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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. Objectives.

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diane langberg phd slides available philip g monroe psyd www globaltraumarecovery org
Diane Langberg, PhD Slides Available:

Philip G. Monroe, PsyD


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

  • 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 
who is stuck
Who is stuck?

The client?

Or the counselor?

common counselor reactions
Common counselor reactions

“How can I get my client to…?”

“How can I get rid of my client?”

common counselor mistakes
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
posttraumatic stress disorder ptsd
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


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)
new dissociative subtype
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
common features of csa clients
Common features of CSA clients
  • Betrayal trauma experiences leading to symptoms of complex PTSD
desnos alters a person s
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
phase one safety stabilization
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
phase two processing memories
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
phase two interventions
Phase two interventions
  • Exposure
  • Stress inoculation


  • 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

revisiting the experience of csa
Revisiting the experience of CSA

Pointing to Corrective Experiences in Therapy

common trauma experiences
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

  • 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
the arc model
The ARC model
  • Attachment
  • Self-Regulation
  • Competency

Kinniburgh, Blaustein, Spinazzola, Psychiatric Annals, May 2005


attachment oriented interventions
Attachment-oriented interventions
  • Predictable routines in therapy
  • Support in-the-moment affect regulation
  • Watch your language
  • Affirm strengths (find them in surprising areas!)
self regulation interventions
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
competency interventions
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
two spiritual disciplines
Two Spiritual Disciplines

Meditation and Solitude as Emotion Regulation Interventions


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

meditation as spiritual discipline
Meditation as spiritual discipline
  • On creation
  • On Scripture
  • On Christ
solitude as spiritual discipline
Solitude as spiritual discipline
  • Goal: having a sanctuary of the heart so we are not controlled by people or noise
posttraumatic growth resilience
Posttraumatic Growth & Resilience

Exploring Movement in Therapy with Adult Survivors

posttraumatic growth ptg
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
related posttraumatic growth
Related: Posttraumatic growth
  • Changes seen in
    • Identity perception (perceived new possibilities)
    • Capacity awareness (strength perception)
    • Appreciation of life and faith (values)
redefining ptg
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
ponder this
Ponder this:
  • Why do most recover from traumatic experiences and do not go on to develop PTSD?
    • Intrinsic capacity?
    • Community supports?
    • Prior experiences?
  • 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.


better definition
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?

a biblical image of resilience
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
resilient individuals
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

different in other cultures
Different in other cultures?
  • YES!
    • Gratitude
    • Pride in culture and ethnicity
    • Appreciation of human differences
    • Karma
biology of resilience
Biology of resilience?
  • Fear/Reward circuits
  • Neuropeptide Y?
threats to resilience
Threats to resilience
  • Passive acceptance of threats
  • Loss of social support and moral foundation
  • Rumination
can you learn resilience
Can you learn resilience?
  • Possible ways to improve it
    • CBT
    • Narrative work
    • Faith engagement
    • Mindfulness
    • Social Support
    • Self-reflection
    • Physical training
    • Sleep
trauma work supporting resilience
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
individual or communal
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


Community expression of resilience

predicting community resilience
Predicting community resilience
  • Active use of family/community resilience stories
  • Active engagement of transcendence
  • Organizational strength
    • Flexibility
    • Connected
    • Available resources
improving community resilience
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
community responses
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