Advances in the Understanding and Treatment of Trauma: Variable Adaptations, Variable Treatments

1. Advances in the Understanding and Treatment of Trauma: Variable Adaptations, Variable Treatments Christine A. Courtois, Ph.D. Psychologist, Private Practice Washington, DC CACourtoisPhD@AOL.COM www.drchriscourtois.com

6. Types of Trauma • Accidental • Interpersonal • Combination

7. Interpersonal Trauma: “A break in the human lifeline” RobertJ. Lifton Self and interpersonal effects brought to treatment

8. Types of Traumatic Stressors Emotional Trauma “It is the essence of emotional trauma that it shatters…absolutisms, a catastrophic loss of innocence that permanently alters one’s sense of being-in-the-world.”(Heidegger, quoted in Stolorow, 2007)

9. Types of Trauma • Type I • Type II • Overlap

10. Types of Trauma • Attachment/Relational • Emotional • Betrayal • Secondary/ “second injury”/institutional

11. What is Complex Trauma? • Repetitive, chronic • Cumulative • Often in attachment relationships • Entrapment & betrayal; second injury • Often over the course of childhood • Impacts development • Other…

12. Trauma and Development • Attachment trauma • Attachment style and Inner Working Model • Secure • Insecure • Disorganized • Lack of self validation/reflection • Effect on brain development • Survival brain vs. learning brain

13. Trauma and Development • Can effect development starting at the neuronal level • Neurons that fire together wire together • Can affect brain structure • Can affect brain function • Right brain/sensory-motor imprint • Left brain development impeded • There may be no words • Speechless terror

14. Types of Traumatic Stressors • Attachment/Relational Trauma • occurs in attachment relationships with primary caregivers • insecurity of response and availability • mis-attunement, non-response • lack of caring and reflection of self-worth • caregiver as the source of both fear and comfort • includes DV and child abuse of all types • often “on top of”/in context of attachment insecurity • neglect, abandonment, non-protection, non-response, sexual and physical abuse and violence, verbal assault

16. Risk/Vulnerability and Protective Factors • Temperament • Gender • Personal history • Previous trauma/PTSD • Culture • Community • Support or not

20. Posttrauma Adaptations(adapted from Wilson, 1989) Note:most individuals who are seriously traumatized have posttraumatic reactions; not all develop posttraumatic disorders.

21. DSM-IV Criteria: PTSD • A. Exposure or experience • B. Persistent reexperiencing, intrusions, dreams of trauma, distress at re-exposure • C. Persistent avoidance of stimuli associated with the trauma and numbing • D. Persistent symptoms of increased arousal

22. Posttraumatic Diagnoses, DSM-IV • Dissociative Disorders • Depersonalization • Dissociative fugue • Dissociative amnesia • Dissociative Identity Disorder • related to severe childhood trauma • DDNOS • Associated Disorders: Axis I, II, & III

23. Limbic System of the Brain Limbic System of the Brain

24. Posttraumatic Stress Disorder (PTSD) • A complex dynamic entity • fluctuating, not static • variable in form, presentation, course, degree of disruption • A multimensionalbio-psycho-social- spiritual-gender stress response syndrome • An allostatic condition

25. Posttraumatic Stress Disorder (PTSD) Allostasis: “refers to the body’s effort to maintain stability through change when loads or stressors of various types place demands on the normal levels of adaptive biological functioning…The failure to “switch off” allostatic mechanisms once the threat or requirement to respond has terminated, however, begins a complex process of “wear and tear” on the nervous and hormonal systems”. ( Wilson, Friedman, & Lindy, 2002, p. 9)

26. Allostasis: One’s thermostat is brokenStress overload

27. Post-trauma Responses and Disorders • Complex Posttraumatic Stress Disorder/ (DESNOS) “PTSD plus” • related to severe chronic abuse, usually in childhood, and attachment disturbance • usually highly co-morbid • often involves a high degree of dissociation • Dissociative Disorders • associated with disorganized attachment and/or abuse in childhood • can develop in the aftermath of trauma that occurs any time in the lifespan • DDNOS may be the most common DD (as currently defined in the DSM)

28. Complex Posttraumatic Stress DisorderDisorders of Extreme Stress Not Otherwise Specified (DESNOS) • Designed to account for developmental issues, co-morbidity, memory variability and reduce stigma • Co-morbidity: • distinct from or co-morbid with PTSD • other Axis I, mainly: • depressive and anxiety disorders • substance abuse/other addictions • impulse control/compulsive disorders • Axes II and III

29. PTSD in Children • No available childhood PTSD or DD diagnosis in the DSM • Children respond as children, not as little adults • work of Terr, Putnam, Pynoos, Perry has been instrumental to early understanding of childhood trauma • Children are very vulnerable, yet resilient • on average, takes less to traumatize them

32. (Proposed) Developmental Trauma Disorder (van der Kolk, 2005) • Domains of impairment in children exposed to complex trauma: • Attachment/relationship capacity • Biology • Affect regulation • Dissociation • Behavioral control • Cognition • Self-concept

33. Symptom Categories and Diagnostic Criteria for Complex PTSD/DESNOS • l. Alterations in regulation of affect and impulses • a. Affect regulation • b. Modulation of anger • c. Self-destructiveness • d. Suicidal preoccupation • e. Difficulty modulating sexual involvement • f. Excessive risk taking • 2. Alterations in attention or consciousness • a. Amnesia • b. Transient dissociative episodes and depersonalization

34. Symptom Categories and Diagnostic Criteria for Complex PTSD/DESNOS • 3. Alterations in self-perception • a. Ineffectiveness • b. Permanent damage • c. Guilt and responsibility • d. Shame • e. Nobody can understand • f. Minimizing • 4. Alterations in perception of the perpetrator • a. Adopting distorted beliefs • b. Idealization of the perpetrator • c. Preoccupation with hurting the perpetrator

35. Symptom Categories and Diagnostic Criteria for Complex PTSD/DESNOS • 5. Alterations in relations with others • a. Inability to trust • b. Revictimization • c. Victimizing others • 6. Somatization • a. Digestive system • b. Chronic pain • c. Cardiopulmonary symptoms • d. Conversion symptoms • e. Sexual symptoms • 7. Alterations in systems of meaning • a. Despair and hopelessness • b. Loss of previously sustaining beliefs

37. Complex PTSD/DESNOS • Controversial • Not a formal DSM diagnosis: Associated Feature of PTSD • Nevertheless, a useful way of organizing symptoms and treatment • A less pejorative way of understanding and approaching the treatment of those who often look and behave like BPD • Empirical investigation underway

38. Child style secure insecure-avoidant insecure-dismissing/ resistant/ambivalent insecure-disorganized/ disoriented/dissociated Adult style autonomous dismissive/detached (“teflon”) preoccupied/anxious (“velcro”) fearful/anxious unresolved/dissociative Attachment Organization(Ainsworth, 1978; Liotti, 1992; Main, 1986, Siegel, 1999)

39. Attachment Relationships • “…are crucial to the process of integration. The difficulties that bring patients to treatment usually involve unintegrated and undeveloped capacities to feel, think, and relate to others (and to themselves) in ways that ‘work’” • Paraphrasing Bowlby, “The therapy relationship involves sanctioning patients to think thoughts, experience feelings and consider actions that parents have forbidden.”(Wallin, 2007)

40. Implications for Treatment • Attachment abuse including ongoing neglect and failure to respond and soothe a child (neglect) is implicated in the development of the DD’s • a wider base beyond overt physical and sexual abuse from which to understand DD’s • The emphasis in treatment is shifted back toward education and the intrapsychic and interpersonal patterns started early in life and away from solely working through the other forms of childhood and adult trauma

41. Evidence-Based Practice • Best research evidence • Clinical expertise • Patient values, identity, context American Psychological Association Council of Representatives Statement, August 2005

42. Note: EBT (Evidence-Based Therapy) is NOT the same as EST (Empirically-Supported Therapy)

43. Evidence-Based Practice • Best research evidence, including: • Effectiveness • Public health • Health services • Health care economics

44. Evidence-Based Practice • Clinical expertise, including: • Clinical assessments, judgments, decision-making • Reflection & consultation • Interpersonal expertise/use of self • ability to collaborate, not exploit • ability to stay “steady state”, attune to client • Understanding of client’s contexts, values • Using available resources • Working from theory

45. Evidence-Based Practice • Patient identity, values, contexts • Ethnicity, race, culture, language, gender, sexual orientation, religion, age, illness or disability status • Treatment acceptability

46. Expert Consensus Guidelines for “Classic PTSD” • ISTSS Guidelines (Foa, Friedman, & Keane, 2000, 2008) • Journal of Clinical Psychiatry (2000) • American Psychiatric Association (2003) • Clinical Efficiency Support Team(CREST, Northern Ireland, 2003) • Veterans’ Administration/DoD(US, 2004) • National Institute of Clinical Excellence(NICE, UK, 2005) • Australian Centre for Posttraumatic Mental Health (2007)

47. Other Expert Consensus Guidelines • Dissociative Disorders • Adult (ISSD, 1994, 1997, 2005, in revision • Children (ISSD, 2001) • Delayed memory issues • Courtois (1999; Mollon, 2004) • Complex trauma (under development) • (Courtois, 1999; CREST, 2003; Courtois & Ford, 2009; ISTSS complex trauma expert consensus survey, in process)

48. Effective Treatments for PTSD* • Psychopharmacology • Psychotherapy (CBT, especially) • Psych-education Other supportive interventions *Few studies have evaluated using a combination of these approaches although combination treatment commonly used and may have advantages

49. Treatment Goals • educate about and de-stigmatize PTSD sx • increase capacity to manage emotions • reduce co-morbid problems • reduce levels of hyperarousal • re-establish normal stress response • decrease numbing/avoidance strategies • face rather than avoid trauma, process emotions, integrate traumatic memories

50. Treatment Goals • restore self-esteem, personal integrity • normal psychosexual development • reintegration of the personality • restore psychosocial relations • trust of others • foster attachment to and connection with others • restore physical self • restore spiritual self • prevent re-victimization/reenactments SAFETY IS THE FOUNDATION