WORKING WITH TRAUMA Presented By Rick Haid

TRAUMA DEFINITION

TRAUMA DEFINITION Trauma is: The exposure to an extreme stressor involving direct personal experience of an event that involves actual or threatened death or serious injury; or Threat to one's physical integrity; or Witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or Definition adapted from: http://www.ncstac.org/content/projects/trauma.htm

TRAUMA DEFINITION Trauma (cont.) Learning about unexpected or violent death, serious harm, or threat of death; or Injury experienced by a family member or other close associate. Definition adapted from: http://www.ncstac.org/content/projects/trauma.htm

TRAUMA DEFINITION The person's response to the event must involve: Intense fear; Helplessness or horror; Or in children, the response must involve disorganized or agitated behaviour. Definition adapted from: http://www.ncstac.org/content/projects/trauma.htm

TRAUMA DEFINITION The traumatic event can be experienced in various ways: Recurrent & intrusive recollections of the event Recurrent and distressing dreams during which the event is replayed Dissociative states Intense physiological distress and reactivity Definition adapted from: http://www.ncstac.org/content/projects/trauma.htm

TRAUMA DEFINITION Traumatic event experienced (cont.) Deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event Diminished interest or participation in previously enjoyed activities Feeling detached or estranged from others Reduced ability to feel emotions Definition adapted from: http://www.ncstac.org/content/projects/trauma.htm

TRAUMA DEFINITION Traumatic event experienced (cont.) A sense of a foreshortened future Difficulty falling or staying asleep Hypervigilance Exaggerated startle response Irritability or outbursts of anger And difficulty concentrating or completing tasks. Definition adapted from: http://www.ncstac.org/content/projects/trauma.htm

POST TRAUMATIC STRESS DISORDER

Diagnostic criteria for 309.81 PTSD The person has been exposed to a traumatic event in which both of the following were present: The person experienced/witnessed, or was confronted with an event/s that involved actual/threatened death/serious injury, or a threat to the physical integrity of self/other The person's response involved intense fear, helplessness, or horror. (In children, this may be expressed instead by disorganized or agitated behaviour).

PTSD B. The traumatic event is persistently re-experienced in one (or more) of the following ways: Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. Recurrent distressing dreams of the event. Note: In children, there may be repetitive frightening dreams without recognisable content.

PTSD Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experienced, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when the intoxicated). Note: in young children, trauma specific re-enactment may occur. 4. Intense psychological distress and exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event.

PTSD Physiological reactivity on exposure to internal or external cue that symbolises or resembles an aspect of the traumatic event.

PTSD Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid activities, places, or people that arouse recollections of the trauma Inability to recall an important aspect of the trauma

PTSD Persistent avoidance (cont.) Markedly diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect (e.g. unable to have loving feelings) Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal lifespan).

PTSD D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response

PTSD E. Duration of the disturbance (symptoms in criteria B, C, and D) is more than one month.   F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

PTSD Specify if: Acute If duration of symptoms is less than 3 months. Chronic If duration of symptoms is 3 months or more. With delayed onset: if onset of symptoms is at least six months after the stressor.

WORKING WITH TRAUMA

WORKING WITH TRAUMA The trauma system is really about the limbic system. Picture from: www.mhhe.com/socscience/ intro/ibank/set1.htm

WORKING WITH TRAUMA This physiological storing of emotion has a definite CAUSATIVE event, unlike Phobia, which has no clear cause or onset.   When working with a traumatized client, we avoid catharsis or abreaction – these are UNWANTED in trauma therapy.

Watch for cues in the client of them becoming over-stimulated: WORKING WITH TRAUMA Watch for cues in the client of them becoming over-stimulated: Breathing (big give-away). Listening for breath in the voice is an important cue for the therapist Agitation, twitching Hand wringing Variable pulse Cold sweat Muscle tension

WORKING WITH TRAUMA Cues of over-stimulation (cont.) Dilation of pupils Increased heart rate Head ache/stomach ache (this is a shut down response – i.e., blood to muscles) Ringing in ears Dissociation feels uncomfortable

WORKING WITH TRAUMA SOMATISING gives negative meaning via the body. Panic attacks are probably about being out of control. Teach breath control, and when to use it Focus their attention - ask questions about the colour of the chair etc, five things they can see in the room, hear in the room etc This is to GROUND them and to provide DISTRACTION

WORKING WITH TRAUMA Somatising (cont.) With verbal assignments, the client may struggle because trauma turns off BROCCA'S area in the brain - so they need to DO something This turning off of Brocca's area leads to the observed "Speechless Terror" Loss of narrative or the ability to expand on narrative occurs l.e. it is disconnected If you can DISTRACT them for 5-10 minutes, the anxiety disappears. AMYGDALA function ceases.

WORKING WITH TRAUMA People's thoughts SWITCH OFF in trauma. They are flooded with bodily responses. Adrenalin is released. Body numbing occurs (either though blood redirection, dissociation or natural opoids) These responses make it bearable when you can't run away The trouble being -they hang around once the trauma has gone

When processing with a client, ask: WORKING WITH TRAUMA When processing with a client, ask: What do you remember? What is your body feeling? What affect are you feeling? There is a PATHOLOGICAL response to trauma: The person is overwhelmed Sleep difficulties Panic/Exhaustion Extreme avoidance

WORKING WITH TRAUMA INTRUSION AVOIDANCE Flashbacks Numbing Sleep disturbance Hyper vigilance Irritability Affect Deregulation AVOIDANCE Numbing Avoidance of triggers Social withdrawal Depression Anxiety

WHAT TRAUMATISED PEOPLE NEED

NEEDS Most of all people need to feel relatively safe They need to know that you will respect their boundaries They need to know they can leave if they want to They will not be touched if they do not want to be They need to feel accepted and not judged

NEEDS People usually need to talk and be listened to Often people need to have their feelings paid attention to Sometimes people need to be left alone Your presence is the most important gift you can give Detachment

NEEDS WHAT YOU CAN DO TO HELP: Begin simply Establish safety through chosen technique Let the survivor lead Ask questions Always ask with permission As long as the survivor is not overwhelmed and is willing, create space for her to move into discussing more emotionally difficult material Let people tell their story

NEEDS What you can do to help (cont.) Allow the experience & expression of feeling Ask the survivor what she feels Reflect what you see and hear Do not push for catharsis Focussing on body sensations helps the nervous system to unwind from trauma If the person seems overwhelmed, lead away from emotionally painful material

NEEDS What you can do to help (cont.) Enhancing the feeling of safety is a way to monitor overwhelming thoughts and feelings and allow integration of difficult material Help people recognize and develop their resources Avoid pushing for recovery too soon Take care of yourself to avoid vicarious traumatisation.

NEEDS Establishing safety can be achieved through the use of Oases: activities which subsume the client’s attention, thus reducing hyperarousal and negative self talk Anchors: which relate to a familiar and protective memory of a person, place or thing. The Safe Place: is a form of anchor relating to an actual site known to client

NEEDS The Fantasy Safe Place creates unlimited potential in terms of client control and determination in that it can be influenced and directed by the client The placement of the traumatic experience in the past, by breaking this nexus between recall of trauma and somatic response, is a theme which binds all counselling interventions.

EFFECTS OF CHILDHOOD SEXUAL ABUSE ON MENTAL HEALTH

EFFECTS OF CSA General interpersonal sensitivity Elevated levels of sensitivity to rejection Difficulties with trust and intimacy Higher levels of loneliness and social isolation Difficulty with parenting Disruptions to sexuality Distortions to perceptions of bodily functions

EFFECTS OF CSA Higher levels of (destructive) promiscuity Significantly higher levels of re-victimisation – roughly one half of previously abused women are further abused (physically, sexually, emotionally) during adulthood.

*When compared to non-abused samples EFFECTS OF CSA Women who were sexually abused as children report*: Higher levels of depression and anxiety Higher rates of eating disorders Higher rates of substance abuse Self-mutilation Suicidal ideation and suicidality Dissociation Pain and somatic reactions Higher rates of low self-esteem/ self-confidence *When compared to non-abused samples

Elaine Westerlund, Women’s Sexuality after childhood incest, 1992. EFFECTS OF CSA Incest survivors’ perceptions of their bodies: 74% expressed negative or distorted body perceptions (eg. Saw their body as dirty, nasty, evil, bad) of particular note, the body was seen as having caused the abuse 63% saw femaleness as equated with rape and abuse 56% viewed reproduction as an unwelcome event Elaine Westerlund, Women’s Sexuality after childhood incest, 1992.

Elaine Westerlund, Women’s Sexuality after childhood incest, 1992. EFFECTS OF CSA Incest survivors’ perceptions (cont.) 42% expressed feelings of detachment from their body 30% expressed body hatred, which led to self punishment in the form of anorexia or neglect (of exercise, hygiene, nutrition) 28% felt that they were not in control of their body 19% actively and consciously disowned their body, perceiving it as having betrayed them. Elaine Westerlund, Women’s Sexuality after childhood incest, 1992.

DEFENCES: DISSOCIATION

DEFENCES: DISSOCIATION Helps maintain borderline symptoms (memories re-enacted rather than recalled) Self inducement of altered states of consciousness – numbness, deadness, detachment Use predicts self harm as affect regulating strategy Keeps memories and affect associated with trauma out of consciousness at a price

DEFENCES: DISSOCIATION Inhibition of affect  high levels of anxiety Clouding of conscious experience Adaptive value: minimises child’s awareness of constant threat & allows continued dependence on caregivers

DISRUPTIONS TO SENSE OF SELF

DISRUPTIONS TO SENSE OF SELF “I wasn’t feeling myself today” For many people this feeling/state of being occurs and then passes without causing major disruption to everyday life. For a short period of time they feel estranged from themselves and others. For others, particularly those who have been traumatised during childhood, this state can persist and permeate each day It involves feeling cut off from the basic feeling which is at the core of knowing oneself.

A WORD OF CAUTION Trauma is a complex area Counsellor should be well trained Re-experiencing can lead to re-traumatisation Do not allow client to engage with memories without establishing safety When trauma or PTSD is evident refer on to trained professional