Survivors of trauma who do not recover independently, and who go on to develop longer-term problems as a result of their experiences, may require formal treatment. There is also a mounting body of research suggesting that early interventions with high risk survivors may facilitate the recovery process and reduce the prevalence of subsequent Posttraumatic stress disorder. The purpose of this chapter is to provide a brief overview of common interventions used in the treatment of acute stress disorder and Posttraumatic stress disorder, and to discuss their application as a preventive strategy.
Aims of treatment
It is reasonable to assume that virtually all human beings will experience a psychological reaction to very frightening or upsetting events. This raises questions about what constitutes an adaptive psychological response to trauma and, as a corollary, what are reasonable treatment goals. Severe traumatic events profoundly affect survivors’ views of themselves and the world. In most cases, it is reasonable to suggest that the survivor will never be the same person again. Equally, those changes need not all be bad. Recovery from trauma can result in personal growth, with the development of improved coping strategies and more adaptive models of the self and the world.
Ideally, treatment would serve to eliminate all the symptoms of Posttraumatic stress disorder and return the survivor to pretrauma levels of functioning. In reality, that will not always be possible. As with other disorders, factors such as the severity of the condition, chronicity, and comorbidity (particularly in the form of axis II disorders) are likely to affect treatment efficacy. In acute cases of Posttraumatic stress disorder with few complications, it is reasonable to expect a high degree of success with relatively few sessions (6 to 10).
In such cases, elimination of Posttraumatic stress disorder symptoms, a return to prior functioning, and low risk of relapse would be achievable goals. (Importantly, this is not to imply that the person will never again experience distressing memories of the event but, rather, that such intrusive phenomena will be infrequent and manageable). On the other hand, treatment goals for a Vietnam veteran with, for example, a 30-year history of Posttraumatic stress disorder, high levels of comorbid alcohol abuse, and poor social and occupational functioning, would be more conservative. It may be a question of helping that person to manage the symptoms more effectively, reducing their impact on quality of life, relationships, and general functioning.
Psychological treatments: description
Several psychological approaches have been proposed for the treatment of Posttraumatic stress disorder and excellent reviews of the area can be found elsewhere. Regrettably, few of those approaches have been the subject of adequately controlled treatment outcome research. The following discussion focuses primarily upon cognitive behavioral approaches, since those have been the most comprehensively studied. However, it should not be assumed that the interventions are the exclusive domain of cognitive behavioral therapy. On the contrary, several of the following strategies (notably exposure to the traumatic memories) are used in some form in a variety of alternative intervention models, including brief psychodynamic approaches and hypnotherapy.
Cognitive behavioral approaches to the treatment of Posttraumatic stress disorder and related disorders routinely comprise a combination of several components. This discussion is limited to those core components of treatment that have been the subject of empirical evaluation.
Posttraumatic stress disorder is an anxiety disorder characterized by persistent arousal, with high levels of fear relating to trauma-related memories and external cues. This, in combination with a poor understanding of their own psychological reactions, leaves many survivors feeling vulnerable and out of control. Thus a vital step in the early part of treatment is that of teaching a repertoire of simple strategies to manage the arousal and distress. These interventions do not address the underlying causes and are not usually seen as a treatment for Posttraumatic stress disorder per se. Rather, they provide ways to manage anxiety and distress when it occurs. As such, they are an important precursor to the painful process of exposure.
Anxiety management may be conceptualized under the three broad headings of physical, cognitive, and behavioral components, with interventions delivered in all three domains. The more physically oriented strategies, which directly address the hyperarousal aspects of traumatic stress reactions, are an excellent starting point. Clinical experience suggests that they often produce rapid effects that not only assist the survivor in feeling better but, perhaps more importantly, improve feelings of self-efficacy and contribute to expectations of recovery.
The rationale is straightforward (in terms of a fight-flight response) and it requires little in the way of psychological mindedness. A simple controlled breathing strategy is a good first step, often introduced in the initial treatment session. Progressive muscle relaxation, aerobic exercise, and advice to reduce the intake of stimulants such as caffeine and nicotine are all potentially useful interventions. They assist the person to gain some initial control over the powerful physical symptoms of hyperarousal.
The intrusive nature of traumatic memories, and the tendency of many trauma survivors to ruminate about their experience, suggests the need for some direct cognitive interventions. Some of these, such as thought stopping and distraction techniques, are designed specifically to gain control over the frequency and duration of distressing cognitive events. Others, such as the use of coping self-statements and guided self-dialogue, are intended to modify the content. More intensive cognitive interventions are likely to occur later in treatment and are discussed below.
Behavioral interventions are often appropriate also, targeted to the specific needs of the client. Since traumatic stress reactions often involve social withdrawal and isolation, interventions may include activity scheduling and social reintegra-tion (much as is commonly used in the treatment of depression). This would normally include encouragement to resume normal routines as quickly as reasonably possible after the trauma. While care should be taken to ensure that excessive commitment to work is not used as an avoidance strategy, resumption of a normal routine helps the survivor to regain a sense of structure and control. Other behavioral interventions are useful to address specific areas such as sleep, communication skills, and assertiveness.
It is reasonable to assume that all successful treatments of Posttraumatic stress disorder involve some kind of opportunity to confront the traumatic memories. Exposure-based treatments, widely used in the management of anxiety disorders for many years, constitute a central component of treatments for Posttraumatic stress disorder. Initially, these approaches were based on the assumption that fear is acquired and maintained by the processes of classical and operant conditioning of stimuli related to the traumatic incident.
The concept of extinction, or habituation, has been used to explain fear reduction following prolonged exposure to the traumatic stimuli. More recently, Foa and Kozak (1986) have proposed the notion of emotional processing to explain anxiety reduction during exposure. They suggested that the processing of corrective information results in changes to the traumatic memory network, modifying both the stimulus-response connections and the meaning attached to the experience. Excellent descriptions of exposure treatment in Posttraumatic stress disorder are provided elsewhere and only a brief overview of the technique will be provided here.
In the treatment of most anxiety disorders, it is generally accepted that live exposure work (known as in vivo) is more efficacious than imaginal exposure. In Posttraumatic stress disorder, in vivo exposure is used for external cues – activities, places, objects, or people – that have become anxiety provoking as a result of the trauma. In the case of Posttraumatic stress disorder, however, since the traumatic memories constitute the primary feared stimulus, much of the exposure work will be imaginal, with the client being asked to recount the traumatic experience in detail.
In order to optimize the efficacy of imaginal exposure, it is important to maximize both stimulus cues (e.g., sights, sounds, smells) and response cues (e.g., cognitions, affect, somatic sensations). Clients are asked to report on their level of anxiety and distress at regular intervals. In conjunction with the clinician’s observations, these indices assist the clinician in pacing the exposure and indicate when anxiety reduction is taking place.
Cognitive restructuring, based on the work of Beck and his colleagues (1979), is sometimes included under the heading of anxiety management. However, the techniques of cognitive therapy have been used to directly treat the core symptoms of Posttraumatic stress disorder. Cognitive processing therapy comprises cognitive restructuring with specific reference to five primary themes: safety, trust, power, self-esteem, and intimacy. Clients in Cognitive processing therapy are taught to identify maladaptive cognitions (or “stuck points”) and to vigorously challenge them using a list of dispute questions. A detailed description of the procedure has been provided by Resick and Schnicke (1993). Various adaptations of cognitive therapy and Cognitive processing therapy have now been trialled in the treatment of Posttraumatic stress disorder.
Psychological Treatments: Empirical Review
Prevention and Early Intervention
The controlled outcome studies quoted above, at first sight, provide impressive support for various approaches to the treatment of chronic Posttraumatic stress disorder. However, it is important to be cautious in our optimism. The treatment of chronic Posttraumatic stress disorder (i.e., of more than 3 months duration) has yet to achieve the levels of efficacy obtainable in the treatment of most other anxiety disorders. As a rule of thumb, around one-third of patients with chronic Posttraumatic stress disorder do very well following treatment.
Another third do reasonably well – although they will probably not meet criteria for a formal diagnosis of Posttraumatic stress disorder at posttreatment, many problems remain and impairment of psychosocial functioning continues. The final one-third of patients fail to respond in any significant way to treatment. The elucidation of those factors that will predict response to treatment, as well as which treatment modality is suited to which patients, is a major challenge for the field.