Effective Treatment for Effective Treatment for Trauma: Myths &GuidelinesTrauma: Myths &Guidelines

Effective Treatment for Effective Treatment for Trauma: Myths &GuidelinesTrauma: Myths &Guidelines

Jonathan Kandell, LCSW, LISACJonathan Kandell, LCSW, LISACSenior Therapist, Codac Behavioral Health,Senior Therapist, Codac Behavioral Health,Licensed Psychotherapist in Private PracticeLicensed Psychotherapist in Private Practice

May 8, 2008May 8, 2008Long Rangers ForumLong Rangers Forum

Tucson, AZTucson, AZ

Today’s TalkToday’s Talk

1.1. What is PTSDWhat is PTSD

2.2. Treating PTSDTreating PTSD

3.3. Guidelines for Professional HelpGuidelines for Professional Help

““Although the world is full of Although the world is full of suffering, it is also full of the suffering, it is also full of the

overcoming of it.”overcoming of it.”Helen Keller, Helen Keller, US blind & deaf educator (1880 - 1968)US blind & deaf educator (1880 - 1968)

““Trauma”Trauma”

““An extreme stressor... that involves An extreme stressor... that involves actual or threatened death or serious actual or threatened death or serious injury, or other threat to one's physical injury, or other threat to one's physical integrity.”integrity.”

““Produces intense fear, helplessness, or Produces intense fear, helplessness, or horror.”horror.”

from the from the DSM-IVDSM-IV

Causes…Causes…

Domestic ViolenceDomestic Violence

Sexual Abuse & Sexual Abuse & RapeRape

War & RefugeesWar & Refugees

SuicideSuicide

Vehicular accidentsVehicular accidents

Genocide Genocide

Community violenceCommunity violence

Natural disastersNatural disasters

Medical traumaMedical trauma

Displacement, Displacement, slavery, traffickingslavery, trafficking

Post Traumatic Stress Disorder Post Traumatic Stress Disorder (PTSD)(PTSD)

PostPost

TraumaticTraumatic

StressStress

DisorderDisorder

re-lived

trauma

anxiety

ruins your life

PTSD in a nutshellPTSD in a nutshell

PTSD in a nutshellPTSD in a nutshell

PTSD PTSD

Fight Flight

FreezeFreeze

PTSD PTSD

Hyper-arousal Tuning out

ParalysisParalysis

This is dissociationThis is dissociation

Dissociation gone awryDissociation gone awry

Dissociation gone awryDissociation gone awry

CompartmentalizationCompartmentalization

Animal aspects:Animal aspects: Fight, flight, freezeFight, flight, freeze

Human aspects:Human aspects: ““Mind Games”Mind Games” ““Analysis Paralysis”Analysis Paralysis”

Being human makes PTSD worse

Your dog doesn’t do this:Your dog doesn’t do this:

I am a terrible dog failure, who must punish myself by refusing the leftover carne

asada.

PTSD PTSD

Hyper-arousal Tuning out

ImmobilityImmobility

Complex PTSD Complex PTSD

Acting Out Avoidance

HelplessnessHelplessness

What it feels like inside…What it feels like inside…

Everything is truly my fault (even though I Everything is truly my fault (even though I act like I don’t care).act like I don’t care).

I can never be forgiven.I can never be forgiven.

Nobody could ever understand me.Nobody could ever understand me.

Come here, but go away.Come here, but go away.

Shame-based arrogance.Shame-based arrogance.

Surrender is a dirty word but fighting is Surrender is a dirty word but fighting is useless.useless.

Jerry Boriskin, PhD

What it feels like inside…What it feels like inside…

I feel nothing at all, except the surges of I feel nothing at all, except the surges of anger.anger.Life sucks and anyone who believes Life sucks and anyone who believes otherwise is stupid.otherwise is stupid.I am a complete cynic, yet everything I am a complete cynic, yet everything should be perfect.should be perfect.I don’t care what anyone says, I am I don’t care what anyone says, I am defective, unlovable, and things are defective, unlovable, and things are hopeless.hopeless.

Jerry Boriskin, PhD

Treating PTSDTreating PTSD

(and associated disorders…)(and associated disorders…)

Treatment MythsTreatment Myths

1.1. You get “cured”You get “cured”

2.2. Medication alone will workMedication alone will work

3.3. All trauma requires treatmentAll trauma requires treatment

4.4. PTSD requires intense “processing” -- PTSD requires intense “processing” -- and it must happen nowand it must happen now

Treatment MisconceptionsTreatment Misconceptions

1.1. You get “cured” or “don’t get cured”You get “cured” or “don’t get cured”

2.2. All trauma requires treatmentAll trauma requires treatment

3.3. All treatment requires processing.All treatment requires processing.

Treatment MisconceptionsTreatment Misconceptions

1.1. You get “cured” or “don’t get cured”You get “cured” or “don’t get cured”

2.2. All trauma requires treatmentAll trauma requires treatment

3.3. All treatment requires processing.All treatment requires processing.

Expected history of PTSD

Traumatic Event 1 month 9 months 3 years

Generally 33% remain symptomatic for 3 years

or longer with greater risk of secondary problems

Many recover without treatment within months of event (45-80%

natural remission at 9 months)

Usual onset of symptoms

Treatment MythsTreatment Myths

1.1. You get “cured” or “don’t get cured”You get “cured” or “don’t get cured”

2.2. All trauma requires treatmentAll trauma requires treatment

3.3. PTSD requires intense “processing” -- PTSD requires intense “processing” -- and it has to happen now.and it has to happen now.

The problem with jumping right inThe problem with jumping right in

Stages of RecoveryStages of Recovery

1.1. Safety Safety

2.2. Remembrance & MourningRemembrance & Mourning

3.3. ReconnectionReconnection

(Judith (Judith Herman)Herman)

Some therapies that workSome therapies that work

Seeking Safety (Najavits)Seeking Safety (Najavits)

Dialectical Behavior Therapy (Linehan)Dialectical Behavior Therapy (Linehan)

Self Trauma Model (Briere)Self Trauma Model (Briere)

Eye Movement Desensitization Reprogramming Eye Movement Desensitization Reprogramming

(Shapiro)(Shapiro)

Acceptance Commitment Therapy (Hayes)Acceptance Commitment Therapy (Hayes)

Schema Therapy (Young)Schema Therapy (Young)

Emotion-Focused Therapy (Greenberger)Emotion-Focused Therapy (Greenberger)

Some Key Points for RecoverySome Key Points for Recovery

Trauma will heal spontaneously if the process isn’t blocked

Trauma will heal spontaneously if the process isn’t blocked

Trauma will heal spontaneously Trauma will heal spontaneously once the process isn’t blockedonce the process isn’t blocked

Trauma will heal spontaneously Trauma will heal spontaneously once the process isn’t blockedonce the process isn’t blocked

Spirituality & Compassion are crucialSpirituality & Compassion are crucial

Guidelines for Seeking Guidelines for Seeking Professional HelpProfessional Help

(and tips for families)(and tips for families)

Guidelines for TreatmentGuidelines for Treatment

Don’t make a career of “managing symptoms”. Build a life worth living.

Avoid unlicensed “healers”

Heal in your own way, true to yourself

While recovery can be slow, you should see (and expect) definite improvement over time!

Advocate when “the System” Advocate when “the System” itself stifles recoveryitself stifles recovery

1.1. ChaosChaos

2.2. Lack of communicationLack of communication

3.3. Colluding with the disease, not recoveryColluding with the disease, not recovery

4.4. ““Programs” and “fads” instead of relationshipsPrograms” and “fads” instead of relationships

Tips for familiesTips for families

Take action: don’t be paralyzed by fearTake action: don’t be paralyzed by fearAdvocate for treatmentAdvocate for treatmentBe your family member’s “reality check” Be your family member’s “reality check” Be assertive--not aggressiveBe assertive--not aggressiveLearn about co-dependencyLearn about co-dependencyPatience, not passivity.Patience, not passivity.Maintain positive expectationsMaintain positive expectations

adapted from Jerry Boriskin

““Although the Although the world is full of world is full of suffering, it is suffering, it is also full of the also full of the

overcoming of it.”overcoming of it.”Helen Keller, Helen Keller, US blind & deaf US blind & deaf

educator (1880 - 1968)educator (1880 - 1968)

Jonathan Kandell, LCSW LISAC327-4505 x1087jkandell@sysmatrix.net

Thank you very much for listening with an open mind!

Some books to learn moreSome books to learn more

Judith Herman, Judith Herman, Trauma and RecoveryTrauma and Recovery (1992) (1992) Peter Levine, Peter Levine, Waking the Tiger: Healing Trauma Waking the Tiger: Healing Trauma

(1997)(1997) Jon Allen, Jon Allen, Coping with Trauma: A Guide to Self-Coping with Trauma: A Guide to Self-

UnderstandingUnderstanding (1995) (1995) Aphrodite Matsakis, Aphrodite Matsakis, I Can’t Get Over It: A I Can’t Get Over It: A

Handbook for Trauma SurvivorsHandbook for Trauma Survivors (1996) (1996) Glen Schiraldi, Glen Schiraldi, Post Traumatic Stress Post Traumatic Stress

SourcebookSourcebook (2000) (2000)

Some therapies that workSome therapies that work

Seeking Safety (Najavits)Seeking Safety (Najavits)

Dialectical Behavior Therapy (Linehan)Dialectical Behavior Therapy (Linehan)

Self Trauma Model (Briere)Self Trauma Model (Briere)

Eye Movement Desensitization Reprogramming Eye Movement Desensitization Reprogramming

(Shapiro)(Shapiro)

Acceptance Commitment Therapy (Hayes)Acceptance Commitment Therapy (Hayes)

Schema Therapy (Young)Schema Therapy (Young)

Emotion-Focused Therapy (Greenberger)Emotion-Focused Therapy (Greenberger)

Skills emphasisSkills emphasis

Seeking Safety (Narjavits)Seeking Safety (Narjavits)1.1. PTSD & substance abuse groupPTSD & substance abuse group2.2. Present-focusedPresent-focused3.3. Core safety skillsCore safety skills4.4. Skills for boundaries, grounding, anger, Skills for boundaries, grounding, anger,

substance abuse, self-talk, compassion, substance abuse, self-talk, compassion, honesty, etc.honesty, etc.

Skills emphasisSkills emphasis

Dialectical Behavior Therapy (Linehan)Dialectical Behavior Therapy (Linehan)

1.1. Designed for borderline, but ok for Designed for borderline, but ok for somesome complex ptsdcomplex ptsd

2.2. Very structuredVery structured

3.3. Skills for interpersonal, emotion, Skills for interpersonal, emotion, mindfulness, and distress tolerancemindfulness, and distress tolerance

4.4. ““Meditation” componentMeditation” component

Exposure emphasisExposure emphasis

Self Trauma Model (Briere)Self Trauma Model (Briere)

1.1. Changing thinking patterns (CBT)Changing thinking patterns (CBT)2.2. ““Titrated” memories in the “therapeutic Titrated” memories in the “therapeutic

window”window”3.3. Re-experiencing memories in a safe Re-experiencing memories in a safe

therapy relationship so the mind is re-therapy relationship so the mind is re-conditionedconditioned

Exposure emphasisExposure emphasis

Eye Movement Desensitization Eye Movement Desensitization ReprogrammingReprogramming (Shapiro) (Shapiro)

1.1. Therapist reactivates memories while Therapist reactivates memories while causing rapid eye-movement.causing rapid eye-movement.

2.2. Controversial in the research community.Controversial in the research community.

Exposure emphasisExposure emphasis

Acceptance Commitment Therapy Acceptance Commitment Therapy (Hayes)(Hayes)

1.1. Emphasis on building a meaningful lifeEmphasis on building a meaningful life

2.2. Acceptance skills for uncomfortable Acceptance skills for uncomfortable mind-body reactions from ptsdmind-body reactions from ptsd

3.3. Being in the “here and now”Being in the “here and now”

4.4. Spiritual selfSpiritual self

Processing emphasisProcessing emphasis

Schema Therapy (Young)Schema Therapy (Young)

1.1. Focuses on inner parts of self, like Focuses on inner parts of self, like “wounded child” and “inner critic”“wounded child” and “inner critic”

2.2. Coping styles/defense mechanismsCoping styles/defense mechanisms

3.3. Methods like empty chair and Methods like empty chair and imagination role playsimagination role plays