Child Abuse: Effects of dissociation on treatment for PTSD
Jan 19, 2013
An important recent study by Marylene Cloitre and colleagues [LINK] has thrown light on three imporant questions:
- How successful is Narrative Therapy (also called Narrative Story Telling NST) in dealing with the effects of childhood-trauma related PostTraumatic Stress Disorder (PTSD)? In New Zealand, the usual "Treatment As Usual", apart from anti-depressants (and see my post with links to the Who Cares videos) is, at best, often a form of NST, which can be considered a modified form of "exposure therapy", where therapist and client establish a therapeutic relationship by means of "supportive counselling" (SC). Then, the client recounts details of the trauma they experienced, "de-sensitising", dealing with dysfunctional avoidance coping behaviors; progressing on to where therapist and client identify and appraise interpersonal schemas, which are then "re-processed", and the results integrated into a re-formulated "lifes story" more supportive of effective living.
- What is the impact of dissociation on course and outcome of treatment for such PTSD?
- What are the requisite components for such treatment?
The Cloitre et al study explored whether a sequenced two-component treatment in which an emotion regulation skills training module preceding exposure would improve outcomes for those with significant dissociation, a less common response to trauma that can have profoundly disabling effects on interpersonal relationships. In the study, analyses were conducted on data from a randomised clinical trial in which 104 women with PTSD related to childhood abuse were assigned to one of three treatment conditions: Skills Training in Affective and Interpersonal Regulation (STAIR) followed by Narrative Story Telling (NST; STAIR/NST), STAIR followed by supportive counseling (SC; STAIR/SC), or SC followed by NST (SC/NST).
- Baseline dissociation was associated with differential outcome such that at low levels of dissociation the three treatments were equally effective but at higher levels STAIR/NST resulted in greater reductions in dissociative symptoms.
- Level of baseline dissociation did not moderate the effect of the treatments on PTSD outcome. At all levels of baseline dissociation, STAIR/NST produced better PTSD outcome.
- At posttreatment, however, participants with high dissociation treated with STAIR/NST continued to improve during follow-up, those treated with STAIR/SC maintained gains, and those treated with SC/NST experienced LOSS of posttreatment PTSD symptom improvements.
The authors conclude that the differential results observed among the treatments depending on severity of dissociation at baseline and at posttreatment suggest the potential clinical utility of identifying a dissociative subtype of PTSD and of the benefits of sequenced, phase-oriented treatment approaches.
Clearly the oft-cited positive outcomes reported in New Zealand for NST should not be overstated -- people benefit in the short term only.
However, the "optimal" treatment consists of a phase-oriented approach incorporating not only "Supportive Counselling" (which should be an element of any therapist-cllient relationship) but skills training in affective and interpersonal self-regulation; followed by explication of interpersonal schemes, and behaviorally specific formulation of post-recovery lifestyle planning -- this is essentially the approach I've outlined on my website page on "essentials of effective trauma treatment".