Lecture 4 Flashcards
(48 cards)
1
Q
trauma
A
emotionally painful experience that overwhelms a person’s ability to cope (feeling out of control)
- primary trauma = direct experience of trauma
- secondary trauma = indirect experience of trauma
2
Q
trauma vs complex trauma
A
- complex is more severe
- complex has more psychosocial impairment
- trauma refers to a single experience, complex trauma a series
3
Q
Childhood trauma
A
- trauma exposure before age 18
4
Q
Types of trauma
A
- go beyond life threatening experiences
- emotional abuse, physical abuse, sexual abuse, neglect
- living in an unsafe neighbourhood, bullying, discrimination
- divorce, witnessing DV, parental mental illness and substance abuse
5
Q
Prevalence of complex trauma
A
- subject to recall bias
- children who have experienced severe trauma often have issues recalling the event
- hard to reliably investigate prevalence of trauma
- foster care: 70% have 3 or more adverse childhood experiences
- adolescents: 62% experience ACE, 18% 3 or more
- children who experience any type of trauma are more likely to experience other types of trauma
6
Q
Trauma and PTSD
A
- after trauma exposure, individuals may develop symptoms of PTSD, this is a normal response to an abnormal experience
- PTSD usually develops within the first 6 months after trauma
- if symptoms develop after 6 months -> late/delayed onset PTSD
7
Q
late/delayed onset PTSD
A
- dependent on age of trauma, they may not realize what happened is not normal
- they may not have developed the necessary coping skills to process it
- parents divorce, loss of a friend, and then the other traumatic experience becomes overwhelming
-children may resist talking about the trauma
-symptoms may not have been triggered yet
8
Q
risk factors of PTSD
A
- trauma characteristics (type, onset, frequency, perpetrators)
- demographic and personality characteristics (age, gender)
- secondary stressors (low social support, parental stress)
- comorbid (internalizing) psychopathology
9
Q
PSTD symptoms - Intrusive Symptoms
A
- repetitive unwanted memories
- flashbacks (re-living the event)
- nightmares
- severe distress when reminded of it
- physical reactions such as, increased hear rate, sweating
10
Q
PTSD Symptoms - Avoiding thoughts and feelings of event
A
- resisting conversations about the event
- avoid situations that bring back unwanted memories or unwanted feelings
11
Q
PTSD symptoms - heightened arousal
A
- being easily startled or fearful
- irritability and anger
- over aware of their surroundings or potential threats
- having trouble concentrating, falling asleep or staying asleep
12
Q
PTSD symptoms - changes in thoughts and feelings
A
- struggling to remember important parts of the event
- ongoing distorted beliefs about oneself
-recurrent feelings of fear, anger, guilt, shame
-feeling detached from others
13
Q
CPTSD
A
- in addition they experience disturbances in self-organization
- emotional dysregulation (persistent sadness, suicidal thoughts, explosive anger)
- negative self perception (worthlessness, shame, guilt)
- interpersonal disturbances (feeling distant from others, relational difficulties)
- exposed to earlier, more long lasting and invasive events or primarily interpersonal nature (i.e. severe abuse and/or neglect) and struggle with poorer functional impairment
14
Q
Development of (C)PTSD symptoms
A
- trauma produces natural and productive behavioural and emotional responses
- these reactions may generalize to innocent trauma reminders or triggers that automatically elicit arousal and fear (classical conditioning)
- avoidant behaviour may develop and be reinforced to minimize the experience of trauma related symptoms (operant conditioning)
- this can limit the development and capacity to engage in interactions with the world
15
Q
Related impairment
A
- as childhood and adolescent trauma disrupt development, they have been linked to a spectrum of (lasting) adverse health consequences
- physical conditions: obesity and diabetes (due to risky behaviors)
- symptoms of andxiety and depression, ADHD diagnosis (trauma rewires the brain)
- lower perceived social support, lower social skills because they withdraw
- behavior/conduct problems (children learn the only emotion to express that is safe is anger)
- poor sleep quality and school related issues
- dose response : more trauma/PTSD = more adverse effects
16
Q
Interventions for (complex) trauma
A
- to prevent a harmful developmental trajectory (complex) trauma in childhood or adolescence should be treated in childhood and adolescence
- goal: optimizing children and adolescent’s functioning in all domains of life
- helping them overcome: traumatic avoidance, feelings of shame, anger, sadness, fear, cognitive, behavioural and social difficulties
- treatment studies in children and adolescents are scare
17
Q
Child Centered Play Therapy (CCPT)
A
- play-based therapy that is used to uncover and process trauma
- emerged from person-centered therapy
- non-directive techniques
- children develop self-actualization
- children can solve their own problems
18
Q
CCPT components
A
- aimed at young children between 3-10 years old who experience social, emotional, behavioural and relational difficulties/disorders
- play based: children can use play to learn, process emotions and make meaning of the world
- can use symbols to communicate with their ideas and emotions
- play therapy allows for the symbolic expression of children’s inner conflict
- using toys, children can attain mastery by using imagination to modify the story
19
Q
Implementing CCPD
A
- therapist provides a safe and consistent environment: same toys, same room, same day, same time
- this is needed so child can process inner experiences and feelings
- therapist should fully accept, understand and empathize with the child (even when their behaviour requires limits)
- the therapist responds to the child’s defensiveness with openness and empathy: allowing the child to learn something new (I can trust others), allowing the child to develop trust and impulse control
- allowing child to build identity, self worth, decision making skills, coping skills
- stimulating adaptive self- and interpersonal functioning
- corrective experiences during play therapy
- translation to home environment is essential
20
Q
Effectiveness and efficacy of CCPT 1
A
- significant decrease in externalizing and internalizing issues
- significant decrease in parental stress
- significant increase in parents’ empathy toward their child
- compared to waitlist condition and alternative treatments
21
Q
Effectiveness and efficacy of CCPT 2
A
- CCPT vs waitlist
- showed significant improvements in social-emotional functioning
(they build empathy, emotion regulation, and social competence) - showed significantly fewer behavioral problems
22
Q
Trauma Focused Cognitive Behavioural Therapy (TF-CBT)
A
- between 3-18 years old
- skill based model that incorporated trauma sensitive interventions with CBT and FT principles/techniques
- psychoeducation, skill building, exposure, trauma narrative processing, parental involvement
- provide safe environment to process, learn and share thoughts feelings, overcome stigma etc.
- in case of dangerous acting out behaviours i.e. suicidal behavior or nonsucical self injury -> other therapy is more appropriate
23
Q
Treatment program TF-CBT
A
- 8-20 sessions
PRAC: coping skills phase
T: trauma narrative and processing phase
ICE: Treatment consolidation and and closure phase - progressive program: each component builds on previously mastered skills
- more sessions for more severe cases
- gradual exposure:
- parallel child and parent sessions with additional conjoint sessions
24
Q
PRAC
A
- psychoeducation
- parenting skills
- relaxation skills
- affective modulation skills
- cognitive coping skills
25
ICE
- in vivo mastery of trauma reminders
- conjoint youth caregiver sessions
- enhancing safety
26
Psychoeducation 1
Providing the child and parents with information about:
- the nature of traumatic experiences: their prevalence, causes, common reactions...
- trauma reminders: any internal/external cues that remind children of their original
trauma and elicit trauma responses
- identifying the child’s trauma reminders and connecting these to the child’s trauma
responses (making sense of the trauma)
- understanding that the child’s emotional and/or behavioral problems are trauma-related
Treatment
- to reassure children and parents that they are not alone or abnormal
-occurs throughout the treatment (when needed)
27
Psychoeducation 2
Gradual exposure is implemented by:
- referring to the child’s traumatic experiences by name (‘car accident’, ‘domestic
violence’) rather than using a euphemism (‘the bad things that happened’)
- directly looking at and facing the child and parents when using words that describe
the traumatic experiences
- not lowering voice tone when talking about the child’s traumatic experiences as it
might convey secrecy, shame, or discomfort
- the therapist models nonavoidance
28
Parenting Skills
- parents are considered the primary agent of change in their children
- parents are informed about their child’ symptoms
- parents receive interventions that parallel those their child is receiving
- parents are supported in addressing their own emotional reactions to their child’s
trauma so that they can become sources of strength, support, and belief
- parents are assisted in recognizing and addressing dysregulation in their child
- enhancement of positive parenting (using praise, positive attention)
- decreasing parental distress
29
Relaxation Skills
- traumatized children suffer from physiological dysregulation
- refocus children and parents on enjoyable activities
- encourage them to learn to self-soothe
- i.e. focused breathing, yoga, muscle relaxation, dancing,
blowing bubbles, drawing
- gradual exposure is implemented by helping children and parents develop a variety of relaxation strategies for when they experience trauma reminders in
different scenarios/settings (at school, at bedtime, at a friend’s house
30
Affective Modulation
1. affective expression: children learn to identify and express their feelings
via photographs of faces, drawing, or other creative interventions
2. affective modulation: children learn to manage their difficult feelings
via problem solving, role playing, social support seeking
parallel parent session(s):
- parents express their own feelings about the trauma and develop optimal coping ways
- parents learn to assist their child in expressing feelings and model appropriate affect
expression and modulation
31
Types of affective modulation
- compare emotions to weather
“Just as the weather changes, our emotions can change too
- role-playing:
illustrate scenarios where affect modulation comes into play -> Challenging situation: loosing a game
Successfully manage your emotions and discuss
why it was helpful
32
Cognitive Coping
- children and parents learn to understand the connections between
their thoughts, feelings, and behaviors
- they examine their own patterns of negative thinking and change
dysfunctional thoughts about everyday events
- only parents use cognitive coping for processing their maladaptive thoughts
about their child’s traumatic event (child is not ready yet)
33
Trauma Narration
- takes much time
- help child develop and cognitively process a detailed narrative (story)
about their traumatic experiences
- interactive, therapeutic process that occurs over several sessions
- gradually encouraged to share its traumatic memories, including associated feelings, sensations, and thoughts (in a written book)
- come to a more accurate and helpful understanding about the trauma
- can now learn to identify unhelpful cognitions and replace them with more
optimal thoughts
Chronic/complex trauma: the child can construct a life narrative (from birth to
present), in which important positive and negative events are identified to contextualize the traumatic experience(s)
- Goal is not to change the traumatic experiences, but to associate them with more helpful feelings, thoughts, and behaviors
34
In Vivo Mastery
- only if feared stimulus is currently innocent, otherwise the stimulus is an appropriate cue for being vigilant to potential danger and avoidance
- therapist, child and parent collaborate in assisting the child in tolerating increasingly distressing reminders (e.g., visiting location of traumatic event)
- child experiences that they can overcome the maladaptive emotional
reactions to trauma reminders and gain feelings of mastery
- child and parents can fall back onto the skills they have already mastered
(e.g., identify trauma cues, cope with negative thinking...)
35
Conjoint Sessions
- transferring agency from therapist to parent
- children can share their narratives with their parents
- parents are prepared to encourage, hear, and praise children for talking openly about their traumatic experiences
36
Enhancing Safety
- important, especially for children who may still encounter dangerous situations
- discussing prevention of future traumatic events
37
Effectiveness and efficacy of TF-CBT
- significant decreases in PTSD symptoms
- significant decreases in emotional and behavioral problems
- gains were maintained at follow-up (range 3-12 months)
- significant enhancement of parental support and parenting practices
- significant reduction of parental depressive and trauma-related symptoms
- parental support predicts symptom decrease in children
- compared to waitlist or alternative interventions
38
EMDR
- brief, eight-phase protocol targeting PTSD symptoms and anxiety linked to future traumatic events
- suited for (young) children and adolescents as it puts less demands on
cognitive and verbal skills
Based on the Adaptive Information Processing (AIP) model:
- PTSD symptoms develop due to maladaptive encoding and/or incomplete processing
of traumatic events
- Trauma memories are stored in a dysfunctional and unprocessed way, causing persistence of these memories and fear behaviors
39
EMDR Phase 1: History and treatment planning
- discuss the client’s history and assess their internal and external recourses
- develop a treatment plan, focusing on which traumatic event to reprocess during treatment
40
EMDR Phase 2: Preparation
- establish a therapeutic alliance
- explain the EMDR therapy process and set expectations
- address client’s concerns and questions
- learn client skills to cope with emotional disturbance
41
EMDR Phase 3: Assessment
- identify the event to reprocess including images, beliefs, feelings, and sensations
- establish initial measures as baseline before reprocessing: (a) subjective distress and
(b) validity of cognition/thought
42
Phase 4: Desensitization
- begin sets of eye movements, taps, or other dual attention bilateral stimulation while the
client thinks about the traumatic event
-bilateral stimulation loads the WM, dampens neuron excitability in the amygdala -> decrease in fear behaviors
- focus on decreasing the client’s distress until it reduces to zero allowing new thoughts, images,
feelings, and sensations to emerge
43
Phase 5: Installation of a positive cognition
- strengthen a positive belief that the client wants to associate with the traumatic event until it
feels completely true
44
Phase 6: Body scan
- client is asked to hold in mind both the traumatic event and the positive belief while
scanning the body from head to toe
- process any lingering disturbance from the body with dual attention bilateral stimulation
45
Phase 7: Closure
- assist client to return to a state of calm in the present moment
- reprocessing is complete when the client feels neutral about it (distress = 0), the positive belief
feels completely true (validity of cognition = 7), and the body is completely clear of disturbance
46
Phase 8: Reevaluation
- beginning of each new session, therapist and client discuss recently processed memories
to ensure that distress is still low and positive cognition is strong
- future targets and directions for continued treatment are determined
47
Efficacy of EMDR
Results:
- Significant decreases in PTSD symptoms, also at follow-ups
- Mixed findings on the efficacy for anxiety and depressive symptoms
Conclusions:
- It is important to modify EMDR therapy based on age, adapting the protocol and
duration of the sessions
- EMDR therapy may be more cost-effective than TF-CBT
48
Future Directions
- research on the cost-effectiveness of trauma interventions and on
stepped-care approaches to better tailor treatment
- deliver the most effective, least intensive treatment
- focus only on certain components of the protocols?
- research on the optimal timing of trauma treatment: earlier
interventions are probably better, but this should be empirically confirmed
- treatment studies in young children are scarce
- larger samples investigating and comparing the effectiveness and efficacy of trauma interventions
