Dialogues in Trauma Recovery Learning Objective #1 Survey ...€¦ · Case Study: Victor •...

Dialogues in Trauma Recovery

Mary D. Moller, DNP, APRN, PMHCNS-BC, CPRP, FAANAssociate ProfessorPacific Lutheran University School of NursingDirector, Psychiatric ServicesNorthwest Integrated Health Tacoma, Washington

Adjunct Faculty InstructorRutgers Robert Wood Johnson Medical SchoolPiscataway, New JerseyPresidentTrauma Institute of New JerseyEast Brunswick, New Jersey

Eric Arauz, MLER

Learning Objective #1

Describe the application of the Murphy-Moller Wellness Model to the complex physiological response systems activated by PTSD in persons recovering from the effects of trauma and abuse

Trauma Recovery Models

Survey of Evidence-Based Practices

National Center for PTSD. www.ptsd.va.gov/Public/understanding_TX/CourseList/Course_NCPTSD_Treatment_1435/assets/00015006.PDF. Accessed August 19, 2016. Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) www.ncbi.nlm.nih.gov/books/NBK207201. Accessed August 19, 2016. Somatic Psychotherapy Today. 2015;5(4). http://usabp.org/wp-content/uploads/2013/10/volume-5-number-4-Fall-2015-SPT.pdf. Accessed August 19, 2016.

• Eye Movement and Desensitization Reprocessing (EMDR)

• Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)

• Dialectical Behavioral Therapy (DBT)• Somatic Experiencing (SE)

EMDR

EMDR Institute Inc. www.emdr.com/what-is-emdr/. Accessed August 19, 2016. National Center for PTSD. www.ptsd.va.gov/Public/understanding_TX/CourseList/Course_NCPTSD_Treatment_1435/assets/00015006.PDF. Accessed August 19, 2016. EMDR Fact Sheet. http://acpcounseling.com/files/emdr_fact_sheet.pdf. Accessed August 19, 2016.

• Creator: Frances Shapiro, PhD (Clinical Psychology)• Physiological component to every subjective experience• Special eye movements “unfreeze” traumatic memory• Length of treatment: Based on severity of symptoms (4–7

weeks)– 3-part process:

• Address initial incident• Identity visceral and environmental triggers• New patterns created to replace memory patterns

TF-CBT

Medical University of South Carolina, National Crime Victims Research and Treatment Center. https://tfcbt.musc.edu/. https://tfcbt.musc.edu/credits.php. Accessed August 19, 2016.National Child Traumatic Stress Network. www.nctsnet.org/nctsn_assets/pdfs/promising_practices/TFCBT_General.pdf. August 19, 2016.

• Creators: Esther Deblinger, PhD, Judith Cohen, MD, Anthony Mannarino, PhD

• Components: Psychoeducation, Parental Involvement, Affect Modulation, Trauma Narrative, Cognitive Coping, Enhance personal future safety

• Length of Treatment: “Over 80% of traumatized children will show significant improvement with 12 to 16 weeks of treatment (once a week; 60- to 90-minute sessions).”

• Highly flexible to allow for adaption to family structure in clinical practice

DBT

PTSD Treatment Help. http://ptsdtreatmenthelp.com/how-dbt-can-help-trauma-victims/. Accessed August 19, 2016.Steil R, et al. J Trauma Stress. 2011;24(1):102-106.

• Creator: Marsha Linehan, PhD (Clinical Psychology)• PTSD treatment by

– Decreasing emotional dysregulation– Reduce self destructive behaviors

• 4 major components:1. Weekly individual (one-to-one) therapy2. Weekly skills-training sessions, usually in the form of

groups3. As-needed consultation between patient and therapist

outside of sessions4. Weekly therapist consultation meeting in which DBT

therapists meet to discuss their DBT cases

SE

Somatic Experiencing Trauma Institute. http://aboutsomaticexperiencing.org/about-se.php. Accessed August 19, 2016. Payne P, et al. Front Psychol. 2015;6:93. Somatic Psychotherapy Today. 2015;5(4). http://usabp.org/wp-content/uploads/2013/10/volume-5-number-4-Fall-2015-SPT.pdf. Accessed August 19, 2016.

• Creator: Peter Levine, PhD (Physiology and Clinical Psychology)

• SE facilitates the completion of self-protective motor responses and the release of thwarted survival energy

• No trauma narrative• Interoception and proprioception as core elements of

trauma therapy• “Bottom Up” approach

Dedication

In recognition of Dr. MilleneFreeman Murphy, co-developer of the Three R’s Program who was tragically killed in a car accident on May 4, 2001.

The Murphy-MollerWellness Model

Moller MD, et al. Arch Psychiatr Nurs. 2006;20(1):21-31.

Level of WellnessCultureKinship

Resources

CultureKinship

Resources

Base of Social Support

Actualized Stable Unstable

Health

Environment/Relationships

Spiritual

Attitudes/Behaviors

The Murphy-MollerWellness Model


Level of Wellness


Actualized Stable Unstable

Health

Environment/Relationships

SpiritualAttitudes/Behaviors

CultureKinshipResources

CultureKinshipResources

Health


• Exercise

• Nutrition

• Each body system in balance

• Rest

• Good health practices

• Information processing

• Endocrine/immune systems

• Sensory function

Environment / Relationships


School/work

Enjoy nature

Resources/residence

Value life skills

Interpersonal relationships

Communication skills

Economics

Support

Attitudes / Behavior


Enjoy life

Manage wellness

Pain/pleasure

Outlook

Worthwhile

Elect to love

Responsible for own behavior

Success takes action

Spiritual


PrayerEmbrace truthAccept forgivenessChoose to follow yourGod/ Higher PowerExpress gratitudeFaithUnderstanding heartLearn from spiritual writings

SPIRITUALThe “Circle of Trust”

• Seek peacefulness through clarification of concerns and trust issues

• Rebuild relationship with God and others

Understanding

AcceptanceTrust



Customs, actions, resourcesUnderstand speech and communicationLanguageThoughts and beliefsUnderstand valuesRace and religion Ethnicity Social groupings – kinship networks


Wellness Assessment ToolHealth

1. I exercise for 30 to 60 minutes a day2. I eat a nutritious diet (Minimum 5 servings

fresh vegetables and fruit a day) and avoid chemicals, high fat content, and refined sugar

3. I try to keep all my body systems in balance. I take care of my hygiene every day

4. I get 6 to 8 hours of undisturbed sleep a night5. I do not use caffeine, alcohol, street drugs, or

ephedrine


Wellness Assessment ToolHealth

6. It is easy for me to remember and to understand what I hear and read (my brain works right)

7. I am free from infections/illness8. My hearing, seeing, feeling (touch), smelling,

and tasting work right9. I have the energy to do the things I want to

do10.I use prescription drugs as prescribed


Case Study: Victor

• 45-year-old divorced Caucasian male diagnosed with Bipolar Disorder with Psychotic Features, rapid cycling, frequent suicide attempts—hanging, overdose, ETOH

• One 25-year-old daughter who has recently married• 4 deployments to combat theatre 2004–2009• Moved frequently since discharge• Most recent employment—forklift operator in Alaska• Admitted to inpatient unit after being picked up by police

running naked in the streets screaming about others trying to kill him

• Discharged to outpatient provider (me)• Has not had a Christmas without suicide attempt in 10 years• Medications on discharge: carbamazepine, lithium,

escitalopram, mirtazapine

Victor: Initial Intake

• I want to diminish the length of my depressions. I want to be able to trust myself and others

• I want to increase my confidence. I used to be the head of the class and now I feel like Dumbo

• I feel drugged and am out sound asleep at 9 PM. I just had a 3-week manic stint when daylight savings changed

• I’m on lithium and carbamazepine but I can’t tell you what lithium does for me except I can identify when I’m in a phase and I don’t do as harmful things

• I just started attending the bipolar support group and I learned 2 things that were very helpful. I’m just coming out of a mania and am a happy camper but I know the depression will hit in 3 to 7 days and will last about 3 weeks

Wellness Assessment Tool on Intake

Health = 15/40Environment/Relationships = 20/40Spiritual = 18/40Attitudes/Behavior = 18/40

Total Score = 71/160

MM-SMAT II Categories

MM-SMAT = Moller-Murphy Symptom Management Assessment Tool.Murphy MF, et al. Arch Psychiatr Nurs. 1993;7(4):226-235.

1. Anxiety2. Depression3. Mania4. Psychosis5. Cognition6. Other Health Problems7. Interpersonal Relationships8. Activities of Daily Living9. Medication Management10. Symptom Management

MM-SMAT Psychosis Scale

MM-SMAT Psychosis Questions

Murphy MF, et al. Arch Psychiatr Nurs. 1993;7(4):226-235.

1. I hear voices no one else seems to2. I see things no one else seems to3. I smell things no one else seems to4. I taste things no one else seems to5. I can read other people’s minds6. I am controlled by an outside force7. Other people try to take advantage of me or harm me8. Other people laugh or talk about me9. Other people can control me10. Other people can read my mind11. When I talk, no one understands me12. Someone is controlling my thoughts13. I feel paranoid14. I have delusions

MM-SMAT Psychosis Scale at Intake

MM-SMAT Psychosis Scale after 6 Weeks TRT:Trauma Reframing Therapy

Moller MD, et al. Arch Psychiatr Nurs. 2006;20(1):21-31.Rice MJ, et al. Arch Psychiatr Nurs. 2006;20(2):94-102.

Application of counterintuitive cognitive processes to the attainment of self-directed wholeness

What are Intuitive Cognitive Processes?

IPS = information processing systems.Buckley TC, et al. Clin Psychol Rev. 2000;20(8):1041-1065.

• IPS develop as we learn how to survive in the world

• IPS allows us to discriminate between safe and unsafe conditions

• Based on the principle that if we follow instructions given to us by adults we will be safe, succeed in life, and achieve desired life goals

Trauma and IPS

Buckley TC, et al. Clin Psychol Rev. 2000;20(8):1041-1065.

• The IPS in trauma and abuse victims are very different from normal

• IPS are shaped as struggles to survive life-threatening experiences occur

• These same IPS develop in children and adolescents who grew in households where domestic violence occurred

Intuitive Cognitive Processes Resulting from Trauma and Abuse

DID = dissociative identity disorder.Hopper JW, et al. J Trauma Stress. 2007;20(5):713-725.

• Individuals with PTSD, DID, and personality disorders defined their world view based on an intuitive and cognitive fear-based achievement of survival

• This intuitive cognitive process occurred during formative development

• This IPS is based on an unsafe world view and operates as a ME survival-centered vs WE cooperative world view

II. Broad World

View:I.

Life Events

III.Response to Life Events

THE NORMAL VIEW OF THE WORLD: WE

The Non-Trauma View of the World


3.

4

THE Trauma Survivor ME VIEW OF THE WORLD

2.

1.

I. The Effect of

Life Events on Me

II. My World

View:The Effects of

Trauma

III. My Response to

Life Events

The Trauma Survivor View of the World


Intuitive Cognitive Processes Developed Out of Fear

Fullana MA, et al. Mol Psychiatry. 2016;21(4):500-508.

• The neurochemistry of fear creates brain damage in structures vital for emotional processing such as the thalamus, amygdala, and hippocampus

• Abuse and trauma IPS result from interactions between genetics and environment forming neural pathways that often “short-circuit”

TRT Paradox

Moller MD, et al. Arch PsychiatrNurs. 2006;20(1):21-31.

• Typical patient intuitive-based cognition and behaviors are usually viewed as counterproductive and destructive

• In TRT, patient feelings are legitimized based on their intuitive IPS and are countered with options for alternate behaviors

• Patient skills such as manipulation and splitting are viewed as psychodynamics that represent strengths used to survive

• TRT separates feelings from behaviors so each can be analyzed separately to understand the meaning and purpose of each

TRT Paradox (continued)


• Patients learn to establish healthy boundaries and limits on previous intuitive responses

• Trauma IPS are replaced with a cognitive assessment of the here-and-now world

• Patients learn to anchor intuitive responses in the present instead of in the trauma

TRT


• Instructs the patient to counter these intuitive fear-based IPS in order to learn how to experience the world in a “we” perspective

• Combines neurobiological research with cognitive-behavioral, psychodynamic, and psychoeducational principles to assist patients in achieving wholeness and the attainment of desired life goals

Basic Principles of TRT


• Victims are not responsible for the fact they were traumatized

• Victims are responsible for their life and their choices

• Victims start to become survivors from the start of treatment

• Victims need help to prevent ongoing: – Violence – Anxiety– Cognitive effects – Victim/perpetrator interplay

Priorities of TRT


• Regain a sense of self by developing safety of body, mind, and spirit

• Complete the unfinished past by discriminating past from present

• Acquire skills needed to label and evaluate the meaning of current sensations and affective states

• Interpret current realities within context of the present

• Identify and use emotions as safety signals not as triggers for the fight/flight responses

• Develop responsibility for own behavior

What Happens in Trauma?

Briere J, et al. Psychiatr Clin North Am. 2015;38(3):515-527. Hopper JW, et al. J Trauma Stress. 2007;20(5):713-725.

A complex relationship between:1. Adaptive physiological changes2. Cognitive functioning 3. Ability to complete activities of daily living4. Emergent and chronic psychiatric

symptoms

Cognitive Dysfunction


Discuss the curriculum and published outcomes of the BE SMART Trauma Recovery Program (Become Empowered: Symptom Management and Recovery from Trauma)

BE SMART Curriculum

Rice MJ, et al. Arch Psychiatr Nurs. 2006;20(2):94-102.

1. Aftermath of abuse/trauma/neglect2. Wellness3. Personality development4. Brain anatomy, physiology, and development5. Cognition, perception, memory6. Anxiety7. Abuse & Health8. Abuse & Environment9. Abuse & Interpersonal Relationships10. Abuse & Attitudes and Behaviors11. Abuse & Spirituality12. Base of Social Support

Issues to be Addressed When Family Members are in Group Together


• Level of readiness to join with identified patient

• Group ground rules• Stages of group process• No blame, no blame, no blame

Pre- / Post- Test Intervention Design


• All subjects volunteered for TRT Group • Approved by WSU Human Subjects IRB• Testing on all measures at Week 2 and Week 12 • Measurements tested

– Wellness Assessment Test– Goldberg Trauma Scale– Cognitive Function Scale from MM-SMAT– ADL Scale from MM-SMAT

Wellness Assessment ToolCronbach Alpha Scores


• Health .626• Interpersonal Relationships .790• Spirituality .940• Attitudes/Behavior .916• Total .942

Sample N = 54


• 123 people attended ≥ 1 of the seven 12-session classes during the study period

• 54 subjects met the study inclusion criteria of attending at least 9 of the 12 sessions including Sessions 2 and 12 and voluntarily completing the assessment tools

• Gender: 44 females, 10 males • Age: 21–67; mean = 44.6

Primary DiagnosisN = 54

BPD = borderline personality disorder; MDD = major depressive disorder; BIPO = bipolar disorder; OCD = obsessive-compulsive disorder; SZAF = schizoaffective disorder; DYS = dysthymia.Rice MJ, et al. Arch Psychiatr Nurs. 2006;20(2):94-102.

0

5

10

15

20

25

PTSD BPD DID MDD BIPO OCD SZAF DYS

46%

24%

9% 7%

4% 2% 2%

8%

Diagnosis by Gender


Age DistributionN = 54


Range Minimum Maximum Mean

Health Week 2 23.00 13.00 36.00 25.1296

Interpersonal Week 2 29.00 11.00 40.00 28.2130

Spiritual Week 2 40.00 00.00 40.00 28.3148

Attitude/Behavior Week 2 28.00 12.00 40.00 27.6667

Week 2 Total Wellness 96.00 56.00 152.00 109.787

Health Week 12 20.00 19.00 39.00 28.7963

Interpersonal Week 12 27.00 12.00 39.00 30.5926

Spiritual Week 12 40.00 00.00 40.00 28.2963

Attitude/Behavior Week 12

28.00 12.00 40.00 30.6667

Week 12 Total Wellness 96.00 58.00 154.00 120.370

Wellness Assessment Test Scores

Rice MJ, et al. Arch Psychiatr Nurs. 2006;20(2):94-102. Rice MJ, et al. Arch Psychiatr Nurs. 2006;20(2):94-102.

Wellness Assessment Scores by GenderGENDER N Mean

Health Week 2 female 44 25.2727male 10 24.5000

Interpersonal Week 2 female 44 29.0114male 10 24.7000

Spiritual Week 2 female 44 29.2500male 10 24.2000

Attitude/Behavior Week 2 female 44 28.0227male 10 26.1000

Week 2 Total Wellness female 44 112.1250male 10 99.5000

Health Week 12 female 44 29.2045male 10 27.0000

Interpersonal Week 12 female 44 30.8182male 10 29.6000

Spiritual Week 12 female 44 30.8636male 10 27.8000

Attitude/Behavior Week 12 female 44 31.0227male 10 29.1000

Week 12 Total Wellness female 44 121.9091male 10 113.6000


Correlations

N Correlation Sig.

Health Week 2 & Health Week 12 54 .524 .005

Interpersonal Week 2 & Interpersonal Week 12

54 .715 .005

Spiritual Week 2 & Spiritual Week 12 54 .830 .005

Attitude/Behavior Week 2 & Attitude/Behavior Week 12

54 .708 .005

Week 2 Total Wellness & Week 12 Total Wellness

54 .783 .005

Paired Sample Correlations


55

Results


• Results indicated the traumatized subjects were not connecting interpersonal skills with attitudes and behaviors, spirituality, and health practices at Week 2 of the program

• By the end of the 12 weeks the subjects demonstrated a convergence of the scores indicating the beginning integration of the 4 domains of wellness

• A strong relationship between spirituality and overall health also emerged as a trend

Results

Rice MJ, et al. Arch Psychiatr Nurs. 2006;20(2):94-102. Lanius RA, et al. Biol Psychiatry. 2003;53(3):204-210. Herman J. Trauma and Recovery. New York, NY: Basic Books; 1997.

• No significant differences in scores between and women• Wellness scores improved in the presence of stable

trauma scores• Cognitive function scores tended to decrease indicating

more awareness of symptoms• It is of interest that interpersonal relationship/environment

scores have the highest correlation with total wellness as studies indicate that safety in both relationships and environment is the most crucial component of recovery from trauma and abuse

Limitations


• The psychological integration identified among the subjects in this study may not describe the experience of all patients who attend the BE SMART or similar psychoeducational programs

• The data suggest the need for an experimental study with other variables to fully account for variance in scores including – Cognitive functioning– Ability to complete activities of daily living– Comorbid medical conditions– History of suicidal behavior– Types of medications


Implement the Wellness Assessment Test in day-to-day work with patients living with any psychiatric diagnosis

Moller Mood Speedometer

Moller MD. Clinical Anecdotes.

• 0–40 = depression

• 40–50 = “boringly” normal

• 50–65 = normal

• 65–75 = where I want to be

• 75–85 = hypomania

• 85– = mania

• Health = 30/40• Environment/Relationships

= 35/40• Spiritual = 28/40• Attitudes/Behavior = 35/40

Previous Score = 71/160Current Score = 128/160

• Mixed amphetamine salts IR 15 mg QID

• Aripiprazole 10 mg q AM

• Lithium carbonate 300 mg BID

• Quetiapine 400–600 mg at HS

• Lamotrigine 100 mg q HS

• Duloxetine 90 mg q AM

Victor Now Stable On

Current Medications Final Wellness Scores

20

30

50

60 60

25

30

35

40

70 70

30

35

40

7070

80 80

70 70

40 40

50

80 80

30 30

35

40

55

60

70

75

8282

75

40 40

45

50

65 65

0

10

20

30

40

50

60

70

80

90

1/1

/20

06

1/1

5/2

006

1/2

9/2

006

2/1

2/2

006

2/2

6/2

006

3/1

2/2

006

3/2

6/2

006

4/9

/20

06

4/2

3/2

006

5/7

/20

06

5/2

1/2

006

6/4

/20

06

6/1

8/2

006

7/2

/20

06

7/1

6/2

006

7/3

0/2

006

8/1

3/2

006

8/2

7/2

006

9/1

0/2

006

9/2

4/2

006

10/

8/2

006

10/

22/

2006

11/

5/2

006

11/

19/

2006

12/

3/2

006

12/

17/

2006

12/

31/

2006

Victor Symptom Chart 2006

55 55

80 80

50 50

80 80

50 50

65

70 70

75 75

50 50

60 60

80 80

75 75

70 70

50

60

70 70

85 85

40 40

50 50

60 60

70 70

40 40

0

10

20

30

40

50

60

70

80

90


40 40

50 50

55 55

70 70

60 60

75 75

50 50

55 55

70 70

60 60

75 75

60 60

65 65

70 70

75 75

0

10

20

30

40

50

60

70

80


Take-Aways

1. Psychiatric wellness is more than a state of mind and body. It is a complex phenomenon comprised of measurable biological, psychological, sociological, and spiritual components

2. Persons recovering from the effects of trauma and abuse can identify personal levels of wellness by understanding the 4 identified wellness domains and how they are affected by the symptoms of PTSD

3. Persons in recovery from PTSD and bipolar disorder can use their scores on the Wellness Assessment Test to document progress in managing the complex physiological response systems in order to attain desired levels of wellness

References

1. Briere J, et al. Complex trauma in adolescents and adults: effects and treatment. Psychiatr Clin North Am. 2015;38(3):515-527.

2. Buckley TC, et al. Information processing and PTSD: a review of the empirical literature. Clin Psychol Rev. 2000;20(8):1041-1065.

3. Fullana MA, et al. Neural signatures of human fear conditioning: an updated and extended meta-analysis of fMRI studies. Mol Psychiatry. 2016;21(4):500-508.

4. Galovski TE, et al. Manualized therapy for PTSD: flexing the structure of cognitive processing therapy. J Consult Clin Psychol. 2012;80(6):968-981.

References

5. Hopper JW, et al. Neural correlates of reexperiencing, avoidance, and dissociation in PTSD: symptom dimensions and emotion dysregulation in responses to script-driven trauma imagery. J Trauma Stress. 2007;20(5):713-725.

6. Moller MD, et al. The three r’s rehabilitation program: a prevention approach for the management of relapse symptoms associated with psychiatric diagnoses. Psychiatric Rehabilitation Journal. 1997;20(3):42-48.

7. Moller MD, et al. The BE SMART trauma reframing psychoeducation program. Arch Psychiatr Nurs. 2006;20(1):21-31.

References

8. Monson CM, et al. Changes in social adjustment with cognitive processing therapy: effects of treatment and association with PTSD symptom change. J Trauma Stress. 2012;25(5):519-526.

9. Mott JM, et al. Change in trauma narratives and perceived recall ability over a course of cognitive processing therapy for PTSD. Traumatology. 2015;21(1):47-54.

10.Mott JM, et al. Characteristics of U.S. veterans who begin and complete prolonged exposure and cognitive processing therapy for PTSD. J Trauma Stress. 2014;27(3):265-273.

References

11.Rougemont-Bücking A, et al. Altered processing of contextual information during fear extinction in PTSD: an fMRI study. CNS Neurosci Ther. 2011;17(4):227-236.

12.Rice MJ, et al. Wellness outcomes of group psychoeducation on trauma and abuse. Arch PsychiatrNurs. 2006;20(2):94-102.

Dialogues in Trauma Recovery Learning Objective #1 Survey ...€¦ · Case Study: Victor •...

Documents

Transcript of Dialogues in Trauma Recovery Learning Objective #1 Survey ...€¦ · Case Study: Victor •...