Advances in the Understanding and Treatment of Trauma: Variable Adaptations, Variable Treatments

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Advances in the Understanding and Treatment of
Trauma Variable Adaptations, Variable Treatments

• Christine A. Courtois, Ph.D.
• Psychologist, Private Practice
• Washington, DC
• CACourtoisPhD_at_AOL.COM
• www.drchriscourtois.com

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Types of Trauma

• Accidental
• Interpersonal
• Combination

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• Interpersonal Trauma
• A break in the human lifeline
• Robert J. Lifton
• Self and interpersonal effects brought to
  treatment

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Types of Traumatic Stressors

• Emotional Trauma
• It is the essence of emotional trauma that it
  shattersabsolutisms, a catastrophic loss of
  innocence that permanently alters ones sense of
  being-in-the-world. (Heidegger, quoted in
  Stolorow, 2007)

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Types of Trauma

• Type I
• Type II
• Overlap

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Types of Trauma

• Attachment/Relational
• Emotional
• Betrayal
• Secondary/ second injury/institutional

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What is Complex Trauma?

• Repetitive, chronic
• Cumulative
• Often in attachment relationships
• Entrapment betrayal second injury
• Often over the course of childhood
• Impacts development
• Other

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Trauma and Development

• Attachment trauma
• Attachment style and Inner Working Model
• Secure
• Insecure
• Disorganized
• Lack of self validation/reflection
• Effect on brain development
• Survival brain vs. learning brain

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Trauma and Development

• Can effect development starting at the neuronal
  level
• Neurons that fire together wire together
• Can affect brain structure
• Can affect brain function
• Right brain/sensory-motor imprint
• Left brain development impeded
• There may be no words
• Speechless terror

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Types of Traumatic Stressors

• Attachment/Relational Trauma
• occurs in attachment relationships with primary
  caregivers
• insecurity of response and availability
• mis-attunement, non-response
• lack of caring and reflection of self-worth
• caregiver as the source of both fear and comfort
• includes DV and child abuse of all types
• often on top of/in context of attachment
  insecurity
• neglect, abandonment, non-protection,
  non-response, sexual and physical abuse and
  violence, verbal assault

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Risk/Vulnerability and Protective Factors

• Temperament
• Gender
• Personal history
• Previous trauma/PTSD
• Culture
• Community
• Support or not

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Posttrauma Adaptations
(adapted from Wilson, 1989)

• Note most individuals who are seriously
  traumatized have posttraumatic reactions
  not all develop posttraumatic disorders.

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DSM-IV Criteria PTSD

• A. Exposure or experience
• B. Persistent reexperiencing, intrusions, dreams
  of trauma, distress at re-exposure
• C. Persistent avoidance of stimuli associated
  with the trauma and numbing
• D. Persistent symptoms of increased arousal

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Posttraumatic Diagnoses, DSM-IV

• Dissociative Disorders
• Depersonalization
• Dissociative fugue
• Dissociative amnesia
• Dissociative Identity Disorder
• related to severe childhood trauma
• DDNOS
• Associated Disorders Axis I, II, III

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Limbic System of the Brain

• Limbic System of the Brain

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Posttraumatic Stress Disorder (PTSD)

• A complex dynamic entity
• fluctuating, not static
• variable in form, presentation, course, degree of
  disruption
• A multimensional bio-psycho-social-
  spiritual-gender
• stress response syndrome
• An allostatic condition

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Posttraumatic Stress Disorder (PTSD)

• Allostasis refers to the bodys effort to
  maintain stability through change when loads or
  stressors of various types place demands on the
  normal levels of adaptive biological
  functioningThe failure to switch off
  allostatic mechanisms once the threat or
  requirement to respond has terminated, however,
  begins a complex process of wear and tear on
  the nervous and hormonal systems.
• ( Wilson, Friedman, Lindy, 2002, p. 9)

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Allostasis Ones thermostat is brokenStress
overload
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Post-trauma Responses and Disorders

• Complex Posttraumatic Stress Disorder/ (DESNOS)
  PTSD plus
• related to severe chronic abuse, usually in
  childhood, and attachment disturbance
• usually highly co-morbid
• often involves a high degree of dissociation
• Dissociative Disorders
• associated with disorganized attachment and/or
  abuse in childhood
• can develop in the aftermath of trauma that
  occurs any time in the lifespan
• DDNOS may be the most common DD (as currently
  defined in the DSM)

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Complex Posttraumatic Stress Disorder Disorders
of Extreme Stress Not Otherwise Specified (DESNOS)

• Designed to account for developmental issues,
  co-morbidity, memory variability and reduce
  stigma
• Co-morbidity
• distinct from or co-morbid with PTSD
• other Axis I, mainly
• depressive and anxiety disorders
• substance abuse/other addictions
• impulse control/compulsive disorders
• Axes II and III

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PTSD in Children

• No available childhood PTSD or DD diagnosis in
  the DSM
• Children respond as children, not as little
  adults
• work of Terr, Putnam, Pynoos, Perry has been
  instrumental to early understanding of childhood
  trauma
• Children are very vulnerable, yet resilient
• on average, takes less to traumatize them

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(Proposed) Developmental Trauma
Disorder (van der Kolk, 2005)

• Domains of impairment in children exposed to
  complex trauma
• Attachment/relationship capacity
• Biology
• Affect regulation
• Dissociation
• Behavioral control
• Cognition
• Self-concept

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Symptom Categories and Diagnostic Criteria
for Complex PTSD/DESNOS

• l. Alterations in regulation of affect and
  impulses
• a. Affect regulation
• b. Modulation of anger
• c. Self-destructiveness
• d. Suicidal preoccupation
• e. Difficulty modulating sexual involvement
• f. Excessive risk taking
• 2. Alterations in attention or consciousness
• a. Amnesia
• b. Transient dissociative episodes and
  depersonalization

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Symptom Categories and Diagnostic Criteria
for Complex PTSD/DESNOS

• 3. Alterations in self-perception
• a. Ineffectiveness
• b. Permanent damage
• c. Guilt and responsibility
• d. Shame
• e. Nobody can understand
• f. Minimizing
• 4. Alterations in perception of the perpetrator
• a. Adopting distorted beliefs
• b. Idealization of the perpetrator
• c. Preoccupation with hurting the perpetrator

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Symptom Categories and Diagnostic Criteria
for Complex PTSD/DESNOS

• 5. Alterations in relations with others
• a. Inability to trust
• b. Revictimization
• c. Victimizing others
• 6. Somatization
• a. Digestive system
• b. Chronic pain
• c. Cardiopulmonary symptoms
• d. Conversion symptoms
• e. Sexual symptoms
• 7. Alterations in systems of meaning
• a. Despair and hopelessness
• b. Loss of previously sustaining beliefs

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Complex PTSD/DESNOS

• Controversial
• Not a formal DSM diagnosis Associated Feature of
  PTSD
• Nevertheless, a useful way of organizing symptoms
  and treatment
• A less pejorative way of understanding and
  approaching the treatment of those who often look
  and behave like BPD
• Empirical investigation underway

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Attachment Organization (Ainsworth, 1978
Liotti, 1992 Main, 1986, Siegel, 1999)

• Child style
• secure
• insecure-avoidant
• insecure-dismissing/ resistant/ambivalent
• insecure-disorganized/ disoriented/dissociated

• Adult style
• autonomous
• dismissive/detached
• (teflon)
• preoccupied/anxious
• (velcro)
• fearful/anxious unresolved/dissociative

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Attachment Relationships

• are crucial to the process of integration. The
  difficulties that bring patients to treatment
  usually involve unintegrated and undeveloped
  capacities to feel, think, and relate to others
  (and to themselves) in ways that work
• Paraphrasing Bowlby, The therapy relationship
  involves sanctioning patients to think thoughts,
  experience feelings and consider actions that
  parents have forbidden. (Wallin, 2007)

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Implications for Treatment

• Attachment abuse including ongoing neglect and
  failure to respond and soothe a child (neglect)
  is implicated in the development of the DDs
• a wider base beyond overt physical and sexual
  abuse from which to understand DDs
• The emphasis in treatment is shifted back toward
  education and the intrapsychic and interpersonal
  patterns started early in life and away from
  solely working through the other forms of
  childhood and adult trauma

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Evidence-Based Practice

• Best research evidence
• Clinical expertise
• Patient values, identity, context
• American Psychological Association Council of
  Representatives Statement,
• August 2005

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Note EBT (Evidence-Based Therapy) is NOT the
same as EST (Empirically-Supported Therapy)
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Evidence-Based Practice

• Best research evidence, including
• Effectiveness
• Public health
• Health services
• Health care economics

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Evidence-Based Practice

• Clinical expertise, including
• Clinical assessments, judgments, decision-making
• Reflection consultation
• Interpersonal expertise/use of self
• ability to collaborate, not exploit
• ability to stay steady state, attune to client
• Understanding of clients contexts, values
• Using available resources
• Working from theory

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Evidence-Based Practice

• Patient identity, values, contexts
• Ethnicity, race, culture, language, gender,
  sexual orientation, religion, age, illness or
  disability status
• Treatment acceptability

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Expert Consensus Guidelines for Classic PTSD

• ISTSS Guidelines (Foa, Friedman, Keane, 2000,
  2008)
• Journal of Clinical Psychiatry (2000)
• American Psychiatric Association (2003)
• Clinical Efficiency Support Team (CREST,
  Northern Ireland, 2003)
• Veterans Administration/DoD (US, 2004)
• National Institute of Clinical Excellence (NICE,
  UK, 2005)
• Australian Centre for Posttraumatic Mental Health
  (2007)

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Other Expert Consensus Guidelines

• Dissociative Disorders
• Adult (ISSD, 1994, 1997, 2005, in revision
• Children (ISSD, 2001)
• Delayed memory issues
• Courtois (1999 Mollon, 2004)
• Complex trauma (under development)
• (Courtois, 1999 CREST, 2003 Courtois Ford,
  2009 ISTSS complex trauma expert consensus
  survey, in process)

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Effective Treatments for PTSD

• Psychopharmacology
• Psychotherapy (CBT, especially)
• Psych-education
• Other supportive interventions
• Few studies have evaluated using a combination
  of these approaches although combination
  treatment commonly used and may have advantages

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Treatment Goals

• educate about and de-stigmatize PTSD sx
• increase capacity to manage emotions
• reduce co-morbid problems
• reduce levels of hyperarousal
• re-establish normal stress response
• decrease numbing/avoidance strategies
• face rather than avoid trauma, process emotions,
  integrate traumatic memories

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Treatment Goals

• restore self-esteem, personal integrity
• normal psychosexual development
• reintegration of the personality
• restore psychosocial relations
• trust of others
• foster attachment to and connection with others
• restore physical self
• restore spiritual self
• prevent re-victimization/reenactments
• SAFETY IS THE FOUNDATION

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Treatment Principles

• First, do no more harm
• Treatment can help and treatment can hurt
• both the helper and the client

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Treatment Principles

• Treatment meets standard of care
• Treatment is individualized
• initial , ongoing, collateral assessment
• not laissez-faire treatment organized and
  planful
• ongoing review/adjustment of treatment plan
• Client empowerment/colloboration
• client engagement in the process, with
  responsibility for progress
• client consulted on/understands treatment plan
• posttraumatic treatment philosophy and techniques
  explained

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Treatment Principles

• Safety and protection
• Safety of self and others, to and from others
• Relationship issues
• Boundaries, limitations, respect
• Responsibilities of the therapist
• trustworthy/non-exploitive
• relationship as container
• Informed consent/refusal client rights
• professional privilege/limits of confidentiality
• right to seek consultation/2nd opinion
• rights to refuse and terminate treatment

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Treatment

• Variable Adaptations
• Variable and Multi-modal Treatments

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Complex Trauma Treatment

• Specialized techniques, applied later
• EMDR for resource installation/affect mgt, CBT
  (exposure therapies), CPT, stress inoculation
• Other techniques as needed (careful application)
• relaxation, exercise, group, education, wellness
• Couple or family work

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Complex Trauma Treatment

• PTSD symptoms
• Depression, anxiety, dissociation
• Problems with affect regulation
• may rely on maladaptive behaviors, substances
• problems with safety
• Negative self-concept
• Problems with self, attachment,relationships
• revictimization/re-enactments
• needy but mistrustful
• Problems functioning?
• Physical/medical concerns
• Other...

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Complex Trauma Treatment

• Not trauma alone (Gold, 2000)
• Multi-theoretical and multi-systemic
• Integrative
• Addresses attachment/relationship issues in
  addition to life issues and trauma symptoms and
  processing of traumatic material

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Treatment Sequence

• Safety, stabilization, skill-building
• Trauma processing
• Integration and meaning, self and relational
  development

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Treatment Sequence
General Stages of Treatment

• Pre-treatment stage Contracting, assessment,
  pre-treatment issues
• Early stage Safety, stabilization,
  skill-building, self-management, security in tx
  relationship
• Middle stage Trauma de-conditioning, processing,
  mourning, resolution, moving on
• Late stage Self and relational development from
  a new perspective
• Note Non-linear and not lockstep a back and
  forth, titrated process with attention to and
  planning for relapse

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Treatment Chronic PTSD

• May be delayed/chronic
• Longer term treatment (ongoing or episodic)
• comorbidity/dual dx
• Psychopharmacology
• Stabilization, skills training, crisis
  management, safety, affect regulation, life
  skills, self-care
• Specialized techniques, applied later
• EMDR for resource installation/affect mgt, CBT
  (exposure therapies), CPT, guided imagery
  energy somatosensory techniques, stress
  inoculation
• Other techniques as needed (careful application)
• relaxation, exercise, group, education,
  wellness, couples or family work, etc.

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Treatment Chronic/Complex PTSD

• Ongoing assessment
• Longer term treatment (ongoing or episodic)
• comorbidity/dual dx/co-ocurring dx
• Sequenced treatment
• more initial emphasis on stabilization,
  self-management, affect regulation, safety,
  relapse planning
• Psychopharmacology
• Specialized techniques, applied later
• EMDR starting w/ resource installation/affect
  mgt, CBT (graduated and/or direct exposure), CPT,
  stress inoculation, relaxation, hypnosis, group,
  education, wellness, couples or family work

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Hybrid Models for Complex Trauma

• TARGET (Ford)
• STAIR-NTP (Cloitre)
• Seeking Safety (Najavits)
• ATRIUM (Miller)
• SAFE Alternatives (Conterio Lader)
• Others...

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Treatment

• Like Posttraumatic Disorders, comprehensive
  treatment must be
• BIO-
• PSYCHO-
• SOCIAL/SPIRITUAL
• Culture and Gender Sensitive

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Bio/Physiological Treatments

• Psychopharmacology
• evidence base developing re effectiveness
• algorithms developed
• not enough by itself
• Medical attention
• preventive
• treatment
• Movement therapy
• Movement therapy

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Bio/Physiological Treatments

• Stress management
• Self-care/wellness
• Exercise (w/ care)
• Nutrition
• Sleep
• Hypnosis/meditation/mindfulness
• Addiction treatment
• Alcohol, drugs, prescription drugs
• Smoking cessation
• Other addictions (sexual, spending)
• Relapse planning

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Bio-physiological Treatments

• Somatosensory/Body-focused Techniques
• (Levine Ogden Rothschild, Scaer)
• Remember The brain is part of the body!
• Paying attention to the body in the room
• interpersonal neurobiology
• Neurofeedback/EEG Spectrum
• Massage and movement therapy
• Dance and theatre
• Yoga

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Psychosocial/Spiritual Treatments

• The therapy relationship--has the most empirical
  support of any technique
• Especially important with the traumatized
• Especially important in interpersonal violence
  and in developmental trauma
• attachment studies
• brain development studies
• striving for secure attachment

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Psychosocial/Spiritual Treatments

• Psych-education (individual or in group)
• individual and group therapy
• trauma focus vs. present focus
• skill-building
• core affect and cognitive processing
• developing connection with others
• identification and meaning-making
• concurrent addiction/ED
• couple and family therapy

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Psychosocial/Spiritual Treatments

• adjunctive groups/services
• AA, Al-Anon, ACA, ACOA, etc.
• Social services/rehabilitation
• Career services
• Internet support and information
• spiritual resources finding meaning in suffering
• Pastoral and spiritual care
• Organized religion
• Other religion/spirituality
• Nature, animals

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Cognitive Behavioral, Emotional/ Information
Processing Treatments

• Education skill development
• numerous workbooks now available on a wide
  variety of topics
• general, CD, self-harm, risk-taking, eating,
  dissociation, spirituality, career, etc.
• Exposure and desensitization (Foa et al.)
• prolonged graduated
• Writing/journaling
• CPT (Resick)
• Journaling (Pennebaker)

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Cognitive Behavioral, Emotional/ Information
Processing Treatments

• Schema therapy (Young McCann Pearlman)
• DBT (may involve tough love stance) (Linehan)
• mindfulness and skill-building
• Narrative therapies (various authors)
• Strength/resilience development
• EMDR resource installation (Leeds Korn)
• Developmental Needs Meeting Strategy (Schmidt)
• Internal Family System work (Schwartz)
• Solution-focused treatment (OHanlon)

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Cognitive Behavioral and Information-Processing
Treatments

• EFTT emotion-focused therapy for trauma
  (Paivio)
• ACT acceptance and commitment therapy
• (Hayes, others)
• FAT/FECT Functional Analytic Therapy
  (Tsai, Kohlenberg)
• IRRT imaginary re-scripting and re-processing
  therapy (Smucker)
• Virtual Reality (Rothbaum, others)

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Affect-Based Treatments

• AEDP Accelerated Experiential-Dynamic
  Psychotherapy (Fosha)
• Affect Experiencing-Attachment Theory
  Approach (Neborsky)
• Healing the Incest Wound
  (Courtois Roth Batson)
• Repair of the Self (Schore, others)
• Techniques for identifying and treating
  dissociation (ISSD, Kluft, Putnam, Ross, others)
  
• Relational and affect-based psychoanalytic
  techniques (Bromberg, Davies Frawley, Chefetz,
  others)

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Core Affects

• Fear/terror
• Anxiety
• Depression
• Anger/rage/outrage
• Shame
• Self-blame/guilt
• Confusion
• Grief/mourning/sadness
• Alienation
• Other

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Relational/Attachment Treatments

• Understand clients attachment style and Inner
  Working Model
• Helps expect how the client relates and behaves
• Strategize how to respond
• Goal to move to secure attachment through
  insights gained in and through the therapy
  relationship

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Relational/Attachment Techniques

• Interpersonal neurobiology (Schore, Siegel)
• Relational and affect-based psychoanalytic tx
• Patient in relationship with others
• determine attachment style
• Therapist
• determine attachment style
• secure connection with the therapist to foster
  secure connections elsewhere (earned security)
• transference/countertransference, enactments, VT
• Spouse/partner/significant other
• couple and family work

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Relational/Attachment Techniques

• Hypnosis or EMDR-based internalization of
  attachment (Brown Leeds
  Korn Omaha)
• Children
• parenting help/training
• Friends
• substitute family
• social and friendship skills
• Support systems
• Work colleagues
• Note Various workbooks and community
  training programs available for these

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Hypnosis/Guided Imagery Techniques

• Caution for ego development, self-soothing,
  attachment, not for memory retrieval
• Hypnosis
• Brown Fromm Brown
• Dolan
• Phillips Frederick
• Kluft
• Schwarz
• Guided Imagery
• Naparstek

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Expressive Techniques

• Art
• collage
• images
• pottery/clay work
• Poetry/writing
• Psychodrama
• Movement

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Spirituality/Mindfulness

• Nature
• Specific spiritual writers and orientations
• The meaning of suffering
• Existential issues
• Religion
• Pastoral care/spiritual issues
• Prayer
• Spiritual formation

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Cultural/Ethnic/Gender/Religious

• Social context/ethnic group and how it might
  contributes to trauma
• racism, sexism, heterosexism and homophobia,
  cultural or ethnic norms, colonialism, etc.
• Blocks or supports to healing
• Take these issues into account
• Healing rituals
• Healers

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Treatment Chronic/Complex PTSD

• Some never fully recover from symptoms
• even after many years/intensive treatment
• those w/ history of childhood abuse/trauma
• and other risk factors
• The absence of symptoms does not mean that the
  disorder has run its course
• patterns of cyclical decompensation have been
  identified
• Treatment is applied according to the phase of
  the decompensation cycle

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Summary

• Trauma studies have increased information and
  understanding
• Trauma can vary dramatically, as can responses
• New conceptual and diagnostic models account for
  variability
• Treatment
• Is multimodal
• Is bio-psycho-social
• Must be individualized
• type of trauma response/disorder
• individual needs
• Has some empirical supportmore to come!

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Resources

• ISTSS.org
• ISSTD.org--new name formerly (ISSD.org)
• 9 month-long courses on the treatment of
  DDs--various locations
• NCPTSD.va.gov (info and links)
• NCTSN.org (child resources)
• Sidran.org (books and tapes)
• APA Division 56, Psychological Trauma APA.org
• traumadivision_at_apa.org please join!!

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The Rewards of the Work
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