Re-Solving PTSD: Looking Back and Looking Forward

Repressing memories of past abuse and sominance

Source: Image by Alexas_Fotos from Pixabay

First responders can experience tragedy and death daily. Healthcare heroes may witness death daily during the pandemic. Soldiers have experienced unspeakable killings and losses during combat now and in the past. Women often relive the trauma of a sexual assault, domestic violence, or repeated sexual abuse they experienced in childhood. All of these and more examples are potential triggers for post-traumatic stress.

Throughout history, humankind has experienced overwhelming traumatic events from wars, natural disasters, tragic accidents, sexual assaults, and others, to name but a few. Such unimaginable experiences overturn our ordered sense of safety and predictability in ways that call for us to either assimilate or accommodate them into our experience. For some of us, and at some times, this process seems to happen allowing us to move forward with few real effects, yet for others, the experience leaves lasting scars that we have come to call PTSD or post-traumatic stress disorder.

PTSD Defined

These days, the abbreviation "PTSD" and the term "trauma" are so common in everyday conversation that everyone feels they know what they mean. Yet, what technically is defined as post-traumatic stress disorder and trauma? The Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) lays out several criteria including:

• The person must have experienced, witnessed, or otherwise faced an event or events involving actual or threatened death, serious injury, or sexual violence from which they do not recover.
• Symptoms cluster into categories of re-experiencing, avoiding, negative alterations in cognition and mood (such as memory difficulties, feeling detached, or persistent negative beliefs) and hyperarousal.

Re-experiencing may include memories of the trauma coming up without warning, vivid flashbacks of intense re-experiencing of the trauma, nightmares of the event, or experiencing intense terror, disgust, sadness, rapid breathing, or heart rate triggered by cues similar to the traumatic event.

Avoidance symptoms include avoiding thoughts and feelings about the trauma, situations, and events similar to the trauma, and related intense feelings associated with them. Paradoxically, temporary relief from decreasing painful emotions typically increases avoidance patterns in the classic vicious cycles.

Negative alterations in thoughts and mood, often include detachment or numbing to reduce painful feelings from intrusive memories; yet some survivors experience the opposite by having continuous intense emotions like anger or shame. They may also feel self-blame, the idea that they will never be normal again, or that nowhere is safe.

Hyperarousal is similar to the person being in a constant “fight or flight” state as they may have been during the traumatic event. This may include constant scanning for danger cues, and constant states of tension eventually resulting in sleep disturbances, irritability, overreactions, and decreased concentration.

Because many, if not most of these symptoms, are present for most people who have experienced intense traumatic events, several criteria must be met for PTSD to be diagnosed:

• First, the symptoms must have been experienced for at least a month following the event.
• At least one intrusion example must be present, such as recurrent dreams, distressing memories, and physiological responses to trauma cues, etc.
• Either avoidance of internal or external reminders of the traumatic event is also required.
• Also, the person must be experiencing at least two symptoms from the list above.

Resolving Solution-Generated Problems

Once defined, the question remains how to resolve PTSD. Most effective treatments help survivors re-experience past traumas to reintegrate their reactions in more positive ways. Yet, alternate and equally effective approaches find resolution by embracing the present and reimagining the future. How can these seemingly opposite treatments be equally successful? The secret lies in how they help us as survivors revise our common solutions--or re-solve our struggles.

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Remembering to Remember

It's not surprising that our most frequent reaction to intense trauma is to turn away from it—mastery by avoidance. We try to "remember to forget" the trauma and create a paradoxical trap for ourselves. We become hypervigilant to detect any hint of the trauma and anything symbolizing or reminding us of it — and, by doing this — remind ourselves of the trauma over and again. Most effective treatments actually do the counter-intuitive thing by helping us "remember to remember!" By deliberately remembering and re-experiencing the trauma, we give ourselves the chance to reintegrate it in the new and more positive way. We gain a new perspective on the trauma. In essence, we "put it to bed" by actually "getting back into bed with it."

Embracing the Present and Rewriting the Future

The now common reversal — going back to go forward — has almost become an accepted standard for PTSD treatment. However, recent research has found that we don't always have to go back to re-experience trauma to resolve it. From this view, the theme is "the best revenge is living well!" The idea is not to allow our perpetrators of past traumas to dominate our present and futures.

So, What Treatments Do Work?

Turning to treatments that work for PTSD, the first stop might be the web site for research-supported psychological treatments for PTSD compiled by the American Psychological Association, Division 12, the Society of Clinical Psychology. Of those five strongly supported treatments, three are considered exposure-based treatments, and two as present-centered or combination approaches. The strongly supported exposure-based approaches include:

• Prolonged Exposure (PE), in which we are consistently exposed to the traumatic material without escape, and then discuss our responses afterword with our practitioner to gain perspective.
• Cognitive Processing Therapy (CPT), in which we are asked to write out our recollections of the trauma and make a stop line each time we experience distress. Then we discuss those points and the entire experience with our practitioner following the exercise to again gain perspective.
• Eye Movement Desensitization and Reprocessing (EMDR), in which we are asked to actively re-imagine the traumatic experience while following a finger or object moving back and forth in front of us. Following several exposures, we again discuss the experience with our practitioner to integrate our experiences in the present.

Of the two present-based approaches, the most strongly supported is:

• Present-Centered Therapy (PCT), which was actually originally used as what is called a "control" condition or a supposed neutral intervention to compare with other assumed "active treatments." To the researchers' surprise, survivors who engaged in information sessions on the nature of their trauma and did problem-solving on how better to relate to others and pursue their values did as well in recovering and dropped out of treatment less than those in alternate exposure treatments.

Why Do "Going Back" and "Going Forward" Work Equally Well?

The essence of vicious cycles is that the solutions driving them make such sense. One option is to simply suppress memories and avoid triggers of the trauma, or "remember to forget." It makes sense. The other is to continue to focus on the trauma to try to sort it out and get beyond it. That makes sense too. The problem is that both solutions can make the problem worse! The bottom line is to break the cycle with interventions that make equal sense or are even more compelling.

• Exposure-based interventions appear counterintuitive at first. Why go toward something that is so distressing? Compelling rationales or explanations that make sense to all involved need to be bought into. Yet once they do make sense, the cycle is reversed, and the trauma can be assimilated in new and more positive ways. This breaks a vicious cycle of avoidance.
• Present-centered therapy, on the other hand, breaks the cycle of rumination, or continually focusing and reliving the trauma over and again. Once more, focusing on the present and future, given such intense past trauma, must also make sense. Quite often, for example, with women trying to get beyond the trauma of rape or former sexual abuse, it can make more sense to resist the draw of their perpetrator or abuser by living well in the present and on into the future. This comes under the idea of "the best revenge is living well" rather than allowing the abuser to continue to impact our lives. This breaks the vicious cycle of ruminating.

In both cases, the resolution is a re-solution, in that it changes or reverses the problematic yet sensible original solution patterns. So, which path is better for us? The answer lies in the patterns of our current problematic solutions to our trauma. If we are stuck in avoiding, then an exposure-based path is best. If we are ruminating or dwelling on the trauma, then a present and future-based path makes the most sense. Trauma is something we all want to get beyond. Now we know there are at least two equally effective paths and four strongly supported types of interventions to break the cycle of PTSD and move us to better tomorrows.