Her Story
This last case study will appear under one name although it is a compilation of a great many different stories. What these stories have in common is a diagnosis: compassion fatigue or secondary posttraumatic stress. This is the PTSD of the witness, the by-stander, the observer. This is the trauma which comes from repeated proximity to trauma. Trauma is traumatizing, and being the witness and listener to repeated and frequent traumas is traumatizing, as well.
There are millions of us who, with moderately strong psychic houses, are determined to undertake lives of service. In fact, we entered the adult world with a mission to help. We are the police officers, firefighters, doctors, nurses, medics, social workers, ministers, priests, rabbis, therapists, teachers, corrections officers, wardens and the inner city workers.
We don’t all suffer from secondary PTSD, but some of us do. What is different about us? Clearly, there are a few main distinctions. First, our temperament predisposes us to absorb trauma. As we talked about in Joy’s story, NFs on the Myers/Briggs test are the great absorbers. We are the thin-skinned folk who cry at the AT&T ads and actually feel each other’s pain, which is the meaning of empathy. This is our great strength and our great weakness. I would estimate about two-thirds to three-quarters of all therapists are NFs.
A second susceptibility to PTSD comes from having had trauma elsewhere in our lives. Trauma builds on trauma. Early trauma, especially childhood trauma, seems to make us more likely to absorb later incidents as trauma. A medical analogy is that you had to have had the chicken pox to be susceptible to shingles. Seems unfair, but, as many of us are fond of saying, it is what it is.
A third predisposing factor is the nature of the trauma or the degree to which we are exposed. I’m reminded of a colleague telling me about something she witnessed in the emergency room. It should have been an uncomplicated birth. Instead, everything went wrong. She described it in gruesome detail, which is how she remembered it, and the way it was imprinted on her brain and in her heart. I’ll spare you the images and simply say that this jarring tragedy will always haunt her and will remain cemented inside her memory banks. So, the horror of the trauma is certainly a factor.
One’s mental state at the time of the trauma and immediately thereafter is a fourth factor to be considered. Someone who works every day with low level trauma, for example, doing police work, or staffing the emergency department, is more prepared for horror than, say, Jackie Kennedy who was enjoying a calm ride in a convertible, surrounded by Secret Service men, the sun shining brightly on her pink suit when unfathomable trauma came from out of nowhere to alter her life.
What happens immediately following the trauma is also an important component. I worked with a police officer who was repeatedly shot at when he arrived on a domestic violence call. The shooter then turned the gun on his wife and held her hostage. The SWAT team was called and arrived with a crisis intervention specialist whose job it was to de-brief and de-traumatize the officer. Being in a situation where one is tended to and treated with respect is a great asset. Think again of Carrie’s story and her friends who surrounded her and “carried” her.
And then there is the Chinese water torture type of trauma which affects many therapists. It’s the combined weight of the water that does you in, as well as the constant dripping. A few drops alone would not take you under, but add enough drips and we’ve got secondary PTSD.
Let me give you an example of what a therapist might hear in one day.
Hour one: a young college student has lost a parent and a favorite grandparent weeks apart and is in despair.
Hour two: A thirty-something woman is a sexual abuse survivor. This week alone she had her car repossessed and the relative with whom she was living has asked her to relocate somewhere else. In other words, she’s been kicked out of her home and has no transportation.
Hour three: A woman in her fifties has been married for thirty years to a wealthy, successful businessman who happens to be addicted to cocaine and has decided to take shooting lessons and join the NRA.
Hour four: A woman, this one in her late forties, a cancer survivor, has never worked because her husband wanted her to stay home and raise the children. After almost thirty years of marriage he has decided to move out, stop paying the bills, send the house into foreclosure and declare bankruptcy.
Hour five: A high school student’s parents are divorcing. Dad has actually moved in with a new girlfriend and her children although there is no divorce yet, leaving mom with a house she can’t afford, no car, and their four kids. The client, at fifteen, is the oldest.
Hour six: A forty-something man explained that his wife has had an affair with a co-worker and, consequently, lost her job. The co-worker, her boss, retained his job. The man loves his wife, but how do you get past three years of lies and a secret life?
Hour seven: Two former high school sweethearts reconnected after a dozen years and quickly married. Almost immediately he got laid off and, while staying home, expanded his interest in pornography to an eight hour a day addiction.
Hour eight: One member of a blended family arrives to start therapy. The family includes a mother-in-law with dementia and a high school aged son with a pregnant girlfriend. The new client reports feeling anxious.
If a friend had one of these stories to tell, you’d go home with a headache. But on they come, one after another, and through it all you feel like the emergency room doctor watching the woman who overdosed on Tylenol and knowing there is nothing you can do, or the police officer at the scene of the wreck where, while waiting for the Jaws of Life, the hand in his grip goes limp, or the firefighter who has to bring out of the house the small, lifeless body he found in the crib.
There is a helplessness so profound that it can be disabling. How does one stand by and watch the horror of life? How does one clean up after the careless smoker? How does one sit and listen as the stories tell themselves and the tellers empty their pathos into our laps? Well, most therapists do it very well. But, that doesn’t mean it doesn’t take a toll. The toll is called secondary PTSD.
Our Signs
Anxiety, depression, apathy, cynicism, alcohol, drugs, shopping, eating, gambling, watching television, religious fixations, sick jokes, fast cars, affairs, isolation, agnosticism, computer games, incessant reading, over exercising, and a fascination with vitamins, make-up and anti-aging creams are a few of the symptoms of secondary PTSD. In short, therapists self-medicate in every way others self-medicate. And it doesn’t make a bit of difference that we might have some good reasons or some benign intent. The possibility for a therapist to fall into a really bad habit or slip into an addiction is ever present. Life is dangerous for all of us, and for those witnessing pain, life is painfully dangerous, just as it is for those actually experiencing pain.
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For those who live in and around pain,
Life is painfully dangerous.
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Anxiety is one of the most prevalent symptoms of secondary PTSD. Our brain chemistry seems to accustom itself to the little shocks and jolts of the trauma we hear all day. I know I sometimes feel myself bracing for what’s coming, preparing, as if I could prepare, and then second-guessing. Should I have said that? Did I miss what the client was trying to tell me? While some therapists, because of their anxiety, get too sure of answers and start making pronouncements instead of offering possibilities, others of us become even more unsure, and our anxiety slows us down as though we are less likely to make mistakes if we move more tentatively.
The anxiety a therapist experiences is understandable. Someone comes in and offers us one side of a story for an hour at a stretch, and we’re expected to guide them to do things such as stay married, separate from parents, leave their spouse of decades, change jobs or place an elderly relative in a nursing home. Clients come to see us when they find themselves in the midst of life’s turmoil, unsure of which way to turn, and they’d like some objective guidance, often some moral guidance. I’d like a quarter for every time I’ve asked a client what he or she thought the high road would be in this case and then suggested he or she walk that path. Are we trained for this? Yes, as much as one can be trained. You can train a teacher or a doctor or a therapist, but most of us are born for our roles and the training simply makes conscious much that we know intuitively. None of that, however, negates the anxiety.
I can feel when my anxiety is the worst. It will wake me in the night and I’ll find myself replaying a conversation I had with someone or rehearsing a conversation I’m soon to have. My anxiety is also bad when I lose my vocabulary or find myself starving right after I’ve eaten. These are clues to me that I’m not paying attention to myself, not staying in the present. Another indicator to me that I’m feeling anxious is my need to supply answers. In my calmer states, I’m content to listen to and be with a client. In my anxious state, I feel like I need to fix things.
I get disorganized when I start feeling depressed. I’ll let my paperwork slide, my handwriting becomes sloppy and my desk starts piling up with stuff I usually handle efficiently. I stay in my office and close my door, eschewing people when I’m sliding into a depression. I’ll say “no” when friends want me to do things with them and I’ll isolate over weekends, too. Colleagues tell me they find themselves unable to do their art work or pursue much loved hobbies when they’re depressed. I’m certain, although I don’t remember ever reading it anywhere, that depression and creativity are mutually exclusive. (Not madness and creativity. That’s a different issue.) I’m talking about normal, mentally stable people who have bouts of both creativity and depression. When we are involved creatively, depression seems to recede. When we are depressed, those creative urges are nowhere to be found.
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Depression and creativity
Are mutually exclusive!
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Writing this book, doing this creative project, I find myself energized and not feeling depressed at all. I am, however, taking an anti-depressant medication every day. I told my primary care physician what I did for a career and that I was feeling overwhelmed, and he asked no questions. He just wrote out a prescription.
Every once in a while I’ll decide I no longer need my anti-depressant. Fortunately I have a daughter-in-law who, after I’ve skipped the medication for less than a week, will say to me, “Are you still taking your Celexa? Because you have been cranky and short the last few days.” Gee, I wonder if I really need it, don’t you? That’s one thing I’ve observed about anti-depressants. You won’t be able to tell as much difference in your mood or well-being as will the people around you. You need a trusted family member or friend you can count on to monitor you and whose head you won’t bite off if they report your increased edginess.
When you find yourself not caring as much about work, not feeling that your efforts are appreciated or worthwhile, that’s a sign that you might be experiencing PTSD. Withdrawing from favorite activities, giving up an exercise program, for example, or not playing the piano when you usually play a couple times a week, these are all signs that should be taken seriously.
Clearly we all know that if we start thinking about that cold beer earlier and earlier in the day we need to pay attention. I’ve heard people who are suffering from PTSD also talk about not being aware of how much they’re drinking or how many packs of cigarettes they’re smoking. That’s because one of the telling signs of posttraumatic stress is not being truly present for life. We live unconsciously when the conscious, real world becomes too much. This is a sign that it’s time to make some life style changes.
Changes in behaviors, like more snacking, a craving for the oil and salt fast food provides, disrupted sleep or sleeping a lot more, shopping with a new vengeance or quitting the golf league you used to live for, are all warning signs. Any sort of isolating behavior and withdrawal from groups or family functions are signs of trouble. Now, let’s be real. We all go through periods when we reorganize and reprioritize our lives. That’s different. You can feel the difference from inside. The one you are controlling. The other is controlling you.
Last on the symptom list is falling for the physical self-improvement come-ons, which include anti-aging creams, new exercise equipment, the latest fad diet or any other type of the commercialism which suggests, “You’re not okay the way you are. If you spend your money the way we want you to and buy what we’re selling, you’ll feel wonderful. Any profit we make from you is merely happenstance.” Falling into this, whether it’s as serious as cosmetic surgery or as negligible as some fancy new face cream, is another indicator of a trauma reaction. What this indicates is that you don’t feel all right. Something needs to change. Why do we always start on the outside when this urge hits us? It never works. Camp out in a therapy waiting room sometime and check out all the beautiful, thin, cosmetically perfect women and all the buff, handsome fellows. Exterior perfection doth not a calm countenance produce.
Our Steps
Medicine is very helpful. Secondary PTSD, because it is less deep-seated than childhood or combat PTSD, seems to respond very well to anti-depressant medication, especially those medications with an anti-anxiety component. Your primary care physician or physician’s assistant will be able to guide you to a medication which will take the edge off your edginess. If you had bronchitis or a sinus infection, surely less severe than pneumonia, you’d still take an antibiotic. Remember, it doesn’t matter if the elephant is standing on your little toe or your whole foot, you are in trauma.
Therapy is very beneficial. Practice what we preach, eh? Quite a few practices offer a support group or a therapy group just for counselors. It would be common for a couple of therapists at a practice to form their own group based on similar ages or similar temperaments. They might meet once a month and talk about what’s on their minds and what is heavy on their hearts, from personal matters to general practice issues. A great many therapists are also “in therapy” as the client.
Creativity is a sure-fire help with secondary PTSD. In one practice, for example, a practice of about twenty therapists, there are four artists, two gourmet cooks, a couple of great and devoted gardeners, an interior designer, a practitioner of energy work, a couple of writers, and that’s just the women. The men practice, as do a number of the women, yoga, Tai Chi and martial arts. Almost all are walkers, from casual strollers to a marathoner. One of the men has horses and another has a small farm on a lake.
Many therapists also have spiritual practices. Mine consist of playing the piano, reading theology, and meditating. Colleagues have altars for meditation, spiritual groups to which they belong, religious affiliations, reading, and prayer rituals. It would be very difficult to do this work if one were without a faith background and felt life was transient and purposeless. Often it is only our faith, in the wide ranges of whatever faiths we possess, which compels us to labor on and trust that all things will be revealed in their own good time.
My Story
This whole book is, of course, my story. These case studies are a vital part of the pathway to my understanding of posttraumatic stress. I’ve said earlier in these pages and I want to repeat once more that I am not an expert on PTSD. These stories, signs, steps, tipping points, hypotheses and adages are what I’ve found and fashioned over the years to help me and those with whom I spend my days. If they are a help to you in any way, I am delighted. If they are not, I am sorry. Therapy is not one-size-fits-all. Different clients resonate with different therapists, and different therapists resonate with different therapeutic theories and techniques.
Even so, there are a few observations I would like to add before I end this story.
The first is to encourage you to use medicine if you or your doctor feels it is necessary or could be helpful. So many people believe anti-depressant medication to be “mind-altering” or “numbing.” Nothing could be further from the truth. The medications used these days are SSRIs: selective serotonin re-uptake inhibitors.
In our brains are (among other things) serotonin, norepinephrine, and dopamine. Typically a doctor will first try to adjust a serotonin level. The SSRI mimics a natural function by keeping the serotonin in our brains. When we are under stress for as little as three weeks, our serotonin levels drop. And when we further anticipate stress, our bodies flush with and absorb the serotonin from our brains, emptying our brains of this “resiliency” chemical. Serotonin in our brains acts like shock absorbers in a car or insulation in a house. We are spared the worst jolts and the worst blasts--they are minimized by the protective layer of serotonin. An SSRI is a serotonin re-uptake inhibitor. It keeps the serotonin from being transferred into our bodies. It keeps the natural chemical in our brains. In effect, it closes the escape route.
Most psychiatrists say 85% of all the people who start taking an anti-depressant stop the medication too soon. Many experts estimate that most of the medications should be taken for two to five years. Some people might need such medication for the rest of their lives. If you live where there are distinct seasons and winters are colder and greyer, the only time to try going off anti-depressant medication is in the spring, when the days are growing longer and the sun is shining more brightly. That way we have nature on our side supporting our efforts.
What happens to us if we need anti-depressant medication and don’t take it varies. Here’s my metaphor of how it might be. Our brain is a glass bowl. We have water in the bowl, and the water is the serotonin in our brains. We float miniature marshmallows on the top of the water. These are the neurotransmitters in our brains. They need to talk to each other--to fire off each other and bump each other and communicate. Obviously, the more water (serotonin) in our bowl, the more the marshmallows (the neurotransmitters) will move.
The neurotransmitters move and this keeps a flow of ideas and thought processes moving in our minds. As the water level (serotonin) in our bowl lowers, which it will do whenever we are stressed, the marshmallows (neurotransmitters) get stuck on the side of the bowl. Our thoughts get stuck. Now I have never seen anyone’s thoughts get stuck in a positive way, repeatedly saying, “I’m talented,” or “I am a good person.” No, instead our marshmallows always get stuck in the negative: “I wonder if he paid the mortgage. I bet he didn’t pay the mortgage. That irresponsible moron is pushing us into bankruptcy. I bet there’s a tag on the door. Does the sheriff come and make you leave everything in the house? What about my mother’s silver?” The ideas are absolutely stuck on this negative run-away train of thought.
I remember working with a couple who really used this image to catch each other. He was on a rant during one of our sessions, and his wife finally punched him in the ribs and said, “Your marshmallows are stuck!” He was taken aback, but really it’s difficult not to laugh or at least smile when someone says to you, “Your marshmallows are stuck.”
Anti-depressants unstick your marshmallows by keeping a necessary level of water in the glass bowl. Try explaining that to a psychiatrist. Call me if they try to lock you up. I’ll come keep you company.
A second generalization I want to mention is that our minds and our bodies are a unit. If you are having gastro-intestinal problems, by all means, see your physician. But remember that all the Prilosec in the universe isn’t going to be effective if you keep thinking and believing and perceiving in ways which keep you in a constant state of stress. Likewise, if you are seeing a therapist to help with the stress, go to a physician and get the heartburn medicine, also. Anything which aids our bodies aids our minds, and anything which supports our mental health will strengthen our physical selves as well.
Many people come into therapy riddled with self-doubt because physicians have been unable to find the answers to ailments which are manifesting in their bodies. Pain, especially, can be such a difficult symptom to pin down. Mental issues like guilt and resentment and shame can show up as physical symptoms. Just because something manifests as a physical symptom doesn’t mean it has only a physical cause, and just because something manifests as a mental health issue, anxiety, for example, doesn’t mean there is only a mental cause. I defy you to have irritable bowel syndrome and not get anxious. For another example, mitral valve prolapse demonstrates the circularity of physical and mental health issues. The heart valve malfunction can cause fatigue, palpitations, chest pain and migraine headaches. This is what anxiety feels like, too. So, are you anxious because your heart is doing something weird or is your heart doing something weird because you’re anxious? Sometimes, many times, the answer is both.
Third, therapists’ offices and doctors’ offices must be safe places where you can tell experiences which are humiliating and shameful. They must be. I have a client I’ve seen on and off for a number of years. She admits that sexual intercourse is painful for her, but she can’t bring herself to tell her gynecologist. Some things are really embarrassing to talk about. So, write it down and hand the doctor a piece of paper. But find yourself a doctor and a therapist you can trust. Word of mouth and networking are great ways to hear about recommendations. Just remember, this person must be someone you can trust, not someone trusted by your friend or your aunt or the car mechanic. A “good” therapist or doctor is the one who is good for you.
Fourth, I fear I have made PTSD sound a lot like alcoholism: you’ll always be in a state of recovery. Yes, I believe that to be true. However, alcoholics who stop drinking and work a program live fulfilling, serene lives and have fulfilling, secure relationships. Likewise, admitting and realizing that we are post-traumatic stress survivors will make a big difference in the quality of our remaining lives. We may never trust as easily as others and we may have to check ourselves for our own paranoias and prejudices, but is that so different from everyone else? We humans are an idiosyncratic lot. You may always have PTSD. I would say you would. The trick is transitioning from victim to survivor. The talent is in playing the cards we are dealt. The tipping point is often in reaching out to a trusted friend or a therapist and asking for some help.
Fifth, here are some general observations for every one of us, but even more essential for PTSD survivors:
Be kind to yourself.
Trust your own intuition and instincts.
Give your power away to no one.
Find blessings every day.
Give gratitude away.
Participate in only reciprocal relationships.
Learn to love silence and the beat of your own heart.
And lastly, PTSD is an explanation, not an excuse. It’s up to you to make something positive out of everything that happens in your life, and PTSD is no exception. It is blatantly unfair that you are a posttraumatic stress victim. But you are a survivor. You’re reading this book and I’m sure this is only one of the things you’re doing to help yourself heal and be healthy. Keep it up. No one will do it for you. No one can. Only you can determine that this life you are living is going to be lived to the fullest and the richest and that no one--not a violent husband, not a voyeuristic brother, not a satanic mother, not a molesting father, not a sexually exploitative brother, not a neglectful mother, not an abandoning father, not an abusive, violent father, not a set of narcissistic, neglectful parents, not a sexually violating father, not a blaming mother, not combat, not drugs, not alcohol, not our temperaments, not adoption, not minority status, not a rapist, and not a life work which is challenging, draining and heart-breaking--nothing, nothing, nothing is going to keep you a victim when you can be a survivor. So, you have posttraumatic stress. What are you going to do about it?