TERRORISM and PTSD
Resources for Clinicians
Mental Health Intervention for Disasters
The aim of all disaster mental health management should be the humane, competent and compassionate care of those affected, with the goal of preventing adverse outcomes for health, and enhancing the well-being of individuals and communities. In particular, it is vital to use all appropriate endeavours to prevent where possible the development of chronic and disabling problems such as PTSD, depression, alcohol abuse and relationship difficulties.
Factors that Facilitate Positive Outcomes and Prevention
There is much evidence to suggest that a number of factors help to facilitate positive outcomes and prevention (Excerpted from Raphael, Disaster Mental Health Response Handbook, NSW Health, 2000). These include:
It is crucial to recognize people's strengths as well as the suffering they have experienced. While survivors' suffering must be acknowledged, and compassion and empathy conveyed to them, it is also important that those who care for them believe in and support their capacity to master this experience.
Information and education help people's understanding and should be an integral part of the support and care systems. Preparation prior to disaster, information about what has happened, education about normal responses to such events, training in what to do to help psychological recovery, information centers and ongoing information feedback to affected communities, all help people's mastery and recovery.
Sharing the experience. Many people may display a need to tell the story of their experience, to give testimony, both to externalise it and obtain emotional release, and to gain understanding and support from others. This varies enormously. It may occur spontaneously as natural groups come together after the disaster. However, there will be others who may not feel ready or who may choose not to talk about their experience. Those involved in the mental health response should be aware of these variable needs and be supportive of what the survivor wants.
Supportive networks are critical and should be retained, reinforced and rebuilt. These networks help people in the ongoing recovery process, both through the exchange of resources and practical assistance, and through to the emotional support they provide to deal with the disaster and its aftermath. Community groups may develop to facilitate support, and should be encouraged.
Possible Obstacles to Help-Seeking
Several studies have pointed out that following a terrorist event such as the Oklahoma City bombing, many of those in closest proximity to the disaster do not believe they need help, and will not seek out services, despite reporting significant emotional distress (Meyer, 1991; Sprang, 2000). Sprang lists several potential reasons for this:
- A feeling that one is "better off" than those more affected, and therefore should not be so upset.
- Pride, or a feeling that distress indicates weakness of some sort. Some individuals may not define services they receive as mental health intervention, especially if unsolicited (lectures, sermons, discussions, community rituals). Indeed, the goal of many disaster mental health workers is to have interventions be a seamless, integrated part of an overall disaster effort, so many may not see these interventions as "mental health" interventions.
- Many individuals are more apt to seek informal support from family and friends, which may not be sufficient to prevent long-term distress in some.
This lack of help-seeking is critical to address. Of individuals studied who were directly exposed to the Oklahoma City bomb blast, nearly half had an active post-disaster psychiatric disorder, with PTSD being diagnosed in 1/3 of the respondents (North et al., 1999). Major Depression was the most commonly associated disorder. No new cases of substance abuse were observed, consistent with previous findings. Symptom onset of PTSD was rather immediate, usually within one or two days, and few other cases developed after the first month.
Crisis Intervention
Generally, there are three stages of intervention, each requiring a different level of involvement:
- Emergency phase: the immediate period after disaster strikes
- Early post-impact phase: anytime from the day after the onset of the disaster until approximately the eighth to twelfth week;
- Restoration phase: marked by the implementation of long- term recovery programs, generally beginning at about the eighth to twelfth week after the onset of the disaster.
Initial mental health interventions
Initial mental health interventions are primarily pragmatic, as reflected in the following stages:
Protect:
Find ways to protect survivors from further harm and from further exposure to traumatic stimuli. If possible, create a "shelter" or safe haven for them, even if it is only symbolic. The less traumatic stimuli people see, hear, smell, taste, feel, the better off they will be. Protect survivors from onlookers and the media.Direct:
Kind and firm direction is needed and appreciated. Survivors may be stunned, in shock, or experiencing some degree of dissociation. When possible, direct ambulatory survivors:Away from the site of destruction Away from severely injured survivors Away from continuing danger
Connect:
The survivors you encounter at the scene have just lost connection to the world familiar to them. A supportive, compassionate, and nonjudgmental verbal or nonverbal exchange may help them experience connection to the shared societal values of altruism and goodness. However brief the exchange, or however temporary its effects, such "relationships" are important elements of the recovery or adjustment process.Help survivors connect:
To loved ones To accurate information and appropriate resources To where they will be able to receive additional support
Triage:
The majority of survivors experience normal stress reactions. However, some may require immediate crisis intervention to help manage intense feelings of panic or grief. Signs of panic are trembling, agitation, rambling speech, erratic behavior. Signs of intense grief may be loud wailing, rage, or catatonia. In such cases, attempt to quickly establish therapeutic rapport, ensure the survivor's safety, acknowledge and validate the survivor's experience, and offer empathy. Medication may be appropriate and necessary, if available.
It is necessary to be aware that needs of individual members of a community may vary greatly. The following early intervention strategies can yield good results:
Providing direct services as soon as is feasible after the event may require temporarily bringing in outside experts. However, it is of the greatest importance that needs assessment, planning and service delivery be done in full co-ordination and with explicit knowledge of local providers. Outside help should at no time be imposed; respectful, coordinated interfacing with local resources, however limited these may be, is essential. Empower local care-providers to assume ever-greater responsibilities for delivering services in their community. This can be achieved by providing in-field training from the start of an intervention. It increases professional self-esteem and helps local resources expand quickly. Work with key community figures and leaders, local media and governmental institutions to make them aware of the benefits to be derived from early community-based interventions. It is important to recognize that care-providers from within a community may themselves be overwhelmed and/or traumatized, and to ensure that comprehensive professional support and supervision are available for them to attend to their own mental health needs.
Basic Principles of Emergency Care
It is helpful to remember and be guided by several "basic principles" or objectives of emergency care.
- Provide for basic survival needs and comfort (e.g., liquids, food, shelter, clothing, heat/cooling).
- Help survivors achieve restful and restorative sleep.
- Preserve an interpersonal safety zone protecting basic personal space (e.g., privacy, quiet, personal effects).
- Provide nonintrusive ordinary social contact (e.g., a "sounding board," judicious uses of humor, small talk about current events, silent companionship).
- Address immediate physical health problems or exacerbations of prior illnesses.
- Assist in locating and verifying the personal safety of separated loved ones/friends.
- Reconnect survivors with loved ones, friends, trusted other persons (e.g., AA sponsors, work mentors).
- Help survivors take practical steps to resume ordinary daily life (e.g., daily routines or rituals).
- Help survivors take practical steps to resolve pressing immediate problems caused by the disaster (e.g., loss of a functional vehicle, inability to get relief vouchers).
- Facilitate resumption of normal family, community, school, and work roles.
- Provide opportunities to grieve losses.
- Help survivors reduce problematic tension, anxiety or despondency to manageable levels.
- Support survivors' indigenous helpers through consultation and training about common stress reactions and stress management techniques.
Debriefing
Debriefing means different things to different people:
Operational debriefing is a routine and formal part of an organizational response to a disaster. It is acknowledged to be an appropriate pactice, which may result in acquiring some overall sense of meaning and a degree of closure.
Psychological or Stress debriefing refers to a variety of practices for which there is little supportive empirical evidence. It is strongly suggested that psychological debriefing is not an appropriate mental health intervention.
Critical Incident Stress Debriefing (CISD) is a formalized structured method of group review of the stressful experience of a disaster. CISD was developed to assist first responders such as fire and police personnel; it was not meant to be used with the survivors of a disaster or their relatives. CISD was never intended as a substitute for therapy. It was designed to be delivered in a group format, and meant to be incorporated into a larger, multi-component crisis intervention system labeled "Critical Incident Stress Management" (CISM).
CISM incorporates seven components: pre-crisis intervention; disaster or large-scale demobilization, and informational briefings ("town meetings"); staff advisement; defusing; CISD; one-on-one crisis counseling or support; family crisis intervention and organizational consultation; follow-up and referral mechanisms for assessment and treatment, if necessary.
Currently, some form of stress debriefing is considered by many to be the standard of care following stressful events, both natural (earthquakes) or manmade (workplace shootings, bombings). Indeed, the National Center for PTSD's Disaster Mental Health Guidebook (which is currently being revised) contains information on how to conduct debriefings. However, more recent research indicates that psychological debriefing is not always an appropriate mental health intervention. Available evidence shows that it may in some instances increase traumatic stress or possibly complicate recovery. Psychological debriefing is also inappropriate for acutely bereaved individuals. While operational debriefing, which involves clarifying events and providing education about normal responses and coping mechanisms, is nearly always helpful, care must be taken before delivering more emotionally-focused interventions.
A recent review of eight debriefing studies, all of which met rigorous criteria for being well-controlled, revealed no evidence that debriefing reduces the risk of PTSD, depression, or anxiety; nor were there any reductions in psychiatric symptoms across studies. Additionally, in two studies, one of which included long-term follow-up, some negative effects of CISD-type debriefings on PTSD and other trauma-related symptoms were reported (Rose, Wesselly, & Bisson, 2000). Therefore, while debriefings as currently employed may be useful for low magnitude stress exposure and symptoms, or for emergency providers, the best studies recommend that for individuals with more severe exposure to trauma, and for those who are experiencing more severe reactions such as PTSD, debriefing is ineffective at best, and possibly harmful.
The question of why debriefing may produce negative results has been considered and early hypotheses have been formulated. One theory connects negative outcomes with heightened arousal in the early post-trauma phase and long-term psychopathology (Shalev, 2001; Bryant, 2000). Because verbalization of the trauma in debriefing is limited, habituation to evoked distress does not occur. The result may be an increase rather than a decrease in arousal. Any such increased distress caused by debriefing may be difficult to detect in a group setting. Thus, attempting to override dissociation and avoidance in the immediate post-trauma phase with debriefing, may be detrimental to some individuals, particularly those experiencing heightened arousal. Also to be considered is the observation that the boundary between debriefing and therapy is sometimes blurred (e.g., challenging thoughts), which may increase distress in some individuals (Bryant, 2000). Finally, debriefers frequently are unable to adequately assess traumatized individuals in a group setting. They may erroneously conclude that a one-time intervention will be sufficient to prevent further symptomatology.
Practice guidelines on debriefing formulated by the International Society for Traumatic Stress Studies conclude there is little evidence that debriefing prevents psychopathology. The guidelines recommend that, while debriefing is often well-received, and while it may be useful to facilitate screening of those at risk, disseminate education and referral information, and improve organizational morale, debriefing (if employed):
Should be conducted by experienced, well-trained practitioners Should not be mandatory Should utilize some clinical assessment of potential participants Should be accompanied by clear and objective evaluation procedures.
The guidelines state that while it is premature to conclude that debriefing should be discontinued altogether, "more complex interventions for those individuals at highest risk may be the best way to prevent the development of PTSD following trauma."
Timing of Follow-Up Services
Timing of intervention is central to the concept of secondary prevention following traumatization to prevent development of PTSD and other negative consequences. Early intervention implies that services will be delivered sometime before chronicity has developed. Unfortunately, almost no research has examined the effects of differential timing of treatment. Although it has been speculated that PTSD develops via neurobiological changes taking place in the first few days or weeks post-trauma, most theoretical models of PTSD do not explicitly address timing of intervention in relation to the processes of symptom worsening, maintenance, and remission. Psychological models focusing on processes of therapeutic exposure, cognitive restructuring, social support, coping, rumination, "working through," and so on have largely been mute as to whether there are critical periods during which initial symptoms remit or become chronic.
As stated above, in the Oklahoma City bombing, symptom onset of PTSD was rather immediate, usually within one or two days; few other cases developed after the first month. Because all the individuals in closest proximity to the Oklahoma City bombing who reported psychiatric symptoms also had PTSD, focusing on PTSD symptoms could identify most cases for triage to psychiatric care. This is consistent with results from a small sample of self-referred patients following the 1993 World Trade Center bombing in New York (Difede et al, 1995). These data indicate that paying particular attention to avoidance and numbing symptoms may efficiently identify those who may be at risk for psychiatric casualty, both PTSD and other disorders. Early identification may be crucial, since data from the Oklahoma City bombing suggest that, of those who were in closest proximity to the bomb blast, 9 out of 10 individuals with PTSD were still symptomatic 6 months after the disaster, indicating that the provision of ongoing treatment is essential.
In the real world of service delivery, the timing of follow-up will also depend on a variety of other factors, including readiness of the survivor, the nature of the traumatic event and its effects, and the nature of the service delivery setting.
Survivor readiness. Some survivors may not attend preventive mental health activities or pursue a mental health referral early in the recovery process because they are busy coping with practical problems caused by the experience (e.g., finding housing, pursuing insurance claims, undergoing physical tests and treatment), or because they do not feel ready to face the emotions brought on by discussing the trauma. They may not recognize the need for services, due to a process of emotional "denial" or because of lack of information about the purposes and practices of psychological counseling, or due to their personal expectation that short-term emotional reactions will pass. Moreover, they may not yet be experiencing significant impairment; some survivors will experience a delayed onset of symptoms. Mental health practitioners should be sensitive to these possibilities. Follow-up, re-screening, and repeated referral may help ensure delivery of referral information at a time when patients may be better able to take advantage of it.
Nature of the traumatic event. Timing of follow-up will also be determined in part by the nature of the trauma and its effects. Some traumatic events are characterized by sudden onset and termination, at least in terms of the event itself, and follow-up may be delivered within a few weeks after the event, perhaps supplemented by occasional longer-term follow-ups as necessary or feasible. Other traumas involve extended periods of continuing exposure to severe stressors, or ongoing experience of negative consequences that may last many months or years (e.g.,loss of housing due to disaster, or medical treatment of serious injury). Follow-up in such cases should, optimally, be delivered for a much longer period of time. When periods of exacerbation of trauma-related problems can reliably be anticipated (e.g., anniversaries of traumatic events), timing of follow-up should correspond to these periods. For example, episodes of terrorist violence often involve criminal trials that take place long after the violent event occurs, but that represent stressful reminders of the original event. Follow-up services delivered in conjunction with trial activities may be useful in supporting survivors.
Nature of the Setting. Post-trauma service delivery settings vary greatly. MVA or assault survivors may be seen in traditional medical settings; rape survivors may seek help at community-based rape crisis centers; combat soldiers may be offered "forward psychiatry" close to the scene of the trauma itself; survivors of hurricanes or floods will be gathered together at community shelters. The nature of the setting will in part determine when, and with what intensity, follow-up services may be delivered. In some environments, routine, systematic, adequately resourced follow-up with all survivors will be feasible. The nature of the setting will also influence who (mental health professionals, medical personnel, paraprofessionals, or others) will deliver mental-health-related follow-up.
Who Should Be Followed-Up?
All survivors should be given educational information to help normalize common reactions to trauma, improve coping, enhance self-care, facilitate recognition of significant problems, and increase knowledge of and access to services. Such information can be delivered in many ways, including public media, community education activities, and written materials. More intensive follow-up services should be targeted toward subgroups of survivors who are at heightened risk of chronic or severe post-trauma problems. Such targeting is warranted for two major reasons. First, resources will often be limited, making it difficult to provide all survivors with costly services. Second, immediate post-trauma distress will remit naturally for many patients (Blanchard et al. 1995) and provision of mental health services may be unnecessary. Hypothetically, it is even possible that too much focus on mental health issues would be iatrogenic for some survivors. Centering their attention on symptoms and problems could create the impression that receiving attention and caring is contingent on needing such help.
Identification of those at significant risk of continuing problems will ideally be based on systematic screening conducted with all survivors. If such screening systems are not in place, identification can be based on a number of criteria, including:
identification and referral by a trauma responder, self-referral, severe level of trauma exposure (e.g., exposure to death and dying), co-occurring injury, level of co-occurring loss, and disaster worker role (e.g., body recovery).
Content of Follow-Up Activities
The variety of follow-up activities appropriate in a given situation may include education, screening, outreach, referral, and treatment.
Survivor and family education. Education for trauma survivors and their families may help normalize common reactions to trauma, improve coping, enhance self-care, facilitate recognition of significant problems, and increase knowledge of and access to services. First, survivors and families should be reassured about common reactions to traumatic experiences and advised regarding positive and problematic forms of coping with them. Information about social support and stress management is particularly important. Second, opportunities to discuss emotional concerns in individual, family, or group meetings can enable survivors to reflect on what has happened. Third, education regarding indicators that initial acute reactions are failing to resolve will be important, as will education about signs and symptoms of PTSD, anxiety, depression, substance use disorders, and other difficulties. Finally, survivors will need information about financial, mental health, rehabilitation, legal, and other services available to them, as well as education about common obstacles to pursuing needed services.
Follow-up screening. Early identification of those at-risk for negative outcomes following trauma can facilitate prevention, referral, and treatment. Screening for current psychopathology and risk factors for future impairment can be accomplished via brief semi-structured interviews and standardized assessment questionnaires. Screening should address past and current psychiatric and substance use problems and treatment, prior trauma exposure, pre-injury psychosocial stressors, and existing social support. Event-related risk factors should also be assessed, including exposure to death, perception of life-threat, and peri-traumatic dissociation. Especially important are acute levels of traumatic stress symptoms, which predict chronic problems. For example, more than three-quarters of MVA patients diagnosed with ASD will have chronic PTSD at 6 months post-trauma (Bryant and Harvey 2000). In follow-up appointments, it will be important to continue to screen for PTSD and other anxiety disorders, depression, alcohol and substance abuse, problems with return to work and other productive roles, adherence to medication regimens and other appointments, and potential for re-traumatization.
Referral. A crucial goal of follow-up activities is referral, as necessary, for appropriate mental health services. In fact referral, and subsequent delivery of more intensive interventions, will depend upon adequate implementation of screening. Screening, whether conducted in formal or informal ways, is what best determines who is in need of referral. Nevertheless, even when those who might benefit from mental health services have been adequately identified, factors such as embarrassment, fear of stigmatization, and cultural norms may limit motivation to seek help or pursue a referral. Those making referrals can directly address these attitudes and attempt to preempt avoidance of needed services; motivational interviewing techniques (Rollnick et al., 1992) may help increase rates of referral acceptance.
Treatment. Research suggests that relatively brief but specialized interventions may effectively prevent PTSD in some subgroups of trauma patients. Several controlled trials have suggested that brief (i.e., 4-5 session) cognitive-behavioral treatments comprised of education, breathing training/relaxation, imaginal and in vivo exposure, and cognitive restructuring, delivered within weeks of the traumatic event can often prevent PTSD in survivors of sexual and non-sexual assault (Foa et al., 1995), and motor vehicle and industrial accidents (Bryant et al., 1998, 1999). Brief intervention with patients hospitalized for injury has been found to reduce alcohol consumption in those with existing alcohol problems (Gentilello et al., 1999). Controlled trials of brief early intervention services targeted at other important trauma sequelae (e.g., problems returning to work, depression, family problems, trauma recidivism, bereavement-related problems remain to be conducted, but it is likely that targeted interventions may be effective in these arenas for at least some survivors.
Treatment of Acute Stress Disorder (ASD) is indicated for the small proportion of people who are at risk of developing long-term PTSD. While the field of treatment for ASD is still young, two well-designed studies offer evidence that brief treatment intervention, utilizing a combination of cognitive behavioral techniques, may be effective in preventing PTSD in a significant percentage of subjects. In their study of a brief treatment program for recent sexual and nonsexual assault victims, all of whom met criteria for PTSD, Foa, Hearst-Ikeda, and Perry (1995) compared repeated assessments with a Brief Prevention Program (BPP) comprised of four sessions of trauma education, relaxation training, imaginal exposure, in vivo exposure, and cognitive restructuring. Two months posttrauma, only 10% of the BPP group met criteria for PTSD, whereas 70% of the repeated assessments group met criteria for PTSD. In a study of motor vehicle and industrial accident victims who met criteria for ASD, Bryant, Harvey, Dang, Sackville, and Basten (1998) compared five sessions of nondirective supportive counseling (support, education, and problem-solving skills) with a brief cognitive-behavioral treatment (trauma education, progressive muscle relaxation, imaginal exposure, cognitive restructuring, and graded in vivo exposure to avoided situations). Immediately post-treatment, 8% in the CBT group met criteria for PTSD, versus 83% in the the supportive counseling group. Six Months Post-Trauma, 17% in CBT met criteria for PTSD, versus 67% in supportive counseling. One important caveat to these interventions is that dropout rate was high, and the authors concluded that those with more severe symptoms may need supportive counseling prior to more intensive cognitive behavioral interventions.
In addition to targeted brief interventions, some trauma survivors may benefit from the provision of ongoing counseling or treatment. Candidates for such treatment would 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 who have preexisting mental health problems.
Empirical Evidence Regarding Behavioral Treatments for PTSD
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, when evaluating the literature, lack of empirical evidence does not necessarily signify lack of treatment efficacy. The current process by which trauma experts evaluate treatment options is to study the empirical literature, as well as take into account clinical consensus on treatments which 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 / potential negative effects, cost, length of treatment, cultural appropriateness, therapist's resources and skills, client's resources and stressors, co-morbidity 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, there are a number of treatment approaches that 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, and merit strong consideration when considering referral options. Listed below are some treatments that have gained empirical support (Friedman, 2000):
Cognitive-Behavioral Therapy (CBT)
There are more published well-controlled studies on CBT than on any other PTSD treatment (over 30). 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, 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 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), but degree of change accomplished is likely to be somewhat less in veterans with chronic combat-related PTSD. 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 alternation of attention back and forth via taps or sounds). It also addresses trauma-related negative beliefs. It has been shown to be more effective than placebo wait list (patients are put on a waiting list to receive treatment, but don't actually receive it by the time they are tested), psychodynamic, relaxation, or supportive therapies. Research comparing EMDR to more standard cognitive-behavioral techniques shows significantly better results with CBT than with EMDR, particularly at three month follow-up, and showing greater sustainability of CBT results. Research looking at the different components of EMDR shows that the eye movement component adds no additional treatment effect above and beyond the imagery exposure and addressing of negative beliefs.
Psychodynamic Therapy
Research on the use of psychodynamic therapy is difficult to conduct because psychodynamic techniques do not focus on symptom reduction, but rather 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 which 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 treatment of trauma, particularly more complex trauma, much more research is needed to demonstrate their effectiveness with PTSD.
Group Therapy
While various studies have shown beneficial effects from most group treatments with respect to psychological distress, depression, anxiety and social adjustment, there have been few rigorous tests of group treatments in which effects on PTSD symptoms have been measured. 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 it is appropriate for crisis intervention, management of complex diagnostic cases, delivery of emotionally-intense therapeutic procedures, and relapse prevention.
Marital and Family Therapy
There are no research studies done on the effectiveness of marital/family therapy for the treatment of PTSD. However, because of trauma's unique effects on interpersonal relatedness, clinical wisdom indicates that spouses and families be included in 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 in chronic schizophrenic and other persistently impaired psychiatric cohorts, they have yet to be formally tested with PTSD clients. Since these therapies appear to generalize well from clients with one mental disorder to 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. with respect to the need to maintain physical safety and appropriate professional boundaries; therefore it is important that therapists be well trained in this modality.
Maximizing Follow-Up Services
For many types of trauma, experience indicates that relatively few survivors make use of available mental health services. This may be due to a lack of awareness of the availability of such services, low perceived need for them, lack of confidence in their utility, or negative attitudes toward mental health care. Therefore, those planning follow-up and outreach services for survivors must consider how to reach trauma survivors to educate them about sources of help and to market their services to the intended recipients.
In the chaos following some kinds of traumatic events (e.g., natural disaster), it is important that workers systematically obtain detailed contact information to facilitate later follow-up and outreach. In addition, it is important that those providing outreach and follow-up efforts be opportunistic in accessing settings where survivors are congregating. Each contact with the system of formal and informal services available to survivors affords an opportunity to screen for risk and impairment and to intervene appropriately. Settings providing opportunities for contact with survivors are diverse (e.g., remembrance ceremonies, self-help group activities, settings where legal and financial services are delivered, interactions with insurance companies). For survivors injured or made ill during the traumatic event, follow-up medical appointments represent opportunities for reassessment, referral, and treatment.
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