Download Application of EMDR in the Treatment of Major Depressive Disorder

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Application of EMDR in the Treatment of Major Depressive Disorder: A
Case Study
Running title: EMDR treatment for major depressive disorder
No. of table: 1, No. of Figs.:4
Dr. Usha Verma Srivastava*
Dr. A. Mukhopadhyay**
-------------------------------------------------------------------------------------------*Consultant Clinical psychologist, The Apollo Clinic, B-38/46-H, Raman
Niwas, Mahmoorganj, Varanasi. Ph.+91 9838045292,
e-mail: [email protected]
**Professor, Dept. of Psychology, MMV . BHU.
Application of EMDR in the Treatment of Major Depressive Disorder: A
Case Study
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Abstract
This article presents a case study applying Eye Movement Desensitization and
Reprocessing in major depressive disorder. The study describes the application of
Shapiro’s Adaptive Information Processing (AIP) model in the treatment of major
depressive disorder and explores the use of EMDR with a 30 year old woman
experiencing depressive symptoms with 3 suicidal attempts in 5 years. Due to strong
negative reactions to psychiatric medicines, her treatment was discontinued several times
and she was referred for psychotherapeutic intervention. After 9 EMDR treatment
sessions, her depression was completely cured; her coping improved and other symptoms
of anxiety and social withdrawal were completely controlled. Effects were checked and
found maintained up to 6 months follow up. The clinical implications of application of
EMDR have been explored.
Key words: EMDR, depression, eye movements, bilateral stimulation, adaptive
information processing, somatic symptoms.
Application of EMDR in the Treatment of Major Depressive Disorder: A
Case Study
INTRODUCTON
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Depression is a serious medical condition that affects thoughts, feelings, and the
ability to function in everyday life. Depression is a disorder of high prevalence and
moderate to high severity. Depression can occur at any age. Although available therapies
alleviate symptoms in over 80 percent of those treated, less than half of people with
depression get the help they need (Regier, Narrow, & Rae, 1993; National Advisory
Mental Health Council, 1993). Despite the enormous advances in brain research in the
past 20 years, depression often goes undiagnosed and untreated; depression produces far
more morbidity in the community. In addition, because suicide is a far greater risk in
depression, the depressive disorder has a greater impact on premature mortality.
Depressed patients suffer as much disability and distress as patients with chronic medical
disorders such as high blood pressure, diabetes, coronary artery disease, and arthritis.
Recovery from individual episodes of depression is readily stimulated by appropriate
treatment, but relapse is common and care over the long-term is essential. Depression
runs in families, reflecting an inherited vulnerability. There is equally strong evidence,
however, that childhood experiences, such as loss of a parent also produce vulnerability
to depression, and the losses experienced in adulthood can also precipitate depressive
episodes. Depression is thus both biological and social in its origin. In spite of the
considerable evidence about the general social correlates of, and the psychosocial risk
factors for depression, we do not know the specific causal pathways that transform social
experiences into psychopathology.
Major depressive disorder is a common costly and disabling condition affecting
4.9%-17.9% of the population in a life time. From 20%-30% of effected persons suffer a
chronic, relapsing course. Many medications and several time limited psychotherapies
has shown establishing efficacy in randomized controlled trials. Among outpatients with
major depressive disorders, treated for the first time, about 50% responded positively (i.e.
exhibited a clinically significant symptom reduction). However of these “responders”
only 50%-70% achieve symptom remission, which since remission is associated with the
best day to day functioning and best prognosis, is the goal of treatment (Rush, Trivedi, &
Fava, 2003; Parker, Roy, & Eyer, 2003).
EMDR is a psychotherapeutic approach that was developed by Shapiro (1989,
2001) to resolve symptoms resulting from disturbing and unresolved life experiences. It
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is based on a theoretical information processing model, which posits that symptoms arise
when events are inadequately processed and may be eradicated when the memories are
fully processed and integrated. Shapiro further maintains that a negative sense of self,
inappropriate emotional responses, and self-destructive behaviors are also manifestations
of inadequately processed material, and that processing the etiological experiences
underlying these current dysfunctions will transform them, allowing new selfperceptions, emotions, and behaviors to emerge. In addition, new experiences are
targeted, processed, and incorporated into memory in order to overcome developmental
and skills deficits. EMDR is an integrative therapy, synthesizing elements of many
traditional psychological orientations, such as psychodynamic, cognitive behavioral,
experiential, physiological, and interpersonal therapies (Shapiro, 2001, 2002; Shapiro &
Maxfield, 2002).
During processing, a client may spontaneously move through the three cognitive
and emotional plateaus (inappropriate feelings of guilt, perceived lack of safety, and
helplessness) to a more mature and balanced view. The clinician can observe this
movement with respect to guilt when the client shifts during a session from a negative
cognition such as "I am a bad person" or "I should have done something" to a positive
cognition such as "I am a good person" or "I did the best I could." In other sessions,
feelings of fear and lack of safety may transform a negative cognition such as "I am in
danger" into a positive one ("It's over, I'm safe now"). A client's confidence in his ability
to make future choices may be reflected in the shift from the cognition "I have no
control" to "As an adult, I can now choose" or "I am now in control." When spontaneous
changes do not occur, the cognitive interweave introduces the appropriate plateaus.
(Shapiro, 2001)
A separate body of research has examined the effects of EMs on physiology
and memory and cognitive processes. Barrowcliff and associates demonstrated that EMs
produce relaxation effects (Barrowcliff, Gray, Freeman, & MacCulloch, 2004;
Barrowcliff, Gray, MacCulloch, Freeman, & MacCulloch, 2003). The finding that EMs
decrease the vividness and/or emotionality of autobiographical memories is very robust
and has been reported by numerous research teams ( Andrade, Kavanagh, & Baddeley,
1997; Kavanagh, Freese, Andrade, & May, 2001; Maxfield, 2004 ; Sharpley,
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Montgomery, & Scalzo, 1996; Van den Hout , Muris, Salemink, & Kindt, 2001). Other
studies found that EMs tend to enhance retrieval of episodic memories (Christman,
Garvey, Propper, & Phaneuf, 2003) and increase cognitive flexibility (Kuiken, Bears,
Miall, & Smith, 2001–2002 ). Although a diversity of researchers have proposed various
models to explain these effects, and the possible role of EMs in EMDR, to date, no single
model has been exclusively supported.
Several new neurobiological theories explain that the difference between the
outcomes of EMDR and Cognitive Behaviour Therapy (CBT) is because of the
differences between memory reconsolidation and extinction (Suzuki, Josselyn,
Frankland, Masushige, Silva, & Kida, 2004). According to these theories, treatments that
rely on extinction (such as exposure therapies) result in the formation of competing
memories, rather than an alteration of the old ones. However, it may prove that EMDR’s
effects are based upon a different process known as reconsolidation that would involve
the change and restorage of the altered targeted memory itself. It has been posited that
longer exposures result in extinction, while shorter exposures result in reconsolidation
(Suzuki et al., 2004).
CASE REPORT
Neha was a 30 year old woman who was experiencing major depressive
disorder along with suicidal ideation and uncontrolled anger out bursts towards her 4 year
old girl child. She was referred to a psychiatrist but due to strong reactions to medicines,
psychiatrist referred her for psychotherapeutic intervention.
When came for the treatment, Neha was depressed and tearful. She tried to
swallow large amount of alprozolam tablets after her mother in law again criticized and
humiliated her when she was going to celebrate New Year eve party with her husband.
Her husband was also concerned that since last few months, whenever angry, she used to
slap her daughter. She regretted it afterwards but she told me, she was unable to control
herself at that time. She is also habitual to taking alprozolam, when anxious or for
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sleeping (not regularly). Her somatic symptoms include dizziness, headache, and
weakness.
She was old upper middle class house wife, living with in laws, husband and a
daughter. After graduating in home science with honors, she got married to the only son
of a business family. She was eldest of her one brother and one sister. The day she
entered her new home, her mother in law started criticizing her every step. After 10
months of marriage she developed severe cough, which could not be cured. She got
treatment of tuberculosis. Whenever the symptoms got worse, her father came and took
her back to her maternal home. She admitted that the moment she stepped in the train
with her father, the coughing stopped. Then it was decided to shift her in the upper floor
of the house, it worked and her coughing stopped but her suicidal ideations remain the
same.
She tried to commit suicide 2 more times before she came for the treatment. Her
anxiety peaked up whenever a guest is coming at the house because it gave her mother in
law a new opportunity to criticize and humiliate her in front of the guests. Her husband
always supported her but couldn’t stop his mother who is very dominating and hard to
please lady. In six years of marriage, she completely lost her sense of self worth, self
confidence, self efficacy compounded by the feelings of guilt, sorrow, self accusation and
a sense of failure.
Measures
Beck Depression Inventory(BDI) (Beck, Ward, Mendelssohn, Mock, &
Erbaugh, 1961).:
It’s a 21 item self report rating inventory on 0-3 point scale, measuring
characteristic attitudes and symptoms of depression.
Reliability: Internal consistency ranges from 0.73 to 0.92.
Validity
: concurrent validity correlation with clinician ratings range from
0.62 to 0.66.
At initial assessment Neha’s score on the Beck Depression Inventory was 39 out
of 63; indicative of major depressive disorder (a score below 12 is considered to be
normal). After the 9 EMDR sessions the score goes down to 13.
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Psychological General Well Being Schedule (PGWBS)(Dupuy, 1984):
It’s a 22 item questionnaire designed to measure self representations of
interpersonal affective or emotional status, reflecting a sense of subjective well being or
distress. A 6 point Likert type scale measures six affective states, namely, anxiety,
depressed mood, positive well being, self control, general health and vitality.
Reliability: Internal consistency alpha coefficient =0.92 (range 0.90-0.94)
Validity
: Cross national studies and community based investigations show
validity of 90.2 to 95.1.
Psychological well being schedule was administered to assess overall well being
of the client and scores indicate increase in low tension, relaxed and not anxious state of
mind as well as low depressed mood state (Decrease in tension and anxiety as well as
depressed mood). An increase in positive well being, self control, general health and
vitality is also indicated.
Stress Resistant Cognitive Behavioral Coping Pattern Scale (SRCBCP
S)(Srivastava, 1995):
It consists 53 items, measuring cognitive coping (problem focused), behavioural
coping (emotion focused) and cognitive with behavioural coping with a response pattern
of 5 point scale.
Reliability: Split half reliability =0.67
Test retest reliability= 0.88
SRCBCPS was used in order to assess the coping pattern of client. It showed an
increase in cognitive (problem focused) coping and cognitive with behavioural coping
pattern and a decrease in behavoiural (emotion focused) coping pattern, as lower scores
denote better coping style.
Rathus Assertiveness Scale (RAS) ( Hindi adaptation, Shukla, 1988):
It’s a 28 item, self report measure of assertive behaviour.
Reliability and Validity: Split half coefficient =0.631
Test retest (after 8 weeks) =0.661
Concurrent validity =0.53
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Rathus assertiveness scale was administered to measure the assertiveness of the
client .
Case Formulation
EMDR treatment was conceptualized according to adaptive information
processing (AIP) model proposed by Shapiro (2001, 2002). AIP model posits that the
emotions and physical sensations inherent in the unprocessed event and stored
inappropriately in memory are the foundation of the current pathology. (Ray & Zabik,
2001; Shapiro, 1995, 2001; Stickgold, 2002)
In Neha’s case her mother in law was critical about her every action, her
cooking, her style of dressing, her gifts, her handling home appliances and humiliated her
in front of everyone. When Neha found it beyond her tolerance, she developed cough so
severe that she was unable to control her bladder. The symptoms disappear as soon as she
was out of the house and on her way to her mom’s home.
When she started living separately but in the same home, she recovered her
bronchial symptoms but she has completely lost her self confidence, her urge to live and
enjoy life, her sense of self worth and self efficacy. She felt anxiety attacks whenever a
guest or relative came home or planned to visit them, and she had to go down to meet
them, or any festive occasion when she had to confront her mother in law for rituals. She
stopped going out of the house for any reason because for that she had to ask or inform
her mother in law, who never let her go without tormenting her even when her husband
was with her.
She became very submissive and never retaliated to her mother in law’s
behaviour, introjected her anger within herself and sunk into deep state of depression.
She started avoiding people, mostly relatives, thinking that she is a failure in her marriage
and has made everyone’s life hell. She is a disappointment to her mother and father and
her perception changed completely negative.
The AIP model assumes that processing of the traumatic events have the effect
of integrating the problematic memory with the larger non dysfunctional memory
networks, thereby facilitating the patient’s sense of self confidence, self worth and
ameliorating the overt symptoms.
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The comprehensive EMDR treatment of Neha’s clinical complaints included
processing memories and current triggers that contributed to the suicidal attempts,
depression and anger outbursts towards her daughter as well as strengthening the positive
resources she needed to adjust to the life like introducing better defenses and coping
strategies and increasing assertiveness.
Intervention
After the diagnostic session, Neha participated in 9, once in a week EMDR
session. The first session included the preparation phase started with the strengthening of
some important emotional resources through a combination of imagery and bilateral
stimulation. These resources are unconditional love, security and understanding of her
husband, parents and her daughter, and then her belief in her own abilities, education and
strength. She was asked to think of memories associated with her parents, her husband
and daughter and her own abilities in past when she was managing her own life while
completing her graduation living in hostel, and focused on them while engaging in
bilateral stimulation.
The emphasis on positive states is consistent with the use of EMDR for the
activation of resources in patients with compromised affect tolerance (Korn& Leeds,
2002) Progressive muscular relaxation and safe place exercise was also taught to the
client to manage the anxiety. In safe lace exercise, she was asked o close her eyes and
imagine herself in a place where she felt sheltered, safe and protected. She found it in her
bedroom with curtains down, door shut and TV on. Bilateral stimulation was given by
tapping her knees. She could successfully manage the practice of safe place in only two
sets of bilateral stimulation. Preparation phase increases the patients’ access to positive
memories and affect if needed during subsequent processing.
At the next meeting, the author initiated the EMDR standard protocol for
treating traumatic memories (Shapiro, 2001).This was the first of the 5 processing
sessions directed at various memories associated with Neha’s conditions. The traumatic
memory reported by Neha, was her experience which she remembered that just after 3
days of her marriage, her mother in law had to go to her sister’s place due to some
medical emergency. She was left at home on her alone, only a maid to tell her how to
carry on. When her mother in law returned, she scolded her saying that that she had
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messed up everything of the house. Neha was shocked and failed in all her efforts to
please her. Her first visit with her husband and the gifts purchased for all the members of
family could not satisfy her mother in law. She asked to her son-“what happened to your
taste, it was never so bad before?” and she looked at Neha with accusing eyes. The
memory was very distressing for Neha. Her negative cognition (NC) was “I am
worthless”.
Her
SUDs
[Subjective Units of Disturbance scale (Shapiro, 1989; Wolpe, 1958) ], was 8. Emotion
felt was of helplessness. Location of body sensation was, she felt cold, shivering all over
and her hands were shaking. Her positive cognition (PC) was “I am worthy and I can be
myself, (I can do whatever I please)”. Desensitization was done with the help of eye
movements (EMs). Checked SUDs which after 6 bilateral stimulations (BLs) became 0.
Then installation was done similarly with BLs and with the selected PC till the VoC
{Validity of Cognition scale (VoC; Shapiro, 1989, 2001)} became 7. Body scan was
done for any tension, tightness or unusual sensation and reprocessed. Then session was
closed.
IIIrd session included processing her memory of her wedding lahanga for which
her mother in law told her that she felt insulted and humiliated in front of all relatives for
such cheap and ugly looking dress.
In IVth session she recalled her memory of a trip to hill station with whole
family, where her mother in law created a scene in front of several guests disrespecting
her saying that her bad luck has giver her such a daughter in law.
During Vth session she recalled her memories of last Karwa chauth puja, when
a daughter in law gives offerings to mother in law and accept her blessings for long life
of her husband. But when she offered her offerings to her mother in law, she refused to
take it saying that she is only showing off it and the fact is she dose not need them or
their blessings and dose not respect them.
VIth and last EMDR session was processing of a very traumatic memory after
which she tried to attempt suicide. It was new year eve and her husband and his group of
friends were throwing a party, and when she was going to attend the party with her
husband and daughter, her in laws created a very ugly scene that a daughter in law of a
reputed family was going out at night to attend a party and it was her low class
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upbringing which also influenced their only son in doing such disrespectable things. She
cried and SUDs was 10 which became 0 after 12 sets of BLs and her VoC, “I do not need
approval of my in laws for anything I do”, became 7.
Table 1indicates the session by session goals and course of Neha’s progress .
Neha was also asked to use log chart including, Trigger, Image, Cognition,
Emotions and Sensation and SUDs (TICES), reporting her emotions and reactions to the
events of the week.
Memories that emerged during the EMDR processing sessions included her
feelings of hopelessness, worthlessness, guilt and inability to control the situation and
most of all a sense of failure and disappointment for her parents.
As the processing progressed session by session, her feelings of guilt and
worthlessness decreased. She started realizing that it was not at all her inability but it was
her mother in law’s possessive feelings for her only son and also that she was scared of
loosing her power and position after the marriage of her son. Neha also realized that her
marriage is not unsuccessful because despite all odds in their life, her husband never
blamed her and strictly told his own mother that he can not even think of divorcing Neha.
Similarly she realized her daughter needs her love and caring and her suicidal thoughts
completely vanished.
After 3 months, she came for a follow up. She was happy and in good mood.
She told me that her 2 sister in laws are coming to spend the vacation of one month with
their families, and will go after celebrating her daughter’s birthday. She was slightly
worried but we revised her coping mechanism, safe place and relaxation exercises to cope
with the stress. We also used role play, and she declared that now she is ready for the
encounter.
After one and a half month, her husband took her to the clinic. She was tearful
and unable to speak. Her husband described that even his sisters and mother criticized
and harassed her continuously, she spend the whole month very bravely, facing them, of
course without replying them for their nasty comments. But on the birthday of her
daughter, when they started it again, she breakdown. She was taking alprozolam for three
or four days for sleeping, which she has stopped previously after the first 6 sessions of
treatment. Her husband was adamant to leave the home to live separately, without his
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parents’ interference. But Neha refused it. She said they are old and deserve the support
of their son at this stage of life. She can not live with the guilt that they lost their son
because of her.
So next three sessions were planned to increase her assertiveness and coping,
because if she can not leave them she should face the bull by the horns. She was asked
what could help her to restore her belief in her abilities to cope, her strength to fight and
win over the situation and live her life fully (Schneider, Hofmann, Rost, & Shapiro,
2008). She described an image of hers living peacefully without feeling any negative
emotions for her in laws’ comments. She was asked “where do you feel it in your body”?
She answered “in my heart”, then she was asked to focus on that image and the body
feeling while simultaneously following the eye movements. With brief sets of EMs her
beliefs in her abilities increased which were then strengthened with another set of EMs.
She became calmer and realized that life doesn’t end up with her in laws disapproval, she
is capable and deserve a lot better, that she is in control now. She still couldn’t reply to
her mother in law to stop insulting her but she could stop reacting to her, emotionally.
Her SUD was 8 and become 0 after processing. But in the next (IX) session, when we
went through the previous session her VoC again declined to 5, so the processing was
done again with SUD 6 which declined to 0 after processing. Accepting her own efficacy,
capacity, ability and her assertion is itself a cognition which she finally realized, asserted
and succeded.
Table 2 indicates the psychometric measures at pre- nd post treatment phase.
After 3 months follow up, standardized measures indicate, no depression,
healthy well being, problem focused coping and increased assertiveness. She started
actively participating with her husband’s social activities along with her husband and
even kept arranging business meetings and functions on behalf of her husband.
DISCUSSION
All humans are understood to have a physiologically-based information
processing system. This can be compared to other body systems, such as digestion in
which the body extracts nutrients for health and survival. The information processing
system processes the multiple elements of our experiences and stores memories in an
accessible and useful form. Memories are linked in networks that contain related
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thoughts, images, emotions, and sensations. Learning occurs when new associations are
forged with material already stored in memory.
When a traumatic or very negative event occurs, information processing may be
incomplete, perhaps because strong negative feelings or dissociation interfere with
information processing. This prevents the forging of connections with more adaptive
information that is held in other memory networks.
It is not only major traumatic events, or “large-T Traumas” that can cause psychological
disturbance. Sometimes a relatively minor event from childhood, such as being teased by
one’s peers or discouraged by one’s parent, may not be adequately processed. Such
“small-t traumas” can result in personality problems and become the basis of current
dysfunctional reactions.
Shapiro proposes that EMDR can assist to successfully alleviate clinical complaints by
processing the components of the contributing distressing memories. These can be
memories of either small-t or large-T traumas. Information processing is thought to occur
when the targeted memory is linked with other more adaptive information. Learning then
takes place, and the experience is stored with appropriate emotions, able to appropriately
guide the person in future.
Implications
The usefulness of EMDR has been demonstrated in this case of major
depressive disorder, following 5 years of unsuccessful treatment efforts, 9 EMDR
sessions eliminated Neha’s depression. EMDR was also used to address her anxiety and
social withdrawal symptoms. She renewed her ability to enjoy her life and to explore new
ways to utilize her intelligence, education, energy and time.
The AIP model posits that the emotions and physical sensations inherent in the
unprocessed event and showed stored inappropriately in the memory are the foundation
of current pathology (Ray & Zbik, 2001; Shapiro, 1995, 2001; Stickgold, 2002). Neha’s
symptoms of dizziness, headache and fatigue were due to her painful memories of
humiliation and criticism of her mother in law, every time there is an audience present.
The memories were comprehensively processed and resolved ecologically, including a
realistic perception on coping with her weaknesses (her lack of assertiveness, her
submissive and suppressive nature).
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In cognitive
therapies, like in exposure therapy, high level of emotional
engagement or “reliving” is encouraged, which is very different from EMDR where, the
client engages in a dual-attention task, which results in the client “distancing” from the
memory—that is, maintaining present-day attention while simultaneously focusing on the
memory. (Jaycox, Foa, & Morral, 1998). A study by Lee, Taylor, and Drummond (2006)
coded clients’ responses during an EMDR session according to whether the responses
were consistent with reliving, distancing, or focusing on other associated material. They
found that distancing was associated with the greatest improvement on a measure of
PTSD symptoms, demonstrating support for this EMDR treatment component and
supporting the concept that EMDR is distinct from exposure therapy. They also
suggested that “distancing may be partly facilitated by the distraction of the eye
movement task”.
This case illustrates how the patient’s own cognitive, emotional, and somatic
associations during EMDR can lead to an accelerated learning experience that results in
both a remediation of symptoms and an enhanced sense of self-efficacy (Shapiro &
Forrest, 1997).
Conclusion
It is not unusual for EMDR processing to result in new insights and an enhanced
sense of self, with the desire to make the painful experience fruitful and to help others.
When the sense of a positive future is lacking, comprehensive treatment is incomplete,
and greater attention should be directed to potential targets manifested in the premorbid
history (Shapiro, 2001). Ultimately, overt symptom reduction, such as pain elimination,
dizziness and fatigue is only one element in the comprehensive clinical picture.
As indicated by Shapiro ( Shapiro, 2001; Shapiro & Forrest, 1997), the
treatment of somatic problems involves not only physical but also psychological and
existential issues. It is the “psychological tension or self identification as a helpless
victim that can be the most debilitating factor” (Shapiro, 2001). It is important to
remember that cases of depression involve the issues of self-worth, self-efficacy, and
unresolved feelings of loss of identity, social status, and an active, positive future. Thus,
in the present case the first step of processing the memories of the past not only consisted
of processing the traumatic events itself, but additional memories involving sense of
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failure, loss, shame, anger at maltreatment, and so forth. These were all necessary for a
permanent elimination of the depression. It is vital to take a comprehensive history of the
case to explore contributing factors, as they may not always emerge during processing
itself. Other targets involving present triggers, and future templates and the material
associated with them should address most of the clinical picture.
The outcome of an EMDR session indicates the linkup of the two networks; an
assimilation of the painful material into its proper perspective (i.e., that it belongs to the
past); and a discharge of the dysfunctional affect, with generalization of the adaptive
conditions through the hitherto isolated material. Thus, after the treatment of a trauma the
client is able to bring up earlier memories that are now fully integrated into the more
adaptive perspective. Along with this new perspective comes the ability to act in a more
appropriate and empowered way.
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19
Table I Pre and Post – treatment assessment: session-wise treatment goals
Sessions
I
II
III
IV
V
VI
Target
Preparation
Mother
Mother
Mother
Mother
Mother in
cognitions
for EMDR
in law ‘s
in law’s
in law
in law ‘s
law’s
reprosessed
sessions.
criticism
criticism
insulting
refusal
of gifts
of
in
wedding
public
dress
VII
VIII
IX
Strengthening
Strengthening
daughter’s
Of coping
Of coping
blame for
birthday
resources
resources
to accept
low class
party
puja
upbringing
Insult in
offerings
Pre -SUD
8
7
8
9
10
10
8
6
Post-SUD
0
0
0
0
0
0
0
0
20
Table 2 Pre and Post – treatment psychometric measures
Measures
Pre treatment scores
Post-treatment
scores
Beck Depression 39
13
Inventory
Psychological
General
Well-
Being Schedule
Anxiety/relaxed
2
13
Depressed/elated
1
12
Negative/positive 3
12
mood
well being
Uncontrolled/self 1
10
control
General
6
12
3
14
sickness/health
Lethargy/vitality
Stress
Resistant
Cognitive
Behavioural
coping
Pattern
Scale.
Problem focused 41
24
21
coping
Emotion focused 46
70
coping
Problem
with 21
12
emotion focused
coping
Rathus
Assertiveness
Scale
Positive
32
48
28
22
assertiveness
traits
Negative
assertiveness
traits
22