BEST TREATMENT PRACTICES FOR TRAUMA RECOVERY

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BEST TREATMENT PRACTICES FOR TRAUMA RECOVERY
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TRAUMA DEFINED

• A traumatic event involves a single experience,
  or an enduring, or repeated events, that
  completely overwhelm the individuals ability to
  cope or integrate ideas and emotions involved in
  that experience.
• It involves a feeling of COMPLETE HELPESSNESS in
  the face of real or perceived threat to ones
  life, or that of a loved ones, to bodily
  integrity, or sanity.
• There is frequently a violation of a persons
  familiar ideas about the world and their human
  rights, putting the person in an extreme state of
  confusion, and insecurity.
• Reactions physiological and psychological.

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POSSIBLE TRAUMATIC EXPERIENCES

• Abuse Physical, Emotional, Verbal, Sexual,
  Neglect, Abandonment
• Violence (murder, rape, robbed, physically
  attacked)
• The threat of violence or sexual abuse, or
  witnessing violence
• Catastrophic events (hurricanes, earthquakes,
  volcanic eruptions, war or other mass violence)
• Car accidents, plane crashes, fires

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POSSIBLE TRAUMATIC EXPERIENCES

• Paramedics, fire fighters and rescue teams
  experiences
• Long-term exposure to conditions like parents who
  are substance abusers, having a parent
  incarcerated, poverty or milder forms of abuse
  such as verbal abuse can be traumatic.
• Medical Procedures, Being diagnosed with a life
  threatening illness
• Being Kidnapped, Held hostage
• Combat
• Battering Relationships, Being Stalked, Bullied,
  Harassed

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• Its not the event that determines whether
  something is traumatic, but the individuals
  experience of the event

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CHILDHOOD TRAUMA ABUSE
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ABUSE STATISTICS

• 1 out of 3 women will experience sexual abuse by
  the time they are 18 years old. (The Publics
  Health)
• 1 out of 5-7 men will experience sexual abuse by
  the time they are 18 years old. (childhelp.org)
• 90 of sexual abuse victims know their
  perpetrator and 68 are abused by family members.
  (National Center for Child Abuse)
• 90 of cases go unreported and untreated, as the
  symptoms of CSA are often misdiagnosed and
  unappreciated. (The Publics Health 2009)
• Over 3 million cases of child abuse are reported
  each year in US. Those reports can have multiple
  children in them. (NCAS)

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PYCHOLOGICAL AFFECTS OF ABUSE

• PTSD Depression
• Anxiety/Panic Failure to thrive
• Agoraphobia/Phobias Rage
• Irritability Mood Disorders
• Substance Abuse Eating Disorders
• Personality Changes/ Disorders Suicidal and
  Homicidal Ideation
• Dissociative Disorders Self-Injury/Cutting
• Negative Self-concept Abusive Partners
• Obsessive Compulsive Feelings of Powerlessness

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RELATIONSHIP ISSUES

• Trusts too easily or does not trust at all
• Difficulty communicating
• Does not set boundaries or sets too many
  boundaries
• Wants to be rescued
• Isolation and withdraw
• Sexual problems/promiscuity
• Fear of abandonment
• Fear of Intimacy
• May be abusive or choose abusive partners
• People pleasing

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ACADEMIC ISSUES

• Inability to concentrate
• Lower test scores
• Comprehension problems
• Memory deficits
• Peer relational issues
• Communication problems
• Attendance issues
• Teen Pregnancy

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POST TRAUMATIC STRESS DISORDER
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PTSD SYMPTOMS

• Intrusive re-experiencing of the trauma
• ? flashbacks, nightmares, triggers
• 2) Hyper-arousal
• ? Problems falling or staying asleep
• ? Difficulty concentrating or
  completing tasks
• ? Anger and irritability
• ? Startle response
• ? Hyper-vigilant
• ? Panic attacks, shortness of breath or
  chest pain
• 3) Avoidance of stimuli and numbing response
• ? Making efforts to avoid thoughts,
  feelings, conversations, people, or places that
• remind them of the trauma.
• ? Restricted range of emotions/Numbing of
  emotions
• ? Feeling detached from others
• ? Dissociation
• ? Substance Abuse
• ? Loss of interest in activities they
  used to enjoy

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DISSOCIATION

• Detachment from immediate surroundings
• Detachment from physical or emotional experience
• It is a disconnect between material in the
  conscious mind and material in the unconscious
  mind.
• Adaptive Survival Skill can become maladaptive
• Can be done consciously or automatically
• It can become pathological and interfere with
  daily functioning

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PTSD SYMPTOMS

• Survivors Guilt
• Rage
• Depression and Grief
• Anxiety and Panic
• Shame and Fear
• Trust Issues
• Loss of appetite
• Sexual dysfunction
• Poor coping skills
• Feelings of hopelessness

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RISK FACTORS

• Previous traumatic experiences, especially in
  early life
• Family history of PTSD or depression
• Being Female
• History of physical or sexual abuse
• History of substance abuse
• History of depression, anxiety, or another mental
  illness
• High level of stress in everyday life
• Lack of support after the trauma
• Lack of coping skills
• Mayo Clinic

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PTSD TYPES

• Acute
• Less than 3 months
• Chronic
• Longer than 3 months
• Delayed onset
• 6 months later
• Complex (Disorder of Extreme Stress)
• Exposed to prolonged traumatic events, especially
  during childhood, such as childhood sexual
  abuse(severe and sustained)
• Often have a personality disorder.
• Long-term effect on adult functioning

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DEVELOPMENTAL TRAUMA

• ? Trauma that is stressful that occurs
  repeatedly and cumulatively over a period of
  time, within specific relationships and
  context(child abuse)
• ? Domains of impairment
• attachment
• biology
• affect (emotional) regulation
• dissociation
• behavioral control
• cognitive processes
• self-concept

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DISSOCIATIVE DISORDERS

• Marked by a dissociation from or interruption of
  a person's fundamental aspects of waking
  consciousness (such as one's personal identity,
  one's personal history, etc.)
• Most dissociative disorders stem from trauma.
• Coping mechanism the person literally
  dissociates himself from a situation or
  experience too traumatic to integrate with his
  conscious self.
• Types
• Dissociative Identity Disorder (Multiple
  Personality Disorder)
• Dissociative Amnesia
• Dissociative Fugue
• Depersonalization Disorder
• Dissociative Disorder NOS
• Scales for this Dissociative Experience
  Scale(DES), SCID-D, SDQ-20

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TRAUMA AND ATTACHMENT

• Trauma that happens in childhood at the hands of
  a caregiver is doubly destructive because it
  destroys the attachment relationship that the
  child would normally need to depend on to manage
  the trauma of the abuse.
• The resolution of attachment issues is a central
  component of trauma recovery

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TYPES OF ATTACHMENT

• Secure
• Parent is aligned with the child and in tune with
  the childs emotions, trustworthy, and reliable.
• Adult is able to create and maintain
  relationships
• Ambivalent
• Parent is inconsistent, unpredictable and
  sometimes intrusive parent communication
• Adult is anxious and insecure, controlling,
  blaming, erratic, unpredictable, and sometimes
  charming
• Avoidant
• Parent is unavailable or rejecting, and punitive
• Adult avoids closeness, or emotional connection,
  distant, superficial relationships, critical,
  rigid or intolerant
• Reactive
• Parent is extremely unattached or malfunctioning,
  and abusive
• Adult cannot establish positive relationships,
  withdrawn, substance abuse
• Disorganized
• Parents ignored, or did not see the childs
  needs. Parental behavior was frightening or
  traumatizing. Often sexual, or physical abusive
• Adult is chaotic, insensitive, explosive,
  abusive, untrusting, while craving security

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SECURE ATTACHMENTS HELP US

• Feel safe
• Develop meaningful connection with others
• Explore our world
• Deal with stress
• Balance emotion
• Experience comfort and security
• Make sense of our lives
• Create positive memories expectations of
  relationships
• Ability to rebound from disappointment,
  discouragement and misfortune

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INSECURE ATTACHMENTS

• Unavailable or avoidant
• Self-absorbed
• Insecure
• Disorganized
• Aggressive
• Angry
• Distrusting of others
• Lack of empathy
• Clinginess
• Trouble learning/Developmental delays
• Lack of Self-control
• Obsession with food

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ADVERSE CHILDHOOD EXPERIENCE STUDYBY KAISER
PERMENENTE

• 1995-1997 17,000 middle class insured individuals
  in the primary care setting
• Confidential Survey for the incidence of
• Abuse
• Sexual, physical, verbal abuse
• Neglect
• Emotional neglect, physical neglect
• Household Dysfunction
• Household substance abuse
• Parental separation and divorce
• Incarcerated household member
• Household member with a mental illness
• Mother treated violently

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ADVERSE CHILDHOOD EVENTS(ACE STUDY) (Kaiser
Permanente)
People with 4 or more ACE were at greater risk
for serious health issues
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ACE STUDY FINDINGS

• Alcoholism and alcohol abuse Illicit Drug Use
• Smoking Early Initiation of Smoking
• Depression Suicide Attempts
• COPD Ischemic heart disease (IHD)
• Fetal death Health-related quality of life
• Liver disease Obesity
• Autoimmune Disease Increased risk for Cancer
• Autobiographical Memory Disturbance Hallucinations
  
• Risk for intimate partner violence Multiple
  sexual partners
• Sexually transmitted diseases Unintended
  pregnancies
• Early initiation of sexual activity Adolescent
  pregnancy

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MEDICAL RISKS(The Publics Health 2009)

• Obesity Hypertension
• Headaches Stomach Problems
• Lowered Immune System Chronic Fatigue
• MS, Lupus, Fibromyalgia Early hysterectomies
• Gynecological issues Diabetes
• Heart disease Substance Abuse
• Sexual Disorders STDs
• Somatic complaints and Body aches MS, Lupus
• Fibromyalgia Autoimmune Disorders
• Increased Risk of Cancer Premature Death

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HOW TRAUMA IMPACTS THE BRAIN
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EMOTIONAL NERVOUS SYSTEM

• TWO PARTS OF NERVOUS SYSTEM

Limbic System
Autonomic Nervous System
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• Limbic System
• Primary responsible for our emotional life
• Helps with formation of memories
• Arousal and hyper-arousal
• Fight, Flight, or Freeze
• It plays a central role in memory processing

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• Amygdala
• Fear center or alarm system/Fight or flight
• Stores highly charged emotional memories
• After trauma can overreact(hyper-responsivity)
• To remember a threat, generalize it to other
  possible threats and carry it out to the future.
  Imprints it
• Explicit or unconscious memory
• Hippocampus
• Plays a role in organizing memories. Explicit or
  Conscious Memory
• Interacts with the amygdala during the encoding
  of emotional memories.
• Encoding of context during fear conditioning
• Stores memory of time and space puts our
  memories into their proper perspective and place
  in our life's time line.
• After trauma can shrink in size and diminish in
  functioning
• Gets damaged in child abuse/ high stress (gaps in
  memory_

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LIMBIC SYSTEM
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AUTONOMIC NERVOUS SYSTEM 1)PARASYMPATHETIC
2)SYMPATHETIC
RESTRICTED
ACTIVATED
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• Medial Prefrontal Cortex
• Moral center, planning complex cognitive
  behaviors, personality expression, decision
  making, moderating correct social
  behavior-delaying gratification
• Appears to be volumetrically smaller and is
  hypo-responsive(under) during symptomatic states
  
• Corpus Coliseum
• Facilitates communication between the 2
  hemispheres.
• During trauma decreased blood flow and
  communication between hemispheres.

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WHEN TRAUMA OCCURS

• The brains main function is to get though the
  event.
• The brain helps us survive by activating
  biological reactions involved in helping us mount
  that fight or flight response.
• The sympathetic nervous system releases
  adrenaline, increases heart rate, pupils dilated,
  accelerated pulse which readies you to move in
  the fight or flight decision.
• The brain actually lowers the chemicals released
  to help us with regular functions which means
  your parasympathetic nervous system energy is
  diverted to help you cope with what you need to
  do to survive.
• Hormones are released to reign in the stress
  response to stop long-term damage to your body.

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• During the first 4 years of life 90 of a childs
  brain develops through the experiences of that
  child.
• The mind and the emotional content of the brain
  are created in the first few years of life
  through the attachment bond between the infant
  and the mother
• Bruce Perry published a huge number of studies
  showing abnormal brain development following
  neglect and abuse of children including
  significantly smaller brains, decreased activity
  in their prefrontal cortex(the moral center/the
  restraint center/the maturity center.)
• Depressed and angry mothers regularly produce
  insecurely attached infants who grow up be
  violent adults.
• The Bomb in the Brain (Freedomain Radio)

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• Abusive mothers who are depressed or angry the
  cortisol levels of both elevated in the mother
  and the child. If you are depressed or angry
  your cortisol levels are higher in both you and
  your child. The mother and the child are a system
  particularly for the 1st few years of life
• Their hippocampus shrinks and they can have
  memory issues
• The amygdala of insecurely attached children is
  larger and they have a greater surging of fight
  or flight, adrenaline and cortisol.
• Their prefrontal cortexes are smaller so they are
  less able to control their fears and other
  irrational emotional reactions in interpersonal
  relationships.
• Physical problem in the brain-fight and flight is
  strong and restraint is weak.
• The Bomb in the Brain (Freedomain Radio)

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• Ainesworth 100 studies over past two decades have
  shown that violence is the result of insecure
  early disorganized attachment
• Violence and Crime-Bessel Vander Colk concludes
  people with childhood, abuse and neglect make up
  almost the entire criminal justice population in
  the United States. Suffered severe abuse.
• Poorly integrated cerebral hemispheres- this poor
  integration and underdevelopment of the orbital
  frontal cortex is the basis for such symptoms as
  difficulty regulating emotions, and lack of cause
  and effect thinking
• The Bomb in the Brain (Freedomain Radio)

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TRAUMA AND SUBSTANCE ABUSE
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THE WAY WE USED TO LOOK AT SUBSTANCE ABUSE AND
TRAUMA

• MENTAL ILLNESS

SUBSTANCE ABUSE
TRAUMA
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THE RELATIONSHIP BETWEEN TRAUMA SUBSTANCE ABUSE

• TRAUMA

SUBSTANCE ABUSE
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THE RELATIONSHIP BETWEEN TRAUMA SUBSTANCE ABUSE

• Those who have been traumatized are at risk for
  substance abuse and those who use substances are
  at risk for experiencing trauma.
• 90 of women who are addicted to alcohol were
  physically or sexually abused as children
  (National Trauma Consortium)
• Victims of trauma are 4-to-5 times more
  vulnerable and therefore likely to experience
  alcohol or substance abuse than the general
  public.
• 82 of adolescents in residential or inpatient
  programs have been a victim of sexual or physical
  abuse.

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THE RELATIONSHIP BETWEEN TRAUMA SUBSTANCE ABUSE

• Escape
• Numbing
• Control
• Distraction
• Self-destructive
• Feel powerful
• Diminish shame and guilt
• Protection
• Acceptance
• Increase or decrease hyper-vigilance/anxiety

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BEST TREATMENT PRACTICES

• Psycho-education(normalization of symptoms)
• About Effects of Trauma, PTSD
• 2) Regulation
• Trigger Recognition
• Grounding,
• Containment Distancing
• Guided Imagery/Calm Place
• Breathing
• Meditation
• Yoga
• Mindfulness
• Journaling
• Music
• Developing a Support System

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• 3) Processing the Trauma
• ? Trauma Focused Cognitive Behavior Therapy
  (TF-CBT by J.A Kohen)
• ? Somatic Experiencing/Body Psychotherapy(SE
  , Peter Levine, Pat Odgen)
• ? Acceptance and Commitment Therapy(ACT by
  Steve Hayes, Kelly Wilson)
• ? Eye Movement Desensitization and
  Reprocessing(EMDR, Francine Shapiro)
• ? Emotional Freedom Technique(EFT, Gary Craig,
  Nick Ortner)

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EYE MOVEMENT DESENSITIZATION AND REPROCESSING

• Created by Francine Shapiro in 1987.
• Bilateral stimulation through eye movements
• Natural way brain processes information and heals
  self(REM Sleep)
• Treats PTSD and a wide range of mental health
  issues.
• Trauma overloads the brains natural coping
  mechanism.
• Unprocessed memories and feelings are stored in
  limbic system of your brain in a raw and
  emotional form, rather than in a verbal story
  mode. These memories can be continually triggered
  when a person experiences event similar to past
  traumatic events.
• EMDR helps create connections between memories,
  enabling the brain to process the traumatic
  memory in a very natural way.

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TREATING TRAUMATIC MEMORIES

• Normal Event

PROCESSING
MEMORY STORED
NORMAL EVENT
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PROCESSING TRAUMATIC EXPERIENES

Distress (No Processing)
Traumatic Event
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PROCESSING TRAUMATIC EXPERIENES

Exposure/EMDR
Traumatic Event
Grading
Memories/Less Distress
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EMDR PROCESS

• Sudden Units of Distress(0-10)
• Emotions Experienced
• Negative Belief About Self
• Validity of Cognition/Positive Belief(0-7)
• Body Scan
• Future Templates

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POST TRAUMATIC GROWTH

• It is the positive change experienced as a result
  of the struggle with a major life crisis or a
  traumatic event
• New opportunities have emerged from the struggle,
  opening up possibilities that were not present
  before
• Change in relationships with others including
  increased compassion or connectedness
• Change in an increased sense of ones own
  strength
• Greater appreciation for life
• Deeping of Spirituality or Change in Beliefs
• It can also increase their resiliency to
  subsequent adversity
• Dr. Richard Tedeschi

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REFERENCES

• Books
• Opening Up the Healing Expressing of Emotions by
  J. Pennebaker
• Outgrowing the Pain by Elaina Gill
• Trauma and Addiction by Tian Dayton, Ph.D.
• Trauma Recovery by Judith Herman
• Diagnostic Statistical Manual of Mental Disorders
• Eye Movement Desensitization and Reprocessing
  Basic Principles, Protocols, and Procedures by
  Francine Shapiro
• EMDR The Breakthrough Therapy by Francine
  Shapiro, PHD
• Trauma Model Colin Ross
• The Developing Mind Daniel Seigal
• Waking the Tiger Peter Levine
• Trust After Trauma Matskis
• Articles
• Crandall, Mark (2007) Post Traumatic Stress
  Disorder What Happens to the Brain.
• Website
• http//acestudy.org/
• Presentations

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• Websites
• Darkness to Light(d2l.org) 
• National Institute of Mental Illness (nih.gov) 
• ISSDT (isst-d.org)
• National Child Abuse Statistics (childhelp.org)
• Sidran.org
• National Alliance on Mental Illness (nami.org)
• Giftfromwithin.org