CHRONIC POST TRAUMATIC STRESS DISORDER (PTSD) AND ITS IMPACTS: An article for the sufferer and their family (by Tim.Loughnan)
This article aims to provide a neurological map for treatment processes where there are issues of Chronic Post Traumatic Stress Disorder (also helpful for attachment trauma and childhood abuse). This map can help us understand how the brain responds to trauma and to describe realistic pathways for recovery from trauma. It focuses particularly on reactivity/anger as a common characteristic of PTSD presentations.
If the person who has experienced trauma is in a relationship it is very important that the partner also understand these pathways for recovery, so that they can notice and foster positive change patterns. To realistically do this, we need to acknowledge that the partner is likely to be suffering the secondary impacts of the trauma response shown in the withdrawal or reactivity of the person carrying the trauma. This also needs careful attention and validation but is not the specific subject of this article. It does suggest however that the partner may need their own counselling support before they could realistically expect to be able to support their partner. That is, they will be carrying their own hurts that must not be dismissed or minimised.
Whether we like it or not, trauma symptoms tend to be triggered most powerfully in our intimate relationships. Ironically this is because these are the people we care about the most and with whom we are at our most vulnerable.
Pathways to recovery:
There are three parts to this:
Firstly we need to map out the neural circuitry involved.
Secondly we need to look at how these pathways respond to trauma.
Thirdly we need to identify realistic pathways for recovery.
The neural circuitry involved:
Broadly speaking the brain has two different pathways of remembering, processing information and learning. The first pathway is highly functioning at birth and is linked to the amygdala and to sub-cortical structures in the brain. It remembers things via emotional tone and through our senses and visceral experience. It is not organised by language or by a conscious narrative description of events. It does not remember things in context in terms of time, space or self awareness. This pathway is also called our limbic system or “fight and flight” system. It serves the function of protecting us from physical and emotional harm. Importantly (as explained further on) it is literally a faster circuit than our more reflective cortical pathway.This means that it brings its interpretation of events to our awareness milliseconds before our more nuanced cortical brain. This pathway is always switched on. As it senses out through our eyes, ears and other senses it is constantly asking the questions “AM I SAFE? IS IT SAFE?” That is, “Am under physical threat?” or “Am I under emotional threat or threat to my integrity as a person, who is valued in my social group?” This means that threats of abandonment, being ridiculed, dismissed, made wrong or having love withdrawn can trigger a limbic response of fight or withdrawal.
When the limbic system is really triggered it gears the body up to fight or run by releasing hormones and altering brain chemistry to go into survival mode. Physiologically these changes are very real and will trigger the person into a response to attack or flee. Depending on our upbringing and personality, most of us will tend to favour a particular response. Some people shut down at the first sign of conflict. Others will easily go into attack mode. Because we are heavily socialised and conditioned these responses can be somewhat masked or converted into less direct forms such as sarcasm, contempt, snide remarks, ridicule or subtle withdrawal of love or attention etc. When we are triggered, curiosity and openness towards the other person shuts down and a defensive black and white response comes forward.
The second pathway develops later and is related to hippocampal and cortical structures. It puts our memories into a structured narrative via language and remembers things in terms of context, time and space. It leads to the conscious organisation of experience and the construction of a sense of self. This the memory we use when we retell a story that has been fully integrated into a narrative. It automatically tells our brain that “this situation is in the past and is different than whatever is happening now”.
What happens under traumatic overload:
Neuroscience research suggest that under situations of traumatic overload hippocampal structures tend to shut down whilst the “fight and flight’ structures remain operative. This means that under overload conditions our brain is left with fragments of memory which are not being automatically placed into a past narrative. Therefore the brain may not be able to distinguish between the past and present. To complicate things, triggers can come via any or all of our senses and we may not be aware of what the trigger is because the memory pathway is unconscious.
To illustrate, if you were assaulted by a man with a mint smelling breathe then when you smell mints you may find yourself feeling very agitated but may not remember why. The brain will scream at you “something isn’t safe” and you may find yourself reacting to whoever is in front of you.
Another layer to this is that broad situational themes can be triggering. For example, when you are in a hurry, feel not in control or feel you are being treated disrespectfully (as often happens with teenage children) then the likelihood of triggering may dramatically increase.
What are realistic pathways to recovery?
FIRSLY IT IS VERY IMPORTANT TO UNDERSTAND THAT A PERSON WITH POST TRAUMATIC STRESS WILL BE DOING THEIR BEST IN THIS OVERWHELMING SITUATION. BECAUSE THEY ARE BEING INFLUENCED BY TRIGGERS BEYOND THEIR CONSCIOUS CONTROL, THERE IS INEVITABLE WITHDRAWAL AND/OR REACTIVITY. TO AN OUTSIDER THIS MAY APPEAR TO BE “EMOTIONALLY LAZY”, AS IF THEY AREN’T REALLY TRYING. THIS IS NOT THE CASE. THE OVERWHELM CAN LEAD TO A CASCADE OF FEELING HELPLESS, GUILTY, UNWORTHY. THERE IS USUALLY A PROFOUND SENSE OF LOST IDENTITY AND RESILIENCE WHICH ADDS A BURDEN TO EVERYDAY LIFE. THIS NEGATIVE PERCEPTION CAN BE EXACERBATED BY THE PARTNERS FEELINGS OF OVERLOAD AND GENUINE NEED FOR SUPPORT.
Therefore an underpinning of all treatment is to remain aware that, in all probability, everyone is doing their best, even when it may not seem so ( the limbic brain in “fight” mode is an unsocialised part of us that reacts first and thinks later. Whatever comes out of ones mouth at this time is NOT representative of the deeper self). Understanding this can go some way to protect the family from the corrosive nature of PSTD symptoms.
What does all of the above point to in terms of realistic change and how to deal with situations that arise? Looking broadly we can consider the positive side and then at the challenges involved:
On the positive side, the adult brain is much more plastic than was recently believed. It can develop new neural pathways via consistent practice over time. The main bridging practice from the “fight flight brain” to the “narrative brain” is language. This is one of the principle ways that a “talking therapy” can help. When a person with PSTD is talking to a therapist, their partner or to themselves internally, they are bridging from the non-languaged fight and flight brain to the narrative brain. Slowly over time this can go some way to building the narrative memory that allocates the trauma to the past and reduces reactivity. Also on the positive side, by becoming involved in new activities, away from trauma, the overload of the brain can begin to settle as new memories build and baseline stress drops. Physical exercise is also a key to supporting recovery both because of its general benefits and also because it helps us harness, release and express the many fight and flight impulses that remain held in our body.
On the challenging side this process takes considerable time, practice, patience and commitment. And its not as if life will ever be the same. There will be an ongoing vulnerability to stress if multiple long term traumas have been involved.
Looking more specifically we can see that:
1. EVERYONE needs support. Family members should not dismiss their own need for counselling support.
2. The person with PSTD is working with a neural circuit that is faster than their reflective cortex and that can be triggered by things outside of conscious awareness. Despite this, work can be done to develop awareness of predictable triggers and how to minimise their impact. Often broad themes in this regard relate to rushing, unpredictable circumstances, loss of a sense of control, feeling not understood or respected or specific circumstances that reconfigure a traumatic experience. Ideally this should occur in consultation with the partner so there is a mutual understanding, a rehearsal of responses and a sense of permission to respond in certain ways that both understand and can broadly agree on.
3. Because of the nature of this circuitry, quite often the best the person can do is play “catch up” with a triggering event. When triggered the body is releasing chemicals to fight or flee. The better choice generally is to “flee” or withdraw (temporarily) as the person’s capacity to think clearly will be reduced and the likelihood of a fight will escalate dramatically. A classic mistake is to try to force the person to keep talking or, worse still, berate them for the need to withdraw.
Examples of withdrawal can include:
- deciding not to keep talking about the subject at that time
- falling back into a “practical helper position” and letting the partner manage the relational stuff at that moment (e.g. with the children)
- physically leaving for a time to settle down via internal dialoguing
- physically leaving very briefly (e.g.:go to the toilet) to do some breathing and centering practices and then returning with the agreement to “leave it for now”.
Withdrawal can trigger feelings of abandonment in the other person. It must be clearly understood that the one withdrawing is only doing so temporarily and that they will come back to process things more once they have done some of their own internal work.
If the person needs to leave, their partner can know that they are doing internal work to integrate the traumatic response via internal dialoguing with themselves. This internal dialogue involves asking questions around:
What is triggering me at the moment?
I’m upset/ angry because …….?
What are the feelings underneath my anger? I feel hurt/ sad/lonely/ anxious because? What part of this may relate to past events?
What part of this is about the “here and now”?
Out of 10, how much belongs with the present?
Out of 10 how much is about the past?
I’ve been caught in “a story” about my partner/family member. What is this story?
What might I be missing that tells a different story?
What might I be exaggerating?
What might I be holding onto/ being stubborn about?
What do I need to say that is more thoughtful and less blaming? (maybe write some notes)
Incidentally this can be a good practice for the partner as well. This builds a knowing between you that both of you are reflecting and trying to take ownership of what has happened.
Research suggests that we are not very good at estimating how long it takes to calm down and for the triggered hormones to wash out of us. We tend to under-estimate the time it takes. Therefore don’t rush to reconnect too quickly and listen to each other if one is not ready (as long as they are not chronically avoiding).
Figuring out the best ways to deal with triggering events takes practice and working through. Sometimes its not helpful to withdraw physically and leave the other person dealing with everything (if you have kids). In this situation it may be about an internal pulling back and an agreement to talk about it later. An underlying key is to minimize the sense of abandonment either person feels and to play to strengths. This means being creative, making new offers about ways to contribute, opening up to new roles and not getting stuck in a rigid identity that doesn’t serve you or our family. For example doing the clothes washing or cleaning the house in your own quiet time and space, may be much less triggering than being the front person with the kids at bedtime. You might offer more of the first and request to extra support in managing the second.
What does realistic change look like?
Usually the person with PTSD wishes they would just wake up one morning and it had all gone away. This is very understandable. There can be a narrative running that it is all a matter of “willpower”. Attached to this will be a related narrative of self blame and self judgement that family members may inadvertently join with. A more accurate mantra is that is more a matter of awareness, practice over time and compassion towards yourself and others.
The willpower narrative can lead to the punishing and unrealistic expectation that “When I stop being reactive altogether, then I’ll be better”. Any outbreak of reactivity leads to a spiral of harsh judgement that “nothing has changed” which sets things backward.
A more realistic outlook is to aim for a decrease in the frequency and intensity of reactive responses and an increased capacity to recover from being triggered. Recovery from being triggered means doing some of the internal dialoging described above and being able to come back to process things with your partner or just resolve it within yourself, depending on the circumstances. If you do need to talk more, ideally your partner will have done the same sort of processing.
In that conversation there may be;
- genuine apologies that need to be made to facilitate connection and safety
- talking about the underlying feelings “When x happened I felt …”
- ownership of what may belong in the past “Partly it reminded me of…. or … I don’t know why I reacted so strongly, but I can feel that most of it is about my trauma” – ownership of what belongs in the present ” I really felt dismissed when you said ….”
Whether any of this works will depend on your intention. Each person must focus on listening and trying to understand the other person’s position, not on defending and trying to be “right”. Importantly, this process should not be making it “all about the trauma from the past”. There will be some aspect of the present that needs to be heard and acknowledged, otherwise the person who reacted will feel voiceless about current concerns and this will only escalate symptoms.
Protecting change:
Working with chronic post traumatic stress is slippery and difficult because of the issues described above. You have to focus on the drift of change rather than on any particular event. Someone who is doing great work in recovery may have a massive triggering event 20 years post incident and lose their balance badly. Do you focus on this event or the drift of change? It would be a grave mistake to negatively over-interpret this loss of balance. Even with great awareness no-one can be aware of every trigger or manage an event that completely blindsided you.
There is a broad model for change used in much of psychological practice that can help. In this model slips are viewed as opportunities. What caught me out? What was the trigger? What can I change to reduce this trigger? What do I need to accept and therefore change my expectations about?
Having a difficulty such as chronic PTSD is likely lead to a dramatic re-evaluation of ones life, priorities, values and identity. Whilst not denying the tremendous upheaval, this can also have a positive side over time. A workaholic may reconnect with core values of being a family man. One may ask “Why do I want to put myself under unnecessary stresses?” “What are my biggest priorities?”, “What do I want to do that might fulfill myself and my family rather than everyone else?”, “How do I want to be remembered?”
Related to this are the themes of function and sense of humour. Most of us are conditioned to function fairly relentlessly. Our worth is defined by what we do. PSTD symptoms piggy-back on these hurried lifestyles, chronically sending our brain a false sense of urgency that increases the likelihood of triggering. For most of us, if we analyse it, we are too busy and defined by what we do. Taking regular time to “smell the flowers”, practice being really present to those we care for and challenging this pattern is an important aspect of recovery as it reduces our baseline stress if adopted as a life choice. Similarly, recovering our sense of humour in whatever ways we can is an aid to recovery. Neurologically, seeing the irony, craziness and, where possible, the funny side of things helps bridge our consciousness from the trauma self who is always on edge, to the reflective self, who is more relaxed and receptive. This however is a longer term goal and not something to put yourself under pressure about if you are in the early stages of recovery from PTSD or have not yet received adequate support.
I hope these notes have been helpful in considering the way forward if you or your family member suffer from PTSD. I hope they can form a starting point for further discussion and exploration if we should work together.
Warm Regards, Tim.
References:
Cozolino, L. The Neuroscience of Psychotherapy.: Building and Rebuilding the Human Brain. W.W.Norton & Co. New York. 2002.
Rothschild,B. The Body Remembers: The Psycho-physiology of Trauma and Trauma Treatment. W.W.Norton & Co. New York. 2000.