WORKING WITH TRAUMA

1. WORKING WITH TRAUMA • Presented By • Rick Haid

2. TRAUMA DEFINITION

3. TRAUMA DEFINITION • Trauma is: • The exposure to an extreme stressor involving direct personal experience of an event that involves actual or threatened death or serious injury; or • Threat to one's physical integrity; or • Witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or Definition adapted from: http://www.ncstac.org/content/projects/trauma.htm

4. TRAUMA DEFINITION • Trauma (cont.) • Learning about unexpected or violent death, serious harm, or threat of death; or • Injury experienced by a family member or other close associate. Definition adapted from: http://www.ncstac.org/content/projects/trauma.htm

5. TRAUMA DEFINITION • The person's response to the event must involve: • Intense fear; • Helplessness or horror; • Or in children, the response must involve disorganized or agitated behaviour. Definition adapted from: http://www.ncstac.org/content/projects/trauma.htm

6. TRAUMA DEFINITION • The traumatic event can be experienced in various ways: • Recurrent & intrusive recollections of the event • Recurrent and distressing dreams during which the event is replayed • Dissociative states • Intense physiological distress and reactivity Definition adapted from: http://www.ncstac.org/content/projects/trauma.htm

7. TRAUMA DEFINITION • Traumatic event experienced (cont.) • Deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event • Diminished interest or participation in previously enjoyed activities • Feeling detached or estranged from others • Reduced ability to feel emotions Definition adapted from: http://www.ncstac.org/content/projects/trauma.htm

8. TRAUMA DEFINITION • Traumatic event experienced (cont.) • A sense of a foreshortened future • Difficulty falling or staying asleep • Hypervigilance • Exaggerated startle response • Irritability or outbursts of anger • And difficulty concentrating or completing tasks. Definition adapted from: http://www.ncstac.org/content/projects/trauma.htm

9. POST TRAUMATIC STRESS DISORDER

10. PTSD • Diagnostic criteria for 309.81 PTSD • The person has been exposed to a traumatic event in which both of the following were present: • The person experienced/witnessed, or was confronted with an event/s that involved actual/threatened death/serious injury, or a threat to the physical integrity of self/other • The person's response involved intense fear, helplessness, or horror. (In children, this may be expressed instead by disorganized or agitated behaviour).

11. PTSD • B. The traumatic event is persistently re-experienced in one (or more) of the following ways: • Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. • Recurrent distressing dreams of the event. Note: In children, there may be repetitive frightening dreams without recognisable content.

12. PTSD • Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experienced, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when the intoxicated).Note: in young children, trauma specific re-enactment may occur. 4. Intense psychological distress and exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event.

13. PTSD • Physiological reactivity on exposure to internal or external cue that symbolises or resembles an aspect of the traumatic event.

14. PTSD • Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: • Efforts to avoid thoughts, feelings, or conversations associated with the trauma • Efforts to avoid activities, places, or people that arouse recollections of the trauma • Inability to recall an important aspect of the trauma

15. PTSD • Persistent avoidance (cont.) • Markedly diminished interest or participation in significant activities • Feeling of detachment or estrangement from others • Restricted range of affect (e.g. unable to have loving feelings) • Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal lifespan).

16. PTSD • D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response

17. PTSD • E. Duration of the disturbance (symptoms in criteria B, C, and D) is more than one month. • F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

18. PTSD • Specify if: • Acute • If duration of symptoms is less than 3 months. • Chronic • If duration of symptoms is 3 months or more. • Specify if: • With delayed onset: if onset of symptoms is at least six months after the stressor.

19. WORKING WITH TRAUMA

20. WORKING WITH TRAUMA • The trauma system is really about the limbic system. Picture from: www.mhhe.com/socscience/ intro/ibank/set1.htm

21. WORKING WITH TRAUMA This physiological storing of emotion has a definite CAUSATIVE event, unlike Phobia, which has no clear cause or onset. When working with a traumatized client, we avoid catharsis or abreaction – these are UNWANTED in trauma therapy.

22. WORKING WITH TRAUMA • Watch for cues in the client of them becoming over-stimulated: • Breathing (big give-away). Listening for breath in the voice is an important cue for the therapist • Agitation, twitching • Hand wringing • Variable pulse • Cold sweat • Muscle tension

23. WORKING WITH TRAUMA • Cues of over-stimulation (cont.) • Dilation of pupils • Increased heart rate • Head ache/stomach ache (this is a shut down response – i.e., blood to muscles) • Ringing in ears • Dissociation feels uncomfortable

24. WORKING WITH TRAUMA • SOMATISING gives negative meaning via the body. Panic attacks are probably about being out of control. • Teach breath control, and when to use it • Focus their attention - ask questions about the colour of the chair etc, five things they can see in the room, hear in the room etc • This is to GROUND them and to provide DISTRACTION

25. WORKING WITH TRAUMA • Somatising (cont.) • With verbal assignments, the client may struggle because trauma turns off BROCCA'S area in the brain - so they need to DO something • This turning off of Brocca's area leads to the observed "Speechless Terror" • Loss of narrative or the ability to expand on narrative occurs l.e. it is disconnected • If you can DISTRACT them for 5-10 minutes, the anxiety disappears. AMYGDALA function ceases.

26. WORKING WITH TRAUMA • People's thoughts SWITCH OFF in trauma. They are flooded with bodily responses. Adrenalin is released. • Body numbing occurs (either though blood redirection, dissociation or natural opoids) • These responses make it bearable when you can't run away • The trouble being -they hang around once the trauma has gone

27. WORKING WITH TRAUMA • When processing with a client, ask: • What do you remember? • What is your body feeling? • What affect are you feeling? • There is a PATHOLOGICAL response to trauma: • The person is overwhelmed • Sleep difficulties • Panic/Exhaustion • Extreme avoidance

28. WORKING WITH TRAUMA • INTRUSION • Flashbacks • Sleep disturbance • Hyper vigilance • Irritability • Affect Deregulation • AVOIDANCE • Numbing • Avoidance of triggers • Social withdrawal • Depression • Anxiety

29. WHAT TRAUMATISED PEOPLE NEED

30. NEEDS • Most of all people need to feel relatively safe • They need to know that you will respect their boundaries • They need to know they can leave if they want to • They will not be touched if they do not want to be • They need to feel accepted and not judged

31. NEEDS • People usually need to talk and be listened to • Often people need to have their feelings paid attention to • Sometimes people need to be left alone • Your presence is the most important gift you can give • Detachment

32. NEEDS • WHAT YOU CAN DO TO HELP: • Begin simply • Establish safety through chosen technique • Let the survivor lead • Ask questions • Always ask with permission • As long as the survivor is not overwhelmed and is willing, create space for her to move into discussing more emotionally difficult material • Let people tell their story

33. NEEDS • What you can do to help (cont.) • Allow the experience & expression of feeling • Ask the survivor what she feels • Reflect what you see and hear • Do not push for catharsis • Focussing on body sensations helps the nervous system to unwind from trauma • If the person seems overwhelmed, lead away from emotionally painful material

34. NEEDS • What you can do to help (cont.) • Enhancing the feeling of safety is a way to monitor overwhelming thoughts and feelings and allow integration of difficult material • Help people recognize and develop their resources • Avoid pushing for recovery too soon • Take care of yourself to avoid vicarious traumatisation.

35. NEEDS • Establishing safety can be achieved through the use of • Oases: activities which subsume the client’s attention, thus reducing hyperarousal and negative self talk • Anchors: which relate to a familiar and protective memory of a person, place or thing. • The Safe Place: is a form of anchor relating to an actual site known to client

36. NEEDS • The Fantasy Safe Place creates unlimited potential in terms of client control and determinationin that it can be influenced and directed by the client • The placement of the traumatic experience in the past, by breaking this nexus between recall of trauma and somatic response, is a theme which binds all counselling interventions.

37. EFFECTS OF CHILDHOOD SEXUAL ABUSE ON MENTAL HEALTH

38. EFFECTS OF CSA • General interpersonal sensitivity • Elevated levels of sensitivity to rejection • Difficulties with trust and intimacy • Higher levels of loneliness and social isolation • Difficulty with parenting • Disruptions to sexuality • Distortions to perceptions of bodily functions

39. EFFECTS OF CSA • Higher levels of (destructive) promiscuity • Significantly higher levels of re-victimisation – roughly one half of previously abused women are further abused (physically, sexually, emotionally) during adulthood.

40. EFFECTS OF CSA • Women who were sexually abused as children report*: • Higher levels of depression and anxiety • Higher rates of eating disorders • Higher rates of substance abuse • Self-mutilation • Suicidal ideation and suicidality • Dissociation • Pain and somatic reactions • Higher rates of low self-esteem/self-confidence *When compared to non-abused samples

41. EFFECTS OF CSA • Incest survivors’ perceptions of their bodies: • 74% expressed negative or distorted body perceptions (eg. Saw their body as dirty, nasty, evil, bad) of particular note, the body was seen as having caused the abuse • 63% saw femaleness as equated with rape and abuse • 56% viewed reproduction as an unwelcome event Elaine Westerlund, Women’s Sexuality after childhood incest, 1992.

42. EFFECTS OF CSA • Incest survivors’ perceptions (cont.) • 42% expressed feelings of detachment from their body • 30% expressed body hatred, which led to self punishment in the form of anorexia or neglect (of exercise, hygiene, nutrition) • 28% felt that they were not in control of their body • 19% actively and consciously disowned their body, perceiving it as having betrayed them. Elaine Westerlund, Women’s Sexuality after childhood incest, 1992.

43. DEFENCES: DISSOCIATION

44. DEFENCES: DISSOCIATION • Helps maintain borderline symptoms (memories re-enacted rather than recalled) • Self inducement of altered states of consciousness – numbness, deadness, detachment • Use predicts self harm as affect regulating strategy • Keeps memories and affect associated with trauma out of consciousness at a price

45. DEFENCES: DISSOCIATION • Inhibition of affect  high levels of anxiety • Clouding of conscious experience • Adaptive value: minimises child’s awareness of constant threat & allows continued dependence on caregivers

46. DISRUPTIONS TO SENSE OF SELF

47. DISRUPTIONS TO SENSE OF SELF • “I wasn’t feeling myself today” • For many people this feeling/state of being occurs and then passes without causing major disruption to everyday life. • For a short period of time they feel estranged from themselves and others. • For others, particularly those who have been traumatised during childhood, this state can persist and permeate each day • It involves feeling cut off from the basic feeling which is at the core of knowing oneself.

48. A WORD OF CAUTION • Trauma is a complex area • Counsellor should be well trained • Re-experiencing can lead to re-traumatisation • Do not allow client to engage with memories without establishing safety • When trauma or PTSD is evident refer on to trained professional