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

Outline  The effects of assault  The ethical responsibility of therapists  Best Practice for Treatment

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

Percentage of Victims With PTSD Assessment

 Assault: 25%  Rape: 30%  Assault involving death threat: 50% How Many Develop PTSD?

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

 Depression  Anxiety  Substance Abuse  Anger  Insomnia  Self-Harm/Emotion Dysregulation Beyond PTSD

These People are Hurting

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

 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 Our Responsibility

 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 What is 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 Why Use Best Practice?

NHMRC approved RANZCP & APS endorsed

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

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

Psychological Interventions for PTSD Imaginal exposure requires 90 minute sessions (C) 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

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

Psychological Interventions zIn 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

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

Treatment Sequencing zPTSD 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)

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

Treatment Sequencing zComplex PTSD Commence with emotion regulation skills Continue with CBT

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

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

Elements of Cognitive Behavior Therapy  Anxiety management techniques  Cognitive therapy  Prolonged exposure

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

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

Appraisals Predict PTSD  A major predictor of PTSD is maladaptive appraisals after assault

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

 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 Prolonged Imaginal Exposure

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

Does CBT Cause Harm?

NO

CBT & Side-Effects  Large-scale studies indicate that: (a)No adverse side-effects (b)No increased drop-outs (c)Better long-term gains

So Why Don’t Therapists Use CBT? (a)Clinicians afraid of coping with client’s distress (b)Clinicians not properly trained (c)Clinicians do not have enough practice to realize the benefits of CBT

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

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

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!