Clinical Applications of the SIDES 21

Management of Dissociative Symptoms 26

New Directions 30

Women and Trauma: A Clinical Forum 31

Motivation Enhancement Group Therapy 32

Note to Librarians 36

Subscription Information 37

NC-PTSD Education & Support Services 38-39

INSIDE THIS ISSUE

Continued on page 23

Spring 1999, Volume 8, Issue 2, ISSN-1052-7168

During the last two decades

the role of trauma on psychological

and biological functioning has received

an enormous amount of clinical and

research attention. This effort has

found its organizing principle within

the diagnosis of Post Traumatic Stress

Disorder (PTSD). The diagnostic

criteria for PTSD focus on the intrusive

memories and disordered arousal that

are distinguishing characteristics of

post-traumatic adaptation. Within this

framework the remaining symptoms of PTSD are understood as

strategies to ward off the emotions, somatic sensations and personal

meanings associated with the trauma. However, the emergence of

pure (simple) PTSD following exposure to a traumatic stressor is the

exception rather than the rule. Extensive research (e.g., in the Field

Trials for PTSD [1-3]) has shown that for a substantial proportion of

patients with PTSD this diagnosis only describes a limited dimension

of their suffering: the majority of people who respond to a trauma

with persistent intrusive and avoidant symptoms also develop a

complex set of other, interrelated problems. Many traumatized

individuals suffer from difficulties with their regulation of affective

arousal, with impaired capacity for cognitive integration of experience

(as in dissociation), impairment in the capacity to differentiate relevant

from irrelevant information, such as occurs in the misinterpretation

of somatic sensations, and with disturbances in relation to self and

others. These phenomena have been variously described as Disorders

of Extreme Stress (1-2) and Complex PTSD (4). These problems

associated with traumatic exposure may require clinical interventions different

from those proven to be effective in simple PTSD.

CLINICAL APPLICATIONS OF THE STRUCTURED INTERVIEW

FOR DISORDERS OF EXTREME STRESS (SIDES)

BESSEL VAN DER KOLK, M.D. & DAVID PELCOVITZ, PH.D.

Research during the past

decade has shown that trauma has a

different impact on adaptation at

different stages of development, and

that trauma early in the life cycle affects

subsequent maturational processes

(e.g., 5). Early in life, when children

primarily depend on their caregivers

for modulation of their physiological

arousal, they are thought to have two

broad ranges of responses to

overwhelming stress: hyperarousal and

Profound changes in affect regulation and self-identity have

not only been observed in traumatized children. Research with rape

victims (7), battered women (8), and concentration camp survivors (9)

has shown that severe and prolonged trauma can have significant long

term impact in the areas of self-regulation and personality development.

The ICD-10 (10) recognizes the occurrence of such post-traumatic

alterations and includes a diagnostic category of lasting personality

changes following catastrophic stress which comprises impairment in

interpersonal, social and occupational functioning including a hostile

or mistrustful attitude towards the world, social withdrawal, feelings of

emptiness and hopelessness, a chronic feeling of being on edge and

constantly threatened and chronic sense of estrangement.

 Bessel van der Kolk, M.D. David Pelcovitz, Ph.D.

dissociation. These ways of coping with traumatic processes: originally put

to use to cope with traumatic experiences, they may come to be utilized

by previously traumatized individuals during periods of subsequent

stress. The literature suggests that the impact of trauma on selfregulation, self-concept and interpersonal functioning is most profound

in younger victims, and when the source of the trauma is interpersonal,

as opposed to natural disasters such as earthquakes or hurricanes (5, 6).
NC-PTSD Clinical Quarterly Volume 8 (2) Spring 1999

22

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 Design

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, Ph.D.

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

 Bruce H. Young, Editor

 The distinction between clinical subtypes and their respective

etiologies may have significant clinical implications related to treatment.

The presence of subtypes or complex PTSD, however, remains

controversial. Keane (1), for example, posits that PTSD might be the

result of a process of conditioned fear effectively transmuting simple

acute PTSD to complex chronic PTSD. Others have underscored the

relevance of pre-existing vulnerabilities to understand the course of

adaptation to trauma, e.g., prior victimization (2) personality characteristics

(3), and intergenerational response (4). Pelcovitz et al. (5) suggest that

complex PTSD is a specific response to extremely severe traumatic events

or events possibly involving interpersonal victimization. In this issue of

the NC-PTSD Clinical Quarterly, we are pleased to have Bessel van der kolk

and David Pelcovitz present their findings about the psychometric

properties and the clinical utility of the Structured Interview for Disorders

of Extreme Stress (SIDES). Findings from studies using the SIDES

may provide a rationale for inclusion of other symptom types (e.g.,

dissociation, self-destructive behavior, problems of identity) to the overall

traumatic stress response as well as contribute to the development of

specific treatment approaches for particular symptom presentations.

 Along the same line, Constance Dalenberg provides guidelines for

the clinical management of dissociative symptoms and practical

suggestions to help clients self-monitor dissociative experiences. Lastly,

senior NC-PTSD staff member, Ronald Murphy, and his colleagues

describe a treatment model designed to address client ambivalence and

increase motivation for behavioral change. Their systematic approach to

helping clients more fully engage in treatment may be appreciated by

clinicians who encounter clients who have difficulty recognizing and

understanding their own resistance to change.

Past issues of the Clinical Quarterly have been posted on our NC-PTSD

Webpage. Plans are underway to post each of the Quarterlys previously published

articles. At this point, a select number of text only articles are posted from

Volumes 1-7. Please visit our webpage:http://www.dartmouth.edu/dms/

ptsd/.

References

1. Keane, T.M., Zimering, R.T., & Caddell, J.M. (1985). A behavioral

formulation of posttraumatic stress disorder in Vietnam

veterans. Behavior Therapist, 8, 9-12.

2. Resnick, H.S., Kilpatrick, D.G., Best, C.L., & Kramer, T.L. (1992).

Vulnerability stress factors in the development of posttraumatic

stress disorder. Journal of Nervous and Mental Disorders, 180,

424-430.

3. Schnurr, P.P., Friedman, M.J., & Rosenberg, S.D. (1993). Preliminary

MMPI scores as predictors of combat-related PTSD. American

Journal of Psychiatry, 150, 479-483.

4. Yehuda, R., Schmeidler, J., Giller, E.L., & Siever, L.J. (1998).

Relationship between PTSD characteristics of Holocaust

survivors and their adult offspring. American Journal of

Psychiatry, 155, 841-843.

5. Pelcovitz, D., van der Kolk, B.A., Roth, S.H., Mandel, F.S., Kaplan,

S., & Resick, P.A. (1997). Development of a criteria set and a

structured interview for disorders of extreme stress (SIDES).

Journal of Traumatic Stress, 10, 3-16.
Volume 8 (2) Spring 1999

23

NC-PTSD Clinical Quarterly

 CLINICAL APPLICATION OF THE SIDES

subjects not included above) [n = 226]. The early interpersonal trauma

group had significantly higher percent endorsement on all complex PTSD

symptoms compared with the disaster group, while the late interpersonal trauma group had significantly higher endorsement on the items

of unmodulated anger, suicidal behavior, and somatization. The early

and late interpersonal trauma groups differed significantly on the items

of unmodulated anger, being self-destructive and suicidal, and on dissociative symptoms. Subjects who had suffered interpersonal abuse before

age 14 developed significantly more dissociative problems, as well as

difficulties modulating anger, self-destructive and suicidal behaviors, than

either the older victims of interpersonal trauma, or the victims of disaster.

These patterns of endorsement strongly support the notion that early

interpersonal traumatization gives rise to more complex post-traumatic

psychopathology than later interpersonal victimization. Exposure to

natural disasters tends to be associated with simple PTSD, and does

not seem to substantially contribute to the development of dissociative

symptomatology, somatization or affect dysregulation problems.

In a third analysis (3) 234 participants in the DSM-IV PTSD

Field Trial who reported sexual and/or physical abuse were evaluated.

Participants were categorized according to type of abuse (physical, sexual,

both), duration of abuse (acute versus chronic), and onset of abuse

(early versus late). Separate logistic regression analyses examined the

relationship between age of onset, duration, abuse type, and the lifetime

diagnosis of complex PTSD (CP) for women and men. Sexually abused

women, especially those who also experienced physical abuse, had a

higher risk of developing CP, although CP symptoms occurred at a high

base rate among physically abused women.

As a result of the DSM-IV PTSD Field Trials for PTSD most

of the symptoms enumerated in the SIDES are listed as separate

diagnoses, such as Dissociative Disorder, Somatization Disorder,

and various Axis II disorders, but also under Associated Features

of PTSD (DSM-IV, p. 425). We propose that in patients with

PTSD these symptoms do not constitute separate double

diagnoses, but represent the complex somatic, cognitive, affective,

and behavioral effects of psychological trauma, particularly trauma

that is prolonged and starts early in the life cycle.

Utility of the SIDES in Clinical Settings

 The concept of Complex PTSD raises important questions about

the treatment of people who suffer from PTSD and associated disorders.

If the fundamental deficit in people who suffer from the long-term sequelae of trauma consists of unbidden intrusions, against which the sufferer defends himself by avoiding stimuli reminiscent of the trauma, effective treatment needs to focus on desensitization of the traumatic memory,

with the goal that the afflicted individual can habituate to the conditioned

stimuli that precipitate traumatic reexperiences. Indeed, good treatment

results have been reported using such approaches. However, at present it is

unclear how various desensitization methods affect the dimensions of

traumatization enumerated in the SIDES: dissociation, somatization, affect dysregulation and altered relationships with self and others. If these

phenomena represent core features of the post-traumatic response, and

reflect problems with self-organization and stimulus discrimination, it becomes an important issue whether desensitization of the traumatic memory

also can effectively address those issues.

In the DSM-IV Field Trials for PTSD (1, 2, 4) we identified

what we considered the seven clinically most relevant issues associated

with trauma, which currently are not included in the PTSD diagnosis

(see Table 1): a) problems with self-regulation, including self-destructive

activities; b) problems with information processing, which is captured,

in part, by the phenomenon of dissociation and the diagnosis of

dissociative disorder; c) somatic functioning (as captured in the

diagnosis of somatization); d) problems with personal identity, such

as excessive self-blame, shame and being permanently damaged; e)

problems in attachment to the perpetrator; f) problems in interpersonal

relationships; and g) alterations in systems of meaning.

The DESNOS workgroup developed a structured interview,

the Structured Interview for Disorders of Extreme Stress (SIDES) to measure

the presence of these criteria. In the DSM IV Field Trial for PTSD this

interview was administered to 523 DSM IV Field Trial subjects (1, 2):

a treatment seeking sample (n=395), obtained through the assessment

of sequential admissions to five outpatient clinics and a non-treatment

seeking community sample of 128 subjects. The SIDES proved to be

a reliable and valid instrument to assess the alterations in functioning

that result from exposure to extreme stress. The inter-rater reliability

as measured by Kappa coefficients for lifetime Disorders of Extreme

Stress was 0.81. Internal consistency using coefficient alpha ranged

from 0.53 to 0.96. In one subset of 395 subjects (1) the correlations

ranged from 0.52 for PTSD and Affect Dysregulation and 0.60 for

PTSD and Somatization; all SIDES sores correlated with PTSD

symptoms at the .0001 level of significance. Subjects who suffered

interpersonal trauma as adults had significantly less dissociation and

affect dysregulation than those with interpersonal childhood trauma,

but significantly more than victims of disasters.

Zlotnick et al. (12) examined the construct validity of the

subscales of the SIDES. Using a clinical sample of 74 survivors of

childhood sexual abuse with PTSD, this study demonstrated that the

subscales of the SIDES correlated highly with instruments

hypothesized to measure similar constructs. Divergent validity was

established for each of subscales of the SIDES. Findings from this

study and other research on the psychometrics of the SIDES supported

that the SIDES is a valid measure of the associated features of PTSD

in survivors of childhood sexual abuse. In another study Zlotnick et

al. (13) found that, compared to 34 women without histories of

sexual abuse, 74 survivors of sexual abuse showed increased severity

on DESNOS symptoms of somatization, dissociation, hostility,

anxiety, alexithymia, social dysfunction, maladaptive schemas, selfdestruction, and adult victimization. In addition, a logistic regression

found that a complex of symptoms representing DESNOS was

significantly related to a history of sexual abuse. The authors concluded

that the results of this study provide support for the idea that

symptoms of DESNOS characterize survivors of sexual abuse.

In a subsequent analysis (2) subjects were divided into the

three trauma groups: early onset (age less than or equal to 13 years)

interpersonal abuse (physical and/or sexual abuse) [n = 149], late

onset interpersonal abuse [n = 87], disaster [n = 58], and other (all
NC-PTSD Clinical Quarterly Volume 8 (2) Spring 1999

24

VAN DER KOLK & PELCOVITZ

The SIDES provides clinicians and researchers with a

rational way of measuring the associated features of PTSD. The

measure allows for further studies to provide empirical support

for expanding the current PTSD DSM-IV diagnosis to include an

additional category of Disorders of Extreme Stress (14, DES,

Davidson, 1993). It can also guide clinicians to set priorities in the

care of traumatized patients. From a research point of view, it

provides a vehicle for the systematic study of post-traumatic changes

across different trauma populations. The SIDES has already been

used to study treatment outcome. In one study, Zlotnick et al. (15)

studied the clinical efficacy of an affect-management group for

women with posttraumatic stress disorder and histories of

childhood sexual abuse. Subjects who completed the affectmanagement treatment group reported significantly fewer posttreatment symptoms of both PTSD and a variety of associated

features than subjects in the wait list control condition. Similarly,

in a study evaluating the efficacy of fluoxetine in PTSD (14), we

found that this drug, while not significantly improving PTSD

symptoms in a chronic veterans population did have a beneficial

effect on interpersonal difficulties, while improving problems with

affect dysregulation in the entire sample.

 In the Zlotnick et al. study (13), they examined clinical

efficacy of an affect management group for women with

posttraumatic stress disorder and histories of childhood sexual

abuse. Subjects who completed the affect-management treatment

group (n=17) reported significantly fewer post-treatment

symptoms of both PTSD and a variety of associated features than

subjects in the wait list control condition (n = 16). The SIDES was

also used in a study to further the understanding of the mechanisms

of self-mutilative behavior in female inpatients (15). The study

found that self-mutilators (n=103) displayed a greater degree of

dissociative symptoms and alexithymia and a greater number of

self-injurious behaviors, as well as higher rates of childhood sexual

abuse, than non-mutilators (n=45). Both dissociative symptoms

and alexithymia were independently associated with self-mutilative

behavior.

Clinical Applications of the SIDES

 For the past several years we have used the SIDES in our

clinical evaluations of a wide variety of traumatized populations. After taking a careful, developmentally based, trauma history we use the

SIDES to elicit information regarding the overall effects of trauma. It

has been particularly valuable in identifying the most critical areas of

psychological impairment which need to be addressed for effective

treatment planning. Post-traumatic patients with high degrees of difficulties on the dimensions of affect regulation, dissociation or somatization may require a different treatment approach than patients who

suffer from simple PTSD. The significance of these symptoms needs

to be examined by a careful investigation of the particular constellation

of impairment. The concept of Complex PTSD raises important questions about the treatment of people who suffer from PTSD and

associated disorders. If the fundamental deficit in people who suffer

from the long-term sequelae of trauma consists of unbidden intrusions, against which the sufferer defends himself by avoiding stimuli

reminiscent of the trauma, effective treatment needs to include desensitization of the traumatic memory, with the goal that the afflicted

individual can habituate to the conditioned stimuli that precipitate traumatic reexperiencing symptoms. However, at present it is unclear how

such desensitization affects these other dimensions associated with

traumatization. If dissociation, problems with attention and stimulus

discrimination, affect dysregulation and altered relationships to self

and others are core features of the post-traumatic response, desensitization may not be able to effectively address those issues.

 Despite the favorable treatment outcome studies using cognitive/behavioral treatments aimed at controlling traumatic intrusion, most

clinicians treating traumatized patients continue to practice some form of

psychodynamic therapy. This raises the question whether these clinicians

are misguided in their choice of interventions, or whether patients who

carry the diagnosis of PTSD primarily seek treatment not for their intrusive symptoms, but for dealing with other problems associated with

PTSD, such as affect dysregulation, dissociative problems, and difficulties

with trust and intimacy, which may respond best to dynamic therapies.

No treatment studies of PTSD have as yet addressed those questions.

 Disturbances related to arousal, attention and stimulus discrimination may be most usefully addressed by helping patients acquire skills that help them label and evaluate the meaning of sensations and affective states, to discriminate present from past, and to

interpret social cues in the context of current realities rather than past

events. Linehan (1993) for example, has developed sophisticated programs that address includes the identification and labeling of emotions, the identification and appropriate utilization of social supports,

focusing on content, rather than affects; scheduling, planning and

anticipating; the judicious use of exercise and food; mindfulness

training, relaxation and stress inoculation exercises.

 Fully effective treatment may require a strategically staged, multimodal treatment approach. On the one hand, a treatment that emphasizes cognitive reorientation to the present, while disregarding past

trauma, may insufficiently address the reliving of the trauma in images,

feelings, or behavior. On the other hand, a treatment approach that

focuses prematurely on exploration of the past may exacerbate, rather

than relieve intrusive affective and somatic symptoms. With appropriate timing, however, different treatment modalities might well be employed in complementary fashion. Thus, recognition of the complex

nature of adaptation to traumatic life experiences may lead to further

developments of a more comprehensive treatment approach to traumabased psychiatric disorders.

References

1. van der Kolk, B.A., Pelcovitz, D., Roth, S.H., Mandel, F.S, McFarlane,

A.C., & Herman, J.L. (1996). Dissociation, somatization, and

affect dysregulation: The complexity of adaptation to trauma.

American Journal of Psychiatry, 153, (Festschrift Supplement),

83-93.

2. Pelcovitz, D., van der Kolk, B.A., Roth, S.H., Mandel, F.S., Kaplan,

S., & Resick, P.A. (1997). Development of a criteria set and a

structured interview for disorders of extreme stress (SIDES).

Journal of Traumatic Stress, 10, 3-16.
Volume 8 (2) Spring 1999

25

NC-PTSD Clinical Quarterly

 CLINICAL APPLICATION OF THE SIDES

Table I: Sample scoring Report

Key: First column: life time present or not.

Second column: current severity:

0= none at all, never,

1= sometimes, somewhat

2= often, moderate,

3= severe, all the time

Name: __________

DES  NOS Results

Lifetime Present Severity

I. Alteration in Regulation of Affect and Impulses

a) Affect Regulation Yes 2.0

b) Modulation of Anger Yes 2.5

c) Self-destructive No 0.0

d) Suicidal Preoccupation Yes 1.0

e) Difficulty Modulating Sexual Involvement Preoccupation Yes 1.5

f) Excessive Risk Taking Yes 2.0

II. Alterations in Attention or Consciousness Yes 2.0

a) Amnesia Yes 2.0

b) Transient Dissociative Episodes and Depersonalization Yes 2.0

III. Alteration in Self-Perception

a) Ineffectiveness Yes 2.0

b) Permanent Damage Yes 2.0

c) Guilt and Responsibility Yes 1.5

d) Shame Yes 2.0

e) Nobody can Understand Yes 0.0

f) Minimizing No 0.0

IV. Alterations In Perception Of The Perpetrator No 0.0

a) Adopting Distorted Beliefs No 0.0

b) Idealization of Perpetrator No 0.0

c) Preoccupation with Hurting Perpetrator No 0.0

V. Alterations in Relationships with Others Yes 1.5

a) Inability to Trust Yes 3.0

b) Revictimization No 0.0

c) Victimizing Others No 0.0

VI. Somatization Yes 0.6

a) Digestive System Yes 0.6

b) Chronic Pain Yes 3.0

c) Cardiopulmonary Symptoms Yes 0.0

d) Conversion Symptoms Yes 0.0

e) Sexual Symptoms No 0.0

VII.Alterations in Systems of Meaning No 0.0

a) Foreshortened Future Yes 0.0

b) Loss of Previously Sustained Beliefs No 0.0
NC-PTSD Clinical Quarterly Volume 8 (2) Spring 1999

26

3. Roth, S.H., Newman, E., Pelcovitz, D., van der Kolk, B.A., &

Mandel, F.S. (1997). Complex PTSD in victims exposed to sexual

and physical abuse: results from the DSM-IV Field Trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress, 10, 539-

555.

4. Herman, J. L. (1993). Sequelae of prolonged and repeated trauma:

evidence for a complex posttraumatic syndrome (DESNOS).

In J.R.T. Davidson & E.B. Foa (Eds.), Posttraumatic stress

disorder: DSM-IV and beyond , (pp. 213-228), Washington, DC:

American Psychiatric Press.

5. Cole, P., & Putnam, F.W. (1992). Effect of incest on self and social

functioning: A developmental psychopathology perspective.

Journal of Consulting and Clinical Psychology, 60, 174-184.

6. Pynoos, R.S. (1993). Traumatic stress and developmental psychopathology in children and adolescents. In J. Oldham, M. Riba

& A. Tasman (Eds.), Review of Psychiatry, 12, (pp. 205-238).

Washington, DC: American Psychiatric Press.

7. Burgess, A. & Holmstrom, L. (1974). Rape trauma syndrome.

American Journal of Psychiatry, 131, 980-986.

8. Walker, L.E. (1984). The battered woman syndrome. New York:

Springer Publishing Co.

9. Krystal, H. (1968). Massive psychic trauma. New York: International University Press.

10. International Statistical Classification of Diseases and Related Health

Problems. (1992). World Health Organization: New York.

11. Zlotnick, C., & Pearlstein, T. (1997). Validation of the Structured

Interview for Disorders of Extreme Stress. Comprehensive

Psychiatry, 38, 243-247.

12. Zlotnick, C., Zakriski, A.L., Shea, M.T., Costello, E., Begin, A.,

Pearlstein, T., & Simpson, E. (1996). The long-term sequelae

of sexual abuse: support for a complex posttraumatic stress

disorder. Journal of Traumatic Stress, 9, 195-205.

13. Zlotnick, C., Shea, M. T., Rosen, K.H., Simpson, E., Mulrenin,

K., Begin, A., & Pearlstein, T. (1997). An affect-management group for women with posttraumatic stress disorder

and histories of childhood sexual abuse. Journal of Traumatic

Stress, 10, 425-436.

14. van der Kolk, B.A., Dreyfuss, D., Berkowitz, R., Saxe, G., Shera,

S., & Michaels, M. (1994). Fluoxetine in Post Traumatic Stress.

Journal of Clinical Psychiatry, 55, 517-522.

15. Zlotnick, C., Shea, M.T., Pearlstein, T., Simpson, E., Costello,

E., Begin, A. (1996). The relationship between dissociative

symptoms, alexithymia, impulsivity, sexual abuse, and selfmutilation. Comprehensive Psychiatry, 37, 12-16.

16. McFarlane, A.C., Weber, D.L., & Clark, C.R. (In press). Abnormal stimulus processing in PTSD. Biological Psychology.

17. Linehan, M.N. (1993). Cognitive-behavioral treatment of border-line personality disorder. New York: Guilford Press.

Bessel van der Kolk, M.D., is Director of the Trauma Center at human Resources Institute Hospital in Brookline, MA and Associate Professor

of Psychiatry at Harvard Medical School. Dr. van der Kolk is a past President

of the International Society for Traumatic Stress Studies and has done extensive

research on developmental and biological aspects of the human adaptation to

trauma, including the study of traumatic memories.

David Pelcovitz, Ph.D., is chief child and adolescent psychologist at North

Shore University Hospital-NYU School of Medicine, and Clinical Associate

Professor of Psychology in Psychiatry at NYU School of Medicine. Dr. Pelcovitzs

current research and publications is on post-traumatic reactions in physically abused

adolescents and adolescents exposed to marital violence.

A copy of the SIDES is available by e-mailing to

bvanderk@traumacenter.org, or by writing to HRI Trauma Center

Research Department (c/o Dr. James Hopper), 227 Babcock Street,

Brookline, MA 02116. The cost is $25 for a copy of the written, selfadministered SIDES instrument, as well as the Traumatic Antecedents

Questionnaire (TAQ), and a self-administered PTSD scale. A

computerized, self-administered version of these three instruments is

available for $250.

VAN DER KOLK & PELCOVITZ
Volume 8 (2) Spring 1999

27

NC-PTSD Clinical Quarterly

THE MANAGEMENT OF DISSOCIATIVE

SYMPTOMS IN PTSD PATIENTS

CONSTANCE J. DALENBERG, PH.D.

Of the many symptoms that

form the diagnostic cluster that we

label PTSD, dissociative

experiences are often the most

emotionally disturbing to the

patient. Dissociation typically is

described as disruption in the

integration of consciousness,

identity, memory or perception.

As Judith Armstrong, James High

and I argued in a recent workshop

for the International Society for the

Study of Traumatic Stress (1), such

symptoms deserve focused clinical

attention for a number of reasons.

1. First, the phenomenological experience of dissociation

(such as the depersonalization or derealization experience)

is distressing for virtually anyone who must live through

it. The feeling of estrangement from the self or ones

environment is terrifying for the dissociative patient, as is

the knowledge that one is not in command of the self

experience.

2. Dissociation can result in practical problems for the patient,

interfering with the performance of social and occupational

activities. The multiple problems in memory also interfere

with any long-term relationship.

3. Dissociative clients are poor predictors of danger (2). They

are over-represented among those who tend to see danger

and ill-intent everywhere, alienating their well-meaning

friends and colleagues. Ironically, they also are overrepresented among those who do not recognize evil even

when it brandishes its claws and fangs. The therapist of

such a client often feels as if he or she was watching a bad

horror film, shouting internally at the young victim-to-be

as she invites the killer into the house. (No, no, you fool.

Lock the door. Cant you see youre in danger?) Both the

underprediction and the overprediction of danger can

precipitate crises for the patient.

4. Dissociation is an impediment to self-understanding for

the client (3-4). For those of us with cognitive or

psychodynamic orientations, who believe that predicting

and understanding the self is a key to developing strategies

to change attitude and behavior, this obstacle is an important

one to target in therapy.

5. Since dissociative symptoms may render the patient a less

reliable reporter of his or her own emotional or cognitive

life (4), they can undermine (or make more difficult) the

accurate diagnosis of the patient. The diagnosis of PTSD

requires someone, typically the patient, to connect

symptoms and memories (5), e.g., to know that a situation

is being avoided because it is a reminder of a trauma. If

the client is unaware of a symptom-trauma connection,

and cannot provide an accurate history of the onset and

course of symptoms, the diagnosis of PTSD is much more

difficult to support.

6. Finally, dissociation may be an impediment to treatment

in general (4-5). Dissociating clients will find it difficult

to describe current triggers to distress, and may report

confusing transference reactions (or emotional reactions to

the therapist) that cannot easily be described (3, 6).

For these reasons and others, it is important to recognize dissociative

symptoms and specifically target them in PTSD treatment.

Targeting Dissociation within the Session

The most important initial goal to be undertaken by treating

professionals is to teach the client to recognize the presence of

dissociation, which naturally involves improving our own ability to

recognize it. One common form of dissociation is the disruption in

the ownership and recognition of emotion, experienced by the patient

as a disconnection between emotional life and present experience. Less

commonly noted forms of dissociation that can occur within sessions

include shifts in topic combined with loss of memory (What was I

saying?), a distant or minimizing verbal style (I was somewhat upset

when it happened) or a sense of distance and disconnection between

therapist and client (1,4, 7-8).

The feeling of estrangement from the self is terrifying

for the dissociative patient, as is the knowledge that

one is not in command of the self experience.

When such events occur, it is helpful to draw attention to

them immediately, but with the understanding that repeated labeling

will be necessary before the client typically accepts that the pattern

actually exists. It is difficult for a client or therapist to be argue with

conviction that a single example of topic-veering was dissociative,

that is, that it was an effort to avoid the self-awareness of painful

thoughts or emotions. Once a pattern of avoidance is identified,

however, the therapist might comment Ive been noticing that every

time I raise the issue of x, you seem to think of another topic to

raise. Is that something you have noticed? If the client replies that

it is not, the therapist is wise to initially accept the clients view. If

the therapist is correct, the avoidance pattern will reoccur. When

and if it does, the therapist might gently remark, Theres that pattern

again. It looks like when we begin to talk about x, it might make you

uncomfortable and you divert. Do you think thats possible?

 Constance Dalenberg, Ph.D.
NC-PTSD Clinical Quarterly Volume 8 (2) Spring 1999

28

It is critical in these initial recognition stages to empathize

with the patients resistance or unwillingness to let another person

label his or her internal state, even a therapist. This resistance is

normal, and has both defensive and healthy functions. If we assume

that a given content is dissociated because it is disconcerting to

accept (or even re-traumatizing), we should hardly expect that the

same content will be greeted warmly by the patient when the

therapist reintroduces it. Additionally, it is healthy for the client to

protect some sense of ownership of the self and to resent therapist

intrusion in the form of interpretations of what might be

unconsciously felt. Therefore, the process of labeling dissociative

diversions typically must include a normalization of this tendency,

often through therapist disclosure. Havent you ever had the

experience of not knowing you were angry or sad until someone

else noticed that you were acting a certain way? I know I have. It

may be that you do feel badly about x, but it passes too quickly for

you to feel it because you push it out of your mind so fast. A

therapist stance of compassionate and non-judgmental curiosity can

facilitate a similar or parallel state in the patient. Bringing the clients

resistance to consciousness also is useful, again often accomplished

most effectively through disclosure. I know I dont like it when

someone else tries to tell me what I probably feel, and I am not

trying to do that. I think thats what is making you a little angry. Im

just inviting you to join me in noticing how it is that you keep moving

away with so much energy when I raise the issue of x. What do

you think that might be about? I thought you might be feeling y,

but maybe its something else.

The client often believes that to be

angry is to risk flying out of control, to

be sad is to risk devastation and suicide,

and to be nervous is to risk freezing

in terror or running from the scene.

While there are methods of treating dissociation that are

useful to the patient outside of therapy, which will be briefly discussed

below, the in-session focus is typically the key to successful treatment.

Prior to therapy, the triggers that lead to the onset of dissociation are

often unconscious. The patient thus typically must be taught to

recognize the specific precursors that trigger this state and the signs

that dissociation has occurred or is occurring. Since one effect of

dissociation is to distort or interfere with long-term memory, the

patient may not recall these specifics. This is likely to require the

therapists vigilant attention within the therapeutic hour, so that these

internal or external events may be brought to the patients conscious

awareness. Some excellent examples of such therapist interventions

are given in Vaillants (9) text on short-term anxiety-regulating

psychotherapy.

Once the patient accepts that a thought or emotion is being

cut off or dissociated, the therapist can begin a titration of guided

brief experiences that allow the client to contemplate the typically

avoided material (5). The client should be encouraged to consider

what it would mean to believe x or to feel y. In so doing, the therapist

may underline the value of the emotions to a client who has a negative

DALENBERG

view of them. The client often believes that to be angry is to risk

flying out of control, to be sad is to risk devastation and suicide, and

to be nervous is to risk freezing in terror or running from the scene.

But the ability to feel sadness, for instance, is also a sign of the capacity

for compassion, intimacy and connection. If one values something

or someone, one is sorry for the damage or loss of that entity. Sadness

can lead to a wish to fill the void or to mend the tear in the clients

relational world. In such cases, the therapist is trying to reduce the

need for dissociation by reducing the intensity of the negative

emotions. This occurs both through reframing the emotions in a

more positive light and through teaching emotional risk management

techniques (e.g., anger management or relaxation to mitigate anxiety).

It may initially seem awkward to teach anger management to a client

who claims to feel little anger, but when fear of anger is present, this

technique may be necessary (5). Guided experiences of allowing the

client to feel the rejected emotions in a safe environment (in which

they can be contained through emotion management, if necessary)

are effective routes to this end (8).

It is also worthwhile to teach the client methods to break out

of an acute dissociative state. Treatment research of clinical interventions

with acute states of dissociation has indicated that asking the patient to

engage in a brief task (of any sort) that involves visual-spatial description,

e.g., touching something while they describe the feel and look of the

object is effective (1). This intervention in part rests on the theory that

dissociation during the acute stage is a disorder of attention, during

which time the patient is unable to be fully mindful (10-11). The

patient also may be taught to more consciously control the dissociative

state (much as we teach the stutterer to stutter on purpose to control

verbalization by bringing on dissociation through the use of imagery

(drifting away from the body, relaxation exercises). The patient then is

taught to return to clear consciousness through verbal spatial narrative

(such as the verbal description of spatial objects described earlier). Body

consciousness exercises, such as observed breathing also serve to disrupt

dissociation in the moment. These skills are described along with other

useful techniques with dissociative and non-dissociative borderline clients

in Linehans workbook (12). Skill development requires regular practice

during and between sessions.

Recommendations for the Client for Use Between Sessions

In a prospective study of 8 women with persistent dissociative

symptoms, Dalenberg et al. (1997) found that most women made

significant gains (defined as reduced self-reported dissociation and

increased productivity) before the cognitive interventions described above

were instituted (1). These gains appeared to be due to the practical selfcare interventions made in Phase 1 of the study, which included exercise,

more attention to maintaining a regular sleep pattern, and a small change

in diet (toward increased reliance on fruits and vegetables and lowered

intake of sugars). These forms of attention and care for the body not

only combat depression but also enhance bodily awareness and increase

energy. A decrease in dissociation as measured by our State Dissociation

Measure appears to naturally accompany these bodily changes (although

this change in the self-reported clarity of cognition may be due to reasons

other than decreased dissociation).

Outside the session, the client also may be given specific help

to organize experience in a more coherent and linear way. The techniques

described below serve not only to provide more usable data for the
Volume 8 (2) Spring 1999

29

NC-PTSD Clinical Quarterly

   

7. Bernstein, E., & Putnam, F. (1986). Development, reliability

and validity of a dissociation scale. Journal of Nervous

and Mental Diseases, 174, 727-735.

8. Bremner, J., & Brett, E. (1997). Trauma-related dissociative states

and long-term psychopathology in posttraumatic stress

disorder. Journal of Traumatic Stress, 10, 37-49.

9. Vaillant, L. (1997). Changing character: Short-term anxietyregulating psychotherapy for restructuring defenses, affects,

and attachment. New York: Basic Books.

10. Langer, E. (1989). Mindfulness. New York: Addison-Wesley.

11. Teasdale, J., Segal, Z., & Williams, J. (1995). How does cognitive

therapy prevent depressive relapse and why should attentional

control (mindfulness) training help? Behavioral Research

and Therapy, 33, 25-39.

12. Linehan, M. (1993). Skills training manual for treating borderline

personality disorder. New York: Guilford Press.

Dr. Constance Dalenberg is the Director of the Trauma Research Institute, and

Associate Professor at the California School of Professional Psychology in San

Diego. Her private clinical and forensic practice focuses on the assessment and

treatment of child abuse survivors. Her publications and presentations center on

the understanding of child abuse memory and testimony, and on the consequences

of trauma in the lives of children and adults.

References

1. Dalenberg, C., Armstrong, J., & High, J. (1997). Evaluating,

managing and treating the dissociative symptom in posttraumatic stress disorder Pre meeting Institute: Annual

meeting of the International Society for the Study of Traumatic

Stress Studies, Montreal.

2. Hedges, L. (1994). Remembering, repeating, and working through

childhood trauma. New York: Jason Aronson.

3. Davies, J., & Frawley, M. (1994). Treating the adult survivor of

childhood sexual abuse. New York: Basic Books.

4. Briere, J. (1996). Therapy for adults molested as children: Beyond

survival. New York: Springer.

5. Jacobs, W.J., & Dalenberg, C. (1998). Subtle presentations of

posttraumatic stress disorder: Diagnostic issues. Psychiatric

Clinics of North America, 21, 835-846.

6. Liotti, G. (1992). Disorganized/disoriented attachment in the

etiology of dissociative disorders. Dissociation, 5, 196-

204.

therapeutic hour, but also to directly counteract the habitual

dissociation of the highly traumatized patient.

Briefly, the severely dissociative patient will dissociate in an

event-specific and an emotion-specific way. As the connections between

event, emotion, and symptom are clarified and stripped of their capacity

to cause terror, this type of dissociation (which I call Type I dissociation)

decreases. However, dissociation may lose its connections to its causal

roots and become habitual, resulting in more generalized dissociative

states (Type II) wherein the person becomes less aware of environmental

triggers in general. Type II dissociation is a partial protector against the

more acutely painful Type I experiences (since the triggers that occur

during these periods may not be processed at all). Thus, as stated

earlier, it is important to conceptualize Type II dissociation in part, as

an attentional disorder, the result of which is a disruption in the

coherency, flow, and story-like quality of daily life. Utilizing selfmonitoring techniques aids the patient in becoming more habitually

conscious of daily life (decreasing Type II dissociation) and more aware

of the triggers of acute episodes (allowing therapy to more effectively

combat Type I dissociation).

The self-monitoring technique I most frequently use to help

the client recognize and track dissociation-laden emotional reactions.

For example, when the client is exhibiting an intense emotional reaction,

I ask him or her to reflect on the following questions:

1. Do you know what triggered the reaction?

(No is the dissociation answer.)

(a) If not, write out a brief account of what you were

thinking, feeling, or doing directly before the

reaction.

(b) If you believe you know the reason, write out the

experience in concrete terms (that is, so that an actor

could reproduce the scene exactly).

2. Think about the trigger, if you know what it might be. Does

your reaction seem as if it is strong in comparison to the event

that triggered it? (Yes is the dissociative answer).

3. How would you wish to respond to this situation? Write out

a response as if it were stage directions to an actor.

It is not surprising that the act of self-monitoring tends to

decrease self-reported symptoms even with no other therapeutic

interventions. Within sessions, the results of the self-monitoring

exercise may be examined with an eye to identification of triggers to

dissociation.

It may be heartening to add that we have found that the

multimodal intervention of self-monitoring, encouragement of selfcare, and in-session cognitive interventions outlined above is effective

in most cases even among treatment failures from other modalities.

Furthermore, successful treatment of the dissociative symptom can be

a turning point in the management of the chronic PTSD patient.
NC-PTSD Clinical Quarterly Volume 8 (2) Spring 1999

30

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

 Executive Director, NC-PTSD

There were many exciting research and educational presentations by National Center for PTSD professionals at the

Annual Meeting of the International Society for Traumatic Stress Studies (ISTSS) recently held in Washington, DC from November

19-23, 1998. The relevance and diversity of National Center initiatives can be ascertained by a brief glance at the ISTSS

program. Broad topics covered included: treatment research, practice guidelines, clinical training, diagnostic assessment, and

gender and cross-cultural issues in PTSD. Specific presentations focused on Persian Gulf veterans, psychobiological findings,

primary care/health issues, and disaster mental health. In all, professionals from the National Center made 43 formal presentations

and displayed 14 posters at the XIV Annual Meeting of ISTSS.

Reflecting the National Center's high priority on treatment research, many presentations focused on treatment research or

clinical training. Special half- or full-day training sessions were devoted to the cooperative study on group treatment for PTSD

(Paula Schnurr, Ph.D.); cost-effectiveness/quality-of-life measurement in outcomes research (Lynda King, Ph.D.); screening for

traumatic experiences and PTSD symptoms (Eve Carlson, Ph.D.); and treatment in a cross-cultural context (Beth Stamm,

Ph.D.).

Research papers, presentations and posters on treatment and assessment focused on advances in cognitive-behavioral

treatment (Terry Keane, Ph.D.), new data analytic strategies for outcomes research (Dan King, Ph.D. and Eve Carlson, Ph.D.),

treatment of veterans who report atrocities (Ray Scurfield, D.S.W.), stages of change in assessment and treatment of PTSD

(Ron Murphy, Ph.D.), and cross-cultural issues in treatment (Beth Stamm, Ph.D.). In addition, a number of new assessment

instruments are in various stages of validity and reliability testing to measure: warzone traumatic experiences of women (Annabel

Prins, Ph.D.), lifetime trauma in veterans (Karen Krinsley, Ph.D.), global functioning among PTSD patients (Rose Zimering,

Ph.D.), preliminary findings on the Brief Trauma Interview (Melanie Vielhauer, Ph.D.), and an analysis of PTSD and alcohol use

(Jeff Knight, Ph.D.).

Notable psychophysiological/psychobiological presentations reported on brain imaging studies showing hippocampal

dysfunction among female child abuse survivors with PTSD (Doug Bremner, M.D.); sleep abnormalities in PTSD (Steve

Woodward, Ph.D.); and heightened autonomic responses to novel trauma-irrelevant stimuli in PTSD (Steve Woodward, Ph.D.).

There were also a number of presentations on PTSD as a risk factor for medical problems and the implications of these

findings for primary care practitioners and for comprehensive health screening protocols (Paula Schnurr, Ph.D., Danny Kaloupek,

Ph.D., and Greg Leskin, Ph.D.).

Anger, aggression, and cycles of violence, especially as they affect children and often as they are expressed cross-culturally,

were the subjects of a number of presentations. Claude Chemtob, Ph.D., Beth Stamm, Ph.D., Eve Carlson, Ph.D., Deborah

Dowdall, Ph.D., Glen Saxe, M.D., and Greg Leskin, Ph.D. were especially prominent with respect to this important area of

concern.

Other presentations worth noting include coping strategies and combat stress among Persian Gulf veterans (Erica

Sharkansky, Ph.D.); ASD and PTSD among recently traumatized children (Glen Saxe, M.D.); religious participation among

combat veterans with/without PTSD (Kent Drescher, Ph.D.); and the beneficial effects of participating in a research protocol

by patients recently hospitalized for a trauma-related injury (Joe Ruzek, Ph.D.).

Several presentations should be singled out because of their important impact on the PTSD field in general and on the

VA's mission in particular. Edna Foa, Ph.D., Terry Keane, Ph.D., and Matt Friedman, M.D., Ph.D. (co-editors) presented the

final draft of the ISTSS-sponsored comprehensive Practice Guideline on PTSD that includes guidelines for all treatment

approaches currently available. This ISTSS initiative is coordinated with VA's Mental Health Practice Guidelines Project that is

directed by Larry Lehmann, M.D.

Julian Ford, Ph.D. chaired an all-day specialty training course on disaster mental health: research, practice, and policy

developments. This presentation was the culmination of National Center efforts to develop a coordinated and coherent

approach to disaster mental health. Other participants were Jane Morgan, R.N. (American Red Cross), Ann Norwood, M.D.,

Col. James Stokes (Department of Defense), Robert DeMartino, M.D., Brian Flynn, Ed.D. (Health and Human Services),

Larry Lehmann, M.D., John Tassey, Ph.D., Paul Ofman, Ph.D. (VA), Joseph Gelsimino, Ph.D., and Rod Haug, Ph.D. (RCS),

Connie Boatwright, R.N. (VAEMSHG), Robert Ursano, M.D. (Uniformed University of the Health Sciences), Joseph Barbera,

M.D. (George Washington University), Betty Pfefferbaum, M.D. (University of Oklahoma Health Sciences Center), Gerald

Jacobs, Ph.D. (Disaster Mental Health Institute), Patricia Tritt, R.N. (EMS, Colorado), Ann Carr (Family Support Network), and

Fred Gusman, M.S.W., Bruce Young, L.C.S.W., and Claude Chemtob, Ph.D. (National Center for PTSD).

continued on page 36
Volume 8 (2) Spring 1999

31

NC-PTSD Clinical Quarterly

 WOMEN AND TRAUMA: A CLINICAL FORUM

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

This column is devoted to increasing understanding of the role of trauma in womens lives and improving approaches to the

professional care of women who have experienced trauma. Clinicians and researchers are invited to exchange information

through brief articles, literature reviews, and commentaries. If you wish to have material included in this column or would like

to suggest topics to be covered here, please contact Marie Caulfield, Ph.D., Womens Health Sciences Division 116B-3, National

Center for PTSD, Boston VA Medical Center, 150 S. Huntington Ave., Boston, MA 02130 or at e-mail address

caulfield.marie@boston.va.gov.

The Role of the Mental Health Professional in Addressing the Physical Complaints of Trauma Survivors

 Marie B. Caulfield, Ph.D.

Clinicians and researchers alike have found that trauma survivors are likely to experience not only emotional symptoms and

difficulties but also may report a wide range of physical complaints and medical conditions. This appears to be particularly true of

female survivors of sexual assault (1, 2). Because the physical complaints of trauma survivors may be out of the range of the expertise

of the non-medical mental health professionals, these issues may present a challenge in working with trauma survivors. This column

discusses some ways that non-medical mental health professionals can aid the trauma survivor around physical and medical complaints, including the role of the mental health provider as adjunct to primary health care.

Mental health professionals generally do not have training in medical problems or treatments. However, they are trained

uniquely well in the science and art of assessment. An initial contribution that mental health professionals can make to the medical care

of their clients is instruction and coaching on self-observation and tracking of symptoms. This is particularly relevant for trauma

survivors who often present with chronic global physical complaints.

For example, a rape survivor may report a range of vague somatic complaints to both her medical and mental health care

providers. By working with her to systematically record symptoms (e.g., pain, fatigue, sleeplessness, gynecological difficulties), mental

health providers can help the client recognize patterns in the symptoms and improve her understanding of these symptoms. In

addition, clear well-recorded information will aid the clients primary care provider in working with the client to address medical causes

and prescribe treatment. Because the mental health professional is likely to have longer-term and more regular contact with the client

than does the primary care provider, the mental health provider can be an important source of information for the medical provider on

the course and severity of physical and psychological symptoms.

Mental health professionals can also aid primary and specialty medical care providers when invasive diagnostic or treatment

procedures are necessary. For example, rape survivors and survivors of child sexual abuse often have substantial gynecological

problems and may experience intense emotional distress around necessary gynecological procedures. Trauma survivors more generally may experience fear or anger during any procedure that leaves them in a vulnerable state, for example, under anesthesia or any

kind of restraints, with tubes down their throat, or with an oxygen mask on their face. Pressuring clients to submit to such procedures

is likely to damage rapport with the patient or discourage the patient from seeking further care.

When such procedures are necessary, however, mental health providers can provide instruction in behavioral medicine

techniques, such as relaxation, imagery, and distraction (3). They can also help the client determine other aspects of the situation that

would make the procedure easier, e.g., having a family member present, listening to music during the procedure, or obtaining more

information about the procedure. Although long-term psychological work may be necessary for trauma survivors to address the wide

range of emotional sequelae of trauma, this type of educational and behavioral intervention may be sufficient for these clients to

tolerate a necessary health care procedure. Working with the client on such preparation can often be done in 1-3 sessions and these

interventions have been cited as major ways in which mental health professionals such as psychologists can decrease the costs of

medical health care (4).

1. Koss, M.P., & Heslet, L. (1992). Somatic consequences of violence against women. Archives of Family Medicine, 1, 53-59.

2. Kimerling, R., & Calhoun, K. (1994). Somatic symptoms, social support, and treatment seeking among sexual assault victims.

Journal of Consulting and Clinical Psychology, 62, 333-340.

3. Horne, D.J., Vatmanidis, P., & Careri, A. (1994). Preparing patients for invasive medical and surgical procedures: II. Using psychological interventions with adults and children. Behavioral Medicine, 20, 15-21.

4. Groth-Marnat, G., & Edkins, G. (1996). Professional psychologists in general health care settings: A review of the financial efficacy

of direct treatment interventions. Professional Psychology: Research and Practice, 27, 161-174.

Dr. Caulfield is a Clinical Psychologist and the Deputy Director for Operations at the Womens Health Sciences Division

of the National Center for PTSD in Boston. She works clinically with women veterans who have experienced trauma.
NC-PTSD Clinical Quarterly Volume 8 (2) Spring 1999

32

MOTIVATING VETERANS TO CHANGE PTSD

SYMPTOMS AND RELATED BEHAVIORS

 RONALD T. MURPHY, PH.D., REBECCA P. CAMERON, PH.D.,

LOIS SHARP, M.S.& GILBERT RAMIREZ, M.A.

Combat veterans receiving treatment for PTSD typically

report chronic, long-term difficulties due to PTSD symptoms and

co-morbid problems such as substance abuse. Treatment programs

usually focus on teaching veterans new coping behaviors and selftalk with the aim of suppressing or replacing maladaptive behavior,

cognitions, and emotions. Also, veterans often participate in exposure treatments or desensitization tasks, in which they are expected

to approach feared or unpleasant cues and memories without resorting to avoidance-based coping strategies.

These approaches are based on the assumption that combat

veterans in treatment are ready to give up long-held styles of thinking

and acting. Unfortunately, clinical experience and our own data have

indicated that combat veterans in treatment are often ambivalent about

changing not only common problems associated with PTSD such as

substance abuse, but also the symptoms of PTSD themselves. One

reason for this may be that trauma-based perceptions of the world

often feel right, i.e., adaptive and protective with regard to safety and

interacting with others. For example, combat veterans with PTSD

often react strongly to challenges to their beliefs about the appropriateness of their mistrust of others, hypervigilance, and need for weapons.

Viewing trauma-based behaviors and cognitions as problematic is often a difficult leap to make for trauma survivors. In addition, problems commonly co-occurring with PTSD such as substance use and

poor relationship skills (e.g., aggressiveness, problems in expressing

feelings, conflict resolution, and lack of warmth) frequently are not

seen as problematic because individuals often learned these behaviors

in environments (e.g., military, families, and neighborhoods) where

they were the norm. This may also be true for PTSD symptoms, that

is, many Vietnam veterans grew up with fathers who experienced combat trauma (i.e., World War II veterans).

Patients will not learn new coping behaviors or ways of

thinking if they are ambivalent about the need to change these old

ways of being. As we discuss later, this may be a factor in poor

outcome in studies of standard VA treatments: patients are not

likely to learn or practice new coping skills if not sure of the need

to do so.

To help patients engage in treatment, we have developed

and evaluated a group treatment protocol, called the Motivation

Enhancement (ME) Group, which aims to raise motivation to change

PTSD symptoms and related problem behaviors. The ME group

targets problem behaviors which patients report ambivalence about

changing or feel no need to change. The goal of the group is to help

patients make decisions about the need to change any behaviors,

coping styles, or beliefs not previously recognized as problematic, in

order to increase engagement in treatment and promote good posttreatment functioning.

The group is conceptually based on the Stages of Change

model of readiness to change (Prochaska & DiClemente, 1983), and

draws specific interventions from the literature on motivational interviewing techniques (Miller & Rollnick, 1991). The Stages of Change

model posits that individuals are at different levels of readiness to

change any particular problematic behavior and that different psychoeducational or therapeutic techniques are needed at each stage to help

individuals resolve questions about the need or ability to change that

behavior. For any particular problem behavior, individuals in the first

stage, called PreContemplation do not believe that they have a problem (What problem?). Here, for example, education about what

constitutes a problem (e.g., hypervigilance, substance abuse, or PTSD

in general) helps individuals move to the next stage, labeled Contemplation. In this stage, individuals may begin to consider the

need for change (Do I need to change?). In this stage, decisional

balance techniques and comparison of ones behavior to population

norms are used to help resolve ambivalence about the need to change.

Once convinced of the need to change, individuals still may be doubtful or ambivalent about their ability to make the necessary changes

(Can I change?). Other stages are Action, in which individuals are

actively making behavior changes, and Maintenance, in which they are

doing what is necessary to maintain the behavioral change.

 Ronald T. Murphy, Ph.D. Rebecca P. Cameron, Ph.D. Lois Sharp, M.S. Gilbert Ramirez, M.A.
Volume 8 (2) Spring 1999

33

NC-PTSD Clinical Quarterly

The ME Group: Implementation

The ME group has been developed and implemented on

the mens treatment unit of the National Center for PTSD in Menlo

Park, a 60-day inpatient program primarily serving Vietnam War

combat veterans. The seven-session group is designed for managed-care environments, and addresses the need in such environments for manualized treatment, measurable outcomes, brief interventions, built-in program evaluation, and assessment of patient satisfaction.

Rationale. As explained to the patients, the purpose of the

group is to help participants make decisions about problems

they might have, i.e., whether behavioral change is necessary for

a particular behavior. More specifically, the goal is to help patients decide whether these behaviors defined as Might Be A

Problem are either Definitely A Problem or Definitely Not A

Problem. A clear distinction is drawn between problems listed as

Might Be A Problem and behaviors and cognitions that they

definitely are convinced they need to change, i.e., Definitely A Problem.

The reasons why it might be useful to make decisions about problems they might or might not have are elicited from the group or

suggested by the group leaders. Patients are encouraged to consider

that post-treatment relapse to PTSD symptoms or related difficulties is often not due to inadequate treatment or unfixable patients,

but rather to unacknowledged problems that lead to gradual or sudden return to old coping styles. We draw from case examples to

illustrate that social isolation and excessive alcohol use often lead to

disconnection from support, poor judgement, and rumination, resulting further in depression, increased hypervigilance, intrusive

thoughts, anger, and loss of control.Thus, the ultimate goal for

patients is to avoid getting blindsided by problems following discharge.

...combat veterans in treatment are

often ambivalent about changing

not only common problems

associated with PTSD, such as

substance abuse, but also the

symptoms of PTSD themselves.

General Structure. The group protocol consists of 7 group sessions: 6 sessions with 4 separate group modules (2 modules are

repeated) and a seventh session which is a repetition of the first

group they attended. This seventh session was added because veterans enter the group on a rolling admission basis and are typically

disoriented during their first few days in the program. Thus they

may enter the group at any module. To accommodate the effects of

rolling admissions and the extent of memory and attention deficit

in this population, and to use behavioral learning principles of

repetition and rehearsal, the first half of each group consists of

reviewing the purpose and format of the group. In this review

period, time is given to individualized identification of problems

patients Might Have. This review is accomplished by group

leaders asking questions of the group, usually with more experienced members answering, thereby educating and acculturating the newcomers. The second half of each session consists

of discussion of the use of specific tools that will assist in patients

deciding whether problems that they Might Have_ are behaviors they

need to change.

Group leaders follow a manualized protocol, but the format is

interactive and makes extensive use of a whiteboard and patient worksheets.

Psychoeducation, group structure and process, and patient workbook forms

are used to increase awareness, enhance motivation, and decrease ambivalence about behavioral change in an objective, non-confrontational atmosphere.

Group Content. A key part of the group is having patients generate a list

of problem areas which they identify as Might Be A Problem for them.

This process occurs in the first half of every session, following the general

review of rationale and purpose. At that time, patients fill out a worksheet

(Form #1), which is divided into three columns: Definitely A Problem,

Might Be A Problem , or Definitely Not A Problem. The goal of the

group is for patients to sort items listed under Might Be A Problem into

Definitely A Problem or Definitely Not A Problem. Under Might Be

A Problem patients are asked to list any problem which they have wondered if they have, or any problem someone told them they have (but the

patient disagreed). We have defined Might Be a Problem in these two

ways to elicit not only problem areas that they have considered as possibly

needing change, i.e., on which they are in Contemplation Stage, but also

problems that they might be unaware of or unwilling to change, i.e.,

Precontemplation Stage.

In Group 1, Rationale and Review, the purpose and potential

value of the group is reviewed in detail. Time is also used for reviewing the

worksheet (Form #1) on which patients identify areas that Might Be A

Problem. Groups 2 & 3, called Comparison to the Average Guy, are

aimed at helping patients compare their behavior to estimated age-appropriate but non-veteran norms in order to help them judge how problematic their behavior might be. Behaviors are categorized along a range

including Average, Moderate Problem, Extreme Problem. Three

dimensions are used to assess behavior at each of these levels: frequency,

severity of consequences, and purpose. Group leaders guide members in

analyzing what a particular behavior would look like at each of the three

levels on each of the three dimensions. For example, if hypervigilance was

the behavior selected, group leaders would elicit a description of normative

levels of safety awareness (e.g., checking to make sure doors are locked

before retiring for the night, installing motion-sensitive lights outside the

house; negative consequences being mild other than the cost of the lights;

purpose being to be reasonably safe), moderately heightened security-consciousness (e.g., checking doors twice, installing a burglar alarm, getting a

big dog; consequences being more time and money invested, maybe intimidating people with the dog; purpose beginning to take on more of an

anxiety-reduction role), and extreme levels of hypervigilance (e.g., checking

the perimeter of the house several times a night, keeping a gun under the

bed; consequences of increased time and energy spent, risk to children from

the gun; purpose being survival and anxiety management).

In Groups 4 & 5, Pros & Cons, decision balance techniques are

reviewed and practiced to help patients decide about the need to change

Might Be A Problem behaviors which they agree they do, but are not sure

are actually problematic. In this simple but effective technique, patients

weight the pro and con of various PTSD symptoms and related behaviors,

such as gun ownership, continued alcohol use, hypervigilance (e.g., setting

perimeters), and social isolation.

Group 6, Roadblocks, focuses on how difficult it can be to

consider changing ones own behaviors. Leaders explain the concept of

roadblocks as being those things that make it difficult to even consider
NC-PTSD Clinical Quarterly Volume 8 (2) Spring 1999

34

 MURPHY, CAMERON, SHARP, & RAMIREZ

Results. Over the course of the study period, participants listed

approximately 4,000 behaviors which they defined as Might Be A

Problem. Again, it must be kept in mind that these are distinguished

from behaviors defined as Definitely a Problem, and thus reflect

unwillingness to acknowledge or ambivalence about changing the

behavior.

This work has potentially important implications for relapse

prevention, in that veterans who use the group successfully to identify

previously unacknowledged problem areas for change may be more

likely to anticipate difficulties and utilize newly-acquired coping strategies following treatment. PTSD treatment is generally oriented towards helping patients acquire skills and change behaviors with an implicit assumption that staff and patients share a common understanding of problem definition and goals. Treatment programs may benefit

from a motivational component such as the ME group to help veterans

further engage in treatment and decide to change behaviors which treatment providers see as critical to adaptive long-term functioning.

We believe that our preliminary clinical and evaluation work

with the development of this group may help clarify why some outcome studies of standard VA treatment show poor results, while controlled studies of behavioral treatment of PTSD symptoms generally

show clear improvement. It may be that motivated or high functioning patients with less ambivalence about the need to change volunteer

or are recruited for controlled trials, while the majority of patients in

the studies of standard treatment are more likely to have chronic PTSD

with more ambivalence about the need to change (which may be a

factor in why they are chronic), as is reflected in the results from our

inpatient sample. In any case, we plan on further modifying and researching the effectiveness of the ME group in the hopes that it may

prove to be a valuable means of motivating combat veterans to learn

new coping styles with less ambivalence about the need to change.

The investigators coded these behaviors into 65 categories including

DSM-IV PTSD criteria B, C, and D, Associated Symptoms, co-morbid

conditions, as well as various behavioral, cognitive, and emotional problem categories. Of the 65 categories, only those endorsed by more than

15% of subjects (18 categories) are reported here.

Behaviors Endorsed as Might Be A Problem. Relatively high

percentages of the patients were ambivalent about or unwilling to

modify PTSD symptoms or closely related behaviors. Almost 50% of

participants classified Anger as Might Be A Problem, followed by

Isolation (35%), Depressive Symptoms (35%), Trust (34%), Health

(34%), Conflict Resolution (29%), Alcohol (28%), Communication

(26%), Relationship/Intimacy (23%), Numbing and other Restricted

Range of Affect (22%), Drugs (22%), Need for Control & Perfectionism (17%), Hypervigilance (16%), and Authority (15%).

Might Be A Problem Behaviors Changed to Definitely A Problem.

Over the course of the group, the problems that most participants

changed their minds about included: Guilt (49%), Anxiety (46%), Anger (45%), Isolation (40%), Smoking (40%), Depressive Symptoms

(34%), Authority (31%), Trust (31%), Communication (31%), and

Health (29%). Participants were least likely to change Conflict Resolution (13%), Need for Control (19%), and Drugs (21%) to Definitely A

Problem.

Patient Rating of Satisfaction. Data from the patient satisfaction questions indicate consistently high levels of satisfaction with all

aspects of group content and process, suggesting that the patients find

it a non-threatening environment in which to evaluate whether they

need to change PTSD-related behaviors. Their ability to clearly verbalize

the core concepts of the purpose and rationale of the group was less

than expected, though upon review the questions assessing this area

were vague and allowed for alternate interpretation.

whether behavior is problematic and in need of change. Common

roadblocks include fears, cognitive distortions, and belief in stereotypes.

Fears might include being overwhelmed by problems, or being rejected

if problems are acknowledged. Cognitive distortions include errors,

such as black-and-white thinking (e.g., If I admit to having one

more problem, I will have to acknowledge being a complete failure) or

blaming of others. Stereotypes can cause problems such as reluctance to

admit to an alcohol problem because of ideas of what it means to be an

alcoholic (e.g., the town drunk, homeless) or wanting to avoid being

perceived as a crazy Vietnam veteran. The group generates a variety of

possible roadblocks and veterans are instructed to fill out their worksheet

using only those that apply to them. Psychological issues related to

shame frequently arise in the context of this group. The collaborative

process additionally provides a supportive context in which veterans can

normalize the difficulty of acknowledging problems.

Post-treatment relapse to PTSD

symptoms or related difficulties is

often not due to inadequate

treatment or unfixable patients,

but rather to unacknowledged

problems that lead to a gradual or

sudden return to old coping styles.

The ME Group: Preliminary Program Evaluation

Procedure. As part of the group structure, data from every group

participant are regularly collected at two points: at the end of each group

and when a patient has completed seven sessions. At the end of each

group, each veteran is asked to list any behaviors which he identified as

Might Be A Problem during the course of that particular session.

Also, patients are asked to report if they had reclassified any behaviors

previously identified from Might Be A Problem to Definitely A

Problem or Definitely Not A Problem at any time during that group

session. It is hoped that patients will identify previously unacknowledged problems, and more importantly, use the group to identify problems requiring change. Such changes would suggest that participation in

the group resulted in increased awareness of and decreased ambivalence

about changing PTSD symptoms and related behaviors.

In addition to these session by session data, patients who

complete all seven sessions of the group are asked to fill out a questionnaire to assess their understanding of group goals and process, ratings

of helpfulness of various group modules, and self-reported changes in

acknowledgment of problem behaviors.

At this time we have collected data on all patients (n=243)

who attended the ME group for any number of sessions (maximum 7

sessions) over an 18 month period. These findings have been previously

reported (Cameron & Murphy, 1998) and are briefly summarized here.
Volume 8 (2) Spring 1999

35

NC-PTSD Clinical Quarterly

 MOTIVATING VETERANS TO CHANGE

Use this form as tool to help you decide where your behavior lies on the range of average, moderate, and extreme.

Example: Hypervigilance

FREQUENCY

OF BEHAVOR

(e.g., how much,

how often, and how

many)

SEVERITY OF

CONSEQUENCES

(e.g., relationships,

employment,

financial, and taking

care of self)

PURPOSE

(The why of the

behavior, i.e., what

function does the

behavior serve?)

Making sure the door is

locked before going to bed

Installing motion detector

lights outside the house

May own a dog

May think about buying a gun but

decides it is too risky

Allows him to feel secure

Limits his relationships

with neighbors and others

Intimidates others with dog

May interfere with work

More time and $ spend on security

Interfering with sleep

Not caring for self

Checking perimeter of the house several

times a night

Multiple locks on doors that are checked

often

Owns mean dogs-Pit bulls

Gun under pillow

May own high caliber weapons

Has multiple weapons

Has no relationships with neigbors-sees

threats everywhere

Keeps spending $

His kids are at risk with gun in home

Difficulty supporting himself

Can not sleep

Health problems

Likely to install motion detector lights and

a burglar alarm system

Checks the loscks at least twice a night

Gets a big dog for protections

May own at least one gu

AVERAGE GUY MODERATE PROBLEM EXTREME PROBLEM

If he owns a gun, it makes

his family nervous

Hes out the cost of the lights

Tells himself its better to be safe

than sorry

Trying to feel safe

Survival

Feels life or death
NC-PTSD Clinical Quarterly Volume 8 (2) Spring 1999

36

Ronald Murphy, Ph.D. is a staff psychologist at the National Center for PTSD in

Menlo Park, where he is involved in clinical work and research. Dr. Murphy recently

completed a NIAAA grant examining the relationship of alcohol use to childhood

trauma and combat exposure severity. He is currently examining how motivation

enhancement interventions for PTSD symptoms affects post-treatment outcome.

Rebecca P. Cameron, Ph.D. is an NIMH postdoctoral fellow at Stanford University

Department of Psychiatry. Dr. Camerons research background is in stress, coping, and social resources. Currently, she is conducting psychotherapy outcome

research focused on providing brief, cost-effective interventions for anxiety and depression.

Lois Sharp is doctoral candidate at the Pacific Graduate School of Psychology, in

Palo Alto. She is interested in working with victims of trauma and her research

interest is in the areas of program and outcome evaluations.

Gilbert Ramirez is a doctoral student in Counseling Psychology at Stanford University. Mr. Ramirez is completing a clinical practicum at the NC-PTSD were he is a cofacilitator in a motivational enhancement group. His research interests include cultural trauma, American Indian mental health, and spirituality/forgiveness.

 NEW DIRECTIONS cont from page 30

References

Prochaska, J.O., & DiClemente, C.C. (1983). Stages and processes of selfchange in smoking: Toward an integrative model of change. Journal of

Consulting & Clinical Psychology, 40, 432-440.

Miller, W.R., & Rollnick, S. (1992). Motivational interviewing. New York:

Guilford.

Murphy, R.T., & Cameron, R.P. Evaluation of a group targeting motivation to change PTSD -related behaviors. Paper presented at the Annual Meeting of the American Psychological Association, San Francisco, CA, August, 1998.

Matt Friedman, M.D., Ph.D. chaired a symposium on

stress and health: its relevance to the problems of Gulf War

veterans. He was joined by Frances Murphy, M.D. (VA) who

presented the latest data from VA and DoD Persian Gulf

registers; Jessica Wolfe, Ph.D. and Darin Erickson (National

Center) who presented five-year longitudinal data on medical

and psychological symptoms among 3,000 veterans; and Bruce

McEwen Ph.D. (Rockefeller University) who reviewed the latest

medical knowledge about the impact of stress on physical health.

Susan Roth, Ph.D. and Matt Friedman, M.D., Ph.D. (coeditors) presented the recently published ISTSS pamphlet:

"Childhood Trauma Remembered: A Report on the Current

Scientific Knowledge Base and its Applications." This publication

is a multidisciplinary collaboration between memory and trauma

experts on the "recovered memory" controversy that provides the

first balanced report on our scientific understanding of the human

memory process and what that implies for clinical and forensic

issues.

Last, but definitely not least, Greg Leskin, Ph.D. and Terry

Keane, Ph.D. chaired an extraordinary all day symposium on the

Vietnam legacy, thirty years after the Tet Offensive. The symposium

provided a broad overview (i.e., political, mental health, media,

historical) about what occurred in Washington and South-East

Asia during and after the Tet Offensive and how that event has

affected our society, our government, VA programs, and Vietnam

veterans. Participants were: Jonathan Shay, Ph.D., M.D., Ron

Spector, Ph.D., Kevin Bowen, Ph.D., Skip Isaacs, Myra MacPherson,

Joan Furey, R.N., M.A., John Wilson, Ph.D., Shad Meshad, M.A.,

Bill Brew, John Sommer, Charles Figley, Ph.D., Richard Kulka,

Ph.D., Fred Gusman, M.S.W., Matt Friedman, M.D., Ph.D., Al

Batres, Ph.D., and Spencer Falcon, M.D.

All in all, it is clear that National Center investigators have been

prolific in generating pertinent research on a wide variety of topics

related to the assessment and treatment of individuals with PTSD.

Note to Librarians

Volume 8 (2), Spring, 1999 follows Volume 8 (1), Winter, 1998.
Volume 8 (2) Spring 1999

37

NC-PTSD Clinical Quarterly

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 ensure we have the funds to continue keeping you informed about

trauma-related topics important in clinical practice, 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
NC-PTSD Clinical Quarterly Volume 8 (2) Spring 1999

38

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 PTSDrelated concerns. Telephone (650) 493-5000 ext. 22977.

National Center for PTSD Web Page

The NC-PTSD Home Page provides up-to-the-minute 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 leading electronic index to 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. Telephone (802) 296-5132.

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.

NC-PTSD EDUCATION & SUPPORT SERVICES
Volume 8 (2) Spring 1999

39

NC-PTSD Clinical Quarterly

NC-PTSD CLINICAL TRAINING PROGRAM

The National Center for PTSD Clinical Training Program provides a one-week, 35-hour series of lectures, group

discussions, clinical observations, and tutorials to educate clinicians about post-traumatic stress disorder. The primary

goal of the Clinical Training Program is to educate clinicians about care for patients with PTSD. Our curriculum covers

a broad range of topics, including diagnosis and assessment, etiology and theory, group and individual psychotherapeutic

treatment, and pharmacology. During the training program, participants have the opportunity to view ongoing clinical

activities at the National Center for PTSD residential rehabilitation program in Menlo Park, the oldest and largest VAbased PTSD program in the United States.

Every year, we welcome many psychiatrists, psychologists, social workers, nurses, readjustment counselors,

and occupational/recreational therapists from the United States and from around the world. Most clinicians who visit the

center have a working knowledge about treating the effects of trauma and PTSD. While the focus of training is on

treatment of male and female veterans, we also encourage visitors who serve other traumatized populations (e.g., survivors of sexual assault or community violence).

Some of the goals of the Clinical Training Program include:

 - Assist individual clinicians to upgrade their clinical skills in the treatment of PTSD

 - Increase knowledge about current PTSD assessment methods and materials

 - Offer consultation and discussion with experienced clinicians and administrators

 - Increase knowledge of therapeutic milieu management in the treatment of PTSD

 - Introduce the National Center for PTSD as an ongoing resource for consultation and information

The National Center for PTSD Clinical Training Program is delivered by a multi-disciplinary staff which

includes psychologists, psychiatrists, social workers, nurses, and counselors. The staff offers multiple clinical perspectives about these different topic areas.

A sample of our core curriculum and presentation topics:

*Group Treatment for Combat Veterans * Cognitive-Behavioral Treatment of PTSD *Assessment of PTSD

*Theories of PTSD and Dissociation *Psychiatric Evaluation of PTSD *Treatment of Traumatic Memories

The Clinical Training Program has been approved for 35 Category One Continuing Education Credits for

physicians, psychologists, social workers, and nurses, A Certificate of Attendance will be granted by the Department

of Veterans Affairs Employee Education Service at Long Beach. The NC-PTSD Clinical Training Program runs from

October to June each year. The program tries to accommodate as many interested parties as possible; however, each

incoming class is limited to 12 people. If you are interested in receiving an application or to request more information,

please call the Clinical Training Program at (650) 493-5000, Extension 22673.

The Clinical Training Program is open to all Department of Veteran Affairs employees whose clinical work

involves the treatment of PTSD. In addition, non-VA clinicians are welcome based on availability. There is no fee

for the training program, but participants are responsible for providing their own transportation, lodging, and meals.

For more information or to request an application:

National Center for PTSD

Education and Clinical Laboratory Division Phone: 650-493-5000, Ext. 22673

VA Palo Alto Health Care System Fax: 650-617-2684

795 Willow Road (352/117) Email: jir@icon.palo-alto.med.va.gov

Menlo Park, CA 94025
NC-PTSD Clinical Quarterly Volume 8 (2) Spring 1999

40