Complex Trauma Slides
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STABILIZATION / SKILLS OF STAGE ONE
- Distress Tolerance
- Self-soothing
- Self-care
- Management of pathological defences
- Restraint from self-endangerment
- Emotion identification & regulation
- Connect to somatic "felt-sense" / Body awareness
- Re-establish sense of body boundaries (*)
- Re-establish integration of experience - SIBAM
- Dual awareness (*)
- Present-moment awareness / mindfulness
- Able to plan, conduct meaningful daily activities
- Able to form attachments
- Able to endure intense therapeutic relationship
- Inter-session control
(*) Addressed at Somatic Trauma workshop, Edinburgh 1998, Babette Rothschild (Body Psychotherapist) Articles & Training: http://www.trauma.cc
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DIFFICULTIES WITH THIS CLIENT GROUP
- May have rapid unpredictable shifts in mood / mental state.
- May be unable to name / describe feelings.
- May have difficulty regulating affect.
- May be phobic about emotional experiencing.
- May be prone to self-harm, suicide attempts.
- May be co-morbid diagnoses & personality disorders.
- May lose touch with present reality - confuse past / present; fantasy reality.
- May have severe attachment problems.
- May still be enmeshed with abusers.
- little expectation of being understood, treated benignly.
- May re-enact trauma in therapeutic environment.
- May have attitude of entitlement ('special patient').
- Risk of regression, dependency.
- May evoke strong counter-transference reactions.
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SIGNS OF DECOMPENSATION / RE- TRAUMATISATION
- Client dissociating in session.
- Shock / Freezing response.
- Client overwhelm: flashbacks, anxiety-panic attacks, "emotional storms".
- Loss of functioning in daily life.
- Return/ increase of self-harming, alcohol/drug misuse.
- Dissociative "switching".
- Need for hospitalizations.
- Increased suicidal / Para suicidal behaviours.
- Learned helplessness.
- Regressive dependency in therapeutic relationship.
- Regressed, child-like behaviour in sessions
- Unrelenting crises.
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S I B A M
Dissociation model developed by Peter Levine for work with symptoms of PTSD (Levine, P. workshops 1991, 1992)
S = Sensation
- Body awareness
- Sensation
- Senses in present
- Physical feelings
- Energy awareness
I = Image
- Concrete memory
- Senses from past
- Symbolic / representational
- Symbol
- Pictures
B = Behaviour
- Posture
- Movement
- Intentional movements
- ANS activation
A = Affect
- Emotions
- Emotional feelings
M = Meaning / belief
- Conclusion, integration
- Understanding, attributes
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STAGE- ORIENTED TREATMENT FOR TRAUMA
Janet, 1889
STABILIZATION
CONTAINMENT
SYMPTOM REDUCTION
EXPLORATION OF TRAUMATIC MEMORIES
REINTEGRATION
REHABILITATION
Herman, 1992
SAFETY
REMEMBRANCE & MOURNING
RECONNECTION
van der Kolk et al.
- STABILIZATION & PSYCHO-EDUCATION
- DE-CONDITIONING OF TRAUMA MEMORIES AND RESPONSES
- RESTRUCTURING TRAUMATIC / PERSONAL SCHEMAS
- RE-ESTABLISHING SECURE SOCIAL CONNECTIONS AND INTERPERSONAL EFFICACY
- BUILDING REPAIRING EMOTIONAL EXPERIENCES
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DUAL AWARENESS
van der Kolk - "observing self" vs. "experiencing self", external reality vs. Internal reality, past vs. present
- "Excellent braking tool" - slows down process (*)
- Use of language:
- "I'm feeling (EMOTION) right now, because I am remembering (TRAUMATIC EVENT). And, I am looking around (PRESENT FOCUS), and can see that it is not happening right now. I am not in danger" (*)
- "It is not then, it is now"
- "It is because you are remembering".... (*)
(*) From workshop on Somatic Trauma Therapy, Edinburgh, held by Babette Rothschild, M.S.W. (Body Psychotherapist)
See: Rothschild, B. "Making Trauma Therapy Safe", Self and Society, Vol. 27(2), May 1999; Rothschild, B. "Introduction to Somatic Trauma Therapy", May 1998.
Articles & Training Schedules: http://www.trauma.cc
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BODY AWARENESS & BOUNDARY EXERCISES (*)
- Sense of boundary at skin level
- Rubbing surface of skin (not massaging muscles) - with own hand, towel, pillow, against wall.....
- Feeling where clothes touch skin; where body meets chair....
- "This is me. This is where I start / stop. This is my boundary". (*)
- Distinguish boundaries with another using safe touch.
- Sense of solidity of bones
- Awareness of spine - against wall, sitting, standing.
- Tapping bones at elbow, wrist, knee, ankle.
- Muscular tension
- Tensing parts which feel vulnerable / shaky.
- Using hard chair / upright posture.
- Muscular resistance in legs, arms, internally.
- Body armouring.
- Compare stretching / tensing.
- Developing language to focus on body sensations / felt sense
- "You're feeling unsafe?" "How do you know?".
- "Where do you feel it in your body?".
- "Do you know that kind of sensation?".
- "What is it like?".
- "What happens in your body when you acknowledge that?".
- Recognising signs of hyper-arousal & shock
- Observe and gauge state of ANS.
(*) From workshop on Somatic Trauma Therapy, Edinburgh, held by Babette Rothschild, M.S.W. (Body Psychotherapist) (babette@nwc.net)
See: Rothschild, B. "Making Trauma Therapy Safe", Self and Society, Vol. 27(2), May 1999; Rothschild, B. "Introduction to Somatic Trauma Therapy", May 1998.
Articles & Training Schedules: http://www.trauma.cc
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DISSOCIATION
Dissociation is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment.
Certain faculties, functions, feelings, memories are split off from immediate awareness/consciousness and compartmentalised in the mind, where they become separate identities.
PURPOSE: way out of intolerable or psychologically incongruous situation
- barrier to keep painful events / memories out of awareness
- analgesia to prevent feeling pain
- escape from experiencing event
- survival method used by children
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DISSOCIATIVE DISORDERS
AMNESIA
- for chunks of childhood
- for recent blocks of time
- loss of personal information
- "spacing out"
- time disorientation
- some forms of self-mutilation
FUGUE
- sudden unexpected travel from home
- unable to recall past
- confusion of personal identity
- assumption of new identity
DEPERSONALISATION
- feeling of detachment from body
- seeing body from distance
- unreality of self
- loss of affective responses (anhedonia)
- sense of physical fragmentation
- proprioceptive (as if floating)
- affective (as if numb / dead)
DEREALISATION
- surroundings seem unreal / foreign
- perceptual disturbances
IDENTITY CONFUSION
- subjective feeling of confusion, turmoil
- uncertainty regarding self (as if another person inside)
- sexual orientation / identity confusion
- sense of puzzlement, uncertainty, conflict
IDENTITY ALTERATION
- inner dialogue
- different age appropriate behaviours / levels of functioning
- objective behaviour suggesting assumption of different identities
- different names, ages, identities associated with parts of self
- inability to recall personal information incompatible with normal forgetting
SOMATISATION
- fainting spells, collapses, epileptic-like seizures, headaches, chronic pain symptoms
- hysterical anaesthesia's or paralyses
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COMPLEX PTSD
Judith Herman, 1992:
" A history of subjection to totalitarian control over a prolonged period (months to years). Examples include hostages, prisoners of war, concentration camp survivors and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organised sexual exploitation"
COMPLEX PTSD is usually a reaction to a combination of specific TRAUMATIC EVENTS and CHRONIC STRESS. Isolation seems to be an important factor.
Sometimes referred to as "TYPE II" TRAUMATISATION.
BORDERLINE PERSONALITY DISORDER, DISSOCIATIVE DISORDERS, and other classes of severe mental illness may have roots in COMPLEX PTSD.
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FEATURES OF COMPLEX PTSD
- ALTERATIONS IN AFFECT REGULATION
- persistent dysphoria
- chronic suicidal preoccupation
- self-injury
- explosive or extremely inhibited anger
- compulsive or extremely inhibited sexuality
- ALTERATIONS IN CONSCIOUSNESS
- amnesia or hypermnesia for traumatic events
- transient dissociative episodes
- depersonalization / derealization
- reliving experiences with intrusive PTSD symptoms or ruminative preoccupation
- ALTERATIONS IN SELF-PERCEPTION
- sense of helplessness or paralysis of initiative
- shame, guilt and self-blame
- sense of defilement or stigma
- sense of difference from others (specialness; utter aloneness; inhuman; no-one could understand)
- ALTERATIONS IN PERCEPTION OF PERPETRATOR
- preoccupation with relationship with perpetrator
- unrealistic attribution of total power to perpetrator
- idealization or paradoxical gratitude
- sense of special or supernatural relationship
- acceptance of belief system or rationalization of perpetrator
- ALTERATIONS IN RELATIONS WITH OTHERS
- isolation and withdrawal
- disruption in intimate relationships
- repeated search for rescuer
- persistent distrust
- repeated failures of self-protection
- ALTERATIONS IN SYSTEMS OF MEANING
- loss of sustaining faith
- sense of hopelessness and despair
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GROUNDING TECHNIQUES
(for client and therapist)
- Pay attention to BODY SENSATIONS - feet on floor, body weight, posture.
- Refocus eyes - move gaze around room.
- Reconnect to SIGHTS, SOUNDS, SENSATIONS.
- Shift position in chair - sit upright .
- Take a deep breath - follow breath in body.
- Wriggle toes.
- Touch watch, ring, arm of chair, clothing...
- Pinch muscle between thumb and forefinger.
- Have something to drink.
- Get up and walk.
- Tell yourself to move out of trance (what does this feel like for you?).
- Ask client if s/he feels tranced / dissociated (use client's term).
- Maintain 50 % of attention with yourself and 50 % with client.
- MAINTAIN RELATEDNESS.
- Come back to holding therapeutic space and not doing work for client.
- GROUNDING WITHIN MOMENT OF "NOW".
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TRAUMATIC MEMORY
Pierre Janet (1889)
- "Vehement emotion" interferes with information-processing on a verbal & symbolic level
- Memories not categorized, but
- Split off from consciousness
- Stored as visual images, affective states, or body sensations
- Memory fragments can return in state dependent fashion
TRAUMATIC MEMORY
- Inflexible
- Without context
- Fragmented / dissociated
- Autistic
- ANS Hyperarousal
- Sensory-motor / non-verbal
- Developmental context in which Trauma occurred?
- Somatic presentation?
- Regressed re-enactments outside of conscious awareness?
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NARRATIVE MEMORY
- Flexible
- Contextual
- Integrated
- Relational
- Minimal arousal
- Symbolic / verbal
- Telling a story within a Relationship
- Needs core sense of SELF and RELATIONSHIP SKILLS
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Reading List
WORKING WITH COMPLEX TRAUMA WORKSHOP
Herman, J.L. (1992) Trauma and Recovery New York: Basic Books
Van der Kolk (1996) Traumatic Stress Guilford Press
Levine, P. (1997) Waking the Tiger North Atlantic Books
Main, T. (1975) The Ailment and Other Psycho-analytic Essays Free Association Books, pp 100-122
Linehan, M.M. (1993) Skills Training Manual for Treating Borderline Personality Disorder, Guilford Press
Mollon, P. (1998) Remembering Trauma: a Psychotherapist's Guide to Memory & Illusion Wiley & Sons Press
Winnicott, D.W. (1965) The Maturational Process and the Facilitating Environment Hogarth Press
Kluft, R.P. (1997) On the treatment of Traumatic Memories of DID Patients: Always? Never? Sometimes? Now? Later? Dissociation Journal, Vol X (2)
Boon, S. (1997) The Treatment of Traumatic Memories in DID: Indications and Contra-indications Dissociation Journal, Vol X (2)
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