An Experiential Approach to Reliving with Complex Trauma Dr Jo Billings Berkshire Traumatic Stress Service UK PTS Conference 2013
An Experiential Approach to Reliving with Complex Trauma
Dr Jo Billings
Berkshire Traumatic Stress Service
UK PTS Conference 2013
A Phase-Based Approach
Stabilisation Processing
trauma
memories
Reclaiming
life
UK PTS Conference 2013
Overview
What is the current evidence base and how to bridge gaps?
How to deal with multiple traumas?
Where to start?
When to stop?
How to manage high degree of distress, dissociation and avoidance?
How to look after yourself?
UK PTS Conference 2013
Current evidence base
UK PTS Conference 2013
PTSD treatment evidence base
Good evidence of efficacy for CBT and EMDR in the treatment of PTSD (Type I trauma) - Exposure elements key
- CT can enhance treatment (guilt, shame)
NICE guidelines recommend TF-CBT and EMDR 8-12 sessions for single incident trauma
>12 sessions for where multiple traumatic events, traumatic bereavement, chronic disability, social problems and significant co-morbid disorders
UK PTS Conference 2013
TF-CBT Treatment Models
Prolonged exposure (Foa)
Cognitive processing therapy (Resick)
Cognitive therapy (Ehlers & Clark)
UK PTS Conference 2013
Prolonged Exposure
9+ sessions
Often 2x week
Psycho-education and treatment rationale
Prolonged exposure 45-60 mins
In vivo exposure
Some cognitive restructuring
UK PTS Conference 2013
Cognitive Processing Therapy
12 sessions
2x week
Written exposure
Explore themes/stuck points with CT
Safety, trust, power/control, esteem, intimacy
Re-write narrative
UK PTS Conference 2013
Cognitive Therapy
8-12 sessions
Psycho-education and treatment rationale
Reliving of key trauma memory
Identifying hotspots
Restructuring key meanings
UK PTS Conference 2013
Cognitive Model (Ehlers & Clarke, 2000)
Current Threat
Intrusions
Arousal Symptoms
Strong Emotions
Strategies Intended to Control Threat/Symptoms
Avoidance/Safety Behaviours
Nature of Trauma Memory Negative Appraisals of
Trauma and/or its Sequelae
Nature of Trauma, Prior
Experiences, Beliefs, Coping, State
of individual
Cognitive Processing during
Trauma
Triggers
UK PTS Conference 2013
Goals of Trauma Focused CBT
1. Elaborate memories
2. Identify and challenge negative appraisals
3. Reduce unhelpful maintenance strategies
UK PTS Conference 2013
Mind the Gap!
Lack of psychological models of developmental and complex trauma
Evidence base for treatment of complex trauma lags far behind that of adult trauma
More gaps than guidance!
UK PTS Conference 2013
Gaps in the Research
Established research on selected samples, with simple and clear research questions
Only established models for single incident adult trauma
Real life in trauma clinic more complicated!
High rates of complexity, comorbidity, physical and situational problems
Multiple traumas
Childhood and adult trauma
Pre-existing problematic schemas
Systemic factors
Clients heterogeneous with wide ranging problems, needs and preferences
Culture/language differences
Working with interpreters
High levels of Risk
Dissociation
Self harm
Limited time/resources
UK PTS Conference 2013
The nature of complex trauma
Developmental
Repeated, prolonged, anticipated
Interpersonal in nature
Often perpetrated by those supposed to protect you
The closer the abusing relative to the victim the worse the prognosis
Further damage caused by collusion, betrayal and denial of others (Waller)
Complex emotional experience – not just fear – guilt, shame, anger, humiliation, disgust
UK PTS Conference 2013
The fallibility of memory
Memory is reconstructive not reproductive
A jigsaw puzzle rather than a DVD – can put the pieces together in many different ways
High probability of trauma memories being distorted and unreliable
Nature of memory influenced by previous experiences of similar events
Memory deficits normal
UK PTS Conference 2013
The fallibility of memory
Childhood experiences encoded non-verbally
Meanings of memories are developmentally congruent (Its my fault)
Children have good procedural and semantic memory but poor autobiographical memory
Poor autobiographical memory in adulthood
Memory problems particularly likely in survivors of childhood trauma
UK PTS Conference 2013
“Memory is changed by subsequent information because what we remember is an amalgam of
what we witness and what we think”
BPS Working Party (1995) Conclusion: General memory is reliable, while memory for detail is not
UK PTS Conference 2013
Complex trauma, complex reactions, complex treatment!
Integrative treatment models
Evidence base as a starting point
Adhere to key theory and principles
Adaptation, creativity and flexibility
Work with key meanings/affect via memory
UK PTS Conference 2013
Continua of Trauma
Nature of Trauma Type I Trauma Not interpersonal Stable background Other protective factors Treatment Implications Specific focus Trauma focussed Classic CBT Brief
Type II Trauma Interpersonal
Unstable background Lack of protective factors
General, multiple foci Schema focussed Phased approach
Longer term
From Rothschild (2000) UK PTS Conference 2013
Where to start?
UK PTS Conference 2013
Memory Meaning
UK PTS Conference 2013
Reliving Restructuring
UK PTS Conference 2013
Getting an overview
Overview of the client’s history
No surprises
‘Cold’ reliving
Positive factors and resilience
UK PTS Conference 2013
From narrative to reliving
UK PTS Conference 2013
Multiple trauma
Multiple/overlapping traumas…where to start?!
Earliest
Easiest
Most recent
Worst
Most symptomatic
Thematic
UK PTS Conference 2013
Traditional Re-living Protocol
Systematic, repeated, prolonged exposure to a traumatic memory
Graded approach with increasing detail if necessary
Start at the beginning
First person, present tense
Finish in a safe place (fast forward if necessary)
UK PTS Conference 2013
Traditional Re-living Protocol
Prompts • “What happens next…”
• “What can you see, hear, smell, taste, feel”
• “What thoughts are going through your mind right now”
• “What do you feel in your body, where do you feel it”
• “What emotions do you feel, how strong”
Ratings • SUDS
• Vividness
• Nowness
UK PTS Conference 2013
Getting the temperature right
UK PTS Conference 2013
Sensory inputs Thalamus
Sensory
gateway
Amygdala
Emotional
valence
Sensory cortices
Parietal, Occipital
and Temporal lobes:
sensory processing
PERIPHERAL SYMPATHETIC & CORTISOL RESPONSES
Prefrontal Cortex
Assessment of threat:
“tracks on-going reality”
Self-soothing
Motor cortex
Hippocampus
Stores memory
of event
UK PTS Conference 2013
Window of Tolerance
Those who have suffered traumatic experiences can oscillate between hyper- and hypo- arousal
Whilst in the window of tolerance a person can receive and integrate sensory information from the environment, while calling on the cortex, including the hippocampus, to assist with this assessment and integration
Ogden, Minton & Pain, 2006
UK PTS Conference 2013
Elaborating Memories?
Narratives
Timelines
Testimony
Story boards
Pictures
Diagrams
Photographs
Maps
Reliving
Revisiting
UK PTS Conference 2013
Life story
Trauma history
Key trauma
Key hotspot
Key meaning
UK PTS Conference 2013
Changing Meanings
UK PTS Conference 2013
Cognitive Restructuring
Socratic questioning
Evidence for and against
Advantages/disadvantages
Cognitive continua
Responsibility pie
Cognitive biases (i.e. hindsight bias)
Surveys
Research
Behavioural experiments
Positive data log
Return to site UK PTS Conference 2013
Updating memories
Verbally
“I know now that…”
“What is different now”
Imagery
Visualising how wounds have healed
Visualising family safe
Physical movement
Movements or actions incompatible with trauma memory
Moving about if trapped
UK PTS Conference 2013
Intervention Points – Complex Trauma
Current Threat
Intrusions
Arousal Symptoms
Strong Emotions
Strategies Intended to Control Threat/Symptoms
Avoidance/Safety Behaviours
Nature of Trauma Memory Negative Appraisals of
Trauma and/or its Sequelae
Nature of Trauma, Prior
Experiences, Beliefs, Coping, State
of individual
Cognitive Processing during
Trauma
Triggers
UK PTS Conference 2013
Intervention Points – Complex Trauma
Current Threat
Intrusions
Arousal Symptoms
Strong Emotions
Strategies Intended to Control Threat/Symptoms
Avoidance/Safety Behaviours
Nature of Trauma Memory Negative Appraisals of
Trauma and/or its Sequelae
Nature of Trauma, Prior
Experiences, Beliefs, Coping, State
of individual
Cognitive Processing during
Trauma
Triggers
UK PTS Conference 2013
Emotional Bridge
UK PTS Conference 2013
Imagery Rescripting
Integrated part of the reliving protocol (Ehlers et
al., 2005)
Aims to introduce new perspectives on what happened by experiencing new views and new emotions
Works with representation in memory of what was experienced
Changes relationship with memory
UK PTS Conference 2013
Imagery Rescripting
Can provide corrective information
Allow for expression of trauma inhibited responses
May be more effective than exposure for emotions other than fear (Grunert et al., 2007)
May be more effective intervention for guilt and anger (Arntz, 2007)
UK PTS Conference 2013
Imagery Rescripting
Can vary from simple update (I know I did not die –
picture self with family now) through to complete imagery transformation (rescuing self, humiliating
perpetrator)
No limits to creativity!
But aim to meet unmet needs at time of trauma (i.e. safety, compassion)
UK PTS Conference 2013
Bring distressing
memory into awareness
Identify hotspot and associated meaning (rate
belief)
Restructure belief
Imagine new memory in
hotspot (re-rate belief)
Plan imagery to update
belief
UK PTS Conference 2013
Bring distressing
memory into awareness
Identify hotspot and associated meaning (rate
belief)
Identify unmet needs
Imagine new memory in
hotspot (re-rate belief)
Plan imagery to meet needs
UK PTS Conference 2013
Imagery Rescripting
“What would you have liked to do then that you couldn’t?”
“What would you like to feel in that moment?”
“What would need to happen for you to feel like that?”
“If you could go back in time and intervene what would you want to do?”
“If someone could come back from the future to help you what would you like them to do?”
UK PTS Conference 2013
Looking after yourself
UK PTS Conference 2013
Looking after yourself
Control empathic attunement
Peer and organisational support
Regular supervision
Use recordings to decentre
Specific training
Caseload balance
Variety of work
Good self care
Optimism and hope
Incorporate positive factors into formulation – to avoid vicarious helplessness
UK PTS Conference 2013