TRANSTORNO DE ESTRESSE PÓS-TRAUMÁTICO: MODELO TEÓRICO E AVALIAÇÃO DE INTERVENÇÃO
EM BOMBEIROS MILITARES DE SANTA CATARINA (POSTTRAUMATIC STRESSDISORDER: THEORETICAL
MODEL AND EVALUATION OF AN INTERVENTION WITH FIREFIGHTERS FROM SANTA CATARINA)
Dissertação aprovada como requisito parcial à obtenção do grau de Mestre em Psicologia, Programa de Pós-graduação em Psicologia Centro de Filosofia e Ciências Humanas da Universidade Federal de Santa Catarina.
Orientador: Prof. Dr. Roberto Moraes Cruz
Coorientadora: Profa. Dra.
Carolina Baptista Menezes
Florianopolis, SC 2019
TRANSTORNO DE ESTRESSE PÓS-TRAUMÁTICO: MODELO TEÓRICO E AVALIAÇÃO DE INTERVENÇÃO EM BOMBEIROS
MILITARES DE SANTA CATARINA
Dissertação aprovada como requisito parcial à obtenção do grau de Mestre em Psicologia, Programa de Pós-graduação em Psicologia, Centro de Filosofia e Ciências Humanas da Universidade Federal de Santa Catarina.
The sheer volume of this dissertation made one of my tutors exclaim that it doesn’t have to be this big – after all, it is merely a dissertation. Without being self-indulgent I state that for me this work is much more than a “mere dissertation”. It is the halfway point in an assignment I accepted and decided to bring to completion.
This dissertation is an important step in a process that started in the middle of 2012, while giving a Rebirthing-Breathwork training to two Russians, one of whom I had already given ten sessions in Inspiration University, in Waynesboro VA, a year earlier. The training took place in the Andalusian spring in the mountains of Southern Spain. I don’t remember exactly what inspired me to start to investigate trauma seriously, but I remember that the inspiration came during that training and was related to an insight in the role the will plays in trauma.
Coming to Brazil and starting to work with Dr. Roberto Moraes Cruz provided me with the opportunity to raise the scientific level of my enquiry significantly. I’m not sure if I could have met an equal level of openness, and a willingness to help me bring my project to completion in academic circles anywhere else in the world. So first of all I offer my sincere, heartfelt thanks to Roberto. I hope you will stick with me until the end of the journey, it will take another few years…
Embarking on a master’s degree in a country where you barely speak the language is not always easy. Therefore it was a relief to get to know my second tutor, who could understand me easily when I spoke and wrote in English. Besides that she offered valuable feedback on my work, and it was because of one of her assignments that I stumbled upon the idea for the observation sheet for Rebirthing Breathwork sessions. So, I offer my sincerest thanks to Dra. Carolina Baptista Menezes.
I also want to thank Dr. Jefferson Luiz Brum Marques for his great openness and for his invaluable support in analyzing the HRV data. I’m looking forward to further work with him in our mutual quest for meaningful physiological data. And I want to thank Dr. Celso Reni Braida for introducing me to the concept of agency at a metaphysical level.
For Study 3 I am greatly indebted to Raquel Costa, who enthusiastically accepted my request to be the clinical psychologist for the project and conducted the diagnostic interviews. I am also
in return for the use of one of the rooms in his yoga center for the RB sessions with the bombeiros. Kailash Yoga is situated right next to the CEBM.
I wish to thank the two psychologists of the CBMSC, Mariana and Priscilla, who recognized the importance of the research and helped me to meet the right people to make it possible. I also want to thank them for their logistic support. Mariana for her perseverance to get the commanding officer’s signature, and Priscilla for her support during the 7 months of the project.
I wish to thank the students and researchers connected to Laboratório Fator Humano and Laboratório de Psicologia Cognitiva. Thank you all for putting up with my foreign quirkiness and my English. Special thanks to Dra Patricia Dalagasperina for helping with the questionnaires and for accompanying me to the CBMSC on several occasions, and to Pedro and Mariana, who agreed to be my Guinee pigs when I needed to test the HRV measurement equipment.
I am most indebted to the five bombeiros who decided to participate in my research – I won’t name them for obvious reasons, but without them the main part of this project would have been impossible. They will be forever in my heart.
Then I want to thank the invisible, but not unnoticeable Spirit of our age whose assignment I accepted and who has taught me so much in return – I sing Your Name in silence and in gratitude!
This section always ends with those nearest to us, to whom we feel most indebted. In my case they are my mother, who still supports me, despite my age; and of course my dearest Siddharta, Luana and Cristiane who share the ups and downs of this project with endless love and courage – and let me not forget the substantial help Cris has given me in the parts that needed translation, sometimes up to the perfect wording of crucial WhatsApp messages…
A race of hyperintelligent pan-dimensional beings once built themselves a gigantic supercomputer called Deep Thought to calculate once and for all the Answer to the Ultimate Question of Life, the Universe and Everything. For seven and a half million years, Deep Thought computed and calculated, and in the end announced that the answer was in fact Forty-two—and so another, even bigger, computer had to be built to find out what the actual question was. And this computer, which was called the Earth, was so large that it was frequently mistaken for a planet— especially by the strange apelike beings who roamed its
surface, totally unaware that they were simply part of a gigantic computer program. And this is very odd, because without that fairly simple and obvious piece of knowledge, nothing that ever happened on the Earth could possibly make the slightest bit of sense. Sadly, however, just before the critical moment of read-out, the Earth was unexpectedly demolished by the Vogons to make way—so they claimed—for a new hyperspace bypass, and so all hope of discovering a meaning for life was lost for ever. Or so it would seem. Douglas Adams, 1980
Yo no busco, yo encuentro. Buscar es partir de hechos conocidos y querer algo conocido en lo nuevo. Encontrar, es lo totalmente nuevo, también en el movimiento. Todos los caminos están abiertos, y lo que se encuentra, es desconocido. Es un riesgo, una sagrada aventura. La incertidumbre de tales riesgos solo puede ser asumido por aquellos, quiénes en la desprotección se saben protegidos, quiénes en la incertidumbre, en la ausencia de conducción son guiados, quiénes en la oscuridad se entregan a una estrella invisible y se dejan atraer por metas, y no determinan en forma humanamente limitada y estrecha la meta. Esta apertura hacía todo nuevo conocimiento, hacía toda nueva vivencia interior y exterior: es la esencia del ser humano moderno, quién frente a todo miedo de "soltar", experimenta, sin embargo, la gracia de sentirse sostenido en la manifestación de nuevas posibilidades. Pablo Picasso, 1936
Ich möchte jeden Menschen Aus des Kosmos Geist entzünden Daß er Flamme werde Und feurig seines Wesens Wesen Entfalte. Die Andern, sie möchten Aus der Kosmos Wasser nehmen Was die Flammen verlöscht, Und wässrig alles Wesen Im Innern lähmt. O Freude, wenn die Menschenflamme
Lodert, auch da wo sie ruht. O Bitternis, wenn das Menschending Gebunden wird, da wo es regsam sein möchte. Rudolf Steiner, 1925
Apesar dos grandes avanços na criação de construtos diagnósticos para os transtornos relacionados ao trauma, ainda não existe, atualmente, nenhum modelo teórico abrangente para traumas psicológicos. Historicamente, as teorias do trauma têm relacionado o trauma psicológico a um dos fatores – biológico ou intrapsíquico. Mais recentemente, se relaciona o trauma cada vez mais unicamente a desregulação de processos (neuro) fisiológicos. Duas abordagens terapêuticas recentes - Eye Movement Desensitization and Reprocessing (EMDR) e Experiência Somática (ES) – atribuíram o trauma ao bloqueio ou desregulação de uma capacidade inata de auto regulação. Este projeto busca analisar criticamente a crescente tendência a reduzir o trauma psicológico a processos fisiológicos; testar a hipótese de que o trauma psicológico é causado pelo bloqueio de uma capacidade inata de auto regulação, com a utilização de uma terceira abordagem terapêutica que envolve diretamente essa capacidade;
explorar os mecanismos psicológicos de processamento de memórias traumáticas; e preparar um modelo alternativo de trauma baseado em agência.
Método. O estudo 1 utiliza argumentos ontológicos e epistemológicos para demostrar que o trauma psicológico não pode ser reduzido unicamente a processos fisiológicos e descreve uma alternativa ao reducionismo fisicalista, baseado em agência e antroposofia.O Estudo 2 consiste em um levantamento de dados, baseado em questionários de auto-relato, que rastreou 61 bombeiros de Santa Catarina por exposição a incidentes críticos e sintomas de TEPT. O estudo 3 é um estudo de caso clínico, investigando a utilização de Rebirthing Breathwork para o tratamento de um bombeiro com TEPT.
Resultado. O estudo 1 propõe a base ontológica para um modelo de trauma alternativo, baseado no conceito de agência e na imagem quadrimembrada de ser humano desenvolvida por Rudolf Steiner. Estudo 2: a exposição a eventos potencialmente traumáticos na amostra de bombeiros foi de 100%. Dependendo do método utilizado para interpretar os resultados do PTSD Checklist for DSM-5, de 3 a 5 bombeiros obtiveram um diagnóstico provisório de TEPT. A correlação foi encontrada entre a avaliação (appraisal) de incidentes críticos e sociodemográficos severos, e fatores do emprego relacionados a idade, educação e se o participante estava ou não na ativa. Estudo 3: o diagnóstico de TEPT de apenas um
entrevista clínica; o bombeiro diagnosticado com TEPT respondeu bem ao tratamento e está em remissão após 8 sessões de Rebirthing Breathwork.
Conclusão. Estudo 1: a imagem quadrimembrada de ser humano desenvolvida por Rudolf Steiner pode ser uma base promissora, a partir da qual se desenvolva um modelo teórico mais amplo sobre o trauma; isso deve ser melhor explorado. O estudo 2 confirma as pesquisas anteriores nas quais os sintomas de TEPT são mais elevados em bombeiros do que na população geral. No estudo de caso (Estudo 3) o tratamento de TEPT com Rebirthing-Breathwork mostrou-se efetivo. Os resultados quantitativos e qualitativos do tratamento apoiam a hipótese de uma capacidade inata de autorregulação, assim como um modelo de processamento proposto pelos investigadores.
Palavras-chave: Transtorno de estresse pós-traumático. Capacidade inata de auto regulação. Incidentes críticos. Rebirthing-Breathwork.
Introdução
Apesar dos grandes avanços na criação de construtos diagnósticos para os transtornos relacionados ao trauma, ainda não existe, atualmente, nenhum modelo teórico abrangente para traumas psicológicos. Historicamente, as teorias do trauma têm relacionado o trauma psicológico a um dos fatores – biológico ou intrapsíquico. Mais recentemente, tem se relacionado o trauma cada vez mais unicamente a desregulação de processos (neuro) fisiológicos. Duas abordagens terapêuticas recentes - Eye Movement Desensitization and Reprocessing (EMDR) e Experiência Somática (ES) – atribuíram o trauma ao bloqueio ou desregulação de uma capacidade inata de auto regulação. EMDR envolve predominantemente o processamento cognitivo de memórias traumáticas, enquanto SE envolve predominantemente o processamento somático. Isso leva a proposição de que a capacidade inata de auto regulação tem um componente cognitivo e um somático. Engajando qualquer um desses componentes pode levar a resolução do trauma. Uma vez engajada a própria capacidade inata leva a resolução do trauma. Rebirthing-Breathwork (RB) não foi submetido a pesquisa científica, mas tem sido sugerido que RB pode ser uma outra modalidade terapêutica para tratar o trauma. Ambas experiências, clínica e empírica, sugerem que RB envolve ambos processamentos, somático e cognitivo. RB engaja essas formas de processamento espontaneamente, sem direção explícita do terapeuta.
Objetivos
Na preparação do desenvolvimento de um modelo de trauma mais abrangente, o Estudo 1 busca analisar criticamente a crescente tendência de reduzir o trauma psicológico a processos fisiológicos e demonstrar que a ontologia fisicalista dominante na ciência contemporânea se apoia em uma falácia epistemológica. Utilizando um modelo recente baseado em agência como um passo intermediário sugere uma ontologia alternativa na qual um modelo mais abrangente de trauma pode ser baseado. Os objetivos do Estudo 2 foram rastrear uma amostra de bombeiros de Santa Catarina com relação a exposição a incidentes críticos e aos níveis de sintomas da Síndrome de Estresse Pós-traumático (TEPT), e analisar a correlação entre os dois. Um objetivo secundário do Estudo 2 foi selecionar candidatos para o Estudo 3. O objetivo primário do Estudo 3 foi testar a eficácia do RB no tratamento de
diretamente a capacidade inata de auto regulação, o sucesso no tratamento apoiaria também a hipótese de que o trauma psicológico é causado pelo bloqueio dessa capacidade inata de auto regulação. O Estudo 3 busca também analisar os processos fisiológicos envolvidos em RB e explorar os mecanismos psicológicos envolvidos no processamento de memórias traumáticas.
Metodologia
O estudo 1 utiliza argumentos ontológicos e epistemológicos para demostrar que o trauma psicológico não pode ser reduzido unicamente a processos fisiológicos e descreve uma alternativa ao reducionismo fisicalista, baseado em agência e antroposofia. O Estudo 2 consiste em um levantamento de dados, baseado em questionários de auto relato, que rastreou 61 bombeiros de Santa Catarina por exposição a incidentes críticos e sintomas de TEPT. O estudo 3 é um estudo de caso clínico que investigou a utilização de RB para o tratamento de um bombeiro com TEPT. Foram utilizadas medidas de TEPT pré e pós tratamento – e sintomas comórbidos, assim como análise quantitativa de medidas fisiológicas e análise qualitativa de relatos pré e pós sessões.
Resultados e Discussão
O estudo 1 propõe a base ontológica para um modelo alternativo de trauma, baseado no conceito de agência e na imagem quadrimembrada de ser humano desenvolvida por Rudolf Steiner. O Estudo 2 mostrou que a exposição a eventos potencialmente traumáticos na amostra de bombeiros foi de 100%. Dependendo do método utilizado para interpretar os resultados do PTSD Checklist for DSM-5 (PCL-5), de 3 a 5 bombeiros obtiveram um diagnóstico provisório de TEPT. Uma correlação foi encontrada entre a avaliação (appraisal) de incidentes críticos e socio-demográficos severos, e fatores de emprego relacionados à idade, educação e se o participante estava ou não na ativa. Fatores de análise exploratórios foram utilizados para analisar a performance de dois instrumentos: PCL-5 e o protótipo de um questionário de histórico de incidentes críticos já existente, adaptado para o uso com profissionais de segurança pública. No estudo subsequente (Estudo 3) o diagnóstico de TEPT de apenas um dos 3-5 bombeiros foi confirmado. Possíveis razões são discutidas. As correlações entre a avaliação (appraisal) de incidentes críticos e
discutidas, assim como possíveis implicações para o desenvolvimento de um novo modelo de trauma. Pesquisa subsequente será requerida para avaliar apropriadamente as possíveis implicações. Estudo 3: o diagnóstico de TEPT de um único bombeiro com diagnóstico provisório foi confirmado por entrevista clínica; o bombeiro diagnosticado com TEPT respondeu bem ao tratamento e está em remissão após 8 sessões de Rebirthing Breathwork. A mudança cognitivo-emocional ocorrida durante o processo de tratamento é descrita em detalhes e a provável origem dos sintomas do trauma foi identificada como trauma de nascimento. A análise inicial do resultado, preliminarmente, apoia a hipótese de que os sintomas de TEPT sāo um resultado do bloqueio de uma capacidade de auto regulação, e o bloqueio está ligado a dissociação e elevada ativação parassimpática.
Considerações Finais
Estudo 1: a imagem quadrimembrada de ser humano desenvolvida por Rudolf Steiner pode ser uma base promissora a partir da qual se possa desenvolver um modelo teórico mais amplo sobre o trauma; isso deve ser melhor explorado. O estudo 2 confirma as pesquisas prévias nas quais os sintomas de TEPT são mais elevados em bombeiros do que na população geral. Recomenda-se investigações subsequentes na relação entre avaliação cognitiva de incidentes críticos e níveis de sintomas de TEPT, assim como fatores socio demográficos e relacionados ao trabalho. No estudo de caso (Estudo 3) o tratamento de TEPT com Rebirthing-Breathwork mostrou-se efetivo. Os resultados quantitativos e qualitativos do tratamento apoiam a hipótese de uma capacidade inata de autorregulação, assim como partes de um modelo de processamento proposto pelos investigadores. Um ensaio clínico controlado randomizado para testar a eficácia de RB no tratamento de TEPT é recomendado como próximo passo. Palavras-chave: Transtorno de estresse pós-traumático. Capacidade inata de auto regulação. Incidentes críticos. Rebirthing-Breathwork.
Despite major advances in the creation of diagnostic constructs for trauma-related disorders there exists, at present, no comprehensive theoretical model for psychological trauma. Historically, trauma theories have related psychological trauma either to biological or to intrapsychic factors. More recently, trauma is increasingly being related solely to the dysregulation of (neuro)physiological processes. Two recent therapeutic modalities, Eye Movement Desensitization and Reprocessing and Somatic Experiencing, attribute trauma to the blocking or dysregulation of an innate capacity for self-regulation. This project seeks to critically analyze the growing tendency to reduce psychological trauma to physiological processes; to test the hypothesis that psychological trauma is caused by the blocking of an innate capacity for self-regulation by using a third therapeutic modality that engages this capacity directly; to explore the psychological mechanisms of the processing of traumatic memories; and to prepare an alternative trauma model, based on agency.
Method. Study 1 uses ontological and epistemological arguments to show that psychological trauma cannot be reduced to physiological processes alone and describes an alternative to physicalist reductionism based on agency and anthroposophy. Study 2 is a survey, based on self-report questionnaires, that screened 61 firefighters from Santa Catarina for exposure to critical incidents and PTSD symptoms. Study 3 is a clinical case study, investigating the use of Rebirthing Breathwork for the treatment of a firefighter with PTSD.
Results. Study 1 proposes the ontological basis for an alternative trauma model, based on the concept of agency and on the fourfold image of the human being developed by Rudolf Steiner. Study 2: the exposure to potentially traumatic events in the sample of firefighters was 100%. Depending on the method used to interpret the results of the PTSD Checklist for DSM-5, 3-5 firefighters obtained a provisional PTSD diagnosis. A correlation was found between the appraisal of critical incidents and several sociodemographic and job-related factors related to age, education and whether or not the participant was on active duty. Study 3: the PTSD diagnosis of only one of the firefighters with a provisional diagnosis was confirmed by a clinical interview; the firefighter diagnosed with PTSD responded well to the treatment and is in remission after 8 sessions of Rebirthing Breathwork.
developed by Rudolf Steiner may prove a fruitful basis from which a more comprehensive trauma model can be developed; this needs to be explored further. Study 2 confirms previous research that PTSD-symptoms are higher in firefighters than in the general population. In the case study (Study 3) the treatment of PTSD with Rebirthing-Breathwork proved successful. Quantitative and qualitative findings from the treatment support the hypothesis of an innate capacity for self-regulation as well as a processing model proposed by the researchers.
Key words: Posttraumatic stress disorder. Innate capacity for self-regulation. Critical incidents. Rebirthing-Breathwork.
Figure 1. Psychological trauma as a result of
blocked processes 33
Figure 2. Allowing as the key to trauma
resolution 35 Figure 3. The polarities of nature and cause of
trauma 50 Figure 4. Stephan’s classification of weak and
strong forms of Emergentism 61
Figure 5. Space-time curvature 78
Figure 6. Perception and cognition in cognitive
psychology 82
Figure 7. The bodily, soul, and spiritual nature of
the human being 97
Figure 8. Spread of participants throughout Santa
Caterina 117
Figure 9. Histograms of age-groups and
time-in-the-job 120
Figure 10. Stacked bar-chart of PCL-5 symptom
cluster severity scores 132
Figure 11. Stacked bar-chart of individual
LEC-5 scores per mode of experience 132
Figure 12. Amount of experienced critical
incidents by 42 participants 138
Figure 13. Dual axes plot with linear fit-lines for CIHQ-EP 0 and 3 ratings with positive LEC-5
“Happened to me” scores 148
Figure 14. “I can rescue myself” (cartoon) 168
Figure 15. The defense-dissociation sequence 172 Figure 16. Trauma as the blocking of cognitive
and somatic processing 174 Figure 17. Resolution of trauma through allowing
cognitive and somatic processing 176 Figure 18. Flow-chart of the overall design of
Study 3 180
Figure 19. Poincaré plot of R-R intervals with
and RB sessions 212 Figure 21. Line-graphs of pre-session HRV
variables 215
Figure 22. Pre- and post-session systolic and
diastolic blood pressure 218
Figure 23. Timeline of emotional-cognitive shift 220 Figure 24. Timeline of traumatic events in the life
Table 1. Anthroposophy’s threefold and fourfold
image of the human being 96
Table 2. Four realms, four kingdoms and their higher
organization 99
Table 3. Levels of agency 102
Table 4. Trauma exposure and prevalence of PTSD 112 Table 5. Point prevalence of PTSD in Firefighters 113 Table 6. Demographical data of the sample 118 Table 7. Job-related data of the sample 119 Table 8. PTSD diagnosis results for 5 participants 130 Table 9. Means and dispersion of PCL-5 cluster totals
and overall total 131
Table 10. Means and dispersion of LEC-5 scores per
mode of experience 134
Table 11. Means and dispersion of LEC-5 positive
item scores 135
Table 12. LEC-5 items according to percentage of
total score 136
Table 13. Means and dispersion of the frequency of
“amount of times” category scores CIHQ-EP 139 Table 14. CIs experienced once or more by at least
50% of participants 140
Table 15. Mean frequency and attribution percentage
per appraisal category CIHQ-EP 142
Table 16. Mean difficulty appraisal rating of the 14
most experienced items 142
Table 17. Items with a mean difficulty rating above 3 143 Table 18. Statistically significant correlations between
LEC-5 and PCL-5 (sub)totals 146
Table 19. Comparison of the meaning given to ratings
in PCL-5 and CAPS-5 161
Table 20. Physical and physiological data related to
after treatment 212 Table 22. Pre-session means of HRV variable linked
to PNS 216
Table 23. Pre- and post-session systolic and diastolic
blood pressure 218
Table 24. The main processing phases during
AIP – Adaptive Information Processing
ASD – Acute Stress Disorder
BAI – Beck Anxiety Inventory
BDI – Beck Depression Inventory
BP – Blood Pressure
BPM – Basic Perinatal Matrix (I, II, II, IV)
CAPS(-5) – Clinician-Administered PTSD Scale (for DSM-5)
CBMSC – Corpo de Bombeiros Militar de Santa Catarina
CEBM(SC) – Centro de Ensino de Bombeiros Militar (de Santa
Catarina)
CI – Critical Incident
CIHQ – Critical Incident History Questionnaire
CNS – Central Nervous System
DSM – Diagnostic and Statistical Manual of mental disorders
DVC – Dorsal Vagal Complex
ECG – Electro Cardiogram
EEG – Electro Encephalogram
EMDR – Eye Movement Desensitization and Reprocessing
HRV – Heart Rate Variability
LEC(-5) – Life Event Checklist (for DSM-5)
LFH – Laboratório Fator Humano
OBE – Out-of-Body Experience
PCSC – Polícia Civil de Santa Catarina
PCL(-5) – PTSD Checklist (for DSM-5)
PMSC – Polícia Militar de Santa Catarina
PNS – Parasympathetic Nervous System
PTE – Potentially Traumatic Event/Experience
PTSD – Posttraumatic Stress Disorder
RB – Rebirthing Breathwork
REM – Rapid Eye Movement
RRi – R-R interval
SAMU – Serviço de Atendimento Móvel de Urgência
SE – Somatic Experiencing
SNS – Sympathetic Nervous System
TA – Thematic Analysis
TE – Trauma(tic) Event
TCLE – Termo de Consentimento Livre e Esclarecido
UFSC – Universidade Federal de Santa Catarina
Acknowledgements 4 Resumo 9 Resumo Expandido 11 Introdução 11 Objetivos 11 Metodologia 12 Resultados e Discussão 12 Considerações Finais 13 Abstract 14 List of Figures 16 List of Tables 18 List of abbreviations 20 Table of contents 21 Presentation 27 Introduction 30
The problem with exclusively physiological trauma
theories 31
Trauma as the interruption of an innate capacity for
self-regulation 31
Self-regulation 35
Trauma and agency 37
Rebirthing-Breathwork: a third therapeutic modality that
engages self-regulation 38
Context 42
Overall research aims 42
Specific research aims 43
Hypotheses 43
STUDY 1 44
Trauma: more than Physics and Biology 45
Introduction 45
PTSD as a diagnostic construct of a trauma-related
Outline and objective of this study 52
Method 53
Part I 55
A Critical Analysis of Emergentism and Physicalism, and an
Alternative Model Based on Agency 55
Darwinian evolution theory and reductionism 55
Emergent properties 57
Emergentism, nonreductive physicalism and the problem
of downward causation 58
Emergentism 59
(Ir)reducibility 62
The problem of downward causation 64
A double “world-knot” 64
Physicalism, the mechanistic model and the sense of touch 65 Physical properties and the primacy of touch 66
Untying the world-knots? 69
Mechanistic views of evolution 71
Self-assembling Lego and Dennett’s cranes 71 An alternative to physicalism and the mechanistic model,
based on agency 74
Epilogue to Part I 81
Perception and Cognition; Subjectivity and Objectivity 81
Part II 85
The anthroposophical ontology, an alternative explanation of life, consciousness and self-consciousness 85
Anthroposophy 85
The higher-order organizing principles responsible for life,
consciousness and self-consciousness 87
Life 87
Consciousness 91
Memory, the I and the human soul 94
Plants, animals and humans: three general levels of agency 100 The scientific credibility of anthroposophy: a summary
Screening for PTSD Symptoms and Exposure to Critical Incidents in a Sample of Firefighters from Santa Catarina,
Brazil 109
Introduction 109
Objectives of this study 116
Method 116
Design 116
Participants and context 117
Inclusion criteria 120 Variables 120 Instruments 121 LEC-5 121 PCL-5 122 CIHQ-EP 123 Procedures 124 Data analysis 127 Results 129
PTSD symptom levels in the sample 129
Exposure to PTEs (critical incidents) 133
LEC-5 133
Criteria A “worst event” 136
CIHQ-EP 137
Results of the correlational analyses 144
Correlations between sociodemographic/job-related data and LEC-5, PCL-5 and CIHQ-EP results 145 Correlations between PCL-5 and LEC-5 results 146 Correlations between CIHQ-EP and PCL-5 and LEC-5 147 Explorational factor analysis of PCL-5 and CIHQ-EP 149
PCL-5 item clusters 150
CIQH-EP 154
Discussion 155
Exposure to potentially traumatic events 155
PTSD symptoms in the sample 157
Involvement in PTEs and appraisal of PTE difficulty 163
The CIHQ-EP 165
Limitations 167
The Efficacy of Rebirthing-Breathwork to Treat Trauma in
Firefighters: A Case Study 171
Introduction 171
Trauma as a blocked innate capacity for self-regulation 171 Accessing the innate capacity for self-regulation through
Rebirthing-Breathwork 176
Method 179
Nature of this study 179
Design 180
‘Gold standards’ 181
Participants and context 182
Inclusion criteria 183
Exclusion criteria 183
Pre-treatment selection 184
Participant and context of the treatment 184
Variables 186
Instruments and Materials 186
PCL-5 187
CAPS-5 189
BDI 189
BAI 190
Procedures 190
Data organization and analyses 197
Analyses 198
Detailed reports of the RB sessions 202
First session, August 7 202
Second session, August 21 202
Third session, September 5 203
Fourth session, September 13 206
Fifth session, September 18 207
Sixth session, October 25 208
Seventh session, November 13 209
Eighth session, November 21 210
Results 212
PTSD diagnosis, and comorbid symptoms 212
HRV and BP Analysis 215
equanimity 218 Searching for the source of the trauma 220 Thematic analysis of post-session reports 223
Discussion 227
Limitations 232
Suggestions for further research 234
Conclusion 235 Overall conclusion 236 References 238 Appendix 1 257 Appendix 2 266 Appendix 3 267 Appendix 4 270 Appendix 5 275 Appendix 6 292
Results factor analyses 292
PCL-5 292
CIHQ-EP 314
Appendix 7 326
A. CAPS-5 326
B. CAPS-5 Training Certificate 347
Appendix 8 348
Appendix 9 349
Concerning the ‘energy cycle’, or stages of a RB session 351
Appendix 10 353
An Exploration of the Processing of Suppressed Memories
during Rebirthing-Breathwork 356
1. Introduction 356
2. The conscious experience of processing past experiences
during Rebirthing-Breathwork 357
3. Overview of the different phases of a
4.1 A classic example 363
5. (Re)processing during EMDR 364
5.1 The Adaptive Information Processing model 364
6. An alternative processing model 365
7. Conclusion 368
References 369
Appendix 11 372
Appendix 12 374
Appendix 13 375
Transcriptions of the post-session reports for sessions 3 &
5–8 375 Session 3 375 Session 5 378 Session 6 380 Session 7 383 Session 8 386
Presentation
This research would not exist in its present form without my own personal and professional experience with both trauma and Rebirthing Breathwork. I consider it therefore prudent to introduce this experience briefly before introducing the research itself.
I have been working with trauma – both as a concept and as experience – since I first took part in a rebirthing training on a boat in Amsterdam, at the end of November 1985. During the second day of that training I was introduced to the concept of birth trauma. A few hours later the concept came to life when I spontaneously appeared to relive part of my own birth trauma (and its release) during a breathwork session (see: de Wit, 2016, pp. 82-85). Although it was Otto Rank who first introduced the concept of birth trauma (Rank, 1924), it was the parallel work of Frédérick Leboyer, a French obstetrician who advocated a radical humanization of childbirth, Stanislav Grof, who experimented with LSD, discovered Holotropic Breathwork and stood at the birth of transpersonal psychology, and Leonard Orr, who discovered Rebirthing Breathwork, that made the concept concrete and presented it to a global audience (Leboyer, 1974/1987; Orr & Ray, 1977; Grof, 1985, 1988, 2010). After my experience in 1985 I worked for a few years as an assistant rebirther, and met Leonard Orr personally in 1987, when he lectured in Holland.
In 1988, I started a new career: I started working as a social therapist, taking care of people with severe intellectual and physical disabilities. As I learned about Anthroposophy and was trained in how to develop a deeper sense of the greater individuality of those severely disabled individuals, rebirthing and trauma temporarily faded to the back of my mind. Nevertheless, occasionally the concept of trauma reintroduced itself during case clinics and during compulsory trainings about sexual abuse, to which the disabled population is particularly prone due to their increased vulnerability.
In 1999 I entered into a relationship with a woman who had been emotionally and sexually abused since childhood. In 2000, while working as a disability nurse in Northern Ireland, I first read about Posttraumatic Stress Disorder and its symptoms; I immediately realized that many of the symptoms had been described to me (and were displayed) by my partner.
Soon my professional life changed; I began working with challenging young people – first in England, and later in Ireland.
Many of them had suffered abuse and appeared to be troubled by trauma. In 2004, I was invited to work in a therapeutic residential unit for boys manifesting challenging sexualized behavior. In this unit I was introduced to, and trained to work with the so-called trauma-model, the clinical perspective from which the unit operated. The basic premise was that the boys had been traumatized and engaged in challenging sexual behavior as a way to numb the memories, the negative self-images and the negative affects that resulted from their experiences: their behavior was, as it were, a pain-killer. It was in this context that I first came in contact with the work of Peter Levine, as well as with a treatment directly inspired by Eye Movement Desensitization and Reprocessing (EMDR). And it was in this context that I started my graduation course in Psychology, while also working full-time in the unit.
When my relationship broke up in 2007, I decided to enroll in a professional Rebirthing-Breathwork training with Leonard Orr. In 2009 I returned to Holland, to work with people with learning difficulties in an anthroposophical setting, and was soon asked to set up a new unit for clients with comorbid psychiatric problems who couldn’t manage life in the normal groups. Using a combination of attachment-theory and the trauma-model inherited from my work in Ireland, I developed an approach that made it possible for these people to live together in a small unit: a sheltered environment with reduced stimulation. In this same period I finished my graduation in Psychology.
By the end of 2010 I became a professional Rebirthing-Breathworker, and in 2011 my wife and I (we had met during the professional Rebirthing Breathwork training in 2007) joined Leonard Orr for five months as co-trainers during his trainings in Brazil, the United States and Spain. During this time I read Peter Levine’s book In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness (Levine, 2010), which worked as a catalyst. The combination of Levine’s somatic trauma-concept and my various personal and professional experiences led to an epiphany and helped me understand trauma on a much deeper level.
Being unsatisfied with the quality of the written material available about Rebirthing Breathwork, I spend the first four months of 2012 writing a book about it, based on my own professional and personal experience (I eventually self-published
this book in 2016). Subsequently (in 2012), I began working on another book, which I gave the working-title Understanding Trauma. I started developing a new theoretical model for trauma based on a thorough review of scientific knowledge and the available empirical/clinical evidence, as well as on my own personal and professional experience.
In 2013 we moved to Florianópolis, Brazil, where I started the process of revalidating my graduate diploma in Psychology at the Universidade Federal de Santa Catarina. It was during this process that I began working with Prof. Dr. Roberto Moraes Cruz. The revalidation was completed in 2016, and when I was accepted as a Master student in the beginning of 2017, I decided to dedicate my research to continuing the trauma-project I had started in 2012. Paulus A. J. M. de Wit, Florianópolis, December 2018
Introduction
The increasingly one-sided focus on physiological processes in order to exhaustively explain psychological trauma is leading theorists into an ontological cul-de-sac and is a major obstruction to the development of a comprehensive understanding of both trauma and its resolution. The greatly increased reliance on bio-neurological models and the decreased popularity of intrapsychic models to explain trauma- and stress-related disorders is a relatively new development; during the second half of the nineteenth century and for most of the twentieth century the competing biological and intrapsychic models both had a strong following (for a concise historical overview see: van der Kolk, Weisaeth, & van der Hart, 1996/2007). Although the increased faith in (neuro)physiological models is understandable – they fit well into the prevailing scientific paradigms of materialistic reductionism and the standard evolution-model based on the concepts of chance and survival – this research has been developed from a radically different perspective and proposes inclusion of non-physiological dimensions as primary components of a theoretical model of psychological trauma. It will be argued that, although trauma-related disorders have a neurophysiological dimension, ultimately, they cannot be satisfactorily explained from neurophysiological dysregulations alone – the core principles underlying trauma-related phenomena have to be sought elsewhere.
This research project is spread out over several studies as will be explained below. One practical reason for this subdivision is that the overall project involves both a (research) master project and a doctoral project. The outline which will be presented in this introduction extends over both the master and the doctoral project. The subsequently presented studies form the dissertation for the master project. The studies that remain outstanding will become part of the doctoral project.
The overall effort from which this research originates is to establish a comprehensive theoretical model for psychological trauma that goes beyond a physiological explanation. This model will need to be able to explain: 1) the mechanisms by which certain experiences can lead to psychological trauma; 2) the underlying principle of psychological trauma; 3) how this underlying principle leads to the symptoms and behaviors that have come to be associated with psychological trauma; and 4) how psychological
trauma is resolved.
The problem with exclusively physiological trauma theories There are two primary reasons why explaining trauma from a purely (neuro)physiological perspective is problematic. The first reason is related to the causation of trauma, the second reason is related to trauma resolution. Apart from directly experiencing a threatening event (an experience that has been linked to the causation of traumatization and presently has been explained by referring to neurophysiological changes), trauma can also result from listening to traumatized others (vicarious or secondary trauma) and from other forms of exposure to aversive details of traumatic events. Furthermore, it has been shown that traumatization can result from killing others (e.g. MacNair, 2001; Maguen et al., 2009; Komarovskaya et al., 2011; MacNair, 2012). These two particular causes of traumatization (hearing others relate their traumatic experiences and killing) strongly suggest a psychological or moral component in the causation of trauma, not a physiological one.
Secondly, theories which try to explain psychological trauma from a fundamentally physiological perspective have particular difficulty in explaining how trauma can be rapidly resolved by certain emerging therapeutic approaches. If current theories are unable to satisfactorily explain certain clinical evidence of trauma resolution, then this also puts their understanding of traumatic phenomena as such to question.
Trauma as the interruption of an innate capacity for self-regulation
In the treatment of trauma-related disorders two therapeutic modalities with a relatively high success-rate are based on a similar hypothesis: that trauma involves the interruption of an innate capacity for self-regulation. These therapeutic modalities are Eye Movement Desensitization and Reprocessing (EMDR) and Somatic Experiencing (SE). Theorists of both approaches have proposed that their interventions facilitate resolution of psychological trauma by engaging an innate capacity for self-regulation (Shapiro, 2001; Levine, 2010). Thinking this hypothesis to logical completion, the conclusion presents itself that, once engaged, it is the innate capacity that effectuates recovery from trauma. This differs from the basic premise on which the majority of therapeutic interventions that deal with trauma-related disorders are based: that the particular intervention “heals” or “repairs”
trauma-related dysregulations directly – be it pharmacologically, through re-conditioning, or by helping to process unintegrated memories. An advanced conclusion to which the recent alternative hypothesis points is that the processes underlying the resolution of psychological trauma are natural processes – like those involved in grieving for instance – and ultimately that psychological trauma is not so much a disorder or pathology, but rather a blocked natural process. This hypothesis is the point of departure for the underlying research.
Although both Shapiro and Levine have initially put forward the hypothesis of an innate capacity for self-regulation, they subsequently have also sought to explain the mechanisms of the therapeutic interventions they discovered in ways that better satisfy the contemporary scientific paradigm. Along with other theorists they continue their efforts to fit the therapeutic mechanisms into existing theories and into the grander scientific model that, ultimately, seeks to reduce all psychological phenomena to (neuro-)physiological processes. Specifically, they are trying to link (and, ultimately, to reduce) their concepts of self-regulation to the purely physiological models of homeostasis and allostasis (e.g. Solomon & Shapiro, 2008; Shapiro & Laliotis, 2010; Payne, Levine, & Crane-Godreau, 2015).
The core procedure of EMDR is the induction of rapid eye movements and/or the use of other forms of bilateral, rhythmical stimulation, in combination with a strict protocol, targeting emotionally charged memories. To explain its success, Shapiro proposed that EMDR activates Adaptive Information Processing (AIP), which she initially explained as an associative cognitive process that facilitates the integration of unintegrated memories/experiences (Shapiro, 2001, 2002).
In contrast, Somatic Experiencing uses a predominantly body-focused approach. It is based on ethological observations of prey animals surviving a predator attack. Such animals can be observed to go through a stage of intense shaking and trembling before returning to normal behavior. Levine (1997, 2010) has proposed that this behavior serves the purpose of completing truncated survival actions and of “resetting” the autonomic nervous system, after it has been engaged in a high-energy survival-cycle. He asserts that in humans this process is often prevented due to what he calls fear-potentiated immobility (Levine, 2010). SE seeks to gently stimulate and facilitate this
process of completion and energetic discharge. Recently Levine introduced an additional concept by proposing that SE facilitates the transmutation of trauma-related procedural memories to episodic memories, which brings it conceptually closer to cognitive processing (Levine, 2015).
Figure 1. Psychological trauma as a result of blocked natural processes (cognitive and/or somatic), using the four main symptom clusters of PTSD from DSM-5 as a basis.
Using the four main symptom-clusters from the diagnostic criteria for Posttraumatic Stress Disorder (PTSD) from the 5th edition of the Diagnostic and statistical manual of mental disorders (DSM-5) (American Psychiatric Association, 2013) as a basis, and taking account of the therapeutic dimensions accessed in EMDR and SE, the hypothesis that psychological trauma results from blocked natural processes can be represented as follows (see Figure 1). In DSM-5 the four main symptom clusters of PTSD are defined in diagnostic Criteria B – E. They are: intrusions (Criterion B), avoidance (Criterion C), negative alterations in cognitions and mood (Criterion D) and marked alterations in arousal and reactivity (Criterion E) (APA, 2013, pp. 271-272). The symptom clusters belonging to Criteria B (intrusions) and E (altered arousal/reactivity) list symptoms that can be said to reflect – respectively – the cognitive and the (survival-related) somatic processes that, once completed, result in the resolution of trauma-related symptoms. The symptoms belonging to Criterion C – avoidance, or the effort to avoid – can be said to reflect what is preventing these natural processes to reach completion. The
symptoms belonging to Criteria D appear on the one hand to be the intermediate effects of this interruption on cognitive and affective levels, but at the same time they appear also to actively contribute to the interruption (as hypothesized in Levine’s concept of fear-potentiated immobility, for instance).
The symptom cluster of intrusions (involving, predominantly, cognitions) is the primary area targeted by EMDR. If we consider intrusions as manifestations of cognitive processing, then clinical evidence from EMDR provides a description of what happens when intruding memories are processed: they rapidly lose their intrusive, emotionally charged character and become integrated into episodic memory. The symptom cluster of marked alterations in arousal and reactivity (involving survival-related somatic processes) is the primary area targeted by SE. SE practitioners and theorists assert that SE facilitates completion of these processes and the model presented by Levine is supported by ample experimental and ethological evidence (Levine, 2010). Clinical evidence from both EMDR and SE supports the hypothesis that enabling either of these processes can resolve trauma-related symptoms.
If avoidance and the effort to avoid reflect the core principle behind the interruption of cognitive and/or somatic processing, then suspension of avoidance (or allowing – to express it positively) should reflect the key attitude that invites resolution of psychological trauma (Figure 2). It can be argued that the highly protocolled approach inherent in EMDR, in combination with the dual focus brought about by the induction of eye movements and/or other rhythmical bilateral stimulation, affords a client the amount of psychological ‘space’ necessary to suspend avoidance and allow adaptive information processing (AIP) to take place (compare, e.g., Lee, Tayler, & Drummond, 2006). In SE establishing an approach that helps a client to suspend avoidance and to trust the somatic processes as they unfold informs the major part of its core methodology (Levine, 1997, 2010, 2015; Payne et al., 2015).
Figure 2. Allowing as the key to trauma resolution.
It is difficult – if not impossible – to conceptualize the effort to avoid, as well as the suspension of avoidance (and allowing and trusting), without the notion of some form of intentionality (be it conscious or not conscious). This notion needs to be handled very carefully, as it has been misunderstood and misused repeatedly in the history of the diagnosis of psychological trauma (see, e.g., van der Kolk et al., 1996/2007); however, it is exactly this notion that puts purely physiological models of psychological trauma to question. The notion of intentionality also invites a reconsideration of past arguments about the role of cognitive appraisal as put forward by Schachter and Singer (1962), Selye (1975) and Lazarus (1984), among others.
Self-regulation
The concept of an innate capacity for self-regulation plays a crucial role in the first sketch of a trauma- and resolution model that is presented above. EMDR and SE appear to enable two distinct aspects – or dimensions – of this innate capacity for self-regulation. AIP appears to be a form of cognitive self-regulation, while in SE the innate self-regulatory capacity has been linked to the concepts of physiological homeostasis and allostasis (Payne, Levine, & Crane-Godreau, 2015). Self-regulation on a somatic level is thought to consist of the gradual re-establishment of homeostasis (or allostasis). Simply put, when a system has been taken out of its physiological equilibrium by being engaged in a life-threatening situation, an inherent drive – the innate
self-regulatory capacity – will attempt to restore the equilibrium by releasing the survival energy (thereby resetting the nervous system). The core of cognitive self-regulation is the drive to process upsetting experiences until they lose their cognitive and affective edge and become part of episodic memory1. While the experiences are being processed they engage a considerable part of an individual’s cognitive capacity; once they have become part of episodic memory, the individual’s cognitive capacity can be used for other tasks, and cognitive equilibrium has been restored, so to speak. As mentioned above, more recently Levine has
1 To illustrate cognitive self-regulation, consider the following
description, based on an actual experience. You are caught in a short traffic jam and can see emergency lights flickering ahead of you. As you approach the “heart” of the traffic jam, you see a police officer guiding traffic past an accident scene. The corpse of a young man is laid out on the road. Forensic officers appear to be taking account of what must have happened to him. You pass the scene. You see a car and a motorbike that appear to have been involved in the accident. There are several police vehicles, an ambulance, a casket waiting for the body… The corpse itself appears to be stripped to his underwear (why?) and a female forensic officer is walking around the body with a notepad. You notice the tattoo on the victim’s arm, a bruise just above the tattoo. For the rest the body appears intact and there are no signs of further injury. You deduce the young man must be dead, because he doesn’t move and the officers appear more concerned about the scene than about removing the body. … And there is – of course – the casket… You drive on. Further on, the traffic jam dissolves quickly, but the scene of the young man’s body remains burned on your retinas. The memory remains prominent for several hours. It affects you and you have to think about it, talk about it with the people you meet. The images of the young man on the road and the casket keep coming back to you. Was he really dead? What actually happened to him? Why was he almost naked? What must his family feel when they receive news of his death? - Yet, every time you talk about the images, or mull them over in your mind, they become a little less prominent.. The next day you read about the accident in a newspaper. Now and then the images fill your mind, but gradually the memories lose their intensity. Over the course of the next few days the images turn into an ordinary memory and you are no longer affected by it… Thus, cognitive self-regulation means that an “upsetting”, possibly “traumatic” experience gradually turns into a “normal”, episodic memory. What helps to process the experience is to think about it (to allow the thinking to unfold in your mind), to talk about it with someone who can listen to you, and – very likely – to sleep over it.
brought both aspects of this self-regulatory capacity closer together by suggesting that trauma-resolution in SE primarily consists of the processing of trauma-related procedural memories, so that they become part of episodic memory (Levine, 2015). Trauma and agency
Another concept that is important in the trauma- and resolution models sketched above is the concept of agency. Bandura (2008) defines human agency as follows: “To be an agent is to influence intentionally one’s functioning and the course of environmental events. People are contributors to their life circumstances, not just products of them” (p. 87). In considering the sense of agency, Moore (2016) distinguishes between the feeling of agency (a “lower level non conceptual feeling of being an agent”, linked to “low-level sensorimotor processes” – p. 1) and the judgement of agency (a “higher-level conceptual judgement of agency”, linked to “background beliefs and contextual knowledge” – p. 1). Loss of agency appears to be strongly associated with traumatization. Potentially traumatic events tend to lead to trauma particularly when the feeling of agency is undermined. However, subsequent traumatization also appears to involve a diminished judgement of agency. Successful trauma treatment restores the sense of agency. Bandura, for example, draws attention to research that indicates that traumatized soldiers that were treated immediately, close to the frontline, and were then sent back to their unit, had a higher sense of agency (“efficacy”) and less posttraumatic stress reactions than soldiers that were evacuated and never returned to combat. Bandura:
Reengagement with traumatic situations in actuality or cognitively is an important part of recovery. However, it is not merely reexperiencing a traumatic event but confronting it in a way that restores the sense of control through reconstrual or improved coping that alleviates stress reactions and behavioral impairments. Indeed, renewed successful coping with an intense threat is an effective way of restoring a sense of personal efficacy. (Bandura, 1997, p. 322).
Particularly during SE clients are gradually encouraged to confront the original traumatic experience in a more effective way – one that reflects a heightened sense of agency. The sense of agency appealed to in SE appears to be closely related to the feeling of agency. A heightened sense of agency can also be encountered in accounts of clients that describe the processing of
traumatic memories during EMDR, in this case judgement of agency appears to be the primary sense involved.
There appears to be a tension between the innate capacity for self-regulation and the sense of agency in individuals suffering from trauma. Traumatized individuals generally have a low sense of agency, while the inherent drive for cognitive and somatic self-regulation is experienced as a threat. They already feel not in control because of their trauma-symptoms, whereas allowing the process of self-regulation to unfold is associated with further loss of control. Paradoxically, allowing the temporary further loss of control associated with self-regulatory processes ultimately leads to restoration of a proper sense of agency.
The definition of agency as a more objective concept proposed by Barandiaran, Di Paolo, and Rhode (2009) considers innate self-regulatory processes an important aspect of agency itself. When discussing “living agency” Barandiaran et al. describe living systems as “far-from-thermodynamic-equilibrium system[s] … that [continually] produce and repair [themselves]”; such systems are “subject to a permanent precariousness … that is compensated by [the living system’s] active organization” (p. 375). The innate capacity for (cognitive and somatic) self-regulation can be seen as a mechanism for self-repair that actively compensates for the inherent precariousness of – particularly – the human living system. Barandiaran et al. consider such mechanisms expressions of a necessary condition of genuine agency. Rebirthing-Breathwork: a third therapeutic modality that engages self-regulation
In order to test the hypotheses that psychological trauma results from blocked natural processes, and that allowing these processes to unfold will lead to a resolution of trauma symptoms, in this research-project another therapeutic modality: Rebirthing-Breathwork (RB) has been used in an experimental research-design. RB appears to activate and engage both the associative cognitive processing activated in EMDR and the somatic processing engaged in SE. RB harnesses the regulatory capacity inherent in the breathing-rhythm, while simultaneously stimulating a cognitive state similar to the state targeted in mindfulness-based practices. It tends to generate a somatic-cognitive cycle that, when allowed to unfold, spontaneously brings unresolved issues to consciousness and leads to their resolution (Dowling, 2000, 2005; Minnet, 2004; De Wit, 2016). Such a cycle,
once activated, can last from about fifteen minutes to more than two hours – with an average duration of about an hour.
At present, RB is not specifically used to treat trauma-related disorders2 – although such application has been suggested (e.g. Manné, 2003). However, considering the relatively high success rates of EMDR and SE in treating psychological trauma, and taking into account their respective similarities with RB, it is hypothesized that RB holds the potential to be another successful therapeutic modality to resolve psychological trauma. Furthermore, because of its undirected nature (it could be described as a process of free-association of the bodymind3), RB
is the ideal candidate to provide supporting evidence for the postulated innate processes of self-regulation and to explore their potential to resolve psychological trauma. In addition, a more in-depth investigation of the process of RB in participants diagnosed with trauma-related disorders holds the potential of revealing evidence of the dimensions of trauma itself.
Social relevance
The social impact of trauma is receiving increasing and sustained attention on a global scale. In the past, there was sporadic public interest for the impact of trauma. There were spikes of interest after the great wars, when hundreds of thousands of soldiers returned from the battlefront suffering from trauma, but, after the two world wars, public attention quickly subsided (Young, 1995). Since the introduction of PTSD in the Diagnostic and Statistical Manual of Mental Disorders (APA, 1980), public attention has not diminished but appears to be steadily increasing. This appears to indicate a – perhaps critical – rise in public awareness of the significance of psychological trauma.
According to an update from the WHO-led World Mental Health Surveys, the proportion of PTSD rated severely disabling was 54.8% for developed countries and 41.2% for developing countries (Kessler et al., 2009). Between 1990 and 2000 the Global Burden of Disease estimated for PTSD rose from 0.4% to 0.6% disability adjusted life years (DALY) (Ayuso-Mateos, 2006). In
2 Rebirthing-Breathworkers have a history of designating almost any
unresolved issue from the past as “trauma” (see, e.g. Van Laere & Orr, 2011, pp. 33-55).
3 Paraphrasing the title of an article by the South African psychoanalyst
addition, as Cavalcante, Morita and Haddad (2009) point out (with regard to PTSD resulting from traffic accidents), most of the social costs of PTSD remain invisible (except for those who suffer from it). This is because PTSD doesn’t only affect the direct victims, but also those in close relationships with them. Furthermore – particularly in the case of accidents and disasters – PTSD is not limited to victims and their social circles, but can also affect professionals attending the accident. The prevalence of PTSD in first-responders is higher than in most other professions (e.g. Marmar et al., 2006).
Estimates for lifetime prevalence of PTSD range from 2.1%–5.0% in the general population to 37% in post-conflict settings, to 80% among Cambodian refugees living in camps (Norris & Slone, 2013; Koenen et al., 2017). For lack of successful treatment methods, trauma has long been considered a chronic illness. This is still the most prevalent view. Considering these variables, contributing to the understanding of successful treatment methods that lessen the global impact of trauma is of high social relevance.
Scientific relevance
Despite advances in creating diagnostic constructs for trauma-related disorders as evidenced in DSM-III to DSM-5 (APA, 1980, 1994, 2013), and despite the continuing research into the dimensions of these diagnostic constructs (e.g. Armour et al., 2012; Liu et al., 2014; Tsai et al. 2015; Armour, Müllerová & Elhai, 2015, Armour et al., 2016; Armour, 2015; Yang et al., 2017), at present there exists no theoretical model that leads to a satisfactory, comprehensive understanding of psychological trauma. A diagnosis implies an underlying phenomenon, but doesn’t explain what the phenomenon is. Likewise, the dimensions of the diagnostic construct try to identify and distinguish salient symptom clusters, but as such they cannot be expected to directly translate to dimensions of a theoretical construct of trauma. Clinical and empirical evidence suggest at least the following dimensions: a moral dimension (evidenced by PTSD resulting from the direct or indirect perpetration of killing and other serious contra-human actions); a cognitive dimension; an emotional dimension; a somatic dimension; and a physiological dimension.
There are several physiology-based and evolution-based models and theories that successfully explain symptom groups of psychological trauma. These include: polyvagal theory (Porges,
2001, 2011); the defense cascade model (Schauer & Elbert, 2010); a model based on limbic kindling (Scaer, 2001); and the fear-conditioning model (e.g. LeDoux, 2000). However, they are all challenged by the speed and the relative success-rates of emerging therapies such as EMDR and SE, as well as by the dimensions at which intervention is effected in these therapies.
Theories and models that primarily (or exclusively) rely on a biological basis for explaining trauma-symptoms imply that (neuro)physiological processes are the primary level on which trauma unfolds, while psychological phenomena (i.e. cognitions (including memories), affects and changes in consciousness) are considered supervenient on the primary processes and therefore secondary (or emergent). Although often not explicitly, in essence, these models and theories are reductionist in nature: they reduce psychological trauma to a long-term dysregulation of the (neuro)physiological homeostasis and to a pathological triggering of survival behaviors that are ‘hard-wired’ into physiological processes through evolutionary adaptation. Such models tend to predict more or less chronic pathologies, that, once set in motion, are difficult to reverse (this particularly applies to the defense cascade model, limbic kindling and LeDoux’s fear-conditioning model). Until the recent emergence of EMDR and SE, such predictions appeared to be supported by the clinical evidence of a relatively strong resistance of trauma to most forms of therapy. However, both the immediacy of results and the relatively high success-rate of EMDR and SE challenge these propositions.
A strong challenge to biology-based models and theories is that psychotropic medication can temporarily alleviate trauma symptoms, but, unlike EMDR and SE, it generally does not lead to a permanent resolution. When medication is terminated the symptoms tend to return. On the other hand, follow-up studies after successful EMDR suggest that changes are permanent (e.g. Wilson, Becker & Tinker, 1997; van der Kolk et al., 2007). Thus, direct intervention on a physiological level generally doesn’t lead to lasting change, but certain interventions that affect unprocessed memories can.
These findings have important repercussions on the validity of theoretical trauma models. When taken seriously, recent clinical evidence doesn’t appear to support trauma models that consider physiological processes the primary basis for trauma while regarding all other levels as supervenient on biological events.
This research hopes to contribute to the development of an alternative theoretical trauma model that takes into account empirical evidence, without trying to explain it immediately according to theories that consider the physiological level the basis of trauma.
Last, but not least: evidence that supports a model that explains trauma-related disorders as resulting from the interruption of a natural process instead of as chronic pathologies must hold important implications for the future treatment of traumatized individuals.
Context
In preparation for this research several lines of enquiry were pursued to establish a specific context. The laboratory to which this research is connected (Laboratório Fator Humano – LFH) has established links with three government organizations involved in emergency responses: the Polícia Militar, the Polícia Civil and the Corpo de Bombeiros of Santa Catarina state. Based on specific experience, as well as on general previous research (e.g. Marmar et al., 2006), it was anticipated that all three organizations have professionals suffering from work-related trauma. The first line of enquiry was to liaise with psychologists and other officials of these organizations to generate interest in the research and to gauge whether there is a possibility to carry out the experiments proposed in this research. This led to an agreement with the Centro de Ensino do Corpo de Bombeiros Militar de Santa Catarina (CEBMSC) to take part in the research. A preliminary survey to measure the exposure to critical incidents and to screen for trauma-related symptoms was undertaken in a class of 67 sergeants-in-training coming from the entire state of Santa Catarina. 61 sergeants-in-training took part in the survey. Of those 61, 7 reported clinical or subclinical symptoms of PTSD. They were approached to take part in the treatment-part of the research and 5 agreed to take part. Subsequent diagnosis confirmed PTSD in only one of the participants. This participant underwent 8 sessions of RB. His treatment is presented in the form of a clinical case study in this dissertation.
Overall research aims
I. To establish an empirical/theoretical basis for the development of a comprehensive theoretical trauma model.
II. To gather data in support of the development of a therapeutic model for trauma resolution that combines and describes the cognitive and somatic processes involved. Specific research aims
I. Critically analyze the current scientific inclination to consider the (neuro)physiological substratum as the causative basis of trauma-related disorders (in the form of a logical/ontological critique) and describe an
alternative ontology, which can be used as the basis for a new, comprehensive trauma model.
II. Screen specific groups for trauma exposure and PTSD (in preparation for III).
III. Evaluate the efficacy of Rebirthing-Breathwork in reducing trauma-related symptoms in traumatized emergency responders.
IV. Explore and analyze the cognitive, somatic and physiological processes taking place during RB in individuals diagnosed with trauma-related disorders. Hypotheses
1. The resolution of trauma is a natural process containing somatic and cognitive elements.
2. An interruption of this process leads to trauma-related disorders.
3. Re-engagement of this natural process leads to trauma resolution.
