Introduction and Overview of Treatment

In the previous chapters, the various models, theories, and research about the consequences and etiology of PTSD have been covered. This chapter serves as an introduction to the various treatments derived from such work and the treatment of PTSD in general. Before we get into the specific models of treatment, from the variety of psychotherapies to biological treatments to integrated and comprehensive treatments, it might be helpful to take a broader and foun-dational view of treatment of PTSD as a whole.

As trauma and its consequences come to disrupt the biological, social, psychological, and even spiritual functioning of trauma victims, society and its members are faced with a profound question, "How can I help?" This is the title of a not-so-famous but powerful book written by Ram Das and Paul Gorman (1985), How Can I Help? My reading of this book led me to the conclusion that in order to help, we must learn to connect to the common humanity in all of us. In other words, we must begin with a deep and profound commitment to empathy. Professionals treating trauma victims are faced with the challenging power of hearing about and confronting human suffering, sometimes from the wrath of nature or the callousness of other human beings, and make no mistake about it, this will challenge a clinician's ability to empathize. Treatment begins with a willingness to face trauma and to stay connected.

The costs of not helping victims of trauma are far reaching, on both a societal and individual scale. Entire groups and communities can develop entrenched and long-standing deficits that result in large-scale dysfunctions and ill health. For example, the American people have lived with the consequences of the Vietnam War veterans returning home with PTSD for almost 40 years. The effects of trauma, unacknowledged and untreated, can be seen in generation after generation following mass trauma as is seen in contemporary Israeli society and in El Salvador. When I was an intern at a local community college with a very large Vietnamese refugee population, I bore witness to several war survivors and their daily struggle with PTSD, 35 years later! The treatment sections of this book are an answer to Ram Das's and Gorman's call to empathy and a step toward answering the question, "How can I help?"

Just as PTSD has its biological, social, psychological, and spiritual consequences, there are equal attempts to address or treat each of these areas in its own right. A physician might address immunological compromise. A group such as the postapartheid Truth and Reconciliation Commission in South Africa might address social consequences. Psychological consequences might be addressed by psychotherapy or counseling. Spiritual consequences might be dealt with by working within one's religious tradition on such issues as trust in God or the forgiveness of perpetrators. For purposes of the CGPTSD, we are going to focus on the specific mental health treatments for PTSD, including psychotherapy in its various forms, psychopharmacological treatment, and more systemic or holistic treatment approaches and leave the other areas to the respective experts and professionals. In diagnostic nomenclature, I am deferring.

Mental health treatment for PTSD has probably been around as long as trauma itself has been around. I cannot imagine that before the advent of modern psychotherapy almost 100 years ago or the widespread popularity of psy-chopharmacological treatments in psychiatry that help or treatment did not exist. I am sure that as long as suffering was observed, help was available in any variety of forms.

Broadly, we are going to approach the mental health treatment of PTSD from the following perspective. Treatment is any specific procedure used for the cure or the amelioration of a disease or pathological condition (Taber's Cyclopedic Medical Dictionary). Taber's also defines therapy as any treatment of a disease or pathological condition (Thomas, 1993). In essence, treatment and therapy are synonymous in a broad sense.

More specifically, psychological treatment or intervention can be defined as any therapy that is intended to bring about change in an individual's mental processes, emotional functioning, and behavior (including social functioning, occupational functioning, etc.) for the purpose of improving overall functioning and subjective well-being. Although psychological interventions do not always target a mental disorder, when they do involve a mental disorder, their purpose is to alleviate and remove symptoms. Psychological treatment is often referred to as psychotherapy. L. R. Wolberg (1967) defined psychotherapy as:

a form of treatment for problems of an emotional nature in which a trained person deliberately establishes a professional relationship with a patient with the object of removing, modifying, or retarding existing symptoms, of mediating disturbed patterns of behavior, and of promoting positive personality growth and development. (p. 3)

The chapters that follow will introduce both psychological interventions in the classic sense and psychobiological interventions such as psychopharmacolog-ical interventions. With the ultimate goals of removing or at least reducing symptoms and their sequelae, each intervention can be understood in terms of the level of biopsychosocial functioning it operates on. For example, pharmacological treatment may operate at the level of neurochemical processes in the brain, but it still seeks to relieve one's subjective sense of vigilance and fear. Cognitive therapy may operate on the level of unconscious and automatic thought processes and content. The former operates at the most fundamentally reduced level and the latter at a more abstract and psychological level. Each level of therapy carries with it at least two sets of goals, the specific goals relevant to the model of treatment (thoughts, chemicals, behavior, etc.) and the broad goals of cure or reduction of PTSD.

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