Trauma Focussed Cognitive therapy for PTSD linked to terrorist violence and civil conflict - lessons from Northern Ireland

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Trauma Focussed Cognitive therapy for PTSD linked to terrorist violence and civil conflict - lessons from Northern Ireland Michael Duffy PhD FBABCP Director of Specialist MSc Cognitive Behavioural

1 Trauma Focussed Cognitive therapy for PTSD linked to terrorist violence and civil conflict - lessons from Northern Ireland Michael Duffy PhD FBABCP Director of Specialist MSc Cognitive Behavioural Psychotherapy (Trauma) Co-ordinator Queen s Trauma Research Network Research Fellow, Centre for Evidence & Social Innovation Assoc. Research Fellow, The George J. Mitchell Institute for Global Peace, Security and Justice 1

2 A Cognitive Model of PTSD (Ehlers & Clark, Behaviour Research and Therapy, 2000) People with PTSD perceive a serious current threat, due to: (1) Characteristics of the trauma memory (2) added meanings, excessively negative appraisals (3) People with PTSD use strategies to control threat that maintain the memory problems and added meanings 2

3 Our first published clinical study relates to PTSD arising from the Omagh bomb 1998 Omagh bombing scene after the explosion

4 Since Omagh bombing - our work has dealt with other traumas in Northern Ireland and beyond

5 Training in PTSD and Complex Grief - Norwegian flags and flowers in Sundvollen, close to Utøya island, where Anders Behring Breivik killed 69 people, near Oslo, Norway

6 Manchester Arena bombing

7 Omagh bomb Scene just before the explosion

8 Scenes immediately after the bombing 8

9 Scenes immediately after the bombing 9

10 Omagh centre after bomb 10

11 The Omagh Car Bombing 1998 clinical trial, Studies of predictors : children study; adolescent study; adult study Car bomb explodes killing 29 people and two unborn babies; 15 of the deceased were aged 17 years or under. 400 injured, many seriously; 135 hospitalised; 7 hospitals involved; Many children and young people sustained physical injuries - loss of limbs, loss of soft tissue, scarring and disfigurement Largest single incident associated with the NI Troubles. Largest airlift of civilian casualties in peace time

12 A COGNITIVE MODEL OF PTSD (Ehlers & Clark 2000) 12

13 The Puzzle COGNITIVE MODEL OF PERSISTENT PTSD (Ehlers & Clark, 2000, Behav. Res. Ther.) Anxiety is about future threat. PTSD is to do with memory for a past event. Solution Individuals are processing the trauma and/or its sequelae in a way which poses a current threat to self. Implications for Therapy Aim of therapy is to process the trauma so it is seen as timelimited, past event which does not necessarily have global implications for one s future.

experiences / beliefs / coping Cognitive

Leads to influences Nature of Trauma Memory

and/or its Sequelae Intrusions Arousal Symptoms

14 A Cognitive Model of PTSD (Ehlers & Clark 2000) Trauma characteristics/ Sequelae Prior experiences / beliefs / coping Cognitive Processing during Trauma Prevents change in Leads to influences Nature of Trauma Memory Matching Triggers Negative Appraisal of Trauma and/or its Sequelae Intrusions Arousal Symptoms Strong Emotions Current Threat Strategies intended to Control Threat/Symptoms 14

15 Nature of Trauma Memory Leads to influences Prevents change in Nature of Trauma Memory Negative Appraisal of Trauma and/or its Sequelae Matching Triggers Intrusions Arousal Symptoms Strong Emotions Current Threat Strategies intended to Control Threat/Symptoms 15

16 Nature of trauma memory cont. Intentional recall poor, reflects poor elaboration of memory and poor integration with other autobiographical memories Unintentional triggering of memory fragments by wide range of low level cues 16

17 Ordinary Autobiographical Memories Awareness of remembering Emotions less strong Details have context, updated with subsequent information Rarely spontaneous Re-experiencing Limited awareness of remembering, Nowness Original emotions (physiology, behavior) Details without context, not updated Easily triggered involuntarily If spontaneous, close/ specific match of triggers Wide range of triggers, sensory similarity, partial match 17

18 Nature of trauma memories Trauma narratives of children with ASD are more fragmented and sensory than trauma narratives of children without ASD Trauma narratives of children with ASD show more disorganisation than their narratives of other events PTSD symptom severity is predicted by narrative disorganisation and misappraisals The nature of trauma memories in acute stress disorder in children and adolescents Salmond, Clare; Meiser-Stedman, Richard; Glucksman, Ed; Thompson, Peter; Dalgleish, Tim; Smith, Patrick (2011) Source Journal of Child Psychology and Psychiatry Vol.52(5),

19 The Role of Triggers Leads to influences Prevents change in Nature of Trauma Memory Negative Appraisal of Trauma and/or its Sequelae Matching Triggers Intrusions Arousal Symptoms Strong Emotions Current Threat Strategies intended to Control Threat/Symptoms 19

20 The role of Triggers Low level Sensory cues Linked to trauma related stimuli Often unnoticed flashbacks appear to come out of the blue 20

21 Negative Appraisals Leads to influences Prevents change in Nature of Trauma Memory Negative Appraisal of Trauma and/or its Sequelae Matching Triggers Intrusions Arousal Symptoms Strong Emotions Current Threat Strategies intended to Control Threat/Symptoms 21

22 Negative Appraisals of Traumatic Event may relate to: Fact trauma happened Happened to ME Behaviour during trauma Emotional reactions during trauma Death of other people 22

23 Negative Appraisals of Sequelae may relate to: Interpretation of initial PTSD symptoms Other people s reactions after trauma Other consequences physical health, appearance, work and finance 23

24 Dysfunctional Strategies Leads to influences Prevents change in Nature of Trauma Memory Negative Appraisal of Trauma and/or its Sequelae Matching Triggers Intrusions Arousal Symptoms Strong Emotions Current Threat Strategies intended to Control Threat/Symptoms 24

25 Strategies intended to control can maintain by: 1. Directly producing PTSD symptoms 2. Preventing change in negative appraisals 3. Preventing change in the trauma memory 25

26 1. Strategies that can increase PTSD symptoms Thought suppression Rumination Selective attention to threat cues 26

27 2. Strategies that prevent change in Negative Appraisals Safety behaviours to prevent or minimise further catastrophes (Salkovskis 1991) Extreme vigilance for possible danger Extra protection Avoidance of reminders (Trauma site) 27

Treatment Goals Leads to influences Prevents change in Nature of Trauma Memory Elaborate Modify Negative Appraisal of Trauma and/or its Sequelae

28 Treatment Goals Leads to influences Prevents change in Nature of Trauma Memory Elaborate Modify Negative Appraisal of Trauma and/or its Sequelae Matching Triggers Discriminate Intrusions Arousal Symptoms Strong Emotions Current Threat Strategies intended to Control Threat/Symptoms Drop 28

29 Goal 1 REDUCE RE-EXPERIENCING BY ELABORATION OF THE TRAUMA MEMORY 29

30 Three main techniques Writing a detailed account of the event Imaginal reliving Visiting the scene. 30

31 Function of reliving Promotes elaboration and contextualisation of trauma memory Helps with identifying idiosyncratic appraisals of the trauma Decreases fear of the memory Facilitates discrimination between now and then 31

32 Working on trauma memories Imaginal reliving and trauma narrative Memory reconstruction: Reconstruct sequence of events, access forgotten details, link unlinked bits Access problematic meanings and change them in the memory (rather than as a mere intellectual insight) 32

33 Strengths of Reliving vs Narrative Reliving Narrative Access emotions Access important details Felt change in meaning Confusion about temporal order Understanding how things followed from each other Long trauma to identify hot spots in long sequence of events Strong dissociation, no contact to present reality 33

34 Imaginal reliving: Procedure - Usually start going through whole event, repeat if short event. Repeat often more detailed and emotional. - Afterwards discuss experience and observed changes, new things the patient remembered or realised - Discuss worst moments and their meanings ( hot spots ) - Initial Homework: repeatedly listen to tape. Note additional detail and rate emotions. 34

35 Updating trauma memories 1. Identify information that is evidence against appraisals of worst moments or predictions made at the time of the trauma - may be simply that outcome was better than expected (e.g., patient did not die, is not paralyzed) - may be contradictory information from course of event (e.g., compliance with perpetrator) -may be realization that an impression, perception was not true (e.g., toy gun) 35

36 Updating trauma memories cont. 2.. Insert the updating information into the relevant part of the trauma memory: - Produce an updated version of written narrative, with new meanings ( I know now that... ); - Incorporate restructured meanings into reliving while holding hotspot in mind 3. After all identified hotspots have been updated, probe for further hotspots with diagnostic complete reliving 36

37 Mike Westminster bridge attack

38 Mike Westminster bridge attack

39 Westminster bridge attack

40 Site visits Very helpful for Then versus Now : Site looks different = Evidence that trauma is in the past (can be fed back into reliving later) Provides retrieval cues for difficult to access parts of the memory, watch for new meanings emerging! Reconstruction of what exactly happened Often provides direct evidence against appraisals (e..g, I could have prevented the event) Behavioral experiment for negative interpretation of symptoms For some patients: Graded (pictures first)

41 Treatment Goals Leads to influences Prevents change in Nature of Trauma Memory Elaborate Modify Negative Appraisal of Trauma and/or its Sequelae Matching Triggers Discriminate Intrusions Arousal Symptoms Strong Emotions Current Threat Strategies intended to Control Threat/Symptoms Drop 41

42 Identifying the Negative Appraisals Follow the affect hotspots in reliving Quiet spots, skipping over, gestures Content of intrusions Probe for meaning Thoughts/Images Hints/Themes from person s history, beliefs and values 42

43 Appraisals - Guilt Unrealistic sense of responsibility about: Fact that the event happened at all Fact that the person survived Actions/failures to act during event Failure to overcome symptoms 43

44 Guilt: Characteristic biases/errors Discounting/screening other explanations Using hindsight Minimizing own experience/symptoms at the time Discounting positive action Not thinking through alternative actions Superhuman standard Emotional reasoning All lead to overestimation of personal responsibility 44

45 Examples of useful techniques Evidence for and against Behavioural experiments Advantages / disadvantages Pie charts Surveys Information from other sources, e.g., police, significant others, statistics Guided imagery 45

46 Treatment Goals Leads to influences Prevents change in Nature of Trauma Memory Elaborate Modify Negative Appraisal of Trauma and/or its Sequelae Matching Triggers Discriminate Intrusions Arousal Symptoms Strong Emotions Current Threat Strategies intended to Control Threat/Symptoms Drop 46

47 Unhelpful Cognitive & Behavioural Strategies Patient in limbo/stuck perceived permanent change Access to memories of old self difficult Withdraw from important people, activities in their life Perception of permanent change maintained 47

48 Strategies intended to control threat Post-trauma behaviours and processing styles are a response to a perceived threat Directly increase symptoms (e.g. thought suppression) Prevent change in meaning or nature of trauma memory Avoidance of thoughts, feelings, places, people Rumination Substance use Safety behaviours 48

49 Stimulus Discrimination Triggers Analysis of when and where intrusions occur Break the link trigger Intrusion Then and now During re-living 49

50 Reclaiming Your Life Explore good reasons problematic predictions Behavioural experiments to test out Start ASAP, discuss in each session and agree homework Link to goals, reconnect with family, friends and relatives Resume former activities 50

51 Omagh Bomb Cognitve therapy study A consecutive series of 91 patients with P.T.S.D. 1 month 34 months post trauma For 86% pre and post treatment standardized measures (PDS or IES) For 14% Case Note Review

52 Profile of Trauma Centre patients in CT treatment programme Trauma mainly related to a Single Incident 25% - received a form of previous counselling 13% - had experienced multiple traumas 54% - 1 or more AXIS 1 disorders

53 MEASURES Post Trauma Diagnosis Scale (Foa et al 1997) Revised Impact of Events Scale (Horowitz et al 1979) BDI (Beck et al 1979) GHQ (Goldberg et al 1988)

54 Omagh bomb TF-CT study Improvement in PTSD symptoms (Omagh - Gillespie, Duffy, et al., 2002 ) Cases Percentage improvement 54

55 Further Research Questions following the first study First, would the model be effective in treating a more chronic and diverse sample--- more complex PTSD Second would the results be as promising in a randomly assigned and controlled trial

56 Participants Fifty-eight patients 35 male, 23 female Mean age 43.5 years (SD = 11.72). Thirty-five patients (60%) were civilians, the remainder were police military personnel or other professions with active involvement Sixteen patients (19%) had been physically injured

57 Clinical Characteristics Most patients (81%) had experienced multiple traumatic events (median 3, range 1-10). Duration of the current episode of PTSD: mean 8.9 years (SD=9.2) range 3 months to 32 years Forty-two patients (72%) were diagnosed with one or more additional Axis I disorders Twenty-nine patients (50%) had previously received psychological treatment for trauma related symptoms

58 The traumatic events Bombings (38%) Shootings and killings (24%) Being taken hostage (14%) Physical assault (14%) Road traffic accidents (9%) Riots (2%) 74% of the index events were directly experienced and 26% were witnessed.

59 Measures Post-trauma Diagnosis Scale (PDS) Beck Depression Inventory (BDI) Sheehan Disability Scale (SDS) All questionnaires completed weekly to provide a clinical end point for all patients plus at 3, 6 and 12 month follow up

60 Cognitive therapy for terrorism related PTSD: (Duffy, Gillespie & Clark, 2007) Pre 12 weeks Post Follow-Up CT Wait

61 Adult community study -Predictors of PTSD among respondents who were present at the time and/or witnessed related traumatic events (variance- multiple regression) Variable adjusted R2 Pre-trauma personal variables.05 Type of exposure.27 Reactions at the time.24 Long-term adverse physical or financial problems.18 Cognitive model predictors.63 Social support.04

62 Current projects Screening children with a history of maltreatment, child neglect or abuse for PTSD A randomized controlled trial comparing TF-CT with Interventionas-usual (IAU) for children and adolescents with PTSD from child maltreatment and abuse Developing a cognitive approach to Persistent Complex Bereavement disorder (PCBD) (Duffy & Wild the Cognitive Behaviour Therapist 2017) Exploring the link between trauma and psychosis

Added meanings. A Cognitive Approach to the Understanding and Treatment of Posttraumatic Stress Disorder

Added meanings. A Cognitive Approach to the Understanding and Treatment of Posttraumatic Stress Disorder A Cognitive Approach to the Understanding and Treatment of Posttraumatic Stress Disorder POSTTRAUMATIC STRESS DISORDER (PTSD) Reexperiencing Avoidance Anke Ehlers Institute of Psychiatry, London, UK DGVT,