TIMBER Psychotherapy For PTSD, Depression and Traumatic
Psychosis
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3/16/2019: “This manual is a scientific treatise on the powerful impact of a medita-
tion-based psychotherapy on the difficult-to-treat conditions such as chronic PTSD,
resistant depression, and traumatic psychosis. Firmly anchored in the contemporary
cognitive neurosciences, fusing the Eastern mysticism with the pragmatism of cog-
nitive behavioral therapy, this compelling textbook urges for a paradigm shift in
trauma therapy. Truly, it opens up new vistas of thought and praxis for the afflicted
as well as for the healers at all levels of experience. I am sure this will also add a lot
of value to the current literature on this topic.”
—Afzal Javed, M.D., President Elect, World Psychiatric Association
3/20/2019: “Trauma has increasingly been identified as a key issue contributing to
mental health problems ranging beyond PTSD to depression, substance misuse, and
psychosis. Complex PTSD is now a term used in ICD-11 to describe conditions
arising from repetitive trauma and is much more descriptive than terms, such as
personality disorder, previously used. This book is therefore very timely in describ-
ing new approaches which have been subjected to scientific evaluation that address
these effects of trauma.”
—David Kingdon, M.D., Professor of Psychiatry, University
of South Hampton, UK
3/23/2019: “It has been my privilege to witness and follow Dr. Pradhan’s ground-
breaking work for some time. This collaboration with Drs. Pinninti and Rathod is
his latest contribution and evolution of the Yoga and Mindfulness Based Cognitive
Therapy (Y-MBCT) models for which TIMBER is the prototype. This book pres-
ents the compelling rationale for these innovative models, as well as their underpin-
ning in cognitive psychology, spirituality, and neuroscience. The emphasis on
cultural context is particularly important, given the cultural origins of the model and
its sensitivity to cultural adaptation in its programmatic implementation.”
—Andres J. Pumariega, M.D., Professor and Chief, Division of Child and
Adolescent Psychiatry, University of Florida College of Medicine
Dedicated to all our clients….
… for trusting us with their deepest thoughts
and feelings
… for sharing their journey on the TIMBER
path with us,
… for practicing meditation with us during
their therapy sessions,
… for their resilience and mindfulness that
kept us inspired and mindful throughout our
work with them in the clinics and in this book
project
We feel privileged and honored to be part of
their journey of recovery...
Foreword
Trauma is a universal experience. All of us go through experiencing trauma one way
or the other through our lifetime, but the type of trauma and our responses are modi-
fied according to a number of factors. Neither all people will respond in the same
way to trauma nor will they respond to the same treatment in the same way. Over
the past few decades, there has been a plethora of therapies in dealing with and
managing trauma-based experiences. As societies have changed social capital and
social support, systems have changed too which has created additional problems in
accessing therapies which are culturally appropriate and suitable. There are a num-
ber of psychiatric conditions which can be caused by traumatic experiences and also
contribute to persistence of traumatic memories. There is no doubt that some mem-
ories can become pathological and affect psychopathology and individual responses.
The symptoms too get affected by the experiences and idioms of distress. These
traumatic memories and experiences can perpetuate pathology and suffering.
In this volume, Pradhan and colleagues describe therapies which target these
memories.
Unlike cognitive behavioral therapy, TIMBER (Trauma Interventions using
Mindfulness Based Extinction and Reconsolidation of memories) psychotherapy
described in this volume offers a novel, evidence-based, and biomarker (D-serine)-
informed mindfulness-based CBT approach. This tackles some of the existing treat-
ment gaps. Combining the new therapy, mindfulness-based tools with cognitive
behavioral therapy, provides a unique way to manage traumatic memories and expe-
riences. TIMBER includes various modified CBT interventions, such as mindfulness-
based graded exposure therapy (MB-GET) and cognitive reprocessing, and these
can be used as therapist-based and self-help approaches so that trauma memories
and their expressions in clients’ daily life can be managed. Reducing stress, manag-
ing distress, and improving coping in the clients, their carers, and others are impor-
tant steps forward. After having established its efficacy in chronic PTSD and
depression, extending this approach’s application to other psychiatric conditions,
such as traumatic psychosis, drug addiction, and borderline personality disorder,
may well prove to be successful.
ix
x Foreword
This treatment manual aims to introduce the practitioners and the clients to a
stepwise approach. The authors deserve our thanks and congratulations for bringing
together these approaches so that our patients get the best approach and best results.
I hope that therapist dealing with trauma will find this approach helpful but that all
therapists will learn from this approach.
Dinesh Bhugra
Mental health and Cultural Diversity IoPPN,
Kings College
London, UK
Preface
Trauma, Traumatic Memories, and TIMBER
Trauma is probably one of the most devastating sufferings of the human mind that
has a wide array of health consequences, both mental and physical. The impact of
trauma is now recognized more widely than ever due to globalization, widespread
social media, and the inadequacies of our existing systems to protect individuals and
communities. Trauma may result in many serious and often chronic mental health
conditions, such as post-traumatic stress disorder (PTSD), treatment-resistant
depression, traumatic psychosis, drug addiction, borderline personality disorder,
etc. Cutting-edge translational research, more so after year 2000, reveals that in
these conditions, pathological trauma memories (TMs) become ingrained into dis-
tinct brain areas through conditioned learning. These TMs lay at the core of the
psychopathologies and influence the formation, maintenance, and expression of the
major symptoms in these often chronic disorders. Some aspects of memory, in par-
ticular the involuntary expressions of the trauma/fear memories, as seen in PTSD or
traumatic psychosis or the likes, can be very problematic and pathogenetic. As
Irving [1] elegantly points it out:
Your memory is a monster; you forget - it doesn’t. It simply files things away. It keeps things
for you, or hides things from you - and summons them to your recall with a will of its own.
You think you have a memory; but it has you!
The victims of trauma are truly the captives of their pathologically ingrained
trauma memories which dictate their lives.
Unfortunately, TMs have been so far neglected or rather unexplored despite the
tremendous influence TMs play in the formation, maintenance, and expression of
the major symptoms in these disorders. One explanation for the suboptimal
responses to the current treatment options for these conditions is that many of them
do not specifically target the TMs. A renewed focus on these aspects can lead to the
development of more efficacious and evidence-based interventions and, therefore,
has much to offer for the scientists, patients, and therapists alike. Cognitive behav-
ioral therapy (CBT), despite its established efficacy and utility, does not yet have a
psychobiological-based platform to address trauma memories comprehensively and
xi
xii Preface
so can result in vulnerability to relapse of symptoms, although many clients may
improve initially.
TIMBER (Trauma Interventions using Mindfulness Based Extinction and
Reconsolidation of memories) psychotherapy is a novel, evidence-based, and
biomarker- informed (plasma D-serine, [2]) mindfulness-based CBT approach
developed by Basant Pradhan, MD, who attempts to address some of the existing
treatment gaps [3, 4]. Technically, TIMBER belongs to the emerging category of
third wave CBT [5, 6]. In addition to incorporating the mindfulness-based tools,
TIMBER involves the use of modified CBT interventions, such as mindfulness-
based graded exposure therapy (MB-GET) and cognitive reprocessing, both of
which in a self-help and user-friendly format target and attempt to change the
trauma memories and their expressions in clients’ daily life. The wellness compo-
nent of TIMBER is aimed at stress reduction and better coping in the clients, in their
significant others, as well as in the therapist, while its illness component targets the
trauma memories and their expressions. Its experiential aspects and fidelity of its
application are enhanced by the therapist practicing with the clients during the ther-
apy sessions, which promotes therapist’s empathy and expertise in applying this
model as well as reduces stress. The translational concepts and the customized and
targeted interventions done in TIMBER have led to a paradigm shift toward a
broader and deeper understanding of chronic PTSD, depression, and traumatic psy-
chosis. The efficacy of TIMBER has been studied in placebo-controlled randomized
studies for chronic PTSD and depression in adults [2, 7], in a pilot study in adoles-
cents [8], and also in a multicentric case series in traumatic psychosis [9]. After
having established the efficacies in chronic PTSD, treatment-resistant depression,
and traumatic psychosis, extending TIMBER’s application to other conditions, such
as drug addiction, borderline personality disorder is likely to enhance the outcomes
for individuals afflicted with these conditions. One of the criticisms levelled against
psychotherapy today, particularly CBT, is for the process being technical with less
emphasis on the experience. The emphasis in this book is primarily on the experien-
tial aspects of TIMBER with theoretical and didactic information included to sup-
plement this experience. In doing so, our goal is to enhance the self-efficacy of the
clients and their family members in addition to delivering TIMBER in culturally
sensitive manner.
This treatment manual serves for the practitioners and the clients as a step-by-
step guide on TIMBER psychotherapy and has been organized into three parts con-
sisting of seven chapters. Cogently describing the important connection between the
traumatic memories giving rise to PTSD, treatment-resistant depression, and trau-
matic psychosis and emphasizing upon the complex relationship between each of
these conditions perpetuating the trauma further in the course of time as well as in
various settings including in the treatment situations, the descriptions, the data, and
the illustrations in this clinical manual unfold in the following seven chapters.
Preface xiii
Selected Bibliography
1. Irving J. A prayer for Owen Meany: a novel, 1st edn. New York, NY: William Morrow; 1989.
2. Pradhan BK, Mitrev L, Moaddel R, Wainer I. D-Serine is a biomarker for clinical response in
(R, S)-ketamine treatment of post-traumatic stress disorder and co-morbid depression. Biochim
Biophys Acta. 2018; S1570-9639(18)30035-9.
3. Hupbach A, Gomez R, Hardt O, Nadel L. Reconsolidation of episodic memories: A subtle
reminder triggers integration of new information. Learn Mem. 2007;14:47–53.
4. Monfils MH, Cowansage KK, Klann E, LeDoux JE. Extinction-reconsolidation boundaries:
key to persistent attenuation of fear memories. Science. 2009;324:951–5.
5. Kahl KG, Winter L, Schweiger U. The third wave of cognitive behavioural therapies. Curr
Opin Psychiatr. 2012;25(6):522–8.
6. Pradhan BK. Yoga and mindfulness based cognitive therapy: a clinical guide. Switzerland:
Springer Publishers; 2014.
7. Pradhan BK, Wainer IW, Moaddel R, Torjman MC, Goldberg M, Sabia M, Parikh T, Pumariega
AJ. Trauma Interventions using Mindfulness Based Extinction and Reconsolidation (TIMBER)
psychotherapy prolong the therapeutic effects of single ketamine infusion on post-traumatic
stress disorder and comorbid depression: a pilot randomized, placebo-controlled, cross-over
clinical trial. Asia Pac J Clin Trials Nerv Syst Dis. 2017;2(3):80–90.
8. Pradhan BK, Gray RM, Parikh T, Akkireddi P, Pumariega A. Trauma Interventions using
Mindfulness Based Extinction and Reconsolidation (TIMBER) as monotherapy for chronic
PTSD in adolescents: a pilot study. Adolesc Psychiatry. 2015;5(2):125–31.
9. Pradhan BK, Pinninti NR, Rathod S. Brief interventions for psychosis: a clinical compendium.
Switzerland: Springer Publishers; 2016.
Contents
Part I Trauma and the Traumatic Memories (TMs): Manifestations,
Mechanisms and Implications
1 Traumatic Memories and the Spectrum of Their Expressions������������������ 3
1.1 Introduction���������������������������������������������������������������������������������������������� 3
1.2 The Many Facets of Trauma and the Spectrum
of Their Expression���������������������������������������������������������������������������������� 4
1.3 Impact of Trauma in Early Life and Risk of PTSD, Depression,
and Psychosis ������������������������������������������������������������������������������������������ 6
1.4 Shared Psychopathologies in PTSD, Traumatic Psychosis,
and Treatment-Resistant Depression�������������������������������������������������������� 7
1.5 Therapeutic Role of Meditation in PTSD and Traumatic Psychosis�������� 9
1.6 TIMBER Psychotherapy for Trauma Memories�������������������������������������� 9
1.7 Conclusion and Future Directions������������������������������������������������������������ 10
References�������������������������������������������������������������������������������������������������������� 11
2 Traumatic Memories (TMs): Neurobiology and Implications������������������ 15
2.1 Introduction���������������������������������������������������������������������������������������������� 15
2.2 Processes Involved in Trauma/Fear Memories���������������������������������������� 16
2.3 Two Different Memory Systems (Verbal and Non-verbal)
in Traumatic Memories���������������������������������������������������������������������������� 17
2.4 Trauma Memories: The Key Players�������������������������������������������������������� 19
2.5 The Newer Cognitive Models of PTSD �������������������������������������������������� 21
2.6 Clinical Relevance of These Findings������������������������������������������������������ 22
2.7 Conclusions and Future Directions���������������������������������������������������������� 24
References�������������������������������������������������������������������������������������������������������� 24
Part II TIMBER Therapy for PTSD, Depression and Traumatic
Psychosis: Methodology, Application and Efficacy
3 Trauma Interventions Using Mindfulness-Based Extinction
and Reconsolidation of Memories (TIMBER)�������������������������������������������� 29
3.1 Introduction���������������������������������������������������������������������������������������������� 29
3.2 Need to Pair the Extinction with Reconsolidation as Done
in TIMBER���������������������������������������������������������������������������������������������� 30
xv
xvi Contents
3.3 Need to Combine Many Therapeutic Components as Done
in TIMBER �������������������������������������������������������������������������������������������� 31
3.4 Mechanism of TIMBER Psychotherapy������������������������������������������������ 34
3.5 Unique Features of TIMBER When Dealing with Trauma
Memories������������������������������������������������������������������������������������������������ 34
3.6 Delivery of TIMBER������������������������������������������������������������������������������ 36
3.7 Stages in TIMBER���������������������������������������������������������������������������������� 36
3.8 The Nuts and Bolts in Applying TIMBER Therapy ������������������������������ 37
3.9 Customization in the TIMBER Therapy������������������������������������������������ 38
3.10 Achieving the Meditation Skills Before Exposure Therapy
Is the Key������������������������������������������������������������������������������������������������ 39
3.11 Trauma-Specific Application of TIMBER Interventions
in Three Steps ���������������������������������������������������������������������������������������� 40
3.11.1 Structure of the 15 Sessions in TIMBER Therapy���������������������� 40
3.11.2 Data on the Efficacy of TIMBER������������������������������������������������ 41
3.11.3 TIMBER Psychotherapy and Biomarkers���������������������������������� 43
3.12 Conclusions and Future Directions�������������������������������������������������������� 44
References�������������������������������������������������������������������������������������������������������� 44
4 Customization and Future Directions in TIMBER������������������������������������ 47
4.1 Introduction�������������������������������������������������������������������������������������������� 47
4.2 Assessment Tools������������������������������������������������������������������������������������ 49
4.2.1 Assessment Scale for Mindfulness
Interventions (ASMI©)������������������������������������������������������������������ 49
4.2.2 The Arousal Response to Trauma Memory
Reactivation (ART-MR©) Scale���������������������������������������������������� 52
4.3 Meditation Home Practice Log�������������������������������������������������������������� 55
4.4 Three Aspects of the TIMBER Psychotherapy�������������������������������������� 56
4.5 Conclusions and Future Directions�������������������������������������������������������� 57
References�������������������������������������������������������������������������������������������������������� 58
5 Discussion and Illustrations of the Therapeutic Processes
in TIMBER ���������������������������������������������������������������������������������������������������� 59
5.1 Nosological and Diagnostic Problems in Trauma Care�������������������������� 59
5.2 Some Problems with the Current System of Care���������������������������������� 60
5.3 Some Proposed Solutions to These Problems���������������������������������������� 61
5.4 How TIMBER Differs from the Contemporary Trauma
Therapies?���������������������������������������������������������������������������������������������� 62
5.5 A Case-Based Illustration of TIMBER�������������������������������������������������� 63
5.6 Conclusion���������������������������������������������������������������������������������������������� 65
References�������������������������������������������������������������������������������������������������������� 66
Contents xvii
Part III Training, Policy and Cultural Aspects of TIMBER
6 Cultural Considerations in Applying TIMBER Therapy�������������������������� 69
6.1 Introduction�������������������������������������������������������������������������������������������� 69
6.2 Cultural Diversity Is the Norm �������������������������������������������������������������� 71
6.3 Culture and Trauma�������������������������������������������������������������������������������� 72
6.4 Culture and Health Services ������������������������������������������������������������������ 74
6.5 Conclusions�������������������������������������������������������������������������������������������� 79
References�������������������������������������������������������������������������������������������������������� 79
7 Therapist Training on TIMBER and Policy Implications�������������������������� 81
7.1 Current Healthcare System Globally������������������������������������������������������ 81
7.2 High- and Middle-Income Countries (HMIC)���������������������������������������� 83
7.3 Low- and Middle-Income Countries (LMIC)���������������������������������������� 84
7.4 Trauma and Health���������������������������������������������������������������������������������� 85
7.5 Importance of Early Intervention������������������������������������������������������������ 86
7.6 Bringing the Different Teams Together (Integrated Care)���������������������� 87
7.7 Impact of Trauma on Staff���������������������������������������������������������������������� 87
7.8 Addressing the Fragmented Care������������������������������������������������������������ 88
7.9 CCBHCs: Future of Integrated System of Care
for the United States ������������������������������������������������������������������������������ 89
7.10 Module for Training the Professionals on the TIMBER
Psychotherapy���������������������������������������������������������������������������������������� 89
7.11 Future Directions for Research�������������������������������������������������������������� 91
7.12 Conclusion���������������������������������������������������������������������������������������������� 92
References�������������������������������������������������������������������������������������������������������� 92
About the Authors
Basant Pradhan, M.D. works in the Cooper University Health Care, Camden,
New Jersey, in the Departments of Psychiatry and Pediatrics where he also serves as
the interim chief of Psychiatry and the founding medical director of the neuro-
modulation interventions and disorder-specific Yoga and Mindfulness Based
Cognitive Therapy (Y-MBCT) programs. In his premedical career, he was a yogi/
monk in a monastery in India. In addition to extensive training in psychiatry and
psychotherapies, he has trained in clinical neurology, clinical psychology, and cog-
nitive neurosciences which greatly inspire him to combine psychotherapy with
brain science and spirituality for diagnostic and treatment purposes. His clinical and
research work since 2001 has focused on the development and application of the
standardized Yoga and meditation modules as stand-alone treatments and also in
combination with medications and neuro-modulation interventions (TMS,
Ketamine, ECT) for many chronic and often difficult-to-treat neuropsychiatric con-
ditions, such as treatment-resistant depression, PTSD, psychosis, addictive disor-
ders, and also cognitive disorders such as dyslexia and Huntington’s disease. His
research has advanced the understanding about neurobiology and therapeutics of
the neuropsychiatric disorders and also is aimed at clarifying the pros and cons of
psychiatric medications for the young. He has been awarded with the Institutional
Bronze Medal from the prime minister of India and has been listed in the registry of
the Marquis: Who’s Who in America. His research has received grant awards from
organizations like the National Institute on Aging (NIA/NIH), the Brain & Behavior
Research Foundation (NARSAD), and the Huntington Study Group, USA. He has
lectured at national and international events and published his research widely.
Also, he has served the executive council of many reputed organizations, such as the
Group for the Advancement of Psychiatry (GAP) and the National Caucus on
Integrative Psychiatry.
Narsimha R. Pinninti, M.D. is a professor of Psychiatry at Rowan University
School of Osteopathic Medicine and also medical director of CCBHC, Oaks
Integrated Care, both in New Jersey. He oversees the CCBHC and is working to
create a system of care for integrating and coordinating care for individuals with
serious mental illnesses and substance abuse issues. As part of this effort, he works
with Dr. Pradhan and Dr. Rathod to bring improvements in system of care and adapt
xix
xx About the Authors
new psychosocial treatments, such as cognitive behavioral therapy for psychosis
and Yoga and Mindfulness Based Cognitive therapy (Y-MBCT) and TIMBER in
real-world situations. In addition, his efforts also include training staff in various
evidence-based treatments and mindfulness-based meditative practices to reduce
stress, to improve health, and to engage with the clients. As a psychiatrist, he runs
an ambulatory detox unit and also provides psychiatric services in day hospitaliza-
tion programs and outpatient program. He is the course director for CBT training
for psychiatric residents; has authored a number of papers in peer-reviewed jour-
nals, book chapters, and books; and has been an invited speaker nationally.
Shanaya Rathod, M.D. is a professor, consultant psychiatrist, and director of
Research at the Southern Health NHS Foundation Trust, UK. She is a visiting pro-
fessor to the University of Portsmouth and the mental health clinical lead for Wessex
Academic Health Science Network and Wessex Clinical Research Network. She is
also the trustee to the Centre for Applied Research and Evaluation International
Foundation. Following her postgraduate medical education, she has completed a
doctorate in medicine and certificate course in Managing Health Services with the
Institute of Healthcare Management and acquired a certificate of advance medical
leader with the British Association of Medical Managers and masters in Leadership.
She has been a fellow with the National Institute for Health and Care Excellence.
She has influenced national strategy through her leadership and research over the
years and has held a number of leadership roles in the NHS in medical and clinical
management. She has a particular interest in developing effective care pathways in
mental health services to improve patient outcomes and experience and the cultural
and religious aspects of psychopathology of mental illness. She has received grants
to explore and improve these areas further. She has published books, book chapters,
and papers in peer-reviewed journals and lectured extensively at national and inter-
national events. She is a recipient of national and international awards.
Part I
Trauma and the Traumatic Memories (TMs):
Manifestations, Mechanisms and Implications