A Narrative Constructivist Perspective of Treatment of PTSD with Ericksonian Hypnosis and EMDR

Abstract

In a trauma survivor, physiological responses are exacerbated when the affect-laden memories stored in associative networks are triggered by environmental sensory inputs or cues and activate the autonomic nervous system. Recovery from trauma involves not only amelioration of physiological and dissociative symptoms, but also the cognitive rebuilding of a viable assumptive world view which integrates the realms of vulnerability, meaning and self-esteem. This world view is contextualized in cultural idioms and values.

From an Ericksonian perspective, persons are usually attempting to problem-solve, even in a dissociative state. A symptom such as an intrusive recollection or recurrent dream of a traumatic event is therefore construed as a request for help in problem-solving. Hypnosis is a structured dissociation which facilitates cognitive flexibility; that is, the broadening of choices of the client' s belief system, rather than direct work on changing affect or behaviors. The goal of Ericksonian hypnosis is to recontextualize the traumatic memory, the affect of fear, and the physiological hyperarousal cued by the traumatic memory. This occurs within a broader context of pride, mastery and courage, and within a context inclusive of other memories and affects, which are positive for the client.

Eye Movement Desensitization and Reprocessing (EMDR), similarly has as its goal the facilitation of a transfer of traumatic data from the cortical right hemisphere to the left hemisphere. EMDR also utilizes the attainment of a state of heightened awareness, or collaborative structured dissociation, in order to facilitate the orientation of the traumatized client's conscious mind toward "revisiting" traumatic memories.

Both interventions can facilitate the self-narrative reconstruction process of trauma survivors by simultaneously modulating the person's hyperarousal while attending to the culturally significant metaphors which form the building blocks of a person' s world of meanings.

Posttraumatic Stress Disorder from a Constructivist Perspective

The experience of victimization by severely traumatizing events lasts far longer than the events because of the intensity of the psychological sequelae which follows. Emotional reactions which overlap across a diversity of victimizations (combat, rape, natural disasters, severe accidents, violent crime, genocide, etc.) include shock, confusion, helplessness, anxiety, fear, and depression. Characteristic symptoms which may follow "a psychologically traumatic event that is generally outside the range of usual human experience" and "would evoke significant symptoms of distress in most people" fall into four domains: 1) re-experiencing the traumatic event, through repetitive, intrusive recollections or recurrent dreams; 2) numbing or reduced responsiveness to the outside world (detachment and/or constricted affect); 3) hyperarousal, including sleep disturbance, exaggerated startle response and hypervigilance; and 4) avoidance of activities or inputs which cue recollections of the traumatic events.

From a Narrative Constructivist perspective, victimization often results in the shattering of basic assumptions persons hold about themselves and their world. Three particular assumptions appear to be most seriously affected: 1) the belief in personal invulnerability; 2) the perception of the world as meaningful and comprehensible; and 3) the view of selfhood in positive terms (Janoff-Bulman, 1985). Recovery from trauma involves not only amelioration of psychological and dissociative symptoms, but also the cognitive rebuilding of a viable assumptive world view which integrates the realms of vulnerability, meaning, and self-esteem. Both the pre-trauma assumptions and those following traumatic events are moderated by cultural beliefs, customs and the social organization of the survivor's root culture.

An Ericksonian Model of PTSD

Persons suffering from the physiological symptoms and the cognitive and "spiritual" issues related to their traumatization focus on negative memories which force a no-choice association of a never-integrated event memory with an environmental cue. The initial traumatic event leaves them no opportunity to connect these event memories with neural pathways of positive events in the domains of mastery, competence or confidence. A PTSD memory intrudes from the unconscious into the waking state. The victim does not so much wish to obliterate the traumatic memory but wishes to contain it in a state where it can be accessed at will rather than intrusively. A feedback loop must be formed to connect the traumatic event memories to healthy neural pathways (Lankton & Zeig, 1988).

Neurophysiology of PTSD

Higher cognitive processes, including those involved in psychotherapy, occur in the prefrontal cortex of the brain. However, affect and primitive memory (sensory inputs) are processed in the limbic system. The thalamus receives sensory inputs; the significance of these inputs is determined by the amygdala; and the hippocampus forms a cognitive map of these inputs according to their levels of significance. The cognitive processing of the prefrontal cortex does not reach the body (autonomic nervous system) or influence affect in a person with PTSD (Van der Kolk, 1994). Physiological responses are exacerbated when the affect-laden memories stored in associative networks are triggered by environmental sensory inputs or cues and activate the autonomic nervous system. PET scans of subjects who have suffered severe trauma demonstrate that the traumatic memories are stored in the amygdala in the right hemisphere. Furthermore, MRIs of traumatized subjects reveal a shortening of the hippocampus in persons with PTSD as compared to normal subjects. This implies a level of brain damage sufficient to impede new learning (Van der Kolk, 1994). Such a deficit would prevent the neutralization of traumatic memories by cognitive processes such as analysis and integration of events and assumptions or beliefs. Furthermore, left hemisphere-driven cognitive processes would not facilitate the diminution of the autonomic response triggered by environmental cues in a person with PTSD.

Rationale for Treatment of PTSD with Ericksonian Hypnosis and/or EMDR

From an Ericksonian perspective, persons are usually attempting to problem-solve, even in a dissociative state (Lankton & Zieg, 1988). A symptom such as an intrusive recollection or recurrent dream of a traumatic event is therefore construed as a request for help in problem-solving. In order to treat the symptoms successfully, one helps to change the person' s style of problem-solving. A major goal is to "package" this new coping mechanism in a way that is acceptable to the person's conscious mind, since he/she has thus far coped with the physiological and cognitive sequelae of trauma in a style maladaptive to non-traumatic or non-crisis states or environments.

The psychotherapist who utilizes Ericksonian hypnosis will let the traumatized person know the following: 1) that all hypnosis is self-hypnosis; 2) that the client chooses only suggestions which are relevant to him/her; 3) that hypnosis is a heightened state of awareness for internal events only; 4) that hypnosis does not "unblock" or "get to the truth" of anything that is not consciously available; 5) and that hypnosis is a structured dissociation which facilitates cognitive flexibility; that is, the broadening of choices of the client' s belief system, rather than direct work on changing affect or behaviors. The goal of Ericksonian hypnosis is to recontextualize the traumatic memory, the affect of fear, and the physiological hyperarousal cued by the traumatic memory, within a broader context of pride, mastery, courage, etc., and within a context inclusive of other memories and affects, which are positive for the client.

Metaphor provides an altered frame of reference that allows the client to entertain novel experience without physiological hyperarousal and attending negative affect. The structured dissociation/metaphor induction process raises the threshold of awareness of physiological arousal, or anxiety; that is, the client is aware less often and less intensely of the signs of anxiety. The healing or recovery which results from the process of structured dissociation and inherent use of metaphor in cognitive restructuring derives from a reassociation of experiences in memory rather than from hypnotic suggestion. That is, there is a shift in experiential memory so that a modulated response occurs in the body's musculoskeletal and autonomic nervous systems when the traumatic memory is evoked.

Eye Movement Desensitization and Reprocessing (EMDR), developed as an intervention for the treatment of trauma and anxiety by Francine Shapiro, Ph.D. (1996), similarly has as its goal the facilitation of a transfer of traumatic data from the cortical right hemisphere to the left hemisphere where this data (inputs) can be analyzed and integrated by the cognitive functions of the left hemisphere, so that recontextualization of the traumatic events may occur and the negative physiological and affective arousal may be concomitantly neutralized or modulated. Despite an essentially behaviorist intervention protocol, EMDR also utilizes the attainment of a state of heightened awareness, or collaborative structured dissociation. This facilitates the orientation of the traumatized client' s conscious mind toward "revisiting" traumatic memories and the cognitive restructuring process, while simultaneously modulating the physiological arousal and associated affect of the client during evocation of traumatic memories. PET scans of persons diagnosed with PTSD who are being treated with EMDR have demonstrated the transfer of traumatic data from the right to left hemisphere during the PET process, whereas the PET scans of PTSD clients not being treated with EMDR during the PET assessment demonstrate no comparable transfer of traumatic data between hemispheres (i.e., no cognitive processing) (Van der Kolk, 1994).

Conclusion

The use of either Ericksonian hypnosis or EMDR, or an interweave of both interventions in the treatment of trauma victims with Posttraumatic Stress Disorder, is worthy of further research and discussion, given the relatively poor results achieved by other psychotherapeutic interventions, both psychodynamic and behavioral, for the amelioration of symptoms involving "spiritual" issues as well as cognitive deficits, hyperarousal, and attendant negative affect. Psychotherapy which does not address the "spiritual" issues of emotional and cognitive detachment from self and others, and from a sense of connectedness with humanity in general, cannot heal the traumatized person because only intellectual cognitive process (understanding) or observable behavior (symptom amelioration) is targeted. Frequently, no attempts are made to contextualize the symptoms and spiritual loss, nor the healing process, within the cultural metaphors most salient to the individual trauma survivor.

Interventions which help to modulate the survivor's arousal while respectfully attending to cultural issues and idioms which facilitate self-healing tend to utilize the survivor's resilience and unique sensibilities in lieu of professional expertise, counsel or values. Furthermore, the personal world of meanings which undergoes rapid rigidification and narrowing following traumatization must evolve both a deconstruction process of the trauma-based beliefs and a reconstruction process (of a new self narrative which integrates both negative and positive self-story elements within a culturally ecological and well-organized elaboration)

Within the context of a sound theoretical base such as the Narrative Constructivist model described here, the interventions of EMDR and Ericksonian Hypnosis can greatly facilitate the integration of the overall capacities of the human mind, body and spirit in a survivor's journey of recovery from trauma.

References

Janoff-Bulman, R. (1988). The aftermath of victimization: Rebuilding shattered assumptions; In Trauma and Its Wake, Charles R. Figley (Ed.), Brunner/Mazel, New York.

Lankton, S. & Zeig, J. (Eds). (1988). Ericksonian monographs; Special treatment populations. New York: Brunner/Mazel.

Shapiro, F. (1996). Errors of context and review of eye movement desensitization and reprocessing research. Journal of Behavior Therapy and Experimental Psychiatry, 27, 313-317.

Van der Kolk, B.A. (1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1, 253-265.