October 15, 2024 • 32 mins
PTSD is the second most common mental health disorder. Current treatments work for about half of those affected, but are there better options? Professor Kim Felmingham breaks down exposure therapy and explores if pharmacological-based interventions such as MDMA/ecstasy are really the answer. Plus find out what her studies on exercise reveal about this promising potential line of treatment.
Visit the Phoenix Australia website for more information about PTSD and current research trials.
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Episode Transcript
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Carly Godden (00:00):
This podcast was made on the lands of the Wurundjeri people.
The Woi-wurrung and the Bunurong. We would like to pay respects
to their elders, past and present and emerging.
From the Melbourne School of Psychological Sciences at the University
of Melbourne. This is PsychTalks.
Cassie Hayward (00:22):
Hi and welcome back to Psych Talks, a series that
explores exciting new research in psychology and neuroscience. I'm Cassie Hayward,
an Associate Professor here at the University of Melbourne's School
of Psychological Sciences. Today I'm without my usual co-host professor
Nick Haslam. But I am going to be joined by
a fabulous guest, Professor Kim Felmingham. Kim is going to
(00:44):
unpack for us her fascinating research into post-traumatic stress disorder,
otherwise known as PTSD. We'll learn what kind of treatments
are being used now and about promising new developments that
might help those affected by this disorder. So stay tuned.
Kim, welcome to PsychTalks.
Kim Felmingham (01:04):
Thanks, Cassie. Thanks for having me.
Cassie Hayward (01:07):
The main thing we're going to talk about today is PTSD,
but I think it's one of those clinical terms that's
kind of seeped into the vernacular of just casual language
like anxiety or OCD. And I think when people use
it in that everyday way, they are probably not using
it in its proper clinical definition. So, I thought to
(01:27):
set the scene today, you could set us straight with
a proper clinical definition of PTSD.
Kim Felmingham (01:33):
There is quite a stringent definition of PTSD the way
that we define it, and there's been a lot of
controversy over this over the years. First up is what
is the nature of the trauma that you've experienced? Because
uniquely amongst the psychological disorders, we actually know the aetiology
of how it starts. It starts with a trauma experience,
(01:55):
but the trauma experience actually has to be one where
you are either witnessing or you're directly experiencing life threat
to yourself or someone else or significant threat to your
own physical integrity is what the core definition of is.
We are recognising emotional abuse as part of that if
(02:16):
it's repeated bullying and you've grown up in a really
aversive environment, but often that goes along with physical abuse
as well. The only exception to that is people who
are observing traumatic incidents say they are first responders or
they are looking at a lot of horrible graphic imagery,
and it's a cumulative trauma. That's now also recognised as trauma. So,
(02:40):
you need to experience that to actually qualify for the diagnosis.
I think way that the word "trauma" is used has
been overused. Increasingly, so people will say that their divorce
is traumatic, and it is, it can be life shattering.
But it's not the clinical definition we use of trauma
for PTSD. And then, you know, we have a very
(03:01):
clear set of symptoms, so we have re-experiencing symptoms. So,
you either need to be having intrusive memories, nightmares, flashbacks
or distress and physiologic reactivity to trauma reminders. So you're triggered.
You need to have avoidance of those triggers and thoughts
and memories. And then there's a whole range of negative
(03:22):
cognitions and mood. A lot of those overlap with depression
and generalised anxiety as well. But there are some that
are quite unique to PTSD. So having emotional numbing, not
being able to feel love or happiness, positive emotions is one.
There's social withdrawal, negative thoughts about yourself and just feeling
(03:45):
really intense negative emotion. And then we've got our hyperarousal symptoms,
so they are often overlapping with other anxiety disorders. So
sleep disturbance, irritability, concentration difficulties, but also more unique to
PTSD is hypervigilance for danger. So, you're constantly looking around
(04:05):
expecting something terrible is going to happen, scanning for threat
and also an exaggerated startle response.
Cassie Hayward (04:12):
But to meet the definition, they have to have something
on the trauma side and something on the symptom side.
Kim Felmingham (04:18):
Yes, you do.
Cassie Hayward (04:18):
So, you could have people who experience- are a first
responder or who experience something but don't end up having
those symptoms.
Kim Felmingham (04:26):
Absolutely.
Cassie Hayward (04:26):
And some people who have those symptoms but haven't had
the trauma to set it off.
Kim Felmingham (04:30):
So, I think something that's missed a lot of the
time is having a trauma experience doesn't equal PTSD. In fact,
only about 10 to 15% of people who have a
trauma develop PTSD. So, really, the story is one of
resilience and recovery. But there's some traumas that are associated
with higher rates of PTSD, so sexual abuse, combat experience,
(04:53):
refugee experience and interpersonal violence far more. And if you've
had childhood or cumulative trauma, you've got a higher risk
as well. But what's fascinating is about 70 or 80%
of us, probably 70% is more realistic, will experience these
types of traumas, Criterion A trauma, but only 10 or 15%
(05:15):
of us actually develop PTSD, and we don't really have
a good answer as to why. What's the difference? What
are the differentiating factors? We've got a range of risk factors,
but we don't have a definitive answer yet. I wish
we did.
Cassie Hayward (05:30):
And of that definition, when we think of the clinical definition,
what proportion of the population would meet that clinical definition
in Australia?
Kim Felmingham (05:40):
So, it's around 7%. So it's actually one of the
more common psychological conditions and the real issue with PTSD.
Once it gets going, it doesn't resolve by itself, so
it can last for decades, and it can really impact
on people's functioning terribly. It can really decimate their relationships,
(06:00):
their occupational functioning, their social functioning, their sense of identity
and self. It's really highly comorbid with depression, significant suicidality,
substance abuse. So, you know, people really need to be able to
access evidence-based treatments. It typically doesn't get better on its own.
Cassie Hayward (06:21):
And I guess with some of those scenarios you mentioned
there might be a stigma around seeking support, sexual assault.
There might be shame associated. So I guess one of
the challenges is convincing those people that they do need
the treatment.
Kim Felmingham (06:38):
Yes, really interesting. There's a lot of stigma, especially in
first responder and combat veterans around. You know, there's some
ideas of PTSD reflecting weakness. It actually isn't. It's a
completely understandable response to the level of the trauma you've
experienced or the cumulative nature of that trauma. One of
(07:00):
the biggest predictors of developing PTSD is having cumulative exposure
ahead of time. So, yes, it is a real challenge.
But there are really effective treatments out there. So the
hardest thing for me as a clinician is getting someone
walking in the door, and they are 60 they've had
these symptoms nightly nightmares for 40 years, you know? And
(07:21):
I did. I treated a veteran who was 72 and
he'd had symptoms for 48 years or 42 years. And
within 10 weeks he didn't have any PTSD symptoms with treatment,
but he just didn't have the access to the treatment.
Cassie Hayward (07:36):
Was it access? Or was it a lack of kind
of wanting to seek treatment?
Kim Felmingham (07:40):
Good question. So what really happened for him was that
he withdrew, and he was able to actually withdraw. He
lived on a farm out in a rural setting. The
work he did didn't involve interacting with anyone. And so
he managed to create a world which felt safe for him.
But he was still suffering from the symptoms. There was
(08:00):
a lot of shame and stigma around it as well.
And what really broke it for him was when he retired,
the symptoms actually got worse. And he then went to
a veterans' self-help group and a few Men's Sheds. And
then he discovered that other men were also having these symptoms,
and that undercut a bit of the shame and stigma
(08:20):
and that then fed his way through to actually getting
into seeing psychologists and getting some effective help.
Cassie Hayward (08:28):
When you do get someone in for treatment when they've
admitted that they need some help and they've gotten over
those barriers to get in, what is the typical therapy
for PTSD at the moment? And how successful is it?
Kim Felmingham (08:40):
Yes. So, look, we've got a range of evidence-based treatments now. Predominantly,
they all involve some element of processing trauma memories, which
we so we have one sort of gold standard treatment
is called prolonged exposure. It's got about 100-over 100 randomised control
trials of evidence of its efficacy. It involves imaginal exposure
(09:03):
where you're actually, rather than pushing the memories out, because
we think that's what maintains PTSD. The more you push
them out, the more they come back in. And so
it involves inviting the memories in and going through them
in detail with the therapist and talking them through. The
old idea was that the mechanism of that was that
(09:23):
led to a habituation or reduction of arousal. But we
now know that that's really not the case. It's more
about you get corrective information as doing that, which actually
can then correct some of the difficult beliefs. So a
classic example is, say, someone who's been sexually assaulted and has
a lot of shame and self-blame that they didn't fight
(09:44):
back. In that, they may have blocked, or their memory is
typically fragmented. So, as we go back through the memory,
remembering just how powerless they were or that the person
had a weapon, actually, can be incredibly helpful, or that
they had a freeze response, which is just a survival
reflex that they didn't choose, that actually can really help
(10:05):
them undercut the shame and the self-blame. And so it's
corrective in that sort of way. We also then do
in vivo exposure, which is gradually overcoming your avoidance to
triggers but doing it in a very gradual way. So
say someone has had a car accident and they, you know,
don't want to get back into a car. We'll start
by just getting them to sit in the car in
(10:26):
the driveway until their anxiety comes down. Nothing bad happens.
It's an example of extinction learning or being able to
learn to reduce your fear in that context. Then you
might start getting them to just reverse their car up
and down the driveway until they feel confident enough. And
then it might be just driving around the local streets,
(10:46):
quiet back roads at a really quiet time, and then
you are progressing gradually up to them resuming driving.
Cassie Hayward (10:52):
And how successful are those treatments?
Kim Felmingham (10:55):
So those treatments we would have probably between 50 and 60%
of people have a good response to that treatment, so
they are no longer PTSD. But you know, that means
we've got 40 or 50% of people who don't and again,
if you've got childhood trauma or more complex PTSD, the
(11:16):
response rate is less than that, but there's a lot
of complexities involved there.
Cassie Hayward (11:20):
How does that compare to treatment for, say, depression or
generalised anxiety or other...?
Kim Felmingham (11:26):
It's pretty much on a par actually. So you know
most of our psychological treatments are actually within that ballpark.
You know, pharmacotherapy will have an equivalent success rate as well.
Except when you go off the pharmacotherapy, you typically can
relapse more than more of these psychological CBT interventions. And look,
(11:47):
PTSD is one of the harder conditions to treat. Given
the complexity and severity of the disorder, it's, I think
it's actually a pretty good response rate. But being a clinician,
what keeps you up at night is the other 40
or 50% what's going on there and how do we
improve it? There are some other evidence based treatments, so
EMDR is one that has got equivalent efficacy to our
(12:10):
exposure treatments.
Cassie Hayward (12:12):
Kim. When you say EMDR, can you just give us
a little snapshot of what that is?
Kim Felmingham (12:17):
So, it stands for Eye Movement Desensitisation Reprocessing and again,
it's been an intervention that's been around for about 20
or 30 years, and it was evolved from Francine Shapiro's work,
and there was a lot of controversy about it initially.
But look, now they've done randomised control trials, and they
(12:38):
do show that it's got equivalent efficacy for relative to
some of our exposure-based treatments. So I think clinicians prefer
to use it, and many clients prefer to use it
because you don't have to talk through the details of
the trauma memory. But, the thing we don't know which
really lit a lot of the controversy about EMDR is
(13:00):
what is the mechanism of it we really don't understand.
It's a really weird therapy to do. So, you get
an image of the trauma memory in mind. And whilst
you keep it in mind, the therapist either does some
bilateral hand movements. So moves their fingers backwards and forwards.
Or they might have hand stimulators that stimulate each hand bilaterally.
(13:24):
Or you might do tapping. And the idea is that
that is going to desensitise the memory. Now there's been
so many hokumm theories, "Ooh you know it's the intrahemispheric alpha rhythms,
and they link, you know they mimic REM sleep comes
into play here," but, you know, I think there isn't any really convincing evidence.
(13:47):
And in fact, some people have done randomised control trials
with and without the eye movements and found equivalent efficacy. So,
it's not necessarily per se about the eye movements or
the interhemispheric element. The most cogent theory, perhaps, I've found,
is it's about memory reconsolidation again. So, the idea is,
(14:07):
if you bring any memory back to mind, it's labile,
which means that whatever you do in a certain period
of time, it can be changed. So the idea is,
if you bring this image to mind of the memory,
it's back in a labile state. And then, if you
are actually doing finger waggling and tapping, it's a dual task,
and our memory and our attentional systems are limited capacity processes.
(14:32):
So therefore, you are using up cognitive resources to be
tracking fingers or to be doing a dual task. And
the theory is that that then means you've got less
brain processes or resources to reconsolidate the memory. So it's
laid back down less strongly is the theory, and we
also have cognitive processing therapy, which has really good evidence
(14:54):
that doesn't necessarily involve working with trauma memories. But it's
much more about the cognitions and beliefs about self. So
you'd use that for someone with a very shame based
PTSD who don't have many reexperiencing symptoms, for example.
Cassie Hayward (15:11):
One thing I hear about in the kind of less
evidence-based space, I guess, in the health podcast space, this
emerging use of drugs like MDMA for treating PTSD a
lot of acronyms there but basically using a pharmacologically supervised
dose of what has traditionally been a recreational drug. What
does the research actually say about that as a treatment?
Kim Felmingham (15:30):
So, in terms of MDMA that's probably got, it's progressed
furthest along. So, they've done the phase three trials. But
the issue with it is that they've only been done
largely by the one group of researchers. So we need
independent replications, and you know there isn't sufficient evidence. The
TGA approved it too early. The FDA has knocked it
(15:53):
back because they think there's insufficient evidence and there are
some real challenges in doing randomised control trials. You can't
blind a control condition, and that actually is quite concerning
because some of those early trials did have major expectancy
effects in the participants. So some participants were flying themselves
(16:13):
self-funding themselves to fly across the US to engage in
these trials. So, they already came in with an expectancy.
It was going to save them. Many desperate people, desperate
for a cure for PTSD, which is understandable. And so,
those expectancies weren't measured adequately enough. So that's one real
flaw with the designs. And we need those independent replications
(16:36):
from independent groups and probably in people who've got even
a bit of cynicism about it and measuring the expectancy effects.
The other thing, I think with the psychedelics that's a
real limitation is this is not going to be a
panacea for treating people. It's not going to be widely
disseminated because it's such an expensive therapy. The estimates at
(16:57):
the moment are it will cost between 10 and $20,000
for a treatment. And if you think about it, you've
got double the clinician time as a standard treatment for PTSD.
And the other thing is, we don't have head to
head randomised control trials of how well does it work
compared to prolonged exposure, for example? So why would you
suggest people do psychedelic therapies or MDMA assisted therapies? if
(17:22):
they might respond better to prolonged exposure, which is cheaper
and can be done in 10 weeks. So I think
we are at a very premature area or level. But look,
the pharmacological adjuncts has been around for about 10 or
15 years, now. They've tried cortisol, yohimbine, oxytocin, MDMA. They've
done D-cycloserine so they've done a whole range of them.
(17:45):
And actually, when you look at the meta-analytic evidence, it's
pretty uninspiring, and they haven't really found large effects. So
I think there's a lot of fascination and interest. And
certainly there's too much hype about MDMA and psychedelics. I'm
sick of reading newspaper articles, and the damaging thing is
(18:06):
that actually hurts vulnerable people because people with PTSD and
trauma are incredibly vulnerable. They are living with a terrible condition,
and then they are desperately seeking treatment. And then that
compounds the expectancy bias, I think in the research.
Cassie Hayward (18:22):
And so just to go back on something you said
about they couldn't do blind trials. So you can't do
a placebo with a hallucinogen or-
Kim Felmingham (18:30):
No, it's impossible to have blind because of the effects
of the MDMA because of the effects. If you're using
psilocybin the person knows they've taken it and they're getting
that active dose relative to a placebo. And the placebos
they've trialled so far really aren't that effective. So in
the maps trials that they've done, they used a very
(18:50):
low dose of MDMA. But it was so low, it
was really not.
Cassie Hayward (18:55):
The person taking it would know they weren't getting the full dose?
Kim Felmingham (18:58):
Yes, pretty much, pretty much. And look, you know, three
of the MDMA papers have just been retracted. Actually, there
have been really serious adverse events in those trials, like
one patient was sexually assaulted, and they've included that data
in some of those papers, so they've been retracted. But
there's even now evidence coming out. They didn't measure serious
(19:18):
adverse events well enough. So, there is reports of increased
suicidal ideation and also people also saying they didn't want
to report they had PTSD still, because they didn't want
to threaten this new frontier of mental health treatment. So,
there's these demand characteristics, so it's really inflating the effects.
So I think we just need to do good critical science.
(19:41):
You know, it's an exciting new potential. I'm all for
getting new treatments for PTSD, but we need to do
the science well.
Cassie Hayward (19:48):
Yeah, I think it definitely highlights the need for that
evidence-based research. And I know you've done some pretty groundbreaking
work around other treatments for PTSD. Maybe around exercise therapy?
Do you want to walk us through some of that research?
Kim Felmingham (20:04):
Yeah, so look, the exercise stuff really came from my
work in neuroscience, So I- there was some research coming out.
There's a neurotrophin in the brain called BDNF
Neurotrophic Factor, and it enhances synaptic plasticity. It's critical for
learning and memory. So, one of the theories about the
exposure therapy is it involves this fear extinction process, which
(20:26):
is unlearning your fear response that is being connected to
stimuli or triggers in the environment. So, exposure therapy, you're
bringing the memory into your mind, and you are in
a safe therapy context and nothing bad happens, so you
can learn to regulate your fear or extinguish it. So anyway,
there was some evidence from animal work that BDNF actually
(20:49):
enhanced fear extinction learning. And so we then took that
into our human trials. So we- I do fear extinction research,
giving people electric shocks, which is a bit mean, but
why not? So, we found that people with BDNF, low
levels of it had poorer extinction learning with PTSD and
(21:10):
we were doing a clinical trial of prolonged exposure in
PTSD patients. And again, we found those people who had
lower levels of BDNF had poorer response to exposure therapy.
So we had a really nice translation from animal science
to human psychophysiology and neuroscience through to actual clinical trials.
Cassie Hayward (21:30):
Which doesn't happen all the time.
Kim Felmingham (21:32):
It's extremely rare and so we then went "Well, this
is exciting. So how do we actually increase BDNF if
we can increase BDNF before they go into the therapy session?
Can we enhance the extinction learning?" And maybe that's going
to enhance treatment outcomes for people. So, the best way
(21:52):
to enhance BDNF is actually through aerobic exercise moderately intense
to intense aerobic exercise. So that's how we devise this trial,
which we've just randomised about 80 people and we are
aiming to get about 110. It has taken five years
off my life, but it's really exciting and worthwhile. So
(22:12):
what we are basically doing is getting people to come in,
and they do 20 minutes of moderate to intense exercise
they are quite sweaty, and then they go into the
therapy room and do standard prolonged exposure for 10 sessions. So,
they do that across 10 weeks.
Cassie Hayward (22:27):
And they do the exercise before each session?
Kim Felmingham (22:29):
They do the exercise before every session. So the idea
is that will enhance their BDNF and then their fear
extinction learning will be better during the exposure, so we
haven't unblinded it. We don't know what the results are
as yet, but one thing that's really intriguing-
Cassie Hayward (22:45):
So just, by unblinding you mean the clinician knows whether
they've exercised or not?
Kim Felmingham (22:49):
Yeah so it's fully, fully, and so we can't analyse
the results. We really don't know until we get to
the end of the trial. But what we have been
tracking is people's dropout rates. And, you know, we've had-.
Prolonged exposure, has fairly high about 25% dropout rates. Normally,
we've actually been getting quite a complex childhood trauma group
of people coming through. It wasn't by design. It's just
(23:11):
who has come into the trial. So the dropout rates
are even higher, which is to be expected. They are
doing a very challenging therapy with really complex trauma. But
the exercise group has got half of the dropout rates
and that wasn't something we predicted, and I've got no
idea why.
Cassie Hayward (23:29):
Are they feeling- Is it because they are feeling more
benefits from the therapy or we don't know yet?
Kim Felmingham (23:34):
I don't know. Is it that they have another thing,
that they'll get out of it as well as doing
these challenging therapies? So that's what's keeping them going. Another
theory might be that because they are doing the exercise,
they are burning off some of the intensity of the
anxiety before coming in so they can tolerate the exposure better.
Cassie Hayward (23:53):
People who already exercise, who are runners or whatever who
do this exercise. Will they have better effects of clinical therapy?
Kim Felmingham (24:04):
Interestingly
Cassie Hayward (24:05):
As a result of their BDNF?
Kim Felmingham (24:07):
Interestingly, they have lower increases in BDNF than people who
are less fit. So the less fit you are, if
you do moderate exercise, you will have a higher rise
of BDNF, which actually works for PTSD. Because many people
with PTSD have metabolic syndrome, they tend towards more overweight
and other health conditions, so it actually might be even
(24:30):
of more benefit for people who-
Cassie Hayward (24:31):
For those who don't, because I was wondering whether it was,
you know, if you think about exercise as a stress
on the body and you've trained your body to deal
with that stress. And there was some translation from that.
But it seems to be more about just that exercise
before therapy increases this BDNF and they get a better outcome. Fascinating.
Kim Felmingham (24:47):
Originally in the trial, I was measuring blood so we
could actually measure BDNF. And then COVID smashed that idea.
And so, we had to progress to telehealth types of
approaches instead so.
Cassie Hayward (25:00):
And it must be exciting for you to, you know,
be on this forefront of different treatments for PTSD.
Kim Felmingham (25:06):
Yeah, well, I mean, that's why I do what I do, really.
My drive isn't really about anything except improving outcomes for
people with PTSD working on the coal face of it
for nearly 30 years. 20 years? You are really- that's
my burning passion is, you know, how can we actually
enhance treatments and accessibility of treatments for people with PTSD? So.
Cassie Hayward (25:30):
Other things that you hear in the kind of wellness
podcast spaces around breathing exercises and yoga and those types of,
kind of, I guess mind body exercise. Is any of
your work looking at that?
Kim Felmingham (25:43):
Not really. But a lot of other people are. So
there are trauma informed yoga practices. People have looked at mindfulness,
people have looked at breathing interventions. And look, you know,
if you look at the randomised controlled trial evidence for that,
the effect sizes aren't huge. They are probably about a
(26:03):
third of what the effect sizes are for the trauma
focused and exposure-based memory work. So EMDR and the exposure treatment.
So it's not your first line treatment. Unfortunately, there's a
lot of clinicians out there where it is the first
line treatment for PTSD. But for me, ethically, if someone
has really flagrant intrusions and nightmares and flashbacks, they really
(26:27):
need trauma focused memory work. But it's not harmful, necessarily.
It can be a nice adjunct, and I use it
for people who say, are very dissociative, aren't connected into
their body at all or can't recognise or connect with emotion.
I might do that sort of work first, that sort
(26:48):
of body-based work more to get that going for someone,
because we really need that for the exposure therapy to work.
So there's a little bit of a fallacy that the
talk therapies, like exposure therapy, don't deal with the body.
It's absolutely not true when we do this work and
similar with EMDR. We actually focus on body, emotion and
(27:11):
thought moment by moment through the narrative of the memory.
So it's all integrated the mind-body stuff.
Cassie Hayward (27:17):
And I guess the way that you integrate yoga or
those other kind of breathing exercise in your clinical therapy
is a great way of using it. But if someone
is out there selling that as the therapy, then that's
where it's dangerous.
Kim Felmingham (27:30):
Beware anyone saying "This is a panacea. This will treat
everyone and cure everyone with PTSD." because it's bunkum because
PTSD in and of itself is an incredibly heterogeneous condition,
so you'll have one person come in. They'll have one
nightmare a month, but they'll have really corrosive shame and
core beliefs that are shocking, and they will avoid social situations.
(27:54):
They probably need more the cognitive based treatments, whereas someone
who's got really intensive nightmares, flashbacks can still qualify for PTSD.
Both of them do. They need trauma memory work, and
that's where the field really needs to evolve, what works
for who? Because we've got a range of different evidence-based treatments.
But we really haven't got good clinical decision tools that
(28:17):
will guide clinicians out there, so you do tend to
find clinicians love mindfulness or they love EMDR. And so
that's what they use for everyone. And we really need
to be taking a case formulation approach. So not diagnostic.
It's not a diagnosis equals treatment for every clinician we
do an individualised case formulation to work out. What are
(28:39):
your pattern of symptoms? What are your maintaining factors and
what's then going to be the best treatment tailored to that?
Cassie Hayward (28:46):
If any of our listeners are dealing with PTSD or
have a loved one who is dealing with it, what's
your advice to them? Maybe, first we start with those
who might not be in treatment at the moment, but
you know that you have it or you know that
your loved one is possibly experiencing PTSD. What's a good
way to encourage them to seek treatment?
Kim Felmingham (29:09):
Look, you know there are really good online resources. Sometimes
that can be a good place to start is to-
Phoenix Australia has some really great resources. Beyond Blue has
some good information as well, just so that you can
start to read a little bit about it and read
about the types of treatments that are available. I'd always
encourage people to seek professional help and to try and
(29:33):
see what is. It's really hard seeing a psychologist, you know,
because there's some bad ones out there. You know, people
will put up a sign "I'm a trauma expert" and
what are their credentials? So, you know, we're going in
and asking people what types of experiences they've had with
delivering these different treatments. And what is the range of options?
(29:54):
How many years? That's actually important stuff to know, to
make decisions. But I think the other hard part is,
you know, gee, the challenging step of going in to
see a stranger and then talking about trauma, some of
the most difficult stuff you might not have told anyone. So,
there's trust. And so, it's also about finding someone who
(30:14):
you really feel you can connect with and feel safe with. So,
it might be starting by just telling a close friend
and talking to a close friend, looking online at resources
what is actually available and out there. And then, you know,
hopefully going and seeking that support if you need it.
Cassie Hayward (30:32):
And you've touched on this briefly. But what should they
be looking out for in terms of credentials because we
know anyone can call themselves a counsellor, and that doesn't
mean they have the right training. But what what should
people be looking for? If they've found someone who they
think might be right, What should they be checking?
Kim Felmingham (30:50):
Well, if they're practising EMDR, they should actually have done
training with an accredited EMDR association, so you can ask
them what kind of training they've done. So, there's the
EMDR Association of Australia. People can actually get to be
accredited EMDR therapists as well, which takes more training and supervision.
Cassie Hayward (31:10):
And they would be a clinical psychologist to start with?
And this would be-
Kim Felmingham (31:13):
Not necessarily, you can be a psycologist and look social workers,
mental health social workers can do EMDR. I would be
looking at people who have they done CPT training. Have
they done prolonged exposure training and ask people those questions? You,
And if they haven't, then what is their experience?
Cassie Hayward (31:31):
Kim. So what's next for you in terms of future
research in this field?
Kim Felmingham (31:36):
I have a lot of post academia fantasies, so I'd
love to set up a trauma retreat service where it
is holistic. It's got nature-based walking. It's got yoga because
I used to be a yoga teacher, in yoga teacher
training for about eight years, but then also doing delivering
EMDR in our exposure-based treatments in a sort of secure,
(31:57):
safe environment and doing intensive therapy because I think it
actually is one of the better modalities if we can
do it. Doing daily exposure therapy so you're really getting
through the hardest part more quickly. It's getting the funding
to do that. So, you know, it's whether I, you know,
get Hollywood celebrities in and charge them a fortune, and
(32:20):
then everyone else can do it for free for the rest.
So these are elaborate fantasies that are probably going to
go nowhere.
Cassie Hayward (32:26):
Fascinating, Kim, thank you for joining us for PsychTalks today.
Kim Felmingham (32:30):
No problem, my pleasure.
Cassie Hayward (32:33):
You've been listening to PsychTalks with me, Cassie Hayward. I'd
like to thank our guest for today, Professor Kim Felmingham.
This episode was produced by Carly Godden with production assistance
from Mairead Murray and Gemma Papprill. Our sound engineer was
Jack Palmer. Thanks for tuning in to this great new
series of PsychTalks. See you next time
This podcast was made on the lands of the Wurundjeri people.
The Woi-wurrung and the Bunurong. We would like to pay respects
to their elders, past and present and emerging.
From the Melbourne School of Psychological Sciences at the University
of Melbourne. This is PsychTalks.
Cassie Hayward (00:22):
Hi and welcome back to Psych Talks, a series that
explores exciting new research in psychology and neuroscience. I'm Cassie Hayward,
an Associate Professor here at the University of Melbourne's School
of Psychological Sciences. Today I'm without my usual co-host professor
Nick Haslam. But I am going to be joined by
a fabulous guest, Professor Kim Felmingham. Kim is going to
(00:44):
unpack for us her fascinating research into post-traumatic stress disorder,
otherwise known as PTSD. We'll learn what kind of treatments
are being used now and about promising new developments that
might help those affected by this disorder. So stay tuned.
Kim, welcome to PsychTalks.
Kim Felmingham (01:04):
Thanks, Cassie. Thanks for having me.
Cassie Hayward (01:07):
The main thing we're going to talk about today is PTSD,
but I think it's one of those clinical terms that's
kind of seeped into the vernacular of just casual language
like anxiety or OCD. And I think when people use
it in that everyday way, they are probably not using
it in its proper clinical definition. So, I thought to
(01:27):
set the scene today, you could set us straight with
a proper clinical definition of PTSD.
Kim Felmingham (01:33):
There is quite a stringent definition of PTSD the way
that we define it, and there's been a lot of
controversy over this over the years. First up is what
is the nature of the trauma that you've experienced? Because
uniquely amongst the psychological disorders, we actually know the aetiology
of how it starts. It starts with a trauma experience,
(01:55):
but the trauma experience actually has to be one where
you are either witnessing or you're directly experiencing life threat
to yourself or someone else or significant threat to your
own physical integrity is what the core definition of is.
We are recognising emotional abuse as part of that if
(02:16):
it's repeated bullying and you've grown up in a really
aversive environment, but often that goes along with physical abuse
as well. The only exception to that is people who
are observing traumatic incidents say they are first responders or
they are looking at a lot of horrible graphic imagery,
and it's a cumulative trauma. That's now also recognised as trauma. So,
(02:40):
you need to experience that to actually qualify for the diagnosis.
I think way that the word "trauma" is used has
been overused. Increasingly, so people will say that their divorce
is traumatic, and it is, it can be life shattering.
But it's not the clinical definition we use of trauma
for PTSD. And then, you know, we have a very
(03:01):
clear set of symptoms, so we have re-experiencing symptoms. So,
you either need to be having intrusive memories, nightmares, flashbacks
or distress and physiologic reactivity to trauma reminders. So you're triggered.
You need to have avoidance of those triggers and thoughts
and memories. And then there's a whole range of negative
(03:22):
cognitions and mood. A lot of those overlap with depression
and generalised anxiety as well. But there are some that
are quite unique to PTSD. So having emotional numbing, not
being able to feel love or happiness, positive emotions is one.
There's social withdrawal, negative thoughts about yourself and just feeling
(03:45):
really intense negative emotion. And then we've got our hyperarousal symptoms,
so they are often overlapping with other anxiety disorders. So
sleep disturbance, irritability, concentration difficulties, but also more unique to
PTSD is hypervigilance for danger. So, you're constantly looking around
(04:05):
expecting something terrible is going to happen, scanning for threat
and also an exaggerated startle response.
Cassie Hayward (04:12):
But to meet the definition, they have to have something
on the trauma side and something on the symptom side.
Kim Felmingham (04:18):
Yes, you do.
Cassie Hayward (04:18):
So, you could have people who experience- are a first
responder or who experience something but don't end up having
those symptoms.
Kim Felmingham (04:26):
Absolutely.
Cassie Hayward (04:26):
And some people who have those symptoms but haven't had
the trauma to set it off.
Kim Felmingham (04:30):
So, I think something that's missed a lot of the
time is having a trauma experience doesn't equal PTSD. In fact,
only about 10 to 15% of people who have a
trauma develop PTSD. So, really, the story is one of
resilience and recovery. But there's some traumas that are associated
with higher rates of PTSD, so sexual abuse, combat experience,
(04:53):
refugee experience and interpersonal violence far more. And if you've
had childhood or cumulative trauma, you've got a higher risk
as well. But what's fascinating is about 70 or 80%
of us, probably 70% is more realistic, will experience these
types of traumas, Criterion A trauma, but only 10 or 15%
(05:15):
of us actually develop PTSD, and we don't really have
a good answer as to why. What's the difference? What
are the differentiating factors? We've got a range of risk factors,
but we don't have a definitive answer yet. I wish
we did.
Cassie Hayward (05:30):
And of that definition, when we think of the clinical definition,
what proportion of the population would meet that clinical definition
in Australia?
Kim Felmingham (05:40):
So, it's around 7%. So it's actually one of the
more common psychological conditions and the real issue with PTSD.
Once it gets going, it doesn't resolve by itself, so
it can last for decades, and it can really impact
on people's functioning terribly. It can really decimate their relationships,
(06:00):
their occupational functioning, their social functioning, their sense of identity
and self. It's really highly comorbid with depression, significant suicidality,
substance abuse. So, you know, people really need to be able to
access evidence-based treatments. It typically doesn't get better on its own.
Cassie Hayward (06:21):
And I guess with some of those scenarios you mentioned
there might be a stigma around seeking support, sexual assault.
There might be shame associated. So I guess one of
the challenges is convincing those people that they do need
the treatment.
Kim Felmingham (06:38):
Yes, really interesting. There's a lot of stigma, especially in
first responder and combat veterans around. You know, there's some
ideas of PTSD reflecting weakness. It actually isn't. It's a
completely understandable response to the level of the trauma you've
experienced or the cumulative nature of that trauma. One of
(07:00):
the biggest predictors of developing PTSD is having cumulative exposure
ahead of time. So, yes, it is a real challenge.
But there are really effective treatments out there. So the
hardest thing for me as a clinician is getting someone
walking in the door, and they are 60 they've had
these symptoms nightly nightmares for 40 years, you know? And
(07:21):
I did. I treated a veteran who was 72 and
he'd had symptoms for 48 years or 42 years. And
within 10 weeks he didn't have any PTSD symptoms with treatment,
but he just didn't have the access to the treatment.
Cassie Hayward (07:36):
Was it access? Or was it a lack of kind
of wanting to seek treatment?
Kim Felmingham (07:40):
Good question. So what really happened for him was that
he withdrew, and he was able to actually withdraw. He
lived on a farm out in a rural setting. The
work he did didn't involve interacting with anyone. And so
he managed to create a world which felt safe for him.
But he was still suffering from the symptoms. There was
(08:00):
a lot of shame and stigma around it as well.
And what really broke it for him was when he retired,
the symptoms actually got worse. And he then went to
a veterans' self-help group and a few Men's Sheds. And
then he discovered that other men were also having these symptoms,
and that undercut a bit of the shame and stigma
(08:20):
and that then fed his way through to actually getting
into seeing psychologists and getting some effective help.
Cassie Hayward (08:28):
When you do get someone in for treatment when they've
admitted that they need some help and they've gotten over
those barriers to get in, what is the typical therapy
for PTSD at the moment? And how successful is it?
Kim Felmingham (08:40):
Yes. So, look, we've got a range of evidence-based treatments now. Predominantly,
they all involve some element of processing trauma memories, which
we so we have one sort of gold standard treatment
is called prolonged exposure. It's got about 100-over 100 randomised control
trials of evidence of its efficacy. It involves imaginal exposure
(09:03):
where you're actually, rather than pushing the memories out, because
we think that's what maintains PTSD. The more you push
them out, the more they come back in. And so
it involves inviting the memories in and going through them
in detail with the therapist and talking them through. The
old idea was that the mechanism of that was that
(09:23):
led to a habituation or reduction of arousal. But we
now know that that's really not the case. It's more
about you get corrective information as doing that, which actually
can then correct some of the difficult beliefs. So a
classic example is, say, someone who's been sexually assaulted and has
a lot of shame and self-blame that they didn't fight
(09:44):
back. In that, they may have blocked, or their memory is
typically fragmented. So, as we go back through the memory,
remembering just how powerless they were or that the person
had a weapon, actually, can be incredibly helpful, or that
they had a freeze response, which is just a survival
reflex that they didn't choose, that actually can really help
(10:05):
them undercut the shame and the self-blame. And so it's
corrective in that sort of way. We also then do
in vivo exposure, which is gradually overcoming your avoidance to
triggers but doing it in a very gradual way. So
say someone has had a car accident and they, you know,
don't want to get back into a car. We'll start
by just getting them to sit in the car in
(10:26):
the driveway until their anxiety comes down. Nothing bad happens.
It's an example of extinction learning or being able to
learn to reduce your fear in that context. Then you
might start getting them to just reverse their car up
and down the driveway until they feel confident enough. And
then it might be just driving around the local streets,
(10:46):
quiet back roads at a really quiet time, and then
you are progressing gradually up to them resuming driving.
Cassie Hayward (10:52):
And how successful are those treatments?
Kim Felmingham (10:55):
So those treatments we would have probably between 50 and 60%
of people have a good response to that treatment, so
they are no longer PTSD. But you know, that means
we've got 40 or 50% of people who don't and again,
if you've got childhood trauma or more complex PTSD, the
(11:16):
response rate is less than that, but there's a lot
of complexities involved there.
Cassie Hayward (11:20):
How does that compare to treatment for, say, depression or
generalised anxiety or other...?
Kim Felmingham (11:26):
It's pretty much on a par actually. So you know
most of our psychological treatments are actually within that ballpark.
You know, pharmacotherapy will have an equivalent success rate as well.
Except when you go off the pharmacotherapy, you typically can
relapse more than more of these psychological CBT interventions. And look,
(11:47):
PTSD is one of the harder conditions to treat. Given
the complexity and severity of the disorder, it's, I think
it's actually a pretty good response rate. But being a clinician,
what keeps you up at night is the other 40
or 50% what's going on there and how do we
improve it? There are some other evidence based treatments, so
EMDR is one that has got equivalent efficacy to our
(12:10):
exposure treatments.
Cassie Hayward (12:12):
Kim. When you say EMDR, can you just give us
a little snapshot of what that is?
Kim Felmingham (12:17):
So, it stands for Eye Movement Desensitisation Reprocessing and again,
it's been an intervention that's been around for about 20
or 30 years, and it was evolved from Francine Shapiro's work,
and there was a lot of controversy about it initially.
But look, now they've done randomised control trials, and they
(12:38):
do show that it's got equivalent efficacy for relative to
some of our exposure-based treatments. So I think clinicians prefer
to use it, and many clients prefer to use it
because you don't have to talk through the details of
the trauma memory. But, the thing we don't know which
really lit a lot of the controversy about EMDR is
(13:00):
what is the mechanism of it we really don't understand.
It's a really weird therapy to do. So, you get
an image of the trauma memory in mind. And whilst
you keep it in mind, the therapist either does some
bilateral hand movements. So moves their fingers backwards and forwards.
Or they might have hand stimulators that stimulate each hand bilaterally.
(13:24):
Or you might do tapping. And the idea is that
that is going to desensitise the memory. Now there's been
so many hokumm theories, "Ooh you know it's the intrahemispheric alpha rhythms,
and they link, you know they mimic REM sleep comes
into play here," but, you know, I think there isn't any really convincing evidence.
(13:47):
And in fact, some people have done randomised control trials
with and without the eye movements and found equivalent efficacy. So,
it's not necessarily per se about the eye movements or
the interhemispheric element. The most cogent theory, perhaps, I've found,
is it's about memory reconsolidation again. So, the idea is,
(14:07):
if you bring any memory back to mind, it's labile,
which means that whatever you do in a certain period
of time, it can be changed. So the idea is,
if you bring this image to mind of the memory,
it's back in a labile state. And then, if you
are actually doing finger waggling and tapping, it's a dual task,
and our memory and our attentional systems are limited capacity processes.
(14:32):
So therefore, you are using up cognitive resources to be
tracking fingers or to be doing a dual task. And
the theory is that that then means you've got less
brain processes or resources to reconsolidate the memory. So it's
laid back down less strongly is the theory, and we
also have cognitive processing therapy, which has really good evidence
(14:54):
that doesn't necessarily involve working with trauma memories. But it's
much more about the cognitions and beliefs about self. So
you'd use that for someone with a very shame based
PTSD who don't have many reexperiencing symptoms, for example.
Cassie Hayward (15:11):
One thing I hear about in the kind of less
evidence-based space, I guess, in the health podcast space, this
emerging use of drugs like MDMA for treating PTSD a
lot of acronyms there but basically using a pharmacologically supervised
dose of what has traditionally been a recreational drug. What
does the research actually say about that as a treatment?
Kim Felmingham (15:30):
So, in terms of MDMA that's probably got, it's progressed
furthest along. So, they've done the phase three trials. But
the issue with it is that they've only been done
largely by the one group of researchers. So we need
independent replications, and you know there isn't sufficient evidence. The
TGA approved it too early. The FDA has knocked it
(15:53):
back because they think there's insufficient evidence and there are
some real challenges in doing randomised control trials. You can't
blind a control condition, and that actually is quite concerning
because some of those early trials did have major expectancy
effects in the participants. So some participants were flying themselves
(16:13):
self-funding themselves to fly across the US to engage in
these trials. So, they already came in with an expectancy.
It was going to save them. Many desperate people, desperate
for a cure for PTSD, which is understandable. And so,
those expectancies weren't measured adequately enough. So that's one real
flaw with the designs. And we need those independent replications
(16:36):
from independent groups and probably in people who've got even
a bit of cynicism about it and measuring the expectancy effects.
The other thing, I think with the psychedelics that's a
real limitation is this is not going to be a
panacea for treating people. It's not going to be widely
disseminated because it's such an expensive therapy. The estimates at
(16:57):
the moment are it will cost between 10 and $20,000
for a treatment. And if you think about it, you've
got double the clinician time as a standard treatment for PTSD.
And the other thing is, we don't have head to
head randomised control trials of how well does it work
compared to prolonged exposure, for example? So why would you
suggest people do psychedelic therapies or MDMA assisted therapies? if
(17:22):
they might respond better to prolonged exposure, which is cheaper
and can be done in 10 weeks. So I think
we are at a very premature area or level. But look,
the pharmacological adjuncts has been around for about 10 or
15 years, now. They've tried cortisol, yohimbine, oxytocin, MDMA. They've
done D-cycloserine so they've done a whole range of them.
(17:45):
And actually, when you look at the meta-analytic evidence, it's
pretty uninspiring, and they haven't really found large effects. So
I think there's a lot of fascination and interest. And
certainly there's too much hype about MDMA and psychedelics. I'm
sick of reading newspaper articles, and the damaging thing is
(18:06):
that actually hurts vulnerable people because people with PTSD and
trauma are incredibly vulnerable. They are living with a terrible condition,
and then they are desperately seeking treatment. And then that
compounds the expectancy bias, I think in the research.
Cassie Hayward (18:22):
And so just to go back on something you said
about they couldn't do blind trials. So you can't do
a placebo with a hallucinogen or-
Kim Felmingham (18:30):
No, it's impossible to have blind because of the effects
of the MDMA because of the effects. If you're using
psilocybin the person knows they've taken it and they're getting
that active dose relative to a placebo. And the placebos
they've trialled so far really aren't that effective. So in
the maps trials that they've done, they used a very
(18:50):
low dose of MDMA. But it was so low, it
was really not.
Cassie Hayward (18:55):
The person taking it would know they weren't getting the full dose?
Kim Felmingham (18:58):
Yes, pretty much, pretty much. And look, you know, three
of the MDMA papers have just been retracted. Actually, there
have been really serious adverse events in those trials, like
one patient was sexually assaulted, and they've included that data
in some of those papers, so they've been retracted. But
there's even now evidence coming out. They didn't measure serious
(19:18):
adverse events well enough. So, there is reports of increased
suicidal ideation and also people also saying they didn't want
to report they had PTSD still, because they didn't want
to threaten this new frontier of mental health treatment. So,
there's these demand characteristics, so it's really inflating the effects.
So I think we just need to do good critical science.
(19:41):
You know, it's an exciting new potential. I'm all for
getting new treatments for PTSD, but we need to do
the science well.
Cassie Hayward (19:48):
Yeah, I think it definitely highlights the need for that
evidence-based research. And I know you've done some pretty groundbreaking
work around other treatments for PTSD. Maybe around exercise therapy?
Do you want to walk us through some of that research?
Kim Felmingham (20:04):
Yeah, so look, the exercise stuff really came from my
work in neuroscience, So I- there was some research coming out.
There's a neurotrophin in the brain called BDNF
Neurotrophic Factor, and it enhances synaptic plasticity. It's critical for
learning and memory. So, one of the theories about the
exposure therapy is it involves this fear extinction process, which
(20:26):
is unlearning your fear response that is being connected to
stimuli or triggers in the environment. So, exposure therapy, you're
bringing the memory into your mind, and you are in
a safe therapy context and nothing bad happens, so you
can learn to regulate your fear or extinguish it. So anyway,
there was some evidence from animal work that BDNF actually
(20:49):
enhanced fear extinction learning. And so we then took that
into our human trials. So we- I do fear extinction research,
giving people electric shocks, which is a bit mean, but
why not? So, we found that people with BDNF, low
levels of it had poorer extinction learning with PTSD and
(21:10):
we were doing a clinical trial of prolonged exposure in
PTSD patients. And again, we found those people who had
lower levels of BDNF had poorer response to exposure therapy.
So we had a really nice translation from animal science
to human psychophysiology and neuroscience through to actual clinical trials.
Cassie Hayward (21:30):
Which doesn't happen all the time.
Kim Felmingham (21:32):
It's extremely rare and so we then went "Well, this
is exciting. So how do we actually increase BDNF if
we can increase BDNF before they go into the therapy session?
Can we enhance the extinction learning?" And maybe that's going
to enhance treatment outcomes for people. So, the best way
(21:52):
to enhance BDNF is actually through aerobic exercise moderately intense
to intense aerobic exercise. So that's how we devise this trial,
which we've just randomised about 80 people and we are
aiming to get about 110. It has taken five years
off my life, but it's really exciting and worthwhile. So
(22:12):
what we are basically doing is getting people to come in,
and they do 20 minutes of moderate to intense exercise
they are quite sweaty, and then they go into the
therapy room and do standard prolonged exposure for 10 sessions. So,
they do that across 10 weeks.
Cassie Hayward (22:27):
And they do the exercise before each session?
Kim Felmingham (22:29):
They do the exercise before every session. So the idea
is that will enhance their BDNF and then their fear
extinction learning will be better during the exposure, so we
haven't unblinded it. We don't know what the results are
as yet, but one thing that's really intriguing-
Cassie Hayward (22:45):
So just, by unblinding you mean the clinician knows whether
they've exercised or not?
Kim Felmingham (22:49):
Yeah so it's fully, fully, and so we can't analyse
the results. We really don't know until we get to
the end of the trial. But what we have been
tracking is people's dropout rates. And, you know, we've had-.
Prolonged exposure, has fairly high about 25% dropout rates. Normally,
we've actually been getting quite a complex childhood trauma group
of people coming through. It wasn't by design. It's just
(23:11):
who has come into the trial. So the dropout rates
are even higher, which is to be expected. They are
doing a very challenging therapy with really complex trauma. But
the exercise group has got half of the dropout rates
and that wasn't something we predicted, and I've got no
idea why.
Cassie Hayward (23:29):
Are they feeling- Is it because they are feeling more
benefits from the therapy or we don't know yet?
Kim Felmingham (23:34):
I don't know. Is it that they have another thing,
that they'll get out of it as well as doing
these challenging therapies? So that's what's keeping them going. Another
theory might be that because they are doing the exercise,
they are burning off some of the intensity of the
anxiety before coming in so they can tolerate the exposure better.
Cassie Hayward (23:53):
People who already exercise, who are runners or whatever who
do this exercise. Will they have better effects of clinical therapy?
Kim Felmingham (24:04):
Interestingly
Cassie Hayward (24:05):
As a result of their BDNF?
Kim Felmingham (24:07):
Interestingly, they have lower increases in BDNF than people who
are less fit. So the less fit you are, if
you do moderate exercise, you will have a higher rise
of BDNF, which actually works for PTSD. Because many people
with PTSD have metabolic syndrome, they tend towards more overweight
and other health conditions, so it actually might be even
(24:30):
of more benefit for people who-
Cassie Hayward (24:31):
For those who don't, because I was wondering whether it was,
you know, if you think about exercise as a stress
on the body and you've trained your body to deal
with that stress. And there was some translation from that.
But it seems to be more about just that exercise
before therapy increases this BDNF and they get a better outcome. Fascinating.
Kim Felmingham (24:47):
Originally in the trial, I was measuring blood so we
could actually measure BDNF. And then COVID smashed that idea.
And so, we had to progress to telehealth types of
approaches instead so.
Cassie Hayward (25:00):
And it must be exciting for you to, you know,
be on this forefront of different treatments for PTSD.
Kim Felmingham (25:06):
Yeah, well, I mean, that's why I do what I do, really.
My drive isn't really about anything except improving outcomes for
people with PTSD working on the coal face of it
for nearly 30 years. 20 years? You are really- that's
my burning passion is, you know, how can we actually
enhance treatments and accessibility of treatments for people with PTSD? So.
Cassie Hayward (25:30):
Other things that you hear in the kind of wellness
podcast spaces around breathing exercises and yoga and those types of,
kind of, I guess mind body exercise. Is any of
your work looking at that?
Kim Felmingham (25:43):
Not really. But a lot of other people are. So
there are trauma informed yoga practices. People have looked at mindfulness,
people have looked at breathing interventions. And look, you know,
if you look at the randomised controlled trial evidence for that,
the effect sizes aren't huge. They are probably about a
(26:03):
third of what the effect sizes are for the trauma
focused and exposure-based memory work. So EMDR and the exposure treatment.
So it's not your first line treatment. Unfortunately, there's a
lot of clinicians out there where it is the first
line treatment for PTSD. But for me, ethically, if someone
has really flagrant intrusions and nightmares and flashbacks, they really
(26:27):
need trauma focused memory work. But it's not harmful, necessarily.
It can be a nice adjunct, and I use it
for people who say, are very dissociative, aren't connected into
their body at all or can't recognise or connect with emotion.
I might do that sort of work first, that sort
(26:48):
of body-based work more to get that going for someone,
because we really need that for the exposure therapy to work.
So there's a little bit of a fallacy that the
talk therapies, like exposure therapy, don't deal with the body.
It's absolutely not true when we do this work and
similar with EMDR. We actually focus on body, emotion and
(27:11):
thought moment by moment through the narrative of the memory.
So it's all integrated the mind-body stuff.
Cassie Hayward (27:17):
And I guess the way that you integrate yoga or
those other kind of breathing exercise in your clinical therapy
is a great way of using it. But if someone
is out there selling that as the therapy, then that's
where it's dangerous.
Kim Felmingham (27:30):
Beware anyone saying "This is a panacea. This will treat
everyone and cure everyone with PTSD." because it's bunkum because
PTSD in and of itself is an incredibly heterogeneous condition,
so you'll have one person come in. They'll have one
nightmare a month, but they'll have really corrosive shame and
core beliefs that are shocking, and they will avoid social situations.
(27:54):
They probably need more the cognitive based treatments, whereas someone
who's got really intensive nightmares, flashbacks can still qualify for PTSD.
Both of them do. They need trauma memory work, and
that's where the field really needs to evolve, what works
for who? Because we've got a range of different evidence-based treatments.
But we really haven't got good clinical decision tools that
(28:17):
will guide clinicians out there, so you do tend to
find clinicians love mindfulness or they love EMDR. And so
that's what they use for everyone. And we really need
to be taking a case formulation approach. So not diagnostic.
It's not a diagnosis equals treatment for every clinician we
do an individualised case formulation to work out. What are
(28:39):
your pattern of symptoms? What are your maintaining factors and
what's then going to be the best treatment tailored to that?
Cassie Hayward (28:46):
If any of our listeners are dealing with PTSD or
have a loved one who is dealing with it, what's
your advice to them? Maybe, first we start with those
who might not be in treatment at the moment, but
you know that you have it or you know that
your loved one is possibly experiencing PTSD. What's a good
way to encourage them to seek treatment?
Kim Felmingham (29:09):
Look, you know there are really good online resources. Sometimes
that can be a good place to start is to-
Phoenix Australia has some really great resources. Beyond Blue has
some good information as well, just so that you can
start to read a little bit about it and read
about the types of treatments that are available. I'd always
encourage people to seek professional help and to try and
(29:33):
see what is. It's really hard seeing a psychologist, you know,
because there's some bad ones out there. You know, people
will put up a sign "I'm a trauma expert" and
what are their credentials? So, you know, we're going in
and asking people what types of experiences they've had with
delivering these different treatments. And what is the range of options?
(29:54):
How many years? That's actually important stuff to know, to
make decisions. But I think the other hard part is,
you know, gee, the challenging step of going in to
see a stranger and then talking about trauma, some of
the most difficult stuff you might not have told anyone. So,
there's trust. And so, it's also about finding someone who
(30:14):
you really feel you can connect with and feel safe with. So,
it might be starting by just telling a close friend
and talking to a close friend, looking online at resources
what is actually available and out there. And then, you know,
hopefully going and seeking that support if you need it.
Cassie Hayward (30:32):
And you've touched on this briefly. But what should they
be looking out for in terms of credentials because we
know anyone can call themselves a counsellor, and that doesn't
mean they have the right training. But what what should
people be looking for? If they've found someone who they
think might be right, What should they be checking?
Kim Felmingham (30:50):
Well, if they're practising EMDR, they should actually have done
training with an accredited EMDR association, so you can ask
them what kind of training they've done. So, there's the
EMDR Association of Australia. People can actually get to be
accredited EMDR therapists as well, which takes more training and supervision.
Cassie Hayward (31:10):
And they would be a clinical psychologist to start with?
And this would be-
Kim Felmingham (31:13):
Not necessarily, you can be a psycologist and look social workers,
mental health social workers can do EMDR. I would be
looking at people who have they done CPT training. Have
they done prolonged exposure training and ask people those questions? You,
And if they haven't, then what is their experience?
Cassie Hayward (31:31):
Kim. So what's next for you in terms of future
research in this field?
Kim Felmingham (31:36):
I have a lot of post academia fantasies, so I'd
love to set up a trauma retreat service where it
is holistic. It's got nature-based walking. It's got yoga because
I used to be a yoga teacher, in yoga teacher
training for about eight years, but then also doing delivering
EMDR in our exposure-based treatments in a sort of secure,
(31:57):
safe environment and doing intensive therapy because I think it
actually is one of the better modalities if we can
do it. Doing daily exposure therapy so you're really getting
through the hardest part more quickly. It's getting the funding
to do that. So, you know, it's whether I, you know,
get Hollywood celebrities in and charge them a fortune, and
(32:20):
then everyone else can do it for free for the rest.
So these are elaborate fantasies that are probably going to
go nowhere.
Cassie Hayward (32:26):
Fascinating, Kim, thank you for joining us for PsychTalks today.
Kim Felmingham (32:30):
No problem, my pleasure.
Cassie Hayward (32:33):
You've been listening to PsychTalks with me, Cassie Hayward. I'd
like to thank our guest for today, Professor Kim Felmingham.
This episode was produced by Carly Godden with production assistance
from Mairead Murray and Gemma Papprill. Our sound engineer was
Jack Palmer. Thanks for tuning in to this great new
series of PsychTalks. See you next time
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