PTSD page 3

What makes this work at Riggs different from psychotherapy in an outpatient setting?
As I’ve said, most of our patients tend to have complicated presentations, many have had trauma in the context of relationships. We don’t often see people who have suffered a car accident and are only worried about driving again. That person might do just fine in an outpatient setting. But our patients, by the time they come to Riggs, are so deeply submerged and confused that getting stable in and making good use of outpatient psychotherapy might not be possible. It’s like there needs to be work done beforehand, before someone can use outpatient work effectively.

We often see people who can’t trust treatment providers, who can’t contain their feelings at the end of sessions, who can’t think straight in the face of strong feelings, or who don’t know what trauma they are reacting to. We sometimes even see people who are suffering trauma that happened to their families, trauma that didn’t necessarily happen directly to them. The trauma has played a major role in shaping their relationships, but they don’t know what it is. It can be particularly hard when a parent has PTSD and they’re trying to parent their child. PTSD can create really chaotic relationships that are more focused on managing fears about the trauma than on relating authentically.

By the time patients get to Riggs, there’s generally a lot going on in terms of complicated relationships, co-morbid disorders, and sometimes substance abuse, suicidality, and eating disorders. Figuring out what the problem is part of what we try to do in our evaluation. In the treatment teams and in the therapeutic community, we have the luxury of seeing someone across contexts, not just in the psychotherapy office, so we get a broad sense of how they act across different kinds of circumstances. The patients also have the benefit of getting constant feedback from both patients and staff. And, like I said earlier, we also work with families to deepen our understanding.

In both our evaluation and treatment, we are constantly trying to pull all of this information together to make sense with the patient about why she is doing what she is doing. While we’re doing this, the Community and Activities programs give opportunity for people to exercise their competencies when often times, in doing this kind of work and in their lives more generally, our patients have felt incompetent and out of control.

I think another way that Riggs can be helpful in addressing complicated presentations that include PTSD, is that in addition to developing understanding, we also have skills-based groups and a nursing staff that help develop ways of coping with intense emotions. So patients, at the same time, get help managing the thoughts and feelings they are working on in psychotherapy. Obviously, in outpatient psychotherapy, there’s just not enough time to do such intensive, multi-faceted work.

What happens when the treatment goes well?
People can learn how to live differently. They learn why they do what they do and they learn that, if they want to, they can change. They get some context for their behaviors and they recognize that the things they have been doing may not be their only options.

Our goal at Riggs is about helping people take charge of their lives. PTSD—or any other disorder, for that matter—can really take over someone’s life. We try to help them regain some control or understand why control might be overwhelming. That might mean very specific approaches on how to calm down when you’re scared. Or it might mean more broad power over how to be in relationships in a different way, how to use your mind, how to tolerate feelings, how to better interpret people’s intentions, or how to assess situations more realistically. It might also involve letting go of some of the destructive things they have done to stabilize themselves.

Good treatment comes in stages and is a collaboration between the patient and the treatment providers. The first priority is to get stable and get some sense of what’s going on. This includes slowing down and taking a look at what’s happening. Initially, it’s also usually important to work on self-care as a lot of people with PTSD become so wrapped up in the chaos of their lives that they stop taking care of themselves. It’s really helpful to establish regular sleep and regular eating for example—to get the basics under control.
Then, slowly, with a little more room, you start to move back and see what comes up. You work through it together. At Riggs, there’s an opportunity to study yourself real-time, and to practice new skills of managing yourself and relating to others. And while you’re here, you’re in a supportive environment where people understand PTSD and the thinking and the behaviors it engenders.

One of the special features of Austen Riggs is an activities program where patients can work with wood, or other crafts, or work on theatrical productions. Does this help people with PTSD?
Yes, it’s a major help. It’s important for people with PTSD—or any other disorder—to learn how to express themselves. For someone who has experienced early trauma, it’s often difficult to get at because it’s not in words. Our goal here is to put as much as we can into words. Creative production can be helpful as a step in that direction. It’s also a place you can step out of being a patient. You can be a student. You can work. And, it’s safe.

It’s fascinating what happens there. People present themselves very differently there than in other situations. We have a lot of patients who self-harm, who cut themselves in an effort to regulate their feelings. But at the Activities program, where you are expected not to abuse the tools or the creative space, they often find a way to manage otherwise. It’s a great experience.

What role does medication play?
Most of the research says that no matter what kind of therapy you do, some kind of medication and therapy is the best approach. For PTSD, medications can be particularly helpful in toning down the body’s hyper-arousal so you can actually get closer to the thing that’s so terrifying, work it through, and begin to live your life again. Also, some people with PTSD get so confused and disorganized about past and present, fantasy and reality that medication can be helpful in re-establishing grounding in the present. We also use medication to target co-morbid conditions. For example, it’s natural for people to get depressed if they can’t live the kind of life they want, and anti-depressants might help with that while you engage in therapy to get at the root of the problem.

How did you get interested in PTSD originally?
Originally, I came at it from a feminist perspective. When I went to college, 15 years ago, there was a movement called Take Back the Night, which sought to give voice to victims of sexual violence. Later, in graduate school, I studied at the Victims of Violence clinic. We treated people there with all kind of trauma histories and very chaotic lives. There were men and women currently in violent relationships, refugees, and people with long histories of physical, sexual, and emotional trauma. I then trained at a Veterans’ Administration hospital, which obviously serves a different population, more often suffering combat-related difficulties.
I left my training feeling like there was something more—much more—I needed to learn about people who couldn’t tolerate the relationship long enough to engage in therapy or who were using the therapeutic relationship in ways I didn’t understand. I wanted to slow down and learn about it. So I applied to Riggs as a psychology fellow. There’s no better way to learn about how people’s minds work that than to meet with them four times a week and work closely with really well trained colleagues.

What do you find so compelling about PTSD?
One way of thinking about PTSD is that it’s somebody doing her best — even though it may look destructive and chaotic — to adapt to a horrific set of experiences. I think there is a tremendous integrity in that, even if it’s difficult to work with as a therapist. The patient has integrity in that they are trying to survive. It’s humbling. I try to hold that in mind, even when patients are sabotaging treatment. I try to remember that they are communicating something in the best way they know how. They are really fighting for something, even if that means sometimes they’re fighting me.

For people who want to learn more about PTSD, what might you suggest they read?
Judith Herman’s book “Trauma and Recovery” was really helpful for me. She’s a feminist clinician- researcher who writes clearly about a broad range of trauma—sexual abuse to political trauma to combat trauma. In this book, she covers diagnosis, history, and treatment accessibly and with great compassion.

The other author that comes to mind is Tim O’Brien. He is a fiction writer who writes about the experience of combat and its aftermath—I don’t think he specifically calls it PTSD—but it’s there in a felt way. His novel “In Lake of the Woods” does a wonderful job of showing how someone can feel disoriented between past and present.