Counselling for Post-Traumatic Stress Disorder


Michael J. Scott & Stephen G. Stradling

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  • Chapters
  • Front Matter
  • Back Matter
  • Subject Index
  • Part 1: Theoretical Background

    Part 2: Applications

    Part 3: Postscript

  • Counselling in Practice

    Series editor: Windy Dryden

    Associate editor: E. Thomas Dowd

    Counselling in Practice is a series of books developed especially for counsellors and students of counselling, which provides practical, accessible guidelines for dealing with clients with specific, but very common, problems. Books in this series have become recognised as classic texts in their field, and include:

    Counselling for Eating Disorders, second edition

    Sara Gilbert

    Career Counselling, second edition

    Robert Nathan and Linda Hill

    Counselling Survivors of Childhood Sexual Abuse, third edition

    Claire Burke Draucker and Donna Martsolf

    Counselling for Depression, second edition

    Paul Gilbert

    Counselling for Alcohol Problems, second edition

    Richard Velleman

    Counselling for Anxiety Problems, second edition

    Diana Sanders and Frank Wills

    Counselling for Family Problems

    Eddy Street

    Counselling for Stress Problems

    Stephen Palmer and Windy Dryden

    Counselling for Grief and Bereavement

    Geraldine M. Humphrey and David G. Zimpfer

    Counselling Couples

    Donald L. Bubenzer and John D. West

    Counselling for Psychosomatic Problems

    Diana Sanders

    Counselling People on Prescribed Drugs

    Diane Hammersley

    Counselling for Fertility Problems

    Jane Read

    Counselling People with Communication Problems

    Peggy Dalton

    Counselling with Dreams and Nightmares

    Delia Cushway and Robyn Sewell


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  • Appendix 1: The Penn Inventory



    On this questionnaire are groups of statements. Please read each group of statements carefully. Then pick out the one statement in each group which best describes the way you have been feeling during the PAST WEEK, INCLUDING TODAY! Circle the number beside the statement you picked. Be sure to read all the statements in each group before making your choice.

      • I don't feel much different from most other people my age.
      • I feel somewhat different from most other people my age.
      • I feel so different from most other people my age that I choose pretty carefully who I'll be with and when.
      • I feel so totally alien to most other people my age that I stay away from all of them at all costs.
      • I care as much about the consequences of what I'm doing as most other people.
      • I care less about the consequences of what I'm doing than most other people.
      • I care much less about the consequences of what I'm doing than most other people.
      • Often I think, ‘let the consequences be damned!’ because I don't care about them at all.
      • When I want to do something for enjoyment I can find someone to join me if I want to.
      • I'm able to do something for enjoyment even when I can't find someone to join me.
      • I lose interest in doing things for enjoyment when there's no one to join me.
      • I have no interest in doing anything for enjoyment when there's no one to join me.
      • I rarely feel jumpy or uptight.
      • I sometimes feel jumpy or uptight.
      • I often feel jumpy or uptight.
      • I feel jumpy or uptight all the time.
      • I know someone nearby who really understands me.
      • I'm not sure there's anyone nearby who really understands me.
      • I'm worried because no one nearby really seems to understand me.
      • I'm extremely disturbed that no one nearby understands me at all.
      • I'm not afraid to show my anger because it's no worse or better than anyone else's.
      • I'm sometimes afraid to show my anger because it goes up quicker than other people's.
      • I'm often afraid to show my anger because it might turn to violence.
      • I'm so afraid of becoming violent that I never allow myself to show anger at all.
      • I don't have any past traumas to feel overly anxious about.
      • When something reminds me of my past traumas I feel anxious but can tolerate it.
      • When something reminds me of my past traumas I feel very anxious but can use special ways to tolerate it.
      • When something reminds me of my past traumas I feel so anxious I can hardly stand it and have no ways to tolerate it.
      • I have not re-experienced a flashback to a trauma event ‘as if I was there again’.
      • I have re-experienced a flashback to a trauma event ‘as if I was there again’ for a few minutes or less.
      • My re-experiencing of a flashback to a trauma event sometimes lasts the better part of an hour.
      • My re-experiencing of a flashback to a trauma event often lasts for an hour or more.
      • I am less easily distracted than ever.
      • I am as easily distracted as ever.
      • I am more easily distracted than ever.
      • I feel distracted all the time.
      • My spiritual life provides more meaning than it used to.
      • My spiritual life provides about as much meaning as it used to.
      • My spiritual life provides less meaning than it used to.
      • I don't care about my spiritual life.
      • I can concentrate better than ever.
      • I can concentrate about as well as ever.
      • I can't concentrate as well as I used to.
      • I can't concentrate at all.
      • I've told a friend or family member about the important parts of my most traumatic experiences.
      • I've had to be careful in choosing the parts of my traumatic experiences to tell friends or family members.
      • Some parts of my traumatic experiences are so hard to understand that I've said almost nothing about them to anyone.
      • No one could possibly understand the traumatic experiences I've had to live with.
      • I generally don't have nightmares.
      • My nightmares are less troubling than they were.
      • My nightmares are just as troubling as they were.
      • My nightmares are more troubling than they were.
      • I don't feel confused about my life.
      • I feel less confused about my life than I used to.
      • I feel just as confused about my life as I used to.
      • I feel more confused about my life than I used to.
      • I know myself better than I used to.
      • I know myself about as well as I used to.
      • I don't know myself as well as I used to.
      • I feel that I don't know who I am at all.
      • I know more ways to control or reduce my anger than most people.
      • I know about as many ways to control or reduce my anger as most people.
      • I know fewer ways to control or reduce my anger than most people.
      • I know of no ways to control or reduce my anger.
      • I have not experienced a major trauma in my life.
      • I have experienced one or more traumas of limited intensity.
      • I have experienced very intense and upsetting traumas.
      • The traumas I have experienced were so intense that memories of them intrude on my mind without warning.
      • I've been able to shape things toward attaining many of my goals.
      • I've been able to shape things toward attaining some of my goals.
      • My goals aren't clear.
      • I don't know how to shape things toward my goals.
      • I am able to focus my mind and concentrate on the task at hand regardless of unwanted thoughts.
      • When unwanted thoughts intrude on my mind I'm able to recognise them briefly and then refocus my mind on the task at hand.
      • I'm having a hard time coping with unwanted thoughts and don't know how to refocus my mind on the task at hand.
      • I'll never be able to cope with unwanted thoughts.
      • I am achieving most of the things I want.
      • I am achieving many of the things I want.
      • I am achieving some of the things I want.
      • I am achieving few of the things I want.
      • I sleep as well as usual.
      • I don't sleep as well as usual.
      • I wake up more frequently or earlier than usual and have difficulty getting back to sleep.
      • I often have nightmares or wake up several hours earlier than usual and cannot get back to sleep.
      • I don't have trouble remembering things I should know.
      • I have less trouble than I used to remembering things I should know.
      • I have about the same trouble as I used to remembering things I should know.
      • I have more trouble than I used to remembering things I should know.
      • My goals are clearer than they were.
      • My goals are as clear as they were.
      • My goals as not as clear as they were.
      • I don't know what my goals are.
      • I'm usually able to let bad memories fade from my mind.
      • Sometimes a bad memory comes back to me, but I can modify it, replace it, or set it aside.
      • When bad memories intrude on my mind I can't seem to keep them out.
      • I worry that I'm going crazy because bad memories keep intruding on my mind.
      • Usually I feel understood by others.
      • Sometimes I don't feel understood by others.
      • Most of the time I don't feel understood by others.
      • No one understands me at all.
      • I have not lost anyone or anything dear to me.
      • I have grieved for those I've lost and can now go on.
      • I haven't finished grieving for those I've lost.
      • The pain of my loss is so great that I can't grieve and don't know how to get started.

    Appendix 2: Cognitive Therapy Scale

    Therapist:____ Patient:____

    Date of Session:____

    Tape ID#:____

    Date of Rating:____ Rater:____

    Session#____ ( ) Videotape ( ) Audiotape ( ) Live Observation

    Directions: For each item, assess the therapist on a scale from 0 to 6, and record the rating on the line next to the item number. Descriptions are provided for even-numbered scale points. If you believe the therapist falls between two of the descriptors, select the intervening odd number (1, 3, 5). For example, if the therapist set a very good agenda but did not establish priorities, assign a rating of a 5 rather than a 4 or 6.

    If the descriptions for a given item occasionally do not seem to apply to the session you are rating, feel free to disregard them and use the more general scale below:

    Please do not leave any item blank. For all items, focus on the skill of the therapist, taking into account how difficult the patient seems to be.

    Part I General Therapeutic Skills
    • Agenda
      • Therapist did not set agenda.
      • Therapist set agenda that was vague or incomplete.
      • Therapist worked with patient to set a mutually satisfactory agenda that included specific target problems (e.g., anxiety at work, dissatisfaction with marriage).
      • Therapist worked with patient to set an appropriate agenda with target problems, suitable for the available time. Established priorities and then followed agenda.
    • Feedback
      • Therapist did not ask for feedback to determine patient's understanding of, or response to, the session.
      • Therapist elicited some feedback from the patient, but did not ask enough questions to be sure the patient understood the therapist's line of reasoning during the session or to ascertain whether the patient was satisfied with the session.
      • Therapist asked enough questions to be sure that the patient understood the therapist's line of reasoning throughout the session and to determine the patient's reactions to the session. The therapist adjusted his/her behaviour in response to the feedback, when appropriate.
      • Therapist was especially adept at eliciting and responding to verbal and non-verbal feedback throughout the session (e.g., elicited reactions to session, regularly checked for understanding, helped summarise main points at end of session).
    • Understanding
      • Therapist repeatedly failed to understand what the patient explicitly said and thus consistently missed the point. Poor empathic skills.
      • Therapist was usually able to reflect or rephrase what the patient explicitly said, but repeatedly failed to respond to more subtle communication. Limited ability to listen and empathise.
      • Therapist generally seemed to grasp the patient's ‘internal reality’ as reflected by both what they explicitly said and what the patient communicated in more subtle ways. Good ability to listen and empathise.
      • Therapist seemed to understand the patient's ‘internal reality’ thoroughly and was adept at communicating this understanding through appropriate verbal and non-verbal responses to the patient (e.g., the tone of the therapist's response conveyed a sympathetic understanding of the patient's ‘message’). Excellent listening and empathic skills.
    • Interpersonal effectiveness
      • Therapist had poor interpersonal skills. Seemed hostile, demeaning or in some other way destructive to the patient.
      • Therapist did not seem destructive, but had significant interpersonal problems. At times, therapist appeared unnecessarily impatient, aloof, insincere or had difficulty conveying confidence and competence.
      • Therapist displayed a satisfactory degree of warmth, concern, confidence, genuineness and professionalism. No significant interpersonal problems.
      • Therapist displayed optimal levels of warmth, concern, confidence, genuineness and professionalism, appropriate for this particular patient in this session.
    • Collaboration
      • Therapist did not attempt to set up a collaboration with patient.
      • Therapist attempted to collaborate with patient, but had difficulty either defining a problem that the patient considered important or establishing rapport.
      • Therapist was able to collaborate with patient, focus on a problem that both patient and therapist considered important, and establish rapport.
      • Collaboration seemed excellent; therapist encouraged patient as much as possible to take an active role during the session (e.g., by offering choices) so they could function as a ‘team’.
    • Pacing and efficient use of time
      • Therapist made no attempt to structure therapy time. Session seemed aimless.
      • Session had some direction, but the therapist had significant problems with structuring or pacing (e.g., too little structure, inflexible about structure, too slowly paced, too rapidly paced).
      • Therapist was reasonably successful at using time efficiently. Therapist maintained appropriate control over flow of discussion and pacing.
      • Therapist used time efficiently by tactfully limiting peripheral and unproductive discussion and by pacing the session as rapidly as was appropriate for the patient.
    Part II Conceptualisation, Strategy and Technique
    • Guided discovery
      • Therapist relied primarily on debate, persuasion or ‘lecturing’. Therapist seemed to be ‘cross-examining’ patient, putting the patient on the defensive, or forcing his/her point of view on the patient.
      • Therapist relied too heavily on persuasion and debate, rather than guided discovery. However, therapist's style was supportive enough that patient did not seem to feel attacked or defensive.
      • Therapist, for the most part, helped patient see new perspectives through guided discovery (e.g., examining evidence, considering alternatives, weighing advantages and disadvantages) rather than through debate. Used questioning appropriately.
      • Therapist was especially adept at using guided discovery during the session to explore problems and help patient draw his/her own conclusions. Achieved an excellent balance between skilful questioning and other modes of intervention.
    • Focusing on key cognitions or behaviours
      • Therapist did not attempt to elicit specific thoughts, assumptions, images, meanings or behaviours.
      • Therapist used appropriate techniques to elicit cognitions or behaviours. However, therapist had difficulty finding a focus or focused on cognitions/behaviours that were irrelevant to the patient's key problems.
      • Therapist focused on specific cognitions or behaviours relevant to the target problem. However, therapist could have focused on more central cognitions or behaviours that offered greater promise for progress.
      • Therapist very skilfully focused on key thoughts, assumptions, behaviours, etc. that were most relevant to the problem area and offered considerable promise for progress.
    • Strategy for change

      (Note: For this item, focus on the quality of the therapist's strategy for change, not on how effectively the strategy was implemented or whether change actually occurred.)

      • Therapist did not select cognitive-behavioural techniques.
      • Therapist selected cognitive-behavioural techniques. However, either the overall strategy for bringing about change seemed vague or did not seem promising in helping the patient.
      • Therapist seemed to have a generally coherent strategy for change that showed reasonable promise and incorporated cognitive-behavioural techniques.
      • Therapist followed a consistent strategy for change that seemed very promising and incorporated the most appropriate cognitive-behavioural techniques.
    • Application of cognitive-behavioural techniques

      (Note: For this item, focus on how skilfully the techniques were applied, not on how appropriate they were for the target problem or whether change actually occurred.)

      • Therapist did not apply any cognitive-behavioural techniques.
      • Therapist used cognitive-behavioural techniques, but there were significant flaws in the way they were applied.
      • Therapist applied cognitive-behavioural techniques with moderate skill.
      • Therapist very skilfully and resourcefully employed cognitive-behavioural techniques.
    • Homework
      • Therapist did not attempt to incorporate homework relevant to cognitive therapy.
      • Therapist had significant difficulties incorporating homework (e.g., did not review previous homework, did not explain homework in sufficient detail, assigned inappropriate homework).
      • Therapist reviewed previous homework and assigned ‘standard’ cognitive therapy homework generally relevant to issues dealt with in session. Homework was explained in sufficient detail.
      • Therapist reviewed previous homework and carefully assigned homework drawn from cognitive therapy for the coming week. Assignment seemed ‘custom tailored’ to help patient incorporate new perspectives, test hypotheses, experiment with new behaviours discussed during session, etc.
    Part III Additional Considerations
    • (a) Did any special problems arise during the session (e.g., non-adherence to homework, interpersonal issues between therapist and patient, hopelessness about continuing therapy, relapse?)

      YES NO

      (b) If yes:

      • Therapist could not deal adequately with special problems that arose. 2 Therapist dealt with special problems adequately but used strategies or conceptualisations inconsistent with cognitive therapy.
      • Therapist attempted to deal with special problems using a cognitive framework and was moderately skilful in applying techniques.
      • Therapist was very skilful at handling special problems using cognitive therapy framework.
    • Were there any significant unusual factors in this session that you feel justified the therapist's departure from the standard approach measured by this scale? YES (Please explain below) NO
    Part IV Overall Ratings and Comments
    • How would you rate the clinician overall in this session, as a cognitive therapist?

    • If you were conducting an outcome study in cognitive therapy do you think you would select this therapist to participate at this time (assuming this session is typical?)

    • How difficult did you feel this patient was to work with?

    • Comments and suggestions for therapist's improvement:
    • Overall rating

      Rating Scale:

    Using the scale above, please give an overall rating of this therapist's skills as demonstrated on this tape. Please circle the appropriate number.

    For instructions on the use of this scale, see Young and Beck (1980).

    Appendix 3: Pain Management

    The thrust of this volume is that post-traumatic stress states should not be treated as if they are a purely intrapsychic process but that context, both the interpersonal and the biological, is important and it is therefore appropriate to address the psychological management of pain in counselling for the sub-population of victims that are affected. Traditionally pain has not been a focus in counselling at a Primary Care level, instead sufferers from chronic pain have been referred by their GP to NHS Pain Management programmes and usually these are group programmes with waiting lists varying from 6 to 18 months. Typically treatment involves attendance of eight half-days a week with a follow-up. In some areas week-long programmes are also offered with follow-up at 6 weeks and 6 months. The programmes have a largely cognitive-behavioural emphasis but vary in the weight given to different cognitive-behavioural strategies. Overall the programmes have been found to be effective but different programmes tend to have used different outcome measures so comparison is difficult (Morley et al., 1999). In this Appendix we detail pain management strategies that can be integrated into the individual cognitive-contextual protocol for post-traumatic states that we have already outlined.

    Morley et al. (1999) identified seven components in CBT pain management programmes: education and socialisation into therapy; relaxation; exercise and fitness; behavioural contingency management; attention management; cognitive restructuring; and social and family management. Material that relates to each of these components can be filtered into the PTSD programme from about session three onwards and may result in the extended PTSD programme comprising 15–16 sessions. The key features of these components are now described.

    Education and Socialisation

    One of the difficulties in securing attendance at traditional pain management programmes is that the pain sufferer can feel that they are being told that their pain is ‘all in the mind’ and default from treatment. If however a person is undergoing counselling for a post-traumatic state a rapport should already have been established and the counsellor can anticipate this fear by careful education on the nature of pain, making non-attendance less likely.

    The neuromatrix theory of pain (Melzack, 1999) proposes that the brain has a neural network that integrates information from multiple sources to produce the sensation of pain – inputs include sensory information and inputs from the body's stress regulation systems. Because the input from sensory information is only one of the inputs it is often not the case that more pain means more tissue damage and interventions to eliminate or drastically reduce tissue damage will not necessarily abolish or significantly reduce pain. But if it is common for the pain experienced by a client not to be explicable in terms of the amount of tissue damage this does not mean that it is therefore ‘all in the mind’. There is a false dichotomy between body and mind though it is convenient to talk at times about the body and at times about the mind. It is important for the counsellor to communicate to the client that there are inputs to the experience of pain other than signals of pain from the site of tissue damage. By influencing the inputs of cognition and emotion (C & E) the client's pain may be attenuated. However it is extremely unlikely that the pain will be abolished on altering the C & E input.

    Most clients can readily accept the interaction of pain and emotion if appeal is made to examples: ‘imagine you've got a bit of a headache and you get a phone call that you have won the Lottery what happens to your headache?’ or ‘you've had an argument with your partner, you're in a bad mood, how bad does your headache now feel?’. Further, because the sensation of pain is heightened by a worsening mood, particular attention to the management of mood will be necessary.

    Monitoring Pain

    Pain should be monitored so that the client can learn what factors do and what factors do not influence the pain and on this basis adjust their coping strategies accordingly. The Present Pain Intensity Scale (PPIS) of Figure A3.1 can be used.

    Figure A3.1 Present Pain Intensity Scale

    Clients should be encouraged to keep a log of their pain, at a minimum morning, afternoon and evening, noting the pain intensity, what the mood was, what activities they were engaged in, what they were thinking, and what (if anything) they did. This pain diary can result in some surprising findings, for example one client had announced that going to a disco and dancing would make her pain worse but surprisingly on monitoring it this was found not to be always the case and she stopped automatically excluding dancing. The diary can be used to disconfirm negative predictions.

    Cognitive Restructuring and Attention Control

    The MOOD framework of Chapter 7 can also be used for pain management. A flare up of pain can result in a downturn in mood (M), the client then observes (O) their thinking when the pain is really bad, then tries to be Objective about their thinking and then decides on a pain management strategy with Detached Mindfulness. For example Isaac had low back pain and PTSD after a lorry reversed into him. As part of treatment designed to increase his activity level he went on an excursion to a local shopping centre with his wife. He turned quickly while wearing rubber soled shoes which caught on the marble floor and he jarred his back. He was so upset about this, feeling he had let his wife down who had been looking forward to shopping, that he went home and went to bed, vowing never to return to the shopping centre.

    At the next counselling session when the incident was reviewed Isaac had not applied the MOOD framework and the counsellor explained that it was for use in relation to pain as for mood. Cross-examination of his thinking revealed that he had used ‘all or nothing thinking’: either he was giving his wife exactly what she wanted, a nice afternoon shopping; or it was a waste of time and the pain was impossible ‘nothing I can do about it’ (except go home to bed); or he was pain free. Isaac's penchant for ‘all or nothing’ thinking had been noted in earlier sessions when he would alternate periods of inactivity with ‘blitzing’, attempting to do tasks at the speed and for the length of time he did before the injury, resulting in forced immobilisation and consequent demoralisation for days. In reviewing the application of the MOOD framework to the shopping centre incident the counsellor asked Isaac to rate his pain when he jarred his back on the PPIS and he rated it at 7. The counsellor then asked how bad it would have been in 20 minutes if he had stood looking at the crowds and in the computer shop window whilst his wife went off for that period to a shop of her interest. He thought that because he does have an interest in computers the pain would probably have come down to a 5 and the shopping could have continued at a café where he could stand to have coffee. The counsellor explained to Isaac that he had implicitly tried to eradicate the pain and this made matters worse and that what he had to do was accept the pain with a detached mindfulness in order to be able to influence and manage it.

    The extent to which clients catastrophise about their pain has been found to be the best predictor of the intensity of pain experienced (Sullivan et al., 1998) and catastrophising predicts disability beyond the variance accounted for by depression and anxiety. In assessing catastrophising the Pain Catastrophising Scale can be used. There are three sub-scales: magnification, rumination and helplessness. Isaac scored 38 on the PCS which meant that he scored more highly than 80 per cent of patients attending outpatient pain clinics and was just at the border of the group of patients who tend to benefit least from such programmes. In particular his rumination score was particularly high, 18, and this was reflected in his coping strategy of going home after the shopping incident and brooding about the pain in bed. The counsellor and Isaac agreed that a major therapeutic goal was for him to learn to acknowledge the pain with detachment whilst simultaneously engaging in tasks that captured his attention.

    Behavioural experiments are one of the most important vehicles for cognitive restructuring. Rather than dispute the logic of a negative thought an experiment is set up to confirm or deny it. This involves an experiential form of learning, so called ‘hot’ cognitions, and represents arguably a more powerful form of learning. The dares referred to in Chapter 7 are in fact behavioural experiments and can be applied to the management of pain. Pain sufferers are understandably fearful of triggering the pain and consequently may not fully explore the limits of what they can do. Clients should be encouraged to gradually dare themselves to try various activities. Eventually clients can learn what pace they can keep up on a daily basis and that departure from that pace will likely lead to demoralisation. For some clients verbalising their limitations means acknowledging them and is viewed as countenancing defeat whilst others are so preoccupied with their pain that they feel others ‘must’ know their pain/limitations without their needing to be verbalised – mind reading.

    Though dares are a good starting point for traumatised pain clients, the gains can be limited by an information processing bias that Goubert and colleagues (2005) have termed ‘lack of generalisation of corrective experience’. They have provided some evidence that whilst a sufferer may discover that they can perform a particular action without undue discomfort such as lift the baby into her pram they refrain from lifting similar weight to the same height, whilst if they do suffer pain performing a particular action not only is that action excluded but so are similar actions, that is the generalisation is for negative but not for positive actions. It is important that the client is made aware of the operation of this onesided generalisation and that steps are taken to counter it. Goubert et al. (2005) also draw attention to the operation of three other information processing biases amongst pain sufferers:

    • over-generalisation – on the basis of the experience of pain in one particular context the person predicts there will be pain again of the same severity in the same context;
    • selective abstraction – the person experiences some difficulty in one aspect of their life like not passing an exam, and takes it out of context – ‘I am never going to qualify because of this back problem’;
    • catastrophising – the person experiences some difficulty but sees it as catastrophic ‘I had some pain today swimming, pretty soon I won't be able to swim at all’.

    The information processing biases can be addressed by asking clients to collect data using the MOOD framework.

    Switching the focus of attention is a useful pain management strategy but its successful implementation takes preparation and practice. The focus can become an external object, for example a computer game, or an aspect of the pain that makes it manageable, for example imagining the pain filling various different coloured balloons on top of their head and each one floating away in turn with their pain. In order to be able to focus on the thinking associated with the pain and to cross-examine it, it will sometimes be necessary for the client to first alter their mood by using a coping relaxation response such as Hanson and Gerber's (1990) ‘signal breath’ technique. The client is taught to take a fairly deep breath that is held for a few moments and then released slowly. Just at the moment the breath is released, the client is instructed to say to themselves a relevant cue word such as ‘relax’ or ‘let go’. During this process an attempt is also made to scan the body quickly and then release areas of excessive muscle tension as the breath is being exhaled. Common target areas for increased tension include the jaw, neck and shoulders. The entire process takes only a few seconds. The technique itself is not meant to significantly reduce pain, but merely as a prelude to engaging the different senses of sight, sound, touch etc. in the awareness of the external object or image.

    Preventing Preoccupation with Pain

    Meichenbaum (1985) has described Self-Instruction Training (SIT) as a way of teaching coping with self-statements that clients can use in stressful situations. The self-statements cover the domains of preparing for the stressor, encountering the stressor, coping with feelings of being overwhelmed, and evaluation of coping efforts. Applied to pain management the essence of preparing for the pain is an acceptance of the pain. This acceptance is a particularly difficult mental framework for many clients to adopt. Understandably clients hope for a life free of pain but often after repeated surgical or anaesthetic intervention it becomes increasingly obvious that they are not going to be pain free. Acceptance involves an acknowledgement that they are unlikely to be pain free. Acceptance is not to be confused with resignation – the essence of acceptance is that they can make a difference to and influence the pain though not eliminate it. A premature focus on acceptance tends to alienate clients and tacit acceptance is achieved via the cognitive restructuring and attention control strategies. Acceptance also involves a refusal to see the experience of pain as a sign of weakness. Towards the end of pain management counselling the acceptance can be formalised in a preparatory coping self-statement such as ‘there is likely to be pain today, but sometimes it is not as bad as others and there are better and worse ways of playing it. I'll play it coolly’ Such a preparation statement helps counter a sense of helplessness. When the client encounters the pain they might use a coping statement such as ‘I'll use signal breath, the MOOD’ and if feeling overwhelmed ‘it doesn't stay this bad for more than … it was X days ago that it was this bad, in between it has not been as bad’. Later the client can evaluate their coping efforts with a phrase such as ‘though it was bad, I managed to keep my cool throughout and made it not as bad as it could have been’. The self-instruction training is best seen as a culmination of earlier work and the coping self-statements as tools that can prevent relapse into preoccupation with pain.

    Preoccupation with pain is also negated by the client continuing to invest in various activities and pastimes. It is explained that unless they invest there can be no return and whilst their injuries might limit investment options they can creatively develop others. Care has to be taken that these investments do not take place in a frenetic way with the client running from the pain. Activities are engaged in with mindfulness of the pain but without letting it dominate. Acceptance of the pain can be particularly problematic if the injury arises from the misdeeds of others. The client's anger at the injustice of the pain inflicted can rise to the fore when pain flares up and interferes with acceptance of pain. Counsellors should help clients differentiate acceptance of the pain from approval of the way in which the pain came about in the first place. The client may be encouraged to write a letter that they do not post to the ‘inflictor’ of their pain as a way of coping with their anger towards their ‘assailant’. In this way the client is helped to separate out acceptance of pain from anger at the perpetrator.

    Communicating About Pain

    Clients are necessarily very aware of their pain and difficulties and can assume that others are equally aware. It is therefore important that clients are taught the dangers of mind reading e.g., ‘if they cared enough they would know how much pain/difficulty I am in’. Clients can resist spelling out their pain or disability because they don't want to be seen as ‘moaning’ but this can send a confusing message to relatives who develop unrealistic expectations. Worse still, clients can push themselves to the extreme one day to meet those expectations and the relative is confused the next day when they are inactive, inviting pejorative comments. Faced with uncertainty about what help should be proffered friends and relatives may retreat, lowering the client's mood.

    Clients can be taught KISS which stands for Keep It Simple Stupid in which they clearly own up to what they usually can and cannot do and simply re-iterate this at appropriate times. In this way the client educates relatives about the rules of the game and it is explained that once they are clear what the rules are they can adjust, but they cannot cope with the switching of rules depending on mood. Relatives can be invaluable in helping pain clients keep active at the appropriate pace and in helping to ensure that they are continuing to invest in life.

    Appendix 4: Children and Adolescents

    Most studies of road traffic accidents, sexual abuse, violence, disaster, terrorism and war have found that 20–50 per cent of children exposed experience PTSD, with an average incidence rate of 36 per cent (Fletcher, 2003). Further, children with sub-syndromal levels of PTSD may experience the same level of functional impairment as those who meet full criteria (Carrion et al., 2002). Brown (2005) has commented that this is particularly important for pre-school children who are less likely than older children to meet the threshold for the avoidance and arousal clusters. A child with PTSD often shows additional difficulties such as separation anxiety and depression and sometimes somatic difficulties with gastrointestinal problems. Younger children may also show developmental regression such as bed wetting or thumb sucking. Traumatised children are a challenge to the counsellor not only because of their diffuse difficulties but also because cognitive behaviour therapy was developed with adults in mind and there is a need to adapt it to meet the developmental stage of the child. But research on the predictors of PTSD in children do highlight the importance of cognitive factors, for example Brown and Kolko (1999) found that attributions about physical abuse (e.g., blaming themselves) accounted for symptoms beyond that accounted for by the severity of the abuse. Further, social information processing patterns such as misperceiving other children's behaviour as having hostile intent influenced the effect child physical abuse had on later conduct problems (Dodge et al., 1995). Thus the cognitions children have surrounding their trauma, often expressed as stories, play a pivotal role in their trauma response and therapeutically the task is to help the child re-author the story adaptively.

    In this volume we have presented a refined cognitive-behavioural model, the cognitive-contextual model, to guide the counselling of PTSD clients. This ecological model is especially pertinent when it comes to children and adolescents, as caregivers' mental health problems and family discord are both risk factors for PTSD whilst children's and caregivers' social support and coping skills are protective against the development of PTSD.

    The first step in counselling the child is to obtain as clear a description as possible of the trauma but this can be highly problematic for a number of reasons:

    • some children do not wish to discuss the trauma in front of their parent or caregiver leaving the latter believing that they may be less effected than they are. If the counsellor suspects this may be the case then with the permission of the adult they should also interview the child alone;
    • the younger the child the more the trauma is likely to be expressed somatically rather than verbally and this is particularly true of children aged 2 to 5 years old. Play materials, drawing paper, puppets, colourful pens should be used to help particularly the younger child ‘draw a picture of any bad things that have happened’. In asking the child about what they have drawn the counsellor has to be extremely careful not to lead the child, but simply to show great interest;
    • the child may have experienced so many traumas that the child could well feel overwhelmed by the task of beginning to describe them and Schauer et al. (2005) have developed a time-line for use in such cases. The child is supplied with a rope and some stones and flowers, the stones are the bad things that have happened and the flowers are the good things and the child is asked to complete the timeline by placing the objects along the rope and given the freedom to change the order as they go along. The counsellor then asks about each of the items and makes notes on what the child has said, identifying ‘hotspots’;
    • there may be misunderstandings or gaps in the child's account of the trauma but it may be possible to correct or fill in an incomplete account with the aid of a parent or caregiver.

    We suggest that counselling with children who have been traumatised is best pursued with the following goals in mind. How much therapeutic effort is expended in the attainment of each will vary from child to child.

    Goal 1 Develop a Definition of the Problem That is Shared between the Child and Parents/Caregivers

    Without agreement on the nature of the child's difficulties it is difficult to make headway. A parent may for example maintain that a child's unruly behaviour is simply because they have become a teenager. The parent may themselves be taking this view because they are wanting to avoid talking about the trauma themselves as they were also affected. The counsellor's task is to negotiate a shared understanding, for example ‘80 per cent of John's reaction is because of the incident and 20 per cent because he was wanting to be independent now that he is a teenager’. The authors have found that presenting the ‘dodgy alarm’ (as an analogy for the amygdala, see Chapter 7) is understandable to children as young as six or seven and is a very credible explanation both to the child and the parent or caregiver of the difficulties encountered. The dodgy alarm may be complemented by explaining to both child and parents/caregiver that if one of them ‘goes over the top’ then things only get really out of hand if the other also goes over the top. An agreement should be brokered in which they both contract to use the ‘traffic lights’ for anger described earlier in this volume (Chapter 7).

    Goal 2 Carefully Check and Enhance the Motivation of the Child and of the Parents/Caregivers and Ensure Safety

    The child or adolescent may well feel that they are attending counselling at the behest of adults but also feel inhibited about expressing their unhappiness, which may be manifest in non-compliance with homework exercises and monosyllabic replies in the counselling session. An important way of engaging the child or adolescent is getting them to first detail the avoidance strategies they use to deal with intrusions and secondly have them reiterate that the chosen ways of coping do not actually work in the long run. The child can also learn this experientially by being asked to use their usual strategies (typically screwing their eyes up or doing something) to try to stop thinking/imagining, say, ‘green bears’. Thirdly the child is encouraged to make specific predictions as to what would happen if they confronted ‘the bully’ when it came into mind of its own accord or if it was triggered by something. The idea is to ensure that the child learns to interact adaptively with the traumatic memory in a spirit of detached mindfulness and to neither run away from it nor get into a fight with it. Counselling is described as an opportunity to learn new ways to handle the bully. The child will rightly point out that they will feel very uncomfortable confronting the bully but by testing out their negative predictions they find they can control the bully rather than have the bully control them. The child or adolescent can be asked if they deliberately called to mind the incident in the session what would they fear happening to them in thirty seconds, a minute, two minutes and the prediction is tested out. In the first instance the prospect of being taught how to calmly postpone consideration of the traumatic material until later is an attractive option to the traumatised child or adolescent and is more likely to engage them in the counselling programme.

    When a child has been exposed to multiple extreme traumas they may need the comfort of being able to escape mentally to a ‘safe place’. This may take a number of forms, in some children it may be the recall of a time and place they felt safe, for example a teenager from Somalia remembered the comfort of her family in the years the militia were inoperative because of international intervention. Her mother in particular was a very warm person and would hug her. Unfortunately the mother was later raped and killed by militia, but she could derive comfort from imagining the sights, sounds and smells of her home, particularly what was being cooked and the warmth of her mother when she was a toddler. She was encouraged that if the traumatic memories got too much at the special time she could have a break by recalling the earlier experience. In doing this she was still writing her autobiography and contextualising the trauma and not avoiding it per se. For some children and adolescents they may take comfort in an imaginary place, perhaps a beach with waves lapping, the sound of birds, the smell of the sea, the feel of sand running through their fingers. The idea here is that the safe place should engage all their senses and they should feel comforted. If at all possible the safe place should be something that is mirrored in the child's day-to-day current reality and the counsellor should emphasise this link. For example the Somali teenager was put in contact with a local Somali Women's group and experienced some re-mothering and was taken on a memorable day out to a beach and a church fete specially laid on for the group.

    Unless the parent or caregiver gives the counselling programme a high priority then the child's attendance is going to be problematic. It has to be emphasised that the child's educational and social development is likely to be significantly impeded unless their post-trauma symptoms are tackled systematically.

    Goal 3 Ensure That the Parent/Caregiver Encourages the Child or Adolescent with Behavioural Experiments – Dares – and Helps Wean Them off Safety Behaviours

    Parents and caregivers can unwittingly reinforce the safety-seeking behaviour of the child. In the young child this may take the form of allowing them to sleep in the adult's bed after they awake with nightmares or with an adolescent allowing them to ring them on their mobile phone when they have been left at home with a baby-sitter. Whilst such reassurance from the parent/caregiver might be reasonable in the first few weeks post-trauma long term it serves to underline the view that they are in a war-zone. It is important to make the parents/caregiver aware that though they may feel guilty for example insisting that the child stay in their own room after waking from a nightmare or tells them they will not respond to a telephone call when they are being looked after by the baby-sitter, they are not actually guilty. The parents/caregiver need also to appreciate that emotional reasoning may stop them meeting their own needs, for example refusing to leave the traumatised child with a close relative for the evening whilst they go out. As a consequence they may feel irritable and over-react to the traumatised child's typically non-compliant behaviour, serving to escalate conflict. Thus though in the short term learning to tolerate guilt feelings is uncomfortable, in the long term not only will they have a better quality of life themselves but the atmosphere at home is likely to be much less fraught. We have previously detailed and evaluated a programme for parents of problem children (Scott and Stradling, 1987) and the strategies are further elaborated in Scott (1989). Dubey et al. (1983) have suggested that parents and caregivers can be given a handout that summarises effective communication as follows:

    Use ‘I’ statements rather than ‘you’ statements and avoid mind-reading. In this way the adult owns their own emotional response e.g., ‘I don't like it when you ask for clean items of school uniform when you are getting ready for school’ as opposed to ‘You know how much there is to do first thing of a morning, you are just trying to be awkward asking for clean clothes then’.

    Try and summarize first in your own mind what you think your child is saying to you. Before making a reply yourself check out with the child that your summary of what they are saying is accurate.

    Give the child ample space to explain him/herself without interruption.

    Signal you have heard what your child has said by giving a non-verbal reply such as nodding or a verbal reply.

    If the parent/caregiver is to encourage a child to do dares it will only be possible in the context of a reasonable relationship, thus communication is at a premium. The dares have to be carefully negotiated with the child, for example a child who has developed separation anxiety since the trauma might be encouraged first of all to spend a few hours in the day at a relative's house, progressing to staying an evening, overnight and then consider climbing a similar ‘ladder’ at a friend's house. The child has to be comfortable at one rung of the ladder before the next step is attempted, if a step is too difficult an intermediate step is attempted before progressing further.

    Goal 4 Tackle the 4 as (Account of the Trauma, Avoidance, Alienation and Anger) But Do so in a Developmentally Appropriate Way

    The counsellor should carefully write down the child's account of their trauma(s) and check that they have got the details right. As with adults the counsellor should note any parts of the story that evoke strong emotion and consider what if any alternative interpretations are possible. Between sessions the child can be encouraged to write or draw or type into the computer their story and this is reviewed in the session alongside the original account. In this way the counsellor comes to understand the perspective from which the child is viewing the trauma. A gentle questioning of this perspective is best conducted in the style of the TV detective Columbo with a juxtaposing of contradictory information in a style of bemused befuddlement – ‘So you blame yourself for not getting the baby out of the house but you don't blame your twin brother, is that right?’

    Children can be helped to become aware of their trauma-related self talk by the counsellor using prompts such as: ‘What were you thinking when you woke up from a dream about it?’; ‘What sort of things were you saying to yourself after it popped into your mind?’; ‘Tell me the first thing that comes into your mind when you come across a reminder’.

    Younger children might need help to understand the connection between thoughts and feelings. One way of doing this is to ask what feelings they would have if they thought a pet cat was outside the room and then to ask what difference it would make to the feelings if they seriously thought a lion was outside. The idea is to convey to the child that what they think makes a difference to how they feel. To further illustrate this a young child with an anger problem might be invited to consider that when they are angry they are a tortoise with the head popping out of their shell and that when they start to get angry they shout ‘Stop’ to themselves, pull their head inside the shell and ‘Think’ about whether what has just happened is really so terrible and whether others are really doing things deliberately to upset them. Then when they have thought it through in their shell to pop their heads out again and then like a tortoise slowly move to where they want. The tortoise strategy can also be used to counter the young child's sense of alienation from others, for example to ask themselves in their ‘shell’ how many children they spoke to at say football practice/majorettes and whether this was really any less often than before the trauma, then to ‘pop their head out’ and join in, ignoring the ‘squeaky voice’ in their head that says they do not fit in.

    Cognitive-behavioural treatments have been shown to be efficacious for childhood victims of sexual abuse (Cohen et al., 2004) and childhood victims of a wide range of violent events (Stein et al., 2003). Further, the data suggest the importance of including both children and their caregivers in these treatments.

    Appendix 5: Eye Movement Desensitisation Reprocessing (EMDR)

    In traditional EMDR (Devilly, 2002) the counsellor goes through the following core protocol:

    • The client is asked to focus on a disturbing image of the trauma, a negative cognition associated with the trauma, and to note the accompanying bodily sensations.
    • The client's initial degree of subjective units of distress SUDS is noted on a 0–10 scale, high score indicating more distress.
    • The counsellor then moves their finger across the client's field of vision, holding the hand about 12 inches away, at a rate of about a sweep a second, returning to the same point about 25 times. After each set of sweeps the client is asked to ‘let go’ of the image, and enquiry is made as to whether anything else has come to mind. No comments are made by the counsellor on what the client reports.
    • After every couple of sets the counsellor enquires about the SUDS, and the sets are repeated until the SUDS gets down to 0 or 1 at which time the client is reassessed for their degree of belief in the negative thought. This is followed by the assessment of degree of belief in a positive thought that they would like to have related to the trauma, e.g. ‘I did make a difference’.
    • The positive thought is installed using sets of sweeps, typically 8–10 sweeps, and the sets are terminated when the client becomes convinced of the thought.
    • Finally the client is asked to identify any physical sensation remaining that is reminiscent of the trauma and sets of sweeps are conducted until these sensations dissipate.

    Throughout the use of the protocol the client is praised for staying with the traumatic material and at each session is informed that they can give a pre-arranged signal to halt the movements. The client is prepared for this interaction with the traumatic material by choosing a metaphor to describe the encounter such as being on a train watching the countryside/trauma pass by or that it is just an old movie that they are watching. Thus the ground is already prepared for adaptive interaction with the traumatic material in a way that is reminiscent of the detached mindfulness advocated by Wells and Sembi (2004). The core protocol is also preceded by a history taking at the beginning of EMDR no different to that outlined in this volume. In particular the counsellor is asked to enquire about the worst moment or moments and it is the thoughts and bodily sensations associated with these ‘hot spots’ that become the prime target for the core protocol. EMDR therapists are advised not to use the core protocol until they have first constructed a ‘safe-place’ for the client to use in the event of feeling overwhelmed by traumatic material (procedures for developing a ‘safe-place’ have been detailed here in Appendix 4 on children and adolescents). Thus in practice the core protocol is not usually used until about the fourth session after trust, rapport and safety have been established.

    Whilst there is evidence that EMDR works, the eye movements and the method of evoking the eye movements have in fact been found not to be essential. It seems that any method of alternative stimulation, for example by the client hearing a sound first in one ear and then in the other or tapping the client first on one hand and then on the other, achieves similar results. Eye movements can also be induced by having the client listen to a ticking clock and moving their eyes across their full field of vision in rhythm with the ticking or by simply looking at a top corner in a room and moving their focus to another top corner at a rate of about a movement a second. The speed of the eye movements has to be adjusted to the maximum the client can tolerate. If the client finds horizontal eye movements uncomfortable diagonal movements can be tried.

    In EMDR for PTSD arising from a single trauma typically three to five sessions involve the use of the core protocol and in these roughly 90-minute sessions it is intended that SUDS ratings should reach 0 or 1 by the end of the session. However if the counsellor runs out of time and this is not achieved the client is praised for working hard and the session concluded with a relaxation or ‘safe-place’ procedure. The focus in the core protocol sessions also includes any new traumatic material that may have come up between sessions such as the contents of a new dream related to a trauma and to document this in a journal for review at the next session. The protocol is as with any therapy tailored to the individual.

    The founders of EMDR are very insistent that practitioners can only become proficient in the use of EMDR by attendance at their weekend workshops but this has not been demonstrated empirically. Further the claim seems implausible given that at the EMDR Level 1 training there are typically at least 60 participants and the only experiential work is about an hour with participants in small groups trying out the core protocol for non-extreme traumas in their own lives (no SUDS greater than 5).

    Those attending Level 1 training are advised that they are not sufficiently equipped as Level 1 graduates to tackle complex trauma cases or cases that have the hallmark of a personality disordered client. However by attendance at Level 2 training they can become so equipped. It seems however that what is taught at these advanced levels is not unique to EMDR but are in fact second generation cognitive therapy skills where the focus is as much on imagery, emotion and relationships as cognition. However EMDR does appear to be an effective way of helping clients become desensitised to a traumatic memory.

    Appendix 6: Refugees

    When PTSD arises as a result of a chronic trauma it is especially difficult for the counsellor and client to put the experiences in an overall benign context. For example many refugees from Somalia were terrorised by militia in the early 1990s, with a brief respite in the mid-1990s because of United Nations presence, and a return of the terror when they withdrew, continuing until the present day. Such refugees often report multiple traumas – beatings, rape, enslavement, seeing loved ones murdered. Usually the refugees cannot read or write and can rarely speak English. Before any counselling can begin, the victim of chronic trauma has to feel safe, this is particularly problematic if they are a refugee and their asylum application is still outstanding, and they greatly fear being returned to their homeland in such circumstances. In keeping with the cognitive-contextual model detailed in this volume it is useful to facilitate contact with the indigenous local community who might, for example, facilitate attendance at a local Somali Women's Centre and/or church or mosque. If the refugee is under age 18, local authority social services can provide support but this stops abruptly at 18. The position is particularly dire for adult failed asylum seekers with a withdrawal of benefit and, in some cases, housing.

    Once a victim of chronic trauma feels safe then counselling for the PTSD can begin with the help of an interpreter. As part of the assessment the client will have detailed a number of horrors and it is important to ask, of all that happened what was the worst thing, and to seek elaboration of this. However care has to be taken not to overwhelm the client and it can be explained by the counsellor that at the next session they would like to know in detail about, say, life before the militia came in the early 1990s. In this way the counsellor begins to help the client contextualise the trauma. The counsellor can offer to write their biography over a number of sessions and it will be theirs to share with whoever they want. At the end of the ‘life before the trauma’ session, the counsellor can then legitimately say that they would like to check details of some of the horrors again at the next session. Following this the focus moves to life now, the dislocation from family, uncertainty of the fate of some family members, or fearfulness of venturing out.

    Refugees' avoidance symptoms understandably include their homeland but can extend to other members of their community if they feel they could be betrayed to authorities in the home country, making the provision of social support doubly difficult. Though in the UK many are too fearful to venture out alone and one client was fearful of using the communal kitchen in the house where she was staying because it meant going down a set of stairs and she would jam a chair against the door of her room whilst inside it. The counsellor can approach these fears by encouraging the client, preferably with the presence of another member of the community, to gradually dare themselves to relinquish these excessive precautions.

    It is especially important to understand the cultural background of the refugee as many are deeply religious whilst British culture is particularly secular. One client, a Catholic refugee from the Congo, was helped when the counsellor suggested that her feeling at the horrors she witnessed must have been like those of Mary witnessing the crucifixion of Christ on the cross and that for her, as for Mary, there was a new life beyond the horror. This resonated with the client because it was a religious sister at risk to her own life who had smuggled her out of the Congo. Indeed it was out of respect for her that she had not committed suicide. Another client, a male refugee from the Congo, had been raped in prison because of his political dissent. A devout educated Catholic he was especially ashamed of what happened to him and was helped by the counsellor suggesting that the perpetrators were so ‘evil’ that they would have done the same to Christ if they had the opportunity and that he need not take his shame any more seriously than Christ would have done and to experience Christ's love in his daily readings of the scripture. The counsellor also had to address the client's guilt that he had got an erection during the rape. It was explained that this was an inevitable bodily reaction to such a violation but it did not mean that he was a willing participant. Counselling in this case was protracted because of a worry that he may have contracted AIDS as a result of the violation.


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