Sallie Foley, Trauma and Trauma treatment, 2009 1 Trauma Course I. Introduction A. Overview of materials for course—syl and bib B. Overview of course expectations C. Overview of lectures D. Confidentiality, difficulty of material reviewed, need for taking responsibility for self in handling this difficult material E. The goal: to develop the ability to self-regulate and self-soothe; to develop safety in treatment so that the person can develop a coherent narrative of what happened to them, grieve, adjust their framework of a ‘just world’ and move on to live a meaningful and related life. F. Many ways that trauma can affect people: accidents, child abuse neglect (12/1000/year), violence, bites from animals, domestic violence, hostage, medical illness, homicide, suicide, natural disasters, death of loved ones, school violence, sexual abuse, rape, terrorism, war, car accidents (children: most common form of unintentional injury—1500 deaths/125,000 injuries/year) II. Attachment, indivduation, regulating anxiety, defense mechanisms • And early use of imaging/transitional objects/introjects to regulate fear/anxiety—peekaboo. • Mediating variables in development of PTSD • The Corpus Callosum Area and childhood neglect (Teicher, et al, Biological Psychiatry, 2004:56:80-85) III. History of trauma in general population A. Former descriptions B. Situations of trauma across cultures and development—attachment disruptions, war, illness, surgeries, cultural genocide, rape, abuse C. Definitions of trauma by DSM IV-TR i. Acute stress disorder ii. PTSD iii. Complex PTSD—symptoms of severe PTSD mimic severe mental illness, but are not. It is fixable, never give up. iv. DESNOS v. Other—differential diagnoses/ADHD, Grief reactions D. Common forms of cultural treatment of trauma historically E. Past ways of treating trauma in last 25 years: the ‘scrape it out’ implosion problem F. New: we are now clueful, We know symptoms mimic severe mental illness but aren’t. It is essentially a biophysical condition, We now know that talking about it is not necessarily the place to go first, especially about painful and recent events, We were taught to cut through the pain to the most upsetting things. Sallie Foley, Trauma and Trauma treatment, 2009 2 G. What is wrong: with PTSD, you establish safety first, not talk. Instead: ask How are you doing, what are your symptoms like? Do not start with: “Tell me what happened,” i.e. 9/11, First responders would say this and it’s wrong place to start. i.e. CISD: used to do this, but go to social circumstances and build in social support. Try to handle the flooding. H. Judith Herman and three phase understanding of trauma treatment: Safety, Recollection and Mourning, Reconnection I. Emphasis on self-regulation and self-soothing, safety J. Problem of kindling K. Recent developments from epidemiology, clinical studies, and biochemistry that are impacting how we think about trauma L. Types of trauma research: Terr on Type I and Type II. Finklehor on betrayal in attachment and not being able to develop enough language or anger to feel separate from perpetrator. Mary Main on individuation. M. Marsh Linehan, Univ. of Washington/Seattle. Dialectical Behavioral Therapy. Mindfulness techniques taught. Teach clients to understand that helplessness drives ‘either-or’ thinking, black/white thinking. When one feels helpless, the move it to move to rigidity because of the fear of chaos. Teaching clients to ‘notice’ their judgment, notice their racing thoughts, notice their either/or thinking, rather than moving into those states. Try exercise with grapes. IV. Trauma and children: earlier it was believed that children didn’t understand and had mild reactions, that interventions weren’t necessary because the reactions were transient. V. Video with Bessel van der Kolk VI. Trauma reactions (thanks to D. Fischer) children all: sleeping difficulties, - infants: feeding/weight gain problems, increased crying, clingy, delays in attaining developmental milestones - toddlers: withdrawn, anxious, clingy, loss of language/babbling, night- mares, play re-enactment, behavior regression - school age: behavioral changes, loss of predictable patterns of reaction interaction, school performance changes, negative behaviors increase, increase in somatic behaviors - adolescents: increase irritability with friends, absenteeism, substance abuse, high risk behaviors , decreased impulse control, over involvement in discussions about trauma - symptoms can be partial, are often overlooked, are distressing, not all children exposed to trauma develop PTSD - disregulation of fight/flight (increased agitation or dissociation), trauma re-enactment, irritability, sleep problems, eating problems, behavioral problems, substance use - Lifetime prevalence: 1-14%. Sallie Foley, Trauma and Trauma treatment, 2009 3 VII. Trauma and the Brain A. Neurobiology and the body 1. The up/down brain of humans—getting the terms straight (handout) 2. How is memory stored 3. The arousal system in the brain-the amygdala is not mediated by the frontal cortex. Threat: The messages to the body. The release of stress chemicals especially cortisol and epi/norepi. It is immediate. It increases alertness, dilating pupils, muscle tension to limbs, focus, short term memory, ocular divergence (seeing out the sides/peripheral vision). This jolt could be sexual arousal, something joyful, an amusement park ride, a danger. The amygdala has to sort it out. 4. The analysis of the threat—comparisons with past threats, and checking out the assessment to see if this is a genuine threat or the appearance of one. If genuine, then stress hormones shut down any function that is not necessary. Anything superfluous to survival, like digestion, sexual function Everything that happens next in the body is about fight or flight. Increased blood pressure, heart rate 5. Endogenous opiods. Your complete internal pharmacy. This is like ‘superpainkiller’ and never lets the person be distracted by the pain. Explain the brain to your colleague. B. Siegal, Scaer, Peter Levine, Bessel van der Kolk C. Fight Flight and Freeze. Peter Levine: Trauma is a fundamentally a highly activated incomplete psycho-physiological response to threat, frozen in time. What is significant in the resolution of trauma is the completion of incompleted responses to threat and the ensuing discharge of the energy that was mobilized for survival.” D. Stress: body’s reaction to demand placed on us. How the body reacts to challenge or threat Stress reaction: physiologically—activation of the autonomic nervouse system (ANS), release of certain hormones into the blood Traumatic stress: state when facing an extreme threat and there is an extreme activation of the ANS. Triggers a survival reflex: flight/flight/freeze to overwhelming situations where we see our life or the lives of others close to us at risk and actual survival appears threatened Traumatic stress creates disruption in normal brain functioning, whereas normal stress does not Normal stress improves problem solving and productivity Genetically programmed reflex activates life-preserving survival response in body/nervous system Freeze: If trapped, freeze response. Assumes a state of immobility manifesting high activation of nervous system; humans often do not move through flight/fight/freeze response. Frozen state of hyperarousal in limbic Sallie Foley, Trauma and Trauma treatment, 2009 4 and implicit (procedural) memory systems may persist. In this state, a person struggles to modulate the arousal response. The highly aroused state of fight or flight is designed to enable short-term defensive actions. If this energy isn’t used by completing the defense actions, the activation is held in the nervous system and is unable to dissipate or release (immobility/freezing response). When energy doesn’t get to ‘complete’ what happens. Even though immobilized, nervous system highly aroused. Not able to discharge any for the fight or flight energy, animals using freezing response allow for biological discharge of excess energy and completion of the arousal cycle. They do this through shaking and trembling and this restores spontaneous breathing and the nervous system to regain balance. Humans too frightened and uncomfortable with surrendering to involuntary sensations and discharge so nervous system remains in state of arousal. A state of continued autonomic hyperarousal remains. But the frozen rezones seek completion and energy exert strong pressure on the organism to resolve. Thins gives rise to many of the symptoms associated with trauma, including dissociation. The frozen state of autonomic hyperarousal or inadequate discharge of energy – excess energy which becomes bound in the person’s mind and body and symptoms of trauma are the result. This arousal or activation is the energy needed to work in healing to trauma. Must teach people to modulate this arousal while working to release frozen activation and impulses bound in the body. E. Dissociation and altered states as hardwired F. Belleruth Naperstek—believes that imaging relies on primitive brain processes. It is the land of emotion and perception and feeling and sensory images. The land of kinesthetic sensation, symbol, metaphor, and muscular activity. The land of imagery is this land and it is the same land that gets activated when we are threatened. G. Imagery is a best practice because it can go exactly where trauma sits in the brain. It goes in the back door. Imagery is a way of working with healing while minimizing distress. It isn’t just