Progressive Counting Within a Phase Model of Trauma-Informed Treatment

Ricky Greenwald

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415829670
• eBook ISBN: 9781136848100
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Clinicians recognize trauma & loss as a prominent source of clients' problems. Progressive counting represents a significant advance in trauma treatment, because it is about as efficient, effective, and well-tolerated as EMDR while being far simpler for therapists to master and do well. PC's value has already been supported by two open trials and a controlled study. Are you ready to provide therapy that routinely affects profound healing and lasting change? This book will show you how.

CHAPTER 1

UNDERSTANDING TRAUMA

Why Trauma Matters

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If you are working as a therapist, chances are that you are trying to help your clients to do better in some way: get in less trouble, do better at school or work, feel less anxious, angry or sad, get along better with others, reduce self-destructive habits, not hurt people … So why not just focus on the problem? Why should we care about trauma?

Following is a partial listing of the kinds of presenting problems (Anda et al., 2006; Fairbank, Putnam, & Harris, 2007; van der Kolk, 2007) that are potentially trauma related:

• disruptive behaviors

• poor frustration tolerance

• depression

• anxiety

• poor concentration

• loss of interest in activities/goals

• “don't care” attitude

• stress

• relationship problems

• anger and volatility

• fighting and aggression

• school/work absences

• substance abuse

• addictions

• criminal behaviors

• noncompliance with medical treatment

• dissociation

• self-destructive and suicidal behaviors

• high-risk behaviors

• medical problems.

This is not to suggest that trauma is the only reason that people have problems. But trauma can find the individual's weak spot. Trauma is a powerful stressor that can either cause new problems, or make pre-existing problems worse. If we try to help people but we don't take trauma into account, we risk ignoring a driving force behind the problems. We risk being less effective.

A Useful Definition of Trauma

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Not long ago, trauma was defined as a horrific event “beyond the scope of normal human experience” (American Psychiatric Association, 1980). To qualify as traumatic, an event should be subjectively perceived as threatening to a person's life or physical integrity, and should include a sense of helplessness along with fear, horror, or disgust. Such events might include being in a car accident, house fire, or natural disaster; being raped; or being assaulted. Through research we have learned to identify a wider range of events as being possibly traumatic — for example, witnessing a parent or sibling being beaten; being diagnosed with a life-threatening illness.

The bad news is that traumatic events are not beyond the scope of normal human experience. By the time most individuals become adults, they will have been exposed to one or more traumatic events. This is not just true for those growing up in high-crime urban areas. Even our (presumably) best-protected children experience trauma. For example, a study of second-year college students (modal age of nineteen) found that 84% had already experienced at least one major trauma (Vrana & Lauterbach, 1994). Among disadvantaged populations, very few escape exposure to major trauma events, and multiple or chronic exposures are more common (see Greenwald, 2002b). Trauma during childhood and adolescence is now so common as to be normative. Of course, the longer someone lives, the more opportunity for exposure to trauma. When we are working with a client with any kind of problem, we can't afford to assume that trauma is not a factor.

Although the focus here is on trauma, it is important to note that other adverse life events can have a trauma-like impact. For example, a person's response to a significant loss can be virtually identical to a posttraumatic response, except that following loss, hyperarousal may not be present (Pynoos, 1990). The research on so-called Adjustment Disorder shows that many children and adolescents do not adjust to or recover from a range of adverse events (Newcorn & Strain, 1992) but maintain some symptoms indefinitely. Research with teens (Joseph, Mynard, & Mayall, 2000) as well as adults (Bodkin, Pope, Detke, & Hudson, 2007; Gold, Marx, Soler-Baillo, & Sloan, 2005; Mol et al., 2005; Robinson & Larson, 2010) has shown that distressing life events such as bereavement, divorce, chronic illness, or unemployment tend to lead to equal or greater PTSD symptoms than do those events that have traditionally been defined as traumatic.

When working with a distressed client, we do not ask if the event qualifies as a trauma before offering help. We will offer essentially the same treatment regardless of whether the source of the distress is an earthquake, a sexual assault, or a death in the family. In this book, the term trauma is intended to apply to major trauma as well as loss and other adverse life events, as long as the event has had a trauma-like impact on the client.

This chapter emphasizes childhood (including adolescent) trauma for several reasons. First of all, some therapy clients are children. Second, the rest of the therapy clients were children once, and almost certainly experienced something during their childhood that qualifies as trauma within the broad definition used here. Finally, as will be further explained later, it is likely that adult clients' childhood trauma history is directly relevant to their presenting problems.

What Makes an Event Traumatic?

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Not every upsetting event is so intense and overwhelming that it is experienced as traumatic. The biggest factor pushing an event into the traumatic range is, not surprisingly, how bad it is. Several factors determine the severity of the exposure to trauma:

• the severity of the event

• the proximity of the experience

• the personal impact of the event

• the after-event impact (e.g., lifestyle disruption).

Severity of the Event

Some events are clearly worse than others. For example, an open-hand spanking is not as bad as being whipped with a belt, which is not as bad as being beaten to the point of broken bones. In most cases, once the event has been described, its severity is readily apparent. However, individuals with special vulnerabilities may experience certain insults especially severely. For example, an elderly person with fragile bones may be more severely injured than a middle-aged person by the same hard fall. Also, how the event is perceived contributes to its severity. For example, a young child who does not understand the danger she was in may not experience a nearly fatal near-miss event (e.g., almost being hit by a car) as traumatic.

Proximity of the Experience

The more directly the individual is involved in the event, the higher the risk of posttraumatic stress symptoms. For example, in a school shooting, children witnessing the event had the most severe symptoms, followed by children nearby who heard the shots but did not see the event, followed by children farther away who neither saw nor heard (Pynoos et al., 1987). However, even distant exposure can have impact, especially when children can personally relate or feel directly affected in some way. For example, a young boy, whose friend told him that the friend had seen a stranger being beaten on the street, became afraid that if he went outside someone might beat him up too.

Personal Impact

Something that happens to the individual or to someone he cares about is likely to have a greater impact than something that happens to a stranger. Children take it very personally when a parent or sibling is victimized or hurt. On the other hand, it is important not to underestimate the impact that an apparently distant event can have on a child.

• A 10-year-old boy's classmate drowned during a school outing. He did not even like the drowned girl, but felt guilty that he had not been friendlier toward her and irrationally blamed himself for her death.

• A 9-year-old girl's best friend's father died of cancer. She became obsessed with the fear that her own parents might have cancer.

After-Event Impact

This critical element of severity of exposure is often overlooked. Imagine that two identical bombs are dropped. One explodes and makes a crater in the ground. The other explodes somewhere else and also makes a similar crater in the ground, but then some nearby buildings collapse into the second crater. Although both bombs had the same strength, the second bomb has had more impact and thus can be considered more severe. Life experiences can be like this too. A traumatic event is more than just the single terrible moment.

• A 24-year-old woman is in a car accident. After the crash, she does not know for a few minutes whether her sister (the driver) is dead or alive. In the hospital, she has to wait by herself in a small room for almost an hour. They cut off and discard the bloody jacket she is wearing, to tend her wounds; her boyfriend gave her this jacket and she treasures it. She is left with a scar on her lower arm and feels that she can no longer wear short sleeve shirts or bathing suits.

• A 4-year-old boy's father dies unexpectedly. His mother becomes depressed and withdrawn. Spring comes around and his father is not there to teach him how to catch a baseball, with the glove he'd already gotten for Christmas. Father's Day comes. His birthday. His first day of school. (This goes on indefinitely, as major losses can have fresh impact at every developmental milestone.)

• A 50-year-old man hurts his back in a work accident when a heavy object fell on him. He is unable to return to work and has to live on disability payments, reducing his income substantially. He feels frequent back pain, which makes it hard to get a good night's sleep. Because of his pain, lack of sleep, loss of income, and inability to work, he becomes irritable. This makes it harder to get along with his wife, and they start snapping at each other and keeping their distance more than before.

In other words, it's not just the event itself but the circumstances surrounding and following the event that may make it traumatic rather than merely upsetting. Personality, social support, and other factors (discussed later in this chapter) also help to determine whether an individual can handle an event or will be overwhelmed.

The “Trauma Wall”

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A popular saying is that “What doesn't kill you makes you stronger,” or, less colloquially, that we grow from adversity. Although this certainly can be true, it is not always the case. Sometimes what doesn't kill you may still hurt you or cause damage. So how does this work — why does it go one way rather than the other?

Here a food analogy is helpful. Usually, we chew food, swallow it, and digest it. It becomes part of our nutrition, something we can grow from. Ideally, we do something similar with an upsetting experience. Kübler-Ross (1969) described a similar process in the stages of processing grief.

For example, let's say your dog dies. Maybe you don't think about it or process it every minute of the day, but now and then you do think about it, remember different aspects: how frisky she was when you first got her, how she liked to have her belly scratched, how badly you feel about having let her out the day she got hit by a car. You remember, you talk to others, you take a walk, you write, you cry, you laugh. Little by little — or bite by bite — the hurt becomes smaller as more gets processed, integrated, digested. When an upsetting experience is digested, it becomes your nutrition, something you grow from. Then it becomes part of long-term memory, part of the past. It is not as fresh or upsetting anymore. Along with the emotional processing, we have organized the elements of the experience into a coherent story, including a perspective that allows us to move on. For example, you might say to yourself, “Well, she loved to play outside. I guess there was always the risk of an accident, but she would have been miserable tied up,” and “She ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of Worksheets
• Acknowledgments
• Introduction
• Chapter 1 Understanding Trauma
• Chapter 2 The Structure of Trauma-Informed Treatment
• Chapter 3 The Research on This Treatment Approach
• Chapter 4 Setting Up Treatment
• Chapter 5 Trauma History
• Chapter 6 Trauma-Informed Case Formulation
• Chapter 7 Making a Treatment Contract
• Chapter 8 Safety and Stabilization
• Chapter 9 Coping Skills
• Chapter 10 Enhancing Attachment
• Chapter 11 Trauma Resolution with PC
• Chapter 12 PC Problem-Solving
• Chapter 13 After Trauma Resolution
• Chapter 14 Case Examples
• Chapter 15 Challenging Cases: Applying the Model
• Appendix A — Trauma-Informed Treatment Information and Resources
• Appendix B — Brief Tools for Obtaining Client Feedback
• Appendix C — Scripts and Forms
• References
• Index