making sense of the complexities of trauma
DESCRIPTION
Making Sense of the Complexities of Trauma. Heather Hartman-Hall, Ph.D. 2012. Training Objectives. Participants will be able to… Identify diagnostic challenges in working with clients who have experienced trauma. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/1.jpg)
Making Sense of the Complexities of Trauma
Heather Hartman-Hall, Ph.D.
2012
![Page 2: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/2.jpg)
Training Objectives
Participants will be able to…
Identify diagnostic challenges in working with clients who have experienced trauma.Understand how current symptoms may reflect adaptations to traumatic experiences.Describe important features of a complex trauma syndrome.
![Page 3: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/3.jpg)
Training Objectives (cont.)
Identify several strategies for helping clients manage self-injurious and suicidal behaviors.
Understand vicarious traumatization and the importance of clinician self-care.
![Page 4: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/4.jpg)
PART ONE: Understanding Complex
Trauma Syndromes
![Page 5: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/5.jpg)
“Psychological trauma is an affliction of the powerless. At the moment of trauma, the victim is rendered helpless by overwhelming force. When the force is that of nature, we speak of disasters. When the force is that of other human beings, we speak of atrocities. Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning.”
– Judith Herman, Trauma and Recovery, 1997
![Page 6: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/6.jpg)
PREVALENCE AND ETIOLOGY
![Page 7: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/7.jpg)
Prevalence
While the criteria for PTSD diagnosis have gotten stricter since 1980, our ability to assess for and detect PTSD has improved; the overall prevalence has remained fairly stable in that period
![Page 8: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/8.jpg)
Prevalence (cont.)
PTSD is still likely underdiagnosed, particularly in several demographic groups (e.g., Brunet, 2007)
In many settings, trauma not routinely assessed as part of intakes (van der Kolk et al., 2005)
![Page 9: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/9.jpg)
Prevalence (cont.)
Estimates for exposure to potentially traumatizing events in the US tend to range around 70% of people surveyed
CDC “ACE” study (2009) >26K non-institutionalized US adults in 5 states
8.7% reported 5 or more ACEsSexual abuse: 17.2% for women, 6.7% for menACEs associated with “multiple mental and physical
health problems”
![Page 10: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/10.jpg)
Prevalence (cont.)
Prevalence rates for PTSD vary depending on the group surveyed; for the general US population lifetime prevalence is estimated to be 6.8-8%
![Page 11: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/11.jpg)
Prevalence (cont.)
National Comorbidity Survey Replication (NCS-R), conducted between 2001 and 2003 (Gradus, 2007) Nationally representative sample of Americans
aged 18 years and older 5K+ participants assessed for PTSD by interview
using DSM-IV criteria Lifetime prevalence of PTSD est. at 6.8%
Among women: 9.7%, men: 3.6%
![Page 12: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/12.jpg)
Prevalence (cont.)
NCS-R yielded estimates similar to first National Comorbidity Survey (early 1990’s):
Lifetime Prevalence of PTSD
Overall Women Men
NCS 7.8% 10.4% 5%
NCS-R 6.8% 9.7% 3.6%
![Page 13: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/13.jpg)
Prevalence (cont.)
DSM-IV-TR: Community-based studies indicate about 8% lifetime prevalence for PTSD adults in the US
![Page 14: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/14.jpg)
Prevalence (cont.)
Random sample of 4,008 US women (Resnick, 1993) Lifetime exposure to any type of civilian traumatic
event: 69% 36% endorsed exposure to crimes that included
sexual or aggravated assault or homicide of a close relative or friend
Lifetime prevalence of PTSD:12.3% significantly higher among crime vs noncrime victims
(25.8% vs 9.4%).
![Page 15: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/15.jpg)
Prevalence (cont.)
Study of 152 women aged 18-45 consecutively seen for routine gynecological care in family physician office (Sansone, et al.,1995) Traumatic experiences were reported by 70.7%
Sexual abuse reported by 25.8% Physical abuse reported by 36.4% Emotional abuse reported by 43.7% Physical neglect reported by 9.3% Witnessing of violence reported by 43.0%
![Page 16: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/16.jpg)
Prevalence (cont.) Random sample of 1008 adult residents of
Manhattan 5-8 weeks after September 11, 2001 terrorist attacks (Galea, et al., 2002) 7.5% reported symptoms consistent with a
diagnosis of current PTSD related to the attacks 20% in residents who lived near World Trade Center Predictors of PTSD: Hispanic ethnicity, prior stressors,
a panic attack during or shortly after the events, proximity to WTC, and loss of possessions due to the events.
9.7% reported symptoms of depression
![Page 17: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/17.jpg)
Prevalence (cont.)
Interviews of 810 adult residents in southern Mississippi (random selection of addresses in each of 3 strata), 18-24 months after Hurricane Katrina (Galea, et al. 2008) 22.5% diagnosed with PTSD in that period Risk factors included:
Being female Financial loss Low social support Post-disaster stressors/traumas
![Page 18: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/18.jpg)
Prevalence – Complex PTSD
Full syndrome estimated <1% in nonclinical population
Sub-syndrome symptoms of CPTSD more common and are associated with childhood trauma
![Page 19: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/19.jpg)
Prevalence – Complex PTSD (cont.)
van Dijke, et al. (2011) found 10-38% of psychiatric inpatients met criteria for Complex PTSD
In one small study of forensic inpatients in Germany, 28% were diagnosed with CPTSD; 44% lifetime prevalence
![Page 20: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/20.jpg)
Interpersonal Trauma and PTSD
Interpersonal trauma is associated with higher rates of PTSD than other types of trauma (accidents, disasters, etc.)
Being victimized by criminal acts more associated with PTSD symptoms
Interpersonal traumas experienced in childhood increase likelihood of PTSD, and of victimization later in life
![Page 21: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/21.jpg)
Gender Differences
National Comorbidity Survey indicated that more males than females in the US experience trauma, but more females develop PTSD
Lifetime prevalence of PTSD for women is about twice that of men
Some studies suggest PTSD lasts longer in females than males
![Page 22: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/22.jpg)
Gender Differences (cont.)
Women more likely to be exposed to interpersonal forms of trauma (Lilly & Valdez, 2012) Females typically report more sexual abuse
than males Experience of interpersonal trauma may be
more predictive of later PTSD than gender
![Page 23: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/23.jpg)
Gender Differences (cont.)
Teenage boys in particular rarely report sexual abuse, particularly by a woman Guilt/shame “Rite of passage” Normalized or even
viewed as positive by peers/other adults
![Page 24: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/24.jpg)
Gender Differences (cont.)
Males may be less likely to seek treatment Gender of therapist may be important Differences in symptom presentation?
Culturally-imposed gender roles (e.g., Evans & Sullivan, 1995)
![Page 25: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/25.jpg)
Special Populations
“…many or even most psychiatric patients are survivors” of abuse (Herman, 1997)
Some estimates suggest 1/3-1/2 of people in treatment for substance abuse have PTSD
Lifetime exposure to trauma has been reported to be higher in adult and juvenile offenders Especially child abuse (Spitzer, et al., 2006)
![Page 26: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/26.jpg)
Early Risk
“Ideally, parenting is the essential buffer against trauma” (Allen, 1995) When a small child’s needs are met predictably
by his environment, more likely to develop secure attachment (Schore, 2002) May affect development of the central nervous system
and the limbic system Secure attachment includes the assumption that
“homeostatic disruptions will be set right”
![Page 27: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/27.jpg)
Early Risk (cont.) Childhood abuse often occurs within the context
of neglect, deprivation, and emotional invalidation (Briere, 1996) Acts of both commission and omission (Korn &
Leeds, 2002): Sexual, physical, emotional abuse Witnessing violence Unmet physical and emotional needs Parental unavailability Failure to protect by caregivers Childhood separations
![Page 28: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/28.jpg)
Early Risk (cont.)
Increasing evidence that childhood trauma puts people at higher risk for mental illness and maladaptive stress responses in adulthood New research using brain scans shows structural
changes (particularly in areas of the brain related to stress response)
“a violation of and challenge to the fragile, immature and newly emerging self (Ford & Courtois, 2009)
![Page 29: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/29.jpg)
Early Risk (cont.)
Childhood traumas can “block or interrupt the normal progression of psychological development in periods when a child…is acquiring the fundamental psychological and biological foundations necessary for all subsequent development (Ford, 2009) Brain shifts from “learning” functions to
“survival” functions
![Page 30: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/30.jpg)
Early Risk (cont.)
When a child is betrayed (e.g., abused or neglected) by a caregiver, child still needs caregiver to survive May remain unaware of the betrayal (Kaehler &
Freyd, 2011) Dissociation
Blame self rather than caregiver Rationalize/excuse the abuser
![Page 31: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/31.jpg)
Risk Factors/Resilience
Most traumas don’t result in mental illness DSM-IV-TR: “severity, duration, and proximity
of an individual’s exposure to the traumatic event are the most important factors” in risk for PTSD… “some evidence that social supports, family history, childhood experiences, personality variables, and pre-existing mental disorders may influence” development of PTSD
![Page 32: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/32.jpg)
Common Reactions to Frightening Experiences Shock Anxiety/worry Irritability/anger Changes in eating or sleeping habits Physical problems or illness Apathy/loss of interest in usual activities Feeling “jumpy”
Most people experience some temporary interference in usual functioning after a
traumatic experience.
![Page 33: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/33.jpg)
Fight or Flight Response
Mammals have developed response to threat through evolution
Sympathetic nervous system Once the response is set off, hormones
released into the body create various changes to prepare the body for vigorous action
Increased heart rate, constriction of blood vessels, tunnel vision, reduced GI and sexual functioning
![Page 34: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/34.jpg)
Fight or Flight Response (cont.)
“Fight or Flight” represents a complex stress response Decades of stress research (e.g. Bracha, et al.
2004) have illuminated four fear responses that occur in order in the face of a threat Initial freeze response Attempt to flee Attempt to fight Tonic immobility
“Freeze, flight, fight, fright response”
![Page 35: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/35.jpg)
Fight or Flight Response (cont.)
Stress response begins with the individual’s appraisal of the event and how it may affect him or her Various individual and situational factors will
influence appraisal Likely an automatic and even unconscious
process Includes whether individual has resources to
cope with stressor
![Page 36: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/36.jpg)
Fight or Flight Response (cont.)
Physiologically, the response to rage and fear are the same
May be an adaptive response to single-incident, intense stress, but can become problematic When continuously activated When natural response is blocked Loss of ability to return to baseline state of
physical calm or comfort
![Page 37: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/37.jpg)
Adaptations to Trauma
A natural response to an overwhelming experience
Strategies that are adaptive in a crisis can backfire when trauma is ongoing or when self-regulation doesn’t come back online
“natural, self-protective efforts gone awry” (Allen, 1995)
![Page 38: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/38.jpg)
Long-Term Effects of Trauma
Physiological changes Dysregulated emotions Disruption of relationships Damaged/changed view of self Changes in world view/belief system Break down of coping strategies Altered perceptions
![Page 39: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/39.jpg)
DIAGNOSTIC CHALLENGES
![Page 40: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/40.jpg)
A Confusing Picture
What are the likely diagnoses for each of the following symptom clusters?
![Page 41: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/41.jpg)
Numerous hospitalizations, history of cutting arms repeatedly, has trouble trusting others but is afraid to be alone.
Appears withdrawn, suspicious of others, occasionally appears to be responding to internal stimuli.
Hypersexuality, risk-taking, substance abuse, insomnia, weight loss.
![Page 42: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/42.jpg)
Episodic confusion, poor memory, inability to attend to conversations, little spontaneous speech, low activity level.
Flat affect, unable to think of anything good that might happen in the future, low energy, finds little enjoyment in activities once enjoyed.
Reports hearing a voice that repeats insults and phrases such as “You should die.” Reports sometimes feeling that she leaves her body and looks down at herself from the sky.
![Page 43: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/43.jpg)
Diagnostic Challenges Misdiagnosis – “bewildering array of
symptoms” (Herman, 1997) Symptoms and functioning often vary over time
and across situations Self-report might not include information about
trauma Strengths/abilities might mask difficulties or
make impairment less obvious Trauma disorders may not be considered,
particularly in some settings
![Page 44: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/44.jpg)
Diagnostic Challenges (cont.)
Comorbidity of trauma with other disorders One large study: 84% of people with PTSD met
criteria for at least one other psychiatric disorder Major depression Substance abuse Other anxiety disorders Schizophrenia Dissociative disorders Personality disorders
Comorbid somatic problems also very common
![Page 45: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/45.jpg)
Cultural Factors
DSM-IV-TR emphasizes importance of considering culture in diagnosis
Research on trauma in mainstream US population might not generalize to other cultures (Carlson, 1997)
Some evidence of higher rates of trauma and/or more severe symptoms among people from ethnic minority groups and deaf people (Davis, et al. 2011; Ford 2012) SES status and its associated stressors may play
a role
![Page 46: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/46.jpg)
Cultural Factors (cont.)
Possible differences in symptom presentation (Schlid & Dalenberg, 2012; Brunet, 2007; Frueh, et al., 2002; Sue & Sue, 1987) Asian cultures more likely to present with physical
symptoms as a trauma response African-American combat veterans with PTSD
may present with more psychotic symptoms Trauma symptoms may present differently in deaf
vs. hearing people
![Page 47: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/47.jpg)
AXIS I DISORDERS ASSOCIATED WITH TRAUMA
![Page 48: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/48.jpg)
Diagnoses Commonly Associated with Trauma
Post-Traumatic Stress Disorder (PTSD) Acute Stress Disorder Borderline Personality Disorder Dissociative Disorders Substance Abuse/Dependence Eating Disorders Other anxiety, mood, somatoform, personality
disorders
![Page 49: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/49.jpg)
PTSD
Symptoms usually begin within 3 months of traumatic experience, but may be a delay of months or even years
Three clusters of symptoms: Re-experiencing Avoidance/numbing Hyperarousal
Bi-phasic condition that alternates between reliving the overwhelming experience, and avoiding thoughts/feelings associated with trauma
![Page 50: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/50.jpg)
PTSD (cont.)
DSM-IV-TR Criterion A: 1.The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.
2.The person's response involved intense fear, helplessness, or horror. (In children, may be expressed instead by disorganized or agitated behavior)
![Page 51: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/51.jpg)
PTSD (cont.)
DSM-III Criterion A: The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone
![Page 52: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/52.jpg)
PTSD: Re-experiencing
One or more for diagnosis of PTSD Examples
Intrusive thoughts or memories of trauma Nightmares Flashbacks Intense distress in response to reminders of the
trauma
![Page 53: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/53.jpg)
PTSD: Avoidance/Numbing
Three or more for diagnosis of PTSD Examples
Avoiding reminders of the trauma Amnesia for some aspects of the experience Loss of interest in activities Feeling detached or estranged from others Restricted range of emotions
![Page 54: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/54.jpg)
PTSD: Hyperarousal
Two or more that have arisen since the traumatic experience
Examples Insomnia Irritability Poor concentration Hypervigilance Exaggerated startle response
![Page 55: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/55.jpg)
Acute Stress Disorder
Symptoms similar to PTSD, difference is timeframe
Symptoms occur within one month of trauma and last 2 days to 4 weeks
![Page 56: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/56.jpg)
Dissociative Disorders
Depersonalization Disorder Dissociative Amnesia Dissociative Fugue Dissociative Identity Disorder Dissociative Disorder Not Otherwise Specified
![Page 57: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/57.jpg)
Dissociative Disorders (cont.)
Characterized by range of experiences related to disruption of awareness/consciousness, memory, identity, perception, etc.
Can present in different ways (sudden vs. gradual, transient vs. chronic, single symptom or entire syndrome)
Individual may or may not be aware of these occurrences, but they cause impairment and/or distress
![Page 58: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/58.jpg)
Dissociative Disorders (cont.)
Link between childhood trauma (especially abuse) and dissociation later in life (e.g., Löffler-Stastka, et al. 2009)
Dissociation as a response to chronic, inescapable stress Shuts out the experience – mental escape when
couldn’t physically escape Allows individual to survive unbearable situation Perhaps adaptive in the short-term, but
detrimental to functioning longer-term
![Page 59: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/59.jpg)
Dissociative Disorders (cont.)
Later in life, dissociative experience may be triggered by memories, perceived threat, or strong feelings
Pathological dissociation was associated with depression, alexithymia, and suicidality in a general population sample (Maaranen, et al., 2005)
![Page 60: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/60.jpg)
Dissociation & Other Diagnoses
Dissociative symptoms have been associated with PTSD, borderline personality disorder, schizophrenia, mood disorders, OCD, somatoform disorders (Spitzer, Barnow, et al., 2006)
![Page 61: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/61.jpg)
Dissociation vs. Psychosis
Dissociation and psychosis can present similarly
Severe dissociation has been associated with comorbid psychosis (Allen et al., 1997; Allen & Coyne, 1995; Moskowitz et al., 2005; Kilcommons, et al., 2008)
![Page 62: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/62.jpg)
THE ROLE OF TRAUMA IN BORDERLINE PERSONALITY DISORDER
![Page 63: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/63.jpg)
Borderline Personality Disorder (BPD)
Diagnosed in about 2% of general US population; about 75% of these are female
DSM-IV-TR: “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts
Examples…
![Page 64: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/64.jpg)
BPD (cont.)
Frantic attempts to avoid abandonment Unstable and intense relationships Identity disturbance Impulsive, potentially self-destructive behaviors Suicidal or self-injurious behaviors Affective instability/reactive mood Chronic feelings of emptiness Intense anger Dissociative symptoms, stress-induced paranoia
![Page 65: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/65.jpg)
BPD (cont.)
BPD diagnostic criteria have remained relatively unchanged since introduced in DSM-III (1980)
Criticisms of current criteria (Lewis & Grenyer, 2009): Extensive symptom overlap with other disorders Reliability and validity of diagnosis in literature
has been inconsistent No reference to widely-accepted role of early
trauma
![Page 66: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/66.jpg)
Perceptions of BPD
Pejorative connotation of the diagnosis In particular, clients with BPD who engage in
self-harm or suicide attempts tend to get negative reactions from clinicians, ER personnel, others (see Treloar & Lewis, 2008 for review) Negative perceptions create “major barrier to
effective service provision” for these patients Education for professionals shows positive effects
![Page 67: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/67.jpg)
BPD and Trauma
DSM-IV-TR: “Physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation are more common in the childhood histories of those with” BPD
Link identified between insecure attachment in infancy and later development of BPD symptoms (e.g., Kaehler & Freyd, 2011)
![Page 68: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/68.jpg)
BPD and Trauma (cont.)
Physical abuse/neglect and inconsistent experiences from caregivers in childhood seen as possible factors in development of BPD (Löffler-Stastka, et al., 2009)
Studies found 81-91% of people with BPD had severe childhood trauma, including physical/emotional abuse, neglect, sexual trauma (e.g., Lewis & Grenyer, 2009; Herman, 1997)
![Page 69: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/69.jpg)
BPD and Trauma (cont.)
Trauma may be one etiological factor among many, including biological, psychological, and social factors (Gratz, et al., 2011; Lewis & Grenyer, 2009)
Possibly, trauma interacts with temperament and biological vulnerabilities
Linehan describes BPD as resulting from inherited proneness to emotional dysregulation and growing up in an invalidating environment
![Page 70: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/70.jpg)
COMPLEX PTSD
![Page 71: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/71.jpg)
Complex PTSD (CPTSD)
Spectrum of trauma responses from brief reaction that improves on its own, to classic PTSD, to complex syndrome
Complex syndrome seen in survivors of prolonged, repeated (often childhood) trauma at the hands of others
![Page 72: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/72.jpg)
CPTSD (cont.)
Loss of coherent sense of self and others that is often a core feature of chronic interpersonal trauma is not captured in current PTSD diagnosis
DSM-IV Field Trial demonstrated that early trauma gives rise to more complex symptoms in addition to PTSD (van der Kolk, et al., 2005)Disorders of Extreme Stress Not Otherwise
Specified (DESNOS)
![Page 73: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/73.jpg)
CPTSD (cont.)
Criteria that were under consideration for DSM-IV for a complex trauma syndrome:
![Page 74: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/74.jpg)
Complex PTSD – Proposed Criteria (Herman, 1992)
A history of ongoing and severe interpersonal trauma
Alterations in affect regulation Including persistent dysphoria, suicidal
preoccupation, self-injury, explosive anger Alterations in consciousness
Including amnesia, dissociative experiences, intrusive memories or flashbacks
![Page 75: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/75.jpg)
Complex PTSD – Proposed Criteria (Herman, 1992, cont.)
Alterations in self-perception Including shame, guilt, feeling of differentness from
others, helplessness Alterations in perception of perpetrator
Including revenge fantasies, idealization, rationalizations
Alterations in relations with others Including isolation, distrust, failure to self-protect
Alterations in systems of meaning Including loss of faith, hopelessness
![Page 76: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/76.jpg)
PROPOSED CHANGES FOR DSM-5
![Page 77: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/77.jpg)
Proposed Changes for DSM-5
Planned release in May, 2013 New diagnostic category: “Trauma- and
Stressor-Related Disorders” Would move trauma disorders from Anxiety
Disorders category Includes adjustment disorders
![Page 78: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/78.jpg)
Proposed Changes for DSM-5:Trauma- and Stressor-Related Disorders
Reactive Attachment Disorder Disinhibited Social Engagement Disorder Acute Stress Disorder Posttraumatic Stress Disorder Adjustment Disorders Trauma- or Stressor-Related Disorder Not
Elsewhere Classified
![Page 79: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/79.jpg)
Proposed DSM-5 Changes to PTSD diagnosis
DSM IV-TR PTSD Criteria A1: The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.
A2: The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behavior.
![Page 80: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/80.jpg)
Proposed DSM-5 Changes to PTSD diagnosis (cont.)
PROPOSED DSM 5 PTSD Criteria A:
Exposure to actual or threatened a) death, b)serious injury, or c) sexual violation, in one or more of the following ways:
![Page 81: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/81.jpg)
Proposed Changes for DSM-5 (cont.)
Directly experiencing the event Witnessing, in person, others experiencing
event Learning that the event occurred to close
relative or friend; actual or threatened death must be violent or accidental
Experiencing repeated or extreme exposure to aversive details of the event E.g., first responders, police officers investigating child
abuse cases
![Page 82: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/82.jpg)
Proposed Changes for DSM-5 (cont.)
4 proposed symptom clusters Intrusion symptoms Avoidance Negative alterations in cognitions and mood Alterations in arousal and reactivity
![Page 83: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/83.jpg)
Proposed Changes for DSM-5 (cont.)
Subtypes PTSD in Preschool Children PTSD with Prominent Dissociative Symptoms
meets criteria for PTSD AND either depersonalization and/or derealization
![Page 84: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/84.jpg)
Proposed Changes for DSM-5 (cont.)
Dissociative Disorders Depersonalization-Derealization Disorder Dissociative Amnesia Dissociative Identity Disorder Dissociative Disorder Not Elsewhere Classified
![Page 85: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/85.jpg)
Proposed Changes for DSM-5 (cont.)
Changes in personality disorder diagnoses also proposed Fewer personality disorders included Impairment must be seen in both “self” and
“interpersonal” domains Impairment must be present in at least one of five
areas Severity of impairment rated from mild to extreme
![Page 86: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/86.jpg)
Proposed Changes for DSM-5 (cont.)
For more about proposed changes, progress of the workgroups, and the timeline for release of DSM 5:
www.dsm5.org
![Page 87: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/87.jpg)
SELF-INJURIOUS AND SUICIDAL BEHAVIORS
![Page 88: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/88.jpg)
Self-Harm
• Tension-relieving self-injurious behaviors vs. suicidal behaviors
• Two different but often related sets of behavior Self-injurious behaviors DO increase the risk
of suicidal behaviors Particularly for people with personality disorders
![Page 89: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/89.jpg)
Suicidal vs. Self-Injurious Behaviors
Maddock et al. (2010) looked at reasons women with BPD gave for SIB and suicide attempts and found the reasons (e.g., to relieve emotional pain, escape, etc.) were not significantly different Suggested clinicians should assess method used
and whether reasons for harming self have resolved in determining risk for suicide
![Page 90: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/90.jpg)
Risk Factors for Self-Harm
Previous suicide attempt/self-injury Psychiatric illness
Mood disorder (Depression, Bipolar Disorder) Substance abuse Schizophrenia Personality disorders Anxiety disorders
![Page 91: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/91.jpg)
Risk Factors for Self-Harm (cont.)
High-risk groups vary by culture/country In the US, women more likely to attempt suicide
but men more likely to complete suicide
![Page 92: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/92.jpg)
Self-Injurious Behaviors (SIB)
the "deliberate, direct injury of one's own body that causes tissue damage or leaves marks for more than a few minutes and that is done in order to deal with an overwhelming or distressing situation” (ASHIC website, 2005)
Examples: cutting/scratching, burning, head banging, swallowing foreign objects
![Page 93: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/93.jpg)
SIB (cont.)
Most SIB is an adaptation to deal with an intolerable experience (Saakvitne, et al., 2000)
A person who has experienced significant, ongoing trauma may develop SIB as a way to cope with overwhelming emotions
The link between SIB and significant childhood trauma has been well established in the research literature (e.g., Osuch, Noll, &
Putnam, 1999; Herman, 1992)
![Page 94: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/94.jpg)
SIB (cont.)
Physical pain is often reduced or even unnoticed while a person is in the act of SIB (e.g., Herman, 1992)
The individual may be unaware of the behavior while it is occurring, particularly if dissociating
![Page 95: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/95.jpg)
SIB (cont.)Many possible reasons for SIB… to manage intense feelings/distress physical pain seen as preferable to emotional pain individual feels he or she deserves to be punished to obtain a sense of control to ground oneself when dissociating or otherwise
losing touch with reality to express anger or hostility to stop flashbacks or other intrusive memories to express emotional pain to prevent suicide attempts to prevent acting out against others
![Page 96: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/96.jpg)
SIB (cont.)
SIB is typically NOT a failed suicide attempt Osuch, Noll, & Putnam, 1999; Herman, 1992 Assess whether the person intended to die or
believed the behavior was life-threatening In fact, SIB is often a coping strategy that acts as
suicide prevention for patients, in that SIB may help them avoid feeling a total loss of control
![Page 97: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/97.jpg)
SIB (cont.)
However, a patient who engages in SIB may also be suicidal, and is likely at increased risk for also making a suicide attempt. It has been estimated that about half of all people
who kill themselves have a history of SIB (Osuch, et al. 1999).
Patients engaging in SIB should also be regularly assessed for suicidal ideation.
![Page 98: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/98.jpg)
SIB (cont.) Borderline Personality Disorder (BPD) diagnosis in
the DSM-IV-TR includes deliberate self-injury as a listed symptom, and therefore the two are often equated
The presence of SIB alone does NOT warrant a diagnosis of an Axis II disorder. SIB occurs with many other diagnoses, including PTSD,
eating disorders, substance abuse, dissociative disorders, developmental disorders, and alexithymia (a lack of ability to express or even have awareness of one's own feelings).
There might also be a psychotic or obsessive-compulsive component to SIB. E.g., in response to hallucinations (Osuch, et al.1999)
![Page 99: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/99.jpg)
SIB (cont.)
Caregiver/loved ones’ reactions to SIB Anger, fear, disgust, worry, hopelessness and
other strong feelings are understandable reactions to SIB
Important to manage reactions rather than act them out on the client
Strong reactions can contribute to the client’s feeling less safe, increasing her anger, shame, distress, tendency to hide SIB (Herman 1992; Saakvitne, et al., 2000)
![Page 100: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/100.jpg)
SIB (cont.)
Research suggests that offering possible reasons for SIB may actually increase risk of additional SIB (Osuch, et al. 1999) Ask open-ended questions about client’s ideas
about why she/he is engaging in SIB
![Page 101: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/101.jpg)
Suicide
Chronic vs. Acute Direct communication is crucial Should be assessed regularly and at critical
points Family/significant other involvement Seasonal variation
![Page 102: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/102.jpg)
PART TWO:
A Trauma-Informed Approach to Treatment
![Page 103: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/103.jpg)
SETTING THE FRAME
![Page 104: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/104.jpg)
“I explained that we were on a journey together – that she picked the path and I held the light for us to see.”
- Susan K. L. Pearson, M. D.
![Page 105: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/105.jpg)
Setting the Frame
Informed Consent Confidentiality Mandated reporting/duty to warn Treatment plan May feel worse before you feel better Safety Your crisis availability/back-up plans Education as part of treatment
![Page 106: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/106.jpg)
Setting the Frame (cont.)
Treatment Goals/plan Client’s role (not passive!) Psychoeducation Validation of the traumatic experience is a
precondition for creating an integrated view of self and establishing the capacity for healthy relationships (Herman, et al. 1995)
![Page 107: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/107.jpg)
Setting the Frame (cont.)
Create a safe environment Physically and psychologically Acknowledge limitations of setting/situation
Eye contact and active listening Physiological aspects of social behavior
Use touch of any kind cautiously if at all
![Page 108: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/108.jpg)
THE THERAPEUTIC RELATIONSHIP –
THE CRITICAL COMPONENT
![Page 109: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/109.jpg)
Therapeutic Relationship
Trauma can disrupt many aspects of interpersonal functioning:
Ability to connect Trust Asking for help Being vulnerable with someone Believing someone else cares
…etc.
![Page 110: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/110.jpg)
Therapeutic Relationship (cont.)
The most important thing you bring to the therapy is YOU
“…the essential therapist task is to provide relational conditions that encourage the safety of the attachment between client and therapist” (Kinsler, Courtois, & Frankel, 2009)
![Page 111: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/111.jpg)
Therapeutic Relationship (cont.)
Appropriate, solid boundaries
Experiencing first-hand how the client behaves in relationships Informative for the therapist Can provide feedback to client
![Page 112: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/112.jpg)
Therapeutic Relationship (cont.)
Providing a consistent presence
Tolerating the pain – starting to help client develop affect regulation
Another opportunity for “secure attachment”
![Page 113: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/113.jpg)
Therapeutic Relationship (cont.)
Managing inherent power imbalance (Courtois, et al., 2009) Strive for egalitarian, collaborative relationship
that encourages empowerment of client Responsibilities and inherent power differences
should be acknowledged Seek to use power effectively on client’s behalf Encourage client’s development and autonomy
![Page 114: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/114.jpg)
Therapeutic Relationship (cont.)
Holding the hope
Once relationship is fairly solid, work towards “putting eggs in more baskets”
Avoid accepting the superhero cape!
![Page 115: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/115.jpg)
“Trouble can always be borne when it is shared.”
-Katherine Paterson
![Page 116: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/116.jpg)
R.I.C.H. Philosophy(Saakvitne, et al. 2000)
An approach for any clinical work with survivors of trauma:RespectInformationConnectionHope
![Page 117: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/117.jpg)
Respect Collaboration Confidentiality Sensitive language Assuming client’s point of view is valid Being fully present Humility Honesty
![Page 118: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/118.jpg)
Information Provide information about effects of trauma Explain treatment plan, including rationale
Include possible risks and benefits Expectations on both sides should be clear and
reviewed as often as needed Community resources Safety planning In inpatient/correctional setting, helping client
understand the process
![Page 119: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/119.jpg)
Connection Genuine empathy and positive regard Clear boundaries Being honest Sitting with painful content and emotions Recognition that the work affects both of you
![Page 120: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/120.jpg)
Hope You can have hope for the client even when
she doesn’t have it for herself Utilize strengths and abilities Help client see progress Keep goals realistic Therapist self-care is crucial!
![Page 121: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/121.jpg)
ASSESSMENT OF TRAUMA AND ITS EFFECTS
![Page 122: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/122.jpg)
“The past isn’t dead – it isn’t even past”
-William Faulkner
![Page 123: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/123.jpg)
Assessment of Trauma
Best tool – good clinical interview May need to spend time establishing trust and
safety first Need to find a balance between a thorough
picture of traumatic experiences, but not triggering re-experiencing or overwhelming feelings/memories
![Page 124: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/124.jpg)
Assessment of Trauma (cont.) “Some of the things I ask about might bring up
upsetting or uncomfortable memories or feelings. It’s important that I understand what you’ve experienced, but we don’t need to rush things. As much as possible, I’d like to know the kinds of things you’ve experienced, but I don’t want to overwhelm you or have you re-live painful experiences right now. At any point if there is anything you don’t want to talk about, just let me know. If you are starting to feel yourself becoming overwhelmed, please let me know right away. If I see you becoming very distressed, I may ask you to stop for a moment so we can check in. ”
![Page 125: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/125.jpg)
Assessment of Trauma (cont.)
In particular, assess:Traumatic experiences and significant lossesSymptomsCurrent safetyStrengths/resources
![Page 126: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/126.jpg)
Assessment:Traumatic Experiences
Many people will not spontaneously report traumatic experiences – you do need to ask May not understand pertinence May not remember details or any of it May be uncomfortable/worry about stigma May think you won’t want to hear about it May worry about becoming overwhelmed
Sometime the opposite problem – “I just want to get it all out at once.”
![Page 127: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/127.jpg)
Assessment:Traumatic Experiences (cont.)
Be non-leading, but ask about various types of traumatic experiences Childhood experiences (physical, emotional,
sexual, neglect) Adult interpersonal violence (domestic violence,
assault, sexual assault, crimes) Street life/drug trade/gangs Accidents Natural disasters Combat/torture for military personnel
![Page 128: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/128.jpg)
Assessment:Traumatic Experiences (cont.)
Examples of questions you could ask: How was discipline handled in your family when
you were younger? Follow-up on “I was hit” or “We were beat” – with
objects? Closed fist or open hand? Did it leave marks/injuries? Did you ever need medical attention?
Have you ever had a very upsetting experience that might still be affecting you?
Have you ever experienced any very frightening events?
(continued…)
![Page 129: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/129.jpg)
Assessment:Traumatic Experiences (cont.)
Did anyone in your childhood ever approach you in a sexual way? In early interviews, I avoid words like rape,
molestation, sexual abuse unless the client uses them first
Have you had any unwanted sexual experiences? Have you ever been in any accidents, fires, or
other catastrophes? Have you served in the military?
Combat experiences? Job-related experiences as appropriate
![Page 130: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/130.jpg)
Assessment:Traumatic Experiences (cont.)
Have you ever been the victim of a crime? Have you been in any relationships as a teenager
or adult where there was hitting, control issues, or sexual experiences that involved coercion? Anything like that going on now?
![Page 131: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/131.jpg)
Assessment: Symptoms
Clinical interview Can start broad (e.g., “How does that experience
still affect you now?”) then move to more specific Specifically ask about various symptom clusters ALWAYS directly ask about self-injury, suicide,
thoughts of harm to others - both past and current Assess substance abuse, past and current
Symptom checklists Psychological testing
![Page 132: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/132.jpg)
Assessment: Safety
Living situation/Finances Basic needs met?
Current relationships Substance abuse Eating disorders Any children/vulnerable adults currently in
danger?
![Page 133: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/133.jpg)
Assessment: Safety (cont.)
Self-injurious behaviors What is the function of the behavior? Differentiate from suicide attempts Past/current – when was most recent episode? Frequency Triggers?
![Page 134: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/134.jpg)
Assessment: Safety (cont.) Suicide Risk
ASK DIRECTLY! Past attempts
What kept attempts from being successful? Recent/current thoughts or impulses Plans
How lethal? How available? Ask about weapons, etc.
Current perturbation/agitation; recent stressors Family history
![Page 135: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/135.jpg)
Assessment: Safety (cont.)
Suicide Risk (cont.) Hopelessness Reasons to live Barriers to acting on suicidal thoughts Start talking about safety plans in initial session
Is client safe right now?
![Page 136: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/136.jpg)
Assessment: Safety (cont.)
Risk to others How do you handle it when you are really angry? Ever hurt anyone intentionally or accidentally
when you were angry or upset? Ever any thoughts of wanting to hurt anyone? If current thoughts of harm:
Specific victim? Plan to act on thoughts? Means? Know your state’s duty to warn statutes!
![Page 137: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/137.jpg)
Assessment: Strengths/Resources
For example: Social network – primary relationships, friends,
family, other important people Personal strengths Interests/hobbies Religious/spiritual beliefs Pets
Can point out where you see strengths as well
![Page 138: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/138.jpg)
Assessment: Additional considerations
Other things to assess along the way: Interpersonal functioning Client’s view of the trauma Client’s view of helpers/treatment Hope/trust
![Page 139: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/139.jpg)
Assessment: Additional considerations (cont.)
Forensic settings Limits to confidentiality Consider likelihood of being able to engage in
treatment at this point Questions of malingering
Validity measures
Mandated reporting
![Page 140: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/140.jpg)
Assessment (cont.)
Opportunity to begin therapeutic process Offer the client hope When possible, end the assessment with
beginning treatment planning/some initial strategies the client can start right away
![Page 141: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/141.jpg)
STAGES OF TREATMENT
![Page 142: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/142.jpg)
Treatment Planning
Psychotherapy for complex trauma “should be based in a systematic (not laissez-faire) shared plan that utilizes effective treatment practices, and is organized around a careful assessment and a hierarchically ordered, planned sequence of interventions”
“Treatment, like complex traumatic stress symptoms, is complex and multimodal” (Courtois, Ford, & Cloitre, 2009)
![Page 143: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/143.jpg)
Treatment Planning (cont.) Simple PTSD – cognitive-behavioral therapy,
exposure, cognitive reprocessing, EMDR, in some cases medication
Complex PTSD – stage model, Dialectical Behavior Therapy (DBT), longer term psychotherapy Limited empirical research (Courtois, et al., 2009)
Some evidence that prolonged exposure not only won’t work, but can make things worse
Initial focus on emotion regulation, dissociation, interpersonal problems
![Page 144: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/144.jpg)
Treatment Planning (cont.)
Empowerment of client should be primary Treatment planning should consider
Type and severity of trauma Past/current traumatic experiences
Crisis vs. chronic distress Current level of functioning Safety issues Client’s resources Substance abuse and other comorbid conditions
![Page 145: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/145.jpg)
Treatment Planning (cont.)
A trauma-informed treatment approach can be integrated with any major theory of psychotherapy, with particular emphasis on the therapeutic relationship
R.I.C.H. Philosophy (Saakvitne, et al. 2000)
![Page 146: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/146.jpg)
Targets of Treatment (Courtois, Ford, & Cloitre, 2009)
Bodily and mental functioning Attachment and trust Inhibition of risky/ineffective behaviors;
improving problem-solving and life management skills
Managing dissociation; integrating emotions and knowledge
![Page 147: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/147.jpg)
Targets of Treatment (cont.)
Improved and integrated sense of self Prevention of reenactments of
trauma/revictimization of self and others Overcoming dynamics of betrayal-trauma Repaired world view/existential sense of life;
spiritual connection and meaning
![Page 148: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/148.jpg)
“It’s never too late to be what you might have been.”
-George Eliot
![Page 149: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/149.jpg)
Stages of Trauma Treatment
Three main stages of treatment for ongoing effects of trauma (Judith Herman, Frank Putnam, Richard Kluft, Christine Curtois, etc.)
1.Safety and establish therapeutic relationship
2.Memory processing and mourning
3.Reconnection
![Page 150: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/150.jpg)
Stage One: Safety/Stabilization
Stabilize symptoms, including co-morbidDevelopment of motivation for treatmentBuilding collaborative allianceBuild hope and trustPsychoeducation
![Page 151: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/151.jpg)
Stage One: Safety (cont.)
Helping client commit to self-care and self-protection
Teaching client to identify and manage strong emotions and impulses
Identification of client’s adaptations to traumatic experiences, and determining which are useful and which aren’t
![Page 152: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/152.jpg)
Stage One: Safety (cont.)
Increasing client’s ability to identify, avoid, and mange dangerous situations and relationships
Establish sobriety if substance abuse is an issue
![Page 153: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/153.jpg)
Stage One: Safety (cont.)
Client practices coping skills in sessions, eventually work towards implementing them between sessions
In inpatient and acute settings, the focus is usually going to be on the safety stage
Build up support system/crisis management
![Page 154: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/154.jpg)
Stage Two: Remembrance and Mourning
Therapist as “witness and ally, in whose presence the survivor can speak of the unspeakable” (Herman, 1997)
Using safety skills while experiencing intense emotions
Learning to feel, rather than detach from, the impact of trauma (Courtois, et al., 2009)
Careful pacing
![Page 155: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/155.jpg)
Stage Two: Remembrance and Mourning (cont.)
“Telling the story” in more detail, with the emotions
Recalling forgotten memories/details Some may never become clear
Mourning losses New perspective of trauma
Loses its intensity and centrality
![Page 156: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/156.jpg)
Stage Three: Reconnection and Integration
“Rejoining the world” Facing the future and confronting fears Addressing unresolved developmental
deficits and fixations Fine-tuning self-regulatory skills Identity issues
![Page 157: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/157.jpg)
Stage Three: Reconnection (cont.)
Intimacy and relationships Finding meaning in life Spirituality Experiencing pleasurable activities that are
not “contaminated” by the traumatic experiences
Regaining a sense of mastery and control
![Page 158: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/158.jpg)
“…and then the day came when the risk to remain tight in a bud was more painful than the risk it took to blossom.”
-Anais Nin
![Page 159: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/159.jpg)
TREATING TRAUMA IN A FORENSIC SETTING
![Page 160: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/160.jpg)
Trauma Work in a Forensic Setting
“Mandated” treatmentTrauma-informed approach for facilityLimitations and uncertaintyAftercare planningMulti-disciplinary teamCoordinate other treatment modalities
![Page 161: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/161.jpg)
TARGETING TREATMENT CHALLENGES
![Page 162: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/162.jpg)
Targeting Treatment Challenges
Strategies for Safety Managing Dissociative Experiences Towards Better Emotional Regulation Improving Interpersonal Functioning
![Page 163: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/163.jpg)
STRATEGIES FOR SAFETY
![Page 164: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/164.jpg)
“Client contracted for
safety.”
![Page 165: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/165.jpg)
Strategies for Safety (cont.)
A safety contract alone is not effective in stopping self-injurious or suicidal behaviors (e.g., Peterson, et al., 2011) A significant number of people who
attempt or complete suicide have “no-suicide” agreements in place at the time of the act (APA, 2003; Jamison, 1999)
![Page 166: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/166.jpg)
Strategies for Safety (cont.)
Crisis Management If someone is drowning, do you give them
swimming lessons, or jump in and rescue them? (George Everly, PhD)
“Triage” – deal with safety and other immediate needs first
Quick response to acute crisis seems to predict better outcomes
When possible, having an “emergency plan” in place beforehand is ideal
![Page 167: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/167.jpg)
Strategies for Safety (cont.) Get client on board for his own safety
“Goal is for you to not get hurt anymore” Treatment goal to manage strong emotions
without impulsive behaviors Crises and safety concerns will likely interfere
with progress in other areas Needs to be a collaboration with client
Be sensitive to client’s perceived need for SIB/suicide plans Avoid a power struggle
![Page 168: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/168.jpg)
Safety Plan1.Pray2.Call my sponsor/go to a meeting
(XXX-XXX-XXXX)3.Watch a movie4.Write down things to talk about in our next session5.Read my therapy journal6.Call Heather’s voice mail (XXX-XXX-XXXX)7.Talk to another resident8.Tell staff member I need help to stay safe
![Page 169: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/169.jpg)
Strategies for Safety (cont.)
If various treatment providers are involved, clear communication is crucial Potential challenges in inpatient/correctional
settings Communication with family when appropriate
![Page 170: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/170.jpg)
Strategies for Safety (cont.)
Additional interventions to consider Increased frequency of sessions Hospitalization Medication changes
![Page 171: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/171.jpg)
Strategies for Safety (cont.)
For chronically suicidal patients, longer-term work to improve affect regulation and coping skills DBT shown to be effective for patients with BPD
and self-harm/suicidal behaviors (e.g., Linehan, et al., 1993)
![Page 172: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/172.jpg)
Safety in Inpatient SettingsRecommendations of the American Association of Suicidology include:Risk is elevated in the month after dischargeSuicide risk should be assessed prior to passes and dischargePatients may not accurately report own suicidal impulsesPatient, family, significant others should be educated about risk and steps to takeConsider overdose risk of medicationsAll clinical staff should have training in assessing and managing suicide risk, and promoting protective factors
![Page 173: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/173.jpg)
After an Episode of SIB
Medical treatment, if needed, should be provided in a neutral, matter-of-fact way
Assess current safety/risk of further SIB or suicide Restrictions to freedom should be based on
actual risk, not as a “punishment” Avoid shaming Engage client in collaboration to determine
next steps of treatment
![Page 174: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/174.jpg)
After an Episode of SIB (cont.)
With client, look at lessons learned New ideas about triggers or warning signs? What coping strategies worked, and which didn’t? What purpose is the SIB or suicide plan serving
right now?
![Page 175: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/175.jpg)
MANAGING DISSOCIATIVE EXPERIENCES
![Page 176: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/176.jpg)
Possible Outward Signs of Dissociation
Episodic confusion about date/place/situation Unfocused gaze Flat/quiet tone of voice Emotionless discussion of painful material Unexplained memory problems May or may not be accompanied by self-
injury
![Page 177: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/177.jpg)
Reducing Risk of Dissociation Managing/avoiding triggers Manage sensations before they become
overwhelming Improve stress/anger management skills Mindfulness Relaxation Engaging in other activities Avoiding substance abuse Consider potential risks of dissociation
![Page 178: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/178.jpg)
Managing Triggers
Bolstering client’s own self-protection Variety of possible triggers
Places, people, sensations associated with trauma
Memories/painful feelings Other people’s trauma stories Upsetting material in books, movies, TV shows
Genuine vs. perceived danger
![Page 179: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/179.jpg)
Grounding
“Present-focused awareness” – a sense of connectedness between oneself and the environment
Gives some distance between self and painful feelings/thoughts/memories
Not the same as relaxation training – an active approach to distract from overwhelming stimulus (Najavits)
![Page 180: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/180.jpg)
Grounding (cont.)
Can help manage Dissociation Flashbacks Intrusive thoughts Disorientation Overwhelming emotions Urges to self-injure
![Page 181: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/181.jpg)
Grounding (cont.)
Might take a lot of practice to develop grounding as a regular habit Practicing in therapy sessions Tracking in time log Need other skills on board to tolerate sensations
that are being avoided Learn the triggers, notice the beginning signs of
dissociation coming on
![Page 182: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/182.jpg)
Grounding (cont.)
Wide variety of grounding strategies Discuss options with client ahead of time, try
client’s preferences first Often takes trial and error Client may use different strategies in different
situations Consider all 5 senses
Goal is to focus attention to something in the present reality
![Page 183: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/183.jpg)
Grounding (cont.)Examples…
Putting hands flat on table or arms of chair/feet flat on the floor, focusing on the sensations
Eye contact Orient to time/date/place/situation Holding/looking at familiar object Getting up and moving around Cold sensations (ice water, holding ice cube) Holding/touching a pet Distraction – small talk, name things in a category,
describe a familiar activity in great detail
![Page 184: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/184.jpg)
TOWARDS BETTER EMOTIONAL REGULATION
![Page 185: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/185.jpg)
Towards Better Emotional Regulation
Help client learn to not fear emotions Many maladaptive behaviors are likely
avoidance/numbing strategies to not feel emotions
Learning connections between experiences, emotions, memories, and behavior
Need to build coping and relaxation skills
![Page 186: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/186.jpg)
Towards Better Emotional Regulation (cont.)
Discuss range of emotional reactions Early signs Improve emotional vocabulary Rating scale Where is the “danger zone”?
“Titrate” emotions to increase ability to tolerate a little at a time
Increase ability to more accurately “read” emotions in others
![Page 187: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/187.jpg)
“No feeling is final”
-Rainer Maria Rilke
![Page 188: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/188.jpg)
IMPROVING INTERPERSONAL FUNCTIONING
![Page 189: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/189.jpg)
Improving Interpersonal Functioning
Can use the therapeutic relationship (individual or group) to identify interpersonal patterns “Laboratory” – what works, what doesn’t?
Addressing manipulative behavior (Saakvitne, 2000)
Opportunity to explore direct vs. indirect communication of needs
Look at impact on relationships Avoid simply labeling the behavior
![Page 190: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/190.jpg)
Improving Interpersonal Functioning (cont.)
Trust is likely to be a struggle Focus of treatment
Understanding safe vs. hurtful relationships Friends/family may need education about
trauma and treatment
![Page 191: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/191.jpg)
Improving Interpersonal Functioning (cont.)
Group therapy/support group might be considered
Learning about relationships Different types of relationships Levels of trust/intimacy Boundaries Assertiveness Social skills
![Page 192: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/192.jpg)
ADDITIONAL TOOLS
![Page 193: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/193.jpg)
Group Therapy
Can be more efficient and cost effective Can be very useful in building interpersonal
skills, reducing isolation, normalizing reactions
Group members can offer a different kind of support than therapist can
Sometimes challenging/confronting by group members is tolerated better
![Page 194: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/194.jpg)
Group Therapy (cont.)
Group therapy “offers a direct antidote to the isolation and social disengagement that characterize” trauma disorders…a group experience where “safety, respect, honesty, privacy, and dedication to recovery are the norm provides unique opportunities for trauma survivors to see and hear, and to be seen and heard by, other persons who also struggle” (Ford, Fallot, & Harris, 2009)
![Page 195: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/195.jpg)
Group Therapy (cont.)
Cautions in group work on trauma: Some basic interpersonal skills need to be on
board (consider pre-treatment modalities) More intense, detailed info about traumatic
experiences may not be appropriate Potentially triggering of dissociation, impulsive
behavior, etc. Potentially traumatizing to other group members
Possible “peer-contagion” effect of self-injury/eating disorders
![Page 196: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/196.jpg)
Group Therapy (cont.)
Exposure to trauma material in group therapy In some research not effective and led to higher
dropout Other research showed more success when
preparation and support between group sessions were included
Key may be that members don’t feel too overwhelmed and feel a sense of control Graduated exposure
![Page 197: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/197.jpg)
Eye Movement Desensitization and Reprocessing (EMDR)
Developed by Francine Shapiro in the late 1980’s
Sensory experiences, cognitions, and emotions associated with traumatic event are processed with exposure and dual-attention stimuli (e.g., eye movements)
![Page 198: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/198.jpg)
EMDR (cont.)
Literature is mixed about EMDR efficacy; some say exposure may be the key Ponniah & Hollon (2009): EMDR reduces PTSD
symptoms to a greater extent than wait-list (but fewer efficacy studies than other treatments)
Seidler & Wagner (2006): no difference between efficacy of trauma-focused CBT and EMDR
Devilly, et al. (1998): no difference between EMDR (with or without eye movements) and standard psychiatric support in veterans
![Page 199: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/199.jpg)
EMDR (cont.)
Davidson & Parker (2001): EMDR was better than no treatment or treatments that did not include exposure; was similar to other therapies that included exposure
van der Kolk, et al. (2007): EMDR improved symptoms better than fluoxetine and pill placebo
Wilson et al. (1997): EMDR produced substantial symptom improvement in PTSD; benefits maintained at 15-month follow-up
![Page 200: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/200.jpg)
EMDR (cont.)
Research that has yielded evidence of improvement has focused on PTSD rather than complex syndrome Particularly single-event PTSD
People with CPTSD usually wouldn’t meet the “readiness criteria for standard EMDR treatment” (Korn & Leeds, 2002)
![Page 201: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/201.jpg)
EMDR (cont.)
Shapiro & Maxfield (2002): “for clients who have substantial impairments related to child abuse or neglect, treatment will not proceed as quickly or as smoothly…such clients often require lengthy” preparation and stabilization prior to the reprocessing stages
![Page 202: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/202.jpg)
Hypnosis Should have specialized training Stabilization/management of symptoms When used appropriately, can be very
useful for anxiety, pain management, substance abuse
NOT advisable to use for “recovering” memories
Being hypnotized could affect ability to testify in court if abuse charges ever went to trial
![Page 203: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/203.jpg)
Creative Expression Art, music, dance/movement, drama, writing Should be provided by a trained practitioner Client should be interested and willing Should be used in conjunction with other
treatment approaches
![Page 204: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/204.jpg)
Creative Expression (cont.)
Relaxation Improving interpersonal/social skills Improving communication/self-expression Increased self-esteem/self-efficacy Increased awareness of bodily
sensations/emotional experiences Decreased shame Might still feel like a “safe” domain
![Page 205: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/205.jpg)
Creative Expression (cont.)
Possible benefits of nonverbal interventions (Johnson, 2000) Access to nonlexical or implicit memory Creativity and spontaneity to counteract
hopelessness/damaged self-image Replace/manage impulses Increased balance in daily living Positive experiences
![Page 206: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/206.jpg)
Creative Expression (cont.)
Especially indicated for Children Clients who demonstrate preference for creative
outlets Difficulties in verbal expression Alexithymia Intellectualization
![Page 207: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/207.jpg)
Journaling Multiple possible uses
Tracking time, moods, activities, triggers Increasing self-expression Containing thoughts and emotions Venting feelings Labeling/describing feelings and experiences “Transitional object” between sessions Practicing boundaries around privacy Communication tool for therapy/other providers Therapy “homework”
![Page 208: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/208.jpg)
Journaling (cont.)
CAUTION!!!
Journaling can become overwhelming and is contraindicated in some cases.
![Page 209: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/209.jpg)
Journaling (cont.)
Journaling can follow steps similar to the stages of trauma treatment Vermilyea (2000) recommends teaching trauma
survivors to start with surface level, “here and now” observations Client instructed to STOP right away if getting into
more upsetting material or distress is increasing Start with time-limited assignments (write for 5
minutes, then stop) to practice Can slowly build up to more emotional material
![Page 210: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/210.jpg)
Leisure Skills
Client may need education about the importance of leisure
Opportunity for positive experiences (ideally with other people)
“Normal” development may have been derailed, may need to learn very basic skills
Work towards balance in life, and identity Learn to enjoy the simple things!
![Page 211: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/211.jpg)
Improving Problem-Solving
Teaching/practicing skills Focus in on actual problem – one at a time! Get the facts straight
Sort out assumptions/distorted thinking Consider alternative courses of action
Predict likely outcomes, pros and cons If unsure, determine whether action is needed at
this point Tolerating trial and error, making mistakes
![Page 212: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/212.jpg)
Improving Problem-Solving (cont.)
Recognizing impulse vs. intentional action Will this action take me in the direction I’ve been
trying to go? Reinforce crisis plans Rule of thumb: No major decisions when
feeling overwhelmed!
![Page 213: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/213.jpg)
“You have brains in your head. You have feet in your shoes. You can steer
yourself any direction you choose.”
- Dr. Seuss
Oh, The Places You’ll Go!
![Page 214: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/214.jpg)
A NEW SENSE OF SELF
![Page 215: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/215.jpg)
A New Sense of Self
Repairing damaged self-image Victim? Survivor? Perpetrator as well? Broader view of self and life experiences Letting go of the tough question: “WHY?”
Understanding views of abuser and/or “bystanders” How do these play out in other relationships?
Exploring world view Is a new perspective possible?
![Page 216: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/216.jpg)
“I am not afraid of storms, for I’m learning how to sail my ship.”
― Louisa May Alcott
![Page 217: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/217.jpg)
PART THREE:
What About You?
![Page 218: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/218.jpg)
VICARIOUS TRAUMATIZATION
![Page 219: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/219.jpg)
Vicarious Traumatization (VT)
“To study psychological trauma is to come face to face both with human vulnerability in the natural world and with the capacity for evil in human nature. To study psychological trauma means bearing witness to horrible events.”
Judith Herman, Trauma and Recovery
![Page 220: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/220.jpg)
VT (cont.)
“VT is the transformation or change in a helper’s inner experience as a result of responsibility for and empathic engagement with traumatized clients” (Saakvitne, et al. 2000)
![Page 221: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/221.jpg)
VT – Possible Effects
VT can affect helpers in a variety of domains
-Identity -Physical health
-Hopefulness/optimism -Work performance
-Empathy -Sense of safety
-Boundaries -Enjoyment of life
-Worldview -Sense of control
-Spirituality
-Self-efficacy …etc.
![Page 222: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/222.jpg)
VT – Risk Factors
Risk Factors for treatment providers
-Lack of training or knowledge
-Isolation/lack of social support
-Imbalanced work load
-Unclear boundaries
-Sense of responsibility for the client
-Helper’s own trauma history
![Page 223: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/223.jpg)
VT – Possible Warning Signs
-Reduced hope
-Trouble concentrating/ making decisions
-Increased sensitivity to disturbing stimuli
-Increased fearfulness
-Increased isolation
-Feeling disconnected from others
-Changes in eating, sleeping, interests, energy,
sex drive
![Page 224: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/224.jpg)
VT – Possible Warning Signs (cont.)
-Chronic illness/fatigue
-Irritability/low frustration tolerance
-Changed attitude towards work/clients
-Not being able to stop thinking about work off hours
-Dreams/nightmares about work
-Emotional numbing
-Loosening of boundaries
![Page 225: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/225.jpg)
“Although the world is full of suffering, it is also full of the overcoming of it.”
-Helen Keller
![Page 226: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/226.jpg)
SELF-CARE FOR THE CLINICIAN
![Page 227: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/227.jpg)
Self-Care as an Ethical Issue
Do no harm VT increases risk of mistakes, lack of investment,
boundary crossings Clinicians are responsible for monitoring
ourselves for burnout or other forms of VT that might affect our clinical work
We are responsible for monitoring ourselves and our colleagues
Consider self-care an ethical responsibility and part of clinical skill set
![Page 228: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/228.jpg)
Therapist Self-Care
“The single most important factor in the success or failure of trauma work is the attention paid to the experience and needs of the helper” (Saakvitne, et al., 2000)
![Page 229: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/229.jpg)
Therapist Self-Care (cont.)
Be reasonable in your expectations Of yourself Of the client Of the work Of your colleagues/workplace
Take potential signs of burn out seriously! Attend carefully to therapeutic boundaries
![Page 230: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/230.jpg)
Therapist Self-Care (cont.)
Don’t subject yourself to unnecessary trauma Avoid becoming isolated and disconnected
from others Nurture your personal relationships Colleague support is critical
R.I.C.H. for each other! Informal and/or formal
Consultation Supervision group
![Page 231: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/231.jpg)
Therapist Self-Care (cont.)
Consider:Physical self-carePsychological self-careEmotional self-careProfessional self-careSpiritual self-care
(Saakvitne, et al. 2000)
![Page 232: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/232.jpg)
Therapist Self-Care (cont.)
You are a valuable resource to your clients!
Honestly evaluate your limitsNotice your reactions to clientsMaintain appropriate boundariesConsult and get supportTake good care of yourself
![Page 233: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/233.jpg)
“You, yourself, as much as anybody in the entire universe, deserve your love
and affection.”
-Buddha
![Page 234: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/234.jpg)
Make a commitment to self-care.
![Page 235: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/235.jpg)
TAKE-HOME POINTS
![Page 236: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/236.jpg)
Take-Home Points
Screening for trauma symptoms should be routine
Careful assessment of trauma symptoms, and understanding the variety of ways trauma can present will help with diagnostic accuracy and treatment planning
Cultural and other individual factors must be considered in assessing trauma
Stage model of trauma treatment
![Page 237: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/237.jpg)
Take-Home Points (cont.)
Current symptoms may reflect behaviors that helped the client endure the trauma
Early attachment experiences contribute to vulnerability to trauma later in life
Complex Trauma Syndrome as a useful conceptualization of the client’s presentation
Importance of collaborating with client to maintain safety and manage crises
![Page 238: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/238.jpg)
Take-Home Points (cont.)
Solid boundaries and a healthy therapeutic connection can be in themselves healing
Understand the resources/limits in your setting; adapt trauma work accordingly
We are all vulnerable to vicarious traumatization and burn out
Self-care is critical!
![Page 239: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/239.jpg)
ADDITIONAL RESOURCES
![Page 240: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/240.jpg)
Additional Resources
Sidran Institute: www.sidran.org
International Society for Traumatic Stress Studies: www.istss.org
Substance Abuse and Mental Health Services Administration (SAMHSA) National Center for Trauma-Informed Care: www.samhsa.gov/nctic
![Page 241: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/241.jpg)
Additional Resources (cont.)
American Association of Suicidology: www.suicidology.org
Seeking Safety: www.seekingsafety.org
National Alliance for the Mentally Ill: nami.org
![Page 242: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/242.jpg)
Additional Resources (cont.)
Trauma and Recovery (1997), Judith Herman, Basic Books
Trauma Recovery and Empowerment: A Clinician's Guide for Working with Women in Groups (1998) Maxine Harris, The Free Press
Seeking Safety (2002), Lisa Najavatis, The Guilford Press
![Page 243: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/243.jpg)
Additional Resources (cont.)
Growing Beyond Survival (2000), Elizabeth Vermilyea, The Sidran Press
Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide (2009), Courtois & Ford (Eds.), The Guilford Press
![Page 244: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/244.jpg)
“Be the change you wish to see in the world.”
-Mahatma Gandhi
![Page 245: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/245.jpg)
To Get Your CEU Certificate
Go to our website: tzkseminars.com Log in using your email address and
password Complete the webinar evaluation Download your certificate
![Page 247: Making Sense of the Complexities of Trauma](https://reader035.vdocuments.mx/reader035/viewer/2022062422/56813e2e550346895da81059/html5/thumbnails/247.jpg)
Tzkseminars Keith Hannan, Ph.D., consultant to juvenile facilities on “Conduct
Disorder.” Dr. Hannan also does a Friday afternoon webinar series on juvenile delinquency
David Shapiro, Ph.D., the father of clinical forensic psychology on the “Fundamentals of Forensic Assessment.” Learn forensic assessment from the best.
David McDuff, M.D., consultant to the Baltimore Orioles and Ravens on “Sports Psychiatry.” This webinar is appropriate for all mental health clinicians interested in working with athletes.
Heather Hartman-Hall, Ph.D., internship training director and talented clinician on “Making Sense of the Complexities of Trauma.”
Scott Hannan, Ph.D., seen on the show “Hoarders,” on “Cognitive Behavioral Therapy for School Refusal.”
Michael Herkov, Ph.D., of the University of Florida, on “The Ten Most Common Ethical Errors.”
New speakers coming soon!!!