PTSD Perspective
 
 
 
 
Combat Operational Stress Control: The Many Realms of Trauma Bob Bornt, LMFT UCLA conference on Trauma During the recent “Current Approaches to the Treatment of Trauma” conference held at UCLA, reference was made to a variety of environmental realms of experience and psychophysiological states that can precipitate trauma and may result in PTSD. The body’s neural relationship to the brain received considerable attention - through discussion of the vagal nerve’s function with trauma. Continual reference was also made to the three general parts of the brain: the neo-cortical structures (new brain), the mid-brain functional structures (old mammalian brain), and the forebrain subcortical relay structures together with the brainstem nuclei (brain core or reptilian brain), which provided the framework for making sense of it all. Ultimately, the perspectives and conclusions of the conference helped me define aspects of trauma’s effects and processes of resolution critical to my work with active duty military and veterans struggling with the experiences of war and long deployment. Research information regarding the traumatic impact on the brainstem and affect relay structures of the forebrain was particularly illuminating. Consideration of this information may account for the inefficiencies in mental health services for military members. Military members, as a whole, are resilient and trained to survive under stress. Nonetheless, news accounts and testimony before Congress reveal that a massive number of individuals are struggling to manage the impact war and long deployment. They are not showing up at mental health facilities for support. When they do, they rarely continue. I have felt a continuing dissonance regarding the conference research information and the presentations of its clinical application. My experience with military clients has formed a perspective that differs somewhat from the clinical interpretations presented at the conference. The behavior of military and veteran clients in response to various approaches to therapy can be one efficient barometer for treatment evaluations. Schema The current understanding of brain processes may offer an understanding of this dissonance and potential for an adaptation of clinical perspectives. We know the brain stores information about “objects and concepts” in neural clusters or schemas in the cortex so that recognition and response to new stimulus flows more efficiently. Activities in the brain get increasingly energized when incoming concepts are incongruent with schema already structured in the brain. The unexpected or excessive use of energy involved in making sense of incoming data in relation to existing schema increases the perception of risk. Thus, automatic survival systems may defend against what is coming if it is too foreign by utilizing adaptive patterns to interpret, design or simply deny new objects or concepts - to avoid increased risk. These defenses appear to be subtle systems organized by higher brain intellect and function, although they are part of the overall neurological survival mechanism. Brain Map While there is no precise map of the brain’s function on its structure, the most recent research, using fMRI scanning, is illuminating the processes of both traumatic impact on the brain’s deepest structures and the potential for healing. Bessel van der Kolk, Boston University School of Medicine, presented the most dramatic information delineating how extreme trauma induces limitations in the processes of the subcortical and brainstem regions of the brain, specifically a shrinking of the thalamus. This is the area where almost all sensory impulses are relayed for functional processing and interpretation and/or integrated for functioning of the autonomic (involuntary) nervous system (ANS) through the reticular formation. Conference discussions of this particular area of the brain seemed to excite everyone’s interest. However, clinical presentations of treatment potentials seemed to edit the potential for van der Kolk’s research in order to conform to their own particular schemas where they remained focused on the cognitive/decisive and/or the functional emotion/memory structures of the brain. In particular, there were many references to similarities between subcortical processes and the integration processes which occur during REM sleep. Yet, in presentation, a strong adherence appeared to remain in the schema that secure attachment, efficient affect regulation and integration are mutually dependent. They may well be in certain realms and aspects of trauma recovery, especially relationship based trauma. However, the process of integrating life experiences during REM sleep, where social engagement functions may be “off-line”, truly excited my interest, especially for working with the impact of war on our young warriors, where sleep deprivation and unintegrated experience are signature PTSD phenomena. This information, combined with my experience with military clients, fortifies my belief that it is possible for efficient affect regulation to be a result of an increase in coherent integration. The Researchers Researchers Bessel van der Kolk, Steven Porges, and Allan Schore presented detailed neurobiological information about the regulation of affect and integration of experience, describing how sensory affect from the body moves through the base brain and is relayed on by functional structures in the right-brain hemisphere where it is integrated – bundled with space, time, sound, sight, etc., into the left-brain and cortical regions where it is categorically stored. The most important quality of storage, in relation to trauma recovery, seemed to be autobiographical memory. It is important to note a distinction here. Memory is complex and distributed throughout the cortex. Autobiographical memory appears to be unique regarding the representation of one’s self in history. Qualities of this representation, both stored and attempting integration into storage, are vital aspects of effective integration and the resolution of traumatic experience. If during an experience, sensory stimulated affect is not regulated within a tolerable range (conducive to survival) at each level of the integrative process, due to interpretations, comparisons, or innate response to threat, regulation capacities are altered or adapted. As the degree of life threat increases, brain neuro-processes inhibit intellectual, then cognitive, then emotional, and then relay capacity leaving the core to shut down and prepare for death. Fortunately, the process can reverse quite rapidly with functionally developed structures returning to homeostasis. It is also clear that experience becomes traumatic when brain structures fail to fully recover and perform once threat has passed. When they are impacted in ways that persist, they continue to cause adaptations or disregulation of new and ongoing sensory stimulated affect. Research is continuing to discover the specifics of stress impact on the body/mind. One important element that seems obvious in military PTSD, especially in light of van der Kolk’s research regarding trauma’s impact on the thalamus and brainstem, is the prolonged and persistent compression to these areas during military duty. Right-brain capacity has long been the focus of relational therapies, but research and treatment must begin to consider what explosions and whiplash do to brain core capacity. New DSM classification for PTSD Among other enlightenment, van der Kolk presented his research as co-principal investigator of the DSM V Field Trials for PTSD. The results identified a clear difference between childhood developmental trauma disorders and those associated with experiences in adulthood. Dr. van der Kolk and his collaborative team have presented a proposal to establish a classification for Developmental Traumatic Disorder, separate from the current adult onset trauma diagnosis, in the upcoming DSM V. His findings have significant meaning for working with a military population, who frequently have both early developmental and wartime traumas. The additional potential for pre-enlistment trauma of childhood compounds treatment and may very well require extreme sensitivity and flexibility in treatment perspectives. New Perspective for Military PTSD Effective treatment may even require new perspectives, which include the impact of an intense single episode, the prolonged exposure to life threat, and the potential for physical compression and injury of the base brain in war. Treatment can get increasingly complex with the comorbidity of multiple realms of trauma. In addition, another unique issue regarding functional trauma must be considered. Marines and their families have addressed the importance of this in many interviews with me. They have expressed disdain for their therapeutic experiences and report that therapy is all about the therapist, and simply state that, “Therapy does not work!” It is extremely important to consider what this means without prejudice. Military-service induced PTSD, regardless of comorbidity, has a different feel to it when explained from the client’s perspective. And it certainly feels different to me, as a therapist working with active duty and veteran clients. The realms of cultural difference and training between military, veteran, and civilian clients contribute to treatment barriers, along with the associated stigma of being mentally ill. However, there is also the power of unity and the intricacies of trust. Unity seems to be the least understood realm of military culture for caregivers, and it seems to be the catalyst creating a deepening, traumatic discontent for therapy by those who serve. The quality of unity in military culture is like that of tribes, clans, and family. Unity knows no border and persists beyond death. At the core of unity is trust. Trust arises out of the capacity to rely on and maintain consistent action. It is a functional process of the brain where efficiency, and thus safety, comes from the brain’s capacity to match incoming data with existing clusters of knowing. A Marine can despise his command, yet he will trust his life to him. A soldier can trust his enemy – when the enemy maintains convention. It is an innately driven phenomenon, which requires a unique environment. Experience has shown me that military clients will also trust a therapist when their ethos is not violated. Relational Trust Military training, especially for Marines, is one of strength and resilience. They are trained to “suck it up and take care of it,” and to only rely on their fellow Marines. Significant attachments are created at the social, emotional, and core survival levels. Trust is embedded and nearly instinctual, even for those discharged in grievance. Attachments developed during military training and deployments, along with the corresponding trust, can present barriers to efficient treatment. While many are finding help in treatment, they are the tip of the iceberg. The body of the iceberg is not showing up at VA hospitals and clinics. They are going it alone (as a group), bonding in bars, jails, and in underground meetings. Unfortunately, evidence is showing they are not healing the wounds of war. Decompression Rest after wartime experience and long deployment is critical for efficient and effective treatment. Rest, neurological rest, happens when there is time and space for the greater neural systems and processes of the body/mind to decompress, to disengage from the job of survival (including the obligation to maintain relationships) and embrace an opportunity to recover and play. Porges delineated the difference between the energetic expressions of play and those of survival. Play invigorates and builds regulatory systems through positive, social interaction, while survival requires limiting and exhausting effort. My great concern and frustration for military clients is that they do not have time to rest, decompress, sleep, or play. The debriefings after tour are exhausting and family reunions demanding. Individually and as a whole, their complete neurologic structure is stressed to the extreme. They are often deprived of sleep by duty and the realities of operational stress, where normal integration during REM sleep in prohibited. This compounds any injury to brain processes, which have occurred due to concussion and brainstem injury. Neurobiological research clearly reveals that the stress load of a negative experience elevates the release of stress-related neural chemicals, particularly from the Hypothalamic-Pituitary-Adrenal axis (HPA). These chemicals are designed to inhibit natural integrative processes. They especially target limbic system, and affect heart rate variability. Some of the neural chemicals released during stress heighten sensory systems as a means of detecting further threat, others increase the body’s readiness to react/respond, while still others shut down life support systems and prepare for death. One signature of PTSD is that all three may be happening at the same time. No effective treatment can occur while there is a barrage of heightened activity in the neurosystem. That state of mind is loaded with uncertainty and risk. Decompression is essential. New Locus of Traumatic Impact Bessel van der Kolk’s latest research revealed that these stress chemicals also cause havoc in forebrain structures, particularly the thalamus. Extreme stress appears to cause the thalamus to shrink, which in turn inhibits its ability to adequately relay information from the brain stem’s sensory/motor receptor system and between other brain structures. What information it does relay is theoretically disorganized or fractured. Inconsistent or disregulated information from an impaired thalamus and would most certainly create distortions in the amygdala and hippocampus capacity to process emotions and memory for interpretation and longer-term storage in cortical regions. The limbic system appears to be the heart of trauma’s expression. What van der Kolk’s research is implying is critical because brain structures build and organize experience based upon each other, influenced by the initial quality of the information relayed from their foundation. The reticular formation’s activating system maintains the cerebral cortex in an alert, conscious state, and filters out repetitive stimuli. The information traveling through its long fibers, directly to the cortex, is regulated through the thalamus. In fMRI scans van der Kolk also noted disruptions in two critical areas of the dorsolaterial prefrontal cortex (dlPFC) involved in insight and planning for the future. The areas regulate space and time qualities of experience. Researcher Joseph LeDoux has shown that the dlPFC has virtually no connecting neural fibers to the functional areas generating emotions. This implies a neural loop between stimulated core affect and automatic action, void of adequate (space and time mediated) insight or planning, and emotional influence. To complicate this, PTSD seems to cause a deactivation in the medial prefrontal cortex (mPFC), which has vibrant connections to the amygdala, hippocampus and the brainstem. Schema in the mPFC normally contains relevant emotion. As van der Kolk joked, it’s where we can get in touch with ourselves through introspection. However, the potential here is for disregulated limbic emotional arousal. The amygdala attaches emotional significance to fractured stimulus relayed from the thalamus. The emotional significance influences what to do about the stimulus. Seemingly uncontrolled emotions come out of nowhere. They become what is feared. Suggestions of turning attention inward are met with avoidance, overwhelm and intensity. The process ignites associative traumatic reflection – from fragmented memory. If the client avoids introspection due to fear, they quickly loose their sense of self. There is a benefit to this complexity. The ability of a therapist to self-regulate affect can be reflected or mentored for the client in a secure attachment. The client can begin to face and learn to control emotions. The process is a (re)development of complex relational structures throughout the brain. Securely regulated emotions directly influence behavior and support a secure sense of self. Unfortunately, the phenomena of automatic physical action, inability to focus or make decisions and the persistent intrusion of traumatic memory remain a problem, particularly when they are not developmental or relationally based, as in war trauma. Controlling emotions is only part of the battle and its not efficient. The fragmentation of information in the thalamus is a very important piece of both chains. Evidence is building to support the concept that aspects of war impact the base brain and subcortical processing structures van der Kolk describes. The brain has been shown to regenerate its capacity, but without decompression these structures have an extreme challenge to regain capacity and efficiently relay affective impulses of experience on towards effective integration. The war will go on in the body/mind 40 years later without the opportunity to regenerate. Coping Systems Porges referred to a natural drive to integrate experience. At best, it is a fluid process of moving a sense of the life experience from potentially threatening in the present to secure awareness that the experience is truly in the past. When this process is compromised, the neurological structures adapt systems to cope with the difficulties. Intensity of threat seems to dictate the brain structure in charge. Initially, the primitive brain will inhibit higher brain structures. Beyond immediate threat, emotional/cognitive structures will attempt to get back on line, even while utilizing disregulated information. As threat further diminishes, these structures begin to socialize with the executive left-brain intellect. Together, they modulate higher-level social coping skills (surviving in relationship offers greater efficiency) and interact with the environment – within a tolerable window of affect. When the natural drive continues to promote potentially disorienting, painful, unregulated experiential affective, coping strategies organize to greater complexity. And, because both client and therapist may migrate (unintentionally) away from this potential, it is worth considering coping systems as affect that can be contacted and attended to. Complying and Attaching Trauma clients, as they have learned to do in their world, rely on adaptive strategies to cope with affect stimulated by even subtle perceptions of threat in therapy. The degree threat perceived sets the tone of coping and the brain structure in charge at the moment. The client’s automatic systems may either ramp up their affect - get agitated or mobilized to create distance, shut down their affect – to disengage or fade away (flat line facial expression), or comply and manipulate - doing what it takes to maintain social connections. A civilian client whose father used loving kindness to perpetuate incest may have a cultural schema for trusting their male “doctor” and not experience the fear usually stimulated by empathetic (loving) gestures from other adult men. However, the potential for highly refined coping systems to utilize compliance for managing the experience is substantial. Military Clients Military clients, on the other hand, appear to be highly alert to stimulus that could activate any change in affect. They (very generally stated here) do not seem to tolerate emotional influence, being especially resistant to the impulse to comply. They have been trained to survive duty through codes of emotional ethics, including training to reject psychic invasion (other than the hierarchy of command). My experience with military clients suggests there is a significant relationship between a lack of trust and a disdain for therapy created by therapeutic interventions that activate coping/compliance, emoting, or innate systems unexpectedly. Duty requires a specific state of mind in constantly changing environments. The offer of a cup of tea or a “thanks for service” comment requires effort to comply (respond). A simple request to “Take a moment, go inside and notice…” may generally be met with “What the #@& you talking about?” A trained state of mind requires the development of trust. Without trust, there can be no introspection of critical information. Trust and the capacity to self-discover and self-regulate seems to rank high, along with learning intrapersonal skills they can utilize on their own – back in action (military or civilian). Generally, there is a strong sense of community and hyper-vigilance for agendas and directives, with little tolerance non-military needs. The VA acknowledges that current war veterans are challenging, as they tend to discontinue care once their percentage disability is confirmed and benefits established. Active duty personnel discharge from care as fast as possible to get back to their units. The majority of our military returning from duty become deeply aware of the reality of their options – complain and a career is thwarted or over. Suck it up, take care of it within, and survive. Trust Happens Trust does seem to be established quite quickly by training military clients to notice affect from their own observing state of mind. The mind they can relate to as “the part that watches you doing, but doesn’t do anything about it.” From this place, they can experience a consistent state during introspection and avoid coping or impulsive stimulation. This process keeps the locus of control within the client, builds trust, often stabilizes regulation, and invites neural clusters representing past experience to process in the present. Past experience seems to automatically integrate, resulting in a subsequent reduction in affective tone. Panel discussions at the conference suggested that this is the same process of integration that happens in REM sleep. I have the privilege of inviting soldiers into a peaceful garden setting designed to help them decompress. The setting itself invites their body/brains to relax some of the vigilance that has been their daily state for so long. Building on this trustworthy environment, they are invited to notice their own state of body and affect. For example, a Marine veteran, seemingly overwhelmed from experiences in Iraq pre-911, said he drank to cope with a persistent, overwhelming guilt he felt for shooting and burning unknown civilians in a rage after his buddy’s brains were blown into his mouth. His shame and rage filled the therapeutic space. We were instantly stuck in circular affective expressions – coping systems. Any sense I had of connecting through empathy and loving presence (words or no words) was instantly challenged and attacked as invasive: “What are you doing?” The veteran’s emotions and intellect were all over the place. However, I noticed a consistent spatial positioning between us, and his left eye seemed to be tracking me. I said, “Painful, huh! I’m wondering if a part of you is aware of your left eye? It seems to be watching me.” Besides appearing baffled, he replied with, “I’m watching you, Bob! I said, “Oh! You see it’s me.” “Yah, I’m wondering what you want.” After a moment I softly suggested, “If, you can trust me!” He struggled in silence for a while, then began to share that he was flashing back to his childhood and molestation while in foster care. He seemed both enraged and relieved, as the abuse became central in the session. It was important to turn his attention to the “watching eye” because it was an affective expression 1) out of his awareness, 2) potentially requiring enormous energy, which we can think of as distracting noise in his neural system, and 3) appearing to be instinctual or at least survival based. Later he described his process. The watching was to see if he could trust me. Could he trust me to not invade, seduce, take advantage or manipulate? Could he trust me to be who I appeared to be? Turning his attention to what he was doing with his eye brought trust into his awareness. When he heard me say, “You see me,” he said he relaxed. And then wham! The foster care memories came flooding in. He told me that what astonished him was that unlike past experiences in therapy, this time he felt like sharing the memories with me. My sense of it was that first he had to internally calm down in order to integrate the experience of being with me. Then he felt more trusting, further stabilizing regulation. Thus, the past found an opportunity to integrate, perhaps not fully, yet to a recognizable degree when the defensive systems were quieter. Triaging Trauma Military and veterans are often only available for short periods of time in my non-clinical garden/workshop outdoor environment. The therapeutic work often requires triage – tending to the most critical issue. In triage, there is a mentoring of efficient affective regulation. However, the focus is on developing the observing mind and training the client to turn attention to their internal affective expressions. The purpose is to support their experience of maintaining physio/psychological control while supporting natural drives for the integration of experiences, temporarily disoriented and inhibited by the impact of military duty. To be efficient, attention must be attuned to affect in the moment with a willingness to turn the client’s attention towards it - in relation to the moment. It might be the specific way a client takes a hammer or stands to the side while walking through a tomato patch. All expression is considered affect, but clinically it is the core affect that defines what may be organizing the client’s experience. Triage happens as close to the core as possible. The challenge is to track the precise locus/loci of affect. The quality of attention must account for possibility that affect is arising out of innate, emotional or intellectual structures. The client may notice attention as invasive. This usually happens when contact, verbal or radiant, triggers coping systems or automatic impulses. To triage, the job is to get the distracting neural noise of disregulated affect quieted down by whatever non-violent method is available. Once things quiet down, focus on affect will invite what is driving it into their awareness. This takes faith and trust in the natural impulses of living things to reorganize towards integration and safety. Think REM sleep! More information regarding: The Triage Method www.TheTriageMethod.com The current farm www.CGOF.org Bob Bornt, MFT 310-625-3366 http://www.TheTriageMethod.comhttp://www.CGOF.orgshapeimage_2_link_0shapeimage_2_link_1