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When the Trauma Doesn't End

How can people learn to live with chronic traumatic stress?

Exposure to traumatic events, such as natural and man-made disasters, can damage mental and physical health. But what happens when the trauma never ends?

When we talk about post-traumatic stress disorder (PTSD), it usually means people dealing with traumatic experiences in their past. But some trauma victims may find themselves trapped in dangerous environments where they can easily become re-victimized—and they often have little choice but to face that risk for years, or even decades.

In the 1980s, before Apartheid was abolished, mental health professionals dealing with victims of political repression in South Africa found that the usual treatment for PTSD provided little help for people living in fear that the victimization could happen again at any time. According to Gillian Straker and her colleagues at South Africa’s Sanctuaries Counseling Team, helping people heal after trauma often focused on providing them with a safe haven where that healing could take place. In countries where the ever-present threat of arrest or violence continues to exist, dealing with continuous traumatic stress (CTS) posed unique problems for therapists.

Though CTS is not considered a disorder in itself, a new diagnosis has been suggested to take continuous traumatic stress into account: Complex PTSD (C-PTSD). The idea was first proposed by Judith Herman in her 1992 book, Trauma and Recovery, in which she suggested people dealing with child physical abuse, intimate partner violence, recurring sexual violence (including women trapped in sexual slavery), and other forms of long-term stress often showed symptoms very different from people experiencing single-event traumas. As a result, they can often become passive and withdrawn (due to learned helplessness), or develop highly unstable personalities. This could lead to dangerous repetitive behaviours such as becoming involved with violent partners, repeated self-harm attempts, or chronic substance abuse.

Though not part of the most recent edition of the DSM, suggested C-PTSD symptoms in adults include:

  • Difficulties regulating emotions, including symptoms such as persistent sadness, suicidal thoughts, explosive anger, or covert anger.
  • Variations in consciousness, such as forgetting traumatic events (i.e., psychogenic amnesia), reliving traumatic events, or having episodes of dissociation (during which one feels detached from one's mental processes or body).
  • Changes in self-perception, such as a chronic and pervasive sense of helplessness, shame, guilt, stigma, and a sense of being completely different from other human beings.
  • Varied changes in the perception of the perpetrator, such as attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge.
  • Alterations in relations with others, including isolation, distrust, or a repeated search for a rescuer.
  • Loss of, or changes in, one's system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair.

Symptoms for children are similar but also include behavioural problems, poor impulse control, pathological self-soothing (through dysfunctional coping mechanism such as self-cutting), and sleep problems. Since C-PTSD does not adequately reflect the kind of developmental impact seen in children, clinicians have suggested an alternative diagnosis, Developmental Trauma Disorder (DTD).

Not everyone experiencing continuous stressful environments will be formally diagnosed with C-PTSD or DTD, however. Some researchers, including Gillian Straker, suggest that continuous traumatic stress (CTS) should be seen as a separate concept instead of a disorder. Though many people experiencing these kinds of repeated traumas will have enough resilience to avoid developing full-blown trauma symptoms, coping with CTS often depends on how or where the trauma takes place. This includes war zones where the threat of physical attack remains very real and a state of “permanent emergency” exists. Soldiers, U.N. peacekeepers, relief agency workers, people in refugee camps, and even civilians living in these war zones often experience CTS on a daily basis.

Since these permanent emergencies can last for decades in some places, the means of providing any kind of help may be fairly limited. Current examples can include countries such as Syria and Libya, and any places where gang violence is a daily reality. Since the threat of attack never really goes away, people experiencing CTS often learn to live with that continuous feeling of danger for as long as they remain in that environment.

And the state of emergency is not just limited to war zones. Religious, sexual, or ethnic minorities in many Western countries are often victimized by violent hate crimes intended to intimidate them. Whether or not individual members experience these crimes directly, the fact that the violence was directed at the community to which they belong can be enough to make them feel victimized. This is often referred to as identity trauma because it involves attacks as much on a person’s sense of identity as a physical threat.

There is also collective trauma which can strike an entire nation after a wide-scale traumatic event, such as 9/11 or the recent Boston Marathon bombings. Though the panic subsides fairly quickly, the ever-present sense of "Will it happen again?" never really goes away.

So what do classic PTSD symptoms such as flashbacks, nightmares, hypervigilance, and the startle response mean for people who are afraid of being re-victimized? People experiencing CTS are usually more preoccupied with the possibility of future traumatic events than by what happened to them in the past. For them, staying vigilant is a healthy way of responding to what they must face, although they need to learn to tell the difference between realistic vs. imagined threats to their safety.

Much as we have seen a sharp rise in conspiracy theories after 9/11, rumours about potential threats are increasingly common among survivors—and cases of panic, even mass hysteria, have been known to strike as people respond to these rumours. In counseling people experiencing CTS, therapists need to help them recognize the difference between real and imaginary threats. Though making sure that people living in high-risk settings stay alert remains important, they also need to keep their natural caution from slipping over into paranoia.

Then again, the opposite problem can also occur, with some people denying that they are at risk at all. The “it can’t happen to me” mentality is also common, despite clear evidence to the contrary. Even though denying or minimizing the risks involved might seem to be a way of coping with the danger of living in a high-risk setting, that denial may also be dangerous if it leads people to take foolish risks.

Before the eruption of Mount St. Helens in 1980, many long-time residents living nearby refused to evacuate despite warnings of an impending eruption. One resident, Harry R. Truman, even became a local media celebrity for refusing to leave and reassuring reporters, “If the mountain goes, I'm going with it. This area is heavily timbered; Spirit Lake is in between me and the mountain; and the mountain is a mile away. The mountain ain't gonna hurt me...boy.” His body was never found and he is believed to be one of the 57 victims of the May 18 eruption.

Ignacio Martin-Baro, a social psychologist and Jesuit priest whose work with victims of repression in El Salvador was tragically ended in 1989 when he and his co-workers were massacred by the Salvadoran Army, outlined four basic responses in people living in chronic fear:

  1. A sensation of vulnerability
  2. Exacerbated alertness
  3. A sense of impotence or loss of control (learned helplessness)
  4. An altered sense of reality, making it impossible to objectively validate one’s own experiences or knowledge

He also suggested that people living under continual fear often become desensitized to violence, increasingly rigid and conservative in their beliefs, paranoid, and obsessed with revenge. That pent-up anger, combined with the frequent rumours that helped reinforce paranoid fears, helps explain why rioting and vigilante justice often breaks out in these communities. This mob violence can strike innocent scapegoats just as easily as actual perpetrators (including attacks on “witches,” "heretics," or anyone else perceived as an outsider).

So how vulnerable are most people to the effects of continuous traumatic stress? The anticipatory anxiety that comes from worrying if a threatening situation will occur, whether that fear is realistic or not, can permanently transform how people respond to threats. Even leaving high-risk communities may not help relieve the long-term effects of stress, because many people retain their past home's cultural values, some of which can cause conflicts in their new communities. And, as our world becomes more interconnected, leaving high-risk environments behind entirely becomes more difficult than ever.

Chronic traumatic stress is a reality for millions of people worldwide. We need to recognize that its effects can last a lifetime, especially for people with no realistic chance of escaping the traumatic environment in which they live. Coming to terms with the possibility of further victimization happening at any time is a challenge that cannot be taken for granted.