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Reconsidering Trauma: Treatment Advances, Relational Issues, and Mindfulness in Integrated Trauma Therapy John Briere, Ph.D. Departments of Psychiatry.

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Presentation on theme: "Reconsidering Trauma: Treatment Advances, Relational Issues, and Mindfulness in Integrated Trauma Therapy John Briere, Ph.D. Departments of Psychiatry."— Presentation transcript:

1 Reconsidering Trauma: Treatment Advances, Relational Issues, and Mindfulness in Integrated Trauma Therapy John Briere, Ph.D. Departments of Psychiatry and Psychology, University of Southern California Psychological Trauma Program, Los Angeles County – USC Medical Center MCAVIC-USC Child and Adolescent Trauma Program, NCTSN

2 Complex trauma exposure Onset Onset Childhood trauma and neglect Childhood trauma and neglect Attachment disruption usual Attachment disruption usual Extended duration and frequency Extended duration and frequency Traumatic processes and well as traumatic events Traumatic processes and well as traumatic events Relational/interpersonal Relational/interpersonal Complexity Complexity Accumulated effects Accumulated effects Interacting effects Interacting effects

3 Complex posttraumatic outcomes – ethnocultural aspects Ethnic/cultural/gender differences in Ethnic/cultural/gender differences in Perception of trauma Perception of trauma The example of sexual trauma The example of sexual trauma Models of injury Models of injury Psychological Psychological Somatic Somatic Spiritual Spiritual Idioms of distress Idioms of distress “Culture-bound” stress disorders “Culture-bound” stress disorders Commonalities of response across groups Commonalities of response across groups

4 Complex posttraumatic outcomes – Chronic posttraumatic stress Symptomatology Symptomatology Reexperiencing Reexperiencing Avoidance Avoidance Hyperarousal Hyperarousal Avoidance and chronicity Avoidance and chronicity Cognitive, emotional, dissociative, substance abuse Cognitive, emotional, dissociative, substance abuse Risk factors Risk factors Trauma, reduced social support and marginalization, reduced affect regulation capacities, nervous system compromise Trauma, reduced social support and marginalization, reduced affect regulation capacities, nervous system compromise

5 Complex posttraumatic outcomes – Self-capacities Identity Identity Other-directness Other-directness Reduce self-access/awareness Reduce self-access/awareness Boundary disturbance Boundary disturbance Susceptibility to influence Susceptibility to influence Relationality Relationality Implicit attachment-related schemata Implicit attachment-related schemata Models of relationship Models of relationship Relational schema Relational schema Conditioning to emotional-cognitive memories Conditioning to emotional-cognitive memories Source attribution errors Source attribution errors “Out of proportion" emotions/thoughts “Out of proportion" emotions/thoughts

6 Complex posttraumatic outcomes – Self-capacities Affect regulation Affect regulation Underdevelopment in the context of maltreatment Underdevelopment in the context of maltreatment Modulation versus tolerance Modulation versus tolerance The imbalance between level of triggerable distress and affect regulation capacity The imbalance between level of triggerable distress and affect regulation capacity The avoidance triad: Substance abuse, dissociation, and tension-reduction The avoidance triad: Substance abuse, dissociation, and tension-reduction “Cluster B” personality disorders “Cluster B” personality disorders Psychosis Psychosis As a feature of posttraumatic stress As a feature of posttraumatic stress As a feature of disturbed self-capacities As a feature of disturbed self-capacities

7 A philosophy of trauma Integrating Eastern models of suffering, attachment, and mindfulness Integrating Eastern models of suffering, attachment, and mindfulness Ubiquity of trauma versus the myth of normality Ubiquity of trauma versus the myth of normality Pain versus suffering Pain versus suffering Trauma seen as bad, pain seen as wrong/pathological, to be avoided Trauma seen as bad, pain seen as wrong/pathological, to be avoided Focused awareness of painful material and paradoxical relief Focused awareness of painful material and paradoxical relief Avoidance can intensify distress, intrusion Avoidance can intensify distress, intrusion Mindfulness as the opposite of avoidance Mindfulness as the opposite of avoidance Attachment: expectation, need, and preoccupation Attachment: expectation, need, and preoccupation Reality as subjectivity Reality as subjectivity Perception versus activated implicit memory Perception versus activated implicit memory Source attribution errors and the complexity of personal experience Source attribution errors and the complexity of personal experience

8 A philosophy of trauma The problem with solely symptom-based models The problem with solely symptom-based models Treatment goals narrow to definable fixing of distress Treatment goals narrow to definable fixing of distress Diminished relevance to a lived life and the opportunity for larger changes Diminished relevance to a lived life and the opportunity for larger changes Reinforces avoidance rather than engaging roots of suffering Reinforces avoidance rather than engaging roots of suffering Natural systems of trauma recovery - Intrinsic processing Natural systems of trauma recovery - Intrinsic processing Self-exposure Self-exposure Recurring thoughts, memories, nightmares, flashbacks, “reenactments” Recurring thoughts, memories, nightmares, flashbacks, “reenactments” Drive to process: verbalization, expression, attraction to trauma reminders, therapy seeking Drive to process: verbalization, expression, attraction to trauma reminders, therapy seeking Posttraumatic growth, acceptance, and integration Posttraumatic growth, acceptance, and integration

9 Assessing trauma and impacts in the clinical interview Process responses and intra-interview signs Process responses and intra-interview signs Activation responses Activation responses Easily triggered cognitive-emotional states Easily triggered cognitive-emotional states Avoidance responses Avoidance responses Dissociative disengagement, lapses, inconsistency, constriction Dissociative disengagement, lapses, inconsistency, constriction Denial, content switching Denial, content switching Affect dysregulation Affect dysregulation Mood swings Mood swings “Falling into the hole” “Falling into the hole” Reports of TRBs Reports of TRBs Relational disturbance Relational disturbance Alertness to interpersonal danger Alertness to interpersonal danger Abandonment issues Abandonment issues Need for protection via control Need for protection via control

10 The Self-Trauma Model – A components approach

11 Distress reduction and affect regulation training Dealing with acute intrusions – grounding Dealing with acute intrusions – grounding Somatosensory feedback (e.g., body in chair) Somatosensory feedback (e.g., body in chair) Details of room Details of room Reminders of past versus present Reminders of past versus present Breath training Breath training Breath and tension/stress Breath and tension/stress Effects of slower, deeper, diaphragmatic breath Effects of slower, deeper, diaphragmatic breath

12 Mindfulness and affect regulation Nonjudgmental self-observation Nonjudgmental self-observation Acceptance of (good, bad, or neutral) thoughts, feelings, and memories versus fighting thoughts/feelings Acceptance of (good, bad, or neutral) thoughts, feelings, and memories versus fighting thoughts/feelings Disturbing thoughts and feeling allowed to come and go (“watching the parade”) Disturbing thoughts and feeling allowed to come and go (“watching the parade”) De-investment in emotional experience: “I don’t trust my inner feelings, inner feelings come and go” (Leonard Cohen) De-investment in emotional experience: “I don’t trust my inner feelings, inner feelings come and go” (Leonard Cohen) Self as relative/contextual/”insubstantial”, Self as relative/contextual/”insubstantial”, “No self” – self concept in flux, result of interrelated conditions, not inherently concrete (self as process) “No self” – self concept in flux, result of interrelated conditions, not inherently concrete (self as process) Less identification with desires, supposed traits, social expectations, therefore less disappointment, betrayal, disillusionment, abandonment concerns Less identification with desires, supposed traits, social expectations, therefore less disappointment, betrayal, disillusionment, abandonment concerns

13 Distress reduction and affect regulation training Trauma-relevant meditation Trauma-relevant meditation Posture, breathing, attention Posture, breathing, attention Exposure via reduced avoidance, greater relaxation Exposure via reduced avoidance, greater relaxation Affect regulation and equanimity (nonreactivity to internal states) Affect regulation and equanimity (nonreactivity to internal states) Stress/arousal reduction Stress/arousal reduction Potential constraints Potential constraints Initial increased activation Initial increased activation Perceived reduced control Perceived reduced control Effects of memory intrusion Effects of memory intrusion Monitoring issues Monitoring issues Therapist must be familiar with meditation procedures Therapist must be familiar with meditation procedures

14 Empirically-based mindfulness-related therapies Dialectical behavior therapy (DBT; Linehan) Dialectical behavior therapy (DBT; Linehan) Mindfulness-based stress reduction (MBSR; Kabat-Zinn) Mindfulness-based stress reduction (MBSR; Kabat-Zinn) Mindfulness-based cognitive therapy (MBCT; Segal, et al) Mindfulness-based cognitive therapy (MBCT; Segal, et al) Acceptance and commitment therapy (ACT; Hayes) Acceptance and commitment therapy (ACT; Hayes)

15 Distress reduction and affect regulation training Trigger identification, recontextualization Trigger identification, recontextualization Understanding and insight alter similarities of stimuli to initial trauma memory Understanding and insight alter similarities of stimuli to initial trauma memory Trigger grid: Trigger grid: How do I know I’m being triggered? How do I know I’m being triggered? What are the triggers, when do they occur? (review of history) What are the triggers, when do they occur? (review of history) What do I think/do after triggers? What do I think/do after triggers? How might I avoid/counter them? How might I avoid/counter them? Creation of self-talk options Creation of self-talk options Analysis of differences between initial event and triggering event Analysis of differences between initial event and triggering event Repetitive exposure and processing of traumatic material as affect regulation training Repetitive exposure and processing of traumatic material as affect regulation training

16 Cognitive interventions Normalizing and reframing of experiences and “symptoms” Normalizing and reframing of experiences and “symptoms” Cognitive reconsideration: An empowering alternative to cognitive restructuring Cognitive reconsideration: An empowering alternative to cognitive restructuring Using exposure processes to prompt reevaluation of cognitions Using exposure processes to prompt reevaluation of cognitions Mindfulness: Practicing nonjudgment and acceptance Mindfulness: Practicing nonjudgment and acceptance Intrusive negative cognitions as “just thoughts,” not representations of reality Intrusive negative cognitions as “just thoughts,” not representations of reality Reduced self-blame through experience of conditionality Reduced self-blame through experience of conditionality Reduced identification with self-criticism (participant-observer) Reduced identification with self-criticism (participant-observer) Insight and the development of a coherent, nonpathologizing narrative Insight and the development of a coherent, nonpathologizing narrative

17 Emotional processing The components of trauma processing The components of trauma processing Exposure Exposure Activation Activation Disparity Disparity Nonreinforcement of CERs and trauma-related assumptions/beliefs (safety) Nonreinforcement of CERs and trauma-related assumptions/beliefs (safety) Counterconditioning Counterconditioning Extinction/resolution Extinction/resolution

18 Emotional processing Titrated exposure and the therapeutic window Titrated exposure and the therapeutic window Limiting factors Limiting factors CER intensity CER intensity Affect regulation skills Affect regulation skills Balance between therapeutic challenge and overwhelming internal experience Balance between therapeutic challenge and overwhelming internal experience Overshooting vs. undershooting the window Overshooting vs. undershooting the window

19 Emotional processing at the session level Repetitive exposure to trauma memories via questions/facilitation of disclosure Repetitive exposure to trauma memories via questions/facilitation of disclosure Activation control Activation control Greater vs. lesser detail Greater vs. lesser detail Time/tense focus: here-and-now vs. there-and-then Time/tense focus: here-and-now vs. there-and-then Emotional vs. cognitive Emotional vs. cognitive Extent of intervention in avoidance Extent of intervention in avoidance Safety, support, validation, encouragement Safety, support, validation, encouragement Emotional discharge/expression Emotional discharge/expression Debriefing/contextualization Debriefing/contextualization

20 Emotional processing Mindfulness as exposure Mindfulness as exposure Reduced cognitive-emotional avoidance Reduced cognitive-emotional avoidance Processing with awareness Processing with awareness Openness to distress, yet Openness to distress, yet The changed relationship to distress = decreased suffering The changed relationship to distress = decreased suffering Increased access to memory Increased access to memory greater exposure greater exposure Titrated levels of distress (through detachment), and Titrated levels of distress (through detachment), and Greater awareness of disparity Greater awareness of disparity

21 Emotional processing Processing “hot spots” with focused CBT or EMDR Processing “hot spots” with focused CBT or EMDR Only when tolerable, always within window Only when tolerable, always within window Greater specificity and intensity of exposure Greater specificity and intensity of exposure Pre-briefing Pre-briefing Two approaches Two approaches Prolonged exposure Prolonged exposure EMDR EMDR Debriefing Debriefing

22 Increasing identity functions Self-exploration, inner directedness, and identity training Self-exploration, inner directedness, and identity training Development of self-knowledge and self-directedness Development of self-knowledge and self-directedness Value of nonleading, open-ended questions Value of nonleading, open-ended questions Avoiding the over-use of interpretations Avoiding the over-use of interpretations Effects of increased mindfulness Effects of increased mindfulness Less attachment to sense of self as enduring and concrete Less attachment to sense of self as enduring and concrete Yet, increased awareness means greater self-awareness Yet, increased awareness means greater self-awareness Greater self-appreciation Greater self-appreciation Acceptance and compassion Acceptance and compassion

23 Increasing relational functioning Cognitive-emotional processing of relational schema Cognitive-emotional processing of relational schema Exposure to relational stimuli, activation of schema, disparity in therapeutic environment, counterconditioning via therapeutic emotional bond, extinction/restructuring Exposure to relational stimuli, activation of schema, disparity in therapeutic environment, counterconditioning via therapeutic emotional bond, extinction/restructuring

24 Psychiatric medications Presenter caveats Presenter caveats Can trauma psychopharmacology “fit” with growth models of trauma recovery? Can trauma psychopharmacology “fit” with growth models of trauma recovery? Traditional Traditional Symptoms as psychopathology, medication as correction Symptoms as psychopathology, medication as correction STM: Nonresolvable/chronic symptoms as overwhelming “trauma load,” preventing processing STM: Nonresolvable/chronic symptoms as overwhelming “trauma load,” preventing processing Medication as support for more effective processing by reducing Medication as support for more effective processing by reducing Anxiety Anxiety Comorbidity Comorbidity Rarely sufficient by themselves Rarely sufficient by themselves

25 Psychiatric medications Limiting issues Limiting issues Psychological treatments often yield larger effect sizes in treatment outcome studies Psychological treatments often yield larger effect sizes in treatment outcome studies Noncompliance as result of side-effects Noncompliance as result of side-effects Potential effects of reducing anxiety during exposure and processing Potential effects of reducing anxiety during exposure and processing Specific concerns about benzodiazepines Specific concerns about benzodiazepines Addiction/dependency concerns for trauma survivors Addiction/dependency concerns for trauma survivors Use of antipsychotic medications Use of antipsychotic medications Potential relapse effects upon discontinuation Potential relapse effects upon discontinuation

26 Psychiatric medications Potential benefits Potential benefits Recommendations from the International Society for Traumatic Stress Studies Recommendations from the International Society for Traumatic Stress Studies First line – SSRIs (only FDA indication for PTSD) First line – SSRIs (only FDA indication for PTSD) Second line – TCAs, MAOIs Second line – TCAs, MAOIs Questionable – mood stabilizers Questionable – mood stabilizers Benzodiazepines – for management of acute anxiety Benzodiazepines – for management of acute anxiety Antipsychotics – for clear psychosis Antipsychotics – for clear psychosis Speculation from research Speculation from research Alpha and Beta blockade for hyperarousal symptoms Alpha and Beta blockade for hyperarousal symptoms

27 Therapist issues in trauma treatment Countertransference/counteractivation Countertransference/counteractivation Personal history Personal history Cultural assumptions/socialization Cultural assumptions/socialization Mindfulness and activation awareness Mindfulness and activation awareness Psychotherapy Psychotherapy Internally directed practice Internally directed practice Social support Social support Consultation Consultation Community of clinicians Community of clinicians


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