The Role of Trauma

Trauma is related to early abuse and/or

neglect, is in the histories of public
mental health individuals who frequently
are self-harming, high users of costly
services and who carry multiple
diagnosis-BPD,DID, or PTSD.

General Population
10% of women and 5% of men are likely

to suffer PTSD
33.3 will have symptoms lasting several
months
Those most vulnerable - inadequate
social support, survivors of child hood
sexual abuse

Public Mental Health Consumers

98% of 275 consumers had exposure to

severely traumatic events

43% suffered from PTSD
Chart review 2% had diagnosis on chart
Another study - 34% admitted to
psychiatric state hospital had PTSD secondary to CSA

The Internal Classification of

Diseases (IDC-10): Has described a
diagnosis - Enduring personality
changes after catastrophic stress

Substance Abuse and Trauma

PTSD 5 times likelihood of alcohol abuse &

dependence
PTSD and veterans - 75% met criteria for
alcohol abuse
60% women & 20% men in alcohol recovery
programs sexual abuse as child
80% reporting physical abuse as children - in
above recovery program

Effects on Dual Diagnosis

When Disclosed
Positive
Increased trust
Increased

understanding D/A
effects
Differentiate D/A, MI
abuse
Devise treatment
plan

Negative
Increase D/A
Increase MI

symptoms
Avoid deal D/A or MI

Effects on Dual Diagnosis

Treatment When Not Disclosed
Significant factor in substance use

remains undisclosed
Potential destabilizing factor when kept
a secret
Secret interferes with treatment
Secret maintains a lower level of trust
Treatable condition remains untreated

Sexual Abuse invisibleWhy is

there so little treatment?
Professionals do not recognize the abuse
Symptoms vary greatly
Symptoms surface years after abuse
Abuse is rarely volunteered
Pervasive avoidance and denial
Misdiagnose
Mid 70s not seen as a problem

Core Beliefs
The shame and despair that come from the
powerlessness and unmanageability help crystallize the
core beliefs about personal unworthiness that were part
of the persons initial addictive system:
I am basically a bad, unworthy person
No none would love me as I am
My needs are never going to be met if I have to
depend on others
Sex is my most important need
(Adapted from Carnes, 1989)

The Addictive Cycle

Preoccupation
Ritualization
Acting out
Despair
Shame blame cycle
Unmanageability

Multiple Addictions

Sex addiction is seldom isolated

More than 83% report multiple addictions
1.
2.
3.
4.
5.

Chemical dependency (42%)

Eating disorders (38%)
Compulsive working (28%)
Compulsive spending (26%)
Compulsive gambling (5%)

Studies of alcoholism treatment find sexual

compulsion in clients, ranging from 42 to
73%.
(NCSAC webpage, 2000)

Complex Post-Traumatic
Stress Disorder
A history of subjection to totalitarian control

over a prolonged period (months to years)

Alterations in affect regulation
Alterations in consciousness
Alterations in self-perception
Alterations in perception of perpetrator
Alterations in relations with others
Alterations in systems of meaning

(Herman, 1992)

High Comorbidity for PTSD

Substance related disorders
Mood disorders
Other anxiety disorders
Personality disorders
(Adapted from Maldonado & Spiegel)

FOCUS ON TREATMENT AND

ASSESSMENT

Assessing Psychological Resilience

Insight into oneself and others
Supple sense of self-esteem
Ability to learn from experience
High tolerance for distress
Low tolerance for outrageous behavior
Open-mindedness

Assessing Psychological Resilience

(Cont.)
Courage
Personal discipline
Creativity
Integrity
Keen sense of humor, constructive

philosophy of life that gives life meaning

Willingness to dream dreams that inspire and
give hope
(Adapted from Wolf & Mosnaim, 1990)

Assessment Process
You will have to ask questions to assess
If symptoms are resulting from abuse.
This should not be used to dredge up
repressed memories.

Assessment Questions
In the course of the day/night, do you hear

voices in or outside your head? What are

they saying? What may cause you to hear
these voices?
Do you ever try not to feel your feelings or

thoughts? Do you usually feel numb?

(Graves)

Assessment Questions (Cont.)

Have you ever been a victim of sexual

abuse?
Have you ever observed sexual abuse?
Have you ever been the victim of
physical abuse?
Have you ever observed physical
abuse?
(van der Kolk)

Continue if Yes to Any of the Above

Do you ever have day dreams or think about

the sexual or physical abuse?

Night dreams Do you have them? Are they
nightmares? If not, do you have any night
dreamsare they neutral or bad? If bad, why
arent they nightmares?
Do you think about the above abuse during
the course of a day?
If yes, how and when does it come about?
(Graves)

Two Basic and Very Important

Questions
How did you get here today?
What do you do that makes you feel

good about yourself? (Something you

may have accomplished.)
(van der Kolk)

Traditional Treatment Approaches

Psychopharmacology
Psychodynamic psychotherapy
Group psychotherapy
Family therapy

Non-traditional Approaches to
Uncovering and Processing
Direct therapeutic exposure
Hypnosis
EMDR
Psychodrama and role play
Creative therapies such as art therapy, music

therapy and dance therapy

Spiritual and religious ceremonies
Testimony

(Adapted from Turner, McFarlane & van der Kolk)

Stages of Recovery from Trauma

Importance of the healing relationship
Creating safety
Naming the problem
Restoring control
Establishing a safe environment
Reconstructing the story
Transforming traumatic memory

Stages of Recovery from Trauma

(Cont.)
Mourning traumatic loss
Learning to fight
Reconciling with oneself
Reconnecting with others
Finding a survivor mission
Resolving the trauma
(Adapted from Herman, 1992)

TREM Model
Trauma, recovery, empowerment
Women with history of:
Serious

mental illness
Substance abuse
Trauma
Homelessness
(Harris, 1998)

Four Core Assumptions of TREM

Symptoms originated as coping

response to trauma
Women with early trauma unable to
develop adult coping skills
Trauma severs connections
Women with repeated abuse feel
powerless.
(Harris)

Group Model
10 33 sessions
4 stages in group program

1.
2.
3.
4.

Empowerment
Trauma recovery
Advanced trauma recovery
Closing rituals
(Harris)

Training for Professionals

Develop awareness of parallel process

for therapist in group

Address secondary trauma issues for

therapist
(Harris, 1998)

Role of Case Management and

Treatment
Most of mental health system is impacted

by individuals with abuse

Case managers are involved in every part
of persons life
Individuals childhood abuse impacts
every part of their lives
Expansion/adaptation of roles by having
protocol assessment for functioning

Psychodrama & Multiple Addictions

Model of addiction interaction (Carnes, 1994)
Examples of models, switching, alternating,

masking, ritualizing
Psychodrama techniques of grounding in
present explore addiction patterns
Role reversal, doubling, mirroring demonstrate
splitting of self and choice of addiction
Psychodrama can explore denial in client and
therapist to protect beliefs and myths
(Sealy, 1999)

Psychodrama/Addiction/Trauma
Allows the traumatized inner child to come

back from the dead and feel alive again

Unspeakable can be spoken within
framework of safety and support
Experimentation of new roles and alternative
ways of being
Role training allow recovering people to work
out issues with new behavior
(Dayton, 1994)

Traumatic Transference
Therapist may suffer vicarious symptoms that

replicate PTSD
Repeated exposure to stories challenges
therapists basic faith
Heightens sense of personal vulnerability
May share clients experience of helplessness
As defense against helplessness may
assume role of rescuer
May violate boundaries of therapy

Traumatic Transference (Cont.)

Identification with clients rage
Experience feelings of profound grief
Identification with perpetrator
Voyeuristic excitement, fascination and

sexual arousal
Witness guilt
Existential panic

(Adapted from Herman, 1992)