An Anatomy of Psycho-trauma: Pain, Illness and Recovery

AN ANATOMY OF PSYCHO-TRAUMA: PAIN, ILLNESS AND RECOVERY 41 An Anatomy of Psycho-trauma: Pain, Illness and Recovery Arman N. Begoyan Submitted July-2013; Reviewed twice Apr-2014; Revised Sept, 2014; Accepted Sept, 2014. Abstract In this article, the anatomy of psycho-trauma (psychological trauma) is expounded in three interconnected stages – Pain, Illness and Recovery. The latter is presented within the framework of Cognitive Conceptual Therapy. Mental or psychic pain that a person can feel their lifetime and which is commonly called “psycho-trauma”, has quite a complicated nature. The real psycho-trauma only develops when the occurred conceptual dissonance becomes conscious and acknowledged by the person: this is when the person really is traumatized. For the “recovery” of the person it is necessary to integrate the traumatic experience into their general experience: the person’s conceptual system. Keywords: scenario of the future, conceptual dissonance, conceptual psychoanalysis, conceptual reframing, conceptual reintegration. 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L’anatomie d’un psycho-trauma: douleur, maladie, et guérison Résumé: Dans cet article, l’anatomie du psycho-trauma (trauma psychologique) est développé en trios phases interconnectées – Douleur, Maladie et Guérison. Celle-ci est présentée dans le cadre de la Thérapie Cognitive Conceptuelle. La douleur mentale ou psychique qu’une personne peut ressentir une vie durant et qui est communément appelée “psycho-trauma” a ,QWHUQDWLRQDO-RXUQDORI3V\FKRWKHUDS\9RO1RSS,661 ‹$XWKRUDQG(XURSHDQ$VVRFLDWLRQRI3V\FKRWKHUDS\ ,-3 5HSULQWVDQGSHUPLVVLRQVZZZLMSRUJXN 42 ARMAN N. BEGOYAN une nature bien compliquée. Le vrai psycho-trauma ne développe que quand la dissonance conceptuelle vécue devient consciente et reconnue par la personne: c’est à ce moment que la personne est réellement traumatisée. Pour la “guérison” de la personne il est nécessaire d’intégrer l’expérience traumatique parmi leurs expériences générales: le système conceptuel de la personne. Mots clés: scenario du future, dissonance conceptuelle, psychanalyse conceptuelle, réencadrement conceptuel, réintégration conceptuelle. Анатомия психотравмы: боль, болезнь и восстановление Резюме: В данной статье рассматриваются три взаимосвязанные стадии, составляющие анатомию психотравмы (психологической травмы): боль, болезнь и восстановление. Работа по восстановлению проводится в структуре когнитивно-концептуальной терапии. Душевная или психическая боль, которую может пережить человек на своем жизненном пути, и которая обычно называется «психотравмой», имеет достаточно сложную природу. Настоящая психотравма развивается только в случае осознавания и признания возникшего концептуального диссонанса. Для «восстановления» необходима интеграция травматического переживания в общий жизненный опыт человека, в его концептуальную систему. Ключевые слова: сценарий будущего, концептуальный диссонанс, концептуальный психоанализ, концептуальный рефрейминг, концептуальная реинтеграция. Introduction Working over the years with clients suffering from PTSD and anxiety disorders, I have gradually discovered that the optimal approach to mental and behavioural disorders is an approach that takes into consideration both the causality and the dynamics of a disorder. As a result, in my clinical practice and theoretical analysis, I have developed an approach – that I call Cognitive Conceptual Therapy (or earlier - Conceptual Psychotherapy - disorders and Recovery therapy) (Begoyan, 2010a). Since the causality and dynamics of any disorder are decisive and are goal-forming moments in the process of psychotherapy, the idea of psychological trauma is considered to be one of the central objects of study in Cognitive Conceptual Therapy. In this article, I have briefly tried to show my conceptualisation of traumatisation and therapy as an anatomy of psychological trauma. And I will present this by discussing three interconnected phenomenon: pain, illness and recovery. The Cognitive Conceptual theory of Psycho-trauma is based on nine basic ideas: 1. Human nature, at any moment of its existence, irrespective of age, level of socialization and education, is inclined to have certain expectations from people, environment and life in general. 2. These expectations, in their turn, in the course of time, are merged into one prognostic system, a “future scenario” – which, in its turn, becomes an integral part of the Person’s Conceptual System (PCS - Begoyan, 2010b). 3. But since man’s prognostic abilities are not perfect, it’s natural that many expected things are not consciously realized in life, or they come into the person’s life from an unexpected direction or through an opposite polarity. This is why any person can come up with the AN ANATOMY OF PSYCHO-TRAUMA: PAIN, ILLNESS AND RECOVERY 4. 5. 6. 7. 8. 9. 43 first act of discrepancy between the content of their expectations (future scenario, PCS) and their actual reality. This is a form of conceptual dissonance, which will be discussed later on in this article. Conceptual dissonance is essentially traumatic in its nature. It refers to the actual experience, and the trauma is the conscious realization of that experience by a person. Conceptual dissonance may occur at any age, but the realization of it, the traumatisation often appears later. Conceptual dissonance, which is the result of the traumatic experience, is the main generator of different mental, behavioural and somatic disorders. In general, our life is full of conceptual dissonance experiences. As to the very first one, it usually already affects us during the first year of life, in early childhood. That’s why many problems are rooted in our childhood. There often needs to be a reorganisation of basic concepts (about life, ourselves and how things work) in order to reduce the conceptual dissonance, and lessen the traumatic effect. If we can readjust our conceptualisations, the dissonance – and thus the trauma – is reduced. Trauma is therefore an experience that needs to be integrated. Unless it is integrated, it cannot be healed. It is the integration of traumatic experience that becomes the objective of Cognitive Conceptual Therapy (Begoyan, 2010a). Pain Mental or psychic pain that a person can feel at any different period of their life (and which is commonly called “psycho-trauma”) has quite a complicated nature and process of initiation and functioning. To state it more clearly, any kind of psycho-trauma has both an informative nature and an emotional impact: and this is usually exacerbated as a result of the discrepancy between our various expectations (future scenarios: “I didn’t expect an earthquake”) and the factual reality (of an earthquake). The above-mentioned discrepancy (or dissonance) is our initial experience of the impact of reality and, before it turns to a psycho-trauma, it has to gain some personal meaning: certain meaning for a certain person. In other words, the moment the person acknowledges the fact of the dissonance, this acknowledgement turns the experience into a psycho-trauma. Expectations and “Scenario of the Future” Every person has certain wishes and expectations, future plans, which – in the course of time – are framed into one conceptual model: a future image, which the person develops, taking into consideration their personal (sometimes others’) prognostic ideals. Most people do not actually meet their expectations in a realistic way: anyone can be an example of this – things really never turn out how you originally imagined them to be. However, this fact does not keep us from mentally modelling a desired “future scenario”. And – in the course of time – this image of future becomes a part of our conceptual system, a part of us, as if it (the desired future) had already started and later, if (or when) our expectations are not met, and a kind of “scenario breakdown” takes place, it is usually experienced as a real trauma, or a loss. Curiously enough, it is the discrepancy between our prognoses and reality that usually proves to be one of the origins of mental, psychological or behavioural issues. This 44 ARMAN N. BEGOYAN dissonance – when certain content of our conceptual system (certain prognosis) contradicts with the other one (perception of certain reality) – is called a “conceptual dissonance”. Conceptual Dissonance as a Psycho-trauma Cognitive or Conceptual Dissonance1 is the conflict between present and new belief systems. It is the inadequacy or incompatibility of certain expectations, or a person’s predictions (Future Scenario), and their actual reality. Conceptual Dissonance is the disturbance/ violation of a personality conceptual integrity. Conceptual dissonance occurs when new experiences cannot be properly explained, or understood, in terms of one’s present beliefs, predictions, and/or expectations. The confused state of being of conceptual dissonance activates the person’s defence mechanisms to try to save the integrity of their conceptual system (homeostasis) and thus their (imagined, expected) future scenario. Within the framework of conceptual psychotherapy, the defence mechanisms (which were introduced by Freud) are viewed – not as an “unconscious regulation of activity” – but as a means for matching the indirect experience with the individual’s perception of himself by way of distorting this experience in his mind (Rogers: Berberyan, 2010); and as the removal of any existential anxiety from the conscious mind by making it unconscious (see R. May & T. Hora: Berberyan, 2010). Pain and Illness It is only after a certain degree of conceptual dissonance that the person experiences the dissonance as pain. This can also, in a relatively chronic condition (intensity and duration), cause other different somatic and mental problems over a course of time: and this can then become an illness, or result in a psychological trauma. Initially the person tries to smooth away the dissonance, so as it doesn’t look like a real trauma, or they will (pretend to) pass any symptoms off casually. However, since most personal smoothing strategies are usually irrational and sometimes destructive, the person can simply intensify the secondary symptoms – of the illness, or the psycho-trauma. When a person begins to realize the reality of their conceptual dissonance, which can have happened a long time ago, or relatively recently, only then it is possible to speak about the trauma. In other words, the illness or trauma is the conscious manifestation of the conceptual dissonance. The illness or trauma is experienced by the person through their physical, emotional and mental pain or suffering, and, of course, these pains and sufferings have a negative influence on the biological, organic and functional systems of humans, resulting in psychosomatic disorders, and causing changes in the heart rate, volatile body temperature, muscular tensions, anxiety, hyperactivity, verbosity (over-talkativeness) and other symptoms. Since the origin of the mental and/or behavioural disorders is informative by nature, and the traumatic experience is a dissonance of information, there comes a strong necessity to revise that information and integrate the new experience into a new and better (more realistic) expectation, but I will come on to this point later. Many specialists, beginning with Freud, and including Horney (1937) and Janov (1971), 1 Cognitive dissonance is usually defined psychologically as “the mental stress or discomfort experienced by an individual who holds two or more contradictory beliefs, ideas, or values at the same time, or is confronted by new information that conflicts with their existing beliefs, ideas, or values”. I prefer using the term “conceptual dissonance”. AN ANATOMY OF PSYCHO-TRAUMA: PAIN, ILLNESS AND RECOVERY 45 have linked the causality of mental and behavioural disorders to early childhood traumas. The principal idea behind all these great psychotherapists’ theories, is the dissatisfaction of the child’s basic needs not being met, especially the need for love and acceptance (according to Janov), and the need for safety and satisfaction (according to Horney): it is this that generates a psycho-trauma. But the point is not in “dissatisfied childhood needs” rather it’s about the “unmet expectations” or “the breakdown of future scenario” in general, irrespective of the person’s age. It’s just because the first conceptual dissonances are usually experienced at a very early age in life, when a lot of reality is unknown or incomprehensible. The child has an inbuilt (unconscious) expectation of being warm, fed, and cared for. That is why the realization of the conceptual dissonance often comes later, at a relatively mature age. The essential difference between this and ways of understanding psychopathology (according to classical psychodynamic theory) is that – from the very start of conceptual dissonance – up to the display of psychopathological symptoms, the person passes through the various stages of their trauma or illness, which is the process of development of neuroses. This process is called “freezing of pain”, according to Janov (Burlachuk et al., 2009). In our understanding, the real psycho-trauma only develops when the occurred conceptual dissonance becomes conscious and acknowledged by the person: this is when the person really is traumatized. Here, by saying “acknowledge”, I mean an adequate understanding and evaluation of a certain event, activity, or process which has taken place earlier and created a conceptual dissonance. It is appropriate to mention here an observation by Shapiro: “The dissociative material is rather a kind of information unavailable for the conscious mind, as it is preserved in an isolated neuronet in a specific form defined by the traumatic experience itself. That information comes up to the conscious level with the information processing.” (Shapiro, 1998, p. 78) Two Case Examples As a result of a piece of psychotherapeutic work with one of my clients (23 years of age), whose initial complaints were some kind of cenesthopathy2 with obsessions, it appeared that the symptoms of her illness were first expressed immediately after she “remembered again “ (at the age 16-17) and then “reconsidered” the mournful event she had experienced in her childhood at the age of 4-5, when one of her close relatives (a 22 year old man) regularly used to commit some sexual assaults on her. Another client, a man of 24, came to me with typical PTSD symptoms. During the first sessions, it appeared that when he was 8, he had lost his father, and since his relatives tried to protect him from the possibility to feel the loss for his father and surrounded him with too much attention and care, he was unable to feel that loss in the emotional-cognitive sense. And only now, some years later, he could acknowledge the real nature of his loss and naturally enough, at this stage in his life, he could begin to experience the feelings which he should have done a long time ago. Conceptual Dissonance and Pathogenic Smoothing Strategies When a person faces the reality that they never expected or desired, he or she turns to certain activities – or putting it more accurately – to certain strategies to “smooth” their dissonance. 2 Cenesthopathy is a syndrome where patients persistently complain of abnormal sensations in some particular part of their body, often giving them odd descriptions, with these sensations being medically unexplainable. 46 ARMAN N. BEGOYAN The main personal strategies within the situation of conceptual dissonance are usually one (or more) of the following: • Any type of distortion of existing reality - “Leaving for other worlds”, “Constructing the desired/alternate reality”. (“Alexander said that he loved me. I thought he was a wonderful person and that he would love me forever. Therefore, it seemed to me today to be impossible that he said he was leaving me.”) • Any type of distortion of the laws and principles of formal logic - (“Alexander said that he loved me. I thought he was a wonderful person and would love me forever. So today, when he told me that he was leaving me, he probably just meant that he was tired and wanted to go off for a while to get some rest.”) • A total rejection of the effectiveness of predictive abilities and anticipations and thus turning to polar values - (“Alexander told me that he loved me. I thought that he was a wonderful person and would love me forever. But, as he told me today that he was leaving me, it means that he has never loved me. I have been wrong about him, and he’s a total bastard.”) However all these strategies can differ in connection with age and psychological type. For example, in childhood, one of the widespread ways of reality distortion (for the sake of smoothing a conceptual dissonance) are several different dissociations, which are expressed in the form of dissociative disorders (especially in case of brutal treatment, or sexual abuse). Lewis (1992) gives an example of initiation and functioning of psychological mechanisms of these kind of distortions in “the phenomenon of an imaginary friend” (Chesnokova & Yaremchuk, 2002; Begoyan, 2008). For each of the three examples above, there now follows a fuller description and possible strategies for sealing with these forms of distortion. * When there is a “distortion of existing reality” It has been well described by McMullin (2000) why and how this occurs; why reality is going to become distorted. McMullin argues that clients are trying to protect their “consonance”, even if the expectation or ‘scheme’ itself causes a level of emotional distress, because dissonance is more stressful and could provoke even greater anxiety. It is equivocal to say: “It is quite normal to be unhappy, so – as if this is my reality – so be it, as you have only this one possibility in life”. These clients will keep thinking that they are ill, or there is something wrong with them, even if it does oppresses them, because their attitudes and behaviour are based on that kind of perception. The clients will protect their “unhealthy” belief systems despite the existence of any opposite arguments or evidence. The key point is – that they have fabricated their “reality” all by themselves: their “reality” is the product of their (fallacious) beliefs about themselves and everything surrounding them: and they will stick with it, because it is theirs, even if it is wrong. (McMullin, 2000, p. 141-148) They have built an “identity” around their belief system. The mechanism of constructing an alternative reality, and developing various psychopathological syndromes lying within this alternative reality, are excellently illustrated by Adler: Only in those cases where the ego has separated itself from the community and approximates to a condition of isolation, are the clamps removed; in dreams, for AN ANATOMY OF PSYCHO-TRAUMA: PAIN, ILLNESS AND RECOVERY 47 example, in which the ego seeks to overwhelm its neighbor; in the terrible uncertainty of a death in the desert, where the torturing thought of slow destruction allows an hallucination to develop like consoling fata morgana, and finally, in the neurosis and psychosis which portray, in reality, the situation of an isolated man struggling for prestige. With ecstatic fervor, such individuals rush drunkenly into the realm of the unsocial, the unreal, and construct new worlds in which hallucination gains a value because rational thinking is not so important. As a rule, enough community feeling still persists for the hallucination to be felt as unreal. This holds generally both for the dream and the neurosis. (Adler, 1983, p. 53) It is very difficult for someone to change someone else’s “reality” – as this might mean that they will have to (or be forced to) change their identity: they will (effectively) have to give up being who they are: their very “self ”: this is an existential crisis. If they cannot be who they (think they) are, then they won’t exist; life won’t be worth living; they may as well give up! * When there is a “distortion of the laws and principles of formal logic” In this case, it is possible to smooth the conceptual dissonance by distortion of the laws and principles of formal logic. And, as a result, the personality’s logic acquires a deficit mode or model of growth. The personality resorts to the denial of any new experience (i.e., becomes more rigid – and the rational and logic understanding of their reality is going to be distorted). Then, a necessity for the new integration of data turns up. After these, the person tries to push the new data, or the new experience, into their already existing concepts or ‘gestalt’, and, as a result, the personality’s intellectual abilities become degenerated. A certain level of degenerative or defective logic is autonomically formed (Begoyan, 2012). It may be possible to help a person become less rigid, to accept the new data, and to continue on with a changed or adapted, more realistic version of reality. It is usually best not just to challenge their logic (as this is well defended), but to help them to experience the benefits of the new reality. * When there is a “rejection of the effectiveness of predictive abilities and anticipations” The essence of this strategy – for the person – is the total rejection of their existing experience concerning a certain topic, object or phenomenon, and a rejection of various parts of their gestalt-concept, as well as the whole gestalt-concept being endowed with polar values (Begoyan, 2012). Below is an example, which better describes this strategy. Ann, 42-year old woman, who’s son had died in 1992 during the ‘Artsakh Liberation War’, during her first therapeutic session said the following: “I have always believed that The Lord will save my family and my child from all kind of evil. I have always believed because I am a true Christian. I go to Church every week. I pray every day and read the Bible every day. I am devoted to my husband. I always help people even strangers when they are in need. And now I 3 All names are fictional. 4 The ‘Nagorno-Karabakh War’, referred to as the ‘Artsakh Liberation War’ by Armenians, was an armed conflict that took place in the late 1980s to May 1994, in the enclave of Nagorno-Karabakhin in south-western Azerbaijan, between the majority of ethnic Armenians of Nagorno-Karabakh (who were backed by the Republic of Armenia), against the Republic of Azerbaijan. 48 ARMAN N. BEGOYAN am asking to the Lord, “Why did You take my son away? Why, my boy?”, and I cannot understand why he did that. Moreover, after all these, I think that he has never existed - that God has died. All this time, I have been in delusion. Now I understand that all my lifestyle was a mistake. Everything that I did was wrong. I should have saved my son myself and should have not relied on God, who is just a myth ...” Recovery The illness caused by a psychological trauma can be treated only by taking into proper consideration the peculiarities and mechanisms of its development. In this case, the psychotherapist’s task is to help the client or patient in “accepting” their new reality in a reasonably rational and constructive way. Recovery is possible only when the necessity of integration of the traumatic experience is accepted. Recovery only happens when the traumatic experience is re-experienced less traumatically and without any further retraumatisation. The Essence of the Traumatic Experience Integrataion As it has been mentioned at the beginning of this article, for the “recovery” of the person it is necessary to integrate the traumatic experience into their general experience: the person’s conceptual system. And since any phenomenon presented in our conscious mind is nothing but information, the “processing” of the (traumatic) information is strongly required. This means they need a new set of here-and-now experiences (both in and out of therapy) on which to base a new set of more realistic expectations, or future scenario. Our approach is quite consistent with the psychodynamic model of information processing (Horowitz, 1979), according to which, because of the “tendency for completeness”, a person will constantly reject the traumatic information in their active memory, unless it (the information) corresponds to the individual’s inner model of the world. If the integrity fails, the information is left in the active memory and will probably be expressed in the form of obsessive thoughts. This process will last as long as a certain level of integration is achieved. The concept of reintegration of traumatic experience and the necessity of re-organizing the traumatic or dissociative information is quite consistent with the ideas of Pavlov (1927) concerning information processing. Pavlov implied some neurological re-balancing in a certain physiological system, which provided a new set of information processing until “the adaptive positive solution” is achieved”. (Shapiro, 1998) Our approach is also in line with Shapiro’s (1995) EMDR techniques. According to this approach, “the symptoms of posttraumatic syndrome are caused by disturbing information accumulated in the nervous system. That information is preserved in the same way it has been initially perceived and experienced, since the information-processing system, which should have “digested” that information, has been blocked for some reasons.” (Ibid., p. 64). AN ANATOMY OF PSYCHO-TRAUMA: PAIN, ILLNESS AND RECOVERY 49 The Process of the Traumatic Experience Integration For the integration of the traumatic experience, it is necessary to analyze the conceptual system of the person. This is the process of conceptual psychoanalysis - the initial stage of our psychotherapeutic approach. In conceptual psychotherapy, the conceptual psychoanalysis serves as both the basic method and establishes the pre-conditions for therapy. During the first stage of psychotherapy, for the purposes of studying the personality, a psychological analysis of the mind is undertaken to establish their points of conceptual dissonance and their “future scenario”, as well as for the purposes of diagnosis and discovering the client’s resources. The psychotherapist uses the method of conceptual psychoanalysis - that is why it serves later as a pre-condition for the psychotherapy, since it is impossible to continue or complete the process of psychotherapy without it. In this phase of therapy, the therapist usually tries: to see the problem from the client’s point of view; to understand his or her vision of the problem; as well as the real facts of the matter, its genesis, and aetiology (as far as this is possible), and then they can finally conceive the whole picture of what they have, and what they should be able to achieve. The next stage is the intervention, which helps to re-integrate the traumatic process. In the process of conceptual psychoanalysis, the therapist should choose or work out a strategy for intervention, which suggests using a set of certain therapeutic techniques, together with a degree of consistency for their usage. In the integration of the traumatic experience, it is better to start with denying or ‘resolving’ the client’s self-diagnosis and their subjective vision of the causality of their disorder. Otherwise, during the process of the therapy the client will express a certain level of resistance, and the resolution will be ineffective. After the self-diagnosis and subjective vision of the disorder casualty have been challenged and (hopefully) denied, the next strategic steps of conceptual psychotherapy should be taken: a conceptual reintegration and conceptual reframing (Begoyan, 2010a). By conceptual reintegration, I mean a strategic approach and a set of certain psychotherapeutic techniques, which will help in changing their beliefs (B) of the person related to the conceptual evaluation (M) of certain a emotional experience (S) that has been “shaped” by the person’s conceptual system (PCS). And by ‘conceptual reframing, I mean a conceptual evaluation and some strategic approaches, which includes a set of certain psychotherapeutic techniques so that the therapist – once a situation (a word, an event, or experience) has been activated or ‘triggered’ (A) –can help the person to learn to change their emotional experience (S), by the therapist helping towards re-organising the person’s conceptual system (PCS), and/or conceptual evaluation (M) in order to develop a certain belief (B) which would provide with constructive desired reaction (behavioural act, emotion, conclusion; C) (see Fig. 1). If the conceptual reintegration is a strategy with a psychodynamic and psychoanalytic nature, within the framework which we can use, for example the technique of hidden interventions5, then the conceptual reframing is a strategy with also a cognitive-behavioural orientation. However, at different times in the psychotherapeutic process, these two types of intervention are used either interchangeably or in parallel. It mainly depends, not only on the feature of psycho-trauma, but also on the client’s cognitive and emotional characteristics. 5 Exposure-Based Intervention – the method is aimed at helping the client to go through the traumatic memories once again, reconsider, reevaluate and integrate them. 50 ARMAN N. BEGOYAN A – Activating situation S – State: emotional experience PCS – Person’s Conceptual System M – Mark: the conceptual evaluation of S (state) B – Beliefs: beliefs about a certain M NST – Nervous System Type: type of nervous system C – Consequence: reaction (behavioural act, emotion, conclusion) Fig. 1. Formula for the Cognitive-Conceptual Therapy (Begoyan, 2010). Conclusion People, in a cognitive sense, definitely lives with, and in, their imagined futures. That is why, in the process of psychotherapy, expectations, desires and future scenarios (in general) are of utmost importance. Even if the psychotherapist (researcher) delves to the client’s past, it is for the purpose of discovering aspects of his present and future scenarios, and to discover further possible developments, changes, transformations and results, transformational aftereffects and finally to help the client to accept their (undesired) future, which has started a long time ago and has already turned into their past. Author Arman Begoyan is head of Clinical Psychology & Psychotherapy Department at the Harmand Hilfmann School of Professional Psychology in Yerevan, Armenia, as well as Chief Psychotherapist of Hilfmann Psychological Services (www.hilfmann.com). He is an author and/or co-author of more than 40 scientific articles/papers in field of Personality Psychology, Clinical Psychology and Psychotherapy. He has been developing Cognitive Conceptual Therapy since 2008, which is an approach based on Cognitive Science, Neuroscience and Psychotherapy (mainly CBT, REBT and Existential Psychotherapy). 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