Effective online therapy and skype consultation. “Effective therapy for post-traumatic stress disorder” Edna B

How does psychotherapy help, through what mechanisms does the psychotherapist achieve the desired changes in the patient’s thinking and behavior? Several factors are described in the literature therapeutic effect, called differently by different authors. We will consider a combined classification compiled on the basis of those described by R.Corsini and B.Rosenberg (1964), I.Yalom (1970), S.Kratochvil (1978). Some of the factors under consideration are characteristic of both individual and group psychotherapy, others - only for group psychotherapy.

1. VERSATILITY. Other designations for this mechanism - “sense of community” and “participation in a group” - indicate that this factor is observed in group psychotherapy and is absent in individual psychotherapy.

Universality means that the patient’s problems are universal, to one degree or another they manifest themselves in all people, the patient is not alone in his suffering.

2. ACCEPTANCE (ACCEPTATION). S. Kratochvil calls this factor “emotional support”. This last term has become entrenched in our psychotherapy.

With emotional support great importance has the creation of a climate of psychological safety. Unconditional acceptance of the patient, along with the therapist's empathy and congruence, is one of the components of the positive relationship that the therapist strives to build. This "Roger triad", which has already been mentioned, has great value in individual therapy and no less in group therapy. In its simplest form, emotional support for an individual occurs when the therapist (in individual therapy) or group members (in group psychotherapy) listen to him and try to understand him. Next comes acceptance and compassion. If the patient is a member of the group, then he is accepted without regard to his situation, his disorders, his characteristics of behavior and his past. He is accepted as he is, with his own thoughts and feelings. The group allows him to be different from other members of the group, from the norms of society, no one condemns him.

To a certain extent, the mechanism of “emotional support” corresponds to the factor of “cohesion” according to I. Yalom (1975). “Cohesion” can be considered as a mechanism of group psychotherapy, identical to “emotional support” as a mechanism of individual psychotherapy. Indeed, only a cohesive group can provide a group member with emotional support and create conditions of psychological safety for him.

Another mechanism close to emotional support is “instilling hope” (I. Yalom, 1975). The patient hears from other patients that they feel better, he sees the changes that are happening to them, this gives him hope that he too can change.

3. ALTRUISM. Positive therapeutic effect can be provided not only by the fact that the patient receives support and is helped by others, but also by the fact that he himself helps others, sympathizes with them, and discusses their problems with them. A patient who comes to the group demoralized, unsure of himself, with the feeling that he himself cannot offer anything in return, suddenly begins, in the process of group work, to feel necessary and useful to others. This factor - altruism - helps to overcome the painful focus on oneself, increases the feeling of belonging to others, a sense of confidence and adequate self-esteem.

This mechanism is specific to group psychotherapy. It is absent in individual psychotherapy, because there the patient is exclusively in the position of a person being helped. In group therapy, all patients play psychotherapeutic roles in relation to other group members.

4. RESPONSE (CATHARISS). Strong expression of affect is important integral part psychotherapeutic process. However, it is believed that response in itself does not lead to any changes, but creates a certain basis or prerequisites for change. This mechanism is universal - it works in both individual and group psychotherapy. Emotional response brings significant relief to patients and is supported in every possible way by both the psychotherapist and members of the psychotherapeutic group.

According to I. Yalom, responding to sadness, traumatic experiences and expressing strong, important emotions for the individual stimulates the development of group cohesion. Emotional response is reinforced by special techniques in psychodrama in “meeting groups” (“encounter groups”). In "meeting groups" anger and its response are often stimulated by strong blows on a pillow symbolizing the enemy.

5. SELF-DISCOVERY (SELF-EXPLORATION). This mechanism in to a greater extent present in group psychotherapy. Group psychotherapy stimulates frankness, the manifestation of hidden thoughts, desires and experiences. In the process of psychotherapy, the patient reveals himself.

In order to better understand the mechanism of self-exploration and the mechanism of confrontation described below in group psychotherapy, let us turn to the scheme of J. Luft and H. Ingham (1970), known in the literature as the “Jogari window” (from the names of the authors - Joser and Harry), which clearly conveys the relationship between the conscious and unconscious areas of the psyche in interpersonal relationships.

1. The open area ("arena") includes behavior, feelings and prayers that are known both to the patient himself, there and to everyone else.
2. The blind spot area is something that is known to others but not known to the patient.
3. Hidden area - something that is known only to the patient.
4. The unknown, or unconscious - that which is not known to anyone.

With self-exploration, a group member assumes responsibility because he takes the risk of realizing feelings, motives and behavior from his hidden or secret area. Some psychotherapists talk about “self-stripping,” which they consider the primary mechanism of growth in a group (O. Mowrer, 1964 and S. Jourard, 1964 - cited in S. Kratochvil, 1978). The man takes off his mask and begins to speak frankly about ulterior motives that the group could hardly guess about. We are talking about deeply intimate information that the patient would not trust to everyone. In addition to various experiences and relationships associated with guilt, this includes events and actions that the patient is simply ashamed of. Things can only come to the point of “self-undressing” if all other members of the group react with mutual understanding and support. There is, however, a risk that if the patient opens up and does not receive support, then such “self-undressing” will be painful for him and cause mental trauma.

6. FEEDBACK OR CONFRONTATION. R. Corsini calls this mechanism “interaction”. Feedback means that the patient learns from other group members how they perceive his behavior and how it affects them. This mechanism, of course, also occurs in individual psychotherapy, but in group psychotherapy its importance increases many times over. This is perhaps the main healing factor of group psychotherapy. Other people can be a source of information about ourselves that is not entirely accessible to us and is located in the blind spot of our consciousness.

For greater clarity, let's use the Jogari window again. If during self-exploration the patient reveals something to others from his secret, hidden area, then during feedback others reveal to him something new about himself from the area of ​​his blind spot. Thanks to the action of these two mechanisms - self-exploration and confrontation - the hidden area and the blind spot area are reduced, due to which the open area ("arena") increases.

In everyday life, we often come across people whose problems are directly written on their faces. And everyone who comes into contact with such a person does not want to point out his shortcomings, because... they are afraid of seeming tactless or offending him. But it is this information that is unpleasant for a person that provides him with material with which he could change. There are many such delicate situations in interpersonal relationships.

For example, a person who tends to talk a lot and does not understand why people avoid talking to him is told in a therapy group that his way of verbal communication is very boring. A person who does not understand why many people are unfriendly to him learns that his unconscious ironic tone irritates people.

However, not all information about a person received from others is feedback. Feedback must be distinguished from interpretation. Interpretation is an interpretation, an explanation; these are our thoughts, reasoning about what we saw or heard. Interpretation is characterized by statements such as: “I think that you are doing such and such,” and feedback is: “When you do such and such, I feel like this...” Interpretations may be erroneous or may represent the interpreter's own projections. Feedback, in essence, cannot be wrong: it is an expression of how one person reacts to another. Feedback can be non-verbal, manifested in gestures or facial expressions.

The presence of differentiated feedback is also of significant value to patients. Not every behavior can be assessed unambiguously - negatively or positively - it affects people differently. different people. Based on differentiated feedback, the patient can learn to differentiate his behavior.

The term confrontation is often used for negative feedback. G. L. Isurina and V. A. Murzenko (1976) consider confrontation in the form of constructive criticism to be a very useful psychotherapeutic factor. At the same time, they point out that when confrontation alone predominates, criticism is no longer perceived as friendly and constructive, which leads to increased psychological defense. Confrontation must be combined with emotional support, which creates an atmosphere of mutual interest, understanding and trust.

7. INSIGHT (AWARENESS). Insight means understanding and awareness by the patient of previously unconscious connections between the characteristics of his personality and maladaptive modes of behavior. Insight refers to cognitive learning and, together with emotional corrective experience (see below) and experience of new behavior, is combined by I. Yalom (1970) into the category of interpersonal learning.

S. Kratochvil (1978) distinguishes three types, or levels, of insight:
Insight N1: awareness of the connection between emotional disorders and intrapersonal conflicts and problems.
Insight N2: awareness of one’s own contribution to the emergence of a conflict situation. This is what is called “interpersonal awareness.”
Insight N3: awareness of the underlying causes of current relationships, states, feelings and behavior patterns rooted in the distant past. This is "genetic awareness".

From a psychotherapeutic point of view, insight N1 is an elementary form of awareness, which in itself has no therapeutic value: its achievement is only a prerequisite for the patient's effective cooperation in psychotherapy. The most therapeutically significant insights are N2 and N3.

The subject of constant debate among various psychotherapeutic schools is the question of whether genetic awareness alone is sufficient or, conversely, only interpersonal awareness. S. Kratochvil (1978), for example, is of the opinion that only interpersonal awareness is sufficient. From this you can go straight to learning new ways of behavior. Genetic awareness, from his point of view, can be useful in that it leads the patient to abandon childhood forms of response and replace them with the reactions and attitudes of an adult.

Genetic awareness is an exploration of one's own life history that leads the patient to understand his or her present ways of behaving. In other words, it is an attempt to understand why a person became the way he is. I. Yalom (1975) believes that genetic awareness has limited psychotherapeutic value, which strongly disagrees with the position of psychoanalysts.

From a certain point of view, insight can be seen as a consequence of psychotherapy, but it can be spoken of as healing factor, or mechanism, since it is primarily a means of changing maladaptive forms of behavior and eliminating neurotic symptoms. In achieving these goals, it is, as a rule, always a very effective, but not necessarily necessary, factor. Ideally, based on deep awareness, symptoms can disappear and behavior can change. However, the relationships between awareness, symptoms, and behavior are actually much more complex and less clear-cut.

8. CORRECTIVE EMOTIONAL EXPERIENCE. Corrective emotional experience is an intense experience of current relationships or situations, due to which the incorrect generalization made on the basis of past difficult experiences is corrected.

This concept was introduced by psychoanalyst F. Alexander in 1932. Alexander believed that since many patients suffered psychological trauma in childhood due to the poor attitude of their parents towards them, the therapist needed to create a “corrective emotional experience” to neutralize the effects of the primary trauma. The therapist reacts to the patient differently than his parents reacted to him in childhood. The patient experiences emotions, compares relationships, corrects his positions. Psychotherapy takes place as a process of emotional re-education.

The most striking examples can be taken from fiction: the story of Jean Valjean from “Les Miserables” by V. Hugo and a number of stories from the works of A.S. Makarenko, for example, the episode when Makarenko entrusts all the money of the colony to one guy, former thief. Unexpected trust, which comes into contrast with earlier justified hostility and mistrust, corrects existing relationships through strong emotional experience and changes the guy’s behavior.

During emotional adjustment, people around them behave differently than a patient with inappropriate forms of behavior might expect based on his false generalization (generalization). This new reality makes it possible to redifferentiate, that is, distinguish between situations in which a given response is appropriate or not. Thanks to this, the preconditions are created for breaking the vicious circle.

So, the essence of this mechanism is that the patient, in a psychotherapeutic situation (whether individual or group psychotherapy), re-experiences an emotional conflict that he has not been able to resolve until now, but the reaction to his behavior (the psychotherapist or group members) different from the one he usually provokes in others.

For example, a female patient with strong feelings of mistrust and aggressiveness toward men, resulting from her experiences and disappointments in the past, might be expected to bring this mistrust and aggressiveness toward male patients in the psychotherapy group. Unexpected manifestations on the part of men can have an effective impact here: they do not distance themselves from the patient, do not show irritation and dissatisfaction, but, on the contrary, are patient, courteous, and affectionate. The patient, who behaves in accordance with her previous experience, gradually begins to realize that her primary generalized reactions are unacceptable in the new situation, and she will try to change them.

A type of corrective experience in a group is the so-called “corrective repetition of the primary family” proposed by I. Yalom (1975) - repetition family relations patient in the group. The group resembles a family: its members are largely dependent on the leader; group members may compete with each other to gain "parental" favor. The therapeutic situation can evoke a number of other analogies with patients' families, provide corrective experiences, and work through unresolved relationships and conflicts in childhood. Sometimes the group is deliberately led by a man and a woman so that the group situation imitates the family situation as closely as possible. Low-adaptive relationships in a group are not allowed to “frozen” into rigid stereotypes, as happens in families: they are compared, reevaluated, and the patient is encouraged to test a new, more mature way of behavior.

9. TESTING NEW BEHAVIOR (“REALITY CHECK”) AND TEACHING NEW WAYS OF BEHAVIOR.

In accordance with the awareness of old maladaptive stereotypes of behavior, a transition to the acquisition of old ones is gradually taking place. The psychotherapy group provides a number of opportunities for this. Progress depends on the patient’s readiness for change, on the degree of his identification with the group, on the persistence of his previous principles and positions, on individual character traits.

In consolidating new reactions, impulse from the group plays a large role. The socially insecure patient, who is trying to gain acceptance by passive waiting, begins to become active and express his own opinion. Moreover, by this he not only does not lose the sympathy of his comrades, but they begin to appreciate and recognize him more. As a result of this positive feedback, the new behavior is reinforced and the patient becomes convinced of its benefits.

If change occurs, it triggers a new cycle of interpersonal learning based on ongoing feedback. I. Yalom (1975) speaks of the first turn of the “adaptation spiral”, which originates within the group and then goes beyond its boundaries. As inappropriate behavior changes, the patient's ability to improve relationships increases. Thanks to this, his sadness and depression decrease, self-confidence and frankness increase. Other people like this behavior significantly more than the previous behavior and express more positive feelings, which in turn reinforces and stimulates further positive changes. At the end of this adaptive spiral, the patient achieves independence and no longer requires treatment.

In group psychotherapy, systematically planned training can also be used - training based on the principles of learning. For example, an insecure patient is offered “assertive behavior training”, during which he must learn to insist on his own, assert his opinion, and make independent decisions. The rest of the group members resist him, but he must convince everyone of the correctness of his opinion and win. Successful completion of this exercise earns approval and praise from the group. Having experienced satisfaction, the patient will try to transfer the new experience of behavior to a real life situation.

Similarly, in a group you can learn to resolve conflict situations in the form of a “constructive dispute”, disagreement with the established rules.

When learning new ways of behavior, modeling and imitation of the behavior of other group members and the therapist play an important role. I. Yalom (1975) calls this mechanism of therapeutic action “imitating behavior,” and R. Corsini (1989) calls it “modeling.” People learn to behave by observing the behavior of others. Patients imitate their peers, observing which forms of their behavior the group approves and which they reject. If the patient notices that other group members are being open, taking certain risks associated with self-disclosure, and the group approves of this behavior, then this helps him behave in the same way.

10. PRESENTATION OF INFORMATION (LEARNING BY OBSERVATION).
In the group, the patient gains new knowledge about how people behave, information about interpersonal relationships, and adaptive and maladaptive interpersonal strategies. What is meant here is not the feedback and interpretations that the patient receives regarding his own behavior, but the information that he acquires as a result of his observations of the behavior of others.

The patient makes an analogy, generalizes, and draws conclusions. He learns by observing. In this way he learns some of the laws of human relationships. He can now look at the same things from different angles, get acquainted with different opinions on the same issue. He will learn a lot even if he does not actively participate.

Many researchers especially emphasize the importance of observation for positive change. Patients who simply observed the behavior of other group members used their observations as a source of awareness, understanding, and resolution of their own problems.

R. Corsini (1989), when studying the factors of the therapeutic effect of psychotherapy, divides them into three spheres - cognitive, emotional and behavioral. The author considers “universality”, “sense”, “modeling” to be cognitive factors; to emotional factors - “acceptance”, “altruism” and “transfer” (a factor based on emotional connections between the therapist and the patient or between patients of the psychotherapeutic group); to behavioral ones - “reality check”, “emotional response” and “interaction” (confrontation). R. Corsini believes that these nine factors underlie therapeutic change. Cognitive factors, writes R. Corsini, boil down to the commandment “know yourself”; emotional - to “love your neighbor” and behavioral - to “do good”. There is nothing new under the sun: philosophers have been teaching us these commandments for thousands of years.

EFFECTIVENESS OF PSYCHOTHERAPY

In 1952, the English psychologist Hans Aysenck compared the effectiveness of traditional psychodynamic therapy with the effectiveness of conventional medical methods treatment of neuroses or with no treatment in several thousand patients. The results obtained by the psychologist surprised and frightened many therapists: the use of psychodynamic therapy does not increase patients' chances of recovery; In fact, more untreated patients recovered than those who received psychotherapeutic treatment (72% versus approximately 66%). In subsequent years, Aysenck supported his conclusions with additional evidence (1961, 1966) as critics continued to argue that he was wrong. They accused him of excluding from his analysis several studies that supported the effectiveness of psychotherapy. They offered the following counterarguments: perhaps patients who did not receive therapy suffered less severe disorders than those who received it; non-medical patients may actually have received therapy from frequent psychotherapists; therapists assessing untreated patients may have used different, less stringent criteria than psychotherapists assessing their own patients. There has been much debate about how to interpret the results of H.Aysench, and this debate has shown that more reliable methods for assessing effectiveness need to be developed.

Unfortunately, performance evaluation work still varies widely in quality. In addition, as D. Bernstein, E. Roy et al. point out. (1988), it is difficult to define exactly what is meant by successful therapy. Because some therapists are interested in changes in the areas of unconscious conflicts or ego strength, while others are interested in changes in overt behavior, different effectiveness researchers have different judgments about whether therapy was effective for a given patient. These points must be kept in mind when considering research on overall efficiency psychotherapy.

Recent reviews are more optimistic than H. Aysenck's studies. A number of works have refuted the “null hypothesis” of H. Aysench, and now the real percentage of spontaneous recovery ranges from 30 to 45.

Using a special mathematical procedure called meta-analysis (“analysis of analyses”), Smith M. L., Glass G. V., Miller T. J. (1980) compared the results of 475 studies that reported on the conditions of patients who received psychotherapy and those who did not receive treatment. The main conclusion was this: the average patient who received psychotherapy felt better than 80% of those patients who did not receive therapy. Other meta-analyses confirmed this conclusion. These reviews showed that if the results of all forms psychological treatment considered together, the point of view about the effectiveness of psychotherapy is confirmed.

However, critics of meta-analysis argue that even such a complex combination of results, representing a “hodgepodge” of good and mediocre studies of the effectiveness of treatment various methods, may be misleading. Critics say these studies don't answer a more important question: which methods are most effective in treating certain patients.

Which of the main psychotherapeutic approaches is most effective in general, or which approach is preferable when treating specific problems of patients? Most reviews are not found significant differences in the overall effectiveness of the three main areas of psychotherapy. Critics have pointed out that these reviews and meta-analyses are not sensitive enough to detect differences between individual methods, but even studies that have carefully compared psychodynamic, phenomenological, and behavioral treatments have found no significant differences between these approaches, although they have noted their advantage over no treatment. When differences between methods are identified, there is a tendency to identify more high efficiency behavioral methods, especially in the treatment of anxiety. Favorable Results behavioral therapy and the attractiveness of phenomenological therapy to many psychotherapists has led to these two approaches becoming increasingly popular, while the use of psychodynamic therapy as the dominant method of treatment has become less and less popular.

Evaluating research on the effectiveness of psychotherapy can be approached from a completely different perspective and the question can be formulated as follows: are attempts to measure the effectiveness of psychotherapy correct?

On the issue of the effectiveness of psychotherapy, many share the opinion expressed back in 1969 by H.H.Strupp, Bergin A.E. (quoted by R. Corsini): The problem of psychotherapy research should be formulated as a standard scientific question: what specific therapeutic interventions produce specific changes in specific patients under specific conditions?

R. Corsini, with his characteristic humor, writes that he finds the “best and most complete” answer to this question in C. Patterson (1987): before any model subject to research can be applied, we need: 1) taxonomy problems or psychological disorders patient, 2) taxonomy of patients' personalities, 3) taxonomy of therapeutic techniques, 4) taxonomy of therapists, 5) taxonomy of circumstances. If we were to create such classification systems, the practical problems would be insurmountable. Let's assume that the five listed classes of variables each contain ten classifications, then the research project will require 10x10x10x10x10, or 100,000 elements. From this C. Petterson concludes that we do not need complex analyzes of many variables and we should abandon the attempt to accurately study psychotherapy, because it is simply not possible.

Psychotherapy is an art based on science, and, like art, simple measurements such a complex activity.

As Avicenna said, a doctor has three main tools: words, medicine and a knife. In the first place, undoubtedly, is the word - the most powerful way impact on the patient. A bad doctor is the one whose conversation with him does not make the patient feel better. A sincere phrase, support and acceptance of a person with all his vices and shortcomings - this is what makes a psychiatrist a true healer of the soul.

The above applies to all specialties, but most importantly to psychotherapists.

Psychotherapy is healing technique verbal influence, which is used in psychiatry and narcology.

Psychotherapy can be used either alone or in combination with medication. Greatest effect psychotherapy provides treatment to patients with neurotic spectrum disorders (anxiety-phobic and obsessive-compulsive disorders, panic attacks, depression, etc.) and psychogenic diseases.

Classification of psychotherapy

Today there are three main areas of psychotherapy:

  • Dynamic
  • Behavioral (or behavioural)
  • Existential-humanistic

They all have different mechanisms of influence on the patient, but their essence is the same - focusing not on the symptom, but on the whole personality.

Depending on the required purpose practical psychotherapy May be:

  • Supportive. Its essence is to strengthen and support the patient’s existing protective forces, as well as developing behavioral patterns that will help stabilize emotional and cognitive balance.
  • Retraining. Complete or partial reconstruction of negative skills that worsen the quality of life and adaptation in society. The work is carried out through support and approval positive forms patient behavior.

Depending on the number of participants, psychotherapy can be individual and group. Each option has its pros and cons. Individual psychotherapy is a springboard for patients who are not prepared for group sessions or who refuse to participate in them due to their character traits. In turn, the group option is much more effective in terms of mutual communication and exchange of experience. A special variety is family psychotherapy, which involves working together with two spouses.

Areas of therapeutic influence in psychotherapy

Psychotherapy is a good treatment method due to three areas of influence:

Emotional. The patient is provided with moral support, acceptance, empathy, the opportunity to express his own feelings and not be judged for it.

Cognitive. There is awareness and “intellectualization” of one’s own actions and aspirations. In this case, the psychotherapist acts as a mirror that reflects himself to the patient.

Behavioral. During psychotherapy sessions, habits and behavior patterns are developed that will help the patient adapt to the family and society.

A good combination of all the above areas is practiced in cognitive- behavioral psychotherapy(CBT).

Types and methods of psychotherapy: characteristics

One of the pioneers of psychotherapy and psychoanalysis was the famous Austrian psychiatrist and neurologist Sigmund Freud. He formed the psychodynamic concept of the emergence of neuroses based on the suppression of the needs and demands of the individual. The psychotherapist’s task was to transfer unconscious stimuli and make the client aware of them, thereby achieving adaptation. Subsequently, Freud's students and many of his followers founded their own schools of psychoanalysis with principles that differed from the original doctrine. This is how the main types of psychotherapy that we know today arose.

Dynamic psychotherapy

Formation of dynamic psychotherapy as effective method We owe the fight against neuroses to the works of K. Jung, A. Adler, E. Fromm. The most common variant of this direction is person-centered psychotherapy.

The treatment process begins with a long and scrupulous psychoanalysis, during which the patient’s internal conflicts are clarified, after which they move from the unconscious to the conscious. It is important to bring the patient to this point, and not just voice the problem. For effective treatment The client needs long-term cooperation with the doctor.

Behavioral psychotherapy

Unlike proponents of psychodynamic theory, behavioral psychotherapists see the cause of neurosis as incorrectly formed behavioral habits, and not hidden incentives. Their concept states that a person’s behavior patterns can be changed, depending on which his condition can be transformed.

Behavioral psychotherapy methods are effective in treating various disorders (phobias, panic attacks, obsessions, etc.). Showed itself well in practice confrontation and desensitization technique. Its essence is that the doctor determines the cause of the client’s fear, its severity and connection with external circumstances. Then the psychotherapist carries out verbal (verbal) and emotional influences through implosion or flooding. At the same time, the patient mentally imagines his fear, trying to paint a picture of it as brightly as possible. The doctor reinforces the patient’s fear so that he feels the reason and gets used to it. A psychotherapy session lasts about 40 minutes. Gradually, a person gets used to the cause of the phobia, and it ceases to worry him, that is, desensitization occurs.

Another subtype of behavioral technique is rational-emotive psychotherapy. Here the work is carried out in several stages. First, the situation is determined and emotional connection person with her. The doctor determines the client’s irrational urges and ways to overcome them. difficult situation. Then he evaluates the key points, after which he clarifies (clarifies, explains) them, and analyzes each event together with the patient. Thus, irrational actions are recognized and rationalized by the person himself.

Existential-humanistic psychotherapy

Humanistic therapy is the newest method of verbal influence on the patient. What is being analyzed here is not the deepest motives, but the formation of a person as an individual. The emphasis is on higher values ​​(self-improvement, development, achieving the meaning of life). Viktor Frankl contributed a major role to existentialism, who saw the lack of personal fulfillment as the main cause of human problems.

There are many subtypes of humanitarian psychotherapy, the most common of which are:

Logotherapy– a method of dereflection and paradoxical intention, founded by V. Frankl, which allows you to effectively cope with phobias, including social ones.

Client-centered therapy– a special technique in which the main role in treatment is played not by the doctor, but by the patient himself.

Transcendental Meditation– a spiritual practice that allows you to expand the boundaries of your mind and find peace.

Empirical therapy– the patient’s attention is focused on the deep emotions he experienced earlier.

The main feature of all of the above practices is that the line in the doctor-patient relationship is blurred. The psychotherapist becomes a mentor, as equal as his client.

Other types of psychotherapy

In addition to the verbal method of communication with the doctor, patients can attend classes in music, sand, and art therapy, which help them relieve stress, show their creativity and open up.

Clinical psychotherapy: conclusions

Psychotherapy has an invaluable influence on the patient during treatment and rehabilitation. Neurotic spectrum disorders are more effectively amenable to drug correction if it is combined with the work of a psychotherapist or psychologist, and sometimes even without taking medications; psychotherapy can lead to the complete disappearance of painful manifestations. In the future, patients move from taking medications to using the skills acquired in psychotherapy sessions. IN in this case it acts as a step from pharmacotherapy to self-control over painful manifestations (phobias, panic attacks, obsessions) and the patient’s mental state. Therefore, working with a psychotherapist should mandatory carried out with patients and their relatives.

Year of issue: 2005

Genre: Psychology

Format: PDF

Quality: OCR

Description: Members of a special commission created to develop guidelines for treatment methods for PTSD were directly involved in the preparation of materials presented in the book “Effective Therapy for Post-Traumatic Stress Disorder.” This commission was organized by the Board of Directors of the International Society for Traumatic Stress Studies (ISTSS) in November 1997. Our goal was to describe various ways therapy, based on a review of extensive clinical and research literature prepared by experts in each specific field. The book “Effective Therapy for Post-Traumatic Stress Disorder” consists of two parts. The chapters of the first part are devoted to an overview of the results of the most important studies. The second part provides a brief description of the use of different therapeutic approaches in the treatment of PTSD. This guideline aims to inform clinicians of the developments we have identified as best for the treatment of patients diagnosed with post-traumatic stress disorder (PTSD). PTSD is complicated mental condition which develops as a result of experiencing a traumatic event. Symptoms that characterize PTSD include repeated replay of the traumatic event or episodes; avoidance of thoughts, memories, people or places associated with the event; emotional numbness; increased arousal. PTSD is often comorbid with other mental disorders and is a complex illness that can be associated with significant morbidity, disability, and impairment of life. important functions.

When developing this practical guide, a special commission confirmed that traumatic experiences can lead to the development of various disorders, such as general depression, specific phobias; disorders of extreme stress not otherwise specified (DESNOS), personality disorders such as borderline anxiety disorder and panic disorder. However, the main focus of this book is the treatment of PTSD and its symptoms, which are listed in the Diagnostic and Statistical Manual, Fourth Edition. mental illness(Diagnostic and Statistical Manual of Mental Disorders, DSM-IV, 1994) of the American Psychiatric Association.
The authors of the Effective Treatments for Post-Traumatic Stress Disorder manual acknowledge that the diagnostic scope of PTSD is limited and that these limitations may be particularly evident in patients who have experienced childhood sexual or physical abuse. Often, patients diagnosed with DESNOS have a wide range of problems in relationships with other people, which contribute to impairments in personal and social functioning. About successful treatment Relatively little is known about such patients. The consensus among clinicians, supported by empirical data, is that patients with this diagnosis need long-term and complex treatment. The Special Commission also recognized that PTSD is often accompanied by other mental disorders, and these comorbidities require medical personnel sensitivity, attention, as well as clarification of the diagnosis throughout the entire treatment process. Disorders requiring special attention are substance abuse and general depression as the most common comorbid conditions. Practitioners may refer to guidelines for these disorders to develop treatment plans for individuals demonstrating multiple disorders and to the comments in Chapter 27.
The Effective Treatment for Post-Traumatic Stress Disorder guideline is based on cases of adults, adolescents, and children suffering from PTSD. The purpose of the guide is to assist the clinician in treating these individuals. Because PTSD is treated by clinicians with a variety of backgrounds, these chapters were developed using an interdisciplinary approach. Psychologists, psychiatrists, social workers, art therapists, family counselors and other specialists actively participated in the development process. Accordingly, these chapters address a wide range of professionals involved in the treatment of PTSD.
The Special Commission excluded from consideration those individuals who are currently being subjected to violence or insults. These individuals (children who live with an abusive person, men and women who are abused and abused in their home), and those living in war zones may also meet criteria for a diagnosis of PTSD. However, their treatment, and the associated legal and ethical issues, differ significantly from the treatment and problems of patients who have experienced traumatic events in the past. Patients who are directly in a traumatic situation need special attention clinicians. These circumstances require the development of additional practical guidelines.
Very little is known about the treatment of PTSD in industrialized regions. Research and development on these topics is carried out mainly in Western industrialized countries. The Special Commission is keenly aware of these cultural limitations. There is a growing belief that PTSD is a universal response to traumatic events that is found across many cultures and societies. However, there is a need for systematic research to determine the extent to which treatments, both psychotherapeutic and psychopharmacological, that have proven effective in Western societies will be effective in other cultures. In general, practitioners should not limit themselves to only the approaches and techniques outlined in this manual. The creative integration of new approaches that have demonstrated effectiveness in treating other disorders and have sufficient evidence is encouraged. theoretical basis, in order to improve the results of therapy.

The book “Effective Therapy for Post-Traumatic Stress Disorder” is based on an analysis of the results of research on the effectiveness of psychotherapy for adults, adolescents and children suffering from post-traumatic stress disorder (PTSD). The purpose of the manual is to assist the clinician in the treatment of such patients. Since PTSD treatment is carried out by specialists with various professional training, the authors of the chapters of the manual took an interdisciplinary approach to the problem. The book as a whole brings together the efforts of psychologists, psychiatrists, social workers, art therapists, family counselors, etc. The chapters of the manual are addressed to a wide range of specialists involved in the treatment of PTSD.
The book “Effective Therapy for Post-Traumatic Stress Disorder” consists of two parts. The chapters of the first part are devoted to an overview of the results of the most important studies. Part two provides a brief description of the use of different therapeutic approaches to treat PTSD.

"Effective Therapy for Post-Traumatic Stress Disorder"


  1. Diagnosis and evaluation
Treatment approaches for PTSD: a review of the literature
  1. Psychological debriefing
  2. Psychopharmacotherapy
  3. Treatment of children and adolescents
  4. Group therapy
  5. Psychodynamic therapy
  6. Treatment in hospital
Psychosocial rehabilitation
  1. Hypnosis
  2. Art therapy
Therapy Guide
  1. Psychological debriefing
  2. Cognitive behavioral therapy
  3. Psychopharmacotherapy
  4. Treatment of children and adolescents
  5. Desensitization and reprocessing using eye movements
  6. Group therapy
  7. Psychodynamic therapy
  8. Treatment in hospital
  9. Psychosocial rehabilitation
  10. Hypnosis
  11. Marriage and family therapy
  12. Art therapy

Conclusion and conclusions

A post about serious medical research.

Not long ago, PubMed published a meta-analysis comparative effectiveness different methods treatment of anxiety disorders. Randomized controlled trial, all business. In total, almost 40,000 patients participated in all this. Three “diagnoses” were examined: panic disorder, generalized anxiety disorder and social phobia. The effectiveness of several options was assessed and compared drug treatment and various “psychological” techniques.

Among other things, when summing up the results in the PubMed publication, there was the following phrase: “Pre-post ES for psychotherapies did not differ from pill placebos; this finding cannot be explained by heterogeneity, publication bias or allegiance effects” (c). Seeing her, some agitated individuals with attention deficit disorder began to joyfully exclaim in capslock: I knew, I believed, I hoped - psychotherapy is ineffective, it’s all a scam, the effect is like a placebo... They say “who would doubt it” (c).

Since these enthusiastic cries began to be reposted across the network, even on the pages of quite serious people related to both science and medicine, I consider it necessary to analyze in detail the essence of the research conducted. Because the topic is interesting, and a lot of work was done by researchers just to skim the text without bothering themselves with trying to understand the essence of what was written. But this essence can be quite unexpected for someone who doesn’t read carefully >:3

In the first lines there is a bit of obligatory skepticism. A publication in PubMed is a so-called abstract; only brief results are indicated there and that’s all. There is no description of research methods and other important details on which the interpretation of the results depends.

For example, there is no description of the exact clinical picture of anxiety disorders. Agree that to evaluate the effectiveness of therapy:
-a person experiencing psychological discomfort from large crowds of people on public transport or in a crowd...
-an agarophobe who panics when he has to cross the threshold of his home...
-a terry persecuted schizophrenic who experiences panic anxiety from the fact that right now huge orangutans from the future with lasers in their hands are chasing him across the roofs of houses...

That's three big differences, although in all three options it is possible to diagnose “anxiety disorder”. In all three options, the effectiveness of the same techniques will be completely different - and this does not cause any surprise, taschemta. That's how it should be.
There is no description of a universal effectiveness indicator and a method for calculating it for different therapy methods.
Also no detailed description research methods, that is, for example, it is unknown how the researchers formulated and defined “psychological placebo” - yes, they have a similar indicator in their publication.

But - chu! I don’t want the post to look like an attempt at justification by looking for a speck in someone else’s eye. Yes, from the abstract it is not clear what conditions were studied (clinical form, severity of anxiety, and so on), it is not clear how exactly the analysis was carried out and according to what criteria. This is a moment of obligatory skepticism. Let's take it as an axiom that this study was organized correctly, the indicators were formulated accurately and reliably, and the methods were fully consistent with the clinic.

So, the researchers assessed the effectiveness of the therapy. For this purpose, the universal indicator “effect sizes” (hereinafter ES) was used.

Indicators of the effectiveness of therapy for anxiety disorders are as follows:

ES not selective inhibitors serotonin reuptake = 2.25
ES of selective serotonin reuptake inhibitors = 2.09
Benzodiazepine ES = 2.15
ES of tricyclic antidepressants = 1.83

ES of mindfulness cognitive therapy = 1.56
ES "relaxation" (no explanation, interpret it as you wish) = 1.36
ES of individual cognitive behavioral therapy = 1.30
ES of group cognitive behavioral therapy = 1.22
ES of psychodynamic therapy = 1.17
ES of remote impersonal psychotherapy (for example, psychotherapeutic correspondence over the Internet) = 1.11
ES method of processing emotional trauma using eye movements Francine Shapiro = 1.03
ES of interpersonal therapy = 0.78

ES combinations of cognitive psychotherapy and “drugs” (that is, medications without specifying which ones) = 2.12

ES of "exercise" (whatever that means) = 1.23

ES of drug placebo = 1.29
ES of psychological placebo = 0.83
ES waitlists = 0.20

Here are all the main figures that can be compared and analyzed.

From these data it is clear that individual cognitive psychotherapy is indeed more effective than drug placebo, and group therapy is slightly less effective than drug placebo.

But let's take a moment to remember what a drug placebo is. The "placebo effect" is a situation where medical research patients are quietly fed pacifiers - and the patients still get better. That is, the patient in the control group is confident that he is being treated with real medications, like everyone else, but he is secretly given a pacifier. Placebo. This is done with patients in control groups to compare the results of drug treatment and non-treatment.

The placebo effect is a pronounced psychological effect. A classic example is when patients in group 1 are given a pacifier by an ugly, angry, rude and always irritated nurse, and patients in group 2 are given a pacifier by a kind and smiling manager. department. The nurse rudely forces you to drink and stick out your tongue, and the head of the department talks about the achievements of medicine and describes the pacifier given as the latest, unique and very effective remedy. And in the second group the placebo effect was significantly higher than in the first.

When a person receives a drug placebo, he is sure that he is participating in a drug study, and a new one at that (the person was notified, he signed consent to participate). The person is convinced that he is being fully treated with the latest medications; all the conditions, all the treatment, all the activities, actions, and the surrounding environment point precisely to this. And his conviction helps him recover. This is nothing more than an element of “suggestion”, that is, it is an element of psychotherapeutic influence.

Thus the ecstatic cry" THE EFFECTIVENESS OF PSYCHOTHERAPY WAS THE SAME AS THE EFFECTIVENESS OF DRUG PLACEBO" actually makes sense "THE EFFECTIVENESS OF PSYCHOTHERAPY WAS THE SAME AS THE EFFECTIVENESS OF PSYCHOTHERAPY." Let's give a pat to those people who read diagonally and, taking a few words out of context, make themselves look like fools ^_^
It was not for nothing that the researchers separated the medicinal placebo from the psychological placebo (no matter how they defined the latter, but skepticism was higher).

Efficiency drug therapy higher than the effectiveness of psychotherapy, especially when it comes to a generalized clinic of psychiatric conditions
- the effectiveness of cognitive psychotherapy is 1.5-2 times higher than the effectiveness of “psychological placebo”. Drug therapy is also approximately one and a half times more effective than drug placebo.
-the total effectiveness of cognitive psychotherapy and drug therapy exceeds the effectiveness of almost all isolated techniques.
- the effectiveness of cognitive psychotherapy is significantly higher compared to Shapiro’s technique and interpersonal ( interpersonal) psychotherapy

If these conclusions are expressed in simple human language:

-IN severe cases Medicines help better than psychotherapy
-Psychotherapy has proven effectiveness.
-Psychotherapy and medications are more effective together than separately.
-Psychotherapy is more effective the less “dancing with a tambourine” in it. The more of these dances, the less the result.

And now, placing your hand on the fifth intercostal space on the left, tell me: these conclusions turned out to be really breaking news for you, or did you already guess about something like this before?)))

I can’t say anything about the effectiveness of physical exercise. Go figure what they meant: active image life and physical labor fresh air.

Associated with this file 50 file(s). Among them: strukturirovannie_tehniki_terapii_sherman.doc, Effektivnaya_terapia_posttravmaticheskogo_stressovogo.pdf, A_Lengle_Yavlyaetsya_li_lyubov_schastyem.pdf, Gorbatova E.A. - Theory and practice of psychological training (Ps and 40 more file(s).
Show all linked files

Effective therapy for post-traumatic stress disorder
disorders
Edited by
Edna B. Foa Terence M. Keane Matthew J. Friedman
Moscow
"Cogito-Center"
2005

UDC 159.9.07 BBK88 E 94
All rights reserved. Any use of materials from this book in whole or in part
without permission of the copyright holder it is prohibited
Edited by E
BOTTOM
Foa. Terence M. Keane, Matthew Friedman
Translation from English under general editing N. V. Tarabrina
Translators: V.A. Agarkov, SA. Pitt- chapters 5, 7, 10, 17, 19, 22, 27 O.A. Crow - chapter 1,
2,11,12,14,15,16, 23, 24, 26 E.S. Kalmykova- chapters 9, 21 EL. Misko- chapters 6, 8, 18, 20 ML.
Padun- chapters 3, 4, 13, 25
E 94 Effective therapy for post-traumatic stress disorder / Ed. Edna Foa,
Terence M. Keane, Matthew Friedman. - M.: “Cogito-Center”, 2005. - 467 p. (Clinical psychology)
UDC 159.9.07 BBK88
This guide is based on an analysis of research into the effectiveness of psychotherapy for adults, adolescents, and children with post-traumatic stress disorder (PTSD). The purpose of the manual is to assist the clinician in the treatment of such patients.
Since PTSD treatment is carried out by specialists with various professional training, the authors of the chapters of the manual took an interdisciplinary approach to the problem. The book as a whole brings together the efforts of psychologists, psychiatrists, social workers, art therapists, family counselors, etc. The chapters of the manual are addressed to a wide range of specialists involved in the treatment of PTSD.
The book consists of two parts. The chapters of the first part are devoted to an overview of the results of the most important studies. Part two provides a brief description of the use of different therapeutic approaches to treat PTSD.
© Translation into Russian by Cogito Center, 2005 © The Guilford Press, 2000
ISBN 1-57230-584-3 (English) ISBN 5-89353-155-8 (Russian)

Contents i. Introduction.............................................................................................................7
2. Diagnosis and assessment...........................................................................................28
Terence M. Keane, Frank W. Wethers, and Edna B. Foa
I. Approaches to the treatment of PTSD: a review of the literature
3. Psychological debriefing...................................................................51
Jonathan E. Bisson, Alexander S. McFarlane, Suzanne Ros
4. ...............................................75
5. Psychopharmacotherapy......................................................................... 103
6. Treatment of children and adolescents................................................................ 130
7. Desensitization and reprocessing using eye movements.... 169
8. Group therapy...................................................................................189
David W. Foy, Shirley M. Glynn, Paula P. Schnurr, Mary K. Jankowski, Melissa S. Wattenberg,
Daniel S. Weiss, Charles R. Marmar, Fred D. Guzman
9. Psychodynamic therapy..............................................................212
10. Treatment in hospital.............................................................................239
AND. Psychosocial rehabilitation.......................................................270
12. Hypnosis.............................................................................................................298
Etzel Cardena, Jose Maldonado, Otto van der Hart, David Spiegel
13. ....................................................336
David S. Riggs
^.Art therapy..............................................................................................360
David Reed Johnson

II. Therapy Guide
15. Psychological debriefing................................................................377
Jonathan E. Bisson, Alexander Macfarlane, Suzanne Ros
16. Cognitive behavioral therapy............................................381
Barbara Olasov Rothbaum, Elizabeth A. Meadows, Patricia Resick, David W. Foy
17. Psychopharmacotherapy.........................................................................389
Matthew J. Friedman, Jonathan R.T. Davidson, Thomas A. Mellman, Stephen M. Southwick
18. Treatment of children and adolescents...............................................................394
Judith A. Cohen, Lucy Berliner, John S. March
19. Desensitization and processing
using eye movements......................................................................398
Cloud M. Chemtob, David F. Tolin, Bessel A. van der Kolk, Roger C. Pitman
20. Group therapy...................................................................................402
David W. Foy, Shirley M. Glynn, Paula P. Schnurr, Mary K. Jankowski, Melissa S. Wattenberg,
Daniel S. Weiss, Charles R. Marmar, Fred D. Guzman
21. Psychodynamic therapy..............................................................405
Harold S. Kadler, Arthur S. Blank Jr., Janice L. Krapnick
22. Treatment in hospital.............................................................................408
Christine A. Curti, Sandra L. Blum
23. Psychosocial rehabilitation.......................................................414
Walter Penk, Raymond B. Flannery Jr.
24. Hypnosis.............................................................................................................418
Etzel Cardena, Jose Maldonado, Otto van der Hart, David Spiegel
25. Marriage and family therapy....................................................423
David S. Riggs
26. Art therapy..............................................................................................426
David Reed Johnson
27. Conclusion and conclusions.............................................................................429
Aryeh W. Shalev, Matthew J. Friedman, Edna B. Foa, Terence M. Keene
Subject index
457

1
Introduction
Edna B. Foa, Terence M. Keane, Matthew J. Friedman
Members of a special commission created to develop guidelines for treatment methods for PTSD were directly involved in the preparation of the materials presented in this book. This commission was organized by the Board of Directors of the International Society for Traumatic Stress Studies (ISTSS) in November 1997.
Our goal was to describe the various therapies based on a review of the extensive clinical and research literature prepared by experts in each specific field. The book consists of two parts. The chapters of the first part are devoted to an overview of the results of the most important studies. The second part provides a brief description of the use of different therapeutic approaches in the treatment of PTSD. This guideline aims to inform clinicians of the developments we have identified as best for the treatment of patients diagnosed with post-traumatic stress disorder (PTSD). PTSD is a complex mental condition that develops as a result of experiencing a traumatic event. Symptoms that characterize PTSD include repeated replay of the traumatic event or episodes; avoidance of thoughts, memories, people or places associated with the event; emotional numbness; increased arousal. PTSD is often comorbid with other mental disorders and is a complex illness that can be associated with significant morbidity, disability, and impairment of vital functions.

8
In developing this practical guide, the Special Commission confirmed that traumatic experiences can lead to the development of various disorders, such as general depression, specific phobias; disorders of extreme stress not otherwise specified (DESNOS), personality disorders such as borderline anxiety disorder and panic disorder. However, the main focus of this book is the treatment of PTSD and its symptoms, which are listed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (Diagnostic and Statistical Manual of Mental Disorders, DSM-IV, 1994)
American Psychiatric Association.
The guideline authors acknowledge that the diagnostic scope of PTSD is limited and that these limitations may be particularly evident in patients who have experienced childhood sexual or physical abuse. Often, patients diagnosed with DESNOS have a wide range of problems in relationships with other people, which contribute to impairments in personal and social functioning. Relatively little is known about the successful treatment of these patients. The consensus among clinicians, supported by empirical data, is that patients with this diagnosis require long-term and complex treatment.
The Special Commission also recognized that PTSD is often accompanied by other mental disorders, and these comorbidities require sensitivity, attention, and clarification of the diagnosis by medical personnel throughout the treatment process.
Disorders requiring special attention are substance abuse and general depression as the most common comorbid conditions.
Practitioners may refer to guidelines for these disorders to develop treatment plans for individuals demonstrating multiple disorders and to the comments in Chapter 27.
This guide is based on cases of adults, adolescents and children suffering from PTSD. The purpose of the guide is to assist the clinician in treating these individuals. Because PTSD is treated by clinicians with a variety of backgrounds, these chapters were developed using an interdisciplinary approach. Psychologists, psychiatrists, social workers, art therapists, family counselors and other specialists actively participated in the development process. Accordingly, these chapters address a wide range of professionals involved in the treatment of PTSD.
The Special Commission excluded from consideration those individuals who are currently being subjected to violence or insults. These individuals (children who live with an abusive person, men

9 and women who experience abuse and violence in their home), as well as those living in war zones, may also meet the criteria for diagnosis
PTSD. However, their treatment, and the associated legal and ethical issues, differ significantly from the treatment and problems of patients who have experienced traumatic events in the past. Patients directly in a traumatic situation require special attention from clinicians. These circumstances require the development of additional practical guidelines.
Very little is known about the treatment of PTSD in industrialized regions. Research and development on these topics is carried out mainly in Western industrialized countries.
The Special Commission is keenly aware of these cultural limitations. There is a growing belief that PTSD is a universal response to traumatic events that is found across many cultures and societies. However, there is a need for systematic research to determine the extent to which treatments, both psychotherapeutic and psychopharmacological, that have proven effective in Western societies will be effective in other cultures.
In general, practitioners should not limit themselves to only the approaches and techniques outlined in this manual. The creative integration of new approaches that have demonstrated effectiveness in the treatment of other disorders and have a sufficient theoretical basis is encouraged in order to improve treatment outcomes.
PROCESS OF WORK ON THE GUIDE
The development process for this guide was as follows. Co-Chairs
A special commission identified specialists in the main therapeutic schools and methods of therapy that are currently used in working with patients suffering from
PTSD. As new effective methods of therapy were found, the composition of the Special Commission expanded. Thus, the Special Commission included specialists from various approaches, theoretical orientations, therapeutic schools, as well as vocational training. The focus of the Guide and its format were determined by the Special Commission over a series of meetings.
The co-chairs instructed the members of the Special Commission to prepare an article on each area of ​​therapy. Each article had to be written by a recognized expert with the support of an assistant, whom he independently selected from among other panel members or clinicians.

10
Articles were required to provide a literature review of research in the field and clinical practice.
Literature reviews for each topic have been compiled using operating systems searches such as "Published International Literature on Traumatic Stress"
International Literature on Traumatic Stress, PILOTS), MEDLINE and PsycLIT In the final version, articles were reduced to a standard format and limited in length. The authors cited literature on the topic, presented clinical developments, provided a critical review of the scientific basis for a particular approach, and presented the articles to the chair. The completed articles were then distributed to all members of the Special Commission for comments and active discussion. The results of the reviews with modifications turned into articles and subsequently became chapters of this book.
Based on articles and careful study of the literature, a set of brief practical recommendations for each therapeutic approach. It can be found in Part II.
Each therapeutic approach or modality in the guideline was rated according to its therapeutic effectiveness. These ratings were standardized according to a coding system adapted by the Agency for Health Care Policy and Research (AHCPR).
The rating system below is an attempt to formulate recommendations for practitioners based on available scientific achievements.
The manual was reviewed by all members of the Special Committee, agreed upon and then presented to the ISTSS Board of Directors, submitted to a number of professional associations for review, presented at the ISTSS Annual Convention Public Forum, and posted on the website
ISTSS for comments from lay members of the scientific community. Materials resulting from this work were also included in the manual.
Published research on PTSD, as well as other mental disorders, contain certain restrictions. In particular, most studies apply inclusion and exclusion criteria to determine whether the diagnosis is appropriate for a particular case; therefore, each study may not fully represent the spectrum of patients seeking treatment. PTSD studies, for example, often do not include patients with substance abuse disorders, suicidal risk, neuropsychological impairment, developmental delays, or cardiovascular diseases. This guideline covers studies that do not involve these patient populations.

11
CLINICAL PROBLEMS Type of injury
Most randomized clinical trials, conducted on veterans of wars (mostly Vietnam) showed that treatment was less effective for this contingent compared with non-combat veterans whose PTSD was associated with other traumatic experiences (for example, rape, accidents, natural disasters ). This is why some experts believe that war veterans suffering from PTSD are less responsive to treatment than those who have experienced other types of trauma. This conclusion is premature. The difference between veterans and other patients with PTSD may be due to the greater severity and chronicity of their PTSD rather than to characteristics specific to military trauma. Besides, low performance the effectiveness of treatment for veterans may be associated with the characteristics of the sample, since groups are sometimes formed from volunteers - veterans, chronic patients with multiple disorders. Overall on this moment It cannot be definitively concluded that PTSD following certain traumas may be more resistant to treatment.
Single and multiple injuries
No studies have been conducted among patients with PTSD. clinical trials to answer the question of whether the number of previous traumas may influence the course of treatment for PTSD. Because most studies have been conducted on either military veterans or sexually abused women, most of whom have experienced multiple traumas, it has been found that much of what is known about the effectiveness of treatment applies to people who have had multiple traumatic experiences. Studies of individuals with single and multiple traumatization would be of great interest to determine whether the former are expected to respond better to treatment. However, conducting such studies can be quite challenging because it would require controlling for factors such as comorbid diagnoses, severity, and chronicity of PTSD, all of which may be a stronger predictor of treatment outcome than the amount of trauma experienced.