Presenter(s): Ronald Beavers, Ph.D . Shawna Charles, Ph.D. Cand .

1. “Recovering A-NEW” A Culturally Competent Cognitive/Behavioral Treatment ModelGround Zero: The Urban War Zone Presenter(s): Ronald Beavers, Ph.D. Shawna Charles, Ph.D. Cand. vetserviceprogram@sbcglobal.net Veterans Service Outreach Program-VSOP of PIF, Inc. Los Angeles, California Authored By: Ronald Beavers

2. Ground Zero: The Urban War Zone

3. Goals Today • Think about best care • Think about priorities for change in treatment of women with Trauma • Questions: • What are special challenges of treatment in the community? • What are most important changes in practice to adjust treatment for women with Trauma? • What will have most impact? • What can be changed?

4. Historic Changes? • Improvements… • Continued implementation of Community Stressors for PTSD/SUD • First routine screening that is cultural competent for PTSD in South Los Angeles Ground Zero: Urban War Zone • Court Mandated individual sessions immediately, 3 to 6 months after court ordered • PTSD/SUD Cultural Practice Guidelines • Significant Community interest in evidence-based care (Recovering A-New) • Efforts to better integrate TX, and Social care • Access and appropriate care • Training initiatives • Community integration of mental health planning, and services • Community research on PTSD/MH in CBO’s

5. CBO’s Fundamentals are Strong • Caring professionals • Extensive system of care • Performance orientation • Expertise related to problems of community, e.g. … • PTSD • SUD • Anger • Guilt • Bereavement • Support for innovation

6. Community Treatment More Visible? • Federal Gov’t and Local Officials City/County Departments attention, with political relevance • Greater importance of: • Accountability • Outcome measurement • Accessibility of services • Community Customer satisfaction

7. Ground Zero: The Urban War Zone Stressors • Based on the final 2008 FBI Crime Reports. • LA City Crime Report 2007 - 2008

8. Challenges for Community in Delivering Best Care for Re-entry, and All • New issues (Re-entry) • Familiar problems, new twists • Historic problems, continuing challenges (Inadequate and a disparity in mental/health care, i.e., South Central even before Watts Riot (1965 )

9. New Issues • African American Men Access to Appropriate Care • Women and Their Children • Appropriate Assessing and Diagnosing** • Family involvement • Importance of cultural competency • Clinical and Social functioning

10. Younger Clients • Stage-of-life issues • Still working/desire to work • School issues • Significant family roles • Son or daughter • Parent • Spouse • Finding and forming relationships • Activity levels higher • Integration with civilian life • Provider-patient discrepancies in age? • Q: When do you think it went wrong?

11. Women Clients • More women with PTSD/SUD into Community care • Are we ready? • Specialist women services • Female staff • General climate • How integrate with men? • Trauma/SUD work

12. Focus on Functioning/Role Maintenance? • Marriage-family-work-social connection: These suffered in returning to the community. • These represent quality of life, that PTSD disrupts • If returnees fail or experience significant impairment in these domains, this may help maintain PTSD • Should we organize treatment around partner, family, work, social, and PTSD?

13. Family Issues • Partner conflict-divorce prevention • Sexual functioning • Parenting skills • Domestic violence • Budgeting skills • Impact on family members

14. Spouse/Partner/Family Involvement in Care? • Not just the province of family clinics • Partners/Parents • Include in assessment process • Involve in treatment planning if possible • Involve in treatment • Management of current stressors, social activities, positive recreation • Couples functioning? • Couples conflict resolution/problem solving? • Mechanisms? • SO or couples groups • Cognitive-behavioral couples therapy? • Workshops

15. Treatment Works, when you Work-it! + + + - - _ _ Healthy-life Style lacking Poor habits Social Malady Treatment/Drug free No Support Denial Non-Tx. Disease/Death AUTHENTICADAPTIVE ADOPTIVEABERRANT

16. "Seven Virtues of Ma’at" • ORDER : • BALANCE: • HARMONY: • COMPASSION: • RECIPROCITY: • JUSTICE: • TRUTH:

17. The Recovering A-New: What are we facing S.C. LA Our Morbidity reflects the needs in treatment which address the populations that is of greater risk for trauma, e.g., youth in inter-cities, community combat, rape victims, murder, abused youth (physically and/or sexually) and the ever increasing domestic violence; these primary variables can have constellated features and manifesting other complex disorders.

18. The Recovering A-New: What are we facing S.C. LA Cont. • The population that is most affected are African Americans, Latinos, adolescents and women, which appear to be greater impacted and are at higher risk in the actual manifestation of Post Traumatic Stress Disorder; this sometimes precipitate the use of alcohol and/or illicit chemicals to psychologically numbing, and avoidance from the sometimes overwhelming symptoms of Post Traumatic Stress Disorder PTSD. This material is more culturally competent that address the critical as well as complex issues which encompass the different levels of trauma, and its impact on this population.

19. Possible Topics in Couples Skills Training • What is PTSD? • Triggers for PTSD symptoms • Planning together to manage problem • Coping with problem situations • Social isolation • Parenting • Anger • Substance abuse • Communication training • Communication of positive emotions • Commitment to change • Self-care for significant others

20. PTSD/SUD CBO’s In Recovery? • SESSION PSYCHO-EDUCATION In/Out Patient (Cultural Relevance) • MONTH ONE  Trauma and Addiction (Co-Morbidity): Overview Disease of Chemical Dependency Mental Health, Anxiety and Trauma Progress/Symptoms Guilt, Shame, and Recovery  Self-help Group, and Individual Session

21. CBO’s in Tx.Recovery Cont. • GROUP:CONTINUING TRAUMA AND RECOVERY PLANNING/RELAPSE PREVENTION (Four (4) times per month) SESSION • MONTH ONE  High Risk Factors - Individual Planning Session • MONTH TWO  Signs and Symptoms - Individual Planning Session • MONTH THREE  Hypervigilance, Startled Response, Memory Make a focus of treatment • Work Success support groups • Coping skills training adapted to changing faulty belief systems.

22. Cultural Specialized Support Groups  SPECIALIZED TRACTS (One (1) tract per month) • SPIRITUALITY TRACT  WEEK ONE: Spiritual (Becoming Grounded) Recovery  WEEK TWO: Open Discussion  WEEK THREE Spiritual Recovery - Developing the Inner Voice  WEEK FOUR: Having Fun with Spirituality • GRIEF AND LOSS TRACT  WEEK ONE: The Grief Process  WEEK TWO: Grief and Chemical Dependency  WEEK THREE: Cognitive Therapy  WEEK FOUR: Behavioral Change Exercise Coping with my anger and solving difficult situations

23. Familiar Problems, The Boogieman • Drug/Alcohol problems • PTSD

24. Drug/Alcohol Problems? Abusing substances… • Makes PTSD symptoms worse. Substances can make you feel more depressed, more suicidal, less stable. Even if substance abuse appears to “solve” some PTSD symptoms for a short while (such as getting to sleep or “numbing out” for a few hours), in the long run it never solves them. • Prevents you from knowing yourself. With substances, you get lost. To heal from PTSD, you need to become more and more aware of who you really are—without substances. • Does not get your needs met. You may be using substances to feel loved, to accept yourself, to feel less pain, to feel nurtured. However, substances cannot give you these. You need to learn safe coping methods to gratify these very important needs.

25. Alcohol/Substance Abuse • Screen all patients for PTSD/trauma exposure and alcohol/sa • Integrate PTSD and SA programming? • Patient education • Concurrent PTSD/SA protocols • Seeking Safety (Najavits, 2002) (Beavers, 2010) • Moderation training? • Increase collaboration between PTSD and SA treatment?

26. PTSD • TBI complicate treatment for some? • Importance of driving behavior • Need for in vivo exposure methods • How integrate older and younger Client’s?

27. Historic Problems, and A Solution to our Problem • Lack of cultural specific evidence-based care, application of Practice Guidelines • Lack of culture competency in program evaluation • Mental health stigma • OUR SOLUTION Recovering A-NEW, a Culturally Competent CBT Model evidence-based developed in South Central Los Angeles (Beavers, 2010)

28. Evidence-Based Care/Practice Guidelines • What are leading treatments for PTSD? • Can we deliver them to our community at-large? • Therapy in the ABPsi’s LCPP Practice Guideline, that is effective. • Significant benefit – Strongly recommended • Cognitive Therapy • Exposure Therapy • Stress Inoculation Training • Behavioral Change Models • Best developed treatments combine the two elements • e.g., Cognitive Processing Therapy (Resick & Schnicke, 1993) Behavioral Change (Nobles, Goddard and Cavill) NTU (Phillips); Recovering A-NEW (Beavers) • Not standard care

29. Trauma-Focused Treatment in CBO’s • Provided for AA, and other minorities In HSA’s • Individual trauma processing • Provided frequently • Requires extended individual care • Group trauma processing • Most common form of trauma-focused treatment • Usually connecting/bonding and telling • Emphasis on safety/trust, support • Powerful, positive emotional experience • Not clear about benefits

30. CB Theoretical Models of PTSD • Behavioral Model (Keane) • Cognitive Models • Emotion Processing Theory (Foa) • Dual Representation Theory (Brewin) • Cognitive Theory of PTSD (Ehlers & Clark)

31. Behavioral Model of PTSD (Keane et al., 1985) • Based on Mowrer’s Two-Factor Learning Theory • Factor 1: Classical Conditioning : Traumatic Event (UCS) paired with Neutral Stimuli (External and Internal) leads to them becoming triggers (CS) of trauma-related distress (CRs). • Factor 2: Operant Conditioning : Trauma triggers (CS) are avoided (or escaped) reducing distress in the short term (- reinforcement) • Failure to Extinguish CR

32. Behavioral Model of PTSD (Nobels, Goddard, and Cavil et al., 1995 • ATHUENTIC • ADAPTED • ADOPTED • ABBERANT • Moving from Aberrant to Authentic State. • ‘African Centered Behavioral Change Model’

33. Treatment Implications of Behavioral Model • Habituation to trauma-related distress • Repeated exposure to trauma triggers (CS) (external and internal) in absence of negative consequences (UCS) (i.e. extinction of CS) • Discrimination between dangerous and safe situations

34. Emotion Processing Theory (Foa) • PTSD as impaired emotional processing of trauma • Very large pathological fear structure of traumatic event • Contains trauma stimuli, responses, and meaning elements • Easily activated (ambiguous stimuli) and disruptively intense • Disorganized and fragmented • Unrealistic elements • Harmless stimuli associated with escape or avoidance responses • Contain erroneous evaluations or interpretations • “Anxiety will persist until escape” • “Fear will cause harm” (go crazy, become ill) • “These consequences are terrible”

35. Treatment Implications Of Emotional Processing Theory of PTSD • Fear structure must be activated • Exposure • New corrective information must be provided that is inconsistent with pathological elements of fear structure. Via… • Safety • Habituation • Acceptance • Narratives change in successive retellings • Fewer unfinished thoughts, repetitions • Increased reading level of narrative

36. Imaginal Exposure Tactics • 45-90 minutes • Ask for (sensory) details of scene to increase access to memories • Details of scene • Sensory details • As if happening now (use first person to describe) • Ensure slow attention to emotional aspects of memory • Include attention to thoughts and feelings at time of traumatization • Watch for emotional avoidance

37. Exposure Therapy Points (Rothbaum) • Patients should remain in exposure situation long enough for their anxiety to decrease. • Patients should be allowed to progress at their own pace. • Patients should be praised for exposures completed and encouraged to push themselves further. • The clinician should acknowledge how difficult exposure therapy is for the patient.

38. Therapeutic Comments During Imaginal Exposure (Rothbaum) • You’re doing fine, stay with the image. • You’ve done very well. It took some courage to stick it out. • Stay with your feelings. • I know this is difficult. You’re doing a good job. • Stay with the image, you are safe here. • Feel safe and let go of the feelings.

39. Dual Representation Theory (Brewin) • Trauma can lead to 2 types of memory • Verbally-accessible memories (VAMS) (Cortical) • Representations of conscious experience of the trauma • Can be deliberately retrieved • Especially, “meanings” • Situationally-accessible memories (SAMS) (Limbic) • Representations of non-conscious experience • Cannot be deliberately accessed • Representations accessed automatically when in presence of trauma cues/reminders • Conditioned emotional responses

40. Dual Representation Theory (Cont) • 3 endpoints of emotional processing • Completion/integration • Chronic emotional processing (Rumination) • Permanent preoccupation with consequences of trauma and intrusive memories • Premature inhibition of processing • Results from avoidance • Continued phobic avoidance • Somatization • Vulnerable to reactivation later in life

41. Treatment Implications Of Dual Representation Theory of PTSD • SAMS (hot spots) should be identified and transferred into VAMS (cortical inhibition) • Exposure • These new VAMS will compete with the SAMS when triggers are encountered

42. Cognitive Theory of PTSD • Two key processes lead to sense of threat • Differences in appraisal of trauma and sequelae (e.g., intrusive symptoms) • Differences in nature of memory and link to other memories • Perceived threat also motivates behavioral and cognitive responses that prevent cognitive change and therefore maintain the disorder

43. Cognitive Theory of PTSD • Memories characterized by • Mainly sensory impressions • Sense that “happening right now” • Original emotions and sensory impressions are reexperienced • Affect without recollection • Involuntary reexperiencing triggered by wide range of stimuli and situations

44. Treatment Implications Of Cognitive Theory of PTSD • Trauma memory needs to be elaborated and integrated into context of individual’s preceding and subsequent experience • Problematic appraisals that maintain sense of threat need to be modified • Dysfunctional coping strategies that prevent recovery need to be dropped

45. Cognitive Theory of PTSD (Ehlers and Clark) • Individuals with PTSD have “idiosyncratic negative appraisals of the traumatic event and/or its sequelae that have the common effect of creating a sense of serious current threat” • (Ehlers & Clark, 2000, p. 320)

46. Meaning of PTSD • I am a failure

47. Some Negative Appraisals among Female Client’s • I will always be sick and useless. • I let my hommies down because I couldn’t help (watch their back). • I make bad decisions. • Bad things happened because of me. • I am a failure because I was afraid. • I will never have a normal life or normal relationships. • I am an awful person because I couldn't stop that child from being shot. • I wasn’t strong enough (punkn’t out). • I am ashamed of myself and my actions. • I can’t ever get out of this! • I should have been able to stop what was going on around me.

48. Some Negative Appraisals (cont) • I should have been able to save m brother. • I wish I could get out of the hood. • I am the only person I know who got so screwed up from community everyone else is dead. • Know one cares about us. • I can no longer be a good person, etc.). • My friend got killed for nothing. • It seems like everyone besides my hommies hate us and don’t want us around. • If I get close to someone, I’ll hurt them or they might hurt me. • Once a rejection, always a rejection. I’ll never be able to be a normal person again. • My family don’t understand the person I’ve become.

49. Cognitive Processing Therapy • Developed to help trauma survivors… • Understand how thoughts and emotions are interconnected • Accept and integrate the trauma as an event that actually occurred and cannot be ignored • Experience fully the range of trauma-related emotions • Analyze and confront maladaptive beliefs • Explore how prior experiences and beliefs affected reactions and were affected by trauma

50. Session Outline • 1: Introduction and education • 2: The meaning of the event • 3: Identification of thoughts and feelings • 4: Remembering the trauma • 5: Identification of stuck points • 6: Challenging questions • 7: Faulty thinking patterns