The Real Story of PTSD
Psychiatry is a trauma-informed practice.
Posted Aug 20, 2018
I was driving in Cambridge in a blinding snow storm on Thanksgiving Day, 1970. When I braked to slow down, my car didn’t stop, it just kept on skidding. I slowly continued on. When I approached the stop light at Memorial Hall, I braked far in advance of the light and skidded twenty feet until the car thankfully stopped. I was worried that someone coming up from behind and would crash into me. I couldn’t see out my rear view mirror due to the snow accumulation, so I rolled down my window and stuck my head out to watch what was happening behind me. At that very moment, somebody smashed into my car. My head hit the window frame and knocked me out. The next thing I knew a stranger was sitting in my passenger seat writing down his insurance information. I didn’t know how he got there. Then he was gone. I sat stunned for a while, trying to focus my mind. Finally, I gathered myself together and drove over the bridge to the Mass General Hospital, semi-blind, to have my concussion evaluated.
For the next few months, whenever I slowed down for a stop light, I always stared back in my rear-view mirror, terrified that I’d be hit again. This wasn’t a voluntary decision. I couldn’t not do it. I watched the car behind me until it came to a full stop. The absence of snowy conditions made no difference. This mysterious reality held sway for many months. I was, in fact, suffering from the consequences of trauma.
Something in me changed. What was it? My reality changed. How did this happen? By understanding what this was about opens the door to understanding major trauma of all kinds.
Human consciousness is organized as a drama in the theater of the brain which coalesces at around six years old. The brain continues to write its narratives all through our lives. In it, emotional experience is mapped through the limbic system. A formative play written with good enough loving will promote authenticity and love. Our inner brain theater corresponds to the vagaries of outer reality and conforms to our being and our functioning.
The key consequence of trauma is that it overrides the original primary play and rewrites it. In so doing, the overwhelming violating abuse of the traumatic story generates a new and darker narrative, which is mapped neurally with serotonin, cortisol, and adrenaline.
In this new drama, we not only experience the terrifying feelings; it shifts our perceptions; and our sense of self.
First, let’s look at my traumatic story. My original driving reality was that it was safe and predictable that I could step on my brake, slow down, and predictably come to a stop. I was in control of the car. However, in the incident, my brakes didn’t work - skidding a long ways was very unsafe; it became a world of danger – there was no control; the violent crash was unpredictable and came out of nowhere; I was helpless to prevent it. It was terrifying; I could have been killed. The trauma overrode the original safe and controlled play, and rewrote the script. In my brain, I was inhabiting this new, dangerous and terrifying reality.
The question is how can people recover from the effects of trauma? Recovery is based on taking leave of the new narrative, and returning back to the original one? How can this take place?
Initially, from the brain change I was actually denying reality. I was, in fact, safe, and I was actually in control as I approached a stoplight. But this was no longer a reality I believed. I was experiencing and inhabiting this other brain created script. I rationally tried to talk myself out of my fear. I knew the truth, but, it didn’t work. I came to feel angry that I was subject to this irrational fear and there was nothing I could do about it. But that didn’t change anything. I gave up and resigned myself that this as going to be my new lot in life, staring out my rear view mirror every time I stopped. I accepted that I was powerless to change it. I went on this way for months. One day I noticed that wasn’t looking through the rear-view mirror anymore. The traumatic play had lost its power and I no longer inhabited it. The trauma was over.
I had shifted back to my old narrative of taking for granted safety and predictability. The deactivated experience, like all mapped experience, however remained present in my limbic brain mappings and is still available to be triggered. Life is hard and scars inevitably remain. Sometimes, even now, on a snowy day, I still find myself looking back in my mirror reactively.
In fact it wasn’t really the passage of time that deactivated my car crash story. A newly written play operates timelessly. I didn’t need an intervention, and was able to mourn it on my own as I repeatedly faced it. That does not happen with major trauma. One is seriously lost in a hellish state.
By understanding the etiology of trauma we can see that the process of recovering from trauma is to deactivate the rewritten new play. That is accomplished by mourning the traumatic narrative. Mourning a narrative is the universal agent of change. Mourning is really about a story. Of course it is most associated with grief. In grief, one mourns the deeply-held old play of a life together with a loved one in order to accept a new play that the loved one is gone, which is emotionally denied. One holds onto the old play. Once accepted after denial, bargaining, rage and sadness, this then allows the new reality to be accepted. The past life together can then re-emerge and be present in memory and be carried in one’s heart.
In post trauma one does the opposite: one mourns the new traumatic drama that has been activated so that it will get deactivated and lose its power, to get back to the original play. This is accomplished by facing the trauma again. In a safe way one has to relive the new drama again, over and over. And face and mourn the pain of terror, abuse, fear, and feelings elicited in the body. This reverses the belief in the new story and frees one up for regular reality to emerge again. Major trauma always requires helpful psychiatric intervention. It can’t be done alone. Recovery from trauma isn’t always perfect. It just has to be good enough.
My car crash story is a minor example of trauma to illuminate its central paradigm. Trauma overrides and rewrites a more dangerous and darker internal drama, which is then inhabited and believed.
With major trauma working with a therapist is necessary to deal with, face and relive the traumatic situation in order to mourn it and return to the old narrative.
What is the impact of trauma on the initial writing of the play of consciousness. Trauma by definition is abuse and deprivation. Child abuse–physical, mental, sexual, and emotional neglect, write plays that are directly pernicious as sadistic aggression is infused into the primal play. It’s cortical mappings reflect this trauma as mediated by serotonin, adrenaline and cortisol. When written from trauma it will generate a darker narrative and a damaged play.
It is trauma itself which warps the writing of our formative play. Likewise it informs our developing personalities with a sense of badness and shame in our identities, and interferes with attachment. As such it is the cause of future psychiatric issues. The specific and responsive treatment is psychotherapy, where the trauma is mourned in in the context of safe emotional holding with the therapist. In general, the earlier in life one is subject to trauma, the more damaging it is. I have seen incestuous sexual abuse staring at age four. He was unable to retain the intactness and cohesion of self, which generated a catatonic schizophrenic response. Additional trauma in the rest of childhood, adolescence, and adulthood rewrites the already formed internal drama.
Post traumatic effects are such a major issue in our world. My "driving" story is but a very minor example of the consequences of post trauma. Every day the news shows major trauma–rape, wars, child abuse and neglect. Understanding and addressing trauma is the key to psychiatry. Space dictates that I won’t delve into the specific traumatic consequences of rapes, and child abuse here. I will limit myself to some observations about war trauma. The other major traumas operate in parallel ways.
Veterans have seen and done things in combat that is so outside the experience of regular life. War is inherently kill or be killed. It is the extreme of violence and sanctioned murder. Combat veterans are very prone to suffer post trauma. Combat scenarios are commonly replayed dissociatively full of danger, and horror. They commonly override reality and can feel like it is happening in the present, as the soldier is lost in traumatic war reality. Veterans inhabit their major traumatic play. The power of war trauma is so destructive and overwhelming. Veterans require psychotherapeutic intervention to deal with the overwhelming pain.
The traumatic situation needs to faced and worked through for the soldier to recover and return to his regular drama. The mourning of such situations is a very delicate enterprise and needs to be handled very respectfully. Facing and going back through the experiences is the treatment. It is very difficult. As I said, such experiences leave scars, and people can carry significant damage. Often this is additionally complicated by drug and alcohol abuse,. The suicide rate among veterans is very high. In 2012 more soldiers committed suicide than were killed in combat in the Iraq war. In military records from 1979–2014, an average of 20 veterans a day die from suicide. In another study, a veteran commits suicide every 65 minutes (The United States Department of Veteran’s Affairs). This is a public health emergency.
As is currently in the news, the traumatic separation of children from their parents at our southern border scars these kids deeply for life. It is recognized that their brains change from this traumatic separation. The brain change is actually the new play written from the deprivation of love and the absence of loving safety and holding, that is the basic parental provision. Their brain mappings reflect such enduring emotional trauma. There is no way America should ever contribute to such a travesty.
Suffice it to say that post traumas in all walks of life are the major issue of our times. Trauma and its effects are built into the basic way the brain operates. Traumatic effects are universal. They are not a mystery. And the process of recovery reflects what it takes to undo the damage. When we understand the nature of trauma, the necessary treatment is clear. Psychotherapeutic mourning and reliving, is the healing process to deal with the suffering and struggles on every level.
Psychiatry is a trauma informed practice. We as a society need to refocus our treatment priorities.