Clients with chronic PTSD often face multiple life stressors that lead to impaired general functioning. In addition, individuals with chronic PTSD often have comorbid psychiatric and medical problems (e.g., Davidson, Hughes, Blazer, & George, 1991; Kessler et al., 1995). Therefore, crises during treatment are not unusual, especially if early or multiple traumatic experiences have interfered with the development of healthy coping skills. Poorly modulated affect, self-destructive impulse-control problems (e.g., alcohol binges, substance abuse, risky behaviors), numerous conflicts with family members or others, and severe depression with suicidal ideation are common comorbid conditions with PTSD. These problems require attention but can potentially disrupt the focus on treatment of PTSD. If careful pretreat-ment assessment has determined that chronic PTSD is the client's primary problem, our goal is to maintain the focus on PTSD with periodic reassessment of other problem areas, as needed.
If the client's mood or behavior raises concern about his or her personal safety or the safety of others, the need to focus on this issue and reduce the imminent risk may require temporary cessation of PE. However, if a crisis does not include imminent risk, the therapist should explain to the client that completing the treatment, and thereby decreasing PTSD symptoms and other problems, is likely the best course of action. When appropriate, the therapist may point out the links between the external crisis and the PTSD symptoms and help the patient realize that these situations will improve as the client's ability to manage distress improves and PTSD symptoms decrease. In maintaining the focus of therapy on PTSD symptoms, the therapist should remind the client of the overall goal (i.e., to recover from PTSD), but should not discount the significance of the more immediate crisis. It is also helpful to put the crisis and therapy into chronological perspective. Reminding the client that treatment is brief (9-12 sessions) and determining whether the crisis truly needs to be dealt with prior to the end of treatment (e.g., for safety purposes) can serve to bring the focus back to the goals of treatment. By reaching an agreement at the beginning of the program that crises should be addressed but that the focus of treatment must remain on the PTSD, the therapist will be better able to refocus the client when the need arises.
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