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CBT: An effective treatment for Post Traumatic Stress Disorder (Adapted by John Clark)
Starting the treatment
Obviously, there is no ‘one size fits all’ therapy to help people recover from PTSD or any other stress-related condition, but it helps to have a strategy that you can adapt to suit each particular situation. I have found that the most effective type of therapy is a variant of Cognitive Behaviour Therapy (CBT) known as Stress Inoculation Training (SIT).
SIT combines a number of well-known, tried and tested components of CBT which help PTSD sufferers deal with real or imagined threatening situations.
I have adapted SIT to include relaxation training, psychoeducation, guided self-dialogue (positive self-talk) and communication skills and thought stopping, as well as cognitive restructuring, as I feel that while they are not totally effective as stand-alone treatments for PTSD, they are useful and complement the other components of CBT/SIT. I am convinced that this makes SIT a more complete overall therapy package.
Cognitive Behaviour Therapy (CBT) / Stress Inoculation Training (SIT)
This is one of the most highly developed cognitive behavioural therapies for helping people with PTSD and other stress-related conditions. This approach combines a number of different therapies which involve:
- Psycho-education. This is my (preferred) first stage of SIT and is aimed at ensuring that patients understand the nature of PTSD and its effect on them. There is often an immediate benefit, as the patient is relieved to learn that their symptoms fit into a coherent syndrome. Patients frequently feel as if they are losing their minds. The advantage of this approach makes it an ideal springboard so that therapy gets off to a good start.
- Relaxation and Biofeedback. Regular daily use of a professional relaxation tape. Biofeedback (biodots and GSR instrument) is useful for demonstrating the mind– body connection, i.e. how we think affects how we feel and behave, and if we are able to change how we think about our situation we can then start to change the way we feel about it.
- Deep (diaphragmatic) breathing is taught and used as a quick method to calm the patient prior to and during in vivo (real life) exposure to the patient’s most feared situation, e.g. starting to drive again after a lengthy period of avoidance caused by their PTSD.
- Thought stopping, e.g. refusing to accept harmful/upsetting thoughts or imagery by replacing them with other more helpful and pleasant thoughts and images. With regular practice this technique helps to minimise the effects of unhelpful negative thought processes.
- Communication skills (talking about the accident in a controlled and appropriate way). Often the PTSD sufferer will avoid discussing the traumatic event with others, however it is proven to be helpful with the recovery process.
- Guided self-dialogue (positive self-talk), e.g. ‘John is a safe driver, the accident was not our fault. There was nothing we could do to avoid it’, ‘The past can’t harm me’. I also provide a personalised self-help script for the patient to use as a backup for when they feel anxious prior to or during graded exposure sessions.
- Cognitive restructuring, i.e. modifying the patient’s way of thinking and underlying beliefs about themselves, the world at large and how they see the future. This is effective in restoring an optimistic outlook about the future.
- This therapy includes sensitive, but increased discussions to gauge the patient’s response to certain stressful situations, not only with regard to driving but for other equally traumatic events such as being physically attacked or having an accident that is not car-related. The objective is to prepare the patient by rehearsing coping skills, and by testing the skills in vivo, i.e. in real life conditions.
PTSD and children
It must be realised that not only adults are involved in accidents or incidents that can lead to PTSD. As children these days are ferried from place to place in the family people carrier or car, they are just as vulnerable as everyone else to being involved in a crash or having an accident while on the school bus or when on a field trip or school holiday. For the treating therapist, being faced with the fact that their PTSD patient is a five-year-old child certainly presents a problem. There are of course significant differences in how a small child reacts to PTSD:
- Very young children who have experienced a traumatic event, e.g. a car accident, may have difficulties with sleeping or have nightmares. In some cases they may act and behave much younger than their age. They may avoid doing the things that they associate with the traumatic event, e.g. getting ready to go out in the car or avoiding sitting in the rear or front of the car. It is common for children who have been involved in a traumatic event to avoid contact from time to time with those they previously spent a lot of time with.
- They may try to avoid going to school, or have difficulties with schoolwork, or are unable to fully concentrate when in class. They may also not want to play as often as in the past, avoid certain types of play or no longer have an interest in the things they formerly enjoyed doing.
- In some cases the child may behave aggressively towards other children in the family or in the playground with other children.
- They may also be sad or appear to have less emotion or to feel guilty about things they did or did not do connected to the traumatic experience.
- Very young children (age five and younger) may well experience new fears such as separation anxiety or fear of strangers or animals. They may also complain of bodily symptoms that have no medical cause (e.g. stomach aches). They may also from time to time seem a little vacant or appear to stare into space, or startle more easily than normal. It is fairly common for very young children to forget their toilet training and to soil or wet themselves occasionally.
- Children are at a greater risk of developing problems if the traumatic event was severe, e.g. involving injury and or bloody scenes, particularly if the child’s parents were extremely distressed in the immediate aftermath of the event, or if the child was directly exposed to the event as opposed to learning about it later.
- None of these risk factors means that the child will definitely have problems, but the risk factors increase the likelihood that a child might develop problems following an extremely stressful event.
- It goes without saying that it is unrealistic to expect a young child to understand what is involved in being a PTSD sufferer.
So, how do we treat the child? My solution is to do it by proxy, i.e. explain the facts, symptoms, etc. of PTSD to the family including parents, siblings (if older), relatives, neighbours and teachers. To make this easier for everyone involved with caring for the child, I put together a fact sheet. The example below was used to help a five-year-old boy in Stockport, Cheshire:
“How family, friends, neighbours and school staff can help Ross"
Ross has residual effects from the car accident, but will recover in time.
To help him through this period there are a few practical, helpful things that family, friends and teachers can do with immediate effect, such as:
- Driving in the car: try and associate going in the car with something pleasant, e.g. going to McDonald's or the cinema. This will help Ross to overcome anxiety when he has to go out in the car.
- Ross will probably be more easily startled than normal. This is all part of the after-effects of the accident. Where possible, avoid making loud noises in his presence or approaching Ross from behind.
- Ross may from time to time experience flashbacks of the accident. This will have some effect on Ross, such as he may go a little quiet or his mood may change. It may help to be aware of these changes and realise that this is normal. If possible, try to interest Ross in doing something that he enjoys, e.g. watching a favourite TV programme or playing a game, but don’t push it if he strongly resists it.
- If Ross mentions the accident, do not avoid the subject but reassure him that it was a long time ago and that he is OK now, and so is his mother and sister, and it won’t happen again. Reassure him that he is safe now. It may be worthwhile to mention to him from time to time that it wasn’t your fault and that the other car ran into your car.
- Following a stressful event we are more prone to accidents, particularly in and around the house. If Ross accidentally hurts himself every now and then, it is not because he is clumsy or silly; it is probably a lingering effect of the incident.
- Every now and then Ross will experience feelings of anger and irritability. This is a normal response following a severe traumatic event such as an accident. Do not be surprised if Ross says out of the blue, ‘Why did we have an accident, Mummy?’ It may help to have a ready answer to hand such as 'Accidents do happen to people but we are all fine now’ and ‘It’s all over now’.
- It will help if Ross is given a degree of control in normal everyday things such as choosing what he wants to eat, what he wants to wear, watching certain suitable TV programmes, videos or which games to play.
- Football. I believe that Ross’s father has promised to take Ross to football practice. If possible, this should become a regular part of his weekly activity. It may help if he is then able to associate travelling in the car to the park, etc, with going to play football.
- Ensure that Ross gets adequate sleep, a reasonable diet and regular enjoyable exercise. Football sounds great!
- Cut down on cola drinks. Coca Cola and Pepsi have quite high sugar and caffeine content, which is not good for young children. Fruit juices and water are much better.
- Allow Ross plenty of time to relax, e.g. someone could help him read a book before bedtime.
- Allow time for Ross to deal with the memories of the accident. There may be some aspects of the experience that are difficult for him to forget. But in time things will get better.”
Follow-up to therapy
I am pleased to report that, on following up three months later, I was told that Ross had made a fine recovery. He even sent me a Christmas card.
Case Study: No 1
David, aged 56, Fleetwood, Lancashire
Accident date: March 2001
Diagnosed with PTSD: November 2002
David was an unfortunate victim of local vandals who had removed safety barriers around a quite large hole (three feet wide, six feet long and several feet deep). The hole had been dug by a public utility for access to gas mains. David was on his normal route to nearby shops when he suddenly fell into the hole. He was, of course, quite shocked to find himself in the hole, but managed to extricate himself. An important aspect of this case is that David has very limited vision due to an inherited eye condition called retinitis pigmentosa. David made good progress in recovering from his physical injuries but he no longer felt able to make the trip to the shops or visit the grave of his parents at the cemetery, a 35–40 minute walk from his home, which was a major loss to him.
Therapy strategy: SIT
As mentioned earlier, my initial efforts were to help David understand that his thoughts and feelings were quite natural under the circumstances, i.e. there was no sense in exposing himself to the same risks again and that he should avoid the possibility of this happening again by not walking the route of the accident. My focus was to concentrate our efforts in helping David come to terms with the fact that it was possible to overcome this by recognising that his view of the situation was a major stumbling block to his recovery, i.e. his freedom to go where he wanted, when he wanted. David took to the relaxation tape I provided with enthusiasm (I obtain my supply from the Centre for Stress Management). Combined with deep (diaphragmatic) breathing, David started to change his views on the situation, i.e. he began to challenge his belief that if he ventured out it would be inevitable that he would have another accident. He started to believe instead that it was highly unlikely that this would happen again, and we came to an agreement that we would work together to help him overcome this problem. As David had not made the journey for over two years, it was inevitable that his memory would be a little hazy and, with his limited sight, there would be orientation problems. We solved this by a gradual process whereby I acted as a guide (with my influence gradually reduced) on our trips to the shops and cemetery, until David was able to manage without any help from me. On checking with David a couple of months later, he had not experienced any problems since our last session.
Case study: No. 2
Joan, aged 60 plus, Leeds, Yorkshire
Accident date: June 1998
Following a serious car accident a few miles from her house, Joan had become largely confined to her home. Her physical injuries had largely healed, apart from some occasional pain down her shoulder and right arm. She no longer felt capable of doing her work and had stopped attending church and no longer maintained relationships with friends. Joan’s selfesteem and confidence were also very low. Driving was limited to very short local trips of no more than five minutes there and back, and after each driving experience she was usually reduced to tears and felt exhausted. An additional problem was that Joan’s husband did not drive.
My involvement came about after Joan had an unfortunate experience with a psychologist whom she was seeing some distance away (30–40 minute drive) and who insisted on discussing her relationship with her parents when Joan wanted help to overcome her fear of driving. Fortunately, she had enough presence of mind to call a halt to the therapy. Her solicitor made contact with me through a third party.
Treatment strategy: SIT
We started work on Joan’s problem from day one with an explanation of what PTSD is, was causes it and how we were going to work together on her problem. As Joan was almost constantly on edge we concentrated on helping her to recognise the situations and thoughts that were the cause of this anxiety. She began to accept that while these thoughts were normal in the circumstances, they were unhelpful and inappropriate. This realisation started to minimise the effect of them on her. After quite a few sessions of SIT we made good progress. Joan took to the relaxation quite well, and even though she obviously experienced a great deal of anxiety when we started to increase the length of our graded exposure, there was no hesitation in getting behind the wheel. Joan was a very determined patient. She wanted to get her life back and she succeeded through hard work and application. There were one or two setbacks, but we eventually made it. She resumed her regular church going, took up painting and even started to take her husband (by car) to Blackpool to their favourite hotel again after a gap of five years. I will let Joan tell you in her own words* how she changed her view of her situation and how she is now [*Joan gave me this (unasked for) note near the end of the therapy]:
In the past week, I have driven along the route of the accident 12 times. When the thought came into my mind my mouth became dry and I noticed that the nearer I got to the site I became tense, and my thoughts were wandering and not focused. When I got to the road and began to travel along it I had to make myself concentrate on getting to the end. After I had done this journey eight times it became less of an effort and I found that I could quite easily change the way I thought about the ROAD. I now realise that the ROAD cannot harm me and that it never did – the accident was human error. I also realise that most drivers are careful and that I myself am more capable of driving MY car wherever and whenever I choose.
To counteract the feelings that I experience I make myself physically take stock of how I am sitting and holding the wheel. I take deep breaths and repeat over and over to myself RELAX, RELAX, RELAX.
I am more comfortable now in the manner in which I approach driving, and whilst I am more cautious than I was before, I am happy enough to take the car out without a second thought (well perhaps sometimes).
My normal practice is to follow up a few months after completion of therapy. Joan is doing very well indeed.
Glen R. Schiraldi, PhD, The Post Traumatic Stress Disorder Sourcebook. Lowell House, Los Angeles, USA. ISBN 0-7373-0265-8.
(I use this for educating patients about PTSD.)
Matthew J. Friedman, MD, PhD, Post Traumatic Stress Disorder (The Latest Assessment and Treatment Strategies). Compact Clinicals, Kansas City, Missouri, USA. ISBN 1-887537-14-7.
John Clark trained at the Centre for Stress Management in London and obtained his Diploma in late 2000. He has extensive experience of helping people recover from PTSD and other associated phobia. John has contributed numerous articles on stress-related issues to Stress News.
He frequently speaks on stress matters on local radio in the northwest. He regularly contributes to articles in national newspapers and magazines on stress and health. John is author of ‘Stress: A Management Guide’. Email: email@example.com
Gladeana McMahon is a Fellow and Senior Registered Practitioner of the BACP and an Accredited Cognitive- Behavioural Psychotherapist who is UKCP and UKRC registered. She has written or edited 20 books including an interactive training manual ‘Understanding Trauma’ (National Extension College, Cambridge), and self-help book ‘Coping with Life’s Traumas’ (New leaf, Gill and MacMillan).
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