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Trauma Treatment


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Slideshow by Willem Lammers on the treatment of traumatic memories

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Trauma Treatment

  1. 1. Trauma: Theory and Treatment Willem Lammers, TSTA “ Certain happenings leave indelible and distressing memories, memories to which the sufferer continually returns, and by which he is tormented by day and by night” Pierre Janet, 1919
  2. 2. <ul><li>Bahnhofstrasse 17, 7304 Maienfeld, Switzerland </li></ul><ul><li>Telefon 081 / 302 77 03 Fax 081 / 302 77 04 </li></ul><ul><li> </li></ul><ul><li>© 1999 </li></ul><ul><li>These handouts are only for the personal use of the participants of this IAS training institute </li></ul><ul><li>and may not be copied or otherwise redistributed </li></ul>
  3. 3. Summary <ul><li>The field of psychotrauma is rapidly developing. Since the end of the 1980s neuro-biological research has replaced classical frames of reference and new, highly effective treatment procedures, like EMDR and the meridian-based psychotherapies are slowly taking over the leading role of cognitive-behavioural treatment. </li></ul><ul><li>In my own work I focus on the synthesis of modern trauma theory and the so called 'power therapies'. I especially enjoy the integration of these amazing new developments with my background as a TSTA in the clinical field and I would like you to share my fascination. This presentation will offer a theoretical, methodological and experiential framework from which to understand psychotrauma and its treatment. </li></ul>
  4. 4. Programme <ul><li>Psychotrauma </li></ul><ul><ul><li>Explanation of concepts </li></ul></ul><ul><ul><li>Misunderstandings </li></ul></ul><ul><ul><li>Post-traumatic Stress Disorder </li></ul></ul><ul><ul><li>Coping with traumatic events </li></ul></ul><ul><li>Trauma and the brain </li></ul><ul><li>An information processing model for treatment </li></ul><ul><li>Treatment methods </li></ul><ul><ul><li>EMDR </li></ul></ul><ul><ul><li>The Meridian-based Psychotherapies </li></ul></ul>
  5. 5. Trauma <ul><li>Traumatic events </li></ul><ul><ul><li>happen suddenly and unexpectedly </li></ul></ul><ul><ul><li>can happen once, or repeatedly over years </li></ul></ul><ul><ul><li>lie outside normal experience </li></ul></ul><ul><ul><li>Must be worked through and appropriately integrated in experience </li></ul></ul><ul><li>Human beings are exposed to traumatic events without sufficient protection </li></ul><ul><li>The simple threat or observation of such an event can lead to post-traumatic stress disorder (PTSD) </li></ul>
  6. 6. Traumatic Events <ul><li>Attack, hold-up </li></ul><ul><li>Accidents </li></ul><ul><li>Violent death of a significant other </li></ul><ul><li>Sexual abuse, child abuse </li></ul><ul><li>Torture </li></ul><ul><li>Fire </li></ul><ul><li>War </li></ul><ul><li>Natural catastrophies </li></ul>
  7. 7. Trauma <ul><li>Events can happen to one person or to many </li></ul><ul><li>There is a difference between </li></ul><ul><ul><li>Type 1: PTSD resulting from a single event </li></ul></ul><ul><ul><li>Type 2: Complex PTSD </li></ul></ul><ul><ul><ul><li>result of ongoing or repeated traumatisation </li></ul></ul></ul><ul><ul><ul><li>also called DESNOS – disorder of extreme stress not otherwise specified </li></ul></ul></ul><ul><ul><li>(Lenore Terr) </li></ul></ul><ul><li>In this presentation I will focus on Type 1 trauma </li></ul>
  8. 8. Development of Theory <ul><li>The theory has been developed in waves: </li></ul><ul><ul><li>Janet & Freud </li></ul></ul><ul><ul><li>After the First World War </li></ul></ul><ul><ul><li>After the Second World War </li></ul></ul><ul><ul><li>After the war in Vietnam </li></ul></ul><ul><li>Only since 1980 has there been lasting interest over time for trauma diagnosis and treatment </li></ul><ul><ul><li>DSM-III, DSM-IIIR, DSM-IV </li></ul></ul><ul><ul><li>Cognitive behavioral therapy </li></ul></ul><ul><ul><li>Critical Incident Stress Debriefing CISD (Mitchell) </li></ul></ul><ul><ul><li>Eye Movement Desensitization & Reprocessing EMDR (Shapiro) </li></ul></ul><ul><ul><li>Meridian-based Psychotherapies </li></ul></ul>
  9. 9. DSM-IV: PTSD <ul><li>Criteria </li></ul><ul><ul><li>A person is confronted with a traumatic event </li></ul></ul><ul><ul><li>The traumatic event is reexperienced </li></ul></ul><ul><ul><li>Stimuli, which are connected to the event, are avoided </li></ul></ul><ul><ul><li>The person is in a constant state of alarm </li></ul></ul><ul><ul><li>Symptoms last longer than a month </li></ul></ul><ul><ul><li>The disturbance leads to suffering or injury in relationships and professional life </li></ul></ul><ul><ul><li>This definition was based upon the work with male war veterans </li></ul></ul>
  10. 10. DSM-IV: Re-experiencing <ul><li>The traumatic event is re-experienced constantly in at least one of the following ways: </li></ul><ul><ul><li>Repeated and intrusive memories of the events </li></ul></ul><ul><ul><ul><li>Thoughts, images, perceptions </li></ul></ul></ul><ul><ul><li>Repeated highly charged dreams </li></ul></ul><ul><ul><li>Sudden behaviour or feelings as if the traumatic event is happening again (flashbacks) </li></ul></ul><ul><ul><li>Psychic shock on exposure stimuli connected to the trauma </li></ul></ul><ul><ul><ul><li>internal, external </li></ul></ul></ul><ul><ul><li>Physical reactions on exposure to stimuli connected to the trauma </li></ul></ul><ul><ul><ul><li>internal, external </li></ul></ul></ul>
  11. 11. DSM-IV: Avoidance <ul><li>Characterics </li></ul><ul><ul><li>Conscious avoidance of thoughts, feelings and conversations connected to the trauma </li></ul></ul><ul><ul><li>Conscious avoidance of activities, places, and people which stimulate memories of the trauma </li></ul></ul><ul><ul><li>An inability to remember an important asopect of the trauma </li></ul></ul><ul><ul><li>Loss of interest </li></ul></ul><ul><ul><li>Lack of participation </li></ul></ul><ul><ul><li>Feeling of isolation and alienationfrom others </li></ul></ul><ul><ul><li>A limited range of affect </li></ul></ul><ul><ul><li>A feel of a restricted future </li></ul></ul><ul><ul><ul><li>career, marriage, children, life span </li></ul></ul></ul>
  12. 12. DSM-IV: Hyperarousal <ul><li>Characteristics: </li></ul><ul><ul><li>Difficulty in falling or staying asleep </li></ul></ul><ul><ul><li>Irritability or outbreaks of anger </li></ul></ul><ul><ul><li>Difficulty in concentration </li></ul></ul><ul><ul><li>Hypervigilance </li></ul></ul><ul><ul><li>An exaggerated startle response </li></ul></ul><ul><ul><li>Physiological reactions on exposure to stimuli that represent the trauma </li></ul></ul>
  13. 13. Recovery <ul><li>80% of people recover after a traumatic event </li></ul><ul><li>Support, safety and useful information given after the traumatic event help in recovery </li></ul><ul><ul><li>For children: mother, father </li></ul></ul><ul><ul><li>For grown-ups: family, friends, colleagues, professionals, priest, rabbi </li></ul></ul><ul><li>For the remaining group the risk of PTSD can be minimised by debriefing, counselling and use of the new trauma therapies </li></ul><ul><li>In 2 out of 3 cases PTSD disappears spontaneously after 4 to 6 months </li></ul>
  14. 14. Normal Coping
  15. 15. Coping <ul><li>PTSD can be considered as healed, when the body no longer reacts to memories of the trauma </li></ul><ul><li>Victims are often treated too late because: </li></ul><ul><ul><li>It takes time before safety can be assured </li></ul></ul><ul><ul><li>Insight comes late </li></ul></ul><ul><ul><li>Avoidance behaviour predominates </li></ul></ul><ul><ul><li>Symptoms appear later on </li></ul></ul><ul><ul><li>The helping professions do not recognise psychological problems </li></ul></ul>
  16. 16. Trauma and the Brain <ul><li>Memory </li></ul><ul><li>Normal Information Processing </li></ul><ul><li>The Amygdala </li></ul><ul><li>The Hippocampus </li></ul><ul><li>Traumatic Information Processing </li></ul>
  17. 17. Memory <ul><li>Trauma is a memory disturbance </li></ul><ul><ul><li>The past is perceived as the present, in reaction to internal and external stimuli </li></ul></ul><ul><li>Memory systems </li></ul><ul><ul><li>Implicit memory -> amygdala </li></ul></ul><ul><ul><ul><li>procedural memory </li></ul></ul></ul><ul><ul><ul><li>classical conditioning </li></ul></ul></ul><ul><ul><li>Explicit, declarative memory </li></ul></ul><ul><ul><ul><li>semantic memory -> left frontal lobe </li></ul></ul></ul><ul><ul><ul><ul><li>knowledge, facts </li></ul></ul></ul></ul><ul><ul><ul><li>episodical memory -> hippocampus </li></ul></ul></ul><ul><ul><ul><ul><li>personal, autobiographical memories </li></ul></ul></ul></ul>
  18. 18. The Brain <ul><li>Normal pathways for information processing: </li></ul><ul><li>Information is supplied from the senses to the brain </li></ul><ul><ul><li>Thalamus </li></ul></ul><ul><li>Information is filtered according to emotional significance and attraction or threat are detected </li></ul><ul><ul><li>Amygdala </li></ul></ul><ul><li>Information receives a context, with a verbal or symbolic label </li></ul><ul><ul><li>Hippocampus </li></ul></ul><ul><li>Information is integrated into life‘s narrative </li></ul><ul><ul><li>Through the parahippocampal gyrus to the frontal brain </li></ul></ul><ul><li>The narrative gives meaning to the event in the life of the person </li></ul><ul><ul><li>in words, images and symbols </li></ul></ul>
  19. 20. Amygdala <ul><li>The amygdala is an organ in the limbic system </li></ul><ul><li>It explores all information coming in by the senses, to detect attractivess or threat </li></ul><ul><li>The amygdala secures the survival of the individual and the species </li></ul><ul><ul><li>Food, danger, sexual attractiveness </li></ul></ul><ul><li>The amygdala is the source of primary emotions </li></ul><ul><li>In presence of danger, higher thinking is short-circuited and hormones are produced in the hypothalamus </li></ul><ul><ul><li>&quot;The quick-and-dirty way of information processing&quot; </li></ul></ul><ul><li>This leads to fight -, flight - oder freeze -reactions </li></ul>
  20. 21. The Hippocampus <ul><li>The Hippocampus creates spatial representations of the outer world, independent from sensory impressions </li></ul><ul><li>This creates a context for memories </li></ul><ul><li>The context makes memories autobiographic and personal, places them in time and space and differentiates </li></ul><ul><li>The hippocampus can </li></ul><ul><ul><li>Represent many aspects of the environment </li></ul></ul><ul><ul><li>Create relationships between aspects of reality </li></ul></ul><ul><ul><li>Create a whole out of single stimuli: symbols, words </li></ul></ul><ul><li>In the context of the hippocampus an event becomes an episode </li></ul>
  21. 22. Trauma <ul><li>When a event is traumatic, the amygdala sends a signal that‘s so intensive that the hippocampus cannot place it into a context or give it a name or add a symbol to it </li></ul><ul><li>Strong feelings are saved together with the sensory input into implicit memory, not accessible to conscious processing </li></ul><ul><li>Memories cannot be transformed into narrative experience </li></ul><ul><ul><li>They don‘t make sense, don‘t have meaning, don‘t change in time </li></ul></ul><ul><ul><li>The Broca speech centre in the brain is not accessed </li></ul></ul><ul><ul><li>The events are superimposed on and distorted by current experience </li></ul></ul><ul><li>(Goleman, LeDoux) </li></ul>
  22. 23. An Information Processing Model for Treating Trauma <ul><li>Working relationship </li></ul><ul><li>Accessing Information </li></ul><ul><li>Providing Information </li></ul><ul><li>Accelerated Information Processing </li></ul><ul><li>Integration </li></ul>
  23. 24. The Working Relationship <ul><li>The sine qua non for healthy processing of traumatic events is safety in the working relationship: </li></ul><ul><ul><li>The therapist establishes contact and is able to reduce anxiety </li></ul></ul><ul><ul><li>The full traumatic experience is accessible and accepted in all aspects </li></ul></ul><ul><ul><li>Within the working relationship emotional intensity during accessing of traumatic experiences can be reduced or raised </li></ul></ul><ul><ul><li>The therapist recognises the positive intention of the client </li></ul></ul><ul><ul><li>The relationship helps with the integration of experiences into the future </li></ul></ul><ul><li>All the tools you have or none of them can be used as long as good rapport with the client is maintained </li></ul><ul><li>Let the healing happen in the relationship </li></ul>
  24. 25. Accessing Existing Information <ul><li>Bringing to awareness of information already stored </li></ul><ul><ul><ul><li>from declarative memory systems (events, dates, facts) </li></ul></ul></ul><ul><ul><ul><li>conditioned emotional responses </li></ul></ul></ul><ul><ul><ul><li>behaviour from non-declarative systems </li></ul></ul></ul><ul><li>Examples: </li></ul><ul><ul><li>memories, principles, rules, bodily sensations, emotions, fantasies, beliefs </li></ul></ul><ul><li>The level of emotional intensity must be carefully watched </li></ul>Danger zone, panic, spaced out Emotional intensity Learning zone, processing Stability, no processing
  25. 26. Providing Information <ul><li>The psychotherapist actively offers new information about processing trauma </li></ul><ul><li>This information can be taken from the frame of reference of the psychotherapist </li></ul><ul><ul><li>Dynamically oriented therapists may introduce information about the unconscious </li></ul></ul><ul><ul><li>Behaviour therapists introduce information about reinforcement </li></ul></ul><ul><li>Professionals also present normative data: </li></ul><ul><ul><li>even courageous soldiers feel fear in combat </li></ul></ul><ul><ul><li>perpetrators of abuse may manipulate their victims into feeling responsible for the abuse </li></ul></ul>
  26. 27. Accelerating Information Processing <ul><li>Successful information processing between brain networks leads to adaptive transformation </li></ul><ul><li>Painful nonadaptive information can be reprocessed very rapidly, at the same speed such maladaptive elements were acquired </li></ul><ul><li>This is different from the therapeutic expectations of traditional models of psychotherapy </li></ul><ul><li>These activities do not contain or convey meaning in and of themselves </li></ul><ul><li>EMDR and Meridian-based Psychotherapies explicitly use this type of activities </li></ul><ul><li>(Lipke, Shapiro) </li></ul>
  27. 28. Integration of Information <ul><li>When information has been (re)processed and the transition from the amygdala to the hippocampus has been made, clients need to integrate the experience on a higher level: </li></ul><ul><ul><li>Return to contract and consider current situation </li></ul></ul><ul><ul><li>Future-pacing: When you imagine going into the future, what’s new? </li></ul></ul><ul><li>If traumatic events are not yet completely processed: </li></ul><ul><ul><li>Relaxation or selfhypnosis to close sessions </li></ul></ul><ul><ul><li>Anxiolytic and neuroleptic medication </li></ul></ul>
  28. 29. Techniques for Acceleration of Information Processing: the Power Therapies <ul><li>EMDR </li></ul><ul><li>Meridian-based Psychotherapies </li></ul>
  29. 30. New & Old <ul><li>The new treatment techniques do not replace traditional psychotherapy skills: </li></ul><ul><ul><li>Building a working relationship </li></ul></ul><ul><ul><li>Contracting </li></ul></ul><ul><ul><li>Assessment & diagnosis </li></ul></ul><ul><ul><li>Counselling skills </li></ul></ul><ul><li>The basic attitude in psychotherapy remains the same </li></ul><ul><li>Similar stages in treating trauma can be recognised </li></ul><ul><li>However, they raise the efficacy and speed of more traditional methods </li></ul><ul><li>TA is an excellent starting-point for the use of these methods </li></ul><ul><li>Fighting the past in the present to assure the future </li></ul>
  30. 31. EMDR <ul><li>Eye Movement Desensitisation & Reprocessing is a method of accelerated information processing in the brain </li></ul><ul><li>It was developed by Francine Shapiro </li></ul><ul><li>The client tracks the movement of the therapist‘s hand with his eyes </li></ul><ul><li>It also possible to use other forms of left/right stimulation </li></ul><ul><li>Compared to Cognitive-Behavioural Therapy, EMDR has been proven equally effective in less time </li></ul>
  31. 32. Meridian-based Psychotherapies The cause of all negative emotions is a disruption in the body's energy system (Gary Craig)
  32. 33. Meridian-based Psychotherapies <ul><li>Roger Callahan discovered emotions, physical symptoms and traumatic memories can change by tapping on acupuncture meridian points </li></ul><ul><li>He called his method Thought Field Therapy - TFT </li></ul><ul><li>Others have developed similar methods in the past few years </li></ul><ul><li>We use the general term Meridian-based psychotherapies - MPT </li></ul><ul><li>MPT offers fast, noninvasive procedures that relieve psychological disturbances by eliminating perturbations in the energy field of the body and changing the body's energy system </li></ul>
  33. 34. Assumptions <ul><li>There is a subtle and not scientifically validated energy circulatory system in the human body, whose paths are called meridians in Traditional Chinese Medicine </li></ul><ul><li>This energy field has great influence over, and many times is responsible for, the person's physical, emotional, intellectual and spiritual well-being </li></ul><ul><li>In emotionally disturbing circumstances, the energy system may lose coherence, intentionality and capacity to relate </li></ul>
  34. 35. Treatment <ul><li>The energy system can be (re)balanced by tapping with the fingertips on acupuncture points at the beginning or at the end of the meridians </li></ul><ul><li>Once treated, memories can be normally accessed, but the emotional charge is gone </li></ul><ul><ul><li>The client does not get upset about the circumstance </li></ul></ul><ul><li>This result is lasting for the aspect treated </li></ul><ul><li>In treatment, stages similar to normal processing can be observed </li></ul>
  35. 36. Treatment <ul><li>Indications are trauma, phobias, guilt, grief and addictive cravings </li></ul><ul><li>After trauma treatment, there is a visible and obvious cognition change that shows up in the way clients talk about once troublesome incidents </li></ul><ul><li>Intense emotions -abreactions- are not necessarily part of the treatment process, as in other treatment systems </li></ul><ul><li>Treatment sequences take only minutes </li></ul><ul><li>Effects on emotions are often immediate and thus unbelievable </li></ul>
  36. 37. Starting exercise <ul><li>Most people have some constriction in their breathing which is rather easily corrected with EFT--&quot;Even though I have this constricted breathing....&quot;. </li></ul><ul><li>Take a deep breath and assess how that breath compares to what you consider to be your potential (10). Most people come up with a lower SUDs number, such as 7 or 8. A round or two of EFT usually brings them back to a 10. </li></ul><ul><li>Take a deep breath or two before doing the initial SUDs assessment. This should take care of any &quot;stretching effect&quot; the lungs may need to go through so that the initial SUDs is more likely to be valid. </li></ul><ul><li>People's emotional issues often show up in constricted breathing. Just dealing with the breathing reduces the intensity of the emotional issue. This can be a relatively painless way to &quot;take the edge off&quot; of the emotional problem before working with it directly. </li></ul>