Clare Crole-Rees Neil Kitchiner Veterans NHS Wales. Cognitive Behavioural Conjoint Therapy for PTSD UKPTS Cardiff Dec

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1 Clare Crole-Rees Neil Kitchiner Veterans NHS Wales Cognitive Behavioural Conjoint Therapy for PTSD UKPTS Cardiff Dec

2 VNHSW Clinics/Staff

3 Flying in the Experts

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5 Dr Candice Monson "It was a delight to visit Cardiff to provide a workshop in CPT. The follow-on telephone supervision was an especially enriching experience, as I got to hear about the delivery of CPT by a group of well-seasoned clinicians"

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7 Add Nail YouTube <iframe width="560" height="315" src=" 4EDhdAHrOg" frameborder="0" allowfullscreen></iframe> 4EDhdAHrOg

8 What is CBCT? Cognitive Behavioural Conjoint Therapy for PTSD is a time-limited, manualised, disorderspecific conjoint therapy with the simultaneous goals of improving PTSD and enhancing intimate relationship functioning (Monson and Fredman, 2012)

9 Structure of CBCT sessions Fifteen weekly 75 minute structured sessions Phase 1 of CBCT focuses on establishing the rationale for the therapy and establishing safety within the relationship Phase 2 the generalisation of avoidance beyond specific trauma memories and reminders to avoidance of emotions and other internal states (ie, experiential avoidance), and its role in maintaining both PTSD and relationship problems, are taught Phase 3 of therapy capitalises on the couple's improved communication skills and their developing propensity to approach rather than avoid by examining beliefs that they may each hold that contribute to PTSD symptoms and relationship problems

10 Biopsychosocial Factors Related to Trauma Recovery Genetic/Biological Litigious/fault-finding dyadic adjustment ethnicity Intrapsychic Interpersonal appraisals hippocampus social support serotonin 5-HTTLPR experiential avoidance intimacy Sociocultural views on rape/incest stability of marriage/family Monson, Fredman & Dekel (2010)

11 Why have a couple therapy? There is a growing recognition of the interpersonal nature and consequences of trauma, and the potential power of intimate relationships to ameliorate it Usually involves the intimate partner of the client, but can involve another loved one such as a close family member

12 CBCT is a cognitive processing therapy (CPT) for trauma It does not involve imaginal exposure to the trauma Change occurs through processing the memory by properly contextualising the event and correcting misappraisals, as well as in vivo exposure exercises to create new learning about current situations, triggers and feelings

13 Interpersonal factors in PTSD All traumatic experiences occur in an interpersonal context There is a strong association between social support and PTSD symptoms, possibly more so than any other variable (Ozer et al., 2003, Brewin et al., (2000) This appears to be bi-directional (Kaniasty and Norris, 2008)

14 Role of family functioning Conventional clinical wisdom holds that individual PTSD treatment results in cascading improvements in interpersonal functioning Monson et al., (2006) individual CPT did not reveal significant improvements in many areas of psychosocial functioning, including partner relationships However, relationship functioning affects treatment outcomes of trauma-focussed therapy (Monson et al., 2005)

15 Benefits for treatment engagement Many clients seek help for PTSD because of the resultant psychosocial problems, such as relationship problems, struggles in interaction with their children, and employment difficulties Clinical levels of marital distress were 3.8 times more likely amongst couples with a partner diagnosed with PTSD (Whisman et al., 2000)

16 Soldiers with the most satisfied intimate relationships are most likely to engage in mental health treatment (Meis et al., 2010) Batten et al., (2009) 80% of veterans in the U.S. Department of Veterans Affairs wanted their family members to be more involved in treatment 66% of veterans wanted help to improve their communication skills with family members

17 Benefits for therapy retention Drop out rate for individual evidence-based therapies for PTSD is greater than 25% (Hembree et al., 2003) Drop out rate for CBCT in Monson et al s trials are 15%

18 Significant others play a critical role in Engagement of the traumatised individual in therapy Maintaining their commitment to treatment Promoting their recovery

19 CBCT for PTSD - Published Studies 6 published case studies OIF veteran (Monson et al, 2008) OIF veteran (Fredman, et al. 2011) Shared trauma (Brown-Bowers, et al. 2012) US active duty couple (Blount et al., 2015) Addition of mindfulness (Luedtke et al., 2015) US active duty same sex couple (Blount et al., 2016) 4 uncontrolled studies Male Vietnam veterans and their wives (Monson et al., 2004) Mixed (Monson et al., 2011) Male OIF/OEF veterans and their wives (Schumm et al., 2013) Mixed trauma; present-focused version (Pukay-Martin et al., 2015) 1 controlled study Mixed (Monson et al., 2012)

20 Future Directions Finish PE v. CBCT for PTSD trial 3 Recently-funded Trials: CBCT for PTSD + Parent Management Training Weekend Retreat Delivery Non-inferiority Trial of Home (via video technology) vs. Office Delivery vs. Family Education MDMA-Facilitated CBCT for PTSD Multi-site Patient Preference Trial PE CPT CBCT for PTSD Online delivery

21 How does it work? Manualised treatment 15 sessions Homework each session Consists of a set of behavioural and cognitive interventions to reduce avoidance and numbing and to consider new ways of seeing the event, themselves and others

22 CBCT Sessions overview

23 Cognitive-Behavioural Interpersonal Theory of PTSD Interacting systems: Traumatic stress-related problems result from behavioural, cognitive and emotional factors that interact within each individual and between members of a couple These factors impede natural recovery from a traumatic event

24 Assumptions of CBCT 1) The nature of the problem is the way that the couple relates around the post-trauma sequelae, and the target of intervention is the interaction within the couple 2) PTSD and relationship problems are reciprocally related and therefore addressed concurrently

25 Exclusions When one or more partners do not express a willingness to commit to therapy with the intention of seeing whether the relationship can be improved Ongoing infidelity Severe relationship aggression

26 Assessment Gold standard: 3 assessment meetings as a couple and also meet each individually As a minimum, it is very important to meet the partner individually before starting treatment so that their point of view is validated and they do not feel like an outsider in the therapy Intimate partners of individuals with PTSD will often present with their own mental health problems, particularly depression

27 Assessment cont d Careful assessment of the traumatic event and PTSD symptoms In particular, events associated with high levels of guilt and shame and moral injury and the client s beliefs about their partner s rejection on disclosure These are the most difficult traumatic events to work on in CBCT, but can be the most beneficial A strength of CBCT is that an explicit account of the trauma is not necessary

28 Aggression Research indicates that 50% of presenting civilian couples with PTSD report a history of physical aggression in their relationship in the past year (O Leary and Williams 2006) Up to 63% Veterans report physical aggression in the last year (Byrne and Riggs, 1996) Particular link to hyperarousal symptoms Assess level of severity, and whether both partners are able to commit to immediate cessation of aggression

29 Communication sample As part of the assessment process, it is helpful to have an example of their communication behaviours mins Look for their communication strengths (sharing emotions? Naturally paraphrasing or clarifying?) Look for concerns to address (hostility, disgust, contempt, avoidance)

30 Video First session

31 Paired Discussion What would you do in this situation? Are they suitable for CBC therapy? What are the contra-indications?

32 Self-report measures PTSD: PCL-5 Relationship Adjustment: Dyadic Adjustment Scale Depression Alcohol

33 Adaptations Both partners have PTSD Non-intimate dyads Parts 1 and 2 delivered as a stabilisation intervention before the client undergoes individual trauma-focussed therapy Individual Delivery client attends alone, practices skills with therapist

34 Conceptualisation of Interacting Systems

35 Behavioural mechanisms Behaviours in Partner A: Poor communication, aggression, avoidance Behaviours in Partner B: accommodation ( caretaking ), distancing, assisting with safety behaviours These behaviours maintain PTSD and reduce intimacy

36 Cognitive mechanisms Client: Maladaptive appraisals about the traumatic event and overgeneralised maladaptive post-traumatic appraisals which prevent processing of the memory Processing disturbances such as selective attention to threat Partner: Maladaptive appraisals about the event, and maladaptive appraisals of their partner s symptoms Negative appraisals of themselves in relation to their partner

37 Emotional mechanisms Client: Range of emotions fear, horror, anger, guilt, shame, sadness Partner: guilt, anxiety, anger, sadness Process disturbances such as alexithymia, labelling difficulties, dissociation Leads to reduction in emotional and physical intimacy and positive communication, increase in negative communication, conflict and aggression

38 Conceptualisation - Simon PTSD from serving in Bosnia, Iraq and Afghanistan. He experiences nightmares and flashbacks which he attempts to control through drinking. He is often extremely angry, reacts to small things, and as a result, avoids his wife and children as he feels so guilty about snapping at them. He feels that he is weak and crazy for his symptoms, and feels guilty for letting his mates down as he isn t able to cope. He said that he feels numb and detached, and has lost pleasure in life. He avoids going out to unfamiliar or crowded places and as such is not able to go out on family outings to the swimming pool or park when it is busy. He experiences high levels of guilt for events that he has witnessed and experienced and believes that if Liz knew about these, she would be disgusted with him.

39 Conceptualisation - Liz Liz feels guilty and anxious about Simon s symptoms. She is worried about their relationship and the children, and avoids Simon when he is having a bad day. She tries to avoid talking to Simon about his symptoms or his experiences as she knows this upsets him and she is worried about making his PTSD worse. She takes responsibility for the children in and outside the house as Simon feels so anxious about this. She worries that his symptoms might be her fault. She feels rejected and angry sometimes, but feels guilty for feeling angry. She believes that the only thing that could be so bad that he won t talk about it is that he has raped a local girl when on deployment.

40 Out of session assignments Trauma Impact Questionnaires: Designed to help the couple and therapist better understand how they have each made meaning of events and how they perceive themselves and their relationship Elicits appraisals across domains of blame/responsibility, safety, trust, control and intimacy (STUCK POINTS)

41 Role of Appraisals These appraisals form basis of cognitive interventions and also give a context for understanding behavioural changes The responses to the TIQ can be used to formulate the ways in which PTSD has impacted on and is maintained in their relationship The differences in their appraisals can be explored to highlight fact that they both of their own, differing points of view and ways of seeing the world

42 Video Trauma impact questionnaire (TIQ)

43 Trauma impact questionnaire - 1) How has the trauma affected our relationship to date? Liz He is like a different person. I could tell that he wasn t himself. He just himself off from me and the kids. I could tell that he was somewhere else most of the time. His sleeping is terrible and he is in the spare room now. We are not so close. He never wants to talk to me and I feel that it must be my fault. We never do anything as a couple anymore. John - It is spoiling our relationship. I don t like who I have become. I am angry all of the time. I fly off the handle at tiny things. I still love Liz and the kids but I can t feel it any more. I feel so guilty at who I have become. Sometimes I don t think that I can do this anymore.

44 TIQ Trust Liz I am constantly walking on eggshells and I m scared that I will say the wrong thing. I don t trust my own reactions any more. John Now I know what people are capable of know that I can t trust anyone and it is best to keep a distance I cannot even trust my own head.

45 TIQ - Closeness Liz I still love him but we aren t close anymore. We barely talk together and when we do we argue. We never touch each other anymore, let alone have sex. John We feel like strangers in the same house. When I am in bed my mind starts racing and I get horrible thoughts and cuddling is the last thing that I think about.

46 Conceptualisation of Rebecca and Simon in Pairs What might be the main therapy targets Eg: what beliefs might need addressing? What might be the main avoidance behaviours?

47 Session 1 Psychoeducation about the interpersonal context of PTSD and discussion about how each of the symptom clusters plays out in their relationship Particular focus on the role of avoidance and emotional numbing on maintenance of PTSD and on relationship functioning

48 Goal setting Goal setting SMART goals for improving PTSD and relationship

49 You ve been caught doing something nice Goal is to increase the positive interaction within the relationship Changing focus of attention from negative behaviours Helps to improve emotional intimacy and reexperience pleasurable feelings

50 You ve been caught doing something nice

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52 You ve been caught doing something nice Person caught: Liz Person caught: John Sunday Gave me a lie in Encouraged me to watch the football while she did the kids homework Monday Picked me up from work Ran me a bath Tuesday Wednesday Didn t shout even though I could tell you were cross. Let me go to the pub with Gary Made me lunch Got me a kit kat specially. Thursday Asked how my day was Fixed my straighteners Friday Cooked me dinner Made me a cup of tea Saturday Took my mum out Watched Love Island with me

53 Session 2 Safety Building Goal to increase emotional and physical safety within the relationship and to decrease negative, hostile and critical behaviours as quickly as possible Self-awareness - links are made to hyperarousal symptoms and fight reaction and also to avoidance behaviours flight

54 Individual strategies Slowed breathing retraining Progressive muscle relaxation

55 Dyadic Strategy Time out S = Self-care, early intervention technique (not a form of avoidance or punishment) T = Time-out, mutually agreed process for calling time out, time/circumstances for resuming communication, option for multiple check-ins O = Outlet client uses the time to soothe themselves P = Process resume process of communication

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60 Session 3 Listening and approaching Focuses on overcoming avoidance and enhancing relationship through improved communication Highlights that fear is generalised to include the experience of emotions as well as the traumatic memories, and that avoidance of (memories, emotions, reminders, intimacy) maintains PTSD symptoms and relationship problems

61 Improving communication is best method for improving relationship satisfaction Sharing of negative feelings just as helpful as sharing of positive feelings ( glue that holds a relationship together ) apart from hostility Behavioural and experiential avoidance impairs communication

62 Effective listening skills Introduce basic listening skills through coaching and in-session practice of paraphrasing Paraphrasing ensures that the couple have listened correctly and slows down communication Avoids escalation of conflict

63 Sharing feelings

64 PTSD and Avoidance Use the listening skills to discuss the situations and places that the couple are avoiding, together and individually Develop an avoidance list then open up a discussion about ways in which Approach behaviours will help PTSD and relationship problems

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66 Example of an Avoidance list Paired Discussion: From what you know about this couple so far, what might they be avoiding?

67 Example of an Avoidance list Places public places such as parks, shopping centres, supermarkets, restaurants, cinemas, public transport, taxis People strangers, particularly FAMs, people in Islamic dress. Also acquintances who might make small talk Situations being intimate with his wife, social occasions where he might have to make small talk, being alone with his kids for fear of snapping at them Feelings anxiety, anger, guilt, shame, arousal, pleasure.

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69 Shrinking PTSD through Approach Avoidance List is used as focus of Approach activities Graded exposure hierarchy It is important that these double as shared rewarding activities Vary stimuli and apply approach behaviours across multiple contexts Uses the PROUD acronym

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71 Session 4: Sharing Thoughts and Feelings Introducing concept of communication channels Distinction between problem solving/decision making channel and the sharing channel Goal is to be able to identify and stay on your partner s channel

72 Introduction to Sharing channel Emotional numbing, avoidance and hyperarousal lead to difficulties in identifying and expressing positive and negative emotions and prevent intimacy This session increases attention to the experience, expression and reflection of feelings

73 In-session practice Sharing of feelings Goal is for the couple to develop their reflecting and emotion identification skills, using listening skills from last session Discuss the kinds of feelings that PTSD makes them have, as well as how they feel when they imagine shrinking PTSD in their relationship Practice catching their partner s feelings for homework

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76 Channel checking

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78 Session 5 Sharing thoughts Introduces the idea that feelings and behaviours are responses to thoughts and that there are multiple perspectives Highlights PTSD threat cognitions Highlights the ways in which communication difficulties lead to misinterpretations which maintain PTSD and relationship distress

79 In-session practice The couple uses their communication skills to discuss the kinds of thoughts and related feelings that PTSD makes them have and what they think and feel when they imagine shrinking PTSD in their relationship Homework: Catching your Partner s Thoughts and Feelings

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83 Session 6: Getting U.N.S.T.U.C.K. UNSTUCK is a method of conducting cognitive interventions within the conjoint frame It s purpose is to provide a set of steps which the couple can use together to challenge the ways in which they make sense of daily events, and in appraising traumatic events and reactions to symptoms

84 Advantages of UNSTUCK Emphasises cognitive flexibility rather than thought modification Simple decreases reliance on worksheets and does not require knowledge of thinking errors Is designed to facilitate learning through visual and verbal media

85 UNSTUCK Procedure U = United as a team (collaborative and open-minded). N = Notice & S = Share thoughts - Brainstorm a range of different thoughts using Big Picture Thinking handout T = Test them out to identify the most balanced and realistic U = Use the most balanced and realistic C = Change in feelings and actions? K = Keep practicing the process of testing out new balanced thoughts

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88 Gnome on the shoulder PTSD can be thought of as a little gnome on the shoulder of you client, feeling unhelpful and unrealistic thoughts The couples can work as a team to talk back to the PTSD with the alternative thoughts they have generated together Practiced for homework on trauma-related thoughts such as on approach tasks and relationship-related thoughts

89 Group Exercise In couples, develop a Big Picture worksheet for the stuck point: If Rebecca hears about what I have experienced in Afghanistan then she will reject me!

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92 Session 7: Problem solving to shrink PTSD Focuses on the problem-solving channel Teaches them to shrink the role of PTSD in their relationship by improving communication and decreasing behavioural avoidance

93 Principles of Problem solving Use listening and paraphrasing skills to pinpoint clearly the problem or decision to be made Use sharing thoughts and feelings to clarify why the issue is important and what your needs are Brainstorm possible solutions or decisions Decide on a solution that is agreeable to both of you Decide on a trial period to implement the solution

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95 Phase 3: Making Meaning of the trauma Therapist needs to clarify that you are in agreement with the couple about the index event/s (usually the most distressing) Have upfront discussion about the disclosure of traumatic material and the expectations surrounding this Not exposure per se although some trauma details necessary to put into their proper context

96 Focus is on the emotions surrounding their memories and the meaning of the those events for the here and now, rather than an explicit retelling ( 10,000 foot view) Discuss the fears that your client and their partner have about working on the traumatic material

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98 Session 8: Acceptance Goal is to promote acceptance of the traumatic events, by helping the couple more to a fully contextualised, elaborated and bigpicture view Accepting the reality of the event the way it happened and that there is nothing that you can now do to change it

99 Barriers to Acceptance Just-world thinking (in reality, good behaviours don t always get rewarded and bad behavior doesn t get punished) Situational neglect not considering the context and situational demands that influences our behaviour (we have a tendency to overestimate our personal agency in situations)

100 Barriers to Acceptance cont d Hindsight bias assuming that you had the knowledge then that you have now Undoing Playing out the event with alternative course of action ( If only I.., I should have ) Happily ever after thinking if we had taken an alternative course of action, then there would have been a positive outcome (in reality another course of action could lead to equally bad or worse outcomes)

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102 Stuck Point Log Using the Trauma Impact Questionnaire (TIQ), generate a list of Stuck Points (problematic thoughts) that may have been maintaining Simon s PTSD and the couple s relationship difficulties These stuck points can be about the trauma itself, or about how they see themselves, others and the world since the trauma

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104 From stuck point log, identify a stuck point that may be preventing acceptance and use the UNSTUCK process Examples are often around blame of self or others To begin with, therapist has an active part in the process, coaching the couple and planting questions to facilitate socratic dialogue between the couple As therapy progresses, therapist withdraws from the process

105 Stuck Point Log Stuck Point It was my fault that the boy died Balanced Thought I did the very best that I could in very difficult circumstances. I had to make a call in a very short space of time and I had no way of knowing what would happen. If I had made another decision there may have been even more casualties. I would like things to have worked out differently but it was not my fault. I have let my mates down by having PTSD they all did their job with no problem and aren t bothered by it anymore. I have found out that this isn t the case. Jonesy and Mitch have both been diagnosed with PTSD. Most of the others have been drinking heavily which I now know can be a way to cope. I now know that lots of soldiers develop problems and that this is a normal reaction to what I have seen. It takes a lot of guts to seek help that has been much harder than bottling it up ever was.

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107 Unstuck process

108 Remaining sessions Subsequent sessions take the same format Elicit stuck points related to different cognitive themes: Blame, Trust, Control, Emotional and Physical Closeness and Post-traumatic growth Carry out UNSTUCK process to contextualise and evaluate these beliefs Encourage them to continue this process between sessions

109 Session 9: Blame Inappropriately placed blame is a barrier to recovery It is human nature to want to ascribe fault when something bad happens (this is a form of just world thinking and undoing the event ) Helpful to talk about responsibility as multifaceted dependent on knowledge and intentionality to do harm as well as situational factors at the time

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113 Session 10, 11 & 12 These sessions use UNSTUCK process to address three belief areas of: Trust, control and emotional and physical closeness If the client has previously held positive beliefs in these areas they are disrupted by traumatic events If the client has previous negative beliefs then these are reinforced by the trauma

114 These themes can be seen as here and now consequences of inaccurate appraisals of the traumatic event These sessions are focused on reappraisal of the traumatic event to the extent that there are remaining uncontextualised appraisals

115 Trust Identify beliefs relating to trust of themselves and also others Explore the ways in which trust is multidimensional (many types of trust) and on a continuum

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119 Control Trauma impacts on a person s sense of ability to exert control or influence over oneself or others One of most distressing parts of trauma is that they have little control over the event This can lead to a belief that sharing control with another may lead to revictimisation, and that they must retain control over everything and everyone to prevent future bad things happening (over control)

120 Control Or the trauma may have reinforced a belief that they have no control and therefore future traumatisation is inevitable (undercontrol) Resolution often leads to a realisation that control is multidimensional and that it is on a continuum balanced thinking

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127 Final session and review

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130 Final Thoughts With a partner, discuss what you have learnt from the workshop Might you use this therapy in your practice?

131 Thanks for listening! Clare Crole-Rees e: Neil Kitchiner e:

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