The Unaddressed Moral Dimensions of Trauma

While I was in college, I worked on a unique unit in the Northampton Veterans Administration Hospital dedicated to the treatment of young veterans returning from Vietnam. It was 1971, the height of the Vietnam War, in which 59,000 Americans and millions of Vietnamese would die, and nearly a decade before PTSD would be recognized as a clinical diagnosis in the DSM.

One afternoon, a young African-American veteran, Peter, agitated and distressed, lost his temper and stood up in the middle of a group session, hands clenched. Immediately, the psychologist, Roger Freiban, jumped up and stood face-to-face with him. It felt explosive. Freiban told him to get control of himself. He then asked him why he was not willing to help himself get over the war.

I watched, scared but riveted. Peter answered, speaking inches from Freiban’s face, “I’ll get over [it] when you help me stop the war.”

Over the following 45 years, I have worked clinically with victims of severe psychological trauma, but, in that moment, I learned something essential about the heart of post-traumatic stress disorder that has been ignored and obfuscated by decades of narrowly focused clinical expertise and extravagant scientific research.

What Peter voiced in the midst of his suffering was a deep moral response to injustice and violence. Ironically, this most human of moral reactions has been written out of how we understand PTSD and erased from the great clinical breakthrough that the PTSD diagnosis once represented. In spite of Freiban’s well-intentioned admonition, Peter instinctively knew healing his own suffering was linked to facing the ongoing injustice that caused it.

In the decades following 1979, PTSD has been recognized not only as a diagnosis but also as a cultural meme, of neurological dysfunction, an excited amygdala, and an overly active hippocampus. However, extensive research also shows that PTSD is a “socially mediated phenomena.”[i]

We know, although seldom acknowledge, that well beyond biological substrates for PTSD, people live by moral codes that shape how we interpret our own symptoms as well as profound responsibilities to care for others. Following trauma, we respond not only with nightmares and flashbacks, but also respond to trauma’s violence, injustice, betrayal, and indecency.

The sense of violation generally activates a moral response and a call to action that is as strong as the fear and anxiety response. A shooting, mugging, or rape generates fear but not more significantly than it generates a deep, troubling, and enduring sense that, “This is not right! This should not happen!” If we don’t include this moral dimension, we will not understand PTSD.

Nonetheless, for four decades, PTSD has been taught exclusively as a disorder based on a neurobiological mechanism of anxiety. This defies common experience because every day, in public, we see people responding to horrible traumas with unfettered declarations of moral outrage, protests, and demands for justice and change. They may have anxiety, but they take action with a moral protest which is not predicted nor admitted by the neurological mindset we bring to studying and treating PTSD.

On the television news, we see people like Kim Odom, a mother traumatized by the random killing of her 14-year-old son in front of her house. In the days that followed, she said repeatedly, “No mother should ever have to experience this.” When I recently interviewed her, in a small church near Boston, she pointed to the words of Martin Luther King, Jr. written on the wall: “Our lives begin to end the day we become silent about things that matter.”

The trauma of losing her beloved son led her to research gun violence. She then began to organize her community and speak out to change gun laws and gun trafficking in her neighborhood. She left her job, and rather than turn within to mourn her loss and heal from the trauma in private, she moved out toward it, boldly searching for what it means for her.

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“Why,” I asked her, “didn’t you just want to heal and move on?”

“Exactly because of what it did to me. I cannot ignore what I now know. How could I turn away from my responsibility to all the Stephens and Stephanies in this community?”

On February 14, 2018, a mass shooter murdered 17 students at Margery Stoneman Douglas High School. David Hogg, a survivor of the mass shooting and now an organizer of March For Our Lives, wrote, “When you open your eyes but the nightmare doesn’t go away, you’ve no choice but to do something. Our first job is to remember. Our second job is to act. Remember, act, repeat. Since that day, none of us are the same. But we are alive. And in memory of those who are not, we will remember and act for the rest of our lives.”[ii]

Victims of trauma can become morally activated to work for change throughout our society. I interviewed Alison Malmon, the founder of Active Minds (an organization supporting mental health awareness and education for young adults). Malmon’s story began when she was a junior in college and her beloved older brother committed suicide after struggling with depression. At his funeral, she realized that her brother’s life could have been saved if there were a greater awareness and less stigmatization of depression on college campuses. “After my brother’s death, I resolved—no matter what—to do something to change the way we approach mental health in this country.”

In the community and in my clinical practice, I continually find aspects of this compassionate response to trauma in spite of the suffering and symptoms. I have come to call these people "Menders," borrowing from a kabbalistic notion[iii] that the wholeness of creation was shattered and remains to be mended by human action. I chose a spiritual label because it matches the feeling expressed by many people who respond to trauma’s shattering of their personal world with an “expanded sense of self”[iv] that changes who they are. Menders change how they view themselves, from a limited Self to an “expanded Self”[v][vi][vii] that includes its fundamental sense of Self as an inseparable part of a community to which it feels responsibile. They experience a sense of responsibility that leads them to care for others, awakening an urge to restore the moral universe.[viii]

The construct of becoming a Mender is not limited to a theological framework; the moral responsibility felt by many victims has substantial support, once one looks outside of the treatment models for PTSD. These include frameworks that are philosophical,[ix],[x], developmental,[xi] and which include psychological research, particularly on altruism[xii],[xiii].[xiv],[xv] including Dr. Ervin Staub’s crucial research on “altruism born of suffering’[xvi]. Their response may be an expression of evolutionary behaviors that advantage us in the care for others in danger [xvii],[xviii], just the opposite of what we have come to believe about PTSD.

To this matrix, we can add the wider literature on The Justice Motive[xix] that propels people to act beyond their own self-interest. And the vast entertainment industry continually showcases real or fictionalized Menders: at the time of this writing, a new movie, Till, describes how Emmitt Till’s mother responded to the lynching of her son, taking the horror and trauma back to the society that fostered it in hope of change.

The concept of “post-traumatic growth,” initiated by the research of psychologist George Bonanno in 2004, expanded the response to stress beyond pathology to include many types of resilience and growth. Richard Tedeschi and Lawrence Calhoun then coined the term "post-traumatic growth" and outlined seven areas of growth that might spring from adversity, including compassion and altruism, as well as spiritual development and creative growth.

Tedeschi and Calhoun point in the right direction here but their concept has had limited impact on the core of trauma treatment because it leaps from the complex of suffering to what seems like a positive opportunity far from the moral responsibility evinced by Menders. Theirs is not a celebrated resilience and beneficial growth resilience but an accepted burden. While they are examples of transformation in the PTSD-Growth model, Menders are understandably suspicious of the “good-news” potential of moving beyond trauma. They move toward it, accepting that the responsibilities of what they have endured is about others as much as about their own “growth.”

We can comfortably appreciate that the tremendous work done by clinicians and researchers since 1979 to create the clinical model of PTSD has revolutionized mental health, and has also conquered our culture. [xx] It has done so by ignoring what Menders actually say. The cost of insisting on our model is a narrowing of our treatment universe to an artificial picture of what is real and deserving of attention. Limiting ourselves to treating anxiety, we remain uninvolved in confronting ills and dangers in society, even while Menders do the heavy work of seeking justice and change.

While we, as clinicians, expose ourselves to the gruesome consequences of violence and trauma in the quest for healing and hope, we deprive ourselves of facing the difficult questions of a deeper hope entailed in asking, “Who shall I be?”

Where do we start? By taking Menders seriously. They have much to teach us about a healthy, human response to violation. We should consider the caring parts of our humanity that surprisingly emerges, leading Menders to become activists, caregivers, writers, organizers, and volunteers. It might re-invigorate hope for therapists past the limited promises of treatment,[xxi] re-imagining it as an active hope in making the world safer and more moral for others.[xxii]

Some view the horrific impact of trauma as unspeakable.[xxiii],[xxiv]. Yet, the moral protest of victims of trauma, such as Peter, requires us to ask whether the heart of trauma is unmentionable or just inaudible. The structural revolution that began with the diagnosis of trauma needs to move forward. Menders point to the need to reimagine the role of therapy in mending the world.

This post is part 1 in a series of articles on Menders. Click here to read part 2.