Healing after Trauma: Ten Steps Forward, Nine Steps Back
Most of us have suffered psychological wounds. Just as the body can be damaged, so can the mind. But the similarity ends there, because mental and physical injuries heal by different means.
At another time I’ll explore physical healing in detail, but for now a brief outline will suffice:
A wound to flesh and bone heals through sequential processes of fibro-vascular ingrowth, scar formation, and remodeling. Early steps focus on restoring basic integrity. The first-responders are inflammatory cells that establish barriers and plug leaks. They patch the tissues temporarily, like homeowners securing a tarp over a leaking roof in a storm. Just as the tarp can be blown away by a strong wind, the initial repairs of injured tissue are delicate and easily disrupted. Later, after the acute emergency, more permanent work gets done. The roofing crew tacks down new shingles; the immune system sends in cells that lay down collagen to generate scar. In due time, remodeling follows. Perhaps sections of roof are replaced; scar tissue is strengthened in some areas and softened in others. Fractured bones knitted together with collagen grow harder and stronger across the break.
The body slowly settles on a new form. A minor injury may leave little trace. A major one will sport a permanent scar. But over time healing stabilizes. The pace of change slows, and a new equilibrium is achieved.
In comparison, psychological recovery is only loosely analogous to physical healing. It’s true that early steps differ from later ones, but there is no emotional sequence as predictable as fibro-vascular ingrowth, scar formation, and remodeling. Early on, the personality does its best to cope with overwhelming terror, grief, humiliation, or despair. Denial is very common. To outward observers, the rape victim or bereaved spouse may seem superficially normal, acting as if she or he is doing fine. In other cases, there may be an appearance of collapse; the traumatized person may spend hours sobbing hopelessly, or refuse to get out of bed. Rage is not uncommon, and since the cause or perpetrator of the trauma is usually out of reach, friends and family may endure outbursts and hurtful attacks.
Elizabeth Kubler-Ross outlined five stages of grieving (denial, anger, bargaining, depression, acceptance), while emphasizing that they don’t necessarily follow one another in predictable order. Depression may precede anger; bargaining may come before denial, and so on. There is great variability.
Response to mental as opposed to physical wounding is not stereotyped. It adapts to temperament, personal history, social expectations, psychological insight, maturity, and fatigue. The rape victim who was raised in a safe, loving home will likely react differently from one who was molested in childhood. The newly diagnosed cancer patient with a robust support network may look less fearful or enraged than one who feels isolated.
And yet, fairly consistent modes of adaptation can be identified. Kubler-Ross’s observations confirm that healing after major loss does not occur haphazardly, even if its precise contours aren’t predictable. Although the relative pace, emphasis, and ordering of denial, anger, bargaining, and depression are variable, people tend to cycle through most of them as they stagger toward acceptance after major loss or injury.
Another regular feature of healing after neuropsychological injury is relapse. Here we can compare trauma resolution with addiction recovery. Although Alcoholics Anonymous and other 12-Step groups often treat recidivists as failures who must start over at the beginning, professionals who work in the field know that ‘slips’ are common and sometimes even helpful. For instance, a chaotic relapse after a period of stability may help the addict see more clearly the damaging effects of his or her compulsive behavior.
Relapse can occur after physical injury, but it is less characteristic. Backs that have been weakened by repetitive stress may suffer periodic debilitating spasms. A person who heals after a badly sprained ankle may find the ankle gives way more easily in the future. But in many cases an injury heals almost completely. There may be residual weakness or ongoing pain but it is not common for wounds to reopen or bones to re-break spontaneously or after slight impact.
Yet in the psychological realm, a full-blown meltdown or flashback may follow what seems like a trivial stimulus, even years after the original trauma. The war veteran walking down a suburban street hears a car backfire and dives for cover. The young college student who suffered childhood sexual abuse goes rigid with terror when her new boyfriend places a hand on her thigh.
I have experienced emotional relapse with disturbing regularity, despite considerable improvement. Years ago, I was consistently jumpy and reactive, quick to lash out and slow to trust. Nowadays, I am calmer and less defensive, but I remain prone to regression.
In the face of too many frustrations, I lose my center. A friend’s ill-chosen words may disturb my sleep; and if some project I’m working on encounters obstacles the next day, the combined effect may leave me doubting the quality of my relationships and personality. Even as I try to breathe evenly and maintain perspective, I grow tense and grumpy. Sometimes it gets so bad I end up thinking death might be preferable to life. I no longer contemplate suicide, but the thought that a sudden heart attack might be welcome has a way of undermining confidence in one’s mental health.
This is discouraging, to say the least. Despite years of meditative work, psychological exploration, and journaling, despite my commitment to learning from hardship and embracing life on its own terms, I sometimes feel almost as despairing as in the old days.
The word almost in that last sentence is key. My thinking gets almost as unbalanced, my mood almost as foul, my faith almost as vacuous. I call this: ten steps forward, nine steps back. Because if I look closely, I see that although the despair feels familiar, it is less intense and stubborn than before. It doesn’t lead me to contemplate suicide, and it seldom lasts more than a few hours; usually I wake up the next day feeling back on track. What’s more, as time goes on relapses occur more and more rarely.
Ten years ago it wasn’t uncommon for me to be depressed and near suicide for days on end, with few ‘breathers’ between episodes. Nowadays I feel down only occasionally and for brief periods. Even better, my baseline is more optimistic and enthusiastic. Rather than living with a stubborn low-grade depression and rare hypomanic lifts, I now enjoy a background state of sweet (if slightly sad) acceptance with occasional hours of serenity–or even bliss–during meditation.
If you repeatedly move ten steps forward and nine back, after a few thousand cycles you can cover a lot of ground. It may seem unfair that others move faster, but in most cases the swift are less burdened by baggage. To walk one mile dragging a steamer trunk of sand may be more of an accomplishment than walking ten carrying only a canteen and an apple.
The fact that psychological recovery is fraught with relapse is explained by the science of learning. When an experimental animal hears a tone and then receives an intense electric shock, after just an exposure or two it will react anxiously to the sound of the tone alone. If thereafter the shocks cease, the animal will gradually lower its defenses and begin to ignore the tone. But even after a long period of safety, if the tone is followed by just a mild shock, the animal’s terrorized behavior is likely to return full-force. Th learned behavior, it appears, was displaced rather than erased. It remains at the ready should old threats return.
Unlike physical wounds that heal by means of steadily strengthening scar tissue that replaces weaker repairs, psychological wounds heal by the adoption of new patterns while the old, wounded reactions remain programmed in the nervous system. The reactive mode is not overwritten, and it remains in the background, perpetually vigilant. The person recovering from trauma may gain tools for reacting less strongly or settling more quickly, but deeply ingrained fears are never permanently extinguished. The best we can aim for is less frequent and intense reactions with quicker recovery.
It can feel discouraging to suffer a recurrence after months of stability. But as addiction specialists understand, the subsiding of reactivity does not proceed by a smooth trajectory. It’s more like a receding tide whose progress can only be seen over the long term, while in the short run outsized waves occasionally break upon the drying shore.
Despite the differences between physical and psychological healing, in both circumstances the organism can recover, especially if we arrange circumstances to favor healing. In the case of bodily wounds, one aims for good nutrition and appropriate patterns of gentle activity versus needed rest. In the case of psychological injury, one works to avoid repeated trauma while building up a sense of safety and support (for which I recommend Rick Hanson’s book, Hardwiring Happiness, as a helpful tool). Of key importance is recognizing the patterns of normal healing, so that relapses aren’t viewed as failures but as steps along the path to wellness. Ten steps forward, nine steps back is the normal pace of recovery from psychological wounds.
Meecham, W. (2015). Healing after Trauma: Ten Steps Forward, Nine Steps Back. Psych Central. Retrieved on October 16, 2017, from https://blogs.psychcentral.com/childhood-adversity/2015/03/healing-after-trauma-ten-steps-forward-nine-steps-back/