Cognitivebehavioral Interventions

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Cognitive-behavioral interventions are rooted in learning theories, especially classical conditioning and operant avoidance. Early studies focused exclusively on fear and anxiety reactions. The first treatment approach to be proposed for treating trauma-related symptoms was Stress Inoculation Training (SIT) [47]. The main goal of SIT is to help the patients to understand and manage their trauma-related fear reactions and, as a result, decrease avoidance behavior.

SIT can be conducted in either group or individual format and the classic protocol consists of three steps: education, skills-building and application. During the education phase, the patients receive an explanation for their symptoms and are taught to identify their different "channels" of response (emotions, behaviors, thoughts and sensorimotor level). During the second step, the patients are taught coping skills for each of the channels. Coping skills include relaxing, relaxing imagery, recognition of ''stress deposit'' areas in the body, identification of cues that trigger fear reactions, thought stopping, redirection of thinking, covert rehearsal, etc. During the third step (application), the patient learns how to apply these coping skills in daily situations that provoke anxiety.

Exposure techniques have also been applied to persons suffering from post-traumatic disorders. They use careful, repeated, detailed imagining of the trauma (exposure) in a safe, controlled context to help the survivor face and gain control of the anxiety, fear and distress that was overwhelming during the disrupting event. In some cases memories or reminders can be confronted all at once (''flooding''). For other individuals, it is preferable to work up to the most severe symptoms gradually by using relaxation techniques and by starting with less upsetting life stresses, or by taking the trauma one piece at a time (''desensitization'').

Systematic desensitization involves the pairing of relaxation with either stimuli reminiscent of the traumatic event (''in vivo'' desensitization) or images of the disrupting event (imaginal desensitization). In vivo exposure to traumatic cues would include a return to the scene of a disruptive event and a gradual approach to the cues that are most evocative of the emotions associated with the event together with the practice of cued relaxation responses such as deep breathing and relaxing imagery. Previously, a graduated hierarchy of anxiety-inducing cues is built by the therapist together with the patient and this enables the therapist to control the extent to which the patient is successfully coping with the anxiety and thus determine whether the patient is ready to face the next step in the hierarchy.

Following the same fundamental principles used in ''in vivo'' desensi-tization, imaginal desensitization uses memories, images or other cognitive representations of the disruptive event. The patient is trained in using relaxation skills, and is then confronted with fear cues in imagination, along a graded hierarchy, while in a relaxed state. During each session the exposures are brief, repetitive and focused on one fear cue alone. There is input and feedback from the patient along the sessions, which allows him/ her to develop a sense of control in the process.

In the flooding technique, the patient undergoes an extended exposure to moderate or strong fear-producing cues in the safety of the therapeutic relationship. The fear sequences are repeated as many times as necessary until the event or cues progressively become less aversive.

Along with exposure, cognitive behavioral interventions for trauma include: (a) learning skills for coping with anxiety (such as breathing retraining or biofeedback) and negative thoughts (''cognitive restructuring'');

(b) managing anger; (c) preparing for stress reactions (''stress inoculation''); (d) handling future symptoms related to disruptive events; (e) addressing urges to use alcohol or drugs when trauma symptoms occur; (f) communicating and relating effectively with people (social skills or marital therapy).

A large number of studies have examined the effectiveness of cognitive-behavioral interventions in preventing or treating PTSD or ASD.

Foa et al. [48] reported on the preliminary findings of a therapeutic intervention intended to prevent the development of PTSD in female rape and assault victims. The intervention consisted of four 2-hour sessions. During the first meeting, the therapist introduced the program and gathered information about the subject's symptoms and distorted beliefs related to the disruptive experience they suffered. Also, a list of avoided people and/or situations was generated. In the second session, this list was organized into a hierarchy based on the level of anxiety each item produced. The person was trained in relaxation and deep breathing and then asked to recall the experience (imaginal exposure). The therapist led the person to examine the accuracy of his/her beliefs through oriented questions (cognitive restructuring). This dialogue was audiotaped and the person was instructed to listen to it several times during the week. Also he/she was encouraged to confront daily some of the anxiety-releasing detected situations. The third meeting began with a review of the ''homework'' followed by a new session of imaginal exposure and cognitive restructuring. Again, the person was instructed to listen to the audiotape every day, to confront feared situations, to update a daily diary to record cognitive distortions and negative feelings and thoughts. During the fourth session, imaginal exposure was repeated, followed by cognitive restructuring using the daily diary records. Finally, both the therapist and the person reviewed the new skills the person had obtained. The results were very positive: 2 months after the trauma, 10% of the group of persons who received the program met criteria for PTSD, compared to 70% of the control group.

Bryant et al. [49], treating motor vehicle and industrial accident victims who met criteria for ASD, compared five sessions of non-directive supportive counseling (providing support and education and teaching problem solving skills) with brief cognitive-behavioral treatment (trauma education, progressive muscle relaxation, imaginal exposure, cognitive restructuring, and graded in vivo exposure to avoided situations). At the conclusion of treatment, 8% of the participants in the cognitive-behavioral treatment group and 83% of those in the supportive counseling group met criteria for PTSD. Six months after the trauma, these criteria were met by 17% in the former group and 67% in the latter. There was also a significant reduction in depressive symptoms in the former group compared to the latter.

The magnitude of treatment effects appears greater with cognitive-behavioral interventions than with any other treatment. The questions for the clinician, then, are with what patients is exposure therapy most effective, for what kind of symptoms and at what time. When utilized within a comprehensive treatment program that addresses the psychological, social and physiological elements of the disorder, exposure therapies offer innovative methods to deal with this type of human suffering. The creativity and flexibility of the therapist are essential when focusing on the key symptoms of the affected persons in order to promote the optimal exposure.

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