Posttraumatic experiences:

Asssment and intervention

DAY 2
Eli Somer, Ph.D.
University of Haifa, Israel

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eli@somer.co.il
 Acute Stress Disorder (ASD)
  The person has been exposed to a traumatic event in which
both of the following were present: The person experienced,
witnessed, or was confronted with an event or events that
involved 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 distressing
event, the individual has three (or more) of the following
dissociative symptoms:
  A subjective sense of numbing, detachment, or absence of
emotional responsiveness.
  A reduction in awareness of his or her surroundings (e.g.,
"being in a daze").
  Depersonalization - dissociative amnesia (i.e., inability to
recall an important aspect of the trauma).

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 Acute Stress Disorder (ASD)
  The patient persistently re-experienced the traumatic event
in at least one or more of the following ways: recurrent
images, thoughts, dreams, illusions, flashback episodes, or a
sense 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 marked
distress 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 other
supporters about the experience.
  The disturbance lasts for a minimum of 2 days and a
maximum 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 which
both of the following have been present:1. The person has
experienced, witnessed, or been confronted with an event or
events that involve actual or threatened death or serious
injury, or a threat to the physical integrity of oneself or
others.2. The person's response involved intense fear,
helplessness, or horror. Note: in children, it may be
expressed instead by disorganized or agitated behavior.

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 Posttraumatic Stress Disorder (PTSD)
Criterion B: intrusive recollection The traumatic
event is persistently re-experienced in at least one of the
following 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 and
numbing of general responsiveness (not present before the
trauma), as indicated by at least three of the following:
1.  Efforts to avoid thoughts, feelings, or conversations
associated with the trauma
2.  Efforts to avoid activities, places, or people that arouse
recollections of the trauma

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 Posttraumatic Stress Disorder (PTSD)
Criterion C: avoidance/numbing
Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (not present before the
trauma), as indicated by at least three of the following:
3.  Inability to recall an important aspect of the trauma
4.  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 and
numbing of general responsiveness (not present before the
trauma), as indicated by at least three of the following:
6. Restricted range of affect (e.g., unable to have loving
feelings)
7. Sense of foreshortened future

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 Posttraumatic Stress Disorder (PTSD)
Criterion D: hyper-arousal. Persistent symptoms of increasing
arousal (not present before the trauma), indicated by at
least two of the following
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. 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 Procedures
 Techniques to manage or reduce anxiety
 Exposure Procedures
 Techniques to confront feared memories &
objects
 Cognitive Therapy Procedures
 Techniques 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 underlying
PTSD

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 PSTD treatments
Systematic Desensitization
Joseph Wolpe

  type of counterconditioning
  associates a pleasant, relaxed state with gradually
increasing 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 Follow-Up
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 PSTD treatments
Systematic Desensitization

Imagery Assessment
•  Is the image concrete, with sufficient detail and evidence
of 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 drifting
off or changing the scene

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 PSTD treatments
Systematic Desensitization – Hierarchies
•  Spatio-temporal Hierarchy (Example: A temporal
hierarchy for a public speaking trauma- Someone asks
you to give a speech in two months).
1.  Writing the speech a month before
2.  Rehearsing the speech a week before
3.  The morning of the speech
4.  Reciting the speech while dressing
5.  Approaching the auditorium
6.  Walking up to the podium

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7.  Giving the speech eli@somer.co.il
 PSTD treatments
Systematic Desensitization – Hierarchies
•  A spatial hierarchy for a dog phobia following bite
incident 
1.  Seeing a dog go by in a car
2.  Seeing a dog in a yard on a leash and behind a fence
3.  Dog poking nose through the fence
4.  Passing a leashed dog across the street
5.  Passing a leashed dog on same side of street 

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 PSTD treatments
Systematic Desensitization – Hierarchies
•  Thematic hierarchy - public speaking trauma 
1.  Telling a joke to several friends
2.  Making an announcement to a group of coworkers
3.  Speaking at a meeting
4.  Speaking at company banquet
5.  Giving the main address at a professional convention 

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 PSTD treatments
Systematic Desensitization
Coping Responses
•  Relaxation
  Emotive Imagery (a process where client imagines, in a
covert but vivid manner, the emotional sensations and
feelings of an actual scenario or behavior)
•  Meditation

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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 on a train
•  Being locked in a room
•  Being stuck in an elevator
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 •  Imagine scene
20 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 of

cognitive-behavioral therapy.
  SIT provides a set of clinical guidelines for treating stressed
individuals, 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, an
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overlapping three-phase intervention approach is employed
 PHASE 1: CONCEPTUALIZATION
  In a collaborative fashion, identify the determinants of
the presenting clinical problem or the individual's
traumatic 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, internal
dialogue, feelings, and behaviors.
  Ascertain the degree to which coping difficulties arise from
coping skills deficits or are the results of "performance
failures"
  Collaboratively formulate with the client and significant others
a 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 are
blocking 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 are
directed at the modification, avoidance, and minimization of
the impact of stressors.
  Select each skill according to the needs of the specific client or
group of clients.
  Help the client to break complex stressful problems into more
manageable 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 by
identifying possibilities for change, considering and ranking
alternative solutions, and practicing coping behavioral activities
in the clinic and in vivo.
  Train emotionally focused palliative coping skills, especially
when the client has to deal with unchangeable and
uncontrollable 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 REAHEARSAL
Skills rehearsal
  Promote the smooth integration and execution of coping
responses by means of behavioral and imagery rehearsal.
  Use coping modeling (either live or videotape models). Engage in
collaborative discussion, rehearsal, and feedback of coping skills.
  Use self-instructional training to help the client develop internal
mediators to self-regulate coping responses.
  Solicit the client's verbal commitment to employ specific coping
efforts.
  Discuss possible barriers and obstacles to using coping behaviors.

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 PHASE 2: SKILLS AQCUISITION AND REAHEARSAL
Encouraging application of coping skills
  Prepare the client for application by using coping imagery,
together with techniques in which early stress cues act as signals to
cope.
  Expose the client to more stressful scenes, including using
prolonged 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 foster
in vivo responding.

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 PHASE 2: SKILLS AQCUISITION AND REAHEARSAL
Encouraging application of coping skills
  Employ relapse prevention procedures: Identify high-risk
situations, anticipate possible stressful reactions, and rehearse
coping responses.
  Use counter-attitudinal procedures to increase the likelihood of
treatment adherence (i.e., ask and challenge the client to
indicate where, how, and why he or she will use coping
efforts).
  Bolster self-efficacy by reviewing both the client's successful
and unsuccessful coping efforts. Insure that the client makes
self-attributions for success or mastery experiences (provide
attribution retraining).
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 PHASE 2: SKILLS AQCUISITION AND REAHEARSAL
Maintenance and generalization
  Gradually phase out treatment and include booster and follow-up
sessions.
  Involve significant others in training (e.g., parents, spouse,
coaches, hospital staff, police, administrators), as well as peer and
self-help groups.
  Have the client coach someone with a similar problem (i.e., put
client in a "helper" role).
  Help the client to restructure environmental stressors and develop
appropriate escape routes. Insure that the client does not view
escape or avoidance, if so desired, as a sign of failure, bur rather as
a sign of taking personal control.
  Help the client to develop coping strategies for recovering from
37 failure and setbacks, so that lapses do not become relapses.
 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 the
traumatic memory through reliving the story.
Promotes processing of the highly emotional experience
and recognition that the individual can cope with the
distress associated with the memory.

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 Two main PE procedures:
  In vivo exposure – repeatedly confronting with
trauma-related situations that are avoided.
Reduces excessive fear and encourages the recognition that
situations are not excessively dangerous and individual
can 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 of
traumas (including prolonged trauma such as child abuse)
  Is effective at preventing PTSD when administered shortly
after 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 taught
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 Francine Shapiro

EMDR, which has been so well researched that it is now

recommended as a front line treatment for trauma in the
Practice Guidelines of the American Psychiatric Association, and those
of the Departments of Defense andVeterans Affairs.

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   EMDR is a psychotherapy treatment that facilitates the
accessing and processing of traumatic memories to bring
these to an adaptive resolution.
  During EMDR the client attends to emotionally
disturbing material in brief sequential doses while
simultaneously focusing on an external stimulus.
  Therapist directed lateral eye movements are the most
commonly used external stimulus but a variety of other
stimuli including hand-tapping and audio stimulation are
often used.

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 EMDR technique

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   There are two key processes that lead to a sense of ongoing
threat after trauma:
1.  sense of ongoing threat that is responsible for maintaining
acute stress reactions and helping to turn them into more
chronic post traumatic stress disorder.
2.  appraisal of trauma and it’s sequelae, that is, how a person
talks to themselves about their symptoms, their reactions, and
their experience.
Those judgments they make, judgments of personal weakness, of
guilt, of lack of trust in others, and those are held to play a role
and 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 to

be dangerous for you.

Negative appraisals maintain a sense of ongoing threat, which

lead to the maintenance of traumatic stress reactions.
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   Trauma memory needs to be laid out in more detail, and then
integrated into the context of the individuals experience
before the trauma happened, and afterwards.
  For example, the person might remember having a gun held
to his or her head. But that memory doesn’t include what
happened shortly after that. For example, the person
struggled with or escaped from his or her attacker.
  We need to identify the problematic judgments or appraisals
that maintain a sense of threat and help the person challenge
those.

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   Patricia Resick

  Model developed to treat specific symptoms of survivors of

sexual assault
  12 session structured therapy
  Based on information processing model of PTSD

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   Combines main ingredient of exposure-based therapies
with the cognitive components of most cognitively based
therapies
  Cognitive portion challenges specific cognitions most
likely 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 components
Homework
 “Please write at least one page about what it means to
you that you were raped. Please consider the effects the
rape has had on your beliefs about yourself, your
beliefs about others, and your beliefs about the world.
Also consider the following topics while writing your
answer: safety, trust, power/competence, esteem, and
intimacy. Bring this with you to the next session.”

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 Examples of treatment components
Session 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 you
have addressed here in the A-B-C worksheet. If you are unable to finish
the account in one sitting, just draw a line where you stopped.When you
are ready to begin again, read what you already wrote and then
continue.Try to begin this detailed account as soon as possible. If there
are parts you can’t remember, just draw a line and then continue with
the next instance you remember. Read the account to yourself everyday
until 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 and
white categories. If your performance falls short of
perfect, you see yourself as a total failure. 
  Overgeneralization:You see a single negative event as
a never-ending pattern of defeat. 
  Mental filter:You pick out a single negative detail and
dwell on it exclusively so that your vision of all reality
becomes darkened, like the drop of ink that discolors the
entire beaker of water. 

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   Disqualifying the positive:You reject positive
experiences by insisting they "don't count" for some
reason or other.You maintain a negative belief that is
contradicted by your everyday experiences.
  Jumping to conclusions:You make a negative
interpretation even though there are no definite facts
that convincingly support your conclusion.
  Mind reading:You arbitrarily conclude that someone
is reacting negatively to you and don't bother to check it
out. 

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   The Fortune Teller Error:You anticipate that things
will turn out badly and feel convinced that your
prediction is an already-established fact.
  Magnification (catastrophizing) or
minimization:You exaggerate the importance of things
(such as your goof-up or someone else's achievement),
or you inappropriately shrink things until they appear
tiny (your own desirable qualities or the other fellow's
imperfections). This is also called the "binocular trick.”
 

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   Emotional reasoning:You assume that your negative
emotions necessarily reflect the way things really are: "I
feel it, therefore it must be true." 
  Should statements:You try to motivate yourself with
shoulds 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 emotional
consequence is guilt. When you direct should statements
toward others, you feel anger, frustration, and
resentment. 

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   Labeling and mislabeling: This is an extreme form of
overgeneralization. Instead of describing your error, you
attach a negative label to yourself: "I'm a loser." When
someone else's behavior rubs you the wrong way, you
attach a negative label to him, "He's a damn louse."
Mislabeling involves describing an event with language
that is highly colored and emotionally loaded. 
  Personalization:You see yourself as the cause of some
negative external event for which, in fact, you were not
primarily responsible.
 
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 Practice
  Form threesomes: 1 = client; 2 = therapist; 3 = alter
therapist
  Alter therapist may consult with therapist and/or replace him/
her
  Client:You have survived a motor vehicle accident that
happened 2-months ago. In the accident you were in a
passenger seat when a truck drove through a red light and hit
the left side your car in the middle of a crossroad. The driver
of your car, your friend, was killed.
  Client:You have been diagnosed as suffering from PTSD with
avoidance of cars and flashbacks
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Join the ESTD and become part of a
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dissociation clinicians

Visit our website at www.estd.org, click on the

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 00-9724-8360494

eli@somer.co.il

www.somer.co.il

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