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TRAUMATIC INCIDENT REDUCTIONPrimary Resolution of the Post-Traumatic Stress DisorderRobert H. Moore, Ph.D. This article reprinted from the book Traumatic Incident Reduction: Research & Results (2005, Loving Healing Press) PROBLEM PROFILE The PTSD reaction is most easily distinguished from emotional problems of
other sorts by its signature flashback: the involuntary and often agonizing
recall of a past traumatic incident. It can be triggered by an almost
limitless variety of present cognitive and perceptual cues (Kilpatrick, 1985;
Foa, 1989). Lodged like a startle response beyond conscious control, the
reaction frequently catapults its victims into a painful dramatization of an
earlier trauma and routinely either distorts or eclipses their perception of
present reality. Although we can't confirm that any of the countless animal
species with which researchers have replicated Pavlov's (1927) conditioned
response ever actually flashed back to their acquisition experiences, the
mechanism of classical conditioning is apparent in every case of PTSD. As
salivation is to Pavlov's dog, so PTSD is to its victims. Like emotional problems of other sorts, however, PTSD is not accounted for
solely in terms of antecedent trauma and classical conditioning. In order to
provoke a significant stress reaction, as Ellis (1962) and others
observe, an experience must ordinarily stimulate certain components of an
individual's pre-existing irrational beliefs. Veronen and Kilpatrick
(1983) confirm that the rule holds for trauma as well as for more routine
experience. Errant beliefs -- related to the tolerance of discomfort
and distress; performance, approval, and self-worth; and how others should
behave-- "may be activated by traumatic events and lead to greater
likelihood of developing and maintaining PTSD symptomatology and other emotional
reactions. Individuals who premorbidly hold such beliefs in a dogmatic and
rigid fashion are at greater risk of developing PTSD and experiencing more
difficulty coping with the resulting PTSD symptomatology" (Warren &
Zgourides, 1991, p. 151). Also activated and often shattered by trauma are
assumptions regarding personal invulnerability; a world that is meaningful,
comprehensible, predictable and just; and the trustworthiness of others
(Janoff-Bulman, 1985; Roth & Newman, 1991). Such pre-existing
beliefs and assumptions, plus the various conclusions, decisions and attitudes
specific to a particular traumatic incident (especially when held as
imperatives) constitute the operant cognitive components of PTSD. PRIMARY AND SECONDARY TRAUMA What makes PTSD a particularly persistent and pernicious variety of
disturbance is the occurrence, at the time of its acquisition trauma, of
significant physical and/or emotional pain. Such pain, in association with
the other perceptual stimuli, thoughts, and feelings one experiences at the
time, constitutes the "primary" traumatic incident. The composite
memory of the primary incident, therefore, contains not only the dominant
audio/visual impressions of that moment, but also one's mind-set (motives,
purposes, intentions) and visceral (emotional and somatic) reactions. Thus,
whenever one subsequently encounters a "restimulator" -- any
present-time sensory, perceptual, cognitive, or emotive stimulus similar to
one of those contained in the memory of an earlier trauma -- one is
likely to be consciously or unconsciously "reminded" of and, therefore, to
re-activate its associated pain or upset. It is this subsequent painful
reminder, the involuntary "restimulation" of the primary trauma, that
constitutes the painful secondary experience we recognize as PTSD (Foa,
1989). In the Pavlovian model, the occurrence of the restimulator (trigger stimulus)
equates to the ringing of the bell; the stress reaction itself equates to
salivation. The mechanism is almost indefinitely extendible by association. Once
the dog has been conditioned to salivate to the ringing of the bell, for
example, the bell may be paired with a new perceptual stimulus -- say,
the flashing of a light -- so that the dog will then salivate to the
light as well as to the bell. If one next flashes the light and pulls the dog's
tail, the dog will learn to salivate when his tail is pulled (Hilgard, 1962). By
sequencing stimuli so as to create a "conditioned response chain" in this
manner, we expand the domain of stimuli that will elicit the salivation
response. This process may be illustrated by the following common example: A veteran originally injured in an artillery attack (the primary trauma) will often tend to be restimulated, even years later, by such things as smoke and loud noises. So it's no surprise when he panics, post-war, in response to fireworks. However, should he happen to be triggered into a full-blown panic reaction by a fireworks display while eating fried chicken one day at a picnic in the park, he is likely thereafter, as strange as it seems, to get panicky around fried chicken (whether he flashes back to the park at the time or not). In such a circumstance, fried chicken gets added to the domain of toxic secondary restimulators of his war experience, and the "picnic in the park" incident acquires secondary trauma status and is itself subject to later restimulation. If, for
instance, fried chicken subsequently gets (or previously had gotten) associated
with his mother-in-law (who prepares it for his every visit), his
contact with her also becomes subject to PTSD toxicity by association. The
dynamic effect of such repeated reactions over a period of time is a gradual
increase in the client's toxic secondary reactions. This, in turn, produces a
corresponding reduction of his day-to-day rationality and an inability
both to comprehend and to break out of his increasingly volatile reactive
pattern (see Hayman et al, 1987). The more reactions one experiences, the more new toxic secondary stimuli
develop. The more new toxic stimuli there are, the more reactions one has, which
suggests that those experiencing PTSD would eventually come to spend most of
their time with their attention riveted painfully on past trauma. In point of
fact, that does happen. The longer and more complex the chains or sequences of
secondary incidents become over time, however, the less likely one is to flash
all the way back to the primary trauma. This is why so many PTSD clients who
appear to succeed in getting their attention off their primary traumata
nevertheless withdraw from many of the life activities they previously enjoyed.
Because they flash back to "the big one" a lot less, their PTSD cases are
presumed to have abated. In reality such clients are in worse shape overall
because a lot of little things in their traumatic incident networks (all the
secondary restimulators or "cues" they picked up in the years following their
primary traumata) bother them much more than they did in the past (Gerbode,
1989). PTSD AND THE COGNITIVE THERAPIES Gerbode points out that some of the key cognitions contained in the memory of
any traumatic incident that later cause trouble when they are restimulated are
those specific conclusions, decisions, and intentions the individual generated
during the incident itself in order to cope emotionally with the painful urgency
of the moment. In such a circumstance, not only would certain pre-existing
beliefs govern one's reaction to a traumatic event, but also the traumatic event
itself would give rise to the formulation of new, potential errant cognitions.
Viewed in this light, PTSD is very much a cognitive-emotive disorder and not
nearly as Pavlovian as it at first appears to be. Accordingly, an effective
cognitive-emotive approach is called for in its remediation, one in which the
errant cognitions generated under the duress of the trauma are located and
corrected. Most cognitive therapists have traditionally favored challenging a client's
current disturbance-causing belief system over directly confronting the
earlier experience(s) responsible for its acquisition (Ellis, 1962, 1989). A
therapist's decision to focus an intervention mainly on a client's responses to
day-to-day stressors is most understandable when the client does not
report flashing back at the time of the upsets. Most non-PTSD clients, after
all, have no special awareness of their early acquisition experiences and,
therefore, have little or nothing to say about them. Their attention is fixed on
a steady stream of disturbance-provoking current events for which both we
and they realize they do need more rational coping skills. In the clear-cut
PTSD case in which flashback is evident, the client not only puts the
acquisition experience (the primary trauma) in focus right at the start but also
often seems virtually obsessed by it. Flashback content, which is often
concurrent with the client's upset over something in present time, is so
painfully "charged" that he or she is either barely able to shift attention from
it or else must regularly struggle to resist attending to it (Solomon, 1991). In
such a circumstance, the therapist who focuses intervention exclusively on the
client's dramatic over-reactions to current (secondary) events (on the
restimulator, rather than on what is being restimulated) bypasses
the opportunity to address directly and resolve the core of the client's PTSD
case. Such attention mainly to the present-time "cueing effect," according
to Goodman and Maultsby (1974, p. 62), "explains many failures or partial
successes in psychotherapy, despite the best intentions of patient and
therapist." Given the extreme volatility of the memory of a trauma, though, it's really
no wonder that many therapists and their PTSD clients (tacitly) agree not
to confront such incidents head on. To understand why this is so often the case,
consider the following: It is nearly impossible to get PTSD clients to perceive or appraise objectively a traumatic experience they are in the midst of dramatizing; It is usually difficult, even when they are not dramatizing, to sell PTSD clients on the idea of re-evaluating a traumatic event that has given them nightmares for the last fifteen or twenty years; Cognitive re-structuring, thought stopping, and stimulus blunting techniques give PTSD clients little or no control over their tendency to flash back spontaneously and go into restimulation; and Helping PTSD clients minimize the disruptive impact of their intrusive
thoughts and teaching them not to down themselves over the persistence of their
symptoms is better than nothing. It becomes understandable, then, that many therapists choose to assist
clients in their ongoing struggles to distance themselves from the memories of
their traumata in an attempt simply to limit the frequency and intensity of
their post-traumatic episodes. Therapists may actually bring superb therapeutic skills to bear on clients'
over-reactions to a variety of contemporary stimulus-events (e.g., rage
over a spill, anxiety at a meeting), but unless they help PTSD clients to
resolve the prior trauma (e.g., auto accident, childhood abuse, war experience)
that actively supports their current disturbance and to revise the errant
cognition associated with that primary experience, they have elected not to
address the PTSD at all. The result of such a purely secondary intervention is
that clients' unresolved primary traumas continue intermittently to intrude into
consciousness, and clients are left to struggle alone to secure a sense of
rationality against the influence of these traumas. Because a traumatic incident is, by definition, exceedingly unpleasant, there
is an understandable tendency, at the moment one is occurring, to resist and
protest it as best one can. It is at just such moments of extreme physical
and/or emotional pain, according to Gerbode (1989), that one's thinking
(evaluative cognition) is least likely to be well-reasoned and objective and
most likely to be irrational and distorted. There is, moreover, a subsequent
tendency to suppress and/or repress the memory of such an incident so as not to
have to re-experience the painful emotional "charge" its restimulation
carries with it. Unfortunately,suppression/repression of the memory of a
traumatic incident effectively locks its distorted ideation and painful emotion
away together (along with the incident's sensory and perceptual data) in
long-term storage. Thus, the stage for PTSD is set. Fortunately however,
when accessed with the specific cognitive imagery procedure of TIR, a primary
traumatic incident can be stripped of its emotional charge permitting its
embedded cognitive components to be revealed and restructured. With its
emotional impact depleted and its irrational ideation revised, the memory of a
traumatic incident becomes innocuous and thereafter remains permanently
incapable of restimulation and intrusion into present time (Gerbode 1989).
As Manton and Talbot (1990) observe, "traumatic events...can bring into
consciousness unresolved [prior] situations (with similar themes) such as
incest, child abuse, or the death of an important person in the victim's life"
(p.508). When clients have more than one trauma in their history, the only
completely effective procedure is one that traces each symptom of the composite
post-traumatic reaction back through sequence(s) of related earlier
incidents to each of the contributing primaries. Interestingly, a very
similar observation was made by one of our earliest colleagues, (Freud, 1984)
who wrote: What left the symptom behind was not always a single experience. On the
contrary, the result was usually brought about by the convergence of several
traumas, and often by the repetition of a great number of similar ones. Thus it
was necessary to reproduce the whole chain of pathogenic memories in chronologic
order, or rather in reversed order, the latest ones first and the earliest ones
last (p. 37). The simple fact is that in order to deal effectively with past trauma, we
must guide the client through to its resolution in imagery. The imagery
process itself, however, is just the means by which we help PTSD clients get
through their residual primary pain. It is by revising the errant cognition
associated with that pain that they are freed from the grip of their PTSD.
TRAUMATIC INCIDENT REDUCTION
The most thorough and reliable approach to the resolution of both
long-standing and recent disaster PTSD currently in use is Traumatic
Incident Reduction (TIR), a guided cognitive imagery procedure developed by
Gerbode (1989). A high-precision refinement of earlier cognitive
desensitization procedures, TIR effectively resolves the outstanding
trauma of the majority of the PTSD clients with whom it is used when carried
out according to its strict guidelines. TIR appears to be more efficient and more effective than other
cognitive-imagery or desensitization procedures, as such procedures
frequently focus mainly (and most often incompletely) on secondary episodes. By
tracing each traumatic reaction to its original or primary trauma(ta) and by
taking each primary trauma to its full resolution or procedural "end point" at
one sitting (a crucial requirement), the TIR process leaves clients observably
relieved, often smiling, and no longer committed to their previously errant
cognitions. At that point, the traumatic incidents, their associated
irrational ideation, and consequent PTSD have been fully handled, and clients
are able to re-engage life comfortably in ways they might not have been able
to do since their original traumata. Done one-on-one, the core TIR procedure may be completed in as little
as twenty minutes or it may require two or three hours (average: 1.5 hrs) of
"viewing" per incident. No procedure that is confined to the fifty-minute
hour can be considered flexible enough to handle the average primary traumatic
incident. The therapist needs to be willing to take the time necessary to
guide the client back through the relevant trauma, carefully following TIR
procedural guidelines, to permit the client to work through the painful memories
of the experience in order to restructure its cognitive content as needed for
full resolution. Ideally, PTSD clients correctly identify their active primary
incidents during intake. Clients who have regular flashbacks generally do this
with ease. Such clients may be briefed on TIR the same day and, if not on drugs,
scheduled for viewing the next day. Their PTSD problems can often be alleviated
within the week. It is not unusual for a TIR narrative procedure to
resolve an "unoccluded" (obvious) primary traumatic incident in as little as two
or three hours. Case resolution then would depend mainly on how many primary and
secondary traumata needed to be addressed to restore full functioning. More commonly, however, PTSD clients do not correctly identify all their
active primary incidents at intake. A war veteran, for instance, may at first
report with conviction that it all dates back to Vietnam; he's only had the
problem since then, and that is the content of his flashbacks. Once he gets into
it, however, he is sometimes surprised to discover that his wartime experience
was actually secondary to some previously occluded or less memorable earlier
trauma. In chronic cases, including some phobias and panic disorders in which
flashbacks are absent, clients often have no clue at intake as to where or when
their reaction patterns were actually acquired. Although technically not
classified as PTSD, many such clients have had a significant number of stressful
experiences over the years. Yet they cannot, at first, identify any one incident
as having been much more significant than any other. They are often thoroughly
frustrated and discouraged, as well as genuinely baffled, about the persistence
of their symptoms. Those among them who lead otherwise comfortable lives and
seem not to think much less rationally, day-to-day, than the majority of the population frequently come to the usually erroneous
conclusion that their problems must be genetic in origin ("run in the family").
(Needless to say, such cases are not resolved within the week.) They are not
generally a problem for TIR, however, as they may be handled to resolution very
adequately by the thematic approach, a variation of the narrative procedure.
Thematic TIR does not require clients to be aware of or to identify correctly
the relevant historic components of their cases right at the start of their
intervention. Instead, the thematic procedure simply traces each manifest
(present time) emotional and somatic symptom (theme) back through its chain(s)
of secondary incidents, one at a time, until the originally occluded primaries
come into awareness and can be dealt with routinely. Toward clients' understanding of the TIR routine, which assuredly will be new
to them, it is often useful to draw upon the illustrative value of the Pavlovian
example mentioned earlier and with which they may already be familiar. One may
point out, in this connection, that when the dog's salivation response to the
bell (primary stimulus) is extinguished, the light (secondary stimulus) loses
its restimulative potential automatically (Hilgard, 1962). Likewise, once a
primary incident is completely resolved, none of the stimuli that had later
become associated with it as secondary restimulators is capable of triggering
any further reaction (Gerbode, 1989). This means that when the veteran fully
resolves his "artillery attack" (and any other related primary incidents), he
will no longer be vulnerable to restimulation triggered by the various
secondarily toxic stimuli associated with that experience. At that point, fried
chicken and mother-in-law are back to representing nothing more than
fried chicken and mother-in-law. This may seem like a rather classical Pavlovian explanation, but one of TIR's
main concerns is the ultimate correction of the PTSD client's trauma-related
thought processes. Once clients realize that it was the cumulative effect of
their traumatic incident networks on their cognitive-emotive response sets
over a period of time that is responsible for the persistence of their PTSD
symptoms, and once they understand that there is a way to shut down the
networks' active components permanently, they'll be happy to use the TIR
approach, even if they are already accustomed to another technique. Then, even
thoroughly frustrated and discouraged chronic and absent-flashback PTSD
clients will begin to feel hopeful. The lexicon of TIR reflects its purpose and procedure. The client is called a
"viewer" because his/her primary function is to confront, via the viewing
process, past trauma. The person conducting the session is called a
"facilitator" because his/her purpose is simply to facilitate the viewer's
process of viewing (Gerbode, 1989). Just as "physician" and "patient" become
"analyst" and "analysand" or "surgeon" and "organ donor," based on the
requirements of their respective roles, the designations "facilitator" and
"viewer" are reserved for those whose interaction is governed by the singular
requirements of the TIR process. TIR, like other cognitive-imagery processes, differs
somewhat from most contemporary therapies. Although it holds errant
cognition to be at the root cause of emotional disturbance, unlike the
mainstream cognitive approaches, TIR carries the revision process back to the
specific experience(s) that originally produced and enforced such cognition.
In this regard, TIR is a bit more "personal" than most contemporary cognitive
therapies. Instead of relying mainly upon the therapist's insight into or
inferences about a client's probable belief structure, as is common in RET, TIR
guides clients in the discovery and revision of their own original
disturbance-causing cognitions. What makes such a procedure both necessary and possible is the fact that, in PTSD, the disturbance-causing cognitions (except for the pre-existing ones) were originally generated in response to, and in order to cope with, a traumatically painful and/or upsetting experience. Moreover, the offending cognitions are still being kept in force by the long-term residual impact of the incident. In other words, if it hadn't been for the specific circumstance of the trauma, as subjectively experienced by the client, e.g., "Oh my God, I've been shot! I'm gonna die!", the client wouldn't have formulated the response, e.g., "I should never let my guard down, even for a minute!" Moreover, if the incident hadn't been so emotionally and/or physically painful, making it extremely difficult for the client to confront, its attendant cognition would be a great deal more accessible to routine reappraisal and restructuring. So, while it remains very useful to be able to infer with reasonable
certainty that an anxious client is generally feeling threatened and ineffectual
while an angry client would like to assert control over something (pardon the
reductionism), these are just some of the more obvious "common denominator"
dynamics associated with their respective current disturbances. What we
cannot infer but what TIR reveals to clients who have experienced
trauma is exactly what happened (at a subjective/cognitive-emotive
level) that so overwhelmed them that they would come away from
their experience stuck in an involuntary, out-of-date, and irrational
mind-set constructed, among other things, of numerous fairly obvious
stress-producing mis-evaluations and distortions. In a certain respect, TIR adds a new dimension to our understanding of the
relationship between cognition and emotion. While theorists have long held that
irrational thinking tends to promote upset feelings, TIR suggests that one's
(traumatically) upset feelings also tend to promote irrational thinking. Dodging
the "Which came first?" (chicken or egg) question, it is probably safe to say
that, on the face of it, the causal equation appears to be reversible. That is,
not only does cognition significantly influence emotion, but emotion appears to
significantly influence cognition. Even more critically significant, at least in cases of PTSD, the remedial
equation seems to be reversible as well. Whereas cognitive therapists observe
that the restructuring of one's irrational and distorted thinking produces a
corresponding reduction of emotional disturbance, TIR confirms Ellis' (1990)
observation that a reduction of primary traumatic emotional disturbance produces
a corresponding restructuring of one's irrational and distorted thinking! In
short, the client whose trauma has been fully reduced and resolved and who
has become able to talk (and think) freely and painlessly about it (a TIR
goal) almost immediately and self-directedly begins to display a
substantively rational (moderate, tolerant, objective) viewpoint regarding that
previously painful experience. As always, the client who succeeds in embracing a
more rational viewpoint about an experience, regardless of how unfortunate or
traumatic that experience once seemed, is no longer disturbed over it or
unwittingly under its control. As a consequence, secondary restimulation and
flashbacks cease, life's energy and interest revive, and self-esteem
rebounds. What is particularly remarkable about the cognitive restructuring that
takes place in TIR is that it takes place so obviously and spontaneously during
the course of a given session. Equally remarkable is the fact that it takes
place-- and truly must take place -- without didactic or
corrective facilitator input. The facilitator's role in TIR is mainly to so
conduct the session and guide the viewer in "repeated review" of the selected
trauma (in strict accord with the established protocol) that the viewer will be
able rationally to restructure his own "misconceptions" about it (Raimy, 1975).
Bear in mind that at this level of intervention the viewer is truly the only
one who can decipher (by patient and careful re-examination of the cognitive
images stored in memory) what actually happened or appeared to happen in the
incident, what its significance was, what he or she was thinking at the time,
why it was so extraordinarily painful, how he or she coped with that pain, and
what trauma-related conclusions and/or decisions were made at the time.
So, as the viewer reviews this highly sensitive and very painful material
repeatedly in imagery in order to discharge the emotional impact holding the
cognitive distortions in place, the facilitator says not a word. Although in TIR's handling of PTSD the operant trauma-related distortions
virtually self-correct once the inordinate emotional distress of the
traumatic experience is relieved, viewers frequently want to follow a completed
TIR session with some discussion or review of some of the ways in which certain
of their newly-surrendered trauma-related beliefs and attitudes had
affected them since the occurrence of their original trauma! Most practitioners
find this discussion one of those truly rewarding moments in clinical practice.
It is not only confirmation of a successfully completed specific intervention.
It is re-confirmation of what contemporary theorists have asserted all along
about the relationship between cognition and emotion -- with the
additional suggestion that that relationship may be even more interesting than
we had originally supposed. A fully resolved traumatic experience is neither completely nor mostly
forgotten. It is, by definition, simply benign and incapable of intrusive
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