1. WORKING WITH TRAUMA
Presented By
Rick Haid

2. TRAUMA DEFINITION

3. 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:

4. 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:

5. 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:

6. 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:

7. 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:

8. 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:

9. POST TRAUMATIC STRESS DISORDER

10. 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).

11. 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.

12. 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.

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

14. 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

15. 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).

16. 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

17. 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.

18. 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.

19. WORKING WITH TRAUMA

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

21. 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.

22. 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

23. 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

24. 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

25. 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.

26. 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

27. 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

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

29. WHAT TRAUMATISED PEOPLE NEED

30. 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

31. 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

32. 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

33. 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

34. 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.

35. 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

36. 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.

37. EFFECTS OF CHILDHOOD SEXUAL ABUSE ON MENTAL HEALTH

38. 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

39. 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.

40. *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

41. 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.

42. 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.

43. DEFENCES: DISSOCIATION

44. 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

45. 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

46. DISRUPTIONS TO SENSE OF SELF

47. 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.

48. 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