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|The Long Shadow of Trauma - Page 9|
Looking toward the Future
What difference would it make if DTD made it into the promised land of the DSM? One answer is that it would open the way (not to mention the money spigots) to focus research and treatment on what van der Kolk and his colleagues believe are the central principles organizing the protean symptoms of chronically traumatized children: pervasive biological and emotional dysregulation, failed or disrupted attachment, and a hugely deficient sense of coherent personal identity and competence. These issues transcend and include almost all diagnostic categories, but treatment that doesn't put them front and center, say advocates for DTD, is likely to miss the mark.
Take the pervasive emotional dysregulation, which, according to many experts, could be almost a single-word synonym for the effects of chronic trauma. "What appear to be the symptoms of other disorders are often better understood as extreme dysregulation of emotional states," says Julian Ford, associate professor of psychiatry at the University of Connecticut Health Center and a coauthor of the DTD proposal. "Some youths diagnosed with oppositional-defiant disorder are extremely angry, negativistic, and defiant in large part because they're attempting to defend themselves against what they perceive to be coercion or threats, based upon prior traumatic experience in which they actually were coerced, threatened, or severely harmed." Such a kid doesn't respond well to common behavioral interventions stressing "consequences," which just reinforces his defensiveness and anger. Similarly, a traumatized child already on edge with fear and unable to concentrate in school will not be helped by a diagnosis of attention-deficit disorder and a prescription for Ritalin, a stimulant that will just rev up her already hyperaroused nervous system even more.
The official recognition of DTD, the thinking goes, could allow therapists and researchers to bypass standard diagnoses and hone in specifically on dysregulation, poor attachment, and an inadequate sense of self. One intervention that does this, developed by Ford, is target (Trauma Affect Regulation: Guidelines for Education and Therapy), focuses on helping adolescents and preadolescents to understand something about how trauma affects the brain and nervous system, acquire the self-soothing skills that can help them manage their own stress reactions, and gain a sense of self-confidence and trust in their own resiliency. Another program, the Attachment, Self-Regulation, and Competency (ARC) practice, originating at the Trauma Center at the Justice Resource Institute where van der Kolk is founder and medical director, focuses on building secure attachment relationships between caregivers—who may be child protective-services staff, foster parents, residential counselors, or parents—and traumatized kids. It teaches children and teens how to identify, modulate, and communicate emotion and bodily sensations, and helps them develop a stronger sense of personal identity and competence. The Trauma Center also provides a variety of nontraditional approaches—theater groups, yoga, mind-body, sensorimotor psychotherapy, expressive art therapy, neurofeedback—that promote the integration of psychology and biology to reconnect minds and bodies torn asunder by trauma.
While showing great promise and early success, multifaceted approaches like these tend not to be simple, short, or cheap. Nor have many of them been subjected to "gold standard," random-outcome research that would incline large state service systems to pick them up and pay for them—even if there were an official diagnosis for which they could become the treatment of choice.
Were DTD to go into effect, its supporters believe it would be a game changer. Just as the creation of PTSD "transformed the health care system for individuals exposed to traumatic stress and led to an explosion of specialized research and practice," says psychologist Bradley Stolbach, "the inclusion of [DTD] in DSM-V . . . will be a powerful catalyst for transformation of the systems that serve children."
Finally, the frontline mental health troops—overwhelmed and underpaid social workers and therapists serving in poor communities—seem to respond with a collective "At last!" when they hear about the new diagnosis. Eugene Griffin, psychologist, attorney, and clinical director of the Illinois Childhood Trauma Coalition, recalls bringing Frank Putnam to talk to his staff about complex child trauma in 2004—what it looked like and its long-term consequences. "The day [Putnam] presented, veteran social workers said things like, ÔI've been around 20 years and that's the best description of our kids I've ever heard. We could have told people about these kids 10 years ago.' They got it right away."