Tag Archives: PTSD

PTSD and climbing out of the valley of the shadow of death

By Shirley Porter January 31, 2019

Max came into my office and sat down. He was a big guy in his late 30s. When I asked how I could help, he responded that he believed he had posttraumatic stress disorder (PTSD). When I asked what led him to this conclusion, he said he had been a sniper in the military and had been abused as a child. (Author’s note: The name of this client has been changed, but the content is accurate in accordance with his written and informed consent to share his story.)

My approach to trauma work has evolved over the years based on what we have come to learn about trauma through research, as well as on my own clinical observations. My therapeutic approach is rooted in client-centeredness, transparency, reverence, compassion and a belief in client strength and resiliency. On the basis of these values, essential components of this approach include accessible language/education, collaboration and evidence-based practice.

When it comes to education and accessible language, the use of metaphors can provide our clients with a much-needed bridge to understanding and normalizing their experiences. Active collaboration with our clients allows them the opportunity to find their power and use it. Because the experience of trauma often involves a feeling of loss of control and having things happen against one’s will, safe and respectful practice requires that clients be informed and willing participants in all aspects of the therapeutic process. And, finally, using evidence-based interventions allows us to provide professional, competent care in helping clients to alleviate their distress, process their trauma and reclaim their lives.

Introduction to the valley of the shadow of death

I often use the metaphor of the “valley of the shadow of death” to explain to my clients the experience of PTSD and the stages of healing. Some clients recognize this metaphor from the Bible’s well-known 23rd Psalm, which begins, “The Lord is my shepherd …” However, its use does not require any spiritual or religious belief on the part of the client or the therapist. I chose this metaphor because of its power.

As I wrote in my book Surviving the Valley: Trauma and Beyond, trauma occurs in “a dark and desolate place that exists in the shadow of some kind of significant ending — a real or symbolic death. In this place, you are apt to feel a profound sense of loneliness, despair and hopelessness. … There are no obvious pathways out of the Valley. The terrain looks treacherous and foreboding. It is difficult to know where to begin.”

In the valley of the shadow of death, the sky is often starless. It can be difficult to recall better times or to hope for them in one’s future. Experiences that send one into this valley typically involve the experience of witnessed, threatened or metaphorical death (e.g., the “death” of trust, innocence, a sense of safety, the belief in fairness or justice). Hope can be elusive.

In my practice, this metaphor has proved to be a powerful means of helping clients find the words to explain what their experience has felt like. I typically introduce this concept somewhere between the first and second phases of trauma work, but I am explaining it to readers here so that the metaphor will make sense from the outset. What follows is the phases of trauma work, explained from the perspective of the metaphor of the valley of the shadow of death.

Phase 1: First things first

Max had never been assessed for PTSD previously. His symptomology was intense. At times, he could be completely dissociated from his body, such as when he walked on a broken leg for a week because he did not feel the pain.

Emotionally, Max was numb. He hadn’t felt emotions for years. He lived his life in survival mode — making him fantastic in a crisis — but Max’s body and mind were always on high alert for threats. He was exhausted, having flashbacks and starting to experience life-threatening medical issues.

We began our work together by assessing and identifying his injuries and normalizing his symptoms. I also started to reflect back his strength, resiliency and courage. At the same time, I was clear with him that he deserved, and would need, external supports along the way. We worked on connecting him with resources for veterans and with medical supports. Max found the metaphor of the valley of the shadow of death to be an apt representation of what he had been living.

 

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Once we have determined that our clients are in the valley, we need to identify, assess and begin to respond to their injuries. There also may be crises that require our immediate attention and response. 

Some clients will have landed hard in the valley. They may have physical injuries in addition to the psychological ones. Before we even think about moving forward or delving into details of the trauma, we need to identify and assess injuries by asking clients which ones are causing them the most distress currently. (I use the Traumatic Stress Symptom Screening Checklist, which I developed and included in my book Treating PTSD: A Compassion-Focused CBT Approach.) At this point, we can discuss whether mobilizing community, medical, family or peer supports might be helpful to the client. If the client needs help connecting with these supports, we may need to liaise or advocate on the client’s behalf.

Reassurance is a component of this phase. Some clients may be carrying the added burdens of guilt or shame that can come with the misunderstanding that if they were stronger, they would not have ended up in this dark place. Thus, we may need to let them know that traumatic stress reactions are not a result of weakness or character flaws; rather, these are normal reactions to what they have been through.

Given that despair and hopelessness can be part of the symptomology of individuals who find themselves in the valley, checking for suicidal ideation and intent is also essential at the start. If a client is suicidal, it is best we are aware of this at the outset so that we can conduct a risk assessment, create a safety plan with the client and mobilize appropriate resources.

Some clients will not have the strength at this point to hold on to hope. With these clients, I tell them that with all they are dealing with, I recognize that their strength might be lacking, but not to worry because I will hold on to hope for them. I further reassure them that I fully believe we will be able to get them to a point where they can effectively manage their distress and reclaim their lives. (Many of my clients in this situation have responded with relief and gratitude.)

Clients might also be living in unsafe environments that require safety planning or other interventions. This can be another piece of assessing and responding to crises in this phase.

Phase 2: Stabilization and gathering tools for the journey

Throughout the course of trauma work with Max, I provided him with information on how trauma, and specifically complex trauma, can affect the mind and body. He was familiar with the fight-or-flight trauma responses but had not realized that his capacity to respond so effectively in high-risk situations was a result of conditioning through his military training. His experiences and symptoms started to make sense to him, and thus his shame receded.

Max had learned to ignore his physical needs at an early age, which is common with children who suffer from chronic childhood abuse. The first homework assignment that I gave him had three parts to it: 1) to notice when he was hungry and to eat; 2) to notice when he had to go to the bathroom and to do so; and 3) to notice when he was tired and to go to sleep. He smiled when I gave him this assignment and asked how I knew.

Max related to the image of the “warrior spirit” (described further later in the article). Although it had meant something else in his military life, we redirected the energies of his warrior spirit to focus on protecting his healing and well-being.

 

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After assessing and attending to injuries and addressing any crises that clients might be facing, it is time to help them get their bearings in the valley and gather the tools they will need for their stabilization and containment — both for use now and on their trauma processing journey (should they choose to take this path).

Some clients will need time to rest and heal before moving on to the next phase of trauma work. We would not expect someone who has just been injured to begin what could quickly become a treacherous climb. Likewise, our clients will need to be stabilized before moving forward in trauma work. They need to be at a point at which they can successfully tolerate or reduce their distress without moving into crisis.

Education is an important component of this phase. Our clients need to know what is normal and what kinds of challenges they might encounter on their journey in the valley. Knowledge about how trauma affects the mind and body can provide our clients with footholds in the valley. We want to help them better understand trauma — specifically, what types of experiences can lead to traumatic stress responses, how people tend to react during traumatic events and the range of normal reactions following such events.

Our clients need to be aware that normal reactions following trauma might include difficulties in the physical, emotional, cognitive and spiritual aspects of their lives. During this part of the work, we are normalizing their reactions during and following their trauma experiences while empathizing with their current distress. It is important that we use easy-to-understand language and concepts in recognition that when our clients are in the throes of severe PTSD symptoms, they can handle only small, personally meaningful pieces of information. 

This part of the work also involves helping our clients identify and become comfortable using the tools and resources that will assist them in better tolerating or reducing the distress that they might encounter on their healing journeys. In my work, I have come to recognize 10 such resources or tools to support clients in their journeys.

Within the clients

1) Recognizing their “warrior spirit” within. This involves giving a name to the persona we want to encourage clients to connect with in terms of dual awareness — the strongest, wisest part of who they are that has allowed them to survive the trauma and brought them to this place.

2) Reducing commitments to reduce distress and give clients the time and space to heal.

3) Confronting or advocating with the people, systems, etc., that were involved in causing the trauma in an attempt to address these wrongs or to achieve a sense of justice (when it is safe to do so).

4) Using distraction strategies. These are actions that clients can take to remove themselves from spirals of nonproductive, stress-elevating thinking. Examples: going for a walk, texting a friend, cleaning, drawing.

5) Using mindfulness strategies. This involves moving clients’ awareness from their distressing reliving of past negative events, or their distressing fears of what might happen in the future, to the present moment via the five senses. Examples: noticing a favorite color in the room; feeling the chair one is sitting on; picking up a stone and noticing its texture, color and shape.

6) Using self-soothing strategies. This involves using the senses to calm, soothe or reenergize. Examples: sipping a hot drink, listening to music, inhaling the scents of nature, wearing soft and comfortable clothes, looking at a picture of a loved one.

Through connection with others

7) Seeking counseling support with a mental health professional who specializes in trauma work.

8) Seeking medical support to address physical or psychological pain resulting from injuries or symptoms that are causing distress.

9) Seeking spiritual support from a religious/spiritual leader or peer.

10) Accepting offers of support from caring friends, family members or peers to do household tasks, help with children or take on other responsibilities.

Phase 3: Beginning the climb

Since Max’s life seemed to go from one crisis to the next, it took some time for him to get to a place in which he wanted to start the climb out of the valley. We started with eye movement desensitization and reprocessing (EMDR), but he didn’t want to continue with it because he found the distress that ensued in the days that followed too disruptive to his academics (he was in a college program). Neither did he feel that he had time to do the homework that came with traditional cognitive behavior therapy (CBT). So, I adapted my interventions and created a compassion-focused CBT intervention that we could use in session.

Using a varied approach that met Max’s needs during any given session, we went down many paths together — grief and loss, guilt, shame, anger, dealing with relationship boundaries and so on. Over time, Max began to experience emotions again and had to learn how to manage them. He also started learning to respect his body and its needs. He became very proficient at self-care.

 

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Some of our clients will not want to proceed with the journey to climb out of the valley. For them, stabilization and containment will be enough. Given that the climb out of the valley can be life-threatening if people go into it unprepared or unwilling, we should never push our clients to take this step. Trauma is often about loss of control or boundary violations. Healing cannot be. We need to respect our clients’ decisions and inner knowing.

For those clients who wish to proceed with the climb and who appear to be strong enough and well-resourced enough to manage it, we have a number of evidence-based options to offer them. As trauma therapists, I believe we need to be skilled in more than one evidence-based trauma-processing intervention (e.g., EMDR, trauma-focused CBT, CBT). Too often I hear of clients being blamed when they don’t fit with the therapist’s approach. Being client-centered as a therapist means that we need to select or modify interventions to best fit the needs of individual clients.

Often, our clients will need to travel many pathways related to their trauma. These pathways might explore issues of grief and loss, the question of forgiveness of others and self, anger, ongoing depression and anxiety, the adjustment of relationship boundaries and so on. Each individual client’s pathway will be unique. Each individual client will lead. We will accompany, providing a safe, professional alliance and skilled interventions to assist the client in moving through, and eventually out of, the valley.

Phase 4: Living with the scars and reclaiming one’s life

Max became aware of how the trauma experiences he had survived had changed him. He learned to appreciate his resilience, adaptability and survival skills. He also came to acknowledge and embrace the truth of his strength and courage. Through accepting who he was, and is, along with his entire story, Max came to a place of peace.

During our last few sessions together, Max spoke about the newfound sense of peace he possessed. For our final session, I wrote him a letter reminding him of where he had started and highlighting his subsequent successes. I also recalled the qualities in him that I had come to admire. Finally, I reinforced in the letter the message that he possessed all that he needed inside of himself to deal with whatever challenges he encountered, but I reminded him that if he ever needed support again, he knew how to ask for it.

 

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Some of our clients will have lived in the valley for several months or years. For these clients, the thought of leaving the valley can invoke both excitement and fear because they will be learning to live in a new way. Thus, the last phase of our trauma work involves assisting clients as they learn to live with the scars (visible or invisible) of their trauma experience; reclaim their lives; acknowledge and celebrate their successes; and move forward on life’s path without us.

PTSD does leave scars, but those scars need to become part of one’s story, not all of it. In this final phase, we work with our clients on how to move forward in reclaiming their power and their lives. Sometimes we will need to assist them in identifying community resources that can continue to support them (such as peer support groups) or causes in which they can become involved that will be meaningful to their healing. Clients living with a disability or chronic pain resulting from their trauma experiences might need a team of medical professionals to provide ongoing support.

This is a time for clients to make conscious and informed decisions concerning how they will move forward in creating their lives outside of the valley. What kind of person do they wish to be? What are their hopes and dreams? Who do they want to have walk beside them on their journey? Do they have certain relationships that need to end or change? These are some of the questions that our clients might explore as they exit the valley. 

This final phase is also a time of celebration, kind of like a graduation, as we prepare and plan for the end of the therapeutic relationship. With that being said, some clients will worry about addressing future challenges without our support. In such cases, we can do some role-playing and problem-solving in advance to help alleviate their concerns regarding potential future challenges. For some clients, this might be an opportunity to rewrite their expectations regarding relationship endings. In collaboration with our clients, we can plan how our last sessions will play out.

Somewhere in this phase, we can also take the time to remind clients of where they began in the valley and where they are now, of how they have changed and what they have accomplished. Although this is something we should be doing in each session whenever there is a success, in this final phase we have a chance to summarize all of these successes at one time so that we can both appreciate the extent of their progress. This is often overwhelming for clients — in a positive, celebratory way — as they come to realize how incredible their healing journey out of the valley has been and as they start appreciating the depths of their own strength and resiliency.

 

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Shirley Porter is a registered psychotherapist and a registered social worker who has been providing trauma counseling for more than 25 years. She currently works in the counseling department at Fanshawe College and is an adjunct clinical professor at Western University, both in London, Ontario, Canada. She is the author of two books on trauma: Surviving the Valley: Trauma and Beyond, which was written for survivors of trauma and their support people, and Treating PTSD: A Compassion-Focused CBT Approach, which was written for therapists.

Contact her at traumaandbeyond@gmail.com or via her website, traumaandbeyond.com.

 

 

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Putting PTSD treatment on a faster track

By Bethany Bray August 27, 2018

An exposure-based therapy method has shown to reduce the symptoms of posttraumatic stress disorder (PTSD) in just five sessions, according to researchers.

Written exposure therapy (WET) consists of one 60-minute and four 40-minute sessions, during which clients are guided to write about a traumatic event they have experienced and the thoughts and feelings they associate with it. Researchers recently tested the method’s effectiveness alongside cognitive processing therapy (CPT), a more traditional talk therapy method that typically involves more than five sessions. Clinical trials were conducted at a U.S. Department of Veterans Affairs (VA) medical facility with adults who had a primary diagnosis of PTSD.

The researchers’ findings, published in JAMA Psychiatry this past spring, suggested that WET was just as effective as CPT in reducing PTSD symptoms.

“WET provides an alternative [treatment] that a trauma survivor might be more likely to consent to, especially if verbalizing the trauma narrative causes a sense of shame or guilt,” says Melinda Paige, an American Counseling Association member and assistant professor at Argosy University in Atlanta whose specialty area is trauma counseling. “The more evidence-based options the trauma counselor has to consider, the more options can be offered to the client. WET provides an option for written expression rather than verbal and a shorter length of treatment, which may be preferable to survivors, including [military] service members.”

“Effective trauma treatment is the antithesis of the traumatic event itself in that survivors experience person-centered core conditions such as congruence/genuineness, nonjudgement and empathic understanding, as well as a sense of control over their recovery experience,” adds Paige, a member of the Military and Government Counseling Association (MGCA), a division of ACA.

MGCA President Thomas Watson agrees that the addition of another method to a trauma counselor’s toolbox will only benefit clients. “Those involved with service delivery to service members and others diagnosed with PTSD are always enthusiastic about how applied, evidence-supported treatment approaches have the potential for effective and ethical positive change,” says Watson, an ACA member and assistant professor at Argosy University in Atlanta. “An obvious goal of the WET approach is to implement effective treatment options that are efficient for both client and clinician.”

The research study involved 126 male and female participants, some of whom were military veterans and others who were nonveterans. The participants were randomly sorted into two groups: those who received five sessions of WET and those who received 12 sessions of CPT.

“Although WET involves fewer sessions, it was noninferior to CPT in reducing symptoms of PTSD,” wrote the researchers. “The findings suggest that WET is an efficacious and efficient PTSD treatment that may reduce attrition and transcend previously observed barriers to PTSD treatment for both patients and providers.”

The researchers reported that the WET group had “significantly fewer” dropouts (four) than did the CPT group (25).

This factor is another reason for counselors to consider using WET, Paige notes. “Maintaining a survivor’s physical and emotional safety and doing no harm by utilizing evidence-based and minimally abreactive trauma reprocessing interventions is essential to trauma competency. Therefore, WET may be a less invasive and more tolerable exposure-based PTSD treatment option,” she explains.

At the same time, Benjamin V. Noah, an ACA member and past president of MGCA, was discouraged to see that the study excluded PTSD clients who were considered high risk. Individuals had to be stabilized by medication to be included in the clinical trials.

“Many of the veterans I have worked with dropped their medications [because] they do not like the side effects. Therefore, I believe the study overlooked veterans that may be higher risk,” Noah says. “Additionally, a high risk of suicide was an exclusion for being in the study. Again, this leaves out those veterans who need help the most and could benefit from a short-term approach.”

Noah, a licensed professional counselor in the Dallas area whose area of research is veteran mental health, has used written therapy methods in his own work with veteran clients and has found the methods helpful. A therapy session provides a safe and supportive environment for clients to write about traumatic experiences – particularly clients who may be trigged by the exercise when alone, he explains.

“I have had veterans triggered doing [writing] as homework; keeping the writing in session acts as a safety measure for the [client]. Helping veterans resolve their event or events — which I call the ‘nightmare’ — that led to PTSD has been a focus of my work since I was able to put my own nightmare to bed,” says Noah, a U.S. Air Force veteran and a part-time faculty member in the School of Counseling and Human Services at Capella University.

WET is one of many methods that should be considered by clinicians working with clients who have PTSD, Noah adds.

“I would like to see more research within the VA and National Institute of Mental Health on the use of Viktor Frankl’s logotherapy, solution-focused brief therapy, sand tray therapy and other approaches that counselors are using in their work with veterans,” Noah says. “There are articles focusing on other approaches, but these tend to be the experiences of a few counselors and do not have the research rigor used by [the WET study researchers]. I do applaud the authors for showing the efficacy of a brief therapy approach for use with veterans, and I do plan to look deeper into written exposure therapy and perhaps use it in my future work with veterans.”

 

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Find out more:

 

Read the research in full in JAMA Psychiatry: jamanetwork.com/journals/jamapsychiatry/article-abstract/2669771

 

From the National Institute of Mental Health: “A shorter – but effective – treatment for PTSD

 

Related reading from Counseling Today:

Controversies in the evolving diagnosis of PTSD

Informed by trauma

Exploring the impact of war

 

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Follow Counseling Today on Twitter @ACA_CTonline and Facebook at facebook.com/CounselingToday.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Becoming shameless

By Laurie Meyers April 25, 2017

You should be ashamed of yourself.” How many of us have heard — or perhaps even used — that phrase? Being on the receiving end of such a pronouncement is never pleasant. More important, experts firmly believe that attempting to wield shame as an instrument of change is both ineffective and harmful. In fact, many clinicians say that shame is intertwined with an abundance of issues that typically bring clients to counseling. Furthermore, it often stands as a significant barrier to healing.

In her book I Thought It Was Just Me (But It Isn’t), Brené Brown defines shame as “the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging.” The research professor at the University of Houston’s Graduate College of Social Work believes that shame has become a kind of silent epidemic in society that serves to isolate us and thus damages our sense of connection to others.

Thelma Duffey, the immediate past president of the American Counseling Association, agrees. One of her main initiatives as president focused on issues surrounding bullying and interpersonal violence, both of which can leave people struggling with a deep-seated sense of shame. “I see shame as a deeply painful feeling that people experience when they feel exposed, inadequate or especially vulnerable,” she says. “Unforgiving and powerful, shame can leave many people feeling unworthy and incapable.”

Bullied into shame

The practice of actively shaming others, particularly through bullying behaviors, is all too common in our culture, says Duffey, a practicing licensed professional counselor and licensed marriage and family therapist for more than 25 years.

“Bullying can trigger feelings of shame, leaving people feeling defenseless, embarrassed and confused,” she says. “Some feel such a strong sense of self-consciousness and become so preoccupied with avoiding shame-inducing situations that they withdraw from others, which can lead to an excruciating form of isolation.”

Without the consistent presence of love and support in a person’s life and the provision of a realistic viewpoint from others, there is no counterbalance to shame’s narrative.

“Imagine holding a broken mirror of yourself and believing that the distorted image is what you truly look like,” Duffey says. “Your perception would be off, wouldn’t it? Now imagine you are holding a broken mirror that reflects a distorted image of who you are as a person. If you believe this distortion, it won’t be easy to feel good about yourself or to connect with other people who love you. It will probably lead you to see the world as an unsafe place. In all likelihood, you’ll have to create ways of coping with these images just to survive. Too many times, these coping strategies ultimately keep us from the very connections we desire.”

Duffey says there is an antidote. “I believe that developing a sense of self-compassion is at the core of conquering shame,” she says. “Unfortunately, self-compassion is not always easy to come by, particularly when a person has been mistreated, publicly mocked or hurt, as is generally the case with any bullying situation. In fact, introducing the idea of self-compassion can actually make people wince when they live with feelings of shame, because it sheds light on their self-loathing perceptions.”

Counselors can use a variety of methods to help clients develop self-compassion, but a strong therapeutic bond is the most essential ingredient in that process, says Duffey, who is also a professor and chair of the counseling department at the University of Texas at San Antonio. One of the interventions she uses is Emotional Freedom Techniques (EFT).

“EFT has been described as a type of psychological acupressure that can help unblock distressing situations,” Duffey says. “The idea is to restore balance to the body’s energy field to move negative emotions that can keep us stuck. I also see it as a way for people to center themselves when they are in their uncomfortable emotions and to connect with themselves in a more soothing way.”

Duffey says that EFT in its traditional form has a sequence that involves identifying the problem — for example, shame — and then having clients ask themselves how they feel about the problem right now. Clients then rate the level of intensity of the problem, with 10 being most intense and zero being least intense. Next, the counselor and client come up with a “setup” statement that acknowledges the problem and follow that with an affirmation. Clients then repeat the statement and affirmation while performing a kind of “psychological acupuncture” that involves taking their hands and tapping five to seven times on the body’s “meridian” or energy points.

“A person experiencing shame and with memories of bullying might say something like, ‘Even though it is not always easy for me to see my own value, I deeply and completely love and accept myself,’” she says. “Or, ‘Even though I can still remember the horror of being made fun of, excluded and shunned, I can be on my own side now. And I am not alone. In fact, I am working on loving and accepting myself.’”

Once a person connects with the problem and the idea of loving, self-compassionate affirmations, he or she can use those affirmations to process all sorts of experiences, Duffey says. “The idea, of course, is not about thinking positively or practicing self-delusion,” she notes. “Rather, it is about really being honest about what hurts and confronting these feelings, [and then] offering affirmative statements of hope and compassion while tapping into the body’s energy using acupressure points.”

Duffey recommends the website thetappingsolution.com for those who would like to learn more about EFT.

The trauma-shame connection

At the ACA 2017 Conference & Expo in San Francisco this past March, licensed mental health counselor Thom Field presented “For Shame! The Neglected Emotion in PTSD.” In the session, he explained that shame is a significant component of posttraumatic stress disorder (PTSD), particularly in cases of interpersonal trauma, such as child abuse and intimate partner violence.

Because PTSD’s most common symptoms — hypervigilance, nightmares, flashbacks, intrusive memories and physiological hyperarousal — are all related to fear of external danger, experts in the trauma field have traditionally focused on fear as the primary emotion in PTSD, noted Field, a member of ACA. Using this assumption, therapy techniques for PTSD have focused on methods such as exposure therapy, he said. In exposure therapy, clients are asked to revisit the trauma multiple times because repetition has been shown to help lessen the physical and emotional effect of these memories.

However, new research suggests that trauma survivors often also fear being rejected and exposed as weak. This fear engenders a sense of shame, said Field, an associate professor and associate program director of the counseling master’s program at the City University of Seattle. He explained that the shame is fueled by a persistent negative self-appraisal in which clients who have experienced interpersonal trauma often berate themselves with statements such as “I am weak — an easy target”; “Something is wrong with me if I can’t prevent these things from happening”; or “Why didn’t I do something?” Trauma survivors often feel inadequate, inferior or powerless to affect their own environments, he added.

Field believes that counselors must understand the role of shame to help many of these individuals who are living with PTSD. “Shame is an emotion that arises when a person feels inadequate or corrupted by an irredeemable act or a contaminating event,” Field explained. “The person feels undesirable and unattractive and fears the perceived judgment of others.”

It is also important for counselors to differentiate shame from guilt, Field noted. He defined guilt as regret for a specific action that is bound to external circumstances. It is a feeling connected to what one has done rather than — in the case of shame — what one is, Field emphasized. Whereas guilt can motivate prosocial actions such as reparation, shame usually motivates self-protective actions such as withdrawal or lying to protect secrets, he pointed out.

Among the factors that increase feelings of shame in those who are experiencing PTSD or interpersonal trauma are the attribution of responsibility (such as the perception that having HIV or AIDS is that person’s “fault”); the level of visibility and an inability to “hide” (because of circumstances such as physical disability or disfigurement); and being marginalized, Field said.

Feelings of shame may prevent some people with PTSD from seeking counseling, and even those who do seek counseling may deny the presence or impact of trauma if a counselor asks them about it directly, Field said. Harboring a sense of shame may also make it difficult for clients to trust others, he added, so counselors must take care to proceed slowly and focus on developing the therapeutic alliance. These clients need to be made to feel safe enough to reveal their secrets and process their fear of rejection, humiliation and judgment by others, he emphasized.

An important step in the process is for counselors to facilitate client autonomy with what Field termed “pre-questions.” For instance, a counselor might say, “It seems like it might be helpful to revisit this event. How ready are you to face that?”

“If you dive in [yourself as the counselor], it feels [to the client] like it’s not voluntary,” Field explained. When counselors press the processing of shame before clients are ready, it can cause clients to, in essence, feel shame about their shame.

Counselors should also let clients know what to expect when they decide to share their trauma. For instance, Field said, “The client is going to feel physiological symptoms.”

Through client mirroring and active listening, counselors can help establish a sort of holding container for these clients’ emotions. This takes away the pressure of having to “do” anything with those emotions, allowing clients to feel safe simply “sitting” with their feelings until they are completely ready to process them, Field explained.

Like Duffey, Field thinks that self-compassion is essential to overcoming shame. The ultimate goal is to teach clients to accept their current and past experiences without self-judgment, he said. Field recommended that counselors use some of the exercises developed by psychologist and self-compassion researcher Kristin Neff. These include having clients imagine how they would treat a friend who was in the same circumstance, writing letters to themselves from a place of compassion, changing critical self-talk through reframing, keeping a self-compassion journal and practicing loving-kindness meditation.

The lasting shame of abuse

For clients who were sexually abused as children, the sense of shame is almost primal, says ACA member David Lawson, who has worked with trauma victims for more than 25 years. Time after time, women in their 30s and 40s have sat in Lawson’s office and insisted that it was somehow their fault that they were sexually abused as children.

“They say, ‘There must be something wrong with me.’ ‘I’m bad.’ ‘I’m contaminated,’” says Lawson, a counseling professor at Sam Houston State University in Texas who has conducted extensive research on trauma. “I’ve even had several people say, ‘I must be evil in some way for this to happen to me.’”

When parents are the perpetrators of sexual abuse, the abuse survivors’ sense of shame is particularly strong, Lawson says, because humans are wired to seek attachment with parental and other caregiving figures. To maintain this attachment, child victims must rationalize the abuse. As a result, these children often tell themselves that they are bad rather than accepting that the parent is not good, Lawson explains.

Another factor that contributes to these children’s feelings of shame is the perceived “benefits” they received from their abusers, Lawson says. He recounts the story of a female client in her 20s.

“She was abused from the ages of 5 to 16 by her father [until] her mother finally left the father. Years later she came into therapy, and I said, ‘Tell me about some of the best times in your life.’ She said that they were with her father: ‘At times I felt like I was my father’s girlfriend.’ There were benefits for her. He would buy her things and take her places, which he did not do with her siblings. Then, at night, the abuse would happen.”

The woman went on to confide to Lawson that the worst times in her life were also with her father. “He would tell her, ‘No one else will love you. You are worthless. No one will have you but me,’” Lawson says.

Abusers often use this technique, aware that if their victims feel there is nowhere else they can go and be accepted, there is a greater chance they will stay in the only place they seem welcome. This “acceptance” increases victims’ sense of connection to their abusers, Lawson says.

These patterns are distinct and specific to what Lawson calls the “trauma subculture.” The behaviors and beliefs of survivors of sexual trauma are so antithetical to most people’s expectations that outsiders — including many counselors — often find their reactions difficult to understand, he says.

“One of the hardest things for my students to get over is the way that [sexual trauma survivors] look at the world and the way they think about themselves,” Lawson says. “We just want to run over and hug them, but that just ramps up their shame because they don’t believe that they’re worthy.”

Early in his career, Lawson learned how premature sympathy and acceptance could backfire. He told a client that the abuse the client had suffered was not his fault, and the client got quite angry with Lawson, rejecting his help because he genuinely thought that Lawson didn’t know what he was doing.

What Lawson learned with that experience is that in immediately trying to correct clients’ beliefs about their abuse, counselors threaten to take away a major part of the identities that clients constructed as a way to survive. Today, Lawson urges counselors to move slowly with these clients and first work toward establishing a strong therapeutic bond.

“It may take many sessions just for them to feel comfortable,” he says. “These people don’t trust anyone, so to think that they’re going to trust in a few sessions is naïve and counterproductive.”

Start by accepting these clients where they are and reflecting on the dilemma they are facing, Lawson advises. “On the one hand, they feel an enormous amount of allegiance. On the other hand, they have strong feelings of hate,” he explains.

After counselors have established a relationship, they can introduce the idea of talking about the client’s experience. A counselor could say, “Talk to me about your relationship with your father and how you came to the conclusion that you’re not worthy of anyone else’s love,” Lawson suggests. He adds that counselors must give clients time to reflect and reconstruct how they came to their conclusions about self-worth.

Lawson says that once he asks those kinds of questions and lets clients unpack and narrate their experiences at their own pace, they are usually able to begin seeing how their erroneous, negative self-beliefs were shaped by what happened to them. He cautions, however, that intellectual understanding is not the same as emotional acceptance, which can take additional time. Lawson notes that some experts view this kind of shame as an annihilation of self. Survivors may feel that there is no part of themselves that is worth forgiving, he explains.

In the process of helping clients see themselves as redeemable, fully acknowledge the abuse that happened to them and grieve what was lost, counselors should be supportive, but they must also modulate their affirmation to a level that the client can handle, Lawson cautions. “If we’re too warm and nurturing, the client takes that and rejects it and sees us as incompetent because we don’t understand,” he says.

For that matter, trauma (and shame) may not be the stated concern that brings survivors of sexual abuse into counseling in the first place. Instead, the presenting issue may be depression, anxiety, relationship difficulties or something else, Lawson says. “I deal with whatever they present with and try to help them get some relief from those things,” he says.

But along the way, Lawson introduces the idea of addressing and processing the trauma with clients. He may approach it in a very general way at first, perhaps by asking clients to talk about the trauma as if it happened to someone else.

Lawson may also use a “lifetime line.” He starts by asking clients to pick a year of their lives and talk about everything they can remember about it — good and bad. By doing this, clients are not only processing trauma, but also remembering that there were positive events in their lives too, he says. Lawson also has clients write down all the positive memories to help remind them, as they construct their life narrative, that the abuse does not encompass their entire life.

Lawson says he finds narratives, either written or spoken, vital in treating clients’ shame. By showing compassion for their narratives, counselors can help clients start to feel compassion for themselves, he says.

Shame beliefs

Gray Otis, a licensed clinical mental health counselor in Cedar Hills, Utah, believes that shame is typically a component in traditional mental health disorders such as depression and anxiety. In fact, he says, shame likely underlies most issues for which clients come to counseling.

“Typically, the individuals who come for treatment have strongly held negative core beliefs about themselves,” says Otis, who has extensive postgraduate training in trauma treatment. These negative core beliefs are not just about behavior, he adds, but actually inform people’s sense of who they are.

Otis, whose counseling approach is centered on positive behavioral health, thinks that these beliefs stem from incidents that evoke a sense of shame in the person. Such events typically take place in childhood or adolescence, but adults can experience them too. These incidents may or may not be described as “traumatic.” Negative core beliefs can be caused by an accumulation of painful events, such as consistently being criticized as a child or going through a divorce. The resulting beliefs can take many forms, Otis says, but they generally revolve around reinforced themes — for instance, a person growing to believe that he or she is stupid, unworthy, undeserving and unlovable.

Otis believes the key to addressing clients’ mental health issues is uncovering and dispelling their shame-based negative core beliefs. The difficulty counselors may face in unraveling a client’s core beliefs will vary depending on the person and the complexity of his or her presenting issues. However, Otis says he finds it relatively straightforward to uncover many of these beliefs. When he asks clients to identify some of the things they believe about themselves that are not positive — Otis directs them to use “I am” statements — they can usually identify five or more negative beliefs, he says.

What is particularly potent about the beliefs underlying these “I am” statements is that people tend to perceive them as being inherent, unchangeable personal traits, Otis says. Many of these core beliefs are subconscious, he adds. By helping clients bring them to the surface and recognize that they are beliefs, not traits, counselors can assist clients in replacing negative beliefs with positive core beliefs.

Otis does this by having clients explore the origins of one of their negative beliefs, asking them when they started believing this internalized truth about themselves and what happened that contributed to that belief. Otis then asks clients to focus on one of their most distressful experiences and “freeze” it, as if it were a photograph. He then urges them to describe the emotional sense of the experience, identify their degree of distress and state the shame-based negative core belief (such as “I am never good enough”).

The next step is for clients to specify the positive core belief they desire. Otis then helps them identify life events that reinforce the new, positive core belief. He asks clients to remind themselves of these reinforcing events daily as a way to continue strengthening their positive belief. Next, Otis has clients revisit the experience that engendered the negative belief, and he talks with them about how the event was misinterpreted.

Otis says he also uses methods such as sand tray therapy, eye movement desensitization and reprocessing, and cognitive behavior therapy not only to help clients develop more positive beliefs but also to become more resilient. He emphasizes, however, that the most important factor when working with shame-based negative core beliefs is a strong therapeutic alliance.

Ultimately, he says, helping clients rid themselves of persistent shame is what opens the door to healing.

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Controversies in the evolving diagnosis of PTSD

By Lennis G. Echterling, Thomas A. Field and Anne L. Stewart February 29, 2016

PTSD headshotsTrauma is as old as humanity itself. In fact, for nearly 3,000 years, such epic poems as The Odyssey and The Iliad have given eloquent voice to the psychic scars of war. These “hidden wounds” of combat included overwhelming feelings of anxiety, horrific nightmares, heightened startle reactions, flashbacks of battle scenes and a profound sense of alienation years after the conflicts had ceased. Despite powerful accounts over the millennia of the psychic impact of trauma, it was only 35 years ago that the Diagnostic and Statistical Manual of Mental Disorders (DSM) introduced the condition known as posttraumatic stress disorder (PTSD). Since then, the evolving diagnosis of PTSD has generated numerous and intense controversies. Only dissociative identity disorder has stirred up more debates among researchers and practitioners.

Now that counselors are playing an increasingly important role as service providers for both military and civilian survivors of trauma, it is vital that we become familiar with the historical context and current issues regarding PTSD.

Conceptualizations of trauma

The origins of the PTSD diagnosis stem from two dramatically different conceptualizations of its cause and symptoms. The psychological movement began in the 1790s and considered the syndrome to be primarily a mental one involving altered consciousness and amnesia, which later became known as dissociation.

The somatic movement, which conceptualized a physiological basis for the syndrome, began in England during the 1860s, when researchers described “railway spine” as a consequence of the physical traumas of railroad accidents. During the past 150 years, wars have spurred health care providers to consider, to varying degrees, these contrasting perspectives in hopes of better understanding and treating the psychiatric casualties of combat.

Trauma and wars

From the U.S. Civil War to the recent conflicts in Iraq and Afghanistan, researchers and practitioners have returned again and again to the impact of war-related violence on the psyches of military troops. In the past, however, the prior lessons learned were largely abandoned and ignored in the decades of peacetime that followed wars.

For example, many physicians who were followers of the somatic movement proposed that traumatized Civil War combat veterans were suffering from a cardiac injury, which they labeled “soldier’s heart.” At the same time, other health care providers relied on a psychological conceptualization of the condition, which they referred to as “nostalgia.”

In World War I, psychiatrists originated the term “shell shock” because they considered the symptoms to be physiological reactions to the intense shock waves that emanated from artillery explosions. Other mental health practitioners, influenced by Sigmund Freud’s theories, diagnosed the condition as “war neurosis.”

With the beginning of World War II, many service members once again experienced the horrors of combat. Initially, those who developed posttraumatic reactions were discharged. However, when psychiatrists found that the degree of relatedness in the military unit was a protective factor, they developed treatment strategies for what they termed “combat fatigue.” These treatment strategies emphasized emotional support and rapid return to active duty.

Again, interest in trauma faded once World War II came to an end. Nevertheless, we should note that the first use of the term “posttraumatic” occurred in a follow-up study on veterans who had been diagnosed with combat fatigue. In the heat of battle in the Korean War, the American Psychiatric Association published the first edition of the DSM. The new manual briefly acknowledged that combatants experienced short-lived psychological reactions to war but did not label the syndrome a psychiatric disorder.

Not until the Vietnam War did the demand for a combat-related trauma diagnosis reach a tipping point. In the early 1970s, many returning U.S. veterans exhibited problematic and life-threatening behaviors. At first these behaviors were attributed to noncombat-related neurosis or psychosis. However, with public war protests growing, veterans began advocating for a new disorder called “post-Vietnam syndrome.” Mental health professionals began holding “rap groups” with Vietnam veterans about their experiences and led panel discussions at professional conferences. These efforts led to the American Psychiatric Association’s decision in 1980 to formally accept PTSD as a legitimate diagnostic category in the DSM-III. 

The long-term conflicts in both Iraq and Afghanistan once again have focused attention on the traumas that combatants endure and the pervasive impact of PTSD on the lives of returning veterans. The Rand Corp. estimated the prevalence of PTSD in Iraq and Afghanistan war veterans to be 14 percent, which is twice the estimated lifetime prevalence rate for civilians. With multiple and longer deployments, the risk of military combatants developing PTSD is even greater.

Trauma and the DSM 

In 1951, the DSM-I, which was a slim volume of 130 pages, introduced the syndrome “gross stress reaction.” Although not a disorder, the inclusion of this reaction proved to be both significant and influential for two reasons. First, it acknowledged that the syndrome was a risk not only for veterans of war but also for civilian survivors of catastrophic events. Second, it asserted that this syndrome applied to “normal” persons who experienced intolerable stress, thus disagreeing with the then-dominant psychodynamic assumption that these psychiatric casualties were vulnerable individuals who possessed predisposing neurotic conditions.

In the second edition of the DSM, published in 1968, the American Psychiatric Association revised the title of the syndrome to “transient situation disturbances,” a label with a more clearly negative term. Still, it was not considered a disorder.

Finally, in 1980, PTSD was included as a mental disorder in the DSM-III. It also became the first disorder to include a diagnostic criterion — a traumatic event — that was entirely external to the individual and outside the range of usual human experience. Examples of traumatic events included rape, combat, accidents and disasters. If the event was a “normal” one, such as the loss of a job or divorce, the person’s reaction was diagnosed as an adjustment disorder. Other criteria for PTSD included re-experiencing symptoms, engaging in avoidance and having arousal symptoms.

The addition of PTSD to the DSM-III was not without controversy. Given the disorder’s emphasis on combat-related trauma, there was concern the Vietnam War had politicized the decision with its emphasis on the hidden wounds of combat veterans. Because their dysfunction now was directly tied to military service and not to personality flaws, the Veterans Administration (now the Department of Veterans Affairs) was required to offer services to affected soldiers. In addition, PTSD was recognized as a disorder that merited disability status. Consequently, the Veterans Administration requested more government funding to meet the increased need for psychological services.

Seven years later, the DSM-III-R (revision) appeared with several minor refinements to the diagnosis of PTSD, including operationalizing the symptom clusters. A major contribution of this edition was to identify, for the first time, age-specific features that children and adolescents exhibit in response to trauma.

In 1994, the DSM-IV eliminated the requirement for the precipitating stressor for PTSD to be outside the range of normal human experience. It also expanded the definition of traumatic events to include the indirect experiences of observers and the loved ones of the victims. As a consequence of adding vicarious traumas, the number of qualifying events for PTSD increased by 59 percent. No other diagnosis in the history of the DSM had undergone such a drastic expansion (known as “conceptual bracket creep”) from one volume to another. The DSM-IV-TR (text revision) was introduced six years later and tightened the definition of a traumatic event to something that is “extreme” and “life threatening.” It also added several diagnostic specifiers, such as “acute,” “chronic” and “delayed onset.”

After many postponements, the DSM-5 was finally released in 2013 in a massive volume of 947 pages. The most obvious change in this current edition is that PTSD is no longer classified as an anxiety disorder. Instead, it is included in a new chapter titled “Trauma- and Stressor-Related Disorders.” Another significant change is that the DSM-5 now places restrictions on the operational definition of a traumatic stressor. For example, witnessing an event no longer qualifies as a traumatic stressor unless the person is physically present. In most cases, observing an event through the media is excluded. The DSM-5 also no longer requires an intense emotional reaction to the event because this lacked predictive utility. A new specifier now includes dissociative symptoms such as depersonalization and derealization.

Swinging pendulum

Like a pendulum, the conceptualization of PTSD has swung back and forth over the past century. In the time of Freud, its cause was attributed largely to the individual’s character deficits. During World War II, it was understood to be a normal reaction to persistent combat exposure. Thus, the pendulum moved toward identifying the traumatic event itself as the chief culprit of dysfunction. Following the war, most mental health practitioners gave greater weight to the extreme stressor as the primary cause. This view was reflected in the first edition of the DSM, when it was posited that any “normal” individual would develop symptoms after exposure.

As traumatized veterans returned from the Vietnam War, special interest groups began advocating for the addition of PTSD to the DSM-III to publicly acknowledge the hidden wounds of war. Perhaps most important, by requiring that the stressor had to be outside of normal human experience and so severe that any normal person could be affected, the DSM-III definition of PTSD reflected theBranding-Images_PTSD farthest swing of the pendulum toward placing onus for dysfunction on the traumatic event.

On the basis of new evidence that the majority of survivors did not develop PTSD after exposure to traumatic events, the DSM-IV represented the pendulum’s move back toward the interaction between internal and external causation, judging the individual’s emotional reaction to be just as crucial in the development of psychopathology. In other words, the event itself was no longer considered the sole cause of PTSD. Instead, traumatization was defined both as exposure to an event and an individual’s subsequent response of intense fear, helplessness or horror.

During development of the DSM-5, some scholars suggested that the event should be removed entirely as a diagnostic criterion for PTSD, resembling a return to Freud’s conception of dysfunction being attributed solely to the individual.

A developmental perspective

One serious limitation of the first three editions of the DSM was the lack of consideration of any potential developmental differences in reactions to extreme stress. Therefore, a major contribution of the DSM-III-R was to identify age-specific features that children and adolescents exhibit. For example, the DSM-III-R noted that young children were more likely to relive the trauma in repetitive play.

Still, researchers and clinicians working with children noted that the PTSD criteria in the DSM were not developmentally sensitive and did not capture clinically relevant symptoms for children living in chronically unsafe conditions. A proposal to include a new diagnosis, developmental trauma disorder (DTD), was considered for inclusion in the DSM-5. This diagnosis was proposed on the basis of findings from developmental psychopathology, clinical presentations of children exposed to chronic interpersonal violence and emerging evidence from the field of neurobiology regarding the impact of trauma on brain development. Ultimately, the proposal for DTD was not accepted for inclusion in the DSM-5. The discussion of the merits of an alternative classification system for children experiencing complex trauma is continuing.

Current issues

In addition to the controversies regarding the definition and criteria of PTSD, criticisms have continued to emerge regarding the transparency, representation and integrity of the DSM revision process. Critics have cited the secrecy of the DSM-5 development process and the apparent lingering presence of pharmaceutical company influence on DSM task force members as factors affecting the process.

Many advocates are worried that PTSD is underdiagnosed and undertreated among veterans of both current and past conflicts. For example, an estimated 271,000 Vietnam veterans continue to suffer from PTSD, according to a recent study by Charles Marmar published in JAMA Psychiatry. The New York Times reported that the incidence of PTSD among current military personnel more than doubled between 2005 and 2010, resulting in an overburdened Veterans Affairs (VA) health system. In 2011, the 9th U.S. Circuit Court of Appeals demanded that the VA overhaul its mental health services because delayed and inadequate services were being provided to returning U.S. veterans with PTSD. Harkening back to the conceptualization of “shell shock” in World War I, there now is growing recognition that primary blast waves have caused serious and permanent traumatic brain injuries among veterans of the Iraq and Afghanistan wars.

The prevalence of PTSD among civilians is also a serious problem. The National Sexual Violence Resource Center reported that half of the survivors of sexual assault are estimated to meet diagnostic criteria for PTSD. The high incidence of wide-ranging traumatic events among both children and adults has led many to recommend the use of trauma-informed care involving collaborative, supportive and skill-based interventions that address the pervasive impact of trauma. Recent research also has underscored the need to refine our conceptualization of PTSD by recognizing the crucial role that shame can play in its dynamics. Anxiety regarding external dangers has long been considered the primary emotion of PTSD, but the perceived internal threat of exposing one’s shame often predominates for many survivors, especially among those who have experienced interpersonal violence.

In marked contrast to the issue of underdiagnosis of PTSD, many professionals who intervene after disasters typically provide public education that normalizes reactions to catastrophes. Their criticism of the DSM is that broadening PTSD diagnostic criteria may have the unintended consequence of pathologizing natural human reactions to highly disturbing incidents. A related current issue is that many researchers and practitioners are calling for greater awareness of the phenomenon of posttraumatic growth, suggesting that the majority of trauma survivors eventually achieve higher levels of personal maturity, wisdom and well-being.

In our current environment, PTSD remains a diagnosis that involves controversies. As promoters of human growth and development, counselors are in a unique position to be active participants in this conversation. We can engage most effectively by contributing to refinements in conceptualization, discoveries through research, innovations in practice and empowerment through advocacy efforts that promote the resilience of trauma survivors. Given the prevalence of PTSD and the severity of its impact on individuals, families, relationships and communities, it is our duty as counselors to play a crucial role in alleviating the anguish and pain of those who suffer the consequences of this disorder.

Yes, trauma is as old as humanity. But as our theory, research and practices continue to evolve in the midst of PTSD controversies, we can envision a more humane future in which the diagnosis and treatment of trauma survivors offers healing and hope.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences

Lennis G. Echterling is a professor of counselor education and director of the Ph.D. in counseling and supervision program at James Madison University in Harrisonburg, Virginia. His most recent book is Thriving! A Manual for Students in the Helping Professions. Contact him at echterlg@jmu.edu.

Thomas A. Field is an associate professor and associate program director in the master’s counseling program at City University of Seattle. He also works as an independent contractor at a private practice in the Seattle area. Contact him at tfield@cityu.edu.

Anne L. Stewart is a professor in the Department of Graduate Psychology at James Madison University. She is the president of the Virginia Play Therapy Association, and her most recent book is Play Therapy: A Comprehensive Guide to Theory and Practice. Contact her at stewaral@jmu.edu.

 

Letters to the editor: ct@counseling.org

 

 

Exploring the impact of war

By Keith Myers September 26, 2014

A small town celebrates a homecoming. Parties are given in honor of the combat veteran who has returned home triumphantly. Families and loved ones are reunited, and community leaders show honor to the warrior by offering laud in public ceremonies. All appears to be whole again.

But as the dust settles and the town returns to its normal quiet state, they emerge. Silence seems to activate them. Attempting to sleep exacerbates them. Panic, fear and horror accompany them. They Camo-face-Smallare a reminder of personal losses, and they are joined by a feeling of intense guilt. They are war memories.

These memories are much different from the typical memories one might have about a past life event. For one thing, they are traumatic in nature and carry with them a tidal wave of emotional surge. They overwhelm the body with their intense physiological manifestations. They overwhelm the soul via spiritual and moral injuries. They overwhelm the mind with their unrelenting and intrusive presence. They demand full attention, often invading precisely when their host is trying to avoid them.

War memories are one of the hallmark symptoms of combat trauma and a primary stressor experienced by many combat veterans. Learning about common war stressors provides counselors with a necessary foundation for working with this population. It also helps counselors to better understand the military culture as it relates to the overall clinical context of combat trauma.

In the seminal work on combat trauma, Combat Stress Injury: Theory, Research and Management, William Nash, a U.S. Navy psychiatrist and director of a Marine Corps program to prevent combat stress injuries, speaks of war stressors and the critical role they play in modern warfare. He teaches that war stressors can be divided into five groups: cognitive, emotional, social, physical and spiritual. In this article, I will examine these five categories of combat stress mostly within the context of Operation Iraqi Freedom (OIF, Iraq conflict), Operation Enduring Freedom (OEF, Afghanistan conflict) and Operation New Dawn (OND, Iraq conflict since 2010). 

Cognitive stressors

Changing rules of engagement: A primary cognitive stressor that is common in operational conflicts is the ambiguous or changing “rules of engagement” (ROE). ROE include the standards that determine when military personnel are permitted to fire their weapons and at whom. In the OIF, OEF and OND conflicts, U.S. troops are not allowed to use deadly force unless a clearly armed adversary poses a clear and immediate threat to U.S. troops or civilian life.

As Nash explains in Combat Stress Injury (2006), “This is a laudable standard, one that all honorable warriors hope to meet at all times. But in the three years since the U.S. invaded Iraq, for example, a number of ambiguous situations have become almost commonplace for soldiers and Marines. One is the use by Mujahadeen of civilians, including women and children, as human shields. This was encountered in many areas of Iraq, particularly where fighting was the bloodiest and most contested, such as in An Nasiriyah during the initial push toward Baghdad and during the second battle of Al Fallujah in November 2004.”

These types of ambiguous situations were very common in OEF and OIF. Such impossible choices cause increasing cognitive stress burdens within the context of a traumatic combat environment. 

Boredom: Another cognitive stressor of combat trauma is monotony or boredom. Military clients speak of this often when recalling their deployment experiences. They talk about how their day-to-day work was mostly boring and consisted of long periods (from several hours to several days) with very little action. Some military personnel may constantly patrol the same areas over and over again with nothing significant to report.

Often, the operational activities of a combat zone include a systematic monotony that provides limited recreational activity. However, it is important to note that during these periods of boredom, warriors are still expected to remain on “high alert” because the enemy could strike at any time. This state of being on guard even during periods of boredom and monotony has a significant effect on cognitive stress.

Emotional stressors

Fear and horror: Combat veterans often report that losing buddies and being killed or seriously injured are common fears that everyone experiences on the battlefield. Many of these veterans have directly experienced firefights and enemy ambushes or witnessed the death and injury of multiple buddies in combat. This fear exists on a continuum, ranging from the anticipation and dread of preparing to deploy into a combat zone to the terror that accompanies the threat of being severely injured. The greatest fear for warriors is not being killed or losing a buddy, however. The greatest fear is losing their honor on the battlefield. This kind of honor is upheld in the values and oaths of the different military branches.

The death of friends: Military personnel who deploy and serve in combat zones together form the most intimate of bonds. Nash explains that the emotional impact of losing a close comrade in war is not unlike the loss a mother experiences when her child dies. The levels of disbelief, shock, guilt, shame and longing may be much the same for both.

However, unlike the grieving parent, the warrior has little opportunity to fully experience the intense feelings that accompany the loss or to do the necessary cognitive work that might help him make sense of things. The warrior cannot allow himself to grieve; he must remain partially numb to the loss so that he can continue to do his job. Therefore, numbness becomes adaptive within the work environment of the combat theater.

Guilt and shame: Military leadership places a high priority on responsibility in decision-making because one wrong decision in combat can result in the loss of many lives. Even though this level of responsibility is adaptive and needed, it can contribute to the guilt a warrior experiences. It is not uncommon to hear military clients talk about this guilt, commonly referred to as survivor guilt, when describing their buddies who died in combat. Some warriors state, “I should have been the one who took the fall,” or “I shouldn’t be sitting here right now,” or “I should have done something different.” Sometimes the feelings of intense guilt are manifested in nightmares as the combat veterans’ war memories replay during sleep.

Although it is difficult at times for warriors to overcome this guilt, many of them do not have significant trouble acknowledging it. This acknowledgment should be viewed as a strength and can lead to growth and change when receiving counseling.

Other emotions are related to a sense of shame, such as feeling like a failure on the battlefield. These shame emotions are much more difficult for warriors to acknowledge or express.

Killing: In his masterful and insightful book On Killing: The Psychological Cost of Learning to Kill in War and Society, first published in 1995, Lt. Col. Dave Grossman attests that the act of killing another human being is a traumatic stressor for many combat veterans. He writes that all humans may have an intrinsic aversion to killing members of their own species, an aversion that must be overcome on the battlefield to engage in interpersonal violence. Grossman explains the practical ways that the military desensitizes its members to achieve this purpose. Regardless, killing other humans still remains one of the greatest stressors in combat.

Relationship issues at home: It is well documented that families of military members experience significant stress when their loved one is deployed. It is especially stressful when they may not know where their loved one is or what kind of danger he is experiencing on a daily basis.

This situation is stressful for the warrior as well, especially if some sort of conflict is occurring within the family environment at home. Regardless of whether the issue involves a death in the family or a recent argument with a spouse, the warrior must attempt to continue performing his job well, even while knowing that he cannot address the problem when he “gets off work” later that night, like so many other Americans are able to do. It may be weeks or even months before he is able to fully process the loss of a loved one or address the conflict with his spouse.

Social stressors

Lack of privacy or personal space: Deployed warriors are commonly surrounded by a large number of their comrades, both when sleeping and working. Most of the time, this cannot be avoided, and this lack of personal space is often likened to being packed like a “can of sardines.” For the most part, this tightknit environment is a positive aspect because it enhances the cohesion of the group. This cohesion is vital in combat situations, where warriors must trust one another with their very lives.

However, it also means a near total absence of privacy and the need to share almost all equipment and spaces. This lack of privacy can be stressful, especially when the only items considered personal belongings are weapons and uniforms. Most other items are freely shared among the community of warriors. 

Media, public opinion and politics: It is easy to see the devastating effects that the national media and public opinion had on returning Vietnam War veterans and their families. Many were mocked, ridiculed and spat upon in public and in private. Fortunately, the media and public opinion are much more supportive of combat veterans who have served in the Iraq and Afghanistan conflicts. 

The national media and public opinion wield power to validate or invalidate the sacrifice and service of warriors. Furthermore, every criticism of these more recent wars or the way they were handled inflicts emotional and social wounds on the warriors who faced death each day. On a political level, when wars are not properly funded or when debates rage in Congress, it has a direct impact on the warriors who are fighting to uphold those same political freedoms. However, politicians and media members are rarely held responsible for the influence they have on warriors in theater.

Physical stressors

Harsh conditions: Nash explains that certain regions in the Middle East and Southwest Asia can reach 120 degrees Fahrenheit in the summer, while lows in the winter can go below freezing. Furthermore, the effects of the heat are amplified by the body armor that military personnel wear, including Kevlar (helmet), flak jacket (armored vest) and new ceramic SAPI (small arms protective insert). Wearing this protective gear can raise the temperature underneath the body armor an additional 10-20 degrees. That level of heat makes staying hydrated a significant challenge, while simultaneously making both physical and mental exertion more difficult.

Sleep deprivation: Very few military personnel in a combat zone achieve six to eight hours of sleep every day. On average, combatants are forced to function on four hours of sleep or less. Some veterans in war zones become so sleep deprived that they experience visual and auditory hallucinations. Sleep deprivation affects many levels of functioning, including attention, memory and higher levels of thinking and decision-making. This combat stressor overlaps with many different elements and could also be placed under the cognitive or emotional stressors. 

Pain or injury: During the course of a seven- to 14-month deployment, it is almost impossible to avoid occasional experiences of pain, illness or injury. In fact, many military personnel continue to work through pain and injury.

During a period from 2003-2006, the Department of Defense reported that 18,572 troops were wounded during combat in Iraq. More than half (10,064) returned to duty. According to Nash, this means they returned to their units in Iraq soon after their injuries, usually while still recovering. Some of those injuries were considered to be minor, such as lacerations or eardrum injuries from improvised explosive devices. However, some of those injuries were not so minor. I find the level of resilience and determination that combat veterans exhibit while serving their country in a hostile environment amazing. 

Spiritual stressors

Crises of faith: One common stressor that is rarely discussed is the crisis of faith that many combat veterans experience. Spiritual stressors sometimes occur when one is faced with life-or-death decisions, and this is particularly true in combat. Belief in God can be threatened or challenged when encountering the chaos and helplessness of combat situations. This is especially evident when the warrior has a belief in a benevolent God.

A common question is, “How can God allow this evil to exist when He is supposed to be good?” Some warriors find it impossible to continue believing in this view of God and experience a crisis of faith that affects them on many levels (cognitive, emotional and so on). On the other hand, some veterans’ faith and religious convictions are deepened by their experiences. But no matter whether their faith is ultimately strengthened or weakened, most veterans face spiritual stressors.

Struggle with forgiveness: Nash explains this concept, stating, “Awful things happen in war; they are often unavoidable. And even the bravest and strongest can be pushed to the point of acting in ways that later may be deeply regretted. Finding a way to forgive oneself … can be a significant challenge.”

I have also discovered this to be true in my work with military veterans. It is common for warriors to have an easier time forgiving others than forgiving themselves. Part of this may be attributed to (usethis)military-homewarriors holding themselves to such high personal and professional standards or the level of responsibility that the military instills in them. However, further research is needed in this area before definite conclusions are drawn. An important part of treatment with this population should include a focus around self-forgiveness by the warrior.

Evidence-based treatments for combat trauma

What evidence-based treatments can counselors utilize for posttraumatic stress disorder (PTSD) related to combat? While various types of treatments can be helpful with this population (biofeedback and stress inoculation training, for example), there is not enough space to discuss all of them. Therefore, I will focus on the three empirically based treatments given an A-plus rating by the Army surgeon general in 2012 for reducing combat-related PTSD symptoms among veterans.

EMDR: Eye movement desensitization and reprocessing (EMDR) is an evidence-based psychotherapy treatment that was originally designed to alleviate the disturbance associated with traumatic memories. The Adaptive Information Processing Model posits that EMDR facilitates the reprocessing of traumatic memories to an adaptive resolution. After successful treatment with EMDR, affective distress is relieved, negative beliefs are reformulated and physiological arousal is reduced.

During EMDR, the client attends to emotionally disturbing material in brief sequential doses while simultaneously focusing on an external stimulus. Therapist-directed lateral eye movements are the most commonly used external stimulus, but a variety of other stimuli include hand-tapping and audio stimulation (see emdr.com). A treatment course of 12 sessions is common. I utilize EMDR in my clinical work with combat veterans and have achieved some significant clinical outcomes over the past three years. For information on receiving intensive training in EMDR, see emdrhap.org.

CPT: Cognitive processing therapy (CPT) is derived from cognitive behavior therapy (CBT). According to the National Center for PTSD (ptsd.va.gov), CPT includes four main parts of treatment:

1) Having clients learn about PTSD symptoms and how treatment can help

2) Getting clients to become aware of their thoughts and feelings

3) Having clients learn skills to challenge those thoughts and feelings (cognitive restructuring)

4) Helping clients understand the common changes in beliefs that occur after going through the trauma

CPT puts less focus on the traumatic event itself and more focus on the beliefs resulting from the trauma and the impact those beliefs have had on the person’s life. From there, it is about the client deciding whether those beliefs are accurate or inaccurate. For a helpful and free web-based learning course, visit cpt.musc.edu/. For additional training, check the Center for Deployment Psychology at deploymentpsych.org/workshops.

Prolonged exposure: Prolonged exposure also has its roots in CBT. It focuses on repeated exposure to the traumatic event(s) and the accompanying thoughts, feelings and situations to reduce feelings of anxiety and disturbance.

The National Center for PTSD highlights the four primary elements of prolonged exposure:

1) Education: Having clients learn about their symptoms and how treatment can help

2) Breathing training: To help clients relax and manage distress

3) Real-world practice (in vivo exposure): Reducing clients’ distress in safe situations that they have been avoiding

4) Talking through the trauma (imaginal exposure): Helping clients get control of their thoughts and feelings about the trauma 

Prolonged exposure typically involves eight to 15 sessions, with several homework assignments given in between sessions. For more information on trainings, refer again to the Center for Deployment Psychology. 

Final thoughts

Perhaps you are a professional counselor who has always wanted to serve veterans in your private practice, or perhaps you are a counselor who is already working with this population. Either way, given that it is estimated that up to 20 percent of combat veterans will develop PTSD, it is important that counselors acknowledge and understand the common stressors of war combat. In gaining this knowledge, you can better connect with the military client who is (or who will be) sitting in your office or agency. And by being familiar with the effective treatments and where to obtain training, you will be better equipped to effectively help this client deal with the effects of combat trauma and PTSD.

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Keith Myers is a doctoral student in counselor education and supervision at Mercer University in Atlanta, Ga. A licensed professional counselor and intensively trained eye movement desensitization and reprocessing therapist, he is also a member of the American Counseling Association’s Traumatology Interest Network. Visit his website at keithmyerslpc.com and contact him at keithm355@gmail.com.

Letters to the editorct@counseling.org

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Related reading: See Myers’ piece from August 2013, “Effective treatment of military clients”: ct.counseling.org/2013/08/effective-treatment-of-military-clients/