Transcript Recapitulating Erickson`s Stages in the Treatment of Posttraumatic

The Treatment of Trauma:
Recreating Developmental Stages
Ron J. Llewelyn Psy.D.
Amanda GallowayACMHC-i
Dr. Llewelyn’s Affiliations:
Living Waters Counseling LLC., University of Phoenix, Valley Mental Health,
& The Center for Christian Therapy
Objectives
Learn about the theory,
research and utilization of
Posttraumatic Growth in
our everyday and
therapeutic interactions
offenders and survivors.
Be able to identify the
obstacles that limit a
person’s ability to become
a thriving individual
Walk away with specific
methods to help those
effected by domestic
abuse
Explore Eriksonian and
Freudian developmental
models
Learn to re-create the
developmental conflicts in
treatment.
Understand how
developmental recreation
may enhance
Posttraumatic Growth
Psychological Trauma: The sudden
uncontrollable disruption of our
affiliative bonds.
Lindemann 1944
Types of Offenders
Socially limited
Borderline/Jealous
Antisocial/Narcissistic
Domestic Violence in 3 Minutes
Offender
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Offender
Perception of self (un-projected or reversed)
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Is a threat to their own sense of stability
Has too much power
Can be difficult
May abandon them
The “safest” place to project to
Perception of others and the world
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Fears being found out
Fears not being able to look competent
Needs to use persona
Well-meaning others may expose their incompetence’s
Perception of self starts to change
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Self is threatened
Often insecure
Lost
Out of control
Fears being blamed
Fears abandonment
Underlying shame
Feels limited options
Jealous
Perception of Survivor
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Survivor
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Idealization of the Offender
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May rationalize their behavior to others
May rational their behavior to self
May blame self for their behavior
Due to isolation, feels they are the only one there for them
My become dependent upon them
May perceive them with unrealistic power.
Perception of Close others & the World
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Lowered or lost confidence
Questioning own decisions
Questions if anyone loves them
Blames self for others leaving
Starts to feel defiled
Starts to feel helpless
Starts to feel hopeless
Feels shame, guilt and blame
Identifies with abuser language
Believes that options are few
Increase sense of insecurity
Increase in emotional states
Turning Against the Self
Due to isolation, may feel abandoned
Others will not understand
May see others as a threat
People have failed to rescue them
Understanding the Diagnosis
Diagnostic Comparison
Type 2 – Complex PTSD
Type 1 - PTSD
Affect
Regulation
Re-experiencing
System of
meaning
Consciousness
Avoidance
Numbing
SelfPerception
Somatic
Hyperarousal
Relationships
Perception
of
Perpetrator
Persistent
Dysphoria
Chronic Suicidal
Ideation or SelfInjurious/Parasuicidal
Behavior
Pattern of Generally
Poor Modulation of
Emotional Response
Affect
Regulation
Explosive
Anger/Anger
Inhibition
Emotional Flashbacks
Compulsive
Promiscuity/Extreme
Sexual Inhibition
Amnesia/Hyper
mnesia
Intrusive
Re-experiencing
Deviations
in
Consciousness
Derealization
Depersonalization
Pervasive Sense
of Helplessness
Complete
Difference from
Other People
Alterations
in
Perception
of Self
Feeling Defiled
or Stigmatized
Self-Blame, Guilt,
Shame
Preoccupation with
the Relationship
Acceptance of
Perpetrator’s
Belief System or
Rationalizations
Alterations
in Perception
of
Perpetrator
Idealization of the
Perpetrator or the
Relationship
Preoccupation with
Revenge
Attributing
Perpetrator with
Unrealistic Power
Isolation &
Withdrawal from
Other People
Repeated Failures
in Self-Protection
Disruption in
Intimate
Relationships
Alterations
in
Relationships
with Others
Repeated Search
for a
Rescuer
Persistent Distrust
Anniversary
of Trauma
Occurrences
Shortness of
Breath, Chest
Pains
Re-Experiencing
Physical Sensations
Related to the
Trauma
Somatic
Flashbacks
Bruising,
Sensation of
Being Burned
or Cut
Conversion
Symptoms (Anxiety
Converted into
Physical Symptoms
Numbness, Paralysis,
Isolated Limb
Weakness, Blindness,
Seizures
Digestive
System
Complaints
Chronic Pain
(Headache,
Backache, Deep
Muscle or Bone Pain)
Loss of Sustaining
Faith
Alterations
in Personal
System of
Meaning
Pervasive Sense of
Despair
Pervasive Sense of
Hopelessness
Cognitions & Loss of Meaning
Janoff-Bulman
Epstein
We are not vulnerable
The World is a Source of Joy
The World is Predictable & Controllable
The World is Controllable
We Merit Self Worth
I am Competent & Good
What Is Posttraumatic Growth?
A Disorder?
Areas of Posttraumatic Growth
Outcomes
Grubaugh & Resick, 2007
Improved self efficacy
Change in how one relates to others
Increased Spirituality
Aware of New Possibilities
Greater Appreciation for Life
A Brief Overview of the 3 Staged
Treatment Model for Type II PTSD
Three Stages
3 Reconnection
2
Process &
Grieving
1
Stability
Stage One:
The Corrective Therapeutic Experience:
Working with Attachment, Intrapsychic Conflict, and
Transference Neurosis
Stage one:
Stabilization
Primarily a personal experience
Education
Physical Well
Being
Self Soothing
Primarily a social experience
Boundaries
Safety &
Safety
Planning
Trust
Three Stages in a Social Context
Stage One:
Key Terms
Attachment
Transference & Transference Neurosis
Countertransference
Repetition Compulsion
Temporary Regression
Defense Mechanisms
Stage One:
Psychoeducation
Symptom
Awareness
Environmental
Awareness
• Education about Symptoms/Fight or Flight/Kindling
• Increase right limbic, decrease in prefrontal cortex and
Broca’s Area.
• Disorganized Memory Storage/affective, cognitive &
behavioral incongruence (See next slide)
• Re-enactments
• Alexithymia
• Monitoring stimuli and associated reactions
The Neurobiology of the Fight or Flight Response
Stressful
Event
Thalamus
This occurs before
information
reaches the Cortex
Cortex
Amygdala
Locus Coeruleus
Hypothalamus
Sympathetic NS
Pituitary
Adrenal Medulla
Thyroid
Thyroxin
Adrenal Cortex
Cortisol
Adrenaline
Noradrenalin
Adapted from Preston, O’Neal, & Talaga 2010
Neuro-anatomical Factors
Genetic Expression
Static vs.
Dynamic
Systems
Environmental
Influence
Up/Down
Regulation
Receptor
Change
NT production
Stage One:
Physical Well Being
Medication
Comfort in
Own Skin
Well
Being
Reduced
Caffeine
Diet
sleep
Exercise
Stage One:
Self Soothing
Relaxation Anxiety
Counter-conditioning
Reversal of Operant Conditioning
Stage One:
Self Soothing
Breathing
Exercise/Activity
Clients discover and
adopt healthier
ways of coping with
stressors.
Guided imagery
Journaling/Writing
Art
Music
Nature
Beyond the Pre-Frontal Cortex:
Sensory Motor Trauma Therapy
Stage One:
Safety, Trust & Boundaries
Trust vs.
Mistrust/Oral
Autonomy vs.
Shame &
Doubt
Treatment Through the Corrective
Therapeutic Experience
An In Depth Look at Safety, Trust &
Boundaries
Stage One:
Psychosocial Redevelopment
(Herman, 1992)
Early Stages of Life and Their Spatial
Needs.
(Erikson 1968)
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
Stage 6
Stage 7
Stage 8
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To Receive
To Give in Return
To Hold On
To Let Go
To Make (Go After)
To Make Like (Play)
To Make Things
To Make Things together
To Be Oneself
To Share Being Oneself
• To Lose and Find Oneself in others
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To Make Be
To Take Care of
To be through having
To face not being
Developmental Models
Trust vs. Mistrust
Autonomy vs. Shame
& Doubt
Oral
Anal
Hope
Willpower
Purpose
Initiative vs. Guilt
Industry vs.
Inferiority
Genital
Competence
Latency
Fidelity
Identity vs. Role
Confusion
Intimacy vs.
Isolation
Love
Phallic
Generativity vs.
Stagnation
Care
Integrity vs. Despair
Wisdom
Adapted from Childhood & Society Erikson 1950.
VIII
Old Age
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VII
Adulthood
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VI
Young
Adulthood
V
Adolescence
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IV
School Age
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III
Play Age
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II
Early
Childhood
I
Infancy
Integrity vs.
Despair
Generativity
vs. Stagnation
Intimacy vs.
Isolation
Identity vs.
Confusion
Industry vs.
Inferiority
Initiative vs.
Guilt
Autonomy vs.
Shame & Doubt
Basic Trust vs
Mistrust
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2
3
4
5
6
7
8
Erikson
Eriksonian &Freudian Basics
Crucial Moments
Ratio of Development
Ontogenesis of Hope
Fixation (war)
War
Crisis 1
Crisis 2
Crisis 3
A Strange Situation
Secure
Attachment
Avoidant
Ambivalent
Disorganized
Ainsworth, M. D. S., Bell, S. M., (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange
situation. Child Development, 41, 49-67.
Homeostatic Mechanism of Attachment
“The attachment system acts as
a kind of homeostatic
mechanism for modulating
anxiety and stress by seeking
out an attachment figure for
security and protection.”
(Bowlby, 1978)
Janssen, C. G. C., Schuengel, C., & Stolk, J. (2002). Understanding challenging behaviour in people with severe and profound intellectual disability: A stress-attachment model. Journal of Intellectual
Disability Research, 46, 445-453.
Attachment
(Bartholomew, 1990; Muller & Rosenkranz, 2009)
Stage One:
Safety
Environment
Structure
Predictability
Safety
Stage One:
Safety
Seeking
Help
Change
Trust
Vulnerability
Stage One:
Boundaries
The therapist models
appropriate boundary
setting and enforcement.
The client’s dependence
on the therapist is
redirected toward a
sense of personal
empowerment in the
therapeutic environment.
Enhancing Posttraumatic Growth
through the Corrective Therapeutic
Experience
Repetition Compulsion
“The patient cannot remember the
whole of what is repressed in him, and
what he cannot remember may be
precisely the essential part of it…He
is obliged to repeat the repressed
material as a contemporary
experience instead of remembering it
as something in the past.”
• Sigmund Freud
The Transference Neurosis
Other
previous
relationships
Group
Member
Clients
Offender
Client
Group
Member
Therapist
Violation of
Silence
Group
Member
Essential Treatment Factor
Trust Vs. Mistrust
(Hope)
First World
Ontogenesis of
Hope
Delay of
Gratification/Abandonment
Trust
vs.
Mistrust
Autonomy
vs Shame
& Doubt
Repetition Compulsion:
Transference Testing
Transference
Testing
•Will you do
it?
Passive To
Active
Transformation
•Can you
handle it?
The Transference Neurosis
An Omnipotent Rescuer
An Unpredictable Abuser
Our desire
to save
Our
agenda
Our Own Issues
Inability to sit
with client
Our
projections
Or reenactments
Overly rigid
boundary
response
Overly
Permeable
boundary
response
Autonomy vs. Shame & Doubt
Immature
Dependence
Mature
Dependence
Autonomy vs. Shame & Doubt
(Will Power)
Self Control without loss of self-esteem
Compulsive compliance
or impulsive defiance
Will Power
Autonomy
vs. Shame
& Doubt
Initiative
vs. Guilt
The Therapist Should…
Herman (1997) pg. 135
Remain “Disinterested”
Remain “Neutral”
Initiative vs. Guilt
(Purpose)
Development of
Superego
Development of
Roles
Finding Purpose & Self
Initiative
Initiative
vs. guilt
Industry
vs.
Inferiority
Industry vs. Inferiority
(Competence)
Take School & Cultural
Role
Development of
inadequacy
Competence
Industry
vs.
Inferiority
Identity
vs.
Identity
Confusion
Identity & Repudiation vs. Identity Confusion
(Fidelity)
Impulse Vs. Compulsive
Restraint
Self-Definition
Fidelity
Identity
vs.
Identity
Confusion
Intimacy
vs.
Isolation
Intimacy & Solidarity vs. Isolation
(Love)
Self Abandonment
“Way of Life”
The Defensive Wall
Intimacy
vs.
Isolation
Generativity
vs. Self
Absorption
Generativity vs. Self-absorption/Stagnation
(Care)
Dependency & Maturity
are Reciprocal
Guiding the Next
Generation
Relation to Stage 3
Generativity
vs. Self
Absorption
Integrity vs.
Despair
Integrity vs. Despair
(Wisdom)
Integrity of
experience
Letting go
Sign of conflict is
doctoring of memories
Generativity
vs. Self
Absorption
Contact:
[email protected]
Thank You