Cognitive Behaviour Therapy (CBT) Gerhard Ohrband - ULIM University, Moldova 12th lecture Trauma therapy

Course Structure 1. Introduction: What is CBT? What are differences and similarities with other therapy schools? 2. Diagnostics in CBT 3. Classification of Psychological Disorders (ICD- 10, DSM-IV), Clinical Psychology (Etiology, prevalence, comorbidity and symptoms) 4. Etiological concepts in CBT: learning theories (classical and operant conditioning, vicarious learning, Mowrer’s Two-factor theory) 5. Systematic desensitization: in-vivo exposure and imaginatory 6. Aversion training: overt and covert

Course Structure 7. Response prevention: treating obsessive-compulsive disorder (OCD) 8. Social skills training: anger management, assertiveness training 9. Rational-emotive Therapy (RET) 10. Beck’s Cognitive Therapy for depression 11. Marital and Sex Therapy 12. Trauma Therapy: Expressive writing, work with affirmations, visualizations; working with victims of crimes, accidents and other difficult life-events 13. Relaxation techniques: yoga, meditation, Alexander technique, Feldenkrais 14. CBT at school: helping children with autism, hyperactivity, social phobia, social adjustment problems, learning difficulties and antisocial behaviour. 15. CBT in treating addiction and substance abuse

Content Post-traumatic stress disorder (PTSD) Trauma therapy In detail: Expressive writing (J. Pennebaker)

Post-traumatic stress disorder (PTSD) Relatively new anxiety disorder (first appearance in DSM- III in 1980) Anxiety that follows a traumatic event This event poses a threat to the individual’s life or lives of others Symptoms: Re-experiencing of feelings related to the event (such as intrusive memories, thoughts and images related to the event) Avoidant behaviour (such as denial and emotional numbing) Arousal (such as hypervigilance for trauma-related information) Also: sadness, guilt and anger (Shore et. al., 1989)

PTSD Appears seldom alone but with other disorders or additional diagnoses (Bleich et al., 1997) PTSD is a controversial inclusion in DSM-IV because its validity has been challenged Some researchers point to the ease with which PTSD symptoms can be faked

Study: Burges and Mc Millan, 2001 Participants of a night class were asked to generate symptoms of PTSD from a vignette The class also read a standard PTSD symptom checklist (or one containing bogus items) and were asked to complete the measure as if they were suffering from PTSD One percent of the sample self-generated PTSD symptoms that met DSM-IV criteria, despite 40 per cent claiming that they had witnessed a traumatic event When given the symptom checklist, however, 94 % met the criteria for PTSD Participants correctly identified around 38 % of the bogus items

Events and reference studies EventReference studies RapeGreen, 1994 Road traffic accidentsStallard et al., 1998; Murray et. al., 2002 Bank robberiesKamphuis and Emmelkamp, 1998 WarFontana and Rosenheck, 1993 Natural or human-made disaster Freedy et al., 1994

Prevalence Prevalence rate is around % in the general population Rape is associated with the greatest prevalence Onset of the disorder may be delayed by many years (Blank, 1993)

Study: Dunmoore et al., 1999 Determining the factors which are associated with the onset of PTSD and those who help maintain it They analysed data from 96 victims of physical or sexual assault Some factors were common to both onset and maintenance whereas others where specific to onset Factors associated with both: appraising the event and the consequences of the event (dwelling on the assault and its aftermath) Poor coping strategies (such as avoidance) Factors related to onset: Feeling detached during the assault Being unable to perceive positive responses from others These cognitive factors may prevent recovery by encouraging poor coping strategy or by generating a sense of immediate threat

Other findings Joseph et al., 1994: although crisis support was a good predictor of psychological well-being of survivors after the disaster, feelings of helplessness during the disaster, and bereavement, predicted the frequency of intrusive thoughts about the disaster Joseph et al., 1997: negative attitude towards expressing emotion (for example, agreeing with statements such as, ‘I think getting emotional is a sign of weakness’) were associated with an increased number of PTSD symptoms

Study: Clohessy and Ehlers, 1999 Asked 56 ambulance drivers in the UK to describe the most distressing aspects of their work and administered questionnaires which tapped their ability to cope with this distress and the degree to which the thoughts about the distress were intrusive 21 % of the sample met DSM-IV criteria for PTSD Predictors of the severity of the post-traumatic stress: Poor coping strategy Efforts to suppress intrusive thoughts Dwelling on previous distressing events

Post-traumatic stress disorder (PTSD) Horowitz’s model (1979, 1986): Trauma-related information is processed because of a mechanism called completion tendency. Completion tendency: need for new information to be integrated into existing patterns of thought and memory

Power and Dalgleish (1997) Stunned reaction to the traumatic event Experience of information overload as the individual realises the enormity of the trauma as it ‘sinks in’. Such information cannot be accommodated by existing mental schemata Defence mechanism such as denial and numbing are a means of coping with this lack of accommodation Completion tendency, however, insists on keeping the memory of the event alive through flashbacks and nightmares Anxiety results from the vacillation between these two processes: defence mechanisms and completion tendency

Questions Why do only some individuals develop PTSD? Why is PTSD delayed in some individuals?

A bio-psycho-social model of psychological disorders Biological factors Psychological factors Social Factors Increased vulnerability Non-adaptive behaviour Chronic psychological disorder Stressful life-events reinforcement

Treatment Debriefing (Deahl et al., 1994): effective Drug treatments (O’Brien and Nutt, 1998): mixed success Exposure (Foa and Meadows, 1997): effective Other techniques: Expressive writing (James Pennebaker) For an overview: Shalev et al., 1996; Foa and Meadows, 1997

What therapies treat PTSD symptoms by integrating cognitive, emotional and sensory/motor experience? Noted trauma authority and author Bessel van der Kolk has written, "... re-living trauma often occurs in the form of physical sensations that precipitate emotions of terror and helplessness. Learning how to manage and release these physical sensations from trauma-based emotions is an essential aspect of the effective treatment of PTSD.” There are now a number of schools of what has come to be known a somatic psychotherapy which utilize cognitive, emotional and sensory/motor experience to treat PTSD. These include:

EMDR therapy combines a somatic therapeutic approach with eye movements or other forms of rhythmical stimulation, such as hand taps or sounds that stimulate and integrate the left and right hemispheres of the brain. See Helpguide's EMDR Therapy: A Guide to Making An Informed Choice for more information and practitioner listings.

Somatic experiencing is a therapy developed by Peter Levine that incorporates observations of how animals treat themselves following traumatic events and focuses on restoring normality to the stress response. According to Levine, the symptoms of trauma result from highly activated incomplete biological response to threat. Wild animals have the ability to “shake off” this excess energy. By enabling humans to do the same, trauma can be healed. See Helpguide's Panic, Biology, and Reason: Giving the Body Its Due in the references & resources below for more information and practitioner listings.

Literature Clohessy, S. and Ehlers, A. (1999). PTSD symptoms, response to intrusive memories and coping in ambulance workers. Brithish Journal of Clinical Psychology, 38, Foa, E.B. and Meadows, E.A. (1997). Psychosocial treatments for post- traumatic stress disorder: A critical review. Annual Review of Psychology, 48, Horowitz, M.J. (1986). Stress Response Syndromes (2 nd edition). Northvale, NJ: Jason Aronson Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York: Free Press. Sarason, I. and Sarason, B. (1993). Abnormal Psychology: The problem of maladaptive behavior (7 th edition). Englewood Cliffs, NJ: Prentice Hall. Shalev, A.Y., Bonne, O. and Eth, S. (1996). Treatment of the post- traumatic stress disorder. Psychosomatic Medicine, 58,