Interventions

LaShaun Williams, PsyD

ASSISTING CLIENTS WITH COMPLEX PTSD

Complex PTSD

1. Re-experiencing

2. Avoidance/Numbing

3. Hyperarousal

•~~~ 1. Affective dysregulation

2. Impaired attention and consciousness

3. Impairment in interpersonal functioning

4. Somatization &/or medical problems

5. Compromised systems of meaning

Symptom Clusters

PTSD

Complex PTSD

Phasic Treatment

• PHASE I

• Stabilizing safety

• Psychoeducation

• Effects of trauma

• Responses as adaptations

• Cummulative nature

• Treatment process

• Develop therapeutic alliance

• Reducing symptom acuity

• PHASE II

• Review and reconstruction of trauma memories

• PHASE III

• Engagement in community life

Phasic Treatment

SAFTEY: Theme of Phase I

What does safety mean?

~~~~~~~~

Feeling Safe versus Being Safe

Vermilyea (2000)

PHASE I

Very Unsafe 1-------------------------------------------Very Safe 10

Perceived Safety Actual Safety

Stress Responses

2 9

Dissociation 9 2

Phasic Treatment

SAFTEY: Theme of Phase I

Survival Mode

• Need to react

• No time to think

Recovery Mode

• Need to respond

• Must Reflect & Consider

PHASE I

Psychoeduation

• Ongoing process

• Facilitates transparency

• Facilitates collaboration

• Reinforces differences in

therapeutic relationship

• OK to ask “Why?”

• OK to expect explanation

• OK to expect thoughtfulness

• OK to question the rationale

• OK to disagree

Grounding

SIGHT SOUND TOUCH SMELL TASTE

Look around the room Look at a specific object Notice a specific features (e.g. How many blue things?)

Notice sounds in the room (e.g. fan) Listen to soft music Nature sounds

Pillow Rock Frozen orange Pets

Lotions Scented candles Essential oils Clean laundry

Tea Gum Mints Ginger candy

Using the 5 Senses

Grounding • Orienting Self to Present

• “I am safe.”

• “Today is Monday, May 20th, 2013”

• “I’m at my therapist’s office.”

• Observation Games

• How many windows in this room?

• How many brown things are there?

• How many circular things?

• What’s the distance between me and the bookshelf?

• What’s the length of the table top?

Mentally

Comparisons

SIMILARITIES DIFFERENCES

In You Feel scared Feel alone Could get disappointed

Adult Have help More able to handle it

In the Environment

Wish it’s different Cramped

Pictures on wall Lots of people around

In the Situation

Feel attacked Feel trapped

I made the decision to be here Not trapped

In Others Have power over me Couldn’t disagree

People listen Can find out the reason why

Separating Past and Present Orienting to Present

Containment Skills

• temporarily put experiences aside, rather than allowing them to remain unconscious

Physical

Containment Skills

Removing Yourself from the Situation

Safe Places

Using Imagery

Containment Skills

Removing the Distressing Material

Using Imagery

Containment Skills

• Contains experiences

• Facilitates Other Treatment Activities

• Grounding

• Developing awareness

• Exploration

• Pro’s versus Con’s

Journaling

Containment Skills

Level 1: surface, factual

• Grounding

• Managing time loss

• Increase awareness of day to day events

Level 2: present thoughts, feelings, impulses

• Therapy assignments

• Containment

• Self soothing

Level 3: present-focused writing related to trauma material

Journaling

Cognitive Restructuring

• Systematically identifying and challenging cognitive distortions and replacing them with more positive and accurate thoughts.

• Can be simple consideration of evidence for and against the thought.

• Can be a more involved process…

Challenging Trauma Based Distortions

ghts

“Just because we think it doesn’t make it true.”

Assessing Thoughts: Accurate? DATE

/TIME

SITUATION AUTOMATIC

THOUGHTS

EMOTIONS RATIONAL

RESPONSE

OUTCOME

-At the shelter.

No money in

my pocket.

-Thinking about

some people I

used to hang

with.

-Start craving

cocaine.

“There is

nothing to

do.”

(85%)

“I can’t

stand this

boredom.”

(80%)

Bored

(90%)

Anxious

(95%)

“Actually, there

are plenty of

things I could do;

for example go

to a meeting,

write in my

journal.”

“It is not true that

there is nothing

to do but the

pain of boredom

makes it hard to

see other things

I could do.”

Belief in

automatic

thoughts

(10%)

Bored

(30%)

Anxious

(20%)

Adapted from Beck, et al (1993)

Assessing Thoughts: Functional? Helpful Thinking Harmful Thinking

Constructive

Puts you together

“I can learn.”

Necessary

Helps you do what you need to.

“To find out if I am HIV +, I need a

blood test.”

Positive

Makes you feel better.

“I can focus on what is good in my

life or what I can do.”

Destructive

Tears you apart & destroys you.

“I don’t know anything.”

Unnecessary

Does not change anything.

“What if I’m HIV +?”

Negative

Makes you feel worse.

“There’s so many things wrong with

my life, and there’s nothing that I

do about it.”

Label Dysfunctional Thinking Patterns

•Overgeneralizations “She cut me off

when I was talking. No one wants to

listen to what I have to say.”

• Personalizations Taking responsibility for

negative events, beyond your control. “I ruined

the evening because I chose the restaurant

with the bad service.”

• Dichotomous (All or Nothing) Thinking “If I

can’t make money like I used to, what’s the

point in living.”

Label Dysfunctional Thinking Patterns

•Mind Reading “The counselor doesn’t like

me,… he ignored my question in group.”

•Negative Future Telling Thinking that you

can see how things will be in the future and

its bad.

• Negative Mental Filter Focusing

solely on the negative and

ignoring the positive.

Dialectical Behavior Therapy

(DBT) Skills

•Mindfulness

•Affect Regulation

•Distress Tolerance

• Interpersonal Effectiveness

Identifying and Managing Triggers

“Small things set me off, and before I know it, I’m thinking of

suicide.”

“When I see someone light up, the world narrows and all I can feel is

the need to get high.”

Najavits (2002)

Dialectical Behavior Therapy (DBT)

1. Describe the specific TARGET EVENT

2. Identify the specific PRECIPITATING EVENTS

3. Explain in general the VULNERABILITY FACTORS influencing the event

4. Describe the CHAIN OF EVENTS leading to the TARGET EVENT

5. Identify the CONSEQUENCES of the event

6. Describe in detail alternative SOLUTIONS

7. Outline in detail PREVENTION STRATEGIES

8. Identify REPAIR options

Behavior Chain Analysis

Crisis Continuum LEVEL OF DISTRESS

1 2 3 4 5

Thoughts

Feelings

Behaviors

Sensations

Symptom Management/Coping SKILLS

Thoughts Feelings Impulses Sensations

1

2

3

4

5

.

.

.

Between Trigger and Reaction “Between stimulus and response

there is a space. In that space is our power to choose our

response. In our response lies our growth and our freedom.”

-Victor Frankl (Man’s Search for Meaning)

Bibliography Adams, K. (1998). The Way of the Journal: A Journal Therapy Workbook for

Healing. Lutherville, MD: Sidran Press.

Beck, J. S. (1995). Cognitive Therapy: Basics and Beyond. New York, NY: Guilford Press

Beck, A. T., Wright, F. D., Liese, B. S. (1993). Cognitive Therapy of Substance Abuse. New York, NY: Guilford Press

Braun, B. G. (1988). The BASK (behavior, affect, sensation, knowledge) model of dissociation. Dissociation, 1, 4-23.

Herman, J. L. (1992). Trauma and Recovery. New York: Basic Books.

Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5, 377-391.

Cloitre, M., Courtois, C. A., Ford, J. D., Green, B. L., Alexander, P., Briere, J., Herman, J. L., Lanius, R., Stolbach, B. C., Spinazzola, J., Van der Kolk, B. A., Van der Hart, O., (2012). The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Retrieved from http://www.istss.org [www.istss.org/AM/Template.cfm?Section=ISTSS_Complex_PTSD_Treatment_Guidelines&Template=/CM/ContentDisplay.cfm&ContentID=5185

Courtois, C. (2004). Complex Trauma, Complex Reactions: Assessment and Treatment. Psychotherapy: Research, Practice, Training. Vol 41, No. 4, 412-425.

Bibliography International Society for the Study of Dissociation. (2005). [Chu, J.A.,

Loewenstein, R., Dell, P.F., Barach, P.M., Somer, E., Kluft, R.P., Gelinas, D.J., Van der Hart, O., Dalenberg, C.J., Nijenhuis, E.R.S., Bowman, E.S., Boon, S., Goodwin, J., Jacobson, M., Ross, C.A., Sar, V, Fine, C.G., Frankel, A.S., Coons, P.M., Courtois, C.A., Gold, S.N., & Howell, E.]. Guidelines for treating Dissociative Identity Disorder in adults. Journal of Trauma & Dissociation, 6(4) pp. 69-149. Journal of Trauma & Dissociation, Vol. 6(4) 2005 Available online at www.informaworld.com doi:10.1300/J229v06n04_05)

Kluft, R. P. (1994). Treatment trajectories in multiple personality disorder. Dissociation, 7, 63 – 76.

Kluft, R. P. & Loewenstein, R. J. (2007). Dissociative disorders and depersonalization. In G. O. Gabbard (ed.), Gabbord’s treatment of psychiatric disorders. 4th edn. (pp. 547-572). Washington, DC: American Psychiatric Press.

Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford Press.

Loewenstein, R. L. & Welzant, V. (2010). Pragmatic approaches to stage-oriented treatment for early life trauma-related complex post-traumatic stress and dissociative disorders. The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic. Lanius, R. A., Vermetten, E. & Pain, C. Eds. Cambridge University Press.

Bibliography Nathanson, D. L. (1989). Understanding what is hidden: Shame in Sexual

Abuse. Psychiatric Clinics of North America, 12 (2), 381 – 388.

Nathanson, D. L. (1992). Shame and pride: affect, sex, and the birth of the self. New York, NY: W. W. Norton & Company, Inc.

Najavits, L. M. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York, NY: Guilford Press.

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

Saakvitne, K. W., Gamble, S. G., Pearlman, L.A., & Lev, B. (2000). Risking Connection: A training curriculum for working with survivors of childhood abuse. Lutherville, MD: Sidran Foundation Press.

Salter, A. (1995). Transforming Trauma. Thousand Oaks, CA: Sage Publications, Inc.

Schwarz, R. (2002). Tools for Transforming Trauma. New York, NY: Routledge.

Vermilyea, E. G. (2000). Growing Beyond Survival: A Self-Help Toolkit for Managing Traumatic Stress. Baltimore, MD: Sidran Foundation Press.

LaShaun Annette Williams, PsyD

(202) 361-5992

Drlashaunwilliams.com

info@drlashaunwilliams.com

THANK YOU

Image from Louisiana Tech University Counseling

Phasic Treatment 

There is general agreement that effective treatment of complex post‐traumatic stress and dissociative 

disorders follows a phasic process (Courtois, 2004; Herman, 1992; Lowenstein & Welzant, 2010; 

Schwarz, 2002).  The structure of this conference reflects that consensus with the morning sessions 

focusing on phase I issues including the stabilization of safety and engagement.  In addition, affect 

regulation, skill building, psychoeducation and the development of the treatment alliance are the tasks 

of phase I.  The second phase includes the processing of traumatic experiences and the third phase 

addresses living well in the present.  These phases serve as general guideposts for the work.  Treatment 

of complex posttraumatic stress and dissociative disorders is seldom a linear process, but rather a spiral 

in which we return again and again for deeper and more nuanced understanding and resolution.   

The over‐aching framework for treatment of complex posttraumatic stress and dissociative disorders 

has been described by Courtois (2004) as “multimodal and transtheoretical” due to the applicability of 

various treatment approaches and strategies and the multiplicity of treatment issues to be addressed. 

Trauma informed means understanding that there is a logic to the client’s symptoms and ways of being 

that relate to experiences of trauma.  Loewenstein and Welzant (2010) describe the sometimes 

incomprehensible presentation of our clients as “chronic adaptations to recurring, coercive 

interpersonal trauma” (p. 257).  

Even when we’re getting it right, we can be getting it wrong.  An accurate reflection of the client’s 

experience may set off a series of negative reactions.  For example the client’s response to being seen 

and understood by the therapist may not be experienced as validating.  As Nathanson (1989) points out, 

there is a relationship between shame and all exposure and there is “an inherently shameful quality of 

psychotherapeutic disclosure” (p. 384).    Also, as noted by Salter (1995), for clients abused by sadistic 

perpetrators, their thoughts and feelings were used as an instrument of abuse.  Therefore, the 

therapist’s efforts to know the client better are extremely threatening and terrifying.  Likewise, 

entreaties to clients to open up and share their internal experiences are similarly fraught with danger.  

For such clients, deception and hiding one’s true feelings was essential for survival (Salter, 1995). 

 

Psychoeducation 

Psychoeducation is a tool that is used regularly throughout the treatment.  Beginning in the first session, 

the client is taught what it means to be in treatment.  As part of gaining informed consent it is important 

to explain that since difficult issues are discussed, sessions may feel uncomfortable.  However, they 

should not be re‐traumatizing.  “We won’t be talking in depth about the details of traumatic experiences 

in the beginning.  We’re going to make sure that it’s not overwhelming to be here.”  Ensuring that the 

client remains within the “window of tolerance” [see Ogden, 2006], in which the client is neither hyper‐ 

or hypo‐ aroused allows for the client to engage optimally in sessions.  What kind of relationship is a 

therapeutic one?  A collaborative relationship, in which we work together to make things better.  I 

explain that I have no interest in controlling the client, which then gives me the opportunity to address 

disbelief.  I explain that I don’t expect the client to believe me and that it’s actually appropriate not to 

just take at face value what you’re told by someone you’ve just met.  “I invite you to check me out.” 

 

DBT 

My clients have found DBT Skills training extremely helpful.  The approach addresses many of the 

associated symptoms of repeated and ongoing trauma, such as affective and cognitive dysregulation, 

impaired interpersonal functioning, hyperarousal, impaired attention and consciousness as well as 

somatization.  It is recommended that careful attention be paid to maintaining the integrity of the 

treatment approach.  It is not altogether clear which aspects are responsible for particular treatment 

gains, so adaptations must be made with care.