Considerations in Trauma Work with Children and Adolescents

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Considerations in Trauma Work with Children and
Adolescents

• The Use of Hypnosis for Prevention and Treatment
• Julie H. Linden, Ph.D.
• Philadelphia, PA, USA
• JHLINDEN_at_CS.COM

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Learning Objectives

• Describe developmental variables in the use of
  hypnotic techniques.
• List several theories of trauma and the elements
  of an integrated approach to trauma treatment.
• Name and be able to use several hypnotic
  techniques in the treatment of trauma in children.

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Outline of workshop

• Definitions
• Developmental factors
• Assessment
• Treatment

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What is Trauma?
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Wholist Framework

• The nature of the trauma (process)
• Parameters of the trauma (context)
• Depth of the trauma (effect of the trauma on
  human fulfillment)
• Velent 1998,1999

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Posttraumatic acute-stress reaction

• The constellation of feelings and reactions that
  follows terrifying events

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Trauma

• Defined as the sudden cessation of human
  interaction
• (Lindemann, 1944)

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Trauma

• An Experience is traumatic if it
• 1. Is sudden, unexpected, or non- normative
• 2. Exceeds the individuals perceived ability to
  meet its demand
• 3. Disrupts the individuals frame of
  reference and other central psychological needs
  and related schemas.
• (McCann Pearlman 1990)

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Trauma

• An event that overwhelms the persons perceived
  ability to cope, debilitates through a central
  loss of control and creates the necessity for
  psychological defenses.
• It is the persons response to the event that
  creates the traumatization.
• (E. Gil 1998)

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Definition

• Trauma by proxy
• Feel traumatized as the result of an event that
  happened to someone else.
• Feels traumatic because child identifies with the
  victim.

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TRAUMA EVENTS

• 1. PHYSICAL , SEXUAL ,or VERBAL ABUSE
• (homicide, rape, suicide, torture)
• 2. ACCIDENTS
• 3. CHRONIC ILLNESS MEDICAL PROCEDURES
• 4. DEATH - LOSS OF PARENT, SIBLING
• 5. DIVORCE ADOPTION
• 6. NATURAL DISASTERS
• fears of lightning, fire, etc. to traumas
  from famine, floods, cyclones, tornadoes, etc.
• 7. WAR

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Terrorism

• A special type of disaster
• Weapons of mass destruction
• Chemical, Biological, Radiological, Nuclear,
  high yield Explosives (CBRNE)

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• Straus and Gelles (1996) have estimated that over
  29 million children commit an act of violence
  against a sibling each year

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Assessment

• PTSD ASD

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What kids say stress is...

• When you have to do something to make someone
  else happy and it makes you miserable.
• Feeling really tiny in a big, big room.
• Feeling squished.
• Feeling tight all over.
• Like you cant breathe.
• Like two things fighting in my stomach.

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Common Childhood Fears

• 0-6 months Loss of support, loud noises
• 7-12 months Fear of strangers, fear of sudden,
  unexpected and looming objects
• 1 year Separation from parent, toilet,
  injury, strangers
• 2 years A multitude of fears, including loud
  noises, animals, the dark separation
  from parents, large objects, e.g.
  machines, change in personal
  environment
• 3 years Masks, dark, animals, separation
  from parents
• 4 years Separations from parents, animals,
  dark, noises

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Common Childhood Fears

• 5 years Animals, "bad" people, dark, separation
  from parent, bodily harm
• 6 years Supernatural beings, bodily injuries,
  thunder and lightning, dark, sleeping or
  staying alone, separation from parent
• 7-8 years Supernatural beings, dark, fears based
  on media events, staying alone, bodily
  injury
• 9-12 years Tests and examinations in school,
  school performance, bodily injury,
  physical appearance, thunder and
  lightening, death, dark

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Acute Stress Disorder

• Acute stress disorder (ASD) is an anxiety
  disorder characterized by a cluster of
  dissociative and anxiety symptoms occurring
  within one month of a traumatic event.

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Recognizable stressor

• Acute stress disorder is caused by exposure to
  trauma, which is defined as a stressor that
  causes intense fear and, usually, involves
  threats to life or serious injury to oneself or
  others.

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Symptoms Dissociative Anxiety

• Dissociative symptoms emotional detachment,
  temporary loss of memory, depersonalization, and
  derealization.
• Anxiety symptoms irritability, physical
  restlessness, sleep problems, inability to
  concentrate, and being easily startled.

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Normal acute (e.g. in the first hours or days)
responses to trauma may include

• Feelings of horror, helplessness, fear, or
  disbelief
• Attention and concentration problems
• Preoccupation with the traumatic event
• Hypervigilance to danger, including misperception
  of non-dangerous stimuli as potentially dangerous
• "Survivor guilt" (i.e., guilt about having
  survived when others did not)
•  Reduced emotional responses to the environment
  ("shutting down" or "going numb")
• Feelings of unreality, depersonalization, or
  other dissociative phenomena
• For some, no significant psychological
  difficulties

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Later (e.g. in subsequent hours, days, or weeks)
reactions often

• Intrusive thoughts and recollections of the
  trauma, nightmares, and occasionally flash-backs
  (intrusive sensory reexperiencing of aspects of
  the trauma)
• Sustained feelings of numbness or emotional
  constriction
• Attempts to avoid reminders of the trauma
• Initiation of (or re-involvement in) substance
  abuse
• Evidence of autonomic hyperarousal, such as
  muscle tension, jumpiness and heightened startle
  responses, sleep disturbance, and irritability 
• Problems in interpersonal relationships
• Mood swings
• Anxiety
• Depression and self-isolation

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PTSD Factors

• Existence of recognizable stressor

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PTSD Factors

• Reexperiencing the trauma as evident by
• recurrent/intrusive recollection of events in
  children daydreams and fantasies, usually they do
  not have recurrent nightmares with exact
  repetition of event. Do not experience sudden
  unexpected flashbacks.
• recurrent dreams of events.

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PTSD Factors

• Reexperiencing the trauma as evident by (cont.)
• suddenly acting or feeling as if traumatic event
  were reoccurring because of an association with
  environmental stimulus. Primary process thinking
  is close to the surface, so environmental
  stimulus is often responsible for behavioral
  changes. Children do not consciously link
  changes in mood, affect, thinking and behavior to
  such things as loud noises, darkness or sudden
  visual or auditory stimuli which "remind" them of
  the traumatic event.

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PTSD Factors

• Reexperiencing the trauma as evident by
  (contd.)
• 4. Trauma specific reenactment

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• PERCEPTION IS MORE BASIC AND PRIMITIVE THAN IS
  COGNITION.
• PREVERBAL EXPERIENCE, TRAUMATIC PERCEPTION MAY
  REMAIN AN INDIGESTIBLE PART OF GROWING YOUNG
  PERSONALITY

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Avoidance

• Emotional numbing. This is a defense children
  appear as if uninvolved, but do not exhibit
  psychic numbing. Subdued or mute behavior,
  unemotional third person, journalistic.

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Avoidance

• Sense of foreshortened future
• Avoidance of activities that arouse recollection
  of traumatic event
• Repression (avoiding thoughts, affect)

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Arousal Hyperalertness

• 1. Sleep disturbance- inability to fall asleep,
  night terrors, nightmares
• 2. Irritability or outbursts of anger
• 3. Memory impairment, trouble concentrating
• 4. Hypervigilance/ guilt
• 5. Exaggerated startle response
• Regressed- go into parents bed, sleep in strange
  places, suck their thumbs, enuretic

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• Accidents, suicides and homicides are the three
  leading causes of death among young people in the
  US.
• (US Bureau of Census, 1999)

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Simple VS Complicated Trauma
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• Simple Trauma Complicated Trauma
• Single Event Several Repetitive Events
• Brief Duration Over Long Time
• Late in Life Early in Life
• (after ego dev. solidified)
• No Man-Made Violence Man-Made Violence
• Active Role Passive Role
• Advance Warning Sudden, No Advanced
  Warning

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• Symptoms Time-Limited Symptoms Long Lasting
• can produce characterological change
  may produce neuronal changes both physical
  and psychological symptoms can be
  irreversible.
• Resolution of symptoms Resolution of symptoms
• can occur simply with the usually does not
  occur
• aid of facilitative spontaneously treatment
• environment usually necessary in some
• cases no resolution of symptoms,
  even with treatment
• If treatment is needed, it's Treatment is long
  term, ego-
• brief and time-limited reparative

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Trauma, Dissociation and Hypnosis
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Defenses

• Denial
• Suppression
• Repression
• Splitting
• Dissociation

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Dissociation

• Distancing through
• repression of affect (numbing)
• repression of thought
• repression of behavior
• depersonalization (out of body)
• amnesias
• automatisms (e.g,sleepwalking)

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Advantages of Dissociation

• Need distance in order to master
• Compartmentalize
• Discontinuity in experience
• Dissociation helps to maintain, gain and regain
  control
• Body may handle some of the worst responses

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Dissociation

• DSM definition
• A disruption in the usually integrated functions
  of consciousness, memory,
• identity or perception of the environment.
• May be sudden, gradual, transient or chronic.

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Advantages of Hypnosis for the Treatment of
Trauma

• Can get to original affective state.
• Can train the relaxation response.
• Can create endless containment techniques through
  imagery utilizing trance logic phenomenon.
• Can bridge between the conscious and unconscious
  (accessing pictorial and sensorial memory
  ubiquitous to trauma).

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Hypnosisan altered state of consciousness

• Changes in consciousness reported by those in
  hypnotic state include
• narrowed focus of attention
• dissociation numbing, out of body, spacey
• altered sense of time
• altered sensory perceptions
• (Ref Cardena, 2000)

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Grounding

• Sensory and cognitive awareness
• Keep a person in the present
• Reorient to reality, here and now
• Can prevent unhealthy dissociating
• Regain mental focus

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Grounding Techniques

• Self talk
• Directed imagination (all the senses)
• Energy toning
• Acting as if principles

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• Safe place imagery
• Become absorbed in activity.
• Write in your journal.
• Breathing exercises. Relaxation exercises.
• Visualize a "STOP" sign
• Use positive affirmations.
• Transfer your feeling/memory into a safe
  "container" either through visualization or by
  creating an actual box where you can write the
  feeling/memory on a piece of paper and slip it
  into the box leaving it to be dealt with together
  with your therapist.
• Identify cognitive distortions and replace with
  counter statements.

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• Dance.
• Repeat a grounding phrase "I'm here right now."
  
• Hold a safe object (smooth stone, stuffed animal,
  watch, ring, cup or mug, etc.).
• Pray (e.g. Serenity Prayer). Exercise.
• Draw.
• Find a safe person.
• Listen to a tape of your therapist.
• Listen to a tape of self-affirmations.

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Change sensory experience/input

• Sight allow yourself to see through your eyes,
  look at a picture, read a book
• Touch allow yourself to feel the chair you are
  sitting on, touch ice, hold a smooth stone
• Sound talk to someone, listen to music, TV
• Taste eat something
• Smell perfume, favorite scent

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Consequences of Trauma

• persistent fear state
• disorder of memory
• dysregulation of affect
• avoidance of intimacy

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Symptom ChecklistDefenses Behavior

• Depression
• Repression
• Regression

• Re -experiencing
• Avoidance
• Arousal

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Trauma Models
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Fight FlightFreeze
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Perry- Neurophysiological equivalents in children

• Fight- cry to alert an adult, regressive tantrums
• Flight- often not possible, so dissociate
• Freeze-when an event is perceived as inevitable,
  seen as oppositional defiant.

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Table 1 The Continuum of Adaptive Responses
to Threat Bruce Perry, MD, PhD
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• Hans Selye
• General Adaptation Syndrome (Psychobiological
  model)
• Anne Burgess
• Information Processing of Trauma
• Pierre Janet
• Stabilization, Exploration, Integration
• Judith Herman
• Safety, Remembrance and Mourning, Reconnection

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• FrancineShapiro
• EMDR- Eye Movement Desensitization and
  Reprocessing
• Sandra Bloom
• SAGE- Creating Sanctuary
• Safety, Affect Management, Grieving and
  Emancipation
• Roger Fallot
• TREM- Trauma, Recovery and Empowerment

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Hypnotic Model for Treatment

• Stabilization/Rapport Trust Building
• Uncovering
• Working Through

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Kinds of Interventions

• Play therapy-symbolic
• Houses, toys, costumes, puppets
• Hypnosis/Hypnoidal techniques
• Imagery/relaxation
• Storytelling
• Role playing/ Playback theater
• EMDR
• Sandplay
• Art Therapy
• Board games
• Electronic Techniques
• Lap top writing
• Biofeedback games
• Differ from formal hypnosis in that they utilize
  the naturally occurring trance state and
  relaxation response.

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Plays therapeutic factors

• visualize or use fantasy
• communicate
• form attachments
• enhance relationships
• learn through metaphoric teaching
• develop competence through mastery
• think creatively
• achieve catharsis or abreaction
• develop positive emotion
• helping children overcome resistance
• master developmental fears
• role-play
• develop game play (which helps with
  socialization)

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Play as hypnosis

• Children prefer action to talking
• A function of play, at a biological level is to
  relax and release tension
• Most forms of play for children produce trance
  state narrowed focus of attention, dissociation,
  absorption, imaginative involvement
• At an intrapersonal level, play may provide for
  mastery of conflicts through the use of symbolism
  and wish fulfillment
• Therapeutic play- the use of alone play with
  the therapist, using 1) art medium, toys or
  drama, 2) storytelling through activity and 3)
  make believe. (Sandplay uses all three).

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Hypnotic suggestions and play

• Pair play trance state and hypnoidal suggestion
• Just as do in formal trance induction with
  adults, this is more suitable with children where
  imagination and imaginative involvement is more
  present.
• Sensitivity to timing of suggestion, although can
  be used at any phase of treatment.
• The attachment of words to action (know the power
  of negative suggestions)

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Similarities between hypnoidal play and formal
hypnosis

• Resolve problems at an unconscious level
• Both hypnosis and play reach into the sub
  and unconscious, retrieving those aspects of the
  self, hidden from the client.
• A meditative, focused, absorbed state
• Frequently feel time distortion
• Dissociation
• Accesses original affect
• Simultaneous use of both lobes of the brain

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Characteristics of Post-traumatic Play

• Compulsive Repetition
• Unconscious link between the play and the real
  event
• Literalness of Play
• Failure to relieve anxiety
• Depiction of danger
• Lack of spontaneity and enjoyment

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Interventions for Unhealthy Play

• Physical Movement - ask child to stand up, take a
  deep breath, move arms and legs. This can be a
  pattern interruption to rigid emotional and
  behavioral constriction.
• Verbal statement about the play that may
  encourage child to disengage, to observe (non
  interpretive), rather than to be in it.
• Interrupting the sequence of play by asking the
  child to take specific roles and describe
  perceptions, thoughts, or feelings. This pretend
  play is usually normative play for children and
  may move child out of constricted behavior.

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Interventions for Unhealthy Play (contd)

• Manipulating the toys asking what would happen
  if to elicit the childs creative imagination
  and to consider new options.
• Encouraging child to differentiate between
  traumatic material and current reality in terms
  of environmental changes and new coping
  strategies.
• Videotaping- allows child to be removed from toys
  and play which may be too real or intrusive. May
  not be able to use toys as symbolic and instead
  view them as realistic objects.

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Importance of affect

• Emotional interactions are the foundation of
  cognition and most of the childs intellectual
  abilities, including creativity and abstract
  thinking skills.

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What is attachment?

• An attachment is a reciprocal, enduring emotional
  and physical affiliation between a child and a
  caregiver. (B. James)

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Attachment vs. Trauma-bond relationships

• Attachment Trauma-bond
• Love Terror
• Takes time Instantaneous
• Reciprocity and caring Domination and fear
• Person is experienced as essential same
• for survival
• Proximity?safety(pleasure) Proximity ?conflict
  (alarm/numbing)
• Separate person dependent Not separate person,
  extension of others needs
• Self-mastery Mastery by others
• Autonomy-individuation Obedient to will of other

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Attachment vs. Trauma-bond relationships

• Goals of attachment behavior safety,
  exploration, avoidance of danger, and
  affiliation.
• Goals of trauma-bond behavior objective of
  adults wellbeing, regulation of intensity of
  feeling, limited interaction, and safety

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Childrens Experiences of War in
Bosnia-Herzegovina

• Approximately 16,855 children were killed, died
  due to hunger or cold, or were missing because of
  1992-1995 war in Bosnia
• Over 34,000 children were wounded
• War crimes against children included
• Forced displacement
• Rape
• Forced prostitution
• Torture
• Using children as human shields
• Taking children as hostages
• Killing children in mass murders
• Other forms of persecution
• Severe abuse
• (Commission for Gathering Facts on war Crimes
  1996 report)

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War Trauma

• Children face conflicts related to
• Protection and attachment
• Aggression, power, retaliation and the redressing
  of wrongs
• Fragmentation and incoherence related to loss in
  the moral as well as physical, relational and
  social order
• (S. Rafman 2002)

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Clinical themes

• Good and evil
• Trust and betrayal
• Protection and aggression
• Death as consequence of wrong choice
• (S. Rafman 2002)

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Type and Frequency of PTSD Symptoms

• 1. Being upset when reminded of war
  experiences (92)
• 2. Having intrusive memories (89)
• 3. Being watchful or on guard (84)
• 4. Avoiding thoughts of the war (81)
• 5. Having nightmares (76)
• 6. Feeling cut off from others (76)
• 7. Increased startle response (71)
• 8. Decreased concentration (68)

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Type and Frequency of PTSD Symptoms

• 9. Feeling numb (61)
• 10. Having sleep disturbance ((61)
• 11. Reactivity to war reminders (61)
• 12. Decreased interest (58)
• 13. Flashbacks (58)
• 14. Avoiding war reminders (55)
• 15. Irritability (53)
• 16. Feeling future is unclear (50)
• 17. Amnesia (16)
• From Weine Pavkovic (1995). Items with a star
  () were reported by the Philadelphia group.