Court Specialty Conference

The Primary Destabilizing Factor for the Traumatized

CURRENT STRESSReminders of trauma, life events, lifestyle

UNBEARABLY PAINFUL EMOTIONAL STATES

RETREATisolation

dissociationdepression

SELF-DESTRUCTIVE ACTIONS

substance abuseeating disorders

deliberate self-harmsuicidal actions

DESTRUCTIVE ACTIONS

aggression violence

rages

PAST TRAUMAafraid & alone

SENSITIZED NERVOUS SYSTEM

Jon Allen

Bessel van der Kolk

• “I would say the foundation of all effective treatments involves some way for people to learn that they can change their arousal system….”

• “The issue of self-regulation needs to become front and center in the treatment of traumatized people. That’s number one…”

• Step two…”It’s more than tolerating feelings and sensations. Actually, it is more about knowing that you, to some degree, are in charge of your own physiological system…”

Window of ToleranceOptimal Arousal Zone

10

5

0

Sympathetic Activation….child (or adult) responds with fear, fight, flight states

AROUSAL

Parasympathetic Activation…or child (or adult) becomes submissive, “checked out,” depressed, non-responsive (freeze, dissociative states)

Window of Tolerance(no development)

Affect Dysregulation----------Hyperarousal (preoccupied & disoriented)

No Vegal BrakeSympathetic Dominant

Overshooting the Window

10

5

0

Affect Dysregulation----Hypoarousal(dismissing & disoriented)

To much brakingParasympathetic Dominant

Undershooting the Window

10

5

0

AAAA

AFFECT DYSREGULATION

All gas no brakes…sympathetic nervous system dominant

All brake no gas…parasympathetic nervous system dominant

Emotional management can vary…sadness, disappointment, fear, shame, joy, etc

Overshooting and Undershooting The Window of Tolerance

Hyperarousal: too much arousaltoo integrate

Hypoarousal: too little arousal to integrate

Window of ToleranceOptimal Arousal Zone

Flat affectInability to think clearlyNumbingCollapse (tonic immobility

Emotional reactivityHypervigilanceIntrusive imageryObsessive/cyclical cognitive processingTension, shaking, ungrounded

Regulation

• Self-regulation is an essential organizing principle. “…the best description of development may come from a careful appreciation of the brain’s own self-organizing operations.” Cicchetti and Tucker 1994 and this self-organization of the developing brain occurs in the context of a relationship with another brain.

Schore, A. (2003) Affect Dysregulation and Disorders of the SelfW. W. Norton & Company, Inc. New York, NY

• “The essential task of the first year of human life is the creation of a secure attachment bond of emotional communication between the infant and the primary caregiver.”

Attachment Status – Ainsworth et al. Strange Situation…1978Leeds, A. Strengthening the Self (2002) Santa Rosa, Ca: Andrew Leeds, PhD

• Secure – majority of infants cry, miss mother during her absence in Strange Situation (SS), are quickly comforted on reunion.

• Insecure: Avoidant – infants show little or no distress during separation from mother in SS, & actively avoid contact on her return. Mothers reject attachment behavior at home.

• Insecure: Ambivalent- infants are highly distressed during separation, on reunion are not quickly soothed by mothers who are unpredictably available & intrude on exploration.

• Insecure: Disorganized - result of frightened or frightening parental behavior which may be a result of unresolved parental grief or parental PTSD (Liotti, 1992).

Bowlby

• Bowlby saw attachment as a behavioral system that is activated by perception of danger and feelings of fear…

• Leaving the attachment system to play a major role in how we cope w/frightening experiences

“Children are not resilient, children are malleable.” Bruce Perry, M.D.

“The functional capabilities of the mature brain develop throughout life, but the vast majority of critical structural and functional organization takes place in childhood. Indeed, by 3 years of age the brain has reached 90% of adult size, whereas the body is still only about 18%.”Schore, R: Rethinking the Brain: New Insights into Early Development. New York, Families and Work Institute, 1997

“…70% of our genetic structure is added after birth. “ Schore, A. N. (1994). Affect regulation and the origin of the self. The neurobiology of emotional Development. Hillsdale, NJ:Erlbaum.

SEQUENTIAL NEURODEVELOPMENTDr. Bruce Perry

• The brain is underdeveloped at birth

• The brain organizes from the “bottom” up – brainstem to cortex and from the inside out

• Organization and functional capacity of neural systems is sequential

• Experiences do not have equal “valence” throughout development

Solomon, M. and Siegel, D. (2003) Healing Trauma W.W. Norton & Company, Inc. New York, NY

• When the caregiver’s emotional availability, responsiveness, and reflective capacities are compromised, often as a result of her own trauma and loss, dyadic affective regulation cannot proceed optimally. The more the child’s emotions trigger the caregiver’s fear, shame, helplessness, or guilt, the more (the child) will disengage emotionally. Desperate to maintain and restore the attachment bond, the child resorts to the defense exclusion of whichever emotions produce aversive reactions in the caregiver, regardless of how vital they might be to (the child).

• The chronic reliance on defenses against emotional experience (used) to compensate for…lapses in the caregiver’s affect-regulatory capacities produces adaptations which are categorized by the attachment classification (these classifi cations are) affective functional strategies…secure attachment involves the capacity to feel and deal without the need to resort to defense mechanisms…the strategy of dealing by not feeling is avoidant attachment, and the strategy of feeling (and reeling), but not dealing is resistant/ambivalent attachment…when even defensive efforts are overwhelmed by disruptive emotions…we (develop) disorganized attachment. The only way both self and relationship can be maintained is through momentary immobility-the (child) can neither feel (dissociation) nor deal (paralysis),

Bartholomew (1991) four-Category Model of Adult AttachmentLeeds, A. Strengthening the Self (2002) Santa Rosa, Ca: Andrew Leeds, PhD

• Secure: (secure infant) “it is easy for me to become emotionally close to others. I am comfortable depending on others and having others depend on me. I don’t worry about being alone or having others not accept me. (50%+)

• Dismissing: (avoidant infant)“I am comfortable without close emotional relationships. It is very important to me to feel independent and self-sufficient, and I prefer not to depend on others or have others depend on me.”(15% -20%)

• Preoccupied: (ambivalent/anxious infant)“I want to be completely emotionally intimate with others, but I often find that others are reluctant to get as close as I would like. I am uncomfortable being without close relationships, but I sometimes worry that others don’t value me as much as I value them.”(15%)

• Disoriented or Unresolved Trauma or Grief: (disorganized infant) “I am uncomfortable getting close to others. I want emotionally close relationships, but I find it difficult to trust others completely, or to depend on them. I worry that I will be hurt if I allow myself to become too close to others.”(5%-15%)

“Human beings of all ages are found to be at their happiest and to be able to deploy their talents to

best advantage when they are confident that, standing behind them, there are one or more trusted persons who will come to their aid should difficulties

arise.” John Bowlby, 1973

The Polyvagal Hierarchy—Stephen PorgesOgden, Pat, Minton, Kekhuni, and Pain Clare (2206) Trauma and the Body A Sensorimotor Approach to Psychotherapy.

New York, NY: W.W. Norton & Company, Inc.

The polyvagal theory describes three hierarchically organized subsystems of the autonomic nervous system that govern our neurobiological responses to environmental stimulation and is an attempt to explain the evolution of affective regulation.

1. ventral parasympathetic branch of the vagus nerve – social engagement system (most evolutionarily recent and sophisticated of the subsystems is the ventral vagal complex—originates in the nucleus ambiguous in the brainstem, one of the tiny patches of specialized neurons that make up the reticular activating system). Provides an inhibitory or calming influence on sympathetic arousal. This system allows us to modulate autonomic arousal in a prosocial manner and controls the muscles of our eyes, face, mouth, and inner ear in the service of social communication .

2. sympathetic system – mobilization

3. dorsal parasympathic branch of the vagal nerve – immobilization; bodily shutdown and depends on parasympathetic processes…humans share this with most other vertebrates.

Each of these subsystems corresponds to one of the three arousal zones of the modulation model: The social engagement (vental vagal) system correlates with the optimal arousal zone, the sympathetic system with the hyperaroused zone, and the dorsal vagal system with the hypoaroused zone

The Traumatized Brain

• Threat perception system is enhanced

• The filter system becomes dysregulated

• The self-sensing system gets blunted

SOCIAL ENGAGEMENT SYSTEM AT WORK

Three Types of Emotion Regulation SystemInteractions between different types of emotional regulation systems

Paul Gilbert, PhD

Driven, excited, vitality Content, safe, connected

Anger, anxiety, disgust

Incentive/resource- focused

Wanting, pursuing, achieving, consuming

Activating

Non-Wanting/ Affiliative focused

Safeness-kindness

Soothing

Threat-focused

Protection and Safe-seeking

Activating/inhibiting

Three Types of Emotion Regulation SystemInteractions between different types of emotional regulation systems

Paul Gilbert, PhD

Driven, excited, vitality Content, safe, connected

Anger, anxiety, disgust

THREATactual or perceived

DRIVE SAFE

Three Types of Emotion Regulation SystemInteractions between different types of emotional regulation systems

Paul Gilbert, PhD

Driven, excited, vitality Content, safe, connected

Anger, anxiety, disgust

THREATactual or perceived

DRIVE

DRIVE safe

TONING DOWN THE THREAT SYSTEM

From The Competitive From the Caregiving

Mentality Mentality

Self-critical Dialogues

SHAME

SENSE OF CURRENT THREAT

actual or perceived

Self Soothing DialoguesCompassionate imagery

Compassion Safety

Maintains Ends

TONING DOWN THE THREAT SYSTEM

From The Competitive From the Caregiving

Mentality Mentality

Self-critical Dialogues

SHAME

SAFETY

Self Soothing DialoguesCompassionate imagery

Compassion Safety

Maintains Ends

“There’s an art to knowing when Never try to guess Toast until it smokes Then 20 seconds less…”

Babette Rothschild

SolutionsDAILY Disciplines

• Psychoeducation…includes basic brain knowledge, understanding of emotions, how

emotions present in our bodies, and how we construct meaning

• Neurofeedback Music (Jana Stanfield)

• Anchors, healthy distractions (notice in therapy) Visualizations (Belleruth Naparsek)

• The art of hushing Forgiveness:

• Understanding Triggers (implicit memories) Self and Others

• Perceived fear or Actual fear??? Apps:

• Breath work Stop, Breath, and Think

• Mindfulness EMDR

• Safe relationships My Calm Beat, etc.

• Animal therapy Tapping

• Yoga Narrative Shift

• Aerobic Body Scan (dose)

• Nutrition EMDR

• Journaling…focusing on integration Progressive-Counting

• Gratitude Lists (easy does it) Massage

• Compassionate Letters to the Internal Community Container exerciser (Levine)

• Practicing Compassion Dance

• 12 Step Meetings Chanting ………………etc., etc., etc.

Richard Schwartz…Internal Family Systems

Exiles - the part of the survivor that was initially hurt and then abandoned

Managers -tries to manages our relationships, our appearance andour productivity

Firefighters -go immediately into action to take us away from the pain, shame, and terror

Protective parts - Managers and Firefighters…what they are

protecting are the exiles.

Training Our Minds in, with and for Compassion. An Introduction to Concepts and Compassion-Focused Exercises

Paul Gilbert, et al (2010)

Training Our Minds in, with and for Compassion. An Introduction to Concepts and Compassion-Focused Exercises

Paul Gilbert, et al (2010)

• Bremner, J. D. (2002). Does Stress Damage The Brain? New York: W. W. Norton & Company, Inc.

• Briere, J. (1992). Child Abuse Trauma: Theory and Treatment of the Lasting Effects. Newbury Park, CA: Sage

• Briere, J. (1996). Therapy for Adults Molested as Children. Second Edition, Expanded and Revised. New York: Springer Publishing Co.

• Burdick, D. (2013). MINDFULNESS SKILLS WORKBOOK For Clinicians & Clients. Eau Claire, WI: PESI, Inc.

• Greenwald, R. (Summer 2015). From the Cutting Edge: Trends in Trauma Practice International Journal of Trauma Research and Practice Volume II, Issue 1

• Hanson, R. (2009). the practical neuroscience of Buddha’s Brain happiness, love & wisdom. Oakland, CA: New Harbinger Publications, Inc.

• Frewen, P. and Lanius, R. (2015). Healing the Traumatized Self CONSCIOUSNESS NEUROSCIENCE TREATMENT. New York: W. W. Norton & Company, Inc.

• Leeds, A. Strengthening the Self (2002) Santa Rosa, Ca:

• Lee, D. (November 3-5, 2011). Using compassion to Work with Shame Based Flashbacks in PTSD. International Society for Traumatic Stress Studies (ISTSS). Baltimore, Maryland

• Ogden, P., Minton, K., and Pain, C. (2006). Trauma and the Body A Sensorimotor Approach to Psychotherapy. New York, NY: W. W. Norton & Company, Inc.

• Rothschild, B. (2000). The Body Remembers. New York, NY: W. W. Norton & Company, Inc.

• Schore, A. (2003). Affect Dysregulation ad Disorders of the Self. New York, NY: W.W. Norton & Company, Inc.

• Schwartz, R. (1995). Internal Family Systems Therapy. New York: Guilford Press.

• Siegel, D. (1999). The developing mind: How relationships and the brain interact to shape who we are. New York: Gilford Press.

• Siegel, D. (2007). The mindful Brain: Reflection and attunement in the cultivation of well-being. New York, NY: W. W. Norton & Company, Inc.

• Siegel, D. and Bryson, T. (2012). The Whole-Brain Child. New York: Bantam Books

• Solomon, M. and Siegle, D. (2003) Healing Trauma. New York, NY: W.W. Norton & Company, Inc.

• Van der Kodlk, B. (2014). The Body Keeps The Score. New York, New York. Penguin Group