Development of a group treatment for enhancing motivation to change PTSD symptoms

308

Development of a Group Treatment for Enhancing Motivation to Change PTSD Symptoms R o n a l d T. M u r p h y , Dillard University C r a i g S. R o s e n , VA N a t i o n a l Center f o r P T S D a n d Stanford University School o f Medicine R e b e c c a E C a m e r o n , California State University at Sacramento K a r i n E. T h o m p s o n , Veterans Affairs Medical Center N e w Orleans a n d T u l a n e University School o f Medicine Readiness to change, particularly ambivalence or la& of awareness about the need to change, is a modifiable variable that may underlie poor posttreatment outcome found in some studies of combat veterans with PTSD. The authors describe the PTSD Motivation Enhancement (ME) Group, a manualized brief treatment that is conceptually based on the Stages of Change and draws on interventions from the literature on Motivational Interviewing techniques. The PTSD ME Group targets any PTSD symptom or related problem behavior (e.g., ang~ hypervigilance, owning weapons, depression, and substance use) that patients report ambivalence about changing or feel no need to change. The goal of the group is to help patients make decisions about the need to change any behaviors, coping styles, or beliefs not previously recognized as problematic. Although definitive statements about the effectiveness of the group await controlled trials, initial findings indicate that patients are responding to the group as predicted. Further research will test the hypothesis that addition of the PTSD ME Group to a PTSD treatment program is associated with better learning, practice, and implementation of coping skills, which, in turn, should predict better posttreatment fi~nctioning.

p

TREATMENTS f o r c o m b a t - r e l a t e d postt r a u m a t i c stress d i s o r d e r (PTSD) can be efficacious in clinical trials of specific interventions (Foa, Keane, & F r i e d m a n , 2000; Sherman, 1998). However, r e c e n t findings have suggested that PTSD t r e a t m e n t p r o g r a m s may have a limited impact on symptom r e d u c t i o n for Vietnam veterans with long-standing PTSD (Fontana & Rosenheck, 1997;Johnson et al., 1996). Because of this persistence of symptoms, c o m b a t - r e l a t e d PTSD has b e e n labeled a chronic d i s o r d e r for this p o p u l a t i o n (Bremner, Southwick, Darnell, & Charney, 1996; Zlotnick et al., 1999). O n e u n e x p l o r e d factor that may be associated with PTSD chronicity a n d p o o r response to treatment is patient ambivalence about the n e e d to change (Murphy, Cameron, Sharp, & Ramirez, 1999; Newman, 1994; Prochaska & DiClemente, 1983). Because t r a u m a victims with PTSD are often distrustful, working with t h e m can be a challenge (McBride & Markos, 1994; Zaslov, 1994). In o u r exp e r i e n c e in the VA PTSD t r e a t m e n t system, t r e a t m e n t providers have e x p e r i e n c e d some patients as resistant, hostile to t r e a t m e n t staff, a n d externalizing with r e g a r d to their difficulties. In the past, some have viewed "treatm e n t resistance" as a personality o r "attitude" p r o b l e m i n h e r e n t a m o n g veterans with PTSD, with the conseq u e n c e that p r o g r a m s i m p l e m e n t e d therapeutic c o m m u ,S Y C H O S O C I A L

Cognitive and Behavioral Practice 9, 3 0 8 - 3 1 6 , 2002 1077-7229/02/308- 31651.00/0 Copyright © 2002 by Association for Advancement of Behavior Therapy. All rights of reproduction in any fbrm resmwed.

nity techniques that i n c l u d e d c o n f r o n t a t i o n or "attack therapy" as the preferred way of dealing with the perceived resistance. Such confrontational approaches, which have b e e n a p p l i e d with substance abusers, batterers, a n d o t h e r populations, conflict with the n e e d to establish e m p a t h y a n d a climate of safety within which t r a u m a issues can be addressed (C. M u r p h y & Baxter, 1997; Newman). In o u r view, it is critical to avoid b l a m i n g t r a u m a survivors for difficulties with distrust a n d avoidance, b o t h symptoms o f PTSD. Despite their negative consequences, trauma-based p e r c e p t i o n s a n d strategies for c o p i n g with safety a n d interpersonal interactions often feel "right" or a p p r o p r i a t e to b o t h civilian and military t r a u m a victims. T r a u m a survivors with PTSD often find it difficult to view their trauma-based behaviors a n d cognitions as problematic. In o u r e x p e r i e n c e i m p l e m e n t i n g coping-focused treatments such as symptom skills m a n a g e m e n t , conflict resolution training, e m o t i o n m a n a g e m e n t , a n d cognitive restructuring, veterans with PTSD often s e e m e d reluctant to use new skills or, m o r e importantly, to give up old ways o f coping. For example, PTSD patients may view isolation as an effective way o f r e d u c i n g distress r a t h e r than as a p r o b l e m . A n g e r is a particularly c o m m o n a n d insidious e x a m p l e o f how patients with PTSD can externalize a n d minimize a symptom (Chemtob, Novaco, H a m a d a , & Gross, 1997; Novaco & C h e m t o b , 1998). Many treatmentseeking c o m b a t veterans are tired o f b e i n g angry, a n d tired of the consequences o f their anger, such as physical d a m a g e as a result of violence, family problems, a n d legal

PTSD Motivation Enhancement Group problems. Although such patients come into treatment reporting "anger problems," their view of the problem is often different from the therapist's view. The therapist may assume that patients understand their anger-related behavior as an overreaction to a current situation based on past experiences. In contrast, the patient often firmly sees their anger as a normal response to any interaction with what they view as a hostile, provocative world full of people who are careless, unaware of danger, uncaring, and threatening (DiGiuseppe, 1995; DiGiuseppe, Tafrate, & Eckhardt, 1994). We have frequently heard PTSD-diagnosed veterans say that "the average guy is stupid" with regard to trust or potential harm in the day-to-day world. Treatment staff and patients are often unaware of how their differing assumptions impact the therapeutic alliance. Treatment providers often label patients' lack of practice or use of coping tools as "resistance" or "symptom chronicity," attributing this to a personality trait of "denial" or oppositionality, "bad attitude," or a general fear of change. Even if therapists and clients agree on what problems the client is facing, they may have two opposite views as to the cause of the problems and what needs to be changed (Newman, 1994).

A Stages-of-Change Approach to PTSD Symptoms and Related Problems We therefore began to consider resistance, ambivalence, and symptom chronicity within the Stages of Change in the Transtheoretical Model (Prochaska & DiClemente, 1983) and William Miller's Motivational Interviewing approach (Miller, 1985; Miller & Rollnick, 1991). The Transtheoretical Model assumes that modifiable beliefs about the need to change, rather than personality traits of "denial" or negative attitude, underlie the behavioral change process and response to treatment. One c o m p o n e n t of the Transtheoretical Model, the Stages of Change, describes five stages associated with different beliefs about the need to change and actions toward change, including lack of awareness that a problem exists (precontemplation), ambivalence about the need to change (contemplation), initial steps in preparing for change (preparation), engagement in efforts to change (action), and maintaining change (maintenance). A key assumption in the Transtheoretical Model is that different psychoeducational or therapeutic techniques are n e e d e d at each stage to help individuals resolve questions about the need or ability to change that behavior and move to the next stage. The model has been applied largely to smoking and substance abuse (Prochaska, DiClemente, & Norcross, 1992) but has been extended to a wide variety of patient populations (Rosen, 2000), including male batterers (Daniels & Murphy, 1997; C. Murphy & Baxter, 1997; Levesque, Gelles, & Velicer, 2000). Readiness-to-

change variables have been found to predict psychotherapy dropout (Brogan, Prochaska, & Prochaska, 1999; Smith, Subich, & Kalodner, 1995) and substance use (Belding, Iguchi, & Lamb, 1997; Heather, Rollnick, & Bell, 1993). Motivation enhancement interventions based on the Transtheoretical Model have been effective in reducing HIV risk behaviors (Carey et al., 1997) and alcohol use by college students (Borsani & Carey, 2000), problem drinkers (Miller, Benefield, & Tonigan, 1993), and alcoholics high in anger (Project Match Research Group, 1998). Studies of traumatized populations have examined beliefs about the need to change unspecified "problems" a m o n g adult survivors of child abuse (Koraleski & Larson, 1997) and relationship behaviors a m o n g battered women (Feuer, Meade, Milstead, & Resick, 1999; Wells, 1998). Little is known about readiness to change the wide range of specific PTSD symptoms and related problem behaviors a m o n g combat veterans. Rosen et al. (2001) assessed readiness for change for two different problems, alcohol abuse and anger control, a m o n g male combat veterans entering residential PTSD treatment. Patients varied in their readiness to address these two problems, and could be categorized into subtypes consistent with the Transtheoretical Model. For both alcohol abuse and anger management, patients in the a c t i o n / m a i n t e n a n c e stage for that problem reported more frequent use of change strategies than did patients in the precontemplation stage. The relationship of readiness to change PTSD symptoms to treatment engagement and outcome is unknown. We have adapted the Stages of Change (see Table 1) for conceptualizing readiness to change PTSD symptoms and related behaviors and cognitions. This model includes identification of the specific intervention necessary to move an individual up to the next stage of readiness to change, or belief about the need to change. We have emphasized the conceptualization of the cognitive state of an individual in the form of a question that is unique to each stage, with particular interventions best suited for helping an individual answer that question (Miller, 1985; Miller & Rollnick, 1991; Prochaska & DiClemente, 1983). For any particular problem behavior, individuals in the first stage, precontemplation, do not believe that they have a problem ("What problem?"). Here, for example, education about what constitutes a problem (e.g., hypervigilance, substance abuse, or PTSD in general) helps individuals move to the next stage, contemplation. In this stage, individuals may begin to consider the need for change ("Do I need to change?"). Decisional balance techniques and comparison of one's behavior to population norms are used to help resolve ambivalence about the need to change. Once convinced of the need to change, individuals still may be doubtful or ambivalent about their ability to make the necessary changes ("Can I change?"). Peer modeling and mastery

309

310

Murphy et al.

Table I

PTSD Motivation E n h a n c e m e n t (ME) Group, in an u n c o n t r o l l e d clinical trial. D u r i n g o u r i m p l e m e n t a t i o n of the group, Stage Description Question Intervention we collected preliminary data o n the n e e d Precontemplation Person is not considering or What problem? • Education about for a n d potential value of the group, does not want to change a PTSD in general which we have submitted elsewhere b u t particular behavior summarize in the Preliminary Findings Contemplation Person is certainly thinking Do I need to ° Pros and cons section below. It is i m p o r t a n t to emphaabout changing a change? * Comparison to size, however, that r a n d o m i z e d control behavior norms studies of the group have n o t b e e n comPreparation Person is seriously Can I change? ° Education about pleted. Therefore, the present paper must considering and planning how therapy works be considered a report o n a work in to change a behavior and ° Expose to successfifl has taken steps toward peers progress, a n d we focus here on the ratiochange ° Mastery experiences nale a n d technique for i m p l e m e n t i n g the Action Person activelydoing things How do I ° Skill building PTSD ME Group. to change or modify change? ° Homework The PTSD ME group is conceptually behavior ° Practice, role-play based on the Stages of Change a n d draws Maintenance Person continues to How do I keep • Lifestylechange o n interventions from the literature o n Momaintain behavioral change? ° Continue support tivational Interviewing techniques (Miller, change until it becomes ° Relapse prevention 1985; Miller & Rollnick, 1991). The goal permanent of the group is to help patients make deciNote. Adapted from Miller & Rollnick, 1991: and Prochaska, DiClemente, & Norcross, 1992. sions about the n e e d to change any PTSDrelated behaviors, coping styles, or beliefs n o t previously recognized as problematic in o r d e r to inexperiences are helpful in this preparation stage in buildcrease patient e n g a g e m e n t in t r e a t m e n t a n d p r o m o t e ing self-efficacy and protnoting hope for change. The final adaptive posttreatment coping. The seven-session group stages are action, in which individuals are actively making is designed to meet the needs of managed-care environbehavior changes, a n d m a i n t e n a n c e , in which they are ments that require manualized brief treatments that have doing what is necessary to maintain the behavioral change. measurable outcomes with buih-in p r o g r a m evaluation Skill-building, practice, reinforcement, and relapse prea n d assessment of patient satisfaction. v e n t i o n are best i m p l e m e n t e d in these latter stages. In general, within the Motivational Interviewing a n d Stages of Change frameworks, "resistance" is a result of General Clinical Considerations such factors as a lack of awareness of or sensitivity to negative consequences, the perception of problem behaviors or In i m p l e m e n t i n g this intervention, group leaders consequences as normative, and the presence of emoshould follow the overall approach r e c o m m e n d e d by tional, cognitive, or practical roadblocks to change. ReNewman (1994) a n d Miller a n d colleagues (Miller, 1985; Miller & Rollnick, 1991): objective, n o n c o n f r o n t a t i o n a l , garding patients' perceptions a b o u t what is "normal," m a n y treatment-seeking PTSD veterans grew u p in famia n d always using empathic listening techniques to address patients' responses, n o matter how "oppositional" lies a n d n e i g h b o r h o o d s where substance abuse, marital conflict, a n d aggressiveness were c o m m o n . Even more they might seem. Similar approaches have b e e n advocated for treatment of anger (DiGiuseppe et al., 1994) frequently, u p o n their discharge from the military, veterans in PTSD t r e a t m e n t often report living substanceand batterers (C. Murphy & Baxter, 1997). We have f o u n d that many clinicians, regardless of experience, related lifestyles, where aggressiveness, emotional n u m b have difficulty taking a n o n c o n f r o n t a t i o n a l stance with ing, mistrust, a n d violence have b e e n the n o r m . provocative a n d externalizing patients. However, the basis for change is a therapeutic relationship or working D e v e l o p m e n t o f the PTSD Motivation alliance, best fostered by therapists using reflective techEnhancement Group niques resulting in patients feeling understood, listened As we began to reconceptualize our patients' difficulto, a n d more willing to trust (Horvath & Luborsky, 1993; Miller, 1985). N u m e r o u s studies of psychotherapy sugties in e n g a g e m e n t in a n d utilization of t r e a t m e n t in the readiness-to-change model, we decided that there was an gest that therapist empathy a n d client report of the worku r g e n t clinical n e e d to address patient ambivalence or ing alliance are the best predictors of patient o u t c o m e lack of awareness of the n e e d to change. Therefore, we (Horvath & Symonds, 1991; Miller et al., 1993). developed a n d i m p l e m e n t e d a brief therapy group, the A second general consideration in i m p l e m e n t i n g the Stage of Change Model for PTSD

PTSD Motivation Enhancement Group PTSD ME G r o u p is the i m p o r t a n c e o f p r o m o t i n g interaction a n d participation a n d giving patients a sense o f ownership o f the process a n d their decision-making (Newman, 1994; Rosen & Sharp, 1998). For example, although the facilitator provides an overall structure to the discussion, patients are e n c o u r a g e d to verbalize their responses so that m o r e active, insightful, o r a d e p t g r o u p m e m b e r s can serve as role m o d e l s a n d facilitate observational learning. This a p p r o a c h creates an a t m o s p h e r e o f o p e n n e s s a n d helps p r o m p t anxious o r distrustful m e m b e r s to participate. This is particularly helpful in the PTSD ME Group, since the focus is on the often u n p l e a s a n t task o f discussing ambivalence o r lack o f awareness a b o u t the n e e d to change, especially for p r o b l e m s that others may have b e e n trying to get the p a t i e n t to admit. Most i m p o r t a n t , patients are e n c o u r a g e d to use the process to draw their own conclusions a b o u t w h e t h e r they n e e d to c h a n g e any particular behavior. R e g a r d i n g g r o u p size, in o u r e x p e r i e n c e the n u m b e r o f participants has b e e n dictated by the needs o f the t r e a t m e n t p r o g r a m in which the PTSD ME G r o u p has b e e n e m b e d d e d . Because o f this, we have r u n the g r o u p with anywhere from 4 to 40 participants. A l t h o u g h a larger n u m b e r o f patients e n h a n c e s the benefits o f g r o u p process described above, the ideal n u m b e r of participants may be 8 to 15 using 90-minute sessions, which allows e n o u g h time for each particip a n t to r e p o r t on their progress in accomplishing the various tasks specific to the PTSD ME group. Session

turating the newcomers. In this review period, time is given to individualized identification o f problems that patients "might have." T h e second half o f each session consists of discussion of the use of specific tools that will assist patients in deciding if problems that they might have are behaviors they n e e d to change. G r o u p leaders follow a t r e a t m e n t m a n u a l a n d m a k e extensive use o f a whiteb o a r d a n d patient worksheets that are i n c l u d e d in a patient workbook.

Form 1: A Worksheet for Decision Making About the Need to Change A key p a r t o f the g r o u p is having patients g e n e r a t e a list of behaviors or beliefs that m i g h t be a p r o b l e m for them. This process occurs in the first half o f every session, following the general review o f rationale a n d purpose. At that time, patients fill o u t a worksheet (Form 1) that is divided into three columns: DEFINITELY HAVE, MIGHT HAVE, o r DEFINITELY D O N ' T HAVE. T h e MIGHT HAVE c o l u m n is further divided into two categories: A PROBLEM YOV HAVE WONDERED IF YOU HAVE a n d A PROBLEM OTHERS SAY YOU HAVE (BUT YOU DISAGREE). W e

T h e g r o u p p r o t o c o l consists o f seven 90-minute g r o u p sessions: six sessions with four separate g r o u p m o d u l e s (two modules are r e p e a t e d ) a n d a seventh session which is a r e p e t i t i o n o f the first g r o u p att e n d e d (see Table 2). This seventh "repeat" session was a d d e d because veterans can be d i s o r i e n t e d d u r i n g their first few days in a t r e a t m e n t p r o g r a m . To f u r t h e r a c c o m m o d a t e the effects of rolling admissions a n d the e x t e n t o f m e m o r y a n d attention deficit in this p o p u l a t i o n , behavioral l e a r n i n g principles o f r e p e t i t i o n a n d rehearsal are used by reviewing the purpose, rationale, a n d f o r m a t o f the g r o u p for the first half o f each g r o u p session. This review is a c c o m p l i s h e d by g r o u p leaders asking a series o f questions o f the group, usually with m o r e e x p e r i e n c e d m e m b e r s answering, thereby e d u c a t i n g a n d accul-

have

defined

"might

have" p r o b l e m s in these two ways to elicit n o t only problem areas that they have c o n s i d e r e d as possibly n e e d i n g change (contemplation stage), b u t also problems that they

Table 2 PTSD ME G r o u p S e s s i o n O u t l i n e G r o u p Module

Tasks/Material Covered

Session 1

G r o u p Overview

• Review purpose a n d potential value of the g r o u p • Generate list of problems "definitely have," "might have," "don't have"

Sessions 2 a n d 3

C o m p a r i s o n to the Average Guy

• Review purpose a n d potential value o f the g r o u p • Generate list of problems "definitely have," "might have," "don't have" • Patients c o m p a r e their behavior to estimated ageappropriate n o r m s in order to help t h e m j u d g e how problematic their behavior m i g h t be

Sessions 4 a n d 5

Pros a n d Cons

• Review purpose a n d potential value of the g r o u p • Generate list of problems "definitely have," "might have," "don't have" • Decision balance techniques used to help patients decide about the n e e d to c h a n g e "might be a problem" behaviors which they agree they have, b u t are n o t sure are actually problematic

Session 6

Roadblocks

• Review purpose a n d potential value of the g r o u p • Generate list of problems "definitely have," "might have," "don't have" • Identify fears, cognitive distortions, a n d stereotype beliefs that prevent p r o b l e m identification

Session 7

In rolling admission context, patient repeats first group attended

I m p l e m e n t i n g t h e PTSD ME Group General Structure

311

312

Murphy et al.

m e n t providers ("the therapy was poor" o r "the therapists were i n c o m p e t e n t " ) , o r internal (paProblems You Problems You DEFINITELY DEFINITELY tient feels "broken" o r unfixable). (We also HAVE DON'T HAVE p o i n t o u t some clear predictors o f t r e a t m e n t success like m e d i c a t i o n c o m p l i a n c e a n d following t h r o u g h with aftercare plans.) T h e therapist then offers a third possibility for Patient A t r e a t m e n t n o t working: that patients can be Nightmares Trusting people Drugs Restless b l i n d s i d e d by an u n r e c o g n i z e d p r o b l e m . BeDepression Fly off the handle Hard to get along ing b l i n d s i d e d is d e s c r i b e d as an unacknowlImpatience easily with other people e d g e d p r o b l e m creating a downward spiral or Problem with Emotionally cold sequence o f o t h e r problems. T h e therapist bosses then poses the question, "What are some exDon't care what other people think amples of how a p r o b l e m you d o n ' t think you have creates difficulties for you after treatment?" If n e e d e d , the therapist uses social isoPatient B lation as an example, initially suggesting that isolation may be the first response to stress if it Don't trust anyone Don't like too many Been told I'm a Panic attacks people around me Alcohol mean person is still c o n s i d e r e d an adaptive c o p i n g response at one time Always have to be in after treatment. The patients then describe, charge usually with a m i n i m u m o f i n p u t from the therapist, how a t e n d e n c y to isolate u n d e r stress Figure 1. Examples of Form 1 worksheet responses for two patients participating in may lead to o t h e r p r o b l e m s like disconnection the PTSD ME Group. from support a n d dwelling on past traumas, hurts, or injustices. This in turn could then precipitate excessive alcohol use, depression, increased hyperm i g h t be unaware o f o r unwilling to c h a n g e ( p r e c o n t e m vigilance, intrusive thoughts, anger, and loss of control. plation stage). T h e goal is for patients to eventually sort At the e n d of the rationale review, the therapist points items listed u n d e r M I G H T HAVE into D E F I N I T E L Y HAVE o r o u t that the ultimate goal of the g r o u p is to h e l p patients DFFINITELY D O N ' T HAVE. At the e n d of every session, pato avoid getting b l i n d s i d e d by u n a c k n o w l e d g e d p r o b l e m s tients are given time to review their F o r m 1 a n d d e c i d e if following discharge. T h e r e m a i n d e r of this session (the they want to move any "might have" p r o b l e m s to one of first half o f all m o d u l e s as d e s c r i b e d above) is spent rethe o t h e r columns. Examples of typical F o r m l's comviewing the F o r m 1 worksheet a n d having the patients p l e t e d by two outpatients at the b e g i n n i n g of their particidentify p r o b l e m s they "might have" on that form. ipation in the PTSD ME G r o u p are p r e s e n t e d in Figure 1. T h e s e c o n d m o d u l e , C o m p a r i s o n to the Average Guy (Sessions 2 a n d 3), is a i m e d at h e l p i n g patients c o m p a r e Group Modules their behavior to estimated a g e - a p p r o p r i a t e b u t nonIn the first m o d u l e (Session 1), G r o u p Overview, the PTSD n o r m s in o r d e r to h e l p t h e m j u d g e how p r o b l e m p u r p o s e a n d potential value o f the g r o u p is reviewed in atic their behavior m i g h t be. Behaviors are categorized detail. T h e rationale for the g r o u p is p r e s e n t e d in the folalong a range including average, moderate problem, a n d exlowing way. T h e g r o u p l e a d e r first asks, "In 25 words or treme problem. T h r e e dimensions are used to assess behavless, what's the p u r p o s e o f this group?" As described by ior at each o f these levels: frequency, severity o f consethe therapist, the best response is "to make decisions quences, a n d purpose. G r o u p leaders guide m e m b e r s in a b o u t p r o b l e m s you m i g h t have," which patients are usuanalyzing what a particular behavior would look like at ally able to articulate when the rationale is reviewed in each o f the three levels on each o f the three dimensions. later sessions. T h e therapist then p r o m p t s discussion of For example, if hypervigilance was the behavior selected, the question: "Why would we have a g r o u p a b o u t probg r o u p leaders would elicit a description o f normative lems you ' m i g h t have,' a n d n o t a b o u t p r o b l e m s you know levels of safety awareness, which m i g h t include checking you have?" T h e therapist then asks, "If a patient does to make sure doors are locked at night a n d installing poorly after he leaves PTSD treatment, what reasons motion-sensitive lights outside the house. At this level conmight he give?" Patients are then e n c o u r a g e d to describe sequences are mild, such as cost of the lights. T h e p u r p o s e attributions about continuation or return of PTSD-related of the average level o f safety awareness may be to feel reap r o b l e m s a n d symptoms after treatment. T h e therapist sonably safe. At the m o d e r a t e p r o b l e m level, behaviors summarizes participants' responses by characterizing the might include frequently checking doors a n d windows at attributions as either external, usually b l a m i n g the treatMIGHT HAVES Problems you might Problems you might have: You have have: Problems wondered if you other people say you have have but you disagree

PTSD Motivation Enhancement Group n i g h t a n d installing m o r e e l a b o r a t e alarm systems, with c o n s e q u e n c e s i n c l u d i n g m o r e time a n d m o n e y invested. Here, the p u r p o s e begins to take on m o r e o f an anxietyr e d u c t i o n role. At e x t r e m e levels o f hypervigilance, behaviors may include checking the p e r i m e t e r o f the house all night, k e e p i n g a gun u n d e r the bed, a n d setting b o o b y traps. Consequences are a great deal o f time a n d energy spent a n d risk to c h i l d r e n a n d others from the gun, with the p u r p o s e o f the behavior m o r e a b o u t survival a n d a feeling o f "life o r death." Seeing where their own behavior fits in this range of p r o b l e m s helps patients c o n s i d e r that they m i g h t have a p r o b l e m they h a d n o t previously recognized. In one case, a p a t i e n t spoke u p after the hypervigilance e x a m p l e h a d b e e n reviewed, a n d asked if there m i g h t be some h a r m in teaching his 9-year-old son to crawl u n d e r a wire without t o u c h i n g it, which he h a d b e e n d o i n g for some time. T h e ensuing discussion h e l p e d the p a t i e n t c o n s i d e r that hypervigilance was a p r o b l e m for him that n e e d e d to be addressed. In the third m o d u l e , Pros a n d Cons (Sessions 4 a n d 5), decision balance techniques are reviewed a n d practiced to h e l p patients decide a b o u t the n e e d to c h a n g e "might have" b e h a v i o r s - - b e h a v i o r s they agree that they engage in, b u t are n o t sure are actually problematic. In this simple b u t effective technique, patients weigh the advantages a n d disadvantages o f various PTSD symptoms and related behaviors, such as gun ownership, continued alcohol use, a n d hypervigilance (e.g., "setting perimeters"). A case e x a m p l e involves a Vietnam veteran in an outp a t i e n t PTSD p r o g r a m who a p p l i e d the decision balance tool to the p r o b l e m o f isolation. As a result o f his wife's l o n g - r u n n i n g complaint, he h a d listed isolation on his F o r m 1 in the c o l u m n A P R O B L E M O T H E R S SAY I H A V E , B U T I DISAGREE. U n d e r pros, the p a t i e n t listed "Feel safer"; "When I want to do something, I can j u s t do it"; "Don't have to deal with o t h e r p e o p l e ' s problems"; a n d "Don't get into hassles with o t h e r people." T h e cons i n c l u d e d "Distant from children"; "I get depressed"; "I think m o r e a b o u t b a d things that h a p p e n e d in the war"; a n d "Think m o r e a b o u t using drugs." After some discussion, the patient d e c i d e d that isolation was a "definitely have" problem for him a n d c o n c l u d e d that this behavior h a d significantly limited his functioning for many years. T h e final m o d u l e , Roadblocks (Session 6), focuses on how difficult it can be to c o n s i d e r c h a n g i n g one's own behaviors. Leaders discuss the c o n c e p t o f roadblocks as being things that make it difficult to even consider w h e t h e r a behavior is p r o b l e m a t i c a n d in n e e d o f change. Comm o n roadblocks include shame, fears, cognitive distortions, a n d inaccurate stereotypes a b o u t what it means to have a p r o b l e m . In this context, veterans have often rep o r t e d fears o f b e i n g perceived as weak, or shame a b o u t the distress they have b r o u g h t to loved ones. Cognitive distortions include all-or-nothing thinking such as "If I

313

a d m i t to having o n e m o r e p r o b l e m , I will have to acknowledge b e i n g a c o m p l e t e failure." Stereotypes can cause p r o b l e m s such as reluctance to a d m i t to an alcohol p r o b l e m because o f e r r o n e o u s beliefs a b o u t what it m e a n s to be an alcoholic (e.g., the town d r u n k o r h o m e less) or wanting to avoid b e i n g perceived as a "crazy Vietn a m veteran." Patients often r e p o r t that they want to avoid thinking that they h a d the same p r o b l e m s as a specific p e r s o n in their past, such as a father with an alcohol p r o b l e m o r violent temper, o r a family m e m b e r who h a d b e e n p u t into a mental hospital because o f a "nervous breakdown." After the g r o u p generates a variety o f possible roadblocks, participants are instructed to list on their worksheet only those that they feel apply to them. T h e collaborative process additionally provides a supportive c o n t e x t in which veterans can n o r m a l i z e a n d exp e r i e n c e the universality o f their feelings.

Program Evaluation At the e n d o f every group, each p a r t i c i p a n t is asked to list on a special form any p r o b l e m s that he identified as "might have" d u r i n g the course o f that particular session. Also, patients are asked to r e p o r t if they reclassified any behaviors previously identified as "might have" as "definitely a p r o b l e m " o r "definitely n o t a p r o b l e m " at any time d u r i n g that g r o u p session. Regular collection o f these data allows g r o u p leaders a n d p r o g r a m evaluators to track the frequency a n d type o f items a b o u t which patients show ambivalence r e g a r d i n g change. Perhaps m o r e importantly, these data track individual a n d g r o u p changes in participants' beliefs a b o u t the n e e d to c h a n g e over the course o f the group. In a d d i t i o n to these session-by-session data, patients who c o m p l e t e all seven sessions o f the g r o u p are asked to fill o u t a C o n s u m e r Satisfaction Survey (CSS). T h e CSS uses o p e n - e n d e d questions a n d Likert scale items to assess PTSD ME Group participants' understanding of group goals and process, their ratings of helpfulness of group modules a n d effectiveness o f leaders a n d g r o u p process, a n d self-reported changes in a c k n o w l e d g m e n t o f p r o b l e m behaviors. These data can inform p r o g r a m staff a b o u t patients' a c c e p t a n c e a n d utilization o f the g r o u p a n d allow patients to give f e e d b a c k a b o u t their o p i n i o n s a n d feelings a b o u t g r o u p participation. Social validity is an imp o r t a n t issue (Foster & Mash, 1999) as g r o u p participants must perceive benefits to participation in o r d e r for a treatment to be i m p l e m e n t e d successfully, even when there are statistically measurable improvements in functioning.

Summary of Preliminary Findings Findings from o u r u n c o n t r o l l e d evaluation study o f the PTSD ME g r o u p are in press elsewhere (Murphy,

314

Murphy et al. C a m e r o n , et al., in press) a n d will be briefly s u m m a r i z e d here. Data were collected over an 18-month p e r i o d from 243 inpatients who a t t e n d e d the PTSD ME G r o u p d u r i n g their stay in a VA PTSD t r e a t m e n t p r o g r a m . Participants classified a wide range o f categories of PTSD symptoms a n d related behaviors as "might have" problems, with the highest p e r c e n t a g e o f patients (48%) classifying a n g e r as a "might have." A p p r o x i m a t e l y one-third o f the patients l a b e l e d isolation, depressive symptoms, trust, a n d health as a "might have," a n d a b o u t one-fourth r e p o r t e d conflict resolution, alcohol, c o m m u n i c a t i o n , r e l a t i o n s h i p / i n t i macy, restricted range of affect, a n d drugs as "might have." O t h e r types o f PTSD-related problems, for example, hypervigilance, were r e p o r t e d as "might haves" by 15% to 21% of the patients. R e e x p e r i e n c i n g p r o b l e m s were rarely identified as "might haves." With respect to changes in p r o b l e m awareness a n d ambivalence d u r i n g the course o f the group, veterans on average reclassified a p p r o x i m a t e l y 40% of all items they initially listed as "might have" to either "definitely have" or "definitely d o n ' t have." For patients who classified various p r o b l e m s as "might have," by the e n d of their participation in the g r o u p significantly m o r e veterans reclassified anger, isolation, anxiety, authority, guilt, e m o t i o n a l masking, relationship/intimacy, smoking, a n d trust problems as "definitely have" than "definitely d o n ' t have." G r o u p participants r e p o r t e d high levels o f satisfaction with all aspects o f g r o u p c o n t e n t a n d process, a n d gave high ratings on helpfulness (Franklin et al., 1999). Alt h o u g h conclusive statements a b o u t the effectiveness o f the g r o u p await c o n t r o l l e d trials, these initial findings indicate that patients are r e s p o n d i n g to the g r o u p as predicted. O t h e r findings have indicated that servicec o n n e c t e d c o m p e n s a t i o n a n d ethnicity were significantly related to patients' beliefs a b o u t the n e e d to c h a n g e ( M u r p h y et al., 2000). Specifically, African Americans identified fewer p r o b l e m s that they were ambivalent about changing than Caucasian veterans, a n d having servicec o n n e c t e d c o m p e n s a t i o n was associated with lower frequency o f r e p o r t e d changes in p r o b l e m awareness or ambivalence. We have also analyzed data addressing an i m p o r t a n t assumption u n d e r l y i n g o u r methods: Specifically, the identification o f a behavior, symptom, o r c o p i n g style as a "might have" is associated with some likelihood that a p r o b l e m actually exists. Preliminary findings i n d i c a t e d that each sample o f patients who l a b e l e d a particular category o f PTSD p r o b l e m s (e.g., anger, hypervigilance, isolation, restricted range of affect, etc.) as "might have" were above the cutoff for severe PTSD symptoms on the Intrusions, Avoidance, a n d Hyperaronsal subscales o f the PTSD Checklist (PCL; Weathers, Litz, H e r m a n , Huska, & Keane, 1993). Further, patients initially listing any particular p r o b l e m as "might have" did n o t differ on the three

PCL subscales from patients who h a d listed the same p r o b l e m as "definitely have." Similarly, Rosen et al. (2001) f o u n d a wide range o f readiness to c h a n g e even a m o n g PTSD patients with high levels of objectively assessed a n g e r a n d alcohol problems.

Integrating the PTSD ME Group Into Programs How would the PTSD ME Group, a b r i e f therapy motivation intervention, best be i m p l e m e n t e d within a larger program? In o u r first m a j o r trial at the National C e n t e r for PTSD in Menlo Park, the PTSD ME G r o u p was run concurrently with all o t h e r t r e a t m e n t c o m p o n e n t s in a 60-day i n p a t i e n t VA PTSD p r o g r a m . This a p p r o a c h h a d various plusses a n d minuses. O n e advantage, which initially s e e m e d a disadvantage, was that the rolling admissions policy o f the p r o g r a m created a mix o f senior a n d new patients in all the groups, i n c l u d i n g the PTSD ME Group. This allowed the f o r m a t i o n o f a g r o u p culture, structured a n d unstructured, in which m o r e senior peers acted as advisors a n d role models for newer m e m b e r s o f the group. An i m p o r t a n t disadvantage o f r u n n i n g the g r o u p over the same time p e r i o d as o t h e r groups a n d activities is that patients may be l e a r n i n g c o p i n g skills that they may n o t be convinced they need. For example, given that almost 50% o f patients may be ambivalent a b o u t anger being a p r o b l e m for them, a n u m b e r of participants in a n g e r m a n a g e m e n t groups may be less motivated to learn, practice, o r use new ways o f d e a l i n g with anger. In contrast to the c o n c u r r e n t scheduling of the PTSD ME Group, as was i m p l e m e n t e d at Menlo Park, the PTSD ME G r o u p has b e e n run on a trial basis as p a r t o f the seco n d o f five phases o f t r e a t m e n t in the PTSD O u t p a t i e n t Clinic at the New Orleans VA Medical CenteL Veterans e n t e r i n g into o u t p a t i e n t t r e a t m e n t begin with four weekly PTSD Education G r o u p sessions designed to educate patients a b o u t the d i s o r d e r a n d the t h e r a p e u t i c process. Patients then move to the PTSD ME G r o u p a n d a case m a n a g e m e n t g r o u p where they begin to identify problems, develop t r e a t m e n t plans, a n d discuss progress. T h e third phase focuses on c o p i n g skills such as stress m a n a g e m e n t and cognitive restructuring. T h e fourth phase offers a d e v e l o p m e n t a l perspective, a n d the fifth phase focuses on relapse prevention. Patients move t h r o u g h the phases sequentially, a l t h o u g h n o t necessarily at the same pace. T h e p l a c e m e n t o f the PTSD ME G r o u p early in this sequence affords patients the o p p o r t u n i t y to develop a new perspective on their own personal difficulties with a f o u n d a t i o n o f insight into PTSD and the process of treatment. Patients have an increased awareness o f their potential difficulties a n d are b e t t e r able to articulate these after the PTSD Education Group. Thus, the t h e r a p e u t i c process may be further e n h a n c e d by having the PTSD ME G r o u p n e a r the b e g i n n i n g of treatment,

315

PTSD M o t i v a t i o n E n h a n c e m e n t G r o u p

w h e n p a t i e n t s are d e v e l o p i n g goals a n d objectives. Treatm e n t p l a n n i n g m a y be m o r e r e l e v a n t a n d f o c u s e d , a n d t r e a t m e n t i n t e r v e n t i o n s o f f e r e d in s u b s e q u e n t phases m a y b e m o r e effective. A t h i r d m e t h o d o f i n t e g r a t i n g t h e P T S D ME G r o u p i n t o l a r g e r p r o g r a m s w o u l d be to offer a short, two- o r three-session v e r s i o n o f t h e g r o u p to p a t i e n t s w h o are c o n s i d e r i n g w h e t h e r o r n o t to b e g i n o r c o n t i n u e treatm e n t . P a r t i c i p a t i o n in a w o r k s h o p - t y p e f o r m a t c o u l d h e l p p a t i e n t s identify goals o r p r o b l e m s they h a d n o t previously c o n s i d e r e d , o r r e c o n c e p t u a l i z e t h e n a t u r e o f t h e i r p r e s e n t i n g c o m p l a i n t s . Patients c o u l d t h e n m a k e b e t t e r decisions a b o u t t h e n e e d to b e g i n t r e a t m e n t o r e n g a g e in additional treatment components.

Applying the PTSD ME Group to Nonveteran Populations T h e PTSD ME G r o u p has b e e n primarily i m p l e m e n t e d with c o m b a t veterans, a l t h o u g h we have r u n the g r o u p successfully with a small n u m b e r o f f e m a l e v e t e r a n s w h o s e p r i m a r y t r a u m a i n v o l v e d sexual assault, s o m e t i m e s with m u l t i p l e i n c i d e n t s o r c h i l d h o o d sexual abuse. T h e r e m a y b e b r o a d e r applicability o f t h e g r o u p in that the P T S D s y m p t o m s a n d c o m m o n c o m o r b i d p r o b l e m s targ e t e d by the P T S D ME G r o u p also exist in civilian t r a u m a victims. Clinicians w h o c o n s i d e r u s i n g t h e P T S D ME G r o u p with n o n v e t e r a n P T S D p o p u l a t i o n s m u s t k e e p in m i n d that t h e g r o u p was d e s i g n e d to address p a t i e n t s exp e r i e n c i n g a variety o f p r o b l e m s , with the a s s u m p t i o n t h a t t h e r e will be v a r i a t i o n in r e a d i n e s s to c h a n g e across d i f f e r e n t PTSD s y m p t o m s a n d o t h e r p r o b l e m s . T h e PTSD ME G r o u p , t h e n , m a y n o t be a p p r o p r i a t e for individuals with a r e c e n t , s i n g l e - i n c i d e n t t r a u m a , for e x a m ple, with a c i r c u m s c r i b e d set o f t r a u m a s y m p t o m s a n d less g e n e r a l life dysfunction. S o m e o f t h e P T S D ME G r o u p t e c h n i q u e s , however, may be h e l p f u l for such a p a t i e n t w h o s e e m s a m b i v a l e n t o r u n a w a r e o f t h e n e e d to c h a n g e c e r t a i n c o p i n g b e h a v i o r s o r beliefs r e l a t e d to t h e traum a t i c event. I n t h e p r e s e n t c l i m a t e o f w i d e s p r e a d anxiety f o l l o w i n g the S e p t e m b e r 11 terrorist attacks a n d a n t h r a x scare (Murphy, Wismar, & F r e e m a n , in press; S c h u s t e r et al., 2001), d e t e r m i n i n g w h e n fear-based b e h a v i o r s are m a l a d a p t i v e can be a difficult task for a n y o n e , b u t may b e m o r e so for P T S D p a t i e n t s a n d possibly m e n t a l h e a l t h patients in g e n e r a l (Franklin, Young, & Z i m m e r m a n , 2002). T h e m o t i v a t i o n a l i n t e r v e n t i o n discussed h e r e is still u n d e r d e v e l o p m e n t , particularly b e c a u s e e v i d e n c e f r o m c o n t r o l l e d studies r e g a r d i n g t r e a t m e n t effectiveness is lacking. O u r o n g o i n g r e s e a r c h efforts, i n c l u d i n g t h e use o f r a n d o m i z e d controls, are a i m e d at testing the h y p o t h e sis that a d d i t i o n o f a PTSD ME G r o u p to a PTSD t r e a t m e n t p r o g r a m is associated with b e t t e r l e a r n i n g , practice, a n d i m p l e m e n t a t i o n o f c o p i n g skills, w h i c h in t u r n s h o u l d

predict better posttreatment functioning. Our goal here has b e e n to o f f e r a n e w a p p r o a c h for i n c r e a s i n g t h e effectiveness o f P T S D t r e a t m e n t t h a t can b e e v a l u a t e d by clinicians a n d r e s e a r c h e r s as to its value, practicality, a n d long-term impact on patients' functioning. The outcome o f o u r o w n a n d o t h e r s ' e v a l u a t i o n o f t h e P T S D ME G r o u p will d e t e r m i n e t h e f u r t h e r d e v e l o p m e n t o f this intervention.

References Belding, M., Iguchi, M, & Lamb, R. (1997). Stages and processes of change as predictors of dl~ag use among methadone maintenance patients. Experimental and Clinical Psychopharmacology, 5, 65-73. Borsani, B., & Carey, K. B. (2000). Effects of a brief motivational intervention with college student drinkers. Journal of Consulting and Clinical Psychology, 68, 728-733. Bremner, J. D., Southwick, S. M., Darnell, A., & Charney, D. S. (1996). Chronic PTSD in Vietnam combat veterans: Course of illness and substance abuse. American Journal of Psychiatry, 15, 369-375. Brogan, M. M., Prochaska, J. O., & Prochaska, J. M. (1999). Predicting termination and continuation status in psychotherapy using the transtheoretical model. Psychotherapy, 36, 50-60. Carey, M. E, Maisto, S. A., Kalichman, S. C., Forsyth, A. D., Wright, E. M., &Johnson, B. T. (1997). Enhancing motivation to reduce the risk of HIV infection for economically disadvantaged urban women.Journal of Consulting and Clinical Psychology, 65, 531-541. Chemtob, C. M., Novaco, R. W., Hamada, R. S., & Gross, D. M. (1997). Cognitive-behavioral treatment for severe anger in posttraumatic stress disordel: Journal of Consulting and Clinical Psychology, 65, 184-189. Daniels,J. W., & Murphy, C. W. (1997). Stages and processes of change in batterers' treatment. Cognitive and Behavioral Practice, 4, 123-145. DiGiuseppe, R. (1995). Developing the therapeutic alliance with angry clients. In H. Kassinove (Ed.), Anger disorders: Definition, diagnosis and treatment (pp. 131-150). Philadelphia: Taylor & Francis. DiGiuseppe, R., Tafrate, R., & Eckhardt, C. (1994). Critical issues in the treatment of anger. Cognitive and Behavioral Practice, 1, 111-132. Feuer, C., Meade, L., Milstead, M., & Resick, P. (1999, November). The transtheoretical model applied to domestic violence survivors. Paper presented at the annual meeting of tile International Society for Traumatic Stress Studies, Miami, FL. Foa, E. B., Keane, T. M., & Friedman, M.J. (2000). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. New York: The Guilford Press. Fontana, A., & Rosenheck, R. (1997). Effectiveness and cost of the inpatient treatment of posttraumatic stress disorder: Comparison of three models of treatment. American Journal of Psychiatry, 154, 758-765. Foster, S. L., & Mash, E.J. (1999). Assessing social validity in clinical treatment research: Issues and procedures. Journal of Consulting and Clinical Psychology, 67, 308-319. Franklin, C. L., Murphy, R. T., Cameron, R. E, Ramirez, G., Sharp, L. D., & Drescher, K. D. (1999, November). Perceived helpfulness of a group targeting motivation to change PTSD symptoms. Poster session presented at the annual meeting of the International Society for Traumatic Stress Studies, Miami, FL. Franklin, C. L., Young, D., & Zimmerman, M. (2002). Psychiatric patients" vulnerability in the wake of the September 11 terrorist attacks. Manuscript submitted for publication. Heather, N., Rollnick, S., & Bell, A. (1993). Predictive validity of the Readiness to Change questionnaire. Addiction, 88, 1667-1677. Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology, 61, 561-573. Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A recta-analysis.Journal of Counseling Psychology, 38, 138-149.

316

M u r p h y e t al.

Johnson, D. R., Rosenheck, R., Fontana, A., Lubin, H., Charney, D., & Southwick, S. (1996). Outcome of intensive inpatient treatment for combat-related posttraumatic stress disordm: Ame~4canJournal q[P~ychiatry', 153, 771-777. Koraleski, S. E, & Larson, L. M. (1997). A partial test of the Transtheoretical Model in therapy with adult survivors of childhood sexual abuse.Journal of Counseling Psychology, 44, 302-306. Levesque, D. A., Gelles, R.J., & Velicer, W. E (2000). Development and validation of a stages of change measure for men in batterer treatment. Cogaitive Therapy and Resean'h, 24, 175-199. McBride, M. C., & Markos, R A. (1994). Sources of difficnhy in counselling sexual abuse victims and survivors. Special Issue: Perspecfives on working with difficult clients. Canadian Journal o[ Counseling, 28, 83-99. Miller, W. R. (1985). Motivation 1or treatment: A rm4ew with a special emphasis on alcoholism. P~ychological Bulletin, 99, 84-107. Millet', W. R., Benefield, R. G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Jouraal of Consulting and Clinical P~vcholo~, 61, 455-461. Millet, W. R., & Rollnick, S. (1991). Motivational interviewing. New York: The Guilford Press. Murphy, C. M., & Baxtm; V. A. (1997). Motivating batterers to change in the treatment context.Journal of Interpersonal Violence, 12, 607619. Murph}; R. T., Cameron, R. R, Sharp, L., & Ramirez, G. (1999). Motivating veterans to change PTSD symptoms and related behaviors. PTSD Clinical Quarterly, 8, 32-36. Murphy, R. T., Cameron, R. R, Sharp, L., Ramirez, G., Rosen, C., Drescher, K., & Gusman, D. E (in press). Readiness to change PTSD symptoms and other problems among veterans participating ix a Motivation Enhancement Group. the Behavior Therapist. Murphy, R. T., Drescher, K., Sharp, L., Ramirez, G., Rosen, C., Cameron, R. E, et al. (2000, November). Individual differences in readiness to change PTM): Service-connection and ethnicit~,. Poster session presented at annual meeting of the International Society for ]3"aumatic Stress Studies, San Antonio, TX. Murphy, R. T., Wismar, K., & Freeman, K. (in press). Predictors of stress symptoms among AIi'ican-American college students following the September 11, 2001, terrorist attacks. Journal of Nervous and

Mental Disease. Newman, C. E (1994). Understanding client resistance: Methods for enhancing motivation to change. Coguitive and Behavioral Practice, 1, 47-69. Novaco, R. W., & Chemtob, C. C. (1998). Anger and trauma: Conceptualization, assessment and treatment. In V. M. Follette, J. h Ruzek, & E R. Abueg (Eds.), Cognitive-behavioral therapiesfor trauma (pp. 162-190). New York: The Guiltord Press. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change in smoking: Toward an integrative model of change. Journal of Consulting and Clinical Ps~cholo~, 40, 432-440. Prochaska,J. O., DiClemente, C. C., & Norcross,J. C. (1992). In search

of how people change: Applications to addictive behaviors. American P*ychologi~t, 47, 1102-1114. Project Match Research Group. (1998). Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes. Alcoholism: Clinical and Experimental Research, 22, 1300-1311. Rosen, C. S. (2000). is the sequencing of change processes by stage consistent across health problems? A meta-analysis. Health Psychology', 19, 593-604. Rosen, C. S., Murphy, R. T., Chow, H. C., Dreschet; K. D., Ramirez, G., Ruddy, R., & Gusman, E (2001). Posttraumatic stress disorder patients' readiness to change alcohol and anger problems. Psychotherapy, 38, 233-244. Rosen, C. S., & Sharp, L. (1998, November). Using the Elaboration Likelihood Model (ELM) to improve inotivational interventions. in R. Murphy (Chair), Stages of Change in assessment and twatment of PTSD. Symposium conducted at the annual meeting of the Intm: national Society for Study of Traumatic Stress, Washington, D.C. Schuster, M. A., Stein, B. D.,Jaycox, L. H., Collins, R. L., Marshall, G. N., Elliott, M. N., et al. (2001). A national survey of stress reactions after the September 11, 2001, terrorist attacks. New England Journal of Medicine, 345, 1507-1512. Sherman, J..J. (1998). Effects of psychotherapeutic treatments for PTSD: A recta-analysis of controlled clinical trials.Journal of Traumatic Stress, 11, 413-435. Smith, K.J., Subich, L. M., & Kalndnet; C. (1995). The transtheoretical model's stages and processes of change and their relation to premature termination. Journal of Counseling Ps~,cholog~; 42, 34-39. Weathers, E W., Litz, B. T., Herman,J. A., Huska, J. A., & Keane, T. M. (1993, November). The PTSD Checklist (PCL): Reliability, validity and diagnostic utili(v. Paper presented at the 9th Manual Confm: ence of the 1STSS, San Antonio. Wells, M. T. (1998, November). Assessing battered women's readiness to change: An instrument development study. Paper presented at the annual meeting of the International Society for Traumatic Stress Studies, Washington, DC. Zaslov, M. R. (1994). Psychology of comorbid posttraumatic stress disorder and substance abuse: Lessons from combat veterans.Journal oJ Ps~,choactiveDrug~, 26, 393-400. Zlotnick, C., Warshaw, M., Shea, M. T., Allsworth, J., Pearlstein, T., & Keller, M. B. (1999). Chronicity in posttraumatie stress disorder (PTSD) and predictors of course of comorbid PTSD in patients with anxiety disorders.Journal of Traumatic Stress, 12, 89-100. Address correspondence to Ronald T. Murphy, Department of Psychology, Dillard Universit}; 2601 Gentilly Blvd., New Orleans, LA 70122.

Received: August 1, 2001 Accepted: March 5, 2002