Psychological Trauma &Psychological Trauma &Addictions TreatmentAddictions Treatment

Case Management and Treatment of Trauma Case Management and Treatment of Trauma Syndromes in Chemical Dependency Treatment Syndromes in Chemical Dependency Treatment

SettingsSettings

Bruce Carruth, Ph.D., LCSWBruce Carruth, Ph.D., LCSWSan Miguel de Allende, GTO, MexicoSan Miguel de Allende, GTO, Mexico

Advanced International Winter Advanced International Winter SymposiumSymposium

Colorado Springs, CO Colorado Springs, CO January 31, 2009January 31, 2009

Neurosis ….Neurosis ….

“… “… is the process of shrinking is the process of shrinking our world to the point where our world to the point where we can manage” we can manage” (Rollo May, (Rollo May, I think)I think)

Unresolved trauma causes our worlds Unresolved trauma causes our worlds to shrinkto shrink

Some initial thoughts about Some initial thoughts about truamatruama

1. Almost everybody experiences a trauma 1. Almost everybody experiences a trauma event sometime in their lives.event sometime in their lives.

2. It’s not what 2. It’s not what happenshappens, it is how we , it is how we handlehandle what happens that creates trauma. what happens that creates trauma. Trauma isn’t an event, trauma is an Trauma isn’t an event, trauma is an experience.experience.

3. Since trauma is a personal experience, 3. Since trauma is a personal experience, everybody’s trauma is different.everybody’s trauma is different.

4. Trauma is, by it’s nature, blindsiding. 4. Trauma is, by it’s nature, blindsiding. It happens when we aren’t looking and It happens when we aren’t looking and

aren’t aren’t prepared and it strikes where we are prepared and it strikes where we are

vulnerablevulnerable

Some initial thoughts Some initial thoughts (con’t)(con’t)

5. Trauma is a wound to our 5. Trauma is a wound to our personhood. personhood. We are never the same We are never the same afterwards.afterwards.

6. Everyone copes with trauma by 6. Everyone copes with trauma by withdrawing, by disconnecting. withdrawing, by disconnecting. Recovery has to be about reconnecting.Recovery has to be about reconnecting.

7. Trauma therapy doesn’t change what 7. Trauma therapy doesn’t change what happened.happened.

The therapy focus is on changing who The therapy focus is on changing who we are today in the face of what happenedwe are today in the face of what happened

SOME SPECIFIC LEARNING GOALS FOR SOME SPECIFIC LEARNING GOALS FOR TODAYTODAY

1. Conceptualize a variety of trauma syndromes1. Conceptualize a variety of trauma syndromes2. That everyone’s trauma is unique in:2. That everyone’s trauma is unique in: symptomssymptoms meaning of the trauma in their lifemeaning of the trauma in their life the process of recoverythe process of recovery3. There is no “best” way to treat trauma 3. There is no “best” way to treat trauma

syndromessyndromes and that treatment has to evolve as the and that treatment has to evolve as the

person evolvesperson evolves4. Trauma treatment has to address more than 4. Trauma treatment has to address more than

symptoms: “symptoms: “no symptom, no problem” isn’t an answerno symptom, no problem” isn’t an answer

5. Recovery requires a variety of healing 5. Recovery requires a variety of healing resourcesresources

self, therapy, spiritual growth, self, therapy, spiritual growth, significant others, a significant others, a

healing communityhealing community

The dimensions of traumaThe dimensions of trauma Our reaction to our environmentOur reaction to our environment Sensory awareness and perception Sensory awareness and perception amplifications, deletions, distortionsamplifications, deletions, distortions Cognitions – cognitive filtersCognitions – cognitive filters MemoryMemory Affect and emotionAffect and emotion terror (fear), grief (sadness), rage (anger) terror (fear), grief (sadness), rage (anger) & shame& shame

How we manage relationships in our lifeHow we manage relationships in our life trust, commitment, attachment, potency in trust, commitment, attachment, potency in relationshipsrelationships

Self and self functions – Self and self functions – our sense of who we our sense of who we are as a person – our roadmaps for how to function in are as a person – our roadmaps for how to function in lifelife

Soul – Soul – the experience of being part of something the experience of being part of something greater than self … attachment / belonging/ greater than self … attachment / belonging/ commitment / connection to a world larger than selfcommitment / connection to a world larger than self

Some different perspectives on Some different perspectives on trauma treatmenttrauma treatment

Medical perspectiveMedical perspective trauma as a neuro-psycho-biological perspectivetrauma as a neuro-psycho-biological perspective

Cognitive-Behavioral perspectiveCognitive-Behavioral perspective treatment of trauma by changing cognitions and treatment of trauma by changing cognitions and

behaviorsbehaviors

Affect Regulation perspectiveAffect Regulation perspective treatmenttreatment of trauma by regulating powerful affectsof trauma by regulating powerful affects

Psychodynamic perspectivePsychodynamic perspective trauma as a wound to self trauma as a wound to self

Interpersonal perspectiveInterpersonal perspective focuses on the interpersonal wounds of traumafocuses on the interpersonal wounds of trauma

Since trauma touches Since trauma touches all parts of our being,all parts of our being,

treatment and recovery treatment and recovery have to address all have to address all parts of our beingparts of our being

… … just like just like addictive illnessaddictive illness

trauma is ultimately a trauma is ultimately a wound to wound to selfself““damaged goods” “not the same person”damaged goods” “not the same person”“a part of me was lost” “forever “a part of me was lost” “forever changed”changed”but trauma is also set of but trauma is also set of symptomssymptoms that interfere with living:that interfere with living:

hyperarousal symptoms: hyperarousal symptoms: startle reactions, startle reactions, hypervigilance, irritability, misinterpreting the hypervigilance, irritability, misinterpreting the environment, hypersensitivity – environment, hypersensitivity – problem ofproblem of keeping the keeping the outsides outoutsides out

constriction symptoms: constriction symptoms: withdrawal, numbing, withdrawal, numbing, forgetting, deadening, isolating, holding in – forgetting, deadening, isolating, holding in – problems problems of trying to hold the insides inof trying to hold the insides in

Intrusion symptoms: Intrusion symptoms: re-enacting, intrusive memories, re-enacting, intrusive memories, reliving, nightmares, preoccupied thoughts – reliving, nightmares, preoccupied thoughts – problem of problem of regulating the commerce between our insides and regulating the commerce between our insides and outsidesoutsides

So, what are we treatingSo, what are we treating

Treatment starts with managing and treating Treatment starts with managing and treating the symptoms of trauma: (and how trauma the symptoms of trauma: (and how trauma manifests in the “now”)manifests in the “now”)

symptom managementsymptom management coping skillscoping skills cognitionscognitions “ “reactive” affectsreactive” affectsAnd then And then generallygenerally needs to proceed to needs to proceed to doing “restorative” work that explores doing “restorative” work that explores the meaning of the trauma experience and the meaning of the trauma experience and “works it through”“works it through”

primary affectsprimary affects telling the tale and reorganizing experiencetelling the tale and reorganizing experience core cognitions and schemascore cognitions and schemas building healthy life and relationships - building healthy life and relationships - reconnectingreconnecting

Recognizing trauma Recognizing trauma syndromessyndromes

1. When people define their life by trauma 1. When people define their life by trauma eventsevents

2. Rigid or inappropriate behaviors in the 2. Rigid or inappropriate behaviors in the face of specific events or triggersface of specific events or triggers

3. Ego defense, unconscious to the person that 3. Ego defense, unconscious to the person that clearly limits functioningclearly limits functioning

difficulty in giving / receiving feedbackdifficulty in giving / receiving feedback misrepresentations of the environmentmisrepresentations of the environment misperceptions of self and self-rolesmisperceptions of self and self-roles

deadening, numbing, dissociation deadening, numbing, dissociation (disconnecting)(disconnecting)

assigning painful / disowned parts of assigning painful / disowned parts of self to the self to the

environmentenvironment

Recognizing trauma syndromes Recognizing trauma syndromes (con’t)(con’t)

4. Distorted affects4. Distorted affects

displaced / distorted / inappropriate displaced / distorted / inappropriate affectsaffects

exaggerated affects (affective overload)exaggerated affects (affective overload)

diminishing (repressing) affectsdiminishing (repressing) affects

5. Psychiatric symptoms5. Psychiatric symptoms

depression (sad, angry, nihilistic, depression (sad, angry, nihilistic, anxious)anxious)

anxiety (fear, phobias, obsessiveness, anxiety (fear, phobias, obsessiveness, withdrawal)withdrawal)

somatization (pain, sleep disorder, somatization (pain, sleep disorder, appetite disorder)appetite disorder)

Recognizing trauma syndromes Recognizing trauma syndromes (con’t)(con’t)

7. Distorted reactions to life events that 7. Distorted reactions to life events that involve helplessness, vulnerability, involve helplessness, vulnerability, constraint, shame, power/controlconstraint, shame, power/control

8. Distortions in relationships: trust, 8. Distortions in relationships: trust, commitment,commitment,

potency, attachmentpotency, attachment

9. And by the typical trauma symptoms:9. And by the typical trauma symptoms:

intrusionintrusion

hyperarousalhyperarousal

constrictionconstriction

the spectrum of the spectrum of psychological traumapsychological trauma

1. Subclinical trauma syndromes: 1. Subclinical trauma syndromes: A trauma reaction A trauma reaction that doesn’t reach the threshold for a trauma that doesn’t reach the threshold for a trauma diagnosis.diagnosis.

2. Cumulative childhood trauma: 2. Cumulative childhood trauma: an adaptive an adaptive response in adulthood to childhood traumaresponse in adulthood to childhood trauma

3. Acute Stress Reaction3. Acute Stress Reaction: : AA psychophysiological psychophysiological reaction to an overwhelming stimuli. A variation of reaction to an overwhelming stimuli. A variation of ASR is Combat Stress Reaction (CSR)ASR is Combat Stress Reaction (CSR)

4. Grief Reaction: 4. Grief Reaction: An inability to experience the An inability to experience the emotions of lossemotions of loss

5. Post-Traumatic Stress Disorder(s): 5. Post-Traumatic Stress Disorder(s): A A significant wound to an individual’s sense of self / significant wound to an individual’s sense of self / personhoodpersonhood

6. Complex PTSD & Dissociative States: 6. Complex PTSD & Dissociative States: A A pervasive and disabling injury to self that produces pervasive and disabling injury to self that produces significant psychiatric complications – often significant psychiatric complications – often produced by ongoing traumatization or torture.produced by ongoing traumatization or torture.

Just because it isn’t in DSM 4 doesn’t mean it Just because it isn’t in DSM 4 doesn’t mean it isn’t realisn’t real

associated psychiatric associated psychiatric disordersdisorders

we often label trauma syndromes as something we often label trauma syndromes as something elseelse

and these disorders are likely to co-occur and these disorders are likely to co-occur with trauma disorderswith trauma disorders adjustment disorders adjustment disorders (mislabeled)(mislabeled)

dissociative disorders dissociative disorders (co-occurring)(co-occurring) panic disorder panic disorder (co-occurring)(co-occurring) phobic disorders phobic disorders (co-occurring)(co-occurring) major depressive disorder major depressive disorder (both)(both) dysthymia dysthymia (both)(both) substance use / abuse disorders substance use / abuse disorders ((both, but both, but

more likely co-occurring)more likely co-occurring) the whole spectrum of personality the whole spectrum of personality disorders disorders (both)(both)

The vulnerable are always more The vulnerable are always more vulnerablevulnerable

Trauma is a wound to one’s Trauma is a wound to one’s sense of selfsense of self

Trauma wounds our dignity and integrityTrauma wounds our dignity and integrity

Trauma alters our beliefs about ourself & the Trauma alters our beliefs about ourself & the worldworld

Trauma alters our ability to rejuvenate / Trauma alters our ability to rejuvenate / recuperaterecuperate

Trauma impacts our ability to trust: Trauma impacts our ability to trust:

Self trust and to trust the environmentSelf trust and to trust the environment

Trauma distorts our sense of time and timingTrauma distorts our sense of time and timing

Time gets defined by traumatic eventsTime gets defined by traumatic events Distorts our sense of when to act: Distorts our sense of when to act:

hesitancy, impulsivityhesitancy, impulsivity

Trauma impacts our sense of connection and soulTrauma impacts our sense of connection and soul

Family, community, spiritual lifeFamily, community, spiritual life

Emotional “symptoms” of Emotional “symptoms” of traumatrauma

A primary effect of trauma is the A primary effect of trauma is the inability to regulate the affects inability to regulate the affects arising from or contaminated by arising from or contaminated by the traumathe trauma

RAGE TERRORRAGE TERROR

GRIEF SHAMEGRIEF SHAME

Healing is being able to once again Healing is being able to once again live in the face of these affectslive in the face of these affects

trauma and vulnerabilitytrauma and vulnerability

trauma strikes the vulnerable trauma strikes the vulnerable person and trauma strikes us person and trauma strikes us where we are vulnerablewhere we are vulnerable

psychological vulnerabilitiespsychological vulnerabilities

psychodevelopmental vulnerabilitiespsychodevelopmental vulnerabilities

psychosocial vulnerabilitiespsychosocial vulnerabilities

… … the wounded are always at greater risk the wounded are always at greater risk of more of more

wounding …wounding …

4 variables in trauma 4 variables in trauma vulnerabilityvulnerability

1. previous unhealed trauma1. previous unhealed trauma

2. psychiatric / psychological deficits / 2. psychiatric / psychological deficits / disordersdisorders

3. unique, idiosyncratic childhood wounding 3. unique, idiosyncratic childhood wounding that makes us vulnerable to rewounding as that makes us vulnerable to rewounding as adultsadults

4. lack of resiliencies4. lack of resiliencies

3 primary symptoms of trauma3 primary symptoms of trauma

1. Hyperarousal, sensitivity1. Hyperarousal, sensitivity

Startle reactions Startle reactions HypervigilanceHypervigilance

Sleep disorders Sleep disorders NightmaresNightmares

Irritableness Irritableness

Inability to delete annoying Inability to delete annoying stimulistimuli

Intense reaction to stimuli Intense reaction to stimuli associated associated

with the traumawith the trauma

Primary symptoms (con’t)Primary symptoms (con’t)

2. Intrusion symptoms2. Intrusion symptoms

Reliving the traumatizing event as if Reliving the traumatizing event as if trauma was reoccurring in the trauma was reoccurring in the presentpresent

(every time I close my eyes I see it all over again”)(every time I close my eyes I see it all over again”)

Reenacting the trauma event in disguised Reenacting the trauma event in disguised

form (repetition compulsion)form (repetition compulsion) Intrusive traumatic memories may be out Intrusive traumatic memories may be out of context to actual trauma of context to actual trauma experienceexperience

(“I keep having thoughts about things I don’t(“I keep having thoughts about things I don’t think happened”)think happened”)

and may be encapsulated in one and may be encapsulated in one sensory experience sensory experience (“at night I hear this sound of …..”)(“at night I hear this sound of …..”)

Primary symptoms (con’t)Primary symptoms (con’t)

3. Constriction (Numbing and Withdrawing)3. Constriction (Numbing and Withdrawing)

People will sometimes describe their People will sometimes describe their constriction symptoms as “building a wall”constriction symptoms as “building a wall”

““Numbness” is an early response to trauma: Numbness” is an early response to trauma: A A primary variable in recovery is getting beyond the numbness primary variable in recovery is getting beyond the numbness and disconnection. Feelings become the enemy & numbness and disconnection. Feelings become the enemy & numbness is safeis safe

Forgetting is a form of constriction Forgetting is a form of constriction The ego defenses of constriction The ego defenses of constriction (repression, denial, dissociation, (repression, denial, dissociation, withdrawal, retroflection) are often the withdrawal, retroflection) are often the most difficult to work with in therapymost difficult to work with in therapy

Phobias may be an unconscious way of Phobias may be an unconscious way of avoiding environmental contactavoiding environmental contact

so, what are we treating? And so, what are we treating? And when?when?

Managing and treating the Managing and treating the symptomssymptoms of of trauma:trauma:

(and how trauma manifests in the “now”)(and how trauma manifests in the “now”)(the early recovery work)(the early recovery work) symptom managementsymptom management coping skillscoping skills cognitionscognitions “ “reactive” affectsreactive” affectsDoing “Doing “restorative” workrestorative” work that explores that explores the trauma and “works it through”the trauma and “works it through”

(when people are more stabilized in recovery)(when people are more stabilized in recovery) core cognitions and schemascore cognitions and schemas primary affectsprimary affects telling the tale and reorganizing the telling the tale and reorganizing the experienceexperience

building healthy life and relationshipsbuilding healthy life and relationships

Co-occurring trauma and Co-occurring trauma and addiction:addiction:

approaches to addressing both approaches to addressing both disordersdisorders

Sequential treatmentSequential treatment treating (stabilizing) one disorder first then treating the treating (stabilizing) one disorder first then treating the

otherother

Parallel treatmentParallel treatment treating both disorders at the same time, but with treating both disorders at the same time, but with

different treatment protocols (and sometimes different different treatment protocols (and sometimes different agencies and different counselors / therapistsagencies and different counselors / therapists

Integrated TreatmentIntegrated Treatment treating the individual with one master treatment plan, treating the individual with one master treatment plan,

in one setting, addressing the individual’s unique needsin one setting, addressing the individual’s unique needs

requires that the therapist/counselor and treatment requires that the therapist/counselor and treatment team understand and have the skills to treat both team understand and have the skills to treat both disordersdisorders

Relative occurrence ofRelative occurrence of trauma trauma disordersdisorders

SUBCLINICAL TRAUMA SYNDROMESSUBCLINICAL TRAUMA SYNDROMES many people some time(s) in life many people some time(s) in life

ACUTE STRESS REACTIONSACUTE STRESS REACTIONS

Almost everyone, some time(s) in lifeAlmost everyone, some time(s) in life

CUMULATIVE CHILDHOOD TRAUMACUMULATIVE CHILDHOOD TRAUMAA significant number of peopleA significant number of people

GRIEF REACTIONS GRIEF REACTIONS A significant percentage (10- 15%) of A significant percentage (10- 15%) of

peoplepeople

POST TRAUMATIC STRESS DISORDERPOST TRAUMATIC STRESS DISORDER small percentage of people (4-7%)small percentage of people (4-7%) COMPLEX PTSD AND DISSOCIATIVE DISORDERSCOMPLEX PTSD AND DISSOCIATIVE DISORDERS Very few peopleVery few people

Subclinical TraumaSubclinical Traumatrauma that doesn’t incapacitate but lurks trauma that doesn’t incapacitate but lurks

around in our lifearound in our life Blindsided by event(s). It strikes where we are vulnerableBlindsided by event(s). It strikes where we are vulnerable We have trouble finding meaning, We have trouble finding meaning, “ “Why me?”, finding cause doesn’t resolve the issueWhy me?”, finding cause doesn’t resolve the issue We may reject or not accept (recognize) support of othersWe may reject or not accept (recognize) support of others We feel disoriented (things aren’t the same)We feel disoriented (things aren’t the same) Our feelings are out of proportion (and we know it) to the Our feelings are out of proportion (and we know it) to the

circumstance, uncomfortable and may be displacedcircumstance, uncomfortable and may be displaced We revert to old coping strategies (smoking, drug use, We revert to old coping strategies (smoking, drug use,

withdrawing, blaming others, trying to fix “it”)withdrawing, blaming others, trying to fix “it”) It connects to some vulnerability in our historyIt connects to some vulnerability in our history The hurt seems to go on and on, we obsess, we keep it in The hurt seems to go on and on, we obsess, we keep it in

front of us even when it doesn’t need to befront of us even when it doesn’t need to be Often are a series of events that overwhelm coping skillsOften are a series of events that overwhelm coping skills May manifest as transient or “on & off” or ongoingMay manifest as transient or “on & off” or ongoing And in the face of all this we keep going and maintain And in the face of all this we keep going and maintain

life on a day-to-day basislife on a day-to-day basis

Treating subclinical traumaTreating subclinical trauma

SupportSupport … …. That the trauma experience is valid. That the trauma experience is valid … …. That the trauma experience will pass. That the trauma experience will pass … …. To keep the experience in perspective. To keep the experience in perspectivePsychoeducation about trauma reactions and Psychoeducation about trauma reactions and process of recoveryprocess of recovery

Acknowledgement of connections of current Acknowledgement of connections of current traumatic event to past traumas / historytraumatic event to past traumas / history

Provide opportunities to step out of the Provide opportunities to step out of the trauma reaction to rest and replenishtrauma reaction to rest and replenish

Cumulative childhood traumaCumulative childhood trauma

Repeated childhood experience that leaves the Repeated childhood experience that leaves the individual feeling unworthy, defective, different…individual feeling unworthy, defective, different…

abandonment, physical disfigurement, learning abandonment, physical disfigurement, learning disabilities, family disabilities, family

violence, parental addiction or psychiatric illness, violence, parental addiction or psychiatric illness, physical illness and physical illness and

disability,disability, poverty and social shunning, abusive poverty and social shunning, abusive siblings, narcissistic, siblings, narcissistic,

antisocial or borderline personality disordered parentsantisocial or borderline personality disordered parents The child develops coping skills to address the The child develops coping skills to address the personal and interpersonal experience and these personal and interpersonal experience and these skills become engrained in the repertoire of the skills become engrained in the repertoire of the individualindividual

The individual develops “deep schemas” about self The individual develops “deep schemas” about self and the world that are congruent with and support and the world that are congruent with and support the understanding of the childhood experience & the understanding of the childhood experience & coping skills coping skills

The child has to adapt an effective response that The child has to adapt an effective response that is congruent with their environment and this is congruent with their environment and this response becomes engrained response becomes engrained

Cumulative childhood trauma Cumulative childhood trauma (con’t)(con’t)

As a young adult, the child seeks out an As a young adult, the child seeks out an environment that supports core schema, environment that supports core schema, affective adaptations and coping behaviors of affective adaptations and coping behaviors of childhood. This is the “entrenched adaptive childhood. This is the “entrenched adaptive stance”stance”

All of this is largely unconsciousAll of this is largely unconscious When the “breakdown” begins to occur (often When the “breakdown” begins to occur (often between 25 – 40), the person is truly befuddled between 25 – 40), the person is truly befuddled and doesn’t know how else to be.and doesn’t know how else to be.

Efforts at therapy/counseling may unwittingly Efforts at therapy/counseling may unwittingly become “part of the problem” become “part of the problem”

for instance, seeking out counseling that supports for instance, seeking out counseling that supports the engrained the engrained

view of the world … “I’m a bad person”, “It’s my view of the world … “I’m a bad person”, “It’s my fault”, finding a fault”, finding a

rescuing counselor, getting retraumatized in rescuing counselor, getting retraumatized in counselingcounseling

All of the above has been well described in the All of the above has been well described in the ACOA literature.ACOA literature.

Treating cumulative childhood Treating cumulative childhood traumatrauma

Treatment needs to be seen as an Treatment needs to be seen as an ongoing (2-5 year) processongoing (2-5 year) process

Therapy needs to be relationally Therapy needs to be relationally focused and the corrective experience focused and the corrective experience needs to, in part, arise from the needs to, in part, arise from the therapeutic relationship. The therapeutic relationship. The relationship is critical to treatmentrelationship is critical to treatment

Intellectualization, idealization, Intellectualization, idealization, projection, introjection and projection, introjection and withdrawing are primary defenses that withdrawing are primary defenses that have to be confronted and utilized in have to be confronted and utilized in the treatment the treatment

Treatment needs to utilize the Treatment needs to utilize the adaptive stance, maximizing the assets adaptive stance, maximizing the assets and strengthening the limiting partsand strengthening the limiting parts

Treating cumulative childhood Treating cumulative childhood trauma (con’t)trauma (con’t)

When treating any trauma, but especially When treating any trauma, but especially cumulative childhood trauma, therapy has to cumulative childhood trauma, therapy has to consider the world the adult has created for consider the world the adult has created for themselves. Good treatment is going to mess themselves. Good treatment is going to mess it up!it up!

The treatment needs to focus on missed The treatment needs to focus on missed developmental phases and missed skillsdevelopmental phases and missed skills

A big piece of the treatment has to be coming A big piece of the treatment has to be coming to accept what happened and living in the to accept what happened and living in the face of what happenedface of what happened

The result of treatment doesn’t have to be The result of treatment doesn’t have to be the perfect person, just good enoughthe perfect person, just good enough

Acute Stress Reactions (ASR)Acute Stress Reactions (ASR)

A trauma response to being A trauma response to being overwhelmed with a recent trauma overwhelmed with a recent trauma experience.experience.

Occurs within a short period Occurs within a short period following the trauma eventfollowing the trauma event

In “uncomplicated ASRs” improvement In “uncomplicated ASRs” improvement often occurs without treatmentoften occurs without treatment

ASRs often occur when a trauma event ASRs often occur when a trauma event in the now activates a prior trauma in the now activates a prior trauma experience (although the person make experience (although the person make not make the connection)not make the connection)

Treating Acute Stress Treating Acute Stress ReactionsReactions

1. Diagnosing:1. Diagnosing:

a) helping people understand what is happeninga) helping people understand what is happening “ “I’m falling apart”, “I think I’m going I’m falling apart”, “I think I’m going

crazy”crazy” b) differential diagnosisb) differential diagnosis addictive illness and addictive illness addictive illness and addictive illness

relapserelapse “ “hidden” PTSD with active trigger eventhidden” PTSD with active trigger event other anxiety disorder w/ environmental other anxiety disorder w/ environmental

stressorstressor “ “complicated” acute stress reactions with complicated” acute stress reactions with people who don’t have very good people who don’t have very good

coping coping skills and lack resilience skills and lack resilience

Treating ASD’s (Con’tTreating ASD’s (Con’t))

2. Creating safety2. Creating safety

slowing the physiological responseslowing the physiological response

exploring & reorganizing the exploring & reorganizing the cognitionscognitions

building boundaries / structurebuilding boundaries / structure

education about ASDeducation about ASD

“ “normalizing” the emotional normalizing” the emotional responsesresponses

building supports in the environmentbuilding supports in the environment

building safety within selfbuilding safety within self

3. Relapse prevention with recovering CD 3. Relapse prevention with recovering CD clientsclients

Treating ASD’s (con’t)Treating ASD’s (con’t)4. Giving room to tell the tale4. Giving room to tell the tale Be creative in letting people tell the Be creative in letting people tell the story in the way story in the way

. they need … “words can’t describe …”. they need … “words can’t describe …”

5. Use of medication5. Use of medication

Benzodiazepines ???Benzodiazepines ???

Sleep medsSleep meds

SSRIs are generally SSRIs are generally counterindicatedcounterindicated

Blunt the affect and take too Blunt the affect and take too long to worklong to work

““BICEPS” model for crisis BICEPS” model for crisis interventionintervention

1. Brief1. Brief 2. Immediate2. Immediate 3. Centralized resources3. Centralized resources 4. Expectations of outcome4. Expectations of outcome 5. Proximity to the trauma site5. Proximity to the trauma site 6. Simplicity6. Simplicity

Acute Stress Disorder and Mass Acute Stress Disorder and Mass TraumasTraumas

In catastrophic disasters and in In catastrophic disasters and in warfare, acute stress reactions are warfare, acute stress reactions are fairly common and may go undetectedfairly common and may go undetected

A variation of ASR is a Combat Stress A variation of ASR is a Combat Stress Reaction (CSR)Reaction (CSR)

We may be more likely to see the We may be more likely to see the coping symptoms: drug and alcohol coping symptoms: drug and alcohol use, numbness & withdrawal, use, numbness & withdrawal, inappropriate affects, impulsive inappropriate affects, impulsive decisionsdecisions

Critical Incident Stress Debriefing Critical Incident Stress Debriefing (CISD) has not been shown to be (CISD) has not been shown to be effective in preventing or effective in preventing or diminishing symptoms in mass trauma diminishing symptoms in mass trauma events, but may be efficacious when events, but may be efficacious when treatment is individualizedtreatment is individualized

Grief reactionsGrief reactions

GriefGrief is the emotional expression is the emotional expression of lossof loss

Complicated griefComplicated grief is getting is getting “stuck” in feelings of loss“stuck” in feelings of loss

Grief reactionGrief reaction is the blocking or is the blocking or distorting of the normal distorting of the normal emotional expression of lossemotional expression of loss

Grief, complicated grief Grief, complicated grief and grief reactions require and grief reactions require

different responsesdifferent responses GriefGrief: : support in expressing the support in expressing the emotions of lossemotions of loss

Complicated griefComplicated grief: : moving beyond moving beyond being stuck in the lossbeing stuck in the loss

Grief reactionGrief reaction: : being able to being able to experience and express the emotions of experience and express the emotions of lossloss

3 categories of losses3 categories of losses

Tangible losses – Tangible losses – marriages, money, marriages, money, careers, driver’s licenses, social careers, driver’s licenses, social status, friendshipsstatus, friendships

Intangible losses: Intangible losses: self esteem, hope, self esteem, hope, belonging and connectedness, joy, love, belonging and connectedness, joy, love, trust in self and others, trust in self and others,

What could have beenWhat could have been had this had this experience not happened to me … the loss experience not happened to me … the loss of a futureof a future

Grief reactions from the Grief reactions from the “outside”“outside”

Emotional constriction or Emotional constriction or inappropriatenessinappropriateness

Apparent feelings on the surface that Apparent feelings on the surface that are denied or displaced are denied or displaced (denying sad or (denying sad or anger)anger)

Avoidance behaviors, lonely in a crowdAvoidance behaviors, lonely in a crowd

Judgmentalness, perfectionism, blamingJudgmentalness, perfectionism, blaming

Difficulty experiencing self, including Difficulty experiencing self, including positive and negative feedbackpositive and negative feedback

Obsessive thought and compulsive ritualObsessive thought and compulsive ritual

Loss of spontaneityLoss of spontaneity

The process of grief workThe process of grief workDiagnosis and differential diagnosisDiagnosis and differential diagnosis cd relapse, “dry drunk” depression, PTSD, personality cd relapse, “dry drunk” depression, PTSD, personality

disorderdisorder

Education about grief and grief reactionsEducation about grief and grief reactionsExploration about client’s experience Exploration about client’s experience with their griefwith their grief

Creating safety with feelings …Creating safety with feelings … especially the disavowed feelingsespecially the disavowed feelings

Catharsis – Catharsis – telling the story as well as expressing telling the story as well as expressing affectaffect

Getting closure on events that Getting closure on events that precipitated the grief – precipitated the grief – saying goodbye, saying goodbye, letting go, finishing unfinished business, forgiving letting go, finishing unfinished business, forgiving self and othersself and others

Reintegration of past self with present Reintegration of past self with present selfself

The goal of grief work is not The goal of grief work is not

to “get rid”to “get rid” of painful of painful feelings, but to accept the feelings, but to accept the pain as a meaningful part of pain as a meaningful part of

life, to honor the pain rather life, to honor the pain rather than repressing or disavowing than repressing or disavowing

it.it.

The pain connects us to The pain connects us to something(s) that we lost that something(s) that we lost that

were very important to us.were very important to us.

Diagnostic Criteria for PTSDDiagnostic Criteria for PTSD

Exposure to traumatic event(sExposure to traumatic event(s) in which:) in which: A) the event involves actual or potential A) the event involves actual or potential death, injury or threat to physical integrity death, injury or threat to physical integrity of self or othersof self or others

B) intense fear, helplessness or horrorB) intense fear, helplessness or horrorIntrusion symptomsIntrusion symptoms Intrusive dreams, Intrusive dreams, memories, flashbacks and distress at memories, flashbacks and distress at environmental cues of the eventenvironmental cues of the event

Withdrawal symptomsWithdrawal symptoms Avoidance of stimuli related Avoidance of stimuli related to event and numbing of general responsivenessto event and numbing of general responsiveness

Thoughts and feelings People, places & Thoughts and feelings People, places & thingsthings

Difficulty recalling aspects of trauma Difficulty recalling aspects of trauma Feeling detached Loss of interest in Feeling detached Loss of interest in

activitiesactivities Restricted affect Loss of hopeRestricted affect Loss of hope

PTSD Diagnostic criteria PTSD Diagnostic criteria (con’t)(con’t)

Hypervigilance symptomsHypervigilance symptoms: : Increased Increased emotional arousalemotional arousal

Problems falling asleepProblems falling asleep

Irritability / outbursts of angerIrritability / outbursts of anger

Difficulty concentratingDifficulty concentrating

HypervigilanceHypervigilance

Exaggerated startle responseExaggerated startle response

These symptoms last over time These symptoms last over time (though they may be transient)(though they may be transient)

Trauma, and PTSD in Trauma, and PTSD in particular, is a wound to particular, is a wound to

one’s sense of selfone’s sense of self1.1. Our self perception / self esteemOur self perception / self esteem2.2. Our trust in ourselves and in othersOur trust in ourselves and in others3.3. Our perception of self in relation to Our perception of self in relation to

othersothers4.4. Our perception of the needs and desires Our perception of the needs and desires

of self and othersof self and others5.5. Our beliefs about the nature of the world Our beliefs about the nature of the world

(faith)(faith)6.6. Our memories and how we rememberOur memories and how we remember7.7. The affects we allow ourselves to feel The affects we allow ourselves to feel

(and the affects we have to disavow)(and the affects we have to disavow)8.8. How we experience our futureHow we experience our future9.9. Our values and ethical stancesOur values and ethical stances10.10. Our spiritual beliefs and positionsOur spiritual beliefs and positions

Some issues about trauma in Some issues about trauma in chemical dependency recoverychemical dependency recovery

especially cumulative childhood trauma, grief reactions especially cumulative childhood trauma, grief reactions and PTSDand PTSD

Trauma symptoms can look similar to Trauma symptoms can look similar to addiction issues in early recoveryaddiction issues in early recovery

The expectation is that the trauma The expectation is that the trauma symptoms will go away with CD recoverysymptoms will go away with CD recovery

The trauma is obscured by being an The trauma is obscured by being an experience rather than a specific experience rather than a specific eventevent

Early addiction treatment efforts tend Early addiction treatment efforts tend to repress the traumato repress the trauma

Deal with the present, not the pastDeal with the present, not the past Suppress strong feelingsSuppress strong feelings Flooding of trauma may provoke relapseFlooding of trauma may provoke relapseTrauma often stays buried until later in Trauma often stays buried until later in recoveryrecovery

What can you What can you reallyreally expect expect to doto do In the first 90 daysIn the first 90 days

build safety, recognize trauma symptoms (in a non-shaming build safety, recognize trauma symptoms (in a non-shaming way), symptom containment & reduction, stabilize, educate, way), symptom containment & reduction, stabilize, educate, build trauma issues into relapse plan, build commitment to build trauma issues into relapse plan, build commitment to future work. Primary treatment resource is future work. Primary treatment resource is manualized manualized treatment programs treatment programs (for instance: “Seeking Safety”)(for instance: “Seeking Safety”)

Once stabilized in recoveryOnce stabilized in recovery make trauma work part of the ongoing recovery plan, make trauma work part of the ongoing recovery plan,

increase awareness of triggers and how they manifest,increase awareness of triggers and how they manifest, manage trauma symptoms when exposed to triggersmanage trauma symptoms when exposed to triggers begin to explore beliefs that arose from trauma,begin to explore beliefs that arose from trauma, begin to explore how disavowed affects relate to trauma,begin to explore how disavowed affects relate to trauma, watch for how the “trauma drama” manifests & gets played watch for how the “trauma drama” manifests & gets played

outout help client begin to tell the story and get the story help client begin to tell the story and get the story

straightstraight

Addictive illness, Addictive illness, psychological trauma psychological trauma

and suicideand suicide People with co-occurring addictive illness People with co-occurring addictive illness and psychological trauma are at high risk and psychological trauma are at high risk for suicidal thoughts and behaviorfor suicidal thoughts and behavior

And people who have a previous suicide And people who have a previous suicide attempt are at even greater riskattempt are at even greater risk

The other high risk factors are treatment The other high risk factors are treatment transitions, drug relapse, relationship transitions, drug relapse, relationship break-ups, sudden debilitating depression.break-ups, sudden debilitating depression.

Suicide risk doesn’t necessarily decrease Suicide risk doesn’t necessarily decrease with sobrietywith sobriety

Ask these questions of Ask these questions of every client with suicide every client with suicide

riskrisk1. Are you thinking about killing yourself1. Are you thinking about killing yourself

2. Have you ever tried to end your life 2. Have you ever tried to end your life beforebefore

3. Do you think you might try to kill 3. Do you think you might try to kill yourself today (or in the immediate yourself today (or in the immediate future)future)

4. Have you thought about ways you might 4. Have you thought about ways you might kill yourselfkill yourself

5. Do you have a way of killing yourself 5. Do you have a way of killing yourself available nowavailable now

The GATE protocolThe GATE protocolfor clients with for clients with

suicide risksuicide risk GGather informationather information

AAccess consultation / supervisionccess consultation / supervision

TTake responsible actionake responsible action

EExtend the action – follow-upxtend the action – follow-up

Trauma and CD recoveryTrauma and CD recovery

Emerging trauma may be a sign of getting Emerging trauma may be a sign of getting healthier. But it doesn’t healthier. But it doesn’t feelfeel that way that way

Trauma symptoms can look like “dry drunk”Trauma symptoms can look like “dry drunk” Hyperarousal, intrusion and constriction symptomsHyperarousal, intrusion and constriction symptoms

Ego defenses of trauma and addiction are Ego defenses of trauma and addiction are similarsimilar

Experiencing the trauma provokes the trauma Experiencing the trauma provokes the trauma in others in the treatment environmentin others in the treatment environment

When trauma brings people When trauma brings people into treatment ….into treatment ….

People often come into addictions People often come into addictions treatment as a result of some traumatic treatment as a result of some traumatic experience.experience.

Don’t let the trauma get overlooked in Don’t let the trauma get overlooked in the hustle to treat the addictionthe hustle to treat the addiction

Often, “resistance to treatment” is a Often, “resistance to treatment” is a function of the trauma response, not function of the trauma response, not resistance to recoveryresistance to recovery

Resistance to experiencing the trauma woundResistance to experiencing the trauma wound

And when the treatment is And when the treatment is traumatizingtraumatizing

Some people have the potential to be Some people have the potential to be traumatized by addictions treatment settingstraumatized by addictions treatment settingsshame based people who get humiliated / scapegoatedshame based people who get humiliated / scapegoated

when traumatic history is “exposed” and the person when traumatic history is “exposed” and the person is overwhelmed and “runs away”is overwhelmed and “runs away”

when the treatment process activates buried trauma when the treatment process activates buried trauma & the person acts out & is blamed& the person acts out & is blamed

confrontation, touching, beingconfrontation, touching, being confined, even showing interest and confined, even showing interest and concernconcern

inappropriate behavior on the part of other inappropriate behavior on the part of other clients or clients or

staffstaff

4 core elements in treating 4 core elements in treating trauma statestrauma states

Creating safetyCreating safety

Building hopeBuilding hope

Building resilience and strengths Building resilience and strengths to transcend the “dark times”to transcend the “dark times”

Consciously using the therapeutic Consciously using the therapeutic relationship as a healing factor relationship as a healing factor in treatmentin treatment

Creating SafetyCreating Safety I can’t make someone feel safe with I can’t make someone feel safe with themselves: Safety has to come from themselves: Safety has to come from withinwithin

Therapy itself is an inherently Therapy itself is an inherently unsafeunsafe environment for trauma environment for trauma survivorssurvivors

Trauma survivors will test to see if Trauma survivors will test to see if the therapy is safe.the therapy is safe.

I can provide an environment that I can provide an environment that doesn’t reinforce “unsafety”doesn’t reinforce “unsafety”

symptom containment as symptom containment as safetysafety

building safety is helping the building safety is helping the client be safe from their client be safe from their symptoms.symptoms.

IntrusionIntrusion – intrusive memories, – intrusive memories, reliving the event, re-enactments reliving the event, re-enactments

hyperarousalhyperarousal – startle reactions, – startle reactions, nightmares, hypervigilancenightmares, hypervigilance

constrictionconstriction – going numb – – going numb – forgetting – phobias and avoidingforgetting – phobias and avoiding

Hope and despair as a special Hope and despair as a special issue for traumatized recovering issue for traumatized recovering

peoplepeople

Hope (the belief that life can be Hope (the belief that life can be better) is essential to recoverybetter) is essential to recovery

Without hope we have despairWithout hope we have despair People with a history of despair People with a history of despair come into recovery and get a message come into recovery and get a message of hope. Hope of hope. Hope activatesactivates despair and despair and the individual becomes cynical, the individual becomes cynical, indifferent, distant, disparaging. indifferent, distant, disparaging. “You can’t trust happiness”“You can’t trust happiness”

chronic hopelessnesschronic hopelessness

therapeutictherapeutic

interventionintervention

negates hope to negates hope to

manage the anxietymanage the anxiety

creates hopecreates hope

creates anxietycreates anxiety

Some issues in addressing Some issues in addressing hope and despairhope and despair

1. you can’t argue someone into hope1. you can’t argue someone into hope 2. hope often best comes in small doses2. hope often best comes in small doses 3. encourage people to embrace hope 3. encourage people to embrace hope when they have itwhen they have it

4. and prepare for the times they don’t 4. and prepare for the times they don’t have it - have it - building islands in the swampbuilding islands in the swamp

5. redefine despair as ego-5. redefine despair as ego-dysdystonictonic 6. hope is both an affect and a self 6. hope is both an affect and a self experience – experience – have the affect, hold the experiencehave the affect, hold the experience

The “hope box”The “hope box” Building strengths for when people crash Building strengths for when people crash into shame, hopelessness, despair, into shame, hopelessness, despair, emptiness emptiness

Create a scrapbook, memories box or other Create a scrapbook, memories box or other depository to store ego enhancing memories.depository to store ego enhancing memories.

The memories are composed of photos, The memories are composed of photos, documents, newspaper clippings, writings documents, newspaper clippings, writings …..…..

Each memory contains a story that validates Each memory contains a story that validates and supports the personand supports the person

Add to the box as therapy progressesAdd to the box as therapy progresses Have clients take out the box occasionally Have clients take out the box occasionally and look at the “scenes” and remember the and look at the “scenes” and remember the feelingsfeelings

Be able to access the box when neededBe able to access the box when needed

Resilience in trauma Resilience in trauma treatmenttreatment

““you just don’t know who you are dealing you just don’t know who you are dealing with”with”

Resilience is more than “getting by”Resilience is more than “getting by”Resilience is the ability to “bounce Resilience is the ability to “bounce back” in the face of adversity:back” in the face of adversity:

Resilience isResilience is l life’s desire to move ife’s desire to move forward in forward in

the face of adversity the face of adversity

Resilience is the ability to tap an Resilience is the ability to tap an inner inner

strength to perseverestrength to persevere The question for therapists is “how do The question for therapists is “how do I help I help

an individual tap their resilience”an individual tap their resilience”

Using the therapeutic Using the therapeutic relationship to treat relationship to treat

trauma statestrauma states1. Modeling integrity, boundedness & safety1. Modeling integrity, boundedness & safety2. Monitoring transference2. Monitoring transference managing expectations of abandonment, managing expectations of abandonment, disregard & other negative experiencedisregard & other negative experience3. Monitoring counter-transference3. Monitoring counter-transference in the face of revulsion, ego defense and in the face of revulsion, ego defense and

client client provocationprovocation in the face of over-identification or rescue in the face of over-identification or rescue

fantasies, fantasies, get supervision and work it through get supervision and work it through 4. Supporting the work without 4. Supporting the work without doingdoing the the

workwork

the therapeutic relationship the therapeutic relationship (con’t)(con’t)

5. modeling interest / concern 5. modeling interest / concern w/o activating shamew/o activating shame

““why are you so interested in me?”why are you so interested in me?”

6. working with projections onto 6. working with projections onto therapist / interpreting the therapist / interpreting the projections w/o activating projections w/o activating defensedefense

The therapeutic relationship The therapeutic relationship becomes a model for building becomes a model for building integrity based relationships integrity based relationships

4 basic therapy processes for working 4 basic therapy processes for working through trauma: Ongoing trauma treatment through trauma: Ongoing trauma treatment

with recovering c.d. clientswith recovering c.d. clients1. Bringing the past to the present & building new 1. Bringing the past to the present & building new

options for managing life todayoptions for managing life today Cognitive Behavioral approachesCognitive Behavioral approaches CBT, Desensitization, Exposure Therapy, ACT, CBT, Desensitization, Exposure Therapy, ACT,

DBTDBT Psychodynamic psychotherapiesPsychodynamic psychotherapies Supportive psychotherapy, Psychodynamic Supportive psychotherapy, Psychodynamic Psychotherapy, Narrative Therapy, Psychotherapy, Narrative Therapy,

Emotionally Focused TherapyEmotionally Focused Therapy Motivational Interviewing (MI) is a bit of bothMotivational Interviewing (MI) is a bit of both

2. Hypnosis2. Hypnosis a) Traditional medical hypnotherapy (NOT a) Traditional medical hypnotherapy (NOT

recommended)recommended) b) Ericksonian hypnosisb) Ericksonian hypnosis

3. EMDR (Eye Movement Desensitization & 3. EMDR (Eye Movement Desensitization & Reprocessing) and similar therapiesReprocessing) and similar therapies

4. 4. Experiences in living today that reorganize the Experiences in living today that reorganize the trauma experience – corrective life experiencestrauma experience – corrective life experiences

Psychopharmacology treatment Psychopharmacology treatment with PTSD with PTSD

1. Anti-anxiety drugs1. Anti-anxiety drugs

Benzodiazepines and SSRI’sBenzodiazepines and SSRI’s

2. Mood stabilizers2. Mood stabilizers

Tegretol, Depakote, LithiumTegretol, Depakote, Lithium

3. Anti-depressants3. Anti-depressants

SSRI’s, TricycliatesSSRI’s, Tricycliates

4. Anti-psychotics4. Anti-psychotics

HaldolHaldol

5. Drugs that block the stress (flight or 5. Drugs that block the stress (flight or fight) responsesfight) responses

Klonopin (Catapres), InderalKlonopin (Catapres), Inderal

All of these drugs All of these drugs onlyonly control control symptoms. symptoms. There is NO “Anti-Trauma” There is NO “Anti-Trauma” pillpill

Drugs that control trauma symptoms Drugs that control trauma symptoms may be counterindicated for may be counterindicated for management of other disorders:management of other disorders:

AnxietyAnxiety

DepressionDepression

(and especially) (and especially) Addictive Illness Addictive Illness

Three variables in adopting a Three variables in adopting a specific approach to therapy specific approach to therapy

with trauma survivorswith trauma survivors

Approach is understandable & Approach is understandable &

acceptable to the clientacceptable to the client

Therapist feels confident, Approach is Therapist feels confident, Approach is congruentcongruent

capable & congruent with with the nature of capable & congruent with with the nature of thethe

the approach trauma & the approach trauma & condition ofcondition of

the clientthe client

Cognitive-Behavioral Treatments Cognitive-Behavioral Treatments for PTSDfor PTSD

1. Exposure therapies1. Exposure therapies Prolonged exposure (PE) (Foa)Prolonged exposure (PE) (Foa)

Systematic desensitizationSystematic desensitization CPT (Cognitive Processing Therapy) (Resick) CPT (Cognitive Processing Therapy) (Resick)

(expos. + cog. restructuring)(expos. + cog. restructuring)

2. Anxiety management2. Anxiety management SIT (Stress Inoculation Training) (Meichenbaum)SIT (Stress Inoculation Training) (Meichenbaum) Relaxation / meditation trainingRelaxation / meditation training Anxiety management training (Kilpatrick)Anxiety management training (Kilpatrick)

33. . Cognitive RestructuringCognitive Restructuring Challenging limiting / inaccurate beliefsChallenging limiting / inaccurate beliefs Constructive Narrative Perspective Constructive Narrative Perspective

(Meichenbaum)(Meichenbaum) Stopping / changing limiting cognitionsStopping / changing limiting cognitions Challenging perceptions of the trauma Challenging perceptions of the trauma

event(s), their event(s), their meanings and impactsmeanings and impacts

44. . Skill BuildingSkill Building Building new / more diverse coping skills and Building new / more diverse coping skills and

behaviorsbehaviors

Cognitive –behavioral Cognitive –behavioral treatments (con’t)treatments (con’t)

55. . Newer CBTs emphasize acceptance, non-Newer CBTs emphasize acceptance, non-judgmentalness, present-centered, mindfulnessjudgmentalness, present-centered, mindfulness

ACT (Acceptance & Commitment Therapy) ACT (Acceptance & Commitment Therapy) (Hayes)(Hayes)

DBT (Dialectical Behavior Therapy) (LinehaDBT (Dialectical Behavior Therapy) (Lineha

6. Schema therapy 6. Schema therapy (Young) (Young)

7. Other CBT approaches7. Other CBT approaches

Manualized treatmentsManualized treatments

Internet based treatmentInternet based treatment

A psychodynamic approach to A psychodynamic approach to treating PTSD / related treating PTSD / related

traumatrauma 1. Developing safety – stabilizing1. Developing safety – stabilizing being safe enough “inside” and with the environmentbeing safe enough “inside” and with the environment

2. Telling the tale, getting the story straight2. Telling the tale, getting the story straight experiencing / embracing the wounded selfexperiencing / embracing the wounded self

3. Corrective emotional experience3. Corrective emotional experience the repair work – methods include CBT, redecisioning, the repair work – methods include CBT, redecisioning,

finishing finishing unfinished business, forgiving, letting go, affect unfinished business, forgiving, letting go, affect

regulation, challenging schemasregulation, challenging schemas

4. Integrating a new (repaired) sense of self & 4. Integrating a new (repaired) sense of self & reconnecting with the worldreconnecting with the world

reconnecting, getting closure on history, coming to reconnecting, getting closure on history, coming to belong again, building belong again, building

healthy relationships and perception of self in relation healthy relationships and perception of self in relation to othersto others

4 stages in recovery from trauma4 stages in recovery from trauma

1.1. Developing safetyDeveloping safetyThe very nature of the trauma experience is The very nature of the trauma experience is

that it is unsafe.that it is unsafe.

The “true fear” is of exposing the damaged The “true fear” is of exposing the damaged self & the pain attached to the damageself & the pain attached to the damage

The fear is most often externalized to the The fear is most often externalized to the environment.environment.

In therapy, the fear may be disowned to the In therapy, the fear may be disowned to the therapist or the therapy … as unsafe.therapist or the therapy … as unsafe.

Therapy, in structure, may recreate the Therapy, in structure, may recreate the trauma scene, where the “victim” submits trauma scene, where the “victim” submits to an unequal relation-to an unequal relation-

ship with the therapist who has ship with the therapist who has inordinate power and statusinordinate power and status

4 stages of therapy (con’t)4 stages of therapy (con’t)2.2. Getting the story straightGetting the story straightWe speak of trauma as being “unspeakable”We speak of trauma as being “unspeakable”

Trauma may be expressed through physical Trauma may be expressed through physical experience and symbols as well as wordsexperience and symbols as well as words

““Symptoms” of trauma may become a way of Symptoms” of trauma may become a way of telling the taletelling the tale

““Victim psychology” will focus excessively Victim psychology” will focus excessively on blameon blame

Victims will take responsibility for the Victims will take responsibility for the trauma as a way of having controltrauma as a way of having control

““What happened” isn’t as important as What happened” isn’t as important as what what it meansit means

Trying to “remember everything” is futileTrying to “remember everything” is futile

Telling our tale (con’t)Telling our tale (con’t)

Our tales are told in metaphor. Our metaphor Our tales are told in metaphor. Our metaphor may or may not have much resemblance to the may or may not have much resemblance to the reality of others.reality of others.

The therapist is the witness to the unfolding The therapist is the witness to the unfolding of the tale. The therapist’s job is to of the tale. The therapist’s job is to provide a container for the tale as it provide a container for the tale as it evolves and to facilitate the person telling evolves and to facilitate the person telling the story in the most healing way possible.the story in the most healing way possible.

Getting the story straight is like Getting the story straight is like constructing a jigsaw puzzle. Seemingly constructing a jigsaw puzzle. Seemingly unconnected pieces get put together to form unconnected pieces get put together to form a coherent image and the missing parts a coherent image and the missing parts become more obvious.become more obvious.

The missing parts often contain the core of The missing parts often contain the core of the trauma experience.the trauma experience.

Telling our tale (con’t)Telling our tale (con’t)Words may not be a very good vehicle for Words may not be a very good vehicle for communicating the trauma experience. Visual communicating the trauma experience. Visual symbols, movies, music, drawings and physical symbols, movies, music, drawings and physical movement may more accurately and effectively movement may more accurately and effectively communicate the experience.communicate the experience.

A variety of unfolding techniques can be A variety of unfolding techniques can be applied to help reveal the tale including applied to help reveal the tale including hypnosis, psychodramatic technique, group hypnosis, psychodramatic technique, group support and psychomotor therapies.support and psychomotor therapies. But But unfolding techniques are a unfolding techniques are a means to the end means to the end, , not the end in itself!not the end in itself!

One story or event in the tale can be a One story or event in the tale can be a metaphor for a series of events. It isn’t metaphor for a series of events. It isn’t necessary or practical to tell the necessary or practical to tell the wholewhole tale, particularly with prolonged and tale, particularly with prolonged and pervasive trauma.pervasive trauma.

Step 3: Corrective Emotional Step 3: Corrective Emotional ExperienceExperience

Corrective emotional experience Corrective emotional experience is about:is about:

1. 1. Creating and living new Creating and living new options that refute the trauma options that refute the trauma experienceexperience

2. Being able to have and 2. Being able to have and “work through” the emotions that “work through” the emotions that were attached to the traumawere attached to the trauma

Corrective Emotional ExperienceCorrective Emotional ExperienceCreating and living new optionsCreating and living new options

Trauma traps us into a set of truths and Trauma traps us into a set of truths and beliefs that are self limiting and beliefs that are self limiting and often repeat the trauma experience.often repeat the trauma experience.

A goal of therapy is to challenge these A goal of therapy is to challenge these truths & beliefs and create new truths & beliefs and create new options for living a more rewarding options for living a more rewarding and versatile life.and versatile life.

Trying out new ways of living / coping Trying out new ways of living / coping create the “corrective emotional create the “corrective emotional experience”experience”

Corrective Emotional Corrective Emotional ExperienceExperience

Creating and living new Creating and living new optionsoptions

Therapy needs to strategically address Therapy needs to strategically address new coping options. Clients resist new coping options. Clients resist because the new options are incongruent because the new options are incongruent with the existing truths and beliefs.with the existing truths and beliefs.

The primary defense against challenging The primary defense against challenging beliefs and truths is to change them in beliefs and truths is to change them in the therapy office but not in “life”.the therapy office but not in “life”.

Corrective Emotional Experience: Corrective Emotional Experience: Reworking the emotions of traumaReworking the emotions of trauma

4 primary emotional responses to trauma are:4 primary emotional responses to trauma are: rage, terror, grief and shame.rage, terror, grief and shame.No one “does” each of these responses equally No one “does” each of these responses equally well.well.

Some trauma experiences lead themselves more to Some trauma experiences lead themselves more to expression through one of these emotions than expression through one of these emotions than through othersthrough others

When one avenue of expression is unavailable, we When one avenue of expression is unavailable, we will use other avenues to express that emotionwill use other avenues to express that emotion

Blocking rage limits experiences of empowermentBlocking rage limits experiences of empowermentBlocking terror limits experiences of feeling Blocking terror limits experiences of feeling safesafe

Blocking grief limits experiences of love and Blocking grief limits experiences of love and belongingbelonging

Blocking shame limits experiences of self love Blocking shame limits experiences of self love and self acceptanceand self acceptance

Corrective emotional experience Corrective emotional experience (con’t)(con’t) The fear of experiencing rage is uncontrolled The fear of experiencing rage is uncontrolled

violence toward self and othersviolence toward self and othersThe fear of experiencing terror is The fear of experiencing terror is uncontrolled panicuncontrolled panic

The fear of experiencing grief is depression The fear of experiencing grief is depression and emptinessand emptiness

The fear of experiencing shame is deep The fear of experiencing shame is deep humiliation and worthlessnesshumiliation and worthlessness

Terror, grief, rage and shame will emerge in a Terror, grief, rage and shame will emerge in a sequence that is unique to the individual. sequence that is unique to the individual. As one emotional response is worked through, As one emotional response is worked through, another will appear. The most difficult another will appear. The most difficult emotional experience for the individual will emotional experience for the individual will be the last to appear.be the last to appear.

Corrective emotional experience Corrective emotional experience (con’t)(con’t)

THE EMOTIONAL BLOCK WITH THE THE EMOTIONAL BLOCK WITH THE TRAUMA EXPERIENCE IS NOT WITH TRAUMA EXPERIENCE IS NOT WITH THE AFFECT THAT IS EXPRESSED, THE AFFECT THAT IS EXPRESSED, BUT WITH THE AFFECT THAT IS BUT WITH THE AFFECT THAT IS UNEXPRESSED.UNEXPRESSED.

Corrective emotional Corrective emotional experience (con’t)experience (con’t)Other emotional themes of trauma survivors Other emotional themes of trauma survivors

include:include:Guilt Rejection/Abandonment Guilt Rejection/Abandonment LonelinessLoneliness

Hurt Overwhelmed Hurt Overwhelmed Empty Empty

The catharsis of these emotions is not the end The catharsis of these emotions is not the end in itselfin itself

But the expression of these emotions of the But the expression of these emotions of the trauma give emotional life to the experience. trauma give emotional life to the experience. The trauma experience cannot be resolved w/o The trauma experience cannot be resolved w/o the expressionthe expression

of the emotional experienceof the emotional experience

These emotional themes are worked out in These emotional themes are worked out in the therapy experience transferentially the therapy experience transferentially as well.as well.

A primary defense of the emotional themes A primary defense of the emotional themes is to project the disowned feeling.is to project the disowned feeling.

The types of therapies that work best in The types of therapies that work best in providing corrective emotional providing corrective emotional experience are the therapies that experience are the therapies that acknowledge and support the awareness acknowledge and support the awareness and expression of affect: and expression of affect:

Emotionally Focused Therapy (S. Emotionally Focused Therapy (S. Johnson)Johnson)

Contemporary Gestalt TherapyContemporary Gestalt Therapy Grief workGrief work Affect regulation therapiesAffect regulation therapies

Stage 4: Integrating a new sense Stage 4: Integrating a new sense of selfof selfAs the corrective emotional experience As the corrective emotional experience

unfolds, the damaged sense of self that unfolds, the damaged sense of self that underlies the pain is exposedunderlies the pain is exposed

Some agendas for selfhood work include Some agendas for selfhood work include redefining the trauma experience in terms redefining the trauma experience in terms of: of:

Self trust Self trust Self in relation to othersSelf in relation to others Self perception and self esteemSelf perception and self esteem Beliefs about self and relation of self to Beliefs about self and relation of self to the worldthe world

Self in relation to the futureSelf in relation to the future Value and ethical positions Value and ethical positions Spiritual beliefsSpiritual beliefs

The process of healing the The process of healing the selfself1. Creating a safe place: 1. Creating a safe place:

emotionally, physically, emotionally, physically, interpersonallyinterpersonally

2. Struggling to find a way to tell the tale2. Struggling to find a way to tell the tale3. Experiencing the pain (and joy)3. Experiencing the pain (and joy)4. Experiencing the damaged self 4. Experiencing the damaged self andand5. Embracing (& allowing others to embrace) 5. Embracing (& allowing others to embrace)

the damaged selfthe damaged self6. Building a stronger sense of self:6. Building a stronger sense of self: Self esteem, potency, interpersonally, Self esteem, potency, interpersonally,

physically, spirituallyphysically, spiritually

7. Connecting with the world in a more 7. Connecting with the world in a more potent waypotent way

Healing is sufficient when:Healing is sufficient when:

1. We can address problems as they arise1. We can address problems as they arise2. We can have at least one person in our life 2. We can have at least one person in our life

with whom we can intimately reveal ourselveswith whom we can intimately reveal ourselves3. We can have firm and flexible boundaries3. We can have firm and flexible boundaries “ “I” boundaries, value boundaries, body I” boundaries, value boundaries, body boundaries, expressive and exposure boundaries, expressive and exposure boundaries, comfort boundariesboundaries, comfort boundaries4. We have (and take) opportunities to 4. We have (and take) opportunities to

rejuvenate:rejuvenate: Physically, emotionally, Physically, emotionally,

intellectually, intellectually, interpersonally, spirituallyinterpersonally, spiritually

ResolutionResolutionThe experience of trauma is never fully The experience of trauma is never fully resolved and recovery is never complete.resolved and recovery is never complete.

The natural unfolding of events The natural unfolding of events reactivates the trauma experience which, reactivates the trauma experience which, again, needs to be recognized, again, needs to be recognized, confronted and expressed.confronted and expressed.

Healing is sufficient when the trauma does Healing is sufficient when the trauma does not dominate experience, but, rather, not dominate experience, but, rather, sits alongside the mundane and the sits alongside the mundane and the ordinary, when the person can live in ordinary, when the person can live in relative harmony with their environmentrelative harmony with their environment

For more informationFor more information

Bruce Carruth, Ph.D., LCSWBruce Carruth, Ph.D., LCSW

(713) 589-3250(713) 589-3250

brucecarruth@earthlink.netbrucecarruth@earthlink.net

Overheads from this (and other) Overheads from this (and other) presentations are available at:presentations are available at:

www.brucecarruth.comwww.brucecarruth.com