to do much more than mess us up psychologically.

A very interesting group of studies, known as the ACE (adverse childhood experiences) studies have indicated that having a bad childhood can lead to numerous problems. The researchers who did the studies, divided adverse childhood experiences into the following categories: childhood sexual abuse, physical abuse, emotional abuse, neglect, substance abuse in the family, domestic violence. They did not determine the number of experiences in a category, simply the number of categories.

The researchers have demonstrated that even when controlling for lifestyle factors (such as drinking and smoking) that people who have had experiences in a number of these categories have an increased risk for physical illnesses such as diabetes, heart disease and cancer. Their risk for psychiatric illness and drug abuse also increases.

The researchers demonstrated that ACEs are extremely common – for example more than 30 percent of the group they studied indicated that they had been physically abused, almost 20 percent indicated they had been sexually abused and over 23 percent had been exposed to family alcohol abuse. This was not a group of people who had reported to mental health professionals. These were normal, everyday people who probably did not think they had too much wrong with them.

This study confirmed that adverse childhood experiences are linked to the development of depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, domestic violence, cigarette smoking, obesity, physical inactivity and sexually transmitted infections.

The more ACEs experienced, the more likely a person is to develop heart disease, cancer, strokes, diabetes, skeletal fractures and liver disease.

It appears that chronic trauma interferes with neurobiological development. Children who have experienced miserable childhoods struggle to integrate sensory, emotional and cognitive information.

There are many other studies which confirm these results. Having a bad childhood does not lead to inevitable problems, but it certainly increases your risk for them.

What are the typical emotional problems which children have who have had these experiences?

Children who have been exposed to ACEs often present with attention problems, difficulty recovering from intense emotions, they are often not aware of their own bodily experiences or find it hard to describe them. They may also experience difficulty in sleep, their appetite may be affected and they may react intensely to sounds or touch. They also often struggle to protect themselves. They may be easily distracted from goals. These children often do not feel good about themselves and may feel helpless or defective. They often find it very hard to trust adults, and may be aggressive with their friends or adults. Some of these children have a too strong need to get close to others, at times sexually.

They will often demonstrate problems at school, in the family, with their friends, and may have problems with the law. They may have health problems.

Do these problems continue into adulthood?

The area in which we see most of these problems is in the area of relationships. This is not surprising as relationship trauma will probably be triggered most severely in relationships. For both parties in these relationships it can be extremely frustrating. The person who has not had similar trauma will often struggle to understand their partner. And the person who has experienced severe interpersonal trauma as a child finds themselves behaving in inappropriate ways and feeling incapable of changing their behaviour.

They find they experience emotions such as panic at inappropriate times; they may feel abandoned in situations which other people will regard as every day. They may find that the respond to sexual advances of someone they love as though they were threatening. They may find that they experience emotions much more strongly intensely than someone who has never had ACEs. Alternatively they may struggle to experience emotions and may feel that they have none. They may struggle to stick to goals and despite their best intentions being distracted. They may struggle to trust others and may find that they lose their temper more easily than others do. They may find that they have health issues which are not always fully explained by medical science.

Can something be done about it?

Yes, psychotherapy does help. But long-standing trauma and long-term ways of functioning do not change overnight. They change in a relationship which demonstrates different ways of relating to the dysfunctional patterns were exposed to. This takes time and typically many obstacles have to be negotiated along the way.

Introduction
You may have heard of posttraumatic stress disorder (PTSD). It is used quite often in the media and it is worthwhile understanding a bit more about the diagnosis and the objectives in treating PTSD. I am referring to “ordinary” PTSD in this article. There is considerable evidence that people exposed to traumatic events over a long period (such as in extremely violent, abusive families, torture, war and so on) can present with more diffuse symptoms. This diagnosis is not made immediately following a traumatic event as most people will be affected in some of these ways following severe trauma. The diagnosis is therefore only made if symptoms persist a month after the event. If you are concerned that you or someone you care about may have PTSD please see a psychologist or psychiatrist yourself or encourage your friend or relative to do it. Quite a bit can be done; it is not necessary to live with these symptoms.
What is PTSD?
PTSD is not a new condition; it has been described in various writings through out the ages. There is some indication that Homer’s Iliad refers to the development of PTSD. Essentially PTSD can develop following extreme traumatic, often life-threatening events. It is therefore one of the very few psychiatric diagnoses which is attributable to a specific event. Various groups of symptoms arise in PTSD. I am going to discuss them briefly as they make it easier to understand the experience of PTSD. The symptom groups I am going to discuss are the reliving of the traumatic event, avoidance of reminders of the event, numbing and increased arousal.
Reliving the event
Our natural way of coming to terms with things is by replaying what has happened in our minds. You can see it easily in yourself, by observing your reactions when you have had an argument with someone. You replay it over and over until you have made some sort of sense of it. You may decide you have to apologise as you were wrong, or decided that your friend was just in a bad mood and that she’ll get over it in time and you can leave it. Once you have the solution, you can leave it alone. However, when exposed to extremely traumatic events, your ability to make sense of them is overwhelmed. They often shatter our assumptions of the world. Things we took for granted, we can no longer take for granted. Where we may have thought we were safe, we now know we are not safe. We all assume that we will arrive safely at our destination, even though we know the roads are dangerous. After a serious accident, we can never again make that assumption. We assume we are safe in our homes, even though we know that robberies happen. After an armed robbery at home, the assumption of safety in our homes cannot be recovered – we know that we could be robbed again.

Another difficulty which arises in the replaying of extremely traumatic events is the nature of the memories. It feels very different to normal memory in which we are aware of our surroundings, we know that what we are thinking of happened in the past and is not currently part of our reality, beyond our recollections. When we experience flashbacks it is as though the traumatic event is happening, again, now. We are experiencing it without the sense that it happened in the past. With a bit of imagination you can understand how debilitating this can be. Let us take an example: If a woman has been raped and she experiences a flashback during her and her husband’s lovemaking, she may see, smell and feel the rapist again.

The person who has severe PTSD is never free of the trauma. He or she will often fear going to bed, as they often wake from severe nightmares in which they relive the trauma or something related to the trauma. Again, consider the implications: If you get into bed at night (every night) knowing that despite your intense desire to have it different that you will wake in the middle of a nightmare, with heart racing, struggling for breath, skin clammy and totally disorientated, it becomes frightening to go to sleep. You may try and avoid it to the point of exhaustion, but when you fall asleep you will again experience the horror of the nightmare. Often, after awakening, they find it impossible to sleep again. Sleep deprivation becomes part of the problem. Often, especially if the trauma happened at night, people start to switch day and night, finding they can sleep in the day and not at night which they associate with danger. If you have to be at work early the next morning, this becomes an enormous problem.

Reminders of the trauma are everywhere. Generally traumatic events happen while we are living our lives and our normal experiences can lead to debilitating symptoms. If someone you love died in a car accident, you will be reminded of what happened where ever you go. Newspaper stories report on crime on every page.
Avoidance
The recognition that a traumatic experience can lead to avoidant behaviours is part of folk-wisdom. Hence the directive that if you fall off a horse to get back on again as soon as possible. People with PTSD avoid reminders of what has happened to them. So if someone has been hijacked, they might find themselves avoiding driving in the area in which they were hijacked, or not driving the time of day that they were hijacked. They may also avoid conversations and activities (such as reading newspapers) which remind them of what has happened. As you will realise, this can become quite debilitating, especially if it involves your own home or generalises to all shopping malls and so on.
Numbing and some other unpleasant symptoms
People with severe PTSD may sometimes find that they cannot remember an important part of the trauma. It is not forgetfulness, it is the awareness that something important happened and I do not remember it. The thought of eventually remembering can be extremely threatening.

People who have PTSD often lose interest in things they normally enjoyed. Other aspects of their experience of life are often affected. They may find that they cannot experience emotions which they normally experienced. If you struggle to express love to the people who are close to you it starts to affect the relationships you have with them. People often feel as though they are detached or estranged from the world. When you have experienced horrors others have not, it is very hard to believe anyone can understand or relate to the experience. In actual fact people who have not experienced severe trauma do not understand the experience.
Increased arousal
Every time you have intrusive images your body responds to them as though you have just been exposed to the trauma. Your body responds by releasing stress hormones. This eventually leads to a state of increased arousal where you are constantly in a physiological state of responding to the traumatic event. You experience difficulties in falling or staying asleep – not only as a result of the nightmares. People frighten easily, finding that they are much more reactive to sounds or sudden movements than they normally are. This is paired with constantly being on the lookout for danger. They may become irritable or have aggressive outbursts. When we consider the problems in relating to others already caused by difficulties in experiencing emotions and by a sense of detachment it is easy to see why aggressive outbursts or irritability can compound relationship difficulties. People also find their ability to concentrate is badly affected.
Treatment of PTSD
There are a few principles that are important in the treatment of PTSD. Medication is often useful and sufferers may be referred to a psychiatrist for medication. However, psychotherapy is generally necessary in managing the symptoms of PTSD. Let us look at the logic of treatment. All psychotherapeutic interventions which have proven to be effective are exposure-based (mainly prolonged exposure and Eye Movement Desensitisation and Reprocessing). Effective treatments all entail revisiting the traumatic event. In the beginning this entails the visualisation of what has happened and telling the story. Later the revisiting can include going to the actual places and so on where the trauma occurred. Why is this necessary? By revisiting the events we are mimicking the natural process of coming to terms with events. We also, by revisiting the trauma, are helping people to desensitise to the event – to no longer have the intense physiological response they initially had. If the traumatised person then experiences reminders or images relating to the trauma, he or she no longer has the strong physiological response to the trauma. They have a sense of mastery over the traumatic event and no longer have to avoid it. It also means that the symptoms of increased arousal abate.

Traumatised people are generally taught some skills before starting desensitisation. These entail managing flashbacks and skills which ameliorate the worst of the anxiety and discomfort associated with the increased arousal and physiological response to exposure to reminders of the traumatic event.

An intrinsic part of coming to terms with trauma is to reconstruct our lives. As discussed, people who have been been exposed to severe trauma experience that their lives and much that they have built their lives on has been shattered. This has to be reconstructed in a way which the person finds meaningful. Often this process also entails coming to terms with how we have responded before, during and after the event. People often experience guilt around trauma which has to be resolved.

As I mentioned in the beginning of this article, it is possible to treat PTSD effectively. Many people find that their symptoms abate completely with treatment, others find that their symptoms are more manageable following treatment.

Many people are afraid of receiving treatment for trauma. I want to spend some time discussing this fear and explaining what can be expected in the treatment of trauma. This will hopefully assist you in deciding whether or not you need treatment and if necessary making the appointment.
Is it a valid fear?
Yes, without doubt is is a completely understandable and valid fear. It takes an enormous amount of courage to eventually decide you need treatment and to seek help. When badly traumatized, you have been exposed to an event or events which have overwhelmed your ability to cope. You will have spent much energy on trying to avoid thinking about what has happened to you, because it is so overwhelmingly bad. Now you are going to have to talk about it and think about it. You know that you will be overwhelmed by the memories. If you have PTSD you may even find that when you think about the event that you relive it to such an extent that you are no longer aware of your present surroundings.
When do I have to get help?
When the trauma you have gone through is affecting your life. If you find that it is dominating your thoughts, affecting relationships, disturbing your sleep and so on, it is time to get help.
What can I expect if I decide to see a psychologist?
You will first have to find someone to see. You can get names of possible people from your GP, from friends and family, and you can do internet searches. Please make sure that the person you decide to see works regularly with trauma. To check this, phone them and ask them. Ask them what psycho-therapeutic approaches they use in dealing with trauma. Those most commonly used with good research are prolonged exposure and EMDR. However, when you talk to a possible therapist you want to hear that you are recognised as a person with individual problems and that you will be treated in that way. You want to be sure that you will not be submitted to a cookie-cutter, one-size-fits-all approach.

If you feel happy with the person, make the appointment. You will probably be very apprehensive going to the first appointment and consider cancelling or simply not going on numerous occasions. Go. You still have to decide if you like the person and whether you can work with him or her.

In the first appointment the psychologist should ask you why you have come in. They should take down a history of the development of the problem as well as your family, education, relationships and work history. They should find out about other possible emotional or physical problems you have had. They also need to find out about previous trauma and how you have managed it.

After you have given the psychologist a brief outline of your life, he or she should look at possible diagnoses of your problem. These have to be explained to you. Possible treatments then have to be discussed with you with all your questions answered. You need to be told of risks in the proposed treatments. The possible consequences of choosing not to treat the trauma have to be discussed. Please make sure that you are given alternatives and that all your questions are answered. You should also make sure that the treatment the psychologist is proposing is scientifically validated. You are entitled to ask what research has been done on the proposed treatment. You are also entitled to ask the psychologist what training and how much experience he or she has in the proposed treatment.

Treatment may include both medication and psychotherapy. Ask questions and ensure you understand why medication is being suggested. You may be referred to your general practitioner or to a psychiatrist for medication.

If you decide on psychotherapy, the psychologist must explain exactly what it entails and what you may experience. You should never feel unsure of what is happening or going to happen. Traumatized people already feel that their lives are out of control and should be assisted in regaining control.
The process of psychotherapy
The relationship you have with the psychologist is critically important in treatment. Before any intrusive or difficult work is undertaken, a good working relationship has to be established. You need to know that you are safe in the relationship and that he or she will be able to handle what you bring in.

The trauma may be focussed on early in treatment if it happened recently. Otherwise, the focus initially will be on gathering more information, consultations with family members if necessary, and teaching you skills to cope with the emotions, images and physiological reactions you have when you think of the trauma.

These containment skills are extremely useful. Generally trauma-work will not be done until you are feeling emotionally stable and competent in using containment skills.

Very often the therapist will group the traumatic events if you are confronting more than one type of trauma. This makes it easier to manage them, and if events are targeted correctly, can lead to a domino effect where events you have not targeted are automatically better once core experiences are dealt with.

If you have multiple traumas, your therapist may start with one that is less upsetting to establish a “way-to-go”. Alternatively he or she may start with an event which happened when you were very young, or with something very bad. Starting with the worst and resolving it often makes all other traumas immediately more manageable. Initial traumas are often useful to target as disabling beliefs are laid down then.

Confronting trauma in psychotherapy is generally upsetting. The material is bad, and it would be unreasonable to expect to feel good while confronting it. However, this is one of the reasons you have been taught containment skills. Use them to control the bad feelings, particularly between sessions or when feeling overwhelmed during a session. Always communicate these feelings to your therapist.

Traumatic events should be targeted specifically. It is often not possible to work in a generalised fashion with trauma. It is also easier to measure whether you have achieved what you set out to do when you confront the event directly. You can check whether you feel better when you think of the traumatic events or not.
In summary
Although confronting trauma is a very frighting thing to do, it should be a controlled process in which you know exactly what is expected, what is happening and recognise improvement in yourself.

Painful memories can take over your life, at times feeling as though they are invading every experience. There are a number of strategies which are useful in helping to contain and set these memories and emotions aside, making them a bit more manageable. This does not imply that you suppress the memories or deny their existence, it is an acknowledgement that they are there and will be dealt with when opportune.

You can use your imagination to create containers in which you put your uncomfortable emotions. You visualise yourself doing this. Any visualisation which helps you control your emotions helps. Avoid violent visualisations of where you act out your aggression or anger.

A technique taught in mindfulness meditation is helpful. In essence you recognise that you have a painful emotion. You do not get involved with it, but simply note its existence. It is there and you can note the effect on your body, your emotions, your thoughts. You note it, recognise it and allow it to pass. This takes a bit of practice, and some training in mindfulness meditation can be helpful.

Self-talk, especially rational talk can be useful. In this you can for example tell yourself that you are in no danger now, that you have control where you never had it and so on.

When experiencing flashbacks it is useful to become aware of your surroundings, of becoming aware of the feel of the floor, the chair, how your clothing feels on your body, what you see around you and so on. It is then helpful to tell yourself the date and time and place and to note that you are safe. Tell yourself that you are only remembering the traumatic event, it is not really happening. Although you are then painfully aware of the event, force yourself to become aware of your current reality.

Validated treatment
There are a few approaches with have been validated for the treatment of trauma. This means that there is sufficient supporting research to indicate that these approaches work. In other words, these methods have been described clearly, the studies have been put together in such a way that they comply with scientific principles and have often been repeated a number of times. The work has been published in journals and the quality of the research has been reviewed by other experts in the field. It is wise to work with a therapist who is up-to-date on treatment research. You have the right, in fact I would go as far as to say the responsibility, to ask your potential therapist what approach he or she will use and what research has been done to validate its efficacy.
What do we want to achieve?
In general, when we approach trauma, we attempt to achieve the following:
We try and desensitise you to the trauma. In other words you should eventually be able to think about what happened without a strong physiological or emotional response to it.
You have been able to place the event in a perspective you can live with.
You have changed any dysfunctional beliefs which arose as a result of the traumatic incident(s).

We cannot change what has happened, but we can to some extent determine the effects of the trauma on you.
What is the process?
In general, the psychologist will take down a history from you. This will include information on what happened and general background. She or he is also looking for any former traumatic events, how old you were when they took place and how you responded to them. This all gives an indication of how you will respond to the current event. She or he will also be noting what symptoms you currently have and previous psychiatric problems you may have had. This enables the psychologist to draw up a treatment plan. The psychologist should discuss the diagnosis with you and explain what to expect from treatment.

A general treatment plan for trauma will generally first establish emotional stability. Medication may be suggested, and you will be taught techniques in order contain any unpleasant or overwhelming emotions you may have. When working with trauma, the specific incident is normally a target for treatment.

It is unpleasant having to face traumatic events. This is generally necessary to help you to come to terms with what has happened. You will always be helped to re-attain emotional stability after facing the trauma.
What are validated treatment methods?
Two which are getting good results are prolonged exposure and Eye Movement Desensitisation and Reprocessing (EMDR).

Prolonged exposure is a cognitive-behavioural approach and gives good results. It requires extensive exposure to the traumatic event and needs commitment to doing the expected homework. It is not always appropriate as if the client is not going to commit to the required homework it could result in further traumatisation.

EMDR also has homework, but much of the work is done in the sessions. I am not going to describe it in detail, but essentially different aspects of memory, thinking and behaviour are targeted with the use of eye movements. It sounds bizarre, but the research results are good. You can look up the research on EMDR at www.emdr.com. You can check whether your therapist was trained by them on their website. It is important that you do not do EMDR with someone who has not been trained by the EMDR Institute.

On occasion you may be assisted in going to the places where the trauma took place. This is not always possible, but is very useful following certain events. It is important to do it properly as done badly it could result in further traumatisation.

In this article I will discuss when you need to receive professional help in dealing with trauma.

There are numerous misconceptions around trauma. Over the last number of years people have come to believe that anyone who is exposed to trauma of any degree or nature has to receive trauma counselling.  This is not true.  We now know that people are very resilient and can and do resolve traumatic situations without professional help.  If we think logically about it, it makes sense.  When you have been traumatised, you need support from the people you love, not a stranger wanting to discuss what has happened and your reactions to the event.  That would feel intrusive and would often be inappropriate.  If you have been traumatised, depending on what the event was, one of the initial things you need is a sense of safety.  You may have material or physical needs which have to be seen to before any possible emotional response.  A psychologist or “trauma counsellor” is not going to provide this.  You need you friends and family to rally around you and to know that you are loved, accepted and protected. 

Many people will say they will manage on their own and are then told that they are avoiding dealing with the event.  It is quite possible that they are correct and that they will come to terms with the trauma on their own.  In fact, more than ninety per cent of people will overcome a single trauma, even if it is quite serious, on their own. 

We also know that people who receive professional help immediately after a trauma, can in fact develop more symptoms than someone who has not had treatment, but has received support from his or her family and friends. 

So when do you need to get help?  When we look at the area of trauma, two diagnoses are commonly made which specifically refer to the person’s reaction to the traumatic event: acute stress disorder and posttraumatic stress disorder.  Other diagnoses are possible following trauma, as people can develop symptoms relating to depression or become very anxious.  Panic attacks are also possible.  These diagnoses are discussed elsewhere on this website. 

Acute stress disorder, which has very similar symptoms to posttraumatic stress disorder is currently diagnosed a few days after the traumatic event up to a month following the event.  After that posttraumatic stress disorder is diagnosed.  This is a technical matter and the only thing of possible interest is that there is some indication that if you develop acute stress disorder that you may be at greater risk for developing posttraumatic stress disorder. 

What do the symptoms of these diagnoses look like?  I am not going to give a list of symptoms, it is not necessary.  In general you may find yourself constantly thinking about the event, even when you do not want to.  You may avoid any reminders of the event.  Your emotions may become blunted.  And you may find that you struggle to relax, that your sleep is affected, that you are very irritable and jumpy.  I would suggest that you consult a psychologist if after a number of weeks, following the traumatic event that you cannot function normally.  If you have the impression that the traumatic event is interfering with your ability to live, to maintain relationships, to go to places you normally would, it would be wise to consult a psychologist

When you consult a psychologist, please ask them what experience they have in dealing with trauma and what treatment methods they use.  You have the right to know.  You also need to know what support there is for the method used in the research.  I will discuss in further articles what you can expect a psychologist to do and indicate what treatment methods are giving good results.

Posttraumatic stress disorder (PTSD) has a checked history, often reflecting the convenience of the times. It has been discovered and lost, proclaimed and debunked repeatedly over the years. With reference to war, soldiers have been shot as traitors and have received compensation for PTSD.