Dealing With A Post-traumatic State. Clinical Analysis

2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43

My interest in working with trauma is more localized in the treatment of PTSD, that is, a condition that arises as a result of poorly lived traumatic experiences. This article describes some general considerations for the treatment of these conditions, derived from case study

Etiologically, PTSD occupies a middle position between acute trauma, full of flooding, undifferentiated affects and mental exhaustion, an operative state in which the client is separated from his drives. Therefore, the symptoms of post-traumatic disorder are: loss of basic security as a reaction to a confrontation with an impossible situation that threatens the loss of self-integrity; background anxiety and undifferentiated somatic stress; toxic emotions in the form of shame and low self-esteem; the tendency to compulsive repetition as a chance to live the experience in a different way.

The challenge in working with PTSD is to gain access to dissociated experiences in a safe atmosphere of a therapeutic relationship and to assimilate the traumatic experience into the broader context of associative relationships. In order for the repressed affects to take their place in experience, they must be lived. Integration is carried out through the work of experience, which includes a holistic combination of affective, sensory and cognitive components. With severe trauma, PTSD is an important stop on the path to mental death and protection of the psyche from decay by maintaining a reduced, but nevertheless, integrity. This is a pause, which implies efforts to find resources for assimilation and more complete integration.

If PTSD is viewed as a result of blocking the experience of affects, then it becomes important in the work to find the therapist as a Other who is able to comfort. In work, the client seems to borrow from the therapist a temporarily disabled capacity for self-comfort. Trauma always occurs alone, and then the way out of the trauma is the prospect of dialogue and the separation of affects with someone.

In PTR, the client is present in the form of a story that is not addressed to anyone. He tells a story that is not filled with emotions and therefore it is impossible to find the client in it. One gets the feeling that he is offering a narrative about a third character. It remains completely incomprehensible what sensations and experiences the person who is placed in this narrative may have. The client looks at his life as if from the outside.

If we try to find a client, then in his place we will meet a person devoid of interest in himself. Intense basic anxiety does not allow paying attention to areas of life that go beyond the conditions of biological survival. It is possible that the resource for awakening interest in oneself is the ability to address one's story to the Other.

Once, a 39-year-old young man, suffering from a psychosomatic disorder in the form of cardialgia and dizziness, turned to an appointment. These disorders appeared in him about 3 years ago after his wife, without declaring war, went to another person. In this case, we can consider as a trauma a violation in the structure of meaningful relationships, which threatens the holistic idea of oneself and means surrender to an inevitable situation. It is known that the breakup happened very quickly, without clarifying the relationship, so the traumatic event turned out to be sudden and unassimilated. According to the client, he diligently avoided the dissemination of negative emotions, because he did not want to show others his sadness, and therefore negative emotional symptoms quickly manifested themselves in the form of positive somatic ones.

From an analytical point of view, these partnerships can be viewed as emotionally dependent, with poorly built boundaries between partners, in such a way that the break of this connection did not go along the border of two subjectivities, but through an invasion of the client's personal space. Thus, the loss of the object of attachment was perceived as the loss of a part of oneself, which led to a significant libidinal disinvestment of the Self. Phenomenologically, the client described the loss of a spouse not just as a loss of an object, but as a better part of himself that is responsible for creativity and the ability to have fun. The wife left and the desire to live with her went away. The traumatic experience here repeated the story of premature separation, when a child without sufficiently developed autonomy is unable to introject maternal care for himself and all the time needs a foreign object to complete his own identity.

The work with this patient took place in several stages. I think it would be better if the stages are understood as the focuses of the work, which throughout the therapeutic relationship did not replace each other sequentially, but were combined in an arbitrary order. Since psychosomatic symptoms were in the first place in the structure of PTSD, the work was initially aimed at understanding the deficit nature of life. The client's boredom became his second skin, and in this state he either engaged in mechanical activities that did not require emotional inclusion or experienced anxiety and somatic symptoms when it was discovered.

At the first stage, the work was aimed at realizing the total control that was present in the client's way of life. Life here and now was completely unimportant for him, since the immediate future was always clouded by the expectation of an imminent catastrophe. Chance became the center of gravity, and therefore existence was made sterile, like a surgical table. The present was a preparation for a tragic future, so it must be made lifeless and unable to create a threat. The work was aimed at confronting the erotic way of building contact and discovering areas of life that could not be brought under control. We explored the ability to trust ourselves in a situation of uncertainty and enjoy the ability to take on the challenges of being.

The next important focus of the work was the line of blocked experiences. These experiences were associated with an ended relationship. At the very beginning of the work, it was noticeable that the client was inclined to replace his own desires with conformal attitudes and had difficulties in showing aggression. So for him, the pole associated with a passive-aggressive pattern of behavior turned out to be very familiar - he felt sadness, resentment, considered himself unjustly abandoned, and even his indignation at the insidiousness of his wife, who left silently, remained locked inside. At the same time, the intensity of his experiences was extremely insignificant - he experienced sadness "as it were," but did not feel anger at all.

The next focus of the work, which logically follows from the previous one, was the topic related to the client's transference characteristics. In addition to the feeling of boredom and somatic countertransference, I had feelings that could be characterized within the framework of the phenomenon of projective identification - I wanted to avenge boredom. Similar components of the relationship were characteristic of the relationship between the client and his spouse. Our task at this stage was to try to discover the client's passion, the form of his presence in his own life. From the point of view of the Self theory, it can be said that the client had limited access to the Id function, trying to make his life devoid of mental excitement, since, being undifferentiated, it intensified somatic responses and led to an increase in unpleasant sensations in the heart region.

We worked in the focusing method, that is, the client focused on bodily sensations, gave them shape, gave names and subjective assessments, paid attention to their changes and thus developed the ability to emotionally sensory awareness. This made it possible to step beyond the facade of the somatic response and discover experiences and needs that could become a source of inspiration.

It can be said that in the experience of the breakdown of the relationship, the client stopped at the stage of anger and powerlessness, and the experiences of anger remained inaccessible to him. Also, the client did not have the opportunity to move on to the next stage of the experience of grief - he did not feel sadness, talking about this feeling as something that should be, but is not felt. Thus, assimilation of traumatic experience was not available to him, and one of the strategies of his work was aimed at exploring the values of relationships and how exactly life changed after his wife left. This topic turned out to be very fruitful, because in addition to being grateful to my wife and the time they were together, it allowed me to focus on the current relationship and take a more aware position in it.

In conclusion, I will give a description of a small piece of the therapy session, which, in my opinion, was very important for understanding how the client does not take responsibility for his life, taking a dependent position in relation to the therapist. We stopped at the metaphor of the current life situation, which looked like this - the client is in a tunnel, from which there are two exits. My intervention was to confront the client's insistence on repeating and walking in circles.

I said that everything that we could talk about here has already been said. There is no exit at this level. I am ready to come back and follow the client as much as I want, but I cannot take a step for him. If I liked to lie, I would write that in this place the client cried and, dancing, went into the distance. However, instead there was just a long silence and it seemed to me that the client first experienced sadness as a feeling, and not as a symbol of the experience. Despair, which has healing potential as it takes away the hope that things will change of their own accord. And then the crisis turns from a dead end into a prospect for development.