making sense of the complexities of trauma heather hartman-hall, ph.d. 2012
TRANSCRIPT
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 syndrome.
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
PREVALENCE AND ETIOLOGY
Prevalence
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 period
Prevalence (cont.)
PTSD is still likely underdiagnosed, particularly in several demographic groups (e.g., Brunet, 2007)
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) >26K non-institutionalized US adults in 5 states
8.7% reported 5 or more ACEsSexual abuse: 17.2% for women, 6.7% for menACEs 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 1990’s):
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 PTSD:12.3% 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 Center 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 <1% in nonclinical population
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 PTSD
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 males 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 child’s 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 child…is 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 don’t result in mental illness DSM-IV-TR: “severity, duration, and proximity
of an individual’s 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 evolution
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 functioning
Fight or Flight Response (cont.)
“Fight or Flight” represents a complex stress response 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 individual’s 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 doesn’t 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 stimuli.
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 enjoyed.
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
trauma 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 disorder 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, 1997)
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
disorders
PTSD
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 others.
2.The person's response involved intense fear, helplessness, or horror. (In children, may be expressed instead by disorganized or agitated behavior)
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
trauma
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 experience
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 distress
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
couldn’t 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 DISORDER
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 contexts
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, 2009): Extensive symptom overlap with other disorders Reliability and validity of diagnosis in literature
has been inconsistent No reference to widely-accepted role of early
trauma
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, 2009)
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 others
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 trauma
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, cont.)
Alterations in self-perception Including shame, guilt, feeling of differentness from
others, helplessness Alterations in perception of perpetrator
Including revenge fantasies, idealization, rationalizations
Alterations in relations with others Including isolation, distrust, failure to self-protect
Alterations in systems of meaning Including loss of faith, hopelessness
PROPOSED CHANGES FOR DSM-5
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-5:Trauma- 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 proposed 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 5:
www.dsm5.org
SELF-INJURIOUS AND SUICIDAL BEHAVIORS
Self-Harm
• 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 disorders
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 different 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 dissociating
SIB (cont.)Many possible reasons for SIB… to manage intense feelings/distress physical pain seen as preferable to emotional pain individual feels he or she deserves to be punished 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 control
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 al.1999)
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 client’s 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 client’s ideas
about why she/he is engaging in SIB
Suicide
Chronic vs. Acute Direct communication is crucial Should be assessed regularly and at critical
points Family/significant other involvement Seasonal variation
PART TWO:
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 Client’s 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 COMPONENT
Therapeutic Relationship
Trauma can disrupt many aspects of interpersonal functioning:
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 relationships 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 client Responsibilities and inherent power differences
should be acknowledged Seek to use power effectively on client’s behalf Encourage client’s 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:RespectInformationConnectionHope
Respect Collaboration Confidentiality Sensitive language Assuming client’s point of view is valid Being fully present Humility Honesty
Information 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
Connection Genuine empathy and positive regard Clear boundaries Being honest Sitting with painful content and emotions Recognition that the work affects both of you
Hope You can have hope for the client even when
she doesn’t 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 isn’t dead – it isn’t 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. It’s important that I understand what you’ve experienced, but we don’t need to rush things. As much as possible, I’d like to know the kinds of things you’ve experienced, but I don’t want to overwhelm you or have you re-live painful experiences right now. At any point if there is anything you don’t 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 in. ”
Assessment of Trauma (cont.)
In particular, assess:Traumatic experiences and significant lossesSymptomsCurrent safetyStrengths/resources
Assessment:Traumatic 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 won’t want to hear about it May worry about becoming overwhelmed
Sometime the opposite problem – “I just want to get it all out at once.”
Assessment:Traumatic 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
Assessment:Traumatic 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 attention?
Have you ever had a very upsetting experience that might still be affecting you?
Have you ever experienced any very frightening events?
(continued…)
Assessment:Traumatic 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
Assessment:Traumatic 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 specific Specifically ask about various symptom clusters ALWAYS directly ask about self-injury, suicide,
thoughts of harm to others - both past and current 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
danger?
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
ASK DIRECTLY! 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 session
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 state’s 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 Client’s view of the trauma Client’s 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 interventions”
“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., 2009)
Some evidence that prolonged exposure not only won’t 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 Client’s 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, 2009)
Bodily and mental functioning Attachment and trust Inhibition of risky/ineffective behaviors;
improving problem-solving and life management skills
Managing dissociation; integrating emotions and knowledge
Targets of Treatment (cont.)
Improved and integrated sense of self Prevention of reenactments of
trauma/revictimization of self and others Overcoming dynamics of betrayal-trauma Repaired world view/existential sense of life;
spiritual connection and meaning
“It’s never too late to be what you might have been.”
-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.)
1.Safety and establish therapeutic relationship
2.Memory processing and mourning
3.Reconnection
Stage One: Safety/Stabilization
Stabilize symptoms, including co-morbidDevelopment of motivation for treatmentBuilding collaborative allianceBuild hope and trustPsychoeducation
Stage One: Safety (cont.)
Helping client commit to self-care and self-protection
Teaching client to identify and manage strong emotions and impulses
Identification of client’s adaptations to traumatic experiences, and determining which are useful and which aren’t
Stage One: Safety (cont.)
Increasing client’s 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 sessions
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 emotions
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 emotions
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 fixations 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
TREATING TRAUMA IN A FORENSIC SETTING
Trauma Work in a Forensic Setting
“Mandated” treatmentTrauma-informed approach for facilityLimitations and uncertaintyAftercare planningMulti-disciplinary teamCoordinate 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, 1999)
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 client’s perceived need for SIB/suicide plans Avoid a power struggle
Safety Plan1.Pray2.Call my sponsor/go to a meeting
(XXX-XXX-XXXX)3.Watch a movie4.Write down things to talk about in our next session5.Read my therapy journal6.Call Heather’s voice mail (XXX-XXX-XXXX)7.Talk to another resident8.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
settings 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 skills DBT shown to be effective for patients with BPD
and self-harm/suicidal behaviors (e.g., Linehan, et al., 1993)
Safety in Inpatient SettingsRecommendations of the American Association of Suicidology include:Risk is elevated in the month after dischargeSuicide risk should be assessed prior to passes and dischargePatients may not accurately report own suicidal impulsesPatient, family, significant others should be educated about risk and steps to takeConsider overdose risk of medicationsAll 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 suicide 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 didn’t? 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 client’s own self-protection Variety of possible triggers
Places, people, sensations associated with trauma
Memories/painful feelings Other people’s trauma stories Upsetting material in books, movies, TV shows
Genuine vs. perceived danger
Grounding
“Present-focused awareness” – a sense of connectedness between oneself and the environment
Gives some distance between self and painful feelings/thoughts/memories
Not the same as relaxation training – an active approach to distract from overwhelming stimulus (Najavits)
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
client’s preferences first Often takes trial and error Client may use different strategies in different
situations 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 – small talk, name things in a category,
describe a familiar activity in great detail
TOWARDS BETTER EMOTIONAL REGULATION
Towards Better Emotional Regulation
Help client learn to not fear emotions Many maladaptive behaviors are likely
avoidance/numbing strategies to not feel emotions
Learning connections between experiences, emotions, memories, and behavior
Need to build coping and relaxation skills
Towards Better Emotional Regulation (cont.)
Discuss range of emotional reactions Early signs Improve emotional vocabulary Rating scale Where is the “danger zone”?
“Titrate” emotions to increase ability to tolerate a little at a time
Increase ability to more accurately “read” emotions in others
“No feeling is final”
-Rainer Maria Rilke
IMPROVING INTERPERSONAL FUNCTIONING
Improving Interpersonal Functioning
Can use the therapeutic relationship (individual or group) to identify interpersonal patterns “Laboratory” – what works, what doesn’t?
Addressing manipulative behavior (Saakvitne, 2000)
Opportunity to explore direct vs. indirect communication of needs
Look at impact on relationships Avoid simply labeling the behavior
Improving Interpersonal Functioning (cont.)
Trust is likely to be a struggle Focus of treatment
Understanding safe vs. hurtful relationships Friends/family may need education about
trauma and treatment
Improving Interpersonal Functioning (cont.)
Group therapy/support group might be considered
Learning about relationships Different types of relationships Levels of trust/intimacy Boundaries Assertiveness Social skills
ADDITIONAL TOOLS
Group Therapy
Can be more efficient and cost effective Can be very useful in building interpersonal
skills, reducing isolation, normalizing reactions
Group members can offer a different kind of support than therapist can
Sometimes challenging/confronting by group members is tolerated better
Group Therapy (cont.)
Group therapy “offers a direct antidote to the isolation and social disengagement that characterize” trauma disorders…a group experience where “safety, respect, honesty, privacy, and dedication to recovery are the norm provides unique opportunities for trauma survivors to see and hear, and to be seen and heard by, other persons who also struggle” (Ford, Fallot, & Harris, 2009)
Group Therapy (cont.)
Cautions in group work on trauma: Some basic interpersonal skills need to be on
board (consider pre-treatment modalities) More intense, detailed info about traumatic
experiences may not be appropriate Potentially triggering of dissociation, impulsive
behavior, etc. Potentially traumatizing to other group members
Possible “peer-contagion” effect of self-injury/eating disorders
Group Therapy (cont.)
Exposure to trauma material in group therapy In some research not effective and led to higher
dropout Other research showed more success when
preparation and support between group sessions were included
Key may be that members don’t feel too overwhelmed and feel a sense of control Graduated exposure
Eye Movement Desensitization and Reprocessing (EMDR)
Developed by Francine Shapiro in the late 1980’s
Sensory experiences, cognitions, and emotions associated with traumatic event are processed with exposure and dual-attention stimuli (e.g., eye movements)
EMDR (cont.)
Literature is mixed about EMDR efficacy; some say exposure may be the key Ponniah & Hollon (2009): EMDR reduces PTSD
symptoms to a greater extent than wait-list (but fewer efficacy studies than other treatments)
Seidler & Wagner (2006): no difference between efficacy of trauma-focused CBT and EMDR
Devilly, et al. (1998): no difference between EMDR (with or without eye movements) and standard psychiatric support in veterans
EMDR (cont.)
Davidson & Parker (2001): EMDR was better than no treatment or treatments that did not include exposure; was similar to other therapies that included exposure
van der Kolk, et al. (2007): EMDR improved symptoms better than fluoxetine and pill placebo
Wilson et al. (1997): EMDR produced substantial symptom improvement in PTSD; benefits maintained at 15-month follow-up
EMDR (cont.)
Research that has yielded evidence of improvement has focused on PTSD rather than complex syndrome Particularly single-event PTSD
People with CPTSD usually wouldn’t meet the “readiness criteria for standard EMDR treatment” (Korn & Leeds, 2002)
EMDR (cont.)
Shapiro & Maxfield (2002): “for clients who have substantial impairments related to child abuse or neglect, treatment will not proceed as quickly or as smoothly…such clients often require lengthy” preparation and stabilization prior to the reprocessing stages
Hypnosis Should have specialized training Stabilization/management of symptoms When used appropriately, can be very
useful for anxiety, pain management, substance abuse
NOT advisable to use for “recovering” memories
Being hypnotized could affect ability to testify in court if abuse charges ever went to trial
Creative Expression Art, music, dance/movement, drama, writing Should be provided by a trained practitioner Client should be interested and willing Should be used in conjunction with other
treatment approaches
Creative Expression (cont.)
Relaxation Improving interpersonal/social skills Improving communication/self-expression Increased self-esteem/self-efficacy Increased awareness of bodily
sensations/emotional experiences Decreased shame Might still feel like a “safe” domain
Creative Expression (cont.)
Possible benefits of nonverbal interventions (Johnson, 2000) Access to nonlexical or implicit memory Creativity and spontaneity to counteract
hopelessness/damaged self-image Replace/manage impulses Increased balance in daily living Positive experiences
Creative Expression (cont.)
Especially indicated for Children Clients who demonstrate preference for creative
outlets Difficulties in verbal expression Alexithymia Intellectualization
Journaling Multiple possible uses
Tracking time, moods, activities, triggers Increasing self-expression Containing thoughts and emotions Venting feelings Labeling/describing feelings and experiences “Transitional object” between sessions Practicing boundaries around privacy Communication tool for therapy/other providers Therapy “homework”
Journaling (cont.)
CAUTION!!!
Journaling can become overwhelming and is contraindicated in some cases.
Journaling (cont.)
Journaling can follow steps similar to the stages of trauma treatment Vermilyea (2000) recommends teaching trauma
survivors to start with surface level, “here and now” observations Client instructed to STOP right away if getting into
more upsetting material or distress is increasing Start with time-limited assignments (write for 5
minutes, then stop) to practice Can slowly build up to more emotional material
Leisure Skills
Client may need education about the importance of leisure
Opportunity for positive experiences (ideally with other people)
“Normal” development may have been derailed, may need to learn very basic skills
Work towards balance in life, and identity Learn to enjoy the simple things!
Improving Problem-Solving
Teaching/practicing skills Focus in on actual problem – one at a time! Get the facts straight
Sort out assumptions/distorted thinking Consider alternative courses of action
Predict likely outcomes, pros and cons If unsure, determine whether action is needed at
this point Tolerating trial and error, making mistakes
Improving Problem-Solving (cont.)
Recognizing impulse vs. intentional action Will this action take me in the direction I’ve been
trying to go? Reinforce crisis plans Rule of thumb: No major decisions when
feeling overwhelmed!
“You have brains in your head. You have feet in your shoes. You can steer
yourself any direction you choose.”
- Dr. Seuss
Oh, The Places You’ll Go!
A NEW SENSE OF SELF
A New Sense of Self
Repairing damaged self-image Victim? Survivor? Perpetrator as well? Broader view of self and life experiences Letting go of the tough question: “WHY?”
Understanding views of abuser and/or “bystanders” How do these play out in other relationships?
Exploring world view Is a new perspective possible?
“I am not afraid of storms, for I’m learning how to sail my ship.”
― Louisa May Alcott
PART THREE:
What About You?
VICARIOUS TRAUMATIZATION
Vicarious Traumatization (VT)
“To study psychological trauma is to come face to face both with human vulnerability in the natural world and with the capacity for evil in human nature. To study psychological trauma means bearing witness to horrible events.”
Judith Herman, Trauma and Recovery
VT (cont.)
“VT is the transformation or change in a helper’s inner experience as a result of responsibility for and empathic engagement with traumatized clients” (Saakvitne, et al. 2000)
VT – Possible Effects
VT can affect helpers in a variety of domains
-Identity -Physical health
-Hopefulness/optimism -Work performance
-Empathy -Sense of safety
-Boundaries -Enjoyment of life
-Worldview -Sense of control
-Spirituality
-Self-efficacy …etc.
VT – Risk Factors
Risk Factors for treatment providers
-Lack of training or knowledge
-Isolation/lack of social support
-Imbalanced work load
-Unclear boundaries
-Sense of responsibility for the client
-Helper’s own trauma history
VT – Possible Warning Signs
-Reduced hope
-Trouble concentrating/ making decisions
-Increased sensitivity to disturbing stimuli
-Increased fearfulness
-Increased isolation
-Feeling disconnected from others
-Changes in eating, sleeping, interests, energy,
sex drive
VT – Possible Warning Signs (cont.)
-Chronic illness/fatigue
-Irritability/low frustration tolerance
-Changed attitude towards work/clients
-Not being able to stop thinking about work off hours
-Dreams/nightmares about work
-Emotional numbing
-Loosening of boundaries
“Although the world is full of suffering, it is also full of the overcoming of it.”
-Helen Keller
SELF-CARE FOR THE CLINICIAN
Self-Care as an Ethical Issue
Do no harm VT increases risk of mistakes, lack of investment,
boundary crossings Clinicians are responsible for monitoring
ourselves for burnout or other forms of VT that might affect our clinical work
We are responsible for monitoring ourselves and our colleagues
Consider self-care an ethical responsibility and part of clinical skill set
Therapist Self-Care
“The single most important factor in the success or failure of trauma work is the attention paid to the experience and needs of the helper” (Saakvitne, et al., 2000)
Therapist Self-Care (cont.)
Be reasonable in your expectations Of yourself Of the client Of the work Of your colleagues/workplace
Take potential signs of burn out seriously! Attend carefully to therapeutic boundaries
Therapist Self-Care (cont.)
Don’t subject yourself to unnecessary trauma Avoid becoming isolated and disconnected
from others Nurture your personal relationships Colleague support is critical
R.I.C.H. for each other! Informal and/or formal
Consultation Supervision group
Therapist Self-Care (cont.)
Consider:Physical self-carePsychological self-careEmotional self-careProfessional self-careSpiritual self-care
(Saakvitne, et al. 2000)
Therapist Self-Care (cont.)
You are a valuable resource to your clients!
Honestly evaluate your limitsNotice your reactions to clientsMaintain appropriate boundariesConsult and get supportTake good care of yourself
“You, yourself, as much as anybody in the entire universe, deserve your love
and affection.”
-Buddha
Make a commitment to self-care.
TAKE-HOME POINTS
Take-Home Points
Screening for trauma symptoms should be routine
Careful assessment of trauma symptoms, and understanding the variety of ways trauma can present will help with diagnostic accuracy and treatment planning
Cultural and other individual factors must be considered in assessing trauma
Stage model of trauma treatment
Take-Home Points (cont.)
Current symptoms may reflect behaviors that helped the client endure the trauma
Early attachment experiences contribute to vulnerability to trauma later in life
Complex Trauma Syndrome as a useful conceptualization of the client’s presentation
Importance of collaborating with client to maintain safety and manage crises
Take-Home Points (cont.)
Solid boundaries and a healthy therapeutic connection can be in themselves healing
Understand the resources/limits in your setting; adapt trauma work accordingly
We are all vulnerable to vicarious traumatization and burn out
Self-care is critical!
ADDITIONAL RESOURCES
Additional Resources
Sidran Institute: www.sidran.org
International Society for Traumatic Stress Studies: www.istss.org
Substance Abuse and Mental Health Services Administration (SAMHSA) National Center for Trauma-Informed Care: www.samhsa.gov/nctic
Additional Resources (cont.)
American Association of Suicidology: www.suicidology.org
Seeking Safety: www.seekingsafety.org
National Alliance for the Mentally Ill: nami.org
Additional Resources (cont.)
Trauma and Recovery (1997), Judith Herman, Basic Books
Trauma Recovery and Empowerment: A Clinician's Guide for Working with Women in Groups (1998) Maxine Harris, The Free Press
Seeking Safety (2002), Lisa Najavatis, The Guilford Press
Additional Resources (cont.)
Growing Beyond Survival (2000), Elizabeth Vermilyea, The Sidran Press
Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide (2009), Courtois & Ford (Eds.), The Guilford Press
“Be the change you wish to see in the world.”
-Mahatma Gandhi
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Tzkseminars Keith Hannan, Ph.D., consultant to juvenile facilities on “Conduct
Disorder.” Dr. Hannan also does a Friday afternoon webinar series on juvenile delinquency
David Shapiro, Ph.D., the father of clinical forensic psychology on the “Fundamentals of Forensic Assessment.” Learn forensic assessment from the best.
David McDuff, M.D., consultant to the Baltimore Orioles and Ravens on “Sports Psychiatry.” This webinar is appropriate for all mental health clinicians interested in working with athletes.
Heather Hartman-Hall, Ph.D., internship training director and talented clinician on “Making Sense of the Complexities of Trauma.”
Scott Hannan, Ph.D., seen on the show “Hoarders,” on “Cognitive Behavioral Therapy for School Refusal.”
Michael Herkov, Ph.D., of the University of Florida, on “The Ten Most Common Ethical Errors.”
New speakers coming soon!!!