Shakespeare's Hamlet, the source of the quote above seems prophetic and deeply disturbed by the prospect of dreaming, suggesting latent fears about his unconscious state. Indeed, dreams can be frightful or benign, revealing or enigmatic but they have an entirely greater potential as I discovered in a book I recently mentioned by Bessel van der Kolk, The Body Keeps the Score. It is not light reading, which comes as a bit of surprise considering its long run on best seller lists. As a reminder, van der Kolk is a psychiatrist, researcher and champion of previously unknown or disregarded approaches to the treatment of trauma.
Among many alternative approaches to PTSD --and all traumas, whether of a violent, sexual, or emotional origin, is one that has some fascinating implications regarding sleep, dreams, and what is known as REM, or rapid eye movement. But before I delve into the substance, a little background is necessary.
For nearly 150 years the practice of psychiatry has focused on one of two principal therapies to address disorders of the mind, Psychoanalysis, a form of talk therapy famously introduced by Sigmund Freud in the late 1800's, and CBT, Cognitive Behavioral Therapy introduced in the 1960's by Aaron Beck. CBT is a form of talk therapy that seeks to reconfigure habituated negative thought patterns that affect mood and behavior.
While these approaches are the standard bearers for therapy both on their own and in conjunction with medication, increasing evidence points to their middling success in the treatment of trauma. Drugs can mediate the emotional intensity of trauma, but they do nothing to address the underlying causes. Talk therapy, regardless of which approach is employed, is equally limited because it depends on a patient's ability to surface and describe the cause of their distress. Many, if not most individuals suffering from trauma are unable to do so--in fact they may not be able to consciously say what caused their condition and attempts to recreate those memories elicit a powerful fight or flight response--emotional outbursts, rage, or a complete shutdown.
Various alternative approaches to severe trauma, and especially PTSD have sought to engage patients' bodies as a doorway to their mind through mindfulness, meditation, yoga, dance, music, Quindong or Tai Chi and other physically grounding and breathing exercises with varying degrees of success. However, in 1987, and quite by serendipity, Dr. Francine Shapiro discovered a form of therapy that has had pronounced success in the treatment of trauma, EMDR, Eye Movement Desensitization and Reprocessing.
While walking in the park one day, absorbed in some disturbing memories of her own, Dr. Shapiro observed that her attention was diverted by the sights around her and the distress she had been feeling was moderated as a result. Through experimentation she discovered that saccadic eye movement, the rapid movement of the eyes that occurs when reading, watching sports or other fast moving visual stimuli had the same calming effect. Over time she developed a therapeutic approach that helped patients desensitize their distress allowing them to more objectively and safely describe the events leading to their trauma.
While today, following dozens of clinical trials, peer reviewed studies and mountains of empirical evidence EMDR is still considered a "non-evidence based treatment" by the American Psychological Association, the number of therapists worldwide who employ EMDR as part of an integrative practice is growing exponentially. But why does EMDR work?
In brief, the use of EMDR allows patients to enter a state in which they are able to access the memory of the events that led to their trauma recreate them, reprocess and integrate them in a less threatening context. Rather than seeing themselves as victims or co-instigators of the violence they experienced, patients are able to create an objective narrative that lets them move past their unconscious repression and otherwise inexplicable amnesia or rage.
Investigating the mechanisms at work in the brain during a reactive episode, Dr. Shapiro and other clinicians have theorized that the inducement of saccadic eye movement disrupts the fight or flight response initiated by the brain's built in 'smoke detector' the amygdala, and while in this state memory prompts can connect the conscious mind to the origins of the trauma.
Why this works still remains somewhat unclear, however, in much the same way a full understanding of the mechanisms behind certain drugs such as Prozac and other Serotonin Uptake Inhibitors is not fully understood. But there is no question that both work--though in very different ways and with very different outcomes. Medications can arrest some manifestations of trauma and PTSD, but they only work while they are being taken and when discontinued, the repressed memories continue to manifest. EMDR, on the other hand has demonstrated durable therapeutic results assisting countless patients to reintegrate their memories resulting in a coherent and healing resolution.
Perhaps the most fascinating aspect of this treatment is its relation to REM sleep. Scientists have known for some time that when we enter the phase known as rapid eye movement sleep, our breathing becomes faster and more irregular and it is during this phase that we dream. Why we enter into this state is not so well understood, however. Research suggests that dreams are the mind's tool for organizing memories and fitting them into coherence with our conscious thoughts. Dreams can be problem solving, metaphoric or project deeply hidden fears and anxieties. Some trauma patients will even waken themselves during dreams that evoke a recreation of their trauma, short circuiting the brain's attempt to assemble a healing narrative.
It seems that Freud and others that suggested the dream state held the key to the hidden causes of emotional disorder were on to something, even if they missed the implications of its use as a curative mechanism. Dreams are powerful stories we tell ourselves. For most trauma patients the healing process only begins when they can give voice to the origins of their distress and EMDR seems able to facilitate a kind of waking dream state in which disturbing memories can be woven into the fabric of consciousness without triggering the traumatic response. To sleep perchance to dream, perchance to heal.
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