CSA Treatment and PTG in Adult Clients: Phase Two Mis -steps and Correctives

1. Diane Langberg, PhD Slides Available: Philip G. Monroe, PsyD www.globaltraumarecovery.org CSA Treatment and PTG in Adult Clients: Phase Two Mis-steps and Correctives

2. Objectives • Identify common clinical mistakes in the treatment of adult survivors of child sexual abuse • Describe best practices during phase two of treatment • Understand common signs of posttraumatic growth and resilience within clients that appear stuck 

3. Who is stuck? The client? Or the counselor?

4. Common counselor reactions “How can I get my client to…?” “How can I get rid of my client?”

5. Common counselor mistakes • Messianic rescuing (over-responsibility) • Boundary crossings or Burnout • Demanding catharsis • Forcing memory processing/exposure • Misunderstanding client resistance • Irritated with client; push harder • Failure to manage “the hour” • Encouraging dissociation

6. CSA and Complex Trauma Brief Review

7. Re-experiencing: (1) Recurrent, intrusive distressing recollection (may be repetitive play) Recurrent, distressing dreams Acting or feeling as if event is recurring Psychological distress on exposure to cues Physiological reactivity on exposure to cues Increased arousal (2) Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response Avoidance or Numbing (3) Efforts to avoid thoughts, feelings, conversations associated with trauma Efforts to avoid activities, places, or people associated with trauma Inability to recall important aspect of trauma Diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect Sense of foreshortened future Posttraumatic Stress Disorder (PTSD)

8. New: Dissociative subtype • Pays more attention to dissociative problems • Derealization • Depersonalization • Sees these symptoms as separate from re-experiencing and/or hypervigilance • Why important? • Clients with this set of symptoms respond better to mindfulness, cognitive restructuring, and DBT style interventions in addition to exposure therapies • Note: also “preschool” subtype

9. Common features of CSA clients • Betrayal trauma experiences leading to symptoms of complex PTSD

10. DESNOS alters a person’s • Ability to regulate affect and impulses • Attention and consciousness • Self-perception • Perception of the perpetrator • Capacity for relationships • Body and brain responses • Perception of meaning and faith

11. Complex Trauma v. Borderline

12. Phase one: Safety & stabilization • Foundation for all treatment • Longest phase and vital to positive outcomes • Features • Therapeutic alliance building • Education about the nature of trauma • Managing vs. reacting to symptoms

13. Phase two: Processing memories Memory work done in concert with phase one skills • Focus: grief, loss, shame, anger rather than anxiety • Context: the tendency to leave (dissociate from) the pain • Goal: Small amounts of memory work with frequent self-care and stabilization

14. Phase two interventions • Exposure • Stress inoculation OR…? • Interpersonal/dynamic interventions “Therapy that emphasized relaxation, relationships, affect, and meaning-making appeared to be more helpful than therapy that emphasized exposure to trauma reminders.” D’Andrea & Pole

15. Revisiting the experience of CSA Pointing to Corrective Experiences in Therapy

16. Common trauma experiences Intense fear, paralysis/helplessness, inability to effect any change, threat of annihilation, leading toexperience of, Loss of voice, control, connection, and meaning, resulting in, Disorganized physical, cognitive, and emotional response systemthereby increasing, Relational pain, distrust, self-contempt, overwhelming anxiety, evidenced as, Running from the past, afraid of the future

17. Correctives • Proceed little by little, without force • Focus on this step over ultimate goal • Embrace repetition • Embrace rest; Identify as NOT failure • Remember: Return to safety/stabilization throughout treatment

18. Dynamic techniques

19. Additional techniques

20. The ARC model • Attachment • Self-Regulation • Competency Kinniburgh, Blaustein, Spinazzola, Psychiatric Annals, May 2005 http://psychrights.org/research/Digest/CriticalThinkRxCites/kinniburgh.pdf

21. Attachment-oriented interventions • Predictable routines in therapy • Support in-the-moment affect regulation • Watch your language • Affirm strengths (find them in surprising areas!)

22. Self-regulation interventions • Expand awareness of affect • Connect affect with body sensations • Normalize reactions • Self-expression through nonverbal means • Encourage kinetic regulation of affect • Connect affect with historical events • Teach grounding techniques

23. Competency interventions • Identify interests/goals • Encourage independent choices • Learning relational safety/danger cues • Encourage connections to others • Identify and affirm strengths • Teach self-awareness  self-care • Construct solutions to problems together • Review outcomes together

24. Two Spiritual Disciplines Meditation and Solitude as Emotion Regulation Interventions

25. Mindfulness Mindfulness is about waking up from a life on automatic pilot, becoming keenly aware and sensitive to our experiences – both internal and external

26. Meditation as spiritual discipline • On creation • On Scripture • On Christ

27. Solitude as spiritual discipline • Goal: having a sanctuary of the heart so we are not controlled by people or noise

28. Posttraumatic Growth & Resilience Exploring Movement in Therapy with Adult Survivors

29. Posttraumatic growth (PTG) • Retrospective perceptions of positive psychological changes after trauma • Not just bouncing back but growing beyond pre-trauma adaptive capacities • Connotes positive change in identity and capacities post trauma

30. Related: Posttraumatic growth • Changes seen in • Identity perception (perceived new possibilities) • Capacity awareness (strength perception) • Appreciation of life and faith (values)

31. Redefining PTG • Holding symptoms and strengths together • Success during phase two includes • Ability to say no • Ability to have hope • Not reduction of triggers and trauma reactions

32. Ponder this: • Why do most recover from traumatic experiences and do not go on to develop PTSD? • Intrinsic capacity? • Community supports? • Prior experiences?

33. Resilience • re·sil·ience • the power or ability to return to the original form, position, etc., after being bent, compressed, or stretched; elasticity. • ability to recover readily from illness, depression, adversity, or the like; buoyancy. http://dictionary.reference.com/browse/resilience

34. Better definition • the ability to recover readily from illness, depression, and adversity • Adapting? • Thriving? Problem with this definition? What does resilience look like in an ongoing storm?

35. A biblical image of resilience? • Joseph? • What you intended for evil… • Jeremiah? • I will never forget this awful time as I grieve…yet I still dare to hope • Esther? • If I perish, I perish • Paul? • Though outwardly we are wasting away, yet inwardly we are being renewed

36. Resilient individuals? • Optimism (realistic optimism) • Cognitive flexibility • Personal moral compass • Role models • Face and reframe fears • Active coping mechanisms • Attending to physical wellbeing • Nurture social network • Recognize strengths Dennis Charney

37. Different in other cultures? • YES! • Gratitude • Pride in culture and ethnicity • Appreciation of human differences • Karma

38. Biology of resilience? • Fear/Reward circuits • Neuropeptide Y?

39. Threats to resilience • Passive acceptance of threats • Loss of social support and moral foundation • Rumination

40. Can you learn resilience? • Possible ways to improve it • CBT • Narrative work • Faith engagement • Mindfulness • Social Support • Self-reflection • Physical training • Sleep

41. Trauma work supporting resilience • Phase 1: Interventions avoid disrupting intact protective factors (meaning, networks, structures) • Phase 2: Re-establish weak social resources (family re-unification, vocational training) • Phase 3: Targeted trauma recovery intervention

42. Individual or communal? • Community’s inherent capacity, hope, and faith to withstand major trauma, overcome adversity, and to prevail, with increased resources, competence and connectedness Judith Landau Individual resilience promoted by community and Community expression of resilience

43. Predicting community resilience • Active use of family/community resilience stories • Active engagement of transcendence • Organizational strength • Flexibility • Connected • Available resources

44. Improving community resilience • Identify agents of change • Identify local values, resources, wisdom • Reinforce open dialogue, to • Identify tangible assets (community genogram) • Re-establish daily patterns, rituals • Re-connectedness

45. Community responses • Use of drama to capture lament • To validate, narrate • To spark conversations • Local conversations where all parties have voice • Goal identification • Resource allocation • Support groups