Principles and Processes:
In this article, we look at the mechanisms that contribute to some trauma survivors going on to develop Post-Traumatic Stress Disorder (PTSD), and give an explanation, based on cognitive theory, for cognitive behavioural treatment interventions that target these mechanisms.
Acute symptoms, such as intrusive memories, and intense feelings of fear, in days, weeks and months following a traumatic experience are common. Fortunately, most trauma survivors experience a decline in post-trauma symptoms over time, usually substantially reduced by 4 months and stabilising at low levels by 12 months post-trauma. For these people, initial acute symptoms may be indicative of healthy emotional processing, as they begin to integrate their experiences, and see a decline in both symptoms, and distress within a year.
For other survivors, their acute symptoms do not decline, and can instead become persistent, or even escalate. These survivors are those who may go on to be formally diagnosed with Post-Traumatic Stress Disorder (PTSD). The difference in outcomes between those whose symptoms decline in due course, and those whose symptoms become persistent and chronic, can be explained by understanding differences in responses to trauma symptoms. At the outset, we should be clear, these differences in responses are not likely to be the result of conscious decisions, or individual fault, but arising from a combination of differences in their personal learning histories (ie. the experiences through which they have learned to respond to their inner experiences), and biological factors
In the course of healthy processing, (i.e. resulting in a reduction in symptoms and distress, over time), negative appraisals, formed at the time of the traumatic incident, about themselves, others, and the world, are modified through elaboration (where new information is added and integrated to the trauma memories) and contextualisation of the trauma memories. Negative appraisals are updated to more workable versions, which do not generate the same levels of distress. At the same time, survivors may habituate to the memories (so that they become less fearful of the memories themselves) reducing both acute distress when experiencing trauma memories, and facilitating further updating of the memory, as it is more easily approached. The sense of current threat declines, and there is less need to avoid situations which may 'trigger' unwanted or intrusive memories.
In contrast, those with persistent symptoms (PTSD) have processed their experiences in a manner which results in a significant sense of current, and ongoing threat, with excessively negative appraisals of their trauma experience and high levels of avoidant behaviour. The helpful processes, of elaboration, contextualisation, and habituation, can be blocked when individuals engage in strategies to avoid any contact with their trauma memories, which is what is typically seen in people with a PTSD diagnosis.
Avoiding one's inner experiences (such as memories, thoughts, feelings, and sensations) is an active process, often requiring both covert behaviour ( i.e. occurs within the individual, where it cannot be seen by others, through strategies such as thought suppression, distraction, thought replacement, dissociation, and rumination and worry behaviours) and overt avoidance of real world situations, because exposure to situations, which resemble the traumatic event, function as 'triggers' for intrusive memories. Intrusive trauma memories lead to intense fear, or panic, and symptoms of hypoarousal, the distressing nature of which encourages avoidance of similar situations in the future. Short term avoidance has the benefit of reducing immediate distress (acting as a powerful reinforcement of their avoidance behaviour - meaning they are likely to continue to be avoidant, and may become more so) but also blocks habituation and desensitisation to the intrusive memories, maintaining distress in the long term.
These strategies are understandable, as acute symptoms are, by their nature, extremely distressing. Nonetheless, avoidance blocks habituation, updating of negative appraisals, elaboration and contextualisation of the memories. Put simply, if the individual cannot 'approach' their memories, the distress remains because they cannot re-examine the appraisals they made of the traumatic event at the time, cannot add any new information to those memories, cannot put their experiences in context, and cannot habituate to the fear being provoked, or learn new, more effective, responses to them. When seen from this perspective we can see why avoidant responding to traumatic memories results in chronic symptoms that persist over time, and do not decline naturally, as they do for survivors who do not respond with avoidance strategies.
The difference between those who respond with avoidant strategies, and those who do not (the reality is there is likely to be a mix of strategies employed by many survivors) is not simply a matter of choice or personal 'resilience'. People use the strategies that they have learned from previous experience, often in childhood. Individuals do not need to have experienced trauma in childhood to have developed avoidant coping strategies, although it raises the likelihood, but avoidant styles may still have been modelled during their childhood and beyond. More so, a lack of active modelling of effective regulation strategies - such as being shown how to soothe oneself when experiencing distress by the compassionate responding from their caregivers -, or exposure to highly critical and blaming environments, may contribute to a reliance on avoidance strategies when faced with the significant distress as a result of a traumatic experience. This is understandable because, if distress cannot be soothed effectively, then avoidance makes sense as a strategy for both managing distress in the moment and attempting to reduce the likelihood of experiencing it in the future. Unfortunately, as we have seen, the result is that distress is actually maintained in the long-term.
Treatment options for PTSD are well established. Cognitive Behavioural Therapy (CBT), and related approaches, are well evidenced as effective in helping trauma survivors reduce symptoms and distress. Below is a brief explanation as to how CBT can work to address the address the processes described to reduce distress. There are protocols, such as those based on Ehlers and Clark's CBT framework for PTSD, that have a strong evidence base, but treatment should always be tailored to the individual, meaning that understanding the principles and processes being targeted is important, as it allows more flexibility in constructing an effective treatment plan.
Although described separately below, in practice multiple processes may be targeted in any intervention, for e.g., cognitive restructuring may involve elements of exposure by virtue of contacting the trauma memory, and inhibitory learning likely takes place alongside habituation, and vise versa. In any case, with each element there are actually many potential interventions that can be tailored to individuals and the specific context in which they are to be used so, although I've included some examples, none of the below should be considered exhaustive.
Emotional identification strategies: Many people struggle to identify and name their feelings. Learning to label feelings requires at least some contact with the unwanted experience, whilst allowing for new information to be added to it. This may access inhibitory learning (see below) as individuals learn to respond differently in the presence of their unwanted experience in that moment (labelling vs immediate avoidance).
Emotional regulation strategies: Building on emotional identification, emotional regulation is intended to increase the repertoire of available responses to unwanted personal experiences (i.e., intrusive thoughts/memories, emotions and sensations), so they can move beyond their current avoidance strategies, when they are not working effectively. 'Grounding' strategies help individuals regain control of their responses so that they feel more in control of their actions and can choose their response to their unwanted thoughts and feelings rather than responding on 'autopilot' with avoidance. Self-soothing strategies, including self-compassion, help individuals respond with kindness to themselves, especially in those individuals who have limited experience of this.
Altering negative appraisals via elaboration and contextualisation: Essentially, individuals are encouraged and facilitated to consider elements of the traumatic event that they not have previously have attended to, because the level of distress they experience discourages the required level of reflection and exploration. This may initially include psychoeducation that helps individuals put their symptoms (and their own actions) into context. This can involve gaining an understanding of the physiological and evolutionary basis of their reactions, symptoms, and avoidance strategies. It may also include helping them to constructing a coherent narrative of the traumatic event, as memories are often fragmented, which can aid individuals to contextualise specific distressing elements of their experience, once seen in the whole. Helping individuals see their experiences in as much context as possible and elaborating (adding new information to their memories), by drawing attention to details or perspectives they have not previously been able to consider, increases their ability to shift unhelpful negative appraisals that have formed following the trauma.
Exposure - Habituation: A key element of trauma focused work in CBT, exposure 'works' in two ways. The first is through classic habituation where, by exposing oneself to a feared object/situation/event, whilst ceasing previous strategies to escape the emotional response, fear will initially spike before diminishing, as the mind learns through experience that there is no immediate danger present. This is useful because the current sense of threat is produced by the mind and body responding to mental representations of the trauma (i.e. memories) as though they are the traumatic event itself. Exposure helps the mind recognise that, although unwanted, these mental representations do not pose a threat.
Exposure - Inhibitory Learning: The second way that exposure 'works' is though inhibitory learning. Here the individual learns new associations with the object of their fear which inhibit old ways of responding (i.e. responding fearfully). Examples of how this might work include, violating the individual's expectations of the outcome so that, for e.g., they learn that they could 'cope' with the emotional response (such as fear) they have previously avoided. The presence of these emotions in future encounters are thereful less likely to provoke distress, as a result, even if the emotions themselves are not extinguished, allowing the individual to make non-avoidant choices that do not maintain distress or symptoms.
Values Based Living: In addition to the direct targeting of symptoms, treatment can also help to reorient the survivor to shift from a focus on symptoms towards a focus on values based living. Symptom reduction is valid goal for treatment, but the danger is always that, in focusing entirely on escape from unwanted thoughts and feelings, the avoidant approach of the individual is actually reinforced. Individuals may gain the counterproductive message that strategies from therapy are intended extinguish any and all trauma related thoughts and feelings for good. This is not only unrealistic (as memories will not be 'deleted, and the individual will maintain the capacity to feel the full range of emotions) but counterproductive, with a likelihood of increasing attempts at avoidance. To counter this, we can shift the focus towards taking active steps towards meaningful values and goals in the individual's life.
Willingness to fully engage in exposure work, which is necessarily uncomfortable, can be enhanced by connecting the work to meaningful parts of the individual's life. For e.g., willingness to allow memories into the individual's awareness, rather than having to engage in immediate strategies to suppress them, which may make it difficult to fully engage in what they are doing at any given moment, and prevent the helpful processes of habituation, elaboration and contextualisation, may be increased if doing so can be connected to important parts of their life, such as improved relationships with loved ones. Indeed, a focus on values can facilitate the building of exposure hierarchies (where targets for exposure work are placed in a hierarchy to be worked through - usually from least distressing to most) that actively reconnect the individual with important parts of their life. The potential is to facilitate not only habituation, but inhibitory learning, whereby the individual actively increases their behavioural repertoire, beyond avoidance, in previously triggering situations. Increasing their repertoire (the behaviours available to them) in the presence of uncomfortable thoughts and feelings, the greater their ability to function in line with their values and therefore the greater their overall quality of life is likely to be, which is the ultimate aim of any intervention.
Christian Hughes is a Psychotherapist, and former uniformed military mental health clinician, specialising in Acceptance and Commitment Therapy, Compassion Focused Therapy & CBT, with expertise in trauma & PTSD and a special interest in Moral Injury.