Traumatic events can have a profound and lasting impact on the emotional, cognitive, behavioral, and physiological functioning of an individual.
Bruce D. Perry, M.D., Ph.D.
In recent year the explosion of reports of trauma experiences in the United States and worldwide has raised questions about how to treat survivors of trauma-in particular, trauma as a result of a disaster that impacts individuals, couples, families and whole communities. This can be either manmade disasters such as the bombing of the Murrah Federal Building in Oklahoma City or the Columbine High School shooting, or natural disasters such as an earthquake in Russia, a flood in Texas, or a fire in Colorado's mountains. Trauma also is a result of street violence (e.g., gang activities, shootings, murder, muggings, rape) and home violence (e.g., childhood sexual, physical, and emotional abuse, spouse abuse, elder abuse), and other kinds of victimization (e.g., violent crime, motor vehicle accidents, road rage).
People of all ages are exposed to these and other kinds of traumatic experiences. Each year, 6 to 7 percent of the U.S. population is exposed to trauma (Norris, 1988). The lifetime prevalence of exposure to traumatic events in the United States is an estimated 39.1 percent (Breslau, Davis, Andreski, & Peterson, 1991).
Trauma survivors might have only mild, transitory symptoms, or they might develop more severe symptoms. Children are particularly vulnerable, as they generally are more helpless and more easily frightened than adults. Adults generally are more knowledgeable, have more emotional resources, and have more perspective on the situation. Vulnerability to trauma increases according to the severity of and exposure to the trauma (Lonigan, Shannon, Finch, Daugherty, & Taylor, 1991; Nader, Pynoos, Fairbanks, & Frederick, 1990; Pynoos, Frederick & Nader, 1987). The severity of exposure to the traumatic experience is mediated by the person's perception and personal meaning of the event (Milgram, Toubiana, Klingman, Raviv & Goldstein, 1988), and prior traumatization, as well as psychopathology, can increase the impact of the trauma experience (Burke, Borus, Burns, Millstein, & Beasley, 1982; Earls, Smith, Reich, & Young, 1988).
Post-traumatic phenomena such as hospitalization and separation from loved ones, as well as other displacements, might add to the traumatization (Cohen, 1988; McFarlane, 1987). Personal styles, such as exhibited by individuals who are more prone to avoidance, denial, and external locus of control, versus individuals who are actively facing and integrating experiences, also may increase their vulnerability (Gibbs, 1989; Hyman, Zelikoff & Clarke 1988).
Gender risk factors also should be considered. For example, Rossman (1992) found that girls used the coping responses of social support (e.g., peers and parents) and expression of distress (e.g., self-blame) significantly more often than boys, who typically use humor and expression of anger (e.g., ventilation). Resilient individuals, as described by Mash and Dozoise (1996), are those who manage to avoid negative outcomes or achieve positive outcomes despite being at significant risk for developing psychopathology. Resilient individuals cope well in spite of great stressors, and they recover from trauma. Resilient people, however, may become overwhelmed if they lose their supports and if the traumatic event persists.
In addition, individuals' perceived safety and security, as well as their ability to assimilate the traumatic event into their perception of themselves and the world, influence their level of traumatization. People who perceive themselves as invulnerable generally hold the following core assumptions about themselves and the world (Janoff-Bulman, 1988):
1. The world is benevolent (people are inherently good; good things happen to people).
2. Events in the world are meaningful and make sense.
3. Good things happen to good people.
Traumatic events often challenge these core assumptions. Bowlby (1969), a developmental ist, suggested that people need to create working models of the environment, and their self-organismic model. Trauma survivors often have difficulty assimilating the traumatic experience into some kind of meaningful context, which shakes up their environmental and organismic model. Frankly (1959) suggested that people who lose the "why" to live also may lose the "how" to live.
According to Perry (1994), experiencing trauma can have severe and long-term effects on the emotional, cognitive, and behavioral functioning of trauma survivors. The term "trauma reaction" refers to the acute stage, which can occur soon after the traumatic experience and includes the psychology and (neuro-) biology of trauma. The survivor's reaction to the trauma might induce various behaviors such as shock, disbelief, anger, anxiety, confusion, and helplessness. Often, trauma survivors report low self-esteem and depression, even suicidal ideation. In addition, they might report concentration problems, cognitive functioning problems, disorganization, memory problems, hypervigilance, agitation, or even apathy. These trauma effects were observed in combat veterans as far back as the Civil War (DeCosta, 1871; Bury, 1918; Frazer & Wilson, 1918; Dobbs & Wilson, 1960; Bleich, Siegel & Garb, 1986).
Only recently, however, has the trauma-associated syndrome (prominent affective symptoms and a hyperactive sympathetic nervous system [Brende, 1982]) been called posttraumatic stress disorder (PTSD) (Perry, 1994). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR, 2000):
The essential feature of Posttraumatic Stress Disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate. (p. 267)
Because many trauma survivors deal with PTSD, for the purpose of this article, the focus will be on the psychological symptomatology and duration criteria (as defined by the DSM-IV-TR) and the biological symptomatology, as well as assessment and treatment of PTSD.
PSYCHOLOGICAL SYMPTOMATOLOGY AND DURATION OF PTSD
The diagnostic criteria for PTSD, according to the DSM-- IV-TR (2000), are:
A. The person has been exposed to a traumatic event in which both of the following were present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
(2) the person's responses involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.
B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
(1) 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.
(2) Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
(3) Acting or feeling as if the traumatic event were recurring (including a sense of reliving the experience), illusions, hallucinations, dissociative flashback episodes, (including those that occur in awakening or when intoxicated). Note: In young children, trauma-- specific reenactment may occur.
(4) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
(5) Psychological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversation associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g., unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hyper vigilance
(5) exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor. (p. 268)
PHYSIOLOGICAL SYMPTOMOTALOGY OF PTSD
Contemporary research on the biology of PTSD has confirmed that there are profound and persistent alterations in physiologic reactivity and stress hormone secretion in people with PTSD. Pitman, Orr, and Shaley (1993) believe that the critical issue of PTSD might be a variety of triggers not directly related to the trauma that precipitate extreme reactions. The brain is an analyzing and amplifying device for maintaining people's internal and external environment (MacLean, 1988), and if emotional arousal is intense and persists, as often has been experienced by trauma survivors, the person may develop conditioned emotional and biological responses with long-term effects. High levels of emotional arousal are likely responsible for the observation that traumatic experiences initially are imprinted as sensations or states of physiological arousal that often cannot be transcribed into personal narratives (van der Kolk & Fisler, 1995).
High levels of emotional arousal can result in chronic hyperarousal, often resulting in the trauma survivor shutting down by avoiding stimuli that reminds them of the trauma, and through emotional numbing (Liz & Keane, 1989). Abnormal psychobiological reactions in PTSD can be broken down into:
1. Conditional responses to specific stimuli (include heightened physiologic arousal [increase in heart rate, skin conductance, blood pressure that can last months or years] to sounds, images, and thoughts relating to the traumatic event) (Blanchard, Gerardi, Kolb, & Barlow, 1986; Malloy, Fairbank, & Keane, 1983; Pitman, Orr, Forgue, deJong, & Claiborn, 1987)
2. High levels of emotional arousal, which may result in chronic hyperarousal, often resulting in trauma survivors' shutting down by avoiding stimuli that remind them of the trauma and through emotional numbing (Liz & Keane, 1989).
According to Kolb (1987), excessive stimulation of the central nervous system (CNS) at the time of trauma can result in permanent neuronal changes impacting learning, habituation, and stimulus discrimination.
Neurohormonal Responses to PTSD
Intense stress is associated with the release of endogenous, stress-responsive neurohormones, such as cortisol, epinephrine, and norepinephrine (Kolk, 1997, p. 16). Stress hormones are helpful in that they increase glucose production to deal with the need for increased energy and bolster the immune system to deal more effectively with the stress. This quick and effective response of the endocrine system helps the body return quickly to baseline levels. Chronic or catastrophic stress as often experienced by trauma survivors, however, has the opposite effect on the endocrine system.
The neurohormone NE initiates the fight-or-flight response. It also assists in memory consolidation (Kolk, 1997). Neuroendocrine studies of Vietnam veterans with PTSD have found good evidence for chronically increased sympathetic nervous system activities in PTSD (Kolk, 1997, p. 18). A study conducted by Kosten, Mason, and Giller (1987) revealed that the urinary NE and epinephrine of PTSD combat veterans were elevated in patients with psychiatric problems.
In acute stress situations, according to Munch, Guyre, and Holbrook (1984), cortisol helps to regulate the release of stress hormone. Yehude, Southwick, and Mason (1990) believed that the function of the glucocorticoid system is to stop other biological responses that set in soon after the person has been exposed to severe stress. Chronic or catastrophic stress associated with trauma decreases glucocorticoid levels, and it is believed that low glucocorticoid levels create a vulnerability for PTSD. A study conducted by Resnick, Yehuda, and Pitman (1995) involved measuring cortisol levels in the blood of 20 rape victims, and a trauma history was obtained from each. Victims with a history of trauma had a significantly higher risk for PTSD after 3 months than those who had no prior history of trauma. In this study, cortisol levels of victims with a trauma history were compared to victims without a history of trauma. The mean initial cortisol levels of victims with a trauma history was 30ug/dL, and 15ug/dL for victims without a trauma history.
It is believed that cortisol levels are associated with immune function. Research also has shown that many chronic PTSD clients who struggle with health problems often report an increased use of medical services (Saxe, Chinman, & Berkowitz, 1994). Wilson (1996) conducted an immunology study of 12 women with a history of childhood sexual abuse and a control group of 12 women without a history of abuse. The study revealed that the immune function between the two groups was almost the same, with the exception of the CD45 lymphocytes (memory cells of the immune system). The women with a history of childhood sexual abuse reported more immunologic challenges, and they immunologically resemble patients with rheumatoid arthritis, lupus, and sarcoidosis (Kolk, 1997).
In short, trauma can create persistent and intense stress, which can impact a person's biological responses. Interest in understanding the physiological impact of trauma on trauma survivors is growing, and research in this area is providing more insight into biological responses generally associated with PTSD.
TRAUMA SURVIVORS WHO ARE AT HIGHER RISK OF PTSD
High levels of stress or exposure to major stressors increases the risk for developing PTSD (Shore, Tatum, & Vollmer, 1986). The impact a traumatic event has on a survivor depends on the duration (from seconds, to minutes, hours, a week, months or even years), the frequency (a one time occurrence versus multiple occurrences), and the severity (threat to the safety or life of others, a loved one, or self). The impact must be sufficient for survivors to question themselves and their relationship with the world.
For example, at the Columbine High School shooting, Eric Harris and Dylan Klebold played "peek-a-boo" and laughed when children pleaded for their lives. Some were shot, and others were left alone. This example illustrates how a traumatic event might challenge the trauma survivor's view of human nature. Previous beliefs that humans are basically good may no longer hold true for trauma survivors, because how can they explain the cruelty associated with manmade disasters and traumas? Epstein (1990) raised four possible questions that trauma survivors should answer:
* Is the world benevolent or malevolent?
* Is the world meaningful or meaningless?
* Am I worthy or unworthy?
* Are others trustworthy or untrustworthy?
Trauma survivors with a history of psychological disorders are at higher risk for PTSD than survivors without that history. For example, in a study conducted by Helzer, Robins, and McEvoy (1987) with trauma survivors, a high correlation was found between behavioral problems prior to age 15 (school expulsion or suspension, early sexual activity, substance abuse, school behavior problems, fighting, running away from home, stealing, lying, truancy, and vandalism [four or more of these problems]) and PTSD after exposure to a traumatic event. Beck, Emery, and Greenberg (1985) found a high correlation between depression and PTSD. Another study, conducted by Beck and Freeman (1990), identified that trauma survivors who have an antisocial disorder are at higher risk for PTSD than are other trauma survivors. These are just a few examples indicating that trauma survivors with a history of these and other personality and psychological disorders are more apt to develop PTSD.
Research also has shown that trauma survivors who come from families with psychiatric histories are at higher risk for developing PTSD. For example, one study conducted by Davidson, Swartz, and Storck (1985) found that 66 percent of combat veterans with a family history of psychiatric disorders developed PTSD. The underlying idea is that those who grow up in a family with a history of psychiatric disorder(s) are more likely to develop maladaptive behavior, thinking, and feeling.
One of the most predictive indicators of trauma survivor's developing PTSD is a lack of coping skills, particularly in how people relate to the world. Dysfunctional coping skills place trauma survivors at higher risk of developing PTSD. Scales such as the Trauma Constellation Identification Scale (Dansky, Roth, & Kronenberger, 1990) can be helpful in assessing the trauma survivor's coping skills. A study conducted by McFarlane ( 1988) found that Australian bush firefighters who scored high on problem-avoidance thinking were at high risk for both acute and chronic distress.
According to Hooley, Orley, and Teasdale (1986), family support of trauma survivors through their emotional depression is important. They further report that lack of support, as well as overinvolved or particularly critical families, have a less desirable effect on the trauma survivor. This means that effectiveness of family support in helping the trauma survivor depends on the nature, quality, and quantity of the support, which can either ameliorate or exacerbate PTSD. For example. a study conducted by Brown and Harries (1978) on trauma responses of women found that women in steady relationships had a lower rate of depression than women without a steady relationship. Interpersonal relationships can provide the support the trauma survivor needs, as well as an opportunity for the survivor to talk about the trauma.
The amount of support provided is less important than the trauma survivor's perception of the support provided. Also, the level of support needed to prevent PTSD varies from person to person. Trauma survivors must talk about the trauma, as much or as little as they feel comfortable with. Interpersonal relationships provide an opportunity for the trauma survivor to talk, which decreases the possibility of PTSD.
Trauma survivors' level of stress or level of exposure, a preexisting personality or psychological disorder, family history. coping style(s), and support influence whether they will develop PTSD. In addition, the coping responses of trauma survivors with PTSD are often impacted. Support, resources, and education can help break this vicious cycle.
ASSESSMENT OF PTSD
PTSD can be assessed effectively through a comprehensive multi-method assessment of structured or semi-structured interviews and self-report measures. PTSD should be assessed using the DSM-IV-TR (2000) criteria, and should not be based on the belief that exposure to trauma will result in PTSD, as not every trauma survivor will actually experience PTSD (Breslau, Davis, Andreski, & Peterson, 1991). A thorough assessment of each trauma survivor is important, because research has shown that individuals who have experienced trauma are at a higher risk for repeat trauma than individuals without a previous history of trauma (Keane & Wolfe, 1990; Shore, Tatum, & Vollmer, 1986).
The assessment should involve questions about potential multiple traumas (stressors) in the trauma survivor's history. Trauma survivors should be assessed regarding the complexity of their trauma experience. Was the survivor exposed once, twice, or more often to a specific trauma or multiple traumatic experiences? Is the trauma survivor putting himself or herself in a situation of continuous traumatization? Are there signs and symptoms of PTSD (such as hyperarousal symptoms, nightmares, intrusive memory)? (Throughout the trauma survivor's lifespan, PTSD symptoms might fluctuate and be experienced with different durations and intensities.) How does the trauma survivor deal with normal life-cycle transitions and normal developmental transitions? Do they worsen the situation? How does the survivor deal with trauma anniversaries and other "triggers" (visual, auditorial, olfactory, and tactile)?
The multi-method assessment also should include careful evaluation of the trauma survivor's: (1) mental health (DSM-IV-TR diagnosis, treatment [inpatient and outpatient], present level of functioning), (2) substance and/or any other drug abuse history and present use, (3) physiological problems (hospitalizations, chronic physical problems [past and present, chronic or acute]). Further, a careful assessment covers the trauma survivor's life history, including family of origin and individual pre- and post-trauma levels of functioning. Finally, the assessment must focus on the trauma survivor's presenting problems, current life situation, strength, resilience (ability and skills to cope), beliefs, and attitude(s).
A multi-method assessment incorporates (1) structured and/or semi-structured interviews, (2) self-report checklists, and (3) empirically developed psychometric measures. with the understanding that no one assessment is sufficient to draw accurate conclusions or the diagnosis of PTSD for trauma survivors. A multi-method assessment also will help to avoid bias toward some trauma survivors (instruments that are less sensitive toward multicultural trauma survivors, immigrants, and so on) and the difficulties that trauma survivors might experience during the assessment (as a result of fatigue, language and/or reading difficulties, or concentration problems).
Some methods might be more conducive than others to some trauma survivors. Kane, Wolfe, and Taylor (1987) reported that using a multi-method assessment can help overcome potential psychometric limitations existing in any one type of instrument. The assessment of PTSD using a multi-method assessment can maximize the accuracy of the diagnoses.
Structured and/or Semistructured Interviews
Structured and/or semistructured interviews allow information to be collected in an organized fashion and give trauma survivors an opportunity to talk about the trauma experience using their own language and metaphors, focusing on areas that were experienced as particularly important and/or traumatic. It also provides an opportunity for the mental health professional to observe the trauma survivor for potential signs and symptoms of PTSD and to ask questions to clarify any information provided by the trauma survivor and prompt the trauma survivor to elaborate on answers, encouraging more sharing of information. The mental health professional can pace the interview according to the trauma survivor's ability to talk about the experience. Six different structured and/or semistructured interviews are available today to assess a trauma survivor for PTSD.
1.Structured Clinical Interview for the DSM-III-R (SCID) (Spitzer, Williams, Gibbon, & First, 1990). The SCID has been used most widely to assess for PTSD across a broad spectrum of trauma survivors. It has been shown to have high reliability when used by different mental health professionals, and high correlation with other PTSD psychometric measures. Diagnostic Interview Schedule (DIS) (Robins, Helzer, Croughan & Ratliff, 1981). The DIS has been popular in communities dealing with situations of disaster. As of this writing, though, this semistructured assessment tool, has little empirical evidence as to its diagnostic (PTSD) ability.
Structured Interview for PTSD (SI-PTSD) (Davidson, Smith, & Kudler, 1989). The SI-PTSD can be used to assess the severity and frequency of some PTSD symptoms (i.e. nightmares). It also allows the mental health professional to assess through observation (rather than questions) for "constricted affect." The SI-PTSD has acceptable reliability and has been validated thus far only with veterans.
4. PTSD Interview (PTSD-1) (Watson, Juba, Manifold, Kucula, & Anderson, 1991). The PTSD-I is a short interview in which trauma survivors are asked to rate their severity of symptoms on a 7-point Likert scale. It was found to have good test-retest reliability as well as internal reliability. Interestingly enough, the PTSD-I can be administered by lay interviewers, but this self-report interview is quite short and therefore might be somewhat limiting.
5. Clinician-Administered PTSD Scale (CAPS) (Weathers, 1993). CAPS was developed in an attempt to address the limitations of the already existing scales. CAPS assesses the severity and frequency of PTSD. It has clear behavioral anchors for diagnosing PTSD symptoms and also can generate continuous and dichotomous indicators of PTSD. CAPS has very good test-retest reliability and good inter-rater reliability. It is a good tool for use by mental health professionals and researchers alike.
6. PTSD Symptom Scale Interview (PSS-I) (Foa, Riggs, Dancu, & Rothbaum, 1993). The PSS-I is a 17 item semistructured interview assessment tool used to assess the severity of PTSD symptoms over a 2-week period. It can be administered by a layperson. The PSS-I has excellent inter-rater reliability and good internal consistency. It has been validated only with female survivors of sexual and criminal assault.
PTSD Self-Report Checklists
A multi-method PTSD assessment should include PTSD self-report checklists, which provide trauma survivors' perceptions of their symptoms. Although this kind of assessment is both time- and cost-effective, it can be somewhat biased because it is the trauma survivor's perception. There are four PTSD self-report checklists.
1. PTSD Checklist (Weathers, Litz, Herman, Huska, & Keane, 1993). The PTSD Checklist is a 17-item measure. It has been shown to have a positive correlation to other standard measures of PTSD (i.e. Mississippi Scale), but thus far has been validated only with male combat veterans.
2. PTSD Symptom Scale Self-Report (PSS-S) (Foa, Riggs, Dance, & Rothbaum, 1993) is a 17-item (the same items as the PSS-I [described earlier]) self-report measure. Today, it has only limited validity data available and has only limited ability to identify trauma survivors with PTSD. The PSS-I's strength is its shortness.
3. Modified PTSD Symptom Scale Self-Report (MPSS-- S) (Falsetti, Resnick, Resnick, & Kilpatrick, 1993). The MPSS-S, a revision of the PSS-S, asks trauma survivors to rate the severity and intensity of PTSD symptoms over 2 weeks. At this time it is not clear if adding the severity and intensity ratings has strengthened the scale.
4. Dutch PTSD Scale (Hovens, Falger, Op den Velde, Mweijer, deGrown, & van Duijn, 1993). The Dutch PTSD is a 28-item scale PTSD originally developed to be used with Dutch World War II resistance fighters. Today, despite its initial psychometric promise, this assessment has been used only with elderly war veterans.
Psychometric (Empirically Derived) Measures
Several empirically derived measures have been developed to identify trauma survivors who do and do not qualify for the PTSD diagnosis.
1. PTSSD Scale of the MMPI-2 (MMPI-PS) (Schlenger & Kulka, 1989). The MMPI-PS is a 75-item scale used thus far only with Vietnam veterans. It was developed to identify veterans with PTSD, other psychiatric problems, or no psychiatric problems. Additional research on this scale is needed.
2. Crime-Related PTSD Scale (Saunders, Arata, & Kilpatrick, 1990). The Crime Related PTSD is a 28-item scale that is self-explanatory.
3. SCL-90R PTSD Subscale (Green, 1991). The SCL-90R PTSD is a 12-item scale used with disaster survivors.
4. War-Zone-Related PTSD Scale (Weathers, Litz, Keane, Herman, Steinberg, Huska & Kraemer, 1996). The War-Zone-Related PTSD is a 25-item scale. Although it seems to be a solid measure, the scale has not been used with non-war-related trauma survivors as of this writing.
5. Impact of Event Scale (IES) (Horowitz, Wilner, & Alvarez, 1979). The IES, 15-item scale. is the most widely used PTSD assessment scale. It has been used with a wide spectrum of trauma survivors. The IES assesses for only intrusion and numbing symptoms, though, which is somewhat limiting.
6. Trauma Symptom Inventory (TSI) (Briere, Elliott, Harris, & Cotman, 1995). The TSI consists of 100 items and 10 clinical scales to assess trauma survivors for severe PTSD symptoms. It assesses the severity and frequency of the PTSD symptomology over 6 months. The scale still is being evaluated regarding its empirical soundness.
7. Mississippi Scale for Combat-Related PTSD (Keane, Caddell, & Taylor, 1988). The Mississippi Scale for Combat-Related PTSD 36-item scale is one of the most widely used PTSD assessment scales. Several versions are available for working with a variety of clients. The scale appears to be a fairly accurate indicator of PTSD.
8. Women's War-Time Stressor Scale (Wolf, Furey, & Sandecki, 1989). The Women's War-Time Stressor Scale consists of 27 items. It is designed to assess psychosocial stressors unique to veterans who have experienced PTSD. The scale has good internal consistency and test-retest reliability (within 12-18 months) and good convergence validity with other PTSD measures.
Psycho-Physiological Assessment
Psycho-physiological measures generally include determining the trauma survivor's heart rate, blood pressure, muscle tension, and peripheral temperature. Trauma-related clues often result in an elevation of these physiological measures for trauma survivors with PTSD (Blachard, Gerardi, Kolb, & Barlow,1986; Malloy, Fairbank, & Keane, 1983; Pitman, Orr, Forgue, deJong, & Claiborn, 1987). Interest in the physiological assessment of trauma survivors is increasing (Shalev, Orr, & Pittman, 1993), but more research is needed with this assessment technique to determine symptomology associated with various trauma survivors with and without PTSD.
Collateral Assessment
During the assessment period it is important to obtain reports from the trauma survivor's mate, family members, and friends, as the survivors themselves can be in denial about possible PTSD symptomology, as well as their ability to function and possible safety issues. The information gathered should include the trauma survivor's medical, psychological/mental health, school and/or job history, to support the trauma survivor's self-report or amplify the change that occurred as a result of the traumatic event.
Collateral assessment generally is not available through empirically based instruments or in-session professional observations. Nevertheless, it is important to get a better understanding of the survivor's functioning, and this might require inviting family and/or friends to join a session.
Synopsis of Assessment Information
Although most mental health professionals probably will use only a few of the assessment tools described above, they should choose at least one from each of the above categories, making sure that they gather information regarding:
* Trauma event
* Coping ability
* Avoidance
* Intrusions
* Reactivations of possible previous trauma
* Irritability
* Neurotic symptoms
* Substance abuse
* Life circumstances
* Life prior to the trauma
* School and/or work performance
* Suicidal or homicidal ideation
* Support
* Commitment to counseling
This information will be a valuable resource to the mental health professional regarding the trauma survivor's history and present level of functioning, as well as to help guide the counseling. During the assessment process, the mental health professional must create a safe environment. This can be established by proceeding at a pace that is comfortable for the trauma survivor.
In addition, the assessment should be as predictable as possible: explaining the procedure, answering questions, and giving the survivor as many choices as possible. The mental health professional should explain the instruments being administered, with the understanding that the results will not be used to judge the trauma survivor but instead to guide the counseling according to the survivor's needs.
During the semistructured interview and collateral assessment a free-floating style is recommended, wherein the mental health professional's questions flow naturally and not in an inquisitorial way. All areas must be covered. The assessment of PTSD in trauma survivors should not be limited to the first counseling session but should be viewed as an ongoing process during the course of counseling.
TREATMENT OF PTSD
Trauma survivors with PTSD can be counseled in many ways. Nevertheless, the following general treatment principles are important and consistent across treatment approaches:
* Be supportive and nonjudgmental toward trauma survivors, and "meet them where they are" regardless of how long ago the trauma occurred, how severe it was, if there is a single or multiple history of trauma, if injury or another's death occurred, if the trauma survivor was in imminent danger, and so on.
* Demonstrate empathic listening.
* Establish safety by giving the trauma survivor as much control as possible, making counseling as predictable as possible, and being consistent during the counseling process.
* Be aware of the physiological, psychological, and developmental effects of trauma and provide psychoeducation.
* Regularly assess for potential safety issues.
In addition, when working with trauma survivors and their families (Jordan, in Review):
* Allow the trauma survivor to grieve.
* Expect the trauma survivor to go to school (children, adolescents, college students) or work (accommodations can be requested, as trauma is a recognized disability).
* Encourage stabilizing the family life after the trauma. Moving or a change of school or job should be discouraged unless school or work is the place of trauma, and in that case the situation should be assessed carefully. Change also can be advisable in situations in which a building or a whole neighborhood has been destroyed and living there is no longer possible. Otherwise, avoiding change is more conducive to receiving support from friends at school, work, and the neighborhood. In situations where a neighborhood has been impacted by the trauma, neighbors will serve as an important resource in the recovery process.
* Encourage trauma survivors to maintain their pre-- trauma routines. If they fear being alone, encourage them to invite a friend or family member to stay. Soft music in the background might be helpful. Also, encourage trauma survivors to enjoy themselves, and have fun alone and with others.
* Carefully assess couples for potential spousal abuse. If children are present, the possibility of child abuse should be considered.
* Assess couples for relationship problems and potential separation or divorce.
* See families together at first, focusing on the parental subsystem, strengthening that system, and teaching self-care. In situations of school violence or any other trauma their children) have experienced, the parents need to be freed from the guilt that they should have protected their child better. The sibling subsystem also should be strengthened, and should be taught self-care.
* Assess trauma survivors (and at times other family members) periodically for depression and suicidal or homicidal ideation. If needed, assess trauma survivors for the possible need for psychotropic medications, or hospitalization to allow stabilization. Often, trauma survivors are unable to ask for the help they need, and their families might not recognize that the trauma survivor has deteriorated. Because they live with the trauma survivor on a daily basis, they may not notice any changes, or they themselves might struggle with depression, suicidality or overall ability to function (they too have preexisting psychological problems, or may be trauma survivors, or be dealing with secondary trauma). Therefore, they might be in denial, or be afraid that the trauma survivor might get angry with them.
* Permit trauma survivors to grieve. Even though this can give rise to confusion, families should allow the grieving process to run its course.
* Focus on the trauma survivor's coping skills. For example, a lack of coping skills in adolescents might result in school truancy, sexual acting out, or suicidality (suicide pacts). Children might respond with anxiety and "clinginess."
* Provide psychoeducation for trauma survivors and their families; explain the physiological effects of trauma. They need to understand that as a result of trauma, the frontal lobe has been impaired, which generally affects planning, abstract thinking, judging, and new learning. This often helps explain why they are suddenly disorganized (when prior to the trauma event they had been highly organized), have concentration problems at school or the job, and have difficulty incorporating new information. Trauma survivors and their families should be told that with single trauma events this is not a permanent situation but should be expected to last at least 6 months.
* Work through the trauma of young children by providing experiential play therapy. Ask parents to provide opportunities for their traumatized child to talk and to be supportive when the traumatized child does talk. Do not push traumatized children to talk about the trauma, as this can retraumatize the child. Adolescent trauma survivors with PTSD are best served through experiential therapy, such as art therapy and music therapy, in conjunction with cognitive behavioral counseling. Adult trauma survivors with PTSD can benefit from cognitive-behavioral counseling (or other approaches such as exposure therapy and the narrative approach), and experiential therapy. Eye movement desensitization and reprocessing (EMDR) can be an effective tool with children, adolescents, and adults.
COGNITIVE-BEHAVIORAL COUNSELING (CBC)
The basic premise of cognitive-behavioral counseling is that cognition can impact emotions. Trauma survivors are dealing with difficulties not because of the traumatic event but, rather, the after-effects, such as the trauma survivors' changed view of themselves and the world. People who are depressed and negative generally recall other negative experiences more easily, which in turn lowers their mood even more (Blaney, 1986). This negative cycle can be broken through CBC. When using CBC in working with trauma survivors with PTSD:
* Carefully listen to and define the trauma survivor's presenting problem.
* Set up a collaborative agenda with the trauma survivor.
* Focus on the agenda items.
* Assign and review homework assignment(s).
* Be active, direct, and encouraging.
* Provide feedback from the former session.
When using CBC, the mental health professional focuses on two topics. These are safety issues and avoidance reactions.
Safety Issues and Intrusive Thoughts
Safety issues are taken very seriously and are addressed before any other topic. CBC mental health professionals operate under the premise that trauma survivors have to do the work and gain the insight, and the mental health professional guides and supports the survivors but cannot do the learning and growing for them. Homework assignments provide an opportunity for trauma survivors to practice skills outside the counseling session and serve as a springboard for further exploration and discussion in the counseling session.
CBC mental health professionals who work with trauma survivors with PTSD use specific techniques that reduce intrusive imagery/thoughts-the hallmark of PTSD. This issue is difficult for trauma survivors to deal with, as these images and thoughts are unbidden and occur at random and often inappropriate times. Trauma survivors often say they do not "feel themselves" any more. The extent of severity and the duration vary from trauma survivor to trauma survivor. Some survivors are bothered so much by this that they cannot fall asleep, or they have nightmares. Others report only limited intrusion.
CBC mental health professionals aim to help trauma survivors cope with intrusive imagery/thoughts through containment, desensitization, journaling, cognitive restructuring, and balancing out.
Containment
Clients need to be told that they can gain some control over their intrusive imagery/thoughts. In this regard, the containment technique can be helpful. For example, the trauma survivor can be told that he or she can set up structured times for intrusive imagery/thoughts, such as every afternoon between 5:00 and 5:30.
Another strategy is to ask the trauma survivor to wear a rubber band on his or her wrist, and every time an intrusive imagery/thought arises, to snap the rubber band. Or the survivor can be instructed to say aloud, "Stop!" or "No!" These approaches help trauma survivors take control of intrusive imagery/thoughts.
Desensitization
The containment exercise described might not work for some trauma survivors. Sufficient time and effort on the survivor's part is necessary before desensitization can take place. PTSD can be difficult to work with and requires adequate time and effort on the counselor's part, too. First, ask the trauma survivor to make an audio recording, describing the trauma in his or her own words. The trauma survivor then is to listen daily to the tape and not turn it off until he or she feels a little more relaxed. Only then can desensitization occur (Foe & Kozak, 1986).
If the trauma survivor is unable to relax even a little during the process, a relaxation technique such as a breathing exercise can assist in the process. Trauma survivors must understand that this technique might increase their emotional pain before lessening it, and realize that they might experience some relief over a 2- to 3-week period.
Before using this technique, CBC mental health professionals must have conducted a thorough assessment and history gathering, to rule out a multi-trauma history, safety issues, and other mental health disorders. The desensitization technique is not appropriate for those survivors and should be used only with those who have single trauma experiences, and then only after careful assessment to assure the trauma survivor's readiness for this technique.
Journaling
In journaling, trauma survivors are asked to write daily about the trauma for 30 minutes (trauma survivors should set an alarm to let them know when to stop writing), for a minimum of 4 days. Sometimes, instructing the trauma survivor to go for a walk or to engage in some exercise after the journaling is helpful.
The theory behind journaling is that writing repeatedly about a particularly traumatic event will lessen the intrusive thoughts and the negative power of the trauma. The time limitation prevents trauma survivors from getting into their feelings too deeply, particularly when they are alone at home without the support of family or friends and the expertise of a mental health professional. The counselor may want to limit the writing time to 20 minutes rather than 30. The trauma survivor brings the journaling into the counseling session to serve as a springboard for further exploration.
Cognitive restructuring
Cognitive restructuring is based on the CBC theory that the trauma exists not only in the trauma survivor's objective reality but also in how he or she has constructed the experience. In cognitive restructuring the client explores the whole trauma event without filtering out certain aspects of the experience. Meichenbaum (1985) believes that this will help the trauma survivor have a more accurate experience of what happened. The client might need some help to verbalize negative aspects of the trauma.
Balancing Out
Because negative experiences outweigh positive experiences for trauma survivors with PTSD, they may need help from the CBC mental health professional to identify positive memories. This can produce more of a balance between positive and negative memories and thereby promote better emotional health for the trauma survivor.
Avoidance Reactions
Trauma survivors with PTSD often report avoidance reactions. They avoid a specific situation or place because it triggers the trauma memory. Or the avoidance reaction could consist of cognitive avoidance, which means avoiding thoughts about the trauma. Avoidance reactions typically are not conscious but, rather, happen automatically. The CBC mental health professional can use desensitization and other techniques to avoid a situation or place, as well as cognitive restructuring and task orientation.
Desensitization
For trauma survivors to deal with their avoidance reactions of specific places or situations, the CBC mental health professional must assess how important those places and situations are to the survivors. Therefore, the survivor should rate these places and situations, subjectively evaluating the extent of discomfort. Trauma survivors should place these ratings in a hierarchical order, and with the help of the CBC mental health professional, develop some strategies for working through the hierarchy. Some trauma survivors find that the strategies originally developed do not work as well as they originally had thought. Flexibility should be permitted in developing new or smaller steps in working through this hierarchy.
Cognitive Restructuring
Many trauma survivors' sense of safety in the world has been affected. The CBC mental health professional must assist trauma survivors in accurately and realistically assessing how safe their present world actually is, recognizing that the trauma survivor might hold some cognitive biases, such as all or nothing thinking, mental filters, overgeneralizations, and jumping to conclusions. Careful assessment of the trauma survivor provides a good baseline of the trauma survivor's belief. The CBC mental health professional is challenged to assist the trauma survivor by correcting biases, exploring overgeneralizations, and helping trauma survivors develop a more realistic view of their environment.
In addition, the CBC mental health professional has to assess what kind of resources the trauma survivor has. These include personal resources; such as resiliency, support systems, partners, spouses, family, friends, and community resources such as housing support and medical assistance. Beyond the assessment, the CBC mental health professional should help trauma survivors achieve a safety level that is comfortable for them.
Task Orientation
Many trauma survivors with PTSD avoid not only threatening situations but all other purposeful activities as well. That trauma survivors are disengaged from purposeful activities is not surprising, as trauma experiences are apt to be overwhelming. One of the CBC mental health professional's challenges is to help trauma survivors become involved once again in purposeful activities. The CBC professional may accomplish this through gentle humor and direct confrontation.
Trauma survivors should be encouraged to separate out their various tasks and problems. Problem definition often is the most overwhelming task in this process. The CBC mental health professional can assist trauma survivors by identifying small steps they need to take to resolve the situation. Keeping the steps small makes the problem more manageable.
SUMMARY
The treatment of trauma survivors with PTSD is complex and can be highly challenging. Mental health professionals should get as much information as possible about how to work with trauma survivors, including research, workshops, and supervision. Ongoing education is important to keep abreast of the changes in assessment and treatment. Mental health professionals working with trauma survivors need to be aware of this cutting-edge research to provide quality care and provide help and guidance in the recovery process. Because mental health professionals who work with trauma survivors are at risk for vicarious traumatization (which occurs when mental health professionals are affected, personally and professionally, by their work with trauma survivors), they should seek regular trauma supervision (with a supervisor who understands trauma therapy, operates from a trauma model, and is knowledgeable about trauma assessment, diagnosis, and treatment), get involved in regular debriefing (individually or in the context of a group/peers), and limit the number of trauma survivors they work with.
Most mental health professionals face significant challenges in working with trauma survivors with PTSD and their families and partners while meeting the needs and providing quality care for all parties involved. Mental health professionals often are asked to provide services without sufficient training, information, the time to gather it, or adequate support. Most mental health professionals do not have the luxury of getting appropriate training before working with trauma survivors. These professionals may find themselves in situations in which they have to work with a trauma survivor with PTSD and not have the time to understand how best to serve the survivor-how to recognize and deal appropriately with safety issues as they arise and initiate the healing process. Mental health professionals often have to rely on information provided in articles and workshops to guide them in working with trauma survivors with PTSD. I hope this article has provided some guidance, through an overview of how to assess, diagnose, and work with trauma survivors with PTSD. Mental health professionals who work with trauma survivors with PTSD should seek additional training, trauma supervision, and regular debriefing.
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Karin Jordan is associate professor and chair of the Graduate Counseling Department, George Fox University, Newberg, Oregon. She has written several chapters and articles on trauma, as well as given presentations on this subject.
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