Posttraumatic Experiences: Asssment and Intervention DAY 2

8/14/2019 Posttraumatic Experiences: Asssment and Intervention DAY 2

1/67

Eli Somer, Ph.D.

University of Haifa, Israel

[email protected]

Posttraumatic experiences:

Asssment and intervention

DAY 2


2/67

Acute Stress Disorder (ASD)

The person has been exposed to a traumatic event in whichboth of the following were present: The person experienced,witnessed, or was confronted with an event or events thatinvolved actual or threatened death or serious injury, or a

threat to the physical integrity of self or others. The person's response involved intense fear, helplessness, or

horror.

[email protected]


3/67


Either while experiencing or after experiencing the distressingevent, the individual has three (or more) of the followingdissociative symptoms:

A subjective sense of numbing, detachment, or absence ofemotional responsiveness.

A reduction in awareness of his or her surroundings (e.g.,"being in a daze").

Depersonalization - dissociative amnesia (i.e., inability torecall an important aspect of the trauma).

[email protected]


4/67


The patient persistently re-experienced the traumatic eventin at least one or more of the following ways: recurrentimages, thoughts, dreams, illusions, flashback episodes, or asense of reliving the experience; or distress on exposure to

reminders of the traumatic event. Marked avoidance of stimuli that arouse recollections of the

trauma (e.g., thoughts, feelings, conversations, activities,places, people).

There are marked symptoms of anxiety or increased arousal(e.g., difficulty sleeping, irritability, poor concentration,hypervigilance, exaggerated startle response, restlessness).

[email protected]


5/67


At least 1of the following applies: The patient feels markeddistress from the symptoms.

They interfere with usual social, job or personal functioning. They block the patient from doing something important such

as getting legal or medical help or telling family or othersupporters about the experience.

The disturbance lasts for a minimum of 2 days and amaximum of 4 weeks and occurs within 4 weeks of the

traumatic event.

[email protected]


6/67

Posttraumatic Stress Disorder (PTSD)

Criterion A: stressor

The person has been exposed to a traumatic event in whichboth of the following have been present:1. The person hasexperienced, witnessed, or been confronted with an event or

events that involve actual or threatened death or seriousinjury, or a threat to the physical integrity of oneself orothers.2. The person's response involved intense fear,helplessness, or horror. Note: in children, it may beexpressed instead by disorganized or agitated behavior.

[email protected]


7/67


Criterion B: intrusive recollection The traumaticevent is persistently re-experienced in at least one of thefollowing ways:

1. Recurrent and intrusive distressing recollections 2. Recurrent distressing dreams 3. Acting or feeling as if the traumatic event were recurring. 4. Intense psychological distress at exposure 5. Physiologic reactivity upon exposure

[email protected]


8/67


Criterion C: avoidance/numbing

Persistent avoidance of stimuli associated with the trauma andnumbing of general responsiveness (not present before thetrauma), as indicated by at least three of the following:

1. Efforts to avoid thoughts, feelings, or conversationsassociated with the trauma

2. Efforts to avoid activities, places, or people that arouserecollections of the trauma

[email protected]


9/67




3. Inability to recall an important aspect of the trauma4. Markedly diminished interest or participation in significant

activities

5. Feeling of detachment or estrangement from others

[email protected]


10/67




6. Restricted range of affect (e.g., unable to have lovingfeelings)

7. Sense of foreshortened future

[email protected]


11/67


Criterion D: hyper-arousal. Persistent symptoms of increasingarousal (not present before the trauma), indicated by atleast two of the following

1. Difficulty falling or staying asleep

2. Irritability or outbursts of anger3. Difficulty concentrating

4. Hyper-vigilance

5. Exaggerated startle response

Criterion E: Duration of the disturbance (symptoms in B, C,and D) is more than one month

[email protected]


12/67

Evidence-based PSTD treatments

Traumatic Anxiety Management ProceduresTechniques to manage or reduce anxiety

Exposure ProceduresTechniques to confront feared memories &

objects

Cognitive Therapy ProceduresTechniques to shift erroneous cognitions

Other techniques

[email protected]


13/67

Cognitive-Behavioral treatments for PTSD

Systematic Desensitization Stress Inoculation Therapy (SIT) Prolonged Exposure (PE) Eye Movement Desensitization and Reprocessing (EMDR) Cognitive Processing Therapy (CPT)

[email protected]


14/67

Cognitive-Behavioral treatments for PTSD

Promote safe confrontations with trauma reminders,memories, situations

Aim at modifying the dysfunctional cognitions underlyingPTSD

[email protected]


15/67

PSTD treatments

Systematic Desensitization

Joseph Wolpe

type of counterconditioning

associates a pleasant, relaxed state with graduallyincreasing anxiety-triggering stimuli

commonly used to treat phobias Appropriate for the treatment of traumatic fears

[email protected]


16/67

PSTD treatments

Systematic Desensitization - outline

Rationale Assessment

Identification of Emotion-Provoking situations Imagery Assessment

Intervention - Relaxation Training

Hierarchy Construction Selection and Training of Counter-conditioning or Coping

Response Scene Presentation

Homework and [email protected]


17/67

PSTD treatments


Imagery Assessment

Is the image concrete, with sufficient detail and evidenceof touch, sound, smell, and sight sensations.

Is the client a participant, not an observer. Can the client switch a scene image on and off upon

instruction.

Can the client hold a particular scene without driftingoff or changing the scene

[email protected]


18/67

PSTD treatments

Systematic Desensitization Hierarchies

Spatio-temporal Hierarchy (Example: A temporalhierarchy for a public speaking trauma- Someone asksyou to give a speech in two months).

1. Writing the speech a month before2. Rehearsing the speech a week before3. The morning of the speech4. Reciting the speech while dressing5. Approaching the auditorium6. Walking up to the podium7. Giving the speech [email protected]


19/67

PSTD treatments


A spatial hierarchy for a dog phobia following biteincident

1. Seeing a dog go by in a car2. Seeing a dog in a yard on a leash and behind a fence3. Dog poking nose through the fence4. Passing a leashed dog across the street5. Passing a leashed dog on same side of street

[email protected]


20/67

PSTD treatments


Thematic hierarchy - public speaking trauma1. Telling a joke to several friends2. Making an announcement to a group of coworkers3.

Speaking at a meeting

4. Speaking at company banquet5. Giving the main address at a professional convention

[email protected]


21/67

PSTD treatments


Relaxation Emotive Imagery (a process where client imagines, in a

covert but vivid manner, the emotional sensations andfeelings of an actual scenario or behavior)

Meditation

[email protected]

Coping Responses


22/67

Reading of miners trapped Having polish on fingernails with no way to remove it Being told someone is in jail Having a tight ring on finger On a journey by train Travelling in an elevator with an operator Travelling alone in an elevator Passing through a tunnel ona train Being locked in a room Being stuck in an elevator

[email protected]


23/67

Imagine scene20 to 40 seconds

When anxiety is felt Hold image Relax away tension

[email protected]


24/67

Daily practice Visualization of previously successful items Practice in vivo Completion of log sheet

[email protected]


25/67

Donald Meichenbaum

SIT is a flexible, individually tailored, multifaceted form ofcognitive-behavioral therapy.

SIT provides a set of clinical guidelines for treating stressedindividuals, rather than a specific treatment formula.

A central concept underlying SIT is that of "inoculation" or"immunization," which has been used both in medicine and in

social-psychological research on attitude change. In order to enhance an individual's coping repertoire and to

empower him or her to use already existing coping skills, anoverlapping three-phase intervention approach is employed

25


26/67

PHASE 1: CONCEPTUALIZATION

In a collaborative fashion, identify the determinants ofthe presenting clinical problem or the individual'straumatic stress concerns by means of: Interviews with the client and significant others. The client's use of an imagery-based reconstruction and

assessment of a prototypic stressful incident.

Psychological and situational assessments. Behavioral observations.

[email protected]


27/67

PHASE 1: CONCEPTUALIZATION Permit the client to tell his or her "story" Have the client disaggregate global traumatic stressors into

specific stressful situations. Have the client appreciate the differences between changeable

and unchangeable aspects of stressful situations. Have the client establish short-term, intermediate, and long-

term behaviorally specifiable goals.

[email protected]


28/67

PHASE 1: CONCEPTUALIZATION Have the client engage in self-monitoring of the commonalities

of stressful situations, stress engendering appraisals, internaldialogue, feelings, and behaviors.

Ascertain the degree to which coping difficulties arise fromcoping skills deficits or are the results of "performancefailures"

Collaboratively formulate with the client and significant othersa reconceptualization of the client's distress.

Debunk myths concerning stress and coping

[email protected]


29/67

PHASE 2: SKILLS AQCUISITION AND REAHEARSAL

Ascertain the client's preferred mode of coping. Explore with the client how these coping efforts can be

employed in the present situation.

Examine what interpersonal or intrapersonal factors areblocking such coping efforts.

[email protected]


30/67

Skills

A. Progressive relaxation B. Controlled breathing / quieting reflex C. Thought stopping D. Cognitive restructuring F. Covert modeling G. Role playing

[email protected]


31/67


Train problem-focused instrumental coping skills that aredirected at the modification, avoidance, and minimization ofthe impact of stressors.

Select each skill according to the needs of the specific client orgroup of clients.

Help the client to break complex stressful problems into moremanageable sub-problems that can be solved one at a time.

[email protected]


32/67


Skills training

Help the client engage in problem-solving activities byidentifying possibilities for change, considering and rankingalternative solutions, and practicing coping behavioral activitiesin the clinic and in vivo.

Train emotionally focused palliative coping skills, especiallywhen the client has to deal with unchangeable anduncontrollable stressors.

[email protected]


33/67


Skills training

Train clients how to use social supports effectively Aim to help the client develop an extensive repertoire of

coping responses in order to facilitate flexible responding. Nurture gradual mastery.

[email protected]


34/67

PHASE 2: SKILLS AQCUISITION AND REAHEARSALSkills rehearsal

Promote the smooth integration and execution of copingresponses by means of behavioral and imagery rehearsal.

Use coping modeling (either live or videotape models). Engage incollaborative discussion, rehearsal, and feedback of coping skills.

Use self-instructional training to help the client develop internalmediators to self-regulate coping responses.

Solicit the client's verbal commitment to employ specific copingefforts.

Discuss possible barriers and obstacles to using coping behaviors.

[email protected]


35/67

PHASE 2: SKILLS AQCUISITION AND REAHEARSALEncouraging application of coping skills

Prepare the client for application by using coping imagery,together with techniques in which early stress cues act as signals tocope.

Expose the client to more stressful scenes, including usingprolonged imagery exposure to stressful and arousing scenes.

Expose the client in the session to graded stressors via imagery,behavioral rehearsal, and role-playing.

Use graded exposure and other response induction aids to fosterin vivo responding.

[email protected]


36/67


Encouraging application of coping skills

Employ relapse prevention procedures: Identify high-risksituations, anticipate possible stressful reactions, and rehearsecoping responses.

Use counter-attitudinal procedures to increase the likelihood oftreatment adherence (i.e., ask and challenge the client toindicate where, how, and why he or she will use copingefforts).

Bolster self-efficacy by reviewing both the client's successfuland unsuccessful coping efforts. Insure that the client makesself-attributions for success or mastery experiences (provideattribution retraining).

[email protected]


37/67

PHASE 2: SKILLS AQCUISITION AND REAHEARSALMaintenance and generalization

Gradually phase out treatment and include booster and follow-upsessions.

Involve significant others in training (e.g., parents, spouse,coaches, hospital staff, police, administrators), as well as peer andself-help groups.

Have the client coach someone with a similar problem (i.e., putclient in a "helper" role).

Help the client to restructure environmental stressors and developappropriate escape routes. Insure that the client does not viewescape or avoidance, if so desired, as a sign of failure, bur rather asa sign of taking personal control.

Help the client to develop coping strategies for recovering fromfailure and setbacks, so that lapses do not become relapses.37


38/67

Edna Foa

Persistent cognitive and behavioral avoidance leads to

chronic PTSD: Limits activation of the trauma memory Limits exposure to corrective information Limits articulation of the trauma memory thus preventing organization and change in the trauma

memory

[email protected]


39/67

Education about common reactions to trauma Breathing retraining (breathing in a calm way) Repeated exposure to the trauma memories Repeated in vivo exposure to avoided situations

[email protected]


40/67

Two main PE procedures:

Imaginal exposure - repeated confrontation with thetraumatic memory through reliving the story.

Promotes processing of the highly emotional experience

and recognition that the individual can cope with thedistress associated with the memory.

[email protected]


41/67

Two main PE procedures:

In vivo exposure repeatedly confronting withtrauma-related situations that are avoided.

Reduces excessive fear and encourages the recognition that

situations are not excessively dangerous and individualcan cope with them.

[email protected]


42/67

Is a safe and effective treatment for PTSD, anxiety,depression, anger and related problems

Is effective in treating PTSD resulting from a variety oftraumas (including prolonged trauma such as child abuse)

Is effective at preventing PTSD when administered shortlyafter a trauma

Is as effective or better than other types of treatment Combined with other therapies does not significantly

improve outcome

Augments gains made with medication Can be used in conjunction with treatments for substance

abuse to treat comorbid clients

Is relatively simple and easily [email protected]


43/67

[email protected]


44/67

[email protected]


45/67

Francine Shapiro

EMDR, which has been so well researched that it is nowrecommended as a front line treatment for trauma in thePractice Guidelines of the American Psychiatric Association, and those

of the Departments of Defense and Veterans Affairs.

[email protected]


46/67

EMDR is a psychotherapy treatment that facilitates theaccessing and processing of traumatic memories to bringthese to an adaptive resolution.

During EMDR the client attends to emotionallydisturbing material in brief sequential doses whilesimultaneously focusing on an external stimulus.

Therapist directed lateral eye movements are the mostcommonly used external stimulus but a variety of otherstimuli including hand-tapping and audio stimulation are

often used.

[email protected]


47/67

EMDR technique

47 [email protected] www.somer.co.il


48/67

[email protected]


49/67

[email protected]

There are two key processes that lead to a sense of ongoingthreat after trauma:

1. sense of ongoing threat that is responsible for maintainingacute stress reactions and helping to turn them into morechronic post traumatic stress disorder.

2. appraisal of trauma and its sequelae, that is, how a persontalks to themselves about their symptoms, their reactions, andtheir experience.

Those judgments they make, judgments of personal weakness, of

guilt, of lack of trust in others, and those are held to play a roleand also maintaining a sense of ongoing threat.


50/67

[email protected]

So for example, if you make the judgment that you cannot protect yourself the world is extremely dangerous other people are going to take advantage of you

Those judgments suggest that the world is going to continue tobe dangerous for you.

Negative appraisals maintain a sense of ongoing threat, whichlead to the maintenance of traumatic stress reactions.


51/67

[email protected]

Trauma memory needs to be laid out in more detail, and thenintegrated into the context of the individuals experiencebefore the trauma happened, and afterwards.

For example, the person might remember having a gun heldto his or her head. But that memory doesnt include whathappened shortly after that. For example, the personstruggled with or escaped from his or her attacker.

We need to identify the problematic judgments or appraisalsthat maintain a sense of threat and help the person challengethose.


52/67

Patricia Resick

Model developed to treat specific symptoms of survivors ofsexual assault

12 session structured therapy Based on information processing model of PTSD

[email protected]


53/67

Combines main ingredient of exposure-based therapieswith the cognitive components of most cognitively basedtherapies

Cognitive portion challenges specific cognitions mostlikely to have been disrupted by trauma

Clients given homework assignments at every session Assumption of CPT is that symptoms of PTSD are caused by

conflict between new information and prior schemas Danger and safety Self-esteem Competence Intimacy

[email protected]


54/67

Examples of treatment componentsHomework

Please write at least one page about what it means toyou that you were raped. Please consider the effects therape has had on your beliefs about yourself, yourbeliefs about others, and your beliefs about the world.Also consider the following topics while writing youranswer: safety, trust, power/competence, esteem, andintimacy. Bring this with you to the next session.

[email protected]


55/67

Examples of treatment componentsSession 2

Discuss the meaning of the event Help client begin to label emotions and recognize thoughts See connection between self statements and feelings

Homework A-B-C worksheets to begin to identify what she was telling

herself and what her emotions were

[email protected]


56/67

Homework ( session 3) Please write about the actual rape. Be sure to include feelings, thoughts

and emotions during the event. Also attend to these thoughts which youhave addressed here in the A-B-C worksheet. If you are unable to finishthe account in one sitting, just draw a line where you stopped. When youare ready to begin again, read what you already wrote and then

continue. Try to begin this detailed account as soon as possible. If thereare parts you cant remember, just draw a line and then continue withthe next instance you remember. Read the account to yourself everydayuntil the next session.

[email protected]


57/67

Session 4 Read account of rape aloud and discuss Assess stuck points

Homework Client is instructed to write the account again, adding any details she might

have left out the first time

Record any thoughts and feelings in parentheses

[email protected]


58/67

Stuck points explored within the following areas:

Safety, Trust, Power/control, Esteem, Intimacy Notion that trauma can lead to:

Assimilation

Change interpretation of trauma in order to save pre-existing beliefs Accommodation

Change beliefs in order to jibe with what happened(e.g., the trauma)

[email protected]


59/67

All-or-nothing thinking: You see things in black andwhite categories. If your performance falls short ofperfect, you see yourself as a total failure.

Overgeneralization: You see a single negative event asa never-ending pattern of defeat.

Mental filter: You pick out a single negative detail anddwell on it exclusively so that your vision of all reality

becomes darkened, like the drop of ink that discolors theentire beaker of water.

[email protected]


60/67

Disqualifying the positive: You reject positiveexperiences by insisting they "don't count" for somereason or other. You maintain a negative belief that iscontradicted by your everyday experiences.

Jumping to conclusions: You make a negativeinterpretation even though there are no definite factsthat convincingly support your conclusion.

Mind reading: You arbitrarily conclude that someoneis reacting negatively to you and don't bother to check it

[email protected]


61/67

The Fortune Teller Error: You anticipate that thingswill turn out badly and feel convinced that yourprediction is an already-established fact.

Magnification (catastrophizing) orminimization: You exaggerate the importance of things

(such as your goof-up or someone else's achievement),or you inappropriately shrink things until they appeartiny (your own desirable qualities or the other fellow'simperfections). This is also called the "binocular trick.

[email protected]


62/67

Emotional reasoning: You assume that your negativeemotions necessarily reflect the way things really are: "Ifeel it, therefore it must be true."

Should statements: You try to motivate yourself withshoulds and shouldn'ts, as if you had to be whipped and

punished before you could be expected to do anything."Musts" and "oughts" are also offenders. The emotionalconsequence is guilt. When you direct should statementstoward others, you feel anger, frustration, and

[email protected]


63/67

Labeling and mislabeling: This is an extreme form ofovergeneralization. Instead of describing your error, youattach a negative label to yourself: "I'm a loser." Whensomeone else's behavior rubs you the wrong way, youattach a negative label to him, "He's a damn louse."

Mislabeling involves describing an event with languagethat is highly colored and emotionally loaded.

Personalization: You see yourself as the cause of somenegative external event for which, in fact, you were not

primarily responsible.

[email protected]


64/67

Practice

Form threesomes: 1 = client; 2 = therapist; 3 = altertherapist

Alter therapist may consult with therapist and/or replace him/her

Client: You have survived a motor vehicle accident thathappened 2-months ago. In the accident you were in apassenger seat when a truck drove through a red light and hitthe left side your car in the middle of a crossroad. The driverof your car, your friend, was killed.

Client: You have been diagnosed as suffering from PTSD withavoidance of cars and flashbacks

[email protected]


65/67

Join the ESTD and become part of a

European network of trauma and

dissociation clinicians

Visit our website at www.estd.org, click on themembership tab and fill out the new member form


66/67


67/67

67

00-9724-8360494

[email protected]

www.somer.co.il

Documents

Posttraumatic Experiences: Asssment and Intervention DAY 2