David J. Morris, a former Marine infantry officer and a reporter in some of the most violent regions of the Iraq war, blacked out while watching a movie and ran out of the theater, only to regain awareness of himself in the lobby as he anxiously scanned other patrons for improvised explosive devices (IEDs). Morris’ girlfriend later told him an explosion in the movie precipitated his flashback.
While in Iraq, Morris had nearly been killed by an IED, and he saw two National Guardsmen killed by them. He was nearly shot down while riding in a helicopter, and with fellow Marines, withstood shelling for seven days. He had many reasons to be triggered by an explosion, even an imaginary one in a movie.
When Morris sought treatment for posttraumatic stress disorder with the Veterans Administration (VA), they recommended prolonged exposure therapy, a form of trauma treatment that attempts to help people like Morris become desensitized to their trauma triggers. In his New York Times article, Morris gave the following description of prolonged exposure therapy:
“The promise of prolonged exposure is that your response to your trauma can be unlearned by telling the story of it over and over again. The patient is asked to close his eyes, put himself back in the moment of maximum terror and recount the details of what happened. According to the theory, the more often the story is told in the safety of the therapy room, the more the memory of the event will be detoxified, stripped of its traumatic charge and transformed into something resembling a normal memory.”
Morris expected, “given enough time and enough story ‘reps,’ when I opened my eyes again, I wouldn’t feel forever perched on the precipice of a smoke-wreathed eternity. I wouldn’t feel scared anymore.”
Just the opposite happened. Instead of “unlearning” his traumatic stress response, becoming desensitized to reminders of war, he was flooded and overwhelmed by the therapy:
“But after a month of therapy, I began to have problems. When I think back on that time, the word that comes to mind is ‘nausea.’ I felt sick inside, the blood hot in my veins. Never a good sleeper, I became an insomniac of the highest order. I couldn’t read, let alone write. I laced up my sneakers and went for a run around my neighborhood, hoping for release in some roadwork; after a couple of blocks, my calves seized up. It was like my body was at war with itself. One day, my cellphone failed to dial out and I stabbed it repeatedly with a stainless steel knife until I bent the blade 90 degrees.”
Morris was told prolonged exposure therapy worked for about 85 percent of the VA patients who used it. However, in his book The Body Keeps The Score (2014), psychiatrist Bessel van der Kolk discussed a study conducted in the early 1990s that contradicts the VA’s statistics. In this study, led by Roger Pitman, Vietnam veterans were asked to repeatedly talk about their wartime experiences. However, Pitman had to stop the study prematurely,
“because many veterans became panicked by their flashbacks, and the dread often persisted after the sessions. Some never returned, while many of those who stayed with the study became more depressed, violent, and fearful; some coped with their increased symptoms by increasing their alcohol consumption, which led to further violence and humiliation, as some of their families called the police to take them to the hospital.”
Van der Kolk also shared:
“A 2010 report on 49,425 veterans with newly diagnosed PTSD from the Iraq and Afghanistan wars who sought care from the VA showed that fewer than one out of ten actually completed the recommended treatment. As in Pitman’s Vietnam veterans, exposure treatment, as currently practiced, rarely works for them. We can only ‘process’ horrendous experiences if they do not overwhelm us. And that means that other approaches are necessary.”
Personally, I am not a fan of exposure therapy. I think it’s too risky, as these studies suggest. I feel certain it would have caused flooding for me too had it been used to treat my flashbacks of childhood sexual abuse. (Fortunately, I was able to use EMDR instead.) After one session I would have never returned, and likely would have lost trust in psychotherapy and the support I needed to heal.
Humans are impressively resilient and adaptive. We can manipulate ourselves and our bodies in extraordinary ways, even detrimentally, and continue to survive. (Think of foot binding of women in China.) At birth, our brains are profoundly underdeveloped, increasing in size by 300 percent over the next two decades of life (Linden, 2007). Maturation involves gaining the biological, psychological, and behavioral capacities that allow us to continually adapt to physical and social environments that are also malleable and ever-changing.
Because we are ‘plastic’ by nature, I think it is safe to assume there are many ways to alter ourselves in our attempts to overcome the fallout of traumatic events. Exposure therapy is one option among many that are available for dealing with the aftereffects of trauma, albeit one that works for some people. Yet, because we are malleable and adaptable, there are also numerous reasons to use a treatment besides that it ‘works’ for some people — we can have reasons for treating trauma other than stopping flashbacks.
For example, instead of making the primary criteria for success that a treatment ‘works,’ we could also think about how treatment alters people, and in turn impacts the social fabric of our communities. We might ask what kind of people we become when we are desensitized to traumatic reminders. We might wonder if, from an evolutionary standpoint, it is even safe to become hardened to memories of war, rape, and abuse. We might also wonder if there is an implicit assumption at work here — that overwhelming fear is the central problem to address, rather than the conditions that lead to war, rape, and abuse. We might question, If we become desensitized to our fear, do we also become desensitized to violence? We might ask, What is more powerful than profound emotions and visceral reactions to motivate us to seek meaningful change? How we treat trauma likely has farther reaching impact than ‘just’ reducing individual experiences of traumatic stress.
I strongly believe trauma treatments should protect our capacity for vulnerability and empathy, while also helping us regain the ability to modulate our defense reactions. (I put the crocodile photo above and a frog photo below as reminders of the need for both strength and sensitivity for sustainable living.) We are likely most resilient and wise when we can defend ourselves and loved ones when the need arises, and the rest of the time (preferably, most of the time) live peaceful, engaged, and meaningful lives. And we need trauma treatments that can help us regain this full expression of our humanity following traumatic events or conditions.
Two views of the nature of traumatic stress
There seems to be two main views of the nature of traumatic stress guiding the treatment of trauma. One view, which informs treatments such as prolonged exposure therapy, focuses on regulating emotions and sensations. People are seen as needing help with controlling overwhelming feelings and the reactions they cause, such as Morris running out of the movie theatre when engulfed by fear. This is a reasonable view, and partly correct. Most people who deal with ongoing traumatic stress are often overwhelmed by their emotions and body sensations. However, when controlling emotional reactions becomes the sole focus of treatment, the whole person is not considered or addressed. Van der Kolk observed:
“Desensitization may make you less reactive, but if you cannot feel satisfaction in ordinary everyday things like taking a walk, cooking a meal, or playing with your kids, life will pass you by.”
The other main view of traumatic stress focuses on the loss of the integrative capacity of both mind and body that trauma causes. High arousal and shutdown at the time of a traumatic event results in fragmented memories and dissociative splitting. Furthermore, as Pat Ogden and colleagues pointed out in their book, Trauma and the Body, “under conditions of arousal that are either too high or too low, traumatic experiences cannot be integrated.” Consequently, trauma often leads to compartmentalization of experience and a fragmented sense of self.
When integration is the goal of treatment, the split off memories, emotions, and sensations are mindfully brought back into awareness, contributing to a sense of self as whole again. Increasing emotional regulation is also central to regaining integrative capacity, although not the primary goal. Rather, treatment begins with modulating arousal, which helps reduce the need to avoid internal and external reactions to traumatic reminders.
The shift in focus from desensitizing emotional reactions to increasing integrative capacity may seem new. Van der Kolk wrote:
“Over the past two decades the prevailing treatment taught to psychology students has been some form of systematic desensitization: helping patients become less reactive to certain emotions and sensations. But is this the correct goal? Maybe the issue is not desensitization but integration: putting the traumatic event into its proper place in the overall arc of one’s life.”
The pioneer of trauma treatment, French psychologist Pierre Janet, identified integration as the focal point of trauma treatment back in the nineteenth century. Janet advocated phase-oriented treatment, which is directed towards integrating traumatic memories in ways that contribute to an integrated sense of self.
Janet identified three stages of phase-oriented treatment, which are still used today:
- Phase 1: Symptom reduction and stabilization
- Phase 2: Treatment of Traumatic Memory
- Phase 3: Personality Integration
Similar to exposure therapy, Phase 1 of phase-oriented treatment addresses emotional regulation. Yet when integration is the treatment goal, emotional regulation is gained by increasing the felt-sense of safety rather than desensitizing a person to feelings and body sensations.
Exposure to memories of past traumas is still a significant part of treatment (Phase 2). However, the goal is to experience these memories within a window of tolerance that increases the likelihood of their integration with non-traumatic memories as well as non-traumatic self-states.
Phase-oriented treatment decreases the likelihood of dysregulation by helping clients to:
- Establish body safety and control of the body
- Establish a safe environment
- Establish emotional and autonomic (arousal) stability
Central to the integrative approach is the development of mindful awareness of the conditions that contribute to high arousal or shut down, along with identifying resources that can help reduce arousal when hyperaroused, or increase arousal when hypoaroused. Resources include skills, practices (e.g, yoga, mindfulness), objects, relationships, services, etc., that support a sense of stability and safety, regardless of what might be going on. With this approach, a person can direct his energy towards full living and greater self-awareness. This is a fundamentally different outcome than exposure therapy, which as van der Kolk observed, “desensitization to our own or to other people’s pain tends to lead to an overall blunting of emotional sensitivity.”
At times, there are benefits to desensitization. When trauma has been chronic, acute, and under treated (if treated at all), survivors will sometimes try to deal with feelings of overwhelm by avoiding the situations that might trigger them, which depending on the person and the conditions of her or his life, can lead to a very circumscribed existence. Thus, sometimes in the beginning stages of treatment people need to desensitize themselves to overwhelming emotions and sensations as a first step towards a more active life. This level of desensitization is sometimes accomplished with medications — an approach myself and many others generally don’t support. However, I know from experience that people who lack resources and support for an extended period often do well in the beginning stages of treatment with some medications in combination with Phase 1 work. Of course, a better approach than medications is to adapt services to fit the needs of the most vulnerable people, such as providing support in their homes, or through technologies such as Skype that allow for contact without forcing clients to endure conditions that might trigger high arousal or shut down.
Desensitization can also be beneficial when a person is aware her intense reactions are out of proportion to the situation, and she has already identified ways to resource herself when overwhelmed. For instance, in Dialectical Behavior Therapy one exercise, called “Opposite to Emotion Action,” encourages a person to take an action when she can tell her anticipated emotional reaction to a situation is unjustified, otherwise causing her to avoid that circumstance and unnecessarily limit her life. For example, if a person anticipates feeling frightened at the dentist, but knows she will be safe, she is encouraged to override her emotional response and keep the appointment. The goal is not to suppress the emotion, but rather to mindfully be open to the possibility of having a new experience. Nevertheless, the process can potentially activate overwhelming feelings and memories that a person must learn how to tolerate.
Sometimes we have to be less sensitive that we would like, or endure conditions we would rather avoid, to live full, meaningful lives. But the operative word here is sometimes. Most of the time, we should aspire to live a life that is open to a variety of experiences and relationships, and have confidence in our ability to tolerate, adapt, learn, and grow, which is the opposite of fear-based, defensive living. And in the best of worlds, we all feel responsible for developing our capacities for both resilience and compassion. Society should also be held responsible for creating conditions that promote thriving as much as simply surviving. Similarly, we deserve trauma treatments that help us not only tolerate suffering, but also allow us to regain the capacity to live the full measure of our humanity.
Linden, David J. 2007. The accidental mind: How brain evolution has given us love, memory, dreams, and God. Cambridge, MA: The Belknap Press of Harvard University Press.
Ogden, Pat, Kekuni Minton, and Clare Pain. 2006. Trauma and the body: A sensorimotor approach to psychotherapy. New York: W. W. Norton & Co.
Kolk, Bessel van der. 2014. The Body Keeps The Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking.
© 2015 Laura K Kerr, PhD. All rights reserved (applies to writing and photography).