Mainstream trauma treatment can invalidate the survivor’s experience
Reducing symptoms at the expense of meaning
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Hey there everyone –
In my last post I wrote a bit about how PTSD became a diagnosis. This week, I’m going to talk about how the diagnosis shapes trauma treatment, and why there can be a gap between the way a clinician approaches trauma treatment–what they think is most likely to bring people relief–and what the survivor might hope for, in terms of reckoning with what happened. This is another huge topic, so I’m going to put a few ideas out there and I’ll expand on them more in the future.
The naming of PTSD as a disorder, rather than a syndrome, meant that the Diagnostic and Statistical Manual III, published in 1980, had to include a list of symptoms that clinicians could use to determine if a survivor of a traumatic event had PTSD. By drawing the clinician’s focus to symptoms—their severity, persistence, increase, or decrease—the diagnosis implied that the work of treating PTSD, like any other medical condition, was to reduce or eliminate altogether the patient’s symptoms. (I’m using the word “patient” here because evidence-based trauma treatments are often provided in clinical settings that are rooted in a medical model.)
Though mainstream, evidence-based treatments like Cognitive Processing Therapy and Exposure Therapy are quite different in their approach to trauma, for example, what they have in common is a focus on symptom reduction. The patient fills out a symptom checklist before each session. They rank the severity of each symptom on a numbered scale. At the end of the protocol, the patient’s scores are compared to their original questionnaire, to see what has improved and what, if anything, remained the same or became worse. The idea here is that if a person’s symptoms abate, they are on their way to no longer having PTSD.
So far, so good. A person with severe PTSD can find it very difficult to function. It can seem like everything is in turmoil and that life is not worth living. Symptom reduction can bring relief. To reduce nightmares and flashbacks; to make it so you don’t have to do your grocery shopping at 3 a.m., or that you can actually be in a crowded place without having a panic attack—any treatment that can increase a person’s capacity to care for themselves and engage with others is a balm. At the same time, increased functionality—the ability to be productive, to be able to take care of oneself without hiring others—is not the same thing as increased meaning and purpose. One can be highly functional and not a “burden to society” but still feel like life is a chore, a litany of meaningless tasks to be endured. A reduction of symptoms does not inexorably lead a person to an increased understanding of what happened, or to feelings of peace or optimism about the future. I’ll come back to this issue in a moment, but first, I want to talk briefly about trauma research.
The desire to better understand the physiology of trauma—the interplay between the body and the brain—has led to exciting research in the neurobiology of arousal. You may have read about the role of the amygdala in mediating the body’s threat response; the way the vagus nerve regulates hyperarousal; the role of the hippocampus in laying down memories, which might explain why traumatic memories are different from memories of ordinary events. The better we understand the neurobiology of trauma, the more we can design somatic interventions that survivors can use to bring themselves out of hyperarousal, increasing their personal power, their ability to understand how the body “works,” and with practice, their capacity to stay in connection with others, even when they feel threatened.
You can see from even this short summary that the focus on symptoms is shaping trauma research and treatment. The fields of medicine, psychiatry and psychology are asking fascinating questions. What is the ultimate source of the symptoms? The body? The brain? The feedback loop between the two?
If we can reduce the body’s hyperarousal; if, that is, we can make the body act the way a body does when it’s “safe,” will that increase the survivor’s belief that he is, actually, safe? To what extent do the ways our body responds to a traumatic event, or a memory of a traumatic event, shape the way we respond to our environment in the present moment?
What would happen if there was a drug that could target a symptom of PTSD and reduce it, or intervene in a mechanism of arousal and block it? Would you take it? If PTSD became a condition understood almost solely as a disorder of arousal, or of the body’s physiology, or as rooted in a problem in a region of the brain, would that change the cultural meaning of trauma?
Does making a disorder that is said to be psychological appear more physical, more of the “body” than the “mind,” change the way trauma is understood by the person who has survived the traumatic event? Does it eliminate the need to process the event? If the symptoms were reduced, would talking about what happened induce a relapse, making things worse?
A few times a week I get a flier in my mailbox offering me a continuing education class for trauma. Most of the time it’s a class on neurobiology, or EMDR. Sometimes it’s a mindfulness technique, designed to help the body combat its chronic arousal. I don’t have a problem with any of these interventions; I think they’re great. But I’m intrigued by the way they try to shape my focus as a practitioner. They give me a sense that I can offer information and practices to my clients that, especially if they are evidence-based, are likely to produce results, no matter what kind of trauma my clients have endured.
There’s a kind of antiseptic nature to these approaches, a distance that is in contrast to the intensity of what trauma actually is. Trauma is often a violation of the body’s integrity. It can include an overriding of our consent. It can involve the overmastering of our will; it can humiliate us; it can force us to grapple with our powerlessness. It is sadism; it is abject hate; it’s being forced to do something to another person; it’s a person we were told would protect us being instead our greatest threat; it’s a military operation in a battle zone; it’s a head-on collision, resulting in death. The vulnerability and shame; the ways we can become unrecognizable to ourselves; the new ways we respond to others—these feelings and reactions and the questions these experiences evoke—they aren’t on the pages of my fliers. But they are the concerns of trauma survivors.
What I’m curious about is the ways the field of mainstream trauma treatment might be interested not only in creating better techniques for symptom management, but also might be invested in preventing clinician burnout. It’s easier to talk about hyperarousal, hour after hour, than to sit in the details of a person’s encounter with evil, or hold with them their belief that they no longer deserve to be part of the human race. It’s more satisfying to believe we have a protocol that can make it better than to sit with our powerlessness to stop the violence that already occurred, that perhaps was committed by a person so callous that they honestly don’t care if they hurt someone else.
I was listening to a podcast interview with the therapist Resmaa Menakem the other day. He said the most important thing about a traumatic event is that “something happened.” He said it over and over. Something happened. Something happened. Each time he said it, it was clear that it was the thing outside the self that was the ultimate engine of the trauma, even as he’s a somatic practitioner, absolutely gifted at working with the body’s arousal response. By calling in the “something” that happened, Menakem is making space for the survivor’s experience, and for the fact that there are two traumas here, the thing that generated the trauma, and then the body and brain’s response.
Often the something that happened is more than a discrete, bounded traumatic event. The event itself is more an eruption, at the level of interpersonal violence, of a larger ideological system. The most recent shooting in Jacksonville, Florida is an expression not of a deranged, lunatic gunman, a lone actor, but rather is a consequence of the network of systems and structures that reinforce and recirculate white supremacy in the United States. In this context, one traumatic event is linked to and evokes the vast chain of similar events that came before.
How does one separate and isolate a series of symptoms, attach them to a single traumatic event, if the body—if your body—is one that has carried you through a lifetime of exposure to ideologies of domination that target an aspect of your body, see it as a symbol of your self? When we include structural violence as a vector of trauma, where is the “before” that can be cordoned off from the traumatic event? Can the body rest, be “symptom free,” if the body has never known peace?
There’s an intrinsic tension between the clinician’s focus on symptom management and the survivor’s focus on meaning. The question trauma evokes in the survivor isn’t “how do I stop the symptoms?” It’s “why did this happen in the first place? How could a person do that? What if I hadn’t gone out that night? What if I hadn’t agreed to be part of that group? What if I hadn’t married that person? Why did I participate? Who am I, now that I know what I and others are capable of doing?”
The survivor wants to understand the meaning of the traumatic event. The self that existed isn’t here anymore. There’s a wasteland, a burnt field where the future used to live. One of the hardest things about trauma work is that we are asked to take on the most difficult knowledge, the most terrifying feelings, when we are on our knees, when we are most convinced we’re permanently broken. We don’t have the skills we need to cope, because the skills we had weren’t designed for this. We don’t have a reason to eat, to get up, to shower. There’s a pane of glass between us and the rest of the world. The memories circle, over and over. We can’t sleep because we’re haunted. It’s hard not to sink into contempt for the rest of humanity, who are oblivious to what this is like. If the clinician jumps too quickly into a focus on symptom reduction, they can invalidate the survivor’s quest to understand the ethical and existential meaning of the event. It is not that there is anything intrinsically wrong with symptom reduction. It’s that it risks erasing the survivor’s self, and the complex meanings that are mapped across its surface.
If you’re a survivor who has felt that there’s something wrong with you, that the treatment isn’t working because you’re too broken to be fixed, I encourage you to release the shame and blame you may carry. There are many ways “in” to working through trauma, and it may be that the approach you are trying needs to be augmented or shifted to bring you a sense of hope.
If you are a clinician who is feeling overwhelmed by the demands of your job, or the methodologies your hospital or clinic uses for trauma, know that you are not alone in your frustration, and that you may be feeling the tension between a framework that focuses on the individual and the need to acknowledge the larger structures and systems that create the context within which interpersonal violence often occurs.
Stay safe out there this week—
xo
Rebecca