About once a month, Dr. Charles Silberstein, psychiatrist at Martha’s Vineyard Hospital, will write a column that directly addresses issues Islanders have with mental health.
A father lost his son in a boating accident. A child was shamed and bullied because she wanted Donald Trump to become president. A mother had her child taken away from her after a drunken brawl with the father. Incapacitated by a battle with cancer, a woman lost her source of income and then lost her housing. All of these are stories of trauma, and all of them happened on Martha’s Vineyard.
Recently at Island Counseling Center (ICC), a branch of Martha’s Vineyard Community Services, a group of mental health professionals discussed how to help people who have recently suffered severe trauma.
Trauma victims frequently lose sleep, have changes in their appetites, and find themselves thinking about or even re-experiencing traumatic events over and over again. Most find it difficult to focus on work, love, and self-care. Some go on to develop posttraumatic stress disorder (PTSD), and feel that after their traumatic experiences, their lives seemed permanently changed; they were no longer themselves.
Some trauma victims’ lives return to normal, and memories fade into the past, but studies suggest that depending on the nature of trauma, 10 percent to 50 percent of individuals who have experienced an acute trauma will develop Acute Stress Disorder (ASD). Most of those people will never be diagnosed, and most of their symptoms will be kept secret. ASD is characterized by up to a month of any or all of the following symptoms: re-experiencing trauma in the form of nightmares, intrusive thoughts, and flashbacks which feel disturbingly real; experiencing recurrent negative and self-effacing thoughts and feelings of despair and/or self-blame; feeling numb, empty or cut off from themselves; feeling persistently on guard, hypervigilant, and so anxious that sleep is disturbed. They often have an exaggerated startle response, and they are ready to flee when faced with small provocations. About half of those individuals will find that their symptoms fade away; another half will find that the symptoms are long-term, and they will meet criteria for PTSD.
The mental health professionals at ICC focused on how to identify people who are at high risk of developing ASD and PTSD, and how to help them. At highest risk are people who have experienced previous trauma and have brains that already know the pathways to protect themselves with hypervigilance, re-experiencing, disconnecting from themselves and feeling numb. When the brain — particularly a young brain — experiences these kinds of protective strategies repeatedly, these pathways become hardwired. People who already have PTSD are at particularly high risk, because they often have depleted levels of hormones like cortisol that help people deal with stress, and they have elevated levels of adrenaline that keep them on guard and reinforce disturbing memories. Those who become numb and feel disconnected from themselves, and those who are preoccupied with self-blame and other negative thoughts, appear to be at particularly high risk. Social support and the company of trusted loved ones is clearly protective, and the absence of that is a major warning sign. Previous mental illness and excessive anxiety and worrying are also markers of increased risk. And of course, people who remain in a traumatic situation and continue to experience highly negative events are at much higher risk of developing enduring symptoms of posttraumatic stress.
There was a time when the treatment of choice for trauma was to get people to talk about the horror right after the event. It turns out that people who had this kind of therapy were actually more likely to develop chronic PTSD. No one knows with certainty why that was, but re-experiencing the trauma in its immediate aftermath may in fact reinforce disturbing memories and high adrenaline anxiety. There is nothing good about continuing to experience fear without relief. It may also have been that the “therapy” was conducted by strangers. One of the cardinal responses to trauma is to feel decreased safety and trust, so processing it with a stranger might not be as useful as with a trusted friend, family member, or familiar doctor. In addition, while the therapists may have helped trauma sufferers unmask the pain, they may cause further harm if they don’t follow up with consistent support through the healing process.
What can we do to help? Most important, if possible, is to get anyone who has experienced an overwhelming frightening event out of the situation and into a place where they can feel safe, supported, and loved. The more familiar those sources of support are, the better. As professional caregivers, we can help people find safe living situations, educate them with regard to healthy coping styles, and help them reframe the narrative that they tell themselves about the trauma to emphasize their strengths and diminish self-blame. We must remember that any work that we do with trauma survivors has the potential to stir up painful memories. The aloof, distant, “blank screen” therapist is probably not going to be helpful, and may actually do harm. Trauma survivors have been shaken to the core, and they need to know that caregivers, while respectful of boundaries, really care, check in, and are thoroughly present.
A wonderful cognitive behavioral therapist, Dr. Diana Dill, speaks of the “arousal scale.” The idea is that we can all measure our levels of mental arousal on a scale of 0 to 100. Zero is comatose. Forty and below includes relaxed regenerative states. Forty to 60 is where we are at our peak performance. Sixty and above are increasingly high states of stress: fight, flight, and freeze. Above sixty, we lose our ability to learn, reason, and carry out tasks. Trauma by necessity sends us into states well above 60. In recovery, it is important to stay below 60, with frequent visits below 40, to regenerate.
The key to overcoming any fear or anxiety is exposure to the fear in such a way that there is an increased sense of control and mastery. If revisiting the fear leads to states above 60 without recovery periods below 40, it is destructive. But if we can learn tools to reliably bring us back to states of relaxation, healing can and does occur. People who have been hurt need comfort. Many people self-soothe through drugs, alcohol, and other behaviors that become compulsive and self-destructive. The key to recovery lies in finding healthy sources of comfort such as therapeutic breathing, creative outlets, and exercise. Good therapists and 12-step meetings can guide people in identifying ways to comfort themselves that work for them.
Signs of successful processing of the trauma include moving on and getting back to the tasks of daily living such as meaningful, low-stress work. Survivors who are able to elicit sympathy and help will do better. Sustaining a positive sense of self-worth is healing and regenerating. When thinking about the trauma, creating a positive story that survivors can tell themselves makes an enormous difference. These are great lessons for all of us, especially for the majority of us who have experienced traumatic events in childhood, and also for caregivers, whether family, friends, or professionals.
Island Counseling Center is at 508-693-7900, ext. 290;