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Treating PTSD, Part Two

Natalie Staats Reiss, Ph.D. is a licensed Psychologist in the state of Ohio (License #6083). She received her Ph.D. in Clinical Psychology from ...Read More

Dr. Dombeck’s previous essay about the the "looming PTSD bubble" made a convincing argument that more research is URGENTLY necessary to help us understand how to effectively treat Post Traumatic Stress Disorder before a significant number of troops with this disorder come home from Iraq and Afganistan. I second his suggestion that we be as proactive as possible to address this potential crisis in the mental health field.

Along these lines, I was interested to read a new preliminary study published in the November issue of the American Journal of Psychiatry (Volume 164, Number 11, pages 1676-1683). This article suggests that an Internet-based form of cognitive behavioral therapy called "DE-STRESS" might be an effective and cost-efficient strategy that could help address this issue. This form of therapy combines highly effective exposure techniques (referred to in Dr. Dombeck’s article) and cognitive strategies for a "one-two punch" against the symptoms of PTSD.

The study involved a group of individuals who developed PTSD in response to the Pentagon attack on September 11, or being in combat in Iraq or Afganistan. Participants were randomly assigned to one of two groups. Group one (24 individuals) received the active treatment. First, participants learned the tools necessary for change via an in-person session with a psychotherapist. During this two-hour session, clients developed a graded hierarchy of stressful situations (i.e., situations that were more stressful were put at the top of the hierarchy and things that were less stressful were put at the bottom) and learned two different stress management techniques: diaphragmatic breathing (a practice of highly controlled, deep, slow, and rhythmic breathing) and progressive muscle relaxation (a practice of tensing and releasing subsequent muscle groups to decrease tension). They were also taught cognitive reframing techniques (how to monitor, challenge, and restate unhelpful thoughts that perpetuate their feelings of anxiety and stress).

The active therapy group then moved to an Internet-based, self-help module. During the first two weeks of the self-treatment mode, participants completed a series of homework assignments. These assignments involved monitoring trauma-related situations that caused distress. Then, the therapist (via e-mail) helped them generate a final stress-related hierarchy. During week 3, clients were instructed to confront the situations on their hierarchy (the exposure component) while using their relaxation techniques. During week 7, participants had to complete 7 on-line trauma writing sessions (writing and re-writing detailed, first person, present-tense accounts of a troubling traumatic experience). The last week included a review of progress, education regarding relapse prevention techniques, and creating an individualized plan for future challenges. Throughout all weeks of therapy, members of group one received therapist contact via e-mail and phone calls.

Group two received supportive therapy (21 individuals). This group also received an initial two-hour meeting with a therapist, who discussed PTSD causes and symptoms, and stress management techniques. Participants in this group were instructed to read educational materials about PTSD and related conditions (such as depression and sleep problems), monitor feelings/moods, and write about non-trauma related concerns and hassles. Group two also received the same amount of email and phone contacts with their therapist as group one. During week 8, group two members planned ways to use the information that they learned to move forward.

Both groups had unlimited access to a special website with specific educational information about PTSD, stress and trauma, co-occurring conditions (e.g., depression, survivor guilt), anger management, and promoting good sleep habits.

The majority of participants in group one experienced decreased PTSD symptom severity, and saw specific gains in decreasing the avoidance of feared situations, as well as decreased hyperarousal (a constant state of being anxious and "hyped-up" and continually scanning the environment for danger). In addition, depression ratings also decreased. 1/3 of group one maintained treatment gains across 6 months.

Obviously, this was a rather small study, so I am not suggesting that this type of therapy is THE solution to treating PTSD. I know from my clinical experience that not all people would be able to stick with a self-directed therapy approach. Others might find the lack of ongoing interpersonal interaction with their therapist a huge negative. However, I find the idea of combining individual psychotherapy sessions and on-line self-help strategies intriguing for several reasons. First, it’s cost effective, and can be used to target large groups of vets (or other individuals suffering from this disorder). Two, it can help to combat and decrease stigma, because the sessions (except for the initial meeting) can be conducted in the privacy of the client’s home. Next, this format can circumvent the problems with having individuals with PTSD rely solely on self-help strategies. PTSD is usually a severe and complicating condition, and most people require contact with a trained mental health expert in order to obtain symptoms relief. Finally, this mode of treatment may be appealing for the convenience factor. Clients do not have to worry about making appointments, arranging transportation, and so on- they can log on at convenient times.

I look forward to reading about expanded trials of the DE-STRESS approach.





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