For nurses and social workers
give words to feelings not expressed or for things for which are no words for
Because survivors and clients with mainly PTSD often avoid their feelings and thoughts concerning the trauma, it is better to be focused on feelings and thoughts someone avoids mainly due to shame. Listen more and offer less solutions or advice. Talk more about feelings than just talk about clinical facts about what happened. Keep in mind that your task is not that of a policeman. So do not talk about details, deprived of feelings, but rather what someone avoids. What both often seem to do - both victims and mental health workers - is not talking about shameful feelings, because workers often fear that clients get confused or decompensate. Often motivated by the thought not to trouble
the client or not knowing what to do or say. Seeking distraction doesn't lessen the flashbacks, nor does increasing medication regulates the flashbacks. Concerning psychosis ask "what happened to you" and what the content of psychosis is. Talking about it doesn't worsen the psychosis. It is better to cry than to watch TV. The central problem is avoidance. Create trust and a emotionally safe atmosphere. Be aware of suicide thoughts during a crisis, furthermore don't be scared to ask about why and how when addressing suicide thoughts and be aware of a possible addiction or excessive use of alcohol.
Help with recent disasters or traumas:
Although it seems logical intuitively, EMDR and exposure with clients who have had a recent traumatic experience is not advisable. The reason for this is that it can cause PTSS. It is better to provide security and assistance with needs. We must focus on developing resilience and give information. Information which makes clear that it is
normal to be anxious, distressed and angry is needed. Giving support and informing bystanders and relatives in order to provide better support is important, in which we do not unnecessarily isolate the client with his / her emotions. Anger and fear are normal feelings that needs to be expressed.
Oxytocin as a therapeutic agent
The study showed that 85% of people with treatment-resistant PTSD recovered as they were given ecstasy along with psychotherapy. Of those who received only psychotherapy and a placebo, just 15% recovered. It is a small group to make any statements about the effects of ecstasy in PTSD, but there are further investigations planned in Switzerland and Israel. Perhaps even more important is the fact that when patients were checked after two months after treatment, 83% of them do not even have a diagnosis of PTSD. And three to five years later, this improvement was still present with no signs of long-term health problems associated with MDMA.
The studies are often quite small in scope.
Still, it is worth considering setting up adouble-blind RCT, as there seems to be a group that often do not benefit from therapy because of their sometimes negative or hostile attitude. Because of the dangers of consumer use in the 80s (War On Drugs USA) these studies disappeared on the shelves. Yet clients who proved therapy-resistant showed a good response and some were free of symptoms. Now that we know that MDMA also produces oxytocin in addition to the antidiuretic hormone, it is the question whether administering oxitocin during therapy also helps clients who have a negative respons and are usually resistant to therapy
Evidence-based treatment of PTSD
Much research has been conducted into the effectiveness of treatment for PTSD.
Effectiveness of treatment for PTSD:
Since the early 80s of the last century the diagnosis of posttraumatic stress disorder (PTSD) is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), there is a lot of research done into the effectiveness of treatment for PTSD. Early this century, it led nationally and internationally to the drafting of guidelines for the treatment of chronic PTSD.
Trauma Focused Cognitive Behavioral Therapy (TF-CBT)
Eye movement desensitization and reprocessing (EMDR) and Brief Eclectic Psychotherapy for PTSD (BEPP) is recommended as a treatment of choice. For patients and clinicians, this is good news because they together can choose the treatment that offers the greatest chance of success.
Source: Foundation Centre '45
Onno van der Hart; Psychologist psychotherapist
Emeritus professor of psychopathology of chronic traumatization
Source: The realization of early childhood traumatization: A challenge against the tide
Onno van der Hart.
"We tend to turn away from everything that's unpleasant."
Marek Edelman (2011, p. 125)
In the psychiatry and mental health care, people with a history of serious and prolonged child abuse, abuse and / or neglect - briefly, early childhood chronic traumatization - often considered to be the most complicated and difficult to treat clients. This is certainly the case with those whose early childhood chronic traumatization led to the origin and survival of the dissociative identity disorder (DIS). This article deals with a number of factors that seriously complicate the recognition of such chronic traumatization and the treatment of its consequences, especially with these clients.
Survivors suffer intense by their ever-reactivated traumatic memories of this chronic traumatization, for which they did not receive help or support as a child and, as adults, often in vain for help. Many of them say that their suffering is often strengthened by the treatment they receive in health care. If they are lucky, these people come to specialist psychotherapists who have been involved in the diagnosis and treatment of the effects of early childhood chronic traumatization. By the time it is so far, however, for many, the hope of progress has largely hit the bottom, they lead an isolated existence, they feel chased and suicidal. At least this is the image I gained over the years on the basis of countless personal testimonies. In the daily
(and nightly) lives of people with a history of early childhood chronic traumatization, an alternation usually occurs between being traumatized by their traumatic experiences and, on the other h"We tend to turn away from everything that's unpleasant."
and, a strong avoidance of it and trying to force it to lead such a normal life : A life characterized by being unable to realize what has been done to them and what its consequences are (non-realization, according to Janet, 1935). This non-realization of the traumatic past prevents them from fully utilizing and developing their qualities and possibilities in ordinary life. In the case of auxiliary workers, there is often a parallel tension between being overwhelmed by the suffering of these clients and the tendency to conclude. Therefore, not only the clients themselves resort to denying and trivializing the terrible reality of the traumatic experiences, but also their families, perpetrators inside or outside the family. Although change appears to be beneficial, professionals with whom they can get - 4
Careers in the (mental) healthcare and sometimes also pastors - and society as a whole is still too much characterized. In this regard, ignorance and care workers can play an important role in the lack of education in this field.
Survivors of chronic childhood traumatization experience great difficulties in realizing such overwhelming harm. Not only as children couldn’t this be brought home, as adults they encounter many factors from within and outside against such realization. A major factor in this non-realization is the dissociation of their personality, characterized by experiencing too little and too much of the trauma. Within the family, the perpetrators of the abuse and other members usually deny the horrible abuse.
Also within the Church and the health care system the tendency to avoid this reality and thus to leave them at their fate often is strongly present. When it becomes clear that chronic traumatization is at the roots of survivors’ suffering and therapists are willing to help them gradually transform the trauma into past perfect, the obstacles in this process are legion. When this process is undertaken, it needs to be accompanied by fostering life and a future perspective instead of survival.
Reliability; reports of child abuse
For an inexperienced worker it is difficult or almost impossible to make a reliable statement about reports of child abuse. Stories from clients suffering from psychosis are seen to arise from their psychotic experiences or are as not trustworthy because of their psychotic biases. Their veracity would be one that one suspect that it might not happened. But as experience show, these reports (92% report trauma) are quite reliable. Yet there are several behaviors, symptoms (distress) and descriptions known to victims to determine with reasonable certainty child abuse. The known literature provides sufficient background. It is only the question of whether social workers want to make this personal. That child abuse or trauma is not often educated in training for psychologists and psychiatrists is unfortunately often the case. Often many consider these mental health workers as specialists and there seems to be not many. Yet the figures show rather to discard not so much as a specialty, but to be a general knowledge they should acquire. That biases in cognition also occur in other disorders, is often not mentioned. For example, reports of people with social phobia show that they think others in the area are all watching them, for example while shopping. In reality it is not so. Cognitive biases are also known in depression. Also normal people and known by every policeman show biases in witness reports of an crime. Fear or anxiety also distorts the perception. The question we must ask ourselves more is, why we don't question the reliability of experiences of
clients with depression, addiction or anxiety or phobia. Also the perception of people with PTSD plays a role, and in such a way that the perception is rather biased and individual. Not only perception is subject to bias, but also the recollection of what happened. Fortunately, most people do not have such biases that what really happened is not true. Again it's about margins. No one can objectively observe 100% or 100% recall objectively. Our brains are made so that we can reasonably rely on it. Similarly our memory. The task of mental health workers is to see the total picture or context of behavior, signs and symptoms that child abuse can be determined with reasonable certainty. But social workers who are not confronted with victims can sometimes doubt their stories because of the bizarre/ shocking and strange details. This is often sparked by the assumption that people with psychotic symptoms are confused and that it didn't seem to happen of is being imagined. These doubts and assumptions often arise from incompetence and lack of experience. Therapists should not take on the role of a policeman judging the truth. We do not act this way regarding to stories of clients with depression, anxiety or other disorder. Again, I rather think that the number of false-negatives is greater than the number of false positives of documented reports of child abuse. Not mentioning whether these experiences are indeed well documented. But as long as the number of missed reports is greater, this is grist to the mill of pedophiles and will not lead to police reports. It is more about margins.
The importance of a structured interview
Many professionals are convinced that examining the complaints on the basis of the DSM-5 is important. But many believe that a client will tell their experiences when a cooperative relationship is established. But actually asking about traumatic experiences should be done with the same commitment as in a anamneses. Without forcing to tell about it and with an open mind, we must picture the course of life, including etiology and symptoms associated with the experiences of the client. It is important not to ask suggestive questions, but that the client themselves reply that they are abused or molested. Indications include problems during school, such as performance, concentration, dissociative behavior, symptoms such as abdominal pain, anxiety, nightmares, problems with sexuality and in children; knowledge of sex that does not suit their age, being sticky or want to be alone, confusion about sexual orientation, suicidal thoughts, auto mutilation, bedwetting, but also not reported hospitalizations.
But above all how the abuse has changed the image of self and others. It is particularly important to determine at what age the abuse began and how long it lasted. Who were the perpetrators, can we identify the symptoms and the beginning of the abuse. Was the child believed and protected when the abuse was mentioned and how did people and others react. Often child sexual abuse is accompanied with physical abuse or emotional neglect. Concerning male victims we must take into account under-reporting by greater feelings of shame and often because they minimize the consequences. The fact that a diagnosis is associated with a particular methodology, so it should also apply to picture the experiences. We live in a time that genes and brain abnormalities set the tone, but we forget how pervasive social and societal factors such as trauma can have a major impact on the development of disorders. It is the task of clinician to disentangle the shared nurture in relation to the diagnosis.
Meta-analysis fMRI; volume hypocampale structure
Hypocampale structures according to a meta-analysis of fMRI studies are smaller in groups exposed to traumatic experiences regardless of the occurrence of PTSD, while additional decrease of hypocampale structures in PTSD was greater.
From other studies appear to go out from a certain favorable effect of medication such as SSRIs
From Scientific American:
The results of EMDR are not better than exposure therapy, that has been used for years by Cognitive Behavior therapists. It also appears that following a finger or listen alternately to clicks doesn't substantially contribute to the success. Briefly EMDR and exposure therapy score all both about the same. EMDR works better than no treatment and better than listening comprehension.