Post-Traumatic Stress Disorder
So you focused on trauma, especially in women and children. Help us understand what Post-Traumatic Stress Disorder is.
Okay. Well, I can tell you about what it says in the DSM-IV.
Which is the official Bible of the Psychiatric Association.
Right. The Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition. I was on the committee that helped write this definition, so I have to take some responsibility. And the committee, I have to say, brought together people who'd worked with traumatized people on many different social settings -- combat veterans, accident victims, less from the sphere of sexual and domestic violence, but we were represented to some degree, and political violence. And what the consensus came out to be was that traumatic events were those that instilled a feeling of terror and helplessness. We used to say, by the way, that these had to be events outside the realm of ordinary human experience. We had to get rid of that, because if you're living in a war zone or you're living in a country emerging from dictator or that's experienced dictatorship, these are not out-of-the-ordinary experiences, unfortunately, but experiences that instill helplessness and terror. And terror turns out to be different from fear.
Fear is something that we're all biologically wired to experience when we're in danger. We share this with other animals. When we perceive danger, we alert, we startle, we look around and figure out, do a quick appraisal of the situation, and we either fight or flee. That's being revised now by some researchers looking more at women who say that "fight or flight" is a little bit more the male response. "Tend and befriend" -- there's a tendency to kind of huddle with one's kind that you observe more in females. But, okay, fight or flight: there's a whole biology of fear that's involved.
Fight or flight doesn't work in conditions of terror and helplessness. Under those conditions, it appears that some kind of biological rewiring seems to happen in people and in animals as well. So that even after the danger is over, the person continues to respond to reminders, to both specific reminders and to generally threatening situations as though this terrifying event were still occurring in the present. So you have the activation of the fear system, hyper-arousal. You have a kind of re-experiencing of the trauma that takes the form of flashbacks, nightmares, and so forth. And then you have this other more poorly understood part of the traumatic syndrome that has to do with a shutting down of responsiveness. Numbing, a sense that things aren't real. There may be amnesia for some, more, or all of the event. A sense in the aftermath that one is just not really oneself. One is going through the motions. There's a loss of connection of things that are or previously of interest. And these are called the numbing or withdrawal or symptoms of PTSD. So hyper-arousal, re-experiencing, numbing is the triad. It's a descriptive formulation. We understand a little bit about the psycho-biology, not a whole lot. And I think we're coming to understand more and more that that's the simple form. That is what happens to some people after a single impact trauma. If you repeat it, over and over, and especially if it begins early on and one's development is formed in this environment, it gets a lot more complicated.
This is often the case of women and children who are in domestic situations where the cycle goes on and on.
I think it's true of people in any situation of coercive control, whether you're talking about a hostage situation that goes on for a long time, whether you're talking about domestic violence or sexual child abuse ... some religious cults have this same captivity kind of situation. And then, of course, the political situations of concentration camps or political prisoners.
In summarizing or introducing your discussion, you say, "The dialectic of trauma gives rise to complicated, sometimes uncanny alterations of consciousness." And then you go on to compare the political doublethink in an Orwell novel with what the psychologists and the psychiatrists call disassociation. So, you're suggesting that this kind of repression, inability to confront both the individual reality and the larger reality, is something that happens to the individual and in some ways to the society.
Yes. It's fascinating. If you talk to survivors of, especially the prolonged and repeated trauma, where the perpetrator, the captor, the torturer isn't content to just have external compliance, but wants the captive to adopt and endorse his worldview, even after liberation you'll get people saying, "I'm living in a double reality. I have the present and the past co-existing in my mind. It's not clear which is more real to me. I have what's left of my old value system, and my old way of seeing the world, and the perpetrator's way of seeing the world co-existing in my mind. I can go back and forth between the two, and I'm not sure which I belong to or which belongs to me any longer." So people have the experience of living in a double reality. And they describe ... even the amnesia, people will describe simultaneously knowing and not knowing what happened. Remembering and not remembering what happened. 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. So, people learn to divide their consciousness under captivity, under conditions of coercive control. And since we don't even understand unitary consciousness very well, when people have double consciousness, double reality, I'm in awe. I think it's a fascinating window into how the mind works.
This experience that you're describing in your book; you quote extensively from the memoirs of everyone from a forced participant in pornographic films to a political prisoner. And there are common elements that run through their sense of this experience which you have just summarized.
That's not surprising, given that the methods of the torturer and the methods of the pimp or the pornographer are often similar. I think when we understand more about criminal gangs as an intermediary form of organization between, say, state-sponsored terrorism and one-family cells of domestic violence, we'll understand more about the transmission of methods of torture, methods of coercive control. But if you use the same methods on people, whether you're doing it in the name of the state, in the name of a criminal gang that's marketing your body, or whether you're doing it in the name of the authority of a father, or the name of some religious cult, the methods are the same and so the mental processes that they produce are likely to be the same.
In your work, you enter this realm of such apparent hopelessness and despair, but the other side of your work is identifying the features of hope and recovery and the road back. I want you to discuss with us the elements of survival. That is, survival and recovery, which is the other part of the title of your book [Trauma and Recovery]. So what are the common elements that we see in people who experience this but make it back?
First of all, I guess I should say, that that's the other reason I stick with this work: I'm constantly in awe of the resilience of the people we work with. They really do get better; they really do make new lives for themselves. They find incredibly creative ways to put the pieces of their lives back together, and a lot of times, since a lot of the work I do now is supervising students, teaching them how to be therapists, I get to observe the way the patients re-instill hope, constantly, not only in my students, but in those who are privileged to watch and observe this process. The students will come in and say, "I just met with the woman from Rwanda. She lost her whole family. She managed finally to get out to Uganda with two of her brother's kids, staying with a minister in Uganda. And she came here. They only could get papers to bring her. She's working under the table, cleaning houses or cleaning offices at night. She has no money. She's living in an apartment with ten people. She has the worst PTSD I ever saw, and she's here for a political asylum evaluation. What do I possibly have to offer this person?" In the first interview, the woman speaks in monosyllables. Her eyes are down, her head is bowed, her shoulders are like this, she's hunched over. If you drop something on the floor or a car backfires outside, she jumps out of her seat. Otherwise, she's immobile like this. You think, "This is the worst depression, this is the worst PTSD I've ever seen ... "
PTSD means Post-Traumatic ...
Post-Traumatic Stress Disorder. "What am I going to do?" So you work on documenting her case for her political asylum here. And you also work with her on trying to understand if she's safe now. What's her environment like now? What does she need now to begin to rebuild her life? And within a few months, this same person comes back into our office and she's lively. She's smiling, she's talking. She's gotten her asylum, so she's safe now. She's starting to work on bringing those kids over. She's joined a church, or she's started an English class (a lot of work we do is through interpreters). She's found, on her own, some kind of community, with our encouragement. And she will come back and say, "You listened to me. You seemed to care. You helped me out. You gave me what I needed to get what I needed. That restored my faith in people." And we feel like all we did was ... we did so little! But it was enough. There's a way in which survivors, many survivors, make do with the least little bit of human caring, human concern, to put back the pieces of their lives. And so, from my point of view, if we can provide that, it's a gift that comes back to us many times over.
So, as you just said, there are three elements. It's providing them a zone of safety. Then they remember and tell their story. And then, very importantly, they have to reconnect. I'm curious as to how you would characterize what you do beyond what you just said. Obviously, you do some interviewing. And is an important element of that interviewing to be a witness and to provide the essential elements of this safety, this support for telling the story?
I think bearing witness is important. I don't want to minimize the skill or the sophistication of the treatment that we do, because a lot of people who come to us do have complicated medical and psychiatric conditions. And they don't just necessarily have Post-Traumatic Stress Disorder. They need all of their needs attended to and they're often quite complex. I'm thinking of a woman, for example, who, it turned out ... here's an example of how complicated it becomes. This is someone who had been repeatedly raped -- it's another political asylum case -- and was having persistent vaginal bleeding, and had never had a medical exam. But because of the vaginal bleeding, was considered unclean, she couldn't have intercourse. Also couldn't enter a mosque. This was an Arab woman, a Muslim woman from Algeria. So getting her proper GYN attention, on the one hand, the medical part of it, needed to be attended to, and on the other hand, we needed to find sort of a friendly mosque. We needed to find someone in the clergy who could actually begin to reconnect her with a spiritual community. And we needed to do some family work in order to start helping her repair her relationship with her husband. And this is someone for whom the meaning of the trauma, in terms of a sense of stigma, contamination, ostracism, and so on, was not metaphorical. It was carried on in the physical symptom of bleeding. And until the bleeding was addressed, there really wasn't any hope of making new meaning out of what happened to her. So we pay a lot of attention to the meaning of specific symptoms in individual cases, and we take an approach that ranges from the biological to the social.
In your work, this emphasis on community, and broader issues such as power, recur again and again. In a specific case of your careful examination of the problem of incest, you end up, if I can summarize, and I hope I'm not being unfair, by looking at the broader society and asking the question, "Will this kind of problem ever go away in a patriarchal society?" And your answer is "No." But that leads you to propose the need for political action. What you have to then look at is the family in which the partners are equal, the male is not the dominant one. And it's only in such an environment that one can find a kind of equality where men, for example, are involved in the rearing of children. More than involved -- are equal partners. And that's how you get at the root of the problem. So, in a way, this analysis goes back to what you learned at the dinner table.
That psychological insight cannot be separated from political insight. And action.
So would you add anything to that? I hope it wasn't an unfair summary. But the individual can't deal with this alone, is what I'm trying to get at.
No, and I think that's the take-home message that I try to give whenever I teach, and whenever I do my therapeutic work. I don't think patients, survivors, victimized people can recover in isolation. They need other people and they need to take action in affiliation with others. I don't think therapists can do therapeutic work alone. When we're isolated with this, we do give in to despair. We do burn out. Or we lose our perspective. Ultimately if you're talking about horrible abuses of power, you're talking about the atrocious things that one person does to another person. And just when you think you've heard everything, and there's simply nothing else that you could imagine that one person would intentionally do to another, somebody comes along with a story that just blows you away all over again. So, you're dealing with very profound questions of human evil, human cruelty, human sadism. The abuse of power and authority. And the antidote to that is the solidarity of resistance. Nobody can do that alone.
You say at one point, "But we do know that the women who recover most successfully are those who discover some meaning in their experience that transcends the limits of personal tragedy. Most commonly women find this meaning by joining with others in social action." And this means concrete things. It means hearing other people's stories, it means mentoring in the context of a tragedy, but also joining organizations that change the laws about what the criminal justice system says is a violation of human rights.
Right. It means going down and testifying before the legislature. Or taking part in some kind of public education campaign, or going to court, or accompanying someone else to court, or demonstrating in favor of the assertion of victim's rights, human rights.
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See also: Interview with Alice Karekezi on Justice in Rwanda: The Rights of Women