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Applied Behavior Analysis as a Treatment for Survivors of Trauma

Understanding trauma has become a major focus for many different fields of mental health, with each proposing a different strategy for addressing traumatic symptoms and core issues. This has not been an easy feat for several reasons. First, the current reports of trauma are only as accurate as the population making them; trauma is an immensely personal and painful experience for the individual, so many survivors decline to report. Second, there are a wide variety of traumas that may have an impact; while traditionally, trauma is spoken of as an “emotional response to a terrible event like an accident, rape, or natural disaster” (APA, 2019), there is now growing research to support the variable, subjective nature of trauma identified through adverse childhood experiences. Third, trauma is difficult to understand due to its two-fold nature: a traumatic incident must occur and there must be an associated emotional reaction. While an individual may have had a documented traumatic experience, they are not automatically going to have a traumatic response.

Psychotherapist taking notes with client on the couch

The complexities of trauma cannot be understated and require the clinician to have intensive, specialized training to reduce the risk of retraumatization of the survivor. The two modules of therapy that have been traditionally used to reduce the symptoms of trauma have been cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR). While both have had success with survivors, the author would like to propose a third option for consideration: Applied Behavior Analysis (ABA). Although ABA has been traditionally applied towards individuals with developmental disabilities, its dedication to evidence-based interventions, data driven results, and contingency management makes it a viable option.

An Overview of Trauma

Current Reports on Trauma: As described above, accurate reports of trauma can be difficult to verify when it comes to analyzing national trends. This is directly related to the individual comfort of the survivor and the accessibility of the resources. If the individual does not feel safe reporting, they won’t. If the individual does not report, then those are not added to the statistics.

The current data suggests that over sixty percent of men and fifty percent of women have had a traumatic experience in their background (DVA, 2018). Men typically report traumatic responses as a result from accidents involving bodily harm, physical assault, military combat, national disaster, or from witnessing a traumatic incident. Women typically report traumatic responses as a result of sexual abuse as a child or rape (DVA, 2018). Finally, it is estimated that approximately six percent of the population are diagnosed with PTSD every year as a result of experiencing trauma (DVA, 2018).

Different Types of Trauma: While the American Psychiatric Association’s definition of a traumatic event is limited to “a terrible event like an accident, rape, or natural disaster” (APA, 2019), there has been significant expansion to other experiences that may contribute to trauma responses. The most common indicators of future trauma responses are typically cited as adverse childhood experiences (ACEs) and include elements such as physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, exposure to significant mental illness, exposure to contemptuous divorce, substance abuse, domestic violence, and separation from family due to crime (Oral et al., 2016). There is no finitely defined set of ACEs, but these are generally considered the most commonly cited.

Different Responses to Trauma: As described above, trauma is difficult to understand due to its two-fold nature: a traumatic incident must occur and there must be an associated emotional reaction. It is possible for individuals to have experienced trauma and not develop traumatic responses, evidenced by a survey of survivors of the September 11th attacks. This survey indicated that fifteen years post-attack, approximately fifteen percent of pedestrians, eleven percent of area residents, and thirteen percent of local workers suffered from posttraumatic stress (Hamwey, 2020). Of course, the author is not suggesting the absence of a PTSD diagnosis indicates a lack of trauma response, but rather as a means to highlight that different people experience and internalize trauma differently. This element makes it especially difficult to be proactive in treating trauma, resulting in what often feels like reactionary measures.

Popular Treatments for Trauma: Trauma informed practices and specializing in trauma are two separate ideologies. Trauma informed practice refers to the general understanding of trauma and commitment to guide everyday practice (regardless of the field) with the intent to avoid revictimization and provide consistent information, humility, and compassion. Having a specialty in trauma implies that a mental health clinician has had specific training in order to guide a trauma survivor through various interventions with the intention to reduce suffering and also avoid revictimization. Every interaction should be considerate of a person’s potential trauma.

The two modules of therapy that have been traditionally used to reduce the symptoms of trauma have been CBT and EMDR. CBT in application towards trauma involves identifying the thoughts associated with maladaptive behaviors, with the goal of increasing positive thinking and emotional regulations (APA, 2017). These sessions typically span twelve to sixteen sessions (APA, 2017).

EMDR is an extremely structured approach to trauma therapy, with six to twelve sessions being conducted approximately twice per week (APA, 2017). The goal is to identify “unprocessed memories” that result from distressing past experiences which are thought to contain the emotions and sensations associated with the trauma (APA, 2017). In EMDR, the focus is on the memory and how to reduce/eliminate the intrusiveness of that memory. The procedures of this therapy utilize “rhythmic left-right stimulation” and associated eye movements, with the goal of reducing the impact of the emotion associated with the memory (APA, 2017).

How Can ABA Help: Although CBT and EMDR have demonstrated efficacy, there is still room for growth. With this in mind, the author would like to propose a third option for consideration: Applied Behavior Analysis (ABA). ABA would be most beneficial in addressing the contingencies that are maintaining the maladaptive behaviors, specifically in states of crisis. Using a four-term contingency, ABA examines a behavior with consideration for the motivations that contribute to the behavior, immediate antecedents that occur before the behavior, and ultimately the consequences that result. For example, consider a woman who has left a violent relationship and is experiencing hypervigilance; she jumps when she sees someone step out from around a corner. Her motivation is to stay safe, random stimuli are viewed as potentially dangerous, and the consequence is the affirmation that she is actually safe. By understanding these contingencies, a behavior therapist can implement an intervention to teach alternative behaviors with the goal to reduce this hypervigilance and return the woman’s sense of control over her life. This is obviously just one example, but there is significant potential for the application of ABA towards survivors of trauma.

Conclusion

Trauma is a complicated and intricate collection of symptoms resulting from adverse experiences. This article has analyzed several barriers to addressing these symptoms, including the hesitation by many survivors to report, the variety of incidents that may be considered traumatic, and the difficulty in conceptually understanding trauma. There are currently two major approaches to treating trauma: CBT and EMDR. The author proposes the consideration of ABA as a third option. Perhaps best used in collaboration with psychotherapeutic, ABA offers evidence-based interventions, data driven results, and contingency management. With this in mind, it would be a beneficial option to explore for future use with survivors of trauma.

Jeridith Lord, MA, LCPC, is Adjunct Professor and Clinical Counselor at Endicott College For further information on this topic, Jeridith Lord can be reached at JLord@mail.endicott.edu.

References

American Psychological Association. (2019). Publication manual of the American Psychological Association (7th ed.).

American Psychological Association. (2017). Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. Retrieved November 17, 2022 from https://www.apa.org/ptsd-guideline/ptsd.pdf

Department of Veterans Affairs. (2018). How Common is PTSD in Adults? Retrieved November 17, 2022, from https://www.ptsd.va.gov/understand/common/common_adults.asp

Hamwey, M. K., Gargano, L. M., Friedman, L. G., Leon, L. F., Petrsoric, L. J., & Brackbill, R. M. (2020). Post-Traumatic Stress Disorder among Survivors of the September 11, 2001 World Trade Center Attacks: A Review of the Literature. International journal of environmental research and public health, 17(12), 4344. https://doi.org/10.3390/ijerph17124344

Oral, R., Marizen, R., Coohey, C., Nakada, S., Walz, A., Kuntz, A., Benoit, J., and Peek-Asa, C., (2016). Adverse childhood experiences and trauma informed care: the future of healthcare. Pediatric research, 79(1), 227-233.

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