Treating PTSD

A Compassion-Focused CBT Approach

Shirley Porter

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351345149
• Edition: 1
• Topic: Psychology
• Subtopic: Post-Traumatic Stress Disorder (PTSD)
• Index: Psychology

Treating PTSD presents a comprehensive, compassion-focused cognitive behavioral therapy (CBT) approach that provides therapists with the evidence-based information they need to understand trauma's effects on the mind and body as well as the phases of healing. Chapters offer discussion, practical tools, and interventions that therapists can use with clients suffering from post-traumatic stress disorder (PTSD) to reduce feelings of distress and increase their sense of safety. Readers are introduced to the metaphor of "the valley of the shadow of death" to explain the experience of PTSD; they're also shown how to identify the work they'll need to do as therapists to accompany clients on their healing journey. Two new compassion-focused CBT interventions for trauma processing are also introduced.

Part I
Therapist Preparation for Trauma Work

1
A Brief History of Our Understanding of Trauma

In traumatic neurosis the operative cause of the illness is not the trifling physical injury but the affect of fright—the psychical trauma… Any experience which calls up distressing affects—such as those of fright, anxiety, shame or physical pain—may act as a trauma of this kind.

—Breuer and Freud (1957, pp. 5–6)

In the above quote, Breuer and Freud provide one of the earliest definitions of potentially traumatic events, and how such highly distressing emotional events can cause injury to the mind, which can result in what we now know of as PTSD. This proposed explanation for the source of traumatic stress reactions, forms the basis of our understanding today. In the century since it was proposed, evidence has mounted to support and expand our understanding of the characteristics of events that are more likely to result in traumatic stress reactions among survivors, as well as how different areas of the mind are affected when a person is suffering from PTSD.

Prior to entering the valley, we need to get our historical bearings. It can be helpful to have an understanding as to how the concept of trauma and treatment interventions have evolved over the past century. Thus, what I would like to do is provide an overview of some of the key developments of our understanding in this area and to point out how individuals suffering from severe traumatic stress reactions were perceived and, consequently, responded to, by professionals at different points in history. It will become apparent that in the not so distant past, trauma survivors were regularly subjected to stigma, minimization, accusations of deception and weak moral character, and in some cases, brutal and cruel retraumatizing interventions used by the medical community. While we might be tempted to look down on past professional responses to trauma, we would be wise not to fool ourselves into believing that we have somehow overcome the stigma, minimization, denial, and tendency to blame the victim that continue to be rampant in many parts of society today. We will also review the current prevalence rates of trauma among civilian, first responder, and military populations, to remind us that people from all walks of life end up in the valley, though for some the risk is increased.

Studies of Hysteria

In the late 1800s, Charcot, a French neurologist, was renowned for his lectures and demonstrations at the famous Salpêtrière Hospital where he worked and taught. During the course of his career, he worked with individuals suffering from “hysteria” (which would later be renamed post-traumatic stress disorder), and he was one of the first to describe typical symptomology. He focused on reporting physical symptoms, which included such things as: “special seizures”, vomiting, partial blindness, paralyses, pain, and sensory impairment (Charcot, 1889). He believed that cases of hysteria were very rare, and in fact it was more likely that physicians would encounter women who were faking their symptoms. (It was believed that hysteria occurred predominantly in women since its cause was thought to be related to the ovaries). His perception of patients presenting with these symptoms is clear within this quote: “one finds himself sometimes admiring the amazing craft, sagacity, and perseverance, which women, under the influence of this great neurosis, will put in play for the purpose of deception—especially when a physician is to be the victim” (p. 230). The emphasis at this point in time appeared to be on noting minute details regarding symptoms and ensuring, through extensive surveillance, that patients were not faking their symptoms in order to gain attention. Charcot treated hysteria using hypnosis.

Around the same time, Breuer and Freud also noted their observations of the symptoms described previously. Additionally, they introduced the concept of dissociation, as related to “abnormal states of consciousness” (Breuer & Freud, 1957). They were among the first to recognize that, for many of their patients, a traumatic event in childhood was connected to persistent symptoms. Breuer and Freud also had a more positive perception of their patients: “among hysterics may be found people of the clearest intellect, strongest will, greatest character and highest critical power” (Breuer & Freud, 1957, p. 13). They proposed that hysterical symptoms would disappear once patients were able to describe in words their experiences and accompanying affect. Thus, psychoanalysis as a treatment for hysteria, often in conjunction with hypnosis, came into being.

Freud attempted to trace the specific source of trauma among several cases of adult hysteria. He identified the common denominator as being a history of childhood sexual abuse, sexual assault, and/or incest. He presented his findings in a paper called, The Aetiology of Hysteria, which was originally published in 1896 (Freud, 1962). A short time later, however, he retracted and revised his theory, reattributing the underlying cause of hysteria to fictional “phantasies” of repressed sexual desires rather than actual childhood sexual abuse experiences (Freud, 1954). Thus, although Freud had initially listened to and believed his clients’ accounts of childhood sexual trauma, at some point he made a decision not only to disbelieve them, but also to turn their narratives of abuse back on them, and in effect blamed his patients’ repressed desires for being the source of their illness.

In a series of lectures at Harvard, Janet (1920) provided a more comprehensive overview of the physiological, emotional, cognitive, and behavioral symptoms of hysteria. These included: amnesia; reenactment of disturbing or feared events during sleep; dissociation; memory, problem-solving, and concentration impairments; constriction of scope of conscious awareness; emotional indifference and depression; and somatic complaints. He recognized that external sensory experiences that were somehow related to a past “dreaded” experience could elicit symptoms, even after years without symptoms. He viewed physical symptoms as a representation and acting out of painful emotion. Janet attributed his patients’ susceptibility to these symptoms as an indicator of moral weakness and psychological instability. Like his mentor, Charcot, Janet also utilized hypnosis as a primary means of treating hysteria.

From Shell-Shock and Combat Exhaustion to PTSD

The next time a spotlight was placed on what we now know of as PTSD was during World War I (WWI). Early in this war, physicians noticed a growing number of psychological casualties. In an effort to explain the source of these injuries, Captain Charles S. Myers, who as medical doctor treated injured soldiers using hypnosis, described three cases in great detail. He traced the origins of the symptoms to the effects of “shell shock”:

these cases … appear to constitute a definite class among others arising from the effects of shell shock. The shells in question appear to have burst with considerable noise, scattering much dust… It is therefore difficult to understand why hearing should be practically unaffected, and the dissociated “complex” be confined to the senses of sight, smell, and taste (and to memory). The close relation of these cases to those of “hysteria” appears fairly certain.

(Myers, 1915, p. 320)

In England and France during WWI, the attitudes and treatment of soldiers suffering from shell shock varied greatly depending on the ideologies of treating physicians. The primary goal, however, was always to get these soldiers back to the front lines as soon as possible. Some were treated with hypnosis and “suggestive therapy” in an environment of quiet and rest. Others were treated much more aggressively using electricity with “firm psychotherapy” (Bogousslavsky & Tatu, 2013). What follows is part of an account by Dr. Yealland, a physician in London, England, of his treatment of a soldier, a veteran of many battles, who was suffering from mutism:

Many attempts have been made to cure him. He has been strapped down in a chair for twenty minutes at a time, when strong electricity was applied to his neck and throat; lighted cigarette ends had been applied to the tip of his tongue and “hot plates” had been placed at the back of his mouth. Hypnotism had been tried. But all these methods proved to be unsuccessful in restoring his voice…

In the evening he was taken to the electrical room, the blinds drawn, the lights turned out, and the doors leading into the room were locked and the keys removed. The only light perceptible was that from the resistance bulbs of the battery. Placing the pad electrode on the lumbar spines and attaching the long pharyngeal electrode, I said to him, “You will not leave this room until you are talking as well as you ever did: no, not before.” The mouth was kept open by means of a tongue depressor; a strong faradic current was applied to the posterior wall of the pharynx, and with this stimulus he jumped backwards, detaching the wires from the battery. “Remember, you must behave as becomes the hero I expect you to be”, I said.

(Yealland, 1918, pp. 6–8)

It should be noted that during WWI, the British Army did not accept the concept of shell shock as a defense for desertion (Babington, 1997). Sympathy and compassion were often non-existent, while suspicion of cowardice and malingering was prevalent. Consequently, 346 British and Commonwealth soldiers were executed for alleged cowardice or desertion, many of whom were likely suffering from traumatic stress injuries (Crocq & Crocq, 2000).

American psychiatrist, Thomas W. Salmon, visited British hospitals, prior to the U.S. entering WWI. His intention was to gain an understanding of shell shock and how it was being treated, so that he could better prepare the U.S. military medical response to these psychological casualties. During his visit he noted that soldiers diagnosed with war neurosis were generally stigmatized within the military and society, and if they did not recover within a short period of time, were certified as “insane” and sent off to their local asylum (Salmon, 1917). He indicated that he didn’t agree with this, and contrasted it with his own experience at home, “in most states our state hospitals enjoy a reputation which would no more stigmatize insane soldiers than it does their sisters and daughters when they require treatment” (Salmon, 1917, p. 16). As a result of his observations in Britain, he developed a comprehensive and detailed plan for treating American soldiers. Additionally, he suggested that the military immediately: allocate resources for the care of soldiers who would suffer from shell shock; implement intensive screening to prevent those more likely to develop nervous disorders from enlisting in the Army; and observe soldiers during their training to identify those more vulnerable to mental and nervous disorders. He emphasized that treatment must be available immediately at the front lines, and only if this was unsuccessful should soldiers be evacuated to the psychiatric hospitals located on military bases. Dr. Salmon’s recommendations for treatment, which focused on proximity, immediacy, and expectancy, came to be known by the acronym PIE (Jones & Wessely, 2003). In summary, soldiers with acute stress reactions were treated immediately at the front lines, with the expectation that they would be returning back to their combat duties. Persuasive psychotherapy was utilized (Crocq & Crocq, 2000). Dr. Salmon’s recommendations were accepted, and this led to a more understanding attitude toward those suffering from shell-shock, as evidenced by the fact that no American soldiers were executed for desertion, and by the development of a treatment approach which demonstrated an underlying belief that rest, safety, reassurance, and encouragement were vital components of the recovery process (Babington, 1997). This remained the first-line of treatment for soldiers suffering with acute stress reactions throughout WWI and the wars that followed.

In World War II (WWII), shell shock was more accurately renamed “combat exhaustion” (Swank & Marchand, 1946). Throughout this war, the American military used aggressive pre-screening measures to proactively weed out anyone who might be considered vulnerable to psychological injury in combat due to character and personality defects (Pols & Oak, 2007). They soon learned, however, that predicting who would suffer from psychological injuries, based on their current screening efforts, was not an exact science. During this war,

more than 800,000 men were classified as 4-F (unfit for military service) due to psychiatric reasons … (and) America’s armed forces lost an additional 504,000 men from the fighting effort due to psychiatric collapse.

(Grossman, 2009, p. 43)

Following WWII, evidence emerged which demonstrated that psychological injuries in the field were not the result of character flaw or some sort of personal deficit, but were rather a predictable consequence that would affect the majority of soldiers who faced the atrocities of war for a prolonged period of time:

Combat exhaustion may appear in as few as fifteen or twenty days or in as many as forty or fifty days… One thing alone seems to be certain: Practically all infantry soldiers suffer from a neurotic reaction eventually if they are subjected to the stress of modern combat continuously and long enough … an occasional soldier seems capable of withstanding combat for an inordinate length of time … No personality type dominates this small “abnormal” group, but it is interesting that aggressive psychopathic personalities … stand out.

(Swank & Marchand, 1946, pp. 243–244)

After WWII, the U.S. Department of Veteran’s Affairs began building hospitals that were affiliated with medical schools in order to provide the best care to injured veterans. It was through these hospitals that WWII veterans suffering from PTSD began receiving psychotherapy (Pols & Oak, 2007).

In Vietnam, “(t)he prevalence of delayed and chronic PTSD, in spite of the careful prevention of psychiatric casualties … was a rude awakening” (Crocq & Crocq, 2000). It was due to the activism of Vietnam veterans that “posttraumatic stress disorder” was finally introduced into the DSM-III (APA, 1980).

One potential contributing factor for the increased prevalence of PTSD among Vietnam veterans as compared to those in WWI and WWII has to do with the firing rates. A mass interview of WWII veterans indicated that on average, no more than 15–25% of soldiers ever fired their weapons—which was attributed to the inherent mental block that human beings have to killing another person (Marshall, 1947). Through operant and classical conditioning techniques, which continue to be used today (Grossman, 2009), the firing rate in Vietnam reached 83% (Glenn, 1987). While a success for the military, this training appears to have contributed to the high rate of psychological injuries among these veterans. As one of my clients, a veteran who served as a sniper in combat zones within the Middle East once said to me, “They taught me how to kill, but they never taught me how to live with it.” Other potential explanations for the increased prevalence of PTSD among this group of veterans include the lack of unit cohesion, in that most of these soldiers entered and left their time in combat as individuals rather than as groups, and that they were subjected to stigma and hostility upon their return to the U.S. (Pols & Oak, 2007).

Vietnam veterans suffering from PTSD have been treated using pharmacological interventions, as well as individual and group psychotherapeutic approaches (Pols & Oak, 2007). Currently, the U.S. Department of Veterans Affairs provides over 200 specialized treatment programs, as well as evidence-based psychotherapeutic care for veterans suffering from PTSD (e.g., Cognitive Processing Therapy, Prolonged Exposure Therapy) (U.S. Department of Veterans Affairs, 2017).

Domestic and Sexual Violence

During the 1970s women’s movement, the realities of domestic and sexual violence in the daily lives of women came to the fore, and with it, came the realization that the majority of individuals in the U.S. who were suffering from PTSD were not soldiers returning from war, but rather, women and children who lived lives of captivity within their own homes (Herman, 1992).

Prior to 1969, studies on rape were focused on protecting the accused. After that time, they began to more appropriately focus on how to protect and support rape survivors (Chappell, Geis, & Fogarty, 1974). Burgess and Holmstrom (1974) introduced the “Rape Trauma Syndrome”. They defined Rape Trauma Syndrome as a two-phase reaction, with somatic, psychological, and behavioral components that occur in response to rape or attempted rape. The first phase is characterized by disorganization in a woman’s life following the rape, which includes significant physical symptomology, and a dominant feeling of fear. There may be pain associated from the actual trauma of rape, as well as muscular tension, sleep disturbance, night terrors, headaches, gastrointestinal pain, and/or gynecological symptoms. The second phase is described as occurring a few weeks after the rape. During this phase the woman attempts to reorganize her life, but begins to experience intrusive symptoms such as phobias and nightmares.

These latter studies helped us to better understand the experience of rape as a significant form of trauma, which often results in rape-related PTSD symptoms—i.e., flashbacks, hypervigilance, nightmares, psychic numbing, constricted behavior due to fear, social withdrawal, sleep disturbance, memory and concentration issues, as well as active avoidance of reminders of the rape—that can sometimes last for years (Burgess, 1983).

It was also during the 1970s and 1980s that research into domestic violence and childhood abuse proliferated. That which had been unspoken and kept in the shadows began to be talked about and explored. As a result we learned about the staggering prevalence and impacts of these types of traumas. In terms of the scope of domestic violence in the U...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Acknowledgments
• Preface
• Introduction
• PART I Therapist Preparation for Trauma Work
• PART II Engaging in Trauma Therapy
• Appendices
• References
• Index