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The views and opinions expressed in these articles and interviews are those of the individuals speaking, and do not necessarily represent those of Applied Metapsychology International.
In recent years, significant media attention given to the Post-Traumatic Stress Disorders (PTSD) of Vietnam veterans, whose post-war “nervous” problems (i.e., sleep disturbances, hyper-vigilance, paranoia, panic attacks explosive rages, and intrusive thoughts) were known to veterans of earlier campaigns as “battle fatigue,” “shell shock,” and “war neurosis” (Kelly, 1985). As any number of mugging, rape, and accident victims have demonstrated, however, one need not have been a casualty of war to experience the problem (APA, 1987). PTSD appears in children as well as adults (Eth & Pynoos, 1985) and has been attributed to abuse, abortions, burns, broken bones, surgery, rape, overwhelming loss, animal attacks, drug overdoses, near drownings, bullying, intimidation, and similar traumata. It manifests as a wide range of anxieties, insecurities, phobias, panic disorders, anger and rage reactions, guilt complexes, mood and personality anomalies, depressive reactions, self-esteem problems, somatic complaints, and compulsions.
The PTSD reaction is most easily distinguished from emotional problems of other sorts by its signature flashback: the involuntary and often agonizing recall of a past traumatic incident. It can be triggered by an almost limitless variety of present cognitive and perceptual cues (Kilpatrick, 1985; Foa, 1989). Lodged like a startle response beyond conscious control, the reaction frequently catapults its victims into a painful acting out of an earlier trauma and routinely either distorts or eclipses their perception of present reality. Although we can’t confirm that any of the countless animal species with which researchers have replicated Pavlov’s (1927) conditioned response ever actually flashed back to their acquisition experiences, the mechanism of classical conditioning is apparent in every case of PTSD. As salivation is to Pavlov’s dog, so PTSD is to its victims.
Like emotional problems of other sorts, however, PTSD is not accounted for solely in terms of antecedent trauma and classical conditioning. In order to provoke a significant stress reaction, as Ellis (1962) and others observe, an experience must ordinarily stimulate certain components of an individual’s pre-existing irrational beliefs. Veronen and Kilpatrick (1983) confirm that the rule holds for trauma as well as for more routine experience. Errant beliefs – related to the tolerance of discomfort and distress; performance, approval, and self-worth; and how others should behave:
“…may be activated by traumatic events and lead to greater likelihood of developing and maintaining PTSD symptomatology and other emotional reactions. Individuals who pre-morbidly [before illness] hold such beliefs in a dogmatic and rigid fashion are at greater risk of developing PTSD and experiencing more difficulty coping with the resulting PTSD symptomatology.” (Warren & Zgourides, 1991, p. 151)”.
Also activated and often shattered by trauma are assumptions regarding personal invulnerability; a world that is meaningful, comprehensible, predictable and just; and the trustworthiness of others (Janoff-Bulman, 1985; Roth & Newman, 1991). Such pre-existing beliefs and assumptions, plus the various conclusions, decisions and attitudes specific to a particular traumatic incident (especially when held as imperatives) constitute the operant cognitive components of PTSD.
Primary and Secondary Trauma
What makes PTSD a particularly persistent and pernicious variety of disturbance is the occurrence, at the time of its acquisition trauma, of significant physical and/or emotional pain. Such pain, in association with the other perceptual stimuli, thoughts, and feelings one experiences at the time, constitutes the “primary” traumatic incident. The composite memory of the primary incident, therefore, contains not only the dominant audio/visual impressions of that moment, but also one’s mind-set (motives, purposes, intentions) and visceral (emotional and somatic) reactions. Thus, whenever one subsequently encounters a “restimulator” or “reactivator” – any present sensory, perceptual, cognitive, or emotive stimulus similar to one of those contained in the memory of an earlier trauma – one is likely to be consciously or unconsciously “reminded” of and, therefore, to re-activate its associated pain or upset. It is this subsequent painful and involuntary reminder, of the primary trauma, that constitutes the painful secondary experience we recognize as PTSD (Foa, 1989).
In the Pavlovian model, the occurrence of the reactivator (trigger stimulus) equates to the ringing of the bell; the stress reaction itself equates to salivation. The mechanism is almost indefinitely extendible by association. Once the dog has been conditioned to salivate to the ringing of the bell, for example, the bell may be paired with a new perceptual stimulus, say, the flashing of a light, so that the dog will then salivate to the light as well as to the bell. If one next flashes the light and pulls the dog’s tail, the dog will learn to salivate when his tail is pulled (Hilgard, 1962). By sequencing stimuli so as to create a “conditioned response chain” in this manner, we expand the domain of stimuli that will elicit the salivation response.
This process may be illustrated by the following common example: A veteran originally injured in an artillery attack (the primary trauma) will often tend to be reactivated, even years later, by such things as smoke and loud noises. So it’s no surprise when he panics, post-war, in response to fireworks. However, should he happen to be triggered into a full-blown panic reaction by a fireworks display while eating fried chicken one day at a picnic in the park, he is likely thereafter, as strange as it seems, to get panicky around fried chicken (whether he flashes back to the park at the time or not). In such a circumstance, fried chicken gets added to the domain of toxic secondary restimulators of his war experience, and the “picnic in the park” incident acquires secondary trauma status and is itself subject to later restimulation. If, for instance, fried chicken subsequently gets (or previously had gotten) associated with his mother-in-law (who prepares it for his every visit), his contact with her also becomes subject to PTSD toxicity by association. The dynamic effect of such repeated reactions over a period of time is a gradual increase in the client’s toxic secondary reactions. This, in turn, produces a corresponding reduction of his day-to-day rationality and an inability both to comprehend and to break out of his increasingly volatile reactive pattern (see Hayman et al, 1987).
The more reactions one experiences, the more new toxic secondary stimuli develop. The more new toxic stimuli there are, the more reactions one has, which suggests that those experiencing PTSD would eventually come to spend most of their time with their attention riveted painfully on past trauma. In point of fact, that does happen. The longer and more complex the chains or sequences of secondary incidents become over time, however, the less likely one is to flash all the way back to the primary trauma. This is why so many PTSD clients who appear to succeed in getting their attention off their primary traumata nevertheless withdraw from many of the life activities they previously enjoyed. Because they flash back to “the big one” a lot less, their PTSD cases are presumed to have abated. In reality such clients are in worse shape overall because a lot of little things in their traumatic incident networks (all the secondary triggers or “cues” they picked up in the years following their primary traumata) bother them much more than they did in the past (Gerbode, 1989).
PTSD And the Cognitive Therapies
Gerbode points out that some of the key cognitions contained in the memory of any traumatic incident that later cause trouble when they are reactivated are those specific conclusions, decisions, and intentions the individual generated during the incident itself in order to cope emotionally with the painful urgency of the moment. In such a circumstance, not only would certain pre-existing beliefs govern one’s reaction to a traumatic event, but also the traumatic event itself would give rise to the formulation of new, potential errant cognitions. Viewed in this light, PTSD is very much a cognitive-emotive disorder and not nearly as Pavlovian as it at first appears to be. Accordingly, an effective cognitive-emotive approach is called for in its remediation, one in which the errant cognitions generated under the duress of the trauma are located and corrected.
Most cognitive therapists have traditionally favored challenging a client’s current disturbance-causing belief system over directly confronting the earlier experience(s) responsible for its acquisition (Ellis, 1962, 1989). A therapist’s decision to focus an intervention mainly on a client’s responses to day-to-day stressors is most understandable when the client does not report flashing back at the time of the upsets. Most non-PTSD clients, after all, have no special awareness of their early acquisition experiences and, therefore, have little or nothing to say about them. Their attention is fixed on a steady stream of disturbance-provoking current events for which both we and they realize they do need more rational coping skills. In the clear-cut PTSD case in which flashback is evident, the client not only puts the acquisition experience (the primary trauma) in focus right at the start but also often seems virtually obsessed by it. Flashback content, which is often concurrent with the client’s upset over something in present time, is so painfully “charged” that he or she is either barely able to shift attention from it or else must regularly struggle to resist attending to it (Solomon, 1991). In such a circumstance, the therapist who focuses intervention exclusively on the client’s dramatic over-reactions to current (secondary) events (on the reactivator, rather than on what is being reactivated) bypasses the opportunity to address directly and resolve the core of the client’s PTSD case. Such attention mainly to the present-time “cueing effect,” according to Goodman and Maultsby (1974, p. 62), “explains many failures or partial successes in psychotherapy, despite the best intentions of patient and therapist.”
Given the extreme volatility of the memory of a trauma, though, it’s really no wonder that many therapists and their PTSD clients (tacitly) agree not to confront such incidents head on. To understand why this is so often the case, consider the following:
- It is nearly impossible to get PTSD clients to perceive or appraise objectively a traumatic experience they are in the midst of re-experiencing;
- It is usually difficult, even when they are not in the middle of re-experiencing one, to sell PTSD clients on the idea of re-evaluating a traumatic event that has given them nightmares for the last fifteen or twenty years;
- Cognitive re-structuring, thought stopping, and stimulus blunting techniques give PTSD clients little or no control over their tendency to flash back spontaneously and go into reactivation; and
- Helping PTSD clients minimize the disruptive impact of their intrusive thoughts and teaching them not to down themselves over the persistence of their symptoms is better than nothing.
It becomes understandable, then, that many therapists choose to assist clients in their ongoing struggles to distance themselves from the memories of their traumata in an attempt simply to limit the frequency and intensity of their post-traumatic episodes.
Therapists may actually bring superb therapeutic skills to bear on clients’ over-reactions to a variety of contemporary stimulus-events (e.g., rage over a spill, anxiety at a meeting), but unless they help PTSD clients to resolve the prior trauma (e.g., auto accident, childhood abuse, war experience) that actively supports their current disturbance and to revise the errant cognition associated with that primary experience, they have elected not to address the PTSD at all. The result of such a purely secondary intervention is that clients’ unresolved primary traumas continue intermittently to intrude into consciousness, and clients are left to struggle alone to secure a sense of rationality against the influence of these traumas.
Because a traumatic incident is, by definition, exceedingly unpleasant, there is an understandable tendency, at the moment one is occurring, to resist and protest it as best one can. It is at just such moments of extreme physical and/or emotional pain, according to Gerbode (1989), that one’s thinking (evaluative cognition) is least likely to be well-reasoned and objective and most likely to be irrational and distorted. There is, moreover, a subsequent tendency to suppress and/or repress the memory of such an incident so as not to have to re-experience the painful emotional charge its reactivation brings up. Unfortunately, suppression/repression of the memory of a traumatic incident effectively locks its distorted ideation and painful emotion away together (along with the incident’s sensory and perceptual data) in long-term storage. Thus, the stage for PTSD is set. Fortunately however, when accessed with the specific cognitive imagery procedure of TIR, a primary traumatic incident can be stripped of its emotional charge permitting its embedded cognitive components to be revealed and restructured. With its emotional impact depleted and its irrational ideation revised, the memory of a traumatic incident becomes innocuous and thereafter remains permanently incapable of restimulation and intrusion into present time (Gerbode 1989).
As Manton and Talbot (1990) observe, “traumatic events…can bring into consciousness unresolved [prior] situations (with similar themes) such as incest, child abuse, or the death of an important person in the victim’s life” (p.508). When clients have more than one trauma in their history, the only completely effective procedure is one that traces each symptom of the composite post-traumatic reaction back through sequence(s) of related earlier incidents to each of the contributing primaries. Interestingly, a very similar observation was made by one of our earliest colleagues, (Freud, 1984) who wrote:
What left the symptom behind was not always a single experience. On the contrary, the result was usually brought about by the convergence of several traumas, and often by the repetition of a great number of similar ones. Thus it was necessary to reproduce the whole chain of pathogenic memories in chronologic order, or rather in reversed order, the latest ones first and the earliest ones last (p. 37).
The simple fact is that in order to deal effectively with past trauma, we must guide the client through to its resolution in imagery. The imagery process itself, however, is just the means by which we help PTSD clients get through their residual primary pain. It is by revising the errant cognition associated with that pain that they are freed from the grip of their PTSD.
Traumatic Incident Reduction
The most thorough and reliable approach to the resolution of both long-standing and recent disaster PTSD currently in use is Traumatic Incident Reduction (TIR), a guided cognitive imagery procedure developed by Gerbode (1989). A high-precision refinement of earlier cognitive desensitization procedures, TIR effectively resolves the outstanding trauma of the majority of the PTSD clients with whom it is used when carried out according to its strict guidelines.
TIR appears to be more efficient and more effective than other cognitive-imagery or desensitization procedures, as such procedures frequently focus mainly (and most often incompletely) on secondary episodes. By tracing each traumatic reaction to its original or primary trauma and by taking each primary trauma to its full resolution or procedural “end point” at one sitting (a crucial requirement), the TIR process leaves clients observably relieved, often smiling, and no longer committed to their previously errant cognitions. At that point, the traumatic incidents, their associated irrational ideation, and consequent PTSD have been fully handled, and clients are able to re-engage life comfortably in ways they might not have been able to do since their original traumatization.
Done one-on-one, the core TIR procedure may be completed in as little as twenty minutes or it may require two or three hours (average: 1.5 hrs) of “viewing” per incident. No procedure that is confined to the fifty-minute hour can be considered flexible enough to handle the average primary traumatic incident. The therapist needs to be willing to take the time necessary to guide the client back through the relevant trauma, carefully following TIR procedural guidelines, to permit the client to work through the painful memories of the experience in order to restructure its cognitive content as needed for full resolution.
Ideally, PTSD clients correctly identify their active primary incidents during intake. Clients who have regular flashbacks generally do this with ease. Such clients may be briefed on TIR the same day and, if not on drugs, scheduled for viewing the next day. Their PTSD problems can often be alleviated within the week. It is not unusual for a single Basic TIR session to resolve an “un-occluded” (obvious) primary traumatic incident in as little as two or three hours. Case resolution then would depend mainly on how many primary and secondary traumata needed to be addressed to restore full functioning.
More commonly, however, PTSD clients do not correctly identify all their active primary incidents at intake. A war veteran, for instance, may at first report with conviction that it all dates back to Vietnam; he’s only had the problem since then, and that is the content of his flashbacks. Once he gets into it, however, he is sometimes surprised to discover that his wartime experience was actually secondary to some previously occluded or less easily remembered earlier trauma.
In chronic cases, including some phobias and panic disorders in which flashbacks are absent, clients often have no clue at intake as to where or when their reaction patterns were actually acquired. Although technically not classified as PTSD, many such clients have had a significant number of stressful experiences over the years. Yet they cannot, at first, identify any one incident as having been much more significant than any other. They are often thoroughly frustrated and discouraged, as well as genuinely baffled, about the persistence of their symptoms. Those among them who lead otherwise comfortable lives and seem not to think much less rationally, day-to-day, than the majority of the population frequently come to the usually erroneous conclusion that their problems must be genetic in origin (“run in the family”). Needless to say, such cases are not resolved within the week. They are not generally a problem for TIR, however, as they may be handled to resolution very adequately by the Thematic TIR approach, a variation of the Basic procedure. Thematic TIR does not require clients to be aware of or to identify correctly the relevant historic components of their cases right at the start of their intervention. Instead, the Thematic technique simply traces each manifest (in the present) emotional and somatic symptom (“theme” or feeling) back through its sequence(es) of secondary incidents, one at a time, until the originally occluded primaries come into awareness and can be dealt with routinely.
Toward clients’ understanding of the TIR routine, which assuredly will be new to them, it is often useful to draw upon the illustrative value of the Pavlovian example mentioned earlier and with which they may already be familiar. One may point out, in this connection, that when the dog’s salivation response to the bell (primary stimulus) is extinguished, the light (secondary stimulus) loses its reactivative potential automatically (Hilgard, 1962). Likewise, once a primary incident is completely resolved, none of the stimuli that had later become associated with it as secondary reactivators is capable of triggering any further reaction (Gerbode, 1989). This means that when the veteran fully resolves his “artillery attack” (and any other related primary incidents), he will no longer be vulnerable to reactivation triggered by the various secondarily toxic stimuli associated with that experience. At that point, fried chicken and mother-in-law are back to representing nothing more than fried chicken and mother-in-law.
This may seem like a rather classical Pavlovian explanation, but one of TIR’s main concerns is the ultimate correction of the PTSD client’s trauma-related thought processes. Once clients realize that it was the cumulative effect of their traumatic incident networks on their cognitive-emotive response sets over a period of time that is responsible for the persistence of their PTSD symptoms, and once they understand that there is a way to shut down the networks’ active components permanently, they’ll be happy to use the TIR approach, even if they are already accustomed to another technique. Then, even thoroughly frustrated and discouraged chronic and absent-flashback PTSD clients will begin to feel hopeful.
The lexicon ofTIR reflects its purpose and procedure. The client is called a “viewer” because his/her primary function is to confront, via the viewing process, past trauma. The person conducting the session is called a “facilitator” because his/her purpose is simply to facilitate the viewer’s process of viewing (Gerbode, 1989). Just as “physician” and “patient” become “analyst” and “analysand” based on the requirements of their respective roles, the designations “facilitator” and “viewer” are reserved for those whose interaction is governed by the singular requirements of the TIR process.
TIR, like other cognitive-imagery processes, differs somewhat from most contemporary therapies. Although it holds errant cognition to be at the root cause of emotional disturbance, unlike the mainstream cognitive approaches, TIR carries the revision process back to the specific experience(s) that originally produced and enforced such cognition. In this regard, TIR is a bit more “personal” than most contemporary cognitive therapies. Instead of relying mainly upon the therapist’s insight into or inferences about a client’s probable belief structure, as is common in RET, TIR guides clients in the discovery and revision of their own original disturbance-causing cognitions.
What makes such a procedure both necessary and possible is the fact that, in PTSD, the disturbance-causing cognitions (except for the pre-existing ones) were originally generated in response to, and in order to cope with, a traumatically painful and/or upsetting experience. Moreover, the offending cognitions are still being kept in force by the long-term residual impact of the incident. In other words, if it hadn’t been for the specific circumstance of the trauma, as subjectively experienced by the client, e.g., “Oh my God, I’ve been shot! I’m gonna die!”, the client wouldn’t have formulated the response, e.g., “I should never let my guard down, even for a minute!” Moreover, if the incident hadn’t been so emotionally and/or physically painful, making it extremely difficult for the client to confront, its attendant cognition would be a great deal more accessible to routine reappraisal and restructuring.
So, while it remains very useful to be able to infer with reasonable certainty that an anxious client is generally feeling threatened and ineffectual while an angry client would like to assert control over something (pardon the reductionism), these are just some of the more obvious “common denominator” dynamics associated with their respective current disturbances. What we cannot infer but what TIR reveals to clients who have experienced trauma is exactly what happened (at a subjective/cognitive-emotive level) that so overwhelmed them that they would come away from their experience stuck in an involuntary, out-of-date, and irrational mind-set constructed, among other things, of numerous fairly obvious stress-producing mis-evaluations and distortions.
In a certain respect, TIR adds a new dimension to our understanding of the relationship between cognition and emotion. While theorists have long held that irrational thinking tends to promote upset feelings, TIR suggests that one’s (traumatically) upset feelings also tend to promote irrational thinking. Dodging the “Which came first?” (chicken or egg) question, it is probably safe to say that, on the face of it, the causal equation appears to be reversible. That is, not only does cognition significantly influence emotion, but emotion appears to significantly influence cognition.
Even more critically significant, at least in cases of PTSD, the remedial equation seems to be reversible as well. Whereas cognitive therapists observe that the restructuring of one’s irrational and distorted thinking produces a corresponding reduction of emotional disturbance, TIR confirms Ellis’ (1990) observation that a reduction of primary traumatic emotional disturbance produces a corresponding restructuring of one’s irrational and distorted thinking! In short, the client whose trauma has been fully reduced and resolved and who has become able to talk (and think) freely and painlessly about it (a TIR goal) almost immediately and self-directedly begins to display a substantively rational (moderate, tolerant, objective) viewpoint regarding that previously painful experience. As always, the client who succeeds in embracing a more rational viewpoint about an experience, regardless of how unfortunate or traumatic that experience once seemed, is no longer disturbed over it or unwittingly under its control. As a consequence, secondary restimulation and flashbacks cease, life’s energy and interest revive, and self-esteem rebounds.
What is particularly remarkable about the cognitive restructuring that takes place in TIR is that it takes place so obviously and spontaneously during the course of a given session. Equally remarkable is the fact that it takes place – and truly must take place – without didactic or corrective facilitator input. The facilitator’s role in TIR is mainly to so conduct the session and guide the viewer in “repeated review” of the selected trauma (in strict accord with the established protocol) that the viewer will be able rationally to restructure his own “misconceptions” about it (Raimy, 1975). Bear in mind that at this level of intervention the viewer is truly the only one who can decipher (by patient and careful re-examination of the cognitive images stored in memory) what actually happened or appeared to happen in the incident, what its significance was, what he or she was thinking at the time, why it was so extraordinarily painful, how he or she coped with that pain, and what trauma-related conclusions and/or decisions were made at the time. So, as the viewer reviews this highly sensitive and very painful material repeatedly in imagery in order to discharge the emotional impact holding the cognitive distortions in place, the facilitator says not a word.
Although in TIR’s handling of PTSD the operant trauma-related distortions virtually self-correct once the inordinate emotional distress of the traumatic experience is relieved, viewers frequently want to follow a completed TIR session with some discussion or review of some of the ways in which certain of their newly-surrendered trauma-related beliefs and attitudes had affected them since the occurrence of their original trauma! Most practitioners find this discussion one of those truly rewarding moments in clinical practice. It is not only confirmation of a successfully completed specific intervention. It is re-confirmation of what contemporary theorists have asserted all along about the relationship between cognition and emotion, with the additional suggestion that that relationship may be even more interesting than we had originally supposed.
A fully resolved traumatic experience is neither completely nor mostly forgotten. It is, by definition, simply benign and incapable of intrusive restimulation.
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