1. overcoming cumulative childhood adversity: treatment approaches Friday afternoon October 6, 2006 Northamerican Assn. of Masters in Psychology Bruce Carruth, Ph.D., LCSW San Miguel de Allende, GTO, Mexico

2. Outline for this afternoon The content of therapy with adversity cognition, affect and self The process of treatment 3 phases and 6 stages

3. the content of therapy with adversity Cognition (I think) AFFECT (I feel) Self (I am)

4. cognition 3 components contact between individual and environment making meaning of data the “cognitive self”

5. Contact Receiving data from the environment withdrawn people miss data in their environment reactive people misinterpret data in their environment in the context of their history, individuals with cumulative trauma have a tendency to misinterpret data from the environment using these observations in therapy

6. Deleting / distorting sensory perceptions internal external Seeing Hearing Feeling Smelling Tasting

7. Some implications for therapy Not listening to what is said Being hypersensitive the specific sensory stimuli (touch, sounds, visual cues) Hypersensitivity / deadening specific feelings

8. Making meaning of data “What does this mean?” data from our environment gets processed in light of our history Because of developmental lags, there may not be sufficient data to process information When unconscious material related to a trauma experience drives the processing When we talk later about “telling the tale”, part of the agenda is to move unconscious, unremembered material to conscious awareness

9. The cognitive orientation of self The “child self” orientation conscious memories of childhood, roles, meanings and how those memories, roles play out today as adults (for better and worse) milestones (singular, defining memories related to “child self”) and efforts today to re-live or conquer those experiences the impact of the “child self” experience in adult relationships and in parenting

10. “self parts” …Child self, family self, interpersonal self, physical self, moral self, spiritual self, sexual self, creative self, doing self, expressive self Some parts of self may contain the trauma experience while other self parts may be quite functional Life problems tend to orient around the wounded parts of self Using the healthy parts of self to help heal the wounded parts

11. Relational parts of self “what did you learn about how to be in relationships” can’t trust, have to give up self, have to be in control, ability to trust self in relation to others, have integrity, have to be right, have to be center of attention, idealizing others The relational wounds will play out in the therapy environment & this becomes the field for a corrective emotional experience Cultural influences in relational patterns

12. Core beliefs / truths / schemas About self (value, efficacy, potency, resilience) About others (individuals and groups) About family About the environment – (others, the world) Tapping core beliefs in therapy Watching core beliefs play out in therapy Using the therapy experience to challenge core beliefs

13. Beliefs and decisions Decisions follow core beliefs: People are _______ and therefore I will _______” It is as important to build new decisions as it is to challenge core beliefs

14. Learned strategy and process The frameworks we have developed to operate in the world Decisioning Managing relationships – interactions with others Managing life – crises, stimulation, recreation, relaxation, parenting, close/casual friendships Patterns for remembering Managing work – getting the job done (taking care of little things, finishing jobs, cooperating / competing with others)

15. affect Two levels of affective experience 1. primary affects terror – safe grief – joy rage – fullfilled / potent shame – integrity 2. Affective (emotional) themes

16. Primary affects Terror safe - about vulnerability Anger fullfillment / potency – about having what I need – being able to have what I need Grief joy – about having love, connectedness, belonging, happiness Shame integrity – about integrity, self- worth, pride

17. Look for the primary affect that hasn’t been “mastered” Anger – struggles around power and control, getting “may way”, getting what I need Shame – struggles around self-esteem, over-valuing or under-valuing self, sensitivity to criticism. “I’m going to be found out” Anxiety – struggles with being safe, not being vulnerable, having enough (money, health, security) “something terrible is going to happen” Sadness – struggles with giving / receiving love, being & staying connected with others, belonging

18. The affect that couldn’t be mastered in childhood Is often covered by other emotions Sue Johnson’s “reactive emotion” In therapy, it becomes important to look for the emotion that is disavowed and not get “locked into” the presenting emotion In relationships we “hire” a partner to express the emotion we disavow & then blame them for expressing it Getting “stuck” in an emotion (repetitive anger, chronic sad, persistent fear)

19. The fears of having the disavowed emotion Terror Grief Rage Shame

20. Therapy becomes the place to be able to experience the disavowed emotion(s) Awareness of when I am having the emotion(s) Learning to express the emotion(s) Being comfortable with others having the disavowed emotion in my presence Learning to look for the emotion (and needs) under the emotion

21. Feeling themes The emotional themes that reflect the wounded parts of self rejected, lonely, hurt, guilty, incompetent, unsure, alone, inept, confused, empty, overwhelmed The emotional themes tend to be self-fulfilling and we tend to orient our lives around validating them. How emotional themes play out in the therapy environment

22. Selfhood dynamics Characterological patterns feeling repressed boundary confused helpless and dependent loveless and invisible stubborn and obstinate needy and impulsive inadequate phobically anxious suspicious and mistrusting alone and isolated conning and manipulative angry and intolerant

23. Treating character patterns Character patterns are relatively immune to cognitive approaches to change Cognitive approaches can become part of the defense (intellectualization) People don’t “give up” character patterns, they evolve patterns to higher functioning levels The primary treatment approach is the therapeutic relationship – the corrective emotional experience Other change processes: support groups, spiritual programs, healthy relationships Supporting positive character patterns: centeredness, perseverance, empathy, curiosity, self-soothing, self- validation,

24. Vulnerability of character pattern pathology Our subsequent wounds (trauma) tend to appear where we are vulnerable: our limiting cognitions disavowed affects limiting character patterns Therapy should seek to strengthen the wounded parts and support the more functional parts

25. 3 phases and 6 stages of trauma treatment 1. building safety (creating a holding environment) and 2. managing the presenting symptoms 3. exposing the wounded self & telling the tale and 4. grieving 5. emotional healing and 6. integrating history with present

26. phase 1 building safety and managing symptoms primary treatment methods are: building / supporting the safe environment environmental manipulation – stabilizing the environment cognitive – behavioral strategies problem solving psychoeducation stress management skill building interpersonal potency normalizing emotions challenging negative / unproductive cognitions working with self-help programs challenging ego defenses that protect the wounded self and related affects building support in beginning to tell the tale and get the story straight

27. Creating Safety I can’t make someone feel safe with themselves: Safety has to come from within Therapy itself is an inherently unsafe environment for trauma survivors Traumatized people will test to see if the therapy is safe. I can provide an environment that doesn’t reinforce “unsafety”

28. A strategy for working with ego defense Retroflecting (holding inside) counter strategy is expressing Deflecting (not letting outside in) counter strategy is absorbing – taking in Projecting (assigning inside to environment) counter strategy is owning Introjecting (internalizing the environment) counter strategy is questioning – challenging Confluence (merging, joining) counter strategy is individualizing

29. phase 2: telling the tale and grieving the goals of “tale-telling” are: to begin to see connections between now and history to begin to get a more coherent and accurate understanding of what happened and why to begin to correct the cognitive distortions that occurred when life is viewed through the eyes of the child to begin to challenge the meta-beliefs & self-truths that arose from the experience of the child to connect “self-experience” with emotions that have been disavowed, distorted, displaced

30. Phase 2 telling the tale and grieving Our tales are told in metaphor. Our metaphor may or may not have much resemblance to the reality of others. The therapist is the witness to the unfolding of the tale. The therapist’s job is to provide a container for the tale as it evolves and to facilitate the person telling the story in the most healing way possible. Getting the story straight is like constructing a jigsaw puzzle. Seemingly unconnected pieces get put together to form a coherent image and the missing parts become more obvious. The missing parts often contain the core of the developmental trauma experience.

31. Telling the tale (con’t) Words may not be a very good vehicle for communicating the trauma experience. Visual symbols, movies, music, drawings and physical movement may more accurately and effectively communicate the experience. A variety of unfolding techniques can be applied to help reveal the tale including hypnosis, psychodramatic technique, group support and psychomotor therapies. But unfolding techniques are a means to the end, not the end in itself! One story or event in the tale can be a metaphor for a series of events. It isn’t necessary or practical to tell the whole tale, particularly with early, prolonged and pervasive deprivation.

32. special issue of “dropping out” As people begin to “tell their tale” and emotionally connect with their woundedness there is an incentive to drop out of treatment. Got some relief from the symptoms Ego defenses “kick in” Fear the unexplored Therapy has to build a safe “holding environment” to allow people to progress

33. grieving as people tell their tale and connect with their self- experience, affect naturally begins to arise. Grieving is the essential element for “letting go” of self-limiting cognitions and self-experience of the past Grief is both an affect and an experience (the emotion has to connect to the experience) The most important material to grieve will be hidden behind the disavowed affect

34. The goal of grief work is not to “get rid” of painful feelings, but to accept the pain as a meaningful part of life, to honor the pain rather than repressing or disavowing it. The pain connects us to something that we lost that was very important to us.

35. Grief reactions Grief is the emotional expression of loss “Grief reaction” is the blocking or distorting of the normal emotional expression of loss 3 kinds of losses tangible losses intangible losses losses of what could have been – a future

36. Grief reactions from the “outside” Emotional constriction or inappropriateness Apparent feelings on the surface that are denied or displaced (denying sad or anger) Avoidance behaviors, lonely in a crowd Judgmentalness, perfectionism, blaming Difficulty experiencing self, including positive and negative feedback Obsessive though and compulsive ritual Loss of spontaneity

38. The process of grief work Diagnosis and differential diagnosis cd relapse, depression, PTSD, personality disorder Education about grief and grief reactions Exploration about client’s experience with their grief Creating safety with feelings Catharsis – telling the story as well as expressing affect Getting closure on events that precipitated the grief – saying goodbye, letting go, finishing unfinished business, forgiving self and others Reintegration of past self with present self

39. Emotional healing: the corrective emotional experience As a result of telling the tale and allowing the grief, the wounded self is exposed and the therapeutic “holding environment” becomes the place where people can experience the self and have a corrective emotional experience …..through the transference in the therapy …..through finding new options to meeting the environment …..through seeing self in a different manner

40. transference Managing the transference means being the “good enough parent” What are the attributes of a “good enough parent”?

41. Recognizing the meaning of the “holding environment” Safe Predictable, reliable Non-judgmental Well bounded “my place” Many children from adversive environments have not had a quality holding environment (or they had to adapt their own)

42. Finding new options “What should I do”? “how should I handle this”? “what can I do differently now than in the past”? “how would (my therapist) handle this”? After the action, incorporating new options

43. Seeing the results Getting feedback Seeing my own results Beginning to trust new actions Appreciating that we all do the best job we can do at the time And that with self monitoring and the ability to receive feedback from others we can continue to do a better job

44. For more information: Telephone based case consultation Telephone based clinical supervision Telephone based psychotherapy Small group, process based workshops in Mexico Contact me at: Bruce Carruth, Ph.D., LCSW bruce@brucecarruth.com 713-589-3250