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.”
Here are five digestible bytes of well-regarded facts, opinions, and ideas about mindfulness meditation’s ability to lead to greater well-being!
1. Reframe the Experience of Pain:
Mindfulness meditation’s ability to provide pain relief can be done by cultivating the ability to parse between the objective sensory dimension of pain and the more subjective judgement that we attach to the pain and the way that we interpret it mentally.
A recent and groundbreaking review looked at 20 randomized control trials examining the effects of mindfulness meditation on the immune system. In reviewing the research, the authors found that mindfulness meditation “Reduced markers of inflammation, high levels of which are often correlated with decreased immune functioning and disease.”
Mindfulness meditation also increased the number of CD-4 cells, which are the immune system’s helper cells involved in destroying infections. There was also increased telomerase activity which helps promote the stability of chromosomes and prevent their deterioration (telomerase deterioration leads to cancer and premature aging).
Deregulation of the brain areas associated with emotional regulation and memory are key contributors to the symptoms associated with PTSD. In addition, an over-activity in the brain’s fear center, the amygdala, can be found in those suffering from Trauma-related disorders. Mindfulness reverses these patterns by increasing prefrontal and hippocampal activity, and toning down the amygdala.
In fact, brain scans confirm that mindfulness meditation is correlated with an increase in gray matter in the hippocampus, a decrease of gray matter in the amygdala, and neuroimaging studies have found that mindfulness meditation also helps to activate the Pre-frontal Cortex.
Dr. Elizabeth Hoge, a psychiatrist at the Center for Anxiety and Traumatic Stress Disorders at Massachusetts General Hospital and an assistant professor of psychiatry at Harvard Medical School, says that mindfulness meditation makes perfect sense for treating anxiety. “People with anxiety have a problem dealing with distracting thoughts that have too much power,” she explains. “They can’t distinguish between a problem-solving thought and a nagging worry that has no benefit.” Mindfulness meditation cultivates the ability to be more discerning. Subsequently, we can use the opportunity to take action on the problem solving, and to see the worry without judgment and more compassion.
In every situation, we can choose to REACT from a place of fear and perhaps anger, or RESPOND more mindfully.
Reacting is a reflexive, and sometimes impulsive, way to behave in a situation. It’s not adaptive and often leads to increased stress and tension. In contrast, responding is a more mindful approach to any given situation. But in order to respond in lieu of reacting, we need to STOP:
Take a breath.
Proceed (more mindfully).
Just ONE extra moment to take a step back, regroup, and consider a healthier response can make a huge difference.
I feel extraordinary heartbroken at the news of the shooting death of at least 49 human beings who came together in a place they felt safe; a place whose four walls bore witness to love without its shackles. The Pulse nightclub in Orlando, Florida was a place in which lovers could hold hands and kiss, to revel in a feeling of belonging without the still all-to-common threats of discrimination, alienation, and condescension. Inside those doors love was love, until hate walked in.
Hate walked in and obliterated this sanctuary, tearing apart lives that he thought were less worthwhile than his own, and infiltrated the heart and soul of a community and greater world who has had to fight for its birthright; to love and be loved. This is what hate does. He is at once insidious and blatantly hostile, unrelenting, unforgiving, and lacks a conscience. He is heartless and mindless, self-serving and sadistic to the core.
As I grapple with the way hate snuffed the life out of so many vibrant beings this past Sunday, I grieve. I am at once angry, anxious, sad, and shocked. 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 because of who they are and whom they love.
I am struggling with how to grieve along side you. My own journey of grief includes humbly offering all of us some words about grief from a psychological perspective, and providing five ways to grieve mindfully.
What Grief Is and Isn’t
Psychologically speaking, according to Dr. Kubler-Ross (1969), “Grief is an emotional response to loss.”
This emotional response is conceptualized as a non-linear expression of different stages of feeling states including Denial, Anger, Bargaining, Depression, and Acceptance (aka: “DABDA”).
Biologically speaking, grief is a homeostatic process, a journey that our mind, brain, and body need to engage in, to best recover from the trauma of a loss. This is an evolutionary need, since attachment and connection to others is embedded within our limbic circuitry. Yes, whether we are conscious of it or not, or like it or not, relationships deeply imprint upon our neural circuitry.
Grief is not, by any means, a one-size-fits-all kind of process. In fact, it is a uniquely individual process that often feels amorphous and difficult to capture with words. When it comes to grief, there is no “normal” or typical way to go through it, and despite what some believe, in my opinion, there is no “normal” time period allotted for grief.
It takes a boat-load of self-compassion to allow oneself to feel whatever it is you are feeling at any given time, without judgment, without comparison to another’s explicit portrayal of their own process. In this way, to grieve is to be mindful of our own thoughts and feelings.
While there is no one “right” way to grieve, to actually grieve is essential for our ability to employ our human capacity to find a renewed sense of meaning. Grief elicits resilience and the capacity to continue to hold this tragedy in our hearts and minds, while still forging forward with purpose and direction.
Five ways to Grieve Mindfully
Accept your feelings: Allow yourself to feel what you feel at any given moment, with a sense of self-compassion, and without judgment.
Express your feelings: Just as important as accepting your feelings, is expressing them in a way that is helpful to you. Journaling, talking about the experience, scrapbooking, or dancing, for example, are helpful ways to process grief instead of allowing the feelings to stay stuck.
Reach out: During this time, it is important to reach out in multiple ways. Reach out for guidance from a spiritual counselor or a psychologist. Reach out to share stories of your loved one with others. Reach out to offer support to other grievers. Find a balance between being with yourself, and being with others, but ultimately, reach out – don’t isolate.
Continue to take care of yourself and others. Living life while grieving often feels like scaling a mountain. Grieving takes energy and can often feel draining. As much as possible during this tough time, continue to eat well, exercise, and maintain wellness practices.
Celebrate life: It is important through the grief process to keep the memory of the tragic incident alive in some way that inspires healing, but also reflects and honors your mourning process. This can include donating to a charity, meditating on behalf of a loved one or a community, and even planting a tree in honor of the tragedy.
If you don’t see what you are looking for, and need a referral to a psychologist or a support network during this time, please directly reach out to me with your name and a brief paragraph regarding the type of help you are seeking. I will help you find a safe space to grieve. Please contact me at DrWolkin@BrainCurves.com.
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.