This winter I was fortunate enough to have two conversations about post traumatic stress disorder PTSD with trauma specialist Dr. Marylene Cloitre.
The following article is based on our conversations.
Do You Have PTSD from Childhood?
Panic. Anxiety. Fear. Nightmares. Insomnia. Fuzzy-brain feeling. Indecision. Confusion. Out-of-body numbness. Dissociation. Reacting to present-day events from the past’s influence. These are all familiar states of being and feeling to people who grew up in an environment influenced by alcoholism, workaholism, narcissism, depression, or otherwise dysfunctional parenting that involved neglect. If you know these feelings, does that mean you have Post Traumatic Stress Disorder?
Marylene and I discussed how PTSD is diagnosed today, as well as historically, and how people with PTSD can get better with therapeutic treatment. (Yes, there’s hope!)
THE BASICS OF POST TRAUMATIC STRESS DISORDER (PTSD)
While many of the questions I discussed with Marylene were focused on the fallout of being someone raised by dysfunctional parents, she also outlined the basics of PTSD in general—as well as a bit of high-level controversy among psychologists. “There is some controversy,” she forewarned me, “about what kinds of experiences can precipitate the development of PTSD. At present, a person has to have had a certain type of event occur in order to qualify for a PTSD diagnosis,” she says. “And childhood adversities such as neglect or psychological abuse are not formally recognized as experiences that can cause PTSD. Still, we know that people who experience childhood adversity do get PTSD—so you can see that there’s something wrong with the existing definition of events that precipitate it.” The good news (for us) is that the DSM that comes out in 2013 will reflect a new diagnostic approach to PTSD which may focus exclusively on the symptoms and abandon the requirement that a certain events (and not others) cause PTSD. (The DSM is the Diagnostic and Statistical Manual of Mental Disorders.)
The 3 Classic PTSD Trigger Events
Be sure to watch at least one of these three raw, honest, first-person accounts of PTSD—each person describes their traumatic event(s) and talks about how they’re dealing with the internalized trauma that came after the event.
Marylene explained that when we talk about the classic view of PTSD, we think of three categories of events that produce PTSD:
- Motor vehicle accidents
A Life-Threatening Event
“Combat, rape, and motor vehicle accidents each have one essential quality in common,” Marylene points out to me. (Can you think of what they have in common? I couldn’t begin to guess—I can’t imagine three events having lessin common than combat, rape, and car accidents.) “They have in common an experience of a threat to one’s life,” Marylene says. “A threat to one’s life or physical integrity is an essential part of the definition of the kind of experience that you need to have to qualify for a PTSD diagnosis.”
Combat can certainly result in death or physical injury, rape often does, as do car accidents—they are linked by being life-threatening.
Hallmark PTSD Symptoms
Marylene explained that back in the 1970s when the diagnosis of PTSD was first developed, as an outcome of the Vietnam War, the “signature symptom” of PTSD was established (and is still part of the diagnosis) which is that of re-experiencing of the trauma, which can take the form of:
- Bodily (stress) reactions when confronted with reminders of the past experience (such as being in the same place where the events happened or encounters with people who remind you of traumatizing individuals)
- Images or thoughts about the trauma automatically triggered by reminders of the past
Other symptoms of the PTSD diagnosis include avoidance of things because they remind you of the past events, feeling emotionally numb and hyper-aroused (sometimes both at the same time or in alternating over time). The diagnosis depends on the intensity level of these symptoms, and the frequency with which they occurred. “If you have these symptoms but not at a high rate, you may be diagnosed with Sub-Syndromal or Sub-Threshold PTSD,” says Marylene.
Human-to-Human Damage & a Sense of Safety
Now, the other aspects of these experiences—combat, rape, and motor vehicle accidents—are feelings of being very unsafe. And if the events involve people (in the case of combat or rape), feelings of mistrust are involved.
“Now here’s something really interesting about PTSD,” Marylene says. “When another human being is involved, when the trauma is caused by interpersonal violence—rape, physical assault, sexual violence, child abuse—people are ten timesmore likely to develop PTSD as opposed to traumatic events that are environmental, like earthquakes or hurricanes.”
This means that when we’re doing damage to one another—it’s extraordinarily worse for us, more hurtful, scarier, and longer-lasting than when the universe puts danger in our way.
Human Well-Being is Inter-Connected
Just as we can damage each other more powerfully than any other force, we can nurture one another more effectively than any outside force—we raise one another.
Marylene went on to explain that we are intrinsically connected, in terms of our well-being, to one another. We rely on one another for safety. “Your very first relationship is the parent relationship. That relationship creates for you a template of what it means to be safe.” (That’s a positive statement for most, but perhaps devastating for us to hear, knowing well the absence of a feeling of safety.)
“We now know that threats to our physical well-being can lead to a PTSD diagnosis—and a threat to one’s well-being can stem from neglect,” Marylene said. “That can be from a single instance—being left alone for days—to repeated instances of this type of event over time. We know that 25% of people who have experienced childhood neglect (yet not physical abuse) have PTSD symptoms,” she says. “But they’re not diagnosed with PTSD due to the fact that their symptoms don’t fit the classic symptoms.”
This is where ‘what is PTSD?’ gets somewhat complex.
Post Traumatic Stress Disorder (PTSD) & Acute Stress Disorder (ASD).
While PTSD was developed as a diagnosis in the 1970s, ASD came after. “Acute Stress Disorder was introduced after PTSD,” Marylene explains. “It was introduced as a disorder because it was thought to be useful as a red flag, as an indicator of people who might develop PTSD later on.”
ASD hits first. If it doesn’t resolve, it becomes PTSD.
Is Fuzzy Brain Syndrome Really Acute Stress Disorder (ASD)?
“Dissociation—feelings of unreality—is one of the hallmarks associated with Acute Stress Disorder (ASD),” Marylene says. “But this is somewhat controversial because that feeling isn’t currently connected to the PTSD diagnosis, although dissociation is widely recognizedwithin the community as a symptom that occurs with PTSD.”
“ASD symptoms occur right after the event. While many people have ASD which resolves on its own within three months or so, it is a risk factor for developing PTSD. It identifies people who are at risk for developing a chronic stress reaction. The timing is essential to the diagnosis,” Marylene explains. “When the acute stress symptoms last past three months following a traumatic event, it can become a conversation about a potential PTSD diagnosis.” The symptoms of ASD are identical to those of PTSD, with the exception of the additional dissociation symptoms.
Dissociation Symptoms of Acute Stress Disorder
- Feeling like the world or things around you are unreal
- Mind freeze or mind shatter
- Feeling outside of your body
ASD and PTSD are, in some ways, as tricky and time-based as diagnosing a physical illness. Say you have flu-like symptoms that resolve themselves quickly. It could have been a 24-hour flu (or food poisoning). But if the symptoms persist, other diagnoses are considered, like a newer, tougher flu-like virus that has much of the same symptoms but for a longer duration.
ASD is a quick visitor. Not so with PTSD. “If a person’s ASD symptoms don’t resolve in a short amount of time on their own,” Marylene says, “they’re then converted into a label called PTSD.”
POST TRAUMATIC STRESS DISORDER & CHILDREN OF TRAUMA & DYSFUNCTIONAL PARENTS
It’s expected that the 2013 edition of the DSM will extend beyond diagnosing PTSD solely according to the three precipitating events of combat, rape, and motor vehicle accidents. “This means that if someone has symptoms of PTSD whether they were raped, in an accident, or combat—or not,” says Marylene, “they can still be treated.” The problem with the current diagnostic setup is “disagreement surrounding the meaning of threat to one’s life.” Marylene explains that people have classically interpreted that to mean “bodily harm or transgressing bodily boundaries,” but neglect of a child is the absence of any of that.
The absenceof bodily harm, yes—but there’s still a threat to one’s life. Marylene points out that the experience of trauma is not as simple as having bodily harm/no bodily harm. She provides insight into why 25% of children who experience neglect who didn’t have physical abuse have PTSD—“When you think of the conditions of survival for a child—you have to be attached, in a care-taking way, to caregivers,” she says. “In order to survive (survival only, putting aside thriving for the moment) attachment and care are essential.” This means that neglect can absolutely be life-threatening (qualifying it for PTSD), especially when we’re talking about a very small child. (A child of neglect will be underweight, have limited physical development, look smaller, and lag cognitively behind the average.
“Attachment to a caregiver is key. We know that the human attachment system is biologically based,” says Marylene. This shouldn’t be a surprise—infants are unable to care for themselves or survive without contact, without physical care. (If you’re unsure of this, read up on studies of touch deprivation in orphanages—and the resulting movements to create orphanage programs in which workers and volunteers hold and cuddle babies as an essential part of their care.)
“The physical care and attachment necessary for survival is the minimumlevel of nurturing a child actually needs for any sort of basis for healthy development,” says Marylene. “But even more, it’s essential to create an environment ripe for thriving. To thrive in society, it’s becoming clearer and clearer to researchers that emotional intelligence is key. And in order for children to be raised in such a way that emotional intelligence enters the picture, consistent and plentiful nurturing and guidance must be present.”
Neglect is an ‘Adverse Event’
At present, neglect goes into a general category of ‘adverse events.’ “Trauma is the experience of feeling unsafe,” Marylene explains. “In the context of neglect, a child is left to fend for him or herself in situations where they are realistically unlikely to be able to manage demand feel overwhelmed, i.e., feeling unsafe (e.g., getting meals, getting to school, navigating travel through violent neighborhoods). That kind of situation involves trauma in a more general sense of the term—traumatized in a global sense.” Those kinds of instances aren’t currently covered by the PTSD diagnosis protocol, but may be in 2013, if the Diagnostic Manual does indeed make PTSD a condition that’s diagnosed only according to symptoms rather than events. These are the diagnostic criteria and symptoms provided by the U.S. Department of Veteran Affairs.
Check out the ACE Study, which discusses the impact on biological health for people raised in households where adverse events took place–an important 10-year longitudinal study. The ACE studies emphasize the role of childhood adversities in producing a wide variety of negative mental health outcomes as well as physical health consequences into the adult years and indeed across the whole life span (including earlier mortality). “Regardless of the debate about the link between childhood adversity and PTSD,” Marylene observes, “there is a definite link between childhood adversity and a range of negative outcomes—beyond and probably related to PTSD.” You can read more about ACE studies here.
RECOVERY & POST TRAUMATIC STRESS DISORDER
People can have PTSD or a sub-syndromal version of it—and not know it—for years and years. So, how can someone finally address PTSD, and overcome it in order to live a more consistently enjoyable life free of fright?
“There are helpful, tested treatments for PTSD,” says Marylene.
Good therapy, that is. “Choosing your therapist and deciding to work with them because you feel safe is the very first part of getting good therapy—that act is therapeutic,” says Marylene. It’s crucial, she adds, that you like your therapist one hundred percent. “If not, get a new one! No question!”
Marylene recommends taking a consumer approach to finding a therapist. “Don’t assume what your therapist says and does is right because they are a doctor. That’s terrible. It’s an old-fashioned view that a therapist knows better. Don’t just stick with someone because they’re in the doctor role, the God role. Therapy has to start from a place where the person feels empowered and safe and comfortable with their therapist.”
Home-based therapy where you try to manage your own treatment is unlikely to be the best approach, because the PTSD repair work involves an interpersonal experience of working with another human being. “The experience of ‘I choose you’ is the beginning of the cure for the person who has experienced inescapable psychological or physical violence at the hands of another person. It’s the opposite of being with a really bad parent, where you have no choice.” It’s a radical and different thing to say, ‘I choose this person,’ says Marylene. “As therapists, we have to be attentive to the issue of the client’s goals, preferences and wishes from the very e very first session. We have to explore how comfortable the client feels with the therapist, with the office or treatment setting, and with the approach that the therapist is talking about.”
(I wrote a post about the process of hiring a therapist herewhich was inspired by my conversation with Marylene.)
Safety in the therapy is key, Marylene says. “The question is, how does a feeling of safety happen? The therapist must make the treatment room safe-feeling—that’s Trauma Therapy 101. With regard to early life trauma, what has felt unsafe for people is when a frightening, confusing or even just novel feeling or experience has occurred and the person receives a negative, very unhelpful or rejecting response to that. So whatever particular interventions are used in therapy, it’s key that the therapist is open, acknowledging accepting of the person’s experience. Acceptance is kind of…the antidote.”
Think about it. If your parent would hit you, then say, “That doesn’t hurt,” there’s no safety in that, Marylene explains. “But if a person comes in and tells their therapist about a horrible experience they had, and the therapist says, “Tell me more…” or the therapist says, “That sounds like a horrible experience…” they are providing a new and different response, an acknowledging response, a positive response, a soothing response. That’s how a person begins to feel safe in therapy.”
Telling about one’s trauma to another human being, having a compassionate person bear witness to one’s story, is another key aspect to healing.
The Three Parts to Treating PTSD
The treatment method used successfully by Marylene and other psychologists on her teams include these three keys:
If you watched the ISTSS videoson the website mentioned earlier, you may have seen the one with the woman who survived the genocide in Rwanda. Her story is powerful. I asked Marylene these two questions: How will we know when a case of PTSD is “cured”? How do we know whether it might ever pop up again for any reason? Her answer was, “If you have three months without symptoms, your PTSD is considered “resolved,” but if you’ve had other trauma in the past, that will have increased your risk for developing it again. It’s complex,” she says. “In the case of the genocide survivor, that woman is considered “cured” if, in the case of seeing green jackets, she’s not triggered by seeing them and her nightmares are gone.”
“Re-emergence of symptoms is possible, and normal,” says Marylene. “If a person’s symptoms re-emerge, they don’t necessarily need to re-enter treatment, but are likely to be helped by a session or two with a therapist. The tune-up session can be used to address the instance that came up and also used as a review of the skills used to process the trauma, even if otherwise you’re doing well.”
1. Telling about the Trauma
Telling of the traumatic experience is essential to healing. “Talking about what happened, really reviewing the experience is important,” says Marylene. “This is based on the idea that a lot of the problems that people have with PTSD (nightmares, for example) are based on avoidance behaviors, avoiding thinking through how to solve a problem because that problem is so scary or avoiding the feelings that you have about past events because they seem overwhelming. So the talking part is about directly considering past events, no longer avoiding what is bothering you and working from there to problem solve what hurts and how to fix it.” The avoidance is actually believed to create the nightmares, bodily stress reactions and other re-experiencing symptoms. “Old emotional reactions belong to the past, not the present,” points out Marylene. “Digging that up and looking at it will help to distinguish past from present.” (Your bossy boss may bother you less once you do.)
Unfortunately, not too many people want to hear tough stories, so people who have experience traumas may have a limited listening base. Also, people don’t want others to think less of them because of the horrible thing they lived through, or that people will think they’re “stupid” or—that they deserved what they got. “A trauma therapist will help you see that you’re not to blame (no child is to blame for their childhood!), and there’s nothing to be ashamed of. The blame for acts of violence lies solely with the person who perpetrates the violence,” Marylene says. “For the therapist, this is called Witnessing—listening as a compassionate party.” She recalled a woman she’d worked with who’d been sexually assaulted. “She never liked people’s reactions to her story. People had really self-protecting responses to her story, or distancing reactions, like, “That couldn’t happen to me.” Or they’d have evaluative type responses, like, ‘No wonder that happened to you.’ Essentially, those around her could not listen to what she had to say from a healing perspective. So she stopped telling people what had happened to her.”
Containing the experience is a key part of the telling process, and this is part of the value a therapist can bring to one’s PTSD recovery. A therapist can help you manage fears about falling apart during the process, and a therapist can provide you with a context for the trauma itself, which is helpful in keeping a potentially evocative event in the here and now, differentiated from the traumatic scenes that were a reality in the past.
2. Meaning-Making of the Trauma
So you’ve talked about what happened to you. And you didn’t fall apart, despite fears to the contrary. What now?
Making meaning of what happened to you is a crucial next step in PTSD recovery. “The purpose of meaning-making is to transform the trauma something that you can live with,” Marylene says. “And even make what’s next a positive step for you.” Marylene provided a great example of how possible it is. “The woman who started MADD (Mother’s Against Drunk Driving) was a mother who lost her child to a drunk driver. She transformed the experience into something positive.”
Yes, positive is possible.
Being “positive” about the experience doesn’t mean getting to a point of saying, ‘I’m glad that happened,’ but it means incorporating it into your life in a way that doesn’t defeat your spirit. “Transforming the experience into something positive isn’t about making a judgment about what happened, it’s not even about making sense of something like, ‘I had a crazy parent.’ It’s about is this: “What can I do with what’s happened and Where do I go from here?’ and making the answer to that question a positive.”
I asked Marylene if writing my blog Guess What Normal Is might be an example of transforming trauma into something positive. “Yes. Definitely,” she said.
“Making a decision to have compassion for and like yourself more—that’s transformative, too.”
Meaning-Making and Acceptance
There’s another piece to this meaning-making, this positive transformation of trauma, which is acceptance. Marylene provides an example, “Let’s say you’ve become an addict after growing up with an alcoholic father. It’s an important realization to see that your dad’s drinking did lead to your own drinking, to accept that, but to say, OK I’m going to stop drinking—and I understand that I am not my father.”
It is important to acceptthat you are the child of an alcoholic (or addict, workaholic, narcissistic, or otherwise dysfunctional parents)—“otherwise, you’re running away from it, denying it, and that doesn’t allow for transformation of self,” Marylene says. “That’s why the telling of one’s story is key, why the therapist bearing witness is so key—you’re then not wasting any more energy denying that what happened did not matter.”
Just the other day, NPR aired a report about how the U.S. military is helping soldiers process PTSD, and the important role of crying—a form of acceptance. The audio for the show is here.
People often ask, ‘Whydid this happen?’ It’s hard to find a why, says Marylene. “People will develop their own Why at some point, and people do make meaning of the story of their past. But there’s no definitive or single answer to the question of Why. The most important “Why’s will be differ from person to person, even when they have experienced similar events.
3. Reintegration after PTSD
A lot of people come to the next natural question in this process, which is—So, What Now? What am I doing to do now? (I see this moment as if standing at the drop-off of a high mountain I’ve successfully climbed—seeing that the gulf between that edge and the next road is too distant to jump to on my own. How to cross? I need to build a bridge.) “This is where people realize that they don’t have to repeat relationships from their past, or be their parent, that they are not their parents,” Marylene says, “and people are liberated by this process in a big way. But, it can be scary.”
Reintegration—or rehabilitation of the self—is all about becoming yourself.
Becoming Yourself, Tools for Re-Integration:
- Goal Setting
- (Your Therapist!)
“The focus within the reintegration phase is on a lot of practical skills, planning, and goals,” says Marylene. “You’re finding new ways of behaving, reacting, and taking action. This is all new, right? Let’s say that when I was a kid that I learned that if something wasn’t right, someone got hit. But, now, I’ve decided that I don’t want live by that rule, that’s not who I want to be. So I have to learn what it is I am going to do in those situations in where something isn’t right and hitting, fighting is not the option I want to choose.”
This extends to all types of coping behaviors (i.e., addictions) as well. “Rehabilitation of self includes practicing alternative patterns of behaviors—‘Instead of drinking, I am going to go for a run,’ which builds a skill. Or, ‘I’m going to clean the house instead of cutting.’ Or, ‘Instead of tolerating an environment of shouting people I am going to leave.’”
Acting different means practicing new skills, and it means totally new behaviors (which necessitates totally new thoughts!) You can see why doing skills-building with a therapist is so essential. “The therapist will help you think about what you might say in various situations—say, dealing with your reaction when an argument breaks out at the table next to you in a restaurant,” says Marylene.
In the case of an angry customer at a restaurant where you’re eating, the old scenario from childhood might suggest that you shout down that person. In therapy, you can discuss different courses of action—options. You might choose to ignore the scene, leave the restaurant (after asking for a gift certificate for another night from the waiter), change to a new table, ask the waiter to intervene, politely ask the people to quiet down, etc. “The therapist will help you imagine yourself acting the way you’d like to behave in various difficult situations. They can help you come up with a script, practice what you’ll say, model it, and so forth, depending on the therapist (not all therapists will role-play, although Marylene does). This is how a person can develop some really important life skills.”
Talk about some concrete parenting—at last!
I asked Marylene for a parting observation for us all—and she provided a beautiful one:
“Life itself provides opportunity for healing. New experiences, new relationships, and new situations can invite us to think of ourselves in ways different from the past. But therapy can help by prodding our imagination—and abilities—to become our better selves while at the same time having compassion for where we have come from.”
Be kind to yourself.
About Marylene Cloitre
Marylene Cloitre is a research scientist at the National Center for PTSD based in the Palo Alto VA and a Professor of Psychiatry and Child and Adolescent Psychiatry at the New York University Medical Center. She is the founding director of the Institute for Trauma and Stress at New York University’s Child Study Center, and former director of the Anxiety and Traumatic Stress Program & director of training at Cornell Medical College. She speaks nationally and internationally about trauma, is the co-author of the books, Treating Survivors of Childhood Abuse: Psychotherapy for the Interrupted Life and Grief in Childhood: Fundamentals of Treatment in Clinical Practice. Her work has been published in numerous professional journals and she served as an expert consultant to a number of agencies during the aftermath of 9/11.