‘The Treatment of PTSD’

The European Society for Traumatic Stress Studies

Conference

Friday 6^th  February’ 1998

First published in European Society for Traumatic Stress Studies Bulletin; volume  6: Number 4 1998

By

Richard Cross

How terribly disabling it would be, imagine a fear that you cannot escape from; filling not only your waking day but your nights as well (re-experiencing the trauma). Making you avoid anything with a connection to the event (avoidance) and subsequently leading to a state of heightened arousal (DSM- III, 198o)  

Conference content (selected ‘personal’ highlights):

Stuart Turner (chair) made the introduction to the start of the conference. His emphasis was that although some controversial issues would be raised and some questions left unanswered the emphasis was that PTSD can be alleviated by the application of various interventions.

In these introductory remarks, some of the concepts of psychotraumatology were introduced. These included a summary of the range of reactions to trauma. The more complex responses were outlined, including effects on personality development, somatisation, shame and guilt driven responses, effects on attitudes and beliefs, co-morbidity e.g. depression. These were discussed as a prelude to discussing about the possible selection of treatment. (DSM -III & ICD-10)

He also commented on the promising link between the degree of arousal and the severity of the PTSD reaction (Saigh, 1984).

Roderick Orner (Lincoln, UK):

Introduced a debate about the ‘Process and Outcome of Psychological Debriefing’, the main thrust of this session was a proposal to limit the usefulness of the debriefing process. Orner proposed that CISD (Mitchell, 1985) may be an example of ‘inspired product promotion ‘that didn’t fulfill to mitigate psychological impact of an traumatic event’ (Mitchell & Beverly, 1985). Furthermore the evidence does not support the view that this process prevents the onset of PTSD.

It was emphasized though that a process of creating an appropriate environment for recovery is an important one for early interventions. For this reason it was advocated that greater recognition be given to naturally emergent ‘buffers’ provided by peer group or social support processes. Furthermore, it was seen that the distinct roles of clinical and research disciplines lie in identifying those individuals who are most at risk.

I enjoyed this session due to my interest in the debriefing process. It is clear that to enable individuals to explore any thoughts, feelings or impressions of the event can be a very beneficial process for many. It allows for the seeing of the event from a different perspective and gives a full picture of what happened. It also encourages the natural support mechanisms to come into place between those who have experienced a traumatic event together (Dyregrov, 1989).

Following the session I am still a firm believer in the process of debriefing (Cross, 1998), but possibly if the beliefs put forward in this presentation are supported by future research the aims and objectives of the process may need to be re-evaluated to:

• Reduce effects of trauma,
• Normalization of reaction,
• Support,
• information giving,
• identification of those at risk

What is clear is that early interventions such as the debriefing process does provide an structured but flexible approach which provides many organizations a method of providing early support.
 

Ulrich Schnyder (Zurich, Switzerland):

Presentation was on ‘Crisis intervention in Survivors of road accidents’ (Caplan, 1964; Parad, 1965)His approach was to propose a 7-point model based on all recent research for basing crisis interventions.

The proposed model is outlined below:

(1) Establish contact: welcome introductions, clarifying, setting, allowing emotional release.
(2) Problem contact: analyzing problem, situation (social), coping resources.
(3) Problem definition: stressor, reactions, strategies.
(4) Goal definition: future & hope.
(5) Working on problem: safety & support, control.
(6) Termination: anticipated from beginning
(7) Follow-up: after 2-3 months.

Outpatient crisis intervention is seen as including 4-6 sessions over a 4-6 week period. The initial interview is clearly structured and aims at clarifying the first four points, whilst the preceding sessions should be aimed at working on the precipitating stressor or problem. The principles of crisis intervention is seen as being not only the rapid application of the ‘model’ but also seen as focusing on the current problem due to time limitations. It is also employs an active therapeutic approach which basis itself on helping the client help themselves. It also supports the importance of Social support and for this reason may mean family based therapy instead of individual therapy.

Tom Lundin (Uppsala, Sweden):

Looked at combining Psychopharmacological and psychotherapeutic approaches, he proposed that DSM-IV diagnosis is not necessary for professional treatment of traumatic stress related symptoms. What is emphasized is the need to help those presenting problems and those early interventions are of benefit/support to normalize symptoms.

For any treatment accurate assessment of individuals is a must (CAPS) and the application of drugs are just as critical as various drugs have beneficial effects for elements presented in PTSD e.g. arousal, hypervigaliance, impulsiveness.

What has become clear is that victims have a greater chance of the onset of PTSD if a weapon is involved and the amount of life threat. It was also commented about certain risk groups:
· survivors with psychiatric illness
· close relatives die suddenly
· children- especially those separated from parents
· body handlers
· individual’s dependent on Psycho social factors e.g. those with disabilities.

Once again it was emphasized that all groups would be helped by the application of peer support, social support, volunteers and self help. Emotional first aid needs to encompass four factors
1. Proximity: should be treated as close to the place they were traumatized.
2. Immediacy: as soon as possible.
3. Expectancy: they are expected to recover.
4. Simplicity: simple as possible treatment.

The aims of such emotional first are;
· to enable the acceptance of the feelings & symptoms experienced;
· identify resources;
· realizing psychologically painful situations
· acceptance of reality
· work on creating an optimistic attitude & to avoid blaming others;
· acceptance of help
· ultimately to resume the activities of daily life.

This approach can be seen as adopting very similar aims as described in the previous presentations and re-emphasizes the importance of early interventions; such as the debriefing structure and the aims of such structures.
 

Lional Bailly (Paris, France): specialized in psychotherapy with traumatized children.
 

A child is not an independent person and must be considered as a part of a family. This means young children see the event through the parent’s absence or presence and the adult’s actions and behavior. It is subsequently modified by their motor skills, maturity both physical & language, and there understanding of the situation.

The event is seen as causing trauma in the child through:
1. fear caused directly by the event.
2. The fear is experienced by the parents / the significant adult (teacher, guide etc.)
3. Destruction in belief in parents (being vulnerable and not protected, lack of love and goodness e.g. family violence)
4. Discovery of world’s violence / injustice (Bulman, 1983)

The treatment is seen as two fold in dealing with parental issues both legal and feelings related e.g. guilt, shame, denial. Children it was emphasized want to talk about the event; however you need to ask. Parents and adults though will severely restrict this therapeutic process and an open and caring atmosphere needs to be encouraged.
 

Nicholas Tarrier (Dept of Clinical Psychology, University of Manchester):
 

This presentation looked at Cognitive - Behavioral approaches to the treatment of PTSD. Studies in the USA have reported that in war veterans exposure treatments are superior to supportive counselling. Furthermore in the treatment of rape victims exposure and stress inoculation are superior to supportive counselling.

The treatments looked at included:

• Exposure (in the mind, memories)
• Anxiety management
• Cognitive therapy (maladaptive thought patterns)

What research has shown is that; flooding (exposure) can be a very beneficial treatment alongside stress inoculation, although flooding may cause some individuals to deteriorate if not undertaken frequently enough.

An interesting element observed in the Manchester study was scores of those on the treatment programme for Expressed Emotion (E.E). This was seen to correlate to participant’s success on the programme. This E.E score was seen as the factor which dictate the ability for individuals to express there thoughts and feelings in a safe environment e.g. critical, non supportive spouse. This once again shows that a sympathetic relationship is of major importance to enable the person to work through the trauma.

What was advocated was a flexible approach incorporating:

Relaxation + CBT + Exposure

However it was also emphasized that this was only a initial study and there would as always be a need for replication of the project to confirm the findings; but the findings relating to Expressed Emotion was promising.
 
 

Conclusion:

As I said at the beginning the above is only a selection of the various presentations of the day. These were chosen on purely personal criteria for this review of the conference. Hopefully it can be seen there are many common themes running through these. It is clear that there is a need for early interventions and that these can greatly help those who have experienced a traumatic event ; particularly if the following is kept in mind:
· Importance of emotional support from peers and family.
· Need for the opportunity to talk about experiences in a non critical environment
· Normalization of the PTS reaction.
· Identification of those at greatest risk of developing PTSD.
· A flexible and easy applied structure of support.
· Information regarding the support network.
· Treating each as an individual with different needs e.g. children.

What is clear is that by the application of such interventions PTSD can be alleviated and by the adaptation of certain approaches these appear to be remarkably successful.

First published in ESTSS Bulletin, Vol 6: Number 4 1998
 
 
 

Richard Cross