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The TAB-P Protocol: The Complete Home-Study Course for Training in Cognitive Behavioral Based Psychotherapy for the Treatment of PTSD and other Anxiety Disorders by Larry D. Smyth, PhD. Havre de Grace, Maryland: The Red Toad Road Co., 1998 & 1999, six manuals and five videotapes and one study guide. $400

Larry Smyth assembled an impressive set of manuals and training tapes designed to teach his cognitive-behavioral approach to the treatment of PTSD and other anxiety disorders.
The course consists of six manuals, five videotapes and one study guide. In addition to the entire home study course, the Clinician's Manual for the Cognitive-Behavioral Treatment of Post Traumatic Stress Disorder and the Client's Manual for the Cognitive Behavioral Treatment of Anxiety Disorders are available for individual purchase without the videotapes and accompanying manuals.

Smyth uses a general cognitive behavioral paradigm, with an information-processing model as its basis. From this model, he conceptualizes PTSD as a specific phobia of memories, which cause both hyperarousal and avoidant/numbing behaviors.
He proposes that "the primary therapeutic task in PTSD treatment is activating the traumatic memories, while keeping physiological arousal in the moderate range, so secondary process thinking can be used to either rewrite the original codes and or revise the meta-cognitions that the traumatic material contradict."

To achieve this goal, Smyth conjectures that the TAB-P treatment outcome is dependent on the following components: (1) the quality of the collaborative therapeutic relationship (T); (2) the clinical complexity of a case; (3) implementation of effective cognitive reframing or assimilation techniques; (4) the use of brief exposure strategies (B), and (5) implementation of prolonged exposure strategies (P). Smyth teaches basic cognitive behavioral skills such as progressive relaxation, relaxation, thought stopping, exposure to introceptive cues and cognitive reframing in this course.

Treatment Follows a Basic Five-step Process
The treatment consists of five basic phases that can be extended based on particular case histories. Smyth has clear criteria to indicate the achievement of each phase, which allows both flexibility and consistency of treatment across different cases. Hence, treatment length depends on the needs of a client.

In the first phase, he conducts assessment, psychoeducation about PTSD, subjective units of distress and goal setting. In phase two, he reviews eye movement technique, relaxation training and introduction to rational thinking. In phase three, he uses cognitive restructuring in the context of some limited exposure to difficult experiences. To change thoughts, Smyth teaches clients through the use of Socratic questioning, metaphors and education. In phase four, he begins brief exposure trials more systematically with repeated trials. In phase five, he utilizes prolonged exposure. Finally, he implements relapse prevention in the termination phase coupled with a review on treatment goals, coping skills and current status.

As a component of treatment, Smyth uses a variant of the eye movement technique (EMT). He emphasizes that EMT is a component of cognitive-behavioral treatment, not a treatment in and of itself. In fact, he believes EMT is a form of anxiety management technique, akin to Wolpe's thought-stopping procedures. He further distinguishes his EMT work from Shapiro's EMDR by stating that he believes EMT is an easily learned technique that can be readily learned by an experienced clinician with an hour of instruction.

Package Serves as an Excellent Introduction
The treatment relies heavily on the client manual, which is a good general introduction to cognitive-behavioral treatment including the client's roles and responsibilities. The manual systematically reviews relaxation, cognitive problem-solving, correcting irrational thoughts and exposure. It contains areas to complete homework as well. The manual is actually geared to general anxiety disorders rather than PTSD, so it may be implemented in a variety of treatment protocols.

Smyth's entire package contains clear concise instructions, summaries and self-tests to help the clinician master the material. Smyth uses acronyms to help mastery of the material and has clear objectives for clinicians to learn portions of the treatment. The videos are extremely helpful in understanding the application of the treatment and provide very clear examples of treatment.

He attends very well to the issues of co-morbidity and complex PTSD, and encourages the adaptation of techniques in ways that address these issues but retain consistency of treatment. It was refreshing to see the materials address the true range of PTSD cases seen in clinical work by including case examples that vary by stressor and those that involve co-morbidity with other anxiety disorders.

Although all clinicians can benefit from the training, it seems especially useful to those clinicians learning how to integrate cognitive-behavioral practice into their treatment plans and those unfamiliar with PTSD. And even though the videotapes integrate the material extremely well, those clinicians familiar with PTSD and cognitive-behavioral treatments may not find the videotaped sessions as necessary. My clinical psychology graduate students who viewed a few segments of the videos found the sessions helpful in demonstrating techniques they were aware of but had never seen implemented.

Naturally, in a work of this scope, one expects to find some gaps in the material covered (e.g. treating co-morbid substance abuse, unique issues for clients based on stressor type). In fact, Smyth recognizes this reality and includes useful references for both clinicians and clients to further their understanding.

Research supports many of the program components, although this treatment itself has not undergone empirical investigation. In particular, the use of brief exposure techniques for PTSD only has been examined in children and, while clinically sensible, the use of brief exposure techniques prior to prolonged exposure needs more investigation. Smyth argues that PE enhances desensitization whereas BE enhances coping strategies, so the use of BE prior to PE prevents relapse. This proposition needs further support. In addition, the use of his version of the eye movement technique also needs empirical support. Given the detail of the manuals and videos, this empirical work could be readily accomplished and contribute to the field.

While I do not agree with all of Smyth's interpretations of the current research on treatment and theory, I find the overall training manual a strong and important piece of work that should serve as a model for clinical practice. Smyth's approach is consistent with a clinical scientist model and he writes to the audience of practicing clinicians in clear, precise language that communicates the nuts and bolts of practice. He is acutely aware of his theory, objectives and the techniques he uses to meet his clinical goals in a way that is flexible but precise. He masterfully distilled the essential information and communicated it to both clinicians and clients.