Multiplex CBT for Traumatized Multi-Cultural Populations

229 Pages·2022·3.543 MB·English

by  Devon E. Hinton

Multiplex CBT for
Traumatized Multicultural
Populations
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Multiplex CBT
for Traumatized
Multicultural
Populations
Treating PTSD and Related Disorders
Devon E. Hinton
HarvardMedicalSchool
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DOI:10.1017/9781009072458
©CambridgeUniversityPress2022
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Firstpublished2022
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LibraryofCongressCataloging-in-PublicationData
Names:Hinton,DevonE.author.
Title:MultiplexCBTfortraumatizedmulticulturalpopulations:treating
PTSDandrelateddisorders/DevonE.Hinton.
Description:NewYork,NY:CambridgeUniversityPress,2022.|Includes
bibliographicalreferencesandindex.
Identifiers:LCCN2021051452(print)|LCCN2021051453(ebook)|
ISBN 9781009073394(paperback)|ISBN9781009072458(ebook)
Subjects:MESH:CognitiveBehavioralTherapy–methods|StressDisorders,
Traumatic–therapy|CulturallyCompetentCare–methods|Minority
Groups–psychology|Refugees–psychology|BISAC:PSYCHOLOGY/Mental Health
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425.5.C6|DDC616.85/21–dc23/eng/20211124
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drawnfromactualcases,everyefforthasbeenmadetodisguisetheidentitiesoftheindividualsinvolved.
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Contents
TherapistIntroduction 1 Session8: EducationAboutBreathing
andItsUsefor
Session1: EducationAbout
Relaxation 97
Trauma-RelatedDisorder
andtheIntroductionof Session9: SleepDisturbance 109
EmotionRegulation
Session10: WorryandGeneralized
Techniques 25
AnxietyDisorder 122
Session2: AppliedStretchingandthe
Session11: AngerandAnger
Toe-to-HeadMuscle
Protocol 136
Relaxationwith
Visualization 37 Session12: SomaticSymptomsIand
Review 142
Session3: ReviewoftheToe-to-Head
MuscleRelaxationwith Session13: SomaticSymptomsIIand
Visualizationandthe Review 152
IntroductionoftheAnxiety
Session14: CulturalSyndromesand
Protocol 45
FinalReview 162
Session4: EducationAboutTrauma
andIntroductionofthe
Trauma-RecallProtocol
(TRP) 53
AppendixA:StretchingHandout 174
Session5: EducationAbout AppendixB:Toe-to-HeadRelaxation
Trauma-RelatedDisorder, withVisualization 177
ModificationofCatastrophic AppendixC:AnxietyProtocol 184
Cognitions,andTeaching AppendixD:Trauma-Recall
EmotionalDistancing 61 Protocol 186
AppendixE:AngerProtocol(Anger
Session6: InteroceptiveExposurewith
Toolbox) 192
ReassociationI:Head
AppendixF:TheWorry
Rotation 72
Questionnaire 198
Session7: InteroceptiveExposurewith AppendixG:“ThinkingaLot”
ReassociationII: Questionnaire 207
Hyperventilation 84 Index 217
v
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Therapist Introduction
Why Use This Treatment
Unique Challenges in Treating Minority and Refugee Populations
Thetreatmentoftraumatizedethnicminoritiesandrefugeespresentsextensivechallenges.
TheyoftenhavepoorEnglishfluencyandminimaleducation,andmanyhaveahistoryof
extensivetraumasandaredealingwithseveraltypesofstress,suchasadaptingtoadiffering
sociocultural context and living in poor urban areas with high levels of crime (Hinton &
Lewis-Fernández,2011).Owingtoelevatedstressandtrauma,thesegroupstendtohavenot
onlyPTSDbutalsoelevatedratesofsomaticcomplaints,comorbidanxietydisorders,and
anxiety-type psychopathological processes such as worry, rumination, and panic attacks
(Hinton & Lewis-Fernández, 2011; Hinton, Pich, Marques, Nickerson, & Pollack, 2010);
anotherdisorderofarousal,anger,isalsoamajortreatmentissueinthesegroups(Hinton,
Rasmussen, Nou, Pollack, & Good, 2009). The resulting symptoms often give rise to
catastrophic cognitions about the meaning of the symptom, such as attribution to
a feared cultural syndrome or interpretation in terms of other culturally specific beliefs.
Asanadditionaltreatmentchallenge,thesegroupsoftenpoorlytolerateexposure(Lester,
Resick,Young-Xu,&Artz,2010;Markowitz,2010).
ff
How Culturally Adapted Multiplex CBT Di ers from Other Treatments
Toaddressthesetherapeuticchallenges,wehavecreatedatreatmentforPTSDthatdiffersin
several ways from other standard treatment packages (Foa & Rothbaum, 1998; Resick &
Schnicke,1996).Thetreatmentisbasedonthemultiplexmodelofthegenerationoftrauma-
relateddistress(Figure1).Thismodelwasdevelopedbasedonclinicalworkwithtrauma-
tized refugees with prominent somatic complaints and multiple comorbidities such as
PTSD, GAD, panic, and anger. We have explored this model of psychopathology and its
relevanceforminorityandrefugeepopulationsinmultiplestudies(Hinton&Good,2016;
Hinton, Hinton, Loeum, & Pollack, 2008; Hinton, Hofmann, Pitman, Pollack, & Barlow,
2008;Hinton&Jalal,2019;Hinton&Lewis-Fernández,2011;Hinton,Nickerson,&Bryant,
2011; Hinton & Patel, 2017; Hinton, Pich, Chhean, Pollack, & Barlow, 2004; Hinton &
Simons,2015).Thetreatmentaimstotargetpsychopathologicalprocessesidentifiedinthis
model.Also,itsefficacyhasbeenshowninmultipletreatmenttrials(seesection“Efficacyof
CulturallyAdapted[CA]MultiplexCBT”).
The treatment targets arousal and triggers of arousal such as pathological worry.
Itaddressestraumaassociationsandcatastrophiccognitions.Itteachesemotionregulation,
includingemotionregulationthroughsomaticregulation.Thetreatmentisasomatic-focused
1
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al
s
u
o
ar
e
or
M
s
m
o
pt
m
y s
s n
otion adaptationative affect, and psychological inflexibility) Trauma memorytriggered by somatic and mental Somatic and mental distress(e.g., dizziness, poor concentration,anger) Catastrophic cognitioabout somatic andmental symptoms
mg
e
en
Poor (poor emotion regulation skills, Triggers of somatic and mental distress Worry Negative emotions (anxiety, depression, fear, anger) Stress Interpersonal conflict Arousal Bereavement-type (recalling the deceased or others from whomone is separated) Trauma-type (trauma recall, startle, hypervigilance) Panic-type (exertional intolerance, hyperventilation and chestbreathing, motion sickness [e.g., traveling in a car], agoraphobia-like syndromes [e.g., public spaces], out-of-blue autonomic surge) Sleep-related phenomena (e.g., poor sleep, nightmare, sleepparalysis, nocturnal panic) Metaphor-guided somatization (e.g., through cognizing distress insomatic metaphors) Hypervigilant surveying of the mind and body for evidence of asyndrome (e.g., “heart disease”) gure1TheMultiplexModeloftheGenerationofTrauma-RelatedDisorder
(cid:129) (cid:129) (cid:129) (cid:129) (cid:129) (cid:129) (cid:129) (cid:129) (cid:129) (cid:129) (cid:129) Fi
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TherapistIntroduction 3
therapy:itaimstodecreasesomaticdistress(e.g.,throughappliedstretching)anditfocuses
onsomaticexperiencinginteachingemotionregulation(e.g.,throughappliedstretchingand
sensorial-typemindfulness).Thetreatmentimprovesemotionadaptationbytargetingwhat
mightbecalledthepooremotionadaptationtriad–namely,pooremotionalregulationskills,
excessivenegativeaffect,andpoorpsychologicalflexibility.Forexample,thetreatmentaims
toteachemotionregulationskills,suchasthroughanemotionalregulationprotocoltaughtat
thebeginningofsessions;toimprovetheemotionalrepertoire,suchasbyteachingequanim-
ity and loving kindness; and to induce a positive mood-state focused on psychological
flexibility, such as through enminding and embodying flexibility metaphors. Hence, the
treatmentmightbecalledasomatic-focusedemotional-regulationtherapythatisculturally
adapted,or,giventheemphasisonflexibilityinthepsychologicaldomainandthe physical
domain(e.g.,stretching),aflexibility-focusedCBTthatisculturallyadapted.
Culturallyadapted(CA)MultiplexCBThasmanyaspectsthatmakeitwellacceptedby,
andefficaciousfor,minorityandrefugeepopulations,asoutlinedinTable1.CAMultiplex
Table1 SomeaspectsofCAMultiplexCBTthatmakeitefficaciousandculturallyappropriate
Treatmentgoal Examplesofhowthetreatmentgoalisaccomplished
Acceptabilityfor (cid:129) Presentinginstructionandinformationinawaythatiseasily
thosewithpoor understood
Englishskills, (cid:129) Teachingemotionandsomaticregulationtechniquesthatareeasily
minimaleducation, done,suchasappliedstretching,decentering/distancing,and
andunfamiliarity meditation
withWestern (cid:129) Framingtreatmentasaddressingcomplaintsofkeyconcern,suchas
psychological somaticsymptoms
concepts
Positiveexpectancy (cid:129) Usingculturallyappropriateanalogies:comparingthetreatment
andtreatment stepstothestepsneededtomakeafavoritedishinthatgroup
credibility (cid:129) Indicatingthattreatmentaddresseskeyconcerns,suchassomatic
complaintsandculturalsyndromes(e.g.,amongCambodianrefugees
suchculturalsyndromesaskhyâlattacks,“weakheart,”and“thinking
alot”)
Reductionof (cid:129) AddressingcatastrophiccognitionsaboutPTSDandanxiety
catastrophic symptoms,includingculturallyspecificcatastrophiccognitions
cognitionsabout (cid:129) Specificallyelicitingthepatient’sunderstandingofsymptomsand
PTSDandother alleviatingthepatient’sconcernsaboutthosesymptoms,suchasby
anxietysymptoms explaininghowthesymptomsarisefromanxietyanddonotindicate
aculturalsyndromeorothercatastrophe
Reductionof (cid:129) Decreasingtriggersofarousal,suchasworry
somaticsymptoms (cid:129) Teachingtechniquestoreducesomaticsymptomsandarousal
(seealsoTable2) (cid:129) Addressingcatastrophiccognitionsaboutsomaticsymptoms
(cid:129) Exploringtraumaassociationstosomaticsymptoms
Reductionof (cid:129) Addressinginsomniaandvarioussleepdisorders,suchasnightmares
sleep-related andsleep-relatedphenomenaandassociatedculturalmeanings(in
problems manyculturalgroupssleepdisordersarequiteprominentandhave
extensivemeanings)
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