The alarming news of another military service member going on a shooting rampage killing and wounding other service members on a military base is unnerving. For us Latinos it is especially upsetting to know that Iván López, a Latino, perpetrated the recent Ft. Hood shooting. I do not care for highlighting a person’s ethnicity or culture in these tragic events, but I feel that I have a responsibility as a Latina, a veteran, and a mental health professional to state the obvious that others are already commenting on.
While psychotherapy remains the gold standard for treatment of post traumatic stress disorder (see for example, Foa EB et al, Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press; 2008), medications are often used to alleviate the symptoms of the illness. Since we last visited the topic of pharmacologic treatment for PTSD (TCPR, June 2007), there’s been some interesting research on this subject, including the use of antibiotics, steroids, and even the drug of abuse, ecstasy.
Only a minority of individuals exposed to trauma will develop PTSD. In attempting to determine the individual risk factors for PTSD, researchers have begun to observe natural recovery from trauma. One potential difference between those who recover naturally and those who continue to experience distressing symptoms might have to do with avoidance: cognitive, emotional and behavioral.
The cognitive model suggests that the belief that the world is excessively dangerous coupled with beliefs about personal incompetence is important in the development of PTSD (Foa & Rothbaum, 1998). Following a traumatic event, such beliefs might be reinforced and therefore lead to avoidance of everyday, previously normal tasks such as grocery shopping, socializing, and traveling by car. Additionally, beliefs about the importance of maintaining strict control over distressing emotions and thoughts might also be factors mediating the development of PTSD (Ehlers & Clark, 2000). Following a traumatic event, these beliefs might lead to attempts to avoid thoughts and memories of the traumatic event and the associated upsetting emotions.
In contrast, natural recovery from trauma might be enhanced by a willingness to return, over time, to normal activities. This behavior may strengthen beliefs about personal ability to manage difficulty, that other people are not generally dangerous, and that even extremely uncomfortable emotions are manageable.
One CBT approach for PTSD systematically and strategically recreates this recovery process by targeting the tendency to avoid feared situations and distressing recollections and emotions. By systematically approaching the avoided stimuli, the individual can learn the same lessons as the person who recovers without intervention. With the assistance of a skilled cognitive behavior therapist, individuals can acquire more accurate and helpful beliefs about themselves, others, and the world following the experience of a traumatic event.
Ehlers, A., & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345.
Foa, E.B., & Rothbaum, B.O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York: Guilford Press.
What is Post Traumatic Stress Disorder (PTSD)?
June is Post Traumatic Stress Disorder (PTSD) Awareness Month. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), PTSD is classified as an anxiety disorder. The forthcoming new DSM has reclassified it as a trauma based condition. PTSD includes features of anxiety such as generalized anxiety and dread. However, experiencing major stress is significant in developing PTSD. PTSD has a clear cause which is a specific, extreme trauma such as rape, violence, natural or man-made disasters such as hurricanes or 9/11, combat war, death of a loved one, car or other accidents, and humanitarian crisis. This extreme trauma is a horrifying and exceptionally stressful experience or event which is usually perceived as life threatening and not within the normal boundaries of day to day living. It leads to severe and uncontrollable psychological symptoms. It is extremely important that the general public understand that PTSD is a NORMAL response to an extremely ABNORMAL situation. Neuroscience has shown that trauma causes specific changes in the brain that requires treatment. It does not mean an individual is insane, dangerous, immoral, has a character flaw, or any other unfounded stigma that is unfortunately associated with PTSD due to misinformation or ignorance. Read more at http://newlatina.net/post-traumatic-stress-disorder-ptsd-what-is-it/
As I sit across from a new client in his early thirties, who survived an assault while at college, he begins to tell me about his previous treatments. He describes a string of therapies addressing many of the problems that followed the traumatic event, such as chronic drug use, sleep problems, depression, rage, suicidal ideation, and risky behaviors. He tells me, “The therapists were so nice, supportive and knowledgeable. I went week after week. I felt better at each session, but I never got better. I just figured, “there must be something wrong with me that I can’t get better.”
Clients with PTSD often present with multiple complaints and problems, as comorbidity with other psychiatric disorders is highly prevalent (79%-88.3%; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). The therapist needs a well-formulated, efficient strategy for change to help the individual recover from PTSD and associated difficulties. The strategy should be based on a research-informed understanding of PTSD and a tailored conceptualization of the individual’s problems. Guided by conceptualization and strategy, the therapist is better able to respond to the individual’s unique challenges, which can include extensive avoidance, shame, guilt, anger, substance use, suicidality, interpersonal disturbances, and more. The ability to communicate this strategy to the individual can provide hope for the future and a framework for understanding an experience that feels frightening and chaotic.
Considering that survivors present with multiple, trauma-associated problems and many evidence-based therapies are available, the therapist can become overwhelmed with decisions such as where to begin therapy, which interventions to select, and how to respond when obstacles arise. These decisions are even more difficult when coupled with the unsubstantiated opinions existing in the mental health field about the treatment of trauma and PTSD. The use of an individualized, theoretically grounded, cognitive-behavioral conceptualization and strategy provides a guide for the therapist when planning treatment and helps the therapist maintain focus on an efficient course of treatment.
The conceptualization-driven course of therapy incorporates any of the possible presenting problems, with the goal of recovery from PTSD and a return to a meaningful life.
A significant percentage of veterans returning from wars exhibit symptoms of posttraumatic stress (PTS). This is now recognized as a serious health problem, but what about the victims of such violence? Refugees live with the constant reminder of what war has done to their lives and those of their families. A randomized/matched study published in the April 2013 issue of Journal of Traumatic Stress (Volume 26, Issue 2, pp. 295-298.) measured the severity of posttraumatic stress symptoms in refugees in Africa before and after learning the Transcendental Meditation (TM) technique. The reductions were dramatic.
Traumatic experiences are quite common, and survivors must in some way emotionally process and integrate these unwanted and painful events. Successful processing yields a realistic perspective in which the traumatic experience is in the past, reducing the person’s sense of current threat. Many trauma survivors accomplish this over time via natural mechanisms of recovery and do not require treatment. When this process is impeded or the natural processing is insufficient, posttraumatic stress disorder (PTSD), depression, and other problems frequently result.
Studies continue to show that PTSD is a common condition, with prevalence in the general US population of about 8%. Prevalence of PTSD in the active military and veteran population is even higher: Among US active duty service men and women returning from current military deployments, PTSD is estimated as high as 14-16% and among US veterans of the wars in Iraq and Afghanistan, estimates range from 4% to 17% (see Hoge et al., 2004; Richardson et al., 2010).
Given the impact of PTSD on individuals and families affected by this condition, dissemination and implementation of effective treatments is a very high priority.
Psychological treatments are aimed at helping the PTSD sufferer to process and integrate traumatic experiences. Cognitive behavioral therapies have extensive and strong empirical support and often result in remission or a decrease in the severity of PTSD, and decreased severity of depression and anxiety. All effective CBT interventions, which commonly include exposure (imaginal and in vivo), cognitive therapy, or skills training (e.g., stress inoculation; affect regulation and interpersonal effectiveness training), help the survivor to become less afraid of or threatened by trauma memories and reminders and of PTSD symptoms themselves, and to feel more competent and better able to cope. Theorists of exposure and cognitive approaches agree that treatment must in some way access or activate trauma memories, thoughts, and feelings, while providing corrective information that serves to modify the person’s unrealistic expectations of harm and danger and to reduce excessive negative emotion.
Prolonged exposure (PE; Foa, Hembree, Rothbaum, 2007) for PTSD has amassed considerable empirical support and is one of the primary treatments being rolled out by the U.S. Department of Veteran’s Affairs and the Department of Defense. While PE is a highly effective treatment, clinicians are sometimes concerned about whether it is an appropriate treatment for individuals with PTSD resulting from certain types of trauma or for those clients whose trauma narratives and current experience are dominated by emotions other than or in addition to fear: guilt, shame, anger, grief, and sadness. This is understandable – exposure-based treatments were designed for amelioration of excessive and/or unrealistic fear, not excessive guilt or anger. Experienced trauma therapists know that fear is but one of the emotional responses to trauma that are important to address in treatment. And most likely all would agree that facing trauma memories and reminders, and dealing with the feelings that result, are of prime importance.
Clinicians are also sometimes concerned that repeated revisiting of some trauma memories, particularly those associated with guilt or shame or anger about what occurred or what one did or did not do during the trauma, will be ineffective or will result in increased negative emotion. Many years of using and studying PE have yielded a rich understanding of emotional processing of traumatic memories via imaginal and in vivo exposure. Imaginal exposure – repeatedly revisiting trauma memories in imagination – and discussing and processing this experience with the therapist is a potent and efficient means of helping the PTSD sufferer to 1) fully access all of the salient information – facts, emotions, thoughts, behaviors, environment – within the trauma memory, 2) contextualize and understand his or her reactions and experience of the trauma and its aftermath, and 3) achieve a realistic perspective on the traumatic event and one’s behavior during it, as well as the impact it has had and will have in the future.
These outcomes are clearly illustrated in the case of a veteran treated with PE whose traumatic experience involved a deadly engagement with the enemy in which several of the men under his command were killed, despite his considerable and courageous efforts to lead this mission successfully and to save lives. The veteran presented for treatment about 5 years after this event with severe PTSD and depression, and he was suffering from extreme guilt and self-blame for the death of his men. In imaginal exposure he revisited the memory of that painful day in which these men under his command were killed and he was shot at while trying to render them aid. He was given a recording of this first imaginal exposure to take home and asked to listen to it daily before the next session, which he did.
During the review of his homework in the following session, the veteran reported that he had listened to the recording of his imaginal exposure frequently, as requested, and that he had done much ‘soul-searching’. He realized that he had done his job as best he could, and that if he had not done his job well, even more people would have died. Moreover, the veteran reported that thinking this over and listening to the session repeatedly had led him to accept that there was probably nothing that he could have done differently, and that he was beginning to feel a lessening of the “guilt and shame and the blame” he held on to for years after the death of his men. The veteran seemed relieved as he told his therapist that even though he had done everything in his power to bring everybody home, it was just not possible, and not up to him. He ended by saying that he was realizing through this process that he needed to try to let this go and to forgive himself.
This case is a good reminder that our powers of recovery are strong, and that when these powers have stalled or been impeded, they can be unleashed or facilitated by good, trauma-focused psychotherapy so that healing can proceed. Prolonged exposure and cognitive therapy, often primed by imaginal revisiting of the trauma memory as suggested by Ehlers and Clark (2000), are powerful and effective procedures that activate these forces and promote a reorganization of the trauma-related information that is more accurate and whole, an acceptance of what has happened, and a reduction of anxiety, guilt, anger, sadness, and other emotions that have dominated the person’s current experience, and result in reduction of PTSD and other trauma-related disorders.
Ehlers, A., & Clark, D.M. (2000). A Cognitive Model of Persistent Posttraumatic Stress Disorder. Behaviour Research and Therapy, 38, 319-345.
Foa, E. B., Hembree, E. A. & Rothbaum, B.O. (2007). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences. New York: Oxford University Press.
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22.
Richardson, L. K., Frueh, B. C., & Acierno, R. (2010). Prevalence estimates of combat-related post-traumatic stress disorder: Critical review. Australian and New Zealand Journal of Psychiatry, 44, 4-19.
Elizabeth A. Hembree, PhD
Department of Psychiatry, Perelman School of Medicine
University of Pennsylvania