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Considerations in Trauma
Work with Children and
Adolescents
The Use of Hypnosis for
Prevention and Treatment
Julie H. Linden, Ph.D.
Philadelphia, PA, USA
[email protected]
Learning Objectives
• Describe developmental variables in
the use of hypnotic techniques.
• List several theories of trauma and
the elements of an integrated
approach to trauma treatment.
• Name and be able to use several
hypnotic techniques in the treatment
of trauma in children.
Outline of workshop
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Definitions
Developmental factors
Assessment
Treatment
What is Trauma?
Wholist Framework
• The nature of the trauma
(process)
• Parameters of the trauma
(context)
• Depth of the trauma (effect of
the trauma on human
fulfillment)
Velent 1998,1999
Posttraumatic acutestress reaction
• The constellation of feelings
and reactions that follows
terrifying events
Trauma
Defined as “the sudden cessation
of human interaction”
(Lindemann, 1944)
Trauma
An Experience is traumatic if it
1. Is sudden, unexpected, or nonnormative
2. Exceeds the individual’s perceived
ability to meet its demand
3. Disrupts the individual’s frame of
reference and other central
psychological needs and related
schemas.
(McCann & Pearlman 1990)
Trauma
An event that overwhelms the person’s
perceived ability to cope, debilitates
through a central loss of control and
creates the necessity for
psychological defenses.
It is the person’s response to the
event that creates the
traumatization.
(E. Gil 1998)
Definition
• Trauma by proxy:
• Feel traumatized as the result of
an event that happened to
someone else.
• Feels traumatic because child
identifies with the victim.
TRAUMA EVENTS
1. PHYSICAL , SEXUAL ,or VERBAL ABUSE
(homicide, rape, suicide, torture)
2. ACCIDENTS
3. CHRONIC ILLNESS; MEDICAL PROCEDURES
4. DEATH - LOSS OF PARENT, SIBLING
5. DIVORCE; ADOPTION
6. NATURAL DISASTERS
fears of lightning, fire, etc. to traumas
from famine, floods, cyclones,
tornadoes, etc.
7. WAR
Terrorism
• A special type of disaster
• Weapons of mass destruction
Chemical, Biological,
Radiological, Nuclear, high yield
Explosives (CBRNE)
• Straus and Gelles (1996) have
estimated that over 29 million
children commit an act of
violence against a sibling each
year
Assessment
PTSD & ASD
What kids say stress is...
• “When you have to do something to
make someone else happy and it makes
you miserable.”
• “Feeling really tiny in a big, big room.”
• “Feeling squished.”
• “Feeling tight all over.”
• “Like you can’t breathe.”
• “Like two things fighting in my
stomach.”
Common Childhood
Fears
• 0-6 months Loss of support, loud noises
• 7-12 months Fear of strangers, fear of sudden,
unexpected and looming objects
• 1 year
Separation from parent, toilet, injury,
strangers
• 2 years
A multitude of fears, including loud
noises, animals, the dark separation
from parents, large objects, e.g.
machines, change in personal
environment
• 3 years
Masks, dark, animals, separation from
parents
• 4 years
Separations from parents, animals,
dark, noises
Common Childhood
Fears
• 5 years
Animals, "bad" people, dark, separation
from parent, bodily harm
• 6 years
Supernatural beings, bodily injuries,
thunder and lightning, dark, sleeping or
staying alone, separation from parent
• 7-8 years Supernatural beings, dark, fears based
on media events, staying alone, bodily
injury
• 9-12 years Tests and examinations in school,
school performance, bodily injury,
physical appearance, thunder and
lightening, death, dark
Acute Stress Disorder
• Acute stress disorder (ASD) is
an anxiety disorder
characterized by a cluster of
dissociative and anxiety
symptoms occurring within one
month of a traumatic event.
Recognizable stressor
• Acute stress disorder is caused
by exposure to trauma, which
is defined as a stressor that
causes intense fear and,
usually, involves threats to life
or serious injury to oneself or
others.
Symptoms:
Dissociative & Anxiety
• Dissociative symptoms: emotional
detachment, temporary loss of
memory, depersonalization, and
derealization.
• Anxiety symptoms: irritability,
physical restlessness, sleep
problems, inability to concentrate,
and being easily startled.
Normal acute (e.g. in the first hours or days)
responses to trauma may include
• Feelings of horror, helplessness, fear, or
disbelief
• Attention and concentration problems
• Preoccupation with the traumatic event
• Hypervigilance to danger, including
misperception of non-dangerous stimuli as
potentially dangerous
• "Survivor guilt" (i.e., guilt about having
survived when others did not)
• Reduced emotional responses to the
environment ("shutting down" or "going
numb")
• Feelings of unreality, depersonalization, or
other dissociative phenomena
• For some, no significant psychological
difficulties
Later (e.g. in subsequent hours,
days, or weeks) reactions often
• Intrusive thoughts and recollections of the trauma,
nightmares, and occasionally flash-backs (intrusive
sensory reexperiencing of aspects of the trauma)
• Sustained feelings of numbness or emotional
constriction
• Attempts to avoid reminders of the trauma
• Initiation of (or re-involvement in) substance abuse
• Evidence of autonomic hyperarousal, such as
muscle tension, jumpiness and heightened startle
responses, sleep disturbance, and irritability
• Problems in interpersonal relationships
• Mood swings
• Anxiety
• Depression and self-isolation
PTSD Factors
• Existence of recognizable stressor
PTSD Factors
•
Reexperiencing the trauma as evident by:
1. recurrent/intrusive recollection of events
in children daydreams and fantasies,
usually they do not have recurrent
nightmares with exact repetition of
event. Do not experience sudden
unexpected flashbacks.
2. recurrent dreams of events.
PTSD Factors
• Reexperiencing the trauma as
evident by (cont.):
3. suddenly acting or feeling as if traumatic
event were reoccurring because of an
association with environmental stimulus.
Primary process thinking is close to the
surface, so environmental stimulus is often
responsible for behavioral changes.
Children do not consciously link changes in
mood, affect, thinking and behavior to such
things as loud noises, darkness or sudden
visual or auditory stimuli which "remind"
them of the traumatic event.
PTSD Factors
• Reexperiencing the trauma as
evident by (cont’d.):
4. Trauma specific
reenactment
PERCEPTION IS MORE BASIC AND
PRIMITIVE THAN IS COGNITION.
PREVERBAL EXPERIENCE,
TRAUMATIC PERCEPTION MAY
REMAIN AN INDIGESTIBLE PART
OF GROWING YOUNG
PERSONALITY
Avoidance:
• Emotional numbing. This is a
defense; children appear as if
uninvolved, but do not exhibit
psychic numbing. Subdued or
mute behavior, unemotional
third person, journalistic.
Avoidance
• Sense of foreshortened future
• Avoidance of activities that
arouse recollection of traumatic
event
• Repression (avoiding thoughts,
affect)
Arousal: Hyperalertness
• 1. Sleep disturbance- inability to fall
asleep, night terrors, nightmares
• 2. Irritability or outbursts of anger
• 3. Memory impairment, trouble
concentrating
• 4. Hypervigilance/ guilt
• 5. Exaggerated startle response
• Regressed- go into parents bed,
sleep in strange places, suck their
thumbs, enuretic
Accidents, suicides and
homicides are the three leading
causes of death among young
people in the US.
(US Bureau of Census, 1999)
Simple VS Complicated
Trauma
Simple Trauma
Complicated Trauma
Single Event
Events
Several Repetitive
Brief Duration
Over Long Time
Late in Life
Early in Life
(after ego dev. solidified)
No Man-Made Violence Man-Made Violence
Active Role
Passive Role
Advance Warning
Sudden, No Advanced
Warning
Symptoms Time-Limited
Symptoms Long Lasting;
can produce characterological
change; may produce neuronal
changes; both physical and
psychological symptoms can be
irreversible.
Resolution of symptoms
can occur simply with the
aid of facilitative
environment
Resolution of symptoms
usually does not occur
spontaneously; treatment
usually necessary; in some
cases no resolution of symptoms,
even with treatment
If treatment is needed, it's Treatment is long term, egobrief and time-limited
reparative
Trauma, Dissociation
and Hypnosis
Defenses
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Denial
Suppression
Repression
Splitting
Dissociation
Dissociation
Distancing through :
−repression of affect (numbing)
−repression of thought
−repression of behavior
−depersonalization (out of
body)
−amnesias
−automatisms
(e.g,sleepwalking)
Advantages of
Dissociation
• Need distance in order to
master
• Compartmentalize
• Discontinuity in experience
• Dissociation helps to maintain,
gain and regain control
• Body may handle some of the
worst responses
Dissociation
DSM definition:
A disruption in the usually
integrated functions of
consciousness, memory,
identity or perception of the
environment.
May be sudden, gradual, transient or
chronic.
Advantages of Hypnosis
for the Treatment of
Trauma
• Can get to original affective state.
• Can train the relaxation response.
• Can create endless containment
techniques through imagery utilizing
trance logic phenomenon.
• Can bridge between the conscious
and unconscious (accessing pictorial
and sensorial memory ubiquitous to
trauma).
Hypnosis
an altered state of
consciousness
Changes in consciousness reported
by those in hypnotic state include:
• narrowed focus of attention
• dissociation: numbing, out of
body, “spacey”
• altered sense of time
• altered sensory perceptions
(Ref: Cardena, 2000)
Grounding
Sensory and cognitive awareness
• Keep a person in the present
• Reorient to reality, here and
now
• Can prevent unhealthy
dissociating
• Regain mental focus
Grounding Techniques
• Self talk
• Directed imagination (all the
senses)
• Energy toning
• Acting “as if” principles
•
Safe place imagery
•
Become absorbed in activity.
•
Write in your journal.
•
Breathing exercises.
Relaxation exercises.
•
Visualize a "STOP" sign
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Use positive affirmations.
•
Transfer your feeling/memory into a safe "container"
either through visualization or by creating an actual box
where you can write the feeling/memory on a piece of
paper and slip it into the box leaving it to be dealt with
together with your therapist.
•
Identify cognitive distortions and replace with counter
statements.
• Dance.
• Repeat a grounding phrase: "I'm here right now."
• Hold a safe object (smooth stone, stuffed animal,
watch, ring, cup or mug, etc.).
•
Pray (e.g. Serenity Prayer).
Exercise.
• Draw.
• Find a safe person.
• Listen to a tape of your therapist.
• Listen to a tape of self-affirmations.
Change sensory
experience/input:
• Sight:
allow yourself to see through your eyes, look at
a picture, read a book
• Touch:
allow yourself to feel the chair you are sitting
on, touch ice, hold a smooth stone
• Sound:
talk to someone, listen to music, TV
• Taste:
eat something
• Smell:
perfume, favorite scent
Consequences of
Trauma
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persistent fear state
disorder of memory
dysregulation of affect
avoidance of intimacy
Symptom Checklist
Defenses
• Depression
• Repression
• Regression
Behavior
• Re -experiencing
• Avoidance
• Arousal
Trauma Models
Fight
Flight
Freeze
Perry- Neurophysiological
equivalents in children
• Fight- cry to alert an adult,
regressive tantrums
• Flight- often not possible, so
dissociate
• Freeze-when an event is
perceived as inevitable, seen as
oppositional defiant.
Table 1: The Continuum of Adaptive
Responses to Threat
Bruce Perry, MD, PhD
• Hans Selye
General Adaptation Syndrome:
(Psychobiological model)
• Anne Burgess
Information Processing of Trauma
• Pierre Janet
Stabilization, Exploration,
Integration
• Judith Herman
Safety, Remembrance and Mourning,
Reconnection
• FrancineShapiro
EMDR- Eye Movement
Desensitization and Reprocessing
• Sandra Bloom
SAGE- Creating Sanctuary:
Safety, Affect Management,
Grieving and Emancipation
• Roger Fallot
TREM- Trauma, Recovery and
Empowerment
Hypnotic Model for
Treatment
Stabilization/Rapport & Trust
Building
Uncovering
Working Through
Kinds of Interventions
• Play therapy-symbolic
Houses, toys, costumes, puppets
• Hypnosis/Hypnoidal* techniques
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Imagery/relaxation
Storytelling
Role playing/ Playback theater
EMDR
Sandplay
Art Therapy
Board games
Electronic Techniques
Lap top writing
Biofeedback games
*Differ from formal hypnosis in that they utilize the naturally
occurring trance state and relaxation response.
Play’s therapeutic factors:
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visualize or use fantasy
communicate
form attachments
enhance relationships
learn through metaphoric teaching
develop competence through mastery
think creatively
achieve catharsis or abreaction
develop positive emotion
helping children overcome resistance
master developmental fears
role-play
develop game play (which helps with
socialization)
Play as hypnosis
• Children prefer action to talking
• A function of play, at a biological level is to
relax and release tension
• Most forms of play for children produce
trance state narrowed focus of attention,
dissociation, absorption, imaginative
involvement
• At an intrapersonal level, play may provide for
mastery of conflicts through the use of
symbolism and wish fulfillment
• Therapeutic play- the use of “alone play” with
the therapist, using 1) art medium, toys or
drama, 2) storytelling through activity and 3)
make believe. (Sandplay uses all three).
Hypnotic suggestions and
play
Pair play trance state and hypnoidal
suggestion
• Just as do in formal trance induction with
adults, this is more suitable with children
where imagination and imaginative
involvement is more present.
• Sensitivity to timing of suggestion,
although can be used at any phase of
treatment.
• The attachment of words to action
(know the power of negative
suggestions)
Similarities between
hypnoidal play and formal
hypnosis
• Resolve problems at an unconscious level:
Both hypnosis and play reach into the sub
and unconscious, retrieving those aspects
of the self, hidden from the client.
• A meditative, focused, absorbed state
• Frequently feel time distortion
• Dissociation
• Accesses original affect
• Simultaneous use of both lobes of the
brain
Characteristics of Posttraumatic Play
• Compulsive Repetition
• Unconscious link between the
play and the real event
• Literalness of Play
• Failure to relieve anxiety
• Depiction of danger
• Lack of spontaneity and
enjoyment
Interventions for
Unhealthy Play
• Physical Movement - ask child to stand up,
take a deep breath, move arms and legs. This
can be a pattern interruption to rigid
emotional and behavioral constriction.
• Verbal statement about the play that may
encourage child to disengage, to observe
(non interpretive), rather than to be in it.
• Interrupting the sequence of play by asking
the child to take specific roles and describe
perceptions, thoughts, or feelings. This
pretend play is usually normative play for
children and may move child out of
constricted behavior.
Interventions for
Unhealthy Play (cont’d)
• Manipulating the toys asking “what would
happen if” to elicit the child’s creative
imagination and to consider new options.
• Encouraging child to differentiate between
traumatic material and current reality in
terms of environmental changes and new
coping strategies.
• Videotaping- allows child to be removed
from toys and play which may be too real
or intrusive. May not be able to use toys as
symbolic and instead view them as
realistic objects.
Importance of affect
• Emotional interactions are the
foundation of cognition and
most of the child’s intellectual
abilities, including creativity
and abstract thinking skills.
What is attachment?:
• An attachment is a reciprocal,
enduring emotional and physical
affiliation between a child and a
caregiver. (B. James)
Attachment vs. Traumabond relationships
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Attachment
Trauma-bond
Love
Terror
Takes time
Instantaneous
Reciprocity and caring
Domination and
fear
Person is experienced as essential
same
for survival
Proximity→safety(pleasure)
Proximity
→conflict
(alarm/numbing)
Separate person dependent
Not separate
person,
extension of other’s needs
Self-mastery
Mastery by
others
Autonomy-individuation
Obedient to will of
other
Attachment vs. Traumabond relationships
• Goals of attachment behavior:
safety, exploration, avoidance
of danger, and affiliation.
• Goals of trauma-bond behavior:
objective of adult’s wellbeing,
regulation of intensity of
feeling, limited interaction, and
safety
Children’s Experiences of War
in Bosnia-Herzegovina
• Approximately 16,855 children were killed,
died due to hunger or cold, or were
missing because of 1992-1995 war in
Bosnia
• Over 34,000 children were wounded
• War crimes against children included:
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Forced displacement
Rape
Forced prostitution
Torture
Using children as human shields
Taking children as hostages
Killing children in mass murders
Other forms of persecution
Severe abuse
(Commission for Gathering Facts on war Crimes 1996 report)
War Trauma
Children face conflicts related to:
• Protection and attachment
• Aggression, power, retaliation and
the redressing of wrongs
• Fragmentation and incoherence
related to loss in the moral as well
as physical, relational and social
order
(S. Rafman 2002)
Clinical themes
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Good and evil
Trust and betrayal
Protection and aggression
Death as consequence of wrong
choice
(S. Rafman 2002)
Type and Frequency of
PTSD Symptoms
1. Being upset when reminded of war
experiences (92%)*
2. Having intrusive memories (89%)*
3. Being watchful or on guard (84%)*
4. Avoiding thoughts of the war (81%)*
5. Having nightmares (76%)
6. Feeling cut off from others (76%)*
7. Increased startle response (71%)*
8. Decreased concentration (68%)*
Type and Frequency of
PTSD Symptoms
9. Feeling numb (61%) *
10. Having sleep disturbance ((61%)*
11. Reactivity to war reminders (61%)*
12. Decreased interest (58%)
13. Flashbacks (58%)*
14. Avoiding war reminders (55%)*
15. Irritability (53%)*
16. Feeling future is unclear (50%)*
17. Amnesia (16%)
From Weine & Pavkovic (1995). Items with a star (*) were
reported by the Philadelphia group.