The rise of PTSD

By Jesse Singal

In 2014, six weeks into her first year at university, Katie was sexually assaulted at a frat party. “It was my first exposure to sex at all,” Katie, who is now 23, told me. “I grew up in a really small conservative town, really Christian parents, and I had never even seen a man naked before.” Not long after that, she was assaulted again after going back to a fraternity brother’s room. “He did not stop when I wanted to stop, and basically said, ‘You should be grateful that I didn’t make you have sex with me’.”

Katie’s mental health began to disintegrate. “I started screaming in my sleep, not being able to sleep, waking up with mental images of very specific things happening and being truly horrified, spiralling out of control, drinking a lot,” she explained. Eventually she had a “full-blown meltdown” in front of her sister. She curled up into a ball and told her everything.

When Katie realised just how precarious her psychological state was, she began to see a therapist. Initially she felt too traumatised even to talk about what had happened. The first step, as she put it, was “talking about talking about it”. She visited a number of different therapists before she felt comfortable opening up about her experiences. “I don’t think any healing would have been possible without some sense of safety, which took distance,” she said. In the beginning, the task of confronting the assaults seemed hopeless. “It’s like a pile of rocks,” she explained. “You don’t really know where to start. You can pick one up off the top but then you still have this big pile.”

Katie began to realise that overcoming trauma wasn’t simply a matter of working through a set of steps or checking off items on a “to-do list”, as she put it. It is “incredibly interconnected…that’s the thing I’ve really learned from this: how interconnected we are within ourselves and to other people, and how lack of connection can really hinder your ability to live, or any desire to live.”

Not long ago Katie might have been encouraged to bottle up her experiences. But in the past 40 years, scientists have made strides in understanding trauma and its treatment. This change has been underpinned by a significant shift in social norms. Open discussion of trauma and its consequences has become less stigmatised with each passing year. In previous eras sufferers drew awkward silences, ridicule or even punishment. Now they elicit sympathy. Post-traumatic stress disorder, and its acronym PTSD, has entered the American vernacular. Searches for the term on Google have almost quadrupled in America since 2004, a period during which American life has become safer and less traumatic by almost every conceivable metric.

The willingness to talk about trauma, to pierce the veil of shame and embarrassment that has traditionally shrouded the subject, is a clear sign of progress. An insidious effect of PTSD is “avoidance”, the desire to stay away from stimuli that might trigger symptoms. Given what we now know about the condition, it stands to reason that you’re likely to deal with trauma better if you live in a place where open discussion of it carries little stigma.

Yet as PTSD has become better understood, psychologists have realised that discussing trauma is not inherently or automatically beneficial. Study after study shows that most people exposed to a traumatic event recover fully without therapy or medication. In some contexts talking repeatedly about a trauma, at least in certain ways, may even exacerbate the problem rather than offer solace. In the worst cases, victims come to identify so closely with their trauma that it becomes the organising feature of their lives. A growing body of evidence suggests that the way in which trauma victims talk about their experiences is as important as whether they talk about it at all.

For much of the 20th century, governments and medical institutions refused to acknowledge the sometimes crippling after-effects of trauma. During the first world war many British soldiers returned home exhibiting symptoms of what today would be labelled PTSD: some became temporarily confused, imagining themselves to be back on the battlefield; others were plagued by terrifying nightmares or hallucinations (Siegfried Sassoon, a British war poet, wrote of “dreams that drip with murder”). Men were diagnosed with one of two conditions based largely on the whim of their particular physician, notes Bessel van der Kolk in “The Body Keeps the Score”, a book on trauma. Those diagnosed with “shell shock” qualified for treatment (such as it was at the time) and a pension. The people identified as suffering from “neurasthenia”, essentially a nervous weakness, were cut off from both. As the amount of patients increased, armies on both sides of the conflict found their numbers depleted. The British armed forces published an order in 1917, stating that “in no circumstances whatever will the expression ‘shell shock’ be used verbally or be recorded in any regimental or other casualty report, or any hospital or other medical document.” Shell shock was transformed into “NYDN” – “Not Yet Diagnosed, Nervous”. At a stroke, discussion of trauma and its symptoms was stifled. The Germans, according to van der Kolk, were even more punitive. They “treated shell shock as a character defect, which they managed with a variety of painful treatments, including electroshock”.

It remained culturally unacceptable for veterans to open up about their experiences in most settings throughout the second world war. “We all came out of the same army and joined the same generation of silence,” said Karl Shapiro, an American poet laureate and veteran. The men of the “Greatest Generation” were expected to be stoic – mid-century conceptions of masculinity left little room for expressions of emotional distress. “They took army dogs and rehabilitated them for civilian life,” said Audie Murphy, a highly decorated American army lieutenant in the second world war. “But they turned soldiers into civilians immediately and let ’em sink or swim.”

The situation changed only during the Vietnam war. American veteran groups advocated vocally for the authorities to acknowledge the ordeal that returning veterans faced (the campaign was helped by domestic opposition to the war). Many soldiers reported suffering from flashbacks, anxiety, insomnia and other psychological symptoms that made it hard to readjust to civilian life. Some ended up homeless, addicted to drugs or worse. Certain hawkish figures, President Richard Nixon foremost among them, fought to prevent full recognition of the toll of trauma, because they thought it would hamper the war effort and tarnish the reputation of the conflict’s cheerleaders. Eventually reason won out. In 1980 the American Psychiatric Association added post-traumatic stress disorder to the “Diagnostic and Statistical Manual of Mental Disorders”, which sets the parameters for discussions of mental health in America and beyond. PTSD was defined as being the consequence of a “psychologically traumatic event that is generally outside the range of usual human experience”. This category includes proximity to death, near-death experiences, serious injury and sexual violence.

Scientists believe that PTSD occurs when the nervous responses that normally help us identify and respond to threats are over-stimulated. This can lead to nightmares, intrusive memories and sudden dissociative flashbacks to the events. PTSD often causes intense physical reactions, such as panic attacks triggered by stimuli that recall the original trauma. Sufferers recount the gruelling repetition of a traumatic incident in their mind, and the feeling of being held hostage by their own nervous system. In an interview last year Jason Kander, a politician from Missouri, spoke of “becoming hypervigilant” as he struggled with PTSD for more than a decade after serving in Afghanistan as an intelligence officer in the US army. At restaurants he was “always thinking about how many exits there were [and] having four different plans as to how you were going to get out of a situation.” He went “about 12 years without a good night’s sleep”, he said.

David Morris, a war correspondent and former marine, was once told by a psychoanalyst that “trauma destroys the fabric of time”, making it hard for an individual to escape the drag of the originating event. As he wrote in “The Evil Hours”: “After trauma, you may move in circles, find yourself being sucked backwards into an eddy, or bouncing about like a rubber ball from now to then and back again. August is June, June is December. What time is it? Guess again. In the traumatic universe, the basic laws of matter are suspended: ceiling fans can be helicopters, car exhaust can be mustard gas.”

More open discussion of PTSD over the last four decades has led to the development of a number of treatments that have been shown to be effective. Katie found two of these particularly helpful. One is known as eye movement desensitisation and reprocessing, whereby patients are asked to focus on the source of their trauma while following instructions from a therapist to move their eyes in particular directions. For Katie this “worked wonders”, she says, though “it’s so hard to explain what’s happening.” (Scientists don’t properly understand why it works.)

Katie also found cognitive-behavioural therapy (CBT) useful. This helps patients address patterns of distorted and negative thinking that tend to exacerbate their suffering. In Katie’s case, these centred on her own sense of culpability for what happened: “How in the world could I have been so stupid? How did I not know that people would hurt me? There must be something wrong with me...I must attract these types of people.” She has also worked to chip away at her belief that the whole world is chaotic and evil, a perception that became pronounced after her assaults. She realised that she had been talking at times like the Joker from the Batman films: “‘The world is chaos, people are bad’ – all these definitive statements of being traumatised that are kind of ridiculous.” The therapy helped her feel that life was more nuanced.

Not all common treatments for trauma are so useful. Critical incident stress debriefings (CISDS) are more controversial. These were developed in the 1980s by a former firefighter and paramedic with a PhD in human development, in response to a counterproductive stoicism he observed among fellow emergency-service personnel. In many parts of America the authorities now offer CISDS via private companies within 72 hours of a major incident such as a fire or car crash. Those involved are brought together in a group and encouraged to discuss their feelings in a structured manner, led by facilitators, so that they don’t keep them to themselves.

Many participants rate their experience of such groups positively, but a meta-analysis published in 2002 summing up all the relevant available research literature suggests that people who participate in CISDS suffer from worse PTSD symptoms over time than those who receive alternate treatments or no treatment at all. (Proponents of CISDdisagree with the methodology used to reach these conclusions.) Some trauma researchers believe that, by exposing us to other people’s symptoms, these sessions may interfere with our natural recovery from a traumatic experience. One emergency responder I spoke to, who attended a CISDafter working at the scene of a horrific bus crash in Utah, told me that he found other people’s accounts so alien he was convinced the discussion had hindered his recovery.

Talking about trauma is not an unalloyed good, in and of itself. There is mounting evidence to suggest that by priming people to view themselves as trauma sufferers, we may actually be increasing their chances of developing PTSD.

In 2011, 33 students at the University of New South Wales in Australia filed into a psychology lab one at a time to watch a disturbing ten-minute video on a MacBook. In the film, a shaky camera approached an overturned grey car on the side of a highway. Crash victims – it was not always clear who was alive and who wasn’t – were splayed out everywhere; some had apparently been violently ejected from their vehicles. Towards the end of the film, the camera fixed on the wide-eyed stare of a dead victim.

The students were participating in a study led by Adam Brown, principal investigator at the Trauma and Global Mental Health Lab at the New School for Social Research in New York, who was then at New York University. Earlier in the term each student had been given a battery of psychological tests. Prior to watching the film, some students were told that the tests revealed them to be extremely adept copers, able to recover quickly from traumatic experiences. Others were informed that they were below-average copers, lacking “control or confidence when dealing with adverse and stressful life events”.

After the film, each student was asked to “close their eyes and relax” for three minutes. When they opened their eyes, the researcher asked them to estimate the number of times the film’s sounds and images intruded on their consciousness during the interlude, and the level of distress that the film made them feel. The adept copers experienced, on average, about four and a half sensory intrusions during the three-minute interlude and rated their distress level at 5.65 on a 10-point scale. The poor copers, by contrast, experienced about 18 intrusions and rated their distress level at almost 8 – a significant difference.

In fact, the assessments of each person’s ability to cope had been fabricated. Simply telling people that they were good or bad at handling stressful events changed their response. Some students were plagued with graphic images of the accident because they expected to experience them.

The participants were informed of the ruse before they left. Even more remarkably, knowing this didn’t curtail the effects of the assessments. Twenty-four hours after the experiment, the poor copers still reported more intrusions and higher distress levels than the good copers, and recalled grisly details from the film more accurately. In a follow-up study last year, conducted on different groups, Brown and his colleagues tracked participants for a full week after they had seen the film. The results were similar.

Brown is fascinated by a concept known as self-efficacy – the extent to which an individual feels that they have control over the world, that they can affect a situation and successfully navigate their experiences. Differences in this capacity may be one reason, Brown reckons, why responses to trauma vary dramatically from person to person. Though it’s important not to extrapolate too much from these two studies, both of which took place in labs, Brown thinks that feeling helpless may be associated with prolonged suffering after some traumatic events. “‘I feel crazy, I’m never going to feel the same way I did before, there’s something permanently damaged, these symptoms will last for ever’ – I think those types of appraisals could inadvertently worsen the symptoms and elevate the levels of distress, which could affect long-term [PTSD] trajectories,” he told me. Acknowledging that distressing symptoms are normal, and that you will eventually recover from them, may be the key to building resilience.

Self-efficacy could be one of the missing links that explains a fundamental mystery about PTSD: what differentiates those who develop the condition after being exposed to trauma and those who do not. A study from 1995 found that more than 60% of American adults had been exposed to an event that the American Psychiatric Association would consider to be a “traumatic stressor”, such as assault, rape or serious accident, yet just 8% of the men and 20% of the women developed PTSD in the long term. Other studies have had similar results.

Additionally, a significant share of people will develop at least one of the symptoms of PTSD shortly after a traumatic incident, but most of those signs abate of their own accord over time. People living in the vicinity of the September 11th 2001 terror attacks provide a striking example. One researcher found that 7.5% of people in a random sample living within seven miles of the twin towers experienced symptoms of PTSD in the eight weeks after the attacks. But a follow-up survey conducted in February 2002 found the rate had declined to around 2%. Roughly 80% of the apparent cases of PTSD dissipated with time – and, given the short period after which the researchers followed up, most probably did so with little or no treatment.

There is a solid body of evidence to suggest that “traumatic stressors produce PTSD in only a minority of victims,” writes Richard McNally of Harvard University in “Remembering Trauma”, which analyses the scientific research in this area. What may make the difference, at least partially, is the meaning of an experience. McNally notes that a deep-seated sense of political righteousness has protected some torture victims. Left-wing activists arrested and tortured by the Turkish authorities experienced fewer negative psychological effects than people wrongly incarcerated or arrested for ordinary crimes. This led researchers to conclude that a positive commitment to a political cause created a buffer that may have protected them from the worst psychological after-effects of torture.

One major finding of recent research into PTSD is that, as McNally puts it, “there is no straightforward relationship between the severity of the trauma and the severity of the PTSD.” A complicated web of cognitive factors play a role in determining whether someone will develop PTSD. Some elements are beyond an individual’s control. Prior mental-health problems, low IQ and greater levels of neuroticism (a personality trait that psychologists define as one’s propensity to experience negative emotions) are all correlated with suffering from more severe PTSD, especially in the wake of less-severe traumas such as minor road accidents or verbal aggression.

There is not much that people can do to change their IQ or core personality traits. Some variables correlated with PTSD outcomes may be more malleable, which is why Brown and other researchers are so interested in self-efficacy. They believe that there may be ways to help people understand that PTSD is not an inevitable response to adverse experiences, and that they have some control over how they respond – that is, improve their self-efficacy and therefore their resilience.

Some promising early studies have already been conducted. One team tested an intervention called “7ROSES” on refugees in Amsterdam who were suffering mental-health problems relating to traumatic experiences. Rather than attend directly to their ordeal, the treatment focused on helping individuals cope and improving their belief in their ability to find a path through their problems. The treatment focused on developing skills for improving self-efficacy in a number of group sessions by, among other things, learning to identify “hopeful messages” and personal strengths. The aim, in one particular case, was “to replace a negative coping strategy (withdrawing; staying alone in his room) with a positive one (seeking social support; talking to a friend)”. Though the study was early and observational, it yielded positive if modest results: a quarter of participants saw improvements in their self-efficacy.

In another study, published in 2016, a group of health workers and social workers in America who were regularly exposed to troubling situations were given online exercises to improve their self-efficacy. They were asked to reflect on the obstacles that sapped them of psychological resilience and to develop strategies for overcoming them. These included considering their own experiences of surmounting obstacles and “identifying negative thoughts indicating self-doubts”. As in the case of the 7ROSES intervention, early results were positive – the programme appeared to improve the participants’ self-efficacy, which in turn reduced the stress induced by hearing about other people’s traumas, known as secondary traumatic stress, which care workers of all kinds are particularly vulnerable to.

Brown is gearing up to conduct another study this summer with staff in emergency departments at hospitals. Over the course of four weeks, participants will be asked to recall instances in which they overcame adversity, identify factors that allowed them to do so, imagine future stress-points that they may encounter and “think through the specifics of how they will solve [them]”, as Brown puts it. The goal is that a person who experiences a potentially traumatising event should not walk away from it feeling so helpless that they might then unravel if symptoms of PTSD arise. Believing that they have it within themselves to overcome an incident could, in itself, raise the chance of them doing so.

Societies that discourage or punish discussion of trauma exacerbate the suffering of those who have been traumatised, robbing them of access to treatment or support. Luckily it has never been easier to talk openly about traumatic experiences in many countries today. But some experts are now questioning whether certain cultural shifts have caused society to cast too wide a net in what they label as traumatic.

In an influential paper in 2016 Nick Haslam, an Australian psychologist, introduced the idea of “concept creep”. He argued that certain concepts, such as “bullying”, “addiction” and “trauma”, have become highly charged and expanded to encompass an ever wider – and at times ever milder – set of experiences.

As Haslam acknowledges, in many cases this expansion is a necessary and positive measure of progress. Rape within marriage began to be criminalised in America only in the 1970s, for example, and in many countries it is still permitted or ignored. In some spheres, however, the definition of trauma – and therefore the potential for someone to view themselves as “traumatised” – has become so broad that Haslam worries harm might ensue. “Expectancy is so powerful,” he told me. In the case of trauma, “expectations about how you’ll react, or what sort of things are overwhelming, or your views about time to recover, or whether you need third-person [help] — all those things matter. How could they not?”

A similar argument found popularity in “The Coddling of the American Mind”, a bestselling book by Jonathan Haidt and Greg Lukianoff published in 2018. The authors wrote that “encouraging more people to use the language of therapy and mental illness [is] likely to have some negative effect”. They argued that the labels themselves become self-fulfilling prophecies. In an email to me, Lukianoff drew on his own life as an example. “I am someone who struggled with depression, but if I incorporated ‘I’m a depressive’ into my self-definition, I would always be tilting in that direction, with a sense of helplessness over it because, after all, it’s what defines me,” he wrote. As Haidt and Lukianoff point out, the solution here isn’t to revert to the old-fashioned reflex of telling people in anguish to “toughen up” (as the disparaging term “snowflake” suggests). Instead, they argue, institutions should seek to find a balance so that they are compassionate towards claims of trauma, while being alive to the potential harm that may come from magnifying an incident in one’s mind.

One obstacle to finding this balance is the currency which the status of having PTSD has now acquired, whether formally diagnosed or not. It is an important milestone in society’s progress that trauma victims can speak up and are no longer seen as malingerers, weaklings or frauds. Some people now display their mental-health status prominently as a badge of identity and a defence against verbal aggression, particularly on social media. I was particularly struck by one exchange I saw on Reddit. A child, who believed they had PTSD because of their startled response when their father called their name loudly – in itself, no evidence of PTSD – was instantly met with a chorus of validation from many on the forum.

In the cacophony of life today, identifying as a sufferer of trauma can bring with it a certain authenticity and authority, even an opportunity to be heard out respectfully. It may also help you find support, especially online, from a ready-made community of fellow sufferers. But, Haslam warns, “once it becomes part of your identity, it’s very hard to let go of. Your sense of self is wrapped up in it and your community is wrapped up in it.” And evidence emerging from trauma research suggests that strong identification with one’s trauma may prevent recovery.

In 2006 Dorthe Berntsen and David Rubin, both psychologists, unveiled a measure they called the Centrality of Event Scale (CES). This was derived from a questionnaire that asked respondents to rate, on a scale from one to five, their agreement with a series of statements such as “this event has become a reference point for the way I understand new experiences,” “this event is making my life different from the life of most other people,” and “I often see connections and similarities between this event and my current relationships with other people.” After more than a decade’s research, they established that the more you view your trauma as a central event in your life, the more likely you are to suffer from prolonged PTSD symptoms and other mental-health problems.

McNally concurs. “One potential clinical implication of this is that if you see your childhood sexual abuse [or other traumatic event] as somehow central to your identity of being a victim, of a survivor of a trauma,” he told me, “it tends to [organise] how you look at life, how you see yourself, how you interpret events in the future.”

If trauma becomes a fundamental part of your identity it grows harder to treat, reckons McNally. He has personally observed this effect among a group of veterans. In the mid-1990s he performed a study on autobiographical memory with servicemen who had fought in Vietnam. He noticed that the ones whose memory was most impaired “were wearing regalia. You immediately spotted them as a Vietnam vet, they had combat stuff on, POW/MIA caps, one guy came in with a loaded gun.” For these folk, “the Vietnam war was a self-defining thing. This is 20 to 30 years after they left the service, they’re still wearing the Vietnam stuff. They’re frozen in the past.”

Structural incentives may compound the problem, McNally says. When campaigning increased to support the mental-health needs of military personnel after the invasions of Iraq and Afghanistan, he noticed that some veterans and their advocates believed it would help their cause to claim that PTSD was, in his paraphrase, a “chronic relapsing condition from which you can never recover”. Yet, given that most people exposed to trauma don’t develop the condition, and those that do often recover if they seek out treatment, this description of PTSD is inaccurate.

Many people who argue that PTSD is a chronic condition believe that they are doing the right thing for trauma sufferers. Yet McNally is concerned that this kind of framing can induce unnecessary suffering: “I wince when I see it – you’re far less likely to take steps in your life that will help you master your fears, help you overcome the symptoms and get back on track again.”

Such concerns are especially pertinent in an age when many people will seek help from online support groups long before – or entirely in place of – seeing a trained therapist. Some may mistake transient symptoms, such as the flashbacks that frequently occur in the immediate aftermath of distressing events, as evidence that they have PTSD. Ruminating over these symptoms with other people who have also diagnosed themselves may actually prolong their suffering.

I was apprehensive about discussing these concerns with Katie, the young woman who had been assaulted in college. Her trauma was clear and acute, and at her lowest points she had considered suicide. But when I broached the subject with her, I found that she had already considered the matter deeply. “I’ve been in two sexual-assault support groups, and it’s so hard because you go in there and your identity to these other people is that you are a sexual-assault survivor,” she said. “But that’s the one thing you’re trying to get away from. In the group, you’re doing work to not become this one thing, and yet that’s all you are in the group. It’s kind of this weird counterintuitive thing.”

She has experienced a range of personalities in these groups. “There are ‘I’m going to ignore this and pretend it never happened because I need to make this new person’ types at one end of the spectrum. And at the other are ‘this is all I am’ types.” Katie saw the healthiest approach for her as residing somewhere in the middle. “I’ve been trying to focus on creating a place where I can go where I’m not inhibited by that identity of being a survivor, or having to live up to that expectation,” she said, but where she is still able to discuss her trauma openly and understand how it has affected her.

Lisa, a 41-year-old New Yorker who was sexually abused by her father, expressed similar sentiments. “There are definitely times when it’s easier to lean into” the role of the victim, she told me, even though this led her to feel strangled by her past. She said that it made her feel “heroic” and “politically interesting”. She repeatedly returned to the same handful of websites that hosted discussions between abuse survivors, even though she found the stories there “emotionally triggering”. “I’d repeat the same search just to feel sorry for myself...In some weird way, reinforcing that sense that no one cared was cathartic.” She found “comfort” in “black-and-white thinking: I’m the unprivileged, others are the privileged,” she said. She also felt that this allowed her to blame the less appealing parts of her own character on the trauma. Lisa has sought help in the past, but hasn’t always found it useful when her therapists focused on her experiences. “Sometimes they’re good at delving into the past and figuring out your story,” she said. “But not everybody’s good at, ‘Okay, so this is where you are now? How do you put one foot ahead of the other?’”

People who have access to validated treatments for PTSD tend to have good outcomes. But America’s mental-health system is inadequate and struggles to provide consistent care. One study from 2017 found that over half of Americans who suffer from a mental-health condition had received no care for it in the past year. In a follow-up email to me, Lisa reflected that one reason her therapy felt ineffective was because she had been able “to see a therapist once a week at most, while I probably needed way more support than that”. That, perhaps, would have made it easier to move beyond endlessly revisiting what happened to her and to turn more assertively toward the future. “Of course, I could barely – and not always – afford once a week, let alone more.” The provision for PTSD sufferers in other countries is even more limited than in America.

Until mental-health services are more accessible to greater numbers of people, many individuals who are in distress will spend time seeking out informal advice online and try to manage their own conditions. And, if increasing numbers of people think they are being traumatised, in ways that lie far beyond the parameters recognised by medical professionals, and if social forces incentivise them to think that way, there are strong reasons for believing that many may be unwittingly doing themselves harm.

In mid-October 2019, five years after her assaults, Katie made a significant advance in her recovery when she told her parents what had happened to her. She hadn’t said any­thing before because she worried that their reaction would be harmful rather than helpful. Instead, “they ended up being truly, truly wonderful. Just the act of being heard kind of added this layer of – maybe my entire life doesn’t have to be a tragedy,’” she explained. “Maybe this is just one of the stories in a full book. Just a moment I’m visiting. But it’s really hard to feel that in the moment, because it truly destroys who you are.”

Despite this improvement, Katie does not yet feel safe or comfortable. She still struggles with a cycle in which she pushes people away, then feels isolated as a result. Part of that stems from the enormous gap in experience between her friends and her. As women in their early 20s, she explained, “my friends’ issues are like, what’s their Halloween costume. So I feel a little more burdened.” Having a therapist means that there is someone “who is willing to sit in the shit with me”, she told me. “We’ve recently been talking about building a boat so you don’t actually have to sit in the sea of shit – so you’re kind of floating along in a little life-raft.”

What does that life-raft look like? In our conversation, I got the sense that Katie had only just started designing it. She is concentrating on the parts of the things that bring her joy. “Today was hard, but I still really love animals. I love hiking. Focus on quality-of-life things that make life worthwhile and make living through horrible things more bearable.”■

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