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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
[email protected]
www.drchriscourtois.com
Types of Trauma
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Accidental
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Interpersonal
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Combination
Interpersonal Trauma:
“A break in the human lifeline”
Robert J. Lifton
Self and interpersonal effects
brought to treatment
Types of Traumatic Stressors
Emotional Trauma
“It is the essence of emotional trauma that it
shatters…absolutisms, a catastrophic loss of
innocence that permanently alters one’s
sense of being-in-the-world.”
(Heidegger, quoted in Stolorow, 2007)
Types of Trauma
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Type I
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Type II
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Overlap
Types of Trauma
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Attachment/Relational
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Emotional
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Betrayal
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Secondary/ “second injury”/institutional
What is Complex Trauma?
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Repetitive, chronic
Cumulative
Often in attachment relationships
• Entrapment & betrayal; second injury
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Often over the course of childhood
• Impacts development
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Other…
Trauma and Development
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Attachment trauma
Attachment style and Inner Working Model
• Secure
• Insecure
• Disorganized
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Lack of self validation/reflection
Effect on brain development
• Survival brain vs. learning brain
Trauma and Development
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Can effect development starting at the
neuronal level
• Neurons that fire together wire together
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Can affect brain structure
Can affect brain function
Right brain/sensory-motor imprint
Left brain development impeded
• There may be no words
• Speechless terror
Types of Traumatic Stressors
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Attachment/Relational Trauma
u occurs in attachment relationships with primary
caregivers
F insecurity of response and availability
F mis-attunement, non-response
F lack of caring and reflection of self-worth
F caregiver as the source of both fear and comfort
u includes DV and child abuse of all types
F often “on top of”/in context of attachment insecurity
F neglect, abandonment, non-protection, nonresponse, sexual and physical abuse and violence,
verbal assault
Risk/Vulnerability and Protective
Factors
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Temperament
Gender
Personal history
• Previous trauma/PTSD
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Culture
Community
• Support or not
Posttrauma Adaptations
(adapted from Wilson, 1989)
Note: most individuals who are seriously
traumatized have posttraumatic reactions;
not all develop posttraumatic disorders.
DSM-IV Criteria: PTSD
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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
Posttraumatic Diagnoses, DSM-IV
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Dissociative Disorders
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Depersonalization
Dissociative fugue
Dissociative amnesia
Dissociative Identity Disorder
– related to severe childhood trauma
• DDNOS
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Associated Disorders: Axis I, II, & III
Limbic System of the Brain
Limbic System of the Brain
Posttraumatic Stress Disorder
(PTSD)
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A complex dynamic entity
• fluctuating, not static
• variable in form, presentation, course, degree of
disruption
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A multimensional bio-psycho-social-
spiritual-gender
stress response syndrome
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An allostatic condition
Posttraumatic Stress Disorder
(PTSD)
Allostasis: “refers to the body’s effort to
maintain stability through change when
loads or stressors of various types place
demands on the normal levels of adaptive
biological functioning…The 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)
Allostasis:
One’s thermostat is broken
Stress overload
Post-trauma Responses and Disorders
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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)
Complex Posttraumatic Stress Disorder
Disorders of Extreme Stress Not Otherwise Specified
(DESNOS)
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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
PTSD in Children
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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
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Children are very vulnerable, yet resilient
• on average, takes less to traumatize them
(Proposed) Developmental Trauma Disorder
(van der Kolk, 2005)
n
Domains of impairment in children
exposed to complex trauma:
u Attachment/relationship capacity
u Biology
u Affect regulation
u Dissociation
u Behavioral control
u Cognition
u Self-concept
Symptom Categories and Diagnostic Criteria
for Complex PTSD/DESNOS
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l. Alterations in regulation of affect and
impulses
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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
Symptom Categories and Diagnostic Criteria
for Complex PTSD/DESNOS
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3. Alterations in self-perception
• a. Ineffectiveness
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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
Symptom Categories and Diagnostic Criteria
for Complex PTSD/DESNOS
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5. Alterations in relations with others
• a. Inability to trust
• b. Revictimization
• c. Victimizing others
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6. Somatization
• a. Digestive system
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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
Complex PTSD/DESNOS
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Controversial
Not a formal DSM diagnosis: Associated
Feature of PTSD
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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
Attachment Organization
(Ainsworth, 1978; Liotti, 1992; Main, 1986, Siegel, 1999)
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Child style
• secure
• insecure-avoidant
• insecure-dismissing/
resistant/ambivalent
• insecure-disorganized/
disoriented/dissociated
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Adult style
• autonomous
• dismissive/detached
(“teflon”)
• preoccupied/anxious
(“velcro”)
• fearful/anxious
unresolved/dissociative
Attachment Relationships
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“…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)
Implications for Treatment
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Attachment abuse including ongoing neglect and
failure to respond and soothe a child (neglect) is
implicated in the development of the DD’s
• a wider base beyond overt physical and sexual
abuse from which to understand DD’s
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
Evidence-Based Practice
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Best research
evidence
Clinical expertise
Patient values,
identity, context
American Psychological
Association Council of
Representatives Statement,
August 2005
Note:
EBT (Evidence-Based Therapy)
is NOT the same as
EST (Empirically-Supported
Therapy)
Evidence-Based Practice
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Best research evidence, including:
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Effectiveness
Public health
Health services
Health care economics
Evidence-Based Practice
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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 client’s contexts, values
• Using available resources
• Working from theory
Evidence-Based Practice
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Patient identity, values, contexts
• Ethnicity, race, culture, language,
gender, sexual orientation, religion,
age, illness or disability status
• Treatment acceptability
Expert Consensus Guidelines for “Classic PTSD”
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ISTSS Guidelines (Foa, Friedman, & Keane, 2000,
2008)
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Journal of Clinical Psychiatry (2000)
American Psychiatric Association (2003)
Clinical Efficiency Support Team (CREST,
Northern Ireland, 2003)
Veterans’ Administration/DoD (US, 2004)
u National Institute of Clinical Excellence (NICE,
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UK, 2005)
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Australian Centre for Posttraumatic Mental Health
(2007)
Other Expert Consensus Guidelines
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Dissociative Disorders
• Adult (ISSD, 1994, 1997, 2005, in revision
• Children (ISSD, 2001)
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Delayed memory issues
• Courtois (1999; Mollon, 2004)
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Complex trauma (under development)
• (Courtois, 1999; CREST, 2003; Courtois &
Ford, 2009; ISTSS complex trauma expert
consensus survey, in process)
Effective Treatments for PTSD*
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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
Treatment Goals
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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
Treatment Goals
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restore self-esteem, personal integrity
• normal psychosexual development
• reintegration of the personality
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restore psychosocial relations
• trust of others
• foster attachment to and connection with others
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restore physical self
restore spiritual self
prevent re-victimization/reenactments
SAFETY IS THE FOUNDATION
Treatment Principles
“First, do no more harm”
Treatment can help and treatment can hurt
both the helper and the client
Treatment Principles
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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
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Client empowerment/colloboration
• client engagement in the process, with responsibility for
progress
• client consulted on/understands treatment plan
• posttraumatic treatment philosophy and techniques
explained
Treatment Principles
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Safety and protection
• Safety of self and others, to and from others
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Relationship issues
• Boundaries, limitations, respect
• Responsibilities of the therapist
– trustworthy/non-exploitive
– relationship as container
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Informed consent/refusal; client rights
• professional privilege/limits of confidentiality
• right to seek consultation/2nd opinion
• rights to refuse and terminate treatment
Treatment
Variable Adaptations
Variable and Multi-modal
Treatments
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
Complex Trauma Treatment
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PTSD symptoms
Depression, anxiety, & dissociation
Problems with affect regulation
• may rely on maladaptive behaviors, substances
• problems with safety
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Negative self-concept
Problems with self, attachment,relationships
• revictimization/re-enactments
• needy but mistrustful
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Problems functioning?
Physical/medical concerns
Other...
Complex Trauma Treatment
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“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
Treatment Sequence
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Safety, stabilization, skill-building
Trauma processing
Integration and meaning, self and
relational development
Treatment Sequence:
General Stages of Treatment
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Pre-treatment stage: Contracting, assessment, pretreatment 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
Treatment: Chronic PTSD
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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.
Treatment: Chronic/Complex PTSD
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Ongoing assessment
Longer term treatment (ongoing or episodic)
• comorbidity/dual dx/co-ocurring dx
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Sequenced treatment
• more initial emphasis on stabilization, selfmanagement, affect regulation, safety, relapse planning
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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, couple’s or family work
“Hybrid” Models for Complex Trauma
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TARGET (Ford)
STAIR-NTP (Cloitre)
Seeking Safety (Najavits)
ATRIUM (Miller)
SAFE Alternatives (Conterio & Lader)
Others...
Treatment
Like Posttraumatic Disorders,
comprehensive treatment must be
BIOPSYCHOSOCIAL/SPIRITUAL
&
Culture and Gender Sensitive
Bio/Physiological Treatments
• Psychopharmacology
– evidence base developing re: effectiveness
– algorithms developed
– not enough by itself
• Medical attention
– preventive
– treatment
• Movement therapy
Bio/Physiological Treatments
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Stress management
Self-care/wellness:
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Exercise (w/ care)
Nutrition
Sleep
Hypnosis/meditation/mindfulness
Addiction treatment
– Alcohol, drugs, prescription drugs
– Smoking cessation
– Other addictions (sexual, spending)
– Relapse planning
Bio-physiological Treatments
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Somatosensory/Body-focused Techniques
(Levine; Ogden; Rothschild, Scaer)
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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
Psychosocial/Spiritual Treatments
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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
Psychosocial/Spiritual Treatments
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Psych-education (individual or in group)
individual and group therapy
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trauma focus vs. present focus
skill-building
core affect and cognitive processing
developing connection with others
– identification and meaning-making
• concurrent addiction/ED
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couple and family therapy
Psychosocial/Spiritual Treatments
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adjunctive groups/services
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AA, Al-Anon, ACA, ACOA, etc.
Social services/rehabilitation
Career services
Internet support and information
spiritual resources: finding meaning in suffering
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Pastoral and spiritual care
Organized religion
Other religion/spirituality
Nature, animals
Cognitive Behavioral, Emotional/
Information Processing Treatments
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Education & skill development
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numerous workbooks now available on a wide
variety of topics
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Exposure and desensitization (Foa et al.)
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general, CD, self-harm, risk-taking, eating,
dissociation, spirituality, career, etc.
prolonged & graduated
Writing/journaling
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CPT (Resick)
Journaling (Pennebaker)
Cognitive Behavioral, Emotional/
Information Processing Treatments
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Schema therapy (Young; McCann & Pearlman)
DBT (may involve “tough love stance”) (Linehan)
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mindfulness and skill-building
Narrative therapies (various authors)
Strength/resilience development
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EMDR resource installation (Leeds & Korn)
Developmental Needs Meeting Strategy (Schmidt)
u Internal Family System work (Schwartz)
u Solution-focused treatment (O’Hanlon)
F
Cognitive Behavioral and
Information-Processing Treatments
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EFTT: emotion-focused therapy for trauma
(Paivio)
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ACT: acceptance and commitment therapy
(Hayes, others)
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FAT/FECT: Functional Analytic Therapy
(Tsai, Kohlenberg)
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IRRT: imaginary re-scripting and reprocessing therapy
(Smucker)
Virtual Reality
(Rothbaum, others)
Affect-Based Treatments
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AEDP: Accelerated Experiential-Dynamic
Psychotherapy
(Fosha)
Affect Experiencing-Attachment Theory
Approach
(Neborsky)
Healing the Incest Wound
(Courtois; Roth & Batson)
n
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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)
Core Affects
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Fear/terror
Anxiety
Depression
Anger/rage/outrage
Shame
Self-blame/guilt
Confusion
Grief/mourning/sadness
Alienation
Other…
Relational/Attachment Treatments
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Understand client’s attachment style and
Inner Working Model
• Helps expect how the client relates and behaves
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Strategize how to respond
Goal: to move to secure attachment through
insights gained in and through the therapy
relationship
Relational/Attachment Techniques
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Interpersonal neurobiology (Schore, Siegel)
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Relational and affect-based psychoanalytic tx
Patient in relationship with others
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determine attachment style
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Therapist
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F
F
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determine attachment style
secure connection with the therapist to foster secure
connections elsewhere (“earned security”)
transference/countertransference, enactments, VT
Spouse/partner/significant other
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couple and family work
Relational/Attachment Techniques
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Hypnosis or EMDR-based internalization of
attachment
(Brown; Leeds & Korn; Omaha)
Children
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Friends
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parenting help/training
substitute family
social and friendship skills
Support systems
Work colleagues
Note: Various workbooks and community
training programs available for these
Hypnosis/Guided Imagery Techniques
Caution: for ego development, self-soothing,
attachment, not for memory retrieval
n Hypnosis
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Brown & Fromm; Brown
Dolan
Phillips & Frederick
Kluft
Schwarz
Guided Imagery
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Naparstek
Expressive Techniques
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Art
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collage
images
pottery/clay work
Poetry/writing
Psychodrama
Movement
Spirituality/Mindfulness
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Nature
Specific spiritual writers and orientations
The meaning of suffering
Existential issues
Religion
Pastoral care/spiritual issues
Prayer
Spiritual formation
Cultural/Ethnic/Gender/Religious
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Social context/ethnic group and how it
might contributes to trauma
– racism, sexism, heterosexism and homophobia,
cultural or ethnic norms, colonialism, etc.
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Blocks or supports to healing
Take these issues into account
Healing rituals
Healers
Treatment: Chronic/Complex PTSD
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Some never fully recover from symptoms
even after many years/intensive treatment
• those w/ history of childhood abuse/trauma
and other risk factors
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The absence of symptoms does not mean
that the disorder has run its course
• patterns of cyclical decompensation have been
identified
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Treatment is applied according to the phase
of the decompensation cycle
Summary
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Trauma studies have increased information
and understanding
• Trauma can vary dramatically, as can responses
• New conceptual and diagnostic models account
for variability
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Treatment
• Is multimodal
• Is bio-psycho-social
• Must be individualized
– type of trauma response/disorder
– individual needs
• Has some empirical support…more to come!
Resources
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ISTSS.org
ISSTD.org--new name; formerly (ISSD.org)
• 9 month-long courses on the treatment of DD’s-various locations
NCPTSD.va.gov (info and links)
NCTSN.org (child resources)
Sidran.org (books and tapes)
APA Division 56, Psychological Trauma APA.org
[email protected] please join!!
The Rewards of the Work