יום שישי, 11 בפברואר 2011

Could cognitive processing therapy (CPT) have saved Hemingway from suicide?

Ernest is a 62 years old novel writer, suffering from PTSD (ante literam) and depression. He was wounded in his leg 40 years ago in WWI, during a bombardment of a medical evacuation point, and ever since he has suffered from many PTSD symptoms such as: insomnia and nightmares, obsessive preoccupations with death and suicide, vivid multi-sensory flashbacks, alcohol dependency, feelings of guilt and shame, and intimacy problems revolving around difficulty to trust his lovers. He came to my clinic depressed, saying that he was diagnosed with an acute liver disease caused by alcohol abuse, and that now being without alcohol, he could not escape the intensity of his war flashbacks. Although he did not believe in psychology, he felt he was unable to bare his intruding thoughts of death and suicide and came to ask for treatment.

Therapy strategy was mainly to get Ernest to talk and write about his emotions directly – stop emotional avoidance, and to move from third person fictional writing to personal writing – accept that the event occurred as it had occurred and that no alternative fictional scenarios can replace it. Ernest being a writer, he had very firm professional positions regarding these issues, and had difficulty to comply. His main subject of writing is his distress, but he only rarely writes about the traumatic event itself, and seldom writes about his emotions in intense situations. His position was that his writing should be clean of emotional import, and that laconic and concrete messages would better explain his experience than pathetic elaborations of what he felt.

On our first session I had to convince him that even though he has been writing about the subject on and on for 40 years, he has not yet processed his experience fully. What grabbed him was the explanation about synthesized emotions compared to natural emotions. He felt he had been synthesizing emotions, and that the natural ability to feel has left him, he was either numb or distressed. He wanted to continue therapy and investigate this issue.

In his first homework he wrote about the effects of his trauma. Everything he was, was described as a result from his trauma – his problematic relationships, his risk taking behaviors, his sexual difficulties. Reviewing his essay, he did not allow me to perform a therapeutic split between his healthy side and injured side.

To his second session he came after reading about blockage points, and said he acknowledges something about this. He feels that his injury wasn’t a real battle injury, that he was awarded a fake medal, he was making coffee in a shed, a kilometer behind the front when a stray shell landed near – he was no hero, so he was not really injured. He cried, and said he was pathetic. I felt this was too intense, too soon for him, so after he calmed down, I asked him only if this direction is good for him, he agreed, and we continued.

We worked on recognizing emotions. He could not mention a situation that brought up an emotion in him. We went over the cognitive model of emotions being based on interpretations of the world. He said the world was basically very hostile, and that emotions are pains he tries to burry deep inside. After elaboration, he accepted that burying deep inside, is fear.
Therapy continued, and Ernest also rephrased his intimacy issues as trust issues, and his trust issues as fear of abandonment, based on his feelings that he was "not man enough". After 12 sessions, Ernest could recognize the blocking effect of the trauma on his cognitions, and the way they jammed his emotions in a state of fear. He recognized that feeling like a fake hero lead him to feel pathetic, unmanly and undeserving of emotions, that his third person characters were made up to deserve more than he did. He got a chance to cry during therapy, and noted how this was much better than drinking, really. His PTSD symptoms inventory was bellow clinical level after 5 months follow-up, but his laconic realism was badly damaged and he could not write prose again.

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