Tackle Trauma

What is Trauma?

Trauma is the emotional reaction to a shocking, unexpected event – an event that is way beyond the range of usual human experience. The event involves a person being exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in one of the following ways:
• Direct exposure
• Witnessing the trauma
• Learning that a relative or close friend was exposed to a trauma. If the event involved actual or threatened death, it must have been violent or accidental.
• Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g. first responders, medics, professionals repeatedly exposed to details of child abuse, professionals collecting body parts).

Note: Indirect exposure does not include indirect, non-professional exposure through electronic media, television, movies or pictures, unless this exposure is work-related.

 Typical Examples of Traumatic Events are:

• Natural disasters, such as earthquakes, volcano eruptions, mudslides, fire, tornadoes and hurricanes
• Man-made disasters, such as collapsing bridges or buildings
• Exposure to war (both civilians and military personnel)
• Terrorist attacks
• Torture
• Violence, explosions, shootings
• Serious motor vehicle accidents
• Child sexual or physical abuse
• Sexual or physical assault and rape
• Robberies, muggings, hijackings and home invasions

What can you Expect After Experiencing a Traumatic Event?

Following a traumatic event, most people typically describe feeling relieved to be alive, followed by some unusually strong, even frightening reactions. These reactions are the typical aftershock of a horrible event – they are normal reactions to an abnormal experience. Having these reactions has nothing to do with personal weakness. These reactions may last for several days, or even a few weeks.

Remember that most trauma survivors (including war veterans, children, and disaster rescue or relief workers) experience these common stress reactions. Understanding what is happening when you, or someone you know reacts to a traumatic event, will help you be less fearful and better able to handle things. These reactions can be classified under four categories - your body's reactions, your feelings, your behaviour and your thoughts.

Common Signs and Signals of Trauma

Most often, these reactions appear shortly after the event, but sometimes there may be a delay. You may think that you are coping well, and then suddenly be overwhelmed by an intense emotional and physical reaction. Sometimes, the delayed reactions are somewhat more subtle in their manifestation, and are not even associated with the original trauma.

Keep in mind that these reactions are normal – you are not falling apart or losing your mind. They are a part of the normal recovery process.

Recovery is an ongoing, gradual process. It doesn't happen through suddenly being 'cured' and it doesn't mean that you will forget what happened. For most, fear, anxiety, arousal symptoms (if present), remembering and efforts to avoid reminders, will gradually decrease over time. Most people will recover from trauma naturally. However, if your emotional reactions are getting in the way of your relationships, work, or other important activities it would be a good idea to talk to a psychologist or counselor who specialises in Trauma Counselling.

What can I do to Help Myself Recover From Trauma?

• Seek professional counselling, even if you feel you are coping fine.
  The object of counselling is to prevent complications. This is much easier than trying to fix complications and problems after they have started. The value of counselling is that it will give you information about what reactions you can expect. This helps you understand what is going on, and therefore helps you manage your reactions better. I have found that all of my clients have experienced huge relief just knowing they are not "going crazy" and knowing what to expect and how to cope with it.

• Reach out to others
  Explain what you have been through and ask for support. Do not try to "be strong" and carry it all by yourself. Women, especially, need to watch out for this one. Typically, a woman will look after everybody else's needs and not her own. This is not healthy in the long run. Read more about this under 'What can parents do for each other?'

• Explain to children what has happened to you
  Explain, without graphic detail, so they are not confused by the non-verbal messages they will pick up. Read more about this under 'What can parents do for each other?'

• Be careful of taking drugs and medication 'to make things easier'.
  Tranquilisers and sleeping tablets can be habit forming (psychologically, if not physically) and could complicate your recovery process. Avoid alcohol for a few weeks. Blocking thoughts and emotions around the trauma now, will only cause it to resurface at a later inappropriate time.

• Do not make any big life decisions for a while. (For example, do not make the decision to sell your house, leave your job or emigrate).
  The natural tendency is to avoid the place where the trauma happened. This is normally not a problem, but if the trauma happened in your usual living or working environment, it is important not to get into a pattern of avoidance, as this will affect your ability to enjoy your normal lifestyle. It is important to 'get back onto the horse once you have been thrown'. Do this with support - do not go to the place where the trauma happened if you are at all uncomfortable about it, as this could cause extreme anxiety reactions that will not help your recovery.

• Maintain your normal daily routine as far as possible.
  Keep to your exercise routine. Structure your time. Keep occupied.

• Eat well-balanced and regular meals, even if you do not feel like eating.
  Your body needs all the help it can get to get through this difficult time.

• Try to do the things you usually find relaxing and enjoyable.

• Give yourself permission to feel rotten, afraid and out of sorts. 
  Be patient with yourself. You will not be yourself for a while. Give it time. Don't force it.

• Tell your friends and family what they can do to help you.
  Most people are very well-meaning, but do tend to give you the wrong sort of advice if they don't know any better. Help them to help you. (Give them these notes to read!)

What can I do to Help Family or Friends Recover From Trauma?

• Do not worry that something is wrong if they cannot stop crying, or seem to be overwhelmed by their feelings for the first few days or weeks. Intense emotional turmoil and physical upheaval is normal after trauma and it will settle down if you give the person time and support.
• Do not expect them to cope fully with their responsibilities initially. Help them re-establish their routine gradually, not all at once. (Father's, brothers, husbands & boyfriends: make a point of stepping in here if it is your daughter, sister, wife or girlfriend who has been through the trauma.) Read more about this under 'What can parents do for each other?'
• Listen carefully and give them space to talk if they want to talk. Don't make them to talk if they don't want to.
• Don't try and take their feelings away from them. Allow them to feel what they are feeling.
• Don't try to 'fix them' or 'sort them out'.
• Spend time with them.
• Help them regain a sense of safety - both physically and emotionally. (For example, you can do practical things such as putting in alarms and burglar guards).
• Do not take their anger or other feelings personally; it is not about you.
• Try to understand that what they went through is very real and very distressing. Show empathy – it is not their fault. What they need most is for you to show that you recognise and accept their feelings and understand their reactions.
• Do not tell them they are 'lucky it wasn't worse'. Traumatised people are not consoled by these 'trite' statements. Instead, show empathy and understanding for what they are going through.
• Do not tell them to 'Think positively', 'Put it behind you', 'Move on', 'Don't think about it'. It does not help and tends to make the person feel more helpless, weak and/or incapable because they cannot get the bad experience out of their mind. It actually helps the healing process NOT to avoid thinking about it completely.
• Do not talk violently or show anger in front of them. (For example, a husband may react with aggressive behaviour and threats such as 'I will kill the bastard' - referring to the man who harmed his wife). The traumatised person has had enough violence already - violence is why they are traumatised in the first place! Do deal with your own anger / helplessness, but outside of the traumatised person's awareness. Read more in this article under 'What can parents / couples do for each other?'

What can I do to Give Immediate Help After an Incident?

If you are the first to be called to a scene, there are a number of things that you can do:

• Ensure that the person is physically safe and that any medical problems are attended to.
• Get a blanket or a jacket to put around the victim's shoulders. This is to keep them warm (the shock will make them feel cold) and to protect their dignity if clothing is torn or soiled.
• Move the person away from the scene of the crime or turn them so that they are not looking at the scene. Try to find a quieter place away from the noise and confusion of police investigations, ambulances, and so forth.
• Encourage the victim to breathe slowly and deeply.
• Stay with the person and reassure them by giving information that is true and contributes to a sense of safety. For example, "the robbers have gone now and the police are here", or "your brother is on his way and should be here soon". Do not lie to the person or use meaningless platitudes. Speak in a clear, calm voice and repeat yourself as necessary.
• Get the victim a warm drink and something to eat. Explain that although they may not feel like eating, it is likely that their blood sugar level is very low and that it helps to have something small to eat. (The warm drink should be something like a calming herbal tea. Do not give coffee as the caffeine will just increase the adrenalin stress reaction).
• If the victim is comfortable (and wishes it) hold their hand but do not hug or intrude on their personal space.
• If the victim is still feeling out of control (ongoing panic, crying uncontrollably or seems to be in a dreamlike state) after two hours, seek help from professional medical and psychological personnel.
• Protect the victim from possible secondary victimisation resulting from insensitive questioning, being blamed for the incident and so forth.
• It is very important that you do not push the victim to talk about what happened, especially where this increases their distress or anxiety.

What is Post Traumatic Stress Disorder (PTSD)?

Post Traumatic Stress Disorder (PTSD) is an anxiety disorder that can occur after you have been through a traumatic event. It has a particular set of symptoms.

Most people who experience a traumatic event have what are considered to be 'normal reactions' to the traumatic experience and recover over time. Not all people develop PTSD. PTSD symptoms usually start soon after the traumatic event, but they may not happen until months or years later. They also may come and go over many years. About half (40% to 60%) of people who develop PTSD get better at some time. But about 1 out of 3 people who develop PTSD will always have some symptoms.

What are the Symptoms of PTSD?

Symptoms of PTSD can be classified under 4 categories:

1. Re-experiencing the trauma in various ways
2. Persistent avoidance of stimuli associated with the trauma
3. Negative alterations in cognitions and mood that are associated with the traumatic event
4. Alterations in arousal and reactivity that are associated with the traumatic event.

1. Re-experiencing Symptoms

These are symptoms that relate to reliving the event and include:

• Intrusive thoughts - bad memories about the event.
• Nightmares - distressing dreams.
• Flashbacks - This is when you feel that you are going through the event all over again - feeling the same fear and horror - as a result of some sort of trigger. A trigger is a sound or sight that causes you to relive the event, such as hearing a car backfire, which can bring back memories of gunfire and war for a combat veteran, or seeing a car accident, which can remind a crash survivor of his or her own accident.
• Emotional distress after exposure to traumatic reminders.
• Physical reactivity after exposure to traumatic reminders.

2. Avoidance

Avoidance of trauma-related stimuli after the trauma, in the following way(s):

• Trauma-related thoughts or feelings
• Trauma-related reminders
• Trying to avoid situations or people that trigger memories of the traumatic event. For example, a person who was in an earthquake may avoid watching television shows or movies in which there are earthquakes. A person who was robbed at gunpoint while withdrawing money from an ATM may avoid ATMs.
• Avoiding talking or thinking about the event. Some people may deliberately keep very busy or avoid seeking help. This keeps them from having to think or talk about the event.

3. Negative thoughts or feelings that began or worsened after the trauma

• Inability to recall key features of the trauma
• Overly negative thoughts and assumptions about oneself or the world
• Exaggerated blame of self or others for causing the trauma
• Negative affect
• Decreased interest in activities
• Feeling isolated
• Difficulty experiencing positive affect

4. Trauma-related arousal and reactivity that began or worsened after the trauma

These are symptoms that relate to feeling 'keyed-up' and can include:

• Irritability or aggression
• Risky or destructive behaviour
• Hypervigilance Always being on the alert and on the lookout for danger
• Heightened startle reaction - Being overly startled when someone surprises you
• Difficulty concentrating
• Difficulty sleeping.

If you have some of these symptoms and they last longer than four weeks, cause you great distress, or interfere with your work or home life, you probably have PTSD, but please note: Don't diagnose yourself – see a psychologist and have a proper assessment and proper treatment. You can be helped.

Common Problems That Relate to PTSD

Symptoms of post-traumatic stress disorder (PTSD) can be terrifying. They may disrupt your life and make it hard to continue with your daily activities. It may be hard just to get through the day. As a result, many people look for ways to cope – unfortunately their so-called 'coping' techniques may actually cause them more harm and result in other problems, such as:

• Drinking or drug problems;
• Employment problems;
• Relationships problems, including divorce and violence;
• Physical symptoms;
• Feelings of hopelessness, shame or despair.

Why Doesn't Everyone Develop PTSD after a Traumatic Event?

It isn't clear why some people develop PTSD and others don't. How likely you are to get PTSD depends on many things. These include:

• How intense the trauma was;
• If you lost a loved one or were hurt;
• How close you were to the event;
• How strong your reaction was;
• How much you felt in control of events;
• How much help and support you got after the event.

Treatment for Trauma

There are various levels of intervention for people who have been traumatised. From the most basic to the most specialised they include:

Victim Support

This is for people who have recently been through a traumatic experience. The majority of people are psychologically healthy, but with a high level of distress. Intervention involves:

• Offering emotional support;
• Giving practical assistance – accompanying to police stations, clinics and hospitals etc.;
• Giving information about what reactions to expect and how to manage the recovery process.

It is a good idea for all people who have experienced trauma to have this form of support. Lay counsellors working for Crisis and Trauma Centres can offer this level of intervention.

Trauma Counselling

About 25% of people who experience trauma do not make significant progress within 3 weeks. It is recommended that these people have trauma counselling to mobilise internal healing resources. Again the majority of people are psychologically healthy, but with high levels of distress. Intervention involves:

• Mediated re-exposure;
• Reframing cognitive distortions;
• Symptom management;
• Problem solving and decision-making.

Registered counsellors (not necessarily psychologists) with the Health Professions Council of South Africa (HPCSA) can offer this level of intervention (If they have specialised in the field of trauma counselling).

Trauma Therapy

A small proportion of victims who do not respond to trauma counselling, or whose symptoms persist beyond a month, will need trauma therapy. Many of these individuals will meet diagnostic criteria for recognised psychological disorders (e.g. PTSD) and will have high levels of distress.

Intervention involves:

• Uncovering repressed traumatic content;
• Desensitising triggers;
• Changing entrenched defensive behaviours.

Only registered psychologists with the Health Professions Council of South Africa (HPCSA) can offer this level of intervention.

A Note on Trauma Counselling and Therapy

Not all registered counsellors and psychologists specialise in trauma counselling and/or therapy. It is important to see someone who knows what they are doing. While good trauma counselling and therapy helps enormously, unskilled trauma counsellors / psychologists can do a lot of damage.

PTSD in Children and Teens

Young children are exposed to many types of traumatic experiences, placing them at risk for PTSD. These include:

Abuse
Witnessing interpersonal violence
Motor vehicle accidents
Experiences of natural distasters
Conditions of war
Dog bites
Invasive medical procedures

Children can also have PTSD. Note: DSM-5 introduced a preschool subtype of PTSD for children ages six years and younger. As children get older, their symptoms are more like those of adults.

Children may not necessarily appear to be frightened or horrified in the way an adult would expect them to be, but do not interpret this as 'the child is ok'. Watch out for subtle signs, such as the child not being able to settle into play routines, needing to have their mother (or primary care-giver) within sight - young children may become upset if their parents are not close by. They may also have trouble sleeping, or suddenly have trouble with toilet training or going to the bathroom.

Children may show signs of the 're-experiencing' symptoms in the following ways:

• Children may express aspects of the trauma by repetitively 'acting out' themes from the trauma in subtle ways. They may, for example, crash their toy car into the bigger lorry and pretend to 'destroy' the lorry, or bury their plastic lion in the sand to make it incapable of attacking the other animals. This sort of play is about gaining mastery over the event - in the real situation the child was weak and helpless, but in play they are the 'master of the universe' and have power to do anything. They may smash and break toys all in an attempt to feel powerful and in control.
• Children may also act out the specific trauma. Children who are in the first few years of elementary school (ages 6 to 9) may act out the trauma through play, drawings, or stories. For example, children may act out parts of the traumatic incident as it occurred – holding a gun to their teddy bear's head, tying up their doll or action man, using the words they heard in the traumatic incident to give instructions to their toys.
• Young children may have frightening dreams, but without recognisable content. The child may wake up from a nightmare feeling frightened, but not be able to tell you about the dream. Don't push for them to tell you – rather just reassure them that their dream was not real, that they are safe and that you are there.
• Children may complain of physical problems or become more irritable or aggressive.
• Children may also develop fears and anxiety that don't seem to be caused by the traumatic event.

What can you, as a Parent, do for Your Child?

The most important thing you can do is to talk about the event and allow the children to talk about it if they want to. Don't go into graphic descriptions of the things that happened, but don't pretend that it didn't happen either.

Children will take their cues from you - if you as the parent give the message that it is not ok to talk about it, then they won't either. Children protect their parents. If they know you are not comfortable with the topic then they will not raise it either, but they will feel the anxiety and confusion. These thoughts and feelings, if not spoken about, will only get repressed and are very likely to manifest in later years – even into adulthood.

Say everyday things as the opportunity arises. For example, you could say, "These men are here to put in the burglar guards to stop the robbers coming in again," in a completely calm and natural way, and then deal with any questions or comments from the child. If, perhaps, you notice the child acting out aspects of the trauma during play, you can talk about it and affirm their feelings. Say something like: "It was horrible wasn't it? We were both so scared, but we are safe now. Daddy has put burglar guards up."

Do talk about feelings - it helps young children to identify the emotion they are feeling in their body and attach a label to it. Allow children to feel their emotions – don't try to cover up and make them feel better by giving them treats, or trying to distract them with another activity. When a child says in a frightened voice: "Mommy that's where the bad men took our car, I don't want to drive past there!" Don't say "Don't be silly, there is nothing to worry about!" Rather acknowledge their real and valid feelings by saying something like: "Yes darling, you are right. That was horrible wasn't it? We were so scared. I know you are scared now and that's ok, but look, there is nobody there now. We have to go this way, because we want to get to the shops." And then continue the conversation with whatever the child says next.

If you were involved in a traumatic incident, but the child wasn't, explain to your children (without graphic detail) what has happened to you, so they are not confused by the bits of conversation and the non-verbal messages they will pick up. Do not make the mistake of thinking that a toddler is too young to know what is going on. Children are skilled at picking up non-verbal cues (body language) and they will pick up your symptoms of anxiety and distress. If no other explanation is given, they will assume it is something to do with them and is their fault. Their imagination may be worse than the reality for them. Young children are egocentric – this means they can only see things from their own point of view – they are not able to put themselves into someone else's shoes. They may think because mommy or daddy is so upset and preoccupied, that they (the child) have done something wrong and mommy or daddy doesn't love them anymore. They will not think it could be something that has nothing to do with them.

What can Parents / Couples do for Each Other?

Reach out to others for support. Explain what you have been through and ask for emotional and practical support. Do not try to 'be strong' and carry it all by yourself.

Women, especially, need to watch out for this one. The woman will typically look after everybody else's needs and not her own. You cannot be the best mom you can be, in the long run, if you don't allow yourself the time and space to recover 'properly' in the short term. Delegate tasks – housework, shopping, lift club etc. It is ok to let things slide for a while; you can take back control in due course. It is also ok to show emotion in front of your children. Just explain to them what it is all about.

Men, do not expect your wife / girlfriend / mother to cope fully with their responsibilities initially. Help them re-establish their routine gradually, not all at once. Women will try to be strong and carry on as normal so as not to upset you. Allow them time to feel 'rotten and out of sorts' for a while.

Understand that your anger is about your own feeling of helplessness and guilt at being unable to prevent the trauma, but also know that if a woman close to you has been through the trauma, you need to focus on her, and channel your energies into helping her recover. Do get your own counselling to deal with your feelings. Don't expect your wife to have to cope with you as well – she will if you let her!

Women understand that men are raised to be our protectors. Your fathers, husbands and boyfriends will go though huge emotional turmoil. If you are the one who went through the trauma they will feel guilt at not having been able to prevent it. If they went through the trauma themselves they may try to pretend they feel nothing and are just fine – encourage them to go for counselling anyway.

What is the Difference Between Stress, Crisis and Trauma?

It is important to note that trauma is different from stress.

All people experience stress in their everyday lives. Stress occurs when we feel overwhelmed by the demands in our daily life - the "wear and tear" our bodies experience as we adjust to our environment. (Read more about stress in my article Stressed to Kill).

A crisis occurs when a person feels overwhelmed, and feels that they can no longer cope with their problems. It involves a change or adjustment e.g. getting married, divorce, death in family.

A traumatic event occurs when a person is exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence directly or indirectly.

Post-traumatic Stress Disorder (PTSD) is an anxiety disorder that can occur after you have been through a traumatic event. Anyone who has gone through a life-threatening event can develop PTSD.