Robert is a middle-aged man who is recovering from a recent heart surgery.  His childhood was marked by severe abuse.  Robert promised to himself that he will remain strong no matter what. He trained extensively and eventually became a police officer as he wanted to protect others from what has happened to him.  He is puzzled by his inability to go on with mentoring of distressed youth, something that he used to define himself by.  His nights are plagued by lack of sleep and sense of shame-inducing vulnerability.  He is getting frustrated with having to attend a cardiac rehabilitation program and seeks out extra work to stay focused.

 

Ana had a lot to deal with as well but never quite got over what has happened to her. She spends long hours rehearsing the past in her mind in an effort to comprehend the motivations of people who hurt her.

 

Six months ago Mazena was in a car accident. She was trapped inside for almost 30 minutes, waiting helplessly for the emergency crew to arrive. She used to be always ready to cheer everyone on. Now she spends sleepless nights, startles at a slightest noise and becomes irritated with such ease that she is beginning to loose connection with people she cares about.

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Robert, Ana and Mazena each deal with post-traumatic stress disorder (PTSD). Each used a different protective strategy to safeguard themselves against future assaults of fate and each is plagued by memories of events that they wished never occurred in their lives. We can understand their reactions by using two complementary models of PTSD: the metacognitive model and the memory processing model.

 

The metacognitive model was developed by Adrian Wells and focuses on reasons why people engage in certain thought processes. Metacognition refers to our ability to observe our thoughts and assumptions that we have about function and controllability of our thoughts. Robert might have promised himself that he has to be strong and might have derived ongoing comfort from his successes. This is quite normal. People enjoy their accomplishments. However most of us feel neutral about neutral days. A person like Robert would become devastated when the stream of proofs of strength slows its course. A heart attack represents a major trigger. It is a proof that despite his best efforts, Robert remained vulnerable to vagaries of life.

 

Anna took a different approach. She is a highly analytical person who derived her professional success from her ability to dissect problems from every angle. When applied to her traumatic past, the analysis backfired. Ana has been rehearsing the traumatic events in her head for many years but remains unable to arrive at a conclusion that is satisfying enough. She is hoping for an elusive sense of closure and a deep insight that will protect her against future violations. Both Robert and Ana share a belief that what they are doing prevents them from getting hurt in the future. So Robert goes on producing proofs of strength with hopes of concealing perceived weakness while Ana rehearses the past in search of answers. Both are very easily triggered by anything that can be construed as a possible warning sign. Robert might become a workaholic. Ana might overanalyze any relationship she might have the opportunity to form and put her prospective partners through a series of tests that they are eventually bound to fail. Each would feel a sense of heightened vulnerability at a thought of modifying these habits.

 

Mazena might not have yet developed such habits fully but she shares a sense of heightened alertness with Robert and Ana. She is fully aware that not allowing music in her house is not protecting her against future vehicle accidents but loud music her. Not being fully aware of where things are or how people move physically about the apartment leads to a sense of pending doom. In fact, Mazena might spend considerate amounts of time sitting immobilized, listening and waiting for something bad to happen. Relationships suffer because talking about trivialities distracts her from her watch. She might find it extremely difficult to fall asleep and would wake with a startle. To be able to sleep we need to be able to shelf the guard duty for a while.

 

Mazena is on a chronic lookout for indications of danger. Robert is on a lookout to quickly cover all indications of personal weakness with stories of professional successes. Ana looks for answers. Such chronic vigilance is extremely tiring and represents the source of many difficulties in lives of persons with PTSD. This process occurs irrespective of whether the traumatic event was caused by callousness of another human being or a fluke chance event such as a blown tire on a highway whilst speeding up to pass another car. In metacognitive terms the lookout state is referred to as attentional syndrome as the affected person has extremely hard time redirecting their attention to something else. The therapeutic interventions aim to assist the person with realizing that such excessive vigilance is not necessary and comes with significant interpersonal costs. Most importantly, bad things might still happen but excessive vigilance robs people of their ability to enjoy their lives when things are reasonably good.

 

Let’s assume that all three agreed to let go of unnecessary vigilance. Yet, Robert just read a memo about restructuring at work while Mazena, still unable to drive on her own, jumped in the back seat at a sound of an ambulance that passed the taxi she was in. The attention syndrome might come back full force because we are left with two other underlying factors. These are best explained by the memory processing theory. One is our tendency to avoid things that make us feel bad. Two is the manner in which traumatic memories are experienced. Edna Foa rooted prolonged exposure (PE) protocol in memory processing theory to deal with these two problems.

 

In PE, clients are encouraged not to avoid situations that create false danger alerts even if these situations produce feelings of great discomfort. Please note that persons entering PE are guided to not to avoid situation that create false danger alerts and not to face situations of real danger. For example, Mazena would be slowly moved from the back seat into the seat next to the driver and eventually encouraged to drive. She would never be advised to drive with a nail sticking out of a tire. Similarly Ana would be encouraged to date and not to question her prospective partner’s intentions at every chance she gets but it might not be in her best interest to confront her original abuser, especially if such an individual continues to present danger to others. Such acts of non-avoidance allow us to see that the situations are benign while avoidance robs us from such information.

 

Persons with PTSD not only avoid external triggers. Many attempt to avoid traumatic memories. In fact, majority form complex relationship with trauma memories.  Many tend to dwell on their experiences (in an attempt to create an understanding of what happened), many resist the memories (to be free from distress) and then get suddenly overwhelmed when the physiological fight-flight-freeze response gets activated seemingly out of nowhere (re-experiencing, flashbacks). Ana is the example of someone who dwells. Some events like severe assault, being taken hostage, being raped, are not things that can be understood, forgotten and forgiven through perseverative rehash. These things are bad and it is impossible to feel good about what has happened. The best we can do is not to allow our lives to be defined by such events.  We can only do so by producing enough good meaningful memories to crowd out the painful ones. However, we cannot avoid our mental processes as our memories would come with us everywhere we go.

 

In fact, if we want to avoid certain thoughts or memories, we have to actively remember what is it that we do not want to remember and might engage in excessive monitoring of our own thought processes. To understand that, you need to appreciate the difference between long term memory and short-term memory. Long term memory consists of memories of events that we know are past and concluded. Let’s reminisce about your favorite vacation trip. Some things, like the number of the seat you had on the plane, would be purged. Some things, like images of your favorite spot on the beach might be accessible with some effort. However the memory is consolidated and you are not living your life basking in the glow of the afternoon sun anymore than you are worrying about being late to catch the plane for the trip that has already taken place. Avoidance prevents consolidation of memories and keeps information in the easily accessible short-term memory compartment of our mind. This makes you experience the past as if it were happening in the present.

 

PE guides the affected persons through their memories in a way that allows them to check the difference between the dangerous past and a much more benign present. It is initially quite difficult because such memories produce a lot of painful feelings and physical reactions. The goal is not to forget. We seldom can: After all these memories pertain to the most threatening moments in our lives. The goal is to gain an ability not to be emotionally overwhelmed when such memories surface spontaneously. 

 

Let's use a simple to understand fear of spiders and principles classical conditioning.  If you are afraid of spiders, you are likely going to have an acute fight-flight-freeze response to being presented with a picture of a spider even if rationally you know that the picture is not harmful. We learn at a rational and a physiological level and the physiological learning do not always respond to reason. You might have heard someone refer to Pavlov’s dogs. At the end of nineteen century a Russian doctor showed that dogs that were fed from a bowl of a certain shape and size would salivate at the sight of the bowl even it did not contain any food. A person with PTSD is faced with a powerfully conditioned trigger and their body jumps into the self-defence mode without much need for intermediate thought processes. If the dogs are always given food in red bowl but no food in blue one, they will eventually stop salivating at the sight of the blue bowl. If we were hurt by some people and/or events but we rationally recognize that the events we are going to be facing are safe despite our body alarm system going into an overdrive, repeated exposure to such situations will extinguish the body alarm response. We need to learn to distinguish a memory from actual danger. It is a lot of work but it is feasible. The alternative is to remain hostage of our own fight-flight-freeze reactions that accompany the memories of the events that trapped us.  

 

To conclude, treatment of PTSD is quite counterintuitive. We might have to give up the thought processes that we regard as highly protective and then face situations that generate discomfort. However, prolonged exposure protocol is one of the most researched and most effective psychological treatments of trauma. Metacognitive approach is somewhat newer, but is also gathering evidence in its own right. Both belong into a larger family of cognitive behavioural interventions. The choice of treatment modality depends on how the person reacts to their trauma experiences. Mazena would likely benefit from straight forward PE. Ana would likely require a metacognitive approach first and it is not clear whether this would need to be followed through with PE. Robert might require both.