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 My beautiful voice had been replaced by the noise of a wounded beast.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.
Here’s some info taken straight from MentalHealth.gov to keep in mind:
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.
According to psychologist Janoff-Bullman, what a mass trauma like this does is challenge our assumptions and brings them into question.
These assumptions may include:
- “the world and people are intrinsically good”
- “good people experience good things”
- “the world is safe”
- “the world is just”
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.”
In honor of PTSD Awareness Month, and in response to the tragedy in Orlando, I offer five ways to help us help our children and ourselves in times of trauma.
- Give Yourself Permission to Feel Many Emotions at Different Times:
One of the core concepts of mindfulness meditation is the idea of having an attitude of non-judgment of, and openness towards, current experiences. After a tragedy, it is natural to react with shock, anger, numbness, sadness, grief, confusion, and even denial. Most often, grieving is not a linear process and you might experience yourself fluctuating between different feelings at different times, on different days and during different weeks. It is okay. Allow yourself to feel what you feel with as little judgment as possible.
- Take Care of Yourself, Then Take Care of Others:
This is true on any given day, but most importantly at a time like this. If you are anxious and your symptoms continue to persist, please reach out for support/professional guidance. More than ever, make a point to engage in your usual routine. Eat well and sleep well. Engage in healthy coping strategies (breath from your diaphragm, take a bath, journal, watch a comedy, create your own safe space and let yourself cry). Managing your own stress is a precursor to helping your children manage theirs.
- Create a Sense of Safety:
For most children, their parents symbolize safety. In times of doubt, children look to their primary attachment figures to cultivate a safe space. Let your children know you are available if they have questions and actively make yourselves available. Children don’t yet have the same cognitive tools needed to cope. Model resilience in the face of hardship without denying that hardship.
- Recognize, Be Real, But Reassure:
It is important to recognize signs of your children’s distress. Sometimes it is not obvious, as fear and anxiety might manifest as physical symptoms (stomach aches and headaches) and/or insomnia (and other sleep difficulties). Children, especially teens, might isolate and/or withdraw. Recognize the pain. Then, it is important to be real with your children. Limited media exposure is a crucial element, but on the flipside, children need to know what happened. If your children do not approach you, take the time to find out what kinds of questions they are having and what kinds of feelings they are experiencing. Use discretion (talk to them in an age-appropriate way) and be honest about what is happening; it is important not to deny the events. After honest, but age-appropriate and discrete discussion, reassure your children’s sense of safety. At this juncture, they are internalizing and probably deeply personalizing the events, wondering “when will something happen to ME.” Reassure through returning to normal routine and sending messages of safety overall. Keep life feeling as safe and predictable as possible under the circumstances.
- Reassess and Regroup:
Different people, of different ages, express trauma differently, at different times. The reaction to trauma will vary greatly. One thing, however, is for sure: The effects of trauma don’t go away easily. They might remit or decrease in severity, but they usually ebb and flow for a very long time.Healing is possible and there is hope amidst this gripping grief. As children develop they will adopt more evolved coping skills in order to adapt, and ideally the appropriate acute treatment will serve as a tool to cultivate increased resilience as time goes on. Yet, continue to reassess and regroup. It is important to continue to check in with yourself and your children if symptoms reemerge, or if other traumatic circumstances arise.
*If you need a referral to a trauma specialist, please contact me at DrWolkin@BrainCurves.com.
Jennifer Wolkin, PhD