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Back from Hell
Healing Post-Traumatic Stress Disorder

By Melinda Elliott

Originally published in Massage Bodywork magazine, December/January 1999.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.



In 1937, as the nation stood on the brink of World War II, Franklin Delano Roosevelt told a Chicago audience, "War is contagion." In fact, war's sickness has swept the world countless times and for thousands of years, leaving in its wake a socially sanctioned form of disease -- war-related trauma.

The effects on society of the traumatic aftermaths of war are only now being documented. A recent book, Shook Over Hell, by Eric T. Dean, Jr. (Harvard University Press, 1997), documents the drastic effects of war on the soldiers of the past century, taking a close look at the Civil War and Vietnam. From its pages, we can draw conclusions about the experiences of millions of other veterans from history and pre-history, as combat related trauma has remained basically the same for generations.

Slowly we are learning how to treat the devastating syndromes caused by war trauma. Even more slowly, alternative bodywork therapies are becoming part of the treatment.

Many massage therapists have inadvertently encountered the abreactions1 of traumatized war veterans, when a veteran begins to weep or have an uncontrollable flashback during a session. Others may have found that combat-traumatized vets begin to shiver or sweat during a session. Possibly those emotional and psychological releases were accompanied by few or fragmented explanations from the client. Trauma erodes trust and often silences the survivor. Veterans are often hesitant to talk about the experiences, which may begin to surface during the relaxation and physical relief of massage.

One massage therapist recalled that Vietnam veterans who came for routine massages in the mid-1990s described their war experiences in detail, as if they had just occurred. "It was as if the letting go into the massage process allowed the body to bring up the memory, even though it was so old," said the therapist who asked to remain anonymous. "They remembered the sounds of the helicopters overhead, the sight of the water buffalo - and still felt the fear triggered by the thought of Agent Orange and napalm."

Indeed, one of the amazing facts about trauma syndromes is that they remain in the body virtually forever unless they are treated successfully in therapy. A Vietnam veteran's poetry speaks of his firsthand experience with long-term trauma:

Memories of all the lost friends
How can one year in your life
Thirty years later still continue to haunt you at night?2


Traumatic Scars of War
Today there is a growing technical literature library on combat trauma and therapies that may help to alleviate its drastic and tragic effects. The studies show that working with veterans is not a challenge to be lightly undertaken. Special training, on-going professional support and guidance, and thorough intellectual knowledge are crucial for the therapist. Without this solid context, a session can end in disastrous retraumatization of the veteran -- and trauma for the therapist as well. These cautions apply for therapists from both mainstream health professions and alternative modalities.

The long-term effects of experiencing war combat are unrelentingly horrendous. Battle-worn veterans through the ages have endured myriads of hellish and seemingly irreparable symptoms that occur in well-documented patterns. The telltale signs of war trauma include recurrent nightmares; insomnia; terrorizing flashbacks; sudden panic attacks; inexplicable shame, dread and despair; a pervasive sense of helplessness; substance abuse and addictions; moodiness; anger; paranoia; isolationism; uncontrollable weeping and grief; sweating, shaking and trembling; constant nervousness and fidgeting; physical weakness; chronic pain; and sometimes total physical and emotional collapse.

These symptoms can be traced back to traumatic events that stimulated the state of hyperarousal and/or froze the fight-or-flight response. Such responses occur when survival mechanisms are activated to keep the physiology on "special alert," or when the overwhelming threat is so great that the system shuts down. A Vietnam vet encapsulated his state of hyperarousal:

"Scared beyond my wits
The scent of fear lingers in the patties of rice
Senses alert, tuned to any danger....
Adrenaline heightens to serve....
Quietness and stress are all that's smelled...."3

Besides hyperarousal, fight-or-flight and, in the face of inescapable threat, freezing/numbness, the primordial responses of the body to a physical threat to survival include dissociation, a type of psychological checking out and a departure from present time and place. In war, or other trauma, any or all of these responses become imprinted in the body's biochemistry, and can be triggered years later by the smallest stimuli -- a scent, a sound, a color, an image or the touch of a therapist's hand.


A Socially Sanctioned "Necessary Evil"
A major step toward understanding the sociology of trauma was taken when, in her landmark book Trauma and Recovery (Basic Books, 1992), Dr. Judith Herman identified ways that certain types of trauma are culturally accepted. Herman stated that the traumatization of men in battle has generally been societally sanctioned as a necessary, or at least an inevitable, evil. In fact, Herman wrote, for centuries cultural norms permitted certain sorts of trauma of both sexes: While men underwent the trials of war experiences, women endured traumatizing assaults closer to home -- rape, incest and other kinds of "sex war" abuse.4

Revealing his own culturally masculine conditioning, one male client explained to his massage therapist, "I've always had to be brave, in my family, in the army, at school. Throw out my chest and go on, no matter what."5 Thus, the treatment of veterans has been complicated by the cultural norms for male behavior: emotional control, bravery, physical strength and silent endurance of pain have been the only acceptable behaviors.

Trauma therapy revealed the reasons that veterans - whom society wanted to regard as brave heroes - frequently became "basket cases" after the war was over. In therapy, as veterans began to allow their war trauma to "unwind," they said they knew their experiences and feelings were not culturally allowable male behaviors. Vietnam veteran Stephen Welch wrote, "It's been 30 years and still I hold back the tears."6

Perhaps because their pain was societally unacceptable, veterans in treatment turned out to be one of the most challenging groups of clients. Adding to the complexity of trauma treatment, the violence that had instigated their war trauma resulted in particularly powerful releases once the trauma was triggered in therapy. The potential for such intense releases requires the therapist to be especially alert, centered and able to take care of him- or herself. When firmly centered, the therapist can facilitate gradual releases for the client, taking the emotions in small, bite-sized amounts, using whatever modality the client and therapist choose. Most therapists will want to refer veterans to a specialized counselor and make the parameters of the massage session clear to the client as soon as the need for trauma therapy surfaces.


Breakthrough Discovery
"Shell shock" was identified as a quasi-justifiable malady during World War II. However, through the 1950s, treatment of combat veterans generally took a limited and rather patchwork approach for several reasons. First, although society sanctioned the traumatizing experience (war), it denied the validity -- or at least the enduring intensity -- of the trauma syndromes veterans suffered in its aftermath. Secondly, the syndrome of war-related trauma symptoms had been only partially documented scientifically and was not widely understood. And third, treatment of war trauma was, with few exceptions, not yet considered a scientifically valid therapeutic specialty.

Forty-three years after Roosevelt called war a contagious sickness, the traumatic after-effects of combat and war-related trauma to veterans finally received its own psychiatric/physiological category. The same type of trauma syndrome was identified in other survivors as well, including victims of assault, rape and childhood abuse.

The new discoveries about trauma began in the 1970s, when it became clear that many Vietnam War survivors were drastically impaired by their combat experiences, and were likely to remain that way. The trauma of the Vietnam survivors seemed particularly severe, perhaps for at least two reasons. First, as a group, those who fought in Vietnam were far younger and less experienced in life at the time they faced combat than those who fought in World War II. Second, their war was so unpopular that societal support for their suffering, and their need to recover from it, was meager at best.

In large part, as a result of clinical documentation of the experiences and symptoms of Vietnam's survivors, in 1980 the American Psychiatric Association added a new grouping to its list of mental afflictions: post-traumatic stress disorder (PTSD).7

Once the PTSD diagnosis was developed, it was used to assess and treat veterans' longstanding emotional, psychological, physical and relational problems. The entire field of trauma treatment took a step forward, and war trauma began to emerge from the hushed closet into which society had thrust it over the centuries.


More Breakthroughs
During the 1980s, the field of trauma treatment progressed quickly. But it was not until the early 1990s that carefully developed theories, delineating PTSD in minute scientific detail, began to bear fruit in terms of a completely new understanding of the "psychobiology" of PTSD. Describing the manifestations of this traumatic psychobiology, Dr. Bessel van der Kolk wrote, "In an apparent attempt to compensate for chronic hyperarousal, traumatized people seem to shut down...Thus, people with chronic PTSD tend to suffer from numbing of responsiveness to the environment, punctuated by intermittent hyperarousal in response to conditional traumatic stimuli."8

In the process of defining his concepts of the "biobehavioral change" caused by PTSD, van der Kolk authored various "bibles" frequently used by therapists who work with trauma survivors, including Traumatic Stress (Guilford Press, New York, 1996) and Psychological Trauma (American Psychiatric Press, 1987).

"What distinguishes people who develop post-traumatic stress disorder from people who are merely temporarily overwhelmed," writes van der Kolk, "is that people who develop PTSD become 'stuck' on the trauma, keep re-living it in thoughts, feelings or images." It is this constant, intrusive "reliving" -- not the actual trauma -- that causes PTSD, he said.9

Another pioneer in understanding the mechanics of trauma, Peter Levine, has carefully described the physiological bases of PTSD. In his classic work, Waking the Tiger (North Atlantic Books, 1997), he suggested one reason for chronic pain, and other results of PTSD, is the heightened sympathetic nervous system support and activation that remains locked in the physiology long after the trauma.

Another breakthrough analysis of trauma physiology was made by Candace Pert, author of Molecules of Emotion (Simon Shuster, New York, 1997). Pert found that neuro-peptide action is responsible for conveying emotions to every cell of the body, where the emotional information affects the activity of each cell.

The findings of van der Kolk, Levine, Pert and many others have resulted in the mapping of PTSD, the territory in which many combat veterans live every day of their lives. The caregivers and institutions that help veterans have gradually absorbed the intellectual breakthroughs and are making efforts to offer more effective treatment. But, there is still a long way to go in the treatment of veterans with PTSD, and plenty of room for alternative therapies.


Where the Vets Are
As society began to "come out of denial" about veterans' trauma and recognized the legitimacy of the maladies affecting its victims, Veterans Administration (VA) hospitals provided new kinds of assistance. For Vietnam veterans in particular, the VA offered group therapy. Some veterans also formed their own support groups, and many became advocates for themselves and their comrades.

Still, the process of obtaining PTSD treatment from the VA can be challenging, although many health care professionals state that the institution offers excellent care and services. "I wouldn't work anywhere else," said one physical therapist at a VA hospital. "Everyone here is very dedicated and committed." Still, as with many kinds of caregiving institutions, stress can arise in dealing with the source of help. One advocate advised veterans:

"The 'stressor' often cited in VA PTSD claims means the incident or events that were life-threatening. In some cases, a non-life-threatening scenario can be considered a 'stressor' (i.e. seeing dead bodies) but usually not. The veteran generally must be able to prove that his life was in some imminent danger ... When a claim is made ... the burden of proof is on the veteran ... The most common way of obtaining 'proof' not in the record is by statements from others who were with the veteran at the same time and can validate the veteran's claim of what happened. Many veterans' magazines run 'locator' sections for just this purpose. Other methods include searches of unit records."10

Traumatized in war, often faced with family and job relationship difficulties, and also frequently confronted with government bureaucracy, veterans deal with high levels of anger. One study stated, "Anger management intervention is an integral part of post-traumatic stress disorder treatment in the Department of Veterans Affairs facilities across the country."11 The presence of intense anger, along with other deep emotions, can cause a veteran -- triggered during therapy -- to undergo an explosive emotional release. "PTSD may cause a person to fly into a rage for no apparent reason or strike out in fear at inappropriate targets."12

"Vets tend to have a more violent type of reaction if a memory comes up," explained Chris Smith, director of education at the Colorado School of Healing Arts in Lakewood, Colorado. Smith, who is also a massage therapist and instructor for the school's 100-hour program in Trauma Touch Therapy, explained, "It takes a therapist who can stay grounded and isn't afraid of the intense emotional outbursts." Because of their war-time experiences, she said, veterans in therapy may tend to be "less resourced" in how to handle stress and "more hyperaroused" than other trauma clients.

According to some therapists who work closely with veterans, the VA and other group programs provide only limited help for veterans. After a certain amount of time has passed, these therapists say talking about the trauma in a group setting can become a useless "rehashing" of the horrors. To emerge from the sense of victimization may likely demand hard, individual work in therapy on the part of the patient. It generally requires facilitation by an extremely grounded and well-versed therapist. If the veteran chooses to try an alternative therapy, such as massage, the process will likely necessitate participation not only in bodywork sessions, but also in simultaneous sessions with a psychotherapist.

One massage therapist who has worked with veterans visited a VA hospital to learn more about PTSD and observed that many of the veterans were in extremely serious condition. "For many vets, the only answer is a great deal of isolation and seclusion and often medication that can have so many other side effects. They often cope by removing stimulation as much as possible," she said.

She added that the VA staff members were at least as concerned about her ability to deal with her role as therapist/caregiver to a Vietnam veteran client as they were with the patient's well-being. "It was incredibly draining working with him," she reported. At the hospital, boundary-setting for caregivers was considered a crucial task.


Processing: "The Issues Are in the Tissues"
Many of the trauma experts of the 1990s have developed methodologies for treatment. From these, some modalities tailored especially for bodywork have evolved. The old massage school adage, "the issues are in the tissues," seems apropos in helping to process at least some of the psychobiological effects of PTSD.

In a presentation called "Trauma: Holding on to Shock," two therapists -- Carl Brahe, MA, and Victoria Hall, RN -- describe trauma's exceedingly long-term effects, and explain their approach, which is based in part on the work of Candace Pert. "The trauma becomes an ongoing body belief, supported by emotional reactions," wrote Brahe and Hall. Because that physiological "belief" is held in the body, they explained, trauma survivors "find ways to fulfill it [by] transforming non-threatening situations into battle scenarios."13

The best way to short-circuit these endless trauma effects is to treat the traumatized mind, emotions and body -- as a whole -- in therapy.

Smith said she believes bodywork in particular can play an especially vital role in the process of unwinding PTSD. The key is for the massage therapist to be well-grounded in intellectual understanding of the physiological mechanisms of trauma -- especially dissociation -- and to be able to maintain clear boundaries during a bodywork session. The bodywork therapist also needs to work on him- or herself with some sort of personal counseling program. As always, it is vital that the therapist understand his/her own issues, to prevent them from contaminating the sessions.

Smith recommends that massage therapists limit the scope of their treatment to their area of expertise -- bodywork -- and refer the clients to professional counseling for psychological assistance.

Besides maintaining well-kept boundaries during a session, therapists must provide a safe space and nonjudgmental listening skills, and offer support in ways that empower the client. Veterans need to be able to talk without being shamed for their long-term inability to recover. While listening attentively, the therapist must take care not to get caught in the drama of the story told by the client or give advice they are not qualified to give.

A particular danger is dissociation, in which the client "checks out" or leaves the body. At that point, the session can enter into a "trauma vortex," spiraling out of the therapist's control. Once the client dissociates, the danger of transference onto the therapist becomes imminent.14

"The stories of the clients can be both horrific and enticing, pulling the bodyworker into the 'drama of the trauma,'" said Smith. But, she pointed out, part of the therapist's job is to avoid getting caught up in the client's drama. "The question for the client at that point is: 'What is going on in your body now?' We take the cognitive material -- the story -- and reference back to the sensations in the body," she explained.

In addition to the Trauma Touch Therapy program taught by Smith, many other somatic methods are available to massage therapists. Among the best-known are Hakomi Integrative Somatics, developed by Pat Ogden; and Peter Levine's Somatic Experiencing.

When asked what specific techniques they use to deal with PTSD symptoms, therapists who have worked with veterans reported everything from massage to breath work to aromatherapy to energy work to cranial sacral techniques. Often the techniques involve only minimal touch, perhaps simply holding a tense area of the body.

Besides such touch-based bodywork, regular full-body massage can be a valuable experience too, if the client is able to relax and receive. Van der Kolk states that "gratifying physical experiences, such as massages ... may be experiences that patients build up that are not contaminated by trauma, and which may serve as a core of new gratifying experiences."15 One physical therapist at a VA hospital said, "Massage feels good. People underestimate that. If you feel good, you are more productive, and you just generally do better." Encouraged by medical academic experts, caregivers and counselors who work daily with PTSD, massage therapy may come to play a greater role in assisting veterans on their long journey of trauma recovery.

Melinda Elliot is a former staff writer for Massage Bodywork magazine.

References
1. The Bantam Medical Dictionary defines "abreaction" as "the release of strong emotion associated with a buried memory."
2. Stephen Welch, "World On Your Shoulders: Day One Hill 875," The Sky Soldiers of the 173rd. http://members.aol.com/RedRuby7/vietnam.html
3. Welch, "Out Post," ibid.
4. Judith Herman, Trauma and Recovery: The Aftermath of Violence - From Domestic Abuse to Political Terror, Basic Books, 1992, pp. 20-32.
5. Kathie Bailey, "The Breath of Life," Massage Therapy Journal, Summer 1992, p. 120.
6. "Hill 875, The First Night," The Sky Soldiers of the 173rd. http://members.aol.com/RedRuby7/vietnam.html
7. Herman, p. 28.
8. Bessel van der Kolk, "The Body Keeps Score: Memory and the Evolving Psychobiology of Post Traumatic Stress," http://www.trauma-pages.com/vanderk4.htm
9. Bessel A. van der Kolk, et al. "Approaches to the Treatment of PTSD," http://www.trauma-pages.com/vanderk.htm
10. Bill Lewis, "PTSD," http://grunt.space.swri.edu/ptsdinfo.htm
11. A. A. Gerlock, "Veterans' Responses to Anger Management Intervention," Issues in Mental Health Nursing 1994; 15(4), Abstract.
12. Carl Brahe and Victoria Hall, "Trauma - Holding on to Shock," http://forthrt.com/~chronicl/archjune/shaman.htm
13. Brahe and Hall, ibid.
14. The Bantam Medical Dictionary defines "transference" as "the process by which the patient comes to feel and act toward the therapist as if he were somebody in the patient's past life." 15. Bessel van der Kolk, "Approaches to the Treatment of PTSD," www.trauma-pages.com/vanderk.htm





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