How we integrate or make sense of our experiences have a lot to do with how they affect us. That's just common sense. However, the drive within psychology towards a research and evidence based practice standards has led to a move away from seeking the consensus of practicing professionals in the field on the formation of theory. A theory informed practice has been the standard for many years. Experts construct a theory based on their professional knowledge, including research. The theory is then tested based on the defined concrete references of the theory, called operational definitions. This is a very common approach to theory construction. For example, testing the theory that the planets orbit the sun, one mathematically works out where each planet should be at some set time in the future based on the theory. When they are found there, that provides one study supporting the criterian validity of the theory that the the planets orbit the sun.

The problem is that psychological constructs are notoriously defined differently by different researchers, and there is little consensus on a grand theory that attempts to explain human behavior. Instead there are a number of theories that have been developed that accounts for behavior based on the thoughts that occur before the behaviors. Research has shown that behavior can change when thoughts about that behavior change. This has been replicated many times. Cognitive behavior therapy is the model in the psychology that enjoys the largest following. But this theory does not explain all or even most behavior, nor does in fit with some of the more common beliefs and assumptions about human behavior.

If changing one's thinking were all that was necessary to change behavior, then more people would be successful with New Year's resolutions. Most people will tell you of their dismal success breaking old habits in the New Year. Throughout 2007, one study tracked over 3000 people attempting to achieve a range of resolutions, including losing weight, visiting the gym, quitting smoking, and drinking less. At the start of the study, 52% of participants were confident of success. One year later, only 12% actually achieved their goal.

Another problem with Cognitive Behavior Theory (CBT) is that it assumes that emotions are just an another form of behavior caused by thoughts. In some cases this may be true. In generally healthy people, emotional issues may well respond to changes in thoughts. But it's clear that Post Traumatic Stress Disorder (PTSD) is largely an emotional disorder, where manifestations have incomplete connections to thoughts. CBT is not the treatment of choice. Some form of exposure therapy is widely used to essentially break the pattern of emotionally driven habitual behavior or extinguish the conditioned emotional responses to thoughts, feelings and external stimulation associated with the trauma. If you experience that memory and it's emotions in a safe setting and recognize that your fears were not realized, then the memory is changed with the addition of this new information. This sort of change is incremental. Such learning may need to be repeated several times the intensity of the emotion subsides to acceptable levels.

Other clinicians see a more profound version of PTSD in combat veterans.

Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerilla wars amplify these challenges. Potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally,

Image by Getty Images via @daylife

psychologically, behaviorally, spiritually, and socially (what we label as moral injury). Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury. (Litz et al., 2009)

Georgetown University ethics professor Nancy Sherman heard stories of moral trauma when she interviewed veterans of Iraq, Afghanistan, Vietnam and World War II for her 2010 book, The Untold War. "It might be where you felt you should have been able to do more for your buddies, but you couldn't, or because you simply survived," she says.

"Regret," she writes, "doesn't begin to capture what the soldiers I talked with feel. It doesn't capture the despair or depth of the feeling -- the awful weight of self-indictment and the need to make moral repair in order to be allowed back into the community in which he feels he has somehow jeopardized his standing." (Silver, 2011)

This is not a new idea, but rather repackaging of a well documented feature of all trauma, and not just trauma related to combat. Themes of shame and guilt pervade the PTSD literature, often referred to as complicating factors.

Studies suggest that those who interpret a traumatic experience as intensely negative are more at risk for posttraumatic distress and disorder than those who view the event as less traumatic. Specifically, a woman's reaction at the time of her victimization is likely to be an important predictor of her later psychological state. (Briere & Jordan, 2004)

Certainly conceiving of a victim's behavior during a traumatic event as transgressions of deeply held moral beliefs and expectations would qualify as a particularly negative interpretation of the event and thus predict a more difficult recovery. She is also more likely to develop a shame-based view of herself based on the conclusion that she has demonstrated a moral defect reflected in her behavior. In my clinical work, I've seen this phenomena in traumatization caused by crime victimization, particularly rape, in natural disasters, such as hurricaine Katrina and the Northridge earthquake in Oakland, Ca, as well as combat trauma from Iraq, Afghanistan and Vietnam. The complicating factor of shameful beliefs about personal responsibility when others are injured is a prominent feature in people struggling with a difficult recovery.

This new conceptualization of moral injury may come in a useful form, one that is easily understood by the client and destigmatizing in the sense that a "mental health" problem is consistent with cultural norms. In addition, the authors further the theory of PTSD and its notorious resistance to treatment. The shame of a moral injury leads the sufferer to withdraw from social contact even with close confidants, under the assumption that if she doesn't hide their shameful behavior, others will know and find her disgusting and worthy of rejection. This prevents the natural healing process of sharing and reexperiencing the trauma with the support of a loved one. The expression of love and acceptance despite their shameful behavior becomes part of the emotional memory and gradually attenuates the shame as well as the intrusive memories, nightmares and flashbacks. The authors note that self esteem has been found to mediate between belief that the world is just and in the willingness to self forgive Therefore, self-esteem may be an protective factor from moral injury. The authors also note that PTSD as well as moral injury involve healthy feelings. The affliction of a moral injury is in part a believe that the sufferer is not worthy of self-forgiveness. (Litz et al., 2009)

Litz et al., (2009) outlines a model they call a "modified CBT" approach. They describe eight components: 1. A strong working alliance. 2. Educating about the concept of moral injury and preparing a plan for change. 3. a "hot-cognitive" exposure based processing or emotion focused self-disclosure. 4. A thorough examination of the implications of this experience on the sufferers concept of self and other cognitive schemas. 5. An imaginal dialogue with a benevolent moral authority (such as a grandparent or pastor) about the target behavior and implications for the future. 6. Fostering self-forgiveness and reconnection to the community. 7. An assessment of goals and values moving forward.

I've found it particularly effective to treat PTSD complicated by shame in a group setting, where the many components often become a natural process of the group's cohesion and mutual support. When other group members who suffer from post trauma symptoms share their story of how they believed they had personal responsibility that resulted in another's injury, it's much easier for the sufferer to see other's over reactions and offer support and validation. This helps them recognize their own exaggerated self-blame and begin the process of self-forgiveness, a kind of "opposite action" treatment.

References

• Briere, J. (2002). Treating adult survivors of severe childhood abuse and neglect: Further development of an integrative model. In L. Berliner, J. Briere, C. T. Hendrix, T. Reid, & C. Jenny (Eds.), The APSAC handbook on child maltreatment; 2nd Edition., Briere (2002) (pp. 1-26). Newbury Park; CA: Sage Publications.
• Briere, J., & Jordan, C. E. (2004). Violence against women: Outcome complexity and implications. Journal Of Interpersonal Violence, 199(11), 1252-1276.
• Litz, B., Stein, N., Delaney, E., Lebowitz, L., Nash, W., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy Clinical Psychology Review, 29 (8), 695-706 DOI: 10.1016/j.cpr.2009.07.003
• Silver, D. (2011, September 3). Beyond PTSD: Soldiers Have Injured Souls. Truthout. Retrieved from http://www.truth-out.org/beyond-ptsd-soldiers-have-injured-souls/1315066215

by Ronald Ruden, MD, PhD

When the Past Is Always Present: Emotional Traumatization, Causes, and Cures introduces a new treatment for trauma. Ronald A. Ruden is an internal medicine physician practicing in Manhattan. Since beginning his practice in 1983, he has dedicated part of the proceeds to follow research interests. His first efforts resulted in the book, The Craving Brain, a neurobiological discussion of addictive behaviors. In 2003 he redirected his interest in understanding traumatization. That has led to three publications in Traumatology, edited by Charles Figley, and to this book.

The book begins with an easy to understand review of the neurobiological and neuropsychological literature as it relates to trauma. His intent is to provide a primer that a lay person could understand. He still provides adequate citations for those who have deeper interests.

Ruden believes that the means to treat Post Traumatic Stress Disorder (PTSD) is to use the senses. This idea, which is at the core of the theory of psychosensory therapy, forms what the author considers the "third pillar" of trauma treatment. The first and second pillars refer to psychotherapy and psychopharmacology. The theory of psychosensory therapy postulates that sensory input, for example, touch "creates extrasensory activity that alters brain function and the way we respond to stimuli". In other words, new sensory input can change memories and their power over us.

"...the human brain can change it's own structure and function with thought and experience, turning on its own genes to change its circuitry, reorganize itself and change its operation, is the most important alteration in our understanding of the brain in 400 years." (Norman Doidge, MD pXVII in Ruden, 2011)

This process of brain modification is called neuro-platisticity. Evidence of this concept has begun a revolution in thinking about the brain. No longer can one assume that brain damage creates an impermeable barrier to recovery. The point is we can change how well our brain functions if we work at it. If we neglect our brain, it will deteriorate before it's time. Yoga, mindfulness, meditation, and exercise enhance resilience. Resilience is associated with high self-esteem, good emotion regulation skills, optimism, healthy relationships, and an active problem solving response. When you believing you can meet your needs, you feel self-contained, like your world can be managed, you can respond to challenges and can readily find help if you need it. Vulnerability is increased by putting aside your needs to care for others, low self-esteem, difficulty in regulating the intensity and duration of emotions, obsessive-compulsive traits, introversion or being very shy, being anxiety prone, substance abuse, poverty and low education.

"In early life, when the limbic system has not completely formed (the hippocampus is not yet functional), highly emotional moments that occur become stored in a separate memory system called procedural [or implicit] memory.... The cognitive component of the event is not stored...." (Ruden, 2011, p24)

When a child experiences trauma, the emotional memory is stored in a part of the brain not easily accessed by our thoughts, our conscious mind. But the memory is there ready to be triggered some event that reminds you of the traumatic memory. You may not even understand why you feel the intense emotions which will add to your confusion and anguish. Chronic release of stress chemicals by repeated triggered panic, changes the landscape of the brain producing self-defeating behavior and thinking, stress related disease, and vulnerability to further traumatization. Retraumatization may be related to repetition compulsion, a homeostatic driven need to heal. If you seek mastery over a situation without new skills to ensure success, the memory is triggered without the healing sense of safe haven, increasing the compulsion to seek mastery. Subconsciously, you may reenact the trauma by repeatedly exposing yourself to a similar trauma.

The second idea presented in this book is that traumatization is encoded into the implicit memory only under special circumstances. Traumatic memories are formed by an emotion-producing event with significant meaning to the individual, the brain must be appropriately primed to acute stress, and the event must be perceived as inescapable. (Ruden, 2011, p47) Encoding is completed at high norepinepherine and dopamine levels, while the prefrontal cortex is shut down. (Ruden, 2011, p59) Ruden insists the trauma must be perceived as inescapable for encoding as a traumatic memory. Feeling trapped, unable to escape takes the prefrontal cortex is taken off line, and we are unable to plan or think. (Ruden, 2011, p47-49) In my clinical experience, feeling trapped, responsible, and in some part to blame for the outcome also appears to play an important role in the development of PTSD.

"The third idea is that traumatization occurs because we cannot find a haven during the event. This is the cornerstone of havening, the particular form of psychosensory therapy described in the book. Using evolutionary biological principles and recently published neuroscientific studies, this book outlines in detail how havening touch de-links the emotional experience from a trauma, essentially making it just an ordinary memory. Once done, the event no longer causes distress." (Yaffe & Ruden Medical Associates)

Ruden's proposed treatment provides another method to unlearn these emotional reactions and retrieve a sense of mastery and safety after a traumatizing experience. Ruden's approach and other sensory-based techniques, are exposure based, a method that has extensive research support. Ruden's claims that animal research supports the notion that bilateral stimulation enhances healing is at best weakly supported by the studies cited.

Rasolkhani-Kalhorn & Harper (2006) appears to be Ruden's primary reference. The authors of this article acknowledge the limitations of the research support for their theory. They use anecdotal research evidence from animal studies to suggest that Eye-movement Desensitization and Reprocessing therapy (EMDR) and other psychosensory therapies, work by stimulating part of the brain to decouple the emotion from the memory. Those studies use fMRI, a scanning technique that can detect brain activity, and other methods. The idea is where there is brain activity when a person is doing something, identifies what parts of the brain are involved. However, every scan shows a lot of activity that is not understood and only some that is thought to be related. The method doesn't prove causation, only a relationship of co-occurance in time or correlation. There is no direct evidence that this correlation in animal brains will translate to human brains. There are real structural differences between humans and animals. So the research results at best only suggest that bilateral stimulation might be related to decoupling emotion from memories.

Ruden's theory is a bit different. When a traumatic event is recalled or reenacted while the survivor is in safe haven, the trauma-induced linkages are disrupted and the emotional response is subsides or is eliminated. According to Behavior Theory, a well research and widely accepted model, a conditioned emotional response is said to "extinguish" when it is repeatedly stimulated when the person feels safe. But Ruden's theory goes much further. He believes that as little as one exposure to to Havening can decouple the memory. Once the traumatic memory is brought into working memory, if it's dislodged before activation, the triggering stimulus is disconnected from the response. The treatment is to create an escape from the memory of trauma. His method of dislodging the memory from working memory involves mental distraction and caressing arms, shoulders, face and tapping rythmically and bilaterally on each shoulder.

However, there is many confounding factors at work in both EMDR and Havening. Besides the exposure process, a proven technique, is built into both methods. Touch effects provides comfort, sensuality, relaxation. Massage therapy has been shown to enhance attentiveness, alleviates depressive symptoms, reduces pain, improves immune function. Cortisol secretion, a hormone that is part of the bodies stress reaction, is diminished. Dopamine and serotonin, pleasure related brain chemicals, are increased. Norepinephrine, a stress chemical is decreased. These are all related to an enhance sense of calm while exposed to the traumatic memory.

Anestis (2009a, 2009b) reviews the literature on EMDR and finds no evidence that it works any better than exposure. From my clinical experience, I've seen many times a one time telling of the story of trauma, another exposure method, resulted in a dramatic decrease in symptoms.

I too have experienced an immediate response from a single administration of totally different treatment technique while in training for hypnotherapy. At age 10, I was in a house struck by lightning. No one was injured, but there were several things that happened that heightened the traumatic impact of the event. I watched one leg of the lightning arc strike a tree outside the window. I knew a loud crash was imminent. I jumped none-the-less at the uncharacteristic "crack" rather than the usual "rumble" of thunder. At about the same moment, the radio behind my head shorted out with a loud pop and started smoking!

Years later, another therapist-in-training and I were paired to attempt a hypnotic regression. I helped direct the therapist trainee by bringing my therapist self of that day, back to comfort my 10 year old self in that memory. From that day until today, despite having lots of experience with lightning since, I have what I consider an unhealthy lack of fear. I have to consciously remind myself to avoid unsafe actions in a storm!

Ruden provides what I think is another explanation for why psychosensory therapies may work for some in as little as a single exposure.

"...the extrasensory response to sensory input [is what] effects change in psychosensory therapy. In the psychsensory therapy havening, touch produces change. It is not the simple act of touch and the brain's concommital response that is therapeutic; it is the meaning the brain ascribes to the touch that appears to be crucial." (Ruden, 2011)

In other words, Ruden sees Havening as a particularly effective way to stimulate his clients to experience comfort and meaning.

A person with a healthy attachment is best suited to respond to supportive comfort from another and will quickly find the meaning implied and benefit immediately. Like most treatment techniques, the overall health of the client is a critical aspect of the outcome. Healthy people get better faster and with less effort. The more resilient factors noted above, that a person has, one would presume they would either not develop PTSD, or be most likely to respond immediately to treatment. Unfortunately, Ruden does not report differences in clients responses based on client characteristics. So his report that a single treatment sometimes works sounds sensational, but is not anything other than an expected outcome from an exposure based method.

Despite the disappointment I experienced with the discovery that Havening offers really nothing new, I enjoyed the book. It's a worthwhile read for it's easy to follow and understand review of the literature. He is a good writer.

References:

Anestis, M. (2009a, June 18). Eye movement desensitization and reprocessing (EMDR): What is it and does it work? Psychotherapy Brown Bag. Retrieved December 31, 2010, from here.
Anestis, M. (2009b, October 23). EMDR: Do bi-lateral eye movements actually add anything to treatment? Psychotherapy Brown Bag. Retrieved December 31, 2010, from here.
Rasolkhani-Kalhorn, T., & Harper, M. (2006). EMDR and Low Frequency Stimulation of the Brain Traumatology, 12 (1), 9-24 DOI: 10.1177/153476560601200102
Ruden, R. (2011). When the Past is Always Present Psychosocial Stress Series. Routledge ISBN: 978-0-415-87564-6
Yaffe & Ruden Medical Associates. (n.d.). Dr. Ruden's Books. Yaffe & Ruden Medical Associates.. Retrieved January 20, 2011, from here.

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Recently, I exchanged messages with Michele Rosenthal, author of the blog, Parasites of the Mind. She asked me a very good question, one that is so much a part of my everyday work, a good long contemplation was needed just to tease out a good answer.

"Speaking of inspiring, how do you inspire a client to believe in what he/she is doing? It's so difficult to believe in anything when PTSD has settled its big black cloud on your head.

Any general rules of the game for (self) empowering belief?"

Another therapist, Mary Redoutey, joined our discussion and attempted to answer this question. She took the conventional route.

"All therapy in essence is self empowered therapy.... The therapist is the partner in the process. I can sit in the chair in my office, can make suggestions, can teach, can do anything as much as I want... and nothing different will happen unless of course the client is present, listens somewhat attentively, suspends negativity long enough to experience a shift in feeling state and/or thoughts or actions.... And the work in the session does not transfer into the client's life unless the client chooses to make the necessary changes. "

Essentially, Mary says that therapists don't change people, people can only change themselves. I have commented on a release for a new book that made this point as well. While it is true that what a client brings to therapy may account for much of the effectiveness of therapy, I don't think this is the core of Michelle's question. As I understand her question, she wants to know what the therapist brings to the therapy room.

My first attempt at replying was rooted in my daily routine. I'm always helping people understand how their past experience impinges on their current symptoms.

"Consider what happens between mother and child. A child develops their self-concept initially based on how they are treated by their mother. In therapy, the therapist communicates his belief in the client. And if the connection already exists, a seed is planted. But as an adult, only the client can nurture the seed to germination and growth. The therapist can only teach them how."

Generally, when I take this tact, which is common with the childhood trauma survivors I see, I am helping them see the importance of exploring their childhood history and their relationships with their caregivers as a way to understand the origins of their symptoms. This is a much more specific answer that still only partly answers Michelle's question.

I think Michelle wants to know what is the therapists role in motivating a client in each and every step through therapy. In other words, what is the client getting from paid expert advice they can't get from a book? From Michelle's point of view, perceptions of her options are clouded by the rollercoaster existence that accompanies PTSD.

There has been extensive research on this topic. Most recently, much of this research has taken on a ideological fervor endorsing Cognitive Behavior Therapy (CBT). I've written often about my opinion CBT. Suffice it to say, CBT may be the core methodology in helping a client manage their thoughts and building treatment plans, but there is much more to behavior change than changing thoughts. One of CBT's central assumptions is patently false. Not all feelings are produced by or changable by thoughts. Much of our earliest learning occurs before thoughts begin to play a major role in our learning around the age of 8.

Patterson (1989) identified common specific factors recognized by virtually all schools of psychotherapy. He included therapist acceptance, permissiveness, warmth, respect, nonjudgmentalism, honesty, genuineness, and empathy or empathic understanding. Three of these, warmth, empathy, and genuineness have considerable research backing. In a previous article, Patterson (1984) points out:

"There are few things in the field of psychology for which the evidence is so strong. The evidence for the necessity, if not the sufficiency, of the therapist conditions of accurate empathy, respect, or warmth, and therapeutic genuineness in incontrovertible.... The fact that specific change occurs in a therapeutic relationship without the addition of so-called specific techniques, such as interpretation, suggestion, instruction, etc., is also evidence of the sufficiency of the relationship by itself. "

More recent research has found the competence of the therapist is critical. Verhofstadt et al. 2008, in their article about the value of emotional similarity and empathic accuracy in support giving with couples. They cite:

"...mounting evidence that unskilled support can be ineffective or even harmful to the support recipient.... In summary, whereas matching the partner's emotion during a support-seeking interaction may provide a sufficient basis for understanding the partner's current affective state(s) and responding with appropriate emotional support and consolation, understanding the partner's specific thoughts and feelings during a support-seeking interaction may provide a sufficient basis for understanding what kind(s) of help the partner desires and how to provide such help in an acceptable way."

Successful therapists must be able to adapt to their clients' emotional uniqueness and to accurately perceive their thoughts and feelings to provide appropriate support in an acceptable way. Perhaps even more important, therapists must be perceptive and adaptive enough to understand the clients complaint that brought them to therapy and the nature of their quandary beyond the clients' own understanding, or the underlying problems. And having discovered what must be done, therapists must be able to provide the clients insight into their dilemma, provide a rationale for a course of action, and persuade their clients to make changes they are unlikely to find easy or achieve without significant discomfort. Initially, clients are often unable to understand the significance of their problems or nature and potential benefit of the required changes. If they did they wouldn't need therapy!

There is only one experience that I find cuts through virtually any dark cloud, and that is the touch of human empathy. When people who are overwhelmed by pain suddenly find someone who seems to understand how they feel, they no longer feel alone and abandoned by the world. A skilled therapist can provide more than the usual kind of empathy. After years of exploring the human condition, the therapist reaches within the client's experience that at least begins to provide some meaning to explain and place in context her experience.

Preston and de Waal (2002) describes the nature of human interaction as involving an exchange of complementary emotional and thought messages. These shared representations allow people to adjust their responses based on the communicated states of others suited to relieve each others' distress. (Cited in Gruhn et al., 2008)

Grillion et al. (2008) describe the emotional exchange between client and therapist and the unique skills required of the therapist.

"When the context becomes safe enough for the client to lower his or her defenses, the alteration of regulatory structures becomes possible. The therapist's own self-regulatory movements reveal his or her inner states to the client. Much like the "good enough mother", the therapist's efforts to regulate his or her own inner states show the client that he or she is in contact with the client. Personal therapy for therapists helps to extend the range of experience that they can draw upon in their work with clients (Schore, 2006, cited in Grillion et al. (2008). According to Amini et al. (1996) the most effective interventions are based on the therapist's awareness of his or her own physical, emotional, and ideational responses to the client's veiled messages.

Accordingly, when the therapist has increasingly expanded self-integration and awareness in regard to his or her state of mind with respect to attachment, then he or she has a larger capacity for assisting clients to achieve integration and awareness. This understanding derives from the primary attachment relationship within the developmental psychobiological perspective in which parents who have secure or "earned" secure states of mind with respect to attachment function in certain ways (including attunement and sensitivity) with their infants that result in attachment security in their children. Therefore, from an attachment point of view, the more secure the therapist is, the greater the likelihood is that he or she can assist clients with achieving greater security (Beebe, 1998, cited in Grillion et al. (2008). Therapist self-awareness broadens "clinical intuition", which is referred to as the art of psychotherapy (Bugental, 1987; Schore, 2006; cited in Grillion et al. (2008). "

Thus the relationship of between therapist and client is perhaps the second most important aspect therapy, right behind client characteristics and motivation. So it is critically important that the client has a good relationship with the therapist. Clients must be willing to shop around to make sure there is a good match. Cooper (2008, quoted in Croft, 2008) makes research based recommendations for finding the right therapist.

"Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. Ask yourself whether you like your therapist and feel respected by them - the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process."

References

Croft, Alison. (2008, October 17). Clients, Not Practitioners, Make Therapy Work. Press release by the British Association For Counselling & Psychotherapy on a new book Cooper, Mick (2008). Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. In Medical News Today. Retrieved May 1, 2009, from http://www.medicalnewstoday.com/articles/125815.php.

Grillon, C., Pine, D., Lissek, S., Rabin, S., & Vythilingam, M. (2009). Increased Anxiety During Anticipation of Unpredictable Aversive Stimuli in Posttraumatic Stress Disorder but not in Generalized Anxiety Disorder Biological Psychiatry DOI: 10.1016/j.biopsych.2008.12.028

Grühn, D., Rebucal, K., Diehl, M., Lumley, M., & Labouvie-Vief, G. (2008). Empathy across the adult lifespan: Longitudinal and experience-sampling findings. Emotion, 8 (6), 753-765 DOI: 10.1037/a0014123

Patterson, C. H. (1984). Empathy Warmth And Genuiness In Psychotherapy: A Review Of Reviews. Psychotherapy, 21, 431-438

Patterson, C. H. (1986). Foundations For A Systematic Eclectic Psychotherapy. Psychotherapy, 29, 427-435

Verhofstadt, L., Buysse, A., Ickes, W., Davis, M., & Devoldre, I. (2008). Support provision in marriage: The role of emotional similarity and empathic accuracy. Emotion, 8 (6), 792-802 DOI: 10.1037/a0013976

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Researchers have added another piece to the puzzle of Post Traumatic Stress Disorder. It seems that the memory of the trauma is burned into memory involving the amygdala. But unlearning the experience is not so simple. The amygdala becomes chronically over reactive. One can be taught to be more calm in certain circumstances, but then it won't work in other similar situations.

One of the treatments that is being used by the VA is virtual re-esposure to battle via video. But this will have limited usefulness using the simple "extinction" paradigm.

The idea of extinction is to gradually introduce simulations of the traumatic event, slow enough to minimize the provoked anxiety. For example, imagine being traumatized by the sound of incoming mortar rounds. A treatment program might gradually turn up the volume of a similar sound until the recovering soldier can hear the noise without a strong emotional response. This new research demonstrates that this approach may have limited usefulness, and may not at all effect the response if the soldier re-experiences incoming mortar rounds. The new learning may be limited to the location the treatment was done and to the simulated sound.

Thus it would seem to indirectly support a previous research that found the technique called "prolonged exposure" more effective than historically standard treatments. In prolonged exposure, the stimulus is introduced with less consideration for the comfort of the client. After the client is virtually flooded with similar stimulation and the resulting emotions while being offered support, and counseling regarding his feelings and survival. This approach may promote a more adaptive skill related to surviving all kinds of trauma. Theoretically, the resulting raised threshold for a panicked response may be applicable to more situations less similar to the traumatic event.

Anxiety Insights

"It is estimated that nearly 15 percent of U.S. soldiers returning from Iraq and Afghanistan develop PTSD, underscoring the urgency to develop better treatment strategies for anxiety disorders. These disorders can lead to myriad problems that hinder daily life - or ruin it altogether - such as drug abuse, alcoholism, marital problems, unemployment and suicide.

Functional imaging studies in combat veterans have revealed that the amygdala, a cerebral structure of the temporal lobe known to play a key role in fear and anxiety, is hyperactive in PTSD subjects. Potentially paving the way for more effective treatments of anxiety disorders, a recent Nature report by Denis Paré, professor at the Center for Molecular and Behavioral Neuroscience at Rutgers University in Newark, has identified a critical component of the amygdala's neural network normally involved in the extinction (pdf), or elimination, of fear memories. Paré's laboratory studies the amygdala and how its activity impacts behavior.

Earlier research has revealed that in animals and humans, the amygdala is involved in the expression of innate fear responses, such as the fear of snakes, along with the formation of new fear memories as a result of experience, such as learning to fear the sound of a siren that predicts an air raid.

In the laboratory, the circuits underlying learned fear are typically studied using an experimental paradigm called Pavlovian fear conditioning. In this research model on rats, a neutral stimulus such as the sound of a tone elicited a fear response in the rats after they heard it paired with an noxious or unpleasant stimulus, such as a shock to the feet. However, this conditioned fear response was diminished with repetition of the neutral stimulus in the absence of the noxious stimulus. This phenomenon is known as extinction. This approach is similar to that used to treat human phobias, where the subject is presented with the feared object in the absence of danger.

Behavioral studies have demonstrated, however, that extinction training does not completely abolish the initial fear memory, but rather leads to the formation of a new memory that inhibits conditioned fear responses at the level of the amygdala. As such, fear responses can be expressed again when the conditioned stimulus is presented in a context other than the one where extinction training took place.

For example, suppose a rat is trained for extinction in a grey box smelling of roses, and later hears the tone again in a different box, with a different smell and appearance. The rat will show no evidence of having been trained for extinction. The tone will evoke as much fear as if the rat had not been trained for extinction.

"Extinction memory will only be expressed if tested in the same environment where the extinction training occurred, implying that extinction does not erase the initial fear memory but only suppresses it in a context-specific manner," notes Paré.

Importantly, it has been found that people with anxiety disorders exhibit an "extinction deficit," or a failure to "forget." However, until recently, the mechanisms of extinction have remained unknown."

I think it's probably a human trait that we seek the simplest solution to a problem even when more complex and proven methods are well known. Even scientists seem to do this, even in their area of study!

Our culture seems to have decided thousands of years ago that negative emotions are bad and should be avoided. Everywhere in the psychological literature is examples of researchers seeking to find ways to help people avoid psychological pain.

Has it occurred to anyone that psychological pain has a purpose? For those of us that believe we evolved to be human beings, we have to assume that most attributes that make us human in some way enhance our survival, or that trait would have been selected out of the gene pool. Negative emotions help us. I make that assumption and help people make sense out of their misery, rather than find ways to avoid it. Misery is the single most powerful motivation for change.

Here is a good example. Surviving a traumatic event involves recurring "flashbacks" of the trauma that persist for sometimes many years. So in keeping with the tradition of helping people avoid their "flashbacks", we have this report from New Scientist.

"It might be the case that people with memory disturbances have to gain some control over the memory representation by remembering it and trying a different emotional response to the memory before successful suppression," he adds.

A drug targeting specific brain regions might eventually boost the ability to suppress, said John Gabrieli, at the Massachusetts Institute of Technology, Cambridge, US.

For a mother haunted by the memory of her son's suicide, he said, "it is hard to imagine that you would ever get her to forget that the event occurred. But the more you could weaken the memory in any dimension, the better it would be.""

Ok, lets try the assumption that flashbacks are somehow helpful. Just how is it helpful for the mother in the example above is haunted by memories of her son's suicide? It's a challenging stretch to the assumption surely. But how is it we would expect there be a way to somehow "forget" the memory? That seems impossible without brain damage and considerable collateral damage to other structures and abilities.

What is there in the psychological literature that might explain recurrent unpleasant memories? Recall that phobia is treated by "exposure", gradually introducing the anxiety or fear provoking stimulus while the patient tries to relax. There is good research to say this works pretty well.

What if the flashbacks were the human body's attempt to provide it's own crude exposure treatment? What if the patient were advised to sit with his feelings, talk about the experience with a trusted counselor and to make sense of the experience in his current life. Might this be a way to find meaning in the seemingly meaninglessness of traumatic event?

Indeed, there are examples of research showing how exposure therapy is effective for PTSD.

Here is an even sillier example.

Monitor on Psychology

"So, again, this suggests that verbalizing an emotion may activate the right ventral lateral prefrontal cortex, which then suppresses the areas of the brain that produce emotional pain.

"[In talk therapy] we tend to focus primarily on content and enhanced understandings and changed understandings," said Lieberman. "But it's not entirely irrelevant that they all involve putting feelings into words.""

Duh! Talk about being blind to anything not in front of your face!