The snakes and ladders board can act as a helpful reminder to the
survivor of their journey towards recovery. If he fails to
reach a target, that failure does not drag him all the way back to square one. Even in failing, he has learned something about how best to set the next target.
It is not necessary to reach square 100 on the snakes and ladders board to have recovered from PTSD. Indeed, I suggest that in some cases reaching square 100 is not possible. Witnessing or being involved in a seriously traumatic event affects the rest of a survivor's life. This may require a person rethinking life-goals or life-values. Perhaps it would be useful to consider full recovery as anything beyond square 91 on the game board. This, if we return to the example of a broken leg cited earlier, there is always the thought in the back of a person's mind that the leg could break again. Likewise with PTSD, some of the symptoms could be awakened if triggers occur. Therefore, reaching the top nine squares on the snakes and ladders board, whilst being aware of the remaining two snakes, may be perceived as recovery.
Errors of information processing in PTSD cases (after Scott & Palmer )
Although there are now a significant number of books and papers on the subject of Post-traumatic Stress Disorder, and suggestions for diagnostic and treatment techniques, very few give any practical comments about recovery. Where PTSD is discussed, evidence is generally anecdotal and has been gleaned from the hundreds of PTSD survivors who have volunteered information as a way of supporting others and affirming their own identifiable milestones in recovery.
Occasionally, PTSD victims have encountered the following difficulties:
1. Making unreasonable generalisations. e.g. All men are sexual abusers. Every teacher is a bully.
2. Mentally filtering aspects of their trauma. e.g. Seizing on a particularly gloomy aspect of an event and dwelling on it. "He could have been killed doing that."
3. Believing 'all or nothing'. e.g. Everything is seen in the most extreme terms - "I am either in control or I am not."
4. Labelling and 'mis-labelling themselves. e.g. Individuals focusing on their emotional state and drawing conclusions about themselves, "Since it happened, I am frightened of my own shadow, I guess I am just a wimp."
5. A discounting attitude. e.g. Disregarding any positive outcomes, for example "I did my best, so what?"
6. Magnification and minimisation of self-worth. e.g. Magnification of shortcomings and making light of strengths. "Since the trauma I am so irritable with my children, and just about manage to get them to school."
7. Making 'should' statements. Inappropriate use of moral imperatives -
should - must - have - ought. e.g. "It's ridiculous that since the attack I now have to take my sister shopping with me. I should be able to do this by myself."
8. Jumping to conclusions. e.g. "Everyone thinks I should be over this by now."
9. Over-personalisation of the situation. Assuming that because something went wrong it must be the survivor's fault. e.g. "I must have made a mistake somewhere for him to have died."
Revised thinking by PTSD survivors in advanced recovery. (Kinchin and others)
Recovery is very difficult to assess. There are tests, which provide a 'score' indicating the depth of traumatic experience. Therefore, if a test is administered and the survivor achieves a 'low score' it may be assumed a survivor is no longer traumatised and has recovered.
However, recovery is more a state of mind than it is a score in any psychoanalytical test. Recovery is a sense of achievement when something previously considered impossible is achievable and the victim feels it is well within grasp.
Recovery might include a person being able to think:
1. I'm not so hard on myself these days.
2. Things can be divided up into what really matters, and what doesn't really matter.
3. I catch myself refocusing on the present.
4. I can share with others.
5. I have learned to cherish laughter.
6. The pain of what happened has immunised me against most petty hurts.
7. I focus on the present and the near future. I leave the past in the past.
8. I am stronger because of what happened to me.
9. I can use what happened to me to support others.
10. Life has new meaning for me.
11. I am starting to get bored with my story about the attack.
12. My memories do not go away, but they are losing their gripping quality.
13. My memories are no longer able to stop me in my tracks. I have control over them.
14. I have the choice now; I can choose to leave it (the traumatic memory) if I want to.
15. I can bear the pain of what happened.
Recovery from PTSD is very much akin to recovery from grief (Worden 1991). It is possible and indeed normal for a person to reach a health resolution to their grief. But the memory of the deceased person is still very real. Likewise, the memory of the trauma will remain for the PTSD victim. There will still be some remaining scar tissue. A child survivor of trauma may well have suffered academically and will have some catching-up to do if he wishes to regain his previous status with his peer group. This catching-up with academic work may be a realistic hurdle rather than an attempt to control of the traumatic memory.
Conversely, the fact that a child is still two reading books behind his classmates, or is some way behind with her mathematics project work, may serve as a reminder of the trauma and the consequences of being traumatised. Consequently, periods of depression, or even relapses into a state of traumatisation may result.
In the same way that a bereaved person may re-experience feelings of grief at anniversaries or other special moments, so a traumatised person may endure a brief re-experiencing of some traumatic symptoms.
Recovery from Complex PTSD
For those survivors who are recovering from Complex PTSD then the snakes and ladders model can still be applied. However, these victims of abuse, or repeated traumas should imagine that they have four counters on the game-board instead of the usual one. The four counters have to be moved independently, each with its own shake of the dice. In this way, one or two counters may reach the top of the board a considerable way ahead of the others. This is how recovery from Complex PTSD is. However, it can be seen that recovery is just as possible, but may take a little longer to achieve.
I believe that the Snakes and Ladders Model is an approach which can be applied to all individuals because:
1. It allows for the oscillations in recovery.
2. It is easy to comprehend since almost everyone has some knowledge of the snakes and ladders game.
3. The process of recovery is easily explained.
4. Although the snakes and ladders model appears to be very simple the model also demonstrates the complexity of PTSD, and allows for extremes of the disorder (C-PTSD) to be worked into the same model.
Alexander D et al
Ambulance Personnel and Critical Incidents
British Journal of Psychiatry 178 pp76-81
American Psychiatric Association
Diagnostic & Statistical Manual of Mental Disorders (DSM-IV)
Washington DC: American Psychiatric Association
Loss Change & Grief: An Educational Perspective
London: David Fulton
Deykin E Y
Post Traumatic Stress Disorder in Children and Adolescents
Medscapes Mental Health 4:4
Dwivedi K N (Ed)
Post-Traumatic Stress Disorder in Children and Adolescents
London: Whurr Publishers
Dyregrov A Adolescents
Psychological Debriefing -
An Effective method?
Traumatology e 4: 2
The Use of Counselling Skills in the Emergency Services
O U Press: Buckingham
Hoel H & Cooper C
Destructive Conflict and Bullying at Work
Counselling at Work
32 pp 3 - 6
Joseph S et al
Understanding Post-Traumatic Stress
Post Traumatic Stress Disorder: The Invisible Injury
Oxon: Success Unlimited
Kinchin D & Brown E
Supporting Children with Post-traumatic Stress Disorder
David Fulton: London
Marr & Field
Bullyside : Death At Playtime
Oxon: Success Unlimited
Mason P H C
PTSD and Parenting
The Post-Traumatic Gazette 6:1
Critical Incident Debriefing
Souvenir Press: London
Rick J et al
Workplace Trauma and its Management
Evidence based practice will affect the way we work
Counselling 12:2 pp 105-107
Scott M J & Palmer S
Trauma and Post-traumatic Stress Disorder
Post-Traumatic Stress Disorder: concepts and theory