Functional Problems In Ptsd

The point of describing what is entailed in a conceptual understanding of a functional analytic case conceptualization is to notice the idiographic nature of the assessment process for the purpose of identifying additional sources of information of variance in problem behaviors to improve clinical outcome. There are many sources about how to conduct and even quantify a functional analysis (e. g., Follette, Naugle, & Linnerooth, 2000; Hawkins, 1986; Hayes, Nelson, & Jarret, 1987; Haynes, 1992, 1998; Haynes & O'Brien, 2000; Haynes & Williams, 2003; Johnston & Pennypacker, 1980; Kanfer & Grimm, 1977; Kanfer & Saslow, 1969; Naugle & Follette, 1998; Nelson & Hayes, 1986). As mentioned above, reviewing the scientific literature about likely sources of control in a particular clinical situation is a typical starting point. In this section we present a few of the symptoms of PTSD and consider them as target behaviors that are the focus of treatment.

In applying an evidence-based intervention, we presume that many of these symptoms are interrelated and may well remit when the nomothetic treatment protocol is utilized. However, that may not, and often does not, happen. There are certainly unique sources of variance not addressed by standard treatment protocols that would improve treatment outcome if properly identified and addressed.

Most of the symptoms of PTSD described under criteria B, C, and D in the DSM-IV (American Psychiatric Association, 1994) are easily thought of as reactions to stress. From a functional analytic perspective these reactions are themselves behaviors that function in a complex context. As behaviors they can be reinforced or punished by others and therefore become more or less likely to occur in the same or similar circumstances. These same behaviors can serve as discriminative stimuli or signs to others in the patient's environment. A discriminative stimulus indicates that certain behaviors are likely to be differentially reinforced or punished in the presence of that particular stimulus. For example, tears could indicate that comforting comments may be reinforcing to the patient. Additionally, these same behaviors can serve as reinforcers or punishers in response to someone else's behavior, thereby making the other person's behavior more or less likely to occur. For example, the sampe tearful response following an expression of intimacy may make intimacy less likely. In a social context, the stress reactions listed in criteria B, C, and D for PTSD can serve multiple functions at the same time, thereby affecting, and being affected by, many others simultaneously. It would be nice if all the consequences of these interdependencies disappeared as a result of, for example, a successful exposure treatment. However, the stress reaction behaviors have created effects of their own that may not be related to the original traumatic event.

Let us consider an analysis of symptoms 5 and 6 from criterion C as target behaviors: feeling of detachment or estrangement from others, and restricted range of affect. These behaviors are part of the numbing phenomena said to characterize PTSD. Presumably the numbing is functionally useful to the patient in that it is an avoidance strategy whose purpose is to control otherwise highly negative feelings. Without disagreeing that these numbing responses are adaptive in the short run, let us further hypothesize about how these target behaviors might arise and be maintained in a way that could lead to an improved outcome if addressed from a functional perspective. The analysis might begin with an explanation of what would lead to a feeling of closeness—the opposite of estrangement and restricted affect. The therapist might begin by taking a behavioral history of the patient's close relationships and find that they were characterized by shared expressions of feelings, wants, and needs, and physical or emotional intimacy. In the case of a couple, for example, the dyad has a common history expressing and reinforcing all of the above.

The expression of these feelings, wants, and needs entails two important verbal behavioral repertoires that Skinner referred to as the ability to tact and mand (1945, 1957). A "tact" is a label for a state condition, or event (including private events such as feelings) that is reinforced by the understanding of the listener (or the "verbal community," as Skinner called it). A "mand" is a request for something that is reinforced by the verbal community by providing whatever the speaker specified. An example of a simple tact would be "I am hungry." The tact is reinforced by the speaker being understood by the listener. An example of a mand would be "Give me a sandwich." The mand would be reinforced by getting the sandwich. Although there are many nuances, let us use these verbal operants to further some additional hypotheses about the maintenance of the numbing behaviors described in criteria C.

Consider this scenario: A married woman experienced a rape. In addition to the initial avoidance behaviors that frequently occur immediately after such a trauma, there is a substantial change in the communication between her and her husband. The husband may be reluctant to ask the question "How do you feel?" because he finds any discussion of what happened to his wife to be extremely aversive. It may remind him of a failure to protect his family, whether the feeling is sensible or not. This change in hus band-initiated conversation may be a contributing variable to her feeling distant from intimate relations. Note that in this example, the husband's decrease in inquiries about feelings is only a function of the wife being present. Nothing she has done, other than be a stimulus in his presence, has led to this change in his behavior. This fact in itself could lead to a sense of distancing in the relationship—and yet the patient has done nothing except be present.

But suppose the husband does engage in a conversation:

HUSBAND: How do you feel? [This is a mand to the victim to reply with a statement of feelings. The wife now runs into an important deficit in her own behavioral repertoire: Namely, she may have no verbal repertoire to label her feelings accurately. She has no experience with the private events she is currently experiencing, so she is not likely to have a learning history from interacting with others so that her verbal behavior would be shaped to describe her feelings.]

WIFE: I don't know. [The husband's mand has not been reinforced, which could lead to a decreased likelihood of further inquiry into her feelings, making her feel more distanced.]

HUSBAND: But I really want to know [how you feel]. [This is a repeated mand.]

WIFE: Well, I guess I feel ashamed. [This is a tact, probably used for the first time in this dyad under these circumstances and probably not completely accurate. In fact, there probably is no well understood label to apply.]

HUSBAND: Ashamed? You have no reason to be ashamed. It wasn't your fault. [In what might have been intended to be a supportive comment, the husband has certainly not reinforced the spouse's tact. Therefore, she is not feeling understood.]

WIFE: Well, maybe guilty that I should have done something to prevent it. [This is another attempt to tact her private experience.]

HUSBAND: There is no reason for you to feel guilty, Honey. There was nothing you could have done. [Again, the husband does not reinforce her talking about her feelings by any indication that he understands them. Although his responses may be intended to be soothing or supportive, they function to make it less likely that she will try to describe her important personal feelings.]

Because intimacy is partially characterized by the sharing of feelings and mutual understanding, exchanges such as this one are likely to decrease her efforts to talk about her feelings. If this pattern were to continue, it seems likely that she would feel more distant from her husband, with whom she formerly felt intimate. One of the mechanisms for this feeling of estrangement is the lack of intimate communication. An additional consequence of the victim's decreased conversations with her husband may be the self-perception of restricted affect because she is verbalizing less affective content (Bem, 1978).

The point of the above analysis is not to suggest that these symptoms of numbing do not have other causes or functions. It is simply to point out that a behavior that has one initial cause may be maintained or increased by influences not directly related to the trauma itself but rather to a change in communication behavior with important people in the individual's environment. Spousal communication could be concomitantly addressed while other kinds of interventions were occurring if this hypothesis seemed plausible. One reason why this case example was chosen was because the victim described feelings of guilt. Whether the tact was understood by the husband is not the only issue that is important. Empirically, there is evidence that feelings of guilt by trauma survivors is a contributing factor in the development of PTSD, especially in the absence of social support (e.g., Kubany et al., 1996; Ullman & Filipas, 2001). Identifying this source of control over portions of the numbing response could explain a significant amount of outcome response. Note how a successful exposure or anxiety management treatment protocol might not target this spousal interaction at all.

Another symptom of PTSD is the avoidance of thoughts, feelings, or conversations associated with the trauma. Avoidance is a high-probability response to trauma for which exposure based interventions could be useful. An additional functional analysis of the victim's social environment might identify other factors that could lead to the maintenance of avoidance of thoughts or conversations associated with trauma. Stigmatization is often one unfortunate consequence of traumatic victimization. However, a functional analysis of stigmatization might yield a more useful understanding of the discriminative stimulus functions of the patient. If we were to collect reports from collaterals in the patient's environment, we might discover that other women who are important in the patient's social network have shown negative reactions to the patient when she starts to discuss anything related to the trauma. Keeping in mind that behaviors are generally multiply determined, we would have to investigate several hypotheses. One possible determinant of the friends' negative reactions is the fact that her experience is evidence that none of them is immune from this kind of victimization. She elicits vague feelings of uneasiness that escalate when the topic of the trauma is mentioned. These subtle social contingencies could make the patient less likely to want to discuss or process the event. In fact, if we observed interactions between this patient and her friends, we might see the friends actively punish the conversation or at least obviously change topics to help manage their own discomfort. The patient then becomes unwilling to engage in conversation about the event not because it is necessarily aversive to her so much as it is aversive to her friends, who have no repertoire for either discussing the topic or soothing their own discomfort at being vulnerable.

There are many other potential reasons a patient may appear to be numb that are not directly related to the traumatic event, but are rather under the control of social processes that must be addressed to achieve maximum treatment effects. Here, a last functional example reveals what we consider to be a discrimination deficit on the part of the client. In this instance the client may have some repertoire for describing (tacting) her feelings. However, she may not properly discriminate with whom to share these feelings. In given social interaction, the person with whom the patient is interacting would or would not be a good candidate for providing socially meaningful reinforcement. It is up to the patient to make that discrimination. Failure to recognize with whom it is appropriate to seek support can lead to ineffective interactions that eventually extinguish all support-seeking behavior or even lead to punishing interactions in which support is not only not forthcoming, but criticism comes instead. The latter might be the case if one discloses a traumatic event to someone who is too young to understand the event or might even be negatively impacted by it.

The point of the general description of a functional analytic case assessment is to call attention to the fact that whereas there are likely common causal factors that will be addressed by standardized treatment, there are many other sources of causal influence that, when they are not considered, may explain large differences in treatment outcome. The obvious etiology of PTsD does not explain the vastly different responses to treatment. This treatment response variability requires us to look more thoroughly for causal factors on which we can intervene. These factors are most frequently found in the posttrauma environment.

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