8

Containment

Controlling Posttraumatic and Dissociative Symptoms1

The concept of a phase-oriented treatment approach for survivors of childhood trauma mandates that basic ego-supportive psychotherapy is the first order of business prior to exploration and abreaction of traumatic events. This work is a formidable task given the pervasive symptomatology that many traumatized patients bring to treatment. Florid posttraumatic and dissociative symptoms create chaos in patients’ lives. These experiences include reexperiencing of past abuse (e.g., flashbacks) and numbing responses, out-of-control state changes such as identity switches in patients with dissociative identity disorder (DID), and the discontinuity of experience seen in partial or complete amnestic events. All of these symptoms can be severe in their expression and are often intolerable to patients, and all must be modulated or stabilized to reduce the level of crisis in patients’ lives. This is the real and important trauma therapy that sets the stage for later abreactive work.

Much of our understanding of the effects of childhood abuse is founded on psychodynamic and psychoanalytic principles. Psychologists Laurie Anne Pearlman, PhD, and Karen Saakvitne, PhD (1995), have observed:

Much if not most of our fundamental premises about insight-oriented psychotherapy with trauma survivors—what it is, how it works, and why it works—are originally psychoanalytic in origin.… The fact that current relationships are influenced by internalized objects and object relationships is a fundamental psychoanalytic concept essential to understanding transferences and reenactment in trauma therapies.… This relatively simple idea elegantly incorporates a developmental perspective and sets the stage for the recognition of the roles that unconscious processes and early relationships play in adult functioning and identity. (pp. 43–44)

Traumatic experiences in childhood disrupt the normal formation of psychic structures that are gradually formed over the course of development. Thus, severe and persistent early abuse strongly affects ego capacities and defenses, self-regulatory mechanisms, and concepts of the self and others.

Although trauma theory derives extensively from psychodynamic and psychoanalytic perspectives, effective treatment interventions draw on an eclectic variety of perspectives, including not only psychodynamics but cognitive-behavioral, object relations, self-psychology, and family/systems theories as well. The overall philosophy of the treatment of trauma survivors is consistent with psychodynamic principles: understanding the role of past experience, transforming conflicted unconscious processes into conscious thoughts and feelings, and integrating repressed and dissociated experiences (Matthews & Chu, 1997). However, early in treatment, when the control of symptomatology is a priority, cognitive-behavior interventions are particularly useful. Although clinicians trained in this modality may have particular expertise, the basic principles involved in a cognitive-behavioral approach can be understood and used by all clinicians treating patients with complex posttraumatic and dissociative disorders.

PSYCHOEDUCATION AS A COGNITIVE-BEHAVIORAL PARADIGM

The basic paradigm for therapeutic interventions used to contain dysphoric or dysfunctional symptomatology has two parts. The cognitive component involves setting out a psychoeducational framework and conceptualizing approaches to achieve treatment goals, and enlisting the patient in an alliance to work toward these goals. The behavioral component consists of instituting and rehearsing interventions, and then repeating or modifying interventions until the treatment goals are attained. This type of cognitive-behavioral approach is not only pragmatic but also tends to minimize the often overly intense transferential aspects of the therapeutic relationship. It offers a task on which both patient and therapist can focus and alleviates the all-too-common pitfall of struggles as to whether the patient or the therapist is going to control the agenda of the therapy. As I have often said to patients, “It isn’t a question of doing it my way or your way. These are the ways that have been shown to help persons like yourself overcome the difficulties that you experience.”

When it comes to the task of controlling posttraumatic and dissociative symptomatology, the cognitive psychoeducational component is more important by far than the behavior techniques. Educating patients about the necessary and possible goal of achieving control of their symptoms is essential to collaboration around this task. Without an alliance concerning symptom control, no interventions or techniques are likely to be effective, and patients are likely to reflexively oppose such efforts: “I’ve tried that and it doesn’t work!” Conversely, with such an alliance, many interventions may work, and patients are then often able to devise individualized techniques that are effective for their particular symptoms. Given that pervasive mistrust is a hallmark of persons with extensive interpersonal abuse, forming and maintaining an alliance around the goal of symptom control with traumatized patients is a major undertaking. Moreover, one of the inherent characteristics of posttraumatic and dissociative experiences is that they feel out of control. That is, patients experience these symptoms as happening to them—overwhelming feelings and sensations that emerge from within, often triggered by unanticipated events in their environments. Very few patients easily accept the idea that they can have much control over the flashbacks and state switches that are part of their daily lives, and it is often difficult to engage them in this task.

One way to approach this dilemma is to clarify that perfect control is not the goal and is not immediately expected. Rather, the expectation is only that patients begin to look at these uncontrolled experiences in such a way that they can begin to have even a minimal impact on them: “I know that you feel as though your flashbacks are totally out of control, and that you have no way of knowing when they will hit and how you can get out of them. However, if you are willing to work very hard with me we may be able to find some small ways that you can alter these experiences to some degree. Do you think it might be possible to get even as little as 5% more control over these difficulties?” Presented in this way, patients are more easily able to see the process as incremental advances in control over the symptoms that are inherently experienced as uncontrollable.

Even some of the most uncontrollable posttraumatic and dissociative symptoms can be contained through extraordinary efforts of patients if they are motivated to do so. The following case illustrates both the possibility of controlling posttraumatic and dissociative symptoms and the difficulties of such control in traumatized patients. The patient was treated many years ago, and at the time, her symptoms were not recognized as probably being posttraumatic in nature:

Mary, a 38-year-old, married woman and mother of two, was hospitalized in 1978 for problems with depression and difficulty functioning in the inpatient unit of a teaching hospital where I was a psychiatric resident. She was known to have a background of considerable trauma, but her difficulties were characterized as “pseudo-neurotic schizophrenia,” which implied a kind of surface functioning over a core of schizophrenic-like psychosis. Her symptomatology included periods of acute decompensation—then described as transient psychosis but now more easily recognized as reexperiencing of the trauma—in which she would become paralyzed with fear and act in a very young and regressed manner. Her clinical course was prolonged (even by the standards of the pre–managed care era) because of the fragility of her condition. Despite sophisticated psychotherapy and use of medications, she had frequent decompensations, making it difficult for her team to see how she could be discharged to home.

Nonetheless, it was eventually decided to begin the transition process to home, and Mary was put on a bus for a home visit and an appointment with her outpatient therapist. The bus headed down a major highway toward her hometown, only to be snowed in by the Northeast blizzard of 1978, and became stranded on the highway, miles from any help. Somewhat surprisingly, Mary did not fall apart. Rather, she rallied both herself and the other passengers on the bus, leading them in camp songs (“100 Bottles of Beer on the Wall,” etc.) to help keep up their spirits and melting snow for drinking water. Eventually, after being rescued by the highway police, she abruptly decompensated and was brought back to the hospital in a disorganized and helpless state.

A similar clinical situation occurred a few years ago with a patient with a dissociative disorder whose seemingly out-of-control symptoms were brought under control by external circumstances:

Jill, a thin and athletic young woman with DID, was hospitalized for suicidal impulses and aggressive acting out. Despite her rather frightening history of florid posttraumatic and dissociative symptoms, and self-destructive and violent behavior, she presented as cooperative and articulate for the most part—but only during the day. As the evening progressed, she began to have episodes of apparent identity switching and flashbacks. During these periods she appeared to be reliving physical and sexual assaults (that had originally occurred during the evening). She would become agitated, panicked, and angry, striking out at anyone who approached her. This behavior continued on a daily basis over several weeks, often necessitating the use of restraints.

Restraining the patient was particularly traumatic for all involved, because while in restraints the patient apparently reexperienced her childhood assaults and sexual molestation. Her screams were piteous, and she could not be reassured or soothed. The hospital staff was split concerning how to intervene. While some staff members believed that she was manipulatively trying “to get attention,” others felt that she had no ability to control the episodes and would continue to need this level of external support. The uncontrollable behaviors escalated to the point that the patient began to throw heavy furniture, and a staff member was injured. After this incident, the staff agreed that better control was necessary, and the patient was told that if the episodes continued for more than three days, arrangements would be made for her transfer to another facility. The patient had made strong attachments to various members of the staff and was panicked at the thought of transfer. The violence never recurred, but it was obvious that the patient had to exercise very intense efforts (with the mental strain clearly visible in her face and tensed and rigid body) to maintain control in the evenings, and she was able to utilize a high level of support through numerous verbal interventions from staff.

Both of these patients were highly symptomatic, decompensated, and regressed. Feeling helpless and exhibiting a certain amount of passivity, they seemed to expect others to assume control of their behavior. The posttraumatic symptoms that they both experienced were quite powerful, and they usually felt unable to control the changes in their experiential states. However, under fairly dire conditions that made it necessary to exercise more control, both patients were able to do so, albeit using an extraordinary amount of personal resources and drawing on the support of others.

A kind of medical analogy may be apt here. Persons with acute viral gastroenteritis almost inevitably suffer from explosive vomiting and diarrhea. These unpleasant events cannot be suppressed beyond a certain point, but given some effort, one can exercise how and when they occur in order to avoid public embarrassment. Similarly, posttraumatic and dissociative symptoms have a kind of powerful urgency, and yet patients can utilize their own resources (and those of others) to help bring them into control. Very frequently, if an alliance is formed between patients and their therapists around this task, patients can consciously work toward the goal of control and make substantial progress over weeks and months. In some circumstances, however, external control may be necessary, and the use of hospitalization and/or sedating medication can be indicated. Persisting, ongoing, uncontrolled symptomatology makes therapeutic gains impossible and eventually destroys the therapeutic process. As a result, such seemingly drastic measures as ending or suspending therapy, hospitalization, or transfer to other caregivers are logical consequences of the failure to begin to establish control.

STRATEGIES FOR CONTROLLING POSTTRAUMATIC AND DISSOCIATIVE SYMPTOMS

There are a variety of techniques for controlling posttraumatic and dissociative symptoms that my colleague, Audrey Wagner, PhD, categorizes as management strategies, safe/special places, and overall crisis planning.

Management Strategies

Many of the management strategies for patients who experience posttraumatic and dissociative symptoms fall into the category of grounding techniques and utilize a focus on the five senses: sight, hearing, touch, smell, and taste. One of the most basic strategies is to ensure good ambient illumination. A well-lit environment can be very helpful in grounding patients, particularly in the evening or at night. Whether in the office, hospital, or at home, this means providing adequate lighting and encouraging patients not to sit in dark or dimly lit environments when they feel anxious and vulnerable. When frightened or overwhelmed, many patients feel compelled to retreat to darkened rooms, hiding in their beds, closets, or other confined spaces. Seeking safety in such places only increases their propensity to lose their bearings in current reality and become more pulled into the flashback experience.

Maintaining visual contact with cues in the environment is also crucial. In many ways, the syndrome of so-called ICU psychosis has similarities to the loss of control of posttraumatic and dissociative symptoms. In intensive care units, severely ill medical or surgical patients are placed in an unfamiliar environment that is dimly lit with few cues as to date or time of day, and they are in contact with many unfamiliar people. Under such conditions, some ICU patients become quite disorganized and disoriented. The solution is often simple. Adding extra lighting, a clock and calendar, and ensuring contact with familiar people and objects often restores patients’ orientation and equilibrium. In a similar way, patients who tend to get lost in dysphoric dissociative states benefit from focusing on their physical environment and on familiar and comforting objects. Psychiatric nurse and expressive therapist, Elizabeth Benham, RN, worked with patients in our program for years and published a description about some of these kinds of interventions in a hospital setting (Benham, 1995):

It is by example that we first teach patients how to ground themselves. When a patient is experiencing florid dissociative symptoms,… we approach the patient and call her by name and identify ourselves. We tell the patient where she is and what month, day, and year it is. We repeat this information over and over in reassuring tones. If the space… is darkened, we illuminate the area by turning on the lights, or opening the drapes. We ask the patient to open her eyes if they are closed, so that the patient can see where she is and who we are. We also ask the patient to try and move her eyes so as not to be in a daze; as this seems to keep patients locked into a dissociated state of flashback. We encourage the patient to look at our faces so that eye contact can be made.… We tell the patient we know she is frightened, but that she is safe. We ask her to begin naming what she sees in the room such as the color of the rug, or chair, how many chairs are in the room. We might ask her to identify what color her shirt is, the color of our clothes, or even how many shoelace holes are in her sneakers. If we know the patient well enough, we might remind her of significant others such as a child or a spouse. Instructing patients to feel their own weight in the place they are sitting is also useful, as is having them sense where their other body parts are touching. For example, we ask, “Can you feel your elbow on the chair?” “How about the glasses on your nose?” “What about the rings on your fingers?” or “Can you feel your watch on your wrist?”

Once the patient is alert enough to recognize us, it is helpful to have the patient reposition the posture that is held during the dissociative or flashback experience. Having her stand up and walk with us allows the patient to connect with the ground.… As we walk with the patient, the patient continues to identify the surroundings. If she is not alarmed by our suggestion, we encourage her to look in a mirror, so that she can see she is an adult and not a child in a traumatic situation. (p. 33)

This description of interventions for posttraumatic symptoms contains several critical elements. It is particularly important to note that although the patient’s emotional state that is induced by reexperiences of early abuse is acknowledged, the etiologic traumatic experience is not explored. That is, patients are asked to find ways to cope with the dysphoric experiences and not to deepen them. In the early phase of treatment, premature exploration most often leads to further loss of control and the emergence of more memories rather than containment. The tone of voice that one uses is also important. It should be reassuring, but it should not be overly soft, soothing, and rhythmic. Some posttraumatic symptoms such as flashbacks can be understood as autohypnotic phenomena, and a tone of voice that is meant to be soothing can have the reverse effect of prolonging the trancelike reexperiencing state. A calm and firm tone of voice with a normal level of pitch and volume that avoids rhythmic cadences will often help orient the patient.

In an interpersonal situation, eye contact is enormously effective. In fact, direct and focused eye contact makes it impossible for patients to remain in dysphoric dissociated states. There are inherent qualities in eye contact that produce a powerful interpersonal connection that is enormously grounding. Many crisis situations have been resolved simply by therapists being quietly and firmly directive, asking patients to look at them and to focus on the therapist’s face and make eye contact. Some traumatized patients have difficulty with direct eye contact, perhaps fearing the anger or hatred seen in the eyes of abuse perpetrators. Even when asked to look directly, some patients may be so fearful that they cannot do so, or they have a terrorized, blank, and unfocused gaze. In these situations, the therapist may direct the patient to look around and name other objects in the room or to look at parts of the therapist’s body that are less threatening (e.g., legs, hair, shirt). Aside from being effective as a grounding technique, eye contact demonstrates that some kind of interpersonal connection can be helpful and not hurtful as it was in the past.

In addition to using sight, the other senses can be used for grounding as well. Hearing and sounds can be used by listening to music, singing, or reading aloud. Using touch can take the form of feeling familiar and soothing objects or paying attention to one’s body and the feelings of one’s surroundings (e.g., the support and the feel of the fabric of a chair). Pleasant, strong-smelling substances can counteract the olfactory hallucinations—most commonly the smells of alcohol, sweat, and semen—that are associated with early trauma such as sexual abuse. Patients can carry a vial or small container of fragrant substances such as coffee beans or potpourri for this purpose. Drinking hot or cold, pungent, or fragrant liquids (e.g., hot coffee or tea, ice water, or juice) can be a part of the grounding strategies as well. For some years there was a sign over the door of the Trauma and Dissociative Disorders Unit at McLean Hospital that read “The Land of the Frozen Oranges.” This referred to the supply of whole oranges that was kept in the freezer for use in grounding. The cold, hard oranges and the pungent smell of them when patients would dig their fingernails into the skins proved to be very helpful for patients to regain a sense of their current reality.

In recent years, there have been initiatives through state mental health divisions for crisis intervention in inpatient programs specifically designed to reduce the use of restraint and seclusion, particularly for patients with histories of trauma. So-called sensory stimulation rooms are designed to provide soothing and grounding sensory input for patients who are agitated or distressed. These rooms are painted in a pleasant color and have comfortable seating. Music can be played, and weighted blankets, squeezable toys, colored glasses, aromatic substances, and a variety of other visual and tactile objects provide sensory input to help calm and ground patients.

Transitional objects—items that remind patients about the presence and support of their therapists—can also be useful grounding tools. Dr. Wagner keeps a bowl of small, smooth stones in her office for just this purpose. Patients may take and keep a stone to use as a tactile grounding strategy and also as a reminder of her presence in their current lives. She also uses photographs and written notes and audiotaped messages (done in the therapy session) as transitional objects. Her patients also can call her office voicemail and listen to the outgoing message as a reminder of her role in their lives, and they can leave a message to simply establish a sense of connection. (She does instruct them specifically to ask for a callback if that is necessary, but otherwise she just listens to the message.)

Using grounding techniques in an office or hospital setting provides the opportunity to learn more about the internal emotional events that precede loss of control. Flashbacks and state switches are experienced as happening abruptly and unpredictably without any warning. However, careful monitoring of emotional states often shows that dysphoric posttraumatic or dissociative states are often preceded by certain specific kinds of internal emotional states that escape the awareness of most patients. Practicing grounding in a treatment setting offers an opportunity to learn about these internal states, as in the following example:

Jane, a young woman with a history of severe physical and emotional abuse, was prone to flashbacks of being berated, humiliated, and beaten by her father whenever she began to feel too close (and hence vulnerable) to another person. Shortly after beginning therapy, I noticed that she wasn’t able to maintain eye contact, and she seemed to drift away into some internal state. She seemed oblivious to my efforts to attract her attention, and then she appeared quite frightened and almost as if she was fending off blows. After considerable efforts on the part of both Jane and me, she was able to maintain visual focus on a small toy rocking horse that was part of the office decor.

After several months of work on grounding, she was even able to look at me briefly for a few seconds at a time. During this process, I asked about her internal emotional experience: “I wonder if you can tell me what you are feeling inside when you begin to have trouble looking at me. Is there some feeling or sensation that you are experiencing during those times?” Eventually, Jane was able to identify levels of increasing anxiety that she experienced as a tightness in the pit of her stomach. She could then recognize that whenever this feeling became worse, she was beginning to lose contact with her current reality. We were then able to devise various relaxation techniques, including simple measures such as taking a series of deep breaths, which tended to reduce the feelings and sensations associated with the anxiety. I also allowed her to borrow the toy rocking horse from my office, which she found helpful when trying to ground herself at home.

Therapists who are familiar with cognitive-behavioral techniques (including some DBT interventions) may also wish to use formal mood monitoring or behavioral chain analysis to help patients track the specific emotions they experience, as well as the intensity of particular emotions that call for therapeutic interventions. This kind of attention to internal emotional states may be extremely helpful for patients to become more aware of their emotional functioning and more able to have control over them.

When patients have intense reexperiencing (e.g., flashbacks and intense emotional states related to the trauma), they can lose the ability to distinguish the past from the present. Cognitive strategies are designed to help them tell the difference between feelings from the past and facts about the present. Dr. Wagner has observed that patients can easily get stuck in the past. She works with patients to put together a list of facts about the present, particularly anything that is true about the present that contradicts the emotional experience about the past, as in this example:

The FACTS

Related posts:

Staying Safe The Therapeutic Dance Good Fences Make Good Neighbors Falling Apart Controversies and Future Directions in the Field of Trauma and Dissociation Complex PTSD

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