The  Trauma  Response  Treatment

WHAT IS TRUAMA?

    It is easy to appreciate the trauma from war, natural disasters, and car accidents. We have eventually learned that the impact of rape, physical abuse, sexual molestation also produce traumatic consequences. These are commonly considered big T(raumatic) events. Recently, little t(raumatic) events such as a child witnessing violence and a disruption or gap in empathic response from caregiver for an infant is also substantiated by PET scan technology.

Post Traumatic Stress Disorder:

Trauma response is the recurrent distressing recollections of the event, dreams, acting or feeling as if the event were recurring, psychophysiological reactivity upon exposure to inner or outer cues.
•    Avoidance of stimuli associated with trauma, general numbing of responsiveness as an effort to avoid thoughts, feelings or anything associated with Trauma
•    Diminished interest in activities, detachment or estrangement; restricted affect and a foreshadowed sense of the future –fails to plan for future
•    Diminished awareness of surroundings (daze) problems concentrating, attention, derealization, depersonalization, dissociation
•    Persistent symptoms of increased arousal such as impaired sleep, irritability, anger outbursts, hypervigilance and exaggerated startle response
•    Problems regulating affective arousal: moderating anger, affect dysregulation, self-destructive or suicide, impulsive
•    Somatization: physical sensations associated with trauma without conscious awareness of event
•    Alterations in self perception, chronic guilt, shame, helplessness, ineffectiveness; sense of being permanently damaged
•    Altered perceptions of perpetrator – adopting distorted beliefs like self blame
•    Altered relationships marked by difficulty with trust and pattern of revictimization
•    Alterations in ones sense of meaning, loss of hope, trust, despair, loss of belief in future
•    Extreme autonomic responses to stimuli reminiscent of the trauma, hyperarousal to intense but neutral stimuli
•    Increased vulnerability to physical illnesses and other mental disorders

When traumatized by those depended upon the symptoms are more severe; failures of self - identity cohesion.

Dissociative Conditions:

    SUBJECTIVE EXPERIENCES OF DISSOCIATIVE STATES

• Memory Problems:  Significant gaps in memory for one or more of the following: your childhood; the day before; your past; recent events; significant life events; etc.

• Depersonalization:  Odd or changed experiences of your self, your mind, or your body.  Experiences of feeling unreal, being detached observer of yourself, or feeling distant, changed,   estranged, or disconnected from your self, your mind, or your body.

• Flashbacks:  Sudden, intrusive memories, pictures, internal ‘videotapes’, nightmares, or body sensations of a previous traumatic experience.  During strongly dissociated flashbacks, a person loses contact with here and now, is instead ‘there and then,’ and it is difficult to ‘pull him or her out of it.’

• Somatoform Dissociation:  Somatic experiences and symptoms (with no medical basis) that affect vision, hearing, sight, smell, taste, body sensation, body functions, or physical abilities.

• Trance:  Staring off into space, thinking about nothing, and being unaware of what is going on around you.  The person is ‘out of touch’ with what is going on around him or her and it is difficult to get his/her attention.

• Identity Confusion:  The uncertainty, puzzlement, internal conflict, and disease that accompany (or result from) internal feelings of division and recurrent, peculiar dissociative experiences.

• Voices:  Auditory voices in your head that comment on what you are doing or thinking; tell you what to do; harass you; call you names; threaten you, etc.

• Ego Alien Experience:  Odd and confusing intrusions from within that influence what you say, what you do, what you feel, what you think, and so on.  These intrusions are caused by other parts of your mind that are so separate and unintegrated (i.e., dissociated) that they feel intrusive, alien, and confusing to you.  These dissociated parts of your mind were created by traumatic experiences that were so overwhelming that they could not be digested (or integrated) when they happened.  These partially split-off pieces of your mind sometimes ‘act on their own’; when they do, they cause peculiar intrusions into your thinking, emotions, body sensations, intentions, and actions.  These dissociated parts of your mind often speak.  When they speak, they can be heard as voices in your head or as sudden strong thoughts that “come from out of nowhere”.

• Self-States and Alters:  Partial or full awareness of the presence of separate parts (in your head) that are different from you.  Only some people have such parts, usually as an after-effect of serious and chronic abuse (emotional, physical, or sexual).  The most common parts are child parts and angry parts.  When activated, these parts exhibit emotions, thoughts, attitudes, impulses, and actions that are often very different from your emotions, thoughts, attitudes, impulses, and actions.

• Self-Alteration:  Suddenly feeling (or being) very different from your usual self.  These changes are so odd and striking that they are often quite puzzling and disconcerting to you.

• Discontinuities of Time:  Long time; “coming to” and discovering that you have done things that you do not remember doing; finding yourself somewhere and having no memory of how you got there.

• Disremembered Actions:  Being told by others of things that you have done---but you have no memory of having done these things.  Finding things among your possessions that you cannot account for.  Discovering evidence that you have done things that you do not remember having done.  Recurrent incidents of disremembered actions point to the presence of alter personalities (i.e., multiple personality disorder).

PARTIALLY-DISSOCIATED INFLUENCES OF ANOTHER SELF-STATE:

• Child Voices:  Hearing crying or the voice of a child in your head.

• Internal Struggle for Control:  Feeling a very powerful struggle inside you about what to do and say.  Voices may try to tell you what to do.

• Persecutory Voices:  Hearing voices in your head that call you names, put you down, or want you to hurt yourself or die.

• Partially Dissociated Speech:  Feeling that the words coming out of your mouth are not in your control or are being controlled by someone other that you.

• Partially Dissociated Thoughts:  Having thoughts that feel like they are imposed on you, don’t really belong to you, or that come “from out of nowhere.”

• Partially Dissociated Emotions:  Sudden strong feelings that “come from out of nowhere” or sudden changes of mood without any reason.

• Partially Dissociated Impulses:  Having strong impulses to do something---but the impulses do not feel like they are “yours.”  The presence, from time to time, of strong impulses to do or say something that you do not wish to do.

• Partially Dissociated Behavior:  Feeling as if some of your behavior is not really “yours” or is controlled by something else inside you.

• Temporarily Dissociated Knowledge and/or Skills:  Suddenly forgetting how to do things that you know very well how to do:  your job, how to drive, your name, etc.

• Disconcerting Experience of Self-Alteration:  Sudden odd changes in your sense of yourself:  feeling like a different person, switching back and forth between feeling like a child and an adult (or a man and a woman), seeing someone else in the mirror, etc.

• Puzzlement about Oneself:  Being very puzzled, again and again, about why you do and say what you do, why you feel the way you do, who you really are.

FULLY-DISSOCIATED ACTIONS OF ANOTHER SELF-STATE:

• Time Loss:  “coming to” and finding that you have done something (or are in the middle of doing something that you have no awareness or memory of having done.

• Fugues:  Finding yourself somewhere and having no memory whatsoever of going to that place.

• Being Told of Disremembered Behavior:  Being told by others that you did or said things that you have absolutely no memory of having done.

• Finding Things Among Your Possessions That You Cannot Account For:  Finding objects, writings, or drawings at your home that you have no idea where they came from.

• Finding Evidence of Your Recent Behavior---That You Don’t Remember Doing:  Finding things moved around or changed.  Discovering tasks completed that you cannot explain.  Discovering that you have injured yourself or attempted suicide.

• dissociative processing looks to inner world for gratification of needs because of inconsistent experience with world.

Borderline Personality Disorder

Regulation theory        

•    Bpd is the most common personality disorder 1-2%, 10% of all patients.

•    PTSD & bpd share massive disturbances in affect regulation, impulse control, interpersonal difficulties, self-integration using dissociation under stress

•    50% of bpd patients also have ptsd stemming from early childhood trauma emphasizing relational attachment trauma in first 2 years rather than later sexual trauma

•    Bpd symptoms are consequences of emotional dysregulation or frantic efforts to obtain comfort but not being able to be comforted

•    Maternal intolerance of autonomy leads to failure of separation – individuation

•    Parental inconsistency, lack of empathy interferes with the establishment of basic trust resulting in an inability to evoke soothing memories

•    Environmental stress / relationship causes neurobiological abnormalities

•    Insecure attachment from abuse, neglect causes affect regulation disturbances due to influences in brain development

•    Abuse – hyperarousal / neglect – hypo arousal from primary attachment  object impacts right limbic structures thereby impairing affective cognitive and behavioral functions

•    Maternal  inconsistency causes mini traumata

•    Experience-dependent attachment relationship is the essential ingredient in neural mechanism developments for self regulation

Lack of maternal empathy, orientation to own needs not the child’s cause bpd

Freeze=dissociation and metabolic shutdown occurs

If the intense affects of infancy are not responded to consistently & lovingly in the mother/child interaction there is dysregulation of amygdalic function

Stress of maternal separation biologically parallels abandonment correlates in bpd

Hypersensitivity to social cues i.e. facial expressions shows negative interpretation of neutral expressions; and their hyper responsiveness can elicit unambiguous avoidant or aggressive responses from others confirming their negative interpretation.

Attachment theory

•    Environment can buffer genetic predispositions

•    Mother’s unavailability results in disorganized attachment even more (by twice) than later abuse

•    Maternal disrupted communications

Affective communication errors

1.    no response

2.    Misattunment

Role confusion behaviors – i.e. role reversal where child nurtures / reassures parent

Negative-intrusive – such as teasing or mocking

Disoriented behavior – confused or frightened

Withdrawing behavior – physical distance, stiffness, Verbal distance, no greeting.. parent is fearful

•    The comfort offered by caregiver buffers (or not) the distressed child

•    the insecure-avoidant attachment leads to lessening attention seeking strategy

•    the insecure ambivalent attachment leads to exaggerating attention expressions because caregiver is inattentive

•    infant disorganized behavior

    dysphoric affect

    conflictual behavior – stilling, freezing, slowed, approach & avoidance

    disoriented – confused, dazed

   absence of consistency; simultaneously contradictory acts

•    Pseudo secure – distress to separation; some proximity seeking; calm in parent’s presence

•    Avoidant – resistant – marked distress to separation & avoidance at reunion leads to loss of behavioral control; helpless, fearful

Increased cortisol and decrease in cognitive function

•    The child develops an internalized model of helpless (hesitant or fearful) or hostile (contradictory) role; where the person related to is enacting the opposite role.

Helpless - Care giving control – person is inhibited, though aggressive with peers; undue attention                 

          seeking; entertainment of parent

Hostile - Escalating non compliance; excessive attention seeking in aggressive manner

 

Treatment

GOALS:

•    STRENGTHENING THE SELF

•    RESOLVING ATTACHMENT ISSUES

•    DEVELOPING AFFECT MANAGEMENT SKILLS (SKILLS TRAINING)

•    DEVELOPING INTERPERSONAL PROBLEM SOLVING SKILLS

•    RESOLVING ADULT DEVELOPMENTAL ISSUES (REFLECT IN SELF-REGULATION / AWARENESS CHRONIC AUTO-IMMUNE ILLNESS)

•    DEVELOPING A COHESIVE AND REALISTIC SENSE OF SELF, MEANING, AND PURPOSE (SPIRITUALITY)

Treatment is multi modal:

Treatment alliance - Treatment should focus on the nonverbal affective interpersonal processes more than the content of trauma for regulation.

•    Therapeutic alliance, effective emotional communication is central

•    Bond between patient & therapist is most critical factor for attachment & trust; medication adjunctive

•    The goal is effortful emotion regulation vs. Unconscious automatic affect regulation

•    Framework: willingness (openness), acceptance, respect, communication, cooperation = sharing whole system and allowing cognitive restructuring

•    Treating shame – permission from trauma parts always obtained prior to interventions

•    denial of their mind’s adaptive maneuver; denial of responsibility results in helplessness and victim role

•    Accepting or owning it allows for change

•    CHANGE FOR THE SYSTEM CAN OCCUR THROUGH ASKING THE SYSTEM TO IMPLEMENT A SET OF VALUES SYSTEM WIDE

            A safety contract consisting of:  agreeing to cooperate with hospitalization if you cannot abstain from self harm in any form .....  aka therapy threatening behavior

                         REQUIRED FOR CHANGE
                            • WILLINGNESS

                  • RESPECT                   

       •ACCEPTANCE                               
  
       • COMMUNICATION         
   
       • COOPERATION

Sensorimotor – Body resources

•    Notice the body’s repetitive responses without interpretation; just have client observe the body

•    Engage in alternative actions

•    Emotional – articulation, processing, expression

•    Sensorimotor – physiological sequences

1.    fosters somatic sense of self

2.    focus on how the body processes information and affects meaning

•    therapy is helping the patient be mindful of present experience; being in the now and practice alternatives

•    reinforce recognized body’s experience, while grounding in the now and bringing the child’s need forward through opposite body action (observing difference)

Somatic resources

•    Proximity – moving towards & away

•    Active motor defenses, boundaries e.g. legs, hands

•    Leaning / support

•    Reaching out by pt or therapist

•    Holding on, letting go

•    Jacobson Relaxation exercises

Somatic experiments

•    Alignment of posture

•    Containment – feel the edges, skin, muscles

•    Centering

•    Grounding – connection to earth

•    Discover somatic reactions of all parts and experiment with different parts being present simultaneously

Medications – psychiatric consultations

Emotional - Build tolerance of negative affect.

•    Affect regulation

•    Distress tolerance

•    Managed abreaction

•    Temporizing techniques

•    Visualization exercises

•    Self hypnosis

Behavioral

•    Desensitization – exposure to threatening stimuli

•    DBT – dialectical behavioral therapy skills from Linehan’s skills book

•    Group therapy – laboratory practicing, socialization, risk taking

Cognitive

•    Logical consequences, reasoning, meaning making

•    ABCs tool (cognitive behavioral therapy) to restructure the interpretation of experience

Additional Resources

•    Eye Movement Desensitization Reprocessing