Transcript CSA Treatment and PTG in Adult Clients: Phase Two Mis

Diane Langberg, PhD
Philip G. Monroe, PsyD
Slides Available:
www.globaltraumarecovery.org
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Identify common clinical mistakes in the
treatment of adult survivors of child sexual
abuse
Describe best practices during phase two of
treatment
Understand common signs of posttraumatic
growth and resilience within clients that
appear stuck
The client?
Or the counselor?
“How can I get my client to…?”
“How can I get rid of my client?”
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Messianic rescuing (over-responsibility)
 Boundary crossings or Burnout
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Demanding catharsis
 Forcing memory processing/exposure
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Misunderstanding client resistance
 Irritated with client; push harder
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Failure to manage “the hour”
 Encouraging dissociation
Brief Review
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Re-experiencing: (1)
 Recurrent, intrusive distressing
recollection (may be repetitive play)
 Recurrent, distressing dreams
 Acting or feeling as if event is
recurring
 Psychological distress on exposure
to cues
 Physiological reactivity on exposure
to cues
Increased arousal (2)
 Difficulty falling or staying asleep
 Irritability or outbursts of anger
 Difficulty concentrating
 Hypervigilance
 Exaggerated startle response
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Avoidance or Numbing (3)
 Efforts to avoid thoughts,
feelings, conversations
associated with trauma
 Efforts to avoid activities,
places, or people associated
with trauma
 Inability to recall important
aspect of trauma
 Diminished interest or
participation in significant
activities
 Feeling of detachment or
estrangement from others
 Restricted range of affect
 Sense of foreshortened future
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Pays more attention to dissociative problems
 Derealization
 Depersonalization
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Sees these symptoms as separate from reexperiencing and/or hypervigilance
Why important?
 Clients with this set of symptoms respond better to
mindfulness, cognitive restructuring, and DBT style
interventions in addition to exposure therapies
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Note: also “preschool” subtype
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Betrayal trauma experiences leading to
symptoms of complex PTSD
Hypervigilance
Distorted sense of self
Addictions
Eating disorders
Sleep disorders
Shame
Dissociation
Self-hatred
Fear
Confusion
Distrustful
Distorted view of God
Control seeking
Self-destructive behavior
Emotional numbness
1.
2.
3.
4.
5.
6.
7.
Ability to regulate affect and impulses
Attention and consciousness
Self-perception
Perception of the perpetrator
Capacity for relationships
Body and brain responses
Perception of meaning and faith
DESNOS
BPD
Primary Affect:
Panic and pain
Relationships:
Passive,
avoidance, revictimization
Present, chronic
Has capacity for
positive affect
Vacillates between
desire and
devaluation
Transient, if
present
Idealized identity
Dissociation:
Cognitive Focus:
Self:
Fear, avoidance
Consistent self
loathing
Confused
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Foundation for all treatment
Longest phase and vital to positive outcomes
Features
 Therapeutic alliance building
 Education about the nature of trauma
 Managing vs. reacting to symptoms
Memory work done in concert with phase one
skills
 Focus: grief, loss, shame, anger rather than
anxiety
 Context: the tendency to leave (dissociate from)
the pain
 Goal: Small amounts of memory work with
frequent self-care and stabilization
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Exposure
Stress inoculation
OR…?
 Interpersonal/dynamic interventions
“Therapy that emphasized relaxation,
relationships, affect, and meaning-making
appeared to be more helpful than therapy that
emphasized exposure to trauma reminders.”
D’Andrea & Pole
Pointing to Corrective Experiences in Therapy
Intense fear, paralysis/helplessness, inability to
effect any change, threat of annihilation, leading
to experience of,
Loss of voice, control, connection, and meaning,
resulting in,
Disorganized physical, cognitive, and emotional
response system thereby increasing,
Relational pain, distrust, self-contempt,
overwhelming anxiety, evidenced as,
Running from the past, afraid of the future
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Proceed little by little, without force
Focus on this step over ultimate goal
Embrace repetition
Embrace rest; Identify as NOT failure
Remember: Return to safety/stabilization
throughout treatment
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Attachment
Self-Regulation
Competency
Kinniburgh, Blaustein, Spinazzola, Psychiatric
Annals, May 2005
http://psychrights.org/research/Digest/CriticalT
hinkRxCites/kinniburgh.pdf
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Predictable routines in therapy
Support in-the-moment affect regulation
Watch your language
Affirm strengths (find them in surprising
areas!)
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Expand awareness of affect
Connect affect with body sensations
Normalize reactions
Self-expression through nonverbal means
Encourage kinetic regulation of affect
Connect affect with historical events
Teach grounding techniques
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Identify interests/goals
Encourage independent choices
Learning relational safety/danger cues
Encourage connections to others
Identify and affirm strengths
Teach self-awareness  self-care
Construct solutions to problems together
Review outcomes together
Meditation and Solitude as Emotion Regulation Interventions
Mindfulness is about
waking up from a life on
automatic pilot,
becoming keenly aware
and sensitive to our
experiences – both
internal and external
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On creation
On Scripture
On Christ
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Goal: having a sanctuary of the heart so we
are not controlled by people or noise
Exploring Movement in Therapy with Adult Survivors
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Retrospective perceptions of positive
psychological changes after trauma
 Not just bouncing back but growing beyond pre-
trauma adaptive capacities
 Connotes positive change in identity and
capacities post trauma
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Changes seen in
 Identity perception (perceived new possibilities)
 Capacity awareness (strength perception)
 Appreciation of life and faith (values)
PTSD
PTG
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Holding symptoms and strengths together
Success during phase two includes
 Ability to say no
 Ability to have hope
 Not reduction of triggers and trauma reactions
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Why do most recover from traumatic
experiences and do not go on to develop
PTSD?
 Intrinsic capacity?
 Community supports?
 Prior experiences?
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re·sil·ience
 the power or ability to return to the original form,
position, etc., after being bent, compressed, or
stretched; elasticity.
 ability to recover readily from illness, depression,
adversity, or the like; buoyancy.
http://dictionary.reference.com/browse/resilience
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the ability to recover readily from illness,
depression, and adversity
 Adapting?
 Thriving?
Problem with this definition? What does resilience
look like in an ongoing storm?
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Joseph?
 What you intended for evil…
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Jeremiah?
 I will never forget this awful time as I grieve…yet I
still dare to hope
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Esther?
 If I perish, I perish
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Paul?
 Though outwardly we are wasting away, yet
inwardly we are being renewed
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Optimism (realistic optimism)
Cognitive flexibility
Personal moral compass
Role models
Face and reframe fears
Active coping mechanisms
Attending to physical wellbeing
Nurture social network
Recognize strengths
Dennis Charney
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YES!
 Gratitude
 Pride in culture and ethnicity
 Appreciation of human differences
 Karma
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Fear/Reward circuits
NeuropeptideY?
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Passive acceptance of threats
Loss of social support and moral foundation
Rumination
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Possible ways to improve it
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CBT
Narrative work
Faith engagement
Mindfulness
Social Support
Self-reflection
Physical training
Sleep
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Phase 1: Interventions avoid disrupting intact
protective factors (meaning, networks,
structures)
Phase 2: Re-establish weak social resources
(family re-unification, vocational training)
Phase 3: Targeted trauma recovery
intervention
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Community’s inherent capacity, hope, and
faith to withstand major trauma, overcome
adversity, and to prevail, with increased
resources, competence and connectedness
Judith Landau
Individual resilience promoted by community
and
Community expression of resilience
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Active use of family/community resilience
stories
Active engagement of transcendence
Organizational strength
 Flexibility
 Connected
 Available resources
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Identify agents of change
Identify local values, resources, wisdom
Reinforce open dialogue, to
Identify tangible assets (community
genogram)
Re-establish daily patterns, rituals
Re-connectedness
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Use of drama to
capture lament
 To validate, narrate
 To spark conversations
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Local conversations
where all parties have
voice
 Goal identification
 Resource allocation
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Support groups