Dr Michael J Scott michaeljscott1virginmediacom Fight or Flight In the new DSM 5 Criteria for PTSD Fight can b e a s i mportant a s Flight Whilst avoidance continues to be part of the symptom profile Fight is given increased recognition ID: 427078
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Slide1
The Truculent Client
Dr Michael J Scott
michaeljscott1@virginmedia.com
Slide2
‘Fight’ or ‘Flight’
Slide3
In the new DSM 5 Criteria for PTSD ‘Fight’ can b
e
a
s
important as ‘Flight’
Whilst avoidance continues to be part of the symptom profile, ‘Fight’ is given increased recognition.
Cluster E in DSM 5 refers, amongst other symptoms, to:
Irritable or aggressive behaviour
and
R
eckless or self-destructive behaviourSlide4
The Incongruence of Client and Therapist Agendas in Trauma Focussed CBT (TFCBT)Slide5
The Powder Keg of Cognitive Avoidance and Increased IrritabilitySlide6
A Vignette Of The Truculent Client
Therapist:
I’ve noticed that you keep looking at the door
Client:
I just want to go
Therapist:
Why is that?
Client:
You’ve got it all there in the notes, and you are asking me about it, haven’t you even bothered to read the records!Slide7
Preventing Derailment
Anger leads to therapist non-compliance with evidence based treatment protocols.
Barlow et al. 2013
Derailment can be prevented by:
Fidelity to a cognitive model of the disorder and
Flexibility in the use of evidence based treatment protocolsSlide8
A DSM 5 Based CBT Model of PTSD
CBT for Common Trauma Responses . London: Sage Publications.
Scott et al.
2012 Slide9
Intrusions in PTSD clients a
re
e
xperienced as unwanted
surprisesTreatment should focus on the management of surprises by the distillation of coping self-statements in 4 stages:
1. Preparing for the stressor
e.g
flashback
2. Encountering the stressor
3. Coping with feeling overwhelmed by the stressor
4. Review of coping effortsSlide10
Anger can be viewed as ineffective
c
oping with a state of terrified
s
urpriseIneffective Coping
A Preventative Function
A Restorative Function
‘
Control Freak’
Disproportionate anger when startled
Avoidance of talking about the trauma
Slide11
Anger and avoidance can
a
lso be addressed using
coping self-statements1. Preparing
for
anger/ avoided situation
2. Encountering
the
anger / avoided situation
3. Coping
with feeling overwhelmed
4. Reflection
on copingSlide12
Psycho-education to prepare for stressors
Useful metaphors
The ‘dodgy alarm’, ’bubble’, ‘lemonade bottle without the top on’
Distress as inappropriately going back in the ‘
Tardis’ to the memory of the trauma and constructing a model of current threat from elements retrieved in this time machine. Focussing on using a different ‘construction kit’. Slide13
The use of coping Self-Statementsconstitutes a Non-Trauma Focussed CBT intervention that
i
s particularly
a
pt for‘The Truculent Client’Slide14
Coping Skills and the Truculent Client
A ‘coping skills’ approach:
Makes it easier to market ‘better ways of handling the flashbacks’ than TFCBT
Is an alternative for those who refuse TFCBTMay be a first step in facilitating TFCBTSlide15
The effectiveness of a Coping Skills approach to PTSD
Increasing evidence
that a coping skills approach to PTSD is effective
The Cochrane Collaboration. Chichester: John Wiley & Son Ltd.
Bisson
et al. 2009
A comparison of Coping Skills/CBT with Support/CBT found:
1. Lower dropout rate in the Coping Skills/CBT group (17%
cf
38%)
2. No difference in recovery between groups at end of treatment
3
. At follow up a significantly higher proportion of clients had recovered from PTSD in the Skills/CBT group (72%
cf
50%)
Psychological Medicine.
Epub
ahead of print. Bryant et al. 2013Slide16
Presentation available at:
michaeljscottptsd.com
Thank You