Post Traumatic
Stress Disorder
Jenn Andrus
Psychotherapy Interventions II
Appalachian State University
Overview
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History/Background
Prevalence
Diagnosis
Course/Comorbitidy/Associated Features
Assessment
Treatment
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Choosing Treatment
Special Populations
Overview of Various Approaches
CBT
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Exposure
Vicarious PTSD: The importance of Self-Care
Some History/Background

Fairly “new” disorder

In 1980, DSM-III delineated distinct criteria for
the diagnosis of PTSD
– “The person has experienced an event that is outside
the range of usual human experience and that would be
markedly distressing to almost anyone”.

The diagnosis of Acute Stress Disroder (ASD) was
added to DSM-IV in 1995
(APA, 2004)
Some History/Background Cont’d


Empirical research on the efficacy of
treatments for ASD and PTSD is not as
extensive as for other DSM Disorders
Consider issues with longitudinal studies
and prevalence data
– Before
– Now
– Later
(Solomon, Z., Horesh, D. 2007 )
Theoretical Models
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Classical Conditioning
Operant Conditioning: Avoidance
Learning: doesn't explain intrusion
Social Cognitive Theory: information, belief,
adjustment
Emotional Processing Theory*
– By? Guess who!?!?
– The “fear structure”
– Everybody has it

Is yours bigger than mine?
– “advanced cognitive model”
(Barlow, 2000)
Diagnosis Today
No longer “outside the range”
 Wide range of “causes”
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Combat
Violent crime
Accidents
Abuse
Disaster
Terror
Much more common then was thought
then..
Prevalence

The NCS report concluded that
– “PTSD is a highly prevalent lifetime disorder that often persists for
years. The qualifying events for PTSD are also common, with many
respondents reporting the occurrence of quite a few such events
during their lifetimes.”

National Comorbidity Survey
– Estimated lifetime prevalence=7.8%

Up to 12% (Foa et al, 2000)
– Women=10.4%
– Men= 5 %
– 60.7% of men and 51.2 % of women reported at least one traumatic
event.
– 10%+ men and 6 % + of women reported FOUR or more types of
trauma during their lifetimes.

The lifetime prevalence of ASD is unclear
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Prevalence for children unclear
(APA, 2004; Kessler et al., 1995)
Prevalence Cont’d
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The prevalence of both disorders is considerably higher among:
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patients who seek general medical care
persons exposed to sexual assault
mass casualties such as those occurring in wars or natural disasters
presence of underlying vulnerabilities such as adverse childhood
experiences or comorbid diagnoses
Risk Factors
– Trauma type and comorbidity

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Women; Anxiety and depression,
Men irritability, impulsiveness, substance abuse
– ASD and/or symptom severity
– Gender differences
– African Americans and Hispanic war vets
Prevalence Cont’d
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The most frequently experienced traumas
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witnessing someone being badly injured or killed
being involved in a fire, flood or natural disaster
being involved in a life-threatening accident
combat exposure
Traumatic events most often associated with PTSD
– Men

rape, combat exposure, childhood neglect and childhood physical
abuse
– Women

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rape, sexual molestation, physical attack, being threatened with a
weapon and childhood physical abuse
Rape victims likely constitute the largest number of PTSD
sufferers (Rothbaum et al., 2005)
Prevalence in Veterans

Lifetime prevalence of PTSD among American Vietnam
theater veterans
– 30.9% men
– 26.9% women.
– 22.5% men and 21.2% of women have had partial PTSD at
some point in their lives.
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More than half of all male Vietnam veterans and almost half
of all female Vietnam veterans, have experienced “clinically
serious stress reaction symptoms.”
Gulf War vets: 10.1% for PTS among those who had
experienced combat
Unclear if prevalence of PTSD among those returning from
Operation Iraqi Freedom or Operation Enduring Freedom
will increase or decrease
Freidman, 2004
So Who Gets PTSD?
“When we were children, we used to think that when we were grown up we would no longer be
vulnerable. But to grow up is to accept vulnerability.. to be alive is to be vulnerable”.
Madeleine L’Engle.

50% to 90% of the population may be exposed to traumatic events during their lifetime
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most exposed individuals do not develop ASD or PTSD.
Only about 25% (Foa et al., 2000).
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Exposure alone does not account for the relationship between distress and a traumatic event.
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Vulnerability “the force with which trauma impacts on the distress of the individual”
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Consider professions that “expose” to trauma” : Law, fire, EMT, Health professions
–
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“the police socialization process molds him/her into a myth of indestructibility. The effect of trauma on this myth
is devastating”
Consider risk factors/prevalence rates
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Those with high levels of symptoms early on, including those with ASD, are at risk of subsequent PTSD
–
Some patients with ASD do not develop PTSD
–
Proportion of patients develop PTSD without first having met the criteria for ASD
(Violanti, & Paton, 2006)
Diagnosis
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In 1980, DSM-III delineated distinct criteria for the
diagnosis of PTSD.
The diagnosis of ASD was added to DSM-IV in 1995 to
distinguish individuals with PTSD like symptoms that lasted
less than 1 month from persons who experienced milder or
more transient difficulties following a stressor.
DSM-IV-TR Diagnostic Criteria for Acute Stress Disorder
(DSM-IV-TR code 308.3)
– Essentially PTSD diagnostic criteria

G. The disturbance lasts for a minimum of 2 days and a maximum
of 4 weeks and occurs within 4 weeks of the traumatic event.
DSM-IV-TR Diagnostic Criteria for
Posttraumatic Stress Disorder
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A. Exposed to a traumatic event in which both of the following were present:
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B. Persistent reexperience in one (or more) of the following ways:
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experienced, witnessed, or was confronted with an event or events that involved actual or
threatened death or serious injury, or a threat to the physical integrity of self or others
response involved intense fear, helplessness, or horror. Note: In children, this may be
expressed instead by disorganized or agitated behavior
Recollections: images, thoughts, or perceptions. Note: In young children, repetitive play may
occur in which themes or aspects of the trauma are expressed.
Dreams Note: In children, there may be frightening dreams without recognizable content
Acting or feelings of “reoccurance” (sense of reliving the experience, illusions, hallucinations,
dissociative flashback episodes, including when intoxicated). Note: In young children,
trauma-specific reenactment may occur.
Psychological distress at exposure to internal or external cues
Physiological reactivity on exposure to internal or external cues
C. Avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma), as indicated by three (or more) of
the following:
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efforts to avoid thoughts, feelings, or conversations associated
efforts to avoid activities, places, or people that arouse recollections
inability to recall an important aspect of the trauma
markedly diminished interest or participation in significant activities
feeling of detachment or estrangement from others
restricted range of affect (e.g., unable to have loving feelings)
sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or
a normal life span)
DSM-PTSD CON’T
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D. Persistent symptoms of increased arousal (not present before the
trauma), as indicated by two (or more) of the following:
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difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
Hypervigilance
exaggerated startle response
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E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more
than 1 month.
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F. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

Specify if:
– Acute: if duration of symptoms is less than 3 months
– Chronic: if duration of symptoms is 3 months or more

Specify if:
– With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.
Some Help?
 “DREAMS”
(Lange, 2000):
– Detachment
– Reexperiencing the event
– Event had emotional effects
– Avoidance
– Month in duration (symptoms for >1
month)
– Sympathetic hyperactivity or
Hypervigilance
“The Triad”
 Three
primary symptom clusters
– Re-experience
– Avoidance
– Arousal
Associated Features
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Associated Features
– Guilt
– Interpersonal Problems
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Interpersonal Constellation
– Those exposed to a trauma with an interpersonal element (i.e abuse),
often evidence additional symptoms.
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Impaired affect modulation
Self-destructive and impulsive behavior
Dissociative Symptoms
Somatic Complaints
Feelings of: ineffectiveness, shame, despair, hoplessness, "permanently
damaged", constant "threat"
Loss of beliefs
Hostility
Social Withdrawal
Social impairment
Personality Change

APA, 2000
Comorbidity
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Associated with increased rates
– affective disorders (MDD, Bipolar Dx)
– anxiety disorders (panic, agoraphobia, OCD, Social, Specific, GAD)
– substance abuse

They may precede, follow or emerge concurrently with PTSD

NCS indicates that at least one additional psychiatric disorder is present in
88.3% of men and 79.0% of women who have a history of PTSD.

59 % of men and 44 % of women who have PTSD meet the criteria for
three or more psychiatric diagnoses.
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Women who have PTSD are 4.1x as likely to develop a major depression
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Women 4.5x as likely to develop mania as women who do not have PTSD.
Comorbidity Cont’d
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Men who have PTSD are 6.9x as likely to develop depression
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Men are 10.4x as likely to develop mania as men
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50%+ men with PTSD also have a comorbid alcohol problem

Significant portion of men and women who have PTSD have a
comorbid illicit-substance use problem.

Phobias tend to be more prevalent than GAD or panic disorder
– the risk of almost all anxiety disorders is high

Rate of attempted suicide in patients who have PTSD is estimated
at 20%
Assessment

Critical in developing appropriate treatment plan

First step in establishing rapport

Consider issues such as
– Culture
– Type of Trauma

Need? I.e. forensic, research

How to approach?
– Video: Dr. Eve Carlson, NCPTSD, Therapeutic Assessment
– Notes please
Assessment Cont’d
MCMI-III, MMPI, Rorschach
The Children's Impact of Traumatic Event Scale – Revised
The Impact of Event Scale
The Impact of Event Scale - Revised
The PTSD Checklist - Civilian Version
The PTSD Checklist - Military Version
The Clinician Administered PTSD Scale for DSM-IV
The Mississippi Scale for Civilian PTSD
The Posttraumatic Stress Diagnostic Scale
The Trauma Symptom Inventory
The Trauma Symptom Checklist for Children
Victims' Web: Assessment Devices
Treatment

APA video (2005)
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Interview
Laura Brown, PhD
“Feminist” approach
Good casual overview, created for training
purposes
During the video, please take a few notes
– Any questions, concerns, ideas?
Choosing a Treatment
 Trauma
treatment research field is
still young, and further difficult to
conduct in some cases
 Comparisons
of different treatments
for PTSD are scarce
– lack of empirical evidence in the
literature does not necessarily signify a
lack of treatment efficacy
Choosing a treatment cont’d
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Type and impact of trauma
Unique client life challenges
Side effects and potential negative effects
Cost
Length of treatment
Cultural appropriateness
Therapist's resources and skills
Client's resources and stressors
Comorbidity of other psychiatric symptoms
Legal, administrative, and forensic concerns
Choosing a Treatment cont’d

All treatments approaches essentially have
the same goal
– Decondition anxiety
– Re-establish feeling of integrity and/or control

Some great resources to refer to!
– Expert Guidelines “The Consensus”
– ITSS
– Anything from Foa!
Treatments for PTSD
 CBT
is most effective!
(Foa, Freidman, & Keane, 2000)
– We will focus on it more later
 Again
consider all factors
– CBT still stronger it appears
 Variants
depending on type of
trauma and/or client
– No one said this was going to be easy
Special Populations
 Remember
to consider
– Type of trauma
– Setting
– Client
Children and Adolescents
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Have generally same symptoms as adults
Additional symptoms and difficulties
– Separation anxiety
– Regression (enuresis, “clingy”, temper)
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Increased risk for comorbidity
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Adolescents at risk for substance abuse,
depression, promiscuity
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Treatment similar to adults
Lauterbachm, & Reiland, 2007
Children Cont’d
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CBT most supported
– will look at one aspect later
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Medication has weak support

Consider “creative” approaches
– more to come
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Consider: age, intelligence, family & social
support, and coping skills
Childhood Sexual Assault Survivors
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Prevalence is 15-33 %
–
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Up to 44% in females seeking treatment
Not all survivors can tolerate exposure based CBT
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Many special considerations
More to come
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High rates of concurrent Substance Abuse
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Gender and Sexuality Issues
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Interpersonal Difficulties
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Therapist Gender
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Revicitmization and Multiple Assaults
(Richard & Lauterbach, 2007)
Multiple Trauma Survivors
 Most
research on single trauma
survivors
 May
need more time
 Later
will look at Narrative Exposure
Therapy for this population
Cross Cultural Treatment
Minority Americans
 Foreign refugee
 Asylum seekers
 Consider
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Language
Culture
Integration of physical and mental
Access
Likely multiple trauma survivors
Wilson et al.
Disaster Situations
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Natural, Terror
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Emotional effects are direct responses to the trauma of disaster.
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Consider other, longer-term responses
– Interpersonal
– Societal
– Economic effects the disaster
Short term psychosocial interventions
– reducing distress
– improving adaptive functioning in the face of the practical and
emotional demands created by the disaster
– preventing longer-term disability
Ehrenreich (2001). Mental Health Workers Without Boarders.
Coping with Disaster
(Foa et al 2000)
Critical Incident Stress Debriefing
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Critical Incident Stress Debriefing
– aimed at forestalling the emergence of
disabling symptoms or minimizing their
enduring effect.
– Should not be used as a "one-off"
intervention or w/o coping skills training
– Inappropriate in situations in which
severe stress and danger are ongoing or
those not at risk
Immediate, group based, CBT approach
Veterans
 Likely
more to surface and to come
 Increase or decrease unclear
 VA/DOD Guidelines
(Freidman, 2004; Solomon, Z., Horesh, D., 2007)
Dual Diagnosis
 Consider
safety
 Consider primary diagnosis
 Limited research
 Some manualized treatments
– Mostly substance abuse
 Trauma
Recovery and Empowerment
Model (TREM)
 Seeking Safety
 Trauma Affect Regulation: Guide for
Education and Therapy (TARGET)
SPMI

Diagnostic Issues
– Likely under diagnosed?

Is TAU appropriate?
– Consider illness management and treatment
Research often only with women
 Not directed at PTSD
 Directed at broad diagnostic groups
 More research needed
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(Wilson et al. 2001)
Inpatients
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No satisfactory studies on inpatient
treatment for PTSD and trauma-related
conditions.
Inpatient therapy is appropriate for
– crisis intervention
– management of complex diagnostic cases,
delivery of emotionally intense therapeutic
procedures
– relapse prevention.
(Foa et al., 2000)
Various Treatments
Psychodynamic Therapy
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Focus on more fluid intra- and interpersonal
processes, not symptom reduction
The unconscious and psychological meaning
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Course of Treatment
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4-5 sessions a week
45-50 mins
2-7 years
Brief = 1-2 meeting a week for 12 sessions
A certain type of client?
Psychodynamic Therapy
Cont’d

Difficult to conduct research
– Mostly case reports

Only one randomized clinical trial of efficacy
– 10 sessions of Brief Psychodynamic Psychotherapy
– Effectively reduction of PTSD intrusion and avoidance
symptoms by approximately 40%, and improvement
was sustained for 3 months.

Has clinician support, especially for complex
trauma
– Left out of Consensus?

More research is needed to demonstrate the
techniques effectiveness with PTSD.
– But that harder then it seems?
IPT
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Developed for the treatment of Depression
Consider utility with “interpersonal
trauma”
– Interpersonal constellation
– Find new ways to understand and behave in
relationships
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IPT group treatment for women assault
survivors (Krupnick, 2001)
Social Rehabilitative Therapies
(PSR)
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Teaching social, coping, and life function skills
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Yet to be formally tested with PTSD clients.
– Usually have comorbid SPMI
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Generalizability?
– reasonable to expect that they will also work with PTSD
clients?

Improvement in self-care, family functioning,
independent living, social skills, and maintenance
of employment
Marital and Family Therapy

No research studies done on the effectiveness of
marital/family therapy in treating PTSD

Consider a trauma's unique effects on interpersonal
relatedness

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Thus, clinical wisdom indicates that spouses and families
ought to be included in the treatment of those with PTSD
– Use as adjunct
– Time-limited, problem focused
Obviously, marriage counseling is typically contraindicated
in cases of domestic violence, until the batterer has been
successfully (individually) rehabilitated
Foa, Keaen, & Freidman
Creative Therapies

No controlled evidence on creative therapies
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Art, drama, music, body-oriented therapies

May be fit to address specific somatic manifestations of
trauma (i.e., sensory defensiveness, somatic memories,
etc.).

Use with children or adults who have trouble responding to
questions or describing feelings in verbal form

Caution is recommended
– Be well trained in this modality.

Video: Standing Tall
Hypnosis


Research indicates very little improvement
in trauma symptoms
May be helpful as an adjunctive rather
than primary treatment, especially
– dissociation
– nightmares

Was left out of Clinical Consensus
Pharmacotherapy
Hyperarousal
 Comorbidity

SSRI’s*
 MAOI’s
 TCA’s
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Consider for seriously “disruptive
symptoms”
(Foa et al. 2000)
Group Therapy

Few tests of group treatments relating to PTSD
symptoms

Three studies of CBT group treatments
– Cognitive Processing Therapy, Assertion Training, Stress
Inoculation Therapy
– Women traumatized by childhood or adult sexual abuse
– All PTSD symptom clusters were reduced 30-60%
– Improvement was sustained for six months.

CBT group treatment for combat veterans
showed a 20% reduction in PTSD symptom
severity
Group Therapy Cont’d
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Study of psychodynamic group treatment found
an 18% reduction in PTSD symptoms among
women with PTSD due to childhood sexual abuse.
One controlled trial of supportive group
treatment for female sexual assault survivors
showed a 19-30% reduction in intrusion and
avoidance symptoms, which was maintained for
six months.
Consider group membership, dynamics, “type”
CBT
Cognitive-Behavioral Therapy
(CBT)
 More
published well-controlled
studies on CBT than on any other
PTSD treatment
(Cahill et al. 2006)
CBT Cont’d

CBT treatments usually involve some combination,
psychoeducation and therapeutic relationship

Other CBT treatment methods may be added to address
related problems
– anger (anger management training, assertiveness training)
– social isolation (social skills training, communication skills
training)

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Have proven very effective in producing significant
reductions in PTSD symptoms (generally 60-80%)
especially rape survivors
Magnitude and permanence of treatment effects appears
greater with CBT than with any other treatment
– Compelling evidence it works!
CB Interventions

Always begin with psychoeducation
– What is PTSD
– What is goal/rationale of treatment

Most TX’s are combos of a sort
(CB+Ex+Relaxation)
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Combining further OK
But research shows it isn’t necessarily more effective
Some CB Interventions
Stress Inoculation Training
 Cognitive Therapy
 Cognitive Processing Therapy
 Systematic Desensitization
 Exposure
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Stress-inoculation training

Meichenbaum (1974)
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Anxiety management
 Female
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Skills for managing and reducing anxiety
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assault survivors
Muscle relaxation
Diaphragmatic breathing
Covert modeling
Role playing
Anxiety management = decreases in
avoidance and anxiety
Cognitive Therapy

Beck (1976)
 Identify
their trauma-related negative
beliefs (e.g., guilt or distrust of others) and
change them to reduce distress
 Pay
attention to appraisals of safety
and danger.
CPT
 See
Barlow
– For rape only
– 12 session, structured
 CT
+ EX
– CT=challenge blame and other
cognitions
– EX=write narrative and review
 Therapist
helps get “unstuck”
(Barlow, 2000; Foa et al., 2000)
Systematic desensitization
 Wolpe
(1958)
– Exposure and relaxation
– Mostly only imaginal exposure
– Create hierarchy/SUDS
– Become proficient and relaxation
– Exposure for hierarchy
Eye Movement Desensitization
and Reprocessing (EMDR)

Francine Shapiro (1995)

Think of the trauma (images/memory)
– Imagninal exposure

Move eyes back and fourth or alternate attention back and
forth using taps or sounds

More effective than psychodynamic, relaxation, supportive,
or placebo wait list therapies

Better results in combo CBT particularly at three-month
follow-up and on (sustainability)
EMDR Cont’d

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The eye movement component adds no additional
treatment effect?!?
Consider number of memories, complexity,
training

Not in consensus

EMDR Video
Foa et al. 2000
Exposure

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Consistently proven effective in both
children and adults
– Is not accepted in clinical practice?!?
Fewer than 20% use
– even after ITSS guidelines
Use in combo with psychoeducation,
cognitive restructuring, coping skills
Lauterbachm D., & Reiland, S. 2007
Exposure Therapy

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Exposure results in habituation so trauma can be
remember without intense anxiety- ability to
think without reexperiencing
Framing therapy
– Opportunity to process/digest the trauma, organize
memories, make sense of the experience, appropriately
compartmentalize.
– Clear rationale: unrealistic/excessive fears

Introduce SUDS and create hierarchy

“Expose” to anxiety provoking cues until anxiety
decrease
Subjective Units of Disturbance
(SUDS)
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A scale of 0 to 10 for measuring the
subjective intensity of disturbance or
distress currently experienced by an
individual.
Individual self assesses where they are on
the scale.
Used as a benchmark to evaluate the
progress of treatment.
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10 = Feels unbearably bad, beside yourself, out of
control as in a nervous breakdown, overwhelmed, at
the end of your rope. You may feel so upset that you
don't want to talk because you can't imagine how
anyone could possibly understand your agitation.
9 = Feeling desperate. What most people call a 10 is
actually a 9. Feeling extremely freaked out to the point
that it almost feels unbearable and you are getting
scared of what you might do. Feeling very, very bad,
losing control of your emotions.
8 = Freaking out. The beginning of alienation.
7 = Starting to freak out, on the edge of some
definitely bad feelings. You can maintain control with
difficulty.
6 = Feeling bad to the point that you begin to think
something ought to be done about the way you feel.
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5 = Moderately upset, uncomfortable. Unpleasant
feelings are still manageable with some effort.
4 = Somewhat upset to the point that you cannot
easily ignore an unpleasant thought. You can handle
it OK but don't feel good.
3 = Mildly upset. Worried, bothered to the point that
you notice it.
2 = A little bit upset, but not noticeable unless you
took care to pay attention to your feelings and then
realize, "yes" there is something bothering me.
1 = No acute distress and feeling basically good. If
you took special effort you might feel something
unpleasant but not much.
0 = Peace, serenity, total relief. No more bad feelings
of any kind about any particular issue.
Exposure Techniques
A
lot of variation in implementation
and duration
–Imaginal: think about it
–In vivo: feared persons or situations that
are realistically safe
–In virtuo: i.e virtual reality, images
–Narrative: tell your “story”
Imaginal Exposure
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Describe and visualize, as vividly as possible, the
trauma in the present tense.
Focus on the entire trauma, including events
immediately before and after.
Keep eyes closed and proved detail.
– Level of involvement, adjust as needed


I.e. past tense, eyes open
Homework: Listen to tape of session once a day
Virtual Exposure
 Virtual
Reality
 Good findings

War Vets

WTC/911
A Protocol: Prolonged Exposure

Prolonged Exposure Protocol as Described by Foa, Dancu and Humbree
– Most comprehensively studied exposure treatment

9 bi-weekly 90 minute sessions

Four components
– education about the nature of trauma and trauma reactions
– training in controlled breathing
– Imaginal exposure to the memory of the traumatic event

Other approaches can and have been used
– Homework

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In vivo exposure to trauma reminders
Listen to tapes
(Barlow, 2000; Foa, Davidson, et al., 1999)
Narrative Exposure Therapy for
Multiply Traumatized clients
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Not uncommon for people to define themselves in trauma:
I.e. war torn regions, CSA, police, firefighters, EMT’s
ongoing assaultees
Similar to Protocol
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–
–
4 sessions, trauma focused
60-120 minutes or until distress is diminished
Detailed oral recall
Psychoeducation

Full Autobiography: Not jut trauma

Probe for sensory, emotional and cognitive elements

Point out ambiguity or inconsistency
Narrative Therapy Cont’d



Goal is to develop less fragmented narrative
Therapist transcribes
Reviewed with client
– Encouraged to make corrections and add detail

Use of translator?

Sending it out? i.e. human rights

Empirical Support: One year post treatment 80% vs 29%
Neuner et al 2004; Richard & Lauterbach
Exposure and CSA

Special Considerations
– Hyper arousal

Those who exhibit high arousal, or are reactive are not good candidates for
exposure
– Numbing/Dissociation

Those who are prone to dissociate and/or are depressed are likely unable to
experience sufficient arousal for exposure
– Intrusive Thoughts
– Affect Regulation and Resistance
– Incomplete or Suspect Narrative
Lauterbachm, & Reiland, 2007
Exposure and Children

Coping skills training
– muscle and breathing relaxation, positive imagery
training, “safe-place”

Explain SUDS

Explain rationale

Same “scripting”
– close eyes?

Ask for periodic SUDS
 Drawing
and play may facilitate
 Assessment
of imagery skill
– Rate 1-10 how clear the image is
 Difficult
imaginers?
– Bring and or use stuff that is
representative of the trauma i.e. tapes,
clothes, sounds.
Children Cont’d

Imaginal Exposure Protocol
–
–
–
–
–
–
relax
positive imagery
recall/recount
collect SUDS,
continue until decrease
close with relaxation

Consider fatigue and developmental level

Consider adjunct Family therapy (psychoeducation)
Lauterbachm, & Reiland, 2007
Vicarious Trauma
 Negative
effects of working with
those with trauma
 “Disruption of the therapists schemas
about the self and world”
 Recognize and acknowledge
 Avoid isolation
 HALT!