1. Why is this treatment needed. 2. Basics and Principles. 3. Data of the first RCT. 4. Structure of the residential treatment

Transcription

1 Martin Bohus Central Institute of Mental Health Mannheim, Germany 1. Why is this treatment needed 2. Basics and Principles 3. Data of the first RCT 4. Structure of the residential treatment 5. Hierarchy of treatment targets 6. Interventions: 7. Trauma- associated emotions 8. Skills-assisted exposure 9. Regain your life! CSA Anxiety Disorders (OR 3.1) Depression (OR 2.7) Eating Disorders (OR 2.7) Substance Abuse (OR 3.4) PTBS (OR 2.4) Sleep Disorders (OR 16.1)) Suicide Attempts (OR 4.14) BPD (OR 3.4) Dissociative Features Low self esteem Somatic Disorders Spatiaro et al., 2010; Chen et al., 2010 Spatiaro et al., 2010; Chen et al., 2010 CSA BPD and PTSD Anxiety Disorders (OR 3.1) Depression (OR 2.7) Eating Disorders PTBS (OR 2.4) Sleep Disorders (OR 16.1) Dissociative Features Suicide Attempts (OR 4.14) (OR27) 2.7) Low self esteem Substance Abuse (OR 3.4) BPD (OR 3.4) Somatic Disorders Spatiaro Spatiaro et et al., al., 2010; Chen et al., ; Chen et al.,

2 Life-time prevalence: 3% Trull et al., 2010 Point Prevalence: 15 years: 6% (Haffner et al., 2007) 20 years: 4,2%; 45 years: 0,7%; male = female Suicide risc: 7% Costs (Germany): 4 Billions per year (15% of total costs for Psychiatry) Affect Regulation Identity-Disturbance t Social Interaction H BPD and PTSD Prevalence of PTSD in BPD samples: Inpatients: 56-58% Community sample: 33% Prevalence of BPD in PTSD samples: 35% 60% 24% 13% 17% 6% 39% 3% 6% 6% 34,3% 24% Emotional Neglegt (86%) Sexual Abuse (60%) Physical Abuse (39%) CAPS > 90 Physical Violence Between Parents (34,3%) Early Life Experiences Interpersonal Violence Emotional Neglect Self- Protection 2

3 Aversive Emotions Anxiety Appetent Emotions Security You have to stay in this family You have to keep attached to your family You have to love your father (mother) Fear Pain Threat Action Urges Short term: Survive Flight Fight Claim for help Freeze Long term: Protect Avoid Understand: Why did this happen? Improve How to manage this problem? It`s all up to YOU! Interpersonal Violence Emotional Neglegt Fear Threat Self-Protection How Whycan didi stay this happen in this family? to me? THIS IS NORMAL -IN OURFAMILY Shame I AM SOMEHOW WRONG I DID SOMETHING WRONG Social Affiliation Guilt I will be rejected or excluded by the others Stäbler et al.,

4 Individual values Individual values Social ranking Social ranking Social affiliation Social affiliation Self-Protection Self-Protection Immediate physiological needs Immediate physiological needs Kenrick et al., 2010; nach Maslow, 1949 Kenrick et al., 2010; nach Maslow, 1949 Memory Processing Social Affiliation Affect Regulation Established Psychosocial Treatments 5 Metaanalysis Taylor & Harvey 2010 PTSD-Symptoms (ES: 0.7) 6 RCTs focussing on PTSD after CSA Zlotnick et al., 1997 Cloitre et al., 2002 Chard et al., 2005 McDonagh et al., 2005 Resick et al., 2008 Cloitre et al., 2010 H Existing PTSD Treatments Often Exclude Severe BPD Clients Meta-analysis of PTSD RCTs found the following common exclusion criteria: (Bradley et al., 2005) Suicide risk (42%) Substance abuse/dependence (62%) Serious comorbidity (62%) Prolonged Exposure exclusion criteria: (Foa et al., 2007) Imminent threat of suicidal or homicidal behavior Serious self-injury (past 3 months) Current psychosis Current high risk of assault (e.g., domestic violence) Severe dissociation* Substance dependence* 4

5 Focusses on traumatic experience Not excluding Highly dissociative features Suicidality Self-harm Current Substance Abuse Eating Disorders Should work for CAPS > % Pe ercent % Treatment Year 35% 65% Treatment + Follow- Up Years Full Remission No Remission Average remission rate in PTSD treatments = 56% (Bradley et al., 2005) (Harned, Chapman, Dexter-Mazza, Murray, Comtois, & Linehan, JCC, 2009) Based on DBT: Structure, Rules, Targets, Skills Adds: Trauma Related Psychoeducation Trauma Related Cognitive Interventions Formal Exposure Protocols Body Therapy Includes: BPD patients with ongoing selfharm and severe dissociative features Trauma-associated Network Cue Primary Emotion Reality 5

6 Trauma-associated Network Cue Primary Emotion Reality Contact Helplessness Disgust Anxiety Anger Sexual arousal Humiliation Threat Confusion Feeling Special Pride Closeness Cue Primary Emotion These emotions can function as internal stimuli Trauma-associated Network Reality Contact Escape Mechanisms Escape Mechanisms Behavior Suicide Attempts Selfharm High Risk Drugs, Alcohol Vomiting Promiscuity Washing and Showering Cognitiv Strategies Suicide ideation Distraction Rumination Denial Minimizing 6

7 Escape Mechanisms Emotional Level: Secondary emotions: Anger Guilt Shame Self-Contempt Self-Hate Emotional escape: o Dissociation o Numbness o Depression Helping the client to identify, label and block the major escape strategies Helping the therapist to discriminate between primary and secondary emotions Helping therapists to deal with trauma related emotions like Guilt; shame; disgust; self-contempt; body related aversive emotions Aversive tension and dissociative features in BPD 1) Reexposure to aversive stimuli 2) Different context conditions 3) Different consequences 4) Emotional and physiological activation 5) Functional neural plasticity ve symptoms dissociativ BPD MD PD HC stress HLM: dependend variable = dissociative experience -group: BPD vs. CC vs. HC: F=26.18; df=2,138; p<.0001; -stress: F=264.64; df=1,3455; p<.0001; -stress group: F=35.78; df=2,3455; p< Ebner-Priemer, Bohus et al. J Psychiatr Res, ** ** 0,8 0,6 HC 0,4 BPD non diss BPD DISS 0,2 0 Aquisition Extinction Reinstatement Ebner-Priemer, Bohus et al., Journal of Psychiatry and Neuroscience, 2009 Conditioning (acquisition, CS+US): Negative Regression: correlation Dissociation correlates dissociation negative with and amygdala hippacampus activation activation (Mauchnik, Bohus et al., in 2011) percent signal change 0,6 0,5 0,4 0,3 0,2 0,1 0-0,1 HC BPD + Disso BPD - Disso neutral pic negative cross pic condition Krause-Utz, Bohus et al

8 Increase Attenuate! Helping the client to taper down acute arousal and to block dissociation during exposure Provide exposure under moderated d stress Use antidissociative skills: Strong sensory inputs during exposure Increase Trauma- Associated Primary Emotions Increase Reality and Context Awareness 3rd problem in chronic PTSD and BPD: Dysfunctional Behavior Severe self-harm Suicide-attempts How to define the inclusion criteria? How to provide safe conditions? Teach stress-tolerance skills Provide clear rules and contingency management 8

9 Mindfulness Stress-Toleranz Emotion-Regulation Interpersonal Competence Self - Esteem Stage I DBT SBDI No DBT DBT-PTSD Residential Program TAU Serious suicide attempt (high medical risk) within the last 2 months Severe aggressive behavior Life threatening out of control high risk behavior Ongoing sexual contacts to the perpetrator Most patients live with PTSD for decades The adapted to an environment which is either used to or reinforcing PTSD related behavior: Maladaptive partners (incl. sexuality) Maladaptive social networks Maladaptive working conditions Maladaptive health system usage Standard DBT How target dysfunctional reinforcers without blaming for intentionality?! 9

10 RCT Design Treatment Group Waiting List DBT-PTSD Follow Up t1 time of randomization t2 discharge / 3 months waiting t3 6 weeks FU / 4.5 months waiting t4 3 months FU / 6 months waiting Waiting Time t5 6 months FU N=64 (n = 32 in each group) 55 Participants (N=82) TG (N=36) WL (N=38) Age M (SD) (10.60) (9.84) Start of sexual abuse M (SD) 7.56 (4.09) 7.59 (4.10) Duration > 5 years M (SD) 48.4% 44.1% CAPS total score M (SD) (13.93) (18.31) Axis-I diagnosis acute M (SD) 303(103) 3.03 (1.03) 300(116) 3.00 (1.16) BPD criteria M (SD) 4.18 (1.66) 3.94 (2.07) 5 BPD criteria N=17 (47%) N=16 (44%) not in analyses: 8 patients WL: 1 non-starter, TG: 3 non-starter, 4 patients have been excluded within first days because of meeting exclusion criteria patients with missing data in LOCF-analyses: WL: 2 patients did not complete t2-t4 assessments, 2 patients did not complete t3-t4 assessment TG: 2 patients dropped out of treatment (2.5%); 2 patients did not complete t4 assessments 56 p= p= HLM analyses: < 5 BPD criteria: Group x time , p=0.038, Hedges g= 1.17 (Completer 1.34) 5 BPD criteria: Group x time , p<0.0001, Hedges g=1.50 (Completer 1.86) Neither the number of BPD criteria nor the severity of Response: reduction of at least 30 points in the CAPS score Remission: not meeting DSM-IV PTSD criteria any more RCT results: effect sizes (Cohen s d) ES t1-t3 WL TG 1,4 1,2 1 0,8 06 0,6 0,4 0,2 0-0,2 CAPS Total CAPS Index PDS BSL FDS SCL BDI Savety Issues 59 10

11 RCT results: Clinical reliable change Clinical rel. change & remission Safety issues: actual self-harm behavior (1) Safety issues: actual self-harm behavior (2) self harm behaviour during treatment pre week 1-3 week 4-6 week 7-9 week pre week 1-3 week 4-6 week 7-9 week urge for self-harm behaviour (2) Suizidal ideation (2) 5 4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 urge for self harm in subjects with self harm before treatment (2) week 1-3 week 4-6 week 7-9 week ,5 4 3,5 3 2,5 2 1,5 1 0,5 0 week 1-3 week 4-6 week 7-9 week Most patients show no change in their urge for self harm behavior, One patient shows a clear decrease. There is no change in suicidale ideation observable. 11

12 Suizidale ideation (1) 5 4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 week 1-3 week 4-6 week 7-9 week Most patients show no change in their suicidale ideation, one patient shows an increase Dialectical Behavioral Therapy Trauma focused cognitive & exposure based interventions Compassion Focussed Therapy ACT (Values) DBT-PTSD 12 weeks residential treatment program Focus chy Dynamic Hierarc Planning and Motivation 7 sessions) Rationale and Skills (4-7 sessions) Exposure (15 sessions) Regain your life (10 sessions) 12

13 Crisis generating behaviour Acute suicidality Life threatening self harm Severe high risk behaviour Severe alcohol or drug intoxication Severe aggressive outbursts Therapy intervening behaviour (maintainance of therapy) Team intervening behavior Inhibiting treatment success of other patients Hospitalization increasing behavior Non-cooperation Neglect of severe somatic diseases Therapy intervening behaviour (progress of therapy) Severe dissociative features Drug abuse (Hypnotics) Alcohol or Cannabis abuse No homework Avoidance of exposure Severe social problems First aim is the reduction of trauma consequences. Treatment allows patients to emotionally remember the trauma without loosing contact to reality. The key component is skills-assisted exposure. DBT-PTSD is treatment in a team. The team is responsible for treatment progress. Team can focus on treatment-interfering behaviour Team can pause or stop treatment. DBT-PTSD is a time limited intensive treatment. DBT-PTSD is a psychological surgery. High precision, security, cooperation and ability for critique is necessary for the team. The team works professionally,;can work under emotional stress, and knows about human bestiality. The patients strategies make sense within the individual context; today they maintain thedisorder. Therapist and supervision group create an environment, where functional strategies are reinforced, and dysfunctional strategies are having aversive consequences. Attention, care, and support is used in this perspective. The team members support each other in the handling of their emotional stress. Be aware reinforcing functional behavior Be aware not to reinforce dysfunctional behavior Major reinforcers: Attention and time of the team! Dialectical Dilemma: 13

14 Underestimate the need for support during emotional crisis Underestimate the problem of reinforcing crisis generating behavior The client belongs to the team The team is responsible for: Treatment structure Treatment progress Observing the rules Observing the limits Balancing the therapists Every rule is made up to discuss the exceptions! Dynamic rigidity DBT rules and principles hold for the team as for the clients Do DBT to the team: Basic assumptions Balance: observing limits vs. pushing engagement Duration of the treatment is fix! Do not prolongate the treatment in case of dysfunctional behavior, minimal treatment success, or emotional need! The only reason to prolongat is extraordinary strenous effort of the client! Always start with the treatment contract Agree to: Non-suicidal contract No communication of the trauma to other clients Observing the limits of other clients Working hard to achieve treatment goals Observing the priciples and rules of the unit Not every rule makes sense to everybody: practice willingness! How to handle suicidality? Differentiate (use diary card): Suicidal communication (diary card 1-3): Skills Suicide threats: (diary card 4): BA and Skills Imminent suicide risk: Transfer to EU Keep contact and help client to work on BA Client and therapist have to convince team that client knows how to handle this situation in the future 14

15 How to handle treatment interferring behavior? Use BA for functional analysis: consider all three potential problems: Client Team Rules Find solutions Lemonade out of lemons Skills Time-Out Basic-group Whenever dysfunctional behavior appears: Cave: Do not use BA as punishment Do not use too many BAs Time out during BA Peer group is revising BA Peer group presents BA to the Nurse Nurse decides whether BA has to be worked through during individual therapy Vulnerability Factors Trigger Reaction Behavior Consequences short term Cognitions Emotions Action ideas Consequences long term Solutions Repair Beginners Course Team Consultation (10 min per client) Individual Therapy ( 2 sessions per week) Skills Group (2 sessions per week) Body Therapy (1or 2 sessions per week) Primary Nurse (1 session per week Diary Card Review (daily) Basic Group (1 session per week) Peer Group (1 session per week) Art therapy (2 sessions per week) Regain your life (1 session per week) Physical Exercise Jiu-Jitsu General rules and principles Principles of Mindfulness Individual Values Principles of learning theory Skills introduction i Read the commitment rules Master of time Master of dialectics Present treatment plan after 3 weeks (20 min) Present discharge plan 3 weeks befor discharge (10 min) Monitor treatment progresss 15

16 Everey communication about a client is a communication with a client! Do not blame the client Do not use words like splitting ; manipulative manipulative or other peiorative items Communicate your own limits as your own limits Use your own emotional reaction to help the client to learn new behavior Targeting: Follow the matrix Use dialectical relationship-strategies Balance: Supporting the clients individual needs Supporting the structure of the unit Follow the clients individual tempo Keep the pace ot the manual Follow the clients individual tempo Keep the structure ot the manual Use your own reaction as a normative model Observe dysfunctional verbal or behavioural in-sessionpatterns and observe your emotional reactions: (e.g. patient looks hostile and falls into silence after reporting suicidal thoughts) Ask the client whether he wants feed-back May I give you short feed-back? Describe the behaviour observed and validate: Sorry, I am observing you falling into silence and looking quite angry, after telling me your suicidal thoughts- I am sure that you have good reasons for.. 16

17 Ask whether your reaction is intended by the client: is this your intention Usually the client denies- then ask for the real intention:..fine, so what is your intention Whatever the client answers- help him to process his intentions adequately: Oh, you feel helpless by yourself and you expect clear advices by me, how to cope with suicidal thoughts? That makes sense to me - so please try to formulate and speak out your expectations, since otherwise we might run into troubles Link functional behaviour to the individual goals of the client: and by the way it might be not entirely useless to learn how to ask for concrete help and advices- when I think of your wish to continue your fellowship program in May? Do not forget to shape functional behaviour! Oh, great, this time you directly ask for skills, I highly appreciate your effort to change your communication stile! Mindfulness Distress Tolerance Tension Warning signals Dissociation Emergency Bag Disstress - Skills Emotion Vulnerability Sleep; Exercise; Nutrition Emotion Regulation Shame Guilt Emotion Regulation Disgust Contamination Self-Hate Grief Radical Acceptance Self esteem Trauma Trauma Memory PTSD; Conditioning, Escape; Avoidance Dissociation; Discrimination; i i i Maladaptive Assumptions Exposure Therapy Decissions for the new way Exposure II Individual Behavior Experiements Sleep Revicitimization Regain yourlife Partners Sexuality Jobs Organize yourself Week end planning After-work activities Jumilage House keeping Improvement of the therapy (clients advisory board) 17

18 Mindfull Body Perception Observing limits and body posture Mirror Training Advocate of the client Works on mikro-targets: Goal of the week Utilizing skills Emotional support during exposure Cooperation within the peer group Daily hussles Review every evening Check A) suicidality B) treatment motivation C) skills D) emotional support Physical examination Individual exercise plan Individual sports plannings Start your exercise program! Jiu-Jitsu Decissin for the new way Nightmare rehearshal Cosemetics Regain your female attractiveness Diagnostics 2h Physical examination Psychopathology 30min History 30 min Treatment Rationale and Structure 30 min Therapy-Contract 30 min Skills-CD 15 min 4 weeks interval for working with CD 18

19 Interviews SKID I IPDE-BPD-Criteria SBDI Self-Ratings BSL-23 Dissoziation Emotionsregulation Verhaltensitems Davidson Trauma Scale PCL BDI II Social basics Financial Situation Partnership and family Education Former treatments Traumatic - Experience Obligatory Treatments Psychoeducation (G) Skills Training (G+I) Mindfulness Training (G) Cognitive Interventions (G+I) Formal Exposure (I) Facultative Treatments Discrimination Training (I) Nightmare Treatment (I) 12 weeks residential program (about 14 h individual intervention (I), 36 h group intervention (G)) 12 weeks residential program According to the general rules of DBT residential settings Step I Functional analysis of major avoidance and escape mechanisms Index Trauma Skills 3 weeks Step II Skills assisted exposure Discrimination training Daily self monitored exposure Body therapy Nightmare rehearshal 6 weeks Step III Regain your life 3 weeks I.a Education Short anamnesis, current major problems Current crisis generating behaviour (SBDI) Education about the treatment Therapy contract Scills- CD Life-Line BA last suicide attempt (f) BA last treatment drop (f) 19

20 + 100 Please list for every year the important positive and negative events and scale between -100 and 100. I.b Motivation Individual Values and Goals Obstacles Dysfunctional Habbits Reinforcers Monsters: Change or Accept Obstacles: Problem Solfing Service Areas: relinquish or move Values Goals Specific Measurable Attainable Relevant Time-bound Monsters are automatic thoughts, cognitions and assumptions, relevant in the older times, but hindering you to acheive your goals I am worthless I hate myself I do not deserve any acheivement I will be rejected I will be embarrasing Monsters: Change or Accept Obstacles: Problem Solfing Service Areas: relinquish or move Values Goals 20

21 Obstacles are deficits in skills, competence etc, which require new learning or problem solving Service Areas are things related to PTSD that make the old life pleasant or at least a bit better: E.g.: Considerations by your partner (no sex) Considerations by your friends Health care benefits Psychotherapists Release from your own demands Release from demands of others Monsters: Change or Accept Obstacles: Problem Solfing Service Areas: relinquish or move Values Goals Step II a) Rationale Sensory Experience Sensory Experience Images Voices Smell; Taste Body Experiences Trauma-Experience Avoid Images Voices Smell; Taste Body Experiences Trauma-Experience Escape: Thoughts About own behaviour About self About the world Trust, safety, etc Emotions Anxiety Powerlessness Disgust Shame Guilt Grief Anger Thoughts About own behaviour About self About the world Trust, safety, etc Emotions Anxiety Powerlessness Disgust Shame Guilt Grief Anger 21

22 On the long run, your brain does not learn, that your traumatic experience belongs to the past. DBT-PTSD helps you to learn, that the trauma, the related emotions, the related cognitions, and the related circumstances belong to the past. Overwhelming State AKZEPTANCE State Avoiding State From uncotrollable intrusions To contollable memory Trauma- Experience Trauma- Experience Work on the flip-chart What is currently the most distressing consequence of the trauma When your brain activates intrusions, what are you thinking about? What emotions show up? How do you handle these emotions? Homework: Consequences of the trauma reg. memory, emotions, behavior Define the traumatic event, which is currently associated with the most distressing emotions or the most dysfunctional avoidance and escape behaviour Techniques: Exploration Work-sheet: Intrusions- diary 22

23 If I speak out loud - It becomes true - It becomes part of my life If it becomes real, it will happen again I never will sustain these feelings I cannot stop crying - I will screw up - I will start self harming I do not want to get re-exposed to this anxiety At the first time, I was dissociated or numb. If I reexperience the trauma, I will be seriously hurt. Apprehensions : I would start to cry and will never be eager to stop it. I will become crazy. Columbo-Technique: How long exactly would you cry? Reality check: Do you know somebody, who is crying his life-long? Joker-question : Why didn't you become insane when it happened? Mostly cognitive: Columbo-Technique Risk assessments Joker- Questions I: Mindfulness II: Stress-Tolerance II: Anti-dissociative Skills Strong sensory activation IV: Trauma-specific emotions See other set of PPTs 23

24 During exposure: Sensory inputs Ice packs Balancing on board Chilly Ammoniac Trampling Distraction: Catch and throw Cognitive tasks Reality check Relationship contingency Daily life Monitoring aversive tension Early signs detection Sensory distracters Emotion regulation Problem solving Cognitions Physical Reactions Emotion Gesture Perception Action Tendecy 141 IB 7A 142 I did something immoral and I was responsible consequently social rejection is threatening Experience of uncontrollable threat guilt Extreme powerlessness Development of pseudocausal explanations Keep social integration Do penance for guilt Self-complaints, Submissive behavior 24

25 Guilt Shame How to survive and emotionally belong to a family that is torturing you? You The How ih only to have survive reason todfind that and this Behave either You deserved adequately did something this emotionally awful reasonable belong happens explanations to a isfamily that otherwiles: or you since are awful is torturing YOU you? You have to find reasonable explanations social rejection! The only reason that this happens is YOU The only reason that this happens is YOU You either did something awful or you are awful You deserved this since Guilt Shame You either did something awful or you are awful Behave adequately otherwiles: social rejection! Rephrase: responsibility Work with graph Be precise Discuss potential alternatives Questions: Are there other explanations? Would other people interpret this the same? How did you interpret the situation at that time? Why exactly did you behave the way you behaved? How exactly did you persuade your father to have sex with you? What exactly did you do to seduce him? How exactly did you ask him to hurt you? Would all fathers in the world react the same? 80%me 20%perpetrat or What tells emotions? What tells ratio? How would you rate somebody else? 25

26 Bru Change from cognitive interventions to Emotional interventions (expo to former helplessness) Shame often goes with guilt (tertiary shame) Shame often goes with disgust (tertiary shame) Normalizing (Education) Stories of other clients Internet Interviews Videos Street-interviews Change of body posture (act opposite) Exposition and strengthen of relationship (hand contacts!) I am worse than I should be - I will loose social attraction Shame is destroing social relations The nicer the therapist the worse? SHAME Hide your impairments Avoid attention Reject yourself Awareness of mental and physical pollution Disgust towards the own body and self Disgust towards food; liquidness and others Typical behavior Restrictive nutrition Vomiting after meal Brushing, washing, showering rituals Cleaning of genitals and mouth with detergents Avoidance of body contact and view Discrimination training Internet research reg. reproducion frequency of skin Imagination 26

27 Severe disgust and behaviour which patients use to reduce it Examples: Very selective intake of food or fluids Brushing one s skin to clean it, frequent washing of the skin Induced vomitting after a meal Drinking detergants / vinegar to clean oneself Interventions: Mindful perception of the present situation Focus on the question: Which elements of the present situation differ from the traumatic situation? Use of all the senses: smells, tactile perception, p vision, sounds etc. Detailed description of the differences between now and then Reduction of aversions regarding particular food or drinks reduces emotional vulnerability by improving the patient s diet. Checklist ready for exposure Does the patient apapropriately know and use skills? Have the patient s fears regarding exposure been assessed and decreased? Have the patient s avoidance and escape strategies been assessed and changed appropriately? dissociation Self mutilation shame guilt self contempt Support during exposure phase has been organized? Taking work leave, who will care for children, inviting a trusted friend. Where can the patient stay after the first exposure sessions, how will she reinforce herself for doing exposure. Has the patient agreed and made a formal decision to use exposure in the treatment? Obligatory Diary Card: weekly Davidson Trauma Scale BSL-23 Facultative weight Urine Analysis 27

28 Skills assisted Exposure Stepwise approach: 1) Trauma-Report 2) Writing; Reading alone; Reading to therapist 3) in sensu-acitvation 4) In-vivo-Exposition (facultative) Please collect: Group - Task 1) Strategies to enhance the Trauma-Network 2) Strategies to enhance reality context Skills assisted Exposure: Activating the Trauma Network Ask the patient to Close her eyes Describe what happens in present tense and in first person singular ( I ) describe all features of the trauma network: What do you see, hear, feel, smell? Use external sensory stimuli which remind of trauma (Vodka, beer, after shave, sweat smell, sounds ; being naked) Get into a trauma-associated body posture Repeat particular sentences / words Block escape strategies (such as dissociation) Describe the trauma in the language she used with the perpetrator Slow motion of hot spot 28

29 Skills assisted Exposure: Activating Contact to Reality Ask the patient to use Sensory stimuli which remind of the present situation: eyes open; therapist's voice, therapist's hands, therapeutic oinks, therapist repeats every word, praise etc.; ice pack, strong smells, etc.) Body posture opposite to that during the trauma (act opposite) Exercise: stamping, balance board, stair running, jogging, riding a bicycle) Cognitive processes which remind of the present tense: This is a memory, language different to that during trauma; ratings of current distress / tendency to dissociate etc; What to you know today?. Moderated Exposure Activation of Trauma-Network Close your eyes Speak as I and in present tense Delineate sensory components Expose to sensory components Aromas; sounds; etc Verbalize emotions and cognitions Mimic the body posture of the trauma Change to native language Repeat sentences Slow motion of hot spot Skills Assisted Exposure Imaginal reliving of index trauma in detail, whilst not fighting any of the associated emotions / cognitions / body sensations Patient is in control of the situation, can say STOP, Homework: Initially: written account ot the index trauma then: 1) listen to tape of session once a day 2) use imaginal reliving once a day Acceptance of the past Induction of grief Go back to the SMART goals Monsters: Change or Accept Obstacles: Problem Solfing Service Areas: relinquish or move Values Goals 29

30 Be clear, that most of these automatic thoughts will pop um uncontrollable. Take them with you Work on your goals anyways! Work on radical acceptance Be clear that the trauma is still part of your memory system The more similar the triggers, the more likely are intrusions Learn to discriminate normal anger, fear, disgust, guilt etc. from PTSD related emotions Learn to discriminate between normal trauma-related memories and PTSD THANK YOU! 30