In the last section, we discussed types of adaptation reactions to trauma. Those were emotional numbing, trigger avoidance, and hypervigilance.
As you are well aware, the most common psychiatric problem in the United States today is depression. Studies show that at least 50 percent of clients who suffer from PTSD also suffer from depression. Have you ever found, like I have, that when a client undergoes severe traumatic exposure, depression is a common side effect?
In this section, we will discuss depression and its various manifestations when linked to PTSD: behavioral depression, learned helplessness, repressed anger, and loss and grief. In this section, we will examine PTSD related to sexual abuse and combat.
4 Manifestations of Depression linked to PTSD
♦ Manifestation #1 - Behavioral
The first type of depression in relation to PTSD is behavioral depression. As you know, behavioral theory states that depression is the natural result of inadequate reinforcement, inadequate rewards, or inadequate recognition. This kind of depression can also occur when clients aren’t loved or supported enough by others or themselves. Trauma survivors, those clients most in need of both, sometimes do not get the amount of either love or support that they require.
Many times this may be a recurring circumstance, yet other circumstances may be a direct result of the nature of the client’s trauma.
Luanne had been raped by her uncle at the age of 12. When Luanne promptly reported the uncle to police, he was convicted and sent to prison. Although the prosecutor had sufficient DNA evidence to support Luanne’s charge, her family refused to believe her and shunned Luanne from all activities, gatherings, and vacations.
Without the love and support of her loved ones, Luanne quickly slipped down into depression.
Think of the level of love and support your PTSD client has received. Would this be an appropriate topic in your next session and how can they acquire this love and support now?
♦ Manifestation #2 - Learned Helplessness
The second type of PTSD induced depression is as you know, learned helplessness depression. The learned helplessness theory was developed by Martin Seligman in 1975. Seligman administered electric shock to animal subjects from which they could not escape.
At first, the animals fought, tried to get away, and uttered cries of pain or anger. Then they sank into listlessness and despair. Later on, in a second set of experiments, the same animals were shocked again. Only this time, by pressing a certain lever or completing some other simple task, they could stop the electric current, but they made no effort to do so.
From these results, Seligman concluded that the animals had learned to be helpless. Even when a means of relief was provided, they had become so set in their powerlessness or so psychologically defeated that they would not or could not end their own suffering. After being subjected to a traumatic experience continuously, trauma survivors can also experience this state. Those most at risk to contract this disorder are abused women and children, prisoners of war, concentration or refugee camp survivors, and torture survivors.
Think of your chronically traumatized client. Could he or she be suffering from learned helplessness?
♦ Manifestation #3 - Repressed Anger
In addition to behavioral depression and learned helplessness, a third type of depression is repressed anger. This results from a client’s hesitation or inability to express anger. Often, clients may be afraid of being ostracized or looked down upon if they expose their emotions. Once a client decides to repress his or her anger, he or she turns that anger inward on themselves.
There are two groups of trauma survivors that most frequently suffer from this suppression of anger.
(1) The first is a group in which anger was punished or anger was used as punishment. For example, battered wives and children will undergo this type of depression because they feel that anger caused their suffering.
(2) The second type of PTSD clients who suffer depression as a result of repressed anger are those clients who have no specific individual to unload their anger onto. Survivors of Hurricane Katrina are an excellent example of this group of people.
Many individuals who went through this natural disaster have no one to specifically blame for their misfortunes, except Mother Nature and in some cases the local or national government. However, these groups are so broad and nonspecific that any anger thrown at them would have little or no satisfying effect. One of my clients, William, who was subjected to Vietnamese torture stated, "Everybody was responsible but nobody was responsible."
♦ Manifestation #4 - Loss and Grief
A fourth cause of depression is the common loss and grief depression. Almost without exception, clients who survive trauma go through a stage of loss and grief. Sometimes, this may be related to the death of a loved one, but most often, it relates to an abstract concept such as trust, security, patriotism, or self-worth. In all these cases, the client will most likely go through a grieving period that could result in depression.
I find that if a client is indeed going through a grieving period that has yielded to depression, it is important to understand just what the client is grieving for. Many times, I have found that clients do not understand grieving for emotional losses as well as physical losses.
Margaret, age 17, had been sexually abused by her father at 14. For years, Margaret had lived with this secret until she had tried to commit suicide earlier that year. I believed that Margaret’s depression was a result of her inability to grieve for the losses of her childhood. Margaret stated, "Every day, I just get these incredibly strong emotions and I don’t know where they’re coming from. I want to scream it’s so bad."
♦ Technique: Listing Negative Feelings
To help Margaret begin her grieving process, I asked her to list these negative feelings as they came upon her throughout her day. The next session, Margaret had listed, "apprehensive," "embarrassed," "insecure," and "immature." I asked Margaret what she thought of these emotions now that she’d seen them on paper.
Margaret said, "They’re all related to what happened with my dad. They’re all a result of that." I asked her, "Do you think that they could be a result of losses you experienced after the abuse? For instance, the emotion ‘apprehensive’ could be a loss of security. What do you think?" Margaret stated, "I see what you’re saying. I think the feeling "immature" could be, like, childhood, because I never had an adolescence."
As you can see, Margaret had begun to understand the reasons behind her overwhelming feelings and could now move on to the next stage of her grief.
In this section, we discussed depression and its various manifestations when linked to PTSD: behavioral depression, learned helplessness, repressed anger, and loss and grief.
In the next section, we will examine ways for a client to better understand his or her emotions related to feeling awareness, thoughts vs. feelings, and writing out the trauma.
Peer-Reviewed Journal Article References:
Chang, C., Kaczkurkin, A. N., McLean, C. P., & Foa, E. B. (2018). Emotion regulation is associated with PTSD and depression among female adolescent survivors of childhood sexual abuse. Psychological Trauma: Theory, Research, Practice, and Policy, 10(3), 319–326.
Choi, K. W., Batchelder, A. W., Ehlinger, P. P., Safren, S. A., & O'Cleirigh, C. (2017). Applying network analysis to psychological comorbidity and health behavior: Depression, PTSD, and sexual risk in sexual minority men with trauma histories. Journal of Consulting and Clinical Psychology, 85(12), 1158–1170.
DeCou, C. R., Mahoney, C. T., Kaplan, S. P., & Lynch, S. M. (2019). Coping self-efficacy and trauma-related shame mediate the association between negative social reactions to sexual assault and PTSD symptoms. Psychological Trauma: Theory, Research, Practice, and Policy, 11(1), 51–54.
Khayyat-Abuaita, U., Paivio, S., Pascual-Leone, A., & Harrington, S. (2019). Emotional processing of trauma narratives is a predictor of outcome in emotion-focused therapy for complex trauma. Psychotherapy, 56(4), 526–536.
Keller, S. M., Feeny, N. C., & Zoellner, L. A. (2014). Depression sudden gains and transient depression spikes during treatment for PTSD. Journal of Consulting and Clinical Psychology, 82(1), 102–111.
Online Continuing Education QUESTION
What are three manifestations of depression in conjunction with PTSD?
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