Lecture 5: phase 2 and 3: Working with

complex trauma

Complex Casework

Kevin Standish

1

Learning outcomes

1. Explore how to manage Trauma Memory, Emotion Processing, and Avoidance

2. Maintaining the therapeutic relationship in the face of difficult therapy

2

3

PHASE 2: TRAUMA MEMORY AND EMOTION PROCESSING

1. Post traumatic emotional dysregulation

2. Processing of trauma emotions

3. SAFER Strategies

4. Evidence based treatments for Trauma processing

5. Preparing the client for trauma and emotion processing

6. Loss and Mourning issues

4

1. Post traumatic emotional dysregulation

Interventions in phase 2 address two Cardinal features of traumatic stress disorders:

1. The avoidance of memories of traumatic events as well as the emotions, stimuli that serve as reminders and associated over generalisation to trauma related reminders

2. The experience of extreme physical, mental and emotional arousal. These extreme state of arousal are avoided by the client.

3. Avoidance may begin as a conscious form of coping, but becomes habitual, automatic and out of conscious control leading to behavioural dissociation

4. The two ends of arousal (hypo-arousal and hyper-arousal) the two extremes of behaviour in order to cope by numbing or acute emotional dysregulation, anger, sleep problems, etc

5

1. Post traumatic emotional dysregulation

1. Hyper-arousal is based on fear rather than anxiety. Fear and anger occur when the individual mobilises to defend against attack or the threat of attack with a fight / flight mechanism.

2. Anxiety results when fearful circumstances inescapable or unmanageable. Anxiety involves hypo-arousal, in the form of freezing or involuntary immobility.

3. Emotional dysregulation begins with high levels of fear that over time become infused with protest, and resignation and ultimately leading to exhaustion

6

7

1. Post traumatic emotional dysregulation

Avoidance + extreme arousal states = post-traumatic emotional dysregulation

8

1. Post traumatic emotional dysregulation

9

1. In neurobiological terms the emotionally disregulated individual is in survival brain mode and at the mercy of the lover reactive regions of the brain without the capacity to put the brakes on through the higher cortical regions of the brain that serve as modulators.

2. The client who alternates between hyper and hypo-arousal is exhibiting complex adaptive capacities that have become locked into the lower brainstem survival mode.

3. The individual is literally helpless to change survival based neural network patterns that result in extreme state of emotional distress (emotion dysregulation), mental disorientation and confusion (dissociation), bodily hyper arousal and exhaustion, and an associated sense of hopelessness and defeat.

Window of tolerance

10

Window of tolerance

11

2. Processing of trauma emotions

12

2. Processing of trauma emotions

1. Emotion processing of trauma enables the client is safely experience and appraise in present time the physical sensations, emotions, and thoughts that they interpreted as signals of overwhelming danger and associated powerlessness after the trauma.

2. Rationale for its use: the process is intended to be more therapeutic rather than merely cathartic and to avoid iatrogenically destabilising the client.

3. It is a structured process designed to facilitate not only remembering but also the clients vivid experience of trauma related emotions and physical sensations in the immediate moment of the therapy session.

4. This experiential technique is planned and prepared for, designed to elicit memory and emotions with a hard but save tolerable degree of arousal

13

2. Processing of trauma emotions

5. Safely experiencing these emotions in the company of the supportive therapist helps the client learn how to gain control.

6. It is more than a simple retelling of the trauma story, as the kind can engage as a memory and its emotional reactions while in a less aroused state, creating a condition of emotional disparity.

7. It is this disparity that leads to counter-conditioning of the original response allowing for the experiencing of other more core emotions: “emotional processing”

8. This emotional processing results in changes in emotional awareness, expression and self understanding, as one as alterations in brain activity and related physiological systems.

14

2. Processing of trauma emotions

9. It is unclear what exactly changes biologically or psychologically when distressing emotions of processed, but perceptional control theory proposes that sustained attention in the face of distress enable clients to reorganise how they interpret the meaning of extreme states of arousal giving them a greater sense of control.

10. Attachment theorists believe experiencing the emotion in the company of a supportive therapist provides counter conditioning of previous indifference or no response. Through a process of attunement, the therapist can co-regulate the emotion, leading to neurological growth stimulating brain development especially the left side and prefrontal cortex of judgement, executive control and functioning.

11. Therapy involves transforming emotionally fragmented memories into meaningful life experiences that although distressing can be lived with rather than feared and avoided.15

16

3. SAFER STRATEGIES

Self Care, symptom control, and stabilization

Acknowledgement vs Avoidance

Functioning

Expression of Emotions

Relationships

17

3.1. Self Care, symptom control, and stabilization

1. Stabilisation is ongoing and monitored through aren’t the entire treatment.

2. If the client is having difficulties in therapy or daily life that can create an increase in symptoms, emotional processing should be paused.

3. A clear discussion of what has been triggered in ways of coping with this needs to be developed.

4. A focus on self care and symptom management can enhance therapeutic processing, these constitute a key part of therapeutically reworking memories in the moment of processing.

18

3.2. Acknowledgement vs Avoidance

1. Memory and emotion processing together is an act of acknowledging the significance and meaning of the troubling memories.

2. Memories recalled without acknowledgement are simply being re-experienced with no working through, bringing about no change.

3. To acknowledge an event or memory of the emotions attached involves examining it to clarify its full range of impact.

4. Helping the client define what they mean in terms of themselves and their lives is an essential part of helping the client process the trauma.

5. Memory + cognitive understanding = emotional processing

Sorting Out Memories and Emotion An Interview with Joseph LeDoux, Ph.D. by Brenda Patoine April, 2007. https://www.dana.org/Publications/ReportDetails.aspx?id=44206

19

3.3. Functioning

1. Therapy must maintain or enhance the client’s functioning, and not just provide symptom relief

2. The ability to live a life free from the lingering effects of trauma is the overall goal.

3. Functioning may become impaired during emotional processing due to the distress and confusion elicited by facing the memories. Daily functioning becomes more difficult as clients give up familiar ways of coping (namely avoidance) and are learning new skills in unfamiliar territory.

4. Decreased ability to function is usually temporary, and over time clients find their functioning begins to increase as a freed from the emotional overload caused by the trauma

20

3.4. Expression of Emotions and Experiential Awareness

1. Catharsis is not the primary goal. However the therapist helps the client to become experientially aware of the multiple levels that the trauma has impacted that were previously inaccessible due to dissociative avoidance.

2. Verbal encoding and expression (symbolising) involve the development of the left side of the brain and put into words what has been contained in a somatosensory form on the right side.

3. Once verbalised, information can be responded to by others to reinforce the individual’s reality and reactions, supporting the development and differentiation of experiences. 21

3.5. Relationships

1. Memory and emotional processing in the context of psycho social support with appropriate responses leads to physiological changes beginning at the neurological level.

2. Clients in secure and responsive therapeutic relationship can begin to incorporate the support and its mirroring of them.

3. Security and a sense of self worth and personal accomplishment comes from being in relationships with others rather than being in isolation and with out interpersonal contact and response.

4. Emotional processing + secure relationship + attunement = personal integration

22

Kolb reflective cycle

23

4. EVIDENCE BASED TREATMENTS FOR TRAUMA PROCESSING

1. Prolonged exposure

2. Cognitive Processing Therapy

3. Other useful approaches

24

4.1.Prolonged exposure

1. Exposure therapy is a set of techniques designed to help patients confront their feared objects, situations, memories, and images (e.g., systematic desensitization, prolonged exposure, flooding).

2. Theoretical Rationale for Exposure TherapyCombination of:

1. Classical conditioning (traumatic event), e.g., little Hans2. Instrumental conditioning

1. Memory of trauma is paired/conditioned to current, unrelated events, e.g., crowds, restaurants, movies

2. Engagement of avoidance activities to reduce anxiety3. Result is world starts to shrink

3. Imaginal re-exposure to memory of trauma in safe setting results in desensitization/habituation of conditioned associations between traumatic memory and negative emotions.https://www.youtube.com/watch?v=9aTDIiTr99Y (11 min)

25

4.2.Cognitive Processing Therapy

1. Learning About Your PTSD Symptoms. CPT begins with education about your specific PTSD symptoms and how the treatment can help.

2. Becoming Aware of Thoughts and Feelings. Next, CPT focuses on helping you become more aware of your thoughts and feelings. When bad things happen, we want to make sense of why they happened. In CPT you will learn how to pay attention to your thoughts about the trauma and how they make you feel. You'll then be asked to step back and think about how your trauma is affecting you now. This will help you think about your trauma in a different way than you did before. It can be done either by writing or by talking to your therapist about it.

26https://www.youtube.com/watch?v=Tx3KdKDZOS8 (2 min)

4.2.Cognitive Processing Therapy

3. Learning Skills. After you become more aware of your thoughts and feelings, you will learn skills to help you question or challenge your thoughts. You will do this with the help of worksheets. You will be able to use these skills to decide the way YOU want to think and feel about your trauma. These skills can also help you deal with other problems in your day-to-day life.

4. Understanding Changes in Beliefs. Finally, you will learn about the common changes in beliefs that occur after going through trauma. Many people have problems understanding how to live in the world after trauma. Your beliefs about safety, trust, control, self-esteem, other people, and relationships can change after trauma. In CPT you will get to talk about your beliefs in these different areas. You will learn to find a better balance between the beliefs you had before and after your trauma.

27

4.3.Other useful approaches

1. Emotion Focused Trauma Therapy

2. EMDR

3. Imagery Rehearsal

4. Narrative Exposure therapy

5. Trauma Affect Regulation

6. Seeking Safety

7. Skills training in Affect regulation

28

29

4.3.1.Emotion Focused Trauma Therapy

30

https://www.youtube.com/watch?v=UtODEXeu94k(EFT couple Therapy3 min)

https://www.youtube.com/watch?v=QpbmxHBWJqM&list=PLF44D10FD20265BB6(Greenberg interview 8 min)

EFT cycle

31

4.3.2.EMDR

32

https://www.youtube.com/watch?v=S2BhZwHXFro4 min Shapiro interview

4.3.3.Imagery Rehearsal

1. Step 1: Lay out the storyline of the nightmare in detail with all elements

2. Step 2: Rewrite the nightmare, The goal of rewriting is to create an alternative, less distressing plot and outcome.  This can be achieved by changing some of the elements, perceived as particularly anxiety-producing. 

3. Step 3: Rehearse it

4. Rehearsing this new storyline for the dream several times throughout the day—and particularly close to when they get ready to go to sleep—the repeated nightmare is changed from a stressful event to a pleasant one

33https://www.youtube.com/watch?v=CLsmRs6RXYM6 min Nightmares

4.3.4.Narrative Exposure therapy

1. Narrative Exposure Therapy (NET) builds on the theory of the dual representation of traumatic memories (Elbert & Schauer, 2002). It is thought to contextualize the sensory, affective and cognitive memories of trauma to understand and process the memory of a traumatic event in the course of the particular life of a client.

2. The patient constructs a chronological narrative of his life story with a focus on the traumatic experiences. Fragmented reports of the traumatic experiences will be transformed into a coherent narrative.

3. Empathic understanding, active listening, congruency and unconditional positive regard are key components of the therapist’s behaviour. For traumatic stress experiences the therapist asks in detail for emotions, cognitions, sensory information, physiological responses and probes for respective observations. The patient is encouraged to relive these emotions while narrating without losing their connection to the “here and now”:

4. NET allows reflection on the person’s entire life as a whole, fostering a sense of personal identity. Working through the biography highlights the recognition and meaning of interrelated emotional networks from experiences, facilitating integration and an understanding of schemas and behavioural patterns that evolved during development. 34

4.3.5.Trauma Affect Regulation

1. https://www.youtube.com/watch?v=X3cRJvBg5GE (2min)

2. http://www.affectregulationtherapy.com

3. Affect Regulation Therapy (A.R.T.) consistently provides rapid results, including reduced stress levels, improvement in mood and emotion regulation and increased commitment to therapy. Using a combination of standard psychotherapy methods from developmental, psychodynamic and behavioural psychology, A.R.T. improves client outcomes and is a suitable support for most mental healthcare programs.

4. Through A.R.T. clients learn to regulate mood and control positive and negative arousal states using three mediums for emotional processing, the cognitive, emotional and the body based self systems. You’ll see immediate and sustained results in clients’ abilities to control affect states and achieve situation appropriate emotional responses.

35

4.3.6.Seeking Safety

1.   Seeking Safety is based on five central ideas: (1) Safety as the priority of treatment. (2) Integrated treatment.(3) A focus on ideals. (4) Four content areas: cognitive, behavioral, interpersonal, and case management. (5) Attention to clinician processes.

2.      Other features include simple, human language and themes (i.e., accessible language that avoids jargon); treatment methods based on educational strategies to increase learning; a focus on potential; emphasis on practical solutions; and an urgent approach to time.

3. http://www.seekingsafety.org/

36

4.3.7. Skill Training in Affect and Interpersonal Regulation (STAIR)1. http://www.ptsd.va.gov/professional/continuing_ed/STAIR_onl

ine_training.asp

37http://www.ptsd.va.gov/apps/STAIR/Session1/wrap_menupage.htm 5 min

5. PREPARING THE CLIENT FOR TRAUMA AND EMOTION PROCESSING

1. Technical Considerations in trauma and emotion processing

2. Tactics for optimizing affective intensity and physical arousal

3. Tactics for enhancing engagement

4. Strategies for enhancing and maintaining reflective self-awareness

5. Determining when to Stop

6. Tactics for Preventing and Managing Crises

38

5.1.Technical Considerations in trauma and emotion processing

1. For clients to engage emotional processing the need to have sufficient resources (personal and interpersonal) and life safety and stability to be able to provide voluntary informed consent.

2. It is important to uncover and understand their beliefs and fears about facing the trauma. What are their expectations for treatment? Clients frequently see therapy as a form of dumping in a cathartic manner in order to “get over it”.

3. It is essential that client understand that the processing of traumatic events does not erase the memories, nor make them emotionally neutral, but become more like memories they can no longer trigger unanticipated and upsetting reactions.

4. Specific information concerning the intensity of treatment, safety and support, risks and benefits and degree of control need to be discussed are the client before treatment starts 39

5.2.Tactics for optimizing affective intensity and physical arousal

1. The therapeutic approach used must best match the clients window of tolerance.

2. Memory and emotional process is safest and most effective if the client is able to stay within the window of tolerance and process their emotion. The goal is to expand the degree of emotional tolerance that the client is able to tolerate.

3. This can be achieved by helping the client immediately use self -calming skills developed in phase 1.

4. Use good tone and carefully chosen words to convey, confidence that the client has the skills to manage the memory

5. Remind the client that they are not alone, and not being safely guided through the re-traumatising memory

6. Redirect the client to less distressing aspects of the event in order to lower the arousal intensity without interrupting the processing and narrative building 40

5.3.Tactics for enhancing engagement

1. Active engagement by the client helps enhance a sense of control.

2. The intent of active engagement is to put the client in the position of being both an active but disciplined and are mindful observer.

3. Tactics for enhancing engagement include experiential techniques in which the client is encouraged to enact the troubling memory or event, through in vivo exposure, through a systematic desensitisation format.

4. Gestalt techniques like the empty chair can enhance behavioural engagement in the processing of the memory

41

5.4.Strategies for enhancing and maintaining reflective self-awareness

1. The ultimate goal is for clients to develop the ability to be reflectively self aware when experiencing traumatic stress reactions

2. It is to help them become a “participant – observer”: developing the client’s capacity to be mindful and to be able to engage in self reflection.

3. During trauma and emotional processing, the therapist models reflective self awareness. This involves enquiring about the nature and source of emotions and thoughts at the client identifies and describes what processing troubling memory.

42

5.5.Determining when to Stop

1. Two criteria are important in judging went “enough” processing has taken place:

1. The client feels no longer as troubled by the memory

2. The client is able to develop a personal lifeline including an understanding that is coherent and that has a narrative structure that makes sense.

2. The extent to which a client has formulated an understanding of what others involved in the event with thinking and feeling, and how their actions followed from these states of mind, is an essential component for resolution.

3. The client is able to understand the logical connections with in a comedy event and how they fit together, the memory begins to resemble other non-traumatic memories.

4. The higher order areas of the brain (prefrontal region) regain inhibitory control over the emotional areas of the brain (limbic system). 43

5.6.Tactics for Preventing and Managing Crises

1. Crisis and decompensation can occur in face to in a variety of ways including hypervigilance, numbing, suicide ideation, self harm and dissociation.

2. Crises can occur for many reasons both external and situational, as well as from the therapy itself

3. Both therapist and the client may be impatient at the pace of therapy resulting in pressure to complete the process. This results in rushing the therapy causing a treatment overload

4. Awareness of transference and counter- transference is essential throughout therapy

5. Stabilisation and safety of priority whenever a crisis is encountered

44

5.7.Loss and Mourning issues

1. Objects trauma involves not only the assault on the self but also involves other major losses: of the self as it might have been, loss of control, the loss of innocence, the loss of sense of safety in the world.

2. The recognition of the loss between the pre-and post event sense of self

3. This is an ambiguous loss: an indistinct loss lacking a clear ending

4. High degree of ambivalence in the primary attachment relationships that have been abusive contributes to difficulties with bereavement

45

6. PHASE 3: CONSOLIDATING THERAPEUTIC GAINS

6.1. Adapting Phase 1 interventions to phase 3

6.2. Adapting phase 2 interventions to phase 3

6.3.Decision about phase work

6.4. Significant issues in Phase 3

46

Phase 3: Consolidating Therapeutic Gains

1. The clients challenging phase 3 is to apply the knowledge and skills gained through our treatment to daily life in the future.

2. The goal of this phase is to consolidate therapeutic gains a move towards ending the treatment.

3. This does not imply a complete recovery from all post-traumatic symptoms or impairment, but understood as achieving the goals that motivated the client to come in the first place.

47

Phase 3: Consolidating Therapeutic Gains

1. Common issues that arise in phase 3:

1. The challenge is to extend the knowledge and skills gained into daily living, making choices from a position of increased self-knowledge, along with healthy self regard and positive and appropriate selfishness

2. Understanding responses and reactions to and from others on a day-to-day basis, sustaining relationships based on improved self-esteem and trust.

3. Connections with family and social systems that dysfunctional and abuse of require decision-making

4. Safeguarding and Child protection issues may become apparent at this stage

48

6.1.Adapting Phase 1 interventions to phase 3

1. Safety stabilisation and self regulation interventions used in phase 1 are applied in phase 3 to reinforce and broaden their application

2. Safety planning, self care, and emotional regulation become aware of life, and the kind examined areas of their life proactively to ensure ongoing safety

3. With increased self knowledge self-determination and pride, skill building and information become important to help the clients make positive choices for the future

49

6.2. Adapting phase 2 interventions to phase 3

1. The memory and emotion processing skills of phase 2 directly applicable to daily living as a client’s becomes a more active partner in addressing life issues.

2. The careful detailed review of physical states, beliefs and effective and cognitive responses to stressful events becomes a template for clients to use in addressing present-day event and choices

3. A processing approach enables client to break those events done into the component parts to achieve a fuller understanding of their reactions on how to develop a more secure attachment in their relationships.

4. These tools help the client to translate the experiences in to personal meaningful processes rather than living life on automatic pilot.

50

6.3.Significant issues in Phase 3

1. A broad range of life issues, linked to the developmental stage of the client and related developmental tasks, often emerge in treatment

2. A focus on career and occupational development alarming a broader range of choices once they have solidified their self-esteem and capacity for autonomy.

3. The development of trustworthy relationships in healthy interdependence with good levels of intimacy based on trust respect is more possible than previously. Included in this healthy sexual relationships that may need specific treatment

4. Child-rearing and parenting issues may need attention as they have had no viable models to learn from

5. Existential issues about life meaning religious beliefs will often emerge in an attempt to seek an answer for what happened to them

6. The end of treatment is a time of great poignancy for the therapist and client. Is it revisits loss careful discussion in preparation for ending is needed. Post therapeutic contracts will need to be in place so that clients can return for “check in or tuneup” treatments

51

7. THE THERAPEUTIC RELATIONSHIP

1. Role of the Therapeutic Relationship

2. Building Therapeutic Relationship

3. Counsellor Qualities: the therapist use of self

4. Barriers to building the therapeutic relationship

5. The role of Attachment style in the therapeutic relationship

6. Maintaining the Therapeutic Relationship

7. Areas of risk and their management

52

7.1. Role of the Therapeutic Relationship

1. The therapeutic relationship is the most powerful instrument in any counselling.

2. When working with complex trauma survivors it is essential to build this relational bridge in which internal and external relational changes can take place for the development of alternative models of relationships and learned secure attachment

3. It is essential to understand “self” of the therapist to establish a secure base from which to operate.

53

7.2. Building Therapeutic Relationship

54

7.3. Counsellor Qualities: the therapist use of self

55

7.4. Barriers to building the therapeutic relationship

56

7.5. The role of Attachment style in the therapeutic relationship

57

7.6. Maintaining the Therapeutic Relationship

58

7.8. Areas of risk and their management

1. Re-parent/rescue me

2. Don't leave me

3. Don't neglect or abuse me

4. Be perfect for me

5. Boundary issues

6. Fix it for me

7. Find my memories

8. Money: what am I worth to you

9. Emergencies

59

8. SEMINAR HOMEWORK

60

Core readings

1. Sanderson (2013):

chapter 6. Therapeutic Challenges.

Chapter 7. Building and Maintaining the Therapeutic Relationship.

2. All of Part 3 Skills to Manage Complex Trauma Symptoms (pg 147-264)

4. Courtois & Ford (2013) chapter 6 phases 2 & 3:trauma memory, emotion processing, and application to the present and future

61

Advanced readings

1. Courtois & Ford (2009) chapter 9. Therapeutic Alliance and Risk Management, Philip J. Kinsler, Christine A. Courtois

2. Courtois & Ford (2013) chapter 9 walking the walk: the therapeutic relationship

62

63