Making Sense of the
Complexities of Trauma
Heather Hartman-Hall, Ph.D.
2012
Training Objectives
Participants will be able to…
Identify
diagnostic challenges in working with
clients who have experienced trauma.
Understand how current symptoms may
reflect adaptations to traumatic experiences.
Describe important features of a complex
trauma syndrome.
Training Objectives (cont.)


Identify several strategies for helping clients
manage self-injurious and suicidal behaviors.
Understand vicarious traumatization and the
importance of clinician self-care.
PART ONE:
Understanding Complex
Trauma Syndromes
“Psychological trauma is an affliction of the
powerless. At the moment of trauma, the victim
is rendered helpless by overwhelming force.
When the force is that of nature, we speak of
disasters. When the force is that of other
human beings, we speak of atrocities.
Traumatic events overwhelm the ordinary
systems of care that give people a sense of
control, connection, and meaning.”
– Judith Herman, Trauma and Recovery, 1997
PREVALENCE AND ETIOLOGY
Prevalence

While the criteria for PTSD diagnosis have
gotten stricter since 1980, our ability to
assess for and detect PTSD has improved;
the overall prevalence has remained fairly
stable in that period
Prevalence (cont.)

PTSD is still likely underdiagnosed,
particularly in several demographic groups
(e.g., Brunet, 2007)

In many settings, trauma not routinely
assessed as part of intakes (van der Kolk et
al., 2005)
Prevalence (cont.)

Estimates for exposure to potentially
traumatizing events in the US tend to range
around 70% of people surveyed

CDC “ACE” study (2009)

>26K non-institutionalized US adults in 5 states
8.7% reported 5 or more ACEs
 Sexual abuse: 17.2% for women, 6.7% for men
 ACEs associated with “multiple mental and physical
health problems”

Prevalence (cont.)

Prevalence rates for PTSD vary depending
on the group surveyed; for the general US
population lifetime prevalence is estimated to
be 6.8-8%
Prevalence (cont.)

National Comorbidity Survey Replication (NCSR), conducted between 2001 and 2003 (Gradus,
2007)



Nationally representative sample of Americans
aged 18 years and older
5K+ participants assessed for PTSD by interview
using DSM-IV criteria
Lifetime prevalence of PTSD est. at 6.8%

Among women: 9.7%, men: 3.6%
Prevalence (cont.)

NCS-R yielded estimates similar to first
National Comorbidity Survey (early 1990’s):
Lifetime
Prevalence
of PTSD
NCS
NCS-R
Overall
Women
Men
7.8%
10.4%
5%
6.8%
9.7%
3.6%
Prevalence (cont.)

DSM-IV-TR: Community-based studies
indicate about 8% lifetime prevalence for
PTSD adults in the US
Prevalence (cont.)

Random sample of 4,008 US women
(Resnick, 1993)

Lifetime exposure to any type of civilian traumatic
event: 69%


36% endorsed exposure to crimes that included
sexual or aggravated assault or homicide of a close
relative or friend
Lifetime prevalence of PTSD:12.3%

significantly higher among crime vs noncrime victims
(25.8% vs 9.4%).
Prevalence (cont.)

Study of 152 women aged 18-45 consecutively
seen for routine gynecological care in family
physician office (Sansone, et al.,1995)

Traumatic experiences were reported by 70.7%





Sexual abuse reported by 25.8%
Physical abuse reported by 36.4%
Emotional abuse reported by 43.7%
Physical neglect reported by 9.3%
Witnessing of violence reported by 43.0%
Prevalence (cont.)

Random sample of 1008 adult residents of
Manhattan 5-8 weeks after September 11, 2001
terrorist attacks (Galea, et al., 2002)

7.5% reported symptoms consistent with a
diagnosis of current PTSD related to the attacks



20% in residents who lived near World Trade Center
Predictors of PTSD: Hispanic ethnicity, prior stressors,
a panic attack during or shortly after the events,
proximity to WTC, and loss of possessions due to the
events.
9.7% reported symptoms of depression
Prevalence (cont.)

Interviews of 810 adult residents in southern
Mississippi (random selection of addresses in
each of 3 strata), 18-24 months after Hurricane
Katrina (Galea, et al. 2008)


22.5% diagnosed with PTSD in that period
Risk factors included:




Being female
Financial loss
Low social support
Post-disaster stressors/traumas
Prevalence – Complex PTSD

Full syndrome estimated <1% in nonclinical
population

Sub-syndrome symptoms of CPTSD more
common and are associated with childhood
trauma
Prevalence – Complex PTSD
(cont.)

van Dijke, et al. (2011) found 10-38% of
psychiatric inpatients met criteria for Complex
PTSD

In one small study of forensic inpatients in
Germany, 28% were diagnosed with CPTSD;
44% lifetime prevalence
Interpersonal Trauma and
PTSD



Interpersonal trauma is associated with higher
rates of PTSD than other types of trauma
(accidents, disasters, etc.)
Being victimized by criminal acts more
associated with PTSD symptoms
Interpersonal traumas experienced in childhood
increase likelihood of PTSD, and of victimization
later in life
Gender Differences



National Comorbidity Survey indicated that more
males than females in the US experience
trauma, but more females develop PTSD
Lifetime prevalence of PTSD for women is about
twice that of men
Some studies suggest PTSD lasts longer in
females than males
Gender Differences (cont.)

Women more likely to be exposed to
interpersonal forms of trauma (Lilly & Valdez,
2012)


Females typically report more sexual abuse
than males
Experience of interpersonal trauma may be
more predictive of later PTSD than gender
Gender Differences (cont.)

Teenage boys in
particular rarely report
sexual abuse,
particularly by a woman



Guilt/shame
“Rite of passage”
Normalized or even
viewed as positive by
peers/other adults
Gender Differences (cont.)



Males may be less likely to seek treatment
Gender of therapist may be important
Differences in symptom presentation?

Culturally-imposed gender roles (e.g., Evans &
Sullivan, 1995)
Special Populations



“…many or even most psychiatric patients
are survivors” of abuse (Herman, 1997)
Some estimates suggest 1/3-1/2 of people in
treatment for substance abuse have PTSD
Lifetime exposure to trauma has been
reported to be higher in adult and juvenile
offenders

Especially child abuse (Spitzer, et al., 2006)
Early Risk

“Ideally, parenting is the essential buffer
against trauma” (Allen, 1995)

When a small child’s needs are met predictably by
his environment, more likely to develop secure
attachment (Schore, 2002)


May affect development of the central nervous system
and the limbic system
Secure attachment includes the assumption that
“homeostatic disruptions will be set right”
Early Risk (cont.)

Childhood abuse often occurs within the context
of neglect, deprivation, and emotional
invalidation (Briere, 1996)

Acts of both commission and omission (Korn &
Leeds, 2002):






Sexual, physical, emotional abuse
Witnessing violence
Unmet physical and emotional needs
Parental unavailability
Failure to protect by caregivers
Childhood separations
Early Risk (cont.)

Increasing evidence that childhood trauma
puts people at higher risk for mental illness
and maladaptive stress responses in
adulthood


New research using brain scans shows structural
changes (particularly in areas of the brain related
to stress response)
“a violation of and challenge to the fragile,
immature and newly emerging self (Ford & Courtois,
2009)
Early Risk (cont.)

Childhood traumas can “block or interrupt
the normal progression of psychological
development in periods when a child…is
acquiring the fundamental psychological
and biological foundations necessary for all
subsequent development (Ford, 2009)

Brain shifts from “learning” functions to
“survival” functions
Early Risk (cont.)

When a child is betrayed (e.g., abused or
neglected) by a caregiver, child still needs
caregiver to survive

May remain unaware of the betrayal (Kaehler &
Freyd, 2011)



Dissociation
Blame self rather than caregiver
Rationalize/excuse the abuser
Risk Factors/Resilience


Most traumas don’t result in mental illness
DSM-IV-TR: “severity, duration, and proximity
of an individual’s exposure to the traumatic
event are the most important factors” in risk
for PTSD… “some evidence that social
supports, family history, childhood
experiences, personality variables, and preexisting mental disorders may influence”
development of PTSD
Common Reactions to
Frightening Experiences







Shock
Anxiety/worry
Irritability/anger
Changes in eating or sleeping habits
Physical problems or illness
Apathy/loss of interest in usual activities
Feeling “jumpy”
Most people experience some temporary
interference in usual functioning after a
traumatic experience.
Fight or Flight Response




Mammals have developed response to threat
through evolution
Sympathetic nervous system
Once the response is set off, hormones
released into the body create various
changes to prepare the body for vigorous
action
Increased heart rate, constriction of blood
vessels, tunnel vision, reduced GI and sexual
functioning
Fight or Flight Response
(cont.)

“Fight or Flight” represents a complex stress
response

Decades of stress research (e.g. Bracha, et al.
2004) have illuminated four fear responses that
occur in order in the face of a threat





Initial freeze response
Attempt to flee
Attempt to fight
Tonic immobility
“Freeze, flight, fight, fright response”
Fight or Flight Response
(cont.)

Stress response begins with the individual’s
appraisal of the event and how it may affect
him or her



Various individual and situational factors will
influence appraisal
Likely an automatic and even unconscious
process
Includes whether individual has resources to
cope with stressor
Fight or Flight Response
(cont.)


Physiologically, the response to rage and fear
are the same
May be an adaptive response to singleincident, intense stress, but can become
problematic



When continuously activated
When natural response is blocked
Loss of ability to return to baseline state of
physical calm or comfort
Adaptations to Trauma



A natural response to an overwhelming
experience
Strategies that are adaptive in a crisis can
backfire when trauma is ongoing or when
self-regulation doesn’t come back online
“natural, self-protective efforts gone awry”
(Allen, 1995)
Long-Term Effects of Trauma







Physiological changes
Dysregulated emotions
Disruption of relationships
Damaged/changed view of self
Changes in world view/belief system
Break down of coping strategies
Altered perceptions
DIAGNOSTIC CHALLENGES
A Confusing Picture
What are the likely diagnoses for each of the
following symptom clusters?
Numerous hospitalizations, history of cutting arms
repeatedly, has trouble trusting others but is afraid
to be alone.
Appears withdrawn, suspicious of others,
occasionally appears to be responding to internal
stimuli.
Hypersexuality, risk-taking, substance abuse,
insomnia, weight loss.
Episodic confusion, poor memory, inability to attend to
conversations, little spontaneous speech, low activity
level.
Flat affect, unable to think of anything good that might
happen in the future, low energy, finds little enjoyment
in activities once enjoyed.
Reports hearing a voice that repeats insults and
phrases such as “You should die.” Reports sometimes
feeling that she leaves her body and looks down at
herself from the sky.
Diagnostic Challenges





Misdiagnosis – “bewildering array of
symptoms” (Herman, 1997)
Symptoms and functioning often vary over time
and across situations
Self-report might not include information about
trauma
Strengths/abilities might mask difficulties or
make impairment less obvious
Trauma disorders may not be considered,
particularly in some settings
Diagnostic Challenges (cont.)

Comorbidity of trauma with other disorders

One large study: 84% of people with PTSD met
criteria for at least one other psychiatric disorder







Major depression
Substance abuse
Other anxiety disorders
Schizophrenia
Dissociative disorders
Personality disorders
Comorbid somatic problems also very common
Cultural Factors



DSM-IV-TR emphasizes importance of considering
culture in diagnosis
Research on trauma in mainstream US population
might not generalize to other cultures (Carlson, 1997)
Some evidence of higher rates of trauma and/or
more severe symptoms among people from ethnic
minority groups and deaf people (Davis, et al. 2011;
Ford 2012)

SES status and its associated stressors may play
a role
Cultural Factors (cont.)

Possible differences in symptom presentation
(Schlid & Dalenberg, 2012; Brunet, 2007; Frueh, et al.,
2002; Sue & Sue, 1987)



Asian cultures more likely to present with physical
symptoms as a trauma response
African-American combat veterans with PTSD
may present with more psychotic symptoms
Trauma symptoms may present differently in deaf
vs. hearing people
AXIS I DISORDERS
ASSOCIATED WITH TRAUMA
Diagnoses Commonly
Associated with Trauma







Post-Traumatic Stress Disorder (PTSD)
Acute Stress Disorder
Borderline Personality Disorder
Dissociative Disorders
Substance Abuse/Dependence
Eating Disorders
Other anxiety, mood, somatoform, personality
disorders
PTSD


Symptoms usually begin within 3 months of
traumatic experience, but may be a delay of months
or even years
Three clusters of symptoms:




Re-experiencing
Avoidance/numbing
Hyperarousal
Bi-phasic condition that alternates between reliving
the overwhelming experience, and avoiding
thoughts/feelings associated with trauma
PTSD (cont.)
DSM-IV-TR Criterion A:
1.The person has experienced, witnessed, or been
confronted with an event or events that involve
actual or threatened death or serious injury, or a
threat to the physical integrity of oneself or others.
2.The person's response involved intense fear,
helplessness, or horror. (In children, may be
expressed instead by disorganized or agitated
behavior)
PTSD (cont.)

DSM-III Criterion A: The person has
experienced an event that is outside the
range of usual human experience and that
would be markedly distressing to almost
anyone
PTSD: Re-experiencing


One or more for diagnosis of PTSD
Examples




Intrusive thoughts or memories of trauma
Nightmares
Flashbacks
Intense distress in response to reminders of the
trauma
PTSD: Avoidance/Numbing


Three or more for diagnosis of PTSD
Examples





Avoiding reminders of the trauma
Amnesia for some aspects of the experience
Loss of interest in activities
Feeling detached or estranged from others
Restricted range of emotions
PTSD: Hyperarousal


Two or more that have arisen since the
traumatic experience
Examples





Insomnia
Irritability
Poor concentration
Hypervigilance
Exaggerated startle response
Acute Stress Disorder


Symptoms similar to PTSD, difference is
timeframe
Symptoms occur within one month of trauma
and last 2 days to 4 weeks
Dissociative Disorders





Depersonalization Disorder
Dissociative Amnesia
Dissociative Fugue
Dissociative Identity Disorder
Dissociative Disorder Not Otherwise Specified
Dissociative Disorders (cont.)



Characterized by range of experiences related
to disruption of awareness/consciousness,
memory, identity, perception, etc.
Can present in different ways (sudden vs.
gradual, transient vs. chronic, single symptom or
entire syndrome)
Individual may or may not be aware of these
occurrences, but they cause impairment and/or
distress
Dissociative Disorders (cont.)

Link between childhood trauma (especially
abuse) and dissociation later in life (e.g., LöfflerStastka, et al. 2009)

Dissociation as a response to chronic,
inescapable stress



Shuts out the experience – mental escape when
couldn’t physically escape
Allows individual to survive unbearable situation
Perhaps adaptive in the short-term, but
detrimental to functioning longer-term
Dissociative Disorders (cont.)


Later in life, dissociative experience may be
triggered by memories, perceived threat, or
strong feelings
Pathological dissociation was associated with
depression, alexithymia, and suicidality in a
general population sample (Maaranen, et al.,
2005)
Dissociation & Other
Diagnoses

Dissociative symptoms have been associated
with PTSD, borderline personality disorder,
schizophrenia, mood disorders, OCD,
somatoform disorders (Spitzer, Barnow, et
al., 2006)
Dissociation vs. Psychosis


Dissociation and psychosis can present
similarly
Severe dissociation has been associated with
comorbid psychosis (Allen et al., 1997; Allen
& Coyne, 1995; Moskowitz et al., 2005;
Kilcommons, et al., 2008)
THE ROLE OF TRAUMA IN
BORDERLINE PERSONALITY
DISORDER
Borderline Personality
Disorder (BPD)



Diagnosed in about 2% of general US
population; about 75% of these are female
DSM-IV-TR: “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
Examples…
BPD (cont.)









Frantic attempts to avoid abandonment
Unstable and intense relationships
Identity disturbance
Impulsive, potentially self-destructive behaviors
Suicidal or self-injurious behaviors
Affective instability/reactive mood
Chronic feelings of emptiness
Intense anger
Dissociative symptoms, stress-induced paranoia
BPD (cont.)


BPD diagnostic criteria have remained relatively
unchanged since introduced in DSM-III (1980)
Criticisms of current criteria (Lewis & Grenyer,
2009):



Extensive symptom overlap with other disorders
Reliability and validity of diagnosis in literature
has been inconsistent
No reference to widely-accepted role of early
trauma
Perceptions of BPD


Pejorative connotation of the diagnosis
In particular, clients with BPD who engage in
self-harm or suicide attempts tend to get
negative reactions from clinicians, ER
personnel, others (see Treloar & Lewis, 2008
for review)


Negative perceptions create “major barrier to
effective service provision” for these patients
Education for professionals shows positive effects
BPD and Trauma


DSM-IV-TR: “Physical and sexual abuse,
neglect, hostile conflict, and early parental
loss or separation are more common in the
childhood histories of those with” BPD
Link identified between insecure attachment
in infancy and later development of BPD
symptoms (e.g., Kaehler & Freyd, 2011)
BPD and Trauma (cont.)


Physical abuse/neglect and inconsistent
experiences from caregivers in childhood seen
as possible factors in development of BPD
(Löffler-Stastka, et al., 2009)
Studies found 81-91% of people with BPD had
severe childhood trauma, including
physical/emotional abuse, neglect, sexual
trauma (e.g., Lewis & Grenyer, 2009; Herman, 1997)
BPD and Trauma (cont.)

Trauma may be one etiological factor among
many, including biological, psychological, and
social factors (Gratz, et al., 2011; Lewis & Grenyer, 2009)


Possibly, trauma interacts with temperament and
biological vulnerabilities
Linehan describes BPD as resulting from
inherited proneness to emotional
dysregulation and growing up in an
invalidating environment
COMPLEX PTSD
Complex PTSD (CPTSD)


Spectrum of trauma responses from brief
reaction that improves on its own, to
classic PTSD, to complex syndrome
Complex syndrome seen in survivors of
prolonged, repeated (often childhood)
trauma at the hands of others
CPTSD (cont.)


Loss of coherent sense of self and others that
is often a core feature of chronic
interpersonal trauma is not captured in
current PTSD diagnosis
DSM-IV Field Trial demonstrated that early
trauma gives rise to more complex symptoms
in addition to PTSD (van der Kolk, et al., 2005)

Disorders of Extreme Stress Not Otherwise
Specified (DESNOS)
CPTSD (cont.)
Criteria that were under consideration for
DSM-IV for a complex trauma syndrome:
Complex PTSD – Proposed
Criteria (Herman, 1992)


A history of ongoing and severe interpersonal
trauma
Alterations in affect regulation


Including persistent dysphoria, suicidal
preoccupation, self-injury, explosive anger
Alterations in consciousness

Including amnesia, dissociative experiences,
intrusive memories or flashbacks
Complex PTSD – Proposed
Criteria (Herman, 1992, cont.)

Alterations in self-perception


Alterations in perception of perpetrator


Including revenge fantasies, idealization,
rationalizations
Alterations in relations with others


Including shame, guilt, feeling of differentness from
others, helplessness
Including isolation, distrust, failure to self-protect
Alterations in systems of meaning

Including loss of faith, hopelessness
PROPOSED CHANGES FOR
DSM-5
Proposed Changes for DSM-5


Planned release in May, 2013
New diagnostic category: “Trauma- and
Stressor-Related Disorders”


Would move trauma disorders from Anxiety
Disorders category
Includes adjustment disorders
Proposed Changes for DSM-5:
Trauma- and Stressor-Related
Disorders






Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Acute Stress Disorder
Posttraumatic Stress Disorder
Adjustment Disorders
Trauma- or Stressor-Related Disorder Not
Elsewhere Classified
Proposed DSM-5 Changes to
PTSD diagnosis


DSM IV-TR PTSD Criteria A1: The person
has experienced, witnessed, or been
confronted with an event or events that
involve actual or threatened death or serious
injury, or a threat to the physical integrity of
oneself or others.
A2: The person's response involved intense
fear, helplessness, or horror. Note: in
children, it may be expressed instead by
disorganized or agitated behavior.
Proposed DSM-5 Changes to
PTSD diagnosis (cont.)
PROPOSED DSM 5 PTSD Criteria A:
Exposure to actual or threatened a) death,
b)serious injury, or c) sexual violation, in one
or more of the following ways:
Proposed Changes for DSM-5
(cont.)




Directly experiencing the event
Witnessing, in person, others experiencing
event
Learning that the event occurred to close
relative or friend; actual or threatened death
must be violent or accidental
Experiencing repeated or extreme exposure to
aversive details of the event

E.g., first responders, police officers investigating child
abuse cases
Proposed Changes for DSM-5
(cont.)

4 proposed symptom clusters




Intrusion symptoms
Avoidance
Negative alterations in cognitions and mood
Alterations in arousal and reactivity
Proposed Changes for DSM-5
(cont.)

Subtypes


PTSD in Preschool Children
PTSD with Prominent Dissociative Symptoms

meets criteria for PTSD AND either depersonalization
and/or derealization
Proposed Changes for DSM-5
(cont.)

Dissociative Disorders




Depersonalization-Derealization Disorder
Dissociative Amnesia
Dissociative Identity Disorder
Dissociative Disorder Not Elsewhere Classified
Proposed Changes for DSM-5
(cont.)

Changes in personality disorder diagnoses
also proposed




Fewer personality disorders included
Impairment must be seen in both “self” and
“interpersonal” domains
Impairment must be present in at least one of five
areas
Severity of impairment rated from mild to extreme
Proposed Changes for DSM-5
(cont.)
For more about proposed changes, progress of
the workgroups, and the timeline for release of
DSM 5:
www.dsm5.org
SELF-INJURIOUS AND
SUICIDAL BEHAVIORS
Self-Harm
• Tension-relieving self-injurious behaviors vs.
suicidal behaviors
• Two different but often related sets of behavior

Self-injurious behaviors DO increase the risk
of suicidal behaviors

Particularly for people with personality disorders
Suicidal vs. Self-Injurious
Behaviors

Maddock et al. (2010) looked at reasons
women with BPD gave for SIB and suicide
attempts and found the reasons (e.g., to
relieve emotional pain, escape, etc.) were not
significantly different

Suggested clinicians should assess method used
and whether reasons for harming self have
resolved in determining risk for suicide
Risk Factors for Self-Harm


Previous suicide attempt/self-injury
Psychiatric illness





Mood disorder (Depression, Bipolar Disorder)
Substance abuse
Schizophrenia
Personality disorders
Anxiety disorders
Risk Factors for Self-Harm
(cont.)

High-risk groups vary by culture/country

In the US, women more likely to attempt suicide
but men more likely to complete suicide
Self-Injurious Behaviors (SIB)


the "deliberate, direct injury of one's own
body that causes tissue damage or leaves
marks for more than a few minutes and that
is done in order to deal with an overwhelming
or distressing situation” (ASHIC website, 2005)
Examples: cutting/scratching, burning, head
banging, swallowing foreign objects
SIB (cont.)



Most SIB is an adaptation to deal with an
intolerable experience (Saakvitne, et al., 2000)
A person who has experienced significant,
ongoing trauma may develop SIB as a way to
cope with overwhelming emotions
The link between SIB and significant
childhood trauma has been well established
in the research literature (e.g., Osuch, Noll, &
Putnam, 1999; Herman, 1992)
SIB (cont.)

Physical pain is often reduced or even
unnoticed while a person is in the act of SIB
(e.g., Herman, 1992)

The individual may be unaware of the
behavior while it is occurring, particularly if
dissociating
SIB (cont.)
Many possible reasons for SIB…
 to manage intense feelings/distress
 physical pain seen as preferable to emotional pain
 individual feels he or she deserves to be punished
 to obtain a sense of control
 to ground oneself when dissociating or otherwise
losing touch with reality
 to express anger or hostility
 to stop flashbacks or other intrusive memories
 to express emotional pain
 to prevent suicide attempts
 to prevent acting out against others
SIB (cont.)

SIB is typically NOT a failed suicide attempt
Osuch, Noll, & Putnam, 1999; Herman, 1992


Assess whether the person intended to die or
believed the behavior was life-threatening
In fact, SIB is often a coping strategy that acts as
suicide prevention for patients, in that SIB may
help them avoid feeling a total loss of control
SIB (cont.)

However, a patient who engages in SIB may
also be suicidal, and is likely at increased risk
for also making a suicide attempt.


It has been estimated that about half of all people
who kill themselves have a history of SIB (Osuch,
et al. 1999).
Patients engaging in SIB should also be
regularly assessed for suicidal ideation.
SIB (cont.)


Borderline Personality Disorder (BPD) diagnosis in
the DSM-IV-TR includes deliberate self-injury as a
listed symptom, and therefore the two are often
equated
The presence of SIB alone does NOT warrant a
diagnosis of an Axis II disorder.


SIB occurs with many other diagnoses, including PTSD,
eating disorders, substance abuse, dissociative disorders,
developmental disorders, and alexithymia (a lack of ability
to express or even have awareness of one's own feelings).
There might also be a psychotic or obsessive-compulsive
component to SIB.
 E.g., in response to hallucinations (Osuch, et al.1999)
SIB (cont.)

Caregiver/loved ones’ reactions to SIB



Anger, fear, disgust, worry, hopelessness and
other strong feelings are understandable
reactions to SIB
Important to manage reactions rather than act
them out on the client
Strong reactions can contribute to the client’s
feeling less safe, increasing her anger, shame,
distress, tendency to hide SIB (Herman 1992;
Saakvitne, et al., 2000)
SIB (cont.)

Research suggests that offering possible
reasons for SIB may actually increase risk of
additional SIB (Osuch, et al. 1999)

Ask open-ended questions about client’s ideas
about why she/he is engaging in SIB
Suicide





Chronic vs. Acute
Direct communication is crucial
Should be assessed regularly and at critical
points
Family/significant other involvement
Seasonal variation
PART TWO:
A Trauma-Informed
Approach to Treatment
SETTING THE FRAME
“I explained that we were on a journey together
– that she picked the path and I held the light
for us to see.”
- Susan K. L. Pearson, M. D.
Setting the Frame

Informed Consent







Confidentiality
Mandated reporting/duty to warn
Treatment plan
May feel worse before you feel better
Safety
Your crisis availability/back-up plans
Education as part of treatment
Setting the Frame (cont.)




Treatment Goals/plan
Client’s role (not passive!)
Psychoeducation
Validation of the traumatic experience is a
precondition for creating an integrated view of
self and establishing the capacity for healthy
relationships (Herman, et al. 1995)
Setting the Frame (cont.)

Create a safe environment



Eye contact and active listening


Physically and psychologically
Acknowledge limitations of setting/situation
Physiological aspects of social behavior
Use touch of any kind cautiously if at all
THE THERAPEUTIC
RELATIONSHIP –
THE CRITICAL COMPONENT
Therapeutic Relationship
Trauma can disrupt many aspects of
interpersonal functioning:
 Ability to connect
 Trust
 Asking for help
 Being vulnerable with someone
 Believing someone else cares
…etc.
Therapeutic Relationship
(cont.)

The most important thing you bring to the
therapy is YOU

“…the essential therapist task is to provide
relational conditions that encourage the
safety of the attachment between client and
therapist” (Kinsler, Courtois, & Frankel, 2009)
Therapeutic Relationship
(cont.)

Appropriate, solid boundaries

Experiencing first-hand how the client
behaves in relationships


Informative for the therapist
Can provide feedback to client
Therapeutic Relationship
(cont.)

Providing a consistent presence

Tolerating the pain – starting to help client
develop affect regulation

Another opportunity for “secure
attachment”
Therapeutic Relationship
(cont.)

Managing inherent power imbalance (Courtois,
et al., 2009)




Strive for egalitarian, collaborative relationship
that encourages empowerment of client
Responsibilities and inherent power differences
should be acknowledged
Seek to use power effectively on client’s behalf
Encourage client’s development and autonomy
Therapeutic Relationship
(cont.)

Holding the hope

Once relationship is fairly solid, work towards
“putting eggs in more baskets”

Avoid accepting the superhero cape!
“Trouble can always be borne when it
is shared.”
-Katherine Paterson
R.I.C.H. Philosophy
(Saakvitne, et al. 2000)
An approach for any clinical work with
survivors of trauma:
 Respect
 Information
 Connection
 Hope
Respect







Collaboration
Confidentiality
Sensitive language
Assuming client’s point of view is valid
Being fully present
Humility
Honesty
Information


Provide information about effects of trauma
Explain treatment plan, including rationale





Include possible risks and benefits
Expectations on both sides should be clear and
reviewed as often as needed
Community resources
Safety planning
In inpatient/correctional setting, helping client
understand the process
Connection





Genuine empathy and positive regard
Clear boundaries
Being honest
Sitting with painful content and emotions
Recognition that the work affects both of you
Hope





You can have hope for the client even when
she doesn’t have it for herself
Utilize strengths and abilities
Help client see progress
Keep goals realistic
Therapist self-care is crucial!
ASSESSMENT OF TRAUMA
AND ITS EFFECTS
“The past isn’t dead – it isn’t even past”
-William Faulkner
Assessment of Trauma

Best tool – good clinical interview


May need to spend time establishing trust and
safety first
Need to find a balance between a thorough
picture of traumatic experiences, but not
triggering re-experiencing or overwhelming
feelings/memories
Assessment of Trauma (cont.)

“Some of the things I ask about might bring up
upsetting or uncomfortable memories or feelings. It’s
important that I understand what you’ve
experienced, but we don’t need to rush things. As
much as possible, I’d like to know the kinds of things
you’ve experienced, but I don’t want to overwhelm
you or have you re-live painful experiences right
now. At any point if there is anything you don’t want
to talk about, just let me know. If you are starting to
feel yourself becoming overwhelmed, please let me
know right away. If I see you becoming very
distressed, I may ask you to stop for a moment so
we can check in. ”
Assessment of Trauma (cont.)
In particular, assess:
 Traumatic experiences and significant losses
 Symptoms
 Current safety
 Strengths/resources
Assessment:
Traumatic Experiences

Many people will not spontaneously report
traumatic experiences – you do need to ask






May not understand pertinence
May not remember details or any of it
May be uncomfortable/worry about stigma
May think you won’t want to hear about it
May worry about becoming overwhelmed
Sometime the opposite problem –

“I just want to get it all out at once.”
Assessment:
Traumatic Experiences (cont.)

Be non-leading, but ask about various types
of traumatic experiences






Childhood experiences (physical, emotional,
sexual, neglect)
Adult interpersonal violence (domestic violence,
assault, sexual assault, crimes)
Street life/drug trade/gangs
Accidents
Natural disasters
Combat/torture for military personnel
Assessment:
Traumatic Experiences (cont.)

Examples of questions you could ask:

How was discipline handled in your family when
you were younger?

Follow-up on “I was hit” or “We were beat” – with
objects? Closed fist or open hand? Did it leave
marks/injuries? Did you ever need medical attention?
Have you ever had a very upsetting experience
that might still be affecting you?
 Have you ever experienced any very frightening
events?
(continued…)

Assessment:
Traumatic Experiences (cont.)

Did anyone in your childhood ever approach you
in a sexual way?




Have you had any unwanted sexual experiences?
Have you ever been in any accidents, fires, or
other catastrophes?
Have you served in the military?


In early interviews, I avoid words like rape,
molestation, sexual abuse unless the client uses them
first
Combat experiences?
Job-related experiences as appropriate
Assessment:
Traumatic Experiences (cont.)


Have you ever been the victim of a crime?
Have you been in any relationships as a teenager
or adult where there was hitting, control issues, or
sexual experiences that involved coercion?

Anything like that going on now?
Assessment: Symptoms

Clinical interview






Can start broad (e.g., “How does that experience
still affect you now?”) then move to more specific
Specifically ask about various symptom clusters
ALWAYS directly ask about self-injury, suicide,
thoughts of harm to others - both past and current
Assess substance abuse, past and current
Symptom checklists
Psychological testing
Assessment: Safety

Living situation/Finances





Basic needs met?
Current relationships
Substance abuse
Eating disorders
Any children/vulnerable adults currently in
danger?
Assessment: Safety (cont.)

Self-injurious behaviors





What is the function of the behavior?
Differentiate from suicide attempts
Past/current – when was most recent episode?
Frequency
Triggers?
Assessment: Safety (cont.)

Suicide Risk


ASK DIRECTLY!
Past attempts



Recent/current thoughts or impulses
Plans




What kept attempts from being successful?
How lethal?
How available? Ask about weapons, etc.
Current perturbation/agitation; recent stressors
Family history
Assessment: Safety (cont.)

Suicide Risk (cont.)




Hopelessness
Reasons to live
Barriers to acting on suicidal thoughts
Start talking about safety plans in initial session

Is client safe right now?
Assessment: Safety (cont.)

Risk to others




How do you handle it when you are really angry?
Ever hurt anyone intentionally or accidentally
when you were angry or upset?
Ever any thoughts of wanting to hurt anyone?
If current thoughts of harm:




Specific victim?
Plan to act on thoughts?
Means?
Know your state’s duty to warn statutes!
Assessment:
Strengths/Resources

For example:






Social network – primary relationships, friends,
family, other important people
Personal strengths
Interests/hobbies
Religious/spiritual beliefs
Pets
Can point out where you see strengths as
well
Assessment: Additional
considerations

Other things to assess along the way:




Interpersonal functioning
Client’s view of the trauma
Client’s view of helpers/treatment
Hope/trust
Assessment: Additional
considerations (cont.)

Forensic settings



Limits to confidentiality
Consider likelihood of being able to engage in
treatment at this point
Questions of malingering


Validity measures
Mandated reporting
Assessment (cont.)



Opportunity to begin therapeutic process
Offer the client hope
When possible, end the assessment with
beginning treatment planning/some initial
strategies the client can start right away
STAGES OF TREATMENT
Treatment Planning


Psychotherapy for complex trauma “should
be based in a systematic (not laissez-faire)
shared plan that utilizes effective treatment
practices, and is organized around a careful
assessment and a hierarchically ordered,
planned sequence of interventions”
“Treatment, like complex traumatic stress
symptoms, is complex and multimodal”
(Courtois, Ford, & Cloitre, 2009)
Treatment Planning (cont.)


Simple PTSD – cognitive-behavioral therapy,
exposure, cognitive reprocessing, EMDR, in
some cases medication
Complex PTSD – stage model, Dialectical
Behavior Therapy (DBT), longer term
psychotherapy



Limited empirical research (Courtois, et al., 2009)
Some evidence that prolonged exposure not only
won’t work, but can make things worse
Initial focus on emotion regulation, dissociation,
interpersonal problems
Treatment Planning (cont.)


Empowerment of client should be primary
Treatment planning should consider


Type and severity of trauma
Past/current traumatic experiences





Crisis vs. chronic distress
Current level of functioning
Safety issues
Client’s resources
Substance abuse and other comorbid conditions
Treatment Planning (cont.)

A trauma-informed treatment approach
can be integrated with any major theory of
psychotherapy, with particular emphasis
on the therapeutic relationship

R.I.C.H. Philosophy (Saakvitne, et al.
2000)
Targets of Treatment
(Courtois, Ford, & Cloitre, 2009)




Bodily and mental functioning
Attachment and trust
Inhibition of risky/ineffective behaviors;
improving problem-solving and life
management skills
Managing dissociation; integrating emotions
and knowledge
Targets of Treatment (cont.)




Improved and integrated sense of self
Prevention of reenactments of
trauma/revictimization of self and others
Overcoming dynamics of betrayal-trauma
Repaired world view/existential sense of life;
spiritual connection and meaning
“It’s never too late to be what you might
have been.”
-George Eliot
Stages of Trauma Treatment
Three main stages of treatment for ongoing
effects of trauma (Judith Herman, Frank
Putnam, Richard Kluft, Christine Curtois, etc.)
1.
2.
3.
Safety and establish therapeutic relationship
Memory processing and mourning
Reconnection
Stage One: Safety/Stabilization
Stabilize symptoms, including co-morbid
 Development of motivation for treatment
 Building collaborative alliance
 Build hope and trust
 Psychoeducation

Stage One: Safety (cont.)

Helping client commit to self-care and
self-protection

Teaching client to identify and manage
strong emotions and impulses

Identification of client’s adaptations to
traumatic experiences, and determining
which are useful and which aren’t
Stage One: Safety (cont.)
Increasing client’s ability to identify,
avoid, and mange dangerous situations
and relationships
 Establish sobriety if substance abuse is
an issue

Stage One: Safety (cont.)



Client practices coping skills in sessions,
eventually work towards implementing them
between sessions
In inpatient and acute settings, the focus is
usually going to be on the safety stage
Build up support system/crisis
management
Stage Two: Remembrance and
Mourning




Therapist as “witness and ally, in whose
presence the survivor can speak of the
unspeakable” (Herman, 1997)
Using safety skills while experiencing intense
emotions
Learning to feel, rather than detach from, the
impact of trauma (Courtois, et al., 2009)
Careful pacing
Stage Two: Remembrance and
Mourning (cont.)


“Telling the story” in more detail, with the
emotions
Recalling forgotten memories/details



Some may never become clear
Mourning losses
New perspective of trauma

Loses its intensity and centrality
Stage Three: Reconnection
and Integration





“Rejoining the world”
Facing the future and confronting fears
Addressing unresolved developmental
deficits and fixations
Fine-tuning self-regulatory skills
Identity issues
Stage Three: Reconnection
(cont.)





Intimacy and relationships
Finding meaning in life
Spirituality
Experiencing pleasurable activities that are
not “contaminated” by the traumatic
experiences
Regaining a sense of mastery and control
“…and then the day came when the risk to
remain tight in a bud was more painful than the
risk it took to blossom.”
-Anais Nin
TREATING TRAUMA IN A
FORENSIC SETTING
Trauma Work in a Forensic
Setting
“Mandated” treatment
 Trauma-informed approach for facility
 Limitations and uncertainty
 Aftercare planning
 Multi-disciplinary team
 Coordinate other treatment modalities

TARGETING TREATMENT
CHALLENGES
Targeting Treatment
Challenges




Strategies for Safety
Managing Dissociative Experiences
Towards Better Emotional Regulation
Improving Interpersonal Functioning
STRATEGIES FOR SAFETY
“Client
contracted
for safety.”
Strategies for Safety (cont.)

A safety contract alone is not effective
in stopping self-injurious or suicidal
behaviors (e.g., Peterson, et al., 2011)
 A significant number of people who
attempt or complete suicide have “nosuicide” agreements in place at the time
of the act (APA, 2003; Jamison, 1999)
Strategies for Safety (cont.)

Crisis Management




If someone is drowning, do you give them
swimming lessons, or jump in and rescue them?
(George Everly, PhD)
“Triage” – deal with safety and other immediate
needs first
Quick response to acute crisis seems to predict
better outcomes
When possible, having an “emergency plan” in
place beforehand is ideal
Strategies for Safety (cont.)

Get client on board for his own safety




“Goal is for you to not get hurt anymore”
Treatment goal to manage strong emotions
without impulsive behaviors
Crises and safety concerns will likely interfere with
progress in other areas
Needs to be a collaboration with client

Be sensitive to client’s perceived need for
SIB/suicide plans

Avoid a power struggle
Safety Plan
1. Pray
2. Call my sponsor/go to a meeting
(XXX-XXX-XXXX)
3. Watch a movie
4. Write down things to talk about in our next
session
5. Read my therapy journal
6. Call Heather’s voice mail (XXX-XXX-XXXX)
7. Talk to another resident
8. Tell staff member I need help to stay safe
Strategies for Safety (cont.)

If various treatment providers are involved,
clear communication is crucial


Potential challenges in inpatient/correctional
settings
Communication with family when appropriate
Strategies for Safety (cont.)

Additional interventions to consider



Increased frequency of sessions
Hospitalization
Medication changes
Strategies for Safety (cont.)

For chronically suicidal patients, longer-term
work to improve affect regulation and coping
skills

DBT shown to be effective for patients with BPD
and self-harm/suicidal behaviors (e.g., Linehan, et
al., 1993)
Safety in Inpatient Settings
Recommendations of the American Association
of Suicidology include:






Risk is elevated in the month after discharge
Suicide risk should be assessed prior to passes and
discharge
Patients may not accurately report own suicidal impulses
Patient, family, significant others should be educated
about risk and steps to take
Consider overdose risk of medications
All clinical staff should have training in assessing and
managing suicide risk, and promoting protective factors
After an Episode of SIB


Medical treatment, if needed, should be
provided in a neutral, matter-of-fact way
Assess current safety/risk of further SIB or
suicide



Restrictions to freedom should be based on
actual risk, not as a “punishment”
Avoid shaming
Engage client in collaboration to determine
next steps of treatment
After an Episode of SIB (cont.)

With client, look at lessons learned



New ideas about triggers or warning signs?
What coping strategies worked, and which didn’t?
What purpose is the SIB or suicide plan serving
right now?
MANAGING DISSOCIATIVE
EXPERIENCES
Possible Outward Signs of
Dissociation






Episodic confusion about date/place/situation
Unfocused gaze
Flat/quiet tone of voice
Emotionless discussion of painful material
Unexplained memory problems
May or may not be accompanied by selfinjury
Reducing Risk of Dissociation








Managing/avoiding triggers
Manage sensations before they become
overwhelming
Improve stress/anger management skills
Mindfulness
Relaxation
Engaging in other activities
Avoiding substance abuse
Consider potential risks of dissociation
Managing Triggers


Bolstering client’s own self-protection
Variety of possible triggers





Places, people, sensations associated with
trauma
Memories/painful feelings
Other people’s trauma stories
Upsetting material in books, movies, TV shows
Genuine vs. perceived danger
Grounding



“Present-focused awareness” – a sense of
connectedness between oneself and the
environment
Gives some distance between self and
painful feelings/thoughts/memories
Not the same as relaxation training – an
active approach to distract from
overwhelming stimulus (Najavits)
Grounding (cont.)

Can help manage






Dissociation
Flashbacks
Intrusive thoughts
Disorientation
Overwhelming emotions
Urges to self-injure
Grounding (cont.)

Might take a lot of practice to develop
grounding as a regular habit




Practicing in therapy sessions
Tracking in time log
Need other skills on board to tolerate sensations
that are being avoided
Learn the triggers, notice the beginning signs of
dissociation coming on
Grounding (cont.)

Wide variety of grounding strategies





Discuss options with client ahead of time, try
client’s preferences first
Often takes trial and error
Client may use different strategies in different
situations
Consider all 5 senses
Goal is to focus attention to something in the
present reality
Grounding (cont.)
Examples…








Putting hands flat on table or arms of chair/feet flat on
the floor, focusing on the sensations
Eye contact
Orient to time/date/place/situation
Holding/looking at familiar object
Getting up and moving around
Cold sensations (ice water, holding ice cube)
Holding/touching a pet
Distraction – small talk, name things in a category,
describe a familiar activity in great detail
TOWARDS BETTER
EMOTIONAL REGULATION
Towards Better Emotional
Regulation

Help client learn to not fear emotions



Many maladaptive behaviors are likely
avoidance/numbing strategies to not feel
emotions
Learning connections between
experiences, emotions, memories, and
behavior
Need to build coping and relaxation skills
Towards Better Emotional
Regulation (cont.)

Discuss range of emotional reactions






Early signs
Improve emotional vocabulary
Rating scale
Where is the “danger zone”?
“Titrate” emotions to increase ability to
tolerate a little at a time
Increase ability to more accurately “read”
emotions in others
“No feeling is final”
-Rainer Maria Rilke
IMPROVING INTERPERSONAL
FUNCTIONING
Improving Interpersonal
Functioning

Can use the therapeutic relationship
(individual or group) to identify interpersonal
patterns


“Laboratory” – what works, what doesn’t?
Addressing manipulative behavior (Saakvitne, 2000)



Opportunity to explore direct vs. indirect
communication of needs
Look at impact on relationships
Avoid simply labeling the behavior
Improving Interpersonal
Functioning (cont.)

Trust is likely to be a struggle



Focus of treatment
Understanding safe vs. hurtful relationships
Friends/family may need education about
trauma and treatment
Improving Interpersonal
Functioning (cont.)


Group therapy/support group might be
considered
Learning about relationships





Different types of relationships
Levels of trust/intimacy
Boundaries
Assertiveness
Social skills
ADDITIONAL TOOLS
Group Therapy




Can be more efficient and cost effective
Can be very useful in building interpersonal
skills, reducing isolation, normalizing
reactions
Group members can offer a different kind of
support than therapist can
Sometimes challenging/confronting by group
members is tolerated better
Group Therapy (cont.)
Group therapy “offers a direct antidote to the
isolation and social disengagement that
characterize” trauma disorders…a group
experience where “safety, respect, honesty,
privacy, and dedication to recovery are the
norm provides unique opportunities for
trauma survivors to see and hear, and to be
seen and heard by, other persons who also
struggle” (Ford, Fallot, & Harris, 2009)
Group Therapy (cont.)

Cautions in group work on trauma:


Some basic interpersonal skills need to be on
board (consider pre-treatment modalities)
More intense, detailed info about traumatic
experiences may not be appropriate



Potentially triggering of dissociation, impulsive
behavior, etc.
Potentially traumatizing to other group members
Possible “peer-contagion” effect of selfinjury/eating disorders
Group Therapy (cont.)

Exposure to trauma material in group therapy



In some research not effective and led to higher
dropout
Other research showed more success when
preparation and support between group sessions
were included
Key may be that members don’t feel too
overwhelmed and feel a sense of control

Graduated exposure
Eye Movement Desensitization
and Reprocessing (EMDR)


Developed by Francine Shapiro in the late
1980’s
Sensory experiences, cognitions, and
emotions associated with traumatic event are
processed with exposure and dual-attention
stimuli (e.g., eye movements)
EMDR (cont.)

Literature is mixed about EMDR efficacy;
some say exposure may be the key



Ponniah & Hollon (2009): EMDR reduces PTSD
symptoms to a greater extent than wait-list (but
fewer efficacy studies than other treatments)
Seidler & Wagner (2006): no difference between
efficacy of trauma-focused CBT and EMDR
Devilly, et al. (1998): no difference between
EMDR (with or without eye movements) and
standard psychiatric support in veterans
EMDR (cont.)



Davidson & Parker (2001): EMDR was better than
no treatment or treatments that did not include
exposure; was similar to other therapies that
included exposure
van der Kolk, et al. (2007): EMDR improved
symptoms better than fluoxetine and pill placebo
Wilson et al. (1997): EMDR produced substantial
symptom improvement in PTSD; benefits
maintained at 15-month follow-up
EMDR (cont.)

Research that has yielded evidence of
improvement has focused on PTSD rather
than complex syndrome


Particularly single-event PTSD
People with CPTSD usually wouldn’t meet
the “readiness criteria for standard EMDR
treatment” (Korn & Leeds, 2002)
EMDR (cont.)

Shapiro & Maxfield (2002): “for clients who
have substantial impairments related to
child abuse or neglect, treatment will not
proceed as quickly or as smoothly…such
clients often require lengthy” preparation
and stabilization prior to the reprocessing
stages
Hypnosis





Should have specialized training
Stabilization/management of symptoms
When used appropriately, can be very
useful for anxiety, pain management,
substance abuse
NOT advisable to use for “recovering”
memories
Being hypnotized could affect ability to
testify in court if abuse charges ever went
to trial
Creative Expression




Art, music, dance/movement, drama, writing
Should be provided by a trained practitioner
Client should be interested and willing
Should be used in conjunction with other
treatment approaches
Creative Expression (cont.)







Relaxation
Improving interpersonal/social skills
Improving communication/self-expression
Increased self-esteem/self-efficacy
Increased awareness of bodily
sensations/emotional experiences
Decreased shame
Might still feel like a “safe” domain
Creative Expression (cont.)

Possible benefits of nonverbal interventions
(Johnson, 2000)





Access to nonlexical or implicit memory
Creativity and spontaneity to counteract
hopelessness/damaged self-image
Replace/manage impulses
Increased balance in daily living
Positive experiences
Creative Expression (cont.)

Especially indicated for





Children
Clients who demonstrate preference for creative
outlets
Difficulties in verbal expression
Alexithymia
Intellectualization
Journaling

Multiple possible uses









Tracking time, moods, activities, triggers
Increasing self-expression
Containing thoughts and emotions
Venting feelings
Labeling/describing feelings and experiences
“Transitional object” between sessions
Practicing boundaries around privacy
Communication tool for therapy/other providers
Therapy “homework”
Journaling (cont.)
CAUTION!!!
Journaling can become overwhelming and is
contraindicated in some cases.
Journaling (cont.)

Journaling can follow steps similar to the
stages of trauma treatment

Vermilyea (2000) recommends teaching trauma
survivors to start with surface level, “here and
now” observations



Client instructed to STOP right away if getting into
more upsetting material or distress is increasing
Start with time-limited assignments (write for 5
minutes, then stop) to practice
Can slowly build up to more emotional material
Leisure Skills





Client may need education about the
importance of leisure
Opportunity for positive experiences (ideally
with other people)
“Normal” development may have been
derailed, may need to learn very basic skills
Work towards balance in life, and identity
Learn to enjoy the simple things!
Improving Problem-Solving

Teaching/practicing skills


Focus in on actual problem – one at a time!
Get the facts straight


Consider alternative courses of action



Sort out assumptions/distorted thinking
Predict likely outcomes, pros and cons
If unsure, determine whether action is needed at
this point
Tolerating trial and error, making mistakes
Improving Problem-Solving
(cont.)

Recognizing impulse vs. intentional action



Will this action take me in the direction I’ve been
trying to go?
Reinforce crisis plans
Rule of thumb: No major decisions when
feeling overwhelmed!
“You have brains in your head. You
have feet in your shoes. You can steer
yourself any direction you choose.”
- Dr. Seuss
Oh, The Places You’ll Go!
A NEW SENSE OF SELF
A New Sense of Self

Repairing damaged self-image




Understanding views of abuser and/or
“bystanders”


Victim? Survivor? Perpetrator as well?
Broader view of self and life experiences
Letting go of the tough question: “WHY?”
How do these play out in other relationships?
Exploring world view

Is a new perspective possible?
“I am not afraid of storms, for
I’m learning how to sail my
ship.”
― Louisa May Alcott
PART THREE:
What About You?
VICARIOUS TRAUMATIZATION
Vicarious Traumatization (VT)
“To study psychological trauma is to come face
to face both with human vulnerability in the
natural world and with the capacity for evil in
human nature. To study psychological trauma
means bearing witness to horrible events.”
Judith Herman, Trauma and Recovery
VT (cont.)
“VT is the transformation or change in a
helper’s inner experience as a result of
responsibility for and empathic
engagement with traumatized clients”
(Saakvitne, et al. 2000)
VT – Possible Effects
VT can affect helpers in a variety of domains
-Identity
-Physical health
-Hopefulness/optimism
-Work performance
-Empathy
-Sense of safety
-Boundaries
-Enjoyment of life
-Worldview
-Sense of control
-Spirituality
-Self-efficacy
…etc.
VT – Risk Factors
Risk Factors for treatment providers
-Lack of training or knowledge
-Isolation/lack of social support
-Imbalanced work load
-Unclear boundaries
-Sense of responsibility for the client
-Helper’s own trauma history
VT – Possible Warning Signs
-Reduced hope
-Trouble concentrating/ making decisions
-Increased sensitivity to disturbing stimuli
-Increased fearfulness
-Increased isolation
-Feeling disconnected from others
-Changes in eating, sleeping, interests, energy,
sex drive
VT – Possible Warning Signs (cont.)
-Chronic illness/fatigue
-Irritability/low frustration tolerance
-Changed attitude towards work/clients
-Not being able to stop thinking about work off
hours
-Dreams/nightmares about work
-Emotional numbing
-Loosening of boundaries
“Although the world is full of
suffering, it is also full of the
overcoming of it.”
-Helen Keller
SELF-CARE FOR THE
CLINICIAN
Self-Care as an Ethical Issue

Do no harm




VT increases risk of mistakes, lack of investment,
boundary crossings
Clinicians are responsible for monitoring
ourselves for burnout or other forms of VT that
might affect our clinical work
We are responsible for monitoring ourselves and
our colleagues
Consider self-care an ethical responsibility and
part of clinical skill set
Therapist Self-Care
“The single most important factor in the
success or failure of trauma work is the
attention paid to the experience and needs of
the helper” (Saakvitne, et al., 2000)
Therapist Self-Care (cont.)

Be reasonable in your expectations






Of yourself
Of the client
Of the work
Of your colleagues/workplace
Take potential signs of burn out seriously!
Attend carefully to therapeutic boundaries
Therapist Self-Care (cont.)


Don’t subject yourself to unnecessary trauma
Avoid becoming isolated and disconnected
from others


Nurture your personal relationships
Colleague support is critical


R.I.C.H. for each other!
Informal and/or formal


Consultation
Supervision group
Therapist Self-Care (cont.)
Consider:
 Physical self-care
 Psychological self-care
 Emotional self-care
 Professional self-care
 Spiritual self-care
(Saakvitne, et al. 2000)
Therapist Self-Care (cont.)
You are a valuable resource to your clients!
Honestly
evaluate your limits
Notice your reactions to clients
Maintain appropriate boundaries
Consult and get support
Take good care of yourself
“You, yourself, as much as anybody in
the entire universe, deserve your love
and affection.”
-Buddha
Make a commitment to self-care.
TAKE-HOME POINTS
Take-Home Points




Screening for trauma symptoms should be
routine
Careful assessment of trauma symptoms,
and understanding the variety of ways trauma
can present will help with diagnostic accuracy
and treatment planning
Cultural and other individual factors must be
considered in assessing trauma
Stage model of trauma treatment
Take-Home Points (cont.)




Current symptoms may reflect behaviors that
helped the client endure the trauma
Early attachment experiences contribute to
vulnerability to trauma later in life
Complex Trauma Syndrome as a useful
conceptualization of the client’s presentation
Importance of collaborating with client to
maintain safety and manage crises
Take-Home Points (cont.)




Solid boundaries and a healthy therapeutic
connection can be in themselves healing
Understand the resources/limits in your
setting; adapt trauma work accordingly
We are all vulnerable to vicarious
traumatization and burn out
Self-care is critical!
ADDITIONAL RESOURCES
Additional Resources

Sidran Institute: www.sidran.org

International Society for Traumatic Stress
Studies: www.istss.org

Substance Abuse and Mental Health Services
Administration (SAMHSA) National Center for
Trauma-Informed Care: www.samhsa.gov/nctic
Additional Resources (cont.)

American Association of Suicidology:
www.suicidology.org

Seeking Safety: www.seekingsafety.org

National Alliance for the Mentally Ill: nami.org
Additional Resources (cont.)
Trauma
and Recovery (1997), Judith Herman,
Basic Books
Trauma
Recovery and Empowerment: A
Clinician's Guide for Working with Women in
Groups (1998) Maxine Harris, The Free Press
Seeking
Safety (2002), Lisa Najavatis, The
Guilford Press
Additional Resources (cont.)

Growing Beyond Survival (2000), Elizabeth
Vermilyea, The Sidran Press

Treating Complex Traumatic Stress
Disorders: An Evidence-Based Guide (2009),
Courtois & Ford (Eds.), The Guilford Press
“Be the change you wish to see in the world.”
-
Mahatma Gandhi
To Get Your CEU Certificate




Go to our website: tzkseminars.com
Log in using your email address and
password
Complete the webinar evaluation
Download your certificate
Contact
info@tzkseminars.com
Tzkseminars







Keith Hannan, Ph.D., consultant to juvenile facilities on “Conduct
Disorder.” Dr. Hannan also does a Friday afternoon webinar series
on juvenile delinquency
David Shapiro, Ph.D., the father of clinical forensic psychology on
the “Fundamentals of Forensic Assessment.” Learn forensic
assessment from the best.
David McDuff, M.D., consultant to the Baltimore Orioles and Ravens
on “Sports Psychiatry.” This webinar is appropriate for all mental
health clinicians interested in working with athletes.
Heather Hartman-Hall, Ph.D., internship training director and
talented clinician on “Making Sense of the Complexities of Trauma.”
Scott Hannan, Ph.D., seen on the show “Hoarders,” on “Cognitive
Behavioral Therapy for School Refusal.”
Michael Herkov, Ph.D., of the University of Florida, on “The Ten
Most Common Ethical Errors.”
New speakers coming soon!!!