How to Help Someone with Posttraumatic Stress (PTSD)

July 25th, 2016   |  

Being close to someone who is suffering because of trauma can be a difficult, bewildering experience. Trauma symptoms may appear suddenly, sometimes surfacing many years after a traumatic event. Or symptoms may creep up gradually. You might notice your loved one seems “off”—not like their usual self. Or their emotions can flare up suddenly and intensely for little apparent reason, even to the person. Some trauma survivors seem unusually flat or numb. They may become needy or clingy. Or they may withdraw, refusing help entirely.

Although symptoms may differ, responses to trauma have a similar underlying cause: a nervous system stuck in threat. Understanding what happens inside a person experiencing posttraumatic stress (commonly referred to as PTSD) provides a pathway to compassion, clarity, and possible solutions. This article is not therapeutic advice, and the advice of a qualified psychotherapist should always be sought. Think of this article as a general guide for families who suspect that a loved one has been impacted by trauma.

Trauma and stress are not the same thing. Stress refers to the body’s response to threat—a physiological and biochemical cascade of bodily changes designed to ensure survival. Informally, “stress” can also refer to subjective experiences: how it feels to be experiencing the challenge in the environment and in the body’s responses.

The difference between stress and trauma is one of degree. Not all stress is bad; we need some challenges to stimulate us and encourage our growth. Trauma (or traumatic stress), on the other hand, refers to an internal state of overwhelm. This is an important point, and it explains why something that is “no big deal” for one person can be extremely traumatizing for another.

Trauma comes from overwhelm—when environmental circumstances are perceived as bigger than the individual’s capacity to handle them. When overwhelm happens, the body automatically mobilizes a survival response to deal with the threat, just as it does during stress. However, when the threat is too big or lasts too long and there is no effective response, it becomes trauma. For example, a person being cruelly taunted may not fight back because if they do, they may get into legal trouble and make the threat even worse. Not fighting back may be the smart thing to do, but the overall result is the body’s automatic survival response is ineffective against the threat.

When there is no way to fight back or run away, instead of deactivating, the mobilized survival response becomes “stuck” in the “on” position. It wants to complete and turn off, as it would if there had been a successful resolution of the threat, but it can’t. As a result, some bodily functions are stuck on “on.” For example, there may be lasting changes in blood pressure, heart rate, digestion, muscle tension, hormonal levels, and emotional reactivity.

Both stress and trauma involve the activation of the body’s threat response cycle. This survival response is hardwired into all vertebrate animals. Under threat, the unconscious brain and the body attempt to:

• Orient to the perceived threat (stopping, looking, listening, etc.)
• Evaluate the perceived threat
• Then, based on that evaluation, respond with either fight, flight, or freeze
• If the stimulus is determined to not be a threat, return to normal (called “deactivation”)

When stress happens, deactivation is possible. Traumatic overwhelm makes deactivation nearly impossible.

Threat responses are unconscious, hardwired, and involuntary. People cannot control these responses. When trauma has occurred, the person’s nervous system may still be involuntarily responding to prior circumstances more than to what’s actually happening.

Most importantly, threat responses are unconscious, hardwired, and involuntary. People cannot control these responses. When trauma has occurred, the person’s nervous system may still be involuntarily responding to prior circumstances more than to what’s actually happening. (This is what causes flashbacks or other re-experiencing of traumatic circumstances.) Posttraumatic stress responses are essentially the body’s survival alarms going off at the wrong time, because they have never been able to completely turn off.

Posttraumatic survival responses also occur much more quickly than conscious thought. In fact, intense activation of the threat response cycle shuts down the cortex, the area of the brain responsible for rational thought and verbal communication. This is why logical arguments don’t work when a person is in a posttraumatic stress response. They may be, literally, “too angry for words.” This also means that, for the most part, people with posttraumatic stress don’t intend to respond inappropriately to things going on in the environment around them and may feel very badly after the event is over, but at the moment, their automatic survival wiring is running the show.

Even when acute trauma triggers are not causing posttraumatic survival responses, a person whose nervous system is stuck in some phase of the threat response cycle is likely suffering. Eventually, they may start to numb out (dissociate) to protect against the ongoing awful feelings. Others become caught in cycles of addictive behaviors in order to try to manage the distress.

When a Loved One Is Experiencing Posttraumatic Stress

Loved ones who understand this can respond with compassion; however, this does not mean putting up with hurtful or dangerous behaviors. Some trauma survivors might even seem okay on the surface, but underneath, managing the unresolved trauma is using up some of their strength and energy. Unresolved trauma also tends to build up inside, making the person more emotionally and physically brittle over time. Eventually, symptoms may appear after a relatively mild stressor, such as a small fender bender.

The ultimate goal of treatment for posttraumatic stress is to foster deactivation of the nervous system and restoration of resilience (flexibility and the ability to “bounce back”). With this comes the ability to be fully present—instead of being partly stuck in the past—and to respond appropriately in the current moment. The neurological term for this resilience/responsiveness is self-regulation.

Here are several suggestions to keep in mind while supporting a loved one impacted by trauma:

• Obtain knowledgeable professional help. Your family member’s deep survival energy going off at the wrong times is most likely bigger than you can handle (or want to handle) on your own. Furthermore, it is unlikely to go away without professional support. Helping professionals working with trauma survivors should be certified in (not just trained in) a reputable method of trauma resolution.
• Get good psychoeducation about posttraumatic stress. This enables you to be your loved one’s strongest advocate when needed. Understanding reduces hopelessness and bewilderment. Accurate knowledge makes it possible to perceive and work toward solutions.
• Practice good self-care. Self-care supports self-regulation, which is likely to have a calming and stabilizing effect on your loved one. Self-care will help protect you from getting drawn into unhealthy coping behaviors. Plus, you’ll likely genuinely feel better.
• Do not expect the trauma survivor to “be strong,” “get over it,” or “just move on.” Their nervous system won’t let them “just get over it” because their body thinks it’s an emergency now! They are already “strong” enough in just having to live with their nervous system going off like this all the time. Healing has no timetable, nor should it.
• Focus on the importance of downregulating. This means learning to move out of a traumatic state and into calm alertness. This is the foundation, the “bread and butter” of trauma therapy. You will not be helping your loved one if you try to get them to talk about the traumatic events before they learn to reliably calm themselves when their survival systems are activated by trauma triggers. Otherwise, symptoms tend to worsen as the person’s nervous system floods and gets even more overwhelmed. This is another reason to get qualified help so your loved one can access what happened in a safe way.
• Orienting to the present can often be helpful for someone having a flashback or otherwise feeling stuck in the traumatic past. To help a “stuck” person return to the present moment, encourage them to look and/or listen carefully to details of what’s around them. They should be using their eyes and ears in this process, as well as their neck, to turn their head as they’re taking in the current environment. For example, in my practice, I often have people look around and name five blue things they can see or four things in my office that interest them. This may shut off the trauma response.
• Support the survivor in feeling safe. We want to help our loved ones turn the threat response off, or at least way down. The details of what makes a person feel safe (or unsafe) probably depend on the specifics of their traumatic experience(s). Someone who was abandoned may need trustworthy people around them. Others who were intruded upon may need solitude or increased personal space. If someone needs to sleep with a radio on at night to feel safe, leave a loud social event early, lower the volume on the television, or perform other non-dangerous rituals, we usually want to support that.
• Be aware of whether treatment is moving toward healing and self-regulation. During some periods in trauma treatment, people may appear to temporarily get worse as they uncover threatening experiences—essentially trading depression (“freeze”) for anxiety (“flight”). Overall, however, the trend should be toward healing and effective self-regulation. If you’re not sure this is happening, the person and/or family should talk with appropriate helping professionals and revisit the treatment plan.

To sum up, it can be incredibly distressing to be living in a nervous system that feels disobedient and unpredictable. However, as Dr. Peter Levine has said, humans were designed to withstand incredibly difficult conditions. With the help of a good practitioner, trauma survivors can access their underlying restorative ability of mind, body, and spirit, and continue on with their lives.

Note: I would like to acknowledge Phyllis Stein, PhD, SEP, for her editing contributions to this article.

References:

1. Butler, E.A., & Randall, A.K. (2012). Emotional Coregulation in Close Relationships. Retrieved from http://emr.sagepub.com/content/5/2/202
2. Center for Substance Abuse Treatment (U.S.). (2014). Treatment Improvement Protocol (TIP) Series, No. 57. Ch. 3. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK207191/
3. Levine, P. (2010). In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley, CA: North Atlantic Books.