PTSD page 2

Tell me more about the patients who might fall into this category of “Complex PTSD.”
You see, part of PTSD is that you’re out there in the world, feeling and acting as if the trauma is still happening or may happen again at any moment. If you don’t know or trust that it’s not or have some understanding of the things you do protect yourself against it, you can’t get a handle on it in order to work through it and put it in its proper context, the past. Often times, our patients find themselves destroying relationships or creating unhealthy relationships without understanding the connections between these kinds of actions and their pasts. Part of what we try to do is work with people to develop their understanding of their lives. If you’ve been in an accident or war, you know something about what the trauma is, but if you’ve grown up in chaotic relationships you may not know anything different. In our work with families, we also try to develop larger family stories so, again, we can put patients’ stories in context. It’s often clear that our patients’ families also don’t have a handle on what has been motivating their behaviors.

So what are relationships like for a person with PTSD?
Typically, they’re experienced as confusing, unfulfilling, and filled with anxiety. People may feel exhausted from the constant energies they are putting towards protecting themselves. Some people cope by withdrawing—sometimes they become depressed to the point of being suicidal. They slowly narrow their worlds until they stop engaging completely. Others feel invincible. They behave as if they are tempting the trauma to happen again, as if they are actively causing the chaos they fear. They may be trying to find comfort in the familiarity of the confusion or to master what was out of their control. They might also be trying to communicate something that either they don’t have words for or that hasn’t been heard completely. People might become promiscuous, for example, or drive recklessly or abuse alcohol or drugs. I think both these ways of being—shutting down and acting out—are ways of managing the overwhelming thoughts and feelings I mentioned earlier.

Across the board, people with PTSD often talk about feeling “on” all the time. They can’t relax. They often can’t sleep. One way of thinking about trauma is that it shatters the world as you’ve known it. Things that were once safe become dangerous. A lot of people also talk about having a very confused sense of who they are, as if it’s disjointed and discontinuous. Losing your sense of yourself and your safety is obviously disorienting—people talk about feeling crazy, jumpy, and scared. They often feel like they can’t control their thinking and can’t even find rest in sleep because of the nightmares. It’s a terrible situation to live in.

Does PTSD wax and wane, or is it pretty consistent?
Again, it varies. There are some kinds of PTSD that are trigger-specific, so people can learn to manage their lives and only very focal areas that are affected. There are other people for whom it becomes a more global problem. In terms of the treatment, there’s a corresponding, wide range of options. In the literature, there’s debate about whether recovery is learning to live with the symptoms or whether it is a working through of the fears.

Where do you stand?
It depends on the trauma. In my experience, both approaches can be useful. The research literature is difficult to summarize, in part because it’s a challenge to get a homogenous sample for a diagnosis that’s so broad. But, generally, there is good evidence that a wide range of treatments can be helpful.

Personally, I think it is most important that a patient find the treatment and the clinician that feels right to them.Some treatment works from the premise that your body and brain work to encode threats and that these memories don’t go away. In that case, the focus is managing symptoms and developing more adaptive behaviors. Generally, these treatments slowly and safely expose a person to triggers, encourage her to tolerate the stress, and help develop coping strategies. Exposure therapies, Somatic therapies, and Eye Movement Desensitization and Reprocessing (EMDR) are all examples—they are slow means of exposing, coping with, and, in Somatic and EMDR’s cases, processing the trauma. People learn to re-train and relax their body, rather than to get overly aroused and hightail it the other way.
There’s other treatment that looks both at the behaviors and the thinking, the ways the person has come to react and to think about the stressor and the triggers. After identifying the problematic thoughts and behaviors, people develop more adaptive skills. That includes, for example, Cognitive Behavioral therapies and Dialectical Behavioral Therapy, which is largely a skills-based approach.

And then there is a psychodynamic approach. That’s generally what guides treatment at Austen Riggs— we try to learn from relationships—past and present. We try to understand the thoughts, feelings, and behaviors that come up in relationships, some of which otherwise might sabotage treatment. Earlier I said something about people with complex histories often become reactive to relationships in ways they don’t understand, so in targeting the relationship, we are trying to get that part organized so someone can stay in treatment and approach the trauma in a safe way. Through the relationship with the therapist, and through developing a personal and family history, people can then start putting together a narrative for what happened, how they’re dealing with it, how to respond more adaptively, and how to construct a more fulfilling life. Generally, psychodynamic psychotherapy focuses on the whole person, including but not only the trauma.

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