Friday, June 14, 2013

Traumatizing Your Characters, Part 10 (!!!): Writing PTSD treatment that's true to life

This is getting comical. But never fear! I think this is pretty much it. Next Tuesday, I'll be posting at YA Highway, a kind of summary about things to consider when writing traumatic events and characters exhibiting PTSD symptoms.

Up to now:
Part 6: Intrusive Recollection
Part 7: Understanding Triggers
Part 8: Avoidance and Numbing
Part 9: Hyper-arousal

Okay ... so you have a traumatized character, and you want to depict him/her going to treatment. This post is for you.

It is widely accepted that treatment for trauma really can't begin until the person is safe--you can't recover from trauma if you're still IN that trauma. Of course, there's a lot of debate about what "safety" means, and whether we're just talking about physical safety (e.g., not still living in the home with an abuser) or both physical and psychological safety (e.g., is living with a temporary foster family a psychologically safe place to deal with traumatic memories?). We have to use our best judgment and keep doing research on that one.

I'm going to describe prolonged exposure therapy in VERY general terms (that often apply to other research-supported treatment approaches as well, such as EMDR). PE is one of the most well-researched and effective treatments for PTSD in existence. There are other treatments like it, such as trauma-focused cognitive behavioral therapy, which is often used with traumatized children and their parents. These are not the only treatments--but there is SOLID evidence to show they work. And I don't like to waste time talking about stuff that I don't believe has a reasonable chance of working. If you're going to apply another model of therapy, it might be cool to see if there's any research support to show it's effective in treating PTSD.

A two-minute video on prolonged exposure therapy:

Once the person is in a reasonably safe place (i.e., not being re-traumatized), treatment can begin, and it generally includes three phases. If you're writing someone receiving treatment for PTSD, please do not have the person walk right in and start dealing in-depth with what happened to him. Because of those avoidance/numbing symptoms, it's unlikely a person with PTSD would even be willing or able to do that. Also, there's work to be done before you can get to that, because of those hyper-arousal symptoms. You can't dive into the deepest, most dangerous waters before you've given the person a nice lifeboat and a life preserver and a tether to LAND.

What you do first is establish some coping skills. Sure, initially you don't expect a person who's been traumatized to be able to use those coping skills when hyper-aroused, but think of it as planting bulbs in the fall--you don't expect them to sprout until the spring. You work with the person on safety and what's referred to as "grounding" skills. Grounding is all about staying in the present. Examples of grounding techniques include counting (like, bricks in the wall, books on the shelf, tiles on the floor) or focusing on a sensory sensation, like the feel of your butt in the chair and your feet on the floor. Some people use objects to hold them in the here and now, like a paperweight or one of those squeeze balls. There are a variety of means to cope (e.g., breathing exercises), but the goal is to develop a way to "come back" or "stay present" when hyper-aroused, so that you can bring your body and mind back into that comfortable cool zone where logic is possible.

Once those skills are well-established, the person can begin to process and grieve the traumatic memories. Usually, it's good to focus on one event, even if the person is dealing with multiple events. In this phase of treatment, the person is asked to describe, in great, painstaking detail, what happened. The therapist asks questions, but also checks in every few minutes and asks the client to identify her distress level on a kind of scale (subjective units of distress, or SUDS). The client uses grounding techniques to keep herself in the moment, but she continues to discuss the memory and think about it with the guidance of the therapist. She does this over repeated sessions and exposures until she is no longer unduly distressed or impaired by the memory. It usually happens relatively rapidly when done right--this therapy only takes 8-12 sessions in a lot of cases!

Describing the trauma repeatedly (and listening to tapes of that description) is only one part of it--if the trauma has led to avoidance of specific places or situations (e.g., driving at night after a carjacking), the therapist will help the client create a "hierarchy" of feared situations that she will gradually expose herself to, starting with the easiest situation and moving to the hardest.

Symptoms can re-emerge during the processing phase, but the therapist is ready for that and helps the client through it. The final phase is about consolidating those coping skills, increasing positive emotion and social connections, and re-engaging with the world.

Aaaand that's pretty much it. Speaking as a psychologist, I guess what I would beg each and every one of you is to do your research if you're writing treatment for PTSD. There are remarkable resources out there, free and available for use and dissemination.

On Monday, I'll do a little wrap-up and answering questions that have come up. If you do have questions that I haven't answered, today would be the day to post them in the comments section!


  1. Having one's therapist character giving the client a life preserver before they get into the deep end is not only accurate, but it's good drama in that allows for a great deal of character development to play out over a longer period of time, as in "Ordinary People" and "Good Will Hunting."

    And for a question, what does listening to the tapes do for the person? Allows them to objectify the event, like writing it out as a story might do?

    1. Listening to the tapes provides additional exposure to the memory in a controlled way. The key to so much of this therapy is control, something that's most often been taken from a person who's endured a trauma. Treatment is about exposure in a very controlled, safe manner--not about retraumatizing, which is why the therapist monitors the exposures carefully and tracks the client's distress to make sure it doesn't tip into the red zone.

  2. I wouldn't exactly call it PTSD, but as you well know, I've been writing a traumatized character (most of mine are, at least a bit, but that's another topic for another day), so this series of posts has been particularly timely.

    Thanks, Sarah!

  3. Love this series. Wishing perhaps it'd been around before I'd written a character dealing with PTSD...

  4. I concur, this has been very informative, so much so I'm bookmarking the series for later reference. Thank you, Sarah.

  5. An excellent post series!!!!

  6. I need to go back over all these trauma posts (because the last one I read was incredibly helpful and have used a lot of the info in my latest draft) but I see now that you're on 10 I need to give myself like half a day. ;P

    Been following you a bit on fb but have been overwhelmed IRL and not online very often. Hope you're doing well!

  7. Hi, first ley me say that your post have helped me a lot.
    I'm used to write about eating disorders as coping mechanisms but I was tired of doing that, and I came across your blog while researching from PSTD.
    One question: there are big differences when treating PTSD and C-PTSD?

  8. Israeli Researchers Track Post-Traumatic Stress In The Brain
    By NoCamels Team December 04, 2012 3 Comments
    First responders like emergency medical technicians, police officers and firefighters are at high risk of developing post-traumatic stress disorder (PTSD). They are often faced with disaster scenes the rest of us only watch in Hollywood movies.

    A Tel Aviv University team is using novel brain-scanning tools, in order to better understand the physical aspects of the PTSD and develop effective treatment methods.

    As someone who has a myriad of genuine life events with gory details... I prefer the Israeli method to sufficiently assist with genuine compassion, humility and assist humanity.

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