A book on psychotherapy (written for traumatized individuals, but illustrative to clinicians)
TRAUMATYS recognizes the complexity of PTSDTrauma involves all dimensions of a person. Consequently, focusing on a single therapeutic approach can be, not only constrictive, but insufficient for treating PTSD.
PTSD is the most severe and prevalent anxiety disorder, often attacking the whole structure of an individual. It is crucial for clinicians to understand the intrapsychic structure of patients with PTSD. Those with the most fragile structures will present a personality disorder; focusing on their trauma and disregarding the personality disorder is detrimental. And, one should not be naive, believing that all memories of abuse are accurate as if they had been recorded. Solid knowledge about memory and trauma is necessary for professionals to be able to reasonably distinguish between true and false memories of abuse.
Most techniques developed for treating PTSD focus on reexperiencing the traumatic event; such as hypnosis, implosive therapy, and EMDR. Such techniques have been shown to be helpful with selected samples of patients. When their efficacy was tested by independent researchers, it was also found that they could be detrimental; e.g. Pitman et al. (1991) reported severe psychological reactions in a third of patients. Caution is thus highly recommended.
Neurobiological, psychophysiological and brain imaging studies support the notion that PTSD is a pathological manifestation of the inability to modulate arousal within the brain. Research also showed that hypersensitivity can develop when trauma is chronic and/or repeated, and extreme levels of arousal can be toxic for neurons. Therefore, having some patients repeatedly relive traumatic events can be harmful to their brain.
Reexperiencing techniques should only be employed in the context of a well-developed therapeutic alliance, after taking a complete history, and with individuals capable of containing intense affects. New evidence points out that it is not necessarily the desensitizing effect of these techniques which is effective, but the emotional and cognitive processing regarding the traumatic event that is healing.
According to recent studies, PTSD is primarily associated with reactions other than fear, such as anger, confusion, guilt, and shame. Cognitive and dynamic approaches are thus crucial for treating PTSD in a comprehensive treatment plan.
The clinical picture becomes even more complex when traumatized individuals present with a personality disorder. James F. Masterson's developmental, self, and object relations theory suggests that individuals with schizoid, narcissistic or borderline personality disorders have erected rigid defensive structures early in life to protect themselves from experiencing emotional abandonment. Traumatic events appear to often break through their defensive structures, forcing them to experience both abandonment and annihilation anxieties. The shock is greater, as are the damages.
To treat traumatized individuals with personality disorders successfully, clinicians need to integrate PTSD models with approaches specifically designed for treating personality disorders. Beyond avoiding moral neutrality, clinicians should avoid presenting a blank screen facade which only fosters abandonment feelings and unnecessary projections. Patients' accurate perceptions of reality should be recognized and validated. Most importantly, personality-focused work should precede trauma-focused work. Such patients present a unique challenge. Flexibility is required.
The debate about false memories has spurred a healthy interest in memory functioning among many clinicians. Although bitter and extreme positions were initially adopted between false memory advocates and trauma accuracy advocates, balanced viewpoints are now emerging.
Considering any memory of abuse as an historical truth is unprofessional, as to dispute any recovered memory of abuse as pure fantasy. Memories vary as the degree to which they are permanently encoded and/or continuously restructured. Clinicians need to be aware of the different contexts in which memories are likely to be retrievable and historically true for the most part, or false memories are likely to be implanted through suggestions and suggestibility. Knowing the factors at play is crucial to any clinician in order to act in accordance with state-of-the-art scientific knowledge, as well as to be ethical toward patients. Above all, clinicians need to differentiate the legal aspects of the question from the therapeutic ones, in order to reduce the risks of being sued and of inadvertently abusing patients.
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