trauma thoughts

[Adam Blatner]

Eric Rutberg wrote recently, "Psychodramatists and cognitive behavioralist's understand the need to elicit the psychobiological response of a patients traumatic past, so it may be processed in the here and now. How this is done in a way that is most effective and ethical and safe is still being established but whether or not it should be done is not really debated in the bulk of scholarly literature."

Good point! I'm not even sure that the major trauma lies with what seems to be the major trauma! What I mean is that there may be significant contaminating factors from such factors as 
   -- overall vision of the situation, morale, is it good or doubtful that what we're doing over here is needed, valuable, worth it, righteous?
   -- whether I feel I'm up to playing on this team. (Without justifying the shooter's act, the idea of sending a Muslim to fight in Iraq when he said he really didn't want to go can be more than a little stressful. What military commander agreed to this?)
    -- whether I have a support system of buddies or have drifted into feelings of isolation
    -- how this situation fits with my religion
    -- have I been primed for this with earlier traumas or stresses that bring forth feelings of dis-empowerment, shame, etc.
(One thing we learned from Vietnam---and looking back, was always true--- was that if trauma is significantly powerful enough and prolonged enough, it can create a disorder whether or not there was any priming. The person may have had a near-perfect childhood, and it would not have been sufficiently protective. This wasn't appreciated through the 1960s, when PTSD (or "war shock") was "always" due to basic neurotic deficits formed in early childhood. But the psychoanalytic system at that time could find those in anyone---no matter how perfect they were. The therapist's theoretical system was self-reinforcing.)
     ... and so forth. 

    One of my mottoes that seems to apply is: Don't put a patient in touch with his negative voices before first getting him pretty well connected with his positive voices. This frequently does not happen. Many patients have several "levels" of negative voices, shame, guilt, and so forth, and in addition, their levels of self-validating inner voices, positive introjects, continuing support in real life, and so forth is far more fragile than (a) they realize or admit to themselves; (b) the therapist realizes. 

       TSM offers a number of devices that speak to shoring up this deficit, to helping possible protagonists first become able to feel valued, safe, and okay---and for many people, it wasn't the trauma that undercut those vacuums, but the other reality that their family and society did little to promote the establishement of a truly resilient sense of self. (I also believe that there are a number of techniques within the TSM model that have their own value and should be more integrated within ordinary psychotherapy.)

       So, some thoughts on trauma work. If the analogy was drawn to medical trauma, we'd be talking as much about physical therapy in the follow-up period, morale, nutrition, social support, comfort, cleanliness and protection against secondary hospital "nosocomial" infection, and so forth as we would about any surgical intervention. Also, in medical trauma, there are often several different traumas co-existing. We should apply the idea of co-morbidity to psychological trauma. 

     For example, in dealing with X and his PTSD,  what if the psychodrama overlooked the fact that the battle trauma was bad, but there was at least as much inner guilt and shame about the way X "medicated" his pain with alcohol or drugs, beat his wife, quit his job, alienated himself from his social network, and spiraled down into a heap?  The original trauma was only a trigger.    So careful history and gradual, holistic work, family sessions, social network inventories, vocational work, etc. -- all may be indicated. 

     Okay, back to work. I'm preparing for a talk to the art therapists in 2 weeks: Preliminary draft at http://www.blatner.com/adam/cartoons/mandalas/aata1109.html      for those who might be interested. Warmly, Adam

 Warmly, Adam 




Adam Blatner, M.D.
   website: www.blatner.com/adam/   
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