Extended confrontation therapy for PTSD

Even though the positive effects of PTSD (Posttraumatic Stress Disorder) are considered in literature (Foa & Meadows, 1997; Grunert, Matloub, Sanger, & Yousif, 1990; Grunert & Dzwierzynski, 1997; Weis, Grunert, Rusch, 2000), it is a fact that not every patient will benefit from this method (Grunert, Smucker, Weis, & Rusch, in print).

As many patients suffering from PTSD refuse to confrontation therapies in clinical practice the application of these methods is only limited (Becker & Zayfert, 2001; Grey, Young, Holmes, 2002). 

According to a survey (Becker, Anderson, & Love, 2001) the majority of clinicians in CBT were against the application of confrontation therapies within a PTSD treatment or ignored it completely. The reason is the risk of a reinforcement of the symptom and/or a retraumatization. The numerous discontinuations of patients with a PTSD in a confrontation therapy are also alarming. A new efficacy study showed (Zayfert, Becker, Gillock, & Schnurr, 2001) that in a study 40 % of the participants with a PTSD broke off their confrontation therapy.

When fear ist not the main PTSD emotion

The fundamental presumption concerning confrontation therapies with trauma victims is that fear is the dominant PTSD emotion and that its avoidance is the first strategy to master it. (Foa & Kozak, 1986).

After all the confrontation therapy is characterized by a long and good documented success story in the treatment of phobias. In the case of phobias the combination of fear and avoidance is decisive for the growth and maintenance of phobic fear

Whereas the basic presumption that fear is always the dominant emotion underlying PTSD symptoms maintaining it requires a review.

The empiric literature considers PTSD more complex than phobic dysfunctions. Other emotions than fear are often characterized as main part of the dysfunction, as guilt, shame, disgust, the breaking of the mental integrity (mental defeat), and anger (Brewin, Andrews, & Rose, 2000; Dunmore, Clark, & Ehlers, 1999; Ehlers, Maercher, & Boos, 2000; Foa, Riggs, & Massie, 1995; Grey, Young, & Holmes, 2002; Lee, Scragg & Turner; 2001; Leskela, Dieperink, & Thuras, 2002; Novaco & Chemtob, 2002). A study of Grunert, Smucker, Weis and Rusch (2003) showed recently that 14 sessions within a confrontation therapy with a victim of an industrial accident, which PTSD was mainly associated with anger, lead to a reinforcement of the PTSD symptoms.

Then after one session only succeeded a complete remission of symptoms with the „imagery rescripting and reprocessing therapy (IRRT)“ – a treatment of imagery that aims at cognitive restructuring and that activated, modified and processed cognitions of anger associated with PTSD. The treatment of a second victim of an industrial accident who showed guilt as the main PTSD emotion resulted after two sessions of confrontation in a reinforcement of symptoms. Also in this case a reduction of symptoms came out after only one IRRT session in which the Imagery therapy activated, modified and processed the relevant cognitions of guilt.

These results are important considering the numberous efficacy studies of the past 15 years of Grunert and his assistants describing the success of the confrontation therapy with victims of industrial and road accidents suffering from PTSD. (e.g., Grunert et. al,, 1990, Grunert, Devine, Smith, Matloub, Sanger, & Yousif, 1992; Grunert, Devine, Matloub, Sanger, Yousif, Anderson, Roell, 1992; Grunert, Hargarten, Matloub, Sanger, Hanel, Yousif, 1992; Grunert & Dzwierzynski, 1997).

A retrospective analysis of the confrontation therapy studies published since 1988 by Grunert and his assistants (Grunert & Grunert, manuscript in work) shows a pattern concerning confrontation therapy and patients who benefitted respectively not benefitted:

  1. If fear was the dominant PTSD emotion and avoidance the main strategy of mastery the confrontation therapy was 90 per cent successful.
  2. If the dominant PTSD emotion was not fear (for example anger, guilt, shame, disgust), the confrontation therapy was less than 20 per cent successful. 

These results suggest a differential indication of interventions depending on whether fear or other negative emotions play a role.

Neurobiologic studies support this idea. They show that the underlying neuronal corrolates of fear and other negative emotions differ from each other.

Limbic structures (e.g. the Amygdala) play a role concerning the processing of fear, whereas while processing complex negative emotions like guilt, shame and disgust higher cortical structures  (e.g. the frontal neocortex) are involved (Beauregard, Lévesque, & Beourgoin, 2001; Damasio, 1998).