Storm Before The Calm
5 Essential Facts About Psychological Trauma
Deborah V. Gross, MD, FASAM, DABAM, LFAPA
August 29, 2023 made 18 years since Hurricane Katrina hit the Gulf Coast of Mississippi and changed many lives forever, mine included. Those memories no longer gut me, but it’s a rare day that passes without something from that time coming to mind. The Michael McDonald song Storm Before the Calm inspired the newsletter title this month. If you’re struggling with trauma, hang on. It gets better. As the song says, “We find our deliverance as we make it through the storm before the calm.”
The head bone is connected to the rest of the body.
Psychological trauma is not solely psychological. It damages the brain in ways that are visible on modern scans. This damage alters memory, perception, emotional tone, and stress responses in the direction of survival. Such responses are sometimes lumped together as “fight or flight,” but “fight, flight, or freeze” is more accurate, since paralyzing fear and avoidance occur at least as often. Survival directives are primitive because they’re designed to ensure survival of the species. They go from the brain to every part of the body, driving our thoughts, feelings, and actions. So PTSD (post-traumatic stress disorder) survivors get injured in every part of the self—physical, intellectual, emotional, relational, and spiritual. Psychiatrist Bessel van der Kolk wrote a pioneering book about trauma called The Body Keeps the Score. Here he expresses how trauma takes over a life:
“Traumatized people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs, and, in an attempt to control these processes, they often become expert at ignoring their gut feelings and in numbing awareness of what is played out inside. They learn to hide from themselves.”
Traumatic experiences give rise to unhealthy behavior of all kinds—substance use, aggression, isolation, self-harm, avoidance, disordered eating, relational compulsivity—in a vain attempt to numb internal pain. Trauma adds to inherited risk for depression, anxiety, addiction, and other psychiatric disorders, further magnifying any tendency toward self-destructive behaviors.
Trauma is not one and done.
I had my first Hurricane Katrina-related panic attack on the one-year anniversary of the storm. I pulled into the parking lot of the treatment center where I worked, opened the car door, put one foot on the ground, and nearly slid to my knees when it hit. For about three seconds, like most people having a panic attack, I thought I was having a heart attack. However, I had walked that road many times with patients, so I soon realized what was happening and breathed my way through it.
My panic attack exemplifies what we call an anniversary reaction. I wasn’t thinking about the date, but, as Dr. van der Kolk said, my body kept the score. The anniversary date of the storm triggered the attack. People in trauma therapy learn to recognize their triggers and develop tools to cope, but it takes time. Until then it can really feel like you’re being attacked from the inside, so it’s tempting to look for almost anything to numb or escape the pain.
Traumatized people sometimes thing they should “just get over it,” but that doesn’t work, and any kind of “should” just makes you feel worse. The more you try to pretend it didn’t happen or doesn’t affect you, the more it eats you up. Healing from trauma is an inside job. You can’t drink it away, drug it away, eat it away, sex it away, or pretend it away by ignoring it. You can’t fix a liver laceration by putting a Band-Aid on your rib cage, after all! An internal wound requires an internal healing. In the case of psychological trauma, that means creating and maintaining a set of appropriate, healing conditions and good self-care.
We can’t heal if active injury is still going on. Someone I’ll call Sandi once came to see me wanting sleep medicine. As we discussed her issues, we realized that she wasn’t sleeping because she was afraid of her partner, who was mean as a snake on a good day but lethal when he drank. She couldn’t sleep because her life was in danger (the body keeps that kind of score, too), though she hadn’t acknowledged this fact before that day. We talked about getting her to safety more than we did about sleep medicine, which I did not prescribe. The road was long, but Sandi made it out and is alive and well today.
PTSD is a psychiatric disorder, yes, but I think about it as an injury. Something happens from an outside source that hurts us. Then we have to figure out how to survive and thrive in spite of it. Having the knowledge and skills to do that depends on having been well cared for early in life. We learn to take care of ourselves as adults by how we are taken care of as children. People who are abused or neglected as children often do not take good care of themselves as adults. They may engage in active self-harm or simply fail to protect themselves, either of which can bring repeated traumatic experiences. Sometimes people see this and conclude that the person “likes it” or wants to be mistreated. Not so.
If the people who were supposed to love and protect me as a child neglect and mistreat me, how would I come to know that safety in relationships even exists? And if I don’t know that there’s such a thing as a safe relationship, why would I look for one? How would I even know one if I saw it? However, the human drive for connection is so strong that most of us will accept a bad love over no love.
“First do no harm” is doctor rule number one, the first part of the oath I took at my medical school graduation. It’s one of the first things we teach our children. Without safety, nothing good happens. If I hurt my arm, it won’t heal if I keep banging on it. We only heal in safety.
Given the right conditions, healing happens.
Healing is an inside job. If I cut my finger, I don’t have to tell my skin cells how to knit themselves together or tell my immune system to send infection-fighting cells to the scene. The body is wise. It knows what to do. I do, however, have to create and maintain the right conditions—keep the area clean, maybe apply a bandage. I might need professional help in the form of a few stitches, maybe antibiotics or physical therapy. Ask yourself: Am I living safely? Do I take good care of my mind and body? Do I keep myself spiritually fed? Do I have good people in my life who treat me well? We must put the necessary conditions for healing in place and keep them in place for as long as it takes. Body, mind, and spirit heal similarly. Create the conditions for healing and you will heal. Maintain these conditions and you will stay well. There may be scars. There may be pain. Things happen that we can’t control. That’s life. But the principle holds. We create conditions for healing and wellness by taking care of ourselves.
It takes however long it takes.
“Hey, doc,” said Sasha, “I think I’m getting better. I’ve been wearing my seatbelt!” I had treated Sasha for PTSD and anorexia nervosa for several years at this point, but this was my first inkling that she never wore her seatbelt. Death was the only escape she could imagine from her constant emotional pain. Only after deciding that her life was worth living did she tell me about it.
Sasha was badly abused in childhood. By not wearing her seatbelt, she repeated her trauma by putting herself in harm’s way. This is repetition compulsion, a common psychological defense mechanism in people with PTSD. It’s an unconscious way of seeking mastery over the experience, of “undoing” the trauma. The self-starvation in Sasha’s eating disorder functioned similarly. Her turning point came when she realized that her eating disorder was a present-day representation of her childhood abuser. Until then, she considered her food restriction useful, a coping strategy that made her feel better. Once Sasha realized that she was harming herself with this behavior and thus re-enacting her abuser’s mistreatment of her, she wanted no part of it. That’s when she started wearing her seatbelt, giving herself the message that she was worthy of care and safety.
Almost everything proceeds in stages—life, grief, psychotherapy, illness, relationships, and healing. It takes however long it takes to heal from trauma. Go easy. Let people help you. Get professional help if you need it. Big problems need big help. Some things are too hard to do by yourself, and healing from trauma is one of them. If you’re struggling, reach out! There are often gifts in our storms, but we don’t find them until we “make it through the storm before the calm.”
NOTE: Much of today’s material is adapted from 90 Ways in 90 Days: A Personal Workshop for Women with Disordered Eating (Manual) by Deborah V. Gross, MD