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Making Sense of the Complexities of Trauma


Making Sense of the Complexities of Trauma Heather Hartman-Hall, Ph.D. 2012 Prevalence (cont.) Prevalence rates for PTSD vary depending on the group surveyed; for the ... – PowerPoint PPT presentation

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Title: Making Sense of the Complexities of Trauma

Making Sense of the Complexities of Trauma
  • Heather Hartman-Hall, Ph.D.
  • 2012

Training Objectives
  • Participants will be able to
  • Identify diagnostic challenges in working with
    clients who have experienced trauma.
  • Understand how current symptoms may reflect
    adaptations to traumatic experiences.
  • Describe important features of a complex trauma

Training Objectives (cont.)
  • Identify several strategies for helping clients
    manage self-injurious and suicidal behaviors.
  • Understand vicarious traumatization and the
    importance of clinician self-care.

  • PART ONE Understanding Complex Trauma Syndromes

  • Psychological trauma is an affliction of the
    powerless. At the moment of trauma, the victim is
    rendered helpless by overwhelming force. When the
    force is that of nature, we speak of disasters.
    When the force is that of other human beings, we
    speak of atrocities. Traumatic events overwhelm
    the ordinary systems of care that give people a
    sense of control, connection, and meaning.
  • Judith Herman, Trauma and Recovery, 1997

  • While the criteria for PTSD diagnosis have gotten
    stricter since 1980, our ability to assess for
    and detect PTSD has improved the overall
    prevalence has remained fairly stable in that

Prevalence (cont.)
  • PTSD is still likely underdiagnosed, particularly
    in several demographic groups (e.g., Brunet,
  • In many settings, trauma not routinely assessed
    as part of intakes (van der Kolk et al., 2005)

Prevalence (cont.)
  • Estimates for exposure to potentially
    traumatizing events in the US tend to range
    around 70 of people surveyed
  • CDC ACE study (2009)
  • gt26K non-institutionalized US adults in 5 states
  • 8.7 reported 5 or more ACEs
  • Sexual abuse 17.2 for women, 6.7 for men
  • ACEs associated with multiple mental and
    physical health problems

Prevalence (cont.)
  • Prevalence rates for PTSD vary depending on the
    group surveyed for the general US population
    lifetime prevalence is estimated to be 6.8-8

Prevalence (cont.)
  • National Comorbidity Survey Replication (NCS-R),
    conducted between 2001 and 2003 (Gradus, 2007)
  • Nationally representative sample of Americans
    aged 18 years and older
  • 5K participants assessed for PTSD by interview
    using DSM-IV criteria
  • Lifetime prevalence of PTSD est. at 6.8
  • Among women 9.7, men 3.6

Prevalence (cont.)
  • NCS-R yielded estimates similar to first National
    Comorbidity Survey (early 1990s)

Lifetime Prevalence of PTSD Overall Women Men
NCS 7.8 10.4 5
NCS-R 6.8 9.7 3.6
Prevalence (cont.)
  • DSM-IV-TR Community-based studies indicate about
    8 lifetime prevalence for PTSD adults in the US

Prevalence (cont.)
  • Random sample of 4,008 US women (Resnick, 1993)
  • Lifetime exposure to any type of civilian
    traumatic event 69
  • 36 endorsed exposure to crimes that included
    sexual or aggravated assault or homicide of a
    close relative or friend
  • Lifetime prevalence of PTSD12.3
  • significantly higher among crime vs noncrime
    victims (25.8 vs 9.4).

Prevalence (cont.)
  • Study of 152 women aged 18-45 consecutively seen
    for routine gynecological care in family
    physician office (Sansone, et al.,1995)
  • Traumatic experiences were reported by 70.7
  • Sexual abuse reported by 25.8
  • Physical abuse reported by 36.4
  • Emotional abuse reported by 43.7
  • Physical neglect reported by 9.3
  • Witnessing of violence reported by 43.0

Prevalence (cont.)
  • Random sample of 1008 adult residents of
    Manhattan 5-8 weeks after September 11, 2001
    terrorist attacks (Galea, et al., 2002)
  • 7.5 reported symptoms consistent with a
    diagnosis of current PTSD related to the attacks
  • 20 in residents who lived near World Trade
  • Predictors of PTSD Hispanic ethnicity, prior
    stressors, a panic attack during or shortly after
    the events, proximity to WTC, and loss of
    possessions due to the events.
  • 9.7 reported symptoms of depression

Prevalence (cont.)
  • Interviews of 810 adult residents in southern
    Mississippi (random selection of addresses in
    each of 3 strata), 18-24 months after Hurricane
    Katrina (Galea, et al. 2008)
  • 22.5 diagnosed with PTSD in that period
  • Risk factors included
  • Being female
  • Financial loss
  • Low social support
  • Post-disaster stressors/traumas

Prevalence Complex PTSD
  • Full syndrome estimated lt1 in nonclinical
  • Sub-syndrome symptoms of CPTSD more common and
    are associated with childhood trauma

Prevalence Complex PTSD (cont.)
  • van Dijke, et al. (2011) found 10-38 of
    psychiatric inpatients met criteria for Complex
  • In one small study of forensic inpatients in
    Germany, 28 were diagnosed with CPTSD 44
    lifetime prevalence

Interpersonal Trauma and PTSD
  • Interpersonal trauma is associated with higher
    rates of PTSD than other types of trauma
    (accidents, disasters, etc.)
  • Being victimized by criminal acts more associated
    with PTSD symptoms
  • Interpersonal traumas experienced in childhood
    increase likelihood of PTSD, and of victimization
    later in life

Gender Differences
  • National Comorbidity Survey indicated that more
    males than females in the US experience trauma,
    but more females develop PTSD
  • Lifetime prevalence of PTSD for women is about
    twice that of men
  • Some studies suggest PTSD lasts longer in females
    than males

Gender Differences (cont.)
  • Women more likely to be exposed to interpersonal
    forms of trauma (Lilly Valdez, 2012)
  • Females typically report more sexual abuse than
  • Experience of interpersonal trauma may be more
    predictive of later PTSD than gender

Gender Differences (cont.)
  • Teenage boys in particular rarely report sexual
    abuse, particularly by a woman
  • Guilt/shame
  • Rite of passage
  • Normalized or even viewed as positive by
    peers/other adults

Gender Differences (cont.)
  • Males may be less likely to seek treatment
  • Gender of therapist may be important
  • Differences in symptom presentation?
  • Culturally-imposed gender roles (e.g., Evans
    Sullivan, 1995)

Special Populations
  • many or even most psychiatric patients are
    survivors of abuse (Herman, 1997)
  • Some estimates suggest 1/3-1/2 of people in
    treatment for substance abuse have PTSD
  • Lifetime exposure to trauma has been reported to
    be higher in adult and juvenile offenders
  • Especially child abuse (Spitzer, et al., 2006)

Early Risk
  • Ideally, parenting is the essential buffer
    against trauma (Allen, 1995)
  • When a small childs needs are met predictably by
    his environment, more likely to develop secure
    attachment (Schore, 2002)
  • May affect development of the central nervous
    system and the limbic system
  • Secure attachment includes the assumption that
    homeostatic disruptions will be set right

Early Risk (cont.)
  • Childhood abuse often occurs within the context
    of neglect, deprivation, and emotional
    invalidation (Briere, 1996)
  • Acts of both commission and omission (Korn
    Leeds, 2002)
  • Sexual, physical, emotional abuse
  • Witnessing violence
  • Unmet physical and emotional needs
  • Parental unavailability
  • Failure to protect by caregivers
  • Childhood separations

Early Risk (cont.)
  • Increasing evidence that childhood trauma puts
    people at higher risk for mental illness and
    maladaptive stress responses in adulthood
  • New research using brain scans shows structural
    changes (particularly in areas of the brain
    related to stress response)
  • a violation of and challenge to the fragile,
    immature and newly emerging self (Ford
    Courtois, 2009)

Early Risk (cont.)
  • Childhood traumas can block or interrupt the
    normal progression of psychological development
    in periods when a childis acquiring the
    fundamental psychological and biological
    foundations necessary for all subsequent
    development (Ford, 2009)
  • Brain shifts from learning functions to
    survival functions

Early Risk (cont.)
  • When a child is betrayed (e.g., abused or
    neglected) by a caregiver, child still needs
    caregiver to survive
  • May remain unaware of the betrayal (Kaehler
    Freyd, 2011)
  • Dissociation
  • Blame self rather than caregiver
  • Rationalize/excuse the abuser

Risk Factors/Resilience
  • Most traumas dont result in mental illness
  • DSM-IV-TR severity, duration, and proximity of
    an individuals exposure to the traumatic event
    are the most important factors in risk for PTSD
    some evidence that social supports, family
    history, childhood experiences, personality
    variables, and pre-existing mental disorders may
    influence development of PTSD

Common Reactions to Frightening Experiences
  • Shock
  • Anxiety/worry
  • Irritability/anger
  • Changes in eating or sleeping habits
  • Physical problems or illness
  • Apathy/loss of interest in usual activities
  • Feeling jumpy
  • Most people experience some temporary
    interference in usual functioning after a
    traumatic experience.

Fight or Flight Response
  • Mammals have developed response to threat through
  • Sympathetic nervous system
  • Once the response is set off, hormones released
    into the body create various changes to prepare
    the body for vigorous action
  • Increased heart rate, constriction of blood
    vessels, tunnel vision, reduced GI and sexual

Fight or Flight Response (cont.)
  • Fight or Flight represents a complex stress
  • Decades of stress research (e.g. Bracha, et al.
    2004) have illuminated four fear responses that
    occur in order in the face of a threat
  • Initial freeze response
  • Attempt to flee
  • Attempt to fight
  • Tonic immobility
  • Freeze, flight, fight, fright response

Fight or Flight Response (cont.)
  • Stress response begins with the individuals
    appraisal of the event and how it may affect him
    or her
  • Various individual and situational factors will
    influence appraisal
  • Likely an automatic and even unconscious process
  • Includes whether individual has resources to cope
    with stressor

Fight or Flight Response (cont.)
  • Physiologically, the response to rage and fear
    are the same
  • May be an adaptive response to single-incident,
    intense stress, but can become problematic
  • When continuously activated
  • When natural response is blocked
  • Loss of ability to return to baseline state of
    physical calm or comfort

Adaptations to Trauma
  • A natural response to an overwhelming experience
  • Strategies that are adaptive in a crisis can
    backfire when trauma is ongoing or when
    self-regulation doesnt come back online
  • natural, self-protective efforts gone awry
    (Allen, 1995)

Long-Term Effects of Trauma
  • Physiological changes
  • Dysregulated emotions
  • Disruption of relationships
  • Damaged/changed view of self
  • Changes in world view/belief system
  • Break down of coping strategies
  • Altered perceptions

Diagnostic Challenges
A Confusing Picture
  • What are the likely diagnoses for each of the
    following symptom clusters?

  • Numerous hospitalizations, history of cutting
    arms repeatedly, has trouble trusting others but
    is afraid to be alone.
  • Appears withdrawn, suspicious of others,
    occasionally appears to be responding to internal
  • Hypersexuality, risk-taking, substance abuse,
    insomnia, weight loss.

  • Episodic confusion, poor memory, inability to
    attend to conversations, little spontaneous
    speech, low activity level.
  • Flat affect, unable to think of anything good
    that might happen in the future, low energy,
    finds little enjoyment in activities once
  • Reports hearing a voice that repeats insults and
    phrases such as You should die. Reports
    sometimes feeling that she leaves her body and
    looks down at herself from the sky.

Diagnostic Challenges
  • Misdiagnosis bewildering array of symptoms
    (Herman, 1997)
  • Symptoms and functioning often vary over time and
    across situations
  • Self-report might not include information about
  • Strengths/abilities might mask difficulties or
    make impairment less obvious
  • Trauma disorders may not be considered,
    particularly in some settings

Diagnostic Challenges (cont.)
  • Comorbidity of trauma with other disorders
  • One large study 84 of people with PTSD met
    criteria for at least one other psychiatric
  • Major depression
  • Substance abuse
  • Other anxiety disorders
  • Schizophrenia
  • Dissociative disorders
  • Personality disorders
  • Comorbid somatic problems also very common

Cultural Factors
  • DSM-IV-TR emphasizes importance of considering
    culture in diagnosis
  • Research on trauma in mainstream US population
    might not generalize to other cultures (Carlson,
  • Some evidence of higher rates of trauma and/or
    more severe symptoms among people from ethnic
    minority groups and deaf people (Davis, et al.
    2011 Ford 2012)
  • SES status and its associated stressors may play
    a role

Cultural Factors (cont.)
  • Possible differences in symptom presentation
    (Schlid Dalenberg, 2012 Brunet, 2007 Frueh,
    et al., 2002 Sue Sue, 1987)
  • Asian cultures more likely to present with
    physical symptoms as a trauma response
  • African-American combat veterans with PTSD may
    present with more psychotic symptoms
  • Trauma symptoms may present differently in deaf
    vs. hearing people

Axis I Disorders Associated with Trauma
Diagnoses Commonly Associated with Trauma
  • Post-Traumatic Stress Disorder (PTSD)
  • Acute Stress Disorder
  • Borderline Personality Disorder
  • Dissociative Disorders
  • Substance Abuse/Dependence
  • Eating Disorders
  • Other anxiety, mood, somatoform, personality

  • Symptoms usually begin within 3 months of
    traumatic experience, but may be a delay of
    months or even years
  • Three clusters of symptoms
  • Re-experiencing
  • Avoidance/numbing
  • Hyperarousal
  • Bi-phasic condition that alternates between
    reliving the overwhelming experience, and
    avoiding thoughts/feelings associated with trauma

PTSD (cont.)
  • DSM-IV-TR Criterion A
  • 1.The person has experienced, witnessed, or been
    confronted with an event or events that involve
    actual or threatened death or serious injury, or
    a threat to the physical integrity of oneself or
  • 2.The person's response involved intense fear,
    helplessness, or horror. (In children, may be
    expressed instead by disorganized or agitated

PTSD (cont.)
  • DSM-III Criterion A The person has experienced
    an event that is outside the range of usual human
    experience and that would be markedly distressing
    to almost anyone

PTSD Re-experiencing
  • One or more for diagnosis of PTSD
  • Examples
  • Intrusive thoughts or memories of trauma
  • Nightmares
  • Flashbacks
  • Intense distress in response to reminders of the

PTSD Avoidance/Numbing
  • Three or more for diagnosis of PTSD
  • Examples
  • Avoiding reminders of the trauma
  • Amnesia for some aspects of the experience
  • Loss of interest in activities
  • Feeling detached or estranged from others
  • Restricted range of emotions

PTSD Hyperarousal
  • Two or more that have arisen since the traumatic
  • Examples
  • Insomnia
  • Irritability
  • Poor concentration
  • Hypervigilance
  • Exaggerated startle response

Acute Stress Disorder
  • Symptoms similar to PTSD, difference is timeframe
  • Symptoms occur within one month of trauma and
    last 2 days to 4 weeks

Dissociative Disorders
  • Depersonalization Disorder
  • Dissociative Amnesia
  • Dissociative Fugue
  • Dissociative Identity Disorder
  • Dissociative Disorder Not Otherwise Specified

Dissociative Disorders (cont.)
  • Characterized by range of experiences related to
    disruption of awareness/consciousness, memory,
    identity, perception, etc.
  • Can present in different ways (sudden vs.
    gradual, transient vs. chronic, single symptom or
    entire syndrome)
  • Individual may or may not be aware of these
    occurrences, but they cause impairment and/or

Dissociative Disorders (cont.)
  • Link between childhood trauma (especially abuse)
    and dissociation later in life (e.g.,
    Löffler-Stastka, et al. 2009)
  • Dissociation as a response to chronic,
    inescapable stress
  • Shuts out the experience mental escape when
    couldnt physically escape
  • Allows individual to survive unbearable situation
  • Perhaps adaptive in the short-term, but
    detrimental to functioning longer-term

Dissociative Disorders (cont.)
  • Later in life, dissociative experience may be
    triggered by memories, perceived threat, or
    strong feelings
  • Pathological dissociation was associated with
    depression, alexithymia, and suicidality in a
    general population sample (Maaranen, et al., 2005)

Dissociation Other Diagnoses
  • Dissociative symptoms have been associated with
    PTSD, borderline personality disorder,
    schizophrenia, mood disorders, OCD, somatoform
    disorders (Spitzer, Barnow, et al., 2006)

Dissociation vs. Psychosis
  • Dissociation and psychosis can present similarly
  • Severe dissociation has been associated with
    comorbid psychosis (Allen et al., 1997 Allen
    Coyne, 1995 Moskowitz et al., 2005 Kilcommons,
    et al., 2008)

The Role of Trauma in Borderline Personality
Borderline Personality Disorder (BPD)
  • Diagnosed in about 2 of general US population
    about 75 of these are female
  • DSM-IV-TR a pervasive pattern of instability of
    interpersonal relationships, self-image, and
    affects, and marked impulsivity beginning by
    early adulthood and present in a variety of
  • Examples

BPD (cont.)
  • Frantic attempts to avoid abandonment
  • Unstable and intense relationships
  • Identity disturbance
  • Impulsive, potentially self-destructive behaviors
  • Suicidal or self-injurious behaviors
  • Affective instability/reactive mood
  • Chronic feelings of emptiness
  • Intense anger
  • Dissociative symptoms, stress-induced paranoia

BPD (cont.)
  • BPD diagnostic criteria have remained relatively
    unchanged since introduced in DSM-III (1980)
  • Criticisms of current criteria (Lewis Grenyer,
  • Extensive symptom overlap with other disorders
  • Reliability and validity of diagnosis in
    literature has been inconsistent
  • No reference to widely-accepted role of early

Perceptions of BPD
  • Pejorative connotation of the diagnosis
  • In particular, clients with BPD who engage in
    self-harm or suicide attempts tend to get
    negative reactions from clinicians, ER personnel,
    others (see Treloar Lewis, 2008 for review)
  • Negative perceptions create major barrier to
    effective service provision for these patients
  • Education for professionals shows positive effects

BPD and Trauma
  • DSM-IV-TR Physical and sexual abuse, neglect,
    hostile conflict, and early parental loss or
    separation are more common in the childhood
    histories of those with BPD
  • Link identified between insecure attachment in
    infancy and later development of BPD symptoms
    (e.g., Kaehler Freyd, 2011)

BPD and Trauma (cont.)
  • Physical abuse/neglect and inconsistent
    experiences from caregivers in childhood seen as
    possible factors in development of BPD
    (Löffler-Stastka, et al., 2009)
  • Studies found 81-91 of people with BPD had
    severe childhood trauma, including
    physical/emotional abuse, neglect, sexual trauma
    (e.g., Lewis Grenyer, 2009 Herman, 1997)

BPD and Trauma (cont.)
  • Trauma may be one etiological factor among many,
    including biological, psychological, and social
    factors (Gratz, et al., 2011 Lewis Grenyer,
  • Possibly, trauma interacts with temperament and
    biological vulnerabilities
  • Linehan describes BPD as resulting from inherited
    proneness to emotional dysregulation and growing
    up in an invalidating environment

Complex PTSD
Complex PTSD (CPTSD)
  • Spectrum of trauma responses from brief reaction
    that improves on its own, to classic PTSD, to
    complex syndrome
  • Complex syndrome seen in survivors of prolonged,
    repeated (often childhood) trauma at the hands of

CPTSD (cont.)
  • Loss of coherent sense of self and others that is
    often a core feature of chronic interpersonal
    trauma is not captured in current PTSD diagnosis
  • DSM-IV Field Trial demonstrated that early trauma
    gives rise to more complex symptoms in addition
    to PTSD (van der Kolk, et al., 2005)
  • Disorders of Extreme Stress Not Otherwise
    Specified (DESNOS)

CPTSD (cont.)
  • Criteria that were under consideration for DSM-IV
    for a complex trauma syndrome

Complex PTSD Proposed Criteria (Herman, 1992)
  • A history of ongoing and severe interpersonal
  • Alterations in affect regulation
  • Including persistent dysphoria, suicidal
    preoccupation, self-injury, explosive anger
  • Alterations in consciousness
  • Including amnesia, dissociative experiences,
    intrusive memories or flashbacks

Complex PTSD Proposed Criteria (Herman, 1992,
  • Alterations in self-perception
  • Including shame, guilt, feeling of differentness
    from others, helplessness
  • Alterations in perception of perpetrator
  • Including revenge fantasies, idealization,
  • Alterations in relations with others
  • Including isolation, distrust, failure to
  • Alterations in systems of meaning
  • Including loss of faith, hopelessness

Proposed Changes for DSM-5
  • Planned release in May, 2013
  • New diagnostic category Trauma- and
    Stressor-Related Disorders
  • Would move trauma disorders from Anxiety
    Disorders category
  • Includes adjustment disorders

Proposed Changes for DSM-5Trauma- and
Stressor-Related Disorders
  • Reactive Attachment Disorder
  • Disinhibited Social Engagement Disorder
  • Acute Stress Disorder
  • Posttraumatic Stress Disorder
  • Adjustment Disorders
  • Trauma- or Stressor-Related Disorder Not
    Elsewhere Classified

Proposed DSM-5 Changes to PTSD diagnosis
  • DSM IV-TR PTSD Criteria A1 The person has
    experienced, witnessed, or been confronted with
    an event or events that involve actual or
    threatened death or serious injury, or a threat
    to the physical integrity of oneself or others.
  • A2 The person's response involved intense fear,
    helplessness, or horror. Note in children, it
    may be expressed instead by disorganized or
    agitated behavior.

Proposed DSM-5 Changes to PTSD diagnosis (cont.)
  • PROPOSED DSM 5 PTSD Criteria A
  • Exposure to actual or threatened a) death,
    b)serious injury, or c) sexual violation, in one
    or more of the following ways

Proposed Changes for DSM-5 (cont.)
  • Directly experiencing the event
  • Witnessing, in person, others experiencing event
  • Learning that the event occurred to close
    relative or friend actual or threatened death
    must be violent or accidental
  • Experiencing repeated or extreme exposure to
    aversive details of the event
  • E.g., first responders, police officers
    investigating child abuse cases

Proposed Changes for DSM-5 (cont.)
  • 4 proposed symptom clusters
  • Intrusion symptoms
  • Avoidance
  • Negative alterations in cognitions and mood
  • Alterations in arousal and reactivity

Proposed Changes for DSM-5 (cont.)
  • Subtypes
  • PTSD in Preschool Children
  • PTSD with Prominent Dissociative Symptoms
  • meets criteria for PTSD AND either
    depersonalization and/or derealization

Proposed Changes for DSM-5 (cont.)
  • Dissociative Disorders
  • Depersonalization-Derealization Disorder
  • Dissociative Amnesia
  • Dissociative Identity Disorder
  • Dissociative Disorder Not Elsewhere Classified

Proposed Changes for DSM-5 (cont.)
  • Changes in personality disorder diagnoses also
  • Fewer personality disorders included
  • Impairment must be seen in both self and
    interpersonal domains
  • Impairment must be present in at least one of
    five areas
  • Severity of impairment rated from mild to extreme

Proposed Changes for DSM-5 (cont.)
  • For more about proposed changes, progress of the
    workgroups, and the timeline for release of DSM

Self-Injurious and Suicidal Behaviors
  • Tension-relieving self-injurious behaviors vs.
    suicidal behaviors
  • Two different but often related sets of behavior
  • Self-injurious behaviors DO increase the risk of
    suicidal behaviors
  • Particularly for people with personality

Suicidal vs. Self-Injurious Behaviors
  • Maddock et al. (2010) looked at reasons women
    with BPD gave for SIB and suicide attempts and
    found the reasons (e.g., to relieve emotional
    pain, escape, etc.) were not significantly
  • Suggested clinicians should assess method used
    and whether reasons for harming self have
    resolved in determining risk for suicide

Risk Factors for Self-Harm
  • Previous suicide attempt/self-injury
  • Psychiatric illness
  • Mood disorder (Depression, Bipolar Disorder)
  • Substance abuse
  • Schizophrenia
  • Personality disorders
  • Anxiety disorders

Risk Factors for Self-Harm (cont.)
  • High-risk groups vary by culture/country
  • In the US, women more likely to attempt suicide
    but men more likely to complete suicide

Self-Injurious Behaviors (SIB)
  • the "deliberate, direct injury of one's own body
    that causes tissue damage or leaves marks for
    more than a few minutes and that is done in order
    to deal with an overwhelming or distressing
    situation (ASHIC website, 2005)
  • Examples cutting/scratching, burning, head
    banging, swallowing foreign objects

SIB (cont.)
  • Most SIB is an adaptation to deal with an
    intolerable experience (Saakvitne, et al., 2000)
  • A person who has experienced significant, ongoing
    trauma may develop SIB as a way to cope with
    overwhelming emotions
  • The link between SIB and significant childhood
    trauma has been well established in the research
    literature (e.g., Osuch, Noll, Putnam, 1999
    Herman, 1992)

SIB (cont.)
  • Physical pain is often reduced or even unnoticed
    while a person is in the act of SIB (e.g.,
    Herman, 1992)
  • The individual may be unaware of the behavior
    while it is occurring, particularly if

SIB (cont.)
  • Many possible reasons for SIB
  • to manage intense feelings/distress
  • physical pain seen as preferable to emotional
  • individual feels he or she deserves to be
  • to obtain a sense of control
  • to ground oneself when dissociating or otherwise
    losing touch with reality
  • to express anger or hostility
  • to stop flashbacks or other intrusive memories
  • to express emotional pain
  • to prevent suicide attempts
  • to prevent acting out against others

SIB (cont.)
  • SIB is typically NOT a failed suicide attempt
    Osuch, Noll, Putnam, 1999 Herman, 1992
  • Assess whether the person intended to die or
    believed the behavior was life-threatening
  • In fact, SIB is often a coping strategy that acts
    as suicide prevention for patients, in that SIB
    may help them avoid feeling a total loss of

SIB (cont.)
  • However, a patient who engages in SIB may also be
    suicidal, and is likely at increased risk for
    also making a suicide attempt.
  • It has been estimated that about half of all
    people who kill themselves have a history of SIB
    (Osuch, et al. 1999).
  • Patients engaging in SIB should also be regularly
    assessed for suicidal ideation.

SIB (cont.)
  • Borderline Personality Disorder (BPD) diagnosis
    in the DSM-IV-TR includes deliberate self-injury
    as a listed symptom, and therefore the two are
    often equated
  • The presence of SIB alone does NOT warrant a
    diagnosis of an Axis II disorder.
  • SIB occurs with many other diagnoses, including
    PTSD, eating disorders, substance abuse,
    dissociative disorders, developmental disorders,
    and alexithymia (a lack of ability to express or
    even have awareness of one's own feelings).
  • There might also be a psychotic or
    obsessive-compulsive component to SIB.
  • E.g., in response to hallucinations (Osuch, et

SIB (cont.)
  • Caregiver/loved ones reactions to SIB
  • Anger, fear, disgust, worry, hopelessness and
    other strong feelings are understandable
    reactions to SIB
  • Important to manage reactions rather than act
    them out on the client
  • Strong reactions can contribute to the clients
    feeling less safe, increasing her anger, shame,
    distress, tendency to hide SIB (Herman 1992
    Saakvitne, et al., 2000)

SIB (cont.)
  • Research suggests that offering possible reasons
    for SIB may actually increase risk of additional
    SIB (Osuch, et al. 1999)
  • Ask open-ended questions about clients ideas
    about why she/he is engaging in SIB

  • Chronic vs. Acute
  • Direct communication is crucial
  • Should be assessed regularly and at critical
  • Family/significant other involvement
  • Seasonal variation

  • A Trauma-Informed Approach to Treatment

Setting the Frame
  • I explained that we were on a journey together
    that she picked the path and I held the light for
    us to see.
  • - Susan K. L. Pearson, M. D.

Setting the Frame
  • Informed Consent
  • Confidentiality
  • Mandated reporting/duty to warn
  • Treatment plan
  • May feel worse before you feel better
  • Safety
  • Your crisis availability/back-up plans
  • Education as part of treatment

Setting the Frame (cont.)
  • Treatment Goals/plan
  • Clients role (not passive!)
  • Psychoeducation
  • Validation of the traumatic experience is a
    precondition for creating an integrated view of
    self and establishing the capacity for healthy
    relationships (Herman, et al. 1995)

Setting the Frame (cont.)
  • Create a safe environment
  • Physically and psychologically
  • Acknowledge limitations of setting/situation
  • Eye contact and active listening
  • Physiological aspects of social behavior
  • Use touch of any kind cautiously if at all

The Therapeutic Relationship The Critical
Therapeutic Relationship
  • Trauma can disrupt many aspects of interpersonal
  • Ability to connect
  • Trust
  • Asking for help
  • Being vulnerable with someone
  • Believing someone else cares
  • etc.

Therapeutic Relationship (cont.)
  • The most important thing you bring to the therapy
    is YOU
  • the essential therapist task is to provide
    relational conditions that encourage the safety
    of the attachment between client and therapist
    (Kinsler, Courtois, Frankel, 2009)

Therapeutic Relationship (cont.)
  • Appropriate, solid boundaries
  • Experiencing first-hand how the client behaves in
  • Informative for the therapist
  • Can provide feedback to client

Therapeutic Relationship (cont.)
  • Providing a consistent presence
  • Tolerating the pain starting to help client
    develop affect regulation
  • Another opportunity for secure attachment

Therapeutic Relationship (cont.)
  • Managing inherent power imbalance (Courtois, et
    al., 2009)
  • Strive for egalitarian, collaborative
    relationship that encourages empowerment of
  • Responsibilities and inherent power differences
    should be acknowledged
  • Seek to use power effectively on clients behalf
  • Encourage clients development and autonomy

Therapeutic Relationship (cont.)
  • Holding the hope
  • Once relationship is fairly solid, work towards
    putting eggs in more baskets
  • Avoid accepting the superhero cape!

  • Trouble can always be borne when it is shared.
  • -Katherine Paterson

R.I.C.H. Philosophy(Saakvitne, et al. 2000)
  • An approach for any clinical work with survivors
    of trauma
  • Respect
  • Information
  • Connection
  • Hope

  • Collaboration
  • Confidentiality
  • Sensitive language
  • Assuming clients point of view is valid
  • Being fully present
  • Humility
  • Honesty

  • Provide information about effects of trauma
  • Explain treatment plan, including rationale
  • Include possible risks and benefits
  • Expectations on both sides should be clear and
    reviewed as often as needed
  • Community resources
  • Safety planning
  • In inpatient/correctional setting, helping client
    understand the process

  • Genuine empathy and positive regard
  • Clear boundaries
  • Being honest
  • Sitting with painful content and emotions
  • Recognition that the work affects both of you

  • You can have hope for the client even when she
    doesnt have it for herself
  • Utilize strengths and abilities
  • Help client see progress
  • Keep goals realistic
  • Therapist self-care is crucial!

Assessment of trauma and its effects
  • The past isnt dead it isnt even past
  • -William Faulkner

Assessment of Trauma
  • Best tool good clinical interview
  • May need to spend time establishing trust and
    safety first
  • Need to find a balance between a thorough picture
    of traumatic experiences, but not triggering
    re-experiencing or overwhelming feelings/memories

Assessment of Trauma (cont.)
  • Some of the things I ask about might bring up
    upsetting or uncomfortable memories or feelings.
    Its important that I understand what youve
    experienced, but we dont need to rush things. As
    much as possible, Id like to know the kinds of
    things youve experienced, but I dont want to
    overwhelm you or have you re-live painful
    experiences right now. At any point if there is
    anything you dont want to talk about, just let
    me know. If you are starting to feel yourself
    becoming overwhelmed, please let me know right
    away. If I see you becoming very distressed, I
    may ask you to stop for a moment so we can check

Assessment of Trauma (cont.)
  • In particular, assess
  • Traumatic experiences and significant losses
  • Symptoms
  • Current safety
  • Strengths/resources

AssessmentTraumatic Experiences
  • Many people will not spontaneously report
    traumatic experiences you do need to ask
  • May not understand pertinence
  • May not remember details or any of it
  • May be uncomfortable/worry about stigma
  • May think you wont want to hear about it
  • May worry about becoming overwhelmed
  • Sometime the opposite problem
  • I just want to get it all out at once.

AssessmentTraumatic Experiences (cont.)
  • Be non-leading, but ask about various types of
    traumatic experiences
  • Childhood experiences (physical, emotional,
    sexual, neglect)
  • Adult interpersonal violence (domestic violence,
    assault, sexual assault, crimes)
  • Street life/drug trade/gangs
  • Accidents
  • Natural disasters
  • Combat/torture for military personnel

AssessmentTraumatic Experiences (cont.)
  • Examples of questions you could ask
  • How was discipline handled in your family when
    you were younger?
  • Follow-up on I was hit or We were beat with
    objects? Closed fist or open hand? Did it leave
    marks/injuries? Did you ever need medical
  • Have you ever had a very upsetting experience
    that might still be affecting you?
  • Have you ever experienced any very frightening
  • (continued)

AssessmentTraumatic Experiences (cont.)
  • Did anyone in your childhood ever approach you in
    a sexual way?
  • In early interviews, I avoid words like rape,
    molestation, sexual abuse unless the client uses
    them first
  • Have you had any unwanted sexual experiences?
  • Have you ever been in any accidents, fires, or
    other catastrophes?
  • Have you served in the military?
  • Combat experiences?
  • Job-related experiences as appropriate

AssessmentTraumatic Experiences (cont.)
  • Have you ever been the victim of a crime?
  • Have you been in any relationships as a teenager
    or adult where there was hitting, control issues,
    or sexual experiences that involved coercion?
  • Anything like that going on now?

Assessment Symptoms
  • Clinical interview
  • Can start broad (e.g., How does that experience
    still affect you now?) then move to more
  • Specifically ask about various symptom clusters
  • ALWAYS directly ask about self-injury, suicide,
    thoughts of harm to others - both past and
  • Assess substance abuse, past and current
  • Symptom checklists
  • Psychological testing

Assessment Safety
  • Living situation/Finances
  • Basic needs met?
  • Current relationships
  • Substance abuse
  • Eating disorders
  • Any children/vulnerable adults currently in

Assessment Safety (cont.)
  • Self-injurious behaviors
  • What is the function of the behavior?
  • Differentiate from suicide attempts
  • Past/current when was most recent episode?
  • Frequency
  • Triggers?

Assessment Safety (cont.)
  • Suicide Risk
  • Past attempts
  • What kept attempts from being successful?
  • Recent/current thoughts or impulses
  • Plans
  • How lethal?
  • How available? Ask about weapons, etc.
  • Current perturbation/agitation recent stressors
  • Family history

Assessment Safety (cont.)
  • Suicide Risk (cont.)
  • Hopelessness
  • Reasons to live
  • Barriers to acting on suicidal thoughts
  • Start talking about safety plans in initial
  • Is client safe right now?

Assessment Safety (cont.)
  • Risk to others
  • How do you handle it when you are really angry?
  • Ever hurt anyone intentionally or accidentally
    when you were angry or upset?
  • Ever any thoughts of wanting to hurt anyone?
  • If current thoughts of harm
  • Specific victim?
  • Plan to act on thoughts?
  • Means?
  • Know your states duty to warn statutes!

Assessment Strengths/Resources
  • For example
  • Social network primary relationships, friends,
    family, other important people
  • Personal strengths
  • Interests/hobbies
  • Religious/spiritual beliefs
  • Pets
  • Can point out where you see strengths as well

Assessment Additional considerations
  • Other things to assess along the way
  • Interpersonal functioning
  • Clients view of the trauma
  • Clients view of helpers/treatment
  • Hope/trust

Assessment Additional considerations (cont.)
  • Forensic settings
  • Limits to confidentiality
  • Consider likelihood of being able to engage in
    treatment at this point
  • Questions of malingering
  • Validity measures
  • Mandated reporting

Assessment (cont.)
  • Opportunity to begin therapeutic process
  • Offer the client hope
  • When possible, end the assessment with beginning
    treatment planning/some initial strategies the
    client can start right away

Stages of treatment
Treatment Planning
  • Psychotherapy for complex trauma should be based
    in a systematic (not laissez-faire) shared plan
    that utilizes effective treatment practices, and
    is organized around a careful assessment and a
    hierarchically ordered, planned sequence of
  • Treatment, like complex traumatic stress
    symptoms, is complex and multimodal (Courtois,
    Ford, Cloitre, 2009)

Treatment Planning (cont.)
  • Simple PTSD cognitive-behavioral therapy,
    exposure, cognitive reprocessing, EMDR, in some
    cases medication
  • Complex PTSD stage model, Dialectical Behavior
    Therapy (DBT), longer term psychotherapy
  • Limited empirical research (Courtois, et al.,
  • Some evidence that prolonged exposure not only
    wont work, but can make things worse
  • Initial focus on emotion regulation,
    dissociation, interpersonal problems

Treatment Planning (cont.)
  • Empowerment of client should be primary
  • Treatment planning should consider
  • Type and severity of trauma
  • Past/current traumatic experiences
  • Crisis vs. chronic distress
  • Current level of functioning
  • Safety issues
  • Clients resources
  • Substance abuse and other comorbid conditions

Treatment Planning (cont.)
  • A trauma-informed treatment approach can be
    integrated with any major theory of
    psychotherapy, with particular emphasis on the
    therapeutic relationship
  • R.I.C.H. Philosophy (Saakvitne, et al. 2000)

Targets of Treatment (Courtois, Ford, Cloitre,
  • Bodily and mental functioning
  • Attachment and trust
  • Inhibition of risky/ineffective behaviors
    improving problem-solving and life management
  • Managing dissociation integrating emotions and

Targets of Treatment (cont.)
  • Improved and integrated sense of self
  • Prevention of reenactments of trauma/revictimizati
    on of self and others
  • Overcoming dynamics of betrayal-trauma
  • Repaired world view/existential sense of life
    spiritual connection and meaning

  • Its never too late to be what you might have
  • -George Eliot

Stages of Trauma Treatment
  • Three main stages of treatment for ongoing
    effects of trauma (Judith Herman, Frank Putnam,
    Richard Kluft, Christine Curtois, etc.)
  • Safety and establish therapeutic relationship
  • Memory processing and mourning
  • Reconnection

Stage One Safety/Stabilization
  • Stabilize symptoms, including co-morbid
  • Development of motivation for treatment
  • Building collaborative alliance
  • Build hope and trust
  • Psychoeducation

Stage One Safety (cont.)
  • Helping client commit to self-care and
  • Teaching client to identify and manage strong
    emotions and impulses
  • Identification of clients adaptations to
    traumatic experiences, and determining which are
    useful and which arent

Stage One Safety (cont.)
  • Increasing clients ability to identify, avoid,
    and mange dangerous situations and relationships
  • Establish sobriety if substance abuse is an issue

Stage One Safety (cont.)
  • Client practices coping skills in sessions,
    eventually work towards implementing them between
  • In inpatient and acute settings, the focus is
    usually going to be on the safety stage
  • Build up support system/crisis management

Stage Two Remembrance and Mourning
  • Therapist as witness and ally, in whose presence
    the survivor can speak of the unspeakable
    (Herman, 1997)
  • Using safety skills while experiencing intense
  • Learning to feel, rather than detach from, the
    impact of trauma (Courtois, et al., 2009)
  • Careful pacing

Stage Two Remembrance and Mourning (cont.)
  • Telling the story in more detail, with the
  • Recalling forgotten memories/details
  • Some may never become clear
  • Mourning losses
  • New perspective of trauma
  • Loses its intensity and centrality

Stage Three Reconnection and Integration
  • Rejoining the world
  • Facing the future and confronting fears
  • Addressing unresolved developmental deficits and
  • Fine-tuning self-regulatory skills
  • Identity issues

Stage Three Reconnection (cont.)
  • Intimacy and relationships
  • Finding meaning in life
  • Spirituality
  • Experiencing pleasurable activities that are not
    contaminated by the traumatic experiences
  • Regaining a sense of mastery and control

  • and then the day came when the risk to remain
    tight in a bud was more painful than the risk it
    took to blossom.
  • -Anais Nin

Trauma Work in a Forensic Setting
  • Mandated treatment
  • Trauma-informed approach for facility
  • Limitations and uncertainty
  • Aftercare planning
  • Multi-disciplinary team
  • Coordinate other treatment modalities

Targeting treatment challenges
Targeting Treatment Challenges
  • Strategies for Safety
  • Managing Dissociative Experiences
  • Towards Better Emotional Regulation
  • Improving Interpersonal Functioning

Strategies for safety
  • Client contracted for safety.

Strategies for Safety (cont.)
  • A safety contract alone is not effective in
    stopping self-injurious or suicidal behaviors
    (e.g., Peterson, et al., 2011)
  • A significant number of people who attempt or
    complete suicide have no-suicide agreements in
    place at the time of the act (APA, 2003 Jamison,

Strategies for Safety (cont.)
  • Crisis Management
  • If someone is drowning, do you give them swimming
    lessons, or jump in and rescue them? (George
    Everly, PhD)
  • Triage deal with safety and other immediate
    needs first
  • Quick response to acute crisis seems to predict
    better outcomes
  • When possible, having an emergency plan in
    place beforehand is ideal

Strategies for Safety (cont.)
  • Get client on board for his own safety
  • Goal is for you to not get hurt anymore
  • Treatment goal to manage strong emotions without
    impulsive behaviors
  • Crises and safety concerns will likely interfere
    with progress in other areas
  • Needs to be a collaboration with client
  • Be sensitive to clients perceived need for
    SIB/suicide plans
  • Avoid a power struggle

  • Safety Plan
  • Pray
  • Call my sponsor/go to a meeting
  • Watch a movie
  • Write down things to talk about in our next
  • Read my therapy journal
  • Call Heathers voice mail (XXX-XXX-XXXX)
  • Talk to another resident
  • Tell staff member I need help to stay safe

Strategies for Safety (cont.)
  • If various treatment providers are involved,
    clear communication is crucial
  • Potential challenges in inpatient/correctional
  • Communication with family when appropriate

Strategies for Safety (cont.)
  • Additional interventions to consider
  • Increased frequency of sessions
  • Hospitalization
  • Medication changes

Strategies for Safety (cont.)
  • For chronically suicidal patients, longer-term
    work to improve affect regulation and coping
  • DBT shown to be effective for patients with BPD
    and self-harm/suicidal behaviors (e.g., Linehan,
    et al., 1993)

Safety in Inpatient Settings
  • Recommendations of the American Association of
    Suicidology include
  • Risk is elevated in the month after discharge
  • Suicide risk should be assessed prior to passes
    and discharge
  • Patients may not accurately report own suicidal
  • Patient, family, significant others should be
    educated about risk and steps to take
  • Consider overdose risk of medications
  • All clinical staff should have training in
    assessing and managing suicide risk, and
    promoting protective factors

After an Episode of SIB
  • Medical treatment, if needed, should be provided
    in a neutral, matter-of-fact way
  • Assess current safety/risk of further SIB or
  • Restrictions to freedom should be based on actual
    risk, not as a punishment
  • Avoid shaming
  • Engage client in collaboration to determine next
    steps of treatment

After an Episode of SIB (cont.)
  • With client, look at lessons learned
  • New ideas about triggers or warning signs?
  • What coping strategies worked, and which didnt?
  • What purpose is the SIB or suicide plan serving
    right now?

Managing Dissociative Experiences
Possible Outward Signs of Dissociation
  • Episodic confusion about date/place/situation
  • Unfocused gaze
  • Flat/quiet tone of voice
  • Emotionless discussion of painful material
  • Unexplained memory problems
  • May or may not be accompanied by self-injury

Reducing Risk of Dissociation
  • Managing/avoiding triggers
  • Manage sensations before they become overwhelming
  • Improve stress/anger management skills
  • Mindfulness
  • Relaxation
  • Engaging in other activities
  • Avoiding substance abuse
  • Consider potential risks of dissociation

Managing Triggers
  • Bolstering clients own self-protection
  • Variety of possible triggers
  • Places, people, sensations associated with trauma
  • Memories/painful feelings
  • Other peoples trauma stories
  • Upsetting material in books, movies, TV shows
  • Genuine vs. perceived danger

  • Present-focused awareness a sense of
    connectedness between oneself and the environment
  • Gives some distance between self and painful
  • Not the same as relaxation training an active
    approach to distract from overwhelming stimulus

Grounding (cont.)
  • Can help manage
  • Dissociation
  • Flashbacks
  • Intrusive thoughts
  • Disorientation
  • Overwhelming emotions
  • Urges to self-injure

Grounding (cont.)
  • Might take a lot of practice to develop grounding
    as a regular habit
  • Practicing in therapy sessions
  • Tracking in time log
  • Need other skills on board to tolerate sensations
    that are being avoided
  • Learn the triggers, notice the beginning signs of
    dissociation coming on

Grounding (cont.)
  • Wide variety of grounding strategies
  • Discuss options with client ahead of time, try
    clients preferences first
  • Often takes trial and error
  • Client may use different strategies in different
  • Consider all 5 senses
  • Goal is to focus attention to something in the
    present reality

Grounding (cont.)
  • Examples
  • Putting hands flat on table or arms of chair/feet
    flat on the floor, focusing on the sensations
  • Eye contact
  • Orient to time/date/place/situation
  • Holding/looking at familiar object
  • Getting up and moving around
  • Cold sensations (ice water, holding ice cube)
  • Holding/touching a pet
  • Distraction sm
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