Post-Traumatic Stress Disorder: The Social Worker Perspective

Post-Traumatic Stress Disorder
Matthew Wolfe
Marywood University
Mark A. Shaffer, MSW, LCSW
Social Work Perspectives on Psychopathology
June 29, 2013

Post-traumatic stress disorder: the social worker perspective Post-traumatic stress disorder (PTSD) is a psychiatric disorder that occurs following a traumatic event and is characterized by re-experiencing the event, avoidance of key details and features of the event as well as a state of hyper-vigilance and arousal (Zlotnick et al., 2001). The condition is relatively common, with almost 8% of adults experiencing PTSD at one point in their life (Bisson & Andrew, 2007). PTSD is more common in populations likely to be exposed to traumatic
events, including members of the armed forces or police force; combat experience increases the lifetime prevalence of PTSD to 49% in men (Bisson & Andrew, 2007). Women may also experience PTSD, an association that is noted with sexual assault, where the lifetime prevalence of PTSD is 29% (Zlotnick et al., 2001). The aetiology of the condition is unclear and may relate to susceptibility due to specific genes or neurodevelopmental characteristics of the individual (Cloitre et al., 2010). Accurate diagnosis and intervention in PTSD is essential as symptoms have a severe impact on the life of the patient, becoming socially disabling (Stein, 2003). Furthermore, patients may demonstrate signs of depression or substance abuse, which could lead to poor outcomes and more severe psychological discomfort (Lukaschek et al., 2012). The aim of this paper is to provide an overview of the diagnostic criteria for PTSD, as detailed in the Diagnostic and Statistical Manual (DSM) of mental disorders, including recent changes to the diagnosis of the condition. These changes will be reviewed from a social worker perspective, in order to evaluate how practice, ethics and values should be applied to these patients.
Comparison of DSM-5 and -IV The diagnosis of PTSD has been controversial for a number of years, with authors suggesting that DSM-IV criteria relies too heavily on an association with ill-defined trauma, leading to an inaccurate pathologizing of normal distress (APA, 2000). A recent update of these criteria has thus been formulated in DSM-5 in order to improve on diagnostic clarity and guide evidence-based treatment based on patient presentation and circumstances (Pitman, 2013). These changes will be considered in the context of social work practice for patients with PTSD. The updated diagnostic criteria for PTSD have favored the formation of four major symptom clusters, compared with three noted in the DSM-IV. The four clusters are: 1) re-experiencing the event, including flashbacks, recurrent dreams or prolonged psychological distress 2) heightened arousal, such as sleep disturbances or hyper-vigilance 3) avoidance and, 4) negative cognitions and mood (APA, 2013). Furthermore, the traumatic event that can lead to PTSD is defined in more explicit terms, including sexual assault and repeated exposure to trauma in police officers or first responders (APA, 2013). It is also worth noting that an individual’s response to the event is now considered less important (e.g. intense fear or helplessness) as such reactions are often poor predictors of PTSD development (APA, 2013). The new criteria have also recognized a preschool subtype of PTSD, where symptoms are present in children under the age of six years, indicating that a developmental component of PTSD is now appreciated (APA, 2013). In addition, PTSD symptoms in association with dissociative symptoms, including feeling detached from one’s mind or body, can be classified as PTSD dissociative subtype. Hence, there is an increased appreciation that PTSD, while a clinical entity in itself, often presents with complex mood and psychological disorders that may benefit from further treatment (Brewin et al., 2009).
Implications for social work practice
Psychosocial and cultural factors Understanding the impact of trauma on the life of the patient is an essential step towards developing a caring and empathic approach towards social care of the patient and can help to understand how the patient is likely to respond to specific interventions and may benefit from certain social tasks (Lukaschek et al., 2012). Furthermore, the exact nature of the traumatic event can shape the response of the individual to a large extent, modifying the way they perceive threat in everyday life and how they view social interactions and situations (Stein, 2003). One of the main difficulties in managing patients with PTSD in the long-term is the fact that patients are often socio-economically deprived either as a result or as a precipitant of their illness (Lukaschek et al., 2012). Evidence has shown that poor socio-economic status, unemployment, low education and environmental instability contribute to a more difficult clinical course and poorer long-term outcome (Andersen et al., 2012). Social workers have a common goal of reducing inequalities to access to care, overcoming social and economic barriers and facilitating optimal community care to patients with mental health problems (McGeary et al., 2011). Hence, in patients with PTSD, a concerted effort needs to be made in order to modify these sources of inequality and restore a normal social situation for the patients (Lukaschek et al., 2012). This requires a balance between therapeutic monitoring (e.g. if the patient if taking psychoactive medications) and social support (Andersen et al., 2012). Specific issues are likely to include building a community support network for the patient as a protective factor against feelings of isolation and victimization. Special cases such as military or combat associated PTSD may require behavioral counseling and management of potentially violent reactions to the trauma (McGeary et al., 2011). Cultural factors may also pose challenges to effective engagement with individuals who have suffered a traumatic event. South Asian women in the UK have been found to have low levels of disclosure regarding sexual abuse imposed upon themselves or their children, risking a stagnant therapeutic situation (Gilligan & Akhtar, 2006). The key to overcoming this barrier it to maintain a culturally-sensitive approach to these patients and recognize the difficulties that may lie in disclosing such information and confronting the events that have occurred (Gilligan & Akhtar, 2006). Engaging with local religious or cultural support groups and providing language-specific information and guidance can be of additional benefit, where cultural factors or comprehension may be more difficult (Stein, 2003).
Sexual abuse in children Evidence suggests that sexual abuse in childhood is a significant contributor to overall PTSD prevalence in the US and that many cases may go unrecognized unless specifically sought (Higgins & McCabe, 2003). The long-term impact of abuse during childhood may be evident for many decades and thus can result in PTSD at varying stages of the lifespan (Jensen et al., 2010). With the specific emphasis on cases of sexual abuse and the recognition that PTSD in children under the age of 6 years may be a clinically distinct category, social workers need to ensure that they can manage such cases in a compassionate and meaningful manner to promote effective coping mechanisms and long term health in this group (Johnson, 2004). A number of services exist for children who have been victims of abuse and social workers remain at the heart of such services (Corcoran & Pillai, 2008). The key to initiating consultation with children is the development of a strong therapeutic alliance, gaining the trust of the child in the process (Corcoran & Pillai, 2008). Therapeutic strategies are numerous and often depend on the extent of the PTSD exhibited, the existence of comorbidities and the experience of and resources available to the social worker in question (Hill, 2009). One of the main strategic approaches is psychoanalytical therapy, with cognitive behavioural therapy (CBT) used most commonly in the US (Jensen et al., 2010). Children should be encouraged to express abuse-related feelings, allowing the social worker to clarify doubts of the self and actively erode stigma and feelings of victimization (Millar & Corby, 2006). Creative therapies may also be beneficial in children who suffer from PTSD, and one of the most common approaches is the use of play therapy (Johnson, 2004). Play therapy involves coordinated play, which is intended to link the internal thoughts of the child to the outside world (Chetnik, 2002). This provides a form of emotional control and expression, leading to a feeling of safety when expressing attitudes and beliefs about the traumatic event (Jensen et al., 2010). The social worker should be aware of therapist interventions with children and should be able to manage feedback and build on such approaches as part of a holistic approach to PTSD management in this age group (Millar & Corby, 2006). Despite the value of these approaches, there remains a relatively low level of quantitative data in support of therapeutic approaches in children with PTSD (Addis & Krasnow, 2000). It is also recognized that social workers may lack sufficient guidance, both formal and informal, when dealing with such children and thus there is a need to clarify the role of the social worker and provide evidence-based guidelines on therapeutic approaches in this context (Addis & Krasnow, 2000).
Co-existing conditions One of the key aspects of social work within the context of PTSD is the need for social workers to be aware of co-existing psychiatric conditions, including depression and dissociative disorder (Stein, 2003). Practitioners need to be aware of changes in the mental state or behavior of the patient during long-term therapy in order to differentiate between deterioration in PTSD symptoms and the emergence of separate psychological issues, which may require specific interventions and tailored management strategies (Wiechelt et al., 2011). Research strongly associates substance abuse disorder with PTSD, which may be a means of coping with the condition or in some cases may have contributed towards the presentation (Wiechelt et al., 2011). Data has shown that patients who have substance abuse difficulties often do not fully benefit from standard PTSD management, including focused CBT, and hence there is a need to specifically manage these patients on an individual basis (Cohen & Hien, 2006). It may also be relevant to note that in individuals with substance abuse disorder, a high level of suspicion should be afforded by the social worker for PTSD symptoms and signs, in light of the strong link between the two clinical entities (Wiechelt et al., 2011). There is considerable overlap between symptoms of PTSD and other psychiatric disorders, further complicating this process of differentiation. Further guidance and refinement of diagnostic criteria has been proposed by some as a means of assisting in the diagnostic process (Cohen & Hien, 2006). In the meantime, social workers should monitor behavioral changes in patients and raise concerns with other members of the community team, when appropriate (Wiechelt et al., 2011).
Ethics and values Ethical management of patients involves maintaining the individuality of the patient, upholding their dignity and well-being and respecting the right of the patient to determine their own outcome (BASW, 2012). Therefore, patients need to be consulted during clinical decision-making processes and their best interests should be pursued at all times (Hutchfield & Coren, 2011). Social workers need to act as advocates for patients where other members of the clinical team can dominate decision-making, particularly where PTSD symptoms are severely limiting in social contexts (Millar & Corby, 2006). In addition to respecting and promoting the rights of the patient during a therapeutic encounter, social workers also need to uphold the dignity of their profession, act in a trustworthy manner and retain accountability for their actions (BASW, 2012). When managing patients with PTSD it is vital that social workers retain a professional approach and do not become overly involved in the emotional state of the client, while respecting that state to the fullest degree (Hutchfield & Coren, 2011). Maintaining objectivity during the therapeutic encounter is vital to ensuring that co-morbidities and persisting factors can be identified, leading to more effective patient care in the long-term (Rauch et al., 2012). While the DSM criteria does not change these factors in the therapeutic alliance, greater consideration should be extended towards both adult and child victims of sexual abuse, confidentiality and disclosure of information are key processes that social workers need to regulate in a professional and empathic manner (BASW, 2012). In summary, PTSD is a challenging condition for both patients and allied health professionals. Social workers are a key component to community management in this patient group, and as such they should be aware of changes to diagnostic criteria and the implications this may have for practice. DSM criteria are useful markers of disease aetiology and diagnosis, but it is important that social workers consider the wider aspects of care, such as socioeconomic inequality and co-morbid psychiatric illness. The emphasis on ethnic minority groups, sexual assault and childhood abuse marks an important step forward in recognizing victims of trauma who are at risk of PTSD. The social work profession needs to consolidate treatments and preventions that are tailored to the patients and the available community resources to meet the needs in the coming years.

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