Download Psychological Trauma & the MICA Consumer

Psychological Trauma &
Addictions Treatment
Case Management and Treatment of Trauma Syndromes in
Chemical Dependency Treatment Settings
Bruce Carruth, Ph.D., LCSW
San Miguel de Allende, GTO, Mexico
Advanced International Winter Symposium
Colorado Springs, CO
January 31, 2009
Neurosis ….
“… is the process of shrinking our world
to the point where we can manage”
(Rollo May, I think)
Unresolved trauma causes our worlds to shrink
Some initial thoughts about truama
1. Almost everybody experiences a trauma event
sometime in their lives.
2. It’s not what happens, it is how we handle what
happens that creates trauma. Trauma isn’t
an event, trauma is an experience.
3. Since trauma is a personal experience,
everybody’s trauma is different.
4. Trauma is, by it’s nature, blindsiding.
It happens when we aren’t looking and aren’t
prepared and it strikes where we are vulnerable
Some initial thoughts (con’t)
5. Trauma is a wound to our personhood. We are
never the same afterwards.
6. Everyone copes with trauma by withdrawing, by
disconnecting. Recovery has to be about
reconnecting.
7. Trauma therapy doesn’t change what happened.
The therapy focus is on changing who we are today in
the face of what happened
SOME SPECIFIC LEARNING GOALS FOR TODAY
1. Conceptualize a variety of trauma syndromes
2. That everyone’s trauma is unique in:
symptoms
meaning of the trauma in their life
the process of recovery
3. There is no “best” way to treat trauma syndromes
and that treatment has to evolve as the person evolves
4. Trauma treatment has to address more than
symptoms: “no symptom, no problem” isn’t an answer
5. Recovery requires a variety of healing resources
self, therapy, spiritual growth, significant others, a
healing community
The dimensions of trauma
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Our reaction to our environment
Sensory awareness and perception
amplifications, deletions, distortions
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Cognitions – cognitive filters
Memory
Affect and emotion
terror (fear), grief (sadness), rage (anger) & shame
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How we manage relationships in our life
trust, commitment, attachment, potency in relationships
Self and self functions – our sense of who we are as a
person – our roadmaps for how to function in life
Soul – the experience of being part of something greater than
self … attachment / belonging/ commitment / connection to a
world larger than self
Some different perspectives on trauma
treatment
Medical perspective
trauma as a neuro-psycho-biological perspective
Cognitive-Behavioral perspective
treatment of trauma by changing cognitions and behaviors
Affect Regulation perspective
treatment of trauma by regulating powerful affects
Psychodynamic perspective
trauma as a wound to self
Interpersonal perspective
focuses on the interpersonal wounds of trauma
Since trauma touches all parts
of our being,
treatment and recovery have to
address all parts of our being
…
just like addictive illness
trauma is ultimately a wound to self
“damaged goods”
“not the same person”
“a part of me was lost”
“forever changed”
but trauma is also set of symptoms that
interfere with living:
hyperarousal symptoms: startle reactions, hypervigilance, irritability,
misinterpreting the environment, hypersensitivity – problem of
keeping the outsides out
constriction symptoms: withdrawal, numbing, forgetting, deadening,
isolating, holding in – problems of trying to hold the insides in
Intrusion symptoms: re-enacting, intrusive memories, reliving,
nightmares, preoccupied thoughts – problem of regulating the
commerce between our insides and outsides
So, what are we treating
Treatment starts with managing and treating the
symptoms of trauma: (and how trauma manifests
in the “now”)
symptom management
coping skills
cognitions
“reactive” affects
And then generally needs to proceed to doing
“restorative” work that explores the meaning of the
trauma experience and “works it through”
primary affects
telling the tale and reorganizing experience
core cognitions and schemas
building healthy life and relationships - reconnecting
Recognizing trauma syndromes
1. When people define their life by trauma events
2. Rigid or inappropriate behaviors in the face of
specific events or triggers
3. Ego defense, unconscious to the person that
clearly limits functioning
difficulty in giving / receiving feedback
misrepresentations of the environment
misperceptions of self and self-roles
deadening, numbing, dissociation (disconnecting)
assigning painful / disowned parts of self to the
environment
Recognizing trauma syndromes (con’t)
4. Distorted affects
displaced / distorted / inappropriate affects
exaggerated affects (affective overload)
diminishing (repressing) affects
5. Psychiatric symptoms
depression (sad, angry, nihilistic, anxious)
anxiety (fear, phobias, obsessiveness, withdrawal)
somatization (pain, sleep disorder, appetite disorder)
Recognizing trauma syndromes (con’t)
7. Distorted reactions to life events that involve
helplessness, vulnerability, constraint, shame,
power/control
8. Distortions in relationships: trust, commitment,
potency, attachment
9. And by the typical trauma symptoms:
intrusion
hyperarousal
constriction
the spectrum of psychological trauma
1. Subclinical trauma syndromes: A trauma reaction that
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doesn’t reach the threshold for a trauma diagnosis.
Cumulative childhood trauma: an adaptive response in
adulthood to childhood trauma
Acute Stress Reaction: A psychophysiological reaction to an
overwhelming stimuli. A variation of ASR is Combat Stress
Reaction (CSR)
Grief Reaction: An inability to experience the emotions of loss
Post-Traumatic Stress Disorder(s): A significant wound to
an individual’s sense of self / personhood
Complex PTSD & Dissociative States: A pervasive and
disabling injury to self that produces significant psychiatric
complications – often produced by ongoing traumatization or
torture.
Just because it isn’t in DSM 4 doesn’t mean it isn’t
real
associated psychiatric disorders
we often label trauma syndromes as something else
and these disorders are likely to co-occur with trauma disorders
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adjustment disorders (mislabeled)
dissociative disorders (co-occurring)
panic disorder (co-occurring)
phobic disorders (co-occurring)
major depressive disorder (both)
dysthymia (both)
substance use / abuse disorders (both, but more likely co-
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the whole spectrum of personality disorders (both)
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occurring)
The vulnerable are always more vulnerable
Trauma is a wound to one’s
sense of self
Trauma wounds our dignity and integrity
Trauma alters our beliefs about ourself & the world
Trauma alters our ability to rejuvenate / recuperate
Trauma impacts our ability to trust:
Self trust and to trust the environment
Trauma distorts our sense of time and timing
Time gets defined by traumatic events
Distorts our sense of when to act: hesitancy, impulsivity
Trauma impacts our sense of connection and soul
Family, community, spiritual life
Emotional “symptoms” of trauma
A primary effect of trauma is the inability to
regulate the affects arising from or
contaminated by the trauma
RAGE
GRIEF
TERROR
SHAME
Healing is being able to once again live in
the face of these affects
trauma and vulnerability
trauma strikes the vulnerable person and
trauma strikes us where we are vulnerable
psychological vulnerabilities
psychodevelopmental vulnerabilities
psychosocial vulnerabilities
… the wounded are always at greater risk of more
wounding …
4 variables in trauma vulnerability
1. previous unhealed trauma
2. psychiatric / psychological deficits / disorders
3. unique, idiosyncratic childhood wounding that
makes us vulnerable to rewounding as adults
4. lack of resiliencies
3 primary symptoms of trauma
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1. Hyperarousal, sensitivity
Startle reactions
Hypervigilance
Sleep disorders
Nightmares
Irritableness
Inability to delete annoying stimuli
Intense reaction to stimuli associated
with the trauma
Primary symptoms (con’t)
2. Intrusion symptoms
Reliving the traumatizing event as if
trauma was reoccurring in the present
(every time I close my eyes I see it all over again”)
Reenacting the trauma event in disguised
form (repetition compulsion)
Intrusive traumatic memories may be out
of context to actual trauma experience
(“I keep having thoughts about things I don’t think happened”)
and may be encapsulated in one
sensory experience
(“at night I hear this sound of …..”)
Primary symptoms (con’t)
3. Constriction (Numbing and Withdrawing)
People will sometimes describe their constriction
symptoms as “building a wall”
“Numbness” is an early response to trauma: A primary
variable in recovery is getting beyond the numbness and disconnection.
Feelings become the enemy & numbness is safe
Forgetting is a form of constriction
The ego defenses of constriction (repression, denial,
dissociation, withdrawal, retroflection) are often the
most difficult to work with in therapy
Phobias may be an unconscious way of avoiding
environmental contact
so, what are we treating? And when?
Managing and treating the symptoms of trauma:
(and how trauma manifests in the “now”)
(the early recovery work)
symptom management
coping skills
cognitions
“reactive” affects
Doing “restorative” work that explores the trauma
and “works it through”
(when people are more stabilized in recovery)
core cognitions and schemas
primary affects
telling the tale and reorganizing the experience
building healthy life and relationships
Co-occurring trauma and addiction:
approaches to addressing both disorders
Sequential treatment
treating (stabilizing) one disorder first then treating the other
Parallel treatment
treating both disorders at the same time, but with different treatment
protocols (and sometimes different agencies and different
counselors / therapists
Integrated Treatment
treating the individual with one master treatment plan, in one
setting, addressing the individual’s unique needs
requires that the therapist/counselor and treatment team understand and
have the skills to treat both disorders
Relative occurrence of trauma disorders
SUBCLINICAL TRAUMA SYNDROMES
many people some time(s) in life
ACUTE STRESS REACTIONS
Almost everyone, some time(s) in life
CUMULATIVE CHILDHOOD TRAUMA
A significant number of people
GRIEF REACTIONS
A significant percentage (10- 15%) of people
POST TRAUMATIC STRESS DISORDER
small percentage of people (4-7%)
COMPLEX PTSD AND DISSOCIATIVE DISORDERS
Very few people
Subclinical Trauma
trauma that doesn’t incapacitate but lurks around in our life
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Blindsided by event(s). It strikes where we are vulnerable
We have trouble finding meaning,
“Why me?”, finding cause doesn’t resolve the issue
We may reject or not accept (recognize) support of others
We feel disoriented (things aren’t the same)
Our feelings are out of proportion (and we know it) to the circumstance,
uncomfortable and may be displaced
We revert to old coping strategies (smoking, drug use, withdrawing,
blaming others, trying to fix “it”)
It connects to some vulnerability in our history
The hurt seems to go on and on, we obsess, we keep it in front of us
even when it doesn’t need to be
Often are a series of events that overwhelm coping skills
May manifest as transient or “on & off” or ongoing
And in the face of all this we keep going and maintain life on a day-today basis
Treating subclinical trauma
Support
…. That the trauma experience is valid
…. That the trauma experience will pass
…. To keep the experience in perspective
Psychoeducation about trauma reactions and
process of recovery
Acknowledgement of connections of current
traumatic event to past traumas / history
Provide opportunities to step out of the trauma
reaction to rest and replenish
Cumulative childhood trauma
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Repeated childhood experience that leaves the individual
feeling unworthy, defective, different…
abandonment, physical disfigurement, learning disabilities, family
violence, parental addiction or psychiatric illness, physical illness and
disability, poverty and social shunning, abusive siblings, narcissistic,
antisocial or borderline personality disordered parents
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The child develops coping skills to address the personal and
interpersonal experience and these skills become engrained
in the repertoire of the individual
The individual develops “deep schemas” about self and the
world that are congruent with and support the
understanding of the childhood experience & coping skills
The child has to adapt an effective response that is
congruent with their environment and this response
becomes engrained
Cumulative childhood trauma (con’t)
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As a young adult, the child seeks out an environment that
supports core schema, affective adaptations and coping
behaviors of childhood. This is the “entrenched adaptive
stance”
All of this is largely unconscious
When the “breakdown” begins to occur (often between 25
– 40), the person is truly befuddled and doesn’t know how
else to be.
Efforts at therapy/counseling may unwittingly become
“part of the problem”
for instance, seeking out counseling that supports the engrained
view of the world … “I’m a bad person”, “It’s my fault”, finding a
rescuing counselor, getting retraumatized in counseling
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All of the above has been well described in the ACOA
literature.
Treating cumulative childhood trauma
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Treatment needs to be seen as an ongoing (2-5
year) process
Therapy needs to be relationally focused and the
corrective experience needs to, in part, arise
from the therapeutic relationship. The
relationship is critical to treatment
Intellectualization, idealization, projection,
introjection and withdrawing are primary
defenses that have to be confronted and utilized
in the treatment
Treatment needs to utilize the adaptive stance,
maximizing the assets and strengthening the
limiting parts
Treating cumulative childhood trauma (con’t)
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When treating any trauma, but especially cumulative
childhood trauma, therapy has to consider the world the adult
has created for themselves. Good treatment is going to mess
it up!
The treatment needs to focus on missed developmental
phases and missed skills
A big piece of the treatment has to be coming to accept what
happened and living in the face of what happened
The result of treatment doesn’t have to be the perfect person,
just good enough
Acute Stress Reactions (ASR)
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A trauma response to being overwhelmed
with a recent trauma experience.
Occurs within a short period following the
trauma event
In “uncomplicated ASRs” improvement
often occurs without treatment
ASRs often occur when a trauma event in
the now activates a prior trauma
experience (although the person make not
make the connection)
Treating Acute Stress Reactions
1. Diagnosing:
a) helping people understand what is happening
“I’m falling apart”, “I think I’m going crazy”
b) differential diagnosis
addictive illness and addictive illness relapse
“hidden” PTSD with active trigger event
other anxiety disorder w/ environmental stressor
“complicated” acute stress reactions with
people who don’t have very good coping
skills and lack resilience
Treating ASD’s (Con’t)
2. Creating safety
slowing the physiological response
exploring & reorganizing the cognitions
building boundaries / structure
education about ASD
“normalizing” the emotional responses
building supports in the environment
building safety within self
3. Relapse prevention with recovering CD clients
Treating ASD’s (con’t)
4. Giving room to tell the tale
Be creative in letting people tell the story in the way
. they need … “words can’t describe …”
5. Use of medication
Benzodiazepines ???
Sleep meds
SSRIs are generally counterindicated
Blunt the affect and take too long to work
“BICEPS” model for crisis
intervention
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Brief
Immediate
Centralized resources
Expectations of outcome
Proximity to the trauma site
Simplicity
Acute Stress Disorder and Mass Traumas
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In catastrophic disasters and in warfare, acute
stress reactions are fairly common and may go
undetected
A variation of ASR is a Combat Stress Reaction
(CSR)
We may be more likely to see the coping
symptoms: drug and alcohol use, numbness &
withdrawal, inappropriate affects, impulsive
decisions
Critical Incident Stress Debriefing (CISD) has not
been shown to be effective in preventing or
diminishing symptoms in mass trauma events,
but may be efficacious when treatment is
individualized
Grief reactions
Grief is the emotional expression of loss
Complicated grief is getting “stuck” in feelings
of loss
Grief reaction is the blocking or distorting of
the normal emotional expression of loss
Grief, complicated grief and grief
reactions require different responses
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Grief: support in expressing the emotions of
loss
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Complicated grief: moving beyond being
stuck in the loss
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Grief reaction: being able to experience and
express the emotions of loss
3 categories of losses
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Tangible losses – marriages, money, careers,
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Intangible losses: self esteem, hope,
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What could have been had this experience
driver’s licenses, social status, friendships
belonging and connectedness, joy, love, trust in
self and others,
not happened to me … the loss of a future
Grief reactions from the “outside”
Emotional constriction or inappropriateness
Apparent feelings on the surface that are
denied or displaced (denying sad or anger)
Avoidance behaviors, lonely in a crowd
Judgmentalness, perfectionism, blaming
Difficulty experiencing self, including positive
and negative feedback
Obsessive thought and compulsive ritual
Loss of spontaneity
The process of grief work
Diagnosis and differential diagnosis
cd relapse, “dry drunk” depression, PTSD, personality disorder
Education about grief and grief reactions
Exploration about client’s experience with their
grief
Creating safety with feelings …
especially the disavowed feelings
Catharsis – telling the story as well as expressing affect
Getting closure on events that precipitated the
grief – saying goodbye, letting go, finishing unfinished business,
forgiving self and others
Reintegration of past self with present self
The goal of grief work is not to “get rid”
of painful feelings, but to accept the pain
as a meaningful part of life, to honor the
pain rather than repressing or disavowing
it.
The pain connects us to something(s) that
we lost that were very important to us.
Diagnostic Criteria for PTSD
Exposure to traumatic event(s) in which:
A) the event involves actual or potential death, injury
or threat to physical integrity of self or others
B) intense fear, helplessness or horror
Intrusion symptoms Intrusive dreams, memories,
flashbacks and distress at environmental cues of the
event
Withdrawal symptoms
Avoidance of stimuli related to
event and numbing of general responsiveness
Thoughts and feelings
People, places & things
Difficulty recalling aspects of trauma
Feeling detached
Loss of interest in activities
Restricted affect
Loss of hope
PTSD Diagnostic criteria (con’t)
Hypervigilance symptoms:
arousal
Increased emotional
Problems falling asleep
Irritability / outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
These symptoms last over time (though
they may be transient)
Trauma, and PTSD in particular, is a
wound to one’s sense of self
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Our self perception / self esteem
Our trust in ourselves and in others
Our perception of self in relation to others
Our perception of the needs and desires of self
and others
Our beliefs about the nature of the world (faith)
Our memories and how we remember
The affects we allow ourselves to feel (and the
affects we have to disavow)
How we experience our future
Our values and ethical stances
Our spiritual beliefs and positions
Some issues about trauma in chemical
dependency recovery
especially cumulative childhood trauma, grief reactions and PTSD
Trauma symptoms can look similar to addiction
issues in early recovery
The expectation is that the trauma symptoms will
go away with CD recovery
The trauma is obscured by being an experience
rather than a specific event
Early addiction treatment efforts tend to repress
the trauma
Deal with the present, not the past
Suppress strong feelings
Flooding of trauma may provoke relapse
Trauma often stays buried until later in recovery
What can you really expect to do
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In the first 90 days
build safety, recognize trauma symptoms (in a non-shaming way), symptom
containment & reduction, stabilize, educate, build trauma issues into relapse
plan, build commitment to future work. Primary treatment resource is
manualized treatment programs (for instance: “Seeking Safety”)
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Once stabilized in recovery
make trauma work part of the ongoing recovery plan,
increase awareness of triggers and how they manifest,
manage trauma symptoms when exposed to triggers
begin to explore beliefs that arose from trauma,
begin to explore how disavowed affects relate to trauma,
watch for how the “trauma drama” manifests & gets played out
help client begin to tell the story and get the story straight
Addictive illness, psychological
trauma and suicide
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People with co-occurring addictive illness and
psychological trauma are at high risk for suicidal
thoughts and behavior
And people who have a previous suicide attempt
are at even greater risk
The other high risk factors are treatment
transitions, drug relapse, relationship break-ups,
sudden debilitating depression.
Suicide risk doesn’t necessarily decrease with
sobriety
Ask these questions of every client
with suicide risk
1. Are you thinking about killing yourself
2. Have you ever tried to end your life before
3. Do you think you might try to kill yourself today
(or in the immediate future)
4. Have you thought about ways you might kill
yourself
5. Do you have a way of killing yourself available
now
The GATE protocol
for clients with suicide risk
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Gather information
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Access consultation / supervision
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Take responsible action
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Extend the action – follow-up
Trauma and CD recovery
Emerging trauma may be a sign of getting
healthier. But it doesn’t feel that way
Trauma symptoms can look like “dry drunk”
Hyperarousal, intrusion and constriction symptoms
Ego defenses of trauma and addiction are similar
Experiencing the trauma provokes the trauma in
others in the treatment environment
When trauma brings people into
treatment ….
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People often come into addictions treatment as
a result of some traumatic experience.
Don’t let the trauma get overlooked in the hustle
to treat the addiction
Often, “resistance to treatment” is a function of
the trauma response, not resistance to recovery
Resistance to experiencing the trauma wound
And when the treatment is traumatizing
Some people have the potential to be traumatized by
addictions treatment settings
shame based people who get humiliated / scapegoated
when traumatic history is “exposed” and the person is
overwhelmed and “runs away”
when the treatment process activates buried trauma & the
person acts out & is blamed
confrontation, touching, being confined, even showing interest and concern
inappropriate behavior on the part of other clients or
staff
4 core elements in treating trauma states
Creating safety
Building hope
Building resilience and strengths to transcend
the “dark times”
Consciously using the therapeutic relationship
as a healing factor in treatment
Creating Safety
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I can’t make someone feel safe with
themselves: Safety has to come from
within
Therapy itself is an inherently unsafe
environment for trauma survivors
Trauma survivors will test to see if the
therapy is safe.
I can provide an environment that doesn’t
reinforce “unsafety”
symptom containment as safety
building safety is helping the client be
safe from their symptoms.
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Intrusion – intrusive memories, reliving
the event, re-enactments
hyperarousal – startle reactions,
nightmares, hypervigilance
constriction – going numb – forgetting –
phobias and avoiding
Hope and despair as a special issue for
traumatized recovering people
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Hope (the belief that life can be better) is
essential to recovery
Without hope we have despair
People with a history of despair come into
recovery and get a message of hope.
Hope activates despair and the individual
becomes cynical, indifferent, distant,
disparaging. “You can’t trust happiness”
chronic hopelessness
therapeutic
intervention
negates hope to
manage the anxiety
creates hope
creates anxiety
Some issues in addressing hope
and despair
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1. you can’t argue someone into hope
2. hope often best comes in small doses
3. encourage people to embrace hope when
they have it
4. and prepare for the times they don’t have it building islands in the swamp
5. redefine despair as ego-dystonic
6. hope is both an affect and a self experience –
have the affect, hold the experience
The “hope box”
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Building strengths for when people crash into
shame, hopelessness, despair, emptiness
Create a scrapbook, memories box or other
depository to store ego enhancing memories.
The memories are composed of photos,
documents, newspaper clippings, writings …..
Each memory contains a story that validates and
supports the person
Add to the box as therapy progresses
Have clients take out the box occasionally and
look at the “scenes” and remember the feelings
Be able to access the box when needed
Resilience in trauma treatment
“you just don’t know who you are dealing with”
Resilience is more than “getting by”
Resilience is the ability to “bounce back” in the
face of adversity:
Resilience is life’s desire to move forward in
the face of adversity
Resilience is the ability to tap an inner
strength to persevere
The question for therapists is “how do I help
an individual tap their resilience”
Using the therapeutic relationship
to treat trauma states
1. Modeling integrity, boundedness & safety
2. Monitoring transference
managing expectations of abandonment,
disregard & other negative experience
3. Monitoring counter-transference
in the face of revulsion, ego defense and client
provocation
in the face of over-identification or rescue fantasies,
get supervision and work it through
4. Supporting the work without doing the work
the therapeutic relationship (con’t)
5. modeling interest / concern w/o
activating shame
“why are you so interested in me?”
6. working with projections onto therapist /
interpreting the projections w/o
activating defense
The therapeutic relationship becomes a
model for building integrity based
relationships
4 basic therapy processes for working through trauma:
Ongoing trauma treatment with recovering c.d. clients
1. Bringing the past to the present & building new
options for managing life today
Cognitive Behavioral approaches
CBT, Desensitization, Exposure Therapy, ACT, DBT
Psychodynamic psychotherapies
Supportive psychotherapy, Psychodynamic
Psychotherapy, Narrative Therapy, Emotionally Focused Therapy
Motivational Interviewing (MI) is a bit of both
2. Hypnosis
a) Traditional medical hypnotherapy (NOT recommended)
b) Ericksonian hypnosis
3. EMDR (Eye Movement Desensitization &
Reprocessing) and similar therapies
4. Experiences in living today that reorganize the trauma
experience – corrective life experiences
Psychopharmacology treatment with PTSD
1. Anti-anxiety drugs
Benzodiazepines and SSRI’s
2. Mood stabilizers
Tegretol, Depakote, Lithium
3. Anti-depressants
SSRI’s, Tricycliates
4. Anti-psychotics
Haldol
5. Drugs that block the stress (flight or fight) responses
Klonopin (Catapres), Inderal
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All of these drugs only control symptoms.
There is NO “Anti-Trauma” pill
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Drugs that control trauma symptoms may
be counterindicated for management of
other disorders:
Anxiety
Depression
(and especially) Addictive Illness
Three variables in adopting a specific
approach to therapy with trauma survivors
Approach is understandable &
acceptable to the client
Therapist feels confident,
capable & congruent with
the approach
Approach is congruent
with the nature of the
trauma & condition of
the client
Cognitive-Behavioral Treatments for PTSD
1. Exposure therapies
Prolonged exposure (PE) (Foa)
Systematic desensitization
CPT (Cognitive Processing Therapy) (Resick)
(expos. + cog. restructuring)
2. Anxiety management
SIT (Stress Inoculation Training) (Meichenbaum)
Relaxation / meditation training
Anxiety management training (Kilpatrick)
3. Cognitive Restructuring
Challenging limiting / inaccurate beliefs
Constructive Narrative Perspective (Meichenbaum)
Stopping / changing limiting cognitions
Challenging perceptions of the trauma event(s), their
meanings and impacts
4. Skill Building
Building new / more diverse coping skills and behaviors
Cognitive –behavioral treatments (con’t)
5.
Newer CBTs emphasize acceptance, nonjudgmentalness, present-centered, mindfulness
ACT (Acceptance & Commitment Therapy) (Hayes)
DBT (Dialectical Behavior Therapy) (Lineha
6. Schema therapy (Young)
7. Other CBT approaches
Manualized treatments
Internet based treatment
A psychodynamic approach to treating
PTSD / related trauma
1. Developing safety – stabilizing
being safe enough “inside” and with the environment
2. Telling the tale, getting the story straight
experiencing / embracing the wounded self
3. Corrective emotional experience
the repair work – methods include CBT, redecisioning, finishing
unfinished business, forgiving, letting go, affect regulation, challenging
schemas
4. Integrating a new (repaired) sense of self & reconnecting
with the world
reconnecting, getting closure on history, coming to belong again, building
healthy relationships and perception of self in relation to others
4 stages in recovery from trauma
1.
Developing safety
The very nature of the trauma experience is that it is
unsafe.
The “true fear” is of exposing the damaged self & the
pain attached to the damage
The fear is most often externalized to the environment.
In therapy, the fear may be disowned to the therapist
or the therapy … as unsafe.
Therapy, in structure, may recreate the trauma scene,
where the “victim” submits to an unequal relationship with the therapist who has inordinate power
and status
4 stages of therapy (con’t)
2.
Getting the story straight
We speak of trauma as being “unspeakable”
Trauma may be expressed through physical experience
and symbols as well as words
“Symptoms” of trauma may become a way of telling
the tale
“Victim psychology” will focus excessively on blame
Victims will take responsibility for the trauma as a way
of having control
“What happened” isn’t as important as what it means
Trying to “remember everything” is futile
Telling our tale (con’t)
Our tales are told in metaphor. Our metaphor may or
may not have much resemblance to the reality of
others.
The therapist is the witness to the unfolding of the
tale. The therapist’s job is to provide a container for
the tale as it evolves and to facilitate the person
telling the story in the most healing way possible.
Getting the story straight is like constructing a jigsaw
puzzle. Seemingly unconnected pieces get put
together to form a coherent image and the missing
parts become more obvious.
The missing parts often contain the core of the trauma
experience.
Telling our tale (con’t)
Words may not be a very good vehicle for communicating
the trauma experience. Visual symbols, movies, music,
drawings and physical movement may more accurately
and effectively communicate the experience.
A variety of unfolding techniques can be applied to help
reveal the tale including hypnosis, psychodramatic
technique, group support and psychomotor therapies.
But unfolding techniques are a means to the end, not
the end in itself!
One story or event in the tale can be a metaphor for a
series of events. It isn’t necessary or practical to tell
the whole tale, particularly with prolonged and
pervasive trauma.
Step 3: Corrective Emotional Experience

Corrective emotional experience is about:
1. Creating and living new options that
refute the trauma experience
2. Being able to have and “work
through” the emotions that were attached
to the trauma
Corrective Emotional Experience
Creating and living new options
Trauma traps us into a set of truths and beliefs
that are self limiting and often repeat the
trauma experience.
A goal of therapy is to challenge these truths &
beliefs and create new options for living a more
rewarding and versatile life.
Trying out new ways of living / coping create the
“corrective emotional experience”
Corrective Emotional Experience
Creating and living new options
Therapy needs to strategically address new coping
options. Clients resist because the new options
are incongruent with the existing truths and
beliefs.
The primary defense against challenging beliefs
and truths is to change them in the therapy
office but not in “life”.
Corrective Emotional Experience:
Reworking the emotions of trauma
4 primary emotional responses to trauma are:
rage, terror, grief and shame.
No one “does” each of these responses equally well.
Some trauma experiences lead themselves more to
expression through one of these emotions than
through others
When one avenue of expression is unavailable, we will
use other avenues to express that emotion
Blocking rage limits experiences of empowerment
Blocking terror limits experiences of feeling safe
Blocking grief limits experiences of love and belonging
Blocking shame limits experiences of self love and self
acceptance
Corrective emotional experience (con’t)
The fear of experiencing rage is uncontrolled violence
toward self and others
The fear of experiencing terror is uncontrolled panic
The fear of experiencing grief is depression and
emptiness
The fear of experiencing shame is deep humiliation and
worthlessness
Terror, grief, rage and shame will emerge in a sequence
that is unique to the individual. As one emotional
response is worked through, another will appear. The
most difficult emotional experience for the individual
will be the last to appear.
Corrective emotional experience (con’t)
THE EMOTIONAL BLOCK WITH THE
TRAUMA EXPERIENCE IS NOT WITH THE
AFFECT THAT IS EXPRESSED, BUT WITH
THE AFFECT THAT IS UNEXPRESSED.
Corrective emotional experience (con’t)
Other emotional themes of trauma survivors include:
Guilt
Rejection/Abandonment
Loneliness
Hurt
Overwhelmed
Empty
The catharsis of these emotions is not the end in
itself
But the expression of these emotions of the trauma
give emotional life to the experience. The trauma
experience cannot be resolved w/o the expression
of the emotional experience
These emotional themes are worked out in the
therapy experience transferentially as well.
A primary defense of the emotional themes is to
project the disowned feeling.
The types of therapies that work best in providing
corrective emotional experience are the
therapies that acknowledge and support the
awareness and expression of affect:
Emotionally Focused Therapy (S. Johnson)
Contemporary Gestalt Therapy
Grief work
Affect regulation therapies
Stage 4: Integrating a new sense of self
As the corrective emotional experience unfolds, the
damaged sense of self that underlies the pain is
exposed
Some agendas for selfhood work include redefining
the trauma experience in terms of:
Self trust
Self in relation to others
Self perception and self esteem
Beliefs about self and relation of self to the world
Self in relation to the future
Value and ethical positions
Spiritual beliefs
The process of healing the self
1. Creating a safe place:
emotionally, physically, interpersonally
2. Struggling to find a way to tell the tale
3. Experiencing the pain (and joy)
4. Experiencing the damaged self and
5. Embracing (& allowing others to embrace) the
damaged self
6. Building a stronger sense of self:
Self esteem, potency, interpersonally,
physically, spiritually
7.
Connecting with the world in a more potent
way
Healing is sufficient when:
1. We can address problems as they arise
2. We can have at least one person in our life with
whom we can intimately reveal ourselves
3. We can have firm and flexible boundaries
“I” boundaries, value boundaries, body
boundaries, expressive and exposure
boundaries, comfort boundaries
4. We have (and take) opportunities to rejuvenate:
Physically, emotionally, intellectually,
interpersonally, spiritually
Resolution
The experience of trauma is never fully resolved
and recovery is never complete.
The natural unfolding of events reactivates the
trauma experience which, again, needs to be
recognized, confronted and expressed.
Healing is sufficient when the trauma does not
dominate experience, but, rather, sits alongside
the mundane and the ordinary, when the person
can live in relative harmony with their
environment
For more information
Bruce Carruth, Ph.D., LCSW
(713) 589-3250
[email protected]
Overheads from this (and other)
presentations are available at:
www.brucecarruth.com