How Victims Learn to Cope: Clinical Strategies for Traumatic Pleasure and Traumatic Repetition Presented by: Rokelle Ler

1. How Victims Learn to Cope:Clinical Strategies for Traumatic Pleasure and Traumatic Repetition Presented by:Rokelle Lerner roklern@aol.comInnerpathretreats.com The 14th Annual Counseling Skills Conference, October 4 2008Las Vegas, NV

2. Disorders Related to Trauma • PTSD • Brief reaction psychosis • Dissociative identity disorder • Dissociative amnesia • Borderline personality disorder • Depersonalization disorder • Somatization disorder • Dream anxiety disorder • Antisocial, Borderline and Narcissistic Personality Disorder

3. Trauma • Event outside the range of human experience that can not be processed in healthy ways • Un-metabolized trauma is the precursor to addiction, eating disorders, suicide, violence

4. Small “I” Traumas • Trauma of not being seen • Trauma of being in distress with nobody around to comfort • Trauma of being alone with no one available for connection • Trauma of having needs with no possibility of having those needs met Shapiro, 1998

5. Trauma that is Most Severe • Sanctuary Trauma: Occurring in places that should have been safe: • Process Trauma: Hurt over time rather than one single event

6. Trauma Threatens Basic Needs Survival: So we get rid of sights, sounds by dissociation, repression or addiction. Sense of Order: We want to complete or resolve the experience

7. ABUSE PROCESS • Event outside the range of human experience that can’t be processed in healthy ways. • Projection: • Introjection: • Reaction: • Acting Out:

8. TraumaticAbstinence: deprivation that is driven by terror and fear TraumaticShame: self-hatred rooted in a traumatic experience TraumaticRepetition: repeating behaviors by seeking situations or persons who can re-create the traumatic experience Traumatic Pleasure: High risk behaviors to mask pain and emptiness TraumaBonds: Attachments that occur in the presence of danger, shame or exploitation How Trauma Victims Cope

9. Deprivation around memories of success, stress, shame or anxiety Deny basic needs Avoid sexual pleasure Hoard money No interest in eating for periods of time Sabotage success opportunities Assess for Axis I disorders: anorexia, sexual aversion disorder, agoraphobia and other phobic responses Incremental use strategies Connect relapse with trauma issues Learning to play as well as relaxation techniques CBT: confronting disabling beliefs non-deserving Clinical Strategies Symptoms ofTraumatic Abstinence

10. Engaging in self mutilating behaviors Enduring physical or emotional pain most people would not accept Avoiding mistakes at any cost Suicidal ideation, threats or attempts Numbing of emotions and inability to experience love, joy or sadness Visualization and affirmation Intense family of origin work CBT to restructure faulty or shaming belief Shame reduction strategies: Familiarity with the shame cycle Symptoms of Traumatic Shame: ClinicalStrategies:

11. Living in the unremembered past; trying to resolve the un-resolvable: Inability to stop a childhood pattern Compulsively victimizing others in a similar way that patient was victimized Provoking others: allows the patient to re-live the victim experience Assessment for OCD Cognitive restructuring of key experiences and beliefs about those experiences Abreaction: re-creation of experience (through visualization or psychodrama) to reduce the power of original experience, bring resolution and make it conscious Self-soothing techniques ClinicalStrategies Symptoms ofTraumatic Repetition

12. Finding compulsive pleasure in the presence of danger or violence Only feeling ‘alive’ when dealing with crisis or huge risk. Difficulty sleeping, being with their families or maintaining friendships High risk sex, compulsive gambling, white collar theft, affairs Stimulation and pleasure are compensating for pain and emptiness. Focus on self soothing, empathic connection and triggers for relapse Do a history of how excitement and shame are linked to traumatic past. Debrief the costs and dangers over time. First Step and relapse prevention plan regarding how powerful this is in their life. Clinical Strategies Symptoms ofTraumatic Pleasure

13. Presenting Symptoms:Trauma Bonding • Continuing to seek contact with those whom she knows will cause her further pain • Trusting people who are proven to be unreliable • Loyal to people who have betrayed you • Uncontrollable obsession or fantasizing about those who have hurt you • Remaining a ‘team’ member even when the situation becomes destructive • Lack of bridging between frontal lobes and amygdale • Can’t self soothe, little affect regulation • The most addictive form of attachment

14. Clinical Strategies forTraumatic Bonds • No contact contracts • Teach strategies for detachment • Self-help groups that provide support and perspective • Disrupt beliefs about ‘uniqueness’ • Explore both the ‘pay offs’ and price paid of traumatic bonds • Grief work and rituals around letting go/change

15. PTSD: Three Symptom Clusters • Re-experiencing • Numbing and avoidance • Hyper-arousal Disorders related to PTSD Depression, Anxiety, Panic disorder, Phobias, Substance abuse, Physical somatization

16. Working Through Trauma Bessell Vanderkoch Ph.D • Traumatic memory is stored in the limbic system and in body memory • Since this memory was stored in high arousal, for treatment to work, there must be high arousal for the client: reenactment • Once the right side of the brain has been triggered, focus of treatment is to engage the left side of the brain • Help clients give words to their sensations and change the outcome

17. Developmental TraumaCluster B Disorders: • Borderline Personality Disorder:Pre birth - 14 months • Antisocial Personality Disorder:3 months - 14 months • Narcissistic Personality Disorder:15 months - 22 months Schore, 2002

18. Traumatic Attachments • Traumatic memory is stored in the limbic system and in body memory • Since this memory was stored in high arousal, for treatment to work, there must be high arousal for client: re-enactment • Once the right side of the brain has been triggered, focus of treatment is to engage left side of brain • Help patients to give words to their sensations and change the outcome Bessell van der Kolk Ph.D

19. Trauma effects the ability of the brain to analyze and integrate information Our challenge is to re-program the emotional brain so that it adapts to the present rather than continuing to respond as if the past is the present! Trauma Siegel/Debillis 2003

20. If A Patient Has Unmetabolized Trauma... • Their Limbic system is active! • They’re going to be talking and acting without thinking • We need to avoid language that stimulates the limbic brain: • “You should”, “How could you”, “Don’t...”, “Didn’t I tell you”, “I need you to...”

21. Romancing the Brain • “It could be…” • “Another possibility…” • “Let’s consider…” • “Will you agree to this…” • ”Another way to look at this is…” • ”I invite you to…”

22. Memory but no feeling Feeling but no memory Memory flooding Fugue states Tunnel vision Bodily sensations with no apparent cause Memory Returns: “Blips” Intense bodily sensation Hazy images Repetitive dreams Emotional abreaction Types of Dissociation

23. Shame: 4 Reactions • “Unpacking” Shame Based Trauma: • Realization: Insight • Linking: Awareness • Debriefing: Tell the story Withdraw Avoid

24. When is a Patient Ready for Trauma Processing? • Patient is able to use some safe coping skills • Has no major current crisis or instability • WANTS to do this type of work • Can reach out for help when in danger • Not using substances to such a sever degree that emotionally upsetting work may increase use • Suicide has been evaluated and taken into account • In an ongoing system of care that is stable and consistent, with no immediate planned changes

25. Trauma: Group Tasks Judith Herman Ph.D 1 2 3 Stage of Recovery Remembrance Past Trauma Trauma Homogenous Goal Directed Survivor Group Reconnection Present, future Interpersonal Rel Heterogeneous Unstructured Psychotherapy Safety Present Self-care Homogenous Didactic 12 Step Therapeutic Task Time Orientation Focus Membership Structure Example

26. More General Considerations • Develop flexibility • Listen and Go slowly • Allow her to define what was traumatic • Work with her perception • Always amplify the client’s resiliencies • Take into account the fragile sense of self and the client’s invisible loyalties • Being “stuck” and being “unwilling” are not the same

27. Techniques for Processing Trauma • EMDR: Eye Movement Desensitization Rehabilitation • Psychodrama, journaling, body work • Hypnosis • NLP: Neuro-Linguistic Programming • CBT: Cognitive Behavioral Tx

28. Suggestions • Reframe • Use techniques that connect the mind and body • Triggers for vulnerability • Help to grow her/h voice • Self soothing • Help patient to tell a coherent story

29. Reframe: • Victim • Survivor • Empowerment: “I am responsible for the solution, the resolution and my protection so it never happens again”

30. Connect Body and Mind • Teach patients that the body doesn’t ‘lie’ • Connect emotional responses to physical sensations: movement, body work, play • Use the creative arts: singing, dancing, story telling, writing • The goal is to promote congruence

31. Mystery of the Locked Rooms Exits Relapse Rage Dissociate Self Harm Bingeing Triggers Stress Tone Criticism Odor Expression Fear Shame Anger Pain Despair Anxiety Abandonment Deprivation

32. Signs of Emotional Wellness • Ability to sense a feeling • Locate the feeling in the body • Name the feeling • Express feeling appropriately • Ability to contain feeling • Ability to slow down and stop • Ability to discern if intensity of the feeling matches the situation • Ability to ask: “How old do I feel as I have this feeling?”

33. Format for Disclosing Vulnerability • When you… • Like the time… • I feel/felt… • My request is… • Listen while self soothing Format for Setting Boundaries • External “If you raise your fist in anger, I will call the police” • Internal: “When I feel angry, I will excuse myself and leave the room instead of raging at you”

34. Self Soothing Stephanie Covington PhD Alone With Others • Excuse myself • Breathe • Sip ice water • Read • Take a walk • Call sponsor Daytime • 5 Sights • 4 Sounds • 3 Touch • 2 Smell • 1 Taste Nighttime

35. Tell The Story “When an individual can tell a coherent story, about their past they are well on the way to integration” Mary Main, PhD Life Script Story Telling

36. Writing the Story • Once Upon a Time: Wounding • And when she/he grew up: Present • And the story changed when: Vision

37. Signs of Integration/Healing: • Less arguing, denying or objecting • Not as many questions • Asks what he/s could to do and how people change • She’s envisioning how life might be better

38. An Ending Followed by Confusion/Pain Leading to new beginnings Name the dream Gain perspective Educate friends Tell your story Create Safety Borrow Hopefulness Keep Dreaming Healing Loss of Dreams Transition:

39. Bibliography • Trauma and Recovery, Judith Herman Ph.D, Publisher: Basic Books • Healing Trauma: Attachment, Mind, Body, and Brain, Marion Fried Solomon, Daniel J. Siegel, Marion SolomonW.W. Norton & Company • Trauma and Addiction : Ending the Cycle of Pain Through Emotional Literacy by Tian Dayton Health Communications • Addictions and Trauma Recovery: Healing the Body, Mind, and Spirit by Dusty Miller, Laurie Guidry • Trauma Recovery and Empowerment : A Clinician’s Guide for Working With Women in Groups by Maxine Harris • Living in the Comfort Zone: The Gift of Boundaries in Relationship, Rokelle Lerner, Health Communications