Daniel J. Tomasulo, Ph.D., TEP, MFA tomasulo@att TheHealingCrowd.Com

1. Treating Trauma: Changes in Diagnosis and Treatment: The DM-ID and Interactive-Behavioral Therapy Daniel J. Tomasulo, Ph.D., TEP, MFA tomasulo@att.net TheHealingCrowd.Com

2. INCIDENCE OF SEXUAL ABUSE IN GENERAL POPULATION: • 33% of Females • 25% of Males In Developmentally Disabled Population: • 83 % of Females • 32% of Males

3. Reiss et. al. (1982) Proposed the concept of Diagnostic Over Shadowing, suggesting that the condition of intellectual disability decreases the diagnostic significance of a co-existing psychiatric disorder.

4. Given this proposal, symptoms of PTSD may be overlooked and be thought of as a manifestation of the condition of an intellectual disability.

5. CognitiveTrouble concentratingDifficulty making decisionsBlaming othersMemories of other eventsDifficulty talking about the eventNeed to talkConfusionPoor memory- including difficulty in remembering aspects of the trauma. SYMPTOMS THAT MAY BE PRESENT IN PEOPLE WHO HAVE PTSD

6. BehavioralExpending tremendous energy and attentionAgitationTrouble sleepingHeadachesSpontaneously CryingRecurring NightmaresPhysical ExhaustionStomach problemsNot being able to face certain aspects of the trauma, and avoiding activities, places, or even people that remind you of the event.

7. Our Research for DM-ID Suggests that: Symptoms for PTSD for Intellectually Disabled Adults are more likely to manifest in ways similar to how children display these symptoms

8. People with Dual Diagnosis may not display these symptoms, or may display other symptoms not seen in the general population. Following exposure to a traumatic event three categories of symptom’s are displayed.

9. PERPETRATORS ARE MOST OFTEN NOT STRANGERS. PERPETRATORS: • FAMILY MEMBERS 30% • FRIENDS AND ACQUAINTANCES 30% • SERVICE PROVIDERS 29%

10. Role Reaction and the Trauma of Betrayal • Victim • Offender • (Slot Rattling) • Role Development • Self Protector

11. Teaching Vs. Facilitation Social Skill Training Model IBT Model

12. IBT Interactive –Behavioral TherapyAction Process In Group Work: 4 Stage Modification • Orientation • Warm-up and Sharing • Enactment • Affirmation

14. 1. Re-experiencing the event via intrusive memories, nightmares, psychological distress and/or physiological activity. In people with DD this may manifest in a way similar to how children respond, such as Traumatic-Specific Reenactment2. Persistent efforts to avoid anything associated with the trauma such as external things , people and places. For people with DD the avoidance of concrete external stimuli as well as thoughts and sometimes the complete inability to recall key aspects of the event.3. Hyperarousal, sleep difficulties, irritability, anger and difficulty concentrating. Many of these symptoms may be masked with people with Dual Diagnosis.

15. Charlot’s (1998) research provides descriptions of symptoms which may vary from those more commonly seen in the non-disabled population ---for example, people with intellectual disabilities suffering from depression frequently talk to themselves out loud, rather than ruminate silently. This recent literature suggests that there may be variation in the typical symptom picture of a given disorder, but that the experience of the nature of the disorder, e.g., depression, anxiety, even psychoses, is inherently the same.

16. Mueser (1998) examined the frequency of trauma and PTST among 275 patients with severe mental illness. 98% had been exposed to traumatic events 43% met the diagnostic criterial for PTSD However only 2% had the diagnosis in their chart

17. Ruth Ryan (1994), who has forged new ground in our understanding of posttraumatic stress disorder in people with developmental disabilities, has recommended a six-point treatment protocol for survivors with PTSD (from sexual or other trauma), including medication, psychotherapy, support staff training, and environmental supports.

18. Based on statistics and experience the psychotherapy treatment paradigm is to start with the assumption that every person with intellectual disability has a life complicated by symptoms of PTSD

19. What You See in Others You Strengthen in Yourself The Course in Miracles in Miracles

20. Compassion &Kindness

21. Long Term Effects of Trauma • Generalized hyperarousal and difficulty in modulating arousal • Alterations in neurobiological processes from this hyperarousal may result in high levels of cortisol which can inhibit serotonin, norepinephrine and dopamine which can cause difficulties in stimulus discrimination such as: • Problems with attention and concentration • Dissociation • Somatization

22. Orientation Stage, continued. • Assessment of Role Analysis • Physical • Social • Psychodramatic • Trust and Safety Issues • Begin to Identify Therapeutic Factors • Validate Participation

23. Warm-up and Sharing Stage. • Move to Vertical Self-Disclosure • Building Cohesion • Selecting a Protagonist • Self Selection • Facilitator Selection • Group Selection

24. Warm-up continues • Building Support for the Protagonist • Concretize Issues • Invite Participation • Transitional Stage to Action • Continue Affirming Therapeutic Factors • Cognitive Networking Continues • (This can be painstakingly slow.)

25. Enactment • Assess Support for the Protagonist • Build Support • Select the Double • Facilitator demonstrates • Facilitator Chooses • Protagonist Chooses • Volunteer • Self (Role Prescription) • Assess Participation

26. THE DOUBLE HAS THREE PURPOSES: 1. Providing emotional support 2. Giving emotional expression 3. Reorganize perceptions.

27. Enactment (Additional features) • 247 Ways to Use an Empty Chair • Role Reversal • Use of Auxiliaries • Affirming the Protagonist • Encounters (conflict resolution) • Representational Dramas

28. Affirmation Stage • Validate Each Member’s Participation • Therapeutic Factors Affirmed • Teach Members to Affirm Each Other

29. THERAPEUTIC CONSIDERATIONS • ESTABLISHING THE FRAME • THE THERAPEUTIC ALLIANCE • SUPPORT BEFORE DISCLOSURE • SUPPORT BEFORE CONFRONTATION • SAFETY FIRST • THERAPIST AS MODEL PARTICIPANT • THE RULES: SAFETY AND CONFIDENTIALITY • ATTENDING TO THE PROCESS • A GOOD LEADER FOLLOWS • THEY DID IT, NOT YOU

30. Facilitation as Process • Correction of the family • speaking up • being listened to • safe place to experiment • Empowerment • Decisions during the process • Control of circumstances • Reframe resistance

31. IBT RESEARCH • More than a dozen studies have validated process & outcome using the IBT. Here are three studies focused on: • Interaction • Therapeutic Factors • Global Assessment of Functioning

33. Reliability Ratings on Therapeutic Factors(Part of a Study by Ellen Keller, PsyD.) 1. Acceptance/cohesion .86 2. Universality .90 3. Altruism .76 4. Installation of hope .86 5. Guidance 1.00 • Vicarious Learning/Modeling .45 • Catharsis .96 8. Imparting of information .91

34. Linda Daniels, PSY.D. (J. of Psychotherapy Practice & Research 1998; 7:167-176) IBT Treatment Vs Waiting List (20 subjects each) 16 sessions (50 minutes each) Global Assessment of Functioning TREATMENT MeanSD 43.88 (pre) 10.9 50.83 (post) 11.6 WAIT LIST MeanSD 43.94 (pre) 8.58 45.13 (post) 9.36 An IBT Outcome StudyP = 0.046

35. DM-ID Adaptation of Diagnostic Criteria for PTSD From the Forthcoming Book: Diagnostic Manual for People with Intellectual Disabilities Fletcher, R., Loschen, E., Stavrakaki, C., & First, M. (2007). Diagnostic Manual-Intellectual Disability (DM-ID): A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability. Kingston, NY: NADD Press. Chapter on Posttraumatic Stress Disorder By Daniel J. Tomasulo, Ph.D., TEP, MFA Nancy J. Razza, Ph.D., CGP A publication from the American Psychiatric Association and National Association for Dual Diagnosis

37. …in which both of the following were present:

38. developmental milestones, residential placement, and even adult, consensual sexual experiences have led to posttraumatic reactions in some individuals with ID. It appears that the range of potentially traumatizing events is greater for individuals with a lower developmental age,

40. There is considerable evidence, however, of increased likelihood of disorganized or agitated behavior in individuals with greater levels of impairment

41. (Shameless Self Promotion) Healing Trauma: The Power of Group Treatment for People with Intellectual Disabilities Nancy J. Razza, Ph.D., Daniel J.Tomasulo, Ph.D. APA’s first book on people with intellectual disabilities. Available at Amazon, Barnes and Noble and the APA

42. www.TheHealingCrowd.com Website for articles, clinical research, training, and supervision / consultation

43. Confessions of a Former Child A Therapist’s Memoir from Graywolf Press available at Amazon, Barnes and Noble, Borders and all good bookstores. FormerChild.com PsychCentral.com Proof Positive The R Word:Sticks, Stones and Rosa’s Law “Disquietingly funny, stuffed with entertaining details and penetrating insights.”Kirkus Review