For generations, PTSD (Post Traumatic Stress Disorder) was thought to be something that primarily affected those that had been in military combat and wars. Images emerge of soldiers returning home from World War I, never the same. Violent outbursts of anger. Waking up in the middle of the night in terror over what they had witnessed. This scenario has been played out over film in the past 50 years dozens of times. Tobey Maguire was nominated at the Golden Globes for Best Actor for his 2009 portrayal of Sam Cahill, a US Marine Corps captain returning home from duty. Forced to kill his fellow comrade after being tortured in Afghanistan, Sam shows extreme signs of PTSD upon returning home, including this one scene where he violently destroys his own kitchen. Similarly, the entire narrative arc in Iron Man 3 is shaped by Tony Stark’s traumatic experience of saving New York City from aliens in the 2012 Avengers film. But in recent years, scientists have discovered that the PTSD diagnosis is much more extensive than originally thought. War-battled soldiers returning home represent just the most extreme and obvious examples of what is now known as an entire spectrum of trauma. Car accidents, sexual assault, domestic violence, muggings and shootings are other examples of things that can bring about PTSD, mild or severe. In many instances, like that of sexual assault, memories may be unconsciously suppressed. We see this play out in another critically-acclaimed film, 2012's The Perks of Being a Wallflower. The main character, Charlie, lost his aunt to a tragic car accident years earlier, who also was his sexual abuser as a child. In one of the later scenes in the movie, the realizations of sexual abuse are only just starting to hit him. Perhaps more than other mental health conditions, the cultural awareness around PTSD has increased over the last few years, but it’s still poorly understood by the general public.  So what is PTSD and how does it work? To properly help those experiencing this disorder – whether that be us or someone we love – this is where the conversation starts.

The most obvious starting place for understanding the disorder is to figure out what categorizes as PTSD to begin with. As we zoom out on this conversation, we must clarify that traumatic stress and PTSD are different. The problem is that in today’s culture the two get used so interchangeably, muddying the true understanding of what PTSD is. Harvard Health explains that with PTSD, “distressing symptoms occur after one or more frightening incidents. For the most part, a person with this disorder must have experienced the event him or herself, or witnessed the event in person..the event must have involved serious physical injury or the threat of serious injury or death.”  Some common events that fit into this bucket are:

• • War and military combat (formerly known as shell shock or war neurosis)
  • Motor vehicle accidents (Car accidents, plane crashes, boating accidents)
  • Industrial accidents
  • Natural disasters (tornadoes, hurricanes, volcanic eruptions)
  • Robberies, muggings and shootings
  • Rape and sexual assault
  • Incest and child abuse
  • Hostage-taking and kidnappings
  • Political torture
  • Imprisonment in a concentration camp
  • Refugee status
  • Tragic or unexpected loss of a loved one

 However, just because you have experienced one of these events, doesn’t mean that you’ll necessarily develop PTSD. Additionally, there are plenty of life events that are stressful to the point of trauma that wouldn’t be categorized under the PTSD bucket.

One of the most simple ways to understand this is to view it through the lens of the COVID-19 pandemic. For some, there is traumatic stress attached to the season of lockdown and isolation. But for healthcare workers that were on the frontlines, they were directly exposed to massive amounts of death, in severely emotionally distressing ways.

A 2022 report which assessed nearly 100,000 HCW (healthcare workers) that worked on the frontlines of the pandemic revealed that 20% of HCW were diagnosed with PTSD after the fact. Another nuanced example would be the circumstances under which a spouse or significant other passes away. In every instance, someone would experience the five stages of grief and some level of traumatic stress. But consider the person who suddenly loses their spouse due to a car accident or worse, directly witnessed their spouse dying unexpectedly. In the latter example, there is an increased likelihood of PTSD developing. But in any case, what we’re not saying is that all grief and traumatic stress doesn’t matter. All stressful, traumatic and grief-filled situations must be held with delicate care.  As we open up the conversation on PTSD, we’re simply outlining the clinical differentiations in this section. But as you’ll see from some of what we’ll cover down below, despite the differences there is actually a lot of overlap in terms of how you’d treat PTSD and traumatic stress.

As we mentioned above, the development of PTSD is almost always preceded by a traumatic event. But the details that follow that event can be highly nuanced to the individual. The National Institute of Mental Health explains:  “Symptoms usually begin early, within 3 months of the traumatic incident, but sometimes they begin years afterward. Symptoms must last more than a month and be severe enough to interfere with relationships or work to be considered PTSD. The course of the illness varies.” There are four categories of symptoms, which include: Recurrence: Sufferers often experience flashbacks to the traumatic event, which might be accompanied by physical stress like panic attacks, trembling of the hands, sweating and shortness of breath. It is as if they are reliving it, like in this scene from American Sniper. Waking up in the middle of the night in terror is also a common symptom. This may involve screaming from bad dreams and night terrors, yet another situation which feels like they are suddenly back in the middle of the trauma occurring.  Avoidance: Some sufferers plunge into avoidance, staying away from anything that would remind them of the trauma, including people, places and conversations.  This might look like taking the long route to a destination, to avoid the site of a tragic car crash. It could be avoiding childhood homes, rooms or environments that trigger memories of a traumatic rape or sexual assault. It could look like avoiding certain songs, films or TV shows that remind them of a person they lost. Being exposed to the thing that they are avoiding may bring about a panic attack or intense feelings of anxiety that make the act of simply living a heavy burden to bear. Reactivity: It’s common to also feel tense or on-edge. This may lead to angry outbursts, like the example from Tobey Maguire’s character we highlighted in the opening paragraphs. A person may also be easily startled by things going on in their surrounding environment, such as noise and laughter. To non-sufferers, it may be hard to relate to how seemingly basic things of daily life could trigger such experiences, but for the sufferer, it takes them back to the trauma. Cognitive: Especially in instances of rape and sexual abuse, there may be trouble recounting key moments of the traumatic event. We see this play out throughout The Perks of Being a Wallflower, as trauma is often suppressed beneath the surface. On an emotive level, PTSD sufferers also experience negative thoughts about the world and one’s self. Often, there’s a loss of interest in activities that were once enjoyable. Emotional numbness may ensue, sometimes making the personalities of a sufferer virtually unrecognizable to their loved ones. Clearly, all of these symptoms cause significant disruptions in the ability to live out a normal life. At times, the PTSD sufferer may be non-functional.  In films like Brothers and extreme examples of PTSD, you often see all of these symptoms on-display at once. But in other cases, some people may experience just a few of these things and in a more moderate fashion. And even though symptoms do begin early for many, it may take years for others to get diagnosed.  One Reddit user explains, “I went over 20 years without diagnosis. It wasn't until I had a massive triggering experience that I looked for help and was diagnosed. With PTSD it is always there, it's just a matter of severity.. how long before it becomes a major issue is the big variable.”

6-8% of the population will experience PTSD at any given point during their lifetime. But Harvard is quick to point out that “stress of this severity does not automatically cause PTSD. In fact, most people who are exposed to terrible trauma do not develop this particular illness. The severity of the stressor does not necessarily match the severity of symptoms.” So naturally, the next question would be, how do I prevent this from happening? While there is no bullet-proof method to prevent PTSD from developing, the initial response to a traumatic event is important, whether we are talking about PTSD or traumatic stress.  Studies in this area, comparing two individuals who have experiencing the same traumatic event, have revealed these factors as important preventative measures:

The minutes, days, weeks and months that follow a traumatic event is a critical time period to seek help. The longer someone suffers in silence, the more damaging the trauma becomes. This is obviously easier said than done, especially for those who are in the middle of recurring traumatic events – like sexual abuse or being on the battlefield. Sufferers may feel paralyzed, unsure of where to turn or what to say.

Of course, seeking help would involve disclosing the traumatic event to people that represent safe spaces for you. This may involve openly processing how you are feeling, as messy as that might be at any given moment.

Processing trauma is a healthy way, in addition towards going through the stages of grief, includes having a continuous support system. This may include frequent meetings with a therapist who specializes in trauma for an extended period of time, in addition to open conversations with friends and family.

Those who have not only prevented trauma from becoming PTSD, but also thrive in the aftermath find meaning in what they went through. 

Finding meaning is often accompanied by helping others in a redemptive manner.  After seeking help, disclosing the trauma and chafing a continuous support system for a period of time, this may involve walking other sexual assault survivors through their own healing process. It could involve befriending and sharing the grief process with another person who has tragically lost their spouse. 

For many, finding meaning and helping others is wrapped in a cloak of faith, as with followers of Jesus. Faith helps trauma survivors not only cope with their suffering, but accept it and thrive in the midst of it.  However, as we mentioned above, having these things in place does not necessarily mean that PTSD will be prevented after the exposure to a traumatic event. And if PTSD does inevitably come on, we need to know how to respond in the aftermath.

Since not all people who experience traumatic events develop PTSD, the first step to treatment is confirming a diagnosis. Upon seeking a therapist, they will start exploring all possibilities for what might be at the root of your current emotional state. It’s possible that PTSD could be confused with other disorders, such as OCD. For example, many of the avoidance symptoms related to PTSD are similar to that of OCD.  But after a series of questions and meetings, if your therapist does confirm you have PTSD, there are a few options for treatment, some of which also bear similarities to how you would treat OCD.

One of the breakthrough treatments for PTSD is exposure therapy, particularly for avoidant behaviors. As the name implies, the goal is to expose yourself to traumatic images and ideas in a controlled environment.  While continuing to engage in avoidant behaviors may help the sufferer feel safer in the short term, it only prolongs the recovery process and the presence of PTSD symptoms. Prolonged avoidant behaviors can also make the proverbial wall larger and larger over time. What you’re avoiding might become more triggering the longer you avoid it. So under the guidance of a therapist, exposure therapy has you confront your fear and trauma head-on. You would first create an “exposure hierarchy” or sometimes called a fear hierarchy, in which you’d work with your therapist to rank triggering situations. From there, this type of therapy typically fits into these buckets. Direct Exposure: With direct exposure, you confront the triggering objects, places or situations head-on.  For a soldier that has returned home, this could involve watching a war film for five minutes, eventually upping that up to ten minutes, then thirty, an hour and eventually watching the whole film. For a woman who has experienced sexual assault, it may involve returning to the scene of the assault. For someone who lost a loved one in a tragic accident, it may be returning to the scene of the accident and sitting there for a period of time without fleeing. Of course, this all assumes that you understand what is triggering you in the first place, as we mentioned above. Exposure hierarchies help identify how your avoidant behaviors are manifesting. Even if someone has been through the same traumatic event, their avoidant behaviors may be different. Coming up with a highly customized approach with your therapist is key to success. Imaginal Exposure: If direct exposure is not safe or possible, as in the case of soldiers returning to the battlefield, then a therapist will guide the sufferer through imaginal exposure. This might involve having the sufferer think about the traumatic event, such as a rape, car accident, kidnapping or battlefield. As with direct exposure, repetition is key towards building tolerance over time.  It may be incredibly difficult initially to imagine these things and you may only be able to bear it for a few minutes, but over time you will see an increase in quality of life and tolerance.  Interoceptive Exposure: Many of the symptoms around PTSD can create fear in themselves. The possibility of physical symptoms like body tremors, anxiety attacks and shortness of breath coming on can create more emotional barriers for sufferers. Originally developed for those with panic disorders, interoceptive exposure involves deliberately bringing on these physical sensations in a controlled environment with a therapist. This may sound uncomfortable (and it is), but over time the goal is to learn that these physical symptoms are harmless and build your tolerance for coping with them over time. Perhaps the most powerful form of exposure therapy is by practicing all of the things above together and over a prolonged period of time. If this all sounds like a difficult process to go through that will only provoke your anxiety, that’s because it is! Anxiety will surge, but over time, you’ll find that your anxiety will start to decrease. Exposure therapy is hard work. But what’s the alternative? To stay trapped in the vicious cycles of avoidant behaviors? Freedom is ultimately on the other side of exposure therapy Remarkably, those with exposure therapy success stories ultimately find themselves better equipped to cope with the tragedies of life than the average person. 

Exposure therapy is part of a larger umbrella of a universally-acclaimed talk therapy called CBT (cognitive behavioral therapy). Harvard defines CBT as, “A highly effective psychotherapy [that] focuses on how our thoughts, beliefs, and attitudes can affect our feelings and behavior.” It’s based on the idea that much of reality is shaped by our thoughts and feelings, not externally facing circumstances or variables, like people, situations or events. The benefits of CBT help us better cope with circumstances, even if the externally facing variables don’t change. This is critical for coping after the experience of a traumatic event. Proponents of CBT are quick to point out that CBT is not merely about positive thinking, but rather realistic thinking. How do we interpret the events that happen within reality, both negative and positive? As one psychologist put it:  “The goal with cognitive therapy is to make sure someone has an accurate assessment of the situation. Some situations are genuinely awful, and a negative belief about them makes sense. Some situations are truly good, so a positive thought is accurate.” Of course, central to the idea of CBT would then be how you make sense of the world.  How do we define what’s accurate, genuinely awful or truly good? How do we make sense of suffering, our experiences and the ways people have hurt us? Clearly, it can’t just be based on feel-good emotions.  Dr. John Gottman, one of the most influential psychologists in the world, details in his book The Science of Trust how women have told him some of the best sex they experienced was directly after physical abuse. We see this exact scenario play out with Nicole Kidman’s character in the critically acclaimed show Big Little Lies. But as we witness in the show, it’s doubtful any psychologist would encourage women to lean into their positive emotions in this scenario and view these experiences as “truly good”.  Objectively speaking, in any culture, there’s something deeply troubling about physical abuse. So CBT works best when we align ourselves with objective truth and understand how the world actually works. Thousands of years before the modern roots of CBT, Jesus gave us a foundational paradigm for how to view our experiences.

1. 1. There is a Creator who designed a beautiful world, but humans only have a limited lens into the nature of reality.
   2. Since the beginning of time, something (clearly) has gone horribly wrong, springing about everything from wars and disease to death, mental health issues and racism.
   3. Humans are flawed and play an active role in hurting each other, infected by a condition Jesus labeled חטא (sin), which in its simplest form, means to miss the mark. Think in terms of archery, to which we are essentially missing the bull’s eye on the Creator's original design to love God and love each other.
   4. Jesus claimed to be the primary means himself in which all things are being restored to their original condition, inviting us to follow his way of life.
   5. In the present day, we live in a time period of the “now” (present healing, reconciliation and beauty) and “the not yet” (future and final healing and reconciliation).

 Whether we realize it or not, aspects of this paradigm have undoubtedly influenced modern-day psychology and the way we approach CBT. For a therapist to even guide a patient into an “accurate assessment” of the situation, requires them staking claims to what’s “genuinely awful” and “truly good”. It requires an acknowledgement that things aren’t as they should be and that humans do play an active role in hurting one another. It requires walking their patient through how to cope in the midst of suffering, to live between the healing available “now” and the hope of the “not yet”. And hereby is the importance of aligning ourselves with how the world (objectively) works when practicing CBT.  When it comes to treating trauma, putting CBT into motion would involve helping the patient to navigate the grief and horror of what they’ve been through. It may involve helping a woman who has suffered from sexual assault see that all men will not be like their abuser and there is a profound joy that could come from dating again.  Perhaps most of all, CBT helps the sufferer through the mountain of cognitive distortions that have been built up from the trauma and accept the suffering they’ve endured.  Many have found Jesus’s take on suffering to be the most helpful and transformative in all of history. Jesus and his followers knew that suffering (dealt rightly) can produce perseverance, which in-turn will make us complete as human beings.  Why is it that we always enjoy the underdog story? Why is it that the most compelling narratives in film are often the tragedies that turn into triumphs? It’s because this simple truth is woven into the fabric of our existence. Time and time again we learn that to get the best results out of CBT, we have to get an accurate assessment of the situation. As we’ve observed, we do-so by aligning ourselves with how the world actually works and let everything else flow out of objective truth. To which Jesus says this to his followers: “Therefore everyone who hears these words of mine and puts them into practice is like a wise man who built his house on the rock. The rain came down, the streams rose, and the winds blew and beat against that house; yet it did not fall, because it had its foundation on the rock.”

So where does this leave us? In the end, what causes PTSD is more evident than many of the other mental disorders that are present in our society today. But as we mentioned above, what’s not obvious is why PTSD develops in some people and not others in the wake of a traumatic event. One theory is that some have a genetic predisposition that causes a more intense reaction to stress. Harvard calls this “a greater inborn resilience in response to trauma.” Regardless, the numbers are staggering. 6-8% of the population will develop PTSD at some point in their lifetime and there are currently 8 to 12 million people currently struggling with PTSD in the United States.  It is one of the many disorders causing a meteoric rise in mental illness in recent years, which we covered in a previous blog. But despite this rise, there are significant concerns around the lack of government funding towards mental health, accessible mental healthcare, affordable mental healthcare and quality mental healthcare. It’s been widely-documented that the healthcare system is essentially set-up to be a continuous loop of reactiveness and symptom-management, both for physical and mental illness.  We must ask the troubling questions – why does the government fund what they do? Why are controversial drugs being given a stamp of approval? Is there genuine concern about helping and healing people? Or is something else the motivating factor? In 2021, a group of Yale professors penned an op-ed in the Washington Post entitled, “The FDA is in desperate need of soul-searching”, in which they outline how the FDA has fallen into bed with Big Pharma. It’s a common occurrence for FDA officials to swap roles with those on the boards of Big Pharma companies, such as Biogen. These are clear injustices and red flags that exist within the current operating system.  So if this is the case, where do we find our hope on the long-term outlook of PTSD? Is it in medication initially to cope? Is it in finding a great therapist? Or navigating the complicated and conflicting governmental factors to achieve success? These are all certainly parts of the equation, important and complementary aspects of our healing journey. But in our view the starting point of healing begins with taking a step back and considering how what you believe about the world affects your mental health.  We covered this in our blog on the root causes of mental illness, but we all live our lives by an ideology, which is a “a system of beliefs that we carry which shapes the way we interact with the world around us.” Whether we realize it or not, what we believe about the nature of reality, about God and about ourselves heavily influences the way we approach our PTSD journey. In this regard, we’re big proponents of the way of Jesus as the best foundation to make sense of the world. The way of Jesus proposes that healing is a holistic journey, made up of spirit, mind and body, with everything intertwined like a web. The way of Jesus helps settle the existential questions of the heart, like the meaning of life, our role in the world and the purpose of suffering, making healing a far less lonely journey as we get to walk side-by-side with the one who made us. PTSD may be a big burden to bear, but settling our set of beliefs and then engaging with tools like exposure therapy, CBT and if needed, medication, have statistically shown to be a huge catalyst towards healing for many.  This doesn’t mean the process won’t be painful. Healing often requires hard work.  But the tools are at our disposal for our tomorrow to be much better than our today. For more, click here to visit our Mental Health Hub.