|Critical Issues in
Traumatic Incident Reduction: A Simple Trauma Resolution Technique:
[Originally presented as Lecture Notes from the Seminar of the same name]
Most common approaches to Post-Traumatic Stress Reduction fall into two categories: coping techniques and cathartic techniques. Some therapists give their clients specific in vivo methods for counteracting or coping with the symptoms of PTSD - tools to permit their clients to learn to adapt to, to learn to live with, their PTSD condition. Others encourage their clients to "release their feelings'', to have a catharsis. The idea is that past traumas generate a certain amount of negative energy or "emotional charge'', and the therapist's task is to work with the client to release this charge so that it does not manifest itself as aberrant behavior,
negative feelings and attitudes, or psychosomatic conditions.
Coping methods and cathartic techniques may help a person to feel better temporarily, but they don't resolve trauma so that it can no longer exert a negative effect on the client. Clients feel better temporarily after coping or having a catharsis, but the basic charge remains in place, and shortly thereafter they need more therapy.
The Need for Anamnesis:
Traumatic Incident Reduction (TIR) operates on the principle that a permanent resolution of a case requires anamnesis (recovery of repressed memories), rather than mere catharsis or coping. To understand why clients have to achieve an anamnesis in order to resolve past trauma, we must take a person-centered viewpoint, i.e., the client's viewpoint and, from that viewpoint, explain what makes trauma "traumatic".
Time and Intention:
Let us start by taking a person-centered look at the subject of time (See Fig. 1) Objectively, we view time as a "never-ending stream'', an undifferentiated continuum in which events are embedded. But subjectively, we actually experience time differently. Subjectively, time is broken up into "chunks'' which we shall call "periods'' of time. "A time'', for me, is a period during which something was happening or, more specifically, during which I was
doing something, engaging in some activity. Some periods of time are in the past; some are in the present. Those periods defined by completed activities are in the past; those defined by ongoing (and therefore incomplete) activities are in the present.
The Contents of Present Time:
For that reason, we don't experience present time as a dimensionless point. It has breadth corresponding to the width of the activities in which we are currently engaged. For example, I am still in the period of time when I was a father, when I was attending this conference, when I was delivering this workshop, when I was uttering this sentence, when I was saying this word. These are all activities in which I am engaged, and each defines a period of time with a definite width. In fact, I am inhabiting a host of periods of time simultaneously.
Figure 1: Objective vs. Subjective Time
Figure 2: Intention and Time
A period of time has a simple but definite anatomy, determined by the
activity in which you are engaged, which we call an "activity cycle'' or just a "cycle'' (See Fig. 2). The period of time (and the cycle) starts when the activity starts, continues as long as the activity continues, and ends when the activity ends. The activity in question may be related or unrelated to trauma. It could be trying to get away from a sniper, or it could be vacationing. For instance, the period
of time "when I was going from Paris to Rome'' starts when I begin the process of getting from Paris to Rome, continues while I get the train tickets, get on the train, and eat in the dining car, and ends when I arrive in Paris. If an activity has started but not ended for me, that period of time is still ongoing and is part of my present
The Ruling Intention:
Moreover, each of the activities in which I engage is "ruled'' by a governing intention. In the example I just gave, the intention was to get from Paris to Rome but, in the case of a combat veteran, it could be an intention "to get revenge". In effect, therefore, an activity cycle starts when I formulate an intention, continues so long as that intention continues to exist, and only ends when the intention is ended. Therefore, there is an intimate relation between time and intention.
Each of the activities in Fig. 1 is coextensive with the existence of a corresponding intention. Each continues until the intention is fulfilled or unmade. Present time consists of periods of time that are determined by my current intentions.
Ending an Intention:
In fact, there are only two ways to end an intention and thus to send a period of time into the past:
|An intention ends more or less automatically when it is fulfilled, because you don't keep intending to do things that you know you have
already finished doing.
|Even if an intention is not fulfilled, you can deliberately and consciously decide to unmake the intention. Unmaking it, however, requires that you be aware of it and of your reasons for making it. You cannot unmake an intention of which you are unaware.
In other words, you can't stop doing something you don't know you are doing!
The Effects of Repression:
Repressing an incomplete cycle makes it destructive and, at the same time, much more difficult to complete. As mentioned above, to complete a cycle, I must be aware of the intention that rules it. But if, because of the trauma it contains, I have repressed the incident in which I created the intention, I am not aware that I
have that intention or why I have it, so I cannot unmake it! That period of time continues up into the present, and some energy remains tied up in it. In fact, it makes sense to define "charge'' as "repressed, unfulfilled intention''. Getting rid of charge, then, consists of un-repressing intentions and then unmaking them.
Now it becomes obvious why we need anamnesis in order to resolve the effects of past traumas. To reduce the charge contained in past traumas, the client must come fully into contact with them, so that he can find the unfulfilled intentions that he has repressed and why he formulates them, and unmake them.
To Repress or Not to Repress?:
Whenever something painful and difficult to confront shows up in life, one has a choice.
- Allowing oneself to experience it fully:
a. Thus being fully aware of one's intentions in the incident, and why one formed those intentions.
b. Thus having a choice whether or not to unmake the intentions.
c. At which point, the incident is discharged, by the above definition of "charge'', and becomes a past incident.
Paradoxically, by trying to get rid of the incident by repression, one causes it to remain present indefinitely.
- Repressing it, wholly or partially:
a. Thus not being aware of the intentions one made in the incident, or why one made them.
b. Thus not being able to unmake those intentions.
c. So that the incident remains charged and continues on as part of present time.
Effects of Charge:
"Charge" represents a drain on a person's energy or vitality, because energy remains tied up in the incomplete cycle connected with the intention in the trauma, and more is tied up in the effort to repress the incident. Hence a person with unresolved past traumas tends to be rather listless or goal-less in life. A second effect of past traumas compounds the difficulty: similar conditions in the environment can trigger or "restimulate'' past, repressed traumas, just as the sound
of a bell could cause Pavlov's dog to salivate. When one is reminded of a past trauma, one has, again, the choice given above: one can either allow oneself to become fully aware of what happened in the original incident or one can repress the incident of being reminded. Repression causes the "reminder'' incident to become a secondary trauma in itself. Later, similar occurrences can then restimulate it.
Figure 3. A sequence of traumatic incidents
A Sequence of Traumatic Incidents:
For example (See Fig. 3), consider a Vietnam combat veteran who has a past traumatic incident of being in a combat situation in which a close friend was killed. Contained in this incident are, say, the sound of a helicopter, a loud noise, the taste of chewing gum (assuming he was chewing gum at the time), and, perhaps, children (if he was in a Vietnam village). Also, a tree line. Since this incident is extremely traumatic, the soldier represses it, at least partially. He "doesn't want to think about it''. Later, some years after leaving Vietnam, he goes to a barbeque in the park. There, he is, say, chewing gum and sees some children. He also sees a tree line. He starts to be reminded of the original incident and feels the rage contained in it. This becomes uncomfortable, so he represses the incident in the park, wholly or partly. Contained in it was also a barbeque smell and a dog barking.
In a later incident, he is talking with his wife and chewing gum, and they are barbequing on the back porch with the kids, the dog barks, and the vet suddenly experiences a feeling of rage, because the earlier incident, the one in the park, is restimulated by the common elements: the dog barking, the barbeque smell, and the chewing gum. This is uncomfortable, so he represses this one also, and it becomes another secondary trauma. This incident also contains some additional elements: the sound of traffic, and the person's wife.
Later, he is drinking beer on the back porch with his baby and his wife and smoking a cigarette, and he is trying to talk to his wife but there is also traffic noise. Again, he flies into a rage because of the reminders, although, because the past trauma is repressed, he will attribute the rage to something else, e.g., to the fact that his wife
forgot the salt shaker (for the third time). This incident contains a sensation of being intoxicated, the taste of beer, the smell of cigarette smoke, and his baby. It, too, is repressed.
Later still, he is smoking, drinking beer, and watching TV. The sensation of intoxication and of smoking reminds him of the earlier incident and he feels rage. Now whenever he gets drunk or watches television, he is prone to fly into a rage. Random dream elements restimulate the same sequence of traumas, resulting in recurrent nightmares. Finally, he goes to a therapist and is found to be a full-blown PTSD case.
This is a sequence of traumatic incidents, starting with a "root'' incident and encompassing, probably, a large number of subsequent incidents in which the root incident or one of its sequents got restimulated. The only thing in common to all these incidents is the feeling of rage that he experiences each time. He attributes this rage to something in present time, but it actually stems from the original rage he felt in the root incident.
Tree structure of a
of traumatic incidents
Figure 4. The traumatic incident network
The Traumatic Incident Network:
Although we have only shown a few incidents, in real life a sequence may contain hundreds or even thousands of incidents. Furthermore, the average person usually has a fairly large number of these sequences, with different themes in common. These sequences overlap each other to form a network of traumatic incidents which we call the traumatic incident network or "Net'' (See Fig. 4). The object of Traumatic Incident Reduction (TIR) is to reduce the amount of charge the Net contains so that the person is not subject to the restimulating effects described above and also so that he can reclaim the intention units that are tied up in the Net.
What we have shown, here, is not just the situation of a Vietnam combat veteran or a rape survivor. It is the human condition. Every one of us has had at least some past traumas that cause us to be dysfunctional in certain areas of life - the ones that contain possibilities for restimulation.
The Solution to the Net:
Stating the solution is easy, but accomplishing it is somewhat trickier. Traumas contain very intense, repressed, unfulfilled intentions, such as the intention to get revenge, to escape - and, of course, the intention to repress the incident. The client needs to find the root incident for each sequence and bring it to full awareness. Traumatic Incident Reduction accomplishes this result. When that occurs, the person becomes aware of the intentions in them and, since these intentions are generally no longer relevant to the here and now, he unmakes them. At that point, the cycles contained in the incidents are completed; they become part of the past, and they can no longer be restimulated.
What is required, then, to obtain the necessary anamnesis? An incident has four dimensions, not just three. In order to be aware of an incident, it is necessary to start at the beginning and go through to the end, like viewing a motion picture, not like looking at a snapshot. Hence, we call the TIR procedure "viewing'', the client a
"viewer'', and we call the one who helps the client to do the viewing the "facilitator''.
You can't just glance at a part of an incident and expect thereby to have fully completed the process of anamnesis, because you will miss other parts of it - probably the most important ones, the ones that are most difficult to confront. In order to achieve a full anamnesis, you must be allowed to go through the entire incident without interruptions, without reassurances - in short without any
distractions. Furthermore, it does not suffice to go through the incident only once. If you want to become fully familiar with a movie, you must see it a number of times, and each time you will notice new things about it. The same thing happens during Traumatic Incident Reduction, except that the client is viewing a past traumatic
incident instead of a movie, and that's somewhat harder to do.
Narrative vs. Thematic TIR
If, as is often the case with combat vets and rape victims - survivors of single or discreet incidents - the viewer already knows which trauma needs to be looked at, you can use a relatively simple form of TIR called "Narrative TIR''. You simply have the viewer go through the single, known incident enough times to resolve it. But in
most cases, the viewer starts out being entirely unaware of what the root trauma underlying his difficulties is. So how can he find it?
For that, we use a technique called "Thematic TIR'', in which we can trace back an unwanted feeling, emotion, sensation, attitude, or pain to the root trauma from which it originates.
When the viewer finds and discharges the root incident, a very specific and often quite dramatic series of phenomena appear, showing that the viewer has achieved a thorough discharge. Then we say the viewer has reached an "end point''. These phenomena usually appear in the following order:
1. Good indicators: The viewer appears happy, relieved, or serene. He is not sitting in the middle of something heavy. Sometimes he will laugh or say something cheerful. In the absence of good indicators, no end point has occurred.
2. Realization: Then the viewer will usually voice some kind of realization or insight, a reflection of the fact that he is becoming more aware.
3. Extroversion: Finally, the viewer will open his eyes or otherwise indicate that his attention is now back in present time. He will usually look at the facilitator or at the room, or make some comment to her about something in the here and now.
4. Intention expressed: Often, the viewer will explicitly tell the facilitator what intention was present in the incident. If he doesn't, she has the option of asking him to tell her of any decisions he may have made at the time of the incident.
When you see an "end point", the most important thing to do is to stop! If you continue past the point when the root incident has been discharged and continue to ask the viewer to look for incidents, he may start to wander around more or less randomly in the Net, be upset that you have not acknowleged his accomplishments and insights, or be otherwise distracted by your having gone beyond - and thus having missed - the end point in this very client-centered therapy.
We have found that TIR works well with most clients who fit the criteria for PTSD. An exception is that TIR does not work well with people who are currently abusing drugs or alcohol. Virtually every time we have had a failure, it has turned out that the viewer was drinking heavily or abusing other substances between sessions.
Although the TIR procedure is not complicated or difficult to learn, it can only work in a session environment that is structured in such a way that it is safe. Much of the TIR training involves teaching certain Rules of Facilitation and communication skills specific to the TIR style of working with a client.
Frank A. Gerbode, M.D., Founder
Traumatic Incident Reduction Association (TIRA)