324 CHAPTER 7
associated with the trauma (Bryant & Harvey, 2000; Keane & Barlow, 2002). In this
case, the specifi c stimuli in an exposure hierarchy are those associated with the trauma.
As the individual becomes less aroused and fearful of these stimuli and avoids them
less, mastery and control increase. To help with anxiety and reduce arousal symptoms,
relaxation and breathing retraining are often included in treatment.Cognitive Methods: Psychoeducation and Cognitive Restructuring
To diminish the diffi cult emotions that occur with PTSD, educating patients about
the nature of their symptoms (psychoeducation) can be a fi rst step. As patients
learn about PTSD, they realize that their symptoms don’t arise totally out of the
blue; their experiences become more understandable and less frightening.
Cognitive methods can help patients understand the meaning of their trau-
matic experiences and the (mis)attributions they make about these experiences
and the aftermath (Duffy, Gillespie, & Clark, 2007, Foa et al., 1991, 1999),
such as “I deserved this happening to me because I should have walked down a
different street.”
Studies have examined whether CBT can help prevent acute stress disorder
from evolving into PTSD. In fact, numerous studies have shown that CBT can sig-
nifi cantly reduce the number of people who would have had their diagnosis change
from acute stress disorder to PTSD (Bryant et al., 2005, 2006, 2008).Targeting Social Factors: Safety, Support, and Family Education
Because the traumatic event is invariably a social stressor, the early focus of treat-
ment is to ensure that the traumatized person is as safe as possible (Baranowsky,
Gentry, & Schultz, 2005; Herman, 1992). For instance, in a case
that involves domestic abuse and an ensuing stress disorder, the
therapist and patient will spend time reviewing whether the woman
is safe from further abuse, and if not, how to make her as safe as
possible. For some types of traumatic events, such as combat-related
trauma, group therapy—of any theoretical orientation—can provide
support and diminish the sense of isolation, guilt, or shame about
the trauma or the symptoms of PTSD (Schnurr et al., 2003). More-
over, family or couples therapy can help to educate family members
and friends about PTSD and about ways in which they can support
their loved one (Goff & Smith, 2005; Sherman, Zanatti, & Jones,
2005). Preliminary research suggests that interpersonal therapy
(IPT; see Chapter 4), which focuses on relationship problems, may
be a helpful alternative treatment for those who are not interested in
CBT (Bleiberg & Markowitz, 2005).FEEDBACK LOOPS IN TREATMENT: Posttraumatic Stress Disorder
To appreciate the interactive nature of the neuropsychosocial approach, consider a
study that treated people who developed PTSD after being in traffi c accidents (as
driver, passenger, or pedestrian) (Taylor et al., 2001). Most participants in the study
had sustained injuries in the accident and had PTSD symptoms for over 2 years
prior to treatment, so spontaneous remission of symptoms was unlikely. Prior to
beginning the treatment, 15 of the 50 participants were taking an SSRI, a TCA, or a
benzodiazepine for symptoms. Treatment consisted of 12 weeks of group CBT that
involved: psychoeducation about traffi c accidents, their aftereffects, and PTSD; cog-
nitive restructuring focused on faulty thoughts (such as overrating the dangerous-
ness of road travel); relaxation training; and imaginal and in vivo exposure.
After treatment, participants reported that they had less hyperarousal; that is,
they experienced less autonomic reactivity, such as the startle response. In addition,
they avoided the trauma-inducing stimuli less often and had fewer intrusive reex-
periences of the trauma. These gains were maintained at the 3-month follow-up.
So, an intervention that targets both social factors (group therapy with exposure
to external trauma-related stimuli) and psychological factors (cognitive andRenzo Giraldo/El Comercio/AFP/Getty Images
Culture can help determine what kind of treatment
for PTSD is appropriate. These Peruvian villagers
were threatened by soldiers during a national
state of emergency declared in 2003. Earlier, a
study of Peruvians and Colombians exposed to
traumatic experiences found that those from
villages with a more individualist orientation felt
that individual treatment was more appropriate,
compared to those from more collectivist-
oriented villages (Elsass, 2001).P SN