Abstract
How our conceptualization of stress has changed since early – which century? No longer are men, suffering from the unendurable effects of combat, viewed as either weak, neuraesthenic or, even worse, cowardly, to be punished by the might of the military or sent back to the front line to die like a man. We have grown to recognize, in fits and starts admittedly, that a stiff upper lip in times of disaster is often incompatible with resumption of even an approximation to a normal existence. We have defined stress, redefined it, observed its effects in animals, its more complex effects in us, become more subtle in our assessment of it, become more biological, more psychological.
We have become more refined in its description, in understanding its causes, and in its treatment. We have developed fine treatments for posttraumatic stress disorder (PTSD). In Victoria, we have the National Centre for War-related PTSD, where the appallingly long-term effects of the Vietnam War on veterans and their families are being documented and where treatment is developed and monitored. We have teams who have been trained to offer counselling at disaster sites in the hope of forestalling the formation of PTSD, albeit with limited success. We have, in some hospitals, psychological assistance for those involved in motor car accidents. What we mainly have, though, are individual professionals treating individual patients who have suffered the symptoms of PTSD for too long and have, somehow or other, found their way to therapy. Now we have a book, the aim of which is to enable the practitioner to recognize and treat those whose vulnerabilities to their own disasters have led to acute stress disorder (ASD), one step from the brink of PTSD.
The title of the book, Acute Stress Disorder. a Handbook of Theory, Assessment, and Treatment, is an accurate reflection of the breadth of the contents, but not of the detail, where the real interest lies and where the expertise of the authors as academic, research and clinical psychologists is best reflected. The authors, Associate Professor Bryant and Dr Harvey, are Australian, each have prodigious publication lists belying their relative youth and both have been the recipients of prestigious awards. They give an even-handed, if very brief, theoretical perspective on ASD and PTSD before clarifying their own model, integrating biological and emotional processing perspectives. The book starts with a comparison of ASD and PTSD. Whereas a diagnosis of PTSD can be made only after 1 month post-trauma, ASD can be diagnosed immediately. Another difference between the two disorders is the formal inclusion of dissociation in ASD, beyond the amnesia of PTSD, fuelling the controversy over the existence of such a phenomenon.
The growing recognition that application of cognitive– behavioural therapy to PTSD is highly successful suggests that the book will be valuable for treating ASD. For those practitioners who aspire to evidence-based therapy, the review of assessment tools gives a range of possibilities for capturing change. The description of treatment is thorough in presenting the elements of a cognitive– behavioural approach and is combined with comments on when to treat or leave be. Sensitivity to the client and the meaning of symptoms is evident throughout. Vignettes illustrate graphically some of the means of engaging in the process of therapy, while the diverting chapter devoted to obstacles to therapy would, if not so helpful, challenge the confidence of the more inexperienced therapist. It even describes conditions under which exposure, for example, should not be used. Treatment avoidance and re-traumatization can be the outcome of a too enthusiastic application of exposure therapy.
The book is also strong in its discussion of the legal implications of diagnosing and treating ASD. Of particular interest is the discussion of memory and the care needed to avoid contamination. It is a useful reminder of issues surrounding the recovered memory versus false memory debate.
A book worth owning if you would like to be aware of how to treat ASD and prevent PTSD. And if you are thoughtful of your clients' individuality, their cultural and social backgrounds, their affiliations and their interpretations of their traumatic experiences, you will appreciate the authors' perspective on ASD.