Certified Clinical Trauma Professional: - PowerPoint Presentation

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Certified Clinical Trauma Professional: Trauma, PTSD, Grief & Loss

International Association of Trauma Professionals

J. Eric Gentry, PhD, LMHC

Board-Certified Expert in Traumatic StressSlide2

Welcome

Day ISlide3

EXPERIENTIALPick a trauma to work with for Day Two

Can be your own, role play of a client, or completely made upSUDs < 5All exercises are completely voluntaryIATP 5 Integrative Narrative Model of Trauma Memory Processing (Gentry, 2004)Slide4

Brief History of Traumatic StressHistorical Vernacular of Traumatic StressNostalgia

– Swiss militaryHomesickness – German militaryEstar Roto – Spanish “to be broken”Soldier's Heart/Irritable Heart – Civil WarHysteria – JanetShell-shocked - WWIWar Neurosis - FreudCombat Exhaustion - WWII

Railway Spine/Compensation NeurosisPTSD – DSM III (1980)Slide5

Brief History of Traumatic Stress

19

th

CenturySlide6

Brief History of Traumatic Stress Tx19th Century:Jean Martin Charcot

- symptoms of trauma (1860)John Eric Erichsen – railway spine (1867)Jacob Mendes Da Costa –soldier’s Heart (1871)Pierre Janet – (1883) Dissociation, subconscious, psychasthenia. Developed effective treatment using hypnosis to narrate and integrate memory fragments (not discovered until 1980s). In 1913, Janet publicly charged Freud with plagiarism.

Freud & Breuer – relationship between traumatic life events and subsequent psychological problems. Explained hysteria as reaction to CSA - Aetiology of Hysteria (1896) – Recanted 1905.Slide7

Brief History of Traumatic Stress

Tx

20

th

CenturySlide8

Brief History of Traumatic Stress Tx20th Century:

Joseph Wolpe – Reciprocal Inhibition (1958)Herbert Benson – Relaxation Response (1968)Charles Figley – Vietnam Stress Syndrome > PTSD (1980 - ).

Onno van der Hart – Abreaction Re-evaluated (1992 - )Bessel van der Kolk – Trauma = brain injury / Tx & research pioneer (1989 - )

Louis

Tinnin

–

Anamesis

& The Instinctual Trauma Response (1991)

Cornelia Wilbur

– Sybil’s Therapist. Dissociation

Francine Shapiro

– EMDR (1989)

Patricia Resick/Edna Foa/Donald Michenbaum - CPT/PE/SITBenish, Imel & Wampold – All PTSD Tx equal (2008)Gentry, Rhoton & Baranowsky – Active Ingredients Approach Slide9

The Active Ingredients ApproachTrauma Treatment for the 21st CenturyInternational Association of Trauma Professionals

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Clinical Excellence: Breaking it downSystematic The process is based on an organized and structured “active ingredients” approach

Deliberate (no Automaticity) In order to be successful, we must develop a belief that a sustainable trauma informed and sensitive approach can permeate and be embraced across the organization.Continuous A never-ending process…no matter how good we think we are doing, there is always room for improvement. Dr. Bob’s mantra:

“sucking a little less each day” International Association of Trauma Professionals

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Changing the ParadigmThe relative efficacy of bona fide psychotherapies for treating

post- traumatic stress disorder: A meta-analysis of direct comparisonsSteven G. Benish,

Zac E. Imel, Bruce E. WampoldReceived 4 June 2007; received in revised form 8 October 2007; accepted 23 October 2007

Abstract

Psychotherapy has been found to be an effective treatment of post-traumatic stress disorder (PTSD), but

metaanalyses

have yielded inconsistent results on relative efficacy of psychotherapies in the treatment of

PTSD. The present meta-analysis controlled for potential confounds in previous PTSD meta-analyses by

including only bona fide psychotherapies, avoiding categorization of psychotherapy treatments, and using

direct comparison studies only.

The primary analysis revealed that effect sizes were

Homogenously distributed around zero for measures of PTSD

symptomology

,

and for all measures of psychological functioning, indicating that there were no differences between psychotherapies. Additionally, the upper bound of the true effect size between PTSD psychotherapies was quite small. The results suggest that despite strong evidence of psychotherapy efficaciousness vis-à-vis no treatment or common factor controls, bona fide psychotherapies produce equivalent benefits for patients with PTSD.© 2007 Elsevier Ltd. All rights reserved.Slide12

Wampold & Imel (2015)“Given the evidence that treatments are about equally effective, that treatments delivered in clinical settings are effective (and as effective as that provided in clinical trials), that the manner in which treatments are provided are much more important than which treatment is provided, mandating particular treatments seems illogical

. In addition, given the expense involved in “rolling out” evidence-based treatments in private practices, agencies, and in systems of care, it seems unwise to mandate any particular treatment.”Slide13

Cloitre M, Courtois CA, Charuvastra A, Carapezza R, Stolbach BC, Green BL. (2011). Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices. J Trauma Stress. 2011 Dec;24(6):615-27. doi: 10.1002/jts.20697. Epub 2011 Dec 6.emotion regulation strategiesnarration of trauma memorycognitive restructuringanxiety and stress management

interpersonal skills.International Association of Trauma Professionals

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Psychotherapies for PTSD: what do they have in common?Schnyder, U., Ehlers, A., Elbert, T., Foa, E. B., Gersons, B. P. R., Resick, P. A., … Cloitre, M. (2015). European Journal of Psychotraumatology, 6, 10.3402/ejpt.v6.28186. http://doi.org/10.3402/ejpt.v6.28186 Psychoeducation

emotion regulation and coping skillsimaginal exposurecognitive processingrestructuringmeaning makingemotions

memory processesInternational Association of Trauma Professionals

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The Phoenix:Austrialiahttp://phoenixaustralia.org/the-6-common-elements-of-evidence-based-therapies-for-ptsd/ Therapeutic alliancepsychoeducationemotional regulation and coping skillssome form of exposure to memories of traumatic experiencescognitive processing, restructuring, and/or meaning makingtackling emotions + altering memory processes.

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Common Elements Trauma Approach (CETA)Relaxation -- Learning specific ways to calm the body down. Cognitive Coping -- Learning how thoughts are connected to feelings and behavior. Exposure-Trauma Memories -- Thinking about the trauma with thoughts and feelings in a safe place. Exposure-Live Facing up to situations in real life that are causing too much distress.

Cognitive restructuring -- Learning how to change stuck thoughts that are keeping distress going. Behavioral Activation -- Planning on and participating in pleasurable activities. Problem Solving -- Learning a specific way to come up with realistic solutions to problems.International Association of Trauma Professionals

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Trauma Competency: An Active Ingredients Approach to Treating PTSD Gentry, Baranowsky & Rhoton (in press).

Journal of Counseling and Developmentcognitive restructuring/psychoeducationa deliberate and continually improving therapeutic relationshiprelaxation and self-regulationexposure via narrative

of traumatic experiencesInternational Association of Trauma Professionals

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Healing Trauma: Active IngredientsTherapeutic Relationship Develop and maintain an attunement with the clientEstablish an emotional bond based on liking the client, trustworthiness and transparency

Empower through focusing on building capacity, giving choicesHelp the client find their own voice through curiosity and respectUsing the relationship to stabilize and recognition that healing occurs within a relationshipSlide19

Healing Trauma: Active IngredientsSelf-Regulation/Relaxation Intentional shifting from Sympathetic nervous system activation to Parasympathetic dominance.Relax physically to activate the Parasympathetic system

Increase awareness of tension in the bodyPsycho-education about the body and the stress and trauma responses to normalize symptomsModel self-regulation until client ready for instructionProvide physiology based self-regulation skills trainingSlide20

Healing Trauma: Active IngredientsExposure/Narrative Memory reconsolidation sequence (Ecker, Ticic, & Hulley, 2012):

Reactivate. The memory must be accessed and reactivated after self regulation is achieved. Mismatch/Contradict. While the memory is reactivated, create an experience that contradicts the problematic learning or mental model that the memory had createdCreate New Learning. Build capacity to aid a different viewing of the self in relationship to the habituated patterns and schemas build on the trauma history.Slide21

Healing Trauma: Active IngredientsCognitive RestructuringNormalizing symptoms by helping the client see themselves as human having a normal human experience

Psychoeducation about symptoms and patternsCorrecting and clarifying perceptionsPrepare for a future that is deliberate and intentional (choice directed rather than reactive)Slide22

The Active Ingredients Eric’s Hierarchy

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Exposure/

Narrative

Interoception

&

Self-regulation

Therapeutic Relationship &

Positive Expectancy

Cognitive

Restructuring/

Psycho-education

CRITERION B

All other

SXSlide23

The Empowerment & Resilience Structure: An Active Ingredients Approach

Preparation & RelationshipPsychoeducation & Self-regulation

Integration & Desensitization

Post

Traumatic

G

rowth

&

R

esilience

Rhoton & Gentry, 2014Slide24

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Exposure

Narrative

Interoception

&

Self-regulation

Therapeutic Relationship &

Positive Expectancy

Cognitive

Restructuring/

Psycho-education

The Empowerment & Resilience Structure:

An

Active Ingredients ApproachStage IStage IIIStage IIStageIVWith Stages I & II completed, many survivors will experience a reduction in Criterion B symptoms to a level of comfort and will not need to revisit their trauma memories. Stage IV is self-help.Slide25

STAGE IPreparation & RelationshipInternational Association of Trauma Professionals25Slide26

Stage I: Preparation & RelationshipOrientation and acculturation around the therapy

process (informed consent)Develop ExpectancyDiscovering capacities and strengths while instilling faith and hope in the therapy

processBegin and continue Feedback Informed Therapy (FIT)

Formal and Informal assessments used to increase relationship and connection

Assessing patterns and developing global goals that will fine-tuned through the process

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“

That which is to give light

Must endure burning” - Viktor Frankl

ResiliencySlide28

Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.

- Viktor

FranklSlide29

In 2013, Feedback Informed Treatment (FIT)–that is, formally using measures of progress and the therapeutic alliance to guide care–was deemed an evidence-based practice by SAMHSA, and listed on the official NREPP website.  It’s one of those good ideas.  Research to date shows that FIT as much as doubles the effectiveness of behavioral health services, while decreasing costs, deterioration and dropout rates. 

SCOTT D MILLER - FEEDBACK-INFORMED THERAPYSlide30

Suggestions for Positive Outcomeswww.scottdmiller.com

Collect empirical data evaluating the quality of the therapeutic relationshipGenerate honest feedback from client on methods to improve therapy (i.e. relational)

Be willing to change toward what works best for client—demonstrate that changeSlide31
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STAGE IIPsychoeducation & Skills-buildingInternational Association of Trauma Professionals32Slide33

Stage IITeach the mechanics of the threat response system Creating a common language to enhance ease of discussion and relational connection

Teach impact of environment Convert discussions of anger, sadness, fear etc, to physiological dysregulation Normalize internal negative messages

Normalize perceptions of self, significant relationships and the world view Normalize relationship, emotional and cognitive patterns.

Explore

meaning

of behaviors for the client

Tools for hope/and other self-regulation skills

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UNDERSTANDING TRAUMAMaking it PersonalSlide35

STRESSCause and Effect

Effects

CausesSlide36

Are You 100% Safe Right Now?Slide37

The Body’s Radar System:Anterior Cingulate of the Cortex (ACC)

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Sensory input

Anterior Cingulate CortexSlide39

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Perceived Threat

Physiological

Brain Mechanics

Other Effects

▲

Heart Rate

▲

Basal Ganglia & Thalamic Fx

▲

Obsession

▲

Breathing Rate

▼

Neo-cortical Fx

▲

Compulsion▼ Breathing Volume▼Frontal Lobe activity▼Executive Fx

▼Fine motor control▼Emotional regulation

▼ Speed & Agility

Centralized Circulation▲ Muscle Tension▼Temporal Lobe Activity▼Language (Werneke’

s)

▼

Speech (Broca

’

s)

▼

Strength

▲

Energy

▼

Anterior Cingulate

Constricted thoughts & behaviors

▲

DIS-EASE

Fatigue

Fight

OR

FlightSlide41

International Association of Trauma Professionals41ENERGY

Neocortical FXTHRESHOLDCompulsive Action

Aggression or AvoidanceStress & ReactivityConstricted

MusclesSlide42

International Association of Trauma Professionals42ENERGY

Neocortical FXTHRESHOLD

IntentionalPrinciple-basedIntegritySelf-regulation & Intentionality

Relaxed

MusclesSlide43

Perceived Threat + Relaxed BodyComfortable with no distressMaximal Neocortical FxIntelligenceCreativity & HumorDexterity

Impulse ControlRelational SkillsIntentional vs. Reactive International Association of Trauma Professionals43Slide44

Quick Write & Pair/Share44Slide45

Optimal Performance:SweetSpotSlide46

Cause and EffectSlide47

High Anxiety

Increased basal ganglia activity

Normal

Note the lessened activity of the basal ganglia

http://www.amenclinics.com/bp/atlas/ch2.php

Stress = Perception of ThreatSlide48

Self-RegulationInteroception

&Balancing the ANSSlide49

InteroceptionPresent “felt sense” on one’s own physiological processesBecoming sensitive to “feedback” from one’s bodyLowering threshold of awareness of dysregulationMonitoring rising levels of energy (SNS activation) and recognizing when there is the need for conscious and intentional intervention (i.e., releasing constricted muscles)

You want to know what heals trauma? … Interoception heals trauma- Bessel van der KolkSlide50

Chill

Developing “bodyfull-ness”Interoception + Self-Regulation = Trauma Resolution Slide51

51Body Scan/”Wet Noodle”Diaphragmatic BreathingPeripheral visionPelvic floor relaxation

SKILLSSelf-RegulationSlide52

Non-technical Methods for Self-RegulationBody Scan/”Wet Noodle”52

Head-to-toe

Toe-to-headRELAX TENSE MUSCLES5 secondsRELAX ALL MUSCLES

Secondary

– Tighten tense muscles for 5 seconds then releaseSlide53

53Self Regulation:Peripheral VisionFocus on a spot straight aheadKeeping your focus, widen your field of view and notice what you see in your peripheral visionSlide54

54Self Regulation:Pelvic floor relaxationFocus on 4 points: Bilateral Anterior Superior Iliac Spine and Ischial

Tuberosities Imagine these 4 points pushing outward and muscles in-between softenedSlide55

Self-Regulation

No ClenchingSlide56

Relaxing tension of pelvic floor muscles switches from sympathetic to parasympathetic dominancePsoas, Sphincter, and Kegels (anterior + posterior)Regaining of neocortical functioning in 20-30 secondsRelieves pressure on vagus nerveImpossible to experience stress – comfortable in one’s own skin

Self-Regulation

Porges

(2014; 2011)

B

.

Scaer

(2006)

NIMH (2004)

D.

Bercelli

(

2003)Slide57

Who is squeezing the muscles in your body? STOPSlide58

PostTraumatic Stress DisorderDSM VSlide59

17 Symptoms of PTSDDSM IV - TR

Criterion A: Event 13

2Slide60

20 Symptoms of PTSDDSM V

112

2Criterion A: Event Slide61

DSM-5: PTSD Criterion A The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: Direct exposure Witnessing, in person

Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies or pictures.Slide62

DSM-5: PTSD Criterion B Intrusion (1/5 symptoms needed) Recurrent, involuntary and intrusive recollections. (children may express this symptom in repetitive play)

Traumatic nightmares. (children may have disturbing dreams without content related to trauma )Dissociative reactions (e.g. flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. (children may re-enact the event in play)Intense or prolonged distress after exposure to traumatic reminders.Marked physiological reactivity after exposure to trauma-related stimuli Slide63

DSM-5: PTSD Criterion C Persistent effortful avoidance of distressing trauma-related stimuli after the event (1/2 symptoms needed): Trauma-related thoughts or feelings Trauma-related external reminders (e.g. people, places, conversations, activities, objects or situations) Slide64

DSM-5: PTSD Criterion D Negative alterations in cognitions and mood that began or worsened after the traumatic event (2/7 symptoms needed)Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol or drugs) (C3 in DSM-IV) Persistent (& often distorted) negative beliefs and expectations about oneself or the world (e.g. “I am bad,” “the world is completely dangerous”) (C7 in

DSM-IV)Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences (new)Persistent negative trauma-related emotions (e.g. fear, horror, anger, guilt, or shame) (new) Slide65

DSM-5: PTSD Criterion D Markedly diminished interest in (pre-traumatic) significant activities (C4 in DSM-IV)Feeling alienated from others (e.g. detachment or estrangement) (C5 in DSM-IV)

Constricted affect: persistent inability to experience positive emotions (C6 in DSM-IV) Slide66

DSM-5: PTSD Criterion E Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event (2/6 symptoms needed) Irritable or aggressive behavior (revised D2 in DSM-IV)

Self-destructive or reckless behavior (new) Hypervigilance (D4 in DSM-IV) Exaggerated startle response (D5 in DSM-IV) Problems in concentration (D3 in DSM-IV)

Sleep disturbance (D1 in DSM-IV) Slide67

DSM-5: PTSD Criterion F-HPersistence of symptoms (in Criteria B, C, D and E) for more than one month Significant symptom-related distress or functional impairment Not due to medication, substance or illness Slide68

IATP Assessment InstrumentsACES: Aversive Childhood Experiences Scale (Felitti, 1997)TRS: Trauma Recovery Scale (Gentry, 1996; 2013)PCL: Posttraumatic Checklist (NCPTSD, 2014)CAPS-5: Clinician Administered PTSD Scale (NCPTSD, 2014)

International Association of Trauma Professionals

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Collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the Center for Disease Control and Prevention (CDC)The Adverse Childhood Experiences Study(ACE)

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www.acestudy.orgACEAversiveChildhood ExperiencesSlide71

Why is This Important?Because ACEs are:Surprisingly commonOccur in clustersThe basis for many common public health problems Strong predictors of later social functioning, well-being, health risks, disease, and deathSlide72

Top 10 risk factors for death in the USA

smoking, severe obesity, physical inactivity, depression, suicide attempt,

alcoholism, illicit drug use, injected drug use, 50+ sexual partners,

history of STDSlide73

ACE Study FindingsOf the 17,000+ respondents…More than 25% grew up in a household with an alcoholic or drug user25% had been beaten as childrenTwo-thirds had 1 adverse childhood event1 in 6 people had four or more ACESSource: Adverse Childhood Experiences (ACE) Study. Information available at http://www.cdc.gov/ace/index.htm

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ACE Study FindingsACE Scores of (4 and above) Linked to Physical & Mental Health ProblemsTwice as likely to smoke

Seven times as likely to be alcoholicsSix times as likely to have had sex before age 15Twice as likely to have cancer or heart diseaseTwelve times more likely to have attempted suicideMen with six or more ACEs were

46 times more likely to have injected drugs than men with no history of adverse childhood experiencesMuch more likely to have chronic health issues

Exceedingly high predictability of needing mental health treatment

International Association of Trauma Professionals

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PCLPosttraumatic Check ListNational Center for PTSD (www.ptsd.va.gov)Simple, easy to administerSelf-report or clinician administered20 item – all 20 symptomsCRITERION B: Items 1-5CRITERION C: Items 6-7CRITERION D: Items 8 – 14

CRITERION E: Items 15 – 20Score of > 2 = endorsement of that symptomSlide77

TRSTrauma Recovery ScaleGentry, 1996Developed as an outcome instrumentGood psychometrics (Chronbach’s a = .86 & convergent validity with IES = -.71)Solution-focusedMean score = % recovery from traumaScores > 75 = minimal impairment

Scores < 75 begin impairment spectrum and need stabilization5a & 5b opportunity to discuss “am safe vs. feels safe”Part I is trauma inventory and administered only at intakePart II is repeated measure for outcomesScores < 50 = treatment plan issueSlide78

CAPSClinician Administered PTSD ScaleNational Center for PTSD (www.ptsd.va.gov)

20 item structured clinical interview Primarily for diagnosisGood psychometrics and inter-rater relaibilty“Gold Standard” for diagnosing PTSD (if diagnosis will be questioned or challanged)Clinician administered and clinician scored (not self-report)Each symptom has a qualitative section used to derive quantitative evaluation of symptomIntensity x Frequency/2 = Severity

Severity score of > 2 = endorsement of that symptomSlide79

1. (B1) Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. In the past month, have you had any unwanted memories of (EVENT) while you were awake, so not counting dreams? [Rate 0=Absent if only during dreams] How does it happen that you start remembering (EVENT)? [

If not clear:] (Are these unwanted memories, or are you thinking about [EVENT] on purpose?) [Rate 0=Absent unless perceived as involuntary and intrusive] How much do these memories bother you?Are you able to put them out of your mind and think about something else?

Circle: Distress = Minimal Clearly Present Pronounced ExtremeHow often have you had these memories in the past month? # of times __________

Key

rating dimensions = frequency / intensity of distress

Moderate = at least 2 X month / distress clearly present, some difficulty dismissing memories

Severe

= at least 2 X week / pronounced distress, considerable difficulty dismissing memories

0 – absent

1 – mild

2 – moderate

3 – severe

4 – extremeSlide80

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HOMEWORKNotice the frequency in which you encounter perceived threats over the next 16 hoursGet and keep the muscles in your body relaxed all they way through your encounter with at least one perceived threatBe prepared to discuss in the morning the difference between the time(s) you were able to self-regulate vs. the times you did not