I will introduce this question from a clinical case that I had to treat.
Marco is a 30 year old young man. He comes to consult for psychological help. He is desesperate. He says that 6 months ago, returning from a football match with two friends, he was hit by a car that was passing him despite a double line. His two friends were killed and he survived.
From that moment, his life was turned upside down. Every day he relives this accident. He remembers the scattered pieces of metal, the smell of the car that caught fire, the terrible noise of the impact. He has flashbacks and has nightmares at night.
He says his life has been divided: there is life before and life after. What he experienced is exactly the meaning of the Greek word trauma which means injury. It is an experience of the past which returns to its present. Marco tries to forget what happened but as Montaigne said, "there is nothing that sticks in the memory more than the desire to forget it" and the more Marco tries not to think, the more the memories come back.
He also helps himself in other ways: he has stopped driving and is avoiding all roads that could lead him back to the scene of the accident.
Marco continues to talk about what happened to his family and loved ones ; he knows it's not his fault but he's afraid of being a little guilty. He says "I couldn't have done otherwise" and everyone nods and reassures him. Even the families of his friends who died in the accident reassure him, which makes him feel better at the time but leads him to ask for more reassurance.
Marco shows the basic mechanisms of controlling one's own thoughts which further fix the memory. Thinking about not thinking makes you think more.
As in all trauma-related situations: the more he avoids, the more he confirms that he is no longer able to do what he was doing before .
As for reassurance, the more it works in the moment, the more the person, in this case Marco, becomes dependent and makes the trauma ever more present.
The therapist has to deal with a situation of someone who urgently needs help , a person who needs to be understood and firmly guided in order to overcome the trauma.
The relationship must be warm: "I understand very well" but at the same time, the patient must be aware that he has an expert in front of him who can help him.
I told Marco that I understood him and understood what he was going through and that it was all normal. I also told him that it was possible to solve his problem but that I had to ask him to do something difficult and painful to prepare him to accept.
1st prescription: the "trauma novel"
I asked him to take time each day to recount, on a sheet of paper, the traumatic event in its smallest details, all the sensations experienced, all the most terrible things he had in mind....
And repeat the same exercise every day. Once finished, put the paper in an envelope and bring me the whole "trauma novel" at the next session.
Marco's reaction was: "I can't, I don't want to think about it".
The attitude of the therapist in front of this type of refusal must be flexibility, reception, a metaphorical communication, sufficiently evocative to make the patient accept the prescription.
In this regard, I told him that his wound during this period of 6 months had become infected, that it was full of pus and that the only solution to cure was the use of a scalpel. If I knew of a less aggressive way, of course I would use it, but I insisted there was none.
2nd prescription: the "conjuration of silence"
I told him that continuing to talk to his loved ones to reassure himself was like water with fertilizer that one pours on a plant to stimulate its growth. Instead of communicating with everyone around him, Marco would have had better write his trauma novel earlier.
Marco came back in the second session with a more relaxed face; he gave me his trauma novel. He pointed out that the first days the exercise had been really terrible, that he had been overwhelmed, but that from the 3rd day, his memories came back less, that he wrote more detached and that at the same time, the the fact of not talking about it around him had freed him. He added that it had occurred to him to drive.
The prescription mechanism
Writing the trauma novel has psycho-physiological effects. This externalizes the images and blocks the attempt at a dysfunctional solution of trying at all costs to forget.
Writing has a cerebral function which is to move from short or medium term memories to long term memories. This phenomenon does not start with speech but with writing.
Writing allows memories to be transferred to the archives of the past.
While we write, we get used to the memory, we detach ourselves from emotions (fear, anger...). This is how the trauma moves into the past and promotes healing.
I asked him to do the novel if necessary, if for example the memories came back spontaneously in order to archive them definitively in the past.
Help Marco to start living again.
3rd prescription: the "as if"
I asked him to ask himself the following question every morning: what would I do differently if I had completely overcome this problem? and I recommended that he choose an answer with the least ambition.
We had 4 more sessions and I followed him as he recovered all his life. He no longer used the trauma novel and started living again.
Conclusion :
I will conclude by quoting an aphorism from Robert Frost "the best way out is to push through and move on". Going through the trauma, going through it and getting out of it, these are the essential clinical steps.
We record an efficiency of 95% in the resolution of trauma. The 5% of unresolved cases are because the therapist failed to get the patient to accept the prescription.
