Mardi Horowitz

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CHAPTER 3 EARLY SUPPORT PHASE
(TRUNCATED FOR COPYING, FROM TREATMENT OF STRESS RESPONSE SYNDROMES, permission to copy granted.)
Patients often seek professional help weeks or months after a traumatic event because they still have symptoms and an intuitive sense that they are not recovering. Usually these symptoms occur in an undermodulated state of mind, one characterized by intrusive experiences, dangerous impulses, or a sense of loss of mental control. If so, state stabilization through supportive measures is indicated.
At the biological level, support may include suggestions for restoring nutrition and getting more rest and a prescription for medication may be needed in some cases. At the social level, supportive measures may include recommendations for time structuring, giving advice to people affiliated with the patient, and guiding the patient into mutual-experience discussion groups. At the psychological level, supportive measures involve establishing a therapeutic relationship while carefully listening to the story of the stressor event and communicating possible treatment plans. The patient gains hope for recovery after perceiving empathy and expertise and during discussions of potential therapeutic benefits.
BIOLOGICAL SUPPORT
Shakespeare wrote that sleep knits the raveled sleeve of care. His poetics would have referred to neural networks had he written in our time. Sleep disruption is one of the most frequent symptoms in stress response syndromes, however it is not specific to this disorder. Restoration of unmedicated normal sleep is the best biological support albeit not easily achieved. Patients should be advised on how to develop good sleeping patterns. This may include advice on how to alter their habitual time structure to allow for naps, earlier bedtimes, and uninterrupted sleep insofar as it is logistically feasible. On the other hand, some insomnia symptoms are helped by restricting “extra” sleep time (Krakow et al, 2001). In addition, relaxation techniques may reduce the frequency and/or duration of hyperarousals and tense states of mind. If nightmares have a recurrent content, then this content should be reviewed and counteracted in psychotherapy, as will be discussed later. Sedatives for sleep are usually not indicated because of potentials for overuse, habituation, and possible addictions.
Hyperarousal burns sugar and stress may lead to fatigue and weight-loss. Eating regular meals and avoiding strict diets may be part of sound nutritional advice. Recommendations should also be made against excessive eating of high-caloric comfort foods whenever distressed. The stressed person is less inclined to prepare meals, and adequate nutritional advice should take this into account.
Stress can effect many neurotransmitters, the autonomic nervous system, and hormonal functions as well as their interactive processes. Changes in electrochemistry effect neural networks that connect the limbic, frontal cortical, basal ganglia, and hypothalamic structures. Disturbances in physiology of these networks can disturb arousal control (as in increased frequency of startle reactions and irritability) and alter one’s capacity to regulate alarm reactions (as in fright responses). The amygdala may alter danger recognition set points, the hippocampus may alter memory encoding properties, and the medial prefrontal cortex may alter ability to establish or reduce (desensitize) associational connections.
LeDoux (1996, 2001) reviewed the known anatomical pathways for the development of conditioned fear in animals, pathways most likely the same in humans. Stimuli are relayed from the external environment through the sensory pathways of the thalamus and cortex to the lateral nucleus of the amygdala. In this nucleus a conditioned stimulus and an unconditioned stimulus are integrated. Subsequently, with exposure to the conditioned stimulus, signals that enter the lateral nucleus are given an especially fearful meaning. The lateral nucleus activates the central nucleus of the amygdala, which then activates brain stem areas producing various fear-type reactions.
Connections with the periaquiductal gray region control freezing or immobility type responses. Connections with the lateral hypothalamus control autonomic nervous system responses probably producing in humans a range of responses from heart-pounding arousal to fainting. Connections with the paraventricular hypothalamus control endocrine responses.
LeDoux suggests a mode of biological support by emphasizing the social psychology of active coping on the grounds that in the state of actively doing something well, information transmission can be diverted to the basal nucleus of the amygdala rather than mostly to the central nucleus. From the basal nucleus there are connections to the striatum and motoric circuits. The more the person learns to do active coping, whether it is coping with the fear arousing stimulus or coping with some other aspect of life, the less the person might be vulnerable to a protracted passive fear reaction. The active coping need not be stress-event-targeted, the point is to increase actions related to self-efficacy.
Chemical imbalance may also occur as a part of stress response syndromes. A prominent
catecholamine altered in reactions to stress is dopamine. Dopamine is concentrated in the norepinephrine-rich areas of the brain such as the locus ceruleous and frontal cortex. These brain regions are connected to the emotional arousal regulating functions of the amygdala. Dopamine, serotonin, and GABA may be involved in heightening biological propensities for hyperarousal and hypervigilence. Repeated alarms can lead to fatigue and further dysregulation of cognitive-emotional functioning (Southwick, Krystal, Morgan, et. al., 1993). Trauma-induced alterations in this neural chemistry could lead to either fight-flight arousals or states of relative immobilization.
Long standing biological changes are noted in chronic PTSD. These may generally effect both body and brain, both immunological and stress-response systems. For example, in combat veterans with chronic PTSD, central nervous system levels of norepinephrin were higher than in healthy men, these levels positively correlated with the severity of current PTSD symptoms (Geracioti et al, 2001). These biological changes link to psychological ones, with probable intercausality. That is, adrenergic hypervigilence and arousal can promote intrusive thinking by activation of the brain substrates of these functions. Social triggers of psychological associations that activate neural substrates of intrusive thinking can also promote reactive release of adrenergic substances. Treatment that can alter excesses or deficiencies in any area of linked inter-causalities is likely to benefit all elements in the linkage.
Biological support should include careful attention to substances used as an effort at self-medication to reduce alarm or fatigue. Patients often increase alcohol or heroin as sedatives, nicotine or cocaine as stimulants, and marijuana or St. John’s wart as a mood-altering attempt. Patients should be advised against such self-medication in favor of physician prescribed regimens. Also, all prescription drugs from doctors and dentists should be reviewed to avoid excessive amounts, interactions, or unwarranted continuation of drugs.
Antianxiety and affect-dampening medications are sometimes prescribed to prevent extremes of desperate agitation, emotional flooding, and racing disorganized thoughts. Transient use of such medication has sometimes been effective as a way of reducing explosive entry into extremely undermodulated states. These agents can be used in a single dose or as a very short-term approach when critically needed. Regular, extended use may be addictive. In most instances, it may be indicated to avoid anti-anxiety agents such as a benzodiazepine. Use instead a selective serotonin uptake inhibitor that has an anti-anxiety effect if anxiety and depression are both present.
Sometimes you will receive a patient who has already been on a benzodiazepine type drug for more than two weeks. Cessation of the medication may be indicated. Withdrawal symptoms can occur; they include anxious states of mind, insomnia, depression, depersonalization, headache, nausea, abdominal pain, palpitations, chest pain, visual hallucinations, paranoid thinking, and other experiences similar to those of alcohol and sedative withdrawal syndromes (Miller, 1990). Symptoms may be worse on days 3 to 10 taking up to a month to attenuate.
An interesting question concerns when and if to use sedation during the actual occurrence of stressor events. Usually this question will apply during medical care. For example, combinations of anti-anxiety-sedatives and pain-killers are used already as “conscious sedation” during several procedures such as colonoscopy and coronary angiography. These combinations have memory-reduction effects as well. In one small study of 21 survivors of cardiac arrest, long-acting sedation after resuscitation predicted a favorable outcome assessed in terms of fewer PTSD symptoms (Ladwig, Schoefinius, et al, 1999).
Selective serotonin reuptake inhibitors (SSRI), tricyclics, and monoamine oxidase inhibitors have all been tried on PTSD with some reported successes. The SSRI agents have been shown to be superior to placebos in several well-designed studies (Davidson et al, 2001; Brady et al, 2000; Marshall et al, 2001). At this writing, the Federal Drug Administration has approved sertraline (an SSRI) for the treatment of PTSD and another SSRI, paroxetine, may be under consideration.
Some recurrent schizophrenic episodes may be precipitated by stressful life events. At such times, prescriptions of antipsychotic medications (or adjustments in dosage) may be indicated.
Patients with stress response syndromes can become suicidal. Clinicians should be alert to patients possibly using prescribed medication for that purpose. Contractual agreements with patients to avoid suicide sometimes bolsters adaptive coping efforts and morale. Whenever it can be realistically enhanced, hope is a good medicine. Caution, however, should be used in the volume and kind of medications prescribed.
SOCIAL SUPPORT
Persons who are exposed to traumatic events often experience themselves as overwhelmed. Social support is extremely valuable. Those who provide the support often need reassurance and advice. The following ten principles are helpful in this regard.
1. The victim may need to be transiently protected from excessive stimulation. Structuring time following a disaster should emphasize short-range activities that improve a sense of safety, control, and social connection.
2. Provide the patient with opportunities for communication. Discussion of events with others may be useful because it clarifies differences between realistic and unrealistic interpretations. Debriefing support groups can also be helpful soon after shared stressor events such as an earthquake, a building explosion or airplane crash. Mutual help groups can be extremely valuable even long after an event such as the death of a child, a cancer diagnosis, or heart surgery.
3. Giving time lines for dose-by-dose coping can restore a sense of personal efficacy to a bewildered or overwhelmed victim. The Scarlett O’Hara approach of “I’ll think of that tomorrow” can be adaptive if not prolonged.
4 Activities should include time for respite. It is important for the person to feel that it is all right to rest, or change activities for a period of restoration. Activities that restore a sense of social connection and positive states of mind are valuable. There are a variety of systems for relaxation that may be useful to people. These may range from deep breathing exercises to systematic muscular relaxation or other somatic slow-down practices such as Tai Chi, yoga, and meditation. Music, art, dance, comedy, literature, television, walking, or sports may provide for restorative episodes that, for a time, put aside the unresolved stressor topics.
5. Give the person something to do in the role of helping others if this can restore a sense of worth, competence, and self-esteem. Otherwise, consider a transient reduction in care-taking responsibilities.
6. Remember that the more the person has been traumatized, the longer it will take for symptoms to subside. This may contrast with the expectation in some work environments that the traumatized person return to their usual functional level within a week. The work place provides sustaining interest and social support; the victim should not be isolated from it, but neither should the person have to meet excessive expectations.
7. Children may see repetitious film clips of a disaster on TV and believe that the depicted event is really happening, over and over again. They need adult explanations to reassure them that they are safe and that the dangerous conditions are over.
8. Because sleep disruption is common, the victim may associate efforts to sleep with episodes of unpleasant imagery. It is helpful to increase a sense of safety. This can include leaving lights on or sleeping with a pet. Children may be allowed to sleep with a parent although that is not the usual domestic arrangement. In extreme cases, telling the victim that a companion will stay awake and watch over him or her during sleep can encourage rest.
9. The person may be more at risk for having an accident while driving or operating machinery. For these reasons, keeping the victim from driving unnecessarily or doing hazardous work tasks may be advisable for a time. It must be done tactfully so as to avoid incompetent self-concepts.
10. Right after a traumatic event, the victim's relatives and friends cluster around and want to know what happened. The victim recounts the story again and again. For some this is valuable, for others it is not and can be maladaptive. Later in time, companions may feel tired of hearing about it, but the victim may still feel the need to review what happened, listening may still be useful. The therapist may advise family and friends that being there and listening fulfills a useful function. They do not have to offer solutions, directives, probes, or unsolicited interpre- tations to see themselves as helpful.
PSYCHOLOGICAL SUPPORT
Telling the Story of the Stressor Event
Telling the story of the stressor event to the therapist is an important initial support event for it occurs in a context of relative security. Even during prior experiences of telling the story to potentially critical persons such as police, other victims, relatives or friends, the situation is less calm than with a competent therapist. There is a feature about this security that deserves notice by the therapist: the therapist needs to be aware of his own reactions to hearing stories of trauma. The realities disclosed can be horrible, the therapist can be repelled or fascinated, and can also have human “me too” responses.
Telling the story involves more than recounting reality, it includes inner responses. These responses consist of fantasies that occurred during as well as after the stressor event, and sometimes before. A patient may say, “I knew this would happen to me one day and I expected it would be like…” Differentiating the reality from the fantasy aspect of the story will be important in every aspect of treatment; for very distraught patients, it need not be totally interpreted in the support stage.
Telling the story includes reactions to associations to a series of cascading events. That is, while a criminal assault takes center stage as THE STORY, in actuality this event leads to a cascade of other stressor events such as encounters with law enforcement officers, hospital personnel, insurance providers, lawyers, and relatives or friends who may have seemed hostile, self-interested, or unsympathetic.
Often, patients have not fully developed the components of stories into accurate temporal sequences. They seldom have a complete view of the cause and effect sequences that are involved in a chain of events. Clarification of these cause and effect sequences merely starts in this stage, and it will continue in later stages of the psychotherapy, especially the exploration of meanings and the working through of conflictual themes.
Providing Information and Structuring Tasks
Some patients are in such overload that they can only absorb small amounts of new information. But many, though they are novices to the traumas of life, are able to learn about stress responses and develop coping capacities. The therapist can provide information in a series of short statements. For some patients, additional materials can be given such as bibliotherapies or videocassettes. Such resources include books like Coping With Trauma: A Guide of Self Understanding (Allen, 1999), Life After Trauma: A Workbook for Healing (Rosenbloom and Williams, 1999), and the Post Traumatic Stress Disorder Sourcebook: A Guide to Recovery, Health and Growth (Schiralde, 2000). For disaster victims, some internet resources can be useful such as the Federal Emergency Management Agency (http://www.fema.gov), the Red Cross (www.redcross.org), and local protective resource institutions.
A plethora of things to do or contemplate floods every victim of a stressor event. Confusion can result. In such instances, but not in a way that fosters dependency, the therapist can help in structuring tasks. Topics for contemplation can be prioritized when the time comes for making necessary decisions. Actions can be ordered by efficacy as well as urgency: efficacy refers to actions that can be accomplished readily and can also enhance a sense of capability. Writing down what is said is often valuable as memory fluctuations occur under stress.
Stressor events can be traumatic because they carry a lot of important and possibly dire stimuli and because they shock the person’s self assessment: the person is not in as much control as they had previously assumed. The realization about not being in full control of the situation can lead to an extreme and overgeneralized response such as “I cannot control anything.” This is more likely to persist in a person who before the stressor event had a fear-evoking attitude most of the time. This overgeneralized response can also be latent if it has been replaced by a current attitude of self-efficacy. If and when, after the stressor, the person is engaged in repeated expressions of “I cannot control anything,” then realistic corrections are indicated to reduce the catastrophic overgeneralization (Beck, 1976). Replacement suggestions can be made like “There are things I can control, but these other things are beyond my control.”

Establishing a Therapeutic Alliance
As mentioned, hearing stories about traumas can evoke empathic reactions of horror, terror, disgust, or other forms of repulsion in the clinician. Such reactions are normal, but they can increase the patient’s tension. In addition, some patients test therapists by seeing if they can provoke reactions such as fear (I cannot help such a patient), hopelessness (no one could ever cope with that), or withdrawal (I cannot take in such extreme emotions). Because of such tests, therapists should be alert to countertransference reactions. These can include the therapist unconsciously taking on the role of victim and feeling fear and hopelessness or taking the role of an aggressor and feeling like a sadist who forces the patient to relive memories of bad times.
Wilson (1994) provides a useful list of frequently occurring countertransference reactions reported by therapists who treat victims of trauma (Table 3.1). By recognizing that such reactions may happen in the therapist and other social support persons, the potential negative feedback to the patient can be reduced and a therapeutic alliance restored.
Under strain, some people regress to withdrawn, desperate or excessively anxious attachment patterns. Unfortunately, those prone to desperate forms of seeking contact do so in ways that alienate those who might otherwise help them. By recognizing countertransference reactions, the therapist can avoid alienating the patient and help him or her reduce provocative or unresponsive stances with others.
Establishing appointments, a diagnosis, and a formulation can be quite reassuring. Conveying facts can reduce secondary anxieties. Some people for example, presume that intrusive symptoms represent an unusually lowered control over their mental contents and interpersonal emotional expressions that they fear they are losing their minds. The therapist can reduce fears by giving patients accurate information about the prevalence of symptoms, such as intrusions, after a serious life event, as well as the usual course of improvement. Patients can be told that they do not have to focus attention on intrusive memories, ideas, and feelings. Putting such topics out of mind can restore equilibrium. It does not mean they will be either forgotten or avoided forever.
Putting stressor topics out of mind can be aided by the therapist sanctioning such dosing of emotion. The therapist can help prioritize what topics require current consideration and what topics could be contemplated later. Attention to focusing on positive emotional memories or future opportunities can be encouraged.
It may also help to identify a theme that occurs in some patients: they feel less attractive to others in their posttraumatic states of mind. They cringe because they believe others will see them as cowards, weaklings, malingers, boring, or ugly companions. A realistic reassurance can be given; telling the patient that this is a common stress response can partially restore a rational perspective.
An important part of formulation in this early stage of support is the therapist/patient observations of change in interpersonal patterns that are a consequence of the trauma. The stressor event will, in many instances, lead to altered states of mind, which causes a disruption in the sense of self as part of a community. Adaptation is fostered by fellowship, group-belonging, and appropriate levels of help. Conversely, maladaptive results may occur if the patient heightens dependency on unreliable sources of support, angrily rejects support because it falls short of magically erasing the trauma, or hides-out to avoid possibly embarrassing social contacts. These tendencies are diagrammed in Figure 3.1.
Establishing a commitment to care by giving a plan for what will be done, provides both empathy for the patient’s level of current distress and hope for change. Such initial support can lead to a sharp reduction in symptoms. The patient can then move rapidly toward exploring meanings, improving coping, and working through in the ensuing stages of psychotherapy.

Papers Published Since 1990

1. Horowitz, M.J. Post traumatic stress disorders: psychosocial aspects of the diagnosis. International Journal of Mental Health. 19:21-36, 1990.
2. Horowitz, M.J. A model of mourning: change in schemas of self and other. Journal of the American Psychoanalytic Association. 38(2):297-324, 1990.
3. Horowitz, M.J., Markman, H.C., Stinson, C.H., Ghannam, J.H., and Fridhandler, B. A classification theory of defense. In Singer, J. (ed.), Repression and Dissociation: Implications for Personality Theory, Psychopathology and Health. Chicago: University of Chicago Press, 1990.
4. Horowitz, M.J. Stress, states and person schemas: a commentary on Lazarus' "Theory-based stress measurement." Psychological Inquiry. 1(1): 25-26, 1990.
5. Tunis, S., Fridhandler, B., and Horowitz, M. Identifying schematized views of self with significant others: convergence of quantitative and clinical methods. Journal of Personality and Social Psychology. 59(6):1279-1286, 1990.
6. Horowitz, M.J. Psychotherapy of post traumatic stress disorder. In Bellack, A.S., and Hersen, M. (eds.), Handbook of Comparative Treatments for Adult Disorders. New York: Wiley, 1990.
7. Horowitz, M.J. Person schemas. In Horowitz, M.J. (ed.), Person Schemas and Maladaptive Interpersonal Patterns. Chicago: University of Chicago Press, 1991.
8. Horowitz, M.J. Introduction to the two cases. In Horowitz, M.J. (ed.), Person Schemas and Maladaptive Interpersonal Patterns. Chicago: University of Chicago Press, 1991.
9. Horowitz, M.J., Merluzzi, T.V., Ewert, M., Ghannam, J.H., Hartley, D., and Stinson, C. Role-relationship models configuration. In Horowitz, M.J. (ed.), Person Schemas and Maladaptive Interpersonal Patterns. Chicago: University of Chicago Press, 1991.
10. Horowitz, M.J., Luborsky, L., & Popp, C. A Comparison of the Role-Relationship Models Configuration and the Core Conflictual Relationship Theme. In Horowitz, M.J. (ed.), Person Schemas and Maladaptive Interpersonal Patterns. Chicago: University of Chicago Press, 1991.
11. Horowitz, M.J. Converging several methods for inferring person schemas. In Horowitz, M.J. (ed.), Person Schemas and Maladaptive Interpersonal Patterns. Chicago: University of Chicago Press, 1991.
12. Horowitz, M.J. Emotionality and schematic control processes. In Horowitz, M.J. (ed.), Person Schemas and Maladaptive Interpersonal Patterns. Chicago: University of Chicago Press, 1991.
13. Horowitz, M.J. The wonder of self-reflective conscious awareness: a review of "The Unconscious and the Theory of Psychoneuroses" by Zvi Giora. Contemporary Psychology. 36(7):623-624, 1991.
14. Horowitz, M.J. and Stinson, C.H. University of California at San Francisco, Center for the Study of Neuroses, Program on Conscious and Unconscious Mental Processes. In L.E. Beutler and M. Crago (eds.) Psychotherapy Research: An International Review of Programmatic Studies. Washington: American Psychological Association, pp. 107-114, 1991.
15. Horowitz, M.J. States, schemas, and control: general theories for psychotherapy integration. Journal of Psychotherapy Integration. 1:2, pp. 85-102, 1991.
16. Horowitz, M.J., Stinson, C., and Field, N. Natural Disasters and Stress Response Syndromes. Psychiatric Annals. 21(9):556-562, 1991.
17. Horowitz, M.J. Short-term dynamic therapy of stress response syndromes. In Christoph, P. and Barber, J.P. (eds.), Handbook of Short-Term Psychotherapy, New York: Basic Books, 1991.
18. Horowitz, M.J., Fridhandler, B., and Stinson, C. Person schemas and emotion. Journal of the American Psychiatric Association. 39 (Suppl: "Affect: Psychoanalytic Perspectives"): 173-208. 1991.
19. Horowitz, M.J. Core traits of Hysterical or Histrionic Personality Disorders. In Horowitz, M. (ed.) Hysterical Personality Style and the Histrionic Personality Disorder, pp. 1-14. Northvale, N.J.: Aronson. 1991.
20. Horowitz, M.J. Psychic structure and the process of change. In Horowitz, M. (ed.) Hysterical Personality Style and the Histrionic Personality Disorder, pp. 193-261. Northvale, N.J.: Aronson. 1991.
21. Horowitz, M.J. Conscious representation. Consciousness and Cognition. 1:12-15, 1992.
22. Horowitz, M.J. Stress Response Syndromes: A Review of Post Traumatic and Adjustment Disorders. In Wilson, J. and Raphael, B. (eds.) International Handbook of Traumatic Stress Syndromes. New York: Plenum Press. 1992.
23. Horowitz, M.J. Microanalysis of working through in psychotherapy (first appeared in Am J Psychiatry 131[11]:1208-1212, 1974). In J. Siegfried (Ed.), Therapeutic and everyday discourse as behavior change: Towards a microanalysis in psychotherapy process research. Norwood, N.J.: Ablex Publishing, 1992.
24. Horowitz, M.J. The Langley Porter projects. In Freedheim, D.K. (Ed.), History of Psychotherapy: A Century of Change. Washington, D.C.: American Psychological Association. pp. 422-426. 1992.
25. Horowitz, M.J. and Reidbord, S. Memory, Emotion and Response to Trauma. In Christianson, S.A. (ed.) The Handbook of Emotion and Memory, Hillsdale, New Jersey: Lawrence Erlbaum. pp. 343-357. 1992.
26. Horowitz, M.J. Effects of Psychic Trauma on Mind: Structure and Processing of Meaning. In Barron, J.W., Eagle, M.N., and Wolitsky, D.L.(eds.), Interface of Psychoanalysis and Psychology. Washington, D.C.: APA. 1992.
27. Eells, T.D., Horowitz, M.J. Methods for inferring self- schematization. Psychoanalytic Inquiry. 3:32-34. 1992.
28. Horowitz, M.J., Cooper, S., Fridhandler, B., Perry, J.C., Bond, M., and Vaillant, G. Control processes and defense mechanisms. Journal of Psychotherapy Practice and Research. 1(4):324-336, 1992.
29. Horowitz, M.J. Formulation of states of mind in psychotherapy. In Hamilton, N.G. (ed.), From Inner Resources: New Directions in Object Relations Psychotherapy, Northvale, N.J. Jason Aronson. pp. 75-83. 1992.
30. Horowitz, M.J., Fridhandler, B.F., and Stinson, C.H. Person schemas and emotion. In Shapiro, T., and Emde, R.N., (eds.), Psychoanalytic Perspectives, pp. 173-208. New York: International Universities Press, 1992.
31. Horowitz, M.J. Depression after the death of a spouse. Am J Psychiatry. 149(4):579-80, 1992, April.
32. Horowitz, M.J. The Effects of Psychic Trauma on Mind: Structure and Processing of Meaning. pp. 489-500 in J. Barron, N. Eagle, D. Wolitski. Interface of Psychoanalysis and Psychology. Washington D.C.: American Psychological Association, 1992.
33. Horowitz, M.J., and Eells, T.D. Case formulations using role-relationship model configurations: A reliability study. Psychotherapy Research. 3:57-68, 1993.
34. Eells, T.D., Horowitz, M.J., Stinson, C.H., and Fridhandler, B. Self-representation in anxious states of mind: A comparison of psychodynamic models. In Segal, S.V.and Blatt, S.J. (eds.) Self-Representation and Emotional Disorder: Cognitive and Psychodynamic Perspectives. New York: Guilford Press. 1993.
35. Eells, T.D., Fridhandler, B., Stinson, C.H., Horowitz, M.J. Commentary on "Self-representation in post-traumatic stress disorder: a cognitive perspective" by Richard J. McNally. In S.V. Segal and S.J. Blatt (eds.) Self-Representation and Emotional Disorder: Cognitive and Psychodynamic Perspectives. New York: Guilford Press. 1993.
36. Horowitz, M.J., Field, N., and Classen, C. Stress Response Syndromes and Their Treatment. In Goldberger, L., and Breznitz, S. (eds.), Handbook of Stress: Theoretical and Clinical Aspects, Second Edition, pp. 757-773. New York: Free Press, 1993.
37. Horowitz, M.J., Bonanno, G.A., and Holen, A. Pathological grief: Diagnosis and explanation. Psychosomatic Medicine. 55(3)260- 273, 1993.
38. Horowitz, M.J., Milbrath, C., Reidbord, S., and Stinson, C.H. Elaboration and dyselaboration: Measures of expression and defense in discourse. Psychotherapy Research. 3:278-293, 1993.
39. Horowitz, M.J. Personality structure and the process of change during psychoanalysis. In Horowitz, M., Kernberg, O., and Weinschel, E. (eds.) Psychic Structure and Psychic Change, pp. 1-28. New York: International University Press. 1993.
40. Horowitz, M.J., Stinson, C.H., Fridhandler, B., Ewert, M., Milbrath, C., and Redington, D. Pathological grief: An intensive case study. Psychiatry. 56:356-374, 1993.
41. Stinson, C.H., and Horowitz, M.J. Psyclops: An exploratory graphical system for clinical research and education. Psychiatry. 56(4):375-389, 1993, Nov.
42. Horowitz, M.J., Stinson, C., Curtis, D., Ewert, M., Redington, D., Singer, J., Bucci, W., Mergenthaler, E., Milbrath, C. Topics and signs: Defensive control of emotional expression. Journal of Consulting and Clinical Psychology. 61:421-430, 1993, June.
43. Horowitz, M.J., and Becker, T.C. The difference between termination in psychotherapy and psychoanalysis. Journal of the American Psychoanalytic Association. 41(3):765-773, 1993.
44. Horowitz, M.J. Defensive control of states and person schemas. Journal of the American Psychoanalytic Association. 41:67-89, 1993.
45. Horowitz, M.J. States, schemas, and control: general theories of psychotherapy integration. Clinical Psychology and Psychotherapy. 1:143-152, 1994.
46. Horowitz, M.J. Configurational analysis and the use of Role-relationship models to understand transference. Psychotherapy Research. 3(3&4):184-196, 1994.
47. Horowitz, M.J., Milbrath, C., Jordan, D.S., Stinson, C.H., Ewert, M., Redington, D.J., Fridhandler, B., Reidbord, S.P., and Hartley, D. Expressive and defensive behavior during discourse on unresolved topics: A single case study of pathological grief. Journal of Personality. 62(4):527-563, 1994, Dec.
48. Horowitz, M.J. Psychotherapy research and the views of clinicians. In Tally, D., Strupp, H., and Butler, S. (Eds.), Psychotherapy Research and Practice. New York: Basic Books, pp. 196-205. 1994.
49. Horowitz, M.J., and Stinson, C. Stress response syndromes: Personality features related to neurotic responses to events. Current Opinion in Psychiatry.7:144-149, 1994.
50. Horowitz, M.J., Milbrath, C., Ewert, M., Sonneborn, D., and Stinson, C.H. Cyclical Patterns of States of Mind in Psychotherapy. American Journal of Psychiatry. 151(12):1767-1770, 1994, Dec..
51. Mergenthaler, E.M., and Horowitz, M.J. Linking Computer Aided Text Analysis with Variables Scored from Video Tape. In Faulbaum, F.(ed.) Advances in Statistical Software. New York: Gustav Fischer, pp. 385-393. 1994.
52. Horowitz, M.J. Psychotherapy integration: Implications for research standards. Psychotherapy & Rehabilitation Research Bulletin. 1(3):8-9, 1994.
53. Horowitz, M.J. Does Repression Exist? Yes. The Harvard Mental Health Letter. 11(1): 4-5, 1994.
54. Horowitz, M.J., and Stinson, C.H. Defenses as aspects of person schemas and control processes. In Conte, H., and Plutchik, R. (eds). Ego Defenses: Theory and Measurement, pp. 79-97. 1994.
55. Horowitz, M.J. Cognition, psychodynamics, and control of experience. In Kessel, F. (ed.) Psychology, Science, and Human Affairs: Essays in Honor of William Bevan. Westview Press, pp. 138-150, 1995.
56. Stinson, C., Milbrath, C., and Horowitz, M. Dysfluency and topic orientation in bereaved individuals: Bridging individual and group studies. Journal of Consulting and Clinical Psychology.63(1):37-45, 1995.
57. Eells, T.D., Horowitz, M.J., Singer, J., Salovey, P., Daigle, D., and Turvey, C. The Role Relationship Models Method: A Comparison of Independently Derived Case Formulations. Psychotherapy Research. 5:161-175, 1995, Feb.
58. Horowitz, M.J., Stinson, C.H. Consciousness and Processes of Control. Journal of Psychotherapy Practice and Research. 4:123-139, 1995.
59. Horowitz, M.J., Znoj, H., Stinson, C. Defensive control processes: Use of theory in research, formulation, and therapy of stress response syndromes. In Zeidner, M., and Endler, N. (eds.), Handbook of Coping, pp. 532-553. New York: Wiley and Sons, 1996.
60. Horowitz, M.J., and Kaltreider, N.B. Brief Therapy of the Stress Response Syndrome. In Everly, G.S., and Lating, J.M. (eds.) Psychotraumatology, pp. 231-244. New York: Plenum, 1995.
61. Milbrath, C., Bauknight, R., Horowitz, M.J., Amaro, R., and Sugahara, C. Sequential analysis of topics in psychotherapy discourse: A single case study. Psychotherapy Research. 5(3):199-217, 1995.
62. Horowitz, M.J., Eells, T., Singer, J., and Salovey, P. Role Relationship Models for Case Formulation. Archives of General Psychiatry. 53:627-632, 1995, August. (featured paper with 8 commentaries).
63. Horowitz, M.J., Eells, T., Singer, J., and Salovey, P. Role Relationship Models: A Summation (response to eight separate journal invited commentaries on Role Relationship Model Configurations paper), Archives of General Psychiatry 53:633-654, 1995.
64. Hart, D., Stinson, C., Field, N., Ewert, M., and Horowitz, M. A Semantic Space Approach to Representations of Self and Other in Pathological Grief: A Case Study. Psychological Science. 6(2):96-100, 1995.
65. Eells, T., Fridhandler, B., Horowitz, M. Self Schemas and Spousal Bereavement: Comparing Quantitative and Clinical Evidence. Psychotherapy. 32:270-282, 1995.
66. Horowitz, M.J., Milbrath, C., and Stinson, C. Signs of Defensive Control Locate Conflicted Topics in Discourse. Archives of General Psychiatry. 52:1040-1057, 1995, Dec.
67. Horowitz, M.J. Histrionic Personality Disorder. In Gabbard, G. (ed.), Treatment of Psychiatric Disorders, 2nd edition, pp. 2311-2326. Washington DC: American Psychiatric Press Inc., 1995.
68. Bonanno, G.A., Keltner, D., Holen, A., and Horowitz, M.J. When Avoiding Unpleasant Emotions Might Not be Such a Bad Thing. Journal of Personality and Social Psychology. 69(5):975-990, 1995, Nov.
69. Horowitz, M.J. La struttura della personalita e il processo di cambiamento durante la psicoanalisi. Psicoterapia. 1(2):5-28, 1995.
70. Horowitz, M.J., Sonneborn, D., Sugahara, C., and Maercker, A. Self regard: A new measure. American Journal of Psychiatry. 153:382-385, 1996 (featured article).
71. Horowitz, M.J., Stinson, C.H., and Milbrath, C. Role Relationship Models: A Person Schematic Method for Inferring Beliefs About Identity and Social Action. In Colby, A., Jessor, R., and Shweder, R. (eds.), Ethnography and Human Development. Chicago: University of Chicago Press, 1996.
72. Horowitz, M.J., Ewert, M., & Milbrath, C.M. States of Emotional Control During Psychotherapy. J. Psychotherapy Research and Practice. 5:20-25, 1996.
73. Horowitz, M.J. Psychotherapy for histrionic personality disorder (special article with two editorial commentaries). J. Psychotherapy Practice and Research. 6(2):93-107, 1997, Spring.
74. Horowitz, M.J. Cognitive psychodynamics: The clinical use of states, person schemas, and defensive control process theory. In Stein, D. (ed.) Cognitive Science and the Unconscious. Washington D.C.: American Psychiatric Press, Inc., 1997.
75. Horowitz, M.J., Milbrath, C., and Stinson, C.S. Assessing personality disorders. In Beutler, L., Horowitz, L., and Strupp, H. (eds.) Measuring Change After Treatment for Mood, Anxiety, and Personality Disorders. Washington, D.C.: American Psychoanalytic Association Press, pp. 401-432, 1997.
76. Horowitz, M.J. Configurational analysis for case formulation. Psychiatry. 60:111-119, 1997.
77. Horowitz, M.J., Siegel, B., Holen, A., Bonanno, G., Milbrath, C., Stinson, C. Diagnostic criteria for complicated grief disorders. American Journal of Psychiatry. 154(7) 904-911, 1997, July. (cover article).
78. Horowitz, M.J., Eells, T. Configurational analysis: States of mind, person schemas and the control of ideas and affect. In Eels, T. (ed.) Handbook of Psychotherapy Case Formulation, New York: Guilford Publ., pp. 166-197, 1997.
79. Field, N.P., Hart, D., and Horowitz, M.J. The content of self-other concepts: A network perspective. Imagination, Cognition and Personality. 16:357-378, 1997.
80. Horowitz, M.J. Personlichkeitsstile und belastungsfolgen. Integrative psychodynamisch-kognitive psychotherapy. In A. Maercker (ed.) Therapie der posttraumatischen belassungs-storungen. Heidelberg: Springer, 1997.
81. Horowitz, M. Organizational Levels of Self and Other Schematization, in Westenberg, P.M., Rogers, A.G., Cohn, L.D., and Blasi, A. (eds.) Personality Development. pp. 79-313, New York: Lawrence Erlbaum, 1997.
82. Stormark, K.M., Field, N.P., Hugdahl, K., and Horowitz, M. Selective processing of visual alcoholic cues in abstinent alcoholics: An approach avoidance conflict? Addictive Behaviors. 22:509-519, 1997.
83. Horowitz, M. J. Stress response syndromes: Post-traumatic and adjustment disorders. Chapter 41, in Michels, R. et al. (Ed.), Psychiatry. NY: Lippincott-Raven, 13 pp., 1998.
84. Adler, N., Horowitz, M., Weinstein, N., Moyer, A.: Further validation of a scale to assess positive states of mind. Psychosomatic Med. 1998.
85. Horowitz, M.J., Milbrath, C., Bonanno, G., Field, N., Stinson, C., Holen A. Predictors of complicated grief. J. Personal and Interpers. Loss. 3:257-270, 1998.
86. Maercker, A., Bonanno, G., Horowitz, M., Znoj, H. Prediction of complicated grief by positive and negative themes in narratives. J. Clin. Psychology. 54: 1117-1136, 1998.
87. Horowitz, M.J. Personality disorder diagnoses. Am J Psychiatry. 155(10):1464, 1998, Oct.
88. Field, N.P., Horowitz, M.J. Applying an empty-chair monologue paradigm to examine unresolved grief. Psychiatry. 61(4):279-87, 1998, Winter.
89. Perry, J., Hoglend, P., Shear, K., Vaillant, G., Horowitz, M., Kandos, M., Bille, H., Kagan, D.: Field trial of a diagnostic axis for defense mechanisms for DSM-IV. J. Personality Disorders. 12:56-68, 1998
90. Fridhandler, B., Ellis, T.D., Horowitz, M.J.: Psychoanalytic explanation of pathological grief: Scientific observation of a single case. Psychoanalytic Psychology. 16: 34-57, 1999.
91. Horowitz, M. Posttraumatic Stress Disorder: Dynamic Psychotherapy, in M.Hersen and A.S. Bellak Handbook of Comparative Interventions for Adult Disorders 2nd edition. NY: Wiley & Sons, 1999.
92. Bonanno, G.A., Notarius, C.I., Gunyerath, L., Keltner, O., Horowitz, M.: Interpersonal ambivalence, perceived dyadic adjustment, and conjugal loss. J. Consult.and Clin. Psychol. 66:1012-1021, 1999.
93. Horowitz, M.J. Formulation to plan psychotherapy, in D. Spiegel (ed.) Psychotherapeutic Frontiers: New Principles and Practices, American Psychiatric Press, Inc., 1999.
94. Horowitz, M. Modes of conscious representation and their exploration through psychotherapy, in P. Salovey and Jeffrey Singer (eds.) At Play in the Fields of Consciousness: Essays in Honor of Jerome Singer. New York: Erlbaum, 1999.
95. Bonanno, G., Znoj, H., Siddique, A., Horowitz, M. Verbal autonomic dissociation and adaptation to midlife conjugal loss: A follow up at 25 months. Cognitive Ther. and Research. 23(6):605-624, 1999.
96. Milbrath, C., Bond, M., Cooper, S., Znoj, H., Hans J., Horowitz, M. J., Perry, J. C. Sequential Consequences of Therapists' Interventions. J. Psychother. Pract. Res. 8: 40-54, 1999.
97. Horowitz, M., Znoj, H. Emotional Control Theory: A revision of the concept of defense. Psychotherapy Practice and Research. 8:213-224, 1999.
98. Field, N.P., Nichols C., Holen A., Horowitz, M.J. The relation of continuing attachment to adjustment in conjugal bereavement. J Consult Clin Psychol. 67(2):212-8., 1999 Apr.
99. Horowitz, M. Brief cognitive-dynamic theory of stress response syndromes, in C. Snyder and R. Ingram, (eds.) Handbook of Psychological Change. NY: Wiley, 2000.
100. Donnelly, E., Field, N., Horowitz, M. Expectancy of spousal death and adjustment to conjugal bereavement. Omega. 42:195-208, 2000-2001
101. Horowitz, M. Configurational analysis of the self: a state of mind approach, in Muran, J.C., (ed.) Self-Relations in the Psychotherapy Process. Washington D.C.: APA Books, 67-81, 2001.
102. Horowitz, M. “Making the Case for Psychoanalytic Therapies in the Current Psychiatric Environment”: Comment. JAPA. 47(3):710-716, 1999.
103. Horowitz, M. Sundin, E., Lauer, R, Zanko, A. Coping with grim news from genetic tests. Psychosomatic Medicine, 42:2, 1-6, March-April 2001 (special article).
104. Field, N.P., Sturgeon S.E., Puryear, R., Hibbard, S., Horowitz, M.J. Object relations as a predictor of adjustment in conjugal bereavement. Dev Psychopathol. 13(2):399-412, 2001 Spring.
105. Horowitz, M. Self observation and subjective self-experiences, in Muran, J.C., editor. Self Relations in the Psychotherapy Process. Washington D.C. APA Books, 2001.
106. Horowitz, M., Field, N., Donnelly, E., Epstein, C., Longo, F. Psychologische Wirkung der Bekanntgabe des genetischen Risikis fur Choread Huntington. Editors; A. Maercker, U. Ehlert. Jahrbuch der medizinischen Psychologie: Psychotraumatologie. Hogrefe, Gottingen, Germany, 2001.
107. Horowitz, M., Field, N., Donnelly, E., Epstein, C., Longo, F. Psychological impact of news of genetic risk for Huntington Disease. Amer. J. Medical Genetics. 103, 188-192:2001 (lead article)
108. Sundrin, E., Horowitz, M. Horowitz' Impact of Event Scale: Psychometric Properties. Brit. J. Psychiatry. 180(3):205-209, 2002 March.
109. Horowitz, M. Configurational analysis, in M. Hersen and W. Sledge Encyclopedia of Psychotherapy. New York: Academic Press, Vol. 1, 511-515, 2002.
110. Horowitz, M. Self and Relational Observation. J. Psychotherapy Integration. Vol. 12, No. 2, 115-127, 2002.
111. Horowitz, M. Defining Character Integrity. Journal of the American Psychoanalytic Association, (JAPA), 50:551-573, 2002.
112. Horowitz, M. Schemi-persona e modalita di relazione disfunztionale. Psicaterapia, 2003.
113. Sundin, E., Horowitz, M. Horowitz’ Impact of Event Scale: I. An Evaluation of 20 years of usage. Psychosomatic Medicine 65:870-876, 2003.
114. Blake-Mortimer, J., Field, N., Koopman, C., Classen, C., Horowitz, M., Spiegel, D. Perceptions of family relationships associated with husband’s ambivalence and dependency in anticipating losing his wife with metastatic/ recurrent breast cancer. J. Loss and Trauma. 8:139-147, 2003.
115. Horowitz, M. Persönlichkeitsstile und Belastungsfolgen. 107-128 in A. Maercker, (ed.). Therapie der posttraumatischen Belastingsstörugen. Berlin: Springer, 2003.
116. Ullrich, P.M., Lutgendorf, S.K., Stapleton, J.T., Horowitz, M. Self regard and concealment of homosexuality as predictors of CD4+ cell count over time among HIV seropositive Gay men. Psychology & Health 19(2):183-196, 2004, April.
117. Baccus, J. R., Horowitz, M. J. Role-Relationship models: Addressing maladaptive interpersonal patterns and emotional distress. In Baldwin, M., (ed.) Interpersonal Cognition. New York: Guilford, 2004.
118.[ on CV #280} Horowitz, M. J.H. A life in but not under stress, in C. Figley, (ed.) Mapping Trauma and Its Wake: Autobiographic Essays by Pioneer Trauma Scholars. New York and London: Burner-Ruttledge, 2005.

Books In Sequence:
1. Horowitz, M.J.
(a) Image Formation and Cognition. New York: Appleton-Century-Crofts, 1970.
(b) Second edition, Appleton-Century-Crofts, 1978.
(c) Third edition: Image Formation and Psychotherapy. Northvale, NJ: Aronson, 1983.
(d) Paperback edition in Masterworks Series. Northvale, NJ: Aronson, 1996.
2. Horowitz, M.J., Cohen, F.M., Skolnikoff, A., and Saunders, F. Psychosocial Function in Epilepsy. Springfield, IL: Chas Thomas, 1970.
3. Horowitz, M.J.
(a) Stress Response Syndromes. Northvale, NJ: Aronson, 1976.
(b) Second edition, Aronson, 1986.
(c) Third edition, Aronson, 1997
(d) Fourth edition, Stress Response Syndromes: Personality Styles and Intervention, 2001.
4. Horowitz, M.J. (ed.),
(a) Hysterical Personality. Northvale, NJ: Aronson, 1977.
(b) Second edition: Hysterical Personality and the Histrionic Personality Disorder. Northvale and London: Aronson, 1991.
5. Attkisson, C.C., Hargreaves, W.A., Horowitz, M.J., and Sorenson, J. (eds.), Evaluation of Human Service Programs. New York: Academic Press, 1978.
6. Horowitz, M.J.
(a) States of Mind. New York: Plenum, 1979.
(b) Second edition, States of Mind: Configurational Analysis of Individual Personality. New York: Plenum, 1987.
7. Horowitz, M.J., Marmar, C., Krupnick, J., Wilner, N., Kaltreider, N., and Wallerstein, R.
(a) Personality Styles and Brief Psychotherapy. New York: Basic Books, 1984.
(b) Second edition: Masterworks Series, Northvale, NJ: Aronson, 1997.
(c) Third edition, Aronson, 2001.
8. Horowitz, M.J. (ed.), Psychodynamics and Cognition. Chicago: University of Chicago Press, 1988.
9. Horowitz, M.J. Introduction to Psychodynamics: A New Synthesis. New York: Basic Books, 1988.
10. Horowitz, M.J. Nuances of Technique in Psychodynamic Psychotherapy. Northvale, NJ: Aronson, 1989.
11. Horowitz, M.J. (ed.), Person Schemas and Maladaptive Interpersonal Patterns. Chicago: University of Chicago Press, 1991.
12. Horowitz, M.J., Kernberg, O., and Weinshel, E. (eds.) Psychic Structure and Change in Psychoanalysis. New York: International Universities Press, 1993.
13. Horowitz, M.J. Formulation as a Basis for Planning Psychotherapy Treatment. Washington DC: APPI, 1997.
14. Horowitz, M.J. Cognitive Psychodynamics: From Conflict to Character. New York: Wiley, 1998.
15. Horowitz, M.J. Essential Papers on Posttraumatic Stress Disorder. New York: New York University Press, 1999.
16. Horowitz, M.J. Treatment of Stress Response Syndromes. Washington D.C.: Amer. Psychiatric Press, 2003.
17. Horowitz, M.J. Understanding Psychotherapy Change. In preparation, Amer. Psychological Association


FILM

1. Psychotherapy. 26 min. McGraw-Hill Films, 1979. Winner, Psychiatry, John Muir Medical Film Festival. Winner, Bronze Award, Columbia Film Festival.

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The Horowitz Impact of Event Scale
Below is a list of comments made by people after stressful life events. Using the following scale, please indicate (with a ) how frequently each of these comments were true for you DURING THE PAST SEVEN DAYS in regard to this (these) specific life events _________________________________________________________________.
SCORE EACH ITEM AS ONE OF THESE FOUR CHOICES: (0) Not at all (1)Rarely (3)Sometimes (5) Often
1.I thought about it when I didn't mean to
. . . .
2.I avoided letting myself get upset when I thought about it or was reminded of it
. . . .
3.I tried to remove it from memory
. . . .
4.I had trouble falling asleep or staying asleep because of pictures or thoughts about it that came into my mind . . . .
5.I had waves of strong feelings about it
. . . .
6.I had dreams about it
. . . .
7.I stayed away from reminders of it
. . . .
8.I felt as if it hadn't happened or wasn't real
. . . .
9.I tried not to talk about it
. . . .
10.Pictures about it popped into my mind
. . . .
11.Other things kept making me think about it
. . . .
12.I was aware that I still had a lot of feelings about it, but I didn't deal with them
. . . .
13.I tried not to think about it
. . . .
14.Any reminder brought back feelings about it
. . . .
15.My feelings about it were kind of numb
. . . .


Scoring:
Not at all = 0; Rarely = 1; Sometimes = 3; Often = 5
Total = total the scores, with higher scores reflecting more stressful impact. The scores for the intrusive subscale range from 0 to 35, and is the sum of the scores for items 1, 4, 5, 6, 0, 11, and 14. The scores for the avoidance subscale range from 0 to 40, and is the sum of the scores for items 2, 3, 7, 8, 9, 12, 13, and 15. The sum of the two subscales is the total stress score. It is suggested that the cut-off point is 26, above which a moderate or severe impact is indicated. A score below 8 is subclinical, and 9-25 is a mild to moderate range of stress response.


Reference: Horowitz, M., Wilner, M., and Alvarez, W. (1979). Impact of Event Scale: A measure of subjective stress. Psychosomatic Medicine, 41, 209-218.