On Trauma: A Conversation with Dr. Virginia Demos page 3

Tell us about how the therapeutic community at Riggs plays a role in recovery from trauma?
Patients have access to intensive, four-times a week psychotherapy, which enables them to go into the most painful experiences with a trusted other. While this kind of therapy is available as an outpatient, I think it really helps them to be at Riggs, because once they start to open up, then flashbacks can happen anytime, particularly at night. At the Inn they have nursing staff available to sit with them and keep them oriented in the present as they go through it. And people also learn to trust and rely on peers. The presence of supportive others is extraordinarily helpful to allow them to feel that they’re in a safe place, and no matter what happens, 24/7 someone is available to sit with them to manage something that may have started in therapy, but continues beyond it. We also provide groups, for example, a trauma group, or coping skills group where they have the opportunity to share their experiences with others and not feel so alone and different. It’s very hard to do this work outpatient, where the early phases of recovery can feel so terrifying and disorienting. Once they get past this phase, some can return to outpatient work.

It gets worse before it gets better?
Exactly. It has to because they have split off so much of it. They have had to protect their psyche before they get to treatment. Then flashbacks can come anytime — sights, sounds, a touch, a conversation can trigger a reaction. It is a positive thing if they can recognize it as a flashback, even though it leads to the horror that they’ve been avoiding for so long.

And if they’re in the process of remembering, you want that to happen. And you want them to be in a place where they can get help going through it. If they dissociate in a meeting, or start to tremble, they already feel different from everybody else, so it helps to be in a community where they know other people are going through this. They feel less like a pariah.

What role does medication play in treatment for trauma?
We do use a variety of medications. We tend to use them sparingly because we don’t want to numb our patients, but we don’t want them to be so overwhelmed that they can’t function and can’t work in therapy. We’re aiming for a middle ground, that may be different for each patient, where the medication is taking the edge off, but the patient can still feel enough so they can identify and articulate what is happening.

Some patients want to feel everything and they don’t want to be on meds, or they start on medications and then eventually they want to be off them as their tolerance for emotional pain develops. But for most people medication helps them keep their mind from fragmenting with the onslaught of anxiety and terror, and enables them to continue to think clearly.

Also, the therapist has to be able to sit and bear these experiences with them, and not shut the process down. They have to be able to bear whatever the patient needs to tell them and needs to feel—even if the patient is at a point of experiencing them as in some ways like their abuser. Most of the people who work here are here because they are able to do that. We don’t want to simply manage symptoms; we are dedicated to getting to the bottom of their troubles here, by providing a holding environment to help them through that process, and by helping them to make sense of what goes on in their minds, so they can create a coherent narrative of what happened to them, and begin to feel that they are now in charge of their life.

It sounds like the stakes are really high for people in this condition.
Yes, many people with PTSD would be dead without treatment. The suicide rate for returning veterans is very high. Treatment gives them a chance to live. By the time they get to us, their lives have come apart, and many have already tried to end their lives, so whatever defensive mechanisms they had used up to that time have come apart. Often their only way out, which they hold secretly, even when they come to this place, is, “If this treatment doesn’t work, I’m going to kill myself.” We never see many people who have had trauma. They are managing somehow, and as long as their defenses work, they probably won’t seek treatment. As the saying goes, let sleeping dogs lie.

As I’ve said, treatment becomes necessary when the defenses have failed. They can fail in many ways. Sometimes it’s triggered by the death of a parent, or a spouse, or the break-up of a relationship, or a major career disappointment. Sometimes just getting a massage can trigger a memory, or open up a vulnerability that leads to a breakdown of functioning, which persists. Something has to come apart for them to come here.

If someone doesn’t have the resources to come to Riggs, what would you advise?
Some clinics and therapists may offer groups as well as individual therapy and medications for people with trauma histories. CBT exposure and response prevention strategies are also helpful in many cases. People need some kind of help once they start to uncover such material. As I said earlier, it is hard to do this work outpatient, but some people manage without treatment, others can get help from their local emergency room and day programs, some combination of support of groups and outpatient therapy. Finding a group of people with similar experiences can be very helpful in reducing the shame and isolation of trauma. So many people suffer who do not have the resources for treatment. That’s a painful one, and an important issue for our society to come to grips with.

What books, or other resources, would you recommend for lay people who want to learn more about trauma?
There’s a wonderful book by a man in Boston named Jonathan Shay who works with Vietnamese vets. It’s called Achilles in Vietnam: Combat Trauma and the Undoing of Character. Shay runs groups for veterans with PTSD, and he’s very articulate. Some people can’t bear to hear war stories, but in the group they feel like they have a place where they can tell their story and listen to others and not feel like somebody with three heads. Judith Herman also wrote a text about trauma, entitled Trauma and Recovery, which contains a manual with exercises in it, which many have found helpful. She is also in the Boston area.

What can life look like for people in recovery?
In the end, when people have come through the process and grieve, they realize that the trauma is a part of their life, that it’s never going to go away completely, and that they are different from other people because they know certain horrors exist that others don’t know about.

Sometimes that can be put to good use. One woman I treated, with a terrible history of abuse, went back to school and became a nurse, and she can work with people who are terribly frightened and deeply ill. She knows how to talk to them because she understands their experience, which enables her to bring a much deeper capacity for empathy to her job, thereby providing her patients with emotional comfort as they face painful medical procedures or life threatening diseases.

It sounds like recovery calls for a gradual rebuilding of a person’s life.
Yes. People who are recovering from trauma have to keep believing in themselves. They have to keep reminding themselves that they’re doing alright, and not waiting for the other shoe to drop. They’re often waiting for something to change suddenly, and they have to recognize that they’re living in the regular world now, and although sometimes things happen like that, ordinarily things are more or less predictable, and manageable. They have to start believing that they are capable of managing things and that they can take care of themselves. They don’t have to run scared all the time.

Many of them, have become masterful people pleasers, a skill they learned in order to survive as a child, but which now can interfere with expressing themselves in a more authentic way. So they have to learn to assert themselves without guilt, so they can express their opinions and speak to their own needs and wishes, knowing they are as important, as any one else’s. All these skills are vulnerable to back sliding in the real world, because they are relatively new, and they reverse a long held belief that they did not deserve to be taken seriously, or to feel as worthy and deserving as others.

I think the biggest challenge for some of them will be to get into a new relationship — especially for sexually abused people — to have a normal sexual relationship and to trust someone at a deeply intimate level.

That feels like the hardest thing of all.
Yes, to hang onto the possibility of loving and trusting again. They’ve trusted the therapist and the nursing staff and perhaps some peers, to get through their trauma. Now they need to take this learning out into the world, and be able to tell the difference between people they can trust and the people they need to be a little wary of. Many of them are quite bright, and they recover the use of their minds through this process, and move ahead in their education or career goals, but the intimacy issue may take longer to work through.

What are the challenges for a therapist working with trauma?
This is very challenging work, and staff often get support from other staff, but it is also deeply moving and rewarding to see a traumatized patient become a whole person who now really wants to live. I feel I have grown as a person and learned a great deal from them about courage, determination, humility and endurance. I feel very honored to have had the privilege of working with them, and to have been allowed to witness and to help them through their suffering.