Lecture 7 trauma focused cbt


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The application of TF_CBT to complex trauma

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  • Blanchard, E. B., Hickling, E. J., Malta, L. S., Freidenberg, B. M., Canna, M. A., Kuhn, E., Sykes, M. A.,& Galovski, T. E. (2004). One- and two-year prospective follow-up of cognitive behavior therapy orsupportive psychotherapy. Behaviour Research Therapy, 42(7), 745–759.Basoglu, M., Salcioglu, E., Livanou, M., Kalender, D., & Acar, G. (2005). Single-session behavioral treatmentof earthquake-related posttraumatic stress disorder: A randomized waiting list controlled trial. Journal ofTraumatic Stress, 18(1), 1–11.Lindauer, R. J. L., Gersons, B. P. R., van Meijel, E. P. M., Blom, K., Carlier, I. V. E., Vrijlandt, I., & Olff, M.(2005). Effects of brief eclectic psychotherapy in patients with posttraumatic stress disorder: Randomizedclinical trial. Journal of Traumatic Stress, 18(3), 205–212.McDonagh, A., Friedman, M., McHugo, G., Ford, J., Sengupta, A., Mueser, K., Demment, C. C., Fournier,D., Schnurr, P. P., & Descamps, M. (2005). Randomized trial of cognitive-behavioral therapy for chronicposttraumatic stress disorder in adult female survivors of childhood sexual abuse. Journal of Consultingand Clinical Psychology, 73(3), 515–524.Rothbaum, B. O., Astin, M. C., & Marsteller, F. (2005). Prolonged exposure versus eye movementdesensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18(6),607–616.
  • Lecture 7 trauma focused cbt

    1. 1. Lecture 7:CBT approaches to complex trauma Complex Casework Kevin Standish 1
    2. 2. Treatment Principle for All Types of Trauma treatment “First, do no more harm” Treatment can help and treatment can hurt both the helper and the client 2
    3. 3. Learning Outcomes 1. Review of research on CBT with complex trauma 2. Trauma focused CBT (TF-CBT) 3
    5. 5. CBT and PTSD 1. More published well-controlled studies on CBT than on any other PTSD treatment 2. CBT treatments usually involve some combination of psycho-education and therapeutic relationship 3. Other CBT treatment methods may be added to address related problems 1. anger (anger management training, assertiveness training) 2. social isolation (social skills training, communication skills training) 4. Have proven very effective in producing significant reductions in PTSD symptoms (generally 60-80%) especially rape survivors 5. Magnitude and permanence of treatment effects appears greater with CBT than with any other treatment Compelling evidence it works! 5
    6. 6. SOME CBT INTERVENTIONS FOR PTSD 1. Stress Inoculation Training 2. Cognitive Therapy 3. Cognitive Processing Therapy 4. Systematic Desensitization 5. Exposure 6
    7. 7. Stress-inoculation training 1. Meichenbaum (1974) 1. Anxiety management 2. Female assault survivors 2. Skills for managing and reducing anxiety 1. Muscle relaxation 2. Diaphragmatic breathing 3. Covert modeling 4. Role playing 3. Anxiety management = decreases in avoidance and anxiety 7
    8. 8. Cognitive Therapy 1. Beck (1976) 1. Identify their trauma-related negative beliefs (e.g., guilt or distrust of others) and change them to reduce distress 2. Pay attention to appraisals of safety and danger. 8
    9. 9. Systematic desensitization 1. Wolpe (1958) 1. Exposure and relaxation 2. Mostly only imaginal exposure 3. Create hierarchy/SUDS 4. Become proficient and relaxation 5. Exposure for hierarchy 9
    10. 10. Ways of changing trauma memories : How CBT models differ from normal CBT 1. Prolonged exposure to trauma memory 2. Updating worst moments in memory (Ehlers & Clark) 3. Brief exposure to image with rapid eye movements or other bilateral stimulation (Shapiro) 4. In vivo exposure 5. Discrimination of triggers (Ehlers & Clark) 10
    11. 11. Evidence Base reviewed by NICE 1. EMDR: 11 studies compared with Waiting List (W/L) or other psychological interventions 2. TF-CBT: 16 studies compared with W/L or other psychological interventions 3. E-CBT: 16 studies compared with W/L or other psychological interventions 4. Stress Management: 7 studies compared with W/L or other psychological interventions 5. General CBT: 4 studies compared with W/L or other psychological interventions 6. Other: 6 studies compared with W/L or other psychological interventions 11 http://www.nice.org. uk/nicemedia/live/10 966/29769/29769.pdf Deal with Simple PTSD only Guidelines do NOT deal with Complex PTSD or Chronic PTSD.
    12. 12. NICE Guidelines 2005: Systematic Review of Psychological Treatments for PTSD – Effect sizes compared to wait list 0 0.5 1 1.5 2 Other CBT: Stress management EMDR TF-CBT A priori threshold d = .08 13 RCTs 4 RCTs 3 RCTs 2 RCTs 12
    13. 13. Psychological Interventions 1. Exposure based CBT demonstrated more clinically important effects on self report PTSD symptoms and PTSD diagnosis than W/L. 2. Limited evidence of superiority on clinician rated PTSD symptoms , depression and anxiety 3. Not superior to stress management or other treatments and outcomes varied substantially 13
    14. 14. Psychological Interventions 1. EMDR found support but not as strong as TFCBT 2. Clinically important benefits on clinician rated but not self report PTSD symptoms compared to W/L 3. Limited evidence for clinically important effects on anxiety and depression 4. EMDR was superior to supportive/non- directive therapy but not stress management. 14
    15. 15. Evidence base since NICE 1. Several new studies but no change in conclusions above 2. 4 additional studies comparing trauma focused CBT with waiting list 3. 1 additional study comparing trauma focussed CBT with other treatment 15
    16. 16. Recommendations from evidence base: 1 1. All PTSD sufferers should be offered a course of trauma focused psychological therapy on an individual, out-patient basis (A) 2. Trauma focused psychological interventions should be offered regardless of the time elapsed since the trauma (B) 16
    17. 17. Recommendations from evidence base: 2 1. CBT should be offered even if key trauma was a long time ago 2. Individual face to face therapy is first choice 3. Course of treatment for a single trauma is 8- 12 60 min. sessions 4. Treatment must be flexible with longer sessions if trauma story being related. 17
    18. 18. Recommendations from evidence base: 3 1. Trauma focused psychological interventions should be 8-12 sessions long when the PTSD has arisen from a single incident. (B) 2. If the traumatic event is being discussed sessions should be longer (90 mins), offered on a regular and continuous basis (weekly) with the same person. (B) 18
    19. 19. Recommendations from evidence base: 4 1. In cases of multiple trauma, traumatic bereavement, chronic disability arising from the trauma, significant co-morbidity or social problems longer treatment duration should be considered (> 12 sessions). (C) 2. Treatment should be delivered by competent individuals with appropriate training and supervision. (C) 19
    20. 20. UK Trauma Group Statement on CPTSD (May 2008) 1. NICE states that PTSD develops following a stressful event or situation of an exceptionally threatening or catastrophic nature, and examples that are given include single events such as assaults or road traffic accidents. 2. For adults, we believe that this refers to “simple” PTSD, which commonly develops following a single traumatic event occurring in adulthood. The recommended treatment is brief, trauma-focused psychological therapy. 3. However, the guideline does not apply to situations involving complex trauma, for example where there is a history of multiple traumatic events, including previous childhood trauma and attachment disorder. 20
    21. 21. UK Trauma Group (May 2008) 1. The NICE guidelines do not provide adequate guidance in relation to the assessment and treatment of Complex PTSD. 2. This results in lack of appropriate provision, resources and training to treat people with Complex PTSD, and ensuing limited access to effective treatment services. 3. We propose that a review of the literature on complex PTSD is urgently needed to refine the definition of complex PTSD, and provide more detailed guidance for good practice in the assessment and treatment of complex PTSD. 4. We advise that the multi-phasic treatment recommendations outlined above should be followed as best practice for the treatment of Complex PTSD as we currently understand it. 21
    22. 22. UK Trauma Group (May 2008) 1. Literature on effective treatment for complex PTSD is limited, but what there is so far shows that multi-phasic and multi-modal treatment is indicated for children and adults (e.g. Luxenberg et al., 2001). 2. The literature recommends that the following three stages are included: 3. Establishing stabilisation and safety; 4. Psychological therapy, incorporating trauma-focused elements and some exposure to the trauma; 5. Rehabilitation. 22
    23. 23. SCHEMA THERAPY and PTSD 1. Schema therapy was designed to help people who have chronic difficulties. 2. It was derived from traditional CBT and incorporates practices from other psychotherapies, including psychodynamic, emotional focused therapy, and Gestalt. 3. It retains the structure of a cognitive model but has more of a focus on client needs and core emotional experiences. 4. Recent adaptations to schema therapy such as the mode model have been shown to be effective in treating emotionally dys-regulated clients with extensive trauma histories. 5. Schema therapy is not a treatment model for PTSD per se 6. Although the treatment process and structure can help those with complex trauma as it follows some of the core elements of trauma treatment: 23
    24. 24. SCHEMA THERAPY: 1. Cognitive models have informed understanding of the development, maintenance, and treatment of posttraumatic stress disorder (PTSD). Limited research, however, has examined the relationship of early maladaptive schemas to PTSD among trauma survivors. 2. Harding et al (2011), using a sample of 127 female child sexual abuse survivors, applied a model-based clustering procedure to the 15 subscales of the Young Schema Questionnaire-Short Form and revealed three clusters differentiated primarily by level of schema elevation. 3. Women in the cluster characterized by the highest schema scores reported the most severe PTSD symptoms. 4. A discriminant analysis indicated that schemas of Mistrust/Abuse, Vulnerability to Harm, and Emotional Deprivation contributed most to distinguishing women differentiated on the basis of presumptive PTSD diagnostic status. 5. Results underscore the importance of cognitive factors in the development and/or maintenance of PTSD symptoms and suggest possible treatment targets for cognitive therapy with CSA survivors 24
    25. 25. TRAUMA FOCUSED CBT MODEL: TF-CBT 25 https://www.youtube.com/watch?v=hKAzsf-VqdQ 4min 30 sec
    26. 26. The origins of TFCBT 1. Developed for treating sexually abused children 2. Viewed working with parents as an integral part of treatment Esther Deblinger, Ph.D. Center for Children‟s Support University of Medicine and Dentistry of New Jersey & Judith Cohen, M.D., and Anthony Mannarino, Ph.D. Center for Traumatic Stress in Children and Adolescents Alleghany General Hospital 26
    27. 27. What is TF-CBT? A hybrid treatment model that integrates:  Trauma sensitive interventions  Cognitive-behavioral principles  Attachment theory  Developmental Neurobiology  Family Therapy  Empowerment Therapy  Humanistic Therapy 27
    28. 28. What is TF-CBT? • Evidenced Based treatment model developed by Deblinger, Cohen, and Mannarino that integrates trauma sensitive interventions with cognitive-behavioral strategies. • The therapist structures sessions such that there is a focus on skill building and direct discussion and processing of the abuse experience. • TF-CBT is a time limited, structured model that takes place over 12 – 20 sessions. • Children between the ages of 3 and 18 that have a memory of the trauma and have a diagnosis of Post Traumatic Stress Disorder (PTSD) or Post Traumatic Symptoms. 28
    29. 29. TF-CBT elements 1. Psycho-education 2. Disclosure / Exposure / Working Through of Traumatic Material 3. Cognitive restructuring 4. Problem solving 5. Use of behavioural techniques for example anxiety management 29
    30. 30. TF-CBT Approaches 1. Exposure: The therapist helps confrontation of the traumatic memories (written, verbal, narrative). Detailed recounting of the traumatic experience – repetition. In vivo repeated exposure to avoided and fear- evoking situations that are now safe but that are associated with the traumatic experience. 30
    31. 31. TF-CBT Approaches 1. Cognitive Therapy Focus on the identification and modification of misinterpretations that lead PTSD sufferer to overestimate current threat (fear) Modification of beliefs related to other aspects of the experience and how the individual interprets their behaviour during the trauma (eg: issues concerning shame and guilt). 31
    32. 32. Other - CBT Approaches 1. Stress Management 2. Relaxation Training 3. Breathing re-Training 4. Positive thinking and Self-talk 5. Assertiveness Training 6. Thought Stopping 7. Stress Inoculation Training 32
    33. 33. Difficulties Addressed by TF-CBT 1. CRAFTS  Cognitive Problems  Relationship Problems  Affective Problems  Family Problems  Traumatic Behavior Problems  Somatic Problems 33
    34. 34. Core Values of TF-CBT 1. CRAFTS  Components-Based  Respectful of Cultural Values  Adaptable and Flexible  Family Focused  Therapeutic Relationship is Central  Self-Efficacy is emphasized 34
    35. 35. Choosing TFCBT RCTs demonstrating efficacy/effectiveness of TFCBT for: 1. Ages 3-18 but is being extended to adults 2. Multiple racial/ethnic backgrounds 3. Varying socio-economic status 4. Single or multiple trauma history 5. Placement with biological parents or child welfare 6. Children with behavior problems 35
    36. 36. TFCBT is not for: 1. Clients with extreme therapy-resistant behavior 2. Clients with active suicidal behavior 3. Clients with severe cognitive disabilities 36
    37. 37. 37
    38. 38. Components of TF-CBT Treatment • Developing an empathic and supportive relationship. • Psycho-education and providing a rationale for treatment. • Stress management. • Exposure – Imaginable (prolonged) – In-vivo • Cognitive re-structuring 38
    39. 39. Overview of Re-living • Initially neutral imagery; • Then complete sequence of traumatic imagery, verbal or written to start - (possible hierarchical list); • Rewind and hold - concentrate on the worst part of memory, freeze and hold image, while repeatedly describing in detail all they can remember of the trauma; • Cognitive restructuring during exposure; • Audio-tape; • Constant rating of anxiety - use 0 -10 SUD‟s scale; • Listen to tape as homework • Intersession tasks 39
    40. 40. Hotspots • Notice changes in affect (What was going through your mind? How does it feel?) • Discuss „meaning‟ associated with hotspots • Verbal re-appraisal of hotspots (or imagery) to deal with them • Re-living just hotspots (re-wind and hold) • Build in new meanings 40
    41. 41. After re-living • Rate vividness • Ask how they found doing it • How it compared to what they thought it would be like? • Were they holding anything back? • H/W 41
    42. 42. Imagery Rescripting • What would happen if you allowed the image to continue? Can you change the ending… • What would the image look like projected onto a cinema screen, or seen from a moving train? • Imagine watching the image on TV – switching it off, dimmer,…freeze the image or make it black & white. • Through a zoom lens - make it smaller, or out of focus or further away 42
    43. 43. Additional treatment strategies • Exposure in vivo • Behavioural experiments (to „test out‟ unhelpful appraisals – “I‟m going out of control”, “I‟m vulnerable/weak” etc) 43
    44. 44. Cognitive Restructuring 1. Appraisals of the traumatic event – 2. “this could happen again” 3. “I should have been able to prevent it” 4. Appraisals of symptoms of PTSD – 5. “I am going mad” 6. “I should be over this by now” 7. Some characteristic biases / thinking errors – 8. Using hindsight to evaluate what happened 9. Personalisation 10. Overgeneralization (e.g.. of risk) 11. Catastrophisation (e.g.. if I face my memories ….) 44
    45. 45. Useful ‘Restructuring’ Questions • 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 your reason for acting as you did, at the time? • How could you have known what was going to happen? 45
    46. 46. Useful ‘Restructuring’ Questions: (cont) • 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? 46
    47. 47. 47  reconstruct the fragmented trauma memory & anchor it in the past through discussion, tapes & writing understand & reduce avoidance, encourage desensitization, tackle substance abuse etc
    48. 48. TFCBT – A PRACTICE! A ssessment! P sychoeducation and Parenting Strategies R elaxation A ffective expression and regulation C ognitive coping T rauma narrative and processing I n vivo exposure C onjoint parent child sessions E nhancing personal safety and future growth 48
    49. 49. Assessment Goal: Identify trauma history and presence of trauma-related symptoms. 1) Trauma History 2) Internalizing 3) Externalizing 4) Avoidance 5) Re-experiencing 6) Hyperarousal 7) Interference with daily functioning 49
    50. 50. Trauma-focused Cognitive Behavioral Therapy Child‟s Treatment Coping Skills Training: Emotional Expression Cognitive Coping Relaxation Gradual Exposure & Processing Education: Child Sexual Abuse Healthy Sexuality Personal Safety Caregiver‟s/partner Treatment Coping Skills Training: Emotional Expression Cognitive Coping Relaxation Gradual Exposure & Processing Education (like child sessions) Behavior Management Joint Sessions Coping Skills Exercises Gradual Exposure & Processing Education Regarding Sexuality and Sexual Abuse Personal Safety Skills Family Sessions From Deblinger & Heflin (1996) 50
    51. 51. The Therapist sets an agenda and sticks to the agenda, dealing with “COWS” or Crisis of the Week at the end of each session. 51
    52. 52. TF-CBT is adaptable and flexible to address developmental issues, gender, culture, family values (especially sensitive to sexuality and parenting styles). The therapeutic relationship is central. 52
    53. 53. 1/3 1/3 1/3 Sessions 1 - 4  Psychoeducation /Parenting Skills  Relaxation  Affective Expression and Regulation  Cognitive Coping Sessions 5 - 8  Trauma Narrative Development and Processing  In vivo Gradual Exposure Sessions 9 - 12  Conjoint Parent Child Sessions  Enhancing Safety and Future Development TFTF--CBT Sessions FlowCBT Sessions Flow Entire process is gradual exposure Baseline assessment 53
    54. 54. Psychoeducation Goal: Normalize symptoms, validate experience and reactions, instill hope for recovery. 1) What is trauma? 2) What is PTSD? 3) What is TFCBT? 54
    55. 55. Parenting Goal: Support caregivers to reduce their own stress/anxiety, improve the child-adult relationship, help the caregiver support the child‟s recovery. 1) Praise 2) Rewards 3) Active Ignoring 4) Time Out Specific for kids with PTSD: 1. Confidence in limit-setting 2. Not reinforcing avoidance 3. Coping coaching 55
    56. 56. 1. Teach parents/caregivers active ignoring and how to praise positive behaviors 2. Role play strategies with caregiver 3. Look at fact sheets in regards to trauma 4. Play psycho educational card game with child then child and family What do A therapeutic card you game about child know child sexual development ? Physical abuse & domestic violence 56
    57. 57. Relaxation Goal: Create “tool box” that the client can use in his/her own environment to manage symptoms. Relaxation is not just progressive muscle relaxation and deep breathing… 1. What do you do to relax? 2. Relaxation vs. Distress Tolerance 57
    58. 58. Affective Regulation Goal: Normalize multiple conflicting feelings, teach varying levels of feelings, teach vocabulary for talking about traumatic events competently. 1. Feelings Education (what are emotions?) 2. Connecting feelings to traumatic or difficult events 3. Feelings thermometers 4. Learning self-soothing techniques 58
    59. 59. Affective Regulation EMOTION IDENTIFICATION AND EXPRESSION 1. Ask client to talk about feelings 2. Encourage client to expand feelings vocabulary and match feelings to appropriate situations/events 1. Engage youth in activity that encourages expression of feelings 59
    60. 60. Cognitive Coping Goal: 1. Essential to help clients/families evaluate the ways in which trauma changed their thinking and correct distorted thoughts. 2. Make sure clients don‟t define themselves by their traumatic experiences. Cognitive Processing occurs before and after the Trauma Narrative. First teach the skill, then use it. 60
    61. 61. Cognitive Coping The heart of TFCBT: GOALS: 1. Clarify the difference between thoughts, feelings, and behaviors. 2. Demonstrate how thoughts, feelings, and behaviors affect each other. 61
    62. 62. Cognitive Coping COPING SKILLS Explain at least two of the following strategies: (1) grounding, (2) mindfulness, and or (3) relaxation, including deep breathing, progressive muscle relaxation or guided meditation. 62
    63. 63. TF-CBT Triangle Demonstration 63 https://www.youtube.com/watch?v=g6hMfQOsma4 11min
    64. 64. Trauma Narrative Goal: “To gradually expose client to thoughts, memories, and other innocuous reminders of the abusive experience until they can tolerate those memories without significant emotional distress and no longer need to avoid them.” (Deblinger & Heflin, 1996, p. 71) 1. Comes from Anxiety Framework 2. Un-pairing of harmless stimuli with learned anxiety response. Should include: 1) Before the trauma 2) Components of the trauma (chapters) with specific details, thoughts, feelings, and associated memories 3) The “worst” part 4) “What I learned” or “What I would tell other kids” 5) The future 64
    65. 65. Cognitive Processing of the Trauma Narrative Goal: Identify latent or overt cognitive distortions or unhelpful beliefs and challenge them with the client. 1. Revisit the cognitive triangle, add consequences 2. Use Socratic questioning 3. Never “tell” the clients to change their beliefs 4. Review cognitive coping (thought stopping, positive self-talk) 5. Practice strategies in session 6. Assign homework to practice skills at home 65
    66. 66. CBT Trauma Narrative Lecture 66 https://www.youtube.com/watch?v=evEL5l9QAks 1: 38 min
    67. 67. Common Trauma-Related Thoughts/Feelings 1. Guilt 2. Shame / Disgust 3. Self-Blame 4. Hopelessness 5. Fearfulness 6. Worthlessness 7. Lack of control 8. Depression 67
    68. 68. In-Vivo Exposure Goal: Unpair feared stimuli (triggers) from the learned response of anxiety/fear. Examples: 1. The dark 2. Streets 3. Men Use general and specific fear ladders, set up homework and practice activities with reward systems. 68
    69. 69. Enhancing Safety Goal: Prepare for the future 1. Learn to recognize signs/symptoms that indicate the need for a return to treatment 2. Create usable, meaningful safety plans 3. Plan for using coping skills 4. Consider environmental supports 69
    70. 70. Personal Safety Skills 1. Identify good and bad touch 2. Use “uh-oh” feeling analogy 3. Use role play to teach client assertiveness skills 4. Client practice assertiveness skills in session or taught skills to caregiver 70
    71. 71. Conjoint Sessions Goal: 1) Increased exposure / opportunity for mastery 2) Increase child & caregiver communication 3) Support asking and answering questions 1. Essential to prepare adequately 1. (individual with CG and with client before joint session) 2. Invite prepared questions, comments, feedback 3. Celebrate success! 71
    72. 72. Summary Assessment! P sychoeducation and Parenting Strategies R elaxation A ffective expression and regulation C ognitive coping T rauma narrative and processing I n vivo exposure C onjoint parent child sessions E nhancing personal safety and future growth TF-CBT – it works! 72
    73. 73. Core readings 1. Courtois & Ford (2009) chapter 12. Cognitive Behavioral Therapy, Christie Jackson, Kore Nissenson, and Marylene Cloitre 2.Doron, Miki & Lahad, Mool (2010) Protocol for Treatment of Post Traumatic Stress Disorder : SEE FAR CBT Model: Beyond Cognitive Behavior Therapy 73
    74. 74. 74
    75. 75. 75