Features

Faces of Trauma

By Olivia Shabb, a licensed clinical psychologist and faculty member of the Department of Psychiatry at AUBMC. She has been treating patients affected by the explosion at the Beirut port.

Fall 2020/Winter 2021

How would you characterize the effect of the blast on your patients generally?

We can expect three phases. First is the acute phase after the blast. In this period, we saw a lot of acute stress disorder which is characterized by hyperarousal. This is when the nervous system is riled up, creating constant anxiety, difficulty sleeping, and the sense of being easily and powerfully startled. The explosion occurred at 6:08 pm on a Tuesday when families were reuniting at home. The sense of this cherished space being safe and trusted was shattered.

Once the patient has been stabilized, the second phase begins. This involves the experience of processing events and is followed by overwhelming grief. The shock has mostly passed, and now people must settle into a reality that’s so jarringly different from what they would have expected or chosen. The blast cut short or warped the arc of so many people’s lives. You have a lot of families who have totally renovated and rebuilt their homes, yet they can’t get themselves to step foot in them. Some of these families have emigrated.

The third phase is about reconnecting and making meaning. I don’t think we’re quite there yet. It’s really based on getting your bearings back and plugging into support systems. It involves reflection on how the event has altered or shed light on your values and reoriented your sense of purpose.

Can you give examples of sleep issues?

I had one patient who couldn’t sleep, not only because her nervous system couldn’t settle down, but because she couldn’t decide on which space in her room was safest to sleep in. She’d say, “I can’t sleep near a window; that could make me vulnerable. But if there’s an explosion, the glass will be blown far away, so maybe far, but not too far from the window is best.” She went through all these calculations to figure out where she would be most likely to survive.

People affected by the blast—even those within the same family—have presented a wide variety of PTSD symptoms. Could you elaborate on that?

In a family or with a couple, one person’s coping style might be very alienating to someone else. There was a couple whose home was totally destroyed. The woman became hyperaroused and extremely emotional, while the man fell into this hypercompetent state of emotional suppression we call hypoarousal. She experienced him as callous and emotionally unavailable, whereas he found her emotionality overwhelming and threatening in terms of what they needed to do to get back on their feet.

Can you say more about people’s experiences of home?

People were killed or injured by their own windows shattering. Everyday items they had trusted and found comfort in were weaponized against them. They had to make peace with a space that they felt had betrayed them, that killed their spouse or their child. One woman had to go back to her home and scrub her deceased husband’s blood prints off the bathroom wall. How do you make peace with a space after that? You try to get patients to think of spaces not as perpetrators but as victims of the same crime. In some ways, you anthropomorphize homes so you can give them the same compassion and forgiveness you might give to a person.

What might predict a person’s response to trauma?

The way people have been conditioned to regulate emotions affects how they respond to trauma. A lot of our emotional regulation is learned as we grow and develop. So if I grew up in a household where people weren’t interested in my inner life, then I’m predisposed to suppressing my feelings. That’s hypoarousal, meaning you’re not sufficiently attuned to your emotional system. But if I grew up in a household where people modeled unexamined reactivity, then I might be predisposed to hyperarousal.

What are some of the particularities of doing trauma work in the context of the blast?

Some people come in as parents who want to be functional, to model normalcy for their children. Their chief complaint is not, “I want to feel better,” but rather, “I need to be a competent mom again.” Immediate goals of treatment are therefore geared to people’s familial roles, because they are not presenting as an injured individual, but as the linchpin of an injured system.

In phase one and two, one of the most heartbreaking aspects of the work has been addressing people’s perseveration over the choices they made in the bloody disorientation that followed the blast. For example, one woman was with her children next to the window watching the smoke from the port when the blast happened. She was knocked down, and when she came to, her children were badly injured. She assumed her husband was fine since he had been away from the windows, so she grabbed her children and ran to get help. For hours afterwards, she was unable to entrust her children to anyone since the streets were filled with terrified, severely injured people trying to find their own bearings and the children themselves were too terrified to separate from her. Afterward, neighbors found her husband critically injured. He died soon after being taken to the hospital. This woman was living with excruciating, unrelenting guilt about having prioritized the children. 

Another woman dropped her kids off for a playdate. After the explosion she managed to reach the building, but seeing the destruction, she believed that her children had died. Instead of looking for them, she switched off and began shuttling the wounded to where they were more likely to access hospital care. Later she found that her children were alive under the rubble, and she couldn’t forgive herself for not searching for them. But at the time, she simply couldn’t face the idea of finding their bodies.

So we try to bring context and compassion to the choices that people made in the aftermath of the explosion, to make sense of the experience and fit it into a narrative that is morally and existentially calmer.

You’ve said that this is a collective trauma. Does that require a collective sort of therapy?

In this case, I am not the usual impartial witness to someone else’s trauma. I have my own internal processes to deal with, and sometimes what I’m feeling interacts with what I’m hearing and witnessing in a way that I have to be mindful of. It’s been an unfathomable period of human loss, and we’re all part of this injured and fraying tapestry. The collective trauma has created collective reactions: community-wide disbelief, community-wide anger, community-wide grief, a renewed cry for change on a systemic level, a communal plea to live in a country and society where there is fundamental care and public safety.

Indeed, people did engage in a collective sort of therapy by mass-volunteering to clean up streets and repair homes after the blast. It was heartwarming. People were longing for this collective experience of healing and connection and wanting to be a part of the reconstruction. Even now, there’s a collective energy in people and organizations seeking opportunities to support, to rebuild, to heal.