PTS(D) and Me

Jim White (sports broadcaster): What baffled me – and I don’t know if you’ll just give me a couple of sentences on it – you’re a good-looking man, you played at the highest level, you were a good player, you’re a good husband, a good football administrator, you’re an intelligent fella. So why? 

Clarke Carlisle (professional footballer): Well, here is part of the problem, Jim. Because all of that is an irrelevance. It’s an illness. So that’d be like applying that and saying, why have you got diabetes? It’s all an irrelevance. That circumstantial stuff is irrelevant. When you’ve got an illness, and it takes hold, and it’s not diagnosed or it’s not treated correctly, it will get to that disaster stage. Now that’s why we’re here today. Fellas, we talk to each other. We do talk to each other, but we can be very blasé or flippant. “What’s going on?” “Aw, you know, she’s doing my head in, or he’s doing my head in, they’re doing my head in.” Then we’re like, “Oh OK, let’s pop off.” Do you know what? Ask again. “What can I do for you? Can I help you?” You know, it’s not for me to fix your problems, but what it is for me to do is listen to you, Jim. Because sometimes, as a guy, all you need is to be is listened to and acknowledged. You feel dismissed in this generation, in this 24/7. Everyone wants a piece of you. Just listen to me for once. When guys are going through tough times, there’s often that thought that no-one wants to listen. Nobody’s going to help me. You’ve got to ask yourself, have you given someone the opportunity to help you? You know, in the first ten years of my suffering, I didn’t let anyone help me because I thought I had to deal with it.

A good player in deep distress

This is a video-recorded conversation between Jim White, a well-known Scottish sports broadcaster, and Clarke Carlisle, an English former professional footballer and former Chairman of the Professional Football Association. Carlisle made over 500 appearances during his 17-year career, playing for nine clubs across all four English divisions. At 1.91 m (6 ft 3 in), he was an imposing centre-back and also known to be a highly intelligent footballer (and with a clean sweep of A grades at the end of high school).

In December 2014, Clarke stepped out in front of a lorry in North Yorkshire. He survived physically relatively unscathed, but his mental health deteriorated and he disappeared in 2017, again considering taking his own life. A year later, in the video, he described himself as “very, very content today”.

A 2015 study by FIFPRO (Fédération Internationale des Associations de Footballeurs Professionnels), the worldwide representative organisation for 65,000 professional footballers, found 38% of 607 active professional players and 35% of 219 former players reported suffering from symptoms of depression or anxiety, or both. In a typical 25-person squad, this equates to nine members of the team. Sleep disturbance affected one in four, overall. How much do we talk about mental health, especially in professions where a large majority of staff are male?

Boys don’t cry

Two lessons seem to be learned by many males growing up in this world, perhaps even by most of us. One lesson, learned from a young age through parenting and early socialisation, is “Boys don’t cry”. The second, learned and reinforced in social groups and via the media, is “Men don’t talk about feelings”. These phrases don’t need to be said, as such. Observing and interacting with others is powerful enough to embed these rules in our psyches. Yet these are perhaps two of the worst lessons in human development, and contribute significantly to many problems of mental wellbeing throughout life. 

My paternal grandfather died in 2001 at 92 years of age. A few years before he died, he disclosed to my father some hitherto unknown family history: in World War II, my grandfather served as a sniper in the British army. Most families know about a relative’s history in military service, but we never did. My father asked his father, “Why did you never tell me?” My grandfather said, “Son, if you saw what I saw, you’d never want to talk about it.” His remark perhaps betrays a common male attitude to disclosure. That day, he did disclose some of his experiences of life as a sniper, but not many. What was clear is that he experienced post-traumatic stress (PTS) as a young man, and he didn’t talk about it.

A journey into PTS(D)

I was not in the armed forces, but throughout my late teens and in my mid-20s I experienced what might be referred to flippantly as ‘a series of unfortunate events’. Many of the events centred around death and near-death experiences. This is not the place to describe them, but they were the sort that many people experience once in their life – loss of a parent at a young age, a high-speed car crash, violence (real and threatened), and vicarious experience of life-threatening health problems, among other events, some which are described in poetry here. I just happened to experience a series of such events in rapid succession over a few years at a young age. Some of the traumatic events occurred against a backdrop of a generally stressful day-to-day environment, growing up in a family business. 

On leaving home to study psychology, I had already experienced post-traumatic stress symptoms but further events were to occur during and after university studies, which led to reactivation and new symptoms. Some of these stuck for years. I’d heard of ‘post-traumatic stress disorder’ (PTSD), but associated that with soldiers like my grandfather, and didn’t consider it further. Ironically, that is how I felt, like a soldier under persistent attack. The symptoms as a cluster lasted around 12 years overall. Some lay dormant thereafter and re-emerged occasionally.

Throughout the whole experience, I was high-achieving in education and subsequently in employment, and was known to have a very high capacity for hard work. I probably channelled much of my energy into this as a distraction from what I was feeling, while also trying other means to avoid certain thoughts and feelings, because when I opened the door to all of this, it was very difficult to close. And you can’t simply close the door on PTS and PTSD. If you try, it will get in through the windows. 

For the rest of the article, I’ll refer to PTS(D) to cover both PTS and PTSD. The difference in practice is a set of diagnostic criteria and a diagnosis, but PTSD often remains undiagnosed. Post-traumatic stress (PTS) is a normal and generally adaptive response to experiencing a traumatic or stressful event, such as an accident or assault. PTS is very common and most people will experience it and experience some of the signs. If symptoms persist for months or years, they may fit the diagnosis of post-traumatic stress disorder (PTSD), a clinically diagnosed condition listed in the Diagnostic and Statistical Manual of Mental Disorders (fifth revision, May 2013). According to the National Institute of Mental Health, PTSD will affect 6.8% of U.S. adults in their lifetime. 

My primary experience of PTS(D) was in my teens and 20s. But in later adulthood, pre-empting a major life change, I experienced another episode of PTS(D), after a very long hiatus. In this case, the thoughts and feelings mostly did not relate to memories of the original events (which no longer triggered the same responses), but rather the memories of the PTS(D) symptoms from my younger days. 

The experience of PTS(D)

Symptoms of PTS(D) will depend on the person, but below are some characteristic symptoms which I experienced over many years. Each has psychobiological explanations. For instance, there are physical changes to brain structures. The amygdala helps control emotion, memories, and behaviour, and the right hemisphere, which controls fear and aversion to unpleasant stimuli, can become enlarged. The hippocampus, which helps to consolidate the transfer of information from short-term memory to long-term memory, can become smaller. Brain signals are affected, as are hormone levels, with higher noradrenaline/norepinephrine levels and (counterintuitively) lower cortisol levels. There are also psychological, socio-interpersonal, and cultural explanations. Each kind of explanation may be of more or less help to different people. But I’ll not go into those further here. Rather, I’ll describe the symptoms from an experiential point of view, along with some general information. 

Flashbacks

Flashbacks are perhaps the most well-known symptoms of PTS(D) in popular culture. Traumatic events are reexperienced from memory, as if you are back in the scene, with the emotions and often physical sensations that were present at the time. The flashbacks can take the form of all of the senses, or just one. They can also include feelings of guilt and shame, even if others would see no justification for them. Flashbacks are the first thing that I remember about PTS(D) and were linked to a few traumatic events. Avoiding a trigger or waiting for the scene to play out was often the only thing I could do, but it required a great effort not to get sucked in the vortex of reexperiencing. Flashbacks dissipated over the years, but this took a very long time because I didn’t get proper help at the time, either from friends or professionals. Ultimately, psychotherapy did help but I waited far too long to get it. 

Nightmares and night sweats

Imagine waking up in the middle of the night, night after night, experiencing the death of a loved one – someone different each night – until almost everyone you love has died. They’ve not all died in reality, but rather in your dreams. It hardly bears thinking about, and I didn’t consciously think about it. My unconscious mind did that for me. I would also wake full of sweat – the bed sheets soaking – and this could happen with or without any nightmare. Nightmares can be one of the most acutely distressing symptoms of PTS(D). As they reoccur, and you come to expect them, sleep can become further affected. This occurred over a number of weeks, several years into the experience, until I sought help from a clinical hypnotherapist. Only two or three sessions of clinical hypnotherapy later, and the nightmares stopped. They returned many years later, but only temporarily, as a sign that all was not well. 

Fight, flight and freeze

So-called hypervigilance and heightened startle reactions are well known symptoms of PTS(D). For me, they were the most tiring and debilitating. Everyday things and situations can become potential threats. I became hypersensitive to noise and situations where people were gathered together, especially if I sensed trouble. In some senses, this could be useful: I became an expert at spotting potential disorder or violence. But in most ways, it wasn’t useful. A dropped object, slightly raised voices, unexpected claps, or a demonstration elicited the fight, flight or freeze response. Flight was the usual action – escaping the situation, such as a crowd. Occasionally the fight response prevailed – the body and mind ready to fight (usually a non-existent threat). But sometimes, freeze – the most debilitating of the three – would take over instead. With the freeze response, the body literally becomes immobile, stuck like glue. Fight, flight, and freeze is also characteristic of anxiety more generally, even without PTS(D), and can be visible to others, even though observers probably won’t understand what’s going on for the person.

Dissociation: depersonalisation and derealisation 

With PTS(D), the person can begin to experience dissociation, including depersonalisation (feeling as if the self is not real) and derealisation (feeling as if the world is not real). Disassociation is a common and normal response to trauma. Like fight, flight and freeze, it stems from a survival instinct. But if PTS(D) is left to its own devices, it can become more persistent and problematic, when survival is no longer the issue. It is more common among those who have experienced repeated traumas. I experienced derealisation. It is, for me, the hardest symptom to explain, partly because it is hard to explain something that feels so unreal. It is like seeing the world as an observer through a frosted glass window, or as a dream. The episodes – somewhat like flashbacks but without the imagery of past experiences – didn’t seem to last long. The most common sign to others may be an appearance of being spaced out or frozen, or both. Memory loss is also common. 

Physical manifestations and illnesses  

In my teens, in the context of trauma, I experienced tics (involuntary body movements) for the first time. I had no idea what they were, though later came to learn that tics and Tourette syndrome runs in my family. I learned to suppress them by what I thought of as keeping a ‘clean internal environment’ – a sort-of mindfulness mixed with avoiding known emotional triggers. In my experience of PTS(D) in later life, the tics returned, but this time I was unable to prevent or suppress them. Having forgotten that I ever had them as a teen, I had to adjust to a totally new self-concept – an adult with tics. This was intensely upsetting to me, even though few probably even noticed them, and certainly were not bothered by them. Depending on circumstances, they still come and go, to the extent that I can maintain this internal environment. Deliberate suppression is possible at a price due to the energy required, and when this energy is depleted, it is not possible at all – like trying to resist a sneeze.

Many who experience PTS(D) also experience physical illnesses, often associated with changes to the immune system. I developed shingles (herpes zoster) during my second experience of PTS(D) in adulthood. (As if the emotional pain of PTS(D) symptoms were not enough, shingles is like A Greatest Hits of Physical Pain!). 

Depression and low mood

It is not surprising that depression and PTS(D) often co-occur. The day-to-day toll of PTS(D) is enormous. The flashbacks, the nightmares, the sleep disruption, the fight/flight/freeze state, the physical manifestations and illnesses. Any of these alone can be enough to trigger depression. And yet none of these is even necessary. The event(s) that triggered PTS(D) can be enough. But in combination, the symptoms can be overwhelming. While it is different for everyone, for me it resulted in a combination of numbness, being less interested in doing things I used to enjoy (I could no longer paint or draw, for example), and trouble feeling positive emotions. It was a sort of death of part of my emotional life. There were also bouts of crying, which were often unexpected, and returned later in life as a sort of PTS(D) about PTS(D). Perhaps the most distressing aspect of depression, though, was a loss of sense of self, a kind of detachment from the world, and an inability to envision a positive future. Depression is a very common condition. Each year, 25% of the European population suffer from depression or anxiety (WHO, 2020). Unfortunately, about 50% of major depressions are untreated (WHO, 2020). Thankfully, as I found, help and hope can be found in counselling and psychotherapy, nature, exercise, mindfulness, hobbies, friendship, community and personal development. 

Healing and growth 

It is not for me to give any advice on recovering from PTS(D). This is the job of an experienced doctor, psychologist or psychotherapist trained in PTS(D), not a psychologist who has experienced it. Still, it feels appropriate to share some things that did help me and that seem like fairly low risk things to suggest. What I want to emphasise first though is that PTS(D) is not just a ‘mental’ condition. PTS(D) is profoundly physical. It feels like it is stored in the body and seems to live in you like a virus. Research also indicates a variety of biological changes.

Any effort to recover may need as much focus on the physical as the mental, as well as the interpersonal and the spiritual. For me this included exercise, tai chi, yoga, walking in nature, meditation, and plenty of sleep.

Taking to trusted friends who are able to listen without interruption, judgement or advice is essential. Seeing a professional is especially important if symptoms last for a long period of time – more than a few days or weeks. (For a person to be diagnosed with PTSD, symptoms last for more than a month but often persist for months and sometimes years, as was the case for me.). A general practitioner doctor may be a good place to start, but contact with psychologist or psychotherapist with experience of traumatic stress may well be a necessary step. 

And then there are the spiritual aspects of PTS(D) and recovery. In my late 20s, I explored these via recovery groups, Buddhist meditation, and Quakerism. Most surprisingly for me, in later life, when I reexperienced PTS(D), I found myself writing poetry. Having never written a poem since high school, and previously having no interest in it whatsoever, I wrote dozens of poems within weeks, and published some at https://ptsdays.home.blog/poems/. There is something about writing poetry that is very different to talking or writing prose. I still can’t explain it, but it seemed to help process and wrap up certain events. Perhaps, for me, poetry is most connected to the spiritual aspects of PTSD and recovery. 

“Son, if you saw what I saw, you’d never want to talk about it”

I thought for a long time before writing this article, and throughout writing it, I have wondered whether I should publish it. The sentiment expressed by my grandfather lives within me. Indeed, this article is very different to every other article that I have ever written. Many of my articles concern risk, but there is no risk to me in writing them. This one does concern me and feels very risky, even if that there is – in reality – very little risk. 

But I’m writing this article for a few reasons. The first is for me. Writing is the way that I make sense of the world and in this case, my experience. PTS(D) is the bull in the china shop, and it’s hard to make sense of what’s going on from within the china shop. Writing prose or poetry is like watching a film of the bull from outside of the window. Getting out of the china shop in order to take this perspective is difficult, and writing does not come naturally for everyone. I never imagined writing poetry either. Letting go of perfectionism and just writing from experience seems to be the gentle way. There are other ways out of the china shop, such as via art, talking, and therapy.

The second reason is that, while I can write about PTS(D), and can now talk about the events, I cannot yet talk about the symptoms and experience of PTS(D), except one-to-one in a safe environment with people I trust. I have given talks in front of over 1000 people, but could not (yet) talk about PTS(D) even in a small group. It may be something to do with a profound lingering sadness at being affected for so long in my young years. So I guess this is the talk I cannot give. 

The third reason is to help normalise PTS(D). Any one of the symptoms of PTS(D) can feel stigmatising to some. While an understanding of the cluster of symptoms that constitute the diagnosis of ‘PTSD’ may well have encouraged me to seek help in my teens, one word would probably have discouraged me: ‘disorder’. As retired U.S. Army General Peter Chiarelli said, “no 19-year-old kid wants to be told he’s got a disorder.” (There is now pressure from outside of the psychiatric profession to ‘drop the disorder’ from such labels.) I didn’t want to think of myself as having a ‘disorder’. It seemed stigmatising. It also didn’t fit my self-concept of being in control; PTS(D) actually heightened a need for control, which dissipated significantly during recovery. But it should be understood that post-traumatic stress is a normal response to traumatic experiences. Most people will experience trauma, and people will have different perspectives on what constitutes trauma for them. If you try to manage it alone, the cluster of symptoms known as PTSD is more likely.

The fourth reason is to encourage others to do what I didn’t do enough – give someone the opportunity to help you. Coupled with this is a hope that those who know someone with the signs and symptoms of PTS(D) might ask twice when the person says they are “fine”. You are not there to cure the person, but can give time, a safe space, and a non-judgemental listening ear, perhaps along with gentle encouragement to seek professional help.

The fifth reason is to give hope. From post-traumatic stress can come post-traumatic growth. I could not have imagined what I have been able to do in the years after PTS(D), including moving around the world and getting through some of the most stressful as well as joyful life events. While the bull does occasionally return to the china shop, it has mostly been relaxed or asleep in the field, which is where it ought to be. 

Overcoming denial 

Traumatic experiences are so common that you or someone close to you are likely to experience them at some point in your life, and many of you will experience PTS, which for some will progress to PTSD. It is so ubiquitous that we don’t acknowledge it or talk about it. PTS(D) symptoms can remain hidden for months or years after a triggering event, and many will never come to understand or accept that their cluster of experiences really do amount to PTS(D). 

Going back to Clarke Carlisle’s observation, Dr Peter A. Levine, author of of the book Waking the Tiger: Healing Trauma, wrote that “Because the symptoms and emotions associated with trauma can be extreme, most of us (and those close to us) will recoil and attempt to repress these intense reactions. Unfortunately, this mutual denial can prevent us from healing. In our culture there is a lack of tolerance for the emotional vulnerability that traumatized people experience. Little time is allotted for the working through of emotional events. We are routinely pressured into adjusting too quickly in the aftermath of an overwhelming situation. Denial is so common in our culture that it has become a cliché.” 

It seems that many of us, and especially men, deny our experiences or else try to fight them alone. This prolongs a struggle that is already too much for any of us individually. If you think you may be experiencing PTS(D), or depression, anxiety, or indeed any mental health problem or experience of distress, ask yourself, have you given someone the opportunity to help you?

Getting Help

The following are some English-language resources.

• TED-Ed. An educational video about PTSD.
• PTSD UK. PTSD UK is currently the only charity in the UK dedicated to raising awareness of post-traumatic stress disorder – no matter the trauma that caused it.
• Mind. A UK-based mental health charity.
• US Department of Veteran Affairs, PTSD: National Center for PTSD. A research and educational center of excellence on PTSD and traumatic stress.
• Helpguide. HelpGuide is a nonprofit mental health and wellness website. Our mission is to provide empowering, evidence-based information that you can use to help yourself and your loved ones.
• Black Dog Institute. The Black Dog Institute is dedicated to understanding, preventing and treating mental illness.
• PTSD Association of Canada. A non-profit organization dedicated to those who suffer from post-traumatic stress disorder (PTSD) those at risk for PTSD, and those who care for traumatized individuals.

Some books that may be helpful:

Haig, M. 92015). Reasons to stay alive. Canongate Books Ltd.

Levine, P. A. (1997). Waking the tiger: Healing trauma. North Atlantic Books.

van der Kolk, B. (2015). The body keeps the score: Mind, brain and body in the transformation of trauma. Penguin.

Sincere thanks to the friends who read this article prior to publishing.