1. Traumatic Sensitization and the Victim Dilemma © John Oakley Beahrs, M.D., Group for the Advancement of Psychiatry, November 13, 2021
2. SENSITIZATION Anti-Adaptation 1. Trauma 2. Adrenergic Stimulants 3. KNOWLEDGE of Trauma Institute of Medicine (2003): 1. Prime Societal Vulnerability 2. Challenge: Build RESILIENCE 3. BUT Ever More SENSITIZED
HOW, WHY, WHAT TO DO?
3. VICTIM DILEMMA 1.“VictimIZING” = (a) all too real (b) best prevented
2. “VictimHOOD” = Life Position (a) voluntary control, traumatizes (b) REPUDIATE! (Eger, 2017)
AGENCY & ACCOUNTABILITY
4. AGENCY & ACCOUNTABILITY
Fundamentals of Healthy Humanness
1. AGENCY = “Free Will” (a) perceived controllability (b) ability to make things happen 2. ACCOUNTABILITY = Recognizing (a) one’s actions (b) their consequences
5. HELPLESSNESS ≈ TRAUMA Negates Agency and Accountability
1. Helplessness before (a) mortal threat TRAUMA (b) symptoms Ψ DISORDER 2. Enhancing Agency = (a) VACCINE against trauma (b) RELIEF from posttraumatic sx
6. Associated Questions 1. When do our efforts HELP? 2. Or WORSEN the trauma? 3. How to SHIFT FROM traumatic sensitization TO HEALTHY RESILIENCE?
7. Pre-Developed COMPETENCIES PERSIST 1. Hidden, Defended, STILL ACTIVE 2. Misdirection COMPLICATIONS 3. Accessing & Utilizing Therapeutic 4. RECOVERY, building RESILIENCE 5. Hidden Agency = KEY to CX or TX
8. Relevant Data Known, & UNDER-ATTENDED 1. 2. 3. 4. 5. 6.
Avoidance & Re-Enactment Marks Personal Identity Contagion Hypnosis Posttraumatic Polarization Agency = Hidden but still Active Attending to But One Pole CX
9. AVOIDANCE & RE-ENACTMENT: Undermine Autonomous Strivings
1. Avoidance = Basic Survival (a) traumatic affect (b) adrenergic, sensitizes 2. RE-ENACTMENT = Perverse (a) of what one’s trying to avoid? (b) perplexed both Freud and Terr
10. Neurobiology of Re-Enactment 1. Dopamine = Rewarding, “rush” (a) also sensitizes 2. ADDICTION to Opioids (a) WITHDRAWAL adrenalins (b) further sensitizes 3. CONSCRIPTS to Trauma’s Service (a) abstinence EXTINCTION
11. TRAUMATIC “IDENTITY” usurps autonomous personhood
1. Trauma MARKS one’s “IDENTITY” (a) as different, not necessarily worse. 2. Re-Enactment “False Self” (a) defended at expense of “true self” 3. Individual Social Identities (a) seemingly fixed, but malleable (b) reframing autonomous agency
12. Victimhood Identities = problematic subset 1. Widely Sought, Celebrated, Defended (a) victim vs persecutor vs rescuer (b) conflict ↑↑↑ TRAUMA 2. Beware Fraudulent Trauma Narratives (a) e.g., false Vietnam social stereotype 3. Mis-Rationalize Large Scale Evildoing (a) challenging target for intervention
13. TRAUMATIC CONTAGION displaces pre-existing thinking
1. Trauma & Hypnosis Long Linked (a) identity, mental states, free will all Δ’d post hoc, as if fundamental
(b) massive data under-attended 2. Mutual Suggestion either (-) trauma epidemics, wars, crusades (+) collective pro-social norms
14. Formal Hypnosis Problematic 1. Mis-Implying Less Subject Agency (a) risk covertly promoting complications (b) via well-intended helping efforts 2. Know Hypnosis Research Data (a) to recognize hypnotic phenomena, (b) reframe, and redirect from (c) trauma healthy agency
15. Posttraumatic Polarization 1. Pre-RMC: Natural Values Concord: child protection, tx. victims, family integrity, presumption of innocence 2. Trauma MARKS SALIENCE (“gist”) (a) e.g., child abuse pro-plaintiff (b) broken families pro-defense 3. Selective Affiliation CONFLICT (a) beleaguered “us” vs. evil “them”
Re-Enactment = Interim Victor
16. Destabilization: What Counter-Force is Missing? 1. With Trauma, HIDDEN AGENCY 2. Traumatic ≈ Infants’ Distress: (a) experienced helplessness (b) aversive to all, adrenergic arousal 3. Relief is also Partially Similar: (a) comforting to all parties (b) mediated by endogenous opioids
17. Traumatic ≠ Infantile Distress 1. In Infants: (a) helplessness = uncomplicated (b) nurturant relief = essential 2. In Trauma Victims, pre-developed (a) competencies persist (b) hidden agency “there” & active (c) “nurturance” ↑↑↑ TRAUMA
18. Regressive Dependency 1. ↑ sx ↑ ↑ rescue ↑ ↑ ↑ symptoms 2. Vicious Circle Model (a) surface-level dependency (b) threatens concealed agency
↑↑ anxiety ↑ ↑ ↑ SX 3. Corrective: Access and Challenge Patients’ Hidden Competencies
19. Symptomatic Coercion 1. Threatened Acting Out = Moral Blackmail 2. Appeasement ESCALATION
(a) therapist’s subservience 3. Counter-force symmetrical escalation
(a) “fighting fire with gasoline” 4. Antithesis = “STAND FIRM”
(a) withstand ensuing accusations (b) seek consultation
20. Therapists’ Expectations
Heighten These Risks
1. Seeking Therapeutic Alliance ≈ “validating” victim narratives 2. Being Helpful ≈ temptation to “rescue” 3. Duties to Protect ≈ symptomatic coercion
21. Communication Style Δ 1. Reframing: (a) can shift relative agency
2. Collaborating: (a) informed consent activates agency (b) contracting for specific roles -who does what, for whom, how much, and with what exceptions?
22. Treatment ≠ Protection 1. Separate Issues (a) alliance building > rescuing (b) patient locus of control (c) able, willing, and trustable?
2. If We’re Forced to Protect, DO SO (a) define not as extra treatment (b) but contrary to treatment (c) seek consultation
23. FAMILIES 1. Patients’ Permission Usually Given (a) mobilizes social supports 2. Seek Alternative Narratives (a) often embraced by patient, reframe 3. Convergence toward Focal Point (a) of stories & mutual suggestion 4. Change One Party Via Changing Another (a) e.g., attending Al-Anon, equivalents
24. Re-Activating Trauma is Controversial
1. Fine Line: (a) controlled EXPOSURE TX?, vs (b) RE-ENACTMENT SENSITIZES? 2. Patients’ Locus of Control (a) therapist rescuing re-enactment (b) patient initiative healthy agency 3. Problem: Relevant Agency is Hidden requires therapist’s expertise, boundaries, & knowing under-attended hypnosis data
25. Interdicting Re-Enactment 1. Identify: focal pattern?, addictive? 2. Prepare: (a) in locus of control?
(b) can patient recognize, and (c) accept responsibility over it? 3. ≈ Abstaining from Substance Abuse
(a) very difficult, but can be done
26. Standing Firm Against Symptomatic Coercion 1. What’s Within Therapist’ Agency? 2. Decline Counter-Tx Patient Demands (a) withstand punitive accusations (b) seek colleagues’ support 3. If Forced to Protect Patient, DO SO, BUT
≠ “treatment”, & seek consultation
27. LIMITS Complement Nurturance 1. Limit-Setting is Essential (a) ↑↑↑ with ↑↑↑ competencies
(b) secure limits = anti-traumatic 2. Intrinsically Aversive, hence need (a) confidence in their (b) necessity, and goodness (c) social support Concordance Societal Health
28. Limit-Setting Tradeoffs 1. Consensus Norms (a) societal wellbeing (b) & effectiveness, BUT 2. Enforcement can be ABUSIVE (a) demands correction (b) criminal law once, no longer
29. Anti-Victimizing Doctrines 1. Child Protection ↑↑↑ (a) “battered child” paper 2. Affirmative Action civil rights (a) corrective minority entitlements 3. Womens’ Liberation feminism (a) former role variations newly permitted, promoted, celebrated
30. Potential Tradeoffs = Sensitive 1. Costs to Children? (a) of more capricious disruptions? (b) one-parent households, boyfriends? 2. Re-Inflamed Racial Trauma? (a) with diversity at all time maximum? 3. Social Norms De-Stabilized? (a) by weakening of nuclear families?
31. “Blaming the Victim”? 1. Resistance to Holding Accountable (a) traumatized persons (b) former victims
2. Therapeutic Strategies: (a) RESPECT others’ right to differ, (b) TRULY BLAME only people who knowingly violate others’ rights
32. Growing Up Then & Now? reflections by a World War I veteran
1. Then: “Life’s Rough” (a) bad things happen (b) make the most of things
2. Now: “Make Perfect” (a) “enemy of the good” (b) more traumatizing?
33. Recovered Memory Controversy (RMC) 1. Therapist Consensus, 1993 APA Forum (a) victim memories necessarily true (b) alleged abusers presumed guilty (c) safety/recovery depend on therapists (d) corrective research data are seditious
2. SYMPTOMS ESCALATED (a) regressive dependency on massive scale (b) social polarization, death threats
RE-ENACTMENT = INTERIM VICTOR
34. RMC II: Self-Correction 1. Advocacy: Pro-Family & Innocence 2. Memory Research Newer Data (a) traumatic memory is malleable (b) shaped by suggestive input 3. Corrective Principles Emerged (a) conviction requires physical evidence (b) tx better builds on clients’ strengths
35. Legal Limit-Setting 1st 1. Punitive Judgements (> $ 108) (a) corrective information (b) shared narrative (c) reduced re-enactment 2. Therapists Largely Adapted (a) many came to concur 3. Similar Process May Apply to Other (a) to other mass traumatizations
36. Accessing Agency 1. Patients’ “Yes, but” games (E. Berne) (a) FROM “Here’s what to do” (b) TO “What’s your PLAN?” 2. Defining Personal Identity Δ (a) Who are you? (b) What do you stand for? (c) Where are you headed?
37. Question: Can Pts’ Agency & Accountability be a Primary Tx?
1. Effective, Efficient, Safe? 2. With “Disorders of Extreme Trauma”? (a) e.g., dissociative, extreme borderline? (b) otherwise too labile to be in treatment? 3. Essential Messages: (a) “I can’t change you”, & “won’t even try (b) no threat to hidden agency, but engages patients’ active strategizing
38. Comparative Treatments * 1. “Traditional” Psychotherapy (a) therapist = change agent, crisis resource 2. Patients’ Maximal Agency & Accountability (a) patient accepts most treatment roles 3. Tx. Estimates = Therapist + Peer Ratings (a) composite estimates, reliability ≥ + 0.8
* Beahrs JO: Assessing attributive causation in psychiatry: psychotherapeutic results correlate with self-therapeutic activity. Clinical Neuropsychiatry 3(2):154-161, 2006
39. Exploratory Psychodynamic Tx
(EPT) = BASELINE QUASI-CONTROL 1. Traditional roles. THERAPIST AS (a) primary change agent (b) & bottom-line crisis resource 2. “Therapy” SAID TO OCCUR (a) in scheduled sessions, (b) in therapist’s consulting room 3. Change via TRADITIONAL MODES: e.g., relationship, interpretation, ego states, etc.
40. “Strategic Self-Therapy” (SST) = EXPERIMENTAL GROUP 1. Patient accepts primary responsibility (a) direction & pace of therapy (b) safety from destructive behavior 2. Therapist = solely consultant or catalyst (a) ≠ change agent, ≠ crisis resource (b) indep. sstm = crisis resource 3. “Life itself” = consulting room (a) change occurs via patient’s (b) redefining personal identity
41. Differential Responsibilities 1. Literally Correct (a) patient does what only he/she can do (b) therapist = solely a consultant (c) independent sstm = crisis resource 2. Prevents Therapist’s “Rescuing”, thus (a) avoids threatening hidden agency (b) less polarizing, regression, coercing 3. Separation of Treatment ≠ Protection
(a) pivotal, pt wholly accountable for protection &/or to secure it elsewhere
42. Engagement Phase 1. Informed Consent: Alternatives, Tradeoffs 2. Negotiating Roles & Responsibilities 3. Concluded when Mutual Trust Secured (a) particularly mine, for the patient 4. Patients’ Behavioral Safety = Paramount (a) expect significant testing en route (b) use ER when necessary, but sparingly Pt’s Trustability = Precondition to Proceed
43. SST Proper:
Patients’ Refining Personal Identity 1. Self-Description (character in novel) 2. Value Priorities (manifesto) 3. Sense of Direction (plan): (a) goals (b) “perceived” roadblocks (c) backup plan for overcoming these proceeds from general to more specific
44. Comparative Assessment through therapist & peer estimates
1. Composite Estimates (r ≈ 0.8): regressive potential, self-therapeutic effort & therapeutic progress (mental d/o negation) 2. Regressive dependency: unidimensional 3. Qualifications: (a) no randomized blind controls, (b) EPT doubly more time intensive (c) SST pts slightly more regressive
45. Comparative Effectiveness
1. Regressive Dependency (a) reduced in SST; less cost & stress (b) no correlation w. therapeutic progress, i.e., appears to be a separate issue 2. Therapeutic Progress: Equal in Both (a) SST doubly cost efficient -with 27% dropouts, vs. nil in EPT ≈ 73% effective w. high-risk patients
46. Therapeutic Progress Correlated w Patients’ Self-Tx 1. Linear, p < 0.001, equally in both modalities 2. Correlation ≠ Causation ≠ Material (a) some overlap between the measures 3. Experientally Profound: i.e., patients (a) feel helpless before their sx, but (b) responsible over choice of self-help (helplessness socially reframed ≈ agency)
47. Can We Treat Society’s Traumatic Sensitization Similarly? 1. Roadblocks: Sensitizing Social Mores (a) aversion to “blaming the victim” (b) promotion of victimhood identities (c) constraints against open discourse 2. Available Options are Under-Utilized (a) legal duties of psychiatric patients (b) appropriate risk-taking parameters (c) contracting to Δ local tx. standards
48. Re-Opening Discourse 1. Legal Limits vs Egregious Violations (a) resolving the RMC = viable model 2. Principled Juror v Negative Groupthink (a) the power of standing firm 3. Standing Firm v Coercion & Victimhood (a) healthy agency & accountability
Δ Sensitization RESILIENCE