✅ L4 - Trauma

Question 1

Overview of trauma (recap of last year’s content)?

Answer 1

1. What is trauma?
   - Definition: Exposure to events that have lasting (negative) impacts on mental, physical, emotional and/or social well-being.
   - Worse if traumatic experience is: repeated or prolonged, interpersonal, multiple or occurring at critical stage of development.
2. What causes trauma?
   - Adverse Childhood Experiences (ACEs): set of 10 traumatic events occurring before the age of 18.
   - Prevalence: 47% reported >1 ACE and 9% reported >4 ACEs (UK)
   - Impact: biological, psychological and social consequences, lead to reduced lifespan.
   - Link between ACEs and mental health (depression and anxiety)
   - Strong link between ACEs and psychosis.

Question 2

What are the 4 difficulties people who experienced ‘typical’ traumatic events faced? How is ‘complex’ trauma different?

Answer 2

1. Intrusions:
   - Intrusive memories (flashbacks)
   - Having nightmares
   - Experiencing distress when confronted trauma reminders
2. Avoidance: to trauma-related thoughts and feelings, events resembling stressors
3. Hyperarousal:
   - Difficulty sleeping
   - Irritability (outbursts of anger)
   - Difficulty concentrating
   - Exaggerated startle response
4. Alteration in mood/beliefs
   - Inability to recall traumatic event’s features
   - Change in beliefs (self-world-others)
   - Persistent trauma-related emotions (e.g. fear, guilt, shame)
5. What are complex trauma? (like normal but also have trouble in)
   - Forming and maintaining close relationships with others
   - Emotion regulation (e.g. strong ones like fear & anger, or emotionally numb)
   - Self-concept: negative beliefs about oneself (e.g. shame, guilt)

=> About 20-30% of people experiencing trauma events developed PTSD

Question 3

What is NICE recommended therapy treatment options and duration for PTSD?

Answer 3

1. Offer trauma-focused CBT intervention to adult diagnosed with PTSD or related symptoms who have presented more than 1month after a traumatic event. These interventions include:
   - Cognitive processing therapy
   - Cognitive therapy for PTSD
   - Narrative exposure therapy
   - Prolonged exposure therapy.
   => EMDR is recommended for non-combat related trauma only
2. Recommended that treatment should :
   - Last over 8-12sessions, more if clinically indicated (e.g. experienced multiple traumas)
   - Psychoeducation on: reactions to trauma, strategies for managing arousal and flashbacks, safety planning
   - Elaboration and processing of the trauma-related memories + emotions (e.g. guilt, shame) -> help overcome avoidance
   => NOT excluding people with PTSD from treatment based solely on multiple drug or alcohol misuse.

Question 4

How to establish stabilisation in treatment for people with PTSD?

Answer 4

1. Psychoeducation: understand how the body responses to trauma (e.g. tolerance, memory processing)
2. Grounding: help stay present (prevent intrusive traumatic thoughts) => Examples: breathing rhythm and guided meditation (mindfulness)
3. Trigger discrimination: a strategy for breaking associations between past trauma and present cues (reminders)

Question 5

What is meant by a defence cascade?

Answer 5

1. What is defense cascade: Steps of body’s reflex response to potential stressor (same response for bio/psych/social stressors)
   => Not a conscious process
2. Features:
   - Has 6 stages: (1) Freeze -> (2/3) Flight/Fight -> (4) Fright -> (5) Flag -> (6) Faint
   - Increase arousal from (1)->(4)
   - Decrease arousal from (4)->(6)
   - Increasing dissociation (grasp of reality) from 1-6
   - Stage (4) is peak arousal and peak stressor response

Question 6

What are the key goals and procedure of trauma-focused (TF) CBT?

Answer 6

1. Establish key goals of TF CBT:
   - Elaborate trauma memory.
   - Evaluate memory appraisals.
   - Work on unhelpful coping strategies.
2. Updating trauma memories:
   - Identify trauma memories “hotspots” and explore meaning
   - Evaluate meaning and info to update this meaning to “hotspots”.
3. Working on coping strategies:
   - Evaluate effectiveness of coping strategies
   - Try out new strategies, usually in a behavioural experiment.
4. Re-claiming life:
   - Introduce hobbies stopped because of trauma
   - Identify achievable first-step
   - HW activities during therapy

Question 7

Explain the procedure of Narrative Exposure Therapy (NET)? What are the therapeutic elements of NET and its efficacy?

Answer 7

1. Procedure:
   - Normalisation and psychoeducation.
   - Laying + narrating the lifeline (client narrate their life in detail, including both traumatic and positive events, especially going through traumatic events in slow motion)
2. Therapeutic elements of NET with proven efficacy
   - Prolonged exposure to “hotspots” and activation of fear memory
   - Linking traumatic responses with context (time, place, life)
   - Revisiting of positive life experiences for support and to adjust basic assumptions.
3. Evidence: Effective
   - Schaal et al (2009) compared NET with IPT for Rwandan genocide orphans.
   - At 6-month follow-up, only 25% of NET, but 71% of IPT participants still fulfilled PTSD criteria
   => Follow-up makes a difference

Question 8

What is meant by trauma-informed care?

Answer 8

1. What is trauma-informed care: relates to creating services that aim to reduce harm and promote healing.
2. Why is this important? Therapeutic services can re-traumatize service users by replicating abusive relational patterns (e.g. removing choice, being overly controlling, lack of collaboration, focus on the individual as the problem)
   => Trauma can influence the way that someone makes sense of and responds to their surroundings.
3. The goals of a trauma-informed approach:
   - To raise awareness among staff impact of trauma.
   - To prevent re-traumatisation of clients.
   - To prevent putting trauma on staff’s working with traumatic clients

Question 9

What are the 6 key principles of trauma-informed care?

Answer 9

1. Safety
2. Trust
3. Choice
4. Collaboration
5. Empowerment
6. Cultural consideration

Question 9

What are considered as trauma-informed approach? (at both services and staff level)

Answer 9

1. At services level:

• Applying a “trauma lens” to all policies and procedures.
• Minimise barriers to access.
• Being aware of imbalance of power.
• Prioritising relationships and being conscious of breaks and endings.
• Use of language.

2. At staff level:

• Clear, consistent, reliable
• Gentle approach (e.g. active listening, empathic responding)
• Respect service users wishes.
• Clearly communicating boundaries and stick to them.
• Clearly communicate if unable to deliver a plan to services user (acknowledge how they feel)