Safety and control: Michael McCafferty. Photo:Teri Currie

Back from the Wasteland
By Miriam Axel-Lute

Post-traumatic stress disorder is a normal human reaction to abnormal events, but therapists are still mapping the long road its sufferers must take to feel normal again

When Beth Marie Murphy returned to the United States after a year working as a nurse during the Vietnam War, she nearly got herself court-martialed for telling off a superior. She was seriously depressed, and moved 26 times over the next two decades. “I knew something was wrong, but I didn’t know what it was,” she says. Bob Cagle, also a Vietnam veteran, experienced similar things. “I was angry all the time,” he says. He drifted among 14 jobs in his first few years back.

In 1993, Murphy attended the dedication of the Vietnam Women’s Memorial in Washington, D.C. At a panel discussion, one woman began describing post-traumatic stress disorder. “I said, ‘She’s telling my story!’” recalls Murphy, who worked in the orthopedic international ward, mostly with Vietnamese women and children who’d lost limbs. A short time later she attended a workshop called Healing the Healers. “All I could do was cry, all weekend,” she said. Her newfound awareness brought memories flooding back, and symptoms—nightmares, an extremely sensitive startle reflex, and anxiety (“I felt like something awful was going to happen all the time”)—began to build until they became “almost incapacitating.”

People who’ve experienced trauma can show symptoms of many mental illnesses—depression, voices/visions, dissociation, extreme anxiety, violent acts, inability to concentrate, personality changes, and substance abuse. For a long time these people were either diagnosed as mentally ill, or told there was nothing wrong with them. It still happens frequently, with large numbers of people falling through the gaps in a philosophical war between those who believe that diagnoses like ADHD, depression, and anxiety disorder describe diseases of biological origin that can be treated (though not cured), usually by drugs, and another camp that says that the majority of these “disorders” are just labels put on behavior that current society disapproves of (much like homosexuality was once considered a mental illness), and that mostly we need to become more tolerant of diversity.

Neither of these views describes the plight of one student at Albany’s Free School, says Chris Mercogliano, the school’s director. She had lived the first few years of her life in a violence-ridden neighborhood. When she first came to the Free School, around age 4, he recalls, every time she bumped her head, however minorly, she would clutch it and scream “I’m bleeding! I’m bleeding!” Mercogliano doesn’t know for sure, but he guesses she may well have witnessed someone being shot when she was very young. “Now, are you going to say she had a brain disorder?” he asks.

“There used to be a distinction between mental illness and emotional disturbance,” notes Ed Tick, an Albany-based therapist who focuses on trauma work, especially with veterans. If we separated out all the cases where emotional disturbance was caused by external forces, says Tick, the number of people considered to have an organic mental illness would “shrink way down.”

Post-traumatic stress disorder, an official name for the long-term effects of trauma, was first coined after the Vietnam War, when psychologists were finally convinced that trauma after wartime experiences was not the result of a previously unstable personality. It’s a different kind of label than most in the mental-health field, in that it explicitly acknowledges that the cause of the problems was entirely external. In many people’s minds PTSD is still primarily associated with the experiences of combat veterans, but in fact PTSD can be caused by any traumatic occurrence—such as sexual assault, childhood abuse or neglect, violent crime, car accidents, or natural disasters.

Trauma is not a casual term. The requirements for a diagnosis of PTSD, says Joe Benamati, an expert in childhood trauma recovery at Albany’s Parsons Child and Family Center, which works with abused and neglected children, include that the experience be “outside the realm of normal human experience. It’s not breaking up with a boyfriend or girlfriend. It has to evoke a sense of hopelessness and helplessness.” The psychology diagnostic manual, the DSM-IV, specifies that the experience involve “actual or threatened death or serious injury, or a threat to the physical integrity of self or other.”

For children, it’s generally accepted that neglect and fear of abandonment also qualify. “Expressions of violence, threats of withdrawal of love can be just as traumatic as physical violence,” says Mercogliano.

And, Mercogliano notes, behavior problems in school can be triggered by events that may not be quite as serious as those that meet the PTSD definition, such as a bitter divorce. “Take a kid having trouble concentrating,” he says. “For some kids it’s because all hell is breaking loose at home, and they’ve left part of themselves at home to keep watch.” Mercogliano hastens to add that reactions are extremely variable and cannot be generalized.

In the face of trauma, “PTSD is a breakdown of the normal stress response,” says Benamati. “With a normal stress response, we’re motivated to do something. . . . With traumatic stress we freeze in our tracks.”

PTSD pushes people into “a wasteland. There’s no guideposts, you don’t know what to do, where you are, how to react,” says Michael McCafferty, a readjustment counseling therapist at Albany’s Vet Center on Central Avenue. The Vet Centers are an independent network within the federal Veterans Affairs Agency, and were started after Vietnam veterans were disappointed with the care they were receiving elsewhere in the VA system. They focus on readjustment counseling, especially PTSD.

For adults, at least, some people who work with trauma say the basic manifestations of PTSD are actually remarkably similar. “I’ve seen people with a diagnosis of PTSD from a wide range of traumatic events,” says McCafferty. “How they present is pretty much distilled down to the same things.”

Key symptoms include reexperiencing in some way—whether through flashbacks, nightmares, or “intrusive recollections,” avoidance of things that would remind the person of the event(s), and physiological arousal when reminded of the event. Trauma actually affects the brain in measurable ways, say neuroresearchers, including hyperactivity in sensory areas and depressed response in verbal centers. In children it may actually slow or stop growth in certain areas.

The official definitions translate into many symptoms that by themselves could be mistaken for other problems. McCafferty says he knows veterans who won’t go to a grocery store until 2 AM to avoid crowds. Many have problems with panic, and with substance abuse. Adolescents frequently reenact their trauma, says Benamati, through destructive behavior, and younger children often freeze in the development age when a trauma occurred, so that a 10-year-old who lost his parents at age 5 may still be acting like a 5-year-old. Others develop obsessions that in some way represent or allow them to grasp their trauma, says Mercogliano, who has often observed a correlation between autistic children’s areas of obsession and their life histories.

Attached to kids: (l-r) Richard Kagan and Joe Benamati.

Part of the reason PTSD has gone underdiagnosed its that not everyone who experiences a traumatic event will end up with it—only about 10 to 15 percent will, and it’s very difficult to predict who it will be. There can be people who saw combat who didn’t end up with it, and people who stayed on a base who did. Such disparities can make both the sufferer and those around them slow to validate their experiences.

Tick thinks the traditional clinical definitions are weak descriptors for what most traumatized people have experienced. “It’s not an anxiety disorder, it’s a soul wound,” he says firmly.

“In Post-traumatic Stress Disorder, the soul has fled body, world and cosmos. It will not return if this flight and its resultant lost condition are not recognized and directly addressed,” Tick writes in “Souls Lost in the Wars of the World,” published in Spring: A Journal of Archetype and Culture. He describes an experience many psychologists would call dissociation, in which veterans describe their souls leaving their bodies and hanging out nearby, safe and removed from the horror.

There are differing opinions among practitioners on why PTSD still frequently goes undiagnosed and/or overmedicated, though many say that since Sept. 11, 2001, awareness and training have increased to where many more cases are being identified. McCafferty, of the Vet Center, says that that these days, overmedication often happens because people frequently get all their medications from their primary-care provider, who may not be trained in recognizing or working with trauma survivors—but who may be quite ready to prescribe antidepressants or anti-anxiety meds, for example. McCafferty also sees plenty of people who were given a mental-illness diagnosis decades ago, before the concept of PTSD came into common parlance. Such a diagnosis can be hard to shake.

Mercogliano, whose 2004 book Teaching the Restless has a strong antipsychoactive drug message in it, takes a darker view. He sees a dramatic increase in the impulse to give a biological label to difficult symptoms, especially with children, and says that one reason the biological answers are so appealing is that they remove the responsibility from caretakers’ shoulders. “We’ve got ADD, ODD, you-name-it DD. . . . We’re up to 11 forms of autism now,” he says. “The beauty of the biological model is everyone’s off the hook. . . . We stop asking questions and say ‘There’s a drug.’ ”

“I’m not saying it can all be reduced to trauma,” he adds. “There’s a lot of mystery. But my experience is often [that kids with learning or attention problems] have been traumatized.”

Tick is also deeply suspicious of the rush to medication for “mental illness,” but for him it is being driven by the greed of “big pharma,” which wants to sell more drugs, and the HMOs, which want to pay for less therapy. “Business has taken over health and healing,” says Tick.

Benamati has perhaps the most hopeful perspective on the matter. “I think [practitioners] intuitively know that trauma affects their clients’ lives. [The] problem was that we haven’t had very effective solutions,” he says. “We had a psychiatrist here for many years. I asked him maybe 15 years ago why he didn’t diagnose more kids with post-traumatic stress, and he said ‘I assume they’re all traumatized—look at their families and their life histories. But there’s not much we can do about the trauma.’ And 15 years ago that was true. But not today. What we as a field have done about it for so long is we’ve worked at the symptoms rather than dealing with the fundamental issues of the trauma. So we give people medication for depression, and help them understand the 12 steps of addiction [recovery], and work on assertiveness skills. . . . But none of that got to the fundamental issues of what this trauma has done to the feeling, thinking and acting.”

Benamati and his colleague Richard Kagan are working as part of the National Childhood Traumatic Stress Network, a federally funded project, to identify and develop ways to actually work on responding to the underlying stress, not just the symptoms.

Liz Gialanella, a school psychologist in the Albany School District who works at both Albany High and an elementary school, illustrates the increased awareness Benamati is talking about. “It’s not something I was as sensitized to 10 or 15 years ago when I started,” she says. But now, “I pretty much look for trauma in pretty much any referral I have, including referrals for poor school performance.”

So how does one attack such a complex and deep-seated thing as PTSD?

Though it’s not officially listed as a stage in the process, trauma therapy generally starts with some validation of the person’s experience, and treatment won’t go forward if that validation isn’t there. “I’ve had many veterans who’ve told me that their wives do not want to hear anything about their experience, because it’s about war and killing,” says Cate Regan, team leader at the Vet Center, who calls on everyone to be more willing to listen.

“It’s important for them to realize they’re not crazy, not abnormal. What they’re experiencing is a normal reaction to a very abnormal life event,” says McCafferty.

Real Life Heroes, a workbook and curriculum for traumatized children developed by Kagan, starts with a pledge for the adults who will be going through the exercises with the child that they will listen and validate what the child says. “The success of this activity relies largely on the ability of the adults in children’s lives to show that children will truly be safe to share,” he writes in the introduction.

The first concrete goal of trauma treatment is what McCafferty calls “establishing safety and control.” He means a sense of internal safety, in terms of not being afraid of being flooded by emotions, and some basic control over, or at least self-awareness of, symptoms like anxiety or a hypersensitive startle reflex. “The best gift you can give someone with PTSD is a sense of awareness about themselves, a lead on their own reactions,” he says. “To let them know that this reaction they’ve had in the past that was overwhelming, if they have a one-second delay on it they can do something.”

For some people, establishing a sense of safety is much more practical. “Many of these children’s hyperviligance and hyperactivity is part of threat avoidance. They use it to survive,” says Kagan. “We should respect that. They’re not going to give it up anyway.” Children who’ve been traumatized or threatened by a perpetrator who is still around may need orders of protection or an escort to school, writes Kagan in Rebuilding Attachments with Traumatized Children, which accompanies Real Life Heroes. “In some cases, the most significant step in trauma therapy may be arranging for children to have a guard dog with them in their homes.”

Cognitive behavioral therapy is often used with both children and adults at this stage. This involves education about how what they’re feeling relates to what they’re experiencing, and techniques, from meditation and controlled breathing to positive imagery and “thought stopping” to break the cycle. “I use the device of asking people to in their mind think about a safe time in their life, and from that time pick an image—it might be sitting on their grandmother’s lap, it might be a family picnic on a sunny day, I don’t care what it is—pick an image and build up that image in their minds and in their hearts so they see it and they feel it, so anytime they want to, they can go there,” describes McCafferty.

Murphy learned some of these coping skills in 2001 at a several-month Women’s Trauma Recovery Program sponsored by the U.S. Veterans’ Administration. “It saved my life,” she says.

But CBT by itself isn’t quite enough to prepare trauma survivors to deal with their trauma. Why? “Trauma resides in the body,” says Benamati, quoting the influential trauma expert Bessel van der Kolk. It might seem awfully “alternative” for mainstream counselors, but the idea that the feelings and experiences of trauma are stored bodily has a wide recognition among those who work with PTSD sufferers. So many therapists pair CBT with practices like yoga or dance for adults, and play therapy, dance, music, and other creative expression for children. “Unless you heal the body first, you’ll never get people to unlock that trauma and be able to help them,” says Benamati. Some also use a practice called Eye Movement Desensitization Reprocessing that involves having a client move the eyes rapidly while recounting the traumatic events.

Once a basic sense of safety is established, the next step usually involves revisiting the traumatic experience, and telling the story. We want children to be able to tell the story of what happened to them, within the context of their whole life, and all the positive events in their whole life,” says Kagan. “We want them to be able to tell the story without having to relive the pain of traumatic events.”

Developing the “trauma narrative” is very important, says Benamati, for many reasons. Just being able to talk about it with adults reassures a child that what they experienced isn’t too horrible for people to face and deal with. Also, it allows a therapist to work on correcting “the thinking errors kids have,” says Benamati, such as “‘This happened because I’m unlovable.’ ‘This happened because I was a bad kid.’” He recalls one trainer talking about a girl whose friend was killed in a drive-by shooting who insisted that no one could sit on porches because every time they did someone got shot.

Putting the trauma narrative in context and building a new, more positive perception of the world is a major step in the process. Real Life Heroes is used at Parsons and around the country to help children ages 6-12 through this process. The workbook, filled out by a child with the help of a therapist and a supportive caregiver, involves writing, drawing, collaging, singing and rhythm work, and helps children tell their whole life story. It focuses on positive times when people cared for them or they cared for others before moving into describing their “tough times,” what they learned from them, and what would have made those better.

Once you establish safety and control, says McCafferty, then you “start to work with people on the details and the emotions attached to specific events they are struggling with,” which includes reframing the way they’ve come to look at the world.

Some programs don’t get to this step. Murphy recalls that in the program she attended, “In three-and-a-half months, we got one day to talk about our experiences of Vietnam. Any time memories would come up, they’d say, ‘You have to wait for this phase to deal with it.’”

And sometimes even constructing the trauma narrative is not enough, says Tick, who focuses on what he calls corrective experiences. One of the primary ways he does this is by leading tours to Vietnam [“Another Country,” June 26, 2003]. Seeing that Vietnam is “a country, not a war,” and taking the opportunity to give back, through some sort of charitable act, has been so transformative for some veterans that many of their symptoms, such as nightmares, cease immediately. The reluctance of mainstream treatment providers to pony up for such a powerful program troubles Tick and many of his impoverished clients. One of them told him, “The VA would save a lot of money on medication and treatment if they paid to send me on your trip.”

Tick, who completed a 12-year apprenticeship with a Native American medicine man, also uses rituals, such as sweat lodges, and “a memorial watchfire” held by a veterans’ group “to guide the souls of their dead comrades home to the spirit world. They prayed, told stories, cried out their comrades’ names to the stars, thanked them and vowed to release them.”

Tick tries to take his cues from his clients. Cagle had been having dreams leading up to his first trip to Vietnam with Tick in which he was supposed to go into the jungle and light a candle—something he never would have done while serving because any light immediately made you a target. He had the same feeling while climbing a mountain on the trip, and so Tick stopped at a Buddhist shrine with him, and they lit a candle and said prayers for a 14-year-old Viet Cong whom Cagle had killed and whose presence Cagle was feeling. The presence changed instantly from haunting to friendly.

Surprisingly, given the usually contentious nature of the discussion around psychotropic drugs, McCafferty, Tick, Benamati, and Gialanella all have basically the same perspective on them: For PTSD survivors, they only cover up symptoms, but can sometimes be useful for a limited time if someone’s symptoms are so severe that they are life-threatening or getting in the way of actual treatment. People who can’t sit still in an office long enough to focus on a therapeutic exercise or who are seriously suicidal would be prime candidates for some pharmaceutical help. Tick also mentioned those who have been depressed for so long that they need to know who they are without the depression, to “know what they’re working for.” But drugs should never be a long-term thing, and if overused, can block healing.

Agreement breaks down, however, around two fundamental questions. One is whether substance abuse should be treated before or after trauma. The Vet Center holds to the longtime philosophy that sobriety comes first, and always refers vets to a rehab center first. “People with a substance-abuse problem, the substance abuse becomes their overriding problem,” says McCafferty. “Until they are able to deal with abuse issues, they’re not going to be able to deal with the psychological issues. In our experience here, with hundreds of veterans, it has proven more effective to deal with the substance abuse first.”

But for Tick and Benamati, that approach is backwards. “We have to deal with trauma,” says Benamati firmly. “We can’t just jump to attention deficit, hyperactivity. . . . Even in traumatic bereavement, we have to deal with the trauma before the bereavement. It’s the same with substance abuse. . . . The trauma probably came first, so you that’s what you have to deal with first. . . . Substance abuse is just a symptom of the trauma, if the trauma was there.” Tick has had many clients who have come to him because others they turned to insisted they become clean before they could be helped with their PTSD, and they couldn’t do it in that order.

The other divide, or perhaps it’s more of an uncertainty, is whether PTSD can be cured or just managed. “The only reason they have PTSD is because they’ve been traumatized, and that’s not going to go away,” says Cate Regan, team leader at the Albany Vet’s Center.

“A lot of people I know who have been in treatment for a long time still avoid things, and they will always avoid them,” says McCafferty. “That doesn’t mean it’s compromised their lives. They live very fulfilled lives. I don’t think the goal should be to break down every barrier that a person might feel. The goal is to restore quality of life. Quality of life is not going to be defined by me. It’s going to be defined by the individual.”

That approach, which Tick describes as a belief that PTSD is a “lifelong debilitating anxiety disorder,” infuriates Tick. He believes that if the spiritual side is addressed, that PTSD can in fact be cured, or at least brought one step farther down the road to healing than those at the Vet Center are aiming at. Labeling PTSD sufferers as permanently disabled is a way to invalidate them as citizens and as witnesses of war, he says. And it happens because we are nervous about the magnitude of trauma out there: “If everyone talked about their pain, we’d be 250 million people screaming in agony,” he says.

At Parsons, the question is shied away from; with young kids there are more pressing concerns. “We’re most concerned with making sure kids continue to develop,” says Kagan. Nonetheless, he and Benamati stress that with a permanent attachment to a loving caregiver, recovery is possible.

“Most kids can move beyond this,” says Gialanella. “It’s not that perception that someone is scarred for life.”

Mercogliano, for his part, says experience has shown him that cures are possible. “Kids can and do get better,” he says. “Kids are usually willing to change. It’s the adults around them that struggle with that.”

Murphy, who began to work with Tick a few years ago, describes a middle ground where full healing can happen, but there’s still some effect left behind: “I really do believe it’s a spiritual wound,” she says. “It needs to be opened, drained, healed, but it will always be weak at that point.”

To some extent, the successes speak for themselves. Cagle, after going through one divorce, decades of anger that had worked itself “into his personality,” and “never being able to have an intimate moment,” made his way through the flashbacks and nightmares that emerged when he decided to go back to Vietnam, and today he says enthusiastically, “I’m doing great. . . . That trip was the beginning of my reintegration of my soul with me, being able to connect, especially with my [second] wife.” He has repaired his second marriage, gone back to school, and traveled to Vietnam a second time, and is now working on starting an import business selling Vietnamese handicrafts to support poor street children. “I’m a basically sane person,” he says.

maxel-lute@metroland.net

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