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Trauma derives from the Greek τραῦμα, meaning “wound.” Although it has been used for centuries as a medical term to designate “an injury to living tissue caused by an extrinsic agent,” it was not until 1889 that this word endorsed a psychological meaning with the first clinical descriptions of “traumatic neuroses” in victims of railroad accidents by Oppenheim. Stress was first a mechanics term used to describe the pressure or tension exerted on a material object. It was then been applied to mental health to describe a feeling of psychological strain and pressure. Both psychological trauma and stress can result in psychiatric disorders.
In session 4, metaphors are presented to educate about anxious-depressive distress and to help emotional processing: the “inner child watching DVDs” analogy and “two-television sets” analogy. Catastrophic cognitions about symptoms of distress are addressed: the patient is taught about the physiology of fear. Emotional processing is practiced.
In session 6, diaphragmatic breathing is taught to illustrate that normal breathing relieves anxiety, and hyperventilation is used to show that abnormal breathing can induce symptoms but that those symptoms are not dangerous. The patient is educated about breathing and educated about distress associations to and catastrophic cognitions about symptoms caused by hyperventilation and chest breathing, such as chest tightness, dizziness, cold extremities. The patient is made to hyperventilate to educate about breathing-induced symptoms, to create positive reassociations to dizziness and other sensations, to address distress associations to the symptoms, to reduce fear of the hyperventilation-induced symptoms, and to act as interoceptive exposure that creates new non-threating associations to the symptoms that decreases fear and other negative associations.
In session 5, interoceptive exposure is introduced, focusing on dizziness sensations that are induced by head rolling. There is also the creation of positive associations to dizziness sensations and addressing of catastrophic cognitions about them. We use head rolling to educate about dizziness, to create positive reassociations to dizziness and other sensations, to address distress associations to the symptoms, to reduce fears of dizziness, and to act as interoceptive exposure that creates new nonthreatening associations to the symptoms that decreases fear and other negative associations. There is also further training in emotion regulation (emotion flexibility) by practicing certain emotions.
In session 8, the patient is queried about issues of anger management, and is taught emotion regulation skills. This includes teaching the anger toolbox, a set of tools to use when angry. In this session, the patient is also taught several emotion regulation techniques: diaphragmatic breathing for relaxation, emotion distancing, and the use of adaptive emotional states. Two forms of behavioral activation are taught: encouraging exercise and doing wall push-ups and prescribing pleasurable activities. (Of note, throughout the treatment we have the patient do behavioral activation. We consider such actions as stretching and interoceptive exposure to be a form of behavioral activation in that they cause the patient to enter a new zone of experience and involve activity.)
In the introductory chapter, we introduce transdiagnostic Multiplex CBT for Muslim Cultural Groups. We explain why there is currently a need for culturally sensitive treatments for Muslim populations and how Multiplex CBT fills this need. The chapter provides an overview of Multiplex CBT (e.g., specific treatment elements and key component of each session) and how it is culturally framed for a Muslim population. That is, it goes over the rationale for adapting particular treatment elements for this cultural group such as when teaching mindfulness and attentional control, addressing sleep-related issues, addressing worry, teaching anger management, and providing culturally indicated transitional rituals.
In session 10, cultural syndromes are used as a means to explore catastrophic cognitions and distress associations. The session ends by encouraging the patient to do a transitional ritual. The patient is told of the next follow-up session, if that is planned.
The goal of session 1 is to briefly describe the goals of the treatment, and to begin to educate the patient about anxious-depressive distress and its physical and psychological effects. Culturally appropriate analogies promote the acceptance and recall of the core teaching principles. In this first session, the main metaphor utilized is that of the “inner child” who remembers everything and is easily frightened. This is used as a way to teach about bad memory triggers and about emotional hijacking. In this session, meditation and applied stretching are introduced. The therapist should be sure that the patient does the stretching and other motions, and if the patient doesn’t, encourage the patient to do so with a playful mien. The therapist should maintain a playful (even laughing) demeanor whenever possible. At times, to ensure that a sense of relaxation is being conveyed, the therapist should purposefully slow down and deepen the voice. This also creates a sense of shift in the session and so promotes flexibility and emotion regulation.
In session 9, somatic symptoms and associated and catastrophic cognitions are explored. Sleep-related phenomena are also addressed. Victims of anxiety and depression often have these sleep-related phenomena: nightmares, sleep paralysis, and nocturnal panic. This includes suggestions for how to reduce nightmares. Also, the patient is taught methods that help promote sleep.
In session 3, applied stretching is taught, and the patient is led once more through the whole body muscle relaxation (with contract-release and stretch-release relaxation) with visualization. As in almost all lessons, there is a section on mindfulness and stretching. The chapter introduces a Bad Memory Protocol, which consists of a set of “tools,” for example, emotion regulation and relaxation-type techniques, to be used when unwanted bad memories occur or when upset for any reason. It serves as practice in emotion regulation, a set of emotion regulation techniques. As indicated in the last session, the therapist should be sure that the patient does the stretching and other motions, and if the patient does not, the therapist should encourage the patient to do so, all the while with a playful mien, a playful demeanor. This models a positive way of interacting and it also creates new positive associations to the topics being discussed. At times, to promote relaxation, the therapist should purposefully slow and deepen the voice. This also creates a sense of shift in the session: a shift in voice and emotional register.
Session 2 focuses on “applied muscle relaxation” traditionally used to describe the relaxation of muscles by contracting a muscle, holding the contraction, and then releasing tension. This might also be called “contract-release muscle relaxation.” Another method of muscle relaxation, such as that used in yoga, involves stretching a muscle by forced elongation, holding the forced elongation a certain time, and then releasing it. This might also be called elongation-release relaxation or stretch-release relaxation. Multiplex CBT teaches both applied muscle relaxation (i.e., “contract-release” relaxation) and applied muscle stretching (i.e., “elongation-release” relaxation). Patients who experience anxious-depressive distress have multiple symptoms induced by muscle tension. Examples of sensations caused by muscle tension include joint soreness, muscle soreness, and headache. In addition, those muscle-tension-caused somatic sensations often give rise to catastrophic cognitions, trigger distress associations, and activate interceptive conditioning. In addition, muscle relaxation will decrease arousal and hence fear, and this reduced arousal and fear will decrease symptoms such as cold extremities. Furthermore, applied muscle stretching allows for the introduction of phrases and images that promote a positive self-image of flexibility and prime to being flexible.