The Externalization of Trauma: A View of PTSD Symptoms as Healthy
Individuals who are “symptomatic” of post-traumatic stress disorder (PTSD) may seem sick, crazy, or irrational. They might appear dissociative, clinically depressed, anxious, highly reactive, or rageful (or all of the above). In addition, it’s common for an individual to cultivate a sense of self-loathing for displaying these characteristics. During treatment, both therapist and survivor may agree that these symptoms are a mark of disease, making it their goal to alleviate the symptoms. Alternatively, both may choose to believe that these symptoms are an expression of health versus illness. This could enable more directed treatment, internal compassion, decreasing fear of symptoms, and a relationship between survivor, therapist, and trauma.
According to the DSM IV (American Psychiatric Association, 1994) criteria for diagnosing PTSD includes intrusive memories, thoughts, or dreams of an event, a sense of reliving the event, and intense distress in response to both internal and external cues that resemble an event(s). Individuals may thus avoid triggers or cues, increase isolation or have a sense of ‘waiting for the other shoe to drop’ (a foreshortened future), and detachment. Sleep difficulties are common; mood liabiality, and hyper vigilance are also common (American Psychiatric Association[DSM-IV], 1994). When a survivor feels hopeless, confused, and self-loathing because of the manifestations of their trauma, the initial layer of treatment is frequently the unraveling of self-loathing for the expression of symptoms themselves.
To begin to evaluate trauma and develop a relationship with its influence on survivors, we can draw from the practice of narrative therapy and the concept of externalizing a problem, which recognizes that the person is not the problem; the problem is the problem (Playful approaches to serious problems: Narrative therapy with children and their families. Freeman, Jennifer C.; Epston, David; Lobovits, Dean New York, NY, US: W W Norton & Co. (1997). xvii, 321 pp.). PTSD, as a character in a survivor’s life, uses symptoms as tools to protect us, remind us of our core values, and ensure that what happened before won’t happen again. The trauma response could even correspond to the level of violation on self and values; from this perspective, a profoundly disturbing event calls for a profoundly disturbing response. Flashbacks, dreams, invasive thoughts, and triggers provide specific information about the violation the client’s event(s) infringed upon them. These also exemplify the concept of “stuck points” in Trauma-Focused Cognitive Behavior Therapy (Akin-Little, Angeleque (Ed); Little, Steven G. (Ed); Bray, Melissa A. (Ed); Kehle, Thomas J. (Ed), (2009). Behavioral interventions in schools: Evidence-based positive strategies, School Psychology (pp. 325-333). Washington, DC, US: American Psychological Association, xi, 350 pp.)
The aspect of a survivor’s past that is troublesome can be quite specific and idiosyncratic. Groups of people exposed to the same event often are disturbed by different parts of it. Interpersonal trauma such as child abuse, domestic violence, or sexual assault may render someone feeling responsible for what happened to them, feeling dirty or shameful, betrayed, foolish, unimportant, or completely exposed. Trauma might be conveying to someone that they are at fault for an assault because it wants the individual to have a sense of mastery or agency. Helplessness is too passive, so self-blame is an acceptable tone to assume. An individual might also begin to associate a traumatic feeling of betrayal with a feeling of foolishness, ensuring s/he does not trust people too easily and maintaining inner safety.
The way in which a survivor expresses their PTSD can vary widely and presentations can be very complex and oppressive. It is common for survivors to blame themselves for their past experiences, and they often enter into treatment with a great deal of shame because they feel they should have “gotten over it” without help. A therapist can offer some relief from shame by viewing survivors’ symptoms as useful, even critical to their treatment.
Through the process of healing, a survivor can learn to establish trust in self to clearly identify his/her core values, to reflect his/her significance in the world, and to maintain personal safety. The character of trauma will refrain from presenting images (flashbacks and dreams) when the stuck point has been identified, and will cease making statements that the individual is culpable for what happened once there is a demonstration of mastery over the event. It will hold back on invasive, persistent thoughts once the survivor is able to look at the event rather than avoiding it. PTSD symptoms reflect individual values and provide explicit guidance for healing; if therapist and client are willing to work with trauma, and absorb the information it has to offer, it will not invade with such rigor.