Mood Anxiety and Personality Clinical Academic Group CAG

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Mood Anxiety and Personality Clinical Academic Group (CAG) Cognitive Therapy for PTSD Nick Grey

Mood Anxiety and Personality Clinical Academic Group (CAG) Cognitive Therapy for PTSD Nick Grey Centre for Anxiety Disorders and Trauma Oslo - August 2016

Acknowledgements Martina Mueller, Deborah Lee, Peter Scragg, Kerry Young, Emily Holmes, Chris Brewin, Ann

Acknowledgements Martina Mueller, Deborah Lee, Peter Scragg, Kerry Young, Emily Holmes, Chris Brewin, Ann Hackmann, Freda Mc. Manus, Melanie Fennell, David Clark, Anke Ehlers, Sheena Liness, John Manley, Jen Wild, Idit Albert, Debbie Cullen, Alicia Deale, Richard Stott, Rachel Handley.

Learning Objectives • Be able to assess for diagnosis of PTSD • To understand

Learning Objectives • Be able to assess for diagnosis of PTSD • To understand a cognitive model of PTSD and how this links to treatment • To know when and when not to offer CT-PTSD • To understand the key initial interventions used in CT-PTSD • To be able to provide a rationale for patients for discussing the traumatic memories • To know which memory-focused techniques might be most helpful when • To know how to use your full range of cognitive behaviour therapy techniques to address cognitive themes in PTSD

Accompanying Materials • • Reference list Chapters PTSD in a nutshell Published Questionnaires: Posttraumatic

Accompanying Materials • • Reference list Chapters PTSD in a nutshell Published Questionnaires: Posttraumatic Stress Diagnostic Scale (PDS) Posttraumatic Cognitions Inventory (PTCI) • Unpublished Materials: Information Sheet for Patients Session 1 note sheet Worksheets

ICD PTSD (F 43. 1) • Arises as a response to a stressful event

ICD PTSD (F 43. 1) • Arises as a response to a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. • Reliving of the trauma in intrusive memories or dreams occurring against a persisting background of a sense of ‘numbness’. • Commonly fear and avoidance of cues and reminders. • Usually a state of autonomic hyperarousal. • Usually within 6 months of the event.

ICD 11 proposed definition of PTSD This disorder follows exposure to an extremely threatening

ICD 11 proposed definition of PTSD This disorder follows exposure to an extremely threatening or horrific event or series of events. It consists of 3 core elements: (a) Reexperiencing: vivid intrusive memories, flashbacks, or nightmares that involve reexperiencing in the present, accompanied by fear or horror; (b) Avoidance: marked internal avoidance of thoughts and memories or external avoidance of activities or situations reminiscent of the traumatic event(s); (c) Hyperarousal: a state of perceived current threat in the form of hypervigilance or an enhanced startle reaction. The symptoms must also last for several weeks and interfere with normal functioning.

DSM 5 Criterion A • The person was exposed to the following event(s): death

DSM 5 Criterion A • The person was exposed to the following event(s): death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation in one or more of the following ways: • 1. Experiencing the event(s) him/herself • 2. Witnessing the event(s) as they occurred to others • 3. Learning that the event(s) occurred to a close relative or close friend • 4. Experiencing repeated or extreme exposure to aversive details of the event(s) (e. g. , first responders collecting body parts; police officers repeatedly exposed to details of child abuse)

You need to know what you’re dealing with • • • “traumatic” experiences “flashbacks”

You need to know what you’re dealing with • • • “traumatic” experiences “flashbacks” “PTSD” Need for careful assessment Match re-experiencing symptoms to the event • Comorbidity is the rule rather than exception • Other outcomes after trauma likely

Falsetti (2009) Characteristics with minimal association to PTSD • Severity of intrusions • Frequency

Falsetti (2009) Characteristics with minimal association to PTSD • Severity of intrusions • Frequency of intrusions Characteristics associated with recovery from PTSD • Intrusions not assigned negative meaning • Thought control strategies such as reappraisal and social control • • Characteristics associated with development and maintenance of PTSD Sense of ‘nowness’ Lack of context for intrusions Unwanted and uncontrollable Appear to be uncued Intrusions associated with helplessness Intrusions associated with panic attacks Negative meanings associated to the intrusion (e. g. this thought means I’m going crazy) Thought control strategies like worry and rumination

“Ordinary” Autobiographical Memories • Awareness of remembering • Emotions less strong Reexperiencing • Limited

“Ordinary” Autobiographical Memories • Awareness of remembering • Emotions less strong Reexperiencing • Limited awareness of remembering, ”Nowness“ (no time perspective) • Original emotions (physiology, behavior) • Details have context • Details without context, not updated • Rarely spontaneous • Easily triggered involuntarily • If spontaneous, close/ specific match of triggers • Wide range of triggers, sensory similarity, partial match

Context for treatment • Many people recover without help • Treatment model developed for

Context for treatment • Many people recover without help • Treatment model developed for people who become stuck in their recovery - focus is on identifying and changing maintaining factors

Cognitive Model of Persistent PTSD (Ehlers & Clark, 2000) The Puzzle Anxiety is about

Cognitive Model of Persistent PTSD (Ehlers & Clark, 2000) The Puzzle Anxiety is about future threat. PTSD is to do with memory for a past event. Solution Individuals are processing the trauma and/or its sequelae in a way which poses a threat to self. Implications for Therapy Aim of therapy is to process the trauma so it is seen as time-limited, past event which does not necessarily have global implications for one’s future.

What maintains current threat: Threatening Meanings • Negative appraisals of event and/or sequelae –

What maintains current threat: Threatening Meanings • Negative appraisals of event and/or sequelae – Fact that it happened – Own response behaviour in event – Initial PTSD symptoms – Perceived response of others • Idiosyncratic: can confirm or shatter beliefs

What maintains current threat: Nature of Trauma Memory • • Reliving; ‘nowness’ Intentional recall

What maintains current threat: Nature of Trauma Memory • • Reliving; ‘nowness’ Intentional recall poor Poor elaboration of memory Poor integration with other autobiographical memories • Disjointed, confused, gaps • Unintentional triggering of memory fragments by wide range of low level cues

What maintains current threat: Coping Strategies • Post-trauma behaviours and processing styles as a

What maintains current threat: Coping Strategies • Post-trauma behaviours and processing styles as a response to perceived threat • Type – Avoid: thoughts, feelings, places, people – Substance use; Rumination; Safety Behaviours • Effect – Directly increase symptoms: thought suppression – Memory not processed – Can’t change threatening meanings

Persistent PTSD (Ehlers & Clark, 2000) Nature of Trauma Memory Negative Appraisal of Trauma

Persistent PTSD (Ehlers & Clark, 2000) Nature of Trauma Memory Negative Appraisal of Trauma and/or its Sequelae Matching Triggers Current Threat Intrusions Arousal Symptoms Strong Emotions Strategies Intended to Control Threat/Symptoms

Treatment Goals Ehlers & Clark (2000) Appraisals of trauma and/or sequelae Trauma memory elaborate

Treatment Goals Ehlers & Clark (2000) Appraisals of trauma and/or sequelae Trauma memory elaborate identify and modify Triggers discriminate Current threat intrusions arousal Strong emotions Reduce… Dysfunctional behaviours/ cognitive strategies give up/alter

Trauma characteristics. Prior experience/ beliefs Nature of Trauma Memory Cognitive processing during trauma Negative

Trauma characteristics. Prior experience/ beliefs Nature of Trauma Memory Cognitive processing during trauma Negative Appraisal of Trauma and/or its Sequelae Matching Triggers Current Threat Intrusions Arousal Symptoms Strong Emotions Strategies Intended to Control Threat/Symptoms

CT for PTSD: Effect sizes d for change in PTSD symptoms Van Etten &

CT for PTSD: Effect sizes d for change in PTSD symptoms Van Etten & Taylor, 1998, Meta-analysis CT for PTSD studies

Omagh Dissemination Study (Gillespie et al. , 2002): Improvement in symptoms

Omagh Dissemination Study (Gillespie et al. , 2002): Improvement in symptoms

You can do CT-PTSD in routine clinical settings • N=330; 57% interpersonal violence; 56%

You can do CT-PTSD in routine clinical settings • N=330; 57% interpersonal violence; 56% women, 44% ethnic minority; ave 3 years post trauma • PDS • 14/330 (4. 3%) get worse • RCT criteria (d=1. 84; drop out 11%) vs non-RCT (d=1. 11; 16%) • Drop out related to experiece (10 vs 18%)

You can predict outcome. . . Moderators (treatment works less well if present) •

You can predict outcome. . . Moderators (treatment works less well if present) • • • Long-term unemployment/ severe social problems Never married Needs treatment for multiple traumas Past suicide attempts History of substance dependence Duration since trauma Nonspecific predictors (higher scores if present, but does not affect treatment effect) • Comorbid depression • Comorbid agoraphobia • Comorbid pain • Comorbid personality disorder • Dissociation

Therapy context • Safe environment – practically (room, 90 min sessions) and empathically •

Therapy context • Safe environment – practically (room, 90 min sessions) and empathically • Therapist comfortable with detail • Up to 12 weekly sessions (plus up to 3 monthly boosters) • Tape of each session, patient listens to tape as homework • Weekly questionnaires to track improvement • Belief ratings!

Assessment • • • Current problems and symptoms Description of event (& appraisals) Impact

Assessment • • • Current problems and symptoms Description of event (& appraisals) Impact on life (& appraisals) Co-morbidity Prior trauma Goals

Assessment tools • structured interview – CAPS; SCID • questionnaires – IES; PSS-SR; PDS;

Assessment tools • structured interview – CAPS; SCID • questionnaires – IES; PSS-SR; PDS; PTCI

Cognitive assessment • Cognitive themes – Intrusions – PTCI – Worst moments / hotspots

Cognitive assessment • Cognitive themes – Intrusions – PTCI – Worst moments / hotspots – Most difficult since – Self, world, others – Misinterpretation of symptoms • Maintaining factors – Fragmentation of memory – Rumination – Avoidance – Safety behaviours – Numbing (inc substance use) – Thought suppression

Treatment Goals Ehlers & Clark (2000) Appraisals of trauma and/or sequelae Trauma memory elaborate

Treatment Goals Ehlers & Clark (2000) Appraisals of trauma and/or sequelae Trauma memory elaborate identify and modify Triggers discriminate Current threat intrusions arousal Strong emotions Reduce… Dysfunctional behaviours/ cognitive strategies give up/alter

Trauma characteristics. Prior experience/ beliefs Nature of Trauma Memory Cognitive processing during trauma Negative

Trauma characteristics. Prior experience/ beliefs Nature of Trauma Memory Cognitive processing during trauma Negative Appraisal of Trauma and/or its Sequelae Matching Triggers Current Threat Intrusions Arousal Symptoms Strong Emotions Strategies Intended to Control Threat/Symptoms

Initial interventions • Normalization/Education – Symptoms, emotions, strategies – Procedures, situation etc • “Reclaim

Initial interventions • Normalization/Education – Symptoms, emotions, strategies – Procedures, situation etc • “Reclaim life” – Activities previously valued/enjoyed – Strengths / resilience – ‘time-code’ in memory • Thought suppression

Treatment Goals Ehlers & Clark (2000) Appraisals of trauma and/or sequelae Trauma memory elaborate

Treatment Goals Ehlers & Clark (2000) Appraisals of trauma and/or sequelae Trauma memory elaborate identify and modify Triggers discriminate Current threat intrusions arousal Strong emotions Reduce… Dysfunctional behaviours/ cognitive strategies give up/alter

Why work with trauma memories? • • access meanings restructure meanings behavioural experiment memory

Why work with trauma memories? • • access meanings restructure meanings behavioural experiment memory reconstruction / elaboration

Ways of being memory focused • • • Talking about what happened Reliving Written

Ways of being memory focused • • • Talking about what happened Reliving Written narratives Timelines Stimulus discrimination (then vs. now) Site visit • So both imaginal and in vivo ‘exposure’

Rationale for reliving • • conveyor belt overfull cupboard jigsaw puzzle new type of

Rationale for reliving • • conveyor belt overfull cupboard jigsaw puzzle new type of memory • (habituation)

How to do reliving I • Patient – As realistic as possible – First

How to do reliving I • Patient – As realistic as possible – First person – Present tense – All senses – Start before and end when safer • Therapist – Manage expectations – Supportive – Watch for avoidance behaviour – Cue in information – Ratings of emotions and vividness – Focus on significant emotional content

How to do reliving II • After – Any changes? – Anything surprising? –

How to do reliving II • After – Any changes? – Anything surprising? – Holding back? – Worst moments and meanings? • Listen to tape • Written account

Situation Cognition Emotion Y-fronts removed at gunpoint They’re going to shoot me and kill

Situation Cognition Emotion Y-fronts removed at gunpoint They’re going to shoot me and kill me. Terrified Get an erection when penetrated I must have wanted this to happen. I must be gay. Ashamed Left on floor at end I should’ve known this would happen. It’s my fault. Guilty

Situation Cognition Emotion Update (“what I know now”) Y-fronts removed at They’re going to

Situation Cognition Emotion Update (“what I know now”) Y-fronts removed at They’re going to gunpoint shoot me and kill me. Terrified They don’t shoot me. I don’t die. Get an erection when penetrated I must have wanted this to happen. I must be gay. Ashamed It’s a normal physiological response. It doesn’t mean I wanted it to happen. It doesn’t mean I’m gay. Left on floor at end I should’ve known this would happen. It’s my fault. Guilty It’s not my fault. I couldn’t’ve known what was going to happen. [They] are to blame. They are bad people.

Updating trauma memory I • The worst didn’t happen • Belief: “I’m going to

Updating trauma memory I • The worst didn’t happen • Belief: “I’m going to die

How to tell ‘hotspots’ in reliving • Affect change • Avoidance – Change in

How to tell ‘hotspots’ in reliving • Affect change • Avoidance – Change in tense & person – Leave parts out – Go through parts quickly • Ask for worst moments

It’s not only fear. . . • Holmes, Grey & Young (2005); Grey &

It’s not only fear. . . • Holmes, Grey & Young (2005); Grey & Holmes (2008) • Several worst moments in a trauma – Mean = 4. 8 (2. 4); range 1 -11 • Intruding images are usually of hotspots – 78% of all images match hotspots – 86% of main intrusive images match hotspot • It’s not just fear – Full range of emotions experienced in hotspots – Only 42% emotions in one study were fear, helplessness or horror. 52% in other study. • Cognitive themes also vary – More than half of hotspots are related to psychological threat rather than physical threat – E. g. I’m useless, it’s my fault, I’m all alone vs. I’m going to die

Updating trauma memory II • “I’m trapped” • Physical movement to update • (not

Updating trauma memory II • “I’m trapped” • Physical movement to update • (not all meanings shown in table) Situation Thought/meaning Feeling Fingers inside me I’m dirty and horrible Inside my mouth Disgust Update It’s not my choice. I don’t want to be here, it’s him, I’m not dirty and disgusting, he was doing something disgusting. I’m trapped, I Fear and can’t do anything helplessness I was trapped then but I’m not now [stand up, move arms].

How much reliving? Sessions with any reliving Total minutes of reliving over treatment Ehlers

How much reliving? Sessions with any reliving Total minutes of reliving over treatment Ehlers et al (2003) 10. 5 + 2. 7 3. 5 Ehlers et al (2005) 9. 0 + 2. 4 3. 3 90 83 • Reliving integrated with cognitive and behavioural work over treatment • Reliving used to identify and restructure key meanings • Doesn’t include other forms of memory work in session, or any homework done

Is CT-PTSD acceptable? • Drop out rates • Trials (Ehlers et al, 2003, 2005,

Is CT-PTSD acceptable? • Drop out rates • Trials (Ehlers et al, 2003, 2005, 2014) – 0/28; 1/34; 1/30; 1/31 (2. 4%) • Routine NHS care (Ehlers et al, 2013) – 46/330 (14%)

UPDATING TRAUMA MEMORIES Step 1: Accessing the worst moments of trauma • Revisiting trauma

UPDATING TRAUMA MEMORIES Step 1: Accessing the worst moments of trauma • Revisiting trauma • Function 1: Access problematic meanings and change them in the memory (rather than as a mere intellectual insight). • Function 2: Generate information that helps put meanings in perspective (e. g. , reconstruct sequence of events, access “forgotten” details) • Function 3: For some patients, behavioural experiment to test beliefs about catastrophic consequences

UPDATING MEMORIES PROCEDURE Continued Step 2: Identify information that provides evidence against appraisals of

UPDATING MEMORIES PROCEDURE Continued Step 2: Identify information that provides evidence against appraisals of worst moments or predictions made at the time a. may be information from course of the event, e. g. , - outcome was better than expected (e. g. , patient did not die, is not paralyzed) - contradictory information from course of event (e. g. , compliance with perpetrator because he had knife) - realization that an impression, perception was not true (e. g. , toy gun), sometimes expert advice needed (e. g. , car explosions, electric shock) b. may be result of systematic cognitive restructuring

UPDATING TRAUMA MEMORIES- continued STEP 3: Insert the updating information into the relevant part

UPDATING TRAUMA MEMORIES- continued STEP 3: Insert the updating information into the relevant part of the trauma memory: - Produce an updated version of written narrative, with new meanings (“I know that. . . ”); - Incorporate restructured meanings into reliving while holding hotspot in mind by one or more of the following (whatever most convincing) - verbal reminders - images - incompatible actions - incompatible sensations 4. After all identified hotspots have been updated, probe for further hotspots with “diagnostic” complete reliving

Dissociation • compartmentalization of experience; a type of attention • daydreaming, numbing, spacing out,

Dissociation • compartmentalization of experience; a type of attention • daydreaming, numbing, spacing out, unreal or dreamlike, out-of-body experiences, flashbacks • dissociation during traumatic event • dissociation as a symptom after traumatic event

Dealing with Dissociation • Prevents processing of new information • Provide information / normalisation

Dealing with Dissociation • Prevents processing of new information • Provide information / normalisation • Grounding strategies – to maintain awareness of ‘here and now’ – triggers, first sensations – object, image, phrase • Reliving work – – Identify moment of dissociation imagery techniques graduated: eyes open, written Using grounding objects and updated info on to tape • Precautions / action plan for self-harm

When not to offer CT for PTSD • When person doesn’t have PTSD •

When not to offer CT for PTSD • When person doesn’t have PTSD • When person can’t process info (drunk, depressed, head injury) how to adapt • When person is at risk of imminent harm • When person is more pre-occupied with other issues

Why not into the memory work? • Practical factors • Therapist factors • Patient

Why not into the memory work? • Practical factors • Therapist factors • Patient factors

Reliving: therapist factors • Becker et al (2004) – 83% of 207 psychologists never

Reliving: therapist factors • Becker et al (2004) – 83% of 207 psychologists never opted for exposure therapy to treat their PTSD patients. • Van Minnen et al (2010) – imaginal exposure seen as more credible than medication or supportive counselling but underutilized – Majority of professionals undertrained. – Fears of symptom exacerbation and drop out. • Your Concerns? • How to test?

Effects on therapist • • Countertransference Emotional exhaustion / ‘compassion fatigue’ Secondary PTSD /

Effects on therapist • • Countertransference Emotional exhaustion / ‘compassion fatigue’ Secondary PTSD / ‘vicarious traumatization’ Change in belief systems – Watch behaviours • But see Elwood et al (2010) • Secondary posttraumatic growth

Looking after yourself • Supervision – Formal; informal • Caseload mix • Use CBT…

Looking after yourself • Supervision – Formal; informal • Caseload mix • Use CBT… • General strategies – Diet, exercise, social contact, moderate alcohol use, etc. • Craig & Sprang (2010): “utilization of evidencebased practices predicted decreases in compassion fatigue and burnout, and increases in compassion satisfaction”

Written narrative • In session and / or homework • Particularly helpful when: –

Written narrative • In session and / or homework • Particularly helpful when: – Confusion re. temporal order – Prolonged duration trauma – Strong dissociation

Example of narrative • “They are holding me down and one of them penetrates

Example of narrative • “They are holding me down and one of them penetrates me. I can feel pain. I get an erection. I feel really bad and think that this must mean that I am gay and want this to happen. But I know in reality that this is a normal physiological response and it does not mean that I am gay or wanted it to happen. They continue…”

Updated Memory I’m driving along the middle lane, the van is losing stability, it

Updated Memory I’m driving along the middle lane, the van is losing stability, it makes a violent veer to the right – why does it do that? I feel confused and scared. Now I know the tyre had blown out and we were driving on the wheel. I try to get it to drive steady and come back to the middle lane. I’m fighting with the steering with all my strength – completely pull it, we’ve picked up speed , we’re heading straight for the embankment, John said, “This is it!” and we both thought, “this is it, we’re going to die. I felt I had no control over the van. I didn’t know what was happening. I was 100% convinced I was going to die. I thought, “ I’m making a mess of it” and thought John would have done better. I now know I had more control than I thought and I made the situation safer by pulling in out of the way of the other traffic. I avoided another collision and it could have been a lot worse for John and I if we’d been hit by the other transit or the central barrier. We veer to the embankment. I feel I’ve lost control. We hit the embankment, the windscreen smashes, we’ve been thrown all over the place, I thought I was going to die. I now know I didn’t die, I’d got the van out of danger, it had swung round, gone up the side, pivoted on the front passenger side edge and come to a stop on the edge of the road, looking towards the traffic.

Reliving vs Narrative Reliving • More direct access to emotions • Access important details

Reliving vs Narrative Reliving • More direct access to emotions • Access important details • “Felt change” in meaning Narrative • Confusion about temporal order – Loss of consciousness – Alcohol / drugs • Long trauma – to identify hot spots in long sequence of events • Strong dissociation – no contact to present reality

Prolonged duration • Written narrative • Relive worst periods – What intrusions – Hardest

Prolonged duration • Written narrative • Relive worst periods – What intrusions – Hardest to write about

Multiple events • Identify key re-experiencing symptoms, key meanings, and contexts • Start with

Multiple events • Identify key re-experiencing symptoms, key meanings, and contexts • Start with developing a timeline • What to go for first – What intrusions? – Client preference • More than one at a time? – Common cognitive themes – Explicitly encourage generalization • Narrative Exposure Therapy

Timeline • Facts, context (social, occupational etc), i. e. key events not just trauma

Timeline • Facts, context (social, occupational etc), i. e. key events not just trauma • Re-experiencing symptoms • Beliefs • Where to start and stop – Birth? When traumas began? – When traumas ended? Present day? Future? • Be flexible and creative – ‘enlarge’ sections, use photos etc

Treatment Goals Ehlers & Clark (2000) Appraisals of trauma and/or sequelae Trauma memory elaborate

Treatment Goals Ehlers & Clark (2000) Appraisals of trauma and/or sequelae Trauma memory elaborate identify and modify Triggers discriminate Current threat intrusions arousal Strong emotions Reduce… Dysfunctional behaviours/ cognitive strategies give up/alter

Dealing with Intrusions • Intrusion can be affect without recollection • Identify the triggers

Dealing with Intrusions • Intrusion can be affect without recollection • Identify the triggers – Diary – Detective work for matching stimuli: often lowlevel physical cues such as colour, sound, movement or internal cues (Batman) • Discriminate NOW vs THEN – Break link between trigger and memory

Discriminating triggers • Trigger exact bit of memory – Variety of cues, one at

Discriminating triggers • Trigger exact bit of memory – Variety of cues, one at time • Discriminate then (similarities) vs. now (differences) • Behavioural experiment • Practise

THEN • Dark – can’t see • Feel bad • Group of people •

THEN • Dark – can’t see • Feel bad • Group of people • People attacking • Couldn’t open eyes • Outdoors • Hand broken • Knife in mouth • Can’t move NOW • Dark – can’t see • Feel bad • One person • People helping • Can open eyes • Indoors • Hand OK • Chewing gum in mouth • Can move

THEN NOW • Touched in particular way • Touched in same way • Couldn’t

THEN NOW • Touched in particular way • Touched in same way • Couldn’t move • Didn’t want it to happen • No choice what he did • • Couldn’t speak I was very ill He’s sick, not normal Just 20 then • Can move • I’ve chosen to be with [partner] • I have control over what happens • Can speak • I’m healthy • [partner] is normal • 30 now

Stimulus Discrimination • https: //www. youtube. com/watch? v=m 0 Je 6 z 24 w.

Stimulus Discrimination • https: //www. youtube. com/watch? v=m 0 Je 6 z 24 w. P 4 • Using technology in session

Revisiting the site • • Relive and reconstruct Time-code on memory Then vs. now

Revisiting the site • • Relive and reconstruct Time-code on memory Then vs. now New information New memories and meanings Behavioural experiment Watch for safety behaviours

Site visits • Google street view • Other sources: internet, friends/family/colleagues, photos, official records,

Site visits • Google street view • Other sources: internet, friends/family/colleagues, photos, official records, people still there • ‘Virtual Iraq’ in US

Virtual site visit • https: //www. youtube. com/watch? v=LPfdby A 3198

Virtual site visit • https: //www. youtube. com/watch? v=LPfdby A 3198

Treatment Goals Ehlers & Clark (2000) Appraisals of trauma and/or sequelae Trauma memory elaborate

Treatment Goals Ehlers & Clark (2000) Appraisals of trauma and/or sequelae Trauma memory elaborate identify and modify Triggers discriminate Current threat intrusions arousal Strong emotions Reduce… Dysfunctional behaviours/ cognitive strategies give up/alter

Cognitive techniques • • • Socratic questioning Evidence for and against Advantages / disadvantages

Cognitive techniques • • • Socratic questioning Evidence for and against Advantages / disadvantages Pie charts Surveys Information from other sources, e. g. , police, significant others, statistics • Guided imagery

Overgeneralized threat • “bad things can happen at any time” • Avoidance • Other

Overgeneralized threat • “bad things can happen at any time” • Avoidance • Other Safety Seeking Behaviours – Checking / hypervigilance • If I keep alert I’ll stay safe – Not alone / over protect others – Avoid risks / extra precautions

Addressing overgeneralized threat • Feels more dangerous due to trauma memory • Objective risk

Addressing overgeneralized threat • Feels more dangerous due to trauma memory • Objective risk not changed • Evaluate / calculate actual risk (sequential probabilities) • Identify selective attention to danger cues and role of hypervigilance • Behavioural experiments

Sequential probabilities • • Chance I’ll have an accident - ‘feels’ 80% Times per

Sequential probabilities • • Chance I’ll have an accident - ‘feels’ 80% Times per week driven down that road: 10 How long lived there: 4 years Years x weeks x occasions: 4 x 50 x 10 = 2000 Number of accidents: 1 Probability: 0. 05% How feel isn’t a good guide and is fueled by the nature of the memory. • Any change in actual likelihood of accident because had one? – Safety behaviours: e. g. looking in mirror may increase probability • Can ask about other accidents and also get Do. T official statistics

Anxiety and threat Anxiety is proportional to the perception of danger; that is perceived

Anxiety and threat Anxiety is proportional to the perception of danger; that is perceived likelihood X “awfulness” it will happen if it did ______________ + perceived coping ability when it does perceived rescue factors

How I am now Taking no risks at all. Never leave the house? Partner

How I am now Taking no risks at all. Never leave the house? Partner How I’d like to be How I used to be Very risky behaviour. No sense of danger

Appraisals of what happened • What did or didn’t do – guilt • The

Appraisals of what happened • What did or didn’t do – guilt • The kind of person you are or aren’t – shame • What others did or didn’t do – anger

Shame and guilt • shame: a sense of oneself as defeated, deficient, exposed, failure,

Shame and guilt • shame: a sense of oneself as defeated, deficient, exposed, failure, worthless, inadequate (see Gilbert, 1997) • humiliation focuses on harm done by others; in shame focus is on the self • guilt is about what you do but shame is about who you are (for guilt see Kubany work)

Risk factors for shame/guilt • • pre-existing vulnerability / prior history negative outcome personalisation

Risk factors for shame/guilt • • pre-existing vulnerability / prior history negative outcome personalisation breach of intimacy barrier lack of external sources of information duration of event actions / judgements making decisions - impossible choices

Why guilt in PTSD • About – – Fact event happened at all Fact

Why guilt in PTSD • About – – Fact event happened at all Fact person survived What did / didn’t do during event Failure to overcome symptoms • Cognitive biases – leading to overestimation of personal responsibility – – – Hindsight bias Discount other explanations and positive actions Superhuman standards Violation of personal standards Emotional reasoning

Working with guilt • Hindsight bias – socratic questioning; national lottery • Responsiblity –

Working with guilt • Hindsight bias – socratic questioning; national lottery • Responsiblity – pie chart; child & cooker • Violation of personal standards – “I should / shouldn’t”; label emotional reasoning • Imagery – from observer perspective

Exploring guilt • What other explanations might there be? • Who else was involved?

Exploring guilt • What other explanations might there be? • Who else was involved? • How much power did you actually have to influence what happened • How did things appear to you at the time? • What was the reason for you acting as you did, at the time? • How could you have known what was going to happen? • How much time for reflection and choosing the best course of action did you have? • What was your emotional and physical state at the time? • What did you do that was helpful? • If this was another person, what more would you expect of them? How would you explain their behaviour? • Apart from your feelings, what else might you take into account when considering how you acted?

Pie chart

Pie chart

Why shame in PTSD • what happened • how reacted at time • development

Why shame in PTSD • what happened • how reacted at time • development of symptoms

Shame Misinterpretations about: • How others will perceive the trauma • How others will

Shame Misinterpretations about: • How others will perceive the trauma • How others will perceive one’s actions during the trauma • How others will view one’s symptoms Important to address because: • Shame causes people to withdraw or avoid and can therefore maintain symptoms

Identifying shame • Behaviour in and out of session – Feel “awkward, silly, exposed”

Identifying shame • Behaviour in and out of session – Feel “awkward, silly, exposed” – Labels “weak, useless, inadequate” – Look away, freeze, aggression • Questionnaires • Information sheet • Trauma characteristics

Impact on therapy relationship • Good relationship – Threat of ‘discovery’ (of something bad)

Impact on therapy relationship • Good relationship – Threat of ‘discovery’ (of something bad) so keep safe by withdrawing – ‘if I really tell you then it’ll spoil it all’ – contaminate the relationship • Aggressive patients – I’m not going to be shamed –anything to prevent – “describe what you were feeling just then”

Initial interventions • Therapist reaction: empathic, trustworthy etc • break secrecy, active validating approach,

Initial interventions • Therapist reaction: empathic, trustworthy etc • break secrecy, active validating approach, bring up topic • Normalize & educate • refocusing attention (stops internal shame spiral) • focus with effort outside self

Working with shame • identify internal bully, foster compassionate friend (Paul Gilbert stuff) •

Working with shame • identify internal bully, foster compassionate friend (Paul Gilbert stuff) • hanging up phone on bully, foster selfaffirmation • cognitive techniques: meaning, schema, core beliefs etc • discuss with others – Evidence re what will others think • surveys

Survey 1. If you were walking in London late at night and you saw

Survey 1. If you were walking in London late at night and you saw a man crouched on the ground in a foetal position trying to protect himself while a group of other men were kicking and punching him, what would you think of the man who was being beaten? 2. Would you think he was weak? 3. Would you think he was inferior? 4. Would you think less of him? 5. What would you think of the 12 men who were attacking him?

Dealing with anger • Empathy first • Who/what angry at – Wants to be

Dealing with anger • Empathy first • Who/what angry at – Wants to be heard – Allow time to discuss / vent – Letter • Present frustration – Problem solving – Reclaim life

Anger at behaviour of others during and after trauma – Examine and restructure distortions

Anger at behaviour of others during and after trauma – Examine and restructure distortions taking all context and info into account – Explore explanations for person’s behaviour – challenge assumptions re malicious intent if appropriate – CT re standards (should’s) • black/white thinking, rigidity – Humiliation (Gilbert)

Giving up anger • Who wins? • Conscious decision to stop someone else controlling

Giving up anger • Who wins? • Conscious decision to stop someone else controlling your life (forgive? ) • Challenge assumptions re. letting anger go – “if you weren’t angry what would that mean to you? ” – E. g. it will be forgotten, he will have got away with it etc

Kleim et al (2013) • Ehlers et al (2013) routine NHS care (n=330) •

Kleim et al (2013) • Ehlers et al (2013) routine NHS care (n=330) • Negative trauma-related appraisals and PTSD symptoms both decreased significantly during treatment • Change in negative appraisals predicted symptom change in the following week, independent of a general decrease of each variable over time. • This prediction was not significant in the other direction: PTSD symptom change did not predict negative appraisal change in the following week

 • Change in meanings most important • Can change meanings in various ways

• Change in meanings most important • Can change meanings in various ways • Accessing the memory helps you identify and update meanings

Restructuring images • Peritraumatic vs secondary • Veridical vs non-veridical • Fragments lack context

Restructuring images • Peritraumatic vs secondary • Veridical vs non-veridical • Fragments lack context • Context spontaneously from reliving • Context from imagery techniques – Run past worst point – Watch from new perspective – Explore actions not taken – Bring in other information – Enter body – dissociation – Incorporate spiritual viewpoint – THEN vs. NOW

Permanent change • • • What is and what isn’t permanent Depression Physical injuries

Permanent change • • • What is and what isn’t permanent Depression Physical injuries / pain Losses Identify and work with meanings

Life is full of crap (80%) - BDI 40 • • Accident – Financial

Life is full of crap (80%) - BDI 40 • • Accident – Financial – Physical injuries – PTSD Loss of enjoyment Loss of convenience Divorce Financial aspects Work Life feels hard • • • Job going well New partner – Relationship’s existence – Committed to her I’m able to commit and love Nice home Have Car Cadets – Making a difference to lives – Them getting pleasure Divorce settled Treatment Pleasurable activities – Films, books, music, countryside Distilled moments of enjoyment

Physical injuries • Predictor of poorer treatment response • Meaning of injury (now and

Physical injuries • Predictor of poorer treatment response • Meaning of injury (now and future) • Can maintain ongoing threat? • Social phobia treatment techniques • Address distorted sense permanent change • Grief work for losses

Bereavement • Blocks natural grief process • Dead person is “stuck” at time of

Bereavement • Blocks natural grief process • Dead person is “stuck” at time of trauma (nowness of memories, appearance of dead body) and meaning of that • Regrets about things said/ not said • Often need to discuss beliefs about afterlife • “Complicated grief”

Interpretation of Physical Sensations / Panic Attacks • Can interfere with willingness to do

Interpretation of Physical Sensations / Panic Attacks • Can interfere with willingness to do reliving • Often needs to be addressed before trauma memory work • Information about trauma memory or assumed damage to body during trauma often helpful • Vicious cycle of panic, behavioural experiment • Set up reliving as experiment

Blueprint 1. How did your problems develop? 2. What kept your problems going? 3.

Blueprint 1. How did your problems develop? 2. What kept your problems going? 3. What did you learn in the course of therapy that was helpful? 4. What were the most unhelpful thoughts? What are the alternatives? 5. How could you build on what you learned? 6. If you experience another traumatic event in your life, what would you do differently and how would you try to manage it?

Overall structure of treatment • • • Make sure it is PTSD Provide safe

Overall structure of treatment • • • Make sure it is PTSD Provide safe environment What’s stopping recovery Initial interventions – normalising ++ Memory-focused work Work on meanings Work on behaviours [interweave these] Keeping well

Overall structure of treatment Session Likely activity Diagnostic assessment #1 (cognitive assessment) Outline of

Overall structure of treatment Session Likely activity Diagnostic assessment #1 (cognitive assessment) Outline of event, normalize, reclaim life, rationale for reliving #2 Reliving; identify hotspots and meanings #3 Address one cognitive theme at a time #4 Reliving with restructuring / updating trauma memories #5 Continue to address cognitive themes and update memory #6 In vivo exposure / Discriminating triggers (then vs. now) #7 Continue to work on cognitive themes, triggers and update memory as required #9 On ave. when site visit occurs #10 Start blueprint if not already done so • Reclaim life a strand through every session • 12 weekly sessions – and follow up • Not all techniques with everybody or in exactly this order – flexibility based on personal model of PTSD

Learning Objectives • Be able to assess for diagnosis of PTSD • To understand

Learning Objectives • Be able to assess for diagnosis of PTSD • To understand a cognitive model of PTSD and how this links to treatment • To know when and when not to offer CT-PTSD • To understand the key initial interventions used in CTPTSD • To be able to provide a rationale for patients for discussing the traumatic memories • To know which memory-focused techniques might be most helpful when • To know how to use your full range of cognitive behaviour therapy techniques to address cognitive themes in PTSD

Mood Anxiety and Personality Clinical Academic Group (CAG) nick. 1. grey@kcl. ac. uk www.

Mood Anxiety and Personality Clinical Academic Group (CAG) nick. 1. grey@kcl. ac. uk www. kcl. ac. uk/cadat www. national. slam. nhs. uk/cadat @CADATLondon @nickdgrey