Readers are likely very familiar with the intense and debilitating symptoms of PTSD and trauma in general, either by having known someone with the disorder, or through the coverage these topics get regularly in the news and special documentaries. What they may not fully realize are the more subtle symptoms that I would phrase as an impaired sense of personal efficacy or, to put it differently, a void where mental toughness should be. But first, let us get our heads around a few concepts.
The latest edition of the Diagnostic and Statistical Manual of Mental Disorders  made some important changes to traditional markers of PTSD. They reworked descriptors to more adequately reflect the behavioral aspects of the disorder under the three broad categories of re-experiencing, negative cognitions and mood, and arousal problems. Though the DSM doesn’t talk about mental toughness per se or the lack thereof, it does reference somewhat parallel concepts—the problematic negative cognition patterns that start to emerge in a person suffering with chronic PTSD. These range from a persistent and distorted sense of blame of self or others, to estrangement from others to markedly diminished interest in activities, among other features. In addition, a new subtype is described, the Dissociative Subtype. Its features include prominent dissociative symptoms, either experiences of feeling detached from one’s own mind or body, or experiences in which the world seems unreal, dreamlike or distorted.
In my clinical experience, the cumulative effect is often manifested in the form of a person in the chair opposite me who along with symptoms from the three categories also feels like a ghost with no substance left, a person who indeed now floats around with a detached, dreamlike experience of the world, others, and themselves. In severe cases there is a complete void of volition and initiative, and a badly eroded sense of self-efficacy.
I’m not describing anything new. These effects have been well noted in whole populations who have suffered through natural or man-made disasters for millenia. If physical strength is the ability to produce force against a resistance, then mental toughness must have to do with the ability to stick with that effort, to push back, believing one could yet have an effect, no matter what particular type of resistance one is up against. It is not a trait that some have and others don’t, or the seeming absence a defect of personal identity. To the contrary, it’s a natural human capacity available to all, that has a lot to do with our survival and evolutionary success as a species, but that may need redevelopment or recovery in some, especially following trauma. In the face of a continuing stressor, without the chance for recovery that allows for adaptation, at some point we would all collapse. The collapse of the will to push back and the belief in one’s efficacy—what seems like the evaporation of mental toughness— is perhaps at the heart of the disorder and may be the most troubling feature in the subset of people who go on to develop full-blown PTSD in the aftermath of trauma.
Some may say “Aren’t you really talking about resilience?” Resilience , a well-studied construct according to the APA, is made up of the following aspects:
- A strong support system
- The capacity to make realistic plans and take steps to carry them out.
- A positive view of yourself and confidence in your strengths and abilities.
- Skills in communication and problem solving
- The capacity to manage strong feelings and impulses.
Resilience is really a broader concept and these features, however distinct and valid they may be, still strike me as mainly cognitive, self-absorbed, or situational. They miss something that’s a precursor— more basic, outward-looking, embodied, and elemental—the will to fight back, mental toughness.
The point of this article is how certain insights from strength training hooked up with my therapeutic sensibilities. If physical strength forms the biological base on top of which the superstructure of all other interrelated aspects of well-being are built, and I think it does, it makes sense that enhancing physical strength not only makes us feel better in the short run, but under the right circumstances, promotes overall mental health in the long run. As a side bar, preserving physical strength is quickly gaining traction as the central variable to help people age more gracefully, with relative freedom from premature disease or disability.
What became salient for me is how even brief enactments of strength, or strength displayed quickly, i.e., power, could pluck other strings and be a reminder of capacities not really lost, a powerful reconnection point for someone whose trauma had left them feeling so powerless. The following clinical narrative represents a composite to show what’s possible when you’re tuned into this.
A client who’d been badly abused in childhood was now at least clear of the re-experiencing and arousal symptoms as a result of the early work we’d done. But this person was dogged by the persistent tendency to cave in and comply when met with forceful demands presented by others that resulted in pervasive self-disgust and lack of integrity that showed up in several areas of life. Though in a position of considerable authority and responsibility, this client would instantly capitulate even when leaned upon to do things against better judgment or thought to be wrong. I recognized from the limp handshake, the vacillating voice, the instant withdraw from anything that would risk displeasure or require taking a stand, and the dream-like trance that arose when in the presence of powerful others, that all the residues of dissociative post traumatic stress disorder were there.
Practitioners of Rapid Resolution Therapy will recognize some of the tactics used with the disassembly of anxiety, as I adapted them in the following way. The first thing I wanted this person to do was to reconnect with the natural strength in the body. With certain therapeutic parameters in place, I role played a rather aggressive and obnoxious co-worker regularly encountered at work and around whom my client felt paralyzed. I asked that we both stand up, and of course, got immediate compliance.
I backed the client into a corner with only an uncomfortable foot of distance between our upper bodies. I talked harshly, using some of the co-worker’s demeaning lines and down-putting attitudes. I informed my client that I weighed 240 pounds, was very strong, and could push someone around any direction I wished unless something was done about it. I stipulated hitting wasn’t allowed, but my client could place hands on my chest and do anything that occurred to get me out of the space, as I leaned in a bit more. To our mutual amazement, my client planted both legs hard into the ground, set the jaw, held a big breath, and lowered the center of gravity, much like a linebacker does just before the ball is snapped. With a visceral grunt, my client drove out of the corner using the big muscles, and by an instant recruitment of whole-body strength that came from legs, back, and hips and went all the way up through shoulders, forearms and hands, shoved me halfway back across my office like I was an unloaded blocking sled.
With eyes as big as saucers, my client sat down in the chair slowly, and processed for the next few minutes how different and needed that experience was from anything that had ever been afforded as a child or in later years. Vocal tonality was markedly different—the voice had a more resonant timbre and never wavered. Gone too was the tentative breathlessness with which statements were started or ended. Thorax and shoulders were more open and upright and I could tell this person had the full support of their own air column back again. We are embodied creatures who can learn through movement and sensation as well as the intellect, so you can sometimes use these channels to a produce a profound shift in self perception and the opening of capacities long thought lost.
I then prescribed something for the first time ever in my career for a psychotherapy patient. I recommended aligning with a gym and carrying out a program of strength training for the next six months. I said the power they had briefly accessed needed development and that I wanted this person to get guidance in order to learn to squat, deadlift, press, power clean, and bench press correctly. I got an emphatic nodded “yes” to all I was saying, as if already understanding what I was getting at, without even yet having experienced it.
The brain is an amazing organ as is the rest of our physical endowment. Some key neuropathways reconnected for my client that day. But strength is not a one and done type of project, either in the consultation room or in the gym. My hope is that with a couple follow up sessions and some barbell training, mental toughness will regain tone and reciprocally come back on line as this person makes gains with their physical component. Through regular stressing, recovery, and adaptation, there is no reason why my client cant reap the full benefit of getting stronger at least weekly for years to come, and continue to feel its carryover into all aspects of existence.
I would hasten to offer the disclaimer that what I did here with a few people in a specialized situation should not be construed as advice or a blanket strategy to be used with all trauma survivors. PTSD is a complex disorder that often responds to our interventions, but informed sensitivity to the situation, safety parameters that protect client and therapist, and good timing continue to be essential.
I would say, however, that some clients have called me to share major decisions arrived at and changes made in their private or public lives that bespeak the continuance of strength and a certain mental toughness that has not abated. You see, with an impactful enough experience, such as the one described above, and a symmetrical follow up, such as time in the gym under the bar, the unconscious is thoroughly capable of recognizing a new pattern of adaptation and generalization to other areas of life with an efficiency and elegance that we can scarce imagine. I believe stacking things so that a client can experience their own power, and then staying with a program of strength training, facilitates the development of mental toughness by sending a deep signal to the brain that over time makes structural changes possible, both intracranially and throughout the whole body, and becomes part of the inner architecture of a person who is truly healing, growing, and adapting well to life’s continued challenges.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).Sep 24, 2015.