Coping with Trauma
by Judy Marshall
On September 11 people throughout the world suffered individual and collective trauma. Beyond the horror -- as we emerge from the numbed, but visceral shock of the first weeks after the tragedy, we are faced with an altered, unsure, and frightening reality. There is no one way to correctly deal with this situation emotionally, and each of us must find strategies that work for us, as individuals. Yet, awareness of what is happening to us psychologically is a proactive step towards coping and healing.
It is important to realize that we have been psychologically assaulted at several levels. First, there is the reaction to the previously unimaginable violence, itself. Second, we are being forced to adjust to a state of impending war, with an unpredictable, but imminently dangerous enemy. Lastly, we are grieving -- some, on a more abstract, but personally meaningful level. For others, the grief is intimate, searing and all-encompassing, too often compounded by multiple losses.
In this article, we will focus on the first level of psychological reaction -- our response to the trauma that occurred on September 11. When a human being is the victim of or exposed to violent events, there is always a psychological reaction. Obviously those who physically survived or witnessed the World Trade Center and Pentagon attacks would be expected to have the most intense response. However, it is important to be aware that even those thousands of miles away, including outside the United States, may suffer some degree of psychological symptoms, at times perhaps severe.
To understand what is happening to us psychologically, we need to first clarify the concepts of 'stress' and 'trauma'. Stress and trauma are broadly understood by almost everyone in modern society to involve difficult, sometimes devastating situations that occur in the course of living. Over a lifetime, not all of us will experience serious illness, marital break-up, victimization, abuse, or financial reverses, although likely we will know or be called upon to support someone who has. However painful these and similar situations may be, they clearly are a part of normal human existence.
In contrast, there are stressors, sometimes called 'catastrophic' in the literature, that are outside the realm of usual human experience. Generally, these involve dramatic violence, death or its threat, and the possibility of severe bodily harm. Fortunately, 'catastrophic' or 'post-traumatic' stress (as it has been called since Vietnam) is actually quite rare in terms of percentages. The one exception is during times of war.
As we have become more psychologically knowledgeable, it has become evident that there is more or less a typical reaction that occurs in reaction to 'catastrophic' stress. Not everyone experiences all the symptoms, which often seem strange and dramatic, and therefore frightening. Each reaction is unique in terms of how serious and disabling the symptoms are. Some reactions may be immediate; others delayed. Some people do not react at all or only briefly.
The best way to conceptualize 'catastrophic' or 'post-traumatic' stress is that it is akin to a psychological injury. Our psyche has been injured because of an external threatening event in the same way our body may be injured as a result of a devastating accident. Just as in a physical injury, there is a healing process that has to occur, which typically involves an initial period of pain and disability, and then there's an uphill, sometimes very gradual and uneven path, that requires a balancing act between the right amount of rest and pushing the limit, in order to build back strength and endurance.
When we are exposed to a catastrophic stressor, our sense of reality, psychological integrity, and security is torn, slashed, or obliterated. Our sense of our world as we know it has been destroyed. This has nothing to do with logic or courage or psychological strength. For all the times we have gone to the cash machine and were not robbed. For all the nights we slept soundly throughout and there was no earthquake. For all those fresh Tuesday mornings in September when life went on as usual. For all the life each of us has lived and nothing happened. This sense of security, that everyday reality that we count upon when we step out of the house in the morning, suddenly seems insane, worthless, irrevocably changed. The outside world is no longer experienced as even relatively safe; instead, it has -- out of nowhere -- become a dangerous and threatening place.
In addition to having our sense of reality torn or destroyed, our sense of bodily integrity is also threatened or damaged. In the midst of catastrophic stress, the overall reaction is fear -- not worry, not anxiety, but 'in the gut', animal instinct fear. In a split second, we become the animal within, with the same 'in the blood' 'fight or flight' mechanism that we see when the hair goes up on a cat, a dog or tiger stands ready to spring, or a snake coils in anticipation.
Human beings also seem to condition quickly if the stimulus is intense enough. This is both biological and psychological. A bad case of food poisoning and we may never eat that food again and may even become nauseous every time we smell it. When exposed to catastrophic stress, in an instant, this intense animal fear reaction becomes associated with the trauma involved and sometimes to the world at large. Although the threat of stimulus is no longer present, our entire sense of bodily and psychological integrity has been disrupted -- again, we have been injured. Our usual sense of being, which integrates physical sensations, emotional responses, perceptions, and thoughts, is thrown off-kilter, out-of-whack.
Catastrophic or post-traumatic stress reactions are generally irrational. This intense, animal-like fear occurs, lingers, and may escalate after the fact when the actual danger no longer exists or is not immediately present. In our current situation, the catastrophic stress reaction is complicated because we have also entered a state of war with a terrorist enemy. Thus, some of our anxiety is rational , i.e., realistically-based. However, many of the more dramatic and frightening thoughts and feelings are unrealistic or out-of-proportion. The challenge for all of us is to differentiate the irrational from the rational feelings. If post-traumatic stress festers, it can develop into even greater distress and problems in everyday functioning.
What does not work in response to catastrophic stress is logic, problem-solving, or mental control. The injury is on this basic, primitive and instinctive emotional level, and the healing has to occur on this level as well. A rational mind can be helpful in understanding what is happening, but the usual mental strategies that we are encouraged to use in dealing with life do not have their typical effectiveness.
The hallmark symptom of post-traumatic stress is a tendency to re-experience the trauma. One way this occurs is through flashbacks and nightmares. People describe that out-of-nowhere, they re-experience the scene of the trauma through vivid images and sometimes all the bodily sensations, sights, smells, and sounds that go along with it. This may last only a second or two, sometimes longer, but, it is terrifying. Even for an instant, the body may start to go into that animal fear response as though it's happening all over again.
Immediately after a trauma, these flashbacks can be constant throughout the day, although this is not always the case. With time, they diminish in frequency and vividness, although years after the fact, if something in the environment is reminiscent of the trauma, a flashback can occur.
Now, it is felt by some that this vivid re-experiencing of the trauma is actually part of the healing process. It's similar to the experience most of us have had after awakening from a terrifying dream. When we first realize this was a dream, we are overcome -- bodily -- with relief, but it takes a few minutes to really understand that we are over the danger, to fully reintegrate ourselves back to reality. With post-traumatic stress, it was not a dream. The catastrophe did occur, but by reliving it over and over we begin to master the situation, to put it in perspective. So, everytime we're jolted back to the trauma, we also come back to reality, and over time this builds up a sense of relief, reintegration, and control.
Mastering the kind of fear evoked by catastrophic trauma is similar to what children do. Often, young children play out scary situations over and over, for example, they may ask adults to play 'monster'. Once the adult puts on the scary face and begins to growl, the child's laughter turns to fear and he may say, 'Mommy, stop!' But, then, almost immediately 'Let's do it again.' By the second trial, there is more laughter and less fear and by take #7 of the monster game, the child is giggling and proudly announcing, 'I'm not afraid of you.'
This rather unsophisticated behavior of children gives significant information as to how human beings master anxiety. It's not through 'the head', but an integration on many levels through doing and practice. With catastrophic trauma, the injury involves the most primitive emotional level so healing has to occur at this level as well.
Similar to reliving the trauma, in post-traumatic or catastrophic stress, we also see an obsessive focussing on what happened. In fact, this is even more common than flashbacks or nightmares. The individual cannot stop thinking about what happened, what could have happened, what they could have done differently, why was it the other fellow and not me, what would happen to my children if I had been killed or seriously injured, and so on` and on` and on` People who experience this try to distract themselves. They want to get away from it, but they cannot. They turn on TV, try to read, clean the house, but the thoughts intrude, almost like an outside force sitting on top of the person. In our present situation, this may manifest in hysterical fears and rumors or an obsessive, anxious attention to television news.
As with the flashbacks and nightmares, over time these obsessive thoughts and behaviors should diminish and they also appear to be part of the healing process. If the sense of reality has been destroyed, the healing task is to rebuild and reintegrate, by going over ever possible scenario, fear, feeling, and irrational thought, until the person achieves some sense of control. Again, mastery at this level comes from doing and practice -- not by making a plan or achieving insight.
Post-traumatic stress is paradoxical. If one classic symptom is this intense focussing on and reliving of the trauma, another is the panicky avoidance of things associated with the trauma. It is common for people to become extremely fearful of the place where the catastrophic event occurred or similar places. They may also become fearful of people who are associated with or remind them of the trauma. This fear is generally experienced as panic, which occurs most intensely when they are physically faced with or think about these things. The heart starts beating fast, hands get sweaty. There may be shortness of breath, lightheadedness, a sense of desperation or smothering sensation. Often the symptoms are unbearable. The person has to escape, remove himself immediately from the situation, and this starts a pattern of avoidance behavior.
Avoidance is one area where the healing process can become complicated. Avoidance tends to reinforce itself and can grow, crippling an individual. You can go from being afraid of the restaurant where you were robbed, to fear of eating out, to fear of going out. So, it is important to begin working through the avoidance and facing the fear as soon as possible. There is the old saying, 'If you fall off a horse, get back on the horse.'
In the aftermath of September 11, many have developed fear of flying and even of airplanes as they fly overhead. Likely, for many, this involves a sense of bodily panic, perhaps momentary animal 'flight-or-fight' feelings. This is understandable, given the nature of what occurred. Because our post-traumatic stress reaction is complicated by the fact that we are now involved in a war with terrorists, again it is important to emphasize that we need to learn to distinguish the irrational elements of our anxiety (meaning being fearful over events that do not or no longer pose a threat) from rational concern in our current situation.
Because of the catastrophic and traumatic nature of what occurred, it is likely that everything from loud noises to going into a building of more than several stories to hearing a low-flying plane could cause appreciable, irrational anxiety reactions, clearly out-of-proportion to any real threat. It is important that we work through those feelings by facing the fear or there is the possibility that paralyzing avoidance behavior could result. All our national leaders have advised getting back to life as soon as possible. This is also excellent advice on a psychological basis, not just as a show of national strength or pride.
On the other hand, it is also important that we do not deny the gravity of the situation on a rational basis and take what steps we can to protect ourselves. Each of us has to decide where we do and do not feel safe, but we need to make sure these decisions are made realistically and not out of irrational post-traumatic anxiety. Perhaps, for many, it is still too early to make some of these decisions as the post-traumatic symptoms and feelings still need to be worked through. However, if we do not get back to business and pleasure, a crippling cycle of avoidance behavior may ensue.
Like everything else we've discussed, the way to work through irrational anxiety and panicky avoidance is by practice and doing. This can be very difficult, since the symptoms are so uncomfortable and sometimes it can take a lot of guts to even start the process.
There are two components to facing the fear. The first thing is to learn to reduce the anxiety whenever this occurs, generally through relaxation techniques. Panic and relaxation are incompatible. You cannot feel both at the same time. There are several sophisticated techniques that can be learned with the help of a therapist, although some people do this naturally -- through prayer, meditation, humming a tune, listening to music, counting, reciting the Gettysburg address, whatever... All of us have developed things that we do when we get anxious and some are more effective than others. Still, some of the coping skills that work in everyday life, may not work when a person is faced with intense panic and this is where professional help can be extremely helpful.
The other element is to take 'baby steps' towards breaking through the avoidance. If one was held hostage at work and becomes panicky whenever the thought of work arises, what you want to do is break down the process of returning to work into baby steps -- small segments or goals that can be accomplished one at a time. So, you could begin by just visualizing walking into the company building. You get anxious, just thinking about it. But, use the relaxation technique to bring the anxiety down to a manageable level. Visualize walking into the company building again ... and again, and again until you can do it without getting overwhelmed. Once this step is accomplished, you go on to the next one, perhaps simply driving by the workplace but not going in. Remember, the example of the child with the monster game. It's the exact same principle.
It is important to point out that the long-standing effects of catastrophic stress are often minimal or nil. Ultimately this depends on the person and the nature of the stressor. I have done a lot of counseling with the victims of workplace trauma -- bank tellers who have been held up, delivery men who have been beaten and almost killed, survivors of a shooting rampage or explosion. When these people first seek treatment, they are acutely traumatized and psychologically disabled, but it is amazing and speaks to the strength and resiliency of human beings that, in the course of a few months, they often are fully functioning and back to their old selves or well on their way to being so. Therapy, counseling, and support groups are very successful in treating the effects of catastrophic stress.
Although escalation of avoidance behavior is the most pernicious 'complication' of post-traumatic stress, the individual may also experience other frightening symptoms because of the 'fight or flight' animal reaction that has been conditioned to an event which, in and of itself, no longer poses a danger. There may be general anxiety symptoms such as shakiness, agitation, or crying episodes. There may be the eruption of irrational and childlike fears -- of the dark, of leaving home, of being alone. People also describe the sudden development of compulsive rituals involving safety, such as repeatedly locking the doors, the windows, checking the stoves.
Victims of post-traumatic stress often feel wired, on edge, 'hyper.' Irritability is common and there can be anger outbursts or what seem like mood swings from the outside. Because our most primitive and basic emotional responses, which are at a physical level, have been thrown off kilter, there may be sensitivity to noise and light, along with loss of sexual interest and appetite and sleep disruptions beyond the nightmares.
A person in the midst of post-traumatic stress can have the appearance of a frightened or wounded animal. There is this skittishness and you can almost feel how physically wound up and on guard the person is. One symptom is hypervigilance -- a kind of paranoid scanning of the environment, like a human radar. Often the body feels rigid and tense, and the person is just either very aware of or actually constantly checking out everything around them, as though they anticipate threat suddenly coming from any corner, at any instant. This may particularly occur when the person goes out in public. A related symptom is the exaggerated startle response so that, with an insignificant noise, the person JUMPS or startles like a rocket.
There may be a sense of shellshock. People use words like 'numb,' 'frozen,' 'distant,' and 'detached' to describe what they are feeling -- or not feeling. This may extend to loving emotions, for example, a woman may say she feels 'nothing' when she is around her husband or children, which, of course, is disturbing and can create problems in personal relationships.
Despite the very uncomfortable and dramatic nature of many of the symptoms, post-traumatic stress often resolves spontaneously with time. If it does not, treatment should be sought. Treatment is generally crisis-oriented. It is not about early childhood or analyzing issues or dysfunctional patterns, but geared towards getting the anxiety down and getting the person back to functioning as quickly as possible. If there are complicating factors, such as personal grief, therapy might be more in-depth and issue-oriented down the line, but first the focus is on dealing with the crisis and the immediate, often raw and overwhelming pain. As mentioned previously, psychological treatment is very helpful in dealing with post-traumatic stress. Even if someone is not acutely symptomatic, a session or two may be well worth it.
The tragic events of September 11 have left us psychologically assaulted on several levels. Ironically, it may be the immediate, dramatic and frightening reaction to the catastrophic trauma that may have the least long-term effects psychologically -- both individually and as a nation. Catastrophic stress is by definition an event outside the realm of typical human experience. With time, and sometimes necessary treatment, the effects generally subside. We will reintegrate into a more stable reality, although it will be a different reality than we knew prior to that tragic day in September. We are also having to adjust to living in a state of war and, for many, there is immense personal grief. Psychologically, we cannot go back, but we will go forward. It is also true that out of crisis come the greatest opportunities for genuine, positive personal and collective change.
© Judy Marshall
Judy Marshall, Ph.D., a therapist, is the author of "Self to Soul: A Vision of Psychology and Spirituality". Visit her web site at http://www.psychmaster.com