Specialized Care For Chronic Complex PTSD, Part II: Treatment Options
Julian Ford, Ph.D.
NCP Clinical Quarterly, 7(3): Summer 1997
Real-world evaluations of the effectiveness of intensive treatment programs for military veterans diagnosed with posttraumatic stress disorder (PTSD) report mixed outcomes that appear to vary substantially for different individuals (1). Controlled trials of trauma-focused PTSD treatment have been more encouraging (2), but replication is rare and most positive findings involve relatively acute or subclinical rather than chronic PTSD. Even the best results from controlled trials indicate that a majority of adults with chronic PTSD either fail to complete or to benefit from intensive psychotherapy. For example, two successful controlled trials of cognitive-behavioral treatment of chronic PTSD with male military veterans were able to show a clearly favorable response in fewer than half their participants, and another 25% of candidates declined the treatment (3,4)). Interrupting the downward tragectory of posttraumatic deterioration characterizing chronic PTSD is an enormous challenge for the veteran, the family, and the clinician. Science can guide us, but cannot tell what treatment will most benefit a particular veteran with PTSD.
Two practical steps may be of help. The first is identifying the veterans who show most favorable response to treatment currently. Every practitioner and program has specific programmatic emphases (and idiosyncratic individual strengths and weaknesses) that are a particularly good fit with the needs, attributes, and difficulties of certain clients. Veterans with a common dilemma of military-related PTSD differ tremendously in their core issues and predilections (e.g., bitterness, detachment, addiction, shame, suicidality). Beyond the educational topics and therapeutic goals emphasized by your program, who are the veterans who best respond to you and your program? What do the veterans receiving care from your program say to other veterans to describe how and why you've most helped them? Your strong suits may well differ from what you think your program "should" emphasize and who you think your program "should" serve as primary clientele. Effective programs build upon existing strengths rather than attempting to force the clinicians or veterans to fit an idealized agenda.
On the other hand, it is essential not to overlook the legitimate needs of veterans who do not sufficiently benefit from existing services. The question here is, what are the characteristics of treatment nonresponders, and how can treatment be modified to better serve them? In some cases, the best solution may be to develop alliances with other clinicians or programs that have different but complementary strengths. For example, networks of outpatient and inpatient VA medical center PTSD programs and Vet Centers in several areas of the country provide a forum for formal or informal case conferencing and staffing of clients who need a different mix of clinicians, services, settings, or treatment foci.
Treatment nonresponse often is less due to the match of the veteran with a specific clinic or practitioner than to the chronicity and complexity of symptoms and impairment. Veterans in treatment for military-related PTSD often have a history of early childhood abuse, and associated persistent problems with dysregulation of intense primitive emotions (e.g., shame, guilt, rage), pathological dissociation, preoccupation with unexplained and seemingly unmanageable physical disability and pain, and relationships characterized by ambivalence, abandonment, and victimization. Elana Newman and colleagues (5) conducted a clinical study with veterans in treatment for chronic PTSD, most of whom had histories of childhood abuse, confirming that these men had severe problems with overwhelming rage, shame, guilt, and fear or loss of control, dissociative "spacing out" and derealization, amnesia, inability to trust, despair, hopelessness, feeling permanently damaged and misunderstood, and a loss of sustaining beliefs. How can we address these extreme problems therapeutically?
Posttraumatic therapy includes a range of options that warrant careful consideration (6-8)). Two options of particular potential benefit with DES are in pilot testing by innovative VA PTSD programs. Dialectic Behavior Therapy (DBT) was created originally by Marsha Linehan (9,10) to provide an intensive team treatment approach for the refractory patient presenting with parasuicidal borderline personality disorder. Multisystemic therapy (MST) has been developed by Scott Henggeler and colleagues (11,12) to enhance intractably delinquent adolescents' access to a facilitative social support network (e.g., family, school, community). These interventions are sophisticated conceptually yet down-to-earth operationally. DBT clients spend a year or more working in group therapy on personal safety and commitment to treatment, and carry an "emergency card" listing several dozen practical coping alternatives for para suicidal crises. Both build a safety net for the client, the family, and the clinician to facilitate prevention and management of crises. MST strengthens the parent's psychosocial resources and psychiatric competence in order to change the adolescent's day-to-day ecology. Both approaches devote time and resources to maintaining the treatment team, addressing vicarious traumatization, as well as treatment planning and monitoring. Thus, both provide a milieu in which intense emotion can be safely expressed and worked-through by the client. the support system, and treatment team. Treatment thus can initiate a genuinely posttraumatic phase in the life of the client, the family, and the clinician, enabling them to begin to resolve rather than just repeat unavoidable traumatic sequelae.
References
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2.Solomon, S .D. Gerrity, E. T. , & Muff, A.M. (1992). "Efficacy of treatments for post-traumatic stress disorder: An empirical review." Journal of the American Medical Association, 268, 633-638.
3.Boudewyns, P., Hyer, L., Woods, M., Harrison,W., & McCranie, E. (1990). PTSD among Vietnam veterans: An early look at treatment outcome using direct therapeutic exposure. Journal of Traumatic Stress, 3, 359-368.
4.Keane, T., Fairbank, J., Caddell, J., & Zimering, R. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260.
5.Newman, E., Orsillo, S., Herman, D., Niles, B., & Litz, B. (1995). Clinical presentation of disorders of extreme stress in combat veterans. Journal of Nervous and Mental Disease, 183, 628-632.
6.Keane, T. M. (1995). The role of exposure therapy in psychological treatment of PTSD. National Center for PTSD Clinical Quarterly, 5(4), 1, 3-6.
7.Marmar, C., Weiss, D., & Pynoos, R. (1995). Dynamic psychotherapy of post-traumatic stress disorder. In M. Friedman, D. Charney & A. Deutch (Eds.), Neurobiological and clinical consequences of stress (pp. 495-506). Philadelphia: Lippincott.
8.Ochberg, F. (1993). Posttraumatic therapy. In J. Wilson & B. Raphael (Eds.,) International handbook of traumatic stress syndromes (pp. 773-784). New York: Plenum.
9.Linehan, M., Tutek, D., Heard, H., & Armstrong, H. (1994). Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry, 151,1771-1776.
10.Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
11.Henggeler, S., Pickrel, S., Brondino, M., & Crouch, J. (1996). Eliminating (almost) treatment dropout of substance abusing or dependent delinquents through home-based multisystemic therapy. American Journal of Psychiatry, 153, 427-428.
12.Henggeler, S., Schoenwald, S, & Pickrel, S. (1995). Multisystemic therapy. Journal of Consulting & Clinical Psychology, 63, 709-717.
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