Cautions Regarding Cognitive-Behavioral Interventions Provided Within a
Month of Trauma
A National Center for PTSD Fact Sheet
How effective is Cognitive-Behavioral Therapy for early intervention?
Researchers have conducted over 30 studies examining the effectiveness of
Cognitive-Behavioral Therapy (CBT) in treating PTSD and several studies
examining a brief, five-session treatment for Acute Stress Disorder (ASD). In
general, CBT has proven very effective and produced significant reductions in
PTSD symptoms. CBT treatments are often carefully scripted in treatment
manuals. There are more published well-controlled studies of CBT than of any
other PTSD treatment. Furthermore, the magnitude of treatment effects appears
greater with CBT than with any other treatment.
Bryant et al.1, in treating motor vehicle and industrial accident victims who met criteria for ASD, compared five sessions of nondirective supportive counseling (providing support and education and teaching problem-solving skills), with brief cognitive-behavioral treatment (trauma education, progressive muscle relaxation, imaginal exposure, cognitive restructuring, and graded in vivo exposure to avoided situations). At the conclusion of treatment, 8% of the participants in the CBT group and 83% of the participants in the supportive counseling (SC) group met criteria for PTSD. Six months posttrauma, 17% in the CBT group and 67% in the SC group met criteria for PTSD. There were also significant reductions in depressive symptoms in the CBT group compared to the SC group. Clearly, this is one of the most important developments in years regarding early intervention.
What are the obstacles to using Cognitive-Behavioral Therapy in early intervention?
Excerpted with permission from Bryant, R.A., & Harvey, A.G.2. Acute Stress Disorder: A handbook of theory,
assessment, and treatment. Washington, D.C.: American Psychological
Association Press.
There are a proportion of people for whom any early intervention may be
inappropriate. The following issues are commonly encountered in individuals
with Acute Stress Disorder, and must be carefully addressed in considering
treatment options for these individuals:
Excessive Avoidance
Excessive avoidance may be an important warning
sign that the client needs containment and support vs. exposure. If so, it is recommended
to take a supportive approach until they are better able to use therapy.
However, if therapist determines that exposure treatment can be tolerated,
compare the benefits and disadvantages of proceeding with therapy, give more
attention to cognitive therapy to assist in perceiving response to exposure,
implement a graded exposure regime that commences with less distressing
material, and make sure that all features of the narrative description of the
trauma are eventually integrated in exposure treatment.
Dissociation
Dissociation may indicate a defense or protective
mechanism against overwhelming distress. If dissociative symptoms are present,
it may be best to take a supportive approach until the individual is better
able to use therapy. However, if the therapist determines that even with
dissociative symptoms, exposure treatment can be tolerated, modified exposure
techniques may be effective, such as directing clients to imagine a scene that
they can feel emotional about and then switch to the traumatic memory.
Anger
Anger may serve to inhibit anxiety, especially
when avoidance is unsuccessful. Exposure not the optimal treatment if primary
presentation is anger. It is best to implement CBT program specifically
addressing anger.
Grief
The bereavement process is normal and takes time.
It may not be appropriate to provide exposure during early phases of grieving.
It may be best to provide support until better able to use trauma therapy.
Extreme Anxiety
Any individual who suffers extreme anxiety or
panic attacks in the acute phase should be monitored carefully. Provide
instruction in anxiety management prior to exposure treatment (SIT). Give more
attention to cognitive therapy to assist client in appraising exposure in more
adaptive way. Temporarily suspend exposure if panic or extreme anxiety which is
intolerable by the client occur.
Catastrophic Beliefs
Proceeding with exposure without addressing
clients' interpretations of the recalled memories may simply reinforce their
maladaptive beliefs. Clients who manifest entrenched beliefs arising from their
experience should receive substantive cognitive therapy
Prior Trauma
If prior trauma(s) are too distressing to engage
in CBT, allow the posttraumatic upheaval to settle before directly addressing
the traumatic memories, and take a supportive approach until the client is
better able to use therapy. If, however, the therapist determines that exposure
treatment can be tolerated, prioritize the memories that will be addressed,
mutually agree on compartmentalizing the intrusive memories into an order that
the client feels comfortable addressing. It is usually best to address memories
of the recent trauma first -- they are more accessible and were the reason for
presentation to treatment.
Comorbidity
Comorbid disorders may be exacerbated by the
distress elicited by exposure therapy. Borderline personality disorder and
psychotic disorders may be particularly affected. If deterioration of
preexisting disorders is present, it is best to offer support to contain
preexisting disorder first.
Substance Abuse
Substance abuse is a common posttraumatic response
-- is a form of avoidance behavior that assists in distraction from distressing
intrusive symptoms. If the individual exhibits marked substance abuse, require
sobriety for several months before commencing exposure treatment, and provide
support until better able to use trauma therapy.
Depression and Suicide Risk
Exposure treatment may enhance attention towards
negative aspects of experience. Therefore, it is important to ensure clients
who are severely depressed are provided the appropriate assistance to stabilize
the depression prior to exposure. If the client is a suicide risk, they require
support, containment, and possibly antidepressant medication and hospitalization.
Poor Motivation
If clear ambivalence exists, attempt to educate
the client about the advantages of proceeding with therapy. It is better to not
proceed with therapy in the acute phase if the client is not willing.
Ongoing Stressors
Ongoing stressors can impede with resources to
engage in therapy, and the demands of therapy can impede coping with other
stressors. Delay active treatment until threats to safety or severe ongoing
stressors subside.
Cultural Issues
The rationale for exposure needs to be integrated
in to the client's value system in a way that is congruent with his or her view
of recovery. If discrepancy persists, recognize that a client's culturally
driven outlook must be recognized and validated.
Appropriate versus Inappropriate Avoidance
There are many instances in the initial period
when avoidance behavior is appropriate because of the recency of the trauma. It
is important for clinicians to recognize the functional, and sometimes
safety-enhancing roles of some avoidance behaviors in the acute phase.
Multiple Survivors of the Same Trauma
Sometimes clients' adjustment is directly influenced by the responses of others
also involved in the traumatic event.
Related Fact Sheets
Acute Stress
Disorder
Explains briefly what ASD is, how common it is, who is at risk, how it differs
from PTSD, and effective treatments
Motor vehicle accidents
Describes how motor vehicle accidents can create traumatic stress responses
and PTSD
Psychological
debriefing
A critique on the available evidence for Psychological Debriefing (PD) and
Cognitive-Behavioral Therapy as effective methods of early intervention
Treatment
Information on availble treatments for PTSD
References
1. Bryant, R.A., Sackville, T., Dang, S.T., Moulds, M., & Guthrie, R. (1999). Treating Acute Stress Disorder: An evaluation of cognitive behavior therapy and supportive counseling techniques. American Journal of Psychiatry, 156(11),
1780-1786.
2. Bryant, R.A., & Harvey, A.G. (2000). Acute
Stress Disorder: A handbook of theory, assessment, and treatment. Washington,
D.C.: American Psychological Association Press.
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