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Book Review |
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Book Review |
Reviewed by: Kevin R. Ronan
Department of Psychology
Massey University
Palmerston North
New Zealand
The amount of empirically-based attention directed towards Post-Traumatic Stress Disorder (PTSD) since its
inception in DSM in 1980 has been extensive. The book Treating Post-Traumatic Stress Disorder: A
Handbook and Practice Therapy Manual for Therapy written by Donald Meichenbaum (1997) puts together
much of that information and presents it in this compilation of training-based handouts. Given this handout
material, Meichenbaum makes it clear from early on that the handbook/manual has been put together as a
practically-based guide for helping those mental health professionals working in this area, both those in
inpatient and outpatient settings. All 600 pages of this comprehensive guide are based on the author's
extensive clinical and research experience of over 30 years. Consequently, and for those many of us who
are already familiar with the quality of Meichenbaum's work and the name he has established for himself in
the field of clinical psychology, this pragmatic volume is borne out of the scholarly scientist-practitioner
tradition. That is, it is based on empirically-based approaches towards diagnosis, assessment and treatment
that is combined with clinical wisdom and will no doubt serve as an oft-used resource by many professionals
working in real-world settings. One of the "current concerns" in our field is that of "bridging the gap"
between research and clinical settings (Ronan, 1996). This manual is a largely successful attempt in
compiling a vast amount of information that can be accessed quickly and in one location by practitioners
who are often burdened by many day-to-day pressures that preclude the time necessary to compile such
information in a more singular manner.
Owing to the fact that the book is largely an attempt at organizing numerous handouts, it is important for the
reader to read the Prologue/Introduction to get oriented. Some effort has gone into organizing these
handouts in a manner that has a logical flow. As a consequence, the book contains eight "sections" as they
are referred to that focus on epidemiology/diagnosis, a narrative conceptualization of PTSD, and assessment
followed by general and specific treatment procedures and finishing with some additional
information/resources. Each section also finishes with a section called "Testing Your Expertise" designed to
help consolidate learning from that section.
The first section discusses a number of issues related to epidemiology and diagnosis by first looking at
traumatic events (definitions, incidence, impact) folllowed by an historical overview of the concept of PTSD
and information related to diagnosis (definitions, comorbidity, specific populations). The section finishes
with what is a real highlight of this section - a critical look at "stage" theories related to coping with trauma
or loss. For those of us who have worked in practice settings, how many times have we seen less than
empirically-based assessment or treatment strategies as a normal part of the standard of care? In the area of
coping with emotional reactions to traumatic events, a common misconception held by some practitioners is
that we are all universally subject to a series of stages of emotional reactions to a traumatic event,
particularly that associated with a loss or with grieving (as well as other trauma-related processes) (Wortman
& Silver, 1989). As the guidebook points out, such a stage model is not applicable to all persons and,
importantly, that if we as clinicians inappropriately attempt to apply such a model to a traumatized
individual, we actually run the risk of exacerbating rather than helping the problem (e.g., Wortman & Silver,
1989). This section is a fine demonstration of how intervention not based on an empirically-based approach
can run the risk of not only not helping, but in some cases may actually create further problems or stress for
clients.
The second section offers a narrative perspective on PTSD from a constructivist epistemological perspective.
This section is brief but can be valuable when used within an empirically-based treatment approach. One
area of particular value that the handbook goes into some detail on is the use of metaphor as part of
cognitive reframing that can give some meaning to events that are sometimes hard to understand. In our
own work with anxiety-disordered children and adolescents, we have found that children benefit by being
able to call upon their own "Fear Force" or other superhero when coping with emotional reactions to fearful
(or related) stimuli including traumatic events (e.g., Kendall et al., 1992; Ronan & Deane, 1997). A strength
of this section is in providing lists of examples to describe various emotional states (e.g, metaphors for
hypersensitivity, psychic numbing, intrusive ideation, loss) as well as a long list of "healing" metaphors.
The third section focuses on assessment: general strategies, the special role of the clinical interview, a
review of various specific assessment measures, an emphasis on assessment of both positive (e.g., coping
resources) and negative aspects of an event, and the value of a collaborative approach in helping clients
engage in self-monitoring. This section emphasizes the need for empirically-based strategies within a
multimethod-multitrait approach but also allows for victims and families to be able to tell their "stories."
This section is strong in a number of areas including Meichenbaum recommending two sequential
approaches to assessment. One is more comprehensive when time permits, the second is more pragmatically
based. Multiple gating is recommended that initially uses a more screening-based approach to identify those
who should be followed up with more extensive evaluation. As a child clinical psychologist, I would have
liked a little more emphasis on childhood assessment measures as the section that covers it is quite brief but,
overall, the chapter will undoubtedly prove to be an invaluable resource for practitioners.
The fourth section details potential problems in assessment focusing mainly on the issue of traumatic
memories. The subsections dealing with this issue focus on the background and current research evidence
that provides a basis for the next subsection dealing with factors that clinicians can use to determine the
"authenticity" of a client's recollections. The final subsection on this topic focuses on how therapists and
clients can handle the issue of autobiographical memories of abuse (or other traumatic events). This
discussion is elegant for its use of research, integrating all of the complex issues, and for its clear thinking
in, for example, answering the question "what is our role" as therapists? Given my role as a graduate level
instructor for budding clinicians, I will be using this section to help my own students develop their clear
thinking skills. The section finishes with some words on "helping the helpers" and is a useful guide in
helping clinicians spot stress reactions et al. in themselves and their colleagues and how to go about coping
with them.
The fifth and sixth sections are devoted to treatment. The fifth focuses on a critical analysis of various
alternative treatment approaches; the sixth, on practical guidelines for specific procedures. These two
sections simply have a wealth of comprehensive information that practitioners can draw on when planning
and individualizing their own interventions. Section Five looks at the vast array of psychological and
pharmocological approaches--many without empirical support--that have been used for clients with PTSD
symptomatology and suggests that the treatment outcome literature in this area is still in its infancy.
However, the section does highlight those approaches that do have empirical support (e.g., exposure-based
approaches, some group-based approaches). This section also introduces some general treatment guidelines
and considerations to take into account when individualizing treatment (e.g., nature and length of treatment
considerations). A checklist is provided to help guide the practitioner determine treatment length. The sixth
section is a highlight of the book and includes specific components of an overall strategy to "follow a
constructive narrative perspective, whereby the goal is to help clients to achieve their collaboratively
generated treatment goals, achieve symptom relief and change the 'stories' they tell themselves and others
about their traumatic events" (p. 348). The specific components of such an overall strategy are delineated in
this section and include strategies aimed at education and normalizing about PTSD and recovery, specific
guidelines on dealing with major symptoms (e.g., flashbacks, intrusive ideation), dealing with comorbid
symptoms (e.g., anger, substance abuse) and difficult clients, the use of cognitive procedures to help clients
reduce distorted self-talk, increase problem-solving, "rescript" the clients story, and the use of family-based
intervention. The strength of this section is in its focus on providing "how to" procedural detail in these
areas. Some examples include specifics on exposure-based techniques, stress inoculation training, cognitive
restructuring, and relapse prevention.
The seventh and final text-based section deals specifically with post-disaster interventions by focusing first
on the research literature followed by issues related to assessment and treatment. Issues include an
examination of vulnerability factors, guidelines on providing post-disaster interventions, issues related critical
incident stress debriefing including procedural details, as well as a number of other topics that include
alternative modes of treatment (e.g., peer-based, outreach), the role of religion and ritual in healing, and
working with children (see also Long, Ronan, & Perreira-Laird, 1997; Ronan & Johnston, 1997), in military
settings, in workplaces.
The book finishes with a brief critique on the future of clinical training and an Information/Reference section
that is intended to provide resources on where to get more information (e.g., organizations, books, and
research-based literature), videotaped materials, and a couple of inspirational poems written by former
clients.
Overall, this guidebook will prove to be an excellent resource for practitioners. One explicit goal of the
handook is to help increase the expertise of practicing professionals and, at a minimum, not apply
interventions that revictimize clients based on an ignorance of the research-based literature. In this way, the
goal was met in a rather resounding way. Though some additional attention might have been paid to
organization of the text, it is stated at the outset that the book represents a compilation of training-based
handouts. From my reading, this organizational issue became more and more unimportant as it became
abundantly clear that this book stays firmly within a scientist-practitioner model and provides an absolutely
comprehensive amount of information on those issues that need addressing by professionals working with
those clients impacted by PTSD. I would add that various portions of this book can be used by university
instructors in preparing materials for graduate level courses on psychotherapy with this population.
Long, N. R., Ronan, K. R., & Perreira-Laird, J. (1997). Victims of disaster. In N. N. Singh (Ed.),
Comprehensive clinical psychology: Applications in diverse populations. New York: Pergamon Press: in
press.
Meichenbaum, D. (1997). Treating post-traumatic stress disorder: A handbook and practice manual for
therapy . John Wiley: Brisbane.
Ronan, K. R. (1996). Bridging the gap in childhood anxiety assessment: A practitioner's resource guide.
Cognitive and Behavioral Practice, 3, 63-90.
Ronan, K. R. & Deane, F. P. (1997). Anxiety disorders. In P. Graham (Ed.). Cognitive behaviour therapy
for children and families: Cambridge monograph series in child and adolescent psychiatry. Cambridge:
Cambridge University Press: in press.
Ronan, K. R. & Johnston, D. M. (1997). The effects of a school-based cognitive-behavioral early
intervention on PTSD symptoms, anxiety, and coping following a series of volcanic eruptions. Manuscript
submitted for publication.
Wortman, C. B., & Silver, R. C. (1989). The myths of coping with loss. Journal of Consulting and Clinical Psychology, 57, 349-357.
