Treating Trauma: Changes in Diagnosis and Treatment: The DM-

ID and Interactive-Behavioral Therapy

Daniel J. Tomasulo, Ph.D., TEP, MFA

tomasulo@att.net

TheHealingCrowd.Com

INCIDENCE OF SEXUAL ABUSE IN GENERAL POPULATION:

33% of Females 25% of Males

In Developmentally Disabled Population:

83 % of Females

32% of Males

Reiss et. al. (1982) Proposed the concept of Diagnostic Over Shadowing, suggesting that the condition of intellectual disability decreases the diagnostic significance of a co-existing

psychiatric disorder.      

Given this proposal, symptoms of PTSD may be overlooked and be thought of as a manifestation of the condition of an intellectual disability.

CognitiveTrouble concentrating

Difficulty making decisionsBlaming others

Memories of other eventsDifficulty talking about the event

Need to talkConfusion

Poor memory- including difficulty in remembering aspects of the trauma.

SYMPTOMS THAT MAY BE PRESENT IN PEOPLE WHO HAVE PTSD

BehavioralExpending tremendous energy and attention

AgitationTrouble sleeping

HeadachesSpontaneously CryingRecurring NightmaresPhysical ExhaustionStomach problems

Not being able to face certain aspects of the trauma, and avoiding activities, places, or even people that

remind you of the event.

Our Research for DM-ID Suggests that:

Symptoms for PTSD for Intellectually Disabled Adults are more likely to manifest in ways similar to how children display these symptoms

People with Dual Diagnosis may not display these

symptoms, or may display other symptoms not seen in

the general population.

Following exposure to a traumatic event three

categories of symptom’s are displayed.

PERPETRATORS ARE MOST OFTEN NOT STRANGERS.

PERPETRATORS:

FAMILY MEMBERS 30%

FRIENDS AND ACQUAINTANCES 30%

SERVICE PROVIDERS 29%

Role Reaction and the Trauma of Betrayal• Victim

• Offender• (Slot Rattling)

• Role Development– Self Protector

Teaching Vs. Facilitation

Social Skill Training Model IBT Model

IBT Interactive –Behavioral Therapy

Action Process In Group Work: 4 Stage Modification

• Orientation• Warm-up and

Sharing• Enactment• Affirmation

1. Re-experiencing the event via intrusive memories, nightmares, psychological distress and/or physiological activity. In people with DD this may manifest in a way similar to how children respond, such as Traumatic-Specific Reenactment2. Persistent efforts to avoid anything associated with the trauma such as external things , people and places. For people with DD the avoidance of concrete external stimuli as well as thoughts and sometimes the complete inability to recall key aspects of the event.3. Hyperarousal, sleep difficulties, irritability, anger and difficulty concentrating. Many of these symptoms may be masked with people with Dual Diagnosis.

Charlot’s (1998) research provides descriptions of symptoms which may vary from those more commonly seen in the non-disabled population ---for example, people with intellectual disabilities suffering from depression frequently talk to themselves out loud, rather than ruminate silently. This recent literature suggests that there may be variation in the typical symptom picture of a given disorder, but that the experience of the nature of the disorder, e.g., depression, anxiety, even psychoses, is inherently the same.

Mueser (1998) examined the frequency of trauma and PTST among 275 patients

with severe mental illness.

98% had been exposed to traumatic events

43% met the diagnostic criterial for PTSD

However only 2% had the diagnosis in their chart

Ruth Ryan (1994), who has forged new ground in our understanding of posttraumatic stress

disorder in people with developmental disabilities, has recommended a six-point treatment protocol for survivors with PTSD

(from sexual or other trauma), including medication, psychotherapy, support staff training, and environmental supports.

Based on statistics and experience the psychotherapy treatment paradigm is to start with the

assumption that every person with intellectual disability has a life

complicated by symptoms of PTSD

What You See in Others

You Strengthen in Yourself

The Course in Miracles in Miracles

Compassion &

Kindness

Long Term Effects of Trauma

• Generalized hyperarousal and difficulty in modulating arousal

• Alterations in neurobiological processes from this hyperarousal may result in high levels of cortisol which can inhibit serotonin, norepinephrine and dopamine which can cause difficulties in stimulus discrimination such as:– Problems with attention and concentration– Dissociation– Somatization

• Assessment of Role Analysis– Physical– Social– Psychodramatic

• Trust and Safety Issues• Begin to Identify Therapeutic Factors• Validate Participation

Orientation Stage, continued.

Warm-up and Sharing Stage.

• Move to Vertical Self-Disclosure• Building Cohesion• Selecting a Protagonist

– Self Selection– Facilitator Selection– Group Selection

Warm-up continues

• Building Support for the Protagonist• Concretize Issues• Invite Participation• Transitional Stage to Action• Continue Affirming Therapeutic Factors• Cognitive Networking Continues• (This can be painstakingly slow.)

• Assess Support for the Protagonist• Build Support• Select the Double

– Facilitator demonstrates– Facilitator Chooses– Protagonist Chooses– Volunteer– Self (Role Prescription)

• Assess Participation

THE DOUBLE HAS THREE PURPOSES:

1. Providing emotional support

2. Giving emotional expression

3. Reorganize perceptions.

(Additional features)• 247 Ways to Use an Empty Chair• Role Reversal• Use of Auxiliaries• Affirming the Protagonist• Encounters (conflict resolution)• Representational Dramas

Affirmation Stage

• Validate Each Member’s Participation

• Therapeutic Factors Affirmed

• Teach Members to Affirm Each Other

ESTABLISHING THE FRAME THE THERAPEUTIC ALLIANCE SUPPORT BEFORE DISCLOSURE SUPPORT BEFORE CONFRONTATION SAFETY FIRST THERAPIST AS MODEL PARTICIPANT THE RULES: SAFETY AND CONFIDENTIALITY ATTENDING TO THE PROCESS A GOOD LEADER FOLLOWS THEY DID IT, NOT YOU

THERAPEUTIC CONSIDERATIONS

Facilitation as Process• Correction of the family

– speaking up– being listened to– safe place to experiment

• Empowerment– Decisions during the process– Control of circumstances– Reframe resistance

IBT RESEARCH

• More than a dozen studies have validated process & outcome using the IBT. Here are three studies focused on:

1. Interaction

2. Therapeutic Factors

3. Global Assessment of Functioning

Figure 2

0

10

20

30

40

50

60

70

80

0 2 4 6 8 10 12 14

group sessions

percent of interactive

participation

members leaders

Reliability Ratings on Therapeutic Factors

(Part of a Study by Ellen Keller, PsyD.)

1. Acceptance/cohesion .86

2. Universality .90

3. Altruism .76

4. Installation of hope .86

5. Guidance 1.00

6. Vicarious Learning/Modeling .45

7. Catharsis .96

8. Imparting of information .91

An IBT Outcome StudyP = 0.046

• Linda Daniels, PSY.D.(J. of Psychotherapy Practice & Research 1998; 7:167-176)

• IBT Treatment Vs

• Waiting List(20 subjects each)

• 16 sessions(50 minutes each)

Global Assessment of Functioning

TREATMENT

Mean SD43.88 (pre)10.950.83 (post)11.6

WAIT LIST

Mean SD43.94 (pre)8.5845.13 (post)9.36

Adaptation of Diagnostic Criteria for PTSDFrom the Forthcoming Book:Diagnostic Manual for People with Intellectual Disabilities

Fletcher, R., Loschen, E., Stavrakaki, C., & First, M. (2007). Diagnostic Manual-Intellectual Disability (DM-ID): A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability. Kingston, NY: NADD Press.

Chapter on Posttraumatic Stress DisorderByDaniel J. Tomasulo, Ph.D., TEP, MFANancy J. Razza, Ph.D., CGP

A publication from the American Psychiatric Association andNational Association for Dual Diagnosis

DM-ID

DSM-IV-TR Criteria for Posttraumatic Stress Disorder

Adapted Criteria For Individuals with Mild-Moderate ID

Adapted Criteria For Individuals with Severe/ Profound ID

A. The person has been exposed to a traumatic event…

A. No adaptation.

A. No .adaptation.

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

(1)No adaptation.NOTE: In assessing for traumatic exposure in people with ID, take note that events such as developmental milestones, residential placement, and even adult, consensual sexual experiences have led to posttraumatic reactions in some individuals with ID. It appears that the range of potentially traumatizing events is greater for individuals with a lower developmental age, though no hard data is available that would merit clear-cut distinctions for criteria between Mild-Moderate ID and Severe/Profound ID.

…in which both of the following were present:

• developmental milestones, residential placement, and even adult, consensual sexual experiences have led to posttraumatic reactions in some individuals with ID. It appears that the range of potentially traumatizing events is greater for individuals with a lower developmental age,

(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

(1)No adaptation. There is considerable evidence, however, of increased likelihood of disorganized or agitated behavior in individuals with greater levels of impairment.

(1)Disorganized or agitated behavior appears to be quite common for individuals with a lower developmental age.

• There is considerable evidence, however, of increased likelihood of disorganized or agitated behavior in individuals with greater levels of impairment

(Shameless Self Promotion)

Healing Trauma: The Power of Group Treatment for People with Intellectual Disabilities

Nancy J. Razza, Ph.D., Daniel J.Tomasulo, Ph.D.

APA’s first book on people with intellectual disabilities. Available at Amazon, Barnes and Noble and the APA

www.TheHealingCrowd.com

Website for articles, clinical research, training, and supervision / consultation

Confessions of a Former Child

A Therapist’s Memoir

from Graywolf Press available at Amazon, Barnes and

Noble, Borders and all good bookstores.

FormerChild.com

PsychCentral.com Proof Positive

The R Word:Sticks, Stones and Rosa’s Law

“Disquietingly funny, stuffed with entertaining details and penetrating insights.” Kirkus Review

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