Psychosocial Treatment of Posttraumatic Stress Disorder

SUSAN D. SOLOMON National Institutes of Health

A review of the psychosocial treatment research literature indicates that several forms of therapy appear to be useful in reducing the symptoms of posttraumatic stress disorder (PTSD). Strongest support is found for the treatments that combine cognitive and behavioral techniques. Hypnosis, psychodynamic, anxiety management, and group therapies may also produce short-term symptom reduction. Still unknown is whether any approach produces lasting effects. Imaginal exposure to trauma memories and hypnosis are techniques most likely to affect the intrusive symptoms of PTSD, whereas cognitive and psychodynamic approaches may better address the numbing and avoidance symptom cluster. Treatment should be tailored to the severity and type of presenting PTSD symptoms, to the type of trauma experience, and to the many likely comorbid diagnoses and adjustment problems.

1997 John Wiley & Sons, Inc.* posttraumatic stress disorder (PTSD) traumatic stress treatment psychotherapy psychosocial treatment IN SESSION: PSYCHOTHERAPY IN PRACTICE 3/4:2741, 1997

he treatment literature in the past 15 years reflects an enormous interest in discovering an effective cure for posttraumatic stress disorder (PTSD). Hundreds of original reports have been published describing the effectiveness of various treatments for the effects of exposure to traumatic events, though the vast majority of these reports are case history descriptions rather than systematic empirical studies. After briefly discussing the characteristics of PTSD and the other effects of trauma exposure, this review examines the empirical evidence for the efficacy of different psychosocial treatments for PTSD.

The opinions or assertions contained herein are the private ones of the author, and are not to be considered as official or reflecting the views of the National Institutes of Health. Correspondence and requests for reprints should be sent to Susan D. Solomon, Ph.D., Office of Behavioral and Social Science Research, National Institutes of Health, Federal Building, Room 8C-16, 7550 Wisconsin Avenue, Bethesda, MD 20892-9172. In Session: Psychotherapy in Practice, Vol. 3, No. 4, pp. 2741 (1997) 1997 John Wiley & Sons, Inc..*This article is a US Government work and, as such, is in the public domain in the United States of America. CCC 1077-2413/97/040027-15

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The most common treatments offered to trauma victims include: pharmacotherapy; individual psychotherapy, typically involving either behavioral techniques, cognitive approaches, anxiety management, hypnotherapy, crisis intervention, or psychodynamically oriented approaches; and group therapy, including mutual selfhelp groups, rap groups, and family therapy. These treatments have been applied to a wide variety of trauma populations, including victims of domestic violence, combat, rape, child abuse, accidents, terrorism, and disaster. The array of treatments as well as the explosion of recent journal reports become understandable when viewed in the light of the tremendous amount of trauma experienced in our society. A review of the literature on the epidemiology of trauma reveals that traumatic events are common: Most Americans experience at least one such event over the course of their lives. Recent general population studies have found trauma exposure rates to be as high as 69%, and one such study reported that fully 21% of the population had experienced a traumatic event in the past year alone. Another study found that 17% of the men and 13% of the women who had some trauma exposure had actually experienced more than three such events. These studies clearly show that exposure to traumatic events has become commonplace in our society. The findings support the decision made in the fourth edition of the Diagnostic and statistical manual of mental disorders (DSMIV; American Psychiatric Association, 1994) to no longer define the stressor criterion as an event outside the range of usual human experience, as these events appear to happen to the majority of our population, often repeatedly.

CHARACTERISTICS OF PTSD AND OTHER TRAUMA SEQUELAE

Although PTSD has been diagnosed and studied to a lesser extent than several other psychiatric conditions, it is one of the most common: Current prevalence estimates indicate that approximately 810% of the population will suffer from PTSD sometime in their lives, and for victims of traumas such as rape, the rate of PTSD may be as high as 6080%. Although the concept of war neurosis has been around since World War I, little research on trauma victims was done until very recently. Prior to 1980, events such as military combat were seen as unconnected in any conceptual way to accidents, disasters, rape, or other physical assaults. The beginning of systematic research and treatment for the mental sequelae of exposure to extreme events has been dated to publication in 1980 of the American Psychiatric Associations third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIII), which for the first time included the diagnostic category of posttraumatic stress disorder. Prior to DSMIII, responses to traumatic events were classified as transient situational disturbances and more persistent reactions were presumed to indicate the presence of another disorder. The criteria for the diagnosis of PTSD as currently defined in DSMIV include: (a) perceived or actual threat to life or physical integrity, accompanied by an emotional response of horror, helplessness, or intense fear; (b) reexperiencing of the trauma (e.g., nightmares, flashbacks); (c) avoidance of trauma-related stimuli (e.g., thoughts, activities, places, conversations) and numbing of interest and affect; and (d) increased arousal, in the form of sleep and concentration difficulties, hy-

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pervigilance, exaggerated startle, and irritability. To quality for the diagnosis of PTSD, an individual must present at least one reexperiencing, at least three avoidance/numbing, and at least two arousal symptoms. Symptoms must persist for at least a month and cause sufficient distress or impairment to warrant the diagnosis. PTSD has been found to be a chronic problem for the majority of sufferers. Studies of various trauma populations show that people who spontaneously recover from PTSD usually do so in the first 3 months following the trauma, and those who do not tend to become chronic sufferers. For this reason, DSMIV defines PTSD as chronic if the duration of symptoms is 3 months or longer. Although most improvement occurs within the first year, an estimated 4867% of those who develop PTSD after a traumatic event still suffer from it more than a year after exposure. Over 33% of PTSD sufferers still experience symptoms several times a week after 10 years. In addition to being chronic, PTSD is also a highly comorbid condition: 7988% of persons with PTSD also have a history of at least one other psychiatric disorder. Indeed, sufferers of PTSD are at greatly increased risk for virtually every other psychiatric diagnosis, especially depressive disorders, anxiety disorders, phobias, substance abuse, and somatization disorders. One study found somatization to be fully 90 times more likely in those with PTSD than in those without PTSD. Moreover, those with PTSD are almost eight times as likely to have three or more disorders than individuals without PTSD. Individuals exposed to traumatic events often develop debilitating problems other than psychological impairment. One study of the general population found that people with even a single PTSD symptom were impaired in many areas of life functioning. Like those with full-blown depressive disorders, individuals with one or more PTSD symptoms were more likely than those without any mental disorder to experience poor social support, marital difficulties, occupational problems, low incomes, disability, and a high number of chronic illnesses. Other epidemiologic studies have found that the physical complaints of trauma victims are many and often serious, over and above any injuries sustained during the traumatic event. For example, severely victimized women being treated in an HMO were found to have a number of persistent conditions, including chronic pelvic and other pain, gastrointestinal disorders, headaches, and psychogenic seizures. Other studies have found that sexually assaulted women are at elevated risk for several chronic diseases, somatic symptoms, and perceptions of poor physical health. Given their high rates of physical problems, it is not at all surprising that trauma victims have also been found to be disproportionate users of the health care system. Unusually high rates of physician visits and/or higher hospitalization rates have been found among prisoners of war, survivors of Nazi concentration camps, disaster victims, battered women, sexual assault victims, combat veterans, and crime victims. Yet despite both their disproportionate use of the health care system, and their wide-ranging psychological and functional impairment, trauma victims appear reluctant to seek treatment for their mental health problems: Studies indicate that only 28% of crime victims receive professional mental health services. One study found that sexual assault victims were no more likely than nonvictims to use mental health services, although they continued to seek medical attention for as long as a year after the assault, when somatic symptoms were no longer significantly elevated.

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PSYCHOSOCIAL TREATMENTS FOR PTSD AND OTHER TRAUMA SEQUELAE

Although traumas such as rape, combat, assault, and tragic bereavement may on the surface appear quite different, victims of all these events share what has been characterized as a violation of preexisting schemata of the self and the world. Trauma has been described as shattering three basic assumptions: the belief in personal invulnerability, the perception of the world as meaningful, the positive view of self. Regardless of the type of trauma experience, all victims must deal with the mental distress caused by the violation of these basic beliefs. And regardless of the type of treatment, a primary goal is to develop a realistic appraisal of both the danger and the choices for response that were available during the traumatic event. This typically involves the need to overcome avoidance of external and internal cues (e.g., conversations, places, thoughts, feelings) that trigger memories of the trauma, by providing a safe environment in which the person can reexperience the event without becoming retraumatized. Some form of sustained emotional processing of the trauma memory appears to be essential to the effective treatment of PTSD, regardless of technique. Practically every form of psychotherapy ever devised has been tried on those suffering from PTSD. For example, Vietnam veterans are commonly treated with behavioral techniques, hypnosis, gestalt therapy, psychodynamic therapy, and rap groups. Rape victims are most commonly treated with group psychotherapy and crisis intervention techniques (less treatments for PTSD than interventions aimed at preventing PTSD in the acutely traumatized), but also have been given behavioral and cognitive treatments, as well as psychodynamic psychotherapy. Other psychotherapies also tried on individuals with PTSD include biofeedback, hypnosis, relaxation techniques, self-help groups, family therapy, and multimodal approaches that combine elements of several of these techniques. Although case reports have offered some support for almost all psychosocial treatments of PTSD, few of these treatments have been subjected to systematic test. Most psychosocial treatments are descendants of one of two theoretical perspectives: the insight-oriented therapies that encourage abreaction and catharsis by targeting unconscious conflicts and defenses, and the cognitivebehavioral approaches that are based on learning theory. Pharmacotherapy is also used in the treatment of PTSD, either alone or in conjunction with psychosocial treatment. In general, psychotherapy tends to be much more widely practiced than pharmacotherapy, in part because the etiology of PTSD is unusually well grounded in theory.

COGNITIVEBEHAVIORAL TECHNIQUES

Although no technique has been studied thoroughly as yet, the psychosocial treatments for PTSD that have received the most systematic research attention thus far are the cognitivebehavioral interventions. These interventions include a variety of exposure techniques and anxiety management procedures, which have been studied alone and in combination with one another.

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Exposure

Exposure techniques, all of which involve helping individuals confront their fears, are based on a two-stage behavioral learning theory that suggests that fear and avoidance are acquired when neutral stimuli (words, thoughts, images) are paired with a traumatic event so that these neutral stimuli become aversive in themselves, and thus capable of also rendering many other associated stimuli anxiety-producing. In the second stage, avoidance responses develop as a means of decreasing the anxiety resulting from the presence of the conditioned stimuli. Clinical procedures based on learning theory emphasize direct therapeutic exposure for the reduction of PTSD symptoms. These interventions are designed to reduce anxiety by means of repeated or extended, real or imaginary, exposure to objectively harmless but feared stimuli. Available research suggests that direct therapeutic exposure is most effective in reducing the intrusive symptoms of PTSD, but appears to have little effect on the symptoms of PTSD that relate to emotional numbing and avoidance. Both graded (e.g., systematic desensitization) and nongraded (e.g., prolonged exposure) forms of exposure have been used as treatments for PTSD. Systematic desensitization. This behavioral technique involves pairing graded imaginal exposure with relaxation. After individuals learn relaxation techniques, they are confronted with the avoided stimuli (e.g., trauma memories, places) that have been previously categorized according to increasing levels of adversiveness. Although only two studies have systematically tested this technique for PTSD, both found desensitization to be superior to no treatment, especially in terms of reducing the intrusive symptoms of PTSD. One of these studies found that reductions in nightmares, flashbacks, muscle tension, and hospital readmissions persisted through the 2-year follow-up. Intensive exposure therapy. Flooding and implosion are both intensive exposure techniques involving prolonged or massed exposure to a safe but fear-related cue (e.g., situation, feeling, person), until the anxiety and fear associated with that cue is reduced or extinguished. Both involve the continuous presentation of live or imaginal trauma-related cues. They differ in that implosive therapy is supposed to add a component of exposure to psychodynamic cues, although most studies of implosive therapy do not describe having included this aspect. Available research suggests that intensive imaginal exposure is an effective treatment for PTSD. Three controlled studies comparing these techniques to no treatment or standard care have reported limited improvement 38 months following treatment, in such varied outcomes as depression, fear, state anxiety, sleep disturbances, overall adjustment, and the intrusive symptoms of PTSD. It is possible that observed improvements might have been greater had these studies used optimal exposure conditions; the sessions in these studies were only 4550 min, as opposed to the 90-min session length sometimes required to achieve a more complete reduction in anxiety. And, for clinical reasons, two of the three studies incorporated relaxation techniques, which may also have served to retard or negate the effectiveness of flooding. Despite the demonstrated effectiveness of this technique, it should be noted that cases of severe complications have been reported in the use of flooding for PTSD, including exacerbation of depression, relapse of alcoholism, and precipitation of panic disorder. This has been shown most dramatically (but not exclusively) in two

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studies of live exposure. The more rigorous of these studies involved exposing combat veterans with chronic PTSD to a residential treatment program consisting of 4 weeks of exposure to military cues, including living in tents, wearing uniforms, weapons, artillery, and hand-to-hand combat training. Lebanon War veterans completing this program were found to deteriorate considerably over the course of the next 9 months, in contrast to an untreated control group that showed no such decline. Whereas less intensive real life exposure (four 1-hr sessions) has been found to compare favorably with imaginal flooding in a civilian sample, the efficacy of both live and imaginal exposure appears to depend on providing the individual with both control over the level of exposure, and strong therapeutic support. In sum, no direct comparisons of efficacy have as yet been made among the various exposure techniques. All are designed to result in a reduction in the conditioned emotional response associated with the trauma, and thus, less compulsion to avoid internal or external cues reminiscent of the trauma. However, because individuals with PTSD often also suffer from negative emotional states other than fear and anxiety, which may not extinguish in the same way, direct therapeutic exposure has been primarily recommended for use as an adjunctive treatment. As a whole, available studies suggest that the effectiveness of direct therapeutic exposure is dependent upon several factors: establishing trust and maintaining a good therapeutic relationship; explaining the importance of retelling the story or otherwise revisiting the traumatic experience; clarifying expectations, including potential short-term exacerbation of symptoms; providing control over the duration of exposure and level of adversiveness; supporting a focus on emotionally significant content during the exposure sessions; and redirecting avoidant behaviors.
Treatments Combining Exposure with Cognitive Therapy

Another factor that appears to be essential for successful PTSD treatment is the fostering of new interpretations of the trauma and its implications. Foa et al. (1989) have faulted the strictly behavioral explanation for PTSD as unable to account for many of PTSDs most important symptoms (e.g., startle response, nightmares). Foreshadowing DSMIV, which reformulated the earlier definition of the stressor to incorporate subjective response, Foa noted that perceived threat is a better predictor of the development of PTSD than is actual threat; they argued for a theoretical position that can accommodate the meaning attached to trauma-related cues. Cognitive theories, such as information processing theory, have been advanced to address more fully the array of PTSD symptomatology. Cognitive forms of therapy are designed to examine irrational thoughts and provide the individual with coping skills. Prolonged exposure. Because the trauma structure in individuals with PTSD is unusually stable and broadly generalized, it is easily accessed and highly resistant to change. Most PTSD sufferers are chronically aroused and anxious, as a result of their hyperawareness of threat and tendency to interpret ambiguous cues as threatening. Information processing theories suggest that emotional change cannot occur until traumatized individuals fully access their network of trauma memories in order to accommodate corrective information. According to this view, treatment requires both activation of the fear memory through intensive exposure, and provision of new information that is incompatible with the existing fear structure. Foa and colleagues have developed a treatment called prolonged exposure based on this

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theoretical perspective. This technique includes two initial sessions of information gathering and treatment planning, followed by seven sessions during which the individual relives the trauma by imagining it as vividly as possible, and repeatedly describing it aloud in the present tense for 60 min. The individuals narrative is tape recorded, and she or he is asked to listen to this narrative daily as homework. Additional homework involves live exposure to feared, but objectively safe, situations. In a 1991 study, prolonged exposure was found to be effective in treating chronic PTSD when compared to a no-treatment control group. (More recently, these investigators have combined prolonged exposure with other treatment components such as cognitive restructuring and relaxation training, although the efficacy of this combined cognitivebehavioral approach has not yet been systematically tested; see Jaycox, Zoellner, and Foa in this issue for an in-depth discussion.) Cognitive processing therapy. Victims report many feelings about the trauma other than fear, including anger, disgust, humiliation, and guilt, which may be as strong as the fear but are typically unaffected by exposure techniques. Drawing on McCann and Pearlmans (1990) theory that trauma alters self-schemas, such as fundamental beliefs about safety, trust, power, esteem, and intimacy, Resick and colleagues developed a treatment called cognitive processing therapy. Designed for rape victims, this therapy elicits memories of the event by having the individual describe the traumatic event in writing and then read this account. Maladaptive beliefs are then directly confronted by providing corrective information about conflicts and faulty expectations that interfere with effective coping. Cognitive restructuring methods are used to examine (a) whether the traumatic outcome could have been predicted; (b) whether the trauma could have been modified by any action of the individual; and (c) whether the individual was responsible in any significant way for the negative consequences. When used in a program of 12 weekly group sessions, this technique was found to be effective in reducing symptoms of PTSD and depression in rape victims. Eye movement desensitization and reprocessing (EMD/R). This technique combines saccadic eye movements with exposure and, more recently, with cognitive processing. The individual is required to follow the therapists finger with his or her eyes in a rapid rhythmic side-to-side manner for about 15 to 20 s, while maintaining an image of the traumatic event. The individual then reports the negative selfcognitions, emotions, and physical sensations that emerged. Individuals are first desensitized to the traumatic memory, and then positive thoughts are implanting during the reprocessing phase to replace earlier negative self-evaluations. Any additional memories that emerge are similarly treated in subsequent sessions. EMD/R has been embedded in controversy, partly because its theoretical rationale is poorly developed, and partly because of inflated initial claims of success by its founder, Francine Shapiro. The technique has also drawn criticism as a result of Shapiros requirement that clinicians receive extensive and costly training from her before they are permitted to use the technique in clinical settings. Over the course of the last few years, Shapiro has redefined the role of eye movements from being critical to being epiphenominal, perhaps in response to recent studies that indicate that replacing eye movements with finger tapping or eliminating them altogether has little effect on the outcome. With the addition of a cognitive processing component, as well as the recent increase in number and length of sessions, this technique increasingly resembles the cognitivebehavioral techniques developed by Resick and Foa. Like these other techniques, EMD/R has been shown to be effective in reducing symptoms of PTSD for at least 3 months following treatment, rel-

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ative to an untreated control group. EMD/R may also be effective in reducing negative self-cognitions. Many individuals with PTSD and therapists appear to find it preferable to intensive exposure therapy, perhaps because it allows the individual to determine his or her own level of exposure, and, is therefore, initially less anxiety producing. Given the resemblance, it is not surprising that evidence suggests EMD/R may be as effective as other cognitivebehavioral treatments. However, despite EMD/Rs popularity, no existing evidence supports its superiority.
Anxiety Management Techniques

Whereas direct therapeutic exposure and cognitive therapy techniques are designed to activate fear and correct the underlying pathology, several therapies have been developed to reduce anxiety when it occurs by providing individuals with skills to control fear. These techniques are based on the assumption that conditioned emotional reactions to trauma-related stimuli will always occur to some extent; therefore, traumatized individuals need to learn how to manage these responses. Generally referred to as anxiety management or stress management techniques, these therapies include relaxation training, stress inoculation training, biofeedback, breathing training, social skills training, guided self dialogue, and distraction techniques such as thought stopping (training in self-control over persistent, upsetting thoughts). Because this theoretical perspective views pathological anxiety as a result of deficiencies in coping skills, treatment is aimed at helping the individual learn ways of coping with conditioned emotional reactions to trauma-related cues and situations. Of the anxiety management techniques, stress inoculation training is the one most widely used for treating PTSD. This treatment strives to increase self-monitoring of conditioned stimuli so that coping strategies can be used to curtail anxiety responses early in the process. Although it is called stress inoculation training, it is actually a combination of several techniques, including muscle relaxation, thought stopping, breathing control, communications skills, and most importantly, guided self-dialogue, comprised of stress inoculation (along the lines proposed by Meichenbaum) and cognitive restructuring to addresses maladaptive thoughts. To date, the only controlled efficacy study of stress inoculation training is one that compared this technique to prolonged exposure, supportive counseling, and a wait-list control group. Whereas stress inoculation training was found to be the most effective therapy in reducing PTSD symptoms (as well as anxiety and depression) immediately after treatment, prolonged exposure was found to be superior to the other therapies in a 3.5-month follow-up. The investigators explained this reversal by suggesting that stress inoculation training provides immediate anxiety relief, but that individuals may not have continued to apply the techniques after treatment. This finding seems to indicate the need to incorporate relapse prevention (maintenance) techniques into the stress inoculation training approach in order to achieve lasting improvement. In contrast, prolonged exposure is expected to produce temporary high levels of arousal, but this procedure is believed to lead to permanent change in memory of the trauma, and therefore, lasting gains. Because both techniques have been found to be effective, stress inoculation training is sometimes used as an adjunct to exposure treatment, the assumption being that if individuals cope better with daily stressors as well as with the trauma symptoms, they will have a greater sense of control and thus be less inclined to avoid reminders of their trauma. This blend of techniques has not received any empirical

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support so far; the one study to test the stress inoculation trainingexposure combination found that it was not superior to prolonged exposure or stress inoculation training alone. However, it should be noted that that study made an effort to equate the lengths of all the treatments for comparison purposes, and so neither the prolonged exposure nor the stress inoculation training treatment was given at full dose in the combined treatment condition. Tests are currently underway now to determine if a full course of both treatments is superior to either alone for the treatment of PTSD.

INSIGHT-ORIENTED THERAPIES

Therapies based on insight include psychodynamic techniques and hypnotherapy. As both of these forms of therapy can be traced back to Freud, they understandably share many ingredients, as well as the basic goal of confronting the trauma and diminishing the provoked responses.
Psychodynamic Therapy

The psychodynamic treatment approach actually encompasses a variety of procedures. Most psychodynamic techniques and procedures focus on the principle of energy overload or, more recently, information overload. Through this mechanism, the traumatized individual is faced with the task of integrating the traumatic event into his or her understanding of the meaning of life, self-concept, and world image. According to Horowitzs formulation, which in many ways resembles information processing theory, the emotional reactions of traumatized individuals are the result of discrepancies between internal and external information. Horowitz views response to trauma as vacillating between two phases. In the denial phase, the PTSD symptom cluster of avoidance and emotional numbness emerges as an attempt to control distress. The victim is dazed and selectively inattentive. She or he may experience complete or partial amnesia for the event, may decrease her or his level of physical activity, and may engage in either withdrawal or frantic overactivity. These responses emerge as ways of dealing with the anxiety experienced in the intrusive phase (as evidenced by the intrusiveness and arousal symptoms of PTSD). When these attempts fail or are overwhelmed, the individual once again experiences intrusive thoughts, flashbacks, or nightmares. Horowitz developed a brief dose-related psychoanalytic procedure that is surprisingly similar to the cognitivebehavioral techniques described earlier; however, the psychodynamic therapy is adjusted to fit the individuals phase of symptom expression. During the intrusive phase, the individual is encouraged to avoid disturbing memories, and helped to control anxiety through provision of a supportive therapeutic environment, anxiety management techniques, and/or medication. During the avoidance phase, the individual is encouraged to confront memories with associations and abreaction. Once affect is reduced, the therapist focuses on achieving an understanding of the conscious and unconscious meanings of the symptoms in order to help the individual master the trauma and restore effective functioning. The only two controlled studies that have been conducted on psychodynamic treatment both systematically compared the effectiveness of brief psychodynamic therapy to other approaches for the treatment of PTSD. The more rigorous of the two was a controlled study comparing psychodynamic therapy to trauma desensi-

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tization, hypnotherapy, and a wait-list control group. Participants in all three treatment groups showed more improvement in symptoms than did the control group. The psychodynamic group appeared to achieve a greater reduction in avoidance symptoms, with a lesser change in intrusion symptomatology. The desensitization and hypnotherapy treatment outcomes showed the reverse pattern.
Hypnotherapy

Hypnotherapy techniques are being used with increasing frequency as treatments for PTSD. Like psychodynamic therapy, hypnotherapy can encompass a variety of perspectives and objectives; and like the cognitivebehavioral therapies, hypnotherapy involves an element of exposure. In general, the goal of hypnotherapy is to allow the traumatized person to discharge repressed material and to integrate the traumatic event. There are no systematic studies of hypnosis other than the study described above. In that study, a behavioral approach to hypnosis was employed, with an emphasis on examining the way that the individual dealt with the perception and adjustment to the traumatic event. At 3 months posttreatment, hypnotherapy was found to be equally effective as the other treatment methods, and more effective than no treatment. Within the hypnotherapy condition, the investigators found that individuals were more likely to experience changes in their intrusive symptoms than in their avoidance symptoms, the opposite of the results found for psychodynamic therapy.

PHARMACOTHERAPY

Only a handful of controlled clinical trials have been conducted of pharmacotherapies for PTSD. As with psychotherapy, almost every type of psychotropic agent has been tried on PTSD sufferers, and virtually all have been described as efficacious in case reports. As a result, prescribing practices differ widely from one place to another. Most promising of the tested drugs are the antidepressants, although the effects of these drugs on PTSD are comparatively modest relative to their effects on depression and panic. Fluoxetine has been found to reduce acute symptoms of PTSD in victims of recent trauma, and other serotonin re-uptake inhibitors (sertraline, paroxetine) also hold promise. Tricyclic therapy has been shown to have a modest positive effect, and it appears to be well tolerated without causing major side effects. One study found phenelzine to be more effective than imipramine, particularly in reducing the intrusive symptoms of PTSD, but it is contraindicated with individuals who cannot comply with the dietary and drug and alcohol restrictions required for its use. A drug without these complications is propranolol, shown to be effective in an uncontrolled trial using an offonoff design in a sample of children. Clearly, much more research is needed before any strong conclusions can be drawn about the efficacy of pharmacotherapies for PTSD. For example, none of the drugs has been found to be capable of inducing full remission of PTSD symptoms, and none has been tested for long-term effects on PTSD. Because of the complexity of symptoms and problems typically displayed by victims of trauma, drug treatment alone can never suffice to alleviate the suffering associated with PTSD. However, the relief provided by prescription medication may reduce the tendency of some PTSD sufferers to self-medicate with alcohol or illicit drugs, and drug treat-

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ment may function as a potentially useful facilitator of psychotherapy in some cases.

COMMON BUT EMPIRICALLY UNTESTED THERAPIES

Many therapies are provided to individuals with PTSD that have not yet had the benefit of rigorous study. The most common of these untested treatment modalities are group therapy and crisis intervention programs.
Group Therapy

Psychotherapy is often provided to victims of traumatic events through a variety of types of support groups, including rap or trauma-focus, cognitivebehavioral, psychoeducational, psychoanalytic, psychodrama, process, family, and self-help groups. The assumption underlying group therapy is that the bonding of survivors of the same kind of traumatic events can be conducive to the recovery and adjustment process. Members are presumed to provide each other with the kind of feedback that promotes more accurate perceptions of intrapersonal strengths and more adaptive interpersonal behaviors. The supportive and secure social environment of the group allows for the rebuilding of intimacy in relationships, and the opportunity to give support to others is believed to help repair damage to the trauma survivors own sense of control and self-esteem. There are no systematic and controlled studies of support groups for PTSD, although one study did compare mutual group therapy to psychodynamic therapy for unresolved grief following conjugal bereavement. The results suggest that mutual group therapy may be roughly as effective as brief psychodynamic therapy in reducing key stress symptoms, over the course of a year following treatment. However, as only one third of the participants in that study suffered from PTSD, and there was no untreated comparison condition, the results for both treatments may simply reflect the healing power of time for symptoms of bereavement. It should also be noted that more individuals prematurely terminated from the group than from the psychodynamic treatment, suggesting the need for careful preparation of the individual for the group experience.
Crisis Intervention

Rather than being treatments for PTSD, crisis intervention techniques are actually interventions aimed at preventing PTSD in the newly traumatized. A widespread belief is that immediate intervention following a traumatic event is important for preventing long-term psychological sequelae. Probably the most commonly employed technique is a debriefing model that is designed to be conducted in small groups within 3 days following the traumatic event. The technique involves establishing ground rules (e.g., suspension of rank, confidentiality); re-creation of the event through the participants accounts, including their thoughts during the event, its worst aspects for them, and their reactions to it; normalizing these responses by describing the typical reactions of trauma victims; and, finally, conducting a closing wrap-up session. Whereas this technique has been used with victims of a wide range of traumatic events, no controlled studies of it have yet been conducted. Ex-

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isting uncontrolled studies suggest that, at best, debriefing has no effect, and it may even interfere with recovery, although participants and leaders often report finding it helpful. Preliminary evidence from a recent pilot study by Foa and colleagues suggests that a brief prevention program of four 2-hr weekly sessions may be helpful in preventing chronic PTSD. Developed for female assault victims, the sessions incorporate elements of exposure, relaxation training, and cognitive restructuring. When administered 1-month postassault, this program produced significant short-term reductions in PTSD in a small sample of victims. Future research is needed to see if this brief program is effective in preventing chronic PTSD. However, Foa et al. recommend waiting at least 2 weeks to a month after a trauma before providing therapy of any kind, as victims may be in a state of shock immediately following the event. Depending on the nature of the traumatic event, victims may also be initially overwhelmed with practical demands, such as resettlement for disaster victims, safety for child abuse victims, criminal prosecution for rape victims, and so forth. Such immediate concerns need to be addressed before any psychological intervention can be meaningfully undertaken.

SUMMARY AND CONCLUSIONS

Much is left to be learned about the treatment of PTSD. To date, most treatments for PTSD have received little or no research scrutiny. Almost nothing is known in such important areas as effectiveness of treatment components or of combined treatment approaches, optimal treatment length and timing, the effect of comorbidity, and the differing effects of these techniques on the many types of trauma populations yet to be included in clinical trials. And yet, significant progress has been made in our understanding of the treatment of PTSD. We now know that exposure to the extreme events that can cause PTSD is quite common; most people will experience a trauma at some time in their lives. It has been estimated that 810% of people will develop PTSD and, for a third of these sufferers, the condition will become chronic. Given the extent of trauma in our society, it is not surprising that a wide range of therapies have been used in the treatment of PTSD. In light of the paucity of evidence supporting the efficacy of these treatments, it is encouraging to note that a recent large-scale national survey found a shorter average duration of PTSD symptoms (3 years) among those who obtained professional treatment than among those who did not (over 5 years). It is possible that these results are merely an artifact, in that individuals most willing to seek treatment may also be the ones most likely to heal in its absence. Nonetheless, these findings suggest that the many and varied treatments offered to PTSD sufferers may, overall, help to reduce the duration of PTSD. Unfortunately, whereas PTSD treatment holds the promise of shortening the duration of impairment, most people with PTSD do not receive it. Even those seeking mental health treatment may not recognize the relevance of past trauma to their present problems, and will not discuss their trauma history unless explicitly asked about it. Thus, a complete trauma history should be a required component of any diagnostic procedure. Psychosocial treatment studies suggest that several forms of therapy are useful in reducing the symptoms of PTSD, once diagnosed. The extremely limited number of systematic studies so far indicate that no one approach is likely to be suc-

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cessful in reducing all of the symptoms of PTSD. To date, strongest research support is found for the treatments that combine cognitive and behavioral techniques. Studies of hypnosis, psychodynamic, anxiety management, and group therapies suggest that these approaches may also hold promise. However, further research is needed before any of these approaches can be pronounced effective as lasting treatments for PTSD. Available evidence suggests that exposure and hypnosis techniques may be most likely to affect the intrusive symptoms of PTSD, whereas cognitive and psychodynamic approaches seem to be better suited to addressing the numbing and avoidance symptom cluster. The PTSD symptoms of psychophysiological arousal appear to be those most resistant to current forms of treatment. A major challenge for all of these techniques is that of balancing the individuals need to confront the trauma with the risk that such exposure will retraumatize the individual. Research suggests that exposure must be long enough in duration for the response to extinguish (90-min sessions are recommended), but also must be at an intensity that will not worsen the individuals condition. The latter may best be achieved by a technique that permits individuals to select and control their own level of exposure. Treatment may need to be tailored to the severity and type of presenting PTSD symptoms. For example, individuals who are extremely avoidant may need to be treated initially with a direct therapeutic exposure procedure. On the other hand, individuals who are highly aroused or dissociative in response to trauma-related stimuli may be poor candidates for exposure, and may first require an anxiety management or drug treatment aimed at reducing these symptoms. Treatment may also need to be tailored to the type of trauma experience. Foa and colleagues have noted that the guilt and shame commonly observed in victims of trauma may be an irrational response for a rape victim, but an appropriate one for a combat veteran who killed innocent civilians. The latter may worsen with an exposure technique that the veteran regards as rubbing his nose in what he has done, and he may possibly be treated more effectively by exploring factors that contributed to the behavior, or finding ways of making reparation (e.g., volunteer work). To take another example, although a recurrence of the trauma is unlikely for a veteran who returns to a peace zone, it is a very real threat for a victim of assault, and the latter may need to be trained to discriminate safe from unsafe situations so that realistic precautions are not confused with avoidance. It is worth noting that most controlled studies have been of Vietnam veterans. Most PTSD treatments have not yet been evaluated for victims of torture, child physical and sexual abuse, disaster, physical assault, and accidents. Many techniques (e.g., exposure) may not be applicable for treating people who live with ongoing trauma, such as emergency personnel and individuals still living with abusive spouses. And, although children clearly suffer from PTSD, as yet there are no systematic studies of how children respond to the different techniques described in this review. PTSD treatment studies are, by their very nature, limited in what they can tell us, as the trauma experience typically results in many negative outcomes other than PTSD. Effective treatment of trauma victims requires looking beyond that one diagnosis. Other comorbid diagnoses will affect the decision about which treatment is most appropriate, and sometimes these other conditions must be treated before the PTSD can be addressed. For example, exposure therapy is not likely to bring about improvement in an individual who continues to self-medicate through abuse

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of alcohol or illicit substances. Victims of traumatic events are also likely to display potentially severe problems of adjustment, including grief, guilt, suicide ideation, somatic complaints, poor self-esteem, social impairment, sexual dysfunction, and other problems with intimacy. A multifaceted intervention that targets these problems in functioning may help reduce relapse, and improve the long-term efficacy of any PTSD treatment. And even when the PTSD is refractory, any therapy that alleviates these adjustment problems will significantly reduce the individuals suffering. Because no treatment has yet been found to effect a complete and lasting cure for chronic PTSD, treatment goals that target other aspects of impairment may, in many cases, be more realistic. Although this article delineates differences among the many treatments for PTSD, in practice, the lines distinguishing these techniques are becoming increasingly blurred. Most therapies include multiple components variously designed to (a) address the meaning of the traumatic event; (b) provide exposure and reworking of traumatic memories; and (c) provide social support and coping skills. Indeed, contemporary views emphasize the need for a flexible, integrative approach to treatment in order to deal with the complex and varying needs of individual trauma victims. For example, it may be necessary to modify a standard exposure protocol to overcome defensive and adverse reactions, or to periodically inject exposure into the regular course of another treatment in order to target specific memories as they emerge. Because a variety of outcomes have been found with all of these techniques, it is unclear who will respond best to which treatment approach. However, what is certain is that the success of any PTSD technique depends upon establishing and maintaining a therapeutic context of sufficient safety and trust for positive emotional change to occur.

SELECT REFERENCES/RECOMMENDED READINGS Allen, S. N., & Bloom, S. L. (1994). Group and family treatment of post-traumatic stress disorder. Psychiatric Clinics of North America, 17, 425437. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Boudewyns, P. A. (1996). Posttraumatic stress disorder: Conceptualization and treatment. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. 30, pp. 165189). Pacific Grove, CA: Brooks/Cole. Foa, E. B., & Meadows, E. A. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449480. Horowitz, M. J. (1976). Stress-response syndromes. Northvale, NJ: Aronson. Kessler, R., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 10481060. Litz, B. T., & Roemer, L. (1996). Post-traumatic stress disorder: An overview. Clinical Psychotherapy: An International Journal of Theory and Practice, 3, 153168. McCann, I. L., & Pearlman, L. A. (1990). Psychological trauma and the adult survivor: Theory, therapy and transformation. New York: Brunner/Mazel. McFarlane, A. C. (1994). Individual psychotherapy for post-traumatic stress disorder. Psychiatric Clinics of North America, 17, 393408.

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Resick, P. A., & Schnicke, M. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60, 748756. Shalev, A. Y., Bonne, O., & Eth, S. (1996). Treatment of posttraumatic stress disorder: A review. Psychosomatic Medicine, 58, 165182. Solomon, S. D., & Davidson, J.R.T. (1997). Trauma: Prevalence, impairment, service use, and cost. Journal of Clinical Psychiatry, 58 (Suppl 9), 511.