A phase-oriented treatment of simple to complex PTSD

Transcription

1 A phase-oriented treatment of simple to complex PTSD Alexandra (Sandi) Richman Consultant Clinical Psychologist EMDR Accredited Trainer

2 THERAPEUTIC RELATIONSHIP Fundamental to working with C-PTSD Sense of safety sufficient to trust the therapist to tell them truthfully what experiencing Ability to trust very important if access child self/selves and lose contact with adult self Therapeutic relationship is a lifeline connecting the client to therapist and to the present-day reality Trust is a two-way street! Must be a commitment to safety Must be a commitment to treatment

3 PHASE-ORIENTED TREATMENT (Janet, 1898) Phase 1 : Symptom Reduction & Stabilization Phase 2 : Treatment of Traumatic Memories Phase 3 : Personality Integration

4 STAGES OF TRAUMA RECOVERY (Herman, 1992) STAGE I : Safety and stabilization : Overcoming dysregulation STAGE II : Coming to terms with traumatic memories: Remembrance and mourning STAGE III : Integration and moving on : Reconnection

5 PHASED TRAUMA TREATMENT - ATTACHMENT Phased trauma work has a fairly smooth transition from phase to phase with good enough early attachments. C-PTSD is often characterised by pervasive insecure, often disorganised-type attachment classification Will need much more stabilization work including attachment repair

6 BORDERLINE PERSONALITY DISORDER AND DISSOCIATED SELF STATES Although DSM IV considers BPD and DID to be separate disorders, the shifts between dissociated self-states in BPD and DID are very similar. BPD could be formulated as a disorder of alternating, dissociated self-states BPD have sudden and dramatic shifts in their view of others, who may alternatively be seen as beneficent supporters or as cruelly punitive

7 BPD/DID This description of BPD closely mirrors the identity shifts that occur in DID The signs of BPD can be understood as signs of dissociated self-states : Unstable relationships, identity disturbance Fear of abandonment, difficulty controlling anger Substance abuse Sexual impulsivity

8 TREATMENT GUIDELINES FOR PTSD NICE, 2005 : Trauma-focused CBT and EMDR treatments of choice for simple PTSD No recommendations for Complex PTSD

9 PHASE I : STABILISATION Possible tasks : Reducing risk Affect regulation Grounding Resource Development & Installation (EMDR preparation technique) Reducing dissociation and increasing present orientation

10 PHASE I : STABILISATION Somatic stabilization Building therapeutic relationship J : 2 sessions K : 10 sessions M : many!! Sessions

11 PHASE II : TRAUMA WORK EMDR EMDR including possibly ego state work with traumatised dissociated parts Trauma-focused CBT J : 3 sessions K : 20 sessions M : trauma work, then back to stabilisation, more trauma work, back to stabilisation

12 PHASE II : TRAUMA WORK The sequence of the treatment phases stabilization, trauma processing and resolution makes intuitive sense; in practice the process of trauma treatment is often not so orderly. Instead a back-and-forth sequence occurs with C-PTSD

13 PHASE III : REINTEGRATION Possible tasks : Rebuilding sense of self as prolonged trauma can destroy sense of self and sense of agency Learning to trust others Practice in approaching situations afraid of Learning to regulate emotions in relating to others Future temple work : EMDR

14 PHASE III : REINTEGRATION Ego state work to effect attachment repair J : 1 session + follow-up session K : 15 sessions M : back and forth (3 steps forward, 2 back!)

15 AFFECT MODULATION In the wake of trauma, dissociation and uncontainable arousal go hand-in-hand in truncating and altering information processing The biphasic response to trauma : alternating hyperarousal and numbing and constriction The autonomic nervous system involves a complex interplay between the sympathetic and parasympathetic nervous systems

16 AFFECT MODULATION: DYSREGULATED AROUSAL Sympathetic NS Hyper-arousal A R O U S A L Optimal arousal zone Parasympathetic NS Hypo-arousal Ogden & Minton,2000

17 SOMATIC STABILIZATION Complex trauma clients often suffer high levels of somatization Locked into a painful re-experiencing their trauma and physical pain inflicted Have difficulty verbalizing their boundarytransgressing body experiences Experience their body s boundaries as if they were permeable

18 SOMATIC STABILIZATION Encouraging client to be with pain or discomfort in a non-judgmental, kindly way Slow BLS to encourage coming back into Window of Affect Tolerance Learn to track body sensations with selfregulation rather than acting upon them

19 SOMATIC STABILIZATION Emphasize staying present. Affect dial : turn off unpleasant body sensation Install positive body sensations as resources : inner safe place It is only once you have completed adequate preparation and stabilization of autonomic arousal that you can start doing processing of traumatic memories

20 DISSOCIATION Report feeling disconnected from their body Report no emotion in middle of processing a terribly traumatic experience Report feeling like they are floating above their body Report feeling spaced out, dizzy, sleepy Speak in a completely different voice Report having no idea what they are doing in your office

21 REDUCING DISSOCIATION Need to develop skills to decrease the severity of dissociative symptoms and to move out of dissociative states Pay attention to body sensations, being in the present; noticing with all their awareness Squidgy ball to stay present Walking around room and sitting Practice staying present with therapist : Back of the Head Scale (Jim Knipe) Constant Installation of Present Orientation and Safety (Jim Knipe)

22 REDUCING DISSOCIATION Changing unpleasant smells using essential oils to smell as an alternative Just being with unpleasant feelings in a kindly non-judgmental way Boundaries Feeling clothes touching skin, where body meets chair, feet on the ground Imaginary boundary

23 SAFE (SPECIAL) PLACE Very good indicator of : whether client can self-soothe clues as to the client s current internal arousal state ability to form therapeutic relationship A mental refuge Safe Place for dissociative clients Past place vs special place in the present

24 RESOURCE DEVELOPMENT AND INSTALLATION Memories of positive life event, successes, supportive relationships, protectors, times when dealt with challenges successfully Core of resource is a positive body state Resource development and installation can give client important life skills they do not currently have

25 RESILIENCE I still weep sometimes and I feel pain but I can tell the story of my life. I had not words for my sorrows but I could share some moments with you and you heard and you saw my pain. Maybe I could tell my story before, but I was unable to feel anything. I had to find out how I feel. That was painful but somehow my burden was easier to carry and more distant instead of right inside me. My body is more mine now and I know what I feel. There are moments when sometimes I even try to think about the future