Overcoming cumulative childhood adversity: treatment approaches Friday afternoon October 6, 2006...
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Transcript of Overcoming cumulative childhood adversity: treatment approaches Friday afternoon October 6, 2006...
overcoming cumulative childhood adversity:
treatment approaches
Friday afternoonOctober 6, 2006
Northamerican Assn. of Masters in Psychology
Bruce Carruth, Ph.D., LCSWSan Miguel de Allende, GTO, Mexico
Outline for this afternoon
• The content of therapy with adversity cognition, affect and self
• The process of treatment 3 phases and 6 stages
the content of therapy with adversity
Cognition (I think)
AFFECT (I feel)
Self (I am)
cognition
• 3 components
contact between individual and environment
making meaning of data
the “cognitive self”
Contact
Receiving data from the environment withdrawn people miss data in their environment
reactive people misinterpret data in their
environment
in the context of their history, individuals with
cumulative trauma have a tendency to
misinterpret data from the environment
using these observations in therapy
Deleting / distorting sensory perceptions
internal external
Seeing
Hearing
Feeling
Smelling
Tasting
Some implications for therapy
Not listening to what is said
Being hypersensitive the specific sensory stimuli (touch, sounds, visual cues)
Hypersensitivity / deadening specific feelings
Making meaning of data
“What does this mean?”data from our environment gets processed in
light of our historyBecause of developmental lags, there may
not be sufficient data to process informationWhen unconscious material related to a
trauma experience drives the processingWhen we talk later about “telling the tale”, part of the agenda
is to move unconscious, unremembered material to conscious awareness
The cognitive orientation of self
The “child self” orientation conscious memories of childhood, roles, meanings
and how those memories, roles play out today as adults (for better and worse)
milestones (singular, defining memories related to “child self”)
and efforts today to re-live or conquer those experiences
the impact of the “child self” experience in adult relationships and in parenting
“self parts”
…Child self, family self, interpersonal self, physical self, moral self, spiritual self, sexual self, creative self, doing self, expressive self
Some parts of self may contain the trauma experience while other self parts may be quite functional
Life problems tend to orient around the wounded parts of self
Using the healthy parts of self to help heal the wounded parts
Relational parts of self “what did you learn about how to be in
relationships” can’t trust, have to give up self, have to be in control, ability
to trust self in relation to others, have integrity, have to be right, have to be center of attention, idealizing others
The relational wounds will play out in the therapy environment & this becomes the field for a corrective emotional experience
Cultural influences in relational patterns
Core beliefs / truths / schemas
• About self (value, efficacy, potency, resilience)
• About others (individuals and groups)
• About family• About the environment – (others, the world)
• Tapping core beliefs in therapy• Watching core beliefs play out in therapy• Using the therapy experience to challenge
core beliefs
Beliefs and decisions
• Decisions follow core beliefs:People are _______ and therefore I will _______”
It is as important to build new decisions as it is to challenge core beliefs
Learned strategy and process
The frameworks we have developed to operate in the world
DecisioningManaging relationships – interactions with othersManaging life – crises, stimulation, recreation,
relaxation, parenting, close/casual friendshipsPatterns for rememberingManaging work – getting the job done (taking care of little things, finishing jobs, cooperating / competing
with others)
affect
• Two levels of affective experience
1. primary affects
terror – safe
grief – joy
rage – fullfilled / potent
shame – integrity
2. Affective (emotional) themes
Primary affects
Terror < > safe - about vulnerability
Anger < > fullfillment / potency – about having what I need – being able to have what I need
Grief < > joy – about having love, connectedness, belonging, happiness
Shame < > integrity – about integrity, self- worth, pride
Look for the primary affect that hasn’t been “mastered”
• Anger – struggles around power and control, getting “may way”, getting what I need
• Shame – struggles around self-esteem, over-valuing or under-valuing self, sensitivity to criticism. “I’m going to be found out”
• Anxiety – struggles with being safe, not being vulnerable, having enough (money, health, security) “something terrible is going to happen”
• Sadness – struggles with giving / receiving love, being & staying connected with others, belonging
The affect that couldn’t be mastered in childhood
• Is often covered by other emotions• Sue Johnson’s “reactive emotion”• In therapy, it becomes important to look for
the emotion that is disavowed and not get “locked into” the presenting emotion
• In relationships we “hire” a partner to express the emotion we disavow & then blame them for expressing it
• Getting “stuck” in an emotion (repetitive anger, chronic sad, persistent fear)
The fears of having the disavowed emotion
• Terror
• Grief
• Rage
• Shame
Therapy becomes the place to be able to experience the disavowed emotion(s)
• Awareness of when I am having the emotion(s)
• Learning to express the emotion(s)
• Being comfortable with others having the disavowed emotion in my presence
• Learning to look for the emotion (and needs) under the emotion
Feeling themes
The emotional themes that reflect the wounded parts of self
rejected, lonely, hurt, guilty, incompetent, unsure, alone, inept, confused, empty, overwhelmed
The emotional themes tend to be self-fulfilling and we tend to orient our lives around validating them.
How emotional themes play out in the therapy environment
Selfhood dynamics
• Characterological patterns feeling repressed boundary confused
helpless and dependent loveless and invisible
stubborn and obstinate needy and impulsive
inadequate phobically anxious
suspicious and mistrusting alone and isolated
conning and manipulative angry and intolerant
Treating character patternsCharacter patterns are relatively immune to
cognitive approaches to changeCognitive approaches can become part of the
defense (intellectualization)People don’t “give up” character patterns, they
evolve patterns to higher functioning levelsThe primary treatment approach is the therapeutic
relationship – the corrective emotional experienceOther change processes: support groups, spiritual
programs, healthy relationships
Supporting positive character patterns: centeredness, perseverance, empathy, curiosity, self-soothing, self-validation,
Vulnerability of character pattern pathology
Our subsequent wounds (trauma) tend to appear where we are vulnerable:
our limiting cognitions
disavowed affects
limiting character patterns
Therapy should seek to strengthen the wounded parts and support the more functional parts
3 phases and 6 stages of trauma treatment
1. building safety (creating a holding environment) and
2. managing the presenting symptoms
3. exposing the wounded self & telling the tale and
4. grieving
5. emotional healing and
6. integrating history with present
phase 1building safety and managing symptoms
primary treatment methods are: building / supporting the safe environment environmental manipulation – stabilizing the environment cognitive – behavioral strategies problem solving psychoeducation stress management skill building interpersonal potency normalizing emotions challenging negative / unproductive cognitions
working with self-help programs challenging ego defenses that protect the wounded self and related affects building support in beginning to tell the tale and get the
story straight
Creating Safety
• I can’t make someone feel safe with themselves: Safety has to come from within
• Therapy itself is an inherently unsafe environment for trauma survivors
• Traumatized people will test to see if the therapy is safe.
• I can provide an environment that doesn’t reinforce “unsafety”
A strategy for working with ego defense
Retroflecting (holding inside) counter strategy is expressingDeflecting (not letting outside in) counter strategy is absorbing – taking inProjecting (assigning inside to environment) counter strategy is owningIntrojecting (internalizing the environment) counter strategy is questioning – challengingConfluence (merging, joining) counter strategy is individualizing
phase 2:telling the tale and grieving
the goals of “tale-telling” are: to begin to see connections between now and history to begin to get a more coherent and accurate understanding of what happened and why to begin to correct the cognitive distortions that occurred
when life is viewed through the eyes of the child to begin to challenge the meta-beliefs & self-truths that arose from the experience of the child to connect “self-experience” with emotions that have been disavowed, distorted, displaced
Phase 2telling the tale and grieving
Our tales are told in metaphor. Our metaphor may or may not have much resemblance to the reality of others.
The therapist is the witness to the unfolding of the tale. The therapist’s job is to provide a container for the tale as it evolves and to facilitate the person telling the story in the most healing way possible.
Getting the story straight is like constructing a jigsaw puzzle. Seemingly unconnected pieces get put together to form a coherent image and the missing parts become more obvious.
The missing parts often contain the core of the developmental trauma experience.
Telling the tale (con’t)
Words may not be a very good vehicle for communicating the trauma experience. Visual symbols, movies, music, drawings and physical movement may more accurately and effectively communicate the experience.
A variety of unfolding techniques can be applied to help reveal the tale including hypnosis, psychodramatic technique, group support and psychomotor therapies. But unfolding techniques are a means to the end, not the end in itself!
One story or event in the tale can be a metaphor for a series of events. It isn’t necessary or practical to tell the whole tale, particularly with early, prolonged and pervasive deprivation.
special issue of “dropping out”
• As people begin to “tell their tale” and emotionally connect with their woundedness there is an incentive to drop out of treatment.
• Got some relief from the symptoms• Ego defenses “kick in”• Fear the unexplored• Therapy has to build a safe “holding
environment” to allow people to progress
grieving
• as people tell their tale and connect with their self-experience, affect naturally begins to arise.
• Grieving is the essential element for “letting go” of self-limiting cognitions and self-experience of the past
• Grief is both an affect and an experience (the emotion has to connect to the experience)
• The most important material to grieve will be hidden behind the disavowed affect
The goal of grief work is not to “get rid” of painful feelings, but to accept the pain as a meaningful part of life, to honor the
pain rather than repressing or disavowing it.
The pain connects us to something that we lost that was very important to us.
Grief reactions
Grief is the emotional expression of loss
“Grief reaction” is the blocking or distorting of the normal emotional expression of loss
3 kinds of losses
tangible losses
intangible losses
losses of what could have been – a future
Grief reactions from the “outside”
Emotional constriction or inappropriateness
Apparent feelings on the surface that are denied or displaced (denying sad or anger)
Avoidance behaviors, lonely in a crowd
Judgmentalness, perfectionism, blaming
Difficulty experiencing self, including positive and negative feedback
Obsessive though and compulsive ritual
Loss of spontaneity
The process of grief work
Diagnosis and differential diagnosis cd relapse, depression, PTSD, personality disorder
Education about grief and grief reactionsExploration about client’s experience with
their griefCreating safety with feelingsCatharsis – telling the story as well as expressing affect
Getting closure on events that precipitated the grief – saying goodbye, letting go, finishing unfinished business, forgiving self and others
Reintegration of past self with present self
Emotional healing: the corrective emotional experienceAs a result of telling the tale and allowing the grief,
the wounded self is exposed and the therapeutic “holding environment” becomes the place where people can experience the self and have a corrective emotional experience
…..through the transference in the therapy
…..through finding new options to meeting the environment
…..through seeing self in a different manner
transferenceManaging the transference means being the
“good enough parent”
What are the attributes of a “good enough parent”?
Recognizing the meaning of the “holding environment”
• Safe• Predictable, reliable• Non-judgmental• Well bounded• “my place”• Many children from adversive environments
have not had a quality holding environment• (or they had to adapt their own)
Finding new options
• “What should I do”?
• “how should I handle this”?
• “what can I do differently now than in the past”?
• “how would (my therapist) handle this”?
• After the action, incorporating new options
Seeing the results
• Getting feedback
• Seeing my own results
• Beginning to trust new actions
• Appreciating that we all do the best job we can do at the time
• And that with self monitoring and the ability to receive feedback from others we can continue to do a better job
For more information:
• Telephone based case consultation• Telephone based clinical supervision• Telephone based psychotherapy• Small group, process based workshops in Mexico
• Contact me at: Bruce Carruth, Ph.D., LCSW
713-589-3250