Reconsidering Trauma:Reconsidering Trauma:Treatment Advances, Treatment Advances, Relational Issues, and Relational Issues, and

Mindfulness in Integrated Mindfulness in Integrated Trauma Therapy Trauma Therapy

John Briere, Ph.D.John Briere, Ph.D.Departments of Psychiatry and Psychology, University of Departments of Psychiatry and Psychology, University of

Southern CaliforniaSouthern CaliforniaPsychological Trauma Program, Los Angeles County – USC Psychological Trauma Program, Los Angeles County – USC

Medical CenterMedical CenterMCAVIC-USC Child and Adolescent Trauma Program, NCTSNMCAVIC-USC Child and Adolescent Trauma Program, NCTSN

Complex trauma Complex trauma exposureexposure

OnsetOnset Childhood trauma and neglectChildhood trauma and neglect Attachment disruption usualAttachment disruption usual

Extended duration and frequencyExtended duration and frequency Traumatic processes and well as Traumatic processes and well as

traumatic eventstraumatic events Relational/interpersonalRelational/interpersonal ComplexityComplexity

Accumulated effectsAccumulated effects Interacting effectsInteracting effects

Complex posttraumatic Complex posttraumatic outcomes – outcomes –

ethnocultural aspectsethnocultural aspects Ethnic/cultural/gender Ethnic/cultural/gender

differences in differences in Perception of traumaPerception of trauma

The example of sexual traumaThe example of sexual trauma Models of injuryModels of injury

PsychologicalPsychological SomaticSomatic SpiritualSpiritual

Idioms of distressIdioms of distress ““Culture-bound” stress disordersCulture-bound” stress disorders Commonalities of response across groupsCommonalities of response across groups

Complex posttraumatic Complex posttraumatic outcomes – Chronic outcomes – Chronic posttraumatic stressposttraumatic stress

SymptomatologySymptomatology ReexperiencingReexperiencing Avoidance Avoidance HyperarousalHyperarousal

Avoidance and chronicityAvoidance and chronicity Cognitive, emotional, dissociative, Cognitive, emotional, dissociative,

substance abusesubstance abuse Risk factorsRisk factors

Trauma, reduced social support and Trauma, reduced social support and marginalization, reduced affect regulation marginalization, reduced affect regulation capacities, nervous system compromisecapacities, nervous system compromise

Complex posttraumatic Complex posttraumatic outcomes – Self-outcomes – Self-

capacitiescapacities IdentityIdentity Other-directnessOther-directness Reduce self-access/awarenessReduce self-access/awareness Boundary disturbanceBoundary disturbance Susceptibility to influenceSusceptibility to influence

RelationalityRelationality Implicit attachment-related schemataImplicit attachment-related schemata

Models of relationshipModels of relationship Relational schemaRelational schema Conditioning to emotional-cognitive Conditioning to emotional-cognitive

memoriesmemories Source attribution errorsSource attribution errors ““Out of proportion" emotions/thoughtsOut of proportion" emotions/thoughts

Complex posttraumatic Complex posttraumatic outcomes – Self-outcomes – Self-

capacitiescapacities Affect regulationAffect regulation

Underdevelopment in the context of Underdevelopment in the context of maltreatmentmaltreatment

Modulation versus toleranceModulation versus tolerance The imbalance between level of The imbalance between level of

triggerable distress and affect triggerable distress and affect regulation capacityregulation capacity

The avoidance triad: Substance abuse, The avoidance triad: Substance abuse, dissociation, and tension-reductiondissociation, and tension-reduction

““Cluster B” personality disordersCluster B” personality disorders PsychosisPsychosis

As a feature of posttraumatic stressAs a feature of posttraumatic stress As a feature of disturbed self-capacitiesAs a feature of disturbed self-capacities

A philosophy of traumaA philosophy of trauma Integrating Eastern models of suffering, Integrating Eastern models of suffering,

attachment, and mindfulnessattachment, and mindfulness Ubiquity of trauma versus the myth of normalityUbiquity of trauma versus the myth of normality Pain versus sufferingPain versus suffering

Trauma seen as bad, pain seen as wrong/pathological, Trauma seen as bad, pain seen as wrong/pathological, to be avoided to be avoided

Focused awareness of painful material and paradoxical Focused awareness of painful material and paradoxical reliefrelief Avoidance can intensify distress, intrusionAvoidance can intensify distress, intrusion Mindfulness as the opposite of avoidanceMindfulness as the opposite of avoidance

Attachment: expectation, need, and Attachment: expectation, need, and preoccupationpreoccupation

Reality as subjectivityReality as subjectivity Perception versus activated implicit memoryPerception versus activated implicit memory Source attribution errors and the complexity of Source attribution errors and the complexity of

personal experiencepersonal experience

A philosophy of traumaA philosophy of trauma The problem with solely symptom-based The problem with solely symptom-based

modelsmodels Treatment goals narrow to definable fixing of Treatment goals narrow to definable fixing of

distressdistress Diminished relevance to a lived life and the Diminished relevance to a lived life and the

opportunity for larger changesopportunity for larger changes Reinforces avoidance rather than engaging Reinforces avoidance rather than engaging

roots of sufferingroots of suffering Natural systems of trauma recovery - Natural systems of trauma recovery -

Intrinsic processingIntrinsic processing Self-exposureSelf-exposure

Recurring thoughts, memories, nightmares, flashbacks, Recurring thoughts, memories, nightmares, flashbacks, “reenactments”“reenactments”

Drive to process: verbalization, expression, attraction Drive to process: verbalization, expression, attraction to trauma reminders, therapy seeking to trauma reminders, therapy seeking

Posttraumatic growth, acceptance, and Posttraumatic growth, acceptance, and integrationintegration

Assessing trauma and Assessing trauma and impacts in the clinical impacts in the clinical

interviewinterview Process responses and intra-interview signsProcess responses and intra-interview signs

Activation responsesActivation responses Easily triggered cognitive-emotional statesEasily triggered cognitive-emotional states

Avoidance responsesAvoidance responses Dissociative disengagement, lapses, inconsistency, Dissociative disengagement, lapses, inconsistency,

constrictionconstriction Denial, content switchingDenial, content switching

Affect dysregulationAffect dysregulation Mood swingsMood swings ““Falling into the hole”Falling into the hole” Reports of TRBsReports of TRBs

Relational disturbanceRelational disturbance Alertness to interpersonal dangerAlertness to interpersonal danger Abandonment issuesAbandonment issues Need for protection via controlNeed for protection via control

The Self-Trauma Model – A The Self-Trauma Model – A components approachcomponents approach

Distress reduction and affect Distress reduction and affect regulation training regulation training

Dealing with acute intrusions – Dealing with acute intrusions – groundinggrounding Somatosensory feedback (e.g., body in chair)Somatosensory feedback (e.g., body in chair) Details of roomDetails of room Reminders of past versus presentReminders of past versus present

Breath trainingBreath training Breath and tension/stressBreath and tension/stress Effects of slower, deeper, diaphragmatic Effects of slower, deeper, diaphragmatic

breath breath

Mindfulness and affect Mindfulness and affect regulationregulation

Nonjudgmental self-observationNonjudgmental self-observation Acceptance of (good, bad, or neutral) Acceptance of (good, bad, or neutral)

thoughts, feelings, and memories thoughts, feelings, and memories versusversus fighting thoughts/feelingsfighting thoughts/feelings

Disturbing thoughts and feeling allowed to Disturbing thoughts and feeling allowed to come and go (“watching the parade”)come and go (“watching the parade”)

De-investment in emotional experience: “I De-investment in emotional experience: “I don’t trust my inner feelings, inner feelings don’t trust my inner feelings, inner feelings come and go” (Leonard Cohen)come and go” (Leonard Cohen)

Self as relative/contextual/”insubstantial”,Self as relative/contextual/”insubstantial”, ““No self” – self concept in flux, result of No self” – self concept in flux, result of

interrelated conditions, not inherently concrete interrelated conditions, not inherently concrete (self as process)(self as process)

Less identification with desires, supposed traits, Less identification with desires, supposed traits, social expectations, therefore less disappointment, social expectations, therefore less disappointment, betrayal, disillusionment, abandonment concernsbetrayal, disillusionment, abandonment concerns

Distress reduction and affect Distress reduction and affect regulation training regulation training

Trauma-relevant meditationTrauma-relevant meditation Posture, breathing, attentionPosture, breathing, attention Exposure via reduced avoidance, greater Exposure via reduced avoidance, greater

relaxationrelaxation Affect regulation and equanimity Affect regulation and equanimity

(nonreactivity to internal states)(nonreactivity to internal states) Stress/arousal reductionStress/arousal reduction Potential constraintsPotential constraints

Initial increased activationInitial increased activation Perceived reduced controlPerceived reduced control Effects of memory intrusionEffects of memory intrusion Monitoring issuesMonitoring issues Therapist must be familiar with meditation Therapist must be familiar with meditation

proceduresprocedures

Empirically-based Empirically-based mindfulness-related therapiesmindfulness-related therapies

Dialectical behavior therapy Dialectical behavior therapy (DBT; Linehan)(DBT; Linehan)

Mindfulness-based stress Mindfulness-based stress reduction (MBSR; Kabat-Zinn)reduction (MBSR; Kabat-Zinn)

Mindfulness-based cognitive Mindfulness-based cognitive therapy (MBCT; Segal, et al)therapy (MBCT; Segal, et al)

Acceptance and commitment Acceptance and commitment therapy (ACT; Hayes)therapy (ACT; Hayes)

Distress reduction and affect Distress reduction and affect regulation training regulation training

Trigger identification, recontextualizationTrigger identification, recontextualization Understanding and insight alter similarities Understanding and insight alter similarities

of stimuli to initial trauma memoryof stimuli to initial trauma memory Trigger grid:Trigger grid:

How do I know I’m being triggered?How do I know I’m being triggered? What are the triggers, when do they occur? (review of What are the triggers, when do they occur? (review of

history)history) What do I think/do after triggers?What do I think/do after triggers? How might I avoid/counter them?How might I avoid/counter them?

Creation of self-talk optionsCreation of self-talk options Analysis of differences between initial event and Analysis of differences between initial event and

triggering eventtriggering event

Repetitive exposure and processing of Repetitive exposure and processing of traumatic material as affect regulation traumatic material as affect regulation trainingtraining

Cognitive interventionsCognitive interventions Normalizing and reframing of experiences and Normalizing and reframing of experiences and

“symptoms”“symptoms” Cognitive reconsideration: An empowering Cognitive reconsideration: An empowering

alternative to cognitive restructuringalternative to cognitive restructuring Using exposure processes to prompt reevaluation Using exposure processes to prompt reevaluation

of cognitionsof cognitions Mindfulness: Practicing nonjudgment and Mindfulness: Practicing nonjudgment and

acceptanceacceptance Intrusive negative cognitions as “just thoughts,” Intrusive negative cognitions as “just thoughts,”

not representations of realitynot representations of reality Reduced self-blame through experience of conditionalityReduced self-blame through experience of conditionality Reduced identification with self-criticism (participant-Reduced identification with self-criticism (participant-

observer)observer)

Insight and the development of a coherent, Insight and the development of a coherent, nonpathologizing narrativenonpathologizing narrative

Emotional processingEmotional processing The components of trauma The components of trauma

processingprocessing ExposureExposure ActivationActivation DisparityDisparity

Nonreinforcement of CERs and trauma-Nonreinforcement of CERs and trauma-related assumptions/beliefs (safety)related assumptions/beliefs (safety)

CounterconditioningCounterconditioning Extinction/resolutionExtinction/resolution

Emotional processingEmotional processing Titrated exposure and the Titrated exposure and the

therapeutic windowtherapeutic window Limiting factorsLimiting factors

CER intensityCER intensity Affect regulation skillsAffect regulation skills

Balance between therapeutic challenge Balance between therapeutic challenge and overwhelming internal experience and overwhelming internal experience

Overshooting vs. undershooting the Overshooting vs. undershooting the windowwindow

Emotional processing at the Emotional processing at the session levelsession level

Repetitive exposure to trauma memories Repetitive exposure to trauma memories via questions/facilitation of disclosurevia questions/facilitation of disclosure

Activation controlActivation control Greater vs. lesser detailGreater vs. lesser detail Time/tense focus: here-and-now vs. there-and-Time/tense focus: here-and-now vs. there-and-

thenthen Emotional vs. cognitiveEmotional vs. cognitive Extent of intervention in avoidanceExtent of intervention in avoidance

Safety, support, validation, encouragementSafety, support, validation, encouragement Emotional discharge/expressionEmotional discharge/expression Debriefing/contextualizationDebriefing/contextualization

Emotional processingEmotional processing Mindfulness as exposureMindfulness as exposure

Reduced cognitive-emotional Reduced cognitive-emotional avoidanceavoidance Processing with awarenessProcessing with awareness

Openness to distress, yetOpenness to distress, yet The changed relationship to distress = The changed relationship to distress =

decreased suffering decreased suffering

Increased access to memoryIncreased access to memory greater exposuregreater exposure

Titrated levels of distress (through Titrated levels of distress (through detachment), anddetachment), and

Greater awareness of disparityGreater awareness of disparity

Emotional processingEmotional processing Processing “hot spots” with focused Processing “hot spots” with focused

CBT or EMDRCBT or EMDR Only when tolerable, always within Only when tolerable, always within

windowwindow Greater specificity and intensity of Greater specificity and intensity of

exposureexposure Pre-briefingPre-briefing Two approachesTwo approaches

Prolonged exposureProlonged exposure EMDREMDR

DebriefingDebriefing

Increasing identity Increasing identity functionsfunctions

Self-exploration, inner directedness, and Self-exploration, inner directedness, and identity training identity training Development of self-knowledge and self-Development of self-knowledge and self-

directednessdirectedness Value of nonleading, open-ended questionsValue of nonleading, open-ended questions Avoiding the over-use of interpretationsAvoiding the over-use of interpretations

Effects of increased mindfulnessEffects of increased mindfulness Less attachment to sense of self as enduring and Less attachment to sense of self as enduring and

concreteconcrete Yet, increased awareness means greater self-Yet, increased awareness means greater self-

awarenessawareness Greater self-appreciationGreater self-appreciation

Acceptance and compassion Acceptance and compassion

Increasing relational Increasing relational functioning functioning

Cognitive-emotional processing of Cognitive-emotional processing of relational schemarelational schema ExposureExposure to relational stimuli, to relational stimuli,

activationactivation of schema, of schema, disparitydisparity in in therapeutic environment, therapeutic environment, counterconditioningcounterconditioning via therapeutic via therapeutic emotional bond, emotional bond, extinctionextinction/restructuring/restructuring

Psychiatric medicationsPsychiatric medications Presenter caveatsPresenter caveats Can trauma psychopharmacology “fit” Can trauma psychopharmacology “fit”

with growth models of trauma recovery?with growth models of trauma recovery? TraditionalTraditional

Symptoms as psychopathology, medication as Symptoms as psychopathology, medication as correctioncorrection

STM: Nonresolvable/chronic symptoms as STM: Nonresolvable/chronic symptoms as overwhelming “trauma load,” preventing overwhelming “trauma load,” preventing processingprocessing

Medication as support for more effective Medication as support for more effective processing by reducing processing by reducing

AnxietyAnxiety ComorbidityComorbidity

Rarely sufficient by themselves Rarely sufficient by themselves

Psychiatric medicationsPsychiatric medications

Limiting issues Limiting issues Psychological treatments often yield Psychological treatments often yield

larger effect sizes in treatment outcome larger effect sizes in treatment outcome studiesstudies

Noncompliance as result of side-effectsNoncompliance as result of side-effects Potential effects of reducing anxiety Potential effects of reducing anxiety

during exposure and processingduring exposure and processing Specific concerns about benzodiazepinesSpecific concerns about benzodiazepines

Addiction/dependency concerns for Addiction/dependency concerns for trauma survivorstrauma survivors

Use of antipsychotic medicationsUse of antipsychotic medications Potential relapse effects upon Potential relapse effects upon

discontinuationdiscontinuation

Psychiatric medicationsPsychiatric medications Potential benefitsPotential benefits

Recommendations from the Recommendations from the International International Society for Traumatic Stress StudiesSociety for Traumatic Stress Studies First line – SSRIs (only FDA indication for PTSD)First line – SSRIs (only FDA indication for PTSD) Second line – TCAs, MAOIsSecond line – TCAs, MAOIs Questionable – mood stabilizersQuestionable – mood stabilizers Benzodiazepines – for management of acute Benzodiazepines – for management of acute

anxietyanxiety Antipsychotics – for clear psychosisAntipsychotics – for clear psychosis

Speculation from researchSpeculation from research Alpha and Beta blockade for hyperarousal Alpha and Beta blockade for hyperarousal

symptomssymptoms

Therapist issues in trauma Therapist issues in trauma treatmenttreatment

Countertransference/counteractivationCountertransference/counteractivation Personal historyPersonal history Cultural assumptions/socializationCultural assumptions/socialization

Mindfulness and activation awarenessMindfulness and activation awareness PsychotherapyPsychotherapy Internally directed practiceInternally directed practice

Social supportSocial support ConsultationConsultation Community of cliniciansCommunity of clinicians