TRAUMA-INFORMED CARE PERSPECTIVE
COMPLEX PTSD & TWO ESSENTIAL ELEMENTS
using your compassion and your curiosity
Going Main...
COMPLEX PTSD & TWO CONCEPTS YOU NEED TO KNOW FOR TICP
• A brief history of diagnostics
• Different views
• Borderline? Som...
Bruce Lipton, Ph D: The Biology of Belief
https://www.youtube.com/watch?v=jjj0xVM4x1I
?
WHAT HAS BEEN YOUR EXPERIENCE
Some researchers have argued that “personality traits” may account for re-
exposure to trauma, suggesting, for example, th...
Tamra Sattler Ph D: border_
https://www.youtube.com/watch?v=Ikl4GjQHPz4
BORDERLINE PERSONALITY DISORDER:
ONE VIEW OF THE HISTORICAL DEVELOPMENT
• How did the DSM develop?
• What about the “perso...
If you’ve been raped and abused for years as a child and
adult, your entire organism and personality has been
organized ar...
While the DSM has been praised for standardizing psychiatric
diagnostic categories and criteria, it has also generated con...
BORDERLINE? OR SOMETHING ELSE?
use your compassion and your curiosity
Bessel van der Kolk MD: Childhood Trauma, Affect Regulation and BPD
https://www.youtube.com/watch?v=N2NTADxDuhA
BESSEL VAN DER KOLK MD
proposed: 3 new diagnoses
COMPLEX PTSD
• Ongoing circumstances, many events, sub-threshold events and
circumstances; inability (real/perceived) to e...
TWO CONCEPTS TO KNOW
essential to TICP and treatment
Explains the self-blame, low self-
esteem, self-sabotage of survivors.
Informs us why it is difficult for our
clients to a...
copyright © 2011 Cathy S Harris, LCSW
INTERNALIZED BLAME OF SELF
IBS
“It’s all my fault”
• Self-blame developed as a copin...
It’s not your fault
It’s your fault
and here’s how
believing this has
helped you
survive…
Trauma-Aware
Professional Trauma...
copyright © 2011 Cathy S Harris, LCSW
HOW DOES IT DEVELOP?
Magical Thinking (Egocentrism)
• Causal reasoning that looks fo...
• Children do not have the intellectual capacity to
challenge their own “magical thinking”-they believe
they are the cause...
copyright © 2011 Cathy S Harris, LCSW
A STORY
Mary is 4 years old. At night she hears her parents fighting.
Daddy yells at...
copyright © 2011 Cathy S Harris, LCSW
Is this really the reason Daddy left? No, the adults are having adult
problems. But ...
copyright © 2011 Cathy S Harris, LCSW
COGNITIVE
LEGAL
EDUCATIONAL
OCCUPATIONAL
FINANCIAL
PHYSICAL
SOCIAL
IT’S ALL ABOUT RE...
copyright © 2011 Cathy S Harris, LCSW
THE CHILD HAS NO CHOICE
• Brain development, social, educational, physical & economi...
Why love literally hurts
https://www.psychologicalscience.org/index.php/publications/observer/2013/februa
ry-13/why-love-l...
copyright © 2011 Cathy S Harris, LCSW
ADULT CONSEQUENCES
Now, Mary becomes a person who is constantly striving to be
‘good...
copyright © 2011 Cathy S Harris, LCSW
“I should have gotten A+ on report cards”
Asked, “Can you give A+ on your students’
...
copyright © 2011 Cathy S Harris, LCSW
IBS AS COPING SKILL
• From “I’m bad, I must be causing you to hurt me” the child
rea...
copyright © 2011 Cathy S Harris, LCSW
PURPOSE
• It gave the child-victim an illusion of control; this sense of
power, thou...
copyright © 2011 Cathy S Harris, LCSW
LIFE-LONG EFFECTS: UNRESOLVED IBS
• IBS is supported by ongoing cognitively distorte...
copyright © 2011 Cathy S Harris, LCSW
REVERSAL OF IBS
• Cognitive work
• Expressive work
• Education
• Identify “IBS” mome...
warning: profanity
MMaggie Estep: Emotional Idiot: Kiss me, kill me
https://www.youtube.com/watch?v=CdxGvKhS6wc
copyright © 2011 Cathy S Harris, LCSW
AMBIVALENT ATTACHMENT ISSUES (AAI)
copyright © 2011 Cathy S Harris, LCSW
HOW DOES IT DEVELOP?
• Attachment is necessary for survival
• Survival is paramount
...
Daniel Siegel MD: Ambivalent Attachment
https://www.youtube.com/watch?v=nGhZtUrpCuc&list=PLUuATcN5sfugU6NFvYF2ocHPIPlq3NQfv
copyright © 2011 Cathy S Harris, LCSW
ATTACHMENT THEORY
• Attachment and Borderline Personality Disorder, Fonagy, 2000
• I...
copyright © 2011 Cathy S Harris, LCSW
Child receives balanced,
appropriately child-centered
attention, affection, love
Adu...
THEODORE MILLON
• discouraged borderline–includes avoidant, depressive or
dependent behaviors
• impulsive borderline–inclu...
LET’S TRY THIS AGAIN: WITH TICP
• DISCOURAGED SURVIVOR: LEARNED avoidant, depressive or dependent
behaviors
• IMPULSIVE SU...
copyright © 2011 Cathy S Harris, LCSW
RESOURCES
Get Started!
copyright © 2011 Cathy S Harris, LCSW
HOW DOES AAI MANIFEST?
• Self-sabotage: unfinished education, frequent employment
ch...
copyright © 2011 Cathy S Harris, LCSW
Client is 14 years old. Grew up in home with several IV drug users, absent adult
ove...
copyright © 2011 Cathy S Harris, LCSW
Behavior
Promiscuity,
drugs/alcohol, runaway
cutting, suicide threats
vandalism, tru...
HOW MIGHT YOU WORK WITH THIS CLIENT?
• Validation of expressed experience
• Explanation of IBS
• Explanation of AAI
• Use ...
copyright © 2011 Cathy S Harris, LCSW
WORKING WITH AAI
compassion and curiosity: at all times
• Compassionate confrontatio...
victim
rescuerperpetrator
copyright © 2011 Cathy S Harris, LCSW
?
HOW CAN WE TREAT THESE CONDITIONS
Trauma-Informed Care: COMPLEX PTSD & 2 ESSENTIAL ELEMENTS (conference session 2)
Trauma-Informed Care: COMPLEX PTSD & 2 ESSENTIAL ELEMENTS (conference session 2)
Upcoming SlideShare
Loading in …5
×

Trauma-Informed Care: COMPLEX PTSD & 2 ESSENTIAL ELEMENTS (conference session 2)

8,292 views

Published on

This presentation puts forth a comparison between what is called "Borderline Personality Disorder" and "Complex Post-Traumatic Stress Disorder". Two elements are highlighted: 1)The use of self-blame as a coping defense (by survivors of trauma of all kinds)--called "Internalized Blame of Self: IBS" . 2) The "push/pull" factor that many survivors of trauma experience, stemming, often from "Ambivalent Attachment" in early childhood.

Get a Level I Certification for completing the exams for all 5 in the series plus 2 additional exams.

OR invite Cathy to present face-to-face to your organization!
http://www.trauma-informedtraining.com/contact-us.html

Published in: Education
3 Comments
5 Likes
Statistics
Notes
No Downloads
Views
Total views
8,292
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
0
Comments
3
Likes
5
Embeds 0
No embeds

No notes for slide

Trauma-Informed Care: COMPLEX PTSD & 2 ESSENTIAL ELEMENTS (conference session 2)

  1. 1. TRAUMA-INFORMED CARE PERSPECTIVE COMPLEX PTSD & TWO ESSENTIAL ELEMENTS using your compassion and your curiosity Going Mainstream Series: Level I Presented by Cathy S. Harris, MSW, LCSW www.trauma-informedtraining.com
  2. 2. COMPLEX PTSD & TWO CONCEPTS YOU NEED TO KNOW FOR TICP • A brief history of diagnostics • Different views • Borderline? Something else? • Two Essential Concepts • Practical application: Case example copyright © 2011 Cathy S Harris, LCSW
  3. 3. Bruce Lipton, Ph D: The Biology of Belief https://www.youtube.com/watch?v=jjj0xVM4x1I
  4. 4. ? WHAT HAS BEEN YOUR EXPERIENCE
  5. 5. Some researchers have argued that “personality traits” may account for re- exposure to trauma, suggesting, for example, that “personality traits related to impulse control may be associated with increased probability of encountering a traumatic event” and that “[b]orderline personality may represent the same risk factor among women that antisocial personality does among men” (Lauterbach & Vrana, 2001, p. 30). Given that experiencing trauma is a known risk factor for eventually being designated with the diagnosis of antisocial personality disorder or borderline personality disorder, this line of “research” seems to constitute blaming the victim of the very worst kind, namely, blaming the victim in the name of science and bolstered by so-called scientific findings. Trauma and Retraumatization Nina Kammerer and Ruta Mazelis Presented at the After the Crisis: Healing from Trauma after Disasters Expert Panel Meeting copyright © 2011 Cathy S Harris, LCSW
  6. 6. Tamra Sattler Ph D: border_ https://www.youtube.com/watch?v=Ikl4GjQHPz4
  7. 7. BORDERLINE PERSONALITY DISORDER: ONE VIEW OF THE HISTORICAL DEVELOPMENT • How did the DSM develop? • What about the “personality disorders”? • Freud to Freyd copyright © 2011 Cathy S Harris, LCSW
  8. 8. If you’ve been raped and abused for years as a child and adult, your entire organism and personality has been organized around your trauma. …the way they act is understandable-they’re not just people trying to make your life miserable, but people trying to survive. COLIN ROSS The Trauma Model, 2000 “I view borderline personality disorder as a normal human response to chronic childhood trauma.” BESSEL VAN DER KOLK: THE LIMITS OF TALK Psychotherapy Networker, 2004
  9. 9. While the DSM has been praised for standardizing psychiatric diagnostic categories and criteria, it has also generated controversy and criticism. Critics, including the National Institute of Mental Health, argue that the DSM represents an unscientific and subjective system. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from 'normality'; possible cultural bias; medicalization of human distress ] The publication of the DSM, with tightly guarded copyrights, now makes APA (American Psychiatric Association) over $5 million a year, historically totaling over $100 million. Wikipedia NIMH withdraws support for the DSM V The DSM’s Troubled Revision copyright © 2011 Cathy S Harris, LCSW
  10. 10. BORDERLINE? OR SOMETHING ELSE? use your compassion and your curiosity
  11. 11. Bessel van der Kolk MD: Childhood Trauma, Affect Regulation and BPD https://www.youtube.com/watch?v=N2NTADxDuhA
  12. 12. BESSEL VAN DER KOLK MD proposed: 3 new diagnoses
  13. 13. COMPLEX PTSD • Ongoing circumstances, many events, sub-threshold events and circumstances; inability (real/perceived) to escape: physical and/or emotional captivity • Results: emotion regulation, distress tolerance, revictimization, difficulty in interpersonal relationships • Changes: Consciousness (fragmentation), self-esteem*, view of perpetrator*, view of relationships & the world copyright © 2011 Cathy S Harris, LCSW
  14. 14. TWO CONCEPTS TO KNOW essential to TICP and treatment
  15. 15. Explains the self-blame, low self- esteem, self-sabotage of survivors. Informs us why it is difficult for our clients to accept “it’s wasn’t your fault”. Understanding this concept and how it shows up in clients’ lives, gives us increased compassion and patience, whatever our setting or role. PRIMARY PSYCHOLOGICAL AFTER-EFFECTS Explains the “help me/don’t help me”, “push/pull” syndrome that elicits: “she’s just manipulative” or “he just wants attention”. Core issue for Complex PTSD/ “Borderline”. Accepting that this behavior is not personal helps us refrain from unproductive power struggles and extend increased compassion. INTERNALIZED BLAME OF SELF: IBS AMBIVALENT ATTACHMENT ISSUES: AAI
  16. 16. copyright © 2011 Cathy S Harris, LCSW INTERNALIZED BLAME OF SELF IBS “It’s all my fault” • Self-blame developed as a coping skill • Self-blame was a helpful defense as a child, however in adulthood impedes maturity • IBS is a foundation of treatment; working with it will empower client and create progressive environment for therapy • IBS makes “it all about me” in ways that clients may not even be aware of—this affects communication, relationships and the accomplishment of goals
  17. 17. It’s not your fault It’s your fault and here’s how believing this has helped you survive… Trauma-Aware Professional Trauma-Informed Professional copyright © 2011 Cathy S Harris, LCSW
  18. 18. copyright © 2011 Cathy S Harris, LCSW HOW DOES IT DEVELOP? Magical Thinking (Egocentrism) • Causal reasoning that looks for correlation between actor or utterances and certain events: “It’s raining because I’m sad.” • The outside world is linked with the child’s internal consciousness: “You’re hurting me, so I must be bad. I’m bad, so you hurt me.”
  19. 19. • Children do not have the intellectual capacity to challenge their own “magical thinking”-they believe they are the cause of events happening in their world (Piaget called it “egocentrism”). • Surviving adults, in the face of overwhelming feelings, resort to magical thinking in order to gain a sense of control and to avoid feeling completely vulnerable in a seemingly unpredictable world. HOW DOES IT DEVELOP? (CONT.)
  20. 20. copyright © 2011 Cathy S Harris, LCSW A STORY Mary is 4 years old. At night she hears her parents fighting. Daddy yells at Mommy “her room is always messy!” One day Mary comes home from pre-school and Mommy tells her “Daddy’s not going to live with us anymore”. What does Mary think? “It’s my fault.”
  21. 21. copyright © 2011 Cathy S Harris, LCSW Is this really the reason Daddy left? No, the adults are having adult problems. But Mary’s only resource is magical thinking so she believes that she is the cause. She has no other resource to help her cope with the overwhelming circumstance. How does this help her cope? “Maybe if I clean my room ‘good enough’ Daddy will come back!” In this way Mary takes responsibility for the adults’ actions. Hope is created. She begins to believe, erroneously, that she can control people and environments with her actions.
  22. 22. copyright © 2011 Cathy S Harris, LCSW COGNITIVE LEGAL EDUCATIONAL OCCUPATIONAL FINANCIAL PHYSICAL SOCIAL IT’S ALL ABOUT RESOURCES MAGICAL THINKING ADULT CHILD
  23. 23. copyright © 2011 Cathy S Harris, LCSW THE CHILD HAS NO CHOICE • Brain development, social, educational, physical & economic opportunities are not available • MAGICAL THINKING is the child’s sole resource, thus only way to get a vital sense of psychological control: “I’m bad”, “I caused it”, “I deserve it” • Gives a sense of control because: “I could be good enough” by: good grades, working hard, being sexual, pretty, funny; performing (in various ways)—and “maybe you won’t hurt me/you’ll love me”
  24. 24. Why love literally hurts https://www.psychologicalscience.org/index.php/publications/observer/2013/februa ry-13/why-love-literally-hurts.html
  25. 25. copyright © 2011 Cathy S Harris, LCSW ADULT CONSEQUENCES Now, Mary becomes a person who is constantly striving to be ‘good enough’…pretty enough, smart enough, clean enough, strong enough, rich enough, etc. Unfortunately, this does not work out well in adult relationships. Grown-up Mary relies on her magical thinking rather than become aware of the many adult resources she now has. She often responds to adult situations with immaturity, exhibiting a “self-centered”, helpless personality rather than an empowered identity.
  26. 26. copyright © 2011 Cathy S Harris, LCSW “I should have gotten A+ on report cards” Asked, “Can you give A+ on your students’ reports?” Answer, “No, but I should have gotten A+s.” ADULT, OUT OF 10 SIBLINGS, WAS NOT ABUSED BY FATHER “I was not good enough” for the abuser. As adult: robbed at gunpoint, wasn’t raped. This client’s expression? “I’m not even good enough to be raped by a criminal.” ADULT SCHOOL TEACHER’S EXPRESSION
  27. 27. copyright © 2011 Cathy S Harris, LCSW IBS AS COPING SKILL • From “I’m bad, I must be causing you to hurt me” the child reasons “If I am ‘good enough’ maybe you won’t hurt me” • The adult exclaims “If only I hadn’t left the house when I did, I wouldn’t have gotten into a car accident”… “If only I hadn’t built my house in that field, the tornado wouldn’t have destroyed it” • When victimizers say “you made me” (hurt you)—they reinforce the illusion that the victim could prevent the abuse by being “good enough” in some way
  28. 28. copyright © 2011 Cathy S Harris, LCSW PURPOSE • It gave the child-victim an illusion of control; this sense of power, though false, allowed the child to survive, to make sense of circumstances that made no sense • Understanding IBS as a coping defense is vital to treatment; saying “it wasn’t your fault”, while comforting does not address how continued use of IBS in adulthood inhibits recovery • The primary reason the adult continues to engage in use of IBS is for avoidance of feelings (perceived “bad” feelings)
  29. 29. copyright © 2011 Cathy S Harris, LCSW LIFE-LONG EFFECTS: UNRESOLVED IBS • IBS is supported by ongoing cognitively distorted beliefs and thoughts; inability to recognize adult resources • Self-sabotage creates a vicious cycle of reinforcement of irrational magical thinking: “I’m bad” “I don’t deserve good” • Victims unconsciously seek out relationships and job situations (for example) that seem to prove the “truth” of their low self-esteem: “I’m just a loser” • When adults become parents, themselves, they may unintentionally create the next generation
  30. 30. copyright © 2011 Cathy S Harris, LCSW REVERSAL OF IBS • Cognitive work • Expressive work • Education • Identify “IBS” moments and events • Therapeutic relationship • Positive affirmations
  31. 31. warning: profanity MMaggie Estep: Emotional Idiot: Kiss me, kill me https://www.youtube.com/watch?v=CdxGvKhS6wc
  32. 32. copyright © 2011 Cathy S Harris, LCSW AMBIVALENT ATTACHMENT ISSUES (AAI)
  33. 33. copyright © 2011 Cathy S Harris, LCSW HOW DOES IT DEVELOP? • Attachment is necessary for survival • Survival is paramount • The caretaker offers love and care sometimes and rejection, neglect and abuse at others • The child cannot rationalize this polarity, develops push/pull style of attachment • The survivor-adult cannot conceive a dialectic
  34. 34. Daniel Siegel MD: Ambivalent Attachment https://www.youtube.com/watch?v=nGhZtUrpCuc&list=PLUuATcN5sfugU6NFvYF2ocHPIPlq3NQfv
  35. 35. copyright © 2011 Cathy S Harris, LCSW ATTACHMENT THEORY • Attachment and Borderline Personality Disorder, Fonagy, 2000 • Introduction to BPD Causes, Salter-Pednault, 2008 • Transgenerational Consistencies of Attachment: A New Theory, Fonagy, 1999 • Attachment, the development of the self, and its pathology in personality disorders , Fonagy, 1996
  36. 36. copyright © 2011 Cathy S Harris, LCSW Child receives balanced, appropriately child-centered attention, affection, love Adult can accept rejection; move on Adult can trust and be trustworthy Adult can engage in give and take Adult can conceive of dialects, especially in relationship interactions ATTACHMENT STYLES Child receives inconsistent attention, sometimes rejection, abuse Adult is “needy”, “attention – seeking”, “manipulative” Adult has difficulty trusting; is not consistently trustworthy Adult perceives all is ‘personal’, has difficulty hearing “no”-perceives rejection; either/or thinking Adult puts new friend on pedestal, quickly becomes critical HEALTHY AMBIVALENT
  37. 37. THEODORE MILLON • discouraged borderline–includes avoidant, depressive or dependent behaviors • impulsive borderline–includes antisocial or approval-seeking behaviors • petulant borderline–includes passive-aggressive behaviors • self-destructive borderline–includes depressive or self-destructive behaviors copyright © 2011 Cathy S Harris, LCSW
  38. 38. LET’S TRY THIS AGAIN: WITH TICP • DISCOURAGED SURVIVOR: LEARNED avoidant, depressive or dependent behaviors • IMPULSIVE SURVIVOR: LEARNED antisocial or approval-seeking behaviors • CHILDLIKE SURVIVOR: LEARNED push/pull, ambivalent behaviors • SELF-DESTRUCTIVE SURVIVOR: LEARNED suicidal, self-blame as defense behaviors • ALL OF THESE BEHAVIORS/WAYS OF BEING DEVELOPED AS A RESPONSE AND AS A DEFENSE AND ARE SYMPTOMS OF COMPLEX PTSD copyright © 2011 Cathy S Harris, LCSW
  39. 39. copyright © 2011 Cathy S Harris, LCSW RESOURCES Get Started!
  40. 40. copyright © 2011 Cathy S Harris, LCSW HOW DOES AAI MANIFEST? • Self-sabotage: unfinished education, frequent employment changes, broken relationships, starts MH services but doesn’t follow through • Unhealthy relationships: perpetrator and/or victim • Low self-esteem: (IBS) expressed passively or with hostility (via addictions, self-harm, suicide attempts, fragmentation) • Self-harm: love & hate of self • Frequent hospitalizations: “only time I get attention from” family members • Push/pull: “Take care of me” then, “leave me alone”
  41. 41. copyright © 2011 Cathy S Harris, LCSW Client is 14 years old. Grew up in home with several IV drug users, absent adult oversight. Additional criminal behavior present in home. Very little food in home. “Cult” members lived in home. Client’s adult caretaker often absent. Client often found by neighbors, several blocks away, returned to home. From 12 years old client indicates sexual promiscuity. Client’s mother is not supportive of treatment, resentful that the teen’s “problem child” behavior has become public. Mother’s expression: “she just went crazy”. Biological father absent (“mentally ill”) and step-parent is a methamphetamine user. CASE STUDY “FU! I’M JUST A SCREW UP!”
  42. 42. copyright © 2011 Cathy S Harris, LCSW Behavior Promiscuity, drugs/alcohol, runaway cutting, suicide threats vandalism, truancy A-student when she attends school Diagnoses/Tx Oppositional Defiant Attention Deficit Conduct Disorders Prozac Seroquel Abilify Tegretol Ritalin Psychiatric hospitalization Residential Tx, restraints Outcome Teen: leaves home, lives with abusive boyfriends, use of drugs, alcohol, cutting, overdose, shoplifting, drops out of school Adult: multiple suicide attempts; drug use; multiple Rx for medications; SSI CARE VIA MEDICAL MODEL
  43. 43. HOW MIGHT YOU WORK WITH THIS CLIENT? • Validation of expressed experience • Explanation of IBS • Explanation of AAI • Use of Puppy Story (or other explanation that acknowledges client’s reality, expresses compassion and demonstrates need for taking personal responsibility for recovery) • Skills work: CBT, DBT • Work with what ‘is’ versus what you’d ‘like’ the family to be
  44. 44. copyright © 2011 Cathy S Harris, LCSW WORKING WITH AAI compassion and curiosity: at all times • Compassionate confrontation/hold the “space” • Authenticity • Judicious use of self-disclosure • Be straight, clear • Role-play • Firm, reasonable boundaries • Adults cannot be abandoned • Moderate extremes; normalize the experience
  45. 45. victim rescuerperpetrator copyright © 2011 Cathy S Harris, LCSW
  46. 46. ? HOW CAN WE TREAT THESE CONDITIONS

×