You don't have to relive trauma to heal from it

The Dodo Bird Effect

There are a LOT of therapies out there--over 500 to be exact. Which one of them is the "best"? Well, turns out that's not actually a very easy question to answer scientifically. One thing we do know is that therapy, in general, works well. Among the myriad of outcomes that we measure in medicine, psychotherapy makes a difference in people's mental health. But what we don't know is WHY therapy works--at least not specifically.

One of the problems is the so-called "Dodo bird effect": this comes from Alice in Wonderland, where Alice is put into a race that is designed by the Dodo bird. And in this race, there aren't really any rules: start whenever you want, finish

whenever you want, and all shall have prizes! In other words, when psychotherapies are placed head to head, neither one typically is shown to be on top, and systematic literature reviews looking into psychotherapy outcomes seems to show that this is, in fact, true.

CBT vs. EMDR

One great illustration of this effect is in head to head studies of CBT (cognitive behavior therrapy) and EMDR (eye-movement desensitization and reprocessing) therapies for posttraumatic stress disorder, otherwise known as PTSD. Turns out studies that compare these two therapies show that both of them work to help alleviate the symptoms of PTSD. But does this make any sense? CBT and EMDR have completely different explanatory frameworks. CBT, for example, proposes that our emotions are caused by distorted or inaccurate cognitions or thoughts, and when we examine our thoughts and analyze them for their rational accuracy, we can change them, and hence, change our emotions.

EMDR, however, propses to help with traumatic memories by focusing on them while having some kind of bilateral visual or body stimulation, such as moving the eyes or tapping the fingers, etc. This supposedly mimicks the brain's natural memory processing, such as that found in REM sleep, and helps to alleviate PTSD symptoms.

So how is it that there is no difference between these two treatments in terms of outcomes? That's one of the central questions in psychotherapy research. One popular theory is the "common factor" theory, which proposes that good therapy, no matter what it is, has common features that are the REAL key to improvement, regardless of the surface differences. Such things like therapeutic alliance, trust, understanding from the therapist, a creation of expectation of cure, tasks and actions to perform, and so on. The Contextual Model, as opposed to the Medical Model which treats psychiatric syndromes as if they were medical lesions to be extracted via the proper procedure, proposes that these common factors are what really helps.

What really gets you better from Trauma?

One consequence of this research is that as long as you are engaging in a legitimate therapy, you are very likely to get better. What is a "legitimate therapy?" you ask? Well, in short, it's a treatment which consists of 4 basic features:

1. It is based on some kind of psychological principles

2. It involves a trained therapist and a client or patient seeking help

3. It is intended by the therapist to be remedial (ruling out waiting lists, etc.)

4. It is individualized to the particular recipient

So, the key to getting better from PTSD is "therapy". But, not all therapies are created equal. Some therapy, like Prolonged Exposure therapy, for example, is very hard for patients to tolerate because it involves recounting the traumatic memories in gory detail over and over and over until you become "desensitized" to it. Kind of like flooding or systematic desensitization for phobias.

You might call this "the beatings will continue until morale improves" therapy. And like all the other types of therapy, Prolonged Exposure therapy does work. But it's a rough ride!

My Choice

PTSD can be a challenging and complex illness, and it can also be horribly debilitating. Moreover, I am not a big fan of tormenting my patients, even in the name of getting them better. I think there are much gentler solutions, and I have found them to work. Both psychodynamic oriented therapy, as well as trauma-focused hypnotherapy I have found work very well, and neither of them require patients to recount their traumatic memories in lurid detail.

This means that they are more likely to go through with it, and hence, despite the Dodo Bird effect, are more likely to finish and get better from it. To me, that's a huge win and a huge reason to use it, rather that other kinds of therapy which involve reliving traumatic memories. In such cases, I believe reliving traumatic memories can actually risk RE-traumatizing someone and making them worse--not an ideal outcome!

The Symbolic Dimension

Dreams, symbols, and metaphors are perfect for helping process trauma. Treating the bad memories as themselves visuospatial images that can be manipulated can be particularly powerful. For example, in one case, I remember treating a patient who was complaining that their moods went from intensely "on" to intensely "off"--i.e., either raging or numb. This is a common occurrence in PTSD. I took that to be the beginnings of an attempted metaphor for the patient to use, and so I, in the context of a psychodynamic therapy with all the common factors in place, introduced the idea of a "dimmer switch" as a way to put into images their negative experience of feeling like they were attached to a "light switch". This image popped up later, and the patient did not even remember where it came from (i.e., my suggestion), but it managed to help them process their emotional lability. Many other metaphors were used, many of which from the patient's own dreams, such as fighting giants, heroic quests, and journying with wise mentors, and these helped immensely.

All of this (and a lot more in therapy) was accomplished without going over ANY of the patient's horrific memories. And as such, the patient found it much easier to stick with the treatment, and I did not have to feel like I was the evil Count Rugen, the six-fingered man from the Princess Bride.

EG