Eugenie is telling me the story of the end of her life. At least, it is the end of the life she used to know.
Three years ago, government soldiers came to her home in Kinshasa in the Democratic Republic of Congo and arrested her for working with the political opposition. They took her to their base and locked her in a darkened room. While incarcerated she was the victim of degrading treatment – all she is prepared to share about the experience is that she was raped. After three days she was released, and left bleeding and disorientated on the side of a road. She was rescued by a woman who took her to hospital and contacted her family. They arranged for her escape to Turkey. A few weeks after crossing the border she discovered she was pregnant. She doesn’t know if the child is by her husband or the man who raped her. Her husband, a political activist, disappeared the day she was taken. Her brother is also missing. Recently she heard that her sister has been killed.
Traumatised by this fracturing of her life, Eugenie (not her real name) was referred to a therapy centre in Istanbul that specialises in the treatment of victims of mass trauma events such as war, torture, earthquakes and sexual violence. The Center for Behaviour Research and Therapy – known by its Turkish acronym as Dabatem – is run by the clinical psychologist Ebru Salcioglu, an expert in anxiety disorders, and the psychiatrist Metin Basoglu, former head of trauma studies at the Institute of Psychiatry at King’s College London. Their mission, grounded in 25 years of research into how people experience trauma, is to make effective therapy available to the huge numbers of victims in the developing world who would otherwise receive no help.
While some people understandably crumble after extraordinarily harrowing events, others, like Eugenie have an extraordinary capacity to rebound and survive
The psychologists had arranged for me to meet some of their clients in Istanbul. Eugenie is the first to turn up. She is composed and self-assured, and remarkably forthright about her demons. Yet after a while it becomes apparent that she has come not so much to describe her downfall as her survival. She says her fears no longer control her. She is functioning pretty well. She seems proud, and also grateful. “Before my treatment, I wasn’t able to tell my story to anyone,” she says. “I was dead. Now I feel like telling it. It’s my story.”
You might think, given what happened to her, that a recovery of this scale would take months of intensive therapy. Yet Salcioglu says she has seen Eugenie for just eight sessions, and that she began to get better after four. Many of their clients have reported a similar rate of improvement.
Their successes challenge many of our common notions about the resilience of the human mind. While some people understandably crumble after extraordinarily harrowing events, others, like Eugenie have an extraordinary capacity to rebound and survive. Understanding why could lead us to help many more recover and grow after their experiences.
Tales of extreme resilience are very rare in the media; after every tragedy, we are more often reminded of the permanent scars an event can leave on the mind. “Watching television, you’d think every soldier returning from Iraq and Afghanistan was going to fall apart, that they’re walking time bombs,” says Donald Meichenbaum, who helped treat survivors of the 1995 Oklahoma City bombing, the 1999 Columbine High School shooting and the terrorist attacks of 9/11.
It’s true that a good proportion of people suffering trauma do carry mental illness. On average, around 25% of people exposed to a life-threatening or violent event develop post-traumatic stress disorder, or related disorders that don’t meet its strict diagnostic criteria. Their lives can revolve around their symptoms, which include nightmares, flashbacks, intrusive thoughts, disrupted moods or cognition, hypervigilance and irritability. Usually they harbour irrational fears that cause them to avoid situations that remind them of what happened.
Traumatised survivors of war crimes, and victims of torture and rape – such as Eugenie – typically fear sleeping in the dark. They have difficulty watching anything violent on TV. If they are women they are usually afraid of men and may choose to miss their bus or train if it carries a preponderance of men. Eugenie dreaded being in crowds, yet she also couldn’t bear spending even five minutes on her own. At night, she says, “I would see the soldiers in my mind and all they did to me.”
Left untreated, those symptoms can persist for years. In 2004, Greek psychiatrists discovered that survivors of the 1953 earthquake on the island of Cephalonia, which killed 455 and left many homeless, were still experiencing flashbacks and nightmares, more than half a century later.
Yet it’s still striking that the majority of people who live through an earthquake, terrorist attack or physical abuse do not experience lasting psychiatric symptoms. “People are more resilient than we give them credit for,” says Simon Wessely, professor of psychological medicine at the Institute of Psychiatry, King’s College London. When Wessely’s team asked 1,000 Londoners about their emotional state in the days following the suicide bombings on 7 July 2005, only one in 100 said they felt they needed professional help. A similar survey among residents of New York City after 9/11 by George Bonanno at Columbia University found that a large majority suffered no trauma symptoms at all during the six months that followed (though PTSD rates among those living or working near Ground Zero were around 20%). This rather undermines the received wisdom that everyone in the vicinity of a disaster needs help.
Such extreme differences in the way people cope are striking, and puzzling. What makes some people more resilient, so they require less help and can pull through quicker than others? And why do a minority even manage what psychologists call “post-traumatic growth”, living deeper, more meaningful lives than before?
Some clues come from the High Valley Resilience Study at Harvard Medical School, which followed a group of young people who had been hospitalised in their early teens due to severe psychosis. Following patients from the late 70s to the early 90s, it found that a minority surprised everyone by going on to lead normal lives in adulthood. These survivors did not appear to possess any remarkable innate attributes. Instead, what set them apart was the way they framed the story of their illness and how they integrated it into their personal narratives.
This suggests that resilience and recovery do not require extraordinary resources or an innate toughness, but rather a willingness to adapt to circumstances. The child psychologist Ann Masten calls this “ordinary magic”. Masten, who studies at the Institute of Child Development at the University of Minnesota, points to several key factors, such as connecting with a wider community, sharing your experience with others and developing a sense of meaning in life.
Re-framing your life after a deep upset – getting your story right – can require considerable energy and imagination
In theory, these resources are open to anyone. But that doesn’t mean they are easy to apply. Re-framing your life after a deep upset – getting your story right – can require considerable energy and imagination. All traumatised people have lost something. Usually the thing they have lost is the safe, predictable world that they knew; it can touch a person at the deepest existential level. “Trauma creates a rupture in a person’s life story,” says Stephen Joseph, a psychologist at the University of Nottingham. “It teaches them about the shortness of life, the preciousness of life, the closeness of mortality, the possibility that their loved ones may be gone tomorrow.”
The challenges of drawing on your natural resilience are evident in the city of Van in the far east of Turkey, which I visited after my conversation with Eugenie. It is located in the East Anatolian highlands, a thinly populated, tectonically lively massif of snowy peaks, weathered foothills and scrubby plateaus. Today, the city is best known for an earthquake that killed more than 600 of its residents and left tens of thousands temporarily homeless.
The earthquake struck at 13:41 local time on 23 October 2011. It lasted 25 seconds and caused the partial or total collapse of thousands of houses and office buildings in Van and surrounding villages. Hundreds of aftershocks followed, then two weeks later came a second large earthquake, which killed 40 more. By mid-November the city was unrecognisable. As in Nepal recently, most of the surviving population were living in tents in the open since the houses were too dangerous to enter.
After the earthquake, the Turkish government was not equipped to meet psychological needs
By early 2012, most people had moved to 29,000 steel mobile container units organised by the Turkish government. The government was quick to coordinate food, water, health and other services, to meet basic needs. But it was not equipped to meet psychological needs. So a group of psychologists and counsellors from Yuzuncu Yil University in Van and the Mother Child Education Foundation (Acev) in Istanbul set up a counselling centre in one of the containers. Over the months that followed they treated hundreds of people, including 200 children who had developed problems such as bed-wetting, aggression, obsessive-compulsive habits, sleeplessness, nightmares and a persistent fear of being separated from their parents.
The counselling centre is still operating. Its leader, Fuat Tanhan, tells me that patients with all kinds of issues come here. Some are still indirectly affected by the earthquake, which shook to the surface previously unacknowledged issues within families and relationships. “Everybody lost something, whether it was a family member, a friend, a house, possessions, or just a sense of security.”
Around a quarter developed PTSD, yet the rest showed resilience in the face of the losses. Their strength seemed to come from an ability to reappraise and reform their lives, to think about their lives anew, form closer links to their families, and to change behaviours and habits. One of them says he gave up smoking immediately, for instance – although others became more hedonistic. Whatever their choice, the decision to seize life and start anew seemed to define their survival. “Living through a catastrophic event means you face death,” says Tanhan. “You have the sense you can die any time. This changes your life.”
The idea that becoming acutely aware of your own mortality can trigger dramatic changes in attitudes has a long history in psychology. In his 1974 Pulitzer Prize-winning book The Denial of Death the psychiatrist Ernest Becker proposed that much of what characterises our humanness – our culture, belief systems, sense of self and belonging – is shaped by our need to offset the inevitability of dying. Survivors of traumatic events are brought nose-to-nose with this reality, and they must find ways to temper it, to assure themselves that their lives count for something and that they will not merely end up as “food for worms”, as Becker put it. The task, he wrote, is to create narratives that are “of lasting worth and meaning”, that “outlive or outshine death and decay”.
It seems the ones who respond best are able to re-imagine their lives in the most positive ways. The Austrian psychiatrist Viktor Frankl, during his internment in Auschwitz and Dachau concentration camps during World War Two, helped his fellow prisoners endure the horror around them by getting them to focus on the lives they might lead after the war – the work they would do, or the nurturing of their children. In his most famous book, Man’s Search for Meaning, first published in 1946, he observed that prisoners who lost faith in the future lost their “spiritual hold” on themselves, and quickly declined mentally and physically. He also noted that this was less likely to happen to those with faith. Religions, with their grand scripts for life and death, offer multiple opportunities for dealing with trauma, not all of them successful.
Prayer and ritual were common in Van, where a sociologist told me: “Right after the earthquake I looked at the Koran, and when I saw some verses that I could relate to the incident, I felt deeply relieved.” Religious engagement was the most common coping strategy reported by the earthquake survivors, followed closely by family support. These two are doubtless intertwined, since people tend to pray or conduct religious rituals together.
Relinquishing control is an ultimate form of control
Religion may also offer a feeling of certainty where none exists. In Van, a place that can seem utterly vulnerable to the forces of nature that surround it, delegating responsibility to a higher being is a way of managing the situation. “Earthquakes are totally unpredictable, therefore totally uncontrollable,” says Basoglu. “Relinquishing control is an ultimate form of control.”
Still, bouncing back from trauma does not always require us to build an ambitious existential vision for our place in the world. Frankl stressed that the key was to find meaning in life, rather than the meaning of life. “Live as if you were living already for the second time and as if you had acted the first time as wrongly as you are about to act now!” he exhorted his patients.
The challenge is finding ways to encourage people to make this transition naturally, for themselves. Meichenbaum, the clinical psychologist, says he can tell just from listening to his patients talk and the metaphors they use how well they are likely to cope with their bad experiences and how resilient they will be. Successful adapters tell lucid, forward-looking stories about themselves that join their past to their future. The 25% of people who (on average) go on to develop PTSD, however, tend to be incoherent, fragmented and stuck on negative memories. They describe themselves as “prisoners of the past”, “empty inside”, “not worthy”, and the like. A therapist, says Meichenbaum, should get them to spin another version of their story, one that includes an account of how they survived, how they managed to get to the therapist’s door, and the path they will follow from there.
Retelling your life-story is not the only way to recover from trauma, however – there are many other behaviours that can help you rebuild your mental fortress. Who you mix with may also be crucial.
Retelling your life-story is not the only way to recover from trauma
Before he started working with refugees and earthquake survivors, Basoglu was known for his studies on the psychological effects of torture. One of his most remarkable findings was that torture survivors who are members of political organisations suffer fewer psychological problems afterwards than those with no political involvement, even when they are tortured more severely. Basoglu couldn’t be sure what provided this apparent immunity, but among his favoured theories was that being politically active gives someone “a belief system whereby torture is appraised as merely an instrument of repression used by the regime to protect the interests of the ruling class”. In other words, torture may be less disturbing for activists because it doesn’t controvert their fundamental understanding of how the world works – whereas for the unprepared, it is likely to be crushing.
This may explain why military personnel tend to fare better than civilians when kidnapped, since surviving as a captive could be construed as part of their mission. Nevertheless if a soldier experiences something that conflicts with his deep-held beliefs or sense of order, he is as vulnerable as anyone. Killing an enemy soldier, for example, or failing to prevent the death of a colleague, can trigger what psychologists call “moral injury”, a precursor for a range of pathological behaviours including alcohol abuse, hopelessness, self-loathing, persistent guilt and an inclination to re-cast oneself as immoral, beyond redemption or irreparably damaged.
Friendly fire can have the same effect, says Simon Wessely, who in addition to his role at the Institute of Psychiatry is a psychiatric consultant to the British Army. “Being shot by the Taliban is one thing. That’s in the rules of the game. Being accidentally bombed by the Americans is completely different. That’s a violation of professionalism. It disrupts your worldview. It has a much more dramatic impact on PTSD.”
If a distortion of identity is a risk factor for trauma, a shared identity – turning to others – is a defence against it. Another reason political activists report less distress during torture, and military personnel during captivity, could be their affiliation to their group. Knowing that you have buddies who are rooting for you is gladdening and reassuring. Identifying with others and confiding in them is also critical to recovery from trauma. In his work with survivors of large-scale terrorist attacks in the US, Meichenbaum has found that how a victim responds to a tragedy depends on the level of support they get from close friends and family in the hours and days afterwards. By the same token, survivors of the 2005 London bombings who couldn’t immediately get through to their loved ones on their mobiles (usually because the networks were jammed or overloaded) were far more likely to suffer a substantial stress reaction, according to Wessely’s analysis of the aftermath.
Social connection can help people reach out beyond their own fear and discordance to something grander, a kind of self-transcendence
Social connection is an effective remedy not only because of the comfort it brings, but also because it can help people reach out beyond their own fear and discordance to something grander and more meaningful, a kind of self-transcendence. It grounds them in a cultural identity, or in a social network, that offers an alternative perspective.
I could see this with Eugenie. A long way from her home in DR Congo, she has found a community of exiles in Istanbul, and a support system in her therapists, who have helped pull her out of her dark imaginings and connect with the world around her.
It was also evident in Van, when I meet Suvat Parin, head of the Yuzuncu Yil University sociology department. He has always lived here, an authority on the social dynamics of the community and, lately, how it responds to trauma.
He tells me that in a poor, relatively deprived population like Van’s, social bonds make up for the lack of resources, providing people with a survival strategy. When I ask him to explain, he describes what happened to his own family after the earthquake. “As soon as it stopped we started calling everyone, our relatives, asking about people, where they were, what happened to them, did they survive. It was quite intense. Within two hours we were all gathered in the same place, a group of a hundred people carrying the same surname. We had everything we needed, food, medicine. It was all addressed in a collective manner. It gave us psychological leverage, a means to cope with things. Because you knew you were not alone, that there were people behind you.”
Social resilience, as well as being culturally dependent, cannot account for all the nuances of a community’s response to tragedy. It is puzzling, for example, that women, despite being better than men at building ties and sharing emotions, almost always report higher rates of PTSD after a traumatic event. But lack of social support likely explains why British soldiers returning to civvy street after serving in Iraq and Afghanistan – thus losing ties with their “bands of brothers” – were more vulnerable to PTSD and other mental disorders than their colleagues who remained in service. It may explain why so many Vietnam veterans became psychiatric casualties after returning home to widespread public condemnation – a social alienation that according to military psychologist Dave Grossman amplified their trauma to “a staggering degree of horror”.
The traumatised patients who come for help at Dabatem’s treatment centre in Istanbul have one symptom in common: they are all consumed by fear. This makes them avoidant, and as a result their lives are highly dysfunctional. Salcioglu and Basoglu say the therapist’s task is to get them to do the things they avoid – sleeping in the dark, walking in a crowd, watching the news – and to keep doing them and not to run from them until they understand that their fear is unrealistic and they can tolerate it. “The critical recovery process is exposure,” says Basoglu. “You confront fear and you learn to deal with it. You learn to exercise control over it, instead of letting it control you.”
A distinguishing feature of Dabatem’s behavioural approach – which has none of the cognitive elements often used by therapists – is the speed with which it can be rolled out in disaster zones, where tens of thousands of people may require help. For earthquake survivors, they have designed a treatment programme that can be delivered by a health professional in a single session in which the therapist teaches the patient how to confront their fears and overcome them. This single-session approach has been controversial, since it suggests the patient’s relationship with the therapist is not as crucial as some believe. Still, it has been successful: clinical trials with earthquake survivors suffering chronic PTSD showed that 80% of them improved significantly over the 12 weeks following an initial consultation with one of their therapists. (After six weeks only 4% of the control group had shown any improvement so for ethical reasons the researchers merged them with the treatment group). Preliminary results from a trial with 60 war refugees indicate that 93% were much recovered after 12 sessions, and that many required fewer.
The potential to recover is in the genes. The question is how to mobilise it
Like many other psychologists, Basoglu is optimistic that anyone floored by a traumatic event can rally to live a fully functional life, and sometimes to flourish in a way they hadn’t before, though they may need guiding. “The potential to recover is in the genes. The question is how to mobilise it.” At Dabatem, the aim is not to help patients develop their autobiographical narratives or find a grand arc of meaning. It is to normalise their behaviours so they’re able to do this themselves. Once they have squared up to their fears, says Basoglu, the changes can be astonishing.
On my last day in Istanbul, Sacioglu introduces me to Marie, a refugee from the DR Congo who, if the popular view of trauma held, should expect to endure a life of avoidance and anguish. One night when Marie (whose name has been changed for this article) was 16, a group of militiamen came to her village and killed her mother and her little brother and many of their neighbours and took her into the forest where they held her as a slave. They raped her continuously, every other day, for some weeks, before one of the soldiers took pity on her and led her through the forest to the Rwandan border. From there she found her way to the capital, Kigali, and eventually by plane to Turkey.
At first she slept on the street, then in a centre run by the Turkish government. She was taken to hospital, where she discovered she was four months pregnant. She regularly hallucinated about her mother, and she had severe PTSD: “I couldn’t sleep. I was very scared. I couldn’t stay five minutes on my own. I couldn’t be in the dark because I would see the soldiers in my mind and all that they did to me. I was afraid of men. In a bus I couldn’t be near them. I didn’t even want to sit next to a beautiful woman. I’d rather sit next to a veiled woman so no one would look at us.”
Marie ended up at Dabatem, where Salcioglu made her confront all the reminders of trauma she was trying to avoid. She encouraged her to sit on buses, to walk in the street, to sleep in the dark. They watched documentaries about rape together. You can see how successful this has been just by looking at her. She walks into the room wearing a white T-shirt and jeans, branded earrings, a showy necklace and gold-plated watch. She has arranged her hair in plaits. Although she avoids eye contact and twists her hands together when she describes what happened, she is no longer trying to hide from life. She has started working in a hair salon.
Frankl, were he alive, would doubtless approve of this, with his emphasis on doing and creating as a way of discovering meaning in life. Many therapists share his view that surviving trauma is not only about recovery but also about growth. Sometimes great suffering can lead to a transfiguration. “For most people, trauma represents an existential crisis,” says Stephen Joseph. “It wakes them up to the deep questions of life.” Once awake to those questions, anything is possible.
Follow us on Facebook, Twitter, Google+ and LinkedIn.