Self-Nurturing, Red and Green Flags, Detaching from Emotional Pain (Grounding), Life Choices, and Termination. The key principles of Seeking Safety are (Najavits, 2001): ● Safety as the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions) ● Integrated treatment (working on both trauma and substance abuse at the same time) ● A focus on ideals to counteract the loss of ideals in both trauma and substance abuse ● Four content areas: Cognitive, behavioral, interpersonal, and case management ● Attention to clinician processes (clinicians’ emotional responses, self-care, and so on) Eye Movement Desensitization and Reprocessing Eye movement desensitization and reprocessing (EMDR) is a therapeutic approach based on the theory of Adaptive Information Processing and focuses on the processing of information in order to reduce posttrauma symptoms and distress (Shapiro, 2017). The theory suggests that when PTSD occurs, an individual has inadequately processed traumatic events and that memories of these events are stored in a state-specific form with the original distress and are not integrated with other memories (Beauvais et al., 2021). In this approach, the therapist has the client focus on a visual image related to a traumatic memory, a negative thought about the self, and any related bodily sensation while concurrently providing bilateral stimulation in the form of eye movements, taps, or tones. The client is instructed to notice whatever emerges during this process and then to consider identified positive thoughts and beliefs. Francine Shapiro (2017) theorizes that this protocol allows the client to more fully process traumatic memories in a more adaptive way through a focus on both internal (i.e., distressing thoughts) and bilateral (i.e., eye movements) stimuli. Overall, EMDR combines several therapeutic approaches, including brief exposures to traumatic material and mindfulness regarding the various sensations and thoughts that emerge during the exposure process—with the goal of creating less psychic reactivity to traumatic stimuli, thoughts, or other sequelae. Focusing on traumatic memories may be uncomfortable, but EMDR appears to be effective in reducing PTSD symptoms. Inconsistent practice and lack of specialized training can, however, reduce the efficacy of EMDR (Cusack et al., 2016). In its early years, EMDR was considered somewhat controversial; however, many randomized controlled trials have supports its efficacy and EMDR is now considered a strongly recommended treatment by the Department of Veterans Affairs (Management for Posttraumatic Stress Disorder Work Group, 2017). Psychedelic-Assisted Therapy In the 1950s and 1960s, psychedelics were viewed as useful tools to enhance psychotherapy (Krediet et al., 2020). During this period, significant research was being conducted on the use of psychedelics in the treatment of a variety of disorders. However, use outside medical contexts led to most psychedelic drugs being scheduled (i.e., strictly regulated by the federal government) in the mid-1960s and research came to a halt (Krediet et al., 2020). In recent decades and particularly in the past five years, there has been a renewed interest in how psychedelics can play a role in the treatment of various conditions, including PTSD. Since 2018, the U.S. Food and Drug Administration (FDA) has recommended MDMA and psilocybin be given a breakthrough therapy designation and have approved ketamine for treatment-resistant depression (Krediet et al., 2020). In a review of various psychedelic-assisted approaches, Krediet and colleagues (2020) describe the
rationale for this approach in that “these drugs can catalyze the psychotherapeutic process, for example, by increasing the capacity for emotional and cognitive processing through pharmacologically diminishing fear and arousal, by strengthening therapeutic alliance through increased trust and rapport, or by targeting processes of fear extinction and memory consolidation” (p. 386). Some concerns about the potential for abuse have been expressed; however, there is not current research to support this concern and negative experiences or “bad trips'' are shown to be most associated with individual use in which there was no formal regulation of drug purity or potency or monitoring of safety (Averill & Abdallah, 2022). Currently, the substance that has the most research supporting its use specifically for the treatment of PTSD is MDMA. MDMA-assisted psychotherapy uses MDMA as a part of a larger psychotherapeutic treatment that involves several nondrug preparatory sessions as well as integrative therapy sessions after MDMA sessions (Krediet et al., 2020). This approach follows a standard treatment manual for MDMA-assisted psychotherapy (Mithoefer et al., 2017). Currently, MDMA-assisted psychotherapy for PTSD is in a multicenter phase 3 trial seeking full FDA approval. Promising results across several studies have found that MDMA-assisted psychotherapy results in a majority of patients no longer meeting criteria for PTSD and increased posttraumatic growth (Mithoefer et al., 2013; Mithoefer et al., 2018; Ot’alora et al., 2018), with effects being stable for a period of 3.5 years (Mithoefer et al., 2013). The intense approach to set and setting for MDMA-assisted psychotherapy may be a large component of its effectiveness but also warrants consideration for how it can be integrated into healthcare systems in a way that promotes scalability and safe and responsible use (Averill & Abdallah, 2022). Several other psychedelics have shown effectiveness for other conditions and are beginning to be studied for their utility with PTSD. Ketamine has been FDA approved for the treatment of treatment-resistant depression. In the community, ketamine is being more frequently used to treat PTSD, but fewer studies have been conducted for its treatment. Compared to MDMA, ketamine is typically administered in a clinical facility without formal preparation or integration settings; however, some providers do use ketamine within a larger psychotherapeutic approach (Krediet et al., 2020). Similar to its use with depression, treatment of PTSD using ketamine tends to show rapid, but short-lived, remission of symptoms. Albott and colleagues (2018) showed that repeated infusions can lead to more sustained benefits, but still showed a median time to relapse of 41 days. Psilocybin has received a breakthrough designation from the FDA for use in depression (Krediet et al., 2020). Although there is currently little to no research on the use of psilocybin for the treatment of PTSD, several studies are currently underway at Baylor, the Ohio State University, and Johns Hopkins (Averill & Abdallah, 2022). Historical literature of various classical psychedelics (psilocybin, LSD, ayahuasca) supports their use for the treatment of PTSD, but more formal clinical trials are needed. Of all substances, cannabis has been one of the most widely discussed and deregulated, with the World Health Organization proposing that it be rescheduled to allow for medical applications. Despite cannabis being widely accepted for medical use for PTSD, it differs from other psychedelics in that it is mainly utilized for temporary relief of symptoms rather than treatment (Krediet et al., 2020). Additionally, while cannabis can be utilized as a therapeutic intervention, its use can serve as a means of avoidance for
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