Intervenia experienial n tulburarea de stres posttraumatic

Intervenia experienial n tulburarea de stres posttraumatic Tema 7Intervenia experienial n tulburarea de stres posttraumatic ncepe cu nelegerea experienei unice a clientului cu aceste trei momente-lume. Clientul i terapeutul se angajeaz ntr-un proces de explorare a percepiilor i credinelor clientului care au o mare ncrctur emoional, cunoscute sub numele de scheme emoionale. Acestea sunt organizate de regul n jurul emoiei de fric sau de anxietate, iar identificarea lor l ajut pe terapeut s neleag empatic experienele traumatizante ale clientului. Explorarea empaticn psihoterapia proces-experienial exist un pattern tipic de rspuns al psihoterapeutului pe parcursul edinei terapeutic, denumit explorare empatic. Acesta este aa de diferit de alte abordri, nct putem spune clar c intervenia este una de orientare experienial doar dac ne uitm la interveniile psihoterapeutului. n cadrul explorrii empatice terapeutul reformuleaz emoiile descrise de client pe baza unor reflectri exploratorii, vorbind din punctul de vedere al clientului i cernd ntotdeauna confirmarea acestuia dac a neles sau nu sensul exact al descrierilor fcute. Sunt utilizate de asemenea i ntrebri exploratorii de tipul: Ce simi n interiorul tu acum?, Ce senzaii experieniezi n acest moment?, Unde este localizat emoia n corpul tu?

Din perspectiva psihoterapiei proces-experieniale, tulburarea de stres posttraumatic implic mai multe seturi de scheme concurente:Schemele emoionale ordinare sunt caracteristice pentru lumea pre-victimizare i creaz dificulti deoarece evenimentul traumatizant nu poate fi asimilat lor. Schemele emoionale fric vulnerabilitate sunt activate n timpul traumei i i reprezint curat lumea victimizrii a evenimentului traumatizant propriu-zis. Acestea se centreaz n jurul emoiei de fric, al percepiilor asociate (periculozitate) i al tendinelor de aciune (fug, evitare).Provocarea credinelor preuiteCnd o persoan este victimizat, el/ea experieniaz o profund provocare a unui set cheie de scheme emoionale, cunoscute i sub numele de credine preuite. Exist patru scheme emoionale relaionate cu trauma (dup Elliot & all., 1989):Lumea nesigur: nainte de victimizare majoritatea oamenilor i asum o schem emoional de baz a unei lumi sigure, lume n care mediul lor fizic i social este vzut ca benign n esena lui. Dup victimizare, aceast schem emoional este nlocuit cu cea n care lumea este vzut ca fiind fundamental nesigur, periculoas i impredictibil.Cellalt ruvoitor: traumele care implic crime sau abuz sexual sunt fundamental interpersonale, comparativ cu cele care implic accidente sau dezastre. Violena interpersonal activeaz schema emoional a celuilalt ca puternic, ruvoitor, prdtor. Dup victimizare, aceast schem este proiectat pe numr mare de alte persoane, chiar dac acestea au fost privite anterior ca fiind de ajutor.Cellalt care nu este de ajutor: victimizarea de asemenea deterioreaz credina clientului c ceilali oameni formeaz o comunitate pe care se poate baza i care ofer protecie, asisten i grij. Persoanele de ajutor (familie, prieteni, autoriti legale, profesioniti din sntatea mintal) nu au fost capabili s previn victimizarea atunci cnd aceasta s-a produs, motiv pentru care sunt vzui acum ca fiind abseni, indifereni i ineficieni.Sinele vulnerabil: schemele emoionale de credine preuite despre putere personal, auto-eficien, buntate sau lipsa vulnerabilitii au fost provocate de traum. De obicei, persoana se lupt s nu renune la aceste credine despre sine, dar n acelai timp adopt o organizare a sinelui alternativ, n care sinele este experieniat ca slab, neputincios, fragmentat, vulnerabil, i uneori ca unul care merit o victimizare ulterioar.

Din perspectiva proces-experienial, dificultile de stres posttraumatic mplic un set de scheme emoionale aflate n competiieDe exemplu, n lumea pre-victimizare, adic naintea producerii evenimentului traumatic, un set important de scheme emoionale este acela de securitate calm. Acesta creaz dificulti deoarece evenimentul traumatizant nu poate fi asimilat acestei scheme emoionale, ducnd la experiena universal de protest al nelesului (clientul este n protest emoional fa de un eveniment de via, fapt ce intr n contradicie cu credinele sale fundamentale; cu ct discrepana este mai mare, cu att emoia trit este mai puternic). Cel de-al doilea set de scheme emoionale este de vulnerabilitate nfricotoare. Acesta este activat n timpul traumei i reprezint cu acuratee lumea victimizrii pentru evenimentul traumatizant propriu-zis. Aceste scheme emoionale sunt implicite n emoiile de fric, ruine i furie, mpreun cu interpretrile asociate acestora (ex. pericol) i tendinele spre aciune (ex. fug, evitare).

Schemele emoionale relaionate cu trauma difer de la o persoan la alta, precum i n funcie de experiena de victimizare. Uneori acestea sunt extrem de implicite i pot fi accesate doar indirect, n cadrul edinelor terapeutice, prin metode de expresie activ de tipul tehnicii scaunului gol sau prin metode de re-experieniere de tipul repovestirii traumei. De asemenea, traumele recente interacioneaz ntr-o manier ideosincratic cu traume din viaa anterioar a persoanei.

Principiile generale ale schimbrii n psihoterapia proces-experienial a traumei:1. Furnizarea prezenei empatice psihoterapeutul se raporteaz la client ca o persoan grijulie, creia i pas de el i care este dispus s-l ajute. Aceast prezen i ofer clientul o experien emoional corectiv la imaginile negative ale celorlali ca fiind nepstori, lipsii de afectivitate sau ruvoitori. De regul aceasta este prima sarcin a terapiei i este nevoie de mai multe edine pn cnd clientul care a trecut printr-un eveniment traumatizant s dezvolte ncrederea c terapeutul l nelege i c acestuia i pas de problema lui.

2. Sprijinirea re-ntririi sinelui Psihoterapeuii procesual-experienialiti pleac de la premiza c indivizii umani au o tendin fundamental de a se adapta i de a face fa situaiilor, inclusiv rnilor fizice i emoionale. Pentru a depi dificultile relaionate cu trauma, clientul trebuie s rectige ncrederea n capacitatea sa de a face alegeri cu sens i de a se rentoarce la proiectele de via importante compromise de evenimentul traumatizant. n acest sens, clientul este ajutat s-i clarifice natura proiectului de via ntrerupt i sunt sprijinite tendinele acestuia de cretere. Adiional, clientul este sprijinit s-i exprime emoiile, n principal furia, care l poate ajuta s-i dezvolte capacitatea de auto-protecie asertiv n faa unui potenial pericol.

3. ncurajarea restabilirii lumii ca parial de ncrederelumea post-victimizare nu poate deveni niciodat la fel de sigur ca lumea pre-victimizare, dar un anumit nivel de siguran trebuie restabilit pentru ca persoana s se poat ntoarce la o via tolerabil i s-i continue proiectele de via importante. Sigurana i ncrederea sunt stabilite n contextul relaiei terapeutice, dar este extrem de important pentru client ca acesta s poat face fa mediului su i s descopere c poate s fie mai puin vigilent atunci cnd circumstanele nu sunt amenintoare. ns, fr ndoial, clientul este acela care decide cnd i de unde s nceap s-i recapete ncrederea n lumea sa.

4. Sprijin n reprocesarea traumei n acest scop, terapeutul ncurajeaz i faciliteaz exprimarea emoional controlat a clientului n cadrul edinelor de psihoterapie. Cea mai utilizat metod este de a-l ncuraja pe client s povesteasc, s re-experienieze i s re-proceseze evenimentul traumatizant. Aceast metod permite clientului s proceseze rspunsul afectiv original ntr-o stuaie cu un nivel mult diminuat de ameninare, n care nivelul de excitare emoional poate fi modulat cu atenie. Astfel, terapeutul l ajut pe client s restaureze balana emoional i s-i moduleze emoiile. Odat ce aceast abilitate este restaurat, clientul nu se va mai simi constrns sau dominat de propriile emoii.Repovestirea experienelor traumatizanteMetoda repovestirii traumei se utilizeaz n psihoterapia experienial centrat pe emoii pentru tratamentul dificultilor de stres posttraumatic. Dei este o experien dureroas, oamenii care au fost victimele unor evenimente traumatizante resimt foarte puternic nevoia de a descrie evenimentele respective. Repovestirea l ajut pe client s-i acceseze i s reproceseze reaciile emoionale n timpul edinei terapeutice, cu scopul final de a facilita o reglare emoional mbuntit.

Datorit faptului c procesarea emoional este scurt-circuitat n perioadele de excitaie emoional ridicat, situaia amenintoare rmne nedifereniat, vie i izbitoare, frapant. Acest fapt l poate face pe client s triasc stri de hiperalert i vigilen, cu scopul de a se proteja de un viitor pericol. Aspecte particulare ale situaiei, uneori doar cu o asemnare mrunt cu cele din adevratul eveniment traumatizant, pot scoate la iveal emoii similare cu cele trite n situaia traumatizant.

ScopUnul dintre scopurile punerii clientului s povesteasc situaia traumetizant este de a-l ajuta pe acesta s identifice i s clarifice aspectele relevante ale respectivei situaii. Aceast examinare atent l ajut pe client s-i limiteze patternul reaciilor emoionale maladaptative. Pe msur ce clientul povestete, aspectele importante ale situaiei devin mai clare, incusiv acele aspecte care au rmas neprocesate n momentul producerii evennimentului.

Adesea clientul trebuie s repovesteasc evenimentul traumatizant de mai multe ori pe parcursul terapiei, deoarece povestea se va schimba n timp, att pentru c aliana terapeutic devine mai solid i clientul are mai mult ncredere n terapeut, ct i pentru c, pe parcurs, sunt accesate amintiri adiionale, pe msur ce nelesul evenimentelor ncepe s se clarifice.

Markeri ai procesului terapeuticAutorii modelului psihoterapeutic vorbesc despre aa-ziii markeri ai procesului terapeutic. Acetia reprezint comportamente ale clientului din timpul edinelor de psihoterapie care semnalizeaz faptul c respectivul client este pregtit s lucreze pe o problem particular. Un exemplu este markerul de ruptur auto-critic, atunci cnd o parte a sinelui (criticul) are tendina de a critica alt parte a sinelui (aventurierul). La apariia evident a unui astfel de marker se impune un anumit tip de sarcin terapetutic n cazul exemplului de mai sus rezolvarea conflictului dintre cele dou pri prin tehnica dialogul celor dou scaune. (Elliott & all, 2004)

Etapele sarcinii terapeutice de repovestire a evenimentelor traumatizante (Elliott & all., 2004)Marker clientul se refer la o experien traumatizant care ar putea fi povestit (ex.: eveniment traumatizant, situaie de via perturbat, vis terifiant etc.) sau vorbete despre o reacie intens. Terapeutul identific i reflect (verbalizeaz) markerul ctre client, apoi i propune sarcina terapeutic, explicndu-i scopul repovestirii.

Elaborarea Clientul ncepe s povesteasc detaliat i concret trauma i descrie ceea ce s-a ntmplat dintr-un punct de vedere extern i faptic. Terapeutul pune ntrebri n legtur cu situaia, ce a dus la ea, centrndu-se tot pe fapte, apoi ncurajeaz clientul s re-intre n situaie n imaginar.Adncirea clientul re-experieniaz momente importante sau aspecte ale traumei, n timp ce-i menine sentimentul de siguran. Terapeutul i furnizeaz reflectri evocative, ascult i i reflect amrciunea, l asist pe client n experienierea imediat, l ajut s menin o distan de lucru sigur i oprete sarcina dac este necesar.

Ieirea la iveal a unor noi nelesuri clientul i amintete i difereniaz nelesurile traumei, att pe cele personale, idiosincratice, precum i pe cele care reies acum, din punct de vedere intern. Terapeutul ascult, reflect i ofer suport pentru noile nelesuri, n special cele care duc la o scdere a sentimentului de vinovie.Puncte de vedere alternative Clientul reflecteaz asupra punctelor de vedere alternative i difereniate ale traumei, le evalueaz i integreaz ntr-o poveste coerent aspectele neconectate anterior sau inconsistente legate de experiena sa. Terapeutul ajut clientul s reflecteze asupra i s exploreze punctele de vedere alternative.Reintegrarea Clientul exprim un punct de vedere asupra sinelui, asupra celorlali i asupra lumii, lrgit i mai integrat, n timp ce ia n consideraie noi moduri de aciune, meninndu-i n acelai timp sigurana personal. Terapeutul reflect i subliniaz povestirea integrat, facilitnd explorarea noilor modaliti de aciune.

Studiu de cazPsihoterapia centrat pe emoie ntr-un caz de doliu complicat (Cucu-Ciuhan, 2015)The clinical case is a 25 years old man experiencing posttraumatic stress disorder and panic attacks with prolonged suffering after the loss of his mother. In this article we will call him Mathew, which is not his real name.He first came to therapy describing panic attacks associated with the moments when his girlfriend was smoking. He spoke with his girlfriend about his problems, which he presented as concerns about her health and a sign of his love for her. The girl, who was only an occasional smoker, agreed not to smoke anymore in his presence. But Mathew developed a panic attack a few days after, when he saw a pack of cigarettes in her pocket.

1. Facilitation of a safe and productive therapeutic relationship by emphatic attunement, therapeutic bond and task collaborationPersons with anxiety have a chronic feeling of self-endangerment, the majority of the anxiety disorders being related with painful and dangerous experiences of the self. This is particularly true with the prolonged grief patients. Their experiences often occur in interpersonal situation, leaving the individual with a deep sense of helpless, trapped, and impossible to prevent the dangerous event, which is perceived as meant to happen. With these patients constructing a safe and trusted therapeutic relationship is very important, so the first sessions we emphasized the emphatic attunement, by being present, entering into the clients experience, and resonate with his experience. We also focused on building the therapeutic bond by communicating empathy, caring and presence to the patient.On the task collaboration, we took into account the fact that patients with panic disorder have an intense need of developing a sense of control over their symptoms before working on the repair of their deficiencies in the experimenting of self. We used the cognitive behavior technique of symptoms tracking, Mathew having the task to register his panic attacks over one week. He received a table with five columns: day and hour of the attack, what he was doing/where he was, corporal symptoms and behavior, thoughts, and emotions. We transformed the technique in an experiential manner: for every panic attack he should use a new paper sheet and never read the old ones. He was instructed to fill the table during the panic attack and to describe as accurate and as in detail as he can his symptoms. This paradox technique was intended to help him focus in the present, on the here and now, and it proved to be very efficient. Mathew reported that the symptoms were decreasing in intensity and in two weeks his panic attacks were increasingly rare.

2. Process-experiential formulation of the case by empathic exploration and identification of the maladaptive emotion schemeEach emotion scheme comprises five types of elements (adapted after Elliott et al., 2004):Perceptual-situational elements represent the persons past or current environments and include immediate awareness of the current situation and episodic elements. Mathews perception of the cigarette smoke from his girlfriend reminds him of the smell of cytostatic medicines in his mother room and the trauma of his mother death, activating fear of death.Bodily-expressive elements represent the emotion scheme processes through the body. When he has a panic attack, Mathew experiences trembling, chest pain and intense crises of crying, reliving the moments of his mother death.Symbolic-conceptual elements are verbal or visual representations of the emotion scheme processes produced through reflective self-awareness of the perceptual-situational and bodily-expressive elements. Mathews obsessed thought was: My girlfriend could die in the same terrifying way like my mother!Motivational-behavioral elements are the elements activated by the emotional scheme and represent it in forms of needs, desires, and wishes. Mathew felt the need to protect his girlfriend and to get rid of the fear by trying to convince her to quit smoking.The emotion scheme nuclear processes organizes all the different components around a particular emotion Mathews fear of death.

In the minutes when his mother death was imminent, Mathew tried very hard to understand what his mother could feel, and even sit in an armchair trying to pretend that he was dying too. He entered a suggestive state of mind and experienced an intense fear for his own death. But he quickly decided that the fear for his own death was not a suitable feeling for that moment, and he felt intense guilt and then anger on himself. According to the process-experiential theory of emotion, this is a secondary reactive emotion response. The primary adaptive emotion, fear of death, is hidden by two secondary reactive emotions, guilt and anger. He became angry of the danger of death by cancer (externally focused reaction) and also angry with him for being afraid of death (self-focused reaction). These feelings transformed the original emotion and leaded to actions that are not entirely appropriate to the current situation Mathews persistence on convincing the girlfriend to quit smoking.

3. Reprocessing of problematic experiences by retelling of the traumatic and difficult experiences and meaning creation

We used the retelling of the traumatic event strategy repeatedly, helping Mathew to understand his painful experiences and his emotions related to the trauma. One of the dysfunctional emotions related to the trauma was Mathews feeling of guilt. First, he understood that his profound feeling of guilt was generated by the fact that, when he was trying to empathize with his mother, in her last minutes, and simulated that he is also dying, he activated the fear for his own death. He was feeling guilty that he was thinking of his own death during his mother last minutes of life, instead of offering her emotional comfort. Second, Mathew was feeling guilty because he couldnt stand the smell of her mother wounds when he was by her bed during the last days of her life. He recalls that the smell was so intense, that he only could spend a few minutes at a time, and then he needed to take a break and go to another room before he could return by her side. It was the same smell that he was associating with the cigarettes smell. This was the main perceptual-situational element of his dysfunctional emotion scheme and the anchor or a sensory cue that activated the panic attacks. During the therapy, we reprocessed this feeling of guilt by generalization, and Mathew understood that his self-preservation instinct is stronger that his need to love and compassionate others.

The other dysfunctional emotion was Mathews anger. First, Mathew was angry with himself for being afraid of his own death, instead of being present by his mother side on her last minutes of death. This is a self-focused reaction to trauma. In the therapy, we reprocessed his reaction as a sign of intense love and empathy with the mother. He was so much present by her side that he wanted to feel what she was feeling. Second, Mathew was angry of the danger of death by cancer. This is an externally focused reaction to trauma. In therapy, he understood that this intense emotion is making him to control his girlfriend behavior. By generalization, he understood that there a large number of other possible causes of death, and that not every person that smoke will die from cancer.

4. Reprocessing unfinished interpersonal issues with the mother by empty chair work

Mathew was angry of his mother, because she did not take care of her health in time. The mother died from skin cancer, and Mathew was accusing her for ignoring one melanoma that was changing size and color over the time, and also for loving too much to stay in the sun. We used the empty chair technique to clarify this unfinished business and to solve the interpersonal issue.5. Restructuring and changing of the primary emotion scheme

During this phase of therapy Mathew developed new meanings of the trauma from his internal point of view, and evaluated alternative views of the trauma by integrating previously unconnected or inconsistent aspects of the experience into a more sensible story.

6. Self-empowerment (full resolution)At the end of the therapy, Mathew expressed a more integrated view of self and others and considered new ways of acting, while still maintaining personal safety.