On the evening of March 26th, 2012, Yvonne Kent Pateras suffered a massive hemorrhagic stroke, leaving her unable to speak or move. She also experienced “locked-in” syndrome. These are Yvonne’s own words regarding the traumatic stroke she experienced:
“I had the experience of knowing what was happening to me from the beginning. I felt a sinus rhythm in my head becoming louder. I tried to center myself, but it was over before I had time to act. I opened my mouth to shout for help-the noise that left my body was the most primordial noise. My beautiful voice had been replaced by the noise of a wounded beast. I wouldn’t hear another word for the next for 3 months. I knew that I had not only suffered a stroke, I was paralyzed and locked in. I couldn’t tell my family that I knew what was going on. I tried to just keep my neurons busy and alive. I did simple counting exercises to stay calm and occupied-to keep my adrenaline levels under control. I was determined to survive.”
After four months in the hospital, to everyone’s surprise, and with extraordinary courage, Yvonne was able to regain speech and movement. Yet, in a span of approximately ten months, she suffered three ischemic strokes, and another hemorrhagic one. Since different kinds of strokes require different treatments, medical care was challenging.
Yvonne persevered. She said that recovery required “endless effort.” She can now walk without difficulty. She has a light speech impediment and lost some functioning in her right hand.
As we now know, with post-traumatic growth, trauma like this can often serve as a catalyst for a profound awakening to an emotional and spiritual transformation. Yvonne’s awaking came in the form of writing poetry.
“Following the stroke I went through a spell of re-learning, like being born again. Feelings were overpowering my mind’s concentration and understanding. Writing verses were facilitating the expression of my feelings. Publishing my work also gave me upmost satisfaction, particularly as the response by other stroke victims was so moving. Poetry takes the weight off my legs, gives me wings!!!”
You can find Yvonne’s poetry in her book, Stroke Journeys, by clicking on this link.
There is research that those experiencing PTSD reported improved well-being in response to poetry therapy. This might be the case because a hallmark of having experienced trauma is the subsequent difficulty processing the experience, which results in avoiding and suppressing associated emotions/memories.
Poetry therapy has provided an outlet for those suffering with PTSD to start to integrate many of these feelings, and even more so, to start to reframe the traumatic experience.
Poetry therapy itself is a bit abstract to describe, but there are a few ways to engage with it. Here is a multi-model poetry therapy practice developed by Nicholas Mazza, the founding and continuing editor of the Journal of Poetry Therapy.
According to Mazza’s model, poetry therapy involves three main components:
Receptive/prescriptive: This part of therapy involves the clinician/therapist reading a poem out loud, and then subsequently encouraging the client to react to it, either verbally, non-verbally, or both. The therapist might even prompt: “Is there a particular line in the poem that resonated with you?”, or “I noticed you started to become teary-eyed when I read this line…”
Expressive/creative: This entails actual creative writing. The therapist promotes stream of consciousness writing that might aid in discovering blocked emotions, parsing felt emotions, or retrieving memories that are difficult to articulate. The therapist might offer a prompt to help someone get started.
Symbolic/ceremonial: This includes working with metaphor/simile to help further explain emotions that are hard to describe in a more literal sense. The ceremonial part may consist of writing a letter to someone they may have lost and then burning it.
The efficacy of poetry therapy is still being studied. Most of the empirical evidence for its effectiveness comes through James Pennebaker’s (a pioneer in the field of Positive Psychology) work in the therapeutic use of expressive writing. His studies have indicated that the use of expressive writing, even for as little as 15 minutes over the course of 4 days, resulted in positive health effects. In addition, his initial work dealt with the use of expressive writing to heal wounds from traumatic stressful events.
One case in point is that in the aftermath of 9/11, poetry was utilized as a healing mechanism. According to a New York Times article on October 1, 2001:
“In the weeks since the terrorist attacks, people have been consoling themselves—and one another—with poetry in an almost unprecedented way … Improvised memorials often conceived around poems sprang up all over the city, in store windows, at bus stops, in Washington Square Park, Brooklyn Heights, and elsewhere. …”
In some ways poetry gives us the way to speak about the unspeakable. It is more and more common for those suffering with medical challenges to write their story, many times in poetic form, to aid in their own healing. As always, it is crucial to note that just like with mindfulness approaches to trauma, poetry therapy is most often used in conjunction with other therapies.
On a personal note, I’m particularly drawn to this type of therapy and recently started studying for my MFA at Queens College. I am touched by the profound pain that is both individually and collectively felt, how this pain can displace someone from others and their selves, and yet, the profound capacity for resilience, healing, and growth. Aside from writing my own work, I hope to employ poetry as a technique to help my clients say what they couldn’t otherwise say.
Here’s an example of a poem that I recently published in the British Journal of Medical Practice in this vein:
By way of full-disclosure, I’m tearing up as I write this. In the last few years alone, we have seen a rise in mass school shootings; that is, the death of innocent children, adolescents, and their adult mentors/teachers in cold blood.
I too, continue to grapple with the snuffing out of so many lives, and the lack of response to these deaths that somehow don’t seem to create change. Actually, most school shootings aren’t even talked about.
According to a non-profit that tracks gun violence in America, as of April 20th 2018, there have been 17 shootings since the February shooting at the Marjory Stoneman Douglas High School in Parkland, Florida which launched the Never Again movement. You read that number correctly.
I don’t want to get too political here, but as a mental health practitioner and staunch advocate, I want to go on record saying that gun violence is not a mental health issue. Is mental health sometimes a component in these shootings? Sure. Yet, let’s be clear. The rise of school shootings is not attributable to a national mental health crisis. It is far too easy for someone to get a gun in this country. No matter which side of the gun control debate you are on, it is insulting with those who suffer with mental health to be accountable for this.
Myth: People with mental health problems are violent and unpredictable.
Fact: The vast majority of people with mental health problems are no more likely to be violent than anyone else. Most people with mental illness are not violent and only 3%–5% of violent acts can be attributed to individuals living with a serious mental illness.
Now that I made that clear, I want to discuss PTSD in the context of these shootings.
Undoubtedly, these shootings will impact the victim’s families, friends and communities forever – some might even develop PTSD, as they are certainly at risk, especially those who survived and witnessed the events.
Of course, what we have seen come out of the Parkland shooting is no less than a post-traumatic growth response (learn more in my PTSD packet); while this doesn’t mean the survivors aren’t deeply suffering, many have been able to utilize this suffering as fuel to advocate for gun control in a way it seems that no other organization or group of individuals has been able to before. Their efforts have affected real change, and I pray the change continues.
What I want to address is the idea of virtual trauma. We, as a nation, are privy to these events either in real time, or moments after. Sometimes, the media coverage is more gruesome and detailed than at others. Regardless, we, as a nation, are at risk for PTSD even if we were not directly affected. Whether we were involved or not, these accounts bring up a real sense of danger and deep concern about our and our loved one’s safety.
According to research in the early 2000’s, approximately 15 to 36 percent of the population that did not experience violence directly, will still develop post-traumatic stress disorder (PTSD) symptoms.
The impact of trauma has a wide range. Even just hearing about the event can shatter our assumptions about our world. You see, tragedies like these reverberate in the hearts and minds of much of humanity, as it rips through the basic foundation that we lay our trust upon. That is, we don’t expect people to just shoot other human beings in cold blood. So, it seems that trauma’s effect surpasses the psycho-neurobiological impact of experiencing a direct threat to one’s own life.
Undoubtedly, these assumptions aren’t necessarily true, but can be healthy and adaptive. For many of us, these very assumptions help us get out of bed in the morning and actually go about our lives and are necessary for meaningful experiences and interpersonal relationships.
The figurative ground we walk on becomes shakier and shakier with each shooting. If you notice that after an event you start feeling more irritable, anxious, like you have lost control, depressed, have trouble sleeping and anything else that is not your baseline and does not seem to be going away, please reach out for help.
Children inside U.S. Customs and Border Protection detention facility at the Rio Grande Valley Centralized Processing Center in Rio Grande City, Texas. CBP/via REUTERS 2018
Complex trauma (C-PTSD) is still, relatively, a new term. It was coined in the 1990’s by trauma expert Judith Herman to connote repeated, prolonged (protracted, chronic) trauma. Another name sometimes used to describe the cluster of symptoms referred to as Complex PTSD is Disorders of Extreme Stress Not Otherwise Specified (DESNOS).
In reality, C-PTSD is still actually just a proposed disorder: because 92% of individuals with Complex PTSD also meet diagnostic criteria for PTSD. Complex PTSD is not added as a separate diagnostic classification.
I’m included in the group of many clinicians, however, who render it extraordinarily useful as a separate diagnosis. The current PTSD diagnosis often does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma. While some symptoms may overlap, there are additional possible symptoms as well as possible conceptual differences.
Certainly, more precision in diagnosis leads to more precise treatment, and treatment for PTSD often fails with those experiencing C-PTSD. So, regardless of how one’s cluster of symptoms is labeled, it is crucial for a clinical to know the hallmarks of C-PTSD.
Another trauma expert, Dr. Christine Courtois, wrote that complex trauma is “a type of trauma that occurs repeatedly and cumulatively, usually over a period of time and within specific relationships and contexts.” In her well-known article, Understanding Complex Trauma, Complex Reactions, and Treatment Approaches, Dr. Courtois continues to summarize the characteristics of complex traumatic events as:
Repetitive, prolonged, or cumulative.
Most often interpersonal, involving direct harm, exploitation and maltreatment including neglect/abandonment/antipathy by primary caregivers or other ostensibly responsible adults.
Often occur at developmentally vulnerable times in the victim’s life, especially in early childhood or adolescence, but can also occur later in life and in conditions of vulnerability associated with disability/disempowerment/dependency/age/infirmity, etc.
While there are many types of repeated trauma, it is most often experienced by children who are victims of long-term physical and/or sexual abuse. It also can include: experience in a concentration camp, POW situations, long-term domestic violence, prostitution/brothel situations, and organized child exploitation rings. In all of these circumstances, according to Dr. Herman, the trauma victim is generally held in a state of captivity, physically or emotionally, and in a situation in which there is no actual or perceived way to escape.
As I write this, I humbly and painfully think about how the current #BorderCrisis is a #MentalHealthCrisis, and how this will impact these children long-term. At the heart of C-PTSD is the idea of emotional neglect. When it comes to human beings making emotional attachments and proper development – we need more than just a bed to sleep in.
C-PTSD is not a psychological death sentence, so to speak, and there is treatment, but it needs to be recognized in general, and particularly with regards to what is going on at the border. People need to know that these children need help, and like any challenge, the earlier there’s intervention, the better.
People who experience chronic trauma often report symptoms that are additional to those seen in those diagnosed with PTSD. Dr. Herman initially identified this list of additional symptoms, which aren’t all included in the diagnosis of standard PTSD:
Difficulty Regulating Emotions: May include persistent sadness, suicidal thoughts, explosive anger, or inhibited anger.
Alterations in Consciousness:Includes forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one’s mental processes or body (dissociation).
Alterations in Self-Perception:May include helplessness, shame, guilt, stigma, and a sense of being completely different from other human beings.
Distorted Perceptions of the Perpetrator:Examples include attributing total power to the perpetrator, becoming preoccupied with the relationship to the perpetrator, or preoccupied with revenge.
Difficulties with Relationships to Others:Examples include isolation, distrust, or a repeated search for a rescuer.
Somatization and/or medical problems: Somatic reactions may relate directly to the type of abuse suffered (or any physical damage endured) and can involve all major body systems.
Alteration in One’s System of Meanings:May include a loss of sustaining faith or a sense of hopelessness and despair.
Personal Clinical Note: Patients of mine who have experienced complex trauma, consistently describe feeling a lack of sense of self, very low self-esteem, extreme self-loathing, difficulty in interpersonal relationships, and an inability to discern between any real or potential threats to their minds and/or bodies. Often, and while this can happen in other diagnoses and from enduring a solitary trauma, it is more likely for someone who is chronically traumatized to engage in self-destructive and self-mutilating behaviors.
Many C-PTSD researchers and clinicians report that using the same treatment paradigm as one would use for PTSD (see below), might not cut it, and might even prove problematic. In response to this, the recommended course of treatment “involves the sequencing of healing tasks across several main stages of treatment. These stages include (1) pre-treatment assessment, (2) early stage of safety, education, stabilization, skill-building, and development of the treatment alliance, (3) middle stage of trauma processing and resolution, and (4) late stage of self and relational development and life choice.”
Did you know that Emily Dickinson can change your neurophysiology? Well, maybe not Dickinson herself, but certainly the poetry she wrote.In 2013, researchers at the University of Exeter had subjects take functional MRI’s (i.e., a tool that allows the brain’s activity to be seen in real time) while they read from texts that they had never seen before, these included works of non-fiction, fiction, and poetry.The results indicated two main things:
The brain parts activated in response to reading the poetry were the same as those activated in response to hearing beloved music.
The brain’s response to poetry mimicked the brain “at rest”. That is to say, the same way the brain looks when we feel introspective.
Since humans have an innate response to rhythm and sound, it seems to make sense that poetry and music would align in the brain. Poetry as an art form predates literacy, and poetry was first employed as a way to both remember and convey oral history. Poetry is not much different than music in this way as it is found in ancient hymns and chants that delineated cultural traditions.
In addition, it appears that poetry also serves as a haven for a reflective, contemplative, and daydreaming brain. Therefore, poetry might also prove beneficial to the brain on a cognitive level.
In a 2006 study, researchers observed how brains reacted to Shakespeare’s linguistic craftiness, including his pun-making and also a technique called ‘functional shifting’ during which Shakespeare uses a noun as a verb. When the grammar shifted, the brain “lit up” and responded in its attempt to make sense of the unusual use of the word. This type of stimulation is beneficial to long-term cognitive functioning. Learning, especially learning that is not passive, is neuroprotective.
In 2013, researchers had subjects read both original Shakespeare texts as well as versions that had been translated to be more easily understood by modern audiences. When reading the complex originals, researchers noticed a more intense reaction from the language centers of the brain (for most people, their left hemisphere) as subjects strove to make meaning of the text. Furthermore, during the same study, researchers noticed that when it came to reading Shakespeare’s original poetry, brain regions related to personal and autobiographical memory were activated (found grossly in the right hemisphere).
These findings point to poetry’s ability to foster both a personal connection to a poem, as well as create a sense of self-reflection. To take the latter even further, we can extrapolate that poetry triggers what is called a “reappraisal mechanism,” or the process of reflecting and sometimes rethinking our own experiences in the context of what we are reading.
As one of the authors of the study, Professor Davis, put it:
“Poetry is not just a matter of style. It is a matter of deep versions of experience that add the emotional and biographical to the cognitive.”
So, reading poetry, especially poetry that keeps us on our toes linguistically, is a portal into a space for our self-reflection and growth, as well as serving as a beneficial tool to keeping the brain vital.
At the very least…poetry is like music to our ears!
In honor of International Day of Happiness: Tuesday, March 20, 2018
Ever since brains have evolved enough to desire the abstract feeling of happiness, there’s been both a pursuit of that feeling, and the difficult task of defining exactly what it is. Happiness is known enough to those who feel it, but intangible enough to lack one concise, universal and objective definition.Scientists and psychologists have at least agreed upon its multifaceted and subjective nature, and have noted such words as “joy”, “fulfillment”, “well-being”, “contentment”, and “satisfaction” to be somewhat synonymous.One thing is for certain though, its pursuit is widespread. So, how does one find this state of being? Well, there is an entire field of psychology devoted to this answer, and it’s called, aptly, Positive Psychology. Trying to “Find Happiness” is a common theme in the work that I do, and I have discovered that there are two very surprising ways to help.
1. The most productive way to find happiness is…to stop looking for it!
The more we become obsessed with feeling a certain way, the more we put pressure upon ourselves. In other words, we start “shoulding” all over ourselves, which has proven an unhelpful way to think, i.e. “I know I SHOULD be happy right now, but…”
People who engage in “should” statements are more likely to actually feel anxious or depressed, because if we think we “should” feel a certain way, we often set ourselves up for expectations that sometimes we can’t meet. Why can’t we meet the expectation of “I should be happy”? Well, for one, emotions are transient, and as humans we have the capacity to feel a gamut of emotions.
What if we could allow happiness to find us, organically, without chasing it down, gasping and out of breath?
This brings me to my second seemingly counterintuitive way to find happiness:
2. Don’t discredit any emotion!
Yes, that’s right. By allowing oneself to validate all emotions that are felt, even sadness, one is more likely to feel greater well-being overall. You see, emotions are our compass, part of our life force, and though some emotions are more uncomfortable than others, the old adage of “what we resist, persists” rears its ugly proverbial head!
Resisting discomfort sets us up for perpetual discomfort. This is why mindfulness meditation is such a useful mechanism. While a nice byproduct of mindfulness practice can be relaxation, it is actually a tool used to help people expose themselves to all of their feelings, and with as little judgment as possible, truly embrace them.
One can argue that emotions are neither intrinsically “good or bad”, and to think of them in such dichotomous terms is to do ourselves a disservice. Emotions just are. In fact, every emotion tells us something about our inner experience that might be informing our outer experience. Even Rumi, the Sufi poet, waxed poetic in his ‘The Guest House’ way back in the 13th century about how we should treat every emotion as a visitor, without looking to get rid of any of them, but rather to understand their message and purpose.
The Guest House
This being human is a guest house.
Every morning a new arrival.
A joy, a depression, a meanness,
some momentary awareness comes
as an unexpected visitor.
Welcome and entertain them all!
Even if they are a crowd of sorrows,
who violently sweep your house
empty of its furniture,
still, treat each guest honorably.
He may be clearing you out
for some new delight.
The dark thought, the shame, the malice.
meet them at the door laughing and invite them in.
Be grateful for whatever comes.
because each has been sent
as a guide from beyond.
— Jellaludin Rumi
What Rumi alluded to in his writing, was also recently confirmed by research that indicates that well-being is actually predicated on having a wider range of emotions! Yes, that’s correct, the more you can feel, in all of feeling’s iterations, the better off you are (read more: www.scientificamerican.com/article/negative-emotions-key-well-being/)