How to Find a Therapist

My guest blog at NICU Central posted today; it's about becoming an informed consumer when seeking out clinical help during or after the NICU. So great to collaborate with such an awesome provider and NICU nurse. Check it out for tips in finding a therapeutic collaborator in making sense of the NICU:

The NICU experience; words to describe it. Terrifying, stressful, saddening, maddening, traumatic, disempowering, fearful, unpredictable, scary, mystifying, changing, bizarre lights, jarring sounds, life and death, tubes, new languages, new people, infection, struggle, adjustment, exhaustion, the unknown, the unexpected, lack of time, too much time, stress, fear, fear, fear. Simply using word association to describe the experience brings back the sensation of being in a new place, not knowing the outcome of any minute, of constantly being reminded that nothing is promised and that there's no way of knowing what tomorrow (or even the next hour) might bring. The words fall short of aptly describing the circumstance, but can give a slight sense of just how destabilizing a traumatic birth experience and the subsequent hospitalization of your baby can feel for a NICU parent. I know because I was one... (Read more at NICU Central)

 

Coping with the "Zen" of the NICU: A Breathing Exercise

Being in the NICU is a swift baptism into a world in which nothing is predictable. My feeling was that once we were used to one circumstance, when the words started to make sense or we felt stable, as soon as we started to feel that sweet pang of familiarity, it quickly vanished into the NICU mire and another difficult circumstance would present itself.

My least favorite phrase of all-time, "it's a rollercoaster" felt like some kind of a sick mockery of the groundless world we had suddenly found ourselves floating in. The first time I heard that phrase was the morning after my son Elliott had had a pulmonary hemorrhage and had to be ventilated. His brother William was found to have a grade four bilateral brain bleed and severe infection, and it was related to us that "the 'honeymoon period' [was] over." Welcome to the NICU.

However apt the rollercoaster analogy, it's incredibly difficult to become accustomed to the monumental shifts and surprises, both bad and good, that happen on a fleeting and frequent basis in the NICU. After some time living in that unpredictable world, I realized that the momentary nature of it, the way that it forces one to be "present" and mindful of each breath that you or your little one(s) take in, has this zen-like quality to it. After all, when your baby is in the NICU you can't allow yourself to think one day ahead, even three hours ahead, without making the mistake of creating a false security that can be shattered with one bad blood draw, one bradycardia event, one bad test result. This ability to be "present in the moment", or mindful, is considered something to strive for in Buddhist meditation and mindfulness theory. The challenge is that it is very difficult to stay present emotionally, especially in easier times, when it's simple to distract your mind with the entertainment and interest of day to day life. The NICU, for what it is worth, oftentimes forces the ability to be present in the moment upon its patients and their parents.  

“...the human experience is an experience of nothing to hang on to, nothing that’s set once and for all. Reality is always falling apart. In this fleeting situation, the only thing that makes sense is for us to reach out to one another.”
— Pema Chodron, "Living Beautifully: with Uncertainty and Change"

One author whose work spoke to me whilst our family was in the NICU was Pema Chodron, a Buddhist nun whose books about coping with suffering proved to be incredibly useful in living through the experience. Her books "When Things Fall Apart" and "Living Beautifully: with Uncertainty and Change" speak to the notion of losing your grounding in the world, and how in losing that, one can find incredible strength in learning how to face your fears, embrace the unpredictable nature of the world around you, grow spiritually, and find commonality with others that face the pain in their lives. In "Living Beautifully..." she wrote, "...the human experience is an experience of nothing to hang on to, nothing that's set once and for all. Reality is always falling apart. In this fleeting situation, the only thing that makes sense is for us to reach out to one another."

Here is a simple breathing exercise/meditation that can help promote calmness, even in difficult times. It is designed to help you learn how to ground yourself, even in times of intense stress. The practice can be useful for NICU parents facing the stress of the hospital, but can also be implemented by anyone facing a traumatic circumstance who feels the need for grounding or feels overwhelmed by their anxiety or suffering. I used to love doing it while I held Elliott skin-to-skin in the hospital, and got so used to the practice that I implemented it at home long after he was discharged. At this point I consider it a tool that I have in facing any kind of stress, and use it whenever I feel a sense of anxiety or overwhelm.

Note: Before beginning, check-in with yourself that you're able to safely do a breathing exercise. Be mindful of how you are feeling, especially towards yourself. It's important to approach a stance of forgiveness and self-love in participating in this exercise. If at any point during this breathing exercise you feel triggered or overwhelmed, stop immediately and take notice of the things around you. Call a nurse, your partner, a family member or a friend and tell them how you are feeling. 

  • Sit comfortably, with both feet on the ground and your back against a supportive chair. Close your eyes. Allow your arms to relax. Allow your body to relax. Become aware of your breath, how it feels. Breathe in to the count of six, and breathe out to the count of six. Count as slowly as you can, and breathe in as deeply as possible and out as slowly as possible. Feel your breath in your lungs, notice it. Relax into your breath.

 

  • Once you have established a slow and steady breathing pattern, if you'd like, you can discontinue counting as you inhale/exhale. Notice your breath, how it feels in your body. If your mind starts to wander, come back to your breath and focus on it. Treat the thoughts that enter your mind as passing. If it's useful, you can name them as thoughts or feelings, notice them, let them pass, and return to concentrate on your breath. Connect with how you feel physically in this very moment. Be present with your breathing.

 

  •  Continue in this manner for as long as you'd (reasonably) like to, but for at least 3-5 minutes. When you stop, notice how you feel. Are there any parts of your body that are particularly noticeable in this moment?  Were there any parts of your body that felt particularly stressed? Were there any thoughts dominating your ability to let go of thinking?

 

  • As you accustom yourself to taking time for this meditation, try to delineate more time for it each day. If you'd like, you can even try doing it while holding your baby. As I said before, I think skin-to-skin contact is preferable just due to the closeness it provides, but it's ok if you hold them swaddled. Make sure that you have the ability to sit comfortably and safely hold your baby. Relax into your chair with them snuggled close to you, breathe in their beautiful scent, and find grounding/love/compassion, even in the groundlessness.

Breathing exercises, as simple as they may seem, have the profound ability to induce calmness and presence, even in the most difficult of circumstances. Although at first it may be challenging to let go of thoughts and stresses, with practice, breathing exercises can promote your ability to be present even in fearful times, can provide you with a sense of connection not only with your baby, but with other parents going through similar circumstances, and can make clear what it is that you can hold onto, even in times where it feels like there isn't anything, that you're floating far away from the shore.

For more relaxation techniques and exercises, check out this PDF from the Trauma Center, or go to their website for this and other resources in coping with trauma.

Interview with an Insider: One NICU Nurse Shares Her Insight

Nurses play a very special role in the NICU. They are the communicators, many times delivering messages in plainspeak and providing parents with emotional and practical support where doctors cannot. Sometimes, while in the state of having a baby hospitalized, it's hard to understand where a nurse may be coming from, and it can be challenging if there is a communication difficulty between parents and nurses. Building a trusting, open relationship with your baby's nursing team can be incredibly valuable both to your state of mind, as well as improving the continuum of care for your baby. Even when the relationship is challenging, it is helpful to remember that these individuals are heartfully dedicated to the care of premature and medically complex babies, and that they, too, cope with trauma on a daily basis.

Oftentimes, while a baby or babies are hospitalized, nurses become the primary contact with and support that NICU parents have day to day. Our relationship with the nurses can color our NICU experience; making us feel more supported and part of a team, or, sometimes, making us feel more isolated, fretful or dismpowered. Parents' relationships with their baby's nurses are invaluable during a NICU stay, so I reached out to one of Elliott's primary nurses, Cara Romanos, to ask her a few questions about her experience at the Lucille Packard Children's Hospital. Here are a few insights that may give us a sense of one nurse's values and beliefs.   

What led you to become a NICU nurse?

I have always had a deep love for babies, children and their innate magic. I knew in my heart that I would in some capacity find my work with them. Before becoming a registered nurse, I worked with disabled children, many of whom required nursing care, and found myself drawn toward nursing. Once introduced to the NICU, and most specifically the fragile, heroic, and to my eyes, extraordinarily beautiful preemies, I fell in love.

How would you define your role as a NICU nurse?

I'm an RN who cares for premature babies, babies with birth defects, severe or life-threatening illnesses. I work under the direction of a doctor, or various doctors as I work in a university hospital. Aside from providing nursing care which includes many technological aspects, I also provide comfort and support to families.

What are the challenges in being a NICU nurse?

Working in intensive care is often challenging. Infants can go into distress quickly and as a NICU nurse I have to be constantly aware of and understand distress signs. I need to be very detail-oriented and be able to manage various technologies simultaneously. At the same time, I need to be kind, patient and emotionally objective while, my hope is, always remaining nurturing and deeply compassionate.

“A preemie’s parents are warriors; great warriors. They protect and advocate fiercely for their baby. Their love is so very apparent and unconditional; exceptional. They... have become my heroes and I feel honored to work for them and ‘fight’ at their side. ”

How would you describe your relationship as a nurse with NICU parents?

My hope is that it is nurturing and comforting on my part. I am also a teacher of sorts as I guide them through the sounds, tubes, wires and strange machines that surround their beautiful, fragile baby.

How do NICU nurses support parents while baby is in the hospital?

We can encourage them to touch and hold their baby (or babies, if they have more than one) as often as is appropriate or feasible. We can also encourage them to care for their baby as much as is appropriate as well, like participating in diaper changes and temperature taking.

We also encourage buying a device that can record their voices, so their baby may hear them talking, reading or singing to them when they are unable to be there.

How can parents advocate for their baby?

They may use their voice. If they are unhappy, they should approach the nurse/doctor or whomever directly to talk about their feelings. If they feel they've been ignored, they may talk with their social worker to set up a conference meeting with their medical team, or talk with the nurse manager about a particular nurse or nurses. Most NICUs are family centered and care deeply for the family as a whole.

“I encourage trust. Trust the nurse and the medical team more than what you read on the internet. The team has years of experience and education and your baby’s patho-physiology is more complicated to understand than what can be read by a few articles. Trying to let go as a parent must be very difficult, and most nurses do understand this. My hope is that most of your experiences are met with compassion. ”

What can parents do if they feel uncomfortable with a particular nurse's care?

They may approach the resource/charge nurse working that shift, or the nurse manager if available, and ask to not have that nurse assigned to their baby again. If staffing numbers/acuity allow for it, another nurse may be able to take over for their baby's care.

How can parents develop stronger relationships with their baby's nurses?

This is a difficult question. There are many different nurses with varying personalities and styles of nursing. There are nurses whom you will develop relationships with instantly, and others with whom it will take time.

I encourage trust. Trust the nurse and the medical team more than what you read on the internet. The team has years of experience and education and your baby's patho-physiology is more complicated to understand than what can be read by a few articles. Trying to let go as a parent must be very difficult, and most nurses do understand this. My hope is that most of your experiences are met with compassion.

What are some useful ways parents can take care of themselves while in the NICU that you've observed?

You can take care of yourself.

I know it's very difficult, but by trusting the NICU staff to allow yourself to leave the NICU and to rest. Sleep. Eat nurturing foods. Walk in the sunshine. Talk to each other. Allow yourselves to feel your feelings and don't judge each other if you are reacting to the NICU differently. The NICU is stressful, and if you nurture yourself, you will be more nurturing for your baby.

When parents feel especially overwhelmed by the NICU experience, what do you recommend they do? How can nurses be a resource?

As a nurse, I can call their social worker to the bedside. They are a wonderful and comforting resource and are able to sit down alone, away from the unit to listen and nurture. They are also able to connect them with a psychiatrist for sessions and if needed, medications to aid with depression and anxiety. The NICU experience is deeply traumatizing for families and many suffer from PTSD after their experience. It's very traumatic to witness one's baby having invasive medical procedures and life threatening moments.

When do you find it the toughest to be a NICU nurse?

When I bear witness to intense suffering. Both the babys' and the parents'. I work in a level III-IV intensive care NICU and we care for the tiniest and sickest babies. At times they can experience immense pain. They can often have various central lines, catheters in their chest, bladder, various tubes in their throats and noses, etc. They are fighting for their lives. I can't even imagine the pain the parents must be feeling to have their child in our NICU. When they are at their greatest moment of weakness or need, I know I need to stay strong and be a source of comfort and support.

What are some of the unique skills and gifts that parents bring to the table?

Their immense love of course, which leads to a tender touch and unique depth of connection. Their presence and voices calm and lower their baby's vital signs. I've seen this and love to point it out to their parents so that they are aware of the difference they make in this positive way. They are able to hold their baby bare skin to bare skin which again is soothing, calming and very beneficial to their development.

“I am in awe of the depth of strength preemies have. They are so very fragile and yet powerful in their will for life and ability to endure. They are courageous little ones and my greatest heroes. ”

Do you have any "sparkling moments" or stories that stand out to you in your experience of being a NICU nurse?

I've had many wonderful primary babies who have gifted my life and so have an abundance of "sparkling moments" held in my heart.

There is one little boy who was born at 29 weeks gestation weighing 2 lb., 11 oz. I was the RN on his transport team and we shared a helicopter ride back to my hospital. In our NICU he underwent various major intestinal surgeries, lost bowel, suffered from sepsis and hypovolemic shock. Three times his parents were told to expect him to not live. He spent seven months in the NICU. We both just celebrated our birthday, which we share. He is now a beautiful and completely healthy six year old. My sparkling miracle.

Do you ever feel traumatized by your work? How do you practice self care?

I wouldn't be human if I said I didn't feel at times overwhelmed and traumatized by this work that I love so deeply. As nurses, we care deeply for your baby. We become their biggest advocates and cheerleaders. We "will" them with our care and hope along with you. In doing so, we also feel deeply crushed during the "bad" days and grieve enormously with you if a life is lost.

As nurses, we share with each other and hold each other up. We speak with our church pastors/priests, exercise, cry and allow ourselves to grieve. Some of us even see a therapist when the grief is particularly overwhelming.

What are the biggest strengths of the preemies and their parents that you notice?

I am in awe of the depth of strength preemies have. They are so very fragile and yet powerful in their will for life and ability to endure. They are courageous little ones and my greatest heroes.

A preemie's parents are warriors; great warriors. They protect and advocate fiercely for their baby. Their love is so very apparent and unconditional; exceptional. They too have become my heroes and I feel honored to work for them and "fight" at their side.

 

                       Cara, Eli, and his doppelganger friend.

                       Cara, Eli, and his doppelganger friend.

 

 

 

 

Cara Romanos has worked at Lucile Packard Children's Hospital Stanford for almost 17 years. She loves the magic and wonder that children bring into our beautiful world and she strives to keep it here. She is also mommy to Eli, the sweetest chihuahua she's ever encountered.

After the NICU: What Meaning do You Take with You?

After Elliott was discharged from the NICU and on quarantine, I was left with a lot of time to think. For me, having lost William and spending so many days bedside in the NICU with Elliott, it felt like my entire world had been scrambled into something almost unrecognizable in comparison with what it had looked like even months prior. Transitioning from the "survival" mode of everyday getting to the NICU, making medical decisions, consulting with doctors, nurses and therapists, working towards Elliott's various discharge goals and witnessing Elliott's progress to medical stability was difficult. I had gotten used to the fast-paced nature of the NICU, made friends with his nurses and doctors, become accustomed to the idea that every day could present a new challenge; I even had my favorite places in the hospital to get coffee or take a break from being bedside.

We shifted to a life of being at home on quarantine, adjusting to the day to day, getting used to troubleshooting issues that presented themselves on our own, spending precious alone time with Elliott and starting the process of mourning. All of the events of the past few months started to solidify in my memory, and I started to understand just how this story would profoundly change my life story. But what would that look like? Would this story transform our family into some kind of tragic example of loss? Would we fade away from our friends and family? Was there anything powerful we could take away from it, that, maybe, we wouldn't want to lose, even as painful as the experience was?

When Elliott was about six months old (three adjusted) the peace lily we had put in his room bloomed:

It bloomed in a pairing of two petals, uncommon for peace lilies, which normally  produce one white petal in their flowers.

It was a twin bloom.

When John and I saw it, we were astounded. We felt comforted by it, as if it was some kind of a signal that the earth knew what had happened, that what happened was not to be forgotten. To me, it was also a symbol that despite having gone through that pain, we had somehow been able to move forward. And though it wasn't the way we would have ever chosen to move forward, it had revealed different aspects of ourselves that maybe we hadn't ever noticed before, or seen as a strength. It reminded us that he would always be with us; that our time with him had changed us forever.

Post-traumatic growth is a newer idea in the psychological community. The premise is that after an individual goes through a traumatic or challenging life experience, they then, oftentimes, experience positive psychological changes (Tedeschi, R. & Calhoun, L., 2004). In other words, when you go through an experience in which everything you thought you knew or could rely on is somehow taken away, one oftentimes finds ways of coping with that experience by developing new beliefs or discovering inner resources that before that moment in time were not apparent. Recent articles have shown that, in fact, post-traumatic growth is often more common than the development of PTSD after someone goes through a traumatic experience.

The NICU seems to have the ability to burn away the things that perhaps seemed important in the past, but no longer hold meaning for parents. I don't know a single NICU parent who doesn't understand the very profound value, the gift, of being able to witness your child take a breath unassisted, or swallow without choking, or make eye contact even for a few fleeting moments. Things that for many parents, go (blissfully) without notice.

Oftentimes, for NICU parents, the love that we hold for our children becomes very "operational". In other words, it becomes a very deliberate act of noticing and interacting with our little ones. We go to the NICU, we make decisions and advocate for them, we learn how to participate in their therapies, and accept the problems that present themselves along the way. Love, then, is not just an idea that we have about our relationship, there are actions involved. Prior to having gone through the NICU experience, if you had asked me if I thought I could get through something as challenging, I likely would have told you that I couldn't. That I did get through it in itself is very powerful, and, for me, gave me a sense of just what parts of my sense of self would survive the NICU experience; and it was comforting to discover that it was love that survived it all. It was also awesome to see that my partner had that same sense, and that I could rely on him to carry on on the days that I couldn't.

Despite the pain and anguish of going through an experience that quite literally takes your breath away, perhaps in the survival of that, we find the parts of ourselves that are the most resilient. And I feel gratitude to my boys for having highlighted that for me with their fortitude and grace. Each year, around this time, I get reminded of it when I think to myself about the ways in which I want to move forward in the coming year.

To other NICU parents: what do you DO with the experience of having gone through the hospitalization of your baby? How does your experience make itself known in your day to day life? Have you ever been surprised at how this experience has changed your sense of self or your relationship with your little one(s)? Was there anything of value that you could find in the NICU experience?

References:

Barr, P. (2011). Posttraumatic growth in parents of infants hospitalized in a neonatal intensive care unit. Journal of Loss and Trauma. 16, 117-134.

Spielman, V. & Taubman-Ben-Ari, O. (2009). Parental self-efficacy and stress-related growth in the transition to parenthood: a comparison between parents of pre- and full-term babies. Health and Social Work. 34(3), 201-212.

Taubman-Ben-Ari, O. & Kuint, J. (2010). Personal growth in the wake of stress: the case of mothers of preterm twins. The Journal of Psychology. 144(2), 185-204.

Tedeschi, R. & Calhoun, L. (2004). Posttraumatic growth: conceptual foundations and empirical evidence, Psychological Inquiry. 15(1), 1-18.

 

Trauma: Why Does There Always Have to be a Reason?

Many parents feel a significant amount of guilt and/or shame after going through a traumatic birth experience and the hospitalization of an infant. One of the most salient conversations I had at the NICU was with one of my sons' neonatologists, who told John and I to be gentle with ourselves. He said we would likely have thoughts, lots of them, desperately examining every detail of the days leading up to our babies' birth,  trying to figure out what we did wrong to cause my preterm labor. He was correct. In fact, we had already gotten started researching what it was that made us absolutely responsible for the traumatic birth of the babies. Because how could such a horrific and devastating event happen for no reason? Maybe it was something I ate at dinner, maybe when I moved that piece of furniture a few days ago. Should I have taken a leave of absence at work? Was I too stressed out? Moving. Life events. Did my pets somehow give me an infection? Maybe I wasn't mindful enough. We must have done something wrong.

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Traumatic stress, so it seems, often rolls into our lives hand in hand with guilt and shame. Guilt and shame are so common in the experience of traumatic stress that at one point they were considered as potential diagnostic criteria in the classification of post-traumatic stress disorder. Individuals facing other forms of traumatic stress also oftentimes take up the practice of self-blame in the aftermath ("what was I wearing that prompted him to assault me?"). So what gives? Why is it that when an individual goes through a traumatic experience, it's so common to then manifest shame, self-blame and guilt? And what do we do with that? Why is it so hard for us to sit with the notion that sometimes things happen for no known reason?

Psycho-evolutionary theory holds that an individual feels shame and guilt much in the same way an animal might, indicating to the community around them that they have been harmed and need help (Harman & Lee, 2010). So, maybe when we feel responsible for a tragic event, it's our unconscious way of "performing" our trauma for our community, exhibiting our remorse so that we aren't excommunicated. Fair enough, but what if shame and guilt are holding us back from functioning in our day to day lives? What then?

  1. Learn about your circumstance.

Chances are, there was nothing that you could do to prevent your birth experience from going the way it did. Nothing. This is a great article describing some of the most common pregnancy complications, and how despite how much progress has been made in the business of caring for premature or medically complex babies, the medical community still doesn't know exactly what causes these things to happen. Yes, there are risk factors that can lead to complications. However, most of these risk factors are not things that you can avoid. We often hold the assumption that the medical community has expert knowledge of all ailments we might face. Unfortunately, even though so much valuable research and progress has been made in preventing pregnancy complications, many elements are still little understood.

     2. Be aware of cultural attitudes that may be causing you harm.

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All too often in our society, the unexplainable is not accepted. I was shocked when reading through comments on articles about the World Health Organization's recently released infant mortality and prematurity statistics, to see that many individuals who had never experienced anything remotely like preterm birth had pert answers as to why they felt infant mortality is still an issue in the U.S., offhandedly blaming mothers and families for their own tragic circumstances. Try to shield yourself and your family from these kinds of attitudes, whether in the media or in your own community. When someone asks "What did you do that caused this to happen?", redirect them to the research that shows that you did nothing wrong. If that attitude persists, set a boundary with that individual to protect yourself.

     3. Develop a sense of loving-kindness towards yourself.

This is the tough one. How can we move ourselves from a place of guilt and shame to one in which we hold compassion for ourselves and what we are going through? One trick I learned through my own experience was to try and imagine myself from another person's perspective, even my babies' perspective. What might that other person see? Was I doing the best that I could given my current set of circumstances and the knowledge that I had? If I had known some way of preventing this event from happening, would I have done it? By looking in from the outside, sometimes your strengths and values become more apparent. When you start to see and identify your strengths and values, you will also start to develop the ability to grow loving-kindness for yourself. If imagining yourself through the eyes of another person proves to be difficult, start by using affirmations (it's simple to google free affirmations; peruse them and sort out a few that resonate with you). Simply repeat the affirmations either silently or out loud multiple times a day. It may feel alien or strange at first, but sometimes going through the motions of self-reassurance can jump-start the process to reaching the "real" thing.

     4. Promote loving-kindness of the self in your partner.

Your partner (or other individual who provides you with significant emotional support) will likely be mired in the same struggle with guilt and shame that you are experiencing, even if his/her struggle looks completely different from yours. When coping with a trauma together, try to be gentle with your partner. Remind them of their strengths or the things that you appreciate about them. Check in with them about how they are coping, even if it seems like you've already addressed all the issues together. In doing these things, you will set a precedent of support in your relationship, and create a space in which you can address the various stresses you're both facing.

Shame and guilt are oftentimes the uninvited guests to an already traumatic event. Allowing these emotions to take over can increase your risk for developing acute or post-traumatic stress disorders (Barr, 2010; Harman & Lee, 2010). If your sense of shame and guilt is so overwhelming that you feel powerless against it, it may be time to seek out counseling.

As our neonatologist continued in the conversation that day, he told us his NICU experience spanned decades. He told us that if the birth were our fault, he would surely tell us. He told us he almost never saw patients that had done something that "caused" their pregnancy complications. He told us that tons of research is being done to prevent this very thing from occurring. That if they could resolve preterm labor and other reproductive complications, that he and his colleagues would be unemployed. "Happily unemployed." His words resonated with me. In fact, for months I would deliberately replay what he said in my mind when I started to develop new theories of why our circumstance was all my fault. To this day, I feel gratitude for what he said.

 

References

Barr, P. (2010). Acute traumatic stress in neonatal intensive care unit parents: relation to existential emotion-based personality predispositions. Journal of Loss and Trauma, 15: 106-122.

Harman, R. and Lee, D. (2010). The role of shame and self-critical thinking in the development and maintenance of current threat in post-traumatic stress disorder. Clinical Psychology and Psychotherapy, 17. 13-24.

Leskela, J., Dieperink, M. and Thuras, P. (2002). Shame and posttraumatic stress disorder. Journal of Traumatic Stress, 15:3. 223-226.