Guideline-based programs in the treatment of complex PTSD

The term “post-traumatic stress disorder” (PTSD) is a relatively new diagnostic label, being formally recognized in 1980 in the Diagnostic Statistical Manual for Psychiatric Illness – Third Edition (DSM-III) of the American Psychiatric Association (APA, 1980). Complex Post-Traumatic Stress Disorder (CP) is a more recently discussed, and newly-classified, phenomenon, initially discussed in the early 1990s (Herman, 1992a). Thus, as research into effective treatments for CP is sparse, the treatment of CP is the topic of this study, in which a guideline-based treatment program developed by the researcher for the treatment of CP is implemented and evaluated. Ten individuals participated in this study, undertaking individualized, guideline-based treatment programs spanning a period of six months. In providing background information relevant to this study, an explanation is provided regarding the nature of CP, and the reasons for its consideration as a separate phenomenon to PTSD. The adequacy of the PTSD formulation in enabling effective assessment and treatment of CP is also explored, with endorsement of previous researchers’ conclusions that the CP construct is more useful than the PTSD construct for assessing and treating survivors of long-term and multiple forms of abuse. The PTSD classification is restrictive, and not necessarily appropriate for certain forms of trauma (such as prolonged trauma, or multiple forms of trauma), as such trauma experiences may lead to specific effects that lay outside those formerly associated with PTSD. Such effects include alterations in affect regulation, consciousness, self-perception, interpersonal relationships, and in systems of meaning. Following discussion regarding the PTSD/CP classification, an examination of treatment methods currently used in the treatment of PTSD, and a review of treatment outcome studies, takes place. The adequacy of primary treatment methods in treating CP symptoms is then examined, with the conclusion that a range of treatment methods could potentially be useful in the treatment of CP symptoms. Individuals with a diagnosis of CP may benefit from the adoption of an eclectic approach, drawing on different treatment options for different symptoms, and constantly evaluating client progress and re-evaluating interventions. This review of treatment approaches is followed by details of an initial study undertaken to obtain feedback from individuals who had suffered long-term/multiple trauma and who had received treatment. Participants in this initial study were asked open-ended questions regarding the treatment approach they had experienced, the most useful aspect of the treatment, the least useful aspect, and other strategies/treatment approaches that may have been useful – but which were not used. The feedback obtained from these individuals was used to inform the development of treatment guidelines for use in the main study, as were recommendations made by Chu (1998). The predominant focus of the treatment guidelines was “ego strengthening”, a term coined by Chu (1998) to describe the “initial (sometimes lengthy) period of developing fundamental skills in maintaining supportive relationships, developing self-care strategies, coping with symptomatology, improving functioning, and establishing a positive self identity” (p.75). Using a case study approach, data are then presented relating to each of the ten individuals involved in the treatment program: details of his/her trauma experience(s)and the impact of the trauma (as perceived by each individual); details of each individual’s treatment program (as planned, and as implemented); post-treatment evaluation of the positive and negative aspects of the treatment program (from the therapist’s perspective); and details of the symptoms reported by the individual post-treatment, via psychometric assessment and also during interview. Analysis and discussion of the data relating to the ten participants in the study are the focal point of this study. The evaluation of the effectiveness of each individual’s treatment has been based predominantly on qualitative data, obtained from an analysis of language (discourse analysis) used by participants to describe their symptoms pre- and post-treatment. Both blatant and subtle changes in the language used by participants to describe themselves, their behaviour, and their relationships pre- and post-treatment have provided an insight into the possible changes that occurred as a result of the treatment program. The language used by participants has been a rich source of data, one that has enabled the researcher to obtain information that could not be obtained using psychometric assessment methods. Most of the participants in this study portrayed notable changes in many of the CP symptoms, including being more stable and having improved capacity to explore their early abuse. Although no direct cause-effect relationship between the participants’ treatment program and the improvements described can be established from this study, the participants’ perception that the program assisted them with their symptoms, and reported many aspects of “ego strengthening”, is of major importance. Such self-perception of strength and empowerment is important if an individual is going to be able to deal with past trauma experiences. In fact, abreactive work may have a greater chance of succeeding if those who have experienced long-term or multiple trauma are feeling more empowered, and more stable, as were the participants in this study (post-intervention). In concluding this study, recommendations have been made in regard to the use of guideline-based treatment programs in the responsible treatment of CP. Strengths and limitations of this study have also been highlighted, and recommendations have been made regarding possibilities for future research related to CP treatment. On the whole, this study has supported strongly other research that highlights the importance of focusing on “ego strengthening” in assisting those who have suffered long-term/multiple trauma experiences. Thus, a guideline-based program focusing on assisting sufferers of long-term trauma with some, or all, of the symptoms of CP, is recommended as an important first stage of any treatment of individuals who have experienced long-term/multiple trauma, allowing them to develop the emotional and psychological strength required to deal with past traumatic events. Clinicians who are treating patients whose history depicts long-term or multiple trauma experiences (either from their childhood, or at some stage in their adult life) need, therefore, to be mindful of assessing individuals for symptoms of CP – so that they can treat these symptoms prior to engaging in any work associated directly with the past traumatic experiences.

An integrative model of relationship functioning

This thesis presents an integrative model of relationship functioning, delineating the factors that significantly influence the way in which couples experience lasting and satisfying relationships. Given that marital relationships are complex, multiple intra and interpersonal factors need to be considered in order to better understand the pathways which lead to healthy relationship functioning. The integrative nature of the model is therefore argued to capture the intricate dynamics inherent in couple functioning. The portfolio provides four case studies of different loss experiences which are linked by the theme of disenfranchised grief which is deemed an important issue to deal with in therapy.

The relationship between stress and the symptomatology of fibromyalgia

Fibromyalgia is an unexplained but often debilitating syndrome, characterised primarily by widespread pain. This thesis provides direct evidence that physical and emotional stress exacerbates pain, fatigue and other symptoms of Fibromyalgia and supports the assertion that symptoms may be related to disordered stress-response mechanisma in the human brain. The professional portfolio presents four clinical case studies that demonstrate the utility of Acceptance and Commitment Therapy (ACT) in the psychotherapeutic treatment of people with chronic illness.

The impact of violent video-games on cognition, affect and personality

This research investigated the impact of playing violent videogames. Aggressive or anxious responses were most likely: when the player perceived the violence in the games to be extreme, when the player experienced a heightened sense of becoming 'absorbed' into the game, and during a relatively brief exposure to the game. The portfolio explores the use of manualised interventions in psychology research and practice. Four illustrative case studies regarding the efficacy and effectiveness of adapting manualised interventions for clients with chronic health conditions are presented.

The interaction of diet, obesity and mood to stress response

Acute stress did not alter sucrose and salt preference. A dietary pattern low in sodium and high in potassium and magnesium improved overall mood. Modest weight loss did not alter the daily secretion of cortisol, but did reduce the blood pressure response to stress which may improve cardiovascular risk.

Supporting bereaved individuals

This research found that grief-related beliefs contained elements of a traditional stereotypic view. Further, a bereaved individual's general way of coping influenced how others expected them to grieve. Finally, aspects of both a bereaved individual and support provider were found to impact the willingness of individuals to offer bereavement-related support.

Child-related information processing in step-parents : investigating the Cinderella effect

This thesis examined the over-representation of step-parents as perpetrators of child physical abuse. Results suggested a number of differences between step- and biological parents in attachment, information-processing, and disciplinary practices. Results were used to formulate a model of step-parental abuse, which has potential implications for the prevention of child physical abuse. The professional portfolio presents four cases from forensic practice in which predictions about further criminal behaviour are made. These cases are then used to discuss several practical questions that may be posed by psychologists who are considering which approach (clinical or actuarial) to use.

Pacing strategy and high-intensity cycling performance

This thesis found that a brief maximal acceleration, followed by a steady effort thereafter is the most effective pacing strategy for intense, short-term cycling performance. This strategy leads to an increase in aerobic energy supply early in exercise, which contributes to a faster speed throughout the race.

The development of young adolescent boys' weight and shape concerns

This thesis' longitudinal study found that young adolescent boys' reported significant concerns with their weight and shape, particularly with respect to having a more muscular but lean physique. The strongest predictors of high body dissatisfaction, among boys, were poor perceptions of their sporting ability and low self-esteem. The portfolio examines the use of Single Session Therapy (SST) suggesting that SST can effectively reduce waiting lists and provide a single and complete intervention that is effective in approximately 50% of cases.

Sociocultural influences on body image

Despite an emphasis on large body sizes in Fiji, Fijian and Australian adolescents' personal body ideals were very similar. Both groups were inaccurate in their body size estimations. Perceived body image ideals of sociocultural agents, rather than their specific messages, were more strongly associated with adolescents' body size estimations and ideals. The professional portfolio specifically explores the role of parents in the development, maintenance, and treatment of children and adolescents' separation anxiety. The four case studies illustrated that the incremental benefits of including parents in CBT treatment were not entirely clear.

How the public perceive stalking

The study demonstrated that the context and frame placed on behaviour are significant in whether the behaviour was perceived as stalking. It was argued that stalking laws that have strict intent requirements are more robust against misuses of the law brought about by differences in individual's perceptions. The portfolio investigated the current assessment and treatment practices of individuals who have been convicted of stalking within Victoria. Four case studies are presented.