We see the words Posttraumatic Stress Disorder (PTSD) everywhere—on the front page of major newspapers, on the shelves of bookstores in the self-help section, on prime-time television, and on the floor of Congress. When you hear ‘PTSD’ what do you think? Veterans? September 11th? Hurricane Katrina? What about children who witness domestic violence or are removed from their homes due to parental death, disability or instability? How about bystanders to a drive-by shooting? We also call to mind rape survivors – children and adults. There are those who survive fires, motor vehicle accidents and floods, but are then ravaged by the memories of their experiences and have PTSD. Don’t forget the first responders – to disasters, fires, and interpersonal violence. These workers, including social service and mental health providers, risk secondary exposure to trauma and their own PTSD. With violence, disrupted family bonds, forced displacement and natural disasters as part of our social fabric, we need to take a broad view of the potential PTSD sufferers in the communities we serve.
What is PTSD? Officially labeled in the DSM in 1980 (APA, 1980), PTSD occurs after a traumatic event triggers fear, helplessness or horror. Symptoms include re-experiencing (flashbacks, nightmares), avoidance and numbing, and hyperarousal. Sleep is usually disturbed. Somatic complaints often occur, and long-term health problems (KR Cromer & N Sachs-Ericsson, 2006) have been reported. The avoidance that comes with PTSD leads many individuals to avoid thinking or talking about their difficulties, so they do not often seek mental health care for this disorder.
Most trauma survivors do not develop PTSD. Many have stress reactions, such as reactivity, fear, and disrupted sleep. Most of these will resolve with time in the setting of good social, intrapersonal and coping skills and, on some occasions, with early interventions. Some survivors may develop depression after trauma exposure. Other adults go on to develop panic disorder, generalized anxiety, and substance abuse. Children show more disruptions in their relational and cognitive development, and specifically develop anxiety disorders, disorders of conduct, and exhibit somatic distress. So how do we help those in our communities who have PTSD? Fortunately, we know that good community care, evidence-informed treatments, expressive approaches, and thoughtful, alternative care can be used to alleviate trauma-related suffering.
Treatment begins with a careful assessment and psychoeducation. Information about PTSD helps to normalize symptoms and make clear the path to recovery. Explanations accompanied by some understanding of the biological nature of PTSD (as an overwhelming stress response) help diminish stigma and engage families in treatment. For combat veterans, early work focuses on recognizing the conflicting messages of the warrior mentality (suck it up and drive on) and the veteran’s own instincts (I know that something is not right, and I need help). For children and those involved in community violence, establishing physical safety is crucial. There is clear evidence that very young children’s reactions to trauma are strongly affected by how well the people who take care of them cope with trauma. Clinicians are advised to do a thorough assessment of caregivers and attend to their wellbeing when working with traumatized infants and young children.
All evidence-informed trauma treatments include all or most of the following sequenced, critical components: psychoeducation about PTSD and the effects of trauma exposure; safety planning; goal setting; affect regulation skills; thought restructuring skills; social and communication skills; and exposure. During the repeatedly tell their trauma stories, adding more and more detail, while also learning to cope with their emotional reactions. In addition, clients examine dysfunctional beliefs, such as shame and blame, during this phase of treatment. Examples are Trauma-Focused Cognitive Behavioral Therapy for children and adolescents, Life Skills/Life Story for adolescents, and Cognitive Processing Therapy for adults. Prolonged Exposure is another evidence-based treatment which involves the same central features, with a greater emphasis on exposure. Other treatments include exposure through Virtual Reality and Eye Movement Desensitization and Reprocessing (EMDR).
For children exposed to multiple traumas who have PTSD and a more complex post-traumatic picture, treatments include Child-Parent Psychotherapy (CPP), Trauma Systems Therapy (TST), Attachment, Self-Regulation and Competency (ARC), and Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS). Psychopharmacology as a sole treatment, or combined with psychotherapy, can also be used for adults and some children.
Treatment is best conducted in a culturally informed manner – lives and trauma occur in a context. Attention to micro-aggressions, as well as overt racism is crucial. Respect for language and traditional understanding of symptoms and their function is important and treatment in native language is critical. Community support, both culturally informed and meaningful to the individual and family, has been shown to enhance engagement and support successful treatment.
Non-evidence informed treatments are often sought by individuals (and evidence is emerging to support their value). These include spiritual approaches, yoga, body work, and expressive treatments. Often, due to the disorganizing effects of trauma, survivors have difficulty verbalizing what happened to them or their feelings. Expressive mediums, such as art, music, dance, poetry and drama, enable the client to express feelings, organize and structure their experiences, and process the trauma in a safe, non-threatening way.
At its core, PTSD is a disorder that creates powerlessness. By definition, sufferers experienced an event of overwhelming terror or horror. Gaining mastery in a variety of domains, therefore, can create a sense of self worth and confidence. Physical activity in which a person experiences strength, power and confidence can help to undo the feelings of powerlessness and isolation. Team-based sports, karate, self-defense and dance are examples of recommended activities. Support groups in a variety of community settings, for victims and their families, can do the same. Reconciliation of the horrors witnessed, the innocence lost, and the grief experienced require treatment, community support and an individualized “best match” approach.
Help is available. Mental health practitioners can enhance their skills in assessment and treatment of PTSD. JBFCS offers courses and consultations in trauma assessment and treatment. Online and in-person courses are also offered at many New York settings and on the websites including: www.ncptsd.va.gov; www.nctsn.org; www.istss.org; tfcbt.musc.edu; www.agpa.org. Consultations and collaborations are the best way to enhance individual and agency capacity. When doing trauma-informed work, avoiding secondary traumatic consequences is best achieved by not doing the work alone.
JBFCS programs address trauma and PTSD using evidence-based interventions in young children, school age children & adolescents in clinics, day programs and residential care (PCP, Sanctuary®, SPARCS, TF-CBT, Life Skills/Life Story, adults in clinics (CPT & CBT). Early intervention is done through evidence-informed Crisis Response, Psychological Preparedness Groups (Keep It REAL) and Community Psychoeducation. For more information call 212-632-4519; firstname.lastname@example.org; www.jbfcs.org. Member, National Child Traumatic Stress Network.
This article was written by the JBFCS Center for Trauma Program Innovation and Martha K. Selig Educational Institute Team. Paula G. Panzer, MD, Director. Staff: Randi Anderson; Melanie Cushman; Mary Dino; Amy Feldman; Christina Grosso; Deborah Langosch; Susan Paula; Linda Payne; Caroline Peacock; and Alice Psirakis.