Michael W. Otto, Ph.D.
Dr. Otto advocated a stepped approach to treatment: Everyone who experiences trauma should initially be given information about the symptoms to expect and the availability of effective treatment. Individuals who experience Acute Stress Disorder or PTSD and request treatment should be offered exposure-based CBT. Mandatory counseling and single session debriefing for those who have experienced trauma should be avoided since they have not been shown to be effective, and may increase the likelihood of PTSD.
At the beginning of treatment, therapists should give patients an explanation for the arousal, avoidance, and re-experiencing symptoms that characterize PTSD. The cornerstone of CBT for PTSD is exposure to traumatic thoughts and feelings. Exposure enables patients to discriminate anxiety-laden memories of the trauma from appropriate assessments of the present. It also helps patients convert disorganized memory fragments into a coherent understanding.
When patients are extremely frightened and avoidant, exposure should be limited to less stressful components of the memory. Dr. Otto compared treatment to comforting a frightened child; he said treatment should alternate between evoking negative affect and teaching emotional regulation skills. Re-sensitization or dissociation can occur if patients are overwhelmed by too much negative emotion during exposure. Before patients leave their session, therapists should therefore allow sufficient time for patients to calm down and become re-oriented.
It is important for therapists to predict that patients will want to drop out of treatment and work with patients to develop a strategy for coping with these urges to terminate.
Interoceptive exposure exercises like those Barlow developed for panic can be used to reduce patients’ fear of their own anxiety symptoms. During these exercises patients should be taught to make self-statements such as “that was then, this is now” to discriminate present safety from past danger.
Patients should also evoke trauma-related affect between therapy sessions. Some techniques for additional exposure include: writing assignments, in vivo exposure to avoided situations, listening to taped descriptions of the trauma, and discussing the trauma with family members or friends. Writing exercises can be repeated weekly, with each essay organized around a trauma-related theme such as safety, trust, self-esteem, intimacy, or power and control.
Cognitive restructuring should be added to exposure treatment to counter beliefs such as “it was my fault,” “life is dangerous,” and “good girls don’t get raped.”
Meta-analysis of 10 exposure-based studies produced an effect size of 0.96 compared to an effect size of only 0.41 for 7 studies of drug treatment. Medication seems to interfere with the success of CBT for PTSD. If patients take medication during treatment, use CBT techniques more vigorously as the medication is gradually withdrawn. Never terminate treatment while a patient remains on medication.
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