Ethically Treating PTSD Resulting from Terrorism and other Traumas

Finally, let's look at how mental filters by your client may predispose them to PTSD. These mental filters bring forth some major ethical areas for concern. I use filtering to refer to the mental mechanisms which helps us to individually sort through our world and integrate information. We have found in times of national trauma, due to terrorist attacks, that we can somewhat predict which of our clients will react extremely to the situation based upon what I will call their Filtering Style. I’ve divided filtering into six categories. Let’s look at the first category of positive versus negative filters.

6 Filtering Style Categories

Filter #1 - Positive versus Negative
The first we call the Positive/Negative Filtering is an orientation towards focusing on circumstances that are either positive or negative. Clients unconsciously choose the positive or negative experiences while rarely considering the opposite in their memories of the past and the orientation to the future. Some clients seem to be only able to concentrate on things that are positive while others appear to focus on negative issues.

Regardless of how the client tries to change this filtering style, it appears to be extremely resistant to modification. It’s been my experience that clients experience more severe PTSD if their filtering mechanism is more negative than positive. What filter do you use?

♦ Filter #2 - Global versus Detailed
A second filtering mechanism is that of a global filter versus filtering out details. This perspective is oriented toward focusing on details that either involve large or small components. Some clients are only able to see the “forest” while others can’t see the “forest for the trees.” However, many people seem to be quite flexible and sort of both comfortably.

I’m wondering if you have found, like we have, that PTSD clients who see the world from a more global view are able to more easily put events into perspective. Are you global or a details person?

Filter #3 - Time
Third is a perspective on time which orients toward focusing on details predominantly from the past, present, or future. Some clients can’t seem to get out of the past. They will base present and future decisions on successes or failures in the past. Others choose to ignore both the past and the future adopting a “live for today” attitude. Still others embrace a future-oriented life disregarding past and present requirements. Those who may be too singularly focused on the past appear to experience more severe PTSD. Where is your focus? Past? Present? or Future?

Filter #4 - The Sameness/Difference Sort
Fourth is a same and different perspective. This is a personal focusing preference oriented towards identifying things which are similar or different. Some people choose to highlight those circumstances which they can account for as similar to other conditions in their lives. Contradictory to these clients are those who choose to identify situations and adjust so the resulting circumstances are dissimilar.

My colleagues and I have found PTSD clients appear to focus more on present events similar to past stressors, as opposed to events that differ from the past. What is your focus on, similarities or differences?

♦ Filter #5 - The Switch Referential Index
Fifth, the Switch Referential Perspective filtering is a preference which involves an ability to switch from the client’s own reference point to that of someone else. This perspective can have a number of facets. A client can switch from how “I” feel to how “he” or “she” feels or how “they” feel. The client can suppose what happened to another happened to themselves. The object of the referential switch perspective is to equate the client’s sensory perception to that of another or others. As you know, the ability to switch perspective is an important factor in achieving intimacy and understanding. It is also a valuable asset for those who would aid trauma victims.

Do you notice a pattern with your PTSD clients regarding “I feel” versus “they feel”? What is your referential perspective?

Filter #6 - Authority Perspective
Finally, the Authority Perspective filter is an unconscious sorting preference oriented toward identifying one’s personal source of authority. Such sources can include I, you, us, family, God (religion), culture, ethnicity, and others. One’s sentence structure can identify one’s source for authority. We indicate our authority source when we say “I feel...,” “Do you think...,” “We should...,” “His word...,” etc. As you know, Vietnam veterans who suffer from PTSD usually have a resentment towards authority. However, regarding their perspective concerning authority as lying inside or outside of themselves, I have not noticed a pattern. What is your authority perspective?

The Code of Ethics states that we must show acceptance and be non-judgmental. However, when we experience someone who has the same perspective or filtering system as we do, we have a positive sense of commonality and security in communication. You may experience a feeling of understanding, connecting, and being on the same “wavelength” with your client. His state of rapport creates an awareness of harmony and unity in the treatment session.

However, when rapport is either broken or not established (as in a conflict of perspectives or filters), you may encounter a negative sense of detachment and discomfort in communication in the session. This negative sense can lead you to consider the client as being wrong.

3 Questions to Increase Your Self-Awareness

♦ To increase your self-awareness regarding your filtering or perspective consider the following three questions:
-- 1. Try to determine the perspectives of PTSD clients with whom you communicate on a regular basis.
-- 2. Can you identify their perspectives or filters that are the same or different from yours?
-- 3. Can you identify barriers to your communication due to the PTSD client’s perspective?

Intrusive Imagery
Lastly, I’d like to talk about the problem in working with PTSD clients related to the intrusive imagery. According to Brett & Ostroff, certainly intrusive imagery is a hallmark of PTSD. However, through your work with survivors, therapists may also experience intrusive imagery. Often images of those scenes, that survivor clients have described vividly, are ones which connect in some way with your own psychology. The self-care strategy that is most helpful here is for the therapist to identify his or her own prominent theme in the images (which may differ from the client’s).

For example, the therapist may reexperience intrusive images. While for the client, this memory may represent primarily a disruption in her sense of safety; to the therapist what is prominent may be the sense of betrayal, which is related to trust. Once the therapist has identified this theme, it can be connected to other issues, for example related to trust disruptions in the therapist’s life. This allows the therapist to begin to work with and, over time, to integrate the images; it can then cease to be intrusive for the therapist.

One type of disruption most notably experienced by all taking this home study course is the visualization of the destruction of the Twin Towers. Many of my colleagues reported having visceral reactions when they would see tall buildings on television immediately following the attack.

In summary, we have talked about victims of terrorism experiencing a loss of invulnerability, loss of an orderly world, loss of positive self-image, and loss of trust. We also discussed the role that prior experience and training make in the predisposition to PTSD. The psychodynamics of hostage victims including pathological transference and psychological infantilism were also discussed.

The importance of ventilating feelings and realistic guilt were discussed along with the psychopathology of being held hostage. The factors of feelings of helplessness, existential fear, and sensory input overload were also discussed as they related to psychological anchors and transference regarding the mutual fate bond, six filtering perspectives, and Code of Ethics issues.

It is hoped that this portion of the home study course has provided you with a broader knowledge base regarding the ethical treatment of PTSD resulting from terrorism and other traumas. This is Tracy Catherine Appleton with the Healthcare Training Institute. Thank you for selecting us to be a vehicle for you to earn your Continuing Education credits. I look forward to talking with you in another home study course. Thank you.
Reviewed 2023

Peer-Reviewed Journal Article References:
Himmerich, S. J., Ellis, R. A., & Orcutt, H. K. (2020). Application of PTSD alcohol expectancy symptom clusters to the four-dimensional model of PTSD: Support from moderations of the association between symptoms of posttraumatic stress and alcohol use. Psychological Trauma: Theory, Research, Practice, and Policy, 12(4), 347–355.

Hyland, P., Karatzias, T., Shevlin, M., McElroy, E., Ben-Ezra, M., Cloitre, M., & Brewin, C. R. (2021). Does requiring trauma exposure affect rates of ICD-11 PTSD and complex PTSD? Implications for DSM–5. Psychological Trauma: Theory, Research, Practice, and Policy, 13(2), 133–141.

Macdonald, A., Pukay-Martin, N. D., Wagner, A. C., Fredman, S. J., & Monson, C. M. (2016). Cognitive–behavioral conjoint therapy for PTSD improves various PTSD symptoms and trauma-related cognitions: Results from a randomized controlled trial. Journal of Family Psychology, 30(1), 157–162. 

Robison, M. K., Miller, A. L., & Unsworth, N. (2018). Individual differences in working memory capacity and filtering. Journal of Experimental Psychology: Human Perception and Performance, 44(7), 1038–1053. 

Wendt, M., Luna-Rodriguez, A., & Jacobsen, T. (2012). Conflict-induced perceptual filtering. Journal of Experimental Psychology: Human Perception and Performance, 38(3), 675–686. 

Online Continuing Education QUESTION 9: The Code of Ethics states that we must show acceptance and be non-judgmental. What are three self-awareness questions? To select and enter your answer go to CE Test.