EMOTIONAL RELEARNING AND RECOVERY FROM TRAUMA
Irene had gone on a date that ended in attempted rape. Though she had fought off the attacker, he continued to plague her: harassing her with obscene phone calls, making threats of violence, calling in the middle of the night, stalking her and watching her every move. Once, when she tried to get the police to help, they dismissed her problem as trivial, since "nothing had really happened." By the time she came for therapy Irene had symptoms of PTSD, had given up socializing at all, and felt a prisoner in her own house.
Irene's case is cited by Dr. Judith Lewis Herman, a Harvard psychiatrist whose groundbreaking work outlines the steps to recovery from trauma. Herman sees three stages: attaining a sense of safety, remembering the details of the trauma and mourning the loss it has brought, and finally reestablishing a normal life. There is a biological logic to the ordering of these steps, as we shall see: this sequence seems to reflect how the emotional brain learns once again that life need not be regarded as an emergency about to happen.
The first step, regaining a sense of safety, presumably translates to finding ways to calm the too-fearful, too easily triggered emotional circuits enough to allow relearning.18 Often this begins with helping patients understand that their jumpiness and nightmares, hypervigilance and panics, are part of the symptoms of PTSD. This understanding makes the symptoms themselves less frightening.
Another early step is to help patients regain some sense of control over what is happening to them, a direct unlearning of the lesson of helplessness that the trauma itself imparted. Irene, for example, mobilized her friends and family to form a buffer between her and her stalker, and was able to get the police to intervene.
The sense in which PTSD patients feel "unsafe" goes beyond fears that dangers lurk around them; their insecurity begins more intimately, in the feeling that they have no control over what is happening in their body and to their emotions. This is understandable, given the hair trigger for emotional hijacking that PTSD creates by hypersensitizing the amygdala circuitry.
Medication offers one way to restore patients' sense that they need not be so at the mercy of the emotional alarms that flood them with inexplicable anxiety, keep them sleepless, or pepper their sleep with nightmares. Pharmacologists are hoping one day to tailor medications that will target precisely the effects of PTSD on the amygdala and connected neurotransmitter circuits. For now, though, there are medications that counter only some of these changes, notably the antidepressants that act on the serotonin system, and beta-blockers like propranolol, which block the activation of the sympathetic nervous system. Patients also may learn relaxation techniques that give them the ability to counter their edginess and nervousness. A physiological calm opens a window for helping the brutalized emotional circuitry rediscover that life is not a threat and for giving back to patients some of the sense of security they had in their lives before the trauma happened.
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Another step in healing involves retelling and reconstructing the story of the trauma in the harbor of that safety, allowing the emotional circuitry to acquire a new, more realistic understanding of and response to the traumatic memory and its triggers. As patients retell the horrific details of the trauma, the memory starts to be transformed, both in its emotional meaning and in its effects on the emotional brain. The pace of this retelling is delicate; ideally it mimics the pace that occurs naturally in those people who are able to recover from trauma without suffering PTSD. In these cases there often seems to be an inner clock that "doses" people with intrusive memories that relive the trauma, intercut with weeks or months when they remember hardly anything of the horrible events.19
This alternation of reimmersion and respite seems to allow for a spontaneous review of the trauma and relearning of emotional response to it. For those whose PTSD is more intractable, says Herman, retelling their tale can sometimes trigger overwhelming fears, in which case the therapist should ease the pace to keep the patient's reactions within a bearable range, one that will not disrupt the relearning.
The therapist encourages the patient to retell the traumatic events as vividly as possible, like a horror home video, retrieving every sordid detail. This includes not just the specifics of what they saw, heard, smelled, and felt, but also their reactions—the dread, disgust, nausea. The goal here is to put the entire memory into words, which means capturing parts of the memory that may have been dissociated and so are absent from conscious recall. By putting sensory details and feelings into words, presumably memories are brought more under control of the neocortex, where the reactions they kindle can be rendered more understandable and so more manageable. The emotional relearning at this point is largely accomplished through reliving the events and their emotions, but this time in surroundings of safety and security, in the company of a trusted therapist. This begins to impart a telling lesson to the emotional circuitry—that security, rather than unremitting terror, can be experienced in tandem with the trauma memories.
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The five-year-old who drew the picture of the giant eyes after he witnessed the grisly murder of his mother did not make any more drawings after that first one; instead he and his therapist, Spencer Eth, played games, creating a bond of rapport. Only slowly did he begin to retell the story of the murder, at first in a stereotyped way, reciting each detail exactly the same in each telling. Gradually, though, his narrative became more open and free-flowing, his body less tense as he told it. At the same time his nightmares of the scene came less often, an indication, says Eth, of some "trauma mastery." Gradually their talk moved away from the fears left by the trauma to more of what was happening in the boy's day-to-day life as he adjusted to a new home with his father. And finally the boy was able to talk just about his daily life as the hold of the trauma faded.
Finally, Herman finds that patients need to mourn the loss the trauma brought—whether an injury, the death of a loved one or a rupture in a relationship, regret over some step not taken to save someone, or just the shattering of confidence that people can be trusted. The mourning that ensues while retelling such painful events serves a crucial purpose: it marks the ability to let go of the trauma itself to some degree. It means that instead of being perpetually captured by this moment in the past, patients can start to look ahead, even to hope, and to rebuild a new life free of the trauma's grip. It is as if the constant recycling and reliving of the trauma's terror by the emotional circuitry were a spell that could finally be lifted. Every siren need not bring a flood of fear; every sound in the night need not compel a flashback to terror.
Aftereffects or occasional recurrences of symptoms often persist, says Herman, but there are specific signs that the trauma has largely been overcome. These include reducing the physiological symptoms to a manageable level, and being able to bear the feelings associated with memories of the trauma. Especially significant is no longer having trauma memories erupt at uncontrollable moments, but rather being able to revisit them voluntarily, like any other memory—and, perhaps more important, to put them aside like any other memory. Finally, it means rebuilding a new life, with strong, trusting relationships and a belief system that finds meaning even in a world where such injustice can happen.20 All of these together are markers of success in reeducating the emotional brain.
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