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Reply to the post, state whether you agree with your peers. Read and respond in a scholarly fashion, commenting on how they incorporated theory with evidence-based practice. At a minimum, your response should be three to four paragraphs of three to four sentences each.
The purpose of this initial discussion post is to provide scholarly discourse for the perpetuation of knowledge within the student Psychiatric Mental Health Nurse Practitioner. Specifically, the clinical parameters for identification, assessment, psychotherapeutic strategies of Client-Centered Therapy (CCT) for utilization in patients that have experienced trauma. Peer reviewed clinical research will be included within the discussion for the utilization of different psychotherapeutic techniques of CCT for patients that have experienced trauma and/or have been diagnosed with Post Traumatic Stress Disorder (PTSD). CCT for the treatment of PTSD will be discussed for patients throughout the age spectrum, including children, adolescence, adult, and older populations.
Childhood trauma may manifest within psychiatric disease. This may include post-traumatic stress disorder (PTSD), acute stress disorder, and adjustment disorder. According to Boland et al. (2022), PTSD is associated with anxiety following exposure to traumatic stressful events including but not limited to: accidents, crimes, military combat, assault, natural disaster, diagnosis with life-threatening illness, and physical or sexual abuse. Patients with PTSD have negative thoughts associated with the events, experience flashbacks, and avoid reminders that create these stressors. These patients may organize their lives to contain and mitigate the effects of the traumatic experiences. Moreover, victims of rape or torture may have difficulty with physical touch. These patients are hypervigilant and scan their environments for signals, remain on guard, and on-edge. Other symptoms may include nightmares, dissociative responses with flashbacks including depersonalization/derealization, impairments of memory related to the event, negative perceptions of self and others, increased startle response, and difficulties with concentration. Acute stress disorder mirrors the symptoms of PTSD with intrusion, avoidance, negative mood, and hyperarousal, but is limited to occurring 3 days to 1 month following a traumatic event.
PTSD is closely related to Adverse Childhood Experiences (ACEs) experienced by children during early stages of neurodevelopment. ACEs are repetitive traumatic exposure endured by a child that places them at risk for chronic health problems, mental illness, and substance abuse in adulthood. This may include traumatic experiences including but not limited to neglect, witnessing or experiencing violence, having a family member attempt or die by suicide, house hold challenges, bullying, teen dating violence, and community violence. Risk factors for ACEs are related to families with caregiving challenges for special needs, children who date early, or engage in sexual activity, caregivers with limited understanding of a child’s needs or development, low income, single parents, high levels of parenting or financial stress, corporal punishment for discipline, isolated families, community risk factors, and high conflict with negative communication styles. (Centers for Disease Control and Prevention, n.d.).
Corey (2021) describes person-centered theory, created by Carl Rogers, as an approach that includes fundamental assumptions of patients including their trustworthiness, potential for understanding themselves, resolving their own problems, and having an ability for self-directed growth through therapeutic relationships. Thus, Rogers’ approach is based on three major attributes: congruence (genuineness), unconditional positive regard (acceptance and caring), and accurate empathic understanding (grasping the subjective world of the other person). The outcome of therapy was related to the therapist and the relationship between therapist and patient. Theory and techniques were secondary to the ability of the patient’s capacity for self-healing. Rogers rejected the psychoanalytical model of therapy and challenged the validity of therapeutic procedures of providing advice, suggestion, direction, persuasion, teaching, diagnosis, and interpretation (p.166). He purported that these concepts were often misused and judgmental. Rogers sought to test his underlying hypothesis of the client-centered approach through research into psychotherapy. He and his colleagues identified the ingredients for psychotherapy that could cause a therapeutic change. With confirmation that personal and interpersonal factors, rather than specific techniques were contributory to therapeutic change, Rogers essentially theorized that since perspective is subjective, only the subject can be the best expert on the subject of self (Corey, 2021).
Trauma-focused treatment therapies for children and adolescents are effective in treating core symptoms and usually share several things in common: 1) parental involvement; 2) development of coping skills and mechanisms; and 3) therapist-guided structured retelling of the traumatic story (Wilson & Joshi, 2018). Parental involvement in psychotherapy is thought to be an efficacious treatment for PTSD in children and adolescents (Brent et al., 2022). This type of therapy addresses the patient’s reactions to trauma through the parent-child relationship (Brent et al., 2022). Younger children are seen with their primary caregiver in sessions that focus on emotion regulation and changing maladaptive behaviors (Brent et al., 2022). Exposure to trauma triggers is usually encouraged in order to desensitize children and aid in processing the traumatic experience in a different context (Wilson & Joshi, 2018). This also allows the child to develop coping skills in managing the emotions and thoughts linked to the traumatic memories (Wilson & Joshi, 2018). For school-age children, a more structured approach is required and studies show that strategies that include psychoeducation about the effects of trauma, teaching coping skills, developing safety skills, and being able to process the traumatic experience through a constructive narrative are the most effective (Brent et al., 2022). While the parent is still involved, the sessions may not always be with the parent and child (Brent et al., 2022). Activities and sessions should be flexible and customized to the needs and development of the child (Brent et al., 2022). For example, for the younger school-aged child, puppets or drawing may be appropriate; however, for the older school-aged child, writing may be more suitable. For adolescents, exposure therapy has been shown to meet the needs of teens (Brent et al., 2022). It includes psychoeducation about the effects of trauma as well as training in breathing techniques to manage stressful situations or traumatic triggers (Brent et al., 2022). Adolescents are carefully exposed to previously avoided situations or activities associated with the trauma, and are prompted to repeatedly retell their traumatic story during sessions (Brent et al., 2022). Although parental involvement is essential, their present is not required or necessary for successful therapy sessions (Brent et al., 2022).
Using a CCT approach, the therapist focuses on building a trusting relationship with the parent and child and encourages self-efficacy while allowing the parent and child to be in control (McLean et al., 2017). The idea is that through empathetic understanding, therapeutic genuineness, and unconditional positive regard, the therapist can aid in the parent and child’s ability to develop competence to cope with stressful events (McLean et al., 2017). The emphasis is on rebuilding interpersonal trust (which may have been disrupted due to the unintentional harm of the child), choice and control (to address feelings of being out of control), and confidence in the parent and child’s ability to overcome struggles (McLean et al., 2017). In this kind of therapy, the parent and child guide the pace and content of the session (Corey, 2021). The therapist acts as a guide and uses the techniques of active listening, reflection, limited interpretations and little to no direct advice giving (Corey, 2021). The therapist tries to draw out solutions and strategies rather than prescribing ideas (Corey, 2021). Play and art materials can be provided for use to process emotions and expressions such as anger or aggression (McLean et al., 2017). Parental expression is also encouraged and helps to decrease parental stress so parental availability for the child is optimized (McLean et al., 2017).
Cue-centered treatment is a method of therapy that addresses symptoms in children who have experienced long-term chronic trauma (Wilson & Joshi, 2018). It recognizes that children with complex trauma may not gain optimal benefits from focusing on a single trauma (Wilson & Joshi, 2018). Rather, this type of treatment focuses on aiding the child to become their own agents of change through development of coping mechanisms, increasing insight into relationships between the trauma experiences and emotional and behavior responses (Wilson & Joshi, 2018). This falls in line with the main ideologies of CCT where the key factor is empathy (Rachamim et al., 2021). Empathy is crucial in the engagement of trauma survivors, especially those who suffered interpersonal violence and have developed images of others as distrustful or unhelpful (Rachamim et al., 2021). Offering an empathetic relationship with unconditional positive regards is more likely to lead to positive outcomes (Rachamim et al., 2021).
The application of CCT within the utilization of PTSD for the adult and older adult requires a fundamental comprehension in the psychosocial state of the adult. Erik Erikson’s psychosocial stages for the adult, roughly aged 40 to 65, discusses this period of development to be the measurement of success of an individual in their usefulness and accomplishment. At this stage of development, either an individual has become useful, but otherwise would have a failure in usefulness that would result in a lessened involvement in the world. This period is commonly discussed as generativity versus stagnation (Corey, 2020). The adult will either gain greater generativity with promotion of acts to propel themselves and their community forward. It is described as a period in which the adult raises children, gives back to society, becomes active in their community, and develops themselves within the greater good. However, the lack of development of generativity results in stagnation, a lack of involvement within the world related to unproductivity, disconnection, and isolation.
Within the older adult, aged 65 and older, Erikson described ego integrity versus despair as the final stage within psychosocial developmental stages. This stage is described by Erikson as a reflective view of the past. The older adult comprehensively evaluates their previous actions and events with success encompassing fulfillment of wisdom and ego integrity. A failure in the reflective view upon life is met with guilt, dissatisfaction, and ultimately despair within the older adult (Corey, 2020).
As previously discussed CCT requires the utilization of the patient to have a potential to understand themselves and resolve their own problems. When applied to PTSD, the patient may carry over trauma suffered throughout their life with maladaptive self-processing. The adult patient will typically follow the American Psychiatric Association’s (2013) DSM qualifications including traumatic event with negative thoughts, flashbacks, avoiding reminders, fearfulness, hypervigilance, nightmares, dissociation, depersonalization/derealization, and memory impairments. These symptoms can also manifest within the setting of other mental illness related clinical features, including but not limited to depression disorders, anxiety, and substance use disorders (Sareen, 2023). The concurrent diagnoses with PTSD require the utilization of different, evidence-based psychotherapeutic techniques. Specifically, solution-focused behavioral therapy, and motivational interviewing for substance use disorder. However, the integration of CCT can still be applied, especially within the onset of therapy, and building of patient rapport.
The psychotherapist within the CCT role employs congruence, unconditional positive regard, and accurate empathetic understanding (Corey, 2020). Therefore relationship building with determination of the patient’s maladaptive behaviors within the setting of their past trauma allows the adult and older adult patient to provide their personal experiences. The increased clinical distress of living throughout a life, and into adulthood with poor adaptation to previous trauma can provide difficulty. Specifically, complex relational and interpersonal difficulties related to previous childhood abuse and trauma carried into adulthood can be difficult to treat. The treatment recommendations are primarily for cognitive behavioral therapy and eye movement desensitization for PTSD. However, these therapies are based within the humanistic-experimental psychotherapies. A randomized controlled trial looking at the effects of emotional processing in therapy with patients with childhood abuse found that emotion self regulation or support counseling with exposure was better than exposure alone (Cloitre et al., 2010).
Exposure therapy is intended to facilitate emotional processing, but without attending to emotional regulation or within a well-established counseling relationship is clearly less effective. A key factor within the person-centered therapies is empathy. Those that have suffered interpersonal violence or abuse. Offering a genuine caring relationship, based within empathy is crucial to long-term success. This may be related to the continued rapport developed between the patient and the psychotherapist, with better engagement. Nevertheless, CCT is grounded within the relationship based practices shows a small, but ever growing evidence for its utilization within trauma-focused disorders.
Limitations to Rogers’ person-centered theory are the requirement for a non-judgmental, empathetic, and genuine therapist. Roger was constantly adapting his approach and evolving its usage with contexts spanning individualized therapy to politics in efforts to achieve world peace. The positivity, and promotion of a patient has usage in people that generally have an aptitude for personal growth or can self-compensate for their mental illness’. However, with more pronounced and severe cases of mental illness, this approach may have limited success.
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