Gavin is a good-looking man in his early 30s who strode confidently into the consulting room. At first glance, it was hard to guess that his self-assured manner was masking a profound uncertainty and considerable psychological difficulties.
But as the incongruity between his persona and his subjective sense of self was slowly revealed, it became clear that he was suffering from a profound sense of disconnection at multiple levels following a highly traumatic event. This sense of disconnection is a key characteristic of post-traumatic stress disorder (PTSD).
In response to trauma, the parts of the brain responsible for our survival responses are quickly activated and override our usual processing of emotion via thought. Thus, there is a disconnection between instinctive feeling states/reactions and our cognitive processing systems.
But, as Gavin’s story illustrates, trauma elicits a sense of disconnection that runs deeper than this blunt survival response. A traumatic event takes place outside us, but the effects of this have deep internal reverberations.
One of the most striking of the different levels of disconnection Gavin had was the disjunct between his sense of self before and after the traumatic event. As Gavin put it shortly after we met, he had come to therapy because “I don’t know who I am any more. I used to know but now I don’t.”
Dr Gabe Mate famously defines the essence of trauma as “disconnection from ourselves”, and this certainly appeared to describe Gavin’s experience.
Gavin related how his life had been radically altered on the day that a man had been violently murdered in front of him and his girlfriend in a local park. He later learned that this stabbing attack had occurred as part of a gang feud.
Since this incident, Gavin had been experiencing flashbacks to the event and a feeling of constant hypervigilance. Whereas in the past he had thought of himself as an even-tempered and balanced person, he now frequently felt jumpy and overstimulated and had “a short fuse”. These times alternated with periods of feeling “numb and out of it”, accompanied by feelings of depression and meaninglessness. Gavin confessed “I either feel too much or too little. So, who am I? The guy who feels too much or the guy who feels too little?”
Gavin described himself as tormented and conflicted as he believed that he had been cowardly in not trying to intervene in the attack. He lamented that “the image I had of myself before that day and the image I now have are poles apart.”
Although his girlfriend had repeatedly assured him that there was nothing he could have done differently, he found himself unable to believe that she was not judging him. As a result, he had ended the relationship. Being with her reminded him of what had happened and how he had “failed”. He had also been increasingly avoiding his male friends out of a sense of shame and he even felt distanced from his close-knit family. There were moments when he felt so agitated and irritable that he believed that it was better to be alone.
As Gavin and I unpacked his story, it became increasingly clear that he was suffering from the classic symptoms of PTSD. While the flashbacks and anxiety were troubling for him, he found the sense of disconnection even more distressing. He felt a disconcerting sense of dissociation from his body, he had become untethered from a stable sense of self, he felt alienated from a sense of continuity or predictability of life, and he was interpersonally isolated from friends, intimate relationships and family.
He also felt disconnected at a spiritual and existential level, as life no longer appeared to have any meaning or purpose. Yet, at the same time, he found himself preoccupied with mortality.
The difficulties Gavin was experiencing in the wake of his exposure to an acute trauma were multifaceted and complex and it was clear that a multipronged approach to treatment would be necessary.
An important priority was to assist Gavin in altering the rapidity with which his brain was pushing him towards automatic fight, flight and freeze responses. In this regard, a therapy called eye movement desensitisation and reprogramming (EMDR) was deemed helpful. A second priority was to reconnect him with his body and to urge him to re-engage with the gym and exercise, which he had been doing before the incident.
A third priority was to deal with all the psychological and interpersonal disconnections that had flowed from the event. It was recommended that he engage in psychotherapy, so that his reactions to the event could be processed and normalised and his internal conflicts and guilt addressed.
Gavin went on to make good progress in therapy and to reconnect with both himself and the world. Part of the work was to help him to come to a deeper acceptance of the fragility of life and its essential unpredictability, rather than to restore him to a sense of invincibility.
In some ways PTSD puts us more in touch with life’s realities and strips us of the usual veils that we draw over these in order to protect ourselves. In a paradoxical manner, if the realities unmasked by trauma can be accepted and integrated, we can be more authentically connected to life than we were before.
Nietzsche famously said that a person can be measured by how much truth can be borne without diluting or muting it. To accept the truth of our own vulnerability and the unpredictability of the world is a task indeed and the working through of trauma does provide us with this opportunity.
Prof Gill Straker and Dr Jacqui Winship are co-authors of The Talking Cure. Gill also appears on the podcast Three Associating, in which relational psychotherapists explore their blind spots
Gavin is a fictitious amalgam to exemplify many similar cases. The therapist is a fictional amalgam of both authors
