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Advances in the Understanding and Treatment of Trauma:
Variable Adaptations, Variable Treatments
Christine A. Courtois, Ph.D.Psychologist, Private Practice
Washington, DC [email protected]
www.drchriscourtois.com
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Types of Trauma Accidental
Interpersonal
Combination
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Interpersonal Trauma:
“A break in the human lifeline”Robert J. Lifton
Self and interpersonal effects brought to treatment
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Types of Traumatic Stressors
Emotional Trauma
“It is the essence of emotional trauma that it shatters…absolutisms, a catastrophic loss of innocence that permanently alters one’s sense of being-in-the-world.”
(Heidegger, quoted in Stolorow, 2007)
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Types of Trauma Type I
Type II
Overlap
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Types of Trauma Attachment/Relational
Emotional
Betrayal
Secondary/ “second injury”/institutional
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What is Complex Trauma?
Repetitive, chronic Cumulative Often in attachment relationships
• Entrapment & betrayal; second injury Often over the course of childhood
• Impacts development Other…
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Trauma and Development Attachment trauma Attachment style and Inner Working Model
• Secure • Insecure• Disorganized
Lack of self validation/reflection Effect on brain development
• Survival brain vs. learning brain
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Trauma and Development Can effect development starting at the
neuronal level• Neurons that fire together wire together
Can affect brain structure Can affect brain function Right brain/sensory-motor imprint Left brain development impeded
• There may be no words• Speechless terror
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Types of Traumatic Stressors Attachment/Relational Trauma
occurs in attachment relationships with primary caregiversinsecurity of response and availabilitymis-attunement, non-responselack of caring and reflection of self-worthcaregiver as the source of both fear and comfort
includes DV and child abuse of all typesoften “on top of”/in context of attachment insecurityneglect, abandonment, non-protection, non-response,
sexual and physical abuse and violence, verbal assault
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Risk/Vulnerability and Protective Factors
Temperament Gender Personal history
• Previous trauma/PTSD Culture Community
• Support or not
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Posttrauma Adaptations (adapted from Wilson, 1989)
Note: most individuals who are seriously traumatized have posttraumatic reactions; not all develop posttraumatic disorders.
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DSM-IV Criteria: PTSD
A. Exposure or experience B. Persistent reexperiencing, intrusions,
dreams of trauma, distress at re-exposure C. Persistent avoidance of stimuli
associated with the trauma and numbing D. Persistent symptoms of increased
arousal
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Posttraumatic Diagnoses, DSM-IV
Dissociative Disorders• Depersonalization• Dissociative fugue• Dissociative amnesia• Dissociative Identity Disorder
– related to severe childhood trauma• DDNOS
Associated Disorders: Axis I, II, & III
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Limbic System of the Brain
Limbic System of the Brain
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Posttraumatic Stress Disorder (PTSD)
A complex dynamic entity• fluctuating, not static• variable in form, presentation, course, degree of disruption
A multimensional bio-psycho-social- spiritual-gender stress response syndrome
An allostatic condition
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Posttraumatic Stress Disorder (PTSD)
Allostasis: “refers to the body’s effort to maintain stability through change when loads or stressors of various types place demands on the normal levels of adaptive biological functioning…The failure to “switch off” allostatic mechanisms once the threat or requirement to respond has terminated, however, begins a complex process of “wear and tear” on the nervous and hormonal systems”.
( Wilson, Friedman, & Lindy, 2002, p. 9)
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Allostasis: One’s thermostat is broken
Stress overload
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Post-trauma Responses and Disorders Complex Posttraumatic Stress Disorder/ (DESNOS) “PTSD
plus”• related to severe chronic abuse, usually in childhood, and
attachment disturbance• usually highly co-morbid• often involves a high degree of dissociation
Dissociative Disorders• associated with disorganized attachment and/or abuse in
childhood• can develop in the aftermath of trauma that occurs any
time in the lifespan• DDNOS may be the most common DD (as currently
defined in the DSM)
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Complex Posttraumatic Stress Disorder Disorders of Extreme Stress Not Otherwise Specified
(DESNOS)
Designed to account for developmental issues, co-morbidity, memory variability and reduce stigma
Co-morbidity:• distinct from or co-morbid with PTSD• other Axis I, mainly:
– depressive and anxiety disorders– substance abuse/other addictions– impulse control/compulsive disorders
• Axes II and III
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PTSD in Children No available childhood PTSD or DD
diagnosis in the DSM Children respond as children, not as little
adults• work of Terr, Putnam, Pynoos, Perry has been
instrumental to early understanding of childhood trauma
Children are very vulnerable, yet resilient• on average, takes less to traumatize them
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(Proposed) Developmental Trauma Disorder(van der Kolk, 2005)
Domains of impairment in children exposed to complex trauma: Attachment/relationship capacity Biology Affect regulation Dissociation Behavioral control Cognition Self-concept
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Symptom Categories and Diagnostic Criteria for Complex PTSD/DESNOS
l. Alterations in regulation of affect and impulses• a. Affect regulation• b. Modulation of anger• c. Self-destructiveness• d. Suicidal preoccupation• e. Difficulty modulating sexual involvement• f. Excessive risk taking
2. Alterations in attention or consciousness• a. Amnesia• b. Transient dissociative episodes and
depersonalization
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Symptom Categories and Diagnostic Criteria for Complex PTSD/DESNOS
3. Alterations in self-perception• a. Ineffectiveness• b. Permanent damage• c. Guilt and responsibility• d. Shame• e. Nobody can understand• f. Minimizing
4. Alterations in perception of the perpetrator• a. Adopting distorted beliefs• b. Idealization of the perpetrator• c. Preoccupation with hurting the perpetrator
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Symptom Categories and Diagnostic Criteria for Complex PTSD/DESNOS 5. Alterations in relations with others
• a. Inability to trust• b. Revictimization• c. Victimizing others
6. Somatization• a. Digestive system• b. Chronic pain• c. Cardiopulmonary symptoms• d. Conversion symptoms• e. Sexual symptoms
7. Alterations in systems of meaning• a. Despair and hopelessness• b. Loss of previously sustaining beliefs
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Complex PTSD/DESNOS Controversial Not a formal DSM diagnosis: Associated Feature of
PTSD Nevertheless, a useful way of organizing
symptoms and treatment A less pejorative way of understanding and
approaching the treatment of those who often look and behave like BPD
Empirical investigation underway
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Attachment Organization (Ainsworth, 1978; Liotti, 1992; Main, 1986, Siegel, 1999)
Child style• secure
• insecure-avoidant
• insecure-dismissing/ resistant/ambivalent
• insecure-disorganized/ disoriented/dissociated
Adult style• autonomous
• dismissive/detached
(“teflon”)
• preoccupied/anxious
(“velcro”)• fearful/anxious
unresolved/dissociative
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Attachment Relationships “…are crucial to the process of integration. The
difficulties that bring patients to treatment usually involve unintegrated and undeveloped capacities to feel, think, and relate to others (and to themselves) in ways that ‘work’”
Paraphrasing Bowlby, “The therapy relationship involves sanctioning patients to think thoughts, experience feelings and consider actions that parents have forbidden.” (Wallin, 2007)
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Implications for Treatment Attachment abuse including ongoing neglect and
failure to respond and soothe a child (neglect) is implicated in the development of the DD’s• a wider base beyond overt physical and sexual
abuse from which to understand DD’s The emphasis in treatment is shifted back toward
education and the intrapsychic and interpersonal patterns started early in life and away from solely working through the other forms of childhood and adult trauma
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Evidence-Based Practice Best research
evidence Clinical expertise Patient values,
identity, context
American Psychological Association Council of Representatives Statement, August 2005
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Note: EBT (Evidence-Based Therapy)
is NOT the same as
EST (Empirically-Supported Therapy)
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Evidence-Based Practice Best research evidence, including:
• Effectiveness
• Public health
• Health services
• Health care economics
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Evidence-Based Practice Clinical expertise, including:
• Clinical assessments, judgments, decision-making
• Reflection & consultation• Interpersonal expertise/use of self
– ability to collaborate, not exploit– ability to stay “steady state”, attune to client
• Understanding of client’s contexts, values• Using available resources• Working from theory
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Evidence-Based Practice Patient identity, values, contexts
• Ethnicity, race, culture, language, gender, sexual orientation, religion, age, illness or disability status
• Treatment acceptability
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Expert Consensus Guidelines for “Classic PTSD”
ISTSS Guidelines (Foa, Friedman, & Keane, 2000, 2008)
Journal of Clinical Psychiatry (2000) American Psychiatric Association (2003) Clinical Efficiency Support Team (CREST,
Northern Ireland, 2003) Veterans’ Administration/DoD (US, 2004) National Institute of Clinical Excellence (NICE,
UK, 2005) Australian Centre for Posttraumatic Mental Health
(2007)
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Other Expert Consensus Guidelines
Dissociative Disorders• Adult (ISSD, 1994, 1997, 2005, in revision• Children (ISSD, 2001)
Delayed memory issues• Courtois (1999; Mollon, 2004)
Complex trauma (under development)• (Courtois, 1999; CREST, 2003; Courtois &
Ford, 2009; ISTSS complex trauma expert consensus survey, in process)
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Effective Treatments for PTSD* Psychopharmacology Psychotherapy (CBT, especially) Psych-education
Other supportive interventions
*Few studies have evaluated using a combination of these approaches although combination treatment commonly used and may have advantages
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Treatment Goals educate about and de-stigmatize PTSD sx increase capacity to manage emotions reduce co-morbid problems reduce levels of hyperarousal re-establish normal stress response decrease numbing/avoidance strategies face rather than avoid trauma, process emotions,
integrate traumatic memories
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Treatment Goals 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
restore physical self restore spiritual self prevent re-victimization/reenactments
SAFETY IS THE FOUNDATION
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Treatment Principles
“First, do no more harm”
Treatment can help and treatment can hurt
both the helper and the client
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Treatment Principles Treatment meets standard of care Treatment is individualized
• initial , ongoing, & collateral assessment• not laissez-faire treatment: organized and planful• ongoing review/adjustment of treatment plan
Client empowerment/colloboration• client engagement in the process, with responsibility for
progress• client consulted on/understands treatment plan• posttraumatic treatment philosophy and techniques
explained
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Treatment Principles Safety and protection
• Safety of self and others, to and from others
Relationship issues • Boundaries, limitations, respect• Responsibilities of the therapist
– trustworthy/non-exploitive – relationship as container
Informed consent/refusal; client rights• professional privilege/limits of confidentiality• right to seek consultation/2nd opinion• rights to refuse and terminate treatment
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Treatment
Variable Adaptations
Variable and Multi-modal Treatments
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Complex Trauma Treatment
• Specialized techniques, applied later– EMDR for resource installation/affect mgt,
CBT (exposure therapies), CPT, stress inoculation
• Other techniques as needed (careful application)– relaxation, exercise, group, education,
wellness
• Couple or family work
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Complex Trauma Treatment PTSD symptoms Depression, anxiety, & dissociation Problems with affect regulation
• may rely on maladaptive behaviors, substances• problems with safety
Negative self-concept Problems with self, attachment,relationships
• revictimization/re-enactments• needy but mistrustful
Problems functioning? Physical/medical concerns Other...
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Complex Trauma Treatment “Not trauma alone” (Gold, 2000)
Multi-theoretical and multi-systemic Integrative Addresses attachment/relationship issues in
addition to life issues and trauma symptoms and processing of traumatic material
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Treatment Sequence Safety, stabilization, skill-building Trauma processing Integration and meaning, self and
relational development
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Treatment Sequence: General Stages of Treatment
Pre-treatment stage: Contracting, assessment, pre-treatment issues
Early stage: Safety, stabilization, skill-building, self-management, security in tx relationship
Middle stage: Trauma de-conditioning, processing, mourning, resolution, moving on
Late stage: Self and relational development from a new perspective
Note: Non-linear and not lockstep: a back and forth, titrated process with attention to and planning for relapse
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Treatment: Chronic PTSD May be delayed/chronic
• Longer term treatment (ongoing or episodic)– comorbidity/dual dx
• Psychopharmacology• Stabilization, skills training, crisis management, safety, affect
regulation, life skills, self-care• Specialized techniques, applied later
– EMDR for resource installation/affect mgt, CBT (exposure therapies), CPT, guided imagery & energy & somatosensory techniques, stress inoculation
• Other techniques as needed (careful application)
– relaxation, exercise, group, education, wellness, couples or family work, etc.
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Treatment: Chronic/Complex PTSD Ongoing assessment Longer term treatment (ongoing or episodic)
• comorbidity/dual dx/co-ocurring dx Sequenced treatment
• more initial emphasis on stabilization, self-management, affect regulation, safety, relapse planning
Psychopharmacology Specialized techniques, applied later
• EMDR starting w/ resource installation/affect mgt, CBT (graduated and/or direct exposure), CPT, stress inoculation, relaxation, hypnosis, group, education, wellness, couple’s or family work
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“Hybrid” Models for Complex Trauma
TARGET (Ford)
STAIR-NTP (Cloitre)
Seeking Safety (Najavits)
ATRIUM (Miller)
SAFE Alternatives (Conterio & Lader)
Others...
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Treatment
Like Posttraumatic Disorders, comprehensive treatment must be
BIO-PSYCHO-
SOCIAL/SPIRITUAL &
Culture and Gender Sensitive
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Bio/Physiological Treatments• Psychopharmacology
– evidence base developing re: effectiveness– algorithms developed– not enough by itself
• Medical attention– preventive– treatment
• Movement therapy
• Movement therapy
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Bio/Physiological Treatments Stress management Self-care/wellness:
• Exercise (w/ care)• Nutrition• Sleep• Hypnosis/meditation/mindfulness• Addiction treatment
– Alcohol, drugs, prescription drugs– Smoking cessation– Other addictions (sexual, spending)– Relapse planning
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Bio-physiological Treatments
Somatosensory/Body-focused Techniques(Levine; Ogden; Rothschild,
Scaer)
Remember: The brain is part of the body! Paying attention to the body in the room
• interpersonal neurobiology Neurofeedback/EEG Spectrum Massage and movement therapy Dance and theatre Yoga
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Psychosocial/Spiritual Treatments
The therapy relationship--has the most empirical support of any “technique”
Especially important with the traumatized Especially important in interpersonal
violence and in developmental trauma• attachment studies• brain development studies• striving for secure attachment
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Psychosocial/Spiritual Treatments
Psych-education (individual or in group) individual and group therapy
• trauma focus vs. present focus• skill-building• core affect and cognitive processing• developing connection with others
– identification and meaning-making
• concurrent addiction/ED couple and family therapy
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Psychosocial/Spiritual Treatments adjunctive groups/services
• AA, Al-Anon, ACA, ACOA, etc.• Social services/rehabilitation• Career services• Internet support and information
spiritual resources: finding meaning in suffering
• Pastoral and spiritual care• Organized religion• Other religion/spirituality• Nature, animals
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Cognitive Behavioral, Emotional/ Information Processing Treatments Education & skill development
numerous workbooks now available on a wide variety of topics general, CD, self-harm, risk-taking, eating,
dissociation, spirituality, career, etc. Exposure and desensitization (Foa et al.)
prolonged & graduated Writing/journaling
CPT (Resick) Journaling (Pennebaker)
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Cognitive Behavioral, Emotional/ Information Processing Treatments Schema therapy (Young; McCann & Pearlman) DBT (may involve “tough love stance”) (Linehan)
mindfulness and skill-building Narrative therapies (various authors) Strength/resilience development
EMDR resource installation (Leeds & Korn) Developmental Needs Meeting Strategy (Schmidt)
Internal Family System work (Schwartz) Solution-focused treatment (O’Hanlon)
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Cognitive Behavioral and Information-Processing Treatments
EFTT: emotion-focused therapy for trauma (Paivio)
ACT: acceptance and commitment therapy(Hayes, others)
FAT/FECT: Functional Analytic Therapy (Tsai, Kohlenberg)
IRRT: imaginary re-scripting and re-processing therapy (Smucker)
Virtual Reality (Rothbaum, others)
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Affect-Based Treatments AEDP: Accelerated Experiential-Dynamic
Psychotherapy (Fosha) Affect Experiencing-Attachment Theory
Approach (Neborsky) Healing the Incest Wound
(Courtois; Roth & Batson) Repair of the Self (Schore, others) Techniques for identifying and treating
dissociation (ISSD, Kluft, Putnam, Ross, others)
Relational and affect-based psychoanalytic techniques (Bromberg, Davies & Frawley, Chefetz, others)
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Core Affects Fear/terror Anxiety Depression Anger/rage/outrage Shame Self-blame/guilt Confusion Grief/mourning/sadness Alienation Other…
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Relational/Attachment Treatments
Understand client’s attachment style and Inner Working Model• Helps expect how the client relates and behaves
Strategize how to respond Goal: to move to secure attachment through
insights gained in and through the therapy relationship
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Relational/Attachment Techniques Interpersonal neurobiology (Schore, Siegel) Relational and affect-based psychoanalytic tx Patient in relationship with others
determine attachment style Therapist
determine attachment style secure connection with the therapist to foster secure
connections elsewhere (“earned security”) transference/countertransference, enactments, VT
Spouse/partner/significant other couple and family work
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Relational/Attachment Techniques Hypnosis or EMDR-based internalization of
attachment (Brown; Leeds & Korn; Omaha)
Children parenting help/training
Friends substitute family social and friendship skills
Support systems Work colleagues
Note: Various workbooks and community training programs available for these
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Hypnosis/Guided Imagery Techniques
Caution: for ego development, self-soothing, attachment, not for memory retrieval
Hypnosis Brown & Fromm; Brown Dolan Phillips & Frederick Kluft Schwarz
Guided Imagery Naparstek
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Expressive Techniques
Art collage images pottery/clay work
Poetry/writing Psychodrama Movement
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Spirituality/Mindfulness
Nature Specific spiritual writers and orientations The meaning of suffering Existential issues Religion Pastoral care/spiritual issues Prayer Spiritual formation
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Cultural/Ethnic/Gender/Religious Social context/ethnic group and how it
might contributes to trauma– racism, sexism, heterosexism and homophobia,
cultural or ethnic norms, colonialism, etc.
Blocks or supports to healing Take these issues into account Healing rituals Healers
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Treatment: Chronic/Complex PTSD Some never fully recover from symptoms even after many years/intensive treatment
• those w/ history of childhood abuse/trauma and other risk factors
The absence of symptoms does not mean that the disorder has run its course • patterns of cyclical decompensation have been identified
Treatment is applied according to the phase of the decompensation cycle
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Summary Trauma studies have increased information and
understanding• Trauma can vary dramatically, as can responses• New conceptual and diagnostic models account for
variability Treatment
• Is multimodal• Is bio-psycho-social• Must be individualized
– type of trauma response/disorder– individual needs
• Has some empirical support…more to come!
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Resources
ISTSS.org ISSTD.org--new name; formerly (ISSD.org)
• 9 month-long courses on the treatment of DD’s--various locations
NCPTSD.va.gov (info and links) NCTSN.org (child resources) Sidran.org (books and tapes) APA Division 56, Psychological Trauma APA.org [email protected] please join!!
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The Rewards of the Work
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