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Treating acute trauma in adults: Assessment and intervention in the persistent effects John Briere, Ph.D. Departments of Psychiatry and Psychology Keck School of Medicine, University of Southern California Psychological Trauma Program, LA County – USC Medical Center MCAVIC-USC Child and Adolescent Trauma Program,  National Child Traumatic Stress Network
Severe adult traumas Assaults Physical Sexual Disasters War Torture Prisoner-of-war Refugee trauma
Intensifiers Multiple exposures and/or long duration Event severity Injury and/or near death Witnessed death or severe injury  Sexual trauma Coexisting hild abuse/neglect history Culture Attributions (e.g., guilt, shame)
Primary outcomes Mood/affective disorders Depression (with or without psychosis) Anxiety (panic disorder, GAD, phobias) Posttraumatic stress Psychosis Affect dysregulation Extreme avoidance responses Dissociation Substance abuse Tension reduction behaviors
Assessment instruments Generic MMPI-2, PAI Major symptom clusters PTSD scales Trauma-specific measures by presenter Trauma Symptom Inventory (TSI) Detailed Assessment of Posttraumatic Stress (DAPS)
Treating recent versus chronic posttraumatic disturbance Issues for treating acute (versus chronic) trauma Safety: Assessment and immediate intervention Support: Therapist, relational system Availability Active relatedness Encourage expression Psychoeducation Problems with early therapeutic exposure
Emotional processing The components of trauma processing Exposure Activation Disparity Counterconditioning within relatedness Extinction/resolution Titrated exposure and the therapeutic window The critical role of the therapeutic relationship Overshooting and undershooting
Example of emotional processing of automobile accident
Specific issues associated with treating severe trauma Activation may overwhelm affect regulation capacities Intensity control Importance of moment-by-moment titration Disparity may be hard for the survivor to recognize Don’t assume perception of safety Guilt and shame substantially affect processing Increases emotional load Motivates avoidance, which decreases processing
Specific traumas Combat exposure Therapist’s background: Relevance of war experience Do you have to have been there? Jargon and terminology Pre-casualty military training Pre-military exposure history Type of combat/war Number of deployments Atrocity
Specific traumas Rape Intrusion and violation Shame Client versus therapist gender In terms of activation potential (e.g., therapist-perpetrator match) In terms of level/type of therapeutic exposure Impact of previous childhood sexual abuse
Specific traumas Torture Establish and re-establish safety Cultural/language issues Translators Therapist cultural sensitivity, competence Culture-bound responses Severity of posttraumatic stress Special attention to activatibility in session For exposure: “Start low, go slow” Asylum issues Effects of improved status
Cognitive interventions Normalizing and reframing of experiences and “symptoms” Cognitive reconsideration: An empowering alternative to cognitive restructuring Using exposure processes to prompt reevaluation of cognitions Insight and the development of a coherent, nonpathologizing narrative
Distress reduction and affect regulation training Grounding, breath training Rare paradoxical responses Labeling and discrimination of emotional states Emotional detective work Trigger identification and intervention Mindfulness As cognitive therapy As exposure therapy DBT, MBSR

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John Briere,Severe acute trauma.ppt

  • 1. Treating acute trauma in adults: Assessment and intervention in the persistent effects John Briere, Ph.D. Departments of Psychiatry and Psychology Keck School of Medicine, University of Southern California Psychological Trauma Program, LA County – USC Medical Center MCAVIC-USC Child and Adolescent Trauma Program, National Child Traumatic Stress Network
  • 2. Severe adult traumas Assaults Physical Sexual Disasters War Torture Prisoner-of-war Refugee trauma
  • 3. Intensifiers Multiple exposures and/or long duration Event severity Injury and/or near death Witnessed death or severe injury Sexual trauma Coexisting hild abuse/neglect history Culture Attributions (e.g., guilt, shame)
  • 4. Primary outcomes Mood/affective disorders Depression (with or without psychosis) Anxiety (panic disorder, GAD, phobias) Posttraumatic stress Psychosis Affect dysregulation Extreme avoidance responses Dissociation Substance abuse Tension reduction behaviors
  • 5. Assessment instruments Generic MMPI-2, PAI Major symptom clusters PTSD scales Trauma-specific measures by presenter Trauma Symptom Inventory (TSI) Detailed Assessment of Posttraumatic Stress (DAPS)
  • 6. Treating recent versus chronic posttraumatic disturbance Issues for treating acute (versus chronic) trauma Safety: Assessment and immediate intervention Support: Therapist, relational system Availability Active relatedness Encourage expression Psychoeducation Problems with early therapeutic exposure
  • 7. Emotional processing The components of trauma processing Exposure Activation Disparity Counterconditioning within relatedness Extinction/resolution Titrated exposure and the therapeutic window The critical role of the therapeutic relationship Overshooting and undershooting
  • 8. Example of emotional processing of automobile accident
  • 9. Specific issues associated with treating severe trauma Activation may overwhelm affect regulation capacities Intensity control Importance of moment-by-moment titration Disparity may be hard for the survivor to recognize Don’t assume perception of safety Guilt and shame substantially affect processing Increases emotional load Motivates avoidance, which decreases processing
  • 10. Specific traumas Combat exposure Therapist’s background: Relevance of war experience Do you have to have been there? Jargon and terminology Pre-casualty military training Pre-military exposure history Type of combat/war Number of deployments Atrocity
  • 11. Specific traumas Rape Intrusion and violation Shame Client versus therapist gender In terms of activation potential (e.g., therapist-perpetrator match) In terms of level/type of therapeutic exposure Impact of previous childhood sexual abuse
  • 12. Specific traumas Torture Establish and re-establish safety Cultural/language issues Translators Therapist cultural sensitivity, competence Culture-bound responses Severity of posttraumatic stress Special attention to activatibility in session For exposure: “Start low, go slow” Asylum issues Effects of improved status
  • 13. Cognitive interventions Normalizing and reframing of experiences and “symptoms” Cognitive reconsideration: An empowering alternative to cognitive restructuring Using exposure processes to prompt reevaluation of cognitions Insight and the development of a coherent, nonpathologizing narrative
  • 14. Distress reduction and affect regulation training Grounding, breath training Rare paradoxical responses Labeling and discrimination of emotional states Emotional detective work Trigger identification and intervention Mindfulness As cognitive therapy As exposure therapy DBT, MBSR