International Society for Traumatic Stress Studies

PTSD Awareness Month: What To Be Aware Of

Posted 2 June 2015 in StressPoints by Damion J. Grasso, PhD

Indeed, along with several other health-related topics, June is PTSD Awareness Month. As I reflect on this, I think about circumstances from my own clinical and academic experiences that highlight how important accurate information about identifying, understanding, and treating PTSD can be to mental health professionals and consumers alike. What follows is a non-exhaustive list of key pieces of information that are particularly salient to me given my work in this area. As experts in the field, we take many of these for granted. It is critical that we extend our conversation beyond our inner circle of experts to reach the broader population –those suffering from the disorder and those charged with identifying and serving these individuals.
 

PTSD is not inevitable after trauma exposure


So many mental health professionals talk about ‘treating trauma’ and refer to trauma victims as impaired, when it is the PTSD that is the impairing component and not the traumatic experience per se. We know that by the time we reach adulthood, most of us will have experienced something that could qualify as potentially traumatic – yet only a small proportion of exposed individuals go on to develop PTSD. It is potentially harmful to talk about trauma as a disorder when it affects the majority of the population. Instead we should focus on what factors help individuals to recover from extreme stress and to show resilient outcomes – and what circumstances (risk factors and lack of protective resources) lead to maladaptive outcomes. Referring to trauma as a disorder sends the wrong message. We not only want to empower victims to identify when they may need professional help and to seek it, but also to identify and utilize existing resources to promote recovery.
 

PTSD is more prevalent in high-risk populations with more chronic, pervasive, and multifaceted trauma exposure

 
On the other hand, expecting that the conditional risk of PTSD in special populations such as child welfare and juvenile justice is the same as the conditional risk in the general population can also be harmful. All children identified by child protective services, for example, have experienced some form of adversity and many, if not most, have experienced at least one potentially traumatic event (but likely many more). The evidence for a dose-response relationship between the number of types of potential trauma and adverse outcomes, including PTSD, is quite strong. Also, chronicity, severity, and timing of trauma exposure all play into the conditional risk for PTSD. We need to recognize that in certain high-risk populations, a large proportion of individuals will require professional attention to treat trauma-related mental health problems. Unfortunately, in many of the systems that serve these populations, mechanisms of identifying and addressing trauma-related problems are suboptimal. 
 

PTSD is not the only possible consequence of trauma exposure

 
Trauma exposure, especially when it is chronic, pervasive, multifaceted, and occurs in childhood, is associated with a host of physical and mental health problems. Symptoms need not present like and meet criteria for PTSD to be trauma-related and impairing. Thus, it is not sufficient to rule out PTSD without considering other possible trauma-related symptom presentations – especially in the high-risk populations referenced above. Trauma and PTSD screening does not satisfy the need for broad-based mental health screening.
 

Exposure-based treatment of PTSD, while effective, may seem counterintuitive

 
Exposure-based treatment is hard – perhaps harder than we can really appreciate as providers. Drop out rates for these treatments remain quite high. We need to do a better job at promoting these evidence-based approaches and doing all that we can do to motivate treatment and acknowledge and reward treatment gains. At the onset of therapy we provide patients with a rationale for treatment. This is critical and helps to engage them; however, perhaps we should be doing this much sooner. Pharmaceutical mental health treatments are advertised widely on popular media outlets. I would venture to say that while many could identify a psychopharmacological agent, few could describe effective behavioral approaches for treating PTSD (or behavioral treatments more generally). Also, exposure-based therapies sound frightening. No one wants to engage in revisiting the very memory that they have been working so hard to avoid. We need to change the image of exposure-based therapy, emphasizing the potential benefits of therapy. While we may not have the money to fund television commercials, we can be creative. Just recently I had a breakthrough moment with trauma-exposed foster care youth who are part of a trauma-informed group mentoring program I’ve developed. In one of our didactic sessions we were discussing PTSD as a potential consequence of trauma exposure. One of my newer youth leaders spoke up and shared his history of chronic physical abuse and witnessing domestic violence. He shared with the group some of the psychological problems he experienced and attributed to his abuse. He explained to the group that he was just starting “trauma therapy.” He shared that while he felt nervous about it, he was eager to give it a shot and willing to work hard at it. His sharing this perspective resonated strong with the other youth, some of whom I’m sure have previously resisted engaging in psychotherapy. This observation opened my eyes to how powerful this type of promotion can be, especially among young people who face such high mental health stigma.
 

You are part of the trauma narrative

 
Several months ago I was part of a team of professionals who provided a training to police officers on the potential consequences of children’s exposure to domestic violence and ways to engage with and minimize the burden faced by these children and their families. During my portion I covered the possible consequences of witnessing domestic violence, including the possibility of developing PTSD. I explained some of the risk factors of developing PTSD, as well as how we think individuals who do not develop PTSD use their personal and social resources to recover. I also explained exposure-based intervention approaches, including developing or focusing on the trauma narrative. I stressed to the officers that each one of them functioned as a critical part of the child’s trauma narrative and that the way they handle children and their families in domestic violence situations can either help or hinder recovery and outcomes. This resonated with the officers who later told me that they had never fully realized the importance of their contact with the child. I think that regardless of our role, when we interact with a child during or following a potential trauma, we are part of the narrative. Knowing this should remind us to be mindful of our approach in these situations.
 

PTSD can affect the family

 
With all of the work necessary to treat an individual with PTSD, it is easy to forget the unique needs of their family – their spouse, children, caregivers. There is ample evidence associating PTSD with impaired caregiving, partner conflict, and residual problems in family functioning. A criticism of mental health intervention, more generally, is that we often don’t take a holistic, comprehensive approach to addressing the needs of families. I can think of numerous examples from my own work that highlight the needs of family members who have a loved one with PTSD. For example, during a session with a combat veteran and his wife I learned that his toddler-age daughter witnessed him experiencing a ‘flashback,’ ducking behind bushes in the backyard with a pistol in his hand. Reportedly, the child was later confused and asking a lot of questions. The family sought my advice on what they should tell the child. In another situation I was treating a preadolescent boy with PTSD secondary to physical abuse. His mother, who was also a victim of the violence, was well engaged in her son’s therapy. However, as she observed her son’s developing trauma narrative and reacted to it, it became clear that she needed her own therapy to work through her own trauma-related symptoms. It also became clear that she needed more support at home, especially given that the boy’s behavior had temporary worsened during the trauma narrative phase of treatment (a typical and anticipated phenomenon). I experienced this first-hand as a foster parent for a teenage youth with an extensive trauma history and who was engaged in trauma-focused therapy. Even though my wife and I were both mental health professionals, we needed a lot of professional support to, quite frankly, prevent his placement with us from disrupting and fully support the youth in treatment. The emotional turmoil our foster son experienced affected us personally and made it very difficult to step out of the situation and see it as we would in our mental health professional roles. I realized then that I had been underestimating the impact that trauma and its consequences can have on the families of victims – and how much support they actually need. 
 

Summary

 
My objective for this blog piece was to initiate a dialogue on how we might focus our energy towards raising awareness. Of course, raising awareness about trauma and PTSD should be something we do all the time – not just during PTSD awareness month. The task is not trivial. There is a lot of misinformation that exists and it is often perpetuated. Let’s use this month to brainstorm ways we can improve our work as educators and advocates for trauma recovery and treatment. Please comment here or on social media to share your thoughts and/or experiences and to add to this important dialogue on what we can do as experts in the field to raise awareness of PTSD and promote good practice.
 
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Damion J. Grasso, PhD
is Editor of the ISTSS website and is an Assistant Professor at the University of Connecticut school of Medicine, Departments of Psychiatry and Pediatrics. His work focuses broadly on biological and environmental mechanisms involved in the relationship between cumulative exposure to extreme stress and child psychopathology. Dr. Grasso has also been very involved in developing resources for assessing and treating PTSD in children and adolescents; see a recent clinical resource, Clinical Exercises for Treating Traumatic Stress in Children and Adolescents: Practical Guidance and Ready-to-use resources.