Monday, November 7, 2011

Prerequisite Knowledge for Instructors

Beyond Fight-or-Flight is aimed at all activities associated with preparing a person to survive a violent encounter. These activities include martial arts, self defence, combatives, close-quarter combat, hand-to-hand combat, unarmed combat, and whatever politically neutral name law enforcement is referring to their methods in the various jurisdictions. I'll refer to these collectively as the Activities.

Hopefully, the instructors of the Activities are required to have and maintain an up to date first aid qualification. That takes care of the body, but what about the mind?

As reported in previous blogs, medicine is beginning to appreciate the mind-body connection. While I'm stretching the idea here, I believe there is value in having some understanding of the mind in the same way that first aid gives you some understanding of the body.

I've been working on post traumatic stress (PTS). PTS was officially recognised by the American Psychiatric Association (APA) in 1980 when post traumatic stress disorder (PTSD) was included in their Diagnostic and Statistical Manual of Mental Disorders (DSM) third edition. Prior to that, the condition was categorised as gross stress reaction. The definition of a traumatic event and the symptoms of PTSD within the DSM have changed over the decades.

In 2000, the APA revised the PTSD diagnostic criteria in the fourth edition of its DSM. Diagnostic criteria for PTSD include a history of exposure to a traumatic event meeting two criteria and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms. The diagnostic criteria are:

Criterion A: Stressor
The person has been exposed to a traumatic event in which both of the following have been present:

1.The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.
2.The person's response involved intense fear,helplessness, or horror.

Criterion B: Intrusive Recollection
The traumatic event is persistently re-experienced in at least one of the following ways:

1.Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
2.Recurrent distressing dreams of the event.
3.A sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes.
4.Intense psychological distress at exposure to internal or external cues that recall the traumatic event.
5.Physiologic reactivity upon exposure to internal or external cues that recall the traumatic event

Criterion C: Avoidant/Numbing
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:

1.Efforts to avoid thoughts, feelings, or conversations associated with the trauma
2.Efforts to avoid activities, places, or people that arouse recollections of the trauma
3.Inability to recall an important aspect of the trauma
4.Markedly diminished interest or participation in significant activities
5.Feeling of detachment or estrangement from others
6.Restricted range of affect (e.g. unable to have loving feelings)
7.Sense of foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span)

Criterion D: Hyper-arousal
Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following:

1.Difficulty falling or staying asleep
2.Irritability or outbursts of anger
3.Difficulty concentrating
5.Exaggerated startle response
Criterion E: duration
Duration of the disturbance (symptoms in B, C, and D) is more than one month.

Criterion F: Functional Significance
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

It is not the Activities instructor's responsibility to diagnose PTSD. It is, however, their responsibility to be aware of the condition given the nature of the activities they are involved in. People who have experienced a traumatic event, such as being assaulted, often look to some form of self defence training to regain some sense of control over their lives. Obviously, law enforcement and the military are training their personnel who have often experienced traumatic events.

My work integrates stress theory and emotion theory to develop a survival process model (SPM). This SPM enables you to understand our evolved survival mechanism, the mechanism designed to increase our chances of survival when threatened. It also enables you to understand reactions such as PTSD.

Richard Lazarus argues that stress theory is a subset of emotion theory. They both study the same process, but stress does so in a limited fashion. Stress theory is like one of the blindmen studying an elephant by touching just one part of it. Emotion theory studies the entire elephant. Stress theory is considered a practical subject whereas emotion theory is considered of interest for its own sake. Nothing could be further from the truth. Emotion theory reveals so much more about our survival process than does stress theory.

Just to clarify, emotion and feelings are often used interchangeably. However, feelings are considered to be just one component of a larger construct that is emotion. Emotion involves a subjective feeling, physiological reaction, action tendency, and behavioural component.

I highly recommend Passion and Reason: Making Sense of Our Emotions by Richard S. Lazarus and Bernice N. Lazarus to the readers of this blog. It is a book written for laypersons by a towering figure in the stress and emotion fields.

The SPM involves an appraisal component. A stimuli is appraised, and based on that appraisal evokes an emotion, or not. The appraisal is personal to each person and to each situation. Lazarus argues that emotions are not irrational. They are entirely rational to the person experiencing the emotion. He emphasises:
again and again one could see that it is the way a person appraises what is happening, rather than the realities themselves, that determines the stressful impact. In emotion too, thinking is the powerful agent that influences both the kind and degree of emotion and the potential for coping. Research such as this provides the modern chapter and verse for Shakespeare's intuition expressed in Hamlet: 'For there is nothing either good or bad but thinking makes it so.
When a trainee/student reacts in what may be considered an overreaction, think on the uniqueness of their appraisal which shaped the nature and intensity of their reaction.

I recall a women in a women's self defence class who screamed and panicked when the instructor put her hands lightly around her throat to demonstrate a strangulation attack. Some considered it an overreaction. But we don't know how she is appraising the situation. By judging her and her reaction, are we not becoming part of the problem and not part of the solution?

Hopefully, the Activities have prospective students/trainees complete an application form of some kind. This form will hopefully ask questions concerning medical conditions and background. There is an argument that some form of generic question concerning traumatic events as defined in DSM-IV criterion A could be included on the application form. This may guide the instructor.

The above, and particularly the above recommended book, should reinforce to instructors that one size, one style of instructing, does not fit all. Those disciplinarian/militaristic instructors may not be as helpful as they think they are for people who have experienced trauma and are experiencing PTS to some degree; the people who need our help the most.

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