A One-Session Treatment of PTSD After Single Sexual Assault Trauma. A Pilot Study of the WONSA MLI Project: A Randomized Controlled Trial

Sexual abuse is a crime with devastating health consequences. Accessible, acceptable and affordable treatment of PTSD after sexual abuse is important. In this pilot study, a one-session PTSD treatment and a modified perspective to PTSD treatment is introduced. The aim of the study was to test the efficacy of one session of Modified Lifespan Integration (MLI) on reduction of symptoms of PTSD in individuals with PTSD after one sexual assault. This was a single-center, individually randomized waitlist-controlled treatment study with 1:1 allocation, with the intervention of one 90 - 140 minutes session of MLI and with post-treatment follow-up at 3 weeks (time point two). All participants were females, mean age 24, with PTSD symptoms after one sexual assault during the past 5 years. Exclusion criteria were poor understanding of Swedish, multiple traumas, active substance abuse, active psychosis, ADHD, or autism spectrum disorder. Of 135 interested participants, 38 were finally included, 36 completed baseline measures and were included in the intent to treat analyses and 33 were analyzed per protocol. The primary outcome was the difference between the two trial arms in mean PTSD symptoms as measured by the Impact of Event Scale Revised (IES-R) at time point two. In the intervention arm, 72% no longer scored PTSD in per-protocol analysis, compared to 6% in the waiting list arm. IES-R scores were on average halved in the intervention arm (F=21.37, P<0.001), but were essentially unchanged in the waiting list arm. No adverse effects or drop-outs were seen. One session of Modified Lifespan Integration was an effective treatment with a low drop-out rate for females aged 15-65 with PTSD after one sexual assault. Provided that this result can be replicated, MLI should be offered to these patients in clinical settings. Registration number NCT03141047 was given 03/25/2016 at ClinicalTrials.gov (https://register.clinicaltrials.gov/).


Lifespan Integration and PTSD
In the theory of Lifespan Integration, it is hypothesized that: The core of the PTSD symptoms (intrusion, hypervigilance and avoidance), are due to a failure of the index trauma to anchor as an episodic memory in the person´s chronologic autobiography. As a consequence, fear extinction is not used as a construct in the theory, but fear memory transformation (from a defragmented traumatic memory to an episodic memory) and episodic memory anchoring and integration (from a dissociated episodic memory to an integrated episodic memory, anchored in a chronological time line of the autobiography). Accordingly, the symptoms of PTSD are neither seen as pathologic or dysfunctional cognitions or fear associations, nor as distorted beliefs as suggested in earlier studies (1)(2)(3). The symptoms are rather seen as logic responses to a failed memory construction: Without time anchoring, the limbic system interprets the index trauma not as a terminated earlier life-threatening event that the person has survived, but as a possible threat that needs to be handled in present time. With this perspective, intrusion and hyper vigilance are appropriate and lifesaving processes, and avoidance an effective solution to a neuro-biological conflict between the prefrontal cortex´ cognitions about the index trauma, and the limbic system´s interpretation, of the same trauma.
Subsequently, as the index trauma is transformed into an episodic memory anchored in a chronological time line, the limbic system stops perceiving the index trauma as a potential threat in present time. As a consequence, intrusion and hypervigilance stops, avoidance is no more needed, and the cardinal symptoms of PTSD* declines. In Lifespan Integration, this process is called Trauma Clearing.

A manual based intervention
The MLI is a strict manual based intervention, carried out in one 90-120 minutes single session. The MLI manual is developed for treatment of PTSD. For complex traumatized (CPTSD) patients and patients with developmental traumas (DTD), other protocols are more suitable. For patients who have been unconscious during the trauma, or during parts of the trauma, body work is recommended to be added to the treatment. The MLI is developed from the Lifespan Integration PTSD-protocol (4). The aim of the MLI is Trauma Clearing as in the original PTSD-protocol, and to add a sense of agency and compassion to the reaction of the traumatic event. In clinical practice the patient usually meets the therapist for one 45 minutes session before starting the MLI, and a follow up session after the treatment is also common.
In this manual, we focus on the specific MLI intervention, during one single session.

Who should be treated, and who can perform MLI?
The MLI is constructed for treatment of PTSD after one specific index trauma. During the intervention the therapist and the patient work together with three different phases: 7. Speed Affect Regulation (SAR): A method were the therapist helps the patient to regulate emotions by adjusting the fractions of seconds of memory re-experiencing, and the speed in which the patient is moved from the past to the present along the MC list.
8. Round: The procedure when the therapist reads the MCs and guides the patient from the first to the last MC.
9. Timeline Repetition: The repetition of rounds.
10. Trauma Clearing: The process in which the patient's chronological autobiographic memory is cleared from non-anchored traumatic memories. When a trauma is cleared, there should be no re-experiencing of traumatic memory details when recalling the memory, or when exposed to details associated to the traumatic event. Trauma clearing is the goal of the MLI.

Psychoeducation
It is important that the patient understands how the intervention is carried out, and the purpose of the various phases in the treatment. Psychoeducation of how symptoms of PTSD are explained by the Lifespan Integration theory is therefore obligatory before starting MLI. A schematic drawing of "normal" anchored episodic memories as compared to traumatic nonanchored memories might be helpful. Before starting the treatment, make sure: • There is enough time for the full treatment to be completed -a minimum of 90 minutes is required.
• That the patient understands the importance of carrying the intervention on until the end. If the session is stopped before the trauma is cleared, (i.e. the memories of the trauma is activated without being anchored in the chronological autobiography) the symptoms of PTSD will rise instead of decline.
• That the patient understands that affect regulation will be performed through SAR: If emotions get intense, the therapist will speed up the transition through the timeline, not slow down the process.
• That no place will be given for confirmation or comfort of emotions during the rounds.
Neither will place be given for reflections about the event itself, or for reactions or cognitions about the event during the rounds. It is important to inform the patient that the manual is constructed in this way in order to make the symptoms of PTSD to decline as quick as possible. When the trauma is cleared, confirmation and reflection can be done with less emotional pain.

Episodic Memory Cues List (MCs and MC-list)
In the next step, information about how to make an MC-list is given. Every MC must give an association to a real episodic memory, anchored in time. It

Phase 3: Re-script and Timeline Repetition
The aim of the last phase is to enhance and integrate the feeling of agency and compassion in relation to the index trauma, in to the autobiography. During this phase the therapist helps the patient to re-enter the traumatic event as the older self (it does not matter if the patient is only a few days older or several years older at present time, compared to the age at the time for the traumatic event). The therapist then helps the older self to help the younger self to find alternative imageries of actions or solutions to the traumatic event. In this process imageries of not being alone, of anger being expressed or actions are taken to defend themselves, to punish the perpetrator or simple to call for help or to be comforted are useful. (During the break before phase three is started, the therapist and the patient can discuss how the patient wishes to be helped during the phase). After the imagery, the older self takes the younger self to an imagery place where both the older and younger self feels safe. The older self tells the younger self that she/he has survived, that the traumatic event is terminated and that she/he will now be showed what has happened since then. After this, cue jumping from the first MC after the traumatic event, to the present time, starts again. Depending on the needs of the patient, the following rounds are conducted with or without the imagery re-scripting part. The session is completed when all the cue jumps, including the details from the traumatic event, can be performed in a calm, slow pace, without arousal or affect activations and without disturbing sensations in the body.

Possible Explanations of the Efficacy of MLI
The practice of Rapid Exposure, with a fast and structured retrieval of defragmented details of the index trauma, is hypothesized to catalyze the start of the episodic memory construction, through Hippocampal activation. A process hypothesized to be completed by the following Cue Jumping. This theory is in line both with EPT and the hypothesis that activation of fear structures are needed in order to increase plasticity in the memory structure (2), and the findings that imaginal exposure does not need to be as long as in traditional PE (5,6). The theory is also in line with research and theories exploring stress reduction during treatment as an important factor for new learning and restructuring (7). activated whereas speech areas are shut down, when exposed to traumatic stress (9). By listening and visualizing the chronological MCs given by the therapist during the cue jumping, it is hypothesized that the brain areas associated with speech are bypassed. Allowing more active and therefore plastic networks to be used during the timeline repetition, is thought to speed up the process of consolidation, anchoring and integration of the new episodic memory (i.e. the core of the Lifespan Integration theory).
The practice of Imagery Re-script and Timeline Repetition is in line with the importance EPT gives to processing of negative trauma-related cognitions (2). However, instead of using exposure, habituation and reflection as means for cognitive restructuring, imagery re-script is used to induce a new felt experience of agency and compassion as the bas for a new cognitive concept.
In summary, the use of Rapid Exposure to induce the creation of an episodic memory, the use of Imagery Re-script to create a new cognitive concept and the use of auditive and visual Timeline Repetition to consolidate, anchor and integrate the new episodic memory and the new cognitive concept to the chronologic autobiography, is hypothesized to explain the fast decline of PTSD symptoms in MLI.