overcoming cumulative childhood adversity:

treatment approaches

Friday afternoonOctober 6, 2006

Northamerican Assn. of Masters in Psychology

Bruce Carruth, Ph.D., LCSWSan Miguel de Allende, GTO, Mexico

Outline for this afternoon

• The content of therapy with adversity cognition, affect and self

• The process of treatment 3 phases and 6 stages

the content of therapy with adversity

Cognition (I think)

AFFECT (I feel)

Self (I am)

cognition

• 3 components

contact between individual and environment

making meaning of data

the “cognitive self”

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Receiving data from the environment withdrawn people miss data in their environment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

Deleting / distorting sensory perceptions

internal external

Seeing

Hearing

Feeling

Smelling

Tasting

Some implications for therapy

Not listening to what is said

Being hypersensitive the specific sensory stimuli (touch, sounds, visual cues)

Hypersensitivity / deadening specific feelings

Making meaning of data

“What does this mean?”data from our environment gets processed in

light of our historyBecause of developmental lags, there may

not be sufficient data to process informationWhen unconscious material related to a

trauma experience drives the processingWhen we talk later about “telling the tale”, part of the agenda

is to move unconscious, unremembered material to conscious awareness

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

“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

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

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

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

Learned strategy and process

The frameworks we have developed to operate in the world

DecisioningManaging relationships – interactions with othersManaging life – crises, stimulation, recreation,

relaxation, parenting, close/casual friendshipsPatterns for rememberingManaging work – getting the job done (taking care of little things, finishing jobs, cooperating / competing

with others)

affect

• Two levels of affective experience

1. primary affects

terror – safe

grief – joy

rage – fullfilled / potent

shame – integrity

2. Affective (emotional) themes

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

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

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)

The fears of having the disavowed emotion

• Terror

• Grief

• Rage

• Shame

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

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

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

Treating character patternsCharacter patterns are relatively immune to

cognitive approaches to changeCognitive approaches can become part of the

defense (intellectualization)People don’t “give up” character patterns, they

evolve patterns to higher functioning levelsThe primary treatment approach is the therapeutic

relationship – the corrective emotional experienceOther change processes: support groups, spiritual

programs, healthy relationships

Supporting positive character patterns: centeredness, perseverance, empathy, curiosity, self-soothing, self-validation,

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

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

phase 1building 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

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”

A strategy for working with ego defense

Retroflecting (holding inside) counter strategy is expressingDeflecting (not letting outside in) counter strategy is absorbing – taking inProjecting (assigning inside to environment) counter strategy is owningIntrojecting (internalizing the environment) counter strategy is questioning – challengingConfluence (merging, joining) counter strategy is individualizing

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

Phase 2telling 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.

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.

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

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

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.

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

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

The process of grief work

Diagnosis and differential diagnosis cd relapse, depression, PTSD, personality disorder

Education about grief and grief reactionsExploration about client’s experience with

their griefCreating safety with feelingsCatharsis – 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

Emotional healing: the corrective emotional experienceAs 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

transferenceManaging the transference means being the

“good enough parent”

What are the attributes of a “good enough parent”?

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)

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

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

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