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Section 6
Stages of PTSD Recovery

Question 6 | Test | Table of Contents

Among people who are victims of a severe traumatic experience, 60 – 80% will develop PTSD. As mental health professionals, how can we help these clients manage their PTSD? In this course we will discuss PTSD and the treatment EMDR as it relates to PTSD.

In this section, we will give an introduction that will serve as a review for treating clients with PTSD and that will help begin the discussion of treatment with your client.

As a review for you, here is the normal sequence of traumatic stress reaction and recovery described by Mardi Horowitz. I went over these sequences with, Michelle, age 35, who was experiencing PTSD after a childhood of physical, mental, and sexual abuse along with another experience where she was attacked at knifepoint. Both of these experiences had a traumatizing effect on Michelle.

She shared with me, while shedding tears, "I felt that there was no safe place in the world, including my home. After being attacked at knifepoint, I filed a report to the police. Rape counselors came to see me but I declined their help because at the time I did not realize how much I needed the help. I saw violent images of the attack each time I closed my eyes. I lost all ability to complete simple tasks and to concentrate. I began avoiding social situations and trying to make friends. Last year I was diagnosed with PTSD and I felt such a sense of relief knowing that my condition was real and treatable."

Here are Horowitz’s four stages of PTSD reaction and recovery that I shared with Michelle:
1. Outcry: In this stage of PTSD, you may experience strong, distressing emotions such as feeling stunned, overwhelmed, or frightened.

Michelle responded by telling me, "I had moments of overwhelming emotions that have come out of nowhere."

2. Avoidance and denial: In this stage you may feel numb or blunted because you may feel that it is not true what is happening. You may withdraw or avoid potential supporters, constrict emotionally, or even stare blankly all in an attempt to avoid the reality of the situation.

Michelle and I then discussed how Michelle’s avoidance of social situations and her giving up on making friends fit into this stage.

3. Intrusions: In this stage intense emotions and thoughts related to your stressful event may come to your awareness. Arousal is signaled by hypervigilance, startle reactions, and compulsive repetition of actions that are linked to the event.

Michelle explained that she had been overcautious and jumpy ever since her traumatic experience.

4. Working through until completion: When you are able to face the reality of the event, talk it through with people you trust, experience all thoughts and feelings, correct flawed thoughts, come to terms with what you have experienced, grieve, and restore your equilibrium, then you have reached the last stage. In this stage you can make commitments to live, accept yourself as you are, accept what you have lost, find the silver lining in the trauma, grow beyond your condition before the trauma, and so on.

Do you have a client, like Michelle, who has PTSD, who could benefit from having these four stages of PTSD reaction and recovery explained to him or her?

For PTSD clients, it can be a struggle to know where to begin with the healing process. Michelle told me, "I have a name to my problem but that is only the first step. Where do I go from here?" I helped Michelle gain some focus on what direction her recovery would take by giving her a few focusing questions. I began by stating to Michelle, "It is normal to want to avoid painful memories but they continue to pursue us and only by working through the traumatic memories can you let them go." I stated, "Here are just five examples of questions your healing process will answer." I then discussed the following five questions with Michelle:

1. What does the trauma mean? Why did it happen?
2. How do I make sense of my world again?
3. Who or what was responsible, and how do I make peace with my actual role?
4. Why haven’t I adapted better, and what coping skills will help me cope better?
5. What does it mean to process memories so that I can let them go? How is it done?

Isn’t It Better to Leave the Past Alone?
I have found that many clients dealing with PTSD question whether it is better to leave the past alone. Some clients may worry that by digging into their past, they will just relive their trauma. I usually state to my clients, "Perhaps it is better to leave the past alone. If the past is truly settled, then revisiting it does not usually hurt and it may even result in greater insights and resolution. While it may be the hardest part, most people feel that confronting traumatic material is the most helpful part of treatment." Do you have a client who is hesitant about revisiting the past that could benefit from a similar conversation?

In this section, we gave an introduction that served as a review for treating clients with PTSD and that will help begin the discussion of treatment with your client. We went over Horowitz’s four stages of PTSD reaction and recovery which are outcry, denial and avoidance, intrusions, and working through until completion. In the stage of outcry, your client may experience strong, distressing emotions such as feeling stunned, overwhelmed, or frightened. In the denial and avoidance stage, your client may feel numb or blunted because he or she may feel that it is not true what is happening. In the intrusion stage, intense emotions and thoughts related to your client’s stressful event may come to his or her awareness.

In the final stage, your client can begin making commitments to live, accepting himself or herself as he or she is, accepting what he or she has lost, finding the silver lining in the trauma, growing beyond their condition before the trauma, and so on.

We also discussed questions that your client’s healing process will try to answer. The examples of questions are: What does the trauma mean? Why did it happen?; How do I make sense of my world again?; Who or what was responsible, and how do I make peace with my actual role?; Why haven’t I adapted better, and what coping skills will help me cope better?; and What does it mean to process memories so that I can let them go? How is it done?

In the next section we will discuss the eye movement technique that can be used by your PTSD client as a quick distraction and a way to gain temporary relief from distressing thoughts.

Schiraldi 42-43, 159-161, 191
Case study: http://www.adaa.org/living-with-anxiety/personal-stories/my-story-survival-battling-ptsd
Statistic: http://healmyptsd.com/education/post-traumatic-stress-disorder-statistics
Reviewed 2023

Update
Trauma Recovery Rubric: A Mixed-Method Analysis of Trauma Recovery Pathways in Four Countries

Koutra, K., Burns, C., Sinko, L., Kita, S., Bilgin, H., & Arnault, D. S. (2022). Trauma Recovery Rubric: A Mixed-Method Analysis of Trauma Recovery Pathways in Four Countries. International journal of environmental research and public health, 19(16), 10310. https://doi.org/10.3390/ijerph191610310


Peer-Reviewed Journal Article References:
Barr, N., Kintzle, S., Sullivan, K., & Castro, C. (2018). Suicidality and nonsuicidal high-risk behavior in military veterans: How does PTSD symptom presentation relate to behavioral risk? Traumatology, 24(1), 55–61.

Kloep, M. L., Hunter, R. H., & Kertz, S. J. (2017). Examining the effects of a novel training program and use of psychiatric service dogs for military-related PTSD and associated symptoms. American Journal of Orthopsychiatry, 87(4), 425–433. 

Kumar, A., Azevedo, K. J., Factor, A., Hailu, E., Ramirez, J., Lindley, S. E., & Jain, S. (2019). Peer support in an outpatient program for veterans with posttraumatic stress disorder: Translating participant experiences into a recovery model. Psychological Services, 16(3), 415–424. 

Mitchell, S. M., Taylor, N. J., Jahn, D. R., Roush, J. F., Brown, S. L., Ries, R., & Quinnett, P. (2020). Suicide-related training, self-efficacy, and mental health care providers’ reactions toward suicidal individuals. Crisis: The Journal of Crisis Intervention and Suicide Prevention. Advance online publication. 

QUESTION 6
What are the four stages of PTSD reaction and recovery? To select and enter your answer go to Test.

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