Moral resistance in treatment of
post-traumatic stress disorder
Mahmud Said (1)
(1) Ph. D., Specialist in Educational and Clinical Psychology, Supervisor in Educational Psychology, Therapist and trainer in Psychological Trauma in Traumatic Incident Reduction – TIR.
*Corresponding author E-mail:
mahmudssskk@gmail.com
This case study illustrates with a detailed report the treatment of
a person with post-traumatic stress disorder (PTSD). The therapist noted that
the patient did not improve despite all the necessary psychological
interventions taken, the patient’s request for treatment, and his commitment to
the treatment. Enquiry revealed that the patient unconsciously preferred to
continue suffering and feeling guilty towards his deceased so. The patient was
suffering in order to preserve his loyalty to his deceased son, a phenomenon
which we name moral resistance. PTSD Symptom Scale Interview (PSSI) was applied pre and post treatment and in follow-up.
The Traumatic Incident Reduction (TIR) was the main therapeutic strategy, as well as Rational
Emotive Behavior Therapy (REBT). The study found significant effectiveness of TIR and REBT in treatment of moral resistance aaccording to the PSSI scale. The total score decreased from 43, which indicated a very
severe level of the disorder, to 10 a week after commencement of the treatment,
and to 7 after a month. Scores of 4 was
kept constant in 3 and 6
months follow-up.
Keywords:
PTSD, TIR, REBT, Moral Resistant.
Posttraumatic stress disorder (PTSD)
Post-traumatic stress disorder (PTSD)
is defined as "a psychiatric disorder that can develop following the
direct, personal experiences or witnessing of a traumatic event, often life-threatening
and characterized by re-experiencing, avoidance or numbing and hyperarousal"
(Institute of medicine, 2006). PTSD develops through the subject's exposure to an
unexpected traumatic event such as wars or unexpected loss of a loved one in a traumatic event (Javidi &Yadollahie, 2012). Due
to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) causes to PTSD include exposure to a
traumatic event which occurred to a close family member or a close friend, and the event must have been accidental (American
Psychiatric Association [APA], 2013). The estimated lifetime prevalence of PTSD
in community samples ranges between five to ten percent (ACPMH & logos
2007).
Signs and symptoms of clinically
developing significant psychological distress include avoidance, hyperarousal,
and re-experiencing related to the event (Australian Center for Posttraumatic
Mental health, 2013). Not all people who have been traumatized need medical or
psychological treatment. Necessity of
treatment depends on the severity, duration and continuity of rexperiencing,
avoidance and arousal symptoms, and impairment in functioning and as well as social
involvement, all of which should be reported for at least six months after the
traumatic event. Early treatment is
recommended as soon as signs and symptoms of PTSD are reported (Ballenger
2004). Additional other signs and symptoms
occur include nightmares, flashbacks, intrusive thoughts, guilt feeling,
inappropriate levels of fear and powerlessness joined by functional impairment (Bisson et al,
2013). Another complication of losing family member may be grief development if
not treated (Markowitz, 2017).
Mental health is affected by stigma and discrimination for long time. This problem induces suffering and burden to clients and
their families and leads to delayed treatment (WHO, 2003). Victim’s knowledge
and perception of the traumatic event and the consecutive symptoms affect the
way they deal with, including applying to treatment. Cognitive perception has a
high effectiveness in adopting the appropriate behavior and positive thinking
regarding traumatic event (Benight & Bandura, 2004). The clinician should help
the patient to be aware of the emotions associated with the event, whether it
is fear, anxiety, shame, guilt, anger, or sadness (Shapiro, 2018). Patient’s acceptance
of these emotions plays the main role in avoiding negative internal experiences
such as thoughts, emotions, memories, and sensations (Walser & Westrup,
2007).
The recovery from trauma depends on the nature of the traumatic
event, social support and on patient`s personality (Raja, 2012). People characterized with positive attitudes are better in eliminating the effects of
stress, and have better ability to control their thoughts and behavior, leading
to relief from the trauma effects (Cervone & Pervien, 2013). Cognitive-behavioral therapy and exposure therapy are effective
in treating trauma, exposure therapy is regarded being the first line in the
treatment of trauma (McLean & Foa, 2011).
Traumatic incident reduction (TIR)
Traumatic Incident Reduction (TIR) was
introduced by Gerbode (1988). This method is used in the treatment of PTSD by
recalling the important information about the nature and consequences of the traumatic
events (Carbonell & Figley, 1999). TIR is a brief, clear, memory-based, most similar to imaginal flooding interventions,
and focusing
on memory rather than on symptom management (Valentine, 1997). The goals of TIR
as was conducted by Gerbode (1988), were
increasing re-experiencing of negative emotions
related to the trauma, increasing deliberate cognitive processing of the
trauma, and creating narrative memory of the trauma (Descilo et al,2019).
When conducting TIR the therapist should follow the
following outline: (a) give informed consent, (b) complete pretest measures, (c) have
a one-on-one orientation interview to learn the nature of the trauma and the
roles that they and the mental health practitioner would play, (d) receive a
session of TIR, (e) complete a debriefing session, and (f) complete posttest
and follow-up measures (Valentine & Smith, 2001). The client is directed to
imagine the traumatic event without the use of verbal expression, followed by repeatingly
telling the event. The effectiveness of using this method depends on the client‘s
ability to imagine (Cukor et al, 2009). In the sessions the client describes a
particular negative feeling, attitude, or thinking, which serve to identify
specific incidents for resolution. The therapist reviews the client’s feelings.
Then the client is able to talk calmly about the traumatic event without the
appearance of the symptoms (NREPP, 2013)
Rational emotive
behavior therapy (REBT)
The
cognitive interpretation of a traumatic experience depends on the sequence of events.
A negative interpretation of the traumatic event is followed by irrational
behavior. Irrational beliefs and behaviors are expressed in many forms such as a sense of unreality about the traumatic even,t negative perception of self, life and future, catastrophic misinterpretation of grief reactions, and avoidance behavior accompanied
by anxiety (Boelen et al,2014). REBT originated from rational therapy which
developed to Rational-Emotive Therapy and in 1990 became Rational Emotive
Behavior Therapy. There are many similarities between cognitive-behavioral
therapy and REBT but recently the therapy moved away from its cognitive roots (Froggatt,
2005). REBT deals with irrational beliefs in a broader sense than cognitive
behavior therapy in the treatment of posttraumatic stress responses (Hyland et
al, 2014). Behavioral, cognitive and emotive techniques involved in the
practice of this therapy in order to promote change of negative thoughts,
emotions, and behaviors in a positive manner (Ellis & Dryden, 2007).
ABC model shows the
emotional interaction in which “A”
refers to activating the event, “B” refers to the belief or interpretation of
the activated event, and “C” refers to the
consequent emotional, physiological, and/or behavioral responses (Sorocco &
Lauderdale, 2011). The A-B-C model is considered a cornerstone in the theory
and practice of REBT, the consequences (C) of disturbances in thoughts and
emotions are related to people's own irrational beliefs (B) and not by the activating
event (A) (Kwee & Ellis, 1998).
REBT techniques are useful for therapists working
with parents and families by focusing on their negative thoughts and trying to
change them, enhancing emotional performance, and increasing their ability to
make effective behavior management decisions (Terjesen & Kurasaki, 2009).
In the
grief processes, according to REBT interpretation, the maladaptation occurs when traumatic death
causes negative thoughts which are called
irrational beliefs. There is a disparity
with a person who is traumatized between adaptive rational belief and
maladaptive irrational belief, that
depends on thoughts and emotions (Malkinson, 2010). Psychologists focus
on three levels of client response during sessions: behaviors (i.e., observable
and measurable client reactions), cognitions (.i.e., information processing)
and subjective experience (i.e., feelings and emotions) (David & Cramer,
2010). Recently a number of evocative-emotive techniques used
in REBT therapy such as rational emotive imagery, shame attacking exercises,
role-playing, reverse role playing, forceful coping statements, unconditional
acceptance of clients were added (David et al, 2010). The therapist should use
open-ended questions in sessions to assess thoughts and emotions, intervention
process, and future performance (Turner et al, 2014).
Moral Resistance
We did not find previous studies or references
on moral resistance, which motivated us
to write this paper in order to highlight this important problem and provide
solutions and recommendations.
It is important to make a distinction between moral resistance and Client
engagement. These concepts could be difficult to be
distinguished on the basis of clinical observation without long-term systematic
evaluation, Especially in
the case of our patient who looked for treatment and was committed to, but
unconsciously did not follow the instructions.
It was eventually found that he believed that relieving his distress would
mean him being unfaithful to his late son, thus he feared feeling guilty if his
suffering ends.
Client engagement in treatment is one
of the most significant aspects of the therapeutic process. It reflects the
level of healthy attachment a client creates with the therapist and directly
impacts the prognosis. In this article, we will take an in-depth look into the
core aspects of moral resistance and discuss ways to solve it. We have noticed while
working as a trauma therapist, that while the client came willingly to seek
treatment for his traumatic and severe experience, and the therapist did his
best to provide all necessary interventions, however the treatment did not
reach its goals satisfactorily.
It seems as if the client is unconsciously not
willing to cooperate with the therapist. On the one hand, he asks for help to
alleviate his pain and suffering from trauma and loss and desires bringing
about the desired change and is committed to attending the sessions. On the
other hand, he unconsciously refuses to follow the instructions. While he
consciously declared his wish to feel better and readjust to life, he
unconsciously refrained from ending his suffering, because of his devotion to his
lost son.
In medicine, the term ‘resistance to
treatment’ usually serves to define patients failing to respond to a standard
form of treatment. Similarly, treatment-resistant PTSD applies to those
patients who do not resolve symptoms although they have
been treated adequately with pharmacological, non-pharmacological, or combined
treatment approaches. The definition may vary widely and there is no
universally accepted definition for how long a patient should be treated with no
progress that would be accepted as treatment-resistant. However, considering
the onset of PTSD and symptoms, it might be accepted that twelve months of
treatment failure might be an acceptable definition. This, of course, depends
on adequate treatment trial and the specific expectations for treatment
outcomes. In theory, treatment-resistant PTSD may apply to describe patients
with an initial response to the therapeutic approach but with no significant
improvement achieved, with respect to resolving symptoms, improving sense of self esteem, and
functioning (Zepinic, 2015).
The treatment
The subject of this report is a 56 year old man. In the initial
interview we found him to meet the DSM-5 (APA, 2013) criteria for active PTSD
while his main complains were insomnia and sever psychological distress lasting
for more than one year. He reported that he started experiencing these symptoms
since he lost his elder son. The family
was Israeli Palestinians. This
population is not obliged to serve in the armed forces, according to the
Israeli law, but his son insisted to recruit, against his father will. The son
was killed while serving in the occupied territories in the area of the Gaza
Strip, shot by a Palestinian sniper. The client was very traumatized when he
heard his son was killed.
A diagnosis of PTSD was determined by means of
psychiatric interview. The client signed a consent form for participating in
psychotherapy. The therapist explained the procedures of the sessions in detail
and the initial treatment session was
scheduled.
After
providing all the necessary psychological interventions, the therapist noticed
that the patient did not improve despite his commitment to the sessions and his
request for treatment. Through psychiatric assessment, the therapist discovered
that the patient was not cooperative and believed that if he gets rid of his
suffering, he will be unfaithful to his deceased son
In this study, we used two approaches for treatment
of the PTSD: traumatic incident reduction (TIR), and Rational emotive
behavior therapy (REBT).
The PTSD Symptom Scale Interview (PSSI) (Hembree et
al, 2002) had been used to assess symptoms related
to the identifiable traumatic event and current
symptoms of PTSD for goals of diagnosis as well as following the progression of
the treatment. PSSI scale consists of 17 items representing three domains: Re-experiencing, Avoidance, and Increased
arousal (Foa et al, 1993). The scale was translated to Arabic Language by a
linguist and then sent to three Arab native speakers with high level of
knowledge of English. The PSSI scale was applied pre-treatment and post-intervention
at different intervals: after one week, one
month, three months, and six months. When the therapist got the
impression of lack of progression in the treatment, he added an open, unstructured conversation in order to detect potential causes.
As the client was diagnosed
with PTSD he received information regarding the PTSD syndrome and the
therapeutic procedures that are to be taken. In the beginning of the treatment we
invested in creating therapeutic bond and establishing trust. The client was asked to select one
traumatic event, and he chose the situation of him being informed about the
death of his son. The therapist asked the client to imagine the event and what
happened without talking and then to recount what happened aloud, and
re-experiencing the event again and again. At that time of commencement of the
treatment the therapist got the impression that the client was cooperating and
the therapeutic plan was going in the required direction.
In the following sessions, the client repeated
the event several times. He began with brief words and emotions, gradually
talking more and showing more emotions, and reviving the event. However a
significant improvement in his condition was not observed, in contrast to what
was expected when compared to what had been seen with former clients as well as
what is expected from reports in literature (Descilo et al 2017).
The therapist asked the client whether he felt
his emotions to improve or worsen and the client replied that it felt better, however
this positive response did not match the therapist`s impression of the client
behaviour and gestures. The session went on with the procedure described above,
the therapist taking serious efforts to follow faithfully the TIR protocol,
with no apparent difference. The therapist asked again whether he felt better
or worse, and the client said he felt better. Noticing the discrepancy between
the observed and the reported outcome, the therapist became convinced that the
therapeutic process did not proceed correctly. The therapist shared his
impression with the client, who responded by saying that he was completely cooperative
with what he was asked to do.
At that stage the therapist took a decision to
intermit the continuation of the TIR protocol.
He asked the client if he felt that he was genuinely
willing the treatment? which the patient nodded with a decisive “Yes”. The therapist went on asking whether the
client was fully honest concerning his inner feelings. Again the client answered "yes",
but at that time there was some hesitant tone in his voice. The therapist insisted again whether
the client was definite about it. He said:"
fifty-fifty" .”Why? "I don't know". “Are you sure you want this treatment to help you”? He said, "I
do". “So how come”, asked the therapist, that your involvement is incomplete? "I don’t know" replied the client. Could it
be, wondered the therapist, that your distress is too severe to prevent you of
full participation? ‘”I
don’t think so” was the answer. Do you feel, asked the therapist, that we can
repeat the procedure that we took in the last sessions, re-experiencing again
your traumatic event? The client said, "yes I can". “So what do you
think made it difficult for you to be fully involved in the task? Again the
client said "I don’t know".
Having this dialogue stacked, the
therapist made a switch and asked the client to describe his relationship with his
son. The client replied: "he was my beloved, my friend and my pride, my
heart" and burst into tears, stuttering "I caused his death… I didn't do enough to stop him from
recruiting."
The therapist kept enquiring about
this aspect of the event. “You said you did not agree to recruit him”? He said "yes".
“Tell me, how did your son start thinking about the recruitment and what made
him wishing to become a soldier?” He said, "I did everything
to prevent him but he insisted and I was not
able to refrain him from doing so". “So you did all that and still couldn't
prevent your son recruiting the army?” He said: "yes". “Do you feel that you
failed?” "I had to try harder". “Do you feel guilty”?
He said: "yes". “Do you
feel that if you stopped suffering would mean you betray your sun?” He said: "nearly", and became silent.
Then he burst into tears and murmured “yes,
I agree. If I do
not suffer, it means I am an unfaithful father". “So
deep inside you feel that you should not gain relief from what we were doing in
the treatment because you want to be faithful to your son?” He said: "yes".
“So we may conclude that you resist the treatment due to what you felt inside
as immoral to relieve?” He said: "yes, I agree with you".
This
dialogue represents the REBT therapy which emphasizes reducing symptoms of PTSD
by changing negative to positive thoughts regards the traumatic event (Boelen
et al, 2014; Hyland et al, 2014; Malkinson, 2010). The appliance of TIR
techniques met limits due to the patient`s inner belief that giving up his
suffer meant betraying his son. Only after revealing this negative
(maladaptive) thought, the traumatic incident reduction could take place
efficiently.
PSSI scores are presented in Table
1. The pre-intervention score of 43 indicated a severe symptom level of PTSD (Freeman
et al, 2013). This score dropped drastically to 10 points on that scale after
the first session and to 4 points after one month. Than it remained steadily on the 4 points
level, which represents `no symptom` level. These results are consistent with
what is reported in the relevant literature when applying the TIR method (Descilo
et al, 2017; Cukor et al 2009; Valentine, 1997).
Table
1: Table 1. Results of
Assessments
Severity of PTSD symptom |
Pre-treatment |
Week |
One month |
three months |
six months |
Range of
severity PTSD |
No symptoms |
|
10 |
7 |
4 |
4 |
10 |
Slight symptoms |
|
|
|
|
|
15 |
Moderate symptoms |
|
|
|
|
|
20 |
High moderate symptoms |
|
|
|
|
|
25 |
High symptoms |
|
|
|
|
|
30 |
Severe symptoms |
|
|
|
|
|
35 |
Strongly severe symptoms |
43 |
|
|
|
|
40-50 |
Note: this assessment according to PSSI scale represents
the scores of PTSD pretreatment and post-intervention by TIR and REBT therapy.
Discussion
This
study demonstrates the successful usage of combination of two approaches for
the treatment of a traumatized person, namely, the TIR and the REBT.
Application of these two approaches proved to be highly effective in
alleviating symptoms of PTSD shortly after the commencement of the treatment,
and to endure steadily in six months follow up, as measured by the PSSI scale
In
the beginning of the therapeutic process TIR method was applied. However throughout the sessions the therapist
observed that despite seeming cooperation on the side of the patient, the
symptoms were still present while the client trying to hide it; this is
contrary to the scale results which apparently showed improvement of symptoms. This urged the therapist to look for the causes of the
patient's inability to improve. An REBT dialogue was applied and found that the
client was unwilling to improve because he related to his son with a moral
linkage. The client felt that feeling better and recover from his PTSD symptoms
would mean betrayal his son. The inner formulation was of the like “if I give
up my suffer it shows I do not really care about my son; I would be a bad
father”. This inner belief was
ameliorated by some guilt feelings concerning what he perceived his
responsibility for his son`s death, because he did not do enough to prevent him
from recruiting military service.
The therapist called this moral resistance. In other words, the client with
the PTSD was unwilling to recover because of a moral obligation that expressed loyalty to his
son.
The
unstructured conversation had a significant effect in detecting the client's
rejection of recovery and improvement from the PTSD symptoms. The conversation
was more credible in decoding the inner feelings of the client since it relied
not only on the client manifest wording, but also was attuned to other
unintended signs such as body language and facial expressions.
Resistance in psychoanalysis refers to oppositional behavior when an
individual's unconscious defenses of the ego are threatened by an external source. Sigmund
Freud, the founder of
psychoanalytic theory, developed his concept of resistance as he worked with
patients who unexpectedly developed uncooperative behaviors during sessions of talk therapy. He reasoned that an individual that is
suffering from a psychological affliction, which Freud believed to be derived
from the presence of suppressed illicit or unwanted thoughts, may inadvertently
attempt to impede any attempt to confront an unconsciously perceived threat.
This would be for the purpose of inhibiting the revelation of repressed
information from within the unconscious
mind (Larsen
et al 2008). However in this study, we found that the reason for
resistance to therapeutic interventions was related to the client's unconscious
need to keep preserving his mourning. We
believe that moral resistance has to do with the cultural and social background
in Arab countries, as many people believe that part of their loyalty to the
deceased is to show sadness and to wear black. Due to this prevailing tradition
in Arab countries they tend to reject psychological interventions which aid at
relieving their grief, and prefer to be immersed in the sadness as an
expression of their loyalty to the deceased, In addition, the culture of Arab
countries plays a role in expressing the form of sadness, consistently with
Walter (2010) who found that the expression of emotion by grieving Muslims in
Egypt is very different from that of grieving Muslims in Bali. We believe that
understanding the causes of treatment resistance is important in building a
successful therapeutic relationship with the patient, and this agrees with
Baker (1999) who claimed that understanding resistance as an aspect of the
intersubjective field between therapist and patient, co-determined by both
participants, greatly assists in the treatment of difficult patients.
Resistance analysis in the case of a patient using religious references as
resistance is presented here from an intersubjective perspective on
psychodynamic treatment.
We
consider the moral resistance to be a significant obstacle in treating PTSD
symptoms, and it may be a paramount challenge for scientists and therapists
when treating traumatized persons.
Acknowledgments
Special thanks to my colleagues Adam Said and Dr. Khaula Said and
Dr. Osama Imad and Tsvi Gil and and Umaia Said for their cooperation and
encouragement.
Conflict of Interests:
No financial interest or any conflict of interest exists.
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