International Society for Traumatic Stress Studies


President's Message

What Is the AAETS?

By Matthew J. Friedman, M.D., Ph.D.
Many ISTSS members listed in the 1995/96 Membership Directory received a recent mailing from the American Academy of Experts in Traumatic Stress (AAETS). The stated mission of the Academy is to "increase awareness of the effects of trauma and ultimately improve treatment for survivors." According to this letter, the Academy offers "membership in a prestigious scientific and professional association; a Code of Ethical and Professional Standards; programs to achieve diplomat and fellow credentials; National Training Conferences; the Academy Journal; and listing in The National Registry of Experts in Traumatic Stress."

A membership application form was enclosed with instructions to include a check for $125. Upon approval of application for membership, new members will receive "an elegant membership certificate, suitable for framing." Members will presumably be entitled to become diplomates and then fellows at some future time, but the criteria for those designations were not specified. Finally, members, diplomates and fellows will be entitled to display their Academy credentials as a part of their signature.

This mailing raised a number of questions among ISTSS members that were directed to me and ISTSS headquarters. Therefore, I would like to share with you what we do and don't know about the Academy.

First, there is absolutely no connection between ISTSS and the Academy. Neither I nor any member of the ISTSS Board has been approached by any of its representatives. We have little more information about the Academy other than what was stated in its letter and brochure.
On Feb. 22, Fred Lerner, director of the PTSD Resource Center at the National Center for PTSD, searched three bibliographic databases (PILOTS, to date; PsychINFO, 1967 to date; and MEDLINE, 1990 to date). He was unable to find any publication relevant to PTSD or traumatic stress written or co-authored by any officer or advisory board member of the Academy listed on its letterhead. 

Lerner phoned the Academy for more information and learned the following: the first issue of the Academy's journal, Trauma Response, will appear in March; it will be "practitioner oriented." The Academy had been recruiting for about three months and had attracted over 200 members. The first annual conference is tentatively scheduled for September in the New York City area.
We have been advised that it is not unlawful for an organization to establish itself and to charge a membership fee as long as it accurately represents itself and provides members with the benefits that have been promised. In this case, Academy members should receive the journal, a membership certificate suitable for framing, a listing in The National Registry of Experts in Traumatic Stress, the right to cite the Academy credentials after their names and an opportunity to attend certain conferences.

I received a number of inquiries about the basis for the Academy's "expertness" in traumatic stress. ISTSS members may have personal beliefs about the proper meaning of the term expert. Based on our own legal consultations, members must make their own determinations on whether Academy membership makes someone an expert in the area of traumatic stress.

This is all we know at present. We have been advised not to make specific recommendations regarding the advisability of joining the Academy. However, we will try to keep you informed as we learn more about the organization.

Editor's note

StressPoints Looks to the Future

By Arthur S. Blank Jr., M.D.
As many readers will have noticed, StressPoints has entered a phase of growth and development. Following the vision of the Board of Directors and many members, we are adding features to the newsletter with the objective of boosting its practical value.

The next issue of StresPoints will introduce a "Recently Published" section, with citations for new articles and books not yet in the major databases. I encourage ISTSS members to submit information about their newly published articles for inclusion in this section; please send reprints to Elizabeth Elliott at ISTSS headquarters. Authors of newly published books may send pamphlets or announcements.

Much of the energy for the changes underway is coming from a group of contributing editors, who regularly furnish or obtain reports in their specialized area. As additional funds permit, the size of StressPoints may increase. 

While contributing editors have a special role in the future of StressPoints, all Society members can contribute to our professional communication by submitting news and opinion items. These should be sent to Managing Editor Elizabeth Elliott at ISTSS headquarters. We also welcome your suggestions for further improvements.

Awards committee

ISTSS Seeks Award Nominations

ISTSS is seeking nominations for its Lifetime Achievement, Robert S. Laufer and Sarah Haley awards. The nomination deadline for these awards is May 15. The criteria for each award are described below. Areas of particular interest are PTSD in children, sexual abuse and violence. We encourage you to consider candidates from countries outside of North America.

Lifetime Achievement Award
The Lifetime Achievement Award is the highest honor given by ISTSS, recognizing great contributions to the field of PTSD study over the course of a career. Prior recipients include Robert Lifton, M.D., Ann Burgess, Chaim Shatan, M.D., and others. The recipient will receive $500. The award is presented at the Society's Annual Meeting.

Robert S. Laufer Award
The purpose of the Robert S. Laufer, Ph.D., Memorial Award for Outstanding Scientific Achievement is to recognize a specific accomplishment of outstanding merit in the field of PTSD research. This award recognizes the excellence associated with a particular study or series of related studies, rather than the collected achievements of a career. All ISTSS members are eligible for this award. The recipient will receive $1,000, which will be given by Ellen Frey-Wouters in memory of her husband.

Sarah Haley Award
The Sarah Haley Memorial Award for Clinical Excellence was first given in 1993. It recognizes people whose written and/or verbal contributions to the field of traumatology exemplify the work of Sarah Haley. It is given to a clinician in direct service to traumatized individuals. The recipient will receive $750.

Nomination Procedure
Nominations should be sent to Edna B. Foa, Ph.D., NCPHU, 3200 Henry Avenue, Philadelphia, PA 19129 and should include a one-page statement summarizing the major achievement of the nominee and a vitae.

Toward Practice Guidelines for PTSD

By Harold Kudler, M.D.
At the Business Meeting of the 1995 ISTSS Annual Meeting, I suggested that the Society consider developing practice guidelines for the treatment of PTSD. This initiative does not stem from any desire to direct or constrain the practice of clinicians in the field. Rather it represents concern about managed care requirements for obtaining treatment. These include the ability to define the necessity for treatment and to prescribe a professionally sanctioned course of therapy. 

The ISTSS is the logical body to develop practice guidelines for PTSD. This is not a prerogative but a responsibility. Clinician-generated practice guidelines would be preferable to those generated by insurance companies. If we fail to take the lead, other professional societies will define the standard. ISTSS action may also inform ongoing Veterans Affairs deliberations on the treatment of PTSD. Our efforts may help alert primary care providers to PTSD and direct their liaison with mental health professionals. 

We have a clear opportunity to harness our expertise for the benefit of our patients. ISTSS President Matthew Friedman asked me to head a task force of interested ISTSS members to see whether it is possible to achieve a consensus on recommended PTSD practice guidelines. He will present our recommendations to the Board of Directors for further action. Those of you who have already been working on such guidelines or who have an interest in joining this effort are encouraged to contact me at 919/286-6933.

Creative arts therapies

Nonverbal and Creative Approaches to PTSD

By David Read Johnson, Ph.D., Contributing editor, creative arts therapies
Empirical research on creative approaches to PTSD treatment is sparse, but sorely needed. Though many clinicians endorse the importance of artwork, role playing and creative expression in the assessment and treatment of the disorder, very little empirical evidence exists to support these claims. 

A recent pilot study published in the journal Art Therapy in December 1995 by Charles Morgan and David Johnson at the National Center for PTSD in West Haven, Conn., provides an example of one model for the empirical study of treatment for nightmares. The authors had two veterans with PTSD alternate each week between two conditions: drawing a picture of, or writing in a journal about, their nightmares each morning over the course of 12 weeks. Both veterans reported significant decreases in the frequency and intensity of their nightmares during the art condition, and increase during the journaling condition. The authors suggest that "the isomorphism between visual imagery (in drawings) and the visual modality of nightmares may provide a more effective means of transforming and integrating the traumatic material into normal cognitive schemas."

If you would like to join the ISTSS Creative Art Therapies Interest Area Group, simply write or fax chairperson David Read Johnson, Ph.D., c/o ISTSS headquarters. Ideas for activities, research projects and presentations at the national conference are welcome.

Critical issues

Mugged by Memory

By Mary P. Koss, Ph.D., University of Arizona College of Medicine, Tucson, Ariz.
Sue Miller's protagonist in the novel For Love returns home, only to feel "mugged by memory." Clinicians working with traumatic memories may feel mugged nowadays. After reading hundreds of studies on emotional memory, I find a perspective emerging. Those who seek to find in the literature evidence of memory's photographic perfection conclude that the glass is empty. Those who have stopped magnifying every memory flaw to disprove this extreme position have found substantial evidence of the tenacity of memory.

Prior to the 1980s, 90 percent of the literature on eyewitness testimony was laboratory simulation, which has limited application to real life. It is impossible to recreate in a lab, within ethical guidelines, an experience that is as rich, anxiety-provoking, personally affecting and consequential as a real-life trauma. While field studies overcome many of these disadvantages, little of what has been learned from them has surfaced in the memory debate. 

The following principles are demonstrated in field studies: First, most of the details that crime witnesses tell police are correct and remain correct for several months. Second, investigators' attempts to suggest inaccurate details do not intrude into recall, nor does wrong information published in the media appear in witness statements. Third, among respondents recalling traumas suffered in concentration camps 40 years earlier, the accuracy of memory for conditions, mistreatment, daily routine, housing, food and main guards was remarkable.

Recently, I was the clinical discussant of a presentation by Elizabeth Loftus, Ph.D., in Washington, D.C. I found myself in an odd position. Her slick address was peppered with legal anecdotes and case material from newspapers and magazines. Anyone who works clinically with trauma survivors could go head-to-head at that level of evidence, but even if we wanted to, our professional audiences would not let us get away with it. And so I responded with conclusions from cognitive literature and empirical data from trauma survivors, most of which appeared in the October 1995 special issue of Journal of Traumatic Stress. Some of the audience comments referenced the problem that clinicians have not emphasized third-party validation of memories.

Certainly, any applied profession has a practice forefront that is as yet unvalidated, but I think that the field of trauma studies has amassed a very impressive body of literature in its short history. And we can continue to do more. Intrusive memory is one of the hallmarks of PTSD; however, we have focused too exclusively on PTSD as an endpoint to be predicted by personal characteristics, or to be evaluated with respect to the outcome of interventions. Descriptive data on the phenomena of intrusion are lacking, and we have not paid sufficient attention to whether our memory-focused interventions actually result in measurable changes in intrusive memory, or whether they are effective by acting via reduction of other symptoms of PTSD. 

But overall, we are participating in the dialogue about memory productively, marshalling data to rebut fundamental criticisms. Loftus recently resigned from the American Psychological Association, writing a letter which attempts to further polarize and politicize the issues by dismissing us as unscientific players with whom she can no longer associate. No. The future belongs to those clinicians and cognitive scientists who come together to share technical vocabulary, theoretical formulations, objective approaches to measuring significant memory phenomena and access to ethnically and developmentally diverse populations experiencing real trauma.
For a detailed review, see Koss, M.P., Tromp, S. and Tharan, M. (1995). Traumatic memories: empirical foundations, forensic and clinical implications. Clin. Psychol.: Sci. and Pract., 1:111&shyp;132.

SDO Promotes Therapies to Help Kuwaitis Cope with Stressors

By Fahed Al Naser, Ph.D., Social Development Office, Kuwait
The Iraqi invasion of Kuwait in 1990 and the subsequent occupation caused many psychological and social problems among the Kuwaiti citizens, whose traumatic experiences included violence, abuses, torture and imprisonment, refugees, death and bereavement and others. During the occupation, a country once known for its harmony and prosperity was turned into a land of terror, distress and scarcity. Kuwait's liberation left an ocean of traumatic stress related disorders, which were aggravated by the problem of the prisoners of war and missing persons.

Preliminary studies showed that a considerable segment of the population developed traumatic stress related disorders, including PTSD. It was at this juncture in 1992 that the Amiri Diwan Social Development Office (SDO) was established. Initially, the task of treatment was formidable because counseling and other psychotherapies - due to their social and religious implications - were something alien and unacceptable to the majority of citizens. SDO mobilized campaigns to create awareness and recognition of the need of therapies for proper cure and rehabilitation of the afflicted, with extreme care to safeguard the sanctity and privacy of the individual, family and society. The tenacity of SDO, combined with international cooperation and assistance, generated positive results. 

The SDO sponsored a series of studies, as well as seminars, conferences and training courses in which internationally known scholars shared their expertise and experience in related fields. Modern therapies and methods were introduced and Kuwaitis were enabled to face the present and future challenges.


The French Model of a Care Unit for Victims of Traumatic Events

By Didier Cremniter, M.D., Contributing editor, ALFEST
The development of a medical and psychological care unit for immediate interventions in cases of natural or accidental disasters, crowd accidents or bomb attacks in France was based on our experience in dealing with the victims of the Islamist bomb attacks during the summer of 1995.

The project was directed by Louis Crocq and supported by the political will to define the practical modalities of immediate psychological care for all such victims in France. While special centers for long-term treatment of victims do exist in France, this new option provides an immediate psychological intervention in emergency situations. The opportunity for specialized teams to provide psychological care and debriefing at various locations is the result of a close collaboration with the French SAMU (prehospital emergency medical service). We tested this plan in suburbs of Paris during the summer 1995 bomb attacks by means of duty teams. Every team included a psychiatrist, a psychologist and psychiatric nurse. However, in case of a major disaster requiring more workers, the first line team could be doubled. The team reached the site of the explosion by joining the SAMU, which is well-equipped with ambulances and helicopters. In situ they provided the first psychological debriefing. Those victims who were slightly wounded (acoustic and chest trauma) were transported to the nearest hospital, where psychiatric staff performed debriefings. In addition to the bomb attacks, the unit provided psychological care for hostages in a school in the northern suburbs of Paris and for victims of an accidental explosion in a building.

The role of this unit is to elaborate a rational French model of psychological intervention in collaboration with every regional head psychiatrist and SAMU coordinator. Members of this unit promote a training program not only for the team workers but also for first-aid workers, medical teams and public institutions (railway airport, electricity and gas employees). This mission is being carried out in close collaboration with victim associations and legal authorities.

United Nations

Beijing and Beyond

By Ellen Frey&shyp;Wouters, Ph.D., ISTSS Representative to United Nations
Nearly 50,000 people - more than two-thirds of them women - travelled to China from all over the world to participate in the United Nations Fourth World Conference on Women, held in Beijing (Sept. 4&shyp;15, 1995), and the parallel NGO Forum on Women held in Huairou (Aug. 30 through Sept. 8, 1995). They came carrying the hopes and concerns of the 2.8 billion women and girls who constitute half of humanity. The final document of the conference, the Beijing Declaration and Platform for Action, was unanimously adopted by the 181 UN member states present, and more than 100 countries and most UN organizations made specific commitments to its implementation. 

The world now has an ambitious blueprint to enhance the social, economic and political empowerment of women; improve their health; advance their education and training; promote their marital and sexual rights; and end gender-based violence.

Mental health issues had unprecedented visibility at the UN Conference and NGO Forum. In the first draft of the platform, in 1992, there was virtually no language on mental health or provision for psychological counseling for women in distress. NGO representatives in New York, especially in the World Federation for Mental Health and ISTSS, had worked for three years leading up to this conference to have mental health concerns included in relevant sections of the platform (all forms of violence against women; impact of armed or other kinds of conflict on women; international trafficking; burdens of poverty and programs for poor women; needs of migrant, refugee and displaced women; special concerns of the girl child). These issues were promoted through lobbying governments, recommending new language on mental health for the platform and interacting with other nongovernmental organizations. The efforts contributed to the inclusion of important language on mental health issues in the final Platform for Action.

At the recent UN General Assembly meeting in the fall of 1995, many discussions focused on effective follow-up. Secretary-General Boutros Boutros-Ghali appointed Assistant Secretary-General Rosario Green to oversee the implementation of the Beijing provisions concerning the UN. 

During the 40th session of the Commission on the Status of Women, March 11&shyp;22, 1996, implementation of strategic objectives and action in the critical areas of concern were again discussed. A preliminary report of government efforts to implement the Platform for Action six months after Beijing shows progress. For example, interministerial commissions are being established in many countries and concrete national initiatives may be expected to follow. 

Legislation is being introduced in a number of countries. In the United States, Congresswomen endorsed a "Contract with Women in the USA," which summarizes key parts of the Platform most relevant to women living in the United States. An interagency Council to coordinate implementation was established, chaired by Donna Shalala, head of the Department of Health and Human Services.
Yet, monitoring progress will be a difficult job. Change is likely to come only incrementally, and only where advocates, in most cases nongovernmental organizations, fight existing practices, laws and customs.

European update

European Conference Addresses Traumatic Stress in Crisis Responders

By Roderick ├śrner, European Conference Secretariat
SHEFFIELD, England - From March 17 to 20 - less than a week before the massacre of Dunblane schoolchildren - 300 delegates from 30 countries gathered in Sheffield for the First European Conference on Traumatic Stress in Emergency Services, Peacekeeping Operations and Humanitarian Aid Organizations.

This watershed conference for the field of psychotraumatology, jointly sponsored by the European Society for Traumatic Stress Studies and the Emergency Planning Department of Trent NHS Executive in Sheffield, was the first regional meeting to focus specifically on the needs of responders. More than 100 presentations addressed risks, needs and care programs.

As pointed out by Berthold Gersons, M.D. (The Netherlands), the challenge presented to individuals, professions and organizations is to maintain goal-directed action in spite of complications arising from ambiguities of needs and role conflicts. These all too often engender a sense of uncertainty, and their combined effects for psychotraumatology in Europe has been to limit options for change. We may have had our backs turned to the future for too long and the costs to responders are manifest in compassion fatigue (C. Figley, Ph.D., USA) and a vast array of somatic syndromes (W.S. de Loos, M.D., The Netherlands). 

The conference bolstered the impression that Europe is reclaiming and reasserting its own heritage with respect to conceptualizations of traumatic stress, its sequelae and care provision for its victims. The days of uninformed "product promotion" are numbered (J. Mitchell, Ph.D., USA). A previous focus on techniques for intervention is being replaced by growing appreciation of the value of process factors in critical incident stress management (A. Dyregrov, Ph.D., Norway). Another point of regional divergence may be the extent of reliance on professional staff groups for provision responder support. This may prove to have been an impediment to defining specific standards for training and quality of service provision (Dr. J. Kenardy, Australia).

Evidence was presented that education and realistic exercises that correctly anticipate future incident scenarios are a powerful protector for responders (L. Weisaeth, M.D., Norway). With respect to strengthening social support resources and responder family networks, the challenge is to establish user-friendly information systems backed by policies to minimize the effects of traumatic stress in the workplace (Lt. Col. R. McLellan, Canada). Evidence suggests using systematically gathered data to screen and select staff for particular duties (Col. M.W. de Swart, The Netherlands).

While every responder's experience is invariably deeply personal and idiosyncratic (Lt. Col. I. Palmer, U.K.), a prerequisite for truly turning our backs to the past and achieving an enlightened future is the use of objective evidence as the tool of our trade. In this respect humanitarian aid organizations appear to lag behind other responder groups featured in the conference program. Ultimately, all groups that respond to traumatic stress are developing a keen recognition that interventions at an organizational level promise considerable longer-term rewards (Dr. A. Ager, Scotland). All the more reason for all practice to be informed by evidence (S. Turner, MRCP, U.K.).

StressPoints Staff
Elana Newman, Ph.D.
Elizabeth Elliott, Managing Editor