PSYCHOTHERAPY - Psychoanalysis - Systemics - Pnl - EMDR

The Post Traumatic Stress Disorder and EMDR therapy

Article originally published in the Full Informatiu, Col· legi Oficial de Psicòlegs de Catalunya, No 169, May 2004

There are some expressions that change the history of our profession. “Unconscious”, “Oedipus complex”, “double bind”, “learned helplessness”, “family homeostasis” or “burn-out” to quote but a few examples and asking forgiveness for many others left aside. They change the history of ideas, we may say, perhaps based on the illusion that ideas are some kind of entelechies soaring in the cosmos. However, they are much more. When already born, a true idea has changed or is about to change a particular social practice, which in turn causes more changes in a particular context (a “discourse” let’s say, for that matter …).

The word “esteem” for example, which arose a few years ago, has spread out as a mark of origin, becoming a currency in many expressions alluding to moods. Having self-esteem “low” or “high” or “I see you have no self-esteem problem” are statements that have become a Seña de Identidad. Happy expression this last one too! Everybody can use it without feeling any pang for not having read the novel by Juan Goytisolo.

Although every expression may have been somebody’s creation, not all of them retain the copyright that keep them unmistakable. For instance: “I think, therefore I am”, “God is dead” or, coming back to our field, “Oedipus Complex”. All these automatically evoke its creator. Others, like the aforementioned “self-esteem” do not spell out the author but circulate as a natural element within our professional and social folklore. Some of them even still have the glamour of the author, although it seems that it will end up losing it, like “emotional Intelligence”, which I would like to know how many readers are automatically presented by the name of the author of the book entitled under this lucky combination of words.
It is of great help of course if the referred expression puts out a solution to the given problem, a solution that can be quite specific or as abstruse and ideal that might give the reader the impression that if he could do what he is suggested to, he wouldn’t be complaining of whatever he happens to suffer. A flood of self-help literature drinks in the spring opened by the idea of self-esteem (to continue with our example), offering a wide range of tips and methods for self loving, in that so typically sweetened style, mixing everything from the Tao to quantum mechanics.

“Post traumatic stress” contains all the features required to mark an epoch. To start with, it has a long prehistory under the name of traumatic neurosis, which includes all the debates about trauma and its etiological value, a “narrative” (here’s another one) that began with Freud and have still not finished.

As a coined label (post traumatic stress disorder, PTSD) is fairly recent, appears about the 80ties in the DSM-III, ranged in the chapter on Anxiety Disorders, although some doubts have later been raised about this classification, since PSTD could also be included under Major Depression or also Dissociation. Finally, PSTD has triggered a proliferation of methods to treat it, based on advances in general psychology and neuroscience.

Suffering PTSD means that the person affected has experienced, witnessed, imagined or listened about one or more events entailing deaths or threats to his or another  one’s safety, and has reacted with fear, helplessness and horror leaving intense negative feelings warded off into his emotional memory, stored in the limbic system. Traumatic scenes may come from either natural disasters, or caused by terrorist acts, of being involved in violent situations, such as war veterans or out of having suffered physical and sexual violence, such as abused children or women.

The traumatic event is revived later by:
– Memories and intrusive thoughts.
– Images and sensations causing strong discomfort.
– Recurring dreams and nightmares.
– Often the person has the very real feeling that this is happening right now,    experiencing sensations, illusions, hallucinations and dissociative flashback episodes.
– Intense psychological distress triggered by external or internal stimuli that symbolize an aspect of the traumatic event.
– Sudden attacks of fear without any available explanation.

To defend himself against these horrific experiences, the subject may develop some of the following behaviours:

– Avoid thoughts, feelings, conversations, activities or efforts that might remind him the traumatic event.
– Lose his memory about some important aspect of the traumatic scene.
– Reduce his interest in significant activities.  His mind splits, becomes isolated and restricts his emotional life and his ability to love.
– Foresees future as closed and hopeless.

The subject may also have difficulty in sleeping, irritability, concentration difficulties and keep a hyper alert control, as well as excessive startled responses.

The person suffering from PTSD usually shows a state of emotional numbness and anesthesia. Talking with him we feel that somehow he is not with us, but without losing any detail of our professional gestures. He can develop a mysterious behaviour, as if he kept a secret and maintains a distance fearful of contact with the interviewer. Would we talk in a positive way, trying to reassert him and we may hurt his feelings, as if all hope entailed a danger. He may also narrate true ordeals as if reading the shopping list, with that weird coldness that conveys the mark of dissociation. If he starts to open up he might appear as harassed by painful memories, brought out as in daydreaming or in nightmares and generally fluctuating between states of disinterest and irritability. Everything affects him and feels unable to concentrate on anything definite. All too often he will express feelings of shame and guilt for things that have happened to him or manifest that only a person so weak, worthless or deserving such little estimation could have put up with what has happened or been done to him.

Roughly extracted from the DSM-IV, this description is the same as ever. Speaking of his early hysterical patients, Freud could have given the same portrait, point by point. In fact he did and we could guess it’s now been copied. The belle indifference, the trembling attacks, the seizures  and paralysis seen in his office and that led him to what was perhaps his first great aphorism:  hysterics suffer from reminiscences, make clear the same clinical logic held in the diagnosis of Post traumatic Stress Disorder.

In order to treat these as spectacularly defensive states Freud invented psychoanalysis. With the psychotherapeutic boom which took place during the twentieth century other methods became also relevant. Since less than twenty years we also dispose of the method briefly known as EMDR, which stands for “Eye Movement Desensitization Reprocessing”, discovered by Francine Shapiro.

Just as the couch became the icon of the Freudian invention eyes moving from side to side following the pen in the hand of the therapist will surely become the symbol of EMDR therapy.

At the service of a very easy to describe although very delicate to apply procedure, EMDR combines Freudian conflict theory, cognitive changing of beliefs and behavioural anxiety reduction. As psychoanalysis does, EMDR puts the unconscious to work in order to build new integrations of the conflict, less onerous than the symptom. As cognitive therapy does, EMDR changes negative beliefs about oneself and, as behaviourism does, EMDR reduces emotional disturbance when coping with the traumatic scene. And when it works, because not everything always works, it works very fast, the patient changes in few sessions. Unlock and emotional cleansing, cathartic and processing. Furthermore, it can be applied within the context of other therapies, since their protocols are very simple. In fact, art consists in not mistaking the client when administering the method. Other methods, wrongly chosen may only waste time, money and hope, or will be so slow that the patient will have time to get away. EMDR is so powerful that applied improperly can hurt.

As always, when just appeared, a new therapy looks like capable of serving to everything. Treatment of choice for large caliber trauma, EMDR extends its beneficial influence on the treatment of pain, anxiety, addiction problems, eating disorders, phobias, general inhibitions, attachment difficulties, etc. Time will put things in place, as has always happened with therapeutic booms. It is too early to set limits to its effectiveness, while research is very much alive.
Lacan would be dumbfounded by this opening to his real.

Times have changed since Freud, but perhaps not that much, we have come full circle and we are now the night before the day Freud invented psychoanalysis. The night he resigned his traumatic theory to consider children sexual fantasies as a far more fertile ground for neurosis than having been abused from fathers, uncles, brothers or nannies; a theory which actually he did not deny as much as he has later been unjustly accused of.

Everything wants to be trauma today, so that sometimes we are bent to forget that trauma is not something that happened to me or I that did, but my mind’s reaction to what has happened to me or I did. The defense ends up being the agent of the symptom and is through warding off the painful representations that morphs them into traumatic reminiscences, thus condemned to emerge as terrifying.

This subjectless romanticism we call postmodernism wants everyone to be first of all, victims. If we are accepted as victims, well, maybe then we’ll assume a little responsibility.

Luckily therapeutic methods do not usually fall into this trap. Respecting the client’s hidden emotional agenda and keep faithful to the principle of primum non nuocere may help him to find the minimum of inner peace to live in self reconciliation. Doing so requires commitment on his side and professional caution on ours. That enigmatic pain, that painful mystery we call symptom remains our best compass, and this applies also, and especially for EMDR therapy.

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