Lecture 5 phase 2 and 3 working with complex trauma

Lecture 5: phase 2 and 3:
Working with
complex trauma
Complex Casework
Kevin Standish
1

Learning outcomes
1. Explore how to manage Trauma Memory, Emotion
Processing, and Avoidance
2. Maintaining the therapeutic relationship in the face of
difficult therapy
2

PHASE 2: TRAUMA MEMORY
AND EMOTION PROCESSING
1. Post traumatic emotional
dysregulation
2. Processing of trauma emotions
3. SAFER Strategies
4. Evidence based treatments for
Trauma processing
5. Preparing the client for trauma and
emotion processing
6. Loss and Mourning issues
4

dysregulation
Interventions in phase 2 address two Cardinal features of
traumatic stress disorders:
1. The avoidance of memories of traumatic events as well as the
emotions, stimuli that serve as reminders and associated over
generalisation to trauma related reminders
2. The experience of extreme physical, mental and emotional
arousal. These extreme state of arousal are avoided by the
client.
3. Avoidance may begin as a conscious form of coping, but
becomes habitual, automatic and out of conscious control
leading to behavioural dissociation
4. The two ends of arousal (hypo-arousal and hyper-arousal) the
two extremes of behaviour in order to cope by numbing or
acute emotional dysregulation, anger, sleep problems, etc
5

dysregulation
1. Hyper-arousal is based on fear rather
than anxiety. Fear and anger occur when
the individual mobilises to defend
against attack or the threat of attack with
a fight / flight mechanism.
2. Anxiety results when fearful
circumstances inescapable or
unmanageable. Anxiety involves hypo-
arousal, in the form of freezing or
involuntary immobility.
3. Emotional dysregulation begins with
high levels of fear that over time become
infused with protest, and resignation and
ultimately leading to exhaustion
6

dysregulation
Avoidance + extreme arousal states =
post-traumatic emotional dysregulation
8

dysregulation
9
1. In neurobiological terms the emotionally disregulated
individual is in survival brain mode and at the mercy of the
lover reactive regions of the brain without the capacity to put
the brakes on through the higher cortical regions of the brain
that serve as modulators.
2. The client who alternates between hyper and hypo-arousal is
exhibiting complex adaptive capacities that have become
locked into the lower brainstem survival mode.
3. The individual is literally helpless to change survival based
neural network patterns that result in extreme state of
emotional distress (emotion dysregulation), mental
disorientation and confusion (dissociation), bodily hyper
arousal and exhaustion, and an associated sense of
hopelessness and defeat.

2. Processing of trauma
emotions
12

emotions
1. Emotion processing of trauma enables the client is safely
experience and appraise in present time the physical
sensations, emotions, and thoughts that they interpreted as
signals of overwhelming danger and associated
powerlessness after the trauma.
2. Rationale for its use: the process is intended to be more
therapeutic rather than merely cathartic and to avoid
iatrogenically destabilising the client.
3. It is a structured process designed to facilitate not only
remembering but also the clients vivid experience of trauma
related emotions and physical sensations in the immediate
moment of the therapy session.
4. This experiential technique is planned and prepared for,
designed to elicit memory and emotions with a hard but save
tolerable degree of arousal
13

emotions
5. Safely experiencing these emotions in the company of the
supportive therapist helps the client learn how to gain control.
6. It is more than a simple retelling of the trauma story, as the
kind can engage as a memory and its emotional reactions
while in a less aroused state, creating a condition of
emotional disparity.
7. It is this disparity that leads to counter-conditioning of the
original response allowing for the experiencing of other more
core emotions: ―emotional processing‖
8. This emotional processing results in changes in emotional
awareness, expression and self understanding, as one as
alterations in brain activity and related physiological systems.
14

emotions
9. It is unclear what exactly changes biologically or
psychologically when distressing emotions of processed, but
perceptional control theory proposes that sustained attention
in the face of distress enable clients to reorganise how they
interpret the meaning of extreme states of arousal giving them
a greater sense of control.
10. Attachment theorists believe experiencing the emotion in the
company of a supportive therapist provides counter
conditioning of previous indifference or no response.
Through a process of attunement, the therapist can co-
regulate the emotion, leading to neurological growth
stimulating brain development especially the left side and
prefrontal cortex of judgement, executive control and
functioning.
11. Therapy involves transforming emotionally fragmented
memories into meaningful life experiences that although
distressing can be lived with rather than feared and avoided.15

3. SAFER STRATEGIES
Self Care, symptom control, and stabilization
Acknowledgement vs Avoidance
Functioning
Expression of Emotions
Relationships
17

3.1. Self Care, symptom
control, and stabilization
1. Stabilisation is ongoing and monitored through aren’t the
entire treatment.
2. If the client is having difficulties in therapy or daily life that
can create an increase in symptoms, emotional processing
should be paused.
3. A clear discussion of what has been triggered in ways of
coping with this needs to be developed.
4. A focus on self care and symptom management can enhance
therapeutic processing, these constitute a key part of
therapeutically reworking memories in the moment of
processing.
18

3.2. Acknowledgement vs
Avoidance
1. Memory and emotion processing together is an act of
acknowledging the significance and meaning of the troubling
memories.
2. Memories recalled without acknowledgement are simply being
re-experienced with no working through, bringing about no
change.
3. To acknowledge an event or memory of the emotions attached
involves examining it to clarify its full range of impact.
4. Helping the client define what they mean in terms of
themselves and their lives is an essential part of helping the
client process the trauma.
5. Memory + cognitive understanding = emotional processing
Sorting Out Memories and Emotion
An Interview with Joseph LeDoux, Ph.D. by Brenda Patoine April, 2007.
https://www.dana.org/Publications/ReportDetails.aspx?id=44206
19

3.3. Functioning
1. Therapy must maintain or enhance the client’s functioning,
and not just provide symptom relief
2. The ability to live a life free from the lingering effects of
trauma is the overall goal.
3. Functioning may become impaired during emotional
processing due to the distress and confusion elicited by
facing the memories. Daily functioning becomes more difficult
as clients give up familiar ways of coping (namely avoidance)
and are learning new skills in unfamiliar territory.
4. Decreased ability to function is usually temporary, and over
time clients find their functioning begins to increase as a
freed from the emotional overload caused by the trauma
20

3.4. Expression of Emotions
and Experiential Awareness
1. Catharsis is not the primary goal. However
the therapist helps the client to become
experientially aware of the multiple levels
that the trauma has impacted that were
previously inaccessible due to dissociative
avoidance.
2. Verbal encoding and expression
(symbolising) involve the development of
the left side of the brain and put into words
what has been contained in a
somatosensory form on the right side.
3. Once verbalised, information can be
responded to by others to reinforce the
individual’s reality and reactions,
supporting the development and
differentiation of experiences. 21

3.5. Relationships
1. Memory and emotional processing in the context of psycho
social support with appropriate responses leads to
physiological changes beginning at the neurological level.
2. Clients in secure and responsive therapeutic relationship can
begin to incorporate the support and its mirroring of them.
3. Security and a sense of self worth and personal
accomplishment comes from being in relationships with
others rather than being in isolation and with out
interpersonal contact and response.
4. Emotional processing + secure relationship + attunement =
personal integration
22

4. EVIDENCE BASED
TREATMENTS FOR TRAUMA
PROCESSING
1. Prolonged exposure
2. Cognitive Processing Therapy
3. Other useful approaches
24

4.1.Prolonged exposure
1. Exposure therapy is a set of techniques designed to help
patients confront their feared objects, situations, memories,
and images (e.g., systematic desensitization, prolonged
exposure, flooding).
2. Theoretical Rationale for Exposure Therapy
Combination of:
1. Classical conditioning (traumatic event), e.g., little Hans
2. Instrumental conditioning
1. Memory of trauma is paired/conditioned to current,
unrelated events, e.g., crowds, restaurants, movies
2. Engagement of avoidance activities to reduce anxiety
3. Result is world starts to shrink
3. Imaginal re-exposure to memory of trauma in safe setting
results in desensitization/habituation of conditioned
associations between traumatic memory and negative
emotions.
https://www.youtube.com/watch?v=9aTDIiTr99Y (11 min)
25

4.2.Cognitive Processing
Therapy
1. Learning About Your PTSD Symptoms. CPT begins with
education about your specific PTSD symptoms and how the
treatment can help.
2. Becoming Aware of Thoughts and Feelings. Next, CPT focuses
on helping you become more aware of your thoughts and
feelings. When bad things happen, we want to make sense of
why they happened. In CPT you will learn how to pay attention
to your thoughts about the trauma and how they make you feel.
You'll then be asked to step back and think about how your
trauma is affecting you now. This will help you think about your
trauma in a different way than you did before. It can be done
either by writing or by talking to your therapist about it.
26https://www.youtube.com/watch?v=Tx3KdKDZOS8
(2 min)

4.2.Cognitive Processing
Therapy
3. Learning Skills. After you become more aware of your
thoughts and feelings, you will learn skills to help you
question or challenge your thoughts. You will do this with the
help of worksheets. You will be able to use these skills to
decide the way YOU want to think and feel about your trauma.
These skills can also help you deal with other problems in
your day-to-day life.
4. Understanding Changes in Beliefs. Finally, you will learn
about the common changes in beliefs that occur after going
through trauma. Many people have problems understanding
how to live in the world after trauma. Your beliefs about
safety, trust, control, self-esteem, other people, and
relationships can change after trauma. In CPT you will get to
talk about your beliefs in these different areas. You will learn
to find a better balance between the beliefs you had before
and after your trauma. 27

4.3.Other useful approaches
1. Emotion Focused Trauma
Therapy
2. EMDR
3. Imagery Rehearsal
4. Narrative Exposure therapy
5. Trauma Affect Regulation
6. Seeking Safety
7. Skills training in Affect
regulation
28

4.3.1.Emotion Focused Trauma
Therapy
30
https://www.youtube.com/watch?v=UtODEXeu94k
(EFT couple Therapy3 min)
https://www.youtube.com/watch?v=QpbmxHBWJqM
&list=PLF44D10FD20265BB6
(Greenberg interview 8 min)

4.3.2.EMDR
32
https://www.youtube.com/watch?v=S2BhZwHXFro
4 min Shapiro interview

4.3.3.Imagery Rehearsal
1. Step 1: Lay out the storyline of the nightmare in detail with all
elements
2. Step 2: Rewrite the nightmare, The goal of rewriting is to create an
alternative, less distressing plot and outcome. This can be
achieved by changing some of the elements, perceived as
particularly anxiety-producing.
3. Step 3: Rehearse it
4. Rehearsing this new storyline for the dream several times
throughout the day—and particularly close to when they get ready
to go to sleep—the repeated nightmare is changed from a stressful
event to a pleasant one
33
https://www.youtube.com/watch?v=CLsmRs6RXYM
6 min Nightmares

4.3.4.Narrative Exposure
therapy
1. Narrative Exposure Therapy (NET) builds on the theory of the dual
representation of traumatic memories (Elbert & Schauer, 2002). It is
thought to contextualize the sensory, affective and cognitive
memories of trauma to understand and process the memory of a
traumatic event in the course of the particular life of a client.
2. The patient constructs a chronological narrative of his life story with
a focus on the traumatic experiences. Fragmented reports of the
traumatic experiences will be transformed into a coherent narrative.
3. Empathic understanding, active listening, congruency and
unconditional positive regard are key components of the therapist’s
behaviour. For traumatic stress experiences the therapist asks in
detail for emotions, cognitions, sensory information, physiological
responses and probes for respective observations. The patient is
encouraged to relive these emotions while narrating without losing
their connection to the ―here and now‖:
4. NET allows reflection on the person’s entire life as a whole, fostering
a sense of personal identity. Working through the biography
highlights the recognition and meaning of interrelated emotional
networks from experiences, facilitating integration and an
understanding of schemas and behavioural patterns that evolved
during development.
34

4.3.5.Trauma Affect Regulation
1. https://www.youtube.com/watch?v=X3cRJvBg5GE (2min)
2. http://www.affectregulationtherapy.com
3. Affect Regulation Therapy (A.R.T.) consistently provides rapid
results, including reduced stress levels, improvement in mood and
emotion regulation and increased commitment to therapy. Using a
combination of standard psychotherapy methods from
developmental, psychodynamic and behavioural psychology,
A.R.T. improves client outcomes and is a suitable support for most
mental healthcare programs.
4. Through A.R.T. clients learn to regulate mood and control positive
and negative arousal states using three mediums for emotional
processing, the cognitive, emotional and the body based self
systems. You’ll see immediate and sustained results in clients’
abilities to control affect states and achieve situation appropriate
emotional responses.
35

4.3.6.Seeking Safety
1. Seeking Safety is based on five central ideas: (1) Safety as the
priority of treatment. (2) Integrated treatment.(3) A focus on
ideals. (4) Four content areas: cognitive, behavioral, interpersonal,
and case management. (5) Attention to clinician processes.
2. Other features include simple, human language and themes
(i.e., accessible language that avoids jargon); treatment methods
based on educational strategies to increase learning; a focus on
potential; emphasis on practical solutions; and an urgent approach
to time.
3. http://www.seekingsafety.org/
36

4.3.7. Skill Training in Affect and
Interpersonal Regulation (STAIR)
1. http://www.ptsd.va.gov/professional/continuing_ed/STAIR_onl
ine_training.asp
37
http://www.ptsd.va.gov/apps/STAIR/Session1/wrap_menupage.htm
5 min

5. PREPARING THE CLIENT
FOR TRAUMA AND EMOTION
PROCESSING
1. Technical Considerations in trauma and emotion
processing
2. Tactics for optimizing affective intensity and physical
arousal
3. Tactics for enhancing engagement
4. Strategies for enhancing and maintaining reflective self-
awareness
5. Determining when to Stop
6. Tactics for Preventing and Managing Crises
38

5.1.Technical Considerations in
trauma and emotion processing
1. For clients to engage emotional processing the need to have
sufficient resources (personal and interpersonal) and life
safety and stability to be able to provide voluntary informed
consent.
2. It is important to uncover and understand their beliefs and
fears about facing the trauma. What are their expectations for
treatment? Clients frequently see therapy as a form of
dumping in a cathartic manner in order to ―get over it‖.
3. It is essential that client understand that the processing of
traumatic events does not erase the memories, nor make
them emotionally neutral, but become more like memories
they can no longer trigger unanticipated and upsetting
reactions.
4. Specific information concerning the intensity of treatment,
safety and support, risks and benefits and degree of control
need to be discussed are the client before treatment starts 39

5.2.Tactics for optimizing affective
intensity and physical arousal
1. The therapeutic approach used must best match the clients
window of tolerance.
2. Memory and emotional process is safest and most effective if
the client is able to stay within the window of tolerance and
process their emotion. The goal is to expand the degree of
emotional tolerance that the client is able to tolerate.
3. This can be achieved by helping the client immediately use
self -calming skills developed in phase 1.
4. Use good tone and carefully chosen words to convey,
confidence that the client has the skills to manage the
memory
5. Remind the client that they are not alone, and not being safely
guided through the re-traumatising memory
6. Redirect the client to less distressing aspects of the event in
order to lower the arousal intensity without interrupting the
processing and narrative building 40

5.3.Tactics for enhancing
engagement
1. Active engagement by the client helps enhance a sense of
control.
2. The intent of active engagement is to put the client in the
position of being both an active but disciplined and are
mindful observer.
3. Tactics for enhancing engagement include experiential
techniques in which the client is encouraged to enact the
troubling memory or event, through in vivo exposure, through
a systematic desensitisation format.
4. Gestalt techniques like the empty chair can enhance
behavioural engagement in the processing of the memory
41

5.4.Strategies for enhancing and
maintaining reflective self-awareness
1. The ultimate goal is for clients to develop the
ability to be reflectively self aware when
experiencing traumatic stress reactions
2. It is to help them become a ―participant –
observer‖: developing the client’s capacity to be
mindful and to be able to engage in self
reflection.
3. During trauma and emotional processing, the
therapist models reflective self awareness. This
involves enquiring about the nature and source
of emotions and thoughts at the client identifies
and describes what processing troubling
memory.
42

5.5.Determining when to Stop
1. Two criteria are important in judging went ―enough‖
processing has taken place:
1. The client feels no longer as troubled by the memory
2. The client is able to develop a personal lifeline including
an understanding that is coherent and that has a narrative
structure that makes sense.
2. The extent to which a client has formulated an understanding
of what others involved in the event with thinking and feeling,
and how their actions followed from these states of mind, is
an essential component for resolution.
3. The client is able to understand the logical connections with
in a comedy event and how they fit together, the memory
begins to resemble other non-traumatic memories.
4. The higher order areas of the brain (prefrontal region) regain
inhibitory control over the emotional areas of the brain (limbic
system). 43

5.6.Tactics for Preventing and
Managing Crises
1. Crisis and decompensation can occur in face to in
a variety of ways including hypervigilance,
numbing, suicide ideation, self harm and
dissociation.
2. Crises can occur for many reasons both external
and situational, as well as from the therapy itself
3. Both therapist and the client may be impatient at
the pace of therapy resulting in pressure to
complete the process. This results in rushing the
therapy causing a treatment overload
4. Awareness of transference and counter-
transference is essential throughout therapy
5. Stabilisation and safety of priority whenever a
crisis is encountered
44

5.7.Loss and Mourning issues
1. Objects trauma involves not only the assault
on the self but also involves other major
losses: of the self as it might have been, loss
of control, the loss of innocence, the loss of
sense of safety in the world.
2. The recognition of the loss between the pre-
and post event sense of self
3. This is an ambiguous loss: an indistinct loss
lacking a clear ending
4. High degree of ambivalence in the primary
attachment relationships that have been
abusive contributes to difficulties with
bereavement
45

6. PHASE 3: CONSOLIDATING
THERAPEUTIC GAINS
6.1. Adapting Phase 1 interventions to phase 3
6.2. Adapting phase 2 interventions to phase 3
6.3.Decision about phase work
6.4. Significant issues in Phase 3
46

Phase 3: Consolidating
Therapeutic Gains
1. The clients challenging phase 3 is to apply the knowledge and
skills gained through our treatment to daily life in the future.
2. The goal of this phase is to consolidate therapeutic gains a
move towards ending the treatment.
3. This does not imply a complete recovery from all post-
traumatic symptoms or impairment, but understood as
achieving the goals that motivated the client to come in the
first place.
47

Phase 3: Consolidating
Therapeutic Gains
1. Common issues that arise in phase 3:
1. The challenge is to extend the knowledge and skills gained
into daily living, making choices from a position of
increased self-knowledge, along with healthy self regard
and positive and appropriate selfishness
2. Understanding responses and reactions to and from
others on a day-to-day basis, sustaining relationships
based on improved self-esteem and trust.
3. Connections with family and social systems that
dysfunctional and abuse of require decision-making
4. Safeguarding and Child protection issues may become
apparent at this stage
48

6.1.Adapting Phase 1
interventions to phase 3
1. Safety stabilisation and self regulation interventions used in
phase 1 are applied in phase 3 to reinforce and broaden their
application
2. Safety planning, self care, and emotional regulation become
aware of life, and the kind examined areas of their life
proactively to ensure ongoing safety
3. With increased self knowledge self-determination and pride,
skill building and information become important to help the
clients make positive choices for the future
49

6.2. Adapting phase 2
interventions to phase 3
1. The memory and emotion processing skills of phase 2 directly
applicable to daily living as a client’s becomes a more active
partner in addressing life issues.
2. The careful detailed review of physical states, beliefs and
effective and cognitive responses to stressful events
becomes a template for clients to use in addressing present-
day event and choices
3. A processing approach enables client to break those events
done into the component parts to achieve a fuller
understanding of their reactions on how to develop a more
secure attachment in their relationships.
4. These tools help the client to translate the experiences in to
personal meaningful processes rather than living life on
automatic pilot.
50

6.3.Significant issues in Phase 3
1. A broad range of life issues, linked to the developmental stage of the
client and related developmental tasks, often emerge in treatment
2. A focus on career and occupational development alarming a broader
range of choices once they have solidified their self-esteem and
capacity for autonomy.
3. The development of trustworthy relationships in healthy
interdependence with good levels of intimacy based on trust respect
is more possible than previously. Included in this healthy sexual
relationships that may need specific treatment
4. Child-rearing and parenting issues may need attention as they have
had no viable models to learn from
5. Existential issues about life meaning religious beliefs will often
emerge in an attempt to seek an answer for what happened to them
6. The end of treatment is a time of great poignancy for the therapist
and client. Is it revisits loss careful discussion in preparation for
ending is needed. Post therapeutic contracts will need to be in place
so that clients can return for ―check in or tuneup‖ treatments
51

7. THE THERAPEUTIC
RELATIONSHIP
1. Role of the Therapeutic Relationship
2. Building Therapeutic Relationship
3. Counsellor Qualities: the therapist use of self
4. Barriers to building the therapeutic relationship
5. The role of Attachment style in the therapeutic relationship
6. Maintaining the Therapeutic Relationship
7. Areas of risk and their management
52

7.1. Role of the Therapeutic
Relationship
1. The therapeutic relationship is the most powerful instrument
in any counselling.
2. When working with complex trauma survivors it is essential to
build this relational bridge in which internal and external
relational changes can take place for the development of
alternative models of relationships and learned secure
attachment
3. It is essential to understand ―self‖ of the therapist to establish
a secure base from which to operate.
53

7.2. Building Therapeutic
Relationship
54

7.3. Counsellor Qualities: the
therapist use of self
55

7.4. Barriers to building the
therapeutic relationship
56

7.5. The role of Attachment style
in the therapeutic relationship
57

7.6. Maintaining the
Therapeutic Relationship
58

7.8. Areas of risk and their
management
1. Re-parent/rescue me
2. Don't leave me
3. Don't neglect or abuse
me
4. Be perfect for me
5. Boundary issues
6. Fix it for me
7. Find my memories
8. Money: what am I
worth to you
9. Emergencies
59

Core readings
1. Sanderson (2013):
chapter 6. Therapeutic Challenges.
Chapter 7. Building and Maintaining the Therapeutic Relationship.
2. All of Part 3 Skills to Manage Complex Trauma Symptoms (pg
147-264)
4. Courtois & Ford (2013) chapter 6 phases 2 & 3:trauma memory,
emotion processing, and application to the present and future
61

Advanced readings
1. Courtois & Ford (2009) chapter 9. Therapeutic Alliance and
Risk Management, Philip J. Kinsler, Christine A. Courtois
2. Courtois & Ford (2013) chapter 9 walking the walk: the
therapeutic relationship
62

Lecture 5 phase 2 and 3 working with complex trauma

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