Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (2008)

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Appendix A PTSD Psychological Interventions I.  Trauma-Focused Therapy Trauma-focused therapies are a general class of therapies, not a specific intervention. They may be administered as group or individual therapy. They encourage clients to explore traumatic material in depth, gaining m ­ astery over traumatic memories and taking control of their own lives. This class of therapies includes techniques from various therapeutic ­approaches, including cognitive-behavioral and psychodynamic (Friedman, 2003). II.  Supportive Therapy Supportive therapy refers to a general class of therapies, rather than to a specific intervention. Unlike trauma-focused therapy, supportive therapy does not encourage exploration of traumatic material, instead promoting problem solving and adaptive coping in the present “here and now” con- text (Friedman, 2003). Supportive therapy can be delivered in individual or group therapy formats, which are intended to maintain interpersonal comfort and orient members toward coping (Foa et al., 2000). III.  Cognitive-Behavioral Therapy (CBT) Components CBT is administered either in the group or individual context. It is gen- erally short-term, lasting 8–12 sessions, meeting once or twice weekly. CBT utilizes principles of learning and conditioning to treat disorders and includes components from both behavioral and cognitive therapy. CBT components, 159 

160 TREATMENT OF POSTTRAUMATIC STRESS DISORDER which may be used in the treatment of posttraumatic stress disorder (PTSD) either alone as “types” of CBT or used in combination include exposure, cognitive restructuring, various coping skills or anxiety management, and psychoeducation (Foa et al., 2000; Friedman, 2003, Harvey et al., 2003). Exposure Exposure is a treatment that involves confrontation with frighten- ing stimuli and is continued until anxiety is reduced. Types of exposure include imaginal exposure, which involves exposure to traumatic event through mental imagery, either memory constructed through client’s own narrative or scene presented by therapist based on provided information (Foa et al., 2000), and in vivo, where a client confronts the actual scene or similar events in life. Most salient in this type of exposure is the “correc- tion of erroneous probability estimates of danger and habituation of fearful r ­ esponses to trauma-relevant stimuli” (Foa et al., 2000). In exposure therapy, the client and clinician may create a “fear h ­ ierarchy,” rating feared situations in order of anxiety response; clients may be exposed to the most distressing situation or trigger (flooding) or moder- ately ­anxiety-provoking situations first (Foa et al., 2000). Anxiety manage- ment techniques are usually taught (e.g., relaxation, psycho­education), but more time and attention are given to exposure proper (Foa et al., 2000). The client is exposed to trauma-related stimuli (imaginal or in vivo) with interruptions during which the client reports his or her anxiety level using Subjective Units of Distress Scale (SUDS) (10 [no distress] to 100 [most fear]) (Friedman, 2003). The aim is to extinguish the conditioned emotional response to traumatic stimuli (learn that nothing ”bad” will happen in trau- matic events), which eventually reduces or eliminates avoidance of feared situations. Exposure therapy has received the strongest evidence for PTSD, and clinical practice guidelines recommend it as the first line of treatment unless reasons exist for ruling it out (e.g., patients who were perpetrators of harm) (Foa et al., 2000). Cognitive Restructuring Cognitive therapy (CT) was originally developed by Aaron Beck in 1976 to treat depression, and subsequently developed as a treatment for anxiety (Foa et al., 2000). Beck’s (1976) theory holds that it is the inter­pretation of the event, rather than the event itself, that determines an individual’s mood; therefore, overly negative interpretations lead to negative mood states. CT uses cognitive restructuring techniques aimed at ­ facilitating relearn- ing thoughts and beliefs generated from a traumatic event and increasing awareness of dysfunctional thoughts contributing to anxiety response in 

APPENDIX A 161 inappropriate situations. CT sessions help individuals identify automatic thoughts related to trauma (e.g., I will never be normal again; I’m going to die) and correct or replace dysfunctional thoughts with more rational ones (e.g., I will get better, but it will take time; I feel scared, but I am safe). This often requires the clients to record their thoughts and emotions during stressful or fearful situations between sessions (homework). Various Coping Skills Several coping skills training or anxiety management components are described below. Assertiveness training centers on replacing anxiety r ­ esponse to a reminder of the trauma with an assertive response, and may be delivered either in a group or individual context. This approach helps clients be assertive rather than passive or aggressive in discussing their trau- mas, asking for help and correcting misunderstandings (Foa et al., 2000). Assertiveness training is mainly viewed as a component of treatment for PTSD, rather than a stand-alone intervention (Foa et al., 2000). Biofeedback is another anxiety management technique. Its aim is to facilitate client awareness of physiological responses, such as continuous feedback on heart rate or muscle tension. The goal is to help the client learn to control such processes. Relaxation training also is an anxiety management technique. It i ­nvolves teaching a client how to create a sense of relaxation, eventually in response to reminders of trauma, through diaphragmatic breathing, progressive muscle relaxation, imagery, and other techniques that induce muscle relaxation (and inhibit anxiety response). Relaxation training may induce anxiety in some patients (Foa et al., 2000). Psychoeducation Psychoeducation is either administered as a group or individual ther- apy. Practitioners aim to help clients understand the nature of PTSD and its effect on them. The approach is largely didactic (e.g., explaining origin and nature of emotional and physiological symptoms, normalizing experience, describing prognosis and appropriate expectations). IV.  Cognitive-behavioral therapy approaches CBT approaches utilize the components listed above either alone or as a “package” in specific clinical investigations or trials. Approaches them- selves may be used in combination. Some may also be used independently or as a part of other interventions. 

162 TREATMENT OF POSTTRAUMATIC STRESS DISORDER Prolonged Exposure Consists primarily of exposure (imaginal and in vivo), combined with psychoeducation (Department of Health and Human Services et al., 2003). Cognitive Processing Therapy (CPT) CPT incorporates elements of cognitive restructuring and exposure and focuses on emotional and cognitive consequences of trauma (Foa et al., 2000). The client is asked to write a thorough account of traumatic experi- ences. The client reads the account to their therapist and at home (exposure component) and determines “stuck points,” or moments during the trauma that are particularly difficult to accept and require more attention during cognitive therapy (Foa et al., 2000). CPT targets negative beliefs by con- fronting distorted traumatic memories, and attempts are made to change or modify the erroneous beliefs and subsequently inappropriate emotions. Stress Inoculation Training (SIT) SIT involves anxiety management techniques to handle anxiety that was conditioned at the time of the trauma and generalizes to many situa- tions (Foa et al., 2000) and is designed to increase coping skills for current situations. SIT may include education, muscle relaxation training, breathing retraining, role playing, covert modeling, guided self-dialogue, and thought stopping (Foa et al., 2000). Systematic Desensitization This is a form of exposure typically involving exposure in vivo and/or imaginal exposure and relaxation training (Foa et al., 2000). The approach also includes anxiety management techniques, namely relaxation, aimed at disassociating fear and anxiety from trauma memories through behavioral interventions. Systematic desensitization stems from theory of conditioned fear and operant avoidance of feared stimuli (Foa et al., 2000). Client and clinician often create a “fear hierarchy,” rating feared situations in order of anxiety response, then exposure begins with least fear-inducing situation (e.g., seeing picture of a spider) and progress to most feared situation (e.g., spider crawling up arm). The client is exposed to trauma-related stimuli with interruptions during which relaxation techniques are practiced (client reports anxiety level during interruption using SUDS rating). Habituation occurs through repeated presentation of trauma-related cues paired with relaxation. Evidence suggests that relaxation during exposure does not 

APPENDIX A 163 e ­ nhance treatment effectiveness, so exposure alone has gained more relative support than systematic desensitization (Foa et al., 2000). V.  Eye Movement Desensitization and Reprocessing (EMDR) As originally designed, EMDR includes saccadic eye movements (quick, jumping from one point of fixation to another) believed to reprogram brain function so emotional impact of trauma can be resolved (Friedman, 2003). In the EMDR process, the client is instructed to imagine a traumatic memory and negative cognition and articulates an incompatible positive cognition (e.g., personal worth). The clinician asks the client to contemplate memory while focusing on rapid movement of clinicians’ fingers. After 10–12 eye movements (back and forth) clinician asks client to rate strength of memory and his or her belief in positive cognition. VI.  Psychodynamic Therapy Explores psychological meaning of a traumatic event (Foa et al., 2000). Focus is on bringing unconscious traumatic memories into conscious aware- ness so that the PTSD symptomatology (which are presumed to be a result of these unconscious processes and memories) can be reduced. Treatment is given in weekly sessions 50 minutes in length, traditionally lasting from 12 sessions to more than 7 years (Friedman, 2003). Few empirical investiga- tions with randomized designs, controlled variables, and validated outcome measures have been reported; case reports constitute the bulk of the litera- ture (Foa et al., 2000). Brief psychodynamic psychotherapy (BPP) is typi- cally conducted in 12 sessions and up to 20, and focuses on the traumatic event itself (Foa et al., 2000; Friedman, 2003). VII.  Hypnosis Hypnosis may be used as an adjunct to psychodynamic, cognitive- b ­ ehavioral, or other therapies, and has been shown to significantly enhance their efficacy for many clinical conditions; however, there is a lack of quality evidence on use of hypnosis with PTSD patients. Hypnosis requires profes- sional training (Foa et al., 2000). There is some controversy as to whether the eye movements or the cognitive processing of the traumatic event account for effectiveness of EMDR. 

164 TREATMENT OF POSTTRAUMATIC STRESS DISORDER VIII.  Marital and Family Therapies Marital and family therapy is often used in combination with other therapies (Foa et al., 2000; Friedman, 2003). These approaches focus on symptom relief through increasing help and understanding in the family unit and fostering communication and support, or by treating marital or family disruption (Foa et al., 2000). Marital and family therapy approaches are typically time-limited, problem-focused interventions with courses of treatment varying depending on format of therapy (Foa et al., 2000). IX.  Peer Counseling Peer counseling is not a psychotherapy, but rather a supportive group approach. Voluntary group members convene, without an authority figure or expert, to give to and receive assistance from one another through honest disclosure and response (Friedman, 2003). X.  Psychosocial Rehabilitation Psychosocial rehabilitation is currently suggested only as an adjunct to other forms of treating PTSD, since it is not typically trauma focused (Foa et al., 2000). Techniques are effective, but none listed here have been studied with PTSD patients using randomized, controlled trials (Foa et al., 2000). Techniques include health education and psychoeducational tech- niques, self-care and independent-living skills training, supported housing, family skills training, social skills training, vocational rehabilitation, and case management. References Beck, A. T. 1976. Cognitive therapy and the emotional disorders. New York: International Universities Press. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, and Center for Substance Abuse Prevention. 2003. Prolonged exposure therapy for posttraumatic stress. http://www.modelprograms.samhsa.gov/pdfs/model/PE- PTSD.pdf (accessed September 2007). Foa, E. B., T. M. Keane, and M. J. Friedman. 2000. Effective treatments for PTSD. New York: The Guilford Press. Friedman, M. J. 2003. Post traumatic stress disorder: The latest assessment and treatment strategies. Kansas City, MO: Compact Clinicals. Harvey, A. G., R. A. Bryant, and N. Tarrier. 2003. Cognitive behaviour therapy for post­ traumatic stress disorder. Clinical Psychology Review 23(3):501-522.