Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive Behavior Therapy [1 ed.] 9781607505754, 9781607505747

Citation preview

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

PROTOCOL FOR TREATMENT OF POST TRAUMATIC STRESS DISORDER

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

NATO Science for Peace and Security Series This Series presents the results of scientific meetings supported under the NATO Programme: Science for Peace and Security (SPS). The NATO SPS Programme supports meetings in the following Key Priority areas: (1) Defence Against Terrorism; (2) Countering other Threats to Security and (3) NATO, Partner and Mediterranean Dialogue Country Priorities. The types of meeting supported are generally “Advanced Study Institutes” and “Advanced Research Workshops”. The NATO SPS Series collects together the results of these meetings. The meetings are co-organized by scientists from NATO countries and scientists from NATO’s “Partner” or “Mediterranean Dialogue” countries. The observations and recommendations made at the meetings, as well as the contents of the volumes in the Series, reflect those of participants and contributors only; they should not necessarily be regarded as reflecting NATO views or policy. Advanced Study Institutes (ASI) are high-level tutorial courses to convey the latest developments in a subject to an advanced-level audience. Advanced Research Workshops (ARW) are expert meetings where an intense but informal exchange of views at the frontiers of a subject aims at identifying directions for future action. Following a transformation of the programme in 2006 the Series has been re-named and reorganised. Recent volumes on topics not related to security, which result from meetings supported under the programme earlier, may be found in the NATO Science Series. The Series is published by IOS Press, Amsterdam, and Springer Science and Business Media, Dordrecht, in conjunction with the NATO Public Diplomacy Division.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Sub-Series A. B. C. D. E.

Chemistry and Biology Physics and Biophysics Environmental Security Information and Communication Security Human and Societal Dynamics

Springer Science and Business Media Springer Science and Business Media Springer Science and Business Media IOS Press IOS Press

http://www.nato.int/science http://www.springer.com http://www.iospress.nl

Sub-Series E: Human and Societal Dynamics – Vol. 70 ISSN 1874-6268 (print) ISSN 1879-8292 (online)

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Protocol for Treatment of Post Traumatic Stress Disorder SEE FAR CBT Model: Beyond Cognitive Behavior Therapy

Mooli Lahad Ph.D., Ph.D. Professor of Psychology, Tel Hai College Founder and President of The Community Stress Prevention Center and

Miki Doron M.A., M.H.A.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Director Meitan Company for Psychotherapy Senior Advisor to the Ministry of Defense Guidelines for the Treatment of PTSD Veterans

Published in cooperation with NATO Public Diplomacy Division Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

NATO Advanced Study Institute on Culturally Sensitive Treatment of Post Trauma Istanbul, Turkey 14-23 July 2010

© 2010 The authors and IOS Press. All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without prior written permission from the publisher. ISBN 978-1-60750-574-7 (print) ISBN 978-1-60750-575-4 (online) Library of Congress Control Number: 2010929790 doi: 10.3233/978-1-60750-575-4-i

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Publisher IOS Press BV Nieuwe Hemweg 6B 1013 BG Amsterdam Netherlands fax: +31 20 687 0019 e-mail: [email protected]

Distributor in the USA and Canada IOS Press, Inc. 4502 Rachael Manor Drive Fairfax, VA 22032 USA fax: +1 703 323 3668 e-mail: [email protected]

LEGAL NOTICE The publisher is not responsible for the use which might be made of the following information. PRINTED IN THE NETHERLANDS

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Protocol for Treatment of Post Traumatic Stress Disorder M. Lahad and M. Doron IOS Press, 2010 © 2010 The authors and IOS Press. All rights reserved.

v

About the Authors Prof. Mooli Lahad Ph.D.PhD.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Professor in the Department of Psychology, Tel Hai Academic College and visiting professor in dramatherapy Roehampton University, Great Britain. Prof. Lahad holds two doctoral degrees. One in Psychology and the other in Human & Life Sciences. Senior Medical Psychologist. Supervisor in Educational Psychologist, Supervisor and trainer in Bibliotherapy and Dramatherapy and Creative Arts therapy. Founder and President of the Community Stress Prevention Center. Internationally known expert in the areas of prevention intervention and treatment of trauma and management of emergency situations with, systems communities families and individuals . Awarded the Ilana Banor Israeli Psychologists' Association, for his Excellence in Field Work in Preparing communities for Stress Situations and Emergencies. Awarded the Adler Prize, University of Tel Aviv- School of Social Work, for innovations in preparing civilian systems for times of emergency and the Sapit Lottery award for pioneering internet support for mental health professionals during and after major crisis. Former director of the Psychology Services in Kiryat Shamona. Former Head of the Bibliotherapy Studies at Haifa University. Academic Advisor and Founder of the Institute of Dramatherapy at Tel Hai Academic College Author and co- author and editor of 27 books and numerous articles on coping with stress situations, emergency and crisis. Member of the Advisory Committee for the Treatment of Post traumatic Disturbances in the Rehabilitation Department of the Ministry of Defense, Israel. Former Member of the Advisory Committee to NATO regarding intervention and treatment of behavioral aspects of community disaster management. Clinical director of the Mikud (Focus) clinic for the treatment of PTSD and other anxiety disorders. Have more than thirty years experience as Therapist, supervisor, instructor and facilitator in the treatment of post traumatic stress disorder and other anxiety related treatments.. Miki Doron M.A., M.H.A. Clinical psychologist. Specialist-Supervisior. Certified Health Services Coordinator. Past Chief Mental Health Officer of the IDF. Chair of the Israeli Association for Focused Psychotherapy. Graduate of the International Training Program of the Karl Menninger School of Psychiatry and Mental Health. Has completed many courses in Cognitive Behavioral Psychotherapy in Israel and abroad. Individual and couple psychotherapist using the psychodynamic and the cognitive-behavioral approaches. Instructor and facilitator in the School for Short Term Focused Psychotherapy. Co-author of the Hebrew edition of Prolonged Exposure, A Guide to the Treatment of Post traumatic Stress Disorder. Senior Advisor to the Ministry of Defense and to the Ministry of Health for the treatment of trauma victims. Coordinates the PTSD Project for the Department of Rehabilitation of the Disabled of the Ministry of Defense. Editor of the Treatment Guidelines of Post traumatic Stress Disorder for the Ministry of Defense.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

vi

Acknowledgements We would like to thank our teachers along the way, especially Professor Edna Foa, for her contribution and her innovative approach to trauma therapy. We also wish to thank our students for making it possible for us to learn from their questions, thoughts, and comments. A special note of gratitude is extended to Alon Jaffe for his worthy assistance in solidifying the material and creating a flow of topics as seen in the book. We would like to acknowledge our friends and colleagues who willingly shared their experience, knowledge, passion for learning, and desire to treat those suffering from stress, especially Ruth Ben Asher, whose important comments helped clarify the text and present it in a clearer, more understandable fashion, Mr. Dima Leyin for his help in making things clearer using his many talents. Special words of appreciation to Nira Kaplansky, whose PhD thesis on NDE (NearDeath- Experience) enhanced our confidence in advocating the use of fantastic reality as a recovery space in the approach we present in this book. Last, but not least is our gratitude for the NATO Science for Peace Project who saw the importance in making this knowledge known and spread to mental health professionals in order to promote the treatment of psychotrauma in many areas where this treatment is needed yet scarce.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The authors

Michal Shimshoni: Translation Barbara Doron: Editor Sagit Levi: Graphic-arts editor Published as part of the NATO Science for Peace and Security Project ASI 983481 directed by Dr Nevin Dolek & Prof. Mooli Lahad For reasons of convenience alone, the book has been written in the masculine; it is meant for male and female alike.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

vii

Introduction Psychic trauma and its detrimental repercussions on man's body and soul are as old as the hills. An early example of freeze and paralysis caused by exposure to a traumatic event is the Biblical story of Lot's wife. She turned into a pillar of salt as a result of looking back and witnessing the atrocities and the fire that accompanied the destruction of Sodom. As described in Genesis, 19. 26 "… his wife looked back from behind him and she became a pillar of salt." Though trauma has been known from time immemorial, our understanding is only the tip of the iceberg. We do not fully comprehend how single or multiple exposures to indescribable horrors turn people into frightened human beings, haunted day and night by the terrible sights they have witnessed: "And thy life shall hang in doubt before thee; and thou shalt fear day and night, and shalt have none assurance of thy life." (Deuteronomy, 29, 66). The vast majority of those exposed to traumatic events suffer at some point from varying degrees of symptoms. Most recover spontaneously, while for others suffering becomes unbearable and meets the criteria of the most common psychological disorder stemming from a traumatic experience: posttraumatic stress disorder (PTSD). In the DSM-IV-TR, PTSD is classified as an anxiety disorder. According to various studies, about eight percent of the populations of the Western world suffer from this disorder. Approximately forty percent of them continue to suffer from the symptoms even ten years after the traumatic event.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The question is how can we help these people? For years it was believed that there was no remedy for those suffering from severe psychic trauma. In the last decade a major breakthrough has taken place with the development of new, effective therapy methods, which relieve some of the suffering and cure many people from most of the symptoms. This book and protocol are a joint effort of both authors to draw the components that have aided the most in the recovery process out of proven, effective therapy methods. Our long years of work in the field of psychotrauma and the accompanying disorders have brought us face-to-face with the miseries and the special needs of those suffering from psychotrauma in Israel and around the world. We teach and learn, and learn from teaching the kinds of therapy and types of intervention that should be applied to posttraumatic disorders. It is clear to us that man, his environment, and his life experience, influence the intensity of his reaction to an event, his resiliency and the mode of his recovery. We do not claim that we have a remedy for every pain or a solution for all those suffering from posttraumatic disorder. We are also of the opinion that the evidence based treatments, such as PE (Prolonged Exposure) or EMDR (Eye Movement Desensitization and Reprocessing), should always be considered as treatments of choice. This book does not teach the above mentioned approaches. In the following

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

viii

proposed protocol, we have distilled from the most common therapies those elements that either repeats themselves in all of the methods (such as psycho-education). We have refined methods that in our practice we found to be very disturbing for the clients (such as the exposure, focusing inside, and the in vivo method) and we have added the unique aspects of imagination fantasy and Fantastic Reality. We have attempted to provide solutions for some of the aspects lacking in other models, to present our lessons, and to organize the existing information in this area in a unique fashion. The principles underlying the basis of the proposed model are:

1. Trauma is a problem of processing a memory which is expressed in the imagination- the client imagines that horrific events from his past are recurring in various ways and are plaguing him, making him feel fearful and that he is in danger. 2. Examination of the active regions of the brain while it is recalling the traumatic event points to enhanced activity of the visual cortex and of the limbic system (mainly the amygdale and hippocampus), decreased activity in the front top regions of the cortex, and increased activity in the right frontal lobe. Hence, trauma is indeed, as Van der Kolk called it, "terror beyond words," and, as such, the way to reach it is through the body with the aid of imagination.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

3. Symptom focused cognitive therapy is undoubtedly effective in treatment of clients suffering from post trauma. Its effectiveness is claimed to lie in the usage of cognitive models of memory and mental processing. However, in practice, in order to reach the traumatic memory, CBT uses imagination, calling it "imaginal exposure.".But in the theoretical explanation of its effectiveness in treating psychotrauma, there is no attempt to explore the role and function of the brain process referred to as imagination, and its mechanism. This can be seen with both PE in the section called "imaginal exposure" re-narration and EMDR, when the client imagines (brings forth in the eyes of his mind) the event. 4. Cognitive-behavioral models for treatment of post traumatic stress disorder show the importance of chronological re-narration and resuming daily tasks in reality. They also prove the importance of discussion and of the client's making sense of the event in his life, in accordance with his understanding and knowledge at the time the traumatic event took place, or thereafter. 5. Prolonged exposure and re-narration have clear extenuating value, especially in the passage from emotional memory to verbal memory, or from implicit memory to explicit, declarative memory. Yet therapy that is exclusively focused on words is actually focusing on the secondary final product instead of reviving the primary experience with the aid of the tools with which it is coded, that is, with the help of body and imagination, which is "beyond words." 6. Clients suffering from PTSD avoid playing because they have to remain on guard in order not to remember. This is a continuous task of standing on guard against the danger inherent in the intrusive memory. Allowing oneself to play may be frightening as the client may experience it as "deserting" the guarding position. Thus, it is necessary to reintroduce play and playing and teach the client to acquire the lost ability to play.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

ix

7. Since clients suffering from PTSD feel that they have no choice, that the traumatic event compelled them, its memory controls them. The essence of this protocol is to help them learn to make choices and to gradually experience more control, by using "as if" and "wishful" cards as part of the re-narration. 8. PTSD clients remember segments of their story. Using therapeutic cards as a stimulus for the story of the trauma enables the details to slowly reconstruct a complete, coherent story with colors, shapes, and sound, whilst feeling in control as the story unfolds "outside," in front of the client, through the observation of the cards. Thus the client regains a sense of distancing and observation of the event from a manageable perspective rather than the frightening, sometimes impossible, task of looking inside and telling it.. 9. PTSD clients experience the trauma as one frozen-in-time story with no apparent possibility for change. The current approach gives them the option for re-narration of their tale in various ways, especially in ways that facilitate empowerment through the employment of ”fantastic reality”.

The SEE FAR CBT protocol is made up of a number of components:

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

This is a combined model, emphasizing integration of up to date, effective trauma treatment methods: Somatic Experience –SE, a method focusing on the "bodymemory" (van der Kolk, Rothchild, Levine); fantastic reality - FR, (Lahad), a method based on the work of Winnicot and of S. Jennings, and the Cognitive-Behavioral Psychotherapy theories, and mainly the principles of PE-Prolonged Exposure (Foa), in vivo exposure and imaginal exposure. The model has been tested in treatment of clients suffering from PTSD as a result of rape, violence in the family, robbery, terrorism, war, and military operations. SeE, The body and bodymemory: Based on the current understanding that traumatic memories are "stored" in the body and may reactivate bodily reactions without detected threat, the protocol uses methods adapted from Somatic Experiencing (SE) Focusing, and NLP (Neuro Linguistic Programming). The focus is both on the positive resources imbedded in the body and the body memory of the pain, as well as on the ability of the subjective physical sensation to be authentically reported through the body or the concept of the "felt sense". PTSD clients suffer from various hyper-arousal symptoms the inability to relax and reduce alertness, and hyper-vigilance is translated by the clients as the "fear of fear" in which they invest great energy in order not to encounter fear. This drains their vitality and so the focus on the body should help them to learn to control and regulate the arousal - fearful symptoms. FR, Using therapeutic cards: Quite often the traumatic memory is triggered by flash backs. These are fractures of visual sensory non-verbal memories that activate a flood of excessive fear and horror. In order to get in touch with the visual memory and the non-verbal aspect of the memory, on the one hand, and on the other, to activate the healing potential of fantastic reality, we use therapeutic cards. The cards make it possible for the client to be an observer in his own drama/ trauma. By taking the role of an "observer" the client experiences distancing so that the memory becomes manageable. Another aspect of the therapeutic cards and the fantastic reality is that it creates an "as if space" just like in a theater, a space where all the IFS are possible

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

x

including fantastic, wishful, empowering experiences, that is, the ability to alter the unchangeable via the "if only " or the "as if". CBT, re-narration and in vivo: The CBT methods, evident in their effectiveness, conclude that retelling the traumatic story is probably the most significant component of the symptom reducing effect of the treatment. The other aspect pertinent to the effectiveness is the "in vivo" exposure of the clients to real life situations that for various reasons are avoided by the client. These two components are part of this protocol, albeit with some adaptations. Another aspect adapted from CBT is the reflection, a making sense process that follows the learning experience. It is process whereby the client is encouraged to make sense of and reflect on the therapeutic method used, its outcomes and application to the here and now. In order for the client to become an expert on his own suffering, its origins, and impacts, we propose to combine the dynamic and systematic understanding of the traumatic event in a person's life and the influence of these factors on his personal suffering, together with the knowledge and actions of the therapist. This expertise will help in coping with physical, emotional, and intellectual elements which accompany those who suffer from the disorder, while re-narrating the traumatic event in the fantastic reality, together with homework which includes in vivo exposure to situations, places, and avoided behavior.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The model is based on the concept that it is possible to help clients suffering from PTSD and its accompanying disorders such as depression and intense anxiety - by exposure to the fantastic reality. Specifically, while playing and reconstructing the story with fantastic / supportive elements, the reinstatement of a sense of control occurs.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

xi

Contents About the Authors

v

Acknowledgements

vi

Introduction

vii

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Part 1 Chapter 1. What is Trauma?

3

Chapter 2. When Experiencing Trauma

9

Chapter 3. Posttraumatic Stress Disorder (PTSD)

17

Chapter 4. Posttraumatic Stress Disorder Treatment

22

Chapter 5. Fantastic Reality

35

Chapter 6. Principals of the Somatic Experiencing System

40

Chapter 7. Anchoring Resources in the Body using the Integrative Model of Resiliency BASIC PH

47

Chapter 8. SEE FAR CBT Therapy Model

51

Chapter 9. Therapy Phases

54

Chapter 10. The Structure of the Sessions - An Example of a Ten Session Therapy

80

Part 2 Appendices

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

87

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

This page intentionally left blank

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Part 1

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

This page intentionally left blank

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Protocol for Treatment of Post Traumatic Stress Disorder M. Lahad and M. Doron IOS Press, 2010 © 2010 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-60750-574-7-3

3

Chapter 1 What is Trauma? "So that thou shalt be mad for the sight of thine eyes which thou shalt see." (Deuteronomy, 28, 34) The term trauma is frequently used to describe an experience that has caused stress, anxiety, or a crisis. We consider loss of employment, an accident or death of a loved one to be traumatic experiences. The dictionary definition attributes to the word trauma both physical injury and psychological shock, or an emotional experience with a longterm effect. In reality there are two types of trauma, not clearly distinguishable. Breaking an arm as a result of falling in a soccer game is usually mostly a physical trauma, but breaking an arm as a result of a sudden explosion of a bomb while riding a bus is both a physical trauma and a psychological one with long term implications. A man who broke his arm while playing soccer will usually be sorry that he was injured, and will deal with healing physically while missing playing and desiring to return to the soccer field. But his friend who supposedly experienced a similar physical trauma as a result of the bus exploding might develop posttraumatic stress disorder. Beyond his need to deal with his broken arm, he will have to cope with a new anxiety, unfamiliar to him, for example, anxiety caused by open places, suspicious characters, or riding a bus.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Deuteronomy 28, verse 34: "So that thou shalt be mad for the sight of thine eyes which thou shalt see," enables us to understand that the psychological injury ("madness") develops as a result of man's witnessing a horrific sight. A main aspect of the PTSD symptoms is the persistence of intrusion of the past into daily life by means of unpleasant memories causing anxiety, flashbacks, and nightmares. Throughout our lives, we all have minute traumatic experiences of small magnitude. A thirty minute news broadcast can report many traumatic events: war, terrorism, earthquakes, floods, storms, fires, car/plane/train accidents, rape, kidnapping, and these are only the items that are aired. However, different people experience traumatic events in dissimilar ways and cope with them in their own unique fashion, according to their personality and their individual defense mechanisms. Today more than ever before, researchers and clinicians are examining the reactions of people to changes and to events of a traumatic nature. Various theories try to determine the components of resiliency.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

4

Chapter 1. What is Trauma?

1.1 Types of Trauma Trauma as a One Time or Recurring Experience

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

A terrible one-time event, such as a massive terrorist attack, can cause traumatic reactions in some people. For example, after the 9/11 terrorist attack on the World Trade Center in New York in 2001, thousands of inhabitants of New York City experienced various degrees of posttraumatic disorder. Some of those hurt were not physically present at the World Trade Center or in its vicinity. Their traumatic responses developed as a result of excessive exposure to traumatic hard-to-watch images that were broadcast nonstop on television or because of their relationships with those injured or killed at the site. Natural disasters, such as earthquakes, tornados, fires, floods, or volcanic eruptions are another kind of terrible, single event that evokes traumatic reactions. In general, it can be said that the degree of destructiveness of a single event and the extent of danger to people's lives and their bodies' integrity influence the development of a traumatic response among those who experienced the event.(Norris 2002) . Other single events include industrial or technological disasters: overflowing dams, collapsing bridges or buildings, leakage of chemicals, or radioactive substances, among others. There is an important distinction between the way the community reacts to a single terrorist attack or to a natural catastrophe and the reaction to industrial or technological disasters. Usually, when facing a terrorist attack or a natural calamity, the community at large unites and offers mutual support. This is not the case when technological or industrial disasters occur. Then the community finds it hard to come together, and rather directs most of its attention to finding those responsible and other such concerns. Still when measuring the effect of natural disaster versus other manmade disasters, there are fewer cases of PTSD in the first instance than in the latter. This is attributed to the fact that people are more tolerant of an “act of God” or of nature and accept it, without viewing it as a wish to harm them or a case of neglect that harmed them. However, in the event of terrorism, violence, crime, abuse and even in industrial disaster people feel that someone has wished to inflict sorrow and to harm them or someone betrayed them, and that causes more posttraumatic reactions and accompanying symptomatology (depression, substance abuse and the like). In some cases, terrorist attacks and natural disasters also raise public debate and criticism regarding how well the authorities were prepared for these events and whether they did all that was necessary to prevent them. Focusing on examining what went wrong and finding the culprits can at times harm the recovery of those injured. They may subjectively feel isolated and without proper support, and perhaps public interest is objectively not directed at their plight, and not enough funds are allocated to aid them. Another example of a one-time traumatic event is criminal violence (for example, robbery, breaking into homes, rape, murder). It is well known that criminal violence has a traumatic effect not only on the direct victims but also on those close to them and on the witnesses to the crimes committed. Coping with recurring or persisting traumatic experiences usually heightens the intensity of the traumatic responses and increases their frequency. Combat soldiers, for example, may re-experience traumatic events on a daily basis for months. Recurring terrorist attacks may be a one-time event for the passengers on a specific bus, but for

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 1. What is Trauma?

5

the rescue teams and security forces they pose an experience that each time requires renewed demands to cope with anxiety, anger, and frustration that are aroused by the sights. Becoming a prisoner of war, a political prisoner or being incarcerated in a concentration camp are situations which present many daily and persistent long term traumatic experiences. This is true, as well, of physical, mental, and sexual abuse of children, which might impair the healthy development of the child or adolescent, leaving them with lifelong posttraumatic symptoms and dysfunction.

1.2 Natural Disasters vs. Man-Made Traumas The most persistent traumatic experiences are manmade. Actually, most people in need of psychological therapy after a traumatic event have been hurt by traumatic experiences caused by their fellow men. When discussing the traumatic experience, the source of the injury is a very significant variable. There are two different types of traumatic experiences: factual trauma and trauma caused by an agent. Breaking a leg in a car accident is a factual trauma but breaking a leg as a result of an intentional act of violence by another is trauma caused by an agent. The experience of a man who lost a leg or an eye in a car accident is completely different from that of a person whose eye was taken out or leg amputated as a result of intent. When the hurting agent is close to the victim, the intensity of the possible psychological damage escalates. Epidemiological research of psychological disorders shows that while 3.5-4 percent of those exposed directly to a hurricane will develop post trauma disorder, 60 percent of those raped will suffer from a similar disorder.

1.3 Types of Man Made-Trauma

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Criminal Violence Research (Ozer et al 2003) predicts that more than ten percent of the citizens of the developing countries will, in their lifetimes, experience robbery, break-ins or other modes of physical violence. Research conducted in the United States among 10,000 subjects showed that 3.7 percent had had a traumatic experience in the previous year. A large proportion of them had been car accidents caused by carelessness or negligence of another individual. In addition, many people can be victims of more than one event. The probability of this happening is greater among those living in poor neighborhoods or in a violent social setting. War and Terrorism Taking part in war leaves many emotional scars. These have either a short or long term effect on the soldiers' personalities and coping mechanisms. In some cases the intensity of a specific traumatic experience and/or a culmination of such experiences harm one’s ability to function or even shatter it. Combat soldiers have to cope with difficult situations: being wounded, witnessing their comrades getting hurt or dying, or seeing enemy soldiers and civilians getting killed or wounded. War offers various recurring traumatic experiences.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

6

Chapter 1. What is Trauma?

People who have experienced a bombing on a bus often find it difficult not only to ride a bus again, but even to go out and see buses riding down the street. This, as we will discuss later, causes them to limit their activities and avoid a lot of daily actions. Rape Rape victims are the largest group in the United States suffering from posttraumatic stress disorder (Foa and Riggs, 1993). In a study of four thousand women in the US, one out of eight had been raped once in her life and at least half of these, more than once (Crime Victims Research and Treatment Center, 1992). A third were raped under the age of eleven, and sixty percent under age eighteen. Less than twenty-five percent were raped by a stranger. Eighty-four percent did not report the incident to the police, and four percent of rapes occurred between married couples. In a different study (Kilpatrick and Resnick, 1993) conducted in the United States, half of the women treated as a result of post trauma stress disorder had been raped in the past. Attacks on the body and the psyche are a source of the development of psychological disorders in general and posttraumatic stress disorders in particular.

1.4 The Severity of the Reaction to Trauma The more intensive and difficult the experience is, the greater the potential for having a more severe post trauma reaction. The closer someone is to the epicenter the higher the probability of developing symptoms; geographic proximity as well as social proximity (feeling close to the other victims) are predictors of symptom severity. Factors Subjectively Influencing the Threat Stimulus Threshold

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Surprise: To what extent the event is perceived as a surprise and as a disruption to the planned flow of life. Inability to react: To what degree a person has experienced not having the necessary skills and/or not being able to cope with an event and its personal, psychological and physical characteristics. Helplessness: Personal experience of not being able to help oneself; feeling weak and lacking help or protection. Feeling incompetent, ineffective, or powerless, regarding the ability to cope with the event in a reasonable manner Previous traumatic conditioning: Previous traumatic experiences (loss of loved ones, psychiatric ailment of a family member) and the personal meaning attributed to the mode of coping with them may affect the severity of the reactions. Objective factors, such as the intensity of the threat and its duration: Physical proximity to the event and exposure to images, odors, and noises - can be elements of the sense of danger and the reactions that will accompany coping with it. The intensity of the threat can also be expressed in the meaning that a person gives to various aspects. For example, exposure to a part of another human body in the operating room is a daily occurrence for surgeons, while, for a layperson, exposure to a dismembered body as a result of an accident or event can be extremely traumatic.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 1. What is Trauma?

7

In summary, the impacts of the trauma tend to be worse when the trauma is man- made, recurring, unpredictable, influenced by desire or negative intentions of another person/persons in a sadistic fashion or if the trauma pertains to values, occurs in childhood and is carried out by someone close.

1.5 "In the Eyes of the Beholder" The subjective perception of a traumatic incident and the emotional experience greatly influence the formation of a posttraumatic response and its characteristics. The subjective experience of an event determines the degree of the trauma and not necessarily its objective characteristics. This is true also when discussing traumatic experiences such as rape, floods, volcanic eruptions or acts of terrorism. Furthermore, a person’s perception of how he is coping with an event will affect the degree of his vulnerability to PTSD.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

For example, Dick and Harry shop regularly at the local market. They both had a traumatic experience at the market when they were miraculously saved unharmed from a terrorist attack, although they were exposed to difficult sights. A few weeks later, as they arrived at the market, they heard a large explosion in the distance and understood it was another terrorist attack. Dick might translate the experience into a belief that his life was in danger and therefore he will stop going to the market for many months. Harry, on the other hand, might translate the events into a belief that some mysterious force has protected him and therefore he will feel safe to continue to shop in the market as usual. The different subjective translations of an event will substantially influence the way individuals cope with the traumatic experience. Similarly, there will be fewer cases of posttraumatic reactions among the soldiers of a victorious army than in the defeated one. This will also be true when the victory is only a subjective feeling of the soldiers in a unit. Some people will translate the fact that they came out unscarred from three serious car accidents into a belief that God is looking out for them. Others might identify the third accident as a sign from God that their death is imminent. Many factors on the levels of experience and reality influence the differences in interpretation and in the meaning given to an experience. These factors can be different for various people and for every individual at different times. In some cases, a person can attribute more value to an event than it "really" has and in consequence may suffer from a devaluation of his self-esteem and be ridden with guilt. Or he may be disappointed in the way he reacted to an event or compare his traumatic experience with terrible experiences that others have gone through. For example, one might say: "My grandmother survived the Holocaust and so many other difficult events and I break down from a mere car accident." It is important to remember that not all of the symptoms of those suffering from PTSD result from the trauma. Anxiety and depression that often accompany post traumatic symptoms do not necessarily stem directly from the trauma itself and can be related to a multitude of factors and circumstances. One must not forget that not every traumatic experience leads to the development of PTSD or of its symptoms. The common outcome in most traumatic experiences is recovery without the emergence of severe symptoms. The majority of those having gone through a traumatic experience resume

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

8

Chapter 1. What is Trauma?

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

functioning normally after a period of days and weeks. Only a small percentage of those exposed to trauma will at develop PTSD and that can happen within days, weeks, months or sometimes years after a long period of normal functioning and adaptation.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

9

Chapter 2 When Experiencing Trauma 2.1 The Physical Aspect

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Flight, fight, and freeze are the survival reactions of all mammals and, as such, have helped the human race to survive from ancient times. The increased secretion of adrenaline into the blood when in flight or engaged in a fight helps heighten alertness and general arousal, and enables faster action under pressure and in a state of danger. Freeze is more difficult to explain although in recent studies it has been found to be a survival mechanism for animals under extreme threat by predators. Just before being killed, the freeze reactions either deter the predator from eating a "dead" animal as they do not eat carcasses, or it may protect the attacked animal from sensing any pain as the freeze reaction anesthetizes the body. The effects of an increased level of adrenaline are well known. While driving a car, we have "a near accident.” We get frightened and in the moments following, we feel tense, our muscles shake slightly, we breathe more quickly and our pulse rises. These biological reactions are supposed to help a person cope when facing danger. But too great a level of adrenaline may harm other functions. For example, adrenaline may blur one's vision, or the increased pulse rate may resemble a heart attack. In some people, too much adrenaline makes them nauseous, leading to anxious thoughts that the body has stopped functioning normally. This is experienced as a sign of physical weakness and lack of control. With time, this kind of arousal has a burning-out effect and harms other functions. For example, the blood flowing to the limbs which is meant to enable flight or the fight, reduces the blood flow to the stomach and other vital systems in the body. As a result, there will be an increase in the acidity level in the stomach which can cause an ulcer. Another well known reaction is hyperarousal when facing stimuli that remind one of the traumatic event. These stimuli are commonly called triggers or trigger stimuli. The physical arousal, which includes a steep increase in the adrenaline level, is accompanied by jumpiness, irritability, and the unpleasant experience of acute fear. An example is the hyperarousal experienced by many Israelis during and after the Gulf War at the sound of an escalating motorbike. This noise slightly resembled the sound of the sirens heard during the war and was experienced as an anxiety factor also felt mainly on the physical level. Since these trigger factors are common to most of the population, hyperarousal is known and acknowledged as an acceptable widespread reaction. The situation is usually different for those suffering from post traumatic stress disorder. They too experience hyperarousal reactions due to stimuli they sense or hear. But for others who surround them and who cannot trace any sign of danger or stress, this reaction appears to be uncommon. The difference in perception singles out the PTSD client, and indicates that the recurrence of these reactions is both tiring and frustrating. These clients experience a sense of helplessness and feel that they have no

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 2. When Experiencing Trauma

10

control in the face of a tough unchangeable system. When physical arousal cannot be translated into an active reaction of flight or fight, the apparent reaction is to freeze. This reaction, sometimes called 'playing dead', can be adaptive under certain circumstances for a limited time. The problem here is that though the arousal level of a body that "froze" seems low, actually the body is preparing itself for reactions that demand a high level of arousal. Because the body's readiness for action is not translated into behavior, the inability to discharge this energy in these cases often brings about chronic arousal (Levine, 1997).

2.2 The Nervous System and Post Trauma Responses Physical arousal, and more so, hyperarousal as part of a post traumatic stress disorder, is mediated by the limbic system. This system is responsible for regulating survival behavior (nutrition, reproduction, flight, fight, and freeze) and expressing emotions. The limbic system is part of the central nervous system and is also closely tied to the activity of the autonomic nervous system. The two main systems in the human nervous system are: 1.

The Central Nervous System - composed of the brain and the spinal cord.

2.

The Peripheral Nervous System - composed of nerves carrying signals to and from the central nervous system. The peripheral nervous system is composed of: a. The Somatic Nervous System - responsible for accepting stimuli from the surroundings and the coordination of consciously directed movements of the body.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

b. The Autonomic Nervous System - responsible for the control of bodily functions not consciously directed, such as sweating, heartbeat, breathing, salivation, and intestinal movements. The autonomic system is subdivided into two sections whose combination promises normal functioning. ƒ

The Sympathetic System - includes nerves coming out of the midsection of the spinal cord. Heightens arousal.

ƒ

The Parasympathetic System - includes nerves coming out of the brain and the lower section of the spinal cord. Responsible for relaxation and reducing arousal.

When there is danger, the limbic system works as a detecting, warning and activating system. With the aid of various hormones, it activates the peripheral nervous system and all its subsections, mainly the autonomic system, and causes the body to react to an external situation. First we will get acquainted with two central sections of the limbic system - the amygdale and the hippocampus, and their relationship to the cortex, as a possible explanation for the development of post traumatic stress disorder. Then we will examine the hypothalamic-pituitary axis (HPA) - the hormonal system through which the limbic system activates the peripheral nervous system.

The Amygdala The name comes from the Greek word, amygdale, meaning almond. The amygdala is an almond shaped neural brain structure which is part of the limbic system. It is located

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 2. When Experiencing Trauma

11

deep within the medial temporal lobes of the brain in complex vertebrates, including humans. Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdala are considered part of the limbic system. The amygdala is responsible for excreting hormones, arousal, control of autonomic reactions relating to fear, for processing the emotional reactions and their memory. It is also very important for the ability to identify facial expressions and tones of speech. It is considered one of the brain’s emotional centers. It reacts to emotional stimuli in nerve broadcasting and carries emotional memories learned by conditioning. In a normal situation, when facing a danger, recurring exposure slowly creates habituation or decreased reaction. In such a situation, the amygdala "learns" to associate the stimulus with there being no danger. But when facing an acute persisting stress factor, fear conditioning is formed in the amygdala that may be very strong and resistant to new information.

The Hippocampus

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Hippocampus, the Greek word for seahorse, is a structure in the brain shaped like a seahorse, The hippocampus is located within the temporal lobes and adjacent to the amygdala. and is a part of the limbic system. It plays an important role in navigation, spatial orientation, emotions, and in creating new memories. As one of the most important memory centers in the brain it is mainly responsible for the declarative memory (verbal expression). Damage caused to the hippocampus, for example, a situation of acute or persisting stress, might stop the formation of new declarative memories. In the last few years, a connection has been found between the size of the hippocampus and the level of cortisol in the blood, and the development of PTSD. For example, Lindauer et al. (2004) discovered a considerably smaller volume in the hippocampus of policemen suffering PTSD compared with policemen who experienced trauma but did not suffer PTSD (the control group). This and other studies to a certain degree support the possibility that the volume of the hippocampus, which is small in those suffering PTSD, is a risk factor for PTSD.

The Cortex The cortex is the shell of the brain, also known as cerebral cortex. It is the biggest section of the brain, making up some 85 percent of brain weight. This is the part of the brain where the most complex processing activities take place. The cortex is divided into two hemispheres, right and left, and each of them is subdivided into four main lobes (frontal, parietal, occipital, and temporal). Each sensory system in the body sends information to a certain area in the cortex, where it is processed. Motor reactions or movements of body parts are controlled by other sections of the cortex. Other areas of the cortex that do not process sensory information or control of movement are the sections of association. These sections occupy the relatively largest part of the human cortex, and they are related to memory, thought, and language.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

12

Chapter 2. When Experiencing Trauma

The cortex is responsible for the interpretations a person makes of a traumatic event and the way the declarative story of the trauma will be remembered.

Illustration #1: The internal structure of the human brain, including the limbic system

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The Amygdala, the Hippocampus and the Cortex The amygdala and the hippocampus exist in all mammal brains. Among other functions, these sections make it possible for the brain to identify danger and to react to it quickly. On the one hand, from this perspective, the amygdala and the hippocampus express the basic evolutionary need common to humans and animals - survival preservation of life. On the other hand, this region in the brain is substantially more developed in humans than in other mammals. The cortex allows people to manage language and to realize highly complex motor skills. Man's tendencies and abilities to have reactions of flight, fight, or freeze, are virtually based solely on the functions of the amygdala and the hippocampus. The activity of the cortex has an influence only at a later stage, when man attempts to understand what has happened and what the significance of the event is. For example, the sensation of panic experienced at the time of an accident is based on the amygdala. The sensation felt at a later time of guilt caused by hurting another person or his property is a result of activity in the outer shell of the brain. The concept behind the somatic experiencing - SE method, which will be presented at a later stage, is that an individual's developed cortex represses or decreases his spontaneous reaction of discharge after the stress stimulus has been removed. One usually sees spontaneous movements and shaking in animals, through which they discharge trapped energy in their bodies, caused by hyperarousal that accompanies the reactions of freeze, flight, or fight. In humans the cortex delays these spontaneous reactions and the result is chronic, ongoing hyperarousal.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 2. When Experiencing Trauma

13

The Hypothalamic - Pituitary Axis - HPA The HPA axis is a hormonal system responsible for reacting to danger. The limbic system, the pituitary gland and the adrenal gland are part of this system. To understand what happens on this axis we must start with the amygdala. As noted, stress situations relating to danger cause arousal in the amygdala. When the amygdala receives information about danger it sends signals to the hypothalamus (to the PVN Hypo). As these signals reach the hypothalamus, the hypothalamus factor secretes corticotropin releasing factor-CFR, which reaches the pituitary gland. When CFR is absorbed in the pituitary gland, it secretes ACTH (adrenocorticotropic hormone). This hormone flows through the bloodstream to the adrenal gland and acts on its cortex, causing it to secrete corticosteroid hormones (CORT), and norepinephrine and epinephrine into the bloodstream. The function of norepinephrine and epinephrine is to help the body call upon its energy sources and to prepare the body and brain to cope with the danger. The corticosteroid hormone (CORT) reaches the brain through the bloodstream and attaches itself to special receptors in the hippocampus, amygdala, prefrontal cortex, and in other regions. Its function is to delay and repress the distress response.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The hippocampus is the main regulator, working on repressing and halting the reaction. When the corticosteroid hormone (CORT) is absorbed in the hippocampus it works on repressing secretion of CFR from PVN. Unlike the hippocampus, as long as the stress stimulant is present, the amygdala continues to cause PVN to secrete CRF, thereby continuing the brain's and the body's reaction to danger. The balance between the arousal receptors that the PVN region in the hypothalamus receives from the amygdala, and the repressing receptors arriving from the hippocampus will in the end determine the amount of CRF secreted, and also the amount of ACTH and corticosteroid hormone (CORT). The right balance between these receptors has to be adapted to the demands of the stress situation and its duration. A stress situation that goes on for too long causes cumulative damage to the hippocampus resulting from the degeneration of its cells. As a result, the ability of the hippocampus to regulate the secretion of hormones from PVN is damaged, and thus also affects the pituitary and adrenal glands. A persisting stress situation also causes escalating damage to the other functions that the hippocampus is responsible for, mainly the memory. As stated earlier, various studies have shown a link between the size of the hippocampus and the development of post traumatic stress disorder. Additional studies point out the contraction of the hippocampus in the brains of trauma survivors who experienced recurring abuse in their childhood, or in Vietnam veterans who suffered PTSD. These groups also suffered from a decrease in memory, but other cognitive abilities were not harmed. These factors enable us to understand the great vulnerability of those who experienced trauma in the past, from a physiological perspective. This is a vulnerability that causes an impairment of abilities to cope with future traumas. They also help us understand the difficulties with memory which trauma clients suffer, including the difficulty in remembering the traumatic experience. It is apparent from the different studies that a mild stress experience can heighten one's memory, while an acute or persisting stress experience causes loss of memory, including explicit memories and the memory of the traumatic event.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 2. When Experiencing Trauma

14

From what is known today, unlike the case of the hippocampus, a stress situation does not hamper the amygdala's functioning. This is the part of the brain that is responsible for the creation of emotional memories. Emotional memories can be unconscious memories that are very powerful and they are usually created in conditioning processes. This makes it possible to understand why people who do not exactly remember the traumatic event, still carry intense emotional memories in their brains that become resistant to extinction and continue to influence them for a very long time.

Danger

Hippocampus

Amygdala Repression

Arousal

PVN nucleus in the Hypothalamus CRF

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Pituitary Gland

ACTH CORT

CORT

Adrenal Gland CORT secretion to different regions of the body and brain for coping reactions to danger

Illustration #2: HPA Axis and the Physiological Response to Danger Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 2. When Experiencing Trauma

15

2.3 The Cognitive Aspect Our brain is continuously busy processing physical experiences detected through the senses, comparing them to previous experiences and cataloging them as memories that will help us cope efficiently with similar data in the future. This is the essence of our cognitive functioning. In this fashion, every new experience is added to our memory bank and forms the way we will cope in the future with situations somewhat resembling those of the past. In the brain, different regions cooperate: The right side translates the sensory stimuli and the left side is responsible for the verbal processing and the encoding of the experience as memories. When one is in a state of trauma and the senses are reporting a catastrophic experience, the verbal side has a difficult time systematically processing the experience into words. The experience remains unprocessed and is not encoded in the usual manner as a memory. From this angle, we can compare the work of the brain to that of a high speed computer that continuously records our memories on a disk. A traumatic event can cause a dent in the memory disk and each time the movie reaches the dent, the traumatic event and its memories will either be bothersome or will be re-experienced.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

In addition, the disturbing repetition of the traumatic event, usually leads to the development of generalizations regarding the world and the self ("I can't hold a normal job." "The world is unpredictable."). These beliefs cause the formation of maladaptive interpretations of different experiences, and they hamper the possibility of accepting new information that can refute them. In order to survive, the newborn child is dependent on his human environment and on the feeling of continuity, support, and safety received by belonging to this permanent human environment. From the onset, human beings try to learn the rules, to gain experience, and to try to predict what will happen tomorrow based on what occurred today. The laws, the logic, and the reality, help him feel that the world is logical and predictable. The rules, procedures, and future plans, all of our knowledge about the world in general and our immediate environment in particular, help us develop a sense of safety and control. Every person has inner images, dreams and hopes regarding life, and many of these dreams remain constant for years. A person's life experience influences what he knows about himself and the world, his life philosophy, his religious beliefs and his stance regarding life and what goes on in it. By its nature, the traumatic experience disrupts our sense of continuity. It disrupts the belief that what happened yesterday predicts tomorrow. Often people who have experienced a traumatic event feel that their world has collapsed and that they have no idea what will happen. The emotional experience of continuity is based on beliefs that are not necessarily realistic, but they do have an adaptive function. A onetime traumatic experience will usually cause us to change our attitudes regarding specific issues. A recurring traumatic event will bring about a deep sense of helplessness and an across the board change of our most basic beliefs about ourselves and the world. An example of this is the question raised by a client who experienced severe abuse as a child: "So where was God when these atrocities occurred?" The development of psychological disorders is not influenced solely by a traumatic experience, but also by the interpretation an individual gives to the experience. The psychological meaning of the traumatic experience can change as a person develops or as a result of various exterior changes. Thus, for example, some of the American

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

16

Chapter 2. When Experiencing Trauma

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

soldiers fighting in Vietnam carried out their combat duties without developing PTSD. Only at a later date, when they had returned to their homeland and were called murders of children and rapists by those rallying against the war, did they experience acute emotions of insult and guilt because of their actions during the war. Some of them developed PTSD at that stage.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

17

Chapter 3 Posttraumatic Stress Disorder (PTSD) "And thy life shall hang in doubt before thee; and thou shalt fear day and night, and shalt have none assurance of thy life." (Deuteronomy, 28, 66) The above quotation from the Bible suggests a 'definition' similar in its characteristics to PTSD as it is known to us today. It is interesting to note that these reactions were acknowledged in very early periods. As written in the scriptures, this disorder combines severe anxiety symptoms - "And thy life shall hang before thee, and thou shalt fear day and night"- along with severe depressive symptoms of despair, haunting nightmares and a rift in one's belief system - "and shalt have none assurance of thy life." The combination of these elements are probably at the root of undoubtedly one of the most difficult syndromes and the reason for the difficulties in giving both psychological and psychopharmacological treatment to those suffering from it. According to the DSM-IV-TR the following are the diagnostic criteria for post traumatic disorder: A. Exposure to an event with the following two characteristics. 1) The person experienced a life threatening event or danger of serious injury, or danger to the physical integrity of self or others. 2) The person's response to the event included intense fear, helplessness, and/or horror.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

B. The traumatic event is re-experienced in one or more of the following: 1) Recurring intrusive, distressing memories, images, thoughts and perceptions. 2) Recurring nightmares of the event. 3) Acting or feeling as if the traumatic event is recurring ("flashbacks"). 4) Intensive psychological distress when exposed to cues that remind the person of the trauma or an aspect of it. 5) Physiological arousal when exposed to cues that remind the person of the trauma or an aspect of it. C. Persistent, ongoing avoidance of stimuli that remind the person of the trauma, and numbing of general responsiveness, not existing before the trauma. Three or more of the following: 1) Efforts to avoid thoughts, feelings, or conversations associated with the trauma. 2) An effort to avoid places, people, or activities that are reminders of the trauma. 3) Inability to remember important aspects of the trauma (not as a result of unconsciousness). 4) A marked decrease in interest or participation in significant activities. 5) A feeling of detachment or estrangement from other people. 6) A restricted range of feelings (e.g., unable to feel love).

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 3. Posttraumatic Stress Disorder (PTSD)

18

7) A sense of foreshortened future (e.g., not expecting a career, marriage, children or a normal cycle of life). D. Persistent symptoms of hyperarousal, not existing before the trauma. Two or more of the following: 1) 2) 3) 4) 5)

Difficulty in falling or staying asleep. Irritability and outbursts of anger. Difficulty concentrating. Hyper-vigilance. Exaggerated startle response.

E. Symptoms in sections B, C, and D above go on for more than a month. F. The disorder causes significant difficulty in functioning, e.g., decrease in personal, family, and occupational functioning.

3.1 Common Responses to Trauma The main responses people experience after trauma are fear and anxiety. Frequently, anxiety reactions appear as a result of recalling the trauma (e.g., assault, car accident, terrorist attack). In some cases, the feeling of anxiety might suddenly appear for no apparent reason.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

There are certain environmental signs or situations that will trigger the memory of the trauma and awaken fears. These signs or situations might be (depending on the trauma): certain times of the day, specific places, a person who approaches the victim or turns to him in a way that reminds him of the "assailant," an argument, specific odors, noise, among others. 1. Fear and anxiety can be understood as a person's reaction to his assessment that the situation is dangerous and his life is in danger. Various sensations? in the body, feelings, and thoughts are tightly linked to the change in a person's world view and in the way he sees himself, and to his shattered sense of safety in the world. Fear and anxiety are experienced in two central ways by those who have been through traumatic incident: a) Re-experiencing of memories of the trauma. b) Feeling physical arousal, jumpiness, vigilance, and a startle response. These feelings may cause trauma victims to want to isolate themselves and to keep away from others, and to avoid situations that remind them of the trauma. Sometimes, a "flashback" can be so strong, that the victim feels that the trauma is recurring. The experience is intrusive, and a person may feel that he has no control over it or over what he thinks, feels, experiences, and does. (e.g., a person who experienced an explosion in a factory where he worked might find himself hiding under a chair as a result of hearing a balloon pop at a birthday party.) He might also experience the traumatic event through dreams or nightmares.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 3. Posttraumatic Stress Disorder (PTSD)

19

At times, people will re-experience the trauma in disturbing thoughts or emotions related to their experience when they are awake, without any "flashbacks" or nightmares. 2. Another common reaction to a traumatic event is having problems in concentrating. One example is having problems in reading concentration, not being able to recall what was read or recount a story following a conversation. The frustration of impairment to concentration or to memory can lead a client to feel loss of control (of himself and his thoughts) or to feel that he is losing his mind. Frequently, the difficulty in concentration is the result of intrusive painful feelings and memories connected to the trauma and the attempts to control them. 3. Another frequent reaction to a traumatic event is hyperarousal. This includes: irritability, nervousness, jumpiness, a high level of alertness, trembling, being easily startled, having problems sleeping, and suffering from difficulties in concentrating. Some PTSD clients experience a panic attack. The physical sensations accompanying hyperarousal are perspiring, heart palpitations, a sense of suffocation and tingling. In addition, feeling continuously tense and jumpy can cause irritability or a "short fuse," especially if the person is not getting enough sleep.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

As a result of a traumatic event, one may believe that the world is constantly dangerous, and his body and mind will try to be ready for an encounter with the danger. Therefore, the body will be in an ongoing state of alertness, and will feel ready to react quickly to any danger that comes its way. 4. Avoidance: A person might find himself avoiding situations, places, people and things that remind him of the traumatic event. If it is difficult for someone to be exposed to certain places or aspects of the traumatic incident, he will do everything in his power to avoid contact with them; thereby trying to diminish the sense of danger of recalling the traumatic experience again. The quality and quantity of "avoidance" have a significant influence on the development of PTSD. Avoidance symptoms are the most difficult to treat because their purpose is to reduce tension and distress. When a person feels that giving up "avoidance" will result in a need to cope with situations that remind him of the trauma, he might decide not to give up evasion and to adhere to "avoidance" as a coping strategy. However, as much as it is a beneficial strategy for the short term (reducing anxiety, as one does not meet the fearful stimuli, in the long term "avoidance" has its price, mostly making a person " a prisoner in his own life." Quite often, the attempts to avoid memories and feelings related to the traumatic incident create difficulties in remembering certain aspects of the event. Another result of the attempts to avoid painful thoughts and feelings associated with the trauma is emotional ambiguity and/or numbness. Emotional numbness and a feeling of emptiness may lead to detachment from the environment and to loss of interest in things that in the past were pleasurable, or to feeling distant and estranged from others. 5. Sadness and depression are additional reactions to a traumatic event. A person may experience feelings of hopelessness, despair, and frequent attacks of crying. The despair accompanying PTSD may lead the client to think of harming himself or committing suicide, loss of interest in people who in the past were of interest and in activities that were enjoyable. Some trauma victims report feeling that nothing seems

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

20

Chapter 3. Posttraumatic Stress Disorder (PTSD)

enjoyable or fun, that there is nothing to live for, and plans that they had made for the future are no longer important. 6. Feeling anger is another frequent response. The anger is usually about injustice, lack of decency, and the feeling that one is a victim. In cases of robbery or assault, most of the anger is directed towards the attacker for the damage he caused (physical damage, taking advantage, for having violated personal space, or for taking private property). Feelings of anger may also awaken towards people who are reminders of the traumatic events or towards people who have recovered and are in a good state. Many survivors are also angry with God for having allowed them to be taken advantage of, to be attacked, or to have fallen victim to this kind of trauma. Often survivors get angry at the police for not doing enough after the event, or at the rescue teams and the hospital for not treating them with enough sensitivity. They are also angry at friends and family members because they feel that people close to them do not understand what the victims are going through.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

7. Sometimes the feeling of anger is so intense that the victim desires to curse or harm others. A person who is not accustomed to feeling anger might have difficulties in identifying these harsh feelings and coping with them. Many also direct anger toward themselves for things they did or did not do during the trauma or after it. Directing anger towards oneself can cause feelings of guilt, accusing others, helplessness, and depression. Frequently, an individual might not have patience for those dearest to him. This can be confusing, as he might have difficulty in understanding why he is so angry with those he is closest to. Even though feeling close to others may be pleasant, it also heightens the odds of experiencing intimacy, dependency, vulnerability, and helplessness. Experiencing these feelings in an interpersonal relationship may cause irritability and anger because they are in some ways reminders of the traumatic event or of the lack of belief in humans that one feels as a result of the trauma. The reactions of the immediate environment (family and friends) may be of rejection and ungratefulness. 8. Feeling loss of control. Trauma is never a choice for anyone and so the immediate sensation is that the traumatic incident(s) which superimposes itself on the individual was sudden and unexpected, and thus harmed the victim's sense of control over his life. The feeling of no control of emotions, body, or life might be perceived as unbearable. Frequently, feeling loss of control can be so intense that a person might feel as if he "is going mad" or "losing his mind." 9. People who have experienced a traumatic event might feel guilt and shame. These feelings may be related to things they did or did not do in order to survive during the event. The attempt to guess how they were supposed to act or what they should have been wary of and the tendency for self blame are also common reactions. An individual may blame himself for what happened or develop a belief that he could have acted in certain ways and thus prevented the event. The basis for the feelings of guilt lies in our attempt to believe that we control life and that if we act correctly everything will be fine. A significant source of the feelings of guilt and shame lies in the basic assumption about the world: "it won't happen to me." But when a person is faced with an "it happened to me" experience he might feel that he contributed to it by not preventing the event. Or he may feel ashamed that it happened to him and not to others, or that the world or God betrayed him. Some people will experience shame and guilt because of the way they coped after the traumatic event. Some people believe that the absolute

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 3. Posttraumatic Stress Disorder (PTSD)

21

majority of the victims of a traumatic event do not develop a posttraumatic disorder, and often a person who suffers from PTSD may believe that his reaction is exaggerated and "wrong," and that the “rest of the world” would have coped differently. This causes self defeating statements. It is important to remember that in the cases of rape, assault, robbery, or a terrorist attack, the victim is almost always not responsible for what has happened to him. Furthermore, it must be remembered that even though taking responsibility for an event or feeling guilty about it may provide a sense of control, it can also cause one to feel helpless, depressed, and to have negative feelings and negative cognitions about oneself. Feelings of guilt can also be instigated by acquaintances, family, friends, or society, as people often put the responsibility on the victim or blame him. 10. Self image can also suffer from exposure to a traumatic event. The victim may tell himself that he is a "bad person" because bad things happen to him, or he might say, "If I wasn't so weak and stupid, this wouldn't have happened to me," or "I should have been more courageous." He might be convinced that the world is a dangerous place and that no one can be trusted. A possible outcome might be that the victim avoids activities he used to like and the company of people he used to enjoy. He may also discover that the people he was closest to, whom he had expected to be the most supportive, did not meet his expectations.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The victim who wishes to retell the traumatic story may often discover that friends, family, and spouse/partner find it difficult to hear about the event and will do everything to silence him or to ignore the story. This experience adds to the feeling of isolation, of being outcast and unaccepted.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

22

Chapter 4 Posttraumatic Stress Disorder Treatment In the last decades, many attempts have been made to find an effective treatment for the posttraumatic syndrome. There are an abundance of publications describing cases and effectiveness studies that display a variety of therapy techniques. Yet only a few publications are based on systematic empirical research. The most common therapies offered can be divided into three groups: 1. Medications. 2. Individual Psychotherapy (Behavioral approach, Cognitive Therapy, Anxiety Management, Hypnosis, Crisis Intervention, or Dynamic Psychotherapy). 3. Group Therapy (Support Groups, Family Therapy, Psychodrama, and the like).

A Brief Review of potential psycho-trauma therapy:

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

4.1 Pharmacotherapy Medications administered in treatment of PTSD are meant to reduce symptoms which accompany the posttraumatic syndrome, such as anxiety, depression, and sleep problems. In some cases, they can alleviate the distress and the emotional numbness. Up to now, no drug has been found that achieves remission or full recovery from the syndrome. There are several antidepressants, especially of the Selective Serotonin Reuptake Inhibitor (SSRI) type, such as Sertraline and Paroxitine, that have been found to be effective in diminishing PTSD symptoms (Van Etten & Taylor, 1998).These types of medicines are the first choice among medications (Albucher & Liberzon, 2002, Foa, Keane & Friedman, 2000), due to the relative ease in using them and the comparatively slight complications in taking them (hence, avoiding the prospect of overdosing, and remaining free from side effects). Two large, controlled studies which checked the influence of Sertraline versus a placebo found that the medication reduced re-experiencing, avoidance/numbness, and hyperarousal. It has recently been approved by the U.S. Food & Drug Administration FDA, for treatment of PTSD. There is still a lot more research to be done in order to reach across-the-board conclusions regarding treatment of PTSD with medications. For example, up to now, not enough studies have been done on the long term effects of the medicines. As of today, medications can help, but they cannot provide a solution to the vast range of distress factors related to PTSD. Yet it seems that the alleviation of the symptoms that the medications provide might reduce the need of the client for alcohol or drugs, and medications sometimes make it easier for clients to undergo psychotherapy (Davidson, 1992, Solomon & Johnson, 2002).

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 4. Posttraumatic Stress Disorder Treatment

23

In many cases the optimum treatment is a combination of medication and psychotherapy. Today, research and clinical practice are focused more on psychotherapy, perhaps because the etiology of PTSD is mostly anchored in theory. Controlled studies using psychopharmacology in PTSD using paroxetine, sertraline, fluoxetine (Marshall et al, 2001) suggest the use of SSRIs as the first line treatment gradually reducing the dosage for up to twelve months (Marshall et al, 1998). If full or partial remission appears it is recommended to continue for at least a year. Currently there is no evidence in the research to support treatment beyond one year but as in other anxiety disorders, there is a basis to assume that treatment can be beneficial in the longer terms. First line additional treatment can be SNRI medications with dual action (like venlafaxine) but none of these has been found to have clinical efficacy. Second- line treatment includes MAO inhibitors (Albucher RC & Liberzon I. 2002)

4.2 Dynamic Psychotherapy Dynamic psychotherapy focuses on emotional conflicts that have surfaced as a result of a traumatic event, especially if they are related to early childhood experiences (Horowitz, 1976). Through re-telling the traumatic event in an empathetic, nonjudgmental atmosphere, the client gradually raises his self-esteem and develops more effective ways of thinking and coping with his experiences and his intense feelings. The therapist helps the client to identify current situations that numb the traumatic experiences and reduce PTSD symptoms.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The dynamic approach to therapy includes an array of procedures, most of which focus upon the "energy overload," or as it is called today, "information overload." According to this mechanism, the trauma client is required to integrate the traumatic experience into the meaning of his life, his sense of self, and his world view. As Horowitz put it (1976), the emotional reactions of the person who has suffered trauma are a result of gaps between internal and external information. Horowitz saw the reaction to trauma as swinging between two stages. In the intrusive stage, the individual feels exposed to intense anxiety due to the recurrence of the traumatic event in his life. In the denial stage, the cluster of avoidance and emotional numbness symptoms are present and stand out in an attempt to control the distress. The victim is in a quasi state of shock, his attention is fractional, and full or partial amnesia is possible. In some cases there is a decrease in the client's physical activity, and a tendency to withdraw or to show hysterical, mad behavior (as expected from intrusive hyperarousal symptoms). These behaviors are an attempt to cope with the anxiety experienced in the intrusive stage. When the attempts fail or cause flooding, the client experiences unceasing bothersome thoughts, "flashbacks," or nightmares, and actually returns to the intrusive stage. The therapy developed by Horowitz is suited for the symptomatic stage the client is in. In the intrusive stage, the therapist encourages the client to avoid plaguing memories and helps him control anxiety by providing a supportive therapy atmosphere, anxiety management techniques, and/or medication. In the denial and avoidance stage, the therapist encourages the client to face his memories through associations and abreaction. When the intensity of the emotion diminishes, the therapist focuses on achieving an understanding of the conscious and subconscious significances of the

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

24

Chapter 4. Posttraumatic Stress Disorder Treatment

symptoms, with the goal of helping the client gain control of the trauma and resume normal functioning. Most of the literature about psychodynamic intervention lacks methodical studies. Two controlled studies compared people undergoing short-term psychodynamic therapy and other approaches to PTSD treatment - hypnosis and desensitization - to a control group of people on a waiting list for therapy. All of the groups showed an improvement in comparison to the control group. The psychodynamic therapy group achieved the greatest reduction in avoidance symptoms, but a smaller change in the intrusive symptoms, while in hypnosis and desensitization there was a reverse pattern. 4.3 Trauma and Recovery Judith L. Herman The first principle according to Herman (1992) is that recovery is based on empowerment of the victim. Empowerment in this case means encouragement, help and support given by the therapist, while the control, power, and choice making remains in the hands of the client. Empowerment can occur only in the context of interpersonal relationships; therefore, in the therapy there will be special emphasis on developing the relationship and forming an alliance between the therapist and the client. This relationship enables rehabilitation of basic abilities that were impaired (ability to trust, to take initiative, to be fit, to identify, to be intimate, and have autonomy).

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

In this relationship the client is very dependent on the therapist; therefore "it is the responsibility of the therapist to use the power entrusted in his hands only to further the recovery of the client and to withstand any temptation to abuse it." P.165 (Herman 1992) The therapist must exercise technical neutrality, in the sense that he must avoid trying to influence the client's choices and decisions, but he should not be morally neutral. "The therapist is called to be a witness to a crime. He must take a stance of solidarity with the victim." P.165 (Herman, 1992) According to Herman, in many cases in therapy, trauma victims develop strong transference stemming from past experiences of horror and helplessness. Another characteristic of trauma victim's transference is oversensitivity to the therapist's reactions, including non-verbal ones. The therapist treating the trauma client must take into account this traumatic transference and the resulting complex relationship. According to Herman, because there is fear that the therapist will "catch" the PTSD, and will experience psychological reactions of counter-transference that might hinder the success of the therapy, the therapist is advised to find support, collaboration, and supervision for himself for the duration of the treatment of trauma victims.

4.4 Hypnotherapy Hypnotherapy is quite popular in the treatment of PTSD (Rothbaum, 2009). Like other cognitive approaches, it also incorporates an element of exposure. The goal of this approach is to enable the client to "let go" of repressed material and to integrate memories of the traumatic event. In addition, hypnotherapeutic techniques help in gaining control of memories and the emotional experiences that accompany them.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 4. Posttraumatic Stress Disorder Treatment

25

There has been very little systematic research of this technique. The few empirical findings that do exist indicate an improvement in the intrusive symptoms.

4.5 The Multi Dimensional Approach This approach by Shalev, Galai & Eth (1993), claims that single dimensional explanations of the posttraumatic syndrome only partially explain the disorder and that a multidimensional approach must be applied. The multi dimensional approach includes: 1. A biological dimension. 2. A learning theory/behavioral dimension. 3. A personal meaning dimension, including changes in self worth, self-esteem, and in cognitive authority.

4.6 Group Therapy This approach makes it possible for the clients to share the traumatic memory in a safe, united, and empathetic group of other clients. The premise at the basis of group therapy is that contact between survivors of similar traumas can contribute to the recovery and adaptation process. The feedback the group members provide each other furthers a more precise conception of their interpersonal abilities, as well as more adaptive social behavior (Allen & Bloom, 1994, (Solomon & Johnson, 2002).

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The opportunity the victim has in this framework to support others helps the rebuilding of control and self-esteem. As the comprehension and the processing of the trauma expand, so do the feelings of safety and the ability to trust. The ability to discuss and share coping with feelings evoked by the trauma of shame, blame, anger, fear, doubt, and self doubt, makes clients focus on the past, not on the present. The mere possibility of telling the story of the trauma and of facing the sorrow, the anxiety, and the blame associated with trauma, enables many clients to cope with the symptoms and the memories, and with other aspects of their lives (Koller et al., 1992). Family or couple therapy include psycho education, helping the non-PTSD partner to understand PTSD and its symptoms, defusing the system of "pathological balance" that is responsible for the negative reaction of the PTSD patient toward his spouse and vice versa Phoenix (2007)

4.7 Cognitive - Behavioral Therapy The approaches most systematically researched are those of cognitive behavior therapies. These include various exposure techniques and procedures for anxiety management that have been researched separately and jointly. Even though traumatic events, such as robbery, rape, combat, terrorist attacks or natural disasters seem very different, their victims go through a similar experience as far as the undermining of

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

26

Chapter 4. Posttraumatic Stress Disorder Treatment

their self and their world schemas. The trauma is described as shattering three basic assumptions: 1. The belief in self-resiliency. 2. Seeing the world as meaningful. 3. A positive concept of the self. This undermining of basic beliefs, dispossession of power, and loss of familiarity and control that one has in his world causes great psychological distress. Therefore, most of the cognitive-behavior therapies set as a goal to correctly evaluate the dangers at the time of the event and the possible reactions that were available to the victim at that time. To do so, it is necessary, to a certain degree, to overcome avoidance of internal and external cues (e.g., conversations, places, thoughts, and feelings) associated with the trauma. One of the primary conditions for this is creating a safe, empathetic, supportive environment in which it is possible to process the trauma without the victim re-experiencing the event. In fact, most clinicians agree that a certain degree of emotional processing of the trauma memories is vital for effective treatment of PTSD, regardless of the therapeutic technique. According to the cognitive-behavior therapy approach, the following are characteristic of a pathological trauma: Oversensitivity to a large number of stimuli - Trauma victims often suffer from many symptoms that change and expand through time. For example, sensitivity to noise can cause one not only to stop watching noisy television programs, but to stop watching television all together and even to stop activities outside the home because of a fear that the noise in a shopping mall or movie theater will jeopardize the delicate balance.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Exaggerated reactions - Trauma victims often have extreme reactions to seemingly neutral stimuli. When talking about people suffering from PTSD, the saying "to make a mountain out of a molehill" takes on interesting meanings regarding the identification of dangers or the possibility of physical or mental harm, Faulty associations between "stimulus" and danger - People suffering from PTSD often have an impaired ability to differentiate between different events and their significance. Immediate cognitive associations that we make as humans are the source of the wrong associations which trauma victims make. Faulty associations between reactions and feeling incompetent - In continuation to the above, those who develop a posttraumatic stress disorder, often find that they are incapable of coping with the event and its physical-psychological results. For example, "jumpiness" (startle effect), which is a typical psycho-physiological reaction after traumatic events, can be viewed as a failure to control one's body. Thus, a person finds himself trying to control his jumpiness, and experiences a sense of failure, shame, and anger towards himself every time his body jumps in reaction to a door slammed shut noisily. As a result, he might lose his self-confidence and develop a sense of incompetence, all because of a normal, simple, physical response that should disappear of its own accord in time. Another significant result is the victim trying to cope with "avoidance" by himself. The victim makes heroic efforts to resume activities he had ceased doing because they greatly distressed him. Often, out of a desire to prove that he can do it, the victim does not make gradual attempts. When this attempt fails as well,

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 4. Posttraumatic Stress Disorder Treatment

27

the person's feeling of incompetence is magnified, he feels helpless and ashamed, and assumes that his failures are his own fault.

4.8 Cognitive Behavior Therapy Techniques Exposure Foa et al.’s (2000) approach is based on exposure, aiming to help the client cope with his fears. It consists of a two stage model of the learning theory. In the first stage, non-threatening stimuli become threatening. This is a result of linking them to the traumatic event in a classic conditioning process. In the second stage, an avoidance response develops as a means of reducing distress, which is aroused by the presence of the conditioned stimuli (operant conditioning). Recurrent or prolonged exposure (in vivo or imaginal) to essentially non-harmful anxiety evoking stimuli in a safe, controlled framework enables the client to cope and to gain a sense of control over his fear and distress which were overflowing and impossible to process psychologically at the time of the trauma or immediately after. Foa et al. (2004) suggests that exposure techniques lead to a reduction of intrusive symptoms, yet their influence over avoidance and numbness symptoms is less significant. The following are several exposure techniques in PTSD treatment:

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

In systematic desensitization, the processing entails gradual exposure, while relaxing, to stimuli the client is avoiding (e.g., memories of the event, places), which were earlier ranked in a "fear hierarchy" in order of the threat inherent in them. Various studies examining the influence of systematic desensitization show that the accomplishments of the therapy, like the reduction of nightmares, "flashbacks," muscle tension, and hospitalization were sustained two years after the end of the therapy. In the flooding technique, there is an intense, persistent, concentrated exposure to threatening, yet not harmful reminders (e.g., situations, feelings, people) in vivo or imaginal, until the anxiety and fear associated with them either lessen or disappear. Studies show that intensive exposure in the imagination is an effective therapy for PTSD and may enhance the efficacy of standard psychotherapy. Nevertheless, there are potential complications in flooding therapy, such as deeper depression, relapse of alcoholism, or a heightening of a panic disorder. Exposure techniques are geared to reduce the conditioned emotional response associated with the trauma, thereby reducing the level of avoidance of internal and external reminders of the trauma. But people suffering from PTSD often suffer negative emotional situations of fear and anxiety which are not eliminated in this manner, as they are not directly related to the traumatic event. Thus, direct therapeutic exposure is recommended as a supplementary treatment. In general, studies show that the effectiveness of intensive direct exposure is dependent on several factors: Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

28

1. 2. 3. 4. 5. 6.

Chapter 4. Posttraumatic Stress Disorder Treatment

Creating trust and an ongoing positive therapeutic relationship. Explaining the rationale behind re-narration of the event (in a story or in an experience). Clarifying expectations, including a possible temporary worsening of the symptoms. Gaining control over the duration of the exposure and the level of the threat. Focusing on emotionally significant contents at the time of exposure. Reduction of avoidance behavior.

Exposure treatments are not flooding, as they do not use intensified reconstruction of the event and they occur gradually, according to the client’s abilities. Flooding techniques are sometimes dangerous because the client may experience the flooding session as re-experiencing and the horror-avoidance danger learning may be the outcome of such a session rather than success in controlling the anxiety. Thus, flooding per-se has NOT been recommended in recent years.

4.9 Treatments that Combine Exposure with Cognitive Therapy Another factor that is vital for the treatment of PTSD is the encouragement and nurturing of new interpretations of the trauma and its consequences. Foa and her associates (2004) found that the behavioral model does not provide an explanation for the important symptoms of PTSD, such as startling and nightmares. Foa et al (2004) noted that the threat as perceived or experienced by the victim is a stronger predicting factor for the development of PTSD than the actual threat. Thus, cognitive theories, such as information processing, are designed to allow reexamination of irrational thoughts and to equip the client with coping tools.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

4.10 Prolonged Exposure - PE Since the structure of the trauma of those suffering from PTSD is usually stable and integrated, the disorder influences the emotional, mental, and behavior aspects and is very hard to change. According to this approach, people suffering from PTSD are in a permanent state of arousal and anxiety because of their hyper-vigilance and their tendency to interpret ambiguous reminders as threatening. Theories of information processing claim that emotional change can occur only when the client gains full accessibility to the memories of the trauma in order to incorporate corrected information in the 'trauma story'. Therefore, therapy involves activation of the threatening memory by intensive, prolonged exposure, while at the same time providing new information that does not conform to the existing fear structure. Foa and her colleagues (2004) developed the prolonged exposure method (PE), based on this theoretical concept. It is also composed of the following: • Psycho-education - Psychological guidance of common reactions to trauma and their significance to the client's life. • Relaxation training. For example, teaching the client how to breathe calmly. • Continuous prolonged exposure to memories pertaining to the trauma. • Continuous in vivo exposure to situations the client has been avoiding due to anxiety associated with the trauma.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 4. Posttraumatic Stress Disorder Treatment

29

Schnurr et al.(2007) examined the effectiveness of prolonged exposure show that it is more efficacious than no treatment. Comparing PE to other cognitive approaches indicated that PE and cognitive restructuring1 are equally effective, but combining the two simultaneously does not create better results. According to the study conducted by Foa and her colleagues in 1999 which compared PE and stress inoculation training and their combination to a waitlist control group of clients waiting for therapy, PE was the most efficacious.

4.11 Cognitive Processing Therapy Trauma victims report many emotions in addition to fear, rage, disgust, humiliation, and guilt, which are not affected by exposure techniques. Based on the theory (McCann & Pearlman, 1990) that views the trauma as changing the self schema – such as basic beliefs regarding safety, trust, power, self-esteem, and intimacy, Resick & Scnicke (1992) developed a method called cognitive processing therapy, aimed primarily at treatment of rape victims, which is also applied to victims of child sexual abuse. In this technique, the client is asked to recall memories of the trauma by writing about the event and then reading the account out loud. This causes a confrontation with nonadaptive beliefs in five areas - safety, trust, power, self-esteem, and intimacy - by providing corrective information regarding conflicts and faulty expectations that hamper effective coping. This approach is applied in examining the following issues: 1. 2. 3.

Is it possible to predict the outcomes of a trauma? Could the trauma have been changed by any action taken by the client? Is the client significantly responsible for the negative results?

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

This therapy consists of twelve weekly sessions. It has been found effective in reducing PTSD and depression symptoms among rape victims.

4.12 Eye Movement Desensitization and Reprocessing (EMDR) This technique was developed by F. Shapiro (1995) for treatment of anxiety disorders. EMDR combines eye movements with exposure and cognitive processing with the goal of reprocessing and systematic numbing of the traumatic distress. By focusing simultaneously on the painful traumatic images and on the rhythmically directed eye movements, this technique allows the reduction of the intrusive memories and makes them ambiguous. During treatment, the client is asked to choose an event that left a negative impression on him. The therapist helps the client focus on the various components of the experience, including sensory cognitive (negative beliefs), and emotional and physical elements. This helps the client recall the traumatic experience at a conscious level. The client is asked to focus on the memory and to note his different reactions, while the therapist gives bilateral attention stimuli with the aid of a

1

A cognitive-behavior treatment of PTSD, in which the therapist teaches the client to identify and appreciate evidence of automatic negative thoughts and helps him reconstruct his beliefs regarding the trauma, his self, the world, and the future.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

30

Chapter 4. Posttraumatic Stress Disorder Treatment

visual, auditory, or light touch stimuli. This phase ends when the client is capable of returning to the original memory and experiencing it without emotional distress and with a positive belief in himself. Next, the therapist asks the client to recall the memory again together with the positive faith that has come up while processing or that was chosen at the onset of the therapy, and he strengthens this connection. EMDR has been found effective in treatment of various anxiety disorders, among them reducing acute traumatic memories and images characteristic of the PTSD syndrome (Chemtob et al., 2000; Maxfield 2003), as well as reducing negative perception of the self. However, there are contradictory findings regarding the effectiveness of this method concerning alleviation of symptoms in the long run (Solomon & Johnson, 2002). Parallel to the above discussed therapeutic techniques, there are other techniques used in cognitive-behavior therapy: Crisis intervention, improving social skills and coping skills - With anxiety (breathing and biofeedback), negative thoughts (cognitive restructuring), anger, pressure, future symptoms, and the impulse to take alcohol or medicines in a time of crisis.

4.13 Coping Techniques with Anxiety/Stress In contrast to exposure therapies and cognitive treatment, whose goal is to activate fear and mend the pathology at its base, there are a number of approaches that have been developed with the aim of reducing stress when it is aroused by teaching fear controlling skills.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

These approaches are based on the premises that an emotional reaction conditioned to respond to a stimulus associated with the trauma will always occur to some degree. People who have developed a posttraumatic response have to learn how to cope with this response, which has stemmed mainly from existing faulty coping skills. These techniques include teaching relaxation skills, developing resiliency to stress, biofeedback, breathing exercises, teaching social skills, directed self-dialogues, affect management and techniques geared to distract, like thought stopping (a skill to learn self-control over distressing, unceasing thoughts). Of these, the most prevalent approach used in PTSD therapy is stress inoculation training - SIT (Miechenbaum 1985) This approach aims to enhance the selfmonitoring abilities of the conditioned stimuli and the conditioned responses. The client acquires coping strategies which help him reduce the stress reactions as they rise. Among these strategies there are a few techniques such as muscle relaxation, thought stopping, breathing, communication skills, and the most important: directed selfdialogue that often includes renewed cognitive restructuring in order to cope with nonadaptive thoughts. A study by Foa, E., Doron, M., & Yadin, A. (2004)the efficacy of SIT treatment to PE, supportive counseling, and a waitlist control group, showed that SIT was the most effective treatment for reducing PTSD symptoms right after the end of therapy, and that PE was more effective than other therapies in a 3.5 month follow up study. The researcher raised the possibility that SIT provides an immediate alleviation from stress, but the clients do not continue applying the techniques they learned after therapy is over. These findings point to the importance of integrating

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

.

Chapter 4. Posttraumatic Stress Disorder Treatment

31

maintenance techniques (that prevent regression) in SIT with the goal of achieving persistent improvement. In contrast, PE does cause temporary hyperarousal, but it seems that it leads to a permanent change in the memory of the trauma and thereby an ongoing improvement. Since both treatments were found to be effective, SIT is often combined with exposure therapy. This is based on the notion that clients, coping better with daily pressures as well as with trauma symptoms, will acquire a greater sense of control and therefore will have a lesser tendency to avoid reminders of the trauma. The combination of the approaches has yet to receive concrete empirical support. Studies examining effectiveness of cognitive therapy in treatment of trauma victims: Keane, Fairbank, Caddell and Zimering (1989) - A six month follow-up after therapy showed that imaginal exposure led to a greater reduction in intrusive symptoms in re- experiencing the trauma in comparison with the control group. Boudewyns and Hyer (1990) and Boudewyns et al. (1990) researched the effect of exposure therapy on hospitalized soldiers wounded in combat. These studies compared flooding in the imagination therapy or in vivo exposure with non-directive private counseling. Both studies found that exposure therapy resulted in a great improvement in psychological functioning, but there is no account of the level of the PTSD symptoms. Methodologically, these studies are limited as they did not have a “blind evaluation" of the results of the therapy, and it is possible that they were influenced by the researchers' expectations.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Glynn et al. (1999) compared exposure therapy, combined exposure therapy and family-behavior therapy, and a control group. The findings showed that the groups receiving exposure therapy exhibited greater improvement in the re-experiencing symptoms and in hyperarousal than the control group. The addition of family therapy did not enhance the effectiveness of the treatment. This data did not change in the six month follow-up study. Veterans' organizations encouraged those suffering from combat stress reaction (CST) to participate in cognitive therapy programs while hospitalized. Even though there was not enough control over the contents of these programs, evidence shows that they were not very successful (Creamer, Forbes, Biddle & Elliot, 2002). In project "Co-ach" (strength in Hebrew) - a study carried out by the Israeli army mental health department, CST diagnosed soldiers who received in vivo exposure therapy lived for a month under military conditions, during which they received guidance about the aims of the therapy, cognitive reframing, relaxation training, assertiveness training, strengthening of the self, and gradual exposure to threatening cues. A follow-up study which examined the long term consequences of the therapy (Solomon et al. 1992) showed little success compared to the control group and in some cases, a worsening of symptoms. This failure was also attributed to the fact that exposure therapy did not equip the clients with suitable strategies for reducing anxiety and for gaining adequate control over the experience (Bleich, Shalev, Shoham, Solomon & Kotler, 1992).

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

32

Chapter 4. Posttraumatic Stress Disorder Treatment

4.14 Elements of Cognitive Behavioral Therapy for PTSD, Which Are All Important for the Success of the Treatment 1. Psycho -Education - During the first sessions and throughout the duration of the therapy the client is given information regarding common symptoms of traumatic events. In addition, he receives an explanation of how the main symptoms will be treated during therapy. The goal is to legitimize the traumatic response, to help the client understand his symptoms, and to establish the rationale of the treatment. One of the objectives on the way to reaching this goal is to enable the client to become an expert on his own disorder and a partner in the healing process. The client who is aware of the anxiety elements of his disorder will be able to differentiate between "himself" (and his "self") and the disorder. 2. Exposure and Re-Narration - For a few sessions, the client will be asked to repeatedly imagine the trauma, as vividly as possible. This being the aim, the therapist will help the client tell the narrative of the traumatic experience in a manner that emphasizes all of the relevant details, including sensory reminders and emotional responses. The client will be asked to tell the narrative in the present tense, preferably in first person, focusing on the aspects that most arouse distress. Exposure usually lasts 50 minutes and is followed by assignments. An alternative to exposure/ imaginal renarration includes writing descriptions of the experiences, listening to recordings of triggers to aid exposure, and applying exposure through the paradigms of virtual reality on the computer (Rothbaum, Hodges, Ready, Grapp & Alarcon, 2001). The method that will be described here (SEE FAR CBT) uses therapeutic cards to construct the story and the exposure procedure.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

There are different opinions regarding what the mechanisms of exposure that cause change are: a. Exposure encourages habituation which in turn reduces stress. b. Exposure promotes the stress numbing process - desensitization. c. Exposure promotes correcting the belief that stress is permanent unless avoidance exists. d. Exposure enables an elimination of the negative reinforcement associated with reducing the fear. e. Exposure aids in integrating corrective information into the memory of the trauma. f. Exposure poses the trauma as a separate event which is not an indication of the world as being, on the whole, a threatening place. g. Exposure enables self control by managing exposure exercises. 3. Cognitive Restructuring - The therapist teaches the client to automatically identify and evaluate evidence of negative thoughts and helps him evaluate his beliefs regarding the trauma, the self, the world, and the future. Some of the negative thoughts are dysfunctional and harm functioning in various aspects of life. The therapist must identify these thoughts and lead the client to new understandings about them. 4. Anxiety Control Training - The objective of this training is to provide the client with coping skills to assist him in gaining a sense of control of his fears, reducing the level of arousal, especially when exposed to the traumatic memories. Training usually includes stress inoculation training, relaxation skills, thought stopping, and self talk. Note that there is an argument regarding usage of thought stopping, since an attempt to stop or repress thoughts may enflame them.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 4. Posttraumatic Stress Disorder Treatment

33

5. In Vivo Exposure - Avoidance strategies do not enable the client to emotionally process the trauma and to change his non-adaptive cognitions. Therefore, it is important that the treatment bring the client back to situations he has been avoiding. In vivo exposure means repeated confrontation with avoided trauma related situations. In vivo exposure is very effective in reducing extreme anxiety and unnecessary avoidance. It enables the client to realize that these situations are not dangerous and thereby he can change his dysfunctional cognitions. Prior to in vivo exposure, a list must be composed of avoided situations by the client since, and as a result of, the trauma. The therapist explains the subjective units of distress/ discomfort scale (SUDs) and asks the client to rate the intensity of anxiety he expects to feel in each situation when exposed to it.

4.15 Summary

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

As of today, there is not much empirical data regarding the efficacy of the treatment of the posttraumatic syndrome, nor has a treatment been found that provides a comprehensive, enduring solution to the symptoms. Nevertheless, according to a large national survey in the United States in 1995 (Kessler et al.), the duration of the disorder is shorter among trauma victims who sought some kind of help (3 years) compared to people who did not seek help (more than 5 years). These findings show that the various treatments offered to those suffering PTSD may shorten the duration of the syndrome, and this has been substantiated by two large studies from 1998. Up to now, most empirical studies in this field have supported combining cognitive and behavioral therapy for a most effective treatment of PTSD, especially graded prolonged exposure and EMDR. There is evidence that exposure and hypnosis are techniques that mainly have an impact on intrusive symptoms, and cognitive and psychodynamic therapies chiefly influence avoidance and numbness symptoms. It seems that the hardest to treat are the hyperarousal symptoms. A major challenge for all the approaches is to balance the need of the client to confront the trauma with the danger that this exposure will lead to a renewed trauma. Studies show that exposure needs to be long enough to eliminate the response (90 minute sessions are recommended), but at an intensity that will not worsen the state of the client. This qualification can be solved by giving the client control over the intensity of the exposure. The type of therapy chosen should perhaps be tailored to the severity and kinds of symptoms the client exhibits. Thus, for example, clients suffering from marked avoidance will benefit more from exposure. On the other hand, clients suffering extreme hyperarousal or having a disassociating reaction to reminders of the trauma are less suitable for exposure and will gain more out of anxiety management techniques or pharmacotherapy for reducing these symptoms. It is necessary to match the therapy to the type of trauma. For example, guilt and shame may be less relevant to victims of car accidents than to rape victims or soldiers who were engaged in attacking civilians. For the soldiers, exposure may be experienced as having a "sense of being blamed or shamed"; therefore, examining the factors that led to this kind of behavior or finding a way to correct it (perhaps volunteer work) may be more effective.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

34

Chapter 4. Posttraumatic Stress Disorder Treatment

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Research of trauma therapy is limited by nature, as trauma has many negative consequences that exceed PTSD. Effective therapy of trauma victims requires observing beyond the diagnosis. Having multiple problems may influence the choice of an effective therapy. At times, it is necessary to address the other issues before treating PTSD. For example, exposure therapy is less effective for a client who continues to drink alcohol or use drugs. Many victims suffer from severe problems of adapting, mourning, feelings of guilt, suicidal thoughts, somatic complaints, low self-esteem, social problems, and sexual and other intimacy problems. Multidimensional intervention geared for treating these problems may help prevent regression and enhance the long term efficacy of every type of treatment of PTSD.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

35

Chapter 5

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Fantastic Reality2 "Fantastic reality" is, at first glance, an oxymoron, a contradiction of two incompatible terms. The listener wants a clear answer: Was it or wasn't it? Was it in reality or in the imagination? It seems that in the adult world, a world that strives for order and cataloguing, there must be a clear distinction and separation between the two. Is this always the case? Let us recall what happens in the theater. The lights dim, the curtain goes up, we are swept into a magical illusion on stage and fully believe the drama unraveling before our eyes. Meanwhile, the world around us disappears. The reverse happens when the curtain comes down and the lights are turned up. Did it happen or did it not? Is the fantasy lying? Is the reality disappointing? We read fictional stories (and which story is not?) that cause us to laugh and cry in reality, to hold our breaths when huge spiders threaten to devour Harry Potter, and to sigh in relief when the magical car saves him from danger and ascends above the tree tops. We often experience our dreams as real events, and some of us dare to daydream…Findings of various studies show that between a third and a half of our waking hours as adults are spent daydreaming, holding imaginary conversations, fantasizing about the upcoming vacation or imaginative re-narration of a past rendezvous with a loved one (Klinger, 1990). In his book Halom Hanefesh (The Dream of the Soul) (Cohen, 1996, pages 2122), the author quotes the following excerpt from Coch-Strauss and colleagues: "The potential images of dreams and the awakening fantasies offer us the necessary materials to discover and define ourselves. All we must do is to use them wisely. With these channels we can win a fresh, personal, creative perspective of ourselves and the world around us. This will help us go beyond our usual points of reference in our search for solutions to problems we encounter." During childhood there is no differentiation or separation made between reality and imagination. As all the children who believe in fairies will testify, Tinker Bell, Peter Pan’s fairy, demands that the children declare their belief in fairies; otherwise she is doomed to die. What child would agree that such a sweet fairy die? Children can easily go back and forth between reality and imagination. The younger they are, the more this movement is considered advantageous. But adults in our culture try to wean themselves from the ability to imagine, or at least to conceal and hide this ability, lest they lose points in the race to "apparent sanity." This mechanism is at our disposal during crisis and grave danger. It enables us to temporarily detach ourselves from the terrible, life threatening event. We know about this detachment from accounts of rape victims, survivors of traumatic disasters, torture victims, prisoners, and hostages. The victims report this amazing detachment – this disassociation in the service of survival. "It is possible to see these conscious situations 2 Based on the book Metzeut Fantastit (Fantastic Reality) (Heb.), by Professor Mooli Lahad, Nord Publishing, Dr. Ofra Ayalon editor, 2006

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

36

Chapter 5. Fantastic Reality

as one of nature's small graces that shield against unbearable pain….detached conscious situations are similar to a hypnotic trance. In both cases there is a relinquishing of voluntary action, suspension of initiative and critical judgment, subjective distancing or peace, increased conceptualizing of images, changes in feelings including sensory numbness, analgesia, distortion of reality, including detachment from the self, detachment from reality and changes in the sense of time." (Hilgred in Herman, 1992, page 62). "The fantastic reality" is the link between the infinite ability of the creative imagination to create a world picture, desired or required, and the actions taken to solve problems in reality in the shared space of therapy. The fantastic reality is the "as if" space. It is the space where anything is possible and everything is feasible. In this reality the three laws of the "real" world: time, place and role do not rule. In reality things can happen only at a certain time and place, and preferably the person participating will have a specific role. Sometimes people have several roles or more, usually experienced in reality as a burden or a heavy load that impairs functioning; they tend to call it "dual or multiple responsibility " playing many roles at the same time and feeling unable to be in the moment. In the fantastic reality one can shrink time, or stretch it and have things going on here and now and then and there at the same time. The place can be at the same time in the real space (therapy room) and in another magical venue. This place can be inside (a palace, for example) or outside (a thick forest). The client can simultaneously be himself and play another role. The roles can be realistic, desirable, imaginary, etc.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Landy explains the paradox at the core of the dramatic experience: "It is possible that the most significant aspect of the dramatic paradox has to do with the fact that the actor and the role are at the same time separate and united and the reality of the existence of the actor lies in his coexistence with the fictitious reality of the role he is playing” (Landy, 1993, page 11). Winnicott discusses a similar space called "the potential space." This is the psychic space where positive, fulfilling experiences occur; where there is no need for a realistic object and man can move between reality and imagination in a mentally abstract fashion. The potential space differs from person to person. Its existence depends upon life experiences and not on genetic tendencies. According to Winnicott, playing takes place in the in-between space, the space between the child's inner and outer worlds, between reality and imagination. The child takes the object out of its primary function and creates different uses for it. In play it is important that there be objects and accessories, otherwise it is not a game, but rather a fantasy in which the child does not have anything to form a relationship with, anything to meet and depart from, or anything with which to create something new. Both the creativity and the spontaneity of a person are expressed in the potential space. Creativity is the ability to keep something that is a natural part of infancy throughout life - the ability to create worlds. Winnicott claims that the real self is apparent at the point where reality and dreams touch, and the obligation to adapt is not compulsory (Winnicott, Play and Reality (Heb), 2003.) From the above, we understand that the fantastic reality is not a situation in which clients lose touch with real reality or deny it. Actually, fantastic reality enables a temporary experience during which the left hemisphere "relinquishes" control and Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 5. Fantastic Reality

37

command in order to transcend into the "as if" space, the space of unlimited imagination and possibilities. Processes of the right hemisphere "control" this space. They allow insights and solutions of a different kind .But since the "concession" was temporary, the left hemisphere stays alert, and, in the return from transcendence into the fantastic reality, the control and criticism processes of this hemisphere are reinvited to examine which of the ideas that come up pictorially and in images in the fantastic reality are translatable and applicable in reality. Healing or relaxation is experienced by permitting the psyche to act like a child's, capable of creating a world out of light and shadow games. This experience is possible in a noncritical, nonjudgmental, non-righteous space; space that is creative, encouraging and a place where one plays. This is a space where inventing and fabricating stories are allowed, a space to daydream and to fantasize while knowing that the movement from reality to fantastic reality is in the service of the coping self and its goal is not to become detached from the circles of real life.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Definition: The fantastic reality is the "as if" space, where every "if" is possible. It allows the psyche to play again as it did in early childhood, in a space where laws of reality do not govern. In this space it is possible to fabricate stories as part of a journey in quest of answers and insights, of real life situations in which logical solutions are no longer satisfactory. Actually, in the fantastic reality, it is possible to search for logical, metaphorical answers and solutions and images, with the aim of examining how applicable they will be in the future. Often, the journey to fantastic reality and back brings about relief, even when there is no practical application of the "insights" or "gaining of knowledge" experienced. This relief may stem from the "distancing for the sake of bringing near" principle. Being in fantastic reality is often experienced as a state that simulates a trance. It is possible that the resulting relief is composed of the sensorial experience of all early childhood abilities that enable the adult sharing this to experience what Winnicott calls creating a world. In mainstream psychology and psychotherapy, the action of transcendence into fantastic reality during or immediately after a traumatic incident (and certainly later on) is considered to be dissociation, Dissociation is described as a state in which some integrated part of a person's life becomes separated from the rest of the personality and functions independently and is one of the strongest predicators of PTSD. In some studies, the closer in time this occurred, the greater the chances were of it being a major risk factor predicting the possible development of PTSD. In 2003, Ozer and others found that peritraumatic dissociation - PTDIS that occurs in close proximity to the event, at its margins, predicts a higher risk of developing PTSD (they claim that 70 percent of those who have experienced PTDIS at the acute stage (ASR) will develop PTSD). However, in a critical review of dissociation, Bryant (2007) questions whether it is in fact a critical predictor. One attempt to study the PTDIS was recently made by Kaplansky in her doctoral research (2007). She examined the link between the ability to transcend to a fantastic reality and PTSD. Looking for definite PTDIS, she decided to work with people who had been in life threatening traumatic situations and voluntarily described a situation that was closely associated with fantastic reality. Kaplansky examined a group who had had near death experiences - NDE. The people in this group were exposed to an extreme life threatening event (cardiac arrest, rape, terrorist act, road accidents etc.). They gave an account of the event which included the following fantastic reality elements:

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

38

Chapter 5. Fantastic Reality

transcending, a tunnel with light at the end, an encounter with spirit beings, a feeling of being "out of one’s body," and a sense that "life flashed before my eyes like in a movie." As this phenomenon occurs at the PTDIS stage, it might have made the group at risk for developing PTSD. Kaplansky's research replicated Greyson's findings from 2000 and found that the NDE group not only did not suffer PTSD but its scores on the anxiety and dissociation scales were low in comparison to both the general population and to clients diagnosed as suffering from PTSD. When she checked the PTSD group she then expected them to have no NDE experience; however, this was not the case. The study shows that clients suffering from PTSD also had NDE. But unlike those who enjoyed transcendence into fantastic reality (almost 70% of the stories included floating, light, meeting figures and the like) the PTSD group’s most common NDE experience was "seeing my life flash before my eyes" (over 10 times more). This experience is the closest to experiencing reality and includes elements of guilt, deep sorrow at relinquishing life, and no joy at encountering the light or the spiritual beings. Looking for a potential explanation in the childhood experiences of the NDE group that might have "trained them to transcend into fantastic reality, Kaplansky asked them about childhood imaginative activities. Her study displays a clear distinction between the NDE group, the control group and the group suffering from PTSD in terms of the way they used imagination and its outcomes in their childhood: playing musical instruments, dancing, painting, doing something in the arts and most of all, storytelling and story listening. Those who reported experiencing NDE surpassed the rest in the length of time and the intensity of their stay in the fantastic reality, and yet maintained their ability to move back and forth between fantastic reality and reality.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

This study raises the possibility that children who "practiced" transcending into the fantastic reality and whose parents encouraged such activity, developed steadfastness in extremely threatening situations. Kaplansky maintains that dissociation is a natural attempt of the human mind to protect man from fear of exposure to death and to trauma. Not everybody succeeds in fully using this mechanism. Kaplansky proposes to differentiate between full dissociation – NDE - and partial dissociation. The former "saves" the exposed person from the fear of death, the latter continues the desperate attempt of the mind to complete the transcending process to fantastic reality to no avail. The PTSD stays trapped in parts of dissociation that make his life a misery. This study is one of the foundations on which we propose to use fantastic reality in treatment or in re-narration of the trauma. This will enable the individual to combine fantastic elements in an otherwise impossible and unbearable event so that he can go through the healing experience that dreaming and transcending make possible. From the prospective of the memory theory, we can understand that combining fantastic elements in treatment of trauma victims is founded on the thorough complexity of the human memory, as seen especially in the memory of traumatic events. Tulvig & Garlik (2000) point out dozens of types of memories, each with its own characteristics. The traumatic event, by definition, has elements resistant to forgetting. Traumatic events fortify the appearance of flashbulb memory, known for its resistance, Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 5. Fantastic Reality

39

but this does not contradict another characteristic, related to the abilities to promote distortion of what was experienced. Trauma is accompanied by damage to the ability to concentrate. This influences the way the mind codifies, thus creating gaps in the continuity of the memory. Since trauma causes the precise semantic memory to become fragmented, the emotional memory fills in the gap. The emotional memory includes images, feelings, and information that is not accessible for semantic processing. The dual representation theory (1996) of Brewin et al. similarly proposes that the traumatic information is processed in one of two memory systems and creates two separate representations. The first system is the verbally accessible memory (VAM). This system processes autobiographical memories of the event and is associated with the later verbal description of the trauma. Information that did not receive enough attention in order to be saved in the VAM, is codified in the situationally accessible memory (SAM). This system saves sensory information, especially the visual-spatial, in the shape of images.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Using images in therapy, including creating positive images and associating them with negatively charged ones, rests on the dominance of the SAM system and the traumatic memory. This kind of work has proven most effective.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

40

Chapter 6 Principals of the Somatic Experiencing System3

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The traumatic response is man's reaction to a situation that is either life threatening or poses a threat to his self-integrity. The possibility of a freeze response, also known as a shock reaction, is a brilliant strategy that is applied by the lower, more primitive sections of the nervous system. As noted, earlier this is a strategy of "playing dead," based on the fact that many predators prefer to kill their prey and devour it, rather than to eat an animal already dead. In addition, this strategy numbs one's emotional and physical sensations. When the shock subsides and the heart rate goes back to normal, the animal which was almost a victim gets up on its feet, regains its bearings, stumbles a bit as it resumes walking, and shakes off the energy it trapped while in a freeze response. It then resumes its daily routine. Even though human beings activate similar strategies, exiting the freeze state does not come easily to them and they do not always complete it successfully. On the surface, it seems that a person is resuming his routine. On the face of it, it looks as if he is not in a freeze state nor is he paralyzed, and his functioning is normal (walking, talking, carrying on as always, even at work). But often this is just a facade covering the freeze reaction and the inability to discharge the trapped energy. People relate to their subjective experience in descriptions such as: "I can't think clearly”, “I feel my decision making ability is paralyzed”, "I feel unstable," "I can't return there yet" (to the scene of the event), "I see it (the event) over and over again in my dreams," or "I still feel his hands touching me." Not discharging the energy will manifest itself in hyperarousal, jumpiness, and irritability - known symptoms of the post traumatic response. Why a person does not easily release the trapped energy: A. Feelings of helplessness and hopelessness are often at the base of man's freeze reaction. This brings about persistent beliefs such as: "I can't do anything to save myself." This belief, like others of this type, is integrated, becomes fixed, and after a few various functioning failures, it often becomes a self-fulfilling prophecy. It seems that man constantly fails to save himself (he cannot resume working, his marital life is failing, and others). These kinds of beliefs are products of cognitive processing and interpretations carried out by the neo-cortex as a result of bodily hyperarousal. In these functions, man's developed neo-cortex acts against the instinctive healing reactions (releasing trapped energy), that are naturally led by the most primitive part of the brain (the amygadala). B. Often man does not relate physical signs of discharging energy to the reaction to the traumatic event, and he misinterprets them as signs of weakness and distress. In 3

In this chapter we bring only parts of the SE method. The reader is invited to broaden his knowledge and training in SE therapy in specialized courses.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 6. Principals of the Somatic Experiencing System

41

addition, reactions of trembling and shivering, which many people experience after an extreme threat, are conceived by society as inappropriate and therefore may embarrass them. These kinds of reactions can have an impact on the significant functions of the body: Therefore, ER doctors tend to suppress them and to view them as problematical symptoms. In fact, these bodily reactions may be signs of the body's attempt to discharge trapped energy.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

C. Recurring trauma may cause the nervous system to stay in a state of hyperarousal. As a result, resuming a homeostatic state might be very difficult. A basic principle in Somatic Experiencing is that trauma is in the nervous system, not in the event. The autonomic nervous system is designed to handle charge or activation or stimulus from life events and functions to help us literally digest everyday experience much like our digestive systems are naturally designed to digest lunch. We don't have to think about "working" on the salad and then the soup or sandwich. Our bodies know how to take and absorb what is needed and eliminate the rest. The nervous system basically operates in the same way but more like an electrical system that gently fluctuates, keeping our energy levels within a manageable range. The sympathetic branch of the autonomic nervous system charges up and energizes us and the parasympathetic branch helps us discharge excess energy and relax. When confronted with the overwhelming threat, it is as if the nervous system is wired for 110 volts and is hit with 220. Tremendous defensive survival energies of fight, flight and/or freeze are mobilized when we instinctively react to danger. The over-arousal or high activation of both branches of the autonomic nervous system can result in deregulation and often a jamming occurs that causes either flooding, or freezing/ dissociation. The Somatic Experiencing (SE) method was developed by Peter Levine, a doctor of biophysical medicine and psychology, founder of the Foundation for Human Enrichment (FHE). The treatment is described in his book, Waking the Tiger (1999). He organized some terms adopted from Gendlin, Bendler and Rossi in a new way. His method is based on the understanding that the traumatic event floods the nervous system. When in danger or being threatened, the brain and the body prepare themselves to cope by calling up a great deal of energy that will enable survival behaviors (freeze/flight/fight). When an external or internal break is put on survival behavior, the energy is trapped in the body. If this energy is not naturally discharged when the danger has passed, then remnants of the experience remain in the body and either develop into posttraumatic symptoms or become permanent personality patterns, defenses, and reaction patterns to pressure. Body language, the physical sensations felt by the individual, is the key to going forward through the incomplete traumatic response. In a long enabling process, the therapist helps the client to consciously reconnect to the bodily sensations, to reunite the five sensorial factors of the experience, and to overcome the freeze reaction. The five components of the experience are: sensations, imagery, behavior, affect, and meaning. Each component is a different channel of experience; therefore, a different channel for treatment intervention. Since the physical sensations are a primary component and not a mediator, they enable direct, very effective access to the experience. SE is actually a systematic method of unfreezing and of drawing out feelings of helplessness and hopelessness. The process is slow and by nature not cathartic, thereby allowing the necessary time for healing: enough time so that the nervous system is not rattled and does not undergo another shock. This method adapts itself to the individual

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

42

Chapter 6. Principals of the Somatic Experiencing System

situations and to the unique history of every client; therefore, it cannot be prepared in advance. It encourages the natural therapeutic abilities of the body, and to that end, uses an individual's own sensations and the guidance of a professional, well trained for the job. One may wonder about the fact that this method employs the same sensation that caused the freeze response, as part of the healing process. The experienced sensation is important in the therapy because it is the cornerstone to every developmental advancement in life and because detachment from the experienced sensations is a common outcome of the response to trauma. The attempt to detach oneself from the sensations is often expressed in the fear of experiencing bodily sensations. Nevertheless, it is the key to recovery. Learning to discern between symptoms and good sensations makes it possible to develop strong inner healing resources. These resources will enable an individual to go through the traumatic response and the symptoms.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The basis for this therapy is in the metaphor: "Life is a river running its course." When its route is blocked, the river goes around the barrier and, if necessary, creates a "healing vortex" which softens and "melts" the obstacle and allows the river of life to get back on course. A huge, insurmountable barrier may sometimes fall into the stream. The river will "try" to use the healing vortex. If the barrier is too big and it is impossible to "melt" it, the river will overflow in all directions. It will then create vortices that may rake and sweep everything that stands in their way. These are the "trauma vortices." In close proximity, the "healing vortex" continues its efforts to bring the river back to its regular course, but to no avail, as it is not strong enough. Levine believes that both vortices appear together, because they are often situated in the same place in the body. The "trauma vortex" appears in great strength, while the "healing vortex" is comparatively weak and in need of fortification. This strengthening is carried out through work with the body, together with psychological processing.

Trauma Vortex

Healing Vortex

Illustration # 3: The Trauma and Healing Vortices Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 6. Principals of the Somatic Experiencing System

43

This system teaches us how to identify senses which are felt. It also deals with gradual discharge of trapped energy and with changing fixated response patterns, while being wary of hyperarousal. A strong emphasis is placed on balancing between strengthening a person’s resources and processing traumatic memories. This method enables healing of the natural ability to self regulate, thereby preventing future traumatization. To become a professional SE therapist one should go through the various levels of training. We are only making use of the parts that we have found helpful for SEE FAR CBT protocol, but this book does not attempt in any way to prepare one as a SE therapist. The goal of Somatic Experiencing is to guide a client through a natural process in which the body and mind become more aware of the safety and resource of the current moment, that the moment of danger has passed, and the client can ease into the moment in a more relaxed state. From this place of resource, of “the cup being half full,” so to speak, allows the person to face bits and pieces, more and more, of the experience that was traumatizing, but only from a resourced place. Often, in this process, the pent-up energy is released gently, perhaps with shaking, tears, sweating, or various other physiological and emotional responses. This is done very gently, never exceeding what a client can handle at one time

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

6.1 The Main Components of the SE Method Focusing - Focusing is the process whereby the person is asked to concentrate his attention on certain sensations (good and pleasant, as well as frightening or repulsive) effortlessly. Focusing on the different bodily sensations separately intensifies them and enables the client to acknowledge that the comfort or discomfort derives from the body and from the sensory system, more than from the exterior surroundings. In the end, focusing enables the integration of individual sensations into one complete experience and the development of the ability to "listen" to the body. According to Dr. Peter Levine, through focusing we develop our ability to listen to the “felt sense,” "…the vehicle through which we experience the entire sensation" Levine 1979 (p. 80), which allows "the connection with the instinctive self," Ibid (p. 85). During focusing it is important not to try to interpret or explain what is happening but rather to experience, to observe to and accept things as they are. Titration - Regulating the pace of therapy so that it will not cause hyperarousal or hypoarousal of the autonomic nervous system. The therapist consciously avoids directly entering the "hot" area of the trauma, and, instead, progresses gradually and patiently with the client, one step at a time. The psychological discharge of trapped "frozen" energy will be possible only after the client negotiates with the trauma, and renews his acquaintance with his felt sense and with his vital energies. It is important to give the client the feeling that he controls the pace. Resourcing - Raising the client's conscious awareness of the 'felt sense of pleasant memories of successes, of pleasant sensations or events, and how they are remembered in the body. Anchoring them in the body will be the next step to be used as a helping tool in the discharging process.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

44

Chapter 6. Principals of the Somatic Experiencing System

Pendulation - A real or imaginal movement between polarities (such as pain and relief, painful sensation and its boundaries).The effect of this movement in many cases results in the discharge from the body of entrapped energy, distress or traumatic memory. This is achieved through swinging from the part of the body that is free from sensations of distress and focusing on the felt sense of resourceful sensation, to the parts of the body where there is an awareness of bodily pain, sorrow or suffering (trauma). This action is central to EMDR where bilateral stimulation (pendulation effect) is achieved by moving the eyes or tapping on the left and right shoulders or knees. It is also used in Education Kinesiology (EK) in which the client is encouraged to cross his center in various ways. How this occurs is yet unknown but there is a great amount of evidence supporting the relieving effect of pendulation, otherwise known as bilateral stimulation. Trauma Vortex - An outburst and then pandemonium surfacing after a traumatic event. Peter Levine describes this as a tormenting tailspin of visual images and memories that traps the victim in feelings of helplessness and loss of control. Healing Vortex - An innate ability to cope with difficult situations, to rehabilitate and regain equilibrium. This ability is based on the steadfastness and the elasticity of the brain that reshapes under the influence of new experiences and relationships. At the time of a traumatic event, the healing vortex begins to work parallel to the trauma vortex.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Anchoring in the Body - A process of awareness of sensations that awaken in the body whilst the client focuses on the felt sense. This is a process whereby the client is asked to focus on the sensation (pleasant or unpleasant) and to try and describe the sensation in colors, shapes, textures, temperature, size and pace. When the client is aware of the image and sensation, he is asked to put his palm on that body part and thus "remember" the place and its sensation. The process helps the client to anchor the image in the body and to be able to recall it and evaluate it on a scale known as SUDs from 0-10, that is, from a pleasant to an unpleasant sensation.

6.2 Discharge: Release of Distress and Physical Distress Peter Levine observed how animals cope with extreme stress (including threats to their lives). He noticed that animals discharge distress by certain actions. Examples include trembling, excreting urine or excrement, or the way a dog emerging from water shakes it off. Humans are taught to hold back any uncontrolled discharge. The first learning of the young child is nonverbal and focuses on how not to discharge involuntarily. That is called "toilet training." As early as a few months old, the human baby learns that you do not discharge at any time nor any place but rather only at designated places when time permits. Thus, we teach our children from early on to hold back their discharge and control it. This practice, which is important for our socialization, extends to other forms of discharging, for example, crying (those nearby quickly run to dry the tears, so the crying stops) or trembling when experiencing shock (those close-by hold tightly and calm the person down), being happy (parents often scold their child for being "too" joyful, or yelling (the immediate response of the environment is to quickly silence the yeller).

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 6. Principals of the Somatic Experiencing System

45

According to Levine, treating trauma should include raising the client's level of awareness of the body's discharge of pressure processes, encouraging him to be aware of discharging signs, to be aware of these signs, not to block them and not to be frightened by their occurrence but rather to feel satisfied that the body is discharging the unpleasant physical memory. It is important to teach the client not to get upset or embarrassed when it happens. Expressions of discharging bodily pressures: • • • •

A desire to use the toilet. Yawning, hiccupping, burping, farting. Crying. Sweating, shaking, waves of heat, trembling, feeling cold, itching, tingling, shuddering. • Swallowing saliva, clearing one’s throat, coughing. • Free laughter, smiling, involuntary batting of one's eyes, a sense of trembling of the nose or other parts of the face, heavy breathing, a deep sigh of relief. The client is told by the therapist that he will point out to him whenever he notices these expressions so that he can slowly teach the client to identify the discharge signs and observe them without any effort or worrying. In time, this awareness will enable these bodily pressures to get out of the system, weaken slowly or to disappear. The instruction is usually: "Follow that sensation without any effort or plans and see what happens…

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The Importance of the 3S Principal Studies examining the difference between the response of the neo-cortex (NC) and the limbic system (LS) show a ratio of 1:7 in responding to threat or processing. At the time of a critical incident, when the survival system - fight-flight-freeze - is working quickly4 to save us, the NC works more slowly. This is why one acts quickly and only afterwards comprehends what actually happened and starts thinking of what might have happened if…However, when we process traumatic memory, recalling and telling is rather easy whereas remembering the physical sensations and the "emotional memory" is much harder. For example, when a client says, "I am a coward. I am a frightened chicken," the therapist reframes this behavior by saying "It sounds as if you were very careful." This might be a supportive message and might have a calming effect. The following table demonstrates this clearly:

The Part of the Brain

At the time of an Event

At the Processing Stage

LS

Quick

Slow

NC

Slow

Quick

4 In a controlled experiment the fear reflex started two tenths of a second after hearing a frightening sound and ended 30 tenths of a second after the sound was heard (Goldman, D. 2005, page 42).

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

46

Chapter 6. Principals of the Somatic Experiencing System

From this we learn that since we are at the processing of the experience stage, we will use a slow pace by silently counting seven seconds between posing a new question when addressing sensations or the LS. In order to help the therapists to pace with the LC we use the 3S principle. The 3S principle is the basic principle for working with the amygadala and the limbic system:

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Simple - Ask small, concrete, simple questions. Slow - Work slowly. Sensation - Focus on the sensations

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

47

Chapter 7 Anchoring Resources in the Body using the Integrative Model of Resiliency BASIC PH Historical Overview of Stress and Coping -"The Survival Game" Historically there were several theoretical attempts to describe the human code of survival. Some of these attempts tried to present an exclusive explanation, whilst others tried to highlight one aspect in relation to previous theories. One can deduce from these attempts six fundamental elements in explaining human survival. Freud (1933) stressed the affective world, both inner (i.e. unconscious) and overt, (projection and transference) and it is Freud who stated that early emotional experiences, conflicts and fixations determine the way a person meets the world. Often this unconscious part overrides the transactions of the real world. His students and colleagues, Erikson (1963) and Adler, (1956) albeit from a different angle, highlighted the role of society and the social setting in the way a person meets the world, Adler in his theory of inferiority and the drive for power and Erikson in his eight stages of development

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Jung, who was originally a student of Freud's emphasised the symbolic and archetypal element, imagination, "the culture heritage" and the fantastic inner and outer world. Jung also mentioned intuition as one of his types. Other psychological theories have dismissed the whole idea of psyche and emotion and have attempted to describe the human behaviour in terms of stimulus and response. This has been called behaviourism, but we suggest that they should be called physiologist, because their theory suggests neuro-chemical chains of reactions result in behaviour (Pavlov 1927). Before long, the cognitive school found its own theory about the way a person meets the world and they phrased it "It's all in the mind", or cognitive processes with errors of thought or perception. Last but not least we have the belief and meaning stream, presented by Maslow and later developed into a psychological theory and psychotherapeutic approach by Victor Frankl (1963). Based on his extreme experiences of the Holocaust he founded the Logotherapy Movement. We believe that these exclusive attempts to describe human psychic life have many disadvantages and that human psychic life is more complex than the theoretical attempts to describe it on one or two dimensions. In our approach we tend to relate to the six dimensions that in our experience underlie the coping style of the client: Belief and values, Affect (emotional), Social, Imaginative, Cognitive, and Physiological. We have named it BASIC - Ph. It is this multi-modal approach that suggests a combination between these elements in the unique coping style of each person.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

48

Chapter 7. Anchoring Resources in the Body using the Integrative Model of Resiliency BASIC PH

Obviously, people react in more than one of these modes, and everyone has the potential to cope in all six modes, but each person develops his own special configuration. Most of us at different times have a preferred mode or modes of coping and will use this extensively. From hundreds of observations and interviews with people under stress (Lahad 1981, 1984) it is apparent that each individual has a special way of coping and combining coping mechanisms. In our research of coping mechanisms under stress (Lahad 1984, 1989), we have found different coping styles. There are those whose preferred mode of coping is cognitivebehavioural. The cognitive strategies include information gathering, problem solving, self navigation, internal conversation or lists of activities or preference. Another type will demonstrate an emotional or "affective" coping mode and will use expressions of emotion: crying, laughter or talking with someone about their experiences; or through non-verbal methods such as drawing, reading or writing. A third type will opt for a social mode of coping, and receive support from belonging to a group, having a task, taking a role and being part of an organisation. A fourth will use imagination either to mask the brutal facts, by day-dreaming, pleasant thoughts, or divert their attention using guided imagery; or try and imagine additional solutions to the problem that go beyond the facts -improvisation. Type five will rely on belief and values to guide them through times of stress or crisis. Not only religious belief are meant here, political stands beliefs or feeling of mission (meaning) are also intended, the need for self-fulfilment and strong "self" expressions. "Ph" type people are those who mainly react and cope by using physical expressions together with body movement. Their methods for coping with stress are relaxation, desensitisation, physical exercise and activity. Expending energy is an important component in many modes of coping.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

7.1 Resilience How does the personal BASIC Ph develop? One approach is through the studies of resilience. Resilience is defined as self-stabilising and overall healthy patterns of development which lead neither to a career of disordered behaviour (drugs, delinquency etc.) nor to manifest mental or psychosomatic syndromes. It is noteworthy that temporary oscillations of individual behaviour on the health - disorder spectrum under impact of an acute stressor are implied, but in the medium and long-term a remission of symptoms should occur. The individual degree of resilience is understood as being relative in so far as quantitative and qualitative variations cannot be ruled out (Koferl 1989). It is only in this decade that empirical psychology has begun to conceptualise resilience applying models which are based explicitly on the idea of healthy or adaptive development in the face of stressful influences, rather than by using derivatives of stress - disturbance models. In retrospect, research into coping with stress has also produced decisive contributions. The primary appraisal category, "challenge" in Lazarus' stress model is particularly worthy of consideration (Folkman and Lazarus, 1988). The transformation of the trend towards negative pathogenic effects of a stressful life event through coping and reappraisal processes into a new homeostasis promoting psychological and physical health is of outstanding importance for resilience research. All most recent variations of mainline stress models have, since the mid-eighties, taken account not only of psycho-

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 7. Anchoring Resources in the Body using the Integrative Model of Resiliency BASIC PH

49

pathological syndromes but also of variables in psychological health and well being, (e.g. Lazarus et al 1984, Moos 1984). Empirical research has gained many insights into factors and mechanisms which are important to the development of a resilient person - environment relationship. These findings can be redefined and categorised within the model of BASIC Ph. B, Ph The way of coping and managing a single stressor or multiple risk factors, the decisive question being whether a person merely reacts or also acts (e.g. Rutter, 1985). C, B A low tendency towards problem avoidance or fatalism (e.g. Losel et al., 1989). B, C Cognitions of self-efficacy and self esteem (e.g. Rutter 1985). A, S Availability of an emotionally stable and trustworthy person during early childhood (e.g. Brandt 1984). S Stable emotional relationships with and positive experience in social communication, with other (extra-familial) persons including a social support network of functional size, as well as satisfaction with the different types of support received. S, A, Ph Temperamental characteristics of a child which favour de-escalation and selfcontrol in general as well as in acute crises but which also promote an overall uncomplicated child-parent relationship, even if both parents are in chronic discord (e.g. Chess and Thomas 1985). B, A, C The ability of the child to accept delay in gratification (e.g. Murphy 1987). I, C Curiosity, Motivation and joy in exploratory behaviour already as an infant, as well as motivation to observe and listen (e.g. Murphy 1987). C Higher IQ (e.g. Felsman and Valliant, 1987).

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

B, I, C An open educational climate directed towards the acquisition of autonomy (e.g. Losel et al 1989). S Socially competent behaviour despite chronic stress; helpfulness; popularity with peers and taking on of responsibility for siblings and sometimes also for ill parents (e.g. Werner 1989). Ph Physical attractiveness, particularly in girls (e.g. Elder et al, 1986). Thus we see that BASIC Ph can serve as a model for understanding coping and resilience. Stressful situations become unbearable when they are prolonged and we are no longer capable, using the resources at our disposal, to be rid of or to lessen the stress. Under circumstances where repeated attempts do not avail, the situation could turn into a crisis. Many times a situation becomes a crisis because the individual uses "more of the same thing" to be rid of the stress. In other words, a person becomes set in the mould, using the same mode of coping endlessly, neither progressing nor changing anything. In this case the crisis stems from being stuck or from inflexibility. (On a primary prevention level our "multi-modal approach" aims to teach the individual a number of different options in order to gain flexibility in coping with stressful situations rather than reach a dead-end).

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

50

Chapter 7. Anchoring Resources in the Body using the Integrative Model of Resiliency BASIC PH

In crisis situations it is normal for people to feel bad, but they are not actually "ill", simply, their current distress is too hard for them to cope with. Hodgkinson (1991) suggests that up to 50% of the population exposed to disaster will be potential candidates for crisis intervention. From experience we have learned that some will stay for lengthy treatment, many will meet with us just a few times and a minority will have just one or two meetings. In short-term intervention during emergencies there is no time to develop prolonged contact or for taking long case histories. BASIC Ph is a model to understand the strengths of the client and supply a framework which will enable the therapist to decide whether to suffice with crisis intervention or to introduce short-term psychotherapy. Therefore, the task of the therapist in crisis intervention is to assess and help develop those useful behaviours as soon as possible. (Short-term intervention must identify as quickly as possible the client's mode of functioning and make decisions on the basis of the understanding of this situation.) The practical difference will be that in crisis intervention, the therapist will use what he found existing within the BASIC Ph and in short-term psychotherapy the therapist focuses on what is missing and on the negative coping aspects indicated.

7.2 Locating Resources In order to help clients to locate their resources, we go through the six potential channels and check them. If the client responds to any of the channels, this channel will be 'anchored' for him.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

To check the various channels, we ask the clients to go through the simple relaxation/ focusing process and then to close their eyes and check the following six components. However, all the resourcing processes of the BASIC Ph can be used with eyes open. B (Belief) - What belief helps you feel safe? Do you have any psycho-philosophical statements about life that help you? (For example: "If it doesn’t break me, it will make me," or "I can.") Is there any object that you see as an amulet or keep as a talisman? Focus on this. Close your eyes and check where in your body you sense this. A (Affect) - What emotion makes you feel safe, comfortable, and relaxed? (Repeat the anchoring in the body process.) S (Social Support) - When in distress, who would you want at your side? In your memory, who is the person that helps you in tough times? Imagine someone in your current life that would make you smile and feel happy if he entered the room now. (Again, anchor in the body.) I (Imagination) - Imagine a "safe /pleasant place." C (Cognition) - Thought, Reason, Being Realistic: Which past experience helps you cope? Do you remember an event you learned a lesson from? Try to recall a calming thought. (Keep the thought, shut your eyes, listen to your body…) (Again, anchor in the body.) PH (Physics) - Body: Focus on: Food you like, feeling relaxed, caressing a beloved pet, holding a baby in your arms, physical activity (sports, dance, movement). (Once again, anchor in the body). Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

51

Chapter 8 SEE FAR CBT Therapy Model

SE

Fantastic Reality

CBT

Let us summarize. The model combines three systems:*

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

1. Somatic Experiencing - SE - As mentioned earlier, this technique focuses on the physical memory (which was embedded in the limbic system). Focusing on good sensations and emotional resources as well as on bad sensations with the purpose of discharge is the basis of the therapeutic process. 2. Fantastic Reality - FR - At the basis of this technique are the "as if" (or "if") space and the use of imagination. In many cases PTSD clients will be overwhelmed by compelling thoughts and remorse: "If only I hadn’t gone…, If only I had listened to my wife…, If only the bus had been a little late…, If only I had not tried to use my cell phone whilst driving… It seems as if they wish reality had been different and the unfortunate event had not taken place, It is interesting to note that even when a person was not at all responsible for what happened, he may still suffer from this remorse. Having identified this natural reaction, the model is makes use of this tendency but in a positive way. Thus, the FR encourages using the fantastic imagination to add wishful thoughts and elements to the original story with one condition: that these additional elements do not change the outcome of the incident. 3. Cognitive Behavioral Therapy - CBT - A focused method that includes psychoeducation, imaginal re-narration, in vivo exposure and new cognitive reconstruction. The protocol phases:* See Far CBT is a phase -based protocol that does not compel the therapist to adhere to sessions or stages as we rely on the therapist's assessment as to when to continue to the next phase. A detailed intake interview combined with an assessment and diagnosis of PTSD (see the Clinician-Administered PTSD Scale (CAPS) - Appendices sheets.) 1. Psycho-education - An explanation of the essence of the PTSD phenomenon, including a discussion about common responses; a survey of the different approaches to therapy: SE (the body remembers), in vivo exposure, re-narration in the fantastic reality and the use of therapeutic cards and cognitive processing 2. A mutual decision that therapy is necessary.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

52

Chapter 8. SEE FAR CBT Therapy Model

3. Clarifying the objectives of the therapy. 4. Relaxation, creating a safe/nice place in various ways (the imagination, a card, and others.) and anchoring in the body. 5. Examining avoidances and building an in vivo exposure hierarchy, practicing in vivo exposure, desensitization, practicing exposure in the FR. 6. Re-narration in the fantastic reality using therapeutic cards; continuing to practice in vivo exposure. 7. Processing hot spots that surfaced in the re-narration in the FR, using cards; practicing in vivo exposure. 8. Summary and evaluation of results). * The necessary materials are in the appendices (questionnaires, information sheets and other materials.)

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Important to Remember • SEE FAR CBT therapy simultaneously combines several elements and techniques: psycho-education, relaxation through exhalations, "a safe place" (in the imagination and using therapeutic cards), anchoring in the body, in vivo exposure, re-narration in the fantastic reality through cards. Thus, the above described phases do not necessarily represent a linear continuum of the therapy. For an illustration of this continuum, see the chapter 10 titled: The Structure of the Sessions - An example of a Ten Session Treatment • We cannot "erase" traumatic memories. A traumatic memory is frightening and saddening, but it is not dangerous!!! • Re-narration in the fantastic reality is necessary for significant relief of the symptoms. • In vivo exposure is important for learning and gaining control over anxiety. • Without the client's comprehending the price he is paying for his avoidances, he will not be motivated to make a change. (A certain degree of suffering is necessary to create motivation for change.) • It is important that the therapist relinquish his position as the knowing and interpreting therapist (the interesting therapist), and instead be interested in the client. In other words, he should not be interesting, he should be interested! Only in this way will he make it possible for the therapeutic process to take place.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 8. SEE FAR CBT Therapy Model

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

SEE FAR CBT Model

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

53

54

Chapter 9 Therapy Phases 9.1 Phase One of Therapy - Intake Interview, Evaluation and Diagnosis A. A Detailed Intake Interview (See the "Intake Questionnaire for Trauma Victims"- Appendices sheets.) In order to conduct an intake interview we will use the "Intake Questionnaire for Trauma Victims" which is in the Appendix. Points included in this interview are: the reason for turning to therapy, the current condition, the central traumatic event, other traumatic events, and the client's personal history. The purpose of the interview is to enable us to get to know the client as a whole entity and not merely the symptoms he is suffering from. This interview makes it possible for us to make the primary therapeutic contact with the client and the first construction of the therapeutic alliance. B. Assessing the Symptoms, Diagnosis and Evaluation of Severity

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

With the aid of the questionnaires at the end of the book (attached as an Appendix: BDI, PDS, CAPS, questionnaire for evaluating posttraumatic dysfunctional cognitions), we will try to assemble a comprehensive and detailed picture of the symptoms the client is suffering from. This picture will help us in making the decision as to whether to enter therapy (phase 3) and in planning it and setting goals (phase 4). In addition, the assessment made at this point can be used for comparing the client's situation before and after therapy. 9.2 Phase Two of Therapy -Psycho-Education: PTSD and Approaches to Therapy Psycho-Education about the Essence of the PTSD Phenomenon and its Manifestation (See "What is a Post Traumatic Response - Information Sheets for the Client," Appendices sheets.) It is very important that the client be given the information sheets ("What is a Post Traumatic Response") that are in the appendices of this book. Psycho-education has a few central objectives. The first is normalization: to make the client feel that the therapist understands what he experienced, and that usually his responses to the “abnormal” traumatic event he experienced are normal. Another objective is to enhance the client's feeling of having control of the situation, a sense of control stemming from knowledge. Another aim should be to strengthen the possibility that the client will become the 'professional expert' on the anxiety disorder he is suffering from. This expertise will help the client change his understanding and behavior, as he will know and understand his physical and psychological responses as reminders of the trauma.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 9. Therapy Phases

55

Another objective of the psycho-education is to solidify the relationship between the therapist and the client, especially the feelings of trust the client has in the therapist's professionalism and in his ability to help him. It is important to keep in mind that information gives a sense of control and weakens the feeling of insecurity and anxiety. Discussing Common Responses to Trauma with the Client as Part of PsychoEducation 1.

The main responses that people experience after trauma are fear and anxiety.

Do you feel frightened, tense, pressured? Anxiety responses are often a result of recalling the trauma (e.g., assault, car accident, terrorist attack). Many times there may be a feeling that anxiety appears suddenly for no apparent reason. Have you noticed whether you are more anxious at certain times or in specific circumstances? Frequently, there are reminders in the environment or situations that act as "triggers" which might remind you of the trauma and awaken your fears. These reminders or situations may be (depending on the trauma) certain hours of the day, specific places, a man who approached you, an argument with a person dear to you, various odors, noise among others. Have you noticed the exact triggers that remind you of the trauma?

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

It is possible to understand the feelings of fear and anxiety you experience as reactions to your assessment that the situation is dangerous and that your life is in danger. It is likely that you are experiencing changes in your body, feelings and thoughts resulting from the alteration in your world view and your sense of safety due to the trauma. Post trauma fear and anxiety are usually experienced in two central ways: a) persistent re-experiencing memories of the trauma, b) physical arousal, jumpiness, vigilance, and startle responses. In response to these sensations you may avoid human company and isolate yourself from others as you avoid situations which remind you of the trauma. Let us now talk about these. At times a "flashback" can be so strong that you feel the trauma is recurring. This is an intrusive experience. You may feel that you have no control over it, or over your thoughts, feelings and over what you experience. Sometimes these experiences awaken as a result of external triggers. At other times they seem to appear for no apparent reason. You may also experience the traumatic event in your dreams. Do you have nightmares? What physical changes do you feel when you wake up from nightmares? You are apt to re-experience the trauma in your thoughts or feelings without "flashbacks" or nightmares. Have you had distressing thoughts or bad feelings regarding what you went through? 2. Difficulty concentrating is another common response to trauma. Do you have difficulties in concentrating on reading, following a conversation, remembering things you were told? Tell me about it. What does not being able to concentrate mean to you? Difficulties with concentration, memory, and paying attention to the world around you are both frustrating and annoying. These experiences are likely to cause you to feel loss of control over yourself and your thoughts, or that you are losing your mind. In the effort to digest and comprehend what has happened to you, your brain goes over the Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

56

Chapter 9. Therapy Phases

material related to the event, but it does not process it, it only re-narrates it again and again. Difficulty in concentrating is a result of intrusive, painful feelings and memories of the trauma, and attempts to control them. 3. Another usual response to a traumatic event is hyperarousal. This can be expressed in irritability, nervousness, jumpiness, over alertness, trembling, easily being startled, problems in concentrating and sleeping. Have you noticed these changes in your body since the trauma? Are there times when you experience panic? What happens to your body? Sweat? Increased heartbeat rate? Are you especially alert or vigilant? Do you startle easily? Persistent sensations of tension and jumpiness can cause irritability or "a short fuse," especially if you are not getting enough sleep. Do you feel irritated or angry? Have you observed trembling or anger attacks? Have you paid attention to whether you are more impatient than you were prior to the traumatic event? These changes in your body are the outcome of fear. Animals and man have a number of responses to extreme fright, attack, or threat. One reaction to danger is to freeze. You might have seen a mouse freeze in fear as a cat approached. Other reactions to threat are fight or flight. For example, a cat arches its back and unsheathes its claws when attacked by a dog. The responses of flight or fight require an "adrenaline boost" so that the body can be activated into reacting to the threat. In consequence of the trauma, you understand that there is danger in the world and you wish to be ready for any encounter with it. Therefore, the body, your body, is constantly alert and you feel ready to react quickly to any danger that comes your way.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

4. You may find yourself avoiding situations, places, people, and things that remind you of the trauma. Avoidance is a defense strategy for use in situations which you feel have become dangerous and when you feel that thoughts and feelings cause a sensation of flooding and tension. Are there set places or specific things which are difficult for you to be exposed to as a result of the trauma? Are you making an effort to avoid thoughts and feelings connected to the trauma? How are you doing this? What things are you doing in your effort to forget what happened to you? At times, as a result of the great desire to avoid memories and feelings related to the trauma, it can become difficult to remember certain aspects of the event. Are there memories or parts of the event that you have a hard time recalling? Are there inexplicable time gaps? Another experience that might occur as a result of the efforts to avoid painful thoughts and feelings related to the trauma is emotional numbness. Do you feel emotional numbness, emptiness or detachment from the world around you? Have you lost interest in things you found enjoyable in the past? Do you feel distant or detached from others since the trauma? 5. Additional responses to a traumatic event are sadness and other symptoms of depression. You might experience feelings of hopelessness, despair, and frequent crying attacks. From time to time you may even have thoughts of hurting yourself or committing suicide. Loss of interest in people who in the past appealed to you and in activities that were once enjoyable is also related to the trauma. It is possible that nothing seems fun and joyful, and you may feel that there is nothing to live for and that plans you made for the future are no longer relevant. The feeling that nothing is enjoyable any more may be painful and may push one to despair. Do you feel sad or

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 9. Therapy Phases

57

depressed? Do you cry easily? Do you feel stuck or hopeless? Do you have suicidal thoughts or feelings that there is nothing to live for and you would be better off dead? (If there are suicidal thoughts, an assessment of the risk of suicide must be made and a decision taken whether it is possible to resume this therapy.)

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

6. Anger is also a widespread response. The anger is usually at injustice and unfairness, and at your feeling a victim. In cases of rape or assault, most of the anger is geared at the perpetrator for the damage he caused (physical danger, taking advantage, breaking into your personal space, or taking what was not his to take). Anger may erupt also in the company of people who remind you of the trauma or who have healed and suggest that all is fine with them. Many survivors are also angry with God for allowing them to be taken advantage of, to be assaulted or to fall victim to this kind of trauma. Often survivors are angry at the police for not doing enough after the crime was committed or at the rescue squads and hospital staff for not treating them with enough sensitivity. Survivors are also angry at their friends and families for making them feel that they do not understand what the survivors have undergone. Do you have feelings of anger or aggression? Do you feel differently than you did prior to the trauma? How do these emotions affect you or others close to you? 7. At times the anger is so great that one wishes to harm someone or to curse. If you are not accustomed to feeling anger you may have difficulties identifying and coping with these harsh emotions. Many people also direct anger at themselves because of things they did or did not do during the trauma. Directing anger towards oneself can cause feelings of guilt, blame, helplessness, and depression. Many people find themselves experiencing anger and irritability towards those close to them (family members, friends, parents and children). Is this something that is happening to you? Many times you may lose your patience with those you care for most. This may be confusing as you might find it difficult to comprehend why you are angry with those who are so important to you. Even though closeness may be pleasant, it also raises the odds of experiencing intimacy, dependency, vulnerability, and helplessness. Experiencing these emotions in an interpersonal relationship can bring about irritability and anger because they are somehow reminders of the trauma, or of the lack of trust in people that you feel as a result of the trauma. It is possible that you expect more from those close to you, and therefore when they let you down there is a good chance that your reaction will be anger. 8. At the time of the trauma, unexpected and sudden things occurred, which threatened you, and it is possible that you were forced to, or had to do things against your will. It is possible that you felt that you had no control over your emotions, your body, and your life. Often, feeling loss of control can be so intense that you may feel as if you "are going mad," or "losing your mind." Have you experienced these emotions since the trauma? How was it for you? Have you found anything effective in coping with these emotions and thoughts? 9. People who have experienced trauma might have feelings of guilt and shame. Guilt and shame may be connected to things you did or did not do in order to survive the event. The attempt to guess how you should have behaved or what you should have avoided, and the tendency to self blame are also common reactions. Do you blame yourself for what happened? Do you feel that if you had acted in a different way, or

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

58

Chapter 9. Therapy Phases

had avoided doing something, the trauma would not have taken place? Are there people or things that you avoid because they make you have feelings of guilt or shame? It is important to remember that you are not responsible for what happened to you in cases of rape, assault, robbery and terrorist attack. You did not ask to be harmed or to be treated like this. I believe that no one has the right to harm you, regardless of what you did or did not do. Even if you feel that you made an error in judgment, the "punishment" is not commensurate with the "crime." People make mistakes in judgment every day. Feeling guilty for what happened has to do with your conception that you are solely responsible for things you had no control over (the rapist, the driver, the weather or other things related to the nature of each specific trauma). Taking responsibility for an event and feeling guilty about it may give a sense of control, but it can also cause helplessness, depression, and negative thoughts about oneself. Feeling guilty can also be caused by acquaintances, family, friends, and society, since quite frequently people blame the victim. Has anyone blamed you for the trauma you experienced? What do you think about this? Would you blame your close friend if something similar happened to him?

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

10. Trauma can also hurt one's self image. You might say to yourself that since bad things happen to you, you are "a bad person." Or you might say "if I was not so weak and stupid, this would not have happened to me," or "I should have been more of a hero." Do you have negative thoughts about yourself? It is not unusual to experience the world in a more negative manner and to suffer difficulties in close relationships after a trauma. If you thought that the world was a safe place prior to the trauma, then you may now be convinced that the world is a dangerous place and that you cannot trust others. These changes are a result of fear and anger and you might grow distant from activities you liked and people whose company you enjoyed. In addition, you may discover that the people you love the most are not as supportive as you had expected them to be. Does this sound familiar? Have you noticed having difficulties with other people? It is natural to feel anger, pain and guilt when a loved one gets hurt. You may find out that friends, family or partners have a hard time hearing about the event and they may have an extreme reaction to what happened. It is important to understand that some of the people around you are also experiencing a crisis. Think about how you would feel if this event happened to your partner, to your child or to a close friend. At times, one needs to learn to forgive others even when they do not react to us as we expected them to. Support from your family or from others close to you is an important part of your recovery. It is vital to talk to people who can help you, support you and understand your emotions. Psycho-Education of the other components of the treatment protocol: SE, In Vivo Exposure, Re-Narration in the FR and Cognitive Processing (See information sheets, Appendices sheets). The following passages can be used by the therapist when explaining the approaches to be applied in the therapy: "In the therapy we will concentrate on anxieties and on the symptoms that you have that are related to the trauma, and on the difficulties you have coping with life tasks in Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 9. Therapy Phases

59

the post-trauma period. Many people who have experienced trauma suffer from symptoms that diminish and even disappear with time. There are also many other people who like you, have had traumatic experiences, whose symptoms do not weaken, and continue to cause them great distress. At the time of trauma something happens to our body. People, like other mammals and even reptiles, when confronted with a sudden extreme threat, usually react in one of three ways: fight, flight or freeze. Posttraumatic symptoms repeatedly re-narrate these physical responses that are embedded in our "body memory". The fright, the fear, the escalating tension or paralysis, and helplessness are trapped in the body, even if we do not clearly recall exactly where and when we felt them. It can be said that the physical response to trauma is kept in the body memory or got stuck in the body like a 'bad' food that is giving unpleasant sensation in the belly, until it is out. However unlike 'bad food' you didn't have a chance to get rid of it and what you did was to ignore it, avoid it or avoid anything that would trigger it. These sensations continue to influence your behavior without your being aware of it. In therapy we will try to focus inwards, into the physical sensations and various messages our body transmits to us. We will learn to identify and understand body language and we will look for a way to discharge the energies trapped in it as a result of a trauma. In fact, we will try to arouse the "body memory" in order to achieve energy discharge. In this process we will get help from the pleasant, "safe" body memories in order to cope with those that are distressing and threatening. The discharge will enable us to be freed of the freeze response as well as the helplessness, tension, and unpleasant arousal responses, and to rid the body of them.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

It is interesting to examine how the body remembers. Let us carry out a simple exercise: Try to remember a favorite food, a sweet you love. After you have recalled it, try to imagine the food or the sweet. Do you remember? Now examine in your body how you know you like the food. Sensation and knowledge are the "body memory." The ability to imagine will be one of the main abilities we will employ in therapy. It will help the body and thoughts get free of the impact of the trauma. We will search for different images that will help us relax, and other images that will enable us to take a look at what we experienced. With the help of the imagination we will be able to connect with our physical sensations and even influence them. The imagination will also make it possible for us to search for creative solutions to daily situations and to reach a better understanding of ourselves. One of the main reasons the symptoms persist after the traumatic event is the avoidance of situations, memories, thoughts, and feelings related to the trauma. It is natural that after a traumatic event people either wish to forget everything or to avoid memories, situations, and thoughts that cause pain and distress. In the short run, avoidance helps diminish the distress, but in the long run avoidance preserves the symptoms and gets in the way of healing from the trauma. Can you think of things that you have been avoiding since the trauma? Or things that you liked doing and you don't do them anymore (because of the incident)? Are there things you simply can't bear: listening to certain music, going to noisy places, crowded places? Are there things you just "don't feel like doing." Let's write all of them down. When we agree to confront or deal with the things we avoid through 'real-life' experience "in vivo exposure," to experience situations in reality that we have been Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

60

Chapter 9. Therapy Phases

avoiding, and the painful memories of the traumatic event that are often accompanied by distressing physical sensations, then the opportunity to process the traumatic experience will be opened to us. Only when we relinquish avoidance, we learn that the memories themselves are not dangerous (even if painful and frightening), and that most of the situations we are avoiding are not as dangerous as we perceive them to be. Exposure will bring us (you?) in touch with the anxiety level associated with these situations but gradually you will feel a decrease in the symptoms and they will weaken. To achieve this we will use several processes: in vivo exposure (that is, graded tasks to be carried out in reality), re-narration in the fantastic reality (a gentle graded process of recalling the event using therapeutic cards), and cognitive processing of ideas and feelings that have come up while re-narrating and during in reality exposure (in other words, we will change our beliefs regarding ourselves and the situation). In vivo exposure is exposure to things that you have been avoiding since the event because they are direct or indirect reminders of the trauma, for example, being in crowded, noisy venues; driving a car after an automobile accident. It is important that you know that these exposures will be carried out gradually and only if you are ready for them.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Re-narration through the fantastic reality system. Its objective is to assist in processing the traumatic memory by bringing up in the imagination an event or events that keep coming back to us as part of the posttraumatic disorder (intrusive memories), as well as images and feelings associated with them. During therapy the therapist will ask you to re-narrate the traumatic memories with the use of the cards, again and again in order to lessen the anxiety level or the discomfort that the memory causes you. Cognitive processing focuses on negative beliefs and thoughts. After a trauma, most people conclude that the world is unpredictable. They feel that they do not have any control or the ability to cope with events that take place. Consequently, they perceive the world as absolutely dangerous. As a result of trauma, people also develop a very low self image. These thoughts cause anxiety, avoidance and depression and they fuel the PTSD symptoms. As a result of these beliefs, a person may constantly be tense and therefore feel less efficient in managing or coping with daily situations that call for responsibility. In this treatment we will learn to identify the beliefs formulated as a result of the trauma. We will re-examine them and see if and how they can be altered. In the first stages of the therapy, you may feel that the symptoms have gotten worse. You may experience intensified feelings of fear and anxiety. Involuntary recollections may be more frequent. It is important that you remember that this is not a default in the treatment; rather, it is a sign that the therapy is progressing in the right direction and that the material that was closed in an "iron box" in a disorganized, disorderly fashion, has become accessible and available, and as a result, reorganized in the memory. As therapy progresses and the memories become organized and processed, these emotions and symptoms will weaken until they become more bearable, or completely disappear. At times you may feel that the therapy is boring, oppressive, and tiring, and you might even wish to terminate it. These feelings are very common and usually they are a known sign of progress. They are indirect evidence that important things are going on in the brain. Of course, the choice to stay in therapy is in your hands, but bear in mind that these emotions do not necessarily mean lack of success nor are they a reason to stop therapy. The treatment is a long, hard, gradual process that requires a lot of

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 9. Therapy Phases

61

patience. That being said, the objective is to bring considerable relief of the suffering and a significant improvement in the quality of your life. To reach this goal it is often necessary to cope with unpleasant feelings. It is also worth mentioning that over 80% of those who went through this protocol experienced very significant reduction in symptoms.

9.3 Phase Three of Therapy -Deciding to Get Treatment A Mutual Decision that Therapy is Necessary

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The decision to get treatment is an important stage in the therapist - client relationship. It has a great impact on the developing trust between therapist and client, and on the client's expectations from the therapy. Making this decision is the first experience of the therapy duo in doing something together, while attempting to come to a mutual understanding, and coordinating expectations and willingness "to rely on and trust" one another. It is important at this stage to address the expected difficulties in therapy and the high level of commitment, willingness, and hard work expected from the client in the next stages. The client must be prepared for this. At the same time it is essential to reassure the client, and make it clear to him that we will be there for him and at his side whenever he is in an upheaval or when the therapy leads him to an encounter with painful memories. Mainly, we will emphasize that the first steps of the treatment will be to teach him methods to reduce arousal and that whenever the process becomes difficult for him, we will determine exactly how much he can bear and adjust the pace of progress accordingly or use these methods to calm down, at the same time encouraging him to make the effort to go forward. From the prospective of the therapist, it is imperative to give ample consideration to the suitability of the client to the SEE FAR CBT system. Many factors should be considered. Among them: how motivated the client is, additional psychiatric disorders and socioeconomic aspects that may hinder the therapy (for example, difficulty getting to therapy because he cannot afford a babysitter for his children). These factors may not necessarily lead us to the conclusion that it is not worthwhile to start therapy, but they will require attention. Sometimes practical solutions must be found at this stage, like consulting a psychiatrist, or recruiting a family member to stay with the children during sessions. For both the client and the therapist the decision to begin therapy has a ceremonial nature: the onset of a joint quest whose objective is to lessen the intensity of the symptoms and improve the quality of life.

9.4 Phase Four of Therapy - Clarifying the Objectives Clarifying the Objectives The therapist together with the client must succinctly summarize the main symptoms the client is suffering from. This should be based on what came up in the detailed intake interview (phase one) and a general impression. These symptoms will be defined in terms of a specific therapeutic objective, which will change the client's daily suffering into a list of attainable objectives.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

62

Chapter 9. Therapy Phases

It is very important that both therapist and client understand that the client is suffering from a post trauma disorder. This understanding will help the client identify some of his automatic reactions as symptoms he is suffering from, and not as personality traits over which he has no control. For example: "One of the objectives of our sessions is to lessen the number of times that you startle and jump when you hear a door slammed shut." Another example: "Another objective of the therapy will improve the quality of your sleep, so that you find yourself less and less often getting out of bed at night and roaming the streets with a heavy heart." In order not to cultivate unrealistic expectations from therapy, it is of utmost importance that the objective be written as "lessening" the symptoms and not "erasing" them. In stating the objectives, special attention must be given to identifying the special features of the client as reflected in the symptoms and to combine details that came up in the intake interview (for example, avoiding thrillers) so that the client can identify himself in the objectives. It is also of great significance to pay attention to the relative level of discomfort or suffering each symptom causes the client (at times to his family, as well). This may serve both as incentive and will define the place of this hindrance in the hierarchy of importance for reduction. The therapeutic objectives will be presented to the client so that he can give his comments and approval or disapproval; and for him to express his commitment to them.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

After showing the client the objectives, he can be asked, "Would you be interested in these objectives for our sessions?" If the client does not agree with the objectives or objects to the wording, he should be asked how he would write them, or whether he would like to have different objectives for this therapy? It is important at this stage to establish an agreed sign the client will use to indicate that he feels overwhelmed and wishes to have a break in the session until he recuperates and is able to continue. This permission to say "STOP" is important in order to give the client a sense of control, yet it must be understood that the therapist will challenge this request so that both will be in agreement of how to proceed after the "break."

9.5 Phase Five of Therapy - Relaxation, A Safe Place and Anchoring in the Body At this point the client is taught relaxation techniques and anxiety control. Relaxation through exhaling and using a calming word (see also "Anxiety Management Techniques" (Appendices sheets). 1. "This relaxation technique is based on focusing on breathing, chiefly on exhaling. This is usually relaxing and can be used by you as a tool at a time of need. Focus on your normal breathing pace. Take note: When you inhale your chest rises and when you exhale your chest comes down. Follow your breathing without exerting an effort." 2. "Try to inhale as much air as you can. Try to completely empty your lungs. When you get to the end of the exhalation, stop and count to three and then let the "body's intelligence" inhale as much air as the body needs."

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 9. Therapy Phases

63

3. "Repeat the first two stages three times." 4. "Now think of a word that means restfulness, calmness or relaxation. Say the word in your heart while exhaling. Exhale, let the air out, wooo, and say the word, for instance, calmnessssssssssss…. " 5. "Practice this a few times and resume a normal breathing rate."

A Safe/Pleasant Place One of the most important things to do when treating a client suffering from emotional trauma is to create a safe/pleasant, secure under control atmosphere, together with experiencing safety, and control. In every therapeutic process it is important to create the feeling of safety as part of the therapy relationship. However, in order to help a client who frequently suffers from sudden acute anxiety which takes over, and who takes extreme measures to avoid contact with triggers that might awaken this anxiety, it is especially important to actively "teach" him how to create a safe/pleasant place and to enhance the feeling of control of the level of anxiety.• Moreover, merely going to therapy for the treatment of trauma lessens the degree of avoidance of dealing with the subject and confronting the frightening memories that may exacerbate the anxiety. Therefore, it is imperative to teach the clients how not to allow the memories to flood and awaken such a high degree of anxiety that it makes them feel the event recurring here and now.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Most trauma therapy systems teach the idea of a safe place mostly through guided imagery, recalling a pleasant safe place from the past; some methods include a physical memory. The special feature of the SEE FAR CBT system is that it anchors a sense of a safe/ pleasant place in the concrete outer image that can act as a safety valve in cases when anxiety becomes acute and the client re-experiences the traumatic event in an unbearable fashion and loses some degree of touch with reality (dissociates or panics). In contrast to this experience of flooding, lack of control, and detachment from one's immediate surroundings, the safe/pleasant place acts as a safe, intimate, protected, available personal space, to where one can, by choice, return when the internal or external reality is frightening or paralyzing. After a stay in the safe/ pleasant place, it is possible to renew contact with reality and sometimes to look at the causes of the acute anxiety in vivo. External anchoring in an image or photo (in SEE FAR CBT) or in a card, enables the client to reduce subjective anxiety by "anchoring" in a calming image. The therapist uses the card as a concrete tool which is, after many rehearsals (in a learning process) associated with the ability to lessen frightening arousal. We call the state of being overwhelmed or over-frightened arousal, "boiling." The main thing we want is to work with "hot" material associated with somatic experiences and kinesthetic, sensational memories. We do not want to reach boiling or over-flow. •

Anxiety Management Techniques – Information Sheets for the client are at the end of the book.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

64

Chapter 9. Therapy Phases

Practicing recalling anxiety or arousal and lessening them, by using the external "safe / pleasant place, a card, enables the client to use this technique at a later stage, in various situations in his life in which he experiences threat or overwhelming anxiety.

Ways to Create a Safe/Pleasant Place In this section we will describe a number of alternatives for creating a safe/ pleasant place and how to anchor it. A safe place using guided imagery – Ask the client to choose a real or imaginary place, out in nature (seashore, garden etc) or inside (for example, at home or in a castle). It is important to find out the details prior to embarking on a comprehensive description in guided imagery: a portrayal of the place, the colors, the weather, and the sounds. What is your place in this space? What is pleasant to you there? Are you by yourself or with others? Special odors /scents? After establishing the details, it is possible to give an extensive description to the client (with closed or open eyes), and to re-examine whether this is indeed a view that enables him to feel safe/ pleasant. In the next stage, while relaxing, the entire picture is described in detail and it is anchored in the body (see section on anchoring in the body).

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

A Safe/Pleasant Place through Cards with an Extension in Drawing, with the Safest Place and with Focusing • The client is asked to choose one card from a number of cards the therapist has spread before him. These cards describe pleasant, safe, quiet, or neutral places. Under no circumstances should cards that describe horror scenes be displayed. • The client puts the card he chose on a white sheet of paper, placing it anywhere. He is asked to extend the background around the card, with lines, colors and shapes (not necessarily to draw!). • The client is asked to look at the card and the space around it and try to find the place that gives the clearest feeling of calm and/or safety and/ or quiet. • The therapist asks the client to concentrate on a regular breathing rate whilst focusing on that special place. Then he is asked to try to "photograph" and memorize the image in an attempt to preserve it in his memory. The client is instructed to shut his eyes, and see if he can "see" the image in his mind's eye… • If the image is changed with another pleasant picture, it is possible then to remain with the new picture. If it "gets lost" or if an unpleasant picture surfaces, then it is possible to open one's eyes and to resume focusing on the safe place you have traced in your image, at the same time paying attention to normal breathing. When the feeling of anxiety has eased, try to close your eyes again and continue to focus on the safe/pleasant image. • One can continue the entire process with open eyes. At the end of the process - eyes should be opened very slowly, and the client should look at the image at the place that was identified as "pleasantest and safest;" then he should be asked if he would like to change the picture or add anything to it. At this point the client is encouraged to change the picture or add color or details so that the

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 9. Therapy Phases

65

'space' will be just right for him or if he so wish, to start all over again and create new surroundings. There may be situations where the client will ask for more than one card. This is permissible. In such instances, it is best to encourage him to create a joint space for both cards. In some situations, after opening his eyes, the client will ask to remove part of the card. The therapist can assist him either by concealing the unwanted part, or photocopying the card and cutting out the undesired segment. Of course it is possible to create a safe place using postcards or photographs cut out of magazines.

Anchoring in the Body When the pleasant picture exists, it is important to anchor the feeling associated with it in the body. This is done through the following instruction: "whilst holding the image of the safe/pleasant place in your mind's eye, try to locate in your body how you know that the image you chose and focus on represents a pleasant, safe, calm place. Where do you feel or sense it in your body? What is its size, shape and color/ texture/ temperature? If you have an answer to one or more of these questions, and if you can, place your hand on the place in your body where you feel the pleasant sensation." This is called sensation anchoring. The principle of anchoring in the body is important because the client can use the safe place during therapy sessions when he is overwhelmed, frightened or anxious to reduce his tension to a manageable level and outside therapy, to rehearse relaxation or to control unpleasant sensations or anxiety.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Steps in Locating a Safe Place in the Body There are clients who have difficulties locating the safe place in their bodies (focus and anchor). They can practice tracing it by carrying out one of the following exercises: • Smiling - "With eyes shut, imagine that a person you really like enters the room, whose mere entrance makes you smile from ear to ear. Be aware of the feeling or sensation this image causes and focus on it. Ask yourself where in your body do you know that this person really makes you smile?" (From this point resume the regular anchoring process.) • As an alternative you can ask the client to imagine a photograph of a baby or a pet animal sitting on his lap. • Ask the client to focus on the picture of the memory and when it is clear in his head, to take a deep breath. Now instruct him to locate in his body where it feels good to hold the baby or the pet. When the client imagines this, continue anchoring in the body. The act of anchoring is carried out by locating the sensation and asking the following questions: Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

66

Chapter 9. Therapy Phases

What is the location in the body? Does this sensation have a shape? Does this sensation have a color? Does this sensation have a temperature? Does this sensation have a texture? Does this sensation have a size? Does this sensation have movement?

Figure # 4: Creating safe place through therapeutic cards with extension in drawing

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

9.6 Phase Six of Therapy - Exposure In vivo and Exposure in the Fantastic Reality Exposure In vivo Hierarchy In vivo exposure is a very important, inseparable part of the healing process from PTSD, especially among clients suffering from a high level of avoidance. The basis for many avoiding behaviors lies in the client's continuous belief that the anxiety will continue forever unless he avoids these situations or runs away from them. Furthermore, he goes on believing that the situations are objectively dangerous. He maintains this belief every time he quits an activity or situation that somehow provokes any anxiety, Quitting the situation reduces the fear instantaneously and the cognition that is fostered is "life is dangerous; I am helpless and the only thing that helps me is quitting or avoiding getting closer or dealing with these situations. Slowly, slowly there are more and more things that the client avoids until he is hardly doing anything. In order to help a client gradually resume roles and functions he has been avoiding and to be freed from the shackles of fear and anxiety, the therapist must convey the message that "even though the world is not one hundred percent safe, it is also not one hundred percent dangerous. We have relative safety that can enable us to live and function in the world." The first step of in vivo exposure is composing a list of behaviors, places, interactions the clients does not do since the trauma and then creating a hierarchy of trauma related Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 9. Therapy Phases

67

situations, of various levels of fear, which the client has been avoiding even though, as such, they are not dangerous. Next, the therapist and client together compose a list of various tasks, including exposure to anxiety-causing situations. Even though the client ultimately chooses the exposure situations and the tasks, the therapist should recommend in vivo exposure situations which will increase the odds of the client's success in completing the tasks (that is start with easier, less frightening tasks) and thus gradually climb up the hierarchy ladder. Usually the first exposure task is a situation with which the client has minimal coping difficulty. The more success the client has with the exposure tasks, the harder they get. This can clearly be seen in the drop in the level of the SUDs - Subjective Units of Distress Scale (a subjective measure that we will discuss soon) during and between exposures. Managing unpleasant situations teaches the client that the world is not always dangerous and slowly helps him to regain control over his life. These successes prove the advantages of exposure to the client and thereby help to convince him of the rationale of the therapeutic process. In addition to situations that awaken anxiety, the gradual exposure process should also include situations and activities that the client avoids, those that were a source of pleasure in the past, but since the trauma the client does not feel like doing, for example, putting on makeup or sitting in a quiet, pleasant coffee shop. When the client copes with painful experiences instead of avoiding them, he gets a chance to process the traumatic experience, and the distress will gradually subside. Anxiety will subside following repeated encounters with the avoided situations. As a result of this process, the intensity of the symptoms and pain associated with the traumatic memories will decrease. The confrontation enables the client to learn that anxiety does not last forever. It is proof that the client can bear the anxiety. It is important to emphasize to him that the longer and the more he is exposed, the greater the reduction of the symptoms.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The list of in vivo exposure tasks and situations is divided into four categories: 1. Not dangerous and not frightening: A stimulus that is associatively related to the event, but clearly, in its own right, is neutral and contains no element of danger. One example might be avoiding listening to a certain song or singer. The connection between the disaster and the specific song is personal and associative. Dealing with the song is not dangerous or frightening. 2. Somewhat frightening but not dangerous: For example, for a client who has had a car accident, who finds it frightening to stand on his porch and look at cars, since doing so is related to his traumatic experience. Clearly there is a chance he might witness an accident. But as a spectator from the porch he is not in danger. 3. Somewhat dangerous: For instance, for the client who has almost drowned, wading in shallow water is somewhat dangerous. The shallow water is related to the danger; it is close to the dangerous experience but it does not pose immediate danger. Another example, for the client who avoids driving after a car accident, to get into a car and drive it in a mall's empty car park can be somewhat dangerous, but usually is not. 4. "Does not feel like it": This is a category of behavior the client does not act out. It does not make him anxious; it only gives him a dull, incomprehensible feeling that he "does not feel like it." For example, since the event, a woman does not go to the Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

68

Chapter 9. Therapy Phases

hairdresser because "she does not feel like it," even though in the past she was strict about her appearance and went to the hairdresser several times a month. The therapist trying to convince a client who "does not feel like it" to try in vivo exposure will say, "Nothing ventured, nothing gained" or "The more you try it, the more you will like it." It must be emphasized that this category does not awaken anxiety, but only discomfort or embarrassment. It is useful for initial in vivo exposure. It is only an overture. The main emphasis is on the in vivo exposure tasks of categories 1-3. It is advisable to collect as many "avoidance behaviors" as possible, without any attempt to prioritize them in the first place. Ranking In vivo Exposure Situations (See the "In Vivo Exposure" form - Appendices sheets).

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

As stated earlier, in order to measure the feeling of discomfort or distress we use the Subjective Units of Distress scale - SUDs. This is a subjective self-assessment of the level of distress experienced on a scale of 0-10 or 0-100. One can actually use the term thermometer as a good metaphor for this measure. • The client is asked to go over (with the therapist) the list of avoidances and to give them a rating (0-100) that will reflect the degree that the situation or task causes him discomfort/distress. The scale starts at O - no discomfort and ends at 100 unbearable distress. • Scales permitted are 0-10, numbers used are whole: one, two and so on, or halves: .5, or 0-100, numbers used are tens and fives (e.g., 65). The scale does not permit fractions such as 0.75 or 1.45. • It is important to establish the sense of "0." It is best to ask the client to think of a safe place as a sense of "0" or to ask him, "How did you feel before the trauma?" • After assembling a list of at least ten items (of all categories), ask the client to rate them on a scale of 0-100, just how frightening it was to carry out each item. • When using the SUDs measurement with children, it is advisable to have them imagine a thermometer ranging from 0-100, or to take 10 blocks and to explain to the child that "the greatest pressure" is when all ten blocks are piled one on top of the other or are in one line, and "the least pressure" is when there is no block in the line or in the pile. • When a client gives most or many items the same scale the therapist can ask him: Is the 90 SUDs you gave for entering a shop the same as the 90 SUDs you gave to being alone at home. This may help the client to make a more "accurate" rating. • If the client gives an item which is too complex, such as being on the beach at sunset, we can ask and what about midday, what will the SUDs be then? Or sitting on the porch of a coffee shop and looking at the beach at sunset is the same as walking by the beach?? at sunset? And so we get smaller aspects that have different SUDS and can be exercised as a 'gradual exposure' process. In vivo Exposure tasks (See Homework form - In vivo Exposure Report sheet Appendices sheets) • In vivo exposure tasks are graded. The objective in the first stages is to give the client a sense of success. To this end, it is recommended that the first few assignments be at a SUDs level of 25 or 30.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Chapter 9. Therapy Phases

69

• It is important that the homework assignments have more than one item to carry out. Homework should be "checked." Only in this way will the client feel that he is making progress. • When an item's distress intensity has dropped towards 10 or 15, a new item can be given. It is imperative to encourage the client and give positive feedback for every success, no matter how small. • The client must be allowed to carry out his tasks by himself as much as possible and in accordance with his age. • It is important to carry out in vivo exposure 2-3 times a week. • The therapist must explain to the client about getting used to a situation, numbing of anxiety, and the natural descending curve of anxiety. In other words, when encountering threatening reminders, at first anxiety heightens and only after a while does it begin to gradually drop. In continuation, tasks given should last about 40 minutes, the time the literature acknowledges as the stage when a panic attack subsides immensely • The therapist must make sure the client does not skip stages of the in vivo exposure in an attempt to heal too quickly (for example, he may try to carry out a task whose level of distress is too high for the moment). An attempt of this kind is characteristic of some of the clients who repeatedly experience failure, because they underestimate the degree of tension that accompanies certain experiences. Thus, they find themselves failing at seemingly easy tasks, which fortifies their sense of helplessness in the face of the disorder and depression. • When a client fails to do his homework, it is imperative to study what happened carefully and check if the task was too complex (in fact, too many sub-items could be drawn out of this task to make it gradual) or the original attributed SUDs were misjudged by the client and in fact, the task aroused more fear. • At times the client may report that he did the task but the SUDs levels did not change. Yet again, study carefully what happened, did he followed the task completely was he doing "safety behavior" to control his fears (e,g, sitting in a restaurant, facing the entrance, trying to judge whether every customer who came in was a threat.) or was he distracted by something (looking at the lighting in the mall and thus, not 'seeing' the crowd, or using an MP and listening to music at high volume to divert attention from the shop.

9.7 Using Desensitization Prior to beginning re-narration in the fantastic reality of the traumatic incident, it is important to coach the client and get him used to the process of recalling unpleasant events (at first, events that are not related to the trauma) without 'overflow' of emotions. It is extremely important that the client feel safe, protected, and able to control his internal thermometer. To this end, we coach the client in the process of desensitization. The process may used at times to prepare the client for the in vivo exposure.

Stages of Coaching Desensitization 1. First the client will find the card of a safe place, then he will create a safe space around it, including locating "the safest or most pleasant" point. He will then establish

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

70

Chapter 9. Therapy Phases

the sensation by fully anchoring it in the body (preferably we will help the client to establish more than one resourceful place in the body). We should remind the client of the types of discharge when we deal with unpleasant memories and the importance of reporting on these sensations and not blocking them. 2. Ask the client to recall an unpleasant situation that is not related to the trauma, that, remembering it, he feels 50-60 on the Subjective Units of Distress scale; for example, the embarrassment he felt when people burst into laughter when he slipped on the floor. Ask the client to choose a card representing that situation. After the card is chosen we will thoroughly check to be sure it is not related to the traumatic event. This card will be designated as the concern igniting card. 3. Client will examine the body's reaction to the concern igniting card, and the location of the unpleasant sensation in the body. "Look at the card and tell me where in your body you feel the unpleasant sensation. Focus on this place. What is the sensation there like? What is the color there? Is there any movement? What is the temperature? What does it look like?" At the end of the focusing process, we will conduct an assessment of the SUDs. If the SUDs level escalates, it is not necessarily a bad sign. It is merely the result of focusing on this sensation. The opposite can also occur and this too, is not a cause for worry

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

In fact when the client expresses a SUDs number, we ask "Where in your body do you feel 7" .Once we get a description of that sensation (for example, a black metal cold ball), we will from then on ask about the metal ball as our SUDs representational object. 4. Now we will ask the client to place the concern igniting card (CIC) relative to the safe place, at such a distance that the safe place sensation will not be affected by the presence of the CIC. Make sure that the client sees both cards, that is, that neither card? is concealed. We will verify again that, at the chosen distance, the concern igniting card does not influence the safe place. Now, together with the client we will examine and record the SUDs level. Sometimes there is also an increase at this stage but it, too, is no reason for alarm. 5. We will ask the client to observe the gap between the concern igniting card and the safe place. We will then carry out a SUDs check. 6. We will suggest to the client to try to bring the CIC a little closer to the safe place. We will then examine what happens to the safe place at this distance. We will also carry out a SUDs check and examine changes in the bodily sensations. 7. We will encourage the client to carry out a dialogue between the safe place and the CIC. For example, we will ask the following questions: "What is happening to the safe place now?" "What does it wish to say to the concern igniting card?" "What answer will the concern igniting card give the safe place?" "What is happening now?" At the end of the dialogue we will examine whether the distance stayed the same (the distance between them at which the safe place is not influenced) and we will conduct another SUDs check. 8. We will ask the client to make another attempt at bringing them closer. Afterwards we will carry out another SUDs check, and we will examine the physical sensations ("What is going on in the body?"). Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 9. Therapy Phases

71

9. Now, we will ask the client to silently watch our finger as it moves from the safe place card to the CIC at least 7-10 times (pendulation). We will then perform a SUDs check and inquire about what is happening in the body and in the experience. 10. If SUDs do not subside, we can continue with stage nine 2-3 more times. 12. We can use another type of pendulation by asking the client to focus into the body, while first examining the location of the unpleasant sensation and then the location of the pleasant sensation and pendulate between the two. 14. If necessary, we will continue the pendulation. We will stop only when there is a decline of at least two points on the scale (0-10) or twenty on the (0-100) scale. 15. At this stage it is possible to ask the client to choose a third card (an additional one), whose presence, between the safe place and the CIC should protect the safe place from been affected by the CIC. 16. We will guide the client in putting the "mediating" card in a place that will prevent the CIC from affecting the safe place card. We will examine: "What is happening to the safe place now?" "What is happening to the CIC?" We can find this out in a dialogue such as the following: "What will the mediating card say to the CIC?" "What will CIC reply be?" "What will the mediating card say to the safe place?" "What will the safe place answer?" Now we will examine the SUDs. In the event that there is a decline, we will see whether the client is willing to try to remove the new card (the mediator). 17. We will try to remove the mediating card and we will carry out a SUDs check. 18. For closure we will ask the client: "What did you learn from the process?" "What do you say to yourself regarding what you have learned?" 19. We will focus on the safe place one more time before we wrap up the session.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

20. Time permitting; we will have a short processing discussion with the client about things that might have been aroused in this session. 21. If the process is used as preparation for In Vivo exposure, we should check whether client feels ready to practice in reality. If the SUDs did not substantially decrease, or anxieties not related to the trauma did not come up, it is possible to consider repeating the desensitization process in the next session. In the event that there is a feeling that there was a significant decrease in the SUDs and the client learned that recalling is not dangerous, then it is possible to continue to the imaginal re-narration stage using cards (see stage 7). It is important to remember: • •

To give positive reinforcement to the client for succeeding in reducing anxiety. To prepare the client at the end of the session for the commencement of renarration of the traumatic incident in the next session.

The Therapist Must Adhere to the 3S Principle The meaning of the 3s principle is be attentive, be simple and progress at the rate of information processing that characterizes limbic processes, and speak "body language." Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

72

Chapter 9. Therapy Phases

The 3S principle is central in the SEE FAR CBT system. It ties in with our preliminary instruction, "Do not be interesting, be interested." To repeat the three points of this principle: Simple - It is important to work simply with small, concrete questions. Slow - It is of the utmost importance to work slowly. (Often the therapist is afraid to work slowly for fear that he will bore the client. The contract regulating the clienttherapist relationship allows for the client to make comments; therefore the therapist should not fear this.)

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Sensation - It is imperative to focus on physical sensations. From time to time it is necessary to re-examine the anchoring in the body and the various sensations.

9.8 Phase Seven of Therapy - Re-Narration in the Fantastic Reality using Therapeutic Cards As stated in the previous session, we informed the client that the following week we would begin the re-narration of the traumatic event. Now it is important to emphasize again to the client that the re-narration will be gradual and in any event, we should not reach "boiling" point. "We will employ what we have learned about the safe place and breathing, and we will re-narrate in a fashion similar to the one we used in the desensitization stage." Remind the client again to pay attention to discharge as it happens, not to hold it back, and to try to share it with you as it happens. Tell him that when you notice discharge you will point it out to him.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 9. Therapy Phases

73

Preparations: Placed on the table in order and in lines are HABITAT, SAGA, and COPE cards. The cards are not classified, and are all used unless the therapist has decided that there are topics not appropriate for cultural or other reasons.

9.9 Steps of Re-Narration in the Fantastic Reality 1. We will begin with resourcing; that is, anchoring in the body of at least three locations which the client associates with a comfortable, safe, or calm sensation. It is important to use BASIC PH channels that we found to be dominant,5 thereby strengthening the anchoring of resources. Now use the 'safe place' and its surroundings that were prepared in previous sessions or if needed, let the client create a new safe place using therapeutic cards, and carry out the entire anchoring process including: location, size, sensation, shape, color, and action. 2. Say to the client: "As we stated in our first session, today we are going to re-narrate for the first time, in an orderly fashion using cards, the story of the trauma you experienced. It is important for me to mention that we will go over the story a few times. The more repetitions we make, the greater the likelihood of your discomfort diminishing. It might not happen at first, but as you continue, you will notice it happening. It is vital that you remember what we said about ”discharge.” Discharge is a known good sign that the body is getting rid of tensions and burdens. Do not get excited, and do not feel ashamed if you experience it. If I notice signs of discharging I will draw your attention to them."

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

3. "Let me know if your feeling of discomfort rises to a high level. If this occurs, we will use your safe place to slightly reduce your feeling of discomfort and then we will resume re-narration." 4. Next the client is asked to approach the table where all the cards are spread and choose cards that describe the traumatic event/s. It is not necessary for the cards to tell the story realistically. Nor is it necessary that the therapist understand from the choices what the client is talking about. All that is needed is that the client attribute to the cards part of the story of his event. It is important that the card represents part of the story for the client. In other words, it is not compulsory that the cards precisely describe the event. What matters is that they help the client in an associative or another fashion to focus on re-narrating the event from start to finish. 5. Now we will first ask the client to re-narrate the traumatic story in a general way without using cards. We will encourage him to use the first person in the present tense. When he finishes we will check SUDs measurement. We will also check where in the body a feeling of discomfort arises. We will inquire about the location, size, shape, and motion of this sensation. You might say to the client: “Now that you told me the story, where in your body do you sense it. Focus on this place in the body. What is the sensation there? What is its color? Is there any movement? What is the temperature? What does it look like?" What are the SUDs? This measurement is the baseline. 6. Next the client is asked to open the six cards and arrange them on the table so that they will represent the sequence of the event from beginning to end. After he has finished arranging the cards, he is asked to look at them and see whether this is the 5

See Chapter 7.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

74

Chapter 9. Therapy Phases

desired order and whether this is the correct distance between the cards. When the client says it is, a SUDs check will be performed. 7. Re-Narration: The client is asked to tell the story of the traumatic event using the cards, looking at them and not at the therapist. 8. When he has finished the story, conduct a SUDs check (without going into the body unless client needs focusing). Then ask the client to repeat the story at least three times. At the end of the third time, carry out another SUDs check and examine the body sensations as well, that is, conduct a complete focusing on the body (color, size and others) and then check SUDs. 9. Now ask the client: "If you could choose, which one of all of the six cards would you like to take out?" 10. After he has made his choice, take out the card he had indicated and turn it over (so he cannot see the picture). Direct the client to tell the story again without the card that was removed. When he finishes, do the SUDs check again. (There are clients who ask whether the section on the card that was removed should be included or omitted from the story - the answer: "As you wish.") 11. Ask the client: "Of the remaining cards which one would you like to take out next?" Again, remove the chosen card, turn it face down, ask him to tell the story, and then perform the SUDs check.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

12. At this stage, the therapist turns the two cards that were removed face up and asks the client: "Which of these two cards that you took out, represents or expresses a bigger difficulty?" The therapist will leave the card representing the bigger difficulty face up and the other will be turned face down again. He will then ask: "Of the remaining four cards, which one represents a sensation of assistance or authentically expresses your feeling?" Keep this card face up and turn over the remaining three. 13. Now the therapist lays the card representing the biggest difficulty and the card representing assistance on the table, at a distance that will enable the client to look at both of them, (usually at shoulders' distance).The therapist asks the client to follow the movement of his finger between the two cards (pendulation). The hand should move back and forth at least seven - ten times, between the calming card and the difficult one, while sustaining seven second stops at each card. At the end of the series of back and forth movements, the client is asked to go through the same process by himself (moving his eyes between the two extremes represented by the cards) in 7-10 movements. 14. At the end of this stage examine again what is happening in the body and carry out a SUDs check. 15. Now ask the client to turn over the four cards that were face down and to classify them relative to the calming card and the difficult one, the instruction being: "Place the four remaining cards relative to the comforting picture and the one that brings up difficulties." "Which ones did you place next to each of the cards?" (this arrangement is not necessarily linear; the client my use the whole space) 16. We ask the client to look at the arrangement he made. Then we will again examine the sensations in the body and perform a SUDs check. Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 9. Therapy Phases

75

17. The therapist says: "Now, when it is clear that the event took place and has ended, approach the cards on the table and choose two cards that express something that, if you had had it at the time of the event, it would have assisted you, without negating the outcome of the event." This is the ' I wish stage" or "if only…" " I would have wished that…" "If only I could…." Say to the client: "Keep in mind that the card or cards you choose do not negate the event's outcome; they only make it possible or bearable, or they may somehow feel helpful to you." 18. Say to the client: "Take the two new cards and again construct the story from beginning to end. Integrate the new cards into the original story (of the trauma)." In other words, integrate the "if only" cards. Then ask the client: "Is this the desired distance between the cards?" 19. Then the therapist says: "Now tell the story including the two new cards." "Repeat the story at least three times." 20. See what happens to the client's body and conduct a SUDs check at the end of the third repetition of the story with the two new cards. 21. If the SUDs have gone down, ask the client if he is able to take the "if only" cards out again and rearrange the original story. Check the SUDs.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

22. If SUDs level did not change much, the client may be asked to close his eyes, breathe at a normal rate, focus on the body where he feels the SUDs/the discomfort, and examine the sensation by reminding him of its characteristics (color, shape, sensation). Ask the client to focus on that without any effort. Instruct the client: "We do not have any plans for your brain; do not make any effort; merely observe the sensation." While the client is doing so, silently count up to seven and then say in a matter of fact tone, "What is happening now?" If something is happening, ask the client to observe without exerting any effort and aimlessly whatever is going on. 23. If the sensation lingers, pendulation can be considered. The therapist will direct the client to move from the body place where he feels discomfort to the body place where he feels comfortable and peaceful. The therapist suggests alternating between the two until signs of discharge are seen, encourages discharge until relief is felt. 24. When there is a substantial drop in the SUDs (to a level of 30-40 or less) ask the client to open his eyes and together examine what he has learned from the process. And then ask him what he says to himself about what he has learned. 25. End of the session: Focus on the safe place and ask the client to go back to where this positive sensation is embodied. Say to the client: "Now return to your safe place. Look at the place on your card. You know where your pleasantest and/or safest place is. Look at it, breath normally and very slowly anchor the pleasant sensation in the body." Usually we cannot do the whole 25 steps in one session. So the recommended places to stop are: First time at step number 9 and finish with the safe place (step number 25). In the next session start from the beginning and stop at stage 11 and finish with the safe place (step number 25).

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

76

Chapter 9. Therapy Phases

The next session should start again from the beginning this time ending at stage 16 and finish with the safe place (step number 25). The last session should start from the beginning and end at 25. Still there will be clients who will need an even slower pace. Remember throughout therapy In Vivo tasks should be exercised, reported and checked.

9.10 Phase Eight of Therapy - Hot Spots Hot Spots - are the sections of the traumatic story that when told by the client result in symptoms of acute stress, crying, trembling, and a rise in SUDs. They are often represented by the cards the client asks to take out of his story. On the whole, treatment of Hot Spots is similar to re-narration in the fantastic reality, except that the emphasis here is on the desensitization of the most difficult sections in the story and reintegrating them back into it. The therapist should say to the client:

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

"Now, we have succeeded in relieving the level of pressure and anxiety that accompany the re-narration of the traumatic event; yet there still remain a few parts of the story that, when you tell them, cause the SUDs to go up, or you still feel sad or worried about them. In order to overcome these parts as well and to discharge the energy trapped in this memory that poses a difficulty for you, we will re-narrate them in a manner almost completely identical to the one we employed when we re-narrated the story. Take the card that represents the hardest section of the story for you. Now take at least four cards, so that you can expand the "hot" picture into a story. Use the additional four cards to broaden the part expressed in the "hot" picture which still causes arousal and difficulties. Arrange the cards as we learned and look at them. And answer the question: "Is this the order and the distance between them?" Note: The chosen picture might not be part of the re-narration because the expansion includes it, in which case the client will place the "hot" picture above the series of expanding pictures. Back to the re-narration process: 1. We start with resourcing, that is anchoring in the body of at least three locations with which client associates a comfortable, safe, or calm sensation. In addition, we reestablish a safe place and continue completely anchoring it in the body, including location, size, sensation, shape, color, and movement. 2. Say to the client: "In a similar fashion to what we have done up to now, we are going to re-narrate the story of the traumatic event using the cards, but this time we are going to focus only on the part that arouses great discomfort in you. As always, it is important for me to say that we will repeat the story a few times. The more we repeat it the greater the likelihood that your feeling of discomfort will diminish. It is important that you remember what we said about discharge. Discharge is a good, well known sign that the body is discharging tensions and burdens. Do not get excited or ashamed if you

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 9. Therapy Phases

77

experience it. It is an excellent sign. If I notice such signs, I will draw your attention to them." 3. "As always, you can tell me if your discomfort reaches a high temperature. In such a case, we will use your safe place to slightly reduce the feeling of discomfort and then we will resume re-narration." 4. Now ask the client to take the four (or more) cards that he chose for re-experiencing the "hot" picture. We will ask the client to place the cards on the table in order from beginning to end. Naturally the cards are arranged as he sees fit. When he finishes this task, we ask him to look at them and examine whether this is the order and if this is the distance between the cards. When the client gives his affirmation, we conduct the anchoring in the body process plus a SUDs check. 5. We ask the client to tell the story of the traumatic event using these cards. 6. When he finishes we carry out a SUDs check (without going into details of color, etc.) and the client is asked to repeat the story at least three times. At the conclusion of the third time, we do a SUDs check plus focusing on the sensation in the body and an additional SUDs check. 7. Now ask the client: "If you could choose, which of the four cards would you elect to remove?" 8. After he has made his choice, take out the card he pointed at and place it face down (so he cannot see the picture). Next, instruct the client to tell the story again, this time without the card that was removed. At completion we will conduct a SUDs check.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

9. Now ask the client: "From the remaining cards, which one would you like to remove?" - As before, we will take out the card he pointed at and turn it face down. We will ask him to tell the story again and we will conduct a SUDs check. 10. At this stage, the therapist turns over the two cards that were removed and asks the client: "Of the two cards you took out, which card represents the greatest difficulty?" The card he points at is left face up and the other is placed face down. Then we ask him, "Which of the other two can represent a sensation of assistance or authentically expresses your sensation?" (Turn over the remaining three cards.) 11. Now the therapist puts the most difficult card and the assistance card on the table at a distance that will enable the client to look at them. The therapist asks the client to follow his finger movement as he moves it from card to card and to look at the card his hand stops at. The therapist moves his hand back and forth at least seven times, and stops at each card at least seven seconds. In other words, his hand moves from the reassuring picture to the difficult one and back. At the end of this series the therapist asks the client to perform the same process by himself (following with his eyes at least seven movements between the two extreme cards). At the end of this stage we check to see what is happening in the body now and we carry out a SUDs check. 12. The therapist says: "Now that it is clear that the most difficult section of the story also took place and ended, approach the cards on the table and choose two cards that express something, that if you had had in this section they would have helped you, without negating the results of the event." This is the wish stage: "if only," "I wish

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

78

Chapter 9. Therapy Phases

that…," "If only I could have…".We will emphasize to the client: "Remember, the card or cards you chose do not negate the event. They merely make it possible or bearable." 13. Next the therapist says: "Now we will take the two new cards and again construct the story from beginning to end. First integrate the new cards (the "if only" ones) into the original story (the story of the trauma) and check if the distance between them and the other cards suits you. Then tell the story including the two new cards." 14. The therapist continues and says: "Repeat the story at least three times" (including the two new cards). When this is done we will see what is happening in the client's body at that moment and we conduct a SUDs check. 15. If the SUDs has gone down, we will ask the client to see whether he is capable of extracting the "if only" cards again and whether he can arrange the original hot story anew. Then we again check the SUDs. 16. If SUDs level still persists, we can ask him to open his eyes, breath at a normal rate, focus in the body on the area of discomfort, and examine the sensation, while focusing on the discomfort characteristics (color, shape, sensation), without exerting any effort. (If possible, closed eyes are preferable as even more efficient.) We can repeat to the client: "We do not have any plans for your brain; do not exert any effort, just look at the sensation." While the client is doing so, silently count to seven and then in a matter of fact tone of voice say: "What is happening now?" If anything is happening, ask the client to look at it effortlessly and aimlessly. 17. If the sensation persists, you may consider pendulation. The therapist will direct the client to move from the location of the discomfort sensation to a place in the body where calm comfort resides. The therapist follows and strengthens the discharge to the point of relief.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

18. With a significant drop in SUDs (to a level of 30-40 or lower), ask the client to open his eyes and together check to see what he learned from the process. Ask him what he says to himself about what he has learned. 19. End of session: Practice the safe place using a card. "Return now to your safe place. Look at the card and the space around it. You know where your pleasantest and/or safest place is. Look at it, breathe at a normal rate, and very slowly confirm the sensation of pleasantness in the body." If there are a few hot spots, it is possible to repeat this stage in more than one session until achieving a decline in the SUDs or significant relief.

Note If at any stage the symptoms worsen and reach "boiling" (great disquiet, groaning, incapacity to continue telling the story, etc.) / detachment/ dissociation or muteness, the client??? must focus on the safe place card and the space around it, and use the card and its space until regaining control and achieving a sense of lessening hyperarousal. Under no circumstance should you reach "flooding." When we stop the process in order to practice the "safe place" and regain a reduction in SUDs, we emphasize that after a decline in arousal we will resume the process, especially in order to prevent the

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 9. Therapy Phases

79

mistaken conception acquired through therapy "that the traumatic memory is dangerous." Parallel to processing the hot spots, progress continues in practicing in-vivo exposure.

9.11 Phase Nine of Therapy - Summary and Assessment of Results Assessing the results can be carried out in a conversation, giving the client a chance to freely express his self assessment and his feelings regarding his situation and the extent to which the therapy has helped him. It is recommended that the client be invited for this purpose and that he be assured that he does not have to please the therapist. All he has to do is to say frankly what he felt throughout the entire therapy. Review the original in vivo list and see which of the items lost their original SUDs level and discuss what it means to the client. At the same time, it is possible to reuse the questionnaires used at the first stage of the therapy, thereby getting a more detailed picture of the symptoms, which facilitates making a comparison.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

It is important to let the client tell what he learned from the therapeutic process, his new beliefs about the disorder he suffered, and the way he coped with it. At this stage it is possible to use the content of the conversation that characterized the cognitive processing stage in every session, in an attempt to integrate a new understanding of the disorder and the client's coping with it.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

80

Chapter 10 The Structure of the Sessions An Example of a Ten Session Therapy The SEE FAR CBT protocol is a therapy model focusing on trauma and the disorders that follow it. An informed, intelligent application of the protocol is designed to organize a therapeutic process which will result in lowering the intensity of the symptoms and lessening their frequency in a small number of sessions (10-15 double sessions – 90 minutes long). Yet we recommend that the therapist allow the therapeutic process to evolve in accordance with the pace and organizational capabilities of both the therapist and the client. We place great value on the therapist's awareness of the progress of the therapy and his gearing it to the objective: reducing the PTSD symptoms and improving the client's quality of life. This objective, which is clearly made known to the client, acts as a motivational goal for both partners of the therapy pact and aids the formulation and solidification of this contract.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

We believe that the more experienced in the SEE FAR CBT system the therapist is, the more efficient the therapeutic process will be. In the therapist's first experiences the protocol will play an important role in organization within the therapy framework, and will act as a support for the therapist. In later applications the therapist will know how to incorporate the experience he has acquired in order to enrich the detailed therapy in the protocol and to tailor it better to the specific client. In general we can say that the basis of this system is the simultaneous recurrence of various kinds of therapeutic interventions. Therefore, the psycho-education that appears in the second stage of the therapy, as described above, will reappear in all the therapy sessions as a basic element of making the client a partner, helping him to understand the task and enabling the client to ask question and feel in control. The importance of all of these does not decrease. The same applies to all the other basic elements: relaxation using exhalations, the safe place (using the card), anchoring in the body, in vivo exposure, desensitization, and re-narration in the fantastic reality, using cards. These elements will be intertwined throughout the therapy, in varying degrees. To practically demonstrate how a 'model' set of sessions based on the SEE FAR CBT protocol is conducted, we will now present a detailed example of the ten session treatment (90 minutes each).

10.1 First Session A. Detailed intake interview, diagnostic and assessment of severity questionnaires (for relevant questionnaires see the Appendix at the end of the book: BDI, PDS, CAPS,

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 10. The Structure of the Sessions - An Example of a Ten Session Therapy

81

questionnaire for the assessment of post trauma dysfunctional cognitions). (See phase one of the therapy). B. Psycho-education regarding the essence of the PTSD phenomenon and discussion about common responses to trauma (Phase two of therapy). C. Psycho-education regarding approaches to therapy: Somatic-experiencing, in vivo exposure, re-narration in the fantastic reality (FR) and cognitive processing. The guidance also touches upon expected "obstacles": the difficulty to deal with a frightening topic, the possibility that the symptoms will temporarily worsen as a sign of healing, the desire to forego therapy and the courage to persevere as a result of an understanding that there is a great chance of recovery. It is important to emphasize that the PTSD symptoms are the focal point and that the therapy requires the client's active involvement, including carrying out tasks between sessions and having determination. (Phase two of therapy). D. Presenting information sheets about the post traumatic disorder (page 118) and about approaches to treatment (page 122), and inviting the client to read them for the next session (Phase 2 of therapy). E. Presenting information sheets about anxiety management techniques and asking the client to examine which technique can best serve his needs (see information sheets Appendices sheets) F. Exercising breathing for the first time.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

10.2 Second Session A. Discussion with the client about his PTSD symptoms in light of what he read in the information sheets. (It is both possible and important to learn from the client if he has symptoms that do not appear in the information sheets.) B. Discussion with the client different anxiety management techniques, and practicing the techniques that the client has found suitable for himself. C. Making a joint decision to begin SEE FAR CBT therapy. (Phase three of therapy) D. Clarifying the therapy objectives. (Phase four of therapy) E. Teaching relaxation exercises using exhaling and calming words. (Phase five of therapy) F. Starting to collect a list of things the client avoids. (This list may develop or change over time.) G. Presenting the Subjective Units of Distress Scale - SUDs. A discussion about the client's avoidances. (Phase six of therapy) H. Giving homework for the following week: 1. Practice relaxation exercises applying exhaling and a calming word. 2. Prepare a list of avoidances, take one item from the lower end of the list for practice. 10.3 Third Session A. Check the homework - attempting to thoroughly and concretely understand the contents and details of the situations the client avoids. B. Explain body memory and somatic experiencing (SE) - emphasizing that coping with situations the client avoids is actually coping with memories inherent in the body (can be assisted by information on page 122).

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

82

Chapter 10. The Structure of the Sessions - An Example of a Ten Session Therapy

C. Practice a safe place and anchoring it in the body (Phase five of therapy). D. Practice resourcing. E. Present the rationale behind in vivo exposure, including concrete examples of habituation (Phase six of therapy). F. Explain discharge to the client and prepare him for the possibility of experiencing it. G. Completion of the hierarchy of situations the client avoids, giving SUDs rankings to each one and discussing it. Verify that the hierarchy the client composed is valid and does not include "gaps" that are too large between the tasks (as this could warrant unwanted failures). Tasks will be chosen for the following week according to this hierarchy. Explain to the client the process in which: 1. We will begin with situations that arouse a mild level of distress/discomfort (e.g., 30 SUDs). These are situations that cause anxiety but in reality are not dangerous. 2. The client must record the starting time and the initial SUDs on the recording form (page 99). 3. The client must remain in a state of exposure between 30 - 45 minutes or until the anxiety level decreases by at least 50 percent. 4. The client records the final SUDs 'scores' on the recording form. H. Assign homework for the following week: 1. Begin in vivo exposure according to the task hierarchy that was agreed upon. 2. Add to the list additional situations you avoid. 3. Continue practicing relaxation exercises, applying exhaling and a calming word.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

10.4 Fourth Session A. Check homework, including in vivo exposure and discussion about the client's experience during its course. Together with the client, study his experience while attempting to verify that he carried out the therapeutic task correctly. It is important to go over the in vivo exposure form with the client, and to check with him whether he experienced habituation (a decrease in the SUDs while being in a tension arousing situation). It is of the utmost importance to offer encouragement to the client for all the effort he is exerting in the renewed experience with situations he has avoided up to this point. B. If the client has failed to lower the anxiety level, then you should check the circumstances of the event with him, and together examine whether the task was clear enough. If the client did not attempt to carry out in vivo exposure, it is vital to talk to him again about the rationale behind conducting in vivo exposure and about the objectives of reaching habituation (decrease in SUDs) and changing the perception that the world is a dangerous place all of the time and everywhere. C. Explain discharge to the client, and prepare him for the possibility that he will experience it. D. Practice a safe place, using cards, and anchoring it in the body. (Phase five of therapy) Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Chapter 10. The Structure of the Sessions - An Example of a Ten Session Therapy

83

E. Practice resourcing F. Practice desensitization using a discomfort card and a safe place card. (Phase six of therapy) G. Before the end of the session: Hold a discussion with the client processing. sharing the experience of having a first experience of exposure in the fantastic reality. It is important that the therapist at this point allow talking about sensations, feelings, and thoughts that have accompanied the joint process. This is not "transference"; it is giving a chance for sharing and cooperation. At the same time, there is room to identify the client's dysfunctional beliefs and to try to refute them. H. If possible, scan the card and its surroundings (safe place) for your client and print it for him so that he can use it at home. I. Assign homework for the coming week: 1. Continue practicing relaxation exercises, applying inhaling and a calming word. 2. Practice the 'safe place' focusing on its embodied sensation and if possible other resourcing. 3. Continue in vivo exposure according to the task hierarchy. 4. If you intend to move to re-narration in the fantastic reality using cards (Phase seven) in the next session, you should tell the client that this is what will be the focus of the next meeting.

10.5 Fifth, Six and Seventh Sessions

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

A. Check homework, including in vivo exposure, and discuss the client's experience during its course. Reexamine the implementation of the exposure and the arrival at habituation (Is there a decrease in SUDs?). It is very important to address the difficulty that has arisen in carrying out the exposure and to encourage the client for his attempts and his coping (even if he did not experience habituation). B. Practice the safe place, using cards and anchoring it in the body (Phase five of therapy). Note that the client might choose to change the safe place and or the card representing it. There is nothing wrong with this desire; there is no need to interpret it, only to accept the legitimate possibility that there are various safe places. C. Practice resourcing. D. Remind client of discharge and prepare him for the possibility that he will experience it. E. If necessary, repeat desensitization (Phase six of therapy). G. Explain the rationale behind re-narration in the fantastic reality, using cards (Phase seven of therapy). H. Re-narration in the fantastic reality using cards (Phase seven of therapy). I. Before the end of the session: leave time for psychological experience processing. J. Assign homework for the coming week: 1. Continue practicing relaxation exercises, applying inhaling and a calming word. Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

84

Chapter 10. The Structure of the Sessions - An Example of a Ten Session Therapy

2. Practice the 'safe place' focusing on its embodied sensation and if possible other resourcing. 3. Continue in vivo exposure according to the task hierarchy.

10.6 Eighth and Ninth Sessions A. Check homework, including in vivo exposure, and discuss the client's experience during its course. It is important to readdress the difficulties in carrying out exposure and to encourage the client for his attempts and coping (even if he did not experience habituation). B. Re-narration in the fantastic reality using cards, with an emphasis on the hot spots (Phase eight of therapy). C. Before the end of the session: leave time for psychological experience processing. D. Discuss the coming week's homework for ten minutes: 1. Continue practicing relaxation exercises, applying inhaling and a calming word. 2. Practice the 'safe place' focusing on its embodied sensation and if possible other resourcing. 3. Continue in vivo exposure according to the task hierarchy.

10.7 Tenth Session (This may be the Final Session) (Phase Nine of Therapy) A. Check homework.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

B. Re-narration in the fantastic reality using cards and a specific examination of the SUDs around the "hot spots." C. Assess the client's progress with a detailed discussion about the benefits gained from each skill that was acquired, while reexamining the intensity and frequency of the symptoms he suffered from prior to therapy. It is possible to once again pass out the assessment and diagnostic questionnaires handed out initially in the first session. The findings from the questionnaires can enable the client to identify and observe the changes that have taken place in his life. They can also serve as a basis for a summarizing discussion about the client's satisfaction. D. A discussion about the in vivo exposure tasks and other forms of coping with which the client can continue after the therapy is over. (If possible, it is worthwhile to encourage the desire to resume a full life: in the family, in the community, and in the work force.) E. Before the end of the session: Leave time for psychological experience processing. F. Summarizing and parting from the client, including setting up a follow-up contract (a session every few months).

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Part 2

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

This page intentionally left blank

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

87

Appendices In Vivo Exposure Form In Vivo Exposure Task List Date ______________________________ Therapist ______________________________

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Behavior

Expected SUDs Level

1.

_____ _______________________________________________

2.

_____ _______________________________________________

3.

_____ _______________________________________________

4.

_____ _______________________________________________

5.

_____ _______________________________________________

6.

_____ _______________________________________________

7.

_____ _______________________________________________

8.

_____ _______________________________________________

9.

_____ _______________________________________________

10.

_____ _______________________________________________

11.

_____ _______________________________________________

12.

_____ _______________________________________________

13.

_____ _______________________________________________

14.

_____ _______________________________________________

15.

_____ _______________________________________________

16.

_____ _______________________________________________

17.

_____ _______________________________________________

18.

_____ _______________________________________________

19.

_____ _______________________________________________

20.

_____ _______________________________________________

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

88

Homework Form: In Vivo Report sheet Name _______________________ Date_________________ 1. Situation Practiced_________________________________ Date & Hour

Date & Hour

SUDs (o-100) Before

Peak

After

SUDs (0-100) Before

1.

5.

2.

6.

3.

7.

4.

8.

Peak

After

2. Situation Practiced_________________________________ Date & Hour

Before

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Date & Hour

SUDs (o-100) Peak

After

SUDs (0-100) Before

1.

5.

2.

6.

3.

7.

4.

8.

Peak

After

3. Situation Practiced_________________________________ Date & Hour

Date & Hour

SUDs (o-100) Before

Peak

After

SUDs (0-100) Before

1.

5.

2.

6.

3.

7.

4.

8.

Peak

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

After

Appendices

89

Intake Questionnaire for Trauma Victims I. Demographic Information Name: ______________ I.D. #:_________________ Cell Phone: _______________ Address: ____________________________________ Home Phone: ______________ 1. How old are you? _______ 2. Where were you born? __________ 3. How many siblings do you have, what number are you? _____________________ 4. What is your education? A. Elementary and Middle School B. High School -without matriculation exams C. High School - with matriculation exams D. Vocational High School E. Higher Education F. Academic Education 5. Have you acquired a profession? Yes/No Profession: _______________ Are you currently employed in this profession? Yes/No

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

II. Reason for Application 6. What caused you to seek treatment at this time? ______________________________________________________________________ ______________________________________________________________________ __ 7. How would you rank the level of distress you feel relative to the reason you have applied for help: No Distress 0-20

Mild 20-40

Moderate 40-60

Severe 60-80

Extreme 80-100

8. How long have you felt the distress which led you to apply for help? A. A number of days B. A number of weeks C. A number of months D. A number of years

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

90

Appendices

9. Has there lately been a change in the distress you are experiencing? A. Lately (up to a month) there has been a change for the worse. B. Lately (up to a month) there has been a change for the better. C. The distress has been going on for a long time without any change. D. The level of distress changes at a high frequency (episodes last from hours to days). E. The level of distress changes at a low frequency (episodes last from weeks to months). 10. If there has been a change for the worse lately, can you think of an event that could be related to this? ______________________________________________________________________ _ ______________________________________________________________________ _ 11. Whose initiative/idea was it to go to therapy? A. Mine (the client) B. A member of the family or partner C. A friend D. A professional or professional agency (family doctor, hospital, a government institution, rehabilitation professional, other)

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

E. An employer 12. If the initiative was not yours, what reason was given by the initiator? ______________________________________________________________________ _ ______________________________________________________________________ _ III. The Current Situation 13. What is your family status? A. Single B. Married C. Divorced/Separated D .Widow/Widower 14. Number of children: ________ 15. Who do you live with (you can check more than one answer)? A. Alone B. With housemates C. With my parents D. With my partner E. With my children

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

91

16. In the event that you are involved in a relationship, how would you assess the understanding you are receiving from your partner? A. Great understanding and sharing B. Reasonable understanding C. Little understanding D. No understanding of my situation 17. How close are you and your partner? A. Very close B. Reasonably close C. Not very close D. Not close 18. Would you say that you tend to get angry a lot at your partner? A. Very frequently B. Sometimes C. Rarely D. Never 19. Do you tend to have outbursts in other situations as well (at work, in front of friends and/or family, and/or strangers, and/or various service providers, other)? Guiding Question: At whom are your outbursts directed? What is their frequency? How long does it take you to calm down? ______________________________________________________________________ __________________________________________________________________

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

20. Whom can you rely on in a pressure situation? (You may choose more than one answer.) A. Partner B. First degree family member (please specify) C. A distant relative D. A friend E. A professional 21. Are you currently working or studying (If not, why? Does this bother you?): A. Yes, I work at _______________ and /or I am studying __________(profession/subject) at___________ (name of institution). B. I stopped a few weeks ago C. I stopped a few months ago D. I stopped a few years ago E. I have never worked/studied Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

92

22. Describe your daily routine: I usually get up at ________ and then _____________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ___ 23. Do you suffer from persistent physical problems? Please specify and record when they began: A. The problem_________________________ Year began __________ B. The problem_________________________ Year began __________ C. The problem_________________________ Year began __________ D. The problem_________________________ Year began___________ E. The problem_________________________ Year began __________ 24. Do you have sleeping problems? (You may choose more than one answer.) A. Trouble falling asleep B. Broken sleep C. Rising early D. Difficulty waking up E. Nightmares 25. If you have nightmares, what do you do when one wakes you up at night? A. Wake up my partner Copyright © 2010. IOS Press, Incorporated. All rights reserved.

B. Wake up someone else who is close C. Get out of bed and keep busy D. Try to fall back asleep 26. Do you manage to concentrate on a book or a movie? A. I cannot concentrate for a long period of time. B. It is hard for me to concentrate for a long period of time. C. I am easily distracted, but I can control this situation. D. I have no special difficulty concentrating. 27. In the past did you get together more often with friends and or family? Yes/No (Circle the suitable answer) 28. Are there activities you enjoyed in the past that today, as a result of the traumatic event, you no longer find pleasure in them? Yes/No

Please specify_________________________________

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

93

29. Are there places you refuse to go? A. Yes.

Please specify_________________________________

B. No 30. Are there things that were habitual in the past but now you refuse to do? Yes/No

Please specify_______________________________________________

31. Is it possible to encourage you? A. Impossible B. Very difficult C. Possible with a little effort D. Very easy 32. Have you ever considered putting an end to your life? A. Yes, and I have also thought of the way to do it. B. Often C. Rarely D. Never

IV. Beliefs and Imagination 33. Do you think there is any point in planning the future? (You may check more than one answer.)

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

A. No, there is no point, because for one reason or another I will not succeed in realizing my plans. B. No, because you never know what will happen. C. No, anyway everything is pointless. D. Yes E. Yes, I believe that I will succeed in coping with my problems and I will be happy in the future. 34. To what extent are you able to imagine your situation getting better? Please elaborate what you imagine: __________________________________________________________ __________________________________________________________

V. The Traumatic Event 35. Please tell me about the difficult event you experienced.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

94

Appendices

Guiding Questions: Q1 In what year did the event take place? Q2 What kind of event was it (e.g., car accident, terrorist attack, sexual assault)? Q3 What happened in the event? Q4 What was your emotional response during the event? Q5 Were there injured people in the event, including you? Q6 Were there any fatalities in the event? Q7 Do you think that you should have behaved differently than you did at the time of the event? (When did you begin to think this? Since then, has there been a change in your beliefs regarding your actions at the time of the event? ___________________________________________________________ ___________________________________________________________ A Medical Anamnesis (Physical and Psychological) 36. Have any other traumatic events taken place in your life? (You may check more than one answer.) A. Death of a parent B. Disease or injury of the client C. Disease or severe injury in the family D. Parents divorce E. Violence in the family

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

F. Physical abuse by a family member G. Physical abuse by peer group H. Sexual abuse by family member I. Sexual abuse by peer group J. Sexual abuse by an adult K. Difficulty assimilating in a new country L. Terrorist attack M. Another, please specify_________________ 37. Have you sought treatment in the past? Guiding Questions: Q1 Why did you seek treatment? Q2 Whom did you turn to? Q3 How long was your treatment? Q4 Why did the treatment stop? Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

95

38. Does anyone in your family have a history of psychiatric diseases? If so, which ones? A. Yes, both of my parents B. Yes, one of my parents

Type of disease_________ Type of disease_________

C. Yes, one or more of my siblings D. Yes, my aunt/uncle

Type of disease_________

Type of disease_________

E. Yes, my grandfather/grandmother Type of disease_________ F. No 39. Were you diagnosed in the past with a psychiatric disease? If so, please specify. Yes/No

Type of disease_______________

40. Were you hospitalized in the past as a result of a psychiatric disease? If so, please specify for how long. Yes/No Type of Disease__________ Time hospitalized _______ 41. Do you now or did you in the past take psychiatric medication? If so, please specify kind of medicine and length of time taken. Yes/No Kind of medicine__________ Time taken________ 42. Have you suffered in the past from physical problems? A. No B. Yes Type of problem____________ Its duration________

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Type of problem____________ Its duration________ Type of problem____________ Its duration________ Type of problem____________ Its duration________ Type of problem____________ Its duration________

VI. Using Alcohol, Medicines and Drugs 43. Do you drink alcohol? A. Every day B. A few times a week/month C. On special occasions D. Never 44. Did you drink alcohol before the traumatic event? A. Yes, even more than today. B. Yes, the same as today.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

96

C. Yes, but less than today. D. No. 45. Do you take drugs (you can check more than one answer) and how frequently? (Every day, a few times a week/month, on special occasions, never) A. Hashish/Marijuana

Frequency________

B. Stimulants (cocaine, speed)

Frequency________

C. Causing Deliriums (mushrooms, LSD) Frequency________ D. Ecstasy E. Heroin

Frequency________ Frequency________

46. Did you take drugs before the traumatic event? A. Yes, even more than today B. Yes, the same as today C. Yes, but less than today D. No 47. Did you take medicine to help cope with the traumatic event? If so, please specify type of medicine: Yes/No Type of medicine________________________

VII. Expectations from the Therapy and Degree of Motivation for Treatment

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

_____________________________________________________________ _____________________________________________________________

Summary of the assessor's impression: 1. The subject does not suffer from a stress disorder. 2. The subject is suffering from Acute Stress Disorder (ASD). 3. The subject is suffering from Acute Posttraumatic Stress Disorder (PTSD up to three months). 4. The subject is suffering from Chronic Posttraumatic Disorder (PTSD for more than three months). 5. The subject is suffering from Delayed PTSD (appears more than six months after the event).

Treatment Plan: _____________________________________________________ __________________________________________________________________ __________________________________________________________________

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

__________________________________________________________________

Name and Signature of the Assessor _______________________________________________________________

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

97

Appendices

98

Clinician-Administered PTSD Scale (CAPS) Blake, Weathers, Nagy, Kaloupek, Charney, & Keane, 1995 Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., & Keane, T. M. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 75-90.

Description

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

The CAPS is the gold standard in PTSD assessment. The CAPS is a 30-item structured interview that corresponds to the DSM-IV criteria for PTSD. The CAPS can be used to make a current (past month) or lifetime diagnosis of PTSD or to assesses symptoms over the past week. In addition to assessing the 17 PTSD symptoms, questions target the impact of symptoms on social and occupational functioning, improvement in symptoms since a previous CAPS administration, overall response validity, overall PTSD severity, and frequency and intensity of five associated symptoms (guilt over acts, survivor guilt, gaps in awareness, depersonalization, and derealization). For each item, standardized questions and probes are provided. As part of the trauma assessment (Criterion A), the Life Events Checklist is used to identify traumatic stressors experienced. CAPS items are asked in reference to up to three traumatic stressors. The CAPS was designed to be administered by clinicians and clinical researchers who have a working knowledge of PTSD, but can also be administered by appropriately trained paraprofessionals. The full interview takes 45-60 minutes to administer, but it is not necessary to administer all parts (e.g., associated symptoms). Scoring The most frequently used scoring rule is to count a symptom as present if it has a frequency of 1 or more and an intensity of 2 or more. A PTSD diagnosis is made if there is at least 1 "B" symptom, 3 "C" symptoms, and 2 "D" symptoms as well as meeting the other diagnostic criteria. Severity scores can also be calculated by summing the frequency and intensity ratings for each symptom. Alternative scoring options have been devised and are described in Weathers, Ruscio & Keane (1999). Sample Item B1: Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Frequency Have you ever had unwanted memories of (EVENT)? What were they like? What did you remember? IF NOT CLEAR: Did they ever occur while you were awake, or only in dreams? [EXCLUDE IF MEMORIES OCCURRED ONLY DURING DREAMS] How often have you had these memories in the past month (week)? 0 1 2

Never Once or twice Once or twice a week

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

3 4

99

Several times a week Daily or almost every day

Intensity How much distress or discomfort did these memories cause you? Were you able to put them out of your mind and think about something else? How hard did you have to try? How much did they interfere with your life? 0 1 2. 3 4

None Mild, minimal distress or disruption of activities Moderate, distress clearly present but still manageable, some disruption of activities Severe, considerable distress, difficulty dismissing memories, marked disruption of activities Extreme, incapacitating distress, cannot dismiss memories, unable to continue activities

Versions In the past there were different versions of this measure corresponding to different time periods. The CAPS-1 assessed current and lifetime PTSD. The CAPS-2 assessed one week symptom status. These versions were then renamed CAPS-DX (for diagnosis) and CAPS-SX (for symptom). These two versions were later combined into the CAPS, which can be used to assess either symptoms or diagnoses. A version for children and adolescents (CAPS-CA) is also available.

Montgomery-Åsberg Depression Rating Scale (MADRS) Main reference: Montgomery SA, Asberg M: A new depression scale designed to be sensitive to change. British Journal of Psychiatry 134:382-389, 1979. Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Type: Clinician-rated scale. Main indications: Designed to be used in patients with major depressive disorder, both to measure the degree of severity of depressive symptoms, and particularly as a sensitive measure of change in symptom severity during the treatment of depression. Rating performed by: Trained interviewer. Time period covered by scale: Clinical condition at the time of the interview. Does not specify a time frame during which the patient should be rated. Time required to complete rating: Approx. 15 minutes. Remarks: Is a 10-item checklist. Widely used in drug-treatment trials, mainly because of its particular sensitivity to treatment effects. Since there is a comparative lack of emphasis on somatic symptoms, the scale is useful for the assessment of depression in people with physical illness. The following mean scores correlated with global severity measures, according to a study: very severe, 44; severe, 31; moderate, 25; mild, 15; and recovered, 7.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

100

Appendices

Posttraumatic Stress Diagnostic Scale (PDS) Foa EB. Posttraumatic Stress Diagnostic Scale Manual (1995) National Computer Systems Inc. A Brief History The Post traumatic Stress Diagnostic Scale (PDS) was developed and validated by Edna Foa (1997)to provide a brief but reliable self-report measure of post traumatic stress disorder (PTSD) for use in both clinical and research settings. Description The scale is intended to screen for the presence of PTSD in patients who have identified themselves as victims of a traumatic event or to assess symptom severity and functioning in patients already identified as suffering from PTSD. The test is selfadministered and can usually be completed within 10-15 min and requires a reading age of 13 years. The pencil and paper and computerized scoring versions of the PDS are available from the test distributor. Test items mirror DSM IV criteria for PTSD and items are framed in accessible language. Questions relate to the frequency of distressing and intrusive thoughts, post traumatic avoidance and hyperarousal.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Items The PDS has 49 items. A short checklist identifies potentially traumatizing events experienced by the respondent. Respondents then indicate which of these events has troubled them most in the last month. Respondents then rate their response to this event at the time of its occurrence to determine whether the DSM IV stressor criteria are met (Criterion A1 ‘the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others’ and Criterion A2, ‘the person's response involves intense fear, helplessness, or horror’). Using a four-point scale, respondents then rate 17 items representing the cardinal symptoms of PTSD experienced in the past 30 days. Finally, respondents rate the level of impairment caused by their symptoms across nine areas of life functioning. A diagnosis of PTSD is made only when DSM IV criteria A to F are met. The PDS includes a symptoms severity score which ranges from 0 to 51 and this is obtained by adding up the individual's responses of selected items. The cut offs for symptom severity rating are 0 no rating, 1-10 mild, 11-20 moderate, 21-35 moderate to severe and >36 severe. Validity The PDS has high face validity because items directly reflect the experience of PTSD with high internal consistency (coefficient alpha of 0.92). Test–retest reliability was also highly satisfactory for a diagnosis of PTSD over a 2- to 3-week period (kappa = 0.74). Test–retest using symptoms severity scores yielded a highly significant correlation (0.83). Analysis also revealed an 82% agreement between diagnosis using the PDS and the Structured Clinical Interview for DSM .

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

101

The PDS does not incorporate any formal scales to detect faking or inconsistent responses. The scale was validated on samples aged 18-65. Key Research The PDS has been used in a wide range of clinical and research contexts with a high degree of confidence when use of a structured clinical interview is impractical. PDS has been used in prospective treatment studies helping establish a role for cognitive behavioural therapy in those with established PTSD .Recently; the PDS has been employed in diagnosing PTSD in the emergency services.

The Beck Depression Inventory (BDI) The Beck Depression Inventory (BDI) is a series of questions developed to measure the intensity, severity, and depth of depression in patients with psychiatric diagnoses. Its long form is composed of 21 questions, each designed to assess a specific symptom common among people with depression. A shorter form is composed of seven questions and is designed for administration by primary care providers. Aaron T. Beck, a pioneer in cognitive therapy, first designed the BDI. Purpose The BDI was originally developed to detect, assess, and monitor changes in depressive symptoms among people in a mental health care setting. It is also used to detect depressive symptoms in a primary care setting. The BDI usually takes between five and ten minutes to complete as part of a psychological or medical examination.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Precautions The BDI is designed for use by trained professionals. While it should be administered by a knowledgeable mental health professional who is trained in its use and interpretation, it is often self-administered. Description The BDI was developed in 1961, adapted in 1969, and copyrighted in 1979. A second version of the inventory (BDI-II) was developed to reflect revisions in the Fourth Edition Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, a handbook that mental health professionals use to diagnose mental disorders). The long form of the BDI is composed of 21 questions or items, each with four possible responses. Each response is assigned a score ranging from zero to three, indicating the severity of the symptom. A version designed for use by primary care providers (BDI-PC) is composed of seven self-reported items, each correlating to a symptom of major depressive disorder experienced over the preceding two weeks. Individual questions of the BDI assess mood, pessimism, sense of failure, selfdissatisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas, crying, irritability, social withdrawal, body image, work difficulties, insomnia, fatigue, appetite, weight loss, bodily preoccupation, and loss of libido. Items 1 to 13 assess

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

102

Appendices

symptoms that are psychological in nature, while items 14 to 21 assess more physical symptoms. Results The sum of all BDI item scores indicates the severity of depression. The test is scored differently for the general population and for individuals who have been clinically diagnosed with depression. For the general population, a score of 21 or over represents depression. For people who have been clinically diagnosed, scores from 0 to 9 represent minimal depressive symptoms, scores of 10 to 16 indicate mild depression, scores of 17 to 29 indicate moderate depression, and scores of 30 to 63 indicate severe depression. The BDI can distinguish between different subtypes of depressive disorders, such as major depression and dysthymia (a less severe form of depression). The BDI has been extensively tested for content validity, concurrent validity, and construct validity. The BDI has content validity (the extent to which items of a test are representative of that which is to be measured) because it was constructed from a consensus among clinicians about depressive symptoms displayed by psychiatric patients. Concurrent validity is a measure of the extent to which a test concurs with already existing standards; at least 35 studies have shown concurrent validity between the BDI and such measures of depression as the Hamilton Depression Scale and the Minnesota Multiphasic Personality Inventory-D . Following a range of biological factors, attitudes, and behaviors, tests for construct validity (the degree to which a test measures an internal construct or variable) have shown the BDI to be related to medical symptoms, anxiety, stress, loneliness, sleep patterns, alcoholism, suicidal behaviors, and adjustment among youth.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Factor analysis, a statistical method used to determine underlying relationships between variables, has also supported the validity of the BDI. The BDI can be interpreted as one syndrome (depression) composed of three factors: negative attitudes toward self, performance impairment, and somatic (bodily) disturbance. The BDI has also been extensively tested for reliability, following established standards for psychological tests published in 1985. Internal consistency has been successfully estimated by over 25 studies in many populations. The BDI has been shown to be valid and reliable, with results corresponding to clinician ratings of depression in more than 90% of all cases. Higher BDI scores have been shown in a few studies to be inversely related to educational attainment; the BDI, however, does not consistently correlate with sex, race, or age.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

103

Posttraumatic Cognition Inventory (PTCI)1 Foa et al. 1999 This tool is comprised of the following two questionnaires: Resick, Schnicke, and Markway (1991) Personal Beliefs and Reactions Scale (PBRS) World Assumptions Scale (WAS) Janoff-Bulman, (1989, 1992) The following are a number of sentences. Possibly, some of them will reflect thoughts that you might have had after the traumatic experience and some of them will not reflect your thoughts at the time. Read each sentence carefully and mark to what extent you do or do not agree with the sentence. People have different reactions to traumatic events - there is no right/wrong answer to these sentences. Completely disagree

1

Don't agree to a great extent 2

Slightly disagree

Neutral

3

4

Slightly agree

5

Agree to a great extent 6

Completely agree

7

1. The event took place because of my behavior.---------------------------- 1 2 3 4 5 6 7 2. I can't trust that I'll do the right thing. -------------------------------------- 1 2 3 4 5 6 7 3. I'm a weak person. ---------------------------------------------------------- 1 2 3 4 5 6 7 4. I won't be able to control my anger and I'll do something terrible. ---- 1 2 3 4 5 6 7 5. I can’t manage even the slightest frustration. ----------------------------- 1 2 3 4 5 6 7

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

6. I used to be a happy person but now I'm always miserable. ------------- 1 2 3 4 5 6 7 7. People can't be trusted ------------------------------------------------------- 1 2 3 4 5 6 7 8. I need to be vigilant all of the time. ---------------------------------------- 1 2 3 4 5 6 7 9. I feel dead inside. ------------------------------------------------------------ 1 2 3 4 5 6 7 10. You never can tell who is going to hurt you. ---------------------------- 1 2 3 4 5 6 7 11. I must be careful, especially because one never can tell what is going to happen. ----------------------------------------------------------------- 1 2 3 4 5 6 7 12. I'm worthless. --------------------------------------------------------------- 1 2 3 4 5 6 7 13. I won't be able to control my feelings and something terrible will happen.----------------------------------------------------------------------- 1 2 3 4 5 6 7 14. If I think about the event I won't be able to bear the pain. ------------- 1 2 3 4 5 6 7 15. The event happened to me because of who I am. ----------------------- 1 2 3 4 5 6 7 1

Translated from Dr. E Cohen's Hebrew rendition

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

104

Completely disagree

1

Don't agree to a great extent 2

Slightly disagree

3

Neutral

4

Slightly agree

5

Agree to a great extent 6

Completely agree

7

16. My reactions since the event show that I'm going mad. ---------------- 1 2 3 4 5 6 7 17. I'll never be able to feel normal emotions again. ----------------------- 1 2 3 4 5 6 7 18. The world is a dangerous place. ------------------------------------------- 1 2 3 4 5 6 7 19. I've changed permanently for the worse. --------------------------------- 1 2 3 4 5 6 7 20. Someone else would have prevented the event from happening. ----- 1 2 3 4 5 6 7 21. I feel like an object, not like a person. ------------------------------------ 1 2 3 4 5 6 7 22. Someone else wouldn't have gotten into this situation. ---------------- 1 2 3 4 5 6 7 23. I can't trust other people. --------------------------------------------------- 1 2 3 4 5 6 7 24. I feel detached and estranged from others. ------------------------------- 1 2 3 4 5 6 7 25. I have no future. ------------------------------------------------------------- 1 2 3 4 5 6 7 26. I can't avoid bad things that might happen to me. ----------------------- 1 2 3 4 5 6 7 27. People are not what they seem. -------------------------------------------- 1 2 3 4 5 6 7 28. My life is ruined because of the event. ----------------------------------- 1 2 3 4 5 6 7 29. There's something wrong with me as a person.-------------------------- 1 2 3 4 5 6 7 30. My reactions since the event show that I am not coping well. -------- 1 2 3 4 5 6 7

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

31. Something in me caused the event to happen. --------------------------- 1 2 3 4 5 6 7 32. I won't be able to bear my thoughts about the event and I'll fall apart. -------------------------------------------------------------------------- 1 2 3 4 5 6 7 33. I feel that I don't know myself any more. -------------------------------- 1 2 3 4 5 6 7 34. You never can tell when something terrible will happen to you. ----- 1 2 3 4 5 6 7 35. I can't rely on myself. ------------------------------------------------------- 1 2 3 4 5 6 7 36. Nothing good can ever happen to me. ------------------------------------ 1 2 3 4 5 6 7

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

105

What is a Post Traumatic Response? Information Sheets for the Client The traumatic experience causes an emotional upheaval and is liable to cause great emotional damage. The purpose of these pages is to explain some of the common responses people experience after a traumatic event. People react in various ways; you may experience some of the responses more strongly than others, and some you may not experience at all. Please read the following explanation and think about the changes in your feelings, thoughts, and behavior since you experienced the traumatic event. Remember, it is normal to undergo many changes after a traumatic experience. In fact, most people suffer from problems after a traumatic event. In some cases, an improvement occurs within a few months, and all of the symptoms disappear; in other cases, much more time is needed to see improvement, and professional help is required. Awareness of the changes you have undergone since the traumatic event is the first step towards healing. The following is a description of some of the common reactions to a traumatic experience:

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

1. Fear and anxiety are natural and necessary responses to a dangerous situation. However, when these responses go on for many months, even years, after the traumatic experience, they become very disruptive to our daily functioning. This situation occurs when your view of the world and your sense of safety in it change. You may experience fear and anxiety as a result of recalling the traumatic event, or sometimes you may find that the feeling of anxiety has appeared for no apparent reason. Among factors that are liable to cause anxiety are places, specific times during the day, smells, noises, or any situation that may be a reminder of the traumatic event. The more you pay attention to when you feel the anxiety, the more you will be able to identify the factors and reminders that arouse it. Doing this, you may see that some of the anxiety that seems to come "out of the blue" is actually a result of stimuli and reminders which bring the traumatic event to your mind. 2. Re-experiencing the traumatic event is a common response among those who have experienced a traumatic event. For example, you may think unwanted thoughts associated with the traumatic experience and find yourself unable to get rid of them. Some people who have gone through a traumatic experience have "flashbacks" of the event. These are very live images which give the feeling that the event is happening right now. Nightmares are another common response to a traumatic experience. These symptoms take place because the traumatic experience is so shocking and different from daily events that you have a hard time organizing it within the framework of information you have about the world and within your expectations from it. In order to understand and digest what has happened, your brain keeps surfacing the experience again and again in the memory. 3. Another common response to trauma is hyper-arousal. People who experience hyper-arousal feel jumpy and they tremble. They feel that the body is working at an accelerated speed (e.g., rapid heart rate, high muscle tension). They startle easily and react strongly to little things. This situation can cause difficulties in concentrating, problems falling asleep, low quality of sleep, and waking up numerous times during the night. Persistent hyper-arousal can lead to a state of irritability and impatience, chiefly when you do not get enough sleep. The arousal response stems from overworking the body's normal "alarm system." In an emergency, this system is

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

106

Appendices

activated so that we can react to the dangerous situation when we are at the peak of our alertness and arousal. This alarm system protects us from threatening situations. It exists in animals as well. In times of danger, this system causes us to have one of these reactions: flight, fight, or freeze. They are natural responses for dealing with dangers. But in your case, because of the trauma, this system is activated even when there is no real danger. It can be working for a long time for no reason. It can be turned on by a reminder of the traumatic experience that, by itself, does not pose a threat (e.g., the sound of an ambulance siren as you are walking down the street). This is a false alarm!!! When we try to protect ourselves from danger, the body releases a strong dosage of adrenaline to supply us with the extra energy we need; hence, the sensation of hyper-arousal at a time of danger. Often people who experience trauma see the world as full of dangers. In consequence, their body is in an ongoing state of alertness, ready to respond immediately to every attack. The trouble is that hyper-arousal is effective only in situations of real dangers, for example, when we have to defend ourselves against someone who is threatening us physically. In our daily lives this is an exceptional occurrence. The state of hyperarousal becomes very uncomfortable when it continues for a long time, including in relatively safe or neutral situations. 4. Avoidance is a common way to cope with the pain of the traumatic experience.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Its most widespread manifestation is avoidance of situations that are reminders of the traumatic experience (e.g., avoiding the place where the trauma happened). However, many times factors indirectly related to the traumatic experience trigger anxiety (e.g., the tendency not to go out in the evenings if the traumatic event took place at night). Another way to avoid being connected to the pain of the traumatic experience is to try to ward off painful thoughts and feelings. The attempt not to feel is liable to lead to a feeling of emotional numbness or lack of sensations. This situation may ease the experience of frightening thoughts but it also prevents experiencing pleasant feelings, and, as a result, you are prevented from feeling pleasure and love. Often the painful feelings and thoughts are so intense that the brain simply blocks the entire range of emotions. 5. Many people who have undergone a traumatic experience feel anger, not only with the event and those involved in it, but also towards others. If you are not accustomed to feeling anger or if you don't recall being irritable in the period prior to the trauma, then this emotion can be especially frightening. Feeling anger towards family and other people close to you can be very confusing. Anger can cause us to distance ourselves from people, including those closest to us. Many times, people who have had a traumatic experience feel inner tension, which causes them to be furious and to get mad very easily (have a "short fuse"). Anger can also stem from the feeling that the world is not fair. It can also be directed towards oneself. In addition, it can stem from frustration in the way we reacted at the time of the traumatic event, from the fact we did not recover after the event, from the pain and sadness we keep feeling, and sometimes, also, from the sorrow we are causing those around us. 6. Another recurrent response to a traumatic experience is difficulty concentrating. Often, after a traumatic event you may find it difficult to concentrate whilst reading, watching the TV, following a conversation, or remembering what others said to you. Difficulties concentrating, remembering, and paying attention to the world surrounding

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

107

you can be both very frustrating and irritating. These, in turn, may result in a sense of losing control of yourself and of your thoughts, or give you the feeling that you are "going crazy." In an attempt to digest and understand what has happened to you, your brain repeatedly goes over the material related to the event. However, it does not process it, rather only re-narrates it again and again. You are basically wasting so much energy on shutting the terrible memories out that you have little power left in yourself to concentrate and digest new information. Difficulty concentrating is a result of intrusive, painful feelings and memories of the traumatic experience, and the attempts to control them. 7. In a number of cases, traumatic experiences cause feelings of guilt and shame. Many people blame themselves for things they did or did not do in order to survive at the time of the trauma. For example, they will say: "I should have fought more," "I should have driven more slowly," or "I should have known that would happen." You may feel shame because during the traumatic event you were forced to do things that under normal circumstances you would not have done. At times, also, those close to you may think that you did not do enough or that you could have acted differently.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Having feelings of guilt regarding the traumatic experience means that you are taking sole responsibility for the event. These thoughts and emotions may result in a sense of having greater control, but, by the same token, they can bring about feelings of helplessness and depression. 8. Depression is also a recurrent response to the traumatic experience. It can include a low mood, hopelessness, and despair. You may cry more frequently and lose interest in other people and in activities that you used to enjoy. The feeling that nothing is pleasurable any more must be very painful and discouraging for you. You may also feel that plans you had for the future have lost all meaning and do not interest you any more, or that there is no good reason left to live. These feelings can lead to suicidal thoughts and wishes, to attempts at harming yourself, or attempts to commit suicide. Since the traumatic experience greatly changed your view of the world and of your self-concept, it stands to reason that you will feel sad and even mourn over what you have lost since the event. Even if, at times, it seems to you that your life is pointless, you know that you are now receiving treatment geared at relieving this feeling and aiming to help you cope with the immense pain the event caused you. It is of the utmost importance that you tell your therapist if there is an intensification of thoughts to harm yourself. 9. Self image and world view also get damaged. Self image can become very negative after a traumatic event. You may say to yourself: "If I wasn't so weak, scared or stupid this would not have happened to me." Many people see themselves in a negative light after a traumatic experience. It is also common to have a darker view of others and of the world. You are liable to think that you cannot trust a soul. If in the past you saw the world as safe, then the traumatic experience may cause you to view it as a dangerous place. If you had past bad experiences, then the current traumatic event may convince you that the world is indeed dangerous and that no one can be trusted. These negative thoughts can bring about the feeling that the traumatic experience changed you completely. Interpersonal relationships, even with close ones, can become laden with tension.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

108

Appendices

As a result of mistrust in man and the world, you have difficulties having an intimate relationship, even with those you trust the most. You might witness the fact that those closest to you are having a hard time supporting you and find it difficult to hear about the traumatic experience. 10. Sexual relationships may also be affected by the traumatic experience. A vast number of people have difficulties feeling sexual or being involved sexually. This is particularly true for rape or sexual abuse victims. In addition to the extensive damage done to trust by being taken advantage of sexually or raped, the sexual act in itself is a reminder of the trauma.

Important to Remember! A lot of the responses to the traumatic experience are interrelated. For example, a "flashback" can make you feel that you have no control and therefore will cause fear and hyper-arousal. People may think that the (common) response they are experiencing means that they are "going crazy" or "losing their mind." These thoughts can, in their own right, intensify the feeling of fear. It is important to bear in mind that the more aware you become of the changes that you have undergone since the traumatic incident and the more you process them, the more you will be able to reduce the intensity of the posttraumatic responses.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

(The above material was taken with publisher's permission, from E. Foa, M. Doron, A Yadin (2004) Hashifa Memusheche (Prolonged Exposure) (Heb), Kiryat Shmoneh, Mashabeem Center.)

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

109

Approaches to Treatment Information Sheets for the Client The treatment focuses on anxieties and the symptoms associated with the trauma and on the difficulties in coping with life's tasks in the period after the trauma. Many of those who experienced trauma suffer from symptoms that diminish and even disappear with the passage of time. However, some of the people who have undergone traumatic experiences suffer from symptoms that do not weaken and continue to cause them great distress. Something happens to our body at the time of trauma. People, like mammals and many other animals which encounter sudden, keenly threatening situations, react in one of three ways: fight, flight or freeze. Posttraumatic symptoms again and again reenact these physical reactions that have become set in the "body memory." The fright, the fear, the escalating tension or the paralysis and helplessness are all trapped in the body, even if we do not clearly remember exactly where and when we felt them. It can be said that the physical response to trauma is stored in the body memory and continues to influence our behavior without our awareness. In treatment we will try to focus inwards, on the physical sensations and the various messages our body transmits to us. We will learn to identify and understand the body's language and we will search for the way to discharge the energies trapped in it as a result of the trauma. In fact, we will try to arouse the "body memory" in order to achieve energy discharge. At the same time we will get "safe" and pleasant body memories to help us cope with distressing and threatening body memories. The discharge will enable us to free ourselves from reactions of freeze, helplessness, tension and unpleasant arousal and clear the body of them.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

It is interesting to examine how the body remembers. Let's do a simple exercise: Try to recall a favorite food, a sweet you like. If you remembered, then try to imagine the food or sweet. Does anything come to mind? Now examine how in your body you know you like this food? Sensation and knowledge together are the "body memory." One of the central abilities that we will use in therapy to help the body and thoughts free themselves from the influence of the trauma is the ability to imagine. We will search for different images that help us achieve calmness and other images that allow us to observe what we have gone through. With the help of imagination we can connect to our bodily sensations and have an impact on them. The imagination will also make it possible for us to look for creative solutions for everyday situations. One of the main factors causing symptoms to persist after the trauma is avoidance of situations, memories, thoughts, and feelings relating to the event. It is natural that after a traumatic experience people want to forget everything and avoid memories, situations, and thoughts that cause pain and distress. In the short run avoidance helps diminish the distress, but in the long run it makes you a prisoner in your own life, preventing you from doing things that you would have liked to, and stopping you from making the decisions you otherwise would have made. In fact, you feel that the trauma has robbed your freedom from you. The result of avoidance is that it preserves the symptoms and gets in the way of healing from the trauma. Can you think of things that you have been avoiding since the trauma?

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

110

Appendices

When we agree to experience real life situations that we have been avoiding as a result of the traumatic incident and its painful memories and painful physical sensations, then we will gradually regain control over our life (thoughts, actions and feelings). This is crucial to the possibility of processing the traumatic experience. Only when we abandon avoidance, do we learn that the memories themselves (even if they are painful and frightening), and most of the situations we avoid, are not as dangerous as they seem to us. Through real life experience (i.e., exposure), the anxiety caused by these situations will gradually decline and the symptoms will weaken. To achieve this objective we will employ a number of processes: in vivo exposure (meaning gradual tasks to be carried out in reality), re-narration in the fantastic reality (a gentle, gradual process of recalling the experience), and cognitive processing of ideas and feelings that have surfaced while re-narrating and carrying out exposure tasks (in other words, changing what we think about ourselves and about the situation). In vivo exposure is exposure to things that you have been avoiding since the event because they remind you of the trauma either directly or indirectly; for example, spending time in noisy crowded venues, and driving your car after an accident or not wearing a certain color as it reminds you of something that happened. It is imperative that you realize that these exposures will be carried out gradually and only when you are ready for them.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Re-narration using the fantastic reality. The objective of this protocol is to help with the processing of otherwise 'frozen' intact' frightening story that is kept inside either as a full or as a fragmented story. In this method we will aim at slowly re-narrating the traumatic memory, using images (cards) and utilizing your imagination to pick the cards or images that represent the event or incident for you. Throughout the treatment we will ask you to repeatedly watch the cards and re-narrate the traumatic memories in order to reduce the level of distress or discomfort they cause you. You will also be encouraged to reflect on and try out possible additions or changes you would have liked to introduce or incorporate into the story. Cognitive processing deals with negative beliefs and thoughts. After a trauma, many people conclude that the world is unpredictable. They feel that they lack control or are unable to cope with events taking place and therefore view the world as a thoroughly dangerous place. Another outcome of the trauma is that victims develop a very negative self-image. These are the thoughts that cause anxiety, avoidance, and depression, and they fuel the PTSD symptoms. As a result of these beliefs, you may feel constant stress and tension and, in consequence, feel less capable of coping well with daily situations requiring responsibility. In this therapy we learn to identify the negative, self-blocking, self-criticizing statements and beliefs resulting from the trauma. We will reexamine them and explore if and how it is possible to change them. In the first stages of therapy, you may feel that the symptoms have gotten worse. There may be heightened feelings of fear and fright and even an increased frequency of uncontrolled recollections of the event. It is important to remember that this is not a failure in the therapy. On the contrary, it is a sign that therapy is progressing in the right direction and that the material which was closed in the "steel box" in a disorganized and disorderly fashion has become accessible and approachable and thereby reorganized in the memory. The more the treatment advances and the memories are organized and become processed, the more these feelings and symptoms

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

111

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

will weaken until they become more tolerable or completely disappear. At other times you may feel that the therapy is boring, oppressive and tiring and you may even wish to stop it. These feelings are very common and are usually recognized signs of a process of improvement. They are indirect evidence that important things are going on in the brain. The choice to remain in therapy is, of course, entirely up to you, but keep in mind that these feelings are not necessarily a sign of lack of success or a reason to stop treatment. Therapy is a long, hard, gradual process that demands a lot of patience. In a way, you are rather courageous person to take this chance and work on these frightening and blocking components that the traumatic incident imposed on you. If thoughts to quit this courageous attempt to get rid of the tormenting memories by leaving therapy are aroused, do share this with your therapists. Remember, the aim is to substantially relieve the suffering and improve the quality of life. To reach this goal one must often cope with unpleasant feelings for awhile. This time it is with the help of an experienced helper and a method that was found very effective for many many people.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

112

Appendices

Anxiety Management Techniques The following self help pages on anxiety management techniques can be handed out to clients. They are written in a language which makes them accessible to the clients for personal use. Anxiety Management Techniques A number of effective methods for relieving tension and anxiety have emerged from years of research and therapy. The main ones are described here. It must be pointed out that the effectiveness of these systems is not the same for all people. Each of us may choose the methods that are most suitable for him. Sleeping, eating, and drinking are effectual means of coping with anxiety and tension. Physical exercise facilitates converting the sensation of psychological tension into vital, exhilarating, physical energy. Walking alone or with others, running, dancing, or riding a bike are good healthy ways to release tension. Yoga, relaxation, meditation, rhythmic breathing and other methods of distracting oneself from the cause of the tension help one to concentrate and focus on the body and soul instead of on what gives rise to anxiety and tension. Being in the company of other people, mainly friends and family, helps ward off fears and anxieties. As part of the process of forming an intimate relationship, people customarily share their embarrassments, fears, and anxieties. Unloading emotions relieves tension, and allows others with similar feelings to take part. Humor is a good, effective method for easing tense situations and coping with anxiety.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

At times when community or national events cause tension, taking the initiative and being proactive in activities that contribute to the community or to the environment helps release the feeling of helplessness and being worried. There are additional means for relieving pressure and anxiety. These are self help methods that enable you to practice on your own coping better with various pressures, anxieties, and fears. These methods are based on accumulated knowledge gathered in Israel and worldwide, by mental health professionals. Read the following self help pages carefully, try the methods and choose the method/s most suitable for you. Knowledge and practice in advance may be helpful with coping with future anxiety provoking situations.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

113

Coping Through Imagery It is both possible and worthwhile to sit comfortably, preferably with eyes shut (though not mandatory). Take a few deep breaths and exhale from the chest very slowly. Choose from the following items, those most suitable for you: 1. Imagine a pleasant experience you had and "enter" it. Focus on the fine details of the experience and let yourself enjoy it. If the picture gives you pleasure, return to it and use it as needed. If you did not feel any changes, then choose a different image. 2. Imagine that you are watching a movie (DVD) in which you see yourself going through the bad experience that you are afraid of. It is important that you allow yourself (in the movie) to examine all of the possible ways for coping with the experience. (Remember, this is only a movie, and in the movies all solutions are feasible.) Now, after you have succeeded in imagining the frightening picture, take the remote control and, using the appropriate button, blur it, remove the colors, lower the volume, and reduce the image to a point. After you have managed to gain good control of the picture, enlarge it and then reduce it again. Repeat this exercise a few times, until the image does not provoke such great distress any longer. 3. Recall a person you know, who you believe copes well with stress. Imagine how he would cope with the stress you are experiencing and act like him.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

4. Imagine a stressful situation which in the past you coped with well. Reconstruct your behavior then, and write down the successful coping methods you used. 5. Imagine that the level of your tension is a car speedometer. When you are at the peak of your tension, the hand points to 100. When you are most calm, it points to 0. Now, imagine that you control the gas pedal. Check in your imagination, while concentrating on your physical sensations, at what number the hand is pointing. Lift your foot slightly from the gas pedal. (It is very important to actually imagine yourself in a car, including sitting as if you are driving and moving your leg muscles as if there really is a gas pedal.) Try to reduce by 5 and then to increase by 5. Pay attention to the changes in the position of the speedometer hand. Slowly reduce towards zero and experience the changes in your feelings. (Remember, you do not have to get to "0" stress level, you just have to aspire to reach it. Every success in reducing the level of distress is important.) 6. In certain situations fear is our close companion. In such cases the challenge is to control the fear and not allow it to control us. Imagine your fear to be a big, strong dog whose leash you willingly hold, and walk down the street with him, as though he were a gentle dog. Notice how he is wagging his tail and moving his ears. Smile… 7. Try to get into the role of your childhood hero: "Rambo," "Rocky," "Clint Eastwood," "Patrick Kim," "Tarzan,"…. Imagine how he would cope with your situation and try to experience his feelings after a victory.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

114

Coping with Pressure and Anxiety through Self Talk Instructions Read the following statements and choose the ones which, when you say them to yourself, help improve the way you feel. Then, memorize them, saying them out loud, and use them when necessary. • • • • • • • • • • •

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

• • • • • • •

I won't let fear take control over me; I can overcome it. I won't get pressured by the fact that I am stressed. My feeling of pressure is a normal reaction in stressful situations; others experience the same feeling. The atrocities that I am imagining are not realistic at the moment; I’d better think of real problems. I'm not solving any problems by preoccupying myself all the time with terrible things that might happen. I've already experienced worse pressures and I managed to cope. This is exactly the appropriate time to apply the techniques I have learned for coping with stress. Instead of worrying about disasters that might occur, it would be better to concentrate on what I need and can do now. I can and I must overcome for the sake of those who need me (friends, children, spouse). I've done everything in my power to prepare for the next misfortune. From now on, things are not up to me and there is no point in my worrying about them. Take a breath and exhale the air while saying a calming word such as: calm, peaceful, peace (or any other word that may calm you), until you have let out all of the air. Repeat this action a few times. My fear and anxiety are achievements for the enemy. I will overcome and deny him this achievement. The people surrounding me will be encouraged and strengthened when they see that I'm not in a panic. It's not the end of the world if it was evident that I was stressed. It happens to everybody. There is nothing bad about my being stressed. It's merely a sign that I need to get prepared for expected difficulties. The possibility of my getting hurt or those close to me being hurt is statistically slight. Therefore, I shouldn't consider this possibility a likely one. The fact that others around me seem calm is not proof that they are not stressed. (I should help them.) I wonder what joke could be written about this situation in which everyone is pressured/frightened. In a few hours I’ll feel much better.

(If, up to this point, you have not found, a sentence that is suitable for you, then make one up and write it down.) ______________________________________________________________________ ______________________________________________________________________

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

115

Coping with Pressure and Anxiety Through Actions You Can Carry Out Instructions Read the following list of actions and choose the ones that help you cope with pressure. Then begin carrying them out. Practice the methods that aid you and use them when necessary. • • • • • • • • • • • • •

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

• • • • • • •

Breathe. (Preferably not only deep breaths; make sure air is exhaled slowly, gradually, and deeply to the point that the chest is emptied, and then breathe again.) Keep in contact with your friends and communicate with them, even when you feel like being alone.) Talk with humor about the tension and fear. Laugh with others. Busy yourself with your tasks and concentrate on them. This will help you avoid having distressful thoughts. Help and contribute to others. ("He that helps is helped.") Demand of others, and convince them to continue carrying out their roles and to overcome the tension. Make sure you look and act calm, even if you feel differently. Suck a candy or chew gum. Have a lot of soft drinks (water is preferable). Distract yourself from distressing thoughts by scribbling, humming, whistling, or any other action that does the trick. Do things you usually enjoy: Listen to music or to the radio, watch a movie, prepare a good meal, read a book, write a poem or a story, paint, etc. Make a list of your good coping methods and practice them. Eat a snack or a piece of fruit very slowly. Concentrate on its taste, enjoy it, and accompany it as it goes into your body. Choose a partner and go somewhere relaxing with him (can be done in the imagination as well). Look around (at the view, the street, at people) and enjoy what you see. Open a window and enjoy the fresh air. Invite friends over or go visit them. Read a thriller or watch an action film. Prepare a kit (preferably small and portable) to have with you of objects that help you feel relief when under tension (a water bottle, a flashlight, candy, a warm garment, swipes, etc.) Pray or go to a spiritual center

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

116

Coping with Pressure and Anxiety through Relaxation Instructions Read the list of relaxation techniques, practice them, choose those that help you the most, and use them when necessary. • • • • • • • • • •

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

• • •

Jump fifty jumping jacks, then sit down and wait for the calming sensation that will surface as your heart rate and breathing return to normal. Inhale deeply through your nose and exhale very slowly - to the end - through your mouth. As we said earlier, you can repeat a calming word while carrying out this action. Contract and release parts of your body in which you feel tension. Do this for a few minutes. Do ten pushups and rest. Run quickly, then sit down and rest. Lie on your back on a soft mattress, concentrate on your muscles and relax them one by one. Sit on a chair, let your arms and hands hang freely, place the entire soles of your feet on the floor. Close your eyes, breathe peacefully at a rate suitable for you. Imagine that all of the parts of your body from head to toe are losing weight, to the point that your entire body is weightless. Feel the lightness of your body and enjoy this sensation. Imagine that your body parts are gaining weight to the point of dropping, feel the pleasant heaviness and enjoy it. Follow the entrance of air into your body, accompany its movement into the lungs and out. Do the above actions with soft background music and dim lights. Take a bath or a warm shower. Let yourself rest and fall asleep.

Do Not Forget! When we are under tension our sense of time changes and we often feel that this situation is going to go on for a long time - "that time isn't passing." It is important to keep this in mind and allow yourself to look at timerealistically. Do Not Give Up Humor! Laughter is healthy and good. It enables better breathing which, in turn, helps the body relax and calm down.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Appendices

117

Adaptation of the Protocol for use with Children To adapt the protocol for use with children, we recommend the following steps: 1. Relaxation and directed imagination: shorter duration. Begin session with 30-40 jumps. When the child gets tired, instruct him to sit on a chair and listen to his body, and to hear his breathing slowly regulate itself. 2. Preparing a safe place through a card can sometimes take a long time as the child enjoys drawing the space around it. If this repeats itself in every session, then time should be allocated for preparing the safe place in order not to encourage avoidance through keeping busy with drawing. 3. It is possible to photocopy or scan the safe place for the children to take home to practice. For some kids taking a photo with their cellphone makes the image more accessible. 4. Anchoring in the body with children often requires using examples from their world. For example, think about your favorite sweet. Where do you feel the taste? Or, think about where in your body you feel stroking your dog, or his licking you, and the like. 5. In composing the in vivo exposure hierarchy scale, it is important to inquire whether the child needs an escort. If so, the adult should be instructed on how to carry this out. Distracting should be explained to him; for example, giving sweets while reexperiencing, conversing with the child to distract him, using an MP3 or another music device with earphones. 6. It is important to involve the parents, to explain to them about the syndrome, the therapy method, and the possibility that at first the feelings may be worse and they might witness regression in their child's behavior.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

7. It is imperative to instruct the parents not to turn the in vivo exposure into another test in which the child's failure is evidence of his incompetence. On the contrary, the child should be encouraged, but the adult should not to interfere or do his tasks for him. 8. It is very important to guide the adult as to when to accompany the child and when to observe from a safe distance. 9. In the event that it was decided to employ a reinforcement chart or "token economy method," it should be prepared together with the therapist. Parents and child should also decide on reasonable prizes for successful management of distressful in vivo tasks. Do not permit prizes that seem like "bribery" or are out of proportion. 10. It is important to point out that each success of the child must be accompanied by verbal praise. 11. Teach parents that if the child fails the task, do not reprimand or insult him. Find out with him what prevented his completing the task, and explore the usefulness of constructing a new hierarchy or”gradual exposure method.” For example, first observe the shopping mall from the outside, the next day enter it as far as the guard; the day after that, enter and stay for ten minutes with the adult escort. 12. Once every few sessions hold an explanatory conversation and discussion with the child and his parents, mainly for giving encouragement and boosting motivation. Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

118

Appendices

13. The full protocol of re-narrating in fantastic reality through cards may be too long and intense for children. Therefore, the number of re-narrations per session can be decreased as can the number of steps in each session. The session can end after the pendulation, or after adding the "as if" cards. At any event, the practice of a safe place must be done before the end of the session, regardless of where the adjusted end of the particular session will be. 14. Lessening the number of re-narrations or exposure through cards tasks does not mean that we will skip any of the stages. It only means that each session will be divided into shorter practice units and there might be more sessions. (Altogether not more in time, as the normal time of an adult's session is 90 minutes and for a child sessions can be 50-70 minutes each) 15. Towards the end of the treatment of children, it is important to plan with them how they would like to conclude. Keep in mind that in children's experience, endings usually entail a party or celebration. Allow the child to plan the party, within reason.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

It is possible to prepare and present the child with a certificate for overcoming fears.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

119

Bibliography Books in Hebrew Cohen, A. (1966). Halom Hanefesh (The Soul's Dream) (Heb.), Haifa, Amatzia. Foa, E., Doron, M., & Yadin, A. (2004). Hasefa Memushechet (Prolonged Exposure) (Heb.), Kiryat Shmonah, Merkaz Mashabeem. Goldman, D. (2005). Regashot Harsaneeyim Eich Nochal lhetgaber Alehem ? (Destructive Feelings How Can We Overcome Them?) (Heb.), Ben Shemen, Modan. Herman, J. L., (1992). Trauma Vehachlama (Trauma and Recovery) (Heb.), Tel Aviv, Am Oved, 2005. Lahad. M. (1996). Etur Mashabee Hetmoddedut Beemtzaut Sepur Besheha Chalakeem: Model BASIC PH (Locating Coping Resources Through A Six Part Story: BASIC PH Model) (Heb.), Kiryat Shmonah, Hamerkaz Lematzavie Lahatz. Lahad, M. (2006). Metzeut Fantasteet (Fantastic Reality) (Heb.), Haifa, Nord. Leedo, G. (1998). Hamoach Hareegshe: Hatashteet Hamestoreet Shel Hayye Haregesh (The Sentimental Mind: The Mysterious Infrastructure of the Emotional Life) (Heb.), Tel Aviv, Am Oved. Levin, P. (1999). Lehaeer et Hanamer (Waking the Tiger) (Heb.), Hod Hasharon, Astrolog. Wiencot, D. V.(1958). Meschak Vemetziut (Games and Reality) (Heb.), Tel Aviv, Am Oved, 2003.

Books and Articles in English

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Adler A.(1956), The Individual Psychology of Alfred Adler, (H.L.& R.R Ansbacher Eds.) New York, Basic Books Inc., Adler A.(1958), What Life Should Mean To You (A. Porter ed.) Capricorn. New York, Albucher, R. C., & Liberzon, I. (2002). Psychopharmacological treatment in PTSD: a critical review. Journal of Psychiatric Research, 36, 355-367. Allen, S.N., & Bloom, S.L. (1994). Group and family treatment of post traumatic stress disorder. Journal of Traumatic Stress, 17, 425-437. Allport G.W. (1937), Personality, Holt Pub. N. Y. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders DSM-IV-TR. American Psychiatric Association, Washington, DC. Antonovsky A. (1978), Health Stress and Coping. San Francisco Jossey Bass Publishing Beck, A.T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Becker B. (1976), A Holistic Approach to Anxiety and Stress, The Am. J. Of Psychoanalysis 36, 139-46. Blake, D. D., Weathers, F. W., Nagy, L. M., et al. (1990). A clinician rating scale for assessing current and lifetime PTSD: CASP-1. The Behavior Therapist, 13, 187-188.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

120

Bibliography

Bleich, A., Shalev, A., Shoham, S., Solomon, Z., & Kotler, M. (1992). Theoretical and practical considerations as reflected through Koach—an innovative treatment project. Journal of Traumatic Stress, 5, 265–271. Boudewyns, P., Hyer, L., Woods, M., Harrison, M., & McCranie, E. (1990). PTSD among Vietnam veterans: An early look at treatment outcome using direct therapeutic exposure. Journal of Traumatic Stress, 3, 359368. Boudewyns, P.A. & Hyer, L. (1990). Physiological response to combat memories and preliminary treatment outcome in Vietnam veteran PTSD clients treated with direct therapeutic exposure. Behavior Therapy, 21, 63-87. Brandt O. (1984) Fluchtlingskinder: Eine Untersuchung zu ihrer psychischen Situation. Munich Barth. Breslau, N., Davis, G., Anderski, P. & Peterson, E. (1991). Traumatic events and posttraumatic stress disorder in urban population of young adults. Archives of General Psychiatry, 48, 216-222. Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R., Davis, G. & Anderski, P. (1998). Trauma and post traumatic stress disorder: The 1996 Detroit area survey of trauma. Archives of General Psychiatry, 55, 626632. Brewin, C. R., Dalgleish T., & Joseph, S. (1996). A dual representation theory of post traumatic stress disorder. Psychological Review, 103, ,670-686. Caplan G. Grunbaum M.(1976), Perspective on Primary Prevention. Archives of General Psychiatry, 17. Chemtob, C. M., Tolin, D. F., van der Kolk, B. A., & Pitman, R. K. (2000). Eye movement desensitization and reprocessing. In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies, pp. 139-154. New York: Guilford. Chess S. & Thomas A. (1985), Origins and Evolution of Behaviour Disorders, New York: Brunner/Mazel. Creamer, M., Forbes, D., Biddle, D., & Elliott, P. (2002). Inclient versus day hospital treatment for chronic, combat-related posttraumatic stress disorder: A naturalistic comparison. Journal of Nervous and Mental Disease, 190,183-189. Crime Victims Research and Treatment Center (1992). Rape in America: A Report to the Nation. Charleston, SC, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Davidson, J. (1992). Drug therapy of post-traumatic stress disorder. British Journal of Psychiatry, 160, 309– 314. Davidson, J. R., Hughes, D. Blazer, D. G., & George, L. K. (1991). Post-traumatic stress disorder in the community: an epidemiological study. Psychological Medicine, 21, 713-721. Diagnosis, Management and Treatment (2nd ed) Informa Healthcare: Cornwall, England, disorder. In Nutt DJ, Stein MB, and Zohar J (Eds): Post Traumatic Stress Disorder: Drever J. (1974), A Dictionary of Psychology, Penguin, Harmondsworth, England. Dunham J. (1984), Stress in Teaching Routledge, London. Elder G.H. Jr. Caspi A. & Nguyen T. van (1986), Resourceful and Vulnerable Children: Family Influence in Hard Times. In R.K. Silbereisen, K. Eyferth & G. Rudinger (eds.) Development as an Action in Context (pp 167-86), Berlin, Springer. Erikson E.H. (1963), Childhood and Society Norton NY. events: Applications of the schema construct. Social Cognition, 7, 113Felsman J.K. & Vaillant G.E. (1987) Resilient Children as Adults: A 40- Year Study. In E.J. Anthony and B.J. Cohler (eds.) The Invulnerable Child, (pp 289-314), New York, Guilford. Foa E.B., Riggs D.S., (1993). Posttraumatic stress disorder and rape, in American Psychiatric Press Review of Psychiatry, Vol 12, Edited by Oldham JM, Riba MB, Tasman A. Washington DC, American Psychiatric Press, pp 273-303.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Bibliography

121

Foa, E. B., Keane, T. M., & Friedman, M J. (Eds.) (2000). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press. Foa, E., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychological Assessment, 9, 445-451. Foa, Edna B.; Hembree, Elizabeth A.; Cahill, Shawn P.; Rauch, Sheila A. M.; Riggs, David S.; Feeny, Norah C.; Yadin, Elna (2005) Randomized Trial of Prolonged Exposure for Posttraumatic Stress Disorder with and without Cognitive Restructuring: Outcome at Academic and Community Clinics Journal of Consulting and Clinical Psychology, Volume 73 Number 5. p953-964 Oct 2005 Folkman S. and Lazarus R.S. (1988), Coping as a Mediator of Emotion. Journal of Personality and Social Psychology 54, 466-75. Foulkes S.H.(1964) Therapeutic Group Analysis London, Allen and Unwin Ltd. Frankl V. (1963), Man's Search for Meaning, Boston, Beacon Press. Freud A. & Berlingham D. (1943), War and Children, New York, Willard. Freud S. (1937), Inhibitions, Symptoms and Anxiety, London, Hogarth Press Glynn, S. M., Eth, S., Randolph, E. T., et al. (1999). A test of behavioral family therapy to augment exposure for combat-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 67, 243– 251. Gordon S. (1994), Is there anything I can do? New York, Delacorte Press. Greyson, B., Bush, N. E., (1992). Distressing Near-Death Experiences, Psychiatry, 55, 95-110. Haan N. (1982), The Assessment of Coping, Defense and Stress, In Handbook of Stress, L Goldberger & S. Breznitz, Freepress, NY. Harvey A. G., Bryant, R. A., & Tarrier, N. (2003). Cognitive behaviour therapy for posttraumatic stress disorder. Clinical Psychology Review. 23, 501-522. Hodgkinson P. & Stewart M. (1991), Coping with Catastrophe, London, Routledge. Horowitz, M. (1976). Stress Response Syndromes. New York: Jason Aronson. Janis I. (1971), Stress and Frustration, New York, Harcourt Brace Jovanovich. Kroeber 1963 ed. The Study of Lives 178-98. N.Y. Atherton Press Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Janoff-Bulman, R. (1989). Assumptive worlds and the stress of traumatic Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology Jung C.J. (1923), Psychoanalytical Types, Harcourt, Brace Jovanovitch, NY. Keane, T.M., Fairbank, J.A., Caddell, J.M., & Zimering, R.T. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260. Kessler, R.C., Sonnega, A., Bromet, E.J., Hughes, M., & Nelson, C.B. (1995). Posttraumatic Stress Disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060. Kilpatrick, D.G., Resnick, H.S: (1993). Posttraumatic stress disorder associated with exposure to criminal victimization to clinical and community populations, in Posttraumatic Stress Disorder: DSM- IV and Beyond. Edited by Davidson JRT, Foa EB. Washington DC, American Psychiatric Press, pp 113-143. Klinger, E. (1990). Daydreaming, using waking fantasy and imagery for self-knowledge and creativity. Los Angeles: Tarcher Inc. Kofferl P. 1989, Invulnerability and Psychological Resilience, Paper at lst European Conference of Psychology, Amsterdam. Kroeber 1983, Koller, P., Marmar, C.R., & Kanas, N. (1992). Psychodynamic group treatment of post-traumatic stress disorder in Vietnam veterans. International Journal of Group Psychotherapy, 42, 225-246. Lahad S. (1984), Evaluation of Multi-modal Programme to Strengthen the Coping of Children and Teachers under Stress of Shelling. Columbia Pacific University. Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

122

Bibliography

Lahad, M. (2005). Transcending into Fantastic Reality: Story Making with adolescents in Crisis. In C. Schaefer, J, McCormick & Ohnogi, A. (eds.) International Handbook of Play Therapy: advances in assessment, theory, research and practice, Lanham: Jason Aronson Pub. Landy, R. (1993). Persona and Performance. London: Jessica Kingsley Publishers. Lazarus R. Launier R. (1981), Stress Related to Transactions between Person and Environment. In Pevin L. & Lewis M. (eds.) Prescriptions in Interactional Psychology, New York, Plenum Press. Lazarus R.S. & Folkman S. (1984), Stress Appraisal. and Coping, New York, Springer Publishing Company. Le deux, G. (1998). Hamoach Haregshe: Hatashteet Hamestoreet shel Haii Haregesh (The Emotional Brain: The Mysterious Infrastructure of the Emotional Life) (Heb.). Tel Aviv, Am-Oved. Levine P.A. (1997). Waking the Tiger Healing the Trauma Published by North Atlantic Books, California. Lindauer, R. J., Vlieger, E. J., Jalink, M., Olff, M., Carlier, I. V., Majoie, C. B., den Heeten, G. J., & Gersons, B. P. (2004). Smaller hippocampal volume in Dutch police officers with posttraumatic stress disorder. Biol. Psychiatry, 56, 356–363. Losel R. Bliesner T. Koferl P. (1989), Mental health in spite of stressful childhood: concepts and some results of resilience research. Paper presented at the First European Congress of Psychology, 2-7 July Amsterdam Marshall RD, Beebe KL, Oldham M & Zaninelli R. (2001). Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebo-controlled study. American Journal of Psychiatry, 158: 1982-1988. Marshall, R.D., Scheier, F.R., Fallon, B/A., Knight C.B., Abbate L.A., Goetz D., Campeas, R. & Liebowitz M.R. (1998). An open trial of paroxetine in patients with noncombat- related, chronic posttraumatic stress disorder. Journal of Clinical Psychopharmacology; 18:10-18. Maslow A. (1954), Motivation and Personality. New York Harper. Maxfield, L. (2003). Clinical implications and recommendations arising from EMDR research findings. Journal of Trauma Practice, 2, 61-81. May R. (1950),The Meaning of Anxiety, Ronald Press NY. Health and Social Behaviour, 9. McCann, I. L., & Pearlman, L. A. (1990). Psychological trauma and the adult survivor: Theory, therapy and transformation. New York: Brunner/Mazel.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389. Moos R.H. (1984), Context and Coping, American Journal of Community Psychology, 12. Murphy L.P. (1987), Further reflections on resilience, in: Anthony E.J. and Cohler B.J. (eds.) The Invulnerable Child. New York: Guildford Press. of trauma. New York: Free Press. Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D.S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 52-73.Paper presented at the annual meeting of the Association for Advancement of Behavior Therapy, New York. Pavlov I.P. (1927), Condition Reflexes, An Investigation of the Physiological Activity of the Cerebral Cortex London, Oxford University Press. Pearlin L. & Schooler C. (1978), The Structure of Coping. The Journal of Health and Social Behaviour 9. Phoenix, B. J. Psychoeducation for survivors of trauma. (2007). Perspectives in Psychiatric Care, 43(3): 12331. relationship between cognitive content and posttraumatic stress disorder. Resick, P. A., & Schinicke, M. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60, 748-756. Resick, P. A., Schnicke, M. K., & Markway, B. G. (1991, November). The

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Bibliography

123

Ressler, K.J. & Rothbaum, B.O. (2009). Psychosocial treatments of posttraumatic stress Rosenfeld, L. B., Caye, J., Ayalon, O., Lahad, M.,(2005). When their world falls apart: Helping Families and children manage the effects of disasters, Washington,DC: NASW Press. Rothbaum, B.O., Hodges, L.F., Ready, D., Graap, K., & Alarcon, R.D. (2001). Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder. Journal of Clinical Psychiatry, 62, 617–622. Rothschild, B. (2000). The Body Remembers. New York: W. W. Norton. Rutter M. (1985), Resilience in the face of Adversity. British Journal of Psychiatry, 147. Schachtel E. (1980), Projection and its Relation to Attitudes and Creativity in the Kinaesthetic Responses, Psychiatry 13, 69-100. Schnurr,Paula P. Friedman Matthew J., Engel, Charles C. Foa ,Edna B., (2007) Cognitive Behavioral Therapy for Posttraumatic Stress Disorder in Women: A Randomized Controlled Trial,., Journal of the American Medical Association, February 28, 2007; 297: 820 - 830. Shalev, A.Y., Galai, T., & Eth, S. (1993). Levels of Trauma: A multidimensional approach to the treatment of PTSD. Psychiatry, 56, 166-177. Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures. New York: Guilford Press. Skinner B. (1938), The Behaviour of Organisms, Appleton Century Crofts, NY. Solomon, S. D., & Johnson, D. M. (2002). Psychosocial treatment of posttraumatic stress disorder: A practice-friendly review of outcome research. Journal of Clinical Psychology, 58, 947-959. Solomon, S. D., Gerrity, E. T. & Muff, A. M. (1992). Efficacy of treatments for posttraumatic stress disorder: An empirical review. Journal of the American Medical Association, 268, 633-638. Tulving, E. & Garlik, J. I. M . (eds.) (2000). The Oxford Handbook of Memory. New York: Oxford University Press. Van Etten, M. L., & Taylor, S. (1998). Comparative efficacy of treatments for posttraumatic stress disorder: A meta-analysis. Clinical Psychology & Psychotherapy, 5, 126-145. von Franz M.L. (1987), Interpretation of Fairytales, Spring Publications, Dallas.

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Watson J.B. (1928) Psychological care of infant and child. New York: Norton Watzlawick P. Weakland R. & Fisch R. (1979), Change, Principles of Problem Formation and Problem Resolution, Mental Research Institute, Palo Alto. Werner L. (1989), Vulnerability and Resiliency: In M. Brambring et al (eds.). Children at Risk: Assessment and Longitudinal Research, de Gruyter, Berlin. Witztum E.(1989), Brief Psychotherapy in "Brief Psychotherapy" Dasberg H. Itzigsohn A. & Shefer G. (eds.) Magnes Press, Hebrew University, Jerusalem. Zoellner, L. A., Foa, E. B., & Brigidi, B. (1999). Interpersonal friction and PTSD in female victims of sexual and non-sexual assault. Journal of Traumatic Stress, 12, 697-708.1.

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive

Copyright © 2010. IOS Press, Incorporated. All rights reserved.

This page intentionally left blank

Lahad, M., and M. Doron. Protocol for Treatment of Post Traumatic Stress Disorder : See Far CBT Model: Beyond Cognitive