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Trauma: The Moral Challenge for Therapy

It's time for therapists to listen to survivors who feel the need to act.

Key points

  • Survivors of trauma often feel an instinctual urge to respond to the injustice of their experience.
  • Therapists have lacked the model, vocabulary, and orientation to help those who experience trauma address moral issues.
  • Menders are artificially separated out from conversations about trauma, but their hard work deserves attention.

For the past 40 years, I have treated and evaluated victims of the Holocaust, war, crime, rape, torture, natural disasters, abuse, and kidnapping. When new friends learn of this work, they often express a type of sympathy for having to listen to so much suffering. But my most difficult experience comes from a less predictable moment when I face a feeling of my own limitations and even cowardice as a therapist.

Student survivors of school mass shooting organized to protect other students from similar trauma.
Source: Unsplash

The problem is not hearing the suffering. It's the moment when a victim of trauma begins to talk about what he or she wants to do in response to the injustice and indecency they experienced. They begin to describe a need to take action for justice, change the world, restore decency, and protect vulnerable others from danger. In my role as a therapist, I say “No, first take care of yourself.” I might continue, “Our job here is to help heal you. You have anxiety, nightmares, flashbacks, and obsessions. I can’t let you ignore your own needs.” Restricted to symptoms of anxiety, we are quickly back to what is comfortable territory for a therapist.

This “healing” advice comes from training, best practices, and clinical models. Based on what the field advises, I might say, “Let’s at least wait on those thoughts. We need to address your flashbacks and nightmares. Let’s first calm your agitated amygdala and that agitated vagus nerve.” But the map we will follow is already laid out. It includes my clinical competence while denying any real relevance to the patient’s moral questions. Already feeling confused and overwhelmed, the victim/patient’s instinctual urge to respond to the injustice of their experience is swapped for the convenience of my clinical competence, instead of my moral imagination. “There is no room here for justice in the course of healing.”

We therapists have a long history of telling patients what their traumas mean, often in accordance with our own models. Freud analyzed reports of his female patient’s sexual abuse and rape as hysteria to fit his theory of the unconscious. But it did not stop with Freud: After the Second World War and continuing through the Vietnam War, there was no diagnosis for psychological trauma. Trauma would not manifest in a healthy psyche and no one’s trauma was seen, diagnosed, or treated until Vietnam veterans initiated a protest against psychiatry that, in 1979 ultimately led to the inclusion of the new PTSD diagnosis in the DSM III. It created a revolution: For the first time, the world could make you crazy. Yet the PTSD diagnosis retains a loyalty and self-affirming rigidity about the role of anxiety, namely that PTSD result from neurological activations deep in the brain that have gone awry.

When a moral dilemma arises from PTSD

One of the first times I had to grapple with a moral dilemma presented by a victim of PTSD was in the treatment of a war journalist who had been withdrawn from the theater of war by her editor. She was not sleeping, was drinking too much, and seemed obsessed with her job—even beyond the usual bounds of driven and dedicated war journalists.

Early in treatment, the journalist said “Listen, Doc, I know what you think about trauma, and I know what I have to say to get out of here, so let’s cut to the chase because while we are chitchatting about me, women, families, and kids are being blown up, and if someone like me isn’t willing to go and write the story, the world will not know, and it will not stop.”

While she leveled with me, her editor on the phone, asked, “Yeah, yeah, sure, but is she okay? Is it safe to send her back?” Indeed, I wondered, what does she need? Clinical judgment indicated symptom amelioration. That’s what I told her. She countered by describing the reality of what she sees and the importance of what she writes. “It’s much bigger than me, Doc.” She felt she had a moral responsibility to return to the work, even if it exposed her to more traumas and triggering. Where was I to find the answer to this question in the treatment models for PTSD? She clinched the dilemma when she made it clear that she could live with anxiety but not with knowing she could have done more, knowing what she knew. We discussed ways to take care of herself, but I agreed with her desire to return, in spite of her PTSD. Maybe because of her PTSD.

Another example: On September 11, 2001, I was a first responder at the Pentagon when terrorists flew a plane into the building, killing 184 people. Several weeks later, Major Lincoln Liebner (permission previously granted to identify his name) came into my office with severe PTSD and nightmares. When he learned about the first planes hitting the Twin Towers in New York City, he raced to get to his post in the Joint Chiefs Office at the Pentagon. He was running across the South Lawn when American Airlines Flight 77 flew directly over his shoulder heading into the building. Liebner looked up and saw faces looking out of the windows seconds before the plane exploded. He was the last person on earth to see those people alive. He followed the plane into the flaming hole it ripped in the building and pulled people out of the wreckage before he succumbed to smoke and was sent to the hospital.

In treatment, the moral dilemma arose when after months of intense treatment, Liebner told me he wanted to volunteer to serve in the war in Iraq. He said, “I know, if anyone knows, what terrorists do; I have a responsibility to use that to make the world safer.”

“No,” I thought, "you are the last person who needs to face more carnage." I told him so and we engaged in lengthy discussions about his sense of responsibility. Was it guilt? Helplessness? Rage? Fear? Survivor’s guilt? A hero complex? An effort to quell his anxiety? A way to erase the faces from his mind? We discussed it all. In the end, he remained resolved that the image of those faces led him to a responsibility larger than his own trauma. Because of what he learned, he could not stand by while other innocent people were hurt by terrorism. In a short few weeks, he volunteered and served in the war. Years later, we occasionally had lunch to discuss his choice. He had no regrets.

Taking action in the face of "terrible knowledge"

To discuss the moral imperatives that victims face in therapy, I employ the term "terrible knowledge" to establish the reality and truth of what the victim knows based on a horrible experience. It is knowledge and it is terrible in that it memorializes an assault on decency and safety. It disrupts “normal expectations.” The question what to do with that knowledge? How does that fit in with their own symptoms and purpose now that they have this experience? Simply, because it cannot be forgotten, what do they want to do?

Indeed, some say they want only to return to their "normal" lives. But many say they want justice and feel a responsibility to do something. That responsibility takes many shapes, from private donations and works of art to protesting, lobbying, and forging new organizations. No one expects another person to make the sacrifices they choose. They do not even say it helps them heal or feel better. They only say that they feel like they cannot ignore reality. They know the danger, they know the impact, and they know the haunting. They say in common: “No one else should have to experience what they went through.”

Yet, while the choices of responding are tremendously varied, they share a common quality: Their trauma moves them to think differently about their relationship to others. I have come to call these people "menders" because they feel a new empathy for vulnerable others and a responsibility to address the threat of violence that continues beyond their own trauma.

In addition to my clinical practice where victims of PTSD give voice to their moral reaction to trauma, I interviewed other victims people who were traumatized and who pursued public lives to change and ‘mend’ the world because of their traumatic experience. Many told me that they never entered therapy. Others who sought therapy never discussed their plans to take moral action in the world. For instance, one victim of the Virginia Tech mass shooting I interviewed told me that while she was helped by trauma treatment therapy provided by a fund, they never discussed her decision to work with schools to increase safety and response to mass shootings. She has dedicated herself to protecting other students for the past 15 years.

The world of therapy has not always been safe for victims of trauma. After World War II, psychiatrists were more interested in childhood conflicts than war traumas, even during the treatment of Holocaust survivors. Even 30 years later, at the time of the Vietnam War, there was no formal diagnosis of PTSD available and Vietnam veterans were diagnosed as suffering from depression, anxiety, or other ailments. When the Vietnam veterans realized that psychiatrists were not listening, they formed their own “rap groups” to help themselves and ultimately created pressure that led to the “discovery” of PTSD when the diagnosis was included in the official manual in 1979. And even today we insist on a neurology that comes more from the lab than from listening and observing.

We are at a time once again when therapists need to listen anew to patients. As a therapist, it is frightening to face the moral quandary created by bold—and sometimes dangerous—actions to fight violence, corruption, and betrayal at the heart of psychological trauma, yet that is what drives many victims of PTSD.

This post is part 2 in a series of articles on Menders. Click here to read part 3. To read this series from the beginning, click here.

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