[Neurosis And Human Growth Epub 35
Luther Lazaro
In Neurosis and Human Growth, Dr. Horney discusses the neurotic process as a special form of the human development, the antithesis of healthy growth. She unfolds the different stages of this situation, describing neurotic claims, the tyranny or inner dictates and the neurotic's solutions for relieving the tensions of conflict in such emotional attitudes as domination, self-effacement, dependency, or resignation. Throughout, she outlines with penetrating insight the forces that work for and against the person's realization of his or her potentialities.
In Neurosis and Human Growth, Dr. Horney discusses the neurotic process as a special form of the human development, the antithesis of healthy growth. She unfolds the different stages of this situation, describing neurotic claims, the tyranny or inner dictates and the neurotic's solutions for relieving the tensions of conflict in such emotional attitudes as domination, self-effacement, dependency, or resignation. Throughout, she outlines with penetrating insight the forces that work for and against the person's realization of his or her potentialities.
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While treatment guidelines agree on the first-line interventions for the treatment of posttraumatic stress disorder (PTSD), there is an ongoing debate between experts regarding the treatment of complex posttraumatic stress disorder (C-PTSD). As scientific research is slowly emerging, different treatment approaches are used in clinical practice This article aims to provide a set of treatment options for C-PTSD in adult survivors of repeated exposure to severe violence and abuse, both in childhood and later on in life. The developmental-contextual perspective on mental health forms the basis of this approach. This perspective is elaborated using the tree metaphor. Then, several treatment strategies are suggested. The presented strategies are a combination of the existing evidence-based approaches for the treatment of PTSD and personality disorders. They target psychological damage in survivors while taking their developmental trajectories and ecological environments into consideration. The treatment model presented is based on longstanding clinical practice and it may be a promising framework for treating C-PTSD. However, it still needs to be scientifically examined for acceptability and effectiveness.
PTSD is a diagnostic entity characterized by the core symptoms of re-experiencing, avoidance/numbing, and hyper-arousal/sense of threat. C-PTSD includes the same core symptoms in conjunction with the disturbances in self-regulatory capacities, like emotion regulation difficulties, disruptions in relational capabilities, alterations in attention and consciousness (e.g., dissociation), adversely affected belief systems, and somatic distress and disorganization (1). C-PTSD is assumed to occur after exposure to severe, prolonged, or repeated stressors, like in survivors of childhood neglect, physical and sexual abuse, domestic violence, sex trafficking, exposure to torture, genocide, or other forms of organized violence.
In the past two decades, we have witnessed a proliferation of meta-analytic studies of psychological treatments for PTSD. These studies show that cognitive behavior therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR) are efficacious in alleviating symptoms in the short term (2, 3). EMDR is suggested to be more efficient than TF-CBT in reducing PTSD symptoms and anxiety (4). Another recent study has found that prolonged exposure (PE) and cognitive processing therapy (CPT) are equally effective (5). According to international guidelines, TF-CBT and EMDR are the first-line treatment interventions (6). More recently, written exposure therapy and narrative exposure therapy (NET) have also been recommended. They were associated with a lower dropout risk, compared to TF-CBT and EMDR, but less efficacious (7).
Regarding the treatment duration, there is enough evidence indicating that patients with complex mental disorders are unlikely to respond to short-term treatments (15). It is believed that patients who were exposed to a combination of repeated childhood traumas with additional traumatic experiences in adulthood will suffer from more pervasive impacts. They may need treatment approaches lasting longer and being different from those efficaciously applied in acute PTSD samples (16).
The unimodal approach, like the EMDR therapy, is suggested to last a much shorter time. A format of 8 days combining EMDR (8 sessions of 90 minutes), imaginal and in vivo exposure (8 sessions of 90 minutes) with physical activity, psychoeducation, and supportive interventions offered upon indication in between sessions, has been studied. It has sorted clinically meaningful effects (12) in most participants presenting with a variety of trauma histories and multiple comorbidities. However, the sustainability of both approaches in the long-term (longer than 6 to 12 months posttreatment) has been insufficiently examined.
The C-PTSD treatment strategy presented in this article is based on clinical experience only. We suggest a combination of the existing evidence-based approaches for the treatment of PTSD and personality disorders and plead for therapeutic pluralism, instead of therapeutic sectarianism. We also argue that understanding of, and intervening in the dynamic relationship between survivors and their ecological environments will improve efficacy of the trauma therapy.
American psychoanalyst Karin Horney (17) stated that humans have an innate potential for growth. According to her, therapy does nothing but remove obstacles to growth and enable humans to mature and realize their potential.
We imagine the genetic potential of a human being as a tree seed. A seed grows well if it has an intact genetic code. Moreover, it should be planted in fertile soil with sufficient nutrients and water. It develops roots anchoring a future tree in soil and starts growing above ground into a sprout. Then, sunlight and unpolluted air become essential for its further development. To expand freely, a tree also needs sufficient space, both under and above ground. A tree trunk with branches and leaves emerges, but the roots of a strong and resilient tree are always larger than a crown. All the essential ingredients for tree growth mentioned, are an analogy for epigenetic factors in human development.
In a favorable ecological environment, a tree starts using its resources and capabilities to develop further. Tree leaves make food through the process of photosynthesis. They use energy from sunlight, water, and carbon dioxide to create glucose, essential for tree growth. A mature and healthy tree is genuinely rooted in and intertwined with its ecosystem. Through photosynthesis, leaves produce not only food for a tree but also oxygen necessary for the survival of other species.
A tree also evolves various mechanisms to cope with environmental stressors. It may develop wider root systems to access enough water and nutrients and become more stable against strong winds. It may shed leaves during periods of extreme heat to reduce water loss through transpiration, or enter a state of dormancy during winter and conserve energy until conditions improve. This way, a tree can live for many years and survive in challenging environments, unless a powerful tornado or a flash of lightning strikes it.
A tree does not grow fast. It needs time to mature and become robust enough to respond to environmental stressors. At times, a young tree trunk needs to be assisted in development. Scaffolding should be built around it to prevent it from inclining and help it grow upright.
If a tree, whether a young or an old one, is moved from one place to another, to a different ecological context, it may suffer, dry up, and die. Or it just may be shaken and tormented, but survive. Sometimes, a tree will become stronger and grow better in changed and improved conditions. Migratory processes are always a challenge, both for trees and for humans.
We have coined this metaphor believing that it appropriately mirrors the relationship between an individual and context, its ecological surroundings. This relationship is bidirectional, nonlinear, and fluctuates throughout time. Like trees, humans often start suffering from psychopathology upon cumulation of potentially traumatic experiences over time, when their resilience capacities are worn out, and their environmental resources are weakened. They will recover only upon re-establishing a balance between sources of resilience and stress within their ecological environment (18) (Figure 1).
The process of photosynthesis may also be compromised. Think of a child developing into an adult and facing obstacles in rounding up education and starting to work, building a family, getting firmly rooted in (sub)culture, developing interests in religion and spirituality, becoming socially and politically engaged, and contributing to society.
Examining personal history on a content level helps build a therapeutic alliance with a trauma survivor. Throughout several initial hourly sessions, this alliance receives its foundation blocks. Inquiring into personal history in a curious, respectful, and humble way, creating thereby an opportunity for survivors to express feelings and share memories, helps establish trust in a therapeutic relationship. Safety, transparency, confidentiality, genuineness, positive unconditional regard, and spontaneity are the other essential ingredients that must be established. Patients should experience disclosure as a vehicle for healing psychological wounds, and clinician needs to develop accurate empathy and learn to see the world as a patient sees it. Research suggests that therapeutic alliance is the most critical ingredient of healing encounters and the best predictor of treatment success (23), more so than a therapeutic approach applied.
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