MFTT Gina Ross, Cathy Lawi, Ph.D., Karen Lerner, Ph.D

Introduction
In the aftermath of September 11th, there has been a heightened interest in the treatment of Post Traumatic stress Disorder (PTSD) at more widespread levels. Specifically, examining the connection between trauma and individual and collective violence and trauma’s influence on world politics and economics, is gaining particular attention [1].

Defined as an anxiety disorder that affects at least 10% of individuals involved in a traumatic event [2], PTSD is associated with high rates of both physical and psychological comorbidity [3], a decline in quality of life [4], and economic burden to society [5]. Currently, great effort is devoted to developing and validating effective short-term interventions and treatments of PTSD [6, 7], including Prolonged Exposure (PE), Cognitive Restructuring (CR), Trauma Focused Cognitive Behavioral Treatment (CBT), and Eye Movement Desensitization and Reprocessing (EMDR) [7].
We propose that Somatic Experiencing (SE) can play a very significant part in the healing and prevention of trauma.

Somatic Experiencing:
Somatic Experiencing® (SE) is an integrative mind-body approach for treating trauma, being developed by Peter Levine since the 1980s [8]. Primarily, SE works on re-establishing the body’s natural ability to self-regulate, by discharging arousal energy that has accumulated in the body during a traumatic event, and completing thwarted defensive responses.

The SE method is based on neurobiology research, whereby trauma is perceived as a physiological response consisting of unreleased hormones and electrical energy being “stuck” in the central and/or peripheral nervous systems even after the traumatic event has passed. SE theory contends that PTSD evolves from uncompleted defensive movements in the body, resulting from thwarted flight/flight defenses and a consequent “Freeze” response [9], as well as from unused stress hormones. Therefore, SE therapeutic work focuses on discharging the trauma through the body and completing the thwarted movements.

Indeed, when confronted with danger, the “Freeze” response occurs as a last resort, when the “Fight or Flight” autonomic responses are no longer viable. This type of response is a common and basic survival instinct in animals, enabling them to act as if they were dead when threatened by predators, thus potentially saving the animal’s life or diminishing the pain of getting harmed. Unlike humans, animals do not develop post traumatic responses after they go into a freeze response. They are able to discharge the energy and their transitions between peaceful and dangerous situations are smooth. However, in humans, the energy resulting from the “Freeze” response can remain stuck in the body, resulting in PTSD.
The focus of the therapeutic work is to enable the completion and reconstruction of the defensive movement patterns that were interrupted and uncompleted, in order to release the stored energy in the body. In this way the ticks, body positions and patterns of muscle tension that were caught during the “Freeze” response are reconstructed and thus, resolved.

Levine’s technique can be considered in actuality, a combination of behavior and exposure therapy that is largely based on observing, listening to and working the trauma through the body. SE allows for connections to be made between the physiological, physical, emotional, and cognitive processing levels, resulting in an overall integrated system, which enables the post-traumatic response to be released in an effective manner.

In the first stage of SE, a safe therapeutic space is constructed for the patient. The physiological responses, together with the strong sensory-motor experience, are brought forth in a gradual manner, through close and attentive monitoring of the patient. In this safe environment, one is able to break the connection between the physiological responses associated with the traumatic event and the existence of an actual, current threat. Through the pendulation technique, one shifts attention between sensations associated with the traumatic event and positive sensations related to strength. In this way, exposure to the trauma is achieved in a gradual and regulated manner, thereby restoring resiliency and regulation of the system.

SE is distinguished from other therapeutic approaches in that it taps into the underlying arousal regulatory mechanism in the body, being able to reach levels of arousal that cannot be as easily reached through words. While SE also relies on the exposure/extinction paradigm, it does so in a gentle and gradual –titrated- way, approaching traumatic arousal a little bit at a time, avoiding thus taking the client into a retraumatizing cycle through intense levels of activation, and avoiding burnout on the part of the therapist. Through the SIBAM (an acronym for Sensations, Images from the 5 senses, behavior, affect and meaning) and the integration of the emotional, thinking and physiological brains, SE also takes into account the cognitive approach of most CBT, when cognitive reframes are needed. Through the SE approach, overwhelming experiences during the treatment are avoided, and patients learn how to deal with and regulate the arousal that accompanies the working through of traumatic memories. Furthermore, SE works very successfully with psychosomatic symptoms that do not have an accompanying narrative- whether because of dissociation, or preverbal trauma, including peri and prenatal.

SE research:
There have been recent studies examining the efficacy of SE. Parker et al. investigated the empirical outcomes of SE treatment in survivors of the Tsunami in Southern India in 2004 [10]. Six months after the event, participants with post-traumatic symptoms were given abbreviated SE treatment, comprised of one session, lasting 75 minutes. Results indicated salutary outcomes. Eight months later, 90% of participants reported substantial overall improvement or reduction of hyper-arousal, re-experiencing, and avoidance symptoms. Parker et al., contend that these results show the overall efficacy of SE treatment on PTSD.

Positive outcomes of SE treatment are also found in an exploratory study on survivors of the Tsunami in Thailand, following one or two sessions of abbreviated SE treatment [11]. This early intervention model of SE was applied by Leitch and her team only one month following the Tsunami. Participants were evaluated prior to and immediately following treatment, 3-5 days after treatment and one-year later. Results show that immediately following treatment, 67% of participants reported partial or full remission of symptoms. One year later, 90% report partial or full improvement.

In another pioneer study, Levine et al. [12], describe how one session of SE can eliminate all symptoms of individuals who have been diagnosed with PTSD, who have suffered many years of exhaustion and severe cognitive damage. One patient who suffered from PTSD and severe phobia of heights, following hypoxia while climbing the Himalayas, a year later reports being symptom free.

These results emphasize the overall efficacy of SE treatment on PTSD, both immediately following a traumatic event and also many years later. However, until this point, there have been no methodological studies conducted, investigating the efficacy of SE treatment on individuals suffering from PTSD.
Need to add here the results of the research done by Raja Selvam and company.

The Aim of the Study
This study aims to examine the efficacy of Somatic Experiencing in reducing post traumatic symptoms in people who have been diagnosed with full PTSD.


Method
Subjects:
The subjects will be men and women over the age of 18, fluent in either Hebrew or English, who meet the DSM IV-TR criterion for full PTSD.
Subjects who are taking psychiatric medication may be included, while monitoring medication levels before and after SE treatment.

Exclusion Criterion:
1. A history of psychosis
2. Brain damage
3. Suicidal tendencies
4. Psychological comorbidity (another psychopathology other that PTSD)
5. Complex trauma

Therapists:
The therapists included in this study are all health-care professionals recognized by the Israeli Ministry of Health. All the therapists are qualified SE experts (Somatic Experiencing Practitioners) certified by the Foundation of Human Enrichment (FHE) in the United States and the Israeli Trauma Institute (ITI) in Israel.

Procedure
Recruitment of Participants:
Participants will be recruited via family doctors, general practitioners and psychiatrists, working in Medical Insurance outpatient clinics (Kupot Cholim). The main recruitment will be executed by family doctors and psychiatrists.
Explanatory lectures about SE and the forthcoming study will be presented to Medical Insurance outpatient clinics practitioners to inform them about the criteria and sample relevant for the study. Information sheets for potential participants will be available in clinics, explaining the purpose of the study. Participants who meet the initial appropriate criteria will be offered the option of participating in the study.

When a potential participant is interested in the study, they will be referred to the SE project coordinator for an initial phone screening. Therefore, it is essential that the coordinator have prior clinical experience. The phone screening is brief and consists of questions surrounding psychiatric history, medication, and prior traumatic experiences (to exclude cases of complex trauma). If a participant does not meet criteria for the study, the coordinator will refer them back to their Medical Insurance outpatient clinics so to receive alternative therapeutic treatments offered by their Medical Insurance outpatient clinics.

In cases where participants do meet criteria, the coordinator will arrange a meeting with her where the participants will receive a detailed explanation of the study's course, after which they will be asked to sign an informed consent form. Once the form has been signed the participants will be asked to complete the first set of questionnaires.

A second meeting will be arranged by the coordinator, for a full clinical assessment with the clinical examiner. After this first clinical interview the participants will be randomly selected, 50% will be selected for SE immediate treatment, while 50% will be assigned to the wait-listed control group (who will receive the same treatment after a waiting period of four months).

Following the assessment and randomized selection, the coordinator will match up a participant with one of the selected SE therapists to begin treatment. The treatment will last for 15 weekly sessions, at the therapists' clinics. The course of treatment may be shortened if both therapist and participant agree that there is no longer a need for treatment. At the end of SE treatment, the coordinator will arrange for the participant to meet again with a clinical examiner for another assessment (clinical interview and questionnaires). It is important to clarify that the clinical examiner will not be at all involved with the participants’ therapy. Three months following, the coordinator will arrange for the third and final clinical assessment, and will also mail questionnaires for the participant to fill out. A return envelope will be included so that the participant may complete and hand in these questionnaires with ease. The option for a phone interview will also be possible. In such cases the coordinator will call the participants after they received the questionnaires in the mail, and read the questions to the participants while marking their answers.

Both clinical assessments and treatment sessions will be recorded as a means of quality control, this will only occur after signed consent from the participants. It is important to note that participants who do not want to be recorded will not be excluded from the study or discriminated against in any way. The recording of the sessions is solely for the purpose of the study, any other use will require written consent.

Control group:
The 30 participants randomly selected for the wait-listed control group will receive the same treatment after the duration of four months (the time it takes to complete the SE research protocol). The participants in the control group will also be assessed three times; right after their recruitment, at the end of the four month waiting period, and a third time at the end of the treatment. The participants in the control group will not be assessed at the duration of the three month follow-up period.

Therapist supervision
Mrs. Gina Ross will be providing group supervision for the therapists throughout the research in its entirety. The project coordinator will arrange for group supervision to ensure protocol adherence and for any questions and concerns that may arise.

Duration of study
The study will be conducted over the course of 24 months.

Measures
PTSD Assessment:
The Clinician-Administered PTSD Scale (CAPS) is the gold standard in PTSD assessment. The CAPS can be used to make a current (past month) or lifetime diagnosis of PTSD [13]. It is a 30-item structured interview that corresponds to the DSM-IV criteria for PTSD. In addition to assessing the 17 PTSD symptoms, questions target the impact of symptoms on social and occupational functioning, improvement in symptoms since a previous CAPS administration, overall response validity, overall PTSD severity, and frequency and intensity of five associated symptoms (guilt over acts, survivor guilt, gaps in awareness, depersonalization, and derealization). For each item, standardized questions and probes are provided. As part of the trauma assessment (Criterion A), the Life Events Checklist (LEC) is used to identify traumatic stressors experienced. CAPS items are asked in reference to up to three traumatic stressors. The CAPS was designed to be administered by clinicians and clinical researchers who have a working knowledge of PTSD, but can also be administered by appropriately trained paraprofessionals. The full interview takes 45-60 minutes to administer, but it is not necessary to administer all parts (e.g., associated symptoms).

Psychiatric Disorders Assessment:
The Structured Clinical Interview for DSM-IV (SCID) is a semi-structured interview that assesses thirty-three of the more commonly occurring psychiatric disorders described in the fourth edition of the DSM-IV of the American Psychiatric Association (1994) [14]. It is a semi-structured interview that allows the experienced clinician to tailor questions to fit the patient's understanding; to ask additional questions that clarify ambiguities; to challenge inconsistencies; and to make clinical judgments about the seriousness of symptoms. The main uses of the SCID are for diagnostic evaluation, research, and the training of mental-health professionals. It begins with an overview section that includes questions about basic demographic information (e.g., age, marital status), educational history, and work history, followed by questions about the chief complaint, past episodes of psychiatric disturbance, treatment history, and current functioning. The remainder of the interview is organized into the following sections: mood episodes, psychotic symptoms, differential diagnosis of psychotic disorders, differential diagnosis of mood disorders, substance-use disorders, anxiety disorders, somatoform disorders, eating disorders, and adjustment disorder.

Posttraumatic Symptoms:
Post traumatic symptoms will be measured using the Hebrew translation of the Posttraumatic Diagnostics Scale (PDS) [15]. In this questionnaire the subjects are requested to describe a traumatic event they experienced and rate their subjective fear and helplessness levels on a scale of 1 (not at all) to 4 (very much). Subsequently, the subjects are asked to rate the frequency in which they suffered from each of the 17 post traumatic symptoms in the past month, on a scale from 0 (not at all, or once) to 3 (nearly all the time). The symptoms are divided into the three symptoms categories as defined by the DSM IV-TR: 5 symptoms relating to reexperiencing the event, 5 related to avoidance, and 7 to hyper arousal.

Depression:
Depression will be assessed using The Center for Epidemiological Studies Depression Scale (CES-D) [16]. The CES-D is a 20-item self-report scale intended to measure symptoms of depression in non-clinical populations. The responses are summed to create a total score, which can range from 0 to 60, with a score of 16 or higher considered to have clinical significance. Depression is highly correlated with PTSD [17], therefore it is important to asses this condition, in order to rule out comorbidity.

Sensory Response:
The Adult Sensory Profile is a self report questionnaire, measuring responses to sensory events in everyday life [18]. There are 60 items in the profile. Individuals complete the questionnaire by reporting how frequently they respond in the way described by each item; they use a 5 point Likert scale (nearly never, seldom, occasionally, frequently, and almost always). The Adult Sensory Profile yields four scores which correspond to the four quadrants of sensory processing proposed in Dunn’s model of sensory processing, i.e., sensation seeking, sensation avoiding, sensory sensitivity and low registration.

Flexibility:
The Perceived Ability to Cope with Trauma scale (PACT) is designed to measure people's evaluation of their ability to cope with trauma. The scale includes 20 items that focus on two aspects of coping with trauma: Trauma focus (8 items) and Forward focus (12 items) (Bonanno, Pat-Horenczyk, and Noll, 2011). Participants are asked to report to what degree they would be able to use different kinds of behaviors and strategies in the weeks following a potentially traumatic event. Each item is reported on a 7-point scale (1 = not at all able; 7 = extremely able). The Trauma focus aspect includes behaviors such as: "Pay attention to the distressing feelings that result from the event" and "Face the grim reality head on", whereas the Forward focus aspect includes behaviors such as: "Stay focused on my current goals and plans" and "Look for a silver lining".. Scores are obtained for coping ability, coping polarity, and a total flexibility score (Bonanno et al., 2011).

Post Traumatic Growth:
Post Traumatic growth will be measured using the Post Traumatic Growth Inventory (PTGI)] 19]. In this questionnaire, consisting of 21 items, the subjects are requested to note the level at which changes occurred as a result of their traumatic event. The answers are rated on a 6 point Likert scale (0-did not experience this at all, to, 5- experienced it a lot). This questionnaire has several factors; relating to others, new possibilities, personal strength, spiritual change, and appreciation of life. A factor analysis is preformed by adding the scores given to each of the 5 factors, and a total Post Traumatic Growth Score is calculated by summing up all the questions in the questionnaire. The alpha chronbach for the complete questionnaire is 90.=α [ 20].

Mindfulness:
Mindfulness is the act of deliberately paying attention in a particular way that involves bringing the attention back to the present moment and being non judgmental. The Freiburg Mindfulness Inventory (FMI) consists of 14 items that cover all aspects of mindfulness [21]. The answers are rated on a 4 point Likert scale (0-Rarely, to, 4-Almost always). The items can be split into 4 factors ‘‘Mindful Presence’’, ‘‘Non-judgmental Acceptance’’, ‘‘Openness to Experiences’’, and ‘‘Insight’’. However, due to comparatively high inter-correlations of the factors, it is recommended not splitting the construct into distinct components. The alpha chronbach for the complete questionnaire is α=.86.… (altro)