O'Grady Psychology Associates

Psychotherapy, Marriage Counseling, Neuropsychological Assessment

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Post-traumatic Stress Disorder and Post-traumatic Stress Injury

 Responding to first responders and PTSD

Responding to First Responders:  PTSD and PTSI in First Responders

Psychologists sometimes treat first responders to an emergency. We may see police officers, firefighters, hospital staff, paramedics, and clergy who have suffered psychological trauma after responding to a natural disaster or critical incident. First responders may come to us to help them with post-traumatic stress disorder (PTSD), substance abuse, chronic pain, depression, and anxiety. Treatment for first responders and their families is further complicated by their access to firearms, which increases the risk of suicide.

The symptoms of PTSD, include hyper-vigilance, insomnia, flashbacks, and nightmares. Another “post-traumatic stress injury,” or PTSI. A traumatic injury implies that the reaction to a critical incident must not necessarily lead to a psychiatric disorder or become a chronic condition. Diagnosing a “disorder” may lead first responders to believe that their reactions are wrong and that they won’t get better. By using the word “injury,” we empower people to feel they have some control over how they recover from the event. In the words of Matthew J. Friedman, executive director of the Department of Veterans Affairs National Center for PTSD: “The concept of injury usually implies a discrete time period. At some point, the bleeding will stop. Sometimes the wound heals quickly, sometimes not. A disorder can stretch on for decades.”

An emergency can present first responders with a critical incident—that is, a sudden, unexpected, unusual event that includes the loss or threat of loss of life. First responders who perceive a threat or trauma can react in significant psychological and physiological ways. It’s important for the treating therapist to understand the meaning clients attribute to a critical incident, which affects how it is processed. Police officers at a violent scene might be excited, afraid, or just wonder about what’s for dinner that night.

Stress, left alone, is neither harmful nor toxic. Whether the stress becomes damaging is the result of a complex interaction between the outside world and our physiological capacity to manage it. – John J. Medina, Ph.D.

Our body’s reaction to stress is partly a matter of what stress we encounter, partly its duration, and partly what the responder brings to the event. Other life events can also play a role in reactions to critical incidents. At least 60% of adults in the United States have experienced at least one traumatic event in their life, such as child maltreatment, interpersonal violence, natural disaster or serious accident. Exposure to traumatic events is a risk factor for depression, substance abuse, and PTSD. When a parent or other significant adult has traumatized a child, scars are left that can re-emerge in adulthood. Depression is the most common effect of trauma. However, most who have experienced a critical incident don’t experience long-term consequences; in fact, only about 7% develop PTSD/PTSI, although the percentage is much higher in the military, at 20-30%.

Trauma response doesn’t come out of nowhere. Most people diagnosed with PTSD have had at least two traumatic events in their life. In a study by John Briere (2012) that attempts to predict PTSD, he found that psychological neglect in childhood accounts for the largest percentage of variance, rather than the threat of physical injury. In treating clients with PTSI, it is important to explore the particular incident to which your client’s reaction is tied.

Betrayal for first responders takes four forms: administrative, organizational, personal, and community. An example of betrayal is keeping the first responders locked in a debriefing room, away from press and victims while investigations proceeded—with no provisions made for food or water. This constitutes an institutional failure, or as psychologists would say an empathic failure, and compounds the trauma. In the aftermath of catastrophic events, sometimes the most obvious way to support a traumatized worker is to take care of their physical needs.

Another kind of institutional betrayal was failing to protect a first responder from the press—for example, allowing private observations to be publically recorded. Such inattentiveness and lapse of judgment serve to make the primary trauma much more complex by re-opening wounds from childhood that, when coupled with intense life-threatening trauma, can lead to PTSD or PTSI.

In treating trauma, it is important to:

1. Acknowledge it and move toward forgiveness
2. See the connection between the current critical incident and personal history
3. Help the responder understand why it is so powerful
4. Get peer validation for the first responder’s experience

“What separates people who develop PTSD from people who are merely temporarily distressed is that the people with PTSD start organizing their lives around the trauma.” Bessel A. Van Der Kolk

Treatment elements include cognitive restructuring, development of cohesive narrative, affect regulation and relapse prevention. The real work is ongoing support, through individual and group meetings. Couples and family therapy is also a major component of treatment. Peer support and 12-step programs designed to help first responders are important adjuncts to therapy.

Kamena, M., Kirshman, E., and Fay, Joel(2013). Counseling cops: What clinicians need to know. New York: Guilford Press.

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Strains of Summer on Family Life

 

School is out.  Swim season is in full swing.  From my home, I hear the loud speaker blasting from the community pool.  Cheers erupt at regular intervals. Minivans and SUVs line the streets in the blocks adjacent to the swim club.  Like many parents residing in the suburbs, I enjoyed, sometimes endured, the annual ritual of Swim Team.  My daughters were only briefly interested in the glory of winning.  Mostly, they loved the Cup-of-Noodles and the ice-pops and talking to their friends under cover of gigantic towels.  Engagement in children’s activities is a good thing.  But often parents go too far in the direction of over-involvement.  Psychologists have studied the repercussions of what happens when parents are too attentive to their kids.  We describe this as enmeshment.

Focus on children’s activities often dominates family life in much of our country. We live in a child-centered era.  In the July 2 issue of The New Yorker, the article, ‘Spoiled Rotten’, Elizabeth Kolbert, profiled several families from diverse cultures.  How do parents of different cultures train young people to assume responsibilities?  Ms. Kolbert reports that the Matsigenka children from the Peruvian Amazon spontaneously help with a variety of chores, taking pleasure in their independence and helpfulness.  The Matsigenka culture prizes self-sufficiency and hard work.  They tell stories that reinforce these values.  The characters in their folklore are undone by laziness.

French kids will sit calmly through a three-course meal, while their American counterparts are throwing food before the main course arrives.  UCLA sociologists Carolina Izquierdo and Elinor Ochs assessed children’s participation in household responsibilities in a cohort of Los Angeles children. They found that no child routinely performed household chores without being instructed to.  Even when begged to do a chore, the vast majority still refused.

Here in the US, many well-meaning parents have inadvertently shaped their children to become dependent, manipulative and lazy.  As psychologists, we are often called to help restore harmony and balance to families in which kids rule the roost.

Summertime is often the most trying time for families. Frayed nerves, bored kids, too much time playing video games and watching TV, lead to thankful anticipation of the start of school for both parents and kids.  The comfort of daily routines is a welcome relief after a long, hot summer.

Inevitably, the return to structure and routine brings its own battles over homework and academics, in addition to the social strain of school.  There are ample opportunities for more squabbles and nagging, whining and complaining.  As the New Yorker article points out, parents often take the path of least resistance and do too much for their kids rather than face tantrums and meltdowns.

The fallout of raising over-indulged kids has to lead to a  ‘failure to launch’ for many young adults.  We have added this concept to our training and it is all too familiar in my practice.  Family therapy with adult children is now common.  While the economic troubles of the last three years have undoubtedly contributed to the large numbers of unemployed college graduates, but that is only part of the phenomenon.  As Hara Estroff articulated in Psychology Today, hovering “helicopter parents” are progressing to “jet-powered turbo attack model.” The looming pressures of getting accepted at a good college, SATs, extra-curricular cause yet more parental involvement.  With this degree of pressure, it is common for parents to let kids off the hook for chores and family commitments.

Teaching children to tolerate frustration, empathize with others and to persist in work is essential to raising independent young adults.  As psychologists, we help our clients to establish appropriate expectations for their kids and know when to step in to help and when to leave kids on their own.  In the next month, our clients will be transitioning from summer schedules to back-to-school routines.