BEST TREATMENT PRACTICES FOR TRAUMA RECOVERY

TRAUMA DEFINED

• A traumatic event involves a single experience, or an enduring, or repeated events, that completely overwhelm the individual’s ability to cope or integrate ideas and emotions involved in that experience.

• It involves a feeling of COMPLETE HELPESSNESS in the face of real or perceived threat to one’s life, or that of a loved one’s, to bodily integrity, or sanity.

• There is frequently a violation of a person’s familiar ideas about the world and their human rights, putting the person in an extreme state of confusion, and insecurity.

• Reactions: physiological and psychological.

POSSIBLE TRAUMATIC EXPERIENCES

• Abuse: Physical, Emotional, Verbal, Sexual, Neglect, Abandonment

• Violence (murder, rape, robbed, physically attacked)

• The threat of violence or sexual abuse, or witnessing violence

• Catastrophic events (hurricanes, earthquakes, volcanic eruptions, war or other mass violence)

• Car accidents, plane crashes, fires

POSSIBLE TRAUMATIC EXPERIENCES

• Paramedics, fire fighters and rescue teams experiences

• Long-term exposure to conditions like parents who are substance abusers, having a parent incarcerated, poverty or milder forms of abuse such as verbal abuse can be traumatic.

• Medical Procedures, Being diagnosed with a life threatening illness

• Being Kidnapped, Held hostage

• Combat

• Battering Relationships, Being Stalked, Bullied, Harassed

It’s not the event that determines whether something is traumatic, but the individual’s

experience of the event

CHILDHOOD TRAUMA & ABUSE

ABUSE STATISTICS• 1 out of 3 women will experience sexual abuse by the time they are 18 years

old. (The Public’s Health)

• 1 out of 5-7 men will experience sexual abuse by the time they are 18 years old. (childhelp.org)

• 90% of sexual abuse victims know their perpetrator and 68% are abused by family members. (National Center for Child Abuse)

• 90% of cases go unreported and untreated, as the symptoms of CSA are often misdiagnosed and unappreciated. (The Public’s Health 2009)

• Over 3 million cases of child abuse are reported each year in US. Those reports can have multiple children in them. (NCAS)

PYCHOLOGICAL AFFECTS OF ABUSE

• PTSD Depression• Anxiety/Panic Failure to thrive• Agoraphobia/Phobias Rage• Irritability Mood Disorders• Substance Abuse Eating Disorders• Personality Changes/ Disorders Suicidal and Homicidal Ideation• Dissociative Disorders Self-Injury/Cutting• Negative Self-concept Abusive Partners• Obsessive Compulsive Feelings of Powerlessness

RELATIONSHIP ISSUES

• Trusts too easily or does not trust at all• Difficulty communicating• Does not set boundaries or sets too many boundaries• Wants to be rescued• Isolation and withdraw• Sexual problems/promiscuity• Fear of abandonment• Fear of Intimacy• May be abusive or choose abusive partners• People pleasing

ACADEMIC ISSUES

• Inability to concentrate• Lower test scores• Comprehension problems• Memory deficits• Peer relational issues• Communication problems• Attendance issues• Teen Pregnancy

POST TRAUMATIC STRESS DISORDER

PTSD SYMPTOMS1) Intrusive re-experiencing of the trauma

● flashbacks, nightmares, triggers

2) Hyper-arousal ● Problems falling or staying asleep

● Difficulty concentrating or completing tasks ● Anger and irritability ● Startle response ● Hyper-vigilant ● Panic attacks, shortness of breath or chest pain

3) Avoidance of stimuli and numbing response ● Making efforts to avoid thoughts, feelings, conversations, people, or places that remind them of the trauma. ● Restricted range of emotions/Numbing of emotions ● Feeling detached from others

● Dissociation ● Substance Abuse

● Loss of interest in activities they used to enjoy

DISSOCIATION

• Detachment from immediate surroundings

• Detachment from physical or emotional experience

• It is a disconnect between material in the conscious mind and material in the unconscious mind.

• Adaptive Survival Skill can become maladaptive

• Can be done consciously or automatically

• It can become pathological and interfere with daily functioning

PTSD SYMPTOMS

• Survivor’s Guilt• Rage• Depression and Grief• Anxiety and Panic• Shame and Fear• Trust Issues• Loss of appetite• Sexual dysfunction• Poor coping skills• Feelings of hopelessness

RISK FACTORS

• Previous traumatic experiences, especially in early life • Family history of PTSD or depression • Being Female• History of physical or sexual abuse • History of substance abuse • History of depression, anxiety, or another mental illness • High level of stress in everyday life • Lack of support after the trauma • Lack of coping skills

Mayo Clinic

PTSD TYPESAcute• Less than 3 months

Chronic • Longer than 3 months

Delayed onset• 6 months later

Complex (Disorder of Extreme Stress)• Exposed to prolonged traumatic events, especially during childhood, such as childhood

sexual abuse(severe and sustained)• Often have a personality disorder.• Long-term effect on adult functioning

DEVELOPMENTAL TRAUMA

● Trauma that is stressful that occurs repeatedly and cumulatively over a period of time, within specific relationships and context(child abuse)

● Domains of impairment:*attachment

*biology *affect (emotional) regulation *dissociation *behavioral control *cognitive processes

*self-concept

DISSOCIATIVE DISORDERS• Marked by a dissociation from or interruption of a person's fundamental

aspects of waking consciousness (such as one's personal identity, one's personal history, etc.)

• Most dissociative disorders stem from trauma.• Coping mechanism : the person literally dissociates himself from a situation or

experience too traumatic to integrate with his conscious self.

Types• Dissociative Identity Disorder (Multiple Personality Disorder)• Dissociative Amnesia• Dissociative Fugue• Depersonalization Disorder• Dissociative Disorder NOS

Scales for this: Dissociative Experience Scale(DES), SCID-D, SDQ-20

TRAUMA AND ATTACHMENT

• Trauma that happens in childhood at the hands of a caregiver is doubly destructive because it destroys the attachment relationship that the child would normally need to depend on to manage the trauma of the abuse.

• The resolution of attachment issues is a central component of trauma recovery

TYPES OF ATTACHMENTSecure•Parent is aligned with the child and in tune with the child’s emotions, trustworthy, and reliable.•Adult is able to create and maintain relationships

Ambivalent•Parent is inconsistent, unpredictable and sometimes intrusive parent communication•Adult is anxious and insecure, controlling, blaming, erratic, unpredictable, and sometimes charming

Avoidant•Parent is unavailable or rejecting, and punitive•Adult avoids closeness, or emotional connection, distant, superficial relationships, critical, rigid or intolerant

Reactive•Parent is extremely unattached or malfunctioning, and abusive•Adult cannot establish positive relationships, withdrawn, substance abuse

Disorganized•Parents ignored, or did not see the child’s needs. Parental behavior was frightening or traumatizing. Often sexual, or physical abusive•Adult is chaotic, insensitive, explosive, abusive, untrusting, while craving security

SECURE ATTACHMENTS HELP US:

• Feel safe• Develop meaningful connection with others• Explore our world• Deal with stress• Balance emotion• Experience comfort and security• Make sense of our lives• Create positive memories & expectations of relationships• Ability to rebound from disappointment, discouragement and misfortune

INSECURE ATTACHMENTS:

• Unavailable or avoidant• Self-absorbed• Insecure• Disorganized• Aggressive• Angry• Distrusting of others• Lack of empathy• Clinginess • Trouble learning/Developmental delays• Lack of Self-control• Obsession with food

ADVERSE CHILDHOOD EXPERIENCE STUDYBY KAISER PERMENENTE

1995-1997 17,000 middle class insured individuals in the primary care setting

Confidential Survey for the incidence of:

Abuse:• Sexual, physical, verbal abuse

Neglect:• Emotional neglect, physical neglect

Household Dysfunction:• Household substance abuse• Parental separation and divorce• Incarcerated household member• Household member with a mental illness• Mother treated violently

ADVERSE CHILDHOOD EVENTS(ACE STUDY) (Kaiser Permanente)

People with 4 or more ACE were at greater risk for serious health issues

ACE STUDY FINDINGS• Alcoholism and alcohol abuse Illicit Drug Use• Smoking Early Initiation of Smoking• Depression Suicide Attempts• COPD Ischemic heart disease (IHD)• Fetal death Health-related quality of life• Liver disease Obesity• Autoimmune Disease Increased risk for Cancer• Autobiographical Memory Disturbance Hallucinations

• Risk for intimate partner violence Multiple sexual partners• Sexually transmitted diseases Unintended pregnancies• Early initiation of sexual activity Adolescent pregnancy

MEDICAL RISKS(The Public’s Health 2009)

• Obesity Hypertension• Headaches Stomach Problems• Lowered Immune System Chronic Fatigue• MS, Lupus, Fibromyalgia Early hysterectomies• Gynecological issues Diabetes• Heart disease Substance Abuse• Sexual Disorders STD’s• Somatic complaints and Body aches MS, Lupus• Fibromyalgia Autoimmune Disorders• Increased Risk of Cancer Premature Death

HOW TRAUMA IMPACTS THE BRAIN

EMOTIONAL NERVOUS SYSTEM

TWO PARTS OF NERVOUS SYSTEM

Limbic System

Autonomic Nervous

System

Limbic System• Primary responsible for our emotional life• Helps with formation of memories• Arousal and hyper-arousal • Fight, Flight, or Freeze• It plays a central role in memory processing

Amygdala• Fear center or alarm system/Fight or flight• Stores highly charged emotional memories • After trauma can overreact(hyper-responsivity)• To remember a threat, generalize it to other possible threats and carry it out

to the future. Imprints it• Explicit or unconscious memoryHippocampus• Plays a role in organizing memories. Explicit or Conscious Memory• Interacts with the amygdala during the encoding of emotional memories.• Encoding of context during fear conditioning• Stores memory of time and space; puts our memories into their proper

perspective and place in our life's time line. • After trauma can shrink in size and diminish in functioning • Gets damaged in child abuse/ high stress (gaps in memory_

LIMBIC SYSTEM

AUTONOMIC NERVOUS SYSTEM:

1)PARASYMPATHETIC 2)SYMPATHETIC

RESTRICTED ACTIVATED

Medial Prefrontal Cortex•Moral center, planning complex cognitive behaviors, personality expression, decision making, moderating correct social behavior-delaying gratification•Appears to be volumetrically smaller and is hypo-responsive(under) during symptomatic states

Corpus Coliseum•Facilitates communication between the 2 hemispheres. •During trauma decreased blood flow and communication between hemispheres.

WHEN TRAUMA OCCURS

• The brains main function is to get though the event.• The brain helps us survive by activating biological reactions involved in

helping us mount that fight or flight response.• The sympathetic nervous system releases adrenaline, increases heart rate,

pupils dilated, accelerated pulse which readies you to move in the fight or flight decision.

• The brain actually lowers the chemicals released to help us with regular functions which means your parasympathetic nervous system energy is diverted to help you cope with what you need to do to survive.

• Hormones are released to reign in the stress response to stop long-term damage to your body.

• During the first 4 years of life 90% of a child’s brain develops through the experiences of that child.

• The mind and the emotional content of the brain are created in the first few years of life through the attachment bond between the infant and the mother

• Bruce Perry published a huge number of studies showing abnormal brain development following neglect and abuse of children including significantly smaller brains, decreased activity in their prefrontal cortex(the moral center/the restraint center/the maturity center.)

• Depressed and angry mothers regularly produce insecurely attached infants who grow up be violent adults.

The Bomb in the Brain (Freedomain Radio)

• Abusive mothers who are depressed or angry the cortisol levels of both elevated in the mother and the child. If you are depressed or angry your cortisol levels are higher in both you and your child. The mother and the child are a system particularly for the 1st few years of life

• Their hippocampus shrinks and they can have memory issues

• The amygdala of insecurely attached children is larger and they have a greater surging of fight or flight, adrenaline and cortisol.

• Their prefrontal cortexes are smaller so they are less able to control their fears and other irrational emotional reactions in interpersonal relationships.

• Physical problem in the brain-fight and flight is strong and restraint is weak. The Bomb in the Brain (Freedomain

Radio)

TRAUMA AND SUBSTANCE ABUSE

THE WAY WE USED TO LOOK AT SUBSTANCE ABUSE AND TRAUMA

MENTAL ILLNESS SUBSTANCE ABUSE

TRAUMA

THE RELATIONSHIP BETWEEN TRAUMA & SUBSTANCE ABUSE

TRAUMA

MENTAL ILLNESS

SUBSTANCE ABUSE

THE RELATIONSHIP BETWEEN TRAUMA & SUBSTANCE ABUSE

• Those who have been traumatized are at risk for substance abuse; and those who use substances are at risk for experiencing trauma.

• 90 % of women who are addicted to alcohol were physically or sexually abused as children (National Trauma Consortium)

• Victims of trauma are 4-to-5 times more vulnerable and therefore likely to experience alcohol or substance abuse than the general public.

• 82% of adolescents in residential or inpatient programs have been a victim of sexual or physical abuse.

THE RELATIONSHIP BETWEEN TRAUMA & SUBSTANCE ABUSE

• Escape • Numbing • Control • Distraction • Self-destructive • Feel powerful• Diminish shame and guilt• Protection• Acceptance• Increase or decrease hyper-vigilance/anxiety

BEST TREATMENT PRACTICES

1) Psycho-education(normalization of symptoms) * About Effects of Trauma, PTSD

2) Regulation*Trigger Recognition*Grounding,*Containment & Distancing *Guided Imagery/Calm Place* Breathing* Meditation* Yoga* Mindfulness* Journaling* Music* Developing a Support System

3) Processing the Trauma

● Trauma Focused Cognitive Behavior Therapy (TF-CBT by J.A Kohen)

● Somatic Experiencing/Body Psychotherapy(SE , Peter Levine, Pat Odgen)

● Acceptance and Commitment Therapy(ACT by Steve Hayes, Kelly Wilson)

● Eye Movement Desensitization and Reprocessing(EMDR, Francine Shapiro)

● Emotional Freedom Technique(EFT, Gary Craig, Nick Ortner)

EYE MOVEMENT DESENSITIZATION AND REPROCESSING

• Created by Francine Shapiro in 1987.

• Bilateral stimulation through eye movements• Natural way brain processes information and heals self(REM Sleep)

• Treats PTSD and a wide range of mental health issues.

• Trauma overloads the brains natural coping mechanism.

• Unprocessed memories and feelings are stored in limbic system of your brain in a “raw” and emotional form, rather than in a verbal “story” mode. These memories can be continually triggered when a person experiences event similar to past traumatic events.

• EMDR helps create connections between memories, enabling the brain to process the traumatic memory in a very natural way.

TREATING TRAUMATIC MEMORIES

Normal Event

NORMAL EVENT

PROCESSING

MEMORY STORED

PROCESSING TRAUMATIC EXPERIENES

Traumatic Event Distress (No Processing)

PROCESSING TRAUMATIC EXPERIENES

Traumatic Event

Grading

Exposure/EMDR

Memories/Less Distress

EMDR PROCESS

• Sudden Units of Distress(0-10)

• Emotions Experienced

• Negative Belief About Self

• Validity of Cognition/Positive Belief(0-7)

• Body Scan

• Future Templates

POST TRAUMATIC GROWTH

• It is the positive change experienced as a result of the struggle with a major life crisis or a traumatic event

• New opportunities have emerged from the struggle, opening up possibilities that were not present before

• Change in relationships with others including increased compassion or connectedness

• Change in an increased sense of one’s own strength • Greater appreciation for life• Deeping of Spirituality or Change in Beliefs• It can also increase their resiliency to subsequent adversity

Dr. Richard Tedeschi

REFERENCES BooksOpening Up the Healing Expressing of Emotions by J. PennebakerOutgrowing the Pain by Elaina Gill Trauma and Addiction by Tian Dayton, Ph.D.Trauma Recovery by Judith HermanDiagnostic Statistical Manual of Mental DisordersEye Movement Desensitization and Reprocessing; Basic Principles, Protocols, and Procedures by Francine

ShapiroEMDR: The Breakthrough Therapy by Francine Shapiro, PHDTrauma Model Colin RossThe Developing Mind Daniel SeigalWaking the Tiger Peter LevineTrust After Trauma Matskis

Articles:Crandall, Mark (2007) Post Traumatic Stress Disorder; What Happens to the Brain.Websitehttp://acestudy.org/

PresentationsKehler, Byron Guiding Survivors of Childhood Trauma through RecoveryThe Bomb in the Brain Freedomain Radio

WebsitesDarkness to Light(d2l.org) National Institute of Mental Illness (nih.gov) ISSDT (isst-d.org)National Child Abuse Statistics (childhelp.org)Sidran.orgNational Alliance on Mental Illness (nami.org)Giftfromwithin.org