Traditionally, the understanding of PTSD and its treatment was centered on the traumatic experience and the special condition of traumatic memories. The traumatic experience was believed to trigger defense mechanisms, such as repression or dissociation, whose purpose was to protect the individual from being overwhelmed. These survival mechanisms were assumed to come at a heavy price. The repressed or dissociated memory became ensconced in the unconscious, giving rise to a variety of symptoms. Moreover, the memories would, at times, erupt into consciousness, in the form of nightmares and flash-backs. It was assumed that real treatments, in contrast to merely symptomatic ones, involved unearthing the buried memories, re-experiencing them fully, and processing them in such ways that they became integrated in consciousness. The characteristics and techniques for accessing, surfacing and processing the traumatic memories varied through the history of psychotherapy. This variation shows a cyclic pattern: At some periods there is a clear preference for abreactive techniques (e.g. by means of hypnosis or drugs like pentothal) that lead to an explosive re-experiencing of the trauma; at other times gradual approaches are preferred, allowing for a controlled and less painful emergence of the memories. Often, after a period of interest in abreaction, the pendulum moves in the direction of gradualness. After a while, however, the abreactive preferences may come back with a vengeance. One of the earliest examples of this cycle is the change in Freud's approach to trauma. In their classical work on hysteria, Breuer and Freud (1895/2004) worked with hypnosis, helping the patients to relive the traumatic experiences as if they were happening in the present. In distinction from the original experience, however, the patients were now able to fully express their emotions. Freud, however, became skeptical, especially regarding the role of the therapist, who might unwittingly suggest to the patient what kind of memories were expected. He was also worried by the problematic aspects of the therapeutic relationship, as hypnosis fostered dependence and passivity in ways that carried undertones of an erotic relationship[1]. In the end Freud came to doubt the reliability of the very memories that were recovered by hypnosis. To replace abrupt abreaction by hypnosis, Freud developed the method of free associations, which, he believed, was free from suggestion and led to a dependable process of memory recovery. For a while, together with dream interpretation, this became the royal way to the unconscious. Hypnosis had become suspicious. And yet, there probably remained a kind of professional yearning for the spectacular methods that seemed to lead directly to the repressed memories. Especially as psychoanalysis became longer and longer, the yearnings for the short-circuit that was once offered by hypnosis became manifest. Reich's body-centered techniques were designed to break the patient's repression and resistance, thus leading to the desired breakthrough. Thus, for a while, abreaction became again fashionable. This, in turn, was followed by disappointment and a return to more gradual processes. Another cycle began when Grinker and Spiegel (1945) publicized their abreactive work by means of sodium-amytal (the truth serum) with pilots from World War II. This treatment had considerable repercussion, and many therapists started to practice "narcoanalysis" (as the approach was termed). Once again, disappointment followed upon the initial drama. It should be noted that even during this flurry of abreaction , the gradual methods of psychotherapy remained dominant. The search for new forms of experience in the 60's led to a rebirth of Reich's techniques, as well as other abreactive tools, such as Primal Scream Therapy, which was made famous by John Lennon. This was predictably followed by disappointment and a return to gradual therapeutic conversations. The next turn of the wheel, perhaps the most spectacular of all, arrived in the 80`s with the "epidemics" of multiple-personality disorder. This cycle was powered by growing professional and social awareness about the prevalence of sexual abuse. This development, highly positive in itself, was accompanied by some problematic manifestations. A belief in sexually abusive and sometimes murderous satanic sects became the rage. It was assumed that victims often (or always) developed multiple-personality disorder. From being viewed as an extremely rare condition, multiple-personality suddenly became one of the commonest diagnoses. Not only more and more people were diagnosed with it, but also more personalities were detected. At the peak of the craze, there was a kind of competition for the highest number of "alters", the record being more than a hundred (to a single patient). Hypnosis[2] and group treatments for people with symptoms that were supposedly linked to multiple-personality became a veritable power-house for the elicitation of "alters". The expectable discreditation put an end to the craze, in which, as a colleague once said, the population of "alters" had probably become larger than the official population of America. As it abated, the satanic craze left behind it a scorched earth of broken families and judicial suits, often by patients against their previous therapists that had orchestrated the memories of satanic abuse. A reaction followed, causing additional damage to the many women and men who had been victims of sexual abuse as, for a time, many of them were unjustly accused of suffering from "false memory syndrome". If we follow the development of treatments for PTSD in recent decades, we will be able to detect new (but usually smaller) cycles of abreactive and gradualist treatments. Perhaps the recent interest in psychedelics or other drugs as aids for recovery and processing of traumatic memories may be an example of that pattern. In spite of the variations, all of these treatments, abreactive and gradual allike, have a common denominator: The belief that PTSD is fundamentally the result of repressed traumatic memories, which have to be accessed, surfaced and processed so that the patient may be healed. However, there is a lot of evidence pointing to another direction.
Possibly the most intriguing findings that raise doubts about "trauma-centered" understandings and treatments of PTSD regard battle trauma. The condition was first termed "shell shock" at the time of WWI, because the symptoms were supposed to be the neurological consequence of the physical impact of explosions. Gradually, however, this hypothesis was abandoned and battle trauma was understood to be the result of massive psychological stress. Intensive research on treatments for this condition started already in WWI, continuing through WWII, Korea and Vietnam. Most studies focused on the American and British war experience. One finding on treatment efficacy towered above all others: Frontline treatments were consistently superior to treatments in which the soldier was evacuated to the rear. Frontline treatments were conducted in a field facility, close to the battle front. The defining characteristics of frontline treatments were immediacy, proximity and expectancy. Immediacy meant that treatment was started close in time to the soldier's breakdown. Proximity meant that treatment was administered near the front (the rule of thumb was, "where the sound of the explosions could still be heard"). Expectancy meant conveying the message that the soldier would soon recover and become able to return to duty. Interestingly, apart from their being "frontline", the specific kind of the therapy being administered was not found to predict results. Albert J. Glass, who was chief psychiatrist of the US army at the time of the Korean War, was often asked, which specific treatment elements were effective. His answer was: "Rest, encouragement and chicken soup." The superiority of frontline treatment was replicated in Israel in a study about the First Lebanon War. At the time of follow-up (20 years!) patients who had received frontline treatment had fewer PTSD or other psychiatric symptoms, higher levels of functioning and were much less lonely than those that had been evacuated to the rear (Solomon et al., 2005). Severity of symptoms at the time of treatment was controlled for, so that it was clear that those who received frontline treatment were not the easier cases.
Why are the findings on frontline treatment so intriguing? After all, since the soldiers that received it remained in the battle zone, they should actually be more traumatized than those that were evacuated to the rear. So why did they exhibit less symptoms, better functioning and higher wellbeing, both in the short and in the long run? The continuity principle provides an answer.
Frontline treatment allows for the maintenance and promotion of continuity in function, interpersonal relations and identity. These soldiers were kept in a military routine, even when they were at the field treatment facility. They followed the times of a soldier`s life, were kept in uniform and, as soon as possible, returned to some kind of military duty in their units. Moreover, contact with their unit was not broken. They received news and visits from comrades and commanders. They felt they were still members of the group. And their sense of identity was preserved, as they remained soldiers in their units. Even if sometimes their duties changed (from example, from battle to logistic and support tasks), this provided much more continuity than being evacuated to the rear. This contrasted deeply with soldiers that were evacuated to the rear. These soldiers were often treated in a psychiatric facility in which the military routine was not kept. They would be often in civilian clothes (if not in pajamas). They would have no contact with their comrades or commanders. And they experienced a profound rift in their sense of identity. Many soldiers who were taken out of their units because of battle trauma told of their deep sense of loss, isolation and guilt. They had to build a new identity to explain what had happened to them. This identity was often dictated by their diagnosis of PTSD. This would not in all probability foster a positive sense of self.
The cumulative reports, research and findings from battle trauma and frontline treatment probably constitute the largest field experiment in the history of psychiatry. If we add together all the data regarding frontline treatment since WWI, we are probably talking about tens of thousands of cases. In and by itself this material should make us reconsider our trauma-centered view of PTSD and its treatment. This will be the theme of our upcoming posts.
References
Breuer, J. & Freud, S.. (1895/2004). Studies on hysteria. Penguin Books.
Grinker, R. & Spiegel, J.P. (1945/2015). Men under stress. Lucknow Publishers
Solomon, Z., Shklar, R., & Mikulincer (2005). Frontline treatment of Combat Stress Reaction: A 20-year longitudinal evaluation study. American Journal of Psychiatry, 162, https://doi.org/10.1176/appi.ajp.162.12.2309
[1] This view of Freud`s led to his breach with Breuer, who was deeply offended by Freud`s "innuendos" regarding his treatment of Anna O.
[2] In those years there was a very significant development in the field of clinical hypnosis and its research. Valuable uses of hypnosis were substantiated, for instance, in medical psychology. The (ab)use of hypnosis for unearthing and expelling "alters" can be seen a a fringe, though highly popular, manifestation.
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