“To care for him who shall have borne the battle and for his widow, and his orphan,” President Lincoln March 4, 1865 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

PTSD Treatment at the Erie VA Medical Center

10 Week Psychoeducational group Week 1 Orientation: What is PTSD Week 2 Anger Management Week 3 PTSD and Medication Week 4 Relaxation and Grounding Week 5 Sleep and Nightmare Week 6 Reaching Out – Suicide Week 7 Recovery Thinking and Spirituality Week 8 PTSD and Substance Abuse Week 9 Work and Family Week 10 PTSD Treatment Options

Evidenced Based Treatment Evidence-based behavioral practice entails making decisions about how to promote healthful behaviors by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. Cognitive Processing Therapy (CPT) Prolonged Exposure Therapy (PE)

Evidenced Based Treatments for PTSD Cognitive Processing Therapy 12-session trauma-focused, manualized therapy that has been found effective for posttraumatic stress disorder (PTSD) CPT begins with the trauma memory and focuses on feelings, beliefs, and thoughts which directly emanated from the traumatic event. The therapist then helps the clients examine whether the trauma appeared to disrupt or confirm beliefs prior to this experience, and how much the clients have over-generalized (over-accommodated) from the event to their beliefs about themselves and the world. Clients are then taught to challenge their own self-statements using a Socratic style of therapy (leading clients to understand their reasoning processes and beliefs through questions), and to modify their extreme beliefs to bring them into balance.

Session 1: Patient psycho-education, identifying the index trauma, assigning the impact statement Session 2 and 2A (Traumatic Bereavement-optional): Processing the impact statement, identifying “stuck points,” reviewing cognitive model, introducing/teaching ABC worksheets; exploring issues working with traumatic loss within the CPT framework (optional session) Sessions 3 and 4: Reviewing ABC worksheets; modeling Socratic method, and assigning the first written account of the trauma; emotional processing of first written account and gentle challenging of stuck points Sessions 5 and 6: Processing second written account, introducing and reviewing the Challenging Questions worksheet; introducing Patterns of Problematic Thinking worksheet Sessions 7 to 11: Review Patterns of Problematic Thinking worksheets; introducing Challenging Beliefs worksheet; beginning exploration of trauma-related themes (safety, trust, power/control, esteem and intimacy); assign final impact statement; Session 12: Review Challenging Beliefs worksheets; trauma-related theme, consolidate treatment gains through reading and exploring the final impact statement and review of skills learned through course of CPT Cognitive Processing Therapy (cont)

Outcome measure ConditionPre-treatmentPost-treatmentFollow-up MSDM M PCLCPT TAU Total BDI-IICPT TAU Total BDI-II scoring 0-63 minimal 0-13 mild moderate severe PCL = PTSD Checklist Score CPT Results A Multisite Randomized Controlled Effectiveness Trial of Cognitive Processing Therapy for Military-Related Posttraumatic Stress Disorder -Forbes, D*. PhD 1 ; Lloyd, D. MA 1 ; Nixon, R. PhD 2 ; Elliott, P.PhD 1 ; Varker, T. PhD 1 ; Perry, D. PhD 3 ; Bryant, R.A. PhD 4 ; Creamer, M. PhD

Prolonged Exposure (PE) therapy is an evidence-based psychotherapy for PTSD. It involves 4 primary components: education about reactions to trauma and PTSD; breathing retraining for relaxation; exposure to real-world, trauma-related situations that are objectively safe but avoided due to trauma related distress (in vivo exposure); and exposure to the trauma memory through, repeated recounting of the traumatic event (imaginal exposure). SESSION 1 – Rationale for program Explain treatment procedures SESSION 2 – Introduction to In Vivo SESSION 3 Introduction to Imaginal Exposure SESSION 4-8 (or 4-11) Conduct imaginal exposure; focus on hot spots progressively Conduct in vivo exposure discussion/implementation FINAL SESSION (9 or 12)

Prolonged Exposure for PTSD in a Veterans Health Administration PTSD Clinic Journal of Traumatic Stress, Vol. 22, No. 1, February 2009, pp. 60–64 (C 2009) PDS=Posttraumatic Diagnostic Scale scoring 0 – 51 BDI-II =Beck Depression Inventory II scoring 0-63 minimal 0-13 mild moderate severe Pre-PDSPost-PDSPre-BDI-IIPost-BDI-II Target Trauma MMMM Vietnam OEF/OIF MST