June 27th is PTSD Awareness Day, providing an opportunity to raise awareness, educate and reduce the stigma around posttraumatic stress disorder (PTSD) and provide support for those who are currently living with PTSD.
While most of us are likely to experience a trauma at some point in our life, distress is usually short-term. For some people however, living through or witnessing a traumatic event that causes fear, helplessness or horror in response to the threat of injury or death; such as sexual or physical assault, a serious accident, a sudden death or serious injury of someone close, or a natural disaster, can lead to the development of PTSD. Most PTSD develops shortly after the traumatic event occurs; however, sometimes it can take many months or much longer.
People with PTSD experience four main types of difficulties including; re-living the traumatic event, experiencing flashbacks or nightmares along with strong emotions and physical sensations. Avoidance symptoms – they may avoid situations, thoughts, people or memories which remind them of the traumatic event. Mood and cognitive symptoms – they experience negative changes in their beliefs and feelings and may feel angry, guilty or numb. Arousal/reactivity symptoms – they may feel wound-up, get easily startled, feel as though they are on the alert for danger and have troubles sleeping or concentrating or feel angry and irritable. Some people also experience dissociative symptoms which can lead them feeling detached from their own body or mental processes or persistently experience their world as unreal, dreamlike, distant or distorted.
In addition, it’s common for people suffering from PTSD to experience other difficulties which might have developed in response to the traumatic event or due to coping with PTSD, such as depression, anxiety and alcohol and drug use. PTSD can therefore also impact on and interfere with an individual’s ability to function at work and enjoy relationships and life generally.
So how can we help as clinicians and where do we start?
- Recognise the trauma
Firstly, what I have found most helpful in my work with people with PTSD is recognising the trauma. When a client comes to us for help, they are being brave enough to take steps towards making changes for the better. If we don’t acknowledge their traumatic experience, we can’t offer them effective treatment to support them and give them the opportunity to live a fulfilling life. Clients may feel unheard, stigmatised and drop-out of therapy and never get the help that they need and deserve.
Providing clients with psychoeducation around trauma, particularly on how the brain processes trauma and how our brains are plastic is another helpful way to support clients in beginning to understand their responses and give them hope that they can change and heal. When clients can begin to understand that their experiences, such as dissociation, are the brain and body’s way of trying to cope with an overwhelming experience and that they didn’t get to ‘choose’ the way they responded at the time (flight, fight, freeze or fawn), they can begin to accept how some of their responses were adaptive and actually kept them alive. This hopefully helps clients learn to be more curious and compassionate towards themselves, promoting their healing.
- Bottom-up interventions
Using bottom-up interventions, working through the body to help calm the stress response, is another helpful and necessary way to work with clients. Diaphragmatic breathing, mindful breathing, Progressive Muscle Relaxation (PMR), safe/calm place visualisation, 5 senses grounding are just some interventions that are part of working with PTSD. Finding what works for clients so that they can feel a sense of safety and calm is sometimes challenging but always important.
Armed with some knowledge and skills, clients are more open to begin to process the trauma. This is when having some tools and skills to effectively treat trauma is important for a clinician. There are various ways of working with PTSD, one of them being Eye Movement Desensitization and Reprocessing (EMDR), which was initially developed for the treatment of PTSD. EMDR is now established as an effective treatment with a strong evidence base and is recommended by the National Institute for Health and Care Excellence (NICE) guidelines and by the World Health Organization for the treatment of PTSD.
EMDR is based on an Adaptive Information Processing (AIP) model of how new experiences are integrated into existing memory networks. Normally, memories are processed and integrated using an individual’s past experience and understanding of themselves in the world. Trauma causes a disruption to this processing, resulting in unprocessed information being held in memory networks.
EMDR helps to access this dysfunctionally stored experience and stimulates the innate processing system, allowing it to change the information into an adaptive resolution. This is done in a session by guiding a client to think about a traumatic memory, or a related sensation, while at the same time asking them to either tap or track finger movements with their eyes. This bilateral stimulation (BLS), along with the brief exposure is what is thought helps to enable more adaptive associations to be made. This means people become desensitised to the trauma, which reduces their symptoms, helping them to be able to function better day to day.
Although EMDR is not a ‘quick fix’ or a magic wand that can make all problems disappear, it can lead to fast and significant changes. Clients have reported after EMDR sessions how the traumatic event is now “just a memory”, or “it feels in the past”. Many people find they are able to talk about their experience without feeling overwhelmed, deeply ashamed or angry and they feel lighter. Clients also report doing things in their life that they weren’t able to do before, like set boundaries in relationships or at work, pursue new interests or change careers.
- Therapeutic alliance
Finally, but actually most importantly, working with PTSD is like working with any other human struggle that we see every day as clinicians. This means that the therapeutic alliance is the most important “technique” that can be used with a client. By attuning to our clients, we are validating and encouraging a reparative experience which I believe is the most important part to healing.
Dr Zoe Starnawski
BPS and HCPC Registered Psychologist