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Early conceptualizations

of the development and maintenance of Posttraumatic Stress

Disorder (PTSD) were based

on Mowrer’s Two-Factor

Theory of classical and operant

conditioning (1-2). This

conceptualization was further

developed with the introduction of emotional processing

theory. Foa and colleagues proposed that a fear-based memory

 network develops following a

traumatic event which contains information about

trauma-related stimuli, responses to the trauma, the meaning of trauma-related stimuli, and subsequent responses

(3-4). In order to modify the fear network, it must be

activated so that adaptive and accurate information can

be incorporated into the network that is inconsistent with

an extreme fear reaction. Avoidance of trauma-related

memories and cues, however, prevents this from happening.

The core component of exposure therapy is helping

the client confront realistically safe, feared stimuli until

fear decreases. While there are a number of different adaptations of exposure with trauma survivors, in Foa and

Rothbaum’s approach, the trauma patient is asked to “relive” her trauma experience by describing it aloud repeatedly in present tense for 45-60 minutes (4). The patient is encouraged to use as much detail as possible, especially sensory memories such as smells, sounds, etc. as

well as thoughts and feelings experienced during the event.

An example of imaginal exposure follows:

It’s dark. I’m driving home from

work and decide to stop by an ATM

machine to make a withdrawal

because I won’t have a chance

before work the next day. I drive

into the bank parking lot. It’s

deserted. I think, “Good, no one else

to worry about.” My heart is

beating a little faster anyway, but I

tell myself that I’m safe.” I get out of

my car and walk up to the ATM. I

have my card ready and I begin the

transaction. I get the money and put

it into my purse. Suddenly I hear something rustle and I feel like

someone is behind me. I turn around quickly and see a man with a

ski mask over his head. He’s got a gun and he’s pointing it at me. I’m

terrified. All I can think is that he’s going to kill me. He’s going to kill

me. Somehow he grabs me by my neck. He puts the gun right up to my

temple. It feels cold and hard. I can hardly breathe because I’m so

frightened. My chest feels tight and my legs feel weak. He smells of

tobacco and sweat. I feel a wave of nausea come over me. He stands

behind me with the gun to my head and tells me to withdraw as much

money as I can. I do it, but my hands are shaking. Then he tells me to

hand over the money I had withdrawn. When I do, he starts dragging

me over to my car. I say to myself, “No, you can’t go with him. He’ll

rape you and then he’ll kill you. I’ve got to figure out how to get away.”

My heart is pounding so loud that it’s hard to think. He opens the

door to the driver’s side and tries to push me in. I try to resist. I say,

“no!” This makes him mad and he takes the gun and hits me on my

right cheek and the side of my head. He says, “don’t make me kill you,

bitch.” My cheek stings and I’m afraid he’ll shoot me right there, so I

get into the car and move over to passenger side. He gets in and tells

me again, “don’t do anything stupid or I’ll pop you.” I know what he


 	





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means. He means he’ll kill me. I think about my family, how my kids

aren’t going to have a mother. I feel tears welling up, but then I feel

angry. He starts driving around town. Soon, I realize that I have no

idea where I am. Then...”

The patient finishes her description of her trauma

including the sexual assault and repeats it two more times

while the therapist audiotapes it. Following imaginal exposure, therapist and patient discuss the exposure and insights into the trauma made during exposure to facilitate

cognitive integration. For homework, the patient listens

to her exposure tape multiple times to facilitate further

habituation.

Research Findings and Clinical Conclusions about the

Efficacy of Exposure Therapy

Exposure therapy has been used with great success

for many years to treat a variety of disorders including

phobias, panic, and obsessive-compulsive disorder. In the

last 15-20 years, exposure has been applied and adapted

for treatment of PTSD. Exposure therapy has more empirical evidence for its efficacy than any other treatment

for trauma-related symptoms. Twelve studies were included

in the review of exposure for PTSD in the ISTSS Treatment Guidelines, eight of which were well-controlled

methodologically (5). Eleven out of the twelve studies

found exposure to be an effective treatment for PTSD

for combat veterans, rape survivors, and mixed trauma

survivors. The one study with equivocal results used guilt

and shame-producing stimuli during exposure with combat veterans rather than anxiety-producing stimuli (6).

Given these data, it was concluded that exposure is a highly

effective treatment for trauma, has the strongest empirical data to support its efficacy, and has been evaluated

with a greater number of trauma populations than any

other treatment.

The Expert Consensus Guidelines for the treatment

of PTSD also rated exposure treatment as one of the most

effective treatments for PTSD (7). These guidelines identified exposure therapy as the quickest acting treatment

for PTSD and one of the treatments preferred across

trauma populations. Despite extensive and consistent

empirical evidence supporting the efficacy of exposure

treatment for PTSD, many clinicians are reluctant to use

exposure. In fact, in the Expert Consensus Guidelines,

exposure was rated as less safe than other treatment options such as cognitive therapy, psychoeducation, and

anxiety management and as less acceptable than these other

treatments. They were also reluctant to recommend the

use of exposure when other comorbid conditions were

present (e.g., depression, substance abuse, etc.).

Exposure therapy has more

empirical evidence for its

efficacy than any other treatment

for trauma-related symptoms.

Myths about Exposure Therapy

As we have presented our work with trauma survivors, we have been confronted with a number of beliefs of

clinicians and researchers that have led them to be less

than enthusiastic about exposure therapy. We list and discuss several of these below.

1. Encouraging trauma survivors to relive their trauma in

imagination (the key component in exposure) is cruel and

revictimizing. Exposure elicits traumatic memories and

trauma-related affect particular to the trauma survivor.

These memories are not dangerous in and of themselves.

However, because they have been linked with trauma-related affect, they often feel dangerous. Allowing oneself to

think about the trauma memories actually allows the survivor to process them so that they can be integrated into

memory in an adaptive manner. Moreover, it is important to remember that these memories and feelings are

already experienced, in a nonadaptive fashion, by the

trauma survivor. In reality, successful exposure treatment

reduces the survivor’s intrusive memories and diminishes

painful affect associated with those memories.

2. Exposure takes away the autonomy of trauma survivors

because they are confronted with what they do not wish to

remember. Avoidance is key to understanding PTSD. The

trauma memories intrude into consciousness because they

have not been adequately processed, and because they are

painful, the survivor avoids the memories, which prevents

them from being processed. This vicious cycle has to be

broken in order for the trauma survivor to gain control

over the traumatic experience. Exposure actually empowers

 


 	





!"#$!%

trauma survivors to be able to be in charge of their trauma

memories. Because it is key to therapeutic change, all

good therapists at times confront their clients with painful information that clients would rather avoid. Such “confrontation” is crucial to trauma therapy. While this may

be done in a variety of ways, exposure therapy is a very

efficient and effective way to help the survivor confront

traumatic memories. Like any therapy, it is important to

describe the components of exposure and explain the rationale for them so that the client can make informed

choices about treatment. Also, patients have chosen to

participate in this type of therapy, so therapists are helping them to do what they have not been able to do alone.

Exposure therapy respects that some clients may choose

alternative treatment options.

3. Exposure can only be used with survivors of discrete

traumas such as rape, natural disaster, and motor vehicle

accidents. Exposure-based treatments were first applied to

combat veterans, then to rape survivors, and ultimately

expanded to a variety of trauma populations. Even within

the context of “discrete” traumas, there can be multiple

events and/or multiple perpetrators. In our current studies with rape survivors and mixed trauma survivors, many

have a history of childhood sexual abuse and other chronic

trauma that we also address in treatment. Naturally, with

multiple events to cover, additional sessions are sometimes

necessary. However, in our experience, using the worst

memories and/or typical incidences representative of the

trauma as a whole usually allows generalization to the complete trauma experience.

4. Exposure can only be used with individuals who are

healthy and stable; it cannot be used with the typical trauma

survivor who is complex and fragile. As with most outpatient treatments of trauma, care must be taken with clients who are imminently suicidal, psychotic, or who have

a history of psychotic decompensation. There are no data

to support the use of any trauma-focused therapy with

these populations. All therapists must switch from trauma

therapy to crisis management and containment when a

client becomes actively suicidal. At the same time, however, we have successfully treated or have colleagues who

have treated trauma patients with a history of multiple

psychiatric hospitalizations, multiple suicide attempts,

high levels of dissociation, treatment resistance to other

therapeutic interventions, borderline intelligence, mild

brain injuries, and comorbid disorders such as depression,

panic disorder, and substance abuse.

5. Exposure may induce psychosis or severe depression.

There is no evidence at all to support this. Clients typically feel worse (more intrusive memories, decreased sleep,

increased depression, etc.) for the first half of treatment,

but these problems usually resolve as the trauma is processed. For clients who do not improve or who drop out

prematurely, symptoms are not likely to stay at the same

level. Such clients typically resort to avoidance and acute

symptoms diminish to pre-treatment levels.

6. Exposure cannot address broader trauma-related symptoms other than anxiety and PTSD. Even though the rationale for exposure focuses on modification of fear structures, most strong affect will habituate in the absence of

adverse consequences. In our clinical experience, many

clients note that their feelings of depression, rage, sadness,

and guilt diminish with exposure. Generally, in addition

to reducing PTSD, studies have shown prolonged exposure (PE) also reduces depression and self-blame (5). Pitman et al. did find equivocal results when they used exposure to guilt and shame-producing stimuli in a few combat veterans whose guilt and shame were often related to

their behavior in combat(6). Additionally, Foa et al. report that patients whose primary response is anger rather

than anxiety may not benefit as much from exposure (8).

Preliminary research by Novaco and Chemtob (9) suggests that some trauma populations may benefit from anger management in conjunction with trauma treatment.

Also, exposure is frequently combined with cognitive restructuring to address other issues crucial to trauma resolution

such as self-blame or distorted relationships or worldview.

7. Exposure does not allow trauma survivors to recover at

their own pace. The fact is that patients haven’t recovered

at their own pace if they are presenting for treatment of

PTSD and they need assistance. Therapist sensitivity to

individual differences in their speed of habituation and

response to anxiety-provoking situations is an essential

component of good exposure therapy. At the same time,

making sure that the client’s exposures are long enough

and are repeated frequently enough is vital as well. In this

regard, exposure can be likened to a medical procedure.
	



>





 

The procedure is deemed necessary for recovery, although

not pleasant for the patient. Furthermore, the procedure

must be conducted in the optimal manner to receive optimal recovery.

8. Controlled studies of exposure therapy only use “clean”

PTSD patients. Subjects are not usually excluded for multiple trauma history, other comorbid conditions or for Axis

II pathology. Generally, the primary exclusionary factors

are limited to substance dependence, imminent suicidal

risk, history of psychosis or mania, illiteracy, and mental

retardation (5).

Clinical Guidelines for Exposure

We sometimes hear from clinicians who say they have

tried exposure, but have not found it to be effective. Frequently, important guidelines for exposure have been overlooked making successful use of exposure less likely. Some

of the more important guidelines are discussed below. See

Foa & Rothbaum (4) and Jaycox & Foa (10) for more

detailed guidelines.

1. Patients should remain in the exposure situation long

enough for their anxiety and distress to decrease. The tendency for most clinicians is to back off or discontinue

exposure at the first sign of distress in the patient. While

this is a generally well-intentioned effort to protect the

patient, it actually reinforces avoidance of the trauma and

impedes necessary emotional processing. Initially, a certain amount of distress should be expected and normalized

for the patient. Again, because the trauma memory itself

is not dangerous, trauma-related affect will diminish if

given the chance. We want clients to learn that they do

not need to fear their trauma memories. The therapist’s

job is to help the patient “ride out” the anxiety in a safe

environment until it is significantly diminished and/or

eliminated.

2. The therapist should encourage the patient to use as much

detail as possible, especially for the worst parts of the trauma.

Again, the tendency here is to let the patient summarize

the worst parts or to skip over them entirely. For example,

a rape survivor might give good details of being abducted,

but when she reaches the description of the actual penetration, she may say something vague like, “then he did

it.” This essentially allows the patient to go through the

motions of doing exposure, but still avoid critical elements

of the trauma. In addition to wanting to avoid the memory,

patients may also be embarrassed or ashamed of some

elements. As described above, such avoidance impedes

emotional processing of the trauma and short-circuits the

treatment.

3. Patients should be allowed to progress at their own pace.

Despite the need to do exposures long enough, repeatedly enough, and detailed enough, it is essential to go at

the patient’s pace. This is especially true in the first exposure when the patient is likely to be experiencing high

levels of trauma-related affect. Pushing the patient for details should be avoided in the first exposure. Additionally,

individuals differ in their speed of habituation and response to anxiety provoking situations. The therapist must

take these differences into account. Never proceed to a

new trauma memory or to the next level of the hierarchy

(for in vivo exposure) unless there is sufficient time to

allow for habituation. If the client’s anxiety and distress

do not significantly decrease before the end of the session, be sure to spend time helping the client to relax and

debrief. If a patient is highly anxious after exposure, it is

crucial to help him calm down before ending the session

so that he learns that he can think about the trauma and

experience strong feelings, but still be OK.

4. Therapists should gauge their responses according to patients’ reactions to exposure. Problematic responses tend

to fall at two extremes: either the patient has trouble engaging in the memory or feeling trauma-related emotions;

or the patient is so engaged in the trauma that she is overwhelmed by trauma-related affect. Frequently, when a

patient becomes engrossed in the exposure, she is having

trouble remembering that she is not actually in the trauma

at that moment. In such situations, it is appropriate for

the therapist to remind the patient that she is in a safe

place, that the therapist is right beside her, and what they

are dealing with is just a memory. This helps the patient to

detach slightly from the exposure so that trauma-related

affect is more manageable. The more typical and troublesome scenario is the patient who has trouble engaging in

the exposure. Exposure, of course, requires that the patient trust the therapist enough to engage in the very

memories that he has been actively avoiding. Avoidance

can be quite direct, but it frequently can be amazingly


 	






!"#$!%

subtle. Some patients go through the motions of exposure, but distance themselves emotionally. Their descriptions of the trauma often sound flat and matter-of-fact.

Many trauma survivors have learned to dissociate as a form

of avoidance and may not even realize that they are detaching from the trauma memory. In this situation, it falls

to the therapist to try to engage the patient in the memory

in a gentle manner. This can sometimes be accomplished

by prompting for more details (“where are you standing

as he attacks?”), asking about emotions and thoughts during the trauma (“what do you feel as he says that?”), and

probing for sensory memories (“can you smell him?”).

Anything that makes the memory more vivid may help

patients to engage emotionally. During the preparation

stages before exposure begins, it is crucial to encourage

patients to allow themselves to feel those emotions and

answer any fears about what will happen if they do so.

After the exposure is over, it is also important to reinforce

this message, and praise their efforts to engage in traumarelated emotions.

Although we are clearly advocating the use of exposure therapy for PTSD, we end on a word of caution.

Only therapists trained in exposure therapy should attempt

it with patients. Bad exposure therapy is simply bad therapy.

However, both research and our own clinical experience

suggest that when done properly, exposure therapy is a

highly effective treatment for PTSD.

References

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

A behavioral formulation of post-traumatic stress disorder in combat veterans. The Behavior Therapist,

8, 9-12.

2. Mowrer, O.A. (1960). Learning theory and behavior.

New York: Wiley.

3. Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20-35.

4. Foa, E.B., & Rothbaum, B.O. (1998). Treating the

trauma of rape: A cognitive-behavioral therapy for

PTSD. New York: Guilford.

5. Rothbaum, B.O., Meadows, E.A., Resick, P., & Foy,

D.W. (2000). Cognitive-behavioral therapy. In E.B.

Foa, T. M. Keane, & M.J. Friedman (Eds.), Effective treatments for posttraumatic stress disorder: Practice Guidelines from the International Society for

Traumatic Stress Studies (pp. 60-83). New York, NY:

Guilford.

6. Pitman, R.K., Altman, B., Greenwald, E., Longpre,

R.E., Macklin, M.L., Poitre, R.E., & Steketee, G.S.

(1991). Psychiatric complications during flooding

therapy for posttraumatic stress disorder. Journal of

Clinical Psychiatry, 52, 17-20.

7. Expert Consensus Panel for PTSD. (1999). Treatment

of posttraumatic stress disorder. Journal of Clinical

Psychiatry, 60 [suppl.16], 3-76.

8. Foa, E.B., Riggs, D.S., Massie, E.D., & Yarczower, M.

(1995). The impact of fear activation and anger on

the efficacy of exposure treatment for PTSD. Behavior Therapy, 26, 487-499.

9. Novaco, R.W., & Chemtob, C.M. (1998). Anger and

trauma: Conceptualization, assessment, and treatment. In V.M. Follette, J.I. Ruzek, & F.R. Abueg

(Eds.), Cognitive-behavioral therapies for trauma

(pp. 162-190). New York, NY: Guilford.

10. Jaycox, L.H., & Foa, E.B. (1996). Obstacles in implementing exposure therapy for PTSD: Case discussions and practical solutions. Clinical Psychology

and Psychotherapy, 3, 176-184.

	
	



	


	



	


		



	






		 



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People are story-tellers.

They offer accounts that are

designed to make sense out of

the world and their place in it.

They construct narratives that

include descriptions of behavioral events and of their and

others’ reactions. As Mair (1)

observed, “We live through stories.”

In considering the answer to this question, it is important to keep in mind that not all individuals who have

been sexually abused, raped, or victimized by traumatic

events that were due to intentional human design, will

develop PTSD or other forms of psychopathology. In

fact, epidemiological research indicates that while threequarters of individuals will experience traumatic events

during the course of their lives (i.e., stressors that meet

Criterion A of the DSM-IV diagnosis of PTSD), only

approximately 10% to 25% (depending on the specific

population sampled) will evidence a lifetime instance of

PTSD (3). While a number of stimulus, response, vulnerability and recovery factors can be highlighted as influencing the coping process, the focus of the present discussion is whether these variables are mediated through

the narratives that individuals offer themselves and others.

(1) evidence intrusive ideation and are unable to resolve their

stories and integrate their traumas;

(2) continue to search for an explanation and fail to find satisfactory resolution (i.e., try to answer “why” questions for

which there are not acceptable answers);

(3) engage in “undoing” activities or what has been called

contrafactual thinking (“What – if” or “only – if” thinking);

(4) continually make comparisons between life as it is, as compared to what it might have been or what it was;

(5) see themselves as blameworthy;

(6) see themselves a “victims” and “at risk” with little expectation or hope that things will improve or change.

 The observation that people

tell stories, or actually construct

 their personal realities, is not new

From the philosophical musings of Immanuel Kant to those

of Jean-Paul Satre, from the psychological writings of

Wilhelm Wundt to those of George Kelley, there is a

long tradition of the importance of story-telling or the

creation of personal meaning. Common to this tradition is the view that individuals do not merely respond

to events, but that they respond to their interpretations

of events. This constructivist view has both an historical

and a current tradition. The simplest rendering of the

constructive narrative perspective is the Buddhist observation:

“We are what we think. All that we are

arises with our thoughts. With our

thoughts (“stories”) we make the world.”

Dhammapada

In modern form, Howard (2) observed:

“We are lived by the stories we tell. Beware of the stories you tell yourself, for

you will surely be lived by them.”

Now, consider what happens to people’s stories when

really bad things (traumatic events) are experienced. What

happens to child’s story when she is sexually abused; or

what happens to the account of the individual who is

raped; or to community that is devastated by a natural

disaster that they believe was avoidable?

Meichenbaum and Fitzpatrick (4) compared the nature of the narrative of those individuals who continued

to have difficulties following exposure to traumatic events

versus those who were able to continue functioning, in

spite of the trauma exposure. Once we appreciate these

differences, then we can examine how psychotherapists

and others can help individuals cope more effectively with

the aftermath of trauma exposure.

An examination of the literature indicates that individuals who continue to evidence ongoing distress and

maladaptive behaviors following trauma exposure, tend to:



 	






 	



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In this issue, we begin an occasional column focusing on developments and new thinking related to early intervention to prevent

development of chronic PTSD and other post-trauma problems. It has long been believed that mental health intervention is more likely to

be successful if services are delivered shortly after traumatization. This idea, along with the obvious human desire to respond quickly to help

trauma survivors, has led to the development and widespread implementation of a variety of early intervention approaches. Well-known are

methods of critical incident stress debriefing, now commonly delivered to many trauma survivor audiences (e.g., Red Cross workers, emergency services personnel, disaster victims) following local incidents and large-scale community disasters alike. In major disasters, many of the

other services that are offered are also intended in part to improve the mental health of affected individuals. In the arena of sexual assault,

various forms of support and counseling (e.g., in the ER or via rape crisis center services) are available in many communities to assist women

shortly after their attack. Services designed to reduce mental health casualties associated with combat, long a feature of U.S. military

psychiatry, have continued to evolve; combat stress control teams often now accompany combatants into the warzone and work to prevent

problems due to extreme stress.

What is striking about these various approaches is that they have evolved largely independent of one another. The professionals and

paraprofessional workers who have designed and delivered these services have traveled in different circles, with the result that ideas developed in one sphere have not always fully been brought to bear in the others. This may offer a useful opportunity for a “cross-fertilizing”

dialogue between practitioners and researchers operating in these different fields. What is also striking is that systematic evaluation of the

range of early preventive interventions to assess their impact has been slow to develop. Partly this is due to the very real logistical and ethical

difficulties of evaluating services offered in times of crisis. Perhaps it is also due to the relative newness of the field of traumatic stress research.

Things do appear to be changing rapidly now, however. Randomized controlled trials comparing some alternate early intervention methods

have now appeared in the literature (4). Also, a number of systematic literature reviews related to early intervention have been published

(e.g., 5). Therefore, it also seems a good time to make practitioners aware of evaluation efforts as they unfold.

Across the next decade we can expect to see significant developments in the field of early intervention, as more prospective studies

are conducted to trace the trajectory of traumatic stress symptoms and as a variety of interventions are developed and tested. Cognitivebehavioral preventive treatments are rapidly being developed and evaluated, with promising results to date. On the other hand, early

evidence bearing on the effectiveness of debriefing in preventing PTSD is not so positive (6). It is to be hoped that advocates of a range of

theoretical approaches to traumatic stress will apply their ideas to early intervention, and that delivery settings with significant opportunity to

provide preventive services to trauma victims (e.g., hospital trauma centers) will experiment with new methods of doing so.

In future editions of this column, we’ll highlight innovative early intervention approaches, interview those who have developed

them, and describe efforts to evaluate the effects of these approaches in preventing development of chronic PTSD.

References

1. Foa, E. B., Hearst-Ikeda, D., & Perry, K. J. (1995). Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD

in recent assault victims. Journal of Consulting and Clinical Psychology, 63, 948-955.

2. Bryant, R. A., Harvey, A. G., Dang, S. T., Sackville, T., & Basten, C. (1998). Treatment of acute stress disorder: A comparison of

cognitive-behavioral therapy and supportive counseling. Journal of Consulting and Clinical Psychology, 66, 862-866.

3. Bryant, R. A., Sackville, T., Dang, S. T., Moulds, M., & Guthrie, R. (1999). Treating acute stress disorder: An evaluation of cognitive

behavior therapy and supportive counseling techniques. American Journal of Psychiatry, 156, 1780-1786.

4. Bryant, R. A. & Harvey, A. G. (2000). Acute stress disorder: A handbook of theory, assessment, and treatment. Washington, D.C.:

American Psychological Association.

5. Solomon, S. D. (1999). Interventions for acute trauma response. Current Opinion in Psychiatry, 12, 175-180.

6. Bisson, J. I., McFarlane, A. C., & Rose, S. (2000). Psychological debriefing . In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds.), Effective

treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 39-59). New York: The

Guilford Press.


 	



7

		

	
	
	

Meichenbaum (3) has collated the variety of

metaphors that patients with PTSD offer describe their

hypersensitivity, their psychic numbing, their intrusive

ideation, their sense of personal loss, and the implications for their life.

Consider the impact of individuals telling others

and themselves that they are “prisoners of the past,” or

that they are “soiled goods.” Consider also the impact

on the view of oneself and the world if an individual is a

member of a family or a community that offers a similar

story-line and employs similar metaphorical descriptors.

It is proposed that the language individuals use, the metaphors they employ, have important implications for how

they appraise events and how they construct narratives.

Moreover, when traumatic events occur, they effect individuals’ core beliefs about issues of safety, trust and fairness that provide the scaffold or building blocks of the

stories individuals tell (5-6).

Implications for Treatment

If one adopts a narrative perspective, then psychotherapy

can be viewed as a collaborative co-constructive approach,

where with the help of the therapist, the patient comes

to “re-author” his/her account or construct a new narrative. The PTSD psychotherapy literature is filled with

descriptions of how therapists try to help their patients to:

How can therapists help patients change their accounts from being “victims,” to becoming “survivors,” or

to people who can “thrive”? Moreover, how can the therapist help patients with PTSD develop the intra- and interpersonal coping skills to manage PTSD and comorbid

symtomatology, and to handle any occasions of relapse (as

trauma), as well as to develop skills to reduce the likelihood

of revictimization?

In order to describe the traumatic events that

have transpired and their lingering impact, individuals

often use metaphorical descriptions:

“I am a prisoner of the past.”

“I am soiled goods.”

“I am on sentry-duty all the time.”

“I stuff my feelings.”

Assimilate the traumatic experiences (Janet)

Fabricate a new meaning (McCann & Pearlman)

Develop a healing theory (Figley)

Re-story their lives (Epston & White)

Restructure and conclude the trauma story (Herman)

Come to terms with or resolve their hurt (Thompson)

Rebuild shattered assumptions (Janoff-Bulman)

Develop new mental schema and seek completion (Horowitz)

Acknowledge and work through memories (Courtois)

Reconstruct the self and provide new perspectives about

the past (Harvey)

Develop their own voice and not repeat the voice of

the perpetrator (Meichenbaum)

Individuals who have been exposed to traumatic

events often get “stuck” in engaging in such a narrative

account. Moreover this negative stress-engendering process is further exacerbated by the style and manner with

which they offer their accounts. For example, when traumatic events occur and individuals feel victimized, mere

words often seem inadequate to describe what they have

experienced.

What do all of these psychotherapeutic tasks have

in common? They each imply that patients needs to tell

their stories differently. Patients enter treatment with an

account that reflects a sense of victimization, demoralization, helplessness, and hopelessness. They feel “victimized”

by circumstances, by their feelings and thoughts, and by

the absence of support from others. This is especially true

if they have a history of victimization (Note, that 38% of

female victims in North America have a history of repeated

victimization, Meichenbaum (3)).

Meichenbaum (3) has provided a detailed account

of how these treatment steps can be implemented. The

main treatment features can be highlighted in point form

as a set of core psychotherapeutic tasks.
	











		


In short, the construction of a new narrative emerges

out of the actions that patients take to refashion their lives.

Patients need to perform “personal experiments” in their everyday experience and take the data from these efforts as evidence to unfreeze their beliefs about themselves and the world.

They need to begin to tell themselves new stories that move

them from viewing themselves as “victims” to becoming “survivors.” For example, in one clinical case the patient initially

viewed herself as being a “stubborn victim: and over the course

of treatment she came to view herself as a “tenacious survivor.” In therapy, the patient was asked what she had done that

justifies her observations that she was a “tenacious survivor.”

In answering, not only was she conveying information to the

therapist, she was also able to convince herself of her “tenacity.” This is an evidential model of change that follows from

the constructive narrative perspective.

Therapy provides the safe supportive environment where

patients can begin to experiment (“try on”) their new story.

In turn, the patients can extend their new story-line to their

every day living experiences.

References

1. Mair, M. (1990). Telling psychological tales. International Journal of

Personal Construct Psychology, 3, 121-135.

2. Howard, G.S. (1991). Cultural tales: A narrative approach to think

ing, cross-cultural psychology, and psychotherapy. American Psychologist, 46, 187-197.

6"

6. McCann, L., & Perlman L.A. (1991). Through a glass darkly: Understanding and treating the adult trauma survivor through

constructivist self-development theory. New York: Brunner/Mazel.

3. Meichenbaum, D. (1994). Treating PTSD: A Clinical Handbook. Waterloo, Ontario: Institute Press. (Order from Dr. Meichenbaum,

University of Waterloo, Department of Psychology, Waterloo,

Ontario, Canada N2L 3G1).

4. Meichenbaum, D., & Fitzpatrick, D. (1993). A constructivist narrative perspective on stress and coping. Stress inoculation application. In L. Goldberger & S. Breznitz (Eds.), Handbook of stress:

Theoretical and clinical aspects. New York Free Press.

5. Janoff-Bulman, R. (1992). Shattered assumptions: Toward a new psychology of trauma. New York: Free Press.

CORE TASKS OF PSYCHOTHERAPY

WITH PATIENTS WITH PTSD

1. Develop a therapeutic alliance that is non-judgmental, empathic and supportive. The therapist should validate their patient’s experience and even commend the

patient for his or her ability to be in touch with his/her

feelings. It is also important to ensure the patient’s

safety.

2. Educate the patient about the nature of PTSD and

its various features (e.g., features of traumatic memories, relapse symptoms, and so forth). This is not a

lecture, but arises from a Socratic-dialogue and discovery process (e.g., as a by-product of the patient selfmonitoring).

3. Help the patient stabilize PTSD and comorbid symptoms. Increase the patient’s coping skills and enhance

self-care activities.

4. Nurture hope. Focus on what the patient has been

able to accomplish “in spite of” the trauma experience.

Obtain the “rest of the story” of the signs of resilience

and build on protective factors.

5. Help the patient to do “memory” work of trauma

resolution and reintegration. It is important for patients to share the trauma account and also consider the

implications and conclusions they draw about themselves and the world as a result of having experienced

the trauma.

6. Help the patient find meaning (salvage something

from the trauma) that gives a new sense of purpose,

mastery, control, competence and self-acceptance.

7. Ensure that the patient reconnects with others

(not delimit social contact to only other victims).

8. Ensure that the patient takes credit for any change

(self-attributes improvement to his/her own efforts).

9. Ensure that the patient has the skills to avoid

revictimization.

10. Address issues of relapse prevention (i.e., warning

signs, high-risk situations, coping with lapses, and

anniversary effects of the trauma).

	
	
 
 


	 	 	



	
  	 	 
   		


	 		
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