TRAUMA, EXPOSURE, AND WORLD RECONSTRUCTION
In posttraumatic stress disorder, a traumatic event (or series of events) very suddenly ushers the individual into a new world. Typically, the individual has, to that point, inhabited a world marked for the most part by characteristics of safety, predictability, and controllability. In this world, the possibility of such things as cars suddenly careening into one, dates assaulting one sexually, or flood waters rushing down upon one seemed remote, warranting little attention beyond elementary precautions such as locking one's door and driving carefully. If distressing events threatened, the sense was that one could probably handle them -- get out of the way in time, verbally or physically deal with the threatening rapist, and so forth. Thus, the old world was habitable, viable, comfortably livable in these senses. With an implicit sense of trust in it, one could largely forget it and safely focus one's attention on the many relationships, duties, pastimes, joys, and sorrows occupying center stage in one's world.
The traumatic event radically transforms this world. Like the sudden announcement of imminent atomic holocaust, it takes over the person's whole world and thrusts other parts of that world to the periphery. This transformed world, in contrast with the old one, is precisely unsafe, unpredictable, and uncontrollable. The individual has drawn the "lesson" from the traumatic event that catastrophic things can happen to him or her, and that when they do, there may be no way to see them coming and no way to master or to prevail over their overwhelming power. Further, the lesson is that this is the way the world is, not was, for a now past, brief, anomalous moment in time. The sense is not of something past, but of something present: the new world is one in which such things do happen and in which their recurrence represents an ever-present danger.
The central purpose of this article is to develop the many advantages and implications of conceptualizing trauma in terms of such devastating transformations to patients' conceptions of their worlds, conceived here as the total psychological environments within which they conduct their lives (Bergner, 2005). The article includes (1) an analysis of how this view renders the symptoms of PTSD intelligible, (2) a demonstration of how it integrates research findings on who is most vulnerable to PTSD, (3) a critique of the currently dominant "reprocessing of maladaptive memory structures" accounts of how exposure therapy works, and (4) a reconceptualization of how exposure therapies achieve their salutary results. This work has its origins in a general approach to psychology known as Descriptive Psychology (Ossorio, 1995, 2006), and within this broader framework, an approach to psychotherapy known as Status Dynamics (Ossorio, 1997; Bergner, 1999, 2005, 2007).
WORLDS ACCOUNT MAKES SENSE OF SYMPTOMS
In the transformed world described above, the classical symptoms of PTSD make eminent sense. The individual, living in a state of constant expectation of and vigilance for a return of the dreaded event(s), is chronically anxious. Given the desperate need to avoid further confrontation with such an event, he or she tries strenuously to avoid situations reminiscent of it, and even to suppress all thoughts or images of this event. However, this attempted suppression, coupled with the need to somehow come to terms with such a dangerous presence in one's world, results in a kind of "return of the suppressed" in which self is compelled to relive the event in reveries, dreams, and even flashbacks. Further, the individual is so consumed by the ever-present, life-and-death danger that nothing else matters, leaving him or her emotionally numb to life's other joys and sorrows. Finally, when something in a person's world constitutes such an enormous unthinkable threat, it creates a sense, not of danger past, but of danger present. By way of analogy, consider a bicycle messenger who is given a million dollars in an envelope and instructed to transport it to a bank across town. No matter how slight he might logically estimate the danger of losing this money to be, the magnitude of what is at stake -- of what must not happen at all costs -- creates a powerful sense of present threat. Likewise, when unthinkable and unfaceable dangers have entered the posttraumatic patient's world, logic and probabilities matter little; what is at stake is the possible reoccurrence of the unthinkable, and such circumstances call for constant fear and vigilance. The posttraumatic world is one in which the traumatized find it extremely difficult to live, and one from which many retreat into a highly restricted, safety dominated, anxiety ridden existence.
Third, a number of studies on vulnerability to PTSD have indicated that the greater the immediate, overwhelming, and life-threatening nature of the traumatic event, the greater the likelihood that those exposed to it will suffer PTSD in its aftermath (Hoge, Castro, Messer, McGurk, Cutting, & Koffman, 2004). Those who personally witness horrific events involving such things as the deaths or mutilations of loved ones, and/or who believe that they themselves will very likely perish, are on average more likely to contract PTSD than those exposed to lesser disasters, more distant ones, or ones involving little risk of their own death. If a situation is overwhelming, catastrophic, and life threatening enough -- a combat situation, a civilian war zone, a plane crash, etc. -- few people enter with worlds that can accommodate them. Such events, such horror, such mutilation and death, are too far beyond the pale for a great many people, regardless of their previous worlds. Their old worlds are at high risk of being shattered; the unthinkable has entered them.
Fourth and finally, a number of studies have demonstrated that following a traumatic event, those who are able to find some sense or meaning in the event do better than those who are unable to do so (Nolen-Hoeksema & Larson, 1999). For example, those with a religious outlook who are able to believe that God must have had a purpose for taking their loved one, and that they will ultimately be reunited with that loved one in heaven, are at reduced risk for contracting PTSD. Again paraphrasing this in terms of a worlds point of view, we can say that such persons lived from the outset in a world that could better accommodate their loss. Further, whatever their worlds prior to the traumatic event, if in its aftermath they are able to construct a new and more accomodative one, they are more likely to recover from PTSD.
PSYCHOTHERAPY FOR PTSD
For individuals with PTSD the primary obstacle to recovery is the ongoing presence in their now transformed worlds of something that, like atomic holocaust, has the status of the unthinkable and unfaceable. Accordingly, the preferred therapeutic goal is that of assisting these victims to reconstruct their worlds in such a way that they can accommodate these unthinkables. The goal is to help them, one might say, to make the unthinkable thinkable.
A now substantial body of research suggests that some of the most effective therapies for posttraumatic stress disorder are the various exposure therapies (Foa & Jaycox, 1999; Keane & Barlow, 2002; Resick & Calhoun, 2001; Davidson & Parker, 2001). In these therapies, whether in the form of systematic desensitization, in vivo exposure, flooding, or eye movement desensitization and reprocessing, the patient is made to re-experience the traumatic event(s) in some safe, controlled and established manner. This section presents (1) a case illustration describing the relatively standard, and ultimately successful, use of exposure therapy with a patient; (2) a listing of the various dements contained in this therapy; (3) a critique of the currently prevailing memory processing accounts for explaining the positive outcomes obtained with exposure therapy; and (4) an alternative account of these outcomes in terms of world reconstruction. In this account, I will argue that far more than just the exposure element is critical to the success of these therapies.
The exposure element
From a worlds point of view, what EMDR and other exposure therapies provide are vehicles that enable the patient, assured of the competence of the therapist and the safety and efficacy of the procedure, to look squarely at what had previously been the unthinkable and to reconsider its status as the unthinkable. The patient is typically able, under these conditions, to overcome his or her immediate impulse to flee the terrifying images and thoughts, and instead to look squarely at them -- to "face them down" as it were. Further, particularly in EMDR, an arresting, soothing, and slightly emotionally distancing accompaniment to this is the following of the therapist's hand movements and voice intonations. Under these carefully implemented conditions, patients are able to entertain images of the traumatic events or circumstances and to remove them from the realms of the unthinkable and unfaceable. This is so both for cases involving vivid sensory images and for those not involving such images such as those cited previously.
On the present view, what occurs in exposure therapy is best conceived, not as the reprocessing of a memory structure, but as very much the same kind of thing that occurs in the treatment of persons with pathological grief reactions. In this treatment, a common procedure is one wherein the patient's denial is addressed by a therapist consistently but carefully urging him or her to fully recognize the reality of the loss (Worden, 2002). Like PTSD sufferers, these persons are confronted with a new world where the unthinkable has occurred. In the aftermath, they find themselves unable to fully recognize the reality that the deceased is gone since such recognition, they sense, would leave them nowhere -- would leave them, in other words, in an impossible world where they cannot see how they could survive (Bergner, 2005). The job of the therapist becomes one, then, of helping them to come full face with the reality of their loss and to create a reconstructed world where they can not only go on, but can have a viable and meaningful future.
The therapist knows, indeed seems to take it as a matter of course, that there is nothing here in the nature of blame. That rape was not my fault. I'm not a weak, blameworthy person for having this reaction to combat. Others who have experienced traumas in their pasts -- perhaps very distant pasts -- have found themselves with these symptoms decades later. This is the nature of the beast; it is not reason to blame myself for being weak. Blame does not seem to be anywhere in the picture here.
In these and other ways, the therapist can usher patients into a reconstructed world: a world where the awful events are thinkable and faceable, where they make sense, where these persons have the status of one who has come through a terrible ordeal and emerged a survivor in the human community, where the event is firmly removed from the present and placed in the past, where the remote possibility of its recurrence is something they can live with, and where it is something that others have gone through and not only survived but grown stronger. It may be noted that these considerations may render intelligible the empirical finding that social support in the wake of a traumatic experience is conducive to more positive outcomes (Shalev, Tuval-Mashiach, & Hadar, 2004). In cases where the patient has such support, the sorts of benefits in terms of not being alone with the problem, greater understanding, enhanced empathy, and lessened self-blame may be realized to some degree by the individual's social network.
CONCLUSION
The central contention of this article has been that human trauma is best, most coherently, and most consistently with the empirical evidence, viewed as a state of affairs in which persons, as the result of certain life experiences, reconstruct their worlds in highly debilitating ways. In the article, I have attempted to demonstrate how this view (1) renders the symptoms of PTSD intelligible, (2) integrates research findings on who is most vulnerable to PTSD, (3) exposes ways in which the currently dominant memory structure theory of trauma is inadequate, and (4) provides a superior account of how exposure therapies achieve their salutary results.