Life After Trauma

A Workbook for Healing

The Guilford Press

Contents

After Trauma

Why You Feel Thrown for a Loop

Trauma: a bodily or mental injury usually caused by an external agent.

Traumatic events are extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life. Unlike commonplace misfortunes, traumatic events generally involve threats to life or bodily integrity, or a close personal encounter with violence or death. They confront human beings with the extremities of helplessness and terror, and evoke the responses of catastrophe. The common denominator of trauma is a feeling of intense fear, helplessness, loss of control, and threat of annihilation. —Judith Herman, MD, Trauma and Recovery

WHAT IS TRAUMA?

What makes an event traumatic? There are two conditions. The first is the nature of the event itself—it usually involves actual or feared death or serious physical or emotional injury. The more severe and repeated the circumstances, the more likely they are to be traumatic. The second condition is what the event means to the victim. The same event can be traumatic for one person but not for another. Why? It is because the meaning of the event is just as important as the event itself.

* Paul and Kirk were in similar serious car accidents. Paul is physically injured and emotionally shaken, but over time, life gradually returns to normal. Kirk is also physically injured but more deeply shaken; his life changes in some fundamental ways. For Paul, the accident was a bad experience; for Kirk, it was traumatic.

There is no "right" or "wrong" reaction to any life-threatening event. In different circumstances or at different times in their lives, Paul might experience an event as traumatic but Kirk would not. The particular ways in which people are affected by stressful events can differ widely. This reflects the normal differences among people.

COMMON REACTIONS TO TRAUMA

Trauma can affect the whole person, including changes in body, mind, emotions, and behavior. But each person's specific reactions depend on the particulars of the event and the person's unique self and history. Your emotional makeup, personal history, social relationships, previous coping strategies, age at the time of the trauma, and the availability of support before, during, and following the traumatic experience—all these factors help to shape the meaning of the event for you. The particulars of the event, such as the degree of violence or the element of surprise, also shape your reactions. Traumatic events shake the foundation of a person's life. Certain traumatic experiences, such as extremely early experiences of abuse, may interfere with or even prevent a person from developing a solid sense of self. The next section describes some common reactions to trauma. They are summarized in Table 1.1.

Physical Reactions

* Trauma is a major stress and it is common for the body to react. You may have a rapid heartbeat, muscle tension, nervousness, and sleep difficulties, or any of the other reactions listed in Table 1.1. Alternatively, you may react by feeling numb or out of touch with your body. Experience of trauma also puts people at risk for developing a wide range of physical health problems such as cardiovascular disease.

Mental Reactions

* Changes in the way you think about yourself. You may have previously thought of yourself as strong and independent, but if you experienced a brutal, unexpected attack or some other trauma you may now think you can no longer control your fate. You may now feel much more fearful and vulnerable. Your sense of being in control and able to protect yourself may have been shattered.

* Changes in how you think about the world. Some events seem impossible to understand. How can you explain to a six-year-old why her mother and father have been killed in an automobile accident? Why are so many innocent lives lost in terrorist attacks or natural disasters? Tragedies such as these can challenge your basic sense of order in the world.

* Disruptions in your thoughts. Images from the trauma may pop into your mind unannounced and unwanted. You may not feel able to stop these images or stop replaying the event over and over in your mind.

* Confusion in your sense of what happened when. You may be uncertain about the order of traumatic events or unclear about certain details of what occurred. There may be parts of what happened that you don't remember. Forgetting some of your experience can be unsettling but this is a normal way your brain protects you from being totally overwhelmed.

* Heightened awareness of your surroundings (hypervigilance). You may feel extremely alert for possible danger in your surroundings. You may scan a room more carefully as you enter to see who's there, where the exits are, and whether there seems to be any risk or danger. You may position yourself near the exit or with your back to the wall. It may be hard to let your guard down and relax.

* Lester spent 13 months in Iraq with his National Guard unit. He was a Humvee driver and protected convoys. Every minute of every day was filled with hypervigilant fear of enemy snipers, roadside bombs, and ambushes. He tried going back to his civilian job but he couldn't take the commute and his constant need to scan the roads and check out the other drivers.

* Lessened awareness, disconnection from yourself (dissociation). When feelings become overwhelming and there seems no way out of the situation that triggers them, one protective reaction is to cut off the feelings. This can be experienced as "being outside" yourself, as looking at yourself from outside your body, as feeling very spacey and out of touch with your feelings, or as not being aware of what is going on around you. Everyone experiences this to some degree, for example, when you "space out" and don't hear part of what someone is saying to you or when you don't remember having driven a section of the road. More extreme examples are called dissociation and can include not remembering significant or extended portions of your childhood or finding that there are parts of the present day or week that you do not remember. We discuss dissociation in more detail in Chapter 2.

Emotional Reactions

* Feelings of fear, inability to feel safe. If you have been frequently or severely threatened, you may continue to feel unsafe, even when circumstances no longer pose a danger. This can include a sense of being unable to protect yourself and feeling unprotected or threatened by others.

* Loss of trust in yourself or others. Whether the trauma was a random event or a deliberate action by another person, it can leave a deep sense of distrust. You may feel you cannot count on people or things to be a particular way. You may no longer trust your own abilities or judgment.

* Loss of self-esteem; feeling shame and hate toward yourself. Survivors of accidents, crimes, or combat may feel responsible in some way for what happened. If only you had been smarter, quicker, or somehow better, the event would not have occurred. You may feel that because this happened to you, you must have deserved it.

* Feeling angry, irritable. It's normal to feel angry after trauma but you may feel angry almost all the time toward friends, family, and others who had nothing to do with the trauma. You may find yourself in a rage over small things that didn't used to bother you.

* Feeling helpless. Being a victim of a natural disaster, crime, accident, or repeated abuse can make us realize how helpless we can be. If you have experienced repeated trauma, you may feel that there is nothing you can do to make things better. You may feel that your actions cannot change or influence current situations. This could leave you feeling especially vulnerable to future harm or devastating loss.

* Feeling chronically empty. After going through a traumatic event you may feel empty, used up, numb, and unable to attach any particular name to how you feel.

* Blunted then extreme feelings. You may feel numb, then suddenly feel surges of strong or even overwhelming emotion that is difficult to control.

* Shortly after returning to the United States from Iraq, Juan heard that a buddy from his unit had committed suicide. Juan felt nothing. He knew he was expected to feel sad, confused, or angry, like the other people who were grieving the death. But he felt totally shut down and numb. Occasionally, however, some little thing would happen, like being cut off on the road, and he'd fly into a rage. The rage just seemed to take over and not let go of him for some time.

You may vacillate between these two extremes: At times your emotions may feel too powerful to contain, so they flood out or simply shut down and shut off. You may find it difficult to manage your feelings.

Behavioral Reactions

* Becoming withdrawn or isolated from others. You may start withdrawing and avoiding other people. There could be many reasons for this, for example, it may feel safer or more comfortable to be alone.

* In college, Nancy was date raped by two different men on two separate occasions. She no longer wants to establish any type of relationship with men, let alone date. She is uncomfortable participating in social activities sponsored by her work or her church and spends most of her time alone. Since these assaults, she hasn't been able to develop any new close relationships.

* Avoiding places or situations. Reminders of the trauma may bring back painful and unpleasant memories. You may find yourself avoiding them even if it means disruptions in your day-to-day life.

* Ron had worked and socialized downtown for years, before being assaulted at gunpoint one day on his way to work. Although he had never been afraid to be in the city before, now he could no longer return to work, meet friends, or go to favorite evening spots he used to frequent. Being in the city had become a vivid reminder of the assault.

* Becoming confrontational. You may find yourself challenging or provoking others. You may pick fights or argue more than before.

* Changes in eating patterns or other behaviors. You may find yourself eating more or less than you used to, exercising more or less. You may gain or lose weight as a result. Other behaviors such as sleep patterns or sexual activity can also change.

The above list of common reactions to trauma is by no means complete, but it illustrates the range of typical reactions. You may have feelings, thoughts, or experiences that you don't see listed here; this does not mean that your experience is abnormal; it means only that there are too many possible reactions to list them all here.

SUPPORTIVE RELATIONSHIPS CAN CHANGE FOLLOWING TRAUMA

Supportive people are a primary resource for healing after traumatic experiences. But trauma can challenge and change some or all of your existing relationships. Even when you have supportive friends, family, partner, or work environment, you may still feel isolated. The people in your life may not know how to help you now. Old friends and family may not be able to understand what you are going through. They may themselves feel scared, confused, frustrated, or helpless. This can greatly increase your sense of loss. In Box 1.1 we offer a list of suggestions for how others can help. You can copy this and give it to whomever you wish. This list may also help you talk with those around you about how they can help.

You may find, however, that some people are uncomfortable with your distress, particularly if they are unaccustomed to seeing you that way. They may feel unable to comfort you. Sometimes, it helps to let others know you understand that they won't be able to take away your pain. Explaining that you need someone to listen to you or hold you, without offering advice, can help caring people help you better.

You may feel that some people no longer understand you, making it painful or uncomfortable to be around them. Some may not be able to provide the kind of support you are looking for. You may then feel a loss of connection or intimacy and want to withdraw from these or other relationships. It is OK to protect yourself from relationships that feel hurtful but try to preserve relationships that are generally safe and supportive. If you are struggling with a relationship, we suggest that you try talking to a friend or family member about it before pulling away. For instance, you could say, "I know you care and are really trying to help, but I just need some distance right now."

If you can, try to keep up the connections you have with others in whatever ways feel comfortable, whether it's an annual holiday card, a phone call, or going to a movie. It does not have to be a long conversation over dinner. Just let others know you appreciate their calls but aren't up to extended talks; this can help keep concerned people within reach until you are ready to reach out. You need to attend to your own needs and, as you will see later in this workbook, connecting with others is a basic need we all share.

CHECKING IN WITH YOURSELF

Reading through the possible posttrauma reactions in this chapter may have stirred uncomfortable feelings for you. Take the time now to "check in" with yourself. How do you feel right now? What do you need? Do you need comfort and a break from this work? If so, what are some of the self-care activities that you listed in the box provided in the Prologue? Try doing one of those right now, and come back to the workbook when you feel ready.

Why check In with Yourself?

When feelings are uncomfortable, it's normal to want them to go away. Trying to ignore discomfort or distress is one way to do this. This solution, however, is only temporary and can cause bigger problems later. Distress can escalate and interfere with your day-to-day activities. Just as it is best to care for a cold so it doesn't turn into pneumonia, it is best to care for emotional distress before it creates bigger disruptions. The first step in reducing emotional distress is to recognize that it's there when it's still fairly mild. It's at this point that you can effectively reduce the distress by caring for yourself. But if you are in the habit of ignoring emotional discomfort, you may not find it easy to notice. This is why, from time to time throughout this workbook, we will remind you to do it. Take the time for self-care as you notice the need. Learn to notice on your own when you need self-care and comfort.

How to Check In with Yourself

The ability to notice and recognize emotions is a skill. If noticing mild to moderate feelings of distress is a new skill for you, it will take practice. The more you do it, the better you will get. Box 1.2 lists the key steps for how to check in with yourself. Follow these steps now.

Did you notice any of the emotional or physical reactions described in the box? If so, do you need to find someone to talk to? Would listening to soothing music be helpful? Would a hot bath help? Or spending time outside gardening, or taking a walk? Relaxation or massage? Think about what resources might be available to you, or what might be helpful as you do the difficult work of healing.

LEARNING TO RELAX

Relaxation exercises can directly counteract physical tension in your muscles and calm you emotionally. But it is natural for different people to respond in different ways while trying to relax. Some trauma survivors feel vulnerable when relaxing, because the exercises typically suggest that you close your eyes and pay attention to internal images and sensations. It's all right to start by keeping your eyes open and be sure to find a safe place where you feel comfortable enough to relax. When first learning to relax, some people have a sensation of floating, light headedness, or other unexpected feeling. Try to continue relaxing through these feelings. Relaxing, like any other skill, takes practice. As you practice, you will be able to achieve that relaxed state more and more quickly and completely. Stick with it; don't be discouraged if it feels awkward or ineffective at first. This is a normal part of learning. Box 1.3 provides the steps for a useful relaxation exercise.