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NC-PTSD Clinical Quarterly

Volume 9 (2) Spring 2000

We encourage researchers to explore the viability of the
writing paradigm with individuals who have experienced trauma.
Based on our research so far, we suggest the following strategies:

© We do not recommend writing immediately after a
massive trauma. It would probably be more effective at
least 2-3 weeks after the event. After that time, we have
generally found it to be effective for most individuals
who continue to think, dream, or worry about the event
even if it is 40 years later.

© Set aside a fixed number of days (e.g, 5 days, 30 minutes
per day) for the initial intervention. Repeated interven-
tions in subsequent weeks or months may serve to
integrate new experiences.

® It is possible that in extreme cases of PTSD ~.where
possible hippocampal damage has occurred — writing
may not be helpful.

® For individuals who are unable or unwilling to write,
have them talk alone into a tape recorder. Recent studies
indicate talking in this manner is as effective as writing.

© From a clinical perspective, encourage the client to
experiment with different writing suategies, at different
times, using their own novel procedures.

Writing about significant emotional experiences has been
shown to be a powerful intervention associated with long term ben-
efits. Moreover, writing is most beneficial for those that find it most
difficult to discuss their feelings and experiences. Evidence suggests
that this intervention works by reducing inhibition through disclo-
sure and encouraging cognitive changes about the chosen topic. This
writing intervention is easy to incorporate into existing treatment
programs, easy to adapt to special circumstances, and allows indi-
viduals to dose themselves.

References

1. Pennebaker, J.W. (1997). Opening up: The healing power of
expressing emotion. New York: Guilford Press.

2. Smyth, J. M. (1998). Written emotional expression: Effect sizes,
outcome, types, and moderating variables. Journal of

Consulting and Clinical Psychology, 66, 174-184

3. Smyth, J. M., Stone, A. A., Hurewitz, A.,& Kaell, A. (1999).
Effects of Writing About Stressful Experiences on
Symptom Reduction in Patients With Asthma or
Rheumatoid Arthritis. Journal of the American Medical

Association, 281, 1245-1352.

EFFECTS OF WRITING

4, Christensen, A. J., & Smith, T. W. (1993). Cynical hostility and
cardiovascular reactivity during self-disclosure. Psychoso-
atic Medicine, 55, 193-202.

5. Paez, D., & Velasco, C. (1999, in press). Alexithymia as dis-
positional deficit in self-disclosure and cognitive assimi-

lation of emotional events. Journal of Personality and
Social Psychology.

6. Cole, S. W., Kemeny, M. E., Taylor, S . E., & Visscher, B. R.
(1996). Elevated physical health risk among gay men who
conceal their homosexual identity. Health Psvchology, 15,
243-251.

7. Greenberg, M.A. & Stone, A.A. (1992). Writing about disclosed
versus undisclosed traumas: Immediate and long-term

effects on mood and health. Journal of Personality and
Social Psychology, 63, 75-84.

8. Pennebaker, J.W. & Francis, M.E. (1999). Linguistic inquiry and
word count (LIWC). Mahwah, NJ: Erlbaum Publishers.

9. Pennebaker, J. W., Mayne, T. J., & Francis, M. E. (1997). Linguistic
predictors of adaptive bereavement. Journal of Personality
and Social Psychology, 72, 863-871.

10. Schoutrop, M., Lange, A., Brosschot, J. & Everaerd, W. (1997).
Overcoming Traumatic Events by Means of Writing
Assignments. In A. Vingerhoets, F. van Bussel, & J.
Boelhouwer, (Eds.), The (non)expression of emotions in
health and disease (pp. 279-289). Netherlands: Tilburg
University Press.

11. Gidron, Y., Peri, T.,, Connolly, J. F, & Shalev, A. Y. (1996). Written
disclosure in posttraumatic stress disorder: Is it beneficial
for the patient? Journal of Nervous & Mental Disease, 184,

505-507,

James W. Pennebaker received his Ph.D. in psychology

at the University of Texas at Austin where be is now
Professor of Psychology. His research,which is funded
by the National Institutes of Health, focuses on bow
individuals cope with traumatic experience. Most
recently, be bas been exploring the nature of language
and its links to social bebavior and physical health.

R. Sherlock Campbell is pursuing graduate studies in
Social Psychology at The University of Texas at Austin.
His interests include Health Psychology, especially the
impact of traumatic events on the self concept.

21


NC-PTSD Clinical Quarterly

Volume 9 (2) Spring 2000

continued from page 23

material. While fostering client control, collaboration in the early
stages of trauma therapy paradoxically also means agreement on
the preliminary goals of relinquishing overcontrol. Clients need to
accept that avoidance of trauma feelings and memories is
contributing to both inuusive symptoms and social isolation. The
corresponding goal of therapy is to explore client fears of emotional
experience, and eventually to enable clients to accept their feelings.
Therapist empathic responses validate and convey understanding
of fear, normalize avoidance as a coping strategy, and make the
avoidance processes available for exploration. Therapist responses
also encourage clients to relax control by providing a rationale
that is tailored to their own goals for change. For example, in
therapy with a client who was extremely distressed by intrusive
nightmares of childhood physical abuse (18), the therapist
responded, “But it has not worked to keep all these feelings inside; they are
silleatingarwayat you, demanding attention, escaping inyourdreams.” Mt
the same time, it is important to reassure clients that one of the
goals of therapy is to “find ways to help you gradually get used to your
feelings, so you don tt feel overwhelmed.” Another important aspect of
collaboration is to heighten client experiential awareness of the
negative impact of such emotional overcontrol. This can be
accomplished in the early phase of therapy, through empathic
conjectures, suchas, “Itust beso difficultto beafraid of your own feelings,
like you have to bide from yourself.” Such responses help access and
support a healthy desire to be more spontaneous.

Overcoming avoidance and emotional overcontrol Within the
above relational context, the second affective task in EFT for trauma
is overcoming avoidance processes. This usually is the focus of the
middle phase of therapy. Avoidance includes suppression of
feelings for fear of being overwhelmed or losing contol, and guilt
and shame that interfere with acknowledging feelings and needs.

Fear of overwhelming affective experience is a common theme
among trauma survivors (22). Clients are afraid they will “go crazy”
or become violent if they allow themselves to get in touch with
their anger, or they will “never stop crying” if they allow themselves
to feel their sadness and pain. However, chronic suppression of
threatening feelings such as anger can play a role in generating anxiety
and depression, and disavowal of vulnerable experiences such as
fear, hurt, and shame can contribute to secondary rage. Healing
from the effects of traumatic events is not possible unless all the
feelings and beliefs associated with the trauma are accessed and
available for reprocessing (10). However, appropriate intervention
depends on accurate assessment of different emotional states and
processes as they emerge in the session. This is accomplished, first,
through therapist empathic attunement to client presently-felt
subjective experience. As well, this is accomplished through
knowledge of the characteristics of specific emotions, and
knowledge of the client’s personality history and of specific
disorders (2). Depression, anxiety, and rage are secondary feelings
and defensive reactions that need to be explored, understood, and
changed, and the more core experience needs to be accessed. Even
shame from being humiliated by another or from violating intemal
standards, that contributes to depression or rage, needs to be
disclosed, accepted by another, and lived through in order to be

PAIVIO & GREENBERG

transformed. Intense anger can be a particularly difficult emotion for
traumatized clients to handle. In all cases, anger at violation needs to
validated and its expression supported as a healthy resource that can
promote adaptive behavior (23). However, appropriate intervention
with rage involves exploring the underlying cognitive-affective processes
and management, rather than accessing rage for its adaptive
information, Intervention with generalized and chronic anger involves
focussing expression at specific individuals for specific offenses;
“putting it where it belongs.” Intervention with constricted anger
involves intensification and expression to promote self-empowerment
and self-protective behavior. As a general rule, EFT focuses on
accessing experiences that are disavowed and less available to the client.

Exploring emotional overcontrol is, in part, a process of
gradual exposure to trauma material. Throughout therapy, the therapist
is attuned to the various avoidance processes that emerge as the client
repeatedly tells the story of their victimization. Processes such as
catastrophizing or guilt about experience, shutting down, going numb,
and dissociation, interfere with reprocessing and integrating trauma
material. These processes can be explored through empathic responses,
by directing attention to bodily experience, and the judicious use of
Gestalt-type dialogues. The above processes are conceptualized in
tems of a split between two parts of the self—a critical, catastrophizing,
or controlling self and an experiencing self that feels guilty or afraid
of feelings, or emotionally constricted. In Gestalt dialogues the client
enacts both parts of the self (2, 11, 18). The goal of this therapeutic
work, regardless of the intervention, is, first, to heighten awareness of
maladaptive controlling processes, and, second, to access disavowed
internal experience and allow uninhibited emotional expression once
they feel safe enough to do so. In this way, the person learns to live
through painful emotion and adaptive aspects unique to each emotion
can be integrated into current meaning.

The second fundamental
assumption of emotion
Jocused therapy (EFT) is that
it is only through accessing
emotion and emotional
meaning that emotional
problems can be cured.

For example, when a client states, nervously or flatly, that he or
she feels angry, the therapist can invite exploration by responding,
“There's something really difficult about getting in touch with that feeling?’
Altemately the therapist can ask where in their body they can feel that
anger, to describe the sensations, and to articulate what they think
their body is telling them; “what would your gut say if it could speak’ (8).
This helps people attend to their internal experience as a
26



NC-PTSD Clinical Quarterly

Volume 9 (2) Spring 2000

These methods have been discussed extensively by clinicians in the
behavioral and cognitive-behavior traditions (15) and will will not be
presented here.

In the present paper we will focus on distinctive features of
experiential and emotion focused therapies (1, 2, 16-18). The first is
the quality of the therapeutic relationship with its emphais on
establishing a strong attachment bond. The second is specification
of the processes and techniques for overcoming emotional
constriction or overcontrol. In trauma therapy, avoidance of
important emotional experience must be explored and minimized
because it interferes with integration of traumatic events into current
views of self and reality. EFT also contributes a distinct
conceptualization of the processes and techniques for reexperiencing
and reprocessing trauma material. These techniques generally are
intended to activate trauma memories so that maladaptive aspects of
the memories are available for emotional reprocessing, that is,
modification through the admission of new information.

Through telling and retelling the story of their victimization,
clients gradually leam to tolerate the associated feelings and memories.
EFT uniquely integrates the principles of exposure with construction
of new meaning and emphasizes the role of adaptive emotion and
the therapeutic relationship in psychotherapeutic change. Information
from accessing inhibited adaptive emotion, such as anger at violation
and sadness at loss, rather than skills training or directly challenging
distorted beliefs is what usually modifies meaning. The orienting
information thought to be associated with specific emotions (19) then
can be integrated into and contribute to modifying maladaptive
emotional meaning. For example, assertive anger expression facilitates
the externalization of blame, thus modifying maladaptive guilt and
shame. Primary anger at violation also fosters a sense of
empowerment to counter powerlessness and insecurity. Likewise,
sadness expression permits grieving and accesses self-soothing
resources that help the individual cope with distress. As well, the
therapeutic relationship plays a dual role in promoting change. First,
a supportive relationship helps to contain potentially overwhelming
affect and provides the necessary safety and support so people can
explore trauma material. The relationship also is viewed as directly
curative in repairing negative relational experiences and disconfirming
negative expectations of others.

In sum, both adaptive emotional experience and the
therapeutic relationship are viewed as sources of new information
that modify meaning. The three posited mechanisms of change in
EFT for trauma are (a) accessing and modifying maladaptive emotion
structures, formed through traumatic events, that generate experiences
such as fear/anxiety and shame; (b) accessing adaptive emotional
reactions, such as anger and sadness, so that the associated adaptive
information can be integrated into current meaning systems; and (c)
providing a corrective interpersonal experience with the therapist (18).

There are three interrelated affective tasks in EFT for
interpersonal trauma—establishing the therapeutic relationship,
overcoming avoidance or over control, and reprocessing trauma
memories.

Establishing the therapeutic relationship The fundamental
therapeutic task in EFT is establishment of a safe and collaborative

therapeutic relationship. This usually is the exclusive focus of the
first three sessions and is the fabric of therapy throughout. EFT
particularly attends to establishing a secure attachment bond. The
therapist stance is one of empathic attunement and responsiveness
to client feelings and needs. The therapist’s calm and soothing
presence provides the safety and support necessary for clients to tell
the story of their victimization and allow painful emotional
experience. The narration of traumatic experience, in turn, creates
distance from potentially overwhelming affect. Description and
accurate labelling provides a “handle” for emotional experience and
increases self-control. The person no longer is his or her feelings
but has feelings which he or she can observe and describe. As well,
the client learns to tolerate and regulate intense affect by internalizing
the soothing interactions with the therapist (2).

..techniques generally
are intended to activate
trauma memories so that
maladaptive aspects of
the memories are
available for emotional
reprocessing, thatis,
modification through the
admission ofnew
information.

The primary intervention is empathic responding to client presently-
felt subjective experience, including fear of trauma feelings and
memories and the need for control. Empathic responding serves three
main purposes: It helps clients feel understood, accepted, and less
isolated; it directs clients’ attention to their intemal experience; and it
helps clients articulate the meaning of their experience. Responses that
communicate acceptance and understanding help to strengthen the
person's sense of selfs fragile or stigmatized, and foster interpersonal
trust and acceptance of one’s own experience. Empathic responding
also is thought to foster selfdevelopment by enabling clients to clarify
their own feelings, wants, and needs, and empowering them to express
and value these core aspects of self (7, 20, 21).

Another feature of the therapeutic relationship in EFT is to
allow the client maximum control over the process of therapy (18).
Safety and control are corrective interpersonal experiences for
individuals whose problems stem from experiences of profound
powerlessness and loss of control (13). Client control is accomplished
through a therapeutic relationship that is minimally hierarchical and
through collaboration in establishing the goals of therapy and how these
will be accomplished. Collaboration allows clients to pace themselves
and to make decisions about when they feel able to explore painful

23

Continued on page 26


NC-PTSD Clinical Quarterly

Volume 9 (2) Spring 2000

EMOTION FOCUSED THERAPY FOR
INTERPERSONAL TRAUMA

SANDRA C. PAIVIO, PH.D. & LESLIE S. GREENBERG, PH.D.

The fundamental assumption of
current emotion focused (1) and process-
experiential psychotherapies (2) is that the
emotion system plays an organizing role in
human functioning. Subjective emotional
experience is a complex phenomenon
associated with a network of information
that includes thoughts, feelings, desires,
sensations, and physiological reactions.
This is a multimodal meaning system that,
when activated, provides each individual
with an integrated experience of reality,
sense of him or herself, and orientation toward the world. Negative
learning experiences, such as exposure to traumatic events, may result
in the development of maladaptive emotion structures or meaning
systems that negatively influence affective experience, perceptions,
physiological reactions, and behavior in current situations. The second
fundamental assumption of emotion focused therapy (EFT) is that
it is only through accessing emotion and emotional meaning that
emotional problems, such as those stemming from traumatic
experiences, can be cured.

Sandra C. Paivio, Ph.D.

Trauma as a Source of Emotional Disorder

The therapy approach outlined in the present manuscript
primarily has been implemented in individual therapy for
noncombat-related interpersonal trauma. The perpetrator can be a
stranger, friend, lover, or caregiver, and the person can be exposed
toa single traumatic event or repeated victimization over several
years by one or several perpetrators. Traumatic events involve a
profound assault on the self that include, not only feelings of fear
and helplessness, but hurt, shame, betrayal, loss, rage, and associated
negative beliefs and physiological reactions. This network of
information can continue to be activated long after the event, and
generates a complex of affective disturbances.

From our perspective, there are three main sources of
emotional disorder connected with exposure to trauma—the
physiological effects of extreme emotional arousal, avoidance as a
maladaptive coping strategy, and maladaptive emotional meaning.
First, violence and the chronic threat of violence (e.g., through child
abuse, family violence, or war) result in extreme emotional arousal
that is embedded in memory (3). The arousal symptoms of
posttraumatic stress disorder (PTSD), such as chronic
hypervigilance, and alarm reactions (4), represent the
enduring physiological impact of terror experiences. Automatic alarm
reactions continue to be inappropriately triggered by situations that
resemble past events and activate the fear memory. As well, experiences
of fearand shame during the original trauma continue to resurface and
intrude on current awareness in the form of reexperiencing symptoms.

Another primary source of
emotional disorder that is characteristic of
exposure to trauma is avoidance of emotional
experience. Avoidance of painful emotion
is an adaptive coping strategy that fosters
control and protects the person from being
overwhelmed. However, there is considerable
agreement among scholars that chronic
inhibition of important emotional experience
has several negative consequences. First | 333%]
avoidance of trauma-related emotion is esl ie S. Greenberg, Ph.D.
thought to result in accumulated stress and
tension that can contribute to health problems (5) and to maladaptive
anxiety and rage (6). As well, chronic avoidance of important intemal
experience results in individuals being cut off from core feelings and
needs that define the self, and this has disruptive effects on functioning
(7-9). Avoidance of trauma feelings and memories also filters out
information that could lead to productive action and is thought to
maintain the symptoms of PTSD by preventing integration of the
traumatic event into one’s view of self and the world (10). Thus core
internal experiences that are suppressed remain “unfinished business,”
pressing for integration and intwuding on current awareness (11),

Another source of emotional disorder that is central to
traumatic experiences is the development of maladaptive affective
meaning. Trauma involves the disruption of fundamental
assumptions about self, others, and reality (12). These include
beliefs about personal worth and invulnerability; a world that is
meaningful, fair, and predictable; and other people as benign,
trustworthy, and worth relating to. Following traumatic
victimization people experience themselves as stigmatized and
fragile, the world as unsafe, and others as dangerous or unhelpful.
Alternately, chronic and repeated exposure to traumatic events,
particularly in childhood (e.g., child abuse), forms the basis of a
core sense of self as worthless and insecure while viewing others
as dangerous and untrustworthy. Survivors of all types of
interpersonal trauma commonly report problems, not only with
symptom distress, but with self esteem and interpersonal
relatedness (10).

EFT for Interpersonal Trauma

EFT is. a comprehensive and integrative approach, grounded
in the experiential tradition, that addresses the complex of affective
disturbances stemming from interpersonal trauma. These include
problems with affect dysregulation, emotional overcontrol, and
maladaptive emotional meaning. The first step in therapy with many
trauma survivors is to help them gain mastery over reexperiencing
and arousal symptoms (13-14).When appropriate, commonly
accepted methods for affect management are integrated into EFT.

22



NC-PTSD Clinical Quarterly Volume 9 (2) Spring 2000

Marie B. Caulfield, Ph.D.
Women’s Health Sci. ,

Understanding Problems of Self-Care in Trauma Survivors: A Clinical Model

Self-care behaviors, such as eating, sleeping, bathing, and wearin g clean clothes, are basic to healthy adult functioning.
Deficits in self-care agency and self-care behaviors are central to the problems of many trauma survivors. Problems with diet,
sleep, medications, and adequate health care are only some of the self-care issues that may compromise the health and mental
health of survivors. Critical to helping survivors in engaging in these important activities is a model for understanding why an
individual does not do so. The concept of self-care agency (Orem, 1995) may be a helpful model for trauma clinicians to use
in addressing the pervasive problems in self-care that are evident during treatment of trauma survivors. Why does an individual
not engage in adequate self-care? Orem’s model suggests that a variety of factors may be implicated, including motivation,
decision-making, energy, and knowledge necessary to perform self-care actions.

This concept of self-care agency may be more understandable when talking about medical populations, which is where
its nursing roots began. For example, an individual who has recently suffered a heart attack may not engage in adequate self-
care upon discharge from the hospital for a variety of reasons. This individual may have low motivation because she does not
believe she is in control of her health or because she is getting attention for being ill. Alternatively, she may have low energy
because of her medical problems or due to the depression that often accompanies a heart attack, making self-care more
difficult. Or she may not have had adequate instruction, €.g., regarding diet or medications, making adequate self-care
impossible.

Research has only recently examined the concept of self-care agency deficits in traumatized women. Campbell &
Soeken (1999) presented longitudinal data showing that women who remained ina battering relationship over the course of the
3° years of the study had poorer self-care agency than those who ended the battering relationship earlier. Renker (1999)
found, in a sample of adolescent mothers, that self-care agency was one of the social factors that interacted with physical abuse
during pregnancy to predict infant birth weight.

When self-care becomes a salient clinical target, clinicians need to find ways to conceptualize these problems to help
facilitate change. For example, a knowledge deficit, such as not understanding how to take medication correctly, may require
teaching the client and coaching her in how to do it correctly, while lack of sufficient energy to engage in self-care may suggest
an evaluation of current medications and medical conditions. Within traumatized populations, additional factors may play a
part, such as feelings of hopelessness and powerlessness. For example, Lee (1999) examined women living in squatter
settlements in Pakistan exposed to extraordinary stress and severe poverty. This study specifically examined the perception of
power as an underlying factor that enables self-care agency. Lee found that women’s perception of power did predict self-care
agency and that both of these factors predicted actual self-care behaviors.

Orem’s model may provide a starting place for trauma clinicians and researchers to develop assessment and treatment
models that target self-care behaviors. Over time, we may develop a more trauma-specific models for assesses the deficits in
self-care agency. These new models can lead to improvements in self-care that are critical to the success of any interventions
with trauma survivors.

References
Campbell, J. C., & Koeken, K. L. (1999). Women’s responses to battering over time: An analysis of change. Journal of Interpersonal

Violence, 14, 21-40.
Lee, M. B. (1999). Power, self-care, and health in women living in urban squatter settlements in Karachi, Pakistan: A test of Orem’s theory.

Journal of Advanced Nursing, 30, 248-259.
Orem, D. (1995). Nursing concepts of practice (5" ed.). New York: McGraw-Hill.
Renker, P. R. (1999). Physical abuse, social support, self-care, and pregnancy outcomes of older adolescents. Journal of Obstetrical,

Gynecolgical, and Neonatal Nursing, 28, 377-388.

25


Spring, 2000, Vo! 9, Issue 2, ISSN-1052-71

Clinical Quarterly'

THE EFFECTS OF WRITING
ABOUT TRAUMATIC EXPERIENCE

JAMES W. PENNEBAKER, PH.D. AND R. SHERLOCK CAMPBELL

In the early 1980s, a number of intriguing results started turning up
in labs around the world. Although we had known for many years that
traumatic experiences were associated with health problems, a closer took
suggested that how people interpreted and coped with the trauma was
equally important. In our own work, we were discovering that individu-
als who did not talk about traumas were far more likely to suffer from
health problems than people who had comparable experiences but who
had talked about them — even when controlling for social support, age,
sex, etc. We eventually discovered that having people disclose traumatic
experiences in the laboratory could profoundly affect markers of physi-
cal and mental health. By the mid-1980s, we were finding that having
people write about traumas was a particularly efficient way to improve

= health (1). Since the first studies, dozens of similar experiments using the

James W. Pennebaker, Ph.D. writing technique have been conducted. R. Sherlock Campbell

By way of background, the standard laboratory writing technique involves randomly assigning participants to one of two or

more groups. All writing groups are asked to write about assigned topics for 3-5 consecutive days, 15-30 minutes each day. Writing is

generally done in the laboratory with no feedback given. Those assigned to the control conditions are typically asked to write about

superficial topics, such as how they use their time. The standard instructions for those assigned to the experimental group are a
variation on the following:

For the next (three) days, [would like for you to write about your very: deepest thoughts and feeling about the
most upsetting or traumatic experience of your entire life. In your writing, I'd like you to really let go and
explore your very deepest emotions and thoughts. You might tie your topic to your relationships with others,
including parents, lovers, friends, or relatives, to your past, your present, or your future, or to who you have
been, who you would like to be, or who you are now. You may write about the same general issues or experi-
ences on all days of writing or on different topics each day. Allof your writing will be completely confidential.
Don’t worry about spelling, sentence structure, or grammar. The only rule is that once you begin writing,
continue to do so until your time is up.

‘These simple instructions have proven to be exceptionally powerful. Participants — from children to the elderly, from honor
students to maximum security prisoners — disclose a remarkable range and depth of traumatic experiences. Lost loves, deaths, sexual
and physical abuse incidents, and tragic failures are common themes in all of our studies. If nothing else, the paradigm demonstrates
that when individuals are given the opportunity to disclose deeply personal aspects of their lives, they readily do so. Even though a
large number of participants report crying or being deeply upset by the experience, the overwhelming majority report that the writing
experience was valuable and meaningful in their lives.

Continued on page 19

INSIDE THIS ISSUE

The Effects of Writing About Trauma eriences 17 yomen and Trauma: A Clinical Forum

Emotion Focused Therapy for Interpersonal Trauma 22 NC-PTSD Education and Support Services
New Directions 24 PTSD Clinical Training Program



NC-PTSD Clinical Quarterly

Volume 9 (2) Spring 2000

Altemately assuming responsibility may increase a sense of predictability
and control thus reducing the sense of vulnerability to random acts of
victimization. In any case, there is agreement that internalizing
responsibility for victimization often is inappropriate and maladaptive.
In the safety of the therapy environment this client was able to disclose
and receive the therapist's acceptance and support and thus tolerate
the memories. He also was able to access his healthy adult anger at the
perpetrator for imposing this on him, to verbally express his anger
directly to the imagined perpetrator and, thus, externalize blame and
responsibility. This helped transform maladaptive guilt and shame.

Imaginal confrontation of the assailant or perpetrator usually
is used to access and promote anger expression. Importantly, the
intervention is appropriate for accessing constricted anger experience;
it is not appropriate for uncontrolled rage or a vehicle for acting out
aggressive fantasies. Emotion intensification techniques can be used
to heighten arousal and promote expression in order to relieve tension
and access the associated adaptive information. Physical expression
of anger, such as pounding a pillow with a soft battaca, always is
accompanied by verbalization of the meaning of emotional experience.
Revenge fantasies call for special attention in this type of anger work.
Many clients are disturbed by their revenge fantasies. They are either
afraid, embarrassed, or feel guilty about them. Revenge fantasies need
to be expressed and validated as normal expressions of unresolved
anger at violation, victimization, or betrayal. Clients can be encouraged
to express them in terms of “I am so angry, | feel like...” and reassured
that expressing intense anger in the safety of the therapy session is not
the same as acting on it.

In emotionally evocative interventions, it is important to
follow client moment-to-moment experience because emotion quickly
shifts. Anger expression can heighten arousal thus activating associated
feelings of hurt and humiliation at having been so victimized and
powerless, or sadness at loss and betrayal. After intense anger
expression, clients often collapse into tears and, thereby, are able to
receive the therapist's comfort and support which provides an additional
corrective interpersonal experience. These experiences help clients to
feel less afraid of their own feelings. In general, the goals are to access
adaptive information and modify maladaptive meaning, help the client
feel more empowered and distant from traumatic events, hold the
perpetrator rather than themselves accountable for harm, achieve a
more differentiated and balanced view of others, and perceive the
traumatic event as part of their life rather than defining their life.

Summary

The fundamental assumption underlying the present therapy
model is that the emotion system is associated with a network of
multimodal information and plays an organizing role in human
functioning. Furthermore, it is only through accessing emotion and
emotional meaning that emotional problems, such traumatic stress, can
be cured. Emotionally focused therapy for interpersonal trauma
integrates principles of exposure with construction of new meaning,
and emphasizes the role of adaptive emotion and the therapeutic
relationship in psychotherapaeutic change. The first affective task in
this type of therapy is establishing a safe and supportive therapeutic
relationship. This is accomplished through empathic responsiveness
and providing the client with maximum contol over the process of

PAIVIO & GREENBERG

therapy. The second task involves exploring and reducing
experiential avoidance. The goal is to access previously avoided
trauma material and allow uninhibited emotional expression. In this
way the person learns to tolerate emotional pain and the information
associated with specific emotions is accessed. The third task is
Teprocessing trauma memories through the use of reexperiencing
techniques. These interventions access maladaptive affective
experience so that it can be modified and adaptive emotional
experience so that the associated orienting information can be
integrated into new meaning. New meaning consists of a more
positive view of self and more differentiated view of others and
reality. This contributes to reduced symptom distress and improved
functioning.

References
1. Greenberg, LS. & Paivio, S.C. (1997). Working with emotion in

psychotherapy. New York: Guilford.
Greenberg, L.S., Rice, L.N., & Elliott, R. (1993). Facilitating

Emotional Change. New York: Guilford.

van der Kolk, B. (1996). The body keeps the score: Approaches
to the psychobiology of posttraumatic stress disorder. In
B.A. van der Kolk, A.C. McFarlane, & L. Weisaeth (Eds.),
Traumatic stress: the effects of overwhelming experience
on mind, body, and society. New York: Guilford.

. American Psychiatric Association (1994). Diagnostic and

Statistical Manual of Mental Disorders (4th ed.). Washington,
DC: Author.

. Pennebaker, J.W. & Beall, S.K. (1986). Confronting traumatic
events: Understanding of inhibition and disease. Journal of
Abnormal Psychology, 95, 274-281.

Barlow, D.H. (1988). Anxiety and its disorders: The nature and
treatment of anxiety and panic. New York: Guilford.

7. Bowlby, J. (1988). A secure base. London: Routledge & Kegal

Paul.

8. Comell, WP. & Olio, K.A. (1991). Integrating affect in treatment

with adult survivors of physical and sexual abuse. American
journal of Orthopsychiatry, 61, 59-69.

9. Sroufe, L.A. (1995). Emotional development: The organization
of emotional life in the early years. Cambridge MA:
Cambridge University Press.

10. Resick, P.A. & Schnicke, M.K. (1992). Cognitive processing
therapy for sexual assault survivors. Journal of Consulting
and Clinical Psychology, 60, 748-756.

11. Paivio, S.C. & Greenberg, L.S. (1995). Resolving “unfinished
busine Efficacy of experiential therapy using empty-chair
dialogue. Journal of Consulting and Clinical Psychology, 63,
419-425.

12. Janoff-Bullman, R. 1992. Shattered assumptions: Toward a

new psychology of trauma. New York: the Free Press.
13. Herman, J.L. (1992). Trauma and recovery. New York: Basic

Books.

14, Zomnik, C, Shea, TM,, Rosen, K., Simpson, E,, Mulrenin, K., Begin,
A.& Perlstein, T. (1997). An affect management group for women,
with posttraumatic stress dlisorder and histories of childhood sexual
abuse. Journal of Traumatic Stress, 10, 423-436.

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NC-PTSD Clinical Quarterly

Volume 9 (2) Spring 2000

source of information that can guide them. Directing attention
to bodily experience, along with Gestalt-type techniques for
heightening arousal (e.g., “say that again” or “say it louder”) are
particularly helpful for counteracting emotional numbness (2).

For clients who feel afraid of their anger, for example,
two-chair dialogues can be used to differentiate the two sides of
this conflict, the experiencing side of self that feels angry, and
the controlling/catastophizing side of self that makes them feel
afraid of feeling angry. At in-session “markers” of suppression,
clients can be directed to enact how they control or suppress
their feelings (¢.g., “What do you tell yourself will happen?” or “Make
this other part of yourself afraid.”). Exaggeration and intensification
of catastrophic expectations or injunctions against emotional
expression are used to heighten awareness of the experiential
impact these have on them, that is, how anxious and blocked
these make them feel. Intense experiential awareness of the
tension, isolation, and powerlessness of anger suppression seems
to access a desire to relieve the discomfort through expression,
and motivates adaptive action to stand up for the self. These
dialogues also promote awareness of one’s own specific anxiety
and guilt-producing cognitions. Cliénts recognize that what they
have leamed to say fo themselves leave them feeling confused,
conflicted, and insecure. These interventions thus faciliatate a
greater sense of agency and control over one’s own experience.
Clients can choose to allow their feelings once they feel safe. This
will help them eventually tolerate and explore painful trauma
material. Similar interventions can be used to explore and
transformed catastrophizing about personal safety, negative
expectations about others, and self-blame (1, 2).

Reprocessing and integration of trauma material The third
affective task in EFT for interpersonal trauma is reprocessing
and integrating trauma memories. Reprocessing necessitates
accessing maladaptive aspects of the memory or meaning system
that generate experiences of fear/anxiety, guilt, or shame, and
accessing previously inhibited adaptive emotional responses, such
as anger and sadness. Thus the adaptive information associated
with each emotion can be used to modify meaning. A variety of
reexperiencing techniques can be integrated into an emotionally-
focused approach. However, these techniques are contraindicated
for affect dysregulation problems with accompanying risk of
retraumatization, self-mutiliation, suicidal ideation, or aggressive
behavior. In other cases, that include extreme distress from
intrusive symptoms, anxiety management strategies, such as
provision of structure, breathing regulation, and present-
centeredness, are used to help regulate emotional intensity while
accessing trauma material. For clients unwilling to or unable to
engage in reexperiencing techniques, alternate techniques, such
as empathic exploration of traumatic events are employed. The
goals and principles of therapy remain the same regardless
of the techniques used to acheive them. EFT helps the
individual tell and retell the story of his or her victimization
with accompanying affect in order to relieve tension, alleviate
intrusive symptoms, and integrate trauma experience into
current meaning systems.

EMOTION FOCUSED THERAPY

Gestalt-derived imaginal confrontation techniques can be particularly
effective when the trauma involved someone known to the victim, such
as an abusive parent or an assailant who was a lover or friend. Imaginal
confrontation is used to evoke the trauma material and help clients express
previously constricted feelings and needs directly to imagined other(s).
These types of enactments involve the exploration of thoughts, feelings,
needs, nonverbal behavior, interpersonal reactions, and bodily experience,
in an experientially alive context. This can provide a more holistic,
powerful, and embodied experience than traditional imaginal exposure
techniques or telling the story to the therapist. This experience is integrated
into anew multimodal meaning system. In helping clients to reexperience
traumatic material, the soothing presence of the therapist and directives
to regulate breathing and attend to the present reality of the session are
important in regulating arousal.

In the early stages of EFT, it is typically less threatening for
clients to imaginally confront nonprotective, neglectful, or unhelpful
others (e.g., the police), than it is to confront or even imagine the
perpetrator or assailant. Dialogues with minimally threatening others
gradually expose clients to trauma material which allows for later
confrontation and resolution of issues with the imagined perpetrator.
Safety is provided partly by clarifying that dialogues are not rehearsals
for real life. Rather they are tools for accessing and clarifying internal
experience so that clients can be more aware of and guided by their own
experience. It is an opportunity to reprocess the experience, for
themselves, with no pressure to act in the real world. Clients are
encouraged to tell imagined others exactly what happened during the
victimization, and the impact it had on them (e.g., “tell your truth,” “make
him understand"). This evocation of memory helps to facilitate arousal
and expression of emotion and unmet needs for protection, help, support,
acknowledgement, or justice, and to clarify the meaning of these
experiences. Therapist validation and support helps clients feel entitled
to these needs even if, in real life, others can not be responsive or admit
to negligence or wrong-doing. Anger expression in therapy can help to
empower clients and, later, enable them to acknowledge the pain of losses
and betrayal and grieve for what they have missed. In other situations,
the client first must acknowledge hurt, sadness and loss before they can
move on to anger expression. Vulnerable experience is appropriately
expressed, not to the imagined perpetrator, but either to an imagined
other who the client believes will be responsive to their feelings and needs
or to the therapist. Again, EFT focuses on the experience that is
disavowed and needs support

Confronting the imagined perpetrator usually takes place in the
final integration phase of therapy once the client has worked through
secondary issues and is strong enough to tolerate the experience. For
example, a client who had been sexually molested over a period of years
as child was encouraged to imagine the scene of waiting for the perpetrator
to arrive (2). He reexperienced his dread, not wanting sexual contact,
and having no control over the situation, He also reexperienced his shame
at participating in sexual acts, fear of being found out by family and
friends, and feelings of alienation and isolation. He felt tainted and dirty
and feared being stigmatized and rejected. There are various theoretical
perspectives on the tendency to “blame the victim,” whether self or
another person. For example, psychodynamic and object-relations
models suggest that anger directed at the self (guilt) may be less
threatening than anger directed ata needed and/or dangerous other (24).

27


NC-PTSD Clinical Quarterly Volume 9 (2) Spring 2000

Matthew J. Friedman, M.D., Ph.D.
Executive Director, NC-PTSD

In this New Directions column, I'd like to call attention to the reactivation. of an old direction that hit a dead end several years
ago. The Veterans Health Care Bill of Fiscal Year 2000, the Millennium Bill, has created the Under Secretary for Health's (USH) Committee
on PTSD. This is a reincarnation of the old Chief Medical Director's (CMD's) Special Committee on PTSD, which played a quiet but
decisive role in helping to wansform VA from relative institutional indifference to international leadership in treatment, research, and
education on the psychological consequences of traumatic stress

Since institutional memory spans are short, it is the responsibility of oral historians, such as myself, to pass on important past
events that have a significant bearing on the present and future. Therefore, I shall tell you about the CMD's Special Committee for PTSD
in order to help set the stage for the recently mandated USH Committee that has yet to be selected.

In 1984, because of its concern about VA's commitment to address the problems of Vietnam veterans with PTSD, Congress
mandated that VA establish a Special Committee to provide oversight on all PTSD programs. What made this committee "special" was
that its Annual Report was submitted to the House and Senate Veterans Affairs Committees rather than to VA leadership. Although the
Annual Report was first reviewed by the CMD, and other top VA officials, it could not be altered or withheld from Congress. Since, at
first, many recommendations were not viewed favorably by these top officials, VA usually submitted a lengthy rebuttal whenever the
Special Committee's Annual Report was delivered to Congress.

Tt must be understood that PTSD did not appear to be an important VA priority in 1984, when the Special Committee began
to operate. Furthermore, VA leadership was concerned that any recommendation to upgrade VA PTSD programs would have significant
budgetary implications. This actually was a realistic concern (from their point of view) since the Special Committee recommended: a]
that a PTSD Clinical Team (PCT) be established at every one of VA's 172 medical centers; b] that Readjustment Counseling Service be
supported through expansion of the Vet Center program; c] that there be an appropriate increase in funding of research proposals on
PTSD: di that there be an expansion of VA educational programs devoted to PTSD; and el that the quality of compensation and pension
examinations be improved so that disability claims by veterans with PTSD would be adjudicated properly. Other Special Committee
recommendations that were equally important concemed the establishment and enforcement of minimal standards of care for all veterans
seeking treatment for PTSD.

The Special Committee was extremely effective in making its case to Congress and, eventually, to VA's top leadership. It's
Annual Reports had far reaching effects, most notably in helping to provide justification for a series of Congressional appropriations
earmarked specifically to expand and create a variety of PTSD clinical programs such as PCTs, Vet Centers, Specialized Inpatient PTSD
Units, Dual Diagnosis Units, Specialized Programs for Women Veterans and other clinical initiatives.

Eschewing rhetoric, the Special Committee enunciated two operational principles at the outset that guided all subsequent
activities. First, it stated axiomatically, that military-related PTSD should rank at the top of VA's priorities since the primary mission of
VA is to provide care for men and women whose health has suffered as a result of their service to their country. Second, it stated its policy
that all recommendations would be based on empirical data.

‘Asa result of this second principle, the Special Committee initiated comprehensive surveys of all mental health outpatient
visits and inpatient visits at all VA medical centers for an entire month. It also surveyed all visits to Vet Centers for readjustment
counseling during the same period. It monitored the national veterans benefits process on an annual basis. Itreviewed funding for PTSD
research in comparison with funding for research in other areas ‘And it reviewed VA educational programs to determine whether PTSD
was receiving its fair share of attention and resources.

With respect to hospital-based PTSD treatment and veterans benefits, data generated by the Special Committee revealed
major inconsistencies from one Medical Center to the next and from one Regional Office to the next. As stated in its Annual Reports,
unless one wished to argue that there was much more PTSD in one part of the country than in another, these findings could only be
explained as indicating vast differences in professional competence and institutional priorities with respect to the diagnosis and treatment
of PTSD. These data appeared at about the same time as findings from the National Vietnam Veterans Readjustment Study (NVVRS)
that found that the current and lifetime prevalence of PTSD among Vietnam theater veterans was 15% and 30%, respectively. Taken
together, Special Committee and NVVRS Reports convinced Congress to allocate more money for PTSD programs and convinced VA
officials that PTSD treatment was a major responsibility of the VA system. Special Committee oversight also helped to correct deficiencies
in the peer-review process for research funding and to promote an appropriate allocation of resources for educational programs on
PTSD.

Except for two eminent senior psychiatrists (who were both World War II vetera’ ns), Lawrence Kolb MD and Arthur Arnold
MD, most members of the Special Committee were young professionals in early stages of their careers. They represented different
professional perspectives (e.g., psychiatry, psychology, social work, nursing, and administration). They worked in hospital-based as well
as Vet Center programs. Six were Vietnam veterans while one was the spouse of a theater veteran. And although all had exercised
(continued on page 29)
24



NC-PTSD Clinical Quarterly

Volume 9 (2) Spring 2000

people extoll the virtues of the writing paradigm by noting that it

changed the ways they understood what had happened. Their expla-
nations almost always included words like “I now realize...” or “It
helped me to understand...”

In recent years, we have begun analyzing the language that
individuals use in writing about emotional topics. Our first strategy
was to have independent raters evaluate the essays, however, the rela-
tively poor inter-judge reliability led us to develop a computerized
text analysis system. In 1991, we created a computer program called
LIWC (Linguistic Inquiry and Word Count) that analyzed essays in
text format. LIWC had been developed by having groups of judges
evaluate the degree to which about 2,000 words or word stems were
related to each of several dozen categories (8). The categories in-
cluded negative emotion words (sad, angry), positive emotion words
(happy, laugh), causal words (because, reason), and insight words
(understand, realize). For each essay that a person wrote, we were
able to quickly compute the percentage of total words that repre-
sented these and other linguistic categories.

The interesting pattern that
is emerging from this work is
that people who naturally
dont talk about their
emotional state to a great
degree (men, alexithymics,
and those high in hostility)
benefit more from writing
about traumatic experiences
than more open individuals.

Analyzing the experimental subjects data from 6 writing
studies, three linguistic factors reliably predict improved physical
health. First, the more that individuals use positive emotion words,
the better their subsequent health. Second, a moderate number of
negative emotion words predicts health. Both very high and very
low levels of negative emotion word use correlate with poorer health.
Third, and most important, an increase in both causal and insight
words over the course of writing is strongly associated with improved
health (9). Indeed, this increase in cognitive words covaries with
judges’ evaluations of the construction of a story or narrative. That
is, people who benefit from writing begin with a poorly organized de-
scription and progress to a coherent story by the last day of writing.

PENNEBAKER & CAMPBELL

The language analyses are particularly promising in that they
suggest that certain features of essays predict long term physical
health. Further, these features are congruent with current views on
narratives in psychology. The next issue that is currently being ad-
dressed is the degree to which cohesive stories or narratives predict
changes in real world cognitive processes. That is, does a coherent
story about a trauma produce improvements in health by reducing
ruminations or flashbacks? Does a story ultimately result in the as-
similation of an unexplained experience that allows the person to get
on with life? To what degree does the use and integration of emo-
tion language affect the narrative and, ultimately, health?

Implications for the Use of Writing in PTSD

Despite the clear relevance of the writing technique for the
treatment of PTSD, relatively few studies have actually been con-
ducted. Indeed, two lines of research have yielded contradictory
findings. In two studies in the Netherlands, Schoutrop and her col-
leagues (10) enlisted community samples through newspaper ads who
met criteria for PTSD using the Impact of Events Scale (IES). Most
participants were suffering from accidents, robbery, violent crime or
some combination of such events. In both of her studies, there were
significant reductions in IES scores for those who wrote about the
emotional topics compared with controls who wrote about superfi-
cial topics.

On the contrary, Gidron and his colleagues in Israel (11)
employed 14 outpatients with significant PTSD symptoms and had
them write about either the trauma or about superficial topics for 3
consecutive days. Unlike other writing studies, however, the authors
also required the participants to orally expand on what they had writ-
ten. Unlike any other writing study, the authors found that the writ-
ing/talking intervention for the emotion condition resulted in elevated
symptoms and more health problems than for the controls. Ironi-
y, the Gidron paper bears an intriguing similarity to some of the
‘al Incident Stress Debriefing (CISD) interventions. That is, in-
dividuals were required to orally express their feelings as part of the
“therapy.”

Our sense is that the Gidron project points to a critical fea-
ture of the original writing technique: in writing, people are able to
dose themselves. That is, individuals are encouraged to write in as
much detail with as much emotional involvement as they desire. There
is no social feedback nor “pushing” on the part of the experimenter.
Itis very possible, then, that excessive prodding to express emotions
ina social setting may be counterproductive.

people who benefit from

writing begin with a poorly
organized description and
progress to acoherent story...

20



NC-PTSD Clinical Quarterly Volume 9 (2) Spring 2000

The Education and Clinical Laboratory 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 ClinicalTraining 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

xe & *

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, on the second or 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 orVA Employee Education System.

For more information, or to request an application, please email:
jir@icon. palo-alto.med.va.gov
or telephone FTS 700-463-2673; commercial number 650-493-5000, ext. 22673

31 ——

¥¥U,S. GOVERNMENT PRINTING OFFICE: 2000—584-451


NC-PTSD Clinical Quarterly

Volume 9 (2) Spring 2000

Researchers have relied on a variety of physical and mental
health measures to evaluate the effect of writing. As discussed in
recent reviews (1, 2), writing about emotional experiences relative to
writing about superficial control topics has been found to be associ-
ated with significant drops in physician visits from before to after
writing among relatively healthy samples. Writing about emotional
topics has also been found to influence immune function in beneficial
ways, including t-helper cell growth (using a blastogenesis procedure
with the mitogen PHA), antibody response to Epstein-Barr virus,
and antibody response to hepatitis B vaccinations. Self reports also
suggest that writing about upsetting experiences, although painful in
the days of writing, produce long-term improvements in mood and
indicators of well-being compared to controls.

Behavioral changes have also been found. Students writing
about emotional topics evidence improvements in grades in the
months following the study. Senior professionals who have been laid
off from their jobs get new jobs more quickly after writing. Consis-
tent with the direct health measures, university staff members who
write about emotional topics are subsequently absent from their work
at lower rates than controls. Interestingly, relatively few reliable
changes emerge using self-reports of health-related behaviors. That
is, after writing, experimental participants do not report exercising
more or smoking less. The one exception is that older samples of
men and women in their 40s and older report that writing reduces
alcohol intake.

... several studies have persua-
sively demonstated that writing
about atrauma does more than
allow for the reduction of in-
hibitory processes — it appears
to bring about changes in the
way people think.

The writing effect is remarkably robust. Studies comparing
writing alone versus talking either into a tape recorder or to a thera-
pist find comparable biological, mood, and cognitive effects. In-
deed, the effect sizes of the writing paradigm compare favorably
with those of psychotherapy (2). In fact, in a recent study of indi-
viduals with arthritis and asthma, Smyth and his colleagues (3) found
that those individuals who were asked to write about traumatic expe-
riences compared to control writing showed objective health im-
provements at rates superior to what has been found in any psycho-
therapies with comparable samples (d’s > 1.00 for most behavioral
measures). The effects hold up in studies conducted throughout
Europe, Japan, North America, and across social classes.

EFFECTS OP WRITING

Very few consistent personality or individual difference
measures have distinguished who does versus does not benefit from
writing. Most commonly-examined variables unrelated to outcomes
include anxiety (or Negative Affectivity), and inhibition or constraint.
The one study that preselected participants on hostility found that
those high in hostility benefited more from writing than those low in
hostility (4). In a recent study by Paez and Velasco (5), individuals
high in the trait of alexithymia benefited more from writing than
those low in the trait. Alexithymia is characterized by the inability to
label and understand one’s own emotional state. Finally, in the Smyth
meta-analysis (2), males were found to benefit more than females.
The interesting pattern that is emerging from this work is that people
who naturally don't talk about their emotional state to a great degree
(men, alexithymics, and those high in hostility) benefit more from
writing about traumatic experiences than more open individuals.

Why Does Writing about Traumatic Experiences Work?

Most of the research on disclosure has been devoted
to demonstrating its effectiveness rather than on identifying
the underlying mechanisms. Two very broad models that have
attempted to explain the value of disclosure are those that
invoke inhibitory processes and cognitive processes.

Inhibition and disclosure. The original theory that moti-
vated the first studies on writing was based on the assumption that
not talking about important psychological phenomena was a form
of inhibition. Drawing on the animal and psychophysiological lit-
eratures, it was posited that active inhibition was a form of physi-
ological work. This inhibitory work, which is reflected in autonomic
and central nervous system activity, could be viewed as a long-term
low-level stressor. Such stress, then, could cause or exacerbate psy-
chosomatic processes thereby increasing the risk of illness and other
stress-related disturbances. Just as constraining thoughts, feelings, or
behaviors linked to an emotional upheaval was stressful, letting go
and talking about these experiences should, in theory, reduce the stress
of inhibition.

Findings to support the inhibition model of psychosomat-
ics are growing. Individuals who conceal their gay status, traumatic
experiences in their past, or who are considered inhibited or shy by
others exhibit more health problems than those less inhibited (6).
Whereas inhibition appears to contribute to long term health prob-
lems, the evidence that disclosure reduces inhibition and thereby im-
proves health has not materialized. For example, Greenberg and
Stone (7) found that individuals benefited equally from writing about
traumas about which they had told others as about traumas that they
had kept secret. Self-reports of inhibition before and after writing
have not consistently related to health changes. At this point, then,
the precise role of inhibition in promoting health within the writing
paradigm is not proven.

Cognitive changes associated with writing. In the last
decade, several studies have persuasively demonstrated that writing
about a trauma does more than allow for the reduction of inhibitory
processes — it appears to bring about changes in the ways people
think. Follow-up interviews in the months after writing indicate that

19


NC-PTSD Clinical Quarterly Volume 9 (2) Spring 2000

One might say that in the field of psychotherapy, a hallmark of the 20" century was the advent of new therapies extending
far beyond 19" century formulations of White-European psychoanalysts. At the beginning of the 21% century, matching
appropriate treatment to the patient has become a primary challenge. Empirically-validated treatments are few, but even so,
clinical experience makes it clear that no form of treatment is suitable or appropriate for all individuals diagnosed with
PTSD. A person’s age, developmental capacity, global functioning, capacity to manage physiological arousal, degree of
social support, degree of self-cohesion, cultural values, emotional intelligence, degree of trauma, degree of reactions, etc.,
are just a few of many factors we now consider important when exploring treatment options. Moreover, some survivors
arguably do better with didactic presentations than with process oriented techniques, some benefit more from here-and-
now problem solving attention than with historical review and cognitive re-appraisal, some respond well to confrontation,
others only to supportive approaches. Each new patient challenges our clinical abilities to help harness the patient’s re-
sources and regenerative powers, to help him or her build on diverse strengths, accomplishments, and skills brought to

treatment.

In this issue of the Clinical Quarterly, we are pleased to feature two articles describing distinct forms of psychotherapy that
can be used to broaden the clinical repertoire.The use of writing as a means of clarification, self-dosed exposure, and
positive reinforcement is described by James Pennebaker and Sherlock Campbell. A description of emotion focused therapy,
designed to help resolve trauma-related emotional problems, is presented by Sandra Paivio and Leslie Greenberg. For some
survivors, writing a trauma narrative, either exclusively or before giving an oral narrative, may be more helpful than giving
an oral narrative alone. Survivors who are particularly fearful of being overwhelmed by emotion may benefit from a
structured approach that helps tolerate intense affect and arousal, especially when there is a need to change maladaptive
emotional meaning. These brief introductory articles to the work of Pennebaker, Campbell, Paivio and Greenberg reiterate

the need to carefully consider the best treatment options for our richly diverse patients and clients. A

AO. 7

Bruce H. Young, Editor

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 Behavioral Science Division Women’s Health Science Division
Fred Gusman, M.S.W., Director Terence Keane, Ph.D., Director Marie Caulfield, Ph.D., Acting Director
VAMC, Palo Alto, California 94304 VAMC, Boston, Massachusetts 02130 VAMC, Boston, Massachusetts 02130
Pacific Islands Division Neuroscience Division Northeast Program Evaluation Center
Sarah Miyahira, Ph.D., Acting Director Dennis Charney, M.D., Director Robert Rosenheck, M.D., Director
Honolulu, Hawaii 96813 VAMC, West Haven, Connecticut 06516 VAMC, West Haven, Connecticut 06516

Clinical Quarterly Staff
Editor Bruce H. Young, L.C.S.W.
Managing Editor Josef J. Ruzek, Ph.D.
Executive Editor Fred D. Gusman, M.S.W.
Associate Editors Eve B. Carlson, Ph.D.
Gregory A. Leskin, Ph.D.
Assistant Editor John Aboytes, B.A.
Graphic Design & Layout Bruce H. Young

18

3/2494; commercial number 650-493-5000 ext, 22673/22494; or E-mail: bhh @ icon. palo-alto.med.va.gov
SD Clinical Quarterly, VA Palo Allo Health Care System, 795 Willow Rd (352E117), Menlo Park, CA 94025

Please feel free to contact us at the Education Division: FTS 46:
Please address all correspondence to : Editor, National Center



NC-PTSD Clinical Quarterly

Volume 9 (2) Spring 2000

15. Linehan, M.M. (1993). Cognitive-behavioral treatment for
borderline personality disorder. New York: Guilford.

16. Elliott, R., Davis, L.D., & Slatick, E. (1998). Process-experiential
therapy for posttraumatic stress difficulties. In L.S. Greenberg,
J.C. Watson, & G. Lietar (Eds.), Handbook of Experiential
Psychotherapy, (pp. 249-270). New York: Guilford.

17. Johnson, S. (1998). The heart of the matter. New York: Sage.

18. Paivio, S.C. & Shimp, L.N. (In press). Affective change processes
in therapy for PTSD stemming from child physical abuse.
Journal of Psychotherapy Integration.

19. Fridja, N.H. (1986). The emotions. Cambridge: Cambridge
University Press.

20. Kohut, H. (1984). How does analysis cure? Chicago: University
of Chicago Press.

21. Rogers, C.R. (1975). Empathic: An unappreciated way of being.
Counselling Psychologist, 5, 2-10.

22. Roth, S., & Leibowitz, L. (1988). The experience of sexual trauma.
journal of Traumatic Stress, 1, (79-107).

23. Paivio, S.C. (1999). Experiential conceptualization and treatment
of anger. Journal of Clinical Psychology.

24. Bagle, M.N. (1984). Recent developments in psychoanalysis.

Cambridge, MA: Harvard University Press.

Sandra Paivio is Assistant Professor of Clinical

Psychology at the University of Windsor, Canada, She”

bas published numerous articles in the areas of
psychotherapy research, emotional processes in
psychotherapy, and trauma, and is co-author of a book,
Working with Emotions in Psychotherapy, with Leslie
Greenberg. She recently received a major research grant
to study the process and outcome of psychotherapy with
adult survivors of child abuse.

Leslie S. Greenberg is Professor of Psychology at York
University, Director of the Psychotherapy Research
Clinic and a Past President of the Society for
Psychotherapy Research. He is in private practice in
Couples and Individual therapy in Toronto and trains
therapists in emotionally focused approaches to
treatment. He bas published extensively on research
on individual and couples therapy and is on the
editorial board of a number of journals. Recent books
are: Greenberg, L. & Paivio, S. Working with Emotion in
Psychotherapy. Greenberg, L. Watson, J. & Lietaer, G.
Handbook of Experiential therapy. Greenberg, L. Rice,
L. & Elliott, R. Facilitating Emotional Change. Bobart A.
& Greenberg, L. Empathy reconsidered. New directions
in theory, research and practice.

NEW DIRECTIONS (continued from page 8)

leadership in local clinical, research and educational PTSD
programs, few had any national experience. For some of them
the Special Committee served as an important training ground
that facilitated their maturation as future leaders in VA and in
the PTSD field. They were (in alphabetical order) Bob Baker,
Al Batres, Pat Boudewyns, Spencer Falcon, Joan Furey, Joe
Gelsomino, Fred Gusman, Jack Harrington, Terry Keane, Steve
Petty, Ted Podkul, Jack Smith, Bud Wittlin, and myself.

As Lunderstand it, the USH Cormmittee will submit
a progress report to Congress every year. It will have major
oversight responsibilities for all of VA's PTSD programs. The
quality of clinical services, research activity, educational
initiatives and allocation of veterans benefits will all be evaluated
by this committee. This includes the performance of the
National Center for PTSD. The Committee's report should
serve as an important management tool for VA's top leadership
and enable congress to monitor such programs in order to
sustain VA excellence in this area. So I look forward to the
activities and oversight of the USH Committee on PTSD.
Hopefully, it will reactivate the dynamism and vision of the old
Special Committee and wil! promote excellence in all VA PTSD

programs.

The National Center for PTSD and
Readjustment Counseling Service co-host a
teleconference call to facilitate networking and
information sharing for VA practitioners
interested in disaster mental health. Calls are
scheduled the first Thursday of each month,
11:00am (EST). Phone 800-230-2250 and request
to be connected to the “Mental Health Crisis
Counseling call.”

For futher information, please call Bruce H. Young,
LCSW, Disaster Services Coordinator, NC-PTSD,

650-493-5000 ext. 22494.

To be put on the email list, send request to:
bbh@icon.palo-alto.med.va.gov
and list subject as “MHCC Participant.”

29


NC-PTSD Clinical Quarterly Volume 9 (2) Spring 2000

PTSD Assessment Library
Available upon request are selected instrumients 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 EducationTeam 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 EducationTeam 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 andTreatment, 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 ncptsd.org

PILOTS Database
PILOTS, the only electronic index focused exclusively on the world’s 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. bitp://www ncpisd.org/PILOTS.html

NC-PTSD Research Quarterly
The Research Quarterly reviews recent scientific PTSD literature Telephone (802) 296-5 132 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:bbh @icon palo-alto.med.vagov

Conferences and Training Events
The Menlo Park EducationTeam 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.