Transcript Evidence-based Treatment Options for Trauma

Evidence-based Treatments
for PTSD
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Natural Resiliency and recovery
• Natural recovery occurs when survivors process
through intrusions, thoughts and feelings
• Doesn’t mean that survivors forget the trauma,
or stop having intrusive all memories and
distressing emotions. Healing can go on for
years
• Most people have a few issues but not enough to
meet the criteria for PTSD (you have to meet all the
sections to the get diagnosis)
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Core Reactions
• Escape and Avoidance
• Research has shown that avoidance predicts chronic
and severe post- traumatic stress.
• Evidence based treatments are going to actively stop
this and they are going to have to engage in at least the
memory of the issues
• The client may also appear functional; for example,
holding down two jobs while getting a degree and raising
a family in an effort to keep thoughts and feelings about
a trauma at bay for years
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Commonalities
• All use a scale 1-10 or 1-100 for rating
mood or a Standard Unit of Distress (SUD)
• How you see and think about your past
affects you’re here and now
• See a disruption to the cognitive flow of
thought leading to an anxiety reaction
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Please Note
•This is not met as a training in
any one of these modalities
but as an overview.
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Medication
• SSRI’s
– Sertraline (Zoloft) 50 mg to 200 mg daily
– Paroxetine (Paxil) 20 to 60 mg daily
– Fluoxetine (Prozac) 20 mg to 60 mg daily
• antidepressants for PTSD
– Mirtazapine (Remeron) 7.5 mg to 45 mg daily
– Venlafaxine (Effexor) 75 mg to 300 mg daily
– Nefazodone (Serzone) 200 mg to 600 mg daily
• Benzodiazepines
– Lorazepam (Ativan)
– Clonazepam (Klonopin)
– Alprazolam (Xanax)
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Evidenced Based Therapy
Treatments
• Cognitive Behavior Therapy
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Seeking Safety
Prolonged Exposure Therapy
Stress Inoculation Training (SIT)
Cognitive Processing Therapy (CPT)
Other CBT including cognitive restructuring and
cognitive therapy
– Trauma Focused CBT (for children)
• Eye-Movement Desensitization and
Reprocessing (EMDR)
– Brain Spotting
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Seeking Safety
• Developed by Lisa Najavits PhD and published in
2002
• 25 topic areas – research is on using all 25 topics
• 5 central ideas to the program
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1) safety is the priority of this first-stage of treatment
2) integrated treatment of PTSD and substance abuse
3) a focus on ideals
4) four content areas: cognitive, behavioral, interpersonal,
and case management
– 5) attention to the therapist processes
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Seeking Safety
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Use of educational research strategies
A focus on potential rather than pathology
Attention to Language
Relating the Material to Patients Lives
Clinical Realism
An urgent approach to time
Making the treatment interesting to patients
Practitioners do not have to be Master Level
Clinicians
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Seeking Safety
• Check in
• Ask client to read Quotation
– Ask “What is the main point of the quotation”
• Cover topic and handouts
• Check – out
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Problems
• It is only covering the first stage of healing
does not deal directly with the trauma
• Is a dual diagnosis model so clients without
substance abuse may balk at being in a group
with those who are or bring up family issues
• Clients who want to talk about what
happened can not in group and may have
issue with this
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Prolonged Exposure Therapy
• Developed by Edna Foa PhD
• Used by the VA and has largest body of
research behind it
• Generally between 9-12 sessions but some
bodies of literature say up to 18 sessions
– To apply the evidence based model is 2 sessions per
week 1.5 hours long
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Prolonged Exposure
• Two parts of the treatment
– imaginal exposure - the memory of the traumatic
event(s) done in the session
– in vivo exposure – real life stimuli (people, places,
things) that are reminders of the traumatic event or
raise the anxiety level
– Use of SUD throughout the sessions and homework
• Relaxation training prior to the start of treatment to
help with process
• Is homework based
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Problems
• About a 20% drop out rate
• High level of clinician avoidance to using the
practice
• Must have memory to recall and work on it
• The client must be able to disclose what
happened in detail
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Stress Inoculation Therapy
• Developed by Donald Meichenbaum PhD and
first published in 1985
• patient education about anxiety
• training in coping or anxiety management skills
(i.e., deep muscle relaxation, breathing control,
thought-stopping, assertiveness training,
reassuring self-talk
• SIT consists of 8 to 15 sessions, plus booster
and follow-up sessions, conducted over a 3-to12-month period
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Stress Inoculation Therapy
• Three Stages
– The first stage of SIT is called ‘conceptualization’
• The therapist helps the individual to identify their stressors
and how they respond to these and how successful these
responses have been. Patterns of self-defeating internal
dialogue are identified.
– The second stage is ‘skill acquisition and rehearsal’
• The therapist helps the individual to develop and practice
positive coping statements to be used in stressful situations.
Other techniques such as relaxation and making a realistic
appraisal of situations are also practiced.
– In the third stage ‘application and follow-through’
• the individual begins to apply the newly acquired skills to
progressively more difficult situations in the real world. The
therapist provides support and further training when
necessary.
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Problems
• Does not deal with the memory so
intrusive thoughts tend to still present as
an issue
• Smaller body of research and most of it is
older not much in last 10 years
• For clients who struggle with meditation,
visualization, imagery you will find a high
level of resistance
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Cognitive Processing
Therapy (CPT)
• The original manual, published in 1993, was
authored by Patricia A. Resick and Monika Schnicke
• Is 12-14 sessions but can take more
• In the Veterans’ Administration, there is increasing
use of CPT in group format
• Very cognitive based what we think affects how we
act and feel
• Use of Socratic style of interacting
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Cognitive Processing
Therapy (CPT)
• CPT sessions are structured and each
session has a structured part in the overall
sessions
• Each CPT session has three parts
– Brief update that includes overall mood and PTSD
symptoms
– Review of assigned practice
– Setting new practice assignment: demonstration and
assignment to do at home
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CPT
• Two Key concepts
– Assimilation information about the event is absorbed
without changing prior beliefs. The new information maybe
altered to match prior beliefs in order to reconcile information
about the event with what was known before. It frequency serves
as a process of engaging in undoing or self-blame for the trauma
– Over-accommodation
altering ones beliefs about
oneself and the worked to the extreme to feel safer and more in
control to reconcile information about the event with prior beliefs.
It typically involves generalization trauma-based reactions to
non-traumatic situations – targeted in the last 5 sessions
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CPT
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Use of Stuck Points
Impact Statement
ABC Worksheets
Challenging Questions worksheet
Patterns of Problematic Thinking worksheet
Challenging Beliefs worksheet
Issues topics: Safety, Trust, Power/Control,
Esteem and Intimacy
• Final impact statement/ Meaning of the Event
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Problems
• Can be adapted for illiterate populations
but is a struggle also for those with TBI
• For those who disliked Prolonged
Exposure they feel it is to similar
• Has about a 20% drop out rate
• Must have the memory to work on the
issue
• More difficult with complex trauma
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Other CBT including cognitive restructuring and
cognitive therapy
• Can vary on number of sessions from 5 - 52
• The therapist helps the patient to understand and change thoughts
about trauma and its aftermath. The goal is to understand how
certain thoughts about the trauma cause stress and make symptoms
worse.
• The patient learns to identify thoughts about the world and the
emotional effect on them. With the help of a therapist, client will
learn to replace these thoughts with more accurate and less
distressing thoughts. Emphasis on coping skills with feelings such
as anger, guilt, and fear.
• Cognitive therapy helps the person understand that the traumatic
event and see how it is a normal reaction to a crazy event.
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Problems
• Though CPT is the most researched other forms of
CBT include use of narrative, psycho analytic, client
centered and lack a formalized verifiable model that
is followed consistently
• Body of data can be confusing as to which is most
beneficial numerous training methods and groups
• Variance in numbers relating to completion factors
with client and follow up long term varies with what
variation was used
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Trauma Focused Cognitive
Behavioral Therapy TF-CBT
• Created by Esther Deblinger in the late 1980’s at
the New Jersey CARES Institute
• Used for children and adolescence ages 3-18
• Number of sessions is generally 12 to 16
sessions once a week for 60-90 minutes
• Has child and parent sessions as well as family
sessions to address the trauma
• The goal of TF-CBT is to help address the
biopsychosocial needs of children and to a
lesser extent their families with (PTSD)
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Trauma Focused CBT
• It combines humanistic, cognitive behavioral and
familial strategies in this one therapy to address
the PTSD in children
• Both parents and children learn how to process
their emotions and thoughts that relate to the
traumatic experience and to change those ways
of thinking
• Establishing a secure environment and working
on the though process around those memories
is the primary focus
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Trauma Focused-CBT
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“PRACTICE”
P - Psychoeducation and parenting skills—Discussion and education about child abuse in
general and the typical emotional and behavioral reactions to sexual abuse; training for parents in
child behavior management strategies and effective communication
R - Relaxation techniques—Teaching relaxation methods, such as focused breathing,
progressive muscle relaxation, and visual imagery
A - Affective expression and regulation— Helping the child and parent manage their emotional
reactions to reminders of the abuse, improve their ability to identify and express emotions, and
participate in self-soothing activities
C - Cognitive coping and processing— Helping the child and parent understand the connection
between thoughts, feelings, and behaviors; exploring and correcting of inaccurate attributions
related to everyday events
T - Trauma narrative and processing— Gradual exposure exercises, including verbal, written, or
symbolic recounting of abusive events, and processing of inaccurate and/or unhelpful thoughts
about the abuse
I - In vivo exposure—Gradual exposure to trauma reminders in the child’s environment (for
example, basement, darkness, school), so the child learns to control his or her own emotional
reactions
C - Conjoint parent/child sessions—Family work to enhance communication and create
opportunities for therapeutic discussion regarding the abuse and for the child to share his/her
trauma narrative
E - Enhancing personal safety and future growth—Education and training on personal safety
skills, interpersonal relationships, and healthy sexuality and encouragement in the use of new
skills in managing future stressors and trauma reminders
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Problems
• Child must be able to use basic communication skills
around the trauma and be high enough functioning to
engage in talk therapy
• Is problematic with children who had conduct disorder
prior to trauma so severe neglect cases have not done
well
• It has been focused on children who have fewer
incidents of trauma some argue it has not been shown
effective in those who have infancy and early childhood
trauma
• Poor results with children and adolescents with history of
runaway behavior, suicidal and cutting behaviors
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Eye-Movement Desensitization and
Reprocessing (EMDR)
• founded by Dr Francine Shapiro in 1990
• Number of session vary from 8 to 25 for basic
trauma treatment
• traumatic material need not be verbalized; instead,
patients are directed to think about their traumatic
experiences without having to discuss them or even
have a clear memory of them
• Sets of Eye movements with therapist and/or
auditory or physical stimulation
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EMDR
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negative beliefs or negative cognitions
Positive beliefs or positive cognitions
1-to-7 Validity of Cognition (VOC)
Use of SUD scale frequently
Three pronged protocol
– Past
– Present
– Future
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EMDR
8 phases of treatment
History and Treatment Planning
• 1-2 sessions
Preparation
• 1-4 sessions
For use in each session of EMDR
Assessment
• Use of VOC & SUD scales
Desensitization
drop in SUD scale and reduction
of negative cognitions
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Installation
• Use of positive cognitions and
VOC scale
Body scan
body memories feelings of
tension in the body
Closure
ending of session
Every subsequent session has
Reevaluation
Are the changes in SUD and VOC
sticking
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Problems
• Expensive to be trained in and even more
to be certified in
• Limited training opportunities
• The brain mechanisms behind EMDR are
still not understood
• Clients may report feeling you are “doing”
something to them instead of owning their
process
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Additional Treatments
• (VRET) Virtual Reality
Exposure Therapy
• (ACT) Acceptance &
Commitment Therapy
• Behavioral Activation
• (EFT) Emotional
Freedom Technique
• (NLP) Neuro-Linguistic
Programming
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Meditation
Hypnosis
Massage
Acupuncture
Drumming/Music
Dance and movement
Spiritual/Religious
Healing
• Animal Healing
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Summery
• Different clients react differently to
treatment and a growing body of evidence
is developing to offer more choices and
options to clients.
• Each system has pluses and minuses for it
and this needs to be taken into
consideration when working with a given
client
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Questions?
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