Psychological Trauma - Different Treatment Aspects

*Psychological Trauma*

pp. 401-423

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Post-Traumatique : Changements Positifs et Bénéfices Perçus Suite Aux Evènements de Vie Graves [Positive Psychology and Post Traumatic

Development/Growth: Positive Changes and Perceived Benefits of Serious Life Events]. Bruxelles: DeBoeck; 2011.

[49] Bishop SR, Lau M, Shapiro S, Carlson L, Anderson ND, Carmody J, et al. Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice. 2004;**11**:230-241. DOI: 10.1093/clipsy.

[50] van den Hurk P, Wings T, Giommi F, Barendregt HP, Speckens A, van Schie H. On the relationship between the practice of mindfulness meditation and personality: An exploratory analysis of the mediating role of mindfulness skills. Mindfulness. 2011;**2**:194-200. DOI:

[51] Nyklíček I, Kuijpers KF. Effects of mindfulness-based stress reduction intervention on psychological wellbeing quality of life: Is increased mindfulness indeed the mechanism? Annals of Behavioral Medicine. 2008;**35**:331-340. DOI: 10.1007/

[52] Rosenzweig S, Greeson JM, Reibel DK, Green JS, Jasser SA, Beasley D. Mindfulness-based stress reduction for chronic pain conditions: Variation in treatment outcomes role of home meditation practice. Journal of

Psychosomatic Research. 2010;**68**:29-36. DOI: 10.1016/j.jpsychores.2009.03.010

[53] Anthony WA. Recovery from mental illness: The guiding vision of the mental health service system in the 1990's. Psychosocial Rehabilitation Journal.

[54] Belrose C, Duffaud A, Dutheil F, Trichereau J, Trousselard M. Challenges

reintegration of soldiers with chronic PTSD: A new approach integrating psychological resources and values in action reappropriation. Frontiers in Psychiatry. 2019;**9**:737. DOI: 10.3389/

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[43] Shankland R, Martin-Krumm C. Les outils d'évaluation en Psychologie Positive. [Assessment tools in positive psychology]. Pratiques Psychologiques.

[44] Butler LD, Blasey CM, Garlan RW, McCaslin SE, Azarow J, Chen XH, et al. Posttraumatic growth following the terrorist attacks of September 11, 2001: Cognitive, coping, and trauma symptom predictors in an internet convenience sample.

Traumatology. 2005;**11**(4):247-267. DOI:

[45] Calhoun LG, Tedeschi RG. Meaning reconstruction and the experience of loss. In: Neymeyer RA, editor. Posttraumatic Growth: Positive Lessons of Loss. Washington, DC: American Psychological Association; 2001.

[46] Tedeschi RG, Calhoun LG. Trauma and Transformation: Growing in the Aftermath of Suffuring. Thousand Oaks, CA: Sage; 1995. p. 175. DOI:

[47] Andresen R, Oades L, Caputi P. The experience from recovery schizophrenia: Towards an empirically validated stage model. Australian and New Zeeland Journal of Psychiatry. 2003;**37**:586-594. DOI: 10.1046/j.1440-1614.2003.01234.x

[48] Shapiro S, Carlson LE, Astin JA, Freedman B. Mechanism of mindfulness. Journal of Clinical Psychology. 2006;**62**(3):373-386. DOI:

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**68**

**71**

**Chapter 6**

**Abstract**

nature

**1. Introduction**

people with PTSD, briefly.

The Role of Therapeutic

*Shima Taheri, Amirhosein Shabani*

*and Maryam Ghasemi Sichani*

Landscape in Improving Mental

Post-traumatic stress disorder (PTSD) as a complex disorder, with serious consequences, affects the quality of life of the individual, the family, as well as the community. Therefore, the subject of this chapter is to study how to reduce stress and improve the quality of life of these people and consequently the community. This chapter is based on documentary studies including the foundations of the theory, the study of the results of experiments in the world, and case studies in this field, which shows that the interaction of individuals with PTSD and therapeutic landscapes can act as a therapeutic mechanism. In the following, features from therapeutic landscapes that help to optimize mental health levels are reviewed in

**Keywords:** mental health, therapeutic landscape, PTSD, stress, physical space,

Stress control improves health, prevents diseases, enhances the quality of life, and reduces health costs [1]. To date, little research has been conducted on the positive and negative effects of the physical environment for people with post-traumatic stress disorder (PTSD), and in particular, little is known about what types of outdoor spaces, and what elements and activities in those outdoor spaces, will be of greatest benefit. The complex combination of physical and neurological injuries interwoven with long-lasting emotional challenges may call for unique design concepts [2]. The notable point about research on quality of life and improving the health of people with PTSD is that so far, many studies have been done about them, however, few studies have been conducted on the role of therapeutic landscape in improving the health of people with PTSD, since this object is a very important disorder that can affect the overall life of a person and affect the work, psychosocial, and physical activity, so that stress relief is highly effective in determining the effectiveness of healthcare and rehabilitation. This chapter first gives a brief overview of PTSD and its levels and attributes then investigates the foundations of the theory and philosophy of association with the nature and effects of nature on health in therapeutic landscape form; the next section is about therapeutic landscapes backgrounds for people with PTSD; also, we discuss the need for a therapeutic landscape to improve

Health of People with PTSD

#### **Chapter 6**

## The Role of Therapeutic Landscape in Improving Mental Health of People with PTSD

*Shima Taheri, Amirhosein Shabani and Maryam Ghasemi Sichani*

#### **Abstract**

Post-traumatic stress disorder (PTSD) as a complex disorder, with serious consequences, affects the quality of life of the individual, the family, as well as the community. Therefore, the subject of this chapter is to study how to reduce stress and improve the quality of life of these people and consequently the community. This chapter is based on documentary studies including the foundations of the theory, the study of the results of experiments in the world, and case studies in this field, which shows that the interaction of individuals with PTSD and therapeutic landscapes can act as a therapeutic mechanism. In the following, features from therapeutic landscapes that help to optimize mental health levels are reviewed in people with PTSD, briefly.

**Keywords:** mental health, therapeutic landscape, PTSD, stress, physical space, nature

#### **1. Introduction**

Stress control improves health, prevents diseases, enhances the quality of life, and reduces health costs [1]. To date, little research has been conducted on the positive and negative effects of the physical environment for people with post-traumatic stress disorder (PTSD), and in particular, little is known about what types of outdoor spaces, and what elements and activities in those outdoor spaces, will be of greatest benefit. The complex combination of physical and neurological injuries interwoven with long-lasting emotional challenges may call for unique design concepts [2]. The notable point about research on quality of life and improving the health of people with PTSD is that so far, many studies have been done about them, however, few studies have been conducted on the role of therapeutic landscape in improving the health of people with PTSD, since this object is a very important disorder that can affect the overall life of a person and affect the work, psychosocial, and physical activity, so that stress relief is highly effective in determining the effectiveness of healthcare and rehabilitation. This chapter first gives a brief overview of PTSD and its levels and attributes then investigates the foundations of the theory and philosophy of association with the nature and effects of nature on health in therapeutic landscape form; the next section is about therapeutic landscapes backgrounds for people with PTSD; also, we discuss the need for a therapeutic landscape to improve

the health of people with PTSD and finally introduce some effective environmental factors in the effectiveness of the therapeutic landscape for PTSD.

#### **2. PTSD**

Trauma exposure leads to various psychiatric disorders including depression, anxiety, bipolar disorders, personality disorders, psychotic disorders, and traumarelated disorders, especially post-traumatic stress disorder [3]. Post-traumatic stress disorder is classified in the new class of traumatic and stress disorder [4]. The term post-traumatic stress disorder was first coined in the 1970s to replace post-Vietnam syndrome. The condition was formally recognized in 1980 in the DSM-IV [5].

PTSD generally appears within 3 months after a traumatic experience such as sexual or psychological abuse or assault, a serious accident, natural disaster, or war-related event(s) [6] or a non-war traumatic event such as a terrorist attack, family violence, and serious injury [7]. It often occurs with—and may be exacerbated by or contribute to—related disorders, including depression [8, 9] substance abuse [10], memory loss, and other physical, mental health problems, and suicidal ideation [11, 12]. Although the majority of PTSD cases in the US are caused by non-combat trauma [13, 14], the lifetime prevalence of the disorder is higher in combat-exposed cases [15].

Individuals with PTSD continue to experience the psychological effects of trauma, including re-experiencing symptoms, avoidance of similar stimuli, negative cognition and mood, and increased physical arousal, long after being removed to a safe environment [7]. They may also suffer a wide range of consequences of revealing their problems, such as a higher likelihood of losing jobs or being discriminated against in the workplace, social exclusion, lower income, difficulties in renting residences, exclusion from social communities, and legal difficulties [16]. In addition to the patients themselves, family members, friends, community members, colleagues, and employers are also indirectly affected by PTSD. Currently, more than 2% of the US population (about 7.7 million people) is known to suffer from PTSD, and 8–9% of the US population reports experiencing lifetime PTSD [17].

More than 60% of men and 51% of women face a major stressful event during their lifetime [18, 19]. Of course, the prevalence of PTSD in the typical population is reported to be between 5 and 10% [20, 21], which shows that only a small group of people with a major incident eventually have PTSD [22] which, of course, is highly dependent on stress. According to the World Health Organization, 450 million people in the world are suffering from vascular and psychiatric illness [23]. About 65% of patients with mental disorders live with their families [24]. The overall prevalence of PTSD is about 8% in general, which is 10–12% in women and 5–6% in men. Also, the prevalence of diseases associated with PTSD is high, with about two-thirds of these patients having at least two other disorders [25, 26]. Over 40% of the risk for PTSD may be genetically heritable [27]. Post-traumatic stress disorder (PTSD) stands out as a major mental illness and is becoming a serious public health challenge.

#### **3. The role of nature in improving physical and mental health**

In health geography and environmental psychology, substantial literatures on green space environments emphasize their potential to promote health and well-being [28–31]. Fortunately, there is a recently rediscovered body of evidence

**73**

*The Role of Therapeutic Landscape in Improving Mental Health of People with PTSD*

that supports the view that nature generally, and everyday living environments in particular, can have a profound effect on health and well-being. Connecting with nature can restore cognitive attention [32, 33], improve blood pressure and self-esteem [34], support pro-environmental behaviors [35], decrease symptoms of attention deficit disorder [36], and improve community resilience [37]. Contact with nature is an effective "upstream health promotion" tool for whole populations. That is, it is useful in prevention of mental health conditions [38]. Studies have shown that exposure to natural environments enhances our ability to recover from stress, illness, and injury, and provides a wide range of social, psychological, and physiological benefits [39, 40]. Across our towns and cities, a connection with nature has been found to be a vital, albeit often unconscious, part of being human. In the late 1970s, the environmental psychologist Ulrich began research on the emotional and psychological effects of environmental esthetics on individuals with a special experience in terms of psychological challenges. In 1984, his paper, "The View through a window" can be effective in restoring the patient after surgery," posed a serious discussion about access to nature in hospitals, which was published in the journal Science. The outcomes data revealed that patients with the nature view had shorter hospital stays, suffered fewer postsurgical complications, needed fewer doses of potent narcotic pain medication, and received more positive written

Ulrich's study, cited in thousands of publications—from books to scholarly journals to newspaper and magazine articles—was, and continues to be, signify for two reasons. First, it demonstrated to the medical community—using the same empirical, quantitative methods that they used and respected—that the physical environment, and specifically views of nature, had a measurable positive effect on patient health. Second, it established a business case for providing access to nature. All of the improved health outcomes for patients—duration of hospital stay, amount of pain medication, degree of strain on nursing staff, and level of patient

Physical settings can play a role in coping with stress; in particular, experimental research has found strong evidence between exposure to natural environments and recovery from physiological stress and mental fatigue, giving support to both "stress recovery theory" and "attention restoration theory" [42–44]. In fact, exposure to natural environments protects people against the impact of environmental stressors and offer physiological, emotional, and attention restoration more so than urban environments. Natural places that allow the renewal of personal adaptive resources to meet the demands of everyday life are called "restorative environments." Natural environments elicit greater calming responses than urban environments, and in relation to their vision there is a general reduction of physiological symptoms of stress. Exposure to natural scenes mediates the negative effects of stress reducing the negative mood state and above all enhancing positive emotions. Moreover, one can recover the decrease of cognitive performance associated with stress, especially reflected in attention tasks, through the salutary effect of viewing nature. Giving the many benefits of contact with nature, plans for urban environments should attend to restrictiveness [45]. The neuroscientist Esther Sternberg suggests that part of nature's benefit is derived from the multitude of simultaneous positive sensory experiences [46, 47]. Proximity to nature, especially trees, was also found to have a beneficial effect on the amount of domestic violence in Chicago public housing households [48], women's ability to cope with major life issues [49], and amount of inner-city crime [50]. A study by team of Li [51] showed that nature therapy increases the activity of natural lethal cells that are part of the immune system against cancer risk. This in turn

*DOI: http://dx.doi.org/10.5772/intechopen.86543*

comments in their medical records from staff [41].

satisfaction—translated directly to potential cost savings [6].

#### *The Role of Therapeutic Landscape in Improving Mental Health of People with PTSD DOI: http://dx.doi.org/10.5772/intechopen.86543*

that supports the view that nature generally, and everyday living environments in particular, can have a profound effect on health and well-being. Connecting with nature can restore cognitive attention [32, 33], improve blood pressure and self-esteem [34], support pro-environmental behaviors [35], decrease symptoms of attention deficit disorder [36], and improve community resilience [37]. Contact with nature is an effective "upstream health promotion" tool for whole populations. That is, it is useful in prevention of mental health conditions [38]. Studies have shown that exposure to natural environments enhances our ability to recover from stress, illness, and injury, and provides a wide range of social, psychological, and physiological benefits [39, 40]. Across our towns and cities, a connection with nature has been found to be a vital, albeit often unconscious, part of being human.

In the late 1970s, the environmental psychologist Ulrich began research on the emotional and psychological effects of environmental esthetics on individuals with a special experience in terms of psychological challenges. In 1984, his paper, "The View through a window" can be effective in restoring the patient after surgery," posed a serious discussion about access to nature in hospitals, which was published in the journal Science. The outcomes data revealed that patients with the nature view had shorter hospital stays, suffered fewer postsurgical complications, needed fewer doses of potent narcotic pain medication, and received more positive written comments in their medical records from staff [41].

Ulrich's study, cited in thousands of publications—from books to scholarly journals to newspaper and magazine articles—was, and continues to be, signify for two reasons. First, it demonstrated to the medical community—using the same empirical, quantitative methods that they used and respected—that the physical environment, and specifically views of nature, had a measurable positive effect on patient health. Second, it established a business case for providing access to nature. All of the improved health outcomes for patients—duration of hospital stay, amount of pain medication, degree of strain on nursing staff, and level of patient satisfaction—translated directly to potential cost savings [6].

Physical settings can play a role in coping with stress; in particular, experimental research has found strong evidence between exposure to natural environments and recovery from physiological stress and mental fatigue, giving support to both "stress recovery theory" and "attention restoration theory" [42–44]. In fact, exposure to natural environments protects people against the impact of environmental stressors and offer physiological, emotional, and attention restoration more so than urban environments. Natural places that allow the renewal of personal adaptive resources to meet the demands of everyday life are called "restorative environments." Natural environments elicit greater calming responses than urban environments, and in relation to their vision there is a general reduction of physiological symptoms of stress. Exposure to natural scenes mediates the negative effects of stress reducing the negative mood state and above all enhancing positive emotions. Moreover, one can recover the decrease of cognitive performance associated with stress, especially reflected in attention tasks, through the salutary effect of viewing nature. Giving the many benefits of contact with nature, plans for urban environments should attend to restrictiveness [45].

The neuroscientist Esther Sternberg suggests that part of nature's benefit is derived from the multitude of simultaneous positive sensory experiences [46, 47]. Proximity to nature, especially trees, was also found to have a beneficial effect on the amount of domestic violence in Chicago public housing households [48], women's ability to cope with major life issues [49], and amount of inner-city crime [50]. A study by team of Li [51] showed that nature therapy increases the activity of natural lethal cells that are part of the immune system against cancer risk. This in turn

*Psychological Trauma*

**2. PTSD**

the health of people with PTSD and finally introduce some effective environmental

Trauma exposure leads to various psychiatric disorders including depression, anxiety, bipolar disorders, personality disorders, psychotic disorders, and traumarelated disorders, especially post-traumatic stress disorder [3]. Post-traumatic stress disorder is classified in the new class of traumatic and stress disorder [4]. The term post-traumatic stress disorder was first coined in the 1970s to replace post-Vietnam syndrome. The condition was formally recognized in 1980 in the DSM-IV [5].

PTSD generally appears within 3 months after a traumatic experience such as sexual or psychological abuse or assault, a serious accident, natural disaster, or war-related event(s) [6] or a non-war traumatic event such as a terrorist attack, family violence, and serious injury [7]. It often occurs with—and may be exacerbated by or contribute to—related disorders, including depression [8, 9] substance abuse [10], memory loss, and other physical, mental health problems, and suicidal ideation [11, 12]. Although the majority of PTSD cases in the US are caused by non-combat trauma [13, 14], the

lifetime prevalence of the disorder is higher in combat-exposed cases [15].

the US population reports experiencing lifetime PTSD [17].

**3. The role of nature in improving physical and mental health**

In health geography and environmental psychology, substantial literatures on green space environments emphasize their potential to promote health and well-being [28–31]. Fortunately, there is a recently rediscovered body of evidence

Individuals with PTSD continue to experience the psychological effects of trauma, including re-experiencing symptoms, avoidance of similar stimuli, negative cognition and mood, and increased physical arousal, long after being removed to a safe environment [7]. They may also suffer a wide range of consequences of revealing their problems, such as a higher likelihood of losing jobs or being discriminated against in the workplace, social exclusion, lower income, difficulties in renting residences, exclusion from social communities, and legal difficulties [16]. In addition to the patients themselves, family members, friends, community members, colleagues, and employers are also indirectly affected by PTSD. Currently, more than 2% of the US population (about 7.7 million people) is known to suffer from PTSD, and 8–9% of

More than 60% of men and 51% of women face a major stressful event during their lifetime [18, 19]. Of course, the prevalence of PTSD in the typical population is reported to be between 5 and 10% [20, 21], which shows that only a small group of people with a major incident eventually have PTSD [22] which, of course, is highly dependent on stress. According to the World Health Organization, 450 million people in the world are suffering from vascular and psychiatric illness [23]. About 65% of patients with mental disorders live with their families [24]. The overall prevalence of PTSD is about 8% in general, which is 10–12% in women and 5–6% in men. Also, the prevalence of diseases associated with PTSD is high, with about two-thirds of these patients having at least two other disorders [25, 26]. Over 40% of the risk for PTSD may be genetically heritable [27]. Post-traumatic stress disorder (PTSD) stands out as a major mental illness and is becoming a serious

factors in the effectiveness of the therapeutic landscape for PTSD.

**72**

public health challenge.

helps to increase resistance to stress. Past research demonstrates that naturalistic settings may offer benefits in terms of stress reduction and improved mental states within corrections environments [52].

#### **4. Theoretical and philosophical foundation**

In stress reduction theory, Ulrich is emphasized on health positive results by reducing stress based on two main reasons. First, many people who are ill or caring for a patient experience stress. Second, many people-someone who are not aware of this sign-are demanding environments in order to reduce stress where is predominant in nature [53]. There is powerful evidence that indicates (1) sensory control, (2) social support, (3) physical movement, (4) natural positive distractions help reduce stress [44, 54, 55].

Attention restoration theory was developed by Rachel and Stephen Kaplan in the decade 1980 in their book "Nature Experience: One Psychological Approach" was introduced to describe environmental impacts [32, 56] on humans and emphasizes the role of the natural environment for the physical, psychological recovery of the individual as a factor in the restoration of thought. According to this view, placing in the environment can reduce people's psychological pressure and improve the fatigue of the audience. This theory claims that people after spending time in nature, or even looking at the scenes of nature can focus better. The natural range is with many soft charms that a person can show in "simple and instant attention," such as moving clouds across the sky, the sound of leaves in mild wind, or the sound of flowing water in a stream full of rock. Kaplan's theory defines two-related systems: directed attention, engaging in a particular task, which is often difficult and stressful (like taking a test, doing surgery), requires simultaneous removal of the sensory stimulus. Psychological restoration can be described as the ability to perceive recovery and restoration, so that the observer can understand environmental properties that reduce mental fatigue and stress **Figures 1** and **2** [57].

Since Gesler introduced the concept in 1992, the notion of "therapeutic landscape" has been productively employed to better understand the dynamic between place and wellness [58], a therapeutic landscape includes both the

**75**

**Figure 3.**

**Figure 2.**

*post-traumatic stress [57].*

*The Role of Therapeutic Landscape in Improving Mental Health of People with PTSD*

natural, built, symbolic, and social environments [59]. Moving from its initial application of understanding places reputed for their healing qualities, the therapeutic landscape concept today also encompasses everyday landscapes [60]. Collectively, therapeutic places are culturally constructed, experienced differently by different people, and not necessarily ideal or romantic landscapes [61]. As Gesler and Kearns [62] contend, landscapes are multi-dimensional: the sites of human-environment interaction, products of social processes, and individual or personal constructs. Similarly, contemporary definitions of health include multiple aspects of wellbeing: emotional, spiritual, physical, and social. Gesler's concept suggests that specific landscapes not only provide an identity, satisfying a human need for roots, but can also act as the location of social networks, providing settings for therapeutic activities. This is based on an understanding of the ways in which environmental, societal, and individual factors can work together to preserve health and well-being. Hence, place is understood as being relational, influenced not only by the physical environment, but also by the human mind and material circumstances—reflecting both human agency (through intentions and actions) as well as the structures and constraints imposed by society [63]. Stress, a complex, documentary, and very important

*London: a calm, communal public space, with edible planting, in a therapeutic garden for people living with* 

*PT-guided: performance physical Therapy's "PT guided fitness program" [57].*

*DOI: http://dx.doi.org/10.5772/intechopen.86543*

*The Role of Therapeutic Landscape in Improving Mental Health of People with PTSD DOI: http://dx.doi.org/10.5772/intechopen.86543*

natural, built, symbolic, and social environments [59]. Moving from its initial application of understanding places reputed for their healing qualities, the therapeutic landscape concept today also encompasses everyday landscapes [60]. Collectively, therapeutic places are culturally constructed, experienced differently by different people, and not necessarily ideal or romantic landscapes [61]. As Gesler and Kearns [62] contend, landscapes are multi-dimensional: the sites of human-environment interaction, products of social processes, and individual or personal constructs. Similarly, contemporary definitions of health include multiple aspects of wellbeing: emotional, spiritual, physical, and social. Gesler's concept suggests that specific landscapes not only provide an identity, satisfying a human need for roots, but can also act as the location of social networks, providing settings for therapeutic activities. This is based on an understanding of the ways in which environmental, societal, and individual factors can work together to preserve health and well-being. Hence, place is understood as being relational, influenced not only by the physical environment, but also by the human mind and material circumstances—reflecting both human agency (through intentions and actions) as well as the structures and constraints imposed by society [63]. Stress, a complex, documentary, and very important

#### **Figure 2.**

*Psychological Trauma*

within corrections environments [52].

reduce stress [44, 54, 55].

**4. Theoretical and philosophical foundation**

helps to increase resistance to stress. Past research demonstrates that naturalistic settings may offer benefits in terms of stress reduction and improved mental states

In stress reduction theory, Ulrich is emphasized on health positive results by reducing stress based on two main reasons. First, many people who are ill or caring for a patient experience stress. Second, many people-someone who are not aware of this sign-are demanding environments in order to reduce stress where is predominant in nature [53]. There is powerful evidence that indicates (1) sensory control, (2) social support, (3) physical movement, (4) natural positive distractions help

Attention restoration theory was developed by Rachel and Stephen Kaplan in the decade 1980 in their book "Nature Experience: One Psychological Approach" was introduced to describe environmental impacts [32, 56] on humans and emphasizes the role of the natural environment for the physical, psychological recovery of the individual as a factor in the restoration of thought. According to this view, placing in the environment can reduce people's psychological pressure and improve the fatigue of the audience. This theory claims that people after spending time in nature, or even looking at the scenes of nature can focus better. The natural range is with many soft charms that a person can show in "simple and instant attention," such as moving clouds across the sky, the sound of leaves in mild wind, or the sound of flowing water in a stream full of rock. Kaplan's theory defines two-related systems: directed attention, engaging in a particular task, which is often difficult and stressful (like taking a test, doing surgery), requires simultaneous removal of the sensory stimulus. Psychological restoration can be described as the ability to perceive recovery and restoration, so that the observer can understand environmen-

tal properties that reduce mental fatigue and stress **Figures 1** and **2** [57].

Since Gesler introduced the concept in 1992, the notion of "therapeutic landscape" has been productively employed to better understand the dynamic between place and wellness [58], a therapeutic landscape includes both the

*Low-cost, edible garden interventions in a public park can be added as a temporary or permanent feature [57].*

**74**

**Figure 1.**

*London: a calm, communal public space, with edible planting, in a therapeutic garden for people living with post-traumatic stress [57].*

**Figure 3.** *PT-guided: performance physical Therapy's "PT guided fitness program" [57].*

#### *Psychological Trauma*

health issue, points to the importance of the issue of natural regeneration as a key advantage for PTSD to use for healing therapeutics.

According to above, one of the best ways to avoid tension from patient with PTSD treatment is to take refuge in nature. Studies have shown that the presence of plants in the environment reduces blood pressure, heart rate, muscle tension, stress, fatigue, and aggressive behavior, and factors such as level of comfort, tolerance and self-esteem, sense of well-being, life expectancy and enjoy the work environment. As defined by the World Health Organization (WHO), health is a physical, psychological, and social well-being, not just a lack of illness or illness, so the therapeutic landscape is a setting whose maximum design is trying to create healing properties in space. In fact, healing gardens through connection through human senses can heal and reduce the stress of everyday life. Evidences show that the following factors are effective in reducing stress in such spaces: good feelings from the nature, exercise and activity, social support, sense of control **Figure 3**.

### **5. Conclusion**

Based on the above sections , in **Table 1** provides indicators status in a therapeutic landscape for people with PTSD.


**77**

**Author details**

Branch, Isfahan, Iran

\*, Amirhosein Shabani2

and Maryam Ghasemi Sichani3

1 Young Researchers and Elite Club, Islamic Azad University, Isfahan (Khorasgan)

2 Department of Urban Planning, Islamic Azad University, Najafabad Branch,

3 Architecture Department, Faculty of Architecture and Urban Planning, Islamic

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Azad University of Isfahan (Khorasgan) Branch, Isfahan, Iran

\*Address all correspondence to: shimataheri@rocketmail.com

provided the original work is properly cited.

Shima Taheri1

Najafabad, Iran

*The Role of Therapeutic Landscape in Improving Mental Health of People with PTSD*

**therapeutic landscape for people with PTSD**

Creating ground-level pots suitable for people with PTSD with physical restrictions [like

The presence of attractive elements along the way to increase motivation and proper flooring, as well as the creation of

shadows is essential

wheelchairs]

**Therapeutic landscape** 

Creating a workplace for

Create spaces for strolling

**Indicators**

horticulture

*DOI: http://dx.doi.org/10.5772/intechopen.86543*

Reduce anger and depression/improve general state/increase cognitive

Reduce stress/decrease depression/ improve memory, concentration and

capacity

senses

**Table 1.** *Conclusion.*

**How impact on health Indicators status in a** 


*The Role of Therapeutic Landscape in Improving Mental Health of People with PTSD DOI: http://dx.doi.org/10.5772/intechopen.86543*

**Table 1.** *Conclusion.*

*Psychological Trauma*

**5. Conclusion**

tic landscape for people with PTSD.

Reducing stress/decreasing blood pressure/decreasing anger

Reducing stress/making sense of security for more mobility

Reduced heart rate/reduced anger/

Positive effect on memory and navigation/decreased heart rate and blood pressure/decreased depression

concentration

health issue, points to the importance of the issue of natural regeneration as a

According to above, one of the best ways to avoid tension from patient with PTSD treatment is to take refuge in nature. Studies have shown that the presence of plants in the environment reduces blood pressure, heart rate, muscle tension, stress, fatigue, and aggressive behavior, and factors such as level of comfort, tolerance and self-esteem, sense of well-being, life expectancy and enjoy the work environment. As defined by the World Health Organization (WHO), health is a physical, psychological, and social well-being, not just a lack of illness or illness, so the therapeutic landscape is a setting whose maximum design is trying to create healing properties in space. In fact, healing gardens through connection through human senses can heal and reduce the stress of everyday life. Evidences show that the following factors are effective in reducing stress in such spaces: good feelings from the nature,

Based on the above sections , in **Table 1** provides indicators status in a therapeu-

**therapeutic landscape for people with PTSD**

of short and long plants in combination with the use of green, blue and colorful

elements such as paths, furniture

Abstraction and complexity for patients who are stressed are

Providing road safety for patients with mobility problems [slope, stairs, floors], proper lighting for

the wind flow among the foliage,

Flora and plant species diversity,

Use of water in ponds, lakes, etc. Proper use of water

animals in some spaces [for example, the presence of fish in a pond or domestic birds]

Stress reduction Not too open and not too close Balance between open and

landscapes

activities, etc.

unacceptable

the area

fruit trees

the sound of water

**Therapeutic landscape** 

**Indicators**

Flexibility

enclosed spaces

Vegetable diversity

Minimizing ambiguity

Create a sense of security

Decrease undesirable environmental noise and increase natural sounds

Create a small ecosystem

Spread flowers and plants of colorful and fragrant

key advantage for PTSD to use for healing therapeutics.

exercise and activity, social support, sense of control **Figure 3**.

**How impact on health Indicators status in a** 

Reduced illness/positive distraction Planting diversity, the use

Reducing stress and anxiety Flexibility in various scales and

Reduce stress and calm down The bird's attraction, the sound of

Positive distraction/stress reduction The limited presence of some

**76**

**Author details**

Shima Taheri1 \*, Amirhosein Shabani<sup>2</sup> and Maryam Ghasemi Sichani3

1 Young Researchers and Elite Club, Islamic Azad University, Isfahan (Khorasgan) Branch, Isfahan, Iran

2 Department of Urban Planning, Islamic Azad University, Najafabad Branch, Najafabad, Iran

3 Architecture Department, Faculty of Architecture and Urban Planning, Islamic Azad University of Isfahan (Khorasgan) Branch, Isfahan, Iran

\*Address all correspondence to: shimataheri@rocketmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Smeltzer SC, Brenda G. Brunner and Suddrath's Text Book of Medical Surgical Nursing. 10th ed. Philadelphia: Lippincott; 2002

[2] Ann Sloan D. Environmental Psychology and Human Well-Being Effects of Built and Natural Settings. Cambridge: Academic Press; 2018, 482 p

[3] Compeanab E. Hamnerab: Posttraumatic stress disorder with secondary psychotic features (PTSD-SP): Diagnostic and treatment challenges. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2019;**88**:265-275

[4] Naderi Y, Moradi AR, Hasani J, Noohi S. Effectiveness of emotional schema therapy on cognitive emotion regulation strategies of combat-related post traumatic stress disorder veterans. Iranian Journal of War and Public Health. 2015;**7**(3):147-155

[5] Shalev AY, Yehuda R, McFarlane AC. International Handbook of Human Response to Trauma. New York: Kluwer Academic/Plenum Press; 2000

[6] Cooper Marcus C, Naomi S. Therapeutic Landscapes: An Evidence Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces. New York :John Wiley & Sons Inc; 2014

[7] US Department of Veterans Affairs. PTSD: National Center for PTSD [Internet]. 2016. Available from: http:// www.ptsd.va.gov/professional/PTSDoverview/index.asp [Accessed: 07 April 2016]

[8] Campbell DG, Felker BL, Liu C-F, Yano EM, Kirchner JE, Chan D, et al. Prevalence of depression–PTSD comorbidity: Implications for clinical practice guidelines and primary carebased interventions. Journal of General Internal Medicine. 2007;**22**(6):711-810

[9] Ginzburg K, Ein-Dor T, Solomon Z. Comorbidity of posttraumatic stress disorder, anxiety and depression: A 20-year longitudinal study of war veterans. Journal of Affective Disorders. 2010;**123**(1):249-257

[10] Breslau N, Davis GC, Schultz LR. Posttraumatic stress disorder and the incidence of nicotine, alcohol, and other drug disorders in persons who have experienced trauma. Archives of General Psychiatry. 2003;**60**(3):289-294

[11] Jakupcak M, Cook J, Imel Z, Fontana A, Rosenheck R, McFall M. Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan war veterans. Journal of Traumatic Stress. 2009;**22**(4):303-306

[12] Goodnight J, Ragsdale K, Sam R, Rothbaum BO. Psychotherapy for PTSD: An evidence-based guide to a theranostic approach to treatment. Progress in Neuropsychopharmacology Biological Psychiatry. 2019;**10**(88):418-426

[13] Purtle J. Heroes' invisible wounds of war: Constructions of posttraumatic stress disorder in the text of US federal legislation. Social Science & Medicine. 2016;**149**:9-16

[14] Prigerson HG, Maciejewski PK, Rosenheck RA. Population attributable fractions of psychiatric disorders and behavioral outcomes associated with combat exposure among US men. American Journal of Public Health. 2002;**92**(1):59-63

[15] Kessler RC, Chiu W, Demler O, Walters EE, Revalence P. Severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry. 2005;**62**(6):617-627

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*The Role of Therapeutic Landscape in Improving Mental Health of People with PTSD*

[24] Halligan SL, Yehuda R. Risk factors for PTSD. PTSD Research Quarterly.

[25] Kozaric-Kovacic D, Kocijan-Hercigonja D. Assessment of post-traumatic stress disorder and comorbidity. Military Medicine.

[26] Kozaric-Kovacic D, Kocijan-Hercigonja D, Grubisic-Ilic

M. Posttraumatic stress disorder and depression in soldiers with combat experiences. Croatian Medical Journal.

[27] Sharma S, Ressler KJ. Genomic

Psychopharmacology and Biological

[28] Korpela K, Hartig T. Restorative qualities of favorite places. Journal of Environmental Psychology.

[29] Mitchell R, Popham F. Green space, urbanity and health: Relationships in England. Journal of Epidemiology and Community Health. 2007;**61**:681-683

[30] Richardson E, Mitchell R. Gender differences in relationships between urban green space and health in the United Kingdom. Social Science & Medicine. 2010;**71**(3):568-575

[31] Mitchell R, Pearce J, Shortt N. Place, space and health inequalities. In: Smith K, Bambra C, Hill S, editors. Health Inequalities: Critical Perspectives.

[32] Kaplan S. The restorative benefits of nature: Toward an integrative framework. Journal of Environmental Psychology. 1995;**15**(31):69-182

[33] Kaplan R, Kaplan S. Adolescents and the natural environment: A time out? In: Kahn PH Jr, Kellert SR, editors. Children

2000;**11**(3):1-3

2001;**166**(8):677-680

2001;**42**(2):165-170

1996;**16**:221-233

Oxford: OUP; 2015

updates in understanding PTSD. Progress in Neuro-

Psychiatry. 2019;**90**:197-203

*DOI: http://dx.doi.org/10.5772/intechopen.86543*

[16] Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental cause of population health inequalities. American Journal of Public Health.

[17] Ghaffarzadegan N, Ebrahimvandi A, Jalali MS. A dynamic model of posttraumatic stress disorder for military personnel and veterans. PLoS ONE.

[18] Ahmadizadeh M, Khodabakh A, Jafar A. The effectiveness of problem solving and prolonged exposure therapy methods and a combination of both on the adjustment of veterans suffering from war-related post-traumatic stress disorder. Journal of Military Medicine.

[19] Noohi AM, Tavallaei SA, Karami GR. Post-traumatic stress disorder (PTSD) among aggressive patients attending to Baqiyatallah psychiatric clinic in 2005. Journal of Military Medicine. 2006;**8**(3):175-181

[20] Davidson J. Trauma: The impact of posttraumatic stress disorder. Journal of Psychopharmacology.

[21] Cao H, McFarlane AC, Klimidis S. Prevalence of psychiatric disorder following the 1988 Yun Nan (China) earthquake. Social Psychiatry and Psychiatric Epidemiology.

[22] Galea S, Vlahov D, Resnick H, Ahern J, Susser E, Gold J. Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. American Journal of Epidemiology. 2003;**158**(6):514-524

[23] Parandeh A, Khaghanizadeh M, Karimi Zarchi A. The effect of training conflict resolution on quality of life's on spouses of war veterans post traumatic stress disorder. Journal of Military

Medicine. 2006;**8**(1):45-51

2013;**103**(5):813-821

2016;**11**(10):e0161405

2012;**14**(3):178-185

2000;**14**(2):S5-S12

2003;**38**(4):204-212

*The Role of Therapeutic Landscape in Improving Mental Health of People with PTSD DOI: http://dx.doi.org/10.5772/intechopen.86543*

[16] Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental cause of population health inequalities. American Journal of Public Health. 2013;**103**(5):813-821

[17] Ghaffarzadegan N, Ebrahimvandi A, Jalali MS. A dynamic model of posttraumatic stress disorder for military personnel and veterans. PLoS ONE. 2016;**11**(10):e0161405

[18] Ahmadizadeh M, Khodabakh A, Jafar A. The effectiveness of problem solving and prolonged exposure therapy methods and a combination of both on the adjustment of veterans suffering from war-related post-traumatic stress disorder. Journal of Military Medicine. 2012;**14**(3):178-185

[19] Noohi AM, Tavallaei SA, Karami GR. Post-traumatic stress disorder (PTSD) among aggressive patients attending to Baqiyatallah psychiatric clinic in 2005. Journal of Military Medicine. 2006;**8**(3):175-181

[20] Davidson J. Trauma: The impact of posttraumatic stress disorder. Journal of Psychopharmacology. 2000;**14**(2):S5-S12

[21] Cao H, McFarlane AC, Klimidis S. Prevalence of psychiatric disorder following the 1988 Yun Nan (China) earthquake. Social Psychiatry and Psychiatric Epidemiology. 2003;**38**(4):204-212

[22] Galea S, Vlahov D, Resnick H, Ahern J, Susser E, Gold J. Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. American Journal of Epidemiology. 2003;**158**(6):514-524

[23] Parandeh A, Khaghanizadeh M, Karimi Zarchi A. The effect of training conflict resolution on quality of life's on spouses of war veterans post traumatic stress disorder. Journal of Military Medicine. 2006;**8**(1):45-51

[24] Halligan SL, Yehuda R. Risk factors for PTSD. PTSD Research Quarterly. 2000;**11**(3):1-3

[25] Kozaric-Kovacic D, Kocijan-Hercigonja D. Assessment of post-traumatic stress disorder and comorbidity. Military Medicine. 2001;**166**(8):677-680

[26] Kozaric-Kovacic D, Kocijan-Hercigonja D, Grubisic-Ilic M. Posttraumatic stress disorder and depression in soldiers with combat experiences. Croatian Medical Journal. 2001;**42**(2):165-170

[27] Sharma S, Ressler KJ. Genomic updates in understanding PTSD. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2019;**90**:197-203

[28] Korpela K, Hartig T. Restorative qualities of favorite places. Journal of Environmental Psychology. 1996;**16**:221-233

[29] Mitchell R, Popham F. Green space, urbanity and health: Relationships in England. Journal of Epidemiology and Community Health. 2007;**61**:681-683

[30] Richardson E, Mitchell R. Gender differences in relationships between urban green space and health in the United Kingdom. Social Science & Medicine. 2010;**71**(3):568-575

[31] Mitchell R, Pearce J, Shortt N. Place, space and health inequalities. In: Smith K, Bambra C, Hill S, editors. Health Inequalities: Critical Perspectives. Oxford: OUP; 2015

[32] Kaplan S. The restorative benefits of nature: Toward an integrative framework. Journal of Environmental Psychology. 1995;**15**(31):69-182

[33] Kaplan R, Kaplan S. Adolescents and the natural environment: A time out? In: Kahn PH Jr, Kellert SR, editors. Children

**78**

2016]

*Psychological Trauma*

**References**

Lippincott; 2002

[1] Smeltzer SC, Brenda G. Brunner and Suddrath's Text Book of Medical Surgical Nursing. 10th ed. Philadelphia: [9] Ginzburg K, Ein-Dor T, Solomon Z. Comorbidity of posttraumatic stress disorder, anxiety and depression: A 20-year longitudinal study of war veterans. Journal of Affective Disorders.

[10] Breslau N, Davis GC, Schultz LR. Posttraumatic stress disorder and the incidence of nicotine, alcohol, and other drug disorders in persons who have experienced trauma. Archives of General Psychiatry.

2010;**123**(1):249-257

2003;**60**(3):289-294

2009;**22**(4):303-306

2016;**149**:9-16

2002;**92**(1):59-63

[11] Jakupcak M, Cook J, Imel Z, Fontana A, Rosenheck R, McFall M. Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan war veterans. Journal of Traumatic Stress.

[12] Goodnight J, Ragsdale K, Sam R, Rothbaum BO. Psychotherapy for PTSD: An evidence-based guide to a theranostic approach to treatment. Progress in Neuropsychopharmacology Biological Psychiatry. 2019;**10**(88):418-426

[13] Purtle J. Heroes' invisible wounds of war: Constructions of posttraumatic stress disorder in the text of US federal legislation. Social Science & Medicine.

[14] Prigerson HG, Maciejewski PK, Rosenheck RA. Population attributable fractions of psychiatric disorders and behavioral outcomes associated with combat exposure among US men. American Journal of Public Health.

[15] Kessler RC, Chiu W, Demler O, Walters EE, Revalence P. Severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Archives of General

Psychiatry. 2005;**62**(6):617-627

[2] Ann Sloan D. Environmental Psychology and Human Well-Being Effects of Built and Natural Settings. Cambridge: Academic Press; 2018, 482 p

[3] Compeanab E. Hamnerab: Posttraumatic stress disorder with secondary psychotic features (PTSD-SP): Diagnostic and treatment

challenges. Progress in Neuro-Psychopharmacology and Biological

[4] Naderi Y, Moradi AR, Hasani J, Noohi S. Effectiveness of emotional schema therapy on cognitive emotion regulation strategies of combat-related post traumatic stress disorder veterans. Iranian Journal of War and Public

[5] Shalev AY, Yehuda R, McFarlane AC. International Handbook of Human Response to Trauma. New York: Kluwer

Academic/Plenum Press; 2000

[6] Cooper Marcus C, Naomi S. Therapeutic Landscapes: An Evidence Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces. New York :John Wiley & Sons Inc; 2014

[7] US Department of Veterans Affairs. PTSD: National Center for PTSD [Internet]. 2016. Available from: http:// www.ptsd.va.gov/professional/PTSDoverview/index.asp [Accessed: 07 April

[8] Campbell DG, Felker BL, Liu C-F, Yano EM, Kirchner JE, Chan D, et al. Prevalence of depression–PTSD comorbidity: Implications for clinical practice guidelines and primary carebased interventions. Journal of General Internal Medicine. 2007;**22**(6):711-810

Psychiatry. 2019;**88**:265-275

Health. 2015;**7**(3):147-155

and Nature: Theoretical, Conceptual, and Empirical Investigations. Cambridge, MA: MIT Press; 2002

[34] Pretty J, Peacock J, Sellens M, Griffin M. The mental and physical health outcomes of green exercise. International Journal of Environmental Health Research. 2005;**15**:319-337

[35] Hartig T. Issues in restorative environments research: Matters of measurement. In: Fernández B, Hidalgo C, Salvador C, Martos MJ, editors. Psicología Ambiental: Entre los Estudios Urbanos y el análisis de la Sostenibilidad. Almería: PSICAMB; 2011

[36] Kuo FE, Taylor AF. The potential natural treatment for attention deficit/ hyperactivity disorder: Evidence for a national study. American Journal of Public Health. 2004;**94**:1580-1586

[37] Moore M, Townsend M, Oldroyd J. Linking human and ecosystem health: The benefits of community involvement in conservation groups. EcoHealth. 2006;**3**:255-261

[38] Maller C, Townsend M, Pryor A, Brown P, St Leger L. Healthy nature healthy people: 'Contact with nature' as an upstream health promotion intervention for populations. Health Promotion International. 2006;**21**(1):45-54

[39] Ulrich R. View through a window may influence recovery from surgery. Science Journal. 1984;**224**(4647):420-421

[40] Kofler W. Ecology and Forests for Public Health. Munich: International Council for Scientific Development; 2010

[41] Marberry SO. A Conversation with Roger Ulrich. Healthcare Design. 2010. Available from: www. healthcaredesignmagazine.com/article/ conversation-rogerUlrich?Page=show [Accessed: 01 November 2010]

[42] Taheri S, Shabani A. Conceptual and practical principles in designing healing gardens for veterans with PTSD with a focus on reducing stress—A narrative review. Journal of Molecular Medicine. 2016;**18**(3):230-241

[43] Hartig T, Evans G, Jamner LD, Davis DS, Garling T. Tracking restoration in natural and urban field settings. Journal of Environmental Psychology. 2003;**23**:109-123

[44] Ulrich R. Effects of gardens on health outcomes: Theory and research. In: Cooper Marcus C, Barnes M, editors. Healing Gardens: Therapeutic Benefits and Design Recommendations. New York: John Wiley; 1991

[45] Berto R. The role of nature in coping with psycho-physiological stress: A literature review on restorativeness. Behavioral Sciences (Basel). 2014;**4**(4):394-409

[46] Sachs NA. Interview with Dr. Esther Sternberg, Author of Healing Spaces: The Science of Place and Well-Being [Internet]. 2009. Available from: www. healinglandscape.org/blog/2009/09/ interview-with-dr-esthersternbergauthor-of-healing-spaces-the-scienceof-the-place-and-well-being [Accessed: 01 September 2009]

[47] Sternberg EM. Healing Spaces: The Science and Place of Well-Being. Cambridge, MA: Harvard University Press; 2010

[48] Kuo FE, Sullivan WC. Environment and crime in the inner city: Does vegetation reduce crime? Environment and Behavior. 2001;**33**(3):343-367

[49] Kuo FE. Coping with poverty: Impacts of environment and attention in the inner city. Environment and Behavior. 2001;**33**(1):5-34

**81**

*The Role of Therapeutic Landscape in Improving Mental Health of People with PTSD*

[59] Baer LD, Gesler WM. Reconsidering the concept of therapeutic landscapes in JD Salinger's the Catcherin the Rye.

[60] Thorsen RS. Conceptualizations of pluralistic medical fields: Exploring the therapeutic landscapes of Nepal. Health

Area. 2004;**36**(4):404-413

and Place. 2014;**31**:83-89

2008;**15**:88-96

Routledge; 2002

[61] Dunkley CM. A therapeutic taskscape: Theorizing place-making, discipline and care at a camp for troubled youth. Health and Place.

[62] Gesler W, Kearns RA. Culture/ Place/Health. London and New York:

[63] Milligan C. 'Cultivating health': Therapeutic landscapes and older people in northern England. Social Science and

Medicine. 2004;**58**:1781-1793

*DOI: http://dx.doi.org/10.5772/intechopen.86543*

[50] Kuo FE, Sullivan WC. Aggression

[51] Li Q, Morimoto K, Nakadai A, Inagaki H, Katsumata M, Shimizu T, et al. Forest bathing enhances human natural killer activity and expression of anti-cancer proteins. International Journal of Immunopathology and Pharmacology. 2007;**20**:3-8

[52] Lindemuth AL. Greening in the Red Zone: Disaster, Resilience, and Community Greening. Netherland:

[53] Francis C, Cooper Marcus C. Places

people take their problems. In: Proceedings of Annual Conference of Environmental Design and Research

Association. 1991;**22**:178-84

[54] Ulrich R. Effects of healthcare environmental design on medical outcomes design and health. In: Proceedings Design and Health World Congress and Exhibition; Stockholm:

[55] Ulrich R. Health Benefits of Gardens in Hospitals. Paper for conference, Plants for People International Exhibition Florida; 2002

[56] Kaplan R, Kaplan S. The Experience of Nature: A Psychological Perspective. Cambridge: Cambridge University

[57] Souter-Brown G. Landscape and Urban Design for Health and Well-Being: Using Healing, Sensory and Therapeutic Gardens. London:Routledge Press; 2015

[58] Williams A. Therapeutic

Press of America; 1999. pp. 1-11

Landscapes: The Dynamic between Place and Wellness. Lanham, MD: University

and violence in the inner city: Impacts of environment via mental fatigue. Environment and Behavior.

2001;**33**(4):543-571

Springer; 2014

2001. pp. 49-69

Press; 1989

*The Role of Therapeutic Landscape in Improving Mental Health of People with PTSD DOI: http://dx.doi.org/10.5772/intechopen.86543*

[50] Kuo FE, Sullivan WC. Aggression and violence in the inner city: Impacts of environment via mental fatigue. Environment and Behavior. 2001;**33**(4):543-571

*Psychological Trauma*

2005;**15**:319-337

2011

2006;**3**:255-261

2006;**21**(1):45-54

[39] Ulrich R. View through a window may influence recovery from surgery. Science Journal. 1984;**224**(4647):420-421

[40] Kofler W. Ecology and Forests for Public Health. Munich: International Council for Scientific Development; 2010

[41] Marberry SO. A Conversation with Roger Ulrich. Healthcare Design. 2010. Available from: www. healthcaredesignmagazine.com/article/

and Nature: Theoretical, Conceptual,

conversation-rogerUlrich?Page=show [Accessed: 01 November 2010]

[42] Taheri S, Shabani A. Conceptual and practical principles in designing healing gardens for veterans with PTSD with a focus on reducing stress—A narrative review. Journal of Molecular

[43] Hartig T, Evans G, Jamner LD, Davis DS, Garling T. Tracking restoration in natural and urban field settings. Journal of Environmental Psychology.

[44] Ulrich R. Effects of gardens on health outcomes: Theory and research. In: Cooper Marcus C, Barnes M, editors. Healing Gardens: Therapeutic Benefits and Design Recommendations.

[45] Berto R. The role of nature in coping with psycho-physiological stress: A literature review on restorativeness.

[46] Sachs NA. Interview with Dr. Esther Sternberg, Author of Healing Spaces: The Science of Place and Well-Being [Internet]. 2009. Available from: www. healinglandscape.org/blog/2009/09/ interview-with-dr-esthersternbergauthor-of-healing-spaces-the-scienceof-the-place-and-well-being [Accessed:

[47] Sternberg EM. Healing Spaces: The Science and Place of Well-Being. Cambridge, MA: Harvard University

[48] Kuo FE, Sullivan WC. Environment and crime in the inner city: Does vegetation reduce crime? Environment and Behavior. 2001;**33**(3):343-367

[49] Kuo FE. Coping with poverty: Impacts of environment and attention in the inner city. Environment and

Behavior. 2001;**33**(1):5-34

New York: John Wiley; 1991

Behavioral Sciences (Basel).

2014;**4**(4):394-409

01 September 2009]

Press; 2010

Medicine. 2016;**18**(3):230-241

2003;**23**:109-123

and Empirical Investigations. Cambridge, MA: MIT Press; 2002

[34] Pretty J, Peacock J, Sellens M, Griffin M. The mental and physical health outcomes of green exercise. International Journal of Environmental Health Research.

[35] Hartig T. Issues in restorative environments research: Matters of measurement. In: Fernández B, Hidalgo C, Salvador C, Martos MJ, editors. Psicología Ambiental: Entre los Estudios Urbanos y el análisis de la Sostenibilidad. Almería: PSICAMB;

[36] Kuo FE, Taylor AF. The potential natural treatment for attention deficit/ hyperactivity disorder: Evidence for a national study. American Journal of Public Health. 2004;**94**:1580-1586

[37] Moore M, Townsend M, Oldroyd J. Linking human and ecosystem health: The benefits of community involvement in conservation groups. EcoHealth.

[38] Maller C, Townsend M, Pryor A, Brown P, St Leger L. Healthy nature healthy people: 'Contact with nature' as an upstream health promotion intervention for populations. Health Promotion International.

**80**

[51] Li Q, Morimoto K, Nakadai A, Inagaki H, Katsumata M, Shimizu T, et al. Forest bathing enhances human natural killer activity and expression of anti-cancer proteins. International Journal of Immunopathology and Pharmacology. 2007;**20**:3-8

[52] Lindemuth AL. Greening in the Red Zone: Disaster, Resilience, and Community Greening. Netherland: Springer; 2014

[53] Francis C, Cooper Marcus C. Places people take their problems. In: Proceedings of Annual Conference of Environmental Design and Research Association. 1991;**22**:178-84

[54] Ulrich R. Effects of healthcare environmental design on medical outcomes design and health. In: Proceedings Design and Health World Congress and Exhibition; Stockholm: 2001. pp. 49-69

[55] Ulrich R. Health Benefits of Gardens in Hospitals. Paper for conference, Plants for People International Exhibition Florida; 2002

[56] Kaplan R, Kaplan S. The Experience of Nature: A Psychological Perspective. Cambridge: Cambridge University Press; 1989

[57] Souter-Brown G. Landscape and Urban Design for Health and Well-Being: Using Healing, Sensory and Therapeutic Gardens. London:Routledge Press; 2015

[58] Williams A. Therapeutic Landscapes: The Dynamic between Place and Wellness. Lanham, MD: University Press of America; 1999. pp. 1-11

[59] Baer LD, Gesler WM. Reconsidering the concept of therapeutic landscapes in JD Salinger's the Catcherin the Rye. Area. 2004;**36**(4):404-413

[60] Thorsen RS. Conceptualizations of pluralistic medical fields: Exploring the therapeutic landscapes of Nepal. Health and Place. 2014;**31**:83-89

[61] Dunkley CM. A therapeutic taskscape: Theorizing place-making, discipline and care at a camp for troubled youth. Health and Place. 2008;**15**:88-96

[62] Gesler W, Kearns RA. Culture/ Place/Health. London and New York: Routledge; 2002

[63] Milligan C. 'Cultivating health': Therapeutic landscapes and older people in northern England. Social Science and Medicine. 2004;**58**:1781-1793

**83**

PTSD

**1. Introduction**

**Chapter 7**

**Abstract**

Videoconferencing Psychotherapy

Trauma-Related Psychopathology

The theoretical background of the life-span sequelae of exposure to interpersonal psychological trauma (emotional or physical neglect or abuse or sexual abuse) in childhood, particularly when a primary caretaker is involved, and its assessment and treatment possibilities in a 100% online environment are outlined. These sequelae may be understood as a complex variant of PTSD (CPTSD) or a complicated array of overlapping mental and personality disorders or as transdiagnostic symptoms. However, disorders of extreme stress not otherwise specified (DESNOS) constitute a distinct syndrome of potential clinical utility. In childhood, adolescence, and young adulthood (YA), these symptoms seem encompassed by developmental trauma disorder (DTD). Affect dysregulation, identity alterations, and relational impairment are central features of DESNOS/DTD/CPTSD and can also be understood as trans-diagnostic symptom clusters. More and more people use smartphone apps in daily life. Therefore we started our 100% online treatments in patients' environments and at their convenience (need driven). Our digitally enriched outpatient clinics (DOCs) using smartphone apps for videoconferencing psychotherapy (VCP) and personal data monitoring aim to augment established evidence-based treatment protocols. Also, they facilitate continuously gathering real-time sensor- and self-reported data that improve ecological validity of self-

reports and monitoring for course of treatment and relapse prevention.

**Keywords:** childhood trauma, smartphone, app, videoconferencing psychotherapy,

**1.1 The life-span sequelae of exposure to interpersonal psychological trauma (emotional or physical neglect or abuse or sexual abuse) in childhood**

Caretaker-related traumatic stressors are likely to occur in and contribute to a relational growth-inhibiting early environment, interfere with the development of optimal set points and strive for homeostasis of basic brain functioning, and may therefore adversely impact the development of self- and affect regulation capacities in childhood. Infants of caretakers who are unresponsive or poorly affectively attuned are at risk for developing insecure attachment. Infants who additionally experience an abusive caretaker are at risk for developing post-traumatic states of

in an App Environment for

*Annemiek van Dijke and Jacques van Lankveld*

#### **Chapter 7**

## Videoconferencing Psychotherapy in an App Environment for Trauma-Related Psychopathology

*Annemiek van Dijke and Jacques van Lankveld*

### **Abstract**

The theoretical background of the life-span sequelae of exposure to interpersonal psychological trauma (emotional or physical neglect or abuse or sexual abuse) in childhood, particularly when a primary caretaker is involved, and its assessment and treatment possibilities in a 100% online environment are outlined. These sequelae may be understood as a complex variant of PTSD (CPTSD) or a complicated array of overlapping mental and personality disorders or as transdiagnostic symptoms. However, disorders of extreme stress not otherwise specified (DESNOS) constitute a distinct syndrome of potential clinical utility. In childhood, adolescence, and young adulthood (YA), these symptoms seem encompassed by developmental trauma disorder (DTD). Affect dysregulation, identity alterations, and relational impairment are central features of DESNOS/DTD/CPTSD and can also be understood as trans-diagnostic symptom clusters. More and more people use smartphone apps in daily life. Therefore we started our 100% online treatments in patients' environments and at their convenience (need driven). Our digitally enriched outpatient clinics (DOCs) using smartphone apps for videoconferencing psychotherapy (VCP) and personal data monitoring aim to augment established evidence-based treatment protocols. Also, they facilitate continuously gathering real-time sensor- and self-reported data that improve ecological validity of selfreports and monitoring for course of treatment and relapse prevention.

**Keywords:** childhood trauma, smartphone, app, videoconferencing psychotherapy, PTSD

#### **1. Introduction**

#### **1.1 The life-span sequelae of exposure to interpersonal psychological trauma (emotional or physical neglect or abuse or sexual abuse) in childhood**

Caretaker-related traumatic stressors are likely to occur in and contribute to a relational growth-inhibiting early environment, interfere with the development of optimal set points and strive for homeostasis of basic brain functioning, and may therefore adversely impact the development of self- and affect regulation capacities in childhood. Infants of caretakers who are unresponsive or poorly affectively attuned are at risk for developing insecure attachment. Infants who additionally experience an abusive caretaker are at risk for developing post-traumatic states of

enduring negative affect that may become disorganized attachment working models and chronic dysfunctional self- and affect regulation patterns. Such sequelae of early life "neurodevelopmental injuries" have been described as epidemic and understudied [1].

Also, the life-span sequelae of exposure to interpersonal psychological trauma (emotional or physical neglect or abuse or sexual abuse) in childhood, particularly when a primary caretaker is involved, do not seem to be encompassed by any single DSM disorder [2]. Symptoms include and extend symptoms associated with posttraumatic stress disorder (PTSD) with and without dissociative symptoms. Also, it has been argued that these sequelae also include a complex symptom presentation reflecting disturbances in (interpersonal) self-regulatory capacities and mental disorders that may occur comorbidly with or separately from PTSD [3]. Whether these sequelae are best understood as a complex variant of PTSD (CPTSD) or a complicated array of overlapping mental and personality disorders is controversial [4, 5]. However, there is mounting evidence that a disorder of extreme stress not otherwise specified (DESNOS) formulation of CPTSD constitutes a distinct syndrome of potential clinical utility [6, 7]. In childhood, adolescence, and young adulthood (YA), these symptoms seem encompassed by the developmental trauma disorder (DTD) formulation [8].

#### **1.2 Affect dysregulation, identity alterations, and relational impairment**

Three core features of the DESNOS formulation of CPTSD symptomatology and DTD were identified based on a comprehensive literature review [8]: affect dysregulation, identity alterations (dissociation), and relational impairment (insecure attachment) [3, 9–12].

*Affect dysregulation* is defined as problems in experiencing, managing (keeping emotional arousal within the Window of Tolerance (WoT) [13]), or recovering from extreme states of affect, including both under-regulation of heightened affect states and maladaptive overregulation of affect (e.g., [14]). Under-regulation involves limited access to or capacity for deploying strategies to reduce intense affect states and associated difficulties with impulse control and goal-directed behavior (e.g., anger that escalates into rage or anxiety that becomes an unmanageable state of terror). Overregulation involves nonacceptance and limited awareness or clarity of emotions (e.g., states of profound emotional emptiness or detachment) [15]. The latter has also been defined as alexithymia [16]. Alexithymia type I is characterized by low emotionality and a poor fantasy life in combination with poorly developed cognitions accompanying the emotions. This type is also referred to as core or full-blown alexithymia and displays both cognitive and affective alexithymia (e.g., [17, 18]). Alexithymia type II only suffers from cognitive alexithymia and is characterized by high emotionality and a rich fantasy life in combination with poorly developed cognitions accompanying the emotions. Alexithymia type II has been associated with childhood sexual abuse and PTSD symptoms (e.g., [19]).

Clinically, Lane differentiated levels of emotional awareness (LEAS; e.g., [20]), a three-dimensional cognitive-developmental framework that LEAS scores plausibly track, including the transition from focusing on external/physical to internal/ psychological characteristics, greater conceptual complexity, and self-other differentiation. This concept is closely related to differentiating alexithymia types but highlights the cognitive-developmental character of emotional maturation and also taps into affective agnosia.

*Identity alterations* involve problems with maintaining a coherent sense of (mental and embodied) self within the WoT, which may take the form of dissociation symptoms including somatoform or embodied dissociative symptoms such

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as conversion symptoms, pain, or somatization and psychoform or mentalized dissociative symptoms such as depersonalization, amnesia, or identity alterations that may turn into positive or negative forms of dissociation (e.g., [15, 21]). Trauma-related overwhelming affect and its dysfunctional regulation compromise the integrative capacities associated with cognitive-emotional information processing so that information becomes disassociated, disorganized, or disoriented (e.g., [22]). Janet [23] introduced his model of the mind consisting of two different ways of functioning: (a) activities that preserve and reproduce the past and (b) activities which are directed toward synthesis and creation (i.e., integration). In line with Janet, Van der Hart and colleagues consider dissociation a core feature of trauma: a division of personality into dissociative (biopsychosocial) subsystems that evolve when the individual lacks the capacity to integrate adverse experiences in part or in full, as can be recognized in dissociative identity disorder (DID) patients [23]. Already in Janet's original research (and recently further conceptualized), the existence of dissociative subsystems manifests in positive and negative dissociative symptoms (e.g., dissociative flashback episodes; e.g., in [23]). These positive and negative dissociative symptoms can be further distinguished as psychoform and somatoform dissociative symptoms (e.g., [24]). Negative dissociative symptoms refer to apparent losses of functions, for example, of memory, motor control, skills, and somatosensory awareness. Negative psychoform dissociative symptoms, among others, include loss of memory (amnesia) and loss of affective experiencing (numbness), loss of needs and will (abulia), loss of critical function (a cognitive action) resulting in suggestibility and difficulty thinking things through, loss of previously existing skills, and diminished sense of self. Negative somatoform dissociative symptoms, among others, involve loss of sensory-perceptual or motor functions, e.g., analgesia, paralysis, and aphonia. Positive psychoform dissociative symptoms include traumatic memories and nightmares that have affective, cognitive, and somatosensory components such as dissociative flashbacks and full re-experiencing of traumatizing events, as well as intruding voices, thoughts, and amplified affective experiencing. Positive somatoform dissociative symptoms include intrusions of sensorimotor aspects of traumatic re-experiences, including pain, uncontrolled

behaviors such as tics, sensory distortions, and pseudo-epileptic seizures.

shown to have better internal consistency than the prototypical secure, preoccupied, dismissing, and unresolved attachment categories and to provide a good fit in confirmatory factor analyses: avoidance (i.e., fear of closeness) and anxiety (i.e., fear of abandonment) [26]. Attachment-related avoidance and anxiety were selected to represent adult relational impairment rather than the childhood-based categories of insecure attachment because they were shown to be trait-like risk factors for self-reported psychiatric symptoms (i.e., correlated with psychopathology under conditions of both high and low stress), while the insecure attachment categories were associated with psychopathology in adults only under high-stress conditions [27]. When confronted with potential threatening events, the primary attachment strategy (secure attachment) involves proximity seeking: attempting to move closer, physically or emotionally or both, to persons who are perceived as providing relational security that can serve to alleviate distress and build or access resources, remaining within the WoT. When external (real) or internalized (i.e., working model representations of) attachment figures are unavailable, secondary attachment strategies (insecure attachment: hyper-activation or deactivation of the internalized attachment system) are hypothesized to be activated in order to cope with relational insecurity and related distress: failure of remaining within the WoT. Secondary attachment strategies involve a defensive focus either on fear of abandonment (i.e., attempts to restore proximity and reduce anxiety; hence

*Relational impairment* in adulthood involves two dimensions [25] that have been

*DOI: http://dx.doi.org/10.5772/intechopen.86364*

#### *Videoconferencing Psychotherapy in an App Environment for Trauma-Related Psychopathology DOI: http://dx.doi.org/10.5772/intechopen.86364*

as conversion symptoms, pain, or somatization and psychoform or mentalized dissociative symptoms such as depersonalization, amnesia, or identity alterations that may turn into positive or negative forms of dissociation (e.g., [15, 21]). Trauma-related overwhelming affect and its dysfunctional regulation compromise the integrative capacities associated with cognitive-emotional information processing so that information becomes disassociated, disorganized, or disoriented (e.g., [22]). Janet [23] introduced his model of the mind consisting of two different ways of functioning: (a) activities that preserve and reproduce the past and (b) activities which are directed toward synthesis and creation (i.e., integration). In line with Janet, Van der Hart and colleagues consider dissociation a core feature of trauma: a division of personality into dissociative (biopsychosocial) subsystems that evolve when the individual lacks the capacity to integrate adverse experiences in part or in full, as can be recognized in dissociative identity disorder (DID) patients [23]. Already in Janet's original research (and recently further conceptualized), the existence of dissociative subsystems manifests in positive and negative dissociative symptoms (e.g., dissociative flashback episodes; e.g., in [23]). These positive and negative dissociative symptoms can be further distinguished as psychoform and somatoform dissociative symptoms (e.g., [24]). Negative dissociative symptoms refer to apparent losses of functions, for example, of memory, motor control, skills, and somatosensory awareness. Negative psychoform dissociative symptoms, among others, include loss of memory (amnesia) and loss of affective experiencing (numbness), loss of needs and will (abulia), loss of critical function (a cognitive action) resulting in suggestibility and difficulty thinking things through, loss of previously existing skills, and diminished sense of self. Negative somatoform dissociative symptoms, among others, involve loss of sensory-perceptual or motor functions, e.g., analgesia, paralysis, and aphonia. Positive psychoform dissociative symptoms include traumatic memories and nightmares that have affective, cognitive, and somatosensory components such as dissociative flashbacks and full re-experiencing of traumatizing events, as well as intruding voices, thoughts, and amplified affective experiencing. Positive somatoform dissociative symptoms include intrusions of sensorimotor aspects of traumatic re-experiences, including pain, uncontrolled behaviors such as tics, sensory distortions, and pseudo-epileptic seizures.

*Relational impairment* in adulthood involves two dimensions [25] that have been shown to have better internal consistency than the prototypical secure, preoccupied, dismissing, and unresolved attachment categories and to provide a good fit in confirmatory factor analyses: avoidance (i.e., fear of closeness) and anxiety (i.e., fear of abandonment) [26]. Attachment-related avoidance and anxiety were selected to represent adult relational impairment rather than the childhood-based categories of insecure attachment because they were shown to be trait-like risk factors for self-reported psychiatric symptoms (i.e., correlated with psychopathology under conditions of both high and low stress), while the insecure attachment categories were associated with psychopathology in adults only under high-stress conditions [27]. When confronted with potential threatening events, the primary attachment strategy (secure attachment) involves proximity seeking: attempting to move closer, physically or emotionally or both, to persons who are perceived as providing relational security that can serve to alleviate distress and build or access resources, remaining within the WoT. When external (real) or internalized (i.e., working model representations of) attachment figures are unavailable, secondary attachment strategies (insecure attachment: hyper-activation or deactivation of the internalized attachment system) are hypothesized to be activated in order to cope with relational insecurity and related distress: failure of remaining within the WoT. Secondary attachment strategies involve a defensive focus either on fear of abandonment (i.e., attempts to restore proximity and reduce anxiety; hence

*Psychological Trauma*

understudied [1].

disorder (DTD) formulation [8].

attachment) [3, 9–12].

enduring negative affect that may become disorganized attachment working models and chronic dysfunctional self- and affect regulation patterns. Such sequelae of early life "neurodevelopmental injuries" have been described as epidemic and

Also, the life-span sequelae of exposure to interpersonal psychological trauma (emotional or physical neglect or abuse or sexual abuse) in childhood, particularly when a primary caretaker is involved, do not seem to be encompassed by any single DSM disorder [2]. Symptoms include and extend symptoms associated with posttraumatic stress disorder (PTSD) with and without dissociative symptoms. Also, it has been argued that these sequelae also include a complex symptom presentation reflecting disturbances in (interpersonal) self-regulatory capacities and mental disorders that may occur comorbidly with or separately from PTSD [3]. Whether these sequelae are best understood as a complex variant of PTSD (CPTSD) or a complicated array of overlapping mental and personality disorders is controversial [4, 5]. However, there is mounting evidence that a disorder of extreme stress not otherwise specified (DESNOS) formulation of CPTSD constitutes a distinct syndrome of potential clinical utility [6, 7]. In childhood, adolescence, and young adulthood (YA), these symptoms seem encompassed by the developmental trauma

**1.2 Affect dysregulation, identity alterations, and relational impairment**

DTD were identified based on a comprehensive literature review [8]: affect dysregulation, identity alterations (dissociation), and relational impairment (insecure

Three core features of the DESNOS formulation of CPTSD symptomatology and

*Affect dysregulation* is defined as problems in experiencing, managing (keeping emotional arousal within the Window of Tolerance (WoT) [13]), or recovering from extreme states of affect, including both under-regulation of heightened affect states and maladaptive overregulation of affect (e.g., [14]). Under-regulation involves limited access to or capacity for deploying strategies to reduce intense affect states and associated difficulties with impulse control and goal-directed behavior (e.g., anger that escalates into rage or anxiety that becomes an unmanageable state of terror). Overregulation involves nonacceptance and limited awareness or clarity of emotions (e.g., states of profound emotional emptiness or detachment) [15]. The latter has also been defined as alexithymia [16]. Alexithymia type I is characterized by low emotionality and a poor fantasy life in combination with poorly developed cognitions accompanying the emotions. This type is also referred to as core or full-blown alexithymia and displays both cognitive and affective alexithymia (e.g., [17, 18]). Alexithymia type II only suffers from cognitive alexithymia and is characterized by high emotionality and a rich fantasy life in combination with poorly developed cognitions accompanying the emotions. Alexithymia type II has been associated with childhood sexual abuse and PTSD symptoms (e.g., [19]).

Clinically, Lane differentiated levels of emotional awareness (LEAS; e.g., [20]), a three-dimensional cognitive-developmental framework that LEAS scores plausibly track, including the transition from focusing on external/physical to internal/ psychological characteristics, greater conceptual complexity, and self-other differentiation. This concept is closely related to differentiating alexithymia types but highlights the cognitive-developmental character of emotional maturation and also

*Identity alterations* involve problems with maintaining a coherent sense of (mental and embodied) self within the WoT, which may take the form of dissociation symptoms including somatoform or embodied dissociative symptoms such

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taps into affective agnosia.

hyper-activation) or fear of closeness (i.e., attempts to inhibit proximity seeking and reduce awareness of distress; hence deactivation/inhibition). Clinically and phenomenologically, the secondary attachment strategies appear to involve relatively distinct forms of emotion dysregulation, with under-regulation of emotion predominating in fear of abandonment and overregulation of emotion characterizing fear of closeness [25].

Overall, dysfunctional self-regulation is the core of these problems.

#### **1.3 Childhood interpersonal trauma-related disorders**

Although the life-span sequelae of exposure to psychological trauma-byprimary-caretaker in childhood do not seem to be encompassed by any single DSM disorder [2], the DESNOS formulation of CPTSD in adulthood and DTD in adolescence-YA has been demonstrated *empirically* to be associated with childhood relational adverse experiences that are potentially traumatic (e.g., maltreatment, family violence) consistently across numerous studies [10–12, 28, 29].

CPTSD as defined by DESNOS is theorized to represent the results of developmental adaptations to exposure to interpersonal trauma in developmentally sensitive periods, including altered emotion processing, dissociative shifts in self-awareness and consciousness, and disruption of secure attachment working models (e.g., see [7]).

Borderline personality disorder (BPD) arguably involves similar forms of dysregulation, and, historically, symptoms of somatic symptom disorders (SSD) have been associated with interpersonal trauma and hysteria [6]. Nevertheless, CPTSD can be distinguished in terms of clinical phenomenology from PTSD, BPD, SSD, anxiety disorders, and depression. CPTSD as defined by DESNOS appears to involve hypervigilance related to being harmed, whereas BPD involves extreme sensitivity to perceiving oneself as being abandoned or rejected/shamed [6, 30].

Moreover, certain features of CPTSD that are conceptually related to PTSD (i.e., arousal-related somatic dysregulation; altered personal schemas) may be largely accounted for by PTSD, but CPTSD features that are more clinically and conceptually distinct from PTSD (i.e., affect dysregulation, dissociation) appear to be empirically distinct from PTSD in adults with severe psychopathology [30].

#### **1.4 Network theory of trauma**

As opposed to trying to categorize symptoms within existing classifications/ diagnoses (e.g., dissociative subtype of PTSD), or attempting to get new diagnoses accepted (e.g., DESNOS, CPTSD, DTD), the life-span sequelae of exposure to interpersonal psychological trauma (emotional or physical neglect or abuse or sexual abuse) in childhood can also be understood as *trans-diagnostic* phenomenology.

Network theory supports this trans-diagnostic perspective. According to Borsboom (e.g., [31]), the comprehensive theoretical model of (trauma-related) psychopathology follows five principles to encode the backbone of the *network theory* of mental disorders:

Principle 1. Complexity: Mental disorders are best characterized in terms of the interaction between different components in a psychopathology network. Principle 2. Symptom-component correspondence: The components in the psychopathology network correspond to the problems that have been codified as symptoms in the past century and appear as such in current diagnostic manuals. Principle 3. Direct causal connections: The network structure is generated by a pattern of direct causal connections between symptoms.

Principle 4. Mental disorders follow network structure: The psychopathology network has a nontrivial topology, in which certain symptoms are more tightly

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connected than others. These symptom groupings give rise to the phenomenological manifestation of mental disorders as groups of symptoms that often

These principles imply that the etiology of mental disorders can be thought of in terms of a process of spreading activation in a symptom network. If a symptom arises (which may occur for different reasons depending on person, time, and context), this will increase the probability that a connected symptom arises as well. Thus, coupled sets of symptoms, which are close in the network structure, will tend to synchronize. Mental disorders then arise when groups of tightly coupled symptoms actively maintain each other, leading to a cluster of

Principle 5. Hysteresis: Mental disorders arise due to the presence of hysteresis in strongly connected symptom networks: the network can become self-sustaining, which implies that *symptoms continue to activate each other, even after the triggering cause of the disorder has disappeared*. Although the presence of a trigger can activate a strong network, *the absence/disappearance of that trigger does not deactivate the strongly connected network.* This may well be the explanation for PTSD symptoms and attachment trauma-related insecure self-regulation styles, which develop and endure after the traumatic events have subsided as

**1.5 Inhibitory, excitatory, and combined inhibitory and excitatory (IE) regulation**

Despite a vast amount of research on the benefits of successfully regulating affect for our mental well-being, the role of dysfunctional self- and affect regulation for psychiatric patients remains unclear. However, it has been established that affect dysregulation is involved in the etiology of psychopathology and that dysfunctional self-regulation is often described in patients with complex psychopathology and mental disorders. Dysfunctional affect regulation typically seems to involve an interpersonal context, and attachment theory has become a prominent conceptual framework for understanding the process of development of affect regulation and dysregulation. Whereas some patients react to adversities with inhibited experiencing and social withdrawal, others react hyper-emotionally and tend to cling to a significant other to alleviate (interpersonal) stress and regulate to baseline and

The DESNOS formulation of CPTSD in adulthood and developmental trauma disorder (DTD) in childhood and adolescence have been demonstrated empirically to be associated with qualitatively different self-regulation strategies/styles or three different networks: inhibitory, excitatory, and combined inhibitory and excitatory (IE) regulation (see **Figure 1**; e.g., [7]). Symptoms include disturbances in self-regulation across several domains of functioning, including affective-, cognitive-, somatic-, relational-, reflective-, executive-, behavioral-, and psycho-physiological functioning. Activation of dysfunctional regulation seems to follow trauma-by-primarycaretaker associated negatively biased cognitive-emotional information processing. However, when potentially neutral situations are processed and evaluated as threatening or potentially harmful, dysfunctional regulation is activated false positively. Consequently, this may result in interpersonal misunderstanding and disappointments, which in turn condition and uphold the insecure attachment representation/ working models eventually turning into dysfunctional regulation vicious circles. Mental states associated with *inhibited experiencing* are consistent with overregulation of affect and with the negative psychoform and somatoform dissociative symptoms, including appearing emotionally constricted, expressionless, machinelike, weak or frozen, social avoidant, rigid mental elaborations or mental blancs,

psychopathology symptoms that becomes self-sustaining [31].

observed in attachment-trauma patients (DESNOS/DTD).

*DOI: http://dx.doi.org/10.5772/intechopen.86364*

arise together.

return within the WoT.

connected than others. These symptom groupings give rise to the phenomenological manifestation of mental disorders as groups of symptoms that often arise together.

These principles imply that the etiology of mental disorders can be thought of in terms of a process of spreading activation in a symptom network. If a symptom arises (which may occur for different reasons depending on person, time, and context), this will increase the probability that a connected symptom arises as well. Thus, coupled sets of symptoms, which are close in the network structure, will tend to synchronize. Mental disorders then arise when groups of tightly coupled symptoms actively maintain each other, leading to a cluster of psychopathology symptoms that becomes self-sustaining [31]. Principle 5. Hysteresis: Mental disorders arise due to the presence of hysteresis in strongly connected symptom networks: the network can become self-sustaining, which implies that *symptoms continue to activate each other, even after the triggering cause of the disorder has disappeared*. Although the presence of a trig-

ger can activate a strong network, *the absence/disappearance of that trigger does not deactivate the strongly connected network.* This may well be the explanation for PTSD symptoms and attachment trauma-related insecure self-regulation styles, which develop and endure after the traumatic events have subsided as observed in attachment-trauma patients (DESNOS/DTD).

#### **1.5 Inhibitory, excitatory, and combined inhibitory and excitatory (IE) regulation**

Despite a vast amount of research on the benefits of successfully regulating affect for our mental well-being, the role of dysfunctional self- and affect regulation for psychiatric patients remains unclear. However, it has been established that affect dysregulation is involved in the etiology of psychopathology and that dysfunctional self-regulation is often described in patients with complex psychopathology and mental disorders. Dysfunctional affect regulation typically seems to involve an interpersonal context, and attachment theory has become a prominent conceptual framework for understanding the process of development of affect regulation and dysregulation. Whereas some patients react to adversities with inhibited experiencing and social withdrawal, others react hyper-emotionally and tend to cling to a significant other to alleviate (interpersonal) stress and regulate to baseline and return within the WoT.

The DESNOS formulation of CPTSD in adulthood and developmental trauma disorder (DTD) in childhood and adolescence have been demonstrated empirically to be associated with qualitatively different self-regulation strategies/styles or three different networks: inhibitory, excitatory, and combined inhibitory and excitatory (IE) regulation (see **Figure 1**; e.g., [7]). Symptoms include disturbances in self-regulation across several domains of functioning, including affective-, cognitive-, somatic-, relational-, reflective-, executive-, behavioral-, and psycho-physiological functioning. Activation of dysfunctional regulation seems to follow trauma-by-primarycaretaker associated negatively biased cognitive-emotional information processing. However, when potentially neutral situations are processed and evaluated as threatening or potentially harmful, dysfunctional regulation is activated false positively. Consequently, this may result in interpersonal misunderstanding and disappointments, which in turn condition and uphold the insecure attachment representation/ working models eventually turning into dysfunctional regulation vicious circles.

Mental states associated with *inhibited experiencing* are consistent with overregulation of affect and with the negative psychoform and somatoform dissociative symptoms, including appearing emotionally constricted, expressionless, machinelike, weak or frozen, social avoidant, rigid mental elaborations or mental blancs,

*Psychological Trauma*

izing fear of closeness [25].

**1.4 Network theory of trauma**

*theory* of mental disorders:

hyper-activation) or fear of closeness (i.e., attempts to inhibit proximity seeking and reduce awareness of distress; hence deactivation/inhibition). Clinically and phenomenologically, the secondary attachment strategies appear to involve relatively distinct forms of emotion dysregulation, with under-regulation of emotion predominating in fear of abandonment and overregulation of emotion character-

Overall, dysfunctional self-regulation is the core of these problems.

family violence) consistently across numerous studies [10–12, 28, 29].

Although the life-span sequelae of exposure to psychological trauma-byprimary-caretaker in childhood do not seem to be encompassed by any single DSM disorder [2], the DESNOS formulation of CPTSD in adulthood and DTD in adolescence-YA has been demonstrated *empirically* to be associated with childhood relational adverse experiences that are potentially traumatic (e.g., maltreatment,

CPTSD as defined by DESNOS is theorized to represent the results of developmental adaptations to exposure to interpersonal trauma in developmentally sensitive periods, including altered emotion processing, dissociative shifts in self-awareness and consciousness, and disruption of secure attachment working models (e.g., see [7]). Borderline personality disorder (BPD) arguably involves similar forms of dysregulation, and, historically, symptoms of somatic symptom disorders (SSD) have been associated with interpersonal trauma and hysteria [6]. Nevertheless, CPTSD can be distinguished in terms of clinical phenomenology from PTSD, BPD, SSD, anxiety disorders, and depression. CPTSD as defined by DESNOS appears to involve hypervigilance related to being harmed, whereas BPD involves extreme sensitivity to perceiving oneself as being abandoned or rejected/shamed [6, 30]. Moreover, certain features of CPTSD that are conceptually related to PTSD (i.e., arousal-related somatic dysregulation; altered personal schemas) may be largely accounted for by PTSD, but CPTSD features that are more clinically and conceptually distinct from PTSD (i.e., affect dysregulation, dissociation) appear to be empirically distinct from PTSD in adults with severe psychopathology [30].

As opposed to trying to categorize symptoms within existing classifications/ diagnoses (e.g., dissociative subtype of PTSD), or attempting to get new diagnoses accepted (e.g., DESNOS, CPTSD, DTD), the life-span sequelae of exposure to interpersonal psychological trauma (emotional or physical neglect or abuse or sexual abuse) in childhood can also be understood as *trans-diagnostic* phenomenology. Network theory supports this trans-diagnostic perspective. According to Borsboom (e.g., [31]), the comprehensive theoretical model of (trauma-related) psychopathology follows five principles to encode the backbone of the *network* 

Principle 1. Complexity: Mental disorders are best characterized in terms of the interaction between different components in a psychopathology network. Principle 2. Symptom-component correspondence: The components in the psychopathology network correspond to the problems that have been codified as symptoms in the past century and appear as such in current diagnostic manuals. Principle 3. Direct causal connections: The network structure is generated by a

Principle 4. Mental disorders follow network structure: The psychopathology network has a nontrivial topology, in which certain symptoms are more tightly

pattern of direct causal connections between symptoms.

**1.3 Childhood interpersonal trauma-related disorders**

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#### **Figure 1.**

*Three qualitatively different self-regulation styles or different networks: inhibitory, excitatory, and combined inhibitory and excitatory (IE) regulation operating in self-sustaining, vicious cycles due to the presence of hysteresis in strongly connected childhood trauma-related symptom networks.*

diminished reflective functioning, low or cramped nerve, muscle tension, etc. Mental states associated with *excitatory experiencing* are consistent with underregulation of affect and with the positive psychoform and somatoform dissociative symptoms, including feeling overwhelmed, seizures, hyper-alertness, impulsivity, and difficulty handling intense emotion states. Mental states associated with *combined or altering inhibited and excitatory experiencing* present clinically with mixed features of inhibitory and excitatory (IE) regulation and are associated with more complex psychopathology and DESNOS/DTD (see **Figure 1**; e.g., see [7]).

#### **1.6 Basic affective systems in the brain and trauma**

Panksepp and Biven argue that the basic brain functions strive for survival and homeostasis [32]. Seven basic affective-motivational systems are differentiated, located deep in the most ancient, subcortical regions of mammalian brains: SEEKING (expectancy), FEAR (anxiety), RAGE (anger), LUST (sexual excitement), CARE (nurturance), PANIC/GRIEF (sadness), and PLAY (social joy). Affects need no higher cognitive brain function to work appropriately, nor do they need the ability to use words to express themselves. They are the rawest form of emotional experiencing. In fact, these are referred to as the primary-process emotions. The theory of a SEEKING system has been studied for decades. It stems from the research done on the brain reward system, but it attempts to explain behaviors beyond a simple motivation for a reward. It is not just the reward itself that pushes one to learn, but it is the whole process of reinforcement that urges one to learn new things. "This general-purpose SEEKING response not only helps [animals] spontaneously look for and, with luck and skill, find the resources that they need, but also the means of escaping from danger, which they eventually need to learn to avoid. All this entails looking around and exploring the environment" (p. 133). Individuals can experience problems when something is amiss with the SEEKING system. FEAR systems were designed to help anticipate bad things in the future, and through the process of experience, they become capable of anticipating bad

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things. FEAR, like every other emotional system, is born essentially "objectless," and, like all other emotional systems of the BrainMind, it becomes connected to the real world through learning. FEAR produces terror and promotes chronic anxiety in response to milder, more sustained arousal. However, this system can also become sensitized and overactive, especially if it has been repeatedly traumatized, as is the case in PTSD and other trauma-related disorders [32]. Overactivation and sensitization of the PANIC/GRIEF (sadness) system can be recognized in our patients reporting disrupted attachment bonds or severe emotional neglect, a different kind

However, conditions arising from an overstimulated FEAR or PANIC/GRIEF system, such as chronic anxiety, can be treated through a process of learning. The mind is capable of reconsolidating memories, a phenomenon useful for psychotherapy. By retrieving memories in a different affective context, it can soften the feelings of negative memories. It is their hope that, "Fearful memories can be erased or overridden by 'therapeutic' maneuvers that cleverly use the consolidation process against itself" (p. 208). The CARE system is intertwined with the SEEKING system. The CARE system is at work in the therapist/patient relationship. "Effective psychotherapists share their ability for CARE, along with the ability to recruit the healing power of positive emotions" (p. 310) [32]. Especially in attachment-trauma cases, we can recognize these seven basic affective systems, with disturbed functioning in complex PTSD. Too much FEAR, RAGE, and PANIC/GRIEF and too little

The therapist and the therapeutic relationship therefore facilitate and promote

**1.7 Bad lifestyle, risk behavior, ill health, and physical illness in relation to trauma**

Dysfunctional self- and affect regulation, sensitization, and overactivation of FEAR, RAGE, and PANIC/GRIEF systems may result in bad lifestyle, risk behavior, ill health, and physical illness. Bad lifestyle, risk behavior, ill health, and physical illness have also been associated with exposure to interpersonal psychological trauma (emotional or physical neglect or abuse or sexual abuse) in childhood (many publications, e.g., [33, 34]). The ACE studies by Kaiser Permanente revealed the vast prevalence of physical illness and early death in childhood trauma survivors [33]. Others found the presence of ill health as well as health-undermining behavior to be overrepresented in patients reporting childhood traumas [33, 34]. Difficulties with self- and affect regulation are related to bad lifestyle and risk behavior. Also, the overactivation of insecure attachment-based self-dysregulation strategies may burden organs, e.g., the heart, and stress hormone-releasing activity to the extent

**2. Digitally enriched outpatient clinics (DOCs) using smartphone app for videoconferencing psychotherapy (VCP) and personal data** 

People are becoming more and more supported by technology, and many people use smartphones with apps. Therefore we initiated digitally enriched outpatient clinics using a smartphone app for videoconferencing psychotherapy and ecological momentary assessment (EMA) in the Netherlands. Our DOCs provide technology-supported, evidence-based treatment (including, but not limited to,

SEEKING, CARE, and PLAY are often recognized in our patients.

learning in a secure and attuned stimulating environment.

of function failure and physical illness.

**monitoring**

**2.1 Use of smartphones**

*DOI: http://dx.doi.org/10.5772/intechopen.86364*

of traumatization.

#### *Videoconferencing Psychotherapy in an App Environment for Trauma-Related Psychopathology DOI: http://dx.doi.org/10.5772/intechopen.86364*

things. FEAR, like every other emotional system, is born essentially "objectless," and, like all other emotional systems of the BrainMind, it becomes connected to the real world through learning. FEAR produces terror and promotes chronic anxiety in response to milder, more sustained arousal. However, this system can also become sensitized and overactive, especially if it has been repeatedly traumatized, as is the case in PTSD and other trauma-related disorders [32]. Overactivation and sensitization of the PANIC/GRIEF (sadness) system can be recognized in our patients reporting disrupted attachment bonds or severe emotional neglect, a different kind of traumatization.

However, conditions arising from an overstimulated FEAR or PANIC/GRIEF system, such as chronic anxiety, can be treated through a process of learning. The mind is capable of reconsolidating memories, a phenomenon useful for psychotherapy. By retrieving memories in a different affective context, it can soften the feelings of negative memories. It is their hope that, "Fearful memories can be erased or overridden by 'therapeutic' maneuvers that cleverly use the consolidation process against itself" (p. 208). The CARE system is intertwined with the SEEKING system. The CARE system is at work in the therapist/patient relationship. "Effective psychotherapists share their ability for CARE, along with the ability to recruit the healing power of positive emotions" (p. 310) [32]. Especially in attachment-trauma cases, we can recognize these seven basic affective systems, with disturbed functioning in complex PTSD. Too much FEAR, RAGE, and PANIC/GRIEF and too little SEEKING, CARE, and PLAY are often recognized in our patients.

The therapist and the therapeutic relationship therefore facilitate and promote learning in a secure and attuned stimulating environment.

#### **1.7 Bad lifestyle, risk behavior, ill health, and physical illness in relation to trauma**

Dysfunctional self- and affect regulation, sensitization, and overactivation of FEAR, RAGE, and PANIC/GRIEF systems may result in bad lifestyle, risk behavior, ill health, and physical illness. Bad lifestyle, risk behavior, ill health, and physical illness have also been associated with exposure to interpersonal psychological trauma (emotional or physical neglect or abuse or sexual abuse) in childhood (many publications, e.g., [33, 34]). The ACE studies by Kaiser Permanente revealed the vast prevalence of physical illness and early death in childhood trauma survivors [33]. Others found the presence of ill health as well as health-undermining behavior to be overrepresented in patients reporting childhood traumas [33, 34]. Difficulties with self- and affect regulation are related to bad lifestyle and risk behavior. Also, the overactivation of insecure attachment-based self-dysregulation strategies may burden organs, e.g., the heart, and stress hormone-releasing activity to the extent of function failure and physical illness.

#### **2. Digitally enriched outpatient clinics (DOCs) using smartphone app for videoconferencing psychotherapy (VCP) and personal data monitoring**

#### **2.1 Use of smartphones**

People are becoming more and more supported by technology, and many people use smartphones with apps. Therefore we initiated digitally enriched outpatient clinics using a smartphone app for videoconferencing psychotherapy and ecological momentary assessment (EMA) in the Netherlands. Our DOCs provide technology-supported, evidence-based treatment (including, but not limited to,

*Psychological Trauma*

**Figure 1.**

diminished reflective functioning, low or cramped nerve, muscle tension, etc. Mental states associated with *excitatory experiencing* are consistent with underregulation of affect and with the positive psychoform and somatoform dissociative symptoms, including feeling overwhelmed, seizures, hyper-alertness, impulsivity, and difficulty handling intense emotion states. Mental states associated with *combined or altering inhibited and excitatory experiencing* present clinically with mixed features of inhibitory and excitatory (IE) regulation and are associated with more

*Three qualitatively different self-regulation styles or different networks: inhibitory, excitatory, and combined inhibitory and excitatory (IE) regulation operating in self-sustaining, vicious cycles due to the presence of* 

complex psychopathology and DESNOS/DTD (see **Figure 1**; e.g., see [7]).

Panksepp and Biven argue that the basic brain functions strive for survival and homeostasis [32]. Seven basic affective-motivational systems are differentiated, located deep in the most ancient, subcortical regions of mammalian brains: SEEKING (expectancy), FEAR (anxiety), RAGE (anger), LUST (sexual excitement), CARE (nurturance), PANIC/GRIEF (sadness), and PLAY (social joy). Affects need no higher cognitive brain function to work appropriately, nor do they need the ability to use words to express themselves. They are the rawest form of emotional experiencing. In fact, these are referred to as the primary-process emotions. The theory of a SEEKING system has been studied for decades. It stems from the research done on the brain reward system, but it attempts to explain behaviors beyond a simple motivation for a reward. It is not just the reward itself that pushes one to learn, but it is the whole process of reinforcement that urges one to learn new things. "This general-purpose SEEKING response not only helps [animals] spontaneously look for and, with luck and skill, find the resources that they need, but also the means of escaping from danger, which they eventually need to learn to avoid. All this entails looking around and exploring the environment" (p. 133). Individuals can experience problems when something is amiss with the SEEKING system. FEAR systems were designed to help anticipate bad things in the future, and through the process of experience, they become capable of anticipating bad

**1.6 Basic affective systems in the brain and trauma**

*hysteresis in strongly connected childhood trauma-related symptom networks.*

**88**

cognitive-behavior therapy) in patients' environments and at their convenience in an app environment. Also, EMA facilitates continuously gathering real-time sensorand self-reported data that improve ecological validity of the results of self-reports and outcome monitoring.

Symptoms are considered consequences of mutually reinforcing demographic, personal, social, and contextual factors and (interpersonal) life events that differ for each individual and can change over time. Assessment and monitoring happen intuitively and take place in the here and now of their social and personal contexts in an app environment, rather than discretely, retrospectively, or in an isolated static moment outside the patient's personal world, thereby enriching information relevant for course of treatment, recovery, and (relapse) prevention for similar or different illness over a longer period of time.

There is currently an urgent need for psychotherapeutic interventions that use less therapist time, with the same or better outcomes than with traditional face-toface therapy (e.g., [35, 36]. Anxiety disorders, including PTSD and depression, are among the top 10 most costly medical conditions (e.g., [37]).

#### **2.2 The role of learning in relapse after treatment: transfer failures and erosion of therapy gains in trauma treatment**

Major problems regarding the effectiveness of psychological interventions for (trauma-related) treatment are (1) transfer failures of change processes from therapy room to target situation, e.g., home environment, and (2) relapse after intervention termination. Both problems originate mainly from context-dependent learning in psychological change processes, implying that what is learned in one context generalizes insufficiently to other (target) contexts, and that learned behavior is maintained by context-dependent cues and reinforcement.

Failure to generalize/transfer the mental health gains that clients experience in the practitioner's office in treatment to their situation in daily life is a major issue in mental health care. For example, in the treatment of clients with anxiety disorders, repeated exposure to the feared stimuli reliably leads to extinction of the anxiety and the disinhibition of previously learned avoidance behavior. However, confrontation with the feared stimuli in another context than the one in which exposure took place has been found to lead to reinstatement of the problematic fearful apprehension and avoidance behavior in several experimental studies as well as in comparative clinical studies [38–40]. Another major issue in the clinical practice of mental health care is relapse, referring to the recurrence of mental health problems after the termination of psychological interventions [41]. Context-specific learning processes that lead to reinstatement of fearful behavior contribute to relapse after cognitive-behavioral exposure treatment of anxiety disorders [42, 43].

Our DOCs were initiated to accommodate patients' needs with regard to modern therapy modes and overcome problems with effectiveness of psychological interventions and relapse: we aim to augment the effectiveness of existing and evidencebased psychological interventions for prevalent mental disorders, transcending transfer failure, and relapse issues. A set of ecological momentary assessment and intervention (EMAI) tools that help to facilitate transfer of psychological change to target situations helps increase the effectiveness of already existing evidencebased interventions for trauma-related disorders in home and work environments of patients. Moreover, EMAI helps to maintain these gains over time. This is pursued by incorporating the existing knowledge of well-established methods for technology-enhanced learning and contextual and cross-contextual support of learning and adapting these methods for the development of the EMAI tools in trauma-focused and trauma-informed treatment. Our DOCs build on and extend

**91**

*Videoconferencing Psychotherapy in an App Environment for Trauma-Related Psychopathology*

Findings from the WHO survey reinforce the importance of (interpersonal) negative life events as a major public health problem and highlight the significance of exposure to (interpersonal) negative life events as a risk factor for mental and physical illness, learning problems, low personal and social wellbeing, and personal development. Learning from experience seems crucial in treatment success, resilience, and overcoming adversity. Psychotherapy is learning and facilitates learning from experience. The app will monitor the course of symptoms and function as a support tool for exercises, e.g., send reminders, prompt exposure moments, and suggest cognitive elaborations of beliefs for the therapeutic alliance. The focus of the app environment will be on overcoming dysfunctional regulation, including avoidance. Our DOCs with smartphone app

1.Facilitate context-specific learning (deliver evidence-based treatment at home,

2.Enable easy and flexible collection of personalized data (including self-report

5.Allow for automatic, tailored, trans-diagnostic ecological momentary interventions (EMAI), based on ecological momentary assessment (EMA) of the

6.Allow for delivery of interventions that help maintain therapy gains or prevent relapse into previous problem states based on personalized EMA and

Therapeutic alliance (TA) is an essential factor underlying successful therapy across therapeutic models. A literature review overwhelmingly supported the notion that TA can be developed in psychotherapy by videoconference, with clients rating bond and presence at least equally as strongly as in-person settings across a range of diagnostic groups [44]. Therapists also rated high levels of TA, but often not quite as high as that of their clients early in treatment. The evidence was examined in the context of important aspects of TA, including bond, presence, therapist attitudes and abilities, and client attitudes and beliefs. Also, psychotherapy seems to support and enhance self-reflection. First results support the idea that patients can develop a reflective self in cyberspace [45]. VCP helps facilitate this reflective self, and our app environment embraces and mirrors the personal content using ecologi-

well-established, trans-diagnostic mechanisms of behavior modification and cognitive and emotional change for trauma-related (mental) health improvement. We carefully investigate the involved mechanisms of change for each patient among different types of trauma-related psychopathology. Videoconferencing technology, which allows audio and video information to be shared, is generally associated with good user satisfaction and is found to have similar clinical outcomes to traditional face-to-face psychotherapy. VCP has become well established as a feasible and

*DOI: http://dx.doi.org/10.5772/intechopen.86364*

environment:

work, trips, etc.).

and sensor data).

self-reports.

**2.3 Therapeutic alliance**

cal momentary assessment.

needs and wants of clients.

acceptable mode of psychological treatment delivery.

3.Enable therapeutic support (VCP, chatting).

4.Enable the use of problem-solving techniques.

#### *Videoconferencing Psychotherapy in an App Environment for Trauma-Related Psychopathology DOI: http://dx.doi.org/10.5772/intechopen.86364*

well-established, trans-diagnostic mechanisms of behavior modification and cognitive and emotional change for trauma-related (mental) health improvement. We carefully investigate the involved mechanisms of change for each patient among different types of trauma-related psychopathology. Videoconferencing technology, which allows audio and video information to be shared, is generally associated with good user satisfaction and is found to have similar clinical outcomes to traditional face-to-face psychotherapy. VCP has become well established as a feasible and acceptable mode of psychological treatment delivery.

Findings from the WHO survey reinforce the importance of (interpersonal) negative life events as a major public health problem and highlight the significance of exposure to (interpersonal) negative life events as a risk factor for mental and physical illness, learning problems, low personal and social wellbeing, and personal development. Learning from experience seems crucial in treatment success, resilience, and overcoming adversity. Psychotherapy is learning and facilitates learning from experience. The app will monitor the course of symptoms and function as a support tool for exercises, e.g., send reminders, prompt exposure moments, and suggest cognitive elaborations of beliefs for the therapeutic alliance. The focus of the app environment will be on overcoming dysfunctional regulation, including avoidance. Our DOCs with smartphone app environment:


#### **2.3 Therapeutic alliance**

Therapeutic alliance (TA) is an essential factor underlying successful therapy across therapeutic models. A literature review overwhelmingly supported the notion that TA can be developed in psychotherapy by videoconference, with clients rating bond and presence at least equally as strongly as in-person settings across a range of diagnostic groups [44]. Therapists also rated high levels of TA, but often not quite as high as that of their clients early in treatment. The evidence was examined in the context of important aspects of TA, including bond, presence, therapist attitudes and abilities, and client attitudes and beliefs. Also, psychotherapy seems to support and enhance self-reflection. First results support the idea that patients can develop a reflective self in cyberspace [45]. VCP helps facilitate this reflective self, and our app environment embraces and mirrors the personal content using ecological momentary assessment.

*Psychological Trauma*

and outcome monitoring.

different illness over a longer period of time.

**of therapy gains in trauma treatment**

among the top 10 most costly medical conditions (e.g., [37]).

cognitive-behavior therapy) in patients' environments and at their convenience in an app environment. Also, EMA facilitates continuously gathering real-time sensorand self-reported data that improve ecological validity of the results of self-reports

Symptoms are considered consequences of mutually reinforcing demographic, personal, social, and contextual factors and (interpersonal) life events that differ for each individual and can change over time. Assessment and monitoring happen intuitively and take place in the here and now of their social and personal contexts in an app environment, rather than discretely, retrospectively, or in an isolated static moment outside the patient's personal world, thereby enriching information relevant for course of treatment, recovery, and (relapse) prevention for similar or

There is currently an urgent need for psychotherapeutic interventions that use less therapist time, with the same or better outcomes than with traditional face-toface therapy (e.g., [35, 36]. Anxiety disorders, including PTSD and depression, are

**2.2 The role of learning in relapse after treatment: transfer failures and erosion** 

Major problems regarding the effectiveness of psychological interventions for (trauma-related) treatment are (1) transfer failures of change processes from therapy room to target situation, e.g., home environment, and (2) relapse after intervention termination. Both problems originate mainly from context-dependent learning in psychological change processes, implying that what is learned in one context generalizes insufficiently to other (target) contexts, and that learned behavior is maintained by context-dependent cues and reinforcement.

Failure to generalize/transfer the mental health gains that clients experience in the practitioner's office in treatment to their situation in daily life is a major issue in mental health care. For example, in the treatment of clients with anxiety disorders, repeated exposure to the feared stimuli reliably leads to extinction of the anxiety and the disinhibition of previously learned avoidance behavior. However, confrontation with the feared stimuli in another context than the one in which exposure took place has been found to lead to reinstatement of the problematic fearful apprehension and avoidance behavior in several experimental studies as well as in comparative clinical studies [38–40]. Another major issue in the clinical practice of mental health care is relapse, referring to the recurrence of mental health problems after the termination of psychological interventions [41]. Context-specific learning processes that lead to reinstatement of fearful behavior contribute to relapse after

Our DOCs were initiated to accommodate patients' needs with regard to modern therapy modes and overcome problems with effectiveness of psychological interventions and relapse: we aim to augment the effectiveness of existing and evidencebased psychological interventions for prevalent mental disorders, transcending transfer failure, and relapse issues. A set of ecological momentary assessment and intervention (EMAI) tools that help to facilitate transfer of psychological change to target situations helps increase the effectiveness of already existing evidencebased interventions for trauma-related disorders in home and work environments of patients. Moreover, EMAI helps to maintain these gains over time. This is pursued by incorporating the existing knowledge of well-established methods for technology-enhanced learning and contextual and cross-contextual support of learning and adapting these methods for the development of the EMAI tools in trauma-focused and trauma-informed treatment. Our DOCs build on and extend

cognitive-behavioral exposure treatment of anxiety disorders [42, 43].

**90**

Internet-based trauma-focused guided self-help for PTSD seems a promising treatment option that requires far less therapist time than current first-line face-toface psychological therapy [46]. The Internet-based program includes eight modules that focus on psycho-education, grounding, relaxation, behavioral activation, real-life and imaginal exposure, cognitive therapy, and relapse prevention.

Our DOCs meet and extend these possibilities as our app environment includes VCP options with EMA and EMAI. Our app environment enables us to monitor and study (A) the course and effectivity of our technology-supported assessment and evidence-based treatment and (B) the course (and erosion) of therapy gains after treatment termination over a longer period of time. The premise of this model is that trauma-related symptoms and its mutual interactions differ among patients and may change over time since no one-to-one relation was found for (interpersonal) negative life events, personal characteristics, and any mental or physical illness across the life-span.

Because patients can use the app whenever they need a therapeutic intervention, treatment can be offered more flexibly and be more integrated in patients' daily life (ecological environment). The data will result in personalized information about learning in psychotherapy and potential mediators for recovery/relapse, e.g., risk profiles at treatment onset for poor treatment course/outcome, low self-esteem, interfering (covert) behavior such as risky lifestyle, positive or adverse life events, small chaotic social network, (in)secure attachment behavior, or self-transcendence that help improve assessment- and technology-supported evidence-based treatment.

After initial treatment and during follow-up, the app functions as a support tool monitoring positive and negative life events, lifestyle/somatic well-being, and interpersonal activities to detect early warning signs of potential relapse or crisis (prevention).

#### **3. Digitally enriched therapeutic processes**

#### **3.1 Stuck in a "survival state of mind" or "historical time loop"**

In our patients with complex trauma histories, we can often recognize dysfunctional self- and affect regulation: too much activity of the FEAR, RAGE, and PANIC/GRIEF systems (excitatory dysregulation; see **Figure 1**) or too little activation of the SEEKING, CARE, and PLAY systems (inhibitory dysregulation; see **Figure 1**) or a combination of both due to the presence of hysteresis.

The strongly connected symptom networks have become self-sustaining, and the absence/disappearance of the trauma-related trigger does not deactivate the network. As a result patients report in the app environment often too much negative emotional experience while undertaking few fun, relaxing, healthy, social-bonding activities. And the patient is often stuck in a "survival or destructive state of mind" or "historical time loop," thereby overruling the "learning state of mind." This may well be why complex trauma/DESNOS/DTD patients have poorer therapy outcome and quick erosion of (little to modest) therapy gains [47].

By monitoring the app content, the app possibilities facilitate the therapist to support patients when help, comfort, or encouragement is needed: hence need-driven interventions. The therapist may choose to chat with the patient or initiate a VCP session or provide the patient with useful information from the library via a link in a chat message. To help overcome the "survival or destructive state of mind" or "historical time loop," a therapist-initiated chat contact referring to a therapy motto or personal one-liner may be helpful, or a "ping" [sound] or buzz [sound + sensation] from the smartphone may help overcome depersonalization and dissociation to help the patient to transit, through realization, into a "learning or productive state of mind"

**93**

*Videoconferencing Psychotherapy in an App Environment for Trauma-Related Psychopathology*

associated with activation of the SEEKING, CARE, and PLAY systems and decline of

For complex trauma and DESNOS/DTD, often a phase-oriented treatment program (phase 1, stabilization; phase 2, trauma therapy; and phase 3, rehabilitation) is held [48]. In the app, this was translated into the "toolbox" metaphor. During the therapy process, elements from three toolboxes (REX) are held: toolbox **R**, for selfand affect regulation techniques, healthy lifestyle, etc.; toolbox **E**, for trauma work/ exposure therapies; and toolbox **X**, for X-factor activities—fun, social activities, rehabilitation, work, and sports activities that give meaning to life and help overcome, or alleviate, the burden of symptoms temporarily. During therapy, elements from the three boxes are combined *from the start through the ending*. An example would be that from toolbox X, e.g., social participation—in any form—is a topic already from the start of therapy and parallels with elements from toolbox R, self-regulation techniques, and toolbox E, trauma work in any form [49]. One example could be having a cup of tea with a sister that was also abused as a child. Different elements from the toolboxes REX are paralleled with support from the app environment.

In our DOCs, we provide personalized, need-driven treatment. Patients connect with their assigned clinician using the app. After connection, they automatically receive instructions on how to operate the app environment, as well as an invitation to already start filling the app with personal information. First, patients fill out their personal profile. The planner facilitates planning and organizing significant events and therapy sessions. The planner also facilitates typing cognitions and experiences before the event is happening. Moreover, it facilitates recording anticipatory emotions for that significant event using swipe techniques for levels of arousal. To enhance success, the option of setting a reminder for this event is given. The planner then shows the events and time during the day and asks if the event, e.g., exposure assignment, was performed. In the case of Yes, one can add text to keep notes of this exposure session, accompanied by recording emotional experiencing, mood, and the option of filling out a cognitive schema. However, in the case of No, when the exposure session was not performed, one is reassured and asked what to do next: perform later today or change/alter session. Even canceling is possible, after which again a reassurance message is given with the invitation to plan something else that day, preferably an X-factor activity to lift one's mood. Next patients start using the tracker for registering mood three times a day and activating the steps tracker. Here, patients can access past event-related information and keep diary for significant events during the week, register mood, registering associated emotional experiencing, and (optionally) the first sections of a cognitive schema. Also, they can access notes given by the therapist associated with therapy sessions. Using the support button, the patient can start a chat session with app support or with the therapist. Also, the patient can initiate a VCP session, with and without visual contact, e.g., to team up with the therapist for an online therapist-assisted exposure assignment. The therapist using the portal side of the app environment is able to connect with the patient upon invitation and access the patient's information filled out in the app. The therapist can overview all patients and their app content in a dashboard in order to reply to need-driven activity and contact requests. Moreover, graphs are presented per patients with regard to mood, emotional experiences, activities, and results from "homework," e.g., exposure exercises, cognitive elaborations, and

*DOI: http://dx.doi.org/10.5772/intechopen.86364*

**3.3 Inside the app environment**

**3.2 REX**

excitatory and inhibitory dysregulation symptoms.

*Videoconferencing Psychotherapy in an App Environment for Trauma-Related Psychopathology DOI: http://dx.doi.org/10.5772/intechopen.86364*

associated with activation of the SEEKING, CARE, and PLAY systems and decline of excitatory and inhibitory dysregulation symptoms.

#### **3.2 REX**

*Psychological Trauma*

illness across the life-span.

**3. Digitally enriched therapeutic processes**

**3.1 Stuck in a "survival state of mind" or "historical time loop"**

**Figure 1**) or a combination of both due to the presence of hysteresis.

and quick erosion of (little to modest) therapy gains [47].

In our patients with complex trauma histories, we can often recognize dysfunctional self- and affect regulation: too much activity of the FEAR, RAGE, and PANIC/GRIEF systems (excitatory dysregulation; see **Figure 1**) or too little activation of the SEEKING, CARE, and PLAY systems (inhibitory dysregulation; see

The strongly connected symptom networks have become self-sustaining, and the absence/disappearance of the trauma-related trigger does not deactivate the network. As a result patients report in the app environment often too much negative emotional experience while undertaking few fun, relaxing, healthy, social-bonding activities. And the patient is often stuck in a "survival or destructive state of mind" or "historical time loop," thereby overruling the "learning state of mind." This may well be why complex trauma/DESNOS/DTD patients have poorer therapy outcome

By monitoring the app content, the app possibilities facilitate the therapist to support patients when help, comfort, or encouragement is needed: hence need-driven interventions. The therapist may choose to chat with the patient or initiate a VCP session or provide the patient with useful information from the library via a link in a chat message. To help overcome the "survival or destructive state of mind" or "historical time loop," a therapist-initiated chat contact referring to a therapy motto or personal one-liner may be helpful, or a "ping" [sound] or buzz [sound + sensation] from the smartphone may help overcome depersonalization and dissociation to help the patient to transit, through realization, into a "learning or productive state of mind"

Internet-based trauma-focused guided self-help for PTSD seems a promising treatment option that requires far less therapist time than current first-line face-toface psychological therapy [46]. The Internet-based program includes eight modules that focus on psycho-education, grounding, relaxation, behavioral activation,

Our DOCs meet and extend these possibilities as our app environment includes VCP options with EMA and EMAI. Our app environment enables us to monitor and study (A) the course and effectivity of our technology-supported assessment and evidence-based treatment and (B) the course (and erosion) of therapy gains after treatment termination over a longer period of time. The premise of this model is that trauma-related symptoms and its mutual interactions differ among patients and may change over time since no one-to-one relation was found for (interpersonal) negative life events, personal characteristics, and any mental or physical

Because patients can use the app whenever they need a therapeutic intervention, treatment can be offered more flexibly and be more integrated in patients' daily life (ecological environment). The data will result in personalized information about learning in psychotherapy and potential mediators for recovery/relapse, e.g., risk profiles at treatment onset for poor treatment course/outcome, low self-esteem, interfering (covert) behavior such as risky lifestyle, positive or adverse life events, small chaotic social network, (in)secure attachment behavior, or self-transcendence that help improve assessment- and technology-supported evidence-based treatment. After initial treatment and during follow-up, the app functions as a support tool monitoring positive and negative life events, lifestyle/somatic well-being, and interpersonal activities to detect early warning signs of potential relapse or crisis (prevention).

real-life and imaginal exposure, cognitive therapy, and relapse prevention.

**92**

For complex trauma and DESNOS/DTD, often a phase-oriented treatment program (phase 1, stabilization; phase 2, trauma therapy; and phase 3, rehabilitation) is held [48]. In the app, this was translated into the "toolbox" metaphor. During the therapy process, elements from three toolboxes (REX) are held: toolbox **R**, for selfand affect regulation techniques, healthy lifestyle, etc.; toolbox **E**, for trauma work/ exposure therapies; and toolbox **X**, for X-factor activities—fun, social activities, rehabilitation, work, and sports activities that give meaning to life and help overcome, or alleviate, the burden of symptoms temporarily. During therapy, elements from the three boxes are combined *from the start through the ending*. An example would be that from toolbox X, e.g., social participation—in any form—is a topic already from the start of therapy and parallels with elements from toolbox R, self-regulation techniques, and toolbox E, trauma work in any form [49]. One example could be having a cup of tea with a sister that was also abused as a child. Different elements from the toolboxes REX are paralleled with support from the app environment.

#### **3.3 Inside the app environment**

In our DOCs, we provide personalized, need-driven treatment. Patients connect with their assigned clinician using the app. After connection, they automatically receive instructions on how to operate the app environment, as well as an invitation to already start filling the app with personal information. First, patients fill out their personal profile. The planner facilitates planning and organizing significant events and therapy sessions. The planner also facilitates typing cognitions and experiences before the event is happening. Moreover, it facilitates recording anticipatory emotions for that significant event using swipe techniques for levels of arousal. To enhance success, the option of setting a reminder for this event is given. The planner then shows the events and time during the day and asks if the event, e.g., exposure assignment, was performed. In the case of Yes, one can add text to keep notes of this exposure session, accompanied by recording emotional experiencing, mood, and the option of filling out a cognitive schema. However, in the case of No, when the exposure session was not performed, one is reassured and asked what to do next: perform later today or change/alter session. Even canceling is possible, after which again a reassurance message is given with the invitation to plan something else that day, preferably an X-factor activity to lift one's mood. Next patients start using the tracker for registering mood three times a day and activating the steps tracker. Here, patients can access past event-related information and keep diary for significant events during the week, register mood, registering associated emotional experiencing, and (optionally) the first sections of a cognitive schema. Also, they can access notes given by the therapist associated with therapy sessions. Using the support button, the patient can start a chat session with app support or with the therapist. Also, the patient can initiate a VCP session, with and without visual contact, e.g., to team up with the therapist for an online therapist-assisted exposure assignment.

The therapist using the portal side of the app environment is able to connect with the patient upon invitation and access the patient's information filled out in the app. The therapist can overview all patients and their app content in a dashboard in order to reply to need-driven activity and contact requests. Moreover, graphs are presented per patients with regard to mood, emotional experiences, activities, and results from "homework," e.g., exposure exercises, cognitive elaborations, and

social activities. Also, sensor-based information from the smartphone environment, as well as EMA-based information, is presented per patient at the therapist's request. Next therapists are able to initiate VCP, chatting, push messages for encouragement, and planning of next VCP session, activities, and treatment exercises for patients. As part of the treatment via chat messaging, web information is sent on topics of patient's personal relevance, e.g., food, physical exercises, lifestyle, psycho-education on PTSD, and trauma symptoms. Also, vlog or blog information of experiences of trauma therapy of other patients can be shared.

#### **3.4 Treatment**

*3.4.1 Assessment, self-reported EMA, and predictors of therapy course, effectivity, and erosion*

For assessment, the VC option in the app is used for intake purposes, clinical interviewing using MINI 5 for the presence of any mental disorder [50] and CAPS 5 for the presence of PTSD [51], and visual clinical assessment. Initial assessments can help determine possible treatment options using self-report measures, e.g., LEC-5 [52] and post-traumatic stress disorder checklist for DSM-5 (PCL-5 [53]) or the Short PTSD Rating Interview (SPRINT; [54]), or for more complex trauma histories or symptoms, the Structured Interview for DESNOS-revised self-report (SIDES-rev-sr; [47, 55]) is sent. Working alliance is regularly measured with the patient and therapist version of the Working Alliance Inventory (WAI; [56]).

Inhibitory and excitatory forms of self-dysregulation are assessed for:


#### *3.4.2 Evidence-based psychotherapy protocols for trauma-related disorders*

Using the videoconferencing psychotherapy (VCP) option, we provide psychoeducation about the aftermath of (interpersonal) trauma, PTSD symptoms, and the broader scope of DESNOS/DTD symptoms.

When necessary, psycho-education with regard to dissociation and insecure attachment styles is provided. Since many patients suffering from the aftermath of severe trauma have already tried (and often failed) forms of psychotherapy, motivational interviewing combined with the positive aspects and benefits of our app possibilities is provided.

**95**

prevention plan.

*Videoconferencing Psychotherapy in an App Environment for Trauma-Related Psychopathology*

Evidence-based CBT therapies (many publications, e.g., [62]) like imaginal exposure (IE) aiming at extinction of intrusion symptoms, cognitive therapy (CT) aiming at restructuring trauma-related cognitions and beliefs, and eye movement desensitization and reprocessing (EMDR) protocol using clicks and self-initiated bilateral stimulation aiming at reducing intrusion symptoms and overcoming avoidance, or Imagery Rescripting (ImRs) evidence-based protocols for traumarelated disorders may be provided to patients. Next to these directly trauma-focused therapy forms, interpersonal psychotherapy (IPT; [63]) for PTSD is an option aiming at social and relational rehabilitation while focusing on "role transitions" [63]. Network-oriented interventions are provided with data input from EMA. Selfand affect dysregulation and skill development therapy based on network theory and information from EMA with regard to personalized insecure attachment-based self-regulation symptoms and behaviors will be targeted with EMAI and encompass (i) interventions which "directly change the state of one or more symptoms," (ii) protocols oriented to "inhibition of triggering causes," and (iii) protocols oriented at "inhibiting or modifying symptom-symptom connections." For traumarelated symptoms, aiming at "inhibiting or modifying symptom-symptom connec-

tions," the therapeutic environment of our DOCs seems very well suited.

*3.4.3 Tracking, app-generated EMA, and predictors of therapy course, effectivity,* 

The aim here is building skills to self-regulate [64–67] by monitoring therapy gains and relapse prevention based on EMA data using tracking, self-reports, and clinical observations. Tracking in the app environment taps moment-to-moment tracking of emotions and emotional functioning, mood, movement, behavioral activation and physical exercises, and heart rate information derived from smartphone, combined diary and therapeutic notes, mood before and after events, cognitions and beliefs, cognitive schema, and social network. Also, the planner is used for planning VCP moments, exposure exercises, social events, etc. that can be evaluated with mood charts and cognitive reports before, during, and after the events. Also the therapist can make notes for the patient or send push messages. The built-in sensors synchronizing with Google Fit/Apple Healthkit collect data to reflect physical well-being, activity, and lifestyle. The app facilitates personalized medicine/matched care. Results are combined and discussed in a multidisciplinary team using network theory. Psychotherapy indication is concluded upon, as well as

Based on results from assessment, EMA information, predictors (facilitating and disruptive) of therapy course, effectivity, and erosion are drawn. During therapy, these symptoms and behaviors will receive special attention to try to augment treatment effectivity of otherwise evidence-based treatments. Before ending treatment, results will also be integrated in a personalized relapse-

Ending of treatment and ending of working alliance—albeit in a 100% online environment—is highly comparable to ending of a regular therapeutic environment. However, next to the VCP session, patients have also developed a relation with the app environment, for some, comparable to the bonding with a personal diary. Within the app, the integrative and personalized relapse-prevention plan is integrated, accompanied by a "selfideo," a video in which the patient speaks to him/ herself in a kind and encouraging manner. The content is an abstract of course

*DOI: http://dx.doi.org/10.5772/intechopen.86364*

*and erosion*

matching a psychotherapist for treatment.

*3.4.4 Ending the treatment and the working alliance*

#### *Videoconferencing Psychotherapy in an App Environment for Trauma-Related Psychopathology DOI: http://dx.doi.org/10.5772/intechopen.86364*

Evidence-based CBT therapies (many publications, e.g., [62]) like imaginal exposure (IE) aiming at extinction of intrusion symptoms, cognitive therapy (CT) aiming at restructuring trauma-related cognitions and beliefs, and eye movement desensitization and reprocessing (EMDR) protocol using clicks and self-initiated bilateral stimulation aiming at reducing intrusion symptoms and overcoming avoidance, or Imagery Rescripting (ImRs) evidence-based protocols for traumarelated disorders may be provided to patients. Next to these directly trauma-focused therapy forms, interpersonal psychotherapy (IPT; [63]) for PTSD is an option aiming at social and relational rehabilitation while focusing on "role transitions" [63].

Network-oriented interventions are provided with data input from EMA. Selfand affect dysregulation and skill development therapy based on network theory and information from EMA with regard to personalized insecure attachment-based self-regulation symptoms and behaviors will be targeted with EMAI and encompass (i) interventions which "directly change the state of one or more symptoms," (ii) protocols oriented to "inhibition of triggering causes," and (iii) protocols oriented at "inhibiting or modifying symptom-symptom connections." For traumarelated symptoms, aiming at "inhibiting or modifying symptom-symptom connections," the therapeutic environment of our DOCs seems very well suited.

#### *3.4.3 Tracking, app-generated EMA, and predictors of therapy course, effectivity, and erosion*

The aim here is building skills to self-regulate [64–67] by monitoring therapy gains and relapse prevention based on EMA data using tracking, self-reports, and clinical observations. Tracking in the app environment taps moment-to-moment tracking of emotions and emotional functioning, mood, movement, behavioral activation and physical exercises, and heart rate information derived from smartphone, combined diary and therapeutic notes, mood before and after events, cognitions and beliefs, cognitive schema, and social network. Also, the planner is used for planning VCP moments, exposure exercises, social events, etc. that can be evaluated with mood charts and cognitive reports before, during, and after the events. Also the therapist can make notes for the patient or send push messages. The built-in sensors synchronizing with Google Fit/Apple Healthkit collect data to reflect physical well-being, activity, and lifestyle. The app facilitates personalized medicine/matched care. Results are combined and discussed in a multidisciplinary team using network theory. Psychotherapy indication is concluded upon, as well as matching a psychotherapist for treatment.

Based on results from assessment, EMA information, predictors (facilitating and disruptive) of therapy course, effectivity, and erosion are drawn. During therapy, these symptoms and behaviors will receive special attention to try to augment treatment effectivity of otherwise evidence-based treatments. Before ending treatment, results will also be integrated in a personalized relapseprevention plan.

#### *3.4.4 Ending the treatment and the working alliance*

Ending of treatment and ending of working alliance—albeit in a 100% online environment—is highly comparable to ending of a regular therapeutic environment. However, next to the VCP session, patients have also developed a relation with the app environment, for some, comparable to the bonding with a personal diary.

Within the app, the integrative and personalized relapse-prevention plan is integrated, accompanied by a "selfideo," a video in which the patient speaks to him/ herself in a kind and encouraging manner. The content is an abstract of course

*Psychological Trauma*

**3.4 Treatment**

*and erosion*

social activities. Also, sensor-based information from the smartphone environment, as well as EMA-based information, is presented per patient at the therapist's request. Next therapists are able to initiate VCP, chatting, push messages for encouragement, and planning of next VCP session, activities, and treatment exercises for patients. As part of the treatment via chat messaging, web information is sent on topics of patient's personal relevance, e.g., food, physical exercises, lifestyle, psycho-education on PTSD, and trauma symptoms. Also, vlog or blog information

*3.4.1 Assessment, self-reported EMA, and predictors of therapy course, effectivity,* 

For assessment, the VC option in the app is used for intake purposes, clinical interviewing using MINI 5 for the presence of any mental disorder [50] and CAPS 5 for the presence of PTSD [51], and visual clinical assessment. Initial assessments can help determine possible treatment options using self-report measures, e.g., LEC-5 [52] and post-traumatic stress disorder checklist for DSM-5 (PCL-5 [53]) or the Short PTSD Rating Interview (SPRINT; [54]), or for more complex trauma histories or symptoms, the Structured Interview for DESNOS-revised self-report (SIDES-rev-sr; [47, 55]) is sent. Working alliance is regularly measured with the patient and therapist version of the Working Alliance Inventory (WAI; [56]). Inhibitory and excitatory forms of self-dysregulation are assessed for:

• Problems in affect regulation involve under-regulation and overregulation of affect [15]. Overregulation of affect is assessed with the Bermond-Vorst Alexithymia Questionnaire (BVAQ; [57]), a Dutch 40-item questionnaire with demonstrated psychometric qualities [57]. Under-regulation is assessed with the "Affect instability scale" from the BPDSI [58]. BPDSI scores range from

• Relational impairment and adult relational fears involve "fear of abandonment" and "fear of closeness" (e.g., [25, 26]), which are assessed using the Dutch version of the validated 30-item Relationship Style Questionnaire (RSQ; [59]).

• Dissociation involves positive and negative psychoform and somatoform features [15] and is assessed with the Dissociative Experiences Scale (DES; [60]) for negative (e.g., amnesia) and positive (e.g., intrusions) psychoform features and with the Somatoform Dissociation Questionnaire (SDQ-20; [61]) for negative (e.g., anesthesia, paralysis) and positive (e.g., pain, cramps; [24,

Using the videoconferencing psychotherapy (VCP) option, we provide psychoeducation about the aftermath of (interpersonal) trauma, PTSD symptoms, and the

When necessary, psycho-education with regard to dissociation and insecure attachment styles is provided. Since many patients suffering from the aftermath of severe trauma have already tried (and often failed) forms of psychotherapy, motivational interviewing combined with the positive aspects and benefits of our app

*3.4.2 Evidence-based psychotherapy protocols for trauma-related disorders*

0 = never to 10 = daily (Cronbach's alpha = .81).

26]) somatoform features.

possibilities is provided.

broader scope of DESNOS/DTD symptoms.

of experiences of trauma therapy of other patients can be shared.

**94**

of treatment with the treatment rationale, memorabilia (mental representations of personal victories/highlights of therapy and low points of therapy course with lessons learned), names of significant helpful others, and a forecast of whatever the (fearless/depressedless) future may hold for them.

Next, a traffic light principle is held: green for subclinical symptomatology, red for clinical diagnosis (relapse), and orange for trigger points that may predict transfer to relapse. These triggers can be, e.g., reduced sleep quality, feelings of stress for more than 3 days, over- or under-eating, skipping sports and social activities, etc. The target here is to prevent crossing the border from "orange" to "red."

At the end of therapy, our patients with complex trauma histories have overcome hysteresis effect to some extent (e.g., avoidance and intrusion of trauma triggers), report no or less dysfunctional self- and affect regulation, and report a more balanced activity of the FEAR, RAGE, and PANIC/GRIEF systems with SEEKING, CARE, and PLAY systems as can be concluded from the app content (EMA).

Longitudinal outcome studies and studies of outcome predictors are currently in preparation.

#### **4. Conclusion**

The life-span sequelae of exposure to interpersonal psychological trauma (emotional or physical neglect or abuse or sexual abuse) in childhood, particularly when a primary caretaker is involved, do not seem to be encompassed by any single DSM disorder and interfere with the development of self-regulation skills and development and remainder of homeostasis. Although symptoms include and extend symptoms associated with PTSD with and without dissociative symptoms, it has been argued that these sequelae also include a complex symptom presentation reflecting disturbances in (interpersonal) self-regulatory capacities and mental disorders that may occur comorbidly with or separately from PTSD. Whether these sequelae are best understood as a complex variant of PTSD (CPTSD), or a complicated array of overlapping mental and personality disorders, is controversial. However, there is mounting evidence that a disorder of extreme stress not otherwise specified (DESNOS) formulation of CPTSD or in childhood, adolescence, and young adulthood (YA), developmental trauma disorder (DTD) constitutes a distinct syndrome of potential clinical utility. Three core features of DESNOS/DTD are affect dysregulation, identity alterations (dissociation), and relational impairment (insecure attachment) and empirically have been associated with qualitatively different and dysfunctional self-regulation vicious cycles: inhibitory, excitatory, and combined inhibitory and excitatory (IE) dysregulation. These can be also considered as trans-diagnostic symptoms clustered along the lines of the network theory.

Individuals with mental health problems may face barriers to accessing effective psychotherapies, e.g., waiting lists in general mental health institutions or office hours [68]. People are becoming more and more supported by technology, and many people use smartphones with apps. Therefore we initiated DOCs using smartphone app for VCP. Our DOCs provide with technology-supported evidence-based treatment in patients' environments and at their convenience in an app environment. Also, it facilitates continuously gathering real-time sensor- and self-reported data that facilitates assessment, self-reported EMA, and need-driven treatment and helps target predictors of therapy course, effectivity, and erosion. Treatment is successful when patients with complex trauma histories have overcome hysteresis effect to some extent (e.g., avoidance and intrusion of trauma triggers), report no or less dysfunctional self- and affect regulation, and report a more balanced activity

**97**

**Author details**

Annemiek van Dijke1

provided the original work is properly cited.

2 Open University, Heerlen, The Netherlands

\*Address all correspondence to: a.vandijke@psyQ.nl

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\* and Jacques van Lankveld2

1 Parnassia|psyQ and Niceday, Amsterdam, The Netherlands

*Videoconferencing Psychotherapy in an App Environment for Trauma-Related Psychopathology*

of the FEAR, RAGE, and PANIC/GRIEF systems with SEEKING, CARE, and PLAY systems as can be concluded from the app content (EMA). Also, they have learned that behavior promotes resilience and prevents relapse. The integrative treatment as described aims to encompass the best of both worlds: it combines established evidence-based treatment protocols for PTSD with innovative technology-enriched app environment that captures more complex trauma-related symptoms and behaviors (lifestyle) to augment therapy effect, improve quality of life, and prevent relapse. However, our work remains a "work in progress": a continuous improve-

*DOI: http://dx.doi.org/10.5772/intechopen.86364*

ment of technology-supported evidence-based treatment.

*Videoconferencing Psychotherapy in an App Environment for Trauma-Related Psychopathology DOI: http://dx.doi.org/10.5772/intechopen.86364*

of the FEAR, RAGE, and PANIC/GRIEF systems with SEEKING, CARE, and PLAY systems as can be concluded from the app content (EMA). Also, they have learned that behavior promotes resilience and prevents relapse. The integrative treatment as described aims to encompass the best of both worlds: it combines established evidence-based treatment protocols for PTSD with innovative technology-enriched app environment that captures more complex trauma-related symptoms and behaviors (lifestyle) to augment therapy effect, improve quality of life, and prevent relapse. However, our work remains a "work in progress": a continuous improvement of technology-supported evidence-based treatment.

#### **Author details**

*Psychological Trauma*

preparation.

**4. Conclusion**

the lines of the network theory.

of treatment with the treatment rationale, memorabilia (mental representations of personal victories/highlights of therapy and low points of therapy course with lessons learned), names of significant helpful others, and a forecast of whatever the

The target here is to prevent crossing the border from "orange" to "red."

Next, a traffic light principle is held: green for subclinical symptomatology, red for clinical diagnosis (relapse), and orange for trigger points that may predict transfer to relapse. These triggers can be, e.g., reduced sleep quality, feelings of stress for more than 3 days, over- or under-eating, skipping sports and social activities, etc.

At the end of therapy, our patients with complex trauma histories have overcome hysteresis effect to some extent (e.g., avoidance and intrusion of trauma triggers), report no or less dysfunctional self- and affect regulation, and report a more balanced activity of the FEAR, RAGE, and PANIC/GRIEF systems with SEEKING, CARE, and PLAY systems as can be concluded from the app content (EMA).

Longitudinal outcome studies and studies of outcome predictors are currently in

The life-span sequelae of exposure to interpersonal psychological trauma (emotional or physical neglect or abuse or sexual abuse) in childhood, particularly when a primary caretaker is involved, do not seem to be encompassed by any single DSM disorder and interfere with the development of self-regulation skills and development and remainder of homeostasis. Although symptoms include and extend symptoms associated with PTSD with and without dissociative symptoms, it has been argued that these sequelae also include a complex symptom presentation reflecting disturbances in (interpersonal) self-regulatory capacities and mental disorders that may occur comorbidly with or separately from PTSD. Whether these sequelae are best understood as a complex variant of PTSD (CPTSD), or a complicated array of overlapping mental and personality disorders, is controversial. However, there is mounting evidence that a disorder of extreme stress not otherwise specified (DESNOS) formulation of CPTSD or in childhood, adolescence, and young adulthood (YA), developmental trauma disorder (DTD) constitutes a distinct syndrome of potential clinical utility. Three core features of DESNOS/DTD are affect dysregulation, identity alterations (dissociation), and relational impairment (insecure attachment) and empirically have been associated with qualitatively different and dysfunctional self-regulation vicious cycles: inhibitory, excitatory, and combined inhibitory and excitatory (IE) dysregulation. These can be also considered as trans-diagnostic symptoms clustered along

Individuals with mental health problems may face barriers to accessing effective psychotherapies, e.g., waiting lists in general mental health institutions or office hours [68]. People are becoming more and more supported by technology, and many people use smartphones with apps. Therefore we initiated DOCs using smartphone app for VCP. Our DOCs provide with technology-supported evidence-based treatment in patients' environments and at their convenience in an app environment. Also, it facilitates continuously gathering real-time sensor- and self-reported data that facilitates assessment, self-reported EMA, and need-driven treatment and helps target predictors of therapy course, effectivity, and erosion. Treatment is successful when patients with complex trauma histories have overcome hysteresis effect to some extent (e.g., avoidance and intrusion of trauma triggers), report no or less dysfunctional self- and affect regulation, and report a more balanced activity

(fearless/depressedless) future may hold for them.

**96**

Annemiek van Dijke1 \* and Jacques van Lankveld2

1 Parnassia|psyQ and Niceday, Amsterdam, The Netherlands

2 Open University, Heerlen, The Netherlands

\*Address all correspondence to: a.vandijke@psyQ.nl

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**102**

### *Edited by Ana Starcevic*

Trauma presents as a negative experience or situation of an individual in which coping mechanisms do not always work perfectly. This leads to the appearance of disturbing behavior, thinking, or developing disorders in the area of mental illnesses. Psychological trauma is related to chronic and repetitive experiences and the term and situation that refer to it must be consider objectively because it is up to each survivor to determine if it is traumatic. Future studies in the area of psychological trauma need to be conducted with the aim of defining anatomical correlates of stress and its underlying pathophysiological mechanisms.

Published in London, UK © 2019 IntechOpen © Biggereye / iStock

Psychological Trauma

Psychological Trauma

*Edited by Ana Starcevic*