As we previously noted, a scientifically grounded conceptualization of patients' problems is the first step to effective CBT for trauma. Historical review of the understanding of posttraumatic reactions illuminates several important opportunities for the future of CBT for trauma. Translational research and continued interface between science and practice will further the conceptualization of traumatic reactions in order to improve CBT of them. In general, developers and practitioners of CBT for trauma, looking toward the future should capitalize on the evidence that the sequelae of trauma are wide-ranging, multidimensional, and multidetermined.
Several factor-analytic studies since DSM-IV was published have raised questions about the nature and processes underlying PTSD (Foa, Riggs, & Gershuny, 1995; King, Leskin, King, & Weathers, 1998). These studies reveal that, contrary to the DSM-IV, there appear to be four, not three, clusters of PTSD symptoms. Symptoms of effortful avoidance and emotional numbing, included together in the DSM-IV, appear to have different properties, functions, and possible etiologies, according to these studies. Moreover, memory loss, a symptom included in the DSM-IV's avoidance/numbing cluster, does not appear to be associated with the overall construct of PTSD or the symptom clusters. Interestingly, the most conclusive of these studies (King et al., 1998) does not support the notion that PTSD is an overarching, unitary disorder comprised of four symptom clusters. Rather, PTSD appears to be best conceptualized as a heterogeneous disorder with correlated, but separate, symptom manifestations. Recent typology efforts also support this heterogeneity in PTSD presentation (Miller, Greif, & Smith, 2003).
Another important classification consideration on the horizon is whether or not acute stress disorder (ASD) and PTSD should be classified as anxiety disorders. Evidence supporting abandonment of the anxiety disorder placement indicates that a myriad of emotions, including guilt, shame, disgust, anger, and sadness, have been implicated in preventing recovery from posttraumatic symptoms (Resick, 2001). Moreover, Pitman (1993) has argued that the pathophysiology of arousal in posttraumatic reaction is not simply anxiety. The International Statistical Classification of Diseases, Injury, and Causes of Death-10th Edition (ICD-10; World Health Organization [WHO], 1992) does not classify PTSD as an anxiety disorder; rather, it is categorized within the spectrum of "reactions to severe stress, and adjustment disorders," with the common denominator of stress-related precipitation. A recent taxometric study also buttresses the dimensional versus categorical system of trauma-related diagnoses (Ruscio, Ruscio, & Keane, 2002).
A spectrum of stress disorders, with specifiers beyond "acute," "chronic," and "delayed onset" currently used for PTSD, could more fully describe the phenomenology of trauma survivors and have important treatment ramifications. Like other major DSM-IV disorder classes (e.g., mood, psychotic), there could be a range of disorders with various symptom con stellations and specifiers. SD as well as the dissociative disorders, could be placed in this class. PTSD specifiers such as "prominent dissociation," "prominent emotional numbing," and "prominent anger" could have important theoretical and treatment implications. Additionally, age-related features and presentations of these stress reactions are important. There may even be room for chronic stress reactions to nontraumatic stressors.
It is important to remember that previous statistical approaches to organizing the core features of posttraumatic reactions are limited by the items that comprise the statistical analyses. The DSM-IV PTSD Work Group restricted criteria to "essential features" for making the PTSD diagnosis. However, this approach risks the danger of missing characteristics that have important clinical and treatment relevance. We suggest that, in addition to moving beyond anxiety-based symptom presentations and to enhance recovery among survivors of traumatic stress, CBT for trauma consider and address other frequently observed serious psychological, emotional, and interpersonal problems. Regardless of the diagnostic scheme used, the epi-demiological and taxometric findings argue for distinct assessment of, and multicomponent treatment for, the multidimensional nature of posttraumat-ic pathology (Flack, Litz, Weathers, & Beaudreau, 2002; Keane & Kaloupek, 2002).
In spite of having several very efficacious CBTs for trauma-related pathology (described in this book), it is important to realize that about 50% of the patients in efficacy studies maintain their trauma-related diagnoses at the end of treatment and at follow-up periods (Zayfert, Becker, & Gillock, 2002). This symptom maintenance may be related, in part, to our current conceptualization of trauma sequelae and to the fact that the current evidence-based treatments, in isolation, address some specific aspects of trauma better than others. For example, some treatment studies reveal that avoidance and numbing symptoms, and especially emotional numbing, may be less responsive to our current CBT treatments (e.g., Glynn et al., 1999; Keane & Kaloupek, 1982). There is also some early evidence that different CBTs may be better at addressing the different emotional disturbances resulting from traumatization (e.g., Resick, Nishith, Weaver, Astin, & Feuer, 2002).
In this vein, efforts to determine predictors of treatment response to CBT for trauma may help address diagnostic dilemmas and ultimately improve treatment planning and outcomes. We recommend that future studies consider predictors beyond those that have been traditionally investigated (e.g., PTSD severity, anger, substance abuse), and develop theoretically driven models that can be tested. Following from our recommendations about broadening the range of trauma symptoms to consider, interpersonal functioning, social support, affective regulation, and self-efficacy might be considered. Biological markers may even be useful to consider in the future, as the psychobiological findings become more robust and are shown to correspond with CBT treatment response.
In the last decade the field of CBT for trauma has seen a series of head-to-head trials designed to determine the treatment "winner." These trials have resulted in many more "ties" than declared winners. We anticipate that the next generation of dismantling, combination therapy, and effectiveness studies will reveal very intriguing findings about the key ingredients of efficacious treatment as well as the limits and challenges to using these treatments in clinical settings. Given that many patients simultaneously receive two or more treatments in clinical practice (e.g., Rosen et al., 2004), studies that determine how best to time or integrate treatments for greater efficacy will be valuable. The possibility for psychophar-macological treatments to potentiate or possibly interfere with CBT for trauma should also be investigated. Like others (Foa, Rothbaum, & Furr, 2003), we call for more combination studies aimed at addressing nonre-sponse or partial response to treatment, in lieu of the rates of non- and partial response found in previous studies.
An additional factor to investigate with regard to treatment timing and sequencing relates to the co-occurring diagnoses often given to traumatized individuals. Determining the best sequence or combination of treatments to treat these disorders is very important for the future of CBT for trauma. As an example, many prior PTSD treatment studies have excluded patients with comorbid substance dependence, suggesting that these issues should be addressed prior to a course of CBT for PTSD. There have been a few developing efforts to provide serial or integrative trauma and substance abuse treatment (Coffey, Dansky, & Brady, 2003; Najavits, 2002). Depression, personality disorders, anger problems, self-harming behavior, and relationship dysfunction are other frequently co-occurring diagnoses or clinical issues to address. Researchers have designed several treatments to specifically address these problems in tandem with PTSD treatment (Chemtob, Novaco, Hama-da, & Gross, 1997; Cloitre, Koenen, Cohen, & Han, 2002; Monson, Schnurr, Stevens, & Guthrie, 2004). However, other researchers have argued that the existing CBTs for PTSD should be undertaken first, because effective treatment for PTSD can remedy many of these co-occurring issues (e.g., Cahill, Rauch, Hembree, & Foa, 2003). These are questions in need of further empirical investigation.
The cognitive-behavioral framework has an important role in informing prevention and early-intervention efforts. Because this area has been wrought with controversy, leading with a strong theoretical grounding for these interventions will be crucial. In addition, the caricature of CBT is that it is a mechanical and technical venture devoid of any humanity. A solid therapeutic relationship is essential to all forms of psychotherapy. Treatment process studies that pinpoint specific dimensions of the therapeutic relationship that are detrimental or facilitative of trauma recovery are essential (Cloitre, Stovall-McClough, Miranda, & Chemtob, 2004).
There are a number of intriguing questions to be answered with regard to the effectiveness, versus efficacy, of CBT for trauma. Most of the outcome studies to date have been undertaken in outpatient research clinics. Ongoing efforts to transport these best practices into clinical settings, and likewise, to use the clinical experiences to inform research, will be invaluable.
Although several CBTs for trauma, with solid evidence bases, are available there remains a need for innovative treatments that can help the significant number of patients who do not respond to our current treatments. Understanding of the nature and treatment of trauma is a continuously evolving process. We have come a long way in conceptualizing the aftereffects of trauma and in developing elegant, theoretically driven CBTs that work. We look forward to the advancements that will be made in the next generation of CBT for trauma.
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