The End of Trauma

Author’s Note

This book includes firsthand accounts of a number of courageous people who have endured extreme or potentially traumatic events. With the exception of Jed McGiffin and Maren Westphal, I have altered their names and personal details to preserve confidentiality.

INTRODUCTION

Why Was I Doing Okay?

I first met Jed when he interviewed for the doctoral program in clinical psychology at Columbia University’s Teachers College, where I’m a professor. Like most of the candidates I met that day, Jed was well dressed and respectful as he walked into my office. The fact that he walked into my office came as a bit of a surprise, though. I knew that Jed had been in a terrible accident that had almost killed him. I wasn’t sure he was going to be able to walk.

Jed didn’t say much about the accident that day. There were lots of other things to talk about. It wasn’t until quite a while later that I learned the full story.

Five years earlier, Jed had been trying to make a living as a musician in New York. No small feat. As he put it, “I was a musician who was necessarily a waiter.” Although he had been working at one of New York’s finest restaurants, Babbo Ristorante in Greenwich Village, he was looking to make a change. He had just moved in with his girlfriend, Megan. She was studying nursing. Jed began to think about his longtime interest in psychology. He took a few classes at City College uptown. It had gone well, and he planned to take a full load the next semester.

Thoughts about the future were circling around in Jed’s mind as he completed a long shift on the night of December 21. The restaurant had just closed. It was around 1:30 a.m. Jed headed down to the basement to pick out some wine from the restaurant’s sommelier as holiday gifts for his family. He found four nice bottles and stowed them away in his backpack before heading out the door.

The night was bitter cold. Jed pulled his hoodie snug and waited on the corner of West Eighth Street. The white light of the walk signal shimmered off the frozen pavement, and Jed made his way into the intersection. A garbage truck came around the corner, sudden and fast, and caught him. Before he knew it, he was down.

“I remember the whole thing, vividly,” Jed told me. “I was knocked down by the front bumper and then pulled under by the front wheels. I went down kind of to the left, you know, my left leg went out, and I got run over by the front wheel.”

The front wheel crushed Jed’s leg. Then there was a brief pause.

One second.

Two seconds.

And then the truck’s two double-axle rear wheels hit him.

“The whole twenty-five tons of truck… rolled over me.”

Oddly, the four wine bottles in Jed’s backpack remained intact. But Jed’s leg and part of his hip were flattened into a mess of blood and bone. It was a brutal accident. He screamed wildly.

An emergency response team from the fire department was the first to arrive on the scene. They got there remarkably quickly, in a matter of just a few minutes.

Lieutenant Adrian Walsh found Jed and held his hand.

Jed remembers being acutely aware of the danger he was in.

“I knew it was life or death. I never passed out. I was screaming. I know I was screaming for a while.”

Then he learned that the ambulance that would eventually take him to St. Vincent’s Hospital was delayed. Although St. Vincent’s was only six blocks away, the ambulance was locked up in traffic. The wait was excruciating.

“It was getting really scary. The fire department showed up and they shut down the whole thing. I very much remember the garbage truck. I could see from where I was lying that they’d stopped up the road, I could remember that really vividly.”

Nothing much could be done until the ambulance arrived, but where was it?

“There was a lot of yelling. Lieutenant Walsh was yelling. She was trying to find a way to get me to the hospital. They were getting worried. She was yelling to the fire department. She was pointing to her vehicle, yelling, ‘Can’t we just put him in this thing, and take him to St. Vincent’s?’”

With every minute that ticked by, Jed was in greater and greater danger. He had lost an enormous amount of blood. Lieutenant Walsh later speculated that if there was any luck at all on that fateful night, it was that Jed was lying on the icy cold pavement, which probably slowed the blood loss. Even so, Jed was bleeding profusely. The paramedics had to give him fifty units of blood, nearly five times the body’s normal capacity.

It took twenty-five excruciating minutes for the ambulance to show up. For Jed, it was an eternity. He had no choice but to deal with it.

“I remember being sort of meditative on the pavement, like zoned in, maybe following my breath. I don’t know what I was doing. I was in shock. There was a lot of furor going on. People were shouting, ‘Put a rush on the bus!’ The bus is what they called the ambulance. There was this kind woman, Lieutenant Walsh, holding my hand, trying to keep me calm. And I was just kind of doing my best, in a kind of trance.”

And then the ambulance arrived. Jed felt a brief sense of relief before a sobering realization set in: “I knew, I mean I could tell, moving me was going to be bad. I couldn’t move and they were going to be moving the thing that really hurt, a lot. And then they started shuffling me around and lifted me up.”

Jed remained fully conscious through the whole episode: “It was mind-bending pain. You know, like everything goes white. I think I probably howled quite a bit from there to St. Vincent’s. That’s where things start to fade, because of the pain, my consciousness started to fade.”

The ambulance ride to St. Vincent’s was short, and the ambulance was practically flying. Jed was screaming for pain medication. He had still not yet received anything to numb his agony. There was no time.

“I remember the EMT saying, ‘Hold on, we’ll get you something when we get to the hospital.’”

When they finally arrived at St. Vincent’s, doctors surrounded Jed and immediately began questioning him. They needed details. Jed’s response was clear: “Give me something for the pain, then I’ll answer your questions.”

He began to fade in and out. But one memory remains crystal clear: seeing his girlfriend, Megan. She had been at their apartment in Brooklyn when she received news of the accident. She went straight to the hospital.

“I remember Megan being there, worrying over me. It’s such a hard memory. She looked so upset. She was in tears. I remember feeling helpless. I wanted to do something to convince her, you know, that I was going to be okay. I remember feeling really confident as they wheeled me into surgery, and I said to Megan, ‘I’ll see you on the other side.’ And then they whisked me off.”

That was the last thing Jed remembers of that night.

As Jed continued to bleed out in the operating room, orthopedic specialists busily debated how best to save his mangled leg. Then the lead vascular surgeon arrived. He immediately waved them off. As Jed pieced it together later, the vascular surgeon had said something to the effect of, “There is no way this man is going to live with you guys futzing about him. We’ve got to figure out a way to stop the bleeding.” And then, Jed remembers, the surgeon basically booted the orthopedists out of the operating room.

Jed’s condition was critical. How long it would take to put him back together was not yet clear. Nor was it clear that Jed’s leg could be saved. He had no way of knowing that soon the doctors would be having conversations with Megan and with his immediate family to explain the severity of his injuries. And to prepare them for the very real possibility that he might not make it.

That first night in the trauma center, Jed was in surgery for hours. The medical team labored to keep him alive. As the severity of the assault to his body came into focus, it was decided that he was going to need multiple surgeries, and that the safest way to pull that off was to medically induce him into a coma. Three days after the accident, it became clear that Jed’s leg could not be saved. The entire left leg was amputated. The hip joint was removed as well. Additional surgeries were planned. It looked like Jed was going to have to be kept in a coma for some time.

A medically induced coma is only vaguely like the kind of coma that results from an accident, such as when a traumatic head injury causes the brain to swell or when the brain is deprived of oxygen. A medically induced coma is brought on by intentional, controlled doses of barbiturates, usually pentobarbital or propofol. The barbiturates reduce brain metabolism and induce a temporary state of deep consciousness akin to anesthesia.

Although brain activity is reduced in medically induced comas, there is still some cognitive processing. Patients often report wild and vivid dreams. Sometimes these dreams incorporate sounds that are around them while they are comatose, or medical procedures or sensory experiences, such as being touched or moved.

In one indelible dream, Jed felt like he was falling. He was disembodied. Weightless. Falling endlessly. It was not a pleasant sensation.

“I was in an open-air car of some sort, a structure, like an airplane. Not a human body. I was falling, straight down, next to a waterfall. I was falling parallel to a waterfall. I was falling fast. Careening. It wasn’t really like I was flying. I wasn’t in control. It was kind of vague, but the salient part, the emotion, the physical sense, was a free fall, an endless free fall. It was awful.

“I don’t know how long it went on, the falling, it just went on and on. It seemed like I had been falling for a very long time.

“And then… Whoosh. I sort of landed.

“It was pretty hard but it wasn’t disruptive. It was like ‘Oh, I am back in this body. I am not falling anymore, and I am back in my body.’ It was over. I had been in a state of… what would you call it… limbo, and then I was back in myself.

“And then, this sounds kind of crazy, this medicine man that I had once met, at like a sweat lodge, his voice came to me. He said something like, ‘You had a curse on you,’ or ‘Your family had a curse’… something like that… ‘and now the debt is settled. Everything is going to be fine.’”

Jed laughed as he recalled the medicine man and referred to these kinds of dreams as “my weird psycho-spiritual dreams.” In another dream, the famous chef Mario Batali visited him along with his business partner Joe Bastianich. Jed knew them both. They were Babbo’s co-owners. Mario and Joe had, in fact, visited Jed in the hospital while he was comatose. He distinctly heard, or at least remembers hearing, his mother’s voice announcing their arrival. But the meeting, in Jed’s barbiturate-laden brain, took place not in a sterile hospital room but in a verdant field “somewhere in the South, like Virginia, in the springtime.” Jed didn’t recall any particular conversation, only Mario and Joe’s presence and the peaceful setting.

The bucolic location was a common theme in Jed’s coma dreams.

“I had this whole dream reality built around my convalescence in a plush, long-term care facility. There was a gazebo and rolling hills. The sun was shining. It was warm and pleasant.”

The gazebo reminded Jed of a similar gazebo in the small town he grew up in. It appeared in several other dreams. He remembers dreaming of marrying Megan several times. The wedding dreams sometimes became quite bizarre.

“The first one,” Jed recalls, “was really weird. My sister’s boyfriend, now her husband, now my brother-in-law, was searching online, on the Korean underground, you know like the Internet underground, trying to find a vintage dress for Megan, like a Beatles 1960s-era vintage dress. And we were then driving around this circular mountain, winding up the road to a cupola, a gazebo on top. We were in a red sports car, a convertible. Megan was happy. It was all very early 60s vintage. A 60s vintage wedding.

“There weren’t that many details of the wedding in the dream, but then I remember we had to repeat it. Megan’s father was not happy about something in the wedding, so we had to do it all over again. We were married twice.”

Jed’s hospital dreams were usually odd, but some were profoundly disturbing. These often had a paranoid flavor and involved some sort of punishment for wrongdoing. He called these his “warped” dreams.

“Once I was stuck on a submarine for two weeks. Stuck cooking. I was the cook. It was the punishment for a bad deed, something like that. Like I had misbehaved and was being punished.”

In another dream, Jed remembers being shaved by a nurse or orderly. This could easily have been a residue of an actual event, part of the actual preparation for surgery. But in the dream, Jed was watching the action from a distance. He was watching himself being shaved, and it was extremely painful. The nurse was punishing Jed deliberately.

“It was weird. There was this persecutory content, like I had been a bad boy, or something, I don’t remember what they said, but clearly they were angry and they were punishing me.”

In one of the worst dreams, he recalled, he was on a farm: “This was not a pleasant convalescent home. This was like a farm for… I want to say it was like a fat farm. It was terrible. Again, it was a facility somewhere in the South, a pleasant place. But the patients were just spilling over their beds. They’re all… hideously overweight. It was terrible, almost like a foie gras farm for humans, but a hospital. They’re all being fed intravenously. I was there in a bed, being fed. I was enormous. I was spilling over the bed too. I was farmed.”

•

SURPRISINGLY LITTLE IS known about the mechanism behind such nightmarish imagery, or, for that matter, how often it occurs in induced comas. But it does seem that many patients who have been through induced comas do report these kinds of bizarre hallucinatory dreams.¹

A common complaint is that the dreams are eerie and frightening. Some people describe feeling that they were surrounded by “beings” that were bad or dark or evil, and being taken to “all kinds of places” and experiencing “horrific things.” The induced coma tends to render this nightmarish quality all the more disturbing simply because it can seem to be never ending. That’s because induced comas can last a long time. And unlike the dreams we usually experience during the course of a normal night’s sleep, coma dreams are not punctuated by cycles of sleeping and waking. The dreams a person might experience during a coma can go on and on. One former patient said it was like “an ongoing nightmare that I couldn’t wake from.” Another described “a nightmare that seemed to last forever… an endless series of terrible events, one situation leading to the next.”

Something about the fact that the dreams just keep going makes them seem “unbelievably vivid and detailed,” almost hyperreal. Many people who have experienced induced comas have reported that even after they were brought out of the coma, it still took them several days to realize that the dream events had not actually happened. Worse still, after returning to normal waking consciousness, many found that their coma-induced dreams wouldn’t go away. They seemed to have left a haunting residue, not unlike a traumatic memory.

Another former patient said, “The nightmares I had while in a coma, they still continue to this day,” adding that they “were and are still so real.”

Some have complained that the dream memories are worse than the injuries that necessitated the coma in the first place. For example, “It was more difficult to get over the nightmares than to recover physically,” and, “It took me much longer to heal from the imagery in that coma than it did the physical injuries.”

It’s not clear what to make of these kinds of retrospective memories because no one has ever systematically studied them. It may be that only people with the worst reactions will take the time to talk of their experiences. And in fact, not all coma survivors report nightmarish dreams. Some report that they do not remember any dreams at all from their comas.

Nonetheless, former intensive care unit (ICU) patients reported strikingly similar experiences in a recent study. Hallucinatory experiences are so common in ICUs—in part from the effects of psychoactive drugs—that there is a name for the phenomenon, ICU psychosis.² In the study, 88 percent of the patients interviewed reported having intrusive memories of the hallucinations and nightmares they had while in the ICU—which had included things like nurses turning patients into zombies, guns spouting blood, or birds laughing at each other. They also said that these images continued to invade their consciousness even months after their hospital release.

•

NONE OF THIS boded well for Jed. Not only did he suffer a ghastly traumatic event. Not only did he remember every detail of it: the wheels crushing his leg, the screaming, the bleeding, the icy pavement, the searing pain, the tears on Megan’s face. Now, to pile it on further, he would also have indelible memories of bizarre “warped” coma dreams. And, if that were not enough, eventually the medical team would bring Jed out of the coma and he would discover that his entire leg, clean up to the hip, was gone.

Jed’s family was worried. He had been in the coma for six long weeks. During that time, his body had been handled, rearranged, and patched together. He had endured almost twenty different surgeries. In addition to the amputation, he’d had a tracheotomy, and his colon had been rerouted. What would happen when he came to? What would he remember? How would he react to the knowledge that his leg had been amputated? How would they tell him? And how would he deal with the trauma of such a horrible ordeal?

To everyone’s surprise, Jed already knew his leg was gone. He was not sure how he knew, but he knew. Maybe some of the discussion among the medical team penetrated the coma. Maybe somehow he felt or understood the medical procedures. Or maybe he just understood that the damage was too great.

“I had a sense that my leg was really messed up,” Jed recalled, “like on the pavement. I could see it was bad. I was on death’s door. So on some level I already knew. And for whatever reason, I woke up thinking that it was gone already. I was not surprised.”

The process of bringing someone out of an induced coma happens gradually over the course of several days. This allows for the mind to relocate itself in place and time and for the brain to regain control of the body. It also helps to minimize the sudden shock of waking up in a strange place. Jed recalls becoming aware of his surroundings “in pieces.” “I don’t remember thinking anything like, ‘Oh, here I am in the ICU.’ Nothing like that,” he said. “It was more gradual. There was a slow reckoning. I knew about the leg, but I remember looking down and seeing this hole in my abdomen, and then all these tubes, and all these scars.”

Then there were adverse side effects to deal with: “I remember waking up and realizing I couldn’t talk. Someone was there telling me I wouldn’t be able to talk until the breathing tube was removed.”

It was five days after waking before Jed would be able to talk again. During that time, he could communicate only through gestures or by writing short notes. The use of a breathing tube also meant that his throat had become extremely dry.

“One of the worst parts about waking up, one of the most aversive aspects of it, was that I was parched. My throat was dry as a bone. And they wouldn’t allow me to drink anything. They have to clear you first to swallow. There is a whole swallow team that comes around.”

Some of the first experiences Jed remembers after becoming conscious were comforting. He recalls a great desire to see Megan. He remembered “how soothing her presence was.”

But soon the recollections became much more difficult. Jed began to come to grips with how he had lost his leg. Within a couple of days, he was flooded with memories of the accident.

“I was still not able to talk yet. Then I remember just being pummeled with these memories. I kept replaying the accident. The memories had a deep valence. You know, like a sort of deep traumatic valence. I thought, ‘Oh wow! I can’t believe I have to process all this!’”

The coma memories had also begun to plague him. These were just as bad, maybe worse.

“I spent more time trying to avoid the dream content. You know, it was so salient. There were these themes of paranoia, violation, punishment, mistrust of my environment. All really powerful.”

And then, to Jed’s amazement, it just stopped.

The intrusive images tapered off and then simply stopped. He could remember all the details of the accident. He could easily remember the vivid dreams. But after just a few days, these memories no longer invaded his consciousness. No flashbacks. No frightening images chasing him. He could bring them to mind if and when he wanted to, but he was also able to keep his mind clear when he wanted to.

“The memories were flooding me for the first couple of days for sure. But then they receded. You know, so quickly. I thought how funny that was, how the salience of those memories faded and I no longer had the type of intense reaction that I did when I first woke up.”

For Jed, the transition was profound.

“I had burning questions. I was mostly wondering why I wasn’t more messed up. I was really puzzled, you know. If everybody gets PTSD, why was I doing okay? That was my question, really. Why was I doing okay?”

•

WHY WAS JED doing okay?

How could anybody possibly be okay after such a horrific experience?

The question seems at once profound and unanswerable.

But there is an answer. We’ll never know with absolute certainty, of course, why Jed was psychologically unscathed. The fact that he was in a coma for so long shrouds at least part of his experience in mystery. But we can explain the rest of it, not only for Jed but for anybody faced with serious adversity.

The story begins with how we think about trauma. According to a conventional view, Jed should have been psychologically overwhelmed, his seemingly rapid turnaround nothing more than an illusion, a short-lived denial of the more pernicious psychological wounds lurking deeper in the recesses of his mind. But this perspective, which has dominated our understanding for most of the past half-century, is woefully incomplete.

Until recently, most of what we have known about trauma came from the study of the most severe responses, such as post-traumatic stress disorder, or PTSD. It goes without saying that we should do everything we can to understand severe trauma. The problem arises when we focus only on that goal and ignore the experiences of those who don’t show such extreme reactions. When that happens, we get to know a lot about what can go wrong but not much about what might go right. And, unfortunately, we slowly come to believe that things can only go wrong, that traumatic stress inevitably produces lasting trauma and PTSD.

This kind of reasoning is known as essentialism. It is rooted in the belief that a traumatic event is a “natural kind,” that it has an immutable and unobservable essence that causes us to feel and behave in certain ways.³ We tend to think of PTSD in this way. When we essentialize these concepts, we assume that humans did not invent or create them, but rather, that they always existed, and that humans simply discovered them. Essentialist assumptions are not necessarily wrong. A dog is different from a cat. A stone is different from water. But sometimes essentialist concepts miss the mark, especially when they pertain to mental states. And, as we will see shortly, the conventional view of trauma misses the mark by a wide margin. Neither trauma nor PTSD is a static, immutable category. They are dynamic states with fuzzy boundaries that unfold and change over time.

Yes, PTSD, or at least something like it, does happen. And, sadly, when it does happen, it is often debilitating. But an extreme reaction like PTSD does not simply come about instantaneously because of exposure to a trauma-inducing event. Violent or life-threatening events are undeniably difficult, and most people who encounter them experience at least some form of traumatic stress. They may feel stunned and anxious, for example, or struggle to manage disturbing thoughts, images, and memories. These reactions vary across people and events, and typically they are short-lived, lasting no more than a few hours or a few days, sometimes even a few weeks. In this transient form, traumatic stress is a perfectly natural response. But it is not PTSD.

PTSD is what happens when traumatic stress doesn’t go away, when it festers and expands and eventually stabilizes into a more enduring state of distress. But this outcome is not nearly as common as we might think. Research over the past several decades has shown incontrovertibly that most people exposed to violent or life-threatening events do not develop PTSD. And that can only mean that the events themselves are not inherently traumatic. In fact, no event, not even a violent or life-threatening event, is inherently traumatic. Such events are only “potentially traumatic.” A good part of the rest of it is up to us.

That “rest of it” varies a great deal more than the standard perspective on trauma supposes. Although most people do not develop PTSD, some still suffer in other ways. They may struggle with traumatic stress for a few months or longer, for example, before gradually recovering, or they may begin with less severe stress reactions that slowly worsen over time. Yet, even when we account for these diverse patterns, we still find that most people—a clear majority—are able to cope with traumatic stress reasonably well. Most people exposed to potentially traumatic events are able to continue on with their normal lives relatively quickly and without suffering any long-term difficulties. In short, most people are resilient. My own research has shown this repeatedly, in study after study. Research by other scientists has shown it, too. When we look across the full range of research that has been conducted—studies on all kinds of highly aversive or potentially traumatic events—resilience is almost always the most common outcome.

But even when we account for the empirical fact that we humans are highly resilient, we are still left with the even bigger question of why. Why, when horrible things happen, are we able to cope so well, to shake it off and get on with our lives? What is it that we do that allows us to be so resilient?

Ironically, this is where the failings of the conventional view of trauma are most glaring. If PTSD simply happens because of a traumatic event, then, by the same essentialist logic, most people are resilient to trauma simply because they are resilient. In other words, the conventional view leaves us no choice but to assume that there is something in resilient people, some essence, that makes them impervious.