Some 6 million Americans suffer from active PTSD at any given moment, and nearly half of us will be exposed to major trauma at some point in our lives. Dr. Shaili Jain, a Stanford University psychiatrist and PTSD specialist, explains why silence plays such a large role in the aftermath of trauma, why some people recover quickly and others don’t, and why men experience more trauma but women are more likely to develop PTSD.
Plus… mitigating trauma with the help of “man’s best friend.”
Phil Stieg: Hello I’ like to welcome Dr. Shaili Jain, professor of Psychiatry and Behavioral Sciences at Stanford University. She is a post-traumatic stress disorder specialist and Medical Director of Integrated Care at the Palo Alto, VA. Her recent book, The Unspeakable Mind – Stories of Trauma and Healing from the Frontlines of PTSD Science, highlights the overwhelming prevalence of trauma in our lives and the implications it has regarding PTSD. Let’s learn about the causes, effects, and hopeful cures for PTSD. Dr. Jain welcome.
Shaili Jain: Thanks so much for having me.
Phil Stieg: Let’s get everybody onto the same page. What are the symptoms that one has to manifest in order to get the diagnosis of PTSD?
Shaili Jain: So PTSD is a psychological condition that occurs after one is exposed to a major traumatic incident, typically life-threatening. And in the aftermath of that, the individual develops intrusive recollections of the trauma that typically manifest in really horrific nightmares, flashbacks, an exaggerated startle reaction. Those are some of the kind of in-your-face symptoms of PTSD. It’s normal. If either of us survived a major traumatic event, it is normal in those first few hours, days, weeks that we are going to have that reaction. What happens in PTSD is that reaction doesn’t go away with the passage of time. It stays weeks, months, years, decades in some cases.
So those are your in-your-face kind of symptoms. Lesser known, but equally devastating is the toll that it takes on someone’s emotional life. People with PTSD can live with mood states of irritability. They can be avoidant. They have this emotional numbing where they don’t feel the positive emotions of life. That really takes a toll on their ability to love, create, work. So that’s lesser known, but equally as devastating.
Phil Stieg: One can’t help noticing and reading your book. It’s book ended. It starts with the story about your father’s experience during the 1947 partition. And then the in-between part is about all of the other effects of world trauma and PTSD. Is this a real personal story as well as your idea about how to manage PTSD?
Shaili Jain: Yeah, I mean, I feel like the reason I do this work has always been rooted in a historical trauma that happened decades before I was born. I was born and raised in England, the daughter of immigrants from India. My life was very much separated in time and geography from 1947. But throughout my childhood, unbeknownst to me, the impact of that trauma was very much still there.
Phil Stieg: Through your father’s emotional interaction with you?
Shaili Jain: Yeah, I mean, he was ten when he was orphaned in the 1947 partition of British India. He went on to become a kind of force of nature, built up his life from scratch, built up a new life in England. When I was a child, I couldn’t shake this feeling that no matter how much I loved him, no matter how much he loved me, there was something that was interfering with that. That somehow he was still beholden to this past, even though he didn’t really talk about it that much. but it was always still there. And really my whole professional career has been a journey of figuring out what that thing was and then ultimately culminated in my book when I figured it all out, took a bit of time.
Phil Stieg: It’s also from your father’s perspective, it’s part of the, you know, the greatest generation mentality. You know, the veterans came back, they didn’t talk about it. I liked your use of the word resilience. And is that important, having that characteristic of resilience? Is that important in the recovery from PTSD?
Shaili Jain: I think psychological resilience is a crucial factor in the recovery from many mental health issues, life in general. So in my father’s case, even though it was a very difficult decision for him personally, one of the best things he did was emigrate to a country that was kinder to him. And I think that helped him have the resilience that offset some of his demons related to that horrific childhood trauma.
Phil Stieg: You write about a range of PTSD from partial to standard to complex. Could you differentiate that for us?
Shaili Jain: Partial PTSD refers to people who are living with symptoms of PTSD who have a trauma history, but the symptoms that they have might not quite hit those criteria that someone like me looks for to make that diagnosis. But that doesn’t mean people are not suffering. And a lot of people with partial PTSD, they tend to have those, what I was referring to, those emotional symptoms, more of the numbing, more of the avoidance.
So they don’t have the in-your-face nightmares. And so they’re still suffering, though. And there’s data to support that they have a higher risk of death by suicide, that these people have struggled with a lot of symptoms. So, it’s important that it’s on my radar as a clinician to look out for that.
And then complex PTSD refers to people who typically have lived with chronic trauma over many years. So, imagine somebody who went through years of childhood abuse, whether it be physical abuse, emotional abuse, sexual abuse. Imagine somebody who is in a relationship with horrific intimate partner – violence that went on for years. That’s a very different setup of trauma that’s going to impact you psychologically and physically in a really different way than your “textbook PTSD”.
Phil Stieg: What struck me also is the prevalence of trauma in the world and the way you characterize it obviously. It’s not just somebody abusing me or somebody shooting at me or getting raped. It’s the tsunami. It’s COVID. It’s all of these different kinds of things. What I’m curious is, do you think that there are a lot of people that are traumatized and don’t even know it?
Shaili Jain: Yeah, for sure. I think there’s a lot of people walking around with PTSD, and they don’t know it. The reality is that trauma with the big T is prevalent everywhere.
50% of American men, almost 50% of American women will experience a major traumatic event in their lifetime.
Not all of them will develop PTSD, but a substantial minority will. But when you have such large numbers to begin with, even a substantial minority ends up to massive numbers. So at any given moment in time, 6 million cases of PTSD, active PTSD, that requires treatment. It’s a pressing public health concern.
Phil Stieg: I would imagine that with veterans, one of the barriers to diagnosis and treatment might be the culture of the military, where soldiers are trained to think of themselves as strong and almost indestructible.
Shaili Jain: So many barriers. Some of the barriers are internal, like you say, you might have internalized what your conceptualization is of being strong. We have very real barriers to accessing high-quality mental health care in the United States. We have a shortage of mental health professionals, not only in this country, but globally. So then there’s real barriers too, that even if you want to get help, you can’t get help.
Part of it is that when you’re living with full-blown symptoms of PTSD, from your perspective, it can be utterly bewildering. You don’t know what’s going on. Sometimes people can feel like they’re losing their mind. They can feel like they’re, quote, unquote, going crazy. That’s really, really scary. You know, to be able to confront that, to be able to accept that, and to take action on that is a very unique form of bravery. In my experience, when people come to see someone like me, it’s usually because someone they love has said, enough,
Phil Stieg: You need help.
Shaili Jain: Yeah.
Phil Stieg: And it’s also sad that people that have undiagnosed and untreated PTSD have systemic effects. And you talked a little bit about Richard, the Vietnam veteran who eventually developed A-Fib. Explain that.
Shaili Jain: I think that’s crucial to understand that PTSD rarely lives alone just in terms of mental health diagnoses. It often goes hand in hand with depression, anxiety disorders, addiction. Addiction is a massive one. It’s natural for people who are living with trauma to want to numb some of those distressing feelings. And turning to alcohol, turning to drugs, turning to prescription pills, shopping addiction, sex addiction, food addiction, you name it, that becomes the way of kind of seeking that altered state.
PTSD is an independent risk factor for heart disease, because of the toll it takes on not only physiologically your body from living in this heightened state of stress, but also your behaviors. So, for example, someone with PTSD, they might not really trust their doctor, who tells them that they must take that blood pressure pill. So what do they do? They are non-adherent to a blood pressure medication, and obviously over the years, that can take its toll and lead to cardiovascular events. So not just physiologically, but also behaviorally PTSD can really take over your life and alter your outcomes in terms of mortality and morbidity from a whole host of other conditions, which is why it should be on everybody’s radar, not just me, as a mental health professional.
Phil Stieg: Yeah. So the title, The Unspeakable Mind, How did you come up with the title?
Shaili Jain: Trauma often represents a violation of all we hold to be dear and sacred. Such traumatic events are simply too terrible to utter aloud and hence they become unspeakable. Right?
Phil Stieg: So that’s avoidance.
Shaili Jain: Yes, avoidance – but …
Phil Stieg: Not behavioral avoidance. But mental avoidance.
Shaili Jain: Exactly. But also sometimes the survivor wishes to speak, but the wider community doesn’t want to hear what they have to say. So even though the sufferer themselves might want to speak, if the whole world is telling you, we don’t want to hear what you have to say, then they’re forced into silence, and it becomes unspeakable through another mechanism.
The problem is, PTSD thrives in such conditions. When we don’t speak about it, that’s when the traumatic thoughts and memories become unspeakable. Become unthinkable. And if that happens too long, it impedes our brain’s natural process of recovery from the trauma. So something that didn’t need to become this thing becomes this thing.
Phil Stieg: Is there a cause-and-effect relationship between avoidance and memory issues, or are they separate issues?
Shaili Jain: Good question. Avoidance is integral to the disorder of PTSD. There’s varying degrees of avoidance. One can be that, you know, something bad happened, you have the memories, but you’re just avoiding any reminders. On the other end of the continuum, you can actually bury the memories so deep that you literally deny them their existence. Some people can literally vanish them away. But then guess what happens; as you get older, as the brain ages, as you develop neurodegenerative conditions, those heavily coded memories, the really, really tough ones, they suddenly spring into action. Oftentimes that will happen with people with dementia. They’ll become very preoccupied with something from their past. But that has to do with how trauma memories are encoded. They’re encoded in a different way to regular memories, and they can take on a life of their own.
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Narrator: Some veterans are finding relief from the symptoms of PTSD with the help of man’s best friend – a dog.
The California-based non-profit “Canine Companions” is the largest supplier of service animals in the world and has 57 expert trainers around the country specializing in training dogs to support veterans with PTSD.
Their amazing dogs are trained to mitigate symptoms of PTSD by learning how interrupt nightmares and anxiety behaviors, providing a physical buffer in crowds, and performing tasks like retrieving medications and turning on lights.
Retired Army Sergeant Joe Nieves is one of their clients.
Joe Nieves: I spent twelve years in, in the military, so I got out and for the first year. I didn’t realize how much anxiety I was dealing with. Things just took a turn for me. I ended up in the hospital. I didn’t realize all of the things I was doing to self-medicate, and that was a turning point.
Narrator: At Canine Companions Joe was paired with a Labrador – golden retriever cross named ”Jem” – who knew exactly how to support Joe.
Joe Nieves: I was like, wow, this is amazing. This dog is incredible. I had met service animals before, but I never quite understood just how deep the bond between you and your service dog really is. Jem is incredible. We’re going through training and she makes everything look like we’ve been doing this forever. I feel like we’re a team. And it’s, it’s really, it feels really good to feel like a part of that.
I’m extremely thankful for all the people who have been involved in the process- the puppy raisers, the trainers who taught her all the things that they’ve done, and the people who have donated to the organization.
I’m really looking forward to the moment where when I get Jem home and introduce her to my family and her new life with us. I think more than anything, Jem represents to me the potential to be a better father, better husband, better participant in my family.
I feel like this is where it all turns and it all not instantly better, but like, the potential for amazing is there.
Phil Stieg: Can trauma be passed down through generations?
Shaili Jain: Yeah, there’s a fascinating field known as epigenetics. We’re still in that infancy of understanding this field, but there is early data to suggest that when an individual experiences a major traumatic event, the implications of that are passed on to subsequent generations through a man’s sperm or a woman’s eggs. And that leads to alterations in Neuroanatomy, neurochemistry in the subsequent offspring. And what does that mean? That means that even though the subsequent offspring may not have themselves experienced a major trauma, they are carrying around this kind of inherited profile so that subsequently in their life, if they experience the trauma, they will respond with that vulnerability. That gives a sense of the deep genetic footprint of trauma.
So when you think of mass traumatization, when you think of slavery, when you think of genocide, when you think of the holocaust, you start to get a sense of the massive impact that trauma can have over generations. From a behavioral level, you can imagine if you are raised with people, by people so if you are raised by people who have survived a major trauma, that is going to influence the way they parent, that is going to influence the way they navigate the world. And of course, that has an impact on children as well.
Phil Stieg: It’s got to be incredibly murky, though. How do you separate out the sociologic economic issues and then, as you said, the genetic component — the epigenetic component — from each other? I don’t know if they will ever be able to do that.
Shaili Jain: Exactly. From a researcher’s point of view, it is incredibly murky because there’s so many variables. One thing we do know, believe it or not, I think people are very surprised to hear this. When you survive a major trauma, whether or not you will develop PTSD, a third of that is chalked up to genetics. Believe it or not, how our brains are wired, how our bodies respond to trauma, determines a lot about who will develop PTSD and who won’t.
Phil Stieg: Tell me, are there specific qualities or particular qualities related to PTSD and females?
Shaili Jain: Yes. So even though men are more likely to be exposed to a major traumatic event in their lifetime, PTSD is two to three times more likely to occur in women. Which, on first glance, doesn’t really make sense. Right? If the men are the ones who are being exposed to war and physical assault, why are the women developing PTSD at two to three times the rate? Now, some of this explanation may lie in physiological differences, hormonal differences. My favorite explanation is actually in the types of trauma that women are exposed to.
Women are much more likely to experience sexual assaults. Much more likely to be survivors of intimate partner violence. And if we ask ourselves historically, how a society responded to such traumas, has there been sympathy for victims? Has there been support for such victims? Historically, Unfortunately, no. When the wider society is not ready to hear your experience, then you’re more likely to have the trauma remain unspeakable. And if it remains unspeakable, it’s more likely to become PTSD. For me, as a clinician, it’s fascinating to consider these sociological aspects of PTSD because then we all have a role to play.
Phil Stieg: But it’s also a paradox. The person with PTSD is dominated by their traumatic event, but they’ve also frequently suppressed any memory of the event. How is that working in our brain?
Shaili Jain: There’s two types of memory in PTSD. The first is that involuntary, unwanted, vivid, and emotional memory of the trauma, where the survivor is literally reliving the trauma in the present. These types of memories, they’re intense, they’re disruptive. They’ve been described as these indelible images. They intrude into the survivor’s life in the days, weeks, months, and years after the trauma. These are what we call implicit memories, and that they’re often activated by environmental cues or triggers.
So, for example, if you had a woman who survived a rape and her rapist wore a certain aftershave, a random smell of another person wearing that aftershave can trigger memories of that rape. How bewildering is that? You could be shopping in a grocery store, you could be attending a social event, and suddenly you’re back reliving a sexual trauma, and you have no idea why – but it’s because your brain has been triggered by these environmental cues.
For example, in the book, I tell the story of a Vietnam veteran who lived close to a hospital, and when the helicopter would come for medical emergencies, that sound had the ability to trigger a full-blown flashback of his combat experiences and trauma. And a full-blown flashback can be utterly bewildering because you literally are reliving that experience in your apartment or wherever you are a million miles away. Three decades later, and you’re having the heart beating, the panic, the anxiety, the fear. That is an example of an involuntary, unwanted emotional memory of the trauma that can wreak havoc on your life.
The second memories that we find in PTSD is the voluntarily record trauma narrative. These are different. They’re not implicit memories. They’re explicit memories. These can sometimes be disorganized and vague, and that explains this phenomenon that you sometimes have with people who live with PTSD, that they know they were traumatized, but at the same time, they can’t voluntarily tell you about the trauma. They can’t voluntarily recall it. This is very commonly happens for people who are survivors of childhood abuse. They know it happens. They know they live through it. But if you ask them their story, their story can come out really wonky. Frankly, they can appear to be an unreliable narrator. And that explains why, throughout the decades, people living with PTSD have not been believed, have been victim, blamed, have been shamed. It’s inherent with the types of memories that are integral to the diagnosis.
Phil Stieg: Does trauma in childhood different than what’s experienced as an adult? And does it manifest itself in PTSD in the same way or differently?
Shaili Jain: Trauma in childhood does impact kids. As you know, Children, depending on their age — massive developmental differences. A five-year-old is going to conceptualize death very differently to a 17-year-old. A five-year-old may not understand the permanence of trauma and death. They may blame themselves more because kids of that age tend to be a little self-centered. They think they have more control over the world than they do.
The other thing we’ve got to be aware of, you know, there is this kind of old adage, which I think is very untrue, that kids are tough, kids are resilient. It’s not quite true. The developing brain, as you know, is actually exquisitely vulnerable to insults. So, we have to take trauma exposure in children very seriously, because if they are traumatized and if that is not attended to, that’s going to have repercussions throughout their lifespan.
Phil Stieg: So give me some hope here. Give me an example of somebody who’s had PTSD and you’ve cured them.
Shaili Jain: I think that’s the take-home message that anybody living with PTSD should have an abundance of hope, because we today have many, many treatments that can be incredibly effective in helping to manage this condition. I’m not a fan of the word cure. Being a psychiatrist, I think I tend to be a little bit on the pessimistic side. Cure to me, implies that everything will be back to normal. And I don’t believe after surviving a major trauma, things will be back to normal. That doesn’t mean things can’t be good. That doesn’t mean life can’t be rich and meaningful, but I don’t know if you ever go back to normal.
I think it’s a condition that can be managed, symptoms can be rapidly alleviated. We have a lot of strong evidence to support a whole host of talk psychotherapies that can definitely help alleviate the symptoms of PTSD. We have medications that can help alleviate the symptoms of PTSD. So, yes, there is hope. People do get better. You do not have to live with this forever. When I was starting out in medical school, PTSD was considered a disabled, a permanently disabling condition. That is not true today.
Phil Stieg: So once you get treated, how do you avoid recidivism in this? Are the things that you can do?
Shaili Jain: I’m a massive fan of early intervention. One of the best things you can do is if you think you have PTSD, get help right away. If you wait too long, the symptoms become entrenched and the disorder becomes overly complicated, and then treatment becomes tougher.
I think from the individual’s end, if you feel like you’re struggling, get help sooner than later. And then also to our colleagues on the healthcare end. In my opinion, every healthcare professional has to have mental health issues on their radar. You cannot pass this off to somebody else, because the odds are someone else is going to see it before I see it. Your primary care doctor is going to see it before I see it. And if they’re not looking out for it, if they’re not looking out for it, you’ll miss it.
Phil Stieg: So I’m curious why towards the end of your book when you quote Bernard Shaw and say, we learn from history that we learn nothing from history, I was going, now, where did that come from and why did you say that then? How does that apply to PTSD?
Shaili Jain: Well, guess what? The best way is to reduce the incidence of PTSD. What’s the best thing we could do?
Phil Stieg: Get rid of trauma…
Shaili Jain: Exactly – primary prevention. If humans stopped being inhumane to each other, guess what? You wouldn’t need someone like me. And I think we are at a juncture in our history and evolution where we have to ask ourselves, what are we going to do for primary prevention of PTSD? I think people in my field can come up with all sorts of treatments, but until we solve the problems of war, poverty, racism, there’s never going to be enough treatments.
Phil Stieg: So, as we said, your book is book-ended. Is there anything that you have learned through this passage of yours, both educationally now and in treating people with PTSD about your experience or your father’s experience and the impact that has had on you regarding PTSD?
Shaili Jain: I think from my angle, the impact was undeniable. It changed the whole course of my life, my career trajectory, because I was somewhat of a reluctant person to enter this field of PTSD. But I had to figure out this condition. I had to understand it and I had to make sense of it for me to get resolution of what my life personally was all about. So even though I myself was not the direct victim of this major trauma, it was my job as the subsequent generation of that trauma to make sense of it.
Many of my relatives died under really horrific psychological conditions during the period of that partition. kAnd I think being able to tell their story, even though I never met them, even though I never knew them, that was something that was incredibly important to me. I think it was incredibly important to my father, because he did keep that story alive. He intentionally kept that story alive.
I think telling that story was an integral part of my own healing as someone who comes from a family with a history of trauma on a massive scale. I don’t want to say that in a way that it’s very kind of tidy and neat because it’s not. It’s still very difficult to do this work and it’s still very difficult to bear witness to really tough stories.
Phil Stieg: Well, in listening to your answer, I can see you sort of struggling with how to verbalize it. So it’s clear and patently obvious, looking at you and listening to you, that it’s a process and you’re still working through it. And hopefully by the time you mature, you will find the answer.
Shaili Jain: Right. (laugh)
Phil Stieg: Dr. Shaili Jain, thank you for spending this time with us. You’ve made a huge public health problem understandable approachable, and I hope for many people a way to get an answer to their posttraumatic stress disorder. Thank you for being with us. It’s been truly enjoyable.
Shaili Jain: That’s my pleasure. Thank you so much for having me.