Townsville Psychologist

Counselling Apps

Technology is a part of our lives and a useful tool in helping us through everyday activities. Self-care, relaxation and mindfulness are no exception to this. A growing part of my practice is the inclusion of mindfulness and relaxation activities.  In the 2017 Royal Australian College of General Practitioners (RACGP) Health of the nation report, Mental health was cited as a top-three issue by 65% of female GPs and 53% of male GPs.  These concerns were predominantly depression, mood disorders and anxiety. Self-care and relaxation exercises are pivotal to assisting people in lowering their overall stress responses and assist in the therapeutic process.

Easy to use applications that are freely available such as smiling mind (https://www.smilingmind.com.au/) , headspace (https://www.headspace.com/), What’s Up (https://au.reachout.com/tools-and-apps/whats-up)  or Mindshift (https://www.anxietybc.com/resources/mindshift-app) are great companions to therapy and assist anybody in maintaining a mindful or relaxation routine.

My current app of choice, however, is a paid app called Calm (https://www.calm.com/). This app has many great features, easy to use and assists with relaxation, mindfulness, sleep, anxiety, depression and stress. Calm also offers master classes in areas of anxiety, depression and other ever-changing topics. For therapist or patient alike this is a useful app that I would recommend to anybody.

Referral

RACGP., (2017). General Practice: Health of the Nation, https://www.racgp.org.au/yourracgp/news/media-releases/mental-health-issues-the-main-reason-australians-see-their-gp-(1)/

Psychologist Misconduct

Psychologist Misconduct

According to a recent study by Kremer, Symmons & Furlonger (2018) between the period of 2008-2013, 42 Psychologists were found guilty of misconduct and malpractice in civil and administrative courts across Australia. Of the offenders 25 were male and 17 female. Transgressions included;

  • Boundary Violation
  • Profesisonal – Incompetence
  • Professional – Poor Communication
  • Poor Business practices
  • False use of Dr/Professor or specialist title
  • Professional – Poor reports
  • Misleading registration claim
  • Impairment (mental illness, addiction)

Kremer, Symmons & Furlonger (2018) found the most common category of transgression resulting in a court‐based guilty verdict for psychologists relates to inappropriate sexual liaisons, followed by professional incompetency, and then poor communication in the provision of services. Reasons for transgressions coalesced into three themes: the externalisation of responsibility for personal actions and behaviours, a lack of objectivity concerning why such behaviours occurred, and an inability to understand how personal circumstance affected the provision of ethical services to clients.

Glass in 2003 developed the guidelines around gray areas of boundary crossings and violations. Glass demonstrated his concept in a Venn diagram below;

Boundary Cross.jpg

 

Undertaking psychotherapy is a personal journey and trust is of the utmost importance to form a therapeutic bond. In this process boundaries can sometimes be crossed, however, it is important to understand that these crossings whilst seemingly harmless can be the start of a slippery slope and regular supervision, client check-ins and objective reasoning is important safeguards against the possibilities of transgressions.  

Reference

Glass, L. L. (2003). The gray areas of boundary crossings and violations. American Journal of Psychotherapy, 57(4), 429-44. Retrieved from https://search.proquest.com/docview/213131708?accountid=166958

Kremer, Paul & Symmons, Mark & Furlonger, Brett. (2018). Exploring the Why of Psychologist Misconduct and Malpractice: A Thematic Analysis of Court Decision Documents: Exploring the why of misconduct. Australian Psychologist. 10.1111/ap.12343.

Hotdesking

Activity Based Work or Hotdesking is a shared office approach in which individuals do not have assigned work stations. Rather the office is designed to accommodate all employees on an as needs basis including IT access, meetings, networking etc. Immediately it is clear that the greatest benefit of such a design is that it maximises office space in that you can fit more employees into an a single area. This works by having an employee who is at their desk for 40% of the day and out of the office for 60% of the day. If we have 2 employees that meet this criteria then instead of 2 desks hypothetically they could work from 1. Less space per employee means less overheads and greater savings for the organisation. Another benefit for organisations that have multiple departments is that due to the office spaces being indifferent, departments can be moved and changed as needed throughout office spaces providing greater flexibility. 

So great benefits for the organisation but what about the individual? On average not so great. 

In a study by Morrison & Macky (2017) found that shared desk environments increased distrust, distractions, uncooperative behaviour and negative relationships. Shared desk environments were also found to have a decreased perception of supervisor support. In a study by Hirst (2011) in which observations were made of a team transitioning to a hotdesking system, it was found that social patterns still persisted in that some individuals would arrive early and settle in certain spaces whilst those who were unable to were termed “wanderers” resulting in bigger environmental changes and lower perceived identity at work. Both studies also cited the issue of having to pack up and set up desks on a daily basis which was perceived as a waste of time by employees and an inconvenience. 

On the face of it a shared desk environment makes sense, much like trickle down economics. However, it only makes sense from a financial standpoint and it is at the cost of employee wellbeing. That is not to say that some employees do not enjoy a flexible work environment where they can choose to take a space that is isolated, social, standing, sitting or anything in between but it is a preference and depends on their work style and demands. Workspaces need to accommodate the needs of the worker and should be a reflection of the various work roles of a team. 


References

Hirst, A. (2011). Settlers, vagrants and mutual indifference: Unintended consequences of hot-desking. Journal of Organizational Change Management, 24(6), 767-788. doi:http://dx.doi.org/10.1108/09534811111175742

Morrison, R. L., & Macky, K. A. (2017). The demands and resources arising from shared office spaces. Applied Ergonomics, 60, 103-115. doi:http://dx.doi.org/10.1016/j.apergo.2016.11.007

Theory of Planned Behaviour

Purposeful behaviour has been a buzz phrase for me in the past few months and often working with clients we are inventing small seemingly unrelated purposeful behaviours to achieve. My reasoning for such small purposeful behaviours is not so much the behaviour change but the shift in perceived behavioural control. Behaviours are preceded by a range of variables and some the biggest predictors within that group are perceived behaviour control and attitude. This is demonstrated in the Theory of Planned Behaviour (TPB) which was proposed by Icek Ajzen (1991).

Theory_of_planned_behavior.png

 

In a recent article by Arnautovska et al. (2018) which investigates Physical Activity (PA) in older adults, they provided a summary of TPB;

The TPB (Ajzen, 1991) proposes intention as the proximal predictor of behaviour. It is further hypothesised that intention is predicted by the three beliefbased constructs: attitude (advantages/disadvantages), subjective norm (perceived social approval/disapproval), and perceived behavioural control (facilitators/barriers). In addition, it is proposed that perceived behavioural control directly predicts behaviour. The strength of intention is predicted by a person's evaluation of the target behaviour, perceptions about approval of important others for performing the behaviour, and perceptions of control and ability in relation to behavioural performance. Findings from metaanalyses support the predictive ability of attitudes and perceived behavioural control on intention, with a weaker subjective norm–intention relationship often found (Downs & Hausenblas, 2005; Hagger, Chatzisarantis, & Biddle, 2002). In line with these findings, a review of TPBbased PA studies by Hagger et al. (2002), including persons of all ages, indicated that attitudes and perceived behavioural control were the best predictors of intention (ß = 0.40 and 0.33, respectively), and together with subjective norm predicted 45% of variance in intention. In addition, perceived behavioural control was found to be associated with PA, and together with intention explained 27% of the variance in behaviour.

Our behaviours are the end of the production line of cognitive assembly and therefore provide a function. Subjective norms, attitude and perceived behavioural control are key factors in the process and can be modified to result in modified intentions and therefore modified behaviours.

Reference

Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes50, 179–211. https://doi.org/10.1016/0749-5978(91)90020-T

Arnautovska, U., Fleig, L., O’Callaghan, F., & Hamilton, K. (2018). Older Adult’s Physical Activity: The Integration of Autonomous Motivation and Theory of Planned Behaviour Constructs. Journal of Australian Psychologisthttps://doi.org/10.1111/ap.12346

Downs, D. S., & Hausenblas, H. A. (2005). The theories of reasoned action and planned behavior applied to exercise: A meta‐analytic update. Journal of Physical Activity and Health2(1), 76–97. https://doi.org/10.1123/jpah.2.1.76

Hagger, M. S., Chatzisarantis, N. L. D., & Biddle, S. J. H. (2002). A meta‐analytic review of the theories of reasoned action and planned behavior in physical activity: Predictive validity and the contribution of additional variables. Journal of Sport and Exercise Psychology24(1), 3–32. https://doi.org/10.1123/jsep.24.1.3

Reducing loneliness in later life

Reducing loneliness in later life

A recent study by Dawn et al. (2018) highlighted the major health concern of loneliness for the elderly and especially for those who are widowed. Loneliness is associated with a decrease in physical and psychological health (Coyle & Dugan, 2012). According to Holt-Lunstad, Smith & Layton (2010), mortality risk associated with lack of strong social relationships is similar to smoking, approximately double that of obesity and quadruple that of exposure to air pollution.

Dawn et al. (2018) found that widows experienced significantly higher levels of loneliness than those who continued to be married. However, the study revealed that widows who volunteered 2< hours per week had similar levels of loneliness to individuals continuing to marry and also volunteering at a similar intensity.  

Volunteering appears to influence health through psychosocial pathways like a positive emotional exchange, associated lifestyle factors (increased physical, cognitive, and social activity), self-esteem and purpose in life, as well as through stress-buffering effects that moderate the influence of stressors on health (Matz-Costa, Carr, McNamara & James, 2016).

Interestingly Dawn et al. (2018) also pointed out that not all volunteering is the same. Working and religious organisations were shown to have benefits for younger volunteers, however, not so for the elderly. It is believed that due to the individual's ages they are not assigned as meaningful or important tasks reducing the mutually beneficial outcome.

This study does a great job of highlighting the risk of loneliness as well as a direction to reduce this risk. Volunteering is great for all ages but perhaps it could even be lifesaving for those who have lost a close loved one in later life.  

Reference

Coyle, C. E., & Dugan, E. (2012). Social isolation, loneliness and health among older adults. Journal of Aging and Health, 24(8), 1346–1363. doi:10.1177/0898264312460275

Dawn C Carr, Ben Lennox Kail, Christina Matz-Costa, Yochai Z Shavit; Does Becoming A Volunteer Attenuate Loneliness Among Recently Widowed Older Adults?, The Journals of Gerontology: Series B, Volume 73, Issue 3, 2 March 2018, Pages 501–510, https://doi.org/10.1093/geronb/gbx092

Holt-Lunstad , J., Smith, T. B., & Layton, J. B. (2010). Social relationships and mortality risk: A meta-analytic review. PLoS Medicine, 7, e1000316. doi:10.1371/journal.pmed.1000316

Matz-Costa, C., Carr, D. C., McNamara, T. K., & James, J. B. (2016). Physical, cognitive, social, and emotional mediators of activity involvement and health in later life. Research on Aging , 38, 791–815. doi:10.1177/0164027515606182

Canine Assisted Therapy

Canine Assisted Therapy or ironically CAT for short is growing in popularity and acceptance. This is a branch of Animal Assisted Therapy (AAT) that aims to include highly trained animals within the therapeutic context. CAT is currently still be researched and a paper recently released by Draysnik, Signal & Canoy (2018) indicates that it would be readily accepted by parents as part of a therapeutic intervention in working with children. Children who have experienced trauma have an increased risk of developing PTSD later in life. The current gold standard of assisting children who are experiencing difficulties following trauma is Trauma Focused – Cognitive Behaviour Therapy (TF-CBT). Draysnik, Signal & Canoy (2018) were exploring the acceptance of CAT within the PTSD child population due to a meta-analysis conducted by Hoagwood, Acri, Morrissey, and Peth‐Pierce (2017) which found promising results for CAT and childhood PTSD.

More research needs to be conducted within all forms of AAT to gain further understanding as to it’s mechanics and function. A literature review by Draysnik, Signal & Canoy (2018) stated that;

Extant research on the positive effects of canine‐human interactions (including the production of oxytocin, often referred to as the relational hormone, Beetz, Uvnas‐Moberg, Julius, & Kotrschal, 2012) strongly support the potential for CAT to facilitate the goals of TF‐CBT. Younger children in particular seem to have an innate attraction to canines, which may result from the predictability and simplicity that is characteristic of the behaviour of both (Zilcha‐Mano, Mikulincer, & Shaver, 2011). Just like dogs that derive affection from touch through petting, very young children experience similar affection from their caregivers by way of gentle touch and physical comfort (Levinson, 1984). Therefore, it is suggested that the inherent value of CAT is its potential to help younger children form a commitment to therapy through forming a comforting attachment to the therapy animal (Levinson, 1984).

Although more research is needed in to how best use animals within the therapeutic setting, it is already clear that there is benefits. I look forward to this area of research and hope to incorporate dogs, horses and even dolphins into future interventions.

 

Reference

Beetz, A., Uvnas‐Moberg, K., Julius, H., & Kotrschal, K. (2012). Psychosocial and psychophysiological effects of human‐animal interactions: The possible role of oxytocin. Frontiers in Psychology, 3, 1–15. https://doi.org/10.3389/fpsyg.2012.00234

Dravsnik, J., Signal, T., Canoy, D. (2018) Canine co‐therapy: The potential of dogs to improve the acceptability of trauma‐focused therapies for children, Australian Journal of Psychology, https://doi.org/10.1111/ajpy.12199

Hoagwood, K. E., Acri, M., Morrissey, M., & Peth‐Pierce, R. (2017). Animal‐assisted therapies for youth with or at risk for mental health problems: A systematic review. Applied Developmental Science21(1), 1–13. https://doi.org/10.1080/10888691.2015.1134267

Levinson, B. M. (1984). Human/companion animal therapy. Journal of Contemporary Psychotherapy14(2), 131–144. https://doi.org/10.1007/BF00946311

Zilcha‐Mano, S., Mikulincer, M., & Shaver, P. R. (2011). Pet in the therapy room: An attachment perspective on animal‐assisted therapy. Attachment and Human Development13(6), 541–561. https://doi.org/10.1080/14616734.2011.608987

 

 

 

 

Fawn

When in a perceived stressful situation our autonomic nervous system ramps up to allow the body to meet the demands of the stress. In certain cases, it activates to the point of the fight or flight response. Automatic reactions to the perceived stress that take out conscious control of the brain and just give it simple options. This is an invaluable evolutionary mechanism as it allows an animal to act under pressure and make a snap decision of two valid survival responses.

Another part of this system is the freeze response where due to the perceived danger we can dissociate from ourselves as a last resort survival tool. Common in lizards who are playing dead as a predator is within the area or victims of sexual abuse.

Recently I have come across the fourth ‘F’ in the survival system repertoire which is Fawn. Fawn is described as co-dependant behaviour in which any kind of autonomy or relationship boundaries are forfeited. A fawn relationship could look like a dominant bully and a peer that gives constant praise or an abusive relationship. Fawn I find to be a helpful concept in the understanding of people’s behaviour which often gets typical responses of “Why don’t you think for yourself?”, “Why don’t you just leave?” Fear is what drives Fawn responses and through that fear it becomes easier to understand the behaviour as a response and not a flaw of the person.

For more information on the 4-F’s please see http://pete-walker.com/fourFs_TraumaTypologyComplexPTSD.htm.     

Vitamin D

A recent study found the importance of Vitamin D3 in regulation of dopamine circuits that impact on dopamine dependant behaviours such as managing food consumption and drug use. The study by Trinko et al (2016) used mice to measure the impact of D3 on the dopamine pathways. Mice that were treated with a D3 supplement and fed a high fat diet displayed reduced food intake and weight.

Vitamin D has also been shown to be responsible for increasing intestinal absorption of calcium, magnesium and phosphate (Holick, 2006). This is vital for healthy bone development, immune functioning and maintaining mental wellbeing.

Vitamin D (separated into D2 & D3) is best received through sunlight on the skin. Vitamin D3 is a naturally made by the body during exposure to sunlight and more specifically Ultraviolet B.

Sunlight often gets a bad name and especially here in Australia due to the high skin cancer rates that occur when over exposed to the sun. However, sunlight is so important to human biological functioning and it is something to be embraces whilst also being smart. Be smart, be sun safe but ensure you take those opportunities during the morning (6am-8.30am best times for sunlight absorption for endocrine functioning), during a lunch break at work, sitting by a window or taking that afternoon walk.

Reference

Trinko, J. R., Land, B. B., Solecki, W. B., Wickham, R. J., Tellez, L. A., Maldonado-Aviles, J., … DiLeone, R. J. (2016). Vitamin D3: A Role in Dopamine Circuit Regulation, Diet-Induced Obesity, and Drug Consumption. eNeuro3(3), ENEURO.0122–15.2016. http://doi.org/10.1523/ENEURO.0122-15.2016

Holick MF (March 2006). "High prevalence of vitamin D inadequacy and implications for health". Mayo Clinic Proceedings81 (3): 353–73. doi:10.4065/81.3.353PMID 16529140.

Gottman therapy

Gottman’s theory of the Sound Relationship House is built on 20 years of research and reviews of the previous literature in dysfunctional and functional relationships (Gottman 1994). Gottman found that the 8 predictors of what causes dysfunction in a relationship include more negativity than positivity, escalation of negative affect (The four horseman), emotional disengagement and withdrawal, failure of repair attempts, Negative Sentiment Override, maintaining vigilance and physiological arousal, chronic diffuse physiological arousal and the failure of men to accept influence from women (Gottman 1994). This was contrasted by predictors of a functional relationship which include relationships matched in preferred conflict style, dialogue about perpetual issues and employment of pre-emptive repair techniques (Gottman 1994).  

The above finding led Gottman (1996) to develop the Sound relationship house which is comprised of nine levels and seeks to train couples in functional behaviours and attitudes within the relationship. These levels include building love maps, sharing fondness and admiration, turning towards each other, Positive Sentiment Override, managing conflict, making life dreams and aspirations come true, creating shared meaning, trust and commitment (Gottman 1996). These nine levels could be further organised into three main areas of constructive conflict, shared meaning and Friendship/Intimacy (Gottman 1996).  

Further to Gottman’s research was the development of the “Four Horseman” which Gottman identified as the four biggest predictors of divorce in married heterosexual couples (Gottman 1996). This included criticism, defensiveness, contempt and stonewalling.

A study conducted by Whisman and Uebelacker (2006) highlighted the clinical importance of relationship discord. There findings included that individuals in discordant relationships reported greater social role impairment with relatives, friends and greater work role impairment. It was also reported that higher levels of general distress remained significant when controlling for current mood and mental health disorders. These results suggest that relationship discord is incrementally related to impairment and psychological distress over and above the effects of psychiatric disorders (Whisman & Uebelacker 2006).

 

Reference

Gottman, J. 1994 Why marriages succeed or fail? New York: Simon & Schuster

Gottman, J. 1996, What predicts divorce: The measure. Hillsdale, NJ: Lawrence Erlbaum Associates.

Whisman, M. & Uebelacker, L. 2006, Impairment and Distress Associated With Relationship Discord in a National Sample of Married or Cohabiting Adults, Journal of Family Psychology, Vol. 20, No. 3, 369-377

Efficacy of CBT and EMDR in treating PTSD amongst ADF members

Introduction

Posttraumatic Stress Disorder (PTSD) is the most prevalent mental health disorder reported amongst members of the Australian Defence Force (ADF) (McFarlane et al. 2011). In the Mental Health Prevalence Wellbeing study (McFarlane et al. 2011) which surveyed 49% of current ADF members, found that 22% of the ADF population had experienced a mental health disorder in the past 12 months. The most prevalent disorder was PTSD with 8.6% of ADF males experiencing the disorder compared to 5.2% of the general population (McFarlane et al. 2011). Managing PTSD in the ADF population represents a major challenge for the Australian Department of Defence (DoD) and the Australian Department of Veterans affairs (DVA) due to the associated high risk of suicide, alcohol and substance use, relationship break downs and the propensity to develop co-morbid disorders that are linked to a diagnosis of PTSD (McFarlane et al. 2011). These risk factors significantly impact on the individual, the family, the organisation and society (Forbes et al. 2007).

Prospective studies have shown that most trauma survivors display a range of PTSD reactions in the initial weeks after a traumatic event, but that most of these people adapt effectively within approximately three months (Koren, Arnon, & Klein, 1999). Those that fail to recover by this time are at risk for chronic PTSD (Koren, Arnon, & Klein, 1999). Further underscoring the risk for chronicity in PTSD, Kessler et al. (1995) found that one-third of people with PTSD fail to recover after many years, in many cases after years of mental health treatment.

Whilst the DoD and DVA recognise PTSD as major issue with the implementation of national studies and funding to co-ordinate therapeutic responses, there are obstacles to the achievement of effective and timely treatments, from identifying those at risk of PTSD to using the best evidence-based treatments including psychotherapy and pharmacotherapy (Forbes et al. 2007). The current literature review aims to address the latter in regards to reviewing the efficacy of the current gold standard treatments used by both departments which include Eye Movement Desensitisation and Reprocessing (EMDR) and trauma-focused Cognitive Behavioural Therapy (CBT). The following review is a summary of the current literature of PTSD in the ADF population and the efficacy of the current gold standard treatments that are employed. The literature review used Google Scholar as its main database in searching for articles related to PTSD, CBT, EMDR, ADF.      

PTSD

Traumatic events are profoundly stressful. The stress that results from traumatic events precipitates a spectrum of psycho-emotional and physiopathological outcomes (Iribarren et al. 2005). PTSD is the mental disorder that can result from the experience or witnessing of traumatic or life-threatening events such as terrorist attack, violent crime and abuse, military combat, natural disasters, serious accidents or violent personal assaults (Iribarren et al. 2005). Individuals report difficulty in sleeping, nightmares, flashbacks, intrusive thoughts, physiological arousal and increasingly detached or estranged behaviour (Iribarren et al. 2005). Co-morbid disorders such as depression, substance abuse and problems of memory and cognition are common (Iribarren et al. 2005). The disorder soon leads to impairment of the ability to function in social or family life, which more often than not results in occupational instability, marital problems and divorces, family discord and difficulties in parenting (Iribarren et al. 2005). The disorder can be severe enough and last long enough to impair the person’s daily life and, in the extreme, lead the patient to suicidal tendencies (Iribarren et al. 2005).

The Australian Gender Indicators study revealed that in 2007, Anxiety disorders, affecting 14% of all people aged 16-85 years, were the most common mental disorders reported in the 12 months prior to interview (NSMHW 2007). The most common Anxiety disorder for both men and women was PTSD, but women were almost twice as likely as men to experience this disorder (NSMHW 2007). Females were more likely than males to have experienced Anxiety disorders both in the 12 months prior to interview (18% and 11% respectively) and in their lifetime (32% compared to 20% for men) (NSMHW 2007).

PTSD in the ADF

Members of the ADF are at risk of developing mental disorders, as they are exposed to a range of occupational stressors – for example, exposure to traumatic events and extended periods of time away from their primary social support networks (Mental Health of ADF Members and Veterans Senate Report 2016). Between July 2013 and June 2014, 896 ADF personnel were referred to the ADF Rehabilitation Program with a primary diagnosis of a mental health disorder. Of these, 33.6 per cent were identified as being 'deployment related' (Mental Health of ADF Members and Veterans Senate Report 2016). In this period, 206 of the 896 personnel were referred with a specific diagnosis of PTSD, of which 84 per cent were identified as being 'deployment related'. Since 2000, 108 ADF personnel are suspected or confirmed to have died as a result of suicide, of which 47 had previously deployed. (Mental Health of ADF Members and Veterans Senate Report 2016).

The prevalence of PTSD in Gulf War Veterans assessed at 10–15 years after deployment was 5.4%. Many of those who required treatment did not receive it (Pietrzak 2011). The most common barriers to treatment included limited access to mental health professionals, living in remote or underserved areas, economic and time constraints, stigma associated with mental illness, privacy/confidentiality issues and lack of confidence with mental health professionals (Pietrzak 2011). Up to 20% of those who had sought mental health care were dissatisfied (Pietrzak 2011). The key indicators and factors that contribute to treatment effectiveness are related to disease severity and presentation, treatment effectiveness and psycho‐social condition of the person undergoing treatment (Pietrzak 2011).

Treatment of military veterans with combat‐related PTSD has specific challenges. Military culture and training are designed to produce effective combatants through promoting emotional shut‐down. When this is combined with high levels of anger which is common in PTSD the development of therapeutic alliance can be impaired.  The therapeutic alliance is pivotal when engaging with trauma‐related fear during exposure treatments (Pietrzak 2011). This barrier may prevent habituation to fear, which inhibits self‐ reflection and leads to premature termination of treatment (Pietrzak 2011).  

Combat veterans with PTSD may report large amounts of survivor guilt, perpetrator guilt, grief, and anger. Combat veterans are often reluctant to discuss their experiences for reasons ranging from fear of appearing weak to admitting to perpetrator behaviour to difficulty articulating complex experiences affecting them in many different ways (Sprang 2001).

 

EMDR

Shapiro (1989) argues that EMDR helps individuals reduce or remove the negative affect associated with traumatic memories by activating a neurophysiological process that permits a form of relearning. The eye movements are presumed to activate brain chemistry that permits changes in memory structures and related emotional responses (Shapiro 1989). The basic application of EMDR involves eight phases of treatment (Table 1) with the number of sessions needed varying from one to many, depending on the individual (Shapiro 1989).

Shapiro (1995) proposed a theoretical framework, called Accelerated Information Processing (AIP) which forms one basis for the EMDR treatment strategy. The AIP model is based on the assumption of a "neurological balance in a distinct physiological system that allows information to be processed to an 'adaptive resolution'" (Shapiro 1995). Shapiro (1995) posits that "the eye movements or alternative stimuli used in the EMDR procedure trigger a physiological mechanism that activates the information processing system to an adaptive resolution." Shapiro's main premise about traumatic memories is based on the apparent imbalance which occurs in the nervous system when a person experiences severe psychological trauma, manifested by changes in neurotransmitters and adrenaline. The memories are encoded neurologically in the neurobiologically altered state. Shapiro (1995) hypothesizes that the original material, which is held in this distressing, excitatory state-specific form, continues to be triggered by a variety of internal and external stimuli and is expressed in the form of nightmares, flashbacks, and intrusive thoughts.

There is substantial evidence indicating the efficacy of EMDR against waitlist, pill placebo, supportive counselling, relaxation or treatment as usual (Hogberg 2007 & Kolk et al. 2007). Meta-analyses (Cloiter 2009) indicate that EMDR is an efficacious treatment with outcomes not significantly different from exposure-based therapies in both civilian and military populations. EMDR has been deemed efficacious by the International Society for Traumatic Stress (Shapiro & Maxfield 2002) and is recommended by the DoD and DVA treatment guidelines.

Carlson et al. (1998) found 12 sessions of EMDR with combat veterans resulted in a 77% remission of PTSD with no dropouts. Positive effects were reported on multiple measures at posttest, and effects were maintained at 3- and 9-month follow-up. In a non-randomized retrospective study of treatment outcomes for veterans receiving EMDR, biofeedback, or relaxation training, EMDR was found to be superior to the other two treatments on seven of eight measures (Silver, Brooks, & Obenchain, 1995). This and the Carlson et al. (1998) studies are the only two studies of EMDR with PTSD-diagnosed combat veterans treated across multiple traumatic combat experiences using a sufficient number of sessions rather than a single session or two. The veterans in both of these studies were suffering from chronic PTSD.

According to both the International Society for Traumatic Stress Studies (Chemtob et al. 2000) and the Departments of Veterans Affairs and Defence Joint Clinical Practice Guidelines for PTSD (2004), other randomized studies of EMDR with veterans are flawed because of insufficient treatment doses, offering only two sessions and/or component analyses treating only one memory. Corroborating the need for multiple treatment sessions, a recent analysis of the treatment of 63 war veterans by newly trained EMDR clinicians suggested that wounded combat veterans needed 8.5 sessions of treatment and non-wounded needed 3.8 sessions to eliminate disturbances associated with war-related traumatic memories (Russell et al. 2007). Given EMDR’s in-session rapid effects and the lack of need for homework, it appears particularly suited for frontline treatment, for instance, as an immediate intervention for recently and severely wounded casualties shortly after evacuation (Russell, 2006).

Whilst there is support for EMDR there remains controversy over its mechanisms and delivery. Shapirio (1989) firsts discussed EMDR as a one session treatment in which all 8 phases could be delivered and a positive effect gained. This has been argued by Davidson & Parker (2001) in a meta-analysis conducted into the efficacy of EMDR, it was found that EMDR often needed 12 sessions to take effect (Feske 1998). The same meta-analysis also revealed no evidence for the use of eye movement or alternating stimuli as near zero effect sizes were found between control groups and experimental groups who were exposed to the eye-movements and not exposed to the eye-movements (Davidson & Parker 2001).     

 

Limitations that have been cited into the studies conducted on EMDR include that due to the misguided instructions of EMDR being completed over 1 – 3 sessions which were later retracted by Shapiro (1995), much research is inconclusive due to the limited session numbers. Another limitation in the study of EMDR is the heavy reliance on the process measures (SUDS & VoC) as the predictors of success. Outcome studies which are heavily used in CBT studies are needed and indicate smaller effect sizes than what has previously been reported (Davidson & Parker 2001).

 

Trauma-focused CBT

 

CBT in the context of PTSD is comprised of Psychoeducation about trauma, relaxation training, and identification and modification of cognitive distortions (Maercker et al. 2006). Trauma focused CBT can also involve imaginal reliving of the trauma memory, imaginal exposure, in vivo exposure, facilitation of post-traumatic growth, stress inoculation, graduated exposure to avoided situations and trauma re-experiences,  and rescripting/imagery rescripting (Maercker et al. 2006 & Williams et al. 2003) (Table 2). CBT duration in typical clinical practice is determined by the patient’s response to treatment (Foa et al., 2005).   

Various cognitive distortions are seen in PTSD, depending on the traumatic experience and the nature of the psychological state of the person. Common cognitive distortions include perceiving the world as dangerous, seeing oneself as powerless or inadequate, or feeling guilty about outcomes that could not have been prevented (Friedman 2006). Many survivors feel guilty, thinking that they could have done more to limit the damage, or prevent injury or death, and may have suicidal ideation (Kar 2010). A study has also indicated that PTSD is associated with negative beliefs about self that may influence self-esteem and interpersonal relationships (Christensen 2004). PTSD often co-occurs with depression, and they may share common risk factors. One possible common cognitive risk factor is hopelessness. In a study of female survivors of interpersonal violence, relationships between hopelessness and symptoms of PTSD were due almost entirely too shared variance with depression (Scher & Resick 2005).

Cognitive therapy is based on an underlying theoretical rationale that an individual’s affect and behaviour are largely determined by the way they think and structures the world around them (Garakani et al 2004). Victims generally begin to experience improvement in symptoms and behaviour as they begin to think and act more realistically and adaptively with regard to their situational and psychological difficulties (Smith et al. 2007). In adults, children, and adolescents with PTSD, the effects of CBT have been observed to be partially mediated by changes in maladaptive cognitions, as predicted by cognitive models of PTSD (Smith et al. 2007). It has been proposed that successful processing of traumatic events involves emotional engagement with the trauma memory, organization of the trauma narrative, and correction of dysfunctional cognitions that often follow trauma (Hembree & Foa 2000). One study investigating trauma processing during and after CBT consisting of imaginal exposure combined with rescripting suggested that imaginal reliving during CBT is not crucial for symptom reduction, but it may promote conceptual processing, which in itself predicts a better treatment outcome for PTSD (Kindt et al. 2007).

Table 1. 8 Phases of EMDR Therapy


EMDR Phase

Description

Client history and treatment planning

The clinician gathers information about the client's current level of functioning, current symptoms, stimuli that trigger symptoms, and assessment of the client's stability and life circumstances. With this information, the clinician establishes targets for treatment that encompass the original trauma, subsequent secondary triggers, and adaptive behaviours that will be desirable in the future

Preparation

Tasks in this phase include rapport-building, teaching relaxation procedures, informed consent to treatment, and discussion with the client about the potential loss of secondary gains that might be occurring because of the symptoms

Assessment

The assessment phase entails the clinician clarifying components of the target and provides a pre-treatment baseline. The client identifies an image that accurately represents the memory sequence, as well as the concomitant maladaptive self-evaluation he or she uses when recalling the event. The degree of emotional distress associated with the memory is quantified using Subjective Units of Distress (SUDS) (Wolpe 1991), in which the client assigns a numerical rating to the intensity of the disturbing feelings as he or she recollects the trauma. The client is asked to generate a more adaptive self-evaluative statement that also creates an internal locus of control. The degree to which the client believes the adaptive self-evaluative statement is quantified using the Validity of Cognition (VoC) (Shapiro 1989). A rating of 1 means the client acknowledges the accuracy of the rational self-statement, but the statement does not feel valid, while a 7 indicates emotional congruence with what one knows is true on an intellectual level

Desensitisation

The purpose of this phase is reduction of negative affect as indicated by the SUDS rating. In this phase the client engages in repeated horizontal eye movements at the rate of about one per second, for about 24 eye movements. The rate of speed for the movements as well as the number of eye movements necessary to induce accelerated processing varies between clients. Some clients cannot engage in horizontal eye movement; vertical or diagonal eye movement is also acceptable in this treatment protocol. Other forms of stimulation besides eye movements can also induce accelerated reprocessing. Alternative stimuli used by clinicians and found in the research include alternating hand taps on clients' left and right hands and alternating sounds in the clients' left and right ears

Installation

Installing" is the process of restructuring the critical or otherwise negative self-evaluative statement that had accompanied the distressing memories. The negative self-statements are replaced with more positive, adaptive self-evaluative cognitions. If the client already had some constructive self-statements, those statements are further strengthened during this phase

Body Scan

The client holds the target memory and positive cognition in mind then searches through his or her body for anybody sensations suggesting tension. If the client identifies any, the bodily sensation becomes the target of subsequent sets of eye movements

Closure

It is critical that the client re-establishes a sense of stability and equilibrium by the conclusion of the session, regardless of whether or not the reprocessing was successfully completed. The client is also directed to keep a journal or log of associated thoughts, images, or dreams that occur between treatment sessions

Revaluation

This is done at the beginning of each new session. The purpose is for the clinician to ascertain whether treatment effects are being maintained


Prolonged exposure has been reported to be effective for improving post-traumatic stress symptoms in 60%–65% of trauma victims suffering from PTSD (Grunert et al. 2007). However, a simple habituation model (on which prolonged exposure is based) is observed to be insufficient to address non-fear emotions (eg, guilt, shame, anger) in PTSD. In contrast, by adding an imagery-based, cognitive restructuring component (imagery rescripting and reprocessing therapy) to the treatment of individuals of PTSD who have failed to improve with prolonged exposure alone, 78.3% of clients showed full recovery from their PTSD symptoms and no longer met criteria for PTSD after 1–3 sessions of imagery rescripting and reprocessing therapy (Grunert et al. 2007). It suggests that individualised trauma assessments should be conducted for each patient to identify the predominant trauma-related emotions and cognitions which will help to find the best CBT “treatment fit” for the specific trauma characteristics of each patient (Grunert et al. 2007).

The traumas of war have long been associated with PTSD. In addition, soldiers exposed to combat remain at high risk for developing the disorder (Miyahira et al. 2010). Multicomponent CBT showed promise in a group of male combat veterans with severe and chronic PTSD for improving social functioning beyond that provided by exposure therapy alone, particularly by increasing social engagement and interpersonal functioning (Miyahira et al. 2010). CBT with brief virtual reality exposure has been found to be beneficial in treating PTSD in war veterans (Miyahira et al. 2010). A 12-session integrated treatment using components of cognitive processing therapy for PTSD, and CBT for chronic pain management in veterans with comorbid chronic pain and PTSD, suggested not only the feasibility of this treatment approach but also clinical benefit (Miyahira et al. 2010). 

CBT vs EMDR

Various forms of therapies have been compared with CBT in the treatment of PTSD, namely supportive psychotherapy, problem-solving therapy, present-centred therapy, psycho-dynamic therapy, hypnotherapy, acupuncture, and structured writing therapy (Cottraux et al. 2008). However, more consistent comparison has been with EMDR. A systematic review of 23 clinical trials on the efficacy of CBT in comparison with other psychotherapies suggested that CBT had better remission rates than EMDR or supportive therapies. CBT was comparable with exposure therapy and cognitive therapy in terms of efficacy and compliance. These findings suggested that specific therapies, such as CBT, exposure therapy, and cognitive therapy are equally effective, and more effective than supportive techniques in the treatment of PTSD (Mendes et al. 2008).

Another systematic review of 33 randomized controlled trials compared all psychological treatments for adults suffering from traumatic stress symptoms for three months or more. Types of interventions studied were trauma-focused CBT/exposure therapy, stress management, other therapies (supportive therapy, nondirective counselling, psychodynamic therapy, and hypnotherapy), group CBT, and EMDR. With regard to reduction of clinician-assessed PTSD symptoms measured immediately after treatment, trauma-focused CBT did significantly better than other therapies and wait-list/usual care. There is no significant difference between trauma-focused CBT and stress management, trauma-focused CBT, and EMDR. Group trauma-focused CBT was significantly better than wait-list/usual care. It was concluded that individual and group trauma-focused CBT, EMDR, and stress management are effective in the treatment of PTSD. There was some evidence that individual trauma-focused CBT and EMDR are superior to stress management in the treatment of PTSD at 2–5 months following treatment (Bison & Cochran 2007)

In six studies comparing EMDR directly to trauma‐focused CBT, results were mixed. Three studies found an advantage for EMDR as compared to exposure alone and to exposure plus cognitive therapy. Three studies found exposure or its combination with cognitive restructuring and SIT was superior to EMDR (McFarlane et al. 2011).

The Australian Guidelines recommend trauma‐focused psychological therapy, delivered during 90‐ minute sessions, as the best evidence treatment for PTSD (ACPMH 2007). This type of treatment can be easily delivered in a community setting, given the availability of suitably trained therapists. Findings of more than 30 well controlled studies indicate that trauma‐focused Cognitive Behavioural Therapy (CBT), as well as Eye Movement Desensitization and Reprocessing therapy (EMDR) in addition to in vivo exposure, are the treatments of choice for PTSD (Pietrzak 2011). These treatments were found to be effective, not only in the treatment of PTSD symptoms, but also of co‐morbid anxiety and depression, as well as achieving improvements in broader quality of life (Pietrzak 2011).

Seidler & Wagner (2006) suggest that in the treatment of PTSD, CBT and EMDR tend to be equally efficacious. Seidler & Wagner (2006) stated that future research should not restrict its focus to the efficacy, effectiveness and efficiency of these therapy methods but should also attempt to establish which trauma patients are more likely to benefit from one method or the other.

Discussion

Considering the available literature it is clear that there is evidence for the efficacy of both CBT and EMDR in treating PTSD in the civilian and military population. What is less clear is which therapy is suitable to individuals who present with a specific set of variables and circumstances. The argument that EMDR is able to deliver results in a timely manner which can suit the “let’s get things done now” attitude of ADF members would appear invalid as the recommended session length of 8-12 is comparable with CBT. As both forms of therapy have proven effect and therefore are the current gold standard’s and recommended treatments for PTSD by the DoD and DVA, studies should now focus on dropout rates and assessment. Grunert et al. (2007) discussed the importance of individualised trauma assessments to assist the therapist in discerning a treatment fit for the trauma characteristics being presented. This is especially important for ADF members who are more likely to be exposed to complex multiple traumas. Further dismantling studies as to the effectiveness of CBT and EMDR components would also be useful in identifying presenting characteristics and effectiveness of specific interventions. This could lead to a multi-faceted treatment which is tailored to the specific needs of the ADF member promoting remission and completion of therapy.       

 

Table 2. CBT techniques used in treating PTSD

CBT Technique

Description

Psychoeducation

Education offered to individuals with a mental health condition and their families to help empower them and deal with their condition in an optimal way. For PTSD this includes education on trauma and psychological and physiological reactions to trauma.

Relaxation training

Relaxation training involves instructing the individuals in various relaxation exercises, which are used at times of anxiety or distress. Relaxation its effects by reducing hyperarousal symptoms. Once hyperarousal is reduced, the patient may be less distressed by trauma-related stimuli and, therefore, less avoidant (Taylor et al, 2001)

Cognitive Restructuring

Cognitive Restructuring with PTSD involves challenging maladaptive cognitions of helplessness, hopelessness and worthlessness to reduce fear. This is achieved through questions such as “What is it about this situation that makes you weak?’’, ‘‘How is it that you are to blame?’’, and ‘‘What would you say to a friend in this situation? (Ehlers & Clark, 2000)

Imaginal Reliving

In Imaginal Reliving individuals are asked to relive the traumatic experience in the presence of the therapist, starting from the beginning and continuing to the point when they were safe again, while putting the experience into words (Foa & Rothbaum, 1998)

Imaginal Exposure

In Imaginal Exposure individuals are asked to recall the details of the traumatic event while focusing their attention on any occurring sensory feelings, thoughts, and emotions. Exposure to such memories results in reduction of fear and avoidance. The presumed underlying mechanism is the loosening of the association between unconditioned and conditioned stimuli (Foa et al., 1999)

In vivo Exposure

In vivo exposure involves planned confrontations with situations or objects associated with the trauma and that are therefore anxiety-evoking (Richards et al. 1991)

Post-Traumatic Growth

Post-Traumatic Growth is the subjective experience of positive psychological change reported by an individual as a result of the struggle with trauma. Some theorize it is a coping style, while others think of Post-Traumatic Growth as an outcome of coping with traumatic stress (Sheik 2008)

Stress Inoculation Training

Stress Inoculation Training involves teaching coping skills to manage stress and anxiety. This may include training in deep muscle relaxation, cognitive restructuring, breathing exercises, assertiveness skills, thought stopping, role playing, and guided self-dialogue. Stress Inoculation Training is often used in conjunction with other therapy techniques, such as CBT (Meichenbaum, D & Deffenbacher 1996)

Graded Exposure

Therapists assist the client to construct an exposure fear hierarchy, in which feared objects, activities, or situations are ranked according to difficulty. They begin with mildly or moderately difficult exposures, then progress to harder ones (Opdyke, Williford & North 1995)

Rescripting/Imagery Rescripting

in Imagery Rescripting expression of inhibited responses is facilitated as well as new information provided during evocation of the traumatic memory (Arntz & Weertman 1999)

 

 

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