Psychological Trauma and Posttraumatic Stress Disorder: Part 2, Treatment and Interventions


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One of the 7 other books by Dr. Flannery  published by AMHF to understand, to reduce violence

One of the 7 other books by Dr. Flannery published by AMHF to understand, to reduce violence

In part 1 of this essay we examined the nature of psychological trauma, an individual’s physical and psychological response to sudden, usually unexpected, potentially life-threatening events, and the emergence of posttraumatic stress disorder (PTSD) thirty-one days later. We reviewed the disruptions that may occur in the domains of good physical and mental health (reasonable mastery, caring attachments, and a meaningful purpose in life) and the physical, intrusive, and avoidant trauma symptoms that may accompany these frightening critical incidents.

In part 2 we turn our attention to the various treatment interventions that have been shown to be effective in treating trauma victims. Just as there is no one approach to treating cancer or heart disease at present, there is no single intervention for all trauma victims. Different interventions are helpful to different victims and a good treatment plan includes the individual’s personal characteristics (e.g., age, gender, and previous victimization), the relevant evidence-based research, and the therapist’s clinical judgment as to specific needs. Treatment interventions range from psychological first aid and crisis intervention procedures to cognitive behavior therapy, image desensitization, psychotherapy, and various medications. Each victim and therapist needs to consider the best approach(s) in any individual case. [See (1) for full review.]

Psychological trauma may be acute (occurred within the past six months) or chronic in the form of PTSD (occurred over six months ago). The goals of both acute and chronic trauma conditions are to reduce the fright and anxiety associated with physiological arousal, to reduce overall symptomatology, and to restore reasonable mastery, caring attachments, and a meaningful purpose in the victim’s life. This essay outlines in some detail the areas of needed intervention in acute conditions and, then, the same six areas adapted for chronic situations. Below are the general principles. These steps can be integrated within the various other treatments for trauma noted above.

Acute Conditions

1. Safety First
Clearly, no one can be treated for the impact of trauma if the individual is still in an unsafe situation, such as domestic violence, incest, active combat, and so forth. The individual needs to seek safety first. Seeking physical safety may mean police or family assistance, a shelter for battered women, legal interventions, and the like.

When the victim is safe, medical needs should be attended to next. Physical injuries need to be treated and in sexual-abuse cases, AIDS, venereal disease, possible pregnancy, and a rape-specimen kit need to be assessed. Caregivers and family members providing these services need to focus on creating a psychological holding environment where the victim feels safe, protected, listened to, and where privacy will be maintained. An early goal in this step is to restore an overall sense of trust in people again.

2. No Addictive Behaviors
As we noted in part 1, the symptoms of psychological trauma and PTSD can be intense and very unquieting. Often, victims do not realize that they are experiencing the aftermath of psychological trauma and, thus, do not reach out for help. Many commonly turn to addictive behaviors for relief. Addictive behaviors may include abuse of alcohol, prescribed or street drugs; compulsive sexual behavior; gambling, automobile speeding, and other types of high-risk behaviors. In addition a neurotransmitter in the brain called dopamine is activated, when the individual engages in the addictive behavior, and pleasure is experienced.

When the addictive behavior is again engaged in, dopamine once more floods the body’s nervous system, pleasure follows. The body responds to this full release of dopamine by decreasing the receptors in the nerve cells that receive the dopamine. With fewer dopamine-receiving cells, the body needs to produce more dopamine to get the same effect. In this way the body has to work harder to get the same pleasurable effect and the addictive behavior becomes progressively worse over time.

Aerobic exercise, relaxation exercises, listening to soft music are examples of non-addictive methods to reduce stress (see Step 5.). One additional note of caution: as one curtails the addictive behavior, the physical and intrusive trauma symptoms that the addiction was self-medicating may again become more intense and unpleasant. The use of the non-addictive methods will gradually reduce these intense feelings and thoughts just as the problematic addictive methods had.

3. Restore Reasonable Mastery
Reasonable mastery can be re-instated in small steps first. Encourage the victim to draw up his/her plan for recovery. The victim can consult family, caregivers, clergy, and so forth and begin to develop one’s own steps to recovery. Next, the victim should begin to restore the daily routines of personal care, household chores, child rearing, and finally work. In time, mastery needs to be restored in the areas of personal self-care, interpersonal interactions, and in academic or work skills. Restoring reasonable mastery should be done in small manageable steps and the victim should be alerted to avoid negative thinking (“I am a bad person because this happened to me.”) and false assumptions (“Because this person raped me, I can trust no one.”)

4. Maintaining Caring Attachments
Trusting another person is based on the other individual having predictable behavior (what the person says he or she will do, the person does) and prosocial values of caring, friendship, and emotional support. Restoring a sense of trust in others is an important step in victim recovery. Ask the victim if the victim personally knows someone with predictable behavior and prosocial values. Encourage the victim to observe this person and that person’s interactions with others, so that the victim may observe a trusting relationship. Then encourage the victim to interact with this person directly. Gradually have the victim interact with other trustworthy people so that the sense of trusting others becomes firmly rooted (2, 3).

5. Tone down the Emergency Mobilization
In part 1, we noted how adrenalin (epinephrine) in response to traumatic events mobilizes the body to protect itself. This state of high physiological arousal may last after the crisis has past. The body needs to be restored to its normal physiological resting state. As we noted in Step 2, addictive behaviors are not a productive long-term solution. Aerobic exercise, relaxation exercises, yoga and the like are better strategies. In general most victims can reduce the arousal state in one of three ways: physical exercise, having cognitive control of the situation with a step-by-step coping strategies plan, or by ventilation, which focuses on talking about the victimization in detail.

6. Making Meaning of the Violence
When the first five steps are in place, the victim is then ready to address the psychological aspects of the traumatic event directly. The victim needs to grieve the loss that has taken place in the victim’s life and to develop a new or restored meaningful purpose in life.

The first part of this process is to recall in full detail what happened. The victim needs to read official reports, speak to witnesses, and recall events personally as much as possible. The goal here is to recall any dissociated materials as well so that flashbacks are avoided in the future.

The second part is to grieve the loss. As we noted earlier, all trauma involves some form of loss and loss means that the victim’s normal routines have been dislodged. At this point the victim with the facts of the critical incident fresh at hand needs to review what life was like, how it was disrupted, what was taken or lost, and what life is now like without the lost object. The grieving process may well be accompanied by feelings of anger, sadness, and depression as the victim psychologically comes to terms with what has happened and works toward acceptance of the change as permanent.

Since victims may perceive their victimization as evil acts, the third part for many is to understand the nature of evil in the world. It is often helpful to review some or all of the various faith traditions and philosophies of life that have differing ways to understand the nature of evil. [See (1) for a discussion of the problem of evil.]

When the victim has come to terms with the problem of evil, the final part of the recovery process is to establish or review a meaningful purpose in the victim’s life so that normal human functioning can now be fully restored (5). Many victims put their suffering in some form to help others. Mothers against drunk drivers is an example of utilizing one’s suffering in the service of others. Enriched spiritual growth often happens in the recovery process as well.

Chronic Conditions
Victims of chronic traumatic conditions likewise need to proceed through the six steps noted for acute conditions. However, the lengthy duration of the chronic state requires some important modifications and additions to these six steps.

1. Safety First
As with acute conditions, victims must be safe for the learning needed for recovery to occur. No one can concentrate, if they are in fear of their safety. As with acute conditions, a holding environment needs to be created for the victim and any necessary medical and legal issues need to be addressed. However, in chronic conditions the medical assessments should include also neurological and endocrine assessments to see if the protracted PTSD state has left any residual problems that need to be addressed. It is also to be expected that the re-establishment of trust will take longer in chronic states.

2. No Addictive Behaviors
As in acute conditions, victims may have self-medicated the symptoms of trauma and PTSD. With the passage of time, this self-medication often becomes a full addiction in its own right. Detoxification may be necessary and support groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) may be of immense help in providing support. Victims of chronic conditions should be encouraged to use the more adaptive stress management strategies of aerobic exercise and relaxation exercises. As in acute cases, victims will likely re-experience their PTSD symptoms in strong intensity as they cut back on the addictive behavior. Having a therapist and/or close friends to discuss these painful memories until the adaptive stress management strategies reduce the vividness of the recalled events is important.

3. Restore Reasonable Mastery
Victims of chronic conditions need to restore a reasonable sense of mastery as do victims in acute conditions. Personal self-care, interpersonal skills, and academic work skills need to be restored in manageable steps. In chronic conditions these manageable steps usually need to be taken in much smaller steps.

In chronic conditions faulty mastery may commonly occur in at least two ways. The first is excessive over-control in which the victim is determined to control every last detail of life so that he or she is never caught unprepared a second time. The problem with this strategy is that no one can control all aspects of life and the victim needs to be encouraged to gradually release this exacting grip on life. The second faulty coping strategy goes to the other extreme and gives up control of everything in life. This condition is referred to as learned helplessness. It is based on the faulty assumption that, because one was helpless in one situation (e.g., the traumatic event), the person is helpless in all situations. Over time, persons with learned helplessness give up trying to exercise any reasonable mastery. A helpful intervention in these cases is to have the victim participate in some easily mastered task so that the learned helplessness assumption is quietly challenged. [See (4) for an efficacious approach to the treatment of learned helplessness.]

4. Maintaining Caring Attachments
Re-establishing caring attachments in a chronic condition victim with extensive avoidant symptoms will take longer than in an acute condition. However, the basic process is the same. Victims of rape and domestic violence in chronic states often have serious and understandable issues in re-establishing emotional and sexual intimacy. This process may require sexual therapy counseling in some cases.

5. Tone down the Emergency Mobilization
As in acute cases, victims in chronic states need to utilize adaptive stress management strategies to learn to be truly calm and it will take appreciably longer in chronic conditions to attain this goal. Medicines for short-term use may be helpful adjuncts in these conditions. There are a variety of anti-anxiety medications and antidepressants that are helpful to many (not all) victims in managing intrusive memories, flashbacks and panic attacks.

6. Making Meaning of the Violence
The steps necessary for full recovery are the same in chronic conditions as they are in acute situations with one very important difference. The recalling of the facts of what has happened needs to be addressed very slowly and gradually over time. Trying to recall these details of the event quickly and all at once may result in the victim physically and psychologically re-traumatizing him or herself. It is helpful to begin to recall the events slowly. When the recall becomes to anxiety-provoking or depressing, the victim should stop, take a break, and do some other non-trauma-related task. The victim can come back to the recall process and begin where he or she left off. When the facts are in place, the steps of grieving, addressing evil, and finding restored meaning in life proceed.

The interventions outlined in this essay are individual treatments but there are also important group treatments as primary or adjunctive forms of care. Groups offer many important resources to victims in both acute and chronic situations. Victim groups offer emotional support, acceptance, a network of attachments, new learning for restoring mastery, and seeking a renewed purpose in life by interacting with the other group members.

This overview has illustrated a wide range of helpful treatment interventions in both acute and chronic states. Psychological trauma and PTSD exact an immense toll of suffering. The greater tragedy in today’s age lies in victims not knowing or not utilizing these interventions that can reduce this suffering.

References

1. Flannery R. B. Jr. Posttraumatic Stress Disorder (PTSD): The Victim’s Guide to Healing and Recovery. Second Edition. New York, NY: American Mental Health Foundation, 2012.
2. Pennebaker, J. W. Opening Up: The Healing Power of Confiding in Others. New York, NY: Morrow, 1990
3. Siegal, D. J. The Developing Mind: Toward a Neurobiology of Interpersonal Experience. New York, NY: Guilford, 1999.
4. Flannery R. B. Jr. Becoming Stress-Resistant through the Project SMART Program. New York, NY: American Mental Health Foundation, 2012.
5. Durant, W. and Durant A. The Lessons of History. New York, NY: Simon and Schuster, 1968.
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Dr. Raymond B. Flannery Jr., Ph.D. FAPM, is an internationally recognized scholar and lecturer on the topics of violence, victimization, and stress management. Dr. Flannery is available for lectures and workshops for all types of groups and may be reached at the American Mental Health Foundation.

Email Evander or call 212-737-9027.


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