Saturday, July 25, 2015

Treating PTSD

When he founded psychoanalysis, the first version of talk therapy, Freud constructed a narrative to explain mental illness. He posited that people fell ill for failing to accept something into consciousness. At first, Freud argued that trauma victims became hysterics because they had forgotten past experiences of sexual abuse. By the logic of his narrative, they needed to recall the trauma and tell it as a story. This would release its hold on the psyche and eliminate the need for the trauma to express itself through symptoms. Within Freud’s narrative nothing is ever really forgotten. If you cannot express it in words it will express itself in symptoms.

(For a lengthier discussion of these questions, see my book, The Last Psychoanalyst.)

When Freud’s cures turned out to be mirages, he was obliged to revise his theory. He decided that hysterics were not really suffering from their traumas. They had fallen ill because they could not accept that the trauma was something that they had really, really wanted to happen. At that point, it doesn’t really matter whether a neurotic has been traumatized. As long as he is repudiating his nasty fantasies and perverted desires, he is going to fall ill.

Needless to say, this is an appalling instance of blaming the victim. By the logic of Freud’s narrative, children who are traumatized by sexual abuse really wanted it to happen. You could even trot out some Freudian theories of infantile sexuality to justify that point of view.

Even most Freudians no longer support this aspect of Freudian theory. And yet, those who still adhere to the letter of the Freudian text—French analysts, for example-- will occasionally argue that those who were traumatized by sexual abuse fell ill because the events corresponded to a repressed fantasy.

Freud based his early theorizing on what he called the pleasure principle. It was not as original as he thought, but we will leave that for another time. Patients had repressed their traumas and had repudiated their perverse fantasies because both of them, in different ways, produced experiences of unpleasure.

And yet, Freud had a problem when he started seeing patients who could not forget or repress their horrid thoughts. They could not get the thoughts out of their heads. They felt that they were being assailed and assaulted by these ideas and images.

Among them were cases of what were called war neurotics, survivors of World War I who could not forget their wartime experiences. Freud suggested that they seemed to be compelled to repeat the experience, perhaps in a futile effort to master it.

Freud was less concerned with how he was going to treat these patients than with the possibility that these cases contradicted his famous pleasure principle. If the mind is naturally inclined toward pleasure, we might well expect it to repress or ignore experiences or fantasies that produce unpleasure. So far so good. But, how then can his theory explain why people cannot get painful traumas out of their minds?

To respond to this challenge Freud revised his theory and produced a new narrative. He decided that the human mind had been written into a grander narrative of Biblical proportions, in which it was structured by a conflict between an instinct that seeks life and one that seeks death.

Freud named them Eros and Thanatos, after two Greek mythological figures. Later thinkers added the possibility that the lust after death could produce its own form of satisfaction, one that was more intense, more orgasmic, more powerful than mere pleasure.

Freud did not quite say it, but he implied that if people did not get well by doing psychoanalysis the reason was that they wanted to stay sick, that there was someone extremely powerful inside them that was directing them toward death. Even Freud could not fight so powerful a force.

Freud did not know about post-traumatic stress disorder, but clearly the shell shock experienced by many World War I veterans was its precursor. Today, no one still imagines that Freudian psychoanalysis can treat or cure PTSD. Instead, the American military has chosen to throw in with a psychologist named Edna Foa and her invention: prolonged exposure therapy.

One notes that Foa’s treatment is considered to be a cognitive-behavioral treatment. One notes also that it bears a certain eerie similarity to Freud’s theory of repetition compulsion. If one is to believe David Morris, a former Marine who underwent it, its effectiveness needs seriously to be questioned.

 Morris describes prolonged exposure therapy:

In 2006, the VA began treating veterans with a form of therapy charmingly known as prolonged exposure. It is now a central piece in the VA’s war on PTSD and its most popular type of individual psychotherapy. Prolonged exposure is heavily promoted by the VA, which describes it as the “gold standard” treatment for PTSD.

Prolonged exposure therapy works roughly like this: After taking a brief inventory of the patient’s military service, the therapist asks the veteran to recount the story of his or her worst trauma over and over and over again with eyes closed until the memory of it becomes “habituated,” losing its traumatic charge and becoming like any other normal autobiographical memory. The typical course of treatment lasts about eight weeks and, according to Marsden McGuire, the deputy consultant for mental health care standards at the VA, produces some improvement in 60 percent of veterans who undergo it.

The evidence for its effectiveness is mixed. In some cases it works but in others it has produced negative outcomes:

The problem with prolonged exposure is that it also has made a number of veterans violent, suicidal, and depressed, and it has a dropout rate that some researchers put at more than 50 percent, the highest dropout rate of any PTSD therapy that has been widely studied so far.

One understands that Foa's method comes from the cognitive-behavior treatment of phobias. The latter involves a gradual exposure to different versions and variants of the phobic object. If you are terrified of spiders a therapist might begin by showing you a picture of a spider. Then he might show a more realistic picture. Later he might show you some specimens of spiders. Finally, you will be allowed to examine living spiders under glass. Before you know it you will be allowing tarantulas to crawl up your arm. Voila.

As it happens, exposure and desensitization therapy for phobias is the best treatment available. All forms of psychodynamic therapies have failed to produce anything resembling good results.

Be that as it may, one might well question whether PTSD is another form of phobia and whether it works as well on PTSD as it does with phobias. In some cases it does. In some it does not.

Morris explains his personal experience:

After briefly surveying my time in Iraq with a therapist, who I’ll call Scott here, I was asked to tell the story of my near-death experience in an IED ambush in Baghdad in 2007. In the sessions that followed, I retold this story dozens of times. Whenever I tried to change the subject to another part of my time in Iraq, I was told that the only way forward was to tell my IED ambush story over and over until it no longer bothered me or got my heart rate up. Repetition is the key, Scott explained. After telling the story of my close call in Baghdad roughly 100 times, I began to have trouble sleeping. Eventually, I broke down altogether and was unable to read, write, or leave the house. One night after my cellphone failed to dial out, I stabbed it repeatedly with a stainless steel kitchen knife until I bent the blade 90 degrees.

While the military has decided that exposure therapy is the gold standard, some important psychiatrists have raised significant objections:

In 1991, Roger Pitman, a psychiatry professor at Harvard Medical School, discontinued a pilot study of six Vietnam veterans treated with a technique similar to prolonged exposure, known as imaginal flooding, that resulted in two of the patients becoming suicidal and a third breaking 19 months of sobriety. Other patients became severely depressed or began suffering panic attacks between treatment sessions. The results were so unexpected that Pitman conducted a larger study using 20 Vietnam veterans as subjects, published in 1996 in Comprehensive Psychiatry, and found similar outcomes.

And also:

It is important to emphasize that exposure [therapy] may lead to serious complications,” wrote Bessel van der Kolk in his widely cited 2006 book Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society. In a recent letter in response to a New York Times article I wrote on prolonged exposure, van der Kolk expanded upon these ideas, saying, “The premise that the trauma needs to be relived over and over in order to heal has questionable scientific merit, because the brain areas that go offline during a traumatic experience and precipitate PTSD are once again deactivated when people are pressed to re-create the horrors of the past.”

Obviously, Foa’s method is counterintuitive. Rather than allow patients to feel assailed and assaulted by the trauma, the patient undergoing her therapy is instructed, even badgered, into taking control of the narrative, mastering its arrival.

In principle, it’s better to feel that you can control the narrative than to feel that you are prey to it.

If the treatment works in some cases, this must be one of the reasons.

On the other hand, the treatment might also aggravate the problem by focusing so intently on the trauma that everything else is obscured or neglected.

One basic problem with trauma is that its victims often come to believe that the trauma is the meaning of their lives, that they were once victimized and will forever be victims. If they weren’t a victim before, they are now. And they will act accordingly.

But, if the trauma does not reflect your character, you ought to learn to function as though it never happened. Instead of focusing on the trauma to the exclusion of all else, you should then examine the behaviors and life habits that reflect the trauma and find a way to replace them with more constructive habits.


Ares Olympus said...

re: But, if the trauma does not reflect your character, you ought to learn to function as though it never happened. Instead of focusing on the trauma to the exclusion of all else, you should then examine the behaviors and life habits that reflect the trauma and find a way to replace them with more constructive habits.

It seems like both approaches are necessary, unlearning "destructive habits" (which means paying attention to them first) and relearning "constructive habits" by conscious choice.

The concept of "defense mechanisms" continues to be interesting to me, apparently somewhat unconscious choices we make to avoid discomfort. It makes sense to me that Trauma isn't "what happens to us" but "how we react to what happens" so perhaps your set of "most effective defense mechanisms" you held BEFORE a traumatic situation affect how you respond to that event, and so that's why you can't treat all trauma patients the same way. First you have to observe what behaviors they are using to cope with their discomfort.

Its easy enough to say that people by force of will, can become aware of negative forces within, and rather than acting them out, ignore them, and do something else that is less destructive, that also serves to keep them at bay.

In the least you can recognize things like frustrations are not always about what's happening now, but your inner states, so mental checklists like HALT (Hungry, Angry, Lonely, Tired), would seem vital.

We can't be our best selves all the time, but being aware of the need for self-care means we can reduce unnecessary aggression against a world in front of us.

But with PTSD, all this seems more difficult. Defense mechanisms like disassociation seem amazingly intractable. If a person can't be aware of continuity of time and self and events, no reality would seem to be defendable.

So you really almost have to consider someone (or yourself) as permanently disabled, maybe like AA claims Alcoholism can only be managed, never cured. Your character can "cover" the wounds, but they can never be cured.

Anonymous said...

Experts in PTS (Post-Traumatic Stress) now describe two components of the personality: the ANP (apparently normal personality) and the EP (emototional part). This makes sense because a traumatized person frequently appears to be normal except when he or she is overcome by intense emotions. Although a person with PTS will sometimes suffer subjectively there is no reason to call this natural adaptation a "disorder" except to increase the prestige of so-called mental health experts. Dr. Freud and many other so-called psychotherapists may have an EP buried so deep that they must interact with patients that express the EP while pretending to be the "healer" who is paid like a Doctor expressing the ANP. The rule in psychotherapy is "Physician heal thy self."

Alice Miller criticizes Freudian wish-fulfillment theory in her book "Thou Shalt Not Be Aware." She uses biographical stories rather than theories to expose the contempt shown for children throughout history and the attitudes toward insensitivity to the authentic social needs of children. A well-raised child would have an easier time dealing with trauma in war or society as an adults. A traumatized child is more likely to be triggered by the horrors of war or norms of society (if you were abused as a child then the normal adults did not save you or serve you they simply went about their business while neglecting to save you from some abusive person, so contempt for the norm is baked into child abuse).

Pogo: I never said I was a diplomat said...

Your book, The Last Psychanalyst, has made a nice connection for my work with chronic pain patients.

Many of them have traumatic backgrounds and the process of central sensitization is likely the mechanism by which their pain and multiple unexplained symptoms arise,

But the psychoanalytic culture induces many of them to search relentlessly for a root cause (beyond the sensitization) and they cling to their symptoms.

They only get better by abandoning that search, and behaving as one would if there were no symptoms.
This is going to be very helpful.

Stuart Schneiderman said...

Thank you for the kind words. They make my day.

Anonymous said...

By definition a traumatized person has intrusive thoughts/emotions that interfere with efforts to behave as if there were no symptoms. The EP intrudes upon the efforts of the person to live via the ANP.