A Brief History of PTSD
All treatment modalities evolve. This has been true from the very first days of Freud’s efforts to understand how some physical symptoms he saw had no physical explanation. Within a few decades, not only had a reasonable theory developed, but significant movement towards a variety of treatments had developed, with perhaps Freud’s student and colleague Jung being the first ‘break out’ innovator from the existing standard of treatment.
The area of stress disorder treatment has continued to follow this basic scientific evolution. Early understandings of how stress works on the body indeed start with Freud, who described ‘hysteria’ in upper middle class women. The particular focus on stress study got a large, if not unfortunate boost during World War One, and all subsequent wars since. The language reflected the growth in understanding: initially in World War One, stress reactions were called “shell shock”. By the Second World War, the name changes to “battle fatigue”, and by mid Viet Nam, it is finally being recognized by the as of yet highest assessment of “Post Traumatic Stress Disorder”.
By the end of the Viet Nam war, psychological assessment and understanding had almost a full century of growth beyond Freud in refinement. Treatment specialists began to notice that people other than veterans were suffering from many of the same symptoms. People who had experienced dramatic events in their lives such as fires, natural disasters, or sudden tragic deaths of loved ones developed behavioral symptoms closely matching battle experienced vets. Interestingly, it appears that it is even later that the recognition of PTSD in victims of interpersonal violence occurs. This may be due to larger social dynamics, including the advent of women’s rights and greater attention then given to domestic abuse and the effects of violence in the home.
Treatment, in the form of ‘talk therapy’ also has its roots in Freud. Once again, during the First World War, the stress effects of battle appear to have been largely approached as a scientific curiosity, and treated with some degree of compassion. Treatment appears to have been largely based on giving the victim ‘rest’, and perhaps some supports resembling ‘talk therapy’. By the time of the Second World War, the effort had become one of screening out those individuals that were deemed psychologically weak. This effort was rudimentary and highly biased by today’s standards. The cultural impacts at this time produced a high amount of pressure on soldiers to avoid appearing to be a “coward” at all times.
This pervasive attitude further confused the progress of stress reactivity, as well as leaving many soldiers who suffered from stress reaction unnecessarily shamed and ostracized by society. Anyone who has watched the famous George C. Scott as “Patton” can get a very accurate view of how many at the time viewed soldiers suffering form PTSD. Not much improvement in treatment modalities occurred during the interim of the two ‘great wars”, with perhaps the development of some early medications in the form of sedatives. In most cases, the soldiers treated themselves, like soldier have for centuries, with intoxicating substances.
Again, it is likely that the larger cultural influences during the Viet Nam years impacted the forward movement of treatment. The openness of ideas and intellectual exchange produced by the “love generation” undoubtedly impacted young therapists; talk therapy had entered the mainstream in the form of “rap groups” (Albeit surrounding, at times, the use of marijuana.)
In combination with the larger cultural blending of the mainstreaming of basic psychological talk therapy approaches and the political climate of finger pointing concerning responsibility for all aspects of the war, the most modern version of treatment developed: talk therapy that focused on helping the soldier victim to accurately assess their genuine responsibility for the bad things that had happened to them. While this was a major advancement, it of course was still far too simplified to adequately and fully treat the victim. Thousands of Viet Nam vets can attest to that fact.
By the approach of the turn of the most recent century, clinical approaches to PTSD had advanced to the point where there was a keener understanding of the need for a multi-faceted approach to treatment, with cognitive-behavioral approaches taking the fore. These approaches, essentially, stress the idea that emotions can be managed most effectively if the individual self disciplines and restructures the way that they think and behave. In addition, there was a movement toward a process called “flooding”, where the victim is asked to repeatedly re-live the trauma in treatment in order to begin to gain a realistic perspective (meaning correcting wrong attributions of responsibility) and to desensitize the victim to the trauma. This is, of course, considerably more difficult to do if there is the added problem of addiction to substances as a result of the victim self treating.
Perhaps the latest trend on the scene of treatment is called “Eye Movement Desensitization and Reprocessing.”, or EMDR. This treatment remains quite controversial, and is considered by most mainstream treatment professionals as a ‘fad’ therapy that has simply collected bits and pieces of other, more basic treatments. There are several notable problems with EMDR, including the academic credibility of the originator, the claims of EMDR being able to ‘cure’ people within a few sessions, and the claim that it can effectively treat a very wide variety of disorders. Anyone seriously considering using EMDR to treat PTSD should be very skeptical, and read up on the topic. A good place to start is: http://skepdic.com/emdr.html
The most notable flaw in all of the current treatment methods for stress disorders, including acute stress and post traumatic stress, is that they are modeled largely on the experiences of the battle experienced soldier; not much treatment development has been made from existing research about the bio-chemical nature of stress disorders to address alternate models for treatment. Thus, the cognitive-behavioral restructuring and “talk therapy” approaches are largely based on adult experiences, and at that, adults who had a fairly normative and undamaged ego structure prior to the critical events. What about a child, whose whole life, has been one constant and intensely stressed event?
There are countless children who have grown up in incredibly stressful situations. Think about the child who has only known war, insurgency, and death their entire life. Or the child who’s single parent is addicted to crack, and has had multiple partners, some of whom sexually abused the child? If the child has never had a healthy, intact ego, how can treatments that assume that the victim has had a healthy intact ego at some time prior to the trauma work? Clearly, a better model of treatment for children who have had repeated, chronic and acute stressors their entire lives needs to be developed.
When the adult model and treatment modalities are used with children, and we accept the theory that the child’s ego is far from being at an optimum state of normalcy and health, then repeated review and “flooding” the child with the images of their critical incidents is not just simply ineffective (since they have no suitable ego structure to reassess their trauma experience), but becomes abusive and re-assaulting. One may argue that “play therapy” models would serve to be appropriate methods of treatment. While the “play” in and of itself may be a quite benign tool, the philosophy of the therapist providing the play therapy is critical. If the therapist’s foundation is that the child must repeatedly speak about their critical incidents in order to get better, the “play” simply becomes moot.
This is not to suggest that the child should not speak about their traumatic events. It simply means that the child should be in total control of their revelations, and never pressed. And once they have spoken, they should not be pressed for more details. Often, children who are victims of interpersonal abuse are pressed by doctors, police, social workers, and even mental health professionals to give details so that legal proceedings may ignite. All too often, this just serves to traumatize the child further. The need for a better protocol is glaringly self evident.
The mainstream treatment system also tends to under diagnose or misdiagnose stress disorders in children. Typically, the child comes into treatment for their behavioral symptoms, and the system then treats them based on symptoms, not on likely causations. This works rather well for biologically based diagnoses, like ADHD or depression, but it is a disaster with PTSD. Another reason for under or misdiagnosis is that there is a surprisingly high number of treatment specialists, who even when having a PTSD diagnosis in hand, are severely uncomfortable in addressing the critical incidents. This, of course, is a natural human reaction: who want s to hear a young child describe their rape?
Since most treatment for childhood mental health disorders are focused on highly generic behavioral interventions, these measures often only serve to escalate the child’s overall dysfunction in relation to their PTSD. Because such measures simply do not work, the treating system moves from desperate modality to desperate modality, never to find a really effective means of helping the child…and all because no one has yet discovered that the real problem is PTSD. Children with undiagnosed PTSD will usually have a very long list of medications tried, various levels of treatment, including hospital stays and residential treatment, and a dismal school record. All of the erroneous attempts at helping the child result in simply further brutalizing and confusing the child. Many children begin to assess themselves, after some time in the inadequate system, as being “crazy”, “bad”, and hopeless.
In this writer’s experience, young children who have spent a significant amount of time under stress express their stress symptoms (both Acute Stress and PTSD) differently than adults do. Their symptom profile often does not match the adult model for PTSD. In addition, they require and respond far better in treatment when the treatment is based on what is intuitively understood by all caring adults when a child is hurting: gentleness and patience. Years of treatment development and growing success with young children who have been deeply wounded by interpersonal abuse have demonstrated that a ‘gentling’ approach works.
“Gentling” is as much a comprehensive philosophy of treating young children with stress disorders as it is a specific set of techniques. The structure follows a somewhat standard path of helping the child to feel safe in all environments, sensitizing the child to their own stress reactivity cues and patterns, educating the child on how to interrupt and treat their own reactivity, and finally, a process of stress inoculation that emphasizes age normative behavioral expectations along with a very high structure and nurture component. It is imperative that the pace of the treatment be controlled by the child, not by the care givers or treating professionals. The child is never pressed for repetitive relating of the details of their critical incidents. Generally, a child comes to a point in treatment where this does occur, and it is treated with all due respect and examination, but once stated, it is only returned to if the child desires it, and then, only once. The focus then returns to enthusiastic support of their age normative development.
There is a strong cognitive-behavioral component to Gentling: he child is taught that they can change their painful reality of uncomfortable stress episodes, and that their stress disorder is never and excuse for poor behavior. It is conveyed to the child that while it is understood that they will be cued, triggered, and enter into stress episodes, it is not acceptable to hurt themselves, others, or destroy property. Children are taught to self recognize the initial stages of stress reactivity, and take measures that they have learned to alter the usual outcomes. They need to develop trust in a trustworthy team of helpers to help guide them to use the skills that they have learned, and to accept the support that will be given when a full fledged stress episode occurs.
Every effort is made to recognize the child’s early behavioral “tells” that demonstrate and predict stress episodes. This is done in order to make intervention during a very narrow window of time when heading off a full blown episode. The point is to avoid repeated stress episodes, and this only drives the symptoms deeper, and can permanently alter the child’s bio-chemistry, making it impossible to re-set and calm the child’s chemical-emotional homeostasis.
There are strict protocols for intervention when the child’s stress has blossomed into a full stress episode. This includes constant self assessment by the person intervening; they must remain calm and not personalize the likely attacks (both verbal and physical) that he child may engage in during the stress episode. The support protocol also includes a scrupulous examination of any need for restraining the child during the stress episode. In essence, this is to be avoided at all costs. Any touch initiated during the stress episode by the helper is only with the clear consent of the child, or, only if the child is in genuine, imminent danger of life threatening harm to themselves or someone else. The adult helper avoids giving commands, but relies on neutral tones in giving simple directives to the child, such as: “sit down so that you can calm down.” The overall affective approach that the helper maintains is one of extreme, genuine, respectful gentleness that is devoid of condescension of any kind. This helper countenance takes practice to learn.
Perhaps the most difficult task of the Gentling approach is to get all other adults on board the philosophy, approaches, and techniques. Because children with stress disorders become oppositional, unpredictable, and sometimes violent, adults can quickly revert to an assumption that the child’s behaviors are not based in their history of abuse, but based simply in wanting to manipulate, disobey, or anger the adult who is trying to help. Some adults have a very hard time holding on to the Gentling philosophy and techniques when confronted with a child who is cursing, spitting, and kicking them. But like any therapeutic approach, gentling takes skill building, practice, attentiveness, and self discipline on the part of the therapist.
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