Doing the Best We Can For Assault Victims

Richard Bryant

University of New South Wales

Outline

The effects of assaultThe ethical responsibility of therapistsBest 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

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9 10 11 12

Pe

rce

nt

(%)

Rape Victims

Non-Sexual Assault

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)

DepressionAnxietySubstance AbuseAnger InsomniaSelf-Harm/Emotion Dysregulation

Beyond PTSD

These People are Hurting

Increased suicidePoor physical healthOccupational dysfunction Interpersonal dysfunctionComorbid 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 thereWhy should we adhere to best practice?Trauma survivors can suffer long-term effects –

critical that we give them what we know worksProviding 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)

• 8 - 12 sessions of trauma-focussed treatment is usually sufficient (D)

• More sessions where (for example):

•multiple traumatic events

•traumatic bereavement in addition to

PTSD

•significant disability and/or high

comorbidity

Psychological Interventions

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

Psychological Interventions

In EMDR, no evidence for eye movements per se: • Treatment gains are more likely to be due to:

• engagement with the traumatic memory• cognitive processing• rehearsal of coping or mastery responses

• Importance of in vivo exposure

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

PTSD and depression

• Treat PTSD first, as depression often improves with successful treatment of the PTSD (B)

• Unless depression is too severe (risk, interference) in which case address the depression before commencing PTSD treatment (GPP)

Treatment Sequencing

PTSD and substance use

• Treat both simultaneously (C)

• Do not commence trauma-focussed therapy until substance use under control (D)

Treatment Sequencing

Complex 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/hyperarousalTypically involves breathing retrainingMuscle 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 criminalWe 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!

www.traumaticstressclinic.com.au

www.acpmh.unimelb.edu.au