Helping Survivors of Trauma : Designing and Building a System of Care

1. Helping Survivors of Trauma:Designing and Building a System of Care Josef I Ruzek, Ph.D. Palo Alto University Stanford University joeruzek@gmail.com

2. Core Challenges in Service Delivery? • Clinical best practices • Towards evidence-based treatments • Families and significant others • Social support for survivors: Mutual support organizations • Reaching survivors • Monitoring and using outcomes information • Supporting helpers/clinicians • Building communities of practice among helpers

3. Best Practicesin Treatment of PTSD • Note: not everything is PTSD • Substance abuse • Depression • Anger/violence • Social withdrawal • Marital and family problems • Employment and school problems • Clinical Practice Guidelines for PTSD define best practices

4. Evidence-Based Treatments for PTSD:Clinical Practice Guidelines US Veterans Administration/Dept of Defense http://www.healthquality.va.gov/guidelines/MH/ptsd/ UK National Institute for Clinical Excellence https://www.nice.org.uk/guidance/CG26

5. Exposure-Based Therapies • Emphasize imaginal, in vivo (real world), and narrative (oral and/or written) exposure • Prolonged Exposure • Imaginal exposure • Processing of the revisiting experience • Repeated in vivo exposure • Education about common reactions to trauma • Breathing training • Treatment consists of an average of 8-15 90-minute sessions

6. Prolonged Exposure Therapy (PE) • Manualized CBT • (Foa, Hembree, & Rothbaum, 2007) • 10 to 12+ Weekly (or 2/wk) • 90-Minute Sessions • Individual • http://www.youtube.com/watch?v=AUOYFQTm9lE&list=PL8FBF506DEC670ADF&index=12

7. Cognitive-Based Therapies • Emphasizes reviewing and challenging distressing trauma-related beliefs (e.g., safety, trust, guilt) • Cognitive Processing Therapy • Systematic approach to examining and challenging “stuck points” or negative meanings associated with trauma • Topics • Safety • Trust • Power and control • Esteem • Intimacy

8. Cognitive Processing Therapy (CPT) • Manualized CBT (Resick, Monson, & Chard, 2007) • 12 Weekly (or 2/wk) 1-hour Sessions • Individual or Group • 2 Versions: • Original CPT • CPT-Cognitive or CPT-C

9. ABC Sheets A-Activating Event B-Belief C-Consequence (feeling) That dog is going to kill me Chased by a dog Very Sad, Angry, Scared Chased by a 2nd dog ALL Dogs are bad Are my thoughts above in “B” realistic? What can you tell yourself on such occasions in the future?

10. EMDR • Eye Movement Desensitization and Reprocessing (EMDR) • Involves focusing on distractions like hand movements or sounds while you talk about the traumatic event with the goal of changing how you react to memories of your trauma. • http://www.youtube.com/watch?v=bnjEr7GVhLo&list=PL8FBF506DEC670ADF&index=13

11. Treatment Manuals

12. Cognitive Processing Therapy:Evidence-Based PTSD Treatment for Adultshttp://tfcbt.musc.edu/

13. PE-Web

14. Spouse/Partner/Family Involvement in Care? Family is strong helping resource Family is affected by PTSD Keep individual care, with confidentiality, but Include Partners/Parents Provide education Include in assessment process Involve in goal-setting, if possible and acceptable Involve in treatment, some of the time

15. Mutual Support Organizations for Trauma Survivors Need for mutual support Provides opportunity for involvement of families Relapse prevention A different role for us?: Supporting self-help organizations

16. Reaching Survivors… Web and phone interventions: Are they possible in Ukraine? Might help us reach more people Provide education widely Make it easier to implement evidence-based treatments Help us address more patient and family needs

17. PTSD Coach Hoffman, J. E., Wald, L. J., Kuhn, E., Greene, C., Ruzek, J .I., & Weingardt, K. (2011). PTSD Coach (Version 1.0). [Mobile application software]. Retrieved from http://itunes.apple.com.

18. Key Interventions

19. Tool Examples

20. Currently Available Phone Apps(in English) • Patient/Family Education and Self-Management • PTSD Coach • Mindfulness Coach • mTBI (Concussion Coach) • Moving Forward (Problem-Solving) • Mood Coach • Parenting2Go

21. Currently Available Apps (cont) • Support for Evidence-Based Treatments (EBTs) • Prolonged Exposure Coach • Cognitive Processing Therapy Coach • ACT Coach (Acceptance and Commitment Therapy) • CBT-I Coach (Cognitive-Behavioral Therapy for Insomnia) • Smoking Cessation (Stay Quit Coach) • Provider Support • PFA Mobile (Psychological First Aid) • Provider Resilience

22. Coming Apps • PTSD Family Coach • CBT-I self-administered • VetChange (alcohol and PTSD) • Prevention of PTSD • Trauma Recovery Coach (PTSD prevention and resilience)

23. Monitoring and Using Outcomes Information Benefits to survivor and helper Is treatment working? Should we change it? Patient can review progress Allows evaluation of treatment improvement over time

24. Detection: PC-PTSD Screen In your life, have you ever had any experience that was so frightening, horrible, or upsetting, that, in the past month, you… 1. Have had nightmares about it or thought about it when you did not want to? 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? 3. Were constantly on guard, watchful or easily startled? 4. Felt numb or detached from others, activities, or your surroundings? * RECOMMENDED CUTOFF = 3

25. Assessment Tools Online • National Center for PTSD provides information about a variety of trauma-specific and more general assessment tools • http://www.ptsd.va.gov/professional/pages/assessments/assessment.asp • PTSD Checklist (PCL5) can be used to monitor PTSD symptoms throughout treatment

26. Supporting Helpers/Clinicians? • Can we link helpers? • Is it possible to create a website to support the “Community of Practice”? • Can we do things to help people learn? • Can we reduce burnout and increase motivation? • How can we build more sharing across helpers?

27. What Can You Do? Learn more about EBTs Reading Online courses Other training opportunities? Use phone apps, if possible Use PCL and other questionnaires in your work Based on goals Include families in care if possible Support development of mutual help organizations Participate in a growing Community of Practice among helpers

28. Online Training Opportunities • Evidence-Based Treatments • Trauma Focused CBT (www.musc.edu/tfcbt) • Cognitive Processing Therapy (http://cpt.musc.edu) • PE-Web (http://pe.musc.edu) • Helping Heroes (http://helping-heroes.org) • Child Traumatic Grief (www.musc.edu/ctg)

29. Children: Trauma-Focused CBT

30. Online Resources • National Center for PTSD www.ptsd.va.gov • PTSD Coach Application http://www.ptsd.va.gov/public/pages/PTSDCoach.asp

31. PILOTS: Published International Literature on Traumatic Stress • 50,000+ citations for articles on traumatic stress • Includes reports and foreign-language materials • Trauma-specific thesaurus • CSA platform (like PsycInfo) • Links to online sources • Articles by NCPTSD authors provided as PDFs

32. CTU-Online: Clinician’s Trauma Update • Summarizes clinically relevant articles on treating Veterans & military personnel • Summaries presented in brief format with links to the full article • Emailed every 2 months • Subscribe at: http://www.ptsd.va.gov/professional/newsletters/ctu-online.asp

33. ISTSS • International Society for Traumatic Stress Studies (ISTSS) • www.istss.org

34. Discussion • What needs have you identified? • What is working? • What is not working? • What special challenges do you face?