COLLABORATIVE CHANGE MODEL : Contextual, Relational Treatment of Complex Trauma

1. COLLABORATIVE CHANGE MODEL: Contextual, Relational Treatment of Complex Trauma Mary Jo Barrett www.centerforcontextualchange.org Maryjo.ccc@gmail.com

2. Four Levels of Stress Reactivity

3. Complex Trauma Interpersonal in nature Disruption in attachment in significant relationships Repeated/chronic Over time Involving all forms of traumatization Revictimization through reactions, as well as, actions

4. Understanding states “When acutely threatened, we mobilize vast energies to protect and defend ourselves. We duck, dodge, twist, stiffen and retract. Our muscles contract to fight or flee. However, if our actions are ineffective, we freeze or collapse.” -Levine In normal development, state changes are co-regulated with changes in state becoming smoothed out over the course of development. -Putnam States become traits: “if the neurobiology of a specific response, Hyper-arousal or Dissociation, is activated long enough, there will be molecular, structural and functional changes in those systems.” -Perry

5. Childhood Trauma and Attachment Children who experience trauma-abuse and neglect may be more dramatically affected by chronic hyperarousal than adults. Trauma in childhood occurs before the brain has developed sophisticated modulation techniques. Good enough caregivers provide external modulation for internal states. Responsive, stable, and predictable caregivers and contexts hold traumatized children and alleviate symptoms and prevent trauma mindstates from re-occurring.

6. Survival Skills of Abuse Survivors-Adults and Children (Avoidance) Mistrust of others Flashbacks Anxiety, terror and panic Shame, guilt, self-hatred Cognitive distortions Depression, passivity Dissociation Disturbed relatedness Difficulty attaching Detachment, numbing or withdrawal Sexual promiscuity or aversion to sex Drug and alcohol abuse Eating disorders Suicide Self-mutilation Anger and aggressive behavior Perfectionism Alienation from their bodies Personality disorders, mental illness

7. Trauma-Survival Mindstate Unmanageable stress and the freeze response When we are unable to organize our experiences and make meaning of them in a way that makes predictable sense; our development, growth, and learning are impacted. Complex traumatic histories impair affect regulation, ego adaptive capacities, impulse control, and attachment patterns. Difficulty controlling emotions, cognitions, behavior, and relationship

8. Abuse/Neglect and Complex Trauma Traumatic experiences embedded in ineffective hierarchies and/or hostile contexts: Behavior makes sense. Fight ----- Flight ----- Freeze • Difficulty regulating emotions and impulses • Difficulty in ego adaptive capacity/cognitive consciousness • Somatization • Self loathing, negative perceptions of others, victim/perpetrator cycles (sexually and violently acting out) • Meaning making impaired

9. Attachment and the Brain Responsive caregivers help children self-regulate Responsive caregivers encourage intersubjectivity: making meaning that is resilient, flexible, and solid sense of coherence Avoidance as adaptive

10. The Effects of Abuse and Complex Trauma I experience myself as powerless • Symptoms as attempted solutions I am disconnected from myself, others, and the world around me • Interactional Cycle of Survival I experience myself as devalued I am out of control

11. Emotional Center – Middle Brain Executive Center – Higher Brain Survival Center – Lower Brain

12. Brain informed CCM----We want to build pathways between all parts of the brain, to intersect and strengthen our Engaged Mindstate. And to Build Pathways between Our Engaged Mindstate and the Engaged Mindstates of Others. Lower Brain • This is where our Survival Instinctual Behaviors and Functions exist. It is at the Base of the Brain. This HindBrain regulates; Fight, Flight, Freeze, our autonomic functions; digestion, heart rate, hunger, breathing. This part of our brain manages our impulses. The Hind/Lower brain is reactive and protective.

13. MidBrain • The Limbic regulates emotion and motivation, as well as learning and memory. This part of our brain provides us with greater flexibility of behavior and integrates messages from both inside and outside the body. This is where we process: nurturing, fear, social bonding, joy stress; the range of emotions. This is our library, where and how our body remembers

14. Upper Brain • This section regulates our executive functioning; planning,self awareness, analysis that involves thought and feeling. The Forebrain is where we experience logic, empathy, compassion, creativity, self regulation, self awareness, attention, and problem solving. The Forebrain uses both left and right hemispheres. And the Upper Brain attempts to integrate information from Mid and Lower brain, helps us plan.

15. Traumatic Arousal State Decreases these functions:

16. Bottom-Up Processing

17. Fundamental Elements of Trauma Powerlessness Disconnection Devaluing Out of Control

18. The Trauma Mind Storm of Affect Self-Harm Inability to Trust Pseudo-Competency Eating Problems Rage Fear Unsafe Physical Behaviors THE EYE Anger Guilt Survival Mindstate Terror Stealing Depression Lying Sexual Behaviors Low Self-Esteem Damaged Goods

19. Engaged Mindstate In an engaged mindstate individuals have access to and incorporate tools that regulate; their affect, cognitions, behavior, and relationships. They experience themselves as powerful, in control, valued, and connected to themselves, a support system and to the world around them. They are aware of their strengths, their resources and their vulnerabilities and have developed a skill set to deal with stress. When people are acting from an engaged mindstate, they have self-awareness and other awareness, can engaged in supportive relationships, and have a meaningful vision of the future.

20. Mirror Neuron A mirror neuron is a neuron that fires both when a person acts and when the person observes the same action performed by another.

21. You each become the reflection and extension of the other • A back and forth energy emerges between you- liken to an electrical energy flow • Positive resonance needs certain ingredients to exist-safety being primary

22. Healing, Growth and Change ……… Creating safety through the process of encircling a person with open heart, value, and power by engaging with them in their natural cycles of growth. Collaboratively helping recognize and gather resources from within themselves, their family and their community.

23. Environment for Change Safe- creating refuge; unlikely to be in dangerSeen-Heard-UnderstoodSoothe-lack of stressSecure-assured and steadied

24. What is Therapeutic Change A Differentiation of a Trauma/Survival Mindstate and an Engaged Mindstate which is Based on Present Experience Development of Collaborative Based Therapeutic Goals Effort and Strategies to Build New Patterns of Action-Mind and Body to meet the Collaborative Goals

25. Traumatized people need to have physical & sensory experiences to:

26. Ethical Attunement Therapeutic Talent and Complex Trauma: • Our Gift • Energy Resources: Emotional, physical, spiritual, intellectual, sensual • Giving and Receiving • Natural Cycle of Contraction and Expansion in Relationship Therapeutic Wisdom: • Mindfulness (Empowerment) • Open Hearts (Value/Attachment) • Influence (Idiosyncratic or Relational Power)

27. You as Therapeutic Resource Individual Thoughts/Your Wisdom • How do you think change happens? • Think of a time you changed • What were the essential ingredients of your change? Relational/Therapeutic Thoughts • What are your idiosyncratic gifts for influencing others? • What are the core therapeutic ingredients you bring to your relationships? Heart • Think of a time you gave to another and your gift was received Engaged Mindstate • What is going to help you feel supported today?

28. Energy Domains-Resources Emotional Intellectual Physical Sexual Spiritual

29. Performance, health and happiness are grounded in the skillful management of energy - Jim Loehr

30. Finding Balance Expenditures of Energy Replenishing of Energy

31. To Be Fully Engaged Is To Have Strength Endurance Flexibility Resilience In all of the energy domains

32. When we are depleted • Freeze: we become numb, robotic, lose energy or apathetic, dissociated, become more depressed or detached in our own personal and professional lives. • Flight: it is harder for us: to pay attention, to want to go to work. To stay present in relationships and attuned to self • Fight: we become more irritable, tense, or defensive, critical, cynical, judgmental Or quicker to ‘try to save the day.’ Our hyper vigilance or VPTSD may affect our personal lives, interfering with relationships, life style, sleep or relaxation • Attach: our separation anxiety increases in tandem with instability and un-safety. Our boundaries get blurry-too rigid, to loose. We exhibit insecure or disorganized attachment

33. Resources: Where we find energy and possibility Awareness/Realism- honestly looking at self Creativity- in options and meaning Humor Courage/Initiative Flexibility/Adaptability Faith/Trust Social Support

34. Goals of CCM -Brain Based and Contextual Integrated Interventions • Mindfulness/Self Awareness • Body regulation • Emotional balance • Engaged mindstate interactional communication • Response flexibility • Empathy-self and others • Compassion-self and others • Insight • Modulating emotions • Intuition • Cognitive restructuring

35. Five Essential Ingredients for Healing Attachment and Connection: To build and rebuild relationships where there is felt mutual curiosity, compassion, empathy, connecting to a deep set of values that provide a meaningful vision. Safety and Empowerment: Safe context/boundaries/structure within and between themselves and their relationships Value: Collaboration/Strength based guidance/Understanding and Identifying Vulnerability and Resources Skills: Psycho educational experiences/cognitive behavioral/neuro-mind-body/communication/mindfulness/self-regulation within and between Hope: Creation of workable realities

36. Five Functions of any Integrated and Comprehensive Treatment Model-Guidelines for Standards of Care • Enhance client capabilities • Improve client motivation for treatment • Structure the environment • Generalization to the environment • Enhance therapist’s motivation to provide effective treatment

37. Enhancing client’s capabilities Skills training Interpersonal regulation Stabilization of sense of self and emotion regulation

38. Improve the client’s motivation for change Collaboration: understanding of process of change, designing process and goals-hence engaging in process, and investing in outcome. Interventions that help quickly, that are practical and understandable Clear and Predictable Treatment Plan- Order to putting life in Order

39. Assure generalization to natural environment Homework assignments and practice In session Practice of Skills and Experience Family and Relationship Involvement in the Process

40. Therapist Own Self: Enhance therapist’s capabilities & therapist’s motivation to treat effectively Therapist Use of Self- understanding therapeutic giving and receiving Mindfulness and Ethical Attunement Therapeutic Fittness Collaboration An Effective Model to build therapist’s confidence and self empowerment

41. CCM Provides A Structured Environment Clarity of Model Understanding Attachment Emphasis on Safety Clear Boundaries Predictability Structure of natural cycle of change Clear stategies to teach and practice skills

42. Awareness and Attunement The range of what we think and do Is limited by what we fail to notice And because we fail to notice That we fail to notice There is little we can do To Change Until we notice How failing to notice Shapes our thoughts and deeds -R.D.Laing

43. Collaborative Change Model Creating a Context for Change Challenging Patterns/Cycles and Expanding Realities Consolidation

44. What the caterpillar calls the end of the world, the masters call a butterfly. - Richard Bach

45. Stage One: Creating a Context for Change • Creating Refuge • You and your relationship with your clients-attachment styles • Grounding and Stabilization Strategies • Contextual variables • Multidirected partiality • Every member of a client’s context is worthy of care and consideration • Designing an overall emotional, spiritual, and physical safety plan • Pretreatment planning • Team of people • Assessing for safety • Multiple forms of therapy • Who, what, where, and why

46. Creating a Context for Change, Cont’d. Assessing Vulnerabilities and the Function of the Symptoms • When people feel vulnerable, they act to feel powerful, in control, and/or valued. The function of the symptom is to help with the fear and vulnerability. • Interventions and Strategies to experience both Vulnerabilities and Resources Assessing Resources • Non-symptomatic behaviors that we utilize to help regain power, control, and value. Exploring the Positive and Negative Consequences of Change Understanding and Validating the Client’s Denial, Availability, and Attachment • Understanding and respecting the inability to access facts, awareness, impact, and responsibility of past and current situations

47. Creating a Context for Change, Cont’d. Setting Goals • Both Goals and goals---Long and Shorterm,- emphasis on Small and manageable • Client specific • Vulnerabilities and symptoms that lead to feeling powerful, in control, and valued in the short term • CCM specific • Explaining natural cycle of change, relational brain based, exploring discomfort, mindfulness based practice Introducing Acknowledgement • How clients understand their symptoms, how they contribute to the problem cycles, awareness of impact, facts, and responsibility • Acknowledgement is the awareness and acceptance and open admission that I have a problem and that I will address it. Acknowledgement involves taking responsibility and is a process integral to change. Acknowledgement happens in moments and overtime

48. Stage One Interventions-in the moment and overtime Have a Conversation about Safety Continually creating and recreating Safety- Assessing vulnerabilities and resources Explain the Effects of Trauma Recognizing Survival and Engaged Mindstate Find the Interactional Cycle of Survival Explore Denial • Denial of Facts • Denial of Awareness • Denial of Responsibility • Denial of Impact Explore the Positive and Negative Consequences of Change Acknowledgment

49. Validation What is it? Definition: To accept, legitimize, support, attempt to understand and assign benevolent meaning to your own and/or someone else’s emotions, thoughts and behavior.

50. Function of Validation