Olav Ofstad, 25.10.2016
Abstract
This article is written for survivors of kidnapping and people supporting them, but anyone suffering from the effects of such trauma will benefit from reading it.The article explains how trauma affects our emotions and behaviour, and what can be done to lessen such effects. Various kinds of trauma therapy are briefly presented, indicating a menu of treatments therapists may draw upon.
Anyone traumatized and suffering from post–traumatic stress disorder (PSTD) is urged to accept professional help. However, many do not have access to such support. These victims will benefit from the advice offered here to assist with resuming daily life, returning to work and relating to family, friends and colleagues. Guidance is given on how to deal with flashbacks, sleeping problems and numerous other issues that typically result from trauma. In addition to self-care and relaxation techniques, the article also offers a simple model of self-therapy. This model may, if consistently applied, be a useful tool in the quest for recovery.
Challenges
Most books written by kidnap victims end with joy and optimism. At long last the victim is going to live a normal life again. The reality that awaits him or her is however rarely touched upon in such books, and many survivors are severely traumatized. Without adequate care and support, such consequences may last for a very long time.
But what is trauma really about?
There are different definitions, but a traumatic experience generally involves the fear of death or serious emotional or physical injury. Such experiences are common for kidnapping victims. But exactly what happens when a trauma occurs?
How the brain works
Our experiences in life determine how our brain works. They build neuron connections that become pathways, and these pathways pre-programme our behaviours. This applies to such basic functions as our intake of food, rest and activity, how we relate to danger, connecting with other people, dealing with pain, fear and more.
A traumatic experience may be termed an ‘earthquake’ in the brain, creating pathways that deviate from the brain’s normal patterns. These new pathways work beyond our control. They may interrupt normal thoughts and force intrusive and frustrating thoughts and feelings upon us, disturbing our present life badly.
Flashbacks
Let us assume you have got through your kidnapping ordeal.
Time may have passed, and you may feel OK, but all of a sudden you are mentally torn out of your safe, comfortable situation and are back in the damp, dark basement where you were held. The pain and frustration are upon you in full force.
The ‘bad’ pathways in your brain have somehow got activated, and you have no control over what happens. Such experiences are common after kidnapping. Out of the blue you re-live beatings, torture, death threats, despair, helplessness or any other ordeal the kidnapping forced upon you. This can be extremely vivid. Flashbacks may happen at any time of the day, but are often particularly bothersome at night, effectively preventing you from sleeping. Nightmares that force victims to relive their ordeals time and again are also very common.
There may be a wide range of triggers releasing flashbacks. You might spot people dressed similar to the kidnappers, or find yourself in a street that reminds you of the abduction site. Perhaps you hear someone speaking with an accent similar to that of the kidnappers, or you sense a smell that reminds you of your prison or the food you used to get whilst captured. A certain conversation subject, a touch on your shoulder could be enough. So could media coverage, a hospital visit, a funeral, or the feeling of being confined, such as in a crowd or an elevator. A heated discussion, even with someone you love, could be enough to cause it. Even a certain kind of weather, a date or a particular time of day could spur a flashback. In general, there are few limitations as to what might be triggers.
Sometimes flashbacks hit after a long time, as a nasty surprise to victims who have come to believe that they escaped unharmed.
Flashbacks can be virtual nightmares in their own right, and you may have a hard time snapping out of them. To avoid flashbacks, you may find yourself avoiding anything that might trigger them. Meaning you stay away from crowded streets, avoid strangers or stay at home as much as possible. Obviously, such avoidance may impose serious limitations on your life.
Other effects
Even without explicit flashbacks, traumas manifest themselves in harmful ways. Basic needs typically affected by trauma, are safety, trust, control, intimacy and self-esteem[1].
This may imply a range of negative thoughts and emotions. The lack of control in captivity may have shattered your self-confidence. You may feel that you can no longer trust other people, you do not feel respected as you did before, you feel that you are generally unsafe and that you are unable to connect with and feel close to others. Feelings of sadness, grief and depression are common, and your overall ability to feel joy may be affected. So may your focus, your ability to concentrate as well as your memory. Some victims are bothered by a feeling of emptiness, others by an out of body sensation.
You may find yourself hyper vigilant and irritable, but also vulnerable and helpless. Decision making may be difficult, and many victims are bothered by a sensation of guilt, feeling the kidnapping or the mistreatment was their fault, or blaming themselves for the death of fellow captives. Some avoid discussing their problems with others because of their sense of shame.
You may become withdrawn, easily startled, restless or more confrontational and aggressive. You may change eating habits, sexual habits and lose or put on weight. You might also experience physical problems such as headaches, dizziness, lack of energy, stomach trouble, frequent urination, rashes and other psychosomatic ailments.
No wonder that many victims feel they are going crazy and some turn to drug or alcohol abuse.
As indicated above, the effects of PTSD may be long term. Research on resistance fighters who spent time in prison during World War II discovered that about one third had stress problems even 45 years after the war.[2]
The good news
It is important to know that you are not crazy. What you are experiencing is your mind’s normal reaction to abnormal experiences.
What’s more, it is possible to heal. Some trauma issues may never leave you completely and some of your feelings and views may have changed forever. But constructive healing is likely to make your life worth living again. So yes, you can take your life back.
Debriefing
Debriefing is the first assistance you may receive. This may be provided by the police, the army or a humanitarian organisation, hiring psychologists or psychiatrists with knowledge of first aid trauma treatment. Sometimes it is handled by volunteers or staff trained in the subject.
Security personnel may prioritize interrogating you with a view to catching the kidnappers. While this is important, the debriefing matters to your health. There should be a session separate from the interrogation that gives you the chance to talk through what you experienced and how you felt about it.
Some victims, perhaps euphoric after escaping, reject debriefing, insisting they are fine. What if you don’t feel traumatized? People do react differently to kidnapping ordeals, and you may be among the lucky ones. But please do not reject support right away. The elation and optimism you feel immediately after your release may be deceptive. A good long talk with a caring person may reveal issues that need processing. While you stand to lose if you ignore possible trauma, you have nothing to lose by accepting a debriefing. Opening up can be an important part of a healing process, and if you are traumatized, this could be a beginning.
To the extent you are able to, you should go through your experience from beginning to end. Narrate your trials, and put words to both the physical and mental ordeals. Observe how you react whilst you do this. While it is generally useful to talk, do not push yourself too hard. If you find something too painful to narrate, or if emotions overwhelm you, take a break. You might skip the painful topic and continue with something else. But please note that strong emotional reactions could suggest that you need therapy.
Trauma therapy
While debriefing is a relatively simple form of first aid, trauma therapy requires expertise. Subject to the support at hand, you may be offered an appointment with a trauma therapist and, subject to her assessment, therapy may be suggested.
Again, the advice here is: accept the appointment. Take at least one round. The worst that can happen is that you agree with her that you are fine and need no follow up. Some victims prefer to pick another therapist than the one offered to them, but please note that if you do need therapy, it is important to get it as early as possible. Otherwise the problematic pathways in your brain will get time to settle and strengthen.
So let us say that you have been traumatized, and that the trauma is severe enough to require treatment. Meaning, your life is disturbed by effects that will not go away by themselves. What is trauma therapy about?
The ultimate goal is to achieve a state where the bothersome pathways in your brain are no longer effective, so nasty intrusions from the past no longer cause the problems described above.
Over the years, a wide range of different therapies have emerged, and a first time trauma therapy patient may find some of them surprising.
Robin Shapiro’s Trauma Treatment Handbook (2010) offers a presentation from which the list below and parts of the explanations are borrowed. Please note that many therapists will apply combinations of these methods:
Mindfulness exercises
Breathing exercises, meditation and yoga are tools you may have used while in captivity. They can also be used under the guidance of a therapist or as self-treatment. So can meditative martial arts, such as Qigong. The purpose is to obtain a sense of calm, balance and control and to strengthen the brain’s ability to focus.[3] For a brief presentation of mindfulness exercises, see Stress Reduction Techniques below.
Psychotherapies
These therapies aim at helping the client understand harmful effects of the past, including kidnapping trauma, and offering guidance and support in overcoming them. While early approaches were about long term treatment, perhaps over several years, today’s options also include short term approaches.[4]
Exposure therapies
The common aspect of such therapies is that they help clients face what scares them, but also their avoidance of the same. The idea is that facing the problem head-on will eventually make the client feel less scared or anxious. It must, however, be diligently applied to avoid re-traumatizing the victim. Elements of exposure are included in many therapies.
Cognitive behaviour therapies
These therapies focus on the present and the future. The thinking is that thoughts are behaviour, and behaviour can be changed. Typically, the client will be helped to recognize the problems, and work to replace negative thoughts with positive ones. As the client’s thoughts change, so do feelings and action.
Eye Movement desensitization and reprocessing (EMDR)
A key part of this approach is to ask the client to focus on the trauma while the therapist initiates lateral eye movement or makes the client observe some visual stimulus. The client’s dual focus (the traumatic experience and the visual observation) aims at rendering a sense of control and reducing the pain of thinking of the trauma.[5]
Brainspotting
Here the client is asked to revisit the worst part of his trauma. A relaxing CD, (for example with ocean waves), is turned on. The therapist swipes a wand or pointer in front of the client who watches its movements. A client who reacts with a twitch, blink, pupil dilation, coughing, frowning and more, may indicate a brainspot, meaning a connection to the parts of the brain that are affected by the trauma. The therapist stops the movement and holds the wand, and the client stares at it till his distress subsides.[6]
Observed experiential integration
This method is a ‘relative’ of Brainspotting. One of the client’s eyes is covered at the time while she focuses on the trauma and observes how her stress level changes while shifting from one eye to the other. The treatment may imply going back and forth between the two eyes till the stress clears, of finding brainspots as described above.
Somatic therapies
The focus here is the body. There are a range of such therapies, based on the view that the trauma creates an imbalance in the body that affects movements and emotions. Typically, the therapist helps the client to focus on body movement and sensation while revisiting the traumatic experience. The aim is to release the trauma and create a new balance between the body and the brain.
Hypnotherapy
Hypnosis can be used in a variety of ways. It may subdue painful memories or revive them for confrontation and processing. It may also help the victim create images, events or triggers, all tools aimed at strengthening his ability to cope.
Energy Psychology
This is a combination of western psychotherapy and eastern energy meridian and acupuncture techniques. Commonly, the client revisits the trauma while acupuncture is applied. The aim is to send signals to the brain that reduce the stress and ‘re-calibrate’ the brain. Finger tapping, acupressure or herbs sometimes replace acupuncture, and the treatment may combine psychological support with martial arts, qigong and meditation.
Re-enactment protocol
This is about changing the traumatic story. The client is asked to imagine himself with super human power and describe in present tense how he handles the event or the abusers. If a body part has been hurt, say your arm was injured by the kidnappers, this arm may be used to knock them down in your re-enactment story.
David Grove’s trauma therapy
This method aims at helping the client go through the story without getting stuck at the most painful points. As the client narrates, the therapist rephrases the story in present tense. ‘He beats you up. What happens next, after he beats you up?’ This way the therapist helps the client reach the end of the story where he is safe and the ordeal is over.
Neurofeedback
This term represents methods of training to calm down, using technical equipment and programmes. The client may watch a computer game while wearing sensors that measure certain brainwaves. Observing how his brainwaves compare to a graphically presented optimum level, the client may use commands that influence his brainwaves in a positive way.[7]
Medications
A range of medicines may be used in trauma treatment to calm and relieve symptoms. Medication cannot cure, but some victims use it as a substitute to therapy. Some of the medicines that effectively allay symptoms, are also addictive. Others are effective but less addictive. When you consult a doctor, discuss effects and side effects, including the risk of addiction. For how long should you be taking medicines? Remember, medication is not a lasting solution to your problems. Whatever your condition, please do not fall for the temptation of self-medication.
The therapist
If you are lucky, you will be helped to link up with a good therapist. If not, do your best to find one with a good track record. In some countries this can be difficult, as trauma therapy is uncommon. Your general practitioner may be able to help. The police or the local Red
Cross/Red Crescent may also offer suggestions, or you might get tips from others who have undergone trauma therapy. There are websites where you can find lists of therapists in different countries. The Site of the International Society for the Study of Trauma and Dissociation, http://www.isst-d.org, allows you to search in a number of countries, but there may not necessarily be anyone in your area. To the extent therapists are available, you will find useful advice on selection in an article on the Sidran Institute’s website.[8]
So let us say you have found a therapist with a good reputation and meet her for the first time. What should you expect?
The therapist’s choice of methods will depend on the nature and depth of your trauma as well as her professional background and preference. In many cases this means a combination of therapies.
It may be very difficult for a layperson to opine on the selection of therapy. What you can do, however, is to ask the therapist to explain the approach or approaches she recommends. Showing her the above list might facilitate the discussion. You should feel OK with her choice and be consciously willing to give it a chance. Everyone is not comfortable with martial arts training, hypnotherapy or head on exposure to traumatic memories. The first condition for successful trauma therapy is, however, that your therapist is dedicated and genuinely caring. The two of you will have to cooperate closely, and you have to open up and talk about some of your most vulnerable spots. If this is to work, you must feel supported and cared for. The therapist must connect with your pain and make you feel respected. If she meets these requirements, you may perhaps be open to her suggestions. If she does not, look elsewhere.
Taking care of yourself
What if you cannot find a trauma therapist, you cannot afford one, or for some reason you reject the advice of this article to seek professional help?
There are a number of self-help books on the market. You may wish to purchase such a book, but beware. Some of them are quite comprehensive and include a large number of exercises. Trauma victims taking on such books may need more focus and stamina than they can muster. That might leave them with a sense of failure and add to their misery.
There is, however, a range of relatively simple measures to alleviate trauma effects that are easy to understand and apply. While they may not heal you completely and cannot replace proper professional therapy, they can make a big positive difference.
But first, what can you do to take care of yourself in your daily life?
Respecting yourself
You need to take yourself and your condition seriously. Accept that you have been exposed to something very bad, and do not downplay what happened and the effects it had on you. Give yourself the time and space you need for your healing process. This also means you should allow yourself to grieve feelings of loss or harm that you sustained. Some victims do not cry easily, but when it happens, allow it. It is likely to have a relieving effect.
Finding support
Can you link up with others with similar experiences? Sharing stories with someone who understands what you have been through, can be very useful. It may help you realize that you are not alone, and that your response to the trauma is a natural consequence of what you have been through. Even if you do not find anyone with similar experiences, putting words to your feelings is part of your cleansing process and can help you gain perspective, particularly if you get empathetic feedback.
Is there a good listener in your circle of family and friends, a person who is caring, supportive and non-judgemental?
If you need practical help to fix something in your daily life, don’t be shy to ask good friends or supportive family members. This is the time to draw on good relationships.
Relating to the future
General advice from trauma therapists is that you should be careful with big changes and avoid making large impulsive decisions. Meaning, you do not decide to sell your house, quit your job and shift to another town without some considerable thought. You should, however, make plans for the future. Discuss things you would like to do and make concrete plans together with close friends or family. This will contribute to a more positive perspective. And while you avoid major changes, be open to trying new things. Are there new leisure activities or hobbies you might like to look into? Should you attempt a mountain trek next summer instead of camping by the sea? Should you try squash or join a chess club? Some trauma victims find surprising pleasure in new activities.
Tending to physical health
Commit to not letting your body down. Your physical health is of course important, but staying healthy also gives you a sense of control. So please keep a healthy diet, mind your hygiene, get enough sleep and go for regular medical and dental check-ups.
People suffering from depression may find it difficult to keep a routine of physical exercise, but it can help a lot. Apart from removing muscle tensions and stress hormones, routine exercises may give you a sense of mastering, and, subject to how you exercise, a feel-good sensation from the release of endorphins. So do your best to establish a routine. Pick a time of day when little else happens and stick to it religiously. Maybe a family member can commit to ’egging you on’ to the gym if you tend to get slack?
Can you make a commitment to stay clear of drug and alcohol abuse?
Please note that by taking good care of yourself, you are countering the effects of what you have been through. ‘Self-care is in many ways the opposite of what evoked the trauma’ (Rosenbloom et al., 2010) While the kidnapper mistreated you, you are treating yourself right. That is one way of taking your life back.
Stress reduction techniques
Millions of people know and apply teh techniques we are about to present here for reducing stress. They may also help to build your mental strength, focus and confidence. Discussing research on such mental techniques is beyond the scope of this presentation, but several techniques have proved to have positive effects. Much of the training available focuses on spiritual aspects.If you are not spiritually inclined, you may disregard such aspects and go for mental and emotional benefits. While there is a wide range of approaches, we are going to look at some simple ones, borrowed from my book Surviving Kidnappers (2017).[9]
Breathing exercises
While other techniques discussed here are long term measures, breathing exercises stand out in that they are meant to have immediate relaxing effects. Here is one simple approach:
Sit comfortably but upright with your eyes closed and focus on your breath. Breathe calmly and deeply through your nose. Empty your lungs with each exhale, and feel how the air moves. After repeating this for a while, your attention will drift to something else. Gently bring your focus back to your breath and continue. The sense of drifting attention is normal. The practice of bringing the attention back to the breathing may strengthen your control and focus. To begin with, you might not be able to do this for more than 8-10 minutes, but you might never need more than 15-20 minutes, twice a day.
Meditation
While the Burmese political prisoner Aung San Suu Kyi spent nearly 14 years under house arrest, her daily meditation routine was an essential coping tool.[10] Meditation is both aimed at achieving a state of relaxation and a feeling of balance and may, over time, render improved focus and control.
Mantra meditation
This is a bit similar to the breathing exercise, but you focus on a mantra (word) instead of your breath. A mantra could be any simple word like ‘calm’ or ‘peace’ or whatever appeals to you. A mantra much used in meditation of Indian origin is ’Om’, meaning ‘nothingness’ in Sanskrit. In old Vedic philosophy ‘Om’ was considered the primordial sound of the universe.
The exercise: Find yourself as comfortable a position as possible, sitting upright or lying down. Close your eyes and breathe calmly. Start gently, repeating your mantra in your mind. Your thoughts will drift as they normally do. That is not a problem, but leave your thoughts as soon as they emerge, return to the mantra and gently let it ‘repeat itself’. With time you may feel that your body is at ease. You might also experience so-called blank spots, meaning you discover that for a brief moment you had no thoughts in your mind.
Do this exercise as long as you are comfortable with it, gradually increasing the duration. But 20 minutes is generally considered ample. Beware that it may take time and persistence to get something out of it.
Visual focus
A similar technique is to use your vision instead of a mantra: you may for instance focus on a candlelight or a bonfire. Your inner vision may also do the trick. You may close your eyes and imagine a light, using this as a focal point. Again your thoughts are likely to drift, but keep returning to the image of the light.
Beauty and colours
You may also use particular colours or something of visual beauty as the subject of you focus. There is probably something beautiful in your environment, and if not, you are always free to use your inner eye.
Yoga
In the West Yoga is largely considered a set of physical exercises, aimed at positive relaxation, health and fitness benefits, whereas the Indian roots of Yoga also include spiritual aspects. There are a wide range of Yoga schools, and while a presentation of them exceeds the scope of this article, we should observe that Yoga commonly features in trauma healing therapies. Any traumatized person who masters a yoga technique, has an advantage. Videos demonstrating various techniques are found on the web.
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While you are likely to benefit from breathing exercises, not everyone gets something meaningful out of meditation or Yoga. But if you try such exercises for a few weeks, you may see if it works for you. Aung San Suu Kyi found it difficult to begin with, and might have given up, had it not been for the inspiration of a famous Buddhist teacher.[11]
Even if you don’t experience much relaxation to begin with, you may feel a sense of control, which is essential for mental balance. If you decide to give it a try, establish a routine where you do such exercises at the same time every day.
But remember, only the breathing techniques are supposed to give immediate effect. All the others demand patience. You may also try using a technique aimed at influencing one’s own qualities, see my book, Surviving Kidnappers (to be published in 2016/early 2017) and Markham (2000) Let us, for instance, say that your self-confidence is a major problem after the trauma. Such a technique is a tool to regain it.
Trauma survivors’ suggestions
Even if you follow the above advice on daily life habits, a heavy trauma implies moments of serious distress. You therefore need some ‘first aid tools’ when depression, sorrow or other negative feelings hit you.
What soothes our nerves and helps us calm down is individual to each of us, but some activities have proved to work for a lot of people. Much of the below is borrowed from a collection of trauma survivors’ suggestions presented by Rosenbloom et al. ( 2010:)
Please note that some of the daily routines listed above, such as talking to a good listener, doing some physical exercise or making notes in a journal, can also be used as ‘first aid’ when depression strikes you.
It may take you a while to find out what ‘first aid tools’ work best for you. But when you do, some good advice is to make a list of your ‘first aid tools’, and hang it up where you can easily find it. Based on this list you may plan what to do next time you feel depressed or scared.
Affirmations
An affirmation is a positive statement you make about yourself or others. Such statements, may have a soothing effect and help you counter negative feelings and frustrations. You may use them as first aid when a low mood hits you, but also as daily reminders of important healing aspects.
For affirmations to work well, they should be positively phrased, like ‘I am safe here’ or ‘I have good people around me’. They should also be realistic and something you can believe in. If you state ‘No criminal can ever reach me’ that is not true and not likely to give you the sense of safety you need.
Affirmations can be about relationships of importance to you. They may also be useful observations about your situation, your qualities, and they may express commitment. These are a few of examples you might opt to use[12]:
Whatever statements you adopt, make sure you have them available when you need them. You might wish to create one or more boards with your most important affirmations that you keep easily visible. You may wish to read them out loud or use them for internal self-coaching. Give yourself some time to figure out how such affirmations work for you.
Handling sleeping problems
A common effect of trauma is having problems falling asleep and staying asleep. Both your physical and mental wellbeing and functioning depend on proper sleep. Therapists offer different advice, but the following ones are common:
Vermilyea (2013:98) suggests that sleep planning should start in the morning. You should assess how much sleep you need and what is a good time to get it. Let us say you believe you need eight hours and that 23.00 to 07.00 is the time it would suit you to sleep. If so, try to make sure you are tired at this point of time.
Dyregrov (2004, 2014), who offers a range of sleep improvement techniques, suggests that:
“it is a good idea to set aside some time early in the evening (or earlier) to go through the thoughts that usually enter one’s mind at bedtime. You can also write down the intrusive thought(s) and then ‘talk to’ or instruct your brain when you go to bed, for example by saying the following: ‘Now the parts of my brain that are controlling sleep and rest must make sure that I can fall asleep quickly and have a good night’s sleep. I have given room for the disturbing thoughts earlier today. Now it is time to sleep’.”
If you decide to study the issues of sleep and sleep depravation more throroughly, you might like to try Robert Rosenberg’s book (2014) Sleep soundly every night, feel fantastic every day.
Gathering knowledge about your condition
This is a key element in your long term efforts to heal yourself, but also a contribution to your mental balance here and now. Your increased understanding of yourself is useful. So is the knowledge that you are doing something constructive for yourself. Therefore, take note of your feelings and reactions in different situations, and build up your own little knowledge-base. You may find it useful to use a journal or notebook. While putting words to your thoughts may have a relieving effect there and then, you should also go through your notes once in a while, spending some time pondering what you have noted. Increased knowledge and understanding of yourself can make your trials easier to bear, give you a sense of control and help you plan your future better.
Snapping out of flashbacks
As indicated above, flashbacks can be very nasty. What do you do when a bad one hits you, throwing you back into the dungeon where you were held? Before you can use any of the above tools, you have to get out of the flashback.
So how do you do that?
First of all, breathe deeply and calmly. Are you able to feel your breath? Make sure your feet are on the ground, look around you and observe your environment. If you are in a familiar place, you may fix your eyes on a pleasant spot, such as a painting or a picture you like. You may touch your hands or your body and say to yourself ‘I am here now. I am out of it. It is over. ‘
Another possible remedy is a touchstone - an item that can help bring you back to the present. Let us say you get an amulet or a ring, an item that is new in your life and cannot be associated with your bad memories. When the flashback happens, you fish it out, touch it, observe it, and use it to realize that ‘this is here and now and not back then’.
Roosenbloom et al., (2013) also suggest counting to yourself. If so, you may use a watch, your pulse or objects in your environment.
When the flashback lets go, you may feel like crying. As mentioned earlier, do not hold back when that happens. It normally has a cleansing effect. Crying is also taking your loss seriously and thereby showing respect for yourself. It means you are worth crying for.
Self-therapy
Arguably some of the above exercises and tools may also be called self-therapy, but the idea here is to present some simple and structured cognitive efforts, where you apply your analytical capacity. While a comprehensive discussion of self-therapy is beyond the scope of this article, the following approaches are applicable on a range of trauma effects.
Dissociation versus facing the trauma
Dissociation may be defined as mental and emotional escape. The possibility of such an escape is important, and some of the techniques described above are about escaping nasty memories. However, if you always try to the escape trauma effects, they will not go away. And constant escape will prevent you from developing your strength and an open and trusting relationship with others.
With time, you therefore need to start standing up to the trauma and allow uncomfortable feelings and frustrations. But how do you do that?
Assessing feelings and beliefs
As observed above, traumatic experiences leave traces in our brain that influence how we think and feel about the world and ourselves. Let us take safety as an example. Before the trauma you may have felt quite safe most of the time. Afterwards you may feel that you are never safe. In general, none of us is safe all the time. Neither are we unsafe all the time. The truth is somewhere in between, but how safe are you in different situations?
A simple approach is to do a factual assessment, addressing the situations that bother you one by one. Let us say you feel unsafe every time you leave your home alone. Imagine a scale where Very Safe is 10 and Extremely Unsafe is 1. Let us say that you rate your feeling of safety in this situation at 2, meaning very unsafe.
Next, list the facts you can think of as follows:
For example:
2. Facts that suggest you are safe:
For example:
Once you have listed all relevant facts you can think of, do your best to assess the real level of safety.[13] Take some time and weigh the evidence before you conclude. You might also wish to consult someone you trust. Decide on a final rating. Maybe the evidence suggests a real safety level at 7 or 8, meaning quite safe? Whatever your initial belief or feeling was, accept your final rating as the truth.
This technique can be used to assess a wide range of situations where you are affected by trauma. The situation you assess may be quite general, for example if you feel people no longer respect you, or it may be more specific, as when you feel you can no longer trust a certain friend. The technique is easier to apply on specific situations, where the evidence is more limited.
In any case, summing up, this is the technique:
1. Identify the problem.
2. Rate your feelings on a scale of 1 to 10.
3. List the facts you find.
4. Assess the facts.
5. Figure out a final rating.
This way you may get a better understanding of situations and aspects that bother you. But what if they still evoke troubled feelings and memories, regardless of your new understanding?
The power of repetition
If we repeatedly experience something, it will influence our beliefs and feelings. How can you use repetitions to your advantage?
Let us say that you initially rated the feeling of being safe alone outside your home at 2 , while your evidence-based rating is 8 which implies very little risk. How do you help you brain to accept this?
Every time you go out alone without experiencing problems, your brain learns a lesson, observing that nothing happened. You may feel stressed by doing it, but still you are making a little progress. You may need a lot of repetitions and time to achieve significant progress, but as you keep repeating this experience, you slowly contribute to your healing.
The first time you decide to go out alone, some precautions might be needed. Pick a time and an area generally considered to be safe. You may reduce the feeling of risk by bringing a trusted person, a tough dog or limiting your walk to a few minutes. You might also have someone waiting for you in a car or even drive behind you to ensure an easy retreat.
You may feel stressed, but let us say you are able to do it without major problems. If so, you have given your brain a little lesson, and you should reinforce the lesson by reflecting on what you felt versus the real risk. Next time, go for a slightly longer walk. Again you may be stressed, but for each repetition and small expansion you will be taking another tiny step towards not only a conscious belief but also a feeling that you are OK in such situations. This way you are slowly changing some of the ‘earthquake patterns’ in your brain.
Please also note that every time you make an effort like this, you are taking control. As mentioned before, the feeling of loss of control is a common trauma effect, and regaining it is essential for your healing. Remember, however, the trauma traces can be hard to erase, and you may need a lot of patience.
Start using this technique in situations that are not overly scary. You do not want it to be more difficult than it has to. Also, be careful about challenging your most frightening feelings.
The idea is to strengthen yourself, not to revive the trauma. Let us say that you find the thought of being in a densely crowded street extremely scary. If so, do not force yourself to try it before you are ready. In any case, if your effort gets too stressful, pull out of it, go to a safe place, use your self-care exercises and put the effort on hold.
Another thing we must obviously remember is that some fears are justified, and that there are risks we should avoid. Your fear of walking home alone in dark alleys after a late night in town may be exaggerated, but that does not mean it is safe to do it.
With small cautious steps, you may start challenging your trauma-related concerns, and slowly change how your brain handles them.
Please consider every completed exercise as a victory. Enjoy it, take note of your progress and move forward at a pace you are comfortable with
Family and friends
Let us assume you have a loving family or at least a partner or close friend that cares for you, and wishes to help you to take your life back. This is a blessing, but beware, the interaction may be difficult. Your loved ones may appreciate that you have been through a tough time, but have little clue what it has done to you. If you have changed, say you have become irritable, aggressive or less caring, this may be hard to relate to. You must therefore make sure your loved ones understand what your trauma is about. Let them read this article or other literature on the topic. There is also useful information available on the net.
An understanding spouse should explain to the children why dad or mom is behaving differently, and that he/she still loves them.
Note that your family members may also be traumatized. Waiting and hoping for the release of a loved one can be hell on earth. The family or a partner should also have a debriefing and an assessment of possible trauma effects. In any case, persons close to the victim have been through a tough time and need to take care of themselves, not only the victim.
If you are seeing a trauma therapist, arrange for your spouse, partner, children or close friend to get a session too. Even if they do not need therapy themselves, there are things they should know. Let the therapist explain what you are going through and what kind of support you need. And in case you don’t have that possibility, these are some essential do’s and don’ts for family members/caring persons.
Rules for family and close friends
While you can ask your family members to read this article, it may be trickier to reach out to those beyond your closest circle. How do you as a victim gain the understanding you need from your friends? You do not wish to explain your condition time and again. One possible approach could be to ask your partner or a close friend who has read this article to make a round of phone calls or meet the friends that matter most and give them a little briefing.
Still, both curiosity and compassion may spur people to ask questions of what happened and how you felt. While compassion is nice, you may not like the questions, and curiosity is likely to irritate you. So you may have to steel yourself. A possible response to such questions may be a friendly but disarming ‘Let us talk about something nicer’ or ‘I’ll tell you about it when I am ready for it, OK?’.
Resuming work
Returning to work can be a challenge. If your trauma is severe, you may need a lengthy healing process before you can return. Make sure you give yourself enough time. It is better to wait a month or two extra than to resume work and find that you cannot do it. Subject to the nature of your work and the attitude of your employer, you might fear losing your job. Therefore, stay in touch with your boss and make it clear that you do wish to resume work.
So when is the right time to return? You should feel stable and confident that it is going to work. Meaning, you should be past the period where flashbacks, anger and sorrow are likely to mess up your day. Occasional flashbacks may not be total disasters, but you should know that you can handle them and move on with your work. You should also be confident that you have the energy needed to handle your job. If you are seeing a therapist, discuss resuming work with him. If you don’t have one, a spouse or partner who observes how you function in your daily life may be a good adviser. In any case, be open with your boss. Visit her, sit down and explain your situation. Be honest and tell her how you think you are going to perform. Mention possible needs and challenges, including how you are likely to relate to your colleagues. Based on your discussion, you should agree with your employer when it is OK to start. Part time work is perhaps a good beginning if it works for your employer. The advantage of doing this process with your boss, is that you share the responsibility. Meaning, if things should go wrong it is less of a disaster.
What about your colleagues? They may know precious little about trauma and how it affects people. We are all better at relating to other people’s problems if we understand them. If you are working with a team, you might suggest a little gathering where you give them a few basics of how trauma works. Explain that such experiences tend to leave nasty traces in the brain, and that these influence both mind and behaviour. Let them understand that you are in the process of fighting these effects and getting back to your old self. Ask them kindly to bear with you if they find you snappy, aggressive or sad and withdrawn. They should understand that there is no ill will from your side, and that you are going to need more time and space for yourself than you did before.
Is there anyone among your colleagues you are particularly close to? A caring listener that you can turn to for support when you feel bad, might make your job situation much easier.
An arrangement you might discuss with your boss, is to select a colleague as your representative. If you have a fit or withdraw to your office feeling bad, an assigned supporter who knows your problems and does the explaining needed, could make things easier.
A silver lining?
While the traces a trauma leaves in our brain may require a long hard fight, there may be a silver lining. Your ordeal may bring benefits you never imagined possible. Some trauma victims have stated that they would never have missed the trauma, given the positive changes that happened as they recovered. Most of the following list of such positive changes is borrowed from Rosenbloom et al.:
Do not be surprised if you find that your priorities in life change after trauma. Many victims have, for instance, found that deep and close relationships become more important than having a large social circle.
End notes
[1]Rosenbloom et al., 2010
[2]Op den Velde et al., 1996
[3] A therapist might use such techniques as a supplement to other treatment.
[4]Shapiro (2011:74), who applies the term psychodynamic therapies, presents an example that he terms
effective and ‘georgous work’.
[5]Dyregrov (2013: 29) terms this method ‘ very efficient and rapid and ‘ of less discomfort to those undertaking it than other methods’
[6] This technique is a supplement to clinical treatment/support.
[7]Referring to Peniston & Kulkosky (1991 and 1992), Shapiro (2011:129) observes that early studies have shown that
neurofeedback has helped treat PSTD in veterans.
[8] https://www.sidran.org/resources/for-survivors-and-loved-ones/how-to-choose-a-therapist-for-post-traumatic-stress-and-dissociative-conditions/
[9] Those interested in further studies will find courses on offer as well as a rich literature and guidance on the net.
[10] http://www.budsas.org/ebud/ebmed001.htm
[11] Ibid
[12] For a deeper discussion of the topic, see Rosenbloom et al .(2010)
[13] Rosenbloom et al. (2010) presents a model for systematic assessment termed evidence based analysis, addressing a range of problematic beliefs and thoughts.
References
Dyregrov, A . 2004, 2014Self-Help Methods,
http://krisepsy.netflexcloud.no/media/SELF-HELP%20METHODS%20July%2014.pdf
Op den Welde, W.,Dutch Hovens, J.E., Arts, P.G.H., Frey-Wauters, E., Folger, P.R.J., Van Duijin,H. & De Groen,J.H.H., (1996) Prevalence and Course of Post-Traumatic Stress Disorder in Dutch Veterans of the Civilian Resistance during World War II. Psychological Reports, (78).
Rosenberg, R.S.(2014): Sleep soundly every night, feel fantastic every day, New York, Demos Medical Publishing
Rosenbloom, D. and Williams, M.B. with Watkins, B.E. (2010) Life after Trauma. A Workbook for Healing.Second Edition, London: The Guilford Press
Shapiro, R. (2010) The Trauma Treatment Handbook. Protocols across the Spectrum, New York: Norton & Company Inc.
Vermileya, E.G (2000, 2013) Growing beyond Survival. A self-help toolkit for managing Traumatic Stress, Brooklandville:The Sidran Institute
Abstract
This article is written for survivors of kidnapping and people supporting them, but anyone suffering from the effects of such trauma will benefit from reading it.The article explains how trauma affects our emotions and behaviour, and what can be done to lessen such effects. Various kinds of trauma therapy are briefly presented, indicating a menu of treatments therapists may draw upon.
Anyone traumatized and suffering from post–traumatic stress disorder (PSTD) is urged to accept professional help. However, many do not have access to such support. These victims will benefit from the advice offered here to assist with resuming daily life, returning to work and relating to family, friends and colleagues. Guidance is given on how to deal with flashbacks, sleeping problems and numerous other issues that typically result from trauma. In addition to self-care and relaxation techniques, the article also offers a simple model of self-therapy. This model may, if consistently applied, be a useful tool in the quest for recovery.
Challenges
Most books written by kidnap victims end with joy and optimism. At long last the victim is going to live a normal life again. The reality that awaits him or her is however rarely touched upon in such books, and many survivors are severely traumatized. Without adequate care and support, such consequences may last for a very long time.
But what is trauma really about?
There are different definitions, but a traumatic experience generally involves the fear of death or serious emotional or physical injury. Such experiences are common for kidnapping victims. But exactly what happens when a trauma occurs?
How the brain works
Our experiences in life determine how our brain works. They build neuron connections that become pathways, and these pathways pre-programme our behaviours. This applies to such basic functions as our intake of food, rest and activity, how we relate to danger, connecting with other people, dealing with pain, fear and more.
A traumatic experience may be termed an ‘earthquake’ in the brain, creating pathways that deviate from the brain’s normal patterns. These new pathways work beyond our control. They may interrupt normal thoughts and force intrusive and frustrating thoughts and feelings upon us, disturbing our present life badly.
Flashbacks
Let us assume you have got through your kidnapping ordeal.
Time may have passed, and you may feel OK, but all of a sudden you are mentally torn out of your safe, comfortable situation and are back in the damp, dark basement where you were held. The pain and frustration are upon you in full force.
The ‘bad’ pathways in your brain have somehow got activated, and you have no control over what happens. Such experiences are common after kidnapping. Out of the blue you re-live beatings, torture, death threats, despair, helplessness or any other ordeal the kidnapping forced upon you. This can be extremely vivid. Flashbacks may happen at any time of the day, but are often particularly bothersome at night, effectively preventing you from sleeping. Nightmares that force victims to relive their ordeals time and again are also very common.
There may be a wide range of triggers releasing flashbacks. You might spot people dressed similar to the kidnappers, or find yourself in a street that reminds you of the abduction site. Perhaps you hear someone speaking with an accent similar to that of the kidnappers, or you sense a smell that reminds you of your prison or the food you used to get whilst captured. A certain conversation subject, a touch on your shoulder could be enough. So could media coverage, a hospital visit, a funeral, or the feeling of being confined, such as in a crowd or an elevator. A heated discussion, even with someone you love, could be enough to cause it. Even a certain kind of weather, a date or a particular time of day could spur a flashback. In general, there are few limitations as to what might be triggers.
Sometimes flashbacks hit after a long time, as a nasty surprise to victims who have come to believe that they escaped unharmed.
Flashbacks can be virtual nightmares in their own right, and you may have a hard time snapping out of them. To avoid flashbacks, you may find yourself avoiding anything that might trigger them. Meaning you stay away from crowded streets, avoid strangers or stay at home as much as possible. Obviously, such avoidance may impose serious limitations on your life.
Other effects
Even without explicit flashbacks, traumas manifest themselves in harmful ways. Basic needs typically affected by trauma, are safety, trust, control, intimacy and self-esteem[1].
This may imply a range of negative thoughts and emotions. The lack of control in captivity may have shattered your self-confidence. You may feel that you can no longer trust other people, you do not feel respected as you did before, you feel that you are generally unsafe and that you are unable to connect with and feel close to others. Feelings of sadness, grief and depression are common, and your overall ability to feel joy may be affected. So may your focus, your ability to concentrate as well as your memory. Some victims are bothered by a feeling of emptiness, others by an out of body sensation.
You may find yourself hyper vigilant and irritable, but also vulnerable and helpless. Decision making may be difficult, and many victims are bothered by a sensation of guilt, feeling the kidnapping or the mistreatment was their fault, or blaming themselves for the death of fellow captives. Some avoid discussing their problems with others because of their sense of shame.
You may become withdrawn, easily startled, restless or more confrontational and aggressive. You may change eating habits, sexual habits and lose or put on weight. You might also experience physical problems such as headaches, dizziness, lack of energy, stomach trouble, frequent urination, rashes and other psychosomatic ailments.
No wonder that many victims feel they are going crazy and some turn to drug or alcohol abuse.
As indicated above, the effects of PTSD may be long term. Research on resistance fighters who spent time in prison during World War II discovered that about one third had stress problems even 45 years after the war.[2]
The good news
It is important to know that you are not crazy. What you are experiencing is your mind’s normal reaction to abnormal experiences.
What’s more, it is possible to heal. Some trauma issues may never leave you completely and some of your feelings and views may have changed forever. But constructive healing is likely to make your life worth living again. So yes, you can take your life back.
Debriefing
Debriefing is the first assistance you may receive. This may be provided by the police, the army or a humanitarian organisation, hiring psychologists or psychiatrists with knowledge of first aid trauma treatment. Sometimes it is handled by volunteers or staff trained in the subject.
Security personnel may prioritize interrogating you with a view to catching the kidnappers. While this is important, the debriefing matters to your health. There should be a session separate from the interrogation that gives you the chance to talk through what you experienced and how you felt about it.
Some victims, perhaps euphoric after escaping, reject debriefing, insisting they are fine. What if you don’t feel traumatized? People do react differently to kidnapping ordeals, and you may be among the lucky ones. But please do not reject support right away. The elation and optimism you feel immediately after your release may be deceptive. A good long talk with a caring person may reveal issues that need processing. While you stand to lose if you ignore possible trauma, you have nothing to lose by accepting a debriefing. Opening up can be an important part of a healing process, and if you are traumatized, this could be a beginning.
To the extent you are able to, you should go through your experience from beginning to end. Narrate your trials, and put words to both the physical and mental ordeals. Observe how you react whilst you do this. While it is generally useful to talk, do not push yourself too hard. If you find something too painful to narrate, or if emotions overwhelm you, take a break. You might skip the painful topic and continue with something else. But please note that strong emotional reactions could suggest that you need therapy.
Trauma therapy
While debriefing is a relatively simple form of first aid, trauma therapy requires expertise. Subject to the support at hand, you may be offered an appointment with a trauma therapist and, subject to her assessment, therapy may be suggested.
Again, the advice here is: accept the appointment. Take at least one round. The worst that can happen is that you agree with her that you are fine and need no follow up. Some victims prefer to pick another therapist than the one offered to them, but please note that if you do need therapy, it is important to get it as early as possible. Otherwise the problematic pathways in your brain will get time to settle and strengthen.
So let us say that you have been traumatized, and that the trauma is severe enough to require treatment. Meaning, your life is disturbed by effects that will not go away by themselves. What is trauma therapy about?
The ultimate goal is to achieve a state where the bothersome pathways in your brain are no longer effective, so nasty intrusions from the past no longer cause the problems described above.
Over the years, a wide range of different therapies have emerged, and a first time trauma therapy patient may find some of them surprising.
Robin Shapiro’s Trauma Treatment Handbook (2010) offers a presentation from which the list below and parts of the explanations are borrowed. Please note that many therapists will apply combinations of these methods:
Mindfulness exercises
Breathing exercises, meditation and yoga are tools you may have used while in captivity. They can also be used under the guidance of a therapist or as self-treatment. So can meditative martial arts, such as Qigong. The purpose is to obtain a sense of calm, balance and control and to strengthen the brain’s ability to focus.[3] For a brief presentation of mindfulness exercises, see Stress Reduction Techniques below.
Psychotherapies
These therapies aim at helping the client understand harmful effects of the past, including kidnapping trauma, and offering guidance and support in overcoming them. While early approaches were about long term treatment, perhaps over several years, today’s options also include short term approaches.[4]
Exposure therapies
The common aspect of such therapies is that they help clients face what scares them, but also their avoidance of the same. The idea is that facing the problem head-on will eventually make the client feel less scared or anxious. It must, however, be diligently applied to avoid re-traumatizing the victim. Elements of exposure are included in many therapies.
Cognitive behaviour therapies
These therapies focus on the present and the future. The thinking is that thoughts are behaviour, and behaviour can be changed. Typically, the client will be helped to recognize the problems, and work to replace negative thoughts with positive ones. As the client’s thoughts change, so do feelings and action.
Eye Movement desensitization and reprocessing (EMDR)
A key part of this approach is to ask the client to focus on the trauma while the therapist initiates lateral eye movement or makes the client observe some visual stimulus. The client’s dual focus (the traumatic experience and the visual observation) aims at rendering a sense of control and reducing the pain of thinking of the trauma.[5]
Brainspotting
Here the client is asked to revisit the worst part of his trauma. A relaxing CD, (for example with ocean waves), is turned on. The therapist swipes a wand or pointer in front of the client who watches its movements. A client who reacts with a twitch, blink, pupil dilation, coughing, frowning and more, may indicate a brainspot, meaning a connection to the parts of the brain that are affected by the trauma. The therapist stops the movement and holds the wand, and the client stares at it till his distress subsides.[6]
Observed experiential integration
This method is a ‘relative’ of Brainspotting. One of the client’s eyes is covered at the time while she focuses on the trauma and observes how her stress level changes while shifting from one eye to the other. The treatment may imply going back and forth between the two eyes till the stress clears, of finding brainspots as described above.
Somatic therapies
The focus here is the body. There are a range of such therapies, based on the view that the trauma creates an imbalance in the body that affects movements and emotions. Typically, the therapist helps the client to focus on body movement and sensation while revisiting the traumatic experience. The aim is to release the trauma and create a new balance between the body and the brain.
Hypnotherapy
Hypnosis can be used in a variety of ways. It may subdue painful memories or revive them for confrontation and processing. It may also help the victim create images, events or triggers, all tools aimed at strengthening his ability to cope.
Energy Psychology
This is a combination of western psychotherapy and eastern energy meridian and acupuncture techniques. Commonly, the client revisits the trauma while acupuncture is applied. The aim is to send signals to the brain that reduce the stress and ‘re-calibrate’ the brain. Finger tapping, acupressure or herbs sometimes replace acupuncture, and the treatment may combine psychological support with martial arts, qigong and meditation.
Re-enactment protocol
This is about changing the traumatic story. The client is asked to imagine himself with super human power and describe in present tense how he handles the event or the abusers. If a body part has been hurt, say your arm was injured by the kidnappers, this arm may be used to knock them down in your re-enactment story.
David Grove’s trauma therapy
This method aims at helping the client go through the story without getting stuck at the most painful points. As the client narrates, the therapist rephrases the story in present tense. ‘He beats you up. What happens next, after he beats you up?’ This way the therapist helps the client reach the end of the story where he is safe and the ordeal is over.
Neurofeedback
This term represents methods of training to calm down, using technical equipment and programmes. The client may watch a computer game while wearing sensors that measure certain brainwaves. Observing how his brainwaves compare to a graphically presented optimum level, the client may use commands that influence his brainwaves in a positive way.[7]
Medications
A range of medicines may be used in trauma treatment to calm and relieve symptoms. Medication cannot cure, but some victims use it as a substitute to therapy. Some of the medicines that effectively allay symptoms, are also addictive. Others are effective but less addictive. When you consult a doctor, discuss effects and side effects, including the risk of addiction. For how long should you be taking medicines? Remember, medication is not a lasting solution to your problems. Whatever your condition, please do not fall for the temptation of self-medication.
The therapist
If you are lucky, you will be helped to link up with a good therapist. If not, do your best to find one with a good track record. In some countries this can be difficult, as trauma therapy is uncommon. Your general practitioner may be able to help. The police or the local Red
Cross/Red Crescent may also offer suggestions, or you might get tips from others who have undergone trauma therapy. There are websites where you can find lists of therapists in different countries. The Site of the International Society for the Study of Trauma and Dissociation, http://www.isst-d.org, allows you to search in a number of countries, but there may not necessarily be anyone in your area. To the extent therapists are available, you will find useful advice on selection in an article on the Sidran Institute’s website.[8]
So let us say you have found a therapist with a good reputation and meet her for the first time. What should you expect?
The therapist’s choice of methods will depend on the nature and depth of your trauma as well as her professional background and preference. In many cases this means a combination of therapies.
It may be very difficult for a layperson to opine on the selection of therapy. What you can do, however, is to ask the therapist to explain the approach or approaches she recommends. Showing her the above list might facilitate the discussion. You should feel OK with her choice and be consciously willing to give it a chance. Everyone is not comfortable with martial arts training, hypnotherapy or head on exposure to traumatic memories. The first condition for successful trauma therapy is, however, that your therapist is dedicated and genuinely caring. The two of you will have to cooperate closely, and you have to open up and talk about some of your most vulnerable spots. If this is to work, you must feel supported and cared for. The therapist must connect with your pain and make you feel respected. If she meets these requirements, you may perhaps be open to her suggestions. If she does not, look elsewhere.
Taking care of yourself
What if you cannot find a trauma therapist, you cannot afford one, or for some reason you reject the advice of this article to seek professional help?
There are a number of self-help books on the market. You may wish to purchase such a book, but beware. Some of them are quite comprehensive and include a large number of exercises. Trauma victims taking on such books may need more focus and stamina than they can muster. That might leave them with a sense of failure and add to their misery.
There is, however, a range of relatively simple measures to alleviate trauma effects that are easy to understand and apply. While they may not heal you completely and cannot replace proper professional therapy, they can make a big positive difference.
But first, what can you do to take care of yourself in your daily life?
Respecting yourself
You need to take yourself and your condition seriously. Accept that you have been exposed to something very bad, and do not downplay what happened and the effects it had on you. Give yourself the time and space you need for your healing process. This also means you should allow yourself to grieve feelings of loss or harm that you sustained. Some victims do not cry easily, but when it happens, allow it. It is likely to have a relieving effect.
Finding support
Can you link up with others with similar experiences? Sharing stories with someone who understands what you have been through, can be very useful. It may help you realize that you are not alone, and that your response to the trauma is a natural consequence of what you have been through. Even if you do not find anyone with similar experiences, putting words to your feelings is part of your cleansing process and can help you gain perspective, particularly if you get empathetic feedback.
Is there a good listener in your circle of family and friends, a person who is caring, supportive and non-judgemental?
If you need practical help to fix something in your daily life, don’t be shy to ask good friends or supportive family members. This is the time to draw on good relationships.
Relating to the future
General advice from trauma therapists is that you should be careful with big changes and avoid making large impulsive decisions. Meaning, you do not decide to sell your house, quit your job and shift to another town without some considerable thought. You should, however, make plans for the future. Discuss things you would like to do and make concrete plans together with close friends or family. This will contribute to a more positive perspective. And while you avoid major changes, be open to trying new things. Are there new leisure activities or hobbies you might like to look into? Should you attempt a mountain trek next summer instead of camping by the sea? Should you try squash or join a chess club? Some trauma victims find surprising pleasure in new activities.
Tending to physical health
Commit to not letting your body down. Your physical health is of course important, but staying healthy also gives you a sense of control. So please keep a healthy diet, mind your hygiene, get enough sleep and go for regular medical and dental check-ups.
People suffering from depression may find it difficult to keep a routine of physical exercise, but it can help a lot. Apart from removing muscle tensions and stress hormones, routine exercises may give you a sense of mastering, and, subject to how you exercise, a feel-good sensation from the release of endorphins. So do your best to establish a routine. Pick a time of day when little else happens and stick to it religiously. Maybe a family member can commit to ’egging you on’ to the gym if you tend to get slack?
Can you make a commitment to stay clear of drug and alcohol abuse?
Please note that by taking good care of yourself, you are countering the effects of what you have been through. ‘Self-care is in many ways the opposite of what evoked the trauma’ (Rosenbloom et al., 2010) While the kidnapper mistreated you, you are treating yourself right. That is one way of taking your life back.
Stress reduction techniques
Millions of people know and apply teh techniques we are about to present here for reducing stress. They may also help to build your mental strength, focus and confidence. Discussing research on such mental techniques is beyond the scope of this presentation, but several techniques have proved to have positive effects. Much of the training available focuses on spiritual aspects.If you are not spiritually inclined, you may disregard such aspects and go for mental and emotional benefits. While there is a wide range of approaches, we are going to look at some simple ones, borrowed from my book Surviving Kidnappers (2017).[9]
Breathing exercises
While other techniques discussed here are long term measures, breathing exercises stand out in that they are meant to have immediate relaxing effects. Here is one simple approach:
Sit comfortably but upright with your eyes closed and focus on your breath. Breathe calmly and deeply through your nose. Empty your lungs with each exhale, and feel how the air moves. After repeating this for a while, your attention will drift to something else. Gently bring your focus back to your breath and continue. The sense of drifting attention is normal. The practice of bringing the attention back to the breathing may strengthen your control and focus. To begin with, you might not be able to do this for more than 8-10 minutes, but you might never need more than 15-20 minutes, twice a day.
Meditation
While the Burmese political prisoner Aung San Suu Kyi spent nearly 14 years under house arrest, her daily meditation routine was an essential coping tool.[10] Meditation is both aimed at achieving a state of relaxation and a feeling of balance and may, over time, render improved focus and control.
Mantra meditation
This is a bit similar to the breathing exercise, but you focus on a mantra (word) instead of your breath. A mantra could be any simple word like ‘calm’ or ‘peace’ or whatever appeals to you. A mantra much used in meditation of Indian origin is ’Om’, meaning ‘nothingness’ in Sanskrit. In old Vedic philosophy ‘Om’ was considered the primordial sound of the universe.
The exercise: Find yourself as comfortable a position as possible, sitting upright or lying down. Close your eyes and breathe calmly. Start gently, repeating your mantra in your mind. Your thoughts will drift as they normally do. That is not a problem, but leave your thoughts as soon as they emerge, return to the mantra and gently let it ‘repeat itself’. With time you may feel that your body is at ease. You might also experience so-called blank spots, meaning you discover that for a brief moment you had no thoughts in your mind.
Do this exercise as long as you are comfortable with it, gradually increasing the duration. But 20 minutes is generally considered ample. Beware that it may take time and persistence to get something out of it.
Visual focus
A similar technique is to use your vision instead of a mantra: you may for instance focus on a candlelight or a bonfire. Your inner vision may also do the trick. You may close your eyes and imagine a light, using this as a focal point. Again your thoughts are likely to drift, but keep returning to the image of the light.
Beauty and colours
You may also use particular colours or something of visual beauty as the subject of you focus. There is probably something beautiful in your environment, and if not, you are always free to use your inner eye.
Yoga
In the West Yoga is largely considered a set of physical exercises, aimed at positive relaxation, health and fitness benefits, whereas the Indian roots of Yoga also include spiritual aspects. There are a wide range of Yoga schools, and while a presentation of them exceeds the scope of this article, we should observe that Yoga commonly features in trauma healing therapies. Any traumatized person who masters a yoga technique, has an advantage. Videos demonstrating various techniques are found on the web.
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While you are likely to benefit from breathing exercises, not everyone gets something meaningful out of meditation or Yoga. But if you try such exercises for a few weeks, you may see if it works for you. Aung San Suu Kyi found it difficult to begin with, and might have given up, had it not been for the inspiration of a famous Buddhist teacher.[11]
Even if you don’t experience much relaxation to begin with, you may feel a sense of control, which is essential for mental balance. If you decide to give it a try, establish a routine where you do such exercises at the same time every day.
But remember, only the breathing techniques are supposed to give immediate effect. All the others demand patience. You may also try using a technique aimed at influencing one’s own qualities, see my book, Surviving Kidnappers (to be published in 2016/early 2017) and Markham (2000) Let us, for instance, say that your self-confidence is a major problem after the trauma. Such a technique is a tool to regain it.
Trauma survivors’ suggestions
Even if you follow the above advice on daily life habits, a heavy trauma implies moments of serious distress. You therefore need some ‘first aid tools’ when depression, sorrow or other negative feelings hit you.
What soothes our nerves and helps us calm down is individual to each of us, but some activities have proved to work for a lot of people. Much of the below is borrowed from a collection of trauma survivors’ suggestions presented by Rosenbloom et al. ( 2010:)
- Perform a monotonous, routine activity, for example, play solitaire on your computer or do a puzzle.
- Read something pleasant or interesting.
- Spend time with a pet
- Watch a movie
- Listen to music
- Spend time in nature
- Visualize the stress: put it into an imaginary or real object outside yourself such as a locked box or container.
- Hold an object that soothes you, for example a stuffed animal
- Go for a walk
- Do gardening
- Visualize a safe place and go there in your mind or create a real one that you can visit
- Take a warm bath or shower
- Avoid multi-tasking when you are stressed.
- Break up your activities into manageable pieces.
Please note that some of the daily routines listed above, such as talking to a good listener, doing some physical exercise or making notes in a journal, can also be used as ‘first aid’ when depression strikes you.
It may take you a while to find out what ‘first aid tools’ work best for you. But when you do, some good advice is to make a list of your ‘first aid tools’, and hang it up where you can easily find it. Based on this list you may plan what to do next time you feel depressed or scared.
Affirmations
An affirmation is a positive statement you make about yourself or others. Such statements, may have a soothing effect and help you counter negative feelings and frustrations. You may use them as first aid when a low mood hits you, but also as daily reminders of important healing aspects.
For affirmations to work well, they should be positively phrased, like ‘I am safe here’ or ‘I have good people around me’. They should also be realistic and something you can believe in. If you state ‘No criminal can ever reach me’ that is not true and not likely to give you the sense of safety you need.
Affirmations can be about relationships of importance to you. They may also be useful observations about your situation, your qualities, and they may express commitment. These are a few of examples you might opt to use[12]:
- It is over.
- I am safe here.
- My partner loves me.
- My spouse will support me all the way.
- My parents are there for me.
- I am worth loving.
- My colleagues support me.
- I am important to my children
- I have good friends who care for me.
- I have a strong will.
- It will get better as I keep working on it.
- I shall win in the long run.
- I have the intelligence needed to handle this.
- I shall do what is needed to heal myself.
- I shall take good care of myself.
- I shall handle whatever happens.
Whatever statements you adopt, make sure you have them available when you need them. You might wish to create one or more boards with your most important affirmations that you keep easily visible. You may wish to read them out loud or use them for internal self-coaching. Give yourself some time to figure out how such affirmations work for you.
Handling sleeping problems
A common effect of trauma is having problems falling asleep and staying asleep. Both your physical and mental wellbeing and functioning depend on proper sleep. Therapists offer different advice, but the following ones are common:
- Keep a healthy diet with regular meals
- Get some physical exercise during the day.
- Avoid napping during the day.
- Go to bed at the same time every night.
- Make sure your bedroom is comfortable and soothing.
- A hot bath helps the body relax.
- Avoid late night negative stimulation such as dramatic books or violent films.
- Avoid late intake of caffeine or sugary drinks. A bedtime beverage of hot milk may be good.
- Avoid alcohol and self-medication.
- Avoid late heavy meals (A light snack is OK).
- Avoid late night phone calls, emails or social media interaction.
- Listen to soft music.
- Keep a bedside light on if it soothes you.
Vermilyea (2013:98) suggests that sleep planning should start in the morning. You should assess how much sleep you need and what is a good time to get it. Let us say you believe you need eight hours and that 23.00 to 07.00 is the time it would suit you to sleep. If so, try to make sure you are tired at this point of time.
Dyregrov (2004, 2014), who offers a range of sleep improvement techniques, suggests that:
“it is a good idea to set aside some time early in the evening (or earlier) to go through the thoughts that usually enter one’s mind at bedtime. You can also write down the intrusive thought(s) and then ‘talk to’ or instruct your brain when you go to bed, for example by saying the following: ‘Now the parts of my brain that are controlling sleep and rest must make sure that I can fall asleep quickly and have a good night’s sleep. I have given room for the disturbing thoughts earlier today. Now it is time to sleep’.”
If you decide to study the issues of sleep and sleep depravation more throroughly, you might like to try Robert Rosenberg’s book (2014) Sleep soundly every night, feel fantastic every day.
Gathering knowledge about your condition
This is a key element in your long term efforts to heal yourself, but also a contribution to your mental balance here and now. Your increased understanding of yourself is useful. So is the knowledge that you are doing something constructive for yourself. Therefore, take note of your feelings and reactions in different situations, and build up your own little knowledge-base. You may find it useful to use a journal or notebook. While putting words to your thoughts may have a relieving effect there and then, you should also go through your notes once in a while, spending some time pondering what you have noted. Increased knowledge and understanding of yourself can make your trials easier to bear, give you a sense of control and help you plan your future better.
Snapping out of flashbacks
As indicated above, flashbacks can be very nasty. What do you do when a bad one hits you, throwing you back into the dungeon where you were held? Before you can use any of the above tools, you have to get out of the flashback.
So how do you do that?
First of all, breathe deeply and calmly. Are you able to feel your breath? Make sure your feet are on the ground, look around you and observe your environment. If you are in a familiar place, you may fix your eyes on a pleasant spot, such as a painting or a picture you like. You may touch your hands or your body and say to yourself ‘I am here now. I am out of it. It is over. ‘
Another possible remedy is a touchstone - an item that can help bring you back to the present. Let us say you get an amulet or a ring, an item that is new in your life and cannot be associated with your bad memories. When the flashback happens, you fish it out, touch it, observe it, and use it to realize that ‘this is here and now and not back then’.
Roosenbloom et al., (2013) also suggest counting to yourself. If so, you may use a watch, your pulse or objects in your environment.
When the flashback lets go, you may feel like crying. As mentioned earlier, do not hold back when that happens. It normally has a cleansing effect. Crying is also taking your loss seriously and thereby showing respect for yourself. It means you are worth crying for.
Self-therapy
Arguably some of the above exercises and tools may also be called self-therapy, but the idea here is to present some simple and structured cognitive efforts, where you apply your analytical capacity. While a comprehensive discussion of self-therapy is beyond the scope of this article, the following approaches are applicable on a range of trauma effects.
Dissociation versus facing the trauma
Dissociation may be defined as mental and emotional escape. The possibility of such an escape is important, and some of the techniques described above are about escaping nasty memories. However, if you always try to the escape trauma effects, they will not go away. And constant escape will prevent you from developing your strength and an open and trusting relationship with others.
With time, you therefore need to start standing up to the trauma and allow uncomfortable feelings and frustrations. But how do you do that?
Assessing feelings and beliefs
As observed above, traumatic experiences leave traces in our brain that influence how we think and feel about the world and ourselves. Let us take safety as an example. Before the trauma you may have felt quite safe most of the time. Afterwards you may feel that you are never safe. In general, none of us is safe all the time. Neither are we unsafe all the time. The truth is somewhere in between, but how safe are you in different situations?
A simple approach is to do a factual assessment, addressing the situations that bother you one by one. Let us say you feel unsafe every time you leave your home alone. Imagine a scale where Very Safe is 10 and Extremely Unsafe is 1. Let us say that you rate your feeling of safety in this situation at 2, meaning very unsafe.
Next, list the facts you can think of as follows:
- Facts that suggest you are unsafe:
For example:
- Assaults can never be excluded anywhere
- I am not good at defending myself
2. Facts that suggest you are safe:
For example:
- There have been no assaults in my neighbourhood for many years.
- The streets in my neighbourhood are well lit.
- There is always a good amount of people out on the streets.
Once you have listed all relevant facts you can think of, do your best to assess the real level of safety.[13] Take some time and weigh the evidence before you conclude. You might also wish to consult someone you trust. Decide on a final rating. Maybe the evidence suggests a real safety level at 7 or 8, meaning quite safe? Whatever your initial belief or feeling was, accept your final rating as the truth.
This technique can be used to assess a wide range of situations where you are affected by trauma. The situation you assess may be quite general, for example if you feel people no longer respect you, or it may be more specific, as when you feel you can no longer trust a certain friend. The technique is easier to apply on specific situations, where the evidence is more limited.
In any case, summing up, this is the technique:
1. Identify the problem.
2. Rate your feelings on a scale of 1 to 10.
3. List the facts you find.
4. Assess the facts.
5. Figure out a final rating.
This way you may get a better understanding of situations and aspects that bother you. But what if they still evoke troubled feelings and memories, regardless of your new understanding?
The power of repetition
If we repeatedly experience something, it will influence our beliefs and feelings. How can you use repetitions to your advantage?
Let us say that you initially rated the feeling of being safe alone outside your home at 2 , while your evidence-based rating is 8 which implies very little risk. How do you help you brain to accept this?
Every time you go out alone without experiencing problems, your brain learns a lesson, observing that nothing happened. You may feel stressed by doing it, but still you are making a little progress. You may need a lot of repetitions and time to achieve significant progress, but as you keep repeating this experience, you slowly contribute to your healing.
The first time you decide to go out alone, some precautions might be needed. Pick a time and an area generally considered to be safe. You may reduce the feeling of risk by bringing a trusted person, a tough dog or limiting your walk to a few minutes. You might also have someone waiting for you in a car or even drive behind you to ensure an easy retreat.
You may feel stressed, but let us say you are able to do it without major problems. If so, you have given your brain a little lesson, and you should reinforce the lesson by reflecting on what you felt versus the real risk. Next time, go for a slightly longer walk. Again you may be stressed, but for each repetition and small expansion you will be taking another tiny step towards not only a conscious belief but also a feeling that you are OK in such situations. This way you are slowly changing some of the ‘earthquake patterns’ in your brain.
Please also note that every time you make an effort like this, you are taking control. As mentioned before, the feeling of loss of control is a common trauma effect, and regaining it is essential for your healing. Remember, however, the trauma traces can be hard to erase, and you may need a lot of patience.
Start using this technique in situations that are not overly scary. You do not want it to be more difficult than it has to. Also, be careful about challenging your most frightening feelings.
The idea is to strengthen yourself, not to revive the trauma. Let us say that you find the thought of being in a densely crowded street extremely scary. If so, do not force yourself to try it before you are ready. In any case, if your effort gets too stressful, pull out of it, go to a safe place, use your self-care exercises and put the effort on hold.
Another thing we must obviously remember is that some fears are justified, and that there are risks we should avoid. Your fear of walking home alone in dark alleys after a late night in town may be exaggerated, but that does not mean it is safe to do it.
With small cautious steps, you may start challenging your trauma-related concerns, and slowly change how your brain handles them.
Please consider every completed exercise as a victory. Enjoy it, take note of your progress and move forward at a pace you are comfortable with
Family and friends
Let us assume you have a loving family or at least a partner or close friend that cares for you, and wishes to help you to take your life back. This is a blessing, but beware, the interaction may be difficult. Your loved ones may appreciate that you have been through a tough time, but have little clue what it has done to you. If you have changed, say you have become irritable, aggressive or less caring, this may be hard to relate to. You must therefore make sure your loved ones understand what your trauma is about. Let them read this article or other literature on the topic. There is also useful information available on the net.
An understanding spouse should explain to the children why dad or mom is behaving differently, and that he/she still loves them.
Note that your family members may also be traumatized. Waiting and hoping for the release of a loved one can be hell on earth. The family or a partner should also have a debriefing and an assessment of possible trauma effects. In any case, persons close to the victim have been through a tough time and need to take care of themselves, not only the victim.
If you are seeing a trauma therapist, arrange for your spouse, partner, children or close friend to get a session too. Even if they do not need therapy themselves, there are things they should know. Let the therapist explain what you are going through and what kind of support you need. And in case you don’t have that possibility, these are some essential do’s and don’ts for family members/caring persons.
Rules for family and close friends
- Learn as much as possible about the trauma and its effects. Read, listen to the victim, and talk to trusted resource persons.
- Do not give easy, unfounded advice or answers to the victim. She needs to feel that she is taken seriously. Nor should you switch the conversation to your own problems and feelings. Find another time to discuss these.
- Make sure the trauma victim has space and time for himself. Support him if he wants a special place in the house or elsewhere, where he feels comfortable and can be alone. You may encourage social interaction but there should be no pressure whatsoever.
- Whatever trauma related problem the victim has, respect it. Some agonies may seem small to you, but if they are big to the victim, take that as a fact. Do not ever stop the victim from talking about her problems, and make sure you don’t belittle or reject any of her experiences or the consequences.
- Sometimes survivors feel bad because other victims cope better, and may need your support to accept it.
- Talk about the future. Victims may feel that they have no future, so make plans together.
- While it feels natural to encourage, do not tell the victim that the outcome could have been worse or that everything will be all right. From her viewpoint, it probably does not seem like that, and recovery can indeed be a long and demanding process.
- Never blame relationship issues on the victim’s trauma.This can be a tricky one. Disagreements are a part of life, and domestic arguments may be both irrational and emotional. Try to remember though, that blaming relationship problems on the victim’s condition is bound to add to her depression. Victims are also generally vulnerable to ultimatums, threats and demands that could be related to their condition.
- You will probably find the victim difficult to relate to at times, but try to be as patient as you can. Trauma healing takes time.
- Discuss the flashback issue with the victim and agree on what support is appropriate. This may be to tell her that ‘It is over’, or that ‘You are here with me now. You are safe here’. It may also be to remind the victim to breathe deeply and calmly, to look at the environment, to count, to fish out his touchstone or whatever works best. Maybe the victim wants to be touched or held, but not necessarily. Sometimes this adds to the flashback, even spurring violent response. So ask before doing it.
- Never tell the victim to ‘snap out of it’ or ‘get over it’. If it was easy, he would have done it.
- A victim’s fears can be hard to understand for outsiders, as can his need to confront them in small, gradual steps. Your understanding and support for his efforts are essential.
While you can ask your family members to read this article, it may be trickier to reach out to those beyond your closest circle. How do you as a victim gain the understanding you need from your friends? You do not wish to explain your condition time and again. One possible approach could be to ask your partner or a close friend who has read this article to make a round of phone calls or meet the friends that matter most and give them a little briefing.
Still, both curiosity and compassion may spur people to ask questions of what happened and how you felt. While compassion is nice, you may not like the questions, and curiosity is likely to irritate you. So you may have to steel yourself. A possible response to such questions may be a friendly but disarming ‘Let us talk about something nicer’ or ‘I’ll tell you about it when I am ready for it, OK?’.
Resuming work
Returning to work can be a challenge. If your trauma is severe, you may need a lengthy healing process before you can return. Make sure you give yourself enough time. It is better to wait a month or two extra than to resume work and find that you cannot do it. Subject to the nature of your work and the attitude of your employer, you might fear losing your job. Therefore, stay in touch with your boss and make it clear that you do wish to resume work.
So when is the right time to return? You should feel stable and confident that it is going to work. Meaning, you should be past the period where flashbacks, anger and sorrow are likely to mess up your day. Occasional flashbacks may not be total disasters, but you should know that you can handle them and move on with your work. You should also be confident that you have the energy needed to handle your job. If you are seeing a therapist, discuss resuming work with him. If you don’t have one, a spouse or partner who observes how you function in your daily life may be a good adviser. In any case, be open with your boss. Visit her, sit down and explain your situation. Be honest and tell her how you think you are going to perform. Mention possible needs and challenges, including how you are likely to relate to your colleagues. Based on your discussion, you should agree with your employer when it is OK to start. Part time work is perhaps a good beginning if it works for your employer. The advantage of doing this process with your boss, is that you share the responsibility. Meaning, if things should go wrong it is less of a disaster.
What about your colleagues? They may know precious little about trauma and how it affects people. We are all better at relating to other people’s problems if we understand them. If you are working with a team, you might suggest a little gathering where you give them a few basics of how trauma works. Explain that such experiences tend to leave nasty traces in the brain, and that these influence both mind and behaviour. Let them understand that you are in the process of fighting these effects and getting back to your old self. Ask them kindly to bear with you if they find you snappy, aggressive or sad and withdrawn. They should understand that there is no ill will from your side, and that you are going to need more time and space for yourself than you did before.
Is there anyone among your colleagues you are particularly close to? A caring listener that you can turn to for support when you feel bad, might make your job situation much easier.
An arrangement you might discuss with your boss, is to select a colleague as your representative. If you have a fit or withdraw to your office feeling bad, an assigned supporter who knows your problems and does the explaining needed, could make things easier.
A silver lining?
While the traces a trauma leaves in our brain may require a long hard fight, there may be a silver lining. Your ordeal may bring benefits you never imagined possible. Some trauma victims have stated that they would never have missed the trauma, given the positive changes that happened as they recovered. Most of the following list of such positive changes is borrowed from Rosenbloom et al.:
- New awareness of your inner strength
- Different set of priorities.
- Heightened appreciation for daily life
- Increased empathy and compassion for other people
- Sense of awe at nature and the cycles of life
- Respect for others who have survived trauma
- Deepened emotional life
- Deepened spiritual life
- A philosophy that helps you come to terms with the unexpected
- Acceptance of what was once too frightening to contemplate
- Improved understanding of life’s complexities
- Confidence that you can survive anything
Do not be surprised if you find that your priorities in life change after trauma. Many victims have, for instance, found that deep and close relationships become more important than having a large social circle.
End notes
[1]Rosenbloom et al., 2010
[2]Op den Velde et al., 1996
[3] A therapist might use such techniques as a supplement to other treatment.
[4]Shapiro (2011:74), who applies the term psychodynamic therapies, presents an example that he terms
effective and ‘georgous work’.
[5]Dyregrov (2013: 29) terms this method ‘ very efficient and rapid and ‘ of less discomfort to those undertaking it than other methods’
[6] This technique is a supplement to clinical treatment/support.
[7]Referring to Peniston & Kulkosky (1991 and 1992), Shapiro (2011:129) observes that early studies have shown that
neurofeedback has helped treat PSTD in veterans.
[8] https://www.sidran.org/resources/for-survivors-and-loved-ones/how-to-choose-a-therapist-for-post-traumatic-stress-and-dissociative-conditions/
[9] Those interested in further studies will find courses on offer as well as a rich literature and guidance on the net.
[10] http://www.budsas.org/ebud/ebmed001.htm
[11] Ibid
[12] For a deeper discussion of the topic, see Rosenbloom et al .(2010)
[13] Rosenbloom et al. (2010) presents a model for systematic assessment termed evidence based analysis, addressing a range of problematic beliefs and thoughts.
References
Dyregrov, A . 2004, 2014Self-Help Methods,
http://krisepsy.netflexcloud.no/media/SELF-HELP%20METHODS%20July%2014.pdf
Op den Welde, W.,Dutch Hovens, J.E., Arts, P.G.H., Frey-Wauters, E., Folger, P.R.J., Van Duijin,H. & De Groen,J.H.H., (1996) Prevalence and Course of Post-Traumatic Stress Disorder in Dutch Veterans of the Civilian Resistance during World War II. Psychological Reports, (78).
Rosenberg, R.S.(2014): Sleep soundly every night, feel fantastic every day, New York, Demos Medical Publishing
Rosenbloom, D. and Williams, M.B. with Watkins, B.E. (2010) Life after Trauma. A Workbook for Healing.Second Edition, London: The Guilford Press
Shapiro, R. (2010) The Trauma Treatment Handbook. Protocols across the Spectrum, New York: Norton & Company Inc.
Vermileya, E.G (2000, 2013) Growing beyond Survival. A self-help toolkit for managing Traumatic Stress, Brooklandville:The Sidran Institute
