"Every day, the VA said, eighteen veterans committed suicide. One every eighty minutes.... PTSD was regularly fatal. They never said it like that, and I didn't understand why. When you had cancer, they told you that you had x percent chance of dying especially if you didn't get y and z treatments. No one says that unresolved trauma can kill you. If anyone did, maybe people would take it more seriously. Seriously as cancer."

- From Irritable Hearts: A PTSD Love Story by Mac McClelland

v

According to the U.S. National Institute of Mental Health, one in five people will face a mental health issue during their lifetime.

v

 A stay in the ICU, epecially with significant and invasive interventions, can lead to depression and PTSD. Read about a recent study on the topic here.

WHAT IS TRAUMA?

Trauma is the result of experiencing a highly stressful, possibly life-threatening event, especially one during which you feel helpless. Helpguide.org does an excellent job of summarizing the situations and conditions that can lead to trauma and how it feels to be overwhelmed by its effects.

Sometimes when we have a highly stressful experience, we get shaken up for days or weeks, and then we gradually get back to normal. But sometimes we go numb after a difficult experience. Maybe we simply go on with our lives. However, after weeks, or months, or even years, we may begin to have post-traumatic symptoms. Those symptoms can include anxiety, depression, feelings of worthlessness, difficulty concentrating, flareups of anger, and numbness. The memories of the traumatic event or events may intrude on your thoughts at the slightest reminder, or with no reminder at all. You may have physical pain, such as headaches, which don't seem to have an identifiable cause. Nightmares are an extremely common result of a traumatic experience.

A single event, like an assault or a car accident, can be traumatizing. So can living with an ongoing, heightened level of stress, especially if the stressful events are unpredictable and out of our control. It doesn't matter whether other people, or you, think the event or events are “bad enough,” and it doesn't matter whether people around you or other people who had similar experiences were adversely affected. As the writers at Helpguide.org put it: “It's not the objective facts that determine whether an event is traumatic, but your subjective emotional experience of the event.” (italics in original)

Unfortunately, traumatic events are extremely common. Almost everyone experiences stress during adulthood. Many of us have had chronic stress or trauma in childhood as well. A landmark study published in 1998 found that almost two-thirds of the adults surveyed had experienced at least one significant traumatic event during childhood, and one in eight of them had experienced four or more.

 

Trauma in the Body and the Brain

There is a simple way to describe the brain's and body's systems that makes it easier to understand trauma and its effects. Imagine that the parts of the brain fall into three major categories: the most primitive parts, which we'll call the “lizard brain;” the parts that govern and store emotions, or the “mammal brain,” also known as the limbic system; and the parts that govern decisionmaking, impulse control, rational thought and language (many of them found in the cerebral cortex), which we'll call the “thinking brain.”

The lizard brain handles our emergency responses: the fight or flight instinct, and a third response, freezing or paralysis. If your safety is threatened, adrenaline floods your body and affects multiple systems: it speeds the heartbeat, slows digestion, and causes energy to be gathered to prepare the body to respond to an emergency or a threat. Executive functions automatically take a back seat.

In our modern world, we are not often called upon to run from danger or to fight a predator. When the argument is done, or when the screech of brakes has faded and the ambulance has arrived, we are more likely to tell others, and ourselves, “I'm fine.” But it's very possible that we're not fine.

One theory of trauma, developed by Dr. Peter Levine, is that post-traumatic symptoms spring from the fact that the energy gathered to respond to an emergency was not discharged. It remains trapped in the body and leads to the complications we feel and observe. Where is it trapped? In our lizard brains, and in our mammal brains. We feel unsafe, and our mind and body are hypersensitive to danger. Only when the energy is discharged can we be whole.

Another compelling theory of trauma and PTSD was developed by Dr. Francine Shapiro. She and others have observed that just as the body has an immune system that effectively fights off illness when it's in good working order, the brain has natural methods for processing difficult and even highly stressful experiences. We go over and over that fight with our loved one, or that humiliating experience, and we relive some version of the feelings of anger or embarrassment or whatever they may be. Eventually, the feelings become weaker, and we come to some conclusions about what happened. The memory of the event fades.

A traumatic memory is stuck. Our systems have been overwhelmed and the brain can't process the experience normally.

Memory is associative. We have all had the experience of one thing—a smell, a tone of voice, a place—reminding us of some past experience. Memories are also intimately linked to emotions. Our strongest emotions are often associated with memories that are key to survival. It's a good thing from an evolutionary point of view for strong feelings like fear to be associated with life-threatening experiences. That feeling of fear means that we are less likely to repeat the actions that got us into that dangerous situation. But if you need to drive on that stretch of highway where you almost had an accident in order to get to work every day, that robust evolutionary response can work against you.

A traumatic memory is intertwined with the emotion we felt at the time and the sensory cues we experienced. It will keep coming up, whether in our conscious minds or in nightmares or both. Only when the memory is processed can we be whole.

Chronic stress and traumatic events can change the way our brains are wired, especially when the events happen in early childhood. For more about developmental trauma, see the Trauma in Childhood section below.

 

Stress and Cortisol, The Stress Hormone

There is a factor that can make it more likely that a difficult event will lead to PTSD or post-traumatic symptoms. That factor is stress. Remember how the hormone adrenaline activates our physical systems when we perceive an emergency? Cortisol is another hormone that plays a role in handling stress. 

Ordinarily, cortisol helps us regulate blood sugar levels and metabolism, blood pressure, the immune system and anti-inflammatory responses, and our day-night cycle. 

When we are under stress most of the time, and our bodies have a constantly high level of cortisol, many adverse physical effects can result. Prolonged higher levels of cortisol can lead to impaired thinking and short-term memory, mood swings (including anxiety and depression), weight gain, sleep disruption and lowered immune function. It can feel like we are living with a hair trigger. Over time, that higher set point for stress increases our odds of significant health problems, including diabetes, heart disease and (especially for women) auto-immune disorders.

Many aspects of life can contribute to high ongoing stress, including conflict in our close relationships and pressures on the job. Living in poverty, not knowing whether we will have the resources for basic survival, causes ongoing stress. So does living in a dangerous neighborhood, or simply being a person who other people feel free to criticize and harrass, interactions known as microaggressions. (Here are some examples of microaggressions.) Persistently high levels of stress can be traumatizing, can lead to post-traumatic symptoms on their own, and can make it much more likely that we will suffer severe symptoms if we experience a moderately traumatic single event.

 

Trauma in Childhood

Neglect and abuse in early childhood are very likely to be traumatizing. A baby is completely helpless. He or she depends on adult caregivers for everything: food, shelter, and physical and emotional security. If there is not at least one adult in a small child's life who is there to respond to those needs, that is a life-threatening situation. Childhood trauma is likely to result in deficits in the brain systems that enable us to handle everyday stress, to control our unreasonable or inappropriate impulses, to trust and bond with others, and to handle discomfort, including emotional pain. Trauma in very early childhood is much less likely to be consciously remembered.

Recent studies have shown that if a pregnant person experiences a high level of stress during the last trimester of pregnancy, the baby's cortisol system is likely to be set at an elevated level, meaning that the person will react more extremely to lower levels of stress than a person with a normal cortisol metabolism.

The traumatized child may have trouble focusing in school, may be oppositional or angry, or may tune out. Especially as adolescence arrives, the traumatized young person may suffer from anxiety, depression, or anger and is much more likely to use alcohol or other drugs and to engage in risky behaviors. Both neglect or trauma in infancy or early childhood and high stress in the last trimester of pregnancy also make it much more likely that trauma experienced later in life will lead to serious symptoms (if the person is not already suffering).

That landmark study mentioned in the first section above, known as the ACEs study, found that one in eight people surveyed had experienced four or more potentially traumatizing events or ongoing situations in their childhood. The researchers, Vincent Felitti and Robert Anda, also found a long list of other adverse health effects linked to trauma in childhood. You can read more about the origins of the ACEs study here. The original paper presenting these results, and many many other papers examining this data, can be found at the CDC's ACE Study site.


So What is Normal?

It's normal to feel safe, but to feel afraid sometimes, depending on the situation. Unless you are living in a generally dangerous environment, it's not normal to feel afraid most of the time.

It's normal to be able to interpret another person's mood from their facial expressions and body language (unless you are an individual whose brain is on the autism spectrum).

It's normal to be able to trust others if we judge from the evidence of their actions that they're trustworthy. Not everyone is trustworthy, but it's not normal to be uncomfortable with trusting anyone.

It's normal to feel happy sometimes, and to feel sad sometimes, depending on the situation. It's not normal to be sad all the time, or to feel nothing at all.

It's normal to feel embarrassed sometimes, to regret mistakes, to be insecure or uncertain sometimes. It's not normal to hate yourself or to believe you are always going to be the worst person you know.

It's normal to have a nightmare or to have trouble sleeping now and then, especially if there's some big stress in your life. It's not normal to have nightmares every night.

 

HEALING TRAUMA

What Works

 You can do a lot to manage post-traumatic symptoms on your own. Many people have found some relief managing PTSD symptoms through meditation, body work such as yoga and tai chi, creative activities like writing, making music and art, and working with animals. Grounding, described on the Useful Links page, can quiet the mind in a way similar to meditation. A relationship with a stable and reliable adult can make a significant difference, especially for a young person.

There are several effective approaches to healing trauma.

You can heal trauma through the physical body. Somatic approaches train the body to be calmer and discharge the energy that is stuck. Look for practitioners certified in Somatic Experiencing or Tension & Trauma Releasing Exercises. There are also other body-focused approaches. 

You can help the brain process the memories that are stuck. Look for therapists certified in Eye Movement Desensitization and Reprocessing, or EMDR.

You can re-train the parts of the brain that either overactive or are not activating when they should using neurofeedback.

There are also therapies that use the imagination and emotions to heal trauma. Theater as therapy has been effective for some people. Another method in this category is psychomotor therapy or structures.


What Doesn't Work

Some trauma experts (and the writer of this site) are skeptical about other treatment methods that are sometimes recommended.

Cognitive behavioral therapy (CBT) and therapies derived from it help a person change their thought patterns. CBT is less effective for treating trauma because it works with the parts of your brain that handle executive function, not the deeper systems that handle emergencies. Brain imaging studies have shown that those deeper systems will override executive function when they are triggered. You can't talk yourself out of fight or flight. Your brain's emergency response system will activate much faster.

Prolonged exposure therapy, also sometimes called flooding, requires a sufferer to go over and over the traumatic events.  A person with past trauma will be triggered again and again during the therapy process and might even be re-traumatized. Exposure therapy is used widely in the United States by the Veterans Administration (VA). This type of therapy can be effective for treating some phobias and obsessive-compulsive disorder. However, multiple studies have shown that prolonged exposure therapy can lead to serious complications, including an increase in the severity of PTSD symptoms. Not surprisingly, the VA sees an extremely high dropout rate for this therapy. Somewhat related to exposure therapy, and also not recommended, is Critical Incident Stress Debriefing.

Medication may be necessary to get a person through a crisis, but it's not a long term solution. Some medications, such as SSRIs like Prozac, can be used to manage symptoms, but no medication will address the underlying trauma. For some people, finding the right medication can be difficult and take you through various unpleasant side effects. A medication may become less effective over time.

Substance use is extremely common among trauma survivors. Alcohol, marijuana and painkillers may help you feel better in the short term. Cocaine and other stimulants may enable you to feel something when you are mostly numb. 

If you use alcohol or illegal drugs to get through the day, or the night, you also know that substance use comes with a whole host of other problems: the expense, the legal risks if what you use is a controlled substance, physical addiction, withdrawal symptoms when you stop using, and of course serious wear and tear on your health and on the health of your close relationships. Substance use also won't heal trauma.

 

IF SOMEONE YOU KNOW HAS PTSD

If someone close to you is a combat veteran, a sexual assault survivor, has abuse or neglect in their past, or for whatever reason exhibits post-traumatic symptoms, do your best to listen without judgment and to offer support without advice (unless advice is asked for). Do your best to be reliable and trustworthy. Try not to criticize if the person is forgetful or seems extra sensitive. Don't take it personally if (when) the person has a short fuse or needs to withdraw. Do your best to forgive when the person says the things that hurt you the most. (They're likely to be really good at pushing your buttons.) Try to understand that any stress, bad or good, can be difficult for your friend or loved one to handle.

Michele Rosenthal has ten tips that can help supporters understand what it's like for the person with symptoms.

If you're able to be a steady, supportive friend, the relationship in itself can help the person move toward healing. Here's a piece about the idea of "holding space," a way of being supportive without judgment.

Being understanding and supportive doesn't mean being a punching bag. Set limits. If the person takes out their stress on you, or on any children in the family, do what you need to do to be safe and to keep kids safe.

If the person is not just in pain from past trauma but also attempts to isolate you from your friends and family and is controlling and disrespectful of your boundaries and needs, you may very well be in an abusive relationship. If you're not sure, here are lists of warning signs of an abusive relationship from Hidden Hurt (in England) and from West Island Women's Shelter (in Quebec). The West Island Women's Shelter link includes a button so you can easily erase the site from your browser history. Many people have written about the experience of being in an abusive relationship, and of recovering from the harm it causes (which can definitely be traumatic). This essay by Aphra Behn, on the Shakesville blog, discusses some of the complexity of an abusive relationship.

You are not alone. The PTSD Forum has a very helpful section for supporters.

Substance abuse is highly correlated with past trauma, especially early childhood trauma. Consider carefully whether it is in your best interest to stay with a partner who is abusing drugs or alcohol. If you stay, Al-Anon and similar programs can provide a fellowship of people with similar experiences. Another approach to life with a person who has addiction issues is the CRAFT model (Community Reinforcement and Family Training). Beyond Addiction: How Science and Kindness Help People Change (by Jeffrey Foote, Ph.D., Carrie Wilkens, Ph.D. and Nicole Kosanke, Ph.D., with Stephanie Higgs) is a very readable guide to this model. You can learn more about it from the Center for Motivation and Change.

Some therapists who use somatic experiencing, EMDR, and neurofeedback will take clients who have not yet succeeded at sobriety. Even if a person gets clean and sober, either on their own or with the assistance of in-patient or out-patient rehab or a twelve-step program, remember that it can be very difficult to achieve and maintain sobriety while living with the pain of past trauma still wired into the brain. 


KEY THINGS TO KNOW ABOUT TRAUMA THERAPY

Research tells us that the relationship between the therapist and you, the client, is one of the most important factors in determining whether going through therapy will improve your situation. If you are a trauma survivor, or you think you might be, first look for therapists who have expertise in this area. Then look for a therapist with whom you feel comfortable. If you don't like the way the therapist interacts with you, do your best to find another provider. You have a right to be treated with respect. Healing trauma is risky. If you feel pushed to go faster than you are comfortable, it's OK to say you need to go more slowly. It's essential for your therapist to be available to you between sessions if you are overwhelmed or have a mental health emergency.

The first thing that an effective trauma therapist will do is help you build your internal resources. She or he will give you tools and strategies to help you get back to a relatively calmer state when something (external or internal) triggers an adrenaline response or a difficult memory. (Even without a therapist, you can download the iChill app, for iPhone or Android, if you'd like to get started with some tools.) Have you got an endless stream of negative thoughts? Your therapist will help install a few positive words.

Traumatic memories are like land mines in our brains. The work of the trauma therapist is to help our systems defuse those explosives so they are no longer likely to go off when we stumble onto them. Ultimately, the goal is for the person with PTSD to develop new, healthier neural pathways and to have a resilient response to stress and difficulty going forward.

The conventional image of therapy is a person telling their therapist what happened in the past. In EMDR, somatic experiencing, and neurofeedback, you don't have to talk about, and potentially relive, the traumatic events of the past in order to deal with them.

When processing a traumatic memory, the trauma therapist may ask you to think back to your earliest memory of experiencing the feeling associated with the traumatic memory. Remember, memories are associated with emotions and with other memories. When you process a very early memory, the healing you are doing often has a ripple effect that moves forward in time to heal some of the subsequent memories as well. Part of the work of trauma therapy is finding those earliest, original memories. It's likely that you won't have to process every single difficult memory in order to feel better.

In a therapy session, we open up old wounds. Sometimes we go back in time in our minds and speak with, or even become, our younger selves. A good therapist will make sure that before you leave a session, you've put a bandage over the wounds that you opened up and that the grown-up or present day you is back in the driver's seat. Many therapists will routinely end a session by helping you put disturbing memories and issues into a container, where they will be out of the way until your next session. A mentally constructed container can be an excellent tool to help you set aside persistent thoughts. But traumatic memories won't stay in a container for long. The container is not a permanent solution.

Therapy is not a walk in the park. If you are a survivor of trauma, the process of healing is an excavation of a dangerous swamp, and it can be painful and difficult. Traumatic memories come with a huge mix of feelings—both emotions and physical sensations. They're overwhelming. That's why they're traumatic. Reconnecting with your own feelings and your own physical self can be painful. Rewiring your brain is hard work that happens slowly. Do your best to be patient. At the same time, if you do not feel that you can trust and rely on your therapist for help and guidance at any time between sessions if monsters are rising out of the muck, you are entirely within your rights to find one that you can feel comfortable with. The same goes if you feel like you are just spinning your wheelsalthough your therapist may be able to point out the small signs of progress.

In the book In the Realm of Hungry Ghosts, doctor and author Gabor Maté speaks of a feeling of emptiness and difficulty connecting with others that an individual may try to fill with the use of mind altering substances or compulsive behaviors. At least a part of that feeling has its origins in the brain chemistry built in early childhood. But the brain is changeable, a property known as neuroplasticity. If you can start the brain on a path to healing early trauma, you may discover that your existential aloneness is eased, and you may find some peace that does not rely on an excess of drugs, food, work, or whatever your habit may be.


Barriers to Getting Help

Yes, therapy is expensive. If you have health insurance, a diagnosis of PTSD may or may not help you get the assistance you need. Ask people inside the health care system (your doctor, a prospective therapist) for suggestions about your strategies.

If trauma therapy is out of reach for geographical or financial reasons, consider learning and practicing meditation and grounding techniques on your own. You may feel isolated, but you are not alone. You may find support among online communities.

If you are a military veteran in the United States receiving services from the VA, there are some hospitals that have meditation, yoga, neurofeedback or EMDR available. There is also a network of neurofeedback practitioners in the United States, under the umbrella Homecoming for Veterans, who provide no-cost services to military veterans. (Be sure to ask about the availability of those services when calling any particular clinic.)

There are people working every day to educate the public and decisionmakers about trauma and PTSD and what can actually help, and working to dismantle the many barriers that exist.

 

Further Reading about Doing Therapy and about Healing

Healing is challenging, difficult, time consuming, and sometimes it just sucks. Katie Klabusich on the long road to getting better. (Note: contains swearing.)

More about Somatic Experiencing

What happens when you do EMDR: A step-by-step description of the process a therapist will take you through.

The basics of neurofeedback for PTSD 

One person's experience with neurofeedback (scroll down for Part 1)

Amita Swadhin is a survivor of child sexual abuse. She talks about her healing journey, which included sharing her story, and she invites fellow survivors to share their stories, here.


Excellent books about trauma and trauma healing

The Body Keeps the Score by Bessel van der Kolk, M.D.: In part a memoir of Dr. van der Kolk's education in healing trauma, this is a clearly written history of our understanding of trauma and an excellent summary of each of the most effective treatment options, all backed up with references to medical research, including brain imaging.

Getting Past Your Past by Francine Shapiro, Ph.D.: Extremely readable, connecting early trauma with the issues many of us have in our adult lives and showing how EMDR can clear out the detritus of the past. Includes exercises and practices you can do on your own.

Childhood Disrupted: How Your Biography Becomes Your Biology and How You Can Heal by Donna Jackson Nakazawa: A readable summary of our current understanding of the effects of trauma in childhood, including broader health effects; factors that put women at greater risk of adverse effects; and a list of the strategies that work (for self help and with a therapist).

Waking the Tiger by Peter A. Levine, Ph.D.: Dr. Levine's original, groundbreaking book that introduced a new way of understanding trauma. Covers the biology of trauma, including similarities to trauma in other mammals, exercises for reconnecting with the physical self, and first aid for adults who have just experienced a traumatic event.

In an Unspoken Voice by Peter A. Levine, Ph.D.: A more recent update of Dr. Levine's work, especially useful for clinicians, with many case examples. 

Healing Trauma: A Pioneering Program for Restoring the Wisdom of Your Body by Peter A. Levine, Ph.D.: This slim book takes you through exercises designed to reconnect you with your physical body. As the author notes, it's a good idea to have a friend around when undertaking these exercises. Please seek assistance from a trained therapeutic professional if difficult things start to come up.

In the Realm of Hungry Ghosts by Gabor Maté, M.D.: Dr. Maté has worked with the residents of Vancouver's skid row neighborhood, Downtown Eastside, for many years. He takes the reader through their personal stories of addiction and trauma, and lays out clearly and logically the connections between childhood trauma and substance use.

Irritable Hearts: A PTSD Love Story by Mac McClelland: Journalist McClelland's memoir of going through trauma, and her healing through somatic therapy. Further discussion on the blog on this site.