Reconsidering Trauma: Treatment Advances, Relational Issues, and Mindfulness in Integrated Trauma Therapy

1. Reconsidering Trauma:Treatment Advances, Relational Issues, and Mindfulness in Integrated Trauma Therapy John Briere, Ph.D. Departments of Psychiatry and Psychology, University of Southern California Psychological Trauma Program, Los Angeles County – USC Medical Center MCAVIC-USC Child and Adolescent Trauma Program, NCTSN

2. Complex trauma exposure Onset Childhood trauma and neglect Attachment disruption usual Extended duration and frequency Traumatic processes and well as traumatic events Relational/interpersonal Complexity Accumulated effects Interacting effects

3. Complex posttraumatic outcomes – ethnocultural aspects Ethnic/cultural/gender differences in Perception of trauma The example of sexual trauma Models of injury Psychological Somatic Spiritual Idioms of distress “Culture-bound” stress disorders Commonalities of response across groups

4. Complex posttraumatic outcomes – Chronic posttraumatic stress Symptomatology Reexperiencing Avoidance Hyperarousal Avoidance and chronicity Cognitive, emotional, dissociative, substance abuse Risk factors Trauma, reduced social support and marginalization, reduced affect regulation capacities, nervous system compromise

5. Complex posttraumatic outcomes – Self-capacities Identity Other-directness Reduce self-access/awareness Boundary disturbance Susceptibility to influence Relationality Implicit attachment-related schemata Models of relationship Relational schema Conditioning to emotional-cognitive memories Source attribution errors “Out of proportion" emotions/thoughts

6. Complex posttraumatic outcomes – Self-capacities Affect regulation Underdevelopment in the context of maltreatment Modulation versus tolerance The imbalance between level of triggerable distress and affect regulation capacity The avoidance triad: Substance abuse, dissociation, and tension-reduction “Cluster B” personality disorders Psychosis As a feature of posttraumatic stress As a feature of disturbed self-capacities

7. A philosophy of trauma Integrating Eastern models of suffering, attachment, and mindfulness Ubiquity of trauma versus the myth of normality Pain versus suffering Trauma seen as bad, pain seen as wrong/pathological, to be avoided Focused awareness of painful material and paradoxical relief Avoidance can intensify distress, intrusion Mindfulness as the opposite of avoidance Attachment: expectation, need, and preoccupation Reality as subjectivity Perception versus activated implicit memory Source attribution errors and the complexity of personal experience

8. A philosophy of trauma The problem with solely symptom-based models Treatment goals narrow to definable fixing of distress Diminished relevance to a lived life and the opportunity for larger changes Reinforces avoidance rather than engaging roots of suffering Natural systems of trauma recovery - Intrinsic processing Self-exposure Recurring thoughts, memories, nightmares, flashbacks, “reenactments” Drive to process: verbalization, expression, attraction to trauma reminders, therapy seeking Posttraumatic growth, acceptance, and integration

9. Assessing trauma and impacts in the clinical interview Process responses and intra-interview signs Activation responses Easily triggered cognitive-emotional states Avoidance responses Dissociative disengagement, lapses, inconsistency, constriction Denial, content switching Affect dysregulation Mood swings “Falling into the hole” Reports of TRBs Relational disturbance Alertness to interpersonal danger Abandonment issues Need for protection via control

10. The Self-Trauma Model – A components approach

11. Distress reduction and affect regulation training Dealing with acute intrusions – grounding Somatosensory feedback (e.g., body in chair) Details of room Reminders of past versus present Breath training Breath and tension/stress Effects of slower, deeper, diaphragmatic breath

12. Mindfulness and affect regulation Nonjudgmental self-observation Acceptance of (good, bad, or neutral) thoughts, feelings, and memories versus fighting thoughts/feelings Disturbing thoughts and feeling allowed to come and go (“watching the parade”) De-investment in emotional experience: “I don’t trust my inner feelings, inner feelings come and go” (Leonard Cohen) Self as relative/contextual/”insubstantial”, “No self” – self concept in flux, result of interrelated conditions, not inherently concrete (self as process) Less identification with desires, supposed traits, social expectations, therefore less disappointment, betrayal, disillusionment, abandonment concerns

13. Distress reduction and affect regulation training Trauma-relevant meditation Posture, breathing, attention Exposure via reduced avoidance, greater relaxation Affect regulation and equanimity (nonreactivity to internal states) Stress/arousal reduction Potential constraints Initial increased activation Perceived reduced control Effects of memory intrusion Monitoring issues Therapist must be familiar with meditation procedures

14. Empirically-based mindfulness-related therapies Dialectical behavior therapy (DBT; Linehan) Mindfulness-based stress reduction (MBSR; Kabat-Zinn) Mindfulness-based cognitive therapy (MBCT; Segal, et al) Acceptance and commitment therapy (ACT; Hayes)

15. Distress reduction and affect regulation training Trigger identification, recontextualization Understanding and insight alter similarities of stimuli to initial trauma memory Trigger grid: How do I know I’m being triggered? What are the triggers, when do they occur? (review of history) What do I think/do after triggers? How might I avoid/counter them? Creation of self-talk options Analysis of differences between initial event and triggering event Repetitive exposure and processing of traumatic material as affect regulation training

16. Cognitive interventions Normalizing and reframing of experiences and “symptoms” Cognitive reconsideration: An empowering alternative to cognitive restructuring Using exposure processes to prompt reevaluation of cognitions Mindfulness: Practicing nonjudgment and acceptance Intrusive negative cognitions as “just thoughts,” not representations of reality Reduced self-blame through experience of conditionality Reduced identification with self-criticism (participant-observer) Insight and the development of a coherent, nonpathologizing narrative

17. Emotional processing The components of trauma processing Exposure Activation Disparity Nonreinforcement of CERs and trauma-related assumptions/beliefs (safety) Counterconditioning Extinction/resolution

18. Emotional processing Titrated exposure and the therapeutic window Limiting factors CER intensity Affect regulation skills Balance between therapeutic challenge and overwhelming internal experience Overshooting vs. undershooting the window

19. Emotional processing at the session level Repetitive exposure to trauma memories via questions/facilitation of disclosure Activation control Greater vs. lesser detail Time/tense focus: here-and-now vs. there-and-then Emotional vs. cognitive Extent of intervention in avoidance Safety, support, validation, encouragement Emotional discharge/expression Debriefing/contextualization

20. Emotional processing Mindfulness as exposure Reduced cognitive-emotional avoidance Processing with awareness Openness to distress, yet The changed relationship to distress = decreased suffering Increased access to memory greater exposure Titrated levels of distress (through detachment), and Greater awareness of disparity

21. Emotional processing Processing “hot spots” with focused CBT or EMDR Only when tolerable, always within window Greater specificity and intensity of exposure Pre-briefing Two approaches Prolonged exposure EMDR Debriefing

22. Increasing identity functions Self-exploration, inner directedness, and identity training Development of self-knowledge and self-directedness Value of nonleading, open-ended questions Avoiding the over-use of interpretations Effects of increased mindfulness Less attachment to sense of self as enduring and concrete Yet, increased awareness means greater self-awareness Greater self-appreciation Acceptance and compassion

23. Increasing relational functioning Cognitive-emotional processing of relational schema Exposure to relational stimuli, activation of schema, disparity in therapeutic environment, counterconditioning via therapeutic emotional bond, extinction/restructuring

24. Psychiatric medications Presenter caveats Can trauma psychopharmacology “fit” with growth models of trauma recovery? Traditional Symptoms as psychopathology, medication as correction STM: Nonresolvable/chronic symptoms as overwhelming “trauma load,” preventing processing Medication as support for more effective processing by reducing Anxiety Comorbidity Rarely sufficient by themselves

25. Psychiatric medications Limiting issues Psychological treatments often yield larger effect sizes in treatment outcome studies Noncompliance as result of side-effects Potential effects of reducing anxiety during exposure and processing Specific concerns about benzodiazepines Addiction/dependency concerns for trauma survivors Use of antipsychotic medications Potential relapse effects upon discontinuation

26. Psychiatric medications Potential benefits Recommendations from the International Society for Traumatic Stress Studies First line – SSRIs (only FDA indication for PTSD) Second line – TCAs, MAOIs Questionable – mood stabilizers Benzodiazepines – for management of acute anxiety Antipsychotics – for clear psychosis Speculation from research Alpha and Beta blockade for hyperarousal symptoms

27. Therapist issues in trauma treatment Countertransference/counteractivation Personal history Cultural assumptions/socialization Mindfulness and activation awareness Psychotherapy Internally directed practice Social support Consultation Community of clinicians