{"id":5855,"date":"2023-11-30T03:05:09","date_gmt":"2023-11-30T03:05:09","guid":{"rendered":"https:\/\/www.giftfromwithin.org\/?page_id=5855"},"modified":"2023-11-30T03:05:12","modified_gmt":"2023-11-30T03:05:12","slug":"trauma","status":"publish","type":"page","link":"https:\/\/www.giftfromwithin.org\/ptsd\/trauma\/","title":{"rendered":"Posttraumatic Therapy"},"content":{"rendered":"\n
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Frank M. Ochberg<\/strong> – Department of Psychiatry, Michigan State University, East Lansing, Michigan 48824. The material addressed in this chapter was previously published, in a slightly different format, in Psychotherapy<\/em><\/strong>, Volume 28, No. 1, Spring, 1991.
International Handbook of Traumatic Stress Syndromes<\/em><\/strong><\/a>, edited by John P. Wilson and Beverley Raphael. Plenum Press, New York, 1993.IntroductionMost victims of violence never seek professional therapy to deal with the emotional impact of traumatic events. If they did, they would be sorely disappointed. There are not enough therapists in the world to treat the millions of men, women, and children who have been assaulted, abused and violated as a result of war, tyranny, crime disaster, and family violence. When people do seek help suffering with posttraumatic symptoms they may find therapists who are ill equipped to provide assistance. The credentialed clinicians in psychiatry, psychology, nursing, social work, and the allied professions are only recently learning to catalog, evaluate, and refine a therapeutic armamentarium to serve traumatized clients. The ambitious collection of chapters in this volume is one such arsenal. The prodigious efforts of Charles Figley co-founder of the Society for Traumatic Stress, and organizer of the Psychosocial Stress book series (Brunner\/Mazel) and the Stress and Coping Series (Plenum Press), are important resources for professionals concerned with traumatic stress reactions. A cadre of clinicians have also shared insights and approaches, face-to-face, and through written works, defining principles and techniques that address the worldwide problem of posttraumatic readjustment. Recently, I assembled a sampling of those clinical insights (Ochberg, 1988) and attempted to define the commonalities in assumptions and approaches to therapy. The common ground is the foundation of posttraumatic therapy (PTT). The individual distinctions that separate clinicians who share this common ground are the inevitable differences of creative minds.My purpose in this chapter is to enlarge upon the foundation of PTT and clarify some of the clinical techniques that stand upon this foundation.Foundation of Posttraumatic TherapyFundamental PrinciplesSeveral principles are fundamental to posttraumatic therapy, and discussing these at the outset of therapy is usually advisable. Since traumatized and victimized individuals are, by definition, reacting to abnormally stressful events, they may confuse the abnormality of the trauma with abnormality of themselves.The first principle of PTT is, therefore, the normalization principle<\/em>: There is a general pattern of posttraumatic adjustment and the thoughts and feelings that comprise this pattern are normal, although they may be painful and perplexing, and perhaps not well-understood by individuals and professionals not familiar with such expectable reactions. The word normal can mean many things. Offer and Sabshin (1966) described, among other connotations, the use of the term normal to designate health, an ideal, and a statistical mode. When a doctor says, “This is a normal reaction,” any or all of those three possibilities could be implied. For example, after breaking a bone, a patient has the fracture examined and set. A few days later there is pain and swelling, some itching under the cast, but good circulation and no sign of infection or nerve damage. The doctor has seen this pattern many times before, knows the physiological reasons for discomfort, and the danger signals of disease. The doctor’s reassurance, “This is normal,” means that a healthy healing process is underway. Further explanation of the healing pattern allows the patient to participate actively in the recovery process, understanding the reasons for symptoms, the time course of reequilibration, and the signs of abnormal interference, such as a wound infection.The emotional healing process often includes reexperiencing, avoidance, sensitivity<\/em>, and self-blame.<\/em> These symptoms are easily described, explained, and “set” in a context of adaptation and eventual mastery. By sharing such information, the second principle of PTT, the collaborative<\/em> and empowering principle<\/em>, is recognized: The therapeutic relationship must be collaborative, leading to empowerment of one who has been diminished in dignity and security. This principle is particularly important in work with victims of violent crime. The exposure to human cruelty, the feeling of dehumanization, and the experience of powerlessness create a diminished sense of self. This diminution is normal when it is proportional to the victimization. Survivors of natural disasters experience powerlessness, too, although they are not subjected to cruelty and subjugation. They benefit greatly from a therapeutic alliance that is experienced as collegial and empowering.A third principle is the individuality<\/em> principle: Every individual has a unique pathway to recovery after traumatic stress. Cannon (1939) and Selye (1956) may have identified common physiological and psychological reactions in states of extreme stress, but Weybrew (1967) and others noted the complexity of the human stress response and the fact that one’s pattern is as singular as a fingerprint. This principle suggests that a unique pathway of posttraumatic adjustment is to be anticipated and valued, and not to be feared or disparaged. Therapist and client will walk the path together, aware of a general direction, of predictable pitfalls, but ready to discover new truths at every turn.These three principles can be expressed in various ways and supplemented with other important tenets. For example, an appreciation of coping skills rather than personality limitations allows therapy to proceed without undue emphasis on negative characteristics, and the devastating implication that victimization is deserved (Wilson, 1988). PTT begins with the assumption that a normal individual encountered an abnormal event. To ameliorate the painful consequences, one must mobilize coping mechanisms. How dramatically different this is from the hypothesis that posttraumatic stress disorder and victimization symptoms are products of personality flaws and neurotic defenses that must be identified and treated according to traditional paradigms! Furthermore, an interdisciplinary approach, recognizing the contributions of biology, psychology, and social dynamics, stimulates clinician and client to see beyond any singular explanation for posttraumatic suffering and to search for remedies in many different fields. The contributions of pharmacology, education, nutrition, social work, law, and history are recognized and valued. Intervention may include introduction to a self-help network, exposure to inspirational literature, explanation of the victims’ rights movement, establishment of an exercise regimen, or prescription of anxiolytics. PTT is interdisciplinary. Practitioners should therefore be aware of community resources that are of potential benefit and be willing to assess the merit of these adjuncts to their direct clinical intervention. Often, this requires personal meetings with colleagues from disparate fields. To some degree it also requires a cognitively flexible attitude as to how best serve the patient suffering from PTSD who may need many special (yet not traditional) therapeutic interventions to facilitate the stress recovery process.Techniques of Posttraumatic Therapy<\/em>Many techniques have been used effectively to help survivors readjust after traumatic events. I have found it useful to classify the various methods into four categories:1. The first category is educational and includes sharing books and articles, teaching the basic concepts of physiology to allow an appreciation of the stress response, discussing civil and criminal law with new participants in the process, and introducing the fundamentals of holistic health. The educational process is one of mutual exchange (i.e., a “two-way street”). The client may have resources that he or she finds helpful and wants to share with the clinician.2. The second grouping of techniques falls within the category of holistic health. Although the term holistic health has its critics as well as its supporters, I offer it in the spirit of Merwin and Smith-Kurtz (1988), who noted how physical activity, nutrition, spirituality, and humor contribute to the healing of the whole person, The clinician who promotes these aspects of healing serves as a teacher and a coach, offering concepts that might be new to the client, and shaping abilities that may be latent.3. The third category includes methods that enhance social support and social integration. Family and group therapy could be included here. Exposure to self-help and support groups in the community are other examples. But most important is the sensitive assessment of social skills, the enhancement of these skills, the reduction of irrational fears, and the expert timing of encouragement to risk new relationships. Traditional analytical tools and traditional social work skills are employed to promote healing in supportive human groups.4. Finally, there are clinical techniques that are best categorized as therapy. These include working through grief, extinguishing the fear response that accompanies traumatic imagery, judicious use of medication for target symptoms, the telling of the trauma story, role play, hypnotherapy, and many individualized methods that are consistent with the principles of PTT.These four clusters of techniques are not comprehensive. There are innovations that defy categorization, such as the Native American sweat lodge technique (and other techniques of healing and purification) discussed by Wilson (1988) and testimony of political repression, used as a therapeutic instrument (see Chapters 55 and 57, in this volume; Cienfuegos & Monelli, 1983).But it is not my purpose here to prepare an exhaustive catalog of techniques. My intent is to explain those approaches that I have employed, in residential (Ochberg & Fojtik, 1984) and in outpatient settings, with victimized, traumatized clients.EducationReading the DSM Together<\/em>I will never forget the first time I brought out my green, hardbound copy of the DSM-III (American Psychiatric Association, 1980), moved my chair next to Mrs. M., and showed her the chapter on PTSD. Mrs. M. is a thin, soft-spoken woman in her thirties who was assaulted and raped in South Lansing, Michigan. She was referred by a colleague and had just finished telling me her symptoms, 8 or 9 weeks after the traumatic event. She was frightened, guarded, perplexed, and sad. She had no basis for trusting me. But after she saw the words in the book, as I read them aloud, she brightened, sat up tall, and said, “You mean, that’s me, in that book! I never thought this could be real.”Seldom have I found such a reversal of mood and such a sudden establishment of trust and rapport since Mrs. M., but I have never missed an opportunity to read the criteria list with a client, when it seemed appropriate.The responses vary, from satisfaction that the symptoms are officially recognized, to surprise that anybody else has a similar syndrome. Some patients take pride in making their own diagnosis, pointing out exactly which symptoms apply. Few show any interest in other sections of the book. Most seem to enjoy hearing my explanation of the trouble we (i.e., the members of the American Psychiatric Association committee on PTSD criteria) had formulating the diagnostic category – how some of us argued for placing the description in the “V Code” section with other ”normal” reactions, such as “uncomplicated bereavement,” but others prevailed and the practical consequence of placing this normal reaction to abnormal events in the chapter on anxiety is that insurance companies pay their share of the bill!Reading the DSM-III (American Psychiatric Association, 1980) or DSM-III-R (American Psychiatric Association, 1987) together begins the educative and collaborative process. It opens the door to further education about the physiology of stress and the range of human responses to adversity. The DSM-IV is scheduled for production in 1993, and the architects are considering a “Victim Sequelae Disorder,” in addition to PTSD (R. L. Spitzer, S. 1. Kaplan, & D. Pelcovitz, personal communication, 1989). This should help clinicians and clients, since the list of potential criteria supplements the PTSD symptoms and includes those common features that affect victimized rather than traumatized individuals. I have long considered the distinction important (Ochberg, 1984, 1986, 1988, 1989) and am delighted to see it considered in the DSM-IV (see Appendixes 1 and 2 at the end of this chapter).Introducing Civil and Criminal LawA therapist need not be a lawyer to know about the law. When our clients face the criminal justice system for the first time, understandably they may be concerned, confused, and overwhelmed.Mr. A. was shot in the abdomen at close range by an intruder and almost killed. After heroic surgery, he awoke to the hubbub of an intensive care unit. Between hallucinations, he learned what occurred, received family visits, and began looking at mug shots. His introduction to the world of detectives, prosecutors and judges was better than most. They appreciated his condition and worked slowly and sensitively, after realizing the futility of expecting a positive identification. He appreciated their professional responsibilities and their regard for him. Would it were always so!Victims of violent crime are often treated like pawns in an impersonal bureaucracy (Young, 1988). President Ronald Reagan realized this in commissioning the President’s Task Force on Crime Victims (1982), and the U.S. Congress followed suit by passing the Victims of Crime Act of 1984.Usually, I offer clients who are victims of violent crime several articles and brochures that explain their rights under state law and the role of the victim-witness in the American judicial justice system. In the United States, Michigan is blessed with a model victims’ rights law (Ochberg, 1988 Van Regenmorter, 1989), and a Crime Victim’s Compensation Board that provides financial aid. Clinicians who counsel victims could easily find resources and references in their own states. I find that many clinicians, even in Michigan, are unaware of these resources, but are pleased to know that a portion of their bills can be paid by the state, if their clients report their victimization within a year of the crime.A patient who is in the middle of a trial, cooperating fully with the prosecutor, may know nothing of his or her right to sue the assailant, to have a court injunction against harassment, to receive workers compensation, and, in some instances, to receive representation from the pro bono committee of the county bar association. Moreover, finding the right lawyer is as difficult as finding the right therapist, so I pay close attention to my patients’ experiences with attorneys and maintain an up-to-date referral roster. Sharing information about legal resources is part of the education process.Discussing PsychobiologyFew clients are interested in reading about autonomic nervous system activation, but some read voraciously. To understand the physiology of mammalian arousal during stress is to begin mobilizing the mind in pursuit of recovery. It is relatively easy to impart a basic understanding of the fight\/flight mechanism (Cannon, 1939) and the General Adaptation Syndrome (Selye, 1956). Wilson (1989) and Merwin and Smith-Kurtz (1988) explained the concepts clearly and Wroth (1988) and van der Kolk (1988) discuss more complex implications in the same volume (Ochberg, 1988). Without turning therapy into a didactic exercise, without burdening the client with unsolicited instruction, one can convey the fact that lethal threat has a powerful impact on body chemistry; that our adrenal glands are stimulated; that we are prepared to fight or to flee as if we were facing a wild beast, millennia ago; that all this circuitry is out of date and usually destructive when we face threats in modern society- that PTSD is the predictable outcome in general after extraordinary stress; and that everyone’s individual pattern is different.Furthermore, vigorous use of the large muscles is the intended result of adrenal activation, and physical activity is an advisable measure to ameliorate the effects of PTSD. This point leads to the next educational objective.Reviewing Concepts of Fitness and
Holistic HealthIn designing the milieu and program of the Dimondale Stress Reduction Center (Ochberg & Fojtik, 1984), I hoped for a blend of a health spa, a community college, and a hospital. For several years, we maintained this balance but eventually the hospital bureaucracy crowded out the other elements. I was disappointed, but not surprised. American medicine, particularly hospital-based medicine, places the patient in a passive role and ignores the power of health promotion. In elementary school, we used to call health promotion “hygiene.” Gym teachers, not doctors, got the points across.Now, in an office-based, part-time practice, I do what I can to educate patients about the benefits of exercise and nutrition. The syllabus is in the Merwin and Smith-Kurtz (1988) chapter of Post-traumatic Therapy<\/em>. My approach includes nagging, begging, and heartfelt approval when interest is shown. Since the general category of holistic health promotion includes this educational goal, let us move there now.Promoting Holistic HealthPhysical Activity<\/em>Writing about the development of a healthy fitness routine for PIT clients, Merwin and Smith-Kurtz (1988) observed that
techniques of physical training have changed in recent years as the maxim “no pain, no gain” has been discarded. Exercising past the pain threshold risks injury to muscles, joints, or tendons. The watchwords today are “balance,” “moderation,” and “listen to your body.”<\/em>They go on to describe the three elements of a balanced program: strength, cardiovascular efficiency, and flexibility, and they note the generally accepted activities that provide these elements. Nowadays, I find few clients who are unfamiliar with these principles, but many who lack the motivation to begin or to resume an interrupted routine. Some fear social interaction. Some have injuries that limit activity. Some are generally lacking in initiative, evidencing Criterion C. (4) of PTSD (American Psychiatric Association, 1987), “markedly diminished interest in significant activities.” Relatively early in therapy, I will evaluate the client’s potential for supervised physical activity. I want to know that a recent medical examination has been performed and there are no limitations or restrictions. If there are limitations, I may still promote allowable activity, but only after consultation with the examining physician.Often, the client and I develop an exercise plan, with goals and methods listed in the record. Usually, this process occurs after a preliminary discussion of stress physiology and before agreement on overall treatment objectives. (The client may be ready to take daily walks, but not ready to discuss the details of victimization.) Agreeing on an exercise plan and fulfilling the agreement are separate issues.When there is resistance to exercise, the resistance itself must be confronted. The therapist should not assume to know an individual’s underlying motive for avoiding healthy activity. A gentle, collaborative search for the obstacles and the construction of a path around these obstacles comprise an important chapter of PTT. Having said this, I must admit that I find it very difficult to avoid the methods that ultimately motivated me to undertake a fitness routine: the unremitting urging of well-meaning friends.Therapists are advised to become familiar with supervised, structured fitness programs in their communities. A referral to a specific YMCA, health dub, or aerobic instructor can assure that the milieu is appropriate, the regimen is reasonable, and the opportunity for reinforcement is available.I am delighted when clients adopt a healthy exercise routine, and they know it.Nutrition<\/em>We never learned much about nutrition in medical school (other than infant formulas in pediatrics). I am still baffled by conflicting professional and lay advice on the value of various “healthy” diets. But it makes sense to evaluate a client’s eating habits and look for the common mistakes that contribute to anxiety, irritability, and depression. In general, this is part of good clinical work, but particularly important for posttraumatic (Stress Syndrome) patients who are vulnerable to mood swings and who may have neglected their nutrition.Caffeine Intoxication<\/em>The DSM-III-R (American Psychiatric Association, 1987) requires 5 out of 12 signs, plus the presence of recent excessive caffeine ingestion and the absence of other causes, to make the diagnosis of caffeine intoxication (or “caffeinism”). The 12 signs overlap with the hallmarks of panic, generalized anxiety, and aspects of PTSD: restlessness, nervousness, excitement, insomnia, flushed face, diuresis, gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, and psychomotor agitation. Clients who experience numbing may consciously or unconsciously increase their coffee consumption. A demoralized indifference to preparing and consuming adequate meals may result in excessive drinking of tea, or coffee, or alcohol. Also, caffeine is found in soft drinks, candy, and certain desserts as well as in coffee and tea. The incidence of true caffeine intoxication is relatively rare, but good clinical practice requires that we rule out the diagnosis when anxiety symptoms are present. Furthermore, a discussion of caffeine effects leads to the broader issues of diet, appetite, and meal rituals.Meaning of Healthy Eating<\/em>Food gathering, preparation, and consumption have ritual significance in most cultures. Full participation in the family or tribe requires the equivalent of “bringing home the bacon” or “fixin’ dinner” or “getting to the table on time.” Food sharing is a critical aspect of nurturing and of family cohesion. When a traumatic event interferes with one’s desire to eat, one’s ability to face the ordeal of shopping, and one’s participation in shared meals, more than nutrition is at stake. There is disruption of biochemistry, interpersonal relations, self-esteem, and connection to culture. PTT requires attention to all of these issues, agreement on desired objectives in the short-term and long-term future, and a collaborative search for remedies.Mrs. A. developed agoraphobia in addition to PTSD after being held hostage and surviving a sexual assault. Her therapy was prolonged, involving residential and outpatient treatment. She read every book she could find about coping with stress, and understood the significance of reestablishing her role in her family and community. But a major obstacle was her fear of meeting people who knew about her assault and who felt compelled to make well-intentioned remarks about her recovery. We discussed this situation at length. As she learned to respond to the sympathetic comments of friends and acquaintances without feeling invaded, she overcame her fear of the marketplace. The later phases of PTT were supportive and nondirective. She resumed her functions in the family, and meals became a source of pleasure rather than pain.Referral to Nutrition Experts<\/em>My community has a state-supported university with a department of food science, four hospitals with dietitians, and a professional association of dietitians that holds regular educational conferences. It is relatively easy to identify competent colleagues. Several expressed interest in counseling clients on the fundamentals of food selection and diet. They are experienced in working with eating disorder patients, but not with victims of violence and extreme stress. In those few instances where I made referrals, the outcome was generally good. The clients learned new facts and experienced a feeling of mastery. Those therapists who do not have colleagues close by to assist with nutritional counseling are advised to review the basic facts and the supplementary reference list provided in Ochberg (1988), Chapter 4.HumorFollowing the advice of my colleagues who wrote the section on humor in the chapter just mentioned (Merwin & Smith-Kurtz, 1988), I asked Mrs. R., an adult survivor of incest, to tell me about her ability to laugh. “Do you think my life is funny?” she fumed, casting a look at me that could wither an oak tree. My timing was awful. But usually I can succeed in initiating a discussion about humor, its salutary effect, and ways that we can improve our ability to laugh at ourselves. Smith-Kurtz cites the remarkable example of Norman Cousins (1979), a genius in marshaling humor as a coping mechanism for critical illness. Furthermore, she provides techniques and references to enhance the therapist’s sense of humor.The goal in adding humor to PTT is not for the therapist to be witty, but for the client to have the capacity to laugh. A clinician can facilitate the recovery and the improvement of a client’s sense of humor by setting an example, by searching for instances when the client used humor well, and by providing a good audience when spontaneous humor arises.A week after Mrs. R. cut me down to size, I told her how clumsy a therapist can feel, trying to uncover humor and failing completely. She laughed. Now we can talk freely about her tendency toward sanctimoniousness and her neglect of humor as a healing art. She is interested in elevating her capacity for laughter, and that is a step in the right direction.Spirituality<\/em>Long before psychology and psychiatry were invented, before medicine was a science, there were healers who treated the sick and the wounded. Sometimes they used remedies with a chemical basis for efficacy unknown at the time (e.g., belladonna for diarrhea). But, invariably, there was a sacred, ritual dimension to the treatment. The medicine man invoked spiritual assistance. Sacrifices were required to the gods. Prayers were said, individually and collectively. There is abundant evidence that healing was facilitated (see Wilson, 1989, for a review).The power of prayer in surviving captivity and torture is well known (Fly, 1973; Jackson, 1973), although the mechanism of action is subject to debate.Although I once felt that religion and spirituality had no place in the clinical sciences, I am now convinced that clinicians must evaluate their clients’ spiritual potential. By this I mean their ability to benefit from their own beliefs, particularly a sense of participation in universal, timeless events. For adherents to the major religions, this spiritual dimension may be conceptualized as feeling God’s love. For others, spirituality may be described as a transcendent feeling of harmony and communion with humanity or Nature or the unknown reaches of space.Merwin and Smith-Kurtz (1988) explained that
spirituality is a state of being fully alive and open to the moment. It includes a sense of belonging and of having a place in the universe. A deep appreciation of the natural world, an openness for surprise, a gratefulness for the gratuity of everything, joy and wonderment are all a part of spirituality. Although spiritual growth is a type of healing from which most of us could benefit, a victim’s sense of spirit may be acutely dimmed for a period after the victimization.<\/em>Over time, however, as the victim heals in all areas, the potential for spiritual growth may become greater than ever before and greater than for many people who have not faced the reality of their individual death.<\/em>Usually, I avoid these issues early in therapy. Many patients have complained to me about clergy who focused on their own method of spiritual healing after a trauma, ignoring the feelings of the victimized individual. On the other hand, many clients have been helped by sensitive pastoral counselors, and continue seeing them while seeing me. My role is not to promote any specific spiritual approach. But after a relationship is established, after some progress has been made, I express interest in the client’s experience of spirituality. Often I am surprised by the strength of religious conviction that coexists with pessimism and helplessness. In therapy, the issue then is not creating de nova a spiritual capacity, but identifying and overcoming the obstacles to feeling the embrace of one’s faith.An excellent example of personal triumph over childhood sexual assault, and the effects of racism and sexism, can be found in the autobiographical prose and poetry of Maya Angelou (1978). Her faith in her own indomitable spirit inspires others. I have referred her works to clients and students, when the spiritual dimension of overcoming adversity was relevant. Here is a powerful poem of hers (Angelou, 1978) that can reach the right client at the right time:<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n
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