Anecdotally many of us are aware of the fear and/or suffering entailed when someone is subjected to a serious trauma such as an assault, an accident, a murder, being in violent combat or some type of natural or manmade disaster or accident. On a more formal basis, the impact of trauma on human beings has been well documented by health professionals for well over a century (Foa & Rothbaum, 1998).
In North America it is estimated that as many as 60% of adults have been exposed to some type of horrific event during their lifetime (Taylor, 2006). After a serious trauma such sexual assault, an accident or a disaster, most individuals will develop initial but temporary distressing symptoms such as increased physiological arousal, difficulty sleeping and increased negative affect (Brewin, 2003). However, for some individuals these symptoms can become severe and they may last for months, years or even indefinitely (Taylor, 2006).
PTSD as Defined in the DSM…
Although severe or longstanding reactions to trauma have long been acknowledged (e.g., nervous shock in the 1800’s), formal diagnostic recognition for such symptoms did not occur within the DSM (Diagnostic and Statistical Manual of Mental Disorders) until 1980. Since the 1980’s severe and/or prolonged reactions to experienced trauma are known as Posttraumatic Stress Disorder (PTSD).
Criteria for PTSD are very specific and start with the requirement that the person has to have been exposed to actual or threatened death, serious injury, or sexual violence in a specific manner, such as directly experiencing the event or witnessing it occurring to another person.
To meet criteria for PTSD after exposure to death, serious injury or sexual violence, a person has to experience a specific number of symptoms that fall into four main categories. The four symptom clusters within the DSM-5 (p.271) include: 1) intrusion symptoms such as nightmares or flashbacks, 2) persistent avoidance/numbing, 3) negative alterations in cognitions and mood, and 4) alterations in arousal and reactivity.
A formal diagnosis of PTSD cannot be given until the criteria as specified in DSM-5 are met, including the stipulation that the symptoms cause clinically significant distress or impairment. Interestingly some of the above symptoms, particularly intrusive recollections, efforts to avoid talking about the event and/or difficulty falling asleep, represent common reactions to trauma (Taylor, 2006).
In recognizing the normal propensity for individuals to react adversely to trauma and then often recover independently or without formal intervention, a diagnosis of PTSD cannot be given until at least one month has passed since the onset of the original traumatic event.
Some Known Risk Factors for PTSD…
Given that up to 60% of the population has encountered some type of trauma, while only 5-10% of individuals have ever meet criteria for PTSD, many investigators have been interested in the factors that contribute to the development of PTSD (Ozer et al., 2008; Litz et al., 2002; Taylor, 2006).
Although some research has pointed out risk factors such as being female or previous exposure to trauma, overall the literature points to the notion that peritraumatic psychological processes occurring during and after the trauma are a more significant predictor of PTSD development than prior characteristics (Ozer et al., 2008). In particular, dissociative type psychological responses during the trauma event appear to be the most robust factor contributing a subsequent development of PTSD.
Peritraumatic Dissociation involves psychological reactions such as reduced awareness, feelings of derealization, emotional numbing, an altered sense of time and amnesia (Brooner et al., 2009). Dissociative responding is also implicated in the continued persistence of PTSD symptoms in that “persistent dissociation interferes with the cognitive and emotional processing of traumatic events” (Taylor, 2006, p.37).
Making sense of PTSD using the Model of Emotional Expression…
The notion that interference in one’s ability to process a traumatic event can contribute to the severity and duration of PTSD symptoms can be further explained utilizing Kennedy-Moore & Watson’s (1999) model of emotional expression. This model explains how emotional expression arises from one’s internal emotional experience.
More precisely, the Kennedy-Moore & Watson model describes how there are five main cognitive-evaluative steps that occur in response to a precipitating stimulus (e.g., a sound that reminds someone of a trauma). Furthermore, unique responses at each step can result in either expression or non-expression of emotion (Kennedy-Moore & Watson, 1999, p. 8).
Although the steps do not routinely occur in a linear fashion, the five steps typically involve: 1) Pre-reflective reaction, 2) Conscious perception of response, 3) Labeling and interpretation of response, 4) Evaluation of response as acceptable, and 5) Perceived social context for expression.
Disruptions or circumvention of any of these steps will affect precisely how and even if emotion is expressed. In the case of individuals who are exposed to a traumatic stressor, disruptions at various points may even help determine whether a person goes on to develop PTSD symptoms by altering factors such as the extent to which the person dissociates from the event and the extent to which one attempts to either process or block subsequent emotions.
Understanding such disruptions is important for effectively conceptualizing and treating PTSD because as was mentioned, dissociative responses have been implicated as a contributor to the development of PTSD and many researchers have demonstrated that an inability or unwillingness to fully process a traumatic event is a main cause of persisting re-experiencing symptoms such as an increased startle response, nightmares and intrusive memories (Taylor, 2006; Ozer et al., 2008).
To conceptualize more precisely how disruptions within the process of emotional expression can play a role in the development of PTSD, consider an individual who has just encountered a violent physical assault. When first confronted with the event the individual automatically engages in a pre-reflective reaction, involving perceiving the perpetrator and quickly processing the significance of the event on a cognitive and emotional level (Kennedy-Moore & Watson, 1999). This processing is largely instinctual and if signifying danger it will invoke accompanying physiological changes (e.g., rapid heart rate) characteristic of an alarm response.
A significant disruption at the pre-reflective reaction stage often occurs in individuals who develop extreme physiological responses when exposed to a traumatic event. In particular, an individual may become physiologically overwhelmed to the point that they are no longer inclined to react to danger in the typical “fight or flight” manner, but instead their response is to “freeze” (Brooner et al., 2009; Ozer et al., 2008).
Depending on perspective, freezing can be framed as either adaptive or maladaptive. For instance, freezing could be adaptive in situations where it really isn’t feasible to run away or fight back and where remaining still could actually prevent further injury (e.g., a bear attack). However, freezing can also lead a person to dissociate from the event (e.g., feeling as if they are observing themselves from outside their body) and can also lead to increased guilt and self-blame post-event (e.g., “I should have done something) (Taylor, 2006).
Although initial freezing, may help one to better cope with extreme terror in the moment, if allowed to persist this type of responding could lead to a motivated lack of awareness, where a person will then attempt to avoid all instances of recalling and processing the event (Kennedy-Moore & Watson, 1999).
Individuals who have been traumatized commonly try to avoid any reminders of their distress (Taylor, 2006). Such avoidance interferes with the emotional and cognitive processing of the trauma because the person is not able to adaptively interpret and label their distress and this makes new learning difficult and rigid. As Elliot et al., (2003) explains, “when adaptive emotional processes are interrupted, the person remains in a state of incompletion” (p.297). As a result the person may continue to have re-experiencing symptoms such as flashbacks.
Individuals who remain in a state of “incompletion” may also start to express excessive fear in situations generalized from the original event. Alternately, some may even deny their distress altogether, which could then start to manifest itself in alternate pathological forms as a means of expression.
In support of this, Kennedy-Moore & Watson (1999) pointed out how a lack of verbal comprehension and/or acknowledgement of emotional experience are associated with problems such as depression, substance abuse, and somatization. Interestingly, although not surprising, at least 83% of individuals diagnosed with PTSD have been found to have an additional psychiatric diagnosis (e..g, anxiety, depression etc) and as many as 50% have three or more diagnoses (Schillaci et al., 2009).
PTSD and Emotion: The Case of Too Much or Too Little…
The notion that a failure to effectively process emotion can lead to either over-generalization of distress at one end or denial of intense emotion at the other may help explain why individuals with PTSD are commonly described as being either “emotionally blunted” or “emotionally flooded” (Kennedy-Moore & Watson, 1999, p.240).
In fact effective processing of emotion is so central to understanding and treating PTSD, that current treatment focuses almost exclusively on assisting trauma survivors to stop avoiding cues of the trauma and to facilitate their ability to recall, express and reflect on their distress (Cook et al., 2004; Foa et al., 1995; Hembree et al., 2003; Taylor, 2006).
During treatment for PTSD, the need to process the traumatic event and associated distress is often explained to clients by invoking the use of a filing cabinet analogy (Taylor, 2006). This analogy explains that trauma memories tend to develop quickly and become disorganized and fragmented.
When a person experiences a traumatic event they often try to forget about their distressing trauma memory. However, because the memory may be disorganized, similar to a folder filled with messy crumpled up papers, it can be hard to get the file to stow away neatly. Therefore it becomes necessary to take out the file (the memory) and go through each piece (the memory details, the emotion, the meaning) and re-organize it (process it) before being able to file it away without it being able to just pop open (similar to how unwanted intrusive memories or flashbacks will keep suddenly emerging).
The filing cabinet analogy is further illuminated by the understanding that a traumatic experience is initially encoded in implicit memory through somatosensory processing and if one does not actively recall, explore and reflect on the experience, the trauma will not become encoded within explicit or declarative memory (Luxenberg et al., 2001). Memories that stay locked within the somatosensory sub-cortical realm are more easily involuntarily re-activated by cues, whereas memories that become incorporated into the declarative realm within the frontal cortex are more easily voluntarily recalled and/or controlled.
Traditional Ways of Treating PTSD …
In understanding that processing one’s trauma is crucial to re-gaining executive function over the distressing emotion and memory of the trauma, current treatments for PTSD focus almost exclusively on assisting clients to recall and process the event(s). One way that this process is approached by some clinicians and is through prolonged exposure therapy in the form of imaginal and situational exposure (Cook et al., 2004; Foa et al., 1995; Hembree et al., 2003; Taylor, 2006; Taylor et al., 2003).
Imaginal exposure involves asking clients to expose themselves to the memory of their trauma by repeatedly narrating a vivid description of their trauma experience (Taylor 2006). The intent of imaginal exposure is to help clients habituate to the fear and anxiety invoked by their memories and to provide clients with an avenue for learning that their memories differ significantly from the original trauma in that memories themselves are not dangerous.
In contrast, situational exposure involves asking clients to directly expose themselves repeatedly to actual cues that remind them of the trauma (e.g., sounds or smells) and to situations that they are currently avoiding as a result of the trauma (e.g., driving). Typically both types of exposure are delivered in an individual environment for ninety minute sessions over of period of nine to twelve weeks (Hembree et al., 2003).
In addition to using prolonged exposure to treat PTSD, some therapists also employ cognitive restructuring to try and alter the client’s negative beliefs about the trauma and the subsequent meaning the client infers about themselves, the world or others (Taylor, 2006). Cognitive restructuring may be particularly useful for working with clients who have excessive self-blame about the trauma because it involves helping clients to examine their beliefs to identify distortions (e.g., omitting information) or extremes in thinking (e.g., catastrophizing). The process of helping clients to identify beliefs and to practice considering alternative perspectives functions to help clients reframe their experiences.
With cognitive restructuring and prolonged exposure historically being the two most common approaches within the literature for treating PTSD, several studies have attempted to compare the relative efficacy of each approach. Interestingly there has been mixed findings in this area. In particular there seems to be one group of researchers who have advocated for the sole use of exposure, another group advocating for the use of cognitive restructuring alone and a third group advocating for combining both approaches (cognitive processing).
Prolonged exposure proponents maintain that adding cognitive restructuring to exposure fails to lead to advantages over exposure alone and may even reduce the effectiveness of habituation by incorporating an element of distraction (Foa et al., 2005). These researchers have argued that since cognitive restructuring detracts from treatment gains obtained from exposure therapy, cognitive restructuring can be eliminated from most treatment protocols.
In contrast, Resnick et al., (2008) contended that exposure therapy only addresses the emotional experience of fear while overlooking important emotions such as sadness, anger, and guilt. After breaking down a combined treatment into separate components and finding that cognitive restructuring was more effective at reducing PTSD symptoms than exposure, these researchers concluded that “alteration in the meaning of the traumatic event may be an active mechanism of change and systematic and extensive exposure to the trauma may not be a necessary condition of treatment (Resnick et al., 2008, p.256). These researchers also argue that exposure poses risks for clients who struggle with emotional regulation difficulties, suicidal ideation and addictions because exposure may lead to an initial increase in re-experiencing and hyperarousal symptoms.
Although studies such as those cited above seem to indicate that combining prolonged exposure with cognitive restructuring may not lead to more effective treatment than either approach alone, most PTSD treatment protocols do appear to combine exposure and cognitive restructuring (Luxenberg, 2001; Monson et al., 2006; Taylor, 2006; Taylor et al., 2003). The tendency to frequently combine both approaches seems to result from a belief that both exposure and cognitive restructuring have something valuable to offer and that combining treatments will ensure that nothing valuable gets missed.
EMDR, a relatively newer form of trauma treatment that was developed in the 1980’s, does combine elements of exposure and cognitive restructuring. However, rather than focusing on talking about an individual’s trauma memories, EMDR focuses on a person’s internal experiences while working towards emotional and somatic resolution of disturbing memories that are still stuck or unchanged in the nervous system.
Although both exposure and cognitive restructuring processes contain valuable elements for treating PTSD, even with combining both approaches in a more progressive (and in my clinical experience- more tolerated way) approach such as EMDR, I believe that most traditional approaches to PTSD treatment still fail to fully utilize or acknowledge some remaining essential components of effective trauma therapy: namely, the increased importance of therapeutic relationship for trauma clients, challenges with the emotional defence system that can block effective trauma processing, and the potential importance of somatic processing.
A progressive way to Treat PTSD:
The notion that the therapeutic relationship is a key agent of change is central to emotion-focused therapy (EFT). The therapeutic relationship, solidified through principles such as presence, genuineness, prizing, trust and empathic attunement is the fundamental frame upon which therapy can effectively operate because it provides an avenue for safe exploration of self and a corrective interpersonal experience (Elliot et al., 2003; Gleiser et al., 2008).
Providing a relationally-based framework is particularly important for PTSD clients because most have been interpersonally harmed and are usually afraid of facing their distressing memories and emotions (Kennedy-Moore & Watson, 1999). Focusing on providing a corrective relational experience can serve to help counter-balance clients’ views of others as being hurtful or untrustworthy (Elliot et al., 2003).
Unfortunately standard treatment approaches, including CBT, Cognitive Processing Therapy and even EMDR, seem to take for granted that clients will be willing and ready to access, share and explore painful memories. Although most protocols do make mention of needing to be “respectful” and “sensitive” when asking clients to talk about their experiences and have even acknowledged that “disclosure may only occur as the individual comes to know and trust the therapist”, most therapy approaches not tend to suggest how therapists can facilitate a state of “trust” and “knowing” (Courtois, 2004, p. 416).
Approaches such as EFT and IFS therapy on the other hand make many suggestions on how to enhance the “healing relationship”, where the purpose is to “be with and for the other” (Elliot et al., 2003, p.74). The cornerstone of this “manner of being” with the client is an all encompassing attitude involving empathic attunement, facilitated through elements such as presence, empathic reflections, affirmations and conjectures.
A focus on empathy, communicated thorough acceptance, presence, genuiness, and prizing creates a climate of safety and helps PTSD clients to turn inward and start to process their distressing experience(s). Focusing on creating such a climate is a vital initial focus of therapy for PTSD.
Rather than jump ahead to a more inflexible agenda of processing the trauma, It’s important to initially focus on validating the client by listening to the issues they grapple with and empathically reflecting back to them an understanding of what they have been through and how they are feeling.Sometimes when clients initially describe their experiences, they may convey that they feel as if they are alone in their experience (Taylor, 2006).
EFT therapy can help to address feelings of aloneness by having the therapist remain empathically attuned to the client’s frame of reference in order to establish “common ground” (Bohart & Tallman, 1997). This sense of common ground helps clients to feel understood and to know that although their experience is painful, they are not alone and it does not have to be overwhelming.
An explicit focus on the relationship therefore helps to remove intolerable feelings of aloneness, provides a corrective attachment experience and helps to dissolve “overactive protective systems” that can initially interfere in assisting clients to process their adaptive emotions to completion (Gleiser et al., 2008, p.347).
Although a secure and emotionally facilitating relationship can be enough to help clients resolve their ambivalence about exploring and expressing their distress, sometimes it is helpful for the therapist to both 1) offer clients a more structured rational for why talking about the trauma can help resolve PTSD symptoms, and 2) utilize other approaches such as IFS (internal family systems) to first work on defences or “over-protective systems” that can lead to symptom worsening if not first addressed.
A CBT approach to PTSD treatment universally incorporates psycho-education about common reactions to trauma and exposure therapy into treatment protocols. In particular, it may be helpful to share information about common reactions to trauma, such as feelings of numbness, in order to help normalize a person’s experience and remove common fears about “going crazy”. The filing cabinet analogy mentioned above may help to explain how re-visiting the trauma, although initially painful, can actually help to reduce re-experiencing symptoms.
Unfortunately, cognitive approaches such as psycho-education are after not enough to successfully prepare people effective trauma processing, especially for people with complex trauma and/or more over-protective defence systems. No matter how well a rational for trauma-processing is explained, there is often a strong disconnect between the cognitive and emotional parts of the brain that can cause ambivalence about proceeding with processing work.
If focusing on empathic validation of a client’s ambivalence about processing their trauma and providing a clear rational is not enough to convince a client to explore and process their experience and associated feelings more deeply, it’s important to focus on building trust, developing internal & external resourcing, and engaging in emotional restructuring work (e.g., IFS or EFT) to help better prepare a person’s system for trauma processing.
Because of variables such as personality differences, existing stress levels and varied trauma histories, every client will prepare for trauma processing at their own pace. At the same time, it is important to know that there are options beyond continued supportive counselling to help people prepare for more fully treating the PTSD symptoms.
In particular, IFS can be used to help heal defensive systems that get in the way of proceeding with processing or unburdening painful core emotions that continue to drive emotional and psychological symptoms.In addition, modified EMDR protocols can be used to first build up internal resourcing (e.g., felt sense of being able to cope with processing) and to treat phobic responding and or high anxiety related to trauma material.
Changing behaviours to heal trauma:
Aside from building coping capabilities and processing painful memories, It is also important to help people shift avoidant behavioural patterns that developed as a result of trauma. For clients who are routinely avoiding situational reminders of the trauma, it’s important to encourage them to adopt in-vivo exposure practices and/or increase committed actions that move them in a direction of reclaiming their life as it was before the trauma or as they would like it to be.
Situational exposure can be particularly helpful for clients who need to return to work and for clients who have significantly changed their usual routines as a result of the trauma. Exposure to cues that remind one of the trauma is helpful to reduce long-term fear and anxiety because repeated pairings of conditioned cues with fear that does not lead to actual harm helps to extinguish the conditioned fear response (Gleiser et al., 2008). Although absolute safety, even within a therapeutic environment cannot be guaranteed, situational exposure encourages clients to balance reasonable risk with quality of life in order to re-establish a relative sense of safety.
Before assisting clients to implement this type of exposure it’s important to ensure that they understand the rational for exposure. It’s also important that they are willingly participating in the process and that they work slowly at their own pace in order to ensure success and confidence building at each stage. Success is integral to effective situational exposure because this can increase the sense of empowerment that clients can gain by overcoming trauma (Taylor, 2006).
Changing belief systems to heal trauma:
When people experience a trauma they often experience a challenge to their previously held cherished beliefs (Elliot et al., 2003). In particular their previously positive view of themselves, the world and others may be negatively damaged in that the person may suddenly see themselves as vulnerable, others as malicious or and the world as unpredictable and unsafe.
The negative transformation of previously positive beliefs has been referred to as “meaning protest”, which occurs when implications derived from the trauma (e.g., someone attacked me) cannot be consolidated with previous notions of “calm security” (Elliot et al., 2003). Often these transformed beliefs can lead to negative feelings such as guilt, shame, sadness and anger.
Although the effectiveness of formal cognitive restructuring for treating PTSD symptoms is still being debated by more traditional exposure therapy proponents, it makes intuitive sense that cognitive restructuring could be helpful for addressing negative beliefs and feelings, which are not addressed directly with prolonged exposure.
Trauma retelling as facilitated with approaches such as EFT and IFS, and the cognitive processing aspect of EMDR seems to allow flexibility in exploring the full range of emotions related to trauma because it encourages exploration of the client’s total experience, rather than just experience related to fear and avoidance and there behavioural impact.
A primary goal in exploring the range of experiences and emotions related to trauma is to help clients create new meaning. Meaning creation is an important part of trauma treatment because as cherished beliefs become compromised, individuals are often faced with an existential crisis requiring resolution.
Meaning creation helps to resolve such conflict by allowing clients to “create meaning out of the challenging life event” (Elliot et al., 2003, p.209). This process involves identifying and clarifying a meaning protest such as a traumatic event, specifying the meaning of the event, exploring one’s reaction, evaluating the tenability of the resulting belief, revising the belief in light of new information and emotional experience and applying the revised belief new experiences.
Through a series of elaborate steps meaning creation goes beyond exposure, and cognitive re-framing by identifying, exploring and transforming underlying emotion schemes in order to increase self-awareness and lead to a transformation in emotion, somatic sensations and experience.
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By Dr. Jennifer Barbera C. Psych
