Trauma Crises Intervention

1. What is stress?

a. Stress is a physiological response to anything that we perceive as threatening our well-being.

b. We feel stressed when we fear that we don't have the resources to cope with a particular situation.

c. Stress occurs when the person perceives an external demand as exceeding his capability to deal with it.

2. What is a trauma?

a. Trauma is

i. Beyond normal experience

ii. Generates massive amounts of emotion

iii. Violates normal psychological assumptions

iv. Ruptures expectations about the future

v. Has an existential dimension

b. Foa

i. Intense

ii. Inescapable

iii. Uncontrollable

iv. Unexpected

c. Lazarus - An event that exceeds a person's coping resources

d. Freud - An event that breaks down protective defenses

3. What is traumatizing about a trauma?

a. Traumatizing features of event

i. Fear and threat

ii. Major loss

iii. Exposure to the grotesque

iv. Dehumanization, degradation, humiliation

v. Forced separation, relocation

b. Some of features do increase the risk of PSTD

i. Severe physical harm

ii. Receipt of intentional injury and harm

iii. Exposure to grotesques

iv. Witnessing or learning of violence or harm to loved one

v. Causing a death or severe harm

c. Intensity of symptoms or distress in not a predictor of PSTD - but lack of significant distress can be

4. What are the Phases of a Disaster Experience?

a. Heroic Phase - immediately after the disaster

i. Shock

ii. Fear

iii. Confusion

iv. Adrenalin rush

v. Heroic acts

vi. People coming together

b. Honeymoon Phase - I week to 3-6 months after disaster

i. Attend to basic needs in chaotic environment

ii. Concerns about safety, food, place to sleep

iii. Unrealistic expectations about recovery

iv. Sharing of resources/willingness to help others

v. Denial of extent of needs or emotional impact

c. Disillusionment Phase - 2 months to 1-2 years after disaster

i. Reality of impact on lives and community

ii. Realization of losses and work to be done

iii. Procedures to get assistance

iv. Community politics begin to emerge

v. Grieving

vi. Psychosomatic complaints

vii. Abuse issues

d. Reconstruction Phase - may last several years after the disaster

i. Light at the end of the tunnel

ii. Begin to put the disaster behind

iii. Renewed feeling of empowerment

iv. Post-traumatic stress disorder

v. Return to pre-disaster activities

5. How do people react to disasters?

a. Shock

b. Denial

c. Fear

d. Panic

e. Intense and unpredictable

f. Anxiety

g. Anger

h. Guil

i. Depression

j. Flashbacks

k. Memory problem

1. Physical reactions - rapid heartbeat, sweating

m. Startle reflex

n. Cognitive problems - difficulty

o. Hyper-alertness

p. Sleep disorders

q. Eating problems

r. Fatigue

s. Headaches

t. Interpersonal problems

u. Domestic abuse

v. Substance abuse

6. How is trauma crises intervention different from therapy?

a. You are intervening in a process, not curing a disorder.

b. You are doing psychological first aid. Goal is to help the person handle the trauma.

c. You are trying to help someone regain his previous level of functioning.

d. Focus in on current sources of stress. You are trying to mitigate the effect of present stressors.

e. Expression of distress is normal at this time - attend to the appropriateness and productiveness of the response, not to it's intensity.

f. Your role may be to support the supporters.

g. Sharing another's grief has healing power - sharing is both desirable and unavoidable.

h. You may be experiencing trauma at the same time.

7. Trauma Crises Intervention Goals

a. Goals

i. Primary goal is to help the person cope and heal.

ii. Reduce psycho biological distress.

iii. Address the perception by those in crisis that their reaction is abnormal or that they have totally lost inner strength.

iv. To lessen the impact and mitigate the impact of the trauma.

v. Assist the normal healing by supporting the survivor in whatever ways necessary.

vi. Attempt to stop the vicious circle of catastrophic appraisal and extreme distress.

vii. To help put event into some understandable context.

b. Goals at Different Stages

i. Provide concrete help, food, warmth and shelter

ii. Soothe and reduce states of extreme emotion and increase control of self and of what is controllable

ii. Assist in the painful and repetitive re-appraisal of the trauma

iv. Treat specific syndromes when they can be diagnosed

8. Trauma Crisis Intervention Techniques

a. General Principles

i. Do no harm.

ii. Treatment of early survivors requires therapeutic flexibility.

iii. The more you can handle novelty and uncertainly, the better your impact can be.

iv. Deciding what to, do and how much is the essence of clinical wisdom.

v. Always clarify what was particularly traumatizing for the individual, don't put yourself in his place.

vi. People are often in an altered state, very suggestible, very concrete.

vii. Interventions must be tuned to the needs, capacities, and desires of survivors.

viii. Survivors are trying to process the information

(1) People tell and re-tell the story and as they do so the story may change,become richer and more detailed.

(2) Information is important because you don't want fantasy to fill in theses gaps while they are trying to find a way to assimilate the information

(3) The longer a person goes without resolution, the more fantasy fills in and takes over. Getting the facts makes an enormous difference

b. Assessment of Effect of Primary Stressor

i. Assess the development of symptoms.

ii. Assess the degree to which symptoms are tolerated and the degree they interfere with normal functions.

iii. Assess risk related to event

(1) What part of the event made an impact? What is the psychological reality of the event?

(2) What loss and damage incurred? Evaluate real and symbolic losses, such as loss of continuity with their previous life.

(3) Are secondary stressors present?

(4) What healing resources are present for that person?

c. Assessment of Secondary Stressors

i. Is the survivor secure and out of danger?

ii. Does he have enough control of what is happening?

iii. Are there major uncertainties in the present?

iv. Are negative events or news still expected?

v. Does the survivor have clear enough information about self and significant others?

vi. Have adequate human attention and warmth been given to the survivor?

vii. Has trust been established between survivors and helpers?

viii. Can the current conditions humiliate or dishonor the survivors?

d. Assessment of Coping Ability

i. The specific way a person copes is often less important that whether it is successful.

ii. Can the survivor continue task-oriented activity? How well organized, goal directed and effective is such activity?

iii. Is the survivor overwhelmed by strong emotions most of the time? Can emotions be modulated when such modulation is required?

iv. Is the survivor inappropriately blaming himselD Does the survivor generalize such accusations to his or her personality or self? How isolated, alienated or withdrawn is the survivor?

v. Does he seek the company of others or rather avoid it?

Assessment Instruments for Trauma

Impact of Events Scale - Mardi Horowitz - UC, San Francisco

15 items

four levels of severity of PTSD

2 scales - Intrusion and Avoidance

Trauma Symptom Inventory - John Briere, Ph.D. - Psychological Assessment Resources, Inc./P.O. Box 998/Odessa, Fl 33556/1-800-331 -TEST

100 item test of posftraumatic stress & other psychological sequelae of traumatic events

3 validity scales, 10 clinical scales

Trauma Symptom Checklist for Children - John Briere - PAR

54 items that assess the same as above

2 validity scales, 6 clinical scales, 8 critical items

alternate version excludes sexual items and has 7 critical items

for male and female children, 8 to 16 years of age, separate profiles for males and females, younger (8 - 12 years) and older (13 - 16 years)

Detailed Assessment of Posftraumatic Stress - John Briere - PAR

104 items of trauma exposure and posftraumatic response

2 validity scales, 2 validity scales, 4 trauma specific scales, 5 PTSD scales,

3 trauma associated features (dissociation, substance abuse, suicidality)

 

Wall, T. (1998, October). The hypnotic relationship: A psychodynamic perspective. Workshop presented to the Greater Philadelphia Society of Clinical Hypnosis, Philadelphia, PA.

Gill and Brenman (1959). Hypnosis and related states.

• A particular kind of regressive process which may be initiated by sensory-motor ideational deprivation or by the stimulation of an archaic relationship to the hypnotist.
• The hypnotic state is an induced psychological regression occurring in a setting of a particular regressed relationship between two people in a relatively stable state which includes a subsystem of the ego with various degrees of control of the ego apparatuses.

Wall: The disruption of the normal distribution of attention causes an alteration of consciousness. ["normal distribution of attention" = motile attention that is focused on a variety of processes, including body processes. Hence, the suggestion to relax (to decrease somatic stimuli coming from the body).

• Condensation and displacement: in hypnosis, our imagery is marked by the same phenomena as dreams.
• It has been said that preoedipal patients come into therapy not so much to get well, but to get you.

Four goals of hypnotic interventions:

1. Symptom management.

2. Uncovering or restructuring of material.

3. Reframing, relearning or reinterpreting.

4. Promoting the relationship.

Personality and Hypnosis: A Study of Imaginative Involvements. By Josephine Hilgard

What are the antecendents in a patient's history that promotes the hypnotic experience.

1. Reading - especially fiction and science fiction.

2. Dramatic Arts (involvement in dramatic arts).

3. Religion of a personal commitment.

4. Affective arousal.

5. Sense of adventure.

6. Severity of childhood punishment.

7. Ease of dissociation.

8. Comfort with topographic regression.

9. Perceived power of the hypnotist. Positive emotional bond. Fear of negative reprisal.

Alexythymia: patients who lack an ability to utilize processetic aspects of language and thought. Can not articulate feelings; emotional illiterates. Poor candidates for hypnosis:

1. Pain patients

2. Substance abuse

3. PTSD

4. Somatisizers

Therapist Variables (by Michael Diamond, 1984) affecting quality of hypnosis:

1. Therapist's attainment of mature object relating and comfort with deeper levels of the relationship (maturity and individuation).

2. Empathic capacity.

3. Personal and therapeutic trance skill.

4. Integration of healthy cognitive/behavioral capacities.

5. Self-supervisory ability to deal effectively with countertransferential aspects of the relationship.

Hans Strupp (1989, April) in the American Psychologist

• The first and foremost task of the therapist is to create an accepting and empathic context, which in itself has great therapeutic value because for many people it is a novel and deeply gratifying experience to be accepted and listened to respectfully.
• The second aspect of the therapist's contribution relates to the manner in which he or she understands and deals with the patient's enactments in the treatment process.
• Attempts to clarify the patient's experience with particular emphasis on the metacommunications about the patient-therapist relationship.
• By all odds, the greatest challenge facing the therapist is the skillful management of enactments that often put the therapist on the defensive, evoke boredom, irritation, anger, and hostility and in other respects "put pressure" on the therapist to behave in ways that are incompatible with his or her stance as an empathic listener and clarifier.

Check out this book: Drive, Ego, Object and Self, by Fred Pine.

Five Relational Dimensions

• Transference - all patients come to us and attach to us with the hope that we will be different than their original caregivers. They also come to us with the dread that we will not be different that their original caregivers.
• Working (therapeutic) alliance - the ability of the client to step back, with the therapist, and look at the transference.
• Symbiotic or Fusional alliance - we all attach at some primitive level, in a manner in which the therapist becomes a part of the client.
• Real relationship
• Countertransference

According to Freud (1914), Further Recommendations in the Technique of Psychoanalysis: "...we may say that there the patient remembers nothing of what is forgotten but that he expresses it in action." Transference is a way to remember.

"Transference is a revival in a current object relationship, especially to the analyst, of thought, feeling, and behavior derived from repressed childhood fantasies originating in significant conflictual childhood relationships." (Curtis, 1983).

Freud wrote very little about countertransference. He talked about the importance (in the analyst) of "evenly suspended (distributed) attention." Countertransference was seen as an obstacle to overcome.

Paula Heimann: "Our assumption is that the analyst's unconscious understands that of his patient. This rapport on the deep level comes to the surface in the form of feelings which the analyst notices in response to his patient, in his countertrasnference. This is the most dynamic way in which his patient's voice reaches him." Here, Heimann sees a very positive role played by countertransference. Countertransference is an instrument of treatment.

Projective identification: We become a container for the patient's container. Intrapsychic aspect: the patient projects into his internal image of the therapist, but the patient mistakes his image for the object. In so doing, the patient induces in the therapist an experience of the disowned aspects of himself. [Response: "You know, I think you're trying to inform me about what it was like growing up in your family, and you're letting me know about it, in part, by recreating that situation here."]

Grotstein: Don't listen to the patient; listen to yourself listen to your patient.

Thomas Ogden (1979) defines a three step process as the mechanism for projective identification:

• An aspect of the self is projectively disavowed by unconsciously placing [inducing] it in another person,
• the projector exerts interpersonal pressure to coerce the other person to experience or unconsciously identify with what has been projected,
• the recipient of the projection processes and contains the projected contents leading to a reintrojection of them by the patient in modified form -- they are "reclaimed"/reintegrated.

Four purposes:

• Defense: distance oneself from the unwanted part of keep it alive in someone else.
• Communication: to make oneself understood by pressing the recipient to experience a set of feelings like one's own.
• Object Relatedness: to interact with recipient separate enough to receive the projection, yet undifferentiated enough to allow some misperception to occur to foster a sense of oneness.
• Pathway to Psychological Change: transforming, i.e., reintrojecting the projection after it is modified by the recipient as in mother-infant, patient-therapist relationship.

Christopher Bollas (1987): "In order to find the patient,we must look for him within ourselves. This process invariably points to the fact that there are two patients within the session and therefore two complimentary sources of free association."

The transitional object: the "space" between "objective" reality and the internal, subjective and undifferentiated world. This is where children go when they become completely lost in play. This is the space between the symbol and the symbolized; the analytic space. This is also the "space" we go to in hypnosis.

"Finally, an important attribute of hypnosis is a potentiality for the subject to experience as subjectively real suggested alterations in his environment that do not conform to reality. In trance, the waking distinction between an imagined idea and what is perceived externally to the organism fades, and images may be perceived as originating from external reality. Thus, the waking individual, no matter how hard he tries to imagine someone sitting opposite to him, might at best be able to evoke some kind of imagery but would always be aware of the distinction between this and reality. The subject in deep hypnosis may well be unaware of the distinction, though at some level he will always be able to discriminate." Orne (1959)

Winnicott (1959): "The tendency to regression in a patient is seen as part of the capacity for self-cure."

Come to the edge.

We can't. We're afraid.

Come to the edge.

We can't! We will fall.

Come to the edge.

And they came.

And he pushed them.

And the flew.

-- Appollinaire

 

Luborsky, L. (1985). A verification of Freud's grandest clinical hypothesis: The transference. Clinical Psychology Review, 5, 231-246.

Found experimental data supported the following:

• Each person has one pattern.
• Each person has a special pattern.
• Applies to erotic relationships.
• Part is kept out of awareness.
• Much consistency over time (early vs. late in therapy).
• Some inconsistency over time (early vs. late in therapy).
• Therapist becomes like the pattern of other relationships.
• Current relationship patterns parallel past relationsips.

General Framework

Recovery/growth is a life-long journey.

We learn from everything.

Introduction

This pantheoretical model of therapeutic change relies on the following suppositions:

1. Motivation to change is the largest factor in the "change equation," following only "Client Diagnosis" as the most important predictor of therapy outcome. Therefore, therapy should first and foremost be a process of "motivational interviewing." People are motivated both by pain (a "push" by the past and the now) and by goals (a "pull" from the future).

2. Change occurs in relatively discreet stages, and awareness of the client's position in the "Wheel of Change" facilitates rapport and the setting of appropriate treatment goals/expectations.

3. The process variables that best predict successful therapy outcome are: (1) Rapport, and (2) Absorption.

(Hypnosis is by definition the utilization and enhancement of both rapport and absorption.)

Motivational Interviewing

The goal of motivational interviewing is to (1) maintain rapport at all times, and (2) consistently orient the client toward maximally-enhance motivation to change. (Hypnosis can enhance both rapport and motivation.)

Five General Principles of Motivational Interviewing

Express empathy.

• Acceptance facilitates change.
• Skillful reflective listening is fundamental.
• Ambivalence is normal.

Develop discrepancy.

• Awareness of consequences is important.
• A discrepancy between present behavior and important goals will motivate change.
• The client should present the arguments for change.

Avoid argumentation.

• Arguments are counterproductive.
• Defending breeds defensiveness.
• Resistance is a signal to change strategies.
• Labeling is unnecessary.

Roll with resistance.

• Momentum can be used to good advantage.
• Perceptions can be shifted.
• New perspectives are invited but not imposed.
• The client is a valuable resource in finding solutions to problems.

Support self-efficacy.

• Belief in the possibility of change is an important motivator.
• The client is responsible for choosing and carrying out personal change.
• There is hope in the range of alternative approaches available.

Raise doubt--increase the client's perception of risks and problems with current behavior.

Therapist Tasks and Hypnotic Interventions at Various Stages

The Precontemplation Stage

Task: Raise doubt--increase the client's perception of risks and problems with current behavior.

For some people, what they want is a different perspective. They may not be ready to take action. They may not even be sure they have a problem, or that the problem is "important enough" to make a concerted effort to change.

Hypnotic Interventions

• General ego strengthening.
• Dissociation and strengthening of observing ego (precursor to "inner advisor").
• Experimentation (both within and outside hypnosis) with different perspectives.
• Role reversals (both within and outside hypnosis) in which the client tries to convince the therapist (or some other significant person) s/he is an addict.
• Early "parts" or "ego-state" therapy.

The Contemplation Stage

Task: Tip the balance--evoke reasons to change, risks of not changing, strengthen the client's self-efficacy for change of current behavior.

For others, there is no question that they want to change, but they are not sure what they want to change. For these clients, insight seems most valuable. They learn more about themselves, other people, and their problems. This insight may be enough.

Hypnotic Interventions

• General ego strengthening.
• Age progressions to nonproblematic life style.
• First encounters with the "inner advisor."
• Experimentation (both within and outside hypnosis) with different behaviors.
• Intermediate "parts" or "ego-state" therapy.

The Determination and Action Stages

Task: (1) Help the client to determine the best course of action to take in seeking change. (2) Help the client to take steps toward change.

For still others, they not only want insight, they want to take concrete action. In the Determination Stage, therapy is focused on determining what actions to take. In the Action Stage, clients have decided on the action, and feel ready and committed to take whatever steps are necessary to effect the change.

Hypnotic Interventions

• General ego strengthening.
• Age progressions to nonproblematic life style.
• Experimentation (in and out of hypnosis) with different potential solutions.
• Rehearsals (in hypnosis) of new behaviors/solutions.
• Encounters with the "inner advisor."
• Advanced "parts" or "ego-state" therapy.

The Maintenance Stage

Task: Help the client to identify and use strategies to prevent relapse.

Finally, there are those who have already made the change they want, but need some help, guidance, or support in maintaining the change.

Hypnotic Interventions

• General ego strengthening
• Age regression to problematic behavior (life style) followed by progression to the present.
• Encounters with the "inner advisor."

The Relapse Stage

• Task: Help the client to renew the processes of contemplation, determination, and action, without becoming stuck or demoralized because of relapse.

  In this stage, the focus is on (1) what the client has learned as a result of the relapse, (2) harm reduction, and (3) shame reduction.

  Hypnotic Interventions

  • General ego strengthening.
  • Facilitation of hope.
  • Containment of trauma and shame.
  • Age regression to healthy behavior (life style) followed by progression to the present, bring those "old skills" as well as new learnings.

1. "Therapy" and "Therapeutic" are related, but not synonymous. Many events and experiences (including formal therapy) are potentially "therapeutic." Hence, "therapeutic process" does not begin, nor does it end, with formal therapy.

2. Long-term Intermittent Brief Psychotherapy involves intermittent treatment at various points along the "Stages of Change" continuum, and at various points along a client's "therapeutic journey" (most liberally defined as the client's entire life).