published_or_final_version / Clinical Psychology / Master / Master of Social Sciences

The purpose of this study was to investigate post-traumatic stress disorder among Guatemalan and Salvadoran refugees living in Tucson, Arizona. The questions that guided the study were: (1) Does post-traumatic stress disorder exist among Central American refugees living in Tucson? (2) If so, how does it manifest itself in this population? (3) What counseling or other therapeutic interventions may be helpful for Central Americans experiencing post-traumatic stress disorder? Six Guatemalan and Salvadoran refugees who had reportedly experienced major stressors participated in a semi-structured interview and responded to a health questionnaire based upon post-traumatic stress disorder symptoms. Findings indicate that five out of six participants were experiencing patterns of stress-induced symptoms which were consistent with a DSM III diagnosis of "Post-Traumatic Stress Disorder". Recommendations for intervention with Central American individuals experiencing post-traumatic stress disorder are presented.

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M.A. thesis, Faculty of Humanities, University of the Witwatersrand, 1999

This thesis is part of a creative arts PhD which explores the possibilities of constructed images and the memory of the South African Border War. It was presented together with an exhibition of constructed photographic images entitled BOS. In the thesis I argue that the memory of the war, an event now almost three decades past, continues to be problematic. I also argue that photographs are themselves complex and constructed objects that do not provide a simple truth about either history or memory. Photographs can supplement or support memories but they are always to be viewed with suspicion. In Chapter One I explore the limitations imposed on the speech of conscripts, both during the conflict and in the years following the conclusion of hostilities. In Chapter Two I examine the recent appearance of several ‘anti-­‐ heroic’ memoirs of the conflict written by conscripts. The use of the medical diagnosis of post-­‐traumatic stress syndrome (PTSD) in these writings is critically examined. Chapter Three focuses on a development in the ideas of the two most influential figures in the field of Anglophone photographic theory, Susan Sontag and Roland Barthes. I argue that their initial hostility to the photographic image on ethical/political grounds has been replaced by a more nuanced engagement with the power of the image. I then examine the views of two contemporary writers on photography, both deeply involved with the analysis of traumatic images: Ariella Azoulay and Susie Linfield. In Chapter Four, I engage with the artistic practice of the American photographer, David Levinthal, an important reference point for this project because of his photographic work with miniatures and toys and his place within what I describe as ‘critical postmodernism’. In Chapter Five, I examine the themes of silence and censorship as these pertain to the photography of the Border War using Susan Sontag’s notion of the “ecology of images”. I analyze the types of images which have been produced from the war, looking at the “limited photojournalism” of John Liebenberg and the role of iconic images in the propaganda war. Finally, in Chapter Six, I present an account of the process of creating the work for the BOS exhibition in which I employed a combination of strategies involving appropriation, miniaturization, and re-­‐staging.

This program of research investigated the nature and processes of autobiographical memory deficits in posttraumatic stress disorder (PTSD). Study 1 examined the proposition that difficulties in the retrieval of specific memories present a risk factor for posttraumatic psychopathology. A prospective study of fire-fighters found that a significant predictor of posttraumatic stress was a deficit in retrieving specific memories to positive cues before trauma. Study 2 investigated whether autobiographical retrieval deficits in PTSD can be modified by psychological treatment. Results found that as PTSD symptoms reduced following treatment, individuals with PTSD retrieved more specific memories to positive cues. Together, these results indicated that specific retrieval deficits to positive cues present a vulnerability factor for PTSD. However, this memory style appears to be receptive to modification following therapy. Study 3 investigated the association between autobiographical retrieval deficits and impaired problemsolving in PTSD. Participants with PTSD retrieved more overgeneral categoric memories and took longer to retrieve memories than non-PTSD trauma controls. This deficit was associated with impaired social problem-solving, suggesting that specific retrieval is related to successful problem solving. In an analogue design, Studies 4 and 5 investigated the proposition that resource limitations may underpin autobiographical retrieval deficits. Results generally supported the proposal that reduced cognitive resources may be a mechanism contributing to specific retrieval deficits. Studies 6 and 7 examined rumination as another possible mechanism responsible for these retrieval deficits. Study 6 found high anxious participants retrieved fewer specific memories to positive cues following rumination, compared to distraction. Study 7 found evidence that negative rumination in the high anxious group increased categoric retrieval, whereas positive rumination had no effect. Study 8 found retrieval of trauma-related self-defining memories was strongly associated with personal goals connected to the trauma. Study 9 found that discrepancies in one???s self construct were related to the retrieval of trauma memories to positive cues. This program of research extends current theories of autobiographical memory by identifying risk, maintenance, and recovery factors in the context of PTSD.

The term “post-traumatic stress disorder” (PTSD) is a relatively new diagnostic label, being formally recognized in 1980 in the Diagnostic Statistical Manual for Psychiatric Illness – Third Edition (DSM-III) of the American Psychiatric Association (APA, 1980). Complex Post-Traumatic Stress Disorder (CP) is a more recently discussed, and newly-classified, phenomenon, initially discussed in the early 1990s (Herman, 1992a). Thus, as research into effective treatments for CP is sparse, the treatment of CP is the topic of this study, in which a guideline-based treatment program developed by the researcher for the treatment of CP is implemented and evaluated. Ten individuals participated in this study, undertaking individualized, guideline-based treatment programs spanning a period of six months. In providing background information relevant to this study, an explanation is provided regarding the nature of CP, and the reasons for its consideration as a separate phenomenon to PTSD. The adequacy of the PTSD formulation in enabling effective assessment and treatment of CP is also explored, with endorsement of previous researchers’ conclusions that the CP construct is more useful than the PTSD construct for assessing and treating survivors of long-term and multiple forms of abuse. The PTSD classification is restrictive, and not necessarily appropriate for certain forms of trauma (such as prolonged trauma, or multiple forms of trauma), as such trauma experiences may lead to specific effects that lay outside those formerly associated with PTSD. Such effects include alterations in affect regulation, consciousness, self-perception, interpersonal relationships, and in systems of meaning. Following discussion regarding the PTSD/CP classification, an examination of treatment methods currently used in the treatment of PTSD, and a review of treatment outcome studies, takes place. The adequacy of primary treatment methods in treating CP symptoms is then examined, with the conclusion that a range of treatment methods could potentially be useful in the treatment of CP symptoms. Individuals with a diagnosis of CP may benefit from the adoption of an eclectic approach, drawing on different treatment options for different symptoms, and constantly evaluating client progress and re-evaluating interventions. This review of treatment approaches is followed by details of an initial study undertaken to obtain feedback from individuals who had suffered long-term/multiple trauma and who had received treatment. Participants in this initial study were asked open-ended questions regarding the treatment approach they had experienced, the most useful aspect of the treatment, the least useful aspect, and other strategies/treatment approaches that may have been useful – but which were not used. The feedback obtained from these individuals was used to inform the development of treatment guidelines for use in the main study, as were recommendations made by Chu (1998). The predominant focus of the treatment guidelines was “ego strengthening”, a term coined by Chu (1998) to describe the “initial (sometimes lengthy) period of developing fundamental skills in maintaining supportive relationships, developing self-care strategies, coping with symptomatology, improving functioning, and establishing a positive self identity” (p.75). Using a case study approach, data are then presented relating to each of the ten individuals involved in the treatment program: details of his/her trauma experience(s)and the impact of the trauma (as perceived by each individual); details of each individual’s treatment program (as planned, and as implemented); post-treatment evaluation of the positive and negative aspects of the treatment program (from the therapist’s perspective); and details of the symptoms reported by the individual post-treatment, via psychometric assessment and also during interview. Analysis and discussion of the data relating to the ten participants in the study are the focal point of this study. The evaluation of the effectiveness of each individual’s treatment has been based predominantly on qualitative data, obtained from an analysis of language (discourse analysis) used by participants to describe their symptoms pre- and post-treatment. Both blatant and subtle changes in the language used by participants to describe themselves, their behaviour, and their relationships pre- and post-treatment have provided an insight into the possible changes that occurred as a result of the treatment program. The language used by participants has been a rich source of data, one that has enabled the researcher to obtain information that could not be obtained using psychometric assessment methods. Most of the participants in this study portrayed notable changes in many of the CP symptoms, including being more stable and having improved capacity to explore their early abuse. Although no direct cause-effect relationship between the participants’ treatment program and the improvements described can be established from this study, the participants’ perception that the program assisted them with their symptoms, and reported many aspects of “ego strengthening”, is of major importance. Such self-perception of strength and empowerment is important if an individual is going to be able to deal with past trauma experiences. In fact, abreactive work may have a greater chance of succeeding if those who have experienced long-term or multiple trauma are feeling more empowered, and more stable, as were the participants in this study (post-intervention). In concluding this study, recommendations have been made in regard to the use of guideline-based treatment programs in the responsible treatment of CP. Strengths and limitations of this study have also been highlighted, and recommendations have been made regarding possibilities for future research related to CP treatment. On the whole, this study has supported strongly other research that highlights the importance of focusing on “ego strengthening” in assisting those who have suffered long-term/multiple trauma experiences. Thus, a guideline-based program focusing on assisting sufferers of long-term trauma with some, or all, of the symptoms of CP, is recommended as an important first stage of any treatment of individuals who have experienced long-term/multiple trauma, allowing them to develop the emotional and psychological strength required to deal with past traumatic events. Clinicians who are treating patients whose history depicts long-term or multiple trauma experiences (either from their childhood, or at some stage in their adult life) need, therefore, to be mindful of assessing individuals for symptoms of CP – so that they can treat these symptoms prior to engaging in any work associated directly with the past traumatic experiences.

The clinical adherence to and combination of methods with EMDR to treat PTSD has not been explored. This is of some concern as 27 000 clinicians are trained in EMDR globally. This exploratory study gained information on Australian trained EMDR clinicians' adherence to EMDR, and the methods they combined with EMDR to treat PTSD. Survey responses from 126 clinicians were analysed using predominantly descriptive statistics. The findings of this study showed that the majority of respondents perceived that they closely adhered to the standard EMDR treatment. However, respondents reported adhering more closely to the phases than the steps of EMDR. Statistically significant findings showed that more experienced EMDR level 1 clinicians were more likely to add steps and phases to EMDR, and to change the standard sequence of steps. Clinicians with greater years of experience were also more likely to change the standard sequence of steps. In addition, more experienced EMDR level 2 clinicians, were less likely to educate their clients about PTSD. Almost all respondents combined EMDR with other methods to treat PTSD. Combined methods included CBT, hypnosis / relaxation, system / solution focused methods and exposure. This research has contributed to theory and practice by uncovering that clinicians appear to use EMDR differently to researchers, by changing EMDR to meet client needs, combining EMDR with other methods and Holly Byron 16/9/99 vi therapies, and introducing EMDR in the mid stage of treatment. These findings are vital to reduce the scientist-practitioner divide by accurately testing EMDR's efficacy and enabling future controlled trials to reflect the clinical use of EMDR.

Thesis (Ph. D.)--University of Hong Kong, 2007. / Title proper from title frame. Also available in printed format.