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Gift From Within - Questions & Answers with Frank Ochberg on PTSD
|How To Increase Social Support
Q: Dear Frank, A GFW friend, Lily, asks you to address this issue:
In the literature you often see such-and-such malady, disorder, etc. is improved by social support. Or that social support helps protect against developing whatever it is. That's great and all, but how does a traumatized person actually INCREASE their level of social support? It can't be as simple as -- just get out more, and you'll find more friends. Certainly as people age they're less likely to make new good friends, and some of the maladies alluded to here have social isolation as a symptom. So, knowing that social support **is** good for you, and needing to increase it, how do you actually go about doing that? From an attitude level to the practicals... It's one thing to say it's a problem -- and we recognize that -- but how to actually OVERCOME it? It's not like you can take a vitamin for it or something.
What a perceptive question! I do struggle with this as a therapist, knowing that many of my patients need and deserve decent human interaction, but have huge obstacles in the way. As Lily accurately observes, the diagnostic criteria for PTSD include forms of social distance. That means that socializing cannot simply be prescribed. It is a goal rather than a pathway to the goal. Before examining what pathways have led to the goal of ideal social support, let's consider several well-recognized patterns of social aversion.
One is called social anxiety disorder or social phobia. I have encountered this several times as a psychiatrist and written about it for this GFW site: http://www.giftfromwithin.org/html/FAQ-Social-Phobia.html
A person with Social Anxiety Disorder can tolerate familiar environments but dreads being thrust into a new milieu of strangers without a "lifeline." The lifeline is most often one trusted friend, a person who arrives and leaves at the same time, who can make introductions, and who can provide company and conversation when no one else is around. Standing alone in a sea of strangers can be embarrassing, even terrifying for a person with social phobia. Those unfamiliar with this phenomenon do not appreciate the extreme anguish of phobic experience. It feels like drowning.
A person with this affliction may rush from a room in order to breathe. The friend who is that lifeline may fail to realize how significant they are and wander off to mingle with others, leaving the vulnerable person in a state of panic and humiliation.
Agoraphobia is an overlapping condition with similar situational fears. A large room filled with strangers (like a supermarket) evokes anxiety.
Often the anxiety accompanies a dread that something worse will occur - a visible, mortifying panic attack. Social Anxiety is a fear of being among people who will interact with you. Agoraphobia is a fear of the place where people may recognize your fear.
PTSD creates several sensations and behaviors that isolate survivors. Feeling numb, avoiding triggers, anticipating danger, being irritable- all these symptoms interfere with comfort in the presence of others. Some others are trusted and soothing sources of comfort. But many are just the opposite. A pattern of self-isolation is common with PTSD.
Shyness, a personality characteristic that is reasonable in moderation, can be overwhelming in the extreme. An avoidant personality might like social interaction, but fears rejection and is sensitive to rejection when it occurs. Rejection sensitivity is a feature of atypical depression (http://www.webmd.com/depression/guide/atypical-depression#1). Treatment of atypical depression may improve rejection sensitivity leading to more rational and comfortable social interaction. People with atypical depression are not necessarily shy.
There are many people who have little appetite for socializing - not because of fear or trauma or depression. They prefer solitude or ideas or mechanical objects. If they decide to seek social support, they may find it difficult because it does not come naturally to them.
Finally, there are people who have personalities that alienate others. Often unaware of the impact of their hostility, they find themselves friendless and lonely, blaming others for mistreating or ignoring them. These are among the most difficult patients to assist. They deserve human nourishment, but they seldom succeed in changing entrenched patterns of inter-personal behavior.
Let's start with a relatively easy situation.
I had a patient who was held captive and robbed. She had PTSD. She was religious, poor and overweight. I learned that she lost confidence in her pastor but was anxious about attending a different church. Eventually I discovered that she had no clothes that she could wear comfortably and confidently to a new congregation. Rather than spend our time on flashbacks or nightmares, we spent time finding reduced rate clothing for plus sized women. We succeed. She dressed appropriately, she visited a few congregations, she found the right church for her, social support followed, and PTSD symptoms improved.
Now this may seem too simple, but it is worth some discussion. The obstacle to finding social support may not be obvious and may be shrouded in shame. This patient of mine was sensitive about her weight and sensitive about her poverty. It took some time for us to get those matters out in the open and then to go to the phone book together (that was before Google). I had to listen and learn, not jump to conclusions. My role was not particularly psychiatric in this case. But I did need to be persistent, diplomatic and willing to pitch in the way a decent friend would help out.
Just yesterday I met with a man who has been my patient for several years, dealing with old and fresh traumas. Major traumas. When he was a young teen he was abused by a priest. Several months ago his adolescent son killed himself. There are other issues, too. He has a very good job, is smart, likable, mature, but without male friends. I have encouraged him to find male friends, but as Lily notes in her question to me, "you can't just take a vitamin" and suddenly have friends you never had before. This man was an athlete in younger days. He stays in shape now by exercising at home. He agrees to join a gym so that he might find companionship there. We'll see if that does lead anywhere. I do suggest activities that are healthy, reasonable, and useful whether or not they lead to new relationships. Yoga, aerobics, team sports are good ideas for those who can afford the expense and the emotional risk. I wouldn't expect someone with a social phobia to join a gym, unless accompanied by a trusted friend. Making friends when you have no friends is a huge challenge.
Another patient, one who falls in that last category of driving others away, has a dog. A dog is a considerable asset. Dogs make friends with other dogs and other dog owners. We are working with that. I am encouraged to learn about instances when the dog is brought to a pet store and my patient has an enjoyable conversation with another customer, based on domestic pet interaction. Harry Truman is rumored to have said, thinking about the toxic political atmosphere in Washington, "If you want a friend in this town, get a dog." Dogs can be man's (and woman's) best friend. But they also can help one find a friendly stranger. These strangers are not the same as true friends. They are steps on the pathway to new and true friendships.
A patient who has little difficulty socializing with friends and family does not feel supported. She was a bodybuilder before developing osteoporosis and being attacked by a psychotic individual in the hospital. She has debilitating injuries, PTSD, and a serious loss of confidence. We talk about specific social events on the horizon,
anticipating disappointment, trying to arrange things to be as supportive as possible. It isn't a matter of creating new friendships, but rather of maximizing the meaning of existing social supports.
So, Lily, I see no simple and straightforward answer to your important question, "How can social support be achieved after trauma?" There are different strokes for different folks. The different folks include people who are phobic, people who are numb, people who are shy to begin with, people with forms of biological depression, people with borderline personalities and people whose injuries have changed their life circumstances dramatically.
In each case, there are pathways to better human connection. A friend, a family member or a professional can help by listening, learning, and encouraging steps - one step at a time - toward true friendship. The isolated individual herself or himself can chart a course toward healthy engagement with others. It takes effort and persistence and building upon successful outcomes.
My examples here are far from exhaustive. Do share examples of progress on this site. I'd like to learn more, too!
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