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1Dr. Kathy Seifert http://preventbullyingnow.info firstname.lastname@example.org Developmental and Systems Approaches to the Treatment of Trauma June 1, 2011Dr. Kathy Seifert
2The Effects of Trauma on the Individual Depend on: The nature of the traumaThe severity and chronicity of the trauma
3TraumaFight/Flight /FreezeNumb – unable to actFrontal Cortex Not in UseNew Stressor - High Arousal - ExcitabilityHyper- Vigilant – Poor executive functionIn the days of dinosaurs this reaction to stress was a survival strategy and led to safety.In the days of dinosaurs this reaction to stress was a survival strategyThe Inability to Escape Trauma Leaves one Trapped in Fight or Flight or Freeze Mode
4Trauma Staying stuckTaking ActionFeeling CompetentFeeling IncompetentTaking Effective Action (learning to cope)Takes a Trauma Survivor from “Frozen - Deer in the Head Lights” to Feeling Competent and “Moving On.” This can be done in several ways.
5Frozen Mode of Complex Trauma Leaves a person in constant fearFreezes Normal developmental sequences and does not allow them to progress.Does not allow person to defend herselfReinforces the inevitability of revictimization
6Complex Trauma is different than traditional ideas of PTSD: Child abuse, neglect, domestic violence and attachment trauma happens in the context of family and other intimate relationships .The victim is psychologically and physically immature and dependant on others.His or her development is often seriously compromised by repetitive abuse and inadequate response at the hands of family members or others on whom he or she relies for safety and protection.
7The Effects of Trauma on the Individual Depend on: The individual’s strengths and vulnerabilities within himself, his history and his environment.
8Individual Vulnerabilities Strengths Rigid or irritable temperament Unresolved trauma that negatively affected developmentDevelopmental DelaysMental illnessVulnerable geneticsStrengthsEasy going temperamentGood problem solving skillsGood self- management skillsGood interpersonal skillsStrong genetics
9History No history of trauma Caregivers stress respect for all people and communicationNo history of assaulting othersNo history of bullying or being bulliedSchool successHistory of traumaChaotic household with domestic violenceHistory of assaulting othersIs a bully or is being bullied.Not successful in schoolStrengthsVulnerabilities
10Environment Strengths Vulnerabilities Family and Community does not support crime and drug useSufficient school supports for youth to be successfulFamily is supportive and nurturing with good boundaries and appropriate and effective disciplinary practicesFamily or Community supports crime and drug useInsufficient support for youth to be successful in school.Family is unsupportive and hostile with poor boundaries and inappropriate and effective disciplinary practicesStrengthsVulnerabilities
11The Developmental Level of the Individual When the Trauma Occurs The Effects of Trauma on the Individual Depend on:The Developmental Level of the Individual When the Trauma Occurs
12Brain changes caused by trauma Brain still developing throughout childhood.Make a fist with thumb sticking down – Thumb is brain stem, inside of fist is limbic system (emotions), fingers are cerebral cortex or thinking part of brain.Over proliferation of synapses is followed by use it or loose it trimming.Amygdala – emotional regulation – may be smaller and less effectiveBrain development may be delayedCortisol may be in over abundance causing a constant state of arousal
13The Developmental Level of the Individual When the Trauma Occurs Babies, children and adolescents are more vulnerable to the long term effects of trauma when it interferes with the developmental process.The availability of a support system that can help an individual build strengths to manage the trauma and its effects will, in part, determine the severity and length of time effects will last.Permanency of the changes in the brain and neurochemical systems due to the trauma and support systems is more likely in infancy and childhood.
14Attachment problems are often Part of the trauma picture Attachment problems are often Part of the trauma picture. What is attachment?
15AttachmentAttachment is the heart to heart, 2 way, emotional connection between the primary caregiver and a child. It is a survival mechanism for the child.It makes the caregiver want to be close (babies’ smell, round heads and big eyes, maternal instinct)The caregiver then, meets the child’s needs.It prompts the child to call for help from the caregiver.It forms the basis of all future relationships for the child.It supports healthy brain and skill developmentIt forms the core of self concept and how others are perceived.
16Child Development & Attachment Caregivers build warm, loving, protective relationships with their babies. When a baby is well cared for, she learns to trust her mother and then others and then the outside world. From this she will learn what she needs to know to develop in a healthy manner.
17When attachment bonds are disrupted, there can be problems with Skill developmentInterpersonal relatednessSelf conceptSelf managementTheory of mindEmotional regulationDevelopment of pro-social valuesBrain developmentFamily cohesiveness and relationships
183/4 Attachment stylesSecure - Mom is safe base; forms new relationships somewhat cautiously, but can form deep relationships with others after building trust.Inhibited (ICD 10)a. Anxious - I am afraid of (not sure I can trust) mom and other relationships.b. Ambivalent - I think I want a relationship with mom, but then I don’t; I do and I don’t; sometimes I do and sometimes I don’t; Borderline Personality Disorder. I hate you; don’t leave me.
194. Disinhibited (ICD 10) - Disorganized /Dismissive - I am angry with mom; I must defend myself against everyone; No one is safe. Don’t mess with me; I will hurt you.
20Secure Attachment arousal satisfaction Baby has needs Baby cries to get Mom’s attentionMom attends to his needsHe feels safe, relaxed, & happyHe is good, his mom is good, the world is good.arousalsatisfaction
21Disrupted attachment patterns - relationships Not able to form trusting, reciprocal relationships after age 10 or 11Severe relationship problems with parents and othersHas not developed empathy or compassion after age 10 or 11Does not have effective coping skills and improved behavioral regulation after age 10 or 11.Is not academically or behaviorally successful in school
23Trauma Negatively Affects Moral Development, Kohlberg, 1969 Stage I – Ages Immediate GratificationCan be blocked by TraumaStage II – Ages Reciprocity begins to developCan be blocked by TraumaStage III – Ages 8 – 11. Empathy Develops. More organized , less impulsive.Can be blocked by TraumaStage IV (12-18) Learning the importance ofgroup membership and the “Golden Rule”
24Criteria for Complex PTSD (What else could these symptoms represent?) Difficulty regulation affect, impulses, and emotions (risky behaviors)Alterations in attention and consciousness (dissociation, amnesia, depersonalization)Alterations in self perception (chronic guilt & intense shame)Alterations in perception of the perpetrator (incorporating his or her belief systems)Alterations in relationships to others (not able to feel intimate)Somatization and/or medical problemsAlteration in systems of meaning (despair of ever recovering or being understood)CPTSD is another way to Understand the Symptoms of Several Other Disorders
25Attachment disorders/CPTSD/Developmental Trauma Disorder may be the Youthful presentation of Adult Personality Disorders.87% of those with adult Borderline personality disorder have experienced childhood sexual abuse and 25-71% have been physically abused.
26The Effects of Trauma also depend on The perception and interpretation of the trauma by the individual and those around her.Sexual behavior between parents and children is normalAbuse in the name of discipline
27Outcomes for ineffectively treated trauma Alcohol abuse (2.5X more likely)Drug abuse (4X)Violence, criminal behavior, and personality disorders, particularly BPD and antisocial PD (4X),Depressive disorders (3.4X).
28AssessmentAssessment of all strengths and vulnerabilities of the individual and her environmentUse CARE2 or CANS as a broad based assessmentAssess the developmental level of basic life skills for all people that have experienced childhood trauma and are having difficulty forming relationships or coping with life.For children and teens, us the Behavioral Objective Sequence (BOS) by Sheldon Braaten, research press.comFor adults with personality disorders, there is no developmental tool. The BOS can be used as a guide.At the least, use corrective developmental experiences involving trust and immediate gratification may be needed.
29General Assessment Principles Consult with teachers and other service providers when assessing youth and family to get other perspectives.
30Assessment of Parents Attachment/trauma history Awareness of Emotional & Environment TriggersParenting Attitudes and CompetenciesThe child needs a loving home with nurturing, affection, routine, structure and boundaries.There are skills to learn about anger management, reframing the meaning of behaviors, teaching, rather than punishingParent Mental Health & StabilityParents must take care of their mental health to do this job effectivelyParenting knowledge and styleParents need to learn about attachment and trauma and skills to help their children
31Marital Relationship & Co-Parenting The child will do best if the caregivers take care of their relationship health, as well Adults will recover best in the context of a supportive relationship – relative or friend. Include them in the therapy when appropriate.
32Treatment Treatment which addresses all of the above Treat how the trauma affect the persons whole lifeTreat the effects of trauma on an individual’s development
33Creating a Sense of Belonging Build relationshipsRapport buildingEncourage significant others to be includedEmploy Routines and RitualsDiscourage isolation.Respect the person’s background.Focus on the positive.Offer encouragement.Positive reinforcement 4:1Take pleasure &Laugh together.
34“Tool belt” analogyThose were important skills (tools) at one time (fighting, sneaking, taking care of your own needs)tool. They probably saved your life, so you want to keep them safe in case you ever need them again. Put them in your tool belt.Have you noticed how they don’t work in every situation?Now it is time to learn new tools and when it is best to use which tools.Are you up for that? Alright! Lets go!
35Reframing Oppositional and Defiant Behavior as Survival in a Dangerous Environment.
36The 8 Treatment Components of C-PTSD/DTD/RAD I. Safety and stabilityII. Skill BuildingIII. Emotional /Mental HealthIV. Relationship BuildingV. Holistic TreatmentVI. Acceptance of selfVII. Attachment /relationship/trust workVIII. Processing Trauma
40Create a healing environment The parents / significant others (SO’s) create an environment that is safe, nurturing, without violence or aggression, and with good problem solving and anger management where children can heal and learn to cope.The label you place on a child’s /adults behavior guides what you do about it. Parents and SO’smust learn to reframe “bad behavior,” a negative trait, int o “survival behavior,” a strength that is only to be used in certain circumstances.Don’t take away their survival skills, add new ones to the tool belt, so they only need “survival skills in extreme circumstances.Balance love and limitsParents should be proactive rather than reactive.
41Reframing and coaching through an alternative response (teaching not Punishing I know that in the past fighting was a way to survive and you were good at it. You survived.I want you to learn other ways to solve your problems and only use fighting when you life is in danger.Now, why are you and Johnny fighting. What is the problem and how do we solve it?You also have to go tell Mrs. Jones what happened.Someone may need to apologize.
42The Goal is communication, teaching and connection Change the dance, change the child. Child upsets parent (distancing behavior); parent punishes child in angry tone – Go to your room (distancing behavior); child becomes more angry and defiant – throwing toys around(distancing behavior).Poopy stomping storyChild attempts to make parent angry (distancing behavior); Parent verbalizes child’s behavior and doesn’t take the bait, but makes a game or joke out of it (connection behavior); parent teaches through natural consequences in a calm tone (connection, communication, teaching behaviors); Child responds by accepting limits, feeling closer to parent and learning something.
43The Behavior Objective Sequence By Sheldon BraatanA developmentally sequenced group of skills in 6 Domains.Age is not the determiner of skill levelYouth must learn skills in appropriate developmental sequence.Find out at what level they have mastered skills (can do it 90% of the time without prompting)
44BOS Domains Adaptive Self-Management Communication Interpersonal BehaviorsTask BehaviorsPersonal Behaviors
467 Basic Principles of Treatment - Advice for Parents and Treatment Providers Stay for the long haulStay calmUnderstand where the behavior is coming fromDon’t take it personallyReframe, reframe, reframeUse love, boundaries, and humorCaregivers need respite
47Teaching about attachment to all parties Attachment concepts are not understood by the majority of people.To correct this, other professionals must be educated in a very gentle and respectful wayAs you can see from this workshop, it is complex with voluminous information.Change is not easyChanging beliefs is extremely hard to do.You must be patient and always teaching
48Focus of InterventionChildFamilyFamily RelationsCommunity Systems
49I. SafetySafety and stability are the first priority. Use CPS, if needed. (Ford &Courtois; Herman, 92; Seifert)This is true whether child or adult.
50Skill teaching Methods –BOS BOS – 1 - BraatanMeasure where the child is in each domainStart where the child is.The goal is to build on successful experiences to learn new skillsIt must be everyday by everyone working with the child.Choose one skill that is almost mastered and one that will take a little work ( 2’s & 3’s).Everyone, including the child works on those 2 skills until mastered.Give the child multiple opportunities to practice the skill and coach him through the appropriate response
51BOS -2 (Behavior Objective sequence) Braatan, Researchpress.com Every 8 skills mastered gets a certificateI give kids a binder for certificates.You will see skills mastered without working on them. Give a certificate and lots of praise.Show the child on a chart how he is mastering the skills.Never say this is an elementary school skill. Say, “These are skills that we must all learn to be successful.”This is a reinforcement program. You are building competence and confidence.
52Programs Guided imagery (Seifert) CBT – CBT is based on the Cognitive Model of Emotional Response. Cognitive-behavioral therapy is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change. (http://www.nacbt.org/whatiscbt.htm)DBT – Marsha Linehan. CBT with validation and dialectics added. (http://www.behavioraltech.com/resources/whatisdbt.cfm)Positive reinforcement outweighs consequences by 4 to 1 (Seifert)Relaxation exercises (Seifert)Guided imagery (Seifert)Deep breathing when stressed or upset (Seifert)Do the “three step.” (Seifert)
53Corrective developmental experiences if you are dealing with early childhood trauma (Seifert) Someone reading to a child or adult who is sitting near youPlaying simple games and laughingRoller skatingWalking in the parkBuilding a snowman/snowwomanSwimmingDancingDrumming
54IV. Relationship building (Ford & Courtois; Seifert; Levy & Orlans; Herman) Therapist uses self to build relationship with parents and child . (Ford & Courtois; Herman,92)Maximize relationships between child and family. ( Ford & Courtois; Levy & Orlans)Reconnect to self and others. (Herman, 92)Maintain healthy relationships (Levy & Orlans)
55V. Holistic Treatment (Seifert) Multimodal treatment with CARE2 (Seifert)Whether you're an educator, social worker, mental health professional, juvenile services professional, or a concerned parent, you have the power to provide at- risk children and teenagers with the nurturing, support, and treatment that will give them a second chance at life.You start by identifying the strengths, problems, and stressors of each "at promise" youth.You continue by creating an intervention plan to provide the care, support, and treatment that counteract risk factors and trauma and promote a youth's strengths.You move toward success by executing the intervention plan and by following up.Multi-systemic Therapy (http://mstservices.com/)Multisystemic Therapy (MST) is an intensive family-and community- based treatment program that focuses on the entire world of chronic and violent juvenile offenders — their homes and familes, schools and teachers, neighborhoods and friends. MST works with the toughest offenders. They are adolescents, male and female, between the ages of 12 and 17 who have very long arrest histories.
56VII. Attachment work (Levy & Orlans, Becker-Weideman) Experience secure attachment in safe environment over a substantial period of time (Seifert, Becker- Weideman)Reframe the view and working model of the youth, others and the world from “bad”, negative and unsafe to a more realistic view with positives and negatives, self-esteem, and hope. (levy & Orlans)
57VIII. Processing Trauma (Seifert; Courtois & Ford; Herman; Levy & Orlans) STORY TELLING – Tell a story, but let the character solve the problem and change the ending to one of competence and confidence . (Seifert)Every child can become involved in story tellingFirst let the child make up a “once upon a time” story. Remind her that stories have characters, a beginning, a middle, and an end, and a problem to solve.For smaller children, I write down or type the story. The child illustrates it and we start a book of stories.
58Processing Trauma (Story telling - 2) When ready, they can tell some real stories about their lives. (when child is very stable and has some self soothing skills and family is stable.)The therapists guides the story so that in solving the problem the hero/heroin (the child) gains skills to solve the problem and go happily on with his/her life.Children have to move to learn. They also have to experience some level of emotion to rid themselves of old traumas.When the story level is mastered, the child, parents and therapist can act out one of the stories. Let the child direct. The therapist directs behind the scenes.I kept dress up clothes in my office to help with scenes.
59Psychodrama & Role Play (Seifert; Levy & Orlans) Spend a minor amount of time in the pastYou must change the end of the story.If this happened today, what could you do and who could help you?Let’s act that out.You teach: I am stronger than I was then; I can call for help; My parents now can be trusted to help me.Let child and parents spend time relaxing and sitting quietly with each other after this.They will likely be exhausted.Only use it if you have a supervisor to help you or you have some training in psychodrama.
60Other Methods Visualization Inner child Deep breathing Relaxation exercisesSafe place
61Helping Parents be effective Reframing behaviorStaying CalmSkills – Mindful parentingA Healing EnvironmentProviding a secure baseReducing conflicts
62Longevity and relationships if there are attachment problems These children adults need relationships that last longer than 2 years. (Examples - Will you be here when I have children of my own? I am leaving for college and I wanted to say thanks.Relationships must be appropriate and loving, with good limits and attachment informed therapy.Sometimes the therapist has to be the attachment figure.
63Family Therapy Several Theoretical Bases Any will be effective Attachment therapy is family therapy, even if it is foster parentsCannot ignore this part
64Building Reciprocity - Contracting What is the Child’s Goal – What is one thing you would like to be different in your life. Let him write down 3. (not have my parents yell at me so much.)If the Parent’s could change one thing, what would it be. Have them write down 3. (Have Trevon go to bed at 9 PM without a fuss.)What is the therapist goals. (Help the family have 1 more happy time during the week.)
65Coordinate Community systems NeighborhoodSchoolsJuvenile servicesSocial servicesLaw enforcementRecreation centersPeersBusinesses
66How to Apply These Principles to: Treatment Foster Care, Departments of Social and Juvenile Services, Acute Care and Residential Treatment, Outpatient settings with multiple agency involvementEducate all agenciesCoordinate services; meet on regular basisWork as a teamSet up an list for frequent communication
67Take Home PointsComplex PTSD, Developmental Trauma Disorder, and Disrupted Attachment Patterns or RAD all have strong similarities (May be different forms of same disorder) leading to substance abuse, personality disorders ,criminal behavior, and violence in adulthood when not effectively treated.Trauma negatively affects child development in many areasThe quality of early attachment bonds forms the basis of all future relationships for the child.The balance between healthy and unhealthy biology, environment and experiences will determine the health of development.In families, all members interact with and affect each other in continuing patterns that can be understood as a dance. Change the pattern of the dance.
68Take home points - assessment Assess youth, parents, family systems, community systemsBe thorough, take a holistic viewDevelopmental assessment is essentialBackground information on all is essentialAssessing parents mental health is essential
69Take home points – 8 components of treatment I. Safety and stability (Ford &Courtois; Herman, 92; Seifert)II. Skill Building (Braatan, seifert, Linehan, Ford & Courtois, Levy & Orlans; Van der Kolk)III. Emotional Health (Levy & Orlans)IV. Relationship Building (Ford & Courtois; Seifert; Levy & Orlans; Herman)V. Holistic/ Multi-dimensional Treatment (Seifert)VI. Acceptance of self (Herman; Levy & Orlans)VII. Attachment work (Levy & Orlans)VIII. Processing Trauma (Seifert; Courtois & Ford; Herman)IX. Coordination of Agencies