Monthly Archives: March 2012

Can Trauma Make Us Stronger?

Stephen Joseph, PhD, professor of psychology at University of Nottingham, UK. (Photo credit: Maria Tanner at Lace Market Photography)

Great – another f***ing growth opportunity,” reads the classic bumper sticker. “Classic” here means, “old”, especially given that ‘personal growth’ seems as outdated as Esalen, hot tubs and encounter sessions. In his new book, “What Doesn’t Kill Us”, Stephen Joseph, PhD pries the concept free from associations with self-indulgence by linking it to Grandpa’s good, old-fashioned ‘character building’ – finding strength through suffering.

In 1990, Joseph conducted three-year follow-up interviews with survivors of the Herald of Free Enterprise sinking. Those who lived through the tragedy reported all of the pain, guilt and sleeplessness researchers expected. Yet, surprisingly, 43% also made comments like, “I live everyday to the fullest now,” and “I am more determined to succeed in life now.” Joseph, professor of psychology at the University of Nottingham, UK, used these findings to develop his Changes in Outlook Questionaire (CiOQ), and found it repeatedly confirmed such signs of personal growth in hundreds of trauma survivors.   Like Viktor Frankl, Joseph “… saw two sides of suffering, noting that while there might be nothing inherently good in misfortune, it might be possible to extract something good out of misfortune.” He argues against Freud’s view that therapy’s role is to get clients back to common unhappiness. Rather, the therapist’s job should be to help people lift themselves above their pre-trauma level of functioning – to grow.

"... 'terror'... 'torment'... 'tragedy' .... here it is, 'trauma'."

Every trauma survivor seeks information. They’re filled with questions such as, “ What happened? Why can’t I put it behind me? Why did this have to happen at all?” Joseph presents PTSD as an information-processing problem. To be traumatized is to be blasted with unbearable knowledge at an intolerable volume.  So much, so fast, creates an overload that destroys neurons in the hippocampus and hampers one’s ability to process the memory. These ‘uncategorizable’ recollections drift about the mind in the form of flashbacks and nightmares, like so many piles of paperwork on a desk. To file such memories away properly, the survivor’s understanding of the world must grow. A new file folder with a new category, (one that makes sense of the memory), must be labeled.  Unanswerable “Why me?” questions aren’t resistance or self-pity – they are the start of the search for meaning. 

None of Joseph’s ideas fit on a bumper sticker, and all are ripe for misinterpretation. One can sense his desire for a rubber stamp reading, “OF COURSE”.  Of course trauma survivors suffer, he says. Of course no one would choose trauma for the benefits of post-traumatic growth. Of coursePositive Psychology” doesn’t mean clients censor their pain with smiley-face stickers. He makes it clear that growth is not a guaranteed result of trauma, and lack of growth is not evidence of poor character. First, Ryan and Deci’s basic needs (such as acceptance and belonging) must be met. A client must choose to engage in the growth process before that process can begin. When a person is traumatized enough to meet criteria for post-traumatic stress disorder, growth won’t happen until those symptoms ease in treatment. A more specific, less marketable title might have been, “What Doesn’t Kill Us or Give Us PTSD.”

The last issue is particularly relevant, given’s try at shoehorning the author’s ideas into an “over-diagnosis” narrative.  Joseph straddles the diagnosis debate. He observes that a PTSD diagnosis validates a client’s story. It’s undoubtedly a good thing  survivors have been moved from the file marked, “Malingering coward,” into the one labeled, “Someone with an understandable, treatable illness who is deserving of our compassion.” He’s troubled, though, that the same redefinition moves trauma from the, “I will survive this and grow stronger,” category  to the, “This is something the doctor needs to fix,” file.  In his view, our current understanding can file trauma survival under stiff-lipped perseverance or a treatable illness, but not the process of becoming someone new.

Friedrich Wilhelm Nietzsche (1844-1900). Personal-growth pioneer - not actually to blame for WWII.

Perhaps this critique of the medical model explains why the book is weakest when it addresses treatments for post-traumatic symptoms. It’s clear Joseph’s focus is to break up our thinking about trauma. He encourages therapists to speak in the disease model’s terms long enough to engage the client in the process of growth, but rushes past descriptions of how specific symptoms can be eased so growth can begin. With all of the book’s valuable advice for clients on coping with stress and finding professional help, one wishes the author spent more time on why, how, and how well different treatments work.

In “What Doesn’t Kill Us”, the author wire-walks his way between the fact-free fluff of self-help and the rigid, symptom-focused empiricism of insurance panels, to show how Nietzche‘s maxim can apply to leading a fulfilling life, not just survival in a vicious world. What doesn’t kill us provides the opportunity to nurture changes in our thoughts, behaviors and understanding of how life works. We can grow enough from adversity that the answer to, “Why did this have to happen?” becomes, “So I could be a stronger, more compassionate, more fully-alive person.”

(The New York Times has an excellent article about post-traumatic growth among members of the U.S. military here.)

@ 2012 Jonathan Miller All Rights Reserved

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Stress Management Blogging #2

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Which 12-step group for your client with sex addiction?

Joe Kort, PhD, sexologist and founder of the Center for Relationship and Sexual Health has an useful article up at the Huffington Post on sex addiction treatment. Among other things, he categorizes the different 12-step groups available. Per Dr. Kort:

Various 12-step groups’ meetings are open to sexual addicts, but it’s vital to recognize the fundamental differences between them. Sex Addicts Anonymous (SAA) is most liberal, welcoming everybody — men, women, gay, straight, bisexual, and others — and lets you define your own sexual boundaries. Meetings tend to focus on paraphilias, in which arousal and gratification depend on fantasizing about, and engaging in, atypical and extreme sexual behavior.

Sex and Love Addicts Anonymous (SLAA) focuses on love addicts. People “in love with love” seek, and later crave, that lightning-bolt, blown-away kick of “love at first sight.” Again, everybody is welcome. This program helps those who tend to move on as soon as troubles arise, hoping a new relationship can supply what the last one failed to deliver.

Sexaholics Anonymous (SA) takes the rigid, orthodox approach that no sexual relations should occur outside marriage. They tell participants that “any form of sex with one’s self or with partners other than the spouse is progressively addictive and destructive.” Many gay clients tell me they feel excluded for this reason.

Sexual Compulsives Anonymous (SCA) was born after some gay men felt uncomfortable with SA’s fundamentalist, heterosexist overtones. Members have designed their own recovery program, where gay men can discuss their special needs and talk openly and honestly.

People who’ve never hear of this problem can scoff, “Sex addict? Who isn’t?” The answer is, “Thousands of people. Folks whose sex life causes buckets of shame, a thimbleful of pleasure, and still can’t make themselves stop.”  With the guilt and embarassment that comes with sex addiction, it matters we refer clients to a 12-step group where they will feel they fit in.  More articles like this, please.

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“Normal people don’t do everything perfectly.”

From: Madness: A Bipolar Life by Marya Hornbacher:

“See, the thing is, you’ve got this idea of normal that’s not normal. Normal people don’t do everything perfectly. You don’t have to do everything perfectly to be normal. To be normal, you’ve got to kind of relax and let some things go. Your problem is that you’re so used to being in crisis that your whole perception of yourself is as a fuckup, a permanent fuckup, never someone who gets to not be a fuckup, so you have to torture yourself and hate yourself just to be as good as everyone else. You’re having a hard time realizing that you’re not a fuckup anymore. You’re entering into a whole different period of your life where you are normal. And you’re having a hard time getting used to it.”

                I gaze out the window. “But if you’re not trying to be perfect, then how do you know if you’re doing things right?”

                “There is no right,” she says. “There’s the best you can do. And that’s fine. That’s normal.”

                “The best I can do is sometimes completely fail,” I say.

                She shrugs. “Fine,” she says. “The rest of us do it all the time.”

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Back to Work or Not?

After just a few quick hours of procrastination, I start looking for materials for a new post. The first promising topic I find is a new intervention that helps short-term disability recipients get back to work. Coincidence? I’ll tell myself that it is.

Suzanne Lagerveld, Roland W. B. Blonk, et al, of Utrecht University dub their cognitive-behavioral therapy (CBT)-based intervention, “W-CBT”.  Besides treating mental health symptoms generally, it provides a module that focuses on work-related cognitions and returning to work in gradual steps. For their research just published in the Journal of Occupational Health Psychology, the authors enlisted employees on short-term disability for mild anxiety and depressive issues. They ruled out those with major depression, post-traumatic stress disorder or physical disabilities. One half of their sample received the new modality and regular CBT was provided to the rest. Per their findings, (PDF here, at least for now), W-CBT got clients back on the job significantly faster. After three months, 15% more W-CBT clients were back to work than clients from the standard CBT group. After six months, that gap increased to 18%. As the authors point out, mental-health absenteeism means lost productivity and profits.  The study’s faster return-to-work (RTW) rate provided a euros-and-cents benefit to Dutch employers, the Netherlands’ economy and society as a whole.

So why doesn’t it feel right?

What if he doesn't want to focus on returning to work ASAP?

Part of informed consent is the client’s freedom in choices about their therapy, including their choice of goals. The article doesn’t address who the client is in W-CBT. Is it the employer, who pays part of the insurance cost?  Or is the employee, who might not want to prioritize RTW? You could argue employees are morally obligated get back to work as fast as possible – if you were their clergyperson. Psychotherapists have a duty not to impose their views on clients, even such widely-held values as a work ethic.

The article states clients were not required to address RTW issues, but that the therapists were encouraged to say things such as, “You won’t recover from your symptoms just by sitting at home. It would probably even get worse.” Per this study, that isn’t necessarily true. According to Lagerveld and Blonk’s  findings, W-CBT and regular CBT had about the same effect on mental health symptoms. If it was once OK to imply symptoms grow worse if one doesn’t race back to the job site, it doesn’t appear ethical anymore.

The researchers are to be congratulated on producing a fascinating conundrum – W-CBT may be simultaneously effective, good, and, at least in some situations, ethically wrong.


Work-focused treatment of common mental disorders and return to work: A comparative outcome study. Lagerveld SE, Blonk RW, Brenninkmeijer V, Meij LW, Schaufeli WB. J Occup Health Psychol. 2012 Feb 6.

@ 2012 Jonathan Miller All Rights Reserved

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