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You and Traumatic Stress: Beyond the Medical Model

Mar 22

G’day all! Boutcha’? Stand by one……Hey “Bad Boy Bobby”, can you feel it? It’s comin’! However, you still have a chance to redeem your image. Just get your “peeps” to give mine the word and the massive machinery of the wrestling world, under the guidance of promoter extraordinaire Marty Gold, will swing into action; the “cage match of the century” will begin to take form. Between you and I, and whoever else reads this, I cannot wait to get you in the “square circle”. It will be an experience you will never forget. You won’t be sucker punching drunk farm boys from the Fraser Valley on the big night. You will be in the hands of one of the greatest super heavyweights ever to be made a Charter Member of the Cauliflower Alley Club. I’ll hit you with so many……Ahhh, I better stop here, but are you gettin’ an idea of how to talk on the stick? Man, you really have to abandon that “duhhh, deer caught in the headlights” thing. I guarantee you, it ain’t workin’ for ya’!!

Anyhooo, enough of promoting and down to business. In this offering I would like to continue in the traumatic stress vein. You are not my patients, I would like to educate you. I would like to show you that the field of trauma is not as simple as you have been lead to believe; there is life beyond the medical model (i.e. the idea that you are “sick”). In a nutshell trauma psychology is in need of more theory driven research. Therefore in this humble offering, I would like to open your eyes to just how many competing theories there are in the game, in addition to the one you (may) have been sold i.e. the “medical model”.

It is not difficult to make the arguement that most of the advertising, journal space, and $$$$$$ are gobbled up by the disease oriented approach to trauma. Most of the studies promoting this approach focus on the identification of risk factors to explain psycho-pathological outcomes related to trauma exposure. This approach relies largely upon “inductive reasoning” i.e. the explanation of symptom profiles; here we find the “PTSD vs. non-PTSD” research designs. This type of study does not clearly outline a theoretical model that provides us with testable hypotheses.

On the other hand, those theory models that are driven by “deductive reasoning” are more informative, but also rarer in the literature. It has been long understood that the only way a scientist can support a hypothesis is to first “deduce” by a logical process what the outcome of the experiment “should” be if the hypothesis holds (does this sound familiar to you accomplished investigators???)

So if I was a psychologist at a well regarded University (and not dependent upon guess who for my research dollars?) I would be advocating for theory based experiments with specific testable hypotheses. This leads me to the business at hand; I would like to present for you several (psychological) theories that are more than competitive with the prevailing medical model (that seems to gobble up much of the available research $$$$$). I hope you will see that this “PTSD BUSINESS” is not the only game in town. So what follows is an array of theories that hold as much water as the medical model (all they require is an accumulation of data based upon “deductive reasoning”). I’ll briefly explain them (if any of you are the originator of one of these theories please be patient with me; I admit that I am not an expert in all things). Some are broad and comprehensive, whereas the latter ones are more trauma specific. (If you are interested in references call me and I’ll provide them).

Social Cognitive Theory (SCT)

The SCT is an all encompassing theory of human behaviour that emphasizes the links that exist between the environment, the person, and behaviour. This framework is sometimes called “triadic reciprocal determinism” (I know, I know, but these research geeks are a special breed?). The model focuses on “self-regulation” as the critical mechanism for human adaptation.

The three-way system is thought to work through feedback systems e.g. an internal one (cognitive appraisal) and an external one (changes in the environment). The recalibration of efforts toward desired outcomes is primarily driven by the self-evaluation of successful vs. unsuccessful achievement of valued goals. Quite simply this theory is hypothesizing that we, through forethought and strategic planning, prefer to mold our environments rather than simply respond to them.

The critical aspect of this theory is “self efficacy” (i.e. “am I able to do what is required under these conditions?”) The perception of self efficacy has been found to be highly predictive of human functioning across a wide range of behaviour from athletics to trauma. One’s belief in personal efficacy has been shown to be highly predictive of goal setting and perseverance; two critical aspects of successful adaptation to trauma.

Bottom line: recovery post-trauma places a great demand on our ability to adapt. The interactive process of self evaluation (“can I do it?”) with the horror of what was experienced is central in the understanding of the dynamics of trauma recovery. So I ask you, according to this theory what will you do if a medical professional tells you that you are “sick” and will have a tough time ever reaching “wellness”?

Terror Management Theory (TMT)

TMT focuses on the psychological mechanisms that we use to cope with the inevitability of death (i.e. being a finite organism). According to this theory we develop a (culturally bound) worldview that explains our existence (i.e. the creation of personal values, and the promise of at least symbolic immortality for living up to these values). It follows then that reminders of our mortality increase our efforts to defend our world view thus reducing anxiety and death related thoughts.

Consequently, life threatening events have the ability to undermine or even shatter our core assumptions about safety and justice, how the world operates, and oneself (i.e. our culturally bound worldview). The “rub” lays in our efforts to protect our worldview. This means ,for investigators, studying the ways people find meaning in traumatic events. From the TMT perspective the person who sees the world as “malevolent and meaningless” would have his/her worldview confirmed in a traumatic experience. This could result in bouts of anxiety including hypervigilance, emotional numbing, self medication, withdrawal, religious zealotry etc. Whereas the patient who sees the world in a more balanced fashion would fare better.

Transactional Theory of Stress and Coping (TTSC)

This theory is more focused and magnifies the individual’s interaction with a stressful environment. The theory is comprehensive in that it includes the influence of the traumatic event, the role of cognitive appraisal, coping behaviours, and biopsychosocial reactions.

TTSC overlaps with SCT in that both focus on person X environment interactions mediated by thinking (cognitive appraisal). The applications of TTSC have focused largely upon coping (and its’ effectiveness) with little attention being paid to the cognitive appraisal aspects of the theory. The theory posits that coping can focus on problems (and their solutions), or emotional display (e.g. PTSD symptoms), and/or avoidance.

Broadly speaking TTSC suggests that the victim makes an in depth assessment of self X environment interactions including cognitive appraisal and biopsychosocial outcomes within a traumatic stress context; and that the sum of all of this results in a trauma response. (Are you getting the picture here??? This posttraumatic responding is not as “cut and dried” as the medical model would suggest).

Conservation of Resources Theory (COR)

COR is an interactive stress based theory; that is, individual X environmental factors will predict the degree of stress. The key to this theory is that people (historically) have acted to obtain, retain, and protect their resources. COR postulates that trauma can threaten or deplete “personal characteristics, condition, or energies”. Coping behaviours are thought to focus on regaining lost resources.

Several studies here have looked at trauma as the result of the unpredictable loss of extensive resources that is then mediated by thought; they have shown considerable promise. There seems to be less promise in the notion that loss of resources is a consistently negative predictor in the response to trauma.

Social Support Theory (SST)

A critical resource that has received significant attention in trauma research has been social support; the resource is defined broadly as “aspects of the victim’s world that engage in helping during a significant stressor or trauma”. Much research suggests that social support perceptions are related to biopsychosocial outcomes; including mortality rates (consider here the suicides of some of your brothers and sisters?).

There has been a call for research in this area to be cognizant of cognitive and physiological mediating mechanisms predicting health outcomes. There has been some discussion of how positive and negative influences (think of the support you receive from your employer) effect the interpretation of traumatic experiences and the resulting symptom profile. (Again I ask you, are you getting the picture here? This a far more complex issue than the medical model portrays!!).

Attachment Theory (AT)

This theory outlines the primary importance of the interactions between a primary caregiver and a child (that’s right, even the psycho-dynamic folks have a theory). Simply, if these interactions were avoidant or ambivalent during childhood the adult trauma victim may be at risk due to feelings of self devaluation, failure, shame, and/or self blame. Whereas a victim who experienced secure interactions with the primary caregiver may be in a position to experience a healthier trauma reaction.

Summary

I could go on, however you would have to be pretty obtuse to miss the point being made. The few competing theories that we have reviewed should provide for you the wide variety of theoretical approaches to trauma; ranging from broad theories of human functioning to more detailed and trauma specific theories. The main issue is, that victims be aware that the prevalent medical model (i.e. “take a pill”) is not the only theory in town and there are options that suggest psychotherapy as an alternative. The problem and its’ solution are not as simple as some would have you believe.

Dr. Mike Webster
Reg’d Psychologist
#0655

“Early one morning Woodpecker flew in for
a special meeting with Raven and asked,
‘I’ve heard about essential nature, but
I’m not sure what it is. Is it some-
thing that can be destroyed?
Raven said, ‘That’s really a presump-
tuous question’. Woodpecker ruffled
her feathers a little and asked, ‘You
mean I shouldn’t question the matter?’
Raven said, ‘You presume there is one”.

–Aitken

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3 Comments
  1. Relaxing with the others after a morning spent in meditation, Bear asked, “What is the spirit of being a patient?” Raven said, “Inquiry”. Bear cocked his head and asked, “What do I inquire about?” Raven said, “Good start!”

    –Sister Squirrel

  2. One evening following a meeting, Brother Lynx asked Brother Grizzly, “Does faith play a role in one’s therapeutic relationships?” Grizzly answered, “Great faith”. Lynx asked, “How should I direct it?” Brother Grizzly said, “One, two, three….One, two, three”.

    –Cougar Roshi

  3. Sister Rabbit expressed uncertainty for her safety in attending the meetings with such predators as Fox, Wolf, and Lynx in the group. Raven Roshi attempted to console her by asserting that all were “brothers” and could feel safe at the meetings. Sister Rabbit then asked, “Is there anything that isn’t uncertain?” Raven Roshi was silent.

    –Brother Badger

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