Understanding and Treating PTSD: Introduction M. Tracie Shea and Caron Zlotnick Brown University School of Medicine Although trauma and its consequences are not new, the understanding of the mental, emotional, and physical symptoms that often follow traumatic events as a distinet disor der is relatively recent. The addition of posttraumatic stress disorder (PTSD) to the Diag- nostic and Statistical Manual of Mental Disorders (DSM-I) in 1980 had a large impact on theory, research, and treatment of the psychological consequences of trauma. Much of the early research focused on identification and assessment of symptomatic reactions to trauma and attempts to identify risk factors for the development of PTSD. Research on treatment of PTSD has emerged more recently and is still in the relatively early stages. Since the last edition of In Session on PTSD in 1997, there have been multiple advances in the treatment of PTSD. Most notable is research that has examined the effi- acy of combined psychotherapy approaches in the treatment of PTSD and research that has compared the effectiveness of different treatments. Another area of growth has been the use of pharmacotherapy in the treatment of PTSD, especially the use of sertraline as an effective and well-tolerated treatment for PTSD. In the last few years, there also has been an increased interest among clinicians and researchers in eye-movement desensiti zation and reprocessing (EMDR) for patients with PTSD. The clinical significance of PTSD is reflected in the recent publications of experts’ consensus statements on PTSD (c.g., Ballenger et al., 2000) and on practice guidelines for the treatment of PTSD (e.g.. Foa, Keane, & Friedman, 2000). In the wake of the terrorist attacks on September 11, the effects of trauma have been featured prominently in the media and professional journals, and—hopefully—there will be a heightened importance of appropriate mental health care for trauma survivors. The purpose of this issue of In Session is to describe the theory and practice of the psychosocial approaches at the forefront in PTSD treatment, with plentiful case illustra- tions, The issue begins with an overview of clinically relevant research findings provided in the excellent article by Schnurr, Friedman, and Bernardy. With its summary of findings on the prevalence and course of PTSD, their article provides a context for understanding the importance of developing effective treatments. The discussion of the comorbidity associated with PTSD highlights one of the many comp! ment in this, X issues in Correspondence concerning this article should be addressed to: M. Tracie Shea, Ph.D., Department of Psychi- atry and Human Behavior, Brown University, Butler Hospital Campus, Duncan Bldg., 700 Butler Drive, Prov. idence, RI 02906 LICLP/In Session: Psychotherapy in Practice, Vol. 58(@), 869-875 (2002) Published online in Wiley InterScience (www.interscience.wile.com), DOI: 10.1002/jelp.10063 1002 Wiley Periodicals, Inc.870 JCLP An ession, August 2002 area: PTSD symptoms rarely are found alone, More commonly, the diagno: ated with one or several comorbid disorders or associated features, complicating treat- ment decisions. Their summary of some of the exciting research advances in information processing and psychobiology illustrates the broadening of our knowledge of the mech- anisms that may underlie the development and maintenance of PTSD symptoms, knowl- edge likely to be critical to future advances in prevention and treatment. The section on assessment provides a useful overview of relevant considerations for the practicing cli nician, including a description of a structured interview developed to assess symptoms of PTSD. s is associ- Treatment Approaches for PTSD A wide range of approaches have been used in the treatment of PTSD, including the spectrum of established psychosocial-treatment approaches. The more traditional inter- ventions include behavioral approaches, treatments that combine cognitive and behav- ioral methods, and psychodynamic approaches. Also frequently used—but less well studied—are hypnotherapy, self-help/support groups, and crisis intervention, A treat- ment that appears to be frequently used in practice is eye-movement desensitization and reprocessing (EMDR). EMDR recently has been the focus of considerable research atten- tion, and initial empirical findings suggest that EMDR is efficacious in the treatment of PTSD. As Solomon and Johnson note in their study, the strongest research support exists for treatments that combine cognitive and behavioral techniques, as more studies have been conducted for these approaches Two articles in this issue illustrate the application of cognitive-behavioral approaches in the treatment of PTSD. Both of these treatments have been described in manual form, with explicit guidelines on the type and sequencing of interventions used and focus of each session, Each of these approaches emphasizes the combination of repeated confron- tation of the feared memories and/or associated cues (exposure) together with cognitive re-evaluation of the erroneous interpretations and beliefs stemming from the trauma, for example, about safety, or about the individual’s responsibility for the traumatic event. Both approaches also include instructions in the use of behavioral techniques to improve the individual's ability to cope with anxiety. Jaycox, Zoellner, and Foa describe the appli- cation of their cognitive-behavioral approach, delivered in individual therapy, in the treatment of a young female rape victim. Foy, Ruzek, Glynn, Riney, and Gusman describe their trauma focus group therapy (TFGT) for combat-related PTSD, with an illustration of cognitive restructuring work with an individual member of the group. Krupnick’s article illustrates the use of a psychodynamic approach in the treatment of PTSD. Her article includes a description of Horowitz and colleagues’ brief trauma focused psychodynamic psychotherapy, which was developed for adults with a recent single trauma, and its application in the treatment of a woman with PTSD symptoms following the death of her husband in a plane crash. This treatment, delivered in an individual format, involves the use of standard psychodynamic conceptualizations and interventions, but with a focus on the individual’s trauma, and more generally on themes that are common to trauma survivors. The article by Francine Shapiro and Louise Maxfield describes EMDR in the treat- ment of patients with PTSD and a range of index traumas. The treatment combines other psychotherapies with unique features that include saccadic eye movements and brief interrupted exposures. Central to this model is the notion that if distressing memories of affective, and cognitive level, a traumatic experience are not processed fully on a sensory then they will precipitate dysfunctional reactions under certain conditions in the presentIntroduction 871 EMDR follows a specific treatment protocol designed to facilitate the reprocessing of the dysfunctional reactions associated with the traumatic memories. Their article describes in detail the sequential stages of EMDR, an individual treatment, and illustrates this approach in the treatment of a woman with a fear of earthquakes and a driving phobia due to a car accident. Because the focus of this issue is on psychosocial treatments, the use of pharmacd therapy generally is not addressed. Solomon and Johnson's article provides a brief ove view of the status of pharmacological treatment research in PTSD and notes that sertraline has been approved recently by the FDA as a treatment for PTSD. Pharmacotherapy often is used in practice, and clinically it appears that, for many individuals with PTSD, the use of medication provides an important stabilizing effect that may facilitate the initiation and progress of psychosocial treatments. Combining pharmacotherapy and psychosocial © study treatments in the treatment of PTSD has received virtually no systemati In terms of psychosocial treatments, despite the clear articulation and manualization of treatments for PTSD, the appropriateness and effectiveness of any given strategy may depend upon several factors. Among the issues that may influence choice of treatment are: nced + The frequency and duration of exposui + The type of trauma experi © Lo traumatic events + The specific symptoms that are most disturbing + The presence of associated features and/or comorbid disorders + The nature of the client's current physical and social environment The client characteristics a lowing articles vary in terms of several of these factors, illustrating the diversity that may be present in any individual case of PTSD. These differences also speak to why there is no singular treatment of choice for PTSD \d the circumstances of the traumatic experiences in the fol- nd Duration of Trauma Type As noted previously, much of the early research on treatment of PTSD has focused on combat veterans. Over the years, attention has broadened to include a wider range of traumatic experiences, such as rape, sexual abuse, accidents, and natural disasters, These types of traun are the produ 1 differ in important ways: Some (e.g., combat, torture, rape, sexual abuse) tof human actions, whereas others (e.g., natural disasters) are not. The meaning of the traumatic event or events, and the struggle to make sense of it, may be quite different when human action, particularly human action with clear intention or from a loved one, is involved. For example, the ability to trust others may be a more salient therapeutic issue for a survivor of torture or sexual abuse than for a survivor of hurricane. The sense of personal responsibility for the trauma also differs. Some traumatic experiences may be more likely to be perceived (accurately or not) as avoidable in ret rospect, whereas while feelings of guilt and shame frequently are present in survivors of many kinds of trauma, these may be more severe or problematic depending upon the circumstances of the trauma, For example of a sense of personal responsibility and feelings ilt often are distorted and magnified for survivors of combat, sexual abuse, or rape. Issues of predictability and controllability of the traumatic event(s) and self-for veness become important clinical foci in such cases.872 JCLPIn Session, August 2002 Some types of trauma are associated with increased likelihood of repeated traumatic events. Combat, torture, and physical and/or sexual abuse frequently involve multiple events over long periods of time. Cases of prolonged trauma are likely to be more com- plex and may require longer treatment, as well as multiple treatments. Whether the trauma occurred in childhood or adulthood—and if in childhood, at what age—also are impor- tant factors. Earlier trauma, particularly trauma of a repetitive nature or from a trusted caregiver, will have more serious developmental implications and may result in a wider range of symptoms and greater impairment in adulthood. Two of the articles in this issue involve incidents of trauma that involved human actions: a case of rape (Jaycox et al.) and one combat-related incident (Foy et al.). In each of these cases, chronic feelings of guilt, shame, and exaggerated belief’ in personal respon sibility are central. The client presented by Jaycox et al. dwells on actions she could have taken to prevent the rape. The case narrative presented by Foy et al. illustrates cognitive restructuring with a combat veteran with an inflated sense of responsibility for an a dental explosion resulting in serious injuries. In contrast, the case presented by Krupnick involves a client whose husband was killed in a plane crash. Although guilt is noted, it is less central to this case than in the others. Interpersonal trust is illustrated in the case narratives presented by Jaycox et al nd Foy et al. In the former, the client was experiencing severe difficulty in trusting the intentions of men following the rape that had occurred several years before. This client is described as isolated and disconnected from others. The combat veteran in Foy et al.’s article has a history of several conflicted and disrupted interpersonal relationships. The group format in TFGT provides an important mechanism for rebuilding trust, as this case illustrates. These cases may be contrasted with the case presented by Krupnick, where interpersonal trust is not a theme addressed in the treatment. A common theme among survivors of trauma is a sense of personal vulnerability and loss of control as a result of the trauma, In the case presented by Shapiro and Maxfield, the client who had experienced three earthquakes and a traffic accident grappled with hi own safety and “shaky” reality. During EMDR treatment, the client was able to link together and reprocess a series of chaotic events in her life. At the end of treatment, the client reported a greater mastery over her earthquake-related PTSD. The cases differ in terms of multiple versus single episodes of trauma and the length of treatment mostly is reflective of these differences. The combat veteran presented by Foy etal. had experienced heavy combat and casualties in addition to the focused-on event. The TFGT described by Foy et al. is longer, with 30 weekly sessions followed by five monthly booster sessions. This contrasts with the cases presented by Jaycox et al. and by Krupnick, which involve a single traumatic event, Both treatments are time limited, con- sisting of 12 sessions; in fact, Krupnick notes that the time-limited psychodynamic treat- ment is designed for adults with PTSD following a single traumatic event. In the case presented by Shapiro and Maxfield, the client had experienced repeated exposure to the index trauma (an earthquake) and childhood abuse. However, the client wanted to address, only her fears of earthquakes in treatment. The duration of EMDR was four sessions. Shapiro and Maxfield comment that they believe that a client who presents with multiple traumata may well benefit from additional sessions, Furthermore, although EMDR gen- erally is considered a relatively brief intervention, Shapiro and Maxfield state that treat ment may be completed in a few sessions or over a period of months depending on the severity of the pathology. The kind of treatment outcome that realistically may be expected also is likely to be related to the duration and severity of the trauma. For example, Foy et al.’s combat veteran, although showing improvement, continued to meet PTSD criteria following the treatment. For many trauma survivors, full recovery” will not be possible.873 Symptoms, Associated Features, and Comorbid Disorders The symptoms experienced as most disturbing vary among individuals who have expe rienced trauma and also may vary over time within individuals. The current symptom picture may be salient in making treatment decisions. As noted in Solomon’s and Johnson's review, there is some research evidence to suggest that exposure techniques and hypnosis may be more likely to affect the intrusive symptoms of PTSD, whereas cognitive and psychodynamic therapies may be more effective for numbing and avoidance symptoms. The cognitive-behavioral approaches described in the Foy et al. and Jaycox et al. articles explicitly incorporate both exposure and cognitive strategies implemented in a fixed sequence. Albeit less explicit and briefer, cognitive-behavioral strategies (i.e., cognitive processing and exposure) also are key components of EMDR. In the initial phase of brief psychodynamic therapy described by Krupnick, the primary symptoms influence initial strategies. Intrusive symptoms and hyperarousal may be dealt with by increasing struc- ture and reducing demands in the client's life or by the use of medication to improve the client’s sense of emotional control. In contrast, clients presenting with a more avoidant or numb state gently are reassured and encouraged to allow themselves to let feelings in. Throughout the course of treatment, encouragement to talk about the trauma and explo- ration of the psychological meaning of the event are pursued. Another aspect of psychological functioning that is critical to treatment selection is the general emotional strength of the client, including ability to tolerate intense anxiety or other feelings. Shapiro and Maxfield discuss in their article on EMDR that the therapist must assess the client’s emotional stability and ability to tolerate strong affect before the reprocessing phase of treatment, and, if indicated, affect-management skills should be incorporated into the treatment. Psychodynamic treatment also explicitly addresses in the evaluation phase that there be evidence of pretrauma functioning, including the capacity for basic trust, ability to cope with emotional states, and capacity for psychological think- ing before treatment can proceed. Foy et al. (1996) and Litz, Blake, Gerardi, and Keane (1990) have written about considerations for client features for the use of cognitive— behavioral approaches involving intensive and prolonged imaginal exposure. The TFGT described in this issue by Foy et al. was developed in part due to the difficulty that many combat veterans with PTSD have in tolerating prolonged intensive exposure in individual therapy. TFGT incorporates development and strengthening of coping skills before expo- sure; in addition, the exposure procedure in the group setting provides more support to the individual, Itis more the rule than the exception that individuals meeting criteria for PTSD also meet criteria for another Axis I disorder, Depression, substance abuse, and other anxiety disorders are particularly common, as noted in Schnurr et al.’s review. The presence of depressive symptoms of mild-to-moderate intensity in most cases would not preclude trauma treatment, but the presence of a severe and incapacitating depression is likely to prevent, and may contraindicate, trauma-related work. The presence of substance abuse often is considered contraindicated for treatments involving a trauma focus due to the fear of triggering relapse. However, this is controversial, as some argue that the substance abuse cannot be dealt with effectively until the trauma is addressed because the sub- stances are used to cope with the PTSD symptoms. Two of the cases had histories of alcohol abuse (Foy et al., and Jaycox et al., respectively); both were in remission at the time of treatment. Urges to drink arise as a serious concern in the Jaycox et al. case, which nicely illustrates how the treatment can handle such urges without interrupting the trauma focus work. In the case presented by Shapiro and Maxfield, the client presented with a driving phobia in addition to her PTSD and, at the end of treatment, both disorders874 JCLPIn Session, August 2002 had been treated successfully. As Solomon and Johnson note in their article, further research is needed to examine the effects of comorbidity in PTSD treatment Social and Environmental Context The importance of ascertaining that the client has the necessary safety and support in his/her living environment increasingly has become recognized. Many experts empha- size that the safety and physical well-being of the client is the first treatment priority. This includes a focus on any self-initiated behaviors that pose danger, such as self-mutilation, substance abuse, and unsafe sex. Exploration of trauma memories or affects is not under- taken until such dangers have been addressed and resolved. Thus, for some individual particularly those with prolonged and severe trauma histories, the initial phase of treat- ment will involve environmental (case management) interventions. For others, the initial treatment focus may be the development of more adaptive methods of dealing with pain- ful affects, that is, increasing the ability to tolerate and manage symptoms rather than resorting to self-destructive behavior. Even for clients not suffering from self-threatening behaviors and with reasonably safe and stable environments, it may be important to ensure that adequate support is available before intensive trauma focus. The use of a group format in exposure treatment for PTSD was considered important in the develop- ment of TFGT for this very reason: the provision of support to each member as they undergo exposure. Conclusion The gains in knowledge regarding PTSD treatment have been substantial, particularly in the last decade, where the years of accumulated wisdom in this area have begun to be more formally conceptualized and systematically studied. As the empirical base dev ops, so does the appreciation of the complexity of the issues and the limits of current knowledge regarding the efficacy and generalizability of PTSD treatments. The long- term benefits of early intervention are unknown, The limits of therapeutic response in individuals with chronic PTSD also are unknown. The question of whether to address the trauma directly through exploration and uncovering or through direct therapeutic expo- sure and the optimal timing for such cannot be answered with certainty for many indi- viduals with PTSD. Although there are manualized treatments, clinicians still must often rely on general guidelines and clinical judgment in planning and implementing treatment for PTSD. Perhaps the clearest “truth” at this point in time is the centrality of the therapeutic relationship with trauma survivors. It probably cannot be overemphasized that no inter- vention will be effective without a minimum amount of trust in the therapist. The treat- ments described in this issue vary in terms of their explicit statements regarding the therapeutic relationship, but we doubt that any would disagree that trust is a precondition to benefiting from the treatment. We also would emphasize trust the benefits of the ther- apeutic relationship itself in the treatment of PTSD. These individuals have had their basic assumptions of safety, predictability of human nature, and the very meaning of fe shattered. The experience of regaining trust within the context of a stable, safe, and caring therapeutic relationship is in itself likely to be an important agent of change The series of articles end with a succinct but comprehensive summary by Solomon and Johnson of the outcome research on psychosocial treatments for PTSD. Their art le provides an integrative framework for the preceding clinical articles by describing the body of research—including its gaps—that exists for the many forms of treatment usedIntroduction 875 in practice. This article provides the important reminder that, despite the notable devel opments in treatment research in this ar . there exist relatively few systematic studies of efficacy for many of the treatment approaches practiced. Furthermore, Solomon and John: son note that the majority of the controlled studies have focused on Vietnam veter With the exception of a few controlled trials of rape victims, other trauma populations have received little study. This highlights the importance of conducting more controlled research in this arca and of targeting critical gaps in PTSD treatment research, Select References/Recommended Readings American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.), Washington, DC: Author Ballenger, J.C., Davidson, JR., Lecrubier, Y., Nutt, D.J., Foa, E., Kessler, R.C., McFarlane, A.C. & Shalev, A-Y. (2000). Consensus statement on posttraumatic stress disorder from the Inter- national Consensus Group on Depression and Anxiety, Journal of Clinical Psychiatry, 61 60-65. Foa, E.B., Keane, IM., & Friedn Traumatic Stress, 13, 539-588. Foy, D.W., Kagan, B., McDermott, C., Leskin, G., Sippretle, R.C., & Paz, G. (1996), Practical parameters in the use of flooding for treating chronic PTSD. Clinical Psychology and Psycho- therapy, 3, 169-175, Litz, B.T., Blake, D.D., Gerardi, R.G., & Ki MJ. (2000). Guidelines for treatment of PTSD. Journal of eane, T.M. (1990). Decision-making guide! nes for the use of direct therapeutic exposure in the treatment of posttraumatic stress disorder. The Behay- ior Therapist, 13, 91-93Copyright of Journal of Clinical Psychology is the property of John Wiley & Sons Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. 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