Wednesday, November 21, 2012

Symptoms of what?

A recent piece of research adds to our understanding of PTSD.  This article seems at first glance to show what's already known about PTSD: As usual, the vast majority (84%) of those experiencing combat show no significant ill effects.  But of those that do, the leading contributing factor is adverse childhood experiences.  This fact drives the "vulnerability" theory of PTSD I discuss briefly here.  But what's really important about this study is something else, described in the section below:

"Most notably, about 13% of the soldiers in the study actually showed temporary improvement in symptoms during deployment. These soldiers reported significant symptoms of stress prior to leaving for Afghanistan that seemed to ease in the first months of deployment only to increase again upon their return home."

Noting that these soldiers were more likely "to have have suffered emotional problems and traumatic events prior to deployment," the authors explain the results above by hypothesizing " that army life – despite the fact that it involved combat – offered more in the way of social support and life satisfaction than these particular soldiers had at home."  But I suggest these results should be understood as demonstrating the fundamentally interpersonal nature of that which we call PTSD.

First, it is no surprise adverse childhood experiences are associated with PTSD.  They are, in fact, associated with (major risk factors for) virtually every social ill as well as many medical conditions.  (If you are not familiar with the ACE scale and this research, I suggest a detour to this page first.)  The common model for understanding this progression is contained in the "pyramid" shown here.  According to that model, adverse childhood experiences lead, in ways not fully understood, to "social, emotional, and cognitive impairments" that eventually lead to medical and social problems.  But we, in fact, already have another model of this process with valuable explanatory power: attachment theory.

Attachment theory is based on the understanding that children need to be taken care of and evolution has "designed" an adaptive behavioral system to ensure even infants can adapt to the interpersonal/emotional environment they find themselves in and thereby get their needs met.  That is, "adaptive styles" (secure, avoidant, ambivalent, etc.) are understood as behaviors that are adaptive to the emotional/interpersonal needs of the child's care-taking figure.  These behaviors, and the emotional learning they are based on, are the basement layers of the child's developing model of how the world works.  As it is nicely put on the Wikipedia site re attachment theory:  "Early experiences with caregivers gradually give rise to a system of thoughts, memories, beliefs, expectations, emotions and behaviours about the self and others."  Which then determine how the person relates to others throughout life and thus become the roots of the "social, emotional, and cognitive impairments" that later lead to illness and social dysfunction.

The parenting behaviors that leads to insecure attachments (especially disorganized attachment) do not suddenly transform as the child ages.  On the contrary, the same parenting deficits may become intensified as the child's needs become more varied and less simple to to satisfy (e.g., not simply the provision of a bottle.)  The resulting dysfunction may directly result in the neglect, abandonment, and abuse assessed by the ACE scale.

Further, just as with adverse childhood experiences, the attachment experiences of the child have been shown to leave their mark in the behavior of the adult.  The attachment style observed in the toddler predicts how the adult will relate to their own children as well as the attachment style of their own children.  Indeed, it can be found to affect many adult relationships, especially those, I would argue, in which power and dependency are at issue. (For example, intimate/romantic relationships, as well as relationships with physicians, bosses, and therapists.  For a thorough analysis, see Attachment in Psychotherapy.)

What I am suggesting then is that "social support and life satisfaction" isn't something that comes with "army life" along with your uniform.  It can only be had, if at all, by successfully negotiating the complex interpersonal field of military culture.  Each soldier attempts to meet his/her interpersonal needs as best they can given the developmentally created strength and weaknesses they bring to bear on the task.  

It is not hard to imagine scenarios in which this process goes well, even for the "vulnerable" soldier: the new recruit, highly motivated to belong, makes it through boot camp, becomes an accepted member of a unit, does the job expected of him/her in combat (maybe even a bit above and beyond), earns the respect of fellow soldiers, encounters good leadership, and comes to see him/herself as a valued member of a valued community.  The essential rule of military life - do as you are told and you will be taken care of - is not that terribly demanding, though, of course, it can be severely challenging in combat.  But also in combat, most of ordinary life falls aside and as long as you are doing your job virtually everything else is overlooked.

But it is also not difficult to imagine scenarios when this doesn't go well.  There are so many ways the military recreates early childhood experiences that may stir maladaptive responses. There are innumerable ways to run afoul of the system and just as many by which the system can fail the soldier.  Though officially everything is "by the book," in reality what happens is entirely determined by the interpersonal interactions of those involved.  What constitutes "social support and life satisfaction" differs greatly before, during and after combat and a soldier's success at obtaining them is essentially determined by his/her interpersonal skill and is not the result of the mere presence of "social support" or somehow automatically obtained "life satisfaction."

So that drop in symptoms while deployed suggests that the "vulnerable" are not destined for dysfunction.  That there is an interpersonal environment in which they can and do function.  And that that situation is, in fact, more powerful, more impactful than "the trauma," both the childhood one and whatever occurs in combat.

It also implies that since how we fare in combat is primarily determined by interpersonal considerations, the treatment for the effects of combat must also be primarily interpersonal, whether done while waving a finger back and forth or with two people in a room talking to each other.

p.s.  I know that I have merely suggested, rather than fully made the case that this drop in symptoms should be seen as evidence of the interpersonal nature of that which we call PTSD.  And that this is the first explicit statement by me of that thesis.  So there is much to object to in what I've written.  Although it is my intention to take this discussion in that direction, my posting this now was the result of the research article having just been brought to my attention and my desire to capitalize on the immediacy of the topic.  In later posts I will fill in the data and the arguments I have merely suggested here.

Roy Clymer

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here or see a copy of it found on this blog titled "The Puzzle of PTSD."

Thursday, November 1, 2012

Avoidance, my old friend

I recently became aware that I have been avoiding writing about avoidance.  I'd think about it occasionally.  And I had written (in my head) one rather glib start about how avoidance is a problem only because it works so well.  But then I realized I was avoiding all the feelings connected to avoidance, which is, of course, the purpose of avoidance in the first place.

One of my problems with the idea of PTSD is that the definition focuses exclusively on the emotion of fear.  But what's so special about fear?  Torn flesh and dead bodies produce disgust. (That's why we vomit.)  We feel the anguish of injured, missing, dead comrades.  Murderous rage abounds.  And I can't begin to enumerate the endless daily opportunities, big and small, for shame about what we've done, or what we didn't do that we felt we should have.  Fear is just one of several intense emotions we likely experience in war; why is it the only one that leads to "trauma?"  Why is it the only one seen as damaging?  While that's an important question I'll take up later, fear is uniquely important to avoidance because of it's relationship to any and all aversive human experiences.

We are "designed" to seek out those stimuli/situations/events we experience as pleasant or pleasurable and avoid those that we experience as aversive.  It's how organisms work; how they can be programed by evolution to seek and find those things necessary to survive and reproduce and avoid those that put that at risk.  Fear is the experienced affect that guides us avoid the aversive.  If we've come to learn a particular situation results in an aversive outcome (being shamed, for example) we will fear similar situations. These simple, obvious truths immediately reveals the complications of avoidance.

It is "natural" to avoid anything we find unpleasant.  So if you were attacked on one or more bridges where you suffered painful losses, it makes sense to drive miles out of your way to avoid going over a bridge in your hometown.  Seeing a bridge stirs the memories, and all the associated feelings, of what happened.  Even thinking about driving over it does.  Going out of your way to avoid it, while still somewhat anxiety provoking, is a lot better than what you know will happen if you try to drive over it.  Avoidance works.  Sitting with your back to the wall at a restaurant works (it lets you scan for danger).  So does avoiding crowds and, if you can't, carrying a weapon (e.g, a knife).

Avoidant responses to threatening situations protectect from vulnerability to harm.  But veterans also protect from vulnerability to loss/distress by avoiding family members, loved ones, or any real intimacy.  Avoiding shame is more challenging but veterans do so by avoiding situatiations in which their fears could be revealled (crowds, possibilities of loud noises [e.g., fireworks], being responsible for others).  They also avoid situations likely to stir their rage such as driving, working for demanding bosses, interpersonal conflict.

So you can see why a cabin in the wilderness provides the perfect solution.  No people to care about and thereby risk the anguish of another loss.  No people to threaten you.  No people to see and shame you for hitting the dirt when a car backfires.  No people to to see being turned into wet hamburger.  No wonder so many veterans express a longing for such a solution.

However, as always, our problems are the products of our solutions.  Avoidance is adaptive because it works.  But just because it works so well, it's likely to be retained even when no longer necessary.  Avoidance is self-reinforcing and hence, like drugs, addictive.  And, just like drugs, the price of the payoff ever increases.  As avoidance successfully lessens the fear of dreaded situations, more and more of life may get "roped into" an avoidant lifestyle

We know how to treat avoidance.  A combination of psycho-neuro education, some form of systematic desensitization or exposure therapy, and maybe some medications, all provided, of course, in the context of a theraputic relationship with a respectful, engaged, skillful therapist.  But that's not to say it's easy.  We avoid at the feeling level as well as the behavioral.  Even if the veteran has left the cabin in the woods the wall around his/her heart may long endure.  Dismantling the wall is no small task, especially with life all too often providing incentives to rebuild it.  What man hath put together even god (love) may labor to put asunder.  But let us try.

Roy Clymer

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here or see a copy of it found on this blog titled "The Puzzle of PTSD."