As is the nature of trauma, those who faced this present trauma live in the shadow of the tragic past and those in the past may be re-awakened to the horror and loss they have been carrying. To a large degree many emotionally and physically once again bear witness to a terrifying and unimaginable event.

While a person’s reaction to trauma is a function of the personal meaning of the event to them, their physical and emotional proximity to the traumatic event as well as their personal history, we have come to know that as an initial help, Psychological First Aid (PFA) can mediate the impact of trauma and make possible steps toward healing.

Dealing with trauma across the timeline from acute impact to long term recovery, I have found personally and professionally that there are aspects of Psychological First Aid that are vital in helping and healing at any time.

Here are some suggestions worth knowing and owning in the aftermath of trauma and re-traumatization.

Establishing Safety

Once someone is out of physical and medical danger, the most viable way to establish a sense of psychological safety is connection with familiar networks of support – partners, family, friends, school or church communities. In cases as the Virginia Tech Shooting, often those who have faced the trauma together may become cohorts that for a time provide “ substantive validation” to each other.

Talking together as a validating peer group, meeting together with school counselors or even connecting on-line with family, friends and peers can reduce the isolation and terror. People heal in community. Connection helps normalize feelings and lightens the burden of trauma.

Making Meaning of Common Responses to Trauma

Validating and Normalizing the common stress responses experienced in the aftermath of trauma moves such responses from pathological to understandable. Making meaning of what we feel empowers us; it reduces the sense of helplessness and anxiety so common after trauma. The three common response groups include Hyperarousal, Intrusion and Numbing and Avoidance.

Hyperarousal or the Persistent Expectation of Danger

This is your human fight/flight response in the presence of danger. It is as if your mind and body does not yet know you are safe. Such hyperarousal is reflected in an inability to relax, exaggerated startle response, inability to sleep, concentrate, and irritability. Not everyone experiences this and such responses rarely last more than a few weeks for most. Strategies to address hyperarousal include:

• Self-Care and Buddy Care for basic needs — are you sleeping, eating and do you have a way that you relax?
• If you run, exercise, play music, read the paper, pray or do something that calms you – this is the time to use your relaxation strategies. In the upset of trauma people often forget these valuable routines.
• How are your friends doing? Model and support self-care in the aftermath of trauma for those close to you.
• Be very careful about the use of alcohol and drugs. People often see them as quick ways to relax, but they actually add to the physical and emotional disorganization experienced after trauma.

 Intrusion or Re-experiencing

Feeling caught in the imprint of the trauma, many re-experience the images or sensations felt at the time of trauma as nightmares, flashbacks, or intrusive memories. While bewildering, they are the mind and body’s way of assimilating an incomprehensible event into life experience. Strategies to deal with them include:

• Re-frame them as understandable sequels to an event outside your life experience.
• Share them, write about them, express them in music, art or some medium – move them from frightening fragments to something you have more mastery of.
• Use positive re-focusing — once you have identified them as unassimilated glimpses and traumatic memories, turn to something that feels transformative. People find nature, pets, sports, prayer and helping others to be effective.

 Numbing and Avoidance

Numbing is a response to trauma that involves physical and psychological shutdown. Like the other responses to trauma, it is actually a functional way to survive in the face of overwhelming danger. When numbing persists if often unfolds into avoidance and isolation as an attempt to avoid triggers of traumatic memory or intolerable feelings of loss, grief or pain. The problem with avoidance is that it leaves a person alone with the trauma. It does not allow for the sharing, diluting, normalizing or integrating of a traumatic event. Strategies to deal with numbing and avoidance include:

• Reach for and accept the offer of someone who knows what you have faced and can be a compassionate presence – a friend, a partner, a family member, a professional, a spiritual caregiver.
• Words are not necessary. Just being with someone who cares regardless of whether you are walking, cooking, or shooting hoops or listening to music takes you away from the trauma and allows you to dare to feel again – a crucial start.

Access You Coping Skills

In the aftermath of trauma, it can feel as if you are frozen in time with the trauma. The past seems gone and the future seems impossible. It is really important to reach behind the wall of trauma to your resiliency traits because they still belong to you and they are what you have drawn upon in life to cope in situations of pain, disappointment, adversity and even loss.

• Individual resilience traits include physical strength, intelligence, interpersonal strengths, independence, sense of humor, creativity and spirituality.
• Resilience is also reflected in social skills, problem solving ability, utilizing positive emotions, strong family and community networks.
• Resilience also means knowing when too much time has passed (usually after a month) and you are still suffering in the aftermath of trauma and traumatic loss and you need professional help to reclaim you functioning and your sense of self.

Whether you have just experienced the horror of the recent shooting at Virginia Tech, you are jolted by your loss from the last Virginia Tech Shooting or you have just re-visited the pain and assault of a personal trauma – you are not alone as you try your best to heal and hope.

Frightened boy photo available from Shutterstock.

What is less known is the cause. Hoarding which involves thoughts, feelings and behavior and can be chalked off as eccentric or can be so extreme as to compromise living space, relationships, health and even life is not completely understood. It has usually been considered a symptom of obsessive-compulsive disorder (OCD) but this does not fit for all hoarders. Few hoarders actually seek treatment.

What if hoarding behavior was actually a response to Trauma?

• The findings of a recent study reported in the Journal of Anxiety Disorders indicate that hoarding may not always be a symptom of obsessive compulsive disorder. Rather, it may be a separate disorder that results from the experience of trauma and stressful life events.
• Comparing three clinical groups: hoarding disorder without obsessive compulsive behavior, hoarding disorder with obsessive compulsive behavior, and obsessive compulsive behavior without hoarding, as well as a non-clinical control group,investigators, Landau, Lervolino and colleagues used interview and self-report questionnaires to determine hoarding behavior, obsessive-compulsive personality disorder, traumatic events, material deprivation, work and social adjustment.
• Findings indicate that the hoarders reported the greatest exposure to traumatic and stressful events. Whereas the severity of obsessive-compulsive symptoms were unrelated or negatively correlated with a history of traumatic life events , over 50% of the hoarders linked initial hoarding symptoms to a traumatic or stressful event.

What Would This Mean?

It means we may be expanding our understanding of hoarding in a way that makes meaning to some trapped in this behavior, reduces shame, justifies help and even informs treatment options.

Much as know that the stress reactions of  trauma i.e. the symptoms of hyperarousal, the intrusive images and flashbacks, and the numbing and constriction reflect a persistent survival response despite the fact that the danger has passed, hoarding behavior may represent an excessive need to guard against the loss inherent in traumatic events.

Hoarding Symptoms as Dysfunctional Solutions to Trauma

Hoarding behaviors gather clinical relevance when we consider them in terms of the impact of trauma.

Trauma always involves loss. Whether a traumatic event has threatened your life, robbed you of someone you love, or destroyed your community, it deprives you – suddenly and even violently – of what you had.

Hoarding is the excessive acquisition of things along with the inability to discard them.  Perhaps as a way to offset the assault of sudden loss, people hoard items from papers to car parts that might have value or be needed in the future.

Reflective of personal loss, people often hoard items that have important emotional significance, reminders of happier times, beloved people, and pets. Often attachment to others has been replaced by attachment to things.

Trauma takes from you the sense of safety, predictability and trust you assumed and expected in life.

Perhaps the acquisition of items that cannot be discarded reflects a strong bond to objects that is far safer than a bond to people. Accordingly throwing away any of these objects will result in a profound sense of loss.

Inherent in Trauma is the loss of control, fear and helplessness.

Most hoarders rail against the need for help or the intrusion of someone who wants to help them clean up – even put things away.   Help equates to a lack of control. Objects put out of sight may feel like objects lost forever. Objects of no value may be in piles with a forgotten letter or item of value. To let another help is anxiety producing as it means feeling helpless and risking negative consequences.

Central to Chronic Trauma or Stressful Events is a loss of confidence and mastery – a fear of mistakes.

Those struggling with hoarding often try unsuccessfully to get control but are chronically overwhelmed. They often can’t manage daily activities, often procrastinate or become consumed with a task that is irrelevant to their living situation. They can’t make decisions because decisions always involve the loss of the choice not made.

Trauma always involves shame and self-blame – Whether the victim of  childhood abuse or natural disaster, humans would rather blame self than loss attachment or believe that life is arbitrary and beyond control.

While they persist in hoarding, most hoarders feel shame and are embarrassed by their surroundings. In some way they unwittingly become victims of their own abuse – their solution. Their excessive acquisition keeps them deprived of self-esteem, pride and control.

At the moment of Trauma most people feel existentially alone – cut off from man, God, from hope.

Eventually many hoarders become social isolates. Driving others away because of their hoarding, isolating with shame or avoidance of judgment, they are alone with the illusion of protection – things. The Collyer Brothers were found buried under 30 years of hoarding 170 tons of stuff. There were no people in their lives.

To respect the complexity of people is to know that in most cases they choose not to suffer. If we can add another dimension to understanding extreme and risky behavior we take a step towards some who cannot really step towards us.

 
Photo by Quinn Dombrowsky, available under a Creative Commons attribution license.

For survivors and the thousands who lost so many loved ones on 9/11 this is not only long awaited news, it is a déjà vu of that September day.

Once again there are ongoing calls of condolence and remembrances, non-stop media reports, and the visceral pain of losing a Dad, a child, a partner, a firefighter, a friend, a community, and the illusion of safety.

What Does this Mean for Emotional Healing?

It Invites Revisiting:

Highly charged events like Bin Laden’s Death are quite likely to trigger traumatic memories that unlike ordinary explicit memory for daily events are encoded under fight/flight conditions in those centers of the brain dealing with sensations and emotion. They can be sequestered for years – untold, intrusive as nightmares and flashbacks, haunting but never integrated into the story of one’s life.  While this event might trigger pain, it may offer an opportunity to bear witness, to share and transform traumatic memories.

It Addresses Doubts:

For some the feeling of being thrown back into palpable loss or the grief of now seeing a 10 year old comprehend what happened the day his father was killed, can feel like backsliding, “Have I made no progress in these 10 years?” “Will my children ever recover?”

• It is worth recognizing that just as courage is not without fear; recovery is not without tears-no matter how many years pass.
• It is invaluable to recognize that everyone grieves in their own way in their own time. Some may start the process now.
• For children the opportunity to speak about loss and trauma in their own way at different developmental levels with a safe and loving person to care and to listen is an antidote to despair.

It May Relieve Survivor Guilt:

While many suffer from self-blame and guilt in the aftermath of trauma, many uniformed personnel be they firefighters, police or military suffer extremes of this. Given “their mission focus” and the mandate to “leave no man behind,” many have carried guilt for the men lost on 9/11 or the wars that have followed. If this gives them a sense of “mission accomplished” that affords a long awaited permission to grieve, to forgive self and move back into life – it is reparative.

It Changes the Trauma Narrative:

The nature of the traumatic event itself – whether it is a man-made atrocity or a natural disaster, its duration, its impairment of resources, bears on recovery.  The death of Bin Laden changes the 9/11 trauma narrative that we collectively share, internalize and pass down through generations. It adds another ending. It speaks to our need to feel that justice can still be served, that there is strength in resolve. It reduces the fear of existential terror – we can stand strong together.

It Invites Consideration of Post-Traumatic Growth:

Post-traumatic growth as termed by psychologists, Tedeschi and Calhoun (1996) is defined as personal changes that result from a survivor’s struggle to deal with trauma and its psychological consequences. Such growth is not incompatible with Post-traumatic Stress Symptoms, grief or loss.

On this event of the death of Bin Laden which brings 9/11 and the wars that followed into stark relief  – consider if the trauma you have faced has brought with it growth along any of the following domains identified in the Posttraumatic Growth Inventory ( Tedeschi & Calhoun, 1996):

A renewed appreciation of life

New Possibilities

Enhanced Personal Strength

Improved Relationships with Others

Spiritual Change

To Recover Is Not To Forget – It Is To Live With Respect For Those We Will Always Love.

Photo by Guillaume Cattiaux, available under a Creative Commons attribution license.

Whereas a certain degree of worry can cause us to problem solve, ask for help, change behavior patterns, even enhance our attention to partners, excessive worry burdens us personally and interpersonally. In his book, Worry , psychiatrist Edward Hallowell, suggests that as compared to  “good worry” that leads to constructive action, “ toxic worry” can paralyze us.

What Causes Excessive Worry?

Persistent and excessive worry, also called rumination, may have a number of causes.  Some of these include:

Self Perception

• A negative view of self can fuel anxiety and continual worry. Low self-esteem generates an undue focus on the “ what ifs” in life with a negative expectation of failed coping. The inability to believe that you will find another job, that your partner loves you or that you can adapt your travel plan is more central to the excessive worry than the particular issue you are worried about.
• An inflated or perfectionistic view of self can also be a crippling component in worrying. An inability to tolerate anything less than perfect in self or others can make daily life frightening to navigate.  “I have to be promoted.”  “I can’t go to a local college.”  “I can’t ask for help on the project.”

Trauma

All trauma involves an assault on the assumptions that life is predictable, the world is safe and people are just.  Once the unthinkable has happened, the body and mind are poised for danger.  This could be a result of chronic childhood trauma, combat trauma or adult trauma:

“If a plane could kill my brother on the 90^th floor of the Twin Towers –- why wouldn’t my child be kidnapped?”

As such the neuropsychological trigger for alarm and worry is very easily tripped and difficult to turn off.

Misguided Strategy

One of the misconceptions about excessive worry is that it accomplishes something positive:

“I want to be ready when the other shoe drops.”

What we know about rumination as a strategy for regulating emotion is that it is not only ineffective but highly correlated with anxiety and despair.  Spending days anxiously anticipating “the worst” debilitates rather than prepares for what may or may not happen.

What is The Impact of Excessive Worrying?

Personally, excessive worrying is emotionally and physically costly.

• Emotionally it sets in motion a vicious cycle of poor problem solving, increased vulnerability, anxiety, despair, fear of not coping and the need for more worry. The secondary cost is the self-conscious “worry about worrying.”
• Physically there is evidence that excessive worry sets in motion our bodies’ fight or flight response which, when persistent and prolonged, results in the release of stress hormones, sleeping difficulties and a compromised immune system, among other things. The physical impact serves again to deplete a sense of mastery or confidence in the face of real or imagined threat and increases excessive worry.

Interpersonally, excessive worrying is complicated.

It’s difficult to be intimately involved with someone who is worrying without having a reaction to it. If the worry is occasional it can be instructive, supportive, even helpful to a partner. When it becomes excessive it often trips the following reactions:

• Some partners resent the continual voice of worry: “You put a shadow on everything we do.”

Because worry can be contagious, some partners also become anxious, exacerbating the worries and fears.

Others defend against the anxiety being stirred with anger or criticism: “If I let him know that I am nervous, he gets angry.”

• Some partners stop telling the worrier about what is happening in their life to keep him/her from worrying. This does little to help: “I assume the worst because he won’t let me know what’s happening.”

Perhaps the greatest cost of excessive worrying for anyone is that it deprives them of  the ability to live “in the moments”  of their own life and in the life they share with their partner.

As you will see in the next blog – Worrying need not be a life sentence nor a relationship deal breaker…

Should all dreams be Shared?

Although we consider that all dreams, even nightmares, are opportunities for growth and development, not every dream must or should be shared. Like the best of other dynamics between partners — the choice — to share a dream, do a favor, be sexually intimate … is what makes the action authentic and consciously and unconsciously important to your partner.So you wouldn’t tell a partner about the sexy dream with a high school sweetheart?

It depends — on the dreamer’s feelings, the meaning of the dream and the relationship with the partner. The dream may be registering that sexual interest in the present partner is as “hot” as it was in high school, in which case sharing the dream with that interpretation might be received as a sexually inviting compliment. On the other hand, if the dreamer feels that the dream registers confusion, presents disappointment, or even fear of betrayal as experienced from the high school sweetheart, the dreamer might want to use the dream for self-reflection and understanding rather than sharing.

Dream Sharing

Once you decide to share a dream, you move it from the personal to the interpersonal mode. When couples begin sharing dreams with each other, they begin to think about each other in different ways. Here are some guidelines that will give you a glimpse of the impact of dream sharing.

1. Dreamtelling

• At times, you may feel compelled to tell a dream and automatically share it: “You have to hear this dream.”
• As suggested in Healing Together, you and your partner may share dreams as a step toward renewing or maintaining intimacy, a version of “pillow talk.”
• Hearing or seeing you awakened by a nightmare, your partner may invite you to share it. Often afraid of feeling re-traumatized or contaminating the partner, there is hesitation is sharing such dreams. In reality, telling your partner such dreams is a first step toward diluting the feelings by taking charge of moving them from frightening images into conscious shared language.

2. Dream Listening

• The counterpart to the dreamer’s compliment of trusting you with the privacy of their dreams is the gift of attending to them and listening. It sends the message that “I care about knowing you on many levels.”
• The most effective and respectful way to listen to a dream is to put yourself in the shoes of the dreamer. This position invites empathy and elaboration rather than analysis or scrutiny of the other. “If this was my dream — what would I feel? What would this dream be registering in my unconscious?”
• A valuable step in listening is to repeat the dream just as you hear it. To do so invites you into the dream as if it is yours. It demonstrates to the dreamer that you have attended to and are sharing the dream. For a nightmare or trauma dream, your repetition of the dream can serve to detoxify it by your holding it at a less emotional distance from the dreamer.

3. Dream Collaborating

• Working together, partners may be able to elaborate, reduce the tensions, and expand the understanding of a dream as well as about each other.
• It is often valuable for the dreamer and listener to associate thoughts and feelings about the elements of a dream (the setting of the dream, the storyline, the beginning and ending, the action, the characters). Associating these elements, they may bring to light aspects of the dreamer, unresolved issues, strivings, relationships with others, etc. As such, they share a dialogue that can take them anywhere:

“Why would Uncle Jake be the man driving you to your new job in your dad’s car? Wasn’t he your father’s younger  brother?”

“Yeah, it’s funny but I think I looked up to him even more than my father — maybe I want to bring him with me to the new job.”

“Maybe there is a part of you that’s like Uncle Jake.”

4. Dream Communicating

• At times, the dream that is shared moves unconscious expression to conscious communication between dreamer and listener.
• In the case of one couple who were struggling with the wife’s avoidance of affection and sexual disinterest, her sharing, “You know, I had this sexual dream about you last night” was a step toward revealing her emerging desire.
• In another case, a man who could not own or express to his partner the stress he was feeling communicated it vividly when he shared the dream, “I am riding on a steep road and I start to feel like the car is going to slip over the edge unless I put my foot as far down as I can on the brake, and I wake up sweating, pressing down with all my might!”
• It is always valuable for a dreamer to ask, “Why did I have this dream now?” It may be just as valuable for partners to consider, “Am I trying to communicate something to you in sharing this dream?”

5. Dream Transforming

In the book Healing Together, we recognize that certain dreams — like nightmares — can have a terrifying and disruptive impact on both the dreamer and the partner and warrant professional guidance if they become chronic and compromise life functioning.

We also invite partners to recognize that the listener’s willingness to hear and help hold the nightmare if the dreamer chooses to share it- can be transformative. As described in Healing Together (p. 152-153), there are techniques that draw upon the shared efforts of partners to reduce the power of a nightmare. Working together in the light of day to “Give it a title” or “Alter the Storyline” may really have an impact on the disrupting dream. It may also transform the dreamer’s sense of terror and isolation into trust and connection.

Who you are and who you are to each other is never lost upon the unconscious. Reach for your dreams together …

For Further Reading

Friedman, R. (2008) “Dreamtelling as a Request for containment: Three Uses of Dreams in Group Therapy.” International Journal of Group Psychotherapy, Vol 58, No.3.,327-345.

Combat stress, a cancer diagnosis, a car accident or a sudden job loss are events that can jolt us physically, neurochemically and emotionally.  It is common for people to respond to such distressing events with three clusters of symptoms : Intrusion or re-experiencing; hyperarousal; and constriction, numbing and avoidance.

These symptoms often appear within the first days after a trauma. They usually are very intense at first but eventually subside. Sometimes, however, these reactions are delayed.  Couples  who pull together in the crisis, manage  the deployment,  or work side by side after the storm are baffled when things become tense and symptoms erupt four months after Iraq, when the hospital stay is over, when life is supposed to go on.

You may recognize some of these reactions in yourself or your partner. You may be worried about post-traumatic stress disorder (PTSD), a persistent pattern of these symptoms lasting more than a month  for which you may seek professional help. Even in such cases, understanding these symptoms as normal responses to an  abnormal situation will help you manage their impact on your relationship. Let’s consider them.

Re-experiencing symptoms are  like being caught in the indelible imprint of the traumatic moment. It is as if the hospital scene, the oncoming truck, or the explosion are playing over and over again,  in the form of  a nightmare, a flashback,  a frightening thought or a traumatic memory. Although bewildering and disturbing, such repeated intrusions are actually the mind and body’s way of assimilating or fitting  an incomprehensible experience  into your  existing life schema.

Recognizing re-experiencing as a common response may change your reaction.  When you realize that your wife is watching  reruns in bed to avoid closing her eyes and seeing the accident scene,  you may be less likely  to feel rejected, get mad or blame her for sleep problems. Perhaps you will watch some of the reruns together, remind her that you are next to her,  validate the memory as common after the car accident. You might even ask if she wants to talk about the traumatic memory. According to traumatologist Judith Herman,  “the action of telling the story in the safety of a protected relationship can actually produce a change in the abnormal processing of the traumatic memory.”

Hyperarousal symptoms reflect  the persistent expectation of danger. It is as if your body and mind have not computed that you are no longer in danger.  The inability to relax, constant worry, irritability, sleep difficulties, hypersensitivity to noise, smells, and taste actually are reflections of your body’s fight-or-flight response to danger.

It often comes as  a revelation to partners that the irritability they feel and often direct toward each other over lost keys,  noisy kids, and traffic jams has very little to do with them and much more to do with the hyperarousal they are feeling from the traumatic experience one or both has suffered. Putting behavior in context  can prevent you  from overreacting or retaliating.

Numbing and constriction involve  physical and psychological “shutdown” in order to protect oneself from being overwhelmed by feelings. Often people blame themselves for being unable to cry, or one partner misinterprets numbness in the other as a lack of care or concern. It is hard to realize that we may constrict or unconsciously hold back feelings because we are not emotionally safe enough to deal with them. This is somewhat like the kid who gets hurt in school but holds it together without tears until she sees Mom at the bus stop. Avoidance urges often reflect an attempt to avoid those things that trigger feelings and distress symptoms.

It really helped one couple understand that his negativity and refusal to ” go anywhere or do anything” was really his avoidance of  hearing people ask  ”How are you doing?”  -  the question that immediately triggered the pain of  losing their son in Iraq and the angry urge to answer “How do you expect us to be doing?”  Once she realized and could appreciate the triggers and feelings he was trying to avoid, she could stop feeling so isolated and annoyed. Together they agreed to try going somewhere with the plan of signaling  “time to escape” when needed.

Essentially, understanding  common trauma reactions reduces the fear that you, your partner and the relationship  is forever changed or damaged. Often it gives a couple the language to talk about  and deal with what they observe in themselves or their partner without shame or blame. If you are human, you will react to trauma.  When you are standing next to someone who understands this,  it feels a lot safer.

For Further Reading : Herman,J. 1997. Trauma and Recovery. New York: Basic Books.