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 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


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


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”


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


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


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


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


4 proposed symptom clusters Intrusion symptoms Avoidance Negative alterations in cognitions and mood Alterations in arousal and reactivity


Subtypes PTSD in Preschool Children PTSD with Prominent Dissociative Symptoms

meets criteria for PTSD AND either depersonalization and/or derealization


Dissociative Disorders Depersonalization-Derealization Disorder Dissociative Amnesia Dissociative Identity Disorder Dissociative Disorder Not Elsewhere Classified


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


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)


Appropriate, solid boundaries

Experiencing first-hand how the client behaves in relationships Informative for the therapist Can provide feedback to client


Providing a consistent presence

Tolerating the pain – starting to help client develop affect regulation

Another opportunity for “secure attachment”


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


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


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…)


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


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


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?


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


Increasing client’s ability to identify, avoid, and mange dangerous situations and relationships

Establish sobriety if substance abuse is an issue


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)


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


If various treatment providers are involved, clear communication is crucial Potential challenges in inpatient/correctional

settings Communication with family when appropriate


Additional interventions to consider Increased frequency of sessions Hospitalization Medication changes


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)


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


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


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


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


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


Consider:Physical self-carePsychological self-careEmotional self-careProfessional self-careSpiritual self-care

(Saakvitne, et al. 2000)


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


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


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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Contact

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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!!!

Documents

Making Sense of the Complexities of Trauma