DoD Program Applies Chronic Pain and Trauma Care Approaches to Treat Gulf War Veterans with Idiopathic Illnesses
By Ann Norwood, MD
Walter Reed Army Medical Center, the Uniformed Services University of the Health Sciences and the Henry M. Jackson Foundation for the Advancement of Military Medicine have teamed to provide innovative care for Gulf War veterans with unexplained physical symptoms, sometimes referred to as Gulf War Syndrome. The unique service, called the Specialized Care Program (SCP), utilizes a multidisciplinary mix of medical, physical and psychosocial modalities during an intensive three-week partial hospital program aimed at improving veterans' outlook, overall functioning and quality of life. A 1992 meta-analysis in the journal Pain summarized 65 controlled studies of multidisciplinary chronic pain programs and found they were associated with significant improvements in pain, mood, health-care use and return-to-work rates -- improvements that persisted over time. There may be important parallels between chronic pain patients and Gulf War veterans with idiopathic symptoms.
"Typically, we see Gulf War veterans who have looked to the medical system for answers to their health concerns, but have come up empty," says Major Charles Engel, a psychiatrist, epidemiologist and Gulf War veteran who is the SCP director. "As providers, it bothers us when we don't have clear answers for our patients' concerns. Sometimes, we become overzealous, shotgunning tests and medicines even when we don't expect them to help, an approach that yields false positive results and iatrogenic complications. Other times, we become frustrated and then reduce, label or even deny their concerns, essentially rejecting them. This frequently leaves them angry with the medical system and, in our setting, a military that they perceive has let them down. In the SCP, we emphasize joining with the veteran around his or her health concerns and searching with them for a middle medical ground."
The goal of the SCP is to empower veterans to take charge of their health concerns, rather than wait passively on a medical system that in many cases simply does not have the answers they seek. The multidisciplinary staff helps them develop an individualized program of gradually increasing exercise, provides them education on how to collaborate with providers and communicate with loved ones and employers regarding their health limitations, and offers them cognitive-behaviorally based therapies for traumatic experiences and idiopathic symptoms. Prior to entering SCP, veterans typically complete the Department of Defense Comprehensive Clinical Evaluation Program (CCEP), a program designed to provide timely, accessible, and systematic medical evaluations for individuals with Gulf War-related health concerns. During the SCP, veterans work closely with their internists to arrange lasting primary care follow-up and address their questions about past medical testing.
The SCP has seen 63 veterans to date and is experiencing an increasing demand for services. The numbers of veterans seeking care in the CCEP has decreased in the past two months, but SCP inquiries continue to increase. Many are from non-DoD beneficiaries, such as like reservists and veterans no longer in the military. The SCP is working on ways to offer them care. Over the past six months, the SCP has launched an aggressive effort to examine outcomes. It has developed a detailed database measuring multiple aspects of patients' health status, including satisfaction, and has recently begun using computer-assisted telephone interviews for tracking veterans' status over time. In the future, Engel hopes to launch a larger-scale program evaluation to help policy-makers decide whether the SCP approach might benefit veterans of future deployments.
'97 Meeting Offers New Features, Programs
By Danny Kaloupek
Program Commitee chair
Planning is well underway for the 13th Annual Meeting of ISTSS, which will be held at the historic Queen Elizabeth Hotel in Montreal, Quebec, Canada, Nov. 610. The meeting theme is "Linking Trauma Studies to the Universe of Science and Practice." The theme will be reflected in an exciting array of presentations that showcase findings and developments from other fields with the aim of expanding our perspectives on the field of traumatic stress.
To assist with your planning for travel and meeting attendance, I want bring two features of the program to your attention now:
(1) The premeeting institutes on Nov. 7 will offer an especially diverse and high-quality mix of learning opportunities for beginners and experts alike. Several major figures in the field will be featured in this not-to-be-missed day of professional growth. Details of these offerings will be available soon.
(2) The final half day of the meeting on Nov. 10 will feature an especially strong program in the interest of giving attendees incentive to remain on site. In addition, there will be a closing reception at midday that will include refreshments and prizes (e.g., free memberships or free registrations for the 1998 meeting) for those in attendance. Be sure to plan your stay with this in mind.
This year we are expanding the program to include more sessions and other meeting activities. This change is likely to be felt by attendees as a faster paced and fuller daily schedule. The new schedule also is likely to reduce the amount of time available for informal professional contacts and collegeal working opportunities. For this reason, I want to encourage ISTSS members to consider using the closing reception and the afternoon of Nov. 10 for those get-togethers that may be difficult to arrange during the meeting itself. Stay late and enjoy yourselves!
Mapping the Future for ISTSS
By Terence Keane, PhD
We have made remarkable strides as an organization in the past few years. With this maturity has come a dramatic increase in the size of our membership, the increasing prominence of our journal internationally, the visibility and high quality of our annual conference and the large number of organizations that have begun the affiliation process with us. The field of psychological trauma has developed into a remarkably rich professional area. The vision of our founding members is certainly in the process of being realized. It is now in our hands to elevate our efforts to the next highest level.
It is our mission to provide an opportunity for professional growth and development for mental health professionals concerned about the psychological problems associated with exposure to traumatic events. How we realize or attain this goal depends, in part, on how it is defined. Accordingly, the board of directors will be dedicating its mid-year meeting to devising a mission statement for the Society, articulating goals and objectives for the short and long term, and deciding upon implementation plans for achieving these goals.
Past President Matt Friedman, MD, commissioned a survey of the membership last year to derive input from all members about their professional objectives and those for the Society. John Fairbank, PhD, ably worked with the executive committee to devise, implement, analyze and report on the results of that survey. The findings from the survey will be used as the foundation from which the board will function during the strategic planning session. It promises to be an exciting time. We will report on the efforts of the board at the annual business meeting in Montreal and in a future issue of StressPoints.
Affiliations. Evidence for the international growth in our field comes from various milestones. Chief among them is the proliferation of local chapters, affiliates and like-minded organizations worldwide. We are pleased that many of these groups are looking to ISTSS for guidance in establishing their charters, bylaws and goals. Recent groups that are gaining in prominence in their regions include the societies from Africa, Kuwait and Canada. Each is looking to affiliate with us in order to more fully actualize the objectives we hold in common. As these groups develop, the presence of professionals who are committed to assisting those who have been traumatized will be observed in educational institutions, government halls and in the very communities affected by trauma. This is truly a remarkable achievement.
Traumatic memory. Past President Susan Roth, PhD, has worked tirelessly on the development of the Society's response to the vitriolic debate surrounding the nature of traumatic memory. At the mid-year board meeting, the board will review a document for concurrence before publication. In constructing the document, Roth solicited input from various members, representing the divergence of opinions within the Society. It is the objective to distribute the document widely to all interest groups so that a reasoned voice representing an organization committed to the betterment of traumatized individuals is heard. I must extend my sincere appreciation to Susan and all the Society's members who helped on this project, as well as to our consultants, who contributed their intellect to an issue that has been characterized to this point as yielding more heat than light.
Promoting ISTSS. The clinical,
educational and research accomplishments of ISTSS members are noteworthy not only to us, but also to the professional community at large. In order to more fully recognize the efforts of our membership, Susan Solomon, PhD, chair of the Scientific Publications Committee, and Jessica Wolfe, PhD, chair of the Media Committee, initiated a relationship with a center whose mission is to disseminate behavioral research findings to legislators, policy makers and constituents of all types (patients, clients, mental health professionals, etc.). Working with Journal of Traumatic Stress Editor-elect Dean Kilpatrick, PhD, the Media Committee is attempting to get the finest work published in JTS the media attention it deserves.
Curriculum efforts. Under the able direction of Lyndra Bills, MD, the Curriculum Committee is embarking on the large undertaking of updating the work of prior committees to develop course curricula for each of the disciplines represented in the Society. This Committee is interested in assembling course materials that would supplement existing courses on psychological trauma and assist professors and teachers in assembling new courses. Clearly, the training of the next generation of trauma clinicians, researchers and educators is a key mandate for the Society. If you are interested in contributing materials for consideration to the committee, please feel free to contact Lyndra.
Conference update. Danny Kaloupek, PhD, chair of the Program Committee, has introduced many new facets and features to our annual meeting. As a result, the committee received the largest number of submissions ever for one of our conferences. Commitments from many of our most prominent members to conduct preconference institutes, nightly receptions for all attendees, joint sessions with the International Society for the Study of Dissociation and a sterling list of invited speakers will result in a conference that will truly be international in the spectacular venue of the Queen Elizabeth Hotel in Montreal. Make plans to attend!
ISTSS Awards Committee Seeks Nominees
ISTSS recognizes member achievements through an annual awards process. The Awards Committee is seeking nominations for the four awards described below. The Society will present the awards at the Annual Awards Banquet, Nov. 9, 1997 at the Queen Elizabeth Hotel in Montreal.
Lifetime Achievement Award. This award is the highest honor given by ISTSS. It is awarded to the individual(s) who has made great lifetime contributions to the field of PTSD. Recent winners include Judith Herman, MD, Lars Weisaeth, MD and Charles Figley, PhD.
Chaim Danieli Young Professional Award. This award recognizes excellence in service or research in the field of traumatic stress by an individual who has completed his/her training within the last five years. The award was instituted by Yael Danieli, PhD, in memory of her father. Recent recipients include Doug Bremner, MD, Inge Bramsen, PhD and Frank Weathers, PhD.
Robert S. Laufer Memorial Award for Outstanding Scientific Achievement. This award is given to an individual or group that has made an outstanding contribution to research in the PTSD field. Ellen Frey-Wouters, PhD, established this award in memory of her husband. Recent winners include Terence Keane, PhD, Arieh Shalev, MD and Roger Pitnam, MD.
Sarah Haley Memorial Award for Clinical Excellence. This award is given to a clinician in direct service to traumatized individuals and whose written and/or verbal communications to the field exemplify the work of Sarah Haley. Recent recipients include Laurie Pearlman, PhD, Mary Harvey, PhD and Chaim Shatan, MD.
Nominations should be sent to the Awards Chair Steven Southwick, MD, 27 Marshall Ave., Guilford, CT 06437-3516, fax 203/937-3886. We encourage you to consider candidates from countries outside of North America. The deadline for receipt of nominations is June 13. Nominations should include a one-page statement summarizing the major achievements of the nominee and a vitae.
LETTER TO THE EDITOR
Dear ISTSS Members:
I want to thank you very much for participating in my doctoral research study on vicarious traumatization of therapists working with trauma survivors. Your generous gift of time and attention to completing surveys has contributed to the understanding of the process of therapists' traumatization and the efficacy of selected protective factors. The response to my request for ISTSS member participation was so positive that I was able to complete the data collection in two months. I deeply appreciate your notes of encouragement, feedback and challenge, and wish that I could have responded personally to each one. I was also deeply moved by those who chose to reveal therapeutic examples of times that your work with a survivor challenged you personally and professionally. As I embark on a career working with trauma survivors, I will carry with me the lessons that you have shared.
Denise Walton, PhD
ISTSS Interest Area Updates
By Mary Beth Williams, PhD, LCSW, CTS
Chair, ISTSS Interest Area Groups
Several of the ISTSS interest area groups sent in summary reports of their recent gatherings at the 1996 ISTSS Annual Meeting.
The Child Trauma Interest Area Group wants to plan for more child-focused presentations at the Annual Meeting in 1997. A subcommittee formed to work on a brochure that reviews and updates the goals, mission and directions of this interest area. Frank Putnam, MD, will serve as the group's board liaison. Joyce Silberg will serve as ISSD liaison and Holly Shaw will represent the interest area at UNICEF. Jean Bellows, PsyD, chair, wrote to each member of the interest area group to encourage submission of proposals for premeeting institutes and sessions so that child-related issues will be well represented at the Annual Meeting in November 1997.
Nonverbal and Creative Approaches Interest Area Group members who attended the meeting identified a variety of issues and goals for their attention. These include:
1. Developing a common language among different nonverbal modalities;
2. Exposing practitioners of conventional therapies to nonverbal modalities;
3. Conducting outcome studies with interim assessments;
4. Increasing communication among group members; and
5. Developing a clearer conceptualization of goals to accomplish with patients.
David Read Johnson, PhD, is chair of this interest area group.
Human Rights and Social Policies Interest Area Group members, under the leadership of Yaya de Andrade, PhD, and Steven Weine, discussed potential presentation topics for the l997 Annual Meeting. Two projects were suggested as possible workshops for 1997:
1. The impact of conditions in prisons, including solitary confinement and other control units;
2. The healing context of mental health services, looking at human rights related policies, protocols, and training of professionals.
The Curriculum, Education and Training Interest Area Group met under the leadership of Lyndra Bills. Yael Danieli, PhD, described the development of the presently used ISTSS Curriculum Guide and other members discussed their efforts to develop training programs and curricula. Bills is forming a Curriculum, Education and Training Committee to facilitate a revision of the earlier curriculum. The multi-disciplinary task force includes members and non-members of the interest area.
The Building Bridges Between Professionals and Self-Help Groups Interest Area Group is co-chaired by Anne Marie Eriksson and Jeremy Herman. A major activity of Eriksson's own organization is o send out over 800 ISTSS applications. This interest area encourages and supports self-help mutual aide clearinhouses and information centers, as well as specific self-help groups. Members have been educating others about the availability and value of self-help groups.
The Ethics Interest Area Group drew a small number of individuals who discussed ethical concerns relevant to the field of traumatology. These concerns included the duty to warn professionals entering the profession about the inevitability of coping with vicarious traumatization to some degree and the development of ethical codes in the trauma field by various organizations. The interest area will present a half-day premeeting institute on Ethics and Treatment, Research and Self Care at the 1997 Annual Meeting. This group is co-chaired by John Sommer, Jr., and Mary Beth Williams, PhD.
The Traumatic Loss Interest Area Group meeting was chaired by Bette Spear and Irene Landsman, PhD. Topics included the use of EMDR in treating traumatic loss reactions; representation at the ADEC conference in Washington, D.C., in June 1997, presentation of premeeting institutes in 1996 and 1997, and volunteering of the co-chairs to coordinate inquiries from members and board members about traumatic loss.
As chair of the ISTSS interest areas, I would like to request that chairs of individual interest area groups to furnish names of members who are willing to serve as resources to the board and to members in each specific interest area. If you are interested in joining an interest area or serving in this capacity, please contact Judy Deacetis at ISTSS headquarters.
Wanted: Interest Area Group Chairs
ISTSS is looking for members to fill the following interest area group chair positions:
- Treatment Innovation
- Occupational Trauma
If you are interested in a chair position, please contact istss headquarters at email@example.com or call 847/480-9028.
ISTSS Active in Coalition Advocating for the Treatment Needs of Patients
By Sandy Bloom, MD
On Feb. 28, ISTSS Executive Director Greg Schultz and I represented ISTSS at an important meeting in Washington, D.C., at the invitation of the American Psychiatric Association. The APA invited 23 organizations to discuss the impact of managed care on their particular patient populations. Organizations included the National Alliance for the Mentally Ill, the American Academy of Child and Adolescent Psychiatry, American Society of Addiction Medicine, Child Welfare League of America, Obsessive Compulsive Foundation, National Association of Social Workers and the American Academy of Hispanic Psychiatry.
Harold Eist, MD, president of the APA, has been an outspoken critic of managed care policies that have severely jeopardized the treatment of the mentally ill. After years of trying to improve the situation through negotiations with managed care companies, Eist and his colleagues concede that the situation continues to degenerate.
Eist was instrumental in developing a broad-based coalition of mental health groups, the Mental Health Professionals Coalition, a constructive effort to overcome the interdisciplinary warfare that has plagued the mental health field. This group represents over half a million mental health professionals from all disciplines. On Feb. 20, the coalition held a press conference to introduce a patients' Bill of Rights.
This Bill of Rights asserts that patients have the right to know the full extent of their health benefits, to know the credentials of treating professionals, to know how these professionals are paid and to appeal unfair practices. The document asserts that patients have the right to confidentiality, to choose who they want to treat them, to use the entire scope of their benefits, to fair and appropriate medical review of their care and to hold both the professional, health-care organizations and insurer accountable for harm.
It also insists on the right to receive mental health benefits on the same basis as other illnesses and the right not to be denied other benefits, like life insurance, just because they have sought mental health treatment. The response to this document from one representative of the managed care industry was that the rights are "unrealistic." Nonetheless, this document is being distributed to every member of Congress, major health insurance and managed care organizations, health professional organizations, advocacy groups and the public at large.
At the meeting Jack Schoenholtz, MD, presented information on the economics of health care, detailing the benefits insurance companies have accrued from the creation of the present managed care environment. He believes that a grass roots movement is developing to reverse the current excesses and abuses, as more members of the public suffer from detrimental and sometimes lethal practices.
To assist in this reform process, Eist announced the formation of a nonprofit organization dedicated to health care based on the privacy of a doctorpatient relationship controlled only by the needs of the patient rather than by corporate financial interests.
This organization, The Legal Center for Patient Protection, seeks to be a clearinghouse, offering information and guidance for patients who have grievances against managed care. The Center will provide professionals and consumers with legal consultation about the potential for access to federal and state courts and regulatory agencies when other attempts at redress fail. When litigation is appropriate, local legal counsel may collaborate with the Center, which can bring together specialists with collective clinical and forensic experience. Social change is usually preceded by successful legal precedent, but until now, relatively few attorneys have understood the intricacies involved in federal and state regulation of the insurance industry. The Center will provide the guidance that trial attorneys need.
If you, your patients or their families want to lodge a grievance and explore the possibility of litigation against a managed care practice, you should contact the Center, tel. (202)429-6530; fax, (202)332-8710. Staff are particularly interested in speaking to patients or their family members about their experiences.
ISTSS must consider its position vis-à-vis managed care and what steps the organization should take to help guarantee trauma patients access to the level of care they need. The ISTSS Executive Committee is considering the following proposals:
- Construct a survey of members to get more detailed information about how managed care has been impacting specifically on the treatment of trauma survivors.
- Take whatever steps are necessary to position the ISTSS as one of the players in this developing coalition.
- Offer our mailing list to the Center for the solicitation of funds
- Promote the development of treatment guidelines. Various organizations are doing this in order to set a standard that managed care must abide by if they are to avoid being below the standard of care.
- Distribute information about the Mental Health Bill of Rights Project and the Legal Center for Patient Protection to ISTSS members.
Building Bridges to the Next Millenium: The Blueprints are Ready
By Ellen Frey-Wouters, PhD, LLB, ISTSS representative to the United Nations
The 1990s have seen major United Nations conferences addressing important concerns of the international community: the World Summit for Children (New York, 1990), the UN Conference on Environment and Development (Rio de Janeiro, 1992), the World Conference on Human Rights (Vienna, 1993), the International Conference on Population and Development (Cairo, 1994), the World Summit on Social Development (Copenhagen, 1995), the World Conference on Women (Beijing, 1995), the UN Conference on Human Settlements (Istanbul, 1996) and the World Food Summit (Rome, 1996). These summits drew upon earlier conferences in their respective areas. ISTSS has been involved not just in the conferences themselves, but also in the preparatory activities and in the postconference action plans in pursuit of the established goals and commitments.
The NGO Caucus on Trauma, chaired by the ISTSS representative, fought hard at the Habitat Conference for inclusion of a mental and physical health principle. The most obvious difficulty that faced the inclusion of this principle was the nature of the conference itself. For many nations, the subject of human settlements was one that should only focus on urban planning. They viewed health as a side issue, which did not belong in the document. It was not until the end of the conference that a compromise was reached and it was agreed to include a health principle in the Habitat document. The conference reaffirmed the commitment to the "full and progressive realization of the right to adequate housing" and, in Principle 36, it acknowledged that "human health and quality of life are at the centre of the efforts to develop sustainable human settlements."
The declaration commits UN member states "to promoting and attaining ... the highest attainable standards of physical, mental and environmental health, and the equal access of all to health care ... Good physical and mental health throughout the life span ... is fundamental to ensuring that people of all ages are able to develop their full capacities in health and dignity ..."
The World Food Summit, November 1317, 1996, in Rome, Italy, adopted a Declaration on World Food Security and a Plan of Action. It was recognized that people in virtually every country suffer from hunger and malnutrition, although the extent and pattern differ substantially from country to country and region to region. The conference confirmed that hunger is unacceptable in a world of plenty. About 800 million people are undernourished today: not only people facing acute hunger, victims of conflict and natural disasters, but also people with low income and deficient purchasing power. The NGO Caucus on Trauma was active during the Rome meeting, arguing that hunger constrains human development. Inadequate nutrition results in lasting physical and mental damage.
In its 1997 Report on the World Social Situation, the UN Commission for Social Development recognizes that boundless opportunities for social progress co-exist with intense challenges and problems. International awareness of social issues has reached an unprecedented level and a new sense of urgency exists. A unique emerging partnership between the UN members states, secretariat and nongovernmental organizations has been created. ISTSS, individually and through its membership in the NGO Mental Health Committee, will be a part of a team that is trying to find solutions for the overwhelming crises that face us all. An integrated and coordinated follow-up of the UN conferences is needed. In the mental health field, we will collaborate with countries that wish to take action to help those millions of people who suffer from the reduction of their mental health. ISTSS and the NGO Committee recommended to the General Assembly, ECOSOC and UNICEF that "In all considerations, the specific words physical and mental health shall be used in place of the general term health. Specific statements shall be included recognizing the fact that a destructive and traumatic impact on mental health is inherent in situations such as war, poverty, human rights violations, oppression, violence and other conditions that destroy the quality of life. In studying and considering solutions to problems, provisions of mental health services must be included." In the implementation of the blueprints for the future, ISTSS has a challenging role in the remaining part of this century.
Treating Families of Kidnap Victims
By Spiwak Frida, PhD, Elana Newman, PhD, Fuentes Adolfo, PhD, and Espinel Zelde, MD
Columbia accounts for 70 percent of the world's kidnappings. Kidnapping has become a commercial enterprise among common criminals and guerrillas alike to target both the rich and the poor. Although the goal of the kidnappings is primarily economic (e.g., to acquire ransom), the collective result is one of cultural enslavement.
There are generally two types of kidnapers: (1) guerrillas and (2) "common" criminals. The guerillas are patient with their victims and hold them in remote rural areas for long periods of time (between six months and a year) before the ransom is finally negotiated. Common criminals, who are usually less experienced, more impetuous and have a poorer infrastructure, can only keep prisoners for short periods of time within city limits. In these cases, if demands are not met, the victim will be readily murdered. Although most hostages are returned, approximately five percent are indeed murdered.
The Columbian government created the Presidential Program for the Defense of Personal Liberty in September 1995 to help the families of victims of kidnappings, extortion and disappearance. This victim assistance program is designed to offer immediate psychological assistance and crisis intervention throughout the abduction period and during potential reunification. The Presidential Program staff helps the family interface with all the systems involved in investigating and recovering the hostages, and if necessary, during negotiation. There are currently 18 psychologists working at 23 sites across the country.
Given the rampant corruption and the fact that 75 percent of the captors are not prosecuted, Columbian families are mistrustful of government institutions. In addition, the stress endured during this period taxes the psychological and economic resources of all family members. To be effective, the program uses a variety of innovative outreach strategies, which acknowledge the reality of the families' mistrust and current family upheaval. Rather than insist that clients attent regular sessions at the centers, the psychologists see family members at their convenience, wherever they wish to meet. Sessions may be held at clients' business offices, at home during meals or while these families run daily errands. Sessions can range from two to six hours, depending on the family's needs and can include one to 10 family members.
All services are aimed at helping the family maintain its cohesion and attain its highest possible level of functioning. Social support, stress management and problem-solving are primary interventions. In addition, staff educate families about traumatic response and attempt to foster adaptive coping mechanisms among all family members. Although staff usually meet all the family members during the initial sessions, typically one or two self-selected family leaders are provided continuous help, and they in turn provide provide psychological assistance and communication to the rest of the family. The program prides itself on providing accessible services to these families in a flexible manner. Current efforts are under way to substantially assess our clients' needs.
Peering into the Internet's Future (Part II)
By David Baldwin, PhD
Contributing editor, trauma online
How might Internet capabilities increase communication affect trauma research, clinical work and disaster responses in the future? It's always difficult to predict the 'Net --recent changes have been so rapid that imagining more than several months into the future seems almost ludicrous.
Still, I expect a rapid and continuing expansion of e-mail and Web use. New products, such as WebTV (available now at your local electronics store), connect a modem and RISC chip to existing television sets and provide cheap e-mail and WWW access through a standard TV for those without computers. Democratization of access to information has important societal implications, not restricted to any particular field.
Research collaboration should increase, since close working relationships need not be restricted geographically. This eases the implementation of multi-site and cross-cultural studies, and allows more efficient use of data. This may change the kinds of research questions that can realistically be addressed, in ways that are difficult to predict.
For example, I recently received word that my very small disaster grant application was approved for possible funding by the Natural Hazards Center at UC-Boulder (http://adder.colorado.edu/~hazctr/Home.html).
In the event of a natural disaster in a U.S. city where appropriate ongoing or longitudinal data are being collected -- and given a cooperative principal investigator -- I could travel to the affected area, examine current subjects, and identify high- and low-susceptible PTSD groups with comparable Criterion A exposure. If it is possible to re-test these selected groups, we might learn if variance in predisaster measures predicts vulnerability to PTSD symptoms, if disaster experiences change baseline measures, or both. The ongoing research need not be trauma-focused, it just needs to offer relevant predisaster data and a large enough sample. Using e-mail and the Web certainly simplifies identification of appropriate ongoing research projects, as well as communication with potential collaborators.
The Internet may also offer an avenue for increased mental health responsiveness when whole communities are affected, as by a natural or man-made disaster. Much of the immediate need relates to information, and the Internet can easily provide that. But it can also offer consultation with therapists who are not able to travel to the disaster site, as well as professional supervision and supportive consultation among therapists treating those affected. The idea of a Virtual Trauma Center is not so far-fetched as it might have sounded just a few years ago. For the present, it will offer services that do not require close or personal contact. But future developments in video-conferencing and virtual reality promise to gradually expand the emotional flavor and immediacy of our Internet communications, much as today's email has eclipsed "snail mail."
Finally, online psychotherapy is peeking over the horizon as a potential clinical application, raising difficult ethical and licensing issues. Marlene Maheu, PhD, has created an interactive Web site where professionals can comment on any specific ethical concerns about online therapy -- you can visit her site at (http://cybertowers.com/cgibin/ethics_forum.cgi).
Traumatic Stress News
Bill Seeks to Prevent Return of Children to Abusive Families
Sens. John Chafee, R-R.I., and Jay Rockefeller, D-W. Va., are sponsoring a bill to make it easier for judges, social workers and others to keep children away from abusive family situations. Currently, a 1980 law mandates that a reasonable effort be made to keep families together, but critics have complained that the misinterpretation of this law often results in returning children into dangerous situations. The new law would state that it is unreasonable to reunify families when there is a threat to a child's health or safety. A similar bill in the House is being sponsored by Reps. Barbara Kelly, D-Conn., and Dave Camp, R-Mich. Both bills also have provisions to promote expedited adoption and foster-care placements.
High Bosnian Suicide Rate Reflects Country's Poor Psychological Health
A recent Associated Press article cites statistics on suicide rates that suggest the mental health of Bosnians is worse than it was during the war. In the Muslim third of the country alone, the number of suicides was in the high 40s to low 50s between 1993 and 1995, compared to 27 in 1992, the first year of the war. The article cites experts as saying that as much as 60 percent of the 350,000 residents of Sarajevo suffer from problems related to traumatic stress.
Study: Battered Women in United States Face Barriers
A study by University of California at San Francisco researchers, published recently in Women and Health, identified treatment barriers faced by battered women at the patient, provider and organizational levels. Researchers interviewed 31 battered women and based their findings on the experiences of 16 women who had 36 encounters with the health-care system.
In 10 of the 36 encounters, the violence was not discussed. Some women chose to say nothing about their injuries, and others lied about the source of the injuries. Fear of their partners and fear that their children would be taken away were primary motivators for avoiding discussions of the violence. Embarrassment was another factor.
Violence was discussed in 26 of the 36 encounters. In 14 of these 26 enounters, women said that health-care professionals appeared disinterested or unsympathetic. In four of the 26 instances, women cited organizational barriers to treatment.
DoJ Allocates $2.7 Million to Reduce Child Abuse, Neglect and Violence
The U.S. Department of Justice awarded $2.7 million to five sites to reduce child abuse and neglect and stop the cycle of violence. Sites receiving the "Safe KidsSafe Streets" grants include Huntsville, Ala.; the Sault Sainte Marie Tribe of the Chippewa Indians, Sault Sainte Marie, Mich.; Kansas City, Mo.; Toledo, Ohio; and Chittendon County, Vt. These sites will work to
- restructure the criminal and juvenile justice systems to improve the handling of child abuse cases;
- coordinate parenting programs and support services to protect youth who are at risk of being abused and neglected;
- improve data collection through information sharing across systems and agencies; and
- lauch prevention education and public awareness campaigns to teach community residents how to detect, report and prevent child abuse.
DoJ's Office of Justice Programs received more than 175 applications for these grants.
Survey: More Than Half
of Female Psychologists Experience Sexual Harassment
In a survey sent to 750 practicing female psychologists, 53.4 percent of the 354 respondents reported at least one incident of sexual harassment by a patient. The survey, which was conducted by Robert deMayo, PhD, of Pepperdine University and published in a recent issue of Professional Psychology: Research and Practice (vol. 28, no. 1), indicated that only 10 respondents (2.8 percent) reported that a patient had threatened sexual assault; only one psychologist reported having been sexually assaulted by a patient.
While one psychologist reported 29 incidents of sexual harassment, the total number of incidents reported by respondents equalled less than one in 5,000 therapy sessions.
Study Defines Gulf War Veteran Syndromes, Identifies Possible Causes
Researchers from the University of Texas Southwestern Medical Center report in the Journal of the American Medical Associationthe identification three primary and three secondary syndromes -- as defined by clusters of symptoms -- associated with Gulf War veterans. The three primary syndromes are characterized as Impaired Cognition Syndrome, Confusion-ataxia Syndrome and Arthro-myo-neuropathy Syndrome. One of the "symptoms" associated with Confusion-ataxia Syndrome is having a physician's diagnosis of PTSD. The researchers suggest that most of the symptoms could be the result of combinations of brain, spinal cord and nerve injuries. The researchers also identified possible causes of the syndromes, linking increased prevalence of specific syndromes with exposure to chemical weapons, use of a government-issued insect repellent and taking a anti-nerve-gas drug.
Professional Organizations Back Consumer Bill of Rights
Nine U.S. organizations, representing more than 600,000 health professionals, teamed to support a mental-health and substance-abuse services consumer "Bill of Rights." The document reflects the concern of mental health professionals that health-care system changes, particularly managed care proliferation, have eroded the quality of and access to care for mental health patients.
The organizing principles of the document include Right to Know (with specific sections on benefits, professional expertise, contractual limitations and appeals/grievances), Confidentiality, Choice, Determination of Treatment, Parity, Discrimination, Benefit Usage, Benefit Design, Treatment Review and Accountability. The document will be distributed to all health and managed care organizations, consumer groups and members of Congress.
Dorothy Cantor, Psy.D., president of the American Psychological Association, said, 'The present obsession of today's health-care system on controlling costs is compromising the rights of individuals to competent and quality care. The principles embodied in this Bill of Rights reflect what we as professionals believe individuals are entitled to when they select a health plan and when they seek treatment."
Groups participating in the project were the American Association for Marriage and Family Therapy, American Counseling Association, American Family Therapy Academy, American Nurses Association, American Psychological Association, American Psychiatric Association, American Psychiatric Nurses Association, National Association of Social Workers and National Federation of Societies for Clinical Social Work. Supporting groups were the National Mental Health Association, National Depressive and Manaic Depressive Association, American Group Psychotherapy Association, American Psychoanalytic Association and National Association of Alcoholism and Drug Abuse Counselors.
Compiled by Arthur S. Blank Jr., MD
Readers who have recently published or have seen a new article on a traumatic stress topic can have it listed here by sending a copy to Art Blank, Jr., Psychiatry Service (116A), VA Medical Center, Minneapolis, MN 55417. If you have recently authored or seen a relevant book, please send a publisher's brochure or other material describing the book.
Bernstein DP, Ahluvalia T and Handelsman L: Validity of the childhood trauma questionnaire in an adolescent psychiatric population. J. Am Acad. Child. Adolesc. Psychiatr. 36(3): 340 (March 1997)
Bremner JD, Innis RB and Charney DS: Positron emission tomography measurement of cerebral metabolic correlates of yohimbine administration in combat-related PTSD. Arch. Gen. Psychiatr. 54(3):246 (Mar. 1997).
Cohen H, Kotler M and Cassuto Y: Power spectral analysis of heart rate variability in PTSD patients. Biological Psychiatr. 41(5): 627 (March 1997).
Chemtob CM, Novaco RW and Gross DM: Cognitive-behavioral treatment for severe anger in PTSD. J. Consulting Clin. Psychol.65(1): 184 (Feb. 1997).
Ekblad S and Roth G: Diagnosing PTSD in multicultural patients in a Stockholm psychiatric clinic.
J. Nervous & Ment. Disease 185(2): 102 (1997).
Fawzi MCS, Murphy E and Mollica RF: The validity of screening for PTSD and major depression among Vietnamese former political prisoners. Acta Psychiatrica Scandinavica 95(2): 87 (Feb. 1997).
Fletcher K: "Childhood PTSD," Chapter 6 in Child Psychopathology, Mash E and Barkley R, Eds., New York: Guilford, 1996.
Fontana A, Schwartz LS, Rosenheck R: PTSD among female Vietnam veterans: a causal model of etiology. Am. J. Pub. Health87(2): 169 (Feb. 1997).
Grossman LS, Willer JK and Nelson R: Underdiagnosis of PTSD and dubstance use disorders in hospitalized female veterans.Psychiatr. Services 48(3): 393 (Mar. 1997)
Hales RE and Zatzick DF: Editorial: What is PTSD? Am. J. Psychiatr. 154(2): 143 (Feb. 1997)
Hickling EJ and Blanchard EB: The private practice psychologist and manual-based treatments: PTSD secondary to motor vehicle accidents. Behaviour Res. Ther. 35(3): 191 (Mar. 1997)
Jensen CF, Keller TW, and Raskind MA: Behavioral and neuroendocrine responses to sodium lactate infusion in subjects with PTSD. Am. J. Psychiatr. 154(2): 266 (Feb. 1997)
Joseph S, Dalgleish T and Hodgkinson P: Attitudes towards emotional expression and post-traumatic stress in survivors of the Herald of Free Enterprise disaster. British J. Clin. Psychol. 36(1): 133.
Joseph S, Dalgleish T and Yule W: Impulsivity and post-traumatic stress. Personality and individual differences 22(2): 279 (Feb. 1997).
Kazak AE, Barakat LP and Stuber ML: Posttraumatic stress, family functioning, and social support in survivors of childhood leukemia and their mothers and fathers. J. Consulting Clin. Psychol. 65(1) (Feb. 1997).
Leavitt F: False attribution of suggestibility to explain recovered memory of childhood sexual abuse following extended amnesia.Child Abuse Neglect 21(3): 265 (Mar. 1997).
Litz BT, Orsillo SM and Batres A: PTSD associated with peacekeeping duty in Somalia for U.S. military personnel. Am. J. Psychiatr. 154(2): 178 (Feb. 1997)
Lubben S, Ed.: Refuge: Canada's Periodical on Child Refugee's, special issue, vol. 15, no. 5, (1996).
McFarlane AC: PTSD: the importance of clinical objectivity and systematic research. Med. J. Australia 166(2): 88 (Jan. 1997)
Parson ER: Posttraumatic child therapy (P-TCT): assessment and treatment factors in clinical work with inner-city children exposed to catastrophic community violence. J. Interpersonal Violence 12(2): 172 (Apr. 1997)
Rickford F: Child abuse: Evidence to support the existance of [false memory] syndrome is by no means definitive. Comm. Care1154: 18 (Jan. 1997).
Rodriguez N, Ryan SW and Foy DW: PTSD in adult female survivors of childhood sexual abuse: a comparison study. J. Consulting Clin. Psychol. 65(1): 53.
Sar V, Yargic LI and Tutkun H: Structured interview data on 35 cases of dissociative identity disorder in Turkey. Am. J. Psychiatr. 153(10): 1329 (Oct. 1996).
Shin LM: Kosslyn SM and Pitman RK: Visual imagery and perception in PTSD: a positron emission tomographic investigation.Arch. Gen. Psychiatr. 54(3): 233 (Mar. 1997).
Snell FI and Padin-Rivera E: Group treatment for older veterans with PTSD. J. Psychosocial Nursing & Ment. Health 35(2):10 (Feb. 1997).
Steiner H, Garcia I.G. and Matthews Z.: PTSD in incarcerated juvenile delinquents. J. Am. Acad. Child & Adolesc. Psychiatr.36(3): 357.
Synnott IH: PTSD: What's in a name? Med. J. Australia 166(2): 111 (Jan. 1997).
Tauber Y: The traumatized child and the adult: Compound personality in child survivors of the Holocaust. Israel J. Psychiatr. Related Scis. 33(4): 228 (1996).
Vasterling JJ, Brailey K and Sutker PB: Assessment of intellectual resources in gulf war veterans: relationship to PTSD.Assessment 4(1): 51 (Mar. 1997)
Barrett D, Ed.: Trauma and Dreams, Cambridge: Harvard University Press, 1997.
Brooks B and Siegel P: The Scared Child: Helping Kids Overcome Traumatic Stress, New York: Wiley, 1996.
Horowitz M: Stress Response Syndromes, third ed., Jason Aronson Publishers, 1997.
Peltzer K: Counseling and Psychotherapy of Victims of Organized Violence in Sociocultural Context, Frankfurt: IKO-Publisher of Intercultural Communications, 1996.
Proceedings of "The Psychosocial Aspects of Repatriation of Former Yugoslavian Refugees and Displaced Persons," Ribno, Slovenia, March 79. Utrecht, The Netherlands: Pharos Foundation, 1996.
University of Tuzla Summer Program Seeks Professors, Lecturers
Professional Books Inc. (PBI) will coordinate the book exhibit for the 1997 ISTSS Annual Meeting. PBI researches up-to-date and relevant books in the field and requests that members send titles of books they have recently authored. In addition, PBI requests a list of recent references to which presenters will be referring in lectures. This list of books will be compiled into a bibliography and PBI will endeavor to have these books for sale at the conference and via mail order.
Please respond by June 15 via fax or letter to: Professional Books Inc., 215 California Street, Newton, MA 02158; fax, 617/630-9396.
Professional Books Inc.
Seeks Titles for Annual Meeting Book Store
The University of Tuzla in northeast Bosnia will host a summer program from July 15 through August 15. The university is interested in presenting lecturers and professors with MAs and PhDs in psychiatry, neurology, psychology, physical and mental trauma rehabilitation (especially of children) and public health. The 1996 summer program convened 400 students and academics from Tuzla along with 30 foreign students and academics from 11 European countries and the United States. Participants are expected to give a number of lectures in their areas of expertise to both graduate students and professors. The language of instruction is English, with support from Bosnian translators.
The program is being organized by Foundation YSY (a Dutch student group), the University of Tuzla and various academic and student organizations in Europe and the United States. It is funded by the Dutch government and the Council of Europe, along with several European and American universities. Lecturers and Professors interested in participating should contact Garth Katner, PhD, The F.K. Bernis International Center, St. Norbert College, De Pere, WI 54115, U.S.A.; firstname.lastname@example.org.