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“I have suffered through
many therapists that know squat about PTSD.
All my "ah ha" moments have come from
reading articles like yours and the few good
books that are out there.
I wish someone
would write an article just for family members
and friends that helps them to understand PTSD,
and directly addresses their roles and responsibilities.
They should have some, should they not?
An alcoholic
wouldn't be offered a drink, a diabetic some
forbidden food. I know my analogies are not
clear but hope you understand. Often I have
some pretty good days only to be sabotaged by
those I love most. At least it feels that way.”
This email
request arrived recently. I don't know who voiced
this legitimate call for help, but I hope to
provide just what the writer seeks: an article
for family members and intimate friends who
want to understand PTSD, and to assume effective
roles and responsibilities as caring partners.
If you are a
partner of someone with PTSD, I thank you for
reading this. Somebody who relies on you wants
you to appreciate and respect the condition
that haunts them. With so much in the popular
press, on television and in movies that touches
on trauma, it is easy to have partial information
about traumatic stress, but to miss the full
impact of this profound condition.
When I ask
my patients, “Does your husband or wife
or closest friend really understand?,”
I seldom hear a confident, “Yes they do!”
And when a spouse or loved one does understand,
I feel relieved. The prognosis for improvement
goes up considerably. I have an ally.
So if you are
that person - the partner who is willing to
set aside preconception and take the time to
learn about PTSD, thank you again for your attention.
Here goes!
What
is PTSD?
Post Traumatic Stress Disorder is a medical
condition. It is a specific alteration in brain
function due to experiencing something real,
shocking, and profoundly disturbing. Not everybody
responds to trauma with the PTSD pattern of
mental change. Because of inherited and acquired
predispositions, some will and some will not
develop PTSD after very similar traumatic events.
But once the circuits in the brain are affected
by the PTSD pattern, a survivor has the following
three problems:
Uncontrollable,
Intrusive Memory
First: their memory is seriously impaired. This
is not amnesia: in fact, it is almost the opposite!
The trauma comes back, bursting into awareness,
when it isn't wanted or welcome. This “hot
memory” lasts minutes to hours and may
be clear or altered, like a dream. It is very
disturbing for two reasons. The person with
PTSD becomes flooded with something frightening,
or disgusting, or tragic. And she or he may
feel entirely out of conscious control. Some
of my patients fear they are going crazy. Often
the trauma comes back in subtle ways - a fleeting
feeling, a vague sense of dis-ease. This may
not be terrifying, but when it occurs frequently
it changes one's whole sense of being the person
they once were. Unwanted mental experiences
can also include nightmares, and the nightmare
may have images that were never seen before,
but resemble old demons from childhood. The
worst memory symptom is the waking nightmare,
the flashback. This is as vivid as reality,
and may actually seem like reality. I've been
there, with a patient having a flashback, several
dozen times. It frightens me! We'll talk about
managing your partner’s flashback later.
Emotional
Anesthesia
Second: a person with PTSD feels like a shadow
of their former self. I call this “emotional
anesthesia.” Some tell me they have no
feeling. They are distant and detached. They
wish they had more zest for life and they know
they disappoint those who want them to be interactive
and lively. But the genuine desire to socialize
just isn't there. Your partner may or may not
be depressed. Being depressed is feeling helpless,
hopeless and worthless, and having no energy
for the activities one feels she or he was put
on earth to do. PTSD is not quite the same as
depression, but may bring on an episode of depression
(1).
This second
element of PTSD is often called “being
numb and avoidant.” Your loved one just
isn't fully alive. You, the caring spouse or
friend, can't make this medical symptom go away.
But you can help your partner feel less guilty
and embarrassed about having the affliction.
We'll come back to managing this later, too.
Anxiety
Finally, PTSD makes a person anxious. Anxiety
affects each of us differently. The usual pattern
includes irritability, impaired concentration,
sleep disturbance, being “jumpy”
(easily startled), and worried about threats
and threatening individuals. This last element
of PTSD pattern anxiety is called “hyper
vigilance.” It isn't paranoia, but it
may seem similar. Some of my patients are too
nervous to be intimate. Sexuality is often sacrificed
in the early weeks of PTSD.
It returns,
but shouldn't be rushed. When partners can't
communicate easily and effectively about sex
and other private, personal subjects, matters
inevitably grow worse. Your friend or loved
one may be embarrassed and inhibited. Or you
may be the one who would rather not discuss
“touchy” issues. Or one of you could
be the partner who talks too much, contributing
to discomfort in the other. Remember, partners
with PTSD are far more anxious than they were
before they developed the disorder. They have
too much adrenalin and it makes them less efficient,
less effective, less able to control their behavior.
They aren't sleeping restfully. They cannot
concentrate fully. Loud noises make their hearts
jump.
So there you
have it. PTSD is a physical condition and it
is real. It is not “in your head.”
You can't talk someone out of it, or ignore
it and assume it will just go away. It consists
of three things:
- Haunting, unwanted, frightening
recollections.
- Emotional anesthesia that
diminishes and distances a person.
- Anxiety that affects sleep,
concentration, serenity - and sometimes, sexuality.
By definition,
PTSD lasts at least a month but the difficult
cases last several years.
Before we get
to your role as help-mate, let me add a few
more points about traumatized people. Not all
survivors develop the whole PTSD pattern, but
they may have some of the symptoms mentioned
above. The person with “partial PTSD”
doesn't qualify for the medical diagnosis, but
still needs your understanding and help.
However, many
survivors of trauma have more than PTSD.
Complications
of PTSD
Some survivors have additional medical and psychiatric
conditions that complicate and prolong PTSD
problems. Common among these are preexisting
personality disorders, alcohol and drug abuse,
depression, chronic pain, and bereavement.
Childhood
Abuse
Personality disorders may last a lifetime and
include such traits as dependence, avoidance
and a very insecure sense of self. This is not
the place to discuss personality issues in depth.
But it should be obvious that anyone who was
severely harmed by a parent (incest, physical
abuse, neglect) will adapt in ways that may
expose her or him to further abuse from authority
figures. Your partner may have PTSD related
to early abuse and later abuse. Unfortunately,
this is very, very common. For these survivors
of childhood oppression, PTSD is less than half
of their burden. A much larger issue for these
partners is knowing whom to trust, when to trust,
and how to trust. For now, let’s just
agree that exposure to cruelty from a parent
(or parent surrogate) creates more than PTSD
and requires more information than I can give
here.
Alcohol
and Drug Abuse
Alcohol is such a common “fix” for
insomnia and anxiety that most of my patients
have reported dramatically increased use after
major trauma. Many become alcohol dependent.
Sometimes prescription drugs (often painkillers)
or illicit drugs (often marijuana) are chosen
and used, not for recreation, but for sedation.
This may be the case with your partner, and
if it is you face additional risks and burdens.
PTSD plus alcoholism is more likely to become
a chronic condition. PTSD plus pain from injury
is likely to prolong recovery and include self-medication.
When the trauma includes death of a loved one,
normal grief is complicated by inescapable images
of unnatural dying (see articles by E.K. Rynearson,
M.D. on the http://www.giftfromwithin.org/html/recovery.html
website). War creates the battleground for all
these complications.
Veterans
of War and Violence
Alcoholic survivors may be males with PTSD from
combat or from violent incidents that resemble
combat. We shouldn't stereotype by gender, but
I must point out that the “caregiver burden”
for the wife of the traumatized vet is usually
different than the role of the husband of the
victimized wife. The male veteran with PTSD
has a greater likelihood of being angry, aggressive,
uncommunicative, secretly embarrassed and difficult
to reach than the female with PTSD. Partners
of male veterans have been systematically studied.
A collection of these studies by Drs. Calhoun
and Wampler in the National Center for PTSD
Clinical Quarterly (2) includes the statement,
“almost half of these women (partners)
reported having felt on the verge of a nervous
breakdown."
If you are
a wife or significant other of a veteran who
has become seriously impaired - and is also
menacing to you because of PTSD, you are advised
to seek professional help for yourself. However,
Calhoun and Wampler caution, “many veterans
suffering from chronic PTSD are openly distrustful
and may view the involvement of their partner
(in therapy) as a threat.” Somehow, you
the wife of the veteran, need to assure your
own physical safety as you learn to reduce your
“caregiver burden” and help your
husband overcome the anguish and humiliation
of chronic PTSD.
The emerging
literature on “caregiver burden,”
aimed at helping the help-mate, justifies therapy
and counseling and support groups for the partner
of the person with chronic PTSD. Handling traumatic
stress in a loved one is very stressful for
most normal, caring partners. And the source
of your partner’s PTSD need not be anything
as dramatic as combat or violent crime to justify
your own self-help. One of the most common causes
of PTSD is the automobile accident.
Partners
Helping Partners with PTSD
My guess is that, initially, most readers of
this article will be women who have been abused
and who want their partners to have reasonable
expectations and to be supportive. Their partners,
primarily male, will then read these words.
But regardless of your gender, let me now speak
specifically to you, the partner of the person
with PTSD. I'll use “her” to refer
to the partner with PTSD, but this applies equally
to same-gender partners and women helping men.
Flashbacks
Your partner may have had a flashback at some
point, or may be having them now. Do you know?
Flashbacks are not the same as epileptic seizures,
but we can consider them equally sudden, violent,
and debilitating. You wouldn't want to elicit
a flashback by mistake. In general, you can
help with flashbacks by knowing whether your
partner has them, and learning whether your
presence during an episode is comforting or
not
Don't ask about
the details of a flashback, since that might
bring one on. Do ask if you have ever been particularly
helpful in preventing or minimizing flashback
effects. Build upon your natural ways of being
supportive, and upon your partner’s individual
needs. Some partners want to be physically embraced.
Others are made more anxious by a man’s
touch. Some partners do want to tell you details
of terrifying memories, and they may want to
repeat these details as a way of overcoming
the threat. If it helps your partner, lend an
ear. If you can't take it because you become
too angry with a perpetrator or too overwhelmed
with empathy, point that out. But be caring
as you explain your limitation, and do your
best to find ways of increasing your emotional
resilience so that you can be an effective listener.
If your partner
knows you are working at being able to handle
her trauma history, you'll be respected rather
than resented. If your partner is in therapy
and her therapist has not done anything to help
her overcome flashbacks, she may need a better
therapist. Not every licensed mental health
worker can treat the cardinal symptom of PTSD.
I use something called “The Counting Method”
(see http://www.giftfromwithin.org/html/counting.html
for details). Others use EMDR or “re-exposure
therapy.” These techniques all allow survivors
to remember their most traumatic moments (to
the point of having a flashback in the office)
but to get to the end of it and to eventually
become confident about their ability to remember
at will. In essence, your partner retrains her
brain to have “cool memories” rather
than “hot memories.”
She literally
learns to remember using the normal brain pathways
rather than the PTSD pathways. Unfortunately,
it is a painful process, like resetting a broken
bone. I try to keep it as brief as possible,
while getting the job done. You can help by
assuring that your partner finds her way to
an effective PTSD specialist, if she needs one.
Trigger
Events
Does your partner have other, less dramatic
problems associated with unwanted recollection?
She may have “anniversary reactions”
in which a seasonal reminder causes her to have
sensations rather than memories. She may find
that certain people or places bring back ugly
images and sweaty palms. No harm in asking about
this. In general, help her avoid these unwanted
triggers with dignity. But if she chooses to
risk confrontation (and possible PTSD symptoms)
help with the plan. It may include a quick escape
from her step-father’s house. It may require
you to be near-by as she deals with a family
dinner and formerly abusive relatives. The worst
thing you can do is to set the agenda for her.
That would be giving sugar to a diabetic. You'll
know if you are on the right track. You'll get
positive feedback.
Emotional
Distance
What if your partner is numb? She has little
or no outward expression of feeling. You even
wonder if she loves you. Give it time. Do not
add insult to injury by blaming her for PTSD.
Don't rush her into intimacy. If she is seeing
a counselor, ask if you can come, too - or if
you can visit her therapist alone. This is called
a “collateral visit” and is covered
by most insurance companies. Not every therapist
allows this but I'm always interested, if my
patient approves. This is my chance to explain
the issues that I'm writing about here, and,
more important, to listen carefully to the partner
so that I can help him help her. Often I hear
the question, “When is she going to get
over it?” This is a proper question to
ask, and if I cannot be accurate to the day,
I can often explain what is going well, what
is taking time, and what I expect in terms of
the rate of recovery. Overcoming that numb feeling
and the distance from a loved one that accompanies
emotional anesthesia is never easy to accomplish
or to predict.
Medication
Your partner may benefit from medication. One
of the newest anti-depressant drugs on the market
is Lexapro. A very small dose (10 milligrams)
taken daily for a few months could help with
the mood impairment of PTSD. Lexapro is the
active ingredient of Celexa and both drugs are
selective serotonin reuptake inhibitors (SSRIs).
You can read up on the medications and be able
to discuss them intelligently with your partner,
should she find herself undecided about medication.
When a person has major depression in addition
to PTSD, it really is a “no-brainer.”
Antidepressants are like insulin to a severe
diabetic. Without them, the risks are high (prolonged
depression, medical impairment, suicide). Antidepressants
help over 70% of people with first episode,
biological depression. I usually prescribe a
SSRI for someone with PTSD and depressed mood.
Minor tranquilizers
such as Xanax and Ativan are often helpful in
the beginning, when symptoms are most intense,
or during times of re-exposure to people and
places associated with the original trauma.
Unlike the antidepressants, however, these drugs
can become habit-forming. And they do not mix
well with alcohol.
Several types
of medication help with sleep. Trazodone (originally
marketed as Desyrel) helps with early morning
wakening. If your partner awakens at 2 or 3
AM and cannot get back to sleep, this medication
may be a godsend. And it is not addicting. It
is actually an anti-depressant rather than a
sedative, but it is no longer used as an anti-depressant.
It does help most persons with “early
morning” insomnia.
The medications
that help a person fall asleep are habit-forming,
and should be used sparingly. You can help by
learning about these differences, by supporting
the choices that your partner makes, with her
doctor, and helping her feel good about herself,
even if she requires medical assistance to function
at her best.
Ministry
of Presence
You might also help your partner, if she is
“down,” by being there without imposing
an agenda. As a Red Cross volunteer, I have
dealt with hundreds of grieving loved ones,
simply being there. We call it “the ministry
of presence.” Nothing needs to be said.
You do simple favors. You find a way to be occupied
while the survivor does whatever she does.
Obviously,
you reach a point when being there, and nothing
more, is hard to do. The rules change as PTSD
drags on. Some partners can talk about this;
some have a difficult time communicating. Couples
therapy can help - and you needn't see a PTSD
specialist for that. Any good family or couples
counselor can facilitate effective exchange
and mutual solving of problems. There are support
groups in some communities for persons who care
for loved ones with chronic medical conditions.
“First responders” to traumatic
events are learning ways of being present for
one another. Gift From Within produced a training
film called, “When Helping Hurts,”
to address this issue (available at http://www.giftfromwithin.org/html/video4.html).
You are now a “first responder,”
too.
Ineffective
Therapists
I realize, as I write about counselors and therapists,
there are good ones and bad ones. If you visit
http://www.ptsdinfo.org/ you will find a questionnaire.
The results of the questionnaire change as more
people post their answers, but a trend is already
evident. Most visitors to the PTSD Information
website are survivors of abuse. Most have been
in therapy. Two-thirds report that they were
dissatisfied with their therapist! While this
may be a sample who are seeking information
because of ineffective counseling, the startling
fact is still worth noting. My advice: don't
stay with a therapist whom you don't like or
don't trust. Shop around. Ask friends about
good therapists. If your partner doesn't feel
good about her therapist, ask if you can help
her find another. It may be embarrassing to
leave a doctor. We are authority figures. Many
survivors don't know how to say, “No,”
to a father-figure. Of course, you have to be
careful about turning into a too-dominating
figure yourself. But you can succeed with some
careful thought
Anxiety
Finally, let’s consider the anxiety component
of PTSD. Your partner probably has too much
adrenalin in her system. It may not be quite
that simple. Her fear threshold has been lowered
and she is easily alarmed, even though a blood
sample of adrenalin would be normal. There is
no biological advantage in having one's fear
threshold that low. Eventually, she doesn't
trust her instincts, and that could be a bad
mistake. So many people without PTSD have anxiety
problems. And there are many, many ways to reduce
anxiety. Alcohol is the classic - and the worst
- medicine. But exercise, music, good food in
healthy quantities, laughter, spiritual and
inspirational activity are all tried and tested
and true remedies. It is a matter of individual
taste and individual choice. I have an essay
on “Post-Traumatic Therapy” that
appears on several websites (try http://www.giftfromwithin.org/html/trauma.html,
again). Read it for tips on increasing one's
fitness and humor and spirituality. If your
partner is anxious, but not depressed, she may
be easy to help. I'd try the non-medication
approaches first because the drugs that tranquilize
are more addicting by far than the antidepressants.
But minor tranquilizers do have a purpose and
can make a huge difference, particularly in
the early weeks of PTSD.
Summing
Up
To sum this up, I'd say that being a partner,
a friend, a spouse of someone with PTSD is both
a burden and a gift. The term “caregiver
burden” recognizes that you are at risk,
particularly when you care deeply. You may need
and deserve as much professional help as your
partner. Or you may do fine without a therapist,
as long as you take care of yourself, and then
learn how to be effective as a help-mate.
Helping fellow
human beings is the greatest gift any of us
can experience. It really is better to give
than to receive. And your opportunity to give
begins with listening. Then with learning. Then
with understanding. Sometimes, all you have
to do is be there.
References:
(1) See www.dartcenter.org/oped/oped_030110.html
for a discussion of depression and PTSD in reporters
covering war at home. (back)
(2) Volume
11 (2) 2002, “Reducing Caregiver Burden
and Psychological Distress in Partners of Veterans
with PTSD”.(back)
Resource: Gateway
to Post Traumatic Stress Disorder Information.
© Gift
From Within & Frank M. Ochberg, MD
March 22, 2003
Please ask permission before posting or linking.
Email: Joyceb3955@aol.com
Frank Ochberg
is a psychiatrist and the former Associate Director
of the National Institute of Mental Health and
a member of the team that wrote the medical
definition for Post Traumatic Stress Disorder.
He was the editor of America's first PSTD treatment
text. Dr. Ochberg is the Founder of Gift From
Within.
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