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Integrative Treatment of Complex Trauma for Adolescents (ITCT-A)

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Integrative Treatment of Complex Trauma for Adolescents (ITCT-A) Integrative Treatment of Complex Trauma for Adolescents (ITCT-A) University of Wisconsin-Madison Conference on Child Sexual Abuse October 28, 2015 Cheryl Lanktree, Ph.D. USC-Adolescent Trauma Training Center Department of Psychiatry and Behavioral Sciences Keck School of Medicine University of Southern California National Child Traumatic Stress Network attc.usc.edu Complex trauma exposure • Multiple exposures to multiple types of traumatic events, simultaneous and/or sequential – emotional abuse and neglect – child sexual abuse and exploitation – physical abuse – witnessing domestic violence – Peer or gang assault, “drive bys” – traumatic loss – trauma associated with immigration – serious medical illness or injury • Insecure attachment with primary caretakers Contextual aspects of complex trauma exposure • Trauma intensifiers – Early onset – Extended and frequent exposure; ubiquity – Relational context • Social marginalization – Poverty – Social discrimination • Race/ethnicity • Sexual orientation – Inadequate education – Reduced access to services • , Complex trauma outcomes and attachment effects • Anxiety, depression, anger • Posttraumatic stress • Affect dysregulation • Negative relational and self schema • Identity/self-reference issues • Medical issues, physical neglect of self Complex trauma outcomes and attachment effects (continued) • Avoidance responses – Dissociation – Tension reduction behaviors • Self-injurious behavior • Dysfunctional sexual behavior, • Bulimia • Aggression – Substance abuse – Suicidality “Borderline” or Complex Trauma? • Frantic efforts to avoid real or imagined abandonment • Pattern of unstable and intense interpersonal relationships • Identity disturbance: unstable self-image or sense of self • Impulsivity in areas that are potentially self-damaging: spending, sex, substance abuse, reckless driving, binge eating • Recurrent suicidal behavior, gestures, threats, or self- mutilating behavior • Affective instability, marked reactivity of mood • Chronic feelings of emptiness • Inappropriate, intense anger or difficulty controlling anger • Transient, stress-related paranoid ideation or severe dissociation DSM-V (APA, 2013) Comparing BPD, PTSD & CT Study by Cloitre, et al. (2014) ! BPD symptoms more likely to lead to BPD diagnosis than Complex PTSD: frantic efforts to avoid abandonment, unstable sense of self, unstable and intense interpersonal relationships, and impulsiveness ! Complex PTSD: chronic and repeated traumas, symptoms of PTSD plus disturbances of self- organization--- emotion dysregulation, self- concept and relational difficulties Integrative Treatment of Complex Trauma for Adolescents (ITCT-A) • Initial development: MCAVIC (2001-2005) and MCAVIC-USC (2005-2009) – Multiply traumatized, socially marginalized youth and children – Multi-ethnic, multi-racial, multi-disciplinary staff – Structured, component-based but individualized for each client (assessment-based) – Relational but also cognitive-behavioral – Intensive treatment and advocacy Consultation Community Individual Referral School-based Therapy Group Collateral Referral Screen Assessment Clinic-based Individual Therapy Family Group Hospital-based Therapy Individual &/or Family Forensic Interview Importance of Cultural Focus and Advocacy in ITCT-A • Cultural background and beliefs in assessment and treatment---e.g., importance of family, religion, community, immigration issues, discrimination experiences. Seek consultation from colleagues. • Avoid assumptions: Ask client(s) to describe their cultural and racial identity. • Consider impact of therapist’s cultural background. • Assessment and treatment are culturally appropriate and in client’s primary language. • Agency staff are culturally diverse, opportunities for clients to learn about other cultural groups. • . Creating a welcoming and inviting setting Culturally Diverse Team, Client Art Create a Welcoming Setting Integrative Treatment of Complex Trauma for Adolescents (ITCT-A) • Current project status: USC-Adolescent Trauma Training Center (2012-2016) – Second edition of ITCT-A treatment guide (Briere & Lanktree, 2013; attc.usc.edu) – Substance use/abuse treatment guide (attc.usc.edu) – Mindfulness treatment guide (in progress) – Trainings and conferences, consultations (monthly Zoom calls), website: usc.attc.edu, publications – Multi-site collaborations – National conferences in California (2014, 2015) Collaborations and Adaptations • Centers throughout the U.S.: – El Paso, TX – Southwest Keys Programs: TX, AZ, NM,CA -- Oakland, Los Angeles, Orange County, CA -- U. of Missouri-St. Louis – Denver and other communities, CO – Chicago and other communities, IL – Boston and surrounding communities, MA – Delaware – Adelphi University, Long Island, New York – Oklahoma Collaborations and Adaptations (continued) • Range of settings and duration of treatment • Residential treatment facilities, outpatient clinics, schools—short-term and longer-term treatment • Adaptations include Spanish translations of ITCT-A tools • Community collaborations including trauma-informed services Adaptation of ITCT-A: Storefront/School- Based Program ITCT Treatment Outcome Study (Lanktree et. al., 2012) • 151 clients (children and adolescents) – Similar findings for adolescents-only subsample • Mean age 11.43 years (range: 8-17 yrs.). • 48% Hispanic, 25% Black, 14% non-Hispanic White, 13% Asian • 52% CSA, 27% PA, 17% CV, 31% TL, 31% DV. • 62%: 2 or more types of trauma, 14%: 4 or more traumas • 67% in treatment for 3 to 8 months (Mean=6.79) Evidence-Based Research: Pre-Post Data Average of >40% improvement across symptoms ITCT-A: Core aspects • Assessment-based • Focus beyond posttraumatic stress – Relational issues – Affect dysregulation – Problematic avoidance and “acting out” behaviors • Centrality of therapeutic relationship • Safety within therapy and environment • Customization: Age, gender, culture, affect regulation capacity ---not “one-size-fits-all” • Cultural diversity of clients and economic disadvantage incorporated into interventions ITCT-A: Core aspects (continued) • Focus on the client’s experience – Taking him/her where he/she is – Avoidance of judgmental/authoritarian therapist behaviors • Titrated exposure and cognitive interventions • Affect regulation training and behavior control – including Trigger Identification and Intervention, mindfulness, “urge surfing” • Parent/family interventions • Advocacy and system intervention • Beyond the traditional therapist role ITCT-A Tools (Briere & Lanktree, 2013) • Initial Trauma Review-Adolescent Version (ITR-A) • Possible Interview Question Topics for ITCT-A (PIQT-A) • What Triggers Me? (The Trigger Grid) • Assessment Treatment Flowchart for Adolescents (ATF-A) • Problems-to-Components Grid for Adolescents (PCG-A) Assessment-Treatment Flowchart (ATF-A) • Usually following the Initial Trauma Review (ITR-A) and/ or Possible Interview Question Topics (PIQT) • Completed at intake and each 2-3 month period Priority ranking (circle one for each symptom): 1 = Not currently a problem 2 = Problematic, but not an immediate treatment priority 3 = Problematic, a current treatment priority 4 = Most problematic, requires immediate attention (S) = Suspected, requires further investigation Available at attc.usc.edu ATF-A items (examples) Problem area Tx priority 1. Safety – environmental 1 2 3 4 (S) 2. Caretaker support issues 1 2 3 4 (S) 5. Anxiety 1 2 3 4 (S) 6. Depression 1 2 3 4 (S) 7. Anger/aggression 1 2 3 4 (S) 8. Low self-esteem 1 2 3 4 (S) 9. Posttraumatic stress 1 2 3 4 (S) 10. Attachment insecurity 1 2 3 4 (S) Problems–to-Components Grid for Adolescents (PCG-A) Problem (from ATF-A) Treatment components Safety (environmental) Safety training, system interventions, psychoeducation Caretaker support Family therapy, intervention with caretakers Anxiety Distress reduction/affect regulation training, titrated exposure, cognitive processing Depression Relationship building and support, cognitive processing, group therapy Case study: Tanya Tanya is a 15-year-old bi-racial female with African- American/Hispanic background, referred for outpatient treatment after disclosing sexual abuse by her step-father since age 9. He was also physically abusive toward her mother and threatened to kill Tanya and her siblings. She has been depressed and suicidal, cutting on herself, and engaging in substance abuse and high-risk sexual behaviors. Tanya currently lives with her mother, and describes her relationship with her as “OK.” Her mother appears disengaged from her during the intake interview, and generally has failed to intervene in Tanya’s self- endangering behaviors. ITCT-A Possible Interview Question Topics (PIQT): Examples of what to evaluate • Safety: Is Tanya currently safe? Does she fear others? • Anxiety: Worrying? Feeling something bad might happen? • Depression: Feelings of sadness? Crying? Hopelessness? • Anger/aggression: Getting into fights? Getting mad easily? • Low self-esteem: Feeling bad about herself? Not liking herself? • Post-traumatic stress: Nightmares? Flashbacks? Avoidance? Hyperarousal? ITCT-A Possible Interview Question Topics (PIQT)-- (continued) • Attachment security: Trust of others? Worry about abandonment? • Identity issues: Confused about what she wants? Self-confidence? • Relationship problems: Trouble making friends? • Suicidality: Thoughts about suicide? Wanting to die? • Dissociation: ”Spacing out”? Watching from outside herself? • Substance abuse: Alcohol/drug use? Getting into trouble because of drug or alcohol use? Practice
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