Posttraumatic Stress Disorder
Lucy Berliner, Dr. Dean Kilpatrick  -  2006/5/24
.  Fort Hood
 Thanks for All you do.
Please recommend resources/specific techniques for helping to resolve the problem of guilt feelings in adult survivors of sexual abuse/assault.
1.  Dean Kilpatrick
 Fortunately, there are several techniques with good research validation for dealing with these issues. Specifically, my colleagues and I developed a treatment called "Stress Innoculation Treatment" that includes a component that addresses maladaptive cognitions such as guilt. Another excellent treatment developed by Patricia Resick, Ph.D. is called "Cognitive Processing Therapy." It has considerable research evidence suggesting that it is quite helpful for guilt and other negative emotions following sexual assault.
What things can a non-counselor do to assist clients with post traumatic stress? What credentials should you look for when referring a client to a counselor for this issue?
1.  Barbara Hayler
 What is the best way to present this view of PTSD without making it seem like another "failure" on the part of the survivor?
2.  Lucy
 A non-counselor can be helpful by being knowlegeable about the what PTSD is and giving infomraiton to victims. Key concepts are that PTSD is a failure to recover, meaning the usual process of recovering from afrightening or threatening experience some how failed.[Most victims do not develop PTSD although they may have some of the symptoms] It is related to intense negative emotions experienced during the event that are reexperienced and that the person wants to avoid becasue they are unpleasant. That we have effective treatments so the prognosis is good. Most importantly that hard as it might be confronting the memory this is how people get better. So they non-counselor can help with getting the victim to treatment.
Is it safe to say that most, if not all, victims of violent crime suffer some form of traumatic stress disorder? If so, what methods/techniques work best to get victims to seek out counseling? Is there a web site where advocates can get effective information which will help victims of PTSD understand what they are going through and what they should do? Thanks!
1.  Dean Kilpatrick
 Yes. Battered women have very high rates of PTSD largely due to the pattern of extreme threat and violence they have over time.
2.  Marilyn
 Many of the domestic violence clients I have worked with also have been abused (sometimes sexually) as children and have never before discussed this with anyone - some of this due to the fact that it is an issue that in the past was often NOT discussed or it was not safe to discuss. Environmental, family or news events may bring past events to memory and cause current distress to these women - I've learned to always ask DV victims if anyone in the past has ever done things, said things, asked them to do things showed them things that made them uncomfortable - this at least opens the door, and past abuses often are disclosed and addressed in therapy at this point, along with triggers currently and from the past that add to their distress - identifying triggers can be noted and work begun to begin to reduce the reactions to triggers - it's a long process, but some women are willing to stick with the process. When they do stay with the process, they begin to make sense of things and see self-improvement. This can take quite a long time, but improvement can and does happyen.
3.  Lydia Lindsey
 Many of the battered women we work with have symptoms of ptsd, could it be more prevalent in this population?
4.  Dean Kilpatrick
 I don't know whether it would be accurate to say that most if not all victims suffer some time of traumatic stress disorder. However, most victims of violent crime are changed in some way by what happened. Those most likely to develop problems are those whose crimes are more serious and who lack good social support and other resources. Sometimes, people who have been victims of prior crimes are also more likely to develop problems. It's important to remember that many victims are resilient. The National PTSD Center has a great website though I don't have the address handy, you should be able to find it by using a search engine. Also, OVC has a video tape that my colleagues and I did entitled "Meeting the Mental Health Needs of Crime Victims" (NCJ Number 167235). You can get obtain a copy from the NCJRS website (
Now that more physicians are getting better at identifying victims of violence, what should they do in their practice setting to assess for PTSD and what intervention can be intitiated by the primary care practitioner?
1.  Lucy
 It is a good step forward that primary care providers now screen for violent experiences but screening needs to be accompanied by more startiing with inquiring about the impact of the event because that is what is important. Not everyone who has a violent experience needs formal therapy. A provider can explain that it is normal to have upsetting reactions right away, including posttraumatic stress which is specific distress about the event, but that most people will gradually get better. Normalizing the typical responses and reinforcing use of positive coping (the usual.. talk to people, get some rest and relaxation, be hopeful that things will get better. Alerting people to when to get formal help..symptoms and distress are continuing or getting worse, are interfering with functioning[school/wrok, relationships], the distress in pervasive, etc. Also people who are still in violent situations or are recent victims of crime should be referred to specific servcies to help deal with systems and alternatives. It is big that we can be optimistic.
I have heard very strong opinions both for and against EMDR. What is your opinion of this treatment modality for victims of trauma (when used by licensed and experienced counselors)?
1.  Samata Horwitz
 Could you please elaborate on what is meant by stress innoculation training, prolonged exposure, cognitive processing therapy?
2.  SallyStar J
 I have seen EMDR used successfully in PTSD and personally have had positive results.
3.  Dean Kilpatrick
 EMDR is a controversial treatment for several reasons, but I believe the evidence suggests that it does work, probably not through the stated mechanism. There have been several studies done that show that it works approximately as well without the eye movement part of the treatment. Most experts think that if it does work it is probably due to the fact that clients are encouraged to expose themselves mentally to the traumatic event. There is not much evidence that it produces miraculous cures in one or two sessions. I think there are treatments that have much better research support (i.e., stress innoculation training, prolonged exposure, cognitive processing therapy).
We are working with several children from a family which was allegedly deeply involved with child pornography -- possibly producing their own -- for years. The children were exposed to photographs, sex toys, and websites, even if they weren't used as subjects. They have been removed from the home, but are still responding to conditioning not to talk about anything sexual. The oldest is about 11; how can we best help these children understand that the change in their lives (home, family) is likely to be permanent, their parents will probably go to prison, and that nothing they say or don't say will change the situation, without making their trauma worse? They grew up this way and don't know any other lifestyle.
1.  T.Key
 I think that children will eventually begin to talk, but you have to wait on them to do so. Making sure they are safe and can life a "normal life" with boundaries and showing them what's appropriate will get them to gradually open up about their history and then you can do the work.
2.  Lucy
 This sounds like one of those very sad situations where children's whole life experience has been corrupted by their parents. The good news is that getting them out of that situation is th eonly hope for them. But it has to be kept in mind that it took years for them to develop the adaptive/coping strategies that they are using so it will take a long time to acquire new ones. The priority in this situation is stabiltiy of an alternative placement and reasurrance about what comes next. It will help caregivers if they can understand the children's behavior as a survival strategy that will only go away when they really understand that their environment is differnt, that what happned befoe won't happen there. That reluctance to engage, defense of parents, anger at caregivers if persent are not persnal attacks but survival strategies. Informing the kids that they will not return home and that their parents will go to prison should be done in a very matter of fact way, and then they are offered the opportunity to express feelings,ask questions, etc. There is nothing we can do that can completely counter this type of loss so we shouldn't try to "make it better" but to support children in livng though it and establishing a new life. Therapists are less important in accomplishing these goals than steady adults who will stay in their lives. In terms of responding to symtpoms, that should be indivudalized to the child depending on the symptoms or problems identified during assessment. This is a tyupe of situation where caregivers and professionals should be on high alert for possible sexulization. When children have been exposed to this all their lives they may fall back into that behavior with each other because it is comforting or familiar. Try to prevent it so you do not end up having to separate them in placements.
While we increasingly admit evidence of PTSD in our criminal and civil courts, how do we avoid having the evidence of trauma painted by the defense as trauma from some other source unrelated to the sexual violence, such as: fear of domestic violence from a jealous partner, extreme guilt from being caught in adultery, alarm over the dramatic response of the criminal justice system, or fear of losing a marriage or children in family court as a result of the sexual interaction?
1.  Dean Kilpatrick
 In any court or legal situation, it is important to be as accurate as possible when dealing with expert testimony. This is clearly true of any testimony concerning PTSD. It is not surprising that defense attorneys would attempt to characterize inconvenient PTSD evidence in a way that is self-serving to their clients. However, PTSD has several symptoms that are content specific. For example, avoiding thoughts and feelings surrounding an event, having intrusive images about an event, are symptoms in which identifying the event in question is essential. If a victim has PTSD symptoms that are directly related and involve a rape experience, there is no legitimate way to say that these arise from "extreme guilt from being caught in adultery", or "alarm over the dramatic response of the CJS". What is needed in these types of situations is someone with real expertise in crime-related PTSD and how to assess it. This will help the jury or other triers of fact to sort out real PTSD from defense attorney-manufactured PTSD.
What is the earliest age a treatment provider can begin to see symptoms of PTSD? Is it ever too early to say, "This can be a result of the trauma this child has experienced?"
1.  Lucy
 It is more difficult to diagnose PTSD in very young children because the diagnostic crieria require reporting on internal states. Alternative criteria have been proposed, see Michael Scheeringa's work for excellent example. For the youngest children it is recommended to use the DC 03 diagnostic framework. But it is important not to get bogged down on diagnosis, what counts is distress. So of course very young children can experience fear for which the cure is safety and reassurance (not therapy for the very young set, it is all about the caregiver). On the other hand some types of trauma are not experienced by very young children as traumatic and we should not promote that.An example is touching sexual offenses. It is the meaning not the act that would count for a very young child and since they don't appreciate the meaning they are often not highly distessed. It is usually the caregiver who is most upset so the target is helping the caregiver reduce their own distress and being optimistic. For example, the child is told someone did something they shouldn't have, it won't happen again, the child did nothing wrong, now go out and play. For the youngest children (under 3)it is possible thechild won't even remember what happened if he/she is safe, supported and assisted to return to everyday life. This is why attention to the caregiving environment is so important especially with younger kids.
From the position of the property manager of a public housing complex, what assistance can we give within the laws of privacy and business decorum?
1.  Dean Kilpatrick
 I'm not quite sure what you are asking. There is nothing about being a victim of crime that enhances your socio-economic status, and poor people may be more vulnerable to certain types of crimes than their more affluent counterparts. So, it is likely that you would have many crime victims in a public housing complex. One thing you might do is to provide them with information about crime victim services. Another thing you might do is to make sure that if a crime happens in your facility, that victims get the best services possible. If there is a series of crimes happening in the complex, the best thing you can do is to facilitate neighborhood crime watches and to work closely with police to provide as safe an environment as possible. However, this must be done in a way that is very sensitive to the needs and feelings of the residents.
2.  Barbara Hayler
 Let's not forget about the importance of prevention as well. Anything you (or any landlord or property owner) can do to make an area safer and more protected -- locks, lighting, regular attention to who is using the space, even safe transport -- can be enormously helpful.
Our agency has moved toward more psycho-education for non-disclosing children where there is reason to believe abuse occurred. What would be the best practice for serving children with no disclosures and no observable symptomology?
1.  Lucy
 If a child has not reported and has no sx the possibilties are 1. didn't happen, 2. happened but child recivering naturally as most do, 3. happened and child engaging in maladaptive avoidance (e.g., refusing to remeber/talk about an experience they know they had). What you do should to some extent be mapped on to best assessment of what the situation really is, not giving sa boiler plate. Although similar info can be conveyed, emphasis and amount should be matched to what is most likely. If there is signfiant question about whether it happend then brief future focus review of rules for acceptable behavior and what to do if is the key information. It is unecessary and risky to belabor re sxetc. If Strong suspicion that is happened maladaptive avoidance versus just don't want to talk aboutcan sometimes be sorted out by explaining that being able to say what happneed is evidence that getting better and good in case need to talk in future. Then anticipatory gguidance re trauma reminders, memory being distressing, coping, etc.For the avoidance kids more explanantion about why avoidance makes sense becaseu remebering is upsetting, brief psychoed re why weird asit might seem remembering n purpose can actually help because don't need to avoid. So psychoed is a good way to go inthis situation but adjsuted for your clinical assessment of what is really the story.
How/what to do to help people with PTSD due to long isolation as refugees? How long does the PTSD last? How to overcome to PTSD? Is medication the only solution to treat PTSD?
1.  Dean Kilpatrick
 Refugees have some specific challenges that may complicate their treatment. For one thing, as your question suggests, they often have very complicated and severe traumatic event histories because of their displaced status. They often flee their native land because of trauma occurring there, and they are often vulnerable during the transition. As newcomers, they may be preyed upon by predators. They lack knowledge of language, customs, and potential services. The first step in helping them is providing them with information and encouragement to seek help. PTSD can last a lifetime if untreated. Medication is not the only, or perhaps even the best, way to treat PTSD. There are several cognitive behavioral treatments for PTSD that have been shown to be safe and effective.
When working w/sexual assault victims, espec in the first months of the trauma, and whom may have less than "positive" support networks - what are ways to instill hope for victim, their family,or spouse? How their family reacts & supports them in the first months may affect even their basic safety needs & tx goals. Especially if their spouse is their main support, immigrant familes with less family nearby, or victims who new to area. Ideas?
1.  Dean Kilpatrick
 There is no question that being supported and believed is an important part of facilitating sexual assault victims' recovery. Unfortunately such support and affirmation that they are believed is often in short supply. Also, unfortunately, the CJS often is an ordeal for victims who are put on trial themselves. This is less than perfect, but one thing that helps sometimes is to stress how important and courageous it was for the victim to report the crime and to cooperate with law enforcement. Another thing that is often helpful is to provide the family and friends with accurate information about rape cases and how victims respond and what they need from family and friends. This is not easy. You just do the best you can to help educate victims and families as well as to provide them with all the support you can.
How do we approach professionals that have vicarious trauma reactions of numbing and denial?
1.  jess
 We do not have vicarious traumatization support for our judges, but as advocates we feel it is our responsibility to advocate for systems changes as problems come up. An example, a judge dismissed a stalking order because stalking didn't happen between people that knew each other and thus there was a "jaded" knowledge deficit...we provided a current copy of the RECON of stalking research paper with supporting stats that stalking in fact happens most often between people that know each other...said paper was delivered by the DA during a meeting to discuss the ruling and concerns of our domestic violence and sexual assault we are concerned that restraining orders cannot be served to persons in psychiatric institutions because of HIPPA regulations will not allow medical professionals to confirm or deny a patient is in house...thus, we have some "voluntary" patients using the loop hole to side step a restraining order, voluntarily check out of the facility and then reapproach the victim (who has PTSD) and claim the restraining order was not ever served.
2.  Heather Powers
 Based on some discussion inside our agency, I have been wondering about this issue in regards to judges who try these cases. Is anyone familiar with a court system that offers vicarious traumatization support for judges? This kind of "jaded-ness" can truly affect and inhibit the treatment of survivors in court.
3.  Dean Kilpatrick
 Treating victims can be upsetting to professionals because we have to listen to their story and experience their pain vicariously. Also, one psychological mechanism we use to protect ourselves is to get jaded and sometimes we even discount the victim and their experience in order to protect ourselves. We need to monitor ourselves and our colleagues to make sure that our efforts to protect ourselves are not harming our clients. It is really important for all of us to monitor our own mental health and to take care of ourselves so we can take care of victims.
Do you find children have different reactions than adults. For instance, if an 8 year or a 12 year witnessed a horrific crime, would you expect their response to be different than 20 year or 45 year old?
1.  Lucy
 This is a good question and the answer is it depends. Some research suggests children are more negatively effected. For example a recent report comparing children and adults in terms of PTSD in a NY sample re 9/11 found the children had higher rates of "probable PTSD". Children are quite likely more affected by environmental factors such as caregiver response. There is good evidence that more distressed parents means more distressed kids and less success in therapy for the kids. Or even such things as watching traumatic events on TV can cause sx for children. So agian with kids it is essentail to think of intervention as a collaborationwiththe parent to help the child with an emphasis pn teh centrality of their role. General rule however, is don't assume you can kbnow the effects of a trauma simply by knowing what it was, how old the child is etc, there is a lot of variatin and an indivudalized approach will always lead to a more matched response.
Quite a number of interventions to alleviate or cure PTSD look like therapeutic shortcuts -- one or a few sessions and the victim is better. What are the most prominent of these and what evidence is there as to their efficacy?
1.  Dean Kilpatrick
 One principle I always go on is that if it sounds to good to be true, it probably is. This holds for most of the treatments you are mentioning. Elsewhere, I discussed EMDR. Another treatment that is highly touted is thought field therapy. This treatment has no adequate supporting research. It would be great if there were simple, quick, effective treatments for difficult, complicated problems such as PTSD. Alas, this is not the case.
What are the symptoms of Posttraumatic Stress Disorder?
1.  Dwight Phipps
 Children and adolescent report a number of cognitive changes resulting from PTSD. Many experience difficulties in concentration, especially in school work. Others report memory problems, both in learning new material and in remembering old skills. They become very alert to danger in their environment and becaome affected by any reports of other tramatic events or disaters.
As a youth services student, I am quite new to helping children with posttraumatic stress disorder. What is the best things to do that will help youth?
1.  Lucy
 I would recommend you go to the National CHild Traumatic Stress Network website There is a lot of good information and contacts.
In your work, what is the average length of time for recovery for victims.
1.  Ferlita
 Length of time varies and is different for each person. What I know for sure that will speed the process is the support from other survivors, especially if ocurring during Group sessions.
2.  Dean Kilpatrick
 It depends. There is no set pattern for recovery; each individual is different. Having said that, there is a good bit research data suggesting that many crime victims experience a substantial amount of recovery some where between one and three months after the crime occurs. However, subsequent experiences that involve stressors can make crime-related mental health problems worse even years later. Also, there is evidence that crime-related metnal health problems, although improved in many cases, can last for years without effective treatment.
At what stage in counseling a PTSD victim should an victim advocate "release" the victim to a psychiatrist for services and follow-up?
1.  Kilpatrick
 I assume when you talk about counseling a victim with PTSD you were talking about a victim advocate doing the counseling. Most victims improve within the first two or three months following the crime. One reason to refer is if a victim does not seem to be improving. Another reason is if a victim is having suicidal thoughts or has major substance use problems. By the way, psychiatrists are not the only type of mental health professional who can provide mental health treatment to crime victims. Social workers, clinical psychologists, and licensed professional counselors can too. The key here is to establish a good working relationship with a mental health professional who knows what they are doing with respect to treating crime victims.
What are treatment differences do you perceive between working with someone who has experienced chronic trauma for 15 years (like intimate partner violence or ongoing child abuse) as opposed to someone who has PTSD around a single incident?
1.  Lucy
 The clinical consideration is always what are the problems and needs for this indivudal, to jsut what happened.Yhe field has fallen into a fasle dichotomy of single incident/nothing else wrong and chronic/everythign wrong. Thsi is not the way victims look, it is more of a contunuum of levels of distress and impairment that related to many factors. If the person has more specific PTSD sx then that should be a focus. Three are effective treatment sthat work just as well for people whosePTSD is the result of a recetn single incident or past chronic trauma. If the pateitn shas more broqad and pervasie distress that crosses domains of fucntioning then treatemtns should target those concerns. For example, a victim who is selfharming and has signficant relationship types of problems might benefit by Dialectical Behavior Therapy or it's prinicples. A new book by John Briere and colleague on the pricniples of therapy with trauma vicitms provides a good framework. it is published by Guoford.
Incest often spreads like wildfire in family systems. What steps do you suggest for keeping siblings and other minor-aged relatives safe, while going through the therapy process? Consider that you are treating children under the age of six.
How does one attempt to ask a victim if counseling/treatment is something they would like to look into?
We are planning a training session for family law attorneys. What are the essential training points we should make in order for lawyers to (1) recognize whether clients suffer from PTSD and need a referral; and (2) minimize or avoid further traumatization through litigation?
1.  Kilpatrick
 I am not sure whether you would be addressing the needs of child victims, adult victims, or both. However, I believe the curriculum should start with an overview of the basic types of crimes involved, what they are like, and what types of crime characteristics are most likely to produce PTSD. You also need to have someone describe what PTSD is and how to recognize its symptoms in children and adults. In general, you could say that people need treatment when their PTSD symptoms are causing them great distress and/or are interfering with their life. Litigation is a two-edged sword. It can be stressful, but it can also validate the victim. There are ways to work with victims that enhance their ability to withstand the stress of the CJS process or litigation.
Our organization is conducting a training for domestic violence shelter workers on how to recognize symptoms of trauma and how to repsond appropriately (not how to clinically treat them, just how to handle them). We find that trauma often shows itself in strange ways, such as a woman insisting on having the lights on while sleeping. How can we teach DV shelter workers how to negotiate these symptoms against the rules of the shelter, as well as the wishes of the roommmates and cohabitants of these victims?
I keep getting child clients who have extensive trauma histories that have been labeled ADHD or ODD or Bipolar and placed on medications which don't seem to be helping improve their behaviors. Trauma issues go un-addressed and their behaviors at school and home are perceived as discipline problems and not arousal problems. The solution for these problems which does not work is to change meds or whip them. What i have to offer is perceived as allowing the child to manipulate me. Anyone else having this delimna?
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