Empirical Evidence Regarding Behavioral Treatments for
PTSD
The aim of all disaster mental-health management should be the
humane, competent, and compassionate care of all affected. The
goal should be to prevent adverse health outcomes and to enhance
the well-being of individuals and communities. In particular, it
is vital to use all appropriate endeavors to prevent the
development of chronic and disabling problems such as PTSD,
depression, alcohol abuse, and relationship difficulties and to
help those that do develop these problems to recover quickly.
In addition to targeted, brief early interventions, some
trauma survivors may benefit from ongoing counseling or
treatment. Candidates for such treatment include survivors with a
history of previous traumatization (e.g., survivors of the
current trauma who have a history of childhood physical or sexual
abuse) or those who have preexisting mental health problems.
Below we describe the empirical evidence that currently exists
regarding these ongoing behavioral mental health treatments.
The trauma treatment research field is still young, and
treatment research can be complicated and difficult to conduct.
Because of this, comparisons of different treatments for PTSD are
scarce; therefore, a lack of empirical evidence in the literature
does not necessarily signify a lack of treatment efficacy. The
current process by which trauma experts evaluate treatment
options is to study the empirical literature and take into
account clinical consensus on treatments that have proven
effective in case studies or across clinical settings. The choice
of a treatment modality is based on many factors, including
unique client life challenges; side effects and potential
negative effects; cost; length of treatment; cultural
appropriateness; therapist's resources and skills; client's
resources and stressors; comorbidity of other psychiatric
symptoms; the fluctuating course of PTSD; the need to foster
resilience; and legal, administrative, and forensic concerns.
While there is limited empirical literature on which to base
comparisons of alternative treatment methods, a number of
treatment approaches have gained empirical support. Some of these
treatments have shown promising results across a number of
different settings and with different trauma populations. They
are available within VA hospitals and merit attention when
considering referral options. Listed below are some treatments
that have gained empirical support:
Cognitive-Behavioral Therapy (CBT)
There are more published well-controlled studies on CBT (over
30) than on any other PTSD treatment. CBT treatments for PTSD
include:
Exposure therapy, in which patients are asked to describe
their traumatic experiences in detail, on a repetitive basis,
in order to reduce the arousal and distress associated with
their memories
Cognitive therapy, which focuses on helping patients
identify their trauma-related negative beliefs (e.g., guilt or
distrust of others) and change them to reduce distress
Stress-inoculation training, in which patients are taught
skills for managing and reducing anxiety (e.g., breathing,
muscular relaxation, self-talk)
CBT treatments usually involve some combination of the above
methods combined with education about PTSD and the development of
a good therapist-patient relationship. Other CBT treatment
methods may be added to address related problems, such as anger
(anger management training, assertiveness training) or social
isolation (social skills training, communication skills
training).
In general, cognitive-behavioral methods have proven very
effective in producing significant reductions in PTSD symptoms
(generally 60-80%) in several civilian populations, especially
rape survivors. However, the degree of symptom reduction is
likely to be somewhat less in veterans with chronic
combat-related PTSD. Nevertheless, the magnitude and permanence
of treatment effects appears greater with CBT than with any other
treatment.
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR involves having the patient bring to mind images of the
trauma while engaging in back-and-forth eye movements (or while
alternating oneâs attention back and forth using taps or
sounds). It also addresses trauma-related negative beliefs. It
has been shown to be more effective than psychodynamic,
relaxation, supportive, or placebo wait list therapies (where
patients are put on a waiting list to receive treatment but don't
actually receive it by the time they are tested). Research
comparing EMDR to the more generally accepted
cognitive-behavioral techniques shows significantly better
results with CBT than with EMDR, particularly at three-month
follow-up. CBT results also show greater sustainability. Research
looking at the different components of EMDR shows that the eye
movement component adds no additional treatment effect to the
imagery exposure and the process of dealing with negative
beliefs.
Psychodynamic Therapy
Research on the use of psychodynamic therapy is difficult to
conduct because psychodynamic techniques do not focus on symptom
reduction. Instead, they focus on more fluid intra- and
interpersonal processes. To date, there has been only one
randomized clinical trial on the efficacy of psychodynamic
treatment in reducing PTSD symptoms. In this trial, 18
sessions of Brief Psychodynamic Psychotherapy were shown to
effectively reduce PTSD intrusion and avoidance symptoms by
approximately 40%, and improvement was sustained for 3 months.
While clinicians often support the utilization of psychodynamic
techniques in the treatment of trauma, particularly in the
treatment of more complex trauma, much more research is needed to
demonstrate the techniques effectiveness with PTSD.
Group Therapy
While various studies have shown most group treatments to have
beneficial effects with respect to psychological distress,
depression, anxiety, and social adjustment, there have been few
rigorous tests of group treatments relating to PTSD symptoms.
Three studies of CBT group treatments (including Cognitive
Processing Therapy, Assertion Training, and Stress Inoculation
Therapy) have been conducted with women traumatized by childhood
or adult sexual abuse. All PTSD symptom clusters were reduced
30-60%, and improvement was sustained for six months. One CBT
group treatment for combat veterans showed a 20% reduction in
PTSD symptom severity. One study of psychodynamic group treatment
found an 18% reduction in PTSD symptoms among women with PTSD due
to childhood sexual abuse. One controlled trial of supportive
group treatment for female sexual assault survivors showed a
19-30% reduction in intrusion and avoidance symptoms, which was
maintained for six months.
Inpatient Treatment
There have been no satisfactory studies on inpatient treatment
for PTSD and trauma-related conditions. However, clinical
consensus agrees that inpatient therapy is appropriate for crisis
intervention, management of complex diagnostic cases, delivery of
emotionally intense therapeutic procedures, and relapse
prevention.
Marital and Family Therapy
There have been no research studies done on the effectiveness
of marital/family therapy in treating PTSD. However, because of
trauma's unique effects on interpersonal relatedness, clinical
wisdom indicates that spouses and families ought to be included
in the treatment of those with PTSD. Of note, marriage counseling
is typically contraindicated in cases of domestic violence, until
the batterer has been successfully (individually)
rehabilitated.
Social Rehabilitative Therapies
While social rehabilitative therapies (i.e., teaching social,
coping, and life function skills) have been proven effective for
chronic schizophrenics and other groups of persistently impaired
psychiatric individuals, they have yet to be formally tested with
PTSD clients.
Since these therapies appear to generalize well from clients
with one mental disorder to clients with another, it is
reasonable to expect that they will also work with PTSD clients.
There is clinical consensus that appropriate outcomes would be
improvement in self-care, family functioning, independent living,
social skills, and maintenance of employment.
Hypnosis
While research on the use of hypnosis with trauma survivors
indicates very little improvement in trauma symptoms, clinical
consensus indicates that it can be helpful as an adjunctive
rather than primary treatment, especially with dissociation and
nightmares.
Creative Therapies
There is currently no controlled evidence on creative
therapies (art, drama, music, body-oriented therapies). Some
clinicians believe that such therapies are uniquely fitted to
address specific somatic manifestations of trauma (i.e., sensory
defensiveness, somatic memories, etc.). Caution is recommended in
the use of somatic treatments, especially regarding the need to
maintain physical safety and appropriate professional boundaries;
therefore, it is important that therapists are well trained in
this modality.
References
1.
NSW
Institute of Psychiatry and Centre for Mental Health. (2000).
Disaster Mental Health Response Handbook. North Sydney:
NSW Health.
2.
Sprang, G. (2000). Coping strategies
and traumatic stress symptomatology following the Oklahoma City
bombing.
Social Work and Social Sciences Review, 8(2), 207-218.
3.
North,
C.S., Nixon, S.J., Shariat, S., Mallonee, S., McMillen, J.C.,
Spitznagel, E.L., & Smith, E.M. (1999). Psychiatric disorders
among survivors of the Oklahoma City bombing.
Journal of the American Medical Association, 282(8),
755-762.
4.
Rose, S.,
Bisson, J., & Weseley, S. (2001). Psychological debriefing
for preventing Posttraumatic Stress Disorder (PTSD). The Cochrane
Library, Issue 3: Update Software Ltd.
6.
Bryant, R.A. (2000). Cognitive
behavioral therapy of violence-related posttraumatic stress
disorder.
Aggression and Violent Behavior 5(1), 79-97.
7.
Difede, J., Apfeldorf, W.J.,
Cloitre, M., Spielman, L.A., & Perry, S.W. (1997). Acute
psychiatric responses to the explosion at the World Trade Center:
A case series.
Journal of Nervous and Mental Disease 185( 8),
519-522.
8.
Blanchard, E.B., Hickling, E.J.,
Barton, K.A., Taylor, A.E., Loos, W.R., & Jones-Alexander, J.
(1996). One-year prospective follow-up of motor vehicle accident
victims.
Behaviour Research and Therapy 34(10), 775-786.
9.
Bryant, R.A, & Harvey, A.Gay.
(2000).
Acute Stress Disorder: A handbook of theory, assessment, and
treatment. Washington, D.C.: American Psychological
Association.
10.
Rollnick, S.,
Heather, N., Bell, A. (1992). Negotiating behaviour change in
medical settings: The development of brief motivational
interviewing.
Journal of Mental Health (UK), 1(1), 25-37.
11.
Foa, E.B.,
Hearst-Ikeda, D.E., & Perry, K. J. (1995). Evaluation of a
brief cognitive-behavioral program for the prevention of chronic
PTSD in recent assault victims.
Journal of Consulting and Clinical Psychology, 63(6),
948-955.
12.
Bryant, R.A., Harvey, A.G., Dang,
S.T., Sackville, T., & Basten, C. (1998). Treatment of Acute
Stress Disorder: A comparison of cognitive-behavioral therapy and
supportive counseling.
Journal of Consulting and Clinical Psychology 66(5),
862-866.
13.
Bryant, R.A., Sackville, T., Dang,
S.T., Moulds, M.L., & Guthrie, R. (1999). Treating Acute
Stress Disorder: An evaluation of cognitive behavior therapy and
supportive counseling techniques.
American Journal of Psychiatry 156(11), 1780-1786.
14.
Gentilello, L.M., Donovan, D.M.,
Dunn, C.W., & Rivara, F.P. (1995). Alcohol interventions in
trauma centers: Current practice and future directions.
Journal of the American Medical Association, 274(13),
1043-1048.
15.
Friedman, M.J. (2000). A guide to
the literature on pharmacotherapy for PTSD.
PTSD Research Quarterly 11(1), 1-7.
