Counseling Children with Post Traumatic Stress Disorder
PTSD is difficult to treat in children given their limited cognitive and emotional development. However, there are many tools for the counselor to attenuate or remove the symptoms of PTSD or the disorder itself. Among the evidence-based interventions for counselors is the Cognitive Behavioral Therapy, the Exposure Therapy and Group Therapy among others. The counselor plays a critical role in the recovery of the child, since he or she is in the best position to understand the case from a professional perspective that will allow parents to realize the different options that are available. The counselor treating PTSD in children often requires to work in collaboration with other mental health specialists as well as experts in psychoanalysis. The role of the counselor is to be the fundamental element of the integration of the efforts to improve the condition of the child affected by PTSD.
Counseling Children with Post Traumatic Stress Disorder
In order to understand the different evidence-based counseling approaches to PTSD, which stands for Posttraumatic Stress Disorder it is necessary first to develop a good understanding of what this disorder implies. Posttraumatic Stress Disorder was initially identified in war veterans that would return after battle affected by the consequences of exposure to traumatic events like the ones that they witnessed in the battle.
Initially, the disorder was known as Shell Shock, but later this terminology changed to Posttraumatic Stress Disorder because it was understood that such condition existed not only among the military personnel but also within the civil population. Posttraumatic Stress Disorder encompasses different symptoms across the cognitive, emotional and affective spectrum which condition the whole personality, the behavior and thinking of the individual that suffers from it.
Posttraumatic Stress Disorder affects both children of different age and gender, and it has been observed in all races, social and cultural groups, ethnicities and any other idiosyncratic difference. Therefore it is considered to be a disorder that affects the individual in a systematic way, modifying the core elements of the biology of the brain, which are affected by traumatic events from the past.
The traumatic events could have could have taken place a long time ago during childhood and the PTSD is manifested until adolescence, or the PTSD symptoms might have been always been exhibited by the victim without ever noticing that such spectrum of symptoms were actually in requiring treatment. There are some schools of thought that believe that Posttraumatic Stress Disorder can be treated not from a psychiatric perspective but from a psychological perspective and this is where the role of counseling for individuals, including children that suffer PTSD can be effective.
One of the most effective ways to provide the tools for the counseling that is required for relief from PTSD symptoms includes Cognitive Behavioral Therapy (CBT) which is a tool for counseling in which the therapist understands how the thoughts and the feelings of the individual come to existence in relation to the perception of the world, identifying triggers and strategies to avoid those triggers.
CBT is one of the available, evidence-based interventions for the professional counselor, but, the responses of the patient to the different forms of counseling available for PTSD is different, each individual responds different to the strategy of counseling that is defined by the counselor, whether it is talk therapy, psychotherapy or medications. However, the counselor will probably prefer to start the intervention using the less intrusive approach which is Cognitive Behavioral Therapy.
CBT is composed by different techniques, some of them will be mentioned here, they have demonstrated to be effective according to the evidence that has been presented in different journals and the academic literature. One of them is Prolonged Exposure Therapy, in which with the use of the imagination the child is exposed to repeated and prolonged traumatic experiences that are not real but are perceived by the psyche to be sufficiently real to trigger the stress responses that are similar to the triggers that the client finds in everyday life (Scheeringa, Zeanah, & Cohen, 2011).
Those triggers cause the suffering related to the recall of the stress associated to the trauma. This type of therapy, which is commonly used by counselors that attend children has been impressively developed by the American military agencies. They have developed simulators that through full immersion allow the veteran that suffers from PTSD to re-create the
conditions of the battle, with sounds, visual effects even with smells recreating the entire surroundings which were found at the time of the trauma.
Evidently, such soldiers respond with the stress responses that cause the symptomatology of the PTSD however, with constant exposure there is a desensitization to the event and it becomes less and less likely to trigger the same stress responses. In a sense, the individual becomes neutral to the triggers that previously triggered the PTSD.
At this point it is necessary to make a deeper analysis of what PTSD actually implies in psychological and psychiatric of terms. PTSD is a mental illness that arises as a response to severe trauma (stimuli and information) that is unable to be processed and assimilated by the individual and therefore it remains as part of his daily life and it appears sublimated through different mechanisms.
For example child that was victim of sexual abuse might perceive a friendly approach of another person as a threat associated to the negative event of the past. In the same way, victims of a severe accident seem to experience the event again when there are certain noises and events that trigger the memory of the traumatic event. After this psychological, empirical approach to the understanding of PTSD it is necessary also to consider the psychiatric approach that describe the condition.
According to neurology PTSD is an illness of the mind that can be identified through technologies that analyze the activity of the brain. Victims of PTSD will register abnormally higher levels of anxiety, such anxiety can be so pervasive that eventually will drive the person into a state of depression, which also can be identified through diagnostic technologies (PET scans and encephalograms). It is believed that the traumatic event changes the way in which the brain works.
This is one of the reasons why psychiatrists prefer to treat treatment-resistant PTSD which has not responded to Cognitive Behavioral Therapy using pharmacological agents, the most common ones are the SSRI’s which stand for Selective Serotonin Reuptake Inhibitors, which is a category of medications which includes the well-known drug fluoxetine (Prozac). This drug along with paroxetine (Paxil) are the drugs that are usually given to patients that request psychiatric assistance to manage their condition.
It is interesting to notice that more than 60% of the patients that take the pharmacological therapy will experience improvements in their symptoms. It is not yet known if this medications affect in a direct or indirect way the brain chemistry of the individual. However, the efficiency to treat the symptoms is uncontroversial. From the point of view of the counselor, it is important to try less invasive approaches first and in the majority of the cases even a combination strategy of Cognitive Behavioral Therapy and pharmacological therapy have the greatest rate of success in treating treatment-resistant PTSD.
It has been already discussed one of the techniques that support with evidence its efficiency, another is In Vivo Exposure. It must be said that in this case the conditions that are to be re-created for the patient do not necessarily need to be imaginary. In this variant of the Prolonged Exposure Therapy, there is a direct confrontation of the patient with the situation that is feared or avoided despite the fact that such situation holds no harm and is perfectly safe (Weems & Graham, 2014).
For example, if one child has been abused and as a consequence has become socially withdrawn or socially anxious, he will benefit from integrating into social groups that despite the fear that they will initially cause, eventually will generate a trust that is necessary to understand
that not all situations like the one experienced originally are going to be the rule but rather the exception.
In Vivo Exposure has demonstrated to be very effective particularly in children, who have a very extreme neural plasticity (all of them in general) which implies that the child is able to generate new connections within his brain, new neurological circuitries that allow them to dissociate the traumatic event from recent events that are no longer perceived as dangerous or as a threat (Bedard-Gilligan & Zoellner, 2012).
Another approach that is supported by evidence which is used by counselors is the Cognitive Therapy, which has the goal of modifying the relationships between thoughts and emotions. This implies a cognitive approach to the problem, a process of thought that with the use of logic and with the use of rationality the patient or the sufferer of PTSD is able to convince himself that the condition he is perceiving it, which appears as a threat, actually is a situation that is not a threat at all.
With this therapy it is expected that the patient will able to convince himself about the lack of threat. Another evidence-based counseling approach is the Cognitive Processing Therapy, which is a combination of the elements of Cognitive Therapy and Prolonged Exposure Therapy. This strategy is based on the principle of identifying and challenging problematic thoughts and systems of belief that are not true (to perceive a safe situation as a threat) (Palic & Elklit, 2011).
The term “Stuck Points” refers to the emotions, the beliefs and the thoughts that arise from the traumatic events and that are difficult to be accepted by the conscious awareness of the patient. To complement this approach the patient is encouraged to write and read aloud and with detail his own narrative of the event.
For example a child that was a victim of sexual abuse and that will develop PTSD as a consequence, will benefit later in his life by creating his or her own narrative about what happened, but not only from the point of a victim, but also from the point of view of a victim that overcomes the trauma and that feels empowered to continue his or her life regardless of the events of the past.
The construction of such narrative of the self and the evolution of the self is a very powerful tool that the individual can use over and over, integrating more and more aspects of experience that help to overcome the initial perceptions of helplessness. It is part of this counseling therapy to help the affected patient to identify and modify the Stuck Points that have been mentioned before.
It is only by identifying this source of thoughts that it is possible to be consciously aware of such source and to disregard the feelings, the emotions and the thoughts that spring out of it. Another strategy that has been demonstrated by academic evidence through studies to be effective is the so-called Stress Inoculation Training. This strategy consists in providing coping skills that are to be used to manage some of the symptoms of the PTSD, like muscle relaxing, breathing techniques, role playing and other cognitive tools like guided self-talk.
The goal of such approach is to reduce anxiety and to reduce the avoidant behavior that is related to the memories of the trauma. There is another variant of the Cognitive Behavioral Therapy which has been specifically designed for cases in which there is insomnia. At this point the reader must be reminded that PTSD is a condition that is often characterized by recurrent nightmares and dreams that are very distressing and that cause the patient to have a very disturbed sleep which in turn reduces his psychological resilience to the triggers that he experiences in life.
The Cognitive Behavioral Therapy for Insomnia involves a two day workshop where the patient is trained to manage such nightmares, for example using the image rehearsal therapy or implementing treatment for sleep disordered briefing. It is important to discuss the content of the nightmares with the healthcare provider, in this case the counselor because from a psychoanalytic point of view they contain important clues to understand what the Stuck Points of the patient are.
Since dreams are symbolic, it is necessary that the counselor is trained in psychotherapy or he can refer the patient to a psychotherapy specialist who will help the child and his parents understand the meaning of those dreams in relation to his own symptomatology and their meaning in their daily life. Finally, if the PTSD fails with these approaches, a permanent counseling approach might be necessary both for children to cope with the difficult symptoms of the disorder.
This is the reason why even medicated patients or patients that have already gone through workshops of Cognitive Behavioral Therapy will require lifelong psychological support in order to deal with the symptoms and to continue working with the different aspects of the disease that make life more difficult to handle. In those cases, talk therapy has demonstrated to be effective because the counselor is perceived as a professional figure of support (Meiser-Stedman et al., 2014).
The counselor, under the principle of confidentiality is able to be trusted with the intimacy of the patient without the risk of exposing privacy. In this way, many patients of PTSD develop a lifelong close relationship with her counselor, who often is the only individual that can understand the situation that the patient is going through and therefore the counselor becomes a
very important structural support even if the interventions are based just on talk therapy (Guay et al., 2011).
Finally it is necessary to mention that in the case that all this interventions that are based on cognition and emotion through the manipulation of external stimuli fail, pharmacological treatment should be requested since there is a relatively high chance that pharmacological agents like new generation of antidepressants will improve the resilience to stress and to establish a chemical barrier between the stressful triggers and the Stuck Points and the ability of the child to govern his behavior and his emotions. Essentially, according to the literature, the only pharmacological agents that have demonstrated to be able to work for victims of PTSD are SSRI (Halvorsen, Stenmark, Neuner, & Nordahl, 2014).
In most cases of PTSD it must be said that the most successful approach is a combined one, which implies the use of Cognitive Behavioral Therapy, along with Cognitive Therapy Exposure Therapy and finally Pharmacological Therapy all these under the supervision and the coordination of the counselor who is in the best position to evaluate the very particular evolution of the patient relationship to the disorder that that afflicts him.
The types of counseling that have been described so far are related to the individual treatment of the child, but there are other methods that have demonstrated to be useful in a social manner, one example is Group Therapy, in which the child is placed within a group where the trauma can be discussed. In the case of a child, it will be necessary that the other members of the group have sufficient emotional and cognitive maturity in order to provide the support that is needed.
In many cases, the group can be formed by family members, the child and the counselor, who will guide the development of the group therapy. It is important to notice that many victims
of PTSD will actually manifest the symptoms later in their life, during adolescence or even in adulthood. However, the sooner the condition is addressed the better the prognosis will be (Michelsen, Eriksen, & Maier, 2014). The reason is that research has demonstrated that conditions like PTSD establish neural pathways that reinforce themselves in time.
This implies that a set of behaviors, thoughts and beliefs will reinforce themselves by repetition, in a process called as “kindling” which is also to be found in other disorders like Bipolar Disorder. This is the reason why the intervention needs to be as soon as possible before those patterns establish themselves as the norm.
There are some controversial approaches that can be used as tools for counseling of children that experience PTSD. Given the nature of this research paper, which is to present only those therapies and interventions that are based on evidence, some of the therapies must be ruled out. This includes acupuncture and herbal medicine and other approaches from the Eastern cultures. The fact that there is no research available that confirms of denies the effectiveness of such treatments, should not imply that they have no value at all, and perhaps is just the need of research that is preventing them from being classified as “effective treatments”.
However, there is a growing body of evidence that confirms that there are some new alternative approaches that are empirically effective. One of them is Eye-Movement Desensitization and Reprocessing, (EMDR), a technique where the therapist guides the clients to make eye movements and body movements at the same time that they narrate the traumatic experiences. The mechanism of functioning of such therapy is not well understood, but it is believed to be related to the fact that emotions and thoughts are connected at a neurological level with the body and by modifying the responses of the body it is possible to change the neural pathways of the trauma.
The evidence for the validity of such treatment has been presented by Paula Schnurr, PhD, deputy executive director of the National Center for PTSD. There are other mechanisms to “boost” the treatment and management of PTSD, not all of them can be implemented by the counselor himself (Scheeringa, Myers, Putnam, & Zeanah, 2012).
For example, the use of benzodiazepines, which are mild tranquilizers, can be prescribed on a temporary basis to children to overcome the paralyzing terror that is often related to the exposure to the stimuli triggers the PTSD response. It is very important that these medications are given only on a temporary basis because they are addictive and they can be harmful for the neurological development of the child. Additionally, if the child believes that the pill is the best way to avoid the PTSD responses, he will stop working on the solution of the root problems. Therefore the therapy with benzodiazepines should be used only to cause desensitization of the triggers and gradually should be removed to allow the child to cope with his own neural mechanisms (Sburlati, Schniering, Lyneham, & Rapee, 2011).
Finally, a word should be given to the awareness of the comorbidity of PTSD. There is a higher correlation between PTSD patients and other mental diseases than the general population. For example, depression, anxiety, substance abuse, personality disorders and psychosis are situations that can be the outcomes of a poorly treated PTSD condition. Without the proper treatment, the mental state of the patient will deteriorate and will show other symptoms that are mostly related to the excess of stress triggered by the condition.
It should also be mentioned that Posttraumatic Stress Disorder and trauma in children has been recognized by the APA as one of its main priorities. It is important to mention to parents and counselors that even the most treatment-resistant cases of PTSD, particularly those caused by sexual abuse, can be attenuated with an integral approach that includes the counselor, mental
health specialists, parents and family members that can gradually and progressively reduce the consequences of the exposure to trauma.
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