This alternation of reimmersion and respite seems to allow for a spontaneous review of the trauma and relearning of emotional response to it. For those whose PTSD is more intractable, says Herman, retelling their tale can sometimes trigger overwhelming fears, in which case the therapist should ease the pace to keep the patient's reactions within a bearable range, one that will not disrupt the relearning.
The therapist encourages the patient to retell the traumatic events as vividly as possible, like a horror home video, retrieving every sordid detail. This includes not just the specifics of what they saw, heard, smelled, and felt, but also their reactions—the dread, disgust, nausea. The goal here is to put the entire memory into words, which means capturing parts of the memory that may have been dissociated and so are absent from conscious recall. By putting sensory details and feelings into words, presumably memories are brought more under control of the neocortex, where the reactions they kindle can be rendered more understandable and so more manageable. The emotional relearning at this point is largely accomplished through reliving the events and their emotions, but this time in surroundings of safety and security, in the company of a trusted therapist. This begins to impart a telling lesson to the emotional circuitry—that security, rather than unremitting terror, can be experienced in tandem with the trauma memories.
The five-year-old who drew the picture of the giant eyes after he witnessed the grisly murder of his mother did not make any more drawings after that first one; instead he and his therapist, Spencer Eth, played games, creating a bond of rapport. Only slowly did he begin to retell the story of the murder, at first in a stereotyped way, reciting each detail exactly the same in each telling. Gradually, though, his narrative became more open and free-flowing, his body less tense as he told it. At the same time his nightmares of the scene came less often, an indication, says Eth, of some "trauma mastery." Gradually their talk moved away from the fears left by the trauma to more of what was happening in the boy's day-to-day life as he adjusted to a new home with his father. And finally the boy was able to talk just about his daily life as the hold of the trauma faded.
Finally, Herman finds that patients need to mourn the loss the trauma brought—whether an injury, the death of a loved one or a rupture in a relationship, regret over some step not taken to save someone, or just the shattering of confidence that people can be trusted. The mourning that ensues while retelling such painful events serves a crucial purpose: it marks the ability to let go of the trauma itself to some degree. It means that instead of being perpetually captured by this moment in the past, patients can start to look ahead, even to hope, and to rebuild a new life free of the trauma's grip. It is as if the constant recycling and reliving of the trauma's terror by the emotional circuitry were a spell that could finally be lifted. Every siren need not bring a flood of fear; every sound in the night need not compel a flashback to terror.
Aftereffects or occasional recurrences of symptoms often persist, says Herman, but there are specific signs that the trauma has largely been overcome. These include reducing the physiological symptoms to a manageable level, and being able to bear the feelings associated with memories of the trauma. Especially significant is no longer having trauma memories erupt at uncontrollable moments, but rather being able to revisit them voluntarily, like any other memory—and, perhaps more important, to put them aside like any other memory. Finally, it means rebuilding a new life, with strong, trusting relationships and a belief system that finds meaning even in a world where such injustice can happen.20 All of these together are markers of success in reeducating the emotional brain.
PSYCHOTHERAPY AS AN EMOTIONAL TUTORIAL
Fortunately, the catastrophic moments in which traumatic memories are emblazoned are rare during the course of life for most of us. But the same circuitry that can be seen so boldly imprinting traumatic memories is presumably at work in life's quieter moments, too. The more ordinary travails of childhood, such as being chronically ignored and deprived of attention or tenderness by one's parents, abandonment or loss, or social rejection may never reach the fever pitch of trauma, but they surely leave their imprint on the emotional brain, creating distortions—and tears and rages—in intimate relationships later in life. If PTSD can be healed, so can the more muted emotional scars that so many of us bear; that is the task of psychotherapy. And, in general, it is in learning to deal skillfully with these loaded reactions that emotional intelligence comes into play.
The dynamic between the amygdala and the more fully informed reactions of the prefrontal cortex may offer a neuroanatomical model for how psychotherapy reshapes deep, maladaptive emotional patterns. As Joseph LeDoux, the neuroscientist who discovered the amygdala's hair-trigger role in emotional outbursts, conjectures, "Once your emotional system learns something, it seems you never let it go. What therapy does is teach you to control it—it teaches your neocortex how to inhibit your amygdala. The propensity to act is suppressed, while your basic emotion about it remains in a subdued form."
Given the brain architecture that underlies emotional relearning, what seems to remain, even after successful psychotherapy, is a vestigial reaction, a remnant of the original sensitivity or fear at the root of a troubling emotional pattern.21 The prefrontal cortex can refine or put the brakes on the amygdala's impulse to rampage, but cannot keep it from reacting in the first place. Thus while we cannot decide when we have our emotional outbursts, we have more control over how long they last. A quicker recovery time from such outbursts may well be one mark of emotional maturity.
Over the course of therapy, what seems to change in the main are the responses that people make once an emotional reaction is triggered—but the tendency for the reaction to be triggered in the first place does not disappear entirely. Evidence for this comes from a series of studies of psychotherapy conducted by Lester Luborsky and his colleagues at the University of Pennsylvania.22 They analyzed the main relationship conflicts that brought dozens of patients into psychotherapy—issues such as a deep craving to be accepted or find intimacy, or a fear of being a failure or being overly dependent. They then carefully analyzed the typical (always self-defeating) responses the patients made when these wishes and fears were activated in their relationships—responses such as being too demanding, which created a backlash of anger or coldness in the other person, or withdrawing in self-defense from an anticipated slight, leaving the other person miffed by the seeming rebuff. During such ill-fated encounters, the patients, understandably, felt flooded by upsetting feelings—hopelessness and sadness, resentment and anger, tension and fear, guilt and self-blame, and so on. Whatever the specific pattern of the patient, it seemed to show up in most every important relationship, whether with a spouse or lover, a child or parent, or peers and bosses at work.
Over the course of long-term therapy, however, these patients made two kinds of changes: their emotional reaction to the triggering events became less distressing, even calm or bemused, and their overt responses became more effective in getting what they truly wanted from the relationship. What did not change, however, was their underlying wish or fear, and the initial twinge of feeling. By the time the patients had but a few sessions left in therapy, the encounters they told about showed they had only half as many negative emotional reactions compared to when they first started therapy, and were twice as likely to get the positive response they deeply desired from the other person. But what did not change at all was the particular sensitivity at the root of these needs.