PTSD and CRP
Post-Traumatic Stress Disoder & Consciousness Restructuring Process, by Iona Miller, 2000
by Iona Miller, Asklepia Foundation, ©2000
ABSTRACT: Posttraumatic stress is a disorder, and that implies automatically a chaotic state of being. The sorts of trauma that tend to induce PTSD include combat trauma, crimes, rape, grief, kidnapping, natural disasters, accidents, torture, and imprisonment. Predisposition to dissociation can arise in violent family environments. Those with PTSD become hypervigilant and hyperreactive to environmental threat. The traumatic syndrome is ever present and unchanged. Emotionally, it is as if it keeps on happening. State-related learning and memory encoding help maintain the trance-like steady state. Depression, shame, anxiety, subtance abuse, and survivor guilt are complications.
The nucleus of the disorder is a physioneurosis, somatization, depersonalization, and dissociation. Psychosomatic symptoms are expressions of the dissociation. Therapy proceeds by facilitating information transduction between them. There is poor impulse control and explosive aggressive reactions. There are persistent and profound alterations in stress hormone secretions and immune function. Integration of traumatic memories proceeds by verbal and nonverbal means in therapy. Time does not heal all wounds. Different treatments are needed at different stages of posttraumatic adaptation. CRP offers a way of restructuring the frozen structure of this disorder at the most fundamental level, in the sensory terms in which it is encoded.
KEYWORDS: PTDS, consciousness, creativity, psychotherapy, mind/body healing, integrative therapy, dreams, dreamwork, flashbacks, dissociation, trauma, state-dependent learning and memory, hypervigilance, sleep disorders, Freud, chaos theory, adjustment disorder, hormones, neurotransmitters, paranoia, EMDR, SSRIs, antidepressants, intrusion, intruders, anxiety, self-deception, ufo abduction, abductees, memes, placebo effect, REM, Consciousness Restructuring Process.
WHAT IS POSTTRAUMATIC STRESS DISORDER?
The development of a chronic trauma-based disorder is qualitatively different from simple exaggeration of the normal stress response. In those affected, a cascade of biobehavioral changes leads far beyond simple conditioning. Symptoms are intrusive and lead to hyperarousal and/or avoidant behavior. Frightening and vivid flashbacks are the most striking phenomenon. Prime victimization comes from memories of the event, rather than simply the event itself. Development of PTSD depends on personality and genetic make up, and on whether or not the trauma was expected. Prolonged exposure to severe trauma may cause permanent psychological scars.
Dissociation at the moment of the trauma has been shown to be an important factor in developing full-blown PTSD. Therefore, adults with a predisposition from childhood in chaotic, threatening, sexually abusive or violent families are at greater risk. Dissociation is characterized by feelings of detachment, estrangement, depersonalization, an unusual sense of one’s own reality, being an outside observer of one’s own actions and body, feeling like an automaton, or as if in a dream. Ability to feel emotions of any type, (especially those associated with intimacy, tenderness, sexuality), is markedly decreased, as is ability to express angry feelings. Attacks appear like a psychological seige, therefore “bunkering” mentality prevails.
Flashbacks can be triggered by overreactions to sounds, smells, feelings, or images. During the flashback, the person relives the traumatic event and may completely lose touch with reality, suffering through the trauma for minutes or hours at a time, believing that it is actually happening all over again. There is activation of sensory areas of the brain during flashbacks, right-hemispheric activation, and limbic-system activation.
The psychological function of emotions is to alert us to pay attention to what is happening, so that we can take adaptive action. Generally, we stop having an emotional response when we have realigned our expectations of what is supposed to happen with what is actually happening. We either take action that adjusts the given situation to our expectations, or change our expectations to fit better with what is actually going on.
But in PTSD, emotional arousal and goal-directed action are disconnected from one another because of emotional numbing. Arousal is no longer a cue to pay attention to incoming information. There is no gap between stimulus and response with fight-flight reactions. They either freeze or overreact. The emotions of fear, terror, and helplessness characterize any traumatic event, and avoidance of these feelings would seem to be the result, but chronic reenactment of the damaging event is compulsive.
Those with PTSD are more sensitive to sound intensities than average. They are “reducers” in whom inhibitory feedback loops are activated to dampen a tonic state of hyperarousal. They have difficulty neutralizing stimuli in the environment in order to attend to relevant tasks. To compensate, they tend to shut down, which of course means decreased involvement in ordinary, everyday life. Rather than reacting to the daily environment flexibly, they react to internal stimuli that are irrelevant to current demands.
Trauma effects the hormones of both brain and body creating more psychophysical stress.
Intense distress is accompanied by release of stress-responsive neurohormones which seek to mobilize the energy required to deal with the stress. Chronic and persistent stress inhibits the effectiveness of the stress response and produces desensitization and sleep disturbances combined with hypervigilance.
Time does not heal all wounds. Therapy allows an inner search for healing alternatives within the “deeper” state-dependent psychobiological levels until the sought-for structure is transduced into the verbal level and emerges as a new psychophysical form. The recursive process which manifests in flashbacks and immersive rumination is facilitated, unblocked, and allowed to flow to its healing conclusion. This creates a shift in recurrent intrusive recollections and in recurrent distressing dreams and nightmares.
CRP helps probe into the state-dependent patterns of physiology, memory, and learning that have been encoded during circumstances of stress-released epinephrine by the autonomic nervous system and related responses by the endocrine and neuropeptide systems, and their related existential meanings and sensory images. It provides a healthier means of dissociation and reiteration leading to creative self-organization.
DIAGNOSIS OF POSTTRAUMATIC STRESS DISORDER
The diagnostic criteria for PTSD are listed in the DSM IV:
A. The person has been exposed to a traumatic event in which both of the following were present:
(1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
(2) The person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.
B. The traumatic event is persistently reexperienced in one or more of these ways:
(1) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in children, repetitive play may occur in which themes or aspects of the trauma are expressed.
(2) Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content.
(3) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: in children trauma-specific reenactment may occur.
(4) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
(5) Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspects of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
(1) Efforts to avoid thoughts, feelings, or conversations associated with the trauma.
(2) Efforts to avoid activities, places, or people that arouse recollections of the trauma.
(3) Inability to recall an important aspect of the trauma.
(4) Markedly diminished interest or participation in significant activities.
(5) Feeling of detachment or estrangement from others.
(6) Restricted range of affect (e.g. unable to have loving feelings).
(7) Sense of foreshortened future (e.g. does not expect to have a career, marriage, children, or normal life span).
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) Difficulty falling or staying asleep.
(2) Irritability or outbursts of anger.
(3) Difficulty concentrating.
(5) Exaggerated startle response.
WHAT CAUSES POSTTRAUMATIC STRESS DISORDER?
Any overwhelmingly stressful life situation (surgery, war, natural disaster, robbery, traumatic bereavement, torture, physical battery, accident, rape, malnutrition, etc.) that stimulates excessive arousal by the autonomic and endocrine systems can lead to the symptomology of post-traumatic stress. State-dependent memory, learning, and behavior (SDMLB) is the essential feature of posttraumatic stress syndrome, and the many more subtle dysfunctions associated with it. Fear-conditioning and parasynaptic cellular modulation mediates SDMLB, (Rossi, 1986).
PTSD seems to be the basic process underlying Freud’s original concept of the “traumatic neurosis” as the organic basis of psychopathology. Therefore, the entire history of depth psychology and psychotherapy can now be understood as a prolonged clinical observation of how dissociated or state-dependent memories remain active at unconscious levels, giving rise to “complexes.” These complexes are the source of psychological and psychosomatic problems.
Trauma affects our capacity to regulate bodily homeostatsis. Even years after the trauma has ceased, memories continue to dominate people’s perceptions, and affect capacity to think and make sense out of current experience. Psychological interventions can only effect the degree of reversal of a disorder with such strong biological underpinnings.
Healing those who develop PTSD in the aftermath of overwhelming experience is a complex process, whose dynamics cannot be described like a cookbook recipe--it requires tremendous sensitivity and intuition. Reestablishing a sense of personal safety and equilibrium is a primary goal of all treatment, and this happens within the therapeutic alliance.
Recognition of each person’s unique situation and reactions is paramount. It is critical that the therapist continue to take stock of the safety of the relationship and progress in achieving therapeutic goals. Participants are encouraged to make meaning of their life experiences when they feel personally supported by their therapists. A primary goal is to not retraumatize the person with therapies that force them to relive the original trauma in historical, rather than metaphorical or sensory terms, or compound the episodes with fallacious material.
Because traumatic memories are stored in state-dependent fashion, they are often rendered inaccessible to verbal recall for prolonged periods of time. Because memories are dissociated, they are stored outside of ordinary awareness, and expressed in incomprehensible symptoms as physical ailments, behavioral reenactments, and vivid sensory reliving experiences. Reenactment of the trauma in personal and social relationships is a major source of shame for the victims and is a source of ongoing tragedy.
Constricted ego functioning is a feature of all traumatized individuals. It is even more complex when traumatization comes in childhood, because trauma early in the life cycle fundamentally affects maturation of systems in charge of regulating psychological and biological processes. It can result in lack of emotional control, destructuve behavior against self and others (or animals), brutality (victim/victimizer), learning disabilities, somatization, dissociative problems, and distortions in concepts about self and others.
Reaction to trauma is a process of adaptation over time. In Chaos Theory, attractors describe the characteristic behavior of a dynamical system changing over time. Traumatic events, especially chronic events, act as “strange attractors” in consciousness which keep everything in their orbit, cycling wildly, unpredictably, but within the parameters of the attractor, reiterating the same cues over and over. Memories are embedded in all layers of psychophysical self in, what is known in Chaos Theory, as infinite nesting.
Psychological siege describes the dominance of trauma in memory and its crucial maintenance over time. The feeling of being constantly beseiged or barraged leads to a bunkering mentality which may be acted out, particularly in combat veterans. Over time some people’s PTSD may become subclinical, and yet it may continue to influence their level of functioning.
PTSD is the result of complex interrelationships among psychological, biological, and social processes--one that varies depending on the maturational level of the victim, as well as the length of time for which the person was exposed to the trauma, and the source of the trauma. Central to understanding these processes is awareness of the nature of traumatic memory and its biological substrates that lead to the dominance of the trauma in memory and to its maintenance over time.
Social cues are important for recovery -- whether people are encouraged to attend to their pain and learn from the past or cultivate a “stiff upper lip,” suppressing the profound meaning of their experience. There is often resistance to acknowledging the trauma or depth of its impact. Reality can profoundly and permanently alter people’s psychology and biology. Individuals make a choice whether to examine their reactions to the trauma in order to overcome it, or ignore it and try to go on with their lives. There is a range of reactions from acute trauma to long-term outcome.
The inner structure of the disorder overlaps catagories of dissociative disorder and stress responses. Adjustment disorder, grief reactions, and a variety of characterological adaptations are germaine. The interaction between external events and subjective response can vary widely, even among victims of the same trauma, based on internal processing and approach to life in general. Predisposition and vulnerability reflect on recovery from acute symptomology and long-term resilience. Critical issues include the emergence of chronic patterns of adaptation, in which lack of involvement in current reality, rather than preoccupation with the past are the most pathological features.
The ways people view themselves and their world can be compounded by a host of self-destructive behaviors (e.g. suicide attempts, self-multilation, and eating disorders). Complexity of adaptation includes both hormonal and autonomic nervous system dimensions. This includes unusual patterns of cortisol, norepinepherine, and dopamine metabolite excretion; the role of serotonergic and opioid systems (arousal and numbing); receptor modification by processes such as kindling; and involvement of central pathways involved in the integration of perception, memory and arousal.
Traumatic memories are qualitatively different from memories of ordinary events, in that amnesia co-exists with vivid recollections. Information processing and dissociation affect a person’s ability to perceive and integrate overwhelming experiences. Dissociative fragmentation of the self is common, leading to shattered psyches and lives.
Trauma is particularly devastating in childhood, including traumatic bereavement. Because of their dependence on caregivers, their incomplete biological development, and immature self-concepts and concepts of surroundings, children have unique patterns of reaction and needs for intervention. Although they may suffer from subclinical PTSD in middle age, memories recur and come to dominate their lives as seniors. There is generally greater lack of flexibility or capacity to repair damage with increasing age.
CONVENTIONAL TREATMENT OF PTSD
In actual practice, most clinicians use an eclectic approach, in which we must constantly reevaluate what is being accomplished. The core symptoms of PTSD (including paranoia, intrusions, numbing, and hyperarousal), occupational disabilities, dissociative phenomena, and interpersonal problems and alienation may all need widely different approaches. Treatment, therefore, depends in large part on clinical judgement.
In order to respond to current life and reach their fullest potential, people need to regain control over their emotional responses. It helps to place the trauma in the larger perspective of their lives--as a historical event (or series of events), that occurred at a particular time in a particular place, and that can be expected not to recur if the traumatized individuals take charge of their lives.
The key element is integration of the alien, the unacceptable, the terrifying, and the incomprehensible; the trauma must come to be “personalized” as an integrated aspect of one’s personal history. The therapeutic relationship is the cornerstone of effective treatment.
Critical incident stress debriefing has been proposed as a way of modifying the stress reactions of emergency service workers. Acute stress reactions, with the absence of stable symptom patterns and extreme degrees of physiological hyperarousal at this stage mean that there are unique problems in the treatment of this group.
Traumatized people with high levels of avoidance are often most reluctant to expose themselves to their traumatic memories, even when they seek help. Systematic desensitization and Eye Movement Desensitization and Reprocessing (EMDR) have been applied with limited results. Any positive results with EMDR probably come from mimicing the REM state.
Representations of trauma are more complex than roles like “perpetrator,” and “victim”. They are embedded in numerous affect states, defenses, object relations, and deep meaning configurations. Pertinent to these are subjective decision points in which critical self-judgements are embedded. They include insufficient anticipation of danger, naive trust, impossible choices, guilt and shame, and terror at revealing the content of the traumatic experience to someone new. Other elements include temporally continguous ego states, such as splitting, denial, and dissociation, coupled with temporally contiguous fantasy states, such as murderous vengeance and wishes to die. Intrusions can also remind the person of moments of fantasied safety within the trauma.
The conventional view is that hyperarousal, sleep disturbances, and embeddedness of the trauma makes effective pharmacological treatment essential. Whether antidepressant, antianxiety, or sleeping medications are prescribed or not, dealing with traumatized people requires a staged process of treatment that is responsive to how much the victim can tolerate. Here again, the specific nature of the therapeutic relationship is a critical variable in outcome.
PTSD plays a role in the dysregulation of neurohormones and their roles in the stress response. Intense stress is accompanied by the release of endogenous, stress-responsive neurohormones, such as the catecholamines (including epinephrine and norepinephrine), serotonin, hormones of the hypothalamic-pituitary-adrenal (HPA) axis (including cortisol and other glucocorticoids, vasopressin, oxytocin), and endogenos opioids. These stress hormones help us mobilize energy required to deal with emergency stress by increasing glucose release for quick energy and enhancing immune function. Chronic stress inhibits their effectively and induces desensitization.
Drug therapy for PTSD is based on several biological models and has a few different purposes, (which also can be met with CRP’s intregrative approach). (1). Noradrenergic dysregulation is treated with MAO inhibitors, tricyclic antidepressants, beta-adrenergic blockers and benzodiazepines to calm the body’s alarm center. (2). Serotonergic dysfunction is treated with antidepressant SSRIs to regulate stress resilience, sleep, and for impulse control. (3). Anti-kindling drugs, such as carbamazepine, allegedly regulate an excitability threshold that has been lowered. (4). Anxiolytic drugs, such as clonazepam and buspirone are given in an attempt to reduce the startle response, which is one of the most persistent symptoms of PTSD.
The principle goals of using medication in PTSD are as follows:
1. Reduction of frequency and/or severity of intrusive symptoms.
2. Reduction in the tendency to interpret incoming stimuli as recurrences of the trauma.
3. Reduction in conditioned hyperarousal to stimuli reminiscent of the trauma, as well as in generalized hyperarousal.
4. Reduction in avoidant behavior.
5. Improvement in depressed mood and numbing.
6. Reduction in psychotic or dissociative symptoms.
7. Reduction of impulsive aggression against self and others. (Davidson, van der Kolk).
Intrusion is the active force creating anxiety. Psychiatrist Mardi Horowitz catalogued these intrusions, and Goleman lists them in Vital Lies, Simple Truths (1985). They refer to unbidden ideas and pangs of feeling which are difficult to dispel, and of direct or symbiotic behavioral reinactments of the stress event. They are unbidden thoughts and feelings impinging on awareness. Every variety of intrusion is some aspect of the stress response taken to an extreme. They include the following:
* Pangs of emotion, waves of feeling that well up and subside rather than being a prevailing mood;
* Preoccupation and rumination, a continued awareness of the stressful event that
recurs uncontrollably, beyond the bounds of ordinary thinking through of a problem;
* Intrusive ideas, sudden, unbidden thoughts that have nothing to do with the mental task at hand;
* Persistent thoughts and feelings, emotions or ideas which the person cannot stop once they start;
* Hypervigilance, excessive alertness, scanning and searching with a tense expectancy;
* Insomnia, intrusive ideas and images that disturb sleep;
* Bad dreams, including nightmares and anxious awakening, as well as any upsetting dream. The bad dream does not necessarily have any overt content related to a real event.
* Unbidden sensations, the sudden, unwanted entry into awareness of sensations that are unusually intense or are unrelated to the situation at the moment.
* Startle reactions, flinching or blanching in response to stimuli that typically do not warrant such reactions.
Anxiety swamps attention; denial can erase anxiety. The forms of denial include:
* Avoided associations, short-circuiting expected, obvious connections to the event that would follow from the implications of what is said or thought.
* Numbness, the sense of not having feelings, appropriate emotions that go unfelt.
* Flattened response, a constriction of expectable emotional reactions.
* Dimming of attention, vagueness or avoidance of focusing clearly on information, including thoughts, feelings, and physical sensations.
* Daze, defocused attention that clouds alertness and avoids the significance of events.
* Constricted thought, the failure to explore likely avenues of meaning other than the obvious one at hand; an abbreviated range of flexibility.
* Memory failure, an inability to recall events or their details, a selective amnesia for telling facts.
* Disavowal, saying or thinking that obvious meanings are not so.
* Blocking through fantasy, avoiding reality or its implications by fanciful thoughts of might have been or could be.
The operative principle that unites these forms of denial is that they are all ways of blanking from awareness a troubling fact. These tactics are countermoves to the intrusions listed previously. Denial and intrusion are two sides of attention, the one an avoidance, the other an invasion.
Self-deception involves forgetting and forgetting we have forgotten. Repression creates no trace when it is in progress--it is the sound of a thought evaporating. There are secrets we keep even from ourselves. They are retrievable only under the most extraordinary circumstances, since the essence of repression lies simply in the function of rejecting and keeping something out of consciousness. It suppresses the single class of items which evoke psychological pain. This fear-based pain can be of many varieties: trauma, “intolerable ideas,” unbearable feeling, anxiety, guilt, shame, etc.
Repression lessens mental pain by creating a blind spot as does its cousin denial. It protects a core of forbidden information. The nearer to that core one probes the greater the resistance. The deepest schemas encode the most painful memories, and are the hardest to activate.
Defensive postures include:
* Repression. Forgetting and forgetting one has forgotten.
* Denial and Reversal. What is so is not the case; the opposite is the case.
* Projection. What is inside is cast outside.
* Isolation. Events without feelings.
* Rationalization. I give myself a cover story.
* Sublimation. Replacing the threatening with the safe.
* Selective inattention. I don’t see what I don’t like.
* Automatism. I don’t notice what I do.
A special instance of PTSD is found among those who self-report “alien abduction,” or “UFO abduction.” The symptomology is certainly real enough, and often manifests in unusual biological and psychological syndromes. It would certainly seem that “something” happened, but few case histories reveal any underlying or predisposing hidden or repressed trauma, such as sexual or physical abuse in earlier life (Miller, 1995). Yet persistent PTSD is apparant and disruptive in stories of this projective threat.
Accounts show that these “close encounters” are more like “too close for comfort.” In combat veterans reporting abduction, this issue is hopelessly muddied by confusion over stressors, and the predisposition to dissociation. There are certainly a host of social factors at work, the most likely of which is the notion of “memes” or cultural viruses, or the cultural analogue of genes.
Jung was the first to describe social contagions. As outlined separately by Blackmore, Lynch, and Brodie, a meme is a self-propagating idea, a unit of cultural imitation that, much like a biological or computer virus, effectively programs its own retransmission. They spread through motivating their “host population,” novel configurations of old ideas, and by proselytizers.
Popular beliefs spread like contagions--cognitive viruses. There seems to be no payoff in adopting such a self-defeating pattern of belief as abduction. Does it come from our cultural paranoia about invasions ingrained during the cold war? Does it come from a quasi-religious yearning for contact with something greater than ourselves? Do experiences involve temperal lobe seizures and tectonic strain, as neurologist Michael Persinger believes?
This category, like others, reports emotional experiences ranging from helplessness to intense feelings of revenge, mistrust, betrayal, dependency, love and hate, and the paranoid tendency to replay these issues in the therapeutic dyad. Hypnotherapy, regression, and conventional dreamwork have been used on these cases with mixed reviews (Mack, 199 ; Jacobs, 1999). Mack, (a tenured Harvard psychologist with a background in nightmares, trauma, and psychological assessment), can find no particular psychological abnormalities in this population, who are not generally fantasy-prone nor delusional in other areas of life.
No one seems to have a handle on the source, treatment course, or outcome of these cases. However, they consistently present themselves for treatment, some even reporting they wish they could be classified as mental cases (Hopkins, 1981; Vallee, 1988). Classically, they appear reporting “missing time,” sleep disturbances, “intruders,” and somatic manifestations. Many have no opinion or belief about UFOs or alien contact initially. Above all, the facilitation of false memory syndrome must be avoided.
Therapist belief or disbelief about this phenomenon can influence clients at even the subconscious level. The client is probably best served by a “skeptical” therapist, who is neither a “true believer” nor debunker, and is more concerned with the healing process than any historical facts or conspiracy theories.
The ambiguity of the experience is accentuated more in dreams. Some abductees claim UFO-ET dreams with little or no other intense contact. Intensity can also escalate in this dream dimension through changes in context and increased frequency of UFO-related dreams. Often there is sleep paralysis. These dreams are listed as one of the prominent “symptoms” of UFO abductees. But the rabid rush to misdiagnosis among potential sexual molest victims has led us toward caution in applying “symptom lists” as criteria for diagnosis. In other words, all UFO dreamers have had an imagery experience of some sort, but not all are necessarily therefore abductees, though these dreams are penetrating.
There are those who will present for treatment with a potentially false belief that these dreams make it so, or mask a deeper repressed UFO experience. Psychic contagion has spread these notions. Latent grandiosity to be special or chosen or singled-out, or conversely, low-grade paranoia may lead to notions of persecution, torment, or conspiracy. Projection moves the source of grandiosity or paranoia fom the inside to the outside. Paranoia and grandiosity can even be contaminated with one another leading to an internal split--dissociation, schizoid attitude, where one vacillates between feeling subhuman or superhuman.
PTSD AND CONSCIOUSNESS RESTRUCTURING
PTSD has turned out to be a very common disorder, since exposure to extreme stress is widespread and a large proportion of those exposed become symptomatic. A factor there may be predisposition from homelife in violent or sexually abusive families, or earlier experiences. Over 1 million U.S. teenagers suffer from PTSD; 76 percent of American adults report exposure to extreme stress, and perhaps 10% suffer from PTSD; over 15% of Vietnam veterans continue to suffer PTSD for more than 20 years after the war.
Repeated replaying of upsetting memories serves the function of modifying the emotions associated with the trauma, and in most cases creates a tolerance for the content of the memories. However, those with PTSD begin organizing their lives around the trauma. The meaning they attach to the experience of extraordinary events is as fundamental as the trauma itself. PTSD is an emotional, behavioral, interpersonal, and spiritual disorder.
But, the core issue in PTSD is that the primary symptoms are not symbolic, defensive, or driven by secondary gains. The core issue is the inability to integrate the reality of particular experiences, and the resulting repetitive replaying of the trauma in images, behaviors, feeling, physiological states, and interpersonal relationships. It is, therefore, critical to examine where they have become “stuck” (fixation on the trauma) and around which traumatic events they have built their psychic elaborations.
One way or another, the passage of time modifies how the brain processes trauma-related information. New organization of experiences is the result of iterative learning patterns, in which trauma-related memories become kindled, etching them more deeply and powerfully into the brain. These emotional memories are programmed to last forever. Experiences are initially imprinted as sensations or feeling states, and are not collated and transcribed into personal narratives. Traumatic memories come back as emotional and sensory states with little verbal representation. There is texture to the response.
Time does not positively modify memories in PTSD; the full brunt does not fade with time, as in normal transformation. Adaptation is more complex; the body keeps the score. Stress-induced serotonin dysfunction may lead to impaired functioning of the behavioral inhibition system, leading to behavioral problems including impulsivity, aggression and brutality, compulsive reenactment, and inability to learn from past mistakes.
Traumatic experiences change the way the brain and body work; and so can each therapeutic session which can be just as powerful in the healing direction, creating immediate, discrete changes in psychophysiology. Much depends on whether clients want to know “what happened” or “to heal.” Knowing, or reliving what happened is often unessential and many times would be retraumatizing and terrifying.
If we view trauma as a dimensional continuum over time, the splitting occurs at the point of “T minus 1,” leading to dissociation of part of consciousness just prior to the worst part of the event. This split off, or frozen, or stuck consciousness needs to find a way to move forward through the event with the assurance that it survived and is now all right, so it can rejoin the holistic flow of consciousness.
This integrative therapy is most succesfully done in a dimension other than historical time, such as metaphor or imagery originating with the client, rather than imported metaphors from the therapist. It can also be done in sensory channels. As the story progresses, things get “worse” before they get better and then healing resolution comes and new resources and adjustments come along with it.
Because of the severity of their wounding, PTSD clients are vulnerable to therapeutic exploitation by either unscrupulous or poorly-trained therapists. Because they are shut-down and intimacy is a primary issue, the safety of the therapeutic relationship, and the broader nature of that relationship are crucial if any healing is to take place.
Prospective participants may have to struggle with their need for help, acknowledging dependence, grief, humiliation, and helplessness, as well as overcoming fears of confronting their shame and pain. Shame-based behavior may be amplified by substance abuse and survivor guilt. Other syndromes like major depressive syndrome, personality disorders, paranoid ideation and dissociative disorder can compound the situation.
Therapists, on the other hand, must cope with the horrendous experiences that can befall people and the inescapable truth that reality can damage their fundamental existential sense of safety and trust. The therapists must walk a fine line, intuitively determining when to help the client integrate and recall the traumatic memories, and when to help the person create distance from them and promote functionality. We cannot assume that the primary trauma we are aware of is the only one that affects current symptoms.
Therefore, different therapeutic procedures are helpful at different stages of treatment. These protocols are not only not standardized, they are virtually non-existent, leaving these people at the mercy of practitioners who want to experiment on them with practices that may or may not be germaine to their healing and adaptation.
In terms of information processing, there are six issues which effect those exhibiting PTSD: (1) persistent intrusions of memories related to the trauma interfering with other incoming information; (2) compulsive exposure to situations reminiscent of the trauma; (3) active avoidance of specific triggers of trauma-related emotions, and generalized numbing; (4) loss of modulation of physiological responses to stress in general and capacity to use body signals as guides for action; (5) generalized problems with attention, distractability, and stimulus discrimination; and (6) alteration in psychological defense mechanism and in personal identity.
All these factors filter what new information is selected as relevant. One particular event can activate other, long-forgotten memories of previous traumas, creating a “domino effect.”
Based on criterion formulated for drug treatment of PTSD, we can assume that psychotherapy would have the complementary goals of (1) reduction of intrusive reexperiencing; (2) reduction in the tendency to interpret incoming stimuli as recurrences of the trauma; (3) reduction in conditioned and generalized hyperarousal; (4) reduction in avoidance behavior; (5) improvement in depression and numbing, (6) reduction in dissociative or psychotic symptoms, and (7) reduction of impulsive aggression against self and others.
Effective treatment needs to resolve the spectrum of symptoms, including intrusions, compulsive reexposure, avoidance and numbing, hyperarousal, problems with attention, distractability, stimulus discrimination, altered perceptions of self and others, dissociation and somatization.
We cannot assume that a traumatic situation is amenable to interpretive reconstructive or insight-promoting work at the time we may feel ready to dispense it. However, keeping a watchful eye out for the complex ways in which the trauma may be repeating itself in the present, both in the transference and in the countertransference, may be useful.
The primary presenting imagery is of disintegration, confusion, alienation, and despair. Fixation on the event(s) feels like being pulled into a Black Hole of trauma. People may experience sensory elements of the trauma without being able to make sense out of what they are feeling or seeing. CRP facilitates the direction of their own self-healing call. Verbalizing plays a critical role in reestablishing physical and psychological health.
Exploring the personal meaning of the trauma is critical, since no one can undo their past. Personal attributions, and feelings of guilt in causing (or at least not preventing) the incidents affect whether they see themselves as capable or worthy of having restorative experiences, and whether they consider themselves capable of being entrusted with responsibility, intimacy, and care.
CRP allows them to move further into dark gloomy voids, to go ahead and disintegrate and see what happens when they let those compelling images play out in the therapeutic setting. The call to heal and the call to death are the same call to formlessness and creative restructuring, but the process has gotten stuck at the point of fragmentation. The self is shattered. Shame is the emotion related to having let oneself down.
It would be an error to think of detachment and withdrawl in PTSD as merely a psychodynamic phenomenon, or as a deficit of certain neurotransmitter suppliments. Chronic hyperarousal depletes both the biological and psychological resources needed to experience a wide variety of emotions. Over time there are changes in the CNS which are similar to the effects of prolonged sensory deprivation.
“Healing” does not necessarily mean a cure nor total elimination of all symptoms. It has to do with a subjective process, difficult to describe because it is non-linear, reflects a multi-leveled psychic disorder which carries and stores meaning in biological forms. Yet this syndrome is linked to a timeless and universal experience of healing, in which recurrent dreams and nightmares play a fundamental role.
What are symptoms, dreams, and chronic reliving of the event trying to tell the person who is affected? The meaning of those overwhelming experiences -- their total significance -- is contained and expressed in psychobiological forms which have outlived their adaptive usefulness. The structures can dissolve as they transform from corporeal to verbal form. Traumatic memory gradually becomes narrative memory.
Inchoate sensations and dysphoric affect, complete with the emergency defenses used at the time (e.g. dissociation, splitting, or disavowal), come to be personal stories of tragedy, trauma, and loss. These stories embody tremendous significance for the past, present, and future. Therapy helps the survivor find words to express nuances of subjective meaning in an empathic context, reorganizing everyday experience for traumatized individuals.
Most participants have created a personal myth or framework about their experience, but this story generally is not encompassing enough to initiate healing. The story needs amplification, and the healing comes in filling in the blanks and in the telling and re-telling of the personal tragedy. The task of the therapist is to instill confidence and create an intimacy with the client so the person can begin to believe that they will improve.
The placebo effect is the therapist’s greatest tool in this regard. It is a gift of nature, and our nature, that this phenomenon exists, and it is neither purposeless nor a coincidence that it crops up in all healing attempts and modalities. It can be purposefully deployed, rather than being viewed as a troublesome interloper in treatment.
“The power of the placebo effect is one of the ironies that have to be dealt with in the desire to prove the effectiveness of new treatments. In drug studies, up to 40% of subjects may be placebo responders. This means that there has to be a powerful therepeutic effect before a treatment is of proven benefit, and that the placebo effect is actually one of the most powerful treatments in the therapeutic arsenal. It is important not to scoff at the placebo response, but rather to maximize its potential and usefulness. It is possible that the strength of the placebo response accounts for the power of some of the less conventional forms of psychotherapy. The conviction with which these forms are practiced may maximize people’s natural capacity for healing.” (Turner, McFarlane, van der Kolk, 1996).
So, the therapist should invoke the placebo response. But just as importantly, retraumatizing the participant with historical reliving of the trauma is to be absolutely avoided. Incorporation of missing time or memories through regression is contra-indicated. This can lead to avoidance and alienation, and reinforces the sense of threat. New explorations can be done in less-harmful dimensions which lead to a greater sense of self, rather than withdrawl into self or away from therapeutic interaction.
The incorporation can take place through metaphorical and sensory channels, rather than in the time dimension of historical regression, and this allows the frozen, stuck or traumatized energy to dissolve and flow into the whole, becoming part of the holistic consciousness restructuring. In this process dissociated and repressed material is automatically included. Interpretations should be avoided, although re-framing of experiences may be helpful if a prospective outlook is fostered. Helping the person find their own internal funding and resources is the most helpful approach.
Inappropriate cues and guided imagery for reliving trauma may create false memories through suggestion. The “change history” process and hypnotic “re-frame” of Neuro-linguistic Programming (NLP) work on the principle of imagining things differently. However, these techniques don’t restructure at the deepest psychophysiological level.
Change history is actually an invitation to use imagination and confabulation to fantasize a different reality. Unfortunately, PTSD victims know their body is telling them history hasn’t changed. For them, its still happening. False memories are often created by combining actual memories with suggestions received from others. They can be induced when a person is encouraged to imagine experiencing specific events without worrying about whether they really happened or not.
Suggestion and imagination can create “memories” of events that did not actually occur. Needless to say, this is a diservice to the participant, rather than a therapeutic step forward, and may be construed later as yet another form of victimization. Research has shown that corroboration of an event by another person can be a powerful technique for instilling a false memory. In fact, merely claiming to have seen a person do something can lead that person to make a false confession of wrongdoing.
“Research has helped us understand how false memories of complete, emotional and self-participatory experiences are created in adults. First, there are social and therapeutic demands on individuals to remember, to come up with memories. Second, memory construction by imagining events can be explicitly encouraged when people are having trouble remembering. And, finally, individuals can be encouraged not to think about whether their constructions are real or not. Creation of false memories is most likely to occur when these external factors are present, whether in an experimental setting, in a therapeutic setting, or during everyday activities. False memories are constructed by combining actual memories with content of suggestions received from others. This is a classical example of source confusion, in which the content and the source become dissociated.” (Loftus, 1977).
It is important to heed the cautionary tale in this data: mental health professionals and others must be aware of how greatly they can influence the recollection of events and of the urgent need for maintaining restraint in situations in which imagination is used as an aid in recovering presumably lost memories.
CRP restructuring changes the physiological responses which affects the psyche, and the new psychic outlook feeds back new signals to the body. These are all parts of “completing the story” with its intrinsic meaning, and facilitating its healing goal. The therapist needs to respect the need to keep traumatic details of memories away from consciousness, remembering that these memories are state-bound. He or she must help the survivor differentiate them while providing hope and meaning that the goals are worth the pain of pursuing them.
There are a few technical principles established in conventional PTSD therapy which can act as guidelines for the practitioner:
1. Trauma reconstruction should occur when intrusive rather than numbing aspects of the PTSD are present.
2. Under ideal circumstances, the alliance should be strong and the general transference positive; the intrusion should be limited and should be occurring in the context of a generally improving clinical condition.
3. However, when the therapist is faced with a rapidly deteriorating clinical situation in which there is a significant negative component to the transference, reconstruction of trauma can provide a new temporary structure around which ego functions can be consolidated rather than fragmented and an alliance has the opportunity to develop. (Lindy, 1996).
There are some central points in the question of how to reconstruct trauma:
1. It is the therapist’s task to keep as empathically in contact with the patient in the here and now as possible, including strong feelings directed toward the place or person of the therapist.
2. The therapist, through introspection, should use words to describe feelings in the here and now that can also be applied to the there and then of the trauma. However, it is the patient who should make the reconstruction of the memory, not the therapist.
3. Repetitions in the present, in which the therapist has struggled internally to find words that express anguished meaning, provide an open door for the survivor to find better words to describe his or her uniquely traumatizing events of the past. (Lindy, 1996).
Co-consciousness in the journey process creates an intimate non-verbal bond with the other person. Co-consciousness is an originally shamanic technique which has been incorporated into hypnotherapeutic practice. Shamanic techniques have proven particularly valuable in the treatment of PTSD, particularly with combat veterans. Group work is helpful because original traumas may have been group experiences. Drum-journeys, sweats, vision quest, and even sun-dancing have produced healing and spiritual connection. The nature of shared consciousness dynamics is complex.
One needs to learn by direct experience how to enter and maintain it. Milton Erickson, for example, noted that when he was in this co-consciousness state the information and stories just came to him intuitively from opening to the whole situation. He maintained this increased his therapeutic impact greatly. Abraham Maslow also identified this state, labeling it “trans-human.”
It is our contention that the placebo effect and spontaneous remission operate at the deepest level of enfoldment, before energy differentiates into psychic and somatic. Because it targets this deeper state of primal restructuring of energy, the CRP process offers several advantages over the placebo effect and some of the other healing practices. They include the following:
* A higher frequency of connection with mind/body dynamics than the placebo effect offers;
* The elimination of the dogma and superstition that permeate many shamanic, spiritual (and scientific/medical) approaches;
* The awareness and consciousness expansion for the client in directly experiencing these consciousness dynamics and processes;
* Development of, and familiarity with an inner creative process for problem solving and crisis resolution, and resultant lifestyle changes;
* The client is empowered by the process and experiences the healing dynamics as self and internally generated rather than other-generated and externally imposed, (such as imported metaphors and imagery, or psychoactive medication).
In the journey process, REM seems to be the ideal consciousness to explain the body’s natural healing process as realized in the placebo effect. The CRP journeys seem to trigger natural healing and operate with the same consciousness dynamics as the placebo effect. The chaotic, unstructured or complex consciousness is the dynamics required for consciousness restructuring.
This restructuring of the primal existential sensory self-image, in turn, affects neural patterns (the existential hologram). In the dynamics of REM, it is possible to change the neural firing patterns in the brain by dissolving an old pattern and establishing a new one. When the functioning of the brain is changed, the existential perceptions of the entire person are altered. These precipitate as greater and lesser changes in attitude and behavior. We perceive and sense ourselves differently. Changes in the firing patterns also affect the entire body’s chemistry.
It is necessary to be at the initial conditions of the system for this restructuring to have maximum effect, and REM consciousness seems to be necessary to these processes. This information implies a plausible mechanism by which dreams do their healing and regenerative work, helping us adapt to the exigencies of daily life.
American Psychological Assn., DSM IV
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Hopkins, Budd, Missing Time, Richard Marek Pub., New York, 1981.
Loftus, Elizabeth, “Creating False Memories,” SciAmer, Sept ‘97, pp.70-75.
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van der Kolk, Bessel; McFarlane, Alexander; Weisaeth, Lars, Editors;Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society, Guilford Press, New York, 1996.
Wilson, John P. and Keane, Terence M., Editors, Assessing Psychological Trauma and PTSD, Guilford Press, New York, 1997.
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