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ASSESSMENT DETAILS

Unit/Module: Working With Crisis and Trauma

Educator: Peter Wilson

Assessment Name: Academic essay: Risk Factors and Treatment for Survivors.

Assessment Number: 2

Term & Year: 1_2012

Word Count: 3232

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This paper will use a case study to demonstrate how unresolved trauma from abuse and neglect on a young child can direct the survivors behaviour and reactions towards crisis, trauma and complicated grief in later life. Such variables can lead to a more risk reactions. Conversely, depending on the survivors cognitive schema and resilience, a survivor may develop greater resilience and more easily process traumatic events. This case will examine risk factors and trauma reactions as a result of the sudden and unexpected death of Graces mother. Wiger & Harowski (2003) describe a traumatic event as when a person/child actually believes there is risk of injury or death and loss of personal integrity including despair, horror, rage, loss of hope and feelings of helplessness (American Psychiatric association, 2012). Multifactorial attachment patterns will be discussed including a discussion of some of the best fit therapeutic practices. Discussion will also focus on Dissociative Identity Disorder (DID) diagnosis as it reflects Graces processing and expression of complicated grief, somatization and dissociation in bereavement (Diagnostic and Statistical Manual of Mental Disorders, 2000). An analysis of this case will confirm that understanding DID, as well as timely and correct diagnosis can lead to better predictions for a client at risk for adverse reactions, and therefore more timely treatment strategies. Shulman and Shewbert (2005) suggest that medical crises are an inevitable part of the human experience (p. 633). In August, 2010 Graces mother, Frances, 72 years old took ill and died within the space of a week. Grace had rung her mother on the Monday. She noticed Frances sounded a little vague and her asthma was bad. During the conversation Grace asked if her mother was ok, and Frances said she was going to the doctors the next day. By Friday, Frances was in intensive care on life support. Furthermore, Frances had pneumonia, a major heart attack, and brain damage. The specialist informed the family that Frances only had a small chance of surviving should they take the intubation tube out. The choice for the family was either to risk trying to keep

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Frances alive, with disabilities, or let her die. Frances had told her children never to keep her alive if she had to be put in a nursing home. The family decided to let Frances go, and stressed there was to be as little pain as possible. Over the next three hours the family watched their mother as Frances slipped away. The death certificate said that Frances had cancer throughout her body. Had she survived this trauma, Frances would not have survived the cancer. According to Kersting (1998), new insights have come to light about the biopsychocial effects of traumatic stress and complicated grief risk reactions. It is advisable to identify individuals at risk of negative behavioural, cognitive and affective reactions resulting from loss. In addition, Fonagy (2001) states that females who have undergone earlier trauma are at greater risk of re-traumatization if they experience later trauma. In addition Wayment, Vierthaler, & Jennifer (2002) explored links between attachment styles and risk factors. Variables included attachment to the deceased and suddenness of death. It was determined that survivors with stronger bonds with the person who has died reported greater levels of grief. However, the study only included ninety one participants, so the results are not statistically valid and can be used as a basic guide only. Moreover, Niemeyer (2001) and his co-horts have attempted to define the risk factors for complicated grief determined by the way the loved one died. The most valid factors in statistical analysis included sudden, traumatic and unexpected death, attachment to the bereaved, and the death of a child. Grace is at risk since her system of alters depended on Frances to help with her familial children and other aspects of Graces life. As a result, therapy to help Grace has been hindered by the continuing difficulties with her teenage twin daughters, lack of family support, and her personal inability to access available peer and community help. These factors are mediated by Graces resilience and inner resources on any given day. Grace sees her trauma therapist fortnightly. Wiger &

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Harowski (2003) indicate that as Grace goes through therapy, she will require support for the constant disequilibrium in her current life. Grace has remained stuck in an active state of emotional dis-regularity for eighteen months and is experiencing emotional trauma and complicated grief as a result. According to Green (2000), survivors who are able to communicate distress are more likely to return to a state of equilibrium. Grief is the way a person reacts to major loss. For Grace this involves witnessing the death of her mother. Graces normal grief response includes her separation from Frances, thinking about and missing her. The traumatic response for Grace is causing her distress from renumerating on viewing the actual death process and the loss of her safest childhood attachment figure (Fonagy, 2001). Furthermore, grief is viewed as an adaptive process, influenced by environmental factors and psychological foundations following a traumatic event (Green, 2000).This explains why Grace displays much more grief and distress following the loss of her mother than an individual who developed secure attachments. In addition, Pearlman & Saakvitne (1995) believe that early childhood trauma can result in severe reactions including loss of trust, safety, control, negative expectations and problems with intimacy. Other risk factors for Grace involve intrusive cognitive distortions such as avoiding people and places and sensory intrusions of thoughts, feelings, smells, sounds, tastes and sights (McFarlane, 2003). For example, extreme hyper-arousal reactions involve irritability, increased startle reactions as well as problems in sleep, memory and concentration. Because Frances was traumatic, the experience was imprinted as horror within the Amygdala which stores traumatic memories differently than every day memories (Raphael, 1986). The core of the disequilibrium Grace is enduring lies with problems in her early attachment process (Kersting, 1998). For Grace, the grieving process is further complicated because she is dealing with an unintegrated and fragmented sense of self. Grace has been

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diagnosed with DID which is now recognised as a developmental disorder. Graces fractured psychological system includes identities of different ages, behaviours, cognitive schemas, emotional reactions, varied maturities, memories and attachment patterns (Bowlby, 1988). As such, dissociation is both a neurobiological as well as psychological coping strategy to get through overwhelming abuse and trauma. Attachment is the process of developing emotional bonds to significant others. It is described as a biological mechanism to ensure survival by providing ones need for security and safety (Hooyman & Kramer, 2006). The attachment process in DID is skewed because of the effects of abandonment, neglect, toxic shame, physical, mental, sexual, emotional abuse, and inconsistent responses from the primary care-giver/s (Foa & Kozak, 1986). Additionally, the type of attachment a child displays towards their primary caregiver will influence how relationships are formed and maintained with others throughout life. Mary Ainsworth (1978) developed a means of categorising different patterns of attachment observed in response to separation from the primary caregiver. Analysis of the Strange Situation experiment indicated that there are three patterns of attachment. Sixty five precent of toddlers have a secure attachment, thirty precent an insecure attachment and the remaining 5 percept have disorganised /disoriented attachment styles. This study remains stable across cultures and genders. Importantly, Grace falls into the disorganised/disoriented attachment category which reflects the greatest level of insecurity of attachment as well as impairment in neurological development. Unfortunately, this group represents the greatest number in psychiatric populations and have experienced serious neglect or abuse during early childhood (Ainsworth 1978). The nature of crisis, trauma and complex grief reactions and the ways they impact a survivor means that there are different ways of looking at therapy from clinical,

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phenomenological and theoretical constructs. Now that we have seen some of the more pervasive risk factors through the case of Grace, it is important to brief and analyse some of the strategies currently used in treatment (Bisson, 2008). Cognitive Behaviour Therapy (CBT) analysis the ways in which a survivor views and feels about events and then focuses on addressing cognitive distortions (Kase & Ledley, 2007). By challenging perceptions, beliefs and feelings, behaviours can change. CBT strategies monitor the survivors internal voices and dialogue, and attempts to create equilibrium and collaboration of the system. It also uses available tools like mindfulness to replace negative evaluations of self with positive ones. Psycho-education is an important component of CBT since it empowers the survivor by giving him/her knowledge (Beck, 1995). Narrative Therapy (NT) is also referred to as talk therapy. Psychotherapy uses suggestion, instruction, persuasion and insight in order to bring memories to a conscious level so they can be processed. These tools are geared at helping the survivor manage and eventually overcome dissociative symptomology and create a cohesive identity. Mindfulness (M) interventions look at pervasive symptoms such as depression, anxiety, dysregulation of emotions and dissociative symptoms. Mindfulness exercises, meditations, grounding and relaxation techniques aide the survivor to be more open. This allows access to intrusive memories and emotional feelings such as anger fear shame and guilt left over from the traumatic event (Brierre, 1996). Dialectical Behaviour Therapy (DBT) is a multifactorial treatment approach. It is often implemented before the more invasive treatments such as exposure-based interventions to address difficulties with emotion regulation and distress tolerance (Bisson, 2008). DBT incorporates training in mindfulness as one of four areas of skill-building. In DBT, mindfulness involves three "what" skills (observing, describing, and participating) and three

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"how" skills (taking a nonjudgmental stance, focusing on being present, and finding meaning and happiness in ones life). The survivor is encouraged not to judge physiological and psychological reactions and just to accept what is happening in the present moment. Eye Movement Desensitisitisation Reprocessing (EMDR) holds a different philosophy than other more common strategies. The survivor does not need to continue to go into story. The survivors information processing system (Amygdala) is stimulated, memories are activated, processed and reframed as narrative memory (Davis,1992).This means that the survivor can now view the situation as being in the past (Shapiro, 2001). Exposure Therapy (EP) works on the belief that a survivor habituates to situations that annoy him/her, but are not in themselves dangerous today. The goal is to encourage the survivor to face and confront the things they are afraid of (Brierre, 1996). Treatment of complicated grief (CG) involves processing the emotions. However, for very young alters, therapy becomes more complex since one is working with children who may not even cognitively understand death (http://www.health.harvard.edu/fhg/ 2006). Children need age appropriate interventions. The therapist provides support, comfort, listens to and answers questions. The therapist also works with the older parts to encourage communication with the younger parts. The goal is to teach survivors how to re-parent injured and grieving child alters. Group Therapy (GP) is often used as an adjunctive tool to enable survivors to share their experiences within a safe environment with other survivors. This strategy is often very powerful because of the group dynamics. The survivor can not only witness and learn from other peoples experiences and the ways they deal with the after effects, but he/she can also feel a sense of belonging to something very real and supportive. Last of these chosen therapies includes the Phase Oriented Model of Trauma Counselling elaborated below (Scott & Brierre, 2006). Brierre discussed the therapeutic

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window. This is the psychological space between unhealthy avoidance and complete overwhelm. It is also where the therapy alliance can lead to greatest psychological growth in the areas of processing cognitions and desensitization. Although most of the above post trauma interventions have been empirically tested and proven valid, there still exist areas of controversy. These tend to centre around timely exposure work, timing of therapeutic strategies in the case where comorbid conditions are present, and insufficient debriefing work for both therapist and survivor. The therapist must ensure that the client is in a safe enough place psychologically so that re-traumatisation does not occur (Foa, Molnar & Cashman, 1995). According to the Australian Centre for Posttraumatic Mental Health (2007b) there is a gap between evidence based practice and routine clinical care (p. 3). It is thus imperative that therapists keep abreast of current practices and empirically validated evidence and how these fit into their own therapeutic schema. Any action plan a therapist chooses to use needs to be streamlined to the survivors personal needs. Graces therapist is using The Phase Oriented Model of Trauma Counselling (Brierre, 1996) as the core treatment methodology. Although Grace has been in therapy for three years, she is still in the first phase of trauma processing. There are three phases within this model, the first of which is Stabilisation. This phase focuses on client safety. Graces therapist focuses on dealing with negative coping mechanisms. Self- harm has been a problem for Grace in the past but she has not cut for two years. Grace is an alcoholic. According to Brierre (1996), comorbid conditions are common in survivors and need to be addressed. Fortunately, about a month after Frances death, cessation began and is still holding 18 months later. This phase of treatment uses psycho-education. Learning to communicate with and understand the various parts of her system helps Grace maintain safety, and decreases her

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fear, anxiety, depression and grief. Grace is becoming better at accessing, expressing and releasing feelings. Containment of emotion is an equally desirable goal of therapy. The idea is that Grace will be able to choose expression and containment in appropriate situations. Pharmacological interventions have been utilised with Grace for the past 19 years. She is currently taking 300mg Effexor to help with the heightened anxiety and emotional dysregulation; 100 mg Seroquel which helps with rapid switching and auditory hallucinations and Valium at 10mg per day when needed. This is evidence of a holistic management care plan through Graces local GP, Psychiatrist and Psychologist (Australian Centre for Posttraumatic Mental Health, 2007). It is also important that Grace feels that she leading the therapy session. Her therapist encourages, whilst providing support. For Grace, it is the congruent, consistent, trusting and safe relationship she has with her therapist that forms the foundation for therapy and recovery. Once Grace is ready to work on resolving the memories she has accessed, she will enter into phase two, which is referred to as Treatment (Scott, Jones & Brierre, 2006). Trauma memories that Grace has been able to access and bring to the surface will need to be worked through, processed and stored as narrative memory. Graces therapist must be careful not to rush through this stage at the risk of re-traumatisation. Lack of insight on behalf of the therapist can send the Grace into overwhelm where she retreats into a state of disequilibrium, may self- harm or end therapy. In Graces case where trauma had occurred over many years, coping strategies including dissociation and denial have enabled Grace to adapt. Unfortunately these strategies can be detrimental if they are utilised over long periods of time (Raphael, 1986). The infants within Graces mind are effectively stuck in the time the abuse happened. Grace is experiencing feelings of complicated grief, loss, aloneness and abandonment. Her child alters still view Frances as the mummy who kept them safe and as someone who always loved

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them. Grace needs for her parts to remember and share the good memories, whether actual or imagined in order for them to know that they will not physically die. Grace has stated in therapy that her resilience to life stressors is diminishing. Rak (2002) proposes that survivors draw strength along a continuum from defence including flight, fight, freeze and dissociative responses, through to necessary adaptation and then resilience. Graces case lends credence to the idea that childhood abuse encourages resilient responses later in life. If one understands this, it also enables one to comprehend the concept of resiliency as a positive and adaptive survival response which can lead to growth. Linley & Joseph (2004) postulate post-traumatic growth is different to resilience. According to Mancini & Bonanno (2006) resilience is the ability to maintain relatively stable, healthy levels of psychological and physical functioning in the face of an extreme life event (p. 978). However, post-traumatic growth extends this concept in that the survivor improves to the point that their functioning state is greater than it was prior to the event/s. The third phase is referred to as Personality and is about helping Grace to rehabilitate and integrate her personality states. This part of the process involves getting to a point where Grace is functioning at a high level in a number of primary areas. These include developing the ability to form emotional, physical, intimate and sexual attachments to healthy people. Neimeyer (2001) also believes that therapy is powerful when the client is able to utilize tools to positively impact on his/her current life. According to Neimeyer (2001), Grace needs to find meaning in the loss. This means that she will need to access memories, or even reconstruct them in a way that is significant and comforting for her and her parts. This appears to be imperative in the process of grieving, especially memories that link grief with the way that Grace responds to loss involved in attachment trauma. Furthermore, the aim of grief counselling is in there being a continuing bond which

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continues after death. Grace talks to her mother, and focuses on good memories. Grace knows that Frances has died, but at this stage her little parts cannot conceive of this and are still yearning and searching for their mother. For Grace, her profound and unwavering belief in a higher power has kept her alive. Another goal of therapy is to allow Grace and her parts to understand that they are not stuck in past trauma, the bad things are not happening now and they are safe in this moment in time. The ability to separate past from present will enable Grace to assign trauma and grief to the past. Once this has been achieved, Grace will then be able to remember or at least create new, happy memories which will include being able to feel: wonderment, joy, confidence, happiness and love. Successful therapy will lead to further growth and strengthened resilience (Mancini & Bonanno, 2006). The last thing to note with any therapeutic process, Grace may go through the stages, then fall back and start over again. Grace knows that healing is a process and this is part of the journey (Tedeschi &Calhoun, 1996). Therefore by demonstrating the complex case study of Grace, it can be clearly seen that early childhood abuse has serious consequences that can last a lifetime. Numerous risk factors underlie the way a survivor deals with traumatic events, and there are currently many treatment approaches and strategies to aid the survivor through recovery. There is much the therapeutic community can learn by understanding these. This will lead to continuing positive outcomes since new and better interventions can be developed and implemented (Bisson, 2008). However, existing strategies used today need to be tested with greater numbers to achieve valid and statistical evidence-based practice. Lastly, the therapist must bear witness to a survivor. In this way he/she will be able to live a life that is more conducive to positive outcomes and health. It is also better to use a holistic approach when investigating coping

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strategies, resilience, environmental factors and beliefs so that better outcomes in the healing journey can be achieved.

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References: Ainsworth, M.; Blehar, M.; Waters, E.; and Wall, S. (1978). Patterns of Attachment. Hillsdale, NJ: Erlbaum. American Psychiatric association (2012) 750 First Street NE, Washington, DC 20002-4242. Australian Centre for Posttraumatic Mental Health. (2007b). Australian guidelines for the Treatment of adults with Post Traumatic Disorder.IOM. 2007b. Washington. Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford. Bisson, J. (2008). Using evidence to inform clinical practice shortly after traumatic events. Journal of Traumatic Stress, 21(6), 507-512. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York: Basic Books. Brierre, J. (1996). Using the Phase Oriented Model of Trauma Counselling New York: Springer Publishing Co. Davis, M. (1992). The role of the amygdala in fear and anxiety. Annual Review of Neurosciences, 15, 353-375. Diagnostic and Statistical Manual of Mental Disorders. (2000). 4th ed. Washington, D.C.: American Psychiatric Association. Fanagy, P. (2001). Attachment Theory and Psychoanalysis. New York: Other Press. Falloon I, Laporta M, Fadden G, Graham-Hole, V. (1993) Managing Stress in Families: Cognitive and Behavioural Strategies for Enhancing Coping Skills. London: Routledge. Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: Exposure to corrective Information. Psychological Bulletin, 99, 20-35. Journal of Traumatic Stress, 8, 675690. Foa, E.B., Molnar, C., & Cashman, L. (1995). Change in rape narratives during exposure

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therapy for posttraumatic stress. Green, B. L. (2000). Traumatic loss: conceptual and empirical links between trauma and bereavement. Journal of Personal and Interpersonal Loss, 5, 1-17. Harvard Medical School. (2006). Complicated grief: Looking for help when mourning persists and intensifies. Harvard Mental Health Letter, 23(4), 1-3. http://www.health.harvard.edu/fhg/ 2006). Hooyman, N.R. and Betty J. Kramer (2006) Living through Loss. Columbia University Press. Kase, L., & Ledley, D. R. (2007). Anxiety disorders. Hoboken, NJ: Wiley. Kersting. K. R. (1998). Becoming attached: First relationships and how they shape our capacity to love. New York: Oxford University Press. Linley, P. A., & Joseph, S. (2004). Positive change through trauma and adversity. A review. Journal of Traumatic Stress, 17(1), 11-21. Mancini & Bonanno (2006) Resilience in the face of potential trauma: Clinical practices and Illustrations. Journal of Clinical Psychology Volume 62, Issue 8, pages 971 985, August 2006. McFarlane, 2003 McFarlane, Thomas J. (2003),"Cultivating Your Dream Life", Center Voice: The Newsletter of the Center for Sacred Sciences, Summer-Fall 2003. Neimeyer (2001), Australian Centre for Posttraumatic Mental Health http://www.acpmh.unimelb.edu.au/trauma/treatment.html Title: Attachment style and Bereavement reactions.Title: Meaning reconstruction & the experience of loss. Author(s)/Editor(s): Neimeyer, Robert A. Source/Citation: Washington, DC, US: American Psychological Association; 2001, (xiii, 359) Pearlman. L, A., & Saakvitne. L., (1995) Trauma and the Therapist: Countertransference and Vicarious Traumatization in Psychotherapy with Incest Survivors. Norton (New York). Rak, Carl F. (2002) Heroes in the nursery: Three case studies in resilience.

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Author(s)/Editor(s): Source/Citation: Journal of Clinical Psychology: Special Issue: A second generation of resilience research. Vol 58(3) Mar 2002, US: John Wiley & Sons; 2002, 247-260 Raphael, B. (1986). When disaster strikes: A handbook for the caring professions. London: Unwin Hyman. Scott, C., & Brierre, J. (2006). Biology and psychopharmacology of trauma. In J. Brierre, & Scott (Eds.), Principles of trauma therapy: A guide to symptoms, evaluation, and Treatment (pp. 185-229). Thousand Oaks, CA: Sage Publications. Scott, C., Jones, J., & Brierre, J. (2006). Treating the effects of acute trauma. In J. Brierre, & C. Scott (Eds.) Thousand Oaks, CA: Sage Publications. Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures (2nd Ed.). New York: Guilford Press. Shulman and Shewbert (2005) Crisis Intervention Handbook. Assessment, Treatment, an Research. Third Edition. Albert R. Roberts. OUP USA. Tedeschi &Calhoun, (1996). Tedeschi, R. G., & Calhoun, L. G. (2006). Expert Companions: Posttraumatic growth in clinical practice. In L. G. Calhoun & R. G. Tedeschi (Eds.), Handbook of posttraumatic growth: Research and practice (pp. 291 310). Mahwah, NJ: Erlbaum. Walter, A., Carolyn & McCoyd, Judith L M (2009) Grief and Loss Across the Lifespan: A Biopsychosocial Perspective. Springer Publishing Company. Wayment, Heidi A, Vierthaler, & Jennifer (2002) Author(s)/Editor(s): Author Affiliation: Northern Arizona U, Dept. of Psychology, and Flagstaff, AZ, US Source/Citation: Journal of Loss & Trauma; Vol 7(2) Apr-Jun 2002, United Kingdom. Wiger, D. E., & Harowski, K. J. (2003). Essentials of Crisis Counselling and Intervention. Hoboken, NJ: Wiley. Taylor & Francis/Brunner Routledge; 2002, 129-149.

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CASE STUDY OF ROSE: WORKING WITH CRISIS AND TRAUMA

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