Interview with Forsakken

Post Traumatic Stress Disorder


In this essay I am going to take a look at posttraumatic stress disorder, what can cause it, and how it affects a person.  Then I am going to discuss the cognitive-behavioral therapy model and give the reasons why I believe this to be an effective model.  I will give a fictional case I came up with and use that to describe how one might go through therapy in order to overcome the stress symptoms and lead a more productive life.  At the end I briefly give a few other methods that may be helpful in treating someone with posttraumatic stress disorder.

An Overview of Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is usually diagnosed if someone continues to suffer depression or anxiety from an event that happened over a month prior.  Some symptoms that arise from this disorder are reliving the traumatic event through memories, nightmares, thoughts, avoidance of activities that may pull back the memories of this event, becoming less responsive to surroundings and may view surroundings as being surreal, and may become startled easily and struggle with feelings of guilt (Comer 2008).
There are many things that can affect PTSD.  One experience that is prominent are soldiers who have been in the middle of battle.  The explosions and gunfire surrounding them increase the likelihood of developing PTSD.  Traffic accidents, disasters such as earthquakes and hurricanes may produce symptoms of this disorder.  Victims of rape and violence may also be prone.  Even those who experience terrorism can develop PTSD, including those who have only viewed terrorist acts such as the twin tower attacks through the media (Comer 2008).   
What Causes or influences PTSD?
There are some biological factors that play a part in PTSD.  The hormones cortisol and norepinephrine usually are not acting as they should.  Secondly, there may be damage to the hippocampus and amygdala, two important brain areas.  A hippocampus that isn’t functioning properly may cause memories and flashbacks of the event that caused PTSD.  The amygdala, which is known to deal with matters of fear and anxiety, may pull in memories of the incident where the PTSD symptoms originated.  There is also evidence that the likelihood of PTSD developing is somewhat based on heredity (Comer 2008).  Around four thousand twins involved in the Vietnam War were studied and the identical twins were more likely to develop the stress symptoms than the fraternal twins (True & Lyons, 1999). 
Personality seems to influence someone’s reaction to stress.  Perhaps they are in the middle of a stressful situation or struggle with anxiety prior to the traumatic event.  In this case they will more likely have the onset of PTSD after the traumatic event.  Those who have a negative view toward bad situations or see bad events to be out of their control will more likely experience more stressful symptoms.  One who has grown up in poverty, suffered abuse, underwent traumatic events when younger, or whose parents divorced before they reached ten years of age seem to have an increased risk of developing PTSD.  Those who have less supportive friends and family are more likely to develop a stress disorder.  How severe the trauma is will also likely increase one’s risk (Comer 2008). 
Treatment For PTSD
Treatment seems to play an important role in helping a person with PTSD.  In a survey it was found that without treatment the symptoms lasted an average of five and a half years, but with treatment, only 3 years (Kessler & Zhao, 1999; Kessler et al., 1995).
The Cognitive Behavior Model
In this paper I’m going to take a look at the use of the cognitive behavior model, as that seems to be a popular method for therapists to use in treating someone with PTSD. This model is a combination of behavior therapy and cognitive therapy.
Behaviorists believe that behavior is influenced by the environment around them.   Examples would be operant conditioning, modeling and classical conditioning.  Systems of rewards and punishment cause certain behaviors in people and animals.  An example would be for a parent to offer their teenage son a couple of concert tickets if he scores an “A” on an upcoming exam.  This will encourage the child to put more effort forth to score well on the exam.  Modeling behaviors are learned by a person observing another and therefore repeating them.  John sees that his sister Betty is given a cookie for keeping quiet while his parents watch TV, so he decides that he is going to repeat her behavior in hopes to receive a cookie.  In classical conditioning, two events that frequently occur near the same time become associated with one another in someone’s mind.  Eventually, either of these two events will cause the same reaction in a person.  For instance, a person could knock three times on the table and pour their cat some food at the same time.  If this is repeated, it is likely that the cat will come upon hearing the three knocks on the table.  The cat food is the unconditioned stimulus, the reaction of the cat coming at hearing the sound of food is the conditioned stimulus, the three knocks on the table is the conditioned stimulus, and the cat coming upon hearing the three knocks is the conditioned response (Comer 2008). 
The cognitive model emphasizes on changing a person’s thought pattern (Comer 2008).  Those with PTSD may need to learn to change their thinking.  Many suffer with feeling of guilt or unreasonable fears which need to be looked at head on and a new way of thinking needs to be focused on to diminish these feelings of fear.  The approach to these fears needs to be changed in order for that fear to be overcome. 
How the Cognitive-Behavioral Model is Applied in Therapy

So, when dealing with PTSD, the cognitive-behavioral approach will start by identifying the unhealthy thoughts that the traumatic event(s) has created.  These thoughts are put to the challenge and new positive thoughts replace them.  Behaviors that are negative from these false thoughts are also replaced with behaviors that will lead to healing the mind from the stress (Goulston 2008).  
Let’s move on to see how cognitive-behavioral approach can help a person suffering from PTSD.  I’m going to give the example of a fictitious character named Mandy, a girl who was injured in a boating accident.  Her and her friend were out on a boat going about forty mph when the boat crashed into an unseen rock. Mandy who was standing near the front edge of the boat was knocked into the water from the impact.  As she struggled to the surface she felt an undertow drag her below as water flooded her mouth.  Her boyfriend that she was with reached his hand down, and pulled her back up on the boat and soon medical assistance arrived to save Mandy’s life.  However, her brother was also thrown off the edge but was not saved in time. 
The following months, Mandy begins to react to stimulus that is connected to her traumatic experience.  She will not go swimming because she has developed hydrophobia, something she never had before.  Her favorite movie was once Face Off with John Travolta and Nicholas Cage, but she can no longer watch it without bouts of panic at the fast-paced boat chase.  In fact, she has to redecorate her house because she once loved boating and there were several pictures of her and her friends out boating on her walls.  She avoids anything that has to do with water and boats and loses the thrill of adventures that she ones found enjoyable.  Not only this, she suffers from guilt of her brother’s death.  She wonders why she should have lived while he didn’t. 
Now, let’s look at some of the cognitive-behavior therapies that could be applied in order to help Mandy to overcome her anxiety.  Mandy is dealing with some negative self-feedback.  She is having over generalized thoughts such as “swimming is not safe,” or “boats are dangerous.”  Perhaps a therapist could help reevaluate these thoughts by showing that swimming is generally safe in areas such as a pool or beach.  The therapist could explain to her that boating, taken with the proper precautious can greatly decrease her risks of getting into another boat accident (Goulston 2008). 
A therapist may want to suggest to Mandy to confront the trauma and eventually overcome it.  This can be a very emotional process and doing it under the supervision of a therapist would be Mandy’s best bet.  Before undergoing this process, the therapist may want to go over with Mandy what is referred to as stress inculation training (SIT).  These are stress-reducing tools used when the person is going through the process of dealing with the traumatic event.  They are a good idea because if facing the event becomes too intense, knowing these techniques will buffer the negative stress and allow the person to not be over tensed (Goulston 2008).  
During SIT, Mandy may be taught breathing techniques to buffer possible stress during the process.  Another technique is known as thought stopping.  If the traumatic topic becomes too stressful the therapist may want to stop the thoughts and will ask Mandy to think of something pleasant.  It’s good to pre-meditate the positive things to think about so one is able shift from the traumatic thoughts to the pleasant thoughts with greater ease (Goulston 2008).  These two techniques are good to know before facing the stressors where as a few others that are learned in SITs may be used later on. 
There are some reasons as to why Mandy maybe should face her trauma head on.  The thoughts from the trauma or anything associated with it continue to bother her.  Trying to suppress these emotions instead of dealing with them is like unplugging the oil light on your car so you don’t have to deal with it flashing.  While it may temporarily seem to fix the problem, it is still there and may manifest as a worse problem later on down the road (Goulston 2008). 
When one deals with their trauma repeatedly something called habituation will occur (Goulston 2008).  For example, a young kid goes to a theme park and is at first afraid to go on a large roller coaster that is there, but after three hours of his bigger sister pestering him he decides to go.  He is very afraid the whole ride, but his relentless sister loves it so much and pressures him to go a second time.  He does it again, yet this time he is a little less afraid.  By the tenth time of getting in the same line he no longer needs his sister to convince him of the joy of the ride.  He no longer fears it but finds enjoyment.  The young boy not only went through the process of habituation but that fear of roller coasters now is extinct.  A similar process can be used on Mandy to cause extinction in her fear of water and boats. 
This is not a process that happens immediately.  The first thing that the therapist is going to suggest isn’t to take Mandy out on a high-speed boat to conquer her fear.  Perhaps the therapist will set up a chart of things that trigger Mandy’s fears and rate it on a scale of 1-10, 10 being the memories that traumatize her the most.  How she reacts to these memories will also be taken into consideration.  Perhaps she will give a 9 to being around large bodies of water and during that time she will feel like she can’t breathe like she is being suffocated.  Other such things will be listed.  Perhaps the therapist will ask Mandy to write out her traumatic experience or start off by telling her story as if she is in the middle of it (Goulston 2008). 
There are two therapy methods used to face the traumatic events and the therapist will typically chose one which he thinks is going to be the most beneficial for a particular patient.  One of these is called systematic desensitization where the therapist may direct Mandy with her least disturbing triggers first.  Perhaps prior to the accident there was a song playing on a stereo system that they brought along in the boat.  If Mandy rates this lower than her other trigger the therapist may start with this one and once she is able to listen to this particular song without it triggering negative emotions they will move on to something that had more of an affect.  They will move up the ladder until they confront the most traumatizing part of the experience (Goulston 2008).   
Flooding is another method a therapist may use to confront a traumatizing event.  This is where the entire trauma is confronted and repeatedly until it fades.  In this process, Mandy would go through her experience again and again until she is able to gain control of her emotions.  Eventually, when Mandy is ready the therapist may suggest that she try going to the area where the traumatic experience took place so she can face the trauma with the connections that came with it (Goulston 2008). 
Next, it is time to change the thought process of Mandy.  Before the boating accident Mandy viewed boating as a save leisure activity and that hitting a rock and getting into an accident was the exception and not the rule.  However, because of the trauma that thought process had been replaced with fear.  The goal would be to change her thinking away from the trauma and back to feeling safe in the boat (Goulston 2008).    In doing this, the counselor may want to suggest a course in boat safety, or suggest for Mandy to invest in a map that locates all the dangerous objects in the water.  By doing this, this may cause Mandy to be more secure when she goes boating again.  Maybe suggesting more safety equipment to be on board for her next boating adventure will ease her tension. 

Dealing With Guilt
Another problem Mandy may encounter is the guilt of her brother dying.  This could bring up all sorts of thoughts such as “maybe I shouldn’t have convinced him to go out on the boat with me,” “It’s my fault, I should have planned this out better,” or “I don’t deserve to get help.”  These feelings of guilt may complicate therapy.  First, Mandy is thinking in error.  Hindsight bias is when one thinks they could have stopped the event, yet in reality no one can predict the future.  A therapist can help Mandy to realize that if one is to enjoy life, risks will have to be taken.  People put themselves at risks every time they go out in a car, but they can’t predict an oncoming accident.  It is an impossibility to avoid all of life’s risks.  Perhaps Mandy is struggling with justification distortions.  She may think that there was no need to go out on the boat that day so it is her fault that her brother drowned.  Again, a therapist can help Mandy see that she can’t judge herself for something that she didn’t know was going to happen.  Self-blame or responsibility distortion is another similar misguided thought process for some who struggle with PTSD.  Then there is wrong-doing distortion in which a person may have injured or killed someone in a traumatic situation.  An example would be a police officer shooting down a man who is about to shoot an innocent person.  The action was necessary but the officer may now have a sense of wrong-doing distortion in this case.  A therapist may need to convince this officer that what he did was necessary and remind him that he may have saved another’s life.  Back to Mandy, she may be struggling with survivor’s guilt.  She has the distorted belief that because her brother died, she should have died.  Perhaps the therapist will suggest ways to honor her brother in order to help with her guilt.  The therapist may point out that surviving is nothing to be ashamed about, but to view it as an accomplishment (Goulston 2008).     
Once Mandy feels that her fears have gotten better the therapist may suggest to start off sitting in a boat and when she is comfortable with that, maybe suggest to go on a short slow-paced boat run.  This may take some time; Mandy could become discouraged when some of those fears try to resurface. 

Eye Movement Desensitization and Reprocessing

One approach to CBT for a person who has underwent a traumatic event is the usage of eye movement desensitization and reprocessing (EMDR).  Much of the same therapy as described above is used in EMDR, however eye movement is the newcomer.  If Mandy’s therapist were to use this technique the issues would first be discussed and relaxing techniques would be worked on.  The therapist would then ask Mandy to draw upon a particular memory that is connected to her trauma.  Then the therapist may ask Mandy to rate the distress the memory causes.  Perhaps this memory brings up a negative belief about self such as Mandy feels that she has fear of water when thinking about the undertow dragging her under the water.  Then positive beliefs to replace the negative beliefs are encouraged such as “water is safe.”  Next Mandy will be asked to imagine a place where she feels safe; perhaps a peaceful wooded area away from any water.  This is the place that Mandy will focus her mind on as the session comes to an end (Goulston 2008).     

Next will come the part of the session that involves the eye movement.  The therapist may use his finger or another pointed object and move it back in forth from left to right and instruct the patient to allow their eyes to follow.  This process is repeated and the patient is asked to discuss any feelings that may arise during this time.  This is supposed to help memories that were traumatic to be reprossessed in a more positive light.  This is also supposed to lower the level of distress and at the end of the session the patient will be directed to go to her safe place.  While there are studies that seem to support this therapy, there is no proof yet as to whether the inclusion of eye movement makes much of a difference (Goulston 2008).   

Other Possibilities and Conclusion

This by no means is all of the therapeutic methods used to help PTSD, nor do the methods above help everyone.  For instance, rational emotive behavior therapy doesn’t include facing the past trauma head on, but rather focuses on the present and changing how the past influences the patient.  In multiple channel exposure therapy the panic side of PTSD is addressed and breathing and other techniques are used to help the patient deal with panic.  A newer therapy called virtual reality exposure therapy allows participants to put them in situations similar to their trauma through the use of computers so they can safely face their trauma.  While medication isn’t the preferred method in dealing with PTSD, there are times when it is used such as when the PTSD leads to depression, insomnia, or extreme anxiety (Goulston 2008).  There are other methods used to help PTSD, but what I have discussed in this essay are the ones that most therapists prefer. 
Comer, Ronald J. (2008).  Fundamentals of Abnormal Psychology.  Fifth Edition.  Worth Publishers New York, 132-139, 43-48.

Goulston, Mark MD (2008). Post-Traumatic Stress Disorder For Dummies.  Wiley Publishing Inc., 131-164.

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995).  Posttraumatic stress disorder in the National Comorbidity Survey. Arch. Gen. Psychiat., 52, 1048-1060. 

Kessler, R. C., & Zhao, S. (1999). The prevalence of mental illness.  In A.V. Horwitz & T.L. Scheid (Eds.), A handbook for the study of mental health: Social contexts, theories, and systems.  Cambridge, England: Cambridge University Press.

True, W. R., & Lyons, M. J. (1999).  Generic risk factors for PTSD:  A twin study.  In R. Yehuda (Ed.), Risk factors for posttraumatic stress disorder.  Washington, DC:  American Psychiatric Press.