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Psychological Trauma: Human Cognitions & Affects Tim Dunne Consultant / Chartered Clinical Psychologist Delivered at Webster University, Geneva February.

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Presentation on theme: "Psychological Trauma: Human Cognitions & Affects Tim Dunne Consultant / Chartered Clinical Psychologist Delivered at Webster University, Geneva February."— Presentation transcript:

1 Psychological Trauma: Human Cognitions & Affects Tim Dunne Consultant / Chartered Clinical Psychologist Delivered at Webster University, Geneva February 2008 ©

2 Outline Historical overview of Trauma Historical overview of Trauma Definition of Trauma Definition of Trauma Risk Factors for PTSD Risk Factors for PTSD Cognitions & PTSD Cognitions & PTSD Affects & PTSD Affects & PTSD Individual & Organisational factors affecting development of PTSD Individual & Organisational factors affecting development of PTSD Vicarious Trauma Vicarious Trauma Future Directions Future Directions

3 Trauma: Historical Overview Galen, father of Greek medicine, described trauma symptoms among soldiers in the Peloponnesian wars Galen, father of Greek medicine, described trauma symptoms among soldiers in the Peloponnesian wars 1862 American Civil War = “Soldier’s heart” 1862 American Civil War = “Soldier’s heart” 1891 Boer War = “Disordered action of the heart” (DAH) 1891 Boer War = “Disordered action of the heart” (DAH) WW1 = “Shell shock” WW1 = “Shell shock” WW2 = “Battle fatigue” or “Lack of moral fibre” LMF WW2 = “Battle fatigue” or “Lack of moral fibre” LMF 1950 Korean War = “Old Sergeant syndrome” 1972 “Buffalo Creek syndrome” in USA 1979 Vietnam War = PTSD 1982 Falklands/ Malvinas War = “Battleshock” 1993 = “Gulf War syndrome” 1993 ICD-10 WHO defined clinical criteria for diagnosis of PTSD

4 Trauma: Definition 2 main Definitions – 2 main Definitions – ICD-10 (1993) WHO, & DSM-IV-TR (2000, American Psychiatric Association) 6 Criteria 6 Criteria Person is exposed to traumatic event or events that involve actual or threatened death or serious injury. Response involves intense fear, helplessness or horror Person is exposed to traumatic event or events that involve actual or threatened death or serious injury. Response involves intense fear, helplessness or horror Intrusion - event is relived by the person Avoidance - stimuli associated with the event are avoided Physical - persistent physical symptoms of arousal or hypervigilance Social – disruption in social, occupational or other areas of functioning Time – above symptoms last longer than 1 month

5 Trauma “There is an interval…..of suspended animation, a kind of psychological shock or paralysis. It is caused by a traumatic or sub-traumatic experience which explodes, as it were, the world that is familiar to the person as well as his image of himself (sic) within that world.” “There is an interval…..of suspended animation, a kind of psychological shock or paralysis. It is caused by a traumatic or sub-traumatic experience which explodes, as it were, the world that is familiar to the person as well as his image of himself (sic) within that world.” Source: CIA Counter Intelligence Interrogation manual Source: CIA Counter Intelligence Interrogation manual

6 PTSD Risk Factors Not everyone is affected Not everyone is affected No two people react in the same way to the same event No two people react in the same way to the same event “One in Ten” rule is a good rule of thumb in assessing reactions to large scale events “One in Ten” rule is a good rule of thumb in assessing reactions to large scale events 1.5% of the general population suffering from PTSD at any one time 1.5% of the general population suffering from PTSD at any one time Previous life experience, life stage, mood & individual perceptions of the event all play a part in how the person responds to a traumatic event Previous life experience, life stage, mood & individual perceptions of the event all play a part in how the person responds to a traumatic event

7 High Risk Groups % Shipwreck survivors Shipwreck survivors Bombing/Terrorist survivors Bombing/Terrorist survivors Rape victims Rape victims Combat veterans Combat veterans Victims of bullying Victims of bullying Emergency Rescuers Emergency Rescuers Car crash survivors Car crash survivors General Population General Population

8 Cognitions & Trauma Cognitions refers to any conscious thought, belief, value, idea, image, attitude in the person’s mind Cognitions refers to any conscious thought, belief, value, idea, image, attitude in the person’s mind Hindsight Bias (Brewin, 2003) Hindsight Bias (Brewin, 2003) Assumptive World Views (Janoff-Bulman1989) Assumptive World Views (Janoff-Bulman1989) Key Thoughts at moment of danger Key Thoughts at moment of danger Attribution Theory (Heider,1958) Attribution Theory (Heider,1958) Heuristic Biases (Kahneman & Tversky,1974) Heuristic Biases (Kahneman & Tversky,1974)

9 Hindsight Bias (Brewin, 2003) The tendency for someone to assume, once something is known to have happened, that it could and should have been anticipated The tendency for someone to assume, once something is known to have happened, that it could and should have been anticipated So pervasive that not only onlookers but also victims often blame themselves for not acting differently So pervasive that not only onlookers but also victims often blame themselves for not acting differently HB also relates to the tendency to blame victims for their misfortunes = Maintains Psychological Distance from the trauma in other people HB also relates to the tendency to blame victims for their misfortunes = Maintains Psychological Distance from the trauma in other people Victims of trauma arouse discomfort in others by their mere presence, particularly when the victim does not make a speedy recovery Victims of trauma arouse discomfort in others by their mere presence, particularly when the victim does not make a speedy recovery Victims of trauma shatter our illusions of invulnerability Victims of trauma shatter our illusions of invulnerability

10 Assumptive World View (Janoff- Bulman, 1989) Awareness of our own mortality carries with it a potential for high levels of anxiety Awareness of our own mortality carries with it a potential for high levels of anxiety As a protection against this awareness, people hold cultural worldviews that provide explanations for existence, standards for what is valuable and a promise of immortality to those who live up to these standards As a protection against this awareness, people hold cultural worldviews that provide explanations for existence, standards for what is valuable and a promise of immortality to those who live up to these standards When confronted with reminders of our own mortality, people either exaggerate their own invulnerability or deliberately suppress thoughts of death When confronted with reminders of our own mortality, people either exaggerate their own invulnerability or deliberately suppress thoughts of death When reminders of death become more salient, people undergo subtle changes of which they may be unaware such as increased liking for those who hold similar worldviews and hostility towards those with alternative worldviews When reminders of death become more salient, people undergo subtle changes of which they may be unaware such as increased liking for those who hold similar worldviews and hostility towards those with alternative worldviews

11 Assumptive World View (Janoff- Bulman, 1989) In the presence of victims, people feel ill at ease In the presence of victims, people feel ill at ease Even people who are actively trying to support trauma victims are prone to switch the topic of conversation to something more neutral, press their own perspective on the victim or avoid them altogether Even people who are actively trying to support trauma victims are prone to switch the topic of conversation to something more neutral, press their own perspective on the victim or avoid them altogether Fundamental human difficulty in comprehending and acknowledging our own vulnerability Fundamental human difficulty in comprehending and acknowledging our own vulnerability Historically, the influence of psychoanalytic theories that were rooted in internal fantasies rather than external realities, have, paradoxically, supported these attitudes to victims Historically, the influence of psychoanalytic theories that were rooted in internal fantasies rather than external realities, have, paradoxically, supported these attitudes to victims

12 Assumptive World View (Janoff- Bulman, 1989) The World is Benevolent – positive events are believed to happen frequently & negative events are thought to be rare & people are viewed as generally good The World is Benevolent – positive events are believed to happen frequently & negative events are thought to be rare & people are viewed as generally good The World is Meaningful – Events make sense and bad outcomes are believed to be justly distributed The World is Meaningful – Events make sense and bad outcomes are believed to be justly distributed The Self is Worthy – If we see ourselves as good, we assume we are protected from negative events. After all, if one is good, then only good things should happen! The Self is Worthy – If we see ourselves as good, we assume we are protected from negative events. After all, if one is good, then only good things should happen!

13 Key Cognitions Thoughts which the person has at the moment of danger have been demonstrated to play an important role in the genesis of PTSD Thoughts which the person has at the moment of danger have been demonstrated to play an important role in the genesis of PTSD Thoughts such as “I’m going to die”, “I won’t make it”, “I’ll never see my children again” or “I’m tumbling into the next life” Thoughts such as “I’m going to die”, “I won’t make it”, “I’ll never see my children again” or “I’m tumbling into the next life”

14 Attribution Theory (Heider, 1989) AT seeks to understand how people explain to themselves how events in the world happen AT seeks to understand how people explain to themselves how events in the world happen People use ad hoc biases, categorization processes and other moderating influences to explain, or explain away, events People use ad hoc biases, categorization processes and other moderating influences to explain, or explain away, events 6 Attribution Errors 6 Attribution Errors

15 Attribution Theory (Heider, 1989) Fundamental Attribution Error – Observers underestimate the importance of situation factors and overestimate that of dispositional factors. In other words, people are seen as causes too often and situations are seen as causes too rarely Fundamental Attribution Error – Observers underestimate the importance of situation factors and overestimate that of dispositional factors. In other words, people are seen as causes too often and situations are seen as causes too rarely This locates the problem within the individual and relieves the rest of us and organizations etc of any responsibility for the event This locates the problem within the individual and relieves the rest of us and organizations etc of any responsibility for the event EG= widespread use of medication in psychiatry even though there may be little evidence for its effectiveness in specific situations or conditions EG= widespread use of medication in psychiatry even though there may be little evidence for its effectiveness in specific situations or conditions

16 Attribution Theory (Heider, 1989) Actor/Observer Divergence – People attribute their own actions to the situation but attribute the same actions by someone else to that person’s disposition Actor/Observer Divergence – People attribute their own actions to the situation but attribute the same actions by someone else to that person’s disposition Let ourselves off the hook with this attribution really & blame the other person who might do the same thing as ourselves Let ourselves off the hook with this attribution really & blame the other person who might do the same thing as ourselves

17 Attribution Theory (Heider, 1989) Hedonic Relevance – We see actions which have more affective consequences for ourselves as being more dispositional than other actions Hedonic Relevance – We see actions which have more affective consequences for ourselves as being more dispositional than other actions (EG) – car rolling down a hill when the owner forgot to put the handbrake on. If it crashes into my car, I will tend to see this as deliberately caused. If its not my car which is struck, then it is just an “accident” (EG) – car rolling down a hill when the owner forgot to put the handbrake on. If it crashes into my car, I will tend to see this as deliberately caused. If its not my car which is struck, then it is just an “accident”

18 Attribution Theory (Heider, 1989) People are perceived as more responsible for acts with serious consequences as opposed to actions with trivial consequences People are perceived as more responsible for acts with serious consequences as opposed to actions with trivial consequences Attributions follow affective relationships –thus “good” actions by liked people are attributed to the person and “bad” actions by liked people to the situation. “Good” actions by disliked people are attributed to the situation and “bad” actions by disliked people are attributed to the person Attributions follow affective relationships –thus “good” actions by liked people are attributed to the person and “bad” actions by liked people to the situation. “Good” actions by disliked people are attributed to the situation and “bad” actions by disliked people are attributed to the person

19 Heuristic Biases (Kahneman & Tversky, 1974) Judgement under Uncertainty Judgement under Uncertainty People pay little attention to base rate probability (ie) airplane crashes People pay little attention to base rate probability (ie) airplane crashes People tend to end their search for a causal explanation of events at the first reason which provides a plausible explanation (eg) power of labels such as mental illness or “satisficing” in orgs People tend to end their search for a causal explanation of events at the first reason which provides a plausible explanation (eg) power of labels such as mental illness or “satisficing” in orgs Data which conflicts with my worldview is likely to be discredited while supporting data is unquestioningly accepted (eg) effects of environmental tobacco smoke Data which conflicts with my worldview is likely to be discredited while supporting data is unquestioningly accepted (eg) effects of environmental tobacco smoke Ref: Enstrom,J & Kabat, G (2003) “Environmental Tobacco smoke and tobacco related mortality in a prospective study of Californians ”, The Lancet, bmjjournals.com Ref: Enstrom,J & Kabat, G (2003) “Environmental Tobacco smoke and tobacco related mortality in a prospective study of Californians ”, The Lancet, bmjjournals.com

20 Hierarchy of Negative Cognitions/Beliefs in PTSD Responsibility - “It was my fault, I should have done something” – victims of CSA often present with this NC Responsibility - “It was my fault, I should have done something” – victims of CSA often present with this NC Safety - “I am in danger/ I cannot protect myself/ I cannot trust my judgement/ I can’t trust anyone” – resulting in hypervigilance and often following Rape/RTA/ War Safety - “I am in danger/ I cannot protect myself/ I cannot trust my judgement/ I can’t trust anyone” – resulting in hypervigilance and often following Rape/RTA/ War Choice & Control – “I’m powerless”/ “I’m not in control” Choice & Control – “I’m powerless”/ “I’m not in control” Self-Defectiveness – “I am a failure/ I am permanently damaged / I’m a bad person /I’m a disappointment / I am shameful/ I’m good enough” Self-Defectiveness – “I am a failure/ I am permanently damaged / I’m a bad person /I’m a disappointment / I am shameful/ I’m good enough”

21 Affects & PTSD Strong emotions/feelings experienced by people with PTSD Strong emotions/feelings experienced by people with PTSD Strong physical sensations (eg) heart rate can predict PTSD Strong physical sensations (eg) heart rate can predict PTSD Strong sensory elements associated with PTSD (eg) intrusive images of the event or flashbacks, auditory sensations such as ambulance sirens, smell of petrol/burning fuel Strong sensory elements associated with PTSD (eg) intrusive images of the event or flashbacks, auditory sensations such as ambulance sirens, smell of petrol/burning fuel “Emotional” Brain centrally activated in PTSD (eg) Limbic system, Amygdala, HAP system (Hypothalamus, Adrenal & Pituitary) “Emotional” Brain centrally activated in PTSD (eg) Limbic system, Amygdala, HAP system (Hypothalamus, Adrenal & Pituitary) Right Hemisphere of Brain foremost in PTSD Alan Schore (2007) & Van der Kolk (2007) both maintain that “mobilization for action” is an automated response to threat in humans and all animals (eg) flight/fight response Left hemisphere involved in executive functions, attention, working memory, self-observation, reflection, morals & values, reason High Arousal impairs Pre-Frontal Cortex Functions

22 Affects & PTSD Neuromodulators such as catecholamines are released into the CNS and Peripheral NS Neuromodulators such as catecholamines are released into the CNS and Peripheral NS These chemicals “turn on” heart and muscles and “turn off” stomach These chemicals “turn on” heart and muscles and “turn off” stomach In the Brain, these chemicals “turn off” the pre-frontal cortex – we cannot deliberately direct our attention, hold values or goals in mind, think logically, or imagine alternatives In the Brain, these chemicals “turn off” the pre-frontal cortex – we cannot deliberately direct our attention, hold values or goals in mind, think logically, or imagine alternatives “Primitive” sub-cortical structures control behaviour and implement “hard wired” responses “Primitive” sub-cortical structures control behaviour and implement “hard wired” responses Evolutionary origins = “Stop to think and you're lunch” Evolutionary origins = “Stop to think and you're lunch”

23 Affects & PTSD The result is that traumatic, angry experiences are “burned in” – this is why the bad experiences from our childhood are often more vivid than the good experiences about growing up The result is that traumatic, angry experiences are “burned in” – this is why the bad experiences from our childhood are often more vivid than the good experiences about growing up Defensive responses inconsistent with our values and ideal self are reinforced (eg) irritability and anger Defensive responses inconsistent with our values and ideal self are reinforced (eg) irritability and anger Feelings of Regret, Shame, Guilt, fervent resolutions about the “next time” all have little effect on the Brain’s conditioning, including vulnerability to losing executive functions in similar situations in the future Feelings of Regret, Shame, Guilt, fervent resolutions about the “next time” all have little effect on the Brain’s conditioning, including vulnerability to losing executive functions in similar situations in the future “Primacy of Affect” – Alan Schore (2007) – “the locus of the emotional brain represents the biological substrata of the Unconscious as described by Freud” “Primacy of Affect” – Alan Schore (2007) – “the locus of the emotional brain represents the biological substrata of the Unconscious as described by Freud” “The Body keeps the Score” – van der Kolk (2007) “The Body keeps the Score” – van der Kolk (2007)

24 Affects & PTSD RH = location of “corporeal self” and is centrally involved in bodily-based emotional processes, empathy, processing of non- conscious self images, threat detection, regulation of endocrinological and physiological functions, the human stress response and survival RH = location of “corporeal self” and is centrally involved in bodily-based emotional processes, empathy, processing of non- conscious self images, threat detection, regulation of endocrinological and physiological functions, the human stress response and survival Emotions represent reactions to fundamental relational meanings that have adaptive significance (Lazarus, 1991) Emotions represent reactions to fundamental relational meanings that have adaptive significance (Lazarus, 1991) From an evolutionary perspective, emotions function to signal safety or imminent danger & motivate the person for either approach or avoidance behaviour From an evolutionary perspective, emotions function to signal safety or imminent danger & motivate the person for either approach or avoidance behaviour Affect amplifies and extends the duration and impact of whatever activates it Affect amplifies and extends the duration and impact of whatever activates it

25 Affects & PTSD In summary, emotions are dominant in trauma reactions, not reason In summary, emotions are dominant in trauma reactions, not reason RH is dominant in all forms of affect stimulation RH is dominant in all forms of affect stimulation Historically, psychotherapy has relied on LH, verbal, rational executive Brain Historically, psychotherapy has relied on LH, verbal, rational executive Brain Psychotherapy is not the “talking cure” anymore but the “affect regulating cure” Psychotherapy is not the “talking cure” anymore but the “affect regulating cure” All therapies of whatever school, are now beginning to focus on affect regulation as the primary goal of psychotherapy in treating PTSD All therapies of whatever school, are now beginning to focus on affect regulation as the primary goal of psychotherapy in treating PTSD

26 Individual Factors in PTSD Individual factors – Individual factors – Life Stage Development of the person at time of Trauma Life Stage Development of the person at time of Trauma 3 key phases – Early Adulthood ( yrs “Who will I be?”), Mid-Life ( yrs “Who am I?”), Late Adulthood (60+ “Who was I?”) 3 key phases – Early Adulthood ( yrs “Who will I be?”), Mid-Life ( yrs “Who am I?”), Late Adulthood (60+ “Who was I?”) At each Life phase, individual is particularly vulnerable to stress/trauma At each Life phase, individual is particularly vulnerable to stress/trauma

27 Individual Factors in PTSD Previous exposure to trauma experiences over the life cycle (eg) CSA, RTA, Assault, Losses, Neglect/ Abandonment Previous exposure to trauma experiences over the life cycle (eg) CSA, RTA, Assault, Losses, Neglect/ Abandonment Witnessing trauma to others Witnessing trauma to others Personality – introverted personality appears to be more vulnerable to PSD. “Hardy” personality less so Personality – introverted personality appears to be more vulnerable to PSD. “Hardy” personality less so Cumulative effects of prolonged exposure to stressful and traumatic experiences (eg) police/rescue workers Cumulative effects of prolonged exposure to stressful and traumatic experiences (eg) police/rescue workers “Emotional Intelligence” – those with good EI are thought to be more resilient to developing trauma reactions “Emotional Intelligence” – those with good EI are thought to be more resilient to developing trauma reactions

28 Organizational Factors & PTSD Orgl Culture – macho culture, bullying style of Mgt/ Peers, Long working day, Lack of supportive atmosphere, Crisis & Fire Fighting as normal working day, Tyranny of the Urgent V the Important in work, Excess of Critical Incidents at work, Micromanagement from Senior figures Orgl Culture – macho culture, bullying style of Mgt/ Peers, Long working day, Lack of supportive atmosphere, Crisis & Fire Fighting as normal working day, Tyranny of the Urgent V the Important in work, Excess of Critical Incidents at work, Micromanagement from Senior figures Orgl “Defensive Routines” (eg) Denial of problems, Reactions to Whistleblowers, Orgl “Defensive Routines” (eg) Denial of problems, Reactions to Whistleblowers, Persecutory Leadership/Mgt style Persecutory Leadership/Mgt style Emotions are “contagious” hence importance of social processes in development of anxiety Emotions are “contagious” hence importance of social processes in development of anxiety Management V Leadership Management V Leadership Breaking of the “Psychological Contract” Breaking of the “Psychological Contract”

29 Secondary Trauma Recently recognized phenomena among workers exposed to others’ trauma (eg) therapists/lawyers/aid workers Recently recognized phenomena among workers exposed to others’ trauma (eg) therapists/lawyers/aid workers These professionals can experience range of symptoms secondary to their exposure to clients’ trauma These professionals can experience range of symptoms secondary to their exposure to clients’ trauma Historically, seen as “burn-out” or “counter- transference” Historically, seen as “burn-out” or “counter- transference” ST provides more complex and sophisticated explanation of professionals’ reactions ST provides more complex and sophisticated explanation of professionals’ reactions

30 Secondary Trauma ST can involve profound changes in the profl’s self including: ST can involve profound changes in the profl’s self including: Disruptions in cognitive schemas Disruptions in cognitive schemas Memory functioning Memory functioning Team working Team working Interpersonal relationships Interpersonal relationships Concerns for safety Concerns for safety Intrusive images Intrusive images

31 Secondary Trauma ST is hypothesized to be rooted in the profls’ “empathic engagement” with the client’s traumatic story ST is hypothesized to be rooted in the profls’ “empathic engagement” with the client’s traumatic story Therapist treating torture victims Therapist treating torture victims Lawyer listening to client’s story of rape Lawyer listening to client’s story of rape Aid worker interviewing refugees Aid worker interviewing refugees

32 Similarities between Burn-out & ST Both involve physical reactions (eg) digestive problems, headaches, increased heart rate Both involve physical reactions (eg) digestive problems, headaches, increased heart rate Both involve emotional reactions (eg) anxiety, withdrawal, feelings of helplessness or hopelessness Both involve emotional reactions (eg) anxiety, withdrawal, feelings of helplessness or hopelessness Both involve behavioural reactions (eg) sleep disturbance, increased use of drugs or alcohol Both involve behavioural reactions (eg) sleep disturbance, increased use of drugs or alcohol Both involve work related issues (eg) team working difficulties, conflicts Both involve work related issues (eg) team working difficulties, conflicts Both involve interpersonal relations (eg) arguments, irritability with others Both involve interpersonal relations (eg) arguments, irritability with others Both can result in decreased concern for clients/org and lead to decline in performance at work Both can result in decreased concern for clients/org and lead to decline in performance at work

33 Differences between Burn-out & ST Burn-out more associated with stress in the workplace in general Burn-out more associated with stress in the workplace in general Burn-out can happen in any workplace Burn-out can happen in any workplace Burn-out relates to feelings of overload secondary to work related issues & complexity Burn-out relates to feelings of overload secondary to work related issues & complexity Burn-out progresses gradually as a result of emotional exhaustion Burn-out progresses gradually as a result of emotional exhaustion Burn-out does not result in similar feelings as ST Burn-out does not result in similar feelings as ST ST = traumatic reaction to specific client presented information ST only occurs in those who work with trauma survivors ST related to specific client trauma experiences ST often has sudden onset of symptoms not detectable at an early stage At personal level, ST leads to feelings of hypervigilance, trust issues, feelings of being out of control, intimacy issues, esteem needs, safety concerns and intrusive imagery

34 Conclusion & Future Directions “The Body never lies” – van der Kolk (2007) “The Body never lies” – van der Kolk (2007) Psychotherapy for PTSD will become more Body focused & oriented because that is where the trauma is remembered and felt Psychotherapy for PTSD will become more Body focused & oriented because that is where the trauma is remembered and felt Treatments with major focus on the Body likely to become the “treatment of choice” in PTSD such as EMDR (Shapiro, 1989) & possibly Sensory- Motor therapy (Ogden, 2006) Treatments with major focus on the Body likely to become the “treatment of choice” in PTSD such as EMDR (Shapiro, 1989) & possibly Sensory- Motor therapy (Ogden, 2006) More growth experiences from PTSD recorded & researched More growth experiences from PTSD recorded & researched Affect Regulation likely to become the goal of Psychotherapy treatment in PTSD and related disorders such as Anxiety/ Panic/ Phobic Disorders Affect Regulation likely to become the goal of Psychotherapy treatment in PTSD and related disorders such as Anxiety/ Panic/ Phobic Disorders EMDR = well validated in the literature. Already accepted as the “treatment of choice” by Govt bodies in USA, NICE (UK), France, Sweden, Holland Positive Psychology (Seligman, 2000 address to APA) likely to be major influence (eg) “Broaden & Build” approach of Frederickson (2003) Macro-environment likely to be more competitive following disasters (ie) for- profit orgs such as Bechtel & Blackwater now in the market for provision of relief & reconstruction following disasters

35 References “Post Traumatic Stress Disorder – Malady or Myth?” Chris Brewin (2003) London: Yale UP “Post Traumatic Stress Disorder – Malady or Myth?” Chris Brewin (2003) London: Yale UP “A Guide to Psychological Debriefing: Managing Emotional Decompression & PTSD” David Kinchin (2007) London: Jessica Kingsley Pubs “A Guide to Psychological Debriefing: Managing Emotional Decompression & PTSD” David Kinchin (2007) London: Jessica Kingsley Pubs “A Randomized Clinical Trial of EMDR, Fluoxetine and Pill Placebo in the treatment of PTSD: Treatment Effects and Long Term Maintenance” (2007) van der Kolk, B. et al., Journal of Clinical Psychiatry, Vol. 68, No.1, pp “A Randomized Clinical Trial of EMDR, Fluoxetine and Pill Placebo in the treatment of PTSD: Treatment Effects and Long Term Maintenance” (2007) van der Kolk, B. et al., Journal of Clinical Psychiatry, Vol. 68, No.1, pp “The Shock Doctrine: The Rise of Disaster Capitalism” Naomi Klein (2007) London: Penguin books “The Shock Doctrine: The Rise of Disaster Capitalism” Naomi Klein (2007) London: Penguin books


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