Frank Ochberg on Treating PTSD

Frank Ochberg on Treating PTSD

by Rebecca Aponte
Dr. Ochberg, a leading PTSD and trauma specialist, discusses the Japan tsunami, veteran issues, Stockholm syndrome, therapist burnout, and the importance of a comprehensive treatment approach for trauma survivors.


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Defining Trauma

Rebecca Aponte: You have obviously had a very long and fascinating career. I'd like to touch on some of the moments of insight that you have had that inform us about how to understand traumatized clients and how to help them heal.

To start, trauma is a word that is thrown around a lot these days. What does it mean when we say someone is traumatized?
Frank Ochberg: I was part of the team that wrestled with that definition, and I think it is still an interesting challenge because the word is in general use. I think most of us consider something traumatic as usually something frightening, difficult, that could have relatively minor or huge life shattering consequences. Let's compare it to stress. We get stressed by minor things that get us upset, sometimes mobilized with a lot of energy. But those of us who were part of a new generation that defined Post-Traumatic Stress Disorder really wanted trauma to be way beyond the usual stress.

In the beginning we said a traumatic event is something that is beyond the realm of usual human experience. But then we discovered it isn't—not in terms of living our whole lifetime. You live long enough and something happens that is terrible, unless you are very, very fortunate. And some people are having terrible things happen with great frequency.

So to try to define this, we said at the time that you have to have been very scared, or horrified, or feeling helpless. And it had to have the characteristic of the kind of thing that could kill you, or kill somebody else, or radically change you in a biological way.
We walk through life with the wonderful myth of invulnerability and we think our humanity is something special, sacred and precious.
We walk through life with the wonderful myth of invulnerability and we think our humanity is something special, sacred and precious. And then all of a sudden you are treated like a piece of meat, like you are prey to another human being or to a devastating natural event: you are just a bunch of muscle and bone. And when you visualize that transformation in yourself or in a loved one, it is traumatic.

That is the meaning of trauma to those of us who were in the field of traumatic stress studies and are doing therapy with people who have been traumatized.

RA: How would a therapist assess trauma? How do you know when you are seeing trauma in another person?
FO: Well, by the time somebody comes to see us, they have made a decision and we know something—there's been a telephone call, there's been some form of referral—unless we are in a very, very different circumstance, like being a Red Cross worker or an emergency worker, and then you are exposed to the traumatic event at the same time that the traumatized person is.

But that is relatively unusual for those of us who are in the fields of psychiatry, psychology, psychiatric social work, psychiatric nursing. We usually come on afterward. So our introduction is through a person who is going to become our client—I'm a medical doctor so I still use the word patient, and some of my patients prefer that. They don't think of themselves as clients. But I know that terms matter and people have different attitudes about those terms.

So, early on we're told, "I want to see you because of something that happened." Now, I find that it is usually best for me to delay hearing the trauma story with all of its emotion until the person has a certain sense of comfort and trust.
RA: Is that because you are worried about re-traumatizing them?
FO: It's not so much a worry about re-traumatizing. I want to show respect for the trauma that happened. I want the person who is coming to see me to experience a certain amount of comfort. And some of these people, bless them, they really don't want to traumatize the therapist.
RA: Right.
FO: Now there is a little bit of a back and forth, like a dance that goes on. I know that I am quite senior in the field; I usually get to it explicitly and say, "You know, I've heard a lot—nothing that is exactly like your story—but you don't need to worry about my mental health."

Let me come back to your original question: how I think about the trauma in this person that is coming to see me. And it is usually a mystery to me. I don't know the details. I may have a general sense, but I am looking for important details and distinctions. I'm looking for symptoms. I'm looking to get to know their person and to understand their resilience, their family as a resource. A lot of trauma takes place in the family, so we therapists can't assume that there are loved ones who make things better.
Therapists can't assume that there are loved ones who make things better.

We are always trying to get a sense of who is out there who is going to help my client, my patient, who is going to help me. I take delight in finding a family member who is a great asset. And ultimately it is going to take a village, so I’m thinking about who else is there in this person’s life who helps them feel good about themselves, who helps them overcome the obstacles that they are bringing to me.
RA: So I presume that you would ask your patient about the people in their lives and who does this for them. Is there a way, by talking about experiences from before the traumatic event, you can kind of get a sense of what is different in the person now? Because obviously that is a challenge if they are coming in once the traumatic event has already happened and you don't know who they were before.
FO: Oh, absolutely. It is terribly important. All of us who are therapists have had various kinds of training, and some of our training placed a very, very high importance on formative years—who was there and the roles that they played.

It's early in our conversation now, but let me bring up something that I have formulated and written about the person's "board of directors." I think of this as my patient's conscience. It is the same as a superego.

Even though these events happened when we were very young, I have had patients in their seventies and they still visualize their mother or their grandmother who judges them. It is like a board of directors that holds meetings in your head, somewhere in the frontal lobe. They sit around a table and they say, "Bad girl," even though the girl is a former Circuit Court judge and she is 65 years old. She still can remember, "You put that stitch in wrong; you will never amount to anything."

As I get to know the board of directors, I try to say, "You don't really need to have that grandmother in the director's chair. I don't think you can get her out of the room, but why does she have to be the chief judge of your virtue?" This is not our ego—this is the superego. These are the folks who will keep telling us we are good or we are bad—we amount to something or we don't.

Now, trauma and trauma work are not specifically about self-esteem. But that is always lurking in the background.
Now, trauma and trauma work are not specifically about self-esteem. But that is always lurking in the background. Trauma survivors who have very good, solid self-esteem are going to deal with flashbacks and nightmares and anxiety and a somewhat diminished capacity for feeling joy and love—they are going to deal with that so much better than those whose self-esteem is marginalized. So, I find that, even though I am a trauma specialist, I have to pay a lot of attention to those ghosts who live in our heads and judge us all the time.
RA: That obviously has a lot to do with resiliency—whether they have a good board of directors or have taken the chairperson's seat themselves.
FO: Well, all of these members of the board are ourselves. Once we have incorporated them, they are us. But I find it helps a lot to have this conversation and then to help trauma clients improve their own board of directors.

I remember Maya, who had been raped several times by a sadistic psychopath who inserted himself into her life. She was my patient in the early '90s. We talked about the board of directors and she said, "I know. I'm going to put Arlo, my gay brother, in the chair. He likes me." I remember the name, I remember the way she referred to him. And she did it and it helped. It was a breakthrough.
RA: Is that the client who is in The Counting Method?
FO: Yes, it is.
RA: I was fascinated watching your session with her, because the technique is so similar to EMDR, which I have a little bit of exposure to. One of the things that I liked so much about it is that by counting out loud you filled the verbal space—it felt like there wasn't the pressure on the client to be talking.
FO: I think it is a very useful method. Hadar Lubin and David Johnson in New Haven are the people who have the most experience in doing research with this method, and in training others. They have written the handbook. At Yale a couple of decades ago they trained a group of residents in how to use EMDR, prolonged exposure, and the counting method, and randomly applied these methods over a period of time to a patient pool. It turned out that the counting was the easiest to learn—it was favored by the user. It was really no better in reaching a good outcome, but it was no worse. So it is probably the most efficient and equally effective way of dealing with what I believe is the core element of PTSD.

I think what really harms the person who qualifies for the PTSD diagnosis is this inability to escape the trauma memory. There is fascinating research now by Apostolos Georgopoulos that suggests that this core symptom of PTSD—the inescapable episodic memory that sometimes feels like it is in the present—originates in a disturbance in the discharge of neurons originating in the right temporal lobe. He needs the money to replicate and expand his research, but it suggests that even though PTSD involves several different things, the feature of this inescapable memory, which only occurs in PTSD and not in adjustment disorders or dissociative states or anxiety or depression, is caused by an extreme of perception at the time of traumatization, if you will. It is analogous to being blinded by light that is too intense, like looking at the sun in an eclipse or being deafened by noise that bursts your eardrums.
RA: Is that the moment when the survival instinct takes over?
FO: Well, yes, that could be at the same time. But the symptoms of PTSD are, first, having this trauma memory that won't quit; second, having numbing and avoidance; and, third, having anxiety that isn't necessarily caused by reminders of the trauma—your anxiety mechanism is too easily triggered. EMDR may be better than counting at helping a person control his or her anxiety. I don't think EMDR does much for numbing, but it is a good aid to diminishing anxiety and experiencing a sense of control over it. Prolonged exposure is a way of desensitizing to a number of the features of PTSD.

And counting, I think, is primarily for the flashbacks, the nightmares, the imagery of the trauma itself. But one element of PTSD feeds into the other. As you reach a tipping point and you feel a sense of mastery and control and self-understanding and self-regard, then recovery follows.

A Comprehensive Approach to Trauma Work

RA: It seems like there are some common threads to a lot of these approaches to working with trauma, whether it is EMDR or the counting method. We haven't really touched on cognitive behavioral therapy or psychodynamic approaches. What are the common threads? What matters the most regardless of the approach?
FO: I have a certain reluctance to support what is called evidence-based therapy because the evidence-based issues have to do with elements of therapy rather than the whole of therapy.
Back at Johns Hopkins Medical School, we were told by the surgeons, "We can teach you to take a lung out in seven days, but it is going to take you seven years to know when to take it out."
Back at Johns Hopkins Medical School, we were told by the surgeons, "We can teach you to take a lung out in seven days, but it is going to take you seven years to know when to take it out."

There is a lot of judgment that goes into the timing of opening up certain doors for exploration with someone who has been badly traumatized. And most of our clients have been traumatized more than once. They are vulnerable because of things that happened in childhood. They may be part of a group or a gender that receives way more than a fair share of abuse, and then they become our clients. It is not a simple thing of dealing with one symptom at one point in time. A lot of these evidence-based therapies are elements that work—we don’t want to encourage a whole group of amateurs to be flying by the seat of their pants. They should be well trained. They should have a good sense of what makes a human being tick and then know how to deal with all of the parts that are affected in a way that makes sense.
In my paper on Post-Traumatic Therapy, the therapist is advised to have an overall philosophy that is as normalizing as possible, as collegial as possible, but also attends to individual differences, and then to have an outline and to cover a number of elements of the traumatized person, and to teach your traumatized client about PTSD and related conditions.
Just having a conversation of what this syndrome is is empowering. And it is a good place to start. Years ago, in 1980/1981, I had a patient in Lansing. I took out the DSM-III, and I showed her the PTSD diagnosis. She had been raped in South Lansing. I remember she looked at it printed up and she said, “Oh my god, that’s me in that book.”
It was so important for her to see her symptoms in a book. It took away the mystery. It let her know doctors know something about this. As I am talking to you now I am getting a little chill running up the back of my spine; it was so moving for me. We were talking about something that was over 30 years ago, and she was sitting in this office and looking at the diagnosis in this book, and she smiled probably for the first time since she had been raped. What a gift for her and for me. So sharing something about just the definitions was extremely useful.
Then I think therapy has to include attention to physical situations. When you are traumatized you don’t eat right. You don’t always get agoraphobic, but agoraphobia is literally a fear of the marketplace—people don’t shop where they used to. They don’t necessarily wear the clothes that they used to wear. So you help a person analyze and recover good eating habits, good exercise and health habits. You look into sleep hygiene. And then you can deal with other issues like spirituality, sense of humor. All of these are important elements to consider prior to the counting method or EMDR.
Some of these methods feel a little gimmicky, and to suggest that you wave a finger and someone is better—to me that needs to be timed right and introduced right.
Some of these methods feel a little gimmicky, and to suggest that you wave a finger and someone is better—to me that needs to be timed right and introduced right.
And these other parts of a comprehensive approach—analyzing somebody’s circle of friends and the strength or the threats in their family—are terribly important. Sometimes we actually end up creating a new family through introduction to a therapy group. We have a Michigan Victim Alliance. People who participate in that are working together and helping others together—creating a network if the natural network is insufficient is part of therapy.
RA: It sounds like the overarching thing that is most important is to have this full, comprehensive approach where you are really understanding the person as a full person and their experience and all of the different ways that it affects them, rather than focusing on one or another specific technique for attacking one specific symptom or problem.
FO: Exactly. That is what I am advocating now.
RA: Sometimes you hear about vets suffering from PTSD for years or even decades. Is it really that intractable of a condition? Or if not, is it that treatment isn't going well? What is going on in those cases, in your sense?
FO: Well, there is a lot of research into how long the condition lasts, and it is a little bit like depression. If it lasts a month, the odds are it will last for three. If it lasts for three, the odds are that it will last for a year. If it lasts for a year, the odds are it will last for more than that.

It is very, very misleading to think about the average length of PTSD. Look at how different it is to be called in the middle of the night and told that your child has been murdered, and to go through a trial, and then you deal with the imagery of how your child was murdered. And there may be a period of time where the murderer is at large.

I know these people. These have become my friends. I have spent hours and hours with groups of parents of murdered children. That is not the same as being raped. A predatory rape and a confidence rape are very different. Being drugged and raped so that you didn't know what was happening when it happened and then you wake up and you learn about it—that's different. Being raped by a family member is different. Being in a bus that crashes and you are alive but someone else is dead. So we are talking about vastly different trauma scenes.

And we think of Japan now. Most of us who are senior therapists in this line of work end up being called one way or another when a top news story happens. So you identify with those people and your heart goes out to them. And thinking about kids who are drinking milk and the mothers in Japan don't know if this milk is safe or not—a very special kind of threat. The mothers may or may not qualify for the PTSD diagnosis, but that is trauma. So it is all different kinds.

And with the veterans, there are a lot of special circumstances. I now have a lot of friends who are veterans. Some are my age, which means that they fought in Korea or in Vietnam. And some are younger—they are coming back from Iraq. There is a culture in the military of not exaggerating your wounds. Even though there are people who think that soldiers and marines and sailors with PTSD are exaggerators, it is very few who are.

From a therapist point of view, you deal mainly with people who keep it in. One of the diagnosis criteria is a reluctance to talk about it. So of course there are many people who get no help, who keep it all in, who suffer in silence, and every once in awhile they suffer deeply.

The worst kind of suffering is the survivor guilt.
The worst kind of suffering is the survivor guilt. On April 1, 1970, my client Terry had his best friend die in his arms. Terry feels that his best friend wouldn't have been on that mission with him had Terry not decided to go back to the front—he had been wounded, he didn't have to return. He decided to do it, and he knows that that decision has something to do with that strange adolescent thought that he could get himself killed and his father would be proud of him.

We finally got to that memory after a considerable amount of time working on a trauma problem. Terry feels terrible that he brought his best friend into that adolescent and mythical kind of wish. He is doing better with it, and some of it is through the counting method. But a lot of it is through reframing and working with some of his spiritual beliefs, things that are not ordinarily talked about from therapist to therapist.

Terry is very religious. I asked him if he felt that he determined the length of someone's life. He said, "Oh my god, no. It is a much higher power that determines that." And as he realized that, he shifted his whole way of looking at this episode that occurred 40 years ago. And he started to realize that it wasn't up to him, but he was there for Billy when God called Billy. What a different belief.
RA: That changes the experience in so many ways if that is the way he is looking at it: "I was there," rather than, "It was my fault."
FO: Absolutely. And that doesn't mean that you can somehow turn this into a therapy technique, but through paying a lot of attention to your client's spirituality, religious belief, sense of self, sense of honor and dishonor, it can be possible to help a man in his sixties rethink and re-experience an event that happened in his twenties. That is part of the privilege and the joy of this kind of work.

Advocating for Veterans

RA: Of course, the more that society understands the way that humans respond to trauma, the less stigma there is for victims of traumatic stress. But there is always the risk that people coming back from war with PTSD are only going to face the betrayal of bureaucratic resistance from those who are supposed to help them heal. You have mentioned filling the role of victim advocate as well as psychiatrist. What does that mean?
FO: Very specifically it means to me this year working with Tom Mahany and Tom's group, Honor for All. Tom has gotten a permit for a gathering on June 25, 2011. It is roughly a year after the US Senate passed a resolution, thanks to Senator Conrad from North Dakota, of National PTSD Awareness Day. But nobody was aware of it last year.

So Tom wants to have a celebration, and not just for veterans with PTSD. It is for any veteran. It is honor for all. But there will be no discrimination against those veterans whose wounds are invisible. PTSD is an invisible wound; traumatic brain injury is an invisible wound. These wounds deserve as much honor as any other wound. We are going to have speakers and music, and I'm the medical advisor for this particular initiative.

If you go through the World Wide Web, there are hundreds of groups that are all doing special things for veterans with various obstacles. We are all in this together. I don't think any one group is any more important than another. We are going to do something to make sure that no one is left out. There is a military mantra: No one left behind. You don't leave anybody on the battlefield dead or alive. That is terribly important. And somehow, symbolically, we have left out the service men and women with PTSD.

There is a fair amount of attention now, and it is the attention that comes from realizing that we didn't do the right job. We didn't do it after Vietnam. We missed it in World War II, also. This condition has been around forever. And I think it is biological, it is physical. As I mentioned earlier, I am beginning to think it actually involves a recognizable condition in the right temporal lobe, but we don't have enough proof of that yet.

It is going to help for PTSD to be understood as a medical injury. I think when it is a medical injury the stigma will be reduced. But there is stigma for breast cancer, so we need to learn from the women who have created a breast cancer awareness campaign so that the NFL is playing in pink sneakers and gloves. You get that to happen, you have really started to revolutionize things. I'm going to see what I can do to get the architects of that campaign to help us with de-stigmatizing PTSD.
RA: Still, it is outside the realm of what many therapists would consider doing. Do you think their roles should be more active when dealing with clients who are facing PTSD?
FO: No, I don't. I don't want to suggest that therapists who are very comfortable and who are talented and compassionate and like working in their own setting need to get out of that setting. But I will tell you this: I do teach the psychiatry residents at Michigan State University this particular subject. I do encourage them to write letters on behalf of their patients.

Don't think of it as an onerous task if you have a patient who needs a disability determination, who needs a letter to her employer. You are a doctor. And this is true of other mental health professionals who are not MDs—you have a degree.
You have a certain power in your community and you do need to use it for your client.
You have a certain power in your community and you do need to use it for your client. I don't think you can practice in this area without advocating effectively as a therapist.When you are asked by your client, "Can you document something for me? Can I have a note for my employer?" we have laws in which employers have to give certain accommodations to people with handicaps. You don't have someone who is going to be so startled that they will have to dive under a desk, returning to work in a setting where those particular noises are going off.

So, yes, I do think, at the individual level, to be a trauma therapist is to be a client advocate. But when it comes to participating at the local, national, and international level and trying to change conditions, there are some of us who accept political roles. I have been a cabinet officer in the state of Michigan and I was fairly high up in the hierarchy in the National Institute of Mental Health. In those respects I have experience in public policy and in legal advocacy. I had to testify before Congress on behalf of the constituency that the National Institute of Mental Health stands for.

So I think that is different. There are some of us who work in those two worlds—the clinical world and the political world.
RA: You described getting involved initially in trauma research following the assassinations of Bobby Kennedy, Martin Luther King and President Kennedy. Right now we are watching the aftermath of the earthquake and tsunami in Japan. How do events like these portrayed through the media affect the mental well-being of individuals?
FO: In my case and in the case of my colleagues at Stanford, they affected our mental health by lighting our fuses. We were so shocked and stunned, I think traumatized, if you will—in a good way. We were living through an epoch in history and our collective response was to say, "Let's do something. Now, what can we do?"

So we formed a committee on violence. We read everything we could get our hands on. We wrote a book together—Violence and the Struggle for Existence. Our department chair, David Hamburg, a wonderful leader, was away on sabbatical. He came back and his residents had accomplished what he could have never assigned us. We were moved by events that touched us deeply and we did something. And we are proud together that we were able to do that.

I would certainly encourage anyone who hasn't had the opportunity as a clinical professional to join the Red Cross, or something that takes you to another part of the world—the other part of the world may be another state. If you have never been part of an emergency response and you have something to offer, it is fulfilling. It can change your life.

I think when you asked the question, you were thinking, "But what do these world events do in a negative way, as well?" They do have a particular upsetting impact on a lot of my patients. And I am sure general therapists have noticed that certain world events upset their patients.

A lot of their patients are sensitive. I try to interpret sensitivity as a blessing and a curse. It means that a stimulus causes a greater reaction. And that means, in a way, you are going to get more out of life—the subtle things are going to affect you deeply. You are like a Maserati—a car that is better but hard to drive. You are like a fine violin—it's out of tune, takes a master to play it—a wonderful, fine instrument, but from time to time you will suffer.
I try to interpret sensitivity as a blessing and a a fine violin—it's out of tune, takes a master to play it—a wonderful, fine instrument, but from time to time you will suffer.
It is a special burden to have that sensitivity. And indeed, my sensitive patients perhaps empathize more, identify more, and hurt more than the average person when the world news brings us tragic events.

Vicarious Trauma and Burnout

RA: Now, when that highly sensitive people are the therapists, they especially have to take care of themselves.
FO: That is a very interesting point. I work with journalists nowadays. I have been specializing in helping journalists see all that there is to be seen in a trauma story, and to develop a great appreciation and almost joy in doing it well. This is called the "Dart Center" and the "Dart Society," and Dart is the name of the philanthropist—we have been doing some interesting things over the last 10, 20 years. Well, journalists are sensitive. They don't like to think of themselves that way, but yes, they have their own PTSD, and we therapists can have it, too. It is sometimes called Secondary Traumatic Stress Disorder or Vicarious Traumatization. We aren't there for the actual trauma, but we listen deeply to others, and eventually, through accumulation, we start to have symptoms.

These are not technical, recognized medical terms, but Secondary Traumatic Stress, which can become a disorder, is a disorder of identification with a client or loved one. And to a certain degree it happened in 9-11—people just surfeited with images of New Yorkers jumping to their deaths, or identifying with a widow who had to watch a building crumble and know that her husband was inside.

So secondary trauma exists. Vicarious trauma exists. But burnout is something else. Burnout usually means you have had relentless responsibility, and it just was too much. In the course of this on the job, you become embittered—you lack your elasticity, your sense of humor is gone. And I think if it goes too far we'll have to consider a job change. And maybe it is a matter of definition. But if the damage extends to the point where you can't bounce back, you really are doing a disservice by staying in that job.

These are the police officers who use excessive force. These are the managers who create a hostile work place because they become so embittered. Burnout is bad for everyone around you.
RA: Definitely. Are there warning signs of it? Are there things that people can do if they feel themselves starting to get sucked towards that—is it just a matter of cutting back their responsibilities that have grown to be too much?
FO: Well, there are books written about this. My colleague Joyce Boaz produced a film, When Helping Hurts. It is a good one and it's in its second edition. The message is, yes, you can see it coming.

In the beginning it is compassion fatigue, or it is vicarious trauma. And if you pay attention to just what you are advising your clients and patients to do, you take a break, you get exercise. You may need to go into therapy. You pay attention to these things.

Part of what I have been doing in journalism is talking to the leaders of the BBC and the New York Times and NPR and places like that, so that it can start at the top. When there is sensitivity to the burden that the reporter carries, that the editor carries, even someone who is part of the technical operation of, let's say, NPR—they listen to a lot that doesn't go on the air. They take that home. Somebody has to care about them.
RA: Do you feel like the media is in a particular position where they have to be especially careful since they are funneling the story to the rest of the world?
FO: Absolutely. And I guess those people who are media critics—and everybody, it seems, is a media critic—often express discomfort or distaste with something that has been put on the air or pictured in the newspaper. But I find it is often a matter of telling more rather than less. Telling the context. Portraying someone who has lived through a horrible newsworthy event with their own humanity.

And the best of the journalists rally to this. There is a DART award for the best media portraits of victims of violence. These are not sanitized, antiseptic or censored accounts. These are full accounts where you can identify with the strength of the character and the personality of a survivor who tells a story. It is often a tragic story, but tragedy is ultimately uplifting. It gives us the world as we experience it, and we see elements of nobility and sacrifice. We see mistakes that cause downfall. And we are enlightened.

My point is good trauma journalism is like good literature. It does a terribly important job. It does it by telling the truth in a digestible, sensitive and accurate way.

Stockholm Syndrome

RA: I wanted to talk a little bit about your work in the 1970s that led you to Europe where you helped define Stockholm Syndrome. I was especially surprised to learn that in a hostage situation this is something that is encouraged. Can you briefly define Stockholm Syndrome?
FO: In the mid-'70s I was part of the National Task Force on Terrorism and Disorder that reported through channels to the Attorney General of the United States, and it happened at a time after the Munich massacre in the Olympics of 1972. After a spate of hostage holding conducted by terrorists, we needed to examine hostage negotiation, SWAT practices. This was an emerging and terrible technique to extort concessions from governments by holding hostages, by executing hostages, by torturing people, and a group of us were commissioned to study this. I was the representative of the NIMH and of mental health—I was the only mental health professional. There were a number of lawyers and police officers, people who had diplomatic experiences.

We held hearings all around America and one thing led to another. I ended up having something a bit like a Rhodes scholarship that was available to public health employees. I spent a year with Scotland Yard and with the psychiatry program at the University of London, and I worked on these issues. I debriefed many people who were held hostage. I had a lot of consultation with the FBI. I helped teach detectives at Scotland Yard and at the FBI hostage negotiation techniques.

Along the way, in Stockholm there had been a bank robbery and people were held hostage, and one of the hostages appeared to fall in love with one of her captors. Several people came up with the name "Stockholm Syndrome." What I did was I wrote a memo to the FBI, defining Stockholm Syndrome from the perspective of us who were engaged in negotiation and rescue.

The syndrome begins with one or more hostages experiencing terror. Then there's infantilization—I heard a lot of intimate stories about the meaning of not being able to use a toilet without permission or having to defecate in a bucket in front of these people who were holding them hostage. This was part of the experience. But then, little by little, the hostage who survived was allowed to speak, or—I will use the terms that they used—allowed to have a pot to piss in.

And these became part of the negotiation strategies. But these little gifts of life were creating something paradoxical, ironic, astounding. I met with the senior magistrate of Rome who was held hostage by the Red Brigades. I met with the editor of the largest paper in the North of Holland, who was held hostage by Moluccan terrorists. I met with an older woman who was held in the Spaghetti House siege. And what they were telling me was, "I didn't realize it at the time, but I felt a growing attachment, affection." Sometimes, depending on the age and the gender, it was sexualized. That happened in the original Stockholm case—Kristin had sex in the vault with her assailant. That is somewhat disputed, and after the fact some of the stories changed. Patty Hearst's story has various explanations one way or another. But this is not a result of brainwashing. This is something fundamental.
RA: I've read in your work that it goes way beyond this idea of identification with the captors.
FO: Anna Freud described something that she believed occurred in the concentration camp in which there was identification. I distinguished the Stockholm Syndrome from identification with the aggressor because these people don't necessarily become aggressive. They become bonded. There is a bond, and it is ironic. They have a certain affection for their captor during captivity and afterwards.

So first, there is the bond that the hostage feels to the hostage taker. That bond is a result of terror, infantilization, and then small gifts of life, which are interpreted as gratitude, but gratitude that few adults have experienced. So it has got to be like the gratitude that an infant can't express but feels towards the mother who provides all of these elements of life.

The second part of the Stockholm Syndrome is it is reciprocated. And that's why at one point when I was in the command center when the Moluccan terrorists were holding hostages at a school and on a train, I was advising on something that could promote the Stockholm Syndrome. One of the hostages had a panic attack that looked like a heart attack. I wanted the hostage taker to be telling us through our transmitter what the pulse and the respirations were—in other words, I wanted the hostage taker to play doctor, because I thought that would promote the Stockholm Syndrome. But a medical student played doctor. We had no way of telling her, "Back off, we want to do something here." So we lost that chance.

The last part of the Stockholm Syndrome is that both the hostage and the hostage taker are allied against us. Here we are, we are doing everything we can to rescue them, to help with a safe resolution, but we are suspect and we have to know it. And that does affect the tactics and the choices that are made when you are involved in hostage negotiation. Now, decades later, we look around and we say, could the Stockholm Syndrome play a part in why people stay with a batterer?
RA: That is what I wanted to ask you next. Is Stockholm Syndrome analogous to the special bond between a child and an incestuous parent or battered spouse and their abuser?
FO: I think it is. I think we have to be careful if we want to be precise about Stockholm Syndrome as a part of the analysis in a hostage situation or a kidnap situation. For example, in Singapore people are wondering, is the tolerance for a regime that appears to be autocratic or abusive to some—is that tolerance like Stockholm Syndrome? I think sometimes these are valid conversations but the analogy can be taken a little bit too far. There are lots of reasons why people accommodate brutality. They may not have known anything else. They may feel that through that kind of identification their psychological status is improved. Why do people still support royalty?
There is something deep within us that affects some of us more than others—the order that comes with tyranny.
There is something deep within us that affects some of us more than others—the order that comes with tyranny. And Erich Fromm had a whole thesis on escape from freedom. There are countries, there are epochs, in which people sacrifice freedom for the certainty that comes with despotic rule. I don't want to say that is all Stockholm Syndrome. To me Stockholm Syndrome explains when an adult is forced into an infant-like circumstance and emerges from that circumstance with ironic attachment.
RA: How is that bond unwound? Is that possible?
FO: It seems to go away with time, and when it goes away there may be depression. I have dealt face to face with people who told me, "How could I have done this? I actually admired the person. I felt affection. Now I don't anymore."

I have heard from people who through time overcame the Stockholm Syndrome and felt a certain amount of loss. I think you would experience some grief whenever you lose an object of love, and this was a love bond for survival. It was artificial, it was created in a hostile, deadly environment, then it goes away and you feel the loss. But then, I think, after that comes understanding and appreciation of what a person went through.

I was asked, what is the cure for Stockholm Syndrome? This was in the dialogue with some people in Singapore. And I said the cure is rescue. So if you are subject to any form of tyranny, what you really need is to overthrow the tyrant that is dangerous. Then, when the tyrant is no longer there, you can begin to experience the psychological recovery. But this is so commonplace with seriously abused women, children, and there are some men who are seriously abused, too. But primarily the battering problem is the battered spouse. And she needs safety, rescue. The psychological recovery happens afterward.
RA: Rescue is a complicated concept. How can therapists use that if they are seeing someone who is a battered spouse or who was a sexually abused child? How does the concept of rescue come in?
FO: Sometimes it comes in quite literally. I helped create a residential treatment program for victims through the Sisters of Mercy in the Lansing area, and we had meetings with a group that called themselves Mercy Pilots. They weren't part of the Sisters of Mercy, but they were in the business of providing medical aid through their own private airplanes as needed. They did what was like a witness relocation program, helping to take a woman who was sleeping with the enemy away to another location by private plane and help her get to a new life.

Now, that is not easy to do, and it is dangerous. I remember talking with these pilots about the dangers that might be involved. There are at least two different kinds of battering situations. In roughly two-thirds of the cases, the batterer gets drunk or gets enraged, and then sobers up or calms down and is very apologetic and forgiving. And that is a different situation. That one I think is a little bit more like Stockholm Syndrome, where you go through the capture and then the release, and you can have positive feelings that come from having the threat removed.

But the outcome of a study that was done in Seattle shows that there is another kind of batterer who is relentless and terribly controlling. This one sniffs his wife's underwear looking for the smell of another man. He may have a delusion, and he will track this woman down and kill her if she attempts to escape him. It is a very, very dangerous situation.

When I first became aware of those differences I called my local shelters to see if they were aware of it, and they weren't. It is very important that the professionals who deal with the battered women distinguish between the more common variety and this relentless, obsessive, deadly form. We don't have a witness protection program for the women who unfortunately have been captured by these highly controlling and dangerous men.

But safety is very important for them. If they do choose to leave, it is beyond the experience and the expertise of most therapists, but I think a therapist who has someone like that in his or her practice needs to be aware of what we are talking about now, and does need to educate himself or herself and try to find competent safety resources that can be afforded to those victims.

Now, there is a book by Gavin de Becker called Gift of Fear. He is a very sophisticated security consultant, and writes about the importance of having your fear, which can keep you alive.
As therapists we sometimes have a job of helping the person who has been raised in a terribly hostile environment to learn how to trust trustworthy people and maintain fear of dangerous people.
As therapists we sometimes have a job of helping the person who has been raised in a terribly hostile environment to learn how to trust trustworthy people and maintain fear of dangerous people. This is not easy. But as therapists gain experience with all of these different circumstances, they get better and better at helping their clients reinforce coping mechanisms, good choices, having in their own human environment reliable and kind people.

It's obviously very, very difficult if you have been raised in a part of a city, in a family, in a situation where the only people who kept you alive were criminals or really disturbed people.
RA: Right—that environment looks normal to you.
FO: And this is not too different from the challenge of helping a veteran become a civilian.
RA: Say more about that.
FO: You are moving from a circumstance in which you had a certain set of instincts and the enemy was there to kill you. The job was to kill the enemy, and you had a team that you could trust. And you had others in your life who may have been interested in you but hadn't a clue of what you were going through and how all of your psychological and biological instincts return to deal with combat.

So to help a combat veteran, particularly a young combat veteran, face an entirely different set of challenges—marriage, fatherhood, school, job, going to school with people who don't appreciate the military—it's enough to make some military so enraged that they have to get into a fight. A therapist has to respect these clients and know where they are coming from, and gradually help them learn to master a different set of skills.

I don't want to say that that is similar to a person who comes from a youth and adolescence of crime family. I'm just saying that the job of therapy can be very complicated when you are not dealing with a single trauma and a set of symptoms, but with an adjustment to a certain lifestyle that was necessary for survival and how the rules have changed.
RA: Looking into the future of this field, what makes you feel hopeful?
FO: I just had a conversation with my old boss, Bert Brown, who is over 80 now—I'm in my 70s. Burt was the director of the National Institute of Mental Health for seven years and I helped him with deinstitutionalization and trying to build a community mental health system. We have to admit that we failed in many ways to deliver for America a mental health system that we could be proud of.

But many of my colleagues from that time have moved into the trauma field. There is something about the trauma field that is calling on the best and the brightest, or at least bright enough to deal with these issues. These are the issues of human cruelty, of war, of crime, of trying to be decent in the face of outrageous provocation, which in most normal people calls forth feelings of hatred and disgust and disrespect. In the face of that kind of provocation, how do you help people be humane and to cope and call forth love?

This has been the challenge of all the great nations and religions and movements of all time. So it is exciting—our tools are increasing. We now have journalists as colleagues. It is a wonderful field, the trauma field. Lots of rewards, and still a lot of progress to be made.
RA: Thank you so much for such an interesting and inspiring conversation. I have really enjoyed it.
FO: I have, too. Thank you.

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Frank Ochberg Frank Ochberg, MD has been a leading authority on the treatment of Post-Traumatic Stress Disorder since the 1960s and helped define PTSD for its inclusion in the DSM. He has received many awards for his work, most recently the Lifetime Achievement Award from the International Society for Traumatic Stress Studies. He founded Gift From Within and is currently a professor of psychiatry at Michigan State University.

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Rebecca Aponte Rebecca Aponte was the Operations Manager for from 2008-2012. She then left California for graduate school, earning a PhD in Psychology from Colorado State University - an experience that only deepened her appreciation for the experience she was exposed to during her time with Rebecca now works for the California Department of State Hospitals.

CE credits: 2

Learning Objectives:

  • Describe Ochberg's perspective on effective therapy with traumatized clients
  • Discuss the Stockholm Syndrome
  • Describe the challenges facing veterans dealing with PTSD after battle

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here