David Read Johnson’s research while affiliated with Yale University and other places

The lively debate occurring within the trauma field has led to an increasing array of psychological treatments, which involve increasingly complex arrangements of therapeutic elements, and accompanying theoretical justifications. In this article, we wish to apply the rule of parsimony in an attempt to persuade the reader that the state of affairs in the psychological treatment of trauma may be simpler than currently appears. Our contention is this: the primary therapeutic element in effective treatments for PTSD symptoms is imaginal exposure. Differences among techniques can be largely explained by the different methods through which the client's avoidant responses to imaginal exposure are circumvented or inhibited. The need to differentiate methods from each other has therefore preferentially focused on these secondary aspects, upon which theoretical justifications then are built. The result has been an obfuscation of the role of the central therapeutic factor underlying most approaches. There is a consensus among major psychological approaches to PTSD treatment, including exposure therapy, cognitive-behavioral therapy, and Eye Movement Desensitization and Reprocessing (EMDR), that imaginal exposure to the traumatic memory will lead to the

The authors contend that the primary therapeutic element in psychological treatments for posttraumatic stress disorder is imaginal exposure, and that differences among major approaches are determined more by secondary techniques designed to circumvent the client’s avoidant defenses against exposure. A study is described comparing Prolonged Exposure, Eye Movement Desensitization and Reprocessing, and the Counting Method with 51 multiply-traumatized women. Measures of PTSD were significantly reduced by all three methods, but differences among the methods were negligible. Because the Counting Method utilizes only imaginal exposure as a therapeutic element, support is given to the more parsimonious conclusion that imaginal exposure may be both the necessary and sufficient factor in therapeutic effect, countering a trend in the field toward more complex, multi-faceted treatment packages.

Revisions in the theoretical basis and practical applications of the Counting Method are described based on clinical and research experience with this technique, which aims to reduce intrusive traumatic memories. The importance of the role of imaginal exposure, rather than the therapeutic alliance, is emphasized, and the advantages of a more parsimonious, streamlined approach to exposure therapy are highlighted. Five clinical examples are offered to illustrate the range of application of the Counting Method with different traumatic stressors and different therapeutic challenges.

Revisions in the theoretical basis and practical applications of the Counting Method are described based on clinical and research experience with this technique, which aims to reduce intrusive traumatic memories. The importance of the role of imaginal exposure, rather than the therapeutic alliance, is emphasized, and the advantages of a more parsimonious, streamlined approach to exposure therapy are highlighted. Five clinical examples are offered to illustrate the range of application of the Counting Method with different traumatic stressors and different therapeutic challenges.

This study is a 6-year longitudinal study of 51 treatment-seeking male veterans with combat-related posttraumatic stress disorder. Measures of PTSD and psychiatric symptomatology, social functioning, and program impact were assessed at admission to an inpatient treatment program, at 18 months, and 6 years later. Previous studies had shown that the treatment program's impact on course of illness had been negligible. The sample showed an extremely high mortality rate of 17% over 6 years. The remaining veterans showed improvement in violence and alcohol and drug use, but an increase in hyperarousal symptoms and social isolation. Nearly three-fourths had had an inpatient hospitalization. Veterans' self-ratings, in contrast, indicated significant improvement in all areas of functioning except employment, as well as an overall positive view of the impact of the program on their lives. Results indicate that the majority of the veteran sample had experienced some improvement in their ability to cope with their chronic illness, decreasing their use of violence and substance abuse but still were experiencing high levels of symptomatology. The extremely high mortality rate, however, provides a somber reminder of the seriousness of this disorder.

The use of Interactive Psychoeducational Group Therapy to ameliorate authority problems of veterans with combat-related posttraumatic stress disorder is described. Despite the common occurrence of authority problems in this population, and the degree of damage they have caused in family, work, and legal domains, they are rarely specifically targeted by treatment interventions. A conceptual framework linking psychological trauma with distortions in authority relations is presented, followed by the format, procedures, and case examples of this form of group therapy. By uncovering the distorted beliefs associated with traumatic schemas as they emerge in the group interaction, the group therapist can first help the clients question their assumptions about authority, and then explore more adaptive behaviors. The need to examine in greater detail the causes and impact of authority problems among clients with posttraumatic stress disorder is emphasized.

This study compared treatment outcome at discharge, and 4, 8, and 12 month follow-up between an inpatient program consisting of a mixture of Vietnam combat veterans with posttraumatic stress disorder (PTSD) and general psychiatric patients (N = 42), and the same program at a later period, consisting of only Vietnam combat veterans with PTSD (N = 33). Veterans rated the homogeneous environment higher in satisfaction, support, order, clarity, and amount of discussion of combat, and lower in hostility, than the heterogeneous condition. However, veterans showed no improvement in condition at 12 month follow-up, with the exception of decreased violence, replicating earlier studies. No differences in outcome were found between homogeneous or heterogeneous treatment environments. This study underscores the enduring nature of chronic posttraumatic stress disorder in the veteran population.