by Frank Ochberg, M.D.
“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.
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.
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 “hypervigilance.” 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:
(1) Haunting, unwanted, frightening recollections.
(2) Emotional anesthesia that diminishes and distances a person.
(3) 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.
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.
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.
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.
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.
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 seratonin 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.
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.
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.
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.
(1) See http://dartcenter.org/content/ptsd-101-2#.U1-5f0fD-M8 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)
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.