Doing the Best We Can For Assault Victims

1. Doing the Best We Can For Assault Victims Richard Bryant University of New South Wales

2. Outline • The effects of assault • The ethical responsibility of therapists • Best Practice for Treatment

4. Assault is Common • US National Women’s Study survey 4,000 women – 36% reported rape, assault, or homicide death of loved one

5. Percentage of Victims With PTSD Assessment

6. How Many Develop PTSD? • Assault: 25% • Rape: 30% • Assault involving death threat: 50%

7. Who Develops PTSD?(Issues for Assessment) • Severity of assault • History of psychiatric disorder • History of traumatic events/childhood abuse • Poor social support • Stressors after the assault

8. Beyond PTSD • Depression • Anxiety • Substance Abuse • Anger • Insomnia • Self-Harm/Emotion Dysregulation

9. These People are Hurting

10. Does PTSD Hurt People? • Increased suicide • Poor physical health • Occupational dysfunction • Interpersonal dysfunction • Comorbid psychiatric disorders

11. Our Responsibility • PTSD and other disorders can become chronic and debilitating • If we accept a client for therapy, we MUST ensure that we are using the best techniques available • Otherwise, don’t accept the person for treatment

12. What is Best Practice? • Best Practice defined by exhaustive searches of the literature of properly-conducted trials • This way we can have confidence in the results because there is convergent evidence of the highest standard

13. Why Use Best Practice? • There are dozens of therapy approaches out there • Why should we adhere to best practice? • Trauma survivors can suffer long-term effects – critical that we give them what we know works • Providing therapy that we feel or think works meets our needs …. not the clients

14. NHMRC approved RANZCP & APS endorsed

15. Strength of Recommendations • A:Body of evidence can be trusted to guide practice • B: Body of evidence can be trusted to guide practice in most situations • C:Body of evidence provides some support for recommendation(s) but care should be taken in its application • D:Body of evidence is weak and recommendation must be applied with caution

16. Psychological Interventions for PTSD • Trauma-focussed CBT or EMDR in addition to in • vivo exposure is the first line treatment (A) • Trauma-focussed CBT includes: • Imaginal and in vivo exposure • Trauma-focussed cognitive therapy

17. Psychological Interventions for PTSD • Imaginal exposure requires 90 minute sessions (C) • 8 - 12 sessions of trauma-focussed treatment is usually sufficient (D) • More sessions where (for example): • multiple traumatic events • traumatic bereavement in addition to PTSD • significant disability and/or high comorbidity

18. Psychological Interventions • In cases of prolonged or repeated trauma • More time to establish an alliance • Teach affect regulation • More gradual approach to exposure

19. Psychological Interventions • In EMDR, no evidence for eye movements per se: • Treatment gains are more likely to be due to: • engagement with the traumatic memory • cognitive processing • rehearsal of coping or mastery responses • Importance of in vivo exposure

20. Psychological Interventions • Where one of these trauma-focussed treatments not effective, consider trying another • Where trauma-focussed treatment not effective or not available consider evidence based non trauma-focussed treatment such as stress management

21. Treatment Sequencing • PTSD and depression • Treat PTSD first, as depression often improves with successful treatment of the PTSD (B) • Unless depression is too severe (risk, interference) in which case address the depression before commencing PTSD treatment (GPP)

22. Treatment Sequencing • PTSD and substance use • Treat both simultaneously (C) • Do not commence trauma-focussed therapy until substance use under control (D)

23. Treatment Sequencing • Complex PTSD • Commence with emotion regulation skills • Continue with CBT

24. CBT Understanding • People become scared of reminders because they are associated with the trauma • Many victims learn that the world is a dangerous place and that they “cannot cope” • Systematic avoidance of trauma reminders and restricted daily activities prevent results in maintenance of these beliefs and PTSD symptoms become chronic

25. CBT Interventions for PTSD • Reduce anxiety • Promote safe confrontations with trauma reminders • Aim at modifying the dysfunctional cognitions underlying PTSD

26. Elements of Cognitive Behavior Therapy • Anxiety management techniques • Cognitive therapy • Prolonged exposure

27. Anxiety Management • Goal is to reduce anxiety/hyperarousal • Typically involves breathing retraining • Muscle relaxation often done (but minimally effective) • This intervention has minimal evidence

28. Dysfunctional, Negative Cognitions Underlying PTSD PTSD is characterized by catastrophic appraisals about: • The trauma • One’s response to the trauma • The future

29. Appraisals Predict PTSD • A major predictor of PTSD is maladaptive appraisals after assault

30. Cognitive Therapy A set of techniques that help patients change their negative, unrealistic cognitions by: • Identifying dysfunctional, unrealistic thoughts, and beliefs (cognitions) • Challenging these cognitions • Replacing these cognitions with functional, realistic cognitions

31. Prolonged Imaginal Exposure • Client gives a narrative of the trauma • Narrative in present tense • Critical to engage client’s distress • Exposure for at least 30 minutes duration • Obtain distress ratings during exposure • Identify client’s thoughts following exposure • Initiate daily homework of exposure

32. In Vivo Exposure • Exposure typically involves graded exposure to feared/avoided situations • This procedure is important for avoidant/phobic behaviors

33. Does CBT Cause Harm?

34. NO

35. CBT & Side-Effects • Large-scale studies indicate that: • No adverse side-effects • No increased drop-outs • Better long-term gains

36. So Why Don’t Therapists Use CBT? • Clinicians afraid of coping with client’s distress • Clinicians not properly trained • Clinicians do not have enough practice to realize the benefits of CBT

37. Summary • Therapists have an ETHICAL responsibility to know and use the best treatments for victims of crime • We know CBT is the treatment of choice • It is not a cookbook but clinicians need to adapt CBT to each client’s need

38. Beware • Most trauma survivors will be involved in litigation • Civil or criminal • We must protect ourselves and the client by ensuring we not compromise their testimony

39. DPP’s Concerns • There is MUCH evidence that hypnosis can contaminate memories • This can render one’s testimony inadmissable in court • DPP has focused on hypnosis and EMDR as techniques that can potentially contaminate memories …. do not use them!

41. www.traumaticstressclinic.com.au www.acpmh.unimelb.edu.au