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2. Trauma-Focused (TF) CBT

  • Exposure Therapy
  • Cognitive Processing
  • TF-CBT Kids and Adolescence
  • Acceptance and Commitment Therapy

"... PTSD requires the occurance of a specific type of event from which a person does not recover , (Barlow)"

3. EMDR

  • Overview
  • Accelerated Information Processing (AIP) Model
  • Treatment Goals
  • Research
  • Comparison of TF-CBT and EMDR

4. Case Study

1. Trauma-related thoughts or feelings

2. Trauma-related external reminders

  • people, places, conversations, activities, objects or situations

1. Post Traumatic Stress Disorder

  • History PTSD
  • Diagnostic Features
  • Epidemiology

1) Inability to recall key features of the traumatic event

  • usually dissociative amnesia
  • not due to head injury, alcohol or drugs

2) Persistent (& often distorted) negative beliefs and expectations about

oneself or the world

3. Persistent distorted blame of self or others for causing the traumatic

event or for resulting consequences (new)

4) Persistent negative trauma-related emotions

  • fear, horror, anger, guilt, or shame (new)

5) Markedly diminished interest in pre-traumatic activities

6) Feeling of allienation

7) Constricted affect: persistent inability to experience positive emotions

*PTSD may be especially severe or long-lasting when the stressor is interpersonal or intentional (ie. torture, sexual violence)

"Post traumatic stress disorder is the development of characteristic symptoms following exposure to one or more traumatic events " - DSM 5

Persistent avoidance of stimuli associated

with the trauma

(1/2 symptoms needed)

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1) Direct exposure

2) Witnesses in person

3) Learns that the traumatic event occurred to a close family

member or friend with the actual or threatened death being

either violent or accidental

4) Experiences first-hand repeated or extreme exposure to

aversive details of the traumatic event:

  • professionals repeatedly exposed to details of child abuse
  • Does not include indirect non-professional exposure

through electronic media, television, movies or pictures

Negative alterations in cognitions and mood that are associated with the traumatic event (2/7 symptoms needed)

Psalm 31:9,10,14-16

Post-Traumatic Stress Disorder

Diagnostic Features:

Criterion/Cluster C.

Criterion/Cluster D.

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Diagnostic Features

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Diagnostic Features:

Criterion A:

1.) Recurrent, involuntary and intrusive recollections

  • children may express this symptom in repetitive play

2.) Traumatic nightmares

  • children may have disturbing dreams without content related to trauma

3.) Dissociative reactions (e.g. flashbacks) which may occur on a

continuum from brief episodes to complete loss of consciousness

  • children may re-enact the event in play

4.) Intense or prolonged distress after exposure to traumatic reminders

5.) Marked physiological reactivity after exposure trauma-related stimuli

"It isn’t as though mental problems haven’t resulted from trauma in history... There is evidence of it in the Bible." - Dr. Mooli Lahad,

Diagnostic Features:

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"The trauma doesn't come back as a memory but as a reaction" Bessel Vander Kolk

1. "A deeply distressing or disturbing experience." -Webster's Dictionary

2. "Exposure to actual or threatened death, serious injury or sexual

violation" - DSM 5

3. "Physical injuries of sudden onset and severity which require immediate

medical attention" -University of Florida

4. “PTSD is a whole-body tragedy, an integral human event of

enormous proportions with massive repercussions.”

- Susan Pease Banitt LCSW

Intrusion (re-experiencing) Symptoms (1/5 symptoms needed)

1.) Intrusion (Re-experieincing) symptoms (Criterion B)

2.) Persistent avoidance of stimuli associated with the

trauma (Criterion C)

3.) Negative alterations in cognitions and mood that are

associated with the traumatic event (Criterion D)

4.) Alterations in arousal and reactivity that are

associated with the traumatic event (Criterion E)

Criterion/Cluster B.

DSM-I: 1952, "Gross Stress Reaction"

DSM-II: 1968, previous diagnosis eliminated; "Situational Reaction"

DSM-III: 1980 PTSD officially listed as Anxiety Disorder

DSM-IV: 1994 added numbing and avoidance to criterion for PTSD

DSM-5: 2013 PTSD is listed as a Trauma- and Stressor-Related Disorder

What is TRAUMA?

PTSD 309.81 (F43.10)

Diagnostic Features

1917 - The Statistical Manual for the Use of Institutions for the Insane

1840 - The begining...

Dr. Chaim Shatan

Four Clusters of Symptoms:

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Diagnostic Features

Diagnostic and Statistical Manual of Mental Disorders (DSM)

Historical Journey of PTSD

in the

1.) Irritable or aggressive

behavior

2.) Self-destructive or reckless

behavior

3.) Hypervigilance

4.) Exaggerated startle response

5.) Problems in concentration

6.) Sleep disturbance

Alterations in arousal and reactivity associated

with the traumatic event (2/6 symptoms needed)

Criterion/Cluster E.

Specify whether:

With dissociative features:

  • Depersonalization
  • Derealization

Specify if:

With delayed expression

  • This must be specified if the full criteria are not met until at least 6 months after

the traumatic event; the criteria may be partially met during this time

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Diagnostic Features

Symptoms are not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition."

Criterion H.

Symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion G.

Temperamental

  • negative appraisals
  • inappropriate coping coping strategies
  • development of acute stress disorder

Environmental

  • exposure to repeated upset reminders
  • adverse life events
  • financial/trauma related losses

Developmental regression - including language

Auditory pseudo-hallucination

  • one's thoughts heard in different voices
  • paranoid ideation

Emotional disregulation

Difficulty maintaining stable interpersonal relationships

Persistence of symptoms (in Criteria B, C, D and E) for more than one month

Criterion F.

Diagnostic Features

Associated Features Supporting Diagnosis

Posttraumatic Factors

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1. Depersonalization: feeling as if "this is not happening to me" or one were in a dream

2. Derealization: feeling like "things are not real"

(occurring during trauma)

Environmental

  • Severity (dose of trauma)
  • Perceived threat
  • Personal injury
  • Interpersonal trauma
  • Military
  • Dissociation during trauma
  • Intentional vs nonintentional

Dunmore (2001) found that the "perceived life threat" and "injury threat" during the trauma were significantly correlated with PTSD severity

Criteria B – no change

Criteria C - combines adult Criteria C & D

At least 1/6 symptoms - including avoidance AND negative alterations in cognition and mood

*Preschool does not include: amnesia; foreshortened, future; persistent blame of self or others

Criteria E – 5/6 Symptoms - alterations in arousal and

reactivity

 *Preschool does not include: self- destructive or

reckless behavior

Individual must meet criteria for PTSD diagnosis, and experience high levels of either of the following in reaction to trauma-related stimuli for at least 6 months:

Peritraumatic Factors

New Dissociative Subtype

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Risk and Prognostic Factors

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Diagnostic Features

The Criteria are "Developmentally Sensitive"

  • Certain genotypes may protect or increase risk
  • Young age
  • Being female - via increased chance of sexual trauma
  • Family history of mental illness
  • Existing mental or emotional disorders
  • Epigenetics
  • Low socioeconomic status
  • Lower education
  • Prior trauma

Especially during childhood

  • Childhood adversity

Economic deprivation (poverty)

Family dysfunction

Parental separation/death

  • Cultural characteristics

Fatalistic/Self-blaming coping strategies

  • Lower intelligence
  • Minority racial/ethnic status

Minimum age for diagnosis: one year

Onset: any age

Symptoms begin with 3months of traumatic event

  • diagnosis may be months or years later

Clinical Expression may vary across stage of development

Children

  • avoidance, preoccupation with reminders,
  • negative alterations in primary moods due to limitations in expressing thoughts or labeling emotions
  • may experience co-occurring trauma: physical or domestic violence
  • chronic circumstances may hinder identification of symptomological onset
  • avoidant behaviour may manifest as: restricted play or exploration, reduced participation in school

Adolescents

  • socially undesirable; unable to fit in
  • loss of future aspiration
  • hindered peer relationships due to irritability and aggression
  • reckless behaviour, leading to injury
  • high risk behaviors or thrill seeking

Genetic & Biological factors

Common Comorbid Disorders:

  • Oppositional Defiant Disorder , Separation Anxiety Disorder

Environmental factors

Preschool Subtype: 6 Years or Younger

  • Childhood emotional problems by age 6 (externalizing or anxiety)
  • prior mental disorder (ie. panic disorder, depressive disorder, OCD)

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Temperamental:

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Pretraumatic Factors

Development and Course

Risk and Prognostic Factors

Epidemiology

Recovery rates vary:

33% of people exposed to trauma develop PTSD

• Complete recovery within 3 months in about 1/2 of adults

• Others remain symptomatic for more than 12 months - years

Recovery is significantly quicker in people exposed to unintentional trauma

Factors known to hinder recovery:

  • Reminders of the original trauma
  • Normal 'life stressors' (ie unemployment, illness or bereavement
  • New traumatic experiences
  • Worsening physical symptoms or declining health or cognitive function

Older Adults

in relation to younger adults, those whose PTSD symptoms continue into older adulthood, have reduced:

  •  hyperarousal
  •  avoidance
  •  negative cognitions and mood changes

in relation to younger adults, those who experience trauma as older adults (leading to PTSD) have increased:

  •  avoidance
  • hyperarousal
  •  sleep problems
  •  crying spells

PTSD is associated with:

  •  negative health perceptions
  •  primary health utilization
  •  suicidal ideation

*Older Americans make up 13% of the population, they account for 20% of the people who commit suicide. In fact, older Americans have the highest suicide rate of any age group.

Social support is a protective factor that moderates outcome after trauma

Lifetime risk of PTSD - 8.7%

12month prevalence - 3.5%

Higher Rates among:

• Veterans, High Risk Occupations: Police, Fire Fighters,

Emergency Medical Personnel

1/3 to more than 1/2 of those exposed to trauma, are survivors of:

• rape

• military combat

• captivity

• ethnic/political internment and genocide

Prevalence varies by age/development

  • Evidence suggests that the threshold is lower amongst older adults

Higher rates reported in USA of Latinos, African American, and American Indians than Non-Latino whites; and Asian Americans have a lower rate than non-Latino whites

Development and Course

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Prevalence

Course and Prognosis

Age related concerns:

Declining health, illness, decreased cognitive function, social isolation

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Epidemiology

Course and Prognosis

Epidemiology

  • Cultural and ethnic specific traumas

- ie. racism, genocide

  • Disordered meaning attributed to traumatic event

- Inability to perform funeral rites

- Mass killing

  • Sociocultural issues

- Unpunished perpetrators

  • Immigrant acculturative stress
  • Religious persecutions
  • Clinical expression of symptoms/clusters may very

- Avoidence, numbing, distressing dreams,

somatic symptoms

* dizzyness, shortness of breath, heat

sensation

  • Coping Mechanisms

- may need to be assessed according to

cultural template

  • Cultural syndromes and idioms of distress influence symptomology and comorbidity

- ie: Cambodians (khyal attacks); Latin

Americans, (ataqu de nervios)

  • Social disability, occuaptional disability,

physical disability, economic costs, medical utilization

  • Impaired function, regardless of domains:

social, interpersonal, intrapersonal, developmental, educational, health, occupational

  • Lower: income, education, occupational success

Culture-Related Diagnostic Issues

Functional Consequences of PTSD

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Epidemiology

Patients with comorbid major depressive episode and PTSD were more likely to have attempted suicide, and women with both disorders were more likely to have attempted suicide than men with both disorders.

Approach (int/ext) fear cues

Block Avoidance

Emotion subsides

3. SUDS - set anchor points of things the client anticipates to not being able to get passed with exposure

Trauma Focused CBT (TF-CBT)

"It will always remind me.."

Increased Suicide Risk (HIGH)

3. The new pattern:

  • Adjustment disorder
  • Other post traumatic disorders
  • Anxiety disorders
  • Obsessive-compulsive disorder
  • Major depressive disorder
  • Personality disorders
  • Dissociative disorders
  • Conversion disorder
  • Psychotic disorders
  • Traumatic brain injury

For Child & Adolescents

History: PTSD treatment derived originally from classical and operant conditioning (pairing of stimuli

and response)

Clients: Women are almost three times more likely to suffer with PTSD than men

Settings: Mainly outpatient

People involved: in TF-CBT (C&A) conjoint sessions with parents

Treatment Protocol: Exposure therapy and cognitive approaches are the first line treatment approaches

Assessment: CAPS (30 item) most widely used, may be used also by paraprofessionals

Medication: paroxetine, fluvoxamine, sertraline,

prozac, zoloft

1.Psycho-education & Affect regulation

2.Repeated (gradual) exposure to the trauma memory in imagination

3.Using In-Vivo exposure situations associated with

the traumatic event that are objectively safe but avoided

4. The writing of a Trauma Narrative

5. Cognitive Processing Therapy: comparing beliefs pre- and post trauma, whereas regular CBT focuses on present

CBT (trauma focused):

- Cognitive Processing

- Exposure Therapy

Acceptance & Commitment Therapy

1. Psychoeducation & Treatment rational:

Explain clients that PTSD is a set of expected and normal responses to abnormal circumstances such as intrusive memories and hyper arousal

2. Explain the avoidance pattern:

Fear Cue Anxiety increase

anxiety increase Avoidance

  • Substance Abuse Disorder
  • Depressive Disorders
  • Anxiety Disorders
  • Tramatc Brain Injury
  • Dissociative Identity Disorder

2. Hierarchy of Fear & Avoidance

For Adults

Differential Diagnosis

G'day - howz it goin'?

1. Repeatedly and gradually (really important to avoid re-traumatization!!) approach avoided situations or memories & triggers

Common Comorbidity

Trauma-Focused* CBT

TAKE A DEEP BREATH

OVERVIEW

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PTSD TREATMENT

Exposure*: In Vivo & Imaginal

Treatment Part 1

Prolonged Exposure Protocol

Epidemiology

5. Processing natural emotions

4. Use of worksheets* & Socratic questioning*

IMPORTANT:

Ensure child is ready and has developed some coping skills they can use to regulate some of their anxiety

3. Identifies and challenges maladaptive beliefs

2. Identify 'Stuck Points'

TF-CBT Triangle of Life

1. Focuses on the particular meaning of the traumatic & impact of event

Methods:

  • Play therapy
  • Story books
  • Drawings
  • Songs
  • Dances

The therapists writes down the trauma narrative, and helps the child to remember specific details about the trauma

Treatment Approach (12-18 sessions) - A PRACTICE!

  • Assessment!
  • P sychoeducation and Parenting Strategies
  • R elaxation
  • A ffective expression and regulation
  • C ognitive coping
  • T rauma narrative and processing
  • I n vivo exposure
  • C onjoint parent child sessions
  • E nhancing personal safety and future growth

  • Not Effective for:
  • Clients with extreme therapy-resistant behavior
  • Clients with active suicidal behavior
  • Clients with severe cognitive disabilities

( an adaptation has been made for this

population)

Cognitive defusion: Learning methods to reduce the tendency to reify thoughts, images, emotions, and memories.

Acceptance: Allowing thoughts to come and go without struggling with them.

Contact with the present moment: Awareness of the here and now, experienced with openness, interest, and receptiveness.

Observing the self: Viewing the self (identity) as separate from the content of their experience

Values: Discovering what is most important to one's true self.[9]

Committed action: Setting goals according to values and carrying them out responsibly

  • Demonstrating efficacy/effectiveness for:
  • Boys / Girls, Ages 3-18
  • Multiple racial/ethnic backgrounds
  • Varying socio-economic status
  • Single or multiple trauma history
  • Children with behavior problems
  • It was developed in the late 1980s by Steven C. Hayes, Kelly G. Wilson, and Kirk Strosahl
  • Based on Acceptance & Mindfulness stragegies
  • Treatment plan of 6 stages
  • Seeks to alter client's repeat cycle of attempting to alter the internal self and change their internal experiences

Focused on the meaning individuals make in response

to the traumatic event and how people cope as they try to

regain a sense of mastery or control over their lives

(Resick & Schnicke, 1993).

Purpose:

  • to unpair fearful associations with harmless triggers (e.g. a wall)
  • to identify unhelpful thoughts or beliefs

  • Developed by Deblinger, Cohen & Mannarino

for treating sexually abused children

  • Working with parents is integral to treatment

Treatment Part 2

Cognitive Processing Therapy

Developing the Trauma Narrative

TF-CBT for Child & Adolescents

Core Principles (6)

'Third Wave' of PTSD Treatment:

Acceptance & Commitment Therapy

HISTORY & RESEARCH

focused on the meaning individuals make in response to the traumatic event and how people cope as they try to regain a sense of mastery or control over their lives (Resick & Schnicke, 1993).

3. However, in most studies trauma is not differentiated (e.g. disaster, accident, CSA), so it is difficult to discern what therapy may work better for what type of trauma

4. Some clients do not have improved functioning

despite CBT

Data on treating complex PTSD is limited and inconsistent

Non trauma focused treatment showed no reduction in

PTSD symtoms

A comparison study between trauma focused CBT

and SSRI (paroxetine) showed more (cost) effectiveness long-term

1. A recent meta analysis of PTSD treatment dropout

(Imel et al, 2013) showed that in particular trauma focused CBT had significantly higher drop out rates compared to non-trauma focused therapies (36/18)

2. Complex PTSD still shows poor outcomes of first line treatment

Shows overall effectiveness in adults for CBT

both CPT & Exposure therapy, with the latter being

the most effective component

Ashley, Krystal, Monique

Research II..but..s

RESEARCH

EYE MOVEMENT - Facilitate alternating stimulation between right and left hemispheres of brain

DESENSITIZATION - Removing emotional disturbance associated with traumatic memory

AND

REPROCESSING - Replacement of unhealthy, negative beliefs associated with traumatic memories, with more healthy, positive beliefs

  • 8 Phase approach guided by an information processing model that views pathology as based upon perceptual information that has been maladaptively stored

  • Key to psychological change > Ability to facilitate

appropriate information processing

  • Initially developed by Francine Shapiro
  • 1987 - Chance discovery of impact of eye

movements; Experimented with friends

(70+ ppl)

  • 1989 - Published first controlled study of EMD

> Aim: To resolve trauma symptoms by

desensitizing traumatic memories

  • Saw substantial effects after 1 session
  • Trained 36 clinicians > Obtained feedback
  • Joseph Wolpe found it successful

> Case Study (1991)

  • Publication of over 100 case studies
  • 1990 - Name change to EMDR
  • 1995 - Principles & procedures further

refined and published

  • New experiences are processed by

assimilating or integrating them with the

existing memory network

  • Pathology arises when memories of an

experience are not adequately processed

and are dysfunctionally stored in its own neural network > Contains thoughts, images, emotions, and sensations, that when triggered influence perceptions, attitudes, and behaviour in the present

  • Trauma symptoms are seen as unintegrated and dysfunctionally stored memories

  • Activation of information processing system leads to

resolution of dysfunctionally stored memories

  • EMDR is not based on habituation. Uses short

20-50 second interrupted exposures, rather than continuous 20-100 min exposures

  • EMDR is nondirective. Client can move quickly through scenes or skip scenes spontaneously changing to other memories that arise

  • In EMDR - reliving the traumatic memory in the present is not required

Shapiro believes information processing is primarily facilitated by:

  • Deconditioning that proceeds through relaxation response
  • Neurological changes in brain that activate and strengthen weak associations
  • Factors that are involved with client's dual focus of attention on both the memory and a concurrent task (ie. eye movements)

The process of assimilation is different than

the theory of extinction

  • Effective EMDR depends on effective targeting

  • Examples of targets:

- Early childhood memories

- Recent events that trigger

current disturbances

- Memory of traumatic event

  • Aspects of the target:

- Identify the image

- Identify negative cognition

- Identify desired positive cognition (VOC scale)

- Emotions & level of disturbance (SUD scale)

- Physical sensations

In a Nutshell:

"EMDR utilizes dual attention tasks to help the patient process the traumatic event and involves him or her focusing on negative trauma-related memories, emotions, and thoughts while engaging in a task involving some form of bilateral stimulation (eye movements, taps, tones) until distress has reduced and positive cognitions have increased" (Ponniah & Hollon, 2009)

  • Eye movements (EMs) have been reliably associated with higher cognitive processes and shifts in cognitive content
  • Possible link with REM stage of sleep
  • Hypothesis > That EMs trigger a physiological mechanism that activates the information processing system
  • Type and duration of EM set determined by client feedback (often 24 bidirectional movements)
  • Alternatives to EMs > tapping and tones

EMDR

What is EMDR?

Accelerated Information Processing (AIP) Model

Differences from

Exposure

History

AIP Model

Eye Movements

Targeting

1) Client history and treatment planning

2) Preparation phase

3) Assessment

> Identify components of target; Identify baseline

4) Desensitization

> Working with targets

5) Installation

> Strengthening positive cognitions

6) Body scan

7) Closure

> Reestablishing equilibrium; Debriefing

8) Reevaluation

> Checking maintenance of effects

1) Facilitation of resolution of memories (elicitation of insight, cognitive reorganization, adaptive effects, physiological responses)

2) Desensitize stimuli that trigger present distress as a result of second-order conditioning

3) Incorporate adaptive attitudes, skills, and behaviours for enhanced functioning within larger social systems

Phase 1 (1989-1998): Demonstrating EMDR's effectiveness in treating PTSD

  • Strong evidence EMDR consistently superior to waitlist

Phase 2: Demonstrating EMDR's effectiveness against other trauma-focused treatments for PTSD

  • 4 RCTs comparing EMDR to nonspecific treatments for PTSD > EMDR consistently more effective
  • 9 RCTs comparing EMDR to trauma-focused therapies > Effect sizes equivalent; Lower drop-out rate in EMDR
  • More research needed re complex trauma and adults with childhood trauma

Phase 3: Focused on understanding underlying mechanisms of EMDR effective treatment

EMDR considered EBT for Adult PTSD by:

  • American Psychological Association (2004)
  • US Department of Veterans Affairs and Department of Defense (2004)
  • UK National Institute of Clinical Excellence (2005)
  • Australian Centre for Post-traumatic Mental Health (2007)
  • International Society of Stress Studies (2009)
  • Growing number of international guidelines recommend EMDR for adult PTSD

Ponniah & Hollon (2009) - Review of 57 RCTs on Treatment for Adults PTSD (and ASD)

  • EMDR significantly more effective than waiting list, standard care, and pill placebo
  • More enduring than SSRI fluoextine and greater improvements in symptoms than relaxation training
  • Comparable to TF-CBT
  • EMDR is a simplistic behavioural technique

> There are many components besides EMs

  • Claims to be a "one-session cure" for PTSD

> Is actually an 8-phase treatment

Misconceptions

Treatment Goals

Phases of Treatment

Research

Summary:

  • Mixed findings

- Some studies found EMDR superior to trauma-focused CBT on some measures of PTSD symptoms

- Others reported PSTD symptom reduction as similar between trauma-focused CBT and EMDR

- Others report that EMDR produced smaller shift than trauma-focused

  • Trauma-focused CBT > More evidence as of 2009
  • EMDR > More rapid reduction of symptoms, requires fewer treatment sessions, fewer dropouts, and achieves objectives without 30-60hrs of homework
  • Review of literature by Cochrane Collaboration (2009): comparison of 33 studies comparing TF-CBT, EMDR, Stress Management, Non-Trauma focused therapies.

  • Most were USA studies but included 2 Canadian, 2 Australia, 4 European studies.

  • Both EMDR & TF-CBT consistently showed large effect sizes but were equal in efficacy

  • Stress Management showed a larger effect size than wait-list but both EMDR & TF-CBT were more effective

  • Non-trauma focused therapy were no more effective than wait-list group

  • More research required to differentiate which type of trauma clients may be more suitable for which treatment

  • For EMDR it remains unclear to what extend the eye-movement component contributes to the effectiveness of treatment
  • Stress Management / Stress Innoculation Training
  • Group CBT
  • Supportive Counselling
  • Interpersonal Psychotherapy
  • Family Therapy

Leah is a 70 year-old Caucasian Canadian female client who has been recently married (1.5 years). She was diagnosed with PTSD 6 months after a brutal attempted murder attack that she barely survived whilst she was in her holiday accommodation 2 years ago. Leah presents with flashbacks and reoccurring nightmares where she is being chased either by people or by a bear and can’t escape. She is very disturbed by her lack of memory and has been withdrawing from people who know her, in fear that she has to talk about what has happened. Leah believes she has brought this attack upon herself as she filed a case with the court to obtain back funds she lent a friend, who in turn hired someone to murder her. As the police (local at the holiday destination) were extremely reluctant to investigate or even check up on her, she now believes ‘if even the police can’t be trusted who can?.' Leah frequently experiences disorientation and is easily startled when her husband approaches her or speaks to her. The client recently reported of dream like visions such as large dangerous animals appearing on the road swallowing her up. Leah's husband reports that she frequently has bursts of anger. Her symptoms are causing her significant distress impairing her social activities and relationships, and as a result she gave up her volunteer work as part of an animal rescue service. She abstains from both alcohol and drugs. No suicide ideation reported. Her support system has declined significantly, but she has a supportive husband. Leah came to counselling 1.5 years after the attack and is still presenting all symptoms above.

Practical Tips & Resources

Other Therapies

Comparison Studies: TF-CBT and EMDR

Continued

No use of drugs or alcohol (not attributable to substance or medical condition)

The client recently reported of dream like visions such as large dangerous animals appearing on the road swallowing her up. (Derealization)

Her husband reports his wife frequently bursts of anger and irritability (Alterations in arousal and reactivity)

Her symptoms are causing her significant distress impairing her social activities and relationships (Clinical distress and impairment)

She gave up her volunteer work as part of an animal rescue service (vocational impairment)

Case Study

She now believes ‘if even the police can’t be trusted’ who can (nobody) (Negative Cognitions)

Client beliefs she has brought this attack upon herself

Lack of memory, has been withdrawing from people who know her (Avoidance)

Flashbacks, reoccurring nightmares (Intrusive symptoms )

A brutal attempted murder attack she barely survived (Trauma Incident)

Phase 1 > Taking Client History & Planning Treatment

  • Client readiness
  • Client safety factors:
  • Level of rapport
  • Emotional disturbance
  • Stability
  • Life supports
  • General physical health
  • Neurological impairment / Epilepsy
  • Eye problems
  • Drug and Alcohol abuse
  • Medications
  • Legal Requirements
  • Timing
  • Office vs Inpatient
  • Secondary Gains
  • DID

DIAGNOSTIC CRITERIA FOR PTSD

Diagnostic Features of PTSD and Treatment Considerations:

EMDR & TF-CBT

Phase 2 > Preparation

  • Explain EMDR Theory and introduce procedures
  • Test EMs
  • Communicate how client can stop process
  • Create safe place
  • Set Expectations
  • Address client fears

Phase 3 > Assessment

  • Select target
  • Select Image
  • Identify negative cognition
  • Rate on VOC scale
  • Identify positive cognition
  • Name emotion
  • Rate on SUDs scale
  • Identify body sensations

Phase 4 > Desensitization

  • Go through process with EMs
  • Explore all channels of target
  • Take note of shifts (image, emotions, body)
  • Check SUDs

Phase 5 > Installation

  • Focus on cognitive restructuring > integration of positive cognition
  • Begins after SUDs gets to 0 or 1
  • Check VOC of positive cognition
  • EMs with image and positive cognition
  • Continue until VOC is 7

Phase 6 > Body Scan

  • Hold image and cognition in mind while mentally scanning entire body for lingering tension
  • If any found - target for further EM sets

Phase 7 > Closure

  • End session in a place where client is as stable as possible
  • Visualization if necessary
  • Safety assessment
  • Debriefing
  • Remind of log

Phase 8 > Evaluation

  • Check if effects have been maintained

* Continue working through targets until resolved

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