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Coping with Post-Traumatic Stress

Research shows that after most traumatic events about one in five people who are directly affected will develop long term symptoms of post-traumatic stress disorder. These can include sleeplessness, nightmares, flashbacks, a sense of hyper-vigilance, jumpiness and anxiety and depression.

"There are about 100,000 people in New York who were directly involved with events related to the World Trade Center attack," says Dr. Edna Foa, a professor of clinical psychology who is director of the Center for Study and Treatment of Anxiety at the University of Pennsylvania and one of the world's leading experts on post-traumatic stress disorder, which is called PTSD. "This includes rescue workers, people caught in the buildings, those who saw people jumping or saw pieces of bodies and people who lost loved ones. About 20 to 25 percent will have some chronic problems."

Foa and at least a dozen other major experts are concerned that some efforts to treat traumatic stress or prevent symptoms from becoming chronic can actually do more harm than good. They sent a letter discussing this problem in the wake of the disaster to the newsletter of the American Psychological Association.

For example, the International Critical Incident Stress Foundation sent to New York 100 teams of up to seven members each after September 11th to offer "Critical Incident Stress Debriefings." These are one-shot group or individual sessions in which those who have experienced a traumatic event meet with a trained professional to "process" what happened -- by discussing their experiences in detail, within three days of the incident.

There are no properly controlled studies of this technique -- but a similar therapy, which involves meeting one-on-one for one session with a professional shortly after the event and discussing it explicitly is called Psychological Debriefing. This has been studied extensively -- and the results are distressing.

Of ten studies, eight showed no effect, positive or negative. But the two studies that followed patients longest found that those who had been debriefed did significantly worse. One, a 1997 study of serious burn victims, found that fourteen months after the incident, 26 percent of those who had been debriefed had post-traumatic stress symptoms -- while only nine percent of those who received no psychological intervention did.

The other study which found that those who had been debriefed did worse also looked at the relationship between people's initial reactions and their responses to the therapy. Those whose first reactions did not include many or severe symptoms did not seem to be helped or harmed by the debriefing. But those who had a strong initial reaction were much worse if they got debriefed.

"It was as if the debriefing arrested the course of natural recovery," says Foa.

So what should people do who are experiencing after-effects of the World Trade Center terrorist attack? First, says Foa, allow yourself a chance to recover on your own. There is no evidence that any type of early treatment can help -- and some that some kinds can harm -- so simply do what feels right for you.

If you are having a strong reaction to the events, it is best to talk about your emotions with friends and loved ones. Those who have little initial psychological reaction are less likely to develop symptoms than those who react strongly and experience symptoms right away. As a result, you should not try to get people to talk about it if they aren't ready -- their own methods of coping may be best for them.

Contrary to much of the advice being given by the media, watching images of the catastrophe on television may not always be harmful. "We don't really know what effect television has," says Foa, "but I would think repeated exposure would produce habituation." This could help by allowing strong reactions to diminish over time. "There's a sensitive balance," says Foa. "You don't want to obsess too much and sit inside watching TV all the time either."

As much as possible, try to get back to your normal life. Avoidance of things like the subway or tall buildings can become a habit that is difficult to break.

If symptoms do not diminish on their own after six weeks, says Foa, "That's the time to seek professional help."

Cognitive/behavioral therapy (CBT) is one technique that has been shown by a number of studies to be particularly effective. Studies comparing therapy by those trained in cognitive techniques with ordinary counseling find that CBT consistently does better. CBT involves recalling the trauma with a therapist and learning new ways of thinking about it to improve emotional coping skills. Antidepressant medication like Prozac, Zoloft and Paxil can also be helpful.

There are also heavily-promoted therapies that have little evidence to support their claims. For example, much media attention has been given to a technique called EMDR (Eye Movement Desensitization and Reprocessing), which involves recalling the incident while a therapist moves her fingers in front of your eyes. Most research on EMDR has not been properly controlled-- and it is promoted by a group that sells training in it to therapists. Says Foa, "There are now three studies where it has been compared to exposure [a type of cognitive/behavioral therapy]. In two of the three studies, EMDR was not as effective and the third study, which was done by a proponent of EMDR showed the two were equivalent."

It is a shame that psychological treatment is so vulnerable to fads and so rarely properly researched-- and unsettling to think that some treatments can really make matters worse. To protect yourself, be sure that you know what you are getting, what the research on it shows and that it is appropriate for your needs.

Below are some websites that may be helpful:

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