TREATING INDIVIDUALS with PTSD, COMPLEX PTSD, and COMORBID PSYCHIATRIC DISORDERS

Meichenbaum1

TREATING INDIVIDUALS WITH PTSD, COMPLEX PTSD, and COMORBID PSYCHIATRIC DISORDERS

Donald Meichenbaum, Ph.D.

Distinguished Professor Emeritus,

University of Waterloo, Ontario,

Research Director,

Melissa Institute for Violence Prevention
Miami, Florida

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CONTROVERSIES IN THE TREATMENT OF INDIVIDUALS WITH PTSD

1. Conceptualization of PTSD

1. Issues concerning Criterion A. Non criterion A events can result in equivalent rates of PTSD. Can develop PTSD symptoms in absence of traumatic events. Question of causality.

1. Issues of “Criterion-creep”- what constitutes a Criterion A event?

1. Most individuals (70%+) do not develop PTSD and related adjustment difficulties. Rather they evidence RESILIENCE. Issues of natural recovery process and what gets in the way?

1. Question Diagnostic Criteria A2- - involving fear, horror and helplessness. Evidence of other emotional reactions. Should PTSD be considered an Anxiety Disorder?

1. Issue of symptom overlap and comorbidity. PTSD is an “amalgam” of other disorders. Difficult to discern what symptoms are unique to PTSD.

1. Little evidence of delayed onset PTSD - - issue of subsyndromal reactions.

1. No evidence of special mechanisms of traumatic memories, nor claims of “body memories”.

1. Search for biological markers has not proven successful. Lack sensitivity and specificity to PTSD. Such biological markers may prove to be a vulnerability factor.

1. Need for cultural/racial, gender and developmental factors in assessment and treatment.

1. Treatment Issues

1. Equivalent Outcomes of Treatments for PTSD and Complex PTSD. (See Powers et al. 2010; Wampold et al. 2010). Dismantling studies fail to identify active ingredients DTE, CPT, PCS, EMDR, as examples).

1. Consideration of ACRONYM THERAPIES (PET, DTE, CPT, VRE, EMDR, CBT-ASD, SIT, AMT, ACT, CR, NET, KIDNET, TP, IRT, CP, DBT, IPT, TF-CBT, CBITS, PFA).

1. Integrated Treatments for Patients with Comorbid Disorders (SS, TARGET, STAIR-MPE, DBT- - augmented for exposure).

1. Target-specific Interventions (Sleep disturbance & nightmares, Dissociation, Guilt, Shame, Complicated Grief, Anger, Moral Injuries, Depression, Anxiety- - panic attacks, phobias, Substance Abuse Disorders).

1. Spiritually-oriented Treatments and other treatment approaches

(Twelve Step AA programs, Smart-Recovery, Present-centered treatments, Culturally-based interventions like rituals- - Sweat Lodge activities, Psychodynamic therapies, Hypnosis, Supportive Group treatment, Inpatient treatment, Self-help Internet-based Treatment-Interapy, Community-based Interventions).

1. Pharmacotherapies- (See Friedman et al. 2009). Selective Serotonin Reciptake Inhibitors (SSRI’s such as setraline, paroxetine and fluoxetine) and a Serotonin Norepinephrine Reuptake Inhibitor (SNRI such as venlafaxine extended release) have yielded limitedpositive results. About 30% have complete remission after 12 weeks of SSRI treatment, while half of those having a partial response achieve continual improvement with additional 24 week treatment. More successful in the reduction of positive than negative symptoms. However, discontinuation of SSRI’s is often followed by relapse in those who show a initial and favourable response. “No magic bullet” for treatment of PTSD and Complex PTSD.

1. Treatments to Avoid

Debriefing Procedures such as CISD, Psychoeducational Interventions that can establish “negative” expectations and interfere with natural healing processes, “Energy-based” treatments such as Thought Field Therapy, Trauma Incident Resolution, Visual KinestheticDissociation, Recovery-based Interventions, age regression, certain forms of grief counselling (See Wittouck et al. 2011).

1. How to Spot “Hype” In Psychotherapy Presentation

Presentation style; “Tricks of the trade” to oversell interventions; Check the nature of the Comparison Groups in Randomized Controlled Studies; Issues of Bonafide Treatments; Allegiance Effects; The “packaging” of interventions.

1. Implications for the Treatment of Individuals with PTSD, Complicated PTSD and Comorbid Psychiatric Disorders.

1. What distinguishes those who develop chronic disorders versus those who evidence Resilience? Implications for treatment?

1. What are the common core competencies that cut across diverse interventions?

1. What barriers interfere with the Natural Recovery process and how can these be anticipated and addressed?

1. Critical role of a Case Conceptualization Model that informs ongoing assessment/evaluation and need for integrated treatment decision-making?

1. Need for culturally, racially, gender and developmentally-sensitive interventions.

1. How to become a “critical consumer” of the psychotherapy field? How not to be persuaded by “hype”.

“HOW TO” DEVELOP PERSISTENT PTSD and RELATED ADJUSTMENT PROBLEMS

At the Cognitive Level

Engage in self-focused, “mental defeating” type of thinking. Perception that one has lost

autonomy as a human being, lost the will to exert control and maintain identity, lose the belief

that one has a “free will”. See self as a “victim”, controlled by uninvited thoughts, feelings and

circumstances, continually vulnerable, unlovable, undesirable, unworthy. Use dramatic

metaphors that reinforce this style of thinking. “I am a prisoner of the past”, “Entrapped”,

“Contaminated”, “Damaged goods”, “A doormat”, “A pariah”. Experience a form of mental

exhaustion, mental weariness.

Hold erroneous beliefs that changes are permanent, the world is unsafe, unpredictable and that

people are untrustworthy. Hold a negative, foreshortened view of the future and the belief that

life has lost its meaning.

Engage in self-berating, self-condemnation, self-derogatory “story-telling” to oneself and to

others (i.e., self blame, guilt-engendering hindsight, biased thinking; anger-engendering

thoughts of viewing provocations as being done “on purpose”).

Engage in upward social comparisons, so one compares poorly in one’s coping abilities. Be

preoccupied with what others think of you. Engage in comparison of self versus others;

before versus now; now versus what might have been.

Ruminate repeatedly, dwell on, focus upon, brood, pine over loses, “near miss” experiences.

Replay over and over your concerns about the causes, consequences and symptoms

related to negative affect and losses. Use repetitive thinking cycles (“loss spiral”).

Engage in contra-factual thinking, repeatedly asking “Why me” and “Only if” questions for

which there are no satisfactory answers.

Engage in avoidant thinking processes of deliberately suppressing thoughts, using distracting

behaviors, using substances; avoidant coping behaviors and dissociation.

Have an overgeneralized memory and recall style which intensifies hopelessness and impairs

problem-solving. Difficulty remembering specific positive experiences. Memories are

fragmented, sensory driven and fail to integrate traumatic events into autobiographical

memory or narrative.

Engage in “thinking traps”. For example, tunnel vision as evident in the failure to believe

anything positive could result from trauma experience; confirmatory bias as evident in

the failure to retrieve anything positive about one’s self-identity; or recall any positive

coping memories of what one did to survive, or what one is still able to accomplish

“in spite of” victimization; do mind-reading, overgeneralizing, personalizing, jumping to

conclusions, catastrophizing; “sweating the small stuff”, and emotional reasoning such as

viewing failures and lapses as “end points”.

Evidence “stuckiness’” in one’s thinking processes and behavior. Respond to new situations

in post-deployment settings “as if” one was still in combat (misperceive threats).

At the Emotional Level

Engage in emotional avoidance strategies (“Pine over losses”, deny or shift your feelings,

Clam up, bury your emotions and do not consider the possible consequences of doing so).

Magnify and intensify your fears and anger.

Experience guilt (hindsight bias), shame, complicated grief, demoralization.

Fail to engage in grief work that honors and memorializes loved ones or buddies

who were lost.

Fail to share or disclose feelings, process traumatic memories. Focus on “hot spots” and

“stuck points”.

At the Behavioral Level

Engage in avoidant behaviors of trauma-related feelings, thoughts, reminders, activities

and situations; dissociating behaviors.

Be continually hypervigilant, overestimating the likelihood and severity of danger. Act as if

you are on “sentry duty” all the time; Act like a faulty smoke detector that goes off at the

slightest signal.

Engage in safety behaviors that interfere with the disconfirmation of emotional beliefs

and the processing (‘restorying”) of trauma-related memories and beliefs.

Engage in delay seeking behaviors. Avoid seeking help. Keep secrets and “clam up”.

Engage in high risk-taking behaviors; chasing the “adrenaline rush” in an unsafe fashion;

Put self at risk for revictimization.

Engage in health-compromising behaviors (smoking, substance abuse as a form of self-

medication, lack of exercise, sleep disturbance that goes untreated, poor diet, dependence on

energy drinks, abandonment of healthy behavioral routines).

Engagement in self-handicapping behaviors (“excuse-making”), avoidance behaviors.

Use passive, disengaged coping behaviors, social withdrawal, resigned acceptance, wishful

thinking and emotional distancing.

At the Social Level

Withdraw, isolate oneself, detach from others.

Perceive yourself as being unwanted, a “burden”, thwarted belongingness, distrusting others.

(“No one cares”, “No one understands”. “No one can be trusted”).

Associate with peers and family members who reinforce and support maladaptive behaviors. Put yourself in high-risk situations.

Experience an unsupportive and indifferent social environment (i.e., critical, intrusive,

unsympathetic- - offering “moving on” statements).

Fail to seek social support or help, such as peer-related groups, chaplain services, or

professional assistance.

At the Spiritual Level

Fail to use your faith or religion as a means of coping.

Have a “spiritual struggle” and view God as having punished and abandoned you.

Use negative spiritual coping responses. Relinquish actions to a higher power, plead for

miracles, or divine intervention; Become angry with God; Be demanding.

Experience “moral injuries” that compromise values. Lose your “moral compass” and

“shatterproof beliefs”, experience a “soul wound”.

Avoid contact with religious members who can be supportive.

Psychological Characteristics of Resilient Individuals

Experience Positive Emotions and Regulate Strong Negative Emotions

Be realistically optimistic, hopeful, ability to laugh at oneself, humor, courage, face one’s fears and manage emotions. Positive expectations about the future. Positive self-image. Build on existing strengths, talents and social supports.

Adapt a Task-Oriented Coping Style

Ability to match one’s coping skills, namely direct action present-focused and emotionally-palliative acceptance with the demands of the situation. Actively seek help and garner social supports. Have a resilient role model, even a heroic figure who can act as a mentor. Have self-efficacy and a belief that one can control one’s environment effectively. Self confidence. Seek out new and challenging experiences out of one’s “comfort zone” and evidence “GRIT” or the perseverance and passion to pursue long-term goals.

Be Cognitively Flexible

Ability to reframe, redefine, restory, find benefits, engage in social problem-solving and alternative thinking to adaptively meet changing demands and handle transitional stressors.

Undertake a Meaning-Making Mission

Create meaning and a purpose in life; survivor’s mission. Use one’s faith, spirituality and values as a “moral compass”. Be altruistic and make a “gift” of one’s experience. Share one’s story. General sense of trust in others.

Keep Fit and Safe

Exercise, follow a routine, reduce risks, avoid unsafe high-risk behaviors (substance abuse, chasing “adrenaline rush” activities).

CORE TASKS OF PSYCHOTHERAPY:

WHAT “EXPERT” THERAPISTS DO BASED UPON

THERAPEUTIC PRINCIPLES OF CHANGE

1. Develop a collaborative therapeutic relationship/alliance and help the patient "tell" his/her story. After listening attentively and compassionately to the patient’s distress and “emotional pain”, help the patient identify "strengths" and signs of resilience. "What didhe/she accomplish in spite of ...?" "How was this achieved?" Obtain the “rest of the story”. Use Socratic Questioning.

1. Foster bonding between patient and therapist. Address any ruptures or strains in the alliance and address any therapy-interfering behaviors.
2. Collaborate with the patient in establishing treatment goals and the means to achieve these goals.
3. Encourage the patient’s motivation to change and promote the patient’s belief that therapy can help. (Use Motivational Interviewing Procedures).
4. Monitor the patient’s progress and use the information to guide ongoing treatment.

1. Be culturally-sensitive when conducting assessments and the therapist should developtreatment knowledge and competence in treating ethnically diverse populations.

1. As Bowman (2007) highlights,

“Become more aware of your existing assumptions, and accept that some of these assumptions may not apply to ethnic minority groups” (p. 113)

1. Conduct an ethnocultural assessment that taps the patient’s level of acculturation,circumstances and impact of migration on family and on self.
2. Assess for culturally specific symptomatology and provide culturally-based interventions.
3. Treatment should be sensitive to the patient’s expectations, cultural interpersonal style, values and metaphors/language. Interian and Diaz-Martinez (2007) provide a good example of such cultural adaptation with Hispanic patients as they alter psychotherapy to include such Hispanic concepts such as Simpatico, Respecto, Formalismo (setting examples), Personalismo, Fatalismo, Marianismo (self-sacrifice), Poner de mi parte (doing one’s part), Dichos (saying and proverbs) and religious values. (See Handout onCultural Issues). When conducting these culturally-based interventions, it is important not to impose cultural stereotypes and recognize marked differences within cultural groups.
4. Tailor interventions to ethnic groups. For example, see Hinton et al., (2006) treatment of Cambodian refugees for treatment of panic attacks.
5. Address any potential cultural barriers that might arise in treatment.
6. Be willing to consult with individuals who may be more equipped to deal with ethnic diversity and learn to conduct multicultural therapy.

1. On an ongoing basis educate the patient about his/her problems and possible solutions and facilitate awareness. Use various ways to educate and nurture a sense of curiosity and discovery.

i.Conduct Risk and Protective Factors assessment and provide constructive feedback. Probe about the patient’s views of presenting problems and his/her theories of behavioral change.

ii.Use a Case Conceptualization Model and share therapy rationale.

iii.Have the patient engage in self-monitoring and conduct situational and developmental analyses.

iv.Use videotape modeling films and other educational materials (simple handouts with Acronyms)

v.Use a “Clock metaphor” – “Vicious Cycle” Model

12 o'clock - external and internal triggers

3 o'clock - primary and secondary emotions

6 o'clock - automatic thoughts, thinking patterns and

schemas or beliefs. Note common core recurrent

patterns

9 o'clock - behaviors and resultant consequences

The therapist can use his/her hand to convey the Clock Metaphor by moving his/her hand slowly from 9 o'clock around to 6 o'clock. The therapist can say:

“It sounds like this is just a vicious…(without completing the

sentence) allowing the patient to interject- - "cycle or circle".

To which the therapist can then say, “In what way is this a

vicious cycle? Are you suggesting...?”

The therapist can then help the patient come to appreciate how

his/her appraisal of situations (12 o’clock), feelings (3 o’clock),

thoughts (6 o’clock) and behaviors (9 o’clock) are all

interconnected. The patient can be invited to “collect data” (self-

monitor), if indeed, the “vicious cycle”, as the patient describes it, actually occurs. In this way, the patient can bring into subsequent sessions data supporting the Clock Metaphor.

“If you (the patient) are engaging in such cyclical behaviors, then what is ‘the impact, what is the toll, what is the emotional and behavioral price that you are paying? Is that the way you want things to be? If not, then what can you do about it?”

It is not a big step for the patient to suggest that one of the things he/she could do is “Break the cycle”. “Break the cycle. What did you have in mind?”, the therapist can ask. The therapist can now explore collaboratively with the patient how he/she can break the cycle. Moreover, the therapist can help the patient come to appreciate how he/she has already been trying to “break the cycle” (e.g., by engaging in avoidance behaviors, or being aggressive).

Another way to use the Clock Metaphor is to help the patient view his/her primary and secondary emotions (3 o’clock) as

“commodities” that the patient does something with. The therapist can ask:

“What do you do with all those feelings (emotions)?”

The patient may respond that he/she “stuffs the feelings”, or “drinks them away”, and if he/she does that, then what is the impact, the toll, the price he/she and others pay? Is that the way he or she wants things to be? If not, then what can be done about it?”

Once again, the therapist can use the “art of Socratic questioning” as a way to help the patients generate possible coping solutions. There is a greater likelihood of patients engaging in behavior change efforts if they come up with the ideas and the accompanying reasons for engaging in such behaviors, than if the therapist merely offers suggestions and directives, acting as a “surrogate frontal lobe” for his/her patients.

vi.Therapist models thinking: Ask the patient: “Do you ever find yourself, out there, in your day-to-day experience, asking yourself the kind of questions that we ask each other right here?”

vii. Educate the patient about relapse prevention strategies.

1. There is a caveat that should be highlighted concerning the psychoeducation of patients. Devilly and his colleagues (2006) have noted that under some conditions providing information can undermine the recovery process and act as a self-fulfilling prophesy of despair. They note that in the work on Psychological Debriefing that provides individuals with information about potential trauma responses may have a paradoxical effect on depression and PTSD.

1. Help the patient reconceptualize his/her "problems" in a more hopeful fashion.

1. Do a life-review (UseTime-lines). Identify "strengths."

Timeline 1 –Birth to present. Note stressors and various