I’ve been lowkey annoyed, as a therapist, with all this “Booker should go to therapy” comments because if he can’t tell the truth, psychotherapy won’t be any fucking good for him.
A huge part of talk therapy’s effectiveness is having an experience of being truly seen, of being able to be authentic and real with another human being and feeling their honest empathy and acceptance. If Booker has to lie and hide 90% of his life, the benefit is very limited.
So I’ve been thinking about what’s actually his issue, what’s actually wrong with him, what could be treated.
There’s a little bit of a gimme the Old Guard get, where if a normal human being encountered that much pain and stress—I’m talking physical pain and physiological stress—they would be a burned-out wreck. Their nervous system would just spend all its time pumping out pain signals. So already, their neural healing is as advanced as their other healing.
But if we’re assuming Booker’s incredible history of trauma and years of nihilism has still managed to etch itself onto his brain the way it might a mortal’s... I mean, one therapy is medication, and beyond your usual antidepressants there are experimental PTSD medications with promise, like MDMA (yes, the party drug). He could also try transcranial magnetic stimulation, which is administered over 20-30 treatments over a year (every two or three weeks).
But as for things Booker would consciously work at, there are two well-proven process therapies that don’t rely on talk because they target the physiological and emotional mechanisms of PTSD more than the cognitive ones.
One is biofeedback—here’s an informative video and an informative article. It basically means training your brain and body to react in a different and more controlled way, so that, for example, you’re able to calm down in response to an incipient panic attack, or able to focus on the positive in a stressful situation.
The other is EMDR—here’s an informative video and an informative article. In EMDR the therapist provides sensory stimuli that basically puts your brain into “debug” mode, and you practice going from a feeling of peace and stability, to accessing your traumatic memories, to finding new ways to deal with them, to going back to being okay enough to go back to your life. EMDR is rather unique because the client needs to talk very little; most of the work is done internally.
So those might be of use to Booker. And Quỳnh, if she ends up going too.
Have you heard of EMDR therapy? I’m starting it next week, and I’d never heard of it before. It seems like something writers in particular should be more aware of when writing about recovering trauma victims.
Yes! I’ve actually mentioned it in two posts so far:
Hi there - thanks for creating such a great and useful blog - you'll be seeing a lot of me! So my character lost their entire family from a plague age 12, then walked in on their dad's suicide, which has lead to intense PTSD that manifests as extreme outbursts of anger borne from anxiety, stress, and frustration, which wasn't dealt with until age 17. Is this realistic, and what kind of therapy would they have to help them overcome this and lead a normal life?
Next, as to possible treatments for PTSD…there are a lot. What works is gonna be dependent on your character.
The most popular (and so far, the overall most effective) kind for PTSD is currently cognitive behavioral therapy (CBT). CBT for PTSD lasts from 3-6ish months, but if your character has other, comorbid mental disorders, treatment can take years.
Some possible techniques include:
Cognitive therapy:
In cognitive therapy, your therapist helps you understand and change how you think about your trauma and its aftermath. Your goal is to understand how certain thoughts about your trauma cause you stress and make your symptoms worse.
You will learn to identify thoughts about the world and yourself that are making you feel afraid or upset. With the help of your therapist, you will learn to replace these thoughts with more accurate and less distressing thoughts. You will also learn ways to cope with feelings such as anger, guilt, and fear.
After a traumatic event, you might blame yourself for things you couldn’t have changed. For example, a soldier may feel guilty about decisions he or she had to make during war. Cognitive therapy, a type of CBT, helps you understand that the traumatic event you lived through was not your fault.
Exposure therapy:
In exposure therapy your goal is to have less fear about your memories. It is based on the idea that people learn to fear thoughts, feelings, and situations that remind them of a past traumatic event.
By talking about your trauma repeatedly with a therapist, you’ll learn to get control of your thoughts and feelings about the trauma. You’ll learn that you do not have to be afraid of your memories. This may be hard at first. It might seem strange to think about stressful things on purpose. But over time, you’ll feel less overwhelmed.
With the help of your therapist, you can change how you react to the stressful memories. Talking in a place where you feel secure makes this easier.
You may focus on memories that are less upsetting before talking about worse ones. This is called “desensitization,” and it allows you to deal with bad memories a little bit at a time. Your therapist also may ask you to remember a lot of bad memories at once. This is called “flooding,” and it helps you learn not to feel overwhelmed.
You also may practice different ways to relax when you’re having a stressful memory. Breathing exercises are sometimes used for this.
Eye movement desensitization and reprocessing (EMDR):
While thinking of or talking about your memories, you’ll focus on other stimuli like eye movements, hand taps, and sounds. For example, your therapist will move his or her hand, and you’ll follow this movement with your eyes.
EMDR is a weird one, and we have no idea why it works. Typically therapists don’t use their hands anymore; instead, we have these LED light strips:
The lights move back and forth, and you follow them with your eyes while a therapist asks you about the trauma. In my opinion, EMDR is great for sci-fi / futuristic settings, as it’s such a strange concept but really pretty cool.
Medications are often used to supplement therapy. Antidepressants can help for the psychological symptoms, and sometimes sleeping pills are prescribed to help with trauma-induced nightmares.
Followers with PTSD, what treatments were effective for you?
(1/2) Hi! So slightly sensitive question here. Character A, a 25-year-old male is a victim of rape. He's been hospitalised before for severe PTSD (RTS?) but he declined hospitalisation and had to be brought home. Since he's still suffering, at the advice of a friend he decides to see a therapist. My questions are, 1) Would he be allowed to decide that he does not want to be hospitalised? He's not suicidal but he suffers from suicidal thoughts. He knows that he won't act upon it. He self harms.
(2/2) b) He was catatonic from depression and received one sitting of ETC for it, and that was when he decided to leave the hospital. He’s not catatonic anymore but he is unable to get out of the house without panicking. Would a therapist agree to visit in such a case? c) What kind of therapy should he receive in your opinion? I assume he needs a psychiatrist but I am more familiar with the drugs he could be prescribed, rather than his actual therapy. Could you help me there a little? Thank you!
First off, a few notes - RTS (rape trauma syndrome) is not a diagnosis in the DSM anymore. It’s an outdated term, and has been folded in with PTSD. And I think you mean ECT, not ETC, if you’re talking about electroconvulsive therapy
Okay, now for your questions!
Suicidal thoughts (or in fancy therapy terms, suicidal ideation) do not necessitate hospitalization in and of themselves. Once he’s brought it up in therapy, the therapist will ask a lot more questions to gauge if your character is at imminent risk of committing suicide. Most importantly, the therapist would want to find out if your character has a plan for killing himself. If he does, does he have the means to do it?
If the answer to both of those things is yes, it is very likely that your character could be hospitalized involuntarily.
If the therapist is seriously concerned, but feels like they do not have the grounds to involuntarily hold him, they would likely suggest voluntarily checking themselves in to a hospital to get extra support. They would likely try to come up with a safety contract with him, and make sure his social support system is able to help when he needs it most.
Next question:
Yes, therapists do make home visits to clients with agoraphobia (which sounds like what your character has).
Third question:
It is frankly extremely odd to me that your character would have gotten ECT before ever being seen by a psychiatrist or already have gotten some kind of medication. ECT is a last resort, not a first one. Medications are the first response.
But yes, a psychiatrist would be extremely helpful to your character. However, he would also likely want to see a psychologist or a therapist as well. Psychiatrists are medical doctors that prescribe medications, and are much more expensive than therapists or psychologists.
As for what kind of actual therapy…hmm. You’ve got a couple options here!
Cognitive behavioral therapy (CBT) focuses on exploring relationships among a person’s thoughts, feelings and behaviors. During CBT a therapist will actively work with a person to uncover unhealthy patterns of thought and how they may be causing self-destructive behaviors and beliefs. By addressing these patterns, the person and therapist can work together to develop constructive ways of thinking that will produce healthier behaviors and beliefs.
For instance, CBT can help someone replace thoughts that lead to low self-esteem (“I can’t do anything right”) with positive expectations (“I can do this most of the time, based on my prior experiences”). The core principles of CBT are identifying negative or false beliefs and testing or restructuring them.
Oftentimes someone being treated with CBT will have homework in between sessions where they practice replacing negative thoughts with with more realistic thoughts based on prior experiences or record their negative thoughts in a journal.
Alternatively / supplementally, he could do some Exposure Therapy
Exposure therapy is a type of cognitive behavioral therapy that is most frequently used to treat obsessive-compulsive disorder, posttraumatic stress disorder and phobias. During treatment, a person works with a therapist to identify the triggers of their anxiety and learn techniques to avoid performing rituals or becoming anxious when they are exposed to them. The person then confronts whatever triggers them in a controlled environment where they can safely practice implementing these strategies. There are two methods of exposure therapy. One presents a large amount of the triggering stimulus all at once (“flooding”) and the other presents small amounts first and escalates over time (“desensitization”). Both help the person learn how to cope with what triggers their anxiety so they can apply it to their everyday life.
So in your character’s case, that would start with the therapist being with him as he takes a few steps outside his house, then progresses to a bit farther (maybe to the end of his driveway), etc.
There’s another really interesting thing that could help with his PTSD!
Eye movement desensitization and reprocessing therapy (EMDR) is used to treat PTSD. A number of studies have shown it can reduce the emotional distress resulting from traumatic memories. EMDR replaces negative emotional reactions to difficult memories with less-charged or positive reactions or beliefs. Performing a series of back and forth, repetitive eye movements for 20-30 seconds can help individuals change these emotional reactions. Therapists refer to this protocol as “dual stimulation.” During the therapy, an individual stimulates the brain with back and forth eye movements (or specific sequences of tapping or musical tones). Simultaneously, the individual stimulates memories by recalling a traumatic event. There is controversy about EMDR—and whether the benefit is from the exposure inherent in the treatment or if movement is an essential aspect of the treatment.
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