In the early 1980’s, my Monday evenings were spent as co-leader of an open-ended therapy and support group for Vietnam veterans at the Memphis Vet Center, a storefront clinic and service center housed in downtown Memphis, not far from Beale Street and its blues music. The Memphis Vet Center was the VA’s program to make services more intimate and available to veterans.
The mood of every session varied widely, but anger was a common theme. Group sizes ranged from 3 to 20 participants, homeless vets alongside retired officers. Most attendees came to only a couple of sessions, but there was a sizable block who were ‘regulars’—maybe 100—who attended dozens of sessions in the 3 years I was involved leading the group.
Most group participants had psychological and behavioral problems associated with Post-traumatic Stress Disorder. But as I listened to them talk about themselves and to each other, the most valuable lessons I learned had more to do with their strengths than their weaknesses. First, one of the biggest tragedies of military experience was not the nightmares, flashbacks, shame and/or horror of having witnessed or committed horrible acts, and not even the never-ending negative emotions of their lives. The worst outcome of serving in that war for many was being robbed of the value system they believed prior to their service.
Most Vietnam veterans volunteered in order to contribute to a cause they thought noble and worth their sacrifice: to protect a democratic way of life by providing a check on Communism. Unfortunately, after serving, many vets came to the conclusion that their sacrifice had been wasted by politicized leadership agendas and military tactics that made little sense. The veterans were disillusioned because they began to see they were being used by their country, rather than serving their country.
Moreover, when those combatants returned home, their patriotism was attacked and shamed by those in a protest movement. Home was a place in which they no longer fit. They were hurting, alone and bitter about what they had seen and done. The ideals upon which they had decided to serve had been shattered. In the resulting “values vacuum,” only the unpleasantry of powerful PTSD symptoms was left. Additionally, they were rarely taught how to replace or renew the compromised values system.
A second thing I learned from those Vietnam Veterans was the importance of the “platoon”, usually a squad of 10 or 12 men. Even though together for only 13 months, the bond that quickly developed was very powerful and motivating. It was not uncommon in the sessions to hear men talk about how much they cared for the others in their basic small unit. In fact, often it was only other vets these men felt comfortable with and/or trusted.
I came to realize the healing power in those small groups. The Memphis Vet Center Monday Night Therapy and Support group became a “platoon” where vets could work with each other to rediscover or replace their lost values. Once they accomplished this values clarification, many found more strength to cope with the symptoms of PTSD, and they became more receptive to learning the cognitive and behavioral skills helpful in rebuilding life after trauma.
Since those days at the Vet Center, I have been involved in the treatment of many other folks who had traumatic events in their lives, including Childhood Sexual Abuse, motor vehicle accidents, crime victimization and sexual assault. A common feature of these trauma survivors is this loss of belief in previously-held values. Values can be defined as activities or outcomes considered important in life. Being clear about what is important is often missing for trauma victims. Like the combat veterans’ loss of guiding patriotic values, survivors of Childhood Sexual Abuse (CSA) spend the first 8–10 years of life learning trust, only to find that it was no more authentic than a politician’s promise. Many battered spouses go through life in fear for their physical safety, only to have such fears confirmed by violence eliminating a valuable sense of security. A vacuum is formed where once there was a strongly-held belief about an important feature of life. Without a sense of knowing what is important in life, trauma victims find little motivation to engage in the hard work of coping with unpleasant symptoms.
Addressing this values vacuum is important so victims can find increased strength to cope with the trauma encountered. Since the main method by which we learn values in the first place is through social interaction with important people in our lives, group process is a powerful mechanism by which victims can examine changed values systems and begin to renew and replace them.
Rates of Trauma and Overcoming It
A recent study (Kilpatrick, et al, 2013) reveals that over 80% of 3000 people surveyed report having experienced a major trauma. 80%! These traumas include physical or sexual abuse-53%; death of a family member due to violence-51%; natural disaster-50%; accident/fire-48%; witnessing physical or sexual assault-33%; and combat or warzone exposure-8%.
Most victims of trauma (including most veterans of military combat) “get over it” in 12-18 months. But 20% don’t. They develop PTSD. What is the difference between the 80% who adjust and the 20 % who can’t “get over it”?
An entire article can and should be devoted to the complicated concept of “getting over it.” For starters, even if they get past the trauma, their life narrative is forever changed. Plus, somewhere between 40-60% of folks who have a life trauma end up eventually saying that their life is better for it: an outcome called post-traumatic growth (Calhoun and Tedeschi, 2103).
In fact, if one thinks about it carefully, a good question to consider is WHY IS THERE NOT MORE PTSD, if over 80% of people report having had trauma in life? My experience with Vietnam veterans has led me to the conclusion that folks who “get over it” address the destruction of their values system in some kind of group interaction, formal or otherwise.
Internal Dialogue: The Role of Narrative in Recovery
Each of us spends most of our waking hours engaged in an “internal dialogue” where we describe, evaluate, and re-imagine the events happening around us. To a cognitive-behavioral psychologist, internal dialogue is behavior that can be examined in a technical manner. It is determined by past social experiences and it is changeable.
The incessant internal dialogue going on inside is the raw material of the life story or narrative we each are creating. After a trauma, that narrative naturally becomes negative, even tragic. But the good news is that the trauma-tinged internal dialogue can be modified by changing the patterns and content of interactions with others.
Verbal behavior, including self-talk, is strengthened or weakened by how those listening to it respond to it. When what we say is met with positive reactions from others, similar thoughts and statements in the future are more likely. But when the verbal behavior is met with bland or even negative reactions from those in our social community, such content tends to be weakened. This process of ‘shaping’ what we say and what we think goes on constantly and has been going on in our social interactions since birth.
Thus, the content of internal dialogue is infinitely changeable, depending on with whom one is interacting. However, once set, internal dialogue can and does get stuck if the social group with whom one interacts becomes stagnant where only one type of content (e.g., negative/hopeless) is encouraged over other types. In addition, many exposed to trauma greatly reduce the number and range of people with whom they interact, further reducing input to change internal dialogue.
The narrative of a life can be going along great, maybe even according to one’s life plan, and then WHAM!—a trauma happens, and the narrative changes. Before trauma, a glimpse of the internal dialogue might be summarized as “Everything is okay/I’m in charge/I like my life/ I have hope/this is fun, if not hard.” After trauma, however, it becomes “The hurt is unbearable/I can see no end to it/I can’t do anything to stop this pain/others don’t understand/nothing matters anyway/my life is awful/I’m awful/HELP/leave me alone.”
Specific content in the internal dialogue is important. Social communities encourage asking others for advice, input and even help. Also encouraged, even demanded, is the labeling of the causes of the events that happened and attributions of who caused them. Most of us spend significant time engaged in an internal dialogue musing about who did what and why it was done, influenced greatly by what those around us are saying on similar issues. Unfortunately, after trauma, when victims decrease interaction with others, less input can be provided from other people and internal dialogue can remain stagnant and usually negative.
When that happens the avoidance symptoms of PTSD take over, and the life gets stuck! But the internal dialogue does not stop. Constant negative self-talk, often on “automatic pilot,” goes on indefinitely. Social relations suffer (and stop), health suffers, job/family/marriage and other practical matters get dysfunctional. The narrative that accumulates turns into a pain-filled and hopeless modern tragedy. Mix in alcohol, drug abuse or poor life decisions, and the spiral swirls wildly.
Two Particularly Pernicious Patterns-Values Vacuum and Loss of Self-Efficacy
The unchecked internal dialogue results in an unrelenting and pervasive sense of pain and avoidance, which makes life bad enough. But when the victim stays stuck for too long in this spiral, life worsens.
First, as outlined above, the trauma event often shatters long-held central beliefs and values. The victim loses sight of what is important in life. With the values vacuum often comes a lack of passion and enthusiasm for progress or renewal. The grieving parent loses the motivation to show love to others. An abuse victim dares not place trust in others, however well-meaning. A veteran finds it impossible to take orders or tolerate the petty details of life. Crime victims never allow themselves to assume safety. A rape victim can’t let intimacy happen because it only means more pain. Getting stuck in the negative internal dialogue only creates more being stuck because new interactions and ideas are avoided due to reduced interaction with others.
A second outcome of a life thus interrupted by trauma is a horrible case of the “I can’ts.” Psychologists identify Self Efficacy as the belief a person has that he/she can actually perform a specific behavior. For example, successful cooks have the belief they can prepare a tasty meal, whereas someone who has never done any cooking has very little belief (self-efficacy) in the ability to cook. An experienced driver might have a strong belief that she can drive in heavy traffic, but the new driver is not so certain.
Self efficacy beliefs result from four types of life experiences: performance accomplishments, vicarious experiences of watching another conduct a task, verbal encouragement from others about learning and doing a new skill, and the experience of actual physical sensations/feedback when a task is attempted and completed.
Self efficacy is important because if one has little of it in a particular category of behavior, that person will make very few, if any, attempts to perform that action. Trauma victims who are stuck are convinced they can do nothing about the unpleasantry of their lives. They can’t be honest about the trauma and their shame. They can’t let other people know how completely messed up they feel. They can’t take on new challenges added to the load of daily survival. They can’t, they can’t, they can’t. And sadly, they don’t.
PTSD is a disorder of “being stuck” in a never-ending cycle of avoiding the unpleasantry, believing and/or trusting in nothing once-valued and a lack of belief that something can be done to change this cycle (self-efficacy).
A crucial component in trauma recovery is becoming educated and aware of this process of getting stuck so that plans can be devised to reverse it. Cognitive behavior therapy typically consists of three phases: education about the problems-their causes and effects; identification and practice of skills that reduce the problems; real-time application of the newly learned coping skills in day to day life situations to reduce the problems. The first step in the education phase for trauma victims is to understand why they are stuck. Such an educational rationale then provides the framework on which new skills and behaviors are gradually tried and eventually perfected.
Engineering Post-traumatic Growth-What Must Be Done to Become Unstuck
The good news is that there is much that can be done to change the dynamics described above. In fact, the difference between trauma victims who eventually come to have post-trauma growth and those who go on to get stuck in PTSD is the arrangement of a social community in which self-efficacy is “manufactured” by arranging the four life experiences mentioned above.
Engineering can be defined as the process of combining smaller parts to construct a larger and useful entity. A thousand 2×4 sticks can be made (engineered) into the frame of a 3000 square foot house. Behavioral engineering happens when we combine smaller acts into a longer chain of acts that can produce beneficial outcomes. Attending 120 hours of college classes can result in learning a profession or trade useful for the rest of one’s life.
For the trauma victim, the narrative of “I can’t” must change to “I can.” Behavioral science suggests a technology of behavioral engineering through social interaction, i.e., the power of the group. Trauma victims who survive and learn to thrive make social interaction changes by taking small steps toward being more real and “authentic” with themselves and others. They begin to make gradual progress toward improved coping by learning new stress management skills. And they redefine what is important in their lives by finding passion and meaning in pursuing those values. All of these outcomes happen by changed social interaction patterns, sometimes in therapeutic situations and sometimes in self-help groups or other groups occurring naturally in a person’s life, like family or a work environment.
While it might at first seem difficult if not impossible to find or become a part of such a healing community, changes are more possible than ever in the age of social media. Many opportunities exist in which trauma victims can reach out to others and begin the step by step process of rehabilitation. The necessary conditions for the above changes taking place include finding someone to guide such a journey (therapist, mentor, coach or sponsor), taking small steps toward being more truthful and open about the trauma and its impact (writing or sharing an account of what actually happened), learning new skills to think about and manage stress or modify behavior (stress management training and behavior contracting) , participating in group involvement with others on similar journeys (regular meetups devoted to supporting and challenging oneself and others) and finally, finding meaningful life pursuits that generate passion (values clarification).
Cognitive and behavioral therapies, preferably in group contexts, are available to create the new social communities that will help one re-write the narrative of damaged lives. Many published or online sources exist that show how to create these essential changes. An excellent place to start is this website: cptforptsd.com. Another helpful webpage details the narratives of trauma survivors who achieved post-traumatic growth by clarifying values and finding life pursuits about which they became passionate.
We hope you begin to investigate this approach to trauma recovery through rearranging social interaction in healthy and progressive ways. Our new book, Trauma Recovery: Sessions with Dr. Matt is one way to visualize such a journey in that it describes in detail the narratives of seven trauma victims whose interactions with a therapist and each other achieved the needed changes to recover from trauma. While the book is on sale at Amazon and other booksellers, both Matt and Beth are committed to making a copy of the book available to anyone who is not able to afford its purchase. We can be contacted through our website, drmattbook.com.