June 2011 Featured Article
Disorders due to traumatic stress are among the costliest of all the mental health disorders to both the disordered persons and to society. Described and diagnosed primarily as posttraumatic stress disorder, the underlying human dimension to traumatic stress is complicated by the multifactorial ways in which pathology becomes manifest. Increasingly, pathways to the development of traumatic stress illness are the frame by which research is being conducted, revealing some new ways of preventing, minimizing, and treating affected persons. Increasingly, trauma and the resulting sequelae are not constructed as linear cause and effect, but as processes, experienced by individuals vulnerable due to type of trauma or predisposing factors and transmitted in a variety of ways.to those around them.
Neuroscience is providing important clues to the means by which brain anatomy, brain biology, and brain chemistry coalesce in the presence of life threatening stress. Social factors involving family of origin, attachment, worldview, gender, race, and culture are receiving much needed theoretical reprisal, resulting in new concepts of traumatic stress disorder etiology, formation, and maintenance. Incorporating current perspectives and research from leading traumatic stress researchers and clinicians, including those of Foa, Resick, Keane, Figley, Perry, and Wilson, a systemic framework and visual model is proposed by which to view traumatic stress in terms of triumvirate development pathways: a) pretraumatic vulnerability; b) peritraumatic factors; c) and posttraumatic environment.
EPIDEMIOLOGY OF TRAUMATIC STRESS
Traumatic events that result in PTSD include violent personal assault, kidnapping, military combat, natural and man-made disasters, severe motor vehicle accidents, diagnosis of a life-threatening illness, rape, incest, and childhood sexual abuse (Shaw & Bernard, 2006). Many of these events are common, resulting in a large number of affected individuals. In the USA, approximately 41.2% of women and 61% of men have been exposed to traumatic events (Kessler et al. 1995). In lesser-developed countries, this increases to 83% for men and 71% (Norris & Slone in Ed. Friedman, Keane & Resick, 2007). Acute Stress Disorder, which must be diagnosed within one month of trauma, occurs in 13-33% of adults and 17-21% of children and adolescents exposed to traumatic events (Clark & Beck, 2010). Of all North American residents who experience a sufficiently traumatizing event, approximately 20% will present with ASD, PTSD, or both. The lifetime U.S. prevalence of PTSD ranges from 7.8 to 12.3 percent, with current prevalence rates of 5 to 6 percent (Norris & Slone in Ed. Friedman, Keane & Resick, 2007).
Prevalence rates of PTSD are equally high in refugee populations from war-torn countries and in adults living in urban inner city areas of developed countries (Kessler et al., 1995). PTSD occurring after combat injury appears to be strongly correlated with the extent of injury, and develops over several months. In a study of US soldiers hospitalized for war-related injuries, the prevalence of PTSD was 4.2 percent at one month and 12.2 percent by four months post-injury. Soldiers with a high severity of physical problems a month after injury were at greater risk of PTSD six months later, compared to those with lower physical problem severity. Lifetime rates amongst Vietnam theater veterans are approximately 31% for men and 27% for women. Involvement in current theaters (Iraq and Afghanistan) carries only half the risk. In one study of 368 patients from a community primary care clinic, 65 percent reported a history of traumatic exposure. The prevalence of PTSD in this group was 12 percent (Breslau, 1998).
In terms of gender prevalence, women are more than 2 times more likely to develop PTSD than men, after normalizing for exposure to traumatic events; the National Comorbidity Survey found lifetime prevalence rates of 10.4% and 5.0 % respectively. Although limited research has been conducted, studies indicate that prevalence of trauma is directly related to the socioeconomic status of a population and that in many developing countries, PTSD and variants are likely dramatically underreported.
Pathways FOR the Risk, Development, and Maintenance of Traumatic Stress
Multidisciplinary research into traumatic stress in the social sciences, neurosciences, and medical sciences has expanded the framework by which practitioners in multiple clinical settings assess and treat disorders such as posttraumatic stress disorder. Where traumatic stress was once viewed from the proximal point of trauma and afterwards, current research points to pathways of disorder susceptibility, development, maintenance and resolution that permit clinicians to consider trauma from a more robust set of lenses.
Family and Interpersonal Variables
Persons with functioning social support networks (especially within a nuclear family) are just under half as likely to contract PTSD when controlled for trauma type and severity (Ozer & Weiss, 2004). Attachment failures in infancy and anxious or insecure attachment to spouse or mate in adulthood predict a greater risk of PTSD and ASD and also presage a worse outcome (Besser & Neria, 2011; Weisæth, 1998). Researchers postulate that Early Life Stress (victimization by violence, illness, sexual abuse, extreme emotional abuse, and illness/chronic pain) creates the same neuroendocrine dysfunction as happens with adult PTSD, but creates an even more insidious neural footprint on the developing brain, providing a potentially powerful link to predisposal (Yehuda, 2010, pp.’s 405-406; Cozolino, 2010, p. 284). Based on interpretation of the National Comorbidity Survey (NCS), a large (N = 5,877) nationally representative survey, maternal and paternal involvement and style (authoritative) were implicated (Lauterbach, Koch, & Porter, 2007). A person with pre-existing mental illness, especially depression, panic disorder, and /or personality disorder is almost twice as likely to suffer from PTSD as the average person (Weisaeth, 1998, p. 86).
A 2,387 person study focusing on the mental health of persons directly affected by the World Trade Center disaster in 2001 found that (1) multiple traumatization over the course of a person’s life, (2) a previous diagnosis of major depression, (2), sex (female), and (4) self-description of a life filled with negative events was positively correlated with a diagnosis of PTSD (Boscarino & Adams, 2007).
Factors at the Intersection of Neuroscience/ Genetics and the Environment
Neural development is a complex and dynamic process involving billions of interactions across micro (e.g., the synapse and co-present neurotransmitters) and macro domains (e.g., parent-child interactions and exposure to abuse or trauma); these interactions result in a wholly unique biological, chemical, and genetic constitution, ultimately comprising the human nervous system (Perry, 2009; Green & Ostrander, 2009). Maltreatment or repetitive threat of severe physical insult disrupts this process; trauma, neglect, and related experiences of maltreatment such as prenatal exposure to drugs or alcohol and impaired early attachment bonding all influence the developing brain and it corresponding integration of neural networks. These adverse experiences interfere with experiential neurodevelopment by creating extreme and abnormal patterns of neural, neuro-hormonal, and even autoimmune activity (Perry, 2009; Zeanah, 2009; Gutner et al., 2010). The resulting negative functional impact of impaired or abusive caregiving on the developing child has been well documented (Kay, 2009)
Most research indicates transmitted genetic variables are at least moderately inheritable (Koenen, Nugent, & Amstadter, 2008). The conceptualization of genetic predisposition to traumatic stress, however is migrating from a static to dynamic framework due to growing evidence of gene-environment (gene x environment) interaction. For example, preliminary evidence is suggestive of a link between symptom severity and type (avoidant-numbing) in persons with a relatively common genetically and environmentally mediated dopamine receptor abnormality (Dragan & Oniszczenko, 2009, pp.’s 483-484). Notably, a variety of studies have demonstrated that 30–40% of the variance contributing to all anxiety disorders is heritable (Norrholm & Ressler, 2009), although precise genetic expression vis-a-vis the confluence of environmental impact is unclear.
Precipitating Event and Severity of Trauma
Contrary to popularized wisdom, combat-related trauma is not the most prevalent traumatic experience that leads to PTSD. Based on longitudinal research in the United States, rape by a family member results in PTSD almost 1/2 of the time, physical assault nearly 1/3 of the time (NIMH, 2010). While combat trauma ranks third, gun violence, serious accidents (auto, train, plane, occupational), and the sudden death of a loved one all carry a 14-17% risk for subsequent development of ASD or PTSD. Presence and severity of physical injury is a significant factor.
Reaction to Trauma
An extreme or unusual emotional reaction to traumatic events including expressions of guilt, remorse, or panic is implicated in development and severity of course of PTSD (Friedman, Keane, & Resick, 2007, p. 8). Heightened fear responses at the time of trauma may cross-implicate the adrenal system with an abnormal integration of the amygdala – hippocampal – medial prefrontal cortex pathway, resulting in atypical visual, cognitive, and emotional memory storage and retrieval. PTSD sufferers may re-experience traumatic memories that are triggered by normally benign cognitive, sensory, or emotional stimuli that the brain (utilizing primitive survival-oriented functionality) miscoded at the time of heightened stress (Brewin in Ed. Vasterling & Brewin, 2005, p. 134; Green & Ostrander, 2009, pp.’s 68-75).
Family and Interpersonal Variables
The nature and quality of family and interpersonal relationships should not be considered exclusively preexisting risks, but also serve in the formation, manifestation, and duration of the disorder post-trauma. Factors include:
a) Family environment: People with significant separation from nuclear family (e.g. combat soldiers) or dysfunction within nuclear family have a worse prognosis (Shakespeare-Finch in Ed. Violanti & Paton, 2006)
b) The presence of supportive social networks is an extremely powerful mitigator of distress based on client self-reports from longitudinal studies. (Bland et al., 2005; Boscarino & Adams, 2009)
c) Presence of preexisting conditions such as depression, panic disorder, generalized anxiety, substance abuse or problem-saturated worldviews not only predispose persons, but may also post-dispose them to a worse outcome (multiple sources)
d) Coping styles and character traits are implicated in PTSD development. Persons directly impacted by the 9/11 tragedy(n= 4,817) who self-reported elevated characteristics of gratitude, kindness, hope, leadership, love spirituality, flexibility and teamwork post-event, were among the least likely to experience PTSD, anxiety disorders, and/or depression. Individuals who report extraversion, conscientiousness, and help-seeking were similarly less effected (Peterson & Seligman, 2003; Shakespeare-Finch in Ed. Violanti & Paton, 2006)
e) Subsequent re-traumatization, crises or medical illness (Friedman, Keane, & Resick, 2007)
Genetic, Physiological, Biological, and Neurological Manifestations of Trauma
Sensory input, memory formation and stress response mechanisms are affected in patients with post-traumatic stress disorder (PTSD). The regions of the brain involved in faulty emotion and memory processing with PTSD include the hippocampus, frontal cortex, and amygdala. While the heightened stress response is likely to involve the thalamus, hypothalamus and locus coeruleus. A study by researchers at Columbia University’s Mailman School of Public Health suggests that traumatic experiences “biologically embed” themselves in select genes (especially within the immune system) during and after trauma, altering their functions and leading to the development of post-traumatic stress disorder (PTSD) (Columbia University, Proceedings of the National Academy of Sciences (PNAS), 2011)
ROLE OF THE SYSTEMIC THERAPIST
PTSD from a Systems Perspective: The Emergence of Posttraumatic Growth Framework
Increasingly, research from medical, mental health and social science fields demonstrates complex, multifactorial factors in both etiology and development of traumatic stress disorders. Qualitative findings suggesting family and contextual social relationships post-trauma have the highest positive predictive power for symptom resolution and post-traumatic growth (NIMH, 2010) Research is similarly providing evidence that family systems psychotherapy can reduce the effects of neurochemical insult caused by trauma. This concept, referred to as neural network reintegration or neural plasticity, reinforces that pharmacological treatments are but one element of comprehensive treatment of trauma, and that processes produced within the structure, biology, and chemistry of the brain can sometimes be reversed by psychotherapeutic means (Kay, 2009, p. 290; Siegel, 2010). This orientation towards growth functionality in a client with PTSD has emerged squarely from the extent by which mental health professionals help sufferers of PTSD in the context of how, where, and with whom they live.
Evidence-based therapies for PTSD including cognitive behavioral and cognitive processing therapies (and variants), exposure-based treatments (Foa and colleagues), eye movement desensitization and reprocessing (EMDR: Shapiro), and stress inoculation training (SIT) are increasingly found in a systemic practitioner’s quiver. Furthermore, there appears to be a trend towards utilizing family therapy models to treat traumatic stress of various origins:
a) Chloe Madanes developed a sixteen step strategic family therapy approach based on qualitative research (Gorham, 1997) that has been adapted by some clinics
b) Postmodern researchers (Bracken, 2001; Beaudoin, 2005) propose the use of narrative family approaches for the treatment of families and individuals, with a special focus on restorying and externalizing techniques (Day, 2009)
c) Solution-focused therapies are being researched internationally in conjunction with traumatic stress of different origins. (Price, 2004; multiple sources)
d) The U.S. Army is actively investigating a highly systemic multi-model treatment protocol called PTPG (Posttraumatic Growth Path) that incorporates elements of positive psychology, narrative therapy, and solution-focused family therapy to treat clients and their families from time of trauma (Nelson, 2011).
e) Trauma lenses or overlays are being developed to work with both modern and postmodern family therapy models (Sheinberg & True, 2008 ; Figley & Figley, 2009)
f) Several studies (McCarthy & Thompson, 2010) suggest that the most effective mental health services serving traumatized people target the entire family unit and include a primary focus on developing greater cohesion and support within the family.
Systemic practitioners are prevalent in clinical settings whose served populations have the highest rate of significant trauma including urban mental health agencies, V.A. hospitals and outpatient treatment centers, and military bases (AAMFT, 2011). Increasingly recognized for their breadth of training (individual, family, larger social contexts), family therapists are also well positioned tactically to implement a wide array of preventive interventions: providing psychological first aid after trauma; assisting clients in the development of improved coping skills, utilizing interventions improving attachment to caregivers/mates, and providing guidance to manage symptoms of anxiety and depression, all associated with a lower risk of PTSD after trauma and/or a more benign course (Foa, Keane, & Friedman, 2000; Zeanah, 2009). As a result of the amalgam of current research, several leading figures in the field of traumatic stress, including clinical psychologists and researchers Edna Foa (2007) and Jane Shakespeare-Finch (2010) have increasingly called for more research into family systems treatment approaches as an important, even central component of multi-dimensional treatment for victims of trauma.
As with many mental health disciplines, family therapists may be well served to seek additional training to better collaborate with colleagues from other relevant disciplines, including physicians, research/experimental psychologists, and neuroscientists. Integrative researchers may play a timely role by translating neuroscientific findings into useable assessment tools, which could occur in two ways: (a) Neurological information could be integrated into existing assessment tools; (b) New assessment measures could be created as adjuncts to existing measures (Sprang et al., 2009).
A Proposed Tri-phase Model to Aid the Systemic Therapist in the Prevention, Assessment, and Treatment of Traumatic Stress
This articles proposes a tri-phase framework by which systems-informed therapists can conceptualize cases of trauma-related stress (see Figure 1, next page)
The model incorporates elements of Ericksonian hypnotherapist Andrew Austin’s approach (case study below), and the Neurosequential Model of Therapeutics (Perry, 2006; 2009), which incorporates a “client map” comprised of developmental history and current assessments of both functioning and support to help in tailoring multi-disciplinary interventions. A medical family therapy lens, emphasizing biopsychosocial notions of agency and family/social support was also incorporated. The model is proposed not as a linear tool, but as a multi-purpose framework by which:
a) Systems-informed therapists, especially MFT’s, can utilize the breadth of their training to more holistically to view the victim of trauma
b) Clients suffering from traumatic stress can benefit from a visual toolset that may help them integrate trauma.
c) Pre/peri/posttraumatic factors can be mapped to more clearly visualize development pathways of PTSD and other comorbid conditions
d) An increasingly relational emphasis in trauma treatment can be made explicit
e) Clinicians may be able to integrate richer contexts from which they can more effectively collaborate with other professionals and deveop multi-dimensional treatment interventions
f) Clinicians can help provide client psychoeducation about PTSD and other related disorders
A synopsis of a case presented by neurolinguist and hypnotherapist Andrew T. Austin at 2009 Advanced Mastery Training in Trauma, Boulder, CO. and conceptualized under a tri-phase traumatic stress framework as depicted in Figure 1:
A middle aged male in Manchester, England, reported for therapy complaining of a triad of hyperarousal, avoidant, and re-experiencing symptoms consistent with a diagnosis of Posttraumatic Stress Disorder (DSM-IV, 2000). The client described having been beaten to the point of long-term hospitalization by a group of teenage boys while walking home from a party and had been drinking. A developmental pathway approach was utilized by Mr. Austin, whereby pretraumatic factors/ peritraumatic profile /posttraumatic sequelae were examined in the context of intrinsic factors (emanating within or by self) and extrinsic factors (emanating from other people, beliefs, societal laws and biases)
Initial Client Report
a) Pretrauma: The client reported that his being at the location of the violent beating was an accident, and that he was simply returning from a party of friends.
b) Peritrauma: The client reported that he believed that all members of the “gang” had equally participated in the violent act (extrinsic). Client reported unclear memories of the chronology and detail of the event (intrinsic).
c) Posttrauma: Client reported not being able to escape being pursued by journalists and members of the media about the traumatic event. The client also admitted that he cut off contact from all social friends and most family members.
After the initial report, Andrew Austin utilized the pathways model to elicit details from the client about each of three longitudinal frames from an intrinsic and extrinsic perspective.
Subsequent Client Report
a) Pretrauma: The client reported a distressed childhood due to parental conflict and physical abuse (extrinsic). The client reported regret over lifestyle choices that placed him in the pub, and also regretted refusing a ride home which would have presumably avoided the incident (intrinsic).
b) Peritrauma: The client recalled the trauma after an anxiety reducing exercise; in this context, he reported that all members of the “gang” had, in fact, not equally participated in the violent act and that several had attempted to interrupt the physical beating. Importantly, the client explored his reaction to the trauma, remembering that he had cried out for help and had pleaded, “Please don’t kill me.” The client acknowledged that he’d largely suppressed that part of the memory and felt great shame and guilt at having reacted in that manner (intrinsic), an element he would claim later was the root cause of his PTSD.
c) Posttrauma: Client reported being hounded by journalists and members of the media, but acknowledged that his communication with and reaction to these people was something that he could control. Client had avoided his social support network of family and friends because he believed they were incapable of understanding the frightening experience and it’s symptomatic aftermath (dissociation, anxiety, foreboding, racing heartbeat, and flashbacks to parts of the violent attack.)
After several months more of treatment, the client had integrated a more whole memory and experience related to the trauma and used the contextual information he’d discovered during the three phase analysis to better cope with the aftermath, which helped him reconnect with those close to him. The client reported a dramatic reduction in PTSD symptoms.
A growing coalition of what were once regarded distinct fields of science is providing a new opportunity towards multi-perspective prevention, diagnosis and treatment of posttraumatic stress disorder and the field of sytemic therapy is well positioned to play a significant role in future inquiry, research, and clinical treatment . A tri-phase model implicating pathways of traumatic stress disorder development is proposed as an assistive framework so that marriage and family therapists may evaluate and plan integrative treatment for traumatic stress disorders. Furthermore, as systems-informed academicians and researchers are uniquely positioned to play a prominent role in the next phase of integrative research and treatment development for this critical client population, theoretical modeling constructs that can be the subject of empirically sound research studies are needed to germinate this promising line of inquiry.
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