1. ROBIN M. CARTER-VISSCHER, PH.D. LICENSED CLINICAL PSYCHOLOGIST SIOUX FALLS VA HCS NICHOLAS C. RINEHART, PH.D. LICENSED CLINICAL PSYCHOLOGIST SIOUX FALLS VET CENTER SDCMF SYMPOSIUM SEPTEMBER 10, 2014 Best Practices for Posttraumatic Stress Disorder

2. Welcome and Overview Recovery Oriented Approach Understanding PTSD Treatment Treatments that Work Other best practices Myths about treatment Resources

3. Recovery Oriented Approach Able to establish and maintain healthy habits Solve problems vs. just reacting to problems Able to tolerate painful feelings and memories Able to connect with safe people Be in the community without losing oneself Become more aware of physical signs of stress and anxiety

4. Therapy has come a long way in the past 50 years What we know about treatment now: Structured, time- limited, goal-directed therapy is the most effective method of treatment. Many people are used to long-term therapy that focuses more on discussing how the week went than on building skills. Unfortunately, that is effective to feel better for the moment but research indicates it does not lead to long- term change. We believe people with PTSD have the strength and commitment to reach their own goals once they learn the skills necessary to do so.

5. THERE IS HOPE FOR RECOVERY! Understanding PTSD Treatment Adapted from National Center for PTSD booklet| August 2013 U.S. Department of Veterans Affairs | www.ptsd.va.gov

6. What is PTSD? PTSD can occur after someone goes through or sees a traumatic event like:  Combat exposure  Child sexual or physical abuse  Terrorist attack  Sexual/physical assault  Serious accident  Natural disaster Disorder of impeded recovery  Most people have some stress-related reactions after a traumatic event.  If reactions don’t go away over time (1 year) and they disrupt your life, you may have PTSD.  PTSD symptoms that have not gotten better by 1 year do not get better without treatment www.ptsd.va.gov

7.  Reliving the event (also called reexperiencing): Memories of the trauma can come back at any time. You may have nightmares or flashbacks.  Avoiding situations that remind you of the event: You may try to avoid situations, people, memories or emotions that bring back memories of the event.  Negative changes in beliefs and feelings: The way you think about yourself and others changes because of the trauma. You may have trouble experiencing your emotions, think no one can be trusted, or feel guilt or shame.  Feeling keyed up (also called hyperarousal): You may be jittery and on the lookout for danger. You might suddenly become angry or irritable, have problems sleeping and concentrating, or engage in self-destructive behavior. PTSD has four types of symptoms: www.ptsd.va.gov

8. Treatments That Work Empirically Supported Treatments for PTSD  Medications with FDA indication for PTSD  Sertraline  Paroxetine  Psychotherapy (talk-therapy)  Cognitive-Behavioral Therapy  Exposure Therapy  Cognitive Therapy  Stress Inoculation training  Combinations of exposure therapy with SIT and/or CR  Eye Movement Desensitization and Reprocessing Therapy (EMDR) www.ptsd.va.gov

9. Evidence Based Psychotherapy Evidence Based Psychotherapies (EBPs) are therapy approaches that have evidence showing they are effective in treating a mental health condition.  Researchers around the world have examined them.  They have found better outcomes for people who get these treatments than for people who receive other treatments, or no treatment at all. EBPs can cause positive and meaningful changes in symptoms and quality of life for the people who use them. “Getting better” means different things for different people, and not everyone who gets one of these treatments will be “cured.”  But they will likely do better than people with PTSD who were not treated, or who received other kinds of treatment. www.ptsd.va.gov

10. The “I can take it from here,” approach to therapy. Goal: Teach the skills necessary to leave therapy and live life more fully. It’s not that you’re cured. It’s that you can say, “I can take it from here.”

11. Summary of EBP Findings Several forms of CBT are efficacious PE has received the most empirical evidence with a wide range of traumas Treatment gains generally maintained at follow-up (up to 1 year) Some patients show only a partial or no response Combined CBT treatments are not significantly more efficacious than individual treatments

12. 2008 Institute of Medicine Report “The committee finds that the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD” (chapter 4, p. 97) Reference: Institute of Medicine (IOM): 2008. Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academic Press.

13. Exposure Therapies for PTSD Prolonged Exposure Cognitive Processing Therapy EMDR

14. Prolonged Exposure Therapy (PE) Why it works: Repeated exposure to thoughts, feelings, and situations that you have been avoiding helps you learn that reminders of the trauma do not have to be avoided. In PE, you and your therapist will identify the situations you have been avoiding. You will repeatedly confront those situations until your distress decreases. Exposure therapy is like healing an infected wound: “It’s facing something that can be a little painful and hurtful at the beginning, but it’s a treatment that helps the person go at their own pace.” Dr. Matthew Yoder, VA Psychologist www.ptsd.va.gov

15. PE has four parts: 1) Education: to learn about your symptoms and how treatment can help 2) Breathing retraining: to help you relax and manage distress 3) Real world practice (in vivo exposure): to reduce your distress in safe situations you have been avoiding 4) Talking through the trauma (imaginal exposure): to get control of your thoughts and feelings about the trauma www.ptsd.va.gov

16. Program Structure 8 - 15 weekly therapy sessions 90 minute sessions Individual therapy format Daily practice assignments you do on your own between sessions. With time and practice, you learn to manage your reactions to stressful memories. www.ptsd.va.gov

17. Cognitive Processing Therapy Why it works: Trauma often causes people to struggle with memories and thoughts of the event. You may get “stuck” on these thoughts and feel unable to make sense of the trauma. Focus on developing skills to become your own therapist: CPT can give you skills to handle distressing thoughts. It helps you understand what you went through and how the trauma changed the way you look at the world, yourself, and others. In CPT, you will focus on examining and challenging thoughts about the trauma. By changing your thoughts, you can change the way you feel. www.ptsd.va.gov

18. CPT has four main parts: 1) Learning about your PTSD symptoms and how treatment can help 2) Becoming aware of your thoughts and feelings 3) Learning skills to challenge your thoughts and feelings (cognitive restructuring) 4) Understanding the common changes in beliefs that occur after going through trauma In addition to regular meetings with your therapist, you will get practice assignments to help you use your new skills outside of therapy. www.ptsd.va.gov

19. Program Structure Approximately 12 weekly therapy sessions 50 minute sessions Individual therapy format Topics covered in CPT include: The meaning of the traumatic event(s) Remembering the traumatic event(s) Identification of thoughts and feelings Trust Power & control Intimacy Safety Esteem www.ptsd.va.gov

20. Eye Movement Desensitization and Reprocessing Therapy (EMDR) Why it works: In EMDR, you focus on hand movements or tapping while you talk about the traumatic event. The idea is that the rapid eye movements make it easier for our brains to work through the traumatic memories. Focusing on hand movements or sounds while you talk about the traumatic event may help change how you react to memories of your trauma over time. You also learn skills to help you relax and handle emotional distress. Goal: To help somebody with PTSD sort the memory out. Over time, EMDR can change how someone with PTSD reacts to memories of their trauma. 4 – 12 sessions is common www.ptsd.va.gov

21. EMDR has four main parts: 1) Identification of a target memory, image, and belief about the trauma 2) Desensitization and reprocessing: focusing on mental images while doing eye movements that the therapist has taught you 3) Installing positive thoughts and images, once the negative images are no longer distressing 4) Body scan: focusing on tension or unusual sensations in the body, to identify additional issues you may need to address in later sessions www.ptsd.va.gov

22. Other Evidence Based Practices

23. Cognitive-Behavioral Conjoint Therapy for PTSD (CBCT) Treating PTSD through relationships CBCT for PTSD improves the interpersonal environment in which you exist on a day-to-day basis and capitalizes on the support of significant relationships while you endeavor PTSD treatment. In this way, CBCT for PTSD: 1) helps improve relationship issues we know so often co- occur with PTSD 2) capitalizes on the relationship to make each individual better. www.ptsd.va.gov

24. Program Structure 15 weekly therapy sessions 75 minute sessions Conjoint therapy format Practice assignments you do on your own between sessions to practice new behaviors. With time and practice, you and your significant other learn to manage PTSD symptoms and improve your relationships www.ptsd.va.gov

25. Acceptance and Commitment Therapy Experiential approach to behavior change: It’s a therapy about DOing! Differs from CBT because goal is NOT to change thoughts, rather thoughts are accepted as simply that…thoughts Thoughts are embraced  Passengers on the bus metaphore Assists in answering question:  Given what is important to me, what am I willing to do and experience in order to move me in that direction in this moment?

26. ACT Components Creative Hopelessness  Strategy of using control (current solutions) to reduce anxiety is hopeless…you are NOT hopeless Present moment and mindfulness  Noticing Cognitive Diffusion  Metaphores and exercises to help defuse from thoughts Self as context Conceptualized self Values  Build a more meaningful, full, and vital life based by living a value-based life

27. Seeking Safety Treatment for comorbid PTSD and Substance Use Disorder  Concurrent SUD and PTSD treatment has been found to decrease substance use rather than increase, as many have believed Present-focused, coping skills approach Stage 1 treatment for stabilization and safety first 4 content areas: cognitive, behavioral, interpersonal, and case management Incorporates education and commitments Can be conducted in a variety of ways  Group, individual, all skill modules, selected modules, open groups, closed groups

28. Seeking Safety Topics 25 topics such as  Safety  PTSD: Taking back your power  Red and Green Flags  Commitment  Compassion  When substances control you  Taking good care of yourself  Honesty  Coping with Triggers  Grounding  Creating meaning

29. Additional Practices Coping Skills before beginning EBP for PTSD  Emotional Regulation Symptom management  Substance Use Disorder treatment  Anger Management  CBT for Insomnia  CBT for Chronic Pain

30. Additional Practices Problem-focused, time-limited, goal-oriented individual therapy services Residential PTSD Programs Reintegration Skills for Returning Veterans Support Groups

31. Myths About Treatment Myth: Therapists just nod their heads and listen. Fact: EBPs are active treatments where the patient and therapist work together. Therapists are very engaged. Sessions are goal-oriented. Elements of treatment are skills-based. Myth: Therapy goes on for years and years. Fact: EBPs are time-limited treatments Myth: I can get better on my own. Fact: If you have had PTSD for a year or more, the chance of getting better without counseling or medication is quite small. Myth: If I have to talk about trauma, I’ll “lose it.” Fact: Therapy takes place in a safe, controlled environment, and you work with the therapist to go only as far as you feel safe. You learn coping skills to help you manage your anxiety. Myth: Only a therapist who’s been through what I’ve been through understands this well enough to help me. Fact: Providers with and without their own trauma histories can effectively deliver PTSD treatments. What’s important is that the provider has good training and experience, and can help you develop the skills you need to get better. www.ptsd.va.gov

32. Myth: My trauma happened a long time ago, so treatment won’t work. “One thing that I’ve heard from older Veterans that I’ve treated is, ‘I can’t believe how much time I’ve wasted; that I’ve been living with these symptoms for 35 years. Why didn’t I do this before?’ Thirty years ago, we didn’t know how to treat PTSD. Just like other areas of medicine, we’ve come a long way. So ask yourself, do you want to spend the rest of your years living with your symptoms? What might your life look like if you were free of them? Even if you’re an older person who’s had your symptoms for a long time, the therapy still works, and there’s hope for you to have a different life. The most important thing is just to address it. No matter how long it’s been, there’s good reason to think that you can get better.” Candice Monson, PhD Psychologist and Associate Professor Ryerson University “No matter how long it’s been, there’s good reason to think that you can get better.” www.ptsd.va.gov

33. Resources More About PTSD Treatment at www.ptsd.va.gov/public This guide was created by the National Center for PTSD, U.S. Department of Veterans Affairs. The Center conducts research and education on trauma and PTSD. Our website offers extensive information, educational materials, and multimedia presentations for a variety of audiences, including Veterans and their families, providers, and researchers. Website: www.ptsd.va.gov