The Safety Net

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Post-Traumatic Stress Disorder (PTSD) is a condition that may arise following exposure to any situation in which a person fears serious harm or death. The individual may be physically injured or threatened directly, or he or she may witness a violent situation that causes the person to fear for his/her safety or that of others. Trauma can include single events, such as earthquakes, accidents, or a physical or sexual assault. It can also include long-lasting situations such as domestic violence, childhood sexual abuse, or living with an aggressive peer.

Individuals who may have difficulty understanding a particular situation may also feel assaulted in commonplace situations. For example, a person who does not understand the reasons for having a blood test may simply feel that he is being attacked with a needle. In the general population, about 1 person in 4 who are exposed to a traumatic event will develop symptoms of PTSD.

Post-Traumatic Stress Disorder, as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual, includes three main types of symptoms occurring after trauma:

1. Re-experiencing aspects of the traumatic event or events
2. Avoidance of activities that remind the person of the trauma
3. Physical arousal, an increase in the body’s “fight-or-flight” response

In addition, individuals having experienced prolonged or early trauma may have significant alterations in self-perception, severe interpersonal difficulties, and self-abusive behaviors. A detailed description of PTSD symptoms is given in the articles presented for Consumers and Families and for Service Providers.

Though PTSD frequently begins shortly after the trauma occurs, it can also appear months or years later. Symptoms may wax and wane over time. Other stressors in the person’s life, such as moving or changing jobs, may temporarily make the symptoms worse. While some people will have the full syndrome of PTSD, many people exhibit milder symptoms that make us suspect a history of trauma, though we have no proof. PTSD is usually persistent throughout a person’s life, though treatment and proper supports will provide most people with significant relief.

Suggestions for Regional Center Staff

1. Obtain a detailed trauma history. The history should apply a broad definition of trauma to include possible exposure to abuse/exploitation/neglect in the community or in residential settings, witnessing of traumatic events (e.g., restraint of peers), and medical traumatization and early surgeries. Known and suspected trauma should be included. Staff training in how to obtain a trauma history may be beneficial. Families need to be approached gently and respectfully on these issues as they may experience defensiveness or have persistent guilt regarding their inability to identify or intervene in past abuse. It is helpful to explain to consumers and families that the trauma history is an important part of the clinical history due to the potential impact trauma may have on health and well-being.
   
   
2. Become aware of trauma. Simply being aware that many consumers have had significant traumatic experiences will help service providers to understand and respond to the needs of consumers. It is particularly important for regional center staff to emphasize to families, consumers, service providers, and other members of the person’s planning team that behaviors stemming from PTSD are not intentional or manipulative. For example, a person having a history of trauma who hides or “freezes” when it is time to go to an appointment is not being non-compliant. Instead, the person is likely trying his/her best to cope with fear, intrusive feelings, or memories of abuse.
   
   
3. Develop a network of resources for the treatment of trauma-related concerns. This should include therapists who use verbal and non-verbal therapies, resources for cognitive-behavioral therapies, crisis resources, training resources for service providers, psycho-educational services for consumers and families, and self-help and support groups for consumers.
   
   
4. Consider a diagnosis of PTSD whenever a consumer has psychiatric symptoms. This is particularly true if the person has a known history of trauma or if trauma is strongly suspected based upon history. Individuals who have been homeless or have resided with others having substance abuse problems are highly likely to have been exposed to traumatic events. PTSD often co-exists with other psychiatric disorders, or it can masquerade as almost any other psychiatric syndrome. Individuals who have received personality disorder diagnoses often have severe and complex PTSD symptoms.
   
   
5. Be proactive. Because individuals having PTSD symptoms are often very sensitive to change and unexpected events, it is very helpful to inform people in advance of any changes in their schedules. Some people will benefit from frequent reminders, the use of a calendar, or encouragement (e.g., “On Tuesday we’ll finally get that toothache taken care of. I think you’ll feel much better.”).
   
   
6. Maximize the person’s control over his/her life circumstances. Feelings of helplessness, powerlessness, or submission often trigger PTSD symptoms because a key aspect of a traumatic experience is that of being helpless to protect oneself from an abuser. Individuals having PTSD will often react negatively to direct instructions or interactions in which they feel “bossed around." They may also be particularly alarmed when decisions are made regarding their lives without them being consulted. It is often helpful to approach people in a style that emphasizes their power and choice in a situation. The underlying purpose of rules and requirements should be explained in clear terms. This principle may need to be reinforced with various service providers, as some approaches (such as “…because we said so” or “that’s the rule here”) are likely to trigger PTSD symptoms.
   
   
7. Communicate using positive terms. Critical or negative terms will tend to trigger PTSD symptoms and feelings of shame. Phrasing things in a positive way will help people improve their coping skills without evoking anxiety and self-loathing. For example, “You gave Jane good advice, but now she has to choose what she wants to do” will help the person learn about boundaries and choices, rather than saying “Stop being bossy to Jane.”
   
   
8. Encourage service providers to have adequate support and training. Service providers will need to be able to recognize subtle signs that a person is beginning to have a flashback and learn to work with the consumer to develop a repertoire of proactive strategies to manage dissociation and escalation. They will need to work closely with the person’s therapist, case manager, and psychiatrist to learn appropriate distraction approaches, de-escalation techniques, relaxation techniques, or “grounding” strategies that can derail the progression of PTSD symptoms. They will also need to be able to collaborate with the consumer to develop safe ways to respond to re-experiencing symptoms. For example, a consumer who would leave the premises when feeling fearful was persuaded to “run away” to another residence down the street, and then call residential staff to check in.
   
   
9. Be as dependable as possible. Trauma often involves betrayal, making many people having PTSD particularly sensitive to broken promises. The person may magnify the importance of the agreement due to intense feelings of mistrust. It is not uncommon for the person to focus on a single incident in which they were disappointed while ignoring multiple times when staff followed through as planned. This tends to make the person appear unappreciative, rigid, and unforgiving. The person’s unbalanced view of the situation can be very frustrating for staff, who are extending themselves to assist the individual. It is obviously impossible to always predict when and how one will be able to do something and everyone will at times agree to do something and then not follow through with their agreement. Try to follow through as consistently as possible on plans made with the consumer. Honestly disclose your limitations and communicate what can be provided as clearly as possible. Some people will benefit by using a calendar or journal to document these agreements, as concentration and memory are often negatively affected by PTSD.
   
   
10. Avoid re-traumatization. Individuals having PTSD can be re-traumatized by incidents of aggression or intrusion that further kindle the PTSD process. It is of utmost importance that individuals be protected from aggressive peers. Physical restraint of all kinds should be avoided if at all possible. Management of aggression should focus on intensive efforts to identify warning signs of escalation and intervene proactively.
    
    
11. Be generous with praise and appreciation. Feelings of worthlessness and unworthiness often accompany PTSD. In addition, many consumers who have PTSD are painfully aware that they struggle to do many things that others accomplish effortlessly. It is very healing for individuals to hear that their efforts are appreciated. It is important to recognize partial successes and express thanks to the individual for his or her contributions.

Trauma Resources and Information

National Association for the Dually Diagnosed (NADD)
www.thenadd.org