Post-Traumatic Stress Disorder
Brief Overview
The fifth edition of the Diagnostic and Statistical Manual, fifth edition defines Post Traumatic Stress Disorder (PTSD) as a mental condition or psychological distress which happens to someone after experiencing or witnessing a traumatic or nerve-wracking event. (DSM-5, 2013) Faust & Ven (2014) found that PTSD may occur as a result of one terrifying event or repeated stressful situations for example: by being exposed or witnessing a life threatening situation or indirectly through a close friend or relative which can also lead to PTSD. This definition is also in accordance with the approach that PTSD is caused by an intimidating, unforeseen and overwhelming traumatic event that is contrary to everyday living in a safe and predictable world that tends to be under control. (Ding, Yang, Wu, & Yang, 2014) The purpose of this research paper is to study Post Traumatic Stress Disorder as a mental disorder while talking a closed look at populations impacted by it and brainstorm at ways professionals in the field can go about it to improve the quality of service provided to clients affected by it.
According to Nilsen, Hilland, Kogstad, Heir, Hauff, Lien & Endestad (2016) many experts in this topic, PTSD is such a complex topic not to be examined lightly. Many scholars who have studied this topic for decades indeed agree with the fact that, PTSD is caused by major life stressors such as gang violence, military related trauma, history of abuse or neglect and perceived threat to one’s life. Skeptics about this topic argue that not everybody is at risk to develop this mental disorder after a major life stressor. Instead, they have argued that one’s socio-economic status, age, gender, resilience and coping skills and previous life stressors should be the main indicators to evaluate whether someone is suffering from PTSD. (Nilsen et al., 2016) Reciting the work of peer reviewed other scholars research on PTSD, Gil & Weinberg (2015) have came to the conclusion that only a small minority of trauma-exposed individuals tend to develop PTSD or other trauma related disorders. They have found that individuals with mastery of positive coping strategies, support system and have more protective factors than risk factors are less likely to develop PTSD after a traumatic event. Samuelson, Bartel, Valadez & Jordan (2016) declared that the symptoms for PTSD are associated with subjects reminiscing of the trauma through thoughts and memories of the traumatic event. These factors tend to be associated with neurocognitive impairment which affect memory and cause attention problems for most people. Individuals with PTSD may lose interest in things that they love doing but with life as a whole in the broader spectrum. Gil & Weinberg (2015) found that those suffering from PTSD often experience increased levels of anxiety, breathing and blood pressure, irritability and anger, constant recall of the trauma. Anniversary of the traumatic event or anything that reminds them of their past ordeal may also cause sleeping problems such as bad dreams and nightmares. There is a myriad of research done about several professions dealing with occupational stressors where professional are trained to provide normal response to abnormal events which they must adapt to and cope with over the duration of their careers. For example: soldiers war veterans , especially soldiers transitioning back home to their families from the battlefield, law enforcement, firefighters and other first responders, child welfare workers and children in foster care. The literature suggests that they are more at risk to be exposed to PTSD due to their high exposure to trauma. Too often their way of coping with the exposed trauma is not often therapeutic due to the fact that they tend to employ maladaptive coping skills such as: suppression of thoughts and feelings, reducing communication with friends and loved ones, social isolation, guilt, anger (Chopko, Palmieri, & Adams, 2017). Others that are currently in the prison population, children and youths experience in foster care and child welfare system, victims of gang violence in low-income communities, natural disasters, domestic violence and sexual assault victims and also more likely to developed PTSD also due to their history of traumatic exposure. Clinicians who have worked with individuals with PTSD associated with any of the listed populations have observed that their cognitive views tend to have similar traits in thoughts and actions. Over the years, clinicians in the field realized that individuals with PTSD tend to concur that the world is negative and dangerous place. These negative approaches on the other hand, lead to poor coping mechanisms which fuel PTSD symptoms. (Samuelson et al., 2016) Clients who have suffered from PTSD described it as a hidden wound that is not easy to describe. Since the age range of child in the foster care system ages from 7-17, research shows that the brain of individuals in this age range are not fully develop and their developmental stage is more at risk due to various stressors such as: having experience chronic poverty, exposure to physical and sexual abuse, being removed from their home and loved ones, going into adoption, feeling unsure about their future, constantly being monitored and being told what to do and the list go on and on. Taking children out of the home can cause victimization, increase family tension, reduce involvement in school and increase likelihood to being involved in juvenile justice system. (Kleckovak andVaculik, 2012) Populations affected Sherman, Larsen, J., Straits-Troster Erbes, & Tassey (2015) revealed that more than 15 million of people in the United States will experience PTSD in their lifespan. The majority of PTSD patients are parents, many research have found that more than 70 percent of women and 60 percent of men affected by this mental disorder are parents to a child. This is a troubling statistical data because it entails that children are even more at risks to be exposed to secondary trauma for their parents and this creates sort of a vicious endless cycle where the entire family system is affected by this invisible wound which can creates a tremendous dysfunction in the family environment. For example a sound or a smell and even witnessing an event that is similar to a past traumatic experience can cause flashbacks, nightmares, hallucinations in other words it is like experiencing their nightmare while awake. These are important indicators of a post traumatic event as well as avoiding other people, places, thoughts and detachment from friends or loved one. Issues of Culture and Diversity
Kerr, DeGarmo & Chamberlain (2014) reported that juveniles who are currently in the foster care system or have and history of being in the foster care altogether are more likely to develop delinquent behaviors due to their long history dealing with unresolved trauma. Most at-risk youths in foster care comes from disfranchised communities where the unemployment rate is twice the national average, and where the rate for violent crime is at an alarming rate. The environment where those youths are from may not tell their whole story but can give us an idea about the potential risk factors that needs to be addressed. Research shows that, youths in Child Welfare custody are more likely to have a long history of mental health problems such as: past history of traumas, depression, anxiety, substance abuse, suicidal ideation/attempt, social isolation and many more. Whitted, Delavega & Lennon-Dearing (2012) added that 80 percent of dually involved of youthful offenders in the juvenile justice system have serious mental health problems and only 23 percent in foster care for at least 12 months received services. It is a serious discrepancy because the developmental consequences are more severe when abused and neglect is experienced at a very young age. Therefore, they are more vulnerable to post-traumatic stress disorder which also leads to other problems such as learning and memory difficulty, and attention deficit disorders. These juveniles are likely to have a pessimistic view about the world and are more at risk to become youthful offenders if their current trauma is not well evaluated, treated, addressed and can eventually evolve to criminal behavior. Current Empirically validated treatments ( benefits, risk, and efficacy of treatment)
Treatment According to Fredette, El-Baalbaki, Palardy, Rizkallah, & Guay (2016) Cognitive Behavioral Therapy is a form of psychotherapy and a great technique that expert in the field uses to help treat post-traumatic stress disorder. It is a way to meet the clients where they at and push them forward to a more positive path toward change by having facilitating client to expose and control their fears in a safe and control way. (CBT) is commonly used in therapy to assess and determine someone’s thoughts and actions that lead them in the wrong side of the law. It is an intrapersonal therapeutic intervention designed for group members to develop the skill to understand how their unhealthy thought patterns can affect their emotions and behaviors. (Fredette et al., 2016) For clinicians dealing with children and adolescents with long history of trauma, it is a common tool used to assist them to be more accountable for their behavior and get them to develop positive coping skills to address their maladaptive beliefs. Kerr et., al ( 2014) found that child welfare placements that utilize CBT technique have lower rate of medicated population than non-CBT placements. This could be key in preventing and reducing youths in the child welfare system and lower rate of juvenile incarceration because it can potentially get rid of medication as a way to control behavior which can decline rate of mental health problems in placements because children and youths would have the coping skills to better deal with depression, anxiety, suicidal ideation and attempt and substance abuse. DBT, on the other hand, is a form of CBT, designed to address the juvenile social interaction with others in different environments but more importantly help them learn and practice various coping skills throughout individual or group sessions to achieve positive outcome. (Kleckovak and Vaculik, 2012) DBT believe that everyone is doing the best they can but need to try harder to initiate change. It is a complicated step that can be reinforced by different factors that can influence change. It is a different form of therapy where the first goal is to stay alive, staying in therapy until they can meet their goal, and the most caring therapist they can do is to push clients towards their goals. DBT would really be an important asset in placements to help juveniles manage their emotions, tolerate the stress and start developing effective interpersonal relationships.(Kerr et al., 2014)
Differential Diagnostic considerations
There are various differential diagnosis linked to trauma which does not meet the PTSD criterion for example: Adjustment disorders, Acute stress disorder, Anxiety disorders and obsessive-compulsive disorder, Major depressive disorder, personality disorders, Dissociative disorders, conversion disorder (Functional neurological symptom disorder, psychotic disorders and trauma brain injury. Those listed differential diagnosis means that a client may experience a PTSD criteria but does not meet all of the others criterions to qualify for PTSD as a diagnosis. (DSM-5, 2013)
Procedures for assessment In order to effectively screened and assessed someone with PTSD it is important to repeat the process in various stages to determine the symptoms that are blatant and evident during the first initial assessment session. Researchers in the field highly suggest that clinicians should supplement assessment with newly screenings instruments, symptoms inventories and clinical interviews for more reliability and validity. The PTSD scale is commonly used by clinicians when assessing clients who are affected by PTSD to find out about the different ways they have adapted when dealing with traumatic stressors. Those adaptions continue to get in the way of their lives because PTSD clients act as if the stressor is still present. The PTSD scale is composed of items designed to identify and rate frequency of a primary traumatic event and current symptoms using a severity score from 0 for a symptom that is , 1 for a mild symptopm but not clinically significant, 2 for moderate and represent clinically significant distress, 3 represents symptoms that are severe and overwhelming at times and lastly 4 for a symptom that is currently frequent and incapacitating to the client. Those assessing tools are used to determine how the client is currently doing and allow clinicians to rate the level of PTSD client is currently going through. It is important to note that this process is based on the clinician’s observations and client’s report of their symptoms. Some may say that this process maybe flawed because if clients over report or underreport their current symptoms than it may affect the initial assessment, this is another good reason as to why it is recommend to reassess clients as the relationship and bond between clinician and client is evolving.(Courtois, 2008)
Effects of the disorder on family and caregivers
Effects on Family The effects of PTSD on friends and family members can be traumatizing in itself when dealing with a loved ones being affected by this mental disorder. Sherman et al., (2015) found parenthood can be beneficial to a parent mental health when dealing with PTSD. Many subjects have found that having children motivates them to better manage their maladaptive coping skills and use healthy coping skills to build more positive interactions with their children. However, Gil & Weinberg (2015) discovered that parents with PTSD were three times more likely to report a child experiencing both depression and anxiety than parents without PTSD. This entails that children of a PTSD affected parent are more at risk of being traumatized either by tense or angry reactions from the parent, verbal and physical abuse or neglect. From the children perspective, the child does not know when the affected parent may turn on them due to a flashback or occupational stressor that may provoke or trigger a negative reaction from the PTSD affected parent. The impact on children tends to cause emotions like confusion, guilt, fear because they feel responsible. They are indirectly affected by an invisible wound that they cannot see, do not often understand and makes then unsafe and most of the time they do not know how to deal with it. These unresolved an emotional reaction from the children puts them at risk for anxiety, depression, isolation, and a wide range of mental health problems if not addressed at the beginning stages by a therapist. (Sherman et al., 2015) The effect of this disorder on the significant other in the relation adds a sense of weight, tension, uncertainty, which can be detrimental to the relationship. Chopko, Palmieri, & Adams (2017) stated that a common challenge to expect a loved one suffering from this mental disorder to just get over it or turn off the switch. Being misinformed or uneducated about this issue can be detrimental to the relationship and create emotional detachment, hypervigilance, avoidance, low amount of family support, lack of communication. The reality is that most couples affected by PTSD does not know how to address it or if they attempt to address it without it professional help they ended up doing more harms than good to the affected love one. Having a significant other affected by PTSD can be quite challenging to understand because they may have negative feelings about themselves, are emotionally numb and have a lack of interest doing anything. Various research studies suggests that when family participate in therapy with the affected client, it helps to build stronger coping strategies to help reduce PTSD symptoms and also educate families to deal with a PTSD episode for example. (Gild & Weinberg, 2015)
Caregivers The effects of PTSD on caregivers in the child welfare system for example are somewhat similar to some extent. PTSD does more than affecting children behavior and reactions, it affects their developmental stage; most importantly their decision making process on how to deal with their current reality. The literature states that caretakers in placements should be more transparent to the foster care population for example by admitting that they are wrong for example because it may open a bridge to a relationship between staffs and residents since it will show their human way and it is ok to make mistake. For children from abuse and neglect case, they blame themselves for their parents and if they have been treated like they are worthless human being then they start to think that way. Most children in foster care value trust like gold they put their guard up like armor with their caretakers because they do not want to be vulnerable and get hurt engaging in relationships with their caretakers. Learning how to trust for this population is so challenging because many do not know what being love by a parent feels like and blocks everyone out. Sadly, Social workers and staffs in the Child Welfare system can only see what is on the outside but the reality for this population is that when they act out is usually a cry for help, to be listened and get attention from their caretakers. It is also an opportunity for caretakers to not only address their current issue and react to it in more of a therapeutic way. (Kleckovak andVaculik, 2012)
What roles you as an MSW would take in working with someone who had this diagnosis? In order to provide good quality service when working with PTSD affected patients in a clinical setting, I would create an environment where the client feels safe and free to express their thoughts and emotions by building trust and active listening to concerns. As an MSW, I would take on the role of a facilitator instead of the expert in the room. What that entails is that, the PTSD clients are the experts of their own stories, therefore it is best to have them be the voice of their own story instead of asking them standard questions which may put them at the risk if feeling defensive, uncomfortable and may create a barrier between clinician and client. For example, If I were to meet with the PTSD client for our first session, I would ask about their expectation of today’s session as an ice breaker to create dialogue and also get a sense of they at dealing with this mental disorder. Creating a dialogue where PTSD client feels safe and comfortable to express themselves is essential to build a good rapport with them. This would create a win-win situation for the clinician and client because the clinician would have the opportunity to ask open ended questions, and determine the symptoms and how to come up with a plan to help treat the client while the client feels empowered, have the chance to develop positive coping skills and find resilience because he or she has the opportunity to tell their own story and receiving the medication and help that they need as the same time. It would also be a good approach to ask the PTSD client about what would be different about their life without PTSD or what was life like before they endured their trauma for example. This is one way to engage the client more in conversation without triggering them because it is more of a solution focused or futuristic perspective where the goal is to get the client affected by PTSD to brainstorm or visualize their life without their current problem. Once the client identifies potential criteria that could improve their lives without the problem then as a clinician I would incorporate those criteria in the client’s service plan to help the client work towards them. It can be a hobby, talent, skills or anything positive that can help change their situation for the best.
Conclusion
In essence, Post-Traumatic Stress Disorder is a mental disorder is a really issue which affects the lives of millions of people in the United States. Children of a parent who suffers from PTSD has a higher rate of developing depression and anxiety. Those suffering from PTSD often experience increased levels of anxiety, breathing and blood pressure, irritability and anger, constant recall of the trauma which also creates a challenge to family members and loves ones. Family members are strongly encouraged to also participate in the treatment process of a loved one affected by PTSD because it will increase their awareness on how to better deal with this issue and increase the rate of recovery for the client affected by PTSD. Cognitive Behavioral Therapy and Dialectical Behavioral Therapy is recommended for professionals in the field that are serving this population because they are better alternatives to using medications and are great techniques to teach clients to change their maladaptive behaviors into more positive coping skills. It is important to note that there are endless sources that has been written, studied and analyzed over the years about PTSD however; there is a major limitation on the availability of sources that mentions about ways to prevent PTSD. It is such a broad topic and it is crucial to point that children, juveniles and adults have different ways to cope with it however; the symptoms remains similar for all age groups.
Reference
Chopko, B. A., Palmieri, P. A., & Adams, R. E. (2017). Relationships Among Traumatic Experiences, PTSD, and Posttraumatic Growth for Police Officers: A Path Analysis. Psychological Trauma: Theory, Research, Practice, And Policy, doi:10.1037/tra0000261
Courtois, C. A. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychological Trauma: Theory, Research, Practice, And Policy, S(1), 86-100. doi:10.1037/1942-9681.S.1.86
Faust, K. L., & Ven, T. V. (2014). Policing Disaster: An Analytical Review of the Literature on Policing, Disaster, and Post-traumatic Stress Disorder. Sociology Compass, 8(6), 614- 626. doi:10.1111/soc4.12160
Fredette, C., El-Baalbaki, G., Palardy, V., Rizkallah, E., & Guay, S. (2016). Social support and cognitive–behavioral therapy for posttraumatic stress disorder: A systematic review. Traumatology, 22(2), 131-144. doi:10.1037/trm0000070
Gil, S., & Weinberg, M. (2015). Coping strategies and internal resources of dispositional optimism and mastery as predictors of traumatic exposure and of PTSD symptoms: A prospective study. Psychological Trauma: Theory, Research, Practice, And Policy, 7(4), 405-411. doi:10.1037/tra0000032
Kerr, D. R., DeGarmo, D. S., Leve, L. D., & Chamberlain, P. (2014). Juvenile justice girls ‘depressive symptoms and suicidal ideation 9 years after multidimensional treatment foster care. Journal Of Consulting And Clinical Psychology, 82(4), 684-693. doi:10.1037/a0036521
Nilsen, A. S., Hilland, E., Kogstad, N., Heir, T., Hauff, E., Lien, L., & Endestad, T. (2016). Right temporal cortical hypertrophy in resilience to trauma: An MRI study. European Journal Of Psychotraumatology, 7 Samuelson, K. W., Bartel, A., Valadez, R., & Jordan, J. T. (2016). PTSD Symptoms and Perception of Cognitive Problems: The Roles of Posttraumatic Cognitions and Trauma Coping Self-Efficacy. Psychological Trauma: Theory, Research, Practice, And Policy, doi:10.1037/tra0000210
Sherman, M. D., Larsen, J., Straits-Troster, K., Erbes, C., & Tassey, J. (2015). Veteran–child communication about parental PTSD: A mixed methods pilot study. Journal Of Family Psychology, 29(4), 595-603. doi:10.1037/fam0000124
Trauma- and stressor-Related Disorders. (2013). In Diagnostic and Statistical Manual of Mental Disorders (5th ed., pp. 265-280). American Psychiatric Association.
Whitted, K., Delavega, E., & Lennon-Dearing, R. (2013). The Youngest Victims of Violence: Examining the Mental Health Needs of Young Children Who Are Involved in the Child Welfare and Juvenile Justice Systems. Child & Adolescent Social Work Journal, 30(3), 181-195. doi:10.1007/s10560-012-0286-9