Archive

PTSD treatment guidelines

TraumaRecoveryReviewPt2

 

Having looked at Babette Rothschild’s presentation of basic awareness, focus on present time and place, correct sequencing of recovery tasks (symptom management before all else), and flashback management, in part one of this two-part review, we now turn to the issues of shame, patience, physical activity, and constructive re-thinking. Each has unique challenges and rewards to offer. As before, my format here is both book review and a discussion of key concepts in the context of my own clinical experience.

5: Forgiving yourself and confronting your shame with the truth

I suspect this will be the toughest part of the book for many readers. However, it’s apparent to me that therapy is about non-avoidance, and good symptom management cannot happen without admitting to the symptoms. Shame is one of the central and toughest consequences and an ongoing symptoms of psychological trauma, especially of chronic trauma or neglect (which is likely more traumatizing than abuse, in the opinion of many therapists).

It has always been an odd fact, in my professional experience, that traumatized people take unusual degrees of responsibility for their trauma. Then they feel awful about themselves—shame. Trauma plus shame—that’s a true “double whammy” if there ever was one.

The false attribution of responsibility that people traumatized at any age will exhibit is a complex thing. Part of it is pure misunderstanding due to faulty thinking, and part is surely a desperate attempt to fight off the perception of a world gone mad by giving yourself some control in that world. For whatever reason it happens, it’s clear to me that such false attribution leads to toxic shame and guilt.

There is significant detail in this chapter that cannot be taken up here—essential neuropsychology, one of Rothschild’s special strengths. Basically, she asks that you acknowledge how your brain actually functions when threatened. Only some of what happens when we are threatened is a response to conscious thought at the time of the threat. The rest, the automatic part, cannot, by definition, be our fault—a new idea for many people. Yet, it is essential that we get real about our actual accountability at the time of our trauma. Why? Because our sense of accountability is intimately connected to our shame.

Shame is ubiquitous,  essential to mental health, toxic, and life-saving – complex, in a word. Her treatment of it is extended and worth serious investment. In many ways, this is the heart of the book— twice as long as any of several of the other sections. It’s a critically important subject, and I’m convinced that her thoughts and suggestions will more than reward your time.

6: Avoiding overwhelm by thinking small

This relatively brief section of the book focuses on possibly the simplest of her “key” ideas. It’s one I find myself emphasizing in clinical work over and over: the Great Wall of China was built stone by stone, and your recovery will be accomplished in a similar manner. Focusing less on the wall and more on the stone in front of you will be the most productive approach. Put even more simply—successful recovery work is about process more than objective. “Are we there yet?” You’ll know when you are, and it’ll happen because you just kept on walking, so I tend to stress that we focus on that next step.

Impatience for progress and for the accomplishment of healing is so very easy to understand. Who in their right mind wants to suffer one minute longer than necessary? Yet, we do well to recall the children we’ve seen who ran before they could walk, with predictable results!  Regrettably, there are external forces supporting the notion of a “quick fix”—from insurance companies who expect it all to happen in 6–12 sessions to Internet purveyors of all sorts of simplistic, folkloric, and simply wrong-headed “miracle” cures, invariably presented without a shred of legitimate treatment validation research.

“Over the years I have noticed that the vast majority of supervision and consultation problems presented to me are solved simply by reducing the size of the steps being attempted.” (p. 103) Amen to that! The problem, I’ve always thought, is that we tend to get overly goal-focused, and it just seems reasonable that large steps—speed—will get us there sooner.

Almost invariably, I see individuals in trauma therapy as unaware of two crucial facts about speed: (a) the wreckage that results from going too fact can be serious—in some cases enough emotional overwhelm emerges that they quit therapy (I have seen this happen), and (b) the recovery process does accelerate, but you have to pass through the slow part to get to the fast part. The single most important immediate goal is to be as successful as possible at your present work. Crawl. Walk. Then run. All of us with experience in this domain of human activity will tell you: THIS is the quickest way to complete your recovery.

7: Improving mental resilience by exercising your body

It’s a paradox: at times you need to be still and just watch what’s happening. I would urge that this will deepen your awareness, and teach you that feelings are never fatal and do not necessarily reflect your present reality. Other times, the best thing to do is to move—decisively. I know this as well I as know anything: nothing straightens out a twisted mind quite like an immediate physical urgency. Partly for the sheer humor of it, but mostly because it really drives this point home, I’ve offered at times to put a match to a client’s pants cuff or skirt hem. I have yet for a single person to say that this would not pull them out of whatever hole they’ve fallen into at the moment!

But, there’s a better way (for which we can be grateful)—exercise. Unprocessed trauma memory tends to paralyze people. They simply move less, and even freeze for periods of time, as Rothschild is quick to point out. Part of this has to do with depression, and part is simply a reaction to severe fear. Accompanying this is a loss of body awareness, and, of course, this promotes a sense of dissociation. None of this is healthy or helpful.

However, I have repeatedly found that exercise will NOT be what you want to do. Immobility will seem much preferable. This is a great example of how misled we can be by our feelings. I address this in therapy just as Rothschild does—by fostering a thoughtful dialog. Exercise is THE antidote to immobility, is it not? And becoming more fit will make your body simply feel better (although if you haven’t experienced this you may not initially make sense of this assertion). Rothschild assures us that it tends also to normalize hormones, especially stress hormones, and this reduces the damaging physical aspects of active trauma memory. That’s a lot of payoff for a brisk walk of moderate duration, three times a week.

Relaxed muscles offer wonderful (if temporary) relief from anxiety and stress, yet many victims of psychological trauma simply can’t go directly into relaxation, by any means. There’s another way, and it’s virtually a sure thing: work your muscles. Tired muscles will relax. I’ve promoted this—and seen it work—for years. There’s an additional, hidden benefit here: the act of purposeful exercise tends to shift one’s focus—away from those awful “home movies” you look at, and think about too often, to something quite plain and simple: just huffing up that hill in front of you, or trying to get around the block where your in less than, say, 8 minutes.

Rothschild discloses in this chapter a little about her own experience with posttraumatic stress disorder (PTSD), because getting herself moving turned out to be crucial to her recovery. She emphasizes two things – one must take small steps, with exercise, and the activity you choose needs to fit you. Exercise options are quite varied. I have found that most traumatized women much prefer to stay indoors—one can do that with inexpensive free weights, or yoga, or a treadmill, or by enrolling in a group exercise class. Men seem to prefer to venture outdoors: biking, brisk walking, jogging can work well for them. Weight training is an excellent choice for both. I’ve never had a client initiate exercise who failed to report benefit, both immediate and long term. What you do is up to you. That you do something physical is the essential objective.

8: Improving your mood and feelings by changing your thinking

In my work, I have seen that there is a time for weeping, and a time for thinking, and they usually come in that order. While you may not yet have come to the time for thinking, it will come. Here’s why: the world really is largely what we tell ourselves it is, and at some point in our healing we must pay attention to our thinking, and words we speak to ourselves. For some people, this is an idea so radical as to seem absurd. For those to whom it is NOT absurd, this final section of the book is invaluable. As might be expected, there is a lot of thoughtfulness here. It is also a kind of summing up, as it references a number of skills addressed in the previous chapters.

You think – my life is over. I’m ruined. I’ll never be the same. But if you think about it and realize that nothing is really stopping you from being helpful to others, from being valuable to the world, and if you do that then your life is certainly NOT over. That realization of the impossibility of being worthless and valuable at the same time—this could be a lifesaver, and it all starts with a simple thought.

You think – I don’t know how to get started. I have no idea what to DO. Rothschild suggests you use mindfulness (skill #1) to become aware of what you WANT to do. Realize that if you survived (skill #2) you surely can do something as modest as finding a way to be valuable. You can begin with a very modest activity—a small step (skill #6). For example, offering to help a senior in your neighborhood with grocery shopping, or by walking their dog, or helping someone with yard care (skill #7). If you have underutilized maternal or paternal impulses, consider befriending any of the “lost” kids that always are to be found scattered about our neighborhoods. Some may need tutoring. Some may just need a ball-tossing companion. Once you start looking, your problem well may be winnowing your options and not a lack of them!

Summary: The multiple values of this book

Rothschild’s writing is direct and conversational, and peppered with interesting stories, some of which are about her. She doesn’t minimize the challenges of living with active trauma memory, much less those of navigating therapy, nor does she offer quick fixes. She does however, offer realistic activities and practices—skills which many people do in fact acquire, and ones quite likely to improve one’s quality of life—whether or not one is dealing with the after-effects of psychological trauma.

While clearly directed to those dealing first hand with trauma recovery (and their non-professional family and friends), there is so much good sense in these pages that it is certain that therapists as well, whether trauma specialists or not, would surely enjoy and benefit from reading this well-focused, practical manual.

The book has several brief appendices of significant value. She offers slightly over 3 pages of distinctly sage advice to therapists, all of which I would strongly emphasize. Her comments for those in therapy about how to evaluate progress, and what to expect as their traumatized nervous system heals is outstanding, as are her suggestions about how to manage one’s therapy and therapist. Finally, there’s an excellent brief section addressed to those who are not or cannot be in therapy and are working on their healing by themselves.

So much helpfulness—all in 174 pages. A remarkable achievement!

Advertisements

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.