Dr. Truong Addresses 90 NJ-ACT Members on Domestic Violence PTSD

By Lynn Mollick

Many effective treatments for PTSD in children and adults exist. Some, but not all, are highly structured. There are options for individual and group treatment. The American Psychological Association and the Veterans Administration have published guidelines evaluating the best treatments for PTSD.

Treatments with strong empirical support include:
Prolonged Exposure (PE)
Cognitive Reprocessing Therapy (CPT)
Eye Movement Desensitization & Reprocessing (EMDR)

Treatments with modest or sufficient evidence of efficacy include:
Trauma-focused applications of Cognitive Therapy
Stress Inoculation Therapy
Written Narrative Exposure

Treatments with insufficient evidence to support their use include:
Dialectical Behavior Therapy
Acceptance and Commitment Therapy

Treatments that are harmful include:
Psychological De-briefing (according to APA)
Hypnosis (Dr. Truong asserted it may create false memories)

When patients are unwilling to experience trauma-related emotions, medication may be indicated. Three SSRIs and one SNRI have been demonstrated to be effective. Antipsychotics, benzodiazepines, ketamine, D-cycloserine, and cannabinoids have not.

Dr. Truong described Prolonged Exposure, Cognitive Processing Therapy, and Trauma-Focused CBT in detail. Since so many treatments for PTSD are effective, she advised letting patients choose which to pursue. But when patients exhibit guilt, she prefers CPT, and when they do not have strong literacy skills, she advises PE.

Prolonged Exposure (PE)

Developed by Dr. Edna Foa, PE is administered in 90- or 60-minute sessions twice a week or in massed sessions 5 times per week. Initial sessions focus on:
1) Psychoeducation about trauma, reactions to trauma, PTSD, and the rationale for PE
2) Building a trauma-focused hierarchy
3) In vivo exposure to avoided situations (as long as they are actually safe.)

Later sessions focus on imaginal exposure to the traumatic memory. During imaginal exposure, the patient tells the “story” of their trauma from beginning to end. At first the therapist simply listens, but as sessions pass and the patient re-tells the story, the therapist begins to ask questions that elicit details about the trauma and the patient’s thoughts, feelings, sensations, and behaviors. For example, “What did the perpetrator look like?”

At therapy’s mid-point, the therapist begins to address “hot spots,” the parts of the story that the patient avoids, by focusing on them and asking detailed questions. When patients are very avoidant, the therapist may simply ask the patient to repeat an upsetting word associated with the trauma over and over, to desensitize the patient.

PE sessions should elicit strong emotions. When patients do not experience emotions, they are avoiding and the therapist tells them to close their eyes, speak slowly, and describe the traumatic incident in detail. The therapist always asks for specific details, especially about smells and other sensations.

When patients can’t tell their story because they dissociate or are too emotional, the therapist asks them to open their eyes, to stand or walk as they relate their story, and to focus on the present with statements such as: Where are we now? You are safe. This is now, that was then.

All PE sessions end with a discussion of what the patient learned.

(Additional information about PE and Edna Foa’s 2014 NJ-ACT Master Lecture are available here.)

Trauma-Focused CBT (TF-CBT)

TF-CBT is a highly flexible treatment for children, adolescents, and their non-offending caregivers. It can be used for ongoing trauma as well as for trauma that occurred in the past. TF-CBT techniques comprise the acronym: PRACTICE.

P = Psychoeducation and parenting skills.
R = Relaxation – Dr. Truong recommended belly breathing.
A = Affect regulation
C = Cognitive coping
T = Trauma narration and processing.
I = In vivo mastery of trauma reminders
C = Conjoint parent-child sessions
E = Enhancing feelings of safety

Children and adults benefit from information that describes the perpetrator’s behavior as disturbed. Asking “what’s the difference between the perpetrator and an ordinary person?” diminishes self-blame. Caregivers have often been trauma victims themselves and may require special assistance in helping children feel safe. Cognitive techniques and developing a narrative of the event help children and adults differentiate past danger and present safety.

Additional information about TF-CBT is available here.

Cognitive Processing Therapy (CPT)

Patricia Resick developed CPT, a highly structured treatment that addresses trauma-related thinking, but does not require direct confrontation with traumatic events. In CPT, distorted thinking is called a “stuck point.”

Early CPT sessions focus on modifying self-blame and the “just world myth.” The “just world myth” posits that in life, everyone gets what they deserve and everything happens for a reason. Therapists should use Socratic questioning, not disputation, to guide patients to new conclusions about the world and diminish self-blame.

Later CPT sessions attempt to restructure dysfunctional cognitions about safety, power and control, trust, intimacy, self-esteem and esteem for others.

Throughout her presentation, Dr. Truong emphasized the importance of therapists communicating that trauma-related thoughts are not dangerous. Patients will try to avoid talking about trauma and doing homework; therapists must encourage them to remain on-topic.

Dr. Truong also spoke about therapists’ thinking “this patient is not ready for trauma-focused treatment.” Research and clinical examples demonstrate that trauma-focused treatment is appropriate for almost every patient. Bipolar patients in the manic phase are one exception. Substance abusers who are actively abusing drugs can be treated with the “Seeking Safety” program, which has strong empirical support.

Conclusion

Dr. Truong reported that trauma-focused treatment works for every kind of trauma, including domestic violence, aka Intimate Partner Violence (IPV). IPV develops gradually in relationships which may cause professionals to blame victims for their predicaments, a mistake that mental health professionals should take care to avoid.

Domestic violence occurs across cultures. Worldwide, 30% of women over 15 have experienced domestic violence. This figure is an underestimate since it does not include children or men. Because trauma victims often do not talk about trauma they’ve experienced, Dr. Truong recommended assessing all patients for domestic violence as part of assessment. Dr. Truong also emphasized inquiring about past traumas. Many PTSD patients present with one trauma, but have actually experienced multiple traumas. Often these earlier traumas play a role in maintaining the patient’s distress.