Treatment of posttraumatic disorders

As for the role of counselling in the treatment of acute stress disorder, there is no evidence that non-directive or reflective counselling is effective in the treatment of post-traumatic stress disorder. Indeed, there is substantial anecdotal evidence to suggest that reflective counselling may be destructive in this disorder, apparently because patients are 'retraumatized' by those memories of the traumatic experience that are inevitably recalled, dwelt on, but not actively 'processed' in this form of work.

The advocates of counselling for post-traumatic stress disorder describe active focused methods such as cognitive-behavioural counselling. (41> Such methods need to be used within the context of a sound therapeutic relationship, meeting the core counselling conditions. Given that many clients with post-traumatic stress disorder are, understandably, mistrustful or avoidant, it is likely that, without such core conditions being met, engagement in counselling and commitment to a desensitization approach would be difficult.

The same arguments apply in relation to the counselling of adults who were sexually abused in childhood who present with a wide range of psychiatric problems, and where shame, guilt, and mistrust are common. Women and men who were abused in childhood may value the empathic skills of counsellors, but again there is anecdotal evidence to suggest that a non-directive and reflective approach can retraumatize patients. Unstructured counselling may promote recollection of the abusive experiences, but without providing an opportunity for emotional and cognitive 'processing' of the traumatic experience. Sometimes this can activate powerful intrusive imagery, including flashbacks. There may also be a risk of promoting the unconscious elaboration or distortion of recalled memories in a manner that supports the vexed notion of 'false' memories. The clarity of thinking required in this fraught clinical field is not assisted by texts that advocate counselling without qualification.

The treatment of sexual abuse survivors requires active therapeutic techniques in conjunction with a secure therapeutic relationship. Cognitive, behavioural, and psychodynamic methods have a place for different patients, as do group, couple, and family interventions.

Where counselling skills are required most conspicuously is when the patient needs help in making decisions in relation to their abusive experience, but this would often be in the context of active treatment. For example, the patient may be thinking about confronting their abuser, initiating legal action against them, or warning others that they could abuse again. Here the counsellor or therapist will need to work carefully within the parameters of decision-oriented counselling, neither directly advising the patient nor shrinking from the task presented. This is a difficult area from an ethical standpoint, most particularly when the therapist believes that others might be at risk.

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