One Trauma After Another: The Impact of Homelessness
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Transcript One Trauma After Another: The Impact of Homelessness
Complex Trauma
Brian L. Meyer, Ph.D.
Interim Associate Chief of Mental Health
Clinical Services/ Supervisory Psychologist
H.H. McGuire VA Medical Center
Richmond, Virginia
April 23, 2015
Trauma and PTSD
Prevalence of PTSD
More
men (61%) than women (51%)
experience a trauma at some point in their
lives, but women experience PTSD at
twice the rate of men (10% vs. 5%) (Kessler
et al., 1995; Tolin and Foa, 2006)
Post-Traumatic
Stress Disorder
PTSD is characterized by:
Exposure to a severe life-threatening event
Repetitive re-experiencing of the LT event
Avoidance of stimuli associated with trauma
Negative mood and cognitions
Increased arousal
Trauma and PTSD
Not
all trauma leads to PTSD
Depending on the study, the type of
trauma, and the group studied, 3%-58%
get PTSD
Not all abuse leads to PTSD
LIFE-THREATENING EVENTS
IMPERSONAL
TRAUMATIC
PERSONAL
Who Gets PTSD?
It
depends on:
Severity
Duration
Proximity
PTSD
is mitigated or worsened by:
Childhood experience
Personality characteristics
Family history
Social support
Other Common Psychiatric
Diagnoses in People Exposed
to Traumatic Events
Dysthymic
Disorder
Major Depressive Disorder
Mood Disorder NOS
Bipolar Disorder
Generalized Anxiety Disorder
Phobic Disorder
Panic Disorder
More Common Psychiatric
Diagnoses in People Exposed
to Traumatic Events
ADHD
Oppositional Defiant Disorder
Conduct Disorder
Reactive Attachment Disorder
Borderline Personality Disorder
Antisocial Personality Disorder
Narcissistic Personality Disorder
Complex Trauma
What is Complex Trauma?
Complex psychological trauma results
from “exposure to severe stressors
that (1) are repetitive or prolonged,
(2) involve harm or abandonment by
caregivers or other ostensibly
responsible adults, and (3) occur at
developmentally vulnerable times in
the victim’s life.” Ford and Courtois, 2009
What is Complex Trauma?
The psychological effects of chronic and
cumulative traumas
Results from interpersonal victimization,
multiple traumatic events, and/or
traumatic exposure of prolonged duration
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Sexual and physical abuse
Domestic violence
Ethnic cleansing
Prisoners of war
Torture
Being held hostage
What is Complex Trauma?
Complex trauma is often relational
Trauma creates vulnerability to further
trauma: adults who are traumatized may
have been traumatized previously as
children
Rates of PTSD for
Simple vs. Complex Trauma
Simple
Complex
10-20%
33-75%
Copeland et al., 2007; Kessler et al., 1995
What Are Complex
Traumatic Stress Disorders?
The
sequelae of complex trauma
Also known as Complex PTSD, or CPTSD
People at Risk of Developing Complex
Traumatic Stress Disorders
Economically impoverished inner city minorities
Incarcerated individuals
Homeless persons
Sexually and physically revictimized children or
adults
Victims of genocide or torture
Developmentally, intellectually, or psychiatrically
challenged persons
Civilian workers and soldiers harassed on the job
or in the ranks
Emergency responders
Vogt et al., 2007
Core Problems
in Complex Trauma
Affect
dysregulation
Dissociation
Somatic dysregulation
Impaired self-concept
Disorganized attachment patterns
In addition to symptoms of PTSD and
other comorbid disorders
Ford and Courtois, 2009
Disorders of Extreme Stress Not
Otherwise Specified (DESNOS)
A. Alterations in regulating affect arousal
– Persistent dysphoria
– Difficulty modulating anger
– Self-injurious behavior
– Suicidal preoccupation
– Difficulty modulating sexual involvement
– Addictive behavior
B. Alterations in attention and consciousness
– Amnesia
– Dissociation
– Depersonalization/derealization
Herman, 1992, and Courtois, 2004
Disorders of Extreme Stress Not
Otherwise Specified (DESNOS)
C. Alterations in self-perception
– Chronic guilt, intense shame, and self-blame
– Helplessness
– Sense of defilement
– Sense of being completely different from others
D. Alterations in perception of perpetrator
– Preoccupation with relationship with perpetrator
– Unrealistic attribution of total power to
perpetrator
– Idealization or gratitude
– Sense of special relationship
– Acceptance of belief system of perpetrator
Herman, 1992, and Courtois, 2004
Disorders of Extreme Stress Not
Otherwise Specified (DESNOS)
E. Alterations in relationships with others
– Isolation and withdrawal
– Inability to trust others
– Inability to feel intimate
– Repeated search for rescuer
– Repeated failures of self-protection
F. Somatic and/or medical conditions
– Involving all major body systems
– Chronic pain
Herman, 1992, and Courtois, 2004
Disorders of Extreme Stress Not
Otherwise Specified (DESNOS)
G. Alterations in systems of meaning
– Loss of sustaining faith
– Sense of hopelessness and despair
Note: Some of these symptoms were
included in DSM 5 as symptoms of PTSD
Herman, 1992, and Courtois, 2004
Experiencing Complex Trauma
Emotional instability
Overwhelming feelings of
rage, guilt, shame, despair,
ineffectiveness and/or
hopelessness
Tension reduction activities
such as self-mutilation,
compulsive sexual behavior,
and bulimia
Suicidal or violent behavior
Dissociation
Experiencing Complex Trauma
Loss of a sense of trust, safety, and
self-worth
Loss of a coherent sense of self
Belief of being bad or unlovable
Insecure attachments/damaged
interpersonal relationships
Difficulty functioning in social
settings, including work
Loss of faith
Enduring personality changes
Complex Trauma:
A Case Example
Mr. M.: Physically and emotionally
abused by mother and stepfather,
went to Vietnam to “kill”, multiple
divorces, polysubstance abuse, lost
career and imprisoned, dissociated
experience of killing children in war,
remembered “the laughter of
children”, became suicidal, referred
for treatment
Complex PTSD May be
Confused With:
PTSD
ADHD
Other
anxiety disorders
Bipolar Disorder
Mood Disorder NOS
Psychotic Disorder NOS
Reactive Attachment Disorder
Complex PTSD Often Appears
as or Co-Occurs with:
PTSD
Other Anxiety Disorders
Mood Disorders
Behavior Disorders,
especially ADHD
Substance Use Disorders
Co-morbidity is the rule
Complex PTSD Is Conceptually
Related to:
Anxiety Disorders
Dissociative Disorders
Somatization Disorders
Personality Disorders
That is why DSM 5
places trauma in a new
category entitled
Trauma and StressorRelated Disorders
Complex PTSD Is Much
More Than Simple PTSD
Loss of a coherent sense of self
Problems in self-regulation
Tendency to be revictimized
Other mental health disorders
Substance use disorders
Health problems
Relationship problems
Changes in systems of belief and
meaning
Changes to PTSD
Diagnosis in DSM 5
Trauma and Stressor-Related
Disorders are placed in their
own category
Loss of loved one must be
traumatic or accidental
Elimination of B criterion of
reaction of horror, terror, or
helplessness
– Military and first responders
do their job
Changes to PTSD
Diagnosis in DSM 5
Addition of new criteria involving
negative cognitions (negative beliefs
about the world, blame of self or others
for the trauma) and mood (anxiety,
anger, guilt)
Addition of a new arousal criterion:
self-destructive or reckless behavior
Addition of a dissociative subtype
These changes result in approximately
the same number of people who will
meet criteria for a diagnosis of PTSD
They also move PTSD closer to the
definition of Complex Trauma
Implications of Changes to
PTSD Diagnosis in DSM 5
Angry, depressive, and anxious affects now
apply
– This is a rejoinder to the fear-based model of the
past, recognizing greater complexity
The existence of a dissociative subtype,
combined with the new affective criteria and the
new arousal criterion of self-destructive
behavior, moves the description closer to
Complex Trauma
Implications of Changes to
PTSD Diagnosis in DSM 5
Some of the research on PTSD may no longer apply
Assessment instruments must change
– A new version of the PTSD Checklist, the PCL 5
– The Clinician-Assisted PTSD Scale, the “gold
standard” of PTSD assessment, is also being
revised
Different treatments may be needed for different
phenotypes of PTSD (anger, depression, anxiety,
dissociation)
– This may decrease the use of certain treatments,
particularly Prolonged Exposure, which is fearbased
Complex Trauma and Health:
The Adverse Childhood
Events Study
17,421 adult patients of Kaiser
Permanente
Came out of an obesity program: many
dropouts who lost weight believed that it
protected them (against further sexual
abuse, against violence from prisoners)
Eight categories of events in the home:
physical abuse, emotional abuse, sexual
abuse, someone imprisoned, domestic
violence, substance abuse, chronic mental
illness, and loss of parent
Felitti, Anda, et al., 1998
Complex Trauma and
Health: The ACE Study
Results more than 50 years later:
More than 1/2 of population experienced
one or more ACEs; 1/4 had two or more
Exposure to one category increases
likelihood of exposure to another by 80%
The higher the ACE score, the worse the
health problems
Felitti, Anda, et al., 1998
Complex Trauma and
Health: The ACE Study
Results:
Greater likelihood of health problems:
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Chronic obstructive pulmonary disease
Hepatitis
Sexually transmitted diseases
Obesity
Heart disease
Fractures
Diabetes
Unintended pregnancies
Felitti, Anda, et al., 1998
Complex Trauma and Behavioral
Health: The ACE Study
Results:
Greater likelihood of behavioral health
problems:
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Intravenous drug abuse
Alcoholism
Smoking
Depression
Attempted suicide
Felitti, Anda, et al., 1998
The ACE Study:
A Dose-Response Curve
Complex Trauma and
Health: The ACE Study
Results:
Greater likelihood of occupational
problems:
– Occupational health
– Poor job performance
Felitti, Anda, et al., 1998
The Catalyzing Effect of Complex Trauma
Health
Problems
Substance Abuse
Problems
Traumatic
Experiences
Mental Health
Problems
Criminal
Behavior
Relationship
Problems
Employment
Problems
Treatment of
Complex Traumatic
Stress Disorders
Phases of Integrated Treatment
Phase I:
Safety and
Stabilization
After Herman, 1992
Phase II:
Remembrance
and Mourning
Phase III:
Reconnection
Stage I: Safety and Stabilization
Alliance
building
Psychoeducation about
multiple traumas
Safety
Stabilization
Skills-building
– Affective regulation
– Cognitive
– Interpersonal
Self-care
Stage I: Safety
Safety plans
Tension reduction activities (e.g.,
exercise)
Harm reduction and elimination
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Self-harm and suicidal behaviors
Gambling
Driving
Fighting
Eating
Sex
Medication
Breaking laws
Stage I: Stabilization
Reduction and elimination of drug and
alcohol abuse
Health
Housing
- In a safe neighborhood
Income
- Employment
- Financial skills (budgeting, banking)
Transportation
Setting and keeping a schedule
Stage I: Skill-building
Affect Regulation Skills
- Anger Management
- Relaxation (breathing, progressive
muscle relaxation, Drop 3, etc.)
- Emotional literacy
- Distraction from intense emotion
- Self-soothing strategies
- Behavioral activation
- Changing facial expressions
- Self-talk
- Opposite emotion
Stage I: Skill-building
Cognitive Regulation Skills
- Grounding
- Thought-stopping
- Attending to one thing in the present
moment
- Re-thinking
- Noticing choices
- Seeing the whole picture
- Problem-solving
- Examining the evidence
Empirically-Supported
Treatments for Stage I
Dialectical Behavior Therapy (DBT)
Seeking Safety
Mindfulness-Based Stress Reduction
Therapies for specific problems
- Imagery Rehearsal Therapy
- Cognitive-Behavioral Therapy
- Motivational Interviewing
- SAMHSA’s Anger Management
workbook
Stage II: Remembrance
and Mourning
Exposure
and
desensitization
Processing
Grieving
Constructing a
narrative
Integration of the
trauma
Empirically-Supported
Treatments for Stage II
Cognitive Processing Therapy (CPT)
Prolonged Exposure (PE)
Eye Movement Desensitization and
Reprocessing (EMDR)
Skills Training in Affective and
Interpersonal Regulation (STAIR) Narrative
Therapy holds promise; it sequences Phase
I and Phase II treatment
Stage III: Reconnection
Gradually decrease isolation
Re-establishing estranged relationships
Developing trusting relationships
Developing intimacy
Developing sexual intimacy
Parenting
Community-based activities
Stage III: Reconnection
Giving back to the community
Making amends
Acceptance
Reclaiming
Creativity
Finding meaning
Post-traumatic growth
Treatment of Trauma
There are no Evidence-Based
Psychotherapies for Phase III
trauma treatment*
*but couples and/or family therapy may be
helpful, including Cognitive Behavioral
Conjoint Therapy for PTSD (Monson, 2012)
Medical Treatment of
Complex Trauma
Medication for symptom management and
co-morbid disorders
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Antidepressants
Mood stabilizers
Anticonvulsants
Sleep aids, including Prazosin for nightmares
Atypical antipsychotics No longer
Anxiolytics Not benzodiazepines
Only SSRIs are approved for treating PTSD
There is no medication that specifically
“cures” PTSD
Psychological Treatment of
Complex PTSD
Evidence-based psychotherapies are not, by
themselves, enough, since they are
designed for specific diagnoses; careful
clinical attention must be paid to the
disruptions of cognition, emotion, body,
sense of self, and interpersonal
relationships associated with complex
trauma
Ford and Courtois, 2009
What Needs to Be Done
Agencies Must Provide
Trauma-Specific Services
Train
agency staff to understand the link
between traumatic experiences and negative
health and mental health outcomes
Screen all patients for a trauma history
Provide case management to expand and
link services (including housing, shelter,
employment, family treatment,
transportation, child care, health care,
mental health and substance abuse services,
etc.)
Create a Safe, Supportive,
Non-Threatening Environment
Maximize
choice and control
Avoid provocation and power assertion
Model prosocial behavior and skills
Maintain clear and consistent boundaries
Share power
National Child Traumatic
Stress Network
Create a Safe, Supportive,
Non-Threatening Environment
Provide
services in a respectful and
nonjudgmental manner
Provide a variety of treatments and groups
on trauma: psychoeducation, skills
training, processing, reconnection, and
ongoing support
Provide a range of culturally competent
services
Orient Clients Toward
Resilience
Teach and practice:
Affect regulation skills
Anger management strategies
Problem-solving skills
Problem-focused coping strategies
Communication skills
Stress management skills
Relaxation
Mindfulness
Resources
Trauma
and Recovery, 1992, Judy
Herman
Treating Complex Traumatic Stress
Disorders, 2009, Christine Courtois
and Julian Ford, eds.
Treatment of Complex Trauma:
A Sequenced, Relationship-Based
Approach (2012), Christine Courtois,
Julian Ford, and John Briere
Resources
The
Trauma Recovery Group: A Guide
for Practitioners (2011), Michaela
Mendelsohn, Judith Herman, Emily
Schatzow, and Diya Kallivayalil
Seeking Safety (1998), Lisa Najavits
Skills Training Manual for Borderline
Personality Disorder (1993), Marsha
Linehan
Motivational Interviewing, 3rd Ed.
(2012), William Miller and Sam Rollnick
Resources
Trauma
Focused-Cognitive Behavioral
Therapy : http://tfcbt.musc.edu
EMDR: http://www.emdr.com and
http://emdria.org
Seeking Safety:
http://www.seekingsafety.org and
http://vaww.collage.research.med.va.
gov/collage/E_behav/SS/
Resources
Dialectical
Behavior Therapy:
http://www.behavioraltech.com
Cognitive Processing Therapy:
http://vaww.collage.research.med.va.
gov/collage/CPT/
Prolonged Exposure:
http://vaww.collage.research.med.va.
gov/collage/E_behav/PE/
Resources
Acceptance
and Commitment
Therapy: www.act-for-anxietydisorders.com and
http://vaww.collage.research.med.v
a.gov/collage/E_ACT/training.asp
International Society for Traumatic
Stress Studies: http://www.istss.org
Resources
http://www.motivationalinterview.org/
http://www.motivationalinterview.org/
clinical/METDrugAbuse.PDF
Motivational Enhancement Therapy
Manual (1994), NIH Pub. No. 94-3723.
Order from
http://pubs.niaaa.nih.gov/publications/
match.htm.
http://mid-attc.org/accessed/mi.htm
Contact:
Brian L. Meyer, Ph.D.
[email protected]