Functional Analytic Clinical Assessment in Trauma Treatment

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William C. Follette Amy E. Naugle

Assessment serves a variety of functions. In Chapter 3 of this volume, Pratt, Brief, and Keane provide a review of assessment procedures for the diagnosis of posttraumatic stress disorder (PTSD) as well as scales for assessing treatment outcome. One purpose of assigning a diagnostic label is its implication that a particular treatment will lead to a useful outcome, when properly applied to the appropriate person. If that useful outcome were always the case, then assessment for the purpose of diagnosis, along with an evaluation of treatment integrity, would be all that were necessary. Although much of this volume addresses how to treat patients who have experienced significant traumatic stressors, there is no treatment that is completely guaranteed to alleviate all of the symptoms a patient might report. This chapter focuses on the application of behavioral principles to assess areas of functioning that might need to be considered as treatment planning and implementation proceeds.

Since the establishment of the diagnosis of PTSD in the DSM-III and subsequent updates (American Psychiatric Association, 1980, 1987, 1994, 2000), a considerable volume of literature has been published that describes clinical problems that may be likely to co-occur with PTSD. At the level of diagnostic labels, PTSD is noted to co-occur with depression, anxiety, phobia, and panic disorders perhaps in part because of symptom overlap in diagnostic criteria (Davidson & Foa, 1991). A variety of other diagnostic labels are also associated with PTSD, including substance abuse and Axis II cluster B disorders, such as borderline personality disorders with impulsivity (Foa, Davidson, Frances, & Anxiety Disorders Association of America, 1999).

Treatment guidelines include cognitive therapy to address unrealistic assumptions, thoughts, and beliefs; anxiety management and stress inoculation techniques, including relaxation training; and imaginal or in vivo expo sure (Foa et al., 1999). The same guideline document describes a variety of adjunct medication treatments for more complex cases (Foa et al., 1999).

The experience of trauma exposure is not rare; however, the trauma responses of avoidance and arousal spontaneously extinguish in the majority of people exposed (Breslau, Davis, Andreski, & Peterson, 1991; Breslau et al., 1998). It has been argued that those who experience PTSD have flatter generalization gradients and do not respond to cues of safety (Foa, steketee, & Rothbaum, 1989; Foa, Zinbarg, & Rothbaum, 1992; Rothbaum & Davis, 2003). Rothbaum and Davis describe the conditions that are likely to produce more or less successful outcomes in response to exposure-based treatments.

PTSD is not a response to a traumatic event that occurs in isolation; other factors might serve to ameliorate, maintain, or exacerbate symptoms and course. The purpose of this chapter is to complement what is known about the treatment of PTSD by calling attention to a more complete analysis of variables that are potentially clinically important to consider when treating PTSD.

For the purposes of this chapter, it is assumed that an evidenced-based intervention treatment for PTSD is already being provided. A primary assumption behind applying an empirically supported treatment for PTSD in a specific case is that a significant proportion of variance in outcome can be accounted for by the mechanism(s) presumed to be affected by the treatment protocol (Haynes, Kaholokula, & Nelson, 1999). The effect size for any particular patient will vary depinding on whether those mechanisms of change targeted by an empirically supported treatment are the same mechanisms as those controlling symptoms in a specific patient. For any specific patient, it is likely that common as well as unique factors will influence the presenting problems and outcomes, and the unique factors could well account for the major portion of outcome variance.

Because PTSD is one of the few diagnostic categories in the DSM for which the etiology of the disorder is specified, one might presume that a very homogeneous set of causal factors is present and therefore that each individual patient will respond predictably to treatment. However, patients with PTSD may report a complex set of symptoms that still qualify for the diagnosis. As mentioned earlier, PTSD has a high rate of comorbidity; this comorbidity makes the causal analysis of a particular patient's problems even more difficult. One goal of this chapter is to describe a method that can identify additional (or even alternative) causal factors that, when properly addressed, produce the largest benefits for patients.

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