Evidence-Based Reviews

Counseling trauma victims: 4 brief therapies meet the test

Current Psychiatry. 2005 August;4(8):50-63

References

1. Rothbaum BO, Meadows EA, Resick PA, Foy DW. Cognitive-behavioral therapy. In: Foa E, Keane T, Friedman M (eds). Effective treatments for PTSD. New York: Guilford Press; 2000.

2. Kilpatrick D, Edmonds CN, Seymour AK. Rape in America: A report to the nation. Arlington, VA: National Victims Center; 1992.

3. Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War generation: report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel; 1990.

4. Pfefferbaum B. Posttraumatic stress disorder in children: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1997;36(11):1503-11.

5. Deblinger E, McLeer SV, Henry D. Cognitive behavioral treatment for sexually abused children suffering post-traumatic stress. J Am Acad Child Adolesc Psychiatry 1990;5:747-52.

6. Najavits LM. Seeking Safety: a treatment manual for PTSD and substance abuse. New York: Guilford Press; 2002.

7. Resick PA, Nishith P, Weaver TL, et al. A comparison of cognitive processing therapy, prolonged exposure and a waiting condition for the treatment of posttraumatic stress disorder in female rape victims. J Consult Clin Psychol 2002;70:867-79.

8. Foa EB, Keane TM. Friedman MJ (eds). Effective treatments for PTSD. New York: Guilford Press; 2000.

9. Tarrier N, Sommerfield C. Treatment of chronic PTSD by cognitive therapy and exposure: 5-year follow-up. Behavior Ther 2004;35(2):231-46.

10. Foa EB, Rauch SA. Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring in female assault survivors with posttraumatic stress disorder. J Consult Clin Psychol 2004;72(5):879-84.

11. Foa EB, Riggs DS, Massie ED, Yarczower M. The impact of fear activation and anger on the efficacy of exposure treatment for PTSD. Behav Ther 1995;26:487-99.

12. Foa EB, Rothbaum EO, Riggs D, Murdock T. Treatment of PTSD in rape victims: a comparison between cognitive-behavioral procedures and counseling. J Consult Clin Psychol 1991;59:715-23.

13. Foa EB, Dancu CV, Hembree EA, Jaycox LH, et al. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. J Consult Clin Psychol 1999;67:194-200.

14. McDonagh A, Friedman M, McHugo G, et al. Randomized trial of cognitive-behavioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse. J Consult Clin Psychol 2005;73:515-24.

15. Chard K. An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. J Consult Clin Psychol. (in press).

16. Shapiro F. Eye movement desensitization and reprocessing: basic principles, protocols and procedures (2nd ed). New York: Guilford Press; 2001.

17. Chemtob CM, Tolin DF, van der Kolk BA, Pitman RK. Eye movement desensitization and reprocessing. In: Foa E, Keane T, Friedman M (eds). Effective treatments for PTSD. New York: Guilford Press; 2000.

18. Meichenbaum D. Cognitive-behavior modification: An integrative approach. New York: Plenum Press; 1977.

EMDR is often conducted in 12 to 15 sessions, although some studies report positive changes after 3 to 6 sessions. After obtaining a patient history, establishing rapport, and explaining the treatment, the therapist asks the patient to identify:

visual images of the trauma
his or her affective and physiologic responses to the trauma
negative self-representations the trauma created
positive, alternate self-representations.

The therapist then asks the patient to focus on an image most proximal to the trauma and associated affective and biological reactions. While the patient is thinking, the therapist introduces the distraction stimulation. After a set number of stimulations—such as 20 bilateral eye movements—the therapist asks the patient to “let go” of the memory and discusses any new reactions to the trauma. As patients become less distressed in response to the trauma, they are asked to focus increasingly on alternate positive cognitions while they imagine the trauma.

EMDR has been effective in treating male war veterans, rape victims, and other trauma groups.¹⁷ Initial dismantling studies suggest that eye movements (or other distracting cues) might not be essential for trauma reprocessing, calling into question the mechanisms thought to create change in EMDR. Studies with larger samples comparing EMDR with other CBT models are needed to assess EMDR’s efficacy for trauma survivors.¹⁷

Stress inoculation training

SIT was designed by Meichenbaum¹⁸ (Table 3) to treat anxiety and stress and was adapted for use with trauma survivors. It appears most effective in relieving fear, anxiety, and depressive symptoms associated with traumatic experiences. SIT includes education, muscle relaxation training, breathing retraining, covert modeling, role-playing, guided self-dialog, and thought stopping. Therapists often teach these skills to patients in modules that build on each other.

For example, a patient might receive relaxation training while role-playing a difficult scenario she may face in the future. This helps her learn to remain calm in anxiety-provoking situations.

Unlike PE, SIT does not directly ask patients to recount their traumatic memories, although exposure may be indirect (such as during role-playing exercises). Its purpose is to give patients new skills to manage their anxiety, which in turn decreases PTSD symptoms.

Studies suggest that PE is more effective than SIT alone or SIT/PE combined.¹³ Thus, instead of using SIT as a trauma-focused treatment, some therapists find it useful to help patients gain coping skills before beginning other trauma treatments.

Table 3

Where to learn more about cognitive therapies for PTSD

CBT model	PTSD related to…	Resources
Prolonged exposure	Combat experience, sexual assault, childhood abuse, motor vehicle accidents	Foa EB, Rothbaum BO. Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York: Guilford Press; 1998
Cognitive processing	Sexual assault, childhood abuse, incarceration (of adolescents)	Resick P, Schnicke M. Cognitive processing therapy for rape victims: a treatment manual. Newbury Park, CA: Sage Publications; 1996
EMDR	Combat experience, sexual assault, civilian disasters (for children or adults)	Shapiro F. Eye movement desensitization and reprocessing: basic principles, protocols, and procedures (2nd ed). New York: Guilford Press; 2001
EMDR		EMDR Institute, Inc. Available at: http://www.emdr.com
Stress inoculation training	Sexual and physical assault, motor vehicle accidents	Meichenbaum D. Stress inoculation training for coping with stressors. Available at: http://www.apa.org/divisions/div12/rev_est/sit_stress.html
EMDR: Eye movement desensitization and reprocessing

Related resources

International Society for Traumatic Stress Studies. www.istss.org.
Foa EB, Keane TM, Friedman MJ. Effective treatments for PTSD. New York: Guilford Press; 2000.

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.