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How Victims Learn to Cope: Clinical Strategies for Traumatic Pleasure and Traumatic Repetition Presented by: Rokelle Lerner [email protected]  Innerpathretreats.com. The 14th Annual Counseling Skills Conference, October 4 2008 Las Vegas, NV. Disorders Related to Trauma. PTSD

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How Victims Learn to Cope:Clinical Strategies for Traumatic Pleasure and Traumatic Repetition

Presented by:Rokelle Lerner

[email protected]Innerpathretreats.com

The 14th Annual Counseling Skills Conference, October 4 2008Las Vegas, NV


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Disorders Related to Trauma

  • PTSD

  • Brief reaction psychosis

  • Dissociative identity disorder

  • Dissociative amnesia

  • Borderline personality disorder

  • Depersonalization disorder

  • Somatization disorder

  • Dream anxiety disorder

  • Antisocial, Borderline and Narcissistic Personality Disorder


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Trauma

  • Event outside the range of human experience that can not be processed in healthy ways

  • Un-metabolized trauma is the precursor to addiction, eating disorders, suicide, violence


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Small “I” Traumas

  • Trauma of not being seen

  • Trauma of being in distress with nobody around to comfort

  • Trauma of being alone with no one available for connection

  • Trauma of having needs with no possibility of having those needs met

Shapiro, 1998


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Trauma that is Most Severe

  • Sanctuary Trauma: Occurring in places that should have been safe:

  • Process Trauma: Hurt over time rather than one single event


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Trauma Threatens Basic Needs

Survival:

So we get rid of sights, sounds by dissociation, repression or addiction.

Sense of Order:

We want to complete or resolve the experience


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ABUSE PROCESS

  • Event outside the range of human experience that can’t be processed in healthy ways.

  • Projection:

  • Introjection:

  • Reaction:

  • Acting Out:


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TraumaticAbstinence: deprivation that is driven by terror and fear

TraumaticShame: self-hatred rooted in a traumatic experience

TraumaticRepetition: repeating behaviors by seeking situations or persons who can re-create the traumatic experience

Traumatic Pleasure: High risk behaviors to mask pain and emptiness

TraumaBonds: Attachments that occur in the presence of danger, shame or exploitation

How Trauma Victims Cope


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Deprivation around memories of success, stress, shame or anxiety

Deny basic needs

Avoid sexual pleasure

Hoard money

No interest in eating for periods of time

Sabotage success opportunities

Assess for Axis I disorders: anorexia, sexual aversion disorder, agoraphobia and other phobic responses

Incremental use strategies

Connect relapse with trauma issues

Learning to play as well as relaxation techniques

CBT: confronting disabling beliefs non-deserving

Clinical Strategies

Symptoms ofTraumatic Abstinence


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Engaging in self mutilating behaviors anxiety

Enduring physical or emotional pain most people would not accept

Avoiding mistakes at any cost

Suicidal ideation, threats or attempts

Numbing of emotions and inability to experience love, joy or sadness

Visualization and affirmation

Intense family of origin work

CBT to restructure faulty or shaming belief

Shame reduction strategies:

Familiarity with the shame cycle

Symptoms of Traumatic Shame:

ClinicalStrategies:


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Living in the unremembered past; trying to resolve the un-resolvable:

Inability to stop a childhood pattern

Compulsively victimizing others in a similar way that patient was victimized

Provoking others: allows the patient to re-live the victim experience

Assessment for OCD

Cognitive restructuring of key experiences and beliefs about those experiences

Abreaction: re-creation of experience (through visualization or psychodrama) to reduce the power of original experience, bring resolution and make it conscious

Self-soothing techniques

ClinicalStrategies

Symptoms ofTraumatic Repetition


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Finding compulsive pleasure in the presence of danger or violence

Only feeling ‘alive’ when dealing with crisis or huge risk.

Difficulty sleeping, being with their families or maintaining friendships

High risk sex, compulsive gambling, white collar theft, affairs

Stimulation and pleasure are compensating for pain and emptiness. Focus on self soothing, empathic connection and triggers for relapse

Do a history of how excitement and shame are linked to traumatic past.

Debrief the costs and dangers over time.

First Step and relapse prevention plan regarding how powerful this is in their life.

Clinical Strategies

Symptoms ofTraumatic Pleasure


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Presenting Symptoms: violenceTrauma Bonding

  • Continuing to seek contact with those whom she knows will cause her further pain

  • Trusting people who are proven to be unreliable

  • Loyal to people who have betrayed you

  • Uncontrollable obsession or fantasizing about those who have hurt you

  • Remaining a ‘team’ member even when the situation becomes destructive

  • Lack of bridging between frontal lobes and amygdale

  • Can’t self soothe, little affect regulation

  • The most addictive form of attachment


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Clinical Strategies violence forTraumatic Bonds

  • No contact contracts

  • Teach strategies for detachment

  • Self-help groups that provide support and perspective

  • Disrupt beliefs about ‘uniqueness’

  • Explore both the ‘pay offs’ and price paid of traumatic bonds

  • Grief work and rituals around letting go/change


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PTSD: Three Symptom Clusters violence

  • Re-experiencing

  • Numbing and avoidance

  • Hyper-arousal

    Disorders related to PTSD

    Depression, Anxiety, Panic disorder,

    Phobias, Substance abuse, Physical

    somatization


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Working Through Trauma violenceBessell Vanderkoch Ph.D

  • Traumatic memory is stored in the limbic system and in body memory

  • Since this memory was stored in high arousal, for treatment to work, there must be high arousal for the client: reenactment

  • Once the right side of the brain has been triggered, focus of treatment is to engage the left side of the brain

  • Help clients give words to their sensations and change the outcome


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Developmental Trauma violenceCluster B Disorders:

  • Borderline Personality Disorder:Pre birth - 14 months

  • Antisocial Personality Disorder:3 months - 14 months

  • Narcissistic Personality Disorder:15 months - 22 months

Schore, 2002


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Traumatic Attachments violence

  • Traumatic memory is stored in the limbic system and in body memory

  • Since this memory was stored in high arousal, for treatment to work, there must be high arousal for client: re-enactment

  • Once the right side of the brain has been triggered, focus of treatment is to engage left side of brain

  • Help patients to give words to their sensations and change the outcome

Bessell van der Kolk Ph.D


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Trauma effects the ability of the brain to analyze and integrate information

Our challenge is to re-program the emotional brain so that it adapts to the present rather than continuing to respond as if the past is the present!

Trauma

Siegel/Debillis 2003


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If A Patient Has Unmetabolized Trauma... integrate information

  • Their Limbic system is active!

  • They’re going to be talking and acting without thinking

  • We need to avoid language that stimulates the limbic brain:

  • “You should”, “How could you”, “Don’t...”, “Didn’t I tell you”, “I need you to...”


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Romancing the Brain integrate information

  • “It could be…”

  • “Another possibility…”

  • “Let’s consider…”

  • “Will you agree to this…”

  • ”Another way to look at this is…”

  • ”I invite you to…”


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Memory but no feeling integrate information

Feeling but no memory

Memory flooding

Fugue states

Tunnel vision

Bodily sensations with no apparent cause

Memory Returns:

“Blips”

Intense bodily sensation

Hazy images

Repetitive dreams

Emotional abreaction

Types of Dissociation


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Shame: 4 Reactions integrate information

  • “Unpacking” Shame Based Trauma:

  • Realization: Insight

  • Linking: Awareness

  • Debriefing: Tell the story

Withdraw

Avoid


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When is a Patient Ready for Trauma Processing? integrate information

  • Patient is able to use some safe coping skills

  • Has no major current crisis or instability

  • WANTS to do this type of work

  • Can reach out for help when in danger

  • Not using substances to such a sever degree that emotionally upsetting work may increase use

  • Suicide has been evaluated and taken into account

  • In an ongoing system of care that is stable and consistent, with no immediate planned changes


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Trauma: Group Tasks integrate information

Judith Herman Ph.D

1

2

3

Stage of Recovery

Remembrance

Past Trauma

Trauma

Homogenous

Goal Directed

Survivor Group

Reconnection

Present, future

Interpersonal Rel

Heterogeneous

Unstructured

Psychotherapy

Safety

Present

Self-care

Homogenous

Didactic

12 Step

Therapeutic Task

Time Orientation

Focus

Membership

Structure

Example


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More General Considerations integrate information

  • Develop flexibility

  • Listen and Go slowly

  • Allow her to define what was traumatic

  • Work with her perception

  • Always amplify the client’s resiliencies

  • Take into account the fragile sense of self and the client’s invisible loyalties

  • Being “stuck” and being “unwilling” are not the same


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Techniques for Processing Trauma integrate information

  • EMDR: Eye Movement Desensitization Rehabilitation

  • Psychodrama, journaling, body work

  • Hypnosis

  • NLP: Neuro-Linguistic Programming

  • CBT: Cognitive Behavioral Tx


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Suggestions integrate information

  • Reframe

  • Use techniques that connect the mind and body

  • Triggers for vulnerability

  • Help to grow her/h voice

  • Self soothing

  • Help patient to tell a coherent story


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Reframe: integrate information

  • Victim

  • Survivor

  • Empowerment: “I am responsible for the solution, the resolution and my protection so it never happens again”


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Connect Body and Mind integrate information

  • Teach patients that the body doesn’t ‘lie’

  • Connect emotional responses to physical sensations: movement, body work, play

  • Use the creative arts: singing, dancing, story telling, writing

  • The goal is to promote congruence


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Mystery of the Locked Rooms integrate information

Exits

Relapse

Rage

Dissociate

Self Harm

Bingeing

Triggers

Stress

Tone

Criticism

Odor

Expression

Fear

Shame

Anger

Pain

Despair

Anxiety

Abandonment

Deprivation


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Signs of Emotional Wellness integrate information

  • Ability to sense a feeling

  • Locate the feeling in the body

  • Name the feeling

  • Express feeling appropriately

  • Ability to contain feeling

  • Ability to slow down and stop

  • Ability to discern if intensity of the feeling matches the situation

  • Ability to ask: “How old do I feel as I have this feeling?”


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Format for Disclosing Vulnerability integrate information

  • When you…

  • Like the time…

  • I feel/felt…

  • My request is…

  • Listen while self soothing

Format for Setting Boundaries

  • External “If you raise your fist in anger, I will call the police”

  • Internal: “When I feel angry, I will excuse myself and leave the room instead of raging at you”


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Self Soothing integrate information

Stephanie Covington PhD

Alone

With Others

  • Excuse myself

  • Breathe

  • Sip ice water

  • Read

  • Take a walk

  • Call sponsor

Daytime

  • 5 Sights

  • 4 Sounds

  • 3 Touch

  • 2 Smell

  • 1 Taste

Nighttime


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Tell The Story integrate information

“When an individual can tell a coherent story,

about their past they are well on the way to integration” Mary Main, PhD

Life Script

Story Telling


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Writing the Story integrate information

  • Once Upon a Time:

    Wounding

  • And when she/he grew up:

    Present

  • And the story changed when:

    Vision


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Signs of Integration/Healing: integrate information

  • Less arguing, denying or objecting

  • Not as many questions

  • Asks what he/s could to do and how people change

  • She’s envisioning how life might be better


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An Ending integrate information

Followed by Confusion/Pain

Leading to new beginnings

Name the dream

Gain perspective

Educate friends

Tell your story

Create Safety

Borrow Hopefulness

Keep Dreaming

Healing Loss of Dreams

Transition:


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Bibliography integrate information

  • Trauma and Recovery, Judith Herman Ph.D, Publisher: Basic Books

  • Healing Trauma: Attachment, Mind, Body, and Brain, Marion Fried Solomon, Daniel J. Siegel, Marion SolomonW.W. Norton & Company

  • Trauma and Addiction : Ending the Cycle of Pain Through Emotional Literacy by Tian Dayton Health Communications

  • Addictions and Trauma Recovery: Healing the Body, Mind, and Spirit by Dusty Miller, Laurie Guidry

  • Trauma Recovery and Empowerment : A Clinician’s Guide for Working With Women in Groups by Maxine Harris

  • Living in the Comfort Zone: The Gift of Boundaries in Relationship, Rokelle Lerner, Health Communications


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