Chapter 6: Treatment

Nate told Mack, “Nursing, which I lead, manages the gestalt and milieu. We hand off the emotional part to the psychotherapy team of Sally and Calvin. We have sleep medicine specialists to get involved. Case management, with Janice, is a social work function that gets resources as needed. We find that they are some of the best at getting your social, as opposed to emotional, history.

Gestalt

“Gestalt and milieu are very entwined. With respect to sleep, both have relevant physical components. Our evaluators talked a lot with your colonel. The colonel told you that we would tune your physique and appearance. Actually, it’s broader than that. We believe in repeated developing physical skills as well. Do I remember your having an interest in martial arts?”

“Yes, I do.”

“Middlesex State College is near us, and variously provides us with instructors but also can make classes available. Once you’re approved for off-campus activities, I suggest you take a dance course that covers social dancing, but also dance as a means of improving flexibility and coordination. They also provide instructors for basic judo and tae kwon do. Some people might be surprised that we allow them, but the instruction hugely emphasizes self-control and meditation.”

“I like the idea.”

Gestalt therapy addresses the intellectual, physical, spiritual, and emotional. We’ll use exercises from all to strengthen you. Let me, though, address the emotional. Gestalt methods let us frame the emotional, but we have more effective methods to deal with emotional stress.

EMDR

Calvin, guided by Sally, took on the next part. “The most promising treatment method for cPTSD is EMDR and variants. Since your pathology isn’t only cPTSD, we need to work on several things in parallel. You’re 15 now. We absolutely need to go back to the aunt stuff when you were 10, and the lesser traumas of separation going back to 8 or so.

“Do you know much about EMDR?”

“Not really.”

“From the history, the therapist designates targets for EMDR: distressing memories, or current situations, which cause distress when emotional triggers are encountered. More distant memories often are the best place to start.

“The core EMDR techniques use bilateral stimulation, traditionally a physical method, such as visual interruptions or touching or buzzers in the hands, to interfere with the growing intensity of a flashback. A related Emotional Freedom Technique uses tapping. We have local researchers who are exploring other stimulation techniques, which perhaps will make the treatment less threatening. Bilateral stimulation can break up the negative recollections, but, conversely, they can reinforce good memories.

“Some people wonder why people can’t do EMDR to themselves. Once you have experience, you can to some extent.

“Before then, however, your therapist, above all, is there for safety. The method doesn’t work for everyone. As the therapist, I have to learn to recognize when you’re in distress, if you don’t recognize that yourself. Self-awareness training is a big part. You will be taught a variety of stress reduction methods, including going back to times where you felt creative and in control. It’s good that you keep a notebook with some of these methods, and how they worked for you.

“As we talk about triggering experiences, I will help you develop, around the stress trigger:

• A visual image -- a memory -- that triggers your thinking negatively about yourself

• Emotions, feelings, and sensations brought out by that trigger

• A positive belief that can overcome the negative.

“Once you have that last, rate its intensity, and the intensity of the negative feelings. You’ll then focus on the negative trigger, while I force reprocessing with bilateral stimuli.

“In standard EMDR, these stimuli might be eye movements, buzzers in the hand, tapping, or tones. We’re going to use stimuli of bonobo contact, or human ones derived from bonobo movements. These might be hugs, touching erogenous zones, stroking, or kissing. Just note what you spontaneously experience. Nate and Cheryl, would you demonstrate some generic bonobo lessening of tensions? We might very well have such activity, Mack, in the treatment room.”

Nate and Cheryl stood, smiled, and marched into a full-length body bump, not exactly a hug. Cheryl turned to Mack and said, “Around here, it’s always appropriate to ask for a hug, or bump. As we all gain experience, sometimes that will be calming sex.”

Calvin continued, “After each round, we’ll stop the recall and stimulation, encourage you to let your mind go blank, and see what comes up. Often, this will generate new and even more important triggers.

“I’ll decide, with your help, when to recycle an existing trigger, try a new one, or, if you’re distressed, help you cope with it. It’s not uncommon to lose track, and, if so, the therapist will help you focus.

“When you discover no distress from a trigger, we focus you on the positive belief, and try to use it for other negative things. You might find new things where it helps. If our bonobo hypotheses are correct, there may be sexual stimuli or acts that help banish negativity.

The therapeutic milieu

Janice told Mack, “Milieu therapy is a basic principle here at Moses. It involves the entire treatment team as well as the patient community, but it’s arguably led by nurses. Therapists go deeply when opportunities arise. Patients are constantly evaluated to find their strengths and weaknesses in all aspects of life. One might find that he feels stronger when hitting golf balls. Another might find herself weakened when tempted by desserts. The physical, intellectual and social aspects of the environment all contribute to the emotional atmosphere. This parallels gestalt theory.

“The more autonomy and open communications, the better. Immediate feedback is vital. If you think communications are inadequate, it’s often best to start discussing it with the nurses.”

Physical dimension

“The physical aspects of the treatment environment, according to one textbook, include all concrete features of the external world. These features include the organization, structure and interaction of many spatial components. The study of this interrelationship, called proxemics, is subdivided into three aspects: fixed feature space, semi fixed feature space and informal space. This is Evan’s area of specialization.

“You have physical dimension needs beyond psychiatric treatment.” Calvin said, “Medical treatments don’t neatly fall into the gestalt model, but I tend to put them here. Ideally, your sleep problems, especially your circadian rhythm disorder would be treated by timed bright light, the color temperature of sunshine, as well as melatonin. Part of your physical environment being light, and, where appropriate, room-darkening curtains. Music could help modulate physiological rhythms. More of a strict medical model, if you continue to need stimulants for excessive daytime sleepiness, you’ll get them. You will also continue to get sleep lab tests so we better understand the physiology of your sleep.”

Mack commented, “I’ve studied a good deal about sleep medicine, and concluded mine sucks. Mind you, I’m told being sucked, competently, is a sublime pleasure, so that might not be the best descriptor.”

Calvin guffawed. “Concur on both your observations.”

Evan told him, “Mack, with your agreement, I’m going to transfer you from the hospital units to the research building. You’ll have a small apartment that we’ll use as a tool for your physical gestalt. There are other facilities in the building, and you’ll still interact with other patients, especially your schoolmates. Don’t be ostentatious about your living arrangement.”

Social dimension

Evan continued, “In the milieu model generally, psychiatric nurses can observe the interaction of the members of the therapeutic community and help organize these into a more effective social system. Such as system has leaders and facilitators, characteristic communications patterns, and enough caregivers so clients are confident they will be heard.

“In our research program, you’ll have direct interaction with the researchers, and with patients that are just as much part of the program as are the formal researchers. The bonobo model that we use includes constant nonverbal and verbal communication. If you don’t think you’re being heard, act on it immediately. That might mean that you need to get someone’s attention with a bonobo hug, touch, or grope.