Why does size matter? Since we routinely call upon our memory center thousands of times in the course of a day, shrinkage would create confusion and compromise your capacity for recall. Additionally, a smaller hippocampal unit would make it more difficult to decipher which things were threatening to you and which not. Your judgment would also be reduced, and the stress response would be triggered far too often by non-threatening stimuli.
After a particularly bad auto accident, the hippocampus may be impacted. As such, deciphering what driving conditions are normal and which ones are dangerous may be extremely difficult. Hence, all driving on crowded roads and highways might be perceived as very threatening and compromise the driver’s willingness or confidence in his/her ability to drive. Again, this may contribute to your stress response being left in the “on” position for no good reason.
The limbic system, the area of the brain most responsible for emotions, contains the amygdala, which is thought to be responsible for emotional processing and the acquisition of fear responses. Your amygdala attempts to determine what a given stimulus is and whether or not to react emotionally to the stimulus. When adversely impacted by trauma, this structure in the brain is thought to become “hyper-responsive” in trauma clients. This means that not only does your brain react too strongly to trauma, but also to ANY emotional stimuli; this overreaction can be measured in cortisol levels in your blood plasma and saliva.10 11 You might find yourself crying uncontrollably during a sad part in a movie, or overreacting in fear to a bathroom spider with a handlebar mustache. This would mean that your emotional reactions to items NOT associated with the trauma would be far greater than would otherwise be anticipated. You can imagine how exhausting life would be if everything felt frightening and required you to be on high alert. This is the experience of many combat veterans, including those I have known who have kept watch throughout the night, checking and rechecking the locks on the door and the safety of their children.
As you may know, the brain is divided into four lobes: frontal, parietal, temporal, and occipital. The frontal lobe is responsible for things like personality, decision-making, initiation of activity, emotional reactivity (how one responds to emotions), motivation, social interactions, and even judgment. Evolutionarily speaking, this is the last part of your brain to develop, and it does not stop growing until your early twenties. It is this very same frontal lobe that scientists claim separates us as humans from all other creatures on the planet.
Any trauma that occurs can impact your brain functioning. Within the frontal lobe is the medial prefrontal cortex (mPFC). The mPFC is responsible for inhibiting the stress response, which is housed in the amygdala. Koenigs and Grafman (2009) noted that people exposed to trauma had a decreased activity volume in their frontal cortex, more specifically in the mPFC.12 Why is this decreased activity important to PTSD? If the area of the brain responsible for shutting off the stress response is left on, the stress response continues. Continued stress can then lead to more unhealthy responses to difficult and stressful situations, including drinking alcohol to excess, angry responses, and even social isolation.
The bottom line is this: trauma impacts the structures of the brain, making life considerably more difficult for the survivor. Healing from the traumatic event(s) becomes that much more necessary.
Consider how Jim’s brain may have responded to his trauma. With traumatic impairment of his hippocampus, he reportedly perceived two young boys in the barbershop as too closely resembling his deceased boys, which therefore launched his body into a full-blown panic attack. His under-responsive prefrontal cortex (PFC) didn’t properly regulate his over-reactive amygdala and may have made normal challenges during his work at the auto shop feel overwhelming to him. Fortunately, these changes in the brain can be addressed with good treatment and healing.
Cognitive Behavioral Therapy
Cognitive Behavioral Therapy, usually just called CBT, was developed by Albert Ellis in the 1960s and Aaron Beck in the 1970s.13 CBT holds that our thoughts and beliefs influence how we behave and feel. Such beliefs include how we view ourselves, how we view others, and how we view the world. One person sees himself as inferior, while another sees himself as superior. You perceive your mother as supportive, your sister sees her as critical. One person sees the world as warm and welcoming, the other sees the world as cold and harsh. And as your therapist will tell you is true, how you perceive something is more important than reality when it comes to your feelings and emotions. Said simply, when it comes to your emotions, perception trumps reality (and that is not a political statement).
How Beliefs about Self, Others, and the World Are Developed
Self-views relate heavily to concepts like self-esteem, self-worth, and self-confidence. All of this supports a concept that psychologists call “self-efficacy.”14 When good things happen, it is either because “I worked for it” or because “I got lucky.” Views of self are influenced heavily by parental praise and punishment. Were your parents highly critical of you? If so, then you may think, “I’m not good enough,” and that “No one will ever love me.” On the other hand, if your parents affirmed not only your success, but also your efforts, you may “try and try again.”
Views of others play out heavily in relationships. Was your trust betrayed by someone important to you? Maybe your father said he would show up at your baseball games, but never did. When the people you love let you down, trust becomes an issue.
Views of the world come into play in the work environment, in the community, in government, and for the world as a whole. Is work a competitive place where coworkers backstab each other for promotions? Or is it a place where people cooperate to get the job done? What about government? Are politicians motivated to do good, or are they inherently corrupt?
Cognitive Beliefs or Schemas
The cognitive perspective on human behavior is especially important in explaining how pathological behavior endures over time. Beck (2011) explained that in psychology, views of self, others, and the world go by a technical name; they are called cognitive beliefs or schemas.13 Your beliefs provide a readymade mold into which your experiences are poured. We’ve all had the experience of responding in a knee-jerk fashion, in a rush to judgment that seems to ignore objective facts. This happens because your beliefs influence other interpretations of experience. People tend to fall back on pre-existing biases and prejudices (the beliefs one brings to the experience). We have to. The world is far too complex, and our cognitive abilities are far too limited, for our perspectives on life to be invented anew with each rising sun. Instead, we apply what we have been taught, usually by parents, role models, education, and other previous experiences in life. We have beliefs about ourselves, others, the world, and the future. These beliefs are usually accepted as facts because we just don’t have time to isolate and test the assumptions that underlie all of our thoughts and actions. From our belief system, certain thoughts, feelings, and behaviors arise. As an example, if you believe you are unworthy and unlovable, a friend cancelling their plans to hang out with you might invoke feelings of rejection, while at the same time your friend might have a very good reason why they had to cancel their plans.
Cognitive Therapy and PTSD
This is especially true with PTSD, where the very structure of memory and cognition are changed by a traumatic event. When clients tell me they “can’t remember what happened,” they are really saying that their physiological arousal at the time of the traumatic event was so intense that they cannot recall the details of their experience. This is called “state-dependent memory,”15 which means simply that the state of the body is encoded along with the objective facts of the experience. When the state of your body changes, your memory may not be easily accessible. Symptoms of numbing dampen emotions and prevent traumatic material from reaching your conscious awareness. Hypervigilance (being overly watchful) supports a sense of safety by ensuring that the individual attends
to every possible threat. At the same time, it ensures that you perceive threats that don’t really exist, mobilizing your fight-or-flight system to deal with each such “emergency,” even if the loud noise was only thunder, and not enemy mortars.
Because PTSD changes the very architecture of cognition, it is necessary for your therapist to interpret your statements liberally. Your reluctance to cooperate in therapy can mean either, “I don’t think I’m strong enough to say this out loud,” or “Talking about the traumatic event makes it real again.” When you say, “I can’t move on,” you may be referring to flashbacks or intrusive memories that suddenly return to your mind. Or alternatively, you may be saying, “I can’t move on due to guilt… What happened was my fault.” The term “survivor’s guilt” refers specifically to this phenomenon. Survivor’s guilt occurs sometimes when you survive a traumatic event where others died.16 “I should’ve died along with my mother, father, brother, sister, child, or fellow soldiers.” Survivor’s guilt may lead to “self-flagellation,” that is, punishing yourself for “letting loved ones die on my watch.” This includes any behavior with a high potential for painful consequences, such as risk-taking (e.g., excessive speeding), self-harming (e.g., cutting), self-neglect (e.g., drinking, drugs, loss of jobs and relationships), and not seeking treatment (in order to continue the misery of unresolved trauma). Careful inspection shows that self-blame is actually based on the expectation or assumption that life should be fair for everyone. Life is not fair, and the consequences can be tragic, particularly when you attempt to take responsibility for events beyond your control.
For Jim, schemas (or beliefs about self, others, and the world) about himself became more and more prominent as therapy progressed. “I’m the worst father ever,” he confessed. Not a single day passed in Jim’s life that he didn’t feel guilty for what happened to his sons. If you tell yourself the same thing every day for forty-five years, you are likely to believe it. Jim perceived himself as a failure. Not only did he fail to find his sons when he drove into the water, he was still alive. “If only it could have been me,” he thought. “Why couldn’t it have been me? Why didn’t I check the ice? Why am I still alive when my boys are dead?” Taking responsibility for the impossible was Jim’s way of remaining connected to his sons, his attempt to turn a wish into reality. As long as Jim believed that he was “the worst father ever,” he deserved whatever misery he could bring on himself. To be whole again, Jim needed to let go, and he needed to realize that letting go was not an abandonment of his sons.
Before I go any further, I would like to state that there is a lot of research conducted on the effectiveness of CBT for PTSD treatment. Research has shown repeatedly that CBT is indeed effective in the treatment of PTSD. In a particularly good research study done by Nilamadhab Kar (2011), a meta-analysis conducted using thirty-one randomized control studies, the “gold standard” of psychological research, showed that CBT had successfully reduced trauma-related symptoms in people who were victims of terrorism, combat, sexual assault, refugees, and motor vehicle accidents, as well as disaster survivors.17 So far, so good, right? Another meta-analysis of fifty-five studies of empirically supported treatments for PTSD found that nonresponse and dropout rates were as high as 50 percent.18 This meant even odds, or the flip of a coin on whether or not you’d get better or drop out of treatment, or not very good chances, to my mind, and as I’ll explain later, I think there is a reason for this. Yet CBT is still a major contributor to my theory on how you can heal from trauma.
Freudian Theory
I’ve never been a Freudian, not even a little bit. I never liked his theories on psychosexual development and especially disliked his (over)emphasis on sex, aggression, and the unconscious. But admittedly, I have been profoundly influenced by Freud in two ways, especially as it relates to my theory on healing from a pain in the past.
First, I think Freud’s writings on defense mechanisms were pure genius. The defenses he described are still widely accepted today by most practitioners because they are highly useful and spot-on, including denial, minimization, rationalization, and displacement.19 But when it comes to treating trauma survivors, the defense mechanism that stands out above the others to me is repression. It is well-documented that horrific trauma can be so overwhelming that the only possible mode of survival is to block even the memory of the experience from the delicate mind. It really happened, and it is stored in the brain (in complete detail and living color for future recall), but for now, there is a free pass to survive without the ugly movie in your head. The mind, it appears, is attempting to block the images, the way your mom put her hands over your eyes during the naughty parts of the movie. The memory is frozen, presumably in your hippocampus, only to be triggered some time in the future by an otherwise benign event. Whatever was frozen is now defrosted and fresh, as if it had just happened. Good therapy requires that it (finally) be dealt with and put away successfully in order to return the stress switch back to the “off” position.
Similarly, Freud postulated that the goal of good therapy (psychoanalysis) was to make the unconscious conscious.20 In other words, in order to heal, the trauma must be processed on a conscious level. Hence, the material that has never been allowed to surface (and is thus neither remembered, felt, nor expressed) cannot be released to allow the client to heal. From all indications, Freud, it turns out, was exactly right. That is, no healing will occur until you consciously process and release your traumatic memory.
Gestalt Therapy
The great German theorist and psychologist Fritz Perls is one of the most underrated and underappreciated contributors to modern psychology and especially to psychotherapy. If I asked twenty recent doctoral residents in psychology the question of who are the top five greatest contributors to their style of practice, I don’t know if I I’d hear the name Fritz Perls mentioned even once.
So why do I deem him to be so influential and necessary in successful recovery from trauma? His Gestalt (the German word for the whole picture, entity, or enchilada) theory emphasizes closure, or completion of unfinished business.21 Who do you know that mows 90 percent of their lawn? Makes half the bed? Shaves one leg? We have a need to complete things, to put things away or find a better place for them psychologically. It’s a phenomenon I observe every day in my office. Someone presents feeling stressed and overwhelmed because of their perception of a given situation in their lives. By the end of the session they feel dramatically relieved and better—not because the world has changed, but because they perceive an opportunity to place something painful, scary, or threatening in a better place where it loses its power to upset them. With unresolved trauma, clients cannot seem to let go of their horror because it is unfinished for them. Whether it is blocked partially or completely from their memory (repression), repeats endlessly on a loop, or recurs every night in a nightmarish dream, it is only because it is unfinished.
Jim needed to “finish” his trauma by saying goodbye to his sons and forgiving himself for his perception of his having allowed them to die. He also needed to forgive God22 for “taking his sons away from him.” Finally, he had to believe that he had a life where he could find happiness.
Religion and Forgiveness
Pick a religion, any religion. With the exception of perhaps Satanism, virtually all religion teaches the necessity of forgiveness for living a godly life and achieving peace, wholeness, and connection with the divine. In Buddhism, forgiveness is about removing unhealthy emotions that would otherwise cause harm to the non-forgiving person. Likewise, Sikhism describes forgiveness as the remedy to anger, especially when the forgiving person is aroused by compassion. Judaism requires forgiveness after a sincere apology, but even in its absence, forgiveness is considered a pious act. Islam is a term derived from a Semitic word meaning peace. Forgiveness is thought to be a prerequisite for achieving peace.23
In Christianity, Jesus taught his followers to pray to God the father, “Forgive
us our debts, as we forgive our debtors” (Matthew 6:12, King James Version). Note that he already assumes that we ought to be forgiving others, as it is essential to improve our own status with God. Jesus went on to say, “but if ye forgive not men their trespasses, neither will your Father forgive your trespasses.” (Matthew 6:15, King James Version.)
Perhaps it is fair to conclude that forgiveness is that which lets the afflicted off the hook, as much or more than the offender. How is that so? Because the opposite of forgiveness, resentment or hatred, is known to be a toxin for the grudge holder. A twentieth-century Buddha, Mark Twain, quipped, “Anger is an acid that can do more harm to the vessel in which it is stored them to anything on which it is poured.”24 Research has confirmed that resentment contributes to numerous conditions, including depression, heart disease, and premature death.25
But what exactly is forgiveness? Let’s begin with what it isn’t. Psychologist Syd Simon taught that forgiveness is not forgetting; it is not revenge, nor does it condone the offense. Forgiveness, in the simplest sense of the word, means to let go.26
This translates into two types of forgiveness: forgiveness without reconciliation and forgiveness with reconciliation. They both allow for letting go of the offense, but one restores the relationship to the place or position held prior to the perceived offense, while the other does not. (Think of this as “Mounds Bar” and “Almond Joy;” they are both the same candy, but one has nuts, and the other doesn’t.)
Keep Pain in the Past Page 3