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Psychological Trauma & Addictions Treatment

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Psychological Trauma & Addictions Treatment Case Management and Treatment of Trauma Syndromes in Chemical Dependency Treatment Settings Bruce Carruth, Ph.D., LCSW – PowerPoint PPT presentation

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Title: Psychological Trauma & Addictions Treatment


1
Psychological Trauma Addictions Treatment
  • Case Management and Treatment of Trauma Syndromes
    in Chemical Dependency Treatment Settings
  • Bruce Carruth, Ph.D., LCSW
  • San Miguel de Allende, GTO, Mexico
  • Advanced International Winter Symposium
  • Colorado Springs, CO
  • January 31, 2009

2
Neurosis .
  • is the process of shrinking our world to the
    point where we can manage (Rollo May, I
    think)
  • Unresolved trauma causes our worlds to shrink

3
Some initial thoughts about truama
  • 1. Almost everybody experiences a trauma event
    sometime in their lives.
  • 2. Its not what happens, it is how we handle
    what happens that creates trauma. Trauma isnt
    an event, trauma is an experience.
  • 3. Since trauma is a personal experience,
    everybodys trauma is different.
  • 4. Trauma is, by its nature, blindsiding.
  • It happens when we arent looking and
    arent
  • prepared and it strikes where we are
    vulnerable

4
Some initial thoughts (cont)
  • 5. Trauma is a wound to our personhood. We are
    never the same afterwards.
  • 6. Everyone copes with trauma by withdrawing, by
    disconnecting. Recovery has to be about
    reconnecting.
  • 7. Trauma therapy doesnt change what happened.
  • The therapy focus is on changing who we
    are today in the face of what happened

5
SOME SPECIFIC LEARNING GOALS FOR TODAY
  • 1. Conceptualize a variety of trauma syndromes
  • 2. That everyones trauma is unique in
  • symptoms
  • meaning of the trauma in their
    life
  • the process of recovery
  • 3. There is no best way to treat trauma
    syndromes
  • and that treatment has to evolve as the
    person evolves
  • 4. Trauma treatment has to address more than
    symptoms no symptom, no problem isnt an
    answer
  • 5. Recovery requires a variety of healing
    resources
  • self, therapy, spiritual growth,
    significant others, a
  • healing community

6
The dimensions of trauma
  • Our reaction to our environment
  • Sensory awareness and perception
  • amplifications, deletions, distortions
  • Cognitions cognitive filters
  • Memory
  • Affect and emotion
  • terror (fear), grief (sadness), rage
    (anger) shame
  • How we manage relationships in our life
  • trust, commitment, attachment, potency in
    relationships
  • Self and self functions our sense of who we are
    as a person our roadmaps for how to function in
    life
  • Soul the experience of being part of something
    greater than self attachment / belonging/
    commitment / connection to a world larger than
    self

7
Some different perspectives on trauma treatment
  • Medical perspective
  • trauma as a neuro-psycho-biological
    perspective
  • Cognitive-Behavioral perspective
  • treatment of trauma by changing cognitions and
    behaviors
  • Affect Regulation perspective
  • treatment of trauma by regulating powerful
    affects
  • Psychodynamic perspective
  • trauma as a wound to self
  • Interpersonal perspective
  • focuses on the interpersonal wounds of trauma

8
Since trauma touches all parts of our
being,treatment and recovery have to address
all parts of our being just
like addictive illness
9
trauma is ultimately a wound to selfdamaged
goods not the same persona part of me
was lost forever changed
  • but trauma is also set of symptoms that interfere
    with living
  • hyperarousal symptoms startle reactions,
    hypervigilance, irritability, misinterpreting the
    environment, hypersensitivity problem of
    keeping the outsides out
  • constriction symptoms withdrawal, numbing,
    forgetting, deadening, isolating, holding in
    problems of trying to hold the insides in
  • Intrusion symptoms re-enacting, intrusive
    memories, reliving, nightmares, preoccupied
    thoughts problem of regulating the commerce
    between our insides and outsides

10
So, what are we treating
  • Treatment starts with managing and treating the
    symptoms of trauma (and how trauma manifests in
    the now)
  • symptom management
  • coping skills
  • cognitions
  • reactive affects
  • And then generally needs to proceed to doing
    restorative work that explores the meaning of
    the trauma experience and works it through
  • primary affects
  • telling the tale and reorganizing experience
  • core cognitions and schemas
  • building healthy life and relationships -
    reconnecting

11
Recognizing trauma syndromes
  • 1. When people define their life by trauma events
  • 2. Rigid or inappropriate behaviors in the face
    of specific events or triggers
  • 3. Ego defense, unconscious to the person that
    clearly limits functioning
  • difficulty in giving / receiving
    feedback
  • misrepresentations of the
    environment
  • misperceptions of self and
    self-roles
  • deadening, numbing, dissociation
    (disconnecting)
  • assigning painful / disowned parts
    of self to the
  • environment

12
Recognizing trauma syndromes (cont)
  • 4. Distorted affects
  • displaced / distorted / inappropriate
    affects
  • exaggerated affects (affective
    overload)
  • diminishing (repressing) affects
  • 5. Psychiatric symptoms
  • depression (sad, angry, nihilistic,
    anxious)
  • anxiety (fear, phobias,
    obsessiveness, withdrawal)
  • somatization (pain, sleep disorder,
    appetite disorder)

13
Recognizing trauma syndromes (cont)
  • 7. Distorted reactions to life events that
    involve helplessness, vulnerability, constraint,
    shame, power/control
  • 8. Distortions in relationships trust,
    commitment,
  • potency, attachment
  • 9. And by the typical trauma symptoms
  • intrusion
  • hyperarousal
  • constriction

14
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15
the spectrum of psychological trauma
  • 1. Subclinical trauma syndromes A trauma
    reaction that doesnt reach the threshold for a
    trauma diagnosis.
  • 2. Cumulative childhood trauma an adaptive
    response in adulthood to childhood trauma
  • 3. Acute Stress Reaction A psychophysiological
    reaction to an overwhelming stimuli. A variation
    of ASR is Combat Stress Reaction (CSR)
  • 4. Grief Reaction An inability to experience
    the emotions of loss
  • 5. Post-Traumatic Stress Disorder(s) A
    significant wound to an individuals sense of
    self / personhood
  • 6. Complex PTSD Dissociative States A
    pervasive and disabling injury to self that
    produces significant psychiatric complications
    often produced by ongoing traumatization or
    torture.
  • Just because it isnt in DSM 4 doesnt mean it
    isnt real

16
associated psychiatric disorderswe often label
trauma syndromes as something elseand these
disorders are likely to co-occur with trauma
disorders
  • adjustment disorders (mislabeled)
  • dissociative disorders (co-occurring)
  • panic disorder (co-occurring)
  • phobic disorders (co-occurring)
  • major depressive disorder (both)
  • dysthymia (both)
  • substance use / abuse disorders (both, but more
    likely co-occurring)
  • the whole spectrum of personality disorders
    (both)
  • The vulnerable are always more vulnerable

17
Trauma is a wound to ones sense of self
  • Trauma wounds our dignity and integrity
  • Trauma alters our beliefs about ourself the
    world
  • Trauma alters our ability to rejuvenate /
    recuperate
  • Trauma impacts our ability to trust
  • Self trust and to trust the environment
  • Trauma distorts our sense of time and timing
  • Time gets defined by traumatic events
  • Distorts our sense of when to act
    hesitancy, impulsivity
  • Trauma impacts our sense of connection and soul
  • Family, community, spiritual life

18
Emotional symptoms of trauma
  • A primary effect of trauma is the inability to
    regulate the affects arising from or contaminated
    by the trauma
  • RAGE TERROR
  • GRIEF SHAME
  • Healing is being able to once again live in the
    face of these affects

19
trauma and vulnerability
  • trauma strikes the vulnerable person and trauma
    strikes us where we are vulnerable
  • psychological vulnerabilities
  • psychodevelopmental vulnerabilities
  • psychosocial vulnerabilities
  • the wounded are always at greater risk of more
  • wounding

20
4 variables in trauma vulnerability
  • 1. previous unhealed trauma
  • 2. psychiatric / psychological deficits /
    disorders
  • 3. unique, idiosyncratic childhood wounding that
    makes us vulnerable to rewounding as adults
  • 4. lack of resiliencies

21
3 primary symptoms of trauma
  • 1. Hyperarousal, sensitivity
  • Startle reactions
    Hypervigilance
  • Sleep disorders Nightmares
  • Irritableness
  • Inability to delete annoying stimuli
  • Intense reaction to stimuli associated
  • with the trauma

22
Primary symptoms (cont)
  • 2. Intrusion symptoms
  • Reliving the traumatizing event as if
  • trauma was reoccurring in the present
  • (every time I close my eyes I see
    it all over again)
  • Reenacting the trauma event in disguised
  • form (repetition compulsion)
  • Intrusive traumatic memories may be out
  • of context to actual trauma experience
  • (I keep having thoughts about things I
    dont think happened)
  • and may be encapsulated in one
  • sensory experience
  • (at night I hear this sound of ..)

23
Primary symptoms (cont)
  • 3. Constriction (Numbing and Withdrawing)
  • People will sometimes describe their constriction
    symptoms as building a wall
  • Numbness is an early response to trauma A
    primary variable in recovery is getting beyond
    the numbness and disconnection. Feelings become
    the enemy numbness is safe
  • Forgetting is a form of constriction
  • The ego defenses of constriction (repression,
    denial, dissociation, withdrawal, retroflection)
    are often the most difficult to work with in
    therapy
  • Phobias may be an unconscious way of avoiding
    environmental contact

24
so, what are we treating? And when?
  • Managing and treating the symptoms of trauma
  • (and how trauma manifests in the now)
  • (the early recovery work)
  • symptom management
  • coping skills
  • cognitions
  • reactive affects
  • Doing restorative work that explores the trauma
    and works it through
  • (when people are more stabilized in recovery)
  • core cognitions and schemas
  • primary affects
  • telling the tale and reorganizing the
    experience
  • building healthy life and relationships

25
Co-occurring trauma and addictionapproaches to
addressing both disorders
  • Sequential treatment
  • treating (stabilizing) one disorder first then
    treating the other
  • Parallel treatment
  • treating both disorders at the same time, but
    with different treatment protocols (and sometimes
    different agencies and different counselors /
    therapists
  • Integrated Treatment
  • treating the individual with one master
    treatment plan, in one setting, addressing the
    individuals unique needs
  • requires that the therapist/counselor and
    treatment team understand and have the skills to
    treat both disorders

26
Relative occurrence of trauma disorders
  • SUBCLINICAL TRAUMA SYNDROMES
  • many people some
    time(s) in life
  • ACUTE STRESS
    REACTIONS
  • Almost everyone, some time(s) in life
  • CUMULATIVE CHILDHOOD TRAUMA
  • A significant number of people
  • GRIEF REACTIONS
  • A significant
    percentage (10- 15) of people
  • POST TRAUMATIC STRESS
    DISORDER
  • small
    percentage of people (4-7)
  • COMPLEX PTSD AND DISSOCIATIVE
    DISORDERS
  • Very few people

27
Subclinical Traumatrauma that doesnt
incapacitate but lurks around in our life
  • Blindsided by event(s). It strikes where we are
    vulnerable
  • We have trouble finding meaning,
  • Why me?, finding cause doesnt resolve
    the issue
  • We may reject or not accept (recognize) support
    of others
  • We feel disoriented (things arent the same)
  • Our feelings are out of proportion (and we know
    it) to the circumstance, uncomfortable and may be
    displaced
  • We revert to old coping strategies (smoking, drug
    use, withdrawing, blaming others, trying to fix
    it)
  • It connects to some vulnerability in our history
  • The hurt seems to go on and on, we obsess, we
    keep it in front of us even when it doesnt need
    to be
  • Often are a series of events that overwhelm
    coping skills
  • May manifest as transient or on off or
    ongoing
  • And in the face of all this we keep going and
    maintain life on a day-to-day basis

28
Treating subclinical trauma
  • Support
  • . That the trauma experience is valid
  • . That the trauma experience will pass
  • . To keep the experience in perspective
  • Psychoeducation about trauma reactions and
    process of recovery
  • Acknowledgement of connections of current
    traumatic event to past traumas / history
  • Provide opportunities to step out of the trauma
    reaction to rest and replenish

29
Cumulative childhood trauma
  • Repeated childhood experience that leaves the
    individual feeling unworthy, defective,
    different
  • abandonment, physical disfigurement,
    learning disabilities, family
  • violence, parental addiction or
    psychiatric illness, physical illness and
  • disability, poverty and social shunning,
    abusive siblings, narcissistic,
  • antisocial or borderline personality
    disordered parents
  • The child develops coping skills to address the
    personal and interpersonal experience and these
    skills become engrained in the repertoire of the
    individual
  • The individual develops deep schemas about self
    and the world that are congruent with and support
    the understanding of the childhood experience
    coping skills
  • The child has to adapt an effective response that
    is congruent with their environment and this
    response becomes engrained

30
Cumulative childhood trauma (cont)
  • As a young adult, the child seeks out an
    environment that supports core schema, affective
    adaptations and coping behaviors of childhood.
    This is the entrenched adaptive stance
  • All of this is largely unconscious
  • When the breakdown begins to occur (often
    between 25 40), the person is truly befuddled
    and doesnt know how else to be.
  • Efforts at therapy/counseling may unwittingly
    become part of the problem
  • for instance, seeking out counseling that
    supports the engrained
  • view of the world Im a bad person,
    Its my fault, finding a
  • rescuing counselor, getting retraumatized
    in counseling
  • All of the above has been well described in the
    ACOA literature.

31
Treating cumulative childhood trauma
  • Treatment needs to be seen as an ongoing (2-5
    year) process
  • Therapy needs to be relationally focused and the
    corrective experience needs to, in part, arise
    from the therapeutic relationship. The
    relationship is critical to treatment
  • Intellectualization, idealization, projection,
    introjection and withdrawing are primary defenses
    that have to be confronted and utilized in the
    treatment
  • Treatment needs to utilize the adaptive stance,
    maximizing the assets and strengthening the
    limiting parts

32
Treating cumulative childhood trauma (cont)
  • When treating any trauma, but especially
    cumulative childhood trauma, therapy has to
    consider the world the adult has created for
    themselves. Good treatment is going to mess it
    up!
  • The treatment needs to focus on missed
    developmental phases and missed skills
  • A big piece of the treatment has to be coming to
    accept what happened and living in the face of
    what happened
  • The result of treatment doesnt have to be the
    perfect person, just good enough

33
Acute Stress Reactions (ASR)
  • A trauma response to being overwhelmed with a
    recent trauma experience.
  • Occurs within a short period following the trauma
    event
  • In uncomplicated ASRs improvement often occurs
    without treatment
  • ASRs often occur when a trauma event in the now
    activates a prior trauma experience (although the
    person make not make the connection)

34
Treating Acute Stress Reactions
  • 1. Diagnosing
  • a) helping people understand what is happening
  • Im falling apart, I think Im
    going crazy
  • b) differential diagnosis
  • addictive illness and addictive
    illness relapse
  • hidden PTSD with active trigger
    event
  • other anxiety disorder w/
    environmental stressor
  • complicated acute stress reactions
    with
  • people who dont have very good
    coping
  • skills and lack resilience

35
Treating ASDs (Cont)
  • 2. Creating safety
  • slowing the physiological response
  • exploring reorganizing the
    cognitions
  • building boundaries / structure
  • education about ASD
  • normalizing the emotional responses
  • building supports in the environment
  • building safety within self
  • 3. Relapse prevention with recovering CD clients

36
Treating ASDs (cont)
  • 4. Giving room to tell the tale
  • Be creative in letting people tell the
    story in the way
  • . they need words cant describe
  • 5. Use of medication
  • Benzodiazepines ???
  • Sleep meds
  • SSRIs are generally counterindicated
  • Blunt the affect and take too long
    to work

37
BICEPS model for crisis intervention
  • 1. Brief
  • 2. Immediate
  • 3. Centralized resources
  • 4. Expectations of outcome
  • 5. Proximity to the trauma site
  • 6. Simplicity

38
Acute Stress Disorder and Mass Traumas
  • In catastrophic disasters and in warfare, acute
    stress reactions are fairly common and may go
    undetected
  • A variation of ASR is a Combat Stress Reaction
    (CSR)
  • We may be more likely to see the coping symptoms
    drug and alcohol use, numbness withdrawal,
    inappropriate affects, impulsive decisions
  • Critical Incident Stress Debriefing (CISD) has
    not been shown to be effective in preventing or
    diminishing symptoms in mass trauma events, but
    may be efficacious when treatment is
    individualized

39
Grief reactions
  • Grief is the emotional expression of loss
  • Complicated grief is getting stuck in feelings
    of loss
  • Grief reaction is the blocking or distorting of
    the normal emotional expression of loss

40
Grief, complicated grief and grief reactions
require different responses
  • Grief support in expressing the emotions of
    loss
  • Complicated grief moving beyond being stuck in
    the loss
  • Grief reaction being able to experience and
    express the emotions of loss

41
3 categories of losses
  • Tangible losses marriages, money, careers,
    drivers licenses, social status, friendships
  • Intangible losses self esteem, hope, belonging
    and connectedness, joy, love, trust in self and
    others,
  • What could have been had this experience not
    happened to me the loss of a future

42
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43
Grief reactions from the outside
  • Emotional constriction or inappropriateness
  • Apparent feelings on the surface that are denied
    or displaced (denying sad or anger)
  • Avoidance behaviors, lonely in a crowd
  • Judgmentalness, perfectionism, blaming
  • Difficulty experiencing self, including positive
    and negative feedback
  • Obsessive thought and compulsive ritual
  • Loss of spontaneity

44
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45
The process of grief work
  • Diagnosis and differential diagnosis
  • cd relapse, dry drunk depression, PTSD,
    personality disorder
  • Education about grief and grief reactions
  • Exploration about clients experience with their
    grief
  • Creating safety with feelings
  • especially the disavowed feelings
  • Catharsis telling the story as well as
    expressing affect
  • Getting closure on events that precipitated the
    grief saying goodbye, letting go, finishing
    unfinished business, forgiving self and others
  • Reintegration of past self with present self

46
The goal of grief work is not to get rid of
painful feelings, but to accept the pain as a
meaningful part of life, to honor the pain rather
than repressing or disavowing it.The pain
connects us to something(s) that we lost that
were very important to us.
47
Diagnostic Criteria for PTSD
  • Exposure to traumatic event(s) in which
  • A) the event involves actual or potential
    death, injury or threat to physical integrity of
    self or others
  • B) intense fear, helplessness or horror
  • Intrusion symptoms Intrusive dreams, memories,
    flashbacks and distress at environmental cues of
    the event
  • Withdrawal symptoms Avoidance of stimuli related
    to event and numbing of general responsiveness
  • Thoughts and feelings People, places
    things
  • Difficulty recalling aspects of trauma
  • Feeling detached Loss of
    interest in activities
  • Restricted affect Loss of hope

48
PTSD Diagnostic criteria (cont)
  • Hypervigilance symptoms Increased emotional
    arousal
  • Problems falling asleep
  • Irritability / outbursts of anger
  • Difficulty concentrating
  • Hypervigilance
  • Exaggerated startle response
  • These symptoms last over time (though they may be
    transient)

49
Trauma, and PTSD in particular, is a wound to
ones sense of self
  • Our self perception / self esteem
  • Our trust in ourselves and in others
  • Our perception of self in relation to others
  • Our perception of the needs and desires of self
    and others
  • Our beliefs about the nature of the world (faith)
  • Our memories and how we remember
  • The affects we allow ourselves to feel (and the
    affects we have to disavow)
  • How we experience our future
  • Our values and ethical stances
  • Our spiritual beliefs and positions

50
Some issues about trauma in chemical dependency
recoveryespecially cumulative childhood trauma,
grief reactions and PTSD
  • Trauma symptoms can look similar to addiction
    issues in early recovery
  • The expectation is that the trauma symptoms will
    go away with CD recovery
  • The trauma is obscured by being an experience
    rather than a specific event
  • Early addiction treatment efforts tend to repress
    the trauma
  • Deal with the present, not the past
  • Suppress strong feelings
  • Flooding of trauma may provoke relapse
  • Trauma often stays buried until later in recovery

51
What can you really expect to do
  • In the first 90 days
  • build safety, recognize trauma symptoms (in a
    non-shaming way), symptom containment
    reduction, stabilize, educate, build trauma
    issues into relapse plan, build commitment to
    future work. Primary treatment resource is
    manualized treatment programs (for instance
    Seeking Safety)
  • Once stabilized in recovery
  • make trauma work part of the ongoing recovery
    plan,
  • increase awareness of triggers and how they
    manifest,
  • manage trauma symptoms when exposed to
    triggers
  • begin to explore beliefs that arose from
    trauma,
  • begin to explore how disavowed affects relate
    to trauma,
  • watch for how the trauma drama manifests
    gets played out
  • help client begin to tell the story and get
    the story straight

52
Addictive illness, psychological trauma and
suicide
  • People with co-occurring addictive illness and
    psychological trauma are at high risk for
    suicidal thoughts and behavior
  • And people who have a previous suicide attempt
    are at even greater risk
  • The other high risk factors are treatment
    transitions, drug relapse, relationship
    break-ups, sudden debilitating depression.
  • Suicide risk doesnt necessarily decrease with
    sobriety

53
Ask these questions of every client with suicide
risk
  • 1. Are you thinking about killing yourself
  • 2. Have you ever tried to end your life before
  • 3. Do you think you might try to kill yourself
    today (or in the immediate future)
  • 4. Have you thought about ways you might kill
    yourself
  • 5. Do you have a way of killing yourself
    available now

54
The GATE protocolfor clients with suicide risk
  • Gather information
  • Access consultation / supervision
  • Take responsible action
  • Extend the action follow-up

55
Trauma and CD recovery
  • Emerging trauma may be a sign of getting
    healthier. But it doesnt feel that way
  • Trauma symptoms can look like dry drunk
  • Hyperarousal, intrusion and constriction
    symptoms
  • Ego defenses of trauma and addiction are similar
  • Experiencing the trauma provokes the trauma in
    others in the treatment environment

56
When trauma brings people into treatment .
  • People often come into addictions treatment as a
    result of some traumatic experience.
  • Dont let the trauma get overlooked in the hustle
    to treat the addiction
  • Often, resistance to treatment is a function of
    the trauma response, not resistance to recovery
  • Resistance to experiencing the trauma wound

57
And when the treatment is traumatizing
  • Some people have the potential to be traumatized
    by addictions treatment settings
  • shame based people who get humiliated /
    scapegoated
  • when traumatic history is exposed and the
    person is overwhelmed and runs away
  • when the treatment process activates buried
    trauma the person acts out is blamed
  • confrontation, touching, being confined, even
    showing interest and concern
  • inappropriate behavior on the part of other
    clients or
  • staff

58
4 core elements in treating trauma states
  • Creating safety
  • Building hope
  • Building resilience and strengths to transcend
    the dark times
  • Consciously using the therapeutic relationship as
    a healing factor in treatment

59
Creating Safety
  • I cant make someone feel safe with themselves
    Safety has to come from within
  • Therapy itself is an inherently unsafe
    environment for trauma survivors
  • Trauma survivors will test to see if the therapy
    is safe.
  • I can provide an environment that doesnt
    reinforce unsafety

60
symptom containment as safety
  • building safety is helping the client be safe
    from their symptoms.
  • Intrusion intrusive memories, reliving the
    event, re-enactments
  • hyperarousal startle reactions, nightmares,
    hypervigilance
  • constriction going numb forgetting phobias
    and avoiding

61
Hope and despair as a special issue for
traumatized recovering people
  • Hope (the belief that life can be better) is
    essential to recovery
  • Without hope we have despair
  • People with a history of despair come into
    recovery and get a message of hope. Hope
    activates despair and the individual becomes
    cynical, indifferent, distant, disparaging. You
    cant trust happiness

62
  • chronic hopelessness

  • therapeutic

  • intervention
  • negates hope to
  • manage the anxiety

  • creates hope
  • creates anxiety

63
Some issues in addressing hope and despair
  • 1. you cant argue someone into hope
  • 2. hope often best comes in small doses
  • 3. encourage people to embrace hope when they
    have it
  • 4. and prepare for the times they dont have it -
    building islands in the swamp
  • 5. redefine despair as ego-dystonic
  • 6. hope is both an affect and a self experience
    have the affect, hold the experience

64
The hope box
  • Building strengths for when people crash into
    shame, hopelessness, despair, emptiness
  • Create a scrapbook, memories box or other
    depository to store ego enhancing memories.
  • The memories are composed of photos, documents,
    newspaper clippings, writings ..
  • Each memory contains a story that validates and
    supports the person
  • Add to the box as therapy progresses
  • Have clients take out the box occasionally and
    look at the scenes and remember the feelings
  • Be able to access the box when needed

65
Resilience in trauma treatmentyou just dont
know who you are dealing with
  • Resilience is more than getting by
  • Resilience is the ability to bounce back in the
    face of adversity
  • Resilience is lifes desire to move forward
    in
  • the face of adversity
  • Resilience is the ability to tap an inner
  • strength to persevere
  • The question for therapists is how do I
    help
  • an individual tap their resilience

66
Using the therapeutic relationship to treat
trauma states
  • 1. Modeling integrity, boundedness safety
  • 2. Monitoring transference
  • managing expectations of abandonment,
  • disregard other negative experience
  • 3. Monitoring counter-transference
  • in the face of revulsion, ego defense and
    client
  • provocation
  • in the face of over-identification or
    rescue fantasies,
  • get supervision and work it through
  • 4. Supporting the work without doing the work

67
the therapeutic relationship (cont)
  • 5. modeling interest / concern w/o activating
    shame
  • why are you so interested in me?
  • 6. working with projections onto therapist /
    interpreting the projections w/o activating
    defense
  • The therapeutic relationship becomes a model for
    building integrity based relationships

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4 basic therapy processes for working through
trauma Ongoing trauma treatment with recovering
c.d. clients
  • 1. Bringing the past to the present building
    new options for managing life today
  • Cognitive Behavioral approaches
  • CBT, Desensitization, Exposure
    Therapy, ACT, DBT
  • Psychodynamic psychotherapies
  • Supportive psychotherapy,
    Psychodynamic
  • Psychotherapy, Narrative
    Therapy, Emotionally Focused Therapy
  • Motivational Interviewing (MI) is a
    bit of both
  • 2. Hypnosis
  • a) Traditional medical hypnotherapy (NOT
    recommended)
  • b) Ericksonian hypnosis
  • 3. EMDR (Eye Movement Desensitization
    Reprocessing) and similar therapies
  • 4. Experiences in living today that reorganize
    the trauma experience corrective life
    experiences

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Psychopharmacology treatment with PTSD
  • 1. Anti-anxiety drugs
  • Benzodiazepines and SSRIs
  • 2. Mood stabilizers
  • Tegretol, Depakote, Lithium
  • 3. Anti-depressants
  • SSRIs, Tricycliates
  • 4. Anti-psychotics
  • Haldol
  • 5. Drugs that block the stress (flight or fight)
    responses
  • Klonopin (Catapres), Inderal

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  • All of these drugs only control symptoms. There
    is NO Anti-Trauma pill
  • Drugs that control trauma symptoms may be
    counterindicated for management of other
    disorders
  • Anxiety
  • Depression
  • (and especially) Addictive
    Illness

71
Three variables in adopting a specific approach
to therapy with trauma survivors
  • Approach is understandable
  • acceptable to the
    client
  • Therapist feels confident,
    Approach is congruent
  • capable congruent with with
    the nature of the
  • the approach
    trauma condition of

  • the client

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Cognitive-Behavioral Treatments for PTSD
  • 1. Exposure therapies
  • Prolonged exposure (PE) (Foa)
  • Systematic desensitization
  • CPT (Cognitive Processing Therapy)
    (Resick) (expos. cog. restructuring)
  • 2. Anxiety management
  • SIT (Stress Inoculation Training)
    (Meichenbaum)
  • Relaxation / meditation training
  • Anxiety management training
    (Kilpatrick)
  • 3. Cognitive Restructuring
  • Challenging limiting / inaccurate
    beliefs
  • Constructive Narrative Perspective
    (Meichenbaum)
  • Stopping / changing limiting cognitions
  • Challenging perceptions of the trauma
    event(s), their
  • meanings and impacts
  • 4. Skill Building
  • Building new / more diverse coping
    skills and behaviors

73
Cognitive behavioral treatments (cont)
  • 5. Newer CBTs emphasize acceptance,
    non-judgmentalness, present-centered, mindfulness
  • ACT (Acceptance Commitment Therapy)
    (Hayes)
  • DBT (Dialectical Behavior Therapy) (Lineha
  • 6. Schema therapy (Young)
  • 7. Other CBT approaches
  • Manualized treatments
  • Internet based treatment

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A psychodynamic approach to treating PTSD /
related trauma
  • 1. Developing safety stabilizing
  • being safe enough inside and with the
    environment
  • 2. Telling the tale, getting the story straight
  • experiencing / embracing the wounded self
  • 3. Corrective emotional experience
  • the repair work methods include CBT,
    redecisioning, finishing
  • unfinished business, forgiving, letting go,
    affect regulation, challenging schemas
  • 4. Integrating a new (repaired) sense of self
    reconnecting with the world
  • reconnecting, getting closure on
    history, coming to belong again, building
  • healthy relationships and perception of
    self in relation to others

75
4 stages in recovery from trauma
  • Developing safety
  • The very nature of the trauma experience is that
    it is unsafe.
  • The true fear is of exposing the damaged self
    the pain attached to the damage
  • The fear is most often externalized to the
    environment.
  • In therapy, the fear may be disowned to the
    therapist or the therapy as unsafe.
  • Therapy, in structure, may recreate the trauma
    scene, where the victim submits to an unequal
    relation-
  • ship with the therapist who has inordinate
    power and status

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4 stages of therapy (cont)
  • Getting the story straight
  • We speak of trauma as being unspeakable
  • Trauma may be expressed through physical
    experience and symbols as well as words
  • Symptoms of trauma may become a way of telling
    the tale
  • Victim psychology will focus excessively on
    blame
  • Victims will take responsibility for the trauma
    as a way of having control
  • What happened isnt as important as what it
    means
  • Trying to remember everything is futile

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Telling our tale (cont)
  • Our tales are told in metaphor. Our metaphor may
    or may not have much resemblance to the reality
    of others.
  • The therapist is the witness to the unfolding of
    the tale. The therapists job is to provide a
    container for the tale as it evolves and to
    facilitate the person telling the story in the
    most healing way possible.
  • Getting the story straight is like constructing a
    jigsaw puzzle. Seemingly unconnected pieces get
    put together to form a coherent image and the
    missing parts become more obvious.
  • The missing parts often contain the core of the
    trauma experience.

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Telling our tale (cont)
  • Words may not be a very good vehicle for
    communicating the trauma experience. Visual
    symbols, movies, music, drawings and physical
    movement may more accurately and effectively
    communicate the experience.
  • A variety of unfolding techniques can be applied
    to help reveal the tale including hypnosis,
    psychodramatic technique, group support and
    psychomotor therapies. But unfolding techniques
    are a means to the end, not the end in itself!
  • One story or event in the tale can be a metaphor
    for a series of events. It isnt necessary or
    practical to tell the whole tale, particularly
    with prolonged and pervasive trauma.

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Step 3 Corrective Emotional Experience
  • Corrective emotional experience is about
  • 1. Creating and living new options that
    refute the trauma experience
  • 2. Being able to have and work through the
    emotions that were attached to the trauma

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Corrective Emotional ExperienceCreating and
living new options
  • Trauma traps us into a set of truths and beliefs
    that are self limiting and often repeat the
    trauma experience.
  • A goal of therapy is to challenge these truths
    beliefs and create new options for living a more
    rewarding and versatile life.
  • Trying out new ways of living / coping create the
    corrective emotional experience

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Corrective Emotional ExperienceCreating and
living new options
  • Therapy needs to strategically address new coping
    options. Clients resist because the new options
    are incongruent with the existing truths and
    beliefs.
  • The primary defense against challenging beliefs
    and truths is to change them in the therapy
    office but not in life.

82
Corrective Emotional Experience Reworking the
emotions of trauma
  • 4 primary emotional responses to trauma are
  • rage, terror, grief and shame.
  • No one does each of these responses equally
    well.
  • Some trauma experiences lead themselves more to
    expression through one of these emotions than
    through others
  • When one avenue of expression is unavailable, we
    will use other avenues to express that emotion
  • Blocking rage limits experiences of empowerment
  • Blocking terror limits experiences of feeling
    safe
  • Blocking grief limits experiences of love and
    belonging
  • Blocking shame limits experiences of self love
    and self acceptance

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Corrective emotional experience (cont)
  • The fear of experiencing rage is uncontrolled
    violence toward self and others
  • The fear of experiencing terror is uncontrolled
    panic
  • The fear of experiencing grief is depression and
    emptiness
  • The fear of experiencing shame is deep
    humiliation and worthlessness
  • Terror, grief, rage and shame will emerge in a
    sequence that is unique to the individual. As
    one emotional response is worked through, another
    will appear. The most difficult emotional
    experience for the individual will be the last to
    appear.

84
Corrective emotional experience (cont)
  • THE EMOTIONAL BLOCK WITH THE TRAUMA EXPERIENCE IS
    NOT WITH THE AFFECT THAT IS EXPRESSED, BUT WITH
    THE AFFECT THAT IS UNEXPRESSED.

85
Corrective emotional experience (cont)
  • Other emotional themes of trauma survivors
    include
  • Guilt Rejection/Abandonment
    Loneliness
  • Hurt Overwhelmed
    Empty
  • The catharsis of these emotions is not the end in
    itself
  • But the expression of these emotions of the
    trauma give emotional life to the experience.
    The trauma experience cannot be resolved w/o the
    expression
  • of the emotional experience

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  • These emotional themes are worked out in the
    therapy experience transferentially as well.
  • A primary defense of the emotional themes is to
    project the disowned feeling.
  • The types of therapies that work best in
    providing corrective emotional experience are the
    therapies that acknowledge and support the
    awareness and expression of affect
  • Emotionally Focused Therapy (S. Johnson)
  • Contemporary Gestalt Therapy
  • Grief work
  • Affect regulation therapies

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Stage 4 Integrating a new sense of self
  • As the corrective emotional experience unfolds,
    the damaged sense of self that underlies the pain
    is exposed
  • Some agendas for selfhood work include redefining
    the trauma experience in terms of
  • Self trust
  • Self in relation to others
  • Self perception and self esteem
  • Beliefs about self and relation of self to
    the world
  • Self in relation to the future
  • Value and ethical positions
  • Spiritual beliefs

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The process of healing the self
  • 1. Creating a safe place
  • emotionally, physically,
    interpersonally
  • 2. Struggling to find a way to tell the tale
  • 3. Experiencing the pain (and joy)
  • 4. Experiencing the damaged self and
  • 5. Embracing ( allowing others to embrace) the
    damaged self
  • 6. Building a stronger sense of self
  • Self esteem, potency,
    interpersonally,
  • physically, spiritually
  • 7. Connecting with the world in a more potent
    way

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  • Healing is sufficient when
  • 1. We can address problems as they arise
  • 2. We can have at least one person in our life
    with whom we can intimately reveal ourselves
  • 3. We can have firm and flexible boundaries
  • I boundaries, value boundaries, body
  • boundaries, expressive and exposure
  • boundaries, comfort boundaries
  • 4. We have (and take) opportunities to
    rejuvenate
  • Physically, emotionally,
    intellectually,
  • interpersonally, spiritually

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Resolution
  • The experience of trauma is never fully resolved
    and recovery is never complete.
  • The natural unfolding of events reactivates the
    trauma experience which, again, needs to be
    recognized, confronted and expressed.
  • Healing is sufficient when the trauma does not
    dominate experience, but, rather, sits alongside
    the mundane and the ordinary, when the person can
    live in relative harmony with their environment

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For more information
  • Bruce Carruth, Ph.D., LCSW
  • (713) 589-3250
  • brucecarruth_at_earthlink.net
  • Overheads from this (and other) presentations are
    available at
  • www.brucecarruth.com
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