Therapy: PTSD Symptoms After The Therapy Hour

Q: Dear Frank, How does one keep their mood up after a therapeutic session when they have been talking to their therapist about very serious issues like child abuse, victimization and/or sexual assault?

A: Dear reader, Good question! Just today I received a call from a relatively new patient who seemed upbeat after we had our last session, but then felt terrible several hours later. His previous job placed him in several near-fatal circumstances and two years later he still has vivid flashbacks, nightmares and feelings that he finds difficult to express.

We work effectively on these PTSD symptoms during the therapy hour. Both of us experience gratifying progress. But he, more than once, has that after-therapy-let-down which you raise in your question. I don’t think it comes from being “triggered” during the time with me. I do think our time together is experienced as connected, collegial, and hopeful. But afterwards his sense of security and of personal optimism has some ups and downs. Often he has an awkward interaction with his spouse or a co-worker and his feeling of being understood and accepted is shattered. Perhaps the contrast of feeling connected to his therapist then feeling misunderstood or criticized by a significant other ushers in a deep sense of abandonment.

In other patients, the absence of a significant other is felt acutely – but the emotion is more than mere loneliness. This profound aloneness is like the awful feeling a very young child has when lost for the first time. Or like the feeling a soldier has when badly wounded, going into shock, and he or she cries out, “Mama.” It is a reflex. It is a return to a state of infantile aloneness. When I spent time in Borneo studying orangutans, I heard the pitiful “lost call” of the infant orangutan when separated from its mother. Our primate ancestors have separation anxiety, too!

When they are attached, they are really attached, holding on to mother’s fur 40 feet above ground on a tree limb. To become un-attached is to fall to grave injury or death on the forest floor. PTSD recreates in us many of these primitive emotions – being physically endangered; holding on to a source of sustenance; experiencing a powerful sensation of separation and abandonment that is hard to explain and is often a source of great embarrassment when it is explained.

So, in this situation, I review with my patient the biology of attachment and the fact that a feeling of abandonment when attachment is needed but broken is understandable, normal, and part of the neurology of primates. It is basic, fundamental biology. I try to coach the person into accepting this sensation (alone, abandoned) as a feeling, not prophesy of future separation and nothing to be ashamed of. The feeling does pass. It may be mitigated by forms of self-help (paradoxically, this may be a good time to be alone and not to seek attachment to a family member or friend who cannot fully appreciate the situation). The self-help could include web-based reminders of how PTSD works, of soothing or diverting images, or of inspirational articles and poetry.

There may be other sensations — other than separation and abandonment — that arise after finishing a therapy session. But this feeling of aloneness is worth recognizing. It is common. So in a very meaningful sense, you are not alone in sensing aloneness. You are part of a large family of fellow travelers who have survived trauma and are weathering its inevitable aftershocks.