A Non-Exposure Trauma Treatment Option...2020/10/14 · Cognitive Retructuring for PTSD: A Non‐ Exposure Trauma Treatment Option 10/14/2020 Presented by Suzy Langevin, LICSW, LADC

Cognitive Retructuring for PTSD: A Non‐Exposure Trauma Treatment Option

10/14/2020

Presented by Suzy Langevin, LICSW, LADC I and Andrea Wolloff, LMHC 1

C O G N I T I V E R E S T R U C T U R I N GF O R P T S D

A N o n - E x p o s u r e T r a u m a T r e a t m e n t O p t i o n

Welcome, your facilitator will be: Samson Teklemariam, LPC, CPTM• Director of Training and Professional

Development for NAADAC

• NAADAC, the Association for Addiction Professionals

• www.naadac.org

• [email protected]

www.naadac.org/webinars

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www.naadac.org/cognitive-restructuring-ptsd-webinar

Cost to Watch:Free

CE Hours Available:1.5 CEs

CE Certificate for NAADAC Members:Free

CE Certificate for Non-members:$20

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Using GoToWebinar(Live Participants Only)

Control Panel

Asking Questions

Handouts

Audio (phone preferred)

Polling Questions

Suzy Langevin, LICSW, LADC I• Director of Training & Professional

Development• Open Sky Community Services• Worcester, MA• [email protected]

NAADAC Webinar Presenter

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Andrea Wolloff, LMHC• Private Practice Clinician & Consultant• Westminster, MA• [email protected]

NAADAC Webinar Presenter

Webinar Learning Objectives Describe the key components of CR for PTSD treatment

Provide a rationale for using non-exposure-based techniques for treating co-occurring PTSD & SUD

Know the key counseling skills associated with the practice

Polling Question 1

How many individuals that you treat for substance use disorder also report experiencing trauma, and/or a diagnosis of PTSD?

A. Almost none

B. Less than half

C. About 50-50

D. More than half

E. Almost all

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It is estimated that PTSD effects about 8% of the US population• 1:10 men, 2:10 women• Not everyone who experiences a traumatic event will develop PTSD

Characterized by symptoms of:• Avoidance• Re-experiencing• Hyperarousal• Negative feelings

Trauma & PTSD

Prevalence rates of trauma among individuals with an SUD vary in studies fromhalf to nearly all

• Range from 60-97% • Often higher on clinical instruments than determined by clinical judgment

Potential neurobiological links that make individuals with SUD more likely toexperience symptoms of PTSDComplicated relationship with trauma experienced in the commission of usingsubstances

• Assault and sexual assault while intoxicated• Exchanging sex for drugs or money for drugs• Family disruption/child removal due to neglect

PTSD & SUD

“Gold standard” treatments include exposure• Prolonged Exposure• Cognitive Processing Therapy

• Optional, but exposure element included in clinical trials• EMDR

BUT… treatment drop out is incredibly common• As high as 95% in a number of prospective studies (vs RCTs used to

establish best practice principles

Why doesn’t treatment always work?

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Barriers to Effective Trauma Treatment

• Exposure work is very challenging, and requires a big commitment on the part of the individual entering treatment

• Normal life changes, like moves or job changes, can often disrupt progress

• Avoidance is especially common with co-occurring SUD

• Exposure sessions are designed to be longer that your “typical” 50 min sessions

• To be truly effective, may need to meet more frequently than once per week

• Exposure work is very challenging for clinicians, too!

• Many of us avoid talking about trauma or “back off” when people experience distress talking about their traumatic experiences.

• It’s a lot to sit with hearing.

Clinician ReadinessClient Readiness Time

Polling Question 2

What’s your current comfort level with addressing trauma & PTSD in treatment?

A. Very uncomfortable

B. Somewhat uncomfortable

C. Neutral

D. Somewhat comfortable

E. Very comfortable

CR for PTSD focuses on the impact onCURRENT thoughts and feelings

• Present-based situations and difficulties• Examines the relationship between the experience of trauma

and the development of negative thoughts

Specifically designed for individuals with otherco-morbid psychiatric conditionsShown to be helpful for complex, ongoingtrauma vs. discreet single incidents

A Different Approach: Cognitive Restructuring

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12 to 16 sessions of weekly individual therapy• 1 to 1.5 hours per session• Follows basic structure of a CBT session

Use of symptom assessmentsActive use of treatment handouts each sessionPrimary focus on skill development

• Using CR in everyday life• “Becoming your own therapist”

Treatment Structure

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Breathing Retraining

Psychoeducation

Cognitive Restructuring

A breathing technique that helps individuals relearn breathing patterns to better manage anxiety

Information about trauma & PTSD and its effects

A technique to critically examine thoughts and restructure thoughts to be more accurate and helpful

Treatment Elements

Often when people are anxious, they don’t breathe in a way thatis helpful, often increasing physical sensations of anxietyTeaching Breathing Retraining allows the individual to walk outof the first session with a new skillBreathing can be calming and can be used in session whenneededBreathing can be used anywhere

Breathing Retraining

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Educate about the effects of breathing on anxiety

Provide instruction using the handout

Demonstrate the technique

Steps to TeachingBreathing Retraining

Practice together

Debrief the use of the skill and troubleshoot anydifficulty

Polling Question 3

What strategies do you teach your clients for relaxation?

A. Specific breathing techniques

B. General deep/belly/diaphramatic breathing

C. Progressive muscle relaxation

D. Guided meditations

E. Mindfulness strategies

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Choose a word that you find relaxing.

Take a normal breath in through your nose.

While you exhale, say your calming word very slowly. For example: c-a-a-a-a-l-m.

Steps to Practicing Breathing Retraining

Pause before your next breath, counting to 4 if preferred.

Repeat for about 10 to 15 breaths.

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Goal: Individuals come to understand the symptoms they experience andknow that they are not alone. There is a name to what is experienced.This also allows individuals to explore how trauma has impacted their life.Psychoeducation can serve as a motivator to participate in the treatment.Studies suggest that psychoeducation alone can reduce the experience ofPTSD symptoms for some individuals.

Psychoeducation

Psychoeducation

Avoidance often impacts the person’s ability to come totreatment or to address PTSD directly in session

• It is important for counselors to balance empathy regarding avoidance with education

It is not uncommon for there to be more cancellations whenworking with someone with PTSD

• Substance use a really great way to avoid! This may be even more pronounced with co-occurring PTSD and substance use.

• Framing use as avoidance may be a helpful psychoeducation intervention.

A note about avoidance…

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The cornerstone skill taught in treatment

Gives individuals a framework to evaluate their own thoughts

First used to evaluate more “surface thoughts,” and over time,will be used to challenge and restructure core beliefs impactedby trauma

The 5 Steps of CR

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The Situation

The Feeling

The Thought

What was the situation that led to experiencing a negative emotion?

What negative feeling did you experience?

What’s the thought that led to you feeling that way? Often feelings have similar thoughts that stand behind them over and over.

The 5 Steps of CR

The Evidence

What’s the evidence that supports this thought? What’s the evidence that doesn’t support this thought?

The Restructuring

Taking the evidence on balance, what’s the more accurate and helpful way of looking at the situation? Does that cause you less distress?

Tracking of symptoms on validated measures is a part of the treatmentGives individuals real-time feedback on the impact treatment is having on measurableoutcomesPTSD 5 Checklist (PCL)

• Can be used to make a diagnostic determination of PTSD• Looks at all domains of PTSD symptoms

Beck Depression Inventory (BDI)• Tracks symptoms of depression often co-morbid with PTSD• Can substitute with another instrument, particularly if you need one in public domain, eg PHQ 9

Outcomes

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Outcomes: PTSD Checklist(PCL)Total n= 88

Categories Pre PCLPost PCL

PCL Diff % Diff

Total Cases 57.42 40.05 -17.37 30.3%

Reported Sexual Trauma 58.11 39.16 -18.95 32.6%

Reported Physical Trauma 62.08 47.41 -14.67 23.6%

Other Reported Trauma 54.61 38.48 -16.13 29.5%

Outcomes: Beck Depression Inventory(BDI)Total n= 88

CATEGORIES PRE BDI

POST BDI

BDI DIFF % DIFF

Total Cases 34.62 22.90 -11.72 33.9%

Reported Sexual Trauma 32.95 20.06 -12.89 39.1%

Reported Physical Trauma 41.83 27.75 -14.08 33.7%

Other Reported Trauma 34.25 25.16 -9.09 26.5%

Case Study: Jane, 16

PCL IV Score = 58 (Diagnostic for PTSD)BDI II Score = 17 (Mild Depression)

Thoughts: "I'm never going to be normal again.""If I had never started using drugs in the first place, this

wouldn’t have happened to me. It's all my fault."

PCL IV Score = 24 (Below diagnosic threshold)BDI II Score = 2 (Minimal Depression)

Thought: "I can make the rest of my life whatever I want it to be."

"What's in my past doesn't define my future."

Jane is a 16 year oldCaucasian female residing in an adolescent group home setting. Her "index trauma" was multiple sexual assaults that included being held against her will, after using drugs with her assailant. She had attempted to manage her symptoms by avoiding going to the area where she was assaulted, but eventually it got to the point where seeing the name of the city on a street sign caused a panic attack, and she knew she needed more help.

Pre-treatment

Post-treatment

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Cognitive Processing Therapy• Promulgated by the Veterans Administration• Mobile app resources in development

Seeking Safety• Also non-exposure• Modular based treatment appropriate for groups

Other Treatment Options

References

Najavits, L. (2015) The problem of dropout from “gold standard” PTSD therapies. F1000Prime Reports.Ling, J. et al. (2018) Fear Memory Recall Potentiates Opiate Reward Sensitivity through Dissociable Dopamine D1 vs D4 Receptor-Dependent Memory Mechanisms in the Prefrontal Cortex. The Journal of Neuroscience. Mueser, K.T., Rosenberg, S.D., & Rosenberg, H.J. Treatment of Posttraumatic Stress Disorder in Special Populations: A Congitive Restructuring Program. American Psychological Association, 2009. National Center on PTSD. https://www.ptsd.va.gov/public/understanding_TX/booklet.pdfGielen, N., Havermans, R.C., Tekelenberg, M., & Jansen, A. (2012) Prevalence of posttraumtic stress disorder among patients with substance use disorder: It’s higher than clinicians think. European Journal of Traumatology.

Thank You! Any Questions?

Suzy Langevin, LICSW, LADC [email protected]

Andrea Wolloff, [email protected]

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www.naadac.org/cognitive-restructuring-ptsd-webinar

Cost to Watch:Free

CE Hours Available:1.5 CEs

CE Certificate for NAADAC Members:Free

CE Certificate for Non-members:$20

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Documents

A Non-Exposure Trauma Treatment Option...2020/10/14 · Cognitive Retructuring for PTSD: A Non‐ Exposure Trauma Treatment Option 10/14/2020 Presented by Suzy Langevin, LICSW, LADC