CBT for Postdisaster Distress Jessica Hamblen, PhD National Center for PTSD

1. CBT for Postdisaster Distress Jessica Hamblen, PhDNational Center for PTSD

2. Existing Disaster Treatments Few treatments exists for disaster survivors in the later response stage. The State Crisis Counseling Program provides short-term, single session, interventions aimed at assisting survivors in understanding their reactions and referring for services A few treatment studies exist of CBT for disaster-related PTSD Only 2 disaster treatments did not require a PTSD diagnosis, a debriefing and an EMDR study, but focus was still on PTSD symptoms (Chemtob et al., 1997; Silver et al., 2005) The background is that there are really no other treatments that are specific to disaster in the longer term. (CCP is not a treatment) Instead, there are treatments for PTSD in disaster victims such as studies of the earthquake in Turkey (Basoglu, 2005, 2007), a study of several CBT treatments for PTSD used after the London Bombing (Brewin, 2008), and a study of a specific CBT-PTSD treatment used in response to the Omagh Bombing in Northern Ireland (Duffey et al., 2007) There are 2 disaster treatments that don�t require a PTSD diagnosis, but the focus was still on PTSD symptoms (Chemtob et al., 1997, Silver et al, 2005)The background is that there are really no other treatments that are specific to disaster in the longer term. (CCP is not a treatment) Instead, there are treatments for PTSD in disaster victims such as studies of the earthquake in Turkey (Basoglu, 2005, 2007), a study of several CBT treatments for PTSD used after the London Bombing (Brewin, 2008), and a study of a specific CBT-PTSD treatment used in response to the Omagh Bombing in Northern Ireland (Duffey et al., 2007) There are 2 disaster treatments that don�t require a PTSD diagnosis, but the focus was still on PTSD symptoms (Chemtob et al., 1997, Silver et al, 2005)

3. The Need for Something New: Treatment for Postdisaster Distress Postdisaster distress encompasses a range of cognitive, emotional and behavioral reactions to disaster, including symptoms of: PTSD Depression Stress vulnerability Functional difficulties Postdisaster distress is not a psychiatric diagnosis. This slide introduces the concept of Postdisaster distress and how it differs from focusing on a psychiatric disorder. This slide introduces the concept of Postdisaster distress and how it differs from focusing on a psychiatric disorder.

4. Advantages of a Treatment for Postdisaster Distress Broader approach assists individuals with other primary reactions, comorbid conditions, or subclinical conditions Can be disseminated to community clinicians through a single training Reduces the need for extensive assessment May be seen as more acceptable to survivors This slide continues to emphasize how a treatment focused on postdisaster distress is different from one for PTSD or another disorder. Because of the broader focus, it is appropriate for more people Because it treats more than one disorder you can train clinicians in a single treatment rather than one for PTSD, one for depression, etc Because no diagnosis is required, assessment can be brief It may be more acceptable because it does not pathologize. This slide continues to emphasize how a treatment focused on postdisaster distress is different from one for PTSD or another disorder. Because of the broader focus, it is appropriate for more people Because it treats more than one disorder you can train clinicians in a single treatment rather than one for PTSD, one for depression, etc Because no diagnosis is required, assessment can be brief It may be more acceptable because it does not pathologize.

5. CBT-PD Developed in response to the September 11th terrorists attacks and used following the 2004 Florida Hurricanes, Hurricane Katrina and Hurricane Ike A manualized 10 session cognitive behavioral intervention for postdisaster distress Primary focus is on identifying and challenging maladaptive disaster-related beliefs CBT-PD: Cognitive Behavioral Therapy for Postdisaster Distress It is important to talk about where the manual came from and how it has been used to give it some credibility. Initially developed for the World Trade Center attacks. Later used in Florida in response to 2004 Hurricanes, Baton Rouge in response to Katrina and Rita, and Galveston in response to IkeCBT-PD: Cognitive Behavioral Therapy for Postdisaster Distress It is important to talk about where the manual came from and how it has been used to give it some credibility. Initially developed for the World Trade Center attacks. Later used in Florida in response to 2004 Hurricanes, Baton Rouge in response to Katrina and Rita, and Galveston in response to Ike

6. Overview of intervention A 10 session manualized intervention to treat a range of postdisaster distress Designed to be one part of larger disaster mental health system response To be implemented no sooner than 60 days postdisaster For individuals showing more than transient stress response Intermediate step between crisis counseling and longer term mental health treatment

7. Three Components Psychoeducation (Session 1) Anxiety Management (Session 2) Cognitive Restructuring Taught (Session 3-4) Practice (Session 5-9) Termination (Session 10) There are three main components to the intervention The first session is psychoeducational. The second session is coping skills training and sessions 3-10 focus on Cognitive Restructuring (CR). The �practice sessions� are sessions 5-9, which are simply opportunities to review and practice CRs or �the 5 steps.� The last session is a termination and review session. Some clients will respond quickly to the intervention and will not require all 10 sessions, while we find that most do opt for the full intervention. If they need more help after Session 10, they will be referred to further therapy or an agency as appropriate. The following slides contain more information on each of the components. There are three main components to the intervention The first session is psychoeducational. The second session is coping skills training and sessions 3-10 focus on Cognitive Restructuring (CR). The �practice sessions� are sessions 5-9, which are simply opportunities to review and practice CRs or �the 5 steps.� The last session is a termination and review session. Some clients will respond quickly to the intervention and will not require all 10 sessions, while we find that most do opt for the full intervention. If they need more help after Session 10, they will be referred to further therapy or an agency as appropriate. The following slides contain more information on each of the components.

8. Psychoeducation Emphasized in 1st session, but woven throughout treatment Goals: Education Reassurance/normalization establishment of rapport information gathering in regard to client�s problems in functioning Can be tailored to client�s specific presentation The point of the psychoeducation session is to normalize reactions, instill that you understand what the client is dealing with, and to give them information that they can take home and read. The point of the psychoeducation session is to normalize reactions, instill that you understand what the client is dealing with, and to give them information that they can take home and read.

9. Psychoeducation: Topics Common reactions fear/anxiety Sadness/depression Guilt/shame Anger PTSD Substance abuse Grief/bereavement Sleep problems/nightmares Problems in functioning You�ll see in the manual that each session begins with an overview for what is to take place and how long it should take.You�ll see in the manual that each session begins with an overview for what is to take place and how long it should take.

10. Anxiety Management/Coping Coping skills interwoven throughout intervention, but are formally introduced in Session 2 Three skills: Breathing Retraining - counters physical symptoms of anxiety Pleasant Activities Scheduling � helps depressed and/or isolated individuals Coping Skills Training - increases awareness of alternative, more positive coping strategies In session 2, we address anxiety management, coping skills and problem solving. Breathing retraining is a widely used anxiety management strategy that we will practice ourselves later in the workshop. Session 2 also introduces activities scheduling which is also known as behavioral activation. Activity scheduling is especially emphasized for clients with depression because it has been shown to be a very helpful intervention for that population. There is also a brief section on coping skills training introduced in Session 2. This intervention does not go into coping skills training in depth, but instead provides a list of helpful ways of coping that clients might try. As you will see, the coping skills and anxiety management strategies are often woven into the final step of CR, called the Action Plan. In session 2, we address anxiety management, coping skills and problem solving. Breathing retraining is a widely used anxiety management strategy that we will practice ourselves later in the workshop. Session 2 also introduces activities scheduling which is also known as behavioral activation. Activity scheduling is especially emphasized for clients with depression because it has been shown to be a very helpful intervention for that population. There is also a brief section on coping skills training introduced in Session 2. This intervention does not go into coping skills training in depth, but instead provides a list of helpful ways of coping that clients might try. As you will see, the coping skills and anxiety management strategies are often woven into the final step of CR, called the Action Plan.

11. Breathing Retraining: Instructions Take a normal breath in through your nose. Exhale slowly through your nose or mouth. When exhaling say CALM, RELAX, or EXHALE. Count to 4 then take next breath Practice several times a day, 10-15 times at each practice. Note to trainer: You should demonstrate use of the technique with the audience as a training exercise. �I am going to want you to close your eyes and take in a NORMAL breath � not a deep breath. Focus on a normal breath in and a slow exhalation. It is EXHALATION that relaxes, not INHALATION. As you exhale I want you to say to yourself �calm� or �relax.� Okay? So a normal breath in and then exhale slowly, and say calm or relax to yourself. (If a client wants to use another calming word, that is fine). �I will ask you to pause and count to four after you have exhaled, before taking your next breath, to help you slow your breathing.� Instructions to be read aloud: TAKE A NORMAL BREATH (AUDIENCE INHALES)�.C�A�A�L�L�M (AS AUDIENCE EXHALES)�AND PAUSE�.2�..3���� �TAKE A NORMAL BREATH NOW.� �.C�A�A�L---L�M�.�AND PAUSE�2-----3----4---.� �TAKE A NORMAL BREATH NOW.� Note to trainer: You should demonstrate use of the technique with the audience as a training exercise. �I am going to want you to close your eyes and take in a NORMAL breath � not a deep breath. Focus on a normal breath in and a slow exhalation. It is EXHALATION that relaxes, not INHALATION. As you exhale I want you to say to yourself �calm� or �relax.� Okay? So a normal breath in and then exhale slowly, and say calm or relax to yourself. (If a client wants to use another calming word, that is fine). �I will ask you to pause and count to four after you have exhaled, before taking your next breath, to help you slow your breathing.� Instructions to be read aloud: TAKE A NORMAL BREATH (AUDIENCE INHALES)�.C�A�A�L�L�M (AS AUDIENCE EXHALES)�AND PAUSE�.2�..3���� �TAKE A NORMAL BREATH NOW.� �.C�A�A�L---L�M�.�AND PAUSE�2-----3----4---.� �TAKE A NORMAL BREATH NOW.�

12. Pleasant Activities Scheduling Goal: Review client�s pleasant activities: Increase pleasurable activities Increase number of activities Clients may not be engaging in pleasant activities due to: Depression Avoidance Earlier when we talked about behavioral activation, we were referring to pleasant events scheduling. In your manual is a copy of the pleasant events list and the schedule. A plain old calendar is just fine for this as well. The premise behind pleasant activities scheduling is that people under stress and/or struggling with depression tend to withdraw and isolate. They may have their ratio of pleasant events to negative events out of balance in that they have more negative things going on than positive things. Our job is to help them try to get that ratio into better balance. Activity scheduling can also be used to target avoidance that may be contributing to both symptoms of depression and PTSD. Earlier when we talked about behavioral activation, we were referring to pleasant events scheduling. In your manual is a copy of the pleasant events list and the schedule. A plain old calendar is just fine for this as well. The premise behind pleasant activities scheduling is that people under stress and/or struggling with depression tend to withdraw and isolate. They may have their ratio of pleasant events to negative events out of balance in that they have more negative things going on than positive things. Our job is to help them try to get that ratio into better balance. Activity scheduling can also be used to target avoidance that may be contributing to both symptoms of depression and PTSD.

13. Pleasant Activities Scheduling Feelings Thoughts Behaviors This diagram illustrate the rationale for events scheduling. If we were sad and it were as easy as saying to ourselves, �I don�t want to feel sad, I think I�ll change my feeling,� then we would all do that. We all know it�s not that easy. In order to modify feelings, we typically need to modify our thoughts and or behaviors. Most of this treatment will be focused on changing our thoughts. However, simply increasing pleasant events can have a positive impact on mood. GROUP EXERCISE (IF TIME PERMITS): Come up with an example and use the triangle - use a white board if available. For example, imagine the your boss asks to see you. How might you feel? Nervous? What might you be thinking? That you have done something wrong? That you are in trouble? What would you do in that situation? Cry? Get angry? Say something you might regret later? Now, flip the situation around. Imagine that you felt excited about your boss asking to see you. You might think you are going to be praised or given a new project. Now your behaviors might be thinking about what you need to do to get ready for the meeting. This diagram illustrate the rationale for events scheduling. If we were sad and it were as easy as saying to ourselves, �I don�t want to feel sad, I think I�ll change my feeling,� then we would all do that. We all know it�s not that easy. In order to modify feelings, we typically need to modify our thoughts and or behaviors. Most of this treatment will be focused on changing our thoughts. However, simply increasing pleasant events can have a positive impact on mood. GROUP EXERCISE (IF TIME PERMITS): Come up with an example and use the triangle - use a white board if available. For example, imagine the your boss asks to see you. How might you feel? Nervous? What might you be thinking? That you have done something wrong? That you are in trouble? What would you do in that situation? Cry? Get angry? Say something you might regret later? Now, flip the situation around. Imagine that you felt excited about your boss asking to see you. You might think you are going to be praised or given a new project. Now your behaviors might be thinking about what you need to do to get ready for the meeting.

14. Pleasant Activities: Identifying & Scheduling Spend more time on this for those clients who are more depressed or socially isolated. Have client complete Pleasant Activities Schedule Help client identify and then schedule the activities into their weekly schedule as this will greatly increase the chances that clients will follow through. Follow up each week, especially for clients with more severe symptoms of depression. For people who are very negative the pleasant activities list can be helpful because it helps them see ow many options there are. You may hear them say �there�s nothing I can do. I don�t have any time. I don�t have any money.� The list presents so many choices there is something for everyone. Emphasize things that don�t cost a lot of money and are healthy. Also, focus on activities that decrease avoidance. Feel free to use humor as you go through the list in the training (and with your clients). Some things on the list are strange, like �going naked.� If your depressed client gets a chuckle from something on the list, that�s probably a good thing. Some clients and some therapists love the list and they enjoy revisiting the list every week and finding a new thing that they can add to do. Other people find it just as easy or productive to just have a conversation with a client around what they enjoy. E.g., maybe a client used to enjoy cooking but has stopped doing it. Re-introducing cooking could be one of their pleasant events. You don�t need to use the list at all but it�s there if you need it. It is important to actually schedule the events into a calendar. Therapists can use every day examples to demonstrate the importance of this. For example, we may think about calling a relative or going to the gym but we are much more likely to do it if we commit to a specific time. Optional Activity: have audience members commit to adding one pleasant event to the upcoming week. For people who are very negative the pleasant activities list can be helpful because it helps them see ow many options there are. You may hear them say �there�s nothing I can do. I don�t have any time. I don�t have any money.� The list presents so many choices there is something for everyone. Emphasize things that don�t cost a lot of money and are healthy. Also, focus on activities that decrease avoidance. Feel free to use humor as you go through the list in the training (and with your clients). Some things on the list are strange, like �going naked.� If your depressed client gets a chuckle from something on the list, that�s probably a good thing. Some clients and some therapists love the list and they enjoy revisiting the list every week and finding a new thing that they can add to do. Other people find it just as easy or productive to just have a conversation with a client around what they enjoy. E.g., maybe a client used to enjoy cooking but has stopped doing it. Re-introducing cooking could be one of their pleasant events. You don�t need to use the list at all but it�s there if you need it. It is important to actually schedule the events into a calendar. Therapists can use every day examples to demonstrate the importance of this. For example, we may think about calling a relative or going to the gym but we are much more likely to do it if we commit to a specific time. Optional Activity: have audience members commit to adding one pleasant event to the upcoming week.

15. Example: Activity Scheduling Your client relocated to Baton Rouge after Hurricane Katrina. He doesn�t know many people and misses his old life in New Orleans. What kind of activities would you want to help them schedule? Your client�s husband was killed in the World Trade Center attacks. Since 9/11 she has dedicated her life to her children, making sure they have everything they need. She feels depressed, lonely, and like she has nothing left to give. What kinds of activities would you want to help her schedule? Use these scenarios to help clinicians see that not all activities are of equal value. Also, remind therapists they need to be sensitive to real world issues of money and time. There are two ways to do this. Have therapists brainstorm possible activities while you write them on the board. Or, have therapists break into groups and role play. This helps with giving therapists insight into how clients might push back. In this first scenario look for activities that get the client connected with the community. Joining a group of some kind it better than taking time to prepare a nice meal at home. You could also look for activities that would get him connected into activities that give back some of that New Orleans feel. Maybe there is a music group he could join? Maybe there are others who have relocated who are all attending the same church, etc. In the second scenario, look for activities that will refresh this mom. It is okay for her to take time for herself - even if it is not very much time. So, a solitary activity of taking a bath would be okay in this case.Use these scenarios to help clinicians see that not all activities are of equal value. Also, remind therapists they need to be sensitive to real world issues of money and time. There are two ways to do this. Have therapists brainstorm possible activities while you write them on the board. Or, have therapists break into groups and role play. This helps with giving therapists insight into how clients might push back. In this first scenario look for activities that get the client connected with the community. Joining a group of some kind it better than taking time to prepare a nice meal at home. You could also look for activities that would get him connected into activities that give back some of that New Orleans feel. Maybe there is a music group he could join? Maybe there are others who have relocated who are all attending the same church, etc. In the second scenario, look for activities that will refresh this mom. It is okay for her to take time for herself - even if it is not very much time. So, a solitary activity of taking a bath would be okay in this case.

16. Cognitive Restructuring Introduced in sessions 3 and 4; practiced through remainder of the treatment �Backbone� of treatment Clients taught connection between thoughts and feelings Ultimate goal is to change problematic feelings/behaviors by putting thoughts into more realistic/balanced perspective. Can be used for wide variety of problematic cognitive, emotional, and behavioral patterns CR is the backbone of the intervention. We teach clients to look at the connections between problematic thoughts and feelings. The ultimate goal is to improve feelings by putting thoughts into a more balanced perspective. However, the alternate goal is to help clients figure out how they are going to cope with very, very painful/negative yet sometimes realistic thoughts after a disaster. This is a quick overview of the treatment. We are going to go over it in much more depth as the day proceeds. CR is the backbone of the intervention. We teach clients to look at the connections between problematic thoughts and feelings. The ultimate goal is to improve feelings by putting thoughts into a more balanced perspective. However, the alternate goal is to help clients figure out how they are going to cope with very, very painful/negative yet sometimes realistic thoughts after a disaster. This is a quick overview of the treatment. We are going to go over it in much more depth as the day proceeds.

17. Rationale for CR Feelings are connected to thoughts. What we think determines what we feel. Life experiences shape people�s thinking and beliefs. Traumatic experiences are a type of life experience that greatly shape our thinking. These thoughts are often automatic and we may not be aware of them. First step is to become aware of our thoughts, then we can begin to challenge them Cognitive Restructuring or �CR� forms the backbone of this treatment. We are giving clients the message that for all of us, the way we think determines how we feel. We emphasize that our thoughts don�t come out of nowhere. Prior life experiences shape our thinking and belief systems. Also, our thoughts are so automatic and habitual, we often aren�t even aware of them. Our thoughts may �feel� true even though they often are not. Before we can modify or challenge our thoughts, we need to begin to be more aware of them in the first place. Cognitive Restructuring or �CR� forms the backbone of this treatment. We are giving clients the message that for all of us, the way we think determines how we feel. We emphasize that our thoughts don�t come out of nowhere. Prior life experiences shape our thinking and belief systems. Also, our thoughts are so automatic and habitual, we often aren�t even aware of them. Our thoughts may �feel� true even though they often are not. Before we can modify or challenge our thoughts, we need to begin to be more aware of them in the first place.

18. Example You�re walking down the street and you see a friend of yours across the street that you haven�t seen in a few months and you say �Hey Sally how are you doing?� However, she doesn�t respond and keeps walking. Note to Trainer � ask the group to talk about how they would feel in this situation. Most clients will say they would feel bad or angry. If you ask what they are thinking they will say that Sally doesn�t like them anymore or is mad at them. But, if you ask clients how they would feel if Sally did not see them (because she needs glasses or had something else on her mind), most will say they�d feel fine. EXAMPLE 2: You hear a loud noise outside your house. If you think someone is trying to break in you feel afraid. If you think the neighbors cat knocked over a trash can you might feel annoyed, but not afraid. SO, thoughts and feelings are connected. AND, what you think influences how you feel.Note to Trainer � ask the group to talk about how they would feel in this situation. Most clients will say they would feel bad or angry. If you ask what they are thinking they will say that Sally doesn�t like them anymore or is mad at them. But, if you ask clients how they would feel if Sally did not see them (because she needs glasses or had something else on her mind), most will say they�d feel fine. EXAMPLE 2: You hear a loud noise outside your house. If you think someone is trying to break in you feel afraid. If you think the neighbors cat knocked over a trash can you might feel annoyed, but not afraid. SO, thoughts and feelings are connected. AND, what you think influences how you feel.

19. Guide to Thoughts and Feelings The Guide to Thoughts and Feelings helps clients figure what they are thinking or feeling. The Guide to Thoughts and Feelings is in your manual and helps clients identify thoughts for the 4 feeling states. Fear: if a client knows they are feeling fear but they are not sure what their associated thoughts are, they should ask themselves �what bad thing do I expect to happen?� The answer, is that something bad will happen. Sadness: if a client feels sad then they are probably having thoughts about lost hope or something that is missing in their lives. Guilt or shame tend to correspond with thoughts that they have done something wrong or there is something wrong with them. Anger tends to correspond with thoughts about a situation being unfair or unjust. The Guide to Thoughts and Feelings helps clients figure what they are thinking or feeling. The Guide to Thoughts and Feelings is in your manual and helps clients identify thoughts for the 4 feeling states. Fear: if a client knows they are feeling fear but they are not sure what their associated thoughts are, they should ask themselves �what bad thing do I expect to happen?� The answer, is that something bad will happen. Sadness: if a client feels sad then they are probably having thoughts about lost hope or something that is missing in their lives. Guilt or shame tend to correspond with thoughts that they have done something wrong or there is something wrong with them. Anger tends to correspond with thoughts about a situation being unfair or unjust.

20. The Upsetting Situations Log In Session 3, we ask clients to begin tracking the connections between their thoughts and feelings, using the Upsetting Situations Log which is in your manual. The idea behind this log is that it will help clients become more aware of their thoughts and feelings and the connection between them. They should be encouraged to use the Guide to Thoughts and Feelings to help them if they are having trouble figuring out what thoughts correspond to their feelings. In Session 3, we ask clients to begin tracking the connections between their thoughts and feelings, using the Upsetting Situations Log which is in your manual. The idea behind this log is that it will help clients become more aware of their thoughts and feelings and the connection between them. They should be encouraged to use the Guide to Thoughts and Feelings to help them if they are having trouble figuring out what thoughts correspond to their feelings.

21. Problematic Thinking Styles Goal: Teach clients to identify Problematic Thinking Styles Problematic Thinking Styles - a group of thinking patterns which are often unhelpful, unnecessary, and contribute to negative feelings. Includes: All or None Thinking; Overgeneralizing; Must, Should, Never; Catastrophizing; Emotional Reasoning, Overestimation of Risk, and Self-blame. The slides that follow generally should be reviewed fairly quickly as most audience members will have some prior familiarity with the various thinking styles. Problematic thinking styles are typically referred to in CBT as �cognitive distortions� or �thinking errors.� We find the term �problematic thinking styles� to be more acceptable to clients. Some clients will find it helpful to have labels for their problematic thought patterns and it will help them identify problematic themes in their thinking. For example, many anxious clients tend to catastrophize and they will readily grasp this thinking style and begin to label their own thinking. Many of the thinking styles overlap and often clients will find that more than one problematic thinking style describes a given thought they are having. This is fine and to be expected. The slides that follow generally should be reviewed fairly quickly as most audience members will have some prior familiarity with the various thinking styles. Problematic thinking styles are typically referred to in CBT as �cognitive distortions� or �thinking errors.� We find the term �problematic thinking styles� to be more acceptable to clients. Some clients will find it helpful to have labels for their problematic thought patterns and it will help them identify problematic themes in their thinking. For example, many anxious clients tend to catastrophize and they will readily grasp this thinking style and begin to label their own thinking. Many of the thinking styles overlap and often clients will find that more than one problematic thinking style describes a given thought they are having. This is fine and to be expected.

22. The 5 Steps Step 1: Upsetting Situation Step 2: Feelings Step 3: Thoughts Step 4: Challenge your Thought Step 5: Make A Decision We will be spending the remainder of the training discussing the 5 steps in a lot of detail so you will become extremely familiar with them. The 5 Steps include a) Describing the situation, 2) circling the strongest feeling (which are based on the 4 Common Reactions we described earlier), 3) choosing the core thought associated with the feeling and labeling the style of thinking that applies, 4) challenging the thought, and 5) making a decision This approach to CR is different from more traditional CR approaches in that it makes room for �taking action� or focusing on coping skills other than simply changing the cognition. The reason for this is twofold. First, as we�ve said, the painful cognitions sometimes are in fact accurate and the client�s job will be to cope with a painful or stressful reality. Second, sometimes the client will indeed decide that their thinking is not accurate and they will work on changing their thought but they will continue to feel and struggle with difficult emotion. This is, in fact, quite common. In order to address that challenge, we find it useful to build in coping skills to help clients attain some relief through means other than changing cognitions. We will be spending the remainder of the training discussing the 5 steps in a lot of detail so you will become extremely familiar with them. The 5 Steps include a) Describing the situation, 2) circling the strongest feeling (which are based on the 4 Common Reactions we described earlier), 3) choosing the core thought associated with the feeling and labeling the style of thinking that applies, 4) challenging the thought, and 5) making a decision This approach to CR is different from more traditional CR approaches in that it makes room for �taking action� or focusing on coping skills other than simply changing the cognition. The reason for this is twofold. First, as we�ve said, the painful cognitions sometimes are in fact accurate and the client�s job will be to cope with a painful or stressful reality. Second, sometimes the client will indeed decide that their thinking is not accurate and they will work on changing their thought but they will continue to feel and struggle with difficult emotion. This is, in fact, quite common. In order to address that challenge, we find it useful to build in coping skills to help clients attain some relief through means other than changing cognitions.

23. CR: Katrina/Superdome Situation: Seeing a teenage girl sexually assaulted at the superdome Feeling: Guilt/Shame Thought: It�s my fault the girl was raped. (Self-blame) The following 3 sets of slides provide clinical examples that demonstrate applications of the 5 steps. You can use these examples or do a live CR in front of the group. The client walked into a public restroom at the superdome with her young daughter and saw a teenage girl in a corner of the restroom with 3 men. One of the men had a knife and the woman looked terrified and was partially clothed. It was clear that a sexual assault was happening. One of the men yelled �get out!� at the client and her daughter. She yelled �stop!� at them, but then quickly left the restroom with her daughter. The woman was of course torn between wanting to protect herself and her daughter and wanting to help the girl who was being attacked. She ran out of the restroom with her daughter and she actually was able to locate a police officer outside the Superdome. However, the officer told her that he was busy doing crowd/safety control outside and could not come in. The woman had tremendous levels of guilt and shame about this, even though objectively she acted as effectively as she could have and she kept herself and her daughter safe. She held herself completely to blame for the girl�s sexual assault. As you can see, her thought was �It�s my fault the girl was raped.� -could also have been fear/anxiety -> The following 3 sets of slides provide clinical examples that demonstrate applications of the 5 steps. You can use these examples or do a live CR in front of the group. The client walked into a public restroom at the superdome with her young daughter and saw a teenage girl in a corner of the restroom with 3 men. One of the men had a knife and the woman looked terrified and was partially clothed. It was clear that a sexual assault was happening. One of the men yelled �get out!� at the client and her daughter. She yelled �stop!� at them, but then quickly left the restroom with her daughter. The woman was of course torn between wanting to protect herself and her daughter and wanting to help the girl who was being attacked. She ran out of the restroom with her daughter and she actually was able to locate a police officer outside the Superdome. However, the officer told her that he was busy doing crowd/safety control outside and could not come in. The woman had tremendous levels of guilt and shame about this, even though objectively she acted as effectively as she could have and she kept herself and her daughter safe. She held herself completely to blame for the girl�s sexual assault. As you can see, her thought was �It�s my fault the girl was raped.� -could also have been fear/anxiety ->

24. CR: Example continued 4. Challenge the thought: Evidence for the thought: I saw it happen I was the only one there I didn�t do anything. Evidence against the thought: I yelled to stop there were 3 men they had a knife I did all I could In Step 4, the client generates �evidence� for and against the thought that it was her fault the girl was raped. Notice again that the evidence in support of the thought does not need to be �good� evidence. It is simply an account of the various factors that add weight to the thought in the client�s mind, rational or not. Evidence for the thought: In this case, the client indicated that because she witnessed the assault she felt responsible. She was the only adult there. Even though she actually DID do something (i.e. try to get help from a police officer), in her mind she did not do anything because she was ineffective in seeking help or stopping the attack. A side note here is that the weaker the evidence in support of the thought, the easier to challenge it will be. In terms of evidence against the thought that it was her fault the girl was raped, the client was able to acknowledge that 1) she yelled �stop,� 2) that there were 3 (bigger, stronger) men and only one of her, 3) that they had a knife, and 4) that she did all she could. She might also have added a statement regarding the fact that it was the men who committed this horrible act, not her. In Step 4, the client generates �evidence� for and against the thought that it was her fault the girl was raped. Notice again that the evidence in support of the thought does not need to be �good� evidence. It is simply an account of the various factors that add weight to the thought in the client�s mind, rational or not. Evidence for the thought: In this case, the client indicated that because she witnessed the assault she felt responsible. She was the only adult there. Even though she actually DID do something (i.e. try to get help from a police officer), in her mind she did not do anything because she was ineffective in seeking help or stopping the attack. A side note here is that the weaker the evidence in support of the thought, the easier to challenge it will be. In terms of evidence against the thought that it was her fault the girl was raped, the client was able to acknowledge that 1) she yelled �stop,� 2) that there were 3 (bigger, stronger) men and only one of her, 3) that they had a knife, and 4) that she did all she could. She might also have added a statement regarding the fact that it was the men who committed this horrible act, not her.

25. CR: Example continued 5. Make a Decision: Evidence does not support the thought. New thought: �I did everything I could do in a horrible situation, and it was these men who committed the crime, not me.� In Step 5, the client reviews the evidence for and against the thought and ultimately makes a decision about whether the thought is supported by the weight of the evidence. Encourage the client to think like a judge and really try to objectively examine the STRENGTH of the evidence on both sides of the equation. They should be mindful of distortions in their evidence statements � for example, oftentimes emotional reasoning is represented heavily in evidence supporting problematic thoughts. Ultimately, it will be up to the client to make a determination as to whether or not their thought is supported by the evidence. In the beginning of treatment, the therapist will play a more active role in this determination by helping the client see possible distortions in their evidence. However, do try to avoid getting into a power struggle with the client about this. In Step 5, the client reviews the evidence for and against the thought and ultimately makes a decision about whether the thought is supported by the weight of the evidence. Encourage the client to think like a judge and really try to objectively examine the STRENGTH of the evidence on both sides of the equation. They should be mindful of distortions in their evidence statements � for example, oftentimes emotional reasoning is represented heavily in evidence supporting problematic thoughts. Ultimately, it will be up to the client to make a determination as to whether or not their thought is supported by the evidence. In the beginning of treatment, the therapist will play a more active role in this determination by helping the client see possible distortions in their evidence. However, do try to avoid getting into a power struggle with the client about this.

26. Alternative Feelings/Thoughts Guilt/Shame ? It�s my fault Fear/Anxiety ? Bad things happen. I could be raped. Sadness/Depression ? Things will never be the same Anger ? (It�s not fair) Innocent people are being hurt

27. Example 2: Losing FEMA trailer Fear/Anxiety: I will be living on the street Guilt/Shame: I should have been able to find anther place to live by now. Anger: It�s not fair. I�ve done everything I could. Sadness/depression: I�m going to lose this community Here is another example. Again, ex shows that there are many different thoughts to the same situation. Possible thoughts might be: Fear/Anxiety: I will be living on the street Guilt/Shame: A better/stronger person would be on their feet by now. Anger: It�s not fair. I�ve done everything I could. Sadness: I�m going to lose this community/I don�t have any control over my life.Here is another example. Again, ex shows that there are many different thoughts to the same situation. Possible thoughts might be: Fear/Anxiety: I will be living on the street Guilt/Shame: A better/stronger person would be on their feet by now. Anger: It�s not fair. I�ve done everything I could. Sadness: I�m going to lose this community/I don�t have any control over my life.

28. What to do if 5 steps don�t work Payoff Matrix Problematic Thinking Styles Multiple Alternative Thoughts 2 Step CR Sometimes you�ll find that a client seems to want to �hold onto� a problematic thought or belief, even when there is minimal evidence to support it. In these situations it can help to go through the Payoff Matrix. It helps clients examine the pros and cons of keeping a thought or belief and the pros and cons of changing a thought or belief. The Problematic Thinking Styles approach simply refers to labeling the problematic thinking style and trying to respond to the error in thinking. E.g. �I�m catastrophizing, I should try to look at my thinking more realistically.� Multiple Alternative Thoughts approach refers to simply challenging one�s thinking by generating a list of alternative thoughts � e.g. �Is there another way to look at this situation? How might my friend view this situation?� 2 Step CR is when the client simply identifies the Thought and then identifies an Alternative Thought. For example, they may realize their thought is problematic and they would simply try to counter the thought. Sometimes you�ll find that a client seems to want to �hold onto� a problematic thought or belief, even when there is minimal evidence to support it. In these situations it can help to go through the Payoff Matrix. It helps clients examine the pros and cons of keeping a thought or belief and the pros and cons of changing a thought or belief. The Problematic Thinking Styles approach simply refers to labeling the problematic thinking style and trying to respond to the error in thinking. E.g. �I�m catastrophizing, I should try to look at my thinking more realistically.� Multiple Alternative Thoughts approach refers to simply challenging one�s thinking by generating a list of alternative thoughts � e.g. �Is there another way to look at this situation? How might my friend view this situation?� 2 Step CR is when the client simply identifies the Thought and then identifies an Alternative Thought. For example, they may realize their thought is problematic and they would simply try to counter the thought.

29. CBT for Postdisaster Distress: Results (n=201) Sex n % Male 38 19 Female 163 81 Age 18-39 52 26 40-64 135 67 65+ 14 7 Race/ethnicity NH White 77 38 African American 116 58 Other or mixed 8 4 Education < 12 years 28 14 HS thru some college 121 60 College or more 52 26 Displaced by Katrina � no 23 11 � yes 177 89 The next few slides give information on what we know about how well CBT for Postdisaster Distress works. This data comes from InCourage Program This slide describes who received the treatment. The majority were: Female Middle aged With at least a High School degree Just over half were African American and the vast majority had been displaced by Katrina.The next few slides give information on what we know about how well CBT for Postdisaster Distress works. This data comes from InCourage Program This slide describes who received the treatment. The majority were: Female Middle aged With at least a High School degree Just over half were African American and the vast majority had been displaced by Katrina.

30. Percent of 82 completers scoring 7+ on Sprint-E at pre- and post-treatment A score of 7 on the Sprint-E indicates a probable need for treatment. This slide shows that at the beginning of the intervention 62% of participants indicated a probable need for treatment, whereas at the end of the intervention, only 12% indicated a probable need for treatment.A score of 7 on the Sprint-E indicates a probable need for treatment. This slide shows that at the beginning of the intervention 62% of participants indicated a probable need for treatment, whereas at the end of the intervention, only 12% indicated a probable need for treatment.

31. Prevalence of intense reactions pre- and post-treatment (n = 82 completers) This slide shows the 11 items on the SPRINT-E and the percent of people endorsing each item at an intense level. You can see that there was improvement on all the symptoms following treatment.This slide shows the 11 items on the SPRINT-E and the percent of people endorsing each item at an intense level. You can see that there was improvement on all the symptoms following treatment.

32. Trend in Sprint-E scores for 47 participants with follow-up This last slide shows the trend in SPRINT-E scores over time. As expected there was minimal change between referral and pretreatment (some change is expected as people may be encouraged at the idea of starting in therapy. Then you see substantial change between Pre and Intermediate Treatment. This indicates that the breathing retraining and pleasant activity scheduling that occurs in the first 2 sessions are effective. Finally you see additional change from Intermediate to Post due to the addition of cognitive restructuring. And, these treatment gains are maintained 4 months later.This last slide shows the trend in SPRINT-E scores over time. As expected there was minimal change between referral and pretreatment (some change is expected as people may be encouraged at the idea of starting in therapy. Then you see substantial change between Pre and Intermediate Treatment. This indicates that the breathing retraining and pleasant activity scheduling that occurs in the first 2 sessions are effective. Finally you see additional change from Intermediate to Post due to the addition of cognitive restructuring. And, these treatment gains are maintained 4 months later.

33. Questions?