It's one year now since Haiti was devastated by a horrific earthquake that destroyed homes, killed over 250,000 people and changed life forever for hundreds of thousands of survivors. Aid was late and insufficient, and many still remain homeless. How can one survive this kind of devastating trauma? How can one go on with living?
Traumatic events -- where your life or the life of others is threatened -- can have lasting, recurring psychological effects. When the traumatic event first occurs -- in this case, the earthquake -- some people who are traumatized have great difficulty integrating the memory of the event. They can recall some details of the event, but not all of them. The sequence of the events -- the earth shaking, walls crashing in, people being buried, running away from collapsing buildings, the screaming of innocent people dying in front of you -- becomes disjointed, unclear. It's as if the mind is saying, "This is too much to take in." The sequence in time -- what happened first, what happened next -- is confused. This fragmented and confused memory is a hallmark of post-traumatic stress disorder (PTSD), an anxiety condition that can continue for years for many of the survivors.
Another sign of PTSD is frequent flashbacks, waking in the middle of the night with terror, nightmares, a sense that it is happening once again. These flashbacks often feel real, as if one is reliving the first trauma. People who suffer from PTSD have a sense of "nowness," that it is happening "now" -- not at some distant point in the past. For some, this makes them feel that they are losing their minds, losing control, and that the trauma follows them wherever they go, asleep or awake.
Another component of trauma is the lingering meaning of the events. Psychologists refer to this as "shattered assumptions." The world, others and the self are forever changed. Trust, predictability and control have been shattered, turned upside down. Survivors often feel demoralized -- "Anything can happen at any time. It can all be taken away. I have no control. The world is unfair, evil. God is no longer on my side. I can't trust anyone. I am all alone." Some have shattered beliefs about themselves, feeling guilty that they didn't rescue someone, guilty that they survived while loved ones perished. These assumptions continue for years and result in hopelessness and depression -- or anger toward the world for letting them down. It's not only the traumatic event, it's the meaning of the event that will continue to haunt survivors.
Many people with PTSD experience emotional numbness, often feeling that either they are not real or that what is happening right now is not real. This sense of being spaced out, losing contact with reality, often makes them believe that they are going insane. "If I get lost like this in my mind and it doesn't feel real, maybe I will never come back to reality." These private and frightening experiences can occur at any time, further adding to the confusion and sense of loss of control.
Feeling anxious, demoralized and often angry, survivors of trauma often over-drink or rely on street drugs to take the edge off. This adds to a sense of emotional numbing, but alcohol abuse is one of the worst aids for the PTSD survivor. It only maintains the inability to integrate the experience and move on. Research overwhelmingly shows that overuse of alcohol prolongs and worsens PTSD.
Because the experience of PTSD is so disturbing, many survivors will avoid talking about the traumatic events, avoid going back to the place where the event occurred and avoid watching news stories of the event. Avoidance may give temporary relief, but it also inhibits any integration and processing of the traumatic event and prolongs PTSD.
Traumatic memories disjointed in detail and time, flashbacks, the sense that it is happening once again, frequent waking from nightmares, spacing out, shattered assumptions and the reliance on avoidance and drinking all are the consequences of unresolved PTSD. What can be done for these survivors? The good news is that we do have excellent treatments for PTSD; in fact, the Veterans Administration in the United States provides superb treatment. Cognitive-behavioral therapy is remarkably helpful. But the survivors of Haiti will not have access to these facilities.
Of course, in an ideal world, those surviving PTSD would have excellent psychological counseling. This would include explaining (as I have attempted to do here) the nature of PTSD. This would involve helping the person realize that their memories are disjointed and confusing because that is the nature of a memory of a traumatic event -- it is not clear, not organized in a logical sequence. It is fragmented. "You are not going insane, you have an anxiety disorder." Ideally, a therapist would help the survivor retell the original event, go into the details and then retell it over and over again. This will be difficult, and emotions will escalate, so the therapist will assist in training them with how to relax, how to calm down, how to ride out the storm. The interpretations of the world and the self -- the shattered assumptions -- would be examined. Validating how horrible the original event was, the therapist could help examine whether other less dire, less all-or-nothing interpretations are reasonable. Examining the guilt and the demoralization and coming up with more rational, balanced, life-enhancing interpretations can help the survivor. Going back to the original scene, viewing videos, writing out memories and talking about them in a supportive environment can help process the experience. It takes time, support and emotional pain, but it can help.
Think about PTSD as a fear of a memory. How do we overcome fears? We expose ourselves gradually, often with difficulty, to the event or situation we fear. Sadly, PTSD is not only a fear of the memory; it is a fear that if we remember, we will lose all control. The memory -- disjointed, overwhelming, horrifying -- feels like the real thing. It is as if it is happening all over again. It is as if there is no "then"; it is really "now." It is as if there is no escape; one can never get away from the self. But the reality is that many people with PTSD who get the right help can survive the trauma inside them. Sadly, tragically, many of these poor people in Haiti do not have access to that help. Until they get it, their nightmares will continue.