Symposium presented at the 38th Annual Congress of the European Association for Behavioural & Cognitive Therapies, Dubrovnik, Croatia.
Recurring and distressing thoughts and images of a traumatic event are key characteristics of posttraumatic stress disorder (PTSD). The disorder leads to significant distress and loss of functioning for those who suffer from it. Developing effective treatment for PTSD has received increased interest in the CBT field in recent years, and several protocol-based CBT approaches now exist. However, employing a treatment protocol on a specific case does not always lead to the desired change and expected progress, and a significant proportion of PTSD clients in naturalistic settings fail to respond to our CBT treatments. The central theme for this symposium is “How to progress with protocol-based PTSD treatment when change does not happen as expected?”
The speakers of this symposium present case examples undergoing different protocol-based PTSD treatments that failed to progress as expected. Various attempts to troubleshoot these cases are discussed.
Mervin Smucker Ph.D
The use of imagery interventions in cognitive therapy has been an emerging topic among theorists and clinicians in recent years. Clinicians are finding that intrusive, affect-laden images can contribute to significant distress in a variety of psychological disorders, and that using creative imagery interventions to confront and modify upsetting images can be a powerful approach that leads to alleviation of emotional distress. Research has found that emotional memory tends to be visual in nature, and conversely, mental imagery is generally more emotional than verbal processing of the same material. As such, directly challenging and modifying distressing images appears to be a powerful means of promoting emotional change. In recent years, a number of different cognitive-oriented treatments have emerged that use imagery to promote change with a range of anxiety disorders, depression, and personality disorders.
Mervin R. Smucker
Psychotherapists such as Sigmund Freud, Carl Jung, and Aaron Beck classify and categorize the kinds of deep-level narratives we use to interpret events as archetypes, complexes, or core beliefs (schemas). Freud posited the “unconscious” as the realm where such stories reside. Jung posited the “collective unconscious,” which he conceived of as broadly cultural and even cross-cultural, while Beck’s pioneering work in cognitive therapy draws on the work of earlier psychoanalytic thinkers to posit “schemas” as a form of cognition. When these schemas are maladaptive, they often predispose people to interpret events through stories shaped by deep-seated fears relating to core beliefs of abandonment, mistrust, inherent unlovability, worthlessness, incompetence, and/or vulnerability. Psychotherapy helps people to uncover their narratives and confront underlying maladaptive schemas, with the goal of developing more adaptive schemas and healthier narratives.
There is a growing body of empirical evidence that corroborate the efficacy of imagery rescripting therapy, especially in the treatment of posttraumatic stress. Increasingly, questions relating to the possible effects on the neural substrates compromised in persons with posttraumatic stress have emerged in the scientific community. Recent neuroscience research has reportedly found alterations in the neuro-humeral response, as well as in interregional brain activity (functional connectivity) and neurological development, among persons who have been exposed to significant trauma. These findings could enhance our understanding of how processing of traumatic experience may later directly impact neuroprocessing with respect to trauma memory storage and recall, affect regulation, and physiological response during trauma memory activation in individuals with posttraumatic stress.
It is conceivable that imagery rescripting, when successfully applied, redirects patterns of functional connectivity in persons with posttraumatic stress such that trauma processing, neurohumeral response and subsequent behavioral responses more closely resemble traumatized individuals who have not developed posttraumatic stress. It remains to be seen whether such phenomena can ultimately be demonstrated – such as by means of fMRI research – and whether imagery rescripting therapy can potentially lead to subsequent alterations in neural development.
Logotherapy emphasizes that human beings are themselves responsible for actualizing the potential meaning of their own lives, regardless of the external realities or circumstances. As such, the meaning of life can be discovered in one’s direct interactions with the external world, rather than within the human psyche, a process that Viktor Frankl referred to as the „self-transcendence of human existence.“ As such, the more that an individuals’ focus is directed to something or someone outside the self (e.g., a meaningful, heartfelt encounter with another person), the more one is able to transcend the limitations of individual human existence and, paradoxically, the more self-actualized they may become. In short, self-actualization is viewed as a side-effect of self-transcendence.
An effective cognitive behavioral technique for those suffering from panic attacks makes intentional use of the breath. Persons who suffer from panic attacks tend to hyperventilate (shallow, rapid breathing) when stressed, which may trigger heart palpitations that they then misinterpret in a catastrophic manner (e.g., believing they are dying, are going to pass out, are losing their mind). Engaging in a “focused breathing” exercise – slowing inhaling and exhaling through the nose (with the mouth closed!) – can help to calm the person experiencing sensations of panic. As the hyperventilation is brought under control and the breathing returns to normal, the panic episode may dissipate within several minutes. In this way, individuals prone to panic attacks learn the effectiveness of breath control, and the association between the sensations of panic and breathing.
Logotherapy was developed by Viktor Frankl, a holocaust survivor of Auschwitz and Dachau concentration camps. In contrast to psychoanalysis, which is heavily retrospective and introspective, logotherapy is a meaning-centered psychotherapy that is focused on the future and the meanings to be fulfilled by the individual in his or her future, regardless of what the past has encompassed. The term itself has its origins from the Greek word Logos, or meaning. Frankl’s Logotherapy was part of The Third Viennese School of Psychotherapy with its focus on the meaning of human existence and the individual’s search for meaning to his/her existence, and its de-emphasis on the the „vicious-circle formations and feedback mechanism which play such a great role in the development of neuroses.“ Striving to find meaning to one’s existence is thought to be the primary motivational force in humans, which according to Frankl, can contribute significantly to breaking up the self-centeredness of the neurotic.
Mervin Smucker [Summarized from Frankl, Viktor (1984). Man’s Search for Meaning: An Introduction to Logotherapy.]
A combination of prolonged exposure has sometimes been used in combination with stress inoculation training to treat adult trauma victims suffering from posttraumatic stress (Foa et. al., 1991). This combined approach involves an initial 2-hour evaluation followed by eight weekly sessions (1.5 – 2.0 hours each) that include: (1) education about the normal reactions to assault, (2) breathing training, (3) three types of relaxation training, (4) reliving the assault (imaginal exposure), (5) confronting current feared, but safe, situations (in vivo exposure), (6) cognitive restructuring regarding attributions and beliefs about the assault, (7) assertiveness training via role-play, (8) covert modeling and (9) guided self-dialogue. Following the end of each session, homework is assigned which involves instructing the patient to listen daily to the audio recording of the session and to record their subjective units of distress (SUDS) on a homework sheet, which is then brought to the next therapy for review.
Mervin Smucker, Ph.D., is an international trauma consultant and author of numerous articles and books on trauma and cognitive-behavioural therapy interventions.