General Treatment Goals and Principles

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How can helping be defined with respect to PTSD? From a phenomenological perspective, PTSD can be understood to be about fear, vigilance, and arousal. Consider the following sentiment by a patient in therapy for PTSD:

When I first started coming, I couldn't connect to anyone! I was numb all the time. I didn't care if my son cried. I couldn't feel his pain. I don't know if it was the lack of sleep that kept me feeling like I was in a dream or a daze all the time. I'd go to work, and if I needed gas, I wouldn't stop if I saw someone that looked suspicious, like they might rob me. I almost ran out of gas at least a dozen times. My wife was afraid to talk to me on most days because I kept yelling at her. I was pissed off all the time! But lately, I've realized that underneath all that anger and the numbness was a hell of a lot of fear. I don't want to die! I'm afraid I'm going to die all the time! When I'm not numb and angry, I can't stop thinking about running through that village with those two guys behind me shooting at me, catching up to me after I stumbled and shooting me in the back!

At the core of this patient's experience is the fear of death. This real-life example demonstrates the centrality of the DSM-IV diagnostic criteria. This patient was acutely afraid of being killed on a daily basis. At first he was not particularly conscious of it, but after some therapy sessions he began to see that underneath what he thought was a pretty good return to a normal life after returning home from war, he was afraid. He did not want to die!

Treatment for PTSD is about restoring one's sense of mastery, safety, and security in the world, from helping the brain break loose from fear conditioning to helping the mind break loose from its vigilant search for threat and to gain self-control.

The following are some principles that should guide PTSD treatment:

■ Process. Help the client access traumatic material and be able to discuss it.

■ Integrate. Help the client integrate their experience into a healthy and present- and future-oriented behavioral and emotional framework.

■ Deactivate. Reduce or deactivate hyperactive stress response mechanisms.

Shalev, Friedman, Foa, and Keane (2000) provide the following suggestions for developing treatment goals in PTSD treatment, selecting a treatment, and addressing various complications that may arise:

1. Treatment should be informed by the patient's needs, abilities, and preferences.

2. Consider whether the treatment goals are attainable.

3. Define the focus. Is it stabilization, symptom reduction, or relapse prevention?

4. Does the patient first need to realize that he or she needs to address his or her PTSD and seek help?

5. Are there other adjustment-related or circumstantial issues that need to be addressed first, such as housing or medical care?

The following are seven guidelines for choosing from the various treatments available:

1. Expected efficacy against PTSD. (Does the treatment work for PTSD?)

2. Associated disorders and conditions.

3. Difficulties, side effects, and negative effects.

4. Acceptability and consent.

5. Cultural appropriateness.

6. Length, cost, and availability of resources.

7. Legal, administrative, and forensic implications.

Other complications and important issues include the following:

1. Addressing treatment expectations and defining realistic goals. A prospective patient's expectations should be addressed up front, and the reality of achieving them should be addressed. The focus should be on change and process rather than cure per se. Goals should be predefined, adhered to, and evaluated. If treatment fails or is not working, this can and should be addressed and subsequent alterations made. A long-term orientation should be maintained.

2. Combining various treatment techniques. Combined treatment is common. However, there should be a sound clinical rationale for doing so, with one form of treatment serving as the central-organizing feature. Individual psychotherapy might well serve this function. Additional treatments should be considered, added, and terminated based on analysis of their efficacy. A clinician should not just throw everything available at a particular patient, and ineffective treatments should never continue out of pure momentum and without proper analysis.

3. Addressing complex clinical pictures andcomorbidconditions. Ideally, practitioners should implement a treatment that can address the comorbid conditions and PTSD at the same time. If this is not possible, simultaneous treatment is recommended, particularly for Substance Abuse Disorders.

4. Length that treatment should proceed. There are no hard-and-fast guidelines for addressing this issue. Two helpful questions to guide this process are considering how long the beneficial outcomes can be expected to be sustained and whether therapeutic gains can be maintained with booster sessions or treatment.

5. Features of PTSD that require special attention. Special features of PTSD that must be addressed include respecting defenses; pacing assessment and interventions; being aware of issues of trust and security and whether the person seeks treatment for his or her trauma, particularly if the trauma is discovered in the course of addressing some other clinical issue.

6. Issues in treatment resistance andfailure. PTSD is considered resistant to treatment generally. The reasons for such are similar to other disorders and include chronicity, comorbidity, poor compliance, and adverse life circumstances. The use of clinical wisdom is evoked in such cases.

In their edited volume Treating Psychological Trauma and PTSD (2001), John Wilson, Matthew J. Friedman, and Jacob Lindy provide an unbelievably comprehensive, powerful, and complex discussion of the whole of treatment for PTSD. The reader is directed to this excellent book for more detail. Much of what they and their authors have to say about treating PTSD will be covered in the sections that follow.

Wilson, Friedman, and Lindy (2001) introduce their criteria for healing and recovery from trauma and PTSD with multiple focal points for treatment goals. They begin with the very broad goals of (1) maximizing stabilization of symptoms and functioning, (2) a return toward optimal functioning, (3) integration of the traumatic experience, and (4) reduction of the client's sense of fragmentation and experience of ego-alien states. From these broad goals, they provide three more focused goals. However, before we go on, as was mentioned earlier, these authors' discussion and guidelines for treatment are extremely sophisticated and complex. Simplifying their approach proves very difficult. However, one helpful thing to keep in mind is to frame their work in terms of an embedded network of goals that start out very broad, with almost philosophical principles, and then branches down to very specific treatment issues for specific symptoms and clinical phenomenon.

Getting back to the three more focused goals. For Wilson et al. (2001), healing and recovery from trauma should be concerned with the following:

1. A patient's perception of trauma and its impact on their identity and per-sonhood.

2. The allostatic (regulatory) disruption of their lives in terms of affect regulation and capacity, to reorganize and modify noneffective allostatic processes that perpetuate the syndrome. (Targets should be normalization of the stress response and attenuation of the allostatic load and processes that perpetuate maladaptive and prolonged psychobiological stress responses within the organism to alleviate anxiety, tension, and levels of distress and facilitate a reduction or elimination of maladaptive psycho-biological processes that include cognitive distortion, hyperarousal processes, hypervigilance, startle responses, sleep disturbance, and affective instability, ranging on a continuum from anger to depression to diverse forms of anxiety.)

3. Restoration of a meaningful sense of self-sameness and self-continuity with warmth, dignity, wholeness, purpose, and vitality.

Wilson et al. (2001) state:

The healed self that was once traumatized can project itself into the future with joy, serenity, and a measure of wisdom. Persons who have transformed trauma can do so because of an awareness that the boundary separating the fear of threat from quiescence is more often than not illusory and only creates allostatic load when induced by cognitive appraisals of threat to the psychological basis of existence. (p. 12)

Healing is characterized as "extraordinary changes that occur when those afflicted by trauma emerge with a human radiance, energy, and dignity that is the total antithesis of illness, despair, suffering, and fragmentation of personality" (Wilson et al., 2001).

In their holistic and organismic model, these authors summarize posttraumatic pathology into what they call the five core dimensions of PTSD from their pentahedral model: (1) psychobiological mechanisms, (2) traumatic memories, (3) avoidance, numbing, denial, and coping, (4) self-structure, ego states, and identity, and (5) interpersonal relations. The goals of the various treatment approaches (psychopharmacological, cognitive-behavioral therapy, analytic psychotherapy, etc.) should be understood by their relations to these five core dimensions. Table 11.1 is a heavily borrowed but simplified reproduction of Wilson et al.'s (2001, p. 411).

TABLE 11.1

Treatment Approaches for PTSD and Their Goals

Core treatment approaches

Treatment goals

Psychopharmacotherapy

Facilitate normalization toward homeostasis

Psychodynamic

Restore toward normal intrapsychic functioning

Acute interventions

Reestablish a normal stress response pattern

Cognitive-behavioral

Gain authority of traumatic experiences

Group psychotherapy

Facilitate normalization of PTSD responses and

enhance capacity for healthy relationships

Complex PTSD

Restore a positive self-schema of effective

coping

Dual diagnosis

Determine treatment that fosters recovery from

Axis I and Axis II disorders

Cross cultural

Foster recovery from within an embedded

cultural framework

Children

Foster trauma recovery to overcome interruption

of normal development

Families and couples

Restore healthy attachments, relationships, and

capacity for intimacy

Severe mental illness and PTSD Facilitate social reintegration and support for activities of daily living

As if Wilson et al. (2001) have not provided enough direction, they have introduced 30 principles to guide trauma treatment, with 80 specific target goals for the five core dimensions. For purposes of space, the 30 principles will be listed, with a very brief description, but for the 80 specific goals, the reader is directed to Chapter 3 in Wilson et al.'s book (2001).

Guiding Principles

■ Safety and protection—feelings of vulnerability should be kept to a minimum by providing a safe and secure facility and relationship.

■ Nonjudgmental acceptance of the victim-client—unconditional positive regard should be communicated with an open-minded and flexible approach to really hearing the client.

■ Trauma-specific transference and countertransference must be attended to.

■ Traumatic memory recollection and integration should be approached with respect for ego-defense mechanisms and client readiness.

■ Rapid intervention and the establishment of supportive resources should be implemented in order to aid the stress recovery process.

■ Vulnerability, fear, and uncertainty should be addressed through nur-turance support in order to facilitate healthy coping and mastery.

■ Provide psychoeducational material for understanding and support.

■ Recognize and be alert to changes in nonsymptom areas such as alterations in psychoinformative processes, self-schemas, and beliefs about human nature, justice, authority, and life's meaning.

■ Promote the importance of effective boundary management, including striking a balance between appropriate openness and defensiveness.

■ Promote basic self-maintenance and self-care through meditation, exercise, diet, and health monitoring.

■ Identify and inventory specific traumatic stimuli triggers, such as particular situations, anniversaries, sounds, sights, etc.

■ Recognize that anxiety, anger, and depression are interwoven in PTSD, and encourage management of each.

■ Identify and address treatment for dual-diagnosis issues of alcohol and substance abuse and dependence.

■ Address disturbances in sleep, nightmares, and physiological hyperarousal with specific interventions, such as relaxation training or sleep hygiene.

■ Recognize the different forms of peridissociative and dissociative mechanisms, such as psychic numbing, emotional anesthesia, denial/disavowal, and splitting of object relations.

■ Address the role of self-recrimination, posttraumatic shame, survivor guilt, and victim thinking in the perpetuation of symptoms and expression.

■ Address traumatic effects on Life-stage development.

■ Work toward the requirement of transforming and integrating ego-alien, self-incongruent, and distressing components of the traumatic experience into a new cognitive framework.

■ Recognize that PTSD waxes and wanes and that progress is determined by the pace and dose of treatment the client can manage at different stages and times.

■ Work closely with a primary care physician to monitor the efficacy of any conjoint or co-occurring medical treatment, particularly in the case of alcohol or drug dependency.

■ Carefully screen potential group therapy clients for personality, psychopathological expressions of symptoms, type of trauma exposure, and fitness for a particular group.

■ Prioritize issues when traumatic grief, bereavement, and loss issues are involved.

■ Address comorbid Axis I and Axis II issues, and design treatments accordingly.

■ Recognize that there are at least seven distinct allostatic processes that reflect psychobiological alterations associated with hyperarousal mechanisms and their relation to symptoms.

■ Implement appropriate acute stress interventions in order to quickly reestablish the normal stress response and environmental and intrapersonal supports.

■ Acknowledge and address issues of childhood and adolescent victimization.

■ Recognize reenactment behaviors in children as they manifest in play, fantasies, dreams, and symbolic forms of acting out.

■ Recognize that the process of healing and overcoming pain caused by trauma may result in personal struggles with the meaning of life, justice, the existence of God, and the search for a purpose in living and a state of higher or heightened spirituality and capacity for self-actualization may emerge.

■ Prosocial behavior, altruism, and caring for others should be promoted as appropriate and safe in order to facilitate recovery.

■ Always work within a framework of holistic dynamic functioning.

As the final chapter in their book and perhaps as a final word, Wilson et al. (2001) make a call to all mental health professionals working with trauma survivors to "Do No Harm" and to "Respect the Trauma Membrane" (p. 432). The trauma membrane is conceptualized as the individual and social response to posttraumatic dysfunction that forms a membrane or protective skin of sorts around the victim-survivor. They warn us against overzealous and aggressive treatment and to be guided by the patients, taking their lead rather than the other way around. Treatment begins when "they invite us to enter the space covered by the trauma membrane" (p. 436). Once invited in, we can be assured that we will be tested for trustworthiness and knowledge and to witness ego defenses' protection of "their perceived and experienced sense of vulnerability" (p. 436). We are warned not to induce more trauma (sometimes referred to as secondary traumatization) and give the clients more than they can handle at the moment, which may result in damaging the working alliance and stress newly formed ego defenses and coping mechanisms that have been formed to replace the trauma membrane.

Perhaps I am beating the proverbial dead horse here, but I believe that it bears mentioning one last time. Posttraumatic Stress disorder treatment is about joining survivors and victims in their fear-laden chaos and arousal, acknowledging their experience, walking them through it, calming them down, seeing them through to a sense of safety, and witnessing their revitalization.

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