Trauma Treatment

Post-traumatic stress disorder (PTSD) can be a debilitating condition. Ask anyone who’s been asked to treat intractable PTSD in a client who presents months after it has become so severe that they are frightened to leave home. Not only does it include distressing symptoms for the individual to manage, but may have far-reaching consequences for others. Symptoms and maladaptive coping mechanisms commonly seen in individuals suffering from PTSD, such as substance abuse, depression and anti-social behaviours, are clearly damaging to the fabric of the family, the community and even society at large.

Most, if not all practitioners, will encounter a client with trauma-related symptomology during their careers, even if they choose not to work in this area. This guide will attempt to provide a practical road map to treating individuals with PTSD. A brief synopsis of the history, issues related to diagnosis, risk factors for developing PTSD, and gender differences are discussed as a starting point.

Trauma: Background and diagnosis

The key to understanding the scientific basis and clinical expression of PTSD is the concept of “trauma”. In the initial DSM III formulation, a traumatic event was conceptualized as a catastrophic stressor that was outside the range of human experience. The framers of the original PTSD diagnosis had in mind events such as war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, motor vehicle accidents and so on. They considered traumatic events as clearly different from the very painful stressors that constitute the normal vicissitudes of life, such as divorce, failure, rejection, serious illness, financial crises and the like (by this logic adverse psychological responses to such “ordinary stressors” would, in DSM III terms, be characterized as Adjustment Disorders, rather than PTSD). The dichotimization between traumatic and other stressors was based on the assumption that although most individuals have the ability to cope with ordinary stress, their adaptive capacities are likely to be overwhelmed when confronted by a traumatic stressor.

From a historical perspective, the significant change ushered in by the PTSD concept was the stipulation that the etiological agent was outside the individual him or herself (i.e., the traumatic event) rather than an inherent individual weakness (i.e. a traumatic neurosis). In fact, one cannot make a PTSD diagnosis unless the patient has actually met the “stressor criterion” which means that he or she has been exposed to a historical event that is considered traumatic. Clinical experience with the PTSD diagnosis has shown, however, that there are individual differences regarding the capacity to cope with catastrophic stress so that, while some people exposed to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome. Such observations have promoted a recognition that trauma, like pain, is not an external phenomenon that can be completely objectified. Like pain, the traumatic experience is filtered through cognitive and emotional processes before it can be appraised as an extreme threat. Because of individual differences in this appraisal process, different people appear to have different trauma thresholds, some more resilient and some more vulnerable to developing clinical symptoms after exposure to extremely stressful situations.

For a person to qualify for a diagnosis of P TSD according to the latest DSM 5 diagnostic criteria, they must have had direct exposure to, witnessed or learned about the close exposure of an important other to, or have had indirect exposure to the aversive details of, a traumatic event.

They must also have at least one symptom of intrusive recollections of the event and avoidance of the feelings or reminders. Additionally, they must have negative alterations in cognition and mood following the trauma and in their arousal and reactivity. The symptoms must persist for at least a month and cause functional impairment. The mere experience or initial reaction to a traumatic event does not determine PTSD. What sets it apart from normal responses to trauma is the cluster of symptoms that persist after the event has ceased.

Psychological risk factors for PTSD following trauma exposure

Given that not all people who experience a traumatic event go on to develop PTSD, research has attempted to identify additional factors that increase the risk for PTSD following the traumatic incident. It is useful to know what these apparent risk factors are as ‘prevention efforts’ can be determined and employed. Previous research has identified a number of factors that increase the risk for PTSD. In a review of 68 studies of PTSD (see Ozer, Best, Lipsey & Weiss, 2003), several risk factors were identified that have consistently been found to increase the likelihood of PTSD developing after a traumatic event.

• The experience of another, past traumatic event
• The experience of psychological difficulties prior to experiencing the traumatic event
• Family history of psychological problems
• The extent to which there was a threat to life during the traumatic event
• The amount of support that people felt they had after experiencing the traumatic event
• The person’s emotional response (fear, helplessness, horror, guilt, and shame) at the time of the traumatic event.
• Dissociation at the time of the traumatic event

Of these, dissociation stood out as the strongest predictor of who developed PTSD following a traumatic event, possibly because dissociation suggests the person was not connected with what was happening during the traumatic event. This may limit the extent to which a person can fully process their emotions about the event, and therefore their ability to process the threat inherent in it and their responses at the time of the trauma.

Gender differences in the expression and course of PTSD

A recent meta-analysis by Tolin and Foa (2006) addressed gender differences in PTSD and trauma exposure and confirmed that females are at greater risk for developing PTSD even though they are less likely to be exposed to traumatic events. The gender differences in susceptibility to PTSD may be at least partially related to the fact that women are more likely to experience sexual assault than men. Of potentially traumatic events, exposure to rape carries one of the highest risks for PTSD (Norris, Foster & Weishaar, 2002). A history of depression or anxiety disorder at the time of trauma is also a risk factor for the development of PTSD. A number of epidemiologic surveys have demonstrated that women with PTSD are twice as likely to have depression and anxiety disorders compared with men with PTSD (Breslau, Davis, Andreski, Peterson, Schultz, 1997). As such, much of the increased prevalence of PTSD in women may be mediated by trauma type and comorbidity rather than specific biologic differences per see.

Research by Zlotnick, Zimmerman, Wolfsdorf and Mattia (2001) found that, compared with male patients, female patients experienced more re-experiencing symptoms and were more likely to meet criteria for current PTSD and to report sexual trauma as their index trauma. Men with PTSD were more likely than women with PTSD to meet the criteria for a substance use disorder and for antisocial personality disorder.

There is also some evidence that women recover more slowly from PTSD, and women are four times more likely than men to develop chronic PTSD. In one study, the median time to remission for women was 35 months compared to 9 months for men (Breslau, Kessler & Chilcoat, 1998).

Therapeutic Treatment: An exploration and critique of some treatment models of trauma

Treatment management has focussed on both how to prevent the onset of PTSD in people who have recently experienced a trauma as well as on how to treat a person who has developed this condition. This section will look at both early and continuous interventions for someone who has been exposed to a traumatic stressor.

Early interventions for trauma

Critical incident stress management /debriefing (CISM/ CISD)

This is the most commonly known treatment for the individual or group following a traumatic incident. It is considered an adaptive short term helping process that focuses solely on an immediate and identifiable problem. It spans pre-incident preparedness to acute crisis to post-crisis follow up. Its stated purpose is to enable people to return to their daily routine more quickly and with less likelihood of experiencing post-traumatic stress disorder.

Interestingly, a number of studies have shown that CISD has little or no effect, or that it actually worsens the trauma symptoms (Kagee, 2002). Several meta-analyses in the medical literature either find no preventative benefit of CISM (Barboza, 2005; Rose, Bisson & Wessley, 2002; Harris, Balolu & Stacks, 2002) or negative impact for those debriefed (Van Emmerik, Kamphuis, Hulsbosch, Emmelkamp, 2002).

Such research is perhaps surprising to those who considered this form of trauma debriefing to be the gold standard when it comes to initial trauma treatment. The interesting question is why CISD might leave individuals worse off? The common explanation is that CISD and other forms of psychological debriefing may actually interfere with the natural recovery process inherent in normal individuals. It is hypothesized that the alteration of intrusive and avoidant thoughts that characterizes normal psychological processing following a traumatic event may be disrupted by CISD. CISD may also lead affected people to bypass established personal support systems (family, friends, co-workers, clergy) usually used for non-occupational crises in the belief that the CISD session/s should be sufficient to alleviate their distress. Furthermore, a certain amount of time appears necessary for an individual to process the psychological impact of exposure to a traumatic event, and no external stimulus or programme may be capable (nor necessarily advisable) in shortening this time period (Barboza, 2005; Harris & Stacks, 1998). In concluding her research into the efficacy of CISM and CISD related trauma interventions, Barboza (2005, p. 68) states: “Making someone ‘feel better’ at least momentarily after s/he has experienced a traumatic event is much more desirable than doing nothing. However, given the lack of empirical support for CISD and CISM, they should not be used as a first line treatment or prevention of PTSD until there is a better understanding of their effects.”

Psychological first-aid

So, what role should mental health play in modern emergency services and in immediate trauma response?

Several organisations and researchers recommend that competent mental health personnel provide “psychological first aid” (PFA) to trauma survivors. Specific components of natural resiliency and supportive functions essentially make up this early trauma response, which has been developed over the past few years to replace the various forms of “psychological debriefing”. Reference to the development of PFA can be found in the Field Operations Guide for Psychological First Aid, published by the National Center for Child Traumatic Stress Network and National Center for PTSD (2006). Such an approach includes such things as listening to concerns, conveying compassion, assessing needs, ensuring that basic physical needs are met, and protecting the individual from further harm. Most importantly, those who do not wish to talk are not compelled to talk. For those who want to talk, somebody is there simply to listen. If additional help is needed, affected people may be referred to competent, licensed mental health professionals with experience treating trauma-related stress. As Bledsoe (2003, p. 3) states: “Psychological first aid is not an intervention technique, but only provides practical supportive care while at the same time respecting the wishes of those who do not want to discuss what happened or are not ready to deal with a possible onslaught of emotional responses in the early days following exposure”.

Ongoing treatment for trauma-related distress and/or PTSD:

Trauma work can be both immensely fulfilling and immensely taxing. So familiarity with the various treatment methods in this area is useful, along with an understanding of the rationale, research efficacy and controversies associated with each of these approaches. A few of the main approaches are discussed below.

Short-term approaches: Cognitive-Behavioural Therapy (CBT)

A cognitive approach has been found to be a suitable framework for trauma therapy because traumatic experiences usually impede the emotional process by conflicting with pre-existing cognitive schemas (Jaycox, Zoellner, & Foa, 2002). The cognitive dissonance that occurs when thoughts, memories, and images of trauma cannot be reconciled with current meaning structures causes distress. The cognitive system is driven by a completion tendency: a psychological need “to match new information with inner models based on older information, and the revision of both until they agree” (Horowitz, 1986, p.92).

Such an approach to trauma explains the fluctuation between symptoms of hyperarousal and inhibition commonly seen among trauma survivors. During the acute phase of the trauma, in an attempt to comprehend and integrate the traumatic experience, the trauma survivor normally replays the event that has been stored in active memory. Each replay, however, distresses the traumatised individual, who may inhibit thought processes to modulate the active processing of traumatic information. This observable inhibition gives the appearance that the traumatised individual has disengaged from processing the traumatic memory. Thus, some trauma survivors, as a result of excessive inhibition, display withdrawn and avoidant behaviours. However, when an individual is unable to inhibit traumatic thoughts, the intrusive symptoms are expressed in the hyperarousal symptoms of flashbacks during the waking states and nightmares during sleep states. For this reason, researchers commonly observe trauma survivors as oscillating between denial and numbness, or intrusion and hyperarousal. Once clients can reappraise the event and revise the cognitive schemas they previously held, the completion tendency is served.

Within CBT approaches to trauma, three central tenets of intervention are recognised, namely:

1. The importance of exposure techniques,

2. Cognitive reframing/challenging approaches

3. Anxiety management.

These approaches may include the following:

• Exposure therapy and systematic desensitisation
• Learning skills for coping with anxiety (such as breath retraining or biofeedback)
• Using cognitive restructuring to change negative thoughts
• Managing anger
• Stress Inoculation Training (SIT)
• Handling future trauma symptoms
• Addressing relapse prevention and other substance abuse issues
• Communicating and relating effectively with people (social skills)
• Addressing thought distortions that usually follow exposure to trauma
• Relaxation training and guided imagery.

Any therapist intending to employ a CBT approach to treating traumatised clients needs to be familiar with the triad of exposure techniques, anxiety management methods and cognitive reframing/challenging approaches. There is evidence that the combination of these methods is optimal in this kind of treatment. In one sophisticated, controlled study, a combination of prolonged imaginal exposure (SIT) and supportive counselling was found to significantly reduce symptoms (Foa, Rothbaum, Riggs & Murdock, 1991). More recent research confirms the efficacy of CBT in treating patients with PTSD (see Kar, 2011; Butler, Chapman, Forman and Beck, 2006).

Power Therapies: Eye Movement Desensitization and Reprocessing (EMDR)

Within the short-term therapies on offer for PTSD, are some “Power Therapies”, which tend to rely heavily on the use of specific techniques believed to reduce traumatic stress symptoms, often without the need for insight or understanding. One prominent example of such therapies is Eye Movement Desensitisation and Reprocessing (EMDR) which, despite its popularity, has also been critiqued by more recent research which calls its efficacy into question.

In EMDR, the goal is to help the client desensitize to traumatic stimuli through saccadic eye movements (Shapiro, 1995). The treatment procedure follows a structured sequence. Clients are first asked to perform bilateral eye movements while recalling a disturbing image or memory. The therapist then waves a finger repeatedly across a client’s visual field while he/she tracks it with his/her eyes. The treatment involves a combination of exposure therapy elements and eye movements, hand taps, or sounds to distract the client’s attention. After each sequence, clients indicate their subjective units of distress (SUD). If the SUD is high, the client practices relaxation techniques. When the client is ready, EMDR is resumed. Shapiro (1995) maintains that EMDR, with its brief exposure to associated material, external/internal focus, and structured therapeutic protocol, represents a distinctly different and new paradigm in therapy.

However, EMDR is a controversial therapeutic approach for several reasons. Some argue that EMDR lacks a sound theoretical foundation, empirical data, and sound methodology (Resick, 2004). Much research has been conducted on the efficacy of EMDR in the treatment of patients with PTSD, with some researchers suggesting that the effectiveness of EMDR derives mostly from its cognitive behavioural aspects, which include exposure, cognitive restructuring, anxiety desensitisation, and breathing. Without the lateral eye movements, EMDR is similar to cognitive and exposure therapy methods, which facilitate a client’s processing of traumatic memory. Research comparing the efficacy of CBT versus EMDR approaches to trauma suggests that CBT has better remission rates than EMDR (Kar, 2011). As Harvard psychologist Richard McNally bluntly puts it: “What is effective in EMDR is not new, and what is new is not effective” (cited in Lilienfeld & Arkowitz, 2008, p. 2).

Long-term and shorter-term psychodynamic psychotherapy

Longer-term approaches to trauma intervention tend to be adopted when there has been historical and/or extended traumatization, often involving the adoption of defensive styles which have become entrenched and incorporated into the personality of the client. Such traumas might include a history of childhood physical and/or sexual abuse, long-term torture and imprisonment, an ongoing, severely abusive relationship with a partner or ongoing repression and violation under a brutal state/regime. Particularly with early childhood abuse, there is a suggestion that some individuals go on to develop borderline or dissociative identity disorders and, in other instances, chronically traumatised individuals may be prone to depression, somatic ailments, and substance abuse. In these cases, it is clear that a short-term therapy approach may not be appropriate or sufficient and that clients such as these require the skills of more mature practitioners and more comprehensive approaches.

But briefer forms of psychodynamic treatment of PTSD have also been used with adults suffering from PTSD following exposure to a single traumatic event. Such a dynamic framework uses a supportive therapeutic relationship to uncover the personal meaning of the specific traumatic event and circumstances that follow and the obstacles to normal psychological processing of these events. Making links among the recent trauma, earlier developmental experiences that may have rendered the individual vulnerable to the development of PTSD, and the ways that conflicts are re-enacted in the therapeutic dyad and in daily life, psychodynamically oriented therapists seek to help traumatised individuals re-establish a sense of coherence and meaning in their lives.

Psychodynamic psychotherapy for PTSD has not been studied as extensively as cognitive-behavioural approaches for PTSD. But of the studies that have been conducted, it has been shown that psychodynamic therapy can have a number of benefits. Research by Schottenbauer, Glass and Arnkoff (2008) suggest that a psychodynamic approach for PTSD may help address crucial areas in the clinical presentation of PTSD and the sequelae of trauma that are not targeted by other more commonly used treatments. Psychodynamic therapies, they argue, may be particularly helpful when treating complex PTSD. They cite empirical and clinical evidence that psychodynamic approaches may result in improved self-esteem, increased ability to resolve reactions to trauma through improved reflective functioning, increased reliance on mature defences with concomitantly decreased reliance on immature defences, the internalisation of more secure working models of relationships, and improved social functioning.

Integrative or eclectic approaches

In her review of psychotherapeutic treatment methods for trauma (Eagle, 1999), Eagle identifies what she refers to as eclectic interventions, whereby the practitioner employs a multi-method or integrative approach to their trauma work. She argues that such an integrative approach is particularly applicable to trauma work, given that the nature of the disturbance is both internal and external, manifesting at intrapsychic and behavioural/reactive levels of functioning and characterized by the notion of the shattering of the “stimulus barrier”. She argues that trauma involves a rupturing of psychological boundaries and even of the social fabric of the community and interpersonal relations. Integrative interventions tend to recognize and respond to these multiple layers of disturbance.

The “WITS Model” is widely used in South Africa, where trauma has been endemic for many years. This approach marries psychodynamic and cognitive behavioural principles in its five-part model, involving narration of the story, normalizing of symptoms, addressing self-blame or survivor guilt, mastery and meaning-making. In most of these integrative approaches, the therapists’ stance is an engaged and empathic one, involving reflection, education, clarification and reassurance and balancing non-directive and directive phases of intervention.

She refers to a comparative evaluation of a wide range of trauma approaches which point to essential components of integrative interventions. These include:

1. Supporting adaptive coping skills

2. Normalizing the abnormal

3. Decreasing avoidance

4. Altering attributions of meaning

5. Facilitating integration of the self (Prout & Schwartz, 1991 in ibid).

Eagle argues that any therapist working within their own frame would be well served if they used these pointers as a reference point for holistic intervention.

Furthermore, such approaches recognize and respect individuals who are highly embedded in a communal view of the world or within a cultural frame which has specific understanding of the origins of misfortune and how to ameliorate trauma impact. Eclectic approaches also include self-help and community support groups, which are often highly effective in assisting members to process traumatic experiences.

Pharmacotherapy

Not uncommonly, at the point at which a trauma survivor sees a therapist, he has already been prescribed psychiatric medication for his symptoms and/or maybe self-medicating to avoid the unpleasant symptoms that are generated by the traumatic response. General practitioners or primary care providers will frequently prescribe short-term medication to manage upsetting anxiety symptoms. Typically, these are anxiolytics, such as benzodiazepines.

However, research shows that, apart from the undesirable trait of being addictive (and being given to an already addiction-vulnerable population), benzodiazepines have not been shown to be particularly useful in PTSD treatment and, in fact, may cause disinhibition along with difficulty in integrating the traumatic experience (Gelpin, Bonne, Peri, Brandes & Shalev, 1996).

Several antidepressant drugs used to control PTSD symptoms include tricyclic antidepressants, monamine-oxidase inhibitors and selective serotonin reuptake inhibitors (SSRI’s). Most research seems to conclude that SSRI’s are most effective in treating individuals with PTSD, with the exception of patients with comorbid Bipolar Disorder. Research on the effectiveness of antipsychotics, such as Risperidone, in the treatment of PTSD seems to indicate it is no better than a placebo.

Currently, no single drug has emerged as a definitive treatment for PTSD and pharmacotherapy by itself, appears not to help clients recover from trauma. It may, however, stabilize clients so that psychotherapy and other interventions are made more easily possible.

In short, therapists, even those who do not prescribe, should be aware of the effects that certain medications may have on their clients and provide psychoeducation around these so that clients may make more informed medication-related decisions.

A final word

It is well documented that trauma intervention has an extreme effect on the interventionist, commonly referred to as vicarious traumatization, contamination, secondary traumatization, compassion fatigue and burnout. Therapists need to ensure that they get proper debriefing for themselves, beyond conventional supervision, and that they are aware of their own satiation levels. It may be wise to limit the number of trauma cases within one’s practice and to balance this work with other, less intense cases.

Kelly Quayle is a practising counselling psychologist working with adults and children, using both traditional and online methods. She has a particular interest in working creatively and dynamically with children and provides workshops for children affected by divorce and loss. She has been writing for a lay and professional audience for several years.

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This article was first published in New Therapist: http://www.newtherapist.com/