M.Div, Psy.D, D. Min

An Integrated Evaluation and Treatment Approach With Traumatized Clients

Dr. Donald Hutcheon, C.Psychol.(UK)., R.Psych. #1421


The article focuses on three identifying areas of interest: (a) a discussion of how different sample subtypes have reacted to stressful events causing trauma; (b) a range of evaluation using an assortment of psychometric tests to gain data about respondents’ reaction to the trauma experienced; (c) a description of a treatment approach used with traumatized clients. Specifically, the article provides a descriptive analysis of the data from a small, mixed sample (N=12) and the relevance of using an integrated treatment format with individuals identified with trauma.

Keywords: Posttraumatic stress disorder; magnitude of stressor; three sets of phenomena; PTSD psychological treatment programs

Learning Objectives:

  1. Understanding the utility of using a broad-based array of psychometric tests to assess the degree (i.e., breadth and depth) of a traumatic state;
  2. Understanding the efficacy (i.e., interdependence and strength) of six treatment approaches to dissipate traumatic symptoms;
  3. Increasing the reader’s comfort level in integrating theory and practice of trauma assessment and effective treatment interventions.

Target Audience: MD, Psychologists, Social Workers, Occupational Therapists, Psychiatric Nurses, Registered Clinical Counselors

Program Level: Intermediate


The treatment of traumatized clients as a response to the goals of a trauma-relevant assessment usually includes not just the definition of the relationship between the aversive experiences and outcomes or to identify specific posttraumatic difficulties. It is an expansion of this information that entails assessing the client’s entire symptom of experience as a result of the traumatic experience (Briere, 1997). Historically, studies suggest that those individuals with PTSD may also suffer from other, co-existing disorders such as depression, anxiety disorders (i.e., panic disorder, phobias, and obsessive-compulsive disorder), alcohol and drug abuse, and borderline or antisocial personality disorder (Breslau & Davis, 1992; Burnam, Stein, Golding, Siegel, Sorenson, Forsythe & Telles, 1988; Green, Lindy, Grace, & Glaser, 1989).

Such symptoms and disorder-overlap highlights the significance of assessing the entire range of psychological disorders when evaluating the traumatized client. Specifically, increased rates of psychiatric and medical comorbidity have been found in association with PTSD (Kessler, Sonnega, Bromet, Hughes & Nelson, 1995), including a raised incidence of suicide attempts, depression, hypertension, peptic ulcer disease, and bronchial asthma. Other risk factors include premorbid vulnerability, such as: familial psychopathology, deficiencies in the early environment, other prior trauma, an unstable personality; availability of other support structures; and access to treatment (Davidson & Fairbank, 1993).

An array of stressor characteristics appear to affect posttraumatic outcome. Combined, these stressors can reflect a general construct often referred to as stressor magnitude or stressor intensity (Briere, 1997). Examples of stressor variables that appear to increase stressor magnitude and the likelihood or severity of PTSD include: the presence of life threat; physical injury; extent of combat exposure during war; degree of violence during sexual assault; intentional acts of violence; loss of a friend or loved one; unpredictability and uncontrollability (Briere, 1997, p. 14). Hence, two people who undergo the same stressor (e.g., earthquake, fire) may differ significantly in terms of their posttraumatic response. Specifically, one individual may develop Acquired Stress Disorder (ASD), followed by PTSD, whereas another may experience few short-or-long term effects.

Therefore, two stressors may appear objectively equivalent yet have remarkably different impacts on those involved. Briere (1997) states the aforementioned discrepancy is a result of three sets of phenomena: victim characteristics, subjective appraisal, and social response. In conjunction and of note, those clients who have experienced previous traumas and not sufficiently processed or resolved them – are prone to exacerbated reactions to current traumas (e.g., King, King, Foy, & Gudanowski, 1996; McFarlane, 1989; Roth, Wayland, & Woolsey, 1990). Abramowitz, Deacon & Whiteside (2011) state many psychological treatment programs for PTSD involve exposure, cognitive restructuring, and anxiety management skills. Exposure–based treatments highlight confrontation with fear-evoking memories of the traumatic event (i.e., imaginal exposure) in conjunction with situations or stimuli that have come to evoke avoidance or anxiety symptoms (i.e., situational exposure). Stress inoculation training ( i.e., SIT; Veronen & Kilpatrick, 1983) and cognitive processing therapy (i.e., CPT; Calhoun & Resick, 1993) involve combinations of educational, exposure, relaxation, and cognitive interventions to help the individual manage anxiety symptoms and challenge maladaptive beliefs.

Much of the research focus (Abramowitz et al., 2011) involves treatment packages that incorporate multiple techniques to address symptoms of anxiety and fear. In fact, behavioral and cognitive therapies are the most widely studied psychological interventions for anxiety disorders (Barlow, 2002). Because of the enormous breadth of research, the current paper’s focus is on a specific treatment approach incorporating features of exposure therapy; relaxation; cognitive behavioral therapy and mindfulness meditation. In this regard, a clinical evaluation of trauma survivors must take into account the individual’s entire psychological experience, including the potentially etiologic or moderating events and the possibility of significant comorbidity with less trauma related conditions (Briere, 1997).

Based on the aforementioned factors, a descriptive analysis of the paper’s subgroups’ array of trauma symptoms and a treatment approach to address the symptoms effectively is discussed. More specifically, a treatment paradigm with utility, when implemented on a day-to-day basis to embrace the “broad based” features of the client’s traumatic symptoms.

In order of priority, the paper presents a)the test results from three subgroups (N=12); b) a summary of the range and degree of symptomatology as measured by six standardized psychometric instruments; and, c) an examination of a treatment approach using coping strategies/techniques to increase empowerment, internal locus of control, dignity of risk, and reduce symptoms of PTSD.

Standardized Assessment Instruments

The test procedure utilized an assortment of assessment instruments to evaluate self-esteem; depression; anxiety; anger; and, posttraumatic stress disorder. Specifically, six standardized psychological assessment tests (mentioned below) obtained data reflecting the degree of individual trauma amongst participants in three different subgroups (i.e., Royal Canadian Mounted Police; Armed Forces Veterans; Private outpatients) and collapsed the test results into four sub categories of scores (i.e., Total Mean Score; RCMP Mean Score; VAC Mean Score; Private Outpatient Mean Score). A description of the tests is as follows:

The Personality Assessment Inventory (PAI)

The PAI is a 344-item Inventory consisting of 4 validity and 18 non-overlapping clinical scales, many of which have subscales that can be scored. Specifically, in a study of the PAI profiles of 53 individuals with clinical diagnoses of PTSD Morey (1991) noted:

“The posttraumatic stress group had a more elevated profile {than those with other anxiety disorders}, with mean scores above 70T on DEP (depression) and ARD (anxiety-related disorders). The subscale configuration for the PTSD group was particularly interesting; marked ARD-T (traumatic stress), accompanied by indicators of confusion (SCZ-T), social estrangement (SCZ-S and BOR-N), and poor control over anger and aggression (BOR-A and AGG-P) (p. 104).”

The PAI subscale test results were incorporated into the study to measure the degree of PTSD symptomatology by the respondents. A T score value between 40-59 is considered in the normal range relative to the general population. Roughly, 84% of nonclinical respondents will have a T score below 60 on most scales, while 98% of nonclinical respondents will have scores below 70. Thus a T score at or above 70 represents a pronounced deviation from the typical responses of adults living in the community and is clinically significant.

Index of Self-Esteem (ISE)

The ISE is a 25-item scale designed to measure the degree, severity, or magnitude of a problem the client has with self-esteem. Self-esteem is considered the evaluative component of self-concept. Because problems with self-esteem are often central to social and psychological difficulties, this instrument has a wide range of utility for a number of clinical problems.

Beck Depression Inventory – 2 (BDI-2)

The BDI-2 quickly assesses depression in line with the depression criteria of the DSM. It can be used for screening, diagnosis, and monitoring of therapeutic progress in both inpatient and outpatient settings. The BDI-2 consists of 21 items to assess the intensity of depression in clinical and normal patients. Each item includes a list of four statements arranged in increasing severity about a particular symptom of depression.

Range of Scores: minimum (0-13); mild (14-19); moderate (20-28); severe (29-63)

State-Trait Anxiety Inventory (STAI)

The STAI has been used extensively in research and clinical practice. It comprises separate self-report scales for measuring state and trait anxiety. State anxiety measures how respondents feel “right now.” Trait anxiety assesses how people generally feel and is lifelong, constitutionally based with a heavy genetic overlay. The Trait-Anxiety scale has been widely used in assessing clinical anxiety in medical, surgical, psychosomatic, and psychiatric patients.

State-Trait Anger Expression Inventory (STAXI-2)

The STAXI-2 provides concise measures of the experience, expression, and control of anger. The STAXI-2 was developed for two primary reasons: (a) to assess components of anger for detailed evaluations of normal and abnormal personality, and (b) to provide a means of measuring the contributions of various components of anger to the development of medical conditions, particularly hypertension, coronary heart disease, and cancer. Similar to the STAI above, state anger measures how the respondent feels at this particular moment (e.g., testing room); trait anger measures how the respondent generally feels and is lifelong, constitutionally based with a heavy genetic overlay.

Davidson Trauma Scale (DTS)

The DTS is a “screen” assessing symptoms of PTSD. It is a self-rated symptom scale for posttraumatic stress disorder (PTSD) and has been developed to assess PTSD symptoms and aid in treatment. The 17 items in the scale reflect the symptoms diagnostic of PTSD as defined in the DSM. The Total DTS Score can range from 0-136. Subscores can be computed for three symptom clusters: Intrusion, Avoidance/Numbing, and Hyperarousal. These clusters reflect DSM criteria for PTSD and directly assess both frequency and severity of symptoms for the previous week:

  • The frequency and severity of each symptom is rated on a 5-point scale;
  • The frequency scale ranges from “not at all” (0) to “every day” (4);
  • Severity is rated from “not at all distressing” (0) to “extremely distressing” (4).

Of note: The DTS is intended for use with any adult who has been exposed to a serious trauma, as understood in the DSM; that is, an event that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others, and induced a response of intense fear, or horror.

Sample Description

A small sample (N=12) of three subpopulations was selected from a pool of approximately sixty outpatient clientele which included: Royal Canadian Mounted Police (RCMP; n = 5); Canadian Armed Forces Veterans (VAC; n = 4); Private Outpatients (Private; n = 3). The sample selection was a mixture of individuals treated historically or currently for trauma by the writer and represented typical individuals referred to an outpatient clinic which specializes in the treatment of mood/affect disorder. The combined treatment population of former and current outpatients negates a valid pre-post analysis of variance of the data to reflect any change, post treatment of the sample in toto. As a result, the nature of the current descriptive study is meant to provide:

An overview of the range and severity of traumatic symptoms by the respective outpatient subgroups individually and combined; Subscale mean scores and Total scale mean scores obtained in each of the standardized assessments utilized; any indicators that would preclude the use of the treatment array examined by the writer to address symptoms of trauma. Lastly, a detailed explanation of the integrated treatment strategy utilized with the sample subgroups.


Personality Assessment Inventory (PAI)

PTSD Subscale Configuration (T-Score) (Morey, 1991, p. 104)

  Combined Mean
DEP – depression 71.3 67.4 73.7 74.7
ARD – anxiety related disorder 63.4 58.2 61.5 73.3
ARD-T – traumatic stress 72.3 70.0 80.5 70.0
SCZ-T – confusion 58.2 51.6 60.0 68.0
SCZ-S – social estrangement 65.1 62.5 67.5 70.0
BOR-N – social estrangement 61.9 55.8 63.5 75.5
BOR-A – poor control over anger 62.8 60.4 62.0 69.5
AGG-P – physical aggression 56.8 53.4 61.5 57.0

Index of Self-Esteem (ISE)

The ISE has a clinical cutting score of 30 (+/- 5), with scores above 30 indicating the respondent has a clinically significant problem and scores below 30 indicating the respondent has no such problem.

Combined Mean (N=12) RCMP (n=5) VAC (n=4) Private (n=3)
48.2 42.0 45.0 61.0

Beck Depression Inventory – 2

(Range of Scores)

Minimum (0-13) Mild (14-19) Moderate (20-28) Severe (29-63)

Combined Mean (N = 12) RCMP (n=5) VAC (n=4) Private (n=3)
24.0 20.2 21.2 34.0

State – Trait Anxiety Inventory (STAI)

Normed Reference group: (Working Adults) male – N=1387 female – N=451
State Anxiety 35.72 +/- 10.42 35.20 +/- 10.61
Trait Anxiety 34.89 +/-   9.19 34.79 =/-   9.22

Combined Mean (N=12) RCMP (n=5) VAC (n=4) Private (n = 3)
State Anxiety 45.1 43.8 49.0 45.1
TraitAnxiety 54.8 52.6 63.7 53.0

State – Trait Anger Expression Inventory – 2 (STAXI-2)

*A T score of 60 is one standard deviation above the mean; a T score of 70 is two standard deviations above the mean. Follow-up evaluation is strongly recommended for individuals with STAXI-2 scale or subscale T scores of 65 or higher. Follow-up is also suggested for individuals with two or more T scores in the range of 60-64.

Combined Mean (N=12) RCMP (n=5) VAC (n=4) Private (n=3)
State Anger 48.1 44.5 56.0 44.0
Trait Anger 55.8 54.6 51.0 62.0
Anger Index (Total) 55.7 54.0 52.0

Davidson Trauma Scale (DTS)

The DTS clinical cut off score for suspected PTSD is 62. Scores above this number indicate that no respondent without PTSD will score at/above this level. *This table should not be used as the sole basis for determining whether an individual has PTSD. Other collateral sources are required to make such a determination (e.g., standardized psychological assessment; clinical judgement; collateral interviews with family, colleagues).

Combined Mean (N=12) RCMP (n=5) VAC (n=4) Private (n=3)
Total Score 68.9 62.0 51.6 85.1

Summary of Test Results

The PAI test results in regards to the aforementioned clinical profile of PTSD showed the ARD scale (anxiety related disorder) mean test result was clinically significant (T=73) for the private subgroup, and the two other subgroups. The Combined subgroup mean scores fell at/around 60 T, which was clinically elevated, one standard deviation above the mean of the normal population (i.e., T=50 +/-10T).

For the subscale ARD-T (trauma), the Combined subgroups; RCMP subgroup; VAC subgroup and the Private subgroup test results fell at/above T=70 (98th percentile), which is clinically significant, two standard deviations above the normal population comparison group.

In conjunction, the depression (DEP) scale scores fell at/around T=70 with all subgroups, which was clinically significant (i.e., 98th percentile). The subscale SCZ T (social confusion) test results fell at/around 60 T (i.e., clinically elevated), one standard deviation above the mean for the three subgroups and Combined subgroup scores.

The SCZ-S (social estrangement) and BOR-N ( also social estrangement) subscale test results fell at/around T=60(i.e., clinically elevated), for the Combined subgroup mean score, the RCMP and VAC subgroups but not the Private subgroup, which fell at/above 70 T which was clinically significant (i.e., 98th percentile).

Lastly, the BOR-A (poor control over anger) fell between 60-69 T (>one standard deviation above the mean – clinically elevated) for the three subgroups and Combined subgroup test results mean. The AGG-P ( physical aggression) subgroup test results were below 60 T for the Combined subgroup mean score and two of three subgroups; the third subgroup, VAC (T=61) was slightly above 60T.

APTSD profile was reflected by the elevated scale and subscale scores obtained by the three subgroups and the Combined mean test results, as compared with the general population comparison group (i.e., scores on the PAI are presented in the form of linear T scores that have a mean score of 50T and a standard deviation of 10T).

To further examine the clinical profile of the subgroups as described by the test results from the other assessment instruments, the following data had elevated scores (i.e., at/above clinical cut-off suggesting intervention is required) in the majority of the standardized test scores. Specifically: The Index of Self-Esteem (ISE) test results were clinically elevated (i.e., >30+/-5) in the Combined subgroup scores and respective subgroup test results indicating low self-esteem was prevalent amongst the sample. The Beck Depression Inventory – 2 (BDI-2) scores fell in the moderate range (i.e., 20-28) for the Combined subgroup mean score; RCMP; and VAC subgroups and in the severe range (i.e., 29-63) for the Private subgroup score (i.e., 34). Of note: it has been the writer’s observation during the past twenty years examining the BDI test, that BDI-2 scores above 24-26 often reflect the erosion of cognitive skills required to successfully complete a full work day on the job site (i.e., attention/concentration; problem-solving ability and short-term memory retrieval is compromised).

The State-Trait Anxiety Scale (STAI)State scores for the Combined and two of three subgroups fell in the normal range; the VAC (i.e., armed forces veterans) scores were in the clinically elevated range. The Trait scores for the Combined and three subgroups fell in the clinically significant range (i.e., 98th percentile), two standard deviations above the normal range of scores. Specifically, the elevated STAI trait results suggested a reduced stress tolerance for external stimuli thereby influencing a predisposition of biased interpretation of external stimuli as perceived threat. The STAXI-2 test results fell within the normal range for the Combined and three subgroups, indicating suppression of angry feelings or in contrast, excellent coping strategies to reduce the tendency to “act out” conflicted feelings.

The Davidson Trauma Scale (DTS) total scores fell above the clinical cut-off score (62) for two of three subgroup and the Combined group score. However, the VAC subgroup score (51) was below the cut-off score, but only 1.2% of the respondents who do not have PTSD would score at this range (i.e., non-PTSD respondents with > DTS scores). This is a strong indication of symptoms pertaining to posttraumatic stress, albeit with a slight chance of misdiagnosing the symptoms as non PTSD.

In summary, the array of symptoms pertaining to trauma, including reduced self-esteem and mood-affect problems (i.e., depression; anxiety and PTSD) from a small sample of three subgroups (RCMP; Veterans; Private Outpatients), reflected marked indications of depression (moderate-severe range); trait anxiety (clinically significant range); a PTSD clinical profile as described by the PAI and elevated DTS total scores. The results encouraged a description of a practical therapy program involving easy to use coping strategies/techniques to address the array of traumatic symptoms by the subgroup participants.

The following is an examination of a protocol for treatment that the writer has used effectively with both inpatient and outpatient traumatized clientele, which have closely matched symptoms reflected in the clinical profile of the three subgroups described in the current article.

Treatment Format for Traumatized Clientele

The following array of practical coping strategies/techniques can be taught over a period of eight to ten treatment hours with homework expectations to practice the techniques prior to the next session. The client is informed that these strategies can be used on a regular and/or “as needed” basis. One exception is the first strategy below, “progressive deep muscle relaxation” which should be completed three times per day (i.e., AM;PM;Evening) by very anxious clients, commencing with the sixteen muscle groups, then as time progresses allowing skill development - usually 10-20 repetitions, “chunking” to seven then finally four muscle groups, as detailed below.

  1. Progressive Deep Muscle Relaxation (Bernstein & Borkovec Model, 1973)

    Progressive deep muscle relaxation (PDMR) is a relaxation technique that involves tensing and releasing major skeletal muscle groups with the aim of inducing relaxation. Thus, learning to relax 16 muscle groups (initially) then 7 (after 10+ sessions at 16) then 4 (after becoming experienced at 7 – usually <10 sessions) allow the muscle groups to be “chunked” over time, as skill increases in obtaining a physiologically relaxed state. Jacobson (1938) stated the mind and voluntary muscles work together in an integrated way. Keeping the mind calm allows muscles to relax, and freeing the body of tension reduces sympathetic activity and anxiety.

    Jacobson initially developed PDMR to induce relaxation by promoting awareness of tension in skeletal muscles. Bernstein and Borkovec (1973) later developed a shortened, modified procedure that is now the most frequently used form of PDMR. The primary purpose of this treatment strategy is increasing the brain’s ability to discriminate tension from relaxation and as well, to physiologically relax the respondent. Teaching the technique includes the following general protocol as modified by the writer:

    Seven issues to keep in mind:

    1. darkened room without distractions;
    2. inhaling through the nose (tensing) counting to four then exhaling (relaxation) through the nose;
    3. time period for 16 muscle groups is six minutes plus/minus 30 seconds; 7 muscle groups - one minute thirty seconds plus/minus fifteen seconds; and lastly, 4 muscle groups - thirty seconds plus/minus 5 seconds;
    4. sit in a straight back chair or on the floor, but not on a soft piece of furniture such as a bed – we are learning relaxation not sleeping;
    5. the relaxation exercises are completed three times per day, every day, A.M; P.M, evening – the client’s choice of the time ; f) each muscle group is to be physiologically relaxed twice;
    6. review each muscle group after the overall treatment is completed and re-do those muscle groups that you feel are still tense. In order of priority the following muscle groups are to be relaxed. Of note: always begin the arm and leg portion of the treatment with your dominant side (i.e., right or left side based on handedness). Here is the order to follow:

    Sixteen muscle groups

    Right handed people:

    TENSE each muscle group then hold to a count of four then RELAX - right forearm (twice); right bicep (twice); left forearm (twice) left bicep (twice); upper face (twice); middle face (twice); lower face (twice); neck (twice); chest (twice); stomach (twice); right thigh (twice); right calf (twice); right foot (twice). Then review each muscle group in order and re-do any muscle group that feels tense. Total Time: 6’ +/- 30

    Left handed people:

    Start left side (forearm, bicep) then swing over to the right side muscle groups (forearm, bicep) then left leg - thigh; calf; foot. Total Time: same as above;

    Seven muscle groups (“chunk” 16 muscle groups)

    Same instructions as above, however the following condensed order is followed:

    Right handed people:

    Combine right forearm/right bicep; then left forearm/bicep; then combine upper/middle/lower face; then neck; combine chest and stomach; combine right thigh/calf/foot and then left thigh/calf/foot. Total Time: 1’30” +/- 15 seconds.

    Left handed people:

    Opposite to right side (please view 16 muscle group instructions above);

    Four muscle groups (“chunk” 7 muscle groups)

    Same instructions, however the following condensed order as described below:

    Right and Left handed people:

    Combine both forearms and biceps and then complete tension relaxation protocol; combine upper/middle/lower face/ neck; combine chest/stomach; combine both legs together – tense and then relax right and left thighs/calves/feet. Total time: 30” +/- 5”.

  2. Stressor by Stressor Coping Strategies/Techniques (reducing the tendency to ruminate)

    The “stressor by stressor” coping strategies/techniques is implemented whenever the respondent is feeling an event has caused stress/insecurity and rumination. The following sequence of four activities is meant to stop/greatly reduce rumination about the stressful event and is completed in order (see below) and with practice; the duration is one minute thirty seconds +/- fifteen seconds. Ideally, for the greatest effect, the following steps should be completed in close time proximity to the stressor causing anxiety:

    • Thought Stop (stops rumination about the event);
    • Count (silently) #’s 1-8 while visualizing the numbers ( stop/reduce emotional arousal);
    • Physiologically relax 2-3 muscle groups (relaxes the body);
    • Diaphragmatic breathing – inhaling-exhaling through the nose only; inhaling while counting up from #’s 1-4; exhaling from counting down #’s 4-1. Complete this exercise 2-3 times (regulates heart beat).

    Total Time: 1’ 30” +/- 15” for the four steps.

  3. Rational Emotive Therapy (RET) Techniques: Challenging Catastrophic Thinking Caused by Irrational Beliefs

    Teach the A.B.C model of Rational Emotive Therapy to the respondent. “A” is the actual event which has caused a stressful interpretation; “B” is the irrational belief system which influences a negative, usually “catastrophic” interpretation of an event; “C” is the consequential emotional response which is directly influenced by the interpretation of the event as influenced by irrational beliefs. Specifically, an exaggerated evaluation of the stressful event influenced by rigid, concrete interpretations (e.g., woulds, shoulds, musts, autta be’s, has to be’s).

    Teaching this treatment approach requires the client to challenge the tendency of using rigid, concrete (catastrophizing) interpretations of a stressful event, and replacing it with a moderate, “middle of the road” interpretation, thus reducing over-reaction causing a negative emotional response and subsequent anxiety, frustration, anger.

  4. Cognitive Behavioral Therapy: Identifying Emotional “Triggers” and Automatic Thoughts - Re-Contexting the Automatic Thoughts to More Neutral and Non Judgmental Interpretations

    Just two major issues here. Identifying the respondent’s “emotional triggers” (usually 3-5), which cause automatic stressful thoughts and teaching the individual how to re-context the automatic thoughts to more neutral, non judgmental interpretations.

  5. Mindfulness (mind/body guided meditation): Learning to Complete a Body Scan and Embracing Stress in Nine Body Areas to Neutralize its Interpretation

    Teaching the individual to “embrace” rather than avoid the stressful memory/feeling by allowing the mind, breathing and hearing to occupy an area of worry/distress, permitting the individual to feel the worry, noticing the thoughts that arise or any images that come to mind.

    Letting the individual “feel” the worst part of the situation and noticing how their body is reacting at the moment in each of nine body parts (see below). Becoming more acutely aware of any situations as they come and go and not trying to change the sensations. This form of meditation and exposure technique also incorporates how the individual is able to identify breathing and auditory sensations while they continue to feel the sensations of distress. The following body parts identified to be targeted by the mindfulness activity are as follows:

    Foot; ankle; calf; thigh; waist; chest; neck; then a quick review of each of the body areas prior to proceeding to the head: Length of time: 5-30 minutes.

  6. Systematic Desensitization (also known as graduated exposure therapy)

    This type of behavior therapy is used to help effectively overcome phobias and other anxiety disorders (e.g., posttraumatic stress disorder). It is implemented to overcome fears through gradual and systematic exposure.

    The process of systematic desensitization occurs in three steps (Mischel, Sholda & Ayduk, 2008):

    1. Establish an anxiety stimulus hierarchy. The individual must first identify the items that are causing anxiety. Each item that causes anxiety is given a subjective ranking on the severity of induced anxiety. If the individual is experiencing great anxiety to many different “triggers”, each item is dealt with separately. For each trigger or stimuli, a list is created to rank the events from least anxiety provoking to the greatest anxiety provoking;
    2. Learn the coping mechanism (i.e., progressive deep muscle relaxation - PDMR), which acts as an incompatible response. This allows the individual a means of controlling their fear, rather than letting it increase to intolerable levels.
    3. Connect the PDMR and relaxed state it provides to each level of the hierarchy until the feared stimulus at that particular level of the hierarchy is desensitized and no longer presents as a threat – then move up the hierarchical ladder to the next step and so forth. This activity is completed until all items of the hierarchy of severity of anxiety is completed without inducing anxiety in the client. If at any time during the exercise the coping mechanisms fail or the client fails to complete the coping mechanism due to severe anxiety, the exercise is stopped. Once the client is calm, the last stimuli that was presented without inducing anxiety is presented again and the exercise is continued.

The breadth of research (Abramowitz et al, 2011) during the past fifty years demonstrates that exposure therapy is the treatment of choice for fear-and anxiety-based problems. Ultimately, reducing pathological anxiety requires temporary evocation of a client’s anxiety/urges to perform the unwanted (e.g., avoidance) behaviors. This can provoke fear in a traumatized client. However, there is no evidence that it is dangerous or harmful to provoke temporary anxiety that is experienced during exposure. The distress experienced during the treatment session is short-lived. In conjunction, the client’s reduced anxiety allows them important knowledge about situations they once believed were dangerous (i.e., traumatic event) and about their personal ability to manage their own subjective distress. In conjunction, reducing fears by exposure will not cause “symptom substitution” of additional symptoms.


Abramowitz, J.S., Deacon, B.J. & Whiteside, S.P.H. (2011). Exposure therapy for anxiety: Principles and practice. The Guilford Press.

Barlow, D.H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guilford Press.

Bernstein, D.A., & Borkovec, T.D. Progressive relaxation training: A manual for the helping professions. Chicago: Research Press, 1973.

Breslau, N., Davis, G.C., Andreski, P., & Peterson, E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216-222.

Briere, John (1997). Psychological assessment of adult posttraumatic states. American Psychological Association, Washington, DC.

Burnham, M.A., Stein, J.A., Golding, J.M., Siegel, J.M., Sorenson, S.B., Forsythe, A.B.,, & Telles, C.A. (1988). Sexual assault and mental disorders in a community population. Journal of Consulting and Clinical Psychology, 56, 843-850.

Calhoun, K.S., & Resick, P. (1993). Posttraumatic stress disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (2nd ed., pp. 48-98). New York: Guilford Press.

Davidson, J.R.T., & Fairbank, J.A. (1993). The epidemiology of posttraumatic stress disorder. In Davidson, J.R.T. & Foa, E.B. (Eds.). Posttraumatic Stress Disorder: DSM-IV and Beyond V, (147-172). Washington, D.C.: American Psychiatric Press, Inc.

Green, B.L., Lindy, J.D, Grace, M.C., & Gleser, G.C. (1989). Multiple diagnosis is posttraumatic stress disorder: The role of war stressors. Journal of Nervous and Mental Disease, 177, 329-335.

Jacobson, E. (1938). Progressive relaxation. Chicago, IL: University of Chicago Press.

Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M.A., & Nelson, C.B. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52, 1048-1060.

King, D.W., King, L.A., Foy, D.W., & Gudanowski, D.M., (1996). Prewar factors in combat –related posttraumatic stress disorder: Structural equation modeling with a national sample of female and male vietnam veterans. Journal of Consulting and Clinical Psychology, 64, 520-531.

Morey, L. (1991). Personality assessment inventory. Psychological Assessment Resources Inc. Odessa, Florida.

Mischel, W., Shoda, Y. & Ayduk, O. (2008) Introduction to Personality. John Wiley & Sons, Inc.

Roth, S., Wayland, K., & Woolsey, M. (1990). Victimization history and victim-assailant relationships as factors in recovery from sexual assault. Journal of Traumatic Stress, 3, 169-180.

Veronen, L.J., & Kilpatrick, D.G. (1980). Self-reported fears of rape victims: A preliminary investigation. Behavior Modification, 4, 383-396.

About the Author

Dr. Donald Hutcheon

Dr. Donald Hutcheon, C.Psychol. #82605 (UK)., R.Psych. #1421 (British Columbia) is a licensed psychologist in the Province of British Columbia, Canada. His scope of practice includes: mood/affect disorder; family and couples counseling; treatment of brain injury; performance enhancement in sport; organizational development; strategic planning; conflict resolution. More recently he has written two textbooks, the first pertaining to “Psychogenic Polydipsia” (i.e., compulsive over drinking of any/all fluids) (Hutcheon, 2012) and the second, “How to survive organizational politics” (2014) under the pseudonym Jake Hagerman.

Published by Dr. Robert O' Block in The American Association of Integrative Medicine Journal Spring 2015.