Note: This article was originally published in the Spring 2006 edition of Cutting Edge, the online newsletter of The Meadows.
In Terror's Grip: Healing the Ravages of Trauma
By Bessel A. van der Kolk, MD
From research on trauma's impact on various victim populations, we have learned that the great majority of people not affected immediately and personally by a terrible tragedy sustain no lasting damage. Most of those who witness devastating events are able, in the long term, to find ways of going on with their lives with little change in their capacity to experience love, trust, and hope for the future.
The critical difference between a stressful but normal event and trauma is a feeling of helplessness to change the outcome. This is obvious when people are trapped physically, or their cries for help go unheeded. A nightmarish example is the experience of waking up during anesthesia, which is thought to happen to some 30,000 people a year undergoing surgical procedures in the United States. If this were to happen to you, you would be conscious and aware of where you were and what was happening but, because of muscle relaxants and other drugs, you would be unable to move or speak. Psychological trauma is a frequent result.
As long as people can imagine having some control over what is happening to them, they usually can keep their wits about them. Only when they are faced with inevitable catastrophe do victims experience intense fear and feelings of loss and desertion. Hearing unanswered screams for help or witnessing mutilated human bodies, as happened to some survivors of the September 11th attacks in Manhattan and Washington D.C., is particularly disturbing. In addition, many trauma survivors, including rape and torture victims, have come face-to-face with human evil, witnessing people taking pleasure in inflicting humiliation and suffering.
Feeling helpless against a dire threat, people may experience numbness, withdrawal, confusion, shock, or speechless terror. Staying focused on problem solving, on doing something, however small, about the situation - rather than concentrating on one's distress - reduces the chances of developing post-traumatic stress disorder (PTSD). In contrast, spacing out (dissociating) during a traumatic event often predicts the development of subsequent PTSD. The longer the traumatic experience lasts, the more likely the victim is to react by dissociating. Once a person dissociates, he becomes incapable of goal-directed action.
People's responses to the traumatic event change as time passes. Usually, there is an initial outcry, seeking of help and attempt to re-establish social connections. Once victims have regained a sense of physical safety, they can assess the damage and begin to adjust or assimilate - a process that may take months or years. It is primarily their social context that re-establishes the feeling of safety vital for successful recovery. This initial social response will shape the way the victim comes to perceive the safety of the world and the benevolence or malevolence of others. If people in the social environment refuse to step in when a person's own resources are exhausted, this may become as great a source of devastation as the original trauma itself, seeding further helplessness, rage, and shame. Many people who feel powerless to change the outcome of events resort to "emotion-focused" coping; they try to alter their emotional state instead of the circumstances giving rise to it. About one-third of traumatized people eventually turn to alcohol or drugs in a (usually ill-fated) search for relief. This coping behavior is often a prelude to developing PTSD.
Failing to reset their equilibrium after a traumatic experience, people are prone to develop the cluster of symptoms that we diagnose as PTSD. At the core of PTSD is the concept that the imprint of the traumatic event comes to dominate how victims organize their lives. People with PTSD perceive most subsequent stressful life events in the light of their prior trauma. This focus on the past gradually robs their lives of meaning and pleasure.
People who merely remember a specific event usually do not also relive the images, smells, physical sensations, or sounds associated with that event. Instead, the remembered aspects of the experience coalesce into a story that captures the essence of what happened. As people tell others the story, the narrative gradually changes, and the event is understood as something belonging to the past.
Thus, the core pathology of PTSD is that certain sensations or emotions related to traumatic experiences are dissociated, keep returning in unbidden ways, and do not fade with time. It is normal to distort one's memories over the years, but people with PTSD seem unable to put an event behind them or minimize its impact.
Traumatized people rarely realize that their intense feelings and reactions are based on past experience. They blame their present surroundings for the way they feel and thereby rationalize their feelings. The almost infinite capacity to rationalize in this way keeps them from having to confront the helplessness and horror of their past; they are protected from becoming aware of the true meaning of the messages they receive from the brain areas that specialize in self-preservation and detection of danger.
If the problem with PTSD is dissociation, treatment should consist of association. Freud wrote in Remembering, Repeating and Working Through that "While the patient lives it through as something real and actual, we have to accomplish the therapeutic task, which consists chiefly of translating it back again in terms of the past." Thus, psychotherapy has emphasized helping patients to give a full account of their trauma in words, pictures, or some other symbolic form, such as theater or poetry. For traditional therapy, this has meant focusing on the construction of a narrative that explains why a person feels a particular way, the expectation being that, by understanding the context of the feelings, the symptoms (sensations, perceptions, and emotional and physical reactions) will disappear. Unfortunately, there is little evidence that simply creating a narrative, without the added process of association, succeeds.
Under ordinary conditions, the brain structures involved in interpreting what is going on around us function in harmony. The subcortical areas of the brain represent past experience differently than the more recently evolved parts of the brain, which are located in the prefrontal cortex. These higher cortical structures create language and symbols that enable us to communicate about our personal past. When people are frightened or aroused, the frontal areas of the brain, which analyze an experience and associate it with other knowledge, are deactivated.
In people with PTSD, specific deactivation of the dorsolateral prefrontal cortex (which is responsible for executive function) interferes with the ability to formulate a measured response to a threat. At the same time, high levels of arousal interfere with the adequate functioning of the brain region necessary to put one's feelings into words: Broca's area. Traumatized people suffer speechless terror.
Under conditions of intense arousal, the more primitive areas of the brain - the limbic system and brain stem - may generate sensations and emotions that contradict one's conscious attitudes and beliefs. Sensations of fear and anxiety coming from the subcortex can cause traumatized people to behave irrationally in response to stimuli that are objectively neutral, or merely stressful.
The usual regulatory system of adults is a kind of top-down processing based on cognition and operated by the brain's neocortex. This allows for high-level executive functioning: observing, monitoring, integrating, and planning. The system can function effectively only if it succeeds in inhibiting the input from lower brain levels. However, top-down processing techniques relied upon by traditional psychotherapy inhibit rather than process (or integrate) unpleasant sensations and emotions. A prime characteristic of both children and adults with PTSD is that, in the face of a threat, they cannot inhibit emotional states that originate in physical sensations.
When asked to put their trauma into words, many people respond physically - as if they were traumatized all over again - and so do not gain any relief. In fact, reliving the trauma without being firmly anchored in the present often leaves PTSD sufferers more traumatized. Because recalling the trauma can be so painful, many people with PTSD choose not to expose themselves to situations, including psychotherapy, in which they are asked to do so. A challenge in treating PTSD is to help people process and integrate their traumatic experiences without feeling retraumatized - to process trauma so that it is quenched, not kindled.
Above all, treatment should seek to decondition people from their trauma-based physical responses. Medications such as selective serotonin reuptake inhibitors can alleviate the distress of PTSD, but survivors still need to find ways to put the traumatic event into perspective - as an element of their personal history that happened at a particular time, in a particular place.
In summary, there are three critical steps in treating PTSD: safety, management of anxiety, and emotional processing.
When people's own resources prove inadequate to deal with a threat, they need to rely on others for safety and care. It is critical that trauma victims re-establish contact with their natural social support system. If that system is inadequate to ensure one's safety, the help of institutional resources will be needed.
After safety is assured, psychological intervention may be needed. People have to learn to put words to the problems they face, to name them, and to formulate appropriate solutions. Victims of assault must learn to distinguish between real threats and the haunting, irrational fears that are part of the disorder. If anxiety dominates, victims need help to strengthen their coping skills. Practical anxiety management skills may include training in deep muscle relaxation, control of breathing, role-playing, and yoga.
Trauma victims must gain enough distance from their sensory imprints and trauma-related emotions to observe and analyze them without becoming hyper-aroused or engaging in avoidance maneuvers. One tool for this is serotonin reuptake blockers, which can help PTSD patients gain the necessary emotional distance from traumatic stimuli to make sense of what is happening to them.
After alleviating the most distressing symptoms, it is important to help people with PTSD find a language for understanding and communicating their experiences. To put the traumatic event in perspective, the victim needs to relive it without feeling helpless. Traditionally, following Freud's notion that words can substitute for action to resolve a trauma, victims are asked to articulate, in detail, what happened and what led up to it, their own contributions to what happened, their thoughts and fantasies during the event, the worst part of it, and their reactions to the event, including how it has affected their perceptions of themselves and others. This exposure therapy is thought to reduce symptoms by allowing patients to realize both that remembering the trauma is not equivalent to experiencing it again, and that the experience had a beginning, middle, and end. It belongs to their personal history - to the past, not the present.
The study of trauma has been perhaps the most fertile area within psychiatry and psychology in terms of promoting deeper understanding of how emotional, cognitive, social, and biological forces interact in human development. Trauma study has yielded entirely new insights into the way extreme experiences may profoundly affect our memory, how our bodies as well as our minds respond to stress, our ability to regulate our emotions, and our relationships to other people. Now, it promises to shed light on the fundamental question of how the mind integrates experience to prepare itself for future threats, even as it distinguishes between what belongs to the present and what belongs to the past. These discoveries, together with a range of new therapy approaches, are opening entirely new perspectives on how people who have been traumatized whether by an individual in a private act of violence or by a disaster affecting an entire society - can be helped to overcome the tyranny of the past.
About the Author
Bessel A. van der Kolk, Clinical Consultant for The Meadows and Mellody House, is one of the world's foremost authorities in the area of posttraumatic stress and related phenomena. His research work has ranged from the psychobiology of trauma to traumatic memory, and from the effectiveness of EMDR to the effects of trauma on human development. He is professor of psychiatry at Boston University School of Medicine and medical director of the Trauma Center in Boston, a Community Practice site of the National Child Traumatic Stress Network. The Trauma Center is one of the foremost training sites in the country for psychologists and psychiatrists specializing in the treatment of traumatized children and adults.