The Treatment of Trauma: Recreating Developmental Stages
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Transcript of The Treatment of Trauma: Recreating Developmental Stages
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The Treatment of Trauma: Recreating Developmental
Stages
Ron J. Llewelyn Psy.D.Amanda GallowayACMHC-i
Dr. Llewelyn’s Affiliations: Living Waters Counseling LLC., University of Phoenix, Valley
Mental Health, & The Center for Christian Therapy
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Objectives
Learn about the theory, research and
utilization of Posttraumatic Growth in our everyday and therapeutic interactions
offenders and survivors.
Be able to identify the obstacles that
limit a person’s ability to become a thriving individual
Walk away with specific methods to help those effected by domestic abuse
Explore Eriksonian and Freudian
developmental models
Learn to re-create the developmental
conflicts in treatment.
Understand how developmental recreation may
enhance Posttraumatic
Growth
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Psychological Trauma: The sudden uncontrollable
disruption of our affiliative bonds. Lindemann 1944
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Domestic Violence in 3 Minutes
Offender• Offender• Perception of self (un-projected or reversed)
– Self is threatened– Often insecure– Lost– Out of control– Fears being blamed– Fears abandonment– Underlying shame– Feels limited options– Jealous
• • Perception of Survivor
– Is a threat to their own sense of stability– Has too much power– Can be difficult – May abandon them– The “safest” place to project to
• • Perception of others and the world
– Fears being found out– Fears not being able to look competent– Needs to use persona – Well-meaning others may expose their incompetence’s
Survivor• Perception of self starts to change
– Lowered or lost confidence– Questioning own decisions– Questions if anyone loves them– Blames self for others leaving– Starts to feel defiled– Starts to feel helpless– Starts to feel hopeless– Feels shame, guilt and blame– Identifies with abuser language– Believes that options are few– Increase sense of insecurity– Increase in emotional states– Turning Against the Self
• • Idealization of the Offender
– May rationalize their behavior to others– May rational their behavior to self– May blame self for their behavior– Due to isolation, feels they are the only one there for them– My become dependent upon them– May perceive them with unrealistic power.
• • Perception of Close others & the World
– Due to isolation, may feel abandoned– Others will not understand– May see others as a threat
• People have failed to rescue them
Types of OffendersSocially limited
Borderline/JealousAntisocial/Narcissistic
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Understanding the Diagnosis
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Diagnostic Comparison
Type 1 - PTSD
Re-experiencing
Avoidance Numbing
Hyperarousal
Type 2 – Complex PTSD
Affect Regulatio
n
Consciousness
Self-Perceptio
n
Perception of
Perpetrator
Relationships
Somatic
System of
meaning
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Affect Regulati
on
Persistent Dysphoria
Chronic Suicidal Ideation or Self-
Injurious/Parasuicidal Behavior
Explosive Anger/Anger
Inhibition
Compulsive Promiscuity/Extr
eme Sexual Inhibition
Emotional Flashbacks
Pattern of Generally Poor Modulation of
Emotional Response
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Deviationsin
Consciousness
Amnesia/Hypermnesia
Depersonalization
Derealization
Intrusive Re-
experiencing
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Alterations in
Perception of Self
Pervasive Sense of
Helplessness
Self-Blame, Guilt, Shame
Feeling Defiled or
Stigmatized
Complete Difference from Other
People
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Alterations in
Perception of
Perpetrator
Preoccupation with the
Relationship
Preoccupation with Revenge
Attributing Perpetrator
with Unrealistic
Power
Idealization of the
Perpetrator or the
Relationship
Acceptance of Perpetrator’s Belief System
or Rationalization
s
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Alterations in
Relationships with Others
Isolation & Withdrawal from Other
People
Repeated Search for a
Rescuer
Persistent Distrust
Disruption in Intimate
Relationships
Repeated Failures in
Self-Protection
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Somatic Flashbac
ks
Re-Experiencing
Physical Sensations
Related to the Trauma
Bruising, Sensation of Being
Burned or Cut
Conversion Symptoms (Anxiety
Converted into Physical
Symptoms
Numbness, Paralysis, Isolated Limb Weakness,
Blindness, Seizures
Chronic Pain (Headache,
Backache, Deep Muscle or Bone
Pain)
Digestive System
Complaints
Shortness of Breath,
Chest Pains
Anniversary of
Trauma Occurrence
s
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Alterations in
Personal System
of Meaning
Loss of Sustaining
Faith
Pervasive Sense of
HopelessnessPervasive Sense of Despair
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Cognitions & Loss of Meaning
Janoff-Bulman
We are not vulnerableThe World is Predictable & Controllable
We Merit Self Worth
Epstein
The World is a Source of Joy
The World is Controllable
I am Competent & Good
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What Is Posttraumatic Growth?
“…refers to reports of positive changes in
individuals that occur as the result of
attempts to cope in the aftermath of traumatic
life events.” (Tedeschi & Kilmer, 2005)
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A Disorder?
Could Type 2 PTSD be a form
of coping instead of a “Disorder?”
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Areas of Posttraumatic Growth Outcomes Grubaugh & Resick, 2007
Improved self efficacyChange in how one relates to othersIncreased
SpiritualityAware of New PossibilitiesGreater Appreciation
for Life
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A Brief Overview of the 3 Staged Treatment Model for Type II PTSD
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Three Stages
1 Stability
2Process
& Grieving
3 Reconnectio
n
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Stage One: The Corrective Therapeutic
Experience: Working with Attachment, Intrapsychic
Conflict, and Transference Neurosis
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Safety & Safety
Planning
Education Physical Well
Being
TrustBoundaries
Self Soothing
Stage one: Stabilization
Primarily a personal experience
Primarily a social experience
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Three Stages in a Social ContextIntra-psychic & Therapeutic Interaction
Micro Therapeutic Dynamics
Macro Level Dynamics
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Stage One:Key Terms
Attachment
Transference & Transference Neurosis
Countertransference
Repetition Compulsion
Temporary Regression
Defense Mechanisms
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Stage One: Psychoeducation
• Education about Symptoms/Fight or Flight/Kindling
• Increase right limbic, decrease in prefrontal cortex and Broca’s Area.
• Disorganized Memory Storage/affective, cognitive & behavioral incongruence (See next slide)
• Re-enactments• Alexithymia
Symptom Awareness
• Monitoring stimuli and associated reactions
Environmental
Awareness
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The Neurobiology of the Fight or Flight Response
Stressful Event
Cortex
Locus Coeruleus
Sympathetic NS
Adrenal Medulla
Thyroid
Adrenal Cortex
Pituitary
Hypothalamus
Amygdala
Cortisol
Thyroxin
Noradrenalin
Adrenaline
Adapted from Preston, O’Neal, & Talaga 2010
Thalamus
This occurs before
information reaches the
Cortex
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Neuro-anatomical Factors
Right
Hemisphere
Broca’s
Area
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Genetic Expression
Static vs.
Dynamic
Systems
Up/Down
Regulation
Environmental Influence
Receptor
ChangeNT production
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Stage One: Physical Well Being
Well Bein
g
Medication
Diet sleep
Exercise
Reduced Caffeine
Comfort in Own
Skin
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Stage One:Self Soothing
Relaxation Anxiety
Counter-conditioning
Reversal of Operant Conditioning
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Stage One: Self Soothing
Clients discover and adopt
healthier ways of coping with
stressors.
Breathing
Exercise/Activity
Guided imagery
Journaling/Writing
Art
Music
Nature
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Beyond the Pre-Frontal Cortex:Sensory Motor Trauma Therapy
Reflection of Body States
Experimentation
Toleration
Nerve Stimulation
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Stage One:Safety, Trust & Boundaries
Trust vs. Mistrust/O
ral
Autonomy vs. Shame & Doubt
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Treatment Through the Corrective Therapeutic Experience
An In Depth Look at Safety, Trust & Boundaries
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Stage One:Psychosocial Redevelopment
(Herman, 1992)
“Recovery from trauma requires the reconstruction of basic capacities for
trust, autonomy, initiative,
competence, identity, and intimacy…”
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Early Stages of Life and Their Spatial Needs. (Erikson 1968)
Stage 1• To Receive• To Give in Return
Stage 2• To Hold On• To Let Go
Stage 3• To Make (Go After)• To Make Like (Play)
Stage 4• To Make Things• To Make Things together
Stage 5• To Be Oneself• To Share Being Oneself
Stage 6 • To Lose and Find Oneself in others
Stage 7• To Make Be• To Take Care of
Stage 8• To be through having• To face not being
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Developmental ModelsTrust vs. Mistrust
Oral
Autonomy vs. Shame & Doubt
Initiative vs. Guilt
Industry vs. Inferiority
Identity vs. Role Confusion
Intimacy vs. Isolation
Generativity vs. Stagnation
Integrity vs. Despair
Anal
Genital
Latency
Phallic
Hope
Willpower
Purpose
Competence
Fidelity
Love
Care
Wisdom
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Old Age.
Adulthood.
Young Adulthood
Adolescence.School Age.
Play Age.
Early Childhood
Infancy Basic Trust vs Mistrust
Integrity vs. Despair
Autonomy vs. Shame &
Doubt
Initiative vs. Guilt
Industry vs. Inferiority
Intimacy vs. IsolationIdentity
vs. Confusion
Generativity vs. Stagnation
1 2 3 4 5 6 7 8
VIII
VII
VI
V
IV
III
II
I
Adapted from Childhood & Society Erikson 1950.
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Erikson
“If we know what can go wrong in
each stage, can we say what should
have gone and can go right?” (Erikson, 1968)
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Eriksonian &Freudian Basics
Crucial Moments
Ratio of Development
Ontogenesis of Hope
Fixation (war)
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War
Crisis 1
Crisis 2
Crisis 3
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A Strange Situation
Secure Attachme
ntAvoidant
Ambivalent
Disorganized
Ainsworth, M. D. S., Bell, S. M., (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41, 49-67.
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Homeostatic Mechanism of Attachment
“The attachment system acts as a kind of
homeostatic mechanism for modulating anxiety
and stress by seeking out an attachment figure for security and protection.”
(Bowlby, 1978)
Janssen, C. G. C., Schuengel, C., & Stolk, J. (2002). Understanding challenging behaviour in people with severe and profound intellectual disability: A stress-attachment model. Journal of Intellectual Disability Research, 46, 445-453.
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Attachment(Bartholomew, 1990; Muller & Rosenkranz, 2009)
Attachment Anxiety
Attachment Avoidance
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Stage One:Safety
Environment Structure Predictabili
ty Safety
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Stage One:Safety
Seeking
Help
Change
Trust
Vulnerability
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Stage One:Boundaries
The therapist models appropriate boundary setting and enforcement.
The client’s dependence on the
therapist is redirected toward a sense of personal empowerment in the therapeutic environment.
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Enhancing Posttraumatic Growth through the Corrective Therapeutic Experience
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Repetition Compulsion
“The patient cannot remember the whole of what is repressed in him, and what he cannot remember may be precisely the essential part of it…He is obliged to repeat the
repressed material as a contemporary experience
instead of remembering it as something in the past.”
• Sigmund Freud
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The Transference Neurosis
Therapist
Client
Clients Offender
Other previous
relationships
Group Member
Group Member
Group Member
Violation of Silence
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Essential Treatment Factor
Temporary Regression
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Trust Vs. Mistrust (Hope)
Trust vs.
Mistrust
First World
Ontogenesis of Hope
Delay of Gratification/Abandonment
Autonomy vs Shame
& Doubt
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Repetition Compulsion:Transference Testing
•Will you do it?
Transference Testing
•Can you handle
it?
Passive To Active
Transformation
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The Transference NeurosisAn Omnipotent
Rescuer
Our desire to
save
Our agenda
Our projectio
ns
Or re-enactme
nts
An Unpredictable Abuser
Our Own Issues
Inability to sit with client
Overly rigid boundary response
Overly Permeable boundary response
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Autonomy vs. Shame & Doubt
Immature Dependence
Mature Depende
nce
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Autonomy vs. Shame & Doubt (Will Power)
Autonomy vs. Shame
& Doubt
Self Control without loss of self-esteem
Compulsive compliance or impulsive defiance
Will Power
Initiative vs. Guilt
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The Therapist Should…Herman (1997) pg. 135
Remain “Disinterested”
Remain “Neutral”
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Initiative vs. Guilt (Purpose)
Initiative vs. guilt
Development of Superego
Development of Roles
Finding Purpose & Self Initiative
Industry vs.
Inferiority
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Industry vs. Inferiority(Competence)
Industry vs.
Inferiority
Take School & Cultural Role
Development of inadequacy
Competence
Identity vs.
Identity Confusi
on
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Identity & Repudiation vs. Identity Confusion(Fidelity)
Identity vs.
Identity Confusi
on
Impulse Vs. Compulsive Restraint
Self-Definition
Fidelity
Intimacy vs.
Isolation
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Intimacy & Solidarity vs. Isolation(Love)
Intimacy vs. Isolati
on
Self Abandonment
“Way of Life”
The Defensive Wall
Generativity vs. Self Absorptio
n
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Generativity vs. Self-absorption/Stagnation(Care)
Generativity vs. Self Absorptio
n
Dependency & Maturity are Reciprocal
Guiding the Next Generation
Relation to Stage 3
Integrity vs.
Despair
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Integrity vs. Despair(Wisdom)
Generativity vs. Self
Absorption
Integrity of experience
Letting go
Sign of conflict is doctoring of memories
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