The Treatment of Trauma: Recreating Developmental Stages

The Treatment of Trauma: Recreating Developmental

Stages

Ron J. Llewelyn Psy.D.Amanda GallowayACMHC-i

Dr. Llewelyn’s Affiliations: Living Waters Counseling LLC., University of Phoenix, Valley

Mental Health, & The Center for Christian Therapy

Objectives

Learn about the theory, research and

utilization of Posttraumatic Growth in our everyday and therapeutic interactions

offenders and survivors.

Be able to identify the obstacles that

limit a person’s ability to become a thriving individual

Walk away with specific methods to help those effected by domestic abuse

Explore Eriksonian and Freudian

developmental models

Learn to re-create the developmental

conflicts in treatment.

Understand how developmental recreation may

enhance Posttraumatic

Growth

Psychological Trauma: The sudden uncontrollable

disruption of our affiliative bonds. Lindemann 1944

Domestic Violence in 3 Minutes

Offender• Offender• Perception of self (un-projected or reversed)

– Self is threatened– Often insecure– Lost– Out of control– Fears being blamed– Fears abandonment– Underlying shame– Feels limited options– Jealous

•  • Perception of Survivor

– Is a threat to their own sense of stability– Has too much power– Can be difficult – May abandon them– The “safest” place to project to

•  • Perception of others and the world

– Fears being found out– Fears not being able to look competent– Needs to use persona – Well-meaning others may expose their incompetence’s

Survivor• Perception of self starts to change

– Lowered or lost confidence– Questioning own decisions– Questions if anyone loves them– Blames self for others leaving– Starts to feel defiled– Starts to feel helpless– Starts to feel hopeless– Feels shame, guilt and blame– Identifies with abuser language– Believes that options are few– Increase sense of insecurity– Increase in emotional states– Turning Against the Self

•  • Idealization of the Offender

– May rationalize their behavior to others– May rational their behavior to self– May blame self for their behavior– Due to isolation, feels they are the only one there for them– My become dependent upon them– May perceive them with unrealistic power.

•  • Perception of Close others & the World

– Due to isolation, may feel abandoned– Others will not understand– May see others as a threat

• People have failed to rescue them

Types of OffendersSocially limited

Borderline/JealousAntisocial/Narcissistic

Understanding the Diagnosis

Diagnostic Comparison

Type 1 - PTSD

Re-experiencing

Avoidance Numbing

Hyperarousal

Type 2 – Complex PTSD

Affect Regulatio

n

Consciousness

Self-Perceptio

n

Perception of

Perpetrator

Relationships

Somatic

System of

meaning

Affect Regulati

on

Persistent Dysphoria

Chronic Suicidal Ideation or Self-

Injurious/Parasuicidal Behavior

Explosive Anger/Anger

Inhibition

Compulsive Promiscuity/Extr

eme Sexual Inhibition

Emotional Flashbacks

Pattern of Generally Poor Modulation of

Emotional Response

Deviationsin

Consciousness

Amnesia/Hypermnesia

Depersonalization

Derealization

Intrusive Re-

experiencing

Alterations in

Perception of Self

Pervasive Sense of

Helplessness

Self-Blame, Guilt, Shame

Feeling Defiled or

Stigmatized

Complete Difference from Other

People

Alterations in

Perception of

Perpetrator

Preoccupation with the

Relationship

Preoccupation with Revenge

Attributing Perpetrator

with Unrealistic

Power

Idealization of the

Perpetrator or the

Relationship

Acceptance of Perpetrator’s Belief System

or Rationalization

s

Alterations in

Relationships with Others

Isolation & Withdrawal from Other

People

Repeated Search for a

Rescuer

Persistent Distrust

Disruption in Intimate

Relationships

Repeated Failures in

Self-Protection

Somatic Flashbac

ks

Re-Experiencing

Physical Sensations

Related to the Trauma

Bruising, Sensation of Being

Burned or Cut

Conversion Symptoms (Anxiety

Converted into Physical

Symptoms

Numbness, Paralysis, Isolated Limb Weakness,

Blindness, Seizures

Chronic Pain (Headache,

Backache, Deep Muscle or Bone

Pain)

Digestive System

Complaints

Shortness of Breath,

Chest Pains

Anniversary of

Trauma Occurrence

s

Alterations in

Personal System

of Meaning

Loss of Sustaining

Faith

Pervasive Sense of

HopelessnessPervasive Sense of Despair

Cognitions & Loss of Meaning

Janoff-Bulman

We are not vulnerableThe World is Predictable & Controllable

We Merit Self Worth

Epstein

The World is a Source of Joy

The World is Controllable

I am Competent & Good

What Is Posttraumatic Growth?

“…refers to reports of positive changes in

individuals that occur as the result of

attempts to cope in the aftermath of traumatic

life events.” (Tedeschi & Kilmer, 2005)

A Disorder?

Could Type 2 PTSD be a form

of coping instead of a “Disorder?”

Areas of Posttraumatic Growth Outcomes Grubaugh & Resick, 2007

Improved self efficacyChange in how one relates to othersIncreased

SpiritualityAware of New PossibilitiesGreater Appreciation

for Life

A Brief Overview of the 3 Staged Treatment Model for Type II PTSD

Three Stages

1 Stability

2Process

& Grieving

3 Reconnectio

n

Stage One: The Corrective Therapeutic

Experience: Working with Attachment, Intrapsychic

Conflict, and Transference Neurosis

Safety & Safety

Planning

Education Physical Well

Being

TrustBoundaries

Self Soothing

Stage one: Stabilization

Primarily a personal experience

Primarily a social experience

Three Stages in a Social ContextIntra-psychic & Therapeutic Interaction

Micro Therapeutic Dynamics

Macro Level Dynamics

Stage One:Key Terms

Attachment

Transference & Transference Neurosis

Countertransference

Repetition Compulsion

Temporary Regression

Defense Mechanisms

Stage One: Psychoeducation

• Education about Symptoms/Fight or Flight/Kindling

• Increase right limbic, decrease in prefrontal cortex and Broca’s Area.

• Disorganized Memory Storage/affective, cognitive & behavioral incongruence (See next slide)

• Re-enactments• Alexithymia

Symptom Awareness

• Monitoring stimuli and associated reactions

Environmental

Awareness

The Neurobiology of the Fight or Flight Response

Stressful Event

Cortex

Locus Coeruleus

Sympathetic NS

Adrenal Medulla

Thyroid

Adrenal Cortex

Pituitary

Hypothalamus

Amygdala

Cortisol

Thyroxin

Noradrenalin

Adrenaline

Adapted from Preston, O’Neal, & Talaga 2010

Thalamus

This occurs before

information reaches the

Cortex

Neuro-anatomical Factors

Right

Hemisphere

Broca’s

Area

Genetic Expression

Static vs.

Dynamic

Systems

Up/Down

Regulation

Environmental Influence

Receptor

ChangeNT production

Stage One: Physical Well Being

Well Bein

g

Medication

Diet sleep

Exercise

Reduced Caffeine

Comfort in Own

Skin

Stage One:Self Soothing

Relaxation Anxiety

Counter-conditioning

Reversal of Operant Conditioning

Stage One: Self Soothing

Clients discover and adopt

healthier ways of coping with

stressors.

Breathing

Exercise/Activity

Guided imagery

Journaling/Writing

Art

Music

Nature

Beyond the Pre-Frontal Cortex:Sensory Motor Trauma Therapy

Reflection of Body States

Experimentation

Toleration

Nerve Stimulation

Stage One:Safety, Trust & Boundaries

Trust vs. Mistrust/O

ral

Autonomy vs. Shame & Doubt

Treatment Through the Corrective Therapeutic Experience

An In Depth Look at Safety, Trust & Boundaries

Stage One:Psychosocial Redevelopment

(Herman, 1992)

“Recovery from trauma requires the reconstruction of basic capacities for

trust, autonomy, initiative,

competence, identity, and intimacy…”

Early Stages of Life and Their Spatial Needs. (Erikson 1968)

Stage 1• To Receive• To Give in Return

Stage 2• To Hold On• To Let Go

Stage 3• To Make (Go After)• To Make Like (Play)

Stage 4• To Make Things• To Make Things together

Stage 5• To Be Oneself• To Share Being Oneself

Stage 6 • To Lose and Find Oneself in others

Stage 7• To Make Be• To Take Care of

Stage 8• To be through having• To face not being

Developmental ModelsTrust vs. Mistrust

Oral

Autonomy vs. Shame & Doubt

Initiative vs. Guilt

Industry vs. Inferiority

Identity vs. Role Confusion

Intimacy vs. Isolation

Generativity vs. Stagnation

Integrity vs. Despair

Anal

Genital

Latency

Phallic

Hope

Willpower

Purpose

Competence

Fidelity

Love

Care

Wisdom

Old Age.

Adulthood.

Young Adulthood

Adolescence.School Age.

Play Age.

Early Childhood

Infancy Basic Trust vs Mistrust

Integrity vs. Despair

Autonomy vs. Shame &

Doubt

Initiative vs. Guilt

Industry vs. Inferiority

Intimacy vs. IsolationIdentity

vs. Confusion

Generativity vs. Stagnation

1 2 3 4 5 6 7 8

VIII

VII

VI

V

IV

III

II

I

Adapted from Childhood & Society Erikson 1950.

Erikson

“If we know what can go wrong in

each stage, can we say what should

have gone and can go right?” (Erikson, 1968)

Eriksonian &Freudian Basics

Crucial Moments

Ratio of Development

Ontogenesis of Hope

Fixation (war)

War

Crisis 1

Crisis 2

Crisis 3

A Strange Situation

Secure Attachme

ntAvoidant

Ambivalent

Disorganized

Ainsworth, M. D. S., Bell, S. M., (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41, 49-67.

Homeostatic Mechanism of Attachment

“The attachment system acts as a kind of

homeostatic mechanism for modulating anxiety

and stress by seeking out an attachment figure for security and protection.”

(Bowlby, 1978)

Janssen, C. G. C., Schuengel, C., & Stolk, J. (2002). Understanding challenging behaviour in people with severe and profound intellectual disability: A stress-attachment model. Journal of Intellectual Disability Research, 46, 445-453.

Attachment(Bartholomew, 1990; Muller & Rosenkranz, 2009)

Attachment Anxiety

Attachment Avoidance

Stage One:Safety

Environment Structure Predictabili

ty Safety

Stage One:Safety

Seeking

Help

Change

Trust

Vulnerability

Stage One:Boundaries

The therapist models appropriate boundary setting and enforcement.

The client’s dependence on the

therapist is redirected toward a sense of personal empowerment in the therapeutic environment.

Enhancing Posttraumatic Growth through the Corrective Therapeutic Experience

Repetition Compulsion

“The patient cannot remember the whole of what is repressed in him, and what he cannot remember may be precisely the essential part of it…He is obliged to repeat the

repressed material as a contemporary experience

instead of remembering it as something in the past.”

• Sigmund Freud

The Transference Neurosis

Therapist

Client

Clients Offender

Other previous

relationships

Group Member

Group Member

Group Member

Violation of Silence

Essential Treatment Factor

Temporary Regression

Trust Vs. Mistrust (Hope)

Trust vs.

Mistrust

First World

Ontogenesis of Hope

Delay of Gratification/Abandonment

Autonomy vs Shame

& Doubt

Repetition Compulsion:Transference Testing

•Will you do it?

Transference Testing

•Can you handle

it?

Passive To Active

Transformation

The Transference NeurosisAn Omnipotent

Rescuer

Our desire to

save

Our agenda

Our projectio

ns

Or re-enactme

nts

An Unpredictable Abuser

Our Own Issues

Inability to sit with client

Overly rigid boundary response

Overly Permeable boundary response

Autonomy vs. Shame & Doubt

Immature Dependence

Mature Depende

nce

Autonomy vs. Shame & Doubt (Will Power)

Autonomy vs. Shame

& Doubt

Self Control without loss of self-esteem

Compulsive compliance or impulsive defiance

Will Power

Initiative vs. Guilt

The Therapist Should…Herman (1997) pg. 135

Remain “Disinterested”

Remain “Neutral”

Initiative vs. Guilt (Purpose)

Initiative vs. guilt

Development of Superego

Development of Roles

Finding Purpose & Self Initiative

Industry vs.

Inferiority

Industry vs. Inferiority(Competence)

Industry vs.

Inferiority

Take School & Cultural Role

Development of inadequacy

Competence

Identity vs.

Identity Confusi

on

Identity & Repudiation vs. Identity Confusion(Fidelity)

Identity vs.

Identity Confusi

on

Impulse Vs. Compulsive Restraint

Self-Definition

Fidelity

Intimacy vs.

Isolation

Intimacy & Solidarity vs. Isolation(Love)

Intimacy vs. Isolati

on

Self Abandonment

“Way of Life”

The Defensive Wall

Generativity vs. Self Absorptio

n

Generativity vs. Self-absorption/Stagnation(Care)

Generativity vs. Self Absorptio

n

Dependency & Maturity are Reciprocal

Guiding the Next Generation

Relation to Stage 3

Integrity vs.

Despair

Integrity vs. Despair(Wisdom)

Generativity vs. Self

Absorption

Integrity of experience

Letting go

Sign of conflict is doctoring of memories

Contact: ron@centerforchristianthera

py.com

Thank You