This is the text version of AAMFT's Clinical Update on Post-Traumatic Stress Disorder, Volume 2, Issue 5, September 2000. AAMFT invites you to print out this issue of Clinical Update to use in your work with individuals and families, and to share with other therapists.

Post-Traumatic Stress Disorder

Guest Authored by Charles R. Figley, Ph.D.

Sections:
Introduction: Families Coping With Trauma
Diagnosis and Assessment
Treatment Options
Special Help for Traumatized Children
Professional Resources
About the Author

Sometimes family therapists work with clients who have been exposed to traumatic events that cause extremely frightening and debilitating symptoms. In working with families affected by traumatic events, an MFT will assess and treat the effects of trauma in a family context. The goal of such treatment is to identify and eliminate the unwanted symptoms and enable the family to get on with their lives more aware and prepared for future traumatic incidents.

The field of traumatology, originally known as traumatic stress studies (Figley, 1988), quickly emerged with the American Psychiatric Association’s 1980 publication of the third revision of the Diagnostic and Statistical Manual of Mental Disorders. For the first time, there was a body of research and clinical practice that justified the diagnosis of post-traumatic stress disorder (PTSD). What was significant about PTSD was that it brought together under a single construct such syndromes as battered women syndrome, concentration camp syndrome, combat fatigue, shell shock, war neurosis, rape trauma syndrome, traumatic neurosis, and some lesser known phenomena (Figley, 1978; Herman, 1992).

Since the emergence of PTSD the systemic causes and consequences of trauma have become clear (Figley, 1983, 1989, 1997). Systemic traumatology is concerned with the systemic (e.g., interpersonal and intra-relational) causes and consequences of traumatic events (Figley, 1998, 1999). This is one of the least studied, yet most important, areas within the field of traumatology. It attends, for example, to such questions as the following:

• How do couples cope with the loss of a child and other tragedies they experience?
• How and why does family violence exist and cease?
• How can the intergenerational cycle of violence be ended?
• How do social support groups, including families, prevent and reduce traumatic stress?
• How can small work groups and other identifiable systems recover from the death of a co-worker and other traumatic incidents affecting the group?
• How do schools, companies, neighborhoods, and communities prevent, contribute to, and recover from a traumatic event?
• What are the roles of professionals in assessing and developing prevention and treatment programs?

The study and treatment of families coping with traumatic events has a long and rich history. Some date the origins to family sociologist Rubin Hill’s study of returning World War II veterans to their families (Hill, 1949), which led to the ABCX theory of family stress and coping (Hill, 1953; McCubbin & Patterson, 1983). Family scholars have applied systems models and concepts to families for years. It is common practice in the field of marriage and family therapy to view a family as a system because its members make up a "regularly interacting and interdependent group" who act as a unit (Figley, 1989). Like other systems, the family has its own properties, rules, assigned and ascribed roles of its members (organized power structure), and overt and covert forms of communication. A family, like other systems, will seek help out of desperation, and there is a window of opportunity for positive changes that are lasting and that help prepare the family for future adversities. These second-order changes are much more likely among traumatized families that seek help from family therapists.

Traumatized families can be defined as those who are not effectively coping with a traumatic event or series of events that disrupt normal routines, functions, and characteristics of family life (Figley, 1989, 1997). The systemic impact on families is well documented. Community disasters that disrupt infrastructure are followed by a significant increase in family violence, child neglect, psychological abuse of family members, and other systemic symptoms associated with increased distress (Figley, 1997). Moreover, families must cope with the impact of traumatic stress on individual family members. These include the symptoms of PTSD.

A person with PTSD may re-experience the traumatic event many times, in flashbacks, memory, dreams, or terrifying thoughts. Anniversaries of the experience, or anything that reminds the person of the experience, my trigger symptoms. Persons with PTSD may also suffer from emotional numbness and disturbed sleep, depression, anxiety, intense guilt, irritability, or outbursts of anger. Most people with PTSD try to avoid reminders or thoughts of the event. These symptoms are associated with increased hospitalization and outpatient medical and mental health facilities, an increase in criminal behavior, an increase in depression and other associated features of PTSD, and an increase in truancy and absenteeism.

Families are often desperate to put their lives back in order and return to their pre-trauma state, if that is possible. It is important for a practitioner to evaluate these families differently than the practitioner might go about evaluating typical help-seeking families. One way of viewing traumatized families is through the lens of a model derived from Hill's ABCX Model (Figley, 1989; McCubbin & Patterson, 1983; Montgomery, 1982).

The therapist should evaluate the family’s coping skills that were in place before the trauma. All families cope with stress as a system of individuals working together. How were family members doing prior to the traumatic event? How well did they work together to overcome various challenges in life? Do they tend to see adversities as a challenge for everyone, or do they tend to point fingers and blame others in rather simplistic terms? What are the quality and quantity of their resources (e.g., income, friends, family, spiritual beliefs, social supportiveness, and interpersonal competence)?

The circumstances of the traumatic event are important in understanding how family members have adjusted and accommodated to the memories of the event so far. Loss of life (including pets), the home, the car, and other central elements of family life requires adjustment and grieving. Exposure to unexpected, grotesque, and vile traumatic events requires more adjustment and may be associated with several adjustment disorders, including PTSD, simple/social/complex phobias, and other fear-based problems. If the cause of the trauma is a member of the family, especially as a perpetrator, families require a sense of safety and trust. It is important that all family members have an opportunity to fully disclose their views about the traumatic event unedited and uninterrupted by others in the family.

There is a high correlation between the coping factors found prior to the event and those found following the trauma. Thus, the extent to which families worked together prior to the traumatic event predicts how well they are working together now. It is important to remind the family of previous life challenges and the coping strategies that appeared to work. Among the ways of doing this is utilizing the Traumagram (Figley, 1989). It is a short questionnaire, completed by everyone in the family, that documents when a traumatic event happened to them, how stressful and long-lasting the effects were, who also experienced the event, and the factors that most accounted for overcoming the distress.

It is also important to provide psychoeducation about the normal and expected consequences of events such as the one they have experienced. It is very useful to help families connect with other families who have experienced similar traumatic events, especially those families who can provide a good role model and a sense of hope and inspiration. Immediately following the shooting in Littleton, for example, principals of schools around the country who also experienced shootings called and provided support and suggestions. According to the Jefferson County School Superintendent, this was the most useful help she had received.

Research has demonstrated that traumatized persons will not seek treatment or remain clients unless they feel safe. This sense of safety starts with the clinical setting. How comfortable is the family with the therapist? This will depend, of course, on the particular traumatic experiences of the client family.

Exposure, remembering the forgotten aspects to the traumatic event, is vital in enabling the client to recover. However, studies have shown that managing the remembering is also vital. Often clients "can't" remember because they are afraid. The flooding of memories causes distress and, in many clients, a dissociative reaction. Therefore, it is unwise to treat clients unless they can effectively utilize good self-soothing techniques.

If clients are unable to calm themselves quickly, but are able to avoid or control dissociative reactions, they can be treated for symptom management. Training them in effective visualization techniques can be helpful. They are asked to select a place they can imagine in which they feel perfectly safe and calm, and to describe the scene and inform us about how each of their senses interpret this scene (e.g., smell, see, hear). They should practice this safe-place visualization with the therapist until they are able to reduce their distress levels quickly. Other self-soothing methods can be found in any one of many stress management books available at local book stores.

In addition to self-soothing techniques, it is vital for clients to be responsive to one of many desensitization procedures that will enable them to tolerate recall of highly distressing trauma memories. A recent article reviewed several neoteric treatment approaches (Carbonell & Figley, 1999). Fortunately, these approaches, along with the standard techniques used in Cognitive Behavioral Therapy (CBT), enable the practitioner to match the best procedure for the client.

For example, Thought Field Therapy (TFT) is a useful desensitization technique that utilizes acupressure methods to stimulate areas in the upper torso that store energy. Through a series of tapping exercises, most clients experience quick reductions in distress. Clients can use the easy-to-learn TFT technique between sessions to help them reduce their distress.

Another example is Visual Kinesthetic Disassociation (VKD). This technique enables the client to recall the traumatic event using a specific visualization procedure. In this procedure, the client imagines that he or she is watching the scenes of the traumatic event in a movie theater from the projection booth. The client imagines fast forwarding and rewinding the scene from the booth. This enables the client to access the information and, at the same time, avoid the distress often accompanying the memory.

Other methods, such as Traumatic Incident Reduction and Eye Movement Desensitization and Reprocessing, are useful for desensitization and are reviewed with the client to select the one that best fits.

Some important goals in treatment are to:

-Build rapport and trust among family members

-Clarify the therapist’s role

-Eliminate unwanted consequences of trauma

-Build family social supportiveness

-Develop new rules and skills of family communications

-Promote self-disclosure and other behaviors that promote healing

-Recapitulate traumatic events

-Build a family healing theory

To these generic goals can be added whatever goals that family members identify, assuming those goals are achievable.

A good many traumatized families are highly functional and healthy. Were it not for the traumatic event, they would not be seeking help. Studying how highly functional families help themselves, and noting where they need some help, reveals that functional families have the following skills:

-They are good at detecting traumatic stress because they know the family member so well. Children who have had a difficult day give detectable signs noticed only by those who love and live with them.

-They know how to help traumatized family members confront the stressor. They know how to urge the traumatized member to talk about a problem, or describe the trouble in other ways, such as through artwork or writing. When families help a member release what’s locked inside and get them to talk about what happened to them, how they felt, how they are doing now, and what they will do if something like it happens again, they are able to help traumatized members resolve and eliminate the unwanted consequences of trauma.

-Also, families help the traumatized member correct distorted beliefs about the traumatic event, such as guilt and self-expectations that are unfair. They are good at encouraging traumatized members to adopt more realistic and generous self-referencing statements (e.g., "I did the best I could, under the circumstances").

The Family Empowerment Treatment (FET) approach was developed by studying and borrowing from well-functioning families. It can be used with any family therapy approach, since the purpose is to help families talk about and overcome the unwanted effects of trauma. Once this is accomplished, families may need to resolve more fundamental issues that were present long before the traumatic event.

A thorough assessment of the family should be conducted. With regard to trauma assessment, the clinical interview should focus on the degree to which the family has a clear understanding and acceptance of the traumatic experience; the degree of family cohesion; the extent to which they are solution-oriented rather than blame-oriented; their levels of tolerance of and commitment to one another; the quality and quantity of family affection, cohesion, and family communication; the degree of role flexibility and resource utilization; and any evidence of either substance or physical abuse. In addition, the Traumagram Scale, several measures of PTSD and acute stress symptoms, the Purdue Social Support Satisfaction Scale, and the Family Adaptability and Cohesion Evaluation Scale all can be helpful.

The Family Empowerment Treatment approach comprises five phases:

As with any approach, the therapist should begin by clarifying how he or she can help, and building a commitment with the family to reaching the objectives. It is important that everyone is included in this phase. Some questions that may be asked are: What happened to bring you here? What have you done so far that has helped and not helped? What do you want to happen as a result of our time together?

Listen carefully to how family members describe both the trauma memories and their responses as individuals and as a family. Trauma memory management varies among individuals and within families. Some family members have vivid recollections of the traumatic event and recall it in a clear and direct manner; others either have difficulty remembering or do not wish to discuss it with others. In this early phase of treatment, the author follows six guidelines in the treatment protocol:

-Telling the Family’s Stories. Each member of the family is encouraged to explain their experience with the trauma, focusing on the worst parts, and explaining their thoughts, feelings, emotions, and kinesthetic reactions.

-Promoting New Rules of Communication. The fundamental necessities for trauma treatment is for clients to feel safe, respected, and supported so that they can tell their story, become desensitized from the trauma, and help co-construct a method by which the family will not only cope but thrive, drawing lessons from the traumatic event and, hopefully, acquiring even more love and respect for each other.

-Promoting Understanding and Acceptance. Sometimes families in crisis, particularly couples, emotionally withdraw as a result of distress and the toxic nature of family relationships. Given this challenging reality, the therapist must work to keep clients together in order to reach a level of understanding and acceptance about the trauma and family member reactions.

-Listing Wanted and Unwanted Consequences. While the family is struggling to understand and accept what has happened to them, the therapist should attempt to also get them to articulate their incentives. Sometimes the family has difficulty identifying a clear and reachable objective. They most often start with rather vague and broad goals, such as "to understand why this happened to us." This may not be possible under some circumstances. But to "help us get along better so that we are not fighting; help us work as a team again" is more clear.

-Avoiding Victim Blaming. It is very normal and natural to simplify the situation by using a scapegoat in the family or in some way shifting blame away from the family. Help family members express their feelings, attitudes, and physical reactions in a way that does not hurt another family member.

-Shifting Attention to the Family. Finally, this principle calls for the practitioner to shift the discussion to how the family plays a role in maintaining the trauma in their thoughts, feelings, and behaviors. It is the "now what?" question, suggesting to the family that, although the cause of the trauma may be beyond their control, the consequences can be controlled.

Reframe the Problem

The concept of "reframing" has been around a long time. Another way of saying it is "relearning," or a cognitive shift. Cognitive Behavioral Therapy is viewed as the most effective treatment of PTSD (Foa, Friedman, & Keane, 2000). The most essential component of CBT is cognitive restructuring following exposure to the reminders of the trauma. The same principles can be used in combining standard systemic treatment methods.

Similar to Critical Incident Stress Debriefing procedures (Mitchell, 1992), encourage the family to talk about and consider what each member views as the essential features of what happened during and following the traumatic event. Encourage them to talk about their first thoughts and impressions during the event. Gradually, encourage everyone to talk about the immediate and long-term effects of the event for them and for their family. Eventually, family members should begin to shift their negative self-referencing statements and other observations about the trauma.

Considerable research indicates that acquiring new skills in interpersonal communication that are applied to real couple problems significantly reduces the chances of divorce, family violence, and other problems.

By now the family has listened to initial drafts of a healing theory, an explanation of what happened, and what was learned from the trauma. Moreover, the family has become more aware of its ability, when focusing on rather important, trauma-related matters, to clarify insights about what is being learned in the wake of the traumatic event. If so, there is greater chance that someone in the family had the experience of correcting distortions of a family member (for example, assertions that were associated with feelings of fear, guilt, hostility, or sadness). Substituting new interpretations is a natural byproduct of the above actions, all of which lead to a healing theory.

This final phase is a time for shifting to another, post-treatment phase in which the family will return at some specified number of months as a way of assuring that the family has healed and is better prepared for life’s traumas.

How does the therapist know when therapy is finished? This is a question that has been posed by psychotherapists for years, to be answered rather simplistically, "Whenever the family believes they are finished." Do we ever fully recover from the death of a child or as a child, the death of a parent? Rather than "being finished," we are simply on a journey to wellness and accommodation. Another way to pose the same question is: When do we know when we need to meet less frequently?

There are four useful criteria to keep in mind when working with traumatized families: (1) Did they reach their treatment goals? (2) Did the family develop a healing theory that all members embrace? (3) Did new rules and skills of family communications emerge? (4) Finally, did the family experience a sense of accomplishment?

A sign of success and the end of weekly sessions is when the family members begin to act like the session is routine and regularly talk much more than the therapist. This is not a sign of insubordination or rudeness, but a sign that clients are now empowered to take back control of their lives. This places the therapist in the advantaged role of consultant, providing advice, assistance, and consultation as family members work together toward a common goal.

There is considerable evidence of the resilience of children. Nourished by love, protection, guidance, and attention, they can spring back after even the most horrendous traumatic events (Johnson, 1998). The parent is often the most influential factor in the recovery of the child. When considering the developmental and social factors that determine the suitability of including the child in therapy, the therapist should assess the parents as carefully as the children, because the role the parent plays will determine whether their children can benefit from therapy.

One factor that should be considered is the child’s developmental level. Since the goal of including children in therapy is for both the children and the entire family to recover to a state of adjustment that is acceptable, the therapist must first evaluate whether the child is capable of handling the trauma material generated from this clinical context. If the "no harm" criterion is met, another consideration is whether the child is likely to be traumatized (or at least sensitized) by reminders of the event, which could lead to a condition that is harder to treat.

There are also social factors to take into consideration. Children are exposed to traumatic material on a regular basis in the U.S. Therefore, systemic traumatologists are concerned about the role of culture in treating children or including children in therapy. Similarly, customs and values associated with children, their treatment, and assessment, must be carefully considered. There are several excellent books on the topic (e.g., Nader, Dubrow, and Stamm, 1999).

One of the goals for treatment of traumatized children is to help the child face the truth of what has happened. This involves enabling the child to draw, sing, dance, talk or engage in some other form of self-expression that is also a self-soothing activity.

Another goal is to help the traumatized child deal with the "damaged goods syndrome" (feelings of poor self worth, avoidance of interpersonal relations). This can be challenging, because a child may not want to admit to such feelings.

A third goal is to identify in the child any feelings of guilt or self-blame, and help the child recognize that these feelings are a result of faulty, irrational, and unrealistic information. Eventually the child comes to accept that guilt and self-blame was only a bad phase in the recovery (i.e., "growing up") process.

Another important goal is to help the child deal effectively with emotional reactions. The emotional reactions of fear, hate, sadness, anger, aggression are associated with the way the child views the traumatic event. Changing the child's cognitive perspective changes behavior as well as emotional reactions.

A final, important goal is to help the child reconnect with supportive resources. Most often, these are family members, but sometimes it may be a social worker, a member of the clergy, or a trusted teacher.

Professional Resources

References

Figley, C. R. (Ed.) (1978). Stress disorders among Vietnam veterans: Theory, research, and treatment. New York: Brunner/Mazel.

Figley, C. R. (1983). Families of catastrophe. In C. R. Figley & H. I. McCubbin (Eds.), Stress and the family: Vol. 2. Coping with catastrophe (pp. 134-146). New York: Brunner/Mazel.

Figley, C. R. (1989). Helping traumatized families. San Francisco: Jossey-Bass.

Figley, C. R. (Ed.) (1997). Burnout in families: The systemic costs of caring. New York: CRC Press.

Figley, C. R. (Ed.) (1998). Traumatology of grieving: Conceptual, theoretical, and treatment foundations. Philadelphia: Brunner/Mazel.

Figley, C. R. & McCubbin, H. I. (Eds.) (1983). Stress and the family: Vol. I. Coping with normative transitions. New York: Brunner/Mazel.

Herman, J. (1992). Trauma and recovery: The aftermath of violence. New York: Basic Books.

Hill, R. (1949). Families under stress. New York: Harper & Row.

Johnson, K. (1998). Trauma in the lives of children: Crisis and stress management techniques for counselors, teachers, and other professionals. Alameda, CA: Hunter House.

McCubbin, H. I. & McCubbin, M. (1989). Theoretical orientation to family stress and coping. In C. R. Figley (Ed.), Treating stress in families (pp. 3-43). New York: Brunner/Mazel.

Montgomery, B. (1982). Family crisis as process: Persistence and change. Washington, DC: University Press of America.

Nader, K., Dubrow, K., and Stamm, B. H. (Eds.). (1999). Honoring differences: Cultural issues in the treatment of trauma and loss. Philadelphia: Brunner/Mazel.

Veith, I. (1968). Hysteria: The history of a disease. Chicago: University of Chicago Press.

 

Resources for Practitioners

In addition to the above references, the following are recommended:

Gallo, F. P. (1998). Energy psychology: Exploration at the interface of energy, cognition, behavior, and health. Boca Raton, FL: CRC Press.

Gallo, F. P. (2000). Energy diagnostic and treatment methods. New York: Norton.

Guerney, B. (1977). Relationship enhancement: Skill-training programs for therapy, problem prevention, and enrichment. San Francisco: Jossey-Bass.

International Society for Traumatic Stress Studies. Guidelines for the treatment of PTSD. Northbrook, IL: Author.

Lipke, H. (2000). EMDR and psychotherapy integration: Theoretical and clinical suggestions with focus on traumatic stress. Boca Raton, FL: CRC Press.

Sapolsky, R. M. (1998). Why zebras don’t get ulcers: An updated guide to stress, stress-related diseases, and coping (2nd ed.). New York: Freeman.

Schiraldi, G. R. (2000). The post-traumatic stress disorder sourcebook: A guide to healing recovery, and growth. Los Angeles: Lowell House.

Videotapes

*Figley, C. R., Myers, D., and Wee, D. (1998). Disaster and violence: Picking up the pieces and keeping them together. General Session at the AAMFT Annual Conference, Dallas, TX. (available as audio or video tape)

        Figley, C. R., Ochberg, F., Panos, A., Wilson, J., Williams,
        M.B. &  Dyregrov, A.

(1998). When helping hurts: Sustaining trauma workers. Camden, ME: Gift From Within Foundation.

Nader, K., Parson, S.W., Panos, A., Bell, C., & Ochberg, F. (1995). PTSD in children: Move in the rhythm of the child. Camden, ME: Gift From Within Foundation.

Websites

Among the many excellent sites, here are those recommended:

Academy of Traumatology Standards of Practice at http://sow5938-04.fa99.fsu.edu/SOC.htm. Includes their set of guidelines for working with the traumatized.

David Baldwin Trauma Pages at http://www.trauma-pages.com/index.phtml. Provides good resources on a wide variety of topics relevant to trauma.

Green Cross Foundation at http://www.greencross.org. Home of the Academy of Traumatology, owner of the Traumatic-Stress Forum (discussion group for traumatologists worldwide). To join, go to http://www.interpsych.org. The journal Traumatology is available at http://www.fsu.edu/~trauma/.

Green Cross Projects at http://www.fsu.edu/~gcp/. This is the home page for members of the GCP with links to other relevant sites.

The International Traumatology Institute at http://learningforlife.fsu.edu/traumatology. This is the homepage for the Institutes training and certification program with training sites nationally and internationally.

*This and other AAMFT audio and video tapes can be ordered from Convention Cassettes Unlimited at (800) 776-5454. Or, visit the AAMFT web site at www.aamft.org. To request a catalog of other AAMFT products, please call AAMFT at (703) 838-9808.

About the Author

Charles R. Figley is Professor and Former Director of the Florida State University Interdivisional Ph.D. Program in Marriage & Family. He is also a Professor in the School of Social Work and Director of the FSU Traumatology Institute. He is Founding President of the International Society for Traumatic Stress Studies, Founding Editor of The Journal of Traumatic Stress and the Journal of Family Psychotherapy and current Editor of the journal, Traumatology. He has written over 200 scholarly works, including 16 books. His most recent, published this year by Brunner/Mazel is Treating Compassion Fatigue.

Click here to purchase this or other informative materials from AAMFT.