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Eli Somer, Ph.D.
University of Haifa, Israel
Posttraumatic experiences:
Asssment and intervention
DAY 2
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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.
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Acute Stress Disorder (ASD)
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).
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Acute Stress Disorder (ASD)
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).
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Acute Stress Disorder (ASD)
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.
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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.
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Posttraumatic Stress Disorder (PTSD)
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
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Posttraumatic Stress Disorder (PTSD)
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
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Posttraumatic Stress Disorder (PTSD)
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:
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
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Posttraumatic Stress Disorder (PTSD)
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:
6. Restricted range of affect (e.g., unable to have lovingfeelings)
7. Sense of foreshortened future
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Posttraumatic Stress Disorder (PTSD)
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
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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
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Cognitive-Behavioral treatments for PTSD
Systematic Desensitization Stress Inoculation Therapy (SIT) Prolonged Exposure (PE) Eye Movement Desensitization and Reprocessing (EMDR) Cognitive Processing Therapy (CPT)
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Cognitive-Behavioral treatments for PTSD
Promote safe confrontations with trauma reminders,memories, situations
Aim at modifying the dysfunctional cognitions underlyingPTSD
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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
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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]
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PSTD treatments
Systematic Desensitization
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
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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]
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PSTD treatments
Systematic Desensitization Hierarchies
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
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PSTD treatments
Systematic Desensitization Hierarchies
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
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PSTD treatments
Systematic Desensitization
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
Coping Responses
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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
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Imagine scene20 to 40 seconds
When anxiety is felt Hold image Relax away tension
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Daily practice Visualization of previously successful items Practice in vivo Completion of log sheet
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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
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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.
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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.
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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
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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.
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Skills
A. Progressive relaxation B. Controlled breathing / quieting reflex C. Thought stopping D. Cognitive restructuring F. Covert modeling G. Role playing
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PHASE 2: SKILLS AQCUISITION AND REAHEARSAL
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.
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PHASE 2: SKILLS AQCUISITION AND REAHEARSAL
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.
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PHASE 2: SKILLS AQCUISITION AND REAHEARSAL
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.
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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.
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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.
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PHASE 2: SKILLS AQCUISITION AND REAHEARSAL
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).
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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
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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
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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
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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.
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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.
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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]
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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.
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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.
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EMDR technique
47 [email protected] www.somer.co.il
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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.
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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.
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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.
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Patricia Resick
Model developed to treat specific symptoms of survivors ofsexual assault
12 session structured therapy Based on information processing model of PTSD
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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
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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.
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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
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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.
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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
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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)
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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.
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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
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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.
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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
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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.
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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
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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
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00-9724-8360494
www.somer.co.il