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Book Review
Treating post-traumatic stress disorder:
A handbook and practice manual for therapy

The Australasian Journal of Disaster
and Trauma Studies
Volume : 1997-3


Review of:

Treating post-traumatic stress disorder:
A handbook and practice manual for therapy

by : Donald Meichenbaum.
(1997) John Wiley: Brisbane.


Reviewed by: Kevin R. Ronan
Department of Psychology
Massey University
Palmerston North
New Zealand


Reducing stress in working with PTSD clients: The value of a practitioner's guidebook.

The amount of empirically-based attention directed towards Post-Traumatic Stress Disorder (PTSD) since its inception in DSM in 1980 has been extensive. The book Treating Post-Traumatic Stress Disorder: A Handbook and Practice Therapy Manual for Therapy written by Donald Meichenbaum (1997) puts together much of that information and presents it in this compilation of training-based handouts. Given this handout material, Meichenbaum makes it clear from early on that the handbook/manual has been put together as a practically-based guide for helping those mental health professionals working in this area, both those in inpatient and outpatient settings. All 600 pages of this comprehensive guide are based on the author's extensive clinical and research experience of over 30 years. Consequently, and for those many of us who are already familiar with the quality of Meichenbaum's work and the name he has established for himself in the field of clinical psychology, this pragmatic volume is borne out of the scholarly scientist-practitioner tradition. That is, it is based on empirically-based approaches towards diagnosis, assessment and treatment that is combined with clinical wisdom and will no doubt serve as an oft-used resource by many professionals working in real-world settings. One of the "current concerns" in our field is that of "bridging the gap" between research and clinical settings (Ronan, 1996). This manual is a largely successful attempt in compiling a vast amount of information that can be accessed quickly and in one location by practitioners who are often burdened by many day-to-day pressures that preclude the time necessary to compile such information in a more singular manner.

Owing to the fact that the book is largely an attempt at organizing numerous handouts, it is important for the reader to read the Prologue/Introduction to get oriented. Some effort has gone into organizing these handouts in a manner that has a logical flow. As a consequence, the book contains eight "sections" as they are referred to that focus on epidemiology/diagnosis, a narrative conceptualization of PTSD, and assessment followed by general and specific treatment procedures and finishing with some additional information/resources. Each section also finishes with a section called "Testing Your Expertise" designed to help consolidate learning from that section.

The first section discusses a number of issues related to epidemiology and diagnosis by first looking at traumatic events (definitions, incidence, impact) folllowed by an historical overview of the concept of PTSD and information related to diagnosis (definitions, comorbidity, specific populations). The section finishes with what is a real highlight of this section - a critical look at "stage" theories related to coping with trauma or loss. For those of us who have worked in practice settings, how many times have we seen less than empirically-based assessment or treatment strategies as a normal part of the standard of care? In the area of coping with emotional reactions to traumatic events, a common misconception held by some practitioners is that we are all universally subject to a series of stages of emotional reactions to a traumatic event, particularly that associated with a loss or with grieving (as well as other trauma-related processes) (Wortman & Silver, 1989). As the guidebook points out, such a stage model is not applicable to all persons and, importantly, that if we as clinicians inappropriately attempt to apply such a model to a traumatized individual, we actually run the risk of exacerbating rather than helping the problem (e.g., Wortman & Silver, 1989). This section is a fine demonstration of how intervention not based on an empirically-based approach can run the risk of not only not helping, but in some cases may actually create further problems or stress for clients.

The second section offers a narrative perspective on PTSD from a constructivist epistemological perspective. This section is brief but can be valuable when used within an empirically-based treatment approach. One area of particular value that the handbook goes into some detail on is the use of metaphor as part of cognitive reframing that can give some meaning to events that are sometimes hard to understand. In our own work with anxiety-disordered children and adolescents, we have found that children benefit by being able to call upon their own "Fear Force" or other superhero when coping with emotional reactions to fearful (or related) stimuli including traumatic events (e.g., Kendall et al., 1992; Ronan & Deane, 1997). A strength of this section is in providing lists of examples to describe various emotional states (e.g, metaphors for hypersensitivity, psychic numbing, intrusive ideation, loss) as well as a long list of "healing" metaphors.

The third section focuses on assessment: general strategies, the special role of the clinical interview, a review of various specific assessment measures, an emphasis on assessment of both positive (e.g., coping resources) and negative aspects of an event, and the value of a collaborative approach in helping clients engage in self-monitoring. This section emphasizes the need for empirically-based strategies within a multimethod-multitrait approach but also allows for victims and families to be able to tell their "stories." This section is strong in a number of areas including Meichenbaum recommending two sequential approaches to assessment. One is more comprehensive when time permits, the second is more pragmatically based. Multiple gating is recommended that initially uses a more screening-based approach to identify those who should be followed up with more extensive evaluation. As a child clinical psychologist, I would have liked a little more emphasis on childhood assessment measures as the section that covers it is quite brief but, overall, the chapter will undoubtedly prove to be an invaluable resource for practitioners.

The fourth section details potential problems in assessment focusing mainly on the issue of traumatic memories. The subsections dealing with this issue focus on the background and current research evidence that provides a basis for the next subsection dealing with factors that clinicians can use to determine the "authenticity" of a client's recollections. The final subsection on this topic focuses on how therapists and clients can handle the issue of autobiographical memories of abuse (or other traumatic events). This discussion is elegant for its use of research, integrating all of the complex issues, and for its clear thinking in, for example, answering the question "what is our role" as therapists? Given my role as a graduate level instructor for budding clinicians, I will be using this section to help my own students develop their clear thinking skills. The section finishes with some words on "helping the helpers" and is a useful guide in helping clinicians spot stress reactions et al. in themselves and their colleagues and how to go about coping with them.

The fifth and sixth sections are devoted to treatment. The fifth focuses on a critical analysis of various alternative treatment approaches; the sixth, on practical guidelines for specific procedures. These two sections simply have a wealth of comprehensive information that practitioners can draw on when planning and individualizing their own interventions. Section Five looks at the vast array of psychological and pharmocological approaches--many without empirical support--that have been used for clients with PTSD symptomatology and suggests that the treatment outcome literature in this area is still in its infancy. However, the section does highlight those approaches that do have empirical support (e.g., exposure-based approaches, some group-based approaches). This section also introduces some general treatment guidelines and considerations to take into account when individualizing treatment (e.g., nature and length of treatment considerations). A checklist is provided to help guide the practitioner determine treatment length. The sixth section is a highlight of the book and includes specific components of an overall strategy to "follow a constructive narrative perspective, whereby the goal is to help clients to achieve their collaboratively generated treatment goals, achieve symptom relief and change the 'stories' they tell themselves and others about their traumatic events" (p. 348). The specific components of such an overall strategy are delineated in this section and include strategies aimed at education and normalizing about PTSD and recovery, specific guidelines on dealing with major symptoms (e.g., flashbacks, intrusive ideation), dealing with comorbid symptoms (e.g., anger, substance abuse) and difficult clients, the use of cognitive procedures to help clients reduce distorted self-talk, increase problem-solving, "rescript" the clients story, and the use of family-based intervention. The strength of this section is in its focus on providing "how to" procedural detail in these areas. Some examples include specifics on exposure-based techniques, stress inoculation training, cognitive restructuring, and relapse prevention.

The seventh and final text-based section deals specifically with post-disaster interventions by focusing first on the research literature followed by issues related to assessment and treatment. Issues include an examination of vulnerability factors, guidelines on providing post-disaster interventions, issues related critical incident stress debriefing including procedural details, as well as a number of other topics that include alternative modes of treatment (e.g., peer-based, outreach), the role of religion and ritual in healing, and working with children (see also Long, Ronan, & Perreira-Laird, 1997; Ronan & Johnston, 1997), in military settings, in workplaces.

The book finishes with a brief critique on the future of clinical training and an Information/Reference section that is intended to provide resources on where to get more information (e.g., organizations, books, and research-based literature), videotaped materials, and a couple of inspirational poems written by former clients.

Overall, this guidebook will prove to be an excellent resource for practitioners. One explicit goal of the handook is to help increase the expertise of practicing professionals and, at a minimum, not apply interventions that revictimize clients based on an ignorance of the research-based literature. In this way, the goal was met in a rather resounding way. Though some additional attention might have been paid to organization of the text, it is stated at the outset that the book represents a compilation of training-based handouts. From my reading, this organizational issue became more and more unimportant as it became abundantly clear that this book stays firmly within a scientist-practitioner model and provides an absolutely comprehensive amount of information on those issues that need addressing by professionals working with those clients impacted by PTSD. I would add that various portions of this book can be used by university instructors in preparing materials for graduate level courses on psychotherapy with this population.


References

Kendall, P. C., Chansky, P. E., Kane, M., Kim, R, Ronan, K. R., Sessa, F., & Siqueland, L. (1992). Anxiety disorders in youth: Cognitive behavioral interventions. Needham, MA: Allyn & Bacon.

Long, N. R., Ronan, K. R., & Perreira-Laird, J. (1997). Victims of disaster. In N. N. Singh (Ed.), Comprehensive clinical psychology: Applications in diverse populations. New York: Pergamon Press: in press.

Meichenbaum, D. (1997). Treating post-traumatic stress disorder: A handbook and practice manual for therapy . John Wiley: Brisbane.
    
Ronan, K. R. (1996). Bridging the gap in childhood anxiety assessment: A practitioner's resource guide. Cognitive and Behavioral Practice, 3, 63-90.

Ronan, K. R. & Deane, F. P. (1997). Anxiety disorders. In P. Graham (Ed.). Cognitive behaviour therapy for children and families: Cambridge monograph series in child and adolescent psychiatry. Cambridge: Cambridge University Press: in press.

Ronan, K. R. & Johnston, D. M. (1997). The effects of a school-based cognitive-behavioral early intervention on PTSD symptoms, anxiety, and coping following a series of volcanic eruptions. Manuscript submitted for publication.

Wortman, C. B., & Silver, R. C. (1989). The myths of coping with loss. Journal of Consulting and Clinical Psychology, 57, 349-357.


Copyright

Kevin Ronan © 1997. The author assign to the Australasian Journal of Disaster and Trauma Studies at Massey University a non-exclusive licence to use this document for personal use and in courses of instruction provided that the article is used in full and this copyright statement is reproduced. The authors also grant a non-exclusive licence to Massey University to publish this document in full on the World Wide Web and for the document to be published on mirrors on the World Wide Web. Any other usage is prohibited without the express permission of the author.


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