International Society for Traumatic Stress Studies

1999-01

ISTSS Conference Attendance Tops 1,100

The ISTSS 14th Annual Meeting, "Ending Cycles of Violence: Integrating Research, Practice and Social Policy," proved to be the society's most successful conference to date. The quality of the conference and the educational program, developed under the direction of 14th Annual Meeting Chair Elizabeth Kuh, received a 95 percent rating of excellent or good by the more than 1,100 attendees.

Held at the Downtown Renaissance Hotel in Washington, D.C., the conference explored a variety of traumatic stress topics while providing attendees with numerous opportunities to network and socialize.

Conference highlights included the opening plenary session panel discussion "Original Violence," featuring social activist Gloria Steinem, author and educator Geoffrey Canada, theological scholar Hyun-Kyung Chung, and ISTSS members Merle Friedman (South Africa) and Sahika Yuksel (Turkey).

During its annual awards banquet, the society recognized significant achievements in the field of traumatic stress by several members. The award winners were: Bessel van der Kolk,MD, Lifetime Achievement Award; Allison Harvey, PhD, Chaim Danieli Young Professional Award; Rachel Yehuda, PhD, Robert S. Laufer, PhD, Memorial Award for Outstanding Scientific Achievement; and Sandra L. Bloom, MD, Sarah Haley Memorial Award for Clinical Excellence.


TREATMENT

Enhancing Effective Treatment for Trauma Survivors

Lucy Berliner, MSW

Harborview Center for Sexual Assault 
and Traumatic Stress
University of Washington

Trauma therapists are increasingly concerned about trauma survivors having adequate access to therapy services. The imperative to staunch spiraling health-care expenditures in the United States has produced a massive shift from fee-for-service to managed health care. Patients in managed-care systems are often restricted in the choice of provider, and the length and type of treatment must be approved. A substantial percentage of therapists treating sexual assault victims reports that managed care has had an adverse impact on their practice (Berliner & New, in press).

In addition to cost containment, a stated objective of health care reform is to ensure that services are effective. Fortunately, there is a treatment outcome literature that documents the effectiveness of psychotherapy. The trauma outcome literature is not as well developed, but it is growing. There are now scientifically sound studies demonstrating that psychosocial and pharmacological treatments are effective in treating posttraumatic stress symptomatology.

What can trauma specialists do? For one thing, they should strive to deliver proven treatments to trauma survivors. For example, ISTSS members can rely on the guidelines for treatment of PTSD that will soon be available. Therapists can also take a leading role in educating health-care systems about the current state of knowledge.

A particular area where trauma specialists can make a difference is with crime victim compensation programs. Each state has a fund for crime victims who report to law enforcement. The mental-health benefits usually have capped monetary or session limits, but in many cases, they exceed those of commercial insurance or can be extended when medical necessity is shown (NACVCB, 1997). CVC programs are focusing attention on mental-health benefits because they consume a substantial percentage of all moneys paid to crime victims. The programs want to be sure that therapy is actually addressing crime-related psychological impacts and is effective.

This emphasis has resulted in a variety of efforts. Two states (Washington and California) have established treatment guidelines task forces, and others are considering forming their own. Many states use mental-health professionals on advisory committees, peer or utilization review boards, or as independent mental-health examiners.

This situation creates a real opportunity for ISTSS members to influence practice. Members can become proactively involved in their respective states by developing relationships with CVC programs; offering to serve as consultants, utilization reviewers, or independent examiners; and providing training on trauma impact and treatment to claims managers. By sharing our expertise through collaboration, we can enhance the quality, and perhaps availability, of services for trauma victims.

References

Berliner, L. & New, M. (in press) The impact of health care reform: A survey of victim and offender treatment providers.Sexual Abuse: A Journal of Research and Treatment.

NACVCB (1997) National Association of Crime Victim Compensation Boards Annual Program Survey. WA: DC; Author

For more information, contact: Dan Eddy, executive director, National Association of Crime Victims Compensation Boards, 703/370-2996, e-mail: nacvcb@aol.com.


Editorial

PRESIDENT'S COLUMN

ISTSS Embraces Professional Issues

Alexander C. McFarlane, MD

Traumatic events confront people with horror and threat and present situations that a person's imagination can only partially be prepared for. They inflict both an external and internal reality, which attacks ideals and beliefs about safety, control, and freedom from pain. External realities of danger and events that cannot be controlled have a capacity to kill, maim, brutalize, and destroy. The events also bring an internal reality of fear, horror, and lack of control. This leads to a sense of fragmentation, as well as a constant retraumatization by the memories triggered by reminders of the event. These are events that previous life knowledge does little to equip people for.

Working with the victims of trauma is a demanding process. Even the best intellectual defense does not prevent the permeation of these experiences into the lives of professionals working in this field. Maintaining our sense of sustenance and personal renewal is a critical need if we are to maintain our sensitivity and empathic holding of survivors of traumatic experiences. Relationships and professional support provide the critical carriage to sustain us in the face of this work.

Traumatic experiences are often not part of day-to-day language. Society and trends often revile and withdraw slightly at the discussion or advocacy of these issues. This not only isolates the survivor, but also the clinician. A critical role of ISTSS is to create the cradle where professionals can share such narratives and where a sense of energy and willingness to struggle with eternally difficult issues exists. The society also creates an environment of intellectual rigor trying to understand the scientific basis of the human response to trauma and the optimal treatments.

It is necessary to have an international organization that embraces these interests to provide cohesion and support, which can become too inwardly focused in national organizations. ISTSS supports professions where such issues are often not truly conveyed by the mass media. As J. G. Ballard, the author of Crash wrote, "In the past we have always assumed that the external world around us has represented reality, however confusing or uncertain, and that the inner world of our minds, extremes, hopes, ambitions, represented the realm of fantasy and imagination. These roles, it seems to me, have been reversed. The most prudent and effective method of dealing with the world around us is to assume that it is a complete fiction -- conversely, the one note of reality left to us, is inside our own heads. We live inside an enormous novel. It is now less and less necessary for the writer to invent the fictional content of his novel. The fiction is already there. The writer's task is to invent the reality."

The trauma therapist faces a similar challenge of understanding and documenting. The clinician and social scientist working in the field of trauma often is a critical culture carrier who has to chronicle and interpret the lives of trauma survivors. These are too readily paraded and trivialized in the world at large. This task equally depends upon the sensitive insights of the clinician and the empirical neuroscientist. The strength of the field depends upon the integration of these perspectives.

ISTSS is an unusual organization. This was reflected during the 14th annual conference where such diverse interests, ranging from the consideration of issues of reconciliation and forgiveness to developments in neurobiology, were discussed.

At the 15th annual conference, the program will focus on the need to integrate the different polarities of the society, between the advocate clinician and the researcher. There is a great deal of energy within the organization that can be enhanced to this end. I feel it is one that is constantly presenting new challenges. One of the engaging characteristics is the willingness of the organization to embrace these issues in a flexible manner.

ISTSS is at an important point in its history. It is now moving into a stage of increasing maturity. Many members who were instrumental in developing the initial enthusiasm for the field are no longer involved with the board of directors. To maintain this institutional memory, a past president's council has been set up to advise the organization on strategic issues. One component is how to embrace the newer members and ensure that they have an active voice and are embraced by the aims and aspirations of the society. This will ensure we remain an intellectual, vigorous, and professionally supportive organization that continues to meet the challenges of a changing field.


International Organizations

Healing in Rwanda: A Partnership

By Laurie Anne Pearlman, PhD
Traumatic Stress Institute/Center for Adult & Adolescent Psychotherapy

Starting in April 1994, the swiftest genocide in history took place in Rwanda. Within a few months, about 800,000 Tutsis, the main targets of this horrific violence, were killed as were about 50,000 moderate Hutus and others who in some way were viewed as threats to the government or obstacles to the killing. Despite advance warnings about the danger of killings and even of genocide, the world community stood by passively, allowing the massacres to unfold.

Today, there are hundreds of thousands of people who are struggling to recreate their lives and overcome the physical, material, interpersonal, and psychological losses they have sustained. Without healing and reconstruction, another genocide is imminent. In response to this need, a collaboration has developed.

Ervin Staub, Ph.D., professor of psychology at the University of Massachusetts at Amherst, and I have received a $232,000 grant from the John Templeton Foundation to conduct a project titled "Healing, Forgiveness, and Reconciliation in Rwanda." The project is a group healing intervention, which is nested within the context of research on healing and forgiving.

We have recruited psychiatrist Athanase Hagengimana, M.D., vice-dean of the medical school of the National University of Rwanda, to serve as Rwandan local project coordinator. The team will recruit and train local facilitators to run groups where participants will have an opportunity to write and talk about their experiences in a supportive environment. The sessions include minipsychoeducational lectures and discussions about healing, genocide, and moving into the future.

Staub and I both have histories of social activism. We will make our first trip to Rwanda in January 1999. We will meet community leaders, work with Rwandans to tailor the intervention to the local culture, and work with Hagengimana to select specific research instruments. We will return to Rwanda in June 1999 to train research assistants and facilitators who will then conduct the research and intervention during the remainder of the year.

The project represents an effort to integrate theoretical and clinical knowledge about traumatic stress and psychological knowledge about genocide to help victims of group violence. The partnership with Hagengimana is one of the team's steps to ensure the cultural appropriateness of the intervention. The team hopes to develop an intervention methodology that can be used by local people without extensive training to work with large groups of traumatized people. Interested individuals are invited to contact me at laurie.pearlman@snet.net.


ISTSS News

Origins and Development of the ISTSS -- Part III

Sandra L. Bloom, M.D.
Immediate Past-President, ISTSS

This is the third in a series of articles that look at the origins and development of the ISTSS. It includes edited excerpts from Our Hearts and Our Hopes are Turned to Peace: Origins of the ISTSS to be published by Plenum in the new volume, International Handbook of Human Response to Trauma, edited by Sandy McFarlane, Arieh Shalev, and Rachel Yehuda.

There were direct consequences to the kind of advocacy that Chaim Shatan and Robert Lifton were pursuing. Beginning in 1970, Shatan came under government surveillance. Returning from a meeting at the Pentagon in June 1973, he found his phone had been tapped. After a visit to Washington to offer assistance to American prisoners of war returning from Hanoi, Vietnam, he discovered that someone had tampered with his mail. (Scott, 1993).

The FBI tried to infiltrate the group rap sessions by sending in informers posed as veterans seeking help (Lifton, 1978). Shatan found that plans were afoot to entrap him with blueprints of government munitions plants. A veteran who was suspected of being a part of the security apparatus of the time, sent blueprints and letters to Shatan, detailing how easy it was to get letters out of the Pentagon. Friends at the Center for Constitutional Rights urged Shatan to get the documents out of his office and lock them in their safe, rather than risk a raid, which they believed was imminent. But Shatan's response was to talk longer, louder, and more frequently in order to bring attention to the readjustment problems of the veterans and to make their cause more publicly visible and therefore less vulnerable to government sabotage (Shatan, 1987; 1998).

The Veterans Affairs central office attacked Lifton and Shatan in the press after the two psychiatrists estimated that 20 percent of men who had served in Vietnam were paying a heavy psychological price -- the VA claimed that only 5 percent had
combat-related psychological symptoms. Both were labeled as being hung up on the war and accused of dishonoring brave men (Shatan, 1985).

As Lifton recalls, "I believe that we always function within this dialectic between ethical involvement and intellectual rigor, and that bringing our advocacy 'out front' and articulating it makes us more, rather than less scientific . . . From the beginning, the therapeutic and political aspects of our work developed simultaneously"(Lifton, 1978, pp. 211­212).

Meanwhile on the West Coast, a schizophrenia expert, Philip May, was director of psychological services for the Brentwood Veterans Administration Hospital. In 1971, May recognized that Vietnam veterans were not getting the services they needed, so he hired Shad Meshad, a social worker and Vietnam veteran, to evaluate the situation. Meshad had already started one of the nation's first rap groups in the Los Angeles area and was highly critical of the VA services (Meshad, 1997; Scott, 1993).

So was William Mahedy, who had served as a chaplain in the Vietnam War and was working as a social worker at Brentwood, "Most Brentwood psychiatrists that I met during this period had not the slightest clue how to deal with Vietnam veterans . . . They didn't know how to treat combat-related stress. Nor could they provide any guidance to the kind of total reintegration into society that we knew was necessary." (Mahedy, 1986, p.56).

In response, Meshad created the highly unconventional Vietnam Veteran Resocialization Unit within Brentwood, with the support of the hospital director and set up storefront clinics where rap groups were held.

It was difficult for Vietnam veterans to get the services they needed from the VA for several reasons besides the existing, sometimes virulent, prejudice against them. First, there was no diagnostic code for combat stress in the Diagnostic and Statistic Manual for Mental Disorders-II. This latest edition of DSM had been published by the American Psychiatric Association in 1968. As Art Blank, points out, "As the return of troops from Vietnam was reaching a crescendo, the psychiatric profession's official diagnostic guide backed away from stress disorder even further, and the condition vanished into the interstices of 'adjustment reaction of adult life'" (Blank, 1985, p.73).

But even under DSM-I there had been no classification for delayed stress reactions. So, if the symptoms presented more than two years after discharge from active duty, the VA did not consider them to be service-related problems. If veterans presented systems of posttraumatic psychiatric symptoms, they were misdiagnosed as suffering from depression, paranoid schizophrenia, or character or behavior disorders (Blank, 1985; Wilson, 1988).

Senator Alan Cranston, a World War II veteran and a member of the Senate's Committee on Veterans Affairs, became convinced that the psychological needs of Vietnam veterans were different from those of older veterans. Starting in 1971, Cranston tried to bring about changes in the VA system by seeking better funding for the Vietnam veterans to obtain drug and alcohol rehabilitation as well as specialized readjustment counseling services. The bill he proposed passed the Senate in 1973 and 1975, but the House refused to pass it.

The House was dominated by World War II veterans who had an unwillingness to concede that the Vietnam War had produced different problems than had been previously recognized. In addition, the American Legion and the Veterans of Foreign Wars lobbied against the bill. Taking a more long-term approach, Cranston appointed Max Cleland as a member of his staff to review the VA hospitals. Cleland, a Vietnam veteran, had lost an arm and both legs in the war and had testified for Cranston at the Senate Committee on Veterans Affairs in 1971. In his new position, Cleland visited Meshad's storefront operations at Brentwood. Both Cleland and Meshad testified in 1975 before Senator Cranston's Subcommittee on Health and Hospitals, providing clear evidence that the VA hospitals were not meeting the needs of Vietnam veterans (Scott, 1993).

Besides the problems with the psychiatric diagnostic schemata, there was no organized Vietnam veterans' pressure group advocating for a change in benefits (Scott, 1993). The work of the National Vietnam Veterans Resource Project, created during the First National Conference on the Emotional Needs of Vietnam-Era Veterans, began immediately after the conference. By 1974, the NVRP had catalogued 2,700 diverse veterans' self-help programs, 2,000 of them on college campuses, some out in the community and others in prisons (Lifton, 1973; Shatan, 1974).

Jack Smith sought funding for an empirical study and called it the Vietnam Generation Study, because the intention was to study both veterans and draft resisters. He and a colleague obtained funding from the National Council of Churches, the Russell Sage Foundation, and the Edward F. Hazen Foundation to begin a pilot study (Scott, 1993). In 1975, the Senate Committee for Veterans Affairs initiated a bill, finally approved by Congress, mandating the VA to conduct a study to assess the needs of Vietnam veterans. As a result, the VA provided funds to Arthur Egendorf and the NVRP to complete the Vietnam Generation Study, which eventually culminated in Legacies of Vietnam (Egendorf et al., 1979; 1981; Laufer, 1985).

References

Blank, A. S. (1985). Irrational reactions to post-traumatic stress disorder and Vietnam veterans. In S. M. Sonnenberg, A. S. Blank, & J. A. Talbott (Eds.), The trauma of war: Stress and recovery in Vietnam veterans (pp.69­98). Washington, D.C.: American Psychiatric Press.

Egendorf, A., Kadushin, C., Rothbart, G., Sloan L. & Fine, M. (1979). Urban males of the Vietnam generation, a mental health perspective: preliminary findings of the Vietnam-era project. Paper presented at the American Psychological Association, San Francisco, August.

Egendorf, A., Kadushin, C., Laufer, R., Rothbart, G., Sloan, L. (1981). Legacies of Vietnam: comparative adjustment of veterans and their peers. Washington, D.C.: U. S. Government Printing Office.

Laufer, R. S. (1985). War trauma and human development: The Vietnam Nam Experience. In S. M. Sonnenberg, A. S. Blank, & J. A. Talbott (Eds.), The trauma of war: stress and recovery in Vietnam veterans (pp.31­55). Washington, D.C.: American 
Psychiatric Press.

Lifton, R. J. (1973). Home from the war. New York: Basic Books

Lifton, R. J. (1978). Advocacy and corruption in the healing profession. In C. R. Figley (Ed.), Stress disorders among Vietnam veterans: Theory, research and treatment. Brunner/Mazel.

Mahedy, W. (1986). Out of the night: The spiritual journey of Vietnam vets. New York: Ballantine.

Meshad, S. (1997). Personal interview with the author, Oct. 28, 1997.

Scott, W. (1993). The politic of readjustment: Vietnam veterans since the war. Hawthorne, NY: Aldine de Gruyter.

Shatan, C. (1974). Through the membrane of reality: "Impacted grief" and perceptual dissonance in Vietnam combat veterans.Psychiatric Opinion 11(6), 6­15.

Shatan, C. (1985). Johnny, we don't want to know you: From DEROS and death camps to the diagnostic battlefield.Presented at the founding meeting of the Society for Traumatic Stress Studies, Atlanta, Georgia, Sept. 23.

Shatan, C. (1987). Johnny, we hardly know you: The grief of soldiers and the Vietnam veterans' self-help movement.Presented at the Third Annual Meeting of the Society for Traumatic Stress Studies, Baltimore, MD., Oct. 23.

Shatan, C. (1998). Personal interview with author, February 24, 1998.

Wilson, J. P. (1988). Understanding the Vietnam veteran. In F. Ochberg (Ed.), Post-traumatic therapy and victims of violence(pp. 227­253). New York: Brunner/Mazel.


Share Your Opinions

The Traumatic StressPoints editors want to know what you think about the newsletter. A survey will be
distributed soon to all ISTSS members with e-mail accounts. Don't forget to let us know what you think.


RESEARCH

Recently Published

Readers are encouraged to submit recommendations of recently published articles. Please submit copies or full references to Elana Newman, Ph.D., University of Tulsa, Department of Psychology, 600 South College Avenue, Tulsa, OK 74104. Similarly, book information (publisher's brochure, full citation, or other material) is welcome.

In order to accommodate other columns in Traumatic Stresspoints, the Recently Published column was not included in the last issue and is abbreviated in this issue. Therefore, not every article or book submitted has been able to be listed.

Adamec, R., Kent, P., & Merali, Z. (Dec 1, 1998). Neural plasticity, neuropeptides and anxiety in animals -- Implications for understanding and treating affective disorders following traumatic stress in humans. Neuroscience and Biobehavioral Reviews, 23, 301­308.

Bouwer, C. & Stein, D.J. (1998). Survivors of torture presenting at an anxiety disorders clinic in South Africa: Symptomatology and pharmacotherapy, Journal of Nervous and Mental Disease, 186, 316­318.

Breslau, N., Kessler, R.C. & Andreski, P. (1998). Trauma and Posttraumatic stress disorder in the community: The 1996 Detroit survey of trauma. Archives of General Psychiatry, 55, 626­632.

Bromet, E., Sonnega, A., & Kessler, R.C. (1998). Risk factors for DSM-III-R Posttraumatic stress disorder: Findings from the National Comorbidity Survey. American Journal of Epidemiology, 147, 353­361.

Farley, M, Barkan, H. Prostitution, violence and posttraumatic stress disorder. Women and Health, 27,37­49.

Gal, R. (1998). Colleagues in distress:"Helping the helpers.' International Review of Psychiatry, 10, 234­238.

Grayson, D., Dobson, M. & Marshall, R. (1998). Current combat-related disorders in the absence of PTSD among Australian Vietnam Veterans. Social psychiatry and Psychiatric Epidemiology, 33, 186­192

Jaycox, L.H., Foa, E.B., & Morral, A.R. (1998). Influence of emotional engagement and habituation on exposure. Journal of Consulting and Clinical Psychology, 66, 185­192.

Mason, P.H.C. (1998). Recovering from the war. High Springs, Fl. Patience Press.

Vinton, L. (1998). A nationwide survey of domestic violence shelters' programming for older women. Violence Against Women, 4, 599­571.


ISTSS News

RESEARCH

Relationship of Adverse Childhood Experiences to the Leading Causes of Death

By Mary Koss
University of Arizona

The Adverse Childhood Experiences Study was designed to describe the long-term relationship of household conditions, neglect, abuse, sexual and physical maltreatment of children on their adult disease risk factors, quality of life, health-care use, and mortality. The ACE study was conducted during a seven-month period at Kaiser Permanente's San Diego Health Appraisal Clinic.

After visiting the clinic for a standardized medical evaluation, all 13,494 patients were mailed the ACE questionnaire (response rate 71%). Risk-factor screening items were taken from the Centers for Disease Control and Prevention Behavioral Risk Factor Survey program, the Third National Health and Nutrition Examination Survey, and the Diagnostic Interview Schedule depression measure developed by NIMH. Disease conditions were assessed from medical histories. The categories of childhood exposure were assessed by multi-item standardized measures tapping psychological, physical, and sexual abuse; and household dysfunction including substance abuse, mental illness, criminal behavior, and violence against the respondent's mother by anyone living in the home.

Results showed that both the prevalence and risk measured by adjusted odds ratio increased for smoking, severe obesity, physical activity, depressed mood, and suicidal attempts as the number of different forms of adverse childhood experiences increased. These are the risk factors underlying the leading causes of death. Strong evidence of clustering of these risk factors was found. Whereas 56% of those with no childhood exposures had none of the 10 risk factors, only 14% of those with four or more forms of adverse childhood exposures had none. Among persons with 4 or more risk factors, the odds ratios for the presence of disease were elevated, ranging from 1.6 for diabetes to 3.9 for chronic bronchitis or emphysema. A significant dose-response relationship was found between the number of childhood exposures and each of the risk factors for the leading causes of death (p < .001). Likewise, there was a strong dose-response relationship between exposures and diseases including ischemic heart disease, cancer, chronic bronchitis or emphysema, history of hepatitis or jaundice, skeletal fractures, and poor self-rated health (p < .05). However, these are associations based on retrospective, self-report and subject to all the limitations inherent in this data source.

The findings suggest hazardous health behaviors used as coping devices in the face of household stress may be among the mediators linking adverse childhood exposures to deleterious health outcomes. The positive neuroregulatory effects of health-risk behaviors such as smoking provide biobehavioral explanations for a link between adverse experiences and disease. The article enumerates prevention strategies at the primary, secondary, and tertiary levels aimed at reducing mortality linked to adverse childhood environments. The authors conclude, "The magnitude of the difficulty of introducing the requisite changes into medical and public health research, education, and practice can be offset only by the magnitude of the implications that these changes have for improving the health of the nation" (p. 256).

Reference

Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., & Marks, J.S. (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences Study. Am J Prev Med 14: 245­258.


APA Division 12 Approves New Section

The American Psychological Association's Division of Clinical Psychology (Division 12) has approved the establishment of a new section for clinical emergencies and crises (Section VII). The purpose of Section VII is to advance the clinical and scientific understanding of psychological and behavioral emergencies and crises as well as the clinical abilities needed to evaluate and manage them. Emergencies include life-threatening behaviors such as acute suicidality, potential violence, and risk to vulnerable victims of violence.

Membership is open to Division 12 members, nonmembers of Division 12 who are members of APA (Affiliate member), APA associate members and students.

For more information, contact: Phillip M. Kleespies, PhD, Section VII Representative (Pro Tem),Psychology Service (116 B), VA Medical Center, 150 South Huntington Ave., Boston, MA 02130; e-mail, Kleespies.Phillip_M_PHD@Boston
.VA .GOV.


BOOK REVIEW

By Elana Newman, PhD
University of Tulsa

Transforming the Pain: 
A Workbook on Vicarious Traumatization
by Karen W. Saakvitne & Laurie Anne Pearlman. New York: W.W. Norton & Co., 1996. Softcover. $17.

Working in the field of traumatic stress can have a profound impact on our lives in both negative and positive ways. As Herman (1992) elucidated, impartiality is virtually impossible when confronting the egregious inequity of traumatic life events; compassion and effective work require that we alter our political, emotional, and relational world in the light of our work with survivors. The staff at the Traumatic Stress Institute/Center for Adult & Adolescent Psychotherapy (TSI/CAAP) has been instrumental in educating clinicians, researchers, and policy makers about the potential personal costs of working with trauma survivors. Rather than pathologize the impact of traumatic life events on individuals and those who treat them, the TSI/CAAP staff have created a non-pathological model to explain and respond to both clients' and therapists' needs. In their workbook, Transforming the Pain, they distill two previous theoretical treatises, Trauma and the Therapist (1995) and Psychological Trauma and the Adult Survivor (1990), into a highly accessible and practical workbook detailing specific ways to prevent and ameliorate deleterious effects upon the professional.

The book is organized into an introduction, five succinct chapters, a complete reference section, annotated bibliography, and listing of TSI/CAAP resources. In the introduction, the authors explain their background and recommended approach to using the workbook. In Chapter 1, the relevant concepts, definitions, signs, and predictors of vicarious traumatization are described. Vicarious traumatization is defined as the occupational hazard that professionals experience when fundamental assumptions about the world and self's controllability, benevolence, trust, and esteem are betrayed. Unlike countertransference, vicarious traumatization refers to the destructive but normative generalized response to trauma work, rather than a personal response to a particular client situation. There is an outstanding, succinct synopsis of constructivist self development theory that describes how traumatic life events may affect client's and professional's inner and social worlds.

The remainder of the book details strategies to assess, prevent, and remediate the potential ill-effects of trauma work upon the professional. Chapter 2 provides self-assessment questions that help professionals examine their work and personal lives in terms of the constructivist self-developmental theory. The next chapter reviews strategies to address and transform vicarious traumatization by changing concrete aspects of one's professional, organizational, and personal life. Chapter 4 includes 18 powerful exercises to assess, address, and transform vicarious traumatization. The final chapter summarizes strategies to help professionals maintain their commitment to taking care of themselves in the face of trauma. A detailed reference section and annotated bibliography is also included that will inspire readers to pursue other books on self-care and vicarious traumatization.

The exercise section of the book is especially noteworthy. I have seen Laurie Pearlman use these exercises with Colombian clinicians and assumed it was her dynamic style that made these exercises so effective. Recently, I tried two exercises in the classroom with neophyte therapists and was stunned that I was equally effective. Supervisors, teachers, and workshop leaders will benefit from using these exercises with appropriate groups.

Transforming the Pain is a superb introductory resource for all trauma professionals including police, clergy and crisis workers. It is an accessible book I repeatedly recommend to students and colleagues grappling with the impact of trauma work. Although much of the practical advice seems so sensible and obvious, many of us forget to assess our own needs and health given the quick pace of our lives. This clear compilation of exercises, self-assessment tools, and advice is an important reminder of the need to take care of ourselves in order to enhance our professional and personal effectiveness. It is a useful book for all professionals who engage in trauma work to reread periodically during their professional development.

References

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

McCann, I.L. & Pearlman, L. A. (1990). Psychological trauma and the adult survivor: Theory, therapy, and transformation.New York: Brunner/Mazel.

Pearlman, L.A. & Saakvitne, K. W. (1995). Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. 
New York: Norton.

Submit calendar items to: 
Traumatic StressPoints editor
60 Revere Drive, Suite 500
Northbrook, Il 60062 
e-mail: F.Strong@istss.org

 


 

BOOK REVIEW

By David Lisak, PhD
University of Massachusetts-Boston

Psychobiology of Posttraumatic Stress Disorder, R. Yehuda and A.C. McFarlane (Eds.). Annals of the New York Academy of Sciences, V. 821. New York: The New York Academy of Sciences, 1997. Hardbound. $110.

The recent torrent of findings that has emerged from the field of neuroscience has had an enormous impact on the understanding of psychological trauma. Neurobiological research has begun to uncover the neural mechanisms underlying some of the clinical hallmarks of posttraumatic symptoms and states. This research confirms some long held perspectives based on clinical research and challenging others.

Neurobiological research and what it tells us about the phenomena of trauma are important not only to neurobiological researchers, but to all trauma researchers and clinicians. This research promises -- and is beginning to deliver -- answers to fundamental questions about the nature of posttraumatic symptoms, their course, and ultimately, new methods for their treatment. As our understanding of the neurobiology of posttraumatic symptoms increases, so too will our understanding of how interventions -- psychological and psychopharmacological -- can interrupt those symptom processes. More fundamentally, this new generation of neuroscience research has already upended the old reductionistic assumption that formerly underlay much neurobiological research. The brain not only acts on the environment through its control on mental states and behavior, it also is profoundly altered by its environment.

This book stems directly from a conference of the same title that was sponsored by the New York Academy of Sciences in September 1996. The book is divided into seven parts. Part one covers the epidemiological and empirical basis for studies of the biology of PTSD including chapters on its prevalence, longitudinal course, and comorbid disorders and familial risk factors associated with it. Part two summarizes the major psychobiological findings in PTSD research. Chapters focus on the sensitization of the hypothalamic-pituitary-adrenal axis, structural brain changes, evidence from neuroimaging studies, and psychophysiological reactivity, noradrenergic alterations and the psychobiology of sleep disturbances in PTSD patients.

Part three addresses neurodevelopmental issues, with two chapters that summarize findings on neurophysiological and neuroanatomical changes associated with chronic childhood abuse, a model of the neurodevelopmental impact of trauma, and a chapter that focuses specifically on the possible mechanisms by which early trauma can induce long-term vulnerability to mood and anxiety disorders.

Part four tackles the neurobiology of memory impairment in PTSD. Two chapters review, respectively, the performance of PTSD patients on standardized memory tests and content-dependent memory abnormalities in PTSD. Other chapters focus on memory and dissociation, the neurobiology of traumatic memory, hormonal influences on the regulation of memory storage, and a basic chapter on the neural basis of fear conditioning.

Part five begins the book's turn toward linking some of the basic neurobiological research to clinical observations of PTSD patients. One chapter provides a detailed review of research on the impact of stress on the structure and function of the hippocampus and its attendant impact on cognitive functioning. Other chapters outline, respectively, the kindling paradigm as an explanatory model of PTSD symptomology, stressor-induced oscillation as a model for the alternation in PTSD between intrusive and avoidant symptoms, and research on the acoustic startle reflex. The section concludes with two overview chapters, one which summarizes animal models that can be applied to PTSD, and another that synthesizes many of the findings presented in earlier chapters.

Part six addresses the psychobiology of treatment. The first two chapters summarize, respectively, the findings of studies of drug treatment for chronic and acute PTSD, both addressing the relative inadequacy of currently available pharmacological treatments. The third chapter summarizes findings on biological markers of PTSD symptomology with the view to designing objective measures of treatment outcome, while the fourth focuses on psychological processes related the recovery from PTSD.

The final section of the book consists of 31 posters presented at the conference, which detail findings from specific studies on a broad range of topics.

This volume shares the same limitation inherent in all compendia of research, particularly in such a fast-evolving field: the inevitability of datedness. However, the book provides a mixture of data and synthesis, and covers so much material, that it is likely to remain a useful reference for some time. In addition to its obvious usefulness to researchers in the field of traumatic stress, the book has much to offer clinicians who wish to understand and integrate into their work the expanding knowledge base on the psychobiology of trauma. Finally, the book would be an excellent addition to the reading list of any advanced, graduate level course in psychological trauma.


Resources

BOOK REVIEW

By Lizabeth Roemer, PhD
and Chivi Kapungu
University of Massachusetts-Boston

Extending EMDR: A casebook of innovative applications. Philip Manfield (Ed.) New York: W.W. Norton & Co., Ltd., 1998. Hardbound. $37.

Extending EMDR: A casebook of innovative applications, edited by Philip Manfield, is a collection of case studies intended "to pick up where formal EMDR training leaves off" (jacket cover). The stated goal is to assist clinicians while they apply eye movement desensitization and reprocessing to more complex cases. In each chapter, the authors provide a brief overview of their theoretical perspective and background, present a clinical case, and describe how they integrated EMDR with other forms of therapy in the treatment of the client.

The chapters target a varied assortment of presenting problems and themes described as follows: uncomplicated depression, postpartum depression, masochistic personality disorder, denial of rage, major depression, survivor guilt and writer's block, child abuse and neglect, developing a mature identity, a highly defended client, narcissistic vulnerability, and shame. Each treatment involves the targeting of certain representative emotional memories with the EMDR protocol accompanied by a host of other therapeutic interventions that vary depending on the theoretical orientation of the author.

Transcripts, along with notes detailing the therapist's reasons for various clinical decisions, allow the reader to witness the hypotheses developed, tested, and reformulated in the course of therapy. Several important themes, relevant to all psychotherapy, emerge from these chapters, such as how to facilitate the expression of avoided emotion and how to maximize a client's coping resources in order to prepare for trauma or emotion-focused therapy. The reader is often provided with more extensive detail about the author's varying theoretical orientations and how they inform interventions than about EMDR per se. One gets a sense of EMDR as a chameleon that blends into whatever theory a therapist holds, making it highly adaptable, but raising the question of what EMDR adds, if anything, to these therapeutic approaches.

It is difficult for the reader to develop a cohesive overview of the therapies presented; no summary is provided to assist in drawing conclusions for use in one's own practice. Each author has adapted the standard EMDR protocol in a number of ways; few striking similarities emerge in these adaptations and none are highlighted. The reader must sort through a lot of varied material in order to extract useful clinical observations and helpful practical suggestions regarding implementing EMDR. In the absence of any clear, consistent diagnostic or thematic classification of cases, or an overview chapter highlighting the contribution of each chapter, this is not a book that can be easily used to obtain specific information regarding a certain kind of case or certain therapeutic issue that a reader wishes to address.

The authors are careful to present the speculative nature of the work they've done; they are all clear that expansion of EMDR is experimental and that the hypotheses they have developed bear further exploration. Most also note that the outcomes of the therapy would be similar using only their more traditional approaches, although they believe that EMDR enhanced the speed of therapeutic change.

In a few places the book moves from the clinical to the scientific; unfortunately, there, this same care is not taken. In the section of the introduction titled "What is the effect of eye movements?", the editor fails to comment on the lack of evidence for specific effects of eye movements (or bilateral stimulation) in the existing literature (see Feske, 1997; Lohr et al., 1995; for critical reviews). He goes on to propose a highly speculative neurobiological theory for the bilateral stimulation component of EMDR (that it activates the corpus callosum and increases interhemispheric activity) and uses that theory to justify the extension of EMDR to other populations.

Limitations in the single study on which this theory seems to be based (i.e., no comparison group so EMDR-specific effects cannot be determined) are overlooked in this discussion. While there is certainly nothing wrong with speculating about the underlying mechanisms of a clinical technique, to do so without critically reviewing the data presented seems misleading. This lack of clarity regarding biological underpinnings carries into some of the chapters: one author concludes that a client's memory has changed from being stored in the right hemisphere to the left hemisphere. This is a profound oversimplification of neurobiology at best, and detracts from the credibility of the material presented.

In summary, this book seems most useful as a series of examples of eclectic or integrative psychotherapy using a common focused imaginal emotional processing component. The integration of imaginal techniques in the treatment of long-standing psychological difficulties may have clinical utility. However, without a carefully formulated explanation of the unique components of EMDR, the book is less useful as a resource in expanding our understanding of this particular therapy technique and its application.

References

Feske, U. (1998). Eye movement desensitization and reprocessing treatment for posttraumatic stress disorder. Clinical Psychology: Science and Practice, 5, 171­181.

Lohr, J.M., Kleinknecht, R.A., Tolin, D.F., & Barrett, R.H. (1995). The empirical status of the clinical application of eye movement desensitization and reprocessing. Journal of Behavior Therapy and Experimental Psychiatry, 26, 285­302. *


ISTSS News

Several special interest area groups have been without chairperson(s) for several years and it is unclear if some groups have disbanded. As would be expected, SIAGs will change as the field and the needs of the society change; Some SIAGs may no longer be pertinent. Groups currently without chairs are Assessment and Diagnosis, Policy, Treatment Innovation, Occupational Trauma, and Psychopharmacology. If you are interested in chairing an existing SIAG, starting a new one, or your group is not listed, contact Deborah Ross at 847-480-9573.

In a memo circulated early this year by Mary Beth Williams, chair of Interest areas, SIAGs were informed that they need to meet 3 yearly requirements to retain SIAG status:

  • Hold an organizational meeting of the special interest group at the annual meeting at the designated meeting time
  • Present a poster presentation during a designated reception at the annual meeting. At the time of presentation, a SIAG member needs to be available to recruit members and discuss the SIAG's purpose. The time of presentation will be determined by the annual program committee, but is tentatively planned for the opening reception at the November 1999 meeting.
  • Complete an annual report form on the groups activities

SIAG groups are also invited to submit articles for potential publication in Traumatic Stresspoints.

Existing Groups Chair(s)
Curriculum, Education, and Training: Yael Danieli & Lyndra Bills

Ethics Task Force

John Sommer, Jr. & Mary Beth Williams

Integrated Milieu Systems Lyndra Bills and David Wright
Research Methodology Daniel King and Lynda King
Human Rights and Social Policies Ya Ya Andrade
Theory Development Louis Tinnin
Intergenerational Aspects Florabel Kinsler & Andre Novac
Traumatic Loss Irene Landsman & Betty Spear

Building Bridges BetweenProfessionals & Self-Help Groups 

Anne Marie Eriksson & Jeremy Herman

Child Trauma Jean Bellows and Beverly James

Non-Verbal & Creative Arts Approaches

David Read Johnson
Disaster Mental Health Julian Ford

Internet

Charles Figley
Media Roger Simpson