The Website of Dr. Mark Goulston

Stage One: Trauma (Denial)

“This didn’t happen. It couldn’t have happened. I can’t believe it happened.”

As one of my patients whose husband and child had been killed in an auto accident explained to me, “It’s like one moment you’re Bambi prancing through the forest and then, wham, your mom is killed by hunters and suddenly you’re reduced to a deer frozen and staring into the headlights.”

If your personality, or even your self, is composed of your thoughts, feelings and actions (some would add to that your spirituality), and their relationship to each other is created and “hard-wired” over time according to how you perceive reality, trauma suddenly and monumentally changes reality to such an extent that your pre-constructed personality no longer applies. At that point you may experience the complete disconnect between your pre-constructed personality and your new reality as horror.

In the state of horror, your thoughts, feelings and actions decouple and uncouple. That may be why we refer to such states as “wigged out,” “losing your mind,” “becoming unglued” and “becoming unhinged.” In that state of feeling disconnected externally from reality, and internally from your prior “normal” self, horror leads to feeling vulnerable. Feeling vulnerable is a very unstable emotion, and unless something intervenes to make it go away, it quickly can escalate to feeling that the next blow will shatter you. This triggers the feeling of terror. Then, terror internally moves very quickly into panic, and then panic pushes you to “fight or flight.”

Sometimes the shock of it all triggers what is called a “repetition compulsion” an example of which is when spouses and family members go back to the place where a loved one was washed away, and waiting and hoping to see them come back. On a more mundane level, that explains how a three- or four-year-old might keep circling around the escalators in a big store if they have become separated from their parent.

This repetition compulsion is a repetitive behavior built upon magical (wishful to an extreme) thinking that the trauma didn’t happen.

One of the reason people remain stuck in this phase is a deep belief that if it turns out to be a reality, that they won’t be able to tolerate or live with it.

Stage Two: Loss (Depression)

“It did happen. It’s not a bad dream. It’s not going away. I don’t think I can go on.”

Within hours (for the most resilient and most battle worn individuals), or days, or weeks, or never (for those who stay almost permanently frozen, literally in suspended animation), the realization sinks in that life is forever different and never going back to the way it was.

To the degree that you cannot attune, align and reconfigure your thoughts, feelings and actions to a new and different and forever changed reality, you may become and remain depressed.

This may explain the greatly increased death rate of widowers following the death of a wife that they had been so deeply dependent on.

Even though many who have lost so much think nothing — especially talking about it — will help, talking does help. One of my other traumatized patients expressed it best by saying, “Having horror heard helps heal hurt.”

If you don’t believe that, think of an incident of someone drawing you out and deeply listening to you so that you not only vented, but you were able to exhale perhaps after they asked you such evocative questions as:

• Tell me what happened.
• At its worst point, what happened?
• At its worst point, how bad did it get?
• I know you feel you can’t go on, but why have you not given up?

The final question helps serve as a transitional link from Loss to Recovery when people hear themselves say and realize why they haven’t given up.

Stage Three: Recovery (Resolution)

“It’s learning to live with life never being the same again.”

This is what a woman whose husband and child were killed in a car accident told me several months after seeing me, and this was something she arrived at on her own.

The woman above was, of course, still deeply sad, but was no longer devastated. Furthermore, the slightest glimmer of life had returned to her eyes when she came in and shared this with me.

She continued:

Life never being the same again doesn’t mean that it is over. It doesn’t mean that I’ll never laugh again, never enjoy being with friends. And even the toughest realization, it doesn’t mean that I’ll never love again, because that is something my husband, and even my child, would get angry at me if I let happen.

As time passes, and if you are able to keep from withdrawing and keep talking (as the woman above did with me and with a support group) about what you’ve lost, your thoughts, feelings and actions will be able to attune and align themselves to the new reality and then configure themselves to each other in a new way that enables you to adapt to the new reality with your entire personality. In essence, talking with others helps you adjust to doing without something you’ve lost.

I can’t take much credit for the woman’s recovery above, since most of what I did was “just listen” to her. She insisted that helped, but also said that the “Seven Steps to Recovery” she had learned from our sessions and trained herself to do also enabled her to finally have the breakthrough above, which involved the Sixth of the Seventh Steps.

The Seven Steps to Recovery is a way to talk and walk yourself through any upset you’ve had, and make things better instead of worse:

1. Physical Awareness. When you’re feeling in distress after a trauma, think to yourself, “I am physically feeling [what] in my [where in your body].” For example, “light headed and sick to my stomach.”
2. Emotional Awareness. “And emotionally I feel [angry? frustrated? scared? sad? disappointed? hurt? upset?] and how my [fill in the emotion you just named] is [name the level of intensity]. For example, “scared out of my wits and more scared than I can ever remember feeling in my life.”
3. Impulse Awareness. “And feeling [name the physical feeling] and [name the emotional feeling], and feeling it [name the level of intensity], makes me want to [name the impulse].” For example, “sitting down and doing nothing.”
4. Consequence Awareness. “If I act on that impulse, the most likely immediate consequence will be ____, and a longer-term consequence will be ____. For example, “I will probably feel even more out of control and even more hopeless.”
5. Reality Awareness. “While I am holding off (for now) on acting on that impulse, another possible and more accurate perception of what might really be going on is [seeing the world as it actually is can further help you not react to the way it isn't]. “For example, “my life being forever different doesn’t mean my life is over.”
6. Solution Awareness. “A better thing for me to do instead would be to [fill in an alternate behavior and what you need to do to achieve those outcomes]. For example, “learn to live with life being never the same again and to start by interacting with (vs. withdrawing) others, comforting each other, thinking together what we can do now vs. focusing on what we can’t and then have each person commit to doing something to achieve our desired outcome.”
7. Benefit Awareness. “If I try that solution, the benefit to me immediately will be [fill in the immediate benefit]. For example, “I’ll begin to feel more in control and less helpless and even less hopeless.”

If you are a person for whom self-talk does not work (I am such a person), imagine doing the above exercise with someone who cares or cared about you (I imagine my deceased parents and deceased mentors going through the seven steps with me).

Why do the Seven Steps to Recovery work? I view trauma as a horrendous and horrifying event that splits apart the thinking, feeling and acting parts of your personality. When that happens, you feel that the next step will be for you to shatter, or what some patients describe as “fragmenting.” At that point, you begin to panic.

The Seven Steps to Recovery works because it reconnects the thinking, feeling and acting parts of your personality. More than that, it enables you to adapt to the reality of what is, as opposed what no longer is. One patient told me it felt like suturing their personality back together again.

The “tipping point” of the Seven Steps are the Fifth Step, Reality Awareness, Sixth Step, Solution Awareness, and Seventh Step, Benefit Awareness, because those are the three steps that push you perceiving the world differently and into taking positive action. Taking action into life is essential to recovery. It’s only when you take action that you create a new memory. Thoughts thought do not create new memories as profoundly as actions taken. New memories are important in order to dilute out the impact of the horrendous traumatic ones. If you don’t create new memories through action, you can remain stuck.

To help reinforce this, imagine looking at the rings of a hundred year old tree that has been cut. Each ring represents a year. The ring from a year of drought looks different than that of a year of rains than that of a year of floods than that of a year of fires. All put together they give the tree character and each ring is less important than all of them put together which is the life of that tree (kind of makes you wish someone hadn’t cut it).

Applying this to your life, if 2011 is the year of an awful disaster, when you keep acting into life, 2012 could become the year you met the love of your life, had a child, moved into a new home or a job you love. And although the disaster of 2011 doesn’t go away, the life you live after it dilutes its impact on you.

The Seven Steps to Recovery is also a great tool to teach your children to help them overcome setbacks, disappointments and to master stress, and for them to internalize a way of pausing, calming and centering themselves when they hit obstacles later on in life.

For more resources, see “Just Listen,” Road Back from Hell blog and “PTSD for Dummies.”

Every time one of His children kills themselves,
God thunders down at us:
“That is not why I gave you the gift of life!”
And then God cries…

Know any sullen, angry, withdrawn, underachieving teenagers? If so, send this to them and ask them what fits and what doesn’t. And then just listen.

“Given all the things I’m doing that have disappointed you, I’m hoping you won’t just see this as another excuse or a way of manipulating you, both of which I’m very capable of doing and during other times have even been a master at.

In fact I’ve been so good at doing both of those, I’m afraid to tell you what I’m about to and have you think I’m just being dramatic and only trying to get attention or get out of taking responsibility for my actions and paying the consequences for them.

Today, I have a little bigger fish to fry.

I’m losing it. I’m losing my mind, my sense of who I am, of where I belong, and I’m spending more and more time wondering if life is worth living.

I know I don’t have any reason to feel like ending it, I know that so many people have it worse than me, I even know that I have all the reasons to live. I just don’t feel any of them.

I have felt alone for some time now. It hasn’t been a few days or even a few weeks. It’s been at least months.

Also the intensity of rage that I feel not only chills you — which I know is why you back off when it gets really ugly between us — it chills me.

I hate hating you more than I hate you. When I hate you at the level I’m capable of hating you I feel like destroying things. That has escalated and finally shifted to thinking of just destroying me.

But in reality, I don’t want to destroy anything, I just want to destroy the pain I feel and make it go away. But it won’t go away and I can’t make it.

The reasons I drink, do drugs and cut on myself — all of which scare the shit out of you — are because they all relieve me. When I’m stone cold sober and drug free and the pain and the craziness intensifies, all I can think about is numbing myself. I don’t do alcohol and drugs to get high, I do them to get by.

And when I cut on myself, which terrorizes you, I feel like I’m cutting out the pain or at the very least that I’m feeling something. And that gives me relief from the pain of feeling nothing.

Assuming you won’t rub my face in this — which might actually wake me up or push me over the edge, but I don’t think you want to play Russian roulette with me — you’ll probably ask me what you can do to help.

And I wish I had an answer to tell you.

Actually the answer I’d like to tell you, I am telling you by telling you this message and hoping you’ll “just listen.”

I think the hole in my being and the missingness at my core needs warmth from you mom — occasional kindness from pathetic, rational, lecturing, clueless dad is not the same — which I either think you can’t get to because all of us — including dad — fight you or because you no longer have any warmth, either because you didn’t get it from grandma or because it got worn out by all of us.

Dad, you’re not off the hook in this. I think you run interference between mom and me and try to keep the peace and then I think you find your home away from home when you get away to go to work or travel for work or play sports with your buddies.

Maybe a start would be if I saw each of you making the effort to understand me especially when you have no chance of really achieving it.

There is a good chance that neither of you will be able to understand me because I am as different from you as you are from each other, but it might help if I saw you continuing to try and continuing to ask or say things to me like:

‘Tell me what’s happening and how you feel in another way, because I see that I’m not getting it and I want to get it. And then tell me at its worst, what that’s like.’

And if I push you away, you might do well to stand firm and say, ‘We can’t go away because as your parents we can’t allow you to feel so alone in hell and we’ve got to do whatever we can to get you out. Sorry to tick you off, it’s in the parents rule book which you’ll figure out when you become one.’ One of my friend’s parents actually sleeps outside her room on the floor which my friend both resents and feels safer with.

More importantly I think it might help if I saw you not getting so frustrated and throwing your hands up, because I keep pushing back and won’t agree to what you think should make me feel better. Going along with it to get you off my back hasn’t worked and actually made me feel worse.

I think I can live with the pain, I just can’t live with suffering. I think the suffering happens when I feel alone in my pain for a long period of time and it doesn’t let up.

I think if I could feel less alone from the inside out, I could listen to what you and the world are telling me from the outside it.

Feeling alone is feeling that I am unpaired with what everyone seems to have.

Being unpaired with a future worth living causes me to feel hopeless; being unpaired with any help that I or others can provide causes me to feel helpless; being unpaired with a reason to go on causes me to feel that everything is both pointless and meaningless; and being unpaired with doing or accomplishing all the things I’m supposedly capable of causes me to feel worthless.

And feeling unpaired with all of those things cause me to feel des-pair.

I feel like I am trapped in a deep dark cold mine shaft, have run out of food and water and am running out of oxygen and time.

I keep hearing people digging to find me. I hear them thinking they have found me and are all excited. But what I know that they don’t know is that they’re digging in the wrong direction because one of them got a glimpse of a doll in a different mine shaft that I left there many years ago and everyone thinks it’s me.”

Epilogue: Dodging a Bullet, Saving a Son

“Dr. Goulston, please call me when you have a chance,” Frank, a CEO I had been working with, called me with a sense of urgency in his voice. I immediately went into my worry state and returned the call.

“What is it Frank?” I asked doing my best to lay a veneer of calmness over my concern.

“I think you helped me dodge a bullet,” he said with a level of emotion in his voice that was unusual being the highly analytic person he was.

Dodging a bullet sounded better to me that taking a bullet, so I felt immediately relieved. “What do you mean exactly?” I asked.

He explained, “You and I were speaking about my frustration with my moody son who I think is lazy and blowing it in his junior year in high school. After you listened to me, you told me that I was blowing it in not recognizing his pain and you sent me a message (above blog) to give to my son that you told me was the cumulative collection of many of things you have heard teenagers say to their parents. Well I gave it to him, he read it and I asked him what applied to him. He looked at me… no actually he looked right through me and narrowed his eyes in a hostile manner and said, ‘All of it.’ I then said to him, ‘Why didn’t you tell me it was so bad?’ And he replied firmly, but less hostile, ‘Because you didn’t f*%king want to know!’ And he was right. I told him realizing my big error, ‘I’m sorry about that and I’m even more sorry for beating up on you verbally or just walking away in disgust.’”

At this point Frank began to cry with deep emotion in his voice and continued, “Then my son, seemed to let go of much of his anger and looked straight at me and said, ‘I’m sorry for some of the things in that email you sent me that I have already done that you must swear to me you will never tell mom.’”

Frank paused and I asked, “What happened next?”

“That’s where the dodging a bullet comes in,” Frank explained, “I told my son that with his permission I just wanted to bring my laptop with me and sit on his bed and work while he tried to do his homework. I told him it that it wasn’t to spy on him or monitor him, it was just to hang out with him because I couldn’t and wouldn’t allow him to be alone in hell. And he said to me in his still teenage rebellious voice, ‘Suit yourself.’ And that’s what we have been doing and although he won’t admit it, I think we’re turning a corner and he feels a little lighter… as does my wife. I called just to thank you.”

“My pleasure, any thoughts on how you can keep from taking your eye off the ball?” I asked.

“When I clearly saw my son alone in hell, it was a sight that I will never forget, so I don’t think there is much chance I’ll blow it a second time,” Frank said with determination.

“Glad to hear,” I said.

———–

* I recently read the galley of a wonderful new book by Peter Guber called, “Tell to Win” Connect, Persuade and Triumph with the Hidden Power of Story which reminded me of having the above previously unpublished blog. I was so impressed with his book that I was tempted to call this blog, “Tell to Live” which it actually is, but at the last minute chose the one I selected.

• Road Back from Hell – Hell is a Suicidal Teenager
• About Teenage Violence: It’s the Rage
• The Rage of Angels

DISCLAIMER;

Road Back from Hell is meant to be hopeful and helpful to people who might currently be in a dark place in their life and who might find comfort, inspiration and solutions from hearing the stories of others. It is meant for people to share their stories of being in dark places and how they made it back and for visitors to read those stories and take comfort and find solutions to try. It is not a substitute for psychiatric or psychological care. We are not able or staffed to respond to requests for treatment, referrals or to make medical, psychiatric or psychological recommendations.

• Every community has some sort of Mental Health Services- Find Some Help
• Every town has a priest, minister, deacon or elder- Talk to them
• Every school has a Guidance Counselor or Social Worker- Speak to Them
• Every city has a hospital – Go to the E.R. if you are seriously depressed or suicidal or thinking about “ending it all.”
• Every city has a 911 if you are in a dire situation – Call it.

There are resources out there and people who care- Use them.

My colleague Lt. General Marty Steele (USMC retired) recently called me enthusiastically to tell me, “Mark, you’ve got to check out this two person play, ‘Into the Fire.’ It’s a game changer. I watched a performance of it at the University of South Florida and although the audience was skeptical at the beginning, they literally ‘fileted open’ in the ensuing discussion. You know that one of the biggest challenges is helping our brave young men and women returning from Iraq and Afghanistan is not a shortage of programs; it is motivating and mobilizing our soldiers and veterans to seek the help that can help them. I haven’t seen anything that has the potential to do that which is as effective as Carrie Gibson and Tony Curry’s play.”

Read the rest of this entry »

Every time a teenager commits suicide,
God thunders down at us:
“This is not why I gave you the gift of life!”
And then God cries.Right now, in the time it takes for you to read this, a teenager in your town or city wishes she were dead. A teenager in your state is thinking of a way to kill himself. Perhaps he’ll use a gun or a rope or pills or his car or simply go out for a swim from which he won’t return. A teenager in this country has just reached for that gun or is stepping up on that chair and placing his head through the noose of that rope. Or she’s counting out enough pills to finish the job or starting to slice into her wrist and watch the little beads of blood seep to the surface, harbingers of the hemorrhage that will start when she deftly severs her radial artery.

And somewhere out there in the global community to which we all belong, a teenager has just ended his life as the culmination to his absolute, unshakable belief that he belonged nowhere.

Although the suffering of that teenager is over, it has not yet begun for her family. When that teenager’s mother and father make the awful discovery that awaits them, life as they know it will be over. After this moment, if you ever look directly into the eyes of that mother or father, you will see how much of their own lives has been ripped out of them with the suicide of their child. You won’t know what to say and you will find it too painful to keep looking. You’ll look away, hoping that such a horror never befalls you; but somewhere inside you are thinking that there but for the grace of God, goes your teenager and you.

Many of our teens are in danger of falling through the cracks of a “too busy to care” world. If you’re worried that your child has something dark and troublesome on his mind, he probably does. If you’re too busy to take the time to break through to your child, make the time. If your child pushes you away, remember you don’t need his permission to protect him from anything that could hurt him or his future.

In fact it’s your most important job as a parent. If you don’t know how to communicate with your defiant teen, learn to. If you’re that teen who is having despairing thoughts and the following letter and poem relate to you, send it! If you’re a parent worrying about what’s going on inside your teen and you think the letter and poem may relate to him or her, give it to them and ask. Then put everything else aside and take the time to listen to and talk with your teenager.

Dear Mom and Dad,

I’m writing you this letter, because I’m afraid if I tell you how unhappy I am, you’ll become angry or frightened, or even worse, you’ll tell me I’m just trying to make excuses or trying to get attention. Then I’ll have to take it back and reassure you that it’s nothing and I’m okay— when I’m really not. I really don’t know what’s wrong, and I know I don’t deserve to feel as bad as I do because other people have it much worse. But I can’t help it, I do feel as bad as I do. I feel very alone and that nobody in the world knows me— and I’m so confused, that I couldn’t even tell anyone what I want them to know about me. Read this enclosed poem and it might help you to know how I’m feeling. I’m really sorry if I’m a big disappointment to you. Please don’t be angry at me for being so ashamed of me. Can you please help me?

Love,

REACHING OUT FOR HELP

Don’t be fooled by me.
Don’t be fooled by the face I wear.
For I wear a thousand masks, masks that I’m afraid to take off.
And none of them are me.
Pretending is an art that’s second nature to me.
But don’t be fooled, for God’s sake, don’t be fooled.
I give the impression that I’m secure,
That all is sunny and unruffled with me,
Within as well as without,
That confidence is my name and coolness my game,
That the water’s calm and I’m in command,
And that I need no one.
But don’t believe me, please.
My surface may seem smooth, but my surface is my mask.
Beneath this lies no complacence.
Beneath dwells the real me in confusion, in fear, and aloneness.
But I hide this. I don’t want anybody to know it.
I panic at the thought of my weakness and fear of being exposed.
That’s why I frantically create a mask to hide behind,
A nonchalant, sophisticated façade,
To help me pretend, to shield me from the glance that knows.
But such a glance is precisely my salvation. My only salvation.
And I know it.
That is if it’s followed by acceptance, if it’s followed by love.
It’s the only think that will assure me of what I can’t assure myself…
That I am worth something.
But I don’t dare tell you this. I don’t dare. I’m afraid to.
I’m afraid your glance will not be followed by acceptance and love.
I’m afraid you’ll think less of me, that you’ll laugh at me,
And your laugh would kill me.
I’m afraid that deep down I’m nothing, that I’m no good.
And that you will see this and reject me.
So I play my game. My desperate game.
With a façade of assurance without and a trembling child within.
And so begins the parade of masks. And my life becomes a front.
I idly chatter to you in the suave tones of surface talk.
I tell you everything that is really nothing.
And nothing of what’s everything,
Of what’s crying within me.
So when I’m going through my routine, do not be fooled by what I’m saying.
What I’d like to be able to say,
What for survival I need to say, but what I can’t say,
I dislike hiding, honestly.
I dislike the superficial game I’m playing, the phony game.
I’d really like to be genuine and spontaneous and me.
But you’ve got to help me. You’ve got to hold out your hand,
Even when that’s the last thing I seem to want.
Only you can wipe away from my eyes the blank stare of breathing death,
Only you can call me into aliveness.
Each time you’re kind and gentle and encouraging.
Each time you try to understand because you really care,
My heart begins to grow wings, very small wings, very feeble wings,
But wings.
With your sensitivity and sympathy, and your power of understanding
You can breath life into me, I want you to know that.
I want you to know how important you are to me.
How you can be the creator of the person that is me, if you choose to.
Please choose to.
You alone can break down the wall behind which I tremble.
You alone can remove my mask.
You alone can release me from my shaking world of panic and uncertainty.
Please…do not pass me by.
It will not be easy for you.
A long conviction of worthlessness builds strong walls.
The nearer you approach me, the blinder I strike back.
I fight against the very thing I cry out for.
But I am told that love is stronger than walls,
And in that lies my hope.
Please try to beat down those walls with firm hands,
But with gentle hands…for a child is sensitive…
Who am I, you may wonder. I am someone you know very well.
For I am every man you meet and I am every woman you meet.
I am you and I am me.
- Charles C. Finn

To Think About:

• Trying to understand your teenager is more important than what you understand. One of the most exasperating experiences for any teenager is dealing with someone who instead of trying to understand, acts as if they already know. You accomplish trying to understand by keeping your teenager talking and expressing his or her thoughts and by asking questions like: what happened next, what did you feel when that happened, what did you do when that happened, and what did you think when all that happened. Keep asking these questions and alternate the order so you might talk about feelings first, thoughts second, actions third and then changing the order. Don’t worry about arriving at the correct solution. The more your teenager is able to express his thoughts, feelings, and actions into your undivided attention, the more he’ll feel known and felt, the less he’ll feel alone, and the less his despair will be.
• Teenagers have a great sense of despair about how angry they feel towards their parents. They’re so furious with their parents, but still are so dependent upon them that they don’t know what to do with their destructive thoughts other than direct them back at themselves. Helping them to talk about this conflict with you (and not becoming defensive when they vent their hostility at you) will lessen the pain it inflicts on both them and you. As awful as it might be to have them aim their anger at you, it’s much better than having them aim it at themselves.

(c) 2010 Mark Goulston

Reaching Out for Help (click to download PDF of letter and poem)

The Road Back from Hell: A Breakthrough Moment for Us Both

About Teenage Violence: It’s the Rage