clinical discernment our plan for today trauma · 2017-11-10 · clinical discernment: when faith...

Clinical Discernment: When Faith and Trauma Intersect Catholic Psychotherapy Association Conference ‐ 04/15/2016

Jennifer Madere & Gerry Crete 1

Clinical DiscernmentWhen Faith and Trauma

Intersect

Catholic Psychotherapy Association ConferenceApril 15, 2016

Jennifer Madere, M.A. Gerry Ken Crete, [email protected] [email protected]

Our plan for today• Treatment approaches and research congruent

with Catholic understanding of human person.• Assessments and resources to detect and educate

regarding trauma and trauma-related dissociation.• Case examples showing application and benefit of

trauma-focused assessment and treatment with related spiritual struggles.

• *Some resources are practice-ready, however, this presentation is not to substitute for training in EMDR Therapy or any treatment of trauma-related diagnoses.*

Common Intersectionsof Faith & Trauma

Client presenting issues:• Shame / negative feelings or beliefs

toward self• Anxiety / perfectionism / fear• Impulsivity or acting out (external or

internal), whether immoral or seeming to lack in virtue

• Problems in relationships / Attachment patterns

• Treatment-resistant depression• Any event, loss, change, etc, that

surpasses one’s present ability to process and accept.

Trauma• Trauma threatens the capacity for resilience and

leads to dissociation, hyper-vigilance, isolation and a lack of trust.

• An over-adaptation, not a pathology.• The world no longer feels safe, others are a source

of threat and we are left feeling unworthy. • Trauma can cause us to lose hope that we will ever

have a meaningful empathic relationship. • Trauma causes us to believe that we must be self-

sufficient; human engagement and vulnerability is denied.



Self‐Regulation• Real threats versus perceived threats.• Perceived threats cause the same physiological and

brain changes as real threats (fight/flight, muscle tension, heart rate/respiration, circulation, impaired executive functioning).

• Freeze state: powerlessness/dissociation• Good stress can actually help us achieve optimal

performance but distress can create high anxiety. • Self-regulation can involve muscle relaxation (relax

pelvic floor clenching, release muscles) and diaphragmatic breathing.

• Remember painful events while in a relaxed state (reciprocal inhibition). Prayer/meditation can help with this.

Spectrum of Trauma‐Related Disorders

• Adjustment Disorder• Acute Stress Disorder • Post Traumatic Stress Disorder

o DSM-5 - with/without dissociative symptoms. This is where most “Complex PTSD” cases fall diagnostically

• Dissociative Disorderso Dissociative Amnesiao Dissociative Fugueo Depersonalization/Derealization Disordero Otherwise Specified Dissociative Disordero Dissociative Identity Disordero Unspecified Dissociative Disorder

• Dissociation is always serious• Dissociative disorders are

rare

• Always iatrogenic (caused by treatment or “treaters”)

• Cannot be reliably diagnosed

• Diagnosis leads to deterioration

• No specified treatment standard of care

The Fact• Dissociation is a normal and

common response to stress • Undiagnosed DID affects 3.9%

of psychiatric inpatients, and is generally as common as Borderline PD and Schizophrenia

• Can be diagnosed based on pre-existing symptoms

• Reliability is good, especially when using assessments

• Good prognosis in many cases when clinicians are well trained

• See Treatment Guidelines at ISSTD.org

The Myth

Common Misconceptions(Ross, 2015; Steinberg, 2001)

State Dependence of CognitionBruce Perry, 2015

Mental State CALM ALERT ALARM FEAR

Brain AreaPRIMARYSecondary

NEOCORTEXCortex

CORTEXLimbic

LIMBICDiencephalon

DIENCEPHALONBrainstem

Cognition AbstractReflective

ConcreteRoutine

EmotionalReactive

ReactiveReflexive

Functional IQ 120‐100 110‐80 90‐60 70‐50



Bruce Perry, 2010 – www.childtrauma.org

State Dependent Response to Threat

Treatment ApproachesTheory & Research

Treatment ApproachesTheory & Research

• Of many treatment modalities, we will focus on those with which we are most familiar, are congruent with our Faith and that are robustly supported by research.

Other items to mention:• Polyvagal theory (Steven Porges) –

o Safety: Social engagement, immobilization without fearo Danger: Fight/Flight (hyperarousal)o Life threat: Freeze/collapse (hypoarousal)

• Somatic Experiencing (Peter Levine) – Relieving and resolving through intentional focus on body sensations.

Emotionally Focused Couples Therapy and Trauma

• EFT based on attachment theory, family systems theory, and experiential therapy

• Trauma causes insecure attachment• Insecure attachment: anxious clinging, detached

avoidance, and/or fearful avoidance• Secure attachment: mutual vulnerability and

mutual empathy (takes away shame and rebuilds connection, instills hope, promotes self regulation, corrective emotional experiences)

• New beliefs/experiences: Trusting self disclosure, empathic responsiveness, and worthy of God’s love



Relational and Art/Narrative Approach

• Positive emotional bond with therapist where mutual goals are established.

• Hope is essential for positive therapeutic gains. • Survivors need to be heard, understood and

respected. Give words to painful past while staying regulated/present (healing not re-traumatization)

• Rogerian qualities include warmth, caring, authenticity, and transparency.

• Externalizing the trauma may involve writing down one’s narrative or depicting it in art.

• Powerful for a Christian to discover that Christ was present even in our most painful moments.

EMDR Therapy & AIP Model• Adaptive Information Processing Model

o Our brain has a natural inclination toward health. The AIP Model sees most emotional and mental health issues as being the result of unprocessed or maladaptivelyprocessed experience. By identifying and reprocessing pivotal experiences in the past, current struggles and symptoms diminish significantly as the traumatic experience is desensitized and linked to adaptive memory networks.

• Self-referencing beliefs, affect, and body sensations shift from negative to positive as targeted material is reprocessed.

• EMDR Therapy is shown to effectively treat many psychological disorders in addition to PTSD.

EMDR Therapy & AIP Model• Faith & EMDR

o Memory networks built by trauma influence how we relate to others and to God. Early spiritual experiences lay the groundwork for later understanding of self, relationships, the world.

o The ever-increasing effective application of EMDR to psychological disorders thought to be primarily biologically based (such as psychosis) is congruent with our belief that suffering is a result of Original and continued sin in the world.

o EMDR effectively reduces the psychological effects of the sin of others or of the client, removing obstacles to forgiveness, joy, and flourishing in general.

Treatment Planning• 3 Phases of treatment (ISSTD, 2011)

o Stabilization, symptom -reduction, and skills buildingo Treatment of traumatic memorieso Personality (re)integration and rehabilitation

• Our job as clinicians is to remove obstacles to flourishing. o Is it time to forgive or tend wounds?o Is it spiritual dryness/desolation or attachment

trauma?o Is it maladaptive/over-adaptive coping or vice?o Is there a positive relational template?o Is client able to tolerate positive emotion?



AssessmentsAll assessments listed, along with slides of this presentation are available via Dropbox:https://www.dropbox.com/sh/mwx5giqiaazokzl/AAB3CQGZSmDlwodcnJAfQuTAa?dl=0

Or contact Jennifer ([email protected]) to receive a link via email.

Adverse Childhood Experiences Scale (Felitti, 2013; Anda et al, 2010)

• 10 yes /no questions. Verbiage matters!• Original study: combined effort of CDC and Kaiser

Permanente.• Measure overall cumulative stress and risk of

development of severe mental, physical, and relational health issues across diverse populations (Anda, et al, 2010).

• Responses/scores were linked to incidence and development of physical and mental health problems later in life.

• World Health Organization and many subsequent studies have explored the impact of ACEs on health of the worldwide population.

Traumatic Experiences Checklist

• Developed by Nijenhuis, Van der Hart & Vanderlinden in Europe.

• Inquires about 29 specific events including:o Emotional neglect, emotional abuse, physical abuse/bodily

threat, sexual harassment, sexual abuse.o Also adult experiences such as divorce, military combat, severe

physical pain/injury, second generation of family impacted by war trauma (ex Holocaust).

o Find client and clinician forms online – ESTD website.• When helpful:

o As part of intake if client is presenting for trauma treatment or if complex history is known.

o To assess severity and impact of events when complex trauma history is known (perhaps after finding high ACES).



Dissociative Experiences Scale (DES)

• Considered to be the most widely valid and reliable screening for dissociative disorders.o Available in Spanish, and many other languageso Required as preparation for EMDR therapy

• Subscales/Factors:o Absorption Items: 2, 14, 15, 17, 18, 20.o Amnesia Items: 3, 4, 5, 8, 25, 26.o Depersonalization/Derealization Items: 7, 11, 12, 13, 27, 28.o Taxon: 3, 5, 7, 8, 12, 13, 22, 27 (pathological dissociation)

• Score = mean of 28 items• Additional Versions:

o DES-A (Adolescent) and CDES (Child DES)

Multidimensional Inventory of Dissociation

• Published 2006. Paul Dell. Current version 6.0 • Format: 218 items – same 0-10 scale as DES

o Modeled after MMPI. 74 Scales.• Time to administer: 30-60 minutes for client to complete• Time to score: 10 minutes to enter scores, + review results• Training required: familiarity with DES, basic Excel skills• Differentiates and diagnoses:

o Post-Traumatic Stress Disorder, Otherwise Specified Dissociative Disorder, Dissociative Identity Disorder, Somatization Disorder, Borderline Personality Disorder

• Strength relative to other assessments: Broader and deeper assessment without extensive training, and explicitly with numbers.

• Correlates extremely highly with DES, but unlike DES, the MID contains only pathological dissociation items.

• Available to ISST-D members, from [email protected], or [email protected]

MID Mindset: 3 Domains• There are at least 3 levels of explanation for

dissociation, and most psychological diagnoses, for that matter (Dell, 2009):o 1) Neuroanatomical-neurophysiologicalo 2) Psychological (theory)o 3) Phenomenological Signs (observable) and Symptoms

(subjectively experienced by the client)• Phenomenological definition of dissociation: the

phenomena of pathological dissociation are recurrent, jarring, involuntary intrusions in to executive functioning and sense of self.

o The MID is based largely on the viewpoint that the phenomenology of dissociation, and particularly DID, is “overwhelmingly internal and subjective, not external and observable” (p.226)

Case Example:Scrupulosity



Case Example:Psychosis, Dissociation or

Deliverance?

Case Example:Male Survivor

Case Example:Female Survivor

Case Example:Betrayal & Loss



Online Trauma Resources• www.emdria.org (EMDR International Association)• www.emdr.com (Francine Shapiro)• www.traumacenter.org(Bessel van der Kolk)• www.emdrinfo.com(Laurel Parnell)• www.Trauma.cc (Babette Rothschild)• www.stephenPorges.com (Stephen W. Porges)• www.healthjourneys.com (cancer, Belleruth Naparstek)• www.emdrsolutions.com(Robin Shapiro)• www.brainspotting.pro (David Grand)• www.rossinst.com(Colin A. Ross – Dissociative Disorder

Interview Schedule)• www.trauma101.com(free crisis plan; guided imagery

scripts)• http://www.iceeft.com/ (Sue Johnson, EFT)

References• Anda, R., Butchart, A., Felitti, V., Brown, D. (2010). Building a Framework for

Global Surveillance of the Public Health Implications of Adverse Childhood Experiences. American Journal of Preventative Medicine, vol. 39:ppg 93-98.

• Briere, J., & Scott, C. (2006). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage Publications.

• Briere, J., Berliner, L., Bulkly, J. A., Carole, J., & Reid, T. (Eds.). (1996). A self-trauma model for treating adult survivors of severe child abuse. Thousand Oaks, CA: Sage Publications.

• Carlson E., Putnam, F. (1993). An Update on the Dissociative Experiences Scale, Dissociation, 7:1, 16-27.

• Dell , P. (2006) The Multidimensional Inventory of Dissociation (MID): A Comprehensive Measure of Pathological Dissociation, Journal of Trauma & Dissociation, 7:2, 77-106.

• Dell, P. F. (2009). The Phenomena of Pathological Dissociation. In P. F. Dell, J. A. O’Neil, (Eds.), Dissociation and the dissociative disorders: DSM-V and beyond (pp. 225-237). New York: Routledge.

• Dell, P. (2012). An Interpretive Mini-Manual for the Multidimensional Inventory of Dissociation (MID), version 6.0. Available from the author.

• Filetti, V. (2013). Adverse Childhood Experiences Study. Presented at EMDR International Association conference; September, 2013, Austin, TX.

• Foa, E. B. (2011). Prolonged exposure therapy: Past, present, and future. Depression & Anxiety, 28, 1043-1047.

References 2• International Society for the Study of Trauma and Dissociation. (2011). [Chu, J. A.,

Dell, P. F., Van der Hart, O., Cardeña, E., Barach, P. M., Somer, E., Loewenstein, R. J., Brand, B., Golston, J. C., Courtois, C. A., Bowman, E. S., Classen, C., Dorahy, M., ̧Sar,V., Gelinas,D.J., Fine,C.G., Paulsen, S., Kluft, R. P., Dalenberg, C. J., Jacobson-Levy, M., Nijenhuis, E. R. S., Boon, S., Chefetz, R.A., Middleton, W., Ross, C. A., Howell, E., Goodwin, G., Coons, P. M., Frankel, A. S., Steele, K., Gold, S. N., Gast, U., Young, L. M., & Twombly, J.]. Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12, 115–187.

• Johnson, S. M. (2002). Emotionally focused couple therapy with trauma survivors: Strengthening attachment bonds. New York, NY: Guilford Press.

• Kluft, Richard (1985). Chapter, “The Natural History of Multiple Personality Disorder,” in Childhood Antecedents of Multiple Personality, edited by Kluft, and chapter on treatment outcome in Braun’s 1986 edited book, “The Treatment of Multiple Personality.” Both American Psychiatric Press.

• Levine, P. A. (2010). In an unspoken voice: How the body releases trauma and restores goodness. Berkeley, CA: North Atlantic Books.

• Madere, J. (2015, August). Multidimensional Inventory of Dissociation: A tutorial and case review workshop. Presented at the 21st EMDR International Association Annual Conference, Philadelphia, PA.

• Madere, J. (2014, September). Comparing ACES & DES scores: Implications for assessment of diverse populations. Paper presented at the 20th EMDR International Association Annual Conference, Denver, CO.

References 3• Nijenhuis, E.R.S., Van der Hart, O., & Kruger, K. (2002). The psychometric characteristics

of the Traumatic Experiences Questionnaire (TEC): First findings among psychiatric outpatients. Clinical Psychology and Psychotherapy, 9(3), 200-210.

• Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. New York, NY: W.W. Norton.

• Perry, B. (2015). Information presented at: Cross-Discipline Trauma Conference of Central Texas, March 30, 2015.

• Rappaport, L. (2010). Focusing-oriented art therapy: Working with trauma. Person-Centered and Experiential Psychotherapies, 9(2), 128-142.

• Ross, C. (2015). When to Suspect and How to Diagnose Dissociative Identity Disorder. Journal of EMDR Practice and Research, 9(2), 114-120.

• Ross, C., Heber, S., Norton, G., Anderson, G., Anderson, D., Barchet, P. (1989). The Dissociative Disorders Interview Schedule: A Structured Interview. Dissociation, 2(3):169-189.

• Shapiro, F., Kaslow, F., & Maxfield, L. (Eds.). (2007). Handbook of EMDR and family therapy processes. Hoboken, NJ: Wiley.

• Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd ed).) New York, NY: Guilford Press.

• Steinberg, M., Schnall, M. (2001). The Stranger in the Mirror: Dissociation, the Hidden Epidemic. New York, NY: Harper Collins.

• Van der Kolk, B. A. (1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1, 253-265.

clinical discernment our plan for today trauma · 2017-11-10 · clinical discernment: when faith...

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