The End of Trauma: How the New Science of Resilience Is Changing How We Think About PTSD
Trauma has a double meaning. It can mean the physical impact of an event – or it can mean the psychological impact. The End of Trauma: How the New Science of Resilience Is Changing How We Think About PTSD is focused on psychological trauma – but compares and contrasts it with how we heal physically.
Post-traumatic Stress Disorder (PTSD)
Before the DSM-III in 1980, the idea of psychological trauma had struggled to find acceptance. From the initial conditions, which were quite narrow (“outside the range of usual human experience and that would be markedly distressing to almost anyone”), to the broader acceptance of multiple kinds of trauma today, we have transformed our understanding. We know that everyone experiences events differently, and what may be trauma for one may not be trauma for another. More broadly, however, we recognize that, of those who experience trauma, not all of them – or even many of them – will experience PTSD.
Some are frustrated by the “disorder” part of PTSD. They’d prefer to call it a “syndrome” – a set of co-occurring symptoms. However, the distinction with disorder is that it has a negative impact on peoples’ lives – on their ability to function. Many who struggle with PTSD would freely acknowledge that it has an impact on their lives – and not a positive one. However, important to the conversation is the understanding that people can recover from PTSD – if not completely at least partially. Our goal should be to encourage the best outcomes, but that takes more than “just getting over it.”
Resilience
Crawford Stanley “Buzz” Holling first began using the word “resilience” to describe how forests and other ecological systems manage to endure. He explained that the instability in the system was what allowed it to stay alive. Unfortunately for Buzz, the word has been coopted by everyone who wants to sell a wellness course based on little (if any) research. Everyone wants to talk about how they make students “resilient” with an obvious lack of understanding of the word. (You’ll notice we avoid the word in our Extinguish Burnout work.)
The more contemporary definition of resilience is a return to the previous state. The problem here is that the way that things were will never be again. Heracles said that no man steps in the same river twice, for he’s not the same man, and it’s not the same river. In Antifragile, Nassim Taleb explains how we can use adversity to grow. Robert Sapolsky in Why Zebras Don’t Get Ulcers forms a similar conclusion but takes it further, arguing stress is necessary for our survival. Rich Tedeschi explains how growth is possible after trauma – and what seems to lead to it. (See Transformed by Trauma and Posttraumatic Growth.)
Our innate ability to recover from trauma is ordinary magic. It’s the thing that is both magical and expected.
Psychopathology
Just because you’re struggling with an event that was temporarily overwhelming to you doesn’t mean there’s anything inherently wrong with you. (One definition for psychological trauma is a temporarily overwhelming event.) Sometimes, people over-pathologize normal responses. In the absence of a serious loss, a sustained depressed mood might indicate a problem. After the loss of a spouse, a child, or close friend, a period of depression is the normative response.
It’s not wrong to experience and express strong emotions in the presence of a traumatic event. Some will argue that there are stages to traumatic response, perhaps aligned to those of Kubler-Ross’ On Death and Dying. Regardless of the model in use, they accept the reality of strong emotions not being pathological but rather being normal.
The Deception of Recovery
Because clinicians necessarily only see those patients who have struggled to process and resolve their trauma, encountering someone who has processed their trauma well is so outside of their experience that they may believe that the person isn’t “really” okay. This is a sampling error – or “what you see is all there is.” (See Thinking, Fast and Slow for more.) Like a black swan, just because it’s rare and you’ve not seen it doesn’t mean that it can’t happen. (See The Black Swan for more.)
Certainly, I’ve personally observed people who wanted to portray to the world that they’re better than they really are. I’ve also met people who were able to process and recover from traumas that others would have said weren’t recoverable from. The point is that you can’t easily tell whether someone is being deceptive about their recovery – or whether it’s real.
Impact
In terms of normative recovery, the scale of the problem is often inversely related to the difficulty in processing it. Natural disasters, generally, have some of the greatest impact to people and property – objectively speaking. Technical disasters, while tragic, tend to impact fewer people. Acts of intentional violence are even narrower still in their scope of objective impact. However, it’s the intentional acts of violence that cause people the most difficulty to accept.
Our belief in the goodness of others is shaken by the acts of intentional violence. We struggle, because we need to adjust our belief about the world. One thing that may make it better is Mister Rogers’ mother’s appeal to look for the helpers. (See Kindness and Wonder.)
Mindfulness and Resilience
There’s a lot of talk about mindfulness and how it leads to resilience. The problem is that there isn’t research to say that. There’s research to say that meditation matters – see Altered Traits, Happiness, and Emotional Awareness.) Dialectical behavior therapy (DBT) is a proven therapy for the treatment of suicidality in borderline personality patients. (See Cognitive Behavioral Treatment of Borderline Personality Disorder.) That’s why a recent study at Kaiser Permanente raised eyebrows when it said that DBT wasn’t effective.
It takes a closer look to understand why. First, DBT requires the balance between acceptance and the push for change. It’s the fundamental “dialectical” that Marsha Linehan was speaking of. Second, the study used only an online set of study materials for studying DBT, which, in my opinion, weren’t built with best practices for adult learning. (See Efficiency in Learning for more.) Third, and importantly, of the 24 skills of DBT, only four skills were selected for training – all of which were mindfulness.
For me, it had no chance of being successful, because it failed to adhere to the spirit of DBT – but it also attempted to teach the part of DBT that isn’t individually supported by research.
Behavior and Personality Traits
The degree of agreement between behavior and personality traits won’t be a surprise to anyone who has seen Kurt Lewin’s work and his formula that behavior is a function of both person and environment. (See A Dynamic Theory of Personality.) Nor will it surprise anyone who has read Steven Reiss’ work about motivators in conflict. (See Who Am I? and The Normal Personality.)
However, it tends to surprise people who believe in personality tests like CliftonStrengths (see Strengths Finder 2.0), the Enneagram (see Personality Types), or the Myers-Briggs Type Indicator (MBTI – see Quiet.) In fact, entire books have been written about The Cult of Personality Testing.
Emotional Suppression and Reprocessing
Suppressing the emotion related to a trauma is a bad plan. (See No Easy Answers, Assessment and Prediction of Suicide, and How Not to Kill Yourself.) However, there’s not a ton of solid long-term research that proves that repression of emotions is bad as compared to expressing them – due in part to the difficulty of doing that kind of research.
However, there is research that says that if you have an option to change the situation or simply change how you feel about a negative situation, changing the situation is better. While reprocessing events is almost always a positive experience, solving the real, tangible, underlying problem is more effective. Said differently, it’s better to feed someone rather than help them to feel less hunger pain.
Flexibility and Environmentally Appropriate Skills
Flexibility is our ability to adapt to our environment and use skills that are tailored to the situation. Using environmentally appropriate skills is the best strategy, because no one skill or set of skills is best in every situation. Developing this flexibility is two components. First is learning a set of skills and when they’re most likely to be useful. Second is learning how to understand the environment so the most environmentally appropriate skill can be used.
Maybe by using the right skills at the right time, we can find The End of Trauma.