Written and Compiled by Ruwan M Jayatunge M.D. PhD (in progress)
In
matters of truth and justice, there is no difference between large and small
problems, for issues concerning the treatment of people are all the same., Albert Einstein
For treatment, procedures for PTSD in Sri Lanka medications and
psychotherapy are widely used. Some prefer to use indigenous treatment
measures.
The victims of PTSD have
psychological as well as physical (somatic) symptoms. Since there is no magic
bullet for PTSD, the treatment measures generally take fairly a long
time. Connecting with the patient is highly important and the therapeutic
relationship plays a vital role. Therapeutic relationships with the patients the often the foundation of effective treatment. Therefore, therapists
should maintain a good rapport with the
patients.
Phases of Treatment for PTSD
1)
Support
and stabilization
2)
Trauma
Education
3)
Stress
management
4)
Trauma
focus- confronting the memories
5)
Relapse
prevention
6)
Follow-up
and maintenance
Medication
Drug therapy is an essential
component of PTSD treatment. Serotonin Reuptake Inhibitors like fluoxetine
paroxetine are often used to combat depression and anxiety. These drugs provide symptomatic relief.
Sometimes Antipsychotics ( typical and atypical) are prescribed to
relieve severe anxiety, agitation, delusions, hallucinations, and disordered
thought. Drug therapy combined with psychological therapies gives effective
results.
Psychotherapy
According to Stedman's Medical
Dictionary psychotherapy psychotherapy
is a treatment of emotional, behavioral, personality, and psychiatric disorders
based primarily upon verbal or nonverbal communication with the patient, in
contrast to treatments utilizing chemical and physical measures. There are a
number of psychotherapies that can be used to treat PTSD.
Cognitive Behavior Therapy
CBT or Cognitive Behavior Therapy
is an approach that focuses on improving mood by modifying dysfunctional
thinking and behaviour. The goal of CBT is to guide the person's thoughts in a
more rational direction and help the person stop avoiding situations that once
caused anxiety. It teaches people to react differently to the situations that
trigger their anxiety symptoms. Therapy may include systematic desensitization
or real-life exposure to the fired situation.
CBT for PTSD typically begins with
an introduction to how thoughts affect emotions and behavior. Early treatment,
new skills to identify and clarify patterns of thinking are taught using
techniques such as recording thoughts about significant events, identifying
distressing trauma-related thoughts, and converting such dysfunctional thought
patterns into more accurate thoughts.
CBT generally
includes directly discussing the
traumatic event (exposure), anxiety management techniques such as relaxation
and assertiveness training, and correction of inaccurate or distorted trauma-related thoughts. CBT is often accompanied by psycho-education or education
about PTSD symptoms and their effects. CBT
helps victims restructure their thoughts and feelings. Through CBT the
victims can live without feeling
threatened.
Exposure Therapy
Exposure Therapy is one form of
cognitive behavior therapy unique to trauma. Treatment, which uses careful
repeated, detailed imaging of the trauma (exposure) in a safe controlled
context, to help the survivor face and gain, control of fear and distress that
was overwhelmed by the trauma. Intrusive thoughts, flashbacks, and avoidances are
best treated by exposure therapy.
Anger Management
Anger and rage are widespread
emotions in individuals experiencing combat trauma. Combat veterans experience
more anger and hostility than their civilian counterparts. Treatment of the anger
component is a necessary ingredient in trauma recuperation work. In anger
management combatants learn constructive ways to manage their anger.
Eye Movement Desensitization and
Reprocessing
(EMDR)
Eye Movement Desensitization and
Reprocessing (EMDR) is a non-drug, psychotherapy procedure. EMDR was discovered (in 1987) and developed
by Francine Shapiro, Ph.D. - Clinical Psychologist and a senior research fellow
at the Mental Research Institute in Palo Alto, California USA.
EMDR is one of the most researched methods of
psychotherapy used in the treatment of trauma. The Department of Veterans
Affairs Practice Guidelines has placed EMDR in the highest category,
recommended for all trauma populations at all times. In addition, the
International Society for Traumatic Stress Studies current treatment guidelines
have designated EMDR as an effective treatment for PTSD (Chemtob, Tolin, van
der Kolk & Pitman, 2000)
EMDR is a complex treatment
approach that combines salient elements of the major therapeutic schools such
as cognitive, behavioral, psychodynamic, and interactional. It is a specific
treatment approach, which helps a person quickly resolve the emotional aftermath
of traumatic experiences. EMDR is an information-processing therapy and uses an
eight-phase approach. EMDR is helpful in the treatment of PTSD (Posttraumatic
Stress Disorder), unresolved grief, phobias, sexual abuse, combat trauma,
depression, eating disorders, and substance abuse. It can also be used to enhance emotional
resources such as confidence and self-esteem. Recent studies lend empirical
support for the use of cognitive behavioral therapy (CBT) and EMDR in treating
combatants with PTSD. EMDR
Eye movement desensitization and
reprocessing (EMDR) has been reported
to dramatically increase efficiency in the treatment of traumatic memories
(Shapiro, 1989a, 1991a). In a controlled study, Shapiro (1989a) reported very
successful brief EMDR treatment of Vietnam veterans and rape victims suffering from PTSD, with gains maintained at a three-year follow-up (Shapiro, 1991a).
EMDR has been given the same status as CBT as an effective treatment for
ameliorating symptoms of both acute and chronic PTSD (APA 2004). In the practice guidelines of the
International Society for Traumatic Stress Studies EMDR was listed as an
efficacious treatment for PTSD.(FoaE.B Kene T.M & Friedman M.J 2000).
The expression of trauma may differ
from culture to culture. Every culture has its own way of dealing with
traumatic experiences. EMDR is considered to be an effective treatment for PTSD
despite cultural differences. A recent study on Sri Lankan combat veterans
diagnosed with combat-related PTSD showed significant improvements from pre- to
post-treatment following EMDR. (Jayatunge, 2008)
Client-Centered Therapy
Client-centered therapy or Rogerian
therapy is one of the effective talk therapies.
By retelling the traumatic event to a calm, empathic, compassionate, and
nonjudgmental therapist the client achieves a greater sense of self-esteem,
develops effective ways of thinking, and coping, and more successfully deals with
the intense emotions that emerge during therapy.
Carl Rogers emphasized that through client-centered therapy, the process of client self-discovery and actualization occurs in response to
the therapist supplying a consistent empathic understanding of the client’s
experience, based on the attitude of acceptance and
respect. Client-centered therapy is centered upon the expansion of
self-awareness, the enhancement of self-esteem, and greater self-reliance.
Rogers once stated that individuals have
within themselves vast resources for self-understanding and for altering their
self-concepts, basic attitudes, and self-directed behavior; these resources
can be tapped if a definable climate of facilitative psychological attitudes
can be provided.
Rogers' theory provides the conceptual underpinnings to the
client-centered and experiential ways of working with traumatized people.
Furthermore, Rogers' theory provides an understanding of post-traumatic growth processes and encourages therapists to adopt a more positive psychological perspective to
their understanding of how people adjust to traumatic events (Joseph, 2004).
However, in extreme trauma (in C PTSD) Client-Centered Therapy was found to be
not effective.
Trauma Focus Group Therapy
Trauma focus therapy groups are
typically smaller and more structured involving 5-10 patients. Group
composition is controlled in some treatment settings with patients grouped
according to the type of trauma they experienced. Traumatic memories are actively
re-engaged and patients openly discuss traumatic experiences with a co-facilitator. Group therapy deals with “isolation, alienation, and diminished
feelings Also it helps the survivor” feelings in participants. In group
settings, the combatants are able to discuss their pent-up feelings and able to
realize that they are not isolated and that others have similar experiences and
problems.
Rational Emotive Therapy
The American Psychologist Albert
Ellis comes to regard irrational beliefs and illogical thinking as the major
cause of most emotional disturbances. In his view, negative events do not by
themselves cause depression or anxiety. Rather emotional disorders result when
a person perceives the event in an irrational way. So despite the client's
irrational beliefs and long-lasting assumptions rational emotive behavior
therapists often use confrontation techniques. Most of the people suffering
from PTSD have unresolved grief, survival guilt, and irrational beliefs which
lead to depression and anxiety. Rational Emotive Therapy can be used to break
their illogical thinking pattern through friendly mediation.
Psychoanalytic Psychotherapy
Psychoanalytic or psychodynamic
psychotherapy draws on theories and practices of analytical psychology and
psychoanalysis. It is a therapeutic process that helps patients understand and
resolve their problems by increasing awareness of their inner world and its
influence over relationships both past and present. It differs from most other
therapies in aiming for deep-seated change in personality and emotional
development. (British Psychoanalytic Council)
Psychoanalytic Psychotherapy had
been used during the WW1. Some of Freud's patients like the soldier of Darden
Hill and the officer Norman White were successfully treated with
Psychoanalysis. Some of the Sri Lankan combatants who have developed dissociative
phenomena were treated with Psychoanalytic therapies.
Existential Therapy
Existential Therapy focuses on free
will, responsibility for choices, and the search for meaning and purpose through
suffering, love, and work. Existential psychotherapy deals with basic issues of
existence that may be present within a person. Existential Therapy avoids
restrictive models that categorize or label people. Instead, they look for the
universals that can be observed trans-culturally. Existential psychotherapy
aims at enabling clients to find constructive ways of coming to terms with the
challenges of everyday living.
(Reichenberg & Seligman ( 2010) point out that the creation of meaning and purpose is an attempt to
deal with the four existential concerns, of death, freedom, isolation, and meaninglessness.
The
Psychiatrist and the NAZI Holocaust survivor
Viktor Frankl expressed that death is a primary concern because it is inevitable and inescapable.
According to Frankl freedom is an
existential concern because insinuates that there is no master plan for the
universe; therefore, each person is, responsible for creating who he or she is
and what he or she does in life. Frankl developed Logotherapy that tries
to find for the patient the aim and meaning of his own life as a human being
and does not stress the medical aspect of mental health.
According
to Viktor Frankl Logotherapy stems from Existential Psychotherapy,
which espouses that humans are driven by the need to create meaning and
purpose in their lives. Logotherapy
uses three primary techniques Paradoxical Intention, Dereflection, and
Socratic Dialogue. Frankl believed that people can find meaning in
readjusting their attitudes and, perceptions of potentially adverse situations
into developmental opportunities. Psychological trauma could
cause transformation and growth potential by finding meaning and
defending against the primary existential concerns.
People with severe emotional
traumas are struck by the “Tragic Triad.” which consists of pain, guilt,
and suffering. Frankl suggests that people can deal with this triad
of existential, angst through changing their attitudes towards how they perceive and ultimately deal with them. Logotherapy helps PTSD
sufferers deal with survivor, guilt, depression, affect dysregulation, and an
altered worldview following trauma.
Family
and Marital Therapy
Many sufferers of PTSD have
disrupted family relations, Spouse abuse, cruelty to children and sexual
dysfunctions are evident among the affected personnel. Emotional numbing and
constricted affect associated with PTSD interfere with successful marital relationships
and parenting. In family and marital therapy, the therapist applies therapeutic
principles while engaging the participation of family members. Constructive
aspects of the family's relationships are reinforced, while destructive
elements are identified and altered. Family members are taught better
communication skills and ways of positive coping.
Cognitive
Processing Therapy
Cognitive Processing Therapy (CPT)
has been recognized as one of the effective methods that can be used to treat
PTSD. Cognitive processing therapy was developed by Dr Patricia Resick - a
renowned Psychologist in 1988 and she did a lot of single cases until its first
publication in 1992. Many studies have shown the efficacy of Cognitive
processing therapy.
Dr Resick defines (CPT) as a
manualized therapy that includes common elements from general
cognitive-behavioral treatments. It's developed with both cognitive therapy and
written trauma accounts.
CPT is an evidence-based
approach to combat psychological trauma.
CPT is recommended for clients with:, PTSD and comorbid diagnoses such as
depression and substance abuse. It is generally not recommended for clients with
active suicidal behavior, current Psychosis, or victims with severe
dissociation with loss of memory of the traumatic event.
This therapeutic mode is primarily
based on Social Cognitive Theory. When a traumatic event occurs it can
dramatically alter basic beliefs about the world, the self, and others. In
addition, 5 major dimensions that may be disrupted by traumatic events: safety,
trust, power and control, esteem, and intimacy. The CPT focuses on how trauma
survivors integrate traumatic events into their overall belief system through
assimilation or accommodation.
The CPT goals are to process
natural emotions (other than fear) in clients with PTSD, address the content of
the meaning derived from the traumatic memory., accommodation - accepting that
the traumatic event occurred, and discover ways to successfully integrate the
experience into one’s life.
Resick et al. (2002) indicate that
the therapy focuses initially on assimilated–distorted beliefs such as denial
and self-blame. Then the focus shifts to overgeneralized beliefs about oneself
and the world. Beliefs and assumptions held before the trauma are also
considered. Clients are taught to challenge their beliefs and assumptions,
through Socratic questioning and the use of daily worksheets.
Once dysfunctional beliefs are
deconstructed, more balanced self-statements, are generated and practiced. The
exposure component consists of having clients write detailed accounts of the
most traumatic incident(s) that they read to themselves and to the therapists.
Clients are encouraged to experience their emotions while writing and reading,
and the accounts are then used to determine "stuck points": areas of
conflicting beliefs, leaps of, logic, or blind assumptions.
Dr Resick hypothesizes that when
individuals are confronted with new information that is inconsistent with
preexisting schemas (i.e., stored bodies of knowledge), one of two processes
occurs: assimilation or accommodation. Accommodation is the modification of
existing schemas to incorporate new events and information. In trauma
survivors, these processes often involve the themes of agency, safety, trust,
power, esteem, and intimacy. Sobel et al.(2009) suggest that accommodation is
necessary to integrate a new event, traumatized individuals sometimes
over-accommodate trauma-relevant information. They noted that
over-accommodation occurs when schema changes are inaccurate and
over-generalized.
CPT is a highly structured protocol
in, which the client learns the skill of recognizing and challenging,
dysfunctional cognitions, first about the worst traumatic event and, then later
with regard to the meaning of the events for current, beliefs about self and
others.
Foreword
Treatment in Combat-Related PTSD
In war situations, the psychological
management of war casualties is highly important. Management of Combat Stress
is often a decisive factor in mental health well-being. Experts unanimously
agree that treatment of combat stress should begin as soon as possible. The
first organized military system for psychological treatment of combat fatigue
occurred during the Russo-Japanese War
(1904–1906) when physicians were put as close to the front as possible to
allow them to perform evaluations of traumatized soldiers. This “forward
treatment” recognized the value of caring for psychological casualties as
quickly and as close to the action as possible. The point was to keep the
traumatized GI near his unit, as it was observed that the farther from the
point of battle that a soldier traveled, the less successful doctors were in
getting him back in the fight.
CISD (Critical Incident Stress
Debriefing)
Debriefings take place on the
battlefield as soon as possible after the action. Colonel S.L.A. Marshall of
the US Army developed the method of conducting interviews with the surviving
members of small units in the field soon after the battles. Marshall regarded
this finding as one of his two most important contributions to the Army.
Several factors affect an individual's response to a critical incident. Advance
warning allows the person time to develop coping strategies. The more intimate
the person's role, involvement, and proximity to the event, the more potential
impact. The severity of the event and any loss are also contributing issues.
Currently, there is controversy regarding CISD. Some forms of debriefing may
actually make people worse (Mayou & Ehlers, 2006), while other types of
treatment have demonstrated good success in helping people get through trauma.
CyberTherapy
Cyber
therapy is a powerful medium that is effective in treating PTSD. Through Cyber therapy the traumatic
events can be simulated (under a controlled environment) for
desensitization purposes. Cpl. SXDX29 – a known PTSD patient who had an intense
fear of witnessing artillery attacks and had frequent nightmares and
intrusions. When he was shown simulated artillery attacks with
explosions and gunshot sounds in a safe environment he was able to observe it
with moderate distress. After that, he was encouraged to do relaxation
exercises. The second time, he
was able to watch the screen with a lesser amount of distress. Repeating this
cyber simulation several times over 2-4 weeks, reduced his fear and
distressful physiological reaction.
Every time Cpl. SXDX29 watched the simulation he was
encouraged and praised for his bravery by the therapist. While watching he was
encouraged to repeat (self-talk) " I am a soldier and
I have no fear" By the 4th week Cpl. SXDX29 reported that
his nightmares were lesser and he was able to sleep longer periods.
Art
Therapy
Art
therapy is an aesthetic way of achieving catharsis and giving psychological
tranquility to the patient. Artistic endeavors have also been a way for many trauma
survivors to express their feelings in a positive creative way. This can improve
the mood and minimize PTSD-related nightmares.
Josée Leclerc a prominent creative art therapist expresses
that art therapy can engage the
creative potential of individuals especially those suffering from PTSD. According to Josée Leclerc art therapy is a form of mind-body intervention that can influence
physiological and psychological symptoms. He further says that the experience
of expressing oneself creatively can reawaken positive emotions and address
symptoms of emotional numbing in individuals with PTSD.
Meditation
Meditation is a synchronized mind-body technique. It is a technique, defined as, 'the maintained focus of
attention on a single object, through which the mind is calmed and distracting
influences of other internal and external events are reduced. Meditation
enhances cognitive functions strengthening attention span. It helps to achieve optimal growth towards a state of total brain functioning. Mediation
augments the psycho-physiological functioning of the body and helps to achieve full
mental potential.
Relaxation training is one of the
major techniques proposed by the Psychotherapists to combat anxiety. Simple
relaxation or mindfulness breathing (Ananapanasathi Meditation) helps to reduce
anxiolytic feelings. Physiologically, breathing is important to the human body.
Breathing nourishes the body and its various organs with the supply of oxygen,
which is vital for survival. Oxygen is essential for the integrity of the
brain, nerves, glands, internal organs, and healthy skin. Breathing plays an
important role in cleansing the body of toxins and waste products. Hence
systematic and mindful breathing helps to gather more oxygen concentration
in the system and reduce anxiety.
Metta 'Meditation (Meditation
of 'loving-kindness ) projects a profound wish for the happiness
of others. It is a universal feeling without any self-interest or egoistic
feelings. The systematic practice of Metta 'Meditation helps to reduce deep-rooted
angry feelings, self-loathing, and the urge
to seek revenge.
Some
PTSD patients have morbid fear and fear of dying. Marananusmathi Meditation or
progressively and logically thinking about death ( the concept of death
and death as a universal phenomenon ) gives the client to move away from fixation and fear of dying. Marananusmathi Meditation helps the
client to understand the concept of impermanence and that suffering is not
permanent. This meditation is done under an instructor and needs
assessment before practicing and prolific training.
Generally, meditation
helps to have exceptional control over thoughts and facilitates to reduction of dysfunctional patterns of thought and perceptions that generate anxiety. In
addition, it gives a greater ability to manage negative emotions and helps to
gain a greater sense of stability.
Personal
communications
1)
Personal
communication with Dr. Patricia A. Resick- Women's Health Sciences Division of
the National Center for PTSD, VA Boston Healthcare System and Boston
University, Boston, MA.
2)
Personal
communication with Professor James
Alcock -Department of Psychology, Glendon College, York University. Canada
3) Personal communication
with Nancy Pingel: Program Instructor -
Psychosocial Rehabilitation Humber Lakeshore Campus Canada
4) Personal communication with Professor Daya Somasundaram
-University of Adelaide Australia
5) Personal communication
with Dr Mahasen De Silva - Board Certified Psychiatrist:
Colmary-O'Neil Veterans Affairs Medical Center Kansas USA.
6) Personal communication
with Professor Ari
Zaretsky MD FRCPC, Psychiatrist-in-Chief, Sunnybrook Health Sciences Centre,
Associate Professor, Department of Psychiatry, University of Toronto.
7) Personal communication
with Donna Sabella, M.Ed, MSN, Ph.D., RN, Assistant Academic Dean - Health
Sciences, The College of Global Studies, Arcadia University.
