Counselling for Post-traumatic Stress Disorder

Michael J Scott, Stephen G Stradling

• Publisher: SAGE Publications Ltd
• Year: 2006
• Print ISBN: 9781412921008, 9781412920995
• eBook ISBN: 9781446225301
• Edition: 3
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Counselling for Post-traumatic Stress Disorder, Third Edition addresses the specifics of counselling clients who have suffered major trauma, whether recently or in the past, and includes 18 detailed case examples together with transcripts of sessions. The authors? cognitive contextual approach translates the psychobiology of trauma responses into clinically useful analogies and simple drawings that guide the therapist and client. The book is unique in covering the diagnosis and treatment of the full spectrum of post-traumatic states.

In this fully updated Third Edition the needs of special populations - children/adolescents, refugees and those in pain - are also addressed. Additional material includes a new PTSD screening inventory and a counselling competence scale.

Counselling for Post-traumatic Stress Disorder, Third Edition is an invaluable, comprehensive aid for both the experienced and novice therapist working with trauma victims.

Michael J. Scott is a Consultant Psychologist and External Examiner for the MSc Cognitive and Behavioural Psychotherapies Programme at the University of Chester. Stephen G. Stradling is Professor of Transport Psychology at Napier University.

PART 1

THEORETICAL BACKGROUND

1	Post-traumatic Responses

The notion that external stressors can cause individuals distress is an ancient one. In Homer’s Odyssey warriors’ diaries revealed gruelling accounts of intense panic and disturbance both during and following battlefield encounters (Trimble, 1985). A wide variety of labels have been used to describe stress responses. Some of the descriptions are related directly to the trauma in question such as shell-shock and others such as post-traumatic stress disorder (PTSD) (American Psychiatric Association, 1980) have evolved as an attempt to describe a final common pathway that might be reached following exposure to a wide range of relatively severe stressors.

The symptoms of PTSD are clustered under three headings: intrusive recollections of the trauma, avoidance of stimuli associated with the trauma, and disordered arousal. Since PTSD entered the diagnostic nomenclature in 1980 doubts have been raised (Herman, 1993) about whether it represents a comprehensive description of the difficulties of all those exposed to prolonged and repeated trauma, for example childhood abuse, leading to a call for a category of Disorders of Extreme Stress Not Otherwise Specified (DESNOS). The most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, DSM IV (American Psychiatric Association, 1994), did not utilise this category but the issue was addressed by describing a set of associated symptoms including guilt and shame that may co-exist with PTSD and often occur as a result of prolonged trauma. Scott and Stradling (1994) described a series of cases in which the symptom criteria of PTSD have been met following repeated or chronic minor stresses in the absence of a single major traumatic event. More recently Mol et al. (2005) conducted a population study of post-traumatic stress symptoms following negative life events (e.g., divorce, unemployment) and after traumatic events (e.g., accidents, abuse) and found that life events can generate as many PTSD symptoms as traumatic events. It is our view that a PTSD-like disorder should be recognised which can occur in response to non-extreme trauma such as bullying at work. Diagnostic criteria have been and are in a constant state of refinement and whether such changes are incorporated in DSM V, which is not due for publication until at least 2011, remains to be seen.

Acute reaction

Both DSM IV and the World Health Organisation’s diagnostic classification system ICD 10 (WHO, 1992) make the distinction between post-traumatic stress disorder and the immediate acute reaction to an extreme trauma. DSM IV uses the category of acute stress disorder (ASD) to refer to a PTSD-like response which has an onset within four weeks of the trauma and a maximum duration of four weeks. To qualify for acute stress disorder not only must the person have symptoms of intrusion, avoidance and disordered arousal but they must also during or after the trauma experience dissociative symptoms, for example a victim of a road traffic accident might feel that the trauma was happening in slow motion or felt that somehow they seemed to be a spectator at the event. There is some evidence that peri-traumatic dissociative symptoms (occurring at the time of the trauma) are predictive of those who subsequently develop chronic post-traumatic stress disorder (Marmar et al., 1994). In a study of motor vehicle accident survivors (Harvey and Bryant, 1998) assessed for ASD within one month of the trauma 13 per cent of the participants had ASD and a further 21 per cent had sub-clinical levels of ASD. At follow-up 6 months later 78 per cent of ASD participants and 60 per cent of sub-clinical ASD met criteria for PTSD whereas only 4 per cent of those with no ASD subsequently met criteria for PTSD.

Chronic reaction

In addition if it is necessary to distinguish an acute reaction to extreme trauma from emotional disorder it may also be appropriate to distinguish both of them from long-term deleterious personality change. Only ICD 10 identifies a category of Enduring Personality Change after Catastrophic Experience which is defined as the development of symptoms of alienation, emptiness/hopelessness and vulnerability present for at least two years after the trauma and not present before. Strangely ICD 10 states that the category cannot be used if the client has PTSD. But PTSD clients who have been traumatised many years before are often currently more preoccupied with the sense of being damaged and with their difficulties in relating to those close to them than with the trauma itself, albeit that the latter is a continuing concern. Relatives often become focused on the fact that the victim is ‘not the same person’ as before the trauma. Clinically such clients very much resemble clients with a personality disorder. Unfortunately historically clients diagnosed with a personality disorder have often been dismissed and there has therefore been an understandable reluctance to countenance the idea of a post-trauma personality disorder. But with the development of cognitive therapy for personality disorder (Beck et al., 1990) it becomes possible to offer a dual focus on the PTSD and personality change.

A spectrum of trauma responses

PTSD is not a necessary response to an extreme trauma: the first author assessed a man paralysed from the chest down following a motorcycle accident who was not disturbed by recollections of the accident but suffering solely from depression because he could not engage in his previous role. This case highlights one of the key features of the counselling approach described in this volume. The trauma to which the client is exposed should be defined by the cognitive construction that the client puts upon it. In this instance the man’s response to the trauma itself had a positive tone, ‘I could have been dead and I am not!’

For research and legal purposes it is necessary to make a rigid distinction between those who would be considered a case of a particular disorder and those who would be a non-case. DSM IV facilitates making this dichotomy by stipulating the requisite minimum number of symptoms required to be diagnosed as a case of, say, depression or PTSD. But in practice the person one short of the number of requisite symptoms is unlikely to be clinically different to the person who could be deemed a case of the disorder, and as much in need of counselling. This has led to the concept of a sub-syndromal level of disorder. For PTSD a sub-syndromal level of the disorder has been defined (Blanchard and Hickling, 1997) as at least one intrusion and either at least three avoidance or at least two disordered arousal symptoms. Blanchard and Hickling studied motor vehicle accident survivors and found that 15 per cent of those with a sub-syndromal level of PTSD went on to develop the full disorder. Thus clients with a sub-syndromal level of PTSD are deserving of therapeutic attention. In practice there is often an overlap between this category and another diagnostic label, simple phobia. For example a survivor of a road traffic accident might subsequently experience great distress when driving their car and with no other symptom the appropriate label would be driving phobia. But if the symptom profile was that they were distressed at encountering reminders of the accident, for example cars pulling out on the nearside, and had experienced a detachment from others and an emotional numbness then the more comprehensive label of sub-syndromal post-traumatic stress disorder might be more appropriate. The idea of a sub-syndromal level of depression has proved useful in charting the long-term course of that disorder (Judd et al., 1998) and is likely to prove equally fruitful in PTSD.

One of the symptoms of PTSD is hypervigilance and this may be expressed by repeated checking behaviour. Very occasionally this takes place to such an extent (more than an hour or two a day) that the victim can be diagnosed as suffering from obsessive-compulsive disorder.

A trauma may also cause the exacerbation of a condition that a person had recovered from, for example a panic disordered patient may have stopped having panic attacks but finds these reinstated after a minor bump in their car, or a person who has recovered from obsessive-compulsive disorder may restart their compulsive checking rituals.

Pain is often a client’s most prominent preoccupation in the immediate aftermath of a trauma, with psychological difficulties becoming more pronounced with a diminution of pain. For some trauma victims pain continues to be a concern acting as a reminder of the incident and lowering mood. In such cases there needs to be a focus on the psychological difficulties and pain coping strategies. Victims with PTSD plus chronic pain have been found to have a poorer response to cognitive behaviour therapy (CBT) than those with PTSD alone (Gillespie et al., 2002; Taylor et al., 2001). Trauma also appears to be a factor in the development of psychotic illness. Romme and Escher (1989) reported that 70 per cent of people who hear voices developed their hallucinations following a traumatic event.

There are then a great variety of deleterious traumatic responses (and they are not limited to those mentioned above, for example substance abuse) but there is no inevitability about any of them. It is also possible that the person is not detrimentally affected by the trauma and in some sense seems to have gained from the experience. Consider the following example described in the Observer Life Magazine (Vulliamy, 1999) of Thomas Buergenthal who as a child experienced the death camps at Auschwitz and Sachsenhausen. Before he was 12 he experienced incidents such as this:

Suddenly the locomotive sounded a long, shrill whistle. Like wild animals discovered in their hide-outs, the men who had only a second ago been unable to move jumped up, hurling their bodies against the walls of the railroad car. They smashed their heads against the iron bars, hammered with their weak fists against the wooden boards as they screamed, they wept, and then again laughed a gruesome, metallic laugh, they trampled over us … all of them moved from one end of the car to the other as if they were marching in frontal attack against some demonic enemy. They were covered with blood; these men had become insane. Then suddenly the storm-troopers opened fire on the insane marchers, one by one they fell almost in formation. Their war was over … this was the fourth night of the infamous Death March from Auschwitz to nowhere.

Despite these experiences Buergenthal had not had a nightmare in 50 years. Vulliamy concluded

Buergenthal learned his lessons about humanity during those years. They taught him not hatred, cynicism or despair, but something else – something which defies those things … he has harnessed his pain and his compassion to campaign against genocide in El Salvador, Costa Rica, Rwanda and Bosnia.

2	Diagnostic Criteria

As recently as the 1960s the level of agreement about whether a particular client had a particular emotional disorder was often poor. Assessors were focusing on those aspects of the disorder which they personally felt were significant and had their own preferred thresholds as to whether a particular symptom should be regarded as present. Such idiosyncratic interpretations made impossible the controlled comparisons necessary for research. This led to the development of research diagnostic criteria and a consequent much higher level of agreement as to whether a given individual suffered from a particular disorder. DSM IV and ICD 10 and their predecessors have become the reference manuals of diagnostic criteria for mental health. Work is underway on DSM V and a Research Agenda for DSM V was published in 2002 by the American Psychiatric Association. One of the options being considered is to make explicit which DSM diagnoses have been found to have high reliability, for example anxiety disorders including PTSD, and which have much less reliability, for example schizophrenia. Diagnostic reliability refers to the extent to which different assessors using the same criteria agree on a diagnosis. Table 2.1 shows the DSM IV diagnostic criteria for PTSD.

Post-traumatic stress disorder is an unusual disorder in that unlike others such as depression and panic disorder it is not defined simply in terms of symptoms. Rather a person has to experience a particular type of event in a particular type of way in order to meet the two stressor Criteria A1 and A2 of Table 2.1. Whilst Criteria B, C and D refer to the particular symptoms that the traumatised victim might suffer Criterion A1 refers to the objectively extreme nature of the traumatic event whilst A2 refers to an intensely distressing subjective response. The fulfilment of Criteria A is a necessary gateway to PTSD. In the 1987 version, DSM III (APA, 1987), the life event had to be classifiable as extreme and outside the normal range of human experience in order to qualify as an agent for PTSD. The emphasis was on the objective aspects of the trauma. In DSM IV the previous wording was abandoned in favour of a specification of the sort of life events that might lead to PTSD and an additional requirement inserted that the person suffered subjective distress in the aftermath of the incident. DSM IV offers further guidance as to what may constitute a stressor that meets Criterion A1:

Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or man-made disasters, severe automobile accidents or being diagnosed with a life threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experience without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accidents, wars, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced by a family member or close friend, learning about the sudden, unexpected death of a family member or close friend, or learning that one’s child has a life threatening disease. (APA, 1994: 424)

Table 2.1 DSM IV diagnostic criteria for PTSD

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A	The person has been exposed to the traumatic events in which both of the following were present:
	the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injuries, or a threat to the physical integrity of self or others; the person’s response involved intense fear, helplessness or horror. Note: in children, this may be expressed instead by a disorganised or agitated behaviour.
B	The traumatic event is consistently re-experienced in one (or more) of the following ways:
	recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed; recurrent and distressing dreams of the event. Note: in children, there may be frightening dreams without recognisable content; acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: in young children trauma specific re-enactment may occur; intense psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic e...

Table of contents

• Cover Page
• Title
• Copyright
• Contents
• Part 1 Theoretical Background
• Part 2 Applications
• Part 3 Postscript
• Appendix 1 The Penn Inventory
• Appendix 2 Cognitive Therapy Scale
• Appendix 3 Pain Management
• Appendix 4 Children and Adolescents
• Appendix 5 Eye Movement Desensitisation Reprocessing (EMDR)
• Appendix 6 Refugees
• References
• Index