Ebook: Protocol for Treatment of Post Traumatic Stress Disorder
Psychic trauma is as old as mankind itself, but it is still not fully understood how or why the exposure to single or multiple horrific events can overwhelm some people to the extent that they are haunted day and night by the terrible things they have witnessed. Most will recover spontaneously, but others become victims of the most common psychological disorder stemming from such an experience: post traumatic stress disorder (PTSD). It is estimated that 8% of the Western population suffer from this disorder, and that 40% of them will continue to suffer from symptoms even ten years after the trigger event. For many years it was believed that there was no remedy for those suffering from severe psychic trauma, but in the last decade a major breakthrough has seen the development of new and effective therapy methods. Regaining a sense of control is key to helping clients suffering from PTSD and its accompanying disorders. The authors of this book have spent many years working in the field. Here they distill those elements common to all the accepted methods of treatment, and they add the unique aspect of imagination and fantasy, described in a concept they call Fantastic Reality. Whilst not claiming to have a remedy or solution for every sufferer, this book will help to provide solutions for some of the aspects lacking in other models. This book will prove a valuable addition to the resources of all those who work in this field, where effective treatment, though much needed, is still scarce.
Psychic trauma and its detrimental repercussions on man’s body and soul are as old as the hills. An early example of freeze and paralysis caused by exposure to a traumatic event is the Biblical story of Lot’s wife. She turned into a pillar of salt as a result of looking back and witnessing the atrocities and the fire that accompanied the destruction of Sodom. As described in Genesis, 19. 26 “ … his wife looked back from behind him and she became a pillar of salt.” Though trauma has been known from time immemorial, our understanding is only the tip of the iceberg. We do not fully comprehend how single or multiple exposures to indescribable horrors turn people into frightened human beings, haunted day and night by the terrible sights they have witnessed: “And thy life shall hang in doubt before thee; and thou shalt fear day and night, and shalt have none assurance of thy life.” (Deuteronomy, 29, 66).
The vast majority of those exposed to traumatic events suffer at some point from varying degrees of symptoms. Most recover spontaneously, while for others suffering becomes unbearable and meets the criteria of the most common psychological disorder stemming from a traumatic experience: posttraumatic stress disorder (PTSD). In the DSM-IV-TR, PTSD is classified as an anxiety disorder. According to various studies, about eight percent of the populations of the Western world suffer from this disorder. Approximately forty percent of them continue to suffer from the symptoms even ten years after the traumatic event.
The question is how can we help these people?
For years it was believed that there was no remedy for those suffering from severe psychic trauma. In the last decade a major breakthrough has taken place with the development of new, effective therapy methods, which relieve some of the suffering and cure many people from most of the symptoms.
This book and protocol are a joint effort of both authors to draw the components that have aided the most in the recovery process out of proven, effective therapy methods.
Our long years of work in the field of psychotrauma and the accompanying disorders have brought us face-to-face with the miseries and the special needs of those suffering from psychotrauma in Israel and around the world. We teach and learn, and learn from teaching the kinds of therapy and types of intervention that should be applied to posttraumatic disorders.
It is clear to us that man, his environment, and his life experience, influence the intensity of his reaction to an event, his resiliency and the mode of his recovery.
We do not claim that we have a remedy for every pain or a solution for all those suffering from posttraumatic disorder. We are also of the opinion that the evidence based treatments, such as PE (Prolonged Exposure) or EMDR (Eye Movement Desensitization and Reprocessing), should always be considered as treatments of choice. This book does not teach the above mentioned approaches. In the following proposed protocol, we have distilled from the most common therapies those elements that either repeats themselves in all of the methods (such as psycho-education). We have refined methods that in our practice we found to be very disturbing for the clients (such as the exposure, focusing inside, and the in vivo method) and we have added the unique aspects of imagination fantasy and Fantastic Reality. We have attempted to provide solutions for some of the aspects lacking in other models, to present our lessons, and to organize the existing information in this area in a unique fashion.
The principles underlying the basis of the proposed model are:
1. Trauma is a problem of processing a memory which is expressed in the imagination- the client imagines that horrific events from his past are recurring in various ways and are plaguing him, making him feel fearful and that he is in danger.
2. Examination of the active regions of the brain while it is recalling the traumatic event points to enhanced activity of the visual cortex and of the limbic system (mainly the amygdale and hippocampus), decreased activity in the front top regions of the cortex, and increased activity in the right frontal lobe. Hence, trauma is indeed, as Van der Kolk called it, “terror beyond words,” and, as such, the way to reach it is through the body with the aid of imagination.
3. Symptom focused cognitive therapy is undoubtedly effective in treatment of clients suffering from post trauma. Its effectiveness is claimed to lie in the usage of cognitive models of memory and mental processing. However, in practice, in order to reach the traumatic memory, CBT uses imagination, calling it “imaginal exposure.”.But in the theoretical explanation of its effectiveness in treating psychotrauma, there is no attempt to explore the role and function of the brain process referred to as imagination, and its mechanism. This can be seen with both PE in the section called “imaginal exposure” re-narration and EMDR, when the client imagines (brings forth in the eyes of his mind) the event.
4. Cognitive-behavioral models for treatment of post traumatic stress disorder show the importance of chronological re-narration and resuming daily tasks in reality. They also prove the importance of discussion and of the client’s making sense of the event in his life, in accordance with his understanding and knowledge at the time the traumatic event took place, or thereafter.
5. Prolonged exposure and re-narration have clear extenuating value, especially in the passage from emotional memory to verbal memory, or from implicit memory to explicit, declarative memory. Yet therapy that is exclusively focused on words is actually focusing on the secondary final product instead of reviving the primary experience with the aid of the tools with which it is coded, that is, with the help of body and imagination, which is “beyond words.”
6. Clients suffering from PTSD avoid playing because they have to remain on guard in order not to remember. This is a continuous task of standing on guard against the danger inherent in the intrusive memory. Allowing oneself to play may be frightening as the client may experience it as “deserting” the guarding position. Thus, it is necessary to reintroduce play and playing and teach the client to acquire the lost ability to play.
7. Since clients suffering from PTSD feel that they have no choice, that the traumatic event compelled them, its memory controls them. The essence of this protocol is to help them learn to make choices and to gradually experience more control, by using “as if” and “wishful” cards as part of the re-narration.
8. PTSD clients remember segments of their story. Using therapeutic cards as a stimulus for the story of the trauma enables the details to slowly reconstruct a complete, coherent story with colors, shapes, and sound, whilst feeling in control as the story unfolds “outside,” in front of the client, through the observation of the cards. Thus the client regains a sense of distancing and observation of the event from a manageable perspective rather than the frightening, sometimes impossible, task of looking inside and telling it.
9. PTSD clients experience the trauma as one frozen-in-time story with no apparent possibility for change. The current approach gives them the option for re-narration of their tale in various ways, especially in ways that facilitate empowerment through the employment of ”fantastic reality”.
The SEE FAR CBT protocol is made up of a number of components:
This is a combined model, emphasizing integration of up to date, effective trauma treatment methods: Somatic Experience –SE, a method focusing on the “bodymemory” (van der Kolk, Rothchild, Levine); fantastic reality - FR, (Lahad), a method based on the work of Winnicot and of S. Jennings, and the Cognitive-Behavioral Psychotherapy theories, and mainly the principles of PE-Prolonged Exposure (Foa), in vivo exposure and imaginal exposure. The model has been tested in treatment of clients suffering from PTSD as a result of rape, violence in the family, robbery, terrorism, war, and military operations.
SeE, The body and bodymemory: Based on the current understanding that traumatic memories are “stored” in the body and may reactivate bodily reactions without detected threat, the protocol uses methods adapted from Somatic Experiencing (SE) Focusing, and NLP (Neuro Linguistic Programming). The focus is both on the positive resources imbedded in the body and the body memory of the pain, as well as on the ability of the subjective physical sensation to be authentically reported through the body or the concept of the “felt sense”. PTSD clients suffer from various hyper-arousal symptoms the inability to relax and reduce alertness, and hyper-vigilance is translated by the clients as the “fear of fear” in which they invest great energy in order not to encounter fear. This drains their vitality and so the focus on the body should help them to learn to control and regulate the arousal - fearful symptoms.
FR, Using therapeutic cards: Quite often the traumatic memory is triggered by flash backs. These are fractures of visual sensory non-verbal memories that activate a flood of excessive fear and horror. In order to get in touch with the visual memory and the non-verbal aspect of the memory, on the one hand, and on the other, to activate the healing potential of fantastic reality, we use therapeutic cards. The cards make it possible for the client to be an observer in his own drama/ trauma. By taking the role of an “observer” the client experiences distancing so that the memory becomes manageable. Another aspect of the therapeutic cards and the fantastic reality is that it creates an “as if space” just like in a theater, a space where all the IFS are possible including fantastic, wishful, empowering experiences, that is, the ability to alter the unchangeable via the “if only ” or the “as if”.
CBT, re-narration and in vivo: The CBT methods, evident in their effectiveness, conclude that retelling the traumatic story is probably the most significant component of the symptom reducing effect of the treatment. The other aspect pertinent to the effectiveness is the “in vivo” exposure of the clients to real life situations that for various reasons are avoided by the client. These two components are part of this protocol, albeit with some adaptations. Another aspect adapted from CBT is the reflection, a making sense process that follows the learning experience. It is process whereby the client is encouraged to make sense of and reflect on the therapeutic method used, its outcomes and application to the here and now.
In order for the client to become an expert on his own suffering, its origins, and impacts, we propose to combine the dynamic and systematic understanding of the traumatic event in a person’s life and the influence of these factors on his personal suffering, together with the knowledge and actions of the therapist. This expertise will help in coping with physical, emotional, and intellectual elements which accompany those who suffer from the disorder, while re-narrating the traumatic event in the fantastic reality, together with homework which includes in vivo exposure to situations, places, and avoided behavior.
The model is based on the concept that it is possible to help clients suffering from PTSD and its accompanying disorders such as depression and intense anxiety - by exposure to the fantastic reality. Specifically, while playing and reconstructing the story with fantastic / supportive elements, the reinstatement of a sense of control occurs.