An Experiential Approach to Reliving with Complex Trauma · An Experiential Approach to Reliving with Complex Trauma Dr Jo Billings Berkshire Traumatic Stress Service ... Complex

An Experiential Approach to Reliving with Complex Trauma

Dr Jo Billings

Berkshire Traumatic Stress Service

UK PTS Conference 2013

A Phase-Based Approach

Stabilisation Processing

trauma

memories

Reclaiming

life


Overview

What is the current evidence base and how to bridge gaps?

How to deal with multiple traumas?

Where to start?

When to stop?

How to manage high degree of distress, dissociation and avoidance?

How to look after yourself?


Current evidence base


PTSD treatment evidence base

Good evidence of efficacy for CBT and EMDR in the treatment of PTSD (Type I trauma) - Exposure elements key

- CT can enhance treatment (guilt, shame)

NICE guidelines recommend TF-CBT and EMDR 8-12 sessions for single incident trauma

>12 sessions for where multiple traumatic events, traumatic bereavement, chronic disability, social problems and significant co-morbid disorders


TF-CBT Treatment Models

Prolonged exposure (Foa)

Cognitive processing therapy (Resick)

Cognitive therapy (Ehlers & Clark)


Prolonged Exposure

9+ sessions

Often 2x week

Psycho-education and treatment rationale

Prolonged exposure 45-60 mins

In vivo exposure

Some cognitive restructuring


Cognitive Processing Therapy

12 sessions

2x week

Written exposure

Explore themes/stuck points with CT

Safety, trust, power/control, esteem, intimacy

Re-write narrative


Cognitive Therapy

8-12 sessions

Psycho-education and treatment rationale

Reliving of key trauma memory

Identifying hotspots

Restructuring key meanings


Cognitive Model (Ehlers & Clarke, 2000)

Current Threat

Intrusions

Arousal Symptoms

Strong Emotions

Strategies Intended to Control Threat/Symptoms

Avoidance/Safety Behaviours

Nature of Trauma Memory Negative Appraisals of

Trauma and/or its Sequelae

Nature of Trauma, Prior

Experiences, Beliefs, Coping, State

of individual

Cognitive Processing during

Trauma

Triggers


Goals of Trauma Focused CBT

1. Elaborate memories

2. Identify and challenge negative appraisals

3. Reduce unhelpful maintenance strategies


Mind the Gap!

Lack of psychological models of developmental and complex trauma

Evidence base for treatment of complex trauma lags far behind that of adult trauma

More gaps than guidance!


Gaps in the Research

Established research on selected samples, with simple and clear research questions

Only established models for single incident adult trauma

Real life in trauma clinic more complicated!

High rates of complexity, comorbidity, physical and situational problems

Multiple traumas

Childhood and adult trauma

Pre-existing problematic schemas

Systemic factors

Clients heterogeneous with wide ranging problems, needs and preferences

Culture/language differences

Working with interpreters

High levels of Risk

Dissociation

Self harm

Limited time/resources


The nature of complex trauma

Developmental

Repeated, prolonged, anticipated

Interpersonal in nature

Often perpetrated by those supposed to protect you

The closer the abusing relative to the victim the worse the prognosis

Further damage caused by collusion, betrayal and denial of others (Waller)

Complex emotional experience – not just fear – guilt, shame, anger, humiliation, disgust


The fallibility of memory

Memory is reconstructive not reproductive

A jigsaw puzzle rather than a DVD – can put the pieces together in many different ways

High probability of trauma memories being distorted and unreliable

Nature of memory influenced by previous experiences of similar events

Memory deficits normal


The fallibility of memory

Childhood experiences encoded non-verbally

Meanings of memories are developmentally congruent (Its my fault)

Children have good procedural and semantic memory but poor autobiographical memory

Poor autobiographical memory in adulthood

Memory problems particularly likely in survivors of childhood trauma


“Memory is changed by subsequent information because what we remember is an amalgam of

what we witness and what we think”

BPS Working Party (1995) Conclusion: General memory is reliable, while memory for detail is not


Complex trauma, complex reactions, complex treatment!

Integrative treatment models

Evidence base as a starting point

Adhere to key theory and principles

Adaptation, creativity and flexibility

Work with key meanings/affect via memory


Continua of Trauma

Nature of Trauma Type I Trauma Not interpersonal Stable background Other protective factors Treatment Implications Specific focus Trauma focussed Classic CBT Brief

Type II Trauma Interpersonal

Unstable background Lack of protective factors

General, multiple foci Schema focussed Phased approach

Longer term

From Rothschild (2000) UK PTS Conference 2013

Where to start?


Memory Meaning


Reliving Restructuring


Getting an overview

Overview of the client’s history

No surprises

‘Cold’ reliving

Positive factors and resilience


From narrative to reliving


Multiple trauma

Multiple/overlapping traumas…where to start?!

Earliest

Easiest

Most recent

Worst

Most symptomatic

Thematic


Traditional Re-living Protocol

Systematic, repeated, prolonged exposure to a traumatic memory

Graded approach with increasing detail if necessary

Start at the beginning

First person, present tense

Finish in a safe place (fast forward if necessary)


Traditional Re-living Protocol

Prompts • “What happens next…”

• “What can you see, hear, smell, taste, feel”

• “What thoughts are going through your mind right now”

• “What do you feel in your body, where do you feel it”

• “What emotions do you feel, how strong”

Ratings • SUDS

• Vividness

• Nowness


Getting the temperature right


Sensory inputs Thalamus

Sensory

gateway

Amygdala

Emotional

valence

Sensory cortices

Parietal, Occipital

and Temporal lobes:

sensory processing

PERIPHERAL SYMPATHETIC & CORTISOL RESPONSES

Prefrontal Cortex

Assessment of threat:

“tracks on-going reality”

Self-soothing

Motor cortex

Hippocampus

Stores memory

of event


Window of Tolerance

Those who have suffered traumatic experiences can oscillate between hyper- and hypo- arousal

Whilst in the window of tolerance a person can receive and integrate sensory information from the environment, while calling on the cortex, including the hippocampus, to assist with this assessment and integration

Ogden, Minton & Pain, 2006


Elaborating Memories?

Narratives

Timelines

Testimony

Story boards

Pictures

Diagrams

Photographs

Maps

Reliving

Revisiting


Life story

Trauma history

Key trauma

Key hotspot

Key meaning


Changing Meanings


Cognitive Restructuring

Socratic questioning

Evidence for and against

Advantages/disadvantages

Cognitive continua

Responsibility pie

Cognitive biases (i.e. hindsight bias)

Surveys

Research

Behavioural experiments

Positive data log

Return to site UK PTS Conference 2013

Updating memories

Verbally

“I know now that…”

“What is different now”

Imagery

Visualising how wounds have healed

Visualising family safe

Physical movement

Movements or actions incompatible with trauma memory

Moving about if trapped


Intervention Points – Complex Trauma

Current Threat

Intrusions

Arousal Symptoms

Strong Emotions







of individual


Trauma

Triggers


Intervention Points – Complex Trauma

Current Threat

Intrusions

Arousal Symptoms

Strong Emotions







of individual


Trauma

Triggers


Emotional Bridge


Imagery Rescripting

Integrated part of the reliving protocol (Ehlers et

al., 2005)

Aims to introduce new perspectives on what happened by experiencing new views and new emotions

Works with representation in memory of what was experienced

Changes relationship with memory


Imagery Rescripting

Can provide corrective information

Allow for expression of trauma inhibited responses

May be more effective than exposure for emotions other than fear (Grunert et al., 2007)

May be more effective intervention for guilt and anger (Arntz, 2007)


Imagery Rescripting

Can vary from simple update (I know I did not die –

picture self with family now) through to complete imagery transformation (rescuing self, humiliating

perpetrator)

No limits to creativity!

But aim to meet unmet needs at time of trauma (i.e. safety, compassion)


Bring distressing

memory into awareness

Identify hotspot and associated meaning (rate

belief)

Restructure belief

Imagine new memory in

hotspot (re-rate belief)

Plan imagery to update

belief


Bring distressing

memory into awareness

Identify hotspot and associated meaning (rate

belief)

Identify unmet needs

Imagine new memory in

hotspot (re-rate belief)

Plan imagery to meet needs


Imagery Rescripting

“What would you have liked to do then that you couldn’t?”

“What would you like to feel in that moment?”

“What would need to happen for you to feel like that?”

“If you could go back in time and intervene what would you want to do?”

“If someone could come back from the future to help you what would you like them to do?”


Looking after yourself


Looking after yourself

Control empathic attunement

Peer and organisational support

Regular supervision

Use recordings to decentre

Specific training

Caseload balance

Variety of work

Good self care

Optimism and hope

Incorporate positive factors into formulation – to avoid vicarious helplessness


Documents

An Experiential Approach to Reliving with Complex Trauma · An Experiential Approach to Reliving with Complex Trauma Dr Jo Billings Berkshire Traumatic Stress Service ... Complex