“I wondered that too,” said Buck Hanson. “If it were that simple, you head doctors could be put out of business by bartenders and ladies of the night.”
“A rather quaint observation, Mr. Hanson,” Professor Hoffmeister sniffed, “But a cogent idea nevertheless.” Turning to Victor McGinnis, he asked, “Doctor, are not the dynamics of treating PTSD more complex than physical distraction and relaxation techniques?”
“Absolutely. But first, we have to stop the snowballing fear. In a millisecond, we can all come up with the most god-awful thoughts and images that can terrify us. We need first to gain some balance. It’s like trying to have a rooster fight with one leg tied behind your back.”
“Say again?” said Hanson.
“When you were a kid, didn’t you play the game of getting paired with a partner in a circle, each of you grabbing one of your legs behind you and then trying to bump the other out of the circle? The first one to lose their balance or get pushed out of the ring lost.”
“I truly did,” said Hanson, “And was pretty good at it.”
“When you’re dealing with a boogeyman, you have to get both feet on the ground first. Otherwise, it’s easy to get tipped over emotionally. So, the first step is to get ourselves balanced, like I tried to do with Geno. Then we can wrestle with our fears and emotional monsters on a more equal footing.”
“I’m not certain that I’m following you, Doctor,” Loren Hoffmeister said. “Are you saying that we should push all these upsetting thoughts out of our minds and focus only on our physical sensations?”
“Yeah, Doc,” said Hanson. “How in the world do you do that?”
McGinnis said, “It involves refocusing more than pushing. It’s not as difficult as you think. Follow the instructions similar to what I just gave to Geno. And practice.”
Hanson shook his head. “With all due respect, Doc, this sounds like a real stretch to me. I can’t imagine just thinking about your body will do much of anything. Especially since you’re talking here about a guy who slit a baby’s throat and has had screaming nightmares for years.”
McGinnis said, “Since this has piqued your interest, let me give you my quick lecture about fear and PTSD.”
Buck creased his forehead and gave a wry smile. “If this is going to be a medical lecture, could you keep it as close to English as possible?”
“I’ll give it a whirl,” said McGinnis. “We’ll see what you think.” He pushed back his chair, walked over to a flip chart near the wall opposite the one-way mirror, and picked up a felt-tip marker.
“Oh, oh,” said Buck.
“This won’t hurt,” said McGinnis. “I promise.”
“Then let her rip.”
McGinnis began. “When a person is traumatically shocked, by almost getting killed or having someone close to him placed in severe danger, he kicks into a “Fight-or-Flight” response. Alarm bells ring and his body mobilizes for trouble.”
McGinnis scrawled “ALARM” on the chart. “On a physiological level, that means all sorts of chemicals dump into his blood stream. Two of these natural chemicals, ACTH (or adrenocorticotropic hormone) and Beta-endorphins, are major players in the fear response and in its extinction.” He then drew two arrows coming from “ALARM”. At the end of one arrow he wrote “ACTH” and at the other he wrote “BETA ENDORPHIN.”
“Are you following me so far?” he asked.
“Keep writin’,” answered Buck.
“When the alarm bell rings, ACTH is pumped into your system, alerting your brain and body that big time danger is at hand. In humans, this typically starts a rapid chain of catastrophic thinking which can occur in milliseconds.”
Hoffmeister said, “Like ‘the sky is falling; the sky is falling’?”
“More like,” Geno interjected, “I’m in deep, deep shit.”
McGinnis chuckled. “Something like that. Once the alarms are sounded, our bodies go on red alert. If there is no danger, the beta-endorphins, the body’s own tranquilizers, which were secreted at the same time as the ACTH, linger longer in our system while the ACTH degrades more quickly. Within several minutes, if you don’t mess with the process by thinking all sorts of disastrous thoughts, the body returns back to a normal, homeostatic place.”
Hoffmeister shook his head. “You jest, of course. The PTSD process must be more complex than that. Why else would there be hundreds of thousands of people still suffering from this disorder if all they had to do was stop thinking negative thoughts and focus instead on their physiological processes?”
“The answer is learning,” replied McGinnis. He turned to the chart and wrote “LEARNING/CONDITIONING” in large letters. “We have billions of synaptic pathways established in our brains that have resulted from our attempts to survive. If we could look into your heads with an electron microscope, we could actually see where your brain has stored all this learned information. Like your multiplications tables, how you comb your hair and what it’s like to taste a sour lemon.”
“Some of this information is logically based, like numbers memorized in multiplication tables. But a lot is emotionally based, like your grimaces and salivation in response to biting that sour lemon. The emotional information is what’s particularly relevant in dealing with PTSD.
McGinnis turned back from the chart and looked at the group. “Think about it. Think about the years of experiences you’ve had in dealing with emotional monsters and things that go bump in the night.” But understand: only a small portion of our brain is logically driven. Most of that three pound mass of gray matter sitting on our shoulders is controlled by primitive, emotional processes that do not follow logic.”
“Whoa, Doc. Let’s walk a little slower here,” said a glassy-eyed Hanson.
“Buck, if I asked you to raise your right hand, you could do so. Easily and without much reflection. However, if I asked you to raise your heart rate by ten points, you’d be out of luck if all you did was think about it. If, however, you imagined a grizzly bear chasing you, your heart rate might jump up very quickly indeed.”
“Yep, but—?”
“So, your more primitive, reptilian brain responds to a wide variety of threats, whether we put that threat into words or not. Our alarm system has developed well beyond the verbal. If you are frightened, your body does not pause for you to “put it all together” in words; it just reacts. Immediately. Knee-jerk response. It fights or flees. It doesn’t wait around to debate.”
“If I’m following you correctly, Dr. McGinnis,” said Hoffmeister, “you are saying that a PTSD response is an attempt, based on our learning history, to save us from some perceived danger?”
“Bingo.”
“And,” continued Hoffmeister, “treating PTSD is more than a logical, verbal process. It also entails focusing on the non-verbal portions of our brain that have encoded our perceived traumatic experiences. Getting at our distress images and irrational thoughts, so to speak.”
“Yes, Loren, and dealing with our thoughts stemming from these traumatic experiences.”
“Please excuse me, Dr. McGinnis, but I’ve not heard about this particular physical distraction technique you used with Mr. Molinari.” Eyes turned toward Sonya Layton, who had up until this point remained silent.
“It’s not in many textbooks. I picked it up at a workshop at a Montana Psychological Association meeting.” McGinnis then turned to the chart and wrote “FOCUS ON THE PHYSICAL SENSATIONS.”
“One researcher at the meeting proposed the idea that a patient’s anxiety, which might be viewed as a cluster of learned responses, could be partially extinguished by simply focusing on the physical sensations, rather than moving right away to the anxiety-stimulating thoughts themselves.”
Hoffmeister raised his hand. “Excuse me again, but this sounds somewhat like the relaxation training I was introduced to as a college student—closing my eyes, repeating mantras, and all that. I was a psychology major as an undergraduate, so I studied a variety of stress-reduction strategies.”
“My, Dr. Hoffmeister, you have quite a background in psychology,” Sonya said. “We only touched on these ideas in my graduate studies, most often in a history class, but they certainly impressed me as interesting.”
“Ah, how the vocabulary changes over the years, but the concepts remain so much the same. These ideas are more than interesting, Ms. Layton. Although appearing to be dated, these researchers still have something to offer in today’s market of mental health challenges. And American psychology certainly does not have a corner on the conceptual market. Eastern philosophies and religions have contributed to the mix through their rich understanding of the human mind, including transcendental meditation and a focus on the ‘now’. Dr. McGinnis seemed to be helping Mr. Molinari be in the present by focusing on his immediate sensations. A very Zen notion indeed. ”
“Slow down,” Geno Molinari interrupted, clearing his throat. “Things are getting too deep. My brain has already gone south. How about some plain talk that a Butte Wop can understand?”
“Sure, Geno,” McGinnis said. “But we‘ll review all this later and not get bogged down in details right now. The bottom line for our group is that we have some helpful strategies for treating anxiety, a fancy word for fear, and its subset, PTSD.”
“I sure hope so,” said Molinari.
“We’ll be working on your nightmares too, Geno. For now, thank you for having the courage to work with us.”
A soft knock at the door interrupted further discussion. McGinnis scooted his chair away from the table. “Excuse me while I check the door. Please continue our discussion and I’ll be right back.” He opened the door to a small woman with stringy black hair and thick glasses that wrapped around her narrow face and magnified eyes. An apologetic expression flitted back and forth across her forehead. Kathy Orvis, a first year psychology trainee from Missoula, fidgeted as she spoke.
“I’m so sorry for interrupting, Dr. McGinnis, but Dr. Fredericks sent me to tell you that he wants to speak with you immediately.”
“Is there anything wrong, Kathy?”
“I don’t know, Dr. McGinnis.”
McGinnis frowned. “You understand that therapy sessions are not to be interrupted.”
She looked down at the floor and shook her head. “I understand, sir.” Her face flushed.
“He didn’t give you any reason for disrupting this group?”
“No, sir.” She paused and then spoke low, in a confidential tone. “He used a few choice words in chewing out his secretary, for not giving you a phone message. Something about a phone call from the Attorney General’s Office.”
McGinnis’ expression tensed and then softened. “That’s okay, Kathy. I know what he’s referring to. It can wait until I finish with the group.”
“Oh, no, Dr. McGinnis! Dr. Fredericks made it real clear. He wants to see you in his office right now.”
“I’ll take it from here, Kathy.”
“I don’t think you understand, Dr. McGinnis.”
“I’m not following you.”
The nervous intern swallowed and blurted out, “You know how Dr. Fredericks can be. Particularly with the Hospital Review Board breathing down his neck. He’ll kill me if you don’t show up.”
McGinnis touched her shoulder, gave it a gentle squeeze, and she leaned toward him. Reaching toward her with both arms, he gave her a warm hug. “Don’t worry, Kathy. I’ll take care of this. You won’t get any flack.”
She paused and then pulled away from him with an awkward stumble backwards. Blushing with a weak smile, she turned to leave. “I hope so. I really hope so. Sorry again for interrupting your group.”
“No problem. Take care, now. See you in chart rounds tomorrow.” McGinnis shut the door and returned to his chair.
“Sorry for the break in our discussion. Back to the business at hand. Thanks again, Geno, for your hard work. Before we stop for today, however, I want to be sure that none of the group has any more questions or comments.”
Loren Hoffmeister raised his hand and was about to speak when there was a sharp knock at the door. Without waiting for a response, a short, slight, steely-eyed man poked his combed-over head around the door. His open collar and rolled-up shirt cuffs hinted at a relaxed demeanor, but his pursed lips and furrowed forehead spoke a different message.
“Dr. McGinnis, I need to see you. Right now.”
“My apologies, Dr. Fredericks. My group will be finishing shortly. I’ll be right with you.” Vic then nodded at Dr. Carlton Fredericks, the Director of the Department of Psychiatry and Behavioral, and was about ready to return to his group.
A surge of red rushed into Fredericks’ face as he shoved the door completely open. His eyes shriveled to slits as his voice bit off his words. “Dr. McGinnis, please. I need to have you come with me now. Let your interns wrap up this session.”
Dr. Fredericks’ icy command silenced all sound in the room except for the humming of the florescent lights. Hanson stared at his coffee cup ring on the conference table. Hoffmeister’s fingers pounced on a piece of lint on his shirt and began flicking it away. Geno Molinari rediscovered the cellophane wrapper around his Lucky Strikes and poked the pack further up his sleeve. Sonya and Brad exchanged puzzled glances.
Vic McGinnis rose to his feet, glaring at Fredericks. He turned to the group. “Ms. Layton and Mr. Metzger, will you take over? We’ll have our supervisory session at our usual time this afternoon. Until then, I’ll see you all next week.” Without further comment, he walked through the door, held it open for Dr. Fredericks, and swung it shut just short of a slam.
Fredericks was fuming in the hallway. “Damn it, Vic. When I tell you I want to see you now, I mean now!”
“I was just wrapping up our group discussion and was intending—.”
“Maybe you didn’t hear me. ‘Now’ means now!”
Vic McGinnis nodded.
“Do you understand, McGinnis?” Fredericks paused a moment, and then hissed, “The question I just asked requires a response!”
“I understand, Dr. Fredericks. I understand.”
“Enough talking in the hallway. We’ll continue this discussion in my office.”