Who's Treating PTSD?

Furthermore, when subthreshold or subclinical variations of PTSD are considered – for example, the loss of business, home, and sense of identity that prevailed in disasters such as the Gulf oil spill – the loss of a person’s identity could symbolically be equated to a severe threat to one’s very existence (Clinical Psychiatry News, July 2010, p. 10).

I have diagnosed and treated PTSD with good success for more than 30 years using a combination of hypnotic/relaxation techniques plus exposure-based, in vitro guided imagery treatments using reciprocal inhibition and systematic desensitization coupled to cognitive restructuring, and I believe that these are very effective treatments.

The way I approach the PTSD patient is to determine the event or events that caused the disorder. I aim to a get a full picture of who the patient is, including some past life experiences and future goals. Afterward, I explain my proposed treatment plan, which typically uses a hypnotic/relaxation technique that I will teach and a subsequent behavioral modification program using guided imagery coupled to reciprocal inhibition and systematic desensitization employed in an in vitro exposure/desensitization process.

I do this in the first 1.5-hour visit, also teaching the hypnotic/relaxation technique and making certain that the patient is competent at doing this on his or her own. I still prefer the using the Hypnotic Induction Profile Technique as described in Dr. Herbert Spiegel’s and Dr. David Spiegel’s "Trance and Treatment: Clinical Use of Hypnosis" (Arlington, Va.: American Psychiatric Publishing Inc., 2004). This resource is extremely teachable, focused, and well codified to a learning format. After this introduction to the process, I get the patient to develop a hierarchy of events leading up to the trauma that I will later use in the desensitization process. Symptom relief and a return to a regular level of functioning are the main goals.

Treating PTSD takes a substantial amount of time and energy. Specialized treatments for PTSD exist, and therapists embarking on PTSD treatments should proceed only if they are willing to learn these techniques, as I see it. If additional therapy is needed after symptom resolution, a continued CBT or a dynamic approach is useful. However, it’s important to keep in mind that after the PTSD is treated, the clinician might need to focus on issues beyond the original need for care. It’s only fair and proper to make this clear to the patient.

Specific, focused treatments that have shown the best results to date must be seen as the first line of care before less efficacious treatments are tried. Therefore, when we report that a person with PTSD is now in counseling or psychotherapy, the question should be: What kind of therapy?

Let me know your thoughts on this very important topic.

Dr. London writes the column "The Psychiatrist’s Notebook," which regularly appears in Clinical Psychiatry News, an Elsevier publication. He is a psychiatrist with New York University Langone Medical Center. E-mail him.