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Slide 1

The treatment of trauma: Integrating HRV and cognitive behavior therapy Constance J. Dalenberg, Ph.D. Alliant International University Cdalenberg@alliant.edu

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Written in pencil in the sealed freight car Don Pagis Here in this transport I, Eve and Abel my son. If you see my older son Cain, son of man tell him that I

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Statements by reporters and politicians regarding the Sept. 11th attacks It’s..it’s..I can’t tell you what it’s like..it’s just..I can’t tell you what it’s like here. Standing here, it’s overwhelming..I can’t tell you how much..it’s staggering. My reaction to what happens was so…(long pause) I don’t know how to describe it…tumultuous.

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Holocaust victims’ experiences as they relate to child trauma Forced to depend for safety and sustenance on those who cause greatest pain Removed from social, professional and personal obligation Life tasks To learn the rules To anticipate the wishes of a hostile environment To protect the self through public obedience and private disobedience

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Weisel, writing about Holocaust survivors Their sentences are terse, sharp, etched into stone. Every word contains a hundred, and the silence between the words strikes us as hard as the words themselves. They tried to communicate their experience of the Holocaust, but all they communicated was their feeling of helplessness at not being able to communicate the experience.

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Elie Weisel, 1993, p. 161 When language fails, what can be its substitute?

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Why they think you are silent Because you are waiting for them to speak Because you are judging them For their actions at the time For their inarticulation at present

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Why you are really silent Reason 1: Because you are vicariously traumatized yourself

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Disclosing and listening to trauma: Physiological distress in speaker and listener

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Why you are really silent Reason 2: Because you are trying to think of something profound to say

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Duty to the trauma Well, now, what was it really like? How did you feel in Minsk and in Kiev and in Kolomea, when the earth, opening up before your eyes, swallowed up your sons and your prayers? What did you think when you saw blood – your own blood – gushing from the bowels of the earth, rising up to the sun? Tell us, speak up, we want to know, to suffer with you, we have a few tears in reserve, they pain us, we want to get rid of them. (Survivor of the camps, discussing the reporters’ questioning)

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Research result Do you ever feel as if you have an obligation or duty to accurately describe your traumatic experience to your therapist? 92% yes

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Instead Explain what great talent is needed to describe

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Describing trauma In the terrible years of the Yezhov terror, I spent 17 months waiting in line outside the prison in Leningrad. One day someone in the crowd identified me. A woman, lips blue from cold, who, of course, had never heard me called by name before.

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Anna Akhmatova II She started out of the torpor common to us all and whispered – everyone whispered there –Can you describe this? And I said “I can.” And something like a smile passed fleetingly over what had once been her face.

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Instead Listen with emotion

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The wish for an authentic response to the trauma: Dalenberg CT study participant S: I found myself shaking. Really shaking Int: As you told your Vietnam stories S: As I told one story Int: Do you want to tell it first? S: [retells story: deleted at pt request] Int: It makes me shake just to listen to that. What did your therapist do with it? S: (tearfully) Nothing. If I heard “uh-huh” one more time I was going to deck him. Int: Uh..oops S: (laughs) Habit, huh? Int: (laughs) So you didn’t deck him. What did you do? S: I sat there quivering like a jackass, well, like a rabbit..like a child, really. It was..what’s a bigger word than embarrassed…mortifying. How’s that? Mortifying. Does your tape recorder work? Write that down.

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Instead Admit that avoidance is something that you will both struggle with

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Joseph F: Participant in Dalenberg countertransference study I guess the most helpful thing my doctor did…well, this is going to sound strange, but he tried to guess what it must have felt like to me as a kid. And when he was groping around for the words he just hit on a couple that worked. And until that happened, I couldn’t grip them with my mind, you know? They kept slipping away. His descriptions weren’t exactly right, but they were like sandpaper. My own truth stuck to his words well enough for me to trap it and talk about it.

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Benny’s warning Benny: You can’t go, you can’t go to New Zealand T: I can’t? Benny: No, because you know what? T: What? Benny: My mom, my mom she has pictures and magazines at her office T: Yeah? Benny: And do you know what? T: What?

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Benny’s warning II Benny: There’s…New Zealand is right next to Austria. T: It is? Benny: Mm-hmm. And there’s kangaroos in Austria and if they kick you, you’ll die. T: Benny, if I see any Austrian kangaroos in New Zealand, I will be very careful.

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Benny’s background Attacked by a dog bought to be a protector of the family Lost his mom when he was 5 Teased by other children because of his injured face

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Benny’s background Fear: Attacked by a dog Benny is afraid of the kangaroos Loss: Lost his mom at age 4 Benny is overwhelmed by sadness/loss when I leave Shame: Teased by other children because of his injured face Benny is protecting me from shameful injury; is ashamed of his wish for me to stay Betrayal: Angry at the dog, who was bought as his protector Benny is angry at my leaving

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Symptom Patterns

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Where do I get the measures? PTSD Measures www.ncptsd.org Dissociation measures DCS (Dalenberg) or within some PTSD measures Shame measures ISI (www.parinc.com) TSS (Dalenberg) Anger measures MAI or STAXI Acceptance and action questionnaire Hayes et al., 2006

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Clinical interview What emotions flood you when you think about ___? How incapacitating is this emotion? Name something that could happen that would make you happy, nervous, sad, angry, embarrassed. How overwhelming is the emotion How often do these types of events happen.

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Trauma as a reaction to fear

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The biological message of trauma Remember this moment Never go this way again Be prepared Severity defined by The breadth of the definition of “this way” The extent of the preparation

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The purpose of CPTSD treatment To re-regulate the biological system To compartmentalize the trauma To recreate the possibility of the safe, rewarding and approachable world. Through exposing the client to circumstances that contain elements sufficiently similar to activate the emotion/trauma and sufficiently different to allow for change.

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Foa’s Emotional Processing Theory Fear represented in memory as cog structure that is a “program” for escaping danger. This includes: Fear responses (e.g. heart acceleration) Meaning of stimuli (“This man is dangerous” Cognitive responses (“My fast heartrate means that I am afraid.”

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Fear structure becomes pathological when: Associations are inaccurate Physiological and escape/avoidance R’s are evoked by harmless stimuli Excessive and easily triggered responses interfere with adaptive behavior Harmless stimuli and elements are associated with threat meaning

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The mechanisms of CPTSD treatment The connection of fear to its source The creation of safety The de-stigmatization of fear and its consequences

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Foa’s conditions for changing fear structures The whole fear structure must be activated And, simultaneously, new information must be presented that is inconsistent with the fear structure

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The role of “relaxation” Historically preserved as part of the original Exposure and PE packages Not seen as important by theoreticians Relied on by clinicians Would the role of relaxation by enhanced by the addition of HRV technology?

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Trauma as stigma

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Triggers for shame Loss in competition Forced dependence Sexual failure Experience of betrayal Revelation of a secret Biologically, shame involves interruption of a positive affect state

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Doubt as natural to trauma Chronic doubts about what did and did not happen, along with persistent inability to trust one’s perceptions of reality, are perhaps the most permanent and ultimately damaging long-term effects of child sexual abuse. --Davies & Frawley, 1994, p. 109

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Approach to the shame symptom Say it out loud Humanize it Respect the biological Teach anxiety management Fight excessive internalization The use of literature

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The concept of catastrophic loneliness “You couldn’t know what it is like.”

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Traumatic loss themes tend to predominate when: The trauma involves loss of a role The trauma involves loss of a facet of an identity The trauma involves loss of a protected status A religious view A person upon whom one is dependent When there is a preexisting attachment disorder

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Special issues in traumatic loss Focus in less on re-experiencing grief in the moment Focus is more on re-affirming the identity and roles of the patient

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Loneliness in trauma treatment Percent saying “often” or “very often” to the question, how often did you feel entirely alone and misunderstood when you were with your therapist

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The transforming environment Contingent reactions Clinicians often withhold contingent emotional reactions or fail to explain the contingency Exaggerated mirroring Collaborative communication Clinicians often fail to “negotiate” with the patient Psychobiological state attunement Includes amplification of positive states and reduction of negatives Reflection on mental states

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Kotzke Rebbe The only whole heart is a broken one.

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Betrayal and trauma

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Role of anger in trauma therapy For goal-attainment Get out of my way Defense against attack Stop that! Attachment Pay attention to me Restoration of pride How dare you treat me that way? Restoration of justice Serves you right!

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The difficult in dealing with patient anger In the well-known Vanderbilt Psychotherapy project, Strupp noted that: We failed to encounter a single instance in which a difficult patient’s hostility and negativism were successfully confronted or resolved. Admittedly, this may be due to the peculiarities of our therapist sample and the brevity of the therapy; however, a more likely possibility is that therapist’s negative responses to difficult patients are far more common and far more intractable than had been generally recognized.

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Characteristics of the “berserk state”: Shay Beastlike Godlike Socially disconnected, cold, indifferent Crazy, mad, insane Enraged Cruel, without restraint or discrimination Insatiable Devoid of fear Inattentive to own safety, reckless Distractible Exulted, intoxicated, frenzied Insensible to pain Suspicious of friends

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Incapacity to negotiate relationships

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Case example: Incapacity to negotiate Slide I T: I have to leave on vacation, remember, next week C: Mm-hmm T: Do you have any thoughts about that? C: (Angrily) No.

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Case example: Incapacity to negotiate Slide II T: You sound mad C: Just get on with it. T: I wanted to address your feelings about this. C: I don’t want to. Let’s not dwell on it T: But… C: I’m leaving if we have to do this.

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Therapist failing to take responsibility Ms. C: You look angry T: We have to look at that, don’t you think? I’m not angry at all. I think if you search for negatives in me all the time, you are likely to find some Ms. C: But you just look angry. Your brow is furrowed. You don’t smile [Begins to cry] T: But why would I be angry at you? What do you think you have done that would make me angry? What is so bad and anger-provoking about you?

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Critique Messages He, the therapist cannot be wrong about what he is feeling The emotional display he shows to others must match the internal state he believes to be present Therefore, if he is experienced in another way, that person is misconstruing the situation This is the opposite of what he wishes the patient to believe.

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Bifurcation It’s always you It’s never only you.

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Rage over minor injustice or hardship

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Hostile expectation: Bowlby For some the very existence of caretaking and supportive figures is unknown; for others the whereabouts of such figures have been constantly uncertain. For many more the likelihood that a caretaking figure would respond in a supportive and protective way has been at best hazardous and at worst nil. When such people become adults, it is hardly surprising that they have no confidence that a caretaking figure will ever be truly available and dependable. Through their eyes the world is seen as comfortless and unpredictable, and they respond either by shrinking from it or by doing battle with it.

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Manipulation and the abuse victim: Briere By virtue of childhood experience, former abuse victims tend to assume that the world is a hostile environment, where nothing is inherently deserved and thus nothing is ever freely given. From this perspective, the survivor may conclude that the only way to gain needed things or resources is to trade other things for them, or to trick someone into providing them…[T]he child who discovers that servile attention to his or her abuser’s various needs can forestall impending violence or elicit rare praise or affection is likely to conclude that powerful ones should be groomed and catered to, in exchange for love or forestalled abandonment.

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Common mistakes in dealing with patient anger Trying to get the patient to think in a new way about the anger-provoking incident during the angry moment The goal of the therapist during episodes of patient angry arousal is anger management, not anger prevention. Pretending that one is not moved by anger Remember nonreactivity might equal lack of care Counter-hostility Model anger in connection and awareness of differing perspectives

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Example of anger in connection I know that I hurt you and I hope we can try to work it out. That matters to me. But right now you are sending me a message that our whole relationship is in jeopardy instead of just letting us be angry at each other for a short time. I end up being so worried about your threat of destroying our relationship that I stop thinking about the thing I originally did wrong. Don’t you think that might defeat the purpose of your statements, preventing me from changing rather than helping me to change?

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The special issue of dissociation

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Unformulated experience Older theories: beachball theories of dissociation Newer theories “areas of innocence” “refusal to formulate ad interpret” The ability to speak one’s thoughts to oneself spells the end of dissociation

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Reasons for clinical focus The phenomenological experience of dissociation is distressing to virtually all patients Dissociation is a practical problem Dissociation is an impediment to self-awareness And undermines accurate diagnosis and effective treatment

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Recognizing dissociation within a session Confusion, shifts in topic Distant and minimizing verbal style Disruption in ownership and recognition of emotion Sense of distance and disconnection from therapist

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Labeling diversions “I’ve been noticing that every time I raise the issue of x, you seem to think of another topic to raise. Is that something you have noticed?” Sensing that there is something there to interpret “There’s that pattern again. It looks like when we begin to talk about x, it might make you uncomfortable and you divert. Do you think that’s possible?” Trying not to be gripped by the field

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Labeling diversions II “Haven’t you ever had the experience of not knowing you were angry or sad until someone else noticed that you were acting a certain way? I know I have. It may be that you do feel badly about x, but it passes too quickly for you to feel it because you push it out of your mind so fast.” “I know I don’t like it when someone else tries to tell me what I probably feel, and I’m not trying to do that. I think that’s what is making you a little angry. I’m just inviting you to join me in seeing how fascinating it is that you keep moving away with so much energy when I raise the issue of x. What do you think that might be about? I thought you might be feeling y, but maybe it’s something else.”

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Robbing negative emotions of their power I T: So you’re upset with me because I’m leaving on vacation C: I’m not upset. Maggie is upset. She’s only 5, so it’s understandable. T: And it’s not understandable for you? C: Of course not. I don’t get angry at petty unavoidable things

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Robbing negative emotions of their power II T: Aah, you have a problem then, because your therapist regularly gets angry at petty unreasonable things. C: You do not. T: Trust me. I do. This morning I was angry because the television had a little ad for news stories, one of those teasers like “Damage to famous landmark. News at 8” and I had to leave at 8:15 and they still hadn’t told me what had happened. C: And you were mad at that? T: I was mad at that. Grumped my way all the way to the car.

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Teaching clients to break out of dissociative states Through self-awareness exercises Meditation, biofeedback Visuo-spatial description Through analysis of situations that cause dissociation

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Mechanics of Exposure Treatment: TRI Model Typical treatment program consisted of 10-15 weekly treatment sessions of 90 minutes each TRI Model adds 2 ACT sessions 1 preliminary HRV psychoeducation session

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The ACT Model supplementation Recognizing that escape and avoidance will not work, and have not worked. Control of emotion is the problem The principle of addition vs subtraction Stopping the struggle Commitment to action

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Acceptance and Commitment Therapy Pronounced “ACT,” not A.C.T.

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ACT Developed by Steven Hayes and colleagues in the 1980’s

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Thought suppression Effortful suppression of thoughts Initially appears positive, relieving distress Has paradoxical long-term effect – rebound of initial anxiety and avoided imagery Efforts to control and master thoughts and imagery increase Thought suppression associated with negative tx outcome

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ACT Workbook Get out of your mind and into your life Steven Hayes, PhD 2005 New Harbinger Pubs

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Session 1 Overview of treatment rationale Trauma Interview Excellent example given in Prolonged Exposure Therapy for PTSD by Edna Foa, Elizabeth Hembree, & Barbara Rothbaum (Oxford University Press: www.oup.com)

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Trauma Interview should include The client’s narrative Reactions of others to the trauma Psychological and physical health since time of trauma Alcohol and drug use Avoidance strategies Emotion evaluation (see earlier slide)

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Rationale The central role of avoidance The importance of the bodily reaction The importance of secondary emotional reactions

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Client workbook Reclaiming your life from a traumatic experience Barbara Rothbaum Edna Foa Elizabeth Hembree Oxford University Press www.oup.com

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Underengagement and overengagement Under-engagement more frequent Increase prompting questions, model engagement, close eyes, speak in present tense, convey emotion in your body Over-engagement can be experienced as re-traumatization Keep eyes open, use past tense, reassure, step back into conversation and out of imagery

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Session 2 Introduction to HRV training Introduction to ACT principles Exploring the client’s narrative

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Foa’s description of breathing retraining Very often, when people become frightened or upset, they feel like they need more air and may therefore breathe fast or hyperventilate. However, hyperventilation produces anxious feelings..Hyperventilation also produces bodily reactions that resemble fear. These bodily reactions can in turn, make us more afraid. What we really need to do is to slow down our breathing and take in less air. So learning to breathe slowly and calmly provides a useful tool for reducing stress or tension.

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Foa’s breathing retraining description (cont.) In order to calm down or relax one should take normal breaths and exhale slowly. It is exhalation that is association with relaxation, not inhalation. Also, it can be helpful to associate your exhalation with a word that has a calming or relaxing effect. So while you exhale, say the words “calm” or “relax” silently to yourself very slowly. Like this: c-a-a-a-a-l-m.

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Session 3 Discussion of merging of HRV with imaginal exposure as homework assignment Development of 4 line description of story or audiotape of story

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Sample 4-line story I hear the footsteps behind me and my heart begins to race. The man grabs my arm from behind and I am terrified. The man holds a knife under my chin and pushes himself up against me and I am afraid I will die. A stranger comes by and shouts out, and he runs off. I am disoriented and stunned.

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Session 4 Development of the in vivo hierarchy First in session imaginal exposure

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Introduction of the SUDS scale In order to make this list for you, we’re going to use a scale we call SUDS, which stands for Subjective Units of Discomfort. You can see it goes from 0 to 100. If you were having a 100 reaction, you’d be having a lot of (list of clients symptoms – acceleration of HR, sweating, dizziness, fear). If you were at 0, then you would be very calm. And it is subjective, which means that it is what YOU experience. If we both looked out the window of the 20th floor of a hotel, it might be that I am afraid of heights, and I am at a 50, but you are at a 0.

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SUDS Introduction How much discomfort are you feeling right now? Finding a 0 point Finding the 100 point Labelling other scale points Reminder situations Situations avoided due to loss of interest or social anxiety Situations wrongly perceived as dangerous

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Common avoided situations Walking down street in the open Crowded places Being approached Small confined places Public transportation The physical location of the trauma People demographically similar to an assailant

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SUDS results from client

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Sessions 5-10 Imaginal exposure Homework assignments from in vivo exposure Processing of exposure Reminder of ACT principles Evaluation of HRV progress about every 3 sessions

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Session 11-15 Moving away from imaginal exposure, and focusing more on in vivo exposure Acceptance of remaining anxiety as normal reactions (ACT)

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Why include HRV training: 1 As Foa et al. (2002) point out, a minority of patients in PE show a reliable increase in symptoms 21.1% exacerbation of anxiety symptoms 10.5% increase in PTSD symptoms Exacerbation doesn’t mean dropout or poor outcome. The average dropout rate in CT or PT is 20-30%. Therefore there is some evidence that management of the anxiety of treatment is a problem in current treatment.

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Why include HRV training: 2 Both alexithymia and dissociation are highly comorbid with PTSD. Therefore one cannot count on the patient being able to reliably describe their internal state of anxiety during PTSD treatment.

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Why include HRV training: 3 Hyperventilation and Hyperventilation syndrome are comorbid with PTSD (particularly PTSD with panic) The experience of hyperventilation syndrome mimics anxiety and dissociative syndromes Hyperventilation syndrome is curable with high success rates by HRV training.

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HRV training v relaxation training HRV training differs from relaxation training, and has yielded a larger effect on anxiety/depression/sleep than do traditional relaxation paradigms Over 150,000 studies on HRV have been conducted. The largest number of studies are on depression, but the few studies on PTSD generally find that successful PTSD treatment increases HRV.

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Description of sample

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Bottom line

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Treatment success over time

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HRV Defined (MacArthur Network) Heart rate variability (HRV) refers to the beat-to-beat alterations in heart rate. Under resting conditions, the ECG of healthy individuals exhibits periodic variation in R-R intervals. This rhythmic phenomenon, known as respiratory sinus arrhythmia (RSA), fluctuates with the phase of respiration -- cardio-acceleration during inspiration, and cardio-deceleration during expiration. 1/15/2010 Gevirtz 99

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Quantifying HRV How much variability is there? Time domain and geometric analyses What are the underlying rhythms? What mechanism do they represent? How much power does each rhythm have? Frequency domain analysis How much complexity is there? Non-linear analyses

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1/15/2010 Gevirtz 101 EFFECTS OF HRV BIOFEEDBACK ON HEART RATE

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HRV before training

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HRV after training

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Fig. 2. Note the high level of VLF activity accompanying rumination, worry or performance anxiety: From Gevirtz 1/15/2010 Gevirtz 104

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1/15/2010 Gevirtz 105 Ordinary Breathing Produces 3 HR frequencies, HF,LF,&VLF Progression to approx. 6 BPM, (Diaphragmatically) in experienced breathers produces single summated peak at about .1hz: RESONANT FREQUENCY Daily practice in this state increases homeostatic reflexes Vaschillo’s Resonant Frequency Theory

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Fig.3. The “meditators peak” in the .08-.11 range. (Gevirtz, R., 2007) 1/15/2010 Gevirtz 106

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1/15/2010 Gevirtz 107 Leah 1 HF LF VLF

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1/15/2010 Gevirtz 108

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Biofeedback aids J and J biofeedback Nexus biofeedback Freezeframer StressEraser EZAir MyCalmBeat

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Heart Rate RSA Biofeedback Training: A Treatment Manual Resonant Frequency (RFT) Training Based on Lehrer, Vashillo, & Vashillo (2000) Applied Psychophysiology and Biofeedback, 25, 177-191 Richard Gevirtz, Ph.D. CSPP at AIU, San Diego, CA 1/15/2010 Gevirtz 110

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Resources The New Science of Breath by Stephen Elliott (Coherence Press, 2006) Heartsounds tapes or Heart ‘coherence” tapes from www.coherence.com More information from cdalenberg@alliant.edu.

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Readiness for termination The position taken in this book is that abuse-focused psychotherapy can be deemed entirely successful when (a) the abuse trauma underlying “symptomatology” and negative tension-reduction activity has been resolved, (b) abuse-relevant cognitive distortions no longer interfere with the client’s daily functioning or reasonably positive self-perception, and (c) the survivor’s access to self is sufficient to allow adequate self-support and a stable base from which to interact with others (Briere, 1992, p. 108-109)

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Alternative meanings and growth-producing benefits after trauma Survival of trauma as a sign of strength Increased appreciation for life or life blessings Discovery of the availability of support from friends and loved ones Renewed or strengthened religious belief Involvement in social or political action to aid other trauma survivors Change in content and complexity of philosophy of life Increased perspectives on minor obstacles or difficulties

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Client criticisms of the termination phase of trauma treatment Lack of preparatory discussion of termination before its announcement or lack of discussion of termination criteria Lack of preparation of the client (by the therapist) for post-therapy mourning Failure to share and normalize conflictual emotions Lack of clarity as to the rules of post-therapy behavior (e.g., calling one’s former therapist with updates)

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Other excellent treatment resources Cloitre, M., Cohen, L., & Koenen, K. (2006) Treatment survivors of childhood abuse. Guilford Press. John Briere’s treatment model at http://johnbriere.com/stm.htm Dalenberg, C. (2000). Countertransference and the treatment of trauma. American Psychological Assn. Press

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And from the great philosopher, Walt Disney Even miracles take a little time --Cinderella’s fairy godmother

Summary: הפרעה פוסט טראומטית, דלנברג, גבירץ, רולניק ארנון,

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