Personalising Trauma Treatment

Reframing and Reimagining

Michael J Scott

• Publisher: Routledge
• Year: 2022
• eBook ISBN: 9781000550252
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Personalising Trauma Treatment is about helping trauma victims back to their old selves and focuses on altering the perception of the centrality of the trauma.

In this book, clients are taught to rediscover their sense of self by reframing the trauma. Within this new framework the focus is on the client's mental time travel from the trauma to today and reimagining their future. The therapeutic targets are the thoughts and images (cognitions) that interfere with day-to-day functioning. It does not assume that arrested information processing lies at the heart of the development of PTSD, with a consequent need for the client to re-live the trauma. For those clients who were abused in childhood, their experiences are viewed through a particular central window, but other 'windows' may make for more appropriate engagement with their personal world and a reimagining of their view of themselves. Treatment delivery options from telephone consultation, group work and videoconferencing are discussed. With illustrative examples, the author highlights the pathway to recovery for a wide range of clients with the comorbidity often found in real-world settings.

The book will be essential reading for therapists and other mental health professionals working with trauma survivors.

Part I Distilling a New Direction

DOI: 10.4324/9781003178132-1

Introduction

Evidence-supported treatments (EST) for post-traumatic stress disorder (PTSD) have been around for over a decade, but though they are effective, only about half of sufferers fully recover. This makes the development of new treatments essential. There is a paradox that different treatments produce a similar impact on negative appraisals of the trauma and its consequences. McNally and Woud (2019) ask ‘What is it about pro-longed exposure therapy that persuades traumatized crime victims that not everyone in the world is untrustworthy?’. Thus, the precise mechanisms by which ESTs achieve their results are not wholly transparent. The suggestion is that it is negative appraisals about self, others and the personal world that leads to PTSD. These cognitions have been incorporated into the diagnostic criteria for PTSD in the DSM-5 (American Psychiatric Association, 2013). McNally and Woud (2019) also review a study that suggests that it may be the centrality accorded to the trauma that may be pivotal to the development of PTSD.

In Part 1 of this volume, the author challenges the evidence that it is incomplete processing of the trauma that leads to PTSD and thereby the necessity of somewhat toxic trauma-focussed interventions. It is suggested that the hallmark of PTSD is a state of ‘terrified surprise’ and this distinguishes the condition from other trauma-related disorders that may develop such as a specific phobia or depression. The author underlines the finding that there are a wide range of possible responses to trauma, each deserving of appropriate treatment. He cautions that PTSD should not be assumed on the basis of an extreme trauma and intrusions. Consequently, there is a need for reliable diagnosis, particularly as comorbidity is the rule rather than the exception. He adds that centrality can also be an issue in disorders beyond PTSD.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th edn ed.). Washington, D.C.: APA.
• McNally, R. J., & Woud, M. L. (2019). Innovations in the study of appraisals and PTSD: A commentary. Cognitive Therapy and Research, 43, 295–302. 10.1007/s10608-018-09995-2.

Chapter 1 Client's Complaints Post-trauma

DOI: 10.4324/9781003178132-2

Trauma victims may experience a myriad of issues. For some victims, financial and/or occupational problems may result in lowered mood which can become a ready therapeutic target. For other victims, a sense of shame or guilt is not something that they would readily volunteer but is nevertheless debilitating. More generally, trauma is a painful memory and not something most people would wish to detail. Thus, a client's vocalised presenting problem may be a small part of a bigger story. Nevertheless, there can be such graphic descriptions of physical, social and occupational impairment post-trauma, that the therapist can feel easily overwhelmed and both may short circuit the discussion. It is tempting for the clinician to use speedy ‘rules of thumb’ (heuristics) to propel the client into a particular treatment. For example, a reflex referral to a bereavement or pain management group for a client injured in a fatality. Such a rule of thumb may reduce the demands on the therapist's empathy but circumvent detailed consideration of the different factors involved in the client's distress. Heuristics include stopping at the first complaint identified, using the graphic detail of a particular horror or symptom as evidence of a particular debility, offering anything that the clinician is familiar with, focussing primarily on an organisational target and minimising discussion of matters outside their area of expertise or of pre-existing problems. Matters may be complicated further when a client's concern is about a traumatised child or adolescent, and they may or may not have been involved in the same trauma themselves. In such circumstances, the clinician may feel torn that on the one hand they cannot provide the ‘one stop’ shop the adult would wish but on the other hand, there are no readily accessible credible alternative pathways.

‘What brought you here today?’

This is often a therapist's opening gambit in encountering a client for the first time. In response, the client is likely to cite a crisis event such as a car accident, a relationship breakdown or loss of a job. The commonality amongst crises is that the client has experienced one or more as destabilising and is seeking restitution, but the proximal crisis may mask an earlier, perhaps more significant distal crisis. Not only might there be a series of crises to consider but also the client will likely present all of their problems. This should come as no surprise, as the client experiences the totality of their difficulties and may not separate them into the therapist's preferred demarcations of ‘psychological’, ‘physical’, ‘social’ and ‘spiritual’. Frustratingly giving the therapist ‘mental indigestion’ by repeatedly jumping from one domain to another. At that point, the therapist might fantasise longingly about the possibility of the ‘fire alarm’ going off.

Under Duress?

Some clients may have effectively been brought by others to the therapist. This is fairly obvious when children and adolescents present, but oftentimes, they have the good grace to signal this to the therapist by being mute or giving monosyllabic answers. However, adults with less than obvious learning difficulties can sometimes present as a consequence of family members post-trauma concerns. In such instances, it can be questionable as to who has chosen treatment. More generally, adult clients often need space to make admissions such as ‘I am a private person’ or ‘you should sort your problems out yourself’. It may be inferred from such utterances that the hand of others may be operative in the client's presence. Alternatively, it can be that the clients' increased irritability since the crisis has so soured their relationship with their significant other and that the attendance at therapy may be a way of placating their partner. This might particularly be the case if substance abuse/dependence has become an issue since the crisis, but they may be highly ambivalent about addressing this. Teasing out a client's capacity to benefit from treatment and the limits of their autonomy can be a challenge.

What Is a Trauma?

Stressors have been variously termed, hassles, negative life events and extreme traumas, indicating stressors of different severity. The underlying model of Zubin and Spring (1977) is that the more severe the stressor the more likely it is that a person would decompensate, with relatively few people decompensating at lower stressor levels and many more at extreme levels. Not everyone succumbs to the ill effects of even an extreme trauma suggests that response may be cognitively mediated. This mediational role of cognition (thoughts and images) is very apparent in our varying responses to everyday difficulties, such as being late or not meeting a deadline. Traumas are commonly thought of as occupying the high end of the stressor spectrum, but there are no clear demarcations, e.g. a person may be bullied at work, go off sick and experience flashbacks of the bullying episodes, this would probably be best placed at the border between negative life events and extreme trauma.

Hassles (Nezu et al. 1989) and negative life events (Brown & Harris, 1978) have been implicated in the aetiology of depression whilst extreme traumas have been linked to post-traumatic stress disorder (PTSD). However, what determines that a life event should be regarded as negative and a possible causal agent for poor mental health? Spence et al. (2019) have suggested that the negativity can be addressed with regards to the following four considerations:

• Attachment – events that involve negative changes in close relationships often involving loss or rejection.
• Achievement – events that prevent or hinder reaching the desired goal.
• Security – events that jeopardise physical or mental safety and uncertainty of possession, routine or physical existence.
• Identity – events that compromise how we and others view the self, involving stigma, belonging or physical deterioration.

The DSM is the diagnostic ‘bible’ of the American Psychiatric Association and in its current iteration, DSM-5 lists the type of traumas (criterion A) that may lead to PTSD (DSM-5 p274; American Psychiatric Association, 2013) and include, but are not limited to, exposure to war, threatened or actual physical or sexual assault, being kidnapped, being taken hostage, terrorist attack, incarceration as a prisoner of war, natural or man-made disasters, severe motor vehicle accidents and anaphylactic shock. Such traumas are the necessary gateway to PTSD and are commonplace. The estimated lifetime prevalence of exposure to potentially traumatic events according to DSM-IV criterion A was 43.8% (Knipscheer et al., 2020). Further, the lifetime prevalence of exposure to potentially traumatic and other life events was 71.1%.

The Subjective Response to a Trauma

In contrast to its predecessor DSM-IV, there is no specification in DSM-5 American Psychiatric Association (2013) of a necessary emotional reaction at the time of the trauma. This change does not sit easily with the claims of trauma-focussed therapy theoreticians (Ehlers & Clark, 2000; Ehlers & Wild, 2020) that the trauma memory is disjointed (Beierl et al., 2020). If indeed there were problems at the laying down of the traumatic memory (encoding) one would presumably expect some effective signature, such as ‘intense fear helplessness or horror’ as stipulated in DSM-IV-TR (American Psychiatric Association, 2000). The DSM is avowedly atheoretical but having ventured into aetiology by specifying the necessary type of trauma for the development of PTSD, it has strayed into the arena of causation. In so doing it has, however unwittingly, raised a question mark about one of the fundamental tenets of trauma-focussed therapy theoreticians.

The DSM-5 Criteria for PTSD

In the DSM-5 (American Psychiatric Association, 2013), PTSD symptoms are categorised under four headings (see Table 1.1). However, the DSM and Table 1.1 are not checklists, to protect against such misuse, symptoms have to be simultaneously present i.e. the time frame for each symptom has to be clarified, whether it is present in the last month or up to a particular point in time. The symptoms must be evaluated with regards to the same traumatic event/s. For a symptom to be endorsed as present, it must represent a worsening of negative alterations in cognition and mood (clusters D) and hyperarousal (cluster E), whilst the intrusion (cluster B) and avoidance (cluster C) symptoms must originate with the trauma. Importantly, a symptom is only endorsed if it is at a level that it has functionally impaired the person e.g. not only nightmares of the trauma but also ones that woke the person up and they had difficulty getting back to sleep. It is necessary to elicit from the client-specific examples of the manifestation of a symptom, monosyllabic ‘yes’, ‘no’ responses to a therapist's question about a symptom are insufficient, if necessary the therapist should ask clarifying supplementary questions. The interviewer should elicit enough information to gauge the frequency, intensity and time course of each symptom.

Table 1.1 DSM-5 Criteria for PTSD – Trauma and Symptom Prompts

TRAUMA Have you been in a situation in which you thoughtyou were going to die as a result of what happened? Have you been in a situation in which you thought others were going to die as a result of what happened? Have you been in a situation in which you thought yourself or others were going to have a serious injury as a result of what happened? Have you been in a situation in which you were or thought that you were going to be sexually violated? A positive response to at least one of the above is required

INTRUSIONS Do memories of a traumatic incident play on your mind? Do you get upset by them? Do you have distressing dreams of the traumatic incident? Do you lose awareness of your surroundings when you get pictures/thoughts of the traumatic incident coming into your mind? When something reminds you of the traumatic incident, do you get distressed? Do you get any particularly strong bodily reactions when you come across reminders of the traumatic incident? A positive response to at least one of the above is required

AVOIDANCE Do you block out thoughts or pictures of the incident(s) that pop into your mind? Do you avoid conversations or people or places that bring back memories of the incident(s)? A positive response to at least one of the above is required

NEGATIVE ALTERATIONS IN COGNITION AND...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• PART I: Distilling a New Direction
• PART II: Applying the Centrality Framework
• PART III: Managing the Crises That Can Derail Trauma Treatment
• PART IV: Disseminating Trauma Treatment
• Appendix
• Index