Archive

Monthly Archives: September 2013

GuidelinesResearch on traumatic stress disorders grows more voluminous and complex almost daily. While this is a very good thing, it does present an ongoing problem for treatment professionals. How are they to confidently summarize current knowledge so as to be assured of providing state-of-the-art care? A parallel problem exists for consumers of psychotherapy services: how are they to know that the treatment they are getting is the best available?

Treatment guideline summary recommendations, traditionally issued from time to time by major governmental agencies and professional organizations, address this need well[1]. Now we have a new and important guideline publication to guide professionals and consumers alike—the Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder, published late this summer by the Australian Centre for Posttraumatic Mental Health (ACPMH), a non-profit corporation originally devoted to trauma issues of military veterans but now also including the civilian population in their scope of concern.

Overview

An “update, revision and expansion of the original Guidelines” (ACPHC, 2013a, p. 2) published in 2007, the most significant change in this new edition of the Guidelines is the inclusion of recommendations for children and adolescents. Conveniently, it is published in four separate documents: a primary detailed statement of the Guidelines (ACPHC, 2013a), an extensive and lengthy set of appendices (ACPHC, 2013b), a special summary statement focused on children (ACPHC, 2013d), and an overall summary statement (ACPHC, 2013c). All are available for download in PDF format, which may be easily subjected to full-text search using common software. (See References below for details and download links.)

These non-prescriptive (ACPHC, 3013a, p. 2) Guidelines are derived from a systematic review of relevant literature, focusing on 24 specific research questions given to reviewers (ACPHC, 2013b, pp. 25-26). Recommendations are qualified by a grading system developed by the Australian National Health and Medical Research Council  (ACPHC, 3013a, p. 2):

  • Grade A: Available evidence can be trusted to guide practice.
  • Grade B: Available evidence can be trusted to guide practice in most situations.
  • Grade C: Available evidence provides some support for recommendation(s) but care should be taken in its application.
  • Grade D: Available evidence is weak and recommendation(s) must be applied with caution.

In cases where there was no research evidence for a recommendation, Consensus Points (CP) were assigned, based on the consensus opinion of the reviewers if such evidence had been expected, and Good Practice Points (GPP) in cases where no such evidence was expected to exist and none was looked for.

Treatment recommendations

Significantly stronger evidence was found for recommendations for adults than for children. In addition, it is important to realize that “posttraumatic mental health problems manifest in many different ways, and that ASD and PTSD are only two of the issues encountered by health professionals when helping individuals affected by traumatic events” (ACPHC, 2013c, p. 4).

Overall recommendations may be succinctly summarized: Do not medicate potentially traumatized children; do not use “psychological debriefing” at all. For adults, medication should not be used in preference to psychotherapy; in those cases where medication is indicated, the preferred choice is selective serotonin reuptake inhibitor (SSRI) antidepressants.

The single strongest recommendation (Grade A) is for trauma-focused cognitive behavioral therapy (TF-CBT) or eye-movement desensitization and reprocessing (EMDR), with TF-CBT alone being the recommendation for children.

Psychological interventions for adults

  1. Individuals exposed to potentially traumatizing events should not be offered a psychological “de-briefing” intervention [Grade B].
  2. Individuals who are displaying symptoms consistent with Acute Stress Disorder (ASD) or Posttraumatic Stress Disorder (PTSD) in the four weeks after exposure to potentially traumatizing events should be considered for individual TF-CBT, if this is indicated by a thorough clinical assessment [Grade C].
  3. Individuals diagnosed with PTSD should be given TF-CBT or EMDR [Grade A] (ACPMH, 2013a, p. 3).

Pharmacological interventions for adults

  1. Drug treatments should not be used as a blanket intervention for groups of people exposed to potentially traumatizing events [Grade D].
  2. Drug treatments should not be routinely used for individuals with ASD and early PTSD (within first 4 weeks of symptom emergence) [Grade C].
  3. For PTSD, drug treatments should not be used as a first treatment, in preference to TF-CBT pr EMDR [Grade B].
  4. For PTSD, when drug treatments are considered, the first choice should be SSRI antidepressants [Grade C].
  5. SSRI antidepressants should be considered in situations where an individual has not benefited from trauma focused psychological therapy, or has pre-existing conditions (details are given) which interfere with participation in such therapy [GPP] (ACPMH, 2013a, p. 4).

Psychological interventions for children and adolescents

  1. Children exposed to a potentially traumatic event should not be offered “psychological debriefing” [Grade B].
  2. Children of at least school age who have PTSD should be considered for developmentally appropriate TF-CBT [Grade C].
  3. Children exposed to a potentially traumatic event, with symptoms of PTSD, when exposed to the same event, should be considered for a school-based TF-CBT intervention to reduce symptoms [Grade C] (ACPMH, 2013a, p. 4).

Pharmacological interventions for children and adolescents

  1. Pharmacotherapy should not be considered as a blanket therapy for groups of children exposed to a potentially traumatic event [Grade D].
  2. Pharmacotherapy should not be given preference over TF-CBT for children with PTSD [Grade D].
  3. Pharmacotherapy should not be routinely used as an adjunct to TF-CBT for children with PTSD [Grade D]  (ACPMH, 2013a, p. 4).

Development Process and publication formats

The Guidelines are presented very attractively at the ACPMH website, hosted by the University of Melbourne. Four groups are addressed at the website—children, adolescents, adults, and mental health professionals. This largely reflects the focus of the Guidelines (ACPHC, 2013a, p. 1):

“The Guidelines have been designed to be used by: a) the range of general and mental health practitioners planning and providing treatment across clinical settings; b) people affected by trauma making decisions about their treatment; and c) funding bodies making service purchasing decisions.”

The quickest access to this large and significant work is the Guidelines Summary (ACPHC, 2013c). The main Guideline statement (ACPHC, 2013a) will be the focus of professionals, and some consumers; it’s well organized and easy to read into. For children and professionals, there is a brief summary “practitioner guide” statement (ACPHC, 2013d). Finally, for scholars, researchers, and those who wish to examine the basis for these guidelines, there is a separately published very substantial set of Appendices.

Of likely interest to professionals, Appendix 2 offers documentation of the process by which the Guidelines were developed. Key concepts relevant to this process are defined. Of particular interest is this statement concerning limitations of this effort:

“The Guidelines are principally limited to forms of distress consistent with the constructs of ASD and PTSD. They do not seek to address the full range of possible responses to traumatic exposure, including those known as Complex PTSD or Disorders of Extreme Stress Not Otherwise Specified (DESNOS). The original Guidelines were limited to adults; however, the revised version will also include children and adolescents.” (p. 4)

Then, concerning the question of who should actually use the Guidelines:

“There is insufficient evidence available in either the research or clinical practice literature to allow an authoritative specification of competencies required for particular interventions, and so the individual practitioner should be guided by his or her own professional code of conduct with regard to this issue.” (p. 5)

As it was a specific charge given to the Working Group that their recommendations be based on “a systematic review of the literature” (p. 13), the overwhelming bulk of the Appendices document is devoted to Appendix 3, which is the “Evidence Report” commissioned by the ACPMH and undertaken by the Adelaide Health Technology Assessment group, University of Adelaide. Addressed are ASD and PTSD, people “exposed to trauma”, school based interventions, psychological interventions, psychopharmacology, exercise and physical therapies, combined interventions, comorbidities, and “child-specific questions”. Appendix 3 has also several potentially useful sub-appendices. Appendix 5 (p. 592ff) is a complete specification of the DSM-5 Diagnostic Criteria for PTSD.

Summary

This is clearly a serious effort to guide treatment practices. That it is NOT focused solely on a military population is significant, given that, contrary to general public perception, most people with traumatic stress disorders are civilians. The explicitness of recommendations provides well-focused guidance for professionals concerned with providing best-practices care. The extensive and thoroughly documented accounting of the literature review upon which the recommendations are based is a model of transparency well-articulated thoughtfulness.

I find this 2-year large-scale effort fully deserving of respect by both professionals and the general services-consuming population. A large number of contributors, specialists in their fields working closely with each other and with many check and balances, produced what is offered here. In all regards, this is a definitive statement of best-practices treatment for traumatic stress disorders (ASD and PTSD) at this point in time.

Note

1. I am assembling a fairly complete list of such guidelines, and expect to have it completed soon after this present review is published.

References

Australian Centre for Posttraumatic Mental Health. Acute Stress Disorder & Posttraumatic Stress Disorder in Children & Adolescents: A Practitioner’s Guide to Treatment. Melbourne, Victoria, Australia: ACPMH, 2013. (7 pp) [download: http://guidelines.acpmh.unimelb.edu.au/__data/assets/pdf_file/0011/851672/ACPMH_Child_Practitioner_Guide.pdf]

—. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder. Melbourne, Victoria, Australia: ACPMH, 2013a. (177 pp) [download: http://guidelines.acpmh.unimelb.edu.au/__data/assets/pdf_file/0008/851489/ACPMH_Full_ASD_PTSD_Guidelines.pdf]

—. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder – Appendices. Melbourne, Victoria, Australia: ACPMH, 2013b. (596 pp) [download: http://guidelines.acpmh.unimelb.edu.au/__data/assets/pdf_file/0010/851473/ACPMH_Full_Guidelines_Appendices.pdf]

—. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder: Guidelines Summary. Melbourne, Victoria, Australia: ACPMH, 2013c. (50 pp) [download: http://guidelines.acpmh.unimelb.edu.au/__data/assets/pdf_file/0011/851672/ACPMH_Child_Practitioner_Guide.pdf]

—. Australian Guidelines for the Treatment of Adults with Acute Stress Disorder & Posttraumatic Stress Disorder. Melbourne, Victoria, Australia: ACPMH, 2007.  Downloaded 2013.03.20 from http://www.acpmh.unimelb.edu.au/resources/resources-guidelines.html#1.

Advertisements

TraumaBlogEvery breath—a new beginning. And with every breath, we come home.

In this, my first post in this new blog, I want to tell you a little about how I got here, by way of introduction.

Over a period of some 15 years, I have found myself increasingly focused on trauma psychology and the psychotherapy of trauma. My professional life did not begin with that focus, but rather with a near total failure to recognize that the psychology of trauma—much less that of dissociation—mattered much. I will take responsibility for it, but I did have a lot of help in creating this failure of understanding.

Trauma process was anything but a focus of training in graduate school. We learned many useful things, but because there was so much to learn and so little time, we mostly opened doors and looked in; then rushed on. Even several years of internship, during graduate school and afterwards, barely informed me of what lay ahead.

Immediately after graduation, I began directing the admissions department of the major private psychiatric hospital in Portland, Oregon. In reality an internship of a different sort, it was indescribably valuable. I engaged with people in real trouble with their mental health. I can recall dealing with one person who had dissociative identity disorder (DID), and two or three who had posttraumatic stress disorder (PTSD). It was kind of exotic stuff, pretty much as I’d been led to believe in graduate school.

After two years of that I was ready for an increased clinical focus, and was hired to manage a branch office of a county mental health agency in eastern Washington State. As the senior clinician, I tended to get most of the really tough cases, and before long I realized that I simply didn’t know enough. A few of the people in my case load clearly qualified for PTSD diagnoses, while the majority appeared to have one flavor or another of depression, as well as various sorts of anxiety. Many of them were essentially chronic cases. Why couldn’t I do more with them? Why was I the only one bothered by my ineffectiveness?

Then I got my agency to pay for training in eye movement desensitization and processing (EMDR), a new approach to dealing with trauma, which we appeared to have a lot of in rural Washington. I learned a lot about PTSD in that training, came back to my case load to reassess every individual, and discovered that 85% of them had PTSD! I was stunned.

At that point I had a problem: I didn’t think I could share this revelation with my supervisor, because it was just too unexpected, too anomalous. As I began treating people with this new, trauma-focused approach, I saw immediate transformative results. They got better, and I got wiser.

Not only had I been clueless as to what was right under my nose, I had never been instructed in graduate school or by any of my clinical supervisors to routinely look much deeper than the symptoms and “the complaint” that my clients initially offered to me. That laissez-faire approach had clearly been failing my clients.

At this point, I finally confided in my supervisor. To my surprise, he accepted my finding of an 85 percent rate of PTSD in my case load. Why hadn’t he directed me to look for this, if he found my report to be unsurprising? It just wasn’t his focus. It wasn’t anyone’s focus. Still, it quickly became mine. It had to, as I had a fatal flaw: I actually wanted, above all else, to be effective with my clients.

I suggested to him that our entire agency needed to shift its service delivery model to this new orientation, get a lot more individuals trained in how to treat trauma disorders, and start insisting that virtually everyone get assessed for trauma-related disorders. He said that while it might be a good idea to do so, we had to give priority to a major paperwork-compliance problem we were working out with the state, which would take at least another eight months to resolve. We had new software to bring online, for one thing. Maybe we could address this over the next budget period, he proposed.

While that prospect might have worked for him, however, it certainly did not for me. I knew I was finished at the agency. Within 10 days or so, I gave my 30-day notice. I had to go where I could be far more responsive to the needs of my clients, and that meant private practice.

That was about 15 years ago. Since then, I’ve been learning, writing, and doing clinical work—all of which has increasingly been focused on trauma-related disorders. At the same time, my profession has also been continually learning, researching, writing, and working with such disorders. We now understand—those of us with this special focus—that merely having a relative who develops cancer can result in your acquiring PTSD. We understand that children can get a particularly challenging form of it (“complex PTSD”) merely from inadequate parenting. We understand that for the most part, dissociative identity disorder (DID) is advanced, severe PTSD with an early-childhood  onset.

What started out as a large fish has turned into a veritable whale. Is this a good thing? Well, it does have its critics, surely. However, little of what they say amounts to more than a protest about having to alter their basic paradigm for much of mental illness. When it turns out that much of substance abuse is connected to trauma in childhood; that one girl in 3–4 and one boy in 5–6 is sexually abused growing up; that while the mass media is fixated on soldiers with PTSD the reality is that, by more than 2 to 1, individuals with PTSD are neither male nor have any military background—how can this new paradigm be anything BUT a good thing? Solving the wrong problem is never helpful.

I now understand that what some of us know in my profession needs to be passed on more quickly to our peers. They need to understand that just as certain things in medicine (cancer, and obstetrics, for example) are clearly best dealt with by specialists, so it is with trauma disorders. They need to learn how to do better assessments, and then make appropriate referrals.

I also have found that misunderstandings about trauma are endemic in the general population, and that merely treating individual after individual in one’s office will not do much to address that problem. People aren’t getting treatment because they don’t know it’s possible, or they don’t know that their symptoms could well indicate a need for it. At a personal level, this is simply tragic, given the consequences of having to live year after year with PTSD or DID— consequences that touch not just the individual but their spouses, children, work associates, and friends.

So . . . what I want here is this: a chance to dialog with you about psychological trauma disorders, to pass on correct, current and useful information; to tell stories about people who been profoundly affected by trauma, and have found ways not just to manage their symptoms, but to recover from their disorder. I have some things to show you that you really should know about, if your life is touched by any of these disorders. What I want is simply a chance to say them.

One other thing. I’m here because the publisher of Mom Psych and I think essentially the same way about the critical importance of evidence-based psychology. Unless we resort to folkloric explanations and remedies, it’s all we have to push back the darkness. Fortunately, it’s a very powerful tool.

You deserve to know about all this. For the most part it’s good news, and it just keeps getting better. For many of you it will be life-changing information.