Published on March 8, 2014
Lecture 1 : Introduction to Complex Trauma Module: Complex case work. Kevin Standish
Overview 1. 2. 3. 4. Learning outcomes Trauma Defining and understanding complex trauma Complex trauma: common emotions and reactions 5. Three primary domains in complex trauma disorders 6. Readings
1. To define complex trauma and responses. 2. Differentiate complex trauma from PTSD 3. Explore their own reactions to acute trauma, abuse and violence. 4. Introduction of case studies 1. LEARNING OUTCOMES
1. 2. 3. 4. Through Our Eyes: Children, Violence, and Trauma introductory stories of Doris and Hector Safety and self disclosure Trauma: DSM 2. TRAUMA
2.1.Through Our Eyes: Children, Violence, and Trauma http://www.youtube.com/watch?v=z8vZxDa2K PM
2.2.Introductory stories of Doris and Hector Doris: 40-year-old woman sought therapy because has been gave her an ultimatum.Doris has long been unable to trust anyone close to her, yet is terrified of being abandoned. She switches between being highly dependent on a husband wanting emotional and physical closeness, and then distancing and pushing him away. This resulted in confusion for him leading him to withdraw confirming her belief that you will never find anyone trustworthy Doris’s mother suffered from schizophrenia resulting in repeated hospitalisations. Doris was placed with relatives during these hospitalisations. When her mother was at home she was inconsistent in her emotional state and parenting behaviour. Doris’s father was sexually and physically abusive. Doris’s father blamed Doris for all her mother’s problems. Doris Kemp to believe she ruined every relationship and harmed every person she cared about
Hector Hector is a 21-year-old admitted to an inpatient unit for being suicidal. He is the son of refugee parents who fled the country following torture of the Father by the authorities. Hector’s father PTSD behaviour resulted in violence abuse and drinking within the family. At school Hector was bullied for being the teacher’s pet and working hard at school. The parish priest befriended him which later lead to sexual abuse. Whilst in the military he was sexually gang raped by group of soldiers who assumed him to be gay. Following his military discharge he started drinking heavily as it believed he was a monster and disgusting resulting in frequent suicide attempts
2.3.Safety and self disclosure This module may well trigger traumatic memories and students who have experienced trauma. This may become a distressing and unsettling. Please ensure you gain the appropriate support should this occur. If you should choose to share and disclose information regarding personal trauma please do so with care and caution. This is a teaching environment not a therapeutic environment. All students are to treat disclosures with respect and confidentiality throughout this module
2.4.Trauma: DSM 2.4.1 PTSD criteria 2.4.2 Definition 2.4.3.Original Trauma definition 2.4.4.Type1 & Type 2 trauma 2.4.5.Complex trauma not included in the DSM
2.4.1.PTSD criteria Intrusive symptoms Avoidance symptoms Alterations in cognitions and mood Alteration and arousal and reactivity
2.4.2.Definition of trauma Multiple meanings: referring to medical, physical or psychological injury Difficult to find a clear definition of psychological trauma Trauma is used interchangeably with the event itself, or the individual's experience to the event, or their response to the event Consistency in definition: stressor event: psychological or psychic trauma/stressor Response to trauma: post-traumatic reactions or complex traumatic stress disorders
2.4.3. Original trauma definition Trauma was originally considered to be abnormal experience: "outside the range of normal experience" Evidence demonstrates that the majority of adults and substantial minority of children are exposed to traumatic events
2.4.4. Type1 & Type 2 trauma Type 1: single incident trauma "out of the blue": natural disaster, terrorist attack, dramatic accident Type 2: complex or repetitive trauma: ongoing abuse, domestic violence, community violence, war or genocide. Usually involved fundamental betrayal of trust in primary relationships and compromises bio psycho social and emotional development
2.4.5.Type 2: sub-categories Type 2A: multiple traumas experienced by individuals from relatively stable backgrounds who have sufficient resources to manage traumatic events better Type 2B: multiple traumas which so overwhelming that individual cannot separate one from the other, resilience is impaired. Type 2 B(R) those who had resilience in the beginning and type 2B(nR) those who never had any resileince.
1. Complex psychological trauma 2. Complex traumatic stress disorders 3. Proposed DSM criteria 3. DEFINING AND UNDERSTANDING COMPLEX TRAUMA
3.1.Complex psychological trauma Exposure to severe stresses that repetitive or prolonged, Involves harm or abandonment by caregivers or other responsible adults Occur at developmentally vulnerable times in the victim's life such as early childhood or adolescence In addition to being life-threatening or terrifying, these experiences chronic and compromise development and primary relationships
Complex trauma is defined as traumatic attachment that is life or self threatening, sexually violating, emotionally overwhelming, abandoning or personally negating and involves events and experiences that alter the development of the self, by requiring survival take precedence over normal psychobiological development.
3.2.Complex traumatic stress disorders Changes in the mind, emotions, body and relationships experienced following complex trauma include Severe problems with the dissociation, emotional dysregulation, somatic distress, and alienation Complex stress disorders go well beyond the classic definition of what is traumatic in terms of DSM and ICD 10
3.3.Proposed DSM criteria Alterations in the regulation of affective impulses Alterations in attention and consciousness Alterations in self perception Alterations in perception of the perpetrator Alterations in relationship to others Somatisation and medical problems Alterations in systems of meaning Read: Understanding Complex Trauma, Complex Reactions, and Treatment Approaches: http://www.giftfromwithin.org/html/cptsdunderstanding-treatment.html
1. Anxiety reactions 2. Depressive reactions 3. Anger and rage reactions 4. Self enstrangment and emotional deadness 5. Diffuse physical symptoms and depersonalisation 4. COMPLEX TRAUMA: COMMON EMOTIONS AND REACTIONS
4.1.Anxiety reactions These include fear, terror, apprehension, hypervigilance, panic attacks, sleep disturbance and nightmares Various phobias full range of anxiety disorders Physiological hyper-arousal alternating with hypo-arousal
4.2.Depressive reactions Show up in a variety of ways: ongoing diffuse sadness and hopelessness with despair the inability to feel interest in and the enjoyment of most life activities social detachment: not feeling close to other people Not feeling any emotion other than vague sense of flatness frustration or irritability (alexithymia) A feeling of an internal void or sense of emptiness self harm behaviour, chronic suicidal ideation and sporadic suicide attempts
4.3.Anger and rage reactions They struggle with intense feelings of anger and rage ranging from an ongoing sense of irritability, annoyance, disappointment, discussed, contempt and frustration with themselves and others alternating with episodes of uncontrollable rage, impulsive acts of protest and aggression self-directed in the form of self defeating behaviour, self harm substance abuse and acting out or by directing it at others through passive aggressive, aggressive and violent behaviour
4.4. Self enstrangment and emotional deadness A common denominator linking these emotions is a sense of self estrangement and emotional deadness Anxiety is also based on the fear that if feelings were allowed to emerge, they would be so intense that they would result in the victimisation of others, going crazy, causing others to abandon them, or committing suicide/homicide Depressive feelings tend to be based on the experience of “black hole” or a “yearning void” of emptiness, badness and despair
4.5.Diffuse physical symptoms and depersonalisation When emotions have been internalised as personally intolerable it is not surprising these reactions develop into a range of physical reactions somatoform disorders are manifestations of distress: stomach problems, breathing problems, muscular tension problems, high blood pressure, tinnitus, eating disorders, headaches. These often defiant or muddle medical diagnosis but are debilitating and real illnesses and health impairment Trauma survivors experienced physical sensations as dangerous and toxic; being interpreted as signs of painful, frightening, confusing, rather than illnesses
1. Emotion dysregulation 2. Loss of self integrity and self integration (dissociation) 3. Compromised relationship with others 5.THREE PRIMARY DOMAINS IN COMPLEX TRAUMA DISORDERS
5.1.Emotion dysregulation trauma survivors have difficulty coping with emotional responses in reaction to everyday life events. Emotions typically exceed the ability to regulate them because the skills for such modulation were not learnt. That emotional reactions tend to manifest in an all or nothing way "therapeutic window" or "window of tolerance" is the capacity to tolerate and modulate various emotional states Emotion regulation deficit results in little or no conceptualisation of physical and emotional boundaries between self and others. Techniques for skill building in emotional regulation boundary development essential in treatment
Anxiety response http://www.youtube.com/watch?v=jcaHgJarMM 5 minutes
5.2.Loss of self integrity and self integration (dissociation) Persistent emotional and somatic dysregulation tends to elicit and intensify dissociative reactions The associative processes can become automatic and involuntary over time and with recurrent use Post-traumatic dissociation leads to a typical amplification of emotions, physical sensations, knowledge/memory, and associated behavioural impulses Structural theory of the dissociation this to splitting of personal experience into divisions. Often confused with dissociative identity disorder Self perception tends to be profoundly negative and fragmented Negative schemas develop which become dominating organisational beliefs.
Dissociation http://www.youtube.com/watch?v=shFWo_ZH MqM 8 minutes
5.3..Compromised relationship with others Complex trauma survivors have ample reason to mistrust other people insecure and disorganised attachments make children and later adults targets for additional victimisation as their very isolation and neediness with compromised emotional regulation make them very vulnerable Learned patterns of helplessness and expectations of being treated badly confirms expectations regarding not fighting back Five roles in dysfunctional systems: superhero, caretaker, clown, rebel, lost child Dysfunctional sexual relationships range from sexual compulsivity to sexual aversion
Memory, Trauma & Transference http://www.youtube.com/watch?v=tXW1taFj7c 0 12 minutes
1. Sanderson (2013) Part I: Complex Trauma. 1. Understanding Trauma and Complex Trauma. 2. Understanding Trauma Symptoms. 2. Courtois & Ford (2009) chap 1. Defining and Understanding Complex Trauma and Complex Traumatic Stress Disorders, Julian D. Ford and Christine A. Courtois 3. Courtois & Ford (2013) chapter 1 complex trauma and traumatic stress reactions. Chapter 2 complex traumatic stress reactions and disorders 6. READINGS
Seminar Homework Summarise the effects of complex trauma developmentally. Describe how the impact of trauma has different effects depending on the developmental stage that trauma occurs in the lifespan of an individual Read Courtis & Ford (2013) chap 1 pages 11- 22.
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