You can't work on the PTSD until the TS is P

I started graduate school in New York City, studying to become a therapist, just a few days before September 11th, 2001. Like a lot of New Yorkers, that day included a long walk home. After connecting with my fellow therapists-to-be, some of us turned around and headed back downtown to see about volunteering our help. We were all in shock and, like so many, overwhelmed with a desire to be helpful.

The scene at the Red Cross headquarters was chaotic, as you might expect. There were nurses and doctors, therapists and would-be therapists like myself, along with New Yorkers of all stripes hoping to find ways that being helpful might counteract the feeling of such helplessness.

In retrospect, my therapy classmates and I hadn't really thought things through. The Red Cross folks gathered us in the overflowing auditorium of a NYC public high school next door. We waited a long time, understandably, my classmates and I wondering where we might be sent to put our burgeoning therapy skills to work. Would there be use for us as students given we weren't yet licensed as therapists? Would we be sent to city hospitals or perhaps to some sort of triage center further downtown? What could we possibly know about trauma--what could any therapist know that would be relevant in this so-extraordinary circumstance?

After a few hours of waiting a Red Cross employee took the stage. At first her microphone failed and then, after unsuccessfully attempting to make herself heard unaided, someone located a megaphone and she tried for a third time. The announcement was painfully brief. Years have passed, and impaired my exact recollection,  but it went something close to this:

Thank you all for being here. While we appreciate that all of you want to help, we are in need, only, of those with construction experience, particularly the operation of heavy machinery. If you have those skills, please join me immediately on stage. Otherwise, we ask that you leave. I'm certain New York City will need you in the coming weeks and months.
 

We were all stung, though we knew instantly that we'd fooled ourselves. We should have known all along. Five miles further downtown buildings were still smoking. The trauma we sought to help use our psychotherapy skills to heal was still ongoing. We needed to love one another--provide comfort and begin the struggle together to make meaning. But what the city needed was to move steal and concrete, to put out the fires.

Trauma is everywhere

Trauma is a part of any psychotherapy encounter. No one is without it. Life is traumatic. Planes are flown into buildings. Families are torn apart. Women and men are sexually assaulted. There is trauma--not all of it equivalent, but all of it real--everywhere. On occasion I might get a call from a prospective therapy patient: Do you specialize in trauma work? Yes and no is the honest answer: Yes, I'm a therapist who works with those who have experienced  trauma in all of it's forms. I seek to honor it and help people heal from it. No, I'm not a specialist in trauma because I wouldn't be much of a therapist without my fluency with trauma and its emotional repercussions. As therapists, we all must have such fluency, so the idea of specializing in trauma minimizes the very significance of trauma everywhere in our work.

It ain't PTSD until the TS is P

The question--"Are you a specialist in trauma?"--is often asked in tandem, as synonymous with, "Do you specialize in work with PTSD?" The answer is similar, but the equating of trauma and PTSD needs some exploration.

PTSD is the abbreviation of Post-traumatic Stress Disorder. It has a fascinating history as a diagnosis. In short, the diagnosis seeks to define the set of symptoms commonly experienced as a consequence of significant trauma. Therapists who talk about their work with trauma are, to some, PTSD-specialists. Only that conflation of terms (PTSD equals trauma) leaves out a fairly critical piece of the picture: Until the trauma ends, the recovery can't begin. In other words, until the traumatic stress incident (the TS) has ended (becomes post (P)) you can't set about the process of recovery.

There was much work to be done on September 11th, 2001, and it was done gallantly by so many. What wasn't needed--not yet--was therapy.

More than a diagnostic issue in therapy

The matter of whether or not the trauma has ended matters more than in the therapist's making of a differential diagnosis: Too often the therapeutuc recovery work begins before the trauma ends, skipping that critical step of insuring that first the trauma has fully stopped.

The humanistic psychologist Abraham Maslow articulated a now-ubiquitous pyramid outlining a "hierarchy of needs." His assertions are fairly indisputable: Needs like self-actualization, friendship and achievement--while vital human needs so often worked on in therapy--can not be solidly built unless more foundational issues--food, water, safety--are first achieved.

The challenge of safety

Safety is most often what's in jeopardy when trauma occurs. A car accident, a mugging or a sexual assault are all experiences that leave us in physical and emotional unsafety. But there are also chronic traumas where it is more challenging to see the separation between safety and unsafety: A parent with periodic, unpredictable fits of anger; sexual abuse; a relationship with a partner who is controlling and intermittently violent when drinking alcohol. What's needed to make the unsafe safe isn't so black and white.

We commonly assume that when the parent passes away; the partner is gone; or the abuse stops that safety is achieved and the recovery can begin. And yet too often, with these sorts of chronic traumas, the line of demarcation between safe and unsafe, is not so clear. Perhaps we grow up and move away from an abusive parent or lover. Or, as is sometimes the case, an abuser suddenly stops abusing. While this change in the physical proximity of the actual, literal abusing having ceased is an important part of safety, it simply isn't complete safety of the sort that Maslow says we need to work on our more complex projects of fulfillment.

Without honoring the trauma, the trauma doesn't end

I've become fond of the verbiage "to honor" in the realm of meaningful events in our lives--honoring experiences, both painful and wonderful. It's a term that's just amorphous enough to be useful in a variety of contexts. There's a sense in the term of paying respect to what's happened--good or bad.

Honoring trauma can be painful work. When I first began practicing therapy (including in the months after September 11th, with New Yorkers affected by the attacks, who were safe and therefore ready to work on their emotional recovery) I was shocked at how often traumatic experiences weren't fully honored by those who had been traumatized.

In some cases, private trauma is kept private. Sadly this is a frequent part of what allows abusers to keep abusing, though it's also often the case that shame keeps these experiences painfully private. Even when there's been acknowledgement of the experience, the experience is not yet truly honored. I'd like to propose a set of minimum standards for trauma to qualify as over:

1. The actually traumatic experience--the abuse and/ or the ongoing possibility of abuse has fully ceased. There are no lingering abusive activities remaining. (For example a sexual harasser who has stopped the overt harassment but who still stares at or lingers around his or her victim.)

2. The relationship with the abuser (in the case of trauma as a result of a person who has done harm) has either ended or has been dramatically reorganized so as to insure safety and empowerment on the part of the abused. Depending on whether it is safe to do so, this may or may not involve the abuser being confronted and/ or experiencing consequences, but must involve a scenario in which the abused feels fully in control of the terms of the relationship and has established a power base from which to guarantee his or her safety. An apology and punishment of the abuser are often helpful but not always safe to acquire.

3. The individual who experiences the trauma must acknowledge that the trauma took place and was trauma, that he or she was harmed, and wrongdoing on the part of other parties must be proclaimed. This is often meaningful work done in the safety of therapy.

4. The trauma must no longer be private. Even when shame exists (and even when the individual who is traumatized has some culpability), living in private with traumatic experiences allows them to continue. Sharing the experience with close friends, in therapy, or in group therapy can all be meaningful ways of ending the privacy that allows trauma to grow.

5. An individual who has been traumatized must stop--or get help to stop--recreating traumatic experiences. For complex reasons, there's a tendency to put oneself into situations that recreate pre-existing trauma. What follows are new conditions of unsafety that make it impossible to recover from the old ones.

6. There must be an ability to experience negative feelings about a traumatic experience. Anger, sadness, hurt, shame--these are all understandable responses to being abused. These feelings must be honored so that work can begin to develop them.

Anger isn't optional

Anger serves a biological and cultural function. When angry-making things happen, we need to get angry. Among other feelings (including ones there may not be names for) trauma begets anger.

How that anger is expressed--that's a different question. Too often psychology imposes a specific view of how that experience needs to happen--a set of steps or phases through which the abused must go through that may or may not conform to a particular individual's experience or needs. I don't mean to reimpose that view. Rather, I want to assert that a desire to move forward from trauma without anger being given expression to in some fashion, will leave us unable to truly move forward because without it, the trauma hasn't truly ended.

Forgiveness

It is a powerful thing to forgive. I find most often, however, that the people most eager to forgive are those most reluctant to fully assert their safety, including claiming space for their anger. I see expressed a desire for a sort of false forgiveness. Not false because the intent is lacking, but false because forgiveness, as a part of recovering from trauma, can only, therefore, be done once the trauma has ended. We can only forgive someone once we have fully ended their harm to us. We must first be angry at someone, as part of claiming safety, before we can forgive them. Otherwise, we extend an invitation to them to continue to harm us (even if the harm persists in our own heads--a place, after all, where a good deal of harm can be done).

Trauma is a powerful force of life. It brings with it a host of emotional experiences, but also opportunity--to recover and, perhaps, to grow even stronger through the process. We must claim ownership of our safety in order to move through the challenging process of recovery, no matter how eager we are to begin.