csa treatment and ptg in adult clients: phase two mis -steps and correctives
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Diane Langberg, PhD Slides Available: Philip G. Monroe, PsyD www.globaltraumarecovery.org. CSA Treatment and PTG in Adult Clients: Phase Two Mis -steps and Correctives. Objectives. - PowerPoint PPT PresentationTRANSCRIPT
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CSA Treatment and PTG in Adult Clients:
Phase Two Mis-steps and Correctives
Diane Langberg, PhD Slides Available:Philip G. Monroe, PsyD
www.globaltraumarecovery.org
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Objectives
Identify common clinical mistakes in the treatment of adult survivors of child sexual abuse
Describe best practices during phase two of treatment
Understand common signs of posttraumatic growth and resilience within clients that appear stuck
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Who is stuck?
The client? Or the counselor?
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Common counselor reactions
“How can I get my client to…?”
“How can I get rid of my client?”
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Common counselor mistakes
Messianic rescuing (over-responsibility) Boundary crossings or Burnout
Demanding catharsis Forcing memory processing/exposure
Misunderstanding client resistance Irritated with client; push harder
Failure to manage “the hour” Encouraging dissociation
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CSA and Complex TraumaBrief Review
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Posttraumatic Stress Disorder (PTSD)
Re-experiencing: (1) Recurrent, intrusive distressing
recollection (may be repetitive play)
Recurrent, distressing dreams Acting or feeling as if event is
recurring Psychological distress on
exposure to cues Physiological reactivity on
exposure to cues Increased arousal (2)
Difficulty falling or staying asleep
Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response
Avoidance or Numbing (3) Efforts to avoid thoughts,
feelings, conversations associated with trauma
Efforts to avoid activities, places, or people associated with trauma
Inability to recall important aspect of trauma
Diminished interest or participation in significant activities
Feeling of detachment or estrangement from others
Restricted range of affect Sense of foreshortened
future
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Pays more attention to dissociative problems Derealization Depersonalization
Sees these symptoms as separate from re-experiencing and/or hypervigilance
Why important? Clients with this set of symptoms respond better
to mindfulness, cognitive restructuring, and DBT style interventions in addition to exposure therapies
Note: also “preschool” subtype
New: Dissociative subtype
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Common features of CSA clients
Betrayal trauma experiences leading to symptoms of complex PTSD
Hypervigilance Distorted sense of self
Addictions
Eating disorders Sleep disorders Shame
Dissociation Self-hatred Fear
Confusion Distrustful Distorted view of God
Control seeking Self-destructive behavior
Emotional numbness
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DESNOS alters a person’s
1. Ability to regulate affect and impulses
2. Attention and consciousness3. Self-perception4. Perception of the perpetrator5. Capacity for relationships6. Body and brain responses7. Perception of meaning and faith
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Complex Trauma v. Borderline
DESNOS BPD
Primary Affect:
Panic and pain Has capacity for positive affect
Relationships:
Passive, avoidance, re-victimization
Vacillates between desire and devaluation
Dissociation: Present, chronic
Transient, if present
Cognitive Focus:
Fear, avoidance Idealized identity
Self: Consistent self loathing
Confused
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Phase one: Safety & stabilization
Foundation for all treatment Longest phase and vital to positive
outcomes Features
Therapeutic alliance building Education about the nature of trauma Managing vs. reacting to symptoms
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Phase two: Processing memories
Memory work done in concert with phase one skills Focus: grief, loss, shame, anger rather
than anxiety Context: the tendency to leave
(dissociate from) the pain Goal: Small amounts of memory work
with frequent self-care and stabilization
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Phase two interventions
Exposure Stress inoculation
OR…? Interpersonal/dynamic interventions
“Therapy that emphasized relaxation, relationships, affect, and meaning-making appeared to be more helpful than therapy that emphasized exposure to trauma reminders.”
D’Andrea & Pole
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Revisiting the experience of CSAPointing to Corrective Experiences in Therapy
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Common trauma experiences
Intense fear, paralysis/helplessness, inability to effect any change, threat of annihilation, leading to experience of,
Loss of voice, control, connection, and meaning, resulting in,
Disorganized physical, cognitive, and emotional response system thereby increasing,
Relational pain, distrust, self-contempt, overwhelming anxiety, evidenced as,
Running from the past, afraid of the future
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Correctives
Proceed little by little, without force Focus on this step over ultimate goal Embrace repetition Embrace rest; Identify as NOT failure Remember: Return to
safety/stabilization throughout treatment
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Dynamic techniques
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Additional techniques
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The ARC model
Attachment Self-RegulationCompetency
Kinniburgh, Blaustein, Spinazzola, Psychiatric Annals, May 2005
http://psychrights.org/research/Digest/CriticalThinkRxCites/kinniburgh.pdf
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Attachment-oriented interventions
Predictable routines in therapy Support in-the-moment affect
regulation Watch your language Affirm strengths (find them in
surprising areas!)
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Self-regulation interventions
Expand awareness of affect Connect affect with body sensations Normalize reactions Self-expression through nonverbal
means Encourage kinetic regulation of
affect Connect affect with historical events Teach grounding techniques
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Competency interventions
Identify interests/goals Encourage independent choices Learning relational safety/danger
cues Encourage connections to others Identify and affirm strengths Teach self-awareness self-care Construct solutions to problems
together Review outcomes together
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Two Spiritual DisciplinesMeditation and Solitude as Emotion Regulation Interventions
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Mindfulness
Mindfulness is about waking up from a life on automatic pilot, becoming keenly aware and sensitive to our experiences – both internal and external
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Meditation as spiritual discipline
On creation On Scripture On Christ
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Solitude as spiritual discipline
Goal: having a sanctuary of the heart so we are not controlled by people or noise
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Posttraumatic Growth & ResilienceExploring Movement in Therapy with Adult Survivors
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Posttraumatic growth (PTG)
Retrospective perceptions of positive psychological changes after trauma Not just bouncing back but growing
beyond pre-trauma adaptive capacities Connotes positive change in identity
and capacities post trauma
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Related: Posttraumatic growth
Changes seen in Identity perception (perceived new possibilities) Capacity awareness (strength perception) Appreciation of life and faith (values)
PTSD
PTG
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Redefining PTG
Holding symptoms and strengths together
Success during phase two includes Ability to say no Ability to have hope Not reduction of triggers and trauma
reactions
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Ponder this:
Why do most recover from traumatic experiences and do not go on to develop PTSD? Intrinsic capacity? Community supports? Prior experiences?
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re·sil·ience the power or ability to return to the
original form, position, etc., after being bent, compressed, or stretched; elasticity.
ability to recover readily from illness, depression, adversity, or the like; buoyancy.
http://dictionary.reference.com/browse/resilience
Resilience
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Better definition
the ability to recover readily from illness, depression, and adversity Adapting? Thriving?
Problem with this definition? What does resilience look like in an ongoing storm?
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A biblical image of resilience? Joseph?
What you intended for evil… Jeremiah?
I will never forget this awful time as I grieve…yet I still dare to hope
Esther? If I perish, I perish
Paul? Though outwardly we are wasting away,
yet inwardly we are being renewed
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Resilient individuals?
Optimism (realistic optimism) Cognitive flexibility Personal moral compass Role models Face and reframe fears Active coping mechanisms Attending to physical wellbeing Nurture social network Recognize strengths
Dennis Charney
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Different in other cultures?
YES! Gratitude Pride in culture and ethnicity Appreciation of human differences Karma
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Biology of resilience?
Fear/Reward circuits
Neuropeptide Y?
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Threats to resilience
Passive acceptance of threats Loss of social support and moral
foundation Rumination
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Possible ways to improve it CBT Narrative work Faith engagement Mindfulness Social Support Self-reflection Physical training Sleep
Can you learn resilience?
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Trauma work supporting resilience
Phase 1: Interventions avoid disrupting intact protective factors (meaning, networks, structures)
Phase 2: Re-establish weak social resources (family re-unification, vocational training)
Phase 3: Targeted trauma recovery intervention
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Individual or communal?
Community’s inherent capacity, hope, and faith to withstand major trauma, overcome adversity, and to prevail, with increased resources, competence and connectedness
Judith Landau
Individual resilience promoted by communityand
Community expression of resilience
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Predicting community resilience
Active use of family/community resilience stories
Active engagement of transcendence Organizational strength
Flexibility Connected Available resources
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Improving community resilience
Identify agents of change Identify local values, resources,
wisdom Reinforce open dialogue, to Identify tangible assets (community
genogram) Re-establish daily patterns, rituals Re-connectedness
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Community responses
Use of drama to capture lament To validate, narrate To spark
conversations Local
conversations where all parties have voice Goal identification Resource allocation
Support groups