New Advances in Treating Complex Trauma pmonroe@biblical.edu www.dianelangberg.com New Advances in Treating Complex Trauma Diane M. Langberg, PhD Diane Langberg PhD & Associates Philip G. Monroe, PsyD Biblical Seminary

Session Outline Defining Complex Trauma CPTSD Review Diagnostic Differentials Interventions: Talking, Tears & Time Safety & Stabilization Telling the Story Grief & Lament Self-Care Strategies for Renewal

Trauma turns complex when: Terror goes beyond typical PTSD Stressors are interpersonal, premeditated, planned and caused by humans Stressors are repeated and chronic in nature Victims are exploited by “caregivers”

A new diagnosis? Complex Trauma Type II PTSD Judith Herman, Trauma and Recovery Type II PTSD Lenore Terr, Too Scared to Cry? Disorders of Extremes Stress (DES NOS) Besel Van der Kolk, Trauma Center

Complex trauma alters a person’s Ability to regulate affect and impulses Attention and consciousness Self-perception Perception of the perpetrator Capacity for relationships Body and brain responses Perception of meaning and faith

Differential Diagnostics Complex PTSD, PTSD, BPD, or Complicated Grief?

Common trauma experiences Intense fear, paralysis/helplessness, inability to effect any change, threat of annihilation, leading to experience of, Loss of voice, control, connection, and meaning, resulting in, Disorganized physical, cognitive, and emotional response system thereby increasing, Relational pain, distrust, self-contempt, overwhelming anxiety, evidenced as, Running from the past, afraid of the future Intrusive re-experiencing, persistence in avoidance of, but heightened arousal… How does childhood trauma differ from adult trauma? The child does not have the a solid identity nor an ability to contextualize the abuse and so develops a childlike understanding of self and world where safety is absent.

Overlapping diagnoses Posttraumatic Stress Disorder (PTSD) Complex PTSD (C-PTSD or DESNOS) Borderline Personality Disorder (BPD) Complicated Grief (CG) Major Depression Generalized Anxiety

How do you tell the difference? Traumatic Symptoms BPD (DTD?) PTSD Prolonged Grief DESNOS C-PTSD

Anxiety Depression Trauma

Key differentials DESNOS Anxiety Complicated Grief Primary Affect: Panic and pain Worry Intrusive sad or guilty thinking Relationships: Passive, avoidance, re-victimization Varies; trust relationships likely Loss of pre-existing good coping skills Dissociation: Present Not likely Cognitive Focus: Fear Future dangers Loss Self: Consistent self loathing External focus, self in background Compare/ contrast with self prior to loss TIME: Key factor in determining intensity of diagnoses

The biology of trauma? Amygdala + Hippocampus + Cingulate Arousal + Evaluate + Decide Michael Lyles: accelerator, no brakes, no steering Hypothalamus + pituitary + adrenal Cortisol/stress feedback loop In PTSD: low cortisol but more frequent “radar” results in overreaction to weak “signals” and no correction back to norm

Treatment Overview talking, tears, and time

Safety & stabilization Foundation for all treatment Longest phase and vital to positive outcomes Features Alliance building; support networks Coping; grounding Education about the nature of trauma Avoid forced telling or catharsis

Initial goals Increase client self-reflective capacities and compassion for the struggle Support appropriate boundaries Increase positive coping skills and support network

Initial dangers Diving into trauma work before building coping skills Failing to return to phase one during trauma memory work Mastery over frightening and reactive responses must be attained before proceeding to phase two

Talking Memory work done in concert with phase one skills Focus: grief, loss, shame, anger rather than anxiety Context: the tendency to leave (dissociate from) the pain Goal: Small amounts of memory work with frequent self-care and stabilization

Why talk? Truthfully telling of a silenced narrative At right place, improves client self-efficacy Tells the whole story Supports grieving well Brings faith and experience together

Talking dangers Pushing or avoiding the story Believing that telling the story is what heals Seeking catharsis alone

Connection and growth Marital work Parenting Conflict resolution Setting appropriate boundaries Reconnecting to communities

Complex Trauma in the Church Educating the Church, Connecting Victims to God

Caring church leaders may grow weary in well-doing Educating the Church What might it mean if CT clients appear to be resistant, refusing good advice, yet dependant at the same time? Are they sinfully anxious? Are they demon possessed? Are they rebellious? Are they refusing to forgive or get better? Caring church leaders may grow weary in well-doing

Educating the Church: key areas Develop a theology of oppression to explain impact of trauma Failure to love violates the imago dei, true religion 5 facets of oppression (the opposite of love) Abuse of power Deception and false teaching Failure to lead Objectification Forced false worship See my “The nature of Evil in CSA: Theological considerations of oppression and its consequences” in the 2012 Schmutzer, A (ed.) The Long Journey Home: Understanding and Ministering to the Sexually Abused. Wipf & Stock.

Educating the Church: key areas Develop a larger view of healing What constitutes healing? How do we participate in God’s healing? Support? Mercy? Prayer? Listen? Play? Remember: some healing is immediate, other healing grows day by day

Educating the Church: key areas Explore ancillary themes: forgiveness, reconciliation, restoration, restitution, etc. What is the rush? Why forgiveness now? Point in time? Attitude? Why reconciliation now? What bothers us most about brokenness? What does repentance look like? What about restitution?

Lament An Intervention for Counselors and Clients

What is Lament? Canonized complaints to God Lamentations includes Complaint against sin and destruction Agony over personal/corporate sin (in children of God and heathen) Questioning God Waiting expectantly for answers Worship

Does lament resolve hurt/anger? Answers from Scripture? Answers from Science? Snow, McMinn, Bufford & Brendlinger (2011). Resolving anger toward God: Lament as an avenue toward attachment. Journal of Psychology and Theology, 39, 130-142. [study of 192 college students. Lament may increase communion with God but does not seem to decrease anger toward God]

Counselor Self-Care Preventing Vicarious Trauma; Some Directions for Church Leaders

Vicarious trauma “Trauma is contagious” Bearing witness leads to hopelessness, questions of faith, and fear in relationships Temptation: withdrawal or intrusive action VT defined: (Saakvitne & Pearlman) transformation of the therapist's inner experience as a result of empathic engagement with another’s trauma Transforming the Pain

Tend your garden To last the long haul without damage, tend to: Self-care Relationships Faith

A temptation to avoid self-care? I find many therapists feel guilty pursuing beauty and peace and order in their own lives... It is as if somehow they should not have good in their lives while others suffer. However, the Word of God says that He gives us richly all good things to enjoy. To turn from such things is to turn from the gifts in His hand.

For additional resources www.dianelangberg.com Books, CDs, bibliographies on related topics Opportunities for case consultation www.wisecounsel.wordpress.com Phil’s personal and professional musings Contact information: pmonroe@biblical.edu