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Section 12
The Shock Stage of PTSD

Question 12 | Test | Table of Contents

Immediately following the accident your client was probably in the shock and denial phase; he or she felt dazed or confused. The disorientation and numb­ing may have been physical, mental, emotional, or all three. For example, your client may have been injured, but experienced little or no physical pain. He or she may have been cold, but didn’t think you needed a blanket or coat. Your client may have been bleeding, but emotionally detached him or herself from wounds or you dismissed them as unimportant. The denial and shock may have been so absolute that they were unable to believe that the accident had actually occurred, as Laura was.

When Laura’s car was totaled in an accident, she looked at the crumpled bodywork in disbelief. "I felt as if I were watching a movie, that it wasn’t real life," she said later. Then she glanced at her arm. One of the bones was sticking through the skin, yet she felt no physical pain, and instead of shrieking in horror she felt detached. "Isn’t that interesting," she remembered thinking, "I never knew bones were that color."

Laura’s husband was also in the car. He remembered every detail of the accident: the color of the oncoming car, the face of the driver, the names of the police who arrived on the scene, and so on. Laura’s memory was less vivid. She could recall the time of day and what she was thinking, but other memories were vague and confused. For example, she couldn’t remember the exact sequence of events or how long it was before the rescue team and police arrived.

Like Laura, your client’s memory of the accident may be crystal clear in some respects, but cloudy in others. If their memories of the event are partial or distorted, this may be due to the phenomenon of "tunnel vision" that frequently occurs during severe accidents. Tunnel vision in this case means that the survivor remembers vividly some aspects of the trauma, but not others, for example, the way crime victims may remember exact details about their attacker’s weapon, but be unable to identify his or her facial features, size, or clothing.

During the initial shock and denial stage, your client probably experienced the adrenaline reactions common to people in life-threatening situations: the fight, flight, and freeze reactions. You might explain to your client that in emer­gency situations, the adrenal glands function to produce extra adrenaline, which energizes you and mobilizes you for action. Alternatively, the ad­renals may produce noradrenaline, which decreases your functioning. The freeze reaction in its extreme form is often called "going into shock." In that state you may physically pass out or find yourself physically immo­bilized, although aware of what is going on around you.

Both adrenaline and noradrenaline reactions are normal. However, being cool, calm, and collected immediately following an accident is also normal.

Also possible are near-death or out-of-body experiences. Such ex­periences usually occur to individuals who are close to dying, who have died but have been revived, or who are undergoing an intense biological or psychological stress, such as a vehicular accident or criminal assault. Such experiences are not signs of psychosis, brain damage, or mental illness. Although these experiences are not common, they occur more fre­quently than is usually thought. According to the International Associa­tion of Near-Death Studies (IANDS 1992), a 1991 Gallup poll indicated that approximately 13 million people in the United States had had a near-death experience.

During a near-death or out-of-body experience, you feel as if you have left your body and are in the sky or somewhere else removed from the immediate accident, and you view the immediate situation from a safe distance. You may even have a spiritual revelation or encounter. If your client had an out-of-body experience, it may have brought him or her great peace. Alternatively, it might have created mental, emotional, or spiritual con­fusion. David and John, for example, had similar experiences, but were affected by them in different ways.

David was in an airline crash in which his leg was severed. At one point during the accident he was near death and had a spiritual revelation that later enabled him to accept his amputation without undue bitterness or rage. John was in a serious car accident. While he was being tended to by a rescue worker, his heart stopped beating. Although he was quickly revived, during the moments he was dead he had an out-of-body experience in which he viewed the scene of the accident from somewhere in the air. During this experience he also had a spiritual encounter. This experience so challenged John’s previous view of the world and himself that he separated from his wife and went into virtual seclusion to "get himself together." He also quit his job and refused to see his parents and other family members.

John’s life today is full of emotional agitation and spiritual questioning. Yet, prior to the accident, he had no previous emotional or substance abuse problems, and he enjoyed a stable job and a fulfilling marital relationship.

Client Exercise: Reexamining the Accident and Its Immediate Aftermath
Return to your journal entries that describe the accident and the sec­ondary wounding experiences that followed. After re-reading what you’ve written there, consider the following questions:

1. Are there any details you can add now to make the description more complete? If so, add them to your journal.

2. Are there details of the accident that you do not remember? List those events, smells, sights, and other aspects of the accident where your memories seem to be missing.

As an aid to remembering, consider contacting witnesses (if any) or reading newspaper accounts or police reports of the accident. If, however, you feel it would be too traumatic to remember, do not try to stimulate your memory in any way. There is no point to unearthing details you aren’t ready to handle and which you may not need to handle in order to recover. Not every aspect of the trauma needs to be understood and emotionally felt in order for healing to progress. In some situations, trau­matic memories are best left in repression. The best guide in this decision is your own gut reaction.

After you have made additions to your description of the accident, review your writing on any feelings of self-blame you have about the accident or being a victim. If you have not covered the following ques­tions already, consider them carefully:

3. Prior to the accident, did you ever even think you would be involved in an accident like the one you experienced?

4. How did you believe you would act if you were suddenly in a serious accident? Did your actual behavior match your expected behavior? How do you feel about any discrepancies between the way you an­ticipated feeling and acting and the way you actually felt and acted?

5. In assessing your reaction to the accident, are there any ways in which a surge of adrenaline might have influenced your behavior? Are there ways in which noradrenaline, or the numbing response, may have in­fluenced your thoughts and behavior?

Also review your journal entries on secondary wounding, and think about these questions:

6. Did anyone criticize or negatively comment on how you behaved fol­lowing the accident? Were you blamed for the accident, either wholly or in part?

7. To what extent did you agree with your critics? What evidence exists that the views of these critics and others are accurate?

8. If one of your children or someone you loved dearly or respected highly had been in your position during the accident, how would you feel if others criticized that person the way you were criticized? With which parts of the criticism would you concur and with which parts would you then disagree?
- Matsakis PhD, Aphrodite; I Can’t Get Over It: A Handbook for Trauma Survivors; New Harbinger Publications, Inc: California; 1992

Personal Reflection Exercise #5
The preceding section contained information about the shock stage of PTSD.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
O'Connor, D. B., Branley-Bell, D., Green, J. A., Ferguson, E., O'Carroll, R. E., & O'Connor, R. C. (2020). Effects of childhood trauma, daily stress, and emotions on daily cortisol levels in individuals vulnerable to suicide. Journal of Abnormal Psychology, 129(1), 92–107. 

Taylor, S., Charura, D., Williams, G., Shaw, M., Allan, J., Cohen, E., Meth, F., & O'Dwyer, L. (2020). Loss, grief, and growth: An interpretative phenomenological analysis of experiences of trauma in asylum seekers and refugees. Traumatology. Advance online publication.

Tsvieli, N., & Diamond, G. M. (2018). Therapist interventions and emotional processing in attachment-based family therapy for unresolved anger. Psychotherapy, 55(3), 289–297. 

According to Matsakis, what are two possible outcomes of a client’s near-death or "out-of-body" experience? To select and enter your answer go to Test

Section 13
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