Working with trauma : interpersonal and process issues in therapy for people suffering from the effects of traumatic experience
While the issue of avoidance in PTSD is well-documented in terms of symptom presentation, little has been done to address the problem posed to therapists of clients engaging in an avoidance of traumatic material within therapy. The current study uses a two-part approach, combining quantitative and qualitative methods to address avoidance in therapy for PTSD. In Part 1, a correlational design is used to compare clients' coping styles of "monitoring" and "blunting" (Miller, 1980) with change in symptoms over a course of therapy. The results indicate some support for the notion that coping style is relevant to symptom change over a course of therapy for PTSD. A blunting coping style was found to be significantly negatively correlated with degree of improvement in intrusive thoughts and a monitoring coping style significantly positively correlated with improvement in avoidance symptoms over the period. However, the possibility that these results are a function of significant correlations at the outset of therapy is considered. Furthermore, the low response rate resulted in the collection of insufficient data to fully test the hypotheses and, as a result, the study was treated as an exploratory, preliminary analysis and used to highlight research questions for a second phase of the research. In Part 2 of the study, a discourse analytic approach was used to generate avoidant discursive practices in transcribed material from therapy sessions with clients with PTSD. Both clients and therapists were found to use a range of discursive practices which resulted in the conversation moving away from expressions of negative affect or an exploration of traumatic material. Putative explanations for the observed behaviours are discussed and the need for therapists to be aware of these processes and their own emotional reactions to client's traumatic memories is emphasised. Differences in presentation between clients with histories of sexual abuse and those experiencing non-abusive isolated experiences of trauma are raised. The nature of avoidance within therapy is discussed and the impact of the overarching discourse of the therapeutic setting and the associated roles and power dynamics within the dyad are explored. Implications for improving the effectiveness of therapy and suggestions for future research in the field of avoidance in PTSD are proposed and, in particular, a call made for a more process-focused and "dyad-orientated" approach to practice and research in this area.