La prueba de la muerte

My goal in this chapter is to integrate existing opinions and data on the most accepted methods of therapy for PTSD into an approach to therapy based on somatic concepts of trauma. I strongly feel that new models of somatically based treatment for trauma need to be explored and tested in the light of emerging data concerning the psychophysio-logical basis for PTSD, and the theories presented in this book. With this understanding in mind, I beg the forbearance of my psychology and psychiatry colleagues, and hope that the ideas presented may be applicable to some of their treatment paradigms.

With the addition to the DSM-III in 1980 of post-traumatic stress disorder as a diagnosis distinct from other anxiety-based disorders,¹ increasing attention has been given to specific treatment models for this common problem. Group therapy involving trauma victims has been a mainstay of treatment since combat-related trauma was again brought to the world’s attention after World War II.²The impetus to explore treatment models was again revived by the Vietnam War ex-perience, and by the designation of PTSD as a unique condition.

Based on these experiences, enhancement of interpersonal connec-tions through family and social support systems, including those in-volving fellow victims of trauma, has become a central thesis for therapeutic management of PTSD. This approach, together with other forms of cognitive therapy, falls under the category of resourcing the victim’s own self-regulatory mechanisms for dealing with the intru-sion of painful emotional and physical symptoms. Although limited in scope, these therapies provide a useful start to the process of trau-matic healing.

COUNSELING

AND VERBAL/COGNITIVE THERAPY

Memory mechanisms in trauma guarantee that the access to these memories and their meanings in a verbal context may be difficult or

impossible. As we have noted in Chapter 4, traumatic memories tend to be stored in an emotional or somatic context, and the victim simply may not be able to place them in a verbal context. Alexithymia, the inability to adequately express emotions or body sensations in words, undoubtedly relates to this problem. A review in Chapter 11 of per-sonal case studies in trauma from my own practice documents a class of patients presenting with bizarre disorders of stuttering, speech blockage, and impairment of immediate verbal processing, clearly on a dissociative basis. Although from a psychiatric standpoint, dissoci-ation is felt to be a fragmentdissoci-ation of conscious awareness, I have at-tempted to present dissociation as a measurable physiological event, both at the level of the central nervous system and at the dissociated end organ (see Chapter 8).

In this light, a regional physiological basis for these verbal impair-ments in trauma victims, as well as for alexithymia, may well exist based on recent positron emission tomography (PET) findings. Impair-ment of verbal expression in trauma may have its roots in reflex inhibi-tion of metabolic funcinhibi-tion in porinhibi-tions of the left cerebral hemisphere, especially Broca’s area.³References to “speechless terror,” and other metaphorical analogies reflect the well-recognized inhibition of verbal functions in trauma. Cognitive therapy involving verbal interaction, insight, and interpretation under these conditions of impairment of ver-bal expression would be predictably difficult. This dilemma is in keep-ing with the conclusions of many trauma specialists that “talkkeep-ing about the trauma” is rarely sufficient to dissipate the self-perpetuating trauma cycle.⁴

Nevertheless, verbal cognitively based therapy appears to play an important part in initiating the therapeutic process in trauma. The role of the therapist in providing guidance, interpretation, and education through verbal interaction is critical, especially early in the traumatic response. Stabilization through anxiety control skills and identification of the meaning of somatic sensations that represent uncomfortable feeling states, enable the patient to cope with self-perpetuating states of arousal. Encouraging trauma victims to verbalize these somatic sensa-tions may allow them to access and integrate intense feeling states into conscious awareness. Hopefully, doing so may help to diminish the dissociation that contributes to substitution of somatic discomfort for intense emotions. Since access to the underlying hyperarousal and

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anxiety associated with trauma is painful, the presence of the therapist is important in providing a supportive environment for the process. Pa-tients with PTSD suffer from sensitivity to any arousal stimulus. Elici-tation of their fight/flight response has become generalized to a wide variety of nonspecific environmental trauma-related cues, in addition to nonspecific sources of arousal. As a result, a trusting environment is extremely important for trauma patients, based to a considerable extent on their predictably increased sensitivity to the nuances of the thera-pist’s behavior and demeanor. Even the facial characteristics or behav-ioral quirks of the therapist may remind patients of threatening past experiences or perpetrators of their trauma. As a result, great care must be taken to provide an environment of safety and trust to allow the pa-tient to access painful and arousing memories in a form that is bearable and in a setting that is perceived as safe. Bringing these memories and feelings into consciousness, and providing a narrative verbal format for the experience, appears to be necessary to begin the process of inte-grating the memories into conscious experience, and presumably to in-hibit the patient’s cue-related arousal recycling. By learning to apply words to these terrible feelings and memories, the patient may begin to attain skills in containing and to some extent controlling them, and in relegating them to past experience rather than to an ongoing traumatic experience.⁵

Patient education is also an important therapeutic goal. Most pa-tients can understand complexities of psychophysiological concepts that might surprise many therapists. Providing a logical cognitive for-mat for the patient’s sofor-matic and emotional symptoms serves several important functions. Most patients with symptoms characteristic of somatization and affect dysregulation have been labeled and devalued by their medical providers because they are felt to show symptom magnification, psychosomatic symptoms, or behavior indicating sec-ondary gain. Dismissal or approbation by the very people upon whom trauma victims are dependent for support and care enhances and per-petuates the physiological trauma cycle. The pain and suffering that they experience with perceived rejection is greatly enhanced by their intrinsic vulnerability, and as real to them as acute surgical pain.

Most of my traumatized MVA patients experience a period of marked deterioration of both somatic and emotional symptoms when their insurance company begins to question provider reimbursement

or begins the first round of independent medical examinations, and when their legal case becomes active. Their response is usually one of helpless rage, self-doubt, and a sense of devaluation. This process continues to reinforce their state of helplessness, the very basis for their trauma. Under this environment of renewed threat, these pa-tients often experience a recurrence of the entire constellation of physical, cognitive, and emotional symptoms of whiplash.

Detailed education and information about the very valid physiologi-cal basis for their physiphysiologi-cal and emotional symptoms is empowering and restores the sense of control needed for their recovery. Providing words for the meaning of these frightening sensations begins the pro-cess of integrating them into a narrative format and a logical cognitive construct. Knowledge and enlightenment in this environment are criti-cal to reestablishing a sense of validity, and restoring a sense of self in the trauma victim.

Enlightenment through education, however, attacks only one facet of the trauma edifice. Knowledge allows the patient to deal with the unbidden and recurrent symptoms of trauma at a higher level, to facilitate interpretation and understanding, and thereby to help the patient achieve some degree of control over painful sensa-tions or memories when they arise. Knowledge does not alter the basic kindled cycle of arousal, recall, muscle bracing, and auto-nomic cycling that perpetuates trauma. Ultimately, one must gain access to the insidious conditioned trauma response from a physio-logical and unconscious reflexive approach in order to extinguish, desensitize, inhibit, or quench it. Since such a therapeutic process is likely to present substantial risks of flooding and retraumatization, cognitive resourcing and empowerment is clearly indicated. Early limited cognitive therapy may, therefore, play an important role in preparing the patient for other, more confrontational, techniques such as exposure or desensitization.

EXPOSURE