Cognitive Therapy and Posttraumatic Stress
Steenbarger, Brett N., Journal of Cognitive Psychotherapy
Cognitive Therapy and Posttraumatic Stress Treating PTSD: Cognitive-Behavioral Strategies Foy, David W. New York: Guilford Press. 1992. (172 pp.)
Over the past decade, the construct of post-traumatic stress disorder (PTSD) has demonstrated increasing utility as a framework for understanding clinical phenomena. Findings that roughly 25% of all women have had experiences that meet the legal definition of rape (Koss, Gidycz, & Wisniewski, 1987) and sexual abuse (Finkelhor, Hotaling, Lewis, & Smith, 1984) have moved the notion of PTSD from a disorder limited to war veterans to a more general syndrome affecting victims of all violence.
David Foy's edited volume is an attempt to bring the diverse strands of PTSD treatment toghether by highlighting cognitive- behavioral applications to war veterans, battered women, survivors of sexual assault, and child victims of abuse. As David Barlow, the Guilford "Treatment Manuals for Practitioners" series editor, notes, "the goal is to provide therapists with a cross-trauma perspective on PTSD derived from treatment protocols in use at established centers."
Cognitive approaches to the treatment of PTSD tend to fall into one of two camps. A constructivist line of theorizing hypothesizes that traumatic incidents of violence shatter core schemata of safety and predictability, leaving victims with a fragmented sense of identity (Janoff-Bulman, 1985; McCann & Pearlman, 1990). Therapy, from this vantage point, must create an accepting, safe relationship context for the exploration of traumatic events and repair of damaged schemata. Cognitive-behavioral conceptualizations, alternatively, stress that PTSD symptoms are conditioned responses to traumatic stimuli, in which avoidance of trauma-related cues is central to the maintenance of distress (Jones & Barlow, 1990). Treatment, therefore, necessarily involves controlled exposure to threatening stimuli, as in flooding or desensitization, as a means of deconditioning.
Foy's volume is firmly rooted in the second perspective, offering a wealth of guidance regarding cognitive-behavioral assessment and treatment. In the initial chapter, Foy offers a conceptual model of PTSD in which symptoms are mediated by the severity of the stressor(s) and vulnerabilities of the individual. PTSD symptoms are hypothesized as the result of "an immediate conditioned emotional re-action" (p. 7) to overwhelming stressors. Accordingly, an assessment of PTSD must include an understanding of the nature and extent of the trauma as well as an account of the accompanying physical and psychological responses. As the author notes,
For many trauma survivors, avoidance of traumatic cues - external cues, as well as physiological or cognitive ones - becomes a guiding principle for maintaining psychological safety. Paradoxically, re-exposure and desensitization to traumatic cues or memories are vital if self-determination is to be regained (p. 10).
The remainder of the text can be thought of as clinical guides for operationalizing this model with a variety of populations. A worthwhile aspect of the volume is that its chapters assume a parallel organization, beginning with a description of PTSD in the relevant population and a theoretical statement that guides treatment planning and ending with guidelines for assessment and treatment. The literature cited is (within the text's orientation) comprehensive and current, offering useful references for those interested in researching particular assessment tools or outcome studies.
Chapters Two ("A Vet Center Experience: Multievent Trauma, Delayed Treatment Type"; R. Carl Sipprelle) and Three ("Assessment and Treatment of Combat-Related Post-Traumatic Stress Disorder in a Medical Center Setting," Edward M. Carroll and David W. Foy) cover the treatment of veterans in outpatient and inpatient settings respectively. Sipprelle divides the treatment process into three phases - crisis intervention, trauma, and integration - highlighting the goals of group therapy at each juncture. …