A User's Guide to PTSD, Part IV: Postscript
Two years ago I wrote a set of posts called “A User’s Guide to PTSD.” They attracted a lot of attention, and several people friended this LJ in the hope that I would write more in the same vein. I pointed out that I write about mental illness approximately once every two years, so it could be a long wait. If any of them are still reading, I hope they enjoy this follow-up. If you missed the first set, I've linked them below.
Part I: What I Did In The War. (Introduction; background; what happens during trauma; what happened to me.)
Part II: What Does A Flashback Feel Like? (My history with PTSD, what it felt like to me, and dealing with other people who have it.)
Part III: I Don't Have To Do That Any More. (On recovery; lingering effects; book, film, and TV recommendations.)
I recently underwent training to join a team which counsels people in crisis situations. A crisis situation could be finding the body of a loved one who died of natural causes. It could be witnessing a car crash. It could be surviving a brutal mass murder. (All calls are absolutely confidential, so while I discuss the training a bit below, you will never hear any counseling anecdotes on this blog.) Since the team is run by psychiatrists, they’re very concerned with the psychological effects on the volunteers. During the training, I and the other prospective team members were repeatedly asked to consider what triggers we might have and what situations we might find especially disturbing, so we’d either be able to prepare ourselves or bow out of situations involving those triggers.
Since I was abused as a child, had a family member murdered in a domestic violence situation, had other family members die slowly and painfully of natural causes, was in a serious car accident, and have done several suicide interventions not to mention attempting suicide myself, I was confounded by the idea of avoiding crisis situations with possible triggers. What crisis situation wouldn’t have one?
“I think I’d be upset by dead children,” I hazarded. “That’s one I haven’t encountered yet.”
Statistically speaking, a prior history of PTSD puts you at risk of recurrence should you again be exposed to trauma. We are not strong at the broken places. The broken places remain fragile. We build up our strength around them to compensate. If we’re lucky, that’s sufficient.
I do not expect to have any kind of catastrophic meltdown. If I did, I wouldn’t have volunteered. I do expect that, if I come across a particularly disturbing situation, it will exact some sort of price - some sleepless nights, some nightmares, some hyper-vigilance - the sort of thing I’m subject to anyway if there’s a lot of stress in my life. Basically, the same sort of thing the counselors are subject to regardless of personal history, should they encounter something sufficiently unsettling.
One can’t avoid all stress, but it’s easy to avoid work which puts you into direct contact with other people’s traumas. But avoiding it also exacts a price. I sometimes get a feeling as if a fire alarm went off in my head, a sudden sense of urgency and the conviction that something terrible is happening somewhere and I ought to be doing something about it. This sense can keep going at a low level for weeks on end, periodically startling me with an especially intrusive feeling that I should go! Go now! Run!
I used to identify this as a peculiarly specific anxiety attack, though what it really feels like is the world's most useless psychic power. I cope mostly by consciously acknowledging it for what it is - a habitual firing of neurons that were overused for too many years, and never got used to peace. It's not meaningful. It's annoying background noise. It doesn't mean I have to actually do anything, though if it gets especially "loud" stocking up on earthquake supplies or activities of that nature sometimes helps.
But in fact, terrible things really are happening somewhere at any given time, and I really ought to be doing something about them. I don’t expect that being a volunteer crisis counselor will make the alarm turn itself off permanently. But at least I will be doing something.
(I could elaborate, but I had to write three separate essays over the course of ten weeks on “Why I Want to Join the Crisis Response Team (please detail your strengths and weaknesses,)” and I’m a bit sick of the subject. No, I didn’t say anything about fire alarms in my head. I figure that sort of thing can wait till they know I’m not a raving axe maniac me a bit better. Though I think that if most and maybe all people were to disclose absolutely everything that goes on in their heads, they'd all sound at least as strange as I do.)
A year ago I was involved in several (unrelated) extremely stressful situations. I would lie awake at night thinking, “What if right now [something terrible] is happening?” I should note that this wasn’t my internal fire alarm. There really was a reasonable chance that [terrible thing] might, in fact, be happening at any given moment. That being said, my insomniac obsessing was helping neither the situation nor me. I wanted to see a therapist, but my insurance only covers therapy in cases of “major mental illness” as defined by the insurance company.
I went to a psychiatrist and asked for a diagnosis, only to be informed that in her opinion, I was under a lot of stress and would benefit from therapy, but did not have a mental illness, major or otherwise. “Actually, especially given your history with mental illness and what’s going on in your life right now, I think you’re pretty emotionally healthy.”
You can probably imagine my mixed feelings about that statement. (When I explained the situation with my insurance, she kindly wrote down for their behalf that I met the DSM-IV criteria for an adjustment disorder. “Technically speaking,” she added to me. An adjustment disorder is psychiatrist-speak for “temporarily unhinged by the sort of stressors that occur under normal life circumstances (death of a loved one, job loss, divorce, etc), as opposed to the extraordinary stressors that can cause PTSD (rape, combat, natural disaster, etc).” And yes, the therapy was very helpful. I'm now much better at walking away, letting go, and otherwise not pouring all of myself into a futile attempt to fix someone else's life.)
It wasn’t only that, after so many years of trying to fix my mental illness, the fact that I had largely succeeded was now preventing me from getting needed mental health care. It was also that PTSD, even before I knew what it was, had shaped so much of my identity that I felt strange without it, or even contemplating the idea of being without it. And yet she was only telling me what I already knew. It was as if, after many years of debating with myself over whether I was willing to lay down my armor and weapons in order to get out of the war zone, I found that I had already dropped them. And that I’d known I had, but rather than either pick them up or kick some more mud over them, I’d taken mental note of where they lay, just in case, and tried not to think too much about the lack of weight at my belt and back.
I thought of finding a different metaphor, because PTSD is not actually helpful protective armor but rather a set of massively counterproductive and painful reflexes that can feel like they’re all that stands between you and your own destruction. I also realize that my choice of imagery does not exactly shout out “emotional health.” But the metaphor I used is the one which feels true.
I can sleep through the night. I can eat without having to consciously make myself swallow each bite. I can let people touch me. I can walk down a busy street without flinching. I can sit with my back to a window or door. I can sleep while people walk into my room, if I know in advance that they might. I can let people walk up behind me and not turn around. I do notice when people walk up behind me. I guess I kept a pocket knife.
This is not PTSD as defined by psychiatrists and as recorded by history. I no longer meet a single one of the criteria. By that standard, I don’t have that illness any more. What I have now, technically speaking, is a sub-clinical set of reflexes, attitudes, and sensitive areas that were shaped by the experience of having PTSD.
(By the way, it’s still totally fine to say, “Rachel has PTSD.” I’m not particularly attached to the DSM-IV criteria, nor to the concept of having it now vs. having had it in the past.)
To return to the crisis counseling, I’ve considered the possibility that I’m attracted to it because it offers me the chance or excuse to pick my weapons back up, so to speak. But I don’t want to automatically assume that my subconscious is trying to kill me. Sometimes it’s best to operate under the assumption that your instincts are sound. That nothing bad is happening right now. That you’re not in denial. That, however unlikely it may seem, you really are all right.
Any sort of crisis-related field draws people who have been shaped by trauma. Those fields also draw people who haven’t, but are there for other reasons. I know why I’m there - and that it’s fine that that’s why, but it doesn’t make me a better counselor, let alone a better or cooler or stronger or more compassionate person, than those other guys. It’s just the road I happened to drive in on.
Like my first set of posts, this one is intended solely to reflect my own experience, not anyone else’s. That being said, having gone through all of this, I’ve learned some things:
That trauma is influential, but doesn’t define us or our lives or our choices.
That trauma isn’t what makes us special or interesting or ourselves, though how we choose to deal with it may be one of the things that does.
That we all live with our own private battles and own private pain, even those of us who don't have horrific stories to tell.
That ongoing pain and struggle doesn't mean we're not leading quite happy lives anyway.
That we can get much, much better.
That it isn’t our fault if we haven’t yet.
That change is possible, always, at any time, regardless of what we’ve done or haven’t done or for how long.
That it isn’t hopeless unless we’re already dead.
And that, courtesy of one of our more entertaining training sessions, you’re not dead till the coroner says you’re dead.
Part I: What I Did In The War. (Introduction; background; what happens during trauma; what happened to me.)
Part II: What Does A Flashback Feel Like? (My history with PTSD, what it felt like to me, and dealing with other people who have it.)
Part III: I Don't Have To Do That Any More. (On recovery; lingering effects; book, film, and TV recommendations.)
I recently underwent training to join a team which counsels people in crisis situations. A crisis situation could be finding the body of a loved one who died of natural causes. It could be witnessing a car crash. It could be surviving a brutal mass murder. (All calls are absolutely confidential, so while I discuss the training a bit below, you will never hear any counseling anecdotes on this blog.) Since the team is run by psychiatrists, they’re very concerned with the psychological effects on the volunteers. During the training, I and the other prospective team members were repeatedly asked to consider what triggers we might have and what situations we might find especially disturbing, so we’d either be able to prepare ourselves or bow out of situations involving those triggers.
Since I was abused as a child, had a family member murdered in a domestic violence situation, had other family members die slowly and painfully of natural causes, was in a serious car accident, and have done several suicide interventions not to mention attempting suicide myself, I was confounded by the idea of avoiding crisis situations with possible triggers. What crisis situation wouldn’t have one?
“I think I’d be upset by dead children,” I hazarded. “That’s one I haven’t encountered yet.”
Statistically speaking, a prior history of PTSD puts you at risk of recurrence should you again be exposed to trauma. We are not strong at the broken places. The broken places remain fragile. We build up our strength around them to compensate. If we’re lucky, that’s sufficient.
I do not expect to have any kind of catastrophic meltdown. If I did, I wouldn’t have volunteered. I do expect that, if I come across a particularly disturbing situation, it will exact some sort of price - some sleepless nights, some nightmares, some hyper-vigilance - the sort of thing I’m subject to anyway if there’s a lot of stress in my life. Basically, the same sort of thing the counselors are subject to regardless of personal history, should they encounter something sufficiently unsettling.
One can’t avoid all stress, but it’s easy to avoid work which puts you into direct contact with other people’s traumas. But avoiding it also exacts a price. I sometimes get a feeling as if a fire alarm went off in my head, a sudden sense of urgency and the conviction that something terrible is happening somewhere and I ought to be doing something about it. This sense can keep going at a low level for weeks on end, periodically startling me with an especially intrusive feeling that I should go! Go now! Run!
I used to identify this as a peculiarly specific anxiety attack, though what it really feels like is the world's most useless psychic power. I cope mostly by consciously acknowledging it for what it is - a habitual firing of neurons that were overused for too many years, and never got used to peace. It's not meaningful. It's annoying background noise. It doesn't mean I have to actually do anything, though if it gets especially "loud" stocking up on earthquake supplies or activities of that nature sometimes helps.
But in fact, terrible things really are happening somewhere at any given time, and I really ought to be doing something about them. I don’t expect that being a volunteer crisis counselor will make the alarm turn itself off permanently. But at least I will be doing something.
(I could elaborate, but I had to write three separate essays over the course of ten weeks on “Why I Want to Join the Crisis Response Team (please detail your strengths and weaknesses,)” and I’m a bit sick of the subject. No, I didn’t say anything about fire alarms in my head. I figure that sort of thing can wait till they know I’m not a raving axe maniac me a bit better. Though I think that if most and maybe all people were to disclose absolutely everything that goes on in their heads, they'd all sound at least as strange as I do.)
A year ago I was involved in several (unrelated) extremely stressful situations. I would lie awake at night thinking, “What if right now [something terrible] is happening?” I should note that this wasn’t my internal fire alarm. There really was a reasonable chance that [terrible thing] might, in fact, be happening at any given moment. That being said, my insomniac obsessing was helping neither the situation nor me. I wanted to see a therapist, but my insurance only covers therapy in cases of “major mental illness” as defined by the insurance company.
I went to a psychiatrist and asked for a diagnosis, only to be informed that in her opinion, I was under a lot of stress and would benefit from therapy, but did not have a mental illness, major or otherwise. “Actually, especially given your history with mental illness and what’s going on in your life right now, I think you’re pretty emotionally healthy.”
You can probably imagine my mixed feelings about that statement. (When I explained the situation with my insurance, she kindly wrote down for their behalf that I met the DSM-IV criteria for an adjustment disorder. “Technically speaking,” she added to me. An adjustment disorder is psychiatrist-speak for “temporarily unhinged by the sort of stressors that occur under normal life circumstances (death of a loved one, job loss, divorce, etc), as opposed to the extraordinary stressors that can cause PTSD (rape, combat, natural disaster, etc).” And yes, the therapy was very helpful. I'm now much better at walking away, letting go, and otherwise not pouring all of myself into a futile attempt to fix someone else's life.)
It wasn’t only that, after so many years of trying to fix my mental illness, the fact that I had largely succeeded was now preventing me from getting needed mental health care. It was also that PTSD, even before I knew what it was, had shaped so much of my identity that I felt strange without it, or even contemplating the idea of being without it. And yet she was only telling me what I already knew. It was as if, after many years of debating with myself over whether I was willing to lay down my armor and weapons in order to get out of the war zone, I found that I had already dropped them. And that I’d known I had, but rather than either pick them up or kick some more mud over them, I’d taken mental note of where they lay, just in case, and tried not to think too much about the lack of weight at my belt and back.
I thought of finding a different metaphor, because PTSD is not actually helpful protective armor but rather a set of massively counterproductive and painful reflexes that can feel like they’re all that stands between you and your own destruction. I also realize that my choice of imagery does not exactly shout out “emotional health.” But the metaphor I used is the one which feels true.
I can sleep through the night. I can eat without having to consciously make myself swallow each bite. I can let people touch me. I can walk down a busy street without flinching. I can sit with my back to a window or door. I can sleep while people walk into my room, if I know in advance that they might. I can let people walk up behind me and not turn around. I do notice when people walk up behind me. I guess I kept a pocket knife.
This is not PTSD as defined by psychiatrists and as recorded by history. I no longer meet a single one of the criteria. By that standard, I don’t have that illness any more. What I have now, technically speaking, is a sub-clinical set of reflexes, attitudes, and sensitive areas that were shaped by the experience of having PTSD.
(By the way, it’s still totally fine to say, “Rachel has PTSD.” I’m not particularly attached to the DSM-IV criteria, nor to the concept of having it now vs. having had it in the past.)
To return to the crisis counseling, I’ve considered the possibility that I’m attracted to it because it offers me the chance or excuse to pick my weapons back up, so to speak. But I don’t want to automatically assume that my subconscious is trying to kill me. Sometimes it’s best to operate under the assumption that your instincts are sound. That nothing bad is happening right now. That you’re not in denial. That, however unlikely it may seem, you really are all right.
Any sort of crisis-related field draws people who have been shaped by trauma. Those fields also draw people who haven’t, but are there for other reasons. I know why I’m there - and that it’s fine that that’s why, but it doesn’t make me a better counselor, let alone a better or cooler or stronger or more compassionate person, than those other guys. It’s just the road I happened to drive in on.
Like my first set of posts, this one is intended solely to reflect my own experience, not anyone else’s. That being said, having gone through all of this, I’ve learned some things:
That trauma is influential, but doesn’t define us or our lives or our choices.
That trauma isn’t what makes us special or interesting or ourselves, though how we choose to deal with it may be one of the things that does.
That we all live with our own private battles and own private pain, even those of us who don't have horrific stories to tell.
That ongoing pain and struggle doesn't mean we're not leading quite happy lives anyway.
That we can get much, much better.
That it isn’t our fault if we haven’t yet.
That change is possible, always, at any time, regardless of what we’ve done or haven’t done or for how long.
That it isn’t hopeless unless we’re already dead.
And that, courtesy of one of our more entertaining training sessions, you’re not dead till the coroner says you’re dead.