“I thought I was crazy,” says Carro of her own vivid flashbacks,“because my ex had always said I was and now he was gone but I was still experiencing these things.”
When the brains of people with PTSD are scanned during flashbacks,the fear and emotional centres of the brain are lit up. “After trauma,the world is experienced with a different nervous system,” writes Van der Kolk. The body’s alarm system has been recalibrated – with new triggers.
The sound of a bottle set down on a table still sends a jolt through Carro. (“My ex was a big drinker. I avoid pubs now.“) For Julianne,it’s the smell of men’s aftershave.
In fight or flight mode,our mind makes memories a little differently. Thepart of the brain that sorts experiences into a meaningful story,an autobiography,switches off. At the same time,other parts are rushing to encode as much sensory detail as possible. “Because nature wants to remember this threat,” says Forbes. “And the things that jump out are the most dangerous parts – the glint of a knife in the dark.”
Traumatic memories can stay so sharp that they start to throw everyday life into shadow. People lose their passion,they feel numb.
It is the more primitive (and less discerning) parts of our brain that continue to stay alert after a trauma,scanning for any sign,however small,of that same threat. That’s why even passingly familiar sounds,smells and events can trip our newly heightened danger sense. And it’s why traumatic memories tend to be fragmented,rich sensory flashes rather than a clear story. They can stay so sharp that they start to throw everyday life into shadow. People lose their passion,they feel numb.
Therapy involves stitching back together the story of what happened. “Otherwise it’s like opening a PDF,” says Forbes.” You can’t change anything. You can’t think about it differently. It’s happening now in living colour. So,it hits you over and over.”
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A safe therapy environment,he says,is like “keeping that memory open in a Word document,so you can work on it.”
One of the key therapies recommended is cognitive behavioural therapy (CBT),which aims to slowly desensitise the person to the traumatic memory so they can properly process it. “And you can understand maybe why you couldn’t have done anything more or why you didn’t fight back,” says Forbes. Often people are racked by deep shame or guilt. They may have had just a split second,facing two bad options,“but get fixated on the option they didn’t take”.
More intense exposure therapy –putting veterans in virtual-reality headsets to take them back to war zones,for example – sometimes raises concern from experts. Flashbacks and nightmares can themselves be traumatising,creating a wicked feedback loop if they are triggered too often.
One seemingly unconventional therapy that’s gone mainstream isEMDR:Eye Movement Desensitisation and Reprocessing. This meditative practice,used by the likes of Prince Harry and actor Sandra Bullock,can appear strange at first – following the finger of a therapist or flashing lights back and forth with your eyes while recalling a trauma. Yet guiding someone through a memory with lights and other cues is said to activate both sides of the brain,helping it escape the right (more emotional) hemisphere into the left (more rational) and so untangling the knot of trauma.
Burge describes it as “like dreaming manually”,mimicking the eye movement of REM sleep. After all, the vivid world of dreams is thought to be where the mind processes most of our memories,soothing their emotional sting. As with dreaming,scientists aren’t quite sure how EMDR works but insist theresults are remarkable.
Still,some people cannot get past their panic. “We call it looping,” says Burge.
EMDR didn’t work for Carro or Julianne but both say therapy was life-changing. For Julianne,the a-ha moment came when learning how the brain processes trauma,how it’s stored in the body. “I remember being asked to draw all the places on my body I felt it,like ringing in the ears,feeling you’re gonna throw up … and at the end looking at it all and thinking,well,no wonder I feel terrible.”
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Why do some get PTSD and others don’t?
An existing history of trauma,especially from childhood,can put someone more at risk of PTSD if another shock hits them.Genetics play a role too,says Burge. “Some people are just more resilient,they’re less shocked by things going wrong.”
But Forbes says any underlying risk factors are outweighed by what happened during the trauma itself and then what happens in the first week or two afterwards. “So,the more horrific the situation,the longer it goes on,the more you’re physically threatened.” Interpersonal trauma,“when someone has hurt you on purpose” can be especially hard to recover from;as can something that comes out of the blue,tearing up our understanding of the world,of safe and unsafe.
Much comes down to what you were able to do in the moment,too. Someone who could harness their adrenaline to help put out a fire,for example,may fare better than the person trapped in a backroom,hearing their children screaming for help. When the fight-or-flight mode is activated,it keeps firing,even when we can’t move.
After World War I,many soldiers were struck mute,shaking uncontrollably because “they’d been trapped in the trenches,just bombarded and bombarded with no escape”,Forbes says. Then there were the waves of traumatised troops sent aspeacekeepers to Rwanda but ordered not to intervene in the atrocities carried out before their eyes.
‘When trauma comes from the adults,the caretakers,children will blame themselves.’
Extra stresses following a trauma can compound it,say when bushfire or flood survivors face difficult clean-ups and insurance battles,even homelessness. Children separated from their family during a traumatic event usually fare worse. And young people who survive abuse but are not believed by their parents face a particularly dangerous implosion of trauma internally,says Burge. “When trauma comes from the adults,the caretakers,children will blame themselves.”
Julianne speaks of her struggle to get support,fleeing sexual abuse at home as a teenager only to find herself in a violent relationship. “Trauma runs through families too,” she sighs. Her own children developed PTSD from the violence they saw at home,and then those jittery months of homelessness after they fled,lugging “a plastic bag full of stuff between scary motels,missing their friends. Even when you think you’re shielding them from the violence,you’re not. It comes out later.”
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The brains of children exposed to trauma young will often develop differently than normal. Their “normal” may sit closer to that heightened survival mode,with an overactive fear centre andunderdeveloped critical thinking,causing concentration and learning problems. They may not understand how to handle relationships,how to regulate their emotions and so “act out” – or zone out. Some may even struggle to recognise themselves in the mirror. Van der Kolk and others have theorised that,in learning todampen sensations in their body,some children may also stifle the parts of the brain responsible for self-awareness,“a tragic adaptation”. Certainly,it’s harder for a child to bounce back from trauma than an adult,says Burge. “You don’t have the resilience yet. You’re soaking everything up.”
Intergenerational trauma,meanwhile,can be carried down through families,including Indigenous communities in Australia,when culture comes under attack. The shadow of trauma may linger over homes and towns,over childhoods.
“We’ve seen that even in[how genes are expressed] in the next generation,” says Forbes. Some studies suggest thatHolocaust survivors,for example,can pass down to their children tiny chemical changes in the way their bodies experiencestress and starvation,though this isnot well understood and likely rare.
Still,no matter how deep the trauma,“human support is one of the most helpful things we can do for someone”,says Forbes,who helped developAustralia’s PTSD treatment guidelines. Phoenix now runs the Blue Hub trauma centre for police and has recently been commissioned with other agencies to design a statewide Victorian trauma service (recommended by Victoria’s mental healthcare Royal Commission but alreadybehind schedule).
“We used to think we were doing the right thing with psychological debriefing,” he says. “Now we know not everyone wants to talk about[an incident] right away,so it’s about offering support but being guided by the person and their cultural sensitivities too. Then,if things are stuck four weeks later,maybe that’s when we consider an intervention.”
How can psychedelics,horses or art help?
Not long before her PTSD diagnosis,something strange happened to Julianne. A stranger came to her door who seemed to know her. But,though she stared and stared,she couldn’t place him,until he started speaking. Then,in a flood of panic,Julianne realised who it was:this was the man who had tried to kill her just days earlier. A violent ex-partner. And she’d unlocked the door for him. “It’s like my brain didn’t want to process his image again.”
Many people will dissociate and depersonalise like this after trauma. It’s a way of the brain protecting you,says Burge. Where this continues,physical activity,from yoga to kickboxing,can help draw us back into our bodies. So can the act of making something. “The hands are moving,the body’s moving,it ties back into the fight-flight neurobiology,” says Burge,who admits he often “sneaks in” some creativity and movement into his therapy,particularly drama. “The brain wants to recover,it wants to process the trauma,so it’s about finding ways to unplug what’s blocking that. And it won’t always be[traditional] therapy.”
Sometimesanimals can reach us in places other humans can’t. Julianne has been getting to know a big horse named Jack as part of her NDIS-funded horse therapy. “I’m learning so much from him. Horses know not to keep adrenaline stored in their body. They’ll run it off or roll around. When you do meditation,you breathe in and this horse takes a great big breath next to you!”
Art can be a particularly strong scaffold for trauma too,says art therapist Tanja Johnston. She first saw its power as a high-school teacher and now runs the Australian National Veterans Arts Museum (ANVAM) with her husband and veteran Mark,holding art workshops and exhibitions. “It’s been a catalyst to connect veterans who’ve been homeless and estranged from family,or for their family to see them for the first time through their artwork,and understand what they have been experiencing.”
A key speech centre in the brain,Broca’s area,shuts down during trauma and flashbacks. A trained art therapist can help someone express what they can’t verbally,says Burge. “And find solutions. Even if that’s literally drawing a better ending,a trampoline under[someone falling].”
Veterans speak,too,of the power of making that first mark on a canvas. “Many will say they can’t even draw a stick figure at first but then … It’s a release,” says Tanja. “It’s a way of saying,‘I was here’. An Iraq veteran recently made a piece and said,‘I’ve put that all down now. And I’m going to put it aside.’ And you can do that. You can tear it up,chuck it in the bin. But he made it,it’s out of him.”
‘Not everyone wants to sit down with a therapist,not everyone has the confidence to ask for help.’
Some will work with clay or steel or write poetry. “Photography is popular,you know,shooting something,” says Mark,who lives with injuries that cut short his military duty but says he returned “mentally OK”. He keeps his own guitar at the museum (it’s now covered in the signatures of veterans). “Not everyone wants to sit down with a therapist,not everyone has the confidence to ask for help,” he says. But in a workshop or the gallery,conversations happen incidentally. Mark wishes those helping soldiers transition back into the community would “ask about what they’re into,including creative things,and refer people”. “I’ve seen veterans ‘come out’ as artists. But it’s also just about catching people. Early intervention.”
Forbes and Burge agree art therapy needs more attention,not just from government funding but from research itself. The federal government’s new cultural policy includes a$4.2 million pilot to support arts therapy and collect data on its impact and demand.
Pharmaceuticals are still in the picture too. Researchers are perennially testing whether beta-blocker drugs given right after trauma could stop PTSD altogether,by dampening hyperarousal,Forbes says,but results have been disappointing so far.
Psychedelics are the next frontier. Australia’s medical regulator recentlystunned researchers by approving MDMA for treating PTSD. “We don’t want to go down the path we took in the 1960s where it became cowboy territory,” says Forbes. “But careful microdoses,perhaps alongside not just traditional talk therapy but CBT and others,are worth exploring.”
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Carro and Julianne,meanwhile,have found agency (and community) through their advocacy work helping other domestic abuse survivors. “My family are overseas so the sector became a sisterhood,” says Carro. “That was my glimmer of hope.”
These days,while noises in the night can still trip her “antennas”,she’s happily married and managing her PTSD well – and her noisy dachshund Arnie (after Schwarzenegger) helps her feel safe when home alone. Still,PTSD recovery is not clear-cut. In 2020,Carro’s twins were tragically stillborn and,alone in hospital without her husband during COVID lockdowns,she endured her “most vivid flashback yet” – instantly dragged back to the night she miscarried her first child after an assault by her ex. He’s in jail but Carro says the long tail of domestic abuse is not well understood (nor supported by services).
Treating PTSD rarely fits into the kind of neat “10-session intervention” funded by Medicare,Forbes agrees. “We need to get better at picking up the signs of PTSD in the first place.” Even then,a gauntlet of cost barriers and long wait times stop people from accessing psychological support. “Most people are not getting the treatment they need,” says Forbes.
Still,PTSD is not locked in for life. “No matter how dark the clouds are,there’s always hope,” Burge stresses. “Recovery rates keep improving.”
Julianne doesn’t see herself as recovered but after years of being afraid and isolated from the world,she now wants “to experience everything”. With the help of her support worker,she’s been busy adventuring:hiking,kayaking and zip-lining. In the forest,or at the stables with Jack,Julianne feels a calm she never thought she’d find. “I saw snow for the first time last year and I cried. It was just so untouched.”
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