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Trauma care

For over 25 years, Harvard psychiatrists have helped and studied victims of many of the world's most devastating events. What they found is more heartening than you might think.

So much of the time, we focus on the lasting wounds that come from trauma -- the lifelong pain of childhood abuse, the crime victim who is haunted by the event, the scars of wartime service that never heal.

But over 25 years of caring for survivors of extreme violence and torture, my colleagues at Harvard and Massachusetts General Hospital and I found that most trauma victims can transcend the most horrific events imaginable and go on to lead rich and meaningful lives. Ultimately, traumatized people heal themselves -- and what's more, their experience can teach the rest of us how to deal with the tragedies of everyday life.

Since 1981, those of us at the Harvard Program in Refugee Trauma have conducted thousands of clinical interviews, oral histories, and research surveys of traumatized people worldwide. We have found that the survivor's trauma story is essentially a story of healing and survival.

An elderly Cambodian woman who was one of the first patients in the new clinic asked for help after her medical and psychiatric examination by telling us:

"During the year of the snake, the god of the sun came to stay in my body. It made my body shaky all over -- and I fainted. Upon awakening, I can remember as I opened my eyes that it was very dark. I then went to the rice fields to find someone to ask them what time it was. A voice shouted 10 o'clock. Suddenly, the owls began to cry and all the animals that represented death were howling all around me. I could also barely see a small group of people whispering to each other in the forest. I became so frightened that I tried to calm myself by praying to all the gods and the angels in heaven to protect me from danger. I was so paralyzed with fear that I was unable to walk either backward or forward.

"I came to settle in East Boston near the ocean. Now when I dream, I always see an American who dresses in black walking along the sea. One day when I was in my sponsor's house, I had this vision. This year, the year of the cow, I would like the American people to help me build a temple near the seashore. "Since the Pol Pot soldiers killed my children, I am so depressed that all I can think about is just to build a temple -- that is all. God appeared to me again the other day, and he told me to build a temple.

"Please help me make my dream come true. If not, I do not think I can live any more."

This patient had survived the Khmer Rouge labor camps that had killed her five daughters and four of her 10 grandchildren. At that time in traditional psychiatric settings, this patient would have been diagnosed as having a psychotic illness because it seemed she was out of touch with reality by saying she was possessed by the god of the sun, hearing voices, and having hallucinations. But, as her successful care eventually demonstrated, her dreams were a sign of a healing journey focused on her Buddhist religion, which eventually brought relief to her suffering after she entered a Buddhist temple as a nun.

Self-healing, is one of the human organism's natural responses to psychological illness and injury. All of us are familiar with the robust response of the body to physical injuries of all types. The healing of the emotional wounds inflicted on mind and spirit by violence is also a natural process. When violence strikes, a robust physical, psychological, social, and spiritual self-healing response is activated.

The physical response is not a separate set of biological processes for ordinary persons and another for trauma survivors.

Psychological self-healing focuses on reconstructing for the violated person a new world out of one shattered by the violence in which everything the person believes in, such as fairness and kindness, have been destroyed. While most individuals can overcome the physical pain of violence -- even torture -- the psychological suffering inflicted by violent and humiliating acts is difficult to heal.

Another patient, a male Laotian leader who was resettled in America after being captured and tortured by the Communists following the United States withdrawal from Vietnam told us:

"When you feel humiliated you have low self-esteem, you feel shame. You feel your pride has been taken away from you. Humiliation can turn into revenge and depression. I would say both. It's like someone is taking your bravery away and replacing it with something to make you smaller, afraid, and worthless. When I was young, I was taught that human beings are equal and I was proud of the equality. When they take you away, they make you feel worthless. You feel afraid, worthless. You have fear."

This man has now recovered enough to become a national community leader in the United States.

Humiliation, we discovered, is both a tool of violence and a resulting psychological state. As such it needs to be addressed in the healing process -- which is rarely done today.

We've learned not to ask people to give us an elaborate, detailed account of their trauma. Instead, we ask patients to teach us what they've learned -- they'll tell us the story, but the gory details are not the main focus, the main focus is what they're doing to cope with it.

Extensive scientific work by my group, including more than 160 scientific publications, has demonstrated that the three major social instruments of healing are altruism, work, and spirituality. These elements provide concrete methods and tools to promote recovery from trauma. They stimulate biological repair, assist in the construction of post-trauma attitudes and beliefs, and shift the survivor from isolation to rejoining the community.

Unfortunately, it is common medical practice to neglect, ignore or even actively avoid addressing these social self-healing responses, especially spirituality. Studies have shown that medical practitioners feel uncomfortable in bringing spirituality into their treatment approach even with patients who have terminal illnesses.

The social instruments of self-healing are equally relevant for people facing serious health threats such as cancer. Patients confronting medical illnesses share many experiences with those affected by violence. Often the onset of the disease is sudden. The whole world of the patient is completely transformed by the disease and its potential threat to their quality of life and mortality. The illness becomes a traumatic event.

And all of the forces of self-healing found in traumatized people are activated in those with serious illness.

A college administrator who is now 60, had just celebrated her 50th birthday when she was diagnosed with ovarian cancer, turning her life upside down.

Remarkably, her cancer was caught at a very early stage, giving her a very good prognosis. But she was devastated by the diagnosis; she felt her life was ending. She planned her funeral, carefully deciding on the music and who would deliver the eulogy. A year after her diagnosis, although there was no evidence of recurrence, she remained obsessively preoccupied with her mortality.

The turning point for her came when a friend of a friend took her to an ovarian cancer support group meeting. There she met other women coping with the disease, including several in the late stages who were close to death.

Exposure to these women galvanized her to action. She became involved in a network of volunteers who provided moral support and services, such as transportation and meals to women with cancer. After working with the group for a few months, she found that her preoccupation with her own death had ceased. In its place was a deeper connection with her spiritual self and a profound sense of gratitude for each new day that found her alive, healthy, and able to contribute.

Ten years later, she remains free from cancer and is still involved in ovarian cancer advocacy work.

After watching so many people like her, I am absolutely convinced -- and I wasn't 25 years ago -- that patients can recover from incredibly traumatic events and devastating life experiences.

As part of my work, I always start out by telling people the scientific reality that they can recover. "You will get better." That one sentence changes the whole therapy. The person goes from extreme hopelessness to feeling very optimistic. A positive prognosis is the beginning of a cure.

Dr. Richard F. Mollica, a professor of psychiatry at Harvard Medical School and director of the Harvard Program in Refugee Trauma at Massachusetts General Hospital, is the author of a new book, "Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World."