Hot cognitions and Felt sense

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Hot cognitions and Felt sense

• Wessex Psychotherapy Meeting
• 21st of November 2007
• Slide contributions from Mark Latham, Geraldine
  Fletcher, Alison Sedgwick-Taylor, Daniel
  Middlehurst.

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Objectives

• Definitions PTSD, Type 1, Type 2
• Exercise
• CBT Models For Type 1
• Exercise
• Brain structures / hypotheses
• Vicarious trauma
• Exercise if time

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Defintions

• Post traumatic stress disorder (PTSD)
• 3 symptom clusters
• Intrusions
• Avoidance
• Hyperarousal
• Prevalence rates vary according to the
• event experienced.

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Reactions to Trauma

• PTSD is not the only outcome after trauma.
  Conditions such as acute stress disorder,
  phobias, somatisation, depression, OCD, suicide,
  substance abuse, psychosis and head injury/
  neurological damage are common sequelae following
  trauma.

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Types of trauma (Terr)

• Type I trauma
• Unanticipated single event(s)
• e.g. Road Traffic Accident

• Type II trauma
• Long-standing and repeated ordeals
• e.g. Childhood Sexual Abuse

The characteristic feature of PTSD is continual
reliving of an event from the past, with the same
emotional intensity as the original experience
Lee (2006, p142) i.e. Flashbacks
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Traumatic stress
Type I
Type II
Simple
Complex
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Traumatic Stress
Simple Type I
Complex Type I
Type I event
Complex
Simple
Type II event
Complex Type II
persistent and complex PTSD is not necessarily
related to the extent of suffering or the
perceived severity of the event. Lee (2006,
p150)
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Complexity of traumatic response
Individual (pre, peri post trauma appraisals
based on personal history)
Event (Type I or Type II)
X
Determines
Intrusions flashbacks, especially hotspots
Determines
Idiosyncratic meaning
Determines
Level of complexity
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INTRUSIVE RECOLLECTIONS

• Predominantly, though not exclusively visual in
  nature.
• Can take the form of film clips of part of the
  trauma.
• May be single, or multiple static images.
• Can include sounds, smells, somatosensory
  sensations or thoughts.

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FLASHBACKS

• When the re-experiencing reaches the point where
  it feels as if its actually happening again
  usually referred to as a flashback.
• Intrusive recollections and flashbacks usually
  consist of representations of the worst moments
  of the trauma the hot-spots.
• Can consist of various sensory modalities, and
  accompanied by strong affect.

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FLASHBACKS

• Dissociative flashbacks can occur in both
  Simple and Complex Posttraumatic Stress.
• Within PTSD the term dissociation is used to
  cover depersonalisation, derealisation, amnesia,
  numbing and flashbacks.
• Flashbacks are proposed to occur as a result of
  peritraumatic dissociation resulting in the
  trauma information being encoded inadequately.

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ENCODING OF TRAUMA INFORMATION

• At moments of extreme arousal, memory is encoded
  primarily in a sensory-perceptual manner
  data-driven rather than conceptually-driven
• Recollection of these types of memories is more
  likely to be involuntary, and triggered by
  sensory associations.
• Hence intrusive recollections and flashbacks.

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Exercise

• Watch DVD
• Task
• In pairs discuss what aspects suggestive of PTSD
  maybe present? Discuss for 5 minutes and feedback
  to group

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Contemporary Theories of PTSD

• Concentrating on Type 1 trauma (Simple and
  Complex)
• Dual Processing Theory (Brewin)
• Cognitive model of PTSD (Ehlers and Clark)

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Dual Processing Theory

• 2 parts to the fear model
• An unconscious part referred to as the
• situationally accessible memoris (SAMs)
• A more conscious part referred to as
• verbally accessible memories (VAMs)

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Dual Processing Theory

• Postulate that part of memory generated during
  the trauma is not readily accessible to the
  conscious mind and is stored as SAMs. This
  storage is hypothesised to involve the amygdala.
• SAMs can only be accessed when the person is in a
  context similar to the traumatic event.

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Dual Processing Theory

• SAMs
• Therapy
• VAMs

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CT for PSTD Ehlers Clark 2000 Model
Arrows show
Influences Prevents change Leads to
Trauma Characteristics State of Individual Prior
Experiences and Beliefs
Cognitive Processing during Trauma
P E R S P I T S S T D
A N T
Nature of Trauma Memory
Negative Appraisal of Trauma and/or its Sequelae
Matching Triggers
CURRENT THREAT Intrusions Arousal Stimuli Strong
Emotions
Strategies Intended to Control Threat/Symptoms
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Brain Structures
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Notes

• Relays to amygdala and cortex, first flight
  fight response mediated by amygdala
• Role of stress damages hipoccampus, stimulates
  amygdala
• Explain to patients, memories in amygdala and
  connections (influence between amygdala to cortex
  much stronger than the other way around)
• Oxford Cognitive Therapy Centre, Emotional
  Disorders and the Brain

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Reliving Exercise

• In pairs, one persons describes something that
  happened whist getting to work this morning.
• Once the item has been identified, the observer
  asks the subject to close his/her eyes and start
  describing the incident in detail using all
  modalities, sight, hearing, smells, touch.
• After 5 minutes feedback to each other then
  repeat the other way around.

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Treatment for Flashbacks in Simple fear based
Type 1 PTSD

• Activation of the fear network in its entirety,
  via a reliving paradigm, whereby as much detail
  as possible about the original event is retrieved
  and at peak moments of distress, where salient
  meaning can be identified, the therapist
  encourages the client to reframe the meaning
  using Socratic dialogue.

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Treatment for Flashbacks in Simple fear based
Type 1 PTSD

• Identify all flashbacks and intrusions relating
  to the event and their associated meaning (e.g.
  Im going to die)
• Contrast meaning at the time, with post hoc
  knowledge i.e. survival (I did not die)
• Reliving paradigm to activate the fear network
  and flashbacks under controlled circumstances

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Treatment for Flashbacks in Simple fear based
Type 1 PTSD

• At previously identified peak moments of
  distress, the therapist asks the client And what
  do you know now?, which allows the client to say
  I survive this, I dont.
• Technique is known as cognitive re-structuring
  with reliving
• Facilitates the formation of verbally accessible
  memory
• Experience encoded in the here and now, rather
  than how it was encoded at the time of the event

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Treatment for Flashbacks in Complex Type 1 Trauma

• Most people recover from traumatic events without
  developing persistent PTSD
• Yet everyone has their breaking point
• Key question
• What is it about the trauma experience that
  presents such a challenge to the individuals
  view of self, world and/ or others that they
  cannot readily integrate it with their
  pre-existing beliefs?

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RE-EXPERIENCING IN SIMPLE TRAUMA

• Hotspots more likely to represent aspects of a
  discrete trauma, when the individual felt most
  threat and to be fear based.
• Triggers are more likely to relate to
  situational aspects of the trauma, and less
  likely to be linked by interpersonal themes.

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RE-EXPERIENCING IN COMPLEX TRAUMA

• Hotspots are more likely to be related to
  several interpersonal incidents, of which the
  individual may have no recollection or awareness,
  and to consist of a variety of complex emotions.
• Triggers are more likely to relate to themes of
  interpersonal significance, as well as
  situational aspects of traumas.
• Ask patients to rate anxiety levels (can use
  subjective units of distress (0-10 scale)

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Treatment for Flashbacks in Complex Type 1 Trauma

• Hence unpacking the meaning of the experience
  provides the route to understanding the
  psychological reaction
• Therapist can draw on the same principles as for
  treating flashbacks in single event trauma
• Identify all peak moments of distress and the
  content of flashbacks
• Key experiences may be represented in flashbacks

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Treatment for Flashbacks in Complex Type 1 Trauma

• For instance a client who has been repeatedly
  subjected to incidents of domestic violence and
  rape may have six or seven flashbacks with
  differing content, but which convey the same
  meaning (e.g. I am worthless) and trigger the
  same emotional response (e.g. shame).

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Treatment for Flashbacks in Complex Type 1 Trauma

• The personal meaning assigned to adult Type 1
  trauma can often be intrinsically linked to key
  childhood experiences such as abuse.
• There may or not be intrusions and flashbacks to
  these childhood events but there is invariably a
  link or congruence of meaning between childhood
  and adult experiences in complex PTSD.

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Treatment for Flashbacks in Complex Type 1 Trauma

• Factors to consider
• Complex emotional responses (guilt, shame, anger)
• Meaning (confirm or activate a dormant core
  belief)
• Co-morbidity (depression, substance abuse, panic
  and somatisation)

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Treatment for Flashbacks in Complex Type 1 Trauma

• Need to think carefully about timing of re-living
  work
• May need to work on shame, guilt, grief, anger,
  co-morbidity or do work on core-beliefs for some
  time before working on flashbacks through
  re-living work.
• Without the necessary preparation work, the
  re-living with cognitive re-structuring may not
  work, and may make things worse. The process of
  trying to introduce new meaning may not be
  successful.

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Vicarious Traumatisation

• A cumalitive process through which the
  therapists inner experiences is negatively
  transformed through empathic engagement with
  clients trauma material.
• (Pearlman Saakvitne,1995.)

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VT Definition-2

• The phenomena of transmission of traumatic
  stress by bearing witness to the stories of
  traumatic events
• (McCann Pearlman, 1990)
• Vicarious you hear about the trauma

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Related Concepts

• Burnout
• Compassion fatigue
• Secondary traumatic stress (STS)
• Work stress

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Cognitive Theory and VT-contd

• Janoff-Bulman (1985) identify 3 basic
  assumptions or beliefs that may be affected by
  trauma
• The belief that one is invulnerable.
• The view of oneself as positive.
• The belief in a meaningful and just world.

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Cognitive Theory and VT-contd

• McCann Pearlman (1990) suggest working with
  trauma survivors expose the therapist to abuses
  of trust, lack of safety and powerlessness felt
  by clients and as this is assimilated by the
  therapist, disruption in the therapists schemas
  about the world occur.

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VT Disrupts 4 Main Areas of Functioning

• Cognitive schemata
• Psychological needs
• Memory system
• World view/frame of reference
• (McCann Pearlman, 1990
• Pearlman Saakvitne, 1995)

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Cognitive Schemata

• Decreased
• Trust
• Self-esteem
• Connectedness to others
• Sense of safety
• Shattered world view/frame of reference
• Intimacy

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Psychological Needs

• Helplessness
• Hopelessness
• Self-deprecation
• Decreased self-worth

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Memory System

• Internalisation of the clients memories
• Dreams similar to the clients material
• Intrusive thoughts of the clients material
• Powerful emotional states upon reminders of
  traumatic material

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World view/Frame of Reference

• Therapists view of the world could be left in
  tatters Is the world really like that?..
• Spiritual beliefs could be questioned.

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Signs Symptoms-Contd

• Low energy
• Increased hyperarousal
• Irrational fear for the safety of loved ones
• Disrupted sleep/nightmares
• Anger
• Irrational guilt/self-blame
• Alcohol/substance misuse/overexercising

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Normal Response to Emotional Pain?

• There is a cost to caring. Professionals who
  listen to clients stories of fear, pain and
  suffering may feel similar fear, pain and
  suffering because they care.
• Figley
  (1995)

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Contributory Factors

• A higher prevalence rate of stress and minor
  psychiatric disorder has been found in the NHS,
  than any other occupational group in the UK.
• (Borril et al,
  1998)
• Organisational issues, job role, workload, work
  environment and individual personality
  characteristics have all been postulated as
  factors that have contributed to this.

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Four Suggested Processes that lead to VT

• Countertransference-dynamics such as
  victim-perpetrator/abuser-rescuer
  (Courtouis,1988). New therapists are
  particularly vulnerable.
• Empathy-VT said to occur via therapist empathic
  engagement with clients traumatic material.

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Processes that lead to VT-Contd

• 3. Emotional Contagion The reflecting and
  experiencing of the distress of another person at
  a more unconscious level. Therapist observes
  then feels emotions which are parallel to the
  client (Figley, 1995). Therapist finds it
  difficult to differentiate between their own
  emotions and the clients emotions.

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Cognitive Theory and VT

• 4. Cognitive theory suggests that schemas (core
  beliefs) influence how the world is viewed and
  experienced.
• Therapist schemas may be altered by the new
  information they hear from the traumatized client
  as the information may not correspond with the
  therapists own beliefs or schemas.

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Exercise

• In pairs consider what practices/ safeguards can
  be put in place to help protect you against
  trauma?

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Factors identified by visit to Trauma Clinic

• Regular supervision within team
• 12 cases per week per full time equivalent
• Varied case-load
• Range of activities including research, teaching,
  reading seminars.
• Group supervision/ support group (Psychodynamic)
• External supervison

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References

• Borril, C.S, Wall, T. D., West, M.A., Hardy, G.
  E., Shapiro, D. A., Haynes, C. E., Stride, C. B.,
  Woods, D., Carter, A.J. (1998). Stress among
  staff in the NHS trusts final report. UK
  University of Sheffield, Institute of Work
  Psychology, and University of Leeds,
  Psychological Therapies Research Centre.
• Courtois, C. A. (1988). Healing the incest wound
  adult survivors in therapy. London W. W.
  Norton.
• Ehlers and Clark (2000). A cognitive Model of
  PTSD. Behaviour Research and Therapy 38 319-45.
• Figley, C. R. (1995). Compassion fatigue as
  secondary traumatic stress disorder an overview.
  In C. R. Figley (Ed.), Compassion fatigue coping
  with secondary traumatic stress disorder in those
  who treat the traumatized (pp. 1-20). New York
  Brunner/Mazel
• Holmes, E and Brewin, C.R. (2003). Psychological
  Theories of PTSD. Clinical Psychology Review 23
  23-56.
• Janoff-Bulman, R. (1985). The aftermath of
  victimization rebuilding shattered assumptions.
  In C. R. Figley (Ed.), Trauma and its wake the
  study and treatment of post-traumatic stress
  disorder (pp. 15-35). New York Brunner/Mazel.
• McCann, L., Pearlman, L. A. (1990). Vicarious
  traumatization a framework for understanding the
  psychologiacal effects of working with victims.
  Journal of Traumatic Stress, 3, 131-149.
• Oxford Cognitive Therapy Workshop. Emotions and
  the Brain. Check OCTC website. Helen Kennerely
  and Udo Kischka.
• Lee, D. Case Conceptualisation in PTSD. In Case
  Formulation in CBT. Edited by N. Tarrier.
  Routledge 2006.