Post-traumatic stress disorder (PTSD) can be defined as recurrent episodes of anxiety and panic in reaction to a past experience that was overwhelming at both sensory and emotional levels. The individual was unable to process and assimilate the experience, and the emotional trauma becomes repressed, only to reoccur in the future. The basic direction of psychotherapy for PTSD is to help the client re-process these emotions into a form that can be re-assimilate; essentially completing the process that was left undone. However, the methods for doing this are problematic for two main reasons. Firstly, the intensity of the associated emotions and resistance to re-experiencing the trauma; and secondly, the complex superstructure of secondary reactivity that accumulates around the primary experience, which makes it difficult for the client to access and work on the core emotions.
One approach, which I have found particularly helpful, is a form of psychotherapy that combines mindfulness and experiential imagery, called Mindfulness Meditation Therapy (MMT). In this approach, the client is taught how to form a non-reactive relationship with his traumatic memory. The individual literally learns how to "sit" with the felt-sense of the trauma, without becoming caught up in the contents. The purpose here is not to simply re-experience the traumatic memory and emotions, but to learn how to experience them differently. This Mindfulness Based Relationship creates a therapeutic space around the memory imagery and associated emotional energy that allows the client to gradually stop the secondary reactivity of resistance and avoidance. Now a new creative space is created which allows the emotions, which have been confined and frozen in place, to become malleable and change. This process of inner change leads to the eventual resolution and transformation of the trauma. In short, reactivity inhibits change, whereas mindfulness facilitates change and healing.
Mindfulness has of course attracted a great deal of attention in recent years, although there has been little systematic attempt to describe, let alone define, mindfulness. In my view mindfulness describes the quality of conscious relationship with experience in which there is complete presence for the experience and the absence of any form of habitual subjective reactivity. This is invaluable in psychotherapy, because it allows the client to investigate the deep structure of his trauma, rather than staying stuck at the superficial surface structure.
Indeed, when one begins to investigate the internal structure of a traumatic memory, it is always surprising to discover the wealth of subtle feelings that lie just under the surface. Differentiation of the feeling structure of an emotion like anxiety or panic is an essential part of any successful therapy and the conscious experience of this inner structure is transformational.
In addition to feelings, traumatic memories also have a specific internal structure in the form of intense experiential imagery. This imagery may be photographic in quality, revealing the actual memory of the traumatic event, but more often the imagery has an abstract structure with specific colors and shapes, in something resembling a surrealistic collage. Emotional energy is encoded in each of these specific sub-modalities of size, color, intensity, movement and texture. An intense emotion is likely to be encoded in intense colors, such as red and orange, and the imagery is likely to be large and close in the person's inner visual field, whereas neutral emotions are likely encoded in neutral colors, such as pale blue or white, and appear small and distant. The investigative dimension of mindfulness provides the best approach to uncover the detailed inner structure of the emotion and provide meaningful content. This is called the Structural Theory of Emotions, which goes on to propose that by changing the structure of the imagery it is possible to change the intensity of the emotional reaction. Thus, if the color changes from intense red to soft yellow, and the imagery becomes smaller, it is very likely that the emotion will become much less intense. However, for this to work effectively the imagery must arise experientially from the emotional felt-sense, rather than be created through deliberate visualization. Similarly, the direction of change must arise experientially, rather than be imposed externally. This is why mindfulness is such an important part of the transformational process, because it allows the client to be exquisitely sensitive to what is meaningful and what is not.
A central focus in MMT is to uncover this internal structure of the traumatic memory and then to investigate this experiential content. There is no attempt to interpret what arises, only to experience fully and know completely whatever arises. This process essentially de-constructs the emotional complex into smaller parts that the psyche can digest and integrate into more stable configurations that do not continue to generate emotional suffering. Of course, this requires considerable preliminary preparation so that the client can experience the internal imagery without becoming overwhelmed. Therefore, the preliminary phase of MMT is focussed on establishing the Mindfulness Based Relationship (MBR) in which there is sufficient stability and non-reactivity to allow the imagery to unfold into present awareness. There are many approaches to achieve the right MBR, such as watching the imagery as if projected on a screen or placing the imagery at some distance in front. Through mindfulness and careful investigation, the client can discover for himself what works best for establishing the MBR. However, once a client begins to witness specific details about the imagery, he inevitably finds it much easier to observe the imagery without becoming reactive, because the specific structural details give him a specific focus and this tends to prevent hyper-reactivity. The MBR is an essential part of the transformation process for many reasons, the primary reason being that it allows the compacted emotional complex to unfold into more manageable parts. At another level, the MBR allows the client to fundamentally change the way that he relates to his inner emotional experience and he begins to break free from seeing himself as a victim of the emotional trauma. This in itself is an essential requirement for change.
In a relatively short time, the client begins to discover the detailed internal structure of the trauma and associated emotions in the form of experiential imagery. Now he or she can begin to investigate what changes need to happen in the imagery that allow the emotion to resolve. Mindfulness helps this transformational process by creating a therapeutic space in which there is no interference from the ego. The client begins to discover intuitive changes that can be very subtle and beyond rational deduction, but are clearly felt to make a difference. Experiential imagery frequently differentiates into parts, often with different colors and textures and the internal interaction of these parts can be very important for resolution. One client described her anxiety as a black pulsating blob, located on the upper left of her inner visual field that sent tentacles out to her throat, literally strangling her. As she focused mindfulness on this black blob, I asked her what needed to happen next. To her complete surprise, the answer that came up was that the black blob wanted to be allowed to die. It was strangling her to get her attention! Eventually, through continued presence and complete attention to the black blob, it felt sufficiently reassured that it could let go of her throat and proceeded to die. It became white and brittle like ash and crumbled into a small pile on the ground.
One could spend many hours trying to interpret and understand this process, but what was much more important, was her direct experience of the resolution process at the subtle and concrete level of experiential imagery and this is made possible by mindfulness, the sensitive attention to detail and the investigation of the deep structure of experience.
Throughout the whole process of MMT, the client is repeatedly exposed to the source of his or her fear, but in new ways that don't involve being emotionally overwhelmed. This exposure desensitization effect is regarded by most schools of psychotherapy as an essential part of overcoming PTSD and Mindfulness Meditation Therapy provides a very subtle and specific way of doing this through the client's internal experiential imagery. As always, it is what you don't see that runs your life, and therefore the more aware you become of the actual visual structure of you emotions, the more choice and freedom you have. It is not, and this is surprising to many people, the traumatic memory that is the problem, but the unawareness of the detailed inner structure of the trauma as it represents itself in your mind. Once you begin to see what is actually there, the process of healing can be surprisingly quick. Most of the suffering is actually a product of our not seeing the memory and of becoming dissociated from it. Then we generate fear of the unknown, the memory that must not be re-visited and must be avoided at all cost, This inner story and belief system keeps the trauma imprisoned within our mind and body. Mindfulness allows us to penetrate the illusory world of the shadow to see that actually the shadow of the unmentionable monster cast on the dimly lit wall is little more than a frightened mouse.
Healing occurs as we turn towards our inner trauma with mindfulness and compassion, a gentleness of mind that wants to be present and wants to heal. In this inner space of mind, trauma will heal itself.