Saturday, May 17, 2008

Recovering After Trauma

This article describes my viewpoint on trauma and whether or not we can ever "get over it", "move on", or be asymptomatic, and really redefines what healing really means. It means not being mean to ourselves for not "being healed enough" or for "living in the past"...those are all symptoms of complex trauma.

Recovering after trauma

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Judith Herman says you do better if you’re not facing it alone.

Judith Herman helps survivors of trauma work toward recovery. She’s a pioneer in the study of Post–Traumatic Stress Disorder and the sexual abuse of women and children. Herman is Professor of Clinical Psychiatry at Harvard University Medical School and Director of Training at the Victims of Violence Program in the Department of Psychiatry at the Cambridge Hospital, Cambridge, Massachusetts. She spoke with Earth & Sky’s Eleanor Imster in October, 2005, in the aftermath of hurricanes Katrina and Rita, and the earthquake in Kashmir.

Imster: Is a trauma that’s personal and specific, such as rape or torture or child abuse, more damaging than an “impersonal” trauma – such as a hurricane or an earthquake?

Herman: Yes. There’s a big difference. The operative thing seems to be that you’re getting an up close experience of human hatred and malice. Whereas with a hurricane or a flood or a fire, it’s not intentional. No one is intentionally trying to harm you.

The other difference is that with a natural disaster, an earthquake, flood, that sort of thing, there’s no stigma attached to victims. What’s mobilized usually in the aftermath is other people trying to help. Hurricane Katrina is actually an exception to that rule, in the sense that the helpful response was so bungled, and there was a certain amount of victim blaming going on. But usually victims immediately get the sense that other people are trying to help, and that there’s no stigma attached to their plight.

But with rape, for example, the opposite is true. The victim is often blamed or scorned. With child abuse, the trauma is often repeated over and over again. There’s no safe place. With a single–impact kind of trauma, once it’s over, you can get to safety and you can get to people who are going to help you and take care of you and be sympathetic. With something like child abuse, that doesn’t happen, and similarly with rape. So, it’s not surprising that you see much higher levels of distress and post–traumatic stress disorder with the kinds of traumas that are interpersonal.

Imster: How do you know what’s a natural reaction to trauma and what’s PTSD?

Herman: Well, the question is, does it go away? A lot of people have acute stress reactions in the immediate aftermath of the trauma. They have nightmares and sleep disturbances and are very agitated and upset. But over time, it diminishes and goes away. And by six weeks later or two months later, it’s gone. That’s why we call it post traumatic stress disorder. You can think of it as almost a failure of the normal recovery adaptation to any stressor. It’s a question of whether the symptoms diminish over time, or whether the person seems stuck in the past.

Imster: So, if you’re a child who’s getting molested, your feelings of terror and helplessness are what you should feel. But then if it’s stopped, and ten years later, you still have those feelings…

Herman: That’s post traumatic stress.

Imster: PTSD seems to be suddenly appearing in news reports in the newspapers and on TV.

Herman: Right. Because we have all these soldiers in Iraq who are coming back with terrible PTSD.

Imster: And also in the aftermath of hurricanes and earthquakes. But you’re saying that compared to soldiers, and to rape and torture victims, the people who have endured these natural disasters at lesser threat of ending up with PTSD.

Herman: Their chance of recovery from the trauma is greater. And what seems to be a big protective factor in disasters is if there’s another close person that stays with you. If you able to take action together. So, that kids who are separated from their parents are at much higher risk, for example, than are kids who, whatever happened, the family stuck together and they were able to cope, together. Just keeping up your relationships seems to be very protective.

Imster: And that ability to handle it varies between individuals and depends on what kind of situation you’re in?

Herman: And how much social support you have. If you’re not facing it alone, you do much better.

Imster: So, for the survivors of, say, hurricane Katrina, a helpful thing to do would be to look to other people.

Herman: Yes, to find people, buddies, friends, family, to stick together and cope with your losses together.

Imster: When people are about to enter a situation in which they are likely to experience terror and helplessness – such soldiers going off to war – are there ways to help prevent PTSD?

Herman: What they’ve found, as far back as World War II, was that, again, the human connection seemed to be so important. In that war, the emphasis was on getting the soldier back to be with his buddies as quickly as possible. Unfortunately, that often meant going back into the war zone, so that isn’t really ideal. But it’s keeping up those relationships. In Vietnam, the PTSD was much worse, because people had one–year rotations. They were rotated in and out of the war zone individually, rather than as a unit. And that, again, broke up supportive relationships that might have been protective.

Imster: Why are some people more resilient, able to recover more easily from trauma?

Herman: I don’t know that we know the answers to that. We do know that people who are able to stay active in connection with others seem to do better. People who are more naturally sociable and have what we call an “internal locus control”, who aren’t fatalistic, who can see themselves as in charge of the situation and who work closely with others to try to get to safety or stay safe. These people do better. But in terms of what actual characteristics are protective, that’s still something that’s being researched. Because usually we don’t get to see people before the disaster. We’re only seeing them afterwards.

Imster: From what you are telling me, I would guess that child molestation would be the worst, as far as PTSD goes.

Herman: Yes, you do see very severe long–term consequences with child abuse. Because there’s no safe place to go. It’s done in secrecy, and there’s often a tremendous amount of blame and stigma. Kids are often not believed, if they do try to disclose. They’re really trapped. They’re like prisoners. And the abuse usually goes on not just once, but repeatedly, over and over.

Imster: I have read that there’s evidence that there are biological differences in people who suffer form PTSD. For example, research using PET scans, indicates that parts of the brain, the hippocampus, are smaller in people who have PTSD.

Herman: Yes, you’re seeing actual differences in brain functioning with people who have PTSD.

Imster: But, so far, there’s no cure for PTSD.

Herman: That’s right.

Imster: What does that mean? That your hippocampus will never be a normal size again? That your hyper–arousal will never go away?

Herman: We see it as a chronic problem, but that doesn’t mean that people can’t get a lot better. Often times in treatment, we find that people improve to the point where the symptoms really aren’t bothering them. They’re not interfering with their lives. They can get on with their lives and function quite well. Where I think you see some lasting vulnerabilities if there’s another stressor. The damage can be cumulative, so that combat veterans who, say, get sent to another war would be more vulnerable.

Imster: But people can get better and learn to live with PTSD.

Herman: Absolutely. And really, there are very effective treatments, both psychological and pharmacological that really diminish the symptoms to the point that they don’t interfere at all and people can live normal lives.

Imster: When we look to the future, to an increasingly crowded human world, do you think we’ll see more PTSD?

Herman: I don’t know the answer to that. I think the question is really about exposure to violence, not just crowding. I could imagine a very crowded world where people lived together more peacefully, and then you wouldn’t see so much PTSD.

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