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working with trauma
There are two kinds of unpleasant memories:
One - a bad thing happens, it feels awful at the time but gets slowly better. A year later you are coming to terms wiith it, five years later it's history. It may not be pleasant history, but it's history.
Two - a bad thing happens and it stays stuck at the back of your mind. Every time something reminds you of it you feel bad, perhaps as bad as you did when the event was really happening. Perhaps you think it really is happening again. Perhaps you dream about it, in terrible dark dreams that wake you in a sweat, maybe several times a night. Ten years later it may be even worse.
This second kind is trauma, post-traumatic stress disorder, PTSD. Even if you don't qualify for a diagnosis of PTSD, any memory which creates effects that are unpleasant for you fits into this second category.
It seems that traumatic memories are strongly recorded in the amygdala, a part of the brain that looks after the fight-or-flight reflex. When the amygdala sees something that matches the original trauma, it sets off the alarm bells just as it did when the event was really happening. Sometimes these pattern-matches are so strong the whole brain is commandeered into re-enacting the original events. One problem in treating these memories is that talking over the original events may be painful and set off a post-traumatic reaction. This is unpleasant and unnecessary, and prevents useful work being done to re-process the memory. It can even makes matters worse, reinforcing the memory and strengthening the traumatic response.
One solution, originally proposed by Milton Erickson in the 1960's, is to allow the whole brain and body to re-experience the traumatic events in a partially dissociated way while staying very calm, so that the brain can learn that this memory is not really life-threatening. The idea was picked up by the NLP school in the '70s and developed further by David Muss in the early '90s; Muss's book 'The Trauma Trap' contains a self-help protocol for sufferers to use his version of the technique.
The idea has been developed further over the years, and is a very humane way of treating trauma. It does not involve talking over the traumatic events - in fact the patient does not have to describe them at all, just give them a name and watch them on an imagined television screen while in a highly relaxed state. This makes it very useful for victims of sexual abuse, bullying or other events which would be hard to talk about. The very relaxed state also educes the chnace of a physical reaction in people who might otherwise be prone to acting-out their trauma.
In single-incident cases the nightmares, panic attacks and flashbacks of PTSD generally resolve very quickly. However, there may still be other things to be done to relieve depression that often accompanies PTSD, and in some cases the main traumatic pattern is relieved but other traumatic memories then surface which are not related to the pattern that has been treated. These memories are treated in the same way as the original trauma. In multiple or complex trauma the process is the same in essence, though it may take longer to reach a point where the post-traumatic symptoms are no longer intruding in someone's life. As a guide, we would want to see anyone, even with a simple problem, at least twice. Reaching a satisfactory conclusion in a complex case will depend on many factors, but can happen in a handful of sessions.
So what actually happens in a session?
Briefly, the patient is relaxed by whatever method works for him or her; usually a combination of extended out-breath, progressive muscle relaxation and visualisation techniques, all of which come from Yoga. The aim is to achieve a calm, slightly disconnected state in which the patient can imagine resting in a pleasant place. This step can usually be omitted in children, who seem to have much easier access to their imagination. Then the patient is invited to imagine that she/he has a portable TV and video, a laptop, a games console or any other kind of screen, with a remote control, and a tape, film, DVD or whatever of the traumatic event(s). If there are two or three discrete traumatic events there would be one tape of each; if it were a repeating pattern of abuse over several years one would suggest picking three significant examples and having a tape of each; with an unremittingly awful life history (as often emerges in someone who is seriously depressed) a single tape of the whole life is usually best. The patient is invited to float out of himself, press the remote control and watch him/herself watching the tape, without looking at the screen. The therapist suggests that the patient will, somehow, ‘know’ when the tape has finished playing, and that this could happen quite quickly, and that the patient can indicate, perhaps with a nod, when that has happened. Even though the patient is not looking at the memory, there is usually some rapid eye movement activity visible during this phase. When the signal comes, the patient is invited to float back into his body, press the rewind button and watch the events going rapidly backwards on the screen. It is thought that the cognitive effort involved in reconstructing the history backwards keeps the thinking brain active and prevents it surrendering to the emotion connected to the memory; in any case, the body remains reasonably calm even though the mind is visualising the trauma. If a high degree of arousal has been experienced the patient is calmed down and taken back a step. When ready, he/she is invited to press the forward button and watch the events through, fast-forward, on the screen, then the process is repeated backwards, forwards, backwards, etc, always keeping the patient reasonably calm. After two or three passes the view, on the backwards passes only, can be switched to a first-person view, going backwards through the memories as the patient remembers them instead of watching them on the screen. It is useful to ground the start and finish of the film in a calm place, so the therapist may suggest, for example, that a reverse pass should end ‘back at a time when you feel ok, back before anything went wrong’; or that a forward pass could end ‘right here in the present, with you feeling calm and relaxed in that chair, knowing that all of those events are in the past now and that those particular events can never happen again’. When the patient reaches the point where she/he can view the events forwards with no visible signs of physiological arousal, that is no obvious muscle twitching or facial distress, the process is done. This would normally be achieved in six to twelve passes. It is unusual for any one event to need this doing more than once, though people with long and complex histories of overlapping traumatic memories may take several rounds of this process.
It is not at all unusual for someone to have nightmares every night for 25 years and for those nightmares to stop, and the sleep pattern normalise, after a single session. However, and particularly in long-term and complex cases, there may still be much work to do, constructing further reframes of the past and then encouraging the patient's focus of attention into the other direction, towards the future. The history-taking now comes to the fore as the therapist takes the patient through imaginative rehearsal of new patterns of thought and feeling, rehearsing kinds of behaviour that will yield benefits in emotional terms, tapping into old motivations that have been ignored during the traumatised time and re-connecting with the satisfaction of doing those activities again, and so on. All of this work, plus the core trauma work itself, are aimed at helping the patient build a life that meets his or her own emotional needs in a realistic, sustainable and balanced way, as a life in which this happens should be self-sustaining and independent.
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