By Nathilee Caldeira
Dr. Nathilee Caldeira is a Licensed Clinical Psychologist in New York. She has research, teaching and clinical expertise in treating depression, anxiety, posttraumatic stress, alcohol and substance use disorders. For more than 15 years she has worked on research teams and treated survivors of interpersonal violence, including survivors of rape, domestic violence, childhood sexual, physical and emotional abuse. She has also treated survivors of the 9/11 disaster and soldiers returning from combat in Iraq and Afghanistan. She is the founder and director of clinical services at Let’s Talk Psychological Wellness, P.C.
Most persons are exposed to at least one traumatic event over their lifetime. Many of those who experience a traumatic event may experience some stress reactions or symptoms very soon after a traumatic event, but for many these reactions and symptoms resolve in a relatively short period of time and these persons go on to have a long-term and full recovery from the trauma.
However, approximately 6 to 10 percent of those who experience traumatic events are unable to recover quickly and instead develop more serious symptoms that last longer than one month and when taken together develop an illness called posttraumatic stress disorder or PTSD. Prevalence rates of PTSD in Guyana are currently unknown. Studies from the wider Caribbean that focus on Trinidad, Barbados and Jamaica while citing high rates of traumatic events also note prevalence rates for PTSD as unknown.
Those who survive multiple traumatic events, occur early in life and are interpersonal, such as rape, domestic violence or childhood sexual and physical abuse, will experience a recovery that is slower and are at greater risk for developing PTSD. We know that the estimated prevalence rate of interpersonal violence (domestic violence, rape, childhood physical and sexual abuse) is particularly high in Guyana. People who experience car accidents, chronic medical illness and disasters such as floods can also develop symptoms of PTSD.
To meet criteria for PTSD, a person must have been exposed to one or more traumatic event, the traumatic event must have been directly experienced or witnessed and must involve actual or threatened death, serious injury or sexual violence. Learning of violence that occurred to a close family member, or repeated and extreme exposure to aversive details, for example, first responders collecting human remains, may also place a person at risk for developing PTSD.
Persons who are exposed to a traumatic event and develop symptoms in the following categories, last more than one month, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning will meet criteria for PTSD.
Intrusion symptoms: One or more of the following
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event (s).
2. Recurrent, distressing dreams of the event.
3. Reactions such as flashbacks (feeling as though the event is happening again).
4. Intense or prolonged psychological distress to cues that resemble an aspect of the trauma.
5. Marked physiological reactions to cues that resemble an aspect of the trauma.
Avoidance symptoms: One or both of the following:
1. Efforts to avoid distressing memories, thoughts or feelings about the traumatic event (s).
2. Efforts to avoid external reminders such as people, places, conversations activities or situations that are reminders of the trauma.
Negative alterations in thinking and mood symptoms: Two or more of the following:
1. Inability to remember an important aspect of the trauma.
2. Persistent and exaggerated negative beliefs about oneself, others, or the world (e.g., “I’m bad”, “No one can be trusted”, “I am damaged”, “the world is completely dangerous”).
3. Distorted thinking about the cause or consequences of the traumatic event (s) that lead the individual to blame herself/himself or others.
4. Persistent negative emotional state such as fear, horror, anger, guilt or shame.
5. Markedly diminished interest or participation in significant activities.
6. Feeling detached from others.
7. Persistent inability to experience positive emotions such as happiness, satisfaction or loving feelings.
Arousal and reactivity symptoms: Two or more of the following:
1. Irritable behaviour and angry outbursts with little or no provocation.
2. Reckless or self-destructive behaviour.
3. Hypervigilance (always being on guard).
4. Exaggerated startle response.
5. Problems with concentration.
6. Difficulty falling asleep, staying asleep or restless sleep.
Collective research and clinical work has shown us that the development of PTSD, particularly after interpersonal violence significantly and negatively affects a person’s ability to navigate intimate relationships. “Traumatic events call into question basic human relationships. They breach the attachments of family, friendship, love and community.” A survivor’s ability to manage emotions, develop effective coping skills and have a healthy sense of self-worth is significantly compromised. This survivor as an adult when faced with a romantic rejection may experience this end of a relationship as much more catastrophic and overwhelming than it actually is and may see this as something with which they cannot cope.
Research has consistently shown that persons with a history of trauma who develop PTSD symptoms that go untreated tend to self-medicate their symptoms with alcohol and other substances and are at risk for developing an alcohol or substance use disorder. Persons who develop PTSD are also at increased risk for developing symptoms of depression. A person with untreated symptoms of depression may develop severe symptoms such as thoughts about suicide and suicide intent and plan.
This cycle may render persons more vulnerable to new traumatic events. For example, a person who has experienced sexual abuse as a child, has developed symptoms of PTSD, is now self-medicating with alcohol or another substance may lack the judgment and relationship negotiation skills and enter a physically abusive relationship. Because they have evaluated themselves as “bad” and “damaged”, lack financial independence and the skills to manage their emotions effectively, it becomes particularly difficult to leave this abusive relationship, thus continuing the cycle of violence. Most persons can benefit from intervention and treatment to break this cycle.
In Guyana, if we are to seriously tackle the high suicide rate we must also address trauma, PTSD, depression, alcohol and substance use. It will require more than raising awareness. We must follow advances in science. It will require education about mental health, illness and symptoms. It will require advocacy for those suffering and their families. In the short-term it will require integrating assessment and treatment into the primary care system by training all healthcare personnel and providing trained counsellors in schools. It will require long-term efforts such as establishing a psychology training programme to collaborate with the social work training programme at the university level. It will require establishing a system to register mental health professionals such as social workers, mental health counsellors, clinical psychologists and psychiatrists. It will require delivery of evidence-based treatment interventions in community clinics and hospitals.
If we are to effectively tackle suicide in Guyana, we must also examine external stressors and factors such as poverty and high unemployment among youth. We must examine broader challenges such as gender roles, gender inequalities and social norms. Above all, it will require sustained commitment of time and money by the government, non-governmental organizations, businesses and private citizens.
Trauma survivors are our family members, neighbours, co-workers and friends. Mental health cannot be separated from overall health. Let’s educate ourselves, advocate for others, open the shame door, talk about trauma and take action. Recovery is possible.