Transcript BEST TREATMENT PRACTICES FOR TRAUMA

BEST TREATMENT PRACTICES
FOR TRAUMA RECOVERY
TRAUMA DEFINED
• A traumatic event involves a single experience, or an enduring, or
repeated events, that completely overwhelm the individual’s 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 one’s life, or that of a loved one’s, to bodily
integrity, or sanity.
• There is frequently a violation of a person’s familiar ideas about the
world and their human rights, putting the person in an extreme state of
confusion, and insecurity.
• Reactions: physiological and psychological.
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
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
It’s not the event that determines whether
something is traumatic, but the individual’s
experience of the event
CHILDHOOD TRAUMA & ABUSE
ABUSE STATISTICS
• 1 out of 3 women will experience sexual abuse by the time they are 18 years
old. (The Public’s 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 Public’s Health 2009)
• Over 3 million cases of child abuse are reported each year in US. Those
reports can have multiple children in them. (NCAS)
PYCHOLOGICAL AFFECTS OF ABUSE
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PTSD
Anxiety/Panic
Agoraphobia/Phobias
Irritability
Substance Abuse
Personality Changes/ Disorders
Dissociative Disorders
Negative Self-concept
Obsessive Compulsive
Depression
Failure to thrive
Rage
Mood Disorders
Eating Disorders
Suicidal and Homicidal Ideation
Self-Injury/Cutting
Abusive Partners
Feelings of Powerlessness
RELATIONSHIP ISSUES
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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
ACADEMIC ISSUES
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Inability to concentrate
Lower test scores
Comprehension problems
Memory deficits
Peer relational issues
Communication problems
Attendance issues
Teen Pregnancy
POST TRAUMATIC STRESS DISORDER
PTSD SYMPTOMS
1) Intrusive re-experiencing of the trauma
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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
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3) Avoidance of stimuli and numbing response
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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
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
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• Adaptive Survival Skill can become maladaptive
• Can be done consciously or automatically
• It can become pathological and interfere with daily functioning
PTSD SYMPTOMS
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Survivor’s Guilt
Rage
Depression and Grief
Anxiety and Panic
Shame and Fear
Trust Issues
Loss of appetite
Sexual dysfunction
Poor coping skills
Feelings of hopelessness
RISK FACTORS
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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
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
DEVELOPMENTAL TRAUMA
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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
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
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
TYPES OF ATTACHMENT
Secure
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Parent is aligned with the child and in tune with the child’s emotions, trustworthy, and reliable.
Adult is able to create and maintain relationships
Ambivalent
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Parent is inconsistent, unpredictable and sometimes intrusive parent communication
Adult is anxious and insecure, controlling, blaming, erratic, unpredictable, and sometimes charming
Avoidant
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Parent is unavailable or rejecting, and punitive
Adult avoids closeness, or emotional connection, distant, superficial relationships, critical, rigid or
intolerant
Reactive
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Parent is extremely unattached or malfunctioning, and abusive
Adult cannot establish positive relationships, withdrawn, substance abuse
Disorganized
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Parents ignored, or did not see the child’s needs. Parental behavior was frightening or traumatizing.
Often sexual, or physical abusive
Adult is chaotic, insensitive, explosive, abusive, untrusting, while craving security
SECURE ATTACHMENTS HELP US:
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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
INSECURE ATTACHMENTS:
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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
ADVERSE CHILDHOOD EXPERIENCE STUDY
BY 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
ADVERSE CHILDHOOD EVENTS(ACE STUDY)
(Kaiser Permanente)
People with 4 or more ACE were at greater risk for
serious health issues
ACE STUDY FINDINGS
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Alcoholism and alcohol abuse
Smoking
Depression
COPD
Fetal death
Liver disease
Autoimmune Disease
Autobiographical Memory Disturbance
• Risk for intimate partner violence
• Sexually transmitted diseases
• Early initiation of sexual activity
Illicit Drug Use
Early Initiation of Smoking
Suicide Attempts
Ischemic heart disease (IHD)
Health-related quality of life
Obesity
Increased risk for Cancer
Hallucinations
Multiple sexual partners
Unintended pregnancies
Adolescent pregnancy
MEDICAL RISKS
(The Public’s Health 2009)
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Obesity
Headaches
Lowered Immune System
MS, Lupus, Fibromyalgia
Gynecological issues
Heart disease
Sexual Disorders
Somatic complaints and Body aches
Fibromyalgia
Increased Risk of Cancer
Hypertension
Stomach Problems
Chronic Fatigue
Early hysterectomies
Diabetes
Substance Abuse
STD’s
MS, Lupus
Autoimmune Disorders
Premature Death
HOW TRAUMA IMPACTS THE BRAIN
EMOTIONAL NERVOUS SYSTEM
TWO PARTS OF NERVOUS SYSTEM
Limbic
System
Autonomic
Nervous
System
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
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_
LIMBIC SYSTEM
AUTONOMIC NERVOUS SYSTEM:
1)PARASYMPATHETIC
RESTRICTED
2)SYMPATHETIC
ACTIVATED
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.
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.
• During the first 4 years of life 90% of a child’s 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)
• 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)
• 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)
TRAUMA AND SUBSTANCE ABUSE
THE WAY WE USED TO LOOK AT SUBSTANCE
ABUSE AND TRAUMA
SUBSTANCE
ABUSE
MENTAL ILLNESS
TRAUMA
THE RELATIONSHIP BETWEEN TRAUMA &
SUBSTANCE ABUSE
TRAUMA
MENTAL
ILLNESS
SUBSTANCE
ABUSE
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)
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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.
THE RELATIONSHIP BETWEEN TRAUMA &
SUBSTANCE ABUSE
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Escape
Numbing
Control
Distraction
Self-destructive
Feel powerful
Diminish shame and guilt
Protection
Acceptance
Increase or decrease hyper-vigilance/anxiety
BEST TREATMENT PRACTICES
1) 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
3) Processing the Trauma
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Trauma Focused Cognitive Behavior Therapy (TF-CBT by J.A Kohen)
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Somatic Experiencing/Body Psychotherapy(SE , Peter Levine, Pat Odgen)
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Acceptance and Commitment Therapy(ACT by Steve Hayes, Kelly Wilson)
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Eye Movement Desensitization and Reprocessing(EMDR, Francine Shapiro)
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Emotional Freedom Technique(EFT, Gary Craig, Nick Ortner)
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.
TREATING TRAUMATIC MEMORIES
Normal Event
PROCESSING
NORMAL EVENT
MEMORY STORED
PROCESSING TRAUMATIC EXPERIENES
Traumatic Event
Distress (No Processing)
PROCESSING TRAUMATIC EXPERIENES
Exposure/EMDR
Traumatic
Event
Grading
Memories/Less Distress
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
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 one’s 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
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
Kehler, Byron Guiding Survivors of Childhood Trauma through Recovery
The Bomb in the Brain Freedomain Radio
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