Phase Oriented Treatment

All treatment of traumatized individuals needs to be paced according to the degree of involuntary intrusion of the trauma and the individual's capacities to deal with intense emotions. For over a century, clinicians have advocated the application of phase-oriented treatment consisting of (1) establishing a diagnosis, including prioritizing the range of problems suffered by the individual, and (2) designing a realistic phase-oriented treatment plan, consisting of:

1. Stabilization, including identification of feelings by gaining mastery over trauma-related somatic states of hyper- and hypoarousal.

2. Deconditioning of traumatic memories and responses.

3. Integration of traumatic personal schemes.

In the treatment of single-incident trauma, it is often possible to move quickly from one phase to the next; in complex cases of chronic interpersonal abuse clinicians often need to refocus on stabilization (van der Kolk et al., 1996).

In order to overcome the effects of physical hyperarousal and numbing, it is critical for traumatized people to find words to identify bodily sensations and to name emotional states. Knowing what one feels and allowing oneself to experience uncomfortable sensations and emotions is essential in planning how to cope with them. Being able to name and tolerate sensations, feelings, and experiences gives people the capacity to "own" what they feel. Being "in touch' with oneself (a function of an active medial frontal and dorsolateral prefrontal cortex?) seems to be indispensable for mastery and for having the mental flexibility to contrast and compare, and to imagine a range of alternative outcomes (not only a recurrence of the trauma).

This capacity needs to be present before people are ready to be exposed to their traumatic memories. Desensitization, or association of the traumatic imprints to autobiographical memory, is not possible as long as intense emotions overwhelm the victim, just as they did at the time of the original trauma. When traumatized individuals feel out of control and unable to modulate their distress, they are vulnerable to pathological self-soothing behaviors, such as substance abuse, binge eating, self-injury, or clinging to potentially dangerous partners (van der Kolk et al., 1996).

With the advent of effective medications, such as the serotonin reuptake blockers (e.g., van der Kolk et al., 1995), medications increasingly have taken the place of teaching people skills to deal with uncomfortable physical sensations. As long as the trauma is experienced with conditioned physiological responses and "speechless terror," victims tend to continue to react to conditional stimuli as a return of the trauma, without the capacity to define alternative courses of action. However, when the triggers are identified and the individual gains the capacity to attach words to somatic experiences, these lose some of their terror (Harber and Pennebaker, 1992). Thus, the task of therapy is to both create a capacity to be mindful of current experience, and to create symbolic representations of past traumatic experiences with the goal of uncoupling physical sensations from trauma-based emotional responses, thereby taming the associated terror.

Affective hyperarousal can effectively be treated with the judicious use of serotonin reuptake blockers and emotion regulation training, which consists of identifying, labeling, and altering emotional states. Gradually, patients learn to observe, rather than avoiding, the way they feel, and to plan alternative coping strategies. For traumatic reminders to lose their emotional valence, patients must be able to experience new information that contradicts the rigid traumatic memory, such as feeling physically safe, while thinking about the event, not feeling they are to blame, and feeling able to cope with similar events in the future. The critical issue in treatment is reexposure to traumatic imprints, and at the same time experiencing sensations (of mastery, safety, etc.) that are incompatible with the fear and terror associated with the trauma.

Flooding and exposure are by no means harmless treatment techniques: Exposure to information consistent with a traumatic memory can be expected to strengthen anxiety (i.e., sensitize and thereby aggravating PTSD symptomatology). Excessive arousal may make the PTSD patient worse by interfering with the acquisition of new information. When that occurs, the traumatic memories will not be corrected, but merely confirmed: Instead of promoting habituation, it may accidentally foster sensitization.

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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