NC-PTSD Clinical Quarterly Volume 8 (3) Summer 1999

40

Continued on page 42

Summer 1999, Volume 8, Issue 3, ISSN-1052-7168

Over the past decade, an emerging body of work has documented a

very strong association between PTSD

and substance abuse. Indeed, most

women and many men in substance

abuse treatment have a history of

trauma, and rates of current PTSD

range from 12% to 59% (1-4). Among

people with PTSD, rates of substance

abuse are also high (5-7). Moreover,

the disorders have consistently been

found to co-occur across various types

of traumas (8) and substances (9).

Historically, the connection between

PTSD and substance abuse was first emphasized in VA settings with

male combat veterans after the Vietnam War (8). Later, studies of

civilian populations documented high rates, particularly among females

who endured childhood physical and/or sexual abuse (2).

Aside from numbers, the suffering associated with this dual diagnosis is extraordinary, with multiple co-existing life problems, vulnerability to repeated trauma, and difficulties in treatment. Studies that

have compared patients with PTSD and substance abuse to patients

with substance abuse alone, for example, have consistently found the

former more impaired, including more co-morbid Axis I disorders,

particularly mood and anxiety disorders, Axis II disorders, medical problems, psychological symptoms, inpatient admissions, and interpersonal

problems; and lower global level of functioning, compliance with aftercare, and motivation for treatment (1, 9-12). Life problems are often

very severe, including homelessness, HIV, domestic violence, and loss

of custody of ones children (2, 3).

In 1993, I began developing a cognitive-behavioral therapy to address this dual diagnosis under a grant from the NIDA Behavioral

Therapies Development Program. At that point, there had not been a

single published treatment study on this population, nor any psychosocial treatment that had undergone empirical evaluation. Through

repeated trial-and-error, the treatment Seeking Safety (13, 14) was developed while simultaneously testing its impact on a pilot sample of

Seeking Safety:A New Cognitive-Behavioral Therapy

 for PTSD and Substance Abuse

LISA M. NAJAVITS, PH.D.

women with PTSD and substance dependence. In developing the treatment, the major influences on my thinking were works by Herman

(15), Marlatt and Gordon (16), Beck and colleagues (17), Miller (18),

Frankl (19), as well as educational research (20).

The treatment is currently being empirically evaluated in samples

from six populations: a Palo Alto VA sample of male combat veterans;

homeless women; inner-city cocaine-addicted women; adolescent females; incarcerated women; and outpatient women. A description of

the treatment, its initial empirical results, and an in-depth example of

one session follow.

The title of the treatment...

 Seeking Safety expresses its

philosophy: when a person has both

active substance abuse and PTSD,

the most urgent clinical need is to

establish safety.

TREATMENT OVERVIEW

Summary of the treatment. Seeking Safety is a 25-session

treatment based on five key principles.

(I) Safety as the priority of this first stage treatment.

The title of the treatment, Seeking Safety, expresses its

basic philosophy. That is, when a person has both active substance abuse and PTSD, the most urgent clinical need is to

establish safety. Safety is an umbrella term that signifies various elements: discontinuing substance use, reducing suicidality,

minimizing exposure to HIV risk, letting go of dangerous

relationships (such as domestic abuse and drug using

friends), gaining control over extreme symptoms such as

dissociation, and stopping self-harm behaviors such as

cutting . Many of these are self-destructive behaviors that re-

 Lisa M. Najavits, Ph.D.

Women and Trauma: A Clinical Forum 50

Transcend: PTSD & Substance Abuse Treatment 51

NC-PTSD Education & Support Services 55

Seeking Safety: CBT for PTSD & Substance Abuse 40

Differentiating Malingering from PTSD 46

New Directions 49

INSIDE THIS ISSUE
Volume 8 (3) Summer 1999

41

NC-PTSD Clinical Quarterly

NATIONAL CENTER FOR PTSD

Executive Director

Matthew J. Friedman, M.D., Ph.D.

VAMC/ROC White River Junction

Vermont 05009

Education and Clinical Laboratory Division

Fred Gusman, M.S.W., Director

VAMC, Palo Alto, California 94304

Pacific Islands Division

Sarah Miyahira, Ph.D., Acting Director

Honolulu, Hawaii 96813

Behavioral Science Division

Terence Keane, Ph.D., Director

VAMC, Boston, Massachusetts 02130

Womens Health Science Division

Jessica Wolfe, Ph.D., Director

VAMC, Boston, Massachusetts 02130

Editor

Managing Editor

Executive Editor

Associate Editors

Assistant Editor

Graphic Layout

Clinical Quarterly Staff

Please feel free to contact us at the Education Division: FTS 463-2673/2494; commercial number 650-493-5000 ext. 22673/22494; or E-mail: bhh @ icon.palo-alto.med.va.gov

Please address all correspondence to : Editor, National Center for PTSD Clinical Quarterly, VA Palo Alto Health Care System, 795 Willow Rd (352E117), Menlo Park, CA 94025

FROM THE EDITOR...

Neuroscience Division

Dennis Charney, M.D., Director

VAMC, West Haven, Connecticut 06516

Northeast Program Evaluation Center

Robert Rosenheck, M.D., Director

VAMC, West Haven, Connecticut 06516

Bruce H. Young, L.C.S.W.

Josef I. Ruzek, Ph.D.

Fred D. Gusman, M.S.W.

Eve B. Carlson, Ph.D.

Gregory A. Leskin, Ph.D.

John Aboytes, B.A.

Gregory A. Leskin & Bruce H. Young

 Bruce H. Young, Editor

The 1988 National Vietnam Veterans Readjustment Study (1)

reported that almost 75% of male veterans with PTSD had a lifetime

alcohol abuse/dependence disorder. A more recent study (2) reported

that 44% of veterans seeking outpatient treatment met met the criteria for

alcohol abuse/dependence. Dually diagnosed veterans are plagued by

numerous problems. They are less likely to be employed, less likely to be

married, are more socially isolated, more prone to violence, and, not

surprisingly, report low levels of overall physical and mental well-being.

Six years ago, it wasnt uncommon to hear the question, which

disorder do we treat first, PTSD or Alcohol Abuse? however, there are

now programs in development to treat PTSD/Alcohol Abuse comorbidity concurrently, that is, to address the interactive factors between

the two disorders. Several scientist-practitioners have begun to report

preliminary data on PTSD and alcohol comorbidity treatment efficacy. Lisa

Najavits and her colleagues have developed a manualized treatment and

are evaluating their 25 session program in six populations, including male

combat veterans, homeless women, cocaine-addicted women, adolescent

females,incarcerated women, and women in outpatient treatment. Beverly

Donovan and Edgardo Padin-Rivera have developed a 12-week

treatment program to addressPTSD and substance abuse. Preliminary

data suggest that both programs offer promising systematic and

comprehensive treatment. We are very pleased to have these leading experts

report this important work in this issue of the Clinical Quarterly.

Malingering occurs when an individual intentionally

produces false psychological symptoms. In a litigious society such as

ours, it is likely at some point in clinical practice to provide treatment

to a client who is also a claimant or to be called upon to conduct a

forensic evaluation. From either a clinical or legal perspective,

differentiating faked from actual symptoms can be difficult for even

the most astute clinicians. In Guidelines for Differentiating Malingering

from PTSD, Judith Armstrong and James High draw upon their

extensive clincial and forensic experience to delineate common

misconceptions about malingerers and key strategies to minimize the

possibility of deception.

Articles from back issues continue to be posted on our website

www.dartmouth.edu/dms/ptsd/ Your comments about the Clinical

Quarterly are appreciated and suggestions for future topics are always

welcomed.

References

1. Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Hough, R.L., Jordan,

B.K., Marmar, C.R. and Weiss, D.S. (1988). National Vietnam veterans readjustment study: Contractual report of findings, (pp. VI33). North Carolina: Research Triangle Institute.

2. Fontana, A., Rosenheck, R., Spencer, H., and Gray, S. (1995). The

long journey home IV: The fourth progress report on Department

of Veterans Affairs specialized PTSD programs. Department of

Veterans Affairs, Northeast Program Evaluation Center, West

Haven, CT.
NC-PTSD Clinical Quarterly Volume 8 (3) Summer 1999

42

enact trauma (particularly for victims of childhood abuse, who

represent a large segment of people with this dual diagnosis

(2)). The concept of first-stage treatment as stabilization and

safety has been consistently recommended separately in both

the PTSD (15) and substance abuse clinical literatures (21).

Later stages of treatment include mourning (a.k.a. exposure

therapy (22)) and reconnection (15). In Seeking Safety, safety is

taught through a wide range of Safe Coping Skills, asking

patients to become conscious of their decisions via a Safe Coping Sheet, setting a Safety Plan, and a report of unsafe behaviors at each session, for example.

II. Integrated treatment of PTSD and substance abuse.

Seeking Safety is designed to treat PTSD and substance

abuse at the same time. An integrated model is consistently

recommended by clinicians and researchers as more likely to

succeed, more sensitive to patient needs, and more cost-effective (9, 10, 12, 23-25). Indeed, a recent survey of patients with

this dual diagnosis found that they also prefer simultaneous

treatment of both disorders (26). Currently many treatment

systems for substance abuse and mental health remain separate,

which often leaves the patient to integrate treatment for themselves. One of my patients reported that she had to lie to get

into a PTSD treatment program because it did not admit active

substance abusers. Indeed, most settings do not treat the two

disorders simultaneously (23, 24).

It is important to note, however, that integration in

Seeking Safety means attention to both disorders in the present.

It does not mean asking the patient to talk in detail about the

past, which in the stage conceptualization described above, would

be second stage treatment. Despite the known efficacy of

exposure therapy for PTSD (27), numerous experts have recommended that for substance abusers, such work not begin

until they have achieved a period of stable abstinence and functionality (25, 28, 29). The concern is that if patients are overwhelmed by painful feelings about the past, this could trigger

substance abuse as a misguided attempt to cope. In Seeking

Safety, integrated treatment thus means helping patients learn

about the two disorders and why they so frequently co-occur;

teaching safe coping skills to decrease current symptoms of

both PTSD and substance abuse; repeatedly exploring the relationship between the two disorders in the present (e.g., using

crack last week to cope with PTSD flashbacks); and helping

patients understand that healing from each disorder requires

attention to both disorders.

III. A focus on ideals.

It is difficult to imagine two mental disorders that each

individually, and especially in combination, lead to such demoralization and loss of ideals. Thus, this treatment seeks to instill

countervailing humanistic themes to restore patients feelings

of potential for a better future. The title of each session is

framed as a positive ideal, one that is the opposite of some

pathological characteristic of PTSD and substance abuse. Thus,

for example, the session Honesty combats denial, lying, and the

false self . The session Commitment is the opposite of irresponsibility and impulsivity. The session Taking Good Care of

Yourself is a solution for the bodily self-neglect of PTSD and

substance abuse. The language throughout the treatment emphasizes values such as respect, care, integration, and

healing. By aiming for what can be, the hope is that patients

can summon the motivation for the incredibly hard work of

recovery from both disorders.

IV. Four content areas: cognitive, behavioral, interpersonal, and case management.

While originally designed as a cognitive-behavioral intervention (a theoretical orientation that appears well-suited for

first-stage stabilization treatment), the treatment was eventually expanded to include equally strong attention to interpersonal and case management issues. Interpersonal sessions now

comprise a third of the sessions and case management is begun

in the first session and addressed at every session throughout

the treatment. The interpersonal domain is an area of special

need because PTSD most commonly arises from traumas inflicted by others, both for women and men (6). Whether childhood physical or sexual abuse, combat, or crime victimization,

all have an interpersonal valence that raises issues such as whether

to trust others, confusion over what can be expected in relationships, and the need to avoid reenactments of abusive power

(15) both as victims and perpetrators. Similarly, substance abuse

is often precipitated and perpetuated by relationships: many

patients grew up in homes with substance-abusing family members, and substance use may be an attempt to gain acceptance by

others, manage interpersonal conflict. The case management

component of the treatment was added to help patients obtain

necessary help with life problems such as housing, job counseling, HIV testing, domestic violence, childcare, and other typical

difficulties.

V. Attention to therapist processes.

Research shows that for substance abuse patients in particular (and psychotherapy in general), the effectiveness of treatment is determined as much or more by the therapist as by any

particular theoretical orientation or patient characteristics (30).

With this dual diagnosis population, who are often considered

difficult, severe, or extreme (9), it is a major challenge to

provide effective therapy.

Therapist processes emphasized in Seeking Safety include:

building an alliance, compassion for patients experience; attempting to use the various coping skills in ones own life (not

asking the patient to do things that one cannot do oneself);

giving patients control whenever possible (as personal control

was typically taken away as part of trauma and lost to substance

abuse); meeting the patient more than halfway (e.g., heroically doing anything possible within professional bounds to

SEEKING SAFETY
Volume 8 (3) Summer 1999

43

NC-PTSD Clinical Quarterly

help the patient get better); and obtaining feedback from patients about how they really feel about the treatment. The flip

side of such positive therapist processes are countertransference

issues that can detract from effective treatment. Indeed, the

more severe the patient, the more likely that countertransference

may get in the way of the work (31). This includes: harsh confrontation in which the therapist insists on her/his own point

of view, sadism, inability to hold patients accountable due to

misguided sympathy, becoming victim to the patients abusiveness, power struggles, and, in group treatment, allowing a

patient to be scapegoated.

Session topics and format

Examples of session topics are: Honesty; Asking for Help; Compassion; Taking Good Care of Yourself; Creating Meaning; Setting Boundaries in

Relationships; Commitment; Healthy Relationships; Detaching From Emotional

Pain (Grounding); Getting Others to Support Your Recovery; Integrating the

Split Self; Self-Nurturing; Protecting Yourself From HIV; and PTSD: Taking Back Your Power. The treatment has been conducted in a variety of

formats thus far, including group and individual, open and closed group,

50 and 90-minute sessions, singly and co-led, and outpatient and residential. Its empirical testing, however, was a closed group meeting

twice weekly for 12 weeks with 1.5 hour sessions by a single leader.

A typical session

The session begins with a check-in comprised of five questions:

Since the last session, How are you feeling?, What good coping have you

done?, Describe your substance use and any other unsafe behavior, Did you

complete your Commitment, and Case management update. (See below for

a description of Commitments). Next, an inspiring quotation is read

aloud; for example, in the session on PTSD the quotation is from Jesse

Jackson, You are not responsible for being down, but you are responsible for getting up. Most of the session is then devoted to the topic

of the session, with emphasis on relating the material to current and

specific problems patients are experiencing. Strategies to achieve this

include role-plays, experiential exercises, discussion, and the use of a

Safe Coping Sheet that guides patients to contrast their old way of

coping with a new way that is safe. Throughout the treatment, patients are encouraged to identify ways that they can cope safely with any

life situations that arise. They can draw from a list of over 80 Safe

Coping Skills and are encouraged to discover which ones work for them.

Two essential process themes are giving the patient control whenever

possible (to counteract the inherent loss of control associated with

both trauma and substance abuse): the promotion of honesty (to counteract the secrecy and lying typically characteristic of both trauma and

substance abuse) and the balanced provision of patient praise (positive

reinforcement) and holding patients accountable (pushing patients to

adhere to high standards of behavior to move their lives forward). To

close the session, a check-out is conducted in which patients are asked to

Name one thing you got out of todays session (an educational device to

reinforce learning as well as give the therapist feedback), and Name one

Commitment you will complete before the next session. A Commitment is a

between-session assignment that can be any positive, specific step to

move forward in ones life (e.g., Try calling a hotline to ask for support when

you are feeling overwhelmed one time this week). Patients can also select from

a variety of written options if they choose (e.g., Imagine that you are being

interviewed for a TV documentary about what helped you to survive so far

What would you say?).

Examples of session topics are:

Honesty; Asking for Help;

Compassion;

Taking Good Care of Yourself;

Creating Meaning;

Setting Boundaries in Relationships;

and Integrating the Split Self.

Empirical results

Thus far, one published study reports results for the Seeking Safety

treatment (32). It was conducted in a group format, enrolling a total of

27 women of which 17 (63%) completed the minimum-dose of six

sessions. All patients met current DSM-IV criteria for both PTSD and

substance dependence. In addition, 65% of patients met criteria for

one or more personality disorders. It is important to note that most of

the patients in the study had a history of early and repetitive childhood

physical and/or sexual abuse, which as later became clear from research

reports, represents the majority of women with this dual diagnosis (2).

Results were obtained on the 17 patients who met the minimum dose

of six sessions as the intent of this initial study was to assess the impact

of the treatment on them. Patients attended an average of 67% of

available sessions. Based on assessments at pre-treatment, during treatment, post-treatment, and at 3-month follow-up, results showed significant improvements in substance use, trauma-related symptoms,

suicide risk, suicidal thoughts, social adjustment, family functioning,

problem solving, depression, cognitions about substance use, and didactic knowledge related to the treatment. Patients alliance and satisfaction with treatment were very high. Interestingly, the 17 patients who

met the minimum dose of treatment were more impaired than dropouts on a wide variety of measures, yet also more engaged in the treatment. All results are clearly tentative, however, due to the lack of a

control group, multiple statistical comparisons, and the absence of assessment of dropouts.

Example of a session sheet

To provide a feel for the treatment, an excerpt from a session sheet is

provided below. In each session, the therapist is provided with a Therapist Guide that offers background on the topic, goals, strategies on how

to conduct the session, clinical notes, and tough cases that may come

up. Patients are provided with a session sheet that summarizes the

NAJAVITS

main points in the session and offers ideas for Commitments. The

session Creating Meaning is designed to help patients explore assumptions that are common among patients who have the
NC-PTSD Clinical Quarterly Volume 8 (3) Summer 1999

44

dual diagnosis of PTSD and substance abuse. Examples of some of

these beliefs (13) are presented in Table 1.

Table 1. Excerpt from session sheet on Creating Meaning.

References

1. Najavits, L.M., Gastfriend, D.R., Barber, J.P., Reif, S., Muenz,

L.R., Blaine, J., Frank, A., Crits-Christoph, P., Thase, M., and

Weiss, R.D. (1998). Cocaine dependence with and without

posttraumatic stress disorder among subjects in the NIDA

Collaborative Cocaine Treatment Study. American Journal

of Psychiatry, 155, 214-219.

2. Najavits, L.M., Weiss, R.D., and Shaw, S.R. (1997). The link between substance abuse and posttraumatic stress disorder in

women: A research review. The American Journal on Addictions, 6, 273-283.

3. Triffleman, E., (1998). An overview of trauma exposure, posttraumatic stress disorder, and addictions. In H.R. Kranzler

and B.J. Rounsaville (Eds.), Dual diagnosis and treatment:

Substance abuse and comorbid medical and psychiatric disorders (pp. 263-316). Marcel Dekker: New York.

4. Stewart, S.H. (1996). Alcohol abuse in individuals exposed to

trauma: A critical review. Psychological Bulletin, 120, 83-

112.

5. Breslau, N., Davis, G.C., Andreski, P., and Peterson, E. (1991).

Traumatic events and posttraumatic stress disorder in an urban

population of young adults. Archives of General Psychiatry,

48, 216-222.

6. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M. and Nelson,

C.B. (1995). Posttraumatic stress disorder in the national

comorbidty survey. Archives of General Psychiatry, 52, 1048-

1060.

7. Ouimette, P.C., Wolfe, J., and Chrestman, K.R. (1996). Characteristics of posttraumatic stress disorder-alcohol abuse comordibity

in women. Journal of Substance Abuse, 8, 335-346.

8. Keane, T.M. and Wolfe, J. (1990). Comorbidity in post-traumatic

stress disorder: An analysis of community and clinical studies.

Journal of Applied Social Psychology, 20, 1776-1788.

9. Kofoed, L., Friedman, M.J., and Peck, R. (1993). Alcoholism and

drug abuse in inpatients with PTSD. Psychiatric Quarterly, 64,

151-171.

.

Future work. Despite the initial promise of Seeking Safety, it is clearly

in an early stage of development. Future research, some of which is

currently underway, includes the need to study the treatment in randomized controlled trials, to compare and/or combine it with existing

treatments for PTSD (e.g., exposure) and substance abuse (e.g., relapse

prevention), and to study its generalizability to a wide range of patients, clinicians, and settings.

SEEKING SAFETY

MEANINGS THAT HARM EXAMPLES MEANINGS THAT HEAL

Deprivation Reasoning.

Because you have suffered a lot, you

need substances (or other selfdestructive behavior).

--Ive had a hard time, so Im entitled to

get high. --Ive had a hard time, so Im

entitled to get high.

--If you went through whi I did, youd

cut your arm too.

You believe that you shouldnt feel the

way you do.

In your mind, you yell at yourelf and

put yourself down.

Live Well.

A happy, functional life will make up for your suffering far

more than will hurting yourself. Focus on positive steps to make

your life better.

Im Crazy. --I shouldnt want to get high.

--I must be crazy to be feeling this upset.

Honor Your Feelings.

You are not crazy. Your feelings make sense in light of what

you have been through. You can get over them by talking

about them and learning to cope with them.

Time Warp.

Your sense of time is distorted, believing

that a negative feeling will go on

forever..

Beating Yourself Up.

--This craving wont stop.

--If I were to cry, I would never stop.

--Im a bad person.

--My family was right: Im worthless.

Take a clock and time how long it really lasts. Negative feelings

will usually subside after a while; often they will go away

sooner if you distract with activities.

Beating yourself up may echo what others in the past have

yelled at you. But it does not change your behavior; in fact, it

makes you less likely to change. Care and understanding

promote real change.

Observe Real Time.

Love--Not Hate--Creates Change.
Volume 8 (3) Summer 1999

45

NC-PTSD Clinical Quarterly

Lisa M. Najavits is Assistant Professor of Psychology, Harvard Medical School

and a practicing clinical psychologist at McLean Hospital, Belmont, MA. She is

currently principal investigator on three NIH grants, two testing the Seeking

Safety treatment and an Independent Scientist (K02) Award. She is a recipient

of the 1997 Chaim Danieli Young Professional Award of the International

Society for Traumatic Stress Studies and the 1998 Early Career Contribution to

Research Award of the Society for Psychotherapy Research. She can be reached at

617-855-2305 (phone) or (email) at <Lnajavits@hms.harvard.edu>.

10. Brown, P.J., Recupero, P.R., and Stout, R. (1995). PTSD substance

abuse comorbidity and treatment utilization. Addictive Behaviors, 20, 251-254

11. Grice, D.E., Brady, K.T., Dustan, L.R., Malcolm, R., and Kilpatrick,

D.G. (1995). Sexual and physical assault history and posttraumatic stress disorder in substance-dependent individuals. The

American Journal on Addictions, 4, 297-305.

12. Brady, K.T., Killeen, T., Saladin, M.E., Dansky, B., and Becker, S.

(1994). Comorbid substance abuse and posttraumatic stress

disorder: Characteristics of women in treatment. American

Journal on Addictions, 3, 160-164.

13. Najavits, L.M. (in press). Seeking safety: Cognitive-behavioral

therapy for PTSD and substance abuse. New York: Guilford

Press.

14. Najavits, L.M., Weiss, R.D., and Liese, B.S. (1996). Group cognitivebehavioral therapy for women with PTSD and substance use

disorder. Journal of Substance Abuse Treatment, 13, 13-22.

15. Herman, J.L. (1992). Trauma and Recovery. New York: Basic Books.

16. Marlatt, G. and Gordon, J. (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. In

Michael Mahoney (Ed.), The Guilford Clinical Psychology and

Psychotherapy Series. New York: Guilford Press.

17. Beck, A.T., Wright, F.D., Newman, C.F., and Liese, B.S. (1993).

Cognitive therapy of substance abuse. New York: Guilford

Press.

18. Miller, W. and Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford

Press.

19. Frankl, V.E. (1963). Mans search for meaning. New York: Pocket

Books.

20. Najavits, L.M. and Garber, J. (1989). A cognitive-behavioral group

therapy curriculum for inpatient depressed adolescents and

adults. Vanderbilt University, Nashville, TN: Unpublished

manuscript.

21. Kaufman, E. and Reoux, J. (1988). Guidelines for the successful

psychotherapy of substance abusers. American Journal of Drug

and Alcohol Abuse, 14, 199-209.

22. Foa, E.B. and Rothbaum, B.O. (1998). Treating the trauma of rape:

Cognitive-behavioral therapy for PTSD. New York: Guilford Press.

NAJAVITS

23. Abueg, F.R. and Fairbank, J.A., (1991). Behavioral treatment of

the PTSD-substance abuser: A multidimensional stage model.

In P. Saigh (Ed.), Posttraumatic stress disorder: A behavioral

approach to assessment and treatment (pp. 111-146). New York:

Pergamon Press.

24. Evans, K. and Sullivan, J.M. (1995). Treating addicted survivors of

trauma. New York: Guilford Press.

25. Ruzek, J.I., Polusny, M.A., and Abueg, F.R., (1998). Assessment

and treatment of concurrent posttraumatic stress disorder and

substance abuse. In V.M. Follette, J.I. Ruzek, and F.R. Abueg

(Eds.), Cognitive-behavioral therapies for trauma (pp. 226-255).

New York: Guilford Press.

26. Brown, P.J., Stout, R.L., and Gannon-Rowley, J. (1998). Substance

use disorders-PTSD comorbidity: Patients perceptions of

symptom interplay and treatment issues. Journal of Substance

Abuse Treatment, 14, 1-4.

27. Marks, I., Lovell, K., Noshirvani, H., Livanou, M., and Thrasher, S.

(1998). Treatment of posttraumatic stress disorder by exposure

and/or cognitive restructuring: A controlled study. Archives of

General Psychiatry, 55, 317-325.

28. Keane, T.M. (1995). The role of exposure therapy in the psychological treatment of PTSD. National Center for PTSD Clinical

Quarterly, 5, (1), 3-6.

29. Solomon, S.D., Gerrity, E.T., and Muff, A.M. (1992). Efficacy of

treatments for posttraumatic stress disorder. Journal of the

American Medical Association, 268, 633-638.

30. Najavits, L.M. and Weiss, R.D. (1994). Variations in therapist effectiveness in the treatment of patients with substance use disorders: An empirical review. Addiction, 89, 679-688.

31. Imhof, J., Hirsch, R., and Terenzi, R. (1983).

Countertransferentialand attitudinal considerations in the treatment of drug abuse and addiction. International Journal of

Addiction, 18, 491-510.

32. Najavits, L.M., Weiss, R.D., Shaw, S.R., and Muenz, L.R. (1998). Seeking safety: Outcome of a new cognitive-behavioral psychotherapy

for women with posttraumatic stress disorder and substance dependence. Journal of Traumatic Stress, 11, 437-456.
NC-PTSD Clinical Quarterly Volume 8 (3) Summer 1999

46

re-awakened trauma. However,

conversion would not explain

Mikes intentionally produced

symptoms.

PTSD implies a definite

causal link to what is often a compensable event. Therefore, when

evaluating possible PTSD with external incentives at stake it becomes

necessary to carefully assess causality, intentionality, and motivation as

well as traumatic events and symptoms. Furthermore, when incentives

 are at issue, clinicians must report their opinions outside the

therapeutic dyad. This difficult situation demands an objective,

thorough, and sensitive clinical evaluation in which clinicians

must struggle with the implications of believing or disbelieving

their patients reports, often while feeling awed by the enormity of the reported traumatic events. As the case of Iron

Mike illustrates, differentiating malingering from PTSD in the

real world is not simple.

We argue here that assessing PTSD claims for possible

malingering requires sharpening, not discarding, ones clinical

sensitivity. As with any other diagnosis, detection of malingering begins with a thorough evaluation of history and symptoms. Recounting an event said to be traumatic is insufficient.

A simple listing of symptoms, even if obtained in a well validated structured interview, is not enough. Obtaining an alliance with the patient is essential in determining when breaks in

communication occur, when one needs to question further, and

in distinguishing between confusion and genuine memory problems versus lack of cooperation. Verbal descriptions also are

not enough. Observation of emotional and physical behaviors surrounding communication is essential to determining the

meaning and reliability of information. Moreover, unquestioning acceptance of the patients formulation of the problem

is insufficient. Alternative explanations and collateral sources such

as records, family, and testing must also be considered. Our experience is that when clinicians are duped by malingerers, their blindness can usually be traced to an important issue they failed to address in the initial evaluation process. The following guidelines are

offered with basic principles of good clinical practice in mind.

Resnick (1), Pitman et al. (2), and Rogers (3) offer further discussion on a number of these points.

Guidelines for Differentiating Malingering from PTSD

JUDITH G. ARMSTRONG, PH.D. & JAMES R. HIGH, M.D.

Iron Mike came as a

forensic referral two years after an

accident in which he was slightly

injured. Shortly after, a treating

physician declared him permanently disabled by soft neurologic symptoms. A month later he

was hospitalized for anxiety, depression, and psychotic-like behavior. In the hospital he reported that

before his accident he had begun

seeing rifle-carrying Viet Cong. He

said that since the accident he suffered flashbacks of a painful Vietnam combat experience

that earned him his nickname. He expressed horror and guilt

at reliving his terror and his buddys gruesome death. This memory

was related with great catharsis, after which his diagnosis was

changed from Adjustment Disorder to Post-Traumatic Stress Disorder. However, he began exhibiting more neurologic symptoms, necessitating re-evaluation. The neurologists findings were

inconsistent with true brain damage. Some symptoms, including

transient paralysis, appeared conversion-like, while others, including volitional nystagmus, were intentional. Nevertheless

this doctor diagnosed Post-Concussion Syndrome.

It was tempting to dismiss Iron Mikes clinical picture as Malingering, the intentional production of false symptoms motivated by external incentives. His symptoms and disability far exceeded objective findings. Some were intentionally

produced. Furthermore, he would receive a great deal of

money from his lawsuit were his symptoms believed. Yet, he

had been declared permanently disabled before he developed

these symptoms, and he reported his flashbacks as beginning

shortly before the accident, suggesting a prior active PTSD.

An alternative to Malingering is Factitious Disorder. This also

involves the intentional production of false symptoms, but is

motivated by the compulsion to assume a sick role. Iron

Mikes combat history, flashbacks, and pseudo-neurological

symptoms occurred in a medical setting, eliciting both medical

attention and sympathy. However, he was already accepted as

very sick. His symptoms did little to enhance this perception.

Finally, Conversion Disorder deriving from a core of mild

brain damage and PTSD was possible. A combat veteran with

latent, chronic PTSD could experience conversion symptoms

following a concussion from a recent frightening accident that

Judith Armstrong, Ph.D. James High, M.D.
Volume 8 (3) Summer 1999

47

NC-PTSD Clinical Quarterly

ARMSTRONG & HIGH

Malingering Guidelines

 An essential safeguard against being duped by a PTSD

malingerer is having an index of suspicion for malingering. The clinicians index of suspicion should rise when

the patient:

- does not cooperate with the evaluation. This includes

statements of being unable, unwilling, or forgetting

to perform diagnostic tests;

- calls attention to his or her distress but is evasive about

details of symptoms. The malingerer often appears

to relish talking about the trauma but becomes evasive when asked for details of symptoms, while the

opposite tends to be true of the PTSD sufferer;

- shows behavior discrepant with reported symptoms,

e.g. claiming to be unable to work because of anxiety

and flashbacks but engaging in recreational activities;

- presents pre-trauma functioning in an over-idealized

light;

- tends to blame all life problems on the trauma and

resultant PTSD. Patients with true PTSD tend to avoid

treatment, focus on their responsibility-induced sense

of guilt, and attempt to appear normal. By contrast,

malingerers place their trauma at the forefront and

use it to justify their ends.

 Some common misconceptions about malingerers that

may obscure the clinicians perceptiveness include:

- malingerers tend to be men. There is no evidence of

gender differences in frequency of malingering.

- malingerers tend to be sociopaths. Despite the DSMIV assertion of a connection between sociopathy and

malingering, no studies link these two behaviors (3).

- trauma clinicians can spot a fake story of trauma, and

therefore, a convincing story is likely to be true. There

is no connection between the vividness and emotional

impact of a trauma story and its truthfulness.

 PTSD is unique among psychiatric disorders in that the

patients state of mind at the time of the event is crucial

to diagnosis and therefore must be carefully explored in

the interview. True PTSD sufferers are able to describe

Criterion A peritraumatic horror, helplessness, and/or dissociation. Absence of, or vagueness about, these state

of mind aspects of PTSD when recounting relatively

recent traumatic experiences is therefore suspicious.

 When inquiring about trauma, it is important to begin

with non-suggestive questions that encourage patients to

tell their stories. Question carefully for details of B

criteria re-experiencing and dont accept labels. For example, ask what its like for the patient to relive an experience or have a flashback. There are differences between flashbacks and mere unpleasant memories. These

differences must be carefully explored by the clinician. Standardized structured interviews are highly suggestive to

malingerers and are primarily useful in situations where malingering is not an issue.

 Malingerers tend to forget negative symptoms of PTSD.

Carefully check with the patient regarding DSM-IV PTSD

C criteria such as avoidance of trauma-related activities

and detachment from close relationships. Wishing to be

likeable and believable, malingerers often assert their deep

love and closeness toward family, not realizing this is inconsistent with emotional numbing. True PTSD avoidance

serves the purpose of controlling painful symptoms. Malingered avoidance tends to have an external incentive such

as enhancing monetary compensation.

 With unsophisticated malingerers, we have had success using the common clinical technique of inserting a rare and

unlikely symptom (such as hair pulling or decreased need

for sleep) into a series of questions about PTSD symptoms.

 Even sophisticated malingerers may find it difficult to consistently mimic behavioral cues for PTSD such as physical

signs of D criteria hyperarousal and dissociative spacing out when trauma is discussed. Therefore, careful observation of behavioral responses such as staring, startling

and somatic reactions when traumatic material is discussed

during interview can help to distinguish between a true PTSD

sufferer and a malingerer.

 Carlson (4), Briere (5), and Wilson and Keane (6) have published excellent guides for choosing and interpreting tests

for PTSD. The MMPI-2 validity scales can detect symptom exaggeration which may support a finding of malingering. However, the F scale is often elevated in acute PTSD

sufferers since this scale contains many trauma symptoms.

We have found Arbisi and Ben-Poraths (7) recently developed F(p) scale to be extremely helpful in differentiating

individuals who are highly disturbed by trauma from malingerers. Self-report measures without validity scales such

as the Dissociative Experiences Scale, can also help identify

malingering yea-sayers if you ask for detailed examples

of any symptoms reported.

 It is essential to carefully explore the chain of causality, and

consider alternative causes. We have noted earlier that
NC-PTSD Clinical Quarterly Volume 8 (3) Summer 1999

48

   

good clinical practice demands that we not accept unchallenged the patients hypotheses as to the cause of their

problems. Resnick (1) points out that even when the patient has PTSD, providing misleading information about

the cause of ones disorder is as much malingering as is

reporting false symptoms.

 Ultimately, malingering is not simply a diagnosis of clinical

judgement or psychological testing. It is a decision that the

patient more likely than not is misrepresenting facts concerning the nature, severity, and/or cause of his or her distress. Therefore, differentiating true from malingered PTSD

requires seeking corroboration through collateral sources.

Records from medical, military, and legal sources must be

obtained. Likewise, partners should be interviewed to

corroborate behaviors such as the frequency of night time

awakenings, physical activity during sleep, and changes in sexual

activity and emotional availability since the trauma.

Discussion

Where does Iron Mike stand in view of these guidelines? The development of his symptoms in a legal context,

his intentional neurological symptoms, and his eagerness to recount his dramatic Vietnam story as part of his compensation

seeking raised the index of suspicion for malingering. As we

have seen, the fact that his psychiatric nurse and later a court

reporter were moved to tears when he told his combat story

was no guide to the accuracy of his report. Our review of

medical records showed no evidence of peritraumatic alteration of consciousness, organic or psychological, following his

accident. Also, his post accident MMPI was invalid due to

exaggeration. Most importantly, his service records indicated

that he had never been in Vietnam. Iron Mike malingered his

combat and accident-related PTSD and neurological symptoms. An interview with his older brother, however, corroborated chronic, severe physical abuse during his childhood. Thus,

it is possible that his conversion symptoms, as well as some of

his PTSD symptoms, were valid expressions of genuine trauma.

In his case, as in others, the diagnosis of malingering did not

rule out the presence of another psychiatric disorder.

Dealing with the possibility of malingering when asked

to examine on behalf of a third party is relatively straightforward since the evaluators role as decision maker is clear. The

task of separating true from malingered PTSD arises with

greatly increased immediacy and complexity when the patient

in treatment seeks to enlist his or her clinicians intervention

with outside parties to obtain external incentives such as financial benefits, avoidance of onerous duties and punishments,

and obtaining narcotics of questionable necessity. Strasburger

et al. (8) point out that clinicians who agree to help in this way

must recognize that they have taken on an additional role that

may conflict with their therapist role. We agree with these authors that, whenever possible, clinicians should avoid this role

dilemma.

When this is not possible, the clinician enters into the

dual roles of treatment provider and evaluator. In the role of

provider, it is often acceptable to use clinical judgment alone.

As an evaluator, however, more than clincial judgment is required. Careful history taking and symptom evaluation then

take on a new importance. Validated psychological testing

should be obtained. Corroboration whenever possible becomes a necessity. Otherwise clinicians risk colluding with their

patients malingering.

The mere act of requiring that the patient prove

their PTSD is genuine may irreparably damage the therapeutic

alliance. Furthermore, even if you discover malingering there

may still be other illness to treat, including PTSD. A judgement that malingering exists may not end the need for treatment. In fact, the frank discussion of the patients deception

may allow the therapeutic alliance to evolve into a more realistic and genuine relationship, a task requiring exceptional skill

and sensitivity. Sadly, even when the skill exists and the treatment need is acute, confronting the deception more often irrevocably ruptures the alliance. Iron Mikes psychiatrist attempted

to discuss Mikes deceptions in therapy. Mike fired him and

continued therapy with a less skilled and more gullible clinician.

References

1. Resnick, P.J. (1997). Malingering of Posttraumatic Disorders. In

R. Rogers (Ed.), Clinical assessment of malingering and deception. New York: Guilford Press.

2. Pitman, R.K., Sparr, L.F., Saunders, L.S. & McFarlane, A.C. (1996).

Legal Issues in Posttraumatic Stress Disorder. In B.A. van

der Kolk, A.C. McFarlane & L. Weisaeth (Eds.), Traumatic

stress (pp. 378-397). New York: Guilford Press.

3. Rogers, R. (1997). Clinical assessment of malingering and

deception. New York: Guilford Press.

4. Carlson, E.B. (1997). Trauma assessments: A clinicians guide.

New York: Guilford Press.

5. Briere, J. (1997). Psychological assessment of adult posttraumatic states. Washington, DC: American Psychological Association.

6. Wilson, J.P. & Keane, T.M. (1997). Assessing psychological trauma

and PTSD. New York: Guilford Press.

7. Arbisi, P.A. & Ben-Porath, Y.S. (1995). An MMPI-2 Infrequent Response Scale for use with Psychopathological

Populations: The Infrequency- Psychopathology Scale, F(p).

Psychological Assessment, 7, 424-431.

8. Strasburger, L.H., Gutheil, T.G. & Brodsky, B.A. (1997). On

Wearing Two Hats: Role Conflict in Serving as Both

Psychotherapist and Expert Witness. American

Journal of Psychiatry, 154, 448-456.

Judith G. Armstrong is Clinical Associate Professor of Psychology at the

University of Southern California and has a private clinical and forensic

practice in Santa Monica, CA. Dr. Armstrong is an author, along with

Frank Putnam and Eve Carlson of the Adolescent Dissociative

Experiences Scale (A-DES).

James R. High is a board certified psychiatrist in Santa Monica with

extensive clinical and forensic experience in assessment and treatment of

PTSD. Dr. High is Clinical Associate Professor of Psychiatry at the

University of Southern California.
Volume 8 (3) Summer 1999

49

NC-PTSD Clinical Quarterly

 NEW DIRECTIONS Matthew J. Friedman, M.D., Ph.D.

 Executive Director, NC-PTSD

We all take things for granted. Familiarity is one of the major reasons why we do so. For example, we may not realize

that the pleasant woman who has occupied the next office for as long as we can remember is a world famous this-or-that, until

we learn that she has just received some distinguished award or that she will be featured by the national media or that an old

friend in a distant city thinks we are very lucky, indeed, to have her as a colleague.

Im beginning to wonder whether that may also be the case with the clinical, research and educational programs the

Department of Veterans Affairs has developed for PTSDthat they have been taken for granted. Thanks to the vision and

determination 15 years ago of veterans and congressional initiatives, the VA has developed the most comprehensive spectrum

of PTSD treatment programs in the world, ranging from Vet Centers to PTSD Clinical Teams (PCTs) to a variety of residential and inpatient alternatives. VA researchers have spearheaded the development of new psychological and pharmacological

treatments, have established that brain structure and function is altered in PTSD patients, and have made extraordinary

discoveries showing how PTSD results from disruptions in major biobehavioral systems that mediate learning, memory,

coping, and adaptation. Likewise, VA experts have set the national PTSD educational agenda, figure prominently in any list

of influential authors, speakers, and teachers; and have developed some of the most successful training programs in the PTSD

field.

Although VAs Undersecretary for Health, Dr. Kenneth Kizer, has continued to express his support for PTSD and other

specialized mental health programs, questions continue to be raised by a few VA policy makers whether these remarkable

clinical, scientific, and educational advances really provide value added for veterans and for the Department of Veterans

Affairs. I think they have forgotten what it was like 15 years ago. I think they dont realize what a momentous loss it would

be if these programs were to disappear.

From my vantage point within the National Center for PTSD, I can tell you that national and international experts do not

take these accomplishments for granted. Within the United States, VA PTSD clinicians and scientists are highly recruited for

seats on advisory boards research review committees, and a wide variety of federal (e.g., NIMH, military) academic, professional and community task forces.

What is most striking, however, is the excitement that colleagues from other nations continue to express about the

remarkable system VA has established for treatment, research, and education on PTSD. They come to see for themselves so

that they can recreate such programs in their own countries. Indeed, several nations following the example of Australia, plan

to establish their own national centers for PTSD and have come to us for help and advice. A steady stream of visitors, many

of whom are government officials, from Western Europe, Australia, Israel, Kuwait, Japan, Croatia, Canada, and South Africa

have come to learn from us, to let us train their professional staff, and to collaborate with us in order to build global networks

to advance our field. An outstanding example is the ongoing multi-national effort to reduce stress-related disorders and PTSD

among active duty UN/NATO military personnel and among new veterans of such peacekeeping operations.

So theres the irony. As a number of governments as well as colleagues in other U.S. governmental, clinical, and

academic settings discover the value of our clinical and scientific achievements, as they recognize how our work with

American veterans is applicable to veterans and non-veteran trauma survivors elsewhere, and as they look to VA as the world

leader in this rapidly growing field, the Department of Veterans Affairs continues to debate the value added of its PTSD

programs. VA PTSD professionals continue to work in a context of uncertainty about the future and ambiguous support for

its unique and extraordinary spectrum of clinical, research, and educational programs.

During the past few months, I have had the opportunity to consult with the national leadership of Veterans Services

Organizations (VSOs). They are very concerned about the future of VA mental health programs in general and PTSD

programs in particular. From what their constituents tell them, VSOs are concerned that if VA-based PTSD programs were

to disappear, either through budget reduction or reallocation of resources, that veterans with PTSD would be unable to obtain

the treatment they need from clinicians with the specialized expertise needed to deliver such high quality services. Based on

reports from VSO leaders, veterans are especially worried that if outpatient treatment were vouchered to community mental

health or to private sector outpatient clinics, that veterans would be unable to access clinicians with the sophistication and

experience to treat the unique psychological problems that result from military action and war zone trauma.

I share their concerns. Like many of you, I hope that veterans will never be faced with this problem. I hope that the

remarkable spectrum of VA clinical, research, and educational programs can survive the serious budgetary pressures faced

by top VA leadership and that we can continue to serve our veteran clientele. I also hope that by preserving these programs

and by recognizing their value added to the Department of Veterans Affairs, that VA can maintain its global leadership in the

understanding and treatment of stress and trauma-related disorders.
NC-PTSD Clinical Quarterly Volume 8 (3) Summer 1999

50

 WOMEN AND TRAUMA: A CLINICAL FORUM

Marie B. Caulfield, Ph.D., & Annabel Prins, Ph.D.

Adult survivors of physical and sexual child abuse may present with specific difficulties related to the developmental and interpersonal

nature of their trauma. Clinically, many clients presenting with these difficulties will be women, due to the high rate of child abuse of girls, as well

as the higher number of women seeking mental health care. Abusive and neglectful environments may impact on the development of a wide

range of personal resources necessary for establishing and maintaining good social relationships. In this article, we will dis cuss three personal

resources: empathy, social problem-solving, and locus of control.

Empathy

Survivors of child abuse often describe difficulty in experiencing empathy for others. Research suggests that because neglectful and

abusive parents do not model empathy for their children, abused children may not learn perspective-taking, and thus do not have the skills

necessary for empathy. Evidence suggests that good relationships with important others, including non-abusive family members, teachers, and

coaches may help children develop skills that were not fostered in their homes.

Relationships with clinicians can provide opportunities for adult survivors to learn and practice empathic behaviors. Trauma survivors

often are unable to have empathy for themselves, especially with regard to their abusive experiences. They may blame themselves or minimize the

emotional impact of their experience. An empathic response from the therapist can help the client view her life with compassion and it helps to

foster a safe environment in which the survivor can discuss difficult experiences and feelings. The therapist can foster perspective taking by asking

the client questions about what the she imagines other people are thinking. Psychoeducation on the impact of child abuse on empathy can also help

the survivor understand why she may respond to others with indifference or anger rather than empathy in certain situations.

Social Problem-Solving

Children who grow up in abusive or violent homes often show deficits in social problem-solving as adults. Because violence and

coercion were often used to resolve problems in their families of origin, survivors of these abusive situations may not have developed rational,

non-violent means for solving problems. As a result, survivors may arrive at solutions to problems impulsively, and they may apply solutions

that are harmful to themselves or others.

Clinicians can model appropriate social problem-solving by thinking out loud about challenging interpersonal situations faced by the

client, and, where appropriate, through self-disclosure of examples from the therapists own life. Some child abuse survivors may have extreme

deficits in this area, with a limited repertoire of responses to interpersonal interactions. In these cases, even minor interactions within the

therapeutic relationship can be helpful in teaching the client new patterns of relating. Child abuse survivors also may show a tendency towards

black-or-white thinking with regard to interpersonal situations (e.g., the other person is either all bad or all good.) It may be beneficial for clinicians

to view this extreme thinking as a skill deficit rather than as an intractable personality characteristic.

Locus of control

Abusive environments do not allow for learning a sense of internal control over ones environment because abuse often happens

unpredictably. For example, the pattern of physical abuse experienced from an alcoholic parent might teach a child that the world is an unsafe,

erratic place over which the child has no control. As an adult, this learning might generalize to a range of social relationships, with the survivor

feeling that relationships are unsafe and impossible to negotiate. The child abuse survivor may feel helpless as an adult and be incapable of fully

asserting autonomy. This may be compounded for women, many of whom have been socialized to be less assertive than men.

Consistency and predictability within the therapeutic relationship are important for providing child abuse survivors with a sense of

safety. It is crucial that therapists communicate directly that the client and the therapist share control within the therapeutic relationship. For

example, therapists should invite the client to signal for a break if they need one, check in with the client about the specifics of the therapy room

(e.g., do they want the door cracked open, the shades drawn, etc.), and encourage them to voice any concerns or complaints they may have about

the therapist or therapy. In work with trauma survivors, it is important for the therapist to balance the need to address traumatic material in

therapy with teaching the client to pace their disclosures in order to maintain a sense of control.

These areas of social competence are important targets for work with trauma survivors, particularly those who experienced chronic

interpersonal abuse during childhood. In addition to the clinical strategies discussed above, clinicians may find it helpful to incorporate techniques

from cognitive behavioral treatments that address these deficits. Deficits in these areas can compromise the survivors relationships with others,

preventing the survivor from functioning effectively at work, socially, or as a parent or spouse. With extreme deficits, the survivor may become

involved in an abusive situation as an adult. By addressing these areas in treatment, we can help clients build stronger, more reciprocal relationships

with others.

Deficits in Personal Resources in Survivors of Child Abuse: Targets for Clinicians

Marie B. Caulfield, Ph.D. & Kiban Turner, Ph.D.
Volume 8 (3) Summer 1999

51

NC-PTSD Clinical Quarterly

TRANSCEND: A PROGRAM FOR TREATING PTSD AND

SUBSTANCE ABUSE IN VIETNAM COMBAT VETERANS

Over the past decade, there has been

growing recognition that dual problems of Post-Traumatic Stress Disorder (PTSD) and Substance

Abuse (SA) among combat veterans seeking treatment is quite high.

Incidence estimates suggest the

rates of SA among persons with

PTSD may be as high as 60-80%,

while rates of PTSD among substance abusers is between 40-60%

(1-2). Surprisingly, there have been

few studies in the literature that

indicate effective treatment outcomes for veterans. At the VAMC in Brecksville, Ohio, a program

for chemical abusing PTSD patients called Transcend was developed six years ago to fill this void.

Program Description

Transcend is a 12 week partial hospitalization program

for Vietnam veterans diagnosed with PTSD and SA disorders.

Beyond diminishing PTSD symptoms and promoting an addiction-free lifestyle, other goals of the program include developing a

mastery of impulses, acceptance of responsibility for change, diminishing shame, nurturing self-acceptance, and augmenting selfefficacy beliefs. A treatment manual details therapeutic themes,

goals and objectives of each session, and describes specific interventions for each session across the 12 weeks. The manual includes

both a Patient Workbook and Therapist Guidelines and is available

to clinicians upon request from the National Center for PTSD at

Menlo Park/Palo Alto.

The Transcend program format mandates that all clients

complete a primary SA rehabilitation program within six months of

beginning Transcend. A maximum of ten clients enter the program

as a cohort and remain together throughout the three months of

primary treatment. The protocol is logically divided into group cohesion development and skills development (first six weeks) and trauma

processing (weeks seven to twelve). Treatment is structured around

fourteen hours of group therapy each week with addiction recovery

counseling interwoven throughout. Patients submit weekly and random urine checks to verify they are drug free.

The interventions strategies in Transcend derive from an

integration of three process goals. The first is to develop a therapeutic alliance that establishes the clients responsibility for change;

the second is to instill a dedication to self-exploration; and the

third is to engage clients in new, positively reinforcing behaviors. A

basic tenet of the program is that there is no real change without

behavioral change. For the therapists, this means taking responsibility not just for teaching clients new skills, but also emphasizing

the need to act on newly learned behaviors, coaching them in individual sessions,

helping them maintain new skills by providing reinforcement episodes, and instructing them in self-reinforcement.

Peer support is considered vital in

helping dismantle long entrenched patterns of isolation, violence and substance

abuse (3). Hence, group process and feedback are considered among the most potent intervention tools of the program.

From the beginning, therapists teach,

model, and reinforce skills conducive to

building supportive relationships. They

also strive to generate a group atmosphere of non-judgmental listening,

empathic responding, active participation and self-responsibility (4-5). Specific ways to communicate effective feedback are taught early and consistently reinforced.

One of the programs primary assumptions is that veterans who

come for treatment are trapped by ambivalence and fear. Hence, the structure of the program has a sequencing of content that allows for a gradual

emergence into traumatic material. In order to address their ambivalence,

the early weeks of treatment are devoted to developing a sense of group

identity and interpersonal safety. The sequential structure incorporates skill

building exercises (such as problem solving, anger management, and relaxation training) which allow clients to develop a repertoire of calming techniques so they do not become overwhelmed by the emotional work inherent in trauma processing (6). Early sessions focus on enhancing an understanding of the interconnection of PTSD and addictive behaviors, emphasizing similarities among group members, reinforcing empathic responses,

and introducing new interpersonal coping skills. Treatment then proceeds

to an exploration of pre-trauma emotional relationships, including childhood issues and experiences. The emphasis is not on uncovering childhood traumas, but on incidents that reveal vulnerabilities and emotions,

good and bad. Finally, the last six weeks are devoted to processing war zone

trauma, promoting cognitive restructuring and self-acceptance, strengthening self-esteem, diminishing pathological shame, and continuing to build

relapse prevention strategies. The culmination of this process is facilitated

by a group trip to the Vietnam Memorial in Washington, D.C., during the

eleventh week of treatment. We have designed rituals for the trip to the

Wall which are specifically designed to reduce survivor guilt and pathological shame. Although these rituals have maximum emotional effect when

performed at the wall, they could be creatively incorporated into treatment

by any treatment team.

Specific therapeutic interventions attempt to balance directive teaching and client-centered insight with a strong emphasis on active learning.

Group discussion, readings, and written exercises are used to encourage

members to ask questions, scrutinize their beliefs, and engage in dialogues

with one another. Facilitators encourage members to challenge negative

BEVERLY DONOVAN, PH.D. & EDGARDO PADIN-RIVERA, PH.D.

Beverly Donovan, Ph.D. Edgardo Padin-Rivera, Ph.D.
NC-PTSD Clinical Quarterly Volume 8 (3) Summer 1999

52

self-beliefs and self-defeating behaviors. Clients are required to directly

confront SA lifestyles and examine ways addictive behaviors destroy

self-worth and hope. Uncovering and examining defenses against pain,

anger, vulnerability, and grief is a vital aspect of group process. Clients

are enjoined in group to label and express emotions with the suggestion that as intense feelings are brought into conscious awareness their

unconscious influence on behavior will diminish.

Intervention Examples

An intervention we have devised called A letter to your father provides an example of a group cohesion-building exercise. During the fourth week of treatment, each client writes a letter to his or her

father. This assignment is carried out regardless of whether or not the

father is alive. These letters need not be sent, but are portrayed as a way

to allow clients an opportunity to express emotional vulnerability and

to understand how childhood experiences may influence behaviors or

reactions. Often a client will be asked to write more than one letter if

some other male figure greatly influenced his childhood experiences. In

these letters, each group member is asked to write about things his

father did that he is thankful for, things that made him angry or sad,

things he resents or regrets, and ways he wishes his relationship with his

father had been different. The letters are then read over the course of

two group sessions. Group members have the opportunity to demonstrate empathic listening, provide emotional support, and reinforce the

benefits of expressing emotions. The following is an example of what

benefits can be gained from this exercise.

Ray M. wrote a letter to his biological father, who had been

both an alcoholic and abusive. In the letter, he recounted specific incidents of abuse that included being forced to smoke a whole cigar when

he was five years old as a punishment, watching his father kill his pet

kittens with a knife, being terrified at age seven when his father took

him along on an armed robbery attempt, and having to stand helplessly

by as his father beat his mother. His feelings regarding these events

were affirmed by fellow group members who were shocked and appalled by what they heard.

A few weeks later, Ray described his warzone traumatic experiences. His unit had engaged in a number of search and destroy missions in villages. Rays commanding lieutenant instructed the soldiers

to rape and then do whatever else they wanted with the women.

Although most of the company complied, Ray refused. He was taunted

by the lieutenant for his noncompliance and implications were made

that he was homosexual or effeminate. His rage continued to build

towards this officer until during one moment of humiliation in front

of his peers, Ray grabbed his rifle and shoved the bayonet through the

lieutenants abdomen. He later greatly feared that he may have attacked

the officer because he was really a coward and secretly hoped to have to leave

the warzone. During the processing of this event, group members

helped Ray explore his rage. He was given the insight that his anger at

the moment of attack wasnt directed solely towards the lieutenant but

was also fueled by and directed towards his father who had humiliated

him and forced him to stand helplessly by while he beat Rays mother.

This connection between warzone experiences and childhood events

began the process of self-forgiveness, and allowed Ray to feel more

compassion towards himself and consequently to become less judgmental of others.

In contrast to treatments for combat veterans that do not employ trauma

processing, we believe it an essential part of the recovery process (7).

However, our conceptualization is not that this process be enlisted

solely to desensitize the veteran, but rather the emphasis is placed on

two major intervention principles. One is that having others witness

and empathize with the traumatic events and emotions surrounding

them is healing in and of itself. The second is that trauma processing

must incorporate cognitive restructuring of the meaning of these events

and a more compassionate understanding of why decisions were made

during the duress of warfare and must promote self-acceptance and

self-forgiveness (8).

In the Transcend treatment protocol, each client is required to

spend time preparing for trauma processing by writing a detailed account of his war zone experiences. He is then given a three hour session

devoted to telling his story (relating war zone trauma). The following is an example of how this trauma processing may facilitate change.

John D. began his session by relating in a very unemotional

manner what had happened to him when his unit was ambushed. He

mentioned that a good friend, Alan B., died during the firefight, then

quickly tried to move to the description of other events. He was slowed

down by questions from both therapists and fellow group members

who sought details regarding how this man died and his importance to

John. Questions included: How did he die? Did you see him get hit?

Where was he wounded? What did you see when you looked at him? What do you

think about when you recall his death? How long had you known him? What was

he like?

Asking these questions helped elicit an issue of survivor guilt

and eventually promoted movement towards grief resolution. John

clarified that he had refused to take an assignment as radio operator

because he knew it was particularly dangerous. His friend, Alan, however, later consented to this job. John was mad at this friend for accepting the assignment, but he also feared that Alan died because he had

refused it.

The trauma processing sessions always allow time for structured feedback from other group members. The importance of this

cannot be emphasized enough. In this case, ideas for reframing were

provided by fellow combat veterans with feedback like, John, it wasnt

your fault he died. I never would be a radio man either. Shit happens in firefights

and no one can stop it. He was lucky to have someone who really cared about him

like you did. and I know what it feels like to lose a good friend. I know why you

feel guilty. My friend walked point for me on one mission and died. I always felt

like it should have been me.

Since there is an entrenched defense against feeling painful

losses, a gestalt-like procedure was used to assist in emotional expressiveness. John was asked what he would want to say to Alan if he

walked in the door right now. At this point John began to sob and

express more of his emotions. As if talking to his lost friend, he said,

Why did you take that job? I told you it would get you killed. I really felt bad

when you diedI really missed you. I know you will understand why I couldnt

even stop and make sure you were dead. Im glad you havent suffered all these

years like I have. Im glad you werent an invalid for years. You were a real hero in

my book and you always will be.

After this, feedback again provided an opportunity for group

members to actively participate and demonstrate empathic responding.

When asked to describe how he felt, John said he had never told anyone
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NC-PTSD Clinical Quarterly

how guilty and sad he had felt after Alan died, and affirmed that he felt

as if a big weight had been lifted from his shoulders. To continue the

grief work around this incident, John was asked to write a letter to Alan

saying all the things he had related during the group session. He then

took the letter on the group trip to Washington, DC and left it at the

Wall. During the trip, John made a pledge regarding life changes he

was willing to make so he could honor the memory of his friend rather

than punish himself for having survived.

Supplemental Activities and Aftercare

During the 12 weeks of primary treatment, the core structure

of group psychotherapy is enhanced by a number of additional activities designed to restructure the veterans lifestyle and augment recovery.

To help develop healthy ways to relieve tension and anxiety, each client

is required to engage in a structured water therapy program three times

a week. Each must also participate in a community service project for at

least two hours weekly, spending time with elderly, nursing home veterans or volunteering with a local social services organization. These

supplemental activities help break down established isolating patterns,

re-establish self-esteem, increase a sense of self-efficacy and move clients

beyond a predominant victim identification. The structured exercise

program and daily relaxation training helps relieve tension in a natural

manner and assists clients in developing habits which can lead to permanent lifestyle changes.

Coordinated outpatient aftercare is viewed as crucial to sustain

treatment gains (7-10). Hence, clients are required to attend aftercare

group once a week for an hour and a half after completion of the 12-

week program and are encouraged to remain in aftercare for anywhere

from six months to two years. PTSD symptom management and

relapse prevention education continue to be emphasized throughout

this second phase and clients are strongly encouraged to attend additional addiction recovery meetings each week.

From inception, Transcend incorporated a program evaluation component which looked at both effectiveness and efficacy. Outcomes show significant change in PTSD symptomology on the Clinician Administered PTSD Scale (CAPS) and a very low chemical abuse

relapse rate as measured on Addiction Severity Index (ASI) follow-ups.

Data indicates there was a significant decrease in overall CAPS scores

from pre-treatment to post-treatment. In addition, there were significant decreases in the overall Avoidance scores (both Frequency and Intensity measurements) and in the Arousal Frequency scores. Furthermore, these gains have been maintained at six month and one year

follow-up testing. Intrusive symptoms were diminished but the change

failed to reach significance.

As to costs, veterans are housed in a Domiciliary residence,

rather than an inpatient unit. Staff engaged in the program has been

kept at two therapists and one part-time interviewer who is not part of

the treatment staff. This has allowed for efficient, cost-effective treatment; moreover, the small staff greatly facilitate the building of rapport

and better ensures that old patterns of isolation subside. Thus, the

entire program is maintained at very low cost.

References

1. Keane, T.M., Gerardi, R. J., Lyons, J.A., Wolfe, J. (1988). The

interrelationship of substance abuse and post traumatic stress

disorder: Epidemiological and clinical considerations. In M.

Galanter (Ed.), Recent developments in alcoholism, 6, (pp. 27-

48). New York: Plenum Press.

2. Kofoed, L., Friedman, M.J., & Peck, R. (1993). Alcoholism and drug

abuse in patients with PTSD. Psychiatric Quarterly, 64, 151-171.

3. Peck, W.R., Gearing, M.L., Robinowitz, R., Dolan, M.P., & Patterson,

E.T. (1982). Interpersonal problems of Vietnam combat veterans with symptoms of posttraumatic stress disorder. Journal of Abnormal Psychology, 91, 440-450.

4. Clewell, R.D. (1987). Moral dimensions in treating combat veterans with posttraumatic stress disorder. Bulletin of the

Menninger Clinic, 51, 114-130.

5. Haley, S.A. (1974). When the patient reports atrocities. Archives

of General Psychiatry, 30, 191-196.

6. McWhirter, J. J., & Liebman, P.C. (1988). A description of angercontrol therapy to help Vietnam veteran with PTSD. Journal

for Specialists in Group Work, 13, 9-16.

7. Johnson, D.R. (1997). Introduction: Inside the specialized inpatient PTSD units of the Department of Veterans Affairs. Journal of Traumatic Stress, 10, 357-360.

8. Kubany, E.S. & Manke, F.P. (1995). Cognitive therapy for traumarelated guilt: Conceptual bases and treatment outlines. Cognitive and Behavioral Practice, 2, 26- 61.

9. Scurfield, R.M., Kenderdine, S.K. & Pollard, R.J. (1990). Inpatient

treatment for war-related post-traumatic stress disorder: Initial

findings on a longer-term outcome study. Journal of Traumatic Stress, 3, 185-201.

10. Starkey, T.W., & Ashlock, L. (1986). Inpatient treatment of PTSD:

An interim report of the Miami model. VA Practitioner, 1(11),

41-44.

Beverly Donovan is a clinical psychologist and Coordinator of the Transcend treatment program at the Louis Stokes VA Medical Center, Cleveland, OH. Dr. Donovans research interests include PTSD treatment

outcomes, the effects of childhood abuse on war-related PTSD, and traumatic nightmare resolution.

Edgardo Padin-Rivera is a clinical psychologist and Director of Clinical

Support Operations for Mental Health Services at the VA Medical

Center, Cleveland, Ohio. Dr. Padin-Rivera has conducted research on the

emotional life of mentally retarded persons, family communication processes

and PTSD, and is currently engaged in research on PTSD and health

risks, nightmares, and treatment outcome.
NC-PTSD Clinical Quarterly Volume 8 (3) Summer 1999

54

Due to budget cutbacks, we are no longer able to provide free issues of NC-PTSD

Clinical Quarterly to readers not employed by the VA. You can, however, continue to

receive the Clinical Quarterly at nominal cost by using the Superintendent of Documents

order form below.

This change will help ensure that we will have the funds to continue keeping you

informed about trauma-related topics important in clinical practice and helping to

bridge the gap between scientists and practitioners. We will continue to report on

progress in assessing and treating post-traumatic stress disorder.

We also will continue the Clinical Quarterlys regular columns exploring new directions

in the field and issues specific to womens care.

VA employees will continue to receive the Clinical Quarterly at no cost. If youre not

employed by the VA, make sure you dont miss a single issue of the Clinical Quarterly.

Just complete and return the order form to begin your annual subscription today.

ATTENTION READERS
Volume 8 (3) Summer 1999

55

NC-PTSD Clinical Quarterly

PTSD Assessment Library

Available upon request are selected instruments from our library of

assessment and program evaluation tools (with accompanying articles),

together with templates describing over 100 trauma-related measures

courtesy of Beth Stamm, Ph.D., and Sidran Press. Telephone (650) 493-

5000 ext. 22477.

PTSD Article Library

A helpful set of key articles on aspects of PTSD is available to VA or

Vet Center clinicians free of charge. Telephone (650) 493-5000 ext. 22673.

PTSD Video Library

The Menlo Park Education Team maintains a small videotape

lending library exploring topics related to PTSD diagnosis,

evaluation, and treatment. Videotapes may be borrowed free of

charge. Telephone (650) 493-5000 ext. 22673.

PTSD Program Liaison and Consultation

The Menlo Park Education Team can help VA health care professionals

locate needed resources. Services may include assistance in locating relevant

articles, locating resource persons, or problem-solving. Staff are available to

consult in the areas of PTSD Diagnosis and Treatment, Program

Development and Design, Women and Trauma, Relapse Prevention, and

with other PTSD-related concerns. Telephone (650) 493-5000 ext. 22977.

National Center for PTSD Web Page

The NC-PTSD Home Page provides a description of activities of the

National Center for PTSD and other trauma related information. The

world wide web address is: http://www.dartmouth.edu/dms/ptsd/

PILOTS Database

PILOTS, the only electronic index focused exclusively on the worlds

literature on PTSD and other mental health consequences of exposure

to traumatic events, provides clinicians and researchers with the ability

to conduct literature searches on all topics relevant to PTSD. http://

www.dartmouth.edu/dms/ptsd/PILOTS.html

NC-PTSD Research Quarterly

The Research Quarterly reviews recent scientific PTSD literature. Telephone

(802) 296-5132 for subscription information.

Disaster Mental Health Training and Consultation

Education staff provide training in disaster mental health services,

including team development, interfacing with other agencies, on-site

and off-site interventions, debriefing, and psychoeducational and

treatment interventions with disaster survivors and workers. Telephone

(650) 493-5000 ext. 22494 or email: bhh@icon.palo-alto.med.va.gov

Conferences and Training Events

The Menlo Park Education Team provides consultative support for the

development of training in PTSD. Services include assistance in finding

faculty and designing program content. Telephone (650) 493-5000 ext. 22673.

The Education and Clinical Laboratory Education

Division for the National Center for Post Traumatic

Stress Disorder at the Palo Alto CA VAMC, in

collaboration with the VA Employee Education

System offers a Clinical Training Program (CTP).

The training program is approved for 35 Category 1

CEUs for physicians, psychologists, social workers,

and nurses.

Each year we welcome many mental health

professionals from across the United States and from

around the world. Most clinicians who enroll in the

program have a working knowledge about treating

the effects of trauma and PTSD and are looking to

upgrade their clinical skills. The CTP offers a broad

range of educational activities including:

* Lectures

* Clinical consultation

* Clinical observation of group treatment

* Group discussions facilitated by staff

Specific training topics include warzone trauma group

treatment, treatment of women veterans, treatment

of sexual assault related PTSD, relapse prevention,

cross cultural treatment issues, assessment and

treatment of families, disaster mental health services,

cognition and PTSD, assessment of PTSD, and

psychiatric assessment.

Training programs are scheduled for a minimum of

one week, though longer programs are available if

the applicant can justify an extended stay. Programs

are scheduled nine times per year, generally on the

third week of the month.

At present time, funding for attendance is not

available from the National Center. There is no fee

for the training program itself, but participants are

responsible for providing their own transportation,

lodging, and meals. Interested applicants are encouraged

to explore funding options through their local medical

centers or VA Employee Education System. For more

information, or to request an application, please email:

jir@icon.palo-alto.med.va.gov, or call FTS 700-463-2673, or

commercial number 650-493-5000, ext. 22673.

NC-PTSD EDUCATION & SUPPORT SERVICES

Clinical Training Program