Posttraumatic Disorders:  Redefining Posttraumatic Stress Disorder, Related Disorders 
                                                 and the Use of Patient Guided and Enhanced Eye
                                                 Movement Desensitization and Reprocessing (EMDR)

Summary
   Generally, humans are very resilient to extremely painful and dangerous events, loss of loved ones, etc. Posttraumatic symptoms including nightmares are usually temporary. Chronic PTSD and other trauma-related psychiatric disorders results from a conflict between reality and cultural expectations, rather than experiences of severe danger, pain and losses.  A culture-based judgment that an experience "must not occur" seems to block processing of memories and leads to psychiatric disorders. Sometimes a trauma could be processed but a second trauma occurs before the first was processed, and chronic problems develop. In a simple model, we may describe psychotherapy, including EMDR, as addressing the failure of mental processing, the patient's being stuck in cultural judgments and beliefs that prevent normal interactions of left hemisphere (which holds language, and cultural dictates) with other centers (mid brain nuclei and right hemisphere).

Introduction
   Confusion regarding the nature or essence of PTSD and other posttraumatic disorders remains a major problem, and it is not well understood why many patients do very poorly after a trauma and/or seem treatment resistant. Hidden secondary gain from PTSD symptoms are sometimes overlooked, but more importantly, a new understanding of the posttraumatic disorders and their therapies is needed.

   For the last two decades, eye movement desensitization and reprocessing (EMDR) has been used for the treatment of posttraumatic stress disorder (PTSD) and some other conditions, frequently with amazing results. However, mainstream psychiatry hardly considers EMDR a primary treatment for PTSD, even though studies finally seem to be acknowledged as valid. Part of the reluctance to utilize EMDR may be the fact that it does not primarily address patient behavior, but rather how patients feel and handle traumatic memories.  Therapists may also resist using a technique that is not a talk psychotherapy. Older psychotherapeutic techniques often include imagined and practiced exposure to situation that PTSD patients avoided. These may be similarly effective as EMDR for many patients, however, they often appear cruel and slow as compared to EMDR which gives rapid relief without major distress. It may also be argued that EMDR addresses the basic problems of PTSD more directly than forms of desensitization treatments.

   Most patients have complex problems and benefit from complex therapy, which may include cognitive, behavioral, suggestive and other techniques. However, cognitive and suggestive therapies do not need to address details of traumas and specific meaning for the patient. Cognitively, a belief in the flexibility of the mind and a reevaluation of broad beliefs is most important.  (Mental disorders are not defined by abnormal symptoms but by being stuck in those symptoms, or stuck in mental processes that cause them; therapy must strengthen the mind's flexibility and adaptability.)

Explanation of Stress, Chronic PTSD and Related Chronic Symptoms; Role of Culture
   Psychological stress¹ may be explained as response to novelty, i.e. a situation that is either new, or if not new, the person has not yet adjusted to it and does not feel ready for it. Stress is often perceived as positive or mixed. Negative stress or anxiety consists in lasting internal conflict, feeling pressure to but not being able to decide, not finding what is the best (or least bad) response.

   Normally, the human mind is extremely adaptable. All symptoms of mental disorders, anxiety with inability to make decision, panic, agitation, hopelessness, irrational fears, hallucinations, etc., are basically normal; the pathology consists in being 'stuck' in them.

   In most conflicts, if there is no obvious solution, the person should, after taking time to review available data, be able to follow intuition and conscience. Intuition efficiently evaluates much data, but most of the data is outside conscious awareness².  The person's conscience considers ethics and influences intuition. However, cultures teach values and virtues that often conflict with reality and with each other. Language and culture are full of judgments, which, if not followed, lead to guilt and depression.

   Particularly after the experience of traumatic events, thoughts may move into vicious cycles:  conflicts become bigger, decision-making becomes more difficult. With a heightened sense of uncertainty, minor objective dangers may lead to insolvable conflicts and to panic attacks, e.g. in a crowd, the patient may fear that a fire alarm leads to a stampede, that he/she stumbles and is trampled to death. The thought of having a heart attack may be a relief (much less painful than the slow death from being trampled and at the end being burned while still alive). The mind learns panic reactions (brain circuits that initiate a panic reaction get reinforced) and the response becomes more readily induced, often just by a frightening memory or thought. Generalized anxiety disorder is probably also largely the result of learned and generalized responses that originated from a traumatic experience, even though there appears to be a genetic component.

   Often, it is not obvious how chronic pain develops; naturally, the mind should tune down and most of the time ignore continuos and intermittent stimuli which have no longer meaning³. However, pain often has a meaning and may become chronic because of its function(s). Sometimes chronic pain syndromes appear posttraumatic, even when there are no other chronic PTSD symptoms.  Psychotherapy, with or without EMDR may be helpful⁴.

   Where traumas are frequent, most people appear to process the memories and later feel rather stronger because of the trauma⁵. The trauma may at first lead to many PTSD symptoms, such as general uncertainty and anxiety, nightmares, intrusive thoughts, and flash backs, but these eventually resolve to a large extent or completely without therapeutic intervention⁶. Naturally humans are extremely resilient regarding pain, fear, deaths of children and loved ones, etc. Such traumas were, and in many places still are, frequent and perceived as 'normal' or even to be expected.

   Definitions of 'trauma' are controversial. Powerlessness is hardly central since most people are, most of the time, powerless in most regards. Pain, fear of death and witnessing cruelties do not appear pivotal either: these have been common in cultures all over the world⁷. The victim's perception that an experience is negative and outside the range of customary and culturally accepted human experiences, is apparently much more important.  Examples:  Westerners being forced to eat raw, primitive animals; seemingly erratic cruel treatment by family and friends. Cultural expectations may lead normal experiences to become severely traumatic, e.g. being intellectually below average and not able to pass a difficult examination may lead to shame and dishonor, even causing people to commit suicide; the accidental discovery of masturbation and consequent urges may lead to severe guilt and fears. Cultures often exaggerate the perception of acute psychological traumas.

   Multiple traumas, particularly consequent traumas before previous ones are processed, may be a major cause of chronic psychiatric disorders. Traumatization in childhood has probably a poorer prognosis than later traumas, and later psychotherapy that includes EMDR may be less efficacious than in PTSD due to traumas in adulthood⁸ and vulnerability to chronic posttraumatic symptoms is considerably increased if there was significant early life stress⁹. However, many people with a history of severe, repeated traumas, although suffering from some adverse consequences, have later few PTSD symptoms. Bowen Theory suggests that a lower level of differentiation of self¹⁰ probably contributes to severity and chronicity of problems.

   The perception of being part of a family, clan or group and a culture are important. Culture gives people a sense of belonging and, if cultural mandates are obeyed, a feeling of being 'right' and 'good'¹¹. This perception of belonging promotes resilience and the strength to accept extraordinary pain and losses that are considered 'normal' within the culture. In addition, culture becomes part of people's identity. However, there is often a high cost to being part of one's culture.

   Cultural traditions are derived from and feel like instincts¹². They become "second nature." However, while failure of completing an instinctive behavior primarily leads to frustration, transgressions against cultural-traditional expectations lead to embarrassment, shame, guilt, disgust and/or other powerful negative emotions¹³. Additionally, people may severely aggress against individuals who fail culture or disregard traditions. Shame occurs when failing to live up to cultural expectations (whether person tries hard or not), particularly if the failure is observed by important persons. Guilt is a consequence of failing where a choice and free will is perceived, e.g. if a forbidden act was impulsively committed (people are supposed to be able to control impulses when recognizing what is 'right' and 'wrong'), when, because of fatigue or a conflict, a prescribed behavior was omitted (but the person was assumed to know its importance), or when a marginalized person may stop following cultural directives (such persons are considered "bad"). A child may also feel shame when parents refuse rituals, such as circumcision or Christian sacraments. Disgust is mostly perceived by victims and observers of transgressions e.g. when forced to eat food and follow rituals of an alien, as inferior perceived, culture.

   Shame, guilt, and disgust are not only a direct consequence of conflicts with cultural-traditional expectations, they are expected by members of a culture; people who feel ashamed, guilty, and disgusted are considered morally superior to people who do not or no longer experience these feelings and/or who do not express and show such feelings. To clear a family of shame and disgust, suicide, 'honor killing', or murder misrepresented as suicide may become the expected resolution.

   No longer being fully part of one's community contributes to a sense of abandonment with terror or horror.  Being completely ostracized and even considered dead by one's community shifts symptoms of shame and guilt to the sense of social isolation, not belonging, and being uprooted; to severe depression, and often to premature death.

   The root and essence of PTSD is a conflict with prevailing, local and/or personal culture. The patient feels shame, guilt, and/or disgust, leading to terror and a sense of no longer being fully accepted by society.  Psychological traumas without danger of physical injury may lead to PTSD, because they clash with cultural expectations, e.g. when a child is fondled by a relative who portrays himself as loving and is not threatening.  Often, conflicts concerning abuse include conflicts between self-respect and honesty versus maintaining family honor and loyalty. Conversely, intrusive and painful examinations and procedures involving sexual organs, even in children, do not lead to PTSD, if culturally approved, i.e. if the (medical) specialist is assumed to work within professional ethics. Experiencing or witnessing major danger and pain rarely lead to lasting posttraumatic symptoms, if considered "normal", e.g. in accidents, medical treatments or childbirth. PTSD in soldiers mostly occurs in wars which, according to the soldier's view, should not have been fought, at least not in the way he/she experienced it, and in war events that far surpass what is expected according to training and other learning¹⁴.

   Transgressions typically leading to PTSD within a culture, are severely punished, sometimes outside the legal system. Perpetrators of such crimes are particularly loathed, even within prisons.

   In PTSD, being outside cultural expectations usually includes a sense of unpredictability of the future and the victim may lose his/her trust in humanity, nature, spiritual-religious meaning, and/or protection by God. Terror may include an anticipation of further inconceivable victimizations, a sense that fear and pain are unbearable, without foreseeable end and without meaning, possibly recurring over and over. There is also a perception and/or the reality of becoming an outcast, being abandoned and rejected by family, clan, religious community, and society¹⁵. 

   Perception and interpretation of memories varies over time. When traumatized, a person may feel much support and functioning is culturally and pragmatically most important; going on with life may facilitate quick acceptance of events. Much later, there may be stress, temporary isolation and traumas that lead to phases of PTSD more related to the old than any new trauma.

   Shame, guilt, disgust, horror and terror may be sympathetically experienced even if not in danger and not directly witnessing events¹⁶. Hearing about extraordinary suffering, depictions and documentary reporting of violence and working therapeutically with victims may lead to some PTSD symptoms. Even realistic and historical novels, theater, movies and learning about the suffering of animals may lead to sympathetically caused PTSD symptoms. Tortures may include having to observe loved ones being abused or hearing others' screaming in pain.

   In posttraumatic disorders, there is at first overwhelming negative stress, then partial relief, but conflicts remain and victims often feel trapped in negative emotions. Chronic posttraumatic symptoms, such as nightmares, flashback experiences, other dissociative symptoms, feeling 'stuck' in negative emotions, etc. arise when experiences clash with cultural expectations, and the cultural expectations seemingly interfere with the processing of overwhelming negative stress.

   Culture and cultural morality, as expressed in folklore, religion and secular laws, seem closely associated with the language center in the left hemisphere; language itself is full of words that incorporate judgments. Judging events according to cultural standards and traditions often creates major conflicts which are insolvable. Mental processing appears to stop. The patient holds unprocessed, dissociated memory fragments, including images of places where acute or sympathetic pain was experienced, sense of being abandoned, shame, guilt, horror, and associated memories. These memories may be hard to access but are triggered by unpredictable stimuli. Acute, temporary symptoms are normal in any situation of extreme pain, fear, loss, sense of abandonment, etc., but if the experience can soon be accepted as accidental or, within the culture, essentially 'normal', symptoms usually resolve.

   Genetic factors probably contribute to the risk for developing PTSD. Vulnerability is increased with early life stress and victimizations, and if comparable experiences are repeated before the previous victimization was adequately processed. At least temporarily, people are also vulnerable to other anxiety disorders, including panic disorder and psychosomatic disorders. In a chronic state of conflict, the person feels bad and unable to enjoy normal activities. Posttraumatic stress symptoms often contribute to or cause chronic depressive, anxiety and psychosomatic pain disorders without fulfilling criteria of PTSD. Unhealthy lifestyle and poor quality of social interactions may be part cause, part result of chronic depression. Eye Movement Desensitization and Reprocessing (EMDR), cognitive and hypnotic techniques are generally helpful therapies.

   In addition to shame, guilt, and disgust, which are culturally and morally expected, there are negative emotions, which are considered morally wrong or sinful, particularly anger, rage, or hatred; haughtiness or vanity; and envy¹⁷. These are probably also related to psychological traumas. They reflect poor interpersonal relationships:  the person feels mistreated, hopeless and/or helpless, misunderstood, inferior, perceiving poverty, bad luck, lack of talents, etc. as grossly unjust, etc. They are usually not associated with typical PTSD symptoms, but they are characterized by continuous conflicts about the negative perceptions and feelings. The person usually feels 'stuck', similarly as in PTSD. EMDR may be helpful in such conflicts.

   Major traumas, personally or sympathetically experienced, lead to a permanently changed view and perception of the world. However, many victims eventually feel that they are better persons due to the experience and its processing, and PTSD symptoms become minimal and/or well controllable by the person. Rapidly reaching such an outcome is the primary goal of a treatment approach that includes educational cognitive therapy, EMDR, and possibly hypnotic treatment or the teaching of self-hypnosis.

Training of Therapists; Special Instructions
   Only therapists with considerable experience in different therapy approaches that may include behavioral, cognitive, and suggestive techniques should utilize EMDR and the proposed treatment approaches. EMDR, combined with suggestive techniques, should be used by therapists experienced with PTSD, hypnotic techniques and psychotherapy of patients with dissociative symptoms. Ideally, therapists personally experienced the benefits of EMDR in relieving very disturbing memories, they practice meditative and basic self-hypnotic techniques, and they are be able to teach meditative techniques¹⁸.

General Treatment Issues
   Sometimes patients have an obvious goal for relief of some form of suffering;  they come because they believe that change is possible and they appear ready to accept whatever it takes to improve. Otherwise, in all treatments, therapists may need to clarify that there is a positive, unambiguous goal that the patient considers essentially reachable. If reaching the goal causes some losses, issues of grief and lost secondary gain must be addressed. If there are secondary gain and/or other psychodynamic reasons for the patient to hold on to his/her pain, cognitive and/or psychodynamic treatment may be necessary. Models that explain the patients' problems and how they may be addressed, are usually helpful.

   The patient also needs to accept the flexibility of the mind and that seemingly fixed emotional reactions can change. The past influences but does not determine the future:  the brain or mind can change. Chronicity of pain and mental problems are usually self-fulfilling prophecies rather than due to physical abnormalities¹⁹.

   Goals are first clarified in a cognitive or mental process, then they may be evaluated by self-hypnotic techniques, i.e. the patient is taught to use relaxation and meditation techniques (general relaxation, autogenic training); then he/she is asked to imagine and visualize having reached the goal, first for a short time, then after having goal reached for an extended time. While visualizing the future, the patient is encouraged to go through whole days as imagined after the goal is reached. This technique is likely to bring the goal from rational/theoretical thinking to an emotional level. It is also likely to uncover hidden factors that interfere with the patient's progress.

   Eclectic psychotherapy may include EMDR and suggestive (hypnotic) techniques and there may be some overlap in the ways these two therapies work. Introduction to a hypnotic state may include watching a pendulum, inducing eye movements comparable to those achieved in EMDR, and the expectations of a patient who seeks an EMDR therapist may be compared to expectations in hypnotherapy. Both, EMDR and hypnosis benefit from a mental state that is open to major changes in perceptions. EMDR may have some placebo effect, however, it is highly unlikely that a placebo effect is a major component of EMDR's positive results since, in controlled medication studies, PTSD responded poorly to placebo.

Patient History and Diagnostic Considerations
   A general history of the patient's life, psychosocial development, and previous treatment is indicated in most patients. Often, the time of traumatic events helps sort out what chronic symptoms are likely related to traumas. Otherwise, the history may be rather cursory and the patient must not be pressured to give details of traumatic experiences he/she is not readily bringing up. A sense of being stuck in negative emotions may be the key symptom when considering EMDR. While taking a history some issues should be considered:

   Generally, EMDR is used after a detailed evaluation of the patients' traumas and their effect on the patients' perception of self, etc. For some patients with PTSD and related disorders, it is difficult or unbearable, to talk about their worst traumas, particularly details or aspects of the traumatic experiences that make them feel most ashamed, guilty, and terrified. They may be able to think about them, and they may spontaneously remember worst aspects while in therapy, but they feel unable to put them into spoken language, and they may be afraid to talk about them for many reasons.

   When we explain EMDR in a simple, meaningful model, it may seem to patients that it is not important for the therapist to know details of traumas. The patients are probably right. A patient may at first experiment with a lesser issue, without telling the therapist what he/she is thinking about; almost always, there is considerable subjective relief with only one short EMDR episode. EMDR-like relief of "stuck" negative feelings often occurs spontaneously, e.g. when walking or looking out a train window, with the eyes focusing on objects that appear on one side and moves to the other until they disappears. Painful memories become bearable and can be accepted.

   Memories of trauma may be inaccurate and disorganized. They may be (temporarily) lost, but probably only in case of primarily psychological trauma without major injury and pain. Extreme pain and/or fear of death leads generally to very firm, vivid memories, even if the pain itself is not remembered (colors, sounds, and emotions may be re-experienced in the patient's mind, when remembered and in flashbacks, but physical pain is not). In other words, people only remember that, at the time, they interpreted their perceptions as physical suffering. Dissociation may or may not occur; it appears most likely in primarily psychological and prolonged severe physical abuse (endorphin related? example:  experiencing oneself as looking down on victim while being sexually abused, perceiving pain as moderate to severe sensations without hurting, as if on morphine) and in acute and obvious threat to life (adrenaline related? example:  being in war, hyper-alert and fully aware of all details but not feeling that limb was severed, i.e. completely unaware of body while there should be extreme pain). However in torture, mistreatment with obviously no intent of (immediately) killing the victim, fear and stress may actually intensify and/or create pain; this even occurs in voluntary painful treatments, e.g. pain when dentist's drill only touches a gold crown. It is not certain whether knowing of accuracy of memories is important (essentially true versus false memories); however, details do not need to be known by the therapist. Probably much more important are  goals of treatment, and chronic negative emotions associated with and/or resulting from trauma.

   The time of the trauma or stage of processing is considered. When there are acute posttraumatic symptoms, the patient probably needs mostly affirmation of his/her humanness, i.e. affirmation that the patient still is essentially a complete, valued and valuable person, worthy of affection and caring. Caring and sensitive touch, eye contact, talking in a calm voice affirmingly, etc. may be helpful, but the supportive person has to be sensitive to the patient's state of mind, depending on the recent trauma. EMDR may be used to help establish and support a calm scene. Yoga or alternate nose breathing may be helpful. Alternating movements, such as self-hugging while tapping upper arms alternately, or asking the patients to follow back and forth movement with their eyes, as in EMDR, may be helpful, with no instructions what he/she is to think. In the early stages of psychotherapy, the trauma has to be acknowledged without any suggestion that the trauma was worse or less serious than perceived by the patient. Very short meditation may be explained as narrow mental focus (e.g. on breathing or essence of calm scene) and no judgment (sounds, perceptions, including pain, just are; person is to avoid thoughts of reasons, purpose or meaning).

   When asking questions about history and explaining PTSD, it is important to use proper language. If the patient self-abuses or self-injures, it must not be called self-mutilation, since mutilation, by definition, has the goal of disfiguring and/or impairing functions. The term survivor has been widely used in abuse victims. It may be comforting to patients who previously felt belittled, i.e. when there were suggestions that he/she was lying, exaggerating, hypochondriacal, hysterical, or malingering when trying to talk about a trauma and PTSD symptoms. Generally, the term survivor should probably be avoided unless the patient was in significant danger of death, e.g. if intended major injury or murder was part of the victimization; otherwise, the term "survivor" exaggerates the trauma, rather than putting it into perspective. Most patients are aware that there are many situations in life that seem, at least for a short time, life threatening or associated with a fear of losing one's mind, but later the person does not consider him/herself a survivor of an acutely life threatening situation (objectively, there is always a minor danger of an imminent catastrophic disease or accident).

   When talking with an abuse victim who feels guilty, it is important not to simply imply that the guilt belongs to the perpetrator, moving the PTSD victim to feeling stuck in anger and, possibly, vicious revenge thoughts. The therapist is to clarify that the perpetrator was wrong, not the victim, but being wrong must not be considered identical with guilty: causation is not equal with guilt and retribution is hardly helpful; executing the perpetrator does not relieve PTSD²⁰. This may be particularly important if the perpetrator is a close, even loved, relative. Furthermore, the perpetrator is also a victim who was failed by his family and society. Forgiving self and, usually at a much later stage, forgiving the perpetrator, and no longer seeing victimizations in moral terms, are important goals.

   PTSD related problems may be addressed, e.g. being unable to resolve anger and other negative emotions related to psychologically traumatic events, even if there are no typical PTSD symptoms. There appear to be psychodynamic and cultural reasons for such lasting negative emotions, e.g. a patient, whose father died prematurely due to incompetence of medics, probably felt that she would betray her father if she would let go of the anger and stop feeling depressed. A catholic who decided to have an abortion for good reasons may still hold on to guilt feelings (without other PTSD symptoms), believing she is a better person when feeling guilt than if simply acknowledging the reasons for her decision and the positive result (carrying pregnancy to terms and giving newborn up for adoption generally creates much more emotional pain and guilt).

Traumas and EMDR, Explained in Plain Terms (A Simplified Model):
   In the following, material in brackets [ ] may be omitted.

   When a person experiences severe fear, pain, shame, disgust, horror, terror, etc., there is a powerful stress reaction. The stress management system may be overwhelmed. [While memories are usually strengthened by positive reinforcements, such as finding good food or beauty,] extreme stress seems to ingrain specific memories as if edged permanently into the brain. At the same time, processing of data is disturbed: there seems to be a disruption of normal interaction between left hemisphere with midbrain and right hemisphere. [Basic brain functions include language, recognizing cause and effect and judging (mostly left hemisphere); calming, integrating and associative functions and sense of space and relationships (more right hemisphere); long-term declarative memory formation and input or memory screening functions (hypocampus and amygdala important); feelings, emotions, motivation, and state of consciousness (limbic system and areas in mid brain)].

   It appears that extreme stress leads to the loss of balance between the dominant and the non-dominant hemisphere:  between language, cognitions, moral functions, judging, feeling judged, vis-ˆ-vis calm, meditative state of mind, a sense of being in a place, being part of human relationships. Sometimes already during, but mostly after the trauma, there is often some dissociation, e.g., specific memories may appear separate from memories of associated events and feelings, or the sentient mind seems to leave the body. Later, the sense of insecurity, which should be related to specific environmental cues, is felt much of the time, even in an apparently safe and supportive environment. Physiologically, it appears that many important pathways between brain regions are blocked. Areas that handle memories show impaired functions. Areas where acute stress is expressed are not calmed.

   Explaining PTSD and EMDR further:  EMDR appears to adress inadequate interactions of the left hemisphere with the right hemisphere and mid brain. In clashes between culture and reality, interactions appear weakened or blocked.

   Language, cognitive knowledge, scientific and cultural notions including, most importantly, judgment, are almost exclusively located in the gray matter of the left hemisphere. When the neuroanatomist Jill Bolte Taylor, Ph.D. had a massive stroke that destroyed her language center, she was fully aware, observing the neurological changes and she had insight into the catastrophic loss of functions. She stated that it was like a migraine, but describes that, while losing more and more left hemisphere functions, she soon felt a growing sense of peace²¹.

   The with the language center associated "moral center" which guards cultural values and judgments, clashes, in PTSD, with the perception of reality and apparently prevents processing and growth. Naturally, humans are very resilient to pain, fear, losses, etc., when there are no conflicts. However conflicts are frequent, e.g. obeying moral mandates of loyalty and family honor may lead to conflicts that are not resolvable, unless one's culture is renounced. PTSD treatment includes changing and improving personal culture, rebelling against local and family culture, and bringing left and right hemispheres into harmony.

   The eye movements used in EMDR activate many mental pathways which are close to and probably interacting with the pathways that appear largely blocked²². Physiologically, the blocked pathways then become "loosened", and some seem to suddenly open up, creating communications within the mind that allow seeing stuck images and feelings from very different angles. There may be a feeling that traumatic experiences are processed instantly. [Whatever processing took place earlier was not recognizable because of chronic stress symptoms, but with EMDR, it may become apparent.]

   EMDR may also help to deepen insights, bringing them from an intellectual to an emotional level, (in the language of our culture, from the brain to the heart).  For instance, when patients know that they have no objective reason to feel guilty, ashamed, disgusted, dirty, etc., such insights may not help them until EMDR or another psychotherapeutic process has helped them to feel differently about the events.

   After explaining PTSD and related disorders, the goal of cognitive and emotional reinterpretation may be explained without asking the patient about his/her history of traumas. The patient is reminded that severe abuse and traumatizations are frequent but that most victims later feel that they became stronger people, mentally or psychically (or spiritually), wiser and more empathetic.

   What distinguishes people who do and do not develop chronic PTSD are cultural and personal expectations [and factors contributing to vulnerability]. However, these expectations can be reshaped or altered long after the event. Many trauma victims later learn that they were not alone, that many people were victimized in comparable ways, that the events were, within their society and given the circumstances, not extremely unusual and, possibly, even expected, even though regrettable and in some ways 'wrong'²³.

   In order to recognize their own resilience, patients may also recognize that events leading to PTSD are usually not the most dangerous and/or physically painful experiences in a person's life, e.g. being publicly shamed and humiliated versus severe physical punishment; being sodomized versus a motor bike accident; being fondled and/or raped without major physical violence versus major surgery or childbirth. Even when victimization was very severe and included major physical injuries, patients often recall incidents in which they experienced similar pain and fear of death without consequent PTSD symptoms. In other words, chronic PTSD is largely about failed cultural expectations as perceived later, and a major goal of treatment is to help patients change their perceptions and assumptions, to rebel against the cultural expectations that were instilled in them. With treatment, the victim of an unethical act must no longer believe he/she deserves to be seen as inferior; shame, guilt and disgust should ease and disappear.

   If the patient's culture (culture at large, family culture, consequent personally developed values, including personal religious beliefs) designates past events as absolutely unacceptable and against any reasonable expectation, the culture is wrong: the culture instilled expectations that could not be fulfilled²⁴. Cultures are wrong in making victims of human rights violations feel shame, guilt, disgust, and horror; and causing a patient to believe he/she is too bad, or too far removed from normalcy, to remain part of society. If patients feel guilty, they may strive to change guilt to regret, learn from it, and maybe make amends, at least symbolically. If patients feel shame, they should rebel against the notion that they became 'damaged' and inferior, no longer worthy of friendships, because of a failure or victimization. If an individual considers others guilty, he may learn to see them as victims who did not get the help they needed when young and in a bad place.

   PTSD-related symptoms, i.e. feeling stuck in negative emotions related to a trauma but without PTSD, may be addressed in a similar way. Such emotions include anger and guilt. Other negative emotions, e.g. envy, related to feelings of inferiority and shame, may, in the patient's mind, be unrelated to psychological traumas. There may be no specific memories of humiliation or similar experiences. In spite of that, EMDR should be considered.

Patient-Guided and Enhanced EMDR Procedure
   Patients with severe trauma histories may be reluctant or unable to talk about their memories without breaking down crying and feeling panic stricken, even if there has been an ongoing therapeutic relationship:  verbalizing past victimizations sometimes leads to a higher level of despair and/or details may still feel shameful. The patient should perceive the therapist as deeply empathetic. The therapist should never be perceived as mainly curious or as voyeur²⁵. The therapist may start with explanations, short meditation, establishing or reinforcing a calm scene and then EMDR without the therapist knowing the memories the patient feels ready to address. After EMDR, the patient may feel more comfortable and ready to talk about relevant memories.

   Ideally, EMDR is used in conjunction with ongoing psychotherapy or counseling, but may be used outside a context of ongoing psychotherapy in selected cases. Such cases would include a previous evaluation which indicates that the patient is generally quite stable and has a history of functioning fairly well, without episodes of psychosis, dissociation, suicidality, and/or self-injurious behaviors. Once trust is established, EMDR may also be the beginning of an ongoing therapeutic relationship (e.g. doing EMDR during initial evaluation of a patient with posttraumatic issues). In either case, the sense of a therapeutic relationship is very important even if developed during the first few minutes of seeing a new patient²⁶. Taking a short history and explaining PGE-EMDR partly functions to establish and/or strengthen this relationship.

   PGE-EMDR sessions generally last 45-60 minutes. However, sessions should not be scheduled at the end of the day or before the patient must hurry away, since EMDR may bring up memories that are unsettling to the patient. It may be safest if the patient has a resting time in the clinic after the session. In some cases the patient should be able to shortly see a counselor later that day for assurance, or be able to attend a group, as available. If unsettling memories come up, the patient should be able to set up a follow-up EMDR session within a few days, otherwise the next appointment may be scheduled weeks later.

   Before getting into traumatic memories the patient is to find a form of short (couple of minutes) meditation, i.e. establishing a narrow mental focus (e.g. observing own breathing; sense of heaviness and warmth starting with dominant hand and letting feeling spread; repeating few words or one sentence prayer over and over) while not judging anything (accepting noises, cold feet, and other perceptions; "things just are", avoiding thoughts of reasons, meaning). The patient should also have or establish a calm scene, a place where he/she feels safe or secure in self-sufficient way (i. e. not depending on strong friend for safety), still and serene. The calm scene may be reinforced by eye movements.

   The PTSD patient is then instructed to guide memories and imagery during EMDR herself. Before starting eye movements, s/he is asked to think of a most traumatic event that she often remembers, recognizing that, what s/he experienced was not only overwhelming, it was outside the expectations of her culture, including religious beliefs; it seemed as if s/he was abandoned by family, society, and/or God, or that fate and nature were against her. Even looking back at the event, it was much worse than what she and her society would have expected and considered tolerable in those circumstances. (It is not recommended that, in a first session, the patient tries to find a worst, more or less suppressed and much of the time seemingly forgotten memory.)

   S/he is then asked to shortly review the consequent general feelings, e.g. feeling abandoned, deeply humiliated, full of shame and guilt, worthless, dirty, permanently damaged, spiritually destroyed, degraded to a bitter and hateful disabled person, whatever applies.  S/he then must determine how she would like to feel about it, e.g. stronger and more empathetic, and set a goal of feeling good about herself, functioning well in spite of past victimizations.

   The patient is instructed that, during EMDR s/he may, while moving eyes, simply try to hold on to the chosen traumatic memories without any judgment, "the memories just are", not good, not bad. S/he may also make efforts to observe general feelings and keep in mind how s/he wants to feel about the memories and about her/himself.

   EMDR is done in the standard fashion, the therapist sitting diagonally to the patient, feet of the therapist parallel but opposite direction to the body of the patient, both having head directed straight, not towards each other. In other words, in a square, the patient sits in the NW corner looking South, the therapist sits in the SE corner looking North. Patient and therapist find a comfortable distance for the patient to focus on the therapist's hand in front of her face (therapist's arm is half extended). While the patient is instructed to keep her head directed straight ahead, he is to follow the therapist's hand:  the therapist moves the hand to each side of the patient. The therapist observes the patient's focusing while holding the head still and the therapist observes the patient's body language without making eye contact at any time. After a few slow moves, the therapist may speed up the movement, going back and forth to where the patient's eyes sweep about 30¡ to 40¡ right and left.

   While moving the hand back and forth, the therapist may first continue or repeat some simple instructions and/or suggestions and allow or encourage the patient to talk, if he feels like expressing what is felt or comes to mind. Otherwise it may be best to then become silent, except for saying "good" or making another positive short comment every few moves while the patient focuses well. The length of each EMDR episode is partly directed by changes in the patient's body language and facial expressions, partly by the therapist's intuition, and, in following episodes, by patient comments.

   Movements are first slow, avoiding dizziness or nausea in the patient. The therapist also observes whether the eye movements are smooth. Occasionally, an eye position is associated with where the patient looked during a trauma.  Probably more importantly, direction of eyes stimulates different parts of the brain.

   In-between sweeping lateral movements with the hand at a speed that the patient easily follows, the therapist halts the movement on each side for about 10-20 seconds, with or without right-left movements between halting right and left, and observes. Again, the patient is invited to talk or simply observe what happens while stopping gaze on one side²⁷. If eye movements are uneven, the movement may also be stopped at the place where the patient has difficulties to move smoothly. Talking in-between and during EMDR episodes may have a hypnotic quality.

   After stopping one or two EMDR episode(s), the patient may be asked about his level of comfort regarding the memories themselves, comparing at beginning of or before therapy session versus now; then possibly also about associated feelings (of shame, guilt, horror, etc.), about him/herself as a person in the present, etc., depending on where patient is at the time, and whether he would like to make a comment or ask a question.  (Sometimes, patients first report that rapid movements make them feel dizzy or nauseated.)

   Goals may be further elaborated and suggested in general terms in between episodes, they may include:

• Memories are no longer associated with guilt, shame, disgust, and horror. It was false expectations, created by culture, that led to maintaining the sense of permanent impairment due to the trauma(s).
• Feeling able to forgive self, other humans, God, fate, nature, etc.
• Feeling relative comfort about the memories as being clearly in the past, may be including the suggestion that the memories are as if in a drawer that can be opened and closed at will; and feeling that memories are no longer threatening or frightening.
• Feeling that patient could be empathetic and supportive, alleviating pain of person who just experienced very similar trauma at the same stage in life as the patient did. S/he could affirm that the victim is able to heal, is not permanently damaged and still a complete, valuable, good person. The patient would not become sympathetic to the point of severely suffering with the patient and becoming unable to be supportive. The patient can feel empathetic towards the young person he/she was, as we feel empathy when learning about somebody else's past abuse.
• Feeling good about him/herself; feeling whole, complete, valuable in spite of the remembered events.
• If a patient suffers from PTSD because he perpetrated against others while in an extreme condition, or s/he did not stop others from perpetrating cruel acts, s/he may recognize that the environment contributed much and that he can be forgiven and forgive her/himself, if learning form the event (not continuing a pattern of abuse or neglect) and working on make at least symbolic amends.
• If the patient suffers mostly from PTSD due to sympathetic reaction, i.e. without having been directly victimized, his/her goals include moving towards empathy where he/she could be truly supportive to the victims (patient may hope that he/she could handle similar victimizations without developing chronic PTSD).
• Feeling able to function in the world, going places where previously flashbacks occurred, working and being asset to family and society, (also possibly welcoming bad dreams as part of further of processing conflicts).
• Possibly feeling that re-victimization would not lead to relapse into chronic PTSD, the essence of his/her person and meaning in life would not be diminished.

   At the end of any session, the patient may be guided to his/her calm scene, possibly including suggestions of the autogenic training technique.

 
AppendIx:

Regarding culture:
   Cultures and cultural traditions developed very early in human history, and, to a very limited degree, even in non-human animals. Cultures modify natural behaviors. Some traditions are instrumental, e.g. tool use in chimpanzees:  traditions of nut cracking (only in West Africa) or termite fishing. Sometimes cultural expectations only demand a good performance of a normal instinctive behavior, requiring that less talented individuals practice intensely to reach a minimal standard.

   Human cultures developed complex traditions:  they typically exaggerate, suppress or modify (ritualize) instinctual behaviors, giving them a cultural stamp and distinguishing their culture from others. The traditions define a people, and became mandates. Cultures usually also exaggerate, suppress or modify differences between groups of people, particularly genders. Cultures usually define themselves as a people or nation, meaning that everybody is descended from a mythical parent (natio means birth). Cultural adaptation of behaviors resemble the development of instincts in disparate species (cultural pseudospeciation²⁸). It allowed people to live in many different environments, but often there are no specific adaptive functions to cultural traditions. They serve to distinguish themselves from others, making their own seem superior²⁹. Many cultural traditions are essentially cruel, irrational fads. Cultures also deal with frequently occurring conflicts, determining "moral" ways of dealing with them. Cultures also help people sublimate conflicts in games and art forms.

   Instincts are the basis of many feelings and traditional behaviors, however, cultures are extremely important in determining what is considered normal fear, pain and danger, and what constitutes abuse. In wars and law enforcement, much is considered proper by one, abusive by other cultures. More complex are situations within cultures, within families, where many cultures encouraged both empathetic and aggressive attitudes.

   In all cultures (actually throughout nature), females are at a disadvantage because they have a much larger investment in their offspring and are, consequently easier to exploit. Males may feel inferior because of their lack of reproductive potential. Basically, females can do anything males can but not vice versa. Furthermore, at least theoretically, males are rarely sure whether their mates' offspring is theirs. Probably due to these factors, typical male tasks are considered more important, are better paid and more celebrated than typical female accomplishments (this has been observed in all types of cultures throughout history).

   When observing cultural developments, there are often instinctive and cultural factors. Konrad Lorenz observed that in vertebrates, male sexual behavior is often combined with aggression, and female sexual behavior with fear. Usually, males are aggressive primarily towards other males when feeling sexual. In most vertebrates, males and females are attracted to each other but the female has to invite copulation, even though she does not know what the male will do or what copulation means for her.

   Typically, the male sex role includes an aspect of aggression, and humans are unusual in that males easily can force sex. Males often do not wait to be invited by their partner and males may get rather more aroused if a virgin bride is afraid; sympathy rarely stops sexual arousal. Conversely, in mature women, some fear may reinforce arousal. In many cultures the assumed weak and subservient role of females and the aggressive aspect of sex are grotesquely exaggerated, and cultures may persuade women that an empathetic male is effeminate.

   Similarly, children are naturally very dependent on adults, should obey and be respectful under all circumstances. Fears in general and at least the threat of physical punishments are considered normal and may strengthen the bond between children and parents. Children may also have to learn very early not to trust strangers and to defend themselves, essentially to assume that some people are bad, cruel and 'out to get them'. Cultures may train children to fight when insulted. Parents may instill fear in children by punishing them physically for behaviors that are normal in the child's developmental stage. Religious teachings, stories dealing with ghosts and spirits, and stories describing extreme adventures, hunts and warfare may teach children to deal with severe fears. These have often been replaced by graphic depictions of cruelties in children's TV programs, movies and video games.

   Physical, sexual and mental abuse are very relative and culture-bound terms. Obviously, we should move away from cultures that exaggerate aggressive instincts and discriminate against groups. But psychiatric treatment must first observe the culture of the patients, then help them see the human community more broadly and empathetically, and lastly work on improving their personal culture. Ethically a most basic issue is to be broadly empathetic and stop culturally reinforced "us-them" thinking, for example, people must never see themselves as "us males" versus "them females", or "us adults" versus "them juveniles", or "us Americans" versus "them immigrant-foreigners".

______________
1  Biologically, stress is defined as a significant response by an organism to a biological, chemical, physical or emotional factor (e.g. infection, poisoning, cold exposure, injury, acute pain, perceived danger, conflict). People generally like and enjoy stress, stress is usually mostly positive or mixed, e.g. starting a career, falling in love, starting a family. People anticipate that they can handle challenges and that instincts and experience will help with new problems. People also like acute negative stress that is quickly resolved, as, for instance, scary moments while skiing. Stress is perceived as negative when the novelty is negative, i.e. not meaningful and/or contradicting positive goals, when there are conflicting goals, and when the person sees no way out or cannot decide how to proceed. Pain always leads to a stress reactions:  impulses from peripheral nerves indicate potentially dangerous damage to tissue and there is a mental reaction, "screaming" that the sensation must stop, that it is not acceptable. The mental reaction is particularly strong if the pain seems meaningless or should not occur according to cultural expectations and values. However there is usually an immediate down-tuning of the intensity of pain along with some mental adjustments. Both, positive and negative stress are potentially dangerous and can lead to health problems such as peptic ulcers or heart attacks (particularly when they are prolonged).
2  Intuition results from the unconscious processing of innate data, many memories, projected outcomes of possible actions, and instinctual reactions and emotions that are associated with them. Rational explanations for a decision are mostly afterthoughts and hardly reflect what makes a decision or behavior feel right or good.
3  Examples:  people can learn to interpret swimming in ice cold water as refreshing rather than painful, people frequently tune out the sound of trains which sound like an approaching tornado, or dangerous smells, as in a refugee camp without sanitation. Other examples: mouth accustomed to hot foods and drinks (spicy and/or too hot to hold); people with limited income tolerating and eating with rotten teeth (which in the past would have been pulled). Many elderly people function well with slipped disks and collapsed vertebras.
4  A patient in her late twenties suffered from chronic severe pain in her genitalia, on touch and particularly during vaginal examinations and intercourse. She was previously diagnosed with "chronic vulvovaginites" (she suffered from the condition since adolescence, and she had her baby by C-section because of expectation of extreme pain in vulva). Listening to her history (and noting that urination did not hurt), I suggested that her brain was "wired wrong", that she never had reason to learn enjoying sex (first sex was very bad and male partners were abusive and/or non-caring). I then suggested that she could change her mind's interpretation of genital sensations. I advised her to very gently massage vulva with soothing oil, etc. A few weeks later she left town and developed a new relationship; she enjoyed sex. She made other changes in her life; the pain did not return. EMDR was not needed but her mind had to be freed from the belief that her pain was due to an incurable chronic medical disease.
5  Psychiatric Times, April 2004, p.58-60: "Posttraumatic Growth: A New Perspective on Psychotraumatology," by Richard G. Tedschi and Lawrence Calhoun
6  Dreams may be most important in processing traumas. Complex dreams may symbolically resolve psychological conflicts. Nightmares appear to be failed attempts to deal with conflicts: the person wakes up in the pinnacle of the allegory. The patient may be advised to support the spontaneous process of resolving trauma-related conflicts by thinking about the content of nightmares when awake; he/she may think of nightmares as first part of a surrealistic fairy tail about him/her.
7  Inhumane therapies, blatant ignoring of excruciating 'normal' pain, public tortures, warfare with ill-treatment of civilians, cruel initiations, etc. have been, and still are in many areas, widespread. When no longer acceptable in public, modern Westerners often entertain themselves with graphic depictions of cruelties and murder scenes in media and the internet. Books describing true crimes and wars are widely popular.
8  Clinical Psychiatry News, June 2004: "Psychotherapy May Offer More Benefits for PTSD," by Carl Sherman (quoting B. van der Kolk's presentation at the APA meeting); compare Bessel van der Kolks writings.
9  Psychiatric Annals, 1/2003, 33/1, p. 18-29: "Neurobiology of Early Life Stress," by Christine Heim, et al.
10  In simple ternms, differentiation of self may be described as being self-directed, having clear values, not being easily influenced by peers and group leaders, not overreacting emotionally to environmental factors.
11  Humans are probably unique in their  perceived need or urge to be 'right' or 'good' (even when not observed). Naturally, good and right are largely determined by social instincts, however, cultures with complex languages have greatly added to demands and mandates. A 'moral center' comparable to the language center has been proposed (Marc D. Hauser); this 'moral center' is most likely part of or an extension of the language center as languages are already full of judgment-containing words. The grammar of languages may follow and be a further development of a grammar of inborn social behaviors (Irenäus Eible-Eibesfeldt).  (personal interpretation of data and observations)
12  In complex ways, cultures exaggerate, negate or modify what is perceived as natural, and/or cultures guide sublimation or instinctual feelings and frustrations in symbolic and artistic expression.
13  Personal observation and interpretation of anthropological literature.
14  Personal experience in treatment of psychiatric patients.
   Some examples of traumatic situations that overwhelm the coping skills of the person and, according to conventional PTSD definitions, are expected to lead to chronic PTSD, but usually are soon processed as 'normal':
--children in farm families witnessing the butchering of a loved animal, then being forced to eat of the meat.
--female genital mutilation, done in a prepubertal girl, with not even a pretense of anesthesia, and with mother and other close female relatives holding her with no sign of sympathy;
--childbirth without preparation, particularly if there is shame and guilt regarding pregnancy, no family support, an environment that appears surgical, and a contract that the baby is immediately removed for adoption.
15  Rather than posttraumatic stress disorder, PTSD may be interpreted to mean pre-traumatic stress disorder.
16  It has often been observed that sympathetically experienced physical and psychological traumas may lead to PTSD symptoms, e.g. in children, journalists, and persons who help victims in any way, particularly therapists.
17  Such feelings are "addicting", i.e. self-reinforcing: they feel relatively good, the person feels strong and/or important, which is much better than the underlying sense of powerlessness and insignificance.
18  Instructions and practice of Autogenic Training (AT) may be offered in groups, separate from the individual treatment of PTSD. Autogenic training (AT) may be of particular value:  it addresses the physiological systems that respond to stress and includes aspects of relaxation techniques, self-hypnosis (suggesting results of relaxation of muscles, blood vessels, etc.), and including biofeedback features, i.e. the results of the suggestions are directly felt. The six suggestions/steps of AT:  'right hand feels heavy', then letting heavy feeling spread over whole body, expecting sense of sinking into surface one sits or lies on; 'right hand feels [heavy and] warm', then letting comfortable lukewarm and heavy feeling spread; 'heart beats calmly and strongly'; 'breathing evenly' (automatically, passive sensation, i.e. not particularly slowly or deeply); '[particular] warmth in upper abdomen', leading to relaxation of GI and other internal organs; 'cool forehead' suggesting alertness and clarity of mind.
19  Patients may be given examples of external factors that contribute to changes:  willpower, motivation, energy level, perception of pain and pain tolerance, etc. may change dramatically, for instance
-- when deciding to join military because of pressure by family or peers, sense of duty, etc.;
-- when accepting a major career change with move to Third World; or
-- when falling in love, adapting to different culture and planning to have a child (a young women being afraid of any pain and medical professionals, then wanting a baby, and eight months pregnant, feeling ready for labor pain and birth).
20  Reciprocity is instinctive and culturally reinforced, and revenge often feels right. However, generally, there needs to be at least de-escalation, e.g. the murder of a clansman being redeemed with tradable goods and temporary hard labor rather than a revenge murder, or a sadistic person being once abused, not once for each of his victim, and not murdered, even if he committed murder. Victims may feel right about retribution but they are aware that this feeling is temporary and that a change about their own perception is key to moving on and functioning again well.
21  Interview with Terry Gross on "Fresh Air", WHYY, NPR, 6/25/2008; her book: My Stroke of Insight, 2008).
22  Input from the retinas are screened analyzed in many parts of the brain, including mid brain centers. Many patterns, shapes and proportions directly elicit feelings and instinctual responses, both inherently and related to learned responses.
23  PTSD symptoms may develop late when a trauma is reinterpreted as against cultural and natural expectations, e.g. if a perpetrator is later recognized as much more dangerous and sadistic, if a war is reassessed as wrong, or if a African moves into a Western culture and reevaluates initiations of his/her home culture.
24  Abuse is, by definition, "bad" or "wrong"; against instincts and against morals or ethics. However, there are always conflicts between humans in any relationship, between instincts and between moral teachings. People should refrain from harming others because of ethics, mainly insightful empathy and conscience, rather than because of cultural mores. Even if all directly involved people are willing to participate in an inappropriate and/or dangerous act, or if family loyalty demands an action, an ethical person should shortly evaluate consequences for directly and indirectly involved individuals, then act according to his/her conscience, i.e. empathetically, neither selfishly nor blindly following family or group culture.
   Civilizations fail to teach ethics well, and many people become perpetrators of serious unethical acts.  Civilizations should help prevent such acts and limit freedoms of perpetrators. The acts should be seen with empathy for victims and grief for having failed to prevent them, rather than with disgust and moral indignation.
25  People are naturally fascinated by others' accidents and maltreatment, but others' suffering should never become mainly 'interesting'; people must learn to be broadly empathetic and ready to help when the suffering occurs, and to comfort survivors when meeting them, as feasible. Broad empathy has to be learned: people naturally see people (and animals) as "us versus them/others". Empathy mainly works for the "us" group and people may even enjoy watching and participating in the abuse of people perceived as "others".
26  During the initial evaluation of an opiate addiction patient, while being in some withdrawal, the patient reported nightmares about her child. She gave birth on the shore of a lake, screaming for help, but nobody came; after the baby was born, she fell asleep, then found the baby hardly breathing. After a week in a coma, life-support of the baby was discontinued. EMDR done during the admissions interview, before any medication was given, lead to successful treatment of both addiction and PTSD. In some patients, EMDR at initial evaluation addresses primarily nightmares and fear of nightmares with the goal that, if there are further nightmares, the patient can keep their content in mind and contemplate it as symbolic, gradually loosing the sense of fear and horror.
27  Stopping eye movement on both sides was detected accidentally in a session with an eight years old girl with severe trauma history; the death of a close relative lead to her again crying daily and bed wetting. After talking to her about the nature of PTSD and treatment goals, when starting EMDR, she halted her eye movement to her right during the initial slow movement. She then talked in a very low voice (much was not understandable even to her mother, who sat beside her) about her traumas including her guilt about not having been able to protect her little brother. Later she was able to move her eyes freely, she appeared more relaxed halting her gaze on the left (non-dominant) side. This EMDR treatment episode lead to an immediate improvement: crying and bedwetting stopped.
28  Irenäus Eibl-Eibesfeldt Die Biologie des Menschlichen Verhaltens, dritte Ÿberarbeitete Ausgabe, Piper 1997, p. 149, 411ff, 447ff,840ff.
29  Konrad Lorenz, in Die RŸckseite des Spiegels, 1973, Behind the Mirror, 1977, Harcourt Brace Jovanovich, p. 194, talks of groups seeing their own culture as "refined" and others as "crude".