John Briere, Ph.D. Departments of Psychiatry and Psychology, University of Southern California

1. Reconsidering Trauma:Treatment Advances, Relational Issues, and Mindfulness in Integrated Trauma Therapy John Briere, Ph.D. Departments of Psychiatry and Psychology, University of Southern California Psychological Trauma Program, Los Angeles County – USC Medical Center MCAVIC-USC Child and Adolescent Trauma Program, NCTSN

2. Complex trauma exposure • Onset • Childhood trauma and neglect • Attachment disruption usual • Extended duration and frequency • Traumatic processes and well as traumatic events • Relational/interpersonal • Complexity • Accumulated effects • Interacting effects

3. Complex posttraumatic outcomes – ethnocultural aspects • Ethnic/cultural/gender differences in • Perception of trauma • The example of sexual trauma • Models of injury • Psychological • Somatic • Spiritual • Idioms of distress • “Culture-bound” stress disorders • Commonalities of response across groups

4. Complex posttraumatic outcomes – Chronic posttraumatic stress • Symptomatology • Reexperiencing • Avoidance • Hyperarousal • Avoidance and chronicity • Cognitive, emotional, dissociative, substance abuse • Risk factors • Trauma, reduced social support and marginalization, reduced affect regulation capacities, nervous system compromise

5. Complex posttraumatic outcomes – Self-capacities • Identity • Other-directness • Reduce self-access/awareness • Boundary disturbance • Susceptibility to influence • Relationality • Implicit attachment-related schemata • Models of relationship • Relational schema • Conditioning to emotional-cognitive memories • Source attribution errors • “Out of proportion" emotions/thoughts

6. Complex posttraumatic outcomes – Self-capacities • Affect regulation • Underdevelopment in the context of maltreatment • Modulation versus tolerance • The imbalance between level of triggerable distress and affect regulation capacity • The avoidance triad: Substance abuse, dissociation, and tension-reduction • “Cluster B” personality disorders • Psychosis • As a feature of posttraumatic stress • As a feature of disturbed self-capacities

7. A philosophy of trauma • Integrating Eastern models of suffering, attachment, and mindfulness • Ubiquity of trauma versus the myth of normality • Pain versus suffering • Trauma seen as bad, pain seen as wrong/pathological, to be avoided • Focused awareness of painful material and paradoxical relief • Avoidance can intensify distress, intrusion • Mindfulness as the opposite of avoidance • Attachment: expectation, need, and preoccupation • Reality as subjectivity • Perception versus activated implicit memory • Source attribution errors and the complexity of personal experience

8. A philosophy of trauma • The problem with solely symptom-based models • Treatment goals narrow to definable fixing of distress • Diminished relevance to a lived life and the opportunity for larger changes • Reinforces avoidance rather than engaging roots of suffering • Natural systems of trauma recovery - Intrinsic processing • Self-exposure • Recurring thoughts, memories, nightmares, flashbacks, “reenactments” • Drive to process: verbalization, expression, attraction to trauma reminders, therapy seeking • Posttraumatic growth, acceptance, and integration

9. Assessing trauma and impacts in the clinical interview • Process responses and intra-interview signs • Activation responses • Easily triggered cognitive-emotional states • Avoidance responses • Dissociative disengagement, lapses, inconsistency, constriction • Denial, content switching • Affect dysregulation • Mood swings • “Falling into the hole” • Reports of TRBs • Relational disturbance • Alertness to interpersonal danger • Abandonment issues • Need for protection via control

10. The Self-Trauma Model – A components approach

11. Distress reduction and affect regulation training • Dealing with acute intrusions – grounding • Somatosensory feedback (e.g., body in chair) • Details of room • Reminders of past versus present • Breath training • Breath and tension/stress • Effects of slower, deeper, diaphragmatic breath

12. Mindfulness and affect regulation • Nonjudgmental self-observation • Acceptance of (good, bad, or neutral) thoughts, feelings, and memories versus fighting thoughts/feelings • Disturbing thoughts and feeling allowed to come and go (“watching the parade”) • De-investment in emotional experience: “I don’t trust my inner feelings, inner feelings come and go” (Leonard Cohen) • Self as relative/contextual/”insubstantial”, • “No self” – self concept in flux, result of interrelated conditions, not inherently concrete (self as process) • Less identification with desires, supposed traits, social expectations, therefore less disappointment, betrayal, disillusionment, abandonment concerns

13. Distress reduction and affect regulation training • Trauma-relevant meditation • Posture, breathing, attention • Exposure via reduced avoidance, greater relaxation • Affect regulation and equanimity (nonreactivity to internal states) • Stress/arousal reduction • Potential constraints • Initial increased activation • Perceived reduced control • Effects of memory intrusion • Monitoring issues • Therapist must be familiar with meditation procedures

14. Empirically-based mindfulness-related therapies • Dialectical behavior therapy (DBT; Linehan) • Mindfulness-based stress reduction (MBSR; Kabat-Zinn) • Mindfulness-based cognitive therapy (MBCT; Segal, et al) • Acceptance and commitment therapy (ACT; Hayes)

15. Distress reduction and affect regulation training • Trigger identification, recontextualization • Understanding and insight alter similarities of stimuli to initial trauma memory • Trigger grid: • How do I know I’m being triggered? • What are the triggers, when do they occur? (review of history) • What do I think/do after triggers? • How might I avoid/counter them? • Creation of self-talk options • Analysis of differences between initial event and triggering event • Repetitive exposure and processing of traumatic material as affect regulation training

16. Cognitive interventions • Normalizing and reframing of experiences and “symptoms” • Cognitive reconsideration: An empowering alternative to cognitive restructuring • Using exposure processes to prompt reevaluation of cognitions • Mindfulness: Practicing nonjudgment and acceptance • Intrusive negative cognitions as “just thoughts,” not representations of reality • Reduced self-blame through experience of conditionality • Reduced identification with self-criticism (participant-observer) • Insight and the development of a coherent, nonpathologizing narrative

17. Emotional processing • The components of trauma processing • Exposure • Activation • Disparity • Nonreinforcement of CERs and trauma-related assumptions/beliefs (safety) • Counterconditioning • Extinction/resolution

18. Emotional processing • Titrated exposure and the therapeutic window • Limiting factors • CER intensity • Affect regulation skills • Balance between therapeutic challenge and overwhelming internal experience • Overshooting vs. undershooting the window

19. Emotional processing at the session level • Repetitive exposure to trauma memories via questions/facilitation of disclosure • Activation control • Greater vs. lesser detail • Time/tense focus: here-and-now vs. there-and-then • Emotional vs. cognitive • Extent of intervention in avoidance • Safety, support, validation, encouragement • Emotional discharge/expression • Debriefing/contextualization

20. Emotional processing • Mindfulness as exposure • Reduced cognitive-emotional avoidance • Processing with awareness • Openness to distress, yet • The changed relationship to distress = decreased suffering • Increased access to memory • greater exposure • Titrated levels of distress (through detachment), and • Greater awareness of disparity

21. Emotional processing • Processing “hot spots” with focused CBT or EMDR • Only when tolerable, always within window • Greater specificity and intensity of exposure • Pre-briefing • Two approaches • Prolonged exposure • EMDR • Debriefing

22. Increasing identity functions • Self-exploration, inner directedness, and identity training • Development of self-knowledge and self-directedness • Value of nonleading, open-ended questions • Avoiding the over-use of interpretations • Effects of increased mindfulness • Less attachment to sense of self as enduring and concrete • Yet, increased awareness means greater self-awareness • Greater self-appreciation • Acceptance and compassion

23. Increasing relational functioning • Cognitive-emotional processing of relational schema • Exposure to relational stimuli, activation of schema, disparity in therapeutic environment, counterconditioning via therapeutic emotional bond, extinction/restructuring

24. Psychiatric medications • Presenter caveats • Can trauma psychopharmacology “fit” with growth models of trauma recovery? • Traditional • Symptoms as psychopathology, medication as correction • STM: Nonresolvable/chronic symptoms as overwhelming “trauma load,” preventing processing • Medication as support for more effective processing by reducing • Anxiety • Comorbidity • Rarely sufficient by themselves

25. Psychiatric medications • Limiting issues • Psychological treatments often yield larger effect sizes in treatment outcome studies • Noncompliance as result of side-effects • Potential effects of reducing anxiety during exposure and processing • Specific concerns about benzodiazepines • Addiction/dependency concerns for trauma survivors • Use of antipsychotic medications • Potential relapse effects upon discontinuation

26. Psychiatric medications • Potential benefits • Recommendations from the International Society for Traumatic Stress Studies • First line – SSRIs (only FDA indication for PTSD) • Second line – TCAs, MAOIs • Questionable – mood stabilizers • Benzodiazepines – for management of acute anxiety • Antipsychotics – for clear psychosis • Speculation from research • Alpha and Beta blockade for hyperarousal symptoms

27. Therapist issues in trauma treatment • Countertransference/counteractivation • Personal history • Cultural assumptions/socialization • Mindfulness and activation awareness • Psychotherapy • Internally directed practice • Social support • Consultation • Community of clinicians