Which Treatment for PTSD?


The new “Couch” blog by the New York Times recently had a piece by a war veteran who had received treatment for PTSD from the Veteran’s Administration. He described a terrible experience with exposure therapy in which the therapist pressured him to go over and over his trauma, re-traumatizing him in the process. There followed a long string of comments, with many of them arguing about what treatment is best.

I think these arguments are sadly misplaced, as the elements that make for successful resolution of traumatic memories seem to me very simple but not specific to any one treatment. When two key conditions come together, then a transformation occurs. I call this healing process catharsis because it was first described, using that term, by Freud in 1893.

Condition 1: Emotions associated with the trauma need to be consciously experienced.

This is not so easy to achieve and may represent the hardest part of therapy. Humans naturally avoid painful and uncomfortable feelings. We use a myriad of tricks to do so, ranging from incessant activity, to dissociation, to drug use, to self-blame, etc. Bessel van der Kolk and Peter Levine have emphasized the observation that trauma is often carried in the body, and, until accessed, does not come to conscious experience where healing can take place.

Why is it necessary to feel our feelings? A growing body of research suggests that the healing transformation happens when synapses connecting neural networks are modified. Neural networks are groups of neurons that, together, represent specific emotions or other mental contents. Donald Hebb, in 1949, proposed that “neurons that fire together wire together,” meaning that for synapses to be modified, nerve cells have to be active. It appears that conscious experiencing of affects is an indication that the right ones are currently active.

But why and how do these neural connections need to be modified? The answer is that networks representing fear and pain connect directly with brain centers that trigger emergency reactions like hair standing on end, panic, etc. These visceral reactions, the ones that we dread, can, however, be inhibited. Inhibition originates from parts of the pre-frontal cortex, the thoughtful brain, when it is able to ascertain that what appeared to be an emergency was really not, and not to worry. So those neural networks, the “don’t worry” ones, have to be activated simultaneously. Therefore, condition 2:

Condition 2: The experience must be in a context of safety and empathic connection.

Safety and empathic connection are mostly synonymous, but let me emphasize that what really makes humans not worry is the presence of someone who understands and is not overwhelmed by our pain and distress. This is what mothers and primary caregivers do. They provide a context of empathic understanding and connection, and that is what makes vulnerable, dependent children feel safe. Even as adults, what we find most reassuring remains the same– being with someone who understands and is not overwhelmed. Even when the situation is truly hopeless, say a diagnosis of lethal cancer, it is not reassurance, but simply the context of empathic connection that does the most to make us feel better. Would you rather hear, “We’ll fight this cancer.” or “I understand how scared you feel.”

A new wrinkle on this first condition is mindfulness. When sought in the context of solo meditation, expert practitioners tell us that the feeling is one of powerful connectedness to humanity. My thinking is that this state puts us in touch with our own early experiences of safety and empathic connection. At least sometimes, this state seems to be sufficient for healing even in the physical absence of another person. (See my post on mindfulness)

So when these two sets of neural networks, the one representing pain and the one representing safety, are activated at the same time, they “wire together” and inhibit signals that would otherwise trigger a fight/flight reaction. It’s almost that simple.

Exposure therapy was invented when it became clear that traditional desensitization treatment wasn’t working. The reason was that when distress was paired with relaxation, clients found ways to slip away from distress into relaxation and condition #1 was not met. Exposure consists of techniques to force conscious experiencing of emotion. This works OK, except that forcing the experience can obliterate the safety and empathic connection, therefore nullifying condition #2. That is what appears to have happened for the ex-soldier who wrote on “Couch.”

One more factor. In the course of treatment, trauma survivors allow themselves to experience their painful feelings in sessions. Typically this does not happen all at once. Most traumatic experiences have many facets. There might be physical pain, and then the odor, then the fact that someone who could have intervened didn’t and the anger and horror attached to that. In actual therapy sessions, emotions come up one facet at a time. Understandably, only the facet that is consciously experienced can be healed. Healing the others must wait their turn to come to the surface. A good deal of the skill of the therapist is helping the client to share details of the trauma and how they connect to different feelings associated with the experience. Note, however that each facet, each layer of greater intensity of feeling, is different from all others. Going through these one at a time is not repetition, but a step by step uncovering and healing of a complex experience.

It appears that the beginning therapist who treated the soldier may still have been under the influence of Pavlov, in whose experiments repetition was a fundamental aspect of learning. In my experience, with a strong empathic connection, when feelings finally “come into the room” the part of the experience that is activated heals completely and permanently in a few minutes. There may very well be a slower consolidation of the newly strengthened synapses, but repetition does not seem to be part of this “learning” process. Instead, multiple sessions are required to uncover new layers of intensity of feeling and new facets of the experience.

Finally, dreaded and avoided feelings that heal by catharsis are not the only forms of damage from trauma. In particular, something like the Stockholm syndrome regularly results in broken self-esteem. Early life trauma further damages psychological growth and development in what is called complex PTSD. My new book, How We Heal and Grow: The Power of Facing Your Feelings includes more material on the complexities of how people sustain damage and how recovery is possible. I also recommend Bessel van der Kolk’s recent book, The Body Keeps the Score.

Returning to the question in the title of this post, many therapies work to create the two conditions necessary for healing to happen. Which one is for you may be a matter of style or taste. To put this in perspective, however, according to John Norcross, the specific method explains only 8 percent of the effectiveness of therapy, while the therapeutic relationship and the factors associated with the individual therapist are, together, three times as important, that is 24 percent. Perhaps that is because the latter, human factors are critically important in building a context of safety and empathic connection and encouraging clients to face their most troublesome feelings.



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