January 31, 2021
Olivia Shabb, a licensed clinical psychologist and faculty member of the Psychiatry Department at AUBMC, has been treating patients affected by the explosion at the Beirut port.
How would you characterize the effect of the blast on your patients?
Think in terms of three phases. In the immediate aftermath of the blast, acute stress disorder, which is characterized by hyperarousal, was very prevalent. This is when the nervous system is riled up, creating constant anxiety, difficulty sleeping, and the sense of being easily and powerfully startled. The nervous system simply can't turn its alarms off. The explosion occurred at 6:08 pm on a Tuesday, at the end of a working summer day, when families and friends were reuniting at home or in regular hangout spots. The explosion violated their most intimate spaces and shattered the most basic sense of trust and safety, and these dramatic losses were compounded by other crises going on in the country.
In the second phase, the task of processing events and the enormous grief that comes with them begins. The shock has mostly passed, and now people must settle into a reality that's so jarringly different from what they would have expected or chosen. The blast cut short or warped the arc of so many people's lives. Aside from the crushing toll of death and injury, you have a lot of families who have renovated and rebuilt their homes, yet can't set foot in them, or who have emigrated. A lot of people feel alone and unsafe in a broken country. Morally and materially, people feel under-resourced.
The third phase involves reconnecting and making meaning. I don't think we're quite there yet. It's based on getting your bearings back and plugging into support systems that are meaningful. It means considering how the event has shed light on your values and restructured you in a way that has made you feel more purposeful. Many people are still in phase one, actually, or just moving into phase two.
Can you give examples of sleep issues?
I had one patient who couldn't sleep, not only because her nervous system couldn't settle down, but because she couldn't decide on which space in her room was the safest. She'd say, I can't sleep near a window; that could make me vulnerable. But if there's an explosion, the glass will be blown far away, so maybe far but not too far from the window is best. She went through all these calculations to figure out where she would most likely survive.
Another patient would soothe himself to sleep as if he were a child, only to find himself wide awake with a rush of adrenaline, fully dressed, ready to run out the door, and this would happen several times a night.
Can you elaborate on why people—even those within the same family—present such a wide variety of PTSD-symptoms?
In a family or a couple, one person's coping style might be alienating to someone else. There was a couple whose home was totally destroyed. The woman became hyperaroused and extremely emotional, while the man fell into this hypercompetent, organized pattern that relied on a state of emotional suppression we call hypoarousal. She experienced him as callous and emotionally unavailable, whereas he found her emotionality overwhelming and threatening in terms of what they needed to do to get back on their feet.
What about people's experiences of home?
Apart from basic physical repairs, people are having to reconcile emotionally with their homes. People were killed or injured by their own windows shattering. Everyday items they had trusted were weaponized against them. They must make peace with a space they feel betrayed them, that killed their spouse, or their child. One woman had to go back to her home and scrub her deceased husband's blood prints off the bathroom wall. How do you make peace with a space after that? You try to get patients to think of spaces not as perpetrators but as victims of the same crime. In some ways you anthropomorphize homes so you can give them the same compassion and forgiveness you might give a person. And you also work on accepting that spaces that were loved in and lived in might never feel the way they did before the blast; that you might have to build a different relationship with them.
The blast has also affected people' ability to conceive of Lebanon as home. Not only was there no larger structure to rely on in the wake of the disaster, but the larger structure itself is directly responsible for the disaster. Instead of support and accountability, there is a new level of anger and disillusionment. We're lucky to live in a country with strong personal connections, but the support systems that people normally rely on are drained by the financial and health crises, and increasingly, by mass exodus. But even people who have emigrated are wrestling with the mental and emotional gymnastics necessary to manage their attachments to the “home" that is Lebanon.
What are some of the particularities of doing trauma work in the context of the blast?
Some people just want to be functional so their children can have the hope of normalcy. Their chief complaint is not, for example, “I want to feel better," but “I need to be a competent mom again." Immediate goals of treatment have often been related to people's familial roles because they may be the linchpin of an injured system.
As I mentioned before, the first step is safety and stabilization: developing or reconnecting with basic coping mechanisms. Then comes learning to talk about what happened, how it happened, and how to integrate that narrative into a life that you can keep living. In phase one and two, one of the most heartbreaking aspects has been addressing people's perseveration over the choices they made in the bloody disorientation that followed the blast.
For example, one woman was with her children next to the window watching the smoke from the port when the blast happened. She was knocked down, and when she came to, her children were badly injured. She assumed her husband was fine since he had been away from the windows, so she grabbed her children and ran to get help. For hours afterwards, she was unable to entrust her children to anyone since the streets were filled with terrified, severely injured people, and the children themselves were too terrified to separate from her. Afterward, neighbors found her husband critically injured, and he died soon after being taken to hospital. This woman was living with excruciating, unrelenting guilt about having prioritized the children.
Another woman dropped her kids off for a playdate. After the explosion she managed to reach the building, but seeing the destruction, she fully believed her children had died. Instead of looking for them, she “switched off" and began shuttling the wounded to hospitals. Later she found her children were alive under the rubble, and she couldn't forgive herself for not searching for them. But at the time, she simply couldn't face the idea of finding their bodies.
We try to bring context and compassion to the choices that people made in the aftermath of the explosion, to make sense of the experience and fit it into a narrative that is morally and existentially calmer. We also support people in sitting emotionally and physiologically with the experience until it doesn't pack the same punch.
Does a “collective trauma" require a collective sort of therapy?
As a therapist in this case, I am not the usual impartial witness to someone else's trauma. I have my own internal processes to hold and work with, and sometimes it interacts with what I'm hearing and witnessing in a way that I have to be mindful of. It's been an unfathomable period of human loss, and we're all part of this injured and fraying tapestry.
The collective trauma has also created collective reactions: community-wide disbelief, community-wide anger, community-wide grief, a renewed cry for change on a systemic level, a communal plea to live in a country and society where there is fundamental care and safety.
And indeed, people did engage in a collective sort of therapy by mass-volunteering to clean up streets and repair homes after the blast. It was mind-blowing and heart-opening. People were itching for this collective experience of healing and wanting to be a part of the reconstruction. Still now, people and organizations are looking for opportunities to support, to rebuild, and to heal.
Collective therapy now is required, and I think the most important elements of it are systemic change, apology, and accountability on a governmental level. We cannot keep putting the responsibility on individuals or communities to heal themselves when the conditions that govern them are so harmful.
Is there anything you can compare this to in your history to guide you in your practice now?
Absolutely not. You can be trained in trauma treatment, but the scale and nature of the explosion and its aftermath has required a new level of flexibility, creativity, resilience, and reckoning. ER doctors will tell you, “there's nothing that can train you for this," and it's similar with psychology, but one of the things we were able to set up was a crisis-care clinic, and to secure funding to extend our services to blast victims.
Trauma treatment typically assumes that the danger has passed, and that patients in treatment are operating from a safe place. However, this isn't an assumption readily made in this country. The delivery of treatment when there's still such a basic level of mistrust and uncertainty, and when patient and therapist share a traumatic reality, complicates things. Particularly when the explosion was fresh, we were not operating from a baseline of safety. Delivering treatment was a matter of balancing urgency of response with feeling out the facts on the ground in an unprecedented urban disaster.