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Counseling for Post Traumatic Stress Disorder (PTSD) and Emotional Abuse

by Laurie Hartlein

Liberty University

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Counselor Identity, Function, and Ethics in treating PTSD The role and responsibility of a counselor can be a heavy professional burden. Marini and Stebnicki (p.16, 2008) state that the primary role of a Counselor is to assist clients in reaching their optimal level of psychosocial functioning through resolving negative patterns, prevention, rehabilitation, and improving quality of life (Marini, Stebnicki, p. 16, 2008). Counselor Identity is when the professional focuses on the strengthening and wellness of those suffering. However, in dealing with the seriousness of PTSD and emotional abuse, Wilson, Friedman, and Lindy (2004) contend that trauma can transform individual identity and drain a therapists inner empathic resources. Tick (2005) explains the horror of PTSD. He says that to be angry at the world, jump at the slightest sound or quick movement, and live within ones own mind because you know that no one would understand or try to help is to live in hell. According to Marini and Stebnicki (2008), counselor function involves screening the client and determining appropriate ways of helping them to achieve personal goals. Counselors can assist clients with PTSD or those suffering from emotional abuse in a variety of settings. Marini and Stebnicki (2008) emphasize that in any case or setting, emotional memories are forever and a trusting relationship must be developed between the therapist and client. Corey, Corey, and Callahan (p.9, 2011) explain that ethics is concerned with the standards that regulate the behavior and demeanor of its trained professionals (Corey, Corey, & Callanan, p.9, 2011). Counselor ethics involves knowing and understanding codes for individual states and providing care according to those codes. Corey, Corey, and Callanan (2011) maintain that codes of ethics objectives are to educate professionals, provide a mechanism for accountability, and help improve practice.

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ABSTRACT Post Traumatic Stress Disorder (PTSD) impacts Veterans of past and modern warfare by causing distress in every aspect of their lives. PTSD is currently treated using psychodynamic, cognitivebehavioral, and pharmacological approaches. However, new forms of treatment such as using Virtual Reality offer new hope for recovering Veterans. PTSD not only affects the returning Veteran but family members as well. They often suffer forms of abuse in conjunction to living with a PTSD victim. Families are often subjected to emotional abuse. This form of abuse serves as a reminder of how people use fear, humiliation, verbal and/or physical assaults to control another human being. A wide range of psychotherapy is often used in treating victims of both PTSD and emotional abuse. The following research explores treatment options for both PTSD and emotional abuse while analyzing the relationship between their symptoms.

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At the present time, the complexity of Post Traumatic Stress Disorder (PTSD) raises more questions than science can answer (Wilson, Friedman, Lindy, 2004). PTSD occurs when an individual is directly exposed to a traumatic event. Catherall (p. 1, 2004) explains that the Greek translation of trauma is wounding. Today, trauma has reached epic proportions due to the increase of violence in society and the world in general (Seahorn and Seahorn, 2008). It is often the result of an extreme experience that can violate three basic premises: the belief in personal invulnerability, the perception of the world as meaningful, and the positive view of self (Balk, 2001). Clear biological changes occur within the persons body and mind. A complete transformation of individual identity can also occur, as well as, physical illness, accompanied by fear, anxiety, and frustration. Post Traumatic Stress Disorder is a common illness and currently affects 5.2 million Americans (Seahorn and Seahorn, 2008). Throughout the history of warfare, PTSD has had many names. Civil War veterans referred to it as Irritable Heart. World War I and II veterans called it Shell Shock. Other terms that have been used to describe PTSD are Neurosis, Combat Fatigue, or Combat Exhaustion (Seahorn and Seahorn, P.66, 2008). It was not until the Vietnam War that the medical field began to recognize PTSD as a disorder. However, early research on the impact of stress to the human body started with Freud. Wilson, Friedman, and Lindy state that in Freuds Beyond the Pleasure Principle (1920), he worked diligently to differentiate between traumatic neuroses and its relationship to ego defense, anxiety, the concept of the stimulus barrier, and threat anticipation (Wilson, Friedman, and Lindy, p.4, 2004). PTSD starts by first affecting the brain. The neurotransmitters Cortisol and Adrenaline are released when a person is in a situation that requires the fight, flight, or freeze response (Seahorn and Seahorn, p.87, 2008). However, extreme stress causes neural cell death in relation to excessive cortisol

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secretion. Seahorn and Seahorn continue that there are many characteristics of PTSD and symptoms often appear quickly without warning. These symptoms include but are not limited to: hyperarousal, nightmares, insomnia, flashbacks, panic attacks, fear, avoidance, anger, and hopelessness (Seahorn and Seahorn, 2008). PTSD differs from other disorders because it has a larger fear system that is easily activated and often has more severe responses. Many people have problems readjusting to life after experiencing trauma (Seahorn and Seahorn, 2008). Therefore, the rate of recovery after a traumatic event varies among individuals. Cognitive-Behavioral Therapy (CBT) is commonly used for treating PTSD. Follette and Ruzek (2006) explain that there are four common forms of the therapy. They include, Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PE), and Eye Movement Desensitization and Reprocessing (EMDR). Kern (2010) maintains that two individuals, Dr. Patricia A. Resick, PhD and Monika Schnicke, MA developed CPT to specifically treat Post Traumatic Stress Disorder. Follette and Ruzek (2006) state that Cognitive-Processing Therapy (CPT) addresses emotions other than fear and helps the client create a balance for traumatic memories. A course of twelve sessions is usually required in order for the clients goals to be reached. The initial session of Cognitive Processing Therapy explains the symptoms of PTSD to the client. Next the severity of symptoms is measured using the Stressor Specific Version Checklist (PCL-S). Afterwards, the client is asked to write about the traumatic event and why he/she believes the event happened (Follette and Ruzek, 2006). Kern explains that the client is then asked to read the story aloud, often more than once. Errors in thinking such as I am a bad person or Maybe I deserved this are identified and addressed. The therapist helps the client understand these thoughts and to replace them with more positive, realistic thoughts. Kern (2010) states that these

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types of restructuring exercises help the client reassess their thought process and structure it to be more productive. Rothbaum and Schwartz (2002) explain another type of therapy known as Prolonged Exposure Therapy (PE). This is sometimes referred to as imaginal, in vivo, or directed therapy. This type of therapy allows the client to confront the source of their fear using a safe, yet continuous stimulus until their anxiety is alleviated. This type of stimulus helps to reduce avoidance behaviors. Exposure therapy has been proven both safe and effective in the treatment of PTSD (Rothbaum and Schwartz, 2002). Virtual Reality (VR) is a more recent form of exposure therapy that uses computer generated views that change naturally with the clients head motion. According to Rothbaum and Schwartz (2002), during VR sessions patients wear a head mounted display with earphones. A scent machine is used to create the smell of gunpowder while another machine creates vibrations that simulate explosion vibrations. The client is then exposed to the simulations of a combat situation. Rothbaum and Schwartz (2002) further state that the client should be exposed long enough to allow their anxiety to decrease. They caution counselors about using short exposures because it could potentially intensify the clients sensitivity thus causing an increase in fear. However, Rothbaum and Schwartz (2002) maintain that clients should be allowed to progress at their own pace. Exposure therapy helps clients learn not to fear traumatic memories even if they sometimes experience strong feelings. Eye movement desensitization and reprocessing (EMDR) was developed in 1989 by Dr. Francine Shapiro. This is a comprehensive approach that uses eight phases to address past, present, and future traumatic memories. According to Shapiro (2001), Phase I establishes the clients history and identifies specific targets along with the treatment plan. Phase II requires the client to choose a positive image that will promote comfort if the session becomes too upsetting.

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In Phase III, the client identifies a negative image or emotion that will be the target of the EMDR therapy. Shapiro (2001) further explains that Phase IV begins the treatment plan by having the client focus on the negative image or feeling. The therapist will ask the client to follow an object that is moving from side to side with his or her eyes. After several eye movements, the client briefly describes the thoughts or feelings that are being experienced. This phase will end when the clients anxiety or stress level has diminished. According to Shapiro (2001), Phase V is also called the installation phase where the therapist asks the client to focus on the positive image that was identified in Phase III. A new set of eye movements begin and the client is asked to describe on a scale from 1 to 7 how the positive image makes them feel. In Phase VI, a body scan is conducted and the client is asked to identify any body pain or discomfort. The therapist asks the client to focus on the pain and new eye movements begin. Phase VII is considered debriefing where support and information is offered to the client. Phase VIII is the final phase and is often referred to as re-evaluation. This phase is actually the beginning of the next session and the client reviews the previous weeks session and also discusses any new feelings that may have occurred (Shapiro, 2001). Shapiro (2001) contends that clients generally experience a relief in stressful thoughts and emotions following EMDR procedures. Family members and spouses of PTSD sufferers often feel the ripple effect of trauma as the Veteran displays disturbing behavior. According to Seahorn and Seahorn (p. 101, 2008), anger, fear, and aggression can often be triggered by sights, sounds, and even smells. Families desperately try to comfort and heal their loved one and often equate their experiences as walking on egg shells. This frequently causes family members to experience anxiety, worry, and sensitivity. The National Center for PTSD (2001) reports that the National Vietnam Veterans Readjustment Study (NVVRS) revealed that Vietnam Veterans with PTSD were twice as likely

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to experience divorce and often divorced two or more times. These people were also more inclined to have shorter relationships. Family members and spouses also experience physical and emotional abuse from their loved one suffering from PTSD. Treatment options for families include support groups, family counseling, and individual counseling (National Center for PTSD, 2011). When dealing with PTSD and forms of abuse, family members often become secondary trauma victims. According to Loring (1994), emotional abuse causes the most pain and is often the detrimental to a persons self-esteem. Smullens (2002) conveys that emotional abuse statistics are often hard to obtain because it is usually masked by other issues and unlike physical abuse, the scarring is on the inside of a person. The American Psychiatric Association (APA) (1987) states that the suffering inflicted on victims of emotional abuse is as intense and pervasive as that experienced by other trauma victims; it can lead to a diminished or annihilated sense of self and to the terror that is characteristic of PTSD. According to the University of Illinois Counseling Center (2008), emotional abuse is the use of fear, humiliation, and verbal assaults projected onto another human being so that control of that person is maintained. The pattern of emotional abuse generally includes aggressing, denying, and minimizing. Aggressing takes the form of name-calling, threatening, blaming, and criticizing. Denying occurs when the abuser fails to acknowledge reality and refuses to listen or communicate. Minimizing is a less invasive form of denial. The abuser will often criticize the victims emotions and accuse them of taking things the wrong way (The University of Illinois, 2008). Smullens (2002) believes there are five separate cycles of emotional abuse. The first cycle is rage. This type of anger frightens family members and renders them into a state of helplessness. Enmeshment is the second cycle. This cycle causes an individual to be unable to

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function outside of the family circle. The family is considered a unit and autonomy is not allowed. Rejection is the third cycle where love is withdrawn from the victim. The fourth cycle is complete neglect and emotional attachment does not exist. The fifth and final cycle is extreme overprotection. This cycle of emotional abuse comes from overprotection inside a family unit. Family members cannot function as an individual (Smullens, 2002). Loring (1994) contends there are four components in working with emotionally abused clients. They include therapeutic stance, therapeutic endeavor, therapeutic modality, and transformation. Therapeutic stance is also known as the therapeutic relationship between the therapist and the client. Gilbert and Leahy (2007) describe this relationship as the healer and sufferer and they contend that it is the key to success. She emphasizes the importance of learning about the clients interests, talents and dreams in order to instill hope. According to Loring (1994), the therapeutic endeavor consists of an empathic connection, recognition of abuse components, and the process of working through the trauma. She further highlights the importance of exploration, clarification, reassurance, and encouragement during the cycle of therapeutic endeavor. Transforming the clients self is the most important part of therapeutic endeavor. Therapeutic modality is merely choosing the path and form that therapy will take on. Transformation is the merging of hope and coping skills and provides clients with the ability to move past the abuse they have endured (Loring 1994). In todays society, Christian counseling is often judged as being trivial. According to the website, www.christianpsych.org (2010), therapists require concrete examples of using scriptures while maintaining a therapeutic environment. There are a few scriptures that can assist with the enormous task of comforting those with disorders such as PTSD. Psalm 46:1 states, God is our refuge and strength, a very present help in trouble (The Holy Bible, King James Version, 1978).

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Psalm 57:1 proclaims, Be merciful unto me, O God, be merciful unto me: for my soul trusteth in thee: yea, in the shadow of thy wings will I make my refuge, until these calamities be overpast (The Holy Bible, 1978). Brokenness is everywhere and no one escapes the trials of this fallen world. Christian counselors must carefully engage scripture in the healing process without causing the client to feel that they are imposing their values onto the client. 1 Peter 3:7 and Ephesians 6:4 are two examples of scriptures that would be excellent for use with abuse victims. 1 Peter 3:7 states, Likewise, ye husbands, dwell with them according to knowledge, giving honour unto the wife, as unto the weaker vessel, and as being heirs together of the grace of life; that your prayers be not hindered (The Holy Bible, 1978). Ephesians 6:4 also states: And, ye fathers, provoke not your children to wrath: but bring them up in the nurture and admonition of the Lord (The Holy Bible, 1978). The techniques used by Christian counselors should always be Christ-centered and Bible-based. Personal Reflection As human beings, suffering is inevitable. We often inflict pain on each other in one form or another along with the suffering that is already imposed upon us by our environment. As a Christian Counselor, I am reminded daily that my heart is being directed by God to provide care and healing to those suffering. I must keep in mind that empathy and a trusting relationship with my client are the roots for the foundation of healing.

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CONCLUSION Post Traumatic Stress Disorder impacts veteran of past and modern warfare. Emotional abusers use forms of fear, humiliation, verbal, and/or physical assaults to control another human being. Doctors, clinicians, and researchers face numerous obstacles in the attempt to understand and treat PTSD. The extraordinary hurdles faced by the patients and families are even more overwhelming. Different forms of abuse and disorders wreak havoc on human lives every day. It is a counselors job to provide comfort, encouragement and strategies for coping with disorders and disabilities.

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REFERENCES Balk, J. L. (2001, November 1). Eye movement desensitization and reprocessing (EMDR) for post-traumatic stress disorder. Alternative Medicine Alert. Retrieved March 31, 2011, from Www.highbeam.com. Catherall, D. R. (2004). Handbook of stress, trauma, and the family. N.Y., NY: BrunnerRoutledge. Corey, G., Corey, M. S., & Callanan, P. (2011). Issues and ethics in the helping professions (8th ed.). Australia: Brooks/Cole/Cengage Learning. Emotional Abuse. (1987). American Psychiatric Association. Retrieved April 01, 2011, from http://www.psych.org/ Follette, V. M., & Ruzek, J. I. (2006). Cognitive-Behavioral Therapies for Trauma (2nd Edition). New York, NY: Guilford Press. Retrieved March 27, 2011, from Www.ebrary.com. Gilbert, P., & Leahy, R. L. (2007). The therapeutic relationship in the cognitive behavioral psychotherapies. London: Routledge. Kern, T. (2010). Cognitive processing therapy for PTSD. Annals of the American Psycholtherapy Association. Retrieved March 29, 2011, from Www.highbeam.com. Loring, M. T. (1994). Emotional abuse. New York: Lexington Books. Marini, I., & Stebnicki, M. A. (Eds.). (2008). The professional counselor's desk reference. New York: Springer Pub.

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Partners of Veterans with PTSD: Common Problems - National Center for PTSD. (2011, February 17). National Center for PTSD Home. Retrieved March 26, 2011, from http://www.ptsd.va.gov/public/pages/partners-of-vets.asp Rothbaum, B. O., & Schwartz, A. C. (2002). Exposure therapy for posttraumatic stress disorder. American Journal of Psychotherapy. Retrieved March 30, 2011, from Www.highbeam.com. Scott, M. J., & Stradling, S. G. (2006). Counseling for Post-Traumatic Stress Disorder (3rd Ed). U.S.: SAGE. Seahorn, J. J., & Seahorn, E. A. (2010). Tears of a warrior: a family's story of combat and living with PTSD. Fort Collins, CO: Team Pursuits. Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures (2nd ed.). New York, NY: Guilford Press. Smullens, S. (2002). The 5 cycles of emotional abuse: investigating a malignant victimization. Annals of the American Psychotherapy Association. Retrieved March 8, 2011, from Highbeam Research.

Society for Christian Psychology. (n.d.). Retrieved April 4, 2011, from www.christianpsych.org

The Holy Bible: containing the Old and New Testaments ; translated out of the original tongues and with the former translations diligently compared and revised ; commonly known as the Authorized (King James) version. (1978). [Nashville, Tenn.]: Gideons International.

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Tick, E. (2005). War and the soul: healing our nation's veterans from post-traumatic stress disorder. Wheaton, IL: Quest Books. Trustees, B. O. (2008, January 11). Counseling Center Emotional Abuse. Counseling Center of the University of Illinois. Retrieved March 6, 2011, from http://www.counselingcenter.illinois.edu/?page_id=168 What is PTSD? (2011, February 24). National Center for PTSD Home. Retrieved March 4, 2011, from http://www.ptsd.va.gov/ Wilson, J. P., Friedman, M. J., & Lindy, J. D. (2001). Treating psychological trauma and PTSD. New York: Guilford Press.