The Role of Trauma

1
The Role of Trauma

• Trauma is related to early abuse and/or neglect,
  is in the histories of public mental health
  individuals who frequently are self-harming, high
  users of costly services and who carry multiple
  diagnosis-BPD,DID, or PTSD.

2
General Population

• 10 of women and 5 of men are likely to suffer
  PTSD
• 33.3 will have symptoms lasting several months
• Those most vulnerable - inadequate social
  support, survivors of child hood sexual abuse

3
Public Mental Health Consumers

• 98 of 275 consumers had exposure to severely
  traumatic events
• 43 suffered from PTSD
• Chart review 2 had diagnosis on chart
• Another study - 34 admitted to psychiatric state
  hospital had PTSD - secondary to CSA

4
The Internal Classification of Diseases
(IDC-10) Has described a diagnosis - Enduring
personality changes after catastrophic stress
5
Substance Abuse and Trauma

• PTSD 5 times likelihood of alcohol abuse
  dependence
• PTSD and veterans - 75 met criteria for alcohol
  abuse
• 60 women 20 men in alcohol recovery programs
  sexual abuse as child
• 80 reporting physical abuse as children - in
  above recovery program

6
Effects on Dual Diagnosis When Disclosed

• Positive
• Increased trust
• Increased understanding D/A effects
• Differentiate D/A, MI abuse
• Devise treatment plan

• Negative
• Increase D/A
• Increase MI symptoms
• Avoid deal D/A or MI

7
Effects on Dual Diagnosis Treatment When Not
Disclosed

• Significant factor in substance use remains
  undisclosed
• Potential destabilizing factor when kept a secret
• Secret interferes with treatment
• Secret maintains a lower level of trust
• Treatable condition remains untreated

8
Sexual Abuse invisibleWhy is there so little
treatment?

• Professionals do not recognize the abuse
• Symptoms vary greatly
• Symptoms surface years after abuse
• Abuse is rarely volunteered
• Pervasive avoidance and denial
• Misdiagnose
• Mid 70s not seen as a problem

9
Core Beliefs

• The shame and despair that come from the
• powerlessness and unmanageability help
  crystallize the
• core beliefs about personal unworthiness that
  were part
• of the persons initial addictive system
• I am basically a bad, unworthy person
• No none would love me as I am
• My needs are never going to be met if I have to
  depend on others
• Sex is my most important need
• (Adapted from Carnes, 1989)

10
The Addictive Cycle

• Preoccupation
• Ritualization
• Acting out
• Despair
• Shame blame cycle
• Unmanageability

11
Multiple Addictions

• Sex addiction is seldom isolated
• More than 83 report multiple addictions
• Chemical dependency (42)
• Eating disorders (38)
• Compulsive working (28)
• Compulsive spending (26)
• Compulsive gambling (5)
• Studies of alcoholism treatment find sexual
  compulsion in clients, ranging from 42 to 73.
• (NCSAC webpage, 2000)

12
Complex Post-TraumaticStress Disorder

• A history of subjection to totalitarian control
  over a prolonged period (months to years)
• Alterations in affect regulation
• Alterations in consciousness
• Alterations in self-perception
• Alterations in perception of perpetrator
• Alterations in relations with others
• Alterations in systems of meaning
• (Herman, 1992)

13
High Comorbidity for PTSD

• Substance related disorders
• Mood disorders
• Other anxiety disorders
• Personality disorders
• (Adapted from Maldonado Spiegel)

14
FOCUS ON TREATMENT AND ASSESSMENT
15
Assessing Psychological Resilience

• Insight into oneself and others
• Supple sense of self-esteem
• Ability to learn from experience
• High tolerance for distress
• Low tolerance for outrageous behavior
• Open-mindedness

16
Assessing Psychological Resilience (Cont.)

• Courage
• Personal discipline
• Creativity
• Integrity
• Keen sense of humor, constructive philosophy of
  life that gives life meaning
• Willingness to dream dreams that inspire and give
  hope
• (Adapted from Wolf Mosnaim, 1990)

17
Assessment Process

• You will have to ask questions to assess
• If symptoms are resulting from abuse.
• This should not be used to dredge up
• repressed memories.

18
Assessment Questions

• In the course of the day/night, do you hear
  voices in or outside your head? What are they
  saying? What may cause you to hear these voices?
• Do you ever try not to feel your feelings or
  thoughts? Do you usually feel numb?
• (Graves)

19
Assessment Questions (Cont.)

• Have you ever been a victim of sexual abuse?
• Have you ever observed sexual abuse?
• Have you ever been the victim of physical abuse?
• Have you ever observed physical abuse?
• (van der Kolk)

20
Continue if Yes to Any of the Above

• Do you ever have day dreams or think about the
  sexual or physical abuse?
• Night dreams Do you have them? Are they
  nightmares? If not, do you have any night
  dreamsare they neutral or bad? If bad, why
  arent they nightmares?
• Do you think about the above abuse during the
  course of a day?
• If yes, how and when does it come about?
• (Graves)

21
Two Basic and Very Important Questions

• How did you get here today?
• What do you do that makes you feel good about
  yourself? (Something you may have accomplished.)
• (van der Kolk)

22
Traditional Treatment Approaches

• Psychopharmacology
• Psychodynamic psychotherapy
• Group psychotherapy
• Family therapy

23
Non-traditional Approaches to Uncovering and
Processing

• Direct therapeutic exposure
• Hypnosis
• EMDR
• Psychodrama and role play
• Creative therapies such as art therapy, music
  therapy and dance therapy
• Spiritual and religious ceremonies
• Testimony
• (Adapted from Turner, McFarlane van der Kolk)

24
Stages of Recovery from Trauma

• Importance of the healing relationship
• Creating safety
• Naming the problem
• Restoring control
• Establishing a safe environment
• Reconstructing the story
• Transforming traumatic memory

25
Stages of Recovery from Trauma (Cont.)

• Mourning traumatic loss
• Learning to fight
• Reconciling with oneself
• Reconnecting with others
• Finding a survivor mission
• Resolving the trauma
• (Adapted from Herman, 1992)

26
TREM Model

• Trauma, recovery, empowerment
• Women with history of
• Serious mental illness
• Substance abuse
• Trauma
• Homelessness
• (Harris, 1998)

27
Four Core Assumptions of TREM

• Symptoms originated as coping response to trauma
• Women with early trauma unable to develop adult
  coping skills
• Trauma severs connections
• Women with repeated abuse feel powerless.
• (Harris)

28
Group Model

• 10 33 sessions
• 4 stages in group program
• Empowerment
• Trauma recovery
• Advanced trauma recovery
• Closing rituals
• (Harris)

29
Training for Professionals

• Develop awareness of parallel process for
  therapist in group
• Address secondary trauma issues for therapist
• (Harris, 1998)

30
Role of Case Management and Treatment

• Most of mental health system is impacted by
  individuals with abuse
• Case managers are involved in every part of
  persons life
• Individuals childhood abuse impacts every part
  of their lives
• Expansion/adaptation of roles by having protocol
  assessment for functioning

31
Psychodrama Multiple Addictions

• Model of addiction interaction (Carnes, 1994)
• Examples of models, switching, alternating,
  masking, ritualizing
• Psychodrama techniques of grounding in present
  explore addiction patterns
• Role reversal, doubling, mirroring demonstrate
  splitting of self and choice of addiction
• Psychodrama can explore denial in client and
  therapist to protect beliefs and myths
• (Sealy, 1999)

32
Psychodrama/Addiction/Trauma

• Allows the traumatized inner child to come back
  from the dead and feel alive again
• Unspeakable can be spoken within framework of
  safety and support
• Experimentation of new roles and alternative ways
  of being
• Role training allow recovering people to work out
  issues with new behavior
• (Dayton, 1994)

33
Traumatic Transference

• Therapist may suffer vicarious symptoms that
  replicate PTSD
• Repeated exposure to stories challenges
  therapists basic faith
• Heightens sense of personal vulnerability
• May share clients experience of helplessness
• As defense against helplessness may assume role
  of rescuer
• May violate boundaries of therapy

34
Traumatic Transference (Cont.)

• Identification with clients rage
• Experience feelings of profound grief
• Identification with perpetrator
• Voyeuristic excitement, fascination and sexual
  arousal
• Witness guilt
• Existential panic
• (Adapted from Herman, 1992)