New Content Added: To update the content we have added Child Abuse and PTSD information found at the end of the Table of Contents.
In this section, I will present a few ways to identify the way trauma affects a client: the extent of the trauma, anger, and guilt. We will also present two techniques: The Trauma Questionnaire and Benefits and Costs.
♦ The Extent of the Trauma
In treating PTSD, I believe it is necessary to identify what type of trauma a client or group of clients have experienced. I feel that the extent of the trauma is more relevant to the effect of PTSD on the client than the client’s past or present psychological state. As you know, there are some traumatic events that would affect anyone exposed, such as the recent rise in PTSD after 9/11.
Michael, a teenage client of mine, was referred to me by his high school guidance counselor who said that he had been fighting with the teachers and classmates at school, and that his grades had been plummeting. Michael had been shipped from foster home to foster home his whole life, and had finally settled in a permanent residence.
His guidance counselor believed that something at his new home had happened to cause the change in his grades, but Michael refused to talk with her. Once he was referred to me, I witnessed the same behavior that Michael had shown to the school counselor --- silence. The only thing he would say angrily is, "I don’t want to talk about it." I believed that Michael could be exhibiting symptoms of PTSD and perhaps was trying to repress the memories that kept trying to push their way out.
♦ Technique: Trauma Questionnaire
To help Michael begin to talk about the event without having to take the first leap of "talking about it," I asked him to fill out a seven question "Trauma Questionnaire". I requested Michael to answer the questionnaire in a journal and to quietly read it back to himself. When he said again, "I don’t want to talk about it," I responded, "But you’re not talking about it. You’re writing and reading about it." He seemed to be receptive.
The questions I gave to Michael included the following. Although many questions may not apply to Michael, I felt the general nature of the questionnaire would be beneficial.
- Have you ever been in a natural catastrophe, such as an earthquake, fire, or flood?
- Were you ever sexually or physically assaulted, either by a stranger, a group of teenagers, a family member, or anyone else?
- As a child, were you physically maltreated with excessive beatings or spankings? Were a parent’s or caretakers disciplinary measures sadistic?
- Have you ever witnessed the death, torture, rape, or beating of another person? Have you ever seen someone die or be badly injured in a car, airplane, or other accident? Have you ever been injured in such an accident?
- Has anyone in your family or a close friend been murdered?
- As a child, did you ever witness the beating, rape, murder, torture, or suicide of a parent, caretaker, or friend?
- Have you ever been in a situation in which you felt that you or a member of your family would be harmed or killed? Even if your life or the lives of your family members were not directly threatened, did you distinctly fear that you or they were in serious danger?
The next session, Michael had written in his journal about an incident that had taken place about a month ago. He said that while he was walking home, he saw someone robbing a gas station. Michael watched the perpetrators run out of the station and hijack a car and also witnessed them beat the owner of the car even though she had already let them take the vehicle.
Michael told me that he had feared for his life and had hidden behind a trash bin so that the perpetrators could not see him. Now that he had related this incident to me, I could now see where Michael’s anxiety was coming from.
Next, we will briefly discuss anger as a reaction to a trauma. One of Michael’s principle symptoms of his PTSD was, obviously, his anger as exhibited by his angry tone of voice in therapy and fights at school. He frequently lashed out at his teachers and his classmates. This was a new behavior for Michael. I feel that Michael’s anger was his attempt to control the environment around him. When he witnessed the robbery, Michael described feeling scared and ashamed for having to hide behind a dumpster.
He now wishes he could have helped the driver of the car that had been beaten, but instead he ran away. To cope with this feeling of helplessness, Michael used his anger to manipulate his surroundings. Think about your client who chronically displays anger.
Could that client have been the survivor of a traumatic event, childhood abuse perhaps? We will discuss anger in detail in a later section.
♦ Technique: Benefits and Costs
To help Michael control his anger which I believe he used to cope with this feeling of helplessness, by manipulating his surroundings, I asked him to try the "Benefits and Costs" technique.
I asked Michael to take a piece of paper and draw a line down the middle of it longways. On one side, I asked him to write "BENEFITS" in capital letters and then write, "The good things about my anger are…" Then, on the other side of the paper, I asked him to write, "COSTS" in capital letters and then to write, "The bad things about my anger are…" Next, I told Michael to list on the "Benefits" side, the things he gains from displaying anger and on the "Costs" side what he loses from displaying anger.
Under the "Benefits", Michael listed:
"I feel that people will do what I say when I’m mad";
"If I don’t show that I’m angry, I feel like I’ll explode"; and
"My anger can protect me from people who want to hurt me."
Under "Costs", Michael wrote:
"My friends are afraid of me now";
"I get so mad at my teachers that I don’t want to learn anything"; and
"I feel embarrassed that I hurt everyone else’s feelings."
Now that Michael has identified that anger can have negative results, he could more easily be aware of his motives for becoming angry.
Another manifestation of PTSD is a feeling of guilt or shame. Some trauma survivors in trying to fight their feelings of helplessness blame themselves for not doing anything. This was the case with Michael. When he hid behind the dumpster, he felt that he was being a coward in not helping the woman who was badly beaten by the carjackers. Michael felt ashamed that he was the one who could hide and she couldn’t.
I then addressed these feelings in a format I like to call "If I could do it over" technique. First, I asked Michael, "What would you have done to help the woman?" Michael replied, "I could have tried to fight them." I then said, "Michael, did they have guns?" He stated that yes, they did have guns. I asked, "How many were there?" Michael said, "At least three." I then asked, "Michael, what do you think would have happened had you tried to play the hero?"
Michael responded, "I guess they might have shot me and then probably have shot the lady." As you can see, by examining in detail the result of his fantasy "hero" actions, Michael could finally realize his helplessness and begin to accept it as an unavoidable consequence of trauma.
In this section, we presented a few ways to identify how trauma can affect a client: analyzing the extent of the trauma, anger, and guilt. We also presented two techniques: The Trauma Questionnaire and Benefits and Costs.
In the next section, we will examine the three ways clients re-experience a traumatic event: sleep disturbances, flashbacks, and emotional recall. We will also include a technique to help you identify what type of trauma re-experience your client is undergoing.
Peer-Reviewed Journal Article References:
Kira, I., Lewandowski, L., Somers, C. L., Yoon, J. S., & Chiodo, L. (2012). The effects of trauma types, cumulative trauma, and PTSD on IQ in two highly traumatized adolescent groups. Psychological Trauma: Theory, Research, Practice, and Policy, 4(1), 128–139.
Marshall, A. D., Roettger, M. E., Mattern, A. C., Feinberg, M. E., & Jones, D. E. (2018). Trauma exposure and aggression toward partners and children: Contextual influences of fear and anger. Journal of Family Psychology, 32(6), 710–721.
"Sexual assault-characteristis effects of PTSD and psychosocial mediators: A cluster-analysis approach to sexual assault types": Correction to Peter-Hagene and Ullman (2014) (2015). Psychological Trauma: Theory, Research, Practice, and Policy, 7(2), 170.
What are three ways to identify how trauma can affect a client?
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