Lecture 6 vicarious traumatisation in complex trauma therapy
The neurobiological complex trauma model › ... · “Many youth develop complex trauma, which...
Transcript of The neurobiological complex trauma model › ... · “Many youth develop complex trauma, which...
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The neurobiological complex trauma model And its relevance in work with refugee children
Nordisk konferanse for behandlere som arbeider med flyktningerBergen, April, 2013
Dag Ø Nordanger
RKBU Vest / RVTS Vest
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My starting point
Dag Ø. Nordanger, 2013
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Many things are culturally relative
� Expressions of psychological pain are
culture-bound
� If there are universal trauma symptoms,
there is no universal experience of them
� There is no coping strategy which works
for all independent of culture
� Coping which works, works because it
makes meaning in its context
Dag Ø. Nordanger, 2013
Photo of informant
Photo of informant
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But some things are universal
� Every child needs to be regulated to develop in a healthy way
� Infants cannot regulate their bodily states or affects themselves
� If the baby is scared or frustrated, somebody must be there to regulate the affect down – to restore comfort
� If not, in the long run there will be dysfunction, no matter place or culture
Dag Ø. Nordanger, 2013
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DEVELOPMENTAL PSYCHOLOGY
Its probably the most important function of early caregiving
NEUROBIOLOGIAL RESEARCH
A child’s brain totally depends on it for developing normally
TRAUMA PSYCHOLOGY OF TODAY
The most harmful traumas: Those occurring in childhood, and where the child is left alone to regulate intense fair
� E.g. violence on or within families
� Refugees are vulnerable for both
REGULATION
Dag Ø. Nordanger, 2013Palestine
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Complex trauma
Prolonged/repeated exposure to traumatic stress combined with missing help to regulate affect
This means; to understand complex trauma, we need to understand two things:
1. How traumatic stress shapes our neural system
2. How missing help to regulate affect shapes it
Dag Ø. Nordanger, 2013
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How traumatic stress shapes our neural system
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Keep in mind how our brain develops
“Use it, or lose it!”
� The brain is «use dependent» (Bruce Perry).
� “What fires together, wires together” (Hebb’s law)
� Develops first and foremost though social interaction, and more than anytime in infancy
Dag Ø. Nordanger, 2013
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Keep also in mind the “layers” of our brain
Survival brain(Brain stem)
Emotional brain(Limbic system)
Logical brain(Cortex)
Dag Ø. Nordanger, 2013
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Prefrontal cortex(Reasoning)
Amygdala(Alarm central)
Hippocampus(Learning & memory)
Pituary glands(Chemical plant)
Structures of our brain that are particulary central in the understanding of trauma
Dag Ø. Nordanger, 2012
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Dag Ø. Nordanger, 2012
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Prefrontal cortex
AmygdalaHippocampus
Release of adrenaline a. m.
”Fight, flight & freeze” Release of cortisol
HPA-aksen
The stress-response-system
Come on! I am sitting safely here listening to a lecture at the Nordic
refugee conference!
He showed it just for pedagogical reason (that sadist)!
False alarm!
Experiences from earlier in life tell me that snakes
cannot hurt me as long as they are on a photo
Dag Ø. Nordanger, 2012
Threat!
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Prefrontal cortex
Amygdala
HippocampusThreat!
HPA-aksen
� The stress-response system is sensitised, almost all of us will have symptoms of PTSD
� Watchful and on the alert - generalization
� Intrusive memories
� Avoidance of reminders
� Normal phenomenon developed by evolution: We need to remember well life-threating events
� For some it becomes chronic
Dag Ø. Nordanger, 2012
Release of adrenaline a. m.
”Fight, flight & freeze”
Release of cortisol
After life-threatening events
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How co -regulation shapes our neural system
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• Video early interaction, example of co-regulation
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Prefrontal cortex
Amygdala
Hippocampus
Binyrene
HPA-aksen
Sensitive care shapes the same structures
� First, we ARE the child’s prefrontal cortex and hippocampus
� We stimulatate the regulating connections
� Good bodily experiences linked to movement and language > integration
� Gradually, it becomes internalised as own skills
� Gives cognitive control
� Stored memories of other persons as good
Dag Ø. Nordanger, 2013
Release of adrenaline a. m.
”Fight, flight & freeze”
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When there is no help around to regulate affect
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• Video “Still Face” situation, example of how dependent children are on a co-regulating adult
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How trauma stress + missing help
to regulate affect, shape our neural
system
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Prefrontal cortex
Amygdala
Hippocampus
Binyrene
HPA-aksen
� Traumatic stress + the one who should help regulating affect is put out of function (or represents the threat)
Double negative effect
� Overstimulated stress response system + under-developed regulation system
� Goes very easily into «fight-flight» modus, and cannot calm down
� Or into «freeze» modus – if «fight-flight» is not functional
� Stored representations of other people as dangerous
� Those representations are hard to correct because of the weak hippocampus
Utskilling av adrenalin
”Fight, flight or freeze”
When violence infiltrates the care
Dag Ø. Nordanger, 2012
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A summary on the way
� It is not the «Learning brain» (exploration, curiosity) that is developed in these children, but the «Survival brain»(protection, watchfulness)
� Not just PTSD; the survival mode will be seen as problems in same functions as early care normally should promote
� Since a crucial function of early care is to learn to regulate oneself , problems are particularly seen there
“The most significant consequence of early relational
trauma is the loss of the ability to regulate the intensity
and duration of affects” (Alan Schore)
Dag Ø. Nordanger, 2013
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Threat!
If a fight/flight reaction like crying functional, if it saves the child from the situation
If fight/flight is not possible, like if the person who should protect the child is put out of
function or is the threat
Hypo -activation(Dissociation)
Hyper-activation
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Hyper-activation
Hypo-activation
AKTIVERING
Fight/flight modus: Unrest, aggression, acting out, impulsivity, chaos, etc.
Freeze modus: Emptiness, depression, numbness, dissociation, etc.
WINDOW OF TOLERANCEThe optimal zone of activation
The window of tolerance
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3 implications
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We must look for patterns of general regulation problems, not just diagnoses!
� Because regulation problems cross diagnoses
� Consequently, these children get numbers of diagnoses
� … which are not always updated according to our current knowledge base
Dag Ø. Nordanger, 2013
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To illustrate our challenge;
� Anxiety, depression or other emotional problems, ADHD, behavioral
problems, personality disorders and PTSD are all common among
Unaccompanied Minors (bl.a. Huemer et al., 2009)
� Half of children exposed to physical or sexualised violence meet the
criteria for oppositional defiant disorder (Lyttle & Brodie, 2007)
� Half of children exposed to sexual abuse meet the criteria for ADHD
(the most common diagnosis in this group) (McLeer et al., 1994).
And when they grow up …
� Adults with experiences of four or more childhood adversities meet
the criteria for 6,2 DSM-diagnosis, in average! (Putnam et al., 2008)
Dag Ø. Nordanger, 2012
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Affective and physiological dysregulation� Inability to modulate, tolerate, or recover from strong affect states (e.g. fear, anger)
� Dysregulation of bodily functions (e.g. sleep, eating, reactivity to touch and sounds)
� Reduced awareness of sensations, emotions, and bodily states
� Impaired capacity to describe emotions or bodily states
Attentional and behavioral dysregulation� Preoccupation with threat or impaired capacity to perceive threat
� Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking
� Maladaptive attempts at self-soothing (such as self harm)
Self and relational dysregulation� Preoccupation with safety of the caregiver or other loved ones
� Persistent negative sense of self (including feeling of worthlessness)
� Extreme and persistent distrust, defiance or reciprocity in close relations
� Reactive physical or verbal aggression toward peers, caregivers, or other adults,
� Inappropriate (excessive or promiscuous) attempts to achieve intimate contact
� Impaired capacity to regulate empathic arousal
� NB! Not exact phrasing, I have condenced some criter ia to get them into a slide
Is DTD the pattern we should look for?
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2
We must redefine our treatment goals!
For the most complexly traumatised children, healing is not just about
processing traumatic memories. Do we still have a tendency to
speak to the logical brain, when the problem is in the survival brain?
� Improve the ability to stay inside the tolerance window
� Improve the ability to regulate oneself back into the tolerance window at hyper- or hypo-activation
� Expand the tolerance window (often very narrow)
Dag Ø. Nordanger, 2012
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Dag Ø. Nordanger, 2012
“Many youth develop complex trauma, which includes regulation problems in the domains of affect, attachment, behavior, biology, cognition, and perception”
“The duration […] needs to be extended, from the typical 8–16 sessions to 25 sessions and occasionally up to 28–30 sessions”
“Dedicate […] half of the […] sessions to the coping skill building phase”
“[To] ask youth to identify a single “worst” trauma experience […] rarely captures the essence of the youth’s complex traumatic experiences or outcomes”
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We must acknowledge which competence these children primarily need from us!� They do not first and foremost need highly specialised
therapeutic expertise (at least not in the first round)
� They need new life experiences which represent the opposite of what they have got
� So first and foremost they need normal care (help to be regulated) – just an overdose of it
� But how to give that to a child who resists it?! In my view, that is the most important competence we need!
Dag Ø. Nordanger, 2012
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”Kids in stress create in adults their feelings and, if not trained, the adults will mirror their behaviour” (Long & Fecser, 2000)
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Where all people in a child’s network (therapists, social workers, teachers, foster parents & football coaches)
… and the child itself ...
… shared the neurobiological understanding of complex trauma, and the idea of the tolerance window
Let’s imagine a situation
Dag Ø. Nordanger, 2012
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Heine Steinkopf, RVTS SØR, 2012
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Heine Steinkopf, RVTS SØR, 2012
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AKTIVERING
WINDOW OF TOLERANCE
What happened here?
What happened here?
Dag Ø. Nordanger, 2012
The window of tolerance
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And what if …
Self & affect REGULATION
� Being regulators through our own voice and gestures
� Being models for good self-soothing strategies
� Prioritise relation and closeness, rather the correction
� Practise alternative strategies when triggers occur
� Etc. (creativity permitted)
Body & affect AWARENESS
� Create settings for good bodily and tactile experiences
� Practice naming feelings and bodily sensations
� Comment on feelings rather than behaviour
� Identify triggers of affect, investigate their forewarnings
� Etc. (creativity permitted)
Dag Ø. Nordanger, 2012
We all worked systematically together to improve the child’s body & affect awareness and –regulation skills
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Then we could make a huge difference!