From Atrocities to Recovery

What soothing mothers know about trauma recovery

Posted Aug 12, 2019

As mass shooting events follow one another to no end, more and more people are exposed to atrocities: death, injury, disfiguration, life threat, and evil intent, all done for reasons that reason cannot grasp.

From a distance, we can search for reasons, play the blame game, talk highly about 'common denominators' of mass assassins, denounce assault weapons' availability, or discuss alienated members of societies.

From within events, that is, for those laying on the pavement, hearing the shooting, seeing the blood, feeling the dread; or those whose son, daughter, lover or mother were hit, the horror is total, beyond explanation and reasoning.

Or is it total? Aren't there better memories (sort of) to lean on? The man who shouted, "Lie down!" before anyone understood what was going on, and saved lives. The dating partner who protected his girl's body with his own. The teacher who locked a classroom door?

Yes, there might be some, but they don't take away the totality of the experience, a totality etched into in survivors' memory, too horrifying to remember, too intense to forget. A totality made of dominating fear, intolerable sounds, and grotesque views; of seconds that last for hours; of being wide awake in the midst of a nightmare.

Early in my career, I believed in the association between fear and trauma, that is, in fear-driven-memories etched forever into an all excited amygdala, care of stress hormones' surge, or lack thereof. It was a good theme to study and publish about, and, with other fear-and-amygdala researchers, we scored significant success and good standing. It didn't matter much that, in one study, stress hormones went up and in another down: Everyone was listening, waiting for the truth to come down the Sinai mountain.

That was until Ida (not real name) told me her story: She was with a boyfriend, shopping in Jerusalem Downtown Triangle. He hurried to fetch a place in an often-crowded café in the Hillel pedestrian street, leaving her to browse a little more in the, running parallel, Shamai street. It was a bright afternoon. The explosion was brutal. The year was 2002. Suicide bomb attacks occurred monthly – or weekly in bad months. Ida – and everyone around her immediately recognized the sound and the few seconds of deafening silence that followed. She then ran into Hillel to look for her friend. She eventually found him, unharmed. She then lifted her eyes - and fainted. All around her were bodies and body parts, torn clothes hanging from tree branches and blood. Too much to bear.

She was picked by an ambulance and brought to our emergency room in paralyzing panic. She quickly improved and was conscious and communicating a few hours later. For the duration of her stay with us, however, - an entire night - she wouldn't close her eyes. With eyes shut, the 'images' were coming back, intolerable. She nonetheless told me that, walking into Hillel Street's chaos, she experienced no fear and hadn't felt threatened. "The explosion was over," she reasoned, "there was nothing to be afraid of, and I had to find my friend."

Ida's story taught me that, in mass casualty events, grotesque atrocities are the essence of psychological trauma. Fear learning may fade out with time. Memories of atrocities do not extinguish well.

With memories remaining, how does recovery occur?

When they hug a panicked child, soothing mothers often say, "It is over now." 

Mira (not her name) was sitting at a table in a Jerusalem wedding, tired of dancing when the center floor collapsed. She softly fell into the pile of rubble that formed a funnel on the two levels below. Barely harmed, she found herself in total darkness, water pouring from torn tubes above, and men voices rushing everyone out: the gas could explode instantly!

It was only when she got out that Mira realized that her younger sister was missing. She last saw her on the center floor, madly dancing, as young people do. 

Mira tried, but they won't let her in again. After agonizing hours, she returned home alone. She developed the most intense post-traumatic agitation that I ever saw. She had "PTSD" – if you insist on cataloging people – but it was much more. It was the worse-of-kind complicated agony, worsened by Mira, earlier that evening admonishing her reluctant teenager sister to join her and 'have some fun.' 

I was her therapist, but prescribed therapy didn't help. Mira helped herself out, with me witnessing. In her extreme agony, she became irrational, as people in great pain are. On her way out of the rubble, she could have stepped on her sister's body, or, worse, climbed over a chair or a piece of wood that stabbed her sister to death. 

One often finds such delusive thoughts in survivors – or relatives: "He had been an athlete all his life and had a slow heart rate: perhaps the medics missed him for dead?" asked me Itamar's mother, three years after his death in a hostage-taking incident, volunteering a thought that has tortured her day and night. I had been the medic on-site, so she knew whom to ask. Itamar had a gunshot wound in his chest with an extensive exit wound at the back. I had checked that in the morgue.

In his seminal 1944 article "Symptomatology and Management of Acute Grief [1]" Lindemann brings a clinical vignette of "A woman, aged 40, who lost her husband. "..she described her painful preoccupation with memories of her husband and her fear that she might lose her mind. She had a vivid visual image of his presence, picturing him as going to work in the morning and herself as wondering whether he would return in the evening, whether she could stand his not returning, then, describing to herself how he does return, plays with the dog, receives his child.."

With me witnessing through listening, Mira went on to find out if she was her sister's eventual killer. With the energy of a drowning person scrambling to shore, she spotted and 'interviewed' one by one every remaining survivor and rescue worker, sharing her findings with me, weekly. She finally found the municipality's engineer who oversaw the rescue effort, and he told her that, like most of those who danced in the middle of the hall, her sister's body was buried under heavy blocks of cement, crushed as it were. 

"It is all over now," she told me. I couldn't have killed her – or rescue her. 

Eddie (alias), a police officer injured in a bombing incident, managed to pull himself out of the burning bus and set down leaning on a stone fence. As he left the bus, he saw a woman sitting by the door, "gray like ash." In his words, he "failed to pull her out to safety," which was endlessly agonizing. "She was probably dead," he acknowledged, "but I continue to see her eyes staring at me." For him, it was never over. He may still be seeing a professional for post-traumatic stress symptoms.

I could go very intellectual at this point, or haughtily professional, mentioning that Ida had a dissociative response, Mira was processing a grief reaction via self-exposure and Eddie wasn't. I could also refer you to my friend Israel Liberzon's brain-imaging studies showing that PTSD essentially involves a failure to update your life context, such that, despite trauma being 'over,' and current reality safer, the brain doesn't recognize it (we wrote that together in a recent summary article [2].

But I want to leave the readership, at this particular point in time, with the immediacy of experiencing atrocities, and the simplicity of soothing mothers' solutions: "It is all over now."

If even amid agony and piercing memories, you realize how true it is that time passes and nothing remains "here and now," then trauma and atrocities will lose their grip on your life. Sorrow could be there. Eventually also disbelief. Anger sometimes. Piercing loss. Trauma. But your life will be here. Yours.

To do that, listen to children playing (Not with their smartphones! With other children!) or water pouring from a faucet, or your breath, or the wind in the woods. This is the reality. Everything else is over now.

Mothers do that every day. Fathers too. Therapists try as well. You can.  

References

1. Lindemann, E., Symptomatology and management of acute grief. 1944.Am J Psychiatry, 1994. 151(6 Suppl): p. 155-60.

2. Shalev, A., I. Liberzon, and C. Marmar, Post-Traumatic Stress Disorder. N Engl J Med, 2017. 376(25): p. 2459-2469.