Staff Voices - Hope and PTSD Treatment

Staff Voices - Hope and PTSD Treatment

by Priscilla M. Schulz, LCSW-C

Some time ago I was in a family’s living room talking to a group who had come to the US as war refugees. Many had been tortured before fleeing their homeland, before finding safe haven in the US. I had been invited there to talk about PTSD and effective treatment. Many in the room likely suffered with the disorder, but if so, called it “nervousness” and referred to themselves or those with the problem as, “he’s crazy now…too bad.”

The horrors of war, the deaths, imprisonment and torture leave an indelible mark on the human psyche. PTSD, however, a psychiatric diagnosis, does not have to be part of the lingering legacy of war. That was the main point of my talk…and to share resources for help.

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I had rapt attention. There was good response to normalizing trauma and post-trauma reactions, to giving them other words for their distress. I distinguished PTSD and depression from grief. I described what was known about the trauma recovery process. When I got to treatments that work, that help people move forward again with their lives and recover, the room erupted in strong emotions. Some could not believe help was possible. Others seemed anxious to get my attention away from the group to ask their own private questions perhaps. Many seemed frightened. I had touched a raw chord. In part, I had opened a Pandora’s Box of hope after years without it.

Hopelessness is so common among individuals suffering PTSD. Hopelessness is immobilizing, and probably plays a big part in PTSD-associated problems such as depression, social isolation, marital and financial problems. But, could hope play a role in PTSD recovery? Dr. Rich Gilman and several colleagues explore this phenomenon in a recently published paper “Hope as a change mechanism in the treatment of PTSD” (see, below for full citation). They measure the construct, hope, examine its changes across a course of PTSD treatment, and posit that hope may precede or predict PTSD and comorbid depression symptom change.

This study is a report on outcomes of a VA residential program. All its subjects are Veterans/patients who entered the program over the course of several years. There is no control or other comparison group. Everyone received residential program services covering a number of problems including PTSD. PTSD treatment consisted of combined group and individual Cognitive Processing Therapy (CPT), an empirically-supported PTSD treatment.  In general, this study found the following about hope:

  1. Hope did not change consistently across treatment, but it increased significantly beginning in the middle of CPT treatment and from that point on. That is, patients’ hope improved starting from the point in CPT when they  wrote and talked about their traumas, and then continued to improve over the rest of treatment as patients applied the cognitive skills learned in CPT to re-examine trauma-related beliefs;
  2. Pre-treatment PTSD symptom severity did not predict post-treatment levels of hope;
  3. Higher levels of hope at mid-treatment in CPT (trauma processing phase) predicted lower PTSD symptom severity on patients’ self-report measures.

Veterans’ hopefulness improved as they gained better awareness. What do these findings mean? The authors suggest that because hope, as a mental construct, resists change until other changes have given reason to hope, Veterans’ hopefulness may have depended on changing their minds from strident negative views of self and world based on their traumatic experiences, to views that involved a fuller and fairer consideration of their experiences. Cognitive change in CPT, evidenced by change in “stuck points,” usually doesn’t start to happen substantially until after patients have begun work on their trauma accounts (CPT sessions 4 and 5). The authors suggest that Veterans’ hopefulness improved as they gained better awareness of their difficulties and problematic schema, and developed more effective ways to deal with emotional distress by examining their thinking.

Perhaps for the clinician these results can help shape realistic tempered expectations for PTSD treatment: That patients must first wrestle with their trauma experiences in full context, which is essential to all the PTSD effective treatments; that that will start symptom change; and, hope will follow.

To read and understand more, the full citation of this article is:
Gilman, R., Schumm, J. A., & Chard, K. M. (2012). Hope as a change mechanism in the treatment of Posttraumatic Stress Disorder. Psychological Trauma: Theory, Research, Practice, and Policy, 4, 270—277.