Recognizing and understanding

post-traumatic stress disorder

Counselling clients
who suffer from
post-traumatic
stress disorder

The diagnostic category of post-traumatic

stress disorder (PTSD) was first recognized
by the American Psychological Association in
the third edition of its Diagnostic and Statistical
Manual of Mental Disorders (1987). The
essential features of the disorder are exposure
to a psychologically distressing event outside
the range of usual human experience, a reexperiencing of the event in some way, avoidance of stimuli associated with the event, or
numbing of general responsiveness, and
increased arousal. The diagnosis is not made
if the distress lasts less than one month.

Maggie Wilcock

Difficulties with diagnosis

Individuals who have experienced personal
tragedies, for example fires, assaults, road
traffic accidents, may also be present for
counselling; sometimes the diagnosis of
PTSD may be harder to elicit.
Davidson (1992) contends that general
practitioners and psychologists frequently
misdiagnose PTSD in their everyday practice.
He suggests that this may be due to several
factors: perhaps the client is not asked about
the experience of trauma; or the patient may
be reluctant to disclose painful material; or
the practitioner may not be open to hearing it.
Also the symptoms of PTSD are non-specific,
for example, headaches, insomnia, withdrawal and irritability may be confused easily with
other stress reactions, for example anxiety or
depression.
Epstein(1989) also claims that transferential or countertransferential issues may play a
part in the misdiagnosis of PTSD, that is, the
client may project feelings of anger and blame
onto the helper, who in turn may be directed
by his or her own unconscious feelings about
the clients experience. Clients may also be
amnesic for significant aspects of their clinical
history, and may appear unco-operative.
Given these difficulties with diagnosis, it is
important that the counsellor should pay
great attention to clients personal histories in
order to gain access to information about any
life-threatening event which may have preceded current presentation.

The author
Maggie Wilcock is Social Worker for Humberside County
Council and is Specialist Tutor on the Hull University MSc
course in counselling, Hull, UK.
Abstract
Explores issues for counsellors relating to the identification
and understanding of post-traumatic stress disorder.
Suggests aims for therapeutic intervention and argues for
an integrated approach to counselling post-traumatic
stress-disordered clients, drawing on the contribution of
humanistic counselling, behaviour therapy and cognitive
therapy.

The psychological consequences of

experiencing traumatic events
When counselling such clients an understanding is necessary of three areas of psychological

Employee Counselling Today

Volume 8 Number 7 1996 pp. 812
MCB University Press ISSN 0955-8217

Counselling clients who suffer from post-traumatic stress disorder

Employee Counselling Today

Maggie Wilcock

Volume 8 Number 7 1996 812

study that are major contributors to an understanding of PTSD. These are crisis theory,
bereavement theory and cognitive psychology.

shock phase; acknowledgement of loss;

depression or disorganization and despair;
beginnings of recovery; and acceptance of
adjustment.
Those experiencing a loss following a
traumatic event may be prone to complicated
or abnormal bereavement reactions (Clegg,
1988; Gibson, 1991). This may be due to the
suddenness of the event, the fact there was no
time to prepare for the loss, and if the disaster
was a major event, the survivor may be
required to have to cope with the reactions of
others, including media attention.

Crisis theory
A prerequisite for the acquisition of PTSD is
that the individual will have experienced a
psychologically distressing event which is
usually experienced with intense fear, terror,
and helplessness. It is likely that the individual
will be faced with a crisis situation (Taylor,
1989). A crisis may be seen as a transitional
period or a turning point in life (Morrice,
1976, p. 20).
When an individual experiences a crisis a
number of psychological processes may take
place. Initially the individual may dissociate
during the trauma (Wolf and Mosnaim,
1990). This may be explained in terms of the
crisis situation involving sudden discontinuities in experience, which the individual has
difficulty in integrating fully into ordinary
consciousness. It is argued that the individual
copes by directing full attention on one aspect
of the situation, thereby shutting out or not
consciously perceiving or reflecting on other
aspects of the environment (Wolf and
Mosnaim, 1990).
It is particularly common that at times of
crisis an individual may suppress from awareness painful emotions. This may have an
adaptive value at the time of the crisis allowing
the individual to separate him/herself from the
full impact of the physical and emotional
trauma, allowing sufficient energy to take
appropriate action. After the initial shock of
the crisis has subsided, the individual will
experience an outcry phase (Horowitz, 1976).
This involves the individual experiencing
periods of intrusion and periods of denial,
which will carry on until the event is assimilated as part of conscious experience.

Cognitive psychology
Following a traumatic event individuals will
make cognitive adjustments involving attributions and appraisals about the event and its
impact on their lives and self-perceptions.
Evidence suggests that to what a person
attributes the cause of an event is related to
adjustment to the impact of the event (Kendal
and Hollans, 1981). It is generally thought
that people who adjust most successfully to a
trauma perceive the event as being caused by
external, unstable and specific factors, that is,
those which they could not have been expected to control or predict, and which were
specific to that situation or environment.
Of equal significance is how the event is
appraised by the individual. Appraisal is a
continuous process, and may include:
An appraisal of how the event has effected
them, or the meaning of their symptoms.
Prognosis is much improved if these are
seen as normal, and part of the rehabilitative process.
An appraisal of the meaning of the impact
of the trauma. Individuals who adjust well
are often able to reframe the trauma as
having had some positive impact on their
lives.
Appraising the event correctly in the
dimension of time, that is, as something
that has happened in the past, and being
able to put it into a broader perspective.
An extremely significant appraisal is the
individuals self-appraisal, or how the event
has affected their self-concept.
It is not uncommon for people who have
experienced a trauma to develop survivor
guilt. This essentially is an over-exaggerated
guilt reaction, moods may be euphoric at
times, and risk taking may be engaged in.
The cognitions underpinning this are fundamentally related to the persons guilt about

Bereavement theory
Alongside the effects of traumatization, the
survivor of a disaster is also likely to experience some form of loss (Blume, 1990;
Gibson, 1991). Loss may be physical and
tangible, such as death, loss of a limb or a
physical ability, or may be less obvious, for
example, loss of role, loss of control, or loss of
self-identity.
Bereavement theorists frequently refer to
stages of adjustment, through which individuals proceed as part of adjusting to their loss.
Parkes (1972) has identified these as: initial
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Counselling clients who suffer from post-traumatic stress disorder

Employee Counselling Today

Maggie Wilcock

Volume 8 Number 7 1996 812

surviving when others have not, or if the

individual perceives him/herself as in any way
responsible for the trauma.
Similarly, the survivor may experience a
profound feeling of shame. Stone (1992,
p. 132) defines this as a painful awareness of
ones self as defeated, deficient, exposed, a
failure, inadequate, wanting, worthless and
wounded The very essence of the self feels
wrong.
Perhaps one of the most debilitating consequences of trauma which any therapeutic
intervention should seek to redress is the loss
of sense of control or management of oneself
and ones environment. The traumatic event
may have changed the persons view of the
external world as a safe, predictable, orderly
and controllable place (Epstein, 1989). Victims may also experience a loss of control of
their internal worlds, their thoughts, feelings
and behaviours, and believe that they may
never regain control of themselves or their
environment (Peebles, 1989).
In relation to control, it should be noted
that recent evidence suggests that the important factor in mastery of a situation or engagement in coping behaviours is not the individuals actual control of the situation, but his or
her perceived control. Acquiring a sense of
control reduces anxiety and thus enables the
individual to engage in problem-solving
behaviours (Fisher, 1984).

directly. Lazarus and Folkman (1984) also

introduce the concept of trauma mastery.
This involves the recognition of what the
individual can do to cope with the trauma and
its impact, realizing that not all problems can
be mastered.
Therapeutic intervention, then, aims at
helping the individual to tolerate, minimise,
accept or ignore that which cannot be mastered (Lazarus and Folkman, 1984, p. 140).

Arguments for an integrated approach

It is apparent that the needs of individuals
suffering from PTSD vary greatly, both
between individuals and at different times or
stages in the recovery process. It has been
demonstrated that different interventions may
be employed at different stages of the helping
process, in accordance with the fluctuating
needs of the client; for example, there will be
times when the client will be engaged in emotion-focused coping, at other times therapy
may focus more on problem solving. It is
suggested that interventions from different
paradigms may be adopted accordingly at the
relevant stage in the therapeutic process
(Prochaska and Clemente, 1982)
The humanistic approach
The essential contribution of the humanistic
school of counselling for PTSD counsellors is
its recognition of the importance of the therapeutic relationship. It is essential that the
relationship is one in which the client feels
secure and held by the counsellor (Epstein,
1989). Also important is the trust that the
counsellor holds for the clients process of
recovery (Wolf and Mosnaim, 1990). The
ability of the counsellor to remain accepting
and non-judgemental will also be crucial for
clients for whom guilt and shame are particular issues.
A counsellor who communicates the belief
that clients have the potential to find their
own methods of adapting to or coping with a
crisis will convey a message of hope to clients
and engage in interventions consisting of
positive feedback which will assist in the
development of their coping strategies, and
lead to increased feelings of control and
esteem (Gibson, 1991).

Counselling practice with PTSD clients

The aims of therapeutic intervention
Following a traumatic event a clients needs
may include the need to grieve, and the need
to reorganize his or her sense of self and life.
Epstein (1989) emphasizes the importance of
establishing exactly how the traumatic event
has disrupted the individuals sense of self. In
certain cases therapy will aim to assist the
client to reconstruct his or her self, and
restore the adaptive functioning of internal
processes (Schwarz and Prout, 1991).
The aim of therapy may be conceptualized
as consisting of two additional components
which, it is claimed, comprise a useful coping
strategy (Lazarus and Folkman, 1984). First,
helping the client to engage in emotionfocused coping in order to regulate feelings
which may be overwhelming. Second, to
facilitate problem-solving coping, which is
concerned with assisting the client to engage
in behaviour to change problem situations

Dynamic psychotherapy
Dynamic psychotherapy also offers an important contribution to work with clients with
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Counselling clients who suffer from post-traumatic stress disorder

Employee Counselling Today

Maggie Wilcock

Volume 8 Number 7 1996 812

PTSD. First, it purports that an individuals

self has a fragile quality which may be injured
by traumatic experiences (Epstein, 1989). A
key feature will be the facilitation of clients
who are undertaking the process of reintegration of their sense of self and their internal
world in the light of the new evidence provided by the trauma.
Psychodynamic practice is concerned very
much with identifying and interpreting individual defences. Rose (1991, p. 89) describes
how this process is used to work with victims
of rape who suffer from PTSD symptoms:
The major defences, that is, dissociative,
avoidance, and re-enactment, need to be
confronted, explored, and actively linked to
the rape from the beginning.
It is important to realize that care must be
taken when interpreting defence mechanisms,
as these are also strategies which have served a
useful function for the individual (Schwarz
and Prout, 1991). Transferential and countertransferential issues may also influence therapy, commonly feelings of anger, injustice or
sadness, which may emanate from either the
client or the counsellor ( Rose, 1991).

Cognitive techniques
The efficacy of cognitive therapy with PTSD
lies in its premiss that the way we think about
the world is related to the manner in which we
feel and behave in it.
Counsellors may find it useful to assist
clients with the process of reframing and
restructuring memories of traumatic events.
This may involve helping the client to put the
event into a more manageable perspective in
his or her life, to see that it was real, but not
all-encompassing, and occurred in the past
rather than the present.
Similarly, cognitive therapy offers techniques for assisting individuals to change their
appraisals about the world, which may be
preventing them from living effectively. These
commonly include appraising oneself as
powerless, and/or guilty, and appraising the
world as a bad, dangerous and chaotic place.
(Magaro, 1991) It is well established that
anxiety states are maintained by anxious
thoughts and lack of self-confidence. Cognitive therapy seeks to address these thoughts
directly and challenge them (Butler et al.,
1991).
An effective cognitive intervention involves
encouraging the client to focus on the positive
aspects of the experience, for example, on
their own resources in coping with the situation, or the sense of community or family
support engendered by the traumatic event
(Fairbank et al., 1991).

Behaviour therapy
Behavioural techniques are often very effective in helping clients with three aspects of
PTSD. Relaxation techniques may be
employed throughout therapeutic intervention (Epstein, 1989). Desensitization may
also be used to help the client to gain a sense
of control over intrusive symptoms (Foa et al.,
1991). Richards and Rose (1991) claim that
in vivo was effective in the reduction of phobic
anxiety, while imaginal exposure improved
dysphoria and some phobic symptoms. Imaginal exposure requires clients to confront
memories of the event repeatedly. This may
involve then reciting the story of the trauma,
verbally or in writing, or by listening to tape
recordings of their account. This will help the
clients to remember fully their thoughts,
feelings and behaviours at the time of the
trauma, and assist both with desensitization of
affect and assimilation of the event.
In a similar way, re-visiting the sight of the
event, or making contact with features associated with it, is claimed to assist clients with
the assimilation process. Behaviour therapy
also provides a useful framework for problemsolving activities, in which it may be appropriate to engage at any stage during counselling.

Conclusion
PTSD has only received recent recognition,
and research pertaining to the efficacy of
therapeutic interventions is in its genesis.
Counsellors need to be vigilant with regard
to identification of the disorder, particularly
as evidence suggests that PTSD may have a
far higher prevalence in the general population than was formerly recognized (Breslau
et al., 1991).
Of equal importance is the necessity that
counsellors should possess both knowledge
and skills in bereavement processes and crisis
intervention, and an understanding of how to
help clients severe intrusive and denial symptoms.
An integrated approach to intervention has
been suggested. There is evidence that certain
techniques work well for certain symptoms,
however, there is a lack of comparative
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Employee Counselling Today

Maggie Wilcock

Volume 8 Number 7 1996 812

research concerning the superiority of one

approach over another.
There do appear to be certain core features
of any intervention, that is, usually it should
be directed at increasing the clients sense of
control, involve a sensitive balance of challenge and support, and be directed at helping
the individual to assimilate fully and accommodate the memory of the traumatic event.

Foa, E.B., Rothbaum, B.O., Riggs, D.S. and Murdock, T.B.

(1991), Treatment of rape victims: a comparison
between cognitive-behavioural procedures and
counselling, Journal of Consulting and Clinical
Psychology, Vol. 59 No. 5, pp. 715-23.
Gibson, M. (1991), Order from Chaos, Venture Press,
BASW.
Horowitz, M. (1976), Stress Response Syndromes, Jason
Aronson, New York, NY.
Kendall, P. and Hollans, S. (1981), Assessment Strategies
for Cognitive Behavioural Interventions, Academic
Press, London.

References and further reading

Lazarus, R.S. and Folkman, S. (1984), Stress, Appraisal and

Coping, Springer, New York, NY.

American Psychological Association (APA) (1987), Diagnostic and Statistical Manual of Mental Disorders,
3rd ed., APA, Washington, DC.

Magaro, P. (1991), Cognitive Basis of Mental Disorders,

Sage, London.
Morrice, J.K.W. (1976), Crisis Intervention Studies in
Community Care, Pergamon, Oxford.

Blume, E.S. (1990), Secret Survivors, Wiley, London.

Breslau, N., Davis, G.C., Andreski, P. and Peterson, E.
(1991), Traumatic events and post-traumatic stress
disorder in an urban population of young adults,
Archives of General Psychiatry, March 1991, Vol. 48
No. 3, pp. 216-22.

Parkes, C.M. (1972), Bereavement Studies of Grief in Adult

Life, Tavistock, London.
Peebles, M.J. (1989), Post-traumatic stress disorder: a
historical perspective, Bulletin of the Menninger
Clinic, Vol. 53 No. 3, pp. 274-86.

Butler, G., Fennell, M., Robson, P. and Gelder, M. (1991),

Comparison of behaviour therapy and cognitivebehaviour therapy in the treatment of generalized
anxiety disorder, Journal of Consulting and Clinical
Psychology, Vol. 59 No.1, pp. 167-75.

Prochaska, J. and Clemente, C. (1982), Transtheoretical

therapy: toward a more integrative model of change,
Psychotherapy: Theory, Research and Practice, Vol. 19
No. 3, pp. 276-88.
Richards, D.A. and Rose, J.S. (1991), Exposure therapy for
post-traumatic stress disorder, British Journal of
Psychiatry, Vol. 158, pp. 836-40.

Clegg, F. (1988), Disasters: can psychologists help the

survivors?, The Psychologist, Vol. 1 No. 4,
pp. 134-5.

Rose, D.S. (1991), A model for psychodynamic

psychotherapy with the rape victim, Psychotherapy,
Vol. 18, pp. 85-95

Davidson, J. (1992), Drug therapy for post-traumatic

stress disorder, British Journal of Psychiatry,
Vol. 160, March, pp. 309-15.

Schwartz, R.A. and Prout, M.K. (1991), Integrative

approaches in the treatment of post-traumatic stress
disorder, Psychotherapy, Vol. 28 No. 2, pp. 364-73.

Epstein, R.S. (1989), Post-traumatic stress disorder. A

review of diagnostic and treatment issues, Psychiatric Annals, Vol. 19 No. 10, pp. 556-63.

Stone, A.M. (1992),The role of shame in post-traumatic

stress disorder, American Journal of Orthopsychiatry,
Vol. 62 No. 1, pp. 131-6.

Fairbank, J.A., Fitterling, J.M. and Hansen, D.J. (1991),

Patterns of appraisal and coping across different
stress conditions among former POWs with and
without post-traumatic stress disorder, Journal of
Consulting and Clinical Psychology, Vol. 59 No. 2,
pp. 274-81.

Taylor, A.J.W. (1989), Disasters and Disaster Stress, AMS

Press, New York, NY.
Wolf, M.E. and Mosnaim, A.D. (1990), Post-Traumatic
Stress Disorder. Phenomonology and Treatment,
American Psychiatric Press, Washington, DC and
London.

Fisher, S. (1984), Stress and the Perception of Control,

Lawrence Erlbaum, London.

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