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Abstract
In a trauma survivor, physiological
responses are exacerbated when the affect-laden
memories stored in associative networks are
triggered by environmental sensory inputs or
cues and activate the autonomic nervous system.
Recovery from trauma involves not only amelioration
of physiological and dissociative symptoms,
but also the cognitive rebuilding of a viable
assumptive world view which integrates the realms
of vulnerability, meaning and self-esteem. This
world view is contextualized in cultural idioms
and values.
From an Ericksonian perspective,
persons are usually attempting to problem-solve,
even in a dissociative date. A symptom such
as an intrusive recollection or recurrent dream
of a traumatic event is therefore construed
as a request for help in problem-solving. Hypnosis
is a structured dissociation which facilitates
cognitive flexibility; that is, the broadening
of choices of the client' s belief system, rather
than direct work on changing affect or behaviors.
The goal of Ericksonian hypnosis is to recontextualize
the traumatic memory, the affect of fear, and
the physiological hyperarousal cued by the traumatic
memory. This occurs within a broader context
of pride, mastery and courage, and within a
context inclusive of other memories and affects,
which are positive for the client.
Eye Movement Desensitization
and Reprocessing (EMDR), similarly has as its
goal the facilitation of a transfer of traumatic
data from the cortical right hemisphere to the
left hemisphere. EMDR also utilizes the attainment
of a state of heightened awareness, or collaborative
structured dissociation, in order to facilitate
the orientation of the traumatized client's
conscious mind toward "revisiting"
traumatic memories.
Both interventions can facilitate
the self-narrative reconstruction process of
trauma survivors by simultaneously modulating
the person's hyperarousal while attending to
the culturally significant metaphors which form
the building blocks of a person' s world of
meanings.
Posttraumatic Stress
Disorder from a Constructivist Perspective
The experience of victimization
by severely traumatizing events lasts far longer
than the events because of the intensity of
the psychological sequelae which follows. Emotional
reactions which overlap across a diversity of
victimizations (combat, rape, natural disasters,
severe accidents, violent crime, genocide, etc.)
include shock, confusion, helplessness, anxiety,
fear, and depression. Characteristic symptoms
which may follow "a psychologically traumatic
event that is generally outside the range of
usual human experience" and "would
evoke significant symptoms of distress in most
people" fall into four domains: 1) re-experiencing
the traumatic event, through repetitive, intrusive
recollections or recurrent dreams; 2) numbing
or reduced responsiveness to the outside world
(detachment and/or constricted affect); 3) hyperarousal,
including sleep disturbance, exaggerated startle
response and hypervigilance; and 4) avoidance
of activities or inputs which cue recollections
of the traumatic events.
From a Narrative Constructivist
perspective, victimization often results in
the shattering of basic assumptions persons
hold about themselves and their world. Three
particular assumptions appear to be most seriously
affected: 1) the belief in personal invulnerability;
2) the perception of the world as meaningful
and comprehensible; and 3) the view of selfhood
in positive terms (Janoff-Bulman, 1985). Recovery
from trauma involves not only amelioration of
psychological and dissociative symptoms, but
also the cognitive rebuilding of a viable assumptive
world view which integrates the realms of vulnerability,
meaning, and self-esteem. Both the pre-trauma
assumptions and those following traumatic events
are moderated by cultural beliefs, customs and
the social organization of the survivor's root
culture.
An Ericksonian Model
of PTSD
Persons suffering from the
physiological symptoms and the cognitive and
"spiritual" issues related to their
traumatization focus on negative memories which
force a no-choice association of a never-integrated
event memory with an environmental cue. The
initial traumatic event leaves them no opportunity
to connect these event memories with neural
pathways of positive events in the domains of
mastery, competence or confidence. A PTSD memory
intrudes from the unconscious into the waking
state. The victim does not so much wish to obliterate
the traumatic memory but wishes to contain it
in a state where it can be accessed at will
rather than intrusively. A feedback loop must
be formed to connect the traumatic event memories
to healthy neural pathways (Lankton & Zeig,
1988).
Neurophysiology of PTSD
Higher cognitive processes,
including those involved in psychotherapy, occur
in the prefrontal cortex of the brain. However,
affect and primitive memory (sensory inputs)
are processed in the limbic system. The thalamus
receives sensory inputs; the significance of
these inputs is determined by the amygdala;
and the hippocampus forms a cognitive map of
these inputs according to their levels of significance.
The cognitive processing of the prefrontal cortex
does not reach the body (autonomic nervous system)
or influence affect in a person with PTSD (Van
der Kolk, 1994). Physiological responses are
exacerbated when the affect-laden memories stored
in associative networks are triggered by environmental
sensory inputs or cues and activate the autonomic
nervous system. PET scans of subjects who have
suffered severe trauma demonstrate that the
traumatic memories are stored in the amygdala
in the right hemisphere. Furthermore, MRIs of
traumatized subjects reveal a shortening of
the hippocampus in persons with PTSD as compared
to normal subjects. This implies a level of
brain damage sufficient to impede new learning
(Van der Kolk, 1994). Such a deficit would prevent
the neutralization of traumatic memories by
cognitive processes such as analysis and integration
of events and assumptions or beliefs. Furthermore,
left hemisphere-driven cognitive processes would
not facilitate the diminution of the autonomic
response triggered by environmental cues in
a person with PTSD.
Rationale for Treatment
of PTSD with Ericksonian Hypnosis and/or EMDR
From an Ericksonian perspective,
persons are usually attempting to problem-solve,
even in a dissociative state (Lankton &
Zieg, 1988). A symptom such as an intrusive
recollection or recurrent dream of a traumatic
event is therefore construed as a request for
help in problem-solving. In order to treat the
symptoms successfully, one helps to change the
person' s style of problem-solving. A major
goal is to "package" this new coping
mechanism in a way that is acceptable to the
person's conscious mind, since he/she has thus
far coped with the physiological and cognitive
sequelae of trauma in a style maladaptive to
non-traumatic or non-crisis states or environments.
The psychotherapist who utilizes
Ericksonian hypnosis will let the traumatized
person know the following: 1) that all hypnosis
is self-hypnosis; 2) that the client chooses
only suggestions which are relevant to him/her;
3) that hypnosis is a heightened state of awareness
for internal events only; 4) that hypnosis does
not "unblock" or "get to the
truth" of anything that is not consciously
available; 5) and that hypnosis is a structured
dissociation which facilitates cognitive
flexibility; that is, the broadening of choices
of the client' s belief system, rather than
direct work on changing affect or behaviors.
The goal of Ericksonian hypnosis is to recontextualize
the traumatic memory, the affect of fear, and
the physiological hyperarousal cued by the traumatic
memory, within a broader context of pride, mastery,
courage, etc., and within a context inclusive
of other memories and affects, which are positive
for the client.
Metaphor provides an altered
frame of reference that allows the client to
entertain novel experience without physiological
hyperarousal and attending negative affect.
The structured dissociation/metaphor induction
process raises the threshold of awareness of
physiological arousal, or anxiety; that is,
the client is aware less often and less intensely
of the signs of anxiety. The healing or recovery
which results from the process of structured
dissociation and inherent use of metaphor in
cognitive restructuring derives from a reassociation
of experiences in memory rather than from hypnotic
suggestion. That is, there is a shift in experiential
memory so that a modulated response occurs in
the body's musculoskeletal and autonomic nervous
systems when the traumatic memory is evoked.
Eye Movement Desensitization
and Reprocessing (EMDR), developed as an intervention
for the treatment of trauma and anxiety by Francine
Shapiro, Ph.D. (1996), similarly has as its
goal the facilitation of a transfer of traumatic
data from the cortical right hemisphere to the
left hemisphere where this data (inputs) can
be analyzed and integrated by the cognitive
functions of the left hemisphere, so that recontextualization
of the traumatic events may occur and the negative
physiological and affective arousal may be concomitantly
neutralized or modulated. Despite an essentially
behaviorist intervention protocol, EMDR also
utilizes the attainment of a state of heightened
awareness, or collaborative structured dissociation.
This facilitates the orientation of the traumatized
client' s conscious mind toward "revisiting"
traumatic memories and the cognitive restructuring
process, while simultaneously modulating the
physiological arousal and associated affect
of the client during evocation of traumatic
memories. PET scans of persons diagnosed with
PTSD who are being treated with EMDR have demonstrated
the transfer of traumatic data from the right
to left hemisphere during the PET process, whereas
the PET scans of PTSD clients not being treated
with EMDR during the PET assessment demonstrate
no comparable transfer of traumatic data between
hemispheres (i.e., no cognitive processing)
(Van der Kolk, 1994).
Conclusion
The use of either Ericksonian
hypnosis or EMDR, or an interweave of both interventions
in the treatment of trauma victims with Posttraumatic
Stress Disorder, is worthy of further research
and discussion, given the relatively poor results
achieved by other psychotherapeutic interventions,
both psychodynamic and behavioral, for the amelioration
of symptoms involving "spiritual"
issues as well as cognitive deficits, hyperarousal,
and attendant negative affect. Psychotherapy
which does not address the "spiritual"
issues of emotional and cognitive detachment
from self and others, and from a sense of connectedness
with humanity in general, cannot heal the traumatized
person because only intellectual cognitive process
(understanding) or observable behavior (symptom
amelioration) is targeted. Frequently, no attempts
are made to contextualize the symptoms and spiritual
loss, nor the healing process, within the cultural
metaphors most salient to the individual trauma
survivor.
Interventions which help to
modulate the survivor's arousal while respectfully
attending to cultural issues and idioms which
facilitate self-healing tend to utilize the
survivor's resilience and unique sensibilities
in lieu of professional expertise, counsel or
values. Furthermore, the personal world of meanings
which undergoes rapid rigidification and narrowing
following traumatization must evolve both a
deconstruction process of the trauma-based beliefs
and a reconstruction process (of a new self
narrative which integrates both negative and
positive self-story elements within a culturally
ecological and well-organized elaboration)
Within the context of a sound
theoretical base such as the Narrative Constructivist
model described here, the interventions of EMDR
and Ericksonian Hypnosis can greatly facilitate
the integration of the overall capacities of
the human mind, body and spirit in a survivor's
journey of recovery from trauma.
References
Janoff-Bulman, R. (1988). The
aftermath of victimization: Rebuilding shattered
assumptions; In Trauma and Its Wake, Charles
R. Figley (Ed.), Brunner/Mazel, New York.
Lankton, S. & Zeig, J. (Eds). (1988). Ericksonian
monographs; Special treatment populations. New
York: Brunner/Mazel.
Shapiro, F. (1996). Errors
of context and review of eye movement desensitization
and reprocessing research. Journal of Behavior
Therapy and Experimental Psychiatry, 27, 313-317.
Van der Kolk, B.A. (1994).
The body keeps the score: Memory and the evolving
psychobiology of posttraumatic stress. Harvard
Review of Psychiatry, 1, 253-265.
©1998 by
The American Academy of Experts in Traumatic
Stress, Inc. |
