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Most of us have had the reaction "I wish I'd written that" when reading something well written, well organized, genuinely informative and lucid. I had that reaction when I read Jon G. Allen's book, Coping with Trauma: A Guide to Self-Understanding. The book is a product of a unique situation, namely, a Rochester Clinical Psychologist working as a senior staff psychologist in the very specialized long-term Trauma Treatment Center within the psychoanalytic Menninger Clinic. Moreover, Dr. Allen had the unusual assignment of developing a psychoeducational program for trauma clients in that long-term intensive treatment facility. This book, his third related to trauma, is a testimony to the wisdom of specializing on a circumscribed psychiatric disorder, as distinguished from the usual "I-see-all-kinds" private practice. For most of this century, psychiatry has focused on internal emotional conflicts but since the Vietnam War and especially in the last decade the importance of real life trauma has captured a lot of psychiatry's and the public's attention.
Coping with Trauma provides current psychiatric explanations and theories to patients in a language and style they can understand. There are many case illustrations which help the reader see the possible personal relevance of well established clinical observations and beliefs. In keeping with the orientation of the supporting institution, the emphasis in Allen's educational program is on the patient gaining insight, in a general way, into the common history, causes and psychodynamics of severe, lasting reactions to trauma. Self-understanding of the origin and maintenance of trauma symptoms is the clear goal. Although a self-help book, Allen is clearly an insight expert, not a comprehensive self-help expert. Indeed, the other non-insight facets of self-help, such as behavior modification, self-control of emotions, learning coping skills, and cognitive restructuring, are minimized or neglected. Nevertheless, this book does what it intends to do very well: help the trauma victim understand how his/her traditional psychiatrist understands and is thinking about the serious consequences of trauma. This alone is a commendable goal, of course. If the patient becomes more insightful through education, that should improve the collaborative aspects and the outcome of psychodynamic therapy.
The first part of the book describes many types of trauma and how traumas may interfere with normal psychosocial development. The author also discusses important biological aspects of adapting to severe trauma--fight or flight reactions, limbic vs. neocortex "minds," changes in neurotransmitters, etc. The most beneficial parts of the book are the six chapters that describe in some detail the effects of trauma in terms of (1) our evolutionary-based need for safe, nurturing attachment and its disruption by traumatic experiences, (2) the emotions of fear, anger, shame, and depression aroused by trauma in interaction with one's temperament and personality, (3) the mental coping with intense, repetitive painful experiences by pushing the events and the memories out of consciousness (dissociation), (4) the eruption of unwanted memories (flashbacks) and the suppression or distortion of memories that sometimes occur, (5) how the self tries to cope with the internal conflicts and shame arising from trauma, sometimes feeling helpless, sometimes extremely self-blaming, sometimes self-destructive, and (6) the huge impact on relationships in which we may repeat the trauma over and over, become bonded with an abuser, or withdraw, distrust, become over-dependent, vulnerable, controlling or hostile. Most patients would surely find this fundamental and useful stuff. It is presented in a very gentle, reassuring, uncritical manner.
The remaining parts of the book deal with the two most common diagnoses associated with trauma--Posttraumatic Stress Disorder (PTSD) and Dissociative Disorders--and with many possible treatment methods. PTSD has three groups of symptoms: hyperexcitability (anxiety and over-responding), reexperiencing (flashbacks and nightmares), and withdrawal or numbing. The chapter on Dissociative Disorders has an especially good section explaining the understandable development of coping mechanisms for escaping painful memories. It also explains why the Multiple Personality Disorder diagnosis was discontinued. Not surprisingly, there are many other diagnoses that occasionally follow overwhelming trauma--anxiety and panic, depression, addictions, psychosomatic disorders, sexual dysfunction, eating disorders, personality disorders, and others. These are mentioned briefly.
The standard psychiatric treatment for Dissociative Identity Disorder (DID) is hospitalization, if safety is an issue, followed by long-term individual therapy, probably twice a week for months if not years, plus hypnosis (at Menninger's, at least). Dr. Allen recognizes the prohibitive cost of such a regimen. In this program, the purpose of individual therapy is not to produce a catharsis or abreaction--not to quickly release pent-up emotions and repressed experiences. In fact, catharsis may retraumatize a patient. The recommended way to treat traumatic memories, repressed or conscious, is to talk about them, but in a safe setting and in a gradual, controlled, comforting but frank kind of way. The goals are to help the patient understand what has happened and eventually gain a modicum of emotional tolerance ("become able to stand") for the awful things suffered by him/her.
In the chapter titled Self-Regulation, the stated rationale is for self-control to become an antidote to feeling helpless. However, a strong emphasis is first placed on the complex, potentially harmful, long-term, uncertain and difficult nature of self-help methods when used with post-traumatic disorders. He is certainly right when he says the effectiveness of self-control methods in this area have not been researched yet (the exception might be Marcia Linehan's work with Borderline Personality Disorders). Following the warnings, the kinds of self-control methods mentioned are: increasing positive feelings, sleep, relaxation, exercise, meditation, hypnosis and biofeedback, each with its own warnings. Given the context, it seems unlikely that readers will eagerly rush to start seriously planning a self-regulation program, especially if they are given more warnings of grave risks by their psychiatrist when they go to talk with him/her about their possible contributions to their own treatment. That is the dilemma.
Everyone would agree that great caution is needed when we know so little about self-control with serious out-of-control behaviors, like PTSD and DID. Of course, there is no reassurance that the psychiatric insights given so cogently throughout this book will not be mis-understood and mis-used by readers of the book, especially when not in an ongoing program run by professionals. The author doesn't issue such warnings with every psychiatric notion. All thinking persons, regardless of orientation, should be screaming for more research on every treatment and every self-help method.
In my opinion, the solution is not to encourage the avoidance of self-help (impossible because everyone is trying to help themselves all the time), but to positively discuss self-control methods with full acknowledgment that many are not yet proven and may carry risks (much as done by this author). If the determined reader of this book gets beyond the warnings and absorbs this last chapter on self-regulation, he or she could surely find a few self-help methods that seem doable, safe, and promising. They could then find still more helpful self-help methods. The beauty of this book is that it specifically addresses in depth the understanding of a circumscribed and serious set of trauma related problems. Much more needs to be done. Current psychiatric theory is very important, the result of a century of treatment experience and thought. But it is unacceptable to primarily rely on Freudian and Neo-Freudian theory, especially when so many around the world have been traumatized and so very few can afford the standard insight-oriented psychiatric treatment.
I would recommend the book to patients coping with trauma who are able to absorb a great deal of information and then figure out practical applications in their own life. I also think the book would be quite useful for therapists-in-training or for therapists who need to know more in this area and involve their patients more in treatment planning. The book is four years old but that isn't a serious problem except perhaps for the medication recommendations.