Therapeutic approach when identifying and integration trauma

Identifying Trauma
The breadth of effects from trauma and the role of trauma in the development and exacerbation of other mental health issues are without parallel, except perhaps by psychoactive substance use. Despite similarity in destruction to substances, the devastation of trauma is paramount considering substances powerfully mimic and manipulate the nervous system at the chemical level. Trauma and associated effects can be just as damaging in shorter “doses” with more permanent consequences.

Trauma occurs when an event or series of events is perceived as very threatening. The traumatic event is so intense and/or unexpected that their brain generalizes the level of threat to non-equivalent situations. The brain does not realize that the traumatic event may have been abnormal or a special, unfortunate single instance. An overactive fight/flight/freeze/hide (also “fight-or-flight”) response becomes built into the person’s post-trauma response to the environment. The fight-or-flight response circumvents higher functions of the brain and diverts most energy to life-saving quick reflexes and responses (Castex, 2004; Demetral, 2010). Subsequent experiences of trauma, or retraumatization, can confirm and further encode the validity of the initial trauma and a tendency to respond in fight-or-flight (Castex, 2004). The effects of trauma are semi-permanent, persisting and affecting a person’s actions until the events are fully processed and new meanings are assigned to the traumatic events (Gagerman, 1997.)

Reactions to trauma and symptoms of trauma can vary greatly between persons, but follow some trends. An abnormal startle response is common for survivors of trauma, as are unprovoked or incongruently intense responses to seemingly harmless stimuli ((Patterson & Telesco, 2004; Demetral, 2010). Nightmares and flashbacks of traumatic images, sounds, and other perceptions can occur with or without related stimuli triggering recall (Westrup, 2010). Increased anxiety and panic attacks can follow traumatic events. There is a decreased window of tolerance of uncomfortable emotions, as emotional resources are chronically taxed due to hypervigilence and other overly active coping mechanisms (Curran, 2008; Demetral, 2010).

Substance use is often a symptom of trauma. Binge alcohol use is common particularly among males (but also females) with PTSD, as a way to cope with the chronic stress of trauma (Westrup, 2010). Consistent alcohol use where it was not present previously, and does not appear to be in response to a particular recent event, can be a symptom of underlying trauma. Some researchers have found a consistent correlation between traumatic stress and increased alcohol use (Patterson & Telesco, 2004).

Women tend to experience certain symptoms more often. Flackbacks, feeling dissociated, fear of being a wife or mother, and eating disorders are common responses to Military Sexual Trauma (MST) or other forms of PTSD. Of the staggering one-fifth of women who experience sexual trauma in the military, 76% also have a mental health condition – a much higher rate than non-sexually traumatized women in the military. (Westrup, 2010). Victims of sexual trauma can have immense difficulty in relationships with sexuality. The issue of repeated trauma, or retraumatization, is common for women in the military and victims of mass violence, among others (Castex, 2004; Westrup, 2010)

Law enforcement personnel experience trauma directly and through witnesses during their workweek. Along with other first responders, law enforcement personnel have the responsibility of constantly assessing safety for themselves, their colleagues, and civilians, leading to chronic stress, a form of trauma. Officers assigned to inner cities often experience the same trauma as military personnel at war. The effects of trauma on law enforcement personnel include emotional distance from families, disease due to being overstressed, compassion fatigue, and dismissiveness or dissociation from emotion. Family relations can become strained because the family cannot relate to the rush of power which officers feel during their work. Families typically do not follow the chain of command that is present in law enforcement, either (Patterson & Telesco, 2004). Military personnel can have similar problems, and families can have the experience of “putting the unit first.” Soldiers returning from war may have the added difficulty of feeling like an outsider in their families after being gone for so long (Curran, 2008).

Trauma responses can differ between age groups as well. Young children may cry, scream, suck their thumbs, have disrupted sleep or nightmares, be reluctant to leave the house, lose bladder/bowel control, and fear being alone, strangers, and darkness. Older children may have headaches, numerous physical complaints, depression, fears about weather, confusion, difficulty concentrating, and fighting. Adolescents can also experience headaches, and in addition they may have depressive symptoms, change friends, use substances, feel confused often, and perform poorly. Adults may have psychosomatic problems, such as a racing heart, ulcers or upset stomach, anhedonia, and cold or flu symptoms. Adults may also cry easily, have communication difficulties, feel overwhelmed, fear crowds or strangers, and have concentration difficulties at work. Older adults may experience memory loss, agitation, disorientation, confusion, accelerated decline in health, and suspicion (Castrex, 2004).

Treating Trauma

Like all mental health issues, treatment of trauma and related issues depends highly upon the individual. The following paragraphs outline a few trends in treatment.
Creating the experience of safety is crucial to healing trauma. Castrex (2004) recommends using open-ended questions, empowering people with choices and pointing out the multitude of choices, and normalizing reactions to trauma. Forcing or coercing clients to work through trauma can be retraumatizing (Castrex, 2004; Patterson & Telesco, 2004). Normalizing reactions to trauma is an important technique for helping people feel safe and work through traumatic memories (Gagerman, 1997; Castrex, 2004). Group therapy of trauma survivors can provide a safe environment where discussion, validation, and appreciation of traumatic experiences can occur. Individuals are able to recall repressed memories, assign new meanings to trauma, and reorganize their sense of self (Gagerman, 1997).

Both videos alluded to dialectical behavior therapy (DBT) being used as one modality of treatment for people affected by PTSD (Curran, 2008; Westrup, 2010). While DBT was not developed specifically for PTSD, it can be helpful due to the similar symptomology among PTSD and the populations for which it was developed, and the fact that many people who would benefit from DBT have experienced trauma (Patterson & Telesco, 2004; Psych Central Staff, 2007; Westrup, 2010). DBT is helpful for people experiencing abnormally intense responses to emotional situations. Affect regulation is built through psychoeducation, weekly homework, individual therapy, phone calls, and group therapy. The four modules of DBT teach skills in mindfulness, interpersonal effectiveness, distress tolerance, and emotional understanding or insight (Psych Central Staff, 2007).

Several other effective treatment were suggested by Westrup (2010). Seeking Safety (SS), described by Najavitz in 1996, is useful in treating people with PTSD and substance abuse. SS teaches very basic relationship and emotional regulation skills, similar to DBT. Each SS module can be used alone or as part of an ongoing curriculum. Cognitive Reprocessing Therapy and Prolonged Exposure Therapy both aim to assist clients with facing the memories they have been repressing, without victimizing themselves, and while increasing clients’ sense of control. For clients who struggle knowing self and have experienced trauma, Acceptance and Commitment Therapy (ACT) was recommended. ACT allows clients to connect to their past and present internal experiences, similar to the DBT skills of mindfulness and emotional understanding/emotional regulation.

Treating trauma survivors may be difficult for out-group practitioners because trauma has the power to bond people strongly, and the practitioner was not involved in the traumatic event (Castrex, 2004). Thus group can be effective in creating a therapeutic bond with alienated clients. For families, the practitioner can help the family members see themselves as a unit. Partaking in meaningful activities as a family may be beneficial to this process. Practitioners can assist families in brainstorming activities and break down barriers for follow-through (Curran, 2008).

Importance upon provider mental health cannot be overemphasized. The effects of secondary trauma upon providers can lead to high provider burnout, compassion fatigue, depression, and other difficulties (Patterson & Telesco, 2004; Westrup, 2010). Built into DBT is a recommended weekly support group for providers, to continue their personal growth and ensure processing of any countertransference (Psych Central Staff, 2007). Westrup (2010) describes how knowledge of the necessity of self-care is not equivalent to practicing self-care. She briefly recalled the effects of secondary trauma on her life while serving as program director for a highly regarded residential trauma treatment center.
Personal Reflections

When assessing for trauma in my clients’ histories, I know to look for the clusters of symptoms described earlier in this paper. Additionally, I will be more informed of the possibility of trauma in military families and law enforcement. The article by Patterson & Telesco (2004) was particularly illuminating, especially in its comparison of PTSD in law enforcement to soldiers. Personality disorders, especially borderline, have direct links to trauma assessment in my mind. Additionally, I know to assess for the age and context of the trauma, past treatment experiences, retraumatization, and current distressing situations which trauma has made easier to tolerate.

For myself, the treatment of trauma presents many rewards and challenges. Assessment for trauma begins upon first contact with the client or their parents. While much variation is always present, the trauma for most of my clients has come in the form of subtle relational discord or lack of attunement with primary attachment figures. Compiled upon the attachment breaks are usually years of shame and discounting or internal obsession upon emotion. The challenge of communicating the attachment breaks to parents in a disarming way often spans several sessions of education and intervention. When parents are able to see their blind spots and adjust themselves to match their children, my work feels very rewarding.

I have had some experience with survivors of severe trauma while working in an inpatient mental health program and while doing my current work at Recovery Happens. At Recovery Happens, parents of my primary clients more often have trauma then the clients themselves. The work with survivors of trauma at the inpatient level was very taxing for me personally. In my clinical work I focus on creating an experience of attunement for clients. In situations of severe trauma and mental illness, I often felt drained and withdrawn at the end of the day.

One client I worked with had an axis I diagnosis of major depression, recurrent, severe with psychosis, and an axis II diagnosis of cluster C traits, rule out dependent personality disorder. While doing his intake assessment he described growing up with incredible shame and internal discord due to his mother being repeatedly raped and molested by her father from a young age until she was in her 20s. He was a product of that rape. He often experienced auditory and visual hallucinations of his mother and father verbally abusing him, and flashbacks of his mother and father physically abusing him. Also, when he was 10 years old, he was riding his bike with a girl from his neighborhood. She was up ahead of him and a car T-boned her, smashing her into a tree and killing her instantly. He often struggled to free his mind of that image.

I grew professionally and personally due to working with that gentleman. Hearing about his intense trauma sent me into a withdrawn state for the next few days, and it took considerable discussion with my support, exercise and gardening to start feeling better. I was able to see firsthand how trauma shaped someone’s brain and (perhaps) caused psychosis. It gave me a new appreciation for self-care. Other experiences he described helped me understand how vulnerable he saw himself, which may have resulted in his dependent traits. It appeared that repeated traumas and psychological stress due to abuse and shame led to this man to have learned helplessness, void of self, and a sort of permanent Stockholm syndrome.

Having a fundamental understanding of trauma at the micro level will aid my practice at the macro level. Bad policy and poorly thought out business strategies can create chronic stress for affected populations. Swiftly implemented bad policy, such as the recent mental health budget cuts in Sacramento county, retraumatized the already severely traumatized low income population of mental health consumers. Good policy recognizes the attachment people have to the objects of “government” and “services” and embraces its responsibility to those who are served. Also, I know from my undergraduate research that when people are happier, they are more creative, more productive, and less likely to get sick – all of which create a more economically productive, efficient and stable society. As human beings in society, we cannot hide from our responsibility to do good for those who are most vulnerable and tormented.

I know now that for me, doing clinical work is probably not going to be something which lasts much longer, so in the future I believe experiencing vicarious trauma will not be as big a risk. I am filled with profound respect for clinicians who are able to remain balanced and work with trauma. I am personally drawn to bring social work values and practice skills into technology, science and business.

References
Castex, G. M. (2004). Chapter 9: helping people retraumatized by mass violence. In S. L. Straussner & N. K. Phillips (Authors), Understanding mass violence: a social work perspective (pp. 129-142). Boston: Pearson.
Curran, E. (2008). PTSD & Family Therapy. Retrieved April 1, 2011, from http://www.cominghomeproject.net/node/149
Demetral, D. (2010). The psychobiology of stress and the etiology of anxiety disorder(s). From Social Work 223 DSM: California State Univeristy, Sacramento; Fall 2010. Unpublished manuscript.
Gagerman, J. (1997). Integrating dream analysis with intersubjectivity in group psychotherapy.   Clinical Social Work Journal, 25(2), 163-178  
Patterson, G. T., & Telesco, G. A. (2004). Chapter 8: mass violence and law enforcement personnel. In S. L. Straussner & N. K. Phillips (Authors), Understanding mass violence: a social work perspective (pp. 117-125). Boston: Pearson.
Psych Central Staff. (2007). An overview of dialectical behavior therapy. Psych Central. Retrieved April 01, 2011, from http://psychcentral.com/lib/2007/an-overview-of-dialectical-behavior-therapy/
Westrup, D. (2010). Treating female veterans of war. Retrieved April 3, 2011, from http://www.cominghomeproject.net/node/143