development of a stabilization tool kit: the treatment of ... · • carewest operational stress...

Development of a Stabilization Tool Kit: The Treatment of Complex PTSD and OSI within the Military, RCMP and Veterans

Presented By: Dr. Stephen Boucher, MB ChB. FRCS, MRCGP, FRCP(C)

Colleen Clark, MSW, RSW

Stacey Ferland, RPC, MPCP

Susan James, MSW, RSW, RMFT

Please be advised...

• No recording devices allowed out of

respect for client privacy/case studies.

• There will be interview videos with

descriptions of client’s traumatic

experiences.

• No conflict of interest.

COMPLEXITY IN PTSD

• Carewest Operational Stress Injury

Clinic (OSIC) located in Calgary,

Alberta.

• Treats currently serving and retired

military and RCMP members, as well

as their families.

• 206 active clients (2012).

• Team based.

• Biopsychosocial treatments.

• Empirical Exposure based therapies.

Veterans 61%

Serving Regular

Force CF 6%

Serving Reservist

4%

Ex-RCMP

5%

Serving RCMP 13%

Family Members

11%

AVERAGE LENGTH OF STAY: 33 MONTHS

• Combat- related PTSD is among the most

refractory psychiatric conditions (Frueh).

• Is it the staff?

• Is it the patients?

• Is it the treatments we use?

PROLONGED EXPOSURE

• VA/DOD 2010 and IOM 2007; 8-15 sessions.

• 80% veterans clinically significant reduction

in PTSD (Rauch).

• 60% Iraq/Afghan vets , 40% Vietnam Vets no

longer met criteria for PTSD (Yoder).

• Drop out rates of 20-42% (Schnurr).

EMDR

• VA/DOD 2004, 2010 Evidence based.

• IOM 2008, 2012 insufficient evidence.

• Treatment response modest to significant.

• Drop out rate 18.9% (Hembree, 2003).

Limitations of SSRI treatment

• VA/DOD recommended treatments 2010.

• Less than 60% response rate to SSRI

therapy.

• 30% decrease in CAPS scores.

• Remission rate [CAPS <20] low 20%.

• Drop out rates as high as 40% sertraline.

Medications can be life saving

What patients report about empirically based

treatments

Video removed for client privacy. Please contact

[email protected] with

inquiries if you have questions regarding video

footage.

mailto:[email protected]

Treatment Resistant Subpopulations

• 34% of 100 OSIC patients--(childhood abuse-including

physical, sexual, emotional and neglect).

• Extreme Emotional Numbing / Hyperarousal / Dysphoria

• Uncontained Addictions, psychiatric co-morbidity, psychosis,

panic disorder.

• Co-morbid medical illness, pain.

A Vulnerable Sub-Population

• TYPE 2 (Terr, 2003) + TYPE 2 PTSD Sub-population

• Affect dysregulation (van der Kolk et al., 2005).

• Chronic destructive behaviour-self mutilation/eating disorder/drug abuse

etc.

• Alterations in self perception - guilt/shame.

• Distorted relations with others, poor trust.

• Somatization/medical problems.

• Alterations in systems of meaning (Courtois, 2009) - Despair of recovery

• Amnesia and Dissociation.

Childhood Trauma Adult Trauma

Complex PTSD – OSIC Client Traits

• Difficult to diagnose (Resick et al., 2012).

• Increased co-morbidity and functional impairment (Sugaya et. al,

2012).

• Refractory to conventional PTSD psychotherapy treatment.

• Refractory to medications.

• High attrition rates – Eye Movement Desensitization and Reprocessing

and Prolonged Exposure – 15 to 30% (Tuerk et al., 2012, p.3).

• Require prolonged stabilization (“Specialized Stabilization”), trauma

treatment and length of stay (Korn & Leeds, 2002).

• Staged, paced treatment.

Cumulative adult trauma (RCMP Service)




footage.


Continuum of Adult Trauma Damage

Severe Prolonged Repeated Trauma (Herman)

Captivity, Torture, Genocide

------Complex PTSD

Cumulative Police/Military Trauma

Profound Emotional Numbing

Single incident Military/Police Trauma

Degree of

Psychological

Damage

Emotional Numbing




footage.


Emotional Numbing [EN] / Dysphoria

• At interview, look for markers for extreme

Emotional Numbing.

• Persistence of emotional dysregulation

(Numbing / Anger / Dysphoria).

• Increased interpersonal and family problems.

• Increased occupational problems.

• Increased Alcohol abuse, smoking.

• Diminished response to exposure & medication

treatment of PTSD.

Treatment Sequence

• Safety, stabilization, skill building, treatment alliance

• Trauma processing

• Integration and meaning, self and relational development

Introduction to Cat (RCMP Role Description)

• Refer to Case Study provided




footage.


Early Stage of Treatment for Complex PTSD

• Specialized Stabilization

• Safety and Establishing therapeutic alliance

• Attachment

• Psycho education

• Loss and Grief

• Moral Distress

• Measured by mastery of the necessary skills; not

by duration

Kitchur’s Strategic Developmental Genogram

• Proposes ALL traumatic events in individual’s life

likely to have impeded developmental progress.

• Identifies attachment patterns underlying current

symptomology.

• Provides comprehensive strategy for identifying

and addressing fixation and developmental

deficits. (Johnson, 2003; Fosha, 2000)

Developmental Genogram

Types of Interpersonal Trauma

• Attachment/relational

• Physical and sexual abuse

• Emotional/verbal/bullying/antipathy

• Neglect/non-response or protection

• Layered

• Betrayal

• Secondary / “second injury” / institutional

Attachment Trauma and Development

• Can effect development starting at the

neuronal level

• “Neurons that fire together wire together”

• Can affect brain structure and function

• Right brain/sensory-motor imprint

• Left brain development impeded

• There may be no words

• Speechless terror

10 Tenets of Attachment Theory

• Attachment is an innate motivating force.

• Secure dependence complements

autonomy.

• Attachment offers an essential safe haven.

• Attachment offers a secure base.

• Emotional accessibility & responsiveness

builds bonds. (Johnson, 2003b).

Attachment tenets

• Fear & uncertainty activate attachment

needs.

• Process of separation distress is

predictable.

• Finite number insecure forms of

engagement can be identified.

• Attachment involves working models of self

and others.

• Isolation and loss are inherently

traumatizing.

ATTACHMENT

• Complex PTSD is the most difficult for

both therapist and clients to manage

(Courtois, 2008; Muller, 2009)

• Especially when the trauma affected some

type of disruption in the client’s early

attachment process.

Trauma and Development

• Attachment/relational trauma

• Attachment style and Inner Working Model

• Secure

• Insecure

• Disorganized

• Lack of self validation/reflection

• Effect on brain development

• Survival brain vs. Learning brain

Disorganized Attachment

Symptoms of early attachment trauma

• Difficulties in the following areas:

• Regulating and/or inability to regulate a variety of internal and external systems, including consciousness, cognition, emotion, arousal

• Behavioural self-management

• Attachment (both intra and interpersonally)

• Existential meaning making (Coutois, 2008; Ford, Courtois, Steele, Van der Hart, & Nijenhuis, 2005).

Post-trauma Responses and Disorders

• Complex Posttraumatic Stress

Disorder/(DESNOS) “PTSD plus or minus.”

• Related to severe chronic abuse, usually in

childhood, and attachment disturbance.

• Usually highly co-morbid.

• Involves a high degree of dissociation.

Ego States




footage.


Importance of Specialized Stabilization

• This stage of treatment may be most

important as it is, directly related to the

client’s capacity to function (Courtois)

Stabilization includes

• Attention to wellness

• Stress Management

• Medical/somatic concerns

• Medications re: antidepressants; anti-

anxiety drugs can be helpful to target

posttraumatic symptoms which can be

associated with depression, anxiety &

sleep disorders.

Why Use Specialized Stabilization?

• To end emotional dysregulation

• To identify and address emotional numbing

• Prepares client for active trauma therapy

• Builds trust, therapeutic relationship and

repairs attachment issues

Goals of Specialized Stabilization

1. Address Avoidance

A. Decrease somatic distress

B. Decrease dissociation

C. Address emotional dysregulation (Van Voorhees, et. al, 2012)

D. Address emotional numbing

2. Psycho education

3. Promote identity, self-awareness and self-development

4. Address attachment disturbance and spiritual

alienation (Allen & Lauterbach, 2007)

Stabilization and Safety




footage.


Engagement, safety and stabilization

• Safety planning, psycho-education

immediate intervention regarding safety

issues (suicidal/homicidal ideation;

addictions; dangerous relationships;basic

needs).

• Therapist container for client – learning

new skills (impulse control; regulating

affect; managing self-destructive thoughts

and behaviours.

Therapeutic Relationship and Coping




footage.


Therapeutic alliance

• The therapeutic relationship – has the

most empirical support of any “technique”

(as seen in attachment studies; brain

development studies, and therapy

outcome studies).

• Vital with traumatized individuals.

• Vital in interpersonal violence and in

developmental trauma.

Psychoeducation and Establishing treatment framework

• Psycho Education in complex trauma with

the elements of human response to

trauma provides a foundation for skill

building.

• Education can demystify psychotherapy

• Education about trauma and its impact

may help clients understand their

reactions and develop increased self-

compassion.

• Teach the client how PTSD stress and

developmental problems are expected

• Identify adaptive reactions to traumatic

experiences in childhood as normal.

• Clients may need to move back and forth

between treatment phases (crisis; refresh

skills or apply; reformulate their safety plan).

• Neurobiological impact of trauma.

Psychoeducation and Establishing treatment framework

C-PTSD Education and Suicide




footage.


Skills to be developed in stabilization

• Healthy boundaries

• Safety planning

• Assertiveness

• Self-nurturing & Self-Soothing

• Emotional Modulation

• Strategies to contain trauma symptoms

(flashbacks & dissociative episodes)

Stabilization Toolkit

• Grounding, Mindfulness, Relaxation, Workbooks;

Skillbuilding

• O’Shea EMDR Emotional Regulation for

Hyperarousal

• Emotional Numbing accessing and recovery of

emotions – body awareness

• Women’s Group pre-trauma work

• Expressive therapy

• Therapeutic Process Group – Sandtray

• Couple Work

Emotional Regulation Processing

• Specialized Stabilization - graduated emotional exposure

• Address both Hyperarousal / Hypoarousal (Emotional

Numbing)

• Promotes proficiency in identifying and tolerating emotions (Johnson, 2003)

• Modified EMDR Model - bi-lateral stimulation adds symbolic

imagery to emotions being processed. Promotes therapy

engagement and success rate (O’Shea, 2009; Kitchur, 2005)

• Space opened for narratives of client self-awareness and

understanding of experiences.

Emotional Numbing

• Connecting to experience (past, present &

future) focusing on mind and body.

• Focusing on positive emotions and

sensory experience.

• Developmental Genogram; Narrative

Review; Photographs; music; objects;

Mindfulness, expressive arts, journaling.

Treatment Goals for PTSD

• Restore self-esteem, personal integrity

* normal psychosexual development

* reintegration of the personality

• Restore psychosocial relations

* trust of others

* foster attachment to and connection with

others

Treatment Principles for Complex Trauma

• Treatment meets standard of care

• Treatment is individualized

• Client empowerment/colloboration

• Safety and protection

• Relationship issues (caring, acceptance,

empathy)

• Informed consent

The Lighthouse Model of Stabilization

Rage against the storm

The Toolkit "Take the first step in faith. You don't have to see the whole staircase, just take the first

step." ~Martin Luther King, Jr

The hidden toolkit

Question: How do you cope?

Sadness

Fear

Upsetting

memories

Guilt

Anger

Grief

Shame Criticism

Despair

Loss

The window of tolerance.

Toolkit

Anger

Panic

Flashbacks

Numbing

Dissociation

Stabilization Toolkit

• Grounding skills *

• Breathing re-training

• Relaxation exercises/self-soothe strategies

• Bio-feedback

• Mindfulness and meditation (Mindfulness Group) *

• Imagery (container and safe place visualizations) *

• Creative expression (music, art, writing)

• Compassionate mind training exercises

• Emotional regulation techniques and distraction strategies

• Sand Tray Work

• EMDR adapted resourcing/containing work

• Ego state stabilization/parts of self work

Debbie’s Window of Tolerance

Hyperarousal Flight

Fear and hyper vigilant: “ I can’t be trapped, don’t touch me, I can’t get too close or committed. I need to escape, if I

can’t, I will escape with prescription drugs”

Fight

Anger and injustice: “I won’t trust, I won’t be controlled, I will show you, I will push people away, I will test your

credibility”

Hypoarousal Attach

“ I can’t take care of myself, I’m in danger, please love me, don’t leave me alone”

Emotional numbing

Dissociation and depression increase. “I deserved it, I’m weak and helpless, I feel nothing, I’m detached”

Window of Tolerance

Debbie’s parts of self

Grounding, Mindfulness and Imagery

Grounding

Grounding Practice – Role play

5,4,3,2,1

Scenario: Debbie has just arrived for session.

• Emotionally triggered by recent altercation with a member of public

prior to coming in for the appointment.

• Presenting with increased hyperarousal

• Intrusive recollections, anger and behavioural dysregulation.

Mindfulness

• Mindfulness is paying attention, on

purpose, non-judgementally

~ Jon Kabat Zin

Container and safe place imagery

Client examples:

Containers • Sea shipping container

• Tool box

• Filing cabinet

• Book

• Steel trunk

• Treasure chest

• Hat box

Client examples

Safe Place • A beach scene

• A garden scene

• Standing on a mountain top

• A cabin in the woods

• Visualizing colors/patterns

• A clear lake

• Fishing

• Standing behind a waterfall

Safe Place visualization

• Imagery practice

Couple Profile: Jim and Christine

• Married seven years

• Two children; 5 year old girl and 3 year old boy

• Jim previously married from 1993 to 1996

• Both partners have had positive childhoods

• Jim is a 25 yr. member of the RCMP

• Christine’s father was an RCMP officer and she

used to work in the civilian IT department for the

RCMP prior to having children.

• Started couples therapy in July 2011

Marital Issues

• Jim’s intense hyperarousal and its impact on the

family

• Jim’s reactivity to his children’s crying

• Jim’s emotional dysregulation,sense of

hopelessness, and self-criticism

• Lack of emotional connection and validation

• Christine’s minimization of her own needs and

vulnerabilities

• Christine and Jim’s avoidance of marital issues

Barriers to Treatment

• For the first year, inconsistent marital therapy

appointments

• Lack of childcare and limited resources

• Jim’s level of hyperarousal and low distress

tolerance

• Physical sickness

• Avoidance

• Jim’s difficulty focusing on treatment while

working

Impact of PTSD on family




footage.


Secondary Traumatization

• Christine becomes emotionally numb.

• She becomes hyperaroused as she

anticipates Jim’s responses.

• Christine’s emotional distress is managed

through avoidance.

• She decreases her communication with

Jim and shuts down emotionally.

• Christine suffers from physical illness,

sleep disruption, and suspiciousness.

Attachment Styles and Interactional Pattern

• An avoidant attachment style emerges for

both partners

Self awareness of attachment style




footage.


The Tenets of Attachment Theory

• Attachment is an innate motivating force.

• Secure dependence complements

autonomy.

• Attachment offers an essential safe haven.

• Attachment offers a secure base.

• Emotional accessibility and

responsiveness build bonds.

• Fear and uncertainty activate attachment

needs. Dr. Susan Johnson, 2004

The Tenets of Attachment Theory

• The process of separation distress is

predictable.

• A finite number of insecure forms of

engagement can be identified.

• Attachment involves working models of

self and other.

• Isolation and loss are inherently

traumatizing. Dr. Susan Johnson, 2004

Attachment Tracking

• The attachment relationship between the

therapist and the member

• The attachment relationship between the

therapist and the partner

• The couple’s attachment relationship

• How the therapist relates to the couple’s

relationship

Stabilization

• Interventions are geared towards

improving emotion regulation of the couple

system, ensuring safety (physical and

emotional safety), and decreasing

avoidance.

• Safety is established through the de-

escalation of negative cycles of separation

distress.

• Validation of attachment needs and

processes.

Interventions

• The therapist works within the couple’s

window of tolerance and attempts to

expand it.

• The creation of new interactions that

restructure the relationship into a more

secure bond (e.g. withdrawer

engagement, blamer softening).

• Repair of attachment injuries and

violations. Dr. Susan Johnson, 2004

Interventions

• Actively use new interactions to revise

negative models of self that inhibit

emotional engagement with the spouse.

• Consolidation and Integration.

• The goal of therapy is to create a secure

bond. Dr. Susan Johnson, 2004

Safety and Progress




footage.


Special Considerations for Complex PTSD

• The couple’s therapist needs to liaise with

the individual therapist who is working with

the client.

• Careful assessment of the issue of

possible violence due to loss of affect

regulation (ongoing).

• The need to address how survivor clients

deal with posttraumatic reactions and

feelings.

Special Considerations Cont’d

• Psychoeducation re: psychological

trauma and its effects.

• Tailoring the goals of therapy and length of

therapy process to the needs of each

couple.

• Therapist Alliance – The therapist must be

accessible and responsive in a

collaborative way with each partner

throughout the therapy process. » Courtois and Ford, 2009

Partnership, Therapeutic Alliance, and Hope




footage.



• Both technique and relationship are

important influences on outcome.

• The quality of the therapeutic relationship

is of central concern.

• The therapy relationship is the catalyst for

change. Courtois and Ford, 2009


• Individual sessions for the spouse/partner

that is focused on psychoeducation, self-

care, and increasing her resources.

• These sessions are opportunities to

enhance the therapeutic alliance through

attunement and can create a safe haven.

• Individual treatment for the spouse.

• The need to liase with the individual

therapist who is working with the spouse.


• Often times, spouses will not access

individual treatment due to:

• The limited number of sessions covered

by insurance

• The partner’s therapist’s lack of

understanding of Complex PTSD

diagnosis (e.g. Suggesting the spouse

should leave the relationship)

• The difficulty working as a team with a

community based therapist.

Special Considerations

• The course of treatment is non-linear. The

de-escalation phase will be revisited.

However, the frequency and intensity of

the escalation is variable and often

resolved more quickly over time.

• Returning to the de-escalation phase in

couple’s therapy must not be viewed as

therapy/client failure given that the

individual client will alternate between

stabilization and active trauma Tx.

Panel Discussion

Questions?

References

Allen, B. & Lauterbach, D. (2007). Personality characteristics of adult survivors of childhood trauma.

Journal of Traumatic Stress, 20(4), 587-595.

Bryant, R. (2012). Simplifying complex PTSD: Comment on Resick et al. Journal of Traumatic

Stress, 25(3), 252-253.

Courtois, C. A., & Ford, J. D. (2009). Treating complex traumatic stress disorders. New York City,

NY: The Guildford Press.

Creamer, M., Forbes, D. (2004). Treatment of posttraumatic stress disorder in military and veteran

populations. Psychotherapy: Theory, Research, Practice, Training, Vol 41(4), 2004, 388-398.

Fosha, D. (2000). The transforming power of affect: A model for accelerated change. New York City,

NY: Basic Books.

Friedman, M., Resick, P., Bryant, R., Brewin, C. (2011). Considering PTSD for DSM-5.

Depression and Anxiety 28. 9 : 750-769.

References

Frueh, B.C., Turner, S.M., Beidel, D.C., Mirabella, R.F., Jones, W.J,. Trauma Management

Therapy: A preliminary evaluation of a multicomponent behavioral treatment for chronic

combat-related PTSD. Behaviour Research and Therapy 1996;34:533–543. [PubMed:

8826760]

Hassija, C.M., Jakupcak, M., Gray, M.J,. Numbing and dysphoria symptoms of posttraumatic

stress disorder among Iraq and Afghanistan War veterans: a review of findings and

implications for treatment. Behavior modification. 2012 Nov;36(6):834-56. doi:

0.1177/0145445512453735. Epub 2012 Sep 12.

Jaeger, J. Alterations in Emotional Numbing in PTSD: Effects of Treatment and Recovery.

University of Washington, 2010, 87 pages; 3431670.

Johnson, S. M. (2003). Introduction to attachment: A therapist’s guide to primary relationships and

their renewal. In S. M. Johnson & V. E. Whiffen (Eds.), Attachment processes in couple and

family therapy (pp. 3-17). New York City, NY: The Guildford Press.

Korn, D. L. & Leeds, A. M. (2002). Preliminary evidence of efficacy for EMDR resource

development and installation in the stabilization phase of treatment of complex posttraumatic

stress disorder. Journal of Clinical Psychology, 58(12), 1465-1487.

References

Litz, B.T., Schlenger, W.E., Weathers, F.W., Caddell, J.M., Fairbank, J.A., LaVange, L.M.

Predictors of emotional numbing in posttraumatic stress disorder. Journal of Traumatic Stress,

1997 Oct;10(4):607-18.

Kitchur, M. (2005). The strategic development model for EMDR. In R. Shapiro (Ed.) EMDR

Solutions: Pathways to Healing. New York City, NY: W.W. Norton & Company, Inc.

O’Shea, K. & Paulsen, S. (2009). When there are no words [Workshop presentation]. Attended

December 2011.

Orsillo, S.M., Theodore-Oklota, C., Luterek, J.A., Plumb, J. The development and psychometric

evaluation of the emotional reactivity and numbing scale. Journal of nervous and mental

health disease. 2007 Oct;195(10):830-6.

Pagani, M., Di Lorenzo, G., Verardo, A. R., Nicolais, G., Monaco, L., Lauretti, G., Russo, R., Niolu,

C., Ammaniti, M., Fernandez, I. & Siracusano, A. (2012). Neurobiological correlates of EMDR

monitoring – An EEG study. PLoS ONE, 7(9): e45753. doi:10.1371/journal.pone.0045753

References

Rauch, S.A., Defever, E., Favorite, T., Duroe, A., Garrity, C., Martis, B., Liberzon, I.

Journal of Traumatic Stress, 2009 Feb;22(1):60-4. doi: 10.1002/jts.20380.

Resick, P. A., Bovin, M. J., Calloway, A. L., Dick, A. M., King, M. W., Mitchell, K. S.,

Suvak, M. K., Wells, S. Y., Stirman, S. W. & Wolf, E. J. (2012). A critical evaluation of

the complex PTSD literature: Implications for DSM-5. Journal of Traumatic Stress,

25, 241-251.

Sugaya, L., Hasin, D. S., Olfson, M., Lin, K. H., Grant, B. F. & Blanco, C. (2012). Mental health

sequelae of childhood physical abuse. Journal of Traumatic Stress, 25(4), 384-392. doi:

10.1002/jts.21719

Terr, L. C. (2003). Childhood traumas: An outline and overview. The Journal of Lifelong Learning in

Psychiatry, 1(3), 322-334.

Tuerk, P. W., Wangelin, B., Rauch, S. A. M., Dismuke, C. E., Yoder, M., Myrick, H., Eftekhari, A., &

Acierno, R. (2012). Health service utilization before and after evidence-based treatment for PTSD.

Psychological Services. doi: 10.1037/a0030549

References

van der Kolk, B. A. (2001). The assessment and treatment of complex PTSD. In R. Yehuda

(Ed.), Traumatic Stress (pp. 2-29). Arlington, VA: American Psychiatric Press.

van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzala, J. (2005). Disorders of

extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of

Traumatic Stress, 18(5), 389–399 .

Van Voorhees, E. E., Dedert, E. A, Calhoun, P. S., Brancu, M. Runnals, J., Beckham, J. C. &

VA Mid-Atlantic MIRECC Workgroup (2012). Childhood trauma exposure in Iraq and

Afghanistan war era veterans: Implications for posttraumatic stress disorder symptoms and

adult functional social support. Child Abuse & Neglect, 36, 423-432.

Zetterberg, J. (2010). Trauma and recovery: a literature study of Dr. Judith Herman’s research

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