Trauma & Recovery: an REBT Perspective
Mitchell W. Robin, Ph.D.
NOTE: The following is merely intended to provide information about one particular approach to trauma and PTSD. It is not intended as a substitute for therapy or the services of a competent Mental Health practitioner. For referrals to REBT and other CBT (cognitive behavioral therapy) practitioners see the links at the end of the article.
Some brief anecdotes
Over the years I have had occasion to observe people. One of my earliest observations, one that probably led to my decision to study psychology, was watching a schoolyard bully intimidate a small boy. The bully would approach his target and say, "Hi punk!" At which point the bully would squeeze the child's arm until the smaller boy either started to cry or fell to his knees. Each time he would approach he would always say the phrase, "Hi punk," and follow it with a squeeze. It wasn't long before the bully just needed to say, "Hi punk" to get the desired results - fear, and trembling.
Later, in college, I learned about Pavlov's work with the conditioned reflex and thought to myself that the schoolyard bully was a natural born Pavlovian. Still later, now working as a cognitive therapist, I had the opportunity to treat someone who appeared to have a phobic reaction to subways. My client would go to great lengths to avoid taking subways in order to avoid the extreme fear that the client associated with the subway. We discovered that the fear was worse during twilight and was greatest if the client was about to walk downstairs. After a session or two we discovered that many years earlier my client had successfully repelled a violent attack, while walking downstairs during rush hour. The experience had happened during late adolescence, and had not even been thought about for the preceding decade, but as any actor will tell you - the muscle memories were still there. My client had experienced a traumatic event and was reliving that event on a daily basis, but in a different context. The client was not phobic in the traditional meaning of the word, but was suffering from PTSD.
Since then I have worked with many clients who experienced trauma in their lives. Some of them experienced abuse, some were involved in war, and others arrived in my office after 9/11 having been at, or near, ground zero. They all were different. They all were the same. They were different in their histories, but similar in that they all experienced something that was intense, unwanted, undesirable, unavoidable, and potentially overwhelming. They were also alike in their desire to make sense of the experience and to move beyond it. Many felt ashamed that they were traumatized, or had a problem that needed to be worked on. Others were angry at the universe because it hadn't sufficiently protected them. Some saw the traumatizing moment, as a watershed in their lives - after which their life was never, or could never, be the same.
There are many treatments that people who have experienced trauma can avail themselves of. The modality I prefer to use with my clients is REBT, the original cognitive behavioral therapy. Albert Ellis developed REBT, or Rational Emotive Behavior Therapy, almost 50 years ago as an alternative to the forms of therapy then currently available. In a nutshell, REBT maintains that nothing and no one makes us act think or feel dysfunctional. We experience events, and then in our attempts to make sense of them we come to conclusions that either aid us in our attempts at living complete and joyful lives or which effectively sabotage those attempts. REBT practitioners, like myself, help our clients to think straight about the circumstances of their lives and to move forward towards achieving their long cherished goals. Together we identify those thoughts, emotions, and behaviors, which interfere with their recovery and which tend to be self-defeating or self-sabotaging. Together we work on ways to respond more effectively to the traumatic event with out shame or blame. In doing so we help them not only feel better but get better.
Pavlov's Pups and PTSD
Remember Ivan Pavlov, the Russian physiologist who is credited with discovering the conditioned reflex? He made the discovery that certain automatic responses, such as salivation to food, could be transferred to otherwise neutral objects, such as the ringing of a dinner bell. Other researchers followed in his footsteps and were able to document that sometimes, if the circumstances were "right", the animal might learn this new response after one exposure. This is known in the scientific literature as "one trial learning." People who experience PTSD have a lot in common with the dogs in Pavlov's laboratory. They learned an intense visceral association with a previously neutral stimulus and react reflexively to it. Whether Pavlov's pups had any "thoughts" about their experience is hard to determine, but we humans undeniably do. We think about our experiences all the time. We attempt to make sense of them and put them in some convenient context. We discover ourselves behaving reflexively and that, for some of us, starts the cognitive ball rolling. We wonder why we tremble or flinch in the presence of certain events or images. We wonder why other people in the same situation do not.
The way we think about our experiences determines our emotional and behavioral response to those experiences. If we think irrationally or crookedly (i.e., illogically, non-empirically, rigidly) about our life experiences we trend to have self-defeating, immobilizing, dysfunctional negative emotions. If, on the other hand we think rationally (i.e., logically, empirically, flexibly) about negative experiences we may still have strong negative emotions but generally we will be in a better place to respond functionally to them. The goal is not to feel good about bad events but to function effectively (e.g., work towards our long cherished goals to have a happy, productive, fully alive and vital life) in the face of bad events.
Humans and Suffering
As one of my clients once taught me, "Human's are not the only animal which suffers, but we are probably the only animal which suffers about our suffering." This orientation helped my client more fully integrate one of the central notions of REBT: our suffering or disturbabilty comes in large measure from the way we think about the circumstances of our life. There are many life events that are undeniably undesirable, unfortunate, and potentially traumatic. (Note: I have often been challenged about my choice of low key, or "cooler" words when describing these events - my reason in doing so is to provide an alternative way of responding to these events. In my experience hot words and phrases like, "terrible", "awful", "the end of the world", or "the worst thing imaginable" tend to be immobilizing and are linked to an increase in disturbabilty and a decrease in functional flexibility.) It has been my experience that people who have experienced these events may suffer in a number of ways: they have the learned response of heightened stress to a particular stimulus; they experience the distress of fear, anxiety, depression, or anger; and additionally they may experience a secondary problem or distress about their distress, i.e. anger about their anxiety, or depression about their fear. It has been my experience that this secondary problem, if not addressed, can overshadow the primary problem and interfere with resolving the primary problem.
If someone with PTSD beats themselves up for having PTSD it becomes trickier to address the PTSD. As I was once told, "Look Dr. Mitch, ever since I got depressed I realize that I am a worthless individual. You can teach me new ways of thinking and acting but it is no good. I will only be a more skillful worthless individual."
This self-perception was typical of the secondary problem in action. We agreed to target the secondary problem as worth working on and once we got that squared away we were able to work more effectively on the presenting problem.
One typical treatment plan
REBT, like other therapies, does not have a one-size fits all approach to human suffering. However, when I begin to work with someone who has experienced trauma or appears to be suffering from PTSD I begin to hypothesize a constellation of potentially useful interventions and test my hypotheses with my client to see which of the tools in my toolbox would be appropriate for that particular client. Generally I am prepared to assist the client Emotionally, Behaviorally (including stress reduction) and Cognitively. It has been my experience that initially we need to work on stress reduction - which means teaching the client ways to de-stress not dis-stress themselves. Once the client has mastered some of the tools needed to engage in self-calming behavior we can then work on developing more functional responses to the trauma. These more functional responses might include using the self-calming response when re-experiencing the trauma; or challenging ones perceptions about ones worth or value as a consequence of having been traumatized; or learning methods of acting more functionally despite the experience of stress.
Ultimately, I try to teach my clients to avoid making a bad bargain with their future happiness, and to challenge the belief that it is necessary to sacrifice their future on the altar of the past. To go from, "I have experienced this event and it destroyed me and I can never be happy again," to, "I have experienced this event and it confused, frustrated and frightened me BUT, I can still be happy, content and successful despite it. Maybe not as happy, etc., but still happy, etc." or, "While my flashbacks, and intense physical and emotional reactions are unpleasant and undesirable they are quite common for someone who has experienced these events and therefore are not proof of my weakness, worthlessness, or generic unlovability."
NACBT Referral List
Gift From Within
Gateway to PTSD Information
Mitchell W. Robin, Ph.D. is a Licensed Psychologist, and a Professor Emeritus at New York City Technical College, CUNY. He received his clinical training at the world renowned Albert Ellis Institute (formerly known as the Institute for Rational Emotive Behavior Therapy) where he was under the direct supervision of Albert Ellis the "grandfather" of Cognitive Behavioral Therapy.