The treatment of PostTraumatic Stress Disorder (PTSD) is undergoing change. PTSD was "discovered" after veterans returned from Viet Nam with a myriad of symptoms. Earlier wars had resulted in cases of "shell shock" and "combat fatigue" - disorders virtually identical at times to modern day PTSD. Prisoners-of-war, survivors of earthquakes, and persons surviving other severe traumas had also been known to have adjustment problems.
Psychologists working with these populations often noticed that they would have periods where they appeared to be re-living the trauma. This re-living was given the term "abreaction" by Sigmund Freud in 1892. Work with World War II veterans found that assisting combat veterans to abreact the trauma in a controlled environment allowed the symptoms to decrease. Hypnosis was sometimes used as a way to facilitate the abreaction and to manage it. In recent years abreaction has also become an important part of the treatment of dissociative disorders.
The wounds left by trauma have been described as similar to an infected boil. Abreaction is sometimes seen as analogous to lancing the boil to allow the wound to heal. This theory led to the inclusion of abreaction as a part of the dominant treatment paradigm for trauma disorders.
There are several variations of this model, but all emphasize abreaction as a critical healing element. Bennett Braun's BASK model for the treatment of dissociative disorders is an example of an abreaction-focused model. Braun believed that it was important for a traumatic event to be abreacted to the extent that the person relived the Behavior, Affect, Sensation, and Knowledge of the traumatic event. This model has been widely used in the treatment of dissociative disorders, but it has recently been questioned by some.
Recently the idea that abreaction is an important part of the treatment of trauma disorders has been challenged. The "recovered memory debate" has resulted in a re-evaluation of the role of abreaction.
Abreaction is a difficult and painful process. The person is often re-experiencing the trauma as if it is occurring in the present. Pain is sometimes felt in the same part of the body that was hurt during the trauma, and they can experience sights, sounds, and smells that were present in the original traumatic situation. Many clinicians found that the pain that patients went through was severely disruptive to their daily life. A balance seemed to be needed between working on traumatic material from the past and helping the patient function in the present.
Some treatment programs emphasized abreaction to the exclusion of other techniques, and patients were sometimes kept on inpatient units for months and even years. Patients were sometimes tied-down in restraints prior to an abreaction to prevent them from hurting themselves or a staff member. Such "restraint therapy" was used primarily for abuse survivors with severe dissociative disorders. In some cases the therapy seems to have had negative effects independent of the original abuse.
In a recent issue of Dissociation Richard Chefetz has written an article addressing the role of abreaction in therapy for trauma survivors. He maintains a fairly traditional view that abreaction is an essential part of treatment, and he presents vignettes designed to illustrate his points. Chefetz states:
The abreaction of intense affect is not a goal of psychotherapy; it is an inevitable concomitant experience in the therapy of persons with post-traumatic histories, physical and/or sexual abuse, neglect, and related innate experiences. (Chefetz, 1997).
He then presents some excellent guidelines for therapists working with trauma survivors:
- Maintain a calm aura.
- Be capable of uncertainty.
- Track the affect in the patient and in the clinician.
- Make note of pressures toward enactment.
- Avoid re-victimization and enactment of the traumatic transference.
Keep reading for a discussion of these models of trauma work
*Title is adapted from Richard A Chefetz, M.D. "Abreaction: Baby or Bathwater" Dissociation Vol.X, No.4, 12/97.
