•
Stephen Wonderlich, Ph.D.
•
University of North Dakota School of
Medicine
•
& Health Sciences
•
Neuropsychiatric Research Institute
•
Sanford Health
•
Heather Simonich, M.A.
•
Neuropsychiatric Research Institute
•
Kathryn Gordon, Ph.D.

• Eating Disorders
•
Non-Suicidal Self-Injury
• Borderline Personality
•
The Role of Trauma in Self-Damaging Behavior
• Clinical Ideas for ED, NSSI, BPD, and Trauma
•
Trauma Informed School Systems

A.
Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
B.
Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
C.
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

A.
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1.
Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
2.
A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
B.
Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, and other medications; fasting; or excessive exercise.
C.
The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
D.
Self-evaluation is unduly influenced by body shape and weight.
E.
The disturbance does not occur exclusively during episodes of anorexia nervosa.

A. Recurrent episodes of binge eating.
B. The binge-eating episodes are associated with three (or more) of the following:
–
1. eating much more rapidly than normal
–
2. eating until feeling uncomfortably full
–
3. eating large amounts of food when not feeling physically hungry
– 4. eating alone because of being embarrassed by how much one is eating
– 5. feeling disgusted with oneself, depressed, or very guilty after overeating
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

•
1% of women in community
•
99% of cases are female
•
Middle to upper class

•
2% of women in community
•
4-5% of college women
•
90-95% cases are female
•
Middle to upper class
• Broadening to other strata

• 
3.5% of U.S. women
• 
2.0% of U.S. men
•
More social and gender diversity than AN and BN
•
4.5% of black sample = BED
Hudson et al., 2007

Psychiatric Comorbidity in Bulimic Patients
N = 46
No Comorbidity
Anxiety
Mood
Personality Disorder (PD)
Substance Abuse
Anxiety/PD
Mood/PD
Mood/Substance
Substance/PD
Mood/Substance/PD
Mood/Anxiety/PD
Mood/Substance/Anxiety
Mood/Substance/Anxiety/PD
Cases
7
2
7
4
1
3
1
9
2
1
1
3
5
(15%)
(2%)
(20%)
(9%)
(2%)
(4%)
(15%)
(7%)
(2%)
(7%)
(4%)
(2%)
(11%)

•
Gender
•
Age
•
Family History/Genetics
•
Extreme Dieting
•
Weight/shape focused occupation/activities

•
Environmental stress/change
•
Abuse
•
Personality/self concept
•
Depression, anxiety (particularly childhood)
•
Sociocultural influences
Stice, 2001
Jacobi et al., 2002

Non-Suicidal Self-Injury (NSSI)
Socially unaccepted behavior causing intentional and direct injury to one’s body tissue without suicidal intent
(e.g., cut, burn, abrade, hit)
Claes & Muehlenkamp (2014)

Handout

•
Average age of onset – 12-16 years
•
Lifetime prevalence – 18% (teens)
•
Rates increasing, but recently stabilized
•
Females > males (slightly)
– Type of self harm varies by gender
Rodham & Hawtone, 2009
Muehlenkamp et al., 2012
Claes et al., 2010

•
Injury inflicted with a knife, needle, razor or sharp object, burn, abrasion
•
Thighs, forearm
•
Series of cuts – 1 or 2 cm apart
•
Blood and scarring

•
> 70% of ED patients report NSSI
•
25-54% of NSSI report disordered eating
•
NSSI more strongly associated with binge purge
ED than restricting ED
Claes et al., 2010
Muehlenkamp et al., 2012
Golust et al., 2008

Models to Explain Similarities
DISTAL FACTORS PROXIMAL FACTORS BEHAVIOR
Individual Predisposing Factors
TEMPERAMENT
High Emotional Reactivity
Negative Mood Intolerance
PERSONALITY
Impulsive
Obsessive-Compulsive Traits
Perfectionism
Social Predisposing Factors
FAMILY ENVIRONMENT
Low Emotional Support
High Control & Criticism
Low Connectedness
TRAUMATIC EXPERIENCES
Emotional, Physical, Sexual
Abuse
Peer Bullying
CULTURAL PRESSURES
Self-Objectification
Unrealistic Body Stereotypes
Individual Cultural Pressures
Specific Risk Factors
EMOTION DYSREGULATION
Low Distress Tolerance
COGNITIVE DISTORTIONS
Self-Criticism/Guilt
Low Self-Esteem
LOW BODY REGARD
Body Esteem/Body Dissatisfaction
Body Competence
Interceptive Awareness/Alexithymia
Body Integrity
DISSOCIATION
PEER INFLUENCE/CONTAGION
Best Friend/Peer Engagement
Socialization & Selection Efforts
PSYCHIATRIC Disorders
Mood/Anxiety Disorders
Posttraumatic Stress Disorder
Substance Related Disorders
Axis II Personality Disorders
Stressful
Life
Event
NSSI
&
Eating
Disorder

•
Emotional cascade
–
Event – emotion – rumination – behavior
Selby & Joiner, 2009
•
Four Function Theory
Nock & Prinstein, 2008
•
Escape Theory
– Failure experience – negative emotion – dissociation – behavior
Heatherton & Baumeister, 2001

Negative
Reinforcement
Positive
Reinforcement
Interpersonal
Get out of a situation
Get a response from someone else
Intrapersonal
Stop bad feelings
Feel something even if it’s pain

•
Emotion Dysregulation
–
Negative body view
–
Depression
–
Emotion dysregulation
Muehlenkamp et al., 2012
Gordon et al., 2014

• http://www.youtube.com/watch?v=dZJhJJh7Ek&list=PL_F7LS-
9PhvsTVSOfs113c09ENQYeRIhQ

(Miller et al., 1971)

1.
Neglect (food, clothing, housing, medical)
2.
Emotional abuse (degrading, demeaning)
3.
Physical abuse (physical pain, coercion, or dominance)
4.
Witness violence
5.
Sexual abuse (child used for sexual stimulation)

• 10 – 13% of America’s children have been kicked, burned, bit, punched, hit with an object, beaten or threatened with weapon by a parent
• 25% of school children experience a trauma
• 20% of traumatized children have a mental health diagnosis and only 10% of those receive treatment
• 21 – 32% of U.S. women were sexually abused before age 18
Kilpatrick, 1996
Vogeltanz et al., 1999
NCTSN School committee, 2008

National Women
 s Study N = 714 Cases
Age at time of Rape
7.1%
6.1%
3.0%
29.7
22.2%
<11 years old
(29.7%)
11-17 years old
(32.2%)
18-24 years old
(22.2%)
25-29 years old
(7.1%)
>29 years old
(6.1%)
Not sure/refused
(3.0%)
32.2%
Kilpatrick, 1996

Adverse Childhood Experiences
5.
6.
7.
8.
1.
2.
3.
4.
Child physical abuse.
Child sexual abuse.
Child emotional abuse.
Emotional neglect.
Physical neglect.
Mentally ill, depressed or suicidal person in the home.
Drug addicted or alcoholic family member.
Witnessing domestic violence against the mother.
9.
Loss of a parent to death or abandonment, including abandonment by parental divorce.
10.
Incarceration of any family member for a crime.
(Anda & Felitti, 2009)

The ACE Study
(Felitti et al., 1998)
Disease
Smoking
Obesity
Depression
Suicide Gesture
Alcoholism
Illicit Drugs
Injectable Drugs
Sexual Promiscuity
STD
4 or More Adversities
(Odds Ratio)
2.2
1.6
4.6
12.2
7.4
4.7
10.3
3.2
2.5

The ACE Study
(Felitti et al., 1998)
Disease
Heart Disease
Cancer
Stroke
Bronchitis/Emphysema
Diabetes
Hepatitis
Fair/Poor Health
4 or More Adversities
(Odds Ratio)
2.2
1.9
2.4
3.9
1.6
2.4
2.2

15
10
5
0
25
20
ACE & SUICIDE ATTEMPTS
4+
3
0
1
2
ACE Score

The ACE Study
(Felitti et al., 1998)

• Adverse Childhood Experiences (ACEs) are very common
• ACEs are strong predictors of adult health risks and disease
• ACEs are implicated in the 10 leading causes of death in the
United States

Is there a relationship between trauma and disordered eating in traumatized samples?

Incest (N=38) Control (N=27)
Binge 42% 15%
Vomit 24% 4%
Laxative 11% 4%
(Wonderlich, Donaldson, Carson, Staton, Gertz, Leach, Johnson, 1996)

Trauma and Psychopathology
SCID Lifetime Diagnoses
70
60
50
40
100
90
80
30
20
10
0
CSA + Rape
CSA
Rape
Control
Mood
Disorder
Anxiety
Disorder
(CSA)
Substance
Disorder
(CSA,Rape)
Eating
Disorder
(CSA)
(Thompson et al., 2002)

How about in traumatized children?

Five Year Prospective Study of CSA
Children (8 - 13 years)
60
50
40
30
20
10
0
Extreme Diet Binge
CSA (n = 68)
Control (n =
68)
Vomit
(Swanston et al., 1997)

Prospective Study of CA and ED
(Johnson et al., 2002)
No CSA CSA Odds Ratio
Fluctuations in weight (%)
Dieting (%)
Vomiting (%)
19
17
3
41
50
18
3.02
4.80
6.59
Diagnosis
ED (%) 7 27 5.11
Controlling for age, gender, child temperament, eating problems , parental psychiatric, other child adversity. Study of 782 families.

Does trauma influence ED treatment response?

Impact of Traumatic Experiences and
Violent Acts upon Response to Treatment
(Rodriguez et al., 2005)
• 270 women with AN, BN, or BED
• Entered outpatient tx between January 1997 through July 2003
• 160 patients who completed 4 months of tx selected for study sample

Impact of Traumatic Experiences and
Violent Acts upon Response to Treatment
(Rodriguez et al., 2005)
Poor Response Good Response
(n=70) (%) (n=90) (%)
Any type of trauma 53% 37%
Sexual Abuse (repeated) 23% 10%*
Other violent experiences 47%
Both Traumas 23%
30%*
4%***

• Trauma is associated with ED
• Trauma may impact treatment outcome
• Trauma is associated with impulsive, emotionally dysregulated ED

So, how may early trauma operate to increase risk?

Possible Mediators/Mechanisms
Trauma
• Shame
• Dissociation
• Impulse Control
• Anxiety
• Substance Use
• Cognitions
• Mood Instability
ED
(Andrews, 1997; Kent et al., 1999; Hart & Waller, 2002; Murray &
Waller, 2002; Wonderlich et al., 2001)

Psychobiological Mediation
(Animal Studies)
Early Stress
Altered
Biological
Stress Response
Behavioral
Response
Suomi, 1991; Kraemer, 1992; McEwen, 1998;
Meaney et al., 1988; Sapolsky et al., 1986

Suppressed HPA Axis and Trauma
(Carpenter et al., 2007)
4
2
0
12
10
8
6 Controls
Maltreated
0 15 30 45
Elapsed Time
60 75 90

Suppressed HPA Axis and Trauma
(Carpenter et al., 2007)
600
500
400
300
200
100
0
0 15 30 45 60
Elapsed Time
75 90
Controls
Maltreated

Differences in Cortisol for
Abused and Nonabused BN
18
16
14
12
10
8
26
24
22
20
0
30 60 90 12
0
15
0
18
0
21
0
24
0
Time (Minutes)
Abused Bulimic
Nonabused Bulimic
Abused Normal Eater
Nonabused Normal Eater
(Steiger et al., 2001)

Does Child Maltreatment Damage the Brain?
In a child’s brain elevated catecholamines and cortisol may lead to:
• Loss of neurons
• Delays in myelination
• Deviant pruning processes
• Inhibiting of neurogenesis
(Lauder, 1988; Sapolsky, 1990; DeBellis et al., 2002; Dunlop et al.,
1997; Tanapat et al., 1998; Bremner, 1999)

Biological Correlates of Trauma in Children with PTSD
MRI Based Volume

Total Brain (Early Onset, Duration)

Corpus Callosum

Prefrontal Cortex

Superior Temporal Gyrus

Hippocampal Volume

Cerebellum
Ø
Pituitary
(Teicher et al., 1997; Carrion et al., 2001; DeBellis et al., 1999, 2002a,
2002b; 2004; 2006; Thomas & DeBellis, 2004; Tupler & DeBellis, 2006)

Trauma elicits psychobiological changes that may result in increased impulsive dysregulated behavior (i.e., binge, purge, self-harm).

CA
• Sexual
• Physical
• Dissociation
- Somatic
Disconnection
• Lack of Emotion
Regulation Skills
NSSI
Muehlenkamp et al.,
2010
Yates et al., 2008
Gratz & Roemer, 2008

Does Borderline Personality Have
Any Relevance Here?

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five
(or more) of the following:
1.
Frantic efforts to avoid real or imagined abandonment
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5
2.
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3.
Identity disturbance; markedly and persistently unstable selfimage or sense of self

Diagnostic Criteria for 301.83
Borderline Personality Disorder
4.
Impulsivity in at least two areas that are potentially selfdamaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5.
5.
Recurrent suicidal behavior, gestures, or threats, or selfmutilating behavior.
6.
Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7.
Chronic feelings of emptiness
8.
Inappropriate, intense anger or difficulty controlling anger
(e.g., frequent displays of temper, constant anger, recurrent physical fights)
9.
Transient, stress-related paranoid ideation or severe dissociative symptoms

I hurt myself today, to see if I still feel. I focus on the pain, the only thing that's real.
The needle tears a hole. The old familiar sting. Try to kill it all away, but I remember everything.
What have I become? My sweetest friend, everyone I know goes away in the end.
You could have it all, my empire of dirt. I will let you down, I will make you hurt.
I wear this crown of shit, upon my liar's chair. Full of broken thoughts I cannot repair.
Beneath the stain of time, the feelings disappear. You are someone else, I am still right here.
What have I become? My sweetest friend. Everyone I know goes away in the end.
You could have it all, my empire of dirt. I will let you down, I will make you hurt. If I could start again, a million miles away, I would keep myself, I would find a way.

• Inadequate Early Experience
• Deficit or Insufficiency
– Absence of “holding – soothing introjects”
• Search for Caretaking Response
• Need-Fear Dilemma

• Genetic Tendencies and Experience
Shape Schemas
– Schemas more continuous than in syndromes
• Basic Assumptions
– The world is dangerous and malevolent
– I am powerless and vulnerable
– I am inherently unacceptable
• Dichotomous Thinking

(Akiskal, Liebowitz, Klein)
• Primitive Personality = Nonclassical
Mood Disorders
– Subaffective variants
– Particularly irritable cyclothymia
• Bipolar Spectrum
• Tx Focus is on Mood Stabilization

• Biologically Based Deficit in Emotion
Regulation
• Invalidating Environment
• Coping Skills Deficit
• Borderline “Symptoms” are Efforts to
Regulate Negative Emotions

(Herman, Marmar, Perry)
• Significant Proportion of Borderlines Report
History of Child Abuse
• BPD is Adaptation to Traumatic Environment
• Instability in Affect, Self-Other Perceptions,
Relationships Linked to CA
• Complex Post-Traumatic Stress Disorder??
• Post-traumatic Personality Disorder??
• Tx Attends to Effects of CA

Is trauma linked to BPD??

Child Abuse in 712
ED Clinic Patients
30
20
10
0
60
50
40
None
Sexual
Physical
Both
Alcohol Suicide Attempt Shoplifting
Fullerton et al., 1995

72 27 0

CSA (%)
Borderline Other PD No PD
72 27 0
Wonderlich & Swift, 1990

* * *
Childhood Trauma Questionnaire
Wonderlich et al., 2007

Case - Ms. D.
• 40 year old female
• Diagnosis AN-BP, MDE, BPD
• Three near death suicide gestures
• History of trauma – CSA – father
• 5’ 4” – 70 – 80 lbs.
• Unemployed
• Schedule of life activities:
– 5:00 am – 12:00 pm – sleep
– 12:00 pm – 5:00 pm – errands, appointments
– 7:00 pm – 3:00 am – eat, binge, purge

Case of Ms. D. (Continued)
• Treatment
– 2 years, 2-3x week
– Refused medical evaluations
– Various psychotropic medications -

– Focus of treatment
• Binge - unsuccessful
• Weight gain - unsuccessful
• Trauma - triggering
• Suicide – frequent and unsuccessful
• Transference – prominent and complicated
– Mistrust/silence/motionless/angry departures
– Not understood
– Hate me/hate self
– Accept me as I am.

• Follow-up
– Referred to Resident
– Followed Resident to a city 280 miles away
– Returned 2-3 years later
• Up 8 lbs.
• Working

www.NICE.org.uk

(NICE Guidelines)
• Most people with anorexia nervosa should be managed on an outpatient basis with psychological treatment by a service that is competent in giving that treatment and assessing the physical risk of people with eating disorders.

(NICE Guidelines Cont.)
• People with anorexia nervosa requiring inpatient treatment should be admitted to a setting that can provide the skilled implementation of refeeding with careful physical monitoring
(particularly in the first few days of refeeding) in combination with psychosocial interventions.

(NICE Guidelines Cont.)
• Family interventions that directly address the eating disorder should be offered to children and adolescents with anorexia nervosa.

What is the Maudsley
Family Based Approach?
• Outpatient weight restoration treatment
• ~ Twenty sessions over 6-12 months
• Puts PARENTS in charge of weight restoration
(appropriate control, ultimately relinquished)
• Contrary to traditional separation of parents and child
• No assumption about etiology of AN

Maudsley End-of-Outpatient Treatment and Five-Year-Follow-Up
100
80
60
40
20
0
Eisler et al 2000 Eisler et al 2003
Good/Int
Poor

• RCT with 93 weight restored AN patients
• Fluoxetine vs. placebo for 1 year
• No difference in time to relapse or number completing 1 year of treatment

(NICE Guidelines)
• As a possible first step, patients with bulimia nervosa should be encouraged to follow an evidence-based self-help programme.

(NICE Guidelines cont.)
• As an alternative or additional first step to using an evidence-based self-help programme, adults with bulimia nervosa may be offered a trial of an antidepressant drug.

(NICE Guidelines cont.)
• Cognitive behaviour therapy for bulimia nervosa (CBT-BN), a specifically adapted from of CBT, should be offered to adults with bulimia nervosa. The course of treatment should be for 16 to 20 sessions over 4 to 5 months.

(NICE Guidelines cont.)
• Adolescents with bulimia nervosa may be treated with CBT-BN, adapted as needed to suit their age, circumstances and level of development, and including the family as appropriate.

Cognitive Behavior Therapy
(CBT) for Bulimia Nervosa
Fairburn, Marcus, & Wilson, 1993

• 20 sessions/16 weeks
• Manualized
• Reduce dieting
• Increase meals
• Cognitive restructuring
• Problem solving
• Self monitoring

Antidepressant Treatment of Bulimia Nervosa
% R e d u c tio n in B in g e F re q u e n c y
IM I
A M I
D M I
IM I
B u p ro p io n
P h e n e lz in e
T ra z a d o n e
IM I
F lu o x e tin e
D M I
F lu o x e tin e
B ro fa ro m in e
IM I
2 0 m g
6 0 m g
-40 -20 0 20 40 60 80 100

• Self Help
• Outpatient
• Intensive Outpatient
• Partial Hospital
• Residential
• Inpatient

• Medical complications
• Suicidality
• Body weight
• Motivation to recover
• Comorbid disorders
• Impairment in ability to care for self
• Purging behavior
• Environmental stress
• Treatment availability

PSYCHOLOGIST
• Provides initial evaluation and diagnosis
• Conducts individual, family and group therapy to help you and your family to understand and overcome your eating disorder and other related problems like depression or anxiety
• Coordinates your care with the rest of the treatment team
EDI TREATMENT TEAM
DIETITIAN
• Evaluates and assesses nutritional needs
• Provides nutrition education
• Develops an individualized meal plan
• Guides you in normalizing eating and developing healthy attitudes about eating
SOCIAL WORKER
• Contact with community resources
• Collaboration with participating agencies
• Coordination of care
• Educate team on resources in the community
CLINICAL NURSE SPECIALIST OR
PSYCHIATRIST
• Provides evaluations to determine if psychiatric medications might be helpful in treating your eating disorder or related problems like depression or anxiety
• Monitors your response to such medications and adjusts or changes them as needed
PATIENT
• Responsible for making and attending appointments
• Responsible for collaborating with the team and being an active participant in his/her treatment
• Responsible for following recommendations from the treatment team
MEDICAL DOCTOR
• Conducts a thorough medical examination to find out if there are any urgent health problems related to your eating disorder
• Provides medical treatment for health problems if they are found
• Monitors the changes in your physical health throughout your treatment
RECEPTIONIST OR OFFICE SPECIALIST
• Schedules appointments with treatment providers
• Takes telephone messages
• Assists treatment providers in managing paperwork
• Obtains insurance preauthorization; tracks benefits and works with insurance companies to get treatment plans approved
TRIAGE NURSE
• Provides information about programs available at
EDI
• Completes phone assessments and sets up first time appointments for the outpatient clinic
• Takes phone calls from patients, significant others or families with questions on the illness, medications or refills
• Coordinates admissions to the inpatient and partial hospitalization programs
WORKING CLOSELY AND CONSISTENTLY WITH EACH MEMBER OF YOUR TREATMENT TEAM IS AN
IMPORTANT PART OF YOUR RECOVERY. EATING DISORDERS ARE TOO COMPLEX AND DIFFICULT TO
OVERCOME FOR ANY ONE PROFESSIONAL TO “DO IT ALL.” COLLABORATION IS THE KEY.

http://www.youtube.com/watch?v=1
OQbUZeYAik

Negative Affect and Binge
Smyth et.al. 2007
40
38
36
34
32
30
-8 -6 -4 -2 0 2
Hours Relative to Binge
4 6 8

Therapist : “Now, what are we doing here? What I’m noticing is I’m hammering away at this with you and you are holding firm and steady with a hint of curiosity.”
Subject : “Well right, I mean how have I done it up until this time in my life…with alcohol and throwing up. That’s where my serenity, if I’m going to have any, comes from. Just numb me up which means I’m not actually having any serenity in the first place. I’m just numbing the rest of my world out.”
Therapist : “Right, and if you begin to tune into instead of numbing out, so if you use the Palm Pilot to begin to tune into what’s going on inside of you…”
Subject : “That’s going to suck.”

Therapist : “Because?”
Subject : “Because it’s going to be work and who knows what I’m going to see.”
Therapist : “What are you going to see?”
Subject : “I mean, I don’t know.”
Therapist : “I think you have a clue otherwise you wouldn’t be so afraid.”
Subject : “Well probably a lot of things I don’t like.”
Therapist : “Like?”

Subject : “I don’t know.”
Therapist : “Slow down and think about it. What are you so afraid of?
Subject : “I guess probably seeing what’s in there and we’re both pretty certain there is pain in there and probably seeing that. Not only seeing it but having it come out and deal with it. No, no, not only deal with it, but having it come out.

Therapist : “And what will happen if it comes out?”
Subject : “It will be painful. Pain is uncomfortable and there is no room.”
Therapist : “It would swamp what you do. There would be no room for it.”
Subject : “Nope. Well there is no room because I’ve not ever allowed there to be room because the feeling of pain is not something like the feeling of wanting to cry or crying, or if like
I’m going to be angry. I just don’t like that feeling. I don’t like the feeling of being hurt. I just don’t and so…and if you are hurt and allow yourself to be hurt that infects the rest of your world.

Subject : “A perfect example is the phone call that I had where I hung up the phone and I was almost immediately in tears because I had felt like such a failure. I took everything told to me by the other teacher so personally that it just overwhelmed me to the point I lost all of my business-like composure and I became emotional - like creeped in without me realizing it was going to. I don’t like that feeling because it a) hurts and b) there is no control.”
Therapist : “So it’s just better to just block it out than try to figure out what it is, try and respond to it?”
Subject : “That’s all I’ve ever known.”

• Motivational Enhancement
• Emotion Identification/Tolerance/Expression
• Meal Planning/Behavioral Activation
• Urge Control
• Relationship Skills
• Self Regulation Skills
• Self Discrepancy
• Relapse Prevention

Table 2. Core Skills in ICAT
Coping Skill
Emotion Regulation
Meal Planning/Behavioral Activation
Urge Control
Relationship
Self Regulation
Self Discrepancy and Interpersonal
Appraisal
Impulse Control and Relapse
Prevention
PHASE
I
II
II
III
Acronym for Skill
FEEL
CARE
ACT
SAID
SPA
REAL
IV WAIT
Elements in Acronym
Focus, Experience, Examine & Label
Calmly Arrange Regular Eating
Adaptive Coping Techniques
Sensitively Assert Ideas & Desires
Self Protect and Accept
Realistic Expectations Affect Living
Watch All Impulses Today


Find a quiet place.

Let yourself sit for a minute.

Pay attention to your body sensations.

Try not to worry about how you are doing.

Allow a feeling to come.

You may not know what to call it.

Try not to leave it.

Just stay with it for awhile.

Start to wonder what this is.

What do you think this feeling is about?

Where is it coming from?

Can you give it a name?

Try the name out. Does it fit?

Is that all of it, or is there another feeling? If yes, repeat
FEEL.

1.
S: Identify Situation
2.
E: Identify Emotion(s)
3.
A: Identify Action (e.g., binge)

Implementing the SEA – Change Technique
Situation
• Perceived failure at work
• Perceived failure at work
• Perceived failure at work
(Three Strategies for Action)
Emotion Action
• Sad
• Angry
• Sad
•
Angry
• Sad
• Angry
• Self Criticism
• Purging
• Avoid Supervisor
• Identify Feelings
•
Review Self Standards
• Talk to Supervisor
• Identify Feelings
• Decide to go to movie (Self
Distract)
• Discuss situation with friend after movie (Self Protect)

Trauma Focused Cognitive
Behavioral Therapy
(Cohen, Mannarino & Deblinger, 2006)

• Children age 4-18
• Trauma history – single or multiple, any type
• Prominent trauma symptoms (PTSD, depression, anxiety, with or without behavioral problems)
• Children with severe behavior problems may need alternative interventions
• Caregiver involvement is optimal
• Treatment settings: clinic, residential, home, inpatient

P sychoeducation and Parenting Skills
R elaxation
A ffect Expression and Regulation
C ognitive Coping
T rauma Narrative Development and Processing
I n Vivo Gradual Exposure
C onjoint Parent/Child Session
E nhancing Safety and Future Development

• Identify maladaptive beliefs and thoughts
• Promote the notion that thoughts can be changed
• Challenge the maladaptive thoughts
 Is it true?
 Does thinking this lead to positive or negative emotions?
 Does thinking this help you feel good about yourself?
 Does thinking this help you in relationships with friends and family

Examples of Cognitive & Affective
Processing
• Sexuality
 “Am I gay?”; “I was abused because I dress sexy.”
• Body Concerns
 “I might die of AIDS”; “I might be pregnant.”
• Interpersonal Concerns
 “I tore my family apart”; “My friends think I am a slut.”
•
Safety Concerns
 “I will never trust another man.”; “I can’t go anywhere alone.”
•
Self Image
 “I am so stupid.”; “I am unlovable.”

P sychoeducation and Parenting Skills
R elaxation
A ffect Expression and Regulation
C ognitive Coping
T rauma Narrative Development and Processing
I n Vivo Gradual Exposure
C onjoint Parent/Child Session
E nhancing Safety and Future Development http://minnesota.cbslocal.com/video?autoStart=true&topVideoCat
No=default&clipId=7565071

Treatment Collaborative for
Traumatized Youth (TCTY)
Mission:
• To enhance the availability of evidencebased, trauma specific, mental health treatments for traumatized children and their families
• Build a trauma-informed multidisciplinary collaborative network across North Dakota
– Implement & evaluate evidence-based mental health treatments
– Develop trauma-focused trainings for child-serving systems
– Provide community education about the impact of trauma on children and families

•
250 clinicians representing over 40 agencies/centers
• Over 700 children have received services
• SPARCS, TF-CBT, AF-CBT
• Native American Adaptation
• 6 th Annual Meeting of the TCTY – May 12 th , 2014
• Website: tcty-nd.org
• Over 50 presentations to various professional organizations and community groups
• Systems work: Mental Health, Juvenile Justice, Child Protection,
Foster Care and Schools

Clinical Centers with TCTY Trained Clinicians
Belcourt
Devils Lake
Sentinel Butte
Center/Agency with TCTY
Trained Clinician(s)

HEATHER SIMONICH, MA, LPC
NEUROPSYCHIATRIC RESEARCH INSTITUTE
HSIMONICH@NRIFARGO.COM

• Bush Foundation – St. Paul, Minnesota
• Collaboration with Fargo Public Schools (2012-2014)
• Goals:
– Provide professional development on the topic of child traumatic stress for school staff
• Professional Discipline (e.g., administrators, counselors, special education, early childhood)
• Building (e.g., Jefferson, Agassiz, Dorothy Moses - Bismarck)
• District-wide (e.g., NDSU continuing education course for graduate credit)
• State-wide (e.g., ND Elementary Principals Conference)
– Encourage standardized screening and specialized referrals
– Develop a group of “trauma-informed champions” to assure sustainability

• Research demonstrates that children who experience trauma are more likely to have:
– A lower GPA (Hurt et al., 2001; Beers & DeBellis,2002)
– Higher rate of school absences (Beers & DeBellis, 2002)
– Higher likelihood of drop-out (Grogger, 1997)
– More suspensions and expulsions (Eckenrode et al., 1993)
– Decreased IQ and reading ability (Delaney-Black et al., 2003)
– Significant deficits in attention, abstract reasoning, long-term memory for verbal information (Beers & DeBellis, 2002)
– Special education services (Shonk & Cicchetti, 2001)

• Children are more likely to access mental health services through primary care and schools than through specialty mental health clinics. (Costello et al., 1998)
• 10% of children that could benefit from mental health services actually receive care at a mental health facility.
• Schools provide an ideal setting for corrective and supportive experiences – an enormous opportunity to foster resiliency.

• Trauma is clearly not new – but the extensive research that describes trauma’s effects on the developing child is new
• Not suggesting a new category of disability – this is about implementing an adaptable framework for addressing trauma-related challenges within the school setting
• Increase learning and teaching time and decrease time spent on discipline

Overview of Proposed Professional
Development Curriculum (6-12hrs)
1.
Defining Trauma
2.
Traumatic Stress Reactions
3.
Adverse Childhood Experiences Study
4.
Understanding the Neurobiology of Trauma
5.
Resiliency
6.
Creating Trauma-sensitive Schools: Learning from the Washington state Model
7.
Implementing Trauma-sensitive Strategies in the Classroom
– Helping children feel psychologically safe
– Teaching relaxation (i.e., belly breathing)
– Emotional development activities
– Cognitive triangle
– Relationship coaching
– Maintaining connections/building relationships with families
8.
Overview of Evidence-based Mental Health Interventions
9.
Taking Care of Yourself: Secondary Traumatic Stress

• Understanding the experience of traumatic stress assists us to develop compassion, patience and empathy. It is a key intervention in itself.
• Recovery from trauma will occur best in the context of healing relationships.

Learning from the State of Washington
Ron Hertel, Program Supervisor
Office Superintendent of Public Instruction
Phone: 360-725-4968
Email: Ron.Hertel@k12.wa.us
Elementary Implementation Video: http://www.youtube.com/watch?v=A1vbSSQJOHw

(Ann Masten, Ph.D)

1.
What are you currently doing in your classroom that already supports these resiliency factors?
2.
What are small changes you could make in your classroom to further boost these systems that drive resilience?
3.
What are some of the challenges you face in supporting the systems that drive resilience?

• 1 out 4 children will experience a traumatic event before age 16
• Trauma is associated with numerous mental and physical health conditions, in addition to, negative educational outcomes.
• If we are truly invested in supporting our children, we must think about the role of traumatic stress in all childserving systems (e.g., schools, child welfare, mental health)