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Pre-Meeting Institutes (PMI)

Pre-Meeting Institutes are full- or half-day sessions that provide opportunities for intensive training on topics integral to the conference program, presented by leaders in the field.

NOTE: Presenter names are BOLDED, Discussant names are UNDERLINED

8:30 a.m. – Noon, 1:30 – 5:00 p.m.

Cancelled: PMI – 01: Cognitive-Behavioral Conjoint Therapy for PTSD: An Update on the Evidence and Techniques for Delivery

Cancelled: PMI – 02: Helping Children and Families at Highest Risk: Trauma Systems Therapy to Establish and Maintain Safety

PMI – 03: Mental Health Care for Refugee and Immigrant Youth and Families: Evidence-Based Strategies for Providers and Programs 

PMI – 04: Trauma-Informed Change-Making: A Contextualized Model for Strengthening Systems of Support within Communities Affected by Historical and Collective Trauma

8:30 a.m. – Noon

PMI – 05: Trauma-Focused Cognitive-Behavioral Therapy: Advancements and Clinical Applications 

PMI – 06:  Brief Eclectic Psychotherapy (BEPP) for Complex Trauma and Traumatic Grief

PMI – 07: Child-Adult Relationship Enhancement (CARE): Building Skills for Charting a Positive Course to Strengthening Relationships and Promoting Resilience after Trauma in Children and Teens 

PMI – 08: STAIR Narrative Therapy: Using Relational Models to Guide Treatment

PMI  09: Caring for Veterans with PTSD and Moral Injury at the End of Life

1:30 – 5:00 p.m. 

PMI – 10: Cue-Centered Therapy for Chronic Trauma  

PMI - 11: Seeking Safety: A Summary of the Model, New Developments, and Questions

PMI  12: Treating Traumatized Children Who Have Intellectual and Developmental Disabilities: Adapting Trauma-Focused Cognitive Behavior Therapy

PMI  13Trauma Informed Guilt Reduction (TrIGR): A Transdiagnostic Therapy for Guilt and Shame from Trauma and Moral Injury

PMI  14Introduction to the Neurobiology of PTSD: Key Findings and Methodologies

Wednesday, November 13, 2019
Full Day Institutes
(8:30 a.m. – Noon and 1:30 – 5:00 p.m.)

PMI  - 01

Cognitive-Behavioral Conjoint Therapy for PTSD: An Update on the Evidence and Techniques for Delivery

Keyword: Clinical/Intervention Research
Secondary Keywords: Family Relationship Processes/Interventions 
Population Type: Adult
Presentation Level: Introductory
Region: Industrialized Countries

Monson, Candice, PhD, Cpsych1; Fredman, Steffany, PhD21Ryerson University, Department of Psychology, Ryerson University, Toronto, Ontario, Canada
2Pennsylvania State University, The Pennsylvania State University, 119 Health and Human Development, University Park, Pennsylvania, USA

Cognitive-Behavioral Conjoint Therapy for PTSD (CBCT; Monson & Fredman, 2012) is a manualized psychotherapy delivered in a conjoint format with the simultaneous goals of improving PTSD and enhancing relationships. CBCT has been tested in five uncontrolled and four controlled trials documenting effect sizes for PTSD on par or better than first-line individual treatments, with the added benefit of enhanced relationship satisfaction. Follow-up tests of broader outcomes (e.g., comorbid conditions, partner well-being, parenting efficacy/satisfaction) and moderators and mediators of treatment effects have also been published. In this PMI, we will provide a review of the state of evidence on CBCT, as well as an overview of the three phases of the 15-session treatment protocol. We will discuss recent innovations in CBCT, including the addition of parenting strategies, an abbreviated and accelerated version delivered in a 2-day retreat format, the use of MDMA to facilitate outcomes in treatment-resistant cases, video delivery into the home, and a guided, e-health adaptation delivered direct to consumers. Case examples and video demonstrations of key interventions will be used to facilitate learning.

PMI - 02

Helping Children and Families at Highest Risk: Trauma Systems Therapy to Establish and Maintain Safety

Clinical Practice
Secondary Keywords: Child Physical Abuse/Maltreatment; Chronic/Repeated Trauma; Community-Based Programs
Population Type: Child/Adolescent
Presentation Level: Internediate
Region: Industrialized Countries

Brown, Adam, PsyD; Saxe, Glenn, MD
New York University Langone Medical Center, 1 Park Avenue, New York, New York, USA

What tools do you use to help children and families at highest risk? These are the cases where risk of harm is ever present: either from the child’s impulses for self-harm or to harm others, or from risk for maltreatment. In such high-stakes contexts, clinicians must have access to the highest quality of information on risk, use such information to guide decisions, and enact interventions based on these decisions to result in safe outcomes. Clinicians frequently conduct their work with little guidance for these decisions and actions. Trauma Systems Therapy (TST) has frequently been used to provide this guidance. This full day pre-meeting institute presents the application of TST for cases at highest risk. TST was uniquely designed for this purpose and includes specific tools that can strongly support effective care in such difficult and anxiety-provoking clinical contexts. Such tools include: 1. An assessment approach that indicates the most important drivers of the problems that entail risk, such that intervention can be focused on such drivers, 2. A treatment planning approach that helps guides decisions about the safety of the child’s current environment, 3. A treatment engagement approach that maximizes the potential to arrive at needed agreements with children and families for the establishment of safety, or will indicate that such agreements are not possible, and 4. An advocacy approach that organizes information to maximizes the potential that needed decisions will be made from relevant authorities (e.g. child protection, family court judges) for children’s care and protection. The Institute will begin with an overview of the principles and practice of TST so that participants are well oriented to its approach with children and families at highest risk. We will then cover such topics as: 1. Risk assessment for traumatized children and families, 2. Clinical decision tradeoffs and related risk, 3. Effective engagement of children and families in interventions to manage risk (and refinement of decisions based on observed levels of engagement), 4. Implementing interventions to establish and maintain safety, 5. Effective advocacy for needed interventions and services, and 6. Processes to address vicarious traumatization in contexts of high-risk care.  The Institute will include many relevant case examples in which various aspects of TST were applied. Published data will be presented as well. The afternoon session will focus on cases and will be strongly participatory, eliciting audience involvement in describing challenging cases. These cases will be discussed through application of TST principles and tools, so that participants can derive practical knowledge to apply to the children and families at highest risk, in their care. 

PMI - 03    ;

Mental Health Care for Refugee and Immigrant Youth and Families: Evidence-Based Strategies for Providers and Programs

Secondary Keywords: Clinical/Intervention Research; Community-Based Programs; Culture/Diversity; Refugee/Displacement Experiences
Population Type: Lifespan
Presentation Level: Intermediate
Region: Industrialized Countries

Ellis, Heidi, PhD1; Abdi, Saida, LICSW2; Winer, Jeffrey, PhD1; Cardeli, Emma, PhD1; Miller, Alisa, PhD1; Issa, Osob, MSW1; Mulder, Luna, PsyD2
1Children's Hospital Center for Refugee Trauma & Resilience/Children's Hospital Boston, 300 Longwood Avenue, Boston, Massachusetts, USA
2Boston University/Children's Hospital Center for Refugee Trauma & Resilience/ Children's Hospital Boston, 300 Longwood Ave, Boston, Massachusetts, USA

Globally, more than 65.6 million individuals have been forcibly displaced. Among them, nearly 25.4 million are refugees and half are under the age of 18 (UNHCR, 2017). Despite the diversity in cultures and journeys, traumatic stress, acculturative stress, resettlement difficulties, isolation and discrimination are common challenges faced by forcibly displaced persons resettled in a new country. In this full-day pre-meeting institute (PMI), our team of trauma-focused clinical psychologists and social workers from the Refugee Trauma and Resilience Center (RTRC), at Boston Children’s Hospital/Harvard Medical School, led by Dr. Heidi Ellis, will provide expert training in evidence-informed strategies for supporting refugee and immigrant youth and families resettled in industrialized countries (with a focus on the United States and Canada). The RTRC is an NCTSN-funded Category II Treatment and Services Adaptation Center that builds upon a 17-year community-based participatory research program focused on promoting the healthy adjustment of refugee and immigrant families resettled in North America. Findings from our studies have been translated into practice, informing the development of both prevention and intervention efforts. This unique training experience will be both didactic and experiential, with ample opportunity for attendees to ask questions, engage in group discussion, participate in experiential activities and role plays, learn concepts through clinical vignettes and common organizational dilemmas, and apply knowledge directly to their current work environment(s). The PMI will be divided into six integrated modules. The first half of the day will be focused on modules 1-3: (1) Introduction to the Refugee and Immigrant Experience; (2) Strategies for Culturally-Responsive Practice; (3) Engaging Refugee and Immigrant Youth and Families in Mental Health Services. Following lunch, the second half of the day is focused on modules 4-6: (4) Psychosocial Assessment with Refugee and Immigrant Youth and Families. (5) Individual- and System-Level Strategies for Working with Refugee and Immigrant Youth and Families; (6) Collaborative and Interdisciplinary Models of Care for Promoting Whole Community Resilience. Attendees will leave this PMI with (1) an enhanced understanding of the current state-of-the-science of refugee/immigrant mental health interventions, (2) an enhanced capacity to make their current clinical work more culturally responsive to the needs of refugee and immigrant communities, and (3) an understanding of key components for building effective and sustainable mental health prevention and intervention programs and partnerships with refugee and immigrant communities.

PMI - 04

Trauma-Informed Change-Making: A Contextualized Model for Strengthening Systems of Support within Communities Affected by Historical and Collective Trauma

Global Issues
Secondary Keywords: Community/Social Processes/Interventions; Survivors/Descendants of Historical Trauma; Training/Education/Dissemination; War – Civilians in War
Population Type: Lifespan
Presentation Level: Intermediate
Region: Eastern and Southern Africa

Yacevich, Ilya, LMFT1; Shankar, Anita, MPH1; D'Andrea, Wendy, PhD2
1Global Trauma Project, Global Trauma Project, Nairobi, Kenya
2New School for Social Research, 80 Fifth Ave., 6th floor, New York, New York, USA

Trauma-Informed Community Empowerment (TICE) is an adaptable, contextualized intervention framework aimed at reducing the impact of trauma by providing skills training in emotion regulation, stress management and conflict resolution to caregivers who offer community support. The program integrates well-established interventions for posttraumatic stress including Psychological First Aid and the Attachment, Regulation, and Competency (ARC) Framework. TICE provides capacity-building support to groups such as refugee camp staff, community leaders and government employees who are doubly at risk because they are themselves trauma-exposed and serving trauma-impacted communities. By working with service providers, TICE ensures that change happens on both systemic and grassroot [WD1] levels through program assessment, staff support, mentoring, curriculum design, training and supervision in locations such as Kenya, South Sudan, Somalia, Ethiopia, Greece and the United States.

GTP's intervention shows promising outcomes, with significant changes in mental health: a 64% decrease in posttraumatic stress symptoms, 26% decrease in emotional dysregulation and 15% improvement in a physiological indicator of stress.

In this course, presenters will:

  1. provide quantitative and qualitative evidence for TICE’s effectiveness, as well as explore factors associated with data gathering in settings with issues of literacy, cultural/ community trauma, and ongoing violence;
  2. provide an overview of the Trauma-Informed Community Empowerment (TICE) Framework, and share lessons learned from developing a National Trauma-Healing Initiative in South Sudan; and
  3. facilitate exploration of issues of power and privilege relevant to working in under-resourced communities.

Participants will identify strategies for implementing programs that are not only trauma-informed but also community-developed and -owned and gain an appreciation for fostering and maximizing longer-term impacts. Presenters will explore strategies for developing and implementing trauma-informed programs in settings where limited resources, language barriers, cultural differences and societal mistrust of providers create initial barriers to successful implementation. Participants will identify how issues of power and privilege impact effective programming and interventions through reflective practice and real-world examples. Program goals include understanding how to contextualize trauma-informed interventions to maximize success for their use beyond the traditional psychotherapeutic context.

This workshop is appropriate for intermediate levels and for those interested in organizational/program
development, community work, peace-building and clinical services.

Wednesday, November 13, 2019
Half-Day Institutes
(8:30 a.m. – Noon)

 PMI - 05

Trauma-Focused Cognitive-Behavioral Therapy: Advancements and Clinical Applications

Clinical/Intervention Research
Secondary Keywords: Complex Trauma; Culture/Diversity; Sexual Orientation and Trauma; Traumatic Grief 
Population Type: Child/Adolescent
Presentation Level: Intermediate
Region: N/A

Cohen, Judith, MD1; Kinnish, Kelly, PhD2; Kliethermes, Matthew, PhD3; Wozniak, Jessica, PsyD4
1Allegheny General Hospital, 4 Allegheny Center 8th Floor, Pittsburgh, Pennsylvania, USA
2Georgia Center for Child Advocacy, PO Box 17770, Atlanta, Georgia, USA
3University of Missouri St. Louis, 1 University Blvd, St. Louis, Missouri, USA
4Baystate Medical Center, 50 Maple St, Springfield, Massachusetts, USA

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is an evidence-based treatment that has been evaluated and refined over the past 25 years to help children and adolescents recover from the negative effects of traumatic experiences. TF-CBT is a components-based model of psychotherapy that addresses the unique needs of children with PTSD symptoms, depression, behavior problems and other difficulties related to trauma (including sexualized behavior, interpersonal trust, self-image, shame, etc.). Numerous randomized trials demonstrate the effectiveness of the model in addressing trauma-related mental health symptoms and impact with children and families. A systematic review by Carey and McMilan (2012) indicated that TF-CBT is more effective than attention control, standard community care or waitlist control conditions for reducing PTSD, depression and problem behavior symptoms in youth immediately after the termination of treatment and for PTSD 12 months post-intervention. Currently, 21 randomized controlled trials have been conducted in the U.S., Europe, Asia and Africa, comparing TF-CBT to other active treatment conditions and waitlist controls. These studies have documented that TF-CBT was efficacious for improving children’s trauma symptoms and have informed the development of applications of TF-CBT. Various research studies now document that TF-CBT is effective with a range of ages, genders, languages, cultures, treatment settings, caregiving circumstances and trauma types including multiple traumas and complex trauma (Carey & McMilan, 2012; Goldbeck, Muche, Sachser, Tutus, & Rosner, 2016).  Two studies have documented positive results of TF-CBT with sex trafficked children in Cambodia and the Congo (O’Callaghan, McMullen, Shannon, Rafferty, and Black, 2013; Bass, Bearup, Bolton, Murray, and Skavenski, 2011). As the research grows, so does the dissemination of TF-CBT to therapists across the world. The combination of growth in empirical research and an increase in community-based providers being trained in the model has led to an influx of implementation applications. These applications support recovery and resilience in some of the most vulnerable underserved populations. The objective of this presentation will be to provide an overview of several key advancements in TF-CBT research in the last two decades, including newly collected data on the implementation of TF-CBT with children and families in Puerto Rico who demonstrate complex trauma symptoms as well as acute symptoms due to Hurricane Maria. This presentation will also provide an overview of targeted treatment applications addressing specific trauma types, populations and cultural contexts including applications for LBGTQ youth, complex trauma, traumatic grief and commercial sexual exploitation/child sex trafficking.

PMI - 06                                  
Brief Eclectic Psychotherapy (BEPP) for Complex Trauma and Traumatic Grief

Keyword: Clinical Practice
Secondary Keywords: Clinical/Intervention Research; Complex Trauma; Refugee/Displacement Experiences; Traumatic Grief 
Population Type: Adult
Presentation Level: Intermediate
Region: Global

Gersons, Berthold, MD, PhD1; Nijdam, Mirjam, PhD2; Smid, Geert, MD, PhD3
1AMC University of Amsterdam, Oosterpark 45, Amsterdam, Netherlands
2Centrum '45 Arq / Academic Medical Center Amsterdam, Meibergdreef 5, PA1-142, Amsterdam, Netherlands
3Centrum 45, Arq Research, Nienoord 5, Diemen, Netherlands

Being overwhelmed by emotions and experiencing loss of meaning hamper complete recovery for PTSD patients. Brief Eclectic Psychotherapy (BEPP) is an effective, comprehensive evidence-based treatment for PTSD. BEPP focuses on working through difficult emotions and grief originating from often multiple trauma. Making meaning of these traumatic experiences, which resulted in the loss of safety and distrust in the world and in one’s own capabilities to go on with life, are central treatment goals. Four randomized controlled trials have proven its efficacy for first responders like police officers and outpatient populations with PTSD (Gersons et al., 2000; Lindauer et al., 2005; Schnyder et al., 2011; Nijdam et al., 2012). Traumatic grief originates from the loss of loved ones by traumatic death due to killings, war, disaster as experienced by most refugees. Based on BEPP, Brief Eclectic Psychotherapy for Traumatic Grief (BEP-TG) helps recovery from traumatic grief. Four different exposure variants can be chosen depending on the symptoms of the patients. Grief-focused exposure may include stimulus exposure if avoidance of grief-related stimuli plays a role in blocking emotional processing. If excessive grieving behaviour is present, diminishing such behaviour is necessary to catalyse the emotional processing of the loss. Finding meaning entails a detailed evaluation of the loss of the loved person and its implications for the future. Writing assignments are useful tools to enable patients to evaluate meanings and to help bereaved individuals to confront painful aspects of the loss. An ongoing farewell letter is also part of this treatment. The BEPP protocol has been translated into English, German, French, Spanish, Italian, Polish, Georgian, Lithuanian, and Korean.  

In this PMI, participants will get acquainted with the five components of the BEPP and BEP-TG protocols: psycho-education, imaginal exposure to the traumatic event, use of writing assignments and mementos, psychodynamic insights in the phase of meaning-making and integration, and a farewell ritual. Special emphasis will be placed on the application and practice of these techniques in the treatment of individuals with complex PTSD characteristics, such as affect dysregulations, negative self-image, dissociative symptoms and problems in sustaining relationships.   

Fragments of videotaped treatments will be shown. Short interactive exercises and role plays will be used during the PMI to get to know different elements of BEPP and BEP-TG, and data to evaluate the treatments will be presented.

PMI - 07         

Child-Adult Relationship Enhancement (CARE): Building Skills for Charting a Positive Course to Strengthening Relationships and Promoting Resilience after Trauma in Children and Teens

Prevention/Early Intervention
Secondary Keywords: Developmental Processes/Interventions 
Population Type: Child/Adolescent 
Presentation Level: Introductory
Region: N/A

Gurwitch, Robin, PhD1; Berkowitz, Steven, MD2; Masse, Joshua, PhD3; Kamo, Toshiko, MD, PhD4; Schilling, Samantha, MD5
1Duke University Medical Center, 1121 W Chapel Hill St, Suite 100, Durham, North Carolina, USA
2University of Colorado Anschulz Medical Campus, 13001 E 17th Place, MS F546, Room E2309-1, Aurora, Colorado, USA
3University of Massachusetts Dartmouth, , ,
4Tokyo Women's Medical University, Institute of Women's Health, 9-9, Wakamatsu-cho, Shinjuku, Tokyo, Japan
5University of North Carolina at Chapel-Hill, CB#7240, School of Medicine, Chapel Hill, North Carolina, USA

The field of trauma and our understanding of factors impacting recovery and resilience continue to grow and develop. One factor that remains a constant in supporting healing and resilience is positive relationships. As trauma affects the social relationships of the individual, particularly for children and important adults in their lives, creating positive relationships with these adults can significantly aid the healing process. Relationships are critical in prevention and acute and long-term interventions. Strong relationship skills are key principles of evidence-based parenting programs: Parent-Child Interaction Therapy (PCIT), Incredible Years (IY), Helping the Non-compliant Child, Parent-Management Training—Oregon Model (PMTO) and Positive Parenting Program (Triple P). However, these programs require intensive training and treatment. As a result, access to programs designed to improve relationships is lacking. Child-Adult Relationship Enhancement (CARE) was developed to help address this deficiency. Based on the evidenced-based parenting programs, CARE is a trauma-informed set of skills created to enhance relationships and reduce mild/moderate behavior challenges often present after trauma. CARE is for use by any adult interacting with a child/youth. Thus far, CARE has been disseminated to more than 15,000 adults in the United States and has a strong presence in Japan. Evidence is growing, including through randomized controlled trials, for the effectiveness of CARE with different populations and in a variety of settings. Adaptations have been made for the use of CARE in childcare and school settings, in primary and integrated care settings, with foster parents, with military families, and after disasters and terrorist events. CARE has been taught to staff in child protection services, family and drug courts, substance abuse treatment centers, home visiting programs, and domestic violence shelters and to families in these systems. Medical, mental health, allied health professionals and crisis counselors have received CARE training to complement their services, especially to children experiencing trauma. The CARE workshop will teach participants CARE skills they can immediately implement with families they serve. Handouts for use when working with families will be provided. The workshop will include didactic information, videos, activities, and live practice with feedback for the greatest learning potential. Implementation, dissemination efforts, and research will be discussed, helping participants determine how CARE can be useful in their settings, thus improving their efforts as they chart their services to build resilience in families after trauma. 

PMI - 08

STAIR Narrative Therapy: Using Relational Models to Guide Treatment

Clinical Practice
Secondary Keywords: Developmental Processes/Interventions 
Population Type: Adult 
Presentation Level: Intermediate
Region: Industrialized Countries

Cloitre, Marylene, PhD1; Jackson, Christie, PhD2; Ortigo, Kile, PhD31National Center for PTSD-Dissemination and Training Division, 795 Willow Road, Menlo Park, California, USA
2VA, 423 East 23rd Street (11M) , New York, NY, New York, USA
3National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd, Menlo Park, California, USA

STAIR Narrative Therapy is a two-module resource rehabilitation program for survivors of chronic trauma. It focuses on improving emotion regulation and relational capacities through skills strengthening (STAIR) and on reducing trauma-related symptoms through review and meaning-making of traumatic experiences (Narrative Therapy). A key intervention in both modules is the identification and exploration of trauma-generated "relational models."  Clients' "relational models" are based on past interpersonal experiences that shape expectations, feelings and behaviors about how relationships work. Influenced by attachment theory, these models are understood as adaptive strategies for maintaining relationships and remaining connected to the social environment even under traumatic circumstances. During STAIR, a review of the client’s relational models includes validation of the functional value of trauma-generated relational models as well as an invitation to generate alternative, aspirational models of relating which are tested and supported by an expanded repertoire of emotion regulation and interpersonal skills. During Narrative Therapy, meaning analyses of trauma narratives include identification of old relational models embedded in the narrative and a comparison of these to new emerging models of self and relationships with others that have been initiated during STAIR. The use of relational models across both modules supports the development of an integrated sense of self (old and new) in the context of an evolving and more positive set of expectations about relationships. This approach is particularly pertinent to individuals emerging from environments in which they have been have stigmatized or marginalized due to their identity, such as LGBTQ individuals and to those who have suffered from institutional or interpersonal betrayal trauma such childhood abuse and military sexual trauma.  The workshop will provide intensive training on the identification and analysis of relational models. It will include several examples of trauma-generated relational models, guidelines for the creation of alternative models, role play opportunities, video demonstrations and analyses of cases from the audience as available.

PMI - 09                        

Caring for Veterans with PTSD and Moral Injury at the End of Life

Community-Based Programs
Secondary Keywords: Community/Social Processes/Interventions; War – Military/Peacekeepers/Veterans; Aging/Lifecourse; Moral Injury
Population Type: Older People/Aging
Presentation Level: Intermediate
Region: Industrialized Countries

Watson, Patricia, PhD1; Bruce, LeeAnn, PhD, LCSW2; Ermold, Jenna, PhD3
1National Center for PTSD, Executive Division, 215 North Main Street, White River Junction, Vermont, USA
2Intimate Partner Violence Assistance Program, VA Central Office, Washington, District of Columbia, USA
Center for Deployment Psychology, Rockville, Maryland, USA

The Empowering Community Hospices Initiative has put together practical materials improve the care of terminally ill Vietnam-era Veterans with posttraumatic stress disorder (PTSD) and moral injury) especially those Veterans receiving care in the community as delivered by community hospice teams which often lack a dedicated psychologist or training in these areas. This PMI will provide practical strategies the group has created by adapting the existing evidence base on the identification and treatment of PTSD or Moral Injury for a terminally ill population of Veterans, such as those receiving community hospice (e.g., life expectancy on average of about a month) given the limitations of the typical community hospice care team structure which often lacks mental health expertise. The workshop will:

  • Identify best practices and evidence-based interventions, as applied to terminally ill Veterans
  • Discuss survey data from 2700 bereaved families of Vietnam-era Veterans
  • Provide practical, efficient information about caring for Veterans with PTSD and moral injury for family, nurses, chaplains, social workers and clinicians in settings that care for terminally ill Veterans, such as community hospice settings
  • Provide guidance for efficient screening and referral of Veterans at risk
  • Give references to key resources
  • Describe how caregivers can use self-care and peer support to aid them in working with terminally ill Veterans with PTSD and moral injury

Wednesday, November 13, 2019
Half-Day Institutes
(1:30 – 5:00 p.m.)

 PMI - 10                                  

Cue-Centered Therapy for Chronic Trauma

Clinical Practice
Secondary Keywords: Chronic/Repeated Trauma; Complex Trauma
Population Type: Child/Adolescent
Presentation Level: Intermediate
Region: Industrialized Countries

Kletter, Hilit, PhD1; Matlow, Ryan, PhD2; Carrion, Victor, MD2
1Stanford University School of Medicine, 401 Quarry Road, Stanford, California, USA
2Stanford University School of Medicine, 1520 Page Mill Rd., Palo Alto, California, USA

Despite existing high quality interventions for traumatized youth, the population of youth experiencing trauma-related distress is extremely heterogeneous, and new approaches and modalities continue to be needed, as not all youth respond to existing treatments. Specifically, youth with experiences of chronic trauma exposure and ongoing adversity may not benefit from processing isolated traumatic events and thus more efforts are needed to help them develop insight, adaptability and personal empowerment in response to complex trauma reactions. Cue-Centered Therapy (CCT) was developed in recognition of the growing need for a manualized treatment to increase youth insight into how an individual’s trauma history may relate to current cognitive, emotional and physiological experiences and how these in turn may be linked to difficulties with behavior and interpersonal functioning.  A randomized controlled trial of CCT compared to a wait list group found that CCT was effective in reducing youth posttraumatic symptoms and improving overall functioning as well as reducing caregiver anxiety with treatment gains maintained over time (Carrion et al., 2013). In CCT, youth and their caregivers learn and apply principles of classical conditioning as they explore and identify adaptive responses to trauma cues.  CCT includes exploration of youths’ life history of positive and negative experiences, culminating in the processing of chronic stress history and ongoing trauma cues through narrative and gradual exposure techniques.  CCT developers will present an overview of the flexible 15-18 session intervention protocol intended for youth ages 8-18 exposed to chronic, ongoing trauma. CCT is intended for youth with a high allostatic load due to trauma exposure and can be used to address multiple trauma types.  CCT has been delivered in multiple languages (with manuals currently available in English and Spanish) and has been used in school, clinic and community settings. Trainers will discuss and demonstrate how CCT integrates and builds upon core components of existing trauma interventions. Theoretical concepts, goals and objectives for each phase of CCT will be described and case examples will be used to demonstrate core CCT practices. Existing evidence and an update on ongoing research evaluating CCT will be presented.  This interactive workshop will include didactic presentation, group discussion and reflection, and skill practice; attendees will be invited to provide feedback and explore application of CCT with their own patient populations and to engage in discussion of common challenges in the treatment of chronic and ongoing trauma.

PMI - 11

Seeking Safety: A Summary of the Model, New Developments, and Questions 

Community-Based Programs
Secondary Keywords: Clinical/Intervention Research; Complex Trauma; Public Health; Substance Use/Abuse
Population Type: Lifespan
Presentation Level: Intermediate
Region: Industrialized Countries

Najavits, Lisa, PhD1; Schmitz, Martha, PhD, ABPP2
1Treatment Innovations, 28 Westbourne Road, Newton Centre, Massachusetts, USA
2San Francisco VA Medical Center and UCSF, 4150 Clement Street (116P), San Francisco, California, USA

Seeking Safety is an evidence-based behavioral model designed for trauma and/or addiction. It is a present-focused coping-skills model that has been widely implemented with numerous populations, including homeless, criminal justice, transition age youth, and seriously mentally ill. This presentation will describe the model briefly and offer a summary of new findings and clinical expansions. Developments include peer-led Seeking Safety, use of the model with adolescents and for gambling disorder, mobile apps related to Seeking Safety, and various language translations and clinical guides. We will also focus on key questions on Seeking Safety including its evidence base and how it compares to other models for  PTSD and/or substance abuse. The workshop will be interactive and allow time for audience questions and discussion.

PMI - 12

Treating Traumatized Children Who Have Intellectual and Developmental Disabilities: Adapting Trauma-Focused Cognitive Behavior Therapy

Clinical Practice
Secondary Keywords: Assessment/Diagnosis; Culture/Diversity
Population Type: Child/Adolescent
Presentation Level: Intermediate
Region: Industrialized Countries

Hoover, Daniel, PhD, ABPP1; D'Amico, Peter, PhD, ABPP2
1Kennedy Krieger Institute Family Center, 1750 East Fairmount Ave, 2nd Floor, Baltimore, Maryland, USA
2LIJ Medical Center, Northwell Health System, 75-59 263rd Street, Glen Oaks, New York, USA

For over two decades, many children with trauma-related symptoms have been effectively treated with Trauma-Focused Cognitive Behavior Therapy (TF-CBT). The model’s flexibility and applicability to children and families of varying cultures and types of trauma are major strengths. The efficacy of TF-CBT has been demonstrated in more than a dozen randomized controlled trials and across the developmental spectrum for multiple index traumas and settings. Children with intellectual and developmental disabilities (IDD) are an underserved and poorly understood group among mental health clinicians and those who treat traumatic stress. They are exposed to maltreatment, bullying, potentially traumatizing medical and restraint procedures, and other adverse childhood experiences at a rate conservatively estimated to be 2-3 times that of their non-disabled peers. Efforts are underway for adapting TF-CBT to meet the needs of children and caregivers with significant limitations in cognitive, language and other executive functions. As there is a growing evidence base for the effectiveness of cognitive-behavior therapy for anxiety in autism spectrum disorders, this literature is being tapped as a guide for approaching the broader IDD population.

The two presenters, one a certified TF-CBT trainer and the other a director of a trauma clinic serving children with IDD, will start with the issue of bias and “diagnostic overshadowing” in the assessment of IDD/Trauma cases, including the importance of child self-reporting and the current state of the literature in this area. They will then present a formal model based on a “matrix” of TF-CBT steps which allows for flexibilty within fidelity of the treatment relying on assessments of the child and caregivers’: a) verbal comprehension; b) visual-spatial skills; c) sensory differences; d) motivation for treatment; and e) ability to generalize skills learned in therapy. Recommendations for treatment structure, process, and supplemental resources from the IDD/autism literature will be provided. The steps and approach will be illustrated by clinical case examples.

PMI - 13

Trauma Informed Guilt Reduction (TrIGR): A Transdiagnostic Therapy for Guilt and Shame from Trauma and Moral Injury

Clinical Practice
Secondary Keywords: Affective Processes/Interventions; Cognitive Processes/Interventions 
Population Type: Adult
Presentation Level: Intermediate
Region: Industrialized Countries

Norman, Sonya, PhD1; Davis, Brittany, PhD2; Capone, Christy, PhD3; Allard, Carolyn, PhD4; Browne, Kendall, PhD5
1National Center for PTSD, UC San Diego, San Diego, California, USA
2James A. Haley VA Hospital, 13000 Bruce B Downs Blvd, Tampa, Florida, USA
3Department of Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, Rhode Island, USA
4Alliant International University, California School of Professional Psychology, Alliant International University, 10455 Pomerado Rd, San Diego, California, USA
5Center of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Healthcare System; Department of Psychiatry & Behavioral Sciences, University of Washington, 1660 S. Columbian Way, MC: S-116-ATC, Seattle, Washington, USA

Guilt and shame stemming from one's actions or inactions during a traumatic event are risk factors for greater severity of subsequent problems such as posttraumatic stress disorder, depression, substance use disorders, and suicidality. Trauma-related guilt and shame are also core components of moral injury. This pre-meeting institute will begin with a review of the presenters’ and extended research showing that guilt and shame from trauma are related to more severe mental health and functional impairment (e.g., Browne, Myers. Trim, R., & Norman, 2015; Norman, Haller, Kim, … Rauch, 2018). We will present a conceptual model (Non-Adaptive Guilt and Shame; NAGS) to explain these relationships (Norman, Wilkins, Myers, & Allard, 2014). We will share psychometrically strong measures for assessing posttraumatic guilt and shame that can be used for treatment planning and to assess progress throughout treatment (e.g., The Trauma Related Guilt Inventory by Kubany et al., 1996 and the Trauma Related Shame Inventory by ├śktedalen, et al., 2014). The majority of the PMI will be focused on the Trauma Informed Guilt Reduction (TrIGR) therapy protocol (Norman, Allard, Browne, Capone, Davis & Kubany, in press), a six-session cognitive behavioral and acceptance based manualized psychotherapy designed to help trauma survivors accurately appraise posttraumatic guilt and shame and re-engage with important values to aid in recovery from posttraumatic distress. After reviewing completed and in-progress research on TrIGR, we will describe the protocol session by session, using in-person instruction, example videos and role plays. How to apply the protocol to a variety of trauma types including combat, sexual assault, and motor vehicle accidents will be described. Finally, we will discuss strategies to address posttraumatic guilt and shame within other treatment models such as Prolonged Exposure and Cognitive Processing Therapy (Norman and Rodgers, 2014).

PMI - 14

Introduction to the Neurobiology of PTSD: Key Findings and Methodologies

Secondary Keywords: Assessment/Diagnosis; (Neuro)Biological Processes/Interventions; Genetics/Epigenetics; Neuro Imaging
Population Type: Adult
Presentation Level: Introductory
Region: Industrialized Countries

Hayes, Jasmeet, PhD1; van Rooij, Sanne, PhD2; Pineles, Suzanne, PhD3; Logue, Mark, PhD4
1The Ohio State University, College of Arts and Sciences, , Ohio, USA
2Emory University School of Medicine, 69 Jesse Hill Jr Dr SE, Atlanta, Georgia, USA
3National Center for PTSD, VA Boston Healthcare System, Boston University School of Medicine, 150 S Huntington Ave, Boston, Massachusetts, USA
4VA Boston Healthcare System & BUSM, 72 East Concord St., Boston, Massachusetts, USA

Recent advances in neuroimaging, biochemistry and genetics research have paved the way for a greater understanding of the neurobiology of trauma and stress. As new technologies and methods are discovered and applied to neurobiological work, it becomes increasingly important for individuals interested in treating and studying PTSD to learn the tools necessary to evaluate the latest research findings. The purpose of this pre-meeting institute is to provide attendees with an introduction to contemporary biological approaches used to study PTSD, including methodological advantages and limitations inherent in these approaches. The target audience includes clinicians, researchers and students with basic knowledge of the biological aspects of traumatic stress. We will review the following topics:

  1. Structural and Functional Neuroimaging of PTSD: This talk will provide an overview of how neuroimaging data are collected, processed and analyzed and the inherent limitations and advantages of neuroimaging methods. Discussion will include an introduction to advanced tools to image neural networks that play a crucial role in the development and maintenance of PTSD.
  2. Neuroimaging of PTSD treatment: Recent longitudinal neuroimaging studies have identified predictors for PTSD treatment response. This section will include an overview of brain regions that are related to treatment outcome and will interpret these brain results in the context of trauma-focused therapy. Finally, it will discuss potential implications for novel brain-based (additive) treatments for PTSD.
  3. Considering Hormones in PTSD Research: Gonadal hormones have downstream effects on several neurobiological processes implicated in PTSD. Because estrogen and progesterone fluctuate at different phases of the menstrual cycle, scientists often have to make difficult decisions about how to conduct neurobiological research in samples that include premenopausal women. Discussion will include the theoretical importance of this topic as well as practical aspects of measuring menstrual cycle phase. 
  4. Genetics of PTSD: A mix of genetic and environmental influences determines an individual’s risk of psychiatric disorders such as PTSD. Discussion in this section will include methods used to understand and characterize the genetic determinants of PTSD risk including twin studies, candidate gene studies and genome-wide association studies. Gene expression and epigenetic studies and how they are providing insight into the biological underpinnings of PTSD will also be discussed.