Enhancing Quality in
School Mental Health

Clinician concerns about exposure

Exposure techniques constitute a key component in treating students who present with symptoms of post-traumatic stress disorder (PTSD).
While the last newsletter described the typical forms of exposure (i.e. imaginal and in vivo), this article highlights two of the primary concerns voiced by mental health practitioners who use exposure as part of the treatment process for PTSD.
PTSD is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened (NIMH, 2006).
When treating students with PTSD, clinicians typically provide relaxation training before beginning exposure. Treatment then proceeds from imaginal to in vivo as students gain confidence in their ability to cope with the initial fear provoking situation.
Clinicians worry that they may re-traumatize a student during the course of exposure. By asking a student to approach an aversive stimulus, clinicians run the risk of inducing an anxious response from the student.
Clinical sensitivity can minimize some of the potential negative side-effects of exposure.
First, you can prepare students and their caregivers for the possibility of re-traumatization by explaining the rationale of exposure. Try to show your clients how exposure relates to other parts of the treatment process (i.e. relaxation, problem-solving, cognitive restructuring). Second, you should provide reinforcement each time the student engages in the treatment process.
Mental health professionals who work with trauma victims also express concern about vicarious traumatization. While helping students with PTSD, clinicians often re-live traumatic experiences through the thoughts and words of their patients. It should come as no surprise then that therapists may experience trauma through the events conveyed by their clients.
In an article on professional coping with vicarious trauma, the author writes that “the dialectic of trauma constantly challenges the therapist's emotional balance” (Ruzek, 2003).
On the one hand, mental health professionals engage in a corresponding experience of trauma when listening to their clients’ stories; it is only natural for them to respond emotionally. On the other hand, though, mental health professionals should guard against destructive responses (e.g. withdrawal, denial, objectification, etc.) to vicarious trauma that would hinder their ability to render services. (continued on reverse)

Research Finding:
A 2004 study compared trauma focused cognitive behavioral therapy (TF-CBT) to child-centered therapy (CCT) for children with PTSD.
Analyses revealed that children assigned to TF-CBT showed significantly more improvement than those children assigned to CCT.
Cohen, J. (2004). See reverse for full citation.

Anxiety disorders

According to the American Academy of Child and Adolescent Psychiatry, medication usage presents two potential benefits for students displaying symptoms of anxiety:
It can reduce or eliminate troubling symptoms.
It can improve daily functioning.
When used in tandem with cognitive-behavioral techniques, SSRIs have been show to effectively reduce some of the more debilitating symptoms of obsessive-compulsive disorder, PTSD, social phobias, and school refusal.
75-80% of patients with panic disorder showed significant improvement when placed on SSRIs. Some of the more commonly prescribed SSRIs include Lexapro, Paxil, and Celexa.
Benzodiazepines such as Xanax and Valium have been used to treat the symptoms of generalized anxiety and phobias. While they have a 70-80% success rate for treating anxiety disorders, side effects include possible dependence and withdrawal, especially for students with a history of substance abuse problems.
Tricyclic antidepressants like Effexor are effective in treating the symptoms of OCD, depression, and social anxiety. This class of medication has shown to elevate mood and diminish obsessions for patients with OCD and panic disorder.
AACAP (2004). Psychiatric medication for children and adolescents: Part I: How medications are used. Facts for Families.

Concerns about exposure (Continued)

Clinicians then must also have a repertoire of coping responses available to them both during and after the use of exposure.
The literature on professional coping strategies highlights the need for an on-going peer support system that allows therapists to effectively cope with vicarious trauma.
In addition, personal wellness (i.e. nutrition, sleep, exercise) can ward off some of the physiological stress that comes with treating students with PTSD.
Reference
Cohen, J., Deblinger, E., & Mannarino, A. (2004). A multisite, random controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393-402.
National Center for Post-Traumatic Stress Disorder. (2002). Trauma exposure and PTSD in people with severe mental illness. PTSD Research Quarterly, 13(3). Retrieved April 11, 2006 from http://www.ncptsd.va.gov/ncmain/nc_archives.
National Institute of Mental Health (2006). Reliving trauma: Post-traumatic stress disorder. Retrieved April 11, 2006 from http://www.nimh.nih.gov/publicat/reliving.cfm.
Ruzek, J. (1993). Professionals coping with vicarious trauma. NCP Clinical Newsletter, 3(2). Retrieved April 11, 2006 from http://www.ncptsd.va.gov/ncmain/nc_archives/clnc_qtly.