csa treatment and ptg in adult clients: phase two mis -steps and correctives

CSA Treatment and PTG in Adult Clients:

Phase Two Mis-steps and Correctives

Diane Langberg, PhD Slides Available:Philip G. Monroe, PsyD

www.globaltraumarecovery.org

Objectives

Identify common clinical mistakes in the treatment of adult survivors of child sexual abuse

Describe best practices during phase two of treatment

Understand common signs of posttraumatic growth and resilience within clients that appear stuck 

Who is stuck?

The client? Or the counselor?

Common counselor reactions

“How can I get my client to…?”

“How can I get rid of my client?”

Common counselor mistakes

Messianic rescuing (over-responsibility) Boundary crossings or Burnout

Demanding catharsis Forcing memory processing/exposure

Misunderstanding client resistance Irritated with client; push harder

Failure to manage “the hour” Encouraging dissociation

CSA and Complex TraumaBrief Review

Posttraumatic Stress Disorder (PTSD)

Re-experiencing: (1) Recurrent, intrusive distressing

recollection (may be repetitive play)

Recurrent, distressing dreams Acting or feeling as if event is

recurring Psychological distress on

exposure to cues Physiological reactivity on

exposure to cues Increased arousal (2)

Difficulty falling or staying asleep

Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response

Avoidance or Numbing (3) Efforts to avoid thoughts,

feelings, conversations associated with trauma

Efforts to avoid activities, places, or people associated with trauma

Inability to recall important aspect of trauma

Diminished interest or participation in significant activities

Feeling of detachment or estrangement from others

Restricted range of affect Sense of foreshortened

future

Pays more attention to dissociative problems Derealization Depersonalization

Sees these symptoms as separate from re-experiencing and/or hypervigilance

Why important? Clients with this set of symptoms respond better

to mindfulness, cognitive restructuring, and DBT style interventions in addition to exposure therapies

Note: also “preschool” subtype

New: Dissociative subtype

Common features of CSA clients

Betrayal trauma experiences leading to symptoms of complex PTSD

Hypervigilance Distorted sense of self

Addictions

Eating disorders Sleep disorders Shame

Dissociation Self-hatred Fear

Confusion Distrustful Distorted view of God

Control seeking Self-destructive behavior

Emotional numbness

DESNOS alters a person’s

1. Ability to regulate affect and impulses

2. Attention and consciousness3. Self-perception4. Perception of the perpetrator5. Capacity for relationships6. Body and brain responses7. Perception of meaning and faith

Complex Trauma v. Borderline

DESNOS BPD

Primary Affect:

Panic and pain Has capacity for positive affect

Relationships:

Passive, avoidance, re-victimization

Vacillates between desire and devaluation

Dissociation: Present, chronic

Transient, if present

Cognitive Focus:

Fear, avoidance Idealized identity

Self: Consistent self loathing

Confused

Phase one: Safety & stabilization

Foundation for all treatment Longest phase and vital to positive

outcomes Features

Therapeutic alliance building Education about the nature of trauma Managing vs. reacting to symptoms

Phase two: Processing memories

Memory work done in concert with phase one skills Focus: grief, loss, shame, anger rather

than anxiety Context: the tendency to leave

(dissociate from) the pain Goal: Small amounts of memory work

with frequent self-care and stabilization

Phase two interventions

Exposure Stress inoculation

OR…? Interpersonal/dynamic interventions

“Therapy that emphasized relaxation, relationships, affect, and meaning-making appeared to be more helpful than therapy that emphasized exposure to trauma reminders.”

D’Andrea & Pole

Revisiting the experience of CSAPointing to Corrective Experiences in Therapy

Common trauma experiences

Intense fear, paralysis/helplessness, inability to effect any change, threat of annihilation, leading to experience of,

Loss of voice, control, connection, and meaning, resulting in,

Disorganized physical, cognitive, and emotional response system thereby increasing,

Relational pain, distrust, self-contempt, overwhelming anxiety, evidenced as,

Running from the past, afraid of the future

Correctives

Proceed little by little, without force Focus on this step over ultimate goal Embrace repetition Embrace rest; Identify as NOT failure Remember: Return to

safety/stabilization throughout treatment

Dynamic techniques

Additional techniques

The ARC model

Attachment Self-RegulationCompetency

Kinniburgh, Blaustein, Spinazzola, Psychiatric Annals, May 2005

http://psychrights.org/research/Digest/CriticalThinkRxCites/kinniburgh.pdf

Attachment-oriented interventions

Predictable routines in therapy Support in-the-moment affect

regulation Watch your language Affirm strengths (find them in

surprising areas!)

Self-regulation interventions

Expand awareness of affect Connect affect with body sensations Normalize reactions Self-expression through nonverbal

means Encourage kinetic regulation of

affect Connect affect with historical events Teach grounding techniques

Competency interventions

Identify interests/goals Encourage independent choices Learning relational safety/danger

cues Encourage connections to others Identify and affirm strengths Teach self-awareness self-care Construct solutions to problems

together Review outcomes together

Two Spiritual DisciplinesMeditation and Solitude as Emotion Regulation Interventions

Mindfulness

Mindfulness is about waking up from a life on automatic pilot, becoming keenly aware and sensitive to our experiences – both internal and external

Meditation as spiritual discipline

On creation On Scripture On Christ

Solitude as spiritual discipline

Goal: having a sanctuary of the heart so we are not controlled by people or noise

Posttraumatic Growth & ResilienceExploring Movement in Therapy with Adult Survivors

Posttraumatic growth (PTG)

Retrospective perceptions of positive psychological changes after trauma Not just bouncing back but growing

beyond pre-trauma adaptive capacities Connotes positive change in identity

and capacities post trauma

Related: Posttraumatic growth

Changes seen in Identity perception (perceived new possibilities) Capacity awareness (strength perception) Appreciation of life and faith (values)

PTSD

PTG

Redefining PTG

Holding symptoms and strengths together

Success during phase two includes Ability to say no Ability to have hope Not reduction of triggers and trauma

reactions

Ponder this:

Why do most recover from traumatic experiences and do not go on to develop PTSD? Intrinsic capacity? Community supports? Prior experiences?

re·sil·ience the power or ability to return to the

original form, position, etc., after being bent, compressed, or stretched; elasticity.

ability to recover readily from illness, depression, adversity, or the like; buoyancy.

http://dictionary.reference.com/browse/resilience

Resilience

Better definition

the ability to recover readily from illness, depression, and adversity Adapting? Thriving?

Problem with this definition? What does resilience look like in an ongoing storm?

A biblical image of resilience? Joseph?

What you intended for evil… Jeremiah?

I will never forget this awful time as I grieve…yet I still dare to hope

Esther? If I perish, I perish

Paul? Though outwardly we are wasting away,

yet inwardly we are being renewed

Resilient individuals?

Optimism (realistic optimism) Cognitive flexibility Personal moral compass Role models Face and reframe fears Active coping mechanisms Attending to physical wellbeing Nurture social network Recognize strengths

Dennis Charney

Different in other cultures?

YES! Gratitude Pride in culture and ethnicity Appreciation of human differences Karma

Biology of resilience?

Fear/Reward circuits

Neuropeptide Y?

Threats to resilience

Passive acceptance of threats Loss of social support and moral

foundation Rumination

Possible ways to improve it CBT Narrative work Faith engagement Mindfulness Social Support Self-reflection Physical training Sleep

Can you learn resilience?

Trauma work supporting resilience

Phase 1: Interventions avoid disrupting intact protective factors (meaning, networks, structures)

Phase 2: Re-establish weak social resources (family re-unification, vocational training)

Phase 3: Targeted trauma recovery intervention

Individual or communal?

Community’s inherent capacity, hope, and faith to withstand major trauma, overcome adversity, and to prevail, with increased resources, competence and connectedness

Judith Landau

Individual resilience promoted by communityand

Community expression of resilience

Predicting community resilience

Active use of family/community resilience stories

Active engagement of transcendence Organizational strength

Flexibility Connected Available resources

Improving community resilience

Identify agents of change Identify local values, resources,

wisdom Reinforce open dialogue, to Identify tangible assets (community

genogram) Re-establish daily patterns, rituals Re-connectedness

Community responses

Use of drama to capture lament To validate, narrate To spark

conversations Local

conversations where all parties have voice Goal identification Resource allocation

Support groups