SPENCER: George, welcome to the Clearer Thinking Podcast.

GEORGE: Hello Spencer. Happy to be here.

SPENCER: There is so much misinformation about trauma, and it's become this kind of buzzword that everyone is using. So today I want to dig in with you and understand what trauma really is, what's important to understand about it, and what are common misconceptions about it. But let's start with something really simple. What do you think the best definition of trauma actually is?

GEORGE: That's a great question. The definition has varied over the years. The definition that I like is really kind of the original one that was formalized with PTSD, which is basically something out of the realm of normal, everyday experience that is violent or life-threatening or involves sexual violation, anything like that. It's something really like a kind of an emergency situation.

SPENCER: And by that definition, is trauma always traumatizing?

GEORGE: Traumatizing is a funny word. It gets used very loosely, but I actually don't call these types of events traumas. I call them potential traumas because they're potentially traumatic and they don't always lead to long-term trauma, long-term harm, not at all, not by a long shot.

SPENCER: So imagine that we have a situation that's really incredibly frightening, like, let's say there are a hundred students at a school. There's a school shooting, everyone you know feels like their life is in danger. Let's say all the students kind of hide and then they all rush out of the building together. They've all gone through essentially the same experience, but is it fair to say they won't necessarily have the same reaction to that experience?

GEORGE: Yes, completely. That's absolutely fair, and it's absolutely true. That's a school shooting. That's a pretty bad one, that's a pretty serious event, and even within that kind of event, not everybody has the same experience. Most everybody will be deeply upset. That's completely normal, but only a relatively small proportion, even for something as high as a school shooting, will develop lasting trauma reactions, lasting harm.

SPENCER: And when you talk about lasting trauma reactions, is that basically equivalent to talking about PTSD, or is that a broader category than PTSD?

GEORGE: Well, PTSD is a category, but when I say lasting, I'm referring to trauma symptoms that last around a month. It's very normal for most people to have what we think of as trauma symptoms within the first days or a couple of weeks, things like a nightmare or two intrusive thoughts — unpleasant, scary thoughts — popping into your mind, being a little bit on edge. Most people experience that in a very short-term way for just a few weeks at the most. That's the common reaction because that's our brains trying to make sense of what happened. After that, if those symptoms continue, then we get into the realm of long-term trauma and something like PTSD.

SPENCER: So we think about those 100 students that went through the school shooting. Certainly in the hours, but even in the days after, many of them will look like they're having PTSD symptoms, even though many of them won't ultimately get PTSD.

GEORGE: I don't know exactly what to say about what they would look like. I think many of them will experience something like those reactions, PTSD symptoms, at least some PTSD symptoms within a few days. More will experience them over a couple of weeks, and then even fewer will experience them over longer periods than that. So it's really the acute time, like in the first few days, that will be very intense and slowly diminish for most students, most people who go through things like that.

SPENCER: So is it fair to say that long-term trauma reactions, what's unusual about them is not the experience, but that it stays around? It doesn't kind of resolve itself.

GEORGE: Yeah, it doesn't abate. Yeah, that's what we get when we have PTSD.

SPENCER: And what is known about why it doesn't abate for some people? Because obviously some people will go away having had the same experience.

GEORGE: Yeah, yeah. That's a very interesting question. We don't yet have a great answer to that in the field. There have been some great explanations that have some empirical reality. One of them has to do with the levels of cortisol in our body, resting cortisol, or the kind of cortisol reaction that we have. That's a very complicated system in our brain that regulates cortisol. Cortisol does a lot of different things, and for some people, depending on their life experiences, that regulatory process gets a little out of whack. It's either a little bit under-reactive for various reasons, and that's not common, but that's one factor. And there are some other factors too — life experiences, probably a genetic piece to it — all of these are small pieces that kind of add up. And then it could be just a person is in a really bad way, or they're struggling and they're in a high-stress situation for some period of time. Stress kind of disequilibrates us, it gets us a little bit off kilter. And maybe they're in that kind of state when there's exposure to a trauma or there are many other factors and we don't really understand them all. I think it's fair to say.

SPENCER: Tell us about the range of different reactions people have when they go through a potentially traumatic event.

GEORGE: Well, that's an interesting question, and we've studied this. I've studied this now for 35 years, and I've detailed this pretty much in my most recent book, which is called The End of Trauma. I detail a lot of what we know or what we've seen recently in that book. That book came out a few years ago, and what we've seen is that when we follow people over time, we've been able to map different trajectories. Some people, a relatively small percentage of people, show basically chronically elevated symptoms. They have a strong PTSD-type reaction, and it doesn't go away. Over time, they develop PTSD and struggle for years. Another group of people we see has this kind of acute reaction. They get very, very anxious and upset and struggle quite a bit. They continue to struggle after the event, and it gradually goes away after many months, sometimes a year or two. Then we see another group of people, the most common pattern. There are still a few other patterns, but the most common pattern, which we see in the majority of people, in almost every case, is a very short-term disruption in their lives. They're struggling a little bit for a while, and then they basically resume a normal level of function. We see that almost always, in the majority.

SPENCER: Do we know whether it depends on the meaning of the event to the person? Because you could imagine that even if people went through the exact same event, they could interpret it differently, or it could have a different meaning or significance to them. For example, I think almost everyone who is raped would find it incredibly upsetting. But you could imagine one person living in a culture where being raped means you're going to be thrown out of society if anyone finds out. In another culture, people are going to come around you and try to help you and love you, and they don't blame you. You're not going to blame yourself for it or treat it as making you deficient in some way.

GEORGE: Yeah, definitely that is a factor. There are lots of things that go into who is going to show these different patterns, but even within, as I mentioned before, even with the same event, we did a lot of research after 9/11 and spent a lot of time getting people who were actually in the towers or right at ground zero when the planes hit. We interviewed those people at length and followed them over time, and even people within the building, all of those people had to get out at great effort and run for their lives when the towers came down; they had wildly different experiences. Even people who had somewhat the same experiences may have seen it in different ways, like, "Oh my God, this worst thing happened. Why did this happen to me? Who are these strangers who did this?" versus, "I can't believe I got out. I'm so lucky." And that's not going to determine everything, but that's a factor, like many other factors.

SPENCER: Yeah, it is fascinating how people can react so differently to the same event. I sometimes think of it as one's psychological immune system. We know that after something bad happens, even if it's not such a severe bad event, but even just a more minor event, one person will laugh about it, another person will think, "Oh, this always happens to me. Why am I so unlucky?" A third person will think, "Well, I still have it better than a lot of other people." The reaction can be so different and change the meaning, and ultimately change how we feel about the event.

GEORGE: Then that often goes by the name of social comparison. We decide, "Well, this was bad, but I could have been this other person."

SPENCER: Let's talk about types of psychological harm that can happen after a potentially traumatic event. So we've got PTSD, and we're going to go into that more in a little bit. But are there other types? If someone doesn't get PTSD, are there other types of harm that can happen to them? Many people think that if you have a trauma in childhood, for example, it could still be affecting you today, even if you don't have PTSD, and it could still be harming you in some way.

GEORGE: Well, there are a lot of misunderstandings about those things. The example you gave, a trauma in childhood. What's interesting is that when we look at this category of events, say, violent, life-threatening events, most people are going to go through at least one event and often several like that in the course of their lives. Most people go through these types of events, and they are in our past. For most people, they don't produce lasting trauma. If we are, in fact, traumatized, meaning if we have an event in our childhood that has disrupted us in a serious way, or even, as you said, if it didn't cause trauma, but it was something we had to deal with in a really demanding way, if it's in our childhood, it could possibly shape the way we see the world, how we adapt, etc., and it could influence the person we become, which is a lasting issue. But this is life. Essentially, lots of people are shaped by, we're all shaped by the experiences we have.

SPENCER: Sometimes people talk about ACEs or adverse childhood experiences, which is a list of different bad things that can happen to you in childhood. As you point out, many people, most people go through at least some of these adverse childhood experiences. At a population level, it's been found that, on average, people with higher ACEs, when they get to adulthood, have more depression, more anxiety, and more addiction. There seem to be a lot of things that are bad that are correlated with having had these ACEs. Obviously, it can be harder to know about the causality. But how do you interpret that people in adulthood seem to be substantially more depressed and more anxious?

GEORGE: I'm searching for the right word. Suspicious is a good word. I'm also very critical of a lot of the literature on these so-called ACEs because it's often done with a questionnaire, and people often fill out these questionnaires as adults. If someone's doing really poorly, it's well established that if we're doing poorly, our memories will be biased towards negative events. We're likely to remember and report more, or report events that we wouldn't have thought of as really bad events. We'll report them as bad events if we're doing poorly. So the causality, as you mentioned, isn't clear. We can't establish causality from this unless we follow people over time. A lot of the literature on this is skewed by this memory bias. That said, a difficult childhood doesn't condemn people to a life sentence, but it can have a negative effect. There are many things I could say about averages; they are also really misleading. They hide all kinds of effects, etc.

SPENCER: So in our own research, we tried to replicate those effects of whether higher ACEs scores really predict adult depression, anxiety, and stuff like that. Indeed, they do. We did replicate that. But then we looked deeper and asked, to what extent can you predict someone's individual adult anxiety level or depression level using ACEs? Our surprising finding was that it actually did a very bad job of predicting it, with very little predictability at the individual level. It almost seemed like a contradiction. How could it predict it at a population average level but not at the individual level? It's because individual trajectories are so wide; it's very far from a life sentence. There are lots of people who have high ACEs who are doing fine as adults. It's just very wide spread. So at the individual level, it was much less predictive than at the population level.

GEORGE: Yeah, many people have written about what's called the problem of averages. When you average something, you get an overall result, but it can often be misleading. The example I used when I was lecturing on this is that you have a classroom with a bunch of kids in the second grade. They're small. Then you have the teacher, who is much larger. If you take the height of the class, the average is pretty low, but you have this outlier, this tall teacher. Now the average is low, even though you have this tall person. Now you bring, say, the New York Nets to class to do a workshop on losing with dignity. They are really tall men, and now you take the average, and the teacher is the average height now, even though the teacher is just one person. You have these two extreme groups, and the average makes it look like everybody is the teacher's height. Averages can be very misleading in this regard. ACEs fit that perfectly, as the data you just described shows. Some people go through all kinds of stuff and are fine, while other people go through a lot of stuff, or even lesser things, and are really doing poorly. It just depends on so many other factors.

SPENCER: Another thing people sometimes talk about is that trauma in childhood or early adulthood could lead to something like constant vigilance as an adult, where your brain, on some level, is predicting that bad things are going to happen, and you can never fully relax. Maybe you have a lot of muscle tension and neck pain, or you just don't enjoy life very much. Do you think that happens?

GEORGE: I think it's possible, and it probably happens to some people. There are some people who are like that, and they haven't had previous trauma in their past, or they haven't had much, or they're anxious, or there are lots of different things. That's really anxiety, in a sense. What you're describing is anxiety, which can be caused by a number of different factors.

SPENCER: There's also people like Gabor Maté. I don't know if that's how you pronounce his name. You've seen him coming around. He's an extremely popular influencer who says things like, "Trauma is the root of most chronic disease." So what's your reaction to those kinds of claims?

GEORGE: People ask me about Gabor Maté — I'm not 100% sure I'm pronouncing his name correctly either. People ask me about him — and I haven't looked into it too closely, but I prefer to take it one statement at a time. So trauma is the root of most disease, I think, is just kind of an absurd statement because the root of most diseases is diseases. I don't know if he means psychological, psychiatric diseases or physical diseases, but they're caused by so many different things, and psychiatric disorders don't actually have much of a biological underpinning to them. Some people may develop chronic symptoms because of experiences with potential trauma, but I would say that's a dramatic overstatement to say that most diseases of any kind or form are caused that way.

SPENCER: I think what he's saying is just completely false. However, if I'm going to try to make the strongest version of this case that I can, my understanding is that quite a few diseases are influenced by things like stress, where you can get worse symptoms if you have higher anxiety or stress. Would you say that's fair?

GEORGE: Yeah. So what I would say is that, if I may, chronic stress is highly adaptive. Stress is what drives us. We have a stress response system, and it only works if we feel stress. Chronic stress, though, that lasts a month or two, when we get into that domain, then our body starts to get disequilibrated. These complex systems that are in balance with each other start to fall out of balance, and we get physical breakdown. Then we start getting physical symptoms that don't have any clear explanation: back pain, digestive problems, vision problems, whatever we have, and that's clearly associated with chronic stress. That's clear.

SPENCER: What about the work, such as in the book The Body Keeps the Score by Bessel van der Kolk? I imagine you're familiar with his work.

GEORGE: I am, yeah.

SPENCER: What do you think of his perspective?

GEORGE: I always find it a little hard to pin down because I've looked at the book, and it's a little bit hard to pin down. What I prefer to do instead of dismissing the book, which I have a tendency to do, is evaluate specific claims from the book. I ask people sometimes who tell me that they love The Body Keeps the Score to tell me what the claims are, what the points he made that they like. Usually, people can't tell me. I think one of the things that happened from The Body Keeps the Score, and I don't know with 100% certainty whether van der Kolk actually said this or people just extrapolated from his book, is maybe what people want to believe. The common assumption is that the book is saying that we have traumatic events kind of hidden in our bodies that we're not aware of, and they're driving our behavior, and that's patently not possible. There's no real mechanism for that. Our brain stores memories of events, and events that are potentially traumatic, events we can't get over that traumatize us. First of all, we're very aware of them. We don't forget them if they traumatize us; we know about them. I think a lot of the confusion, and this also happens with work, as I believe what he is saying, I'm not 100% sure what he's saying, but I think he and van der Kolk are both saying that you have these events in your past that you aren't even aware of anymore, but they're driving your behavior, causing problems in your life, and that's based on a misunderstanding. We have lots of potentially traumatic events in our lives; typically, most people do have at least one or two, often many more. We can always find disturbing things that happened to us in the past, but if they didn't traumatize us, we're done with them more or less. Sometimes, if it's a chronic situation that really makes our life difficult for a long time, we remember that, but that may change the way we see the world. These isolated events in our past are not driving our behavior as adults unless they were very traumatic and enduring at the time. I think that fundamental misunderstanding leads to a lot of these misconceptions.

SPENCER: I share your opinion that van der Kolk's book is intriguing because it's called The Body Keeps the Score, and it even mentions that phrase, but it never really explains what that means. I've read the book; it never says, "Okay, what I mean by your body keeping the score is this exact thing." If we try to think, what could it even possibly mean? Sometimes people do talk about patterns of muscle tension, such as, "Oh, my neck always gets tight when I'm stressed," or things like that. There is some kind of body-mental link, and it is linked to anxiety, but that's very different than literally being held in your body. I think we can explain that as, when you're anxious, you tend to have muscle tension. Probably that's because anxiety is a fight or flight response, and muscle tension helps you run away, and then that causes all kinds of pain and weird phenomena.

GEORGE: Many people lead stressful lives. We do far too much. We sit at computers, we take on too many tasks, we worry about things, and those kinds of things lead to muscle tension. Those kinds of things lead to all other kinds of problems. One of my colleagues, who I greatly admire, Lisa Feldman Barrett, a brilliant person, has written some really powerful stuff. She said, because we've talked about this, and she put it better than anyone: "The brain keeps the score; the body is the scorecard." The brain is driving what our body does, and if the brain is tracking what we've been through, that may result in how our bodies react, but the brain knows what we've been through. It's not hidden anywhere. It's not mysterious in the way that the body is holding onto it. I think it puts it more on the table with what we know. If it's on the table with what we know, we can try to make sense of it and see about changing it or alleviating it, etc.

SPENCER: That's a great quote. I think another interesting kind of mind-body link is that some things we do to relax the body seem to improve the state of the mind as well, like progressive muscle relaxation, where you ultimately tense and relax the body. It's not clear why that would work to relax the mind, but it seems to work. It seems to go bi-directionally.

GEORGE: I think some of it we could figure out. When you're tense, you tighten your abdomen, and you don't breathe; you don't take in as much oxygen. If we simply take a deep breath, you can feel how your muscles let go a little bit. You can feel that everything, even your brain, is being oxygenated, and you're going to think more clearly. I think some of these are well-known principles.

SPENCER: There's another idea of grounding, which seems to help a lot of people who experience anxiety, where they're kind of in their head, and by focusing on the body or on the environment around them, it gets them out of their head and helps them when they're panicking and things like that. So maybe that's another way the body can be helpful in dealing with these things.

GEORGE: Makes sense. Yeah.

SPENCER: Let's talk about PTSD, because I think that's for many people who go through really severe trauma, if there's a long-term consequence that they may face, and that's one of the most severe. So, what is PTSD exactly?

GEORGE: Well, PTSD is as it's defined. It is when we've experienced, first of all, one of these events that we would say is potentially traumatic, a violent or life-threatening event, a sexual violation outside the realm of normal human experience. After a month or so, that's somewhat arbitrary, but that's how the diagnosis goes. After about a month, if we're still experiencing a lot of these various symptoms, and the symptoms are things like intrusions. It's popping into our mind when we don't want it to. It's disturbing thoughts we're having, maybe nightmares, avoidant behavior, where we're really frightened about certain things, and we're anxious about certain things, being on edge, hyperarousal, feeling like the world is dangerous right now, and I'm unsure of myself. A lot of those kinds of symptoms are getting in the way of our functioning. Then, after a certain period of time, we get into the realm of PTSD.

SPENCER: Do they have to have flashbacks or intrusive thoughts to be considered PTSD? Or can you have it without those?

GEORGE: No, according to the definition, you need to have those. Yeah, otherwise it's something else. And I'm not a real fan of psychiatric diagnoses. I'm often very critical about them because I don't think that they're defined very precisely, and they're not defined through science. They're defined through committees and discussion, and there are a lot of really wise people in these discussions, in these committees that create these diagnoses, but they're not empirically defined, and that causes some problems. It leads to some assumptions that are problematic, like the assumptions that they are in nature and they are biological. They're certainly not biological either; we can never find the biological markers of any of these as we can with other diseases. So those are all problematic. But there's variability in how much and what kind of PTSD reactions people have. That's a little bit of a problem, but that is the way it is. People have different flavors of PTSD, in a sense, but the intrusions, that's definitely unbidden thoughts and nightmarish type things. That's definitely part of the definition.

SPENCER: Yeah, it's really fascinating. Looking at the history of the DSM, the Diagnostic and Statistical Manual that everyone uses in the US for classifying mental disorders, if you go way back, homosexuality was considered a disease in the first two versions of the manual, and there were a lot of really bizarre and egregious classifications. It's improved over time. At the end of the day, it's made by committees. Hopefully those committees are at least looking at studies, and I think they are now looking at studies, but still, there's a lot of subjective decisions to be made.

GEORGE: There's a lot of infighting among those committees. The thing you mentioned about homosexuality is fascinating because it was in the first two versions of the DSM, and the American Psychiatric Association made the mistake of having their convention in San Francisco. I believe it was in the 60s, maybe even the 70s, when by that time, San Francisco had become the gay mecca of America. They had the convention there, and there were lots of protests. I think somebody had a bucket of ice poured on them. The American Medical Association responded to the American Psychiatric Association by removing homosexuality from the DSM, which, in a way, was almost worse because it meant they took it out because people were upset about it. You have to think, "If it's a disease or disorder and you think it wasn't, why did you take it out?" It really underpinned the social side of it, that there's a cultural and social side of these disorders that isn't really supposed to be there. If you think it's a disorder, it's a disorder. It underscored the fact that what's a disorder and what's not wasn't really that well worked out, and still is not that well worked out. There's always a cultural element to it.

SPENCER: When people have PTSD, how common is it that it just goes away eventually on its own versus that it really needs treatment to help it go away?

GEORGE: That's a great question. I'm sure that PTSD can go away with time, but I always like to say that time does heal a lot of things, but time is in no hurry. If it does go away, it's going to take a long time. One of the problems, and one of the reasons why treatment for PTSD is very important, is that when anybody has been suffering for even a period of months, a lot of other things start to fall apart. There's this famous phrase, a downward spiral. If you're not sleeping, you're not able to concentrate, it's going to interfere with your job. If it interferes with your job, it's going to start messing with other elements of your life, maybe harm your relationships, maybe harm your self-esteem, your identity. That happens, and you're going to get depressed about it, and other symptoms are going to happen. The research shows pretty clearly that people who have had long-term PTSD often have a lot of other symptoms too, so it just gets worse rather than going away. Some people, it may go away, but I think treatment is a good option for long-term PTSD.

SPENCER: Someone with severe PTSD, what is their daily life like? Are they thinking about that traumatic event many times throughout the whole day? What's the sort of typical pattern?

GEORGE: There are different flavors. One of my former students, Isaac Galatzer-Levy, and a trauma researcher in Australia, Richard Bryant, did a fantastic paper called 636120 ways to have PTSD. What they did was use binomial equations to calculate because the DSM PTSD diagnosis is complicated; it results in over 600,000 different symptom combinations to get the same disorder. So it does vary greatly. Some people are just anxious about it. They're afraid to go outside because they feel they'll have a flashback in public and fall apart. Other people feel really lousy all the time because they feel the world is unsafe. For some, it inhibits what they can do in their life. If they've been in a terrible automobile accident, they can't be in a car now, which limits them in some way. There are lots of different ways it can impact people's lives, all of them negative for the most part, unfortunately.

SPENCER: You mentioned with PTSD that people tend to think about the traumatic event or have flashbacks. One thing I find really interesting about this is there's such a prevalent idea that we forget trauma. A lot of people believe that. Obviously, it's the case that sometimes, when bad things happen to you, you try not to think about it. If it comes into your mind, you might try to avoid thinking about it, but that's different than actually truly forgetting it, meaning you literally couldn't remember even if you tried. Do you have any comments on that?

GEORGE: I think there is a lot of misunderstanding about that. Some of the misunderstanding comes from something I've kind of already said. I go into this in my book a bit too, The End of Trauma, that a lot of these events that we're talking about, which I've called potentially traumatic events, do happen in people's lives. Most of us will experience a few potentially traumatic events in our lives just because life is dangerous. We're in automobile accidents, we experience natural disasters, medical emergencies, etc. The fact is we do forget some of those events. For example, we've learned when we do interviews with people, we used to go through these checklists and just give people a checklist and say, "Did any of these things happen to you?" People would say, "No, no, no." Then when we're interviewing them later, we might get them talking, and somebody might say, "Wait a minute. You asked me earlier if I had ever had a gun pulled on me. I have had a gun pulled on me. Now I remember." When I first started doing this kind of research, I thought, "How could people forget that?" The reason people can forget those kinds of things is that it didn't traumatize them. It may have been unpleasant, but then, like everything else, you can let it recede into the background. I think that kind of phenomenon has fueled this myth about repressed traumas or hidden traumas. They're not hidden traumas or repressed traumas; they're just events that happened that were not traumatic. We kind of forgot about them. They're there, and we can recall them if we need to, but we don't have to think about them.

SPENCER: Is it accurate to say that while it's possible to forget a severe trauma, you're actually much less likely to forget it than you are to forget just about anything else in your life?

GEORGE: Yeah, I think that's very much true. When we've been seriously traumatized, it's going to impact our life in a big way for some time. If we're traumatized by that event and it has lasting harm, it's not going to be something we forget. It's going to be there. We may not want to think about it. We may do our best not to think about it, change the subject, but we know it's there. It doesn't go away. We don't suddenly not remember it for years. That doesn't happen if it's been serious, because our minds know that it happened.

SPENCER: How do you feel about modern usage of the word trauma? It seems like it's gotten watered down to the point where people will say, "Oh, when I saw that photograph, I was traumatized," or "I was traumatized reading that one-page document," or these kinds of things.

GEORGE: Yeah, it was annoying to me for some time because it flew in the face of everything we know, and I felt like it was confusing the general public about these issues. It was really unfair to people who have been seriously traumatized. It's like putting them in the same category. But I think at some point you just give up because we cannot control language. Language, especially English, especially American English, we love to play with words in this country. We play with them all the time, reinvent them. So there's not much we can do about that.

SPENCER: Do you think that having that attitude towards things can be psychologically unhealthy? If you think there are all these potential traumas around you all the time, if you look at the wrong photograph or read the wrong essay, it could be traumatic. Or do you think it's not a big deal either way?

GEORGE: No, I think it's very unhealthy because it makes us anxious. If we think about it, why would that be? The main reason is our brains are wired for threat. It's very adaptive evolutionarily to be quick to detect threats. We have multiple phases of how our brains do this, and one part of our brain will detect a threat very quickly, even if we're not sure. That's where we react to something that looks like a snake or something like that. The amygdala has a really low threshold because it's better to be quick and reactive than to be wrong. It's better to be quick and reactive but wrong than to miss it. Later, we have other structures that will fill in the details, but it's very important. When we start seeing trauma everywhere, thinking that everything is traumatic, I think that distorts that part of our brain, and we can make ourselves anxious and wound up by the world around us. I think we all have to learn this. The internet plays a big role in this now because it has gone from the wonderful, idealistic thing it was when it was first invented to this enormous money-making machine designed to keep us looking. The internet is going to feed us whatever gets a buzz from us, and dangerous things get a buzz from us. We recently did a paper on TikTok in this way. We have to grow up about that. We have to realize that's happening and take a little bit more control of our own lives. We need to stop doom scrolling. We have to stop looking at the internet all the time. Computers are wonderful tools, but we really have to get some control over it; otherwise, it makes us a little bit crazy.

SPENCER: Is it sometimes genuinely the case that an event happens and most people would be like, "Oh, that wasn't that big a deal," or "That wouldn't be traumatizing," but someone is genuinely traumatized and gets PTSD from it because of something about that event to them, even though it wouldn't upset most people?

GEORGE: Yeah, I think that's possible. It depends. It's not unlimited bandwidth, but to really have a truly traumatic reaction, it has to instigate this system that says, basically, the emergency lights are going on, and you're in big danger. React. It activates all these very primitive systems that are not trivial. If you activate the cortisol system from the HPA axis to a certain neural system, it's going to last for a couple of hours. It puts you in an altered state of consciousness for a couple of hours, this major stress response. These things get activated all the time. It really depends on the individual, how they're perceiving it, and what their experiences are. Some of the individual variation comes from our previous life experience. If we've been through a similar event in the past and we're okay, we're more likely to be calmer in that kind of event. It doesn't generalize to other events, but some people may think, "I know what happens here." There are idiosyncrasies to everything. Everybody is unique, and life is complicated, so some people may react really strongly to something that other people don't. If it's violent or life-threatening in some way, they may have a stronger reaction than anybody else does.

SPENCER: What is CPTSD? Something I hear about more and more, sometimes called Complex PTSD.

GEORGE: Yeah, complex PTSD is interesting. Because I'm a scientist, I'm very skeptical about it. I don't dismiss it as not real, but I don't think we know very much about it yet. The idea is that if you've had chronic exposure to traumatic events, such as chronic physical or sexual abuse, or being in wartime for a long time, or maybe being deployed five or six times in a military context, or any context where you are in constant exposure to traumatic stress, that has an effect, kind of a different kind of PTSD. I don't think it's very well defined yet, and it's not clear whether it's simply having PTSD for a long time, meaning you developed PTSD 12 years ago, 15 years ago, and it's still with you, resulting in all kinds of other symptoms, or that you were exposed to a very long series of traumatic events. I don't think that's been defined yet, but it's definitely what people are looking at when they say CPTSD or complex PTSD; they mean PTSD with a lot of other symptoms tossed in as well. It's just not that well worked out yet.

SPENCER: What would be most characteristic of it? Would it be emotional dysregulation or high anxiety, things like that?

GEORGE: Yes, exactly. Being depressed, anxious, not able to regulate ourselves very much, unpredictable, with also the PTSD symptoms, intrusive thoughts, etc. It always has the PTSD symptoms plus other things.

SPENCER: Suppose someone has just gone through a potentially traumatic event. Do we know anything about what should be done in that first hour, or the first 24 hours, or the first seven days to help that person?

GEORGE: That's a little tricky. People have tried to help others professionally in that beginning period of time, and it has almost always backfired. It almost always either doesn't do anything or makes people worse, usually, because when people have been through something potentially traumatic and they're having these temporary reactions, maybe a nightmare or two, they're kind of on edge. The world seems a much less safe place now than it was before this happened. Then a professional shows up and tells you a little bit about PTSD, and that plays with people's minds a bit. They're thinking, "Why is this person here? Does that mean I'm traumatized?" Most people know what PTSD is, but not everybody knows what it is or that these symptoms are normal. So they're suddenly thinking, "Do I have PTSD?" When somebody shows up to try to help you, that kind of leads you to think maybe I do have PTSD. What I would say we do know is a whole longer story about what I've written about in my book about flexibility. That's a whole different topic.

SPENCER: There were some famous studies, like the so-called Tetris study, where they had people play Tetris right after a potentially traumatic event. They claimed lower rates of trauma or PTSD or whatever it was. Is that just BS?

GEORGE: No, the findings are real, but they didn't actually have trauma. What they did is they showed people disturbing movies. That's a big difference. Then they showed that a week later, I think it was, something like that. I don't remember all the details. There were different versions of the study, and a week or so later, they had people come back to the lab, and they had them play Tetris, and some people didn't. They had fewer intrusive symptoms. The reason is that it has nothing to do with Tetris per se. Tetris is a game, but what Tetris does is occupy your working memory. That means, if you think of it in terms of a computer, your RAM, the memory that you have at your disposal when you're on the computer, not long-term memory, but operating memory. If Tetris is occupying that memory, your brain can't do much else, so you don't have those intrusive symptoms. People have shown that if you give people other things to do that occupy that memory, they also won't have symptoms. It doesn't mean they go away or that you're never going to have them, but at that moment, it's sort of a way of controlling them. You can't necessarily whip out a game of Tetris all the time, like when driving a car, for example, but it was an interesting series of studies that show we do have some ways, possibly, to control that.

SPENCER: It's not going to reduce the rate of people getting PTSD if they play Tetris within the first hour after.

GEORGE: No. As I mentioned before, cortisol is going to last quite a bit of time, and a lot of what our brain does takes care of this already. But intrusions are not evil. They're not bad, especially in the first week or two. We have to think about why our brain does that. Why would our brain play it back? Why would we have a nightmare? The best answer, we don't know 100% for sure. The best answer is, if we've just been through something violent and life-threatening, our brain needs to make sense of that. Our brain needs to put that into what we know about the world because our brain is trying to predict what life is like. That's what our brain does. Suddenly, our brain knows this person that you don't even know can attack you, or you can be driving in your car, and suddenly this is going to happen that you don't expect, and through no fault of your own, this car can come across and hit you and put you in grave danger. Now you're driving a car, and how do you know you are having intrusive thoughts? What if this car is going to hit me? That car is going to hit me, or this stranger that I see looks suspicious now, and our brains need to work that out. How likely is that to happen? What actually happened? Was there anything I could do about it? Was there anything I shouldn't have done? Was there anything else? Is it just a random thing and I can't control it? That doesn't happen. Our brain is trying to work all that out, and the intrusions, the nightmares, that's what they're for, and they gradually abate as our brain works it out. "Okay, that happened, but I'm basically okay." I don't think we necessarily want to get rid of those reactions because they do something. It's only when they don't go away, and when our brain can't work it out for some reason, for whatever complicated reason, we're continuing to have PTSD symptoms. Then we need help, and that's where therapy comes into play, and there are other forms of help, relaxation, or other things that will help us move along in that regard.

SPENCER: In another episode of this podcast, I had on an anonymous multi-time victim of sexual assault. She'd been sexually assaulted by a number of different people in her life. One thing I talked to her about is how one sexual assault she had was from a complete stranger, and another was from a trusted family member. I would have thought that the stranger would have been more upsetting because you could get assaulted by a stranger anytime you're walking on the street, but she actually found it much more traumatic when it was the person who was a trusted family member, perhaps because it eroded that sense of safety in the family or in the home environment. Do we know about what sort of elements of trauma, whether it's unpredictable or predictable, might actually be more traumatic, or is it very idiosyncratic?

GEORGE: It's pretty idiosyncratic, and I don't know if there's any concrete research on that topic or not. Sexual abuse and sexual assault is a very complicated topic for many reasons. One, it has to do with age. Some of these events happen when we're quite young, and our brains are trying to figure out what life is. If they happen pre-adolescent, often, and they're pre-adolescent for girls, sexual assault can happen before adolescence. That is very confusing because when they become adolescents and their bodies start doing things, they don't know what to do with that. It's very complicated. What does it mean now that I'm having sexual desires, and what do I know about that? People can violate me, and now I understand. It gets very complicated when we're with someone. A lot of the sexual assault is with people we know. It's problematic because our normal threat detector is kind of turned off, or when we're feeling comfortable with someone, we're less likely to be paying attention to threatening cues, and so we're quite vulnerable in that situation. I think that's maybe why it was so disturbing; the person is incredibly vulnerable with people they know or feel normally close to. Beyond that, it is also idiosyncratic. I know that's not a tremendously great answer, but the truth is, it is quite idiosyncratic.

SPENCER: Regarding sexual trauma — this is quite a tricky question, which I've heard debated — suppose someone's child gets molested; people will debate how best to handle that to reduce the chance of traumatizing the child. Obviously, you're going to remove the child from that dangerous situation and pursue prosecution of the person who did it. But when discussing it with the child, you can imagine, on the one hand, explaining to the child the full gravity of what happened. On the other hand, you could imagine trying to make it seem less severe in some way or not making it seem like such a big deal, with the idea that maybe that would be less traumatizing to the child if they thought, "Okay, that person shouldn't have done that, but this isn't this huge horrible thing that happened to you." Do you have a perspective on that? What's actually most likely to protect the child's mental health?

GEORGE: Yeah, I'm not 100% sure about that, because I don't normally do things in that realm, and I don't know what that literature is like or what people have done and how well it works. I think it's important for, again, it depends very much on the age of the child, what their experience is, and if children are sexually active, they need to know that it's not okay. We can communicate inadvertently or advertently that you're harmed, and I don't think it's healthy to communicate to people that you've been damaged. But I think it's very important to communicate, especially to children, that it's just not right. It's a complete violation of everything. It violates your trust, and you should tell people, etc. You have rights and protections. I think that's important to communicate for sure.

SPENCER: Let's talk about resilience and flexibility. I know you've done work on these topics. What do these words mean in the context of trauma?

GEORGE: Yeah, those are great questions. Resilience is what I've been studying. Most of my research for the last 35 years is on people who are exposed to potential traumas and don't develop lasting harm, which is most people, and that's what I call resilience. I don't think it's fair to say scientifically that people are resilient. It's more that when people are exposed to something and it doesn't harm them over the long term, they are resilient to that event. I always think you have to be resilient to something, and a person is resilient to that event; it doesn't mean they're necessarily going to be resilient the next time something happens. So that's resilience, basically, at least the way I focus on it, because it's the cleanest way to think about it. Flexibility is a longer story. Flexibility, I believe, from what our research shows, is how people are able to be resilient.

SPENCER: So it's kind of the mechanisms of resilience.

GEORGE: Mechanism, in a way, the process is maybe a better word even, yeah, what people are doing to be resilient.

SPENCER: So you mentioned that at different events, people can be resilient to one event, but not to another. But are there stable individual differences where some people seem to just be more resilient across events?

GEORGE: That's a good question, probably, but it doesn't drive everything. If people are more resilient across events, it's probably because they are more flexible across the events. I think of flexibility as a set of tools that allow us to adapt to these challenges. Like anything, they have to be used. You can have all the tools in the world, but if you don't use them, you're not going to get anywhere. A basketball player who's one of the best players in the game, or a golfer, or whatever other sport we might think of, sports is always a nice metaphor. Having all the skill in the world doesn't necessarily produce the best outcomes if the person isn't using those skills or isn't motivated to use those skills. That's really what happens. Potentially traumatic events are difficult and disturbing. We don't want to think about them. We wish they would just go away, but they don't, and so we have to kind of focus on them, and that's when we get into, "Do I have the skills to get through this?"

SPENCER: So what are some of those tools that are involved in flexibility?

GEORGE: We've broken it down into three basic components. There's another component related to the motivational part, but the three basic components are, first, we read what's happening to us. We focus on what's happening right now, not the bigger problem. We call that context sensitivity. For example, when I'm feeling anxious and traumatized, I think I have PTSD. That's a big problem. But if we ask what's happening right now, well, right now I'm feeling uneasy. I'm feeling like the world is not safe. That's something we can focus on. That's the first step. We really have to focus on something that we can deal with. Then we figure out what it is we decide to do to try to address that problem. I'm feeling anxious and unsafe right now. So then we get to the second step, which we call repertoire, and we ask ourselves, what kind of tools do I have? This is very much individual. What tools do I have? We select a tool that we try to use. I'm going to talk to other people, I'm going to try to push it out of my mind, I'm going to do some internet research, I'm going to talk about it, I'm going to distract myself, whatever it is that we decide to do. Then we explore whether it's working or not. We call that the feedback stage. We try to see if it's working, and if it is, we're good, but if not, we try something else. Those are basically the three stages. They're pretty basic stages or steps that people go through.

SPENCER: And is the idea to imagine this? This would be, say, after a potentially traumatic event. In the weeks after that, most people are kind of going through this process. "Okay, I'm feeling that. What's going on right now? I'm feeling uneasy. Okay, what should I do? Maybe I'll go talk to my friend. Did I feel better after talking to my friend? No, I didn't feel better. So I'm going to do something different next time."

GEORGE: Yeah, it's interesting because it is what happens. Once we realize there's a problem, it always has to be something we can focus on. What's interesting is that it's hard for people sometimes to actually decide, "Okay, something's bothering me, what is it? What is it right now?" That's the key. Then we have to think about our repertoire of responses and the feedback part, where we ask ourselves, did this work? That's actually really interesting and key because a lot of people will try one thing and then give up if it didn't work. "I talked to my friends, and it didn't make me feel better at all. I don't know what to do. I don't know how to cope with this." I think that's part of the myth about resilience, that you're either resilient or you're not. If I tried to cope with it this way and it didn't work, then I must not be resilient. That's completely wrong. Everything we do, even the most resilient people, cope by trial and error. We have to try something else because these are complicated problems. We try something else and see if that works, and it might not work either. So we try something else. That's how we get through it. That's how we adapt. That's the way our minds adapt; that's the way our minds work.

SPENCER: It's helpful to think about it as skills, because then if it's skills, it's something you can learn. It's not some innate, untouchable thing. But I also wonder what goes wrong for people that lack flexibility. Is it that they're feeling anxious and they don't even realize it, or is it that their repertoire has tools that are actually not useful or maybe even self-destructive?

GEORGE: Yeah, that's a great question. Spencer, it's a really great question. In our research, we found that most people don't actually realize that they're doing these things, yet at the same time, the majority of people do have these skills. That's what our research has shown. We measure it, but we find that most people don't realize they have those skills. What we find is that when people are struggling with other kinds of problems, that's where we start to see the deficits. For example, anxious people have a particularly difficult time with this first step, what we call context sensitivity, deciding what the problem is because they're very much preoccupied. Anxiety tends to be a phenomenon where people are preoccupied with certain things they don't want to happen or certain worries they have, and that means they're not paying attention to other things. As you said, these are not innate skills. These are well-documented skills that we develop as we move into adulthood. There's a lot of research in the child literature showing that these skills develop. These are also skills we can improve as adults. We can focus on trying to pay more attention to what the problem is. The repertoire part, most people are not terribly aware of how they cope. We know that people usually cope pretty well, but they're not aware of it. One of the things I often do, and sometimes I conduct workshops on this, is ask people to think about it. What is it that you do? Pay attention to this during the course of your day, for a week or two. What is it you're actually doing when you're struggling? I have a little example about this, if you don't mind me telling this story. I was developing a way to measure this with my students, where we text people randomly during the day, and we ask people what recently happened and how did you cope with it? There's a coping mechanism called reappraisal, which is kind of like reframing, where something bad happens, like someone yells at you, and you might feel really bad, but you might tell yourself, "That person is living in New York City, and they're really struggling, so they're just angry at the world and yelling at me, a complete stranger. It's not really about me." And that is a way you can regulate your emotions. I had always thought that I never do that, that it's kind of dumb. I think that academics invented that idea; it's very cognitive, and I don't really do that. Then when my students and I were developing this way of measuring these kinds of things, I asked my students to text me repeatedly to try it out. I found I was reappraising all the time. I actually didn't even know it. When we start paying attention when things happen, it's a good exercise to do that so we get a sense of what tools we actually have. What are the tools we have in our repertoire? We can improve in that one, in the feedback one as well. That's where we basically say, I can try again. I can try something else. It's possible.

SPENCER: Let's talk about trauma and addiction. Is one way to view that part of their repertoire they're using is kind of using drugs or alcohol to numb the pain or block it out, and it's kind of a self-destructive repertoire?

GEORGE: Well, it is definitely a possible coping mechanism — drugs and alcohol, for sure. It is not a healthy coping mechanism to use all the time. I have a phrase I call "coping ugly" that fits this one. If you're struggling and you just need to get through the day, sometimes people say, "I'm going to have a drink, or I'm going to do this," and I think that's perfectly natural, and it's not bad. If it's just to get through something, it becomes a problem when you use drugs and alcohol all the time. What happens? I'm not an expert in substance abuse, but substance abuse tends to change the brain and lead to a really dysfunctional pattern in the brain that's hard to break. There's literature on liking and wanting, and to put it bluntly, you like something and you also want it, but when you become addicted, you want it without necessarily liking it anymore. It's that part of the brain that just drives, so that becomes dysfunctional. Using any kind of coping mechanism all the time is very inflexible because you're not adapting to the situation. I think using drugs and alcohol over a long period of time to cope is bound to fail, both biologically and in terms of psychological processes.

SPENCER: As far as I'm aware, avoidance is a key part in most, maybe all, anxiety disorders, where instead of facing something head-on, there is some way in which the thing being feared is being avoided, with the idea that when you actually face it, usually anxiety goes down over time, whereas if you avoid it, it tends to maintain anxiety or even make it go up. So is avoidance part of this? And where does the avoidance fit in?

GEORGE: Well, I see avoidant processes loosely defined as adaptive when used. I always think of these things now, because this is where my research has taken me, and this is what the research shows us. Any of these things we do are adaptive in an individual moment. So avoiding something, distracting yourself, not thinking about it, can be very adaptive in a particular moment. And there's good research that shows that it's not adaptive to do it all the time, just like focusing on something really positive is not adaptive to do that all the time, because it's not always going to work. One of the ones that people often talk about is social support. Social support is fantastic. We turn to people for support, we turn to people for sympathy, for information. But it doesn't always work, and using that all the time means, again, not being very flexible and not trying the other things that might be more appropriate in that situation.

SPENCER: So distraction might be in that bucket where, if you know some distraction from your anxieties might be fine, might even be healthy, but if you're always distracting yourself from the thing you fear, then that might become counterproductive and maintain anxiety.

GEORGE: Yeah, and you never deal with it exactly. So, people have written about this in terms of political situations. The political situation is disturbing for whoever you are and whatever the political situation might be. It might feel good to just put it out of your mind. I want to think about that, and that's fine in the short term, but in the long term, it becomes problematic, because then things don't change. So as a metaphor, that's a good example.

SPENCER: Does medication help people with PTSD?

GEORGE: I'm not an expert on medication. I think there's some medication that would help. I would be amazed if there wasn't, but I'm not an expert on that. Got it. What about therapies?

SPENCER: What about therapies? I know that there are a few different therapies that are used for PTSD, for example, prolonged exposure. Do you believe that prolonged exposure is effective for people?

GEORGE: It absolutely is. Prolonged exposure is probably the most effective in terms of the science, but there are other really good therapies. The thing about prolonged exposure is that it's not for everybody because it's hard, and there are some therapists who won't do it because it's hard. They need to be trained, and they need to know what's going on. They're not comfortable doing it because it basically makes people face and tell the story of what happened, and they have to do that repeatedly. It's very hard for people, even though research shows it tends to make people better. It's a hard thing to do, and a lot of patients may not want to do it. So that's a harder approach that not everybody wants, but it can be a very effective approach. The other kinds of therapies are cognitive behavioral type approaches, and as you mentioned earlier, muscle relaxation and things like that. Systematic desensitization is very helpful, along with all kinds of talking therapies. There are lots of different approaches, and it depends on what people are comfortable with, what therapists they know, etc., but they're good.

SPENCER: It's accurate to say that with prolonged exposure, it would involve actually trying to sort of relive in your mind the traumatic event, and then also working with a therapist to process that experience after each session.

GEORGE: Yeah, that's the gist of prolonged exposure. First of all, there's some preparation. The therapist will explain exactly what's going to happen. It's very structured because people are going to have to open up in a very painful way. The therapist explains what we're going to do. There's a lot of communication to people that you're not weak, you're strong. You got through this horrible thing, so you're still here, so you're a strong person. What we're going to do is, I'm going to ask you to tell me from beginning to end what happened. There's always time at the end of the session to let people wind down a little bit. You're not just sending people home. So it's highly structured. It's limited, usually something like 8, 10, or 12 sessions, depending on what the therapist is going to do. In that first session, it really involves describing what happened from beginning to end. That's remarkably powerful in many ways because — and this is complicated — our cortisol system and some other ways that our brain reacts tend to produce fragmented memories. We don't necessarily need to remember the whole thing; we need to remember the important life-threatening details. So people sometimes have these fragmented memories, and they don't actually know exactly what happened until they sit down and tell the whole story. That's powerful because it allows people, maybe for the first time, to actually realize this is what happened. This is what I went through. That's incredibly powerful, and they're doing it in the safety of the therapist's office. There's that element too, and then there's a lot more to it that happens after that, but it's always in the safety of the therapist's office, and it's always in this context of what actually happened, and that happened in the past. I think that's the part of PTSD that's most difficult: it feels like it's the present, but it happened in the past. Exposure helps with that.

SPENCER: How would you compare prolonged exposure to EMDR, eye movement desensitization and reprocessing therapy?

GEORGE: Well, EMDR has a controversial element to it, which is that it's kind of like prolonged exposure with some more bells and whistles. People sometimes move their eyes back and forth, or they do this tapping thing. I've never actually seen it done, and I don't know enough about it, but many people have criticized it as prolonged exposure with unnecessary bells and whistles. My take on it is it is effective, and there are some people who really like it. I think if it's exposure with bells and whistles, whatever, it doesn't really matter if it works. From a scientific perspective and a clinical perspective, you want to know what's actually the part that's working. But if adding these pieces to it helps people, why not?

SPENCER: Because you move your eyes back and forth and that kind of thing.

GEORGE: There's no real scientific explanation for why that would do anything. It's a little bit like Tetris, in a way. But if it works, it works. There's all this research now that shows that placebos work even when people know they're placebos, so bring it on if it's going to help people.

SPENCER: When you talked about prolonged exposure, you said that often, for traumatic events, we remember them, but there are fragmentary memories, and then we retell the story and it kind of comes out. Could you compare that to things like recovered-memory therapy and how that differs?

GEORGE: What is recovered-memory therapy?

SPENCER: Well, it's this idea that sometimes people have traumatic events, they won't really know exactly what they are, and they'll use hypnosis and these kinds of things to try to recover from the trauma.

GEORGE: Oh, that sounds, I'll just be honest, that sounds really wacky to me, because I think it's kind of a myth that there's some trauma that you have to recover actually. I don't know, that doesn't make any sense to me. But what I know about fragmentary memories is that our cortisol system, which first kicks in when we're really in a threatening situation. Our minds aren't interested in the story. Our minds are interested in the bits and pieces of information initially, like the first half hour, say that's dangerous, that moves slowly, that moves really fast. That edge right there is really dangerous. Don't go near that edge, etc. And those are the things that we remember, and we can remember those in a sort of fragmentary, incoherent way. That's all we need. And it also makes it really adaptive over the long term, because we're storing information about things. These things move very fast, etc. So it's only later in the process that our brain will begin to organize it in a more coherent way. And cortisol also blocks our long-term memory, which is super interesting. It allows us to remember information, but it doesn't allow us to remember key past events, because we don't need those events right now. We don't want to mix all that in there.

SPENCER: It just temporarily will block them.

GEORGE: Temporarily, yeah. And I always tell this story about my son. When he was, I don't know, eight or nine or something, we were up in the Catskills, which is the mountain range in upstate New York, and it has a lot of slate, which is very sharp, these sharp, flat pieces of rock. He and a couple of other kids were running down the hill ahead of me and down the trail, and I lost sight of them; they turned a bend, and apparently he fell and hit his knee on this rock and just ripped his knee open. It was horrible, because his bones were exposed, and I was just horrified. I ran down the mountain to get help. I told his sister to hold his back up so he doesn't fall asleep. I ran down the mountain to kind of get some help. What was interesting about that, because I had all these reactions that cortisol gives a person, I had lots of energy. My mind was incredibly focused on what I needed to do. That's part of what cortisol does as well. But I wasn't thinking that I am a bad father, or this has happened in my own life. I wasn't thinking about any of those things because it wasn't relevant. Afterwards, if I had done that, I might have created this kind of mega memory, or this horrific memory linked to all these other periods in my life. But cortisol doesn't allow that because it's not necessary at the time, which is really interesting stuff.

SPENCER: Sounds like it kind of honed you down on what needs to happen now.

GEORGE: Completely. In fact, when the EMTs got to the bottom of the hill, about a mile down the mountain, I saw a woman, and I remember thinking she had a phone. This was a number of years ago, and I needed a phone. I remember thinking I had one shot to get this woman to let me use her phone. I'm running down the mountain like a maniac, and my mind was completely focused on that task, being as appropriate as possible. She just handed me her phone. I went back up, the EMTs arrived, and they told me it was lucky that I had asked them to bring a chainsaw because they needed to cut their way up. I have no memory of asking them to bring a chainsaw, but that was something cortisol just there. My brain was so focused. Those are remarkable responses. Those responses keep us alive, and they result sometimes in these fragmentary pieces because our brains are focusing on what's necessary. Our brains don't necessarily think about having this whole story to tell. Afterwards, when we're in exposure therapy or elsewhere, we can kind of invent a story that's really harmful to us, "It's my fault or the world is horrible in this way," whatever. That's one way that exposure therapy and other kinds of therapy, cognitive behavioral therapy as well, help us get a little bit of clarity. We sit down, we actually focus on these details and try to think about what actually happened.

SPENCER: Are you familiar with IFS or internal family systems therapy?

GEORGE: Not terribly.

SPENCER: It's an idea that's grown in popularity where it involves imagining yourself as having these different parts, and then you kind of talk to the different parts, and you ask them about what they're trying to protect you from. I'm trying to protect you from this situation happening. It's kind of just curious if you have a reaction to that.

GEORGE: Yeah, no, I don't. I don't know about that.

SPENCER: Just a couple more topics before we wrap up. When there's a worldwide event like the COVID pandemic, it can really affect a lot of people psychologically. Do you think that it's fair to say that that caused a kind of mass trauma reaction, or would you put that a different way? Would you say it's a different thing?

GEORGE: Absolutely did not cause a mass trauma reaction, and I think there was a lot of, for lack of a better word, hysteria about that. I call that the resilience blind spot. When something happens to a lot of people at once, we feed on each other, feeling like this is really bad. This is really bad. It happens to mental health professionals too. Mental health professionals tend to forecast overwhelming consequences. During COVID, I remember I was in a couple of international panels with people, and we had huge audiences all over the world that we did on the internet. People were saying this is going to overwhelm our mental health resources, which, of course, it didn't. It overwhelmed our medical resources in many places, but not our mental health resources. People actually coped really well during COVID. Most people did, and the research, and I was asked about that, and that's kind of what I said. I think we're going to cope just fine with this. The research that emerged, when we actually looked at the long-term data, was that, in fact, people did cope really well. Some people were more anxious than usual, of course, some people were chronically anxious, but most people hung in there pretty well. There's an idea that somehow this is going to be a mass trauma, but it actually wasn't, for most people, even a trauma. For most people, it was a chronic stressor, and people developed a lot of physical problems during COVID because of the constant stress. But that's very different than trauma. It's very different than life-threatening danger. There are people, of course, who felt trauma, probably in the medical context to some extent, or people who saw other things. But for the most part, there was a lot of stress involved COVID.

SPENCER: Do some people have a kind of delayed trauma, where at first, after an event, they seem okay, but then they end up getting PTSD anyway?

GEORGE: Yeah. Spencer, that's a really interesting question. The idea of delayed PTSD has been around for a long time, and it was always thought of in this flavor of they're fine, but then suddenly, out of the blue, they have PTSD. That actually doesn't happen. When we started tracking people over time, we realized that doesn't happen. What we do see is there are some people who are struggling, but they don't have PTSD quite; they're struggling, and then they're gradually getting worse, and at some point they're getting worse to the point where they cross over into the threshold of now they have PTSD. It looks like they had PTSD when they were healthy before. But in fact, if we look at them over time, they're struggling, slowly getting worse, and I think...

SPENCER: Maybe they're trying to keep it together and honestly showing those signs.

GEORGE: Yeah, people are showing symptoms, but they're basically keeping it together, maybe functioning. If you're struggling over time, other things kick in too. We might start getting depressed about it, and then the symptom profile gradually increases until we're now in the realm of the disorder. The threshold is somewhat arbitrary. We cross the threshold into disorder, but we're only a little bit worse than before when we crossed that threshold.

SPENCER: Is it believed that trauma reactions are kind of universal? Is this a universal human thing, or do we see cultural variation in how that plays out?

GEORGE: Yeah, that's a great question. I don't have a perfect answer for that. I believe that it's kind of a universal reaction, but I don't have strong feelings about it. It's super interesting, both historically and culturally. If we look at the history part, I've written about this in The End of Trauma, and a number of other people have written about this too. If we go back a couple thousand years, as long as we've had the written word, we see lots of evidence of grief, people struggling with the death of loved ones. You see lots of mention of that. It's in The Iliad, for example, Homer's Iliad, which is maybe close to 3000 years ago, but we don't see mention of trauma symptoms. One of the first mentions of trauma symptoms occurs in the diaries of Samuel Pepys, which is interesting. Pepys was an aristocrat in the 17th century. He was a colleague of Isaac Newton, for example, and he had a role in the government during the Great Fire of London. He had to survey the damage; most of a big chunk of London burned. It was horrific. Pepys kept a diary for 10 years, which is fascinating. Many people study his diary because he wrote everything. He was completely honest. He didn't intend anyone to read it in his lifetime. He wrote it in a kind of quasi-code and didn't intend to show it to people. When he died, he went with all his books to the University of Cambridge, and eventually, probably a hundred years later, they began to decode it. It's a window into the mind of someone in the 17th century, and this is one of the first accounts of trauma symptoms. He was having essentially PTSD symptoms at least six months after that fire, and he was completely confused by it. We can interpret that a number of different ways, but it tells me that he was having genuine trauma symptoms, but it wasn't anything people talked about. He didn't know what to make of it. He was actually asking himself in his diaries, "Why do I have these nightmares about the fire? I don't understand it." That tells us probably that was there, but it just wasn't anything people talked about, and people didn't really identify it until right at the end of the 19th century. That's kind of interesting.

SPENCER: Yeah, the attitude towards war seemed to be so different, where people were much more likely to valorize war. There are even stories about young men being really excited to go to war. There was a sense that only in modern wars did suddenly all these people come back traumatized. Do you think that people weren't recognizing those symptoms, and we just didn't have language for it? Or do you think it could be something else?

GEORGE: I think that people were being traumatized by wars, but they really didn't have language for it. They didn't know what to do, and it was generally interpreted as cowardice because it was valorized in a way. In World War I, when people first began to talk about shell shock, a lot of British soldiers who had shell shock and couldn't go back to the front were shot — the famous phrase "shot at dawn" for cowardice. Even though shell shock was officially recognized in the field, people were being shot for cowardice. Only recently, about 10 to 15 years ago, England decided to honor those people who were shot at dawn, not to erase the cowardice they were associated with. It is curious; it took the military a long time to reconcile this. It's hard enough to get people to fight wars, and so adding on war trauma, there was a resistance to acknowledging that, I think.

SPENCER: It seems also at least somewhat likely to me that the nature of war changed a lot. It might have increased the rate of people being traumatized. World War I was really unique and not like any war before it in terms of just the death toll and the horrors. Obviously, all war could be horrid, but there was a new level of horror that the world had never seen before.

GEORGE: Yeah, I think there's a lot of truth in that. There have been some pretty horrific things, like the famous Vlad the Impaler. He was a nasty guy. I think that was a long time ago — about 500 years ago. The Civil War was also kind of renowned, and I think what's happened since the Industrial Revolution, maybe we can put it at that point, is that technology tended to increase at a faster rate than war strategy. In the Civil War, people were marching in straight lines and just being shot with muskets. In World War I, you had people in these stalemates in the trenches because they were being bombed by planes. There was new technology, but the war strategy hadn't caught up with it, and that's been a feature of modern war ever since. Technology advances quickly, so it could very well be that more things can happen to soldiers now than used to happen.

SPENCER: Final two questions for you. Suppose someone listening to this thinks that they might be suffering from PTSD. What would you advise them to do?

GEORGE: That's a good question. I want to be careful about how I say this. I think if it's within a few weeks, I would say try to wait it out, and if it's more than a month or two and they feel like they have PTSD, see a psychiatrist, see a doctor, and find out.

SPENCER: And would you say a psychiatrist or a psychologist? Because you can get pretty different treatment depending on who you go to.

GEORGE: Yeah, I would say either one, whichever one you're comfortable with. It's absolutely fine to see a psychologist. Definitely, a psychologist can make the diagnosis, but they can also try to probe it a little bit to see what's going on? Is there something else? But, yeah. And I think there's variation in the skill of mental health professionals, like anything else, but mental health professionals would be the way to go. And I would say, stay off TikTok; there's a lot of misinformation on TikTok.

SPENCER: That's probably good advice. And suppose that someone has a loved one who they think has undiagnosed PTSD and is suffering. What would you advise in that case?

GEORGE: That's tricky, because some people may think they have PTSD, but they don't want to see a mental health professional. Depending on the relationship, you can advise someone or suggest it if you think they'll at least listen to the suggestion. But people may also get angry about the suggestion that they have PTSD and need treatment. So that's something people have to judge for themselves and play it by ear.

SPENCER: They could always buy your book,"End of Trauma, as a gift, but that might be a little too direct. So George, thank you so much for coming on the Clearer Thinking Podcast. Great to chat with you.

GEORGE: It's great to talk with you, Spencer. Thanks a lot.