We have suggested above that, following a traumatic event, the majority of people are able to integrate the trauma-related information over time into their schematic models of self, world, and others. In this section we discuss how this assimilation might occur.
The integration of trauma-related information, or emotional processing as Rachman (1980, 2001) has called it, normally occurs as a function of exposure to the information either within a therapeutic context or within a supportive social network. Such exposure can take many forms; for example, systematically recounting the event, returning to the place where it happened, or just talking about it in more general ways. We propose that this exposure serves to reduce post-traumatic symptomatology in two main ways. First, it allows the individual to re-experience the trauma-related information, information that is incompatible with higher-order models, in a safe con-text—an environment in which the higher-order models of safety, controllability, predictability, and so on to which the person clings do still hold. This process allows the individual to begin to conceptualise the event as something anomalous and unusual in a world where the models of meaning and reality that had served for so long do still have a significant place. Foa and her colleagues talk of this process as an integration of non-danger-related information into the fear network (see above). However, we would argue that it is more readily understood at the higher level of meaning represented by schematic models.
The second means by which various forms of exposure to the trauma-related information operate, we propose, is by weakening the links between that information and the generation of fear via the associative level within SPAARS. This is the same principle we have proposed for the success of exposure-based treatments of phobias (see Chapter 11) and depends on the individual experiencing a reduction in fear during the exposure session, when fear is the primary emotion in the PTSD reaction. Such exposure-based emotional processing, as we have suggested, serves to enable the individual to integrate the trauma-related information in memory. Consequently, we would argue, this approach is likely to have little benefit for those individuals with chronic PTSD as a consequence of their very inflexible models of the self, world, and others, because they are unlikely to be able to modify those models to integrate the trauma-related information, regardless of how many times that information is represented through exposure. For these individuals, their sense of reality and meaning has been "shattered" (Janoff-Bulman, 1985) and it seems likely that more cognitive-oriented treatment would be more efficacious in replacing the abandoned, overvalued, inflexible models with more adaptable, functional ones. Furthermore, when the PTSD is primarily based on a past-oriented emotion such as anger, sadness, or disgust, then exposure-based treatment may not be the most efficacious (cf. Jaycox & Foa, 1996), but could serve to exacerbate the emotional distress rather than lead to habituation. Again, in such cases a more cognitive-oriented treatment may be warranted (Dalgleish & Power, 1995).
In this section of the chapter we have reviewed the constellation of difficulties experienced by people with PTSD and discussed the various extant theoretical models of the disorder. We have sketched an analysis of PTSD within the SPAARS model developed in Chapter 5. We have paid particular attention to the issues of chronicity and late onset within PTSD and have discussed briefly the mechanisms by which treatment effects might operate. In sum, we submit that the complexity of post-traumatic reactions can be explained more effectively within multiple-level theories such as DRT and SPAARS than within the simpler single-level theories that exist in the literature.
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