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Gift From Within - PTSD Questions & Answers with Frank Ochberg, M.D.
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|Veterans & PTSD: Military Sexual Assault
Q: Dear Frank, Here is a question for you, recently addressed to me from one of our GFW friends regarding this person's military sexual assault. " A few years ago while serving in the military I was sexually assaulted by a co-worker. But I was intoxicated at the time and he got off for a number of reasons and I couldn't prove it was an assault. And unfortunately I did see him from time to time. I was diagnosed with PTSD by a doctor. My life is difficult as you can imagine. I can't seem to get rid of these flashbacks and nightmares. People think you can get over PTSD. Do survivors ever get over it? How can I make my mind forget what happened. I would appreciate your advice."
A: Dear Joyce, I'm optimistic about getting past the worst parts of PTSD. The reality of cruelty persists. The fact that there is a rapist out there who never admitted his crime, to himself or to others, can't be ignored. But survivors of abuse and assault can learn to respect themselves, despite the social stigma of victimization and the self-stigma that most victims feel. It isn't easy. A voice inside says, "You should have known better." Or it says, "People look down on you." Or it reminds you of every other time in your life that you were hurt and humiliated. These are very common consequences of trauma, particularly sexual trauma. Military sexual trauma has elements of incest. The perpetrator was a brother-in-arms. Incest carries considerable self-stigma. To maintain the dignity and honor of the family, the corps, the tribe, there is a code of silence. To protect the father-figure (a commanding officer), details are suppressed. It is dangerous to speak out. Although many of us are working to change the culture (http://servicewomen.org/) we are in a long struggle and the code of silence persists.
So while this isn't true for everyone, I'd suggest to this veteran, see if you can begin by working backwards, overcoming the secondary effects of sexual trauma. That means telling yourself that you are worthwhile. If you have any self-denigrating thoughts, consider where they originate. Did a parent or an older sibling or some influential person say things that were calculated to humiliate you? Do you feel judged, and judged harshly? On the other hand, are there people you have met who treat you with dignity and respect? Can you imagine them knowing you now, understanding what you have been through, and feeling good about the woman whom you are? These people from our past are often the chorus that forms our conscience. I think of them as "The Board of Directors." They praise us for being like them. They criticize us when we interfere with them. Some of them really do not deserve a place on the Board. They are bullies or they are selfish. But they had influence when we were young and their attitudes linger on.
PTSD has, for many, negative self-concepts. We knew about this when we first formulated the PTSD diagnosis, but only in the most recent formulation are these negative thoughts made explicit. Section D of the latest diagnostic criteria includes these three symptoms:
1. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous").
2. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
3. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
These are symptoms; not realities. They are feelings; not prophesies. Tell yourself that! There are no medications for these distortions of self-image and world-image, but there are good coping techniques. See if you can work with your personal Board of Directors. By now, those sources of self-evaluation are you, not anyone else. But you can think of your conscience (Freud would call it your super-ego) as your Board of Directors. Try to move an ally into the chairperson's position. Put a good friend on the board. Imagine those people whom you respect, judging you now, not any self-serving acquaintances from the past. Here are some Gift From Within links that could help:
When you improve your self-esteem and overcome the negative thinking of PTSD, you are ready to tackle some of the central features of the "invisible wound."
You mention flashbacks and nightmares. Those usually clear up themselves as time passes. But they return with reminders. Let's consider nightmares. These may be re-enactments of the assault or they may be strange combinations of encounters with the rapist and with others from the past or present. Regardless of the content, nightmares can be reduced with medication. A pill that lowers blood pressure has helped many veterans, and others, with posttraumatic nightmares. It is called Prazosin. You start with a very low dose - just a milligram or two. You can have it raised gradually if more is needed. Prazosin can cause postural hypotension - that means you could faint if you rise too quickly from a recumbent position. And if you have low blood pressure it might be dangerous to use. But any experienced trauma therapist should know about Prazosin and give you an opportunity to have it prescribed if you want to try it. Many VA doctors use it now, with positive outcomes.
Trazodone, an antidepressant, not a sedative, does help many restless sleepers get through the night. If your sleep is impaired and you wake up early from a bad dream, you might benefit from this relatively harmless, non-addicting medication. Again, any trained PTSD therapist should know about Trazodone and discuss it with you.
Nightmares do not necessarily require medication. Discussing nightmares and any provocative dreams with a qualified therapist can bring insight and relief. None of us know, with certainty, what dreaming signifies. Vivid dreams often seem to connect images and feelings from the last day's activity to significant issues from the past. It is as though we get a glimpse of the brain's way of filing data, through links and associations. Discussing a dream can lead to discussing other important thoughts and feelings, leading to better understanding of personal history and important inter-personal relationships. Sexual trauma is such an invasion of personal space, of dignity, of intimacy. Having an opportunity to recover a coherent sense of self is part of post-traumatic therapy. Conversations with a mature therapist can begin with consideration of a bad dream, and lead to a calm and comfortable self-confidence.
Flashbacks are similar to bad dreams during the day. Suddenly, a frightening scene is relived, as though it is here and now. But it isn't here and now. Due to the terrifying imprint of a near-lethal, invasive experience, the brain "dissociates." It goes into a trance. This isn't "crazy," but it can resemble psychosis. Some PTSD sufferers think they are "crazy." Tell yourself you are not. Realize that this is the daytime equivalent of a nightmare. Through trial and error, learn to bring yourself out of it. Not easy. An experienced counselor could help, knowing you, knowing who else is in your life. I advise talking this over with a partner, if you trust your partner. Tell him (or her) what you prefer him to do when you are having a flashback and he is there. Should he hold you or keep away? Should he say something to bring you out of it? What should that be? Sometimes, it helps for a person to say the time and date and place - to remind you about the present so you can leave the past.
I use a technique called "the counting method" to bring on a flashback during therapy, allowing both of us to deal with it and overcome it. The Counting Method works. Read about it and learn about it. Ask your therapist to consider it. There are many internet sites that explain and demonstrate the method. Here are a few:
Other treatment techniques help reduce the frequency and the impact of flashbacks. Anything that reduces hyper-vigilance, that improves the ability to socialize successfully, that increases self-confidence, lowers the risk of the flashback.
PTSD is a cluster of disabling symptoms and one feeds into another. Treatment for PTSD depends upon self-education so that the condition is understood, brought down to Earth, made rational and tolerable. PTSD Is very common, but is commonly mis-understood.
It does improve with time. It is not a life-sentence.
I applaud everyone who dares to "come out" and say, "I have PTSD." General Romeo Dallaire, commander of UN troops in Rwanda and now a Senator in Canada did that. And he helped Canada change its rules so that a member of the armed forces can get a medal for PTSD. We should do the same. A medal. Not a code of silence. No stigma. Honor for the invisible wound.
So can you make your mind forget what happened? No. It did happen. It was real. But you need not constantly remember. You are a survivor. You have dignity and worth. We, who know the legacy of PTSD, honor you.
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