What Doesn't Kill Us

Preface

Nietzsche's Dictum

What doesn't kill me makes me stronger.

Nietzsche

AS A CHILD OF THE 1960s AND 1970s I loved American comic books. Hard as they were to get hold of in Belfast, they were dear to me because of the superheroes they depicted: Daredevil, Batman, and the Fantastic Four. But Spider-Man was my favourite of all. Physically transformed after a bite from a radioactive spider, he finds himself gifted with strange superpowers. It isn't until after his Uncle Ben dies at the hands of a criminal that Peter Parker realises his calling in life, turning his newfound powers to fighting crime.

Peter Parker's life as Spider-Man is not easy. J. Jonah Jameson, editor of the Daily Bugle, seeks to make headlines by exposing him as a criminal. His romance with Mary Jane is tortured by the stress of his secret identity.

As a young boy growing up in Belfast at the height of the political violence in Northern Ireland, I discovered in these stories a different world, of skyscrapers, of romance, where people with the courage to stand up for what they believe in can make a difference. I loved that tragedy could be the springboard for transformation. If only real life were like that!

But, as I have got older, I've realised that it is.

Stories about superheroes are metaphors for the challenges we face in life. What Spider-Man had in common with the other comic book characters was that, through no fault of his own, something happened to him that challenged him to set a new, exciting, though difficult course in life. Heroes encounter a life-changing traumatic event. They could crumble in the face of the tragedy, but instead it awakens them to new strength and wisdom. Life is forever changed: their tragedy redefines who they are, and what they must do with their lives.

What I have learned is that these metaphors have real-life counterparts. Ordinary people have the power to live lives just as dramatic and driven as those of superheroes, overcoming traumas no less daunting. Their stories are all the more impressive for being real.

Leon Greenman was one of those people. Born into a Dutch–Jewish family in 1910 in East London, he trained as a boxer and worked as barber, eventually specialising in the trade of antiquarian books. With his Dutch wife Esther, Greenman was living in Rotterdam in 1938 as tensions rose across Europe. Set to return to London, he heard British Prime Minister Neville Chamberlain on the radio declaring 'peace for our time.' He put his plans on hold, thinking there was no rush to move back to London.

The following year, war broke out; then, in 1940, Germany invaded Holland. Greenman gave his passport and life savings to a friend for safekeeping. Later, he heard that British citizens were being allowed to go home in exchange for German prisoners. So he asked his friend for the passport back. But to Greenman's horror, his friend had burned the passport in fear of reprisals for helping Jews.

Unable to elude the Nazis, in 1942 Greenman, Esther, and their two-year-old son, Barney, were sent to Westerbork and then deported to Birkenau, otherwise known as the death camp of Auschwitz. On arrival, he was separated from his wife and child. Esther held his child up for him to see and blew him a kiss. He never saw them again. As a fit young man, Greenman could work as a barber; his arm was tattooed with the number 98288 and he was sent to work in the camps.

On 11 April 1945, now at the Buchenwald camp after a 60 mile death march, he woke up to find the camp deserted of guards. The camp had been liberated by General Patton's 3rd Army. After two more days at the hospital barracks, now free to move around the camp, Greenman visited the ovens where so many lives had been destroyed. There were heaps of ashes and bones. He took some of the bones as tokens of remembrance and as evidence to show the world.

Unlike millions of others, Greenman had escaped the gas chambers. He returned to London and worked as a market vendor and a professional singer under the name of Leon Maure. People did not want to hear about the experiences of the camps and he did not think to tell them. But in 1962, everything changed when he witnessed a rally for the National Front, a white nationalist party that denied that the Holocaust had ever happened. It was then that he realized that it could all happen again.

For the next forty-six years, Greenman protested the rise of the Far Right and devoted himself to giving talks about what had happened. As a result, he received hate mail and death threats and had to install mesh shutters on his windows at home to prevent bricks being thrown in. Despite this, he continued to give talks, take people on tours at Auschwitz, and speak out against fascism. Many schoolchildren got to hear him talk and through him learned about the horrors of the war. About his new mission, he said: 'My purpose now – my duty – is to tell people what happened.' In 1998 the Queen of England awarded him with the Order of the British Empire for his services against fascism.¹ He continued his mission up until his death in 2008 at the age of ninety-seven.

Leon Greenman's story encapsulates what this book is all about: how trauma can transform the course of one's life. Our way of seeing the world can be so completely and radically dismantled and then rebuilt that, in a sense, we step into a new world.

The idea of transformation through trauma goes against the grain of all that is written about the devastating and destructive effects of trauma. Psychological studies have shown that adverse life-events are often the trigger for depression, anxiety or posttraumatic stress. Psychiatrists, too, recognise that life-events such as serious illness, accident or injury, bereavement and relationship breakdown can be threatening to mental health.²

What, then, are we to make of the stories of people who have encountered a life-threatening illness, a harrowing natural disaster, even a man-made horror, and then go on to tell of how it was a transformational turning point in their lives? Such stories seem to point to the truth of Nietzsche's dictum: 'What doesn't kill me makes me stronger.'³ But are these merely the articulations of the lucky few? Or can psychological trauma really have a silver lining for all of us? Surprisingly, the answer to this second question seems to be yes.

Adversity, like the grit that creates the oyster, is often what propels people to become more true to themselves, take on new challenges and view life from a wider perspective. Think, for example, of the great American cyclist Lance Armstrong. He managed to overcome the adversity of his struggle with testicular cancer and went on to win the Tour de France. And not just once did he win, but seven times in a row. In his autobiography, he wrote of how cancer changed his life:

There are two Lance Armstrongs, pre-cancer, and post. Everybody's favourite question is 'How did cancer change you?' The real question is how didn't it change me? I left my house on 2 October 1996, as one person and came back home another … The truth is that cancer was the best thing that ever happened to me. I don't know why I got the illness, but it did wonders for me, and I wouldn't want to walk away from it. Why would I want to change, even for a day, the most important and shaping event of my life?⁴

For all the inspiration and hope they offer, real-life stories like this one do not tell us how transformation comes about. In recent years, however, psychologists have begun to sit up and take notice of the benefits of adversity, and to observe that it is not just the extraordinary few who find trauma transforming, but people from all walks of life. This book will review the new research that is turning on its head what we thought we knew about how people cope with adversity.

This is not to suggest that people should wish for their trauma, tragedy or misfortune to have happened, or that they should wish it on others. Rather, my point is simply that we must recognise adversity as a fact of life.

We all must face difficult events in our lives. What has happened cannot be undone. Our only choice is how to live with what has happened. Consider the case of Harold Kushner, whose son died of a rare ageing disease. In his book When Bad Things Happen to Good People, he wrote:

I am a more sensitive person, a more effective pastor, a more sympathetic counsellor because of Aaron's life and death than I would have been without it. And I would give up all those gains in a second if I could have my son back. If I could choose, I would forego all the spiritual growth and depth which has come my way because of our experience, and be what I was fifteen years ago, an average rabbi, an indifferent counsellor, helping some people and unable to help others, and the father of a bright, happy boy. But I cannot choose.⁵

Not until adversity strikes do many people begin to look deeply within themselves to reappraise what really matters. Adversity can awaken people to new and more meaningful lives.

* * *

This book is the culmination of over twenty years of study and research devoted to understanding the effects of adversity on our psychological systems. And, needless to say, I myself have had personal experiences of adversity during this time that have opened my eyes. As a therapist who has worked with people going through troubled times, and as a researcher who has read many personal accounts of people's experiences of adversity, I am convinced that people do often grow following adversity. In this book, I want to share my experiences as a scientific researcher and therapist, to answer this question of why it is that if two people encounter adversity, one may succumb but the other may thrive.

At the core of this book is the theory of the shattered vase. Imagine that a treasured vase sits in a place of prominence in your house. One day, you accidentally knock it off its perch. It smashes. Sometimes, when vases shatter, there is enough left intact to provide a base from which to start the process of reconstruction. In this case, however, only shards remain.

What do you do? Do you try to put the vase back together as it was, using glue and sticky tape? Do you collect the shards and drop them in the rubbish, as the vase is a total loss? Or do you pick up the beautiful coloured pieces and use them to make something new – such as a colourful mosaic?

When adversity strikes, people often feel that at least some part of them – be it their views of the world, their sense of themselves, their relationships – has been smashed. Those who try to put their lives back together exactly as they were remain fractured and vulnerable. But those who accept the breakage and build themselves anew become more resilient and open to new ways of living. The guiding principle that underscores this book is the belief, drawn from years of research and clinical practice, that focusing on, understanding and deliberately taking control of what we do in our thoughts and actions can enable us to move forward in life following adversity.

There is no doubt that adversity can lead to great psychological suffering. We know that extremely frightening events can lead to very high levels of distress, which, in turn, can persist for many months, even years. Not everyone experiences full-blown posttraumatic stress disorder (PTSD), but most people will develop some of the emotional turmoil of posttraumatic stress following adversity. Research has documented what leads some people to be more vulnerable than others to the effects of trauma, and how best to help those people who are suffering from posttraumatic stress. Cognitive-behavioural treatments have been developed for the treatment of posttraumatic stress and are now recommended by the National Institute for Clinical Excellence in Health – the organisation in the UK responsible for providing guidelines on the treatment of specific clinical conditions. These treatments seem to work. Many thousands upon thousands of people have benefited from these treatments. And thousands of mental health professionals are trained to deliver them.

An industry has grown up to help those who have gone through psychological trauma. For this army of counsellors, psychotherapists, psychologists, psychiatrists and social workers, business is booming. Surely this must be a good thing, right? At one time, I would have agreed that it was. Yet, as my own interests increasingly began to shift over the years away from the topic of PTSD and toward that of growth following adversity, I began to ask questions about the trauma industry and the extent to which it deals with this wider landscape. As our knowledge of PTSD has grown and the trauma industry has expanded, the idea of growth following adversity has become overshadowed. Our understanding of how people adapt following adversity has become lopsided, focusing only on the negative.

Trauma encompasses a landscape of human experience much wider than PTSD alone. It is a complex issue requiring that we take biology, culture and politics into account to determine how to deal with adversity and make sense of our lives. This complexity has led me to three serious concerns about whether the trauma industry's success has had unintended consequences that have actually become part of the problem.⁶

First, the trauma industry has enthusiastically and single-mindedly adopted the language of medicine. As a diagnostic category, PTSD has been beneficial in providing recognition of the suffering experienced by many people, but the language of medicine puts therapists in a doctor-like position, which takes away from patients the responsibility for their own recovery. Indeed, the very word patient is problematic because it portrays the person as someone who is damaged, impaired, deficient, maladjusted, disordered. In short, it subtly shifts responsibility for their recovery into the hands of the therapist. However, trauma is not an illness to be cured by a doctor. Certainly, therapists can offer people guidance and be expert companions along the way, but, ultimately, people must be able to take responsibility for their own recovery and for the meaning that they give to their experiences.

Second, it has also created a culture of expectation in which there is a mistaken assumption that PTSD is both inevitable and inescapable. When disasters strike, often the message that follows is that people will be affected, that they will develop PTSD, and that they will need professional help for the foreseeable future. This may well be true of some people. But research over the past decade has shown us that trauma survivors are not necessarily destined for a life of unremitting despair and that the damaging effects of trauma have been overestimated. If people are told that they are vulnerable and need help, these conditions become a self-fulfilling prophecy. Indeed, what the research actually shows us is that the majority of those who face potentially traumatic events are relatively resilient, able either to resist stressors or recover quickly and then to maintain relatively high levels of functioning.⁷ This is the message that needs to be conveyed: that the majority of people are resilient to the tragedies, misfortunes, and disasters that will befall them.

My third concern is one that I noted earlier: our criterion for successful treatment has become confined to the alleviation of PTSD, which leads us to disregard the body of research showing not only that most people are resilient, but also that many people find benefits in adversity that can provide a springboard to higher levels of functioning than before. Post-traumatic reactions are not one-sided phenomena but multi-faceted, encompassing both distress and growth. People are capable of finding pathways to reverse the destructiveness of trauma and turn it to their advantage. Such observations have in the past been treated as exceptions to the rule – as little more than interesting anecdotes – rather than being seen as part of the very nature of trauma. But therapists who fail to recognise this possibility of growth in their clients do them a disservice.

In short, while the adoption of PTSD as a diagnostic category has been beneficial in terms of increasing access to psychological therapies for those who need them, it has been detrimental in these three ways: in taking responsibility away from people, in creating a culture of expectation and in ignoring the personal growth that often arises following trauma.

The aim of this book is to correct the imbalance – to show that trauma can have both negative and positive implications, and that the negative and the positive go hand in hand. I challenge the trauma industry by offering a new perspective: namely, that posttraumatic stress is a natural and normal process of adaption to adversity that marks the beginning of a transformative journey. Recovery from trauma consists of finding new meanings, creating new webs of understanding and finding reparative methods centered on the sharing of memories. Viewed in this light, posttraumatic stress can be understood as a search for meaning in which the drive to revisit, remember, and think about the trauma is a normal urge to make sense of a shocking experience, to grasp new realities and incorporate them into one's own life story. At the heart of this book is the idea that posttraumatic stress is the engine of transformation – of a process known as posttraumatic growth.

Recognition of the journey of posttraumatic growth begins sooner for some than for others, but all are on the journey itself. A simple idea, but it stands in opposition to decades of psychiatric research that focused on suffering itself rather than on the transformation that can arise through suffering.

As human beings we are storytellers. Trauma triggers within us the need to tell stories to make sense of what has happened. These stories may take the form of conversations with family, friends and colleagues. And our conversations are influenced by what we read in newspapers and see on television, and by the books, songs, and poetry that provide us with language that captures in words, music and images what we are experiencing. Transformation arises through the stories we tell.

It is in the struggle to make sense of a traumatic event that growth can take hold.

For those who are curious about how to apply the new science of posttraumatic growth, Part Three of the book provides specific details regarding the practical steps involved – including the Psychological Well-Being Post-Traumatic Changes Questionnaire (PWB-PTCQ)⁸ and the THRIVE model of change, a six-stage process of exercises and reflections.

What I have to say is grounded in science, but it is stories of people who have encountered adversity that are at the heart of this book. To preserve confidentiality I have used pseudonyms, unless the person has already made themself known publicly. Cases that appear are based on real people, but each has been heavily disguised by changing details of backgrounds and circumstances.

Drawing on the wisdom of the ancient philosophers, the insights of existential and evolutionary psychologists, and the optimism of modern positive psychology, I present the new psychology of adversity – a fresh, inspiring, and humanising perspective on how to manage life and its inevitable challenges.

1

Everything Changes

1

The Flipside of Trauma

IN 1987, ON FRIDAY 6 MARCH, a large passenger cruise ship called the Herald of Free Enterprise left the port of Zeebrugge in Belgium, en route to England. Nearly five hundred passengers, eighty crew and 1100 tons of haulage were on board. Passengers were settling into their seats, queuing up at the restaurants and ordering drinks at the bar. Below, water was flooding on to the car decks.

Unbeknown to passengers and crew, one of the bow doors had not been secured. No one noticed anything was wrong, until the ship attempted to turn. There was a lurch. Then, without warning, within forty-five seconds, the ship had rolled over.

There was no time to sound alarms of any kind. Furniture, cars, trucks and passengers alike were indiscriminately catapulted to port side. People collided with one another, crashed into walls and slipped under the ice-cold water as portholes imploded and water flooded the passenger areas. Electricity went out. The darkness reverberated with screams and shouts of pain and terror. As dead bodies floated in the icy water, many expected death, many lost loved ones, many witnessed unimaginable horrors.

One hundred and ninety-three people died in what was to become one of the most horrific maritime disasters of the twentieth century. It is hard to fathom what it must have been like to experience the Herald tragedy. Imagine the room you are in right now lurching and then suddenly turning upside down, throwing its contents from one side to the other. The ceiling becomes the floor, the lights go out and water starts flooding in.

A few months after the disaster, lawyers acting on behalf of survivors and bereaved relatives contacted the psychology department at the Institute of Psychiatry in London to ask for help. Professor William Yule, who was then head of clinical services, quickly mobilised services to assist survivors and set up a research programme. That is how I became involved. For the next three years, my doctoral study was devoted to investigating the survivors and the roadblocks to recovery that they faced.

Immediately following the disaster, a number of survivors were asked to complete well-known psychological tests to measure posttraumatic stress disorder (PTSD). It was found that levels of psychological distress were high and that many met the criteria for PTSD in the first months following the disaster. Symptoms included recurrent and intrusive distressing recollections of what happened, upsetting dreams, detachment and emotional numbness, difficulty falling or staying asleep, difficulty concentrating and a constant feeling of being on edge. These are all common experiences of people with PTSD.¹

Not surprisingly, those who develop PTSD are also faced with considerable difficulties in their lives at home and at work. Many of the survivors surveyed at this first point in time found their work and relationships were affected, and many struggled to cope.² Of interest were the psychological processes that led to greatest difficulty. We found that psychological distress was most likely to be found in those who blamed themselves in some way.³

As we listened to their stories, it was understandable that many would struggle to rebuild their lives. But little was known about the longer-term effects and so a pressing research question was to find out how the lives of these survivors would unfold over the coming years.

Three years later, we carried out a follow-up survey with survivors. We asked similar questions to those asked before about depression, anxiety and PTSD. We found that the average level of psychological distress was now lower, although it remained a concern and many of the survivors were still struggling. To further explore the psychological processes that lead to difficulties, our survey also asked pointed questions about survivors' experiences during and after the disaster.⁴

We analysed these responses to determine the extent to which the survivors' descriptions of their experiences were related to their current feelings. It turned out that that those who were most distressed were the ones who reported feeling helpless during the accident, who prepared themselves for the worst, who thought they were going to die and who felt paralysed with fear. We also asked the survivors how they coped in the aftermath. Those who were most distressed were the ones who were least emotionally expressive, who lacked social support and who had experienced other life-events in those preceding three years, such as serious illness, family bereavement or loss of employment.⁵

In the time since we conducted this survey, many other studies have reported similar results. It is now commonly accepted that two major roadblocks to recovery are a lack of social support and a preponderance of other life-events to contend with in the aftermath of trauma.⁶

But people are not passive recipients of how their lives unfold. The feelings they have about what has happened distinctly influence their recovery. For example, feelings of guilt and shame can be another important roadblock to recovery. Our survey found that over half the survivors felt guilty that they had stayed alive when so many died, over two-thirds felt guilty about what they did not do in the accident and one-third felt guilty about what they did do to survive. Those who reported such feelings tended to be the ones who were struggling the most psychologically.⁷

How people cope with their experiences is important. Some behaviours can help people feel better in the short term but lead to greater difficulties in the longer term. For example, our survey revealed that many of the survivors were using drink and drugs to help them cope: 73 per cent said that they were drinking more; 44 per cent that they were smoking more; 40 per cent that they were taking sleeping pills; 28 per cent that they were taking antidepressants; and 21 per cent, that they were taking tranquillisers. In addition, we determined that those on either prescribed or non-prescribed medications were in poorer psychological health than those on no medication at all.⁸