Considerations in Trauma Work with Children and Adolescents

The Use of Hypnosis for Prevention and Treatment

Julie H. Linden, Ph.D.Philadelphia, PA, USAJHLINDEN@CS.COM

Learning Objectives

• Describe developmental variables in the use of hypnotic techniques.

• List several theories of trauma and the elements of an integrated approach to trauma treatment.

• Name and be able to use several hypnotic techniques in the treatment of trauma in children.

Outline of workshop

• Definitions• Developmental factors• Assessment• Treatment

What is Trauma?

Wholist Framework

• The nature of the trauma (process)• Parameters of the trauma

(context)• Depth of the trauma (effect of the

trauma on human fulfillment)

Velent 1998,1999

Posttraumatic acute-stress reaction

• The constellation of feelings and reactions that follows terrifying events

Trauma

Defined as “the sudden cessation of human interaction”

(Lindemann, 1944)

Trauma

An Experience is traumatic if it1. Is sudden, unexpected, or non-

normative2. Exceeds the individual’s perceived

ability to meet its demand

3. Disrupts the individual’s frame of reference and other central psychological needs and related schemas.

(McCann & Pearlman 1990)

Trauma

An event that overwhelms the person’s perceived ability to cope, debilitates through a central loss of control and creates the necessity for psychological defenses.

It is the person’s response to the event that creates the traumatization.

(E. Gil 1998)

Definition

• Trauma by proxy:• Feel traumatized as the result of an

event that happened to someone else.

• Feels traumatic because child identifies with the victim.

TRAUMA EVENTS

1. PHYSICAL , SEXUAL ,or VERBAL ABUSE (homicide, rape, suicide, torture)

2. ACCIDENTS

3. CHRONIC ILLNESS; MEDICAL PROCEDURES

4. DEATH - LOSS OF PARENT, SIBLING

5. DIVORCE; ADOPTION6. NATURAL DISASTERS

fears of lightning, fire, etc. to traumas from famine, floods, cyclones,

tornadoes, etc.

7. WAR

Terrorism

• A special type of disaster• Weapons of mass destruction

Chemical, Biological, Radiological, Nuclear, high yield Explosives (CBRNE)

• Straus and Gelles (1996) have estimated that over 29 million children commit an act of violence against a sibling each year

Assessment

PTSD & ASD

What kids say stress is...

• “When you have to do something to make someone else happy and it makes you miserable.”

• “Feeling really tiny in a big, big room.”• “Feeling squished.”• “Feeling tight all over.”• “Like you can’t breathe.”• “Like two things fighting in my stomach.”

Common Childhood Fears

• 0-6 months Loss of support, loud noises • 7-12 months Fear of strangers, fear of sudden,

unexpected and looming objects• 1 year Separation from parent, toilet, injury,

strangers• 2 years A multitude of fears, including loud

noises, animals, the dark separation from parents, large objects, e.g. machines, change in personal

environment• 3 years Masks, dark, animals, separation from

parents• 4 years Separations from parents, animals,

dark, noises

Common Childhood Fears

• 5 years Animals, "bad" people, dark, separation from parent, bodily harm

• 6 years Supernatural beings, bodily injuries, thunder and lightning, dark,

sleeping or staying alone, separation from parent

• 7-8 years Supernatural beings, dark, fears based on media events, staying alone, bodily injury

• 9-12 years Tests and examinations in school, school performance, bodily injury, physical appearance, thunder

and lightening, death, dark

Acute Stress Disorder

• Acute stress disorder (ASD) is an anxiety disorder characterized by a cluster of dissociative and anxiety symptoms occurring within one month of a traumatic event.

Recognizable stressor

• Acute stress disorder is caused by exposure to trauma, which is defined as a stressor that causes intense fear and, usually, involves threats to life or serious injury to oneself or others.

Symptoms: Dissociative & Anxiety• Dissociative symptoms: emotional

detachment, temporary loss of memory, depersonalization, and derealization.

• Anxiety symptoms: irritability, physical restlessness, sleep problems, inability to concentrate, and being easily startled.

Normal acute (e.g. in the first hours or

days) responses to trauma may include • Feelings of horror, helplessness, fear, or

disbelief• Attention and concentration problems• Preoccupation with the traumatic event• Hypervigilance to danger, including

misperception of non-dangerous stimuli as potentially dangerous

• "Survivor guilt" (i.e., guilt about having survived when others did not)

•  Reduced emotional responses to the environment ("shutting down" or "going numb")

• Feelings of unreality, depersonalization, or other dissociative phenomena

• For some, no significant psychological difficulties

Later (e.g. in subsequent hours, days, or weeks) reactions often • Intrusive thoughts and recollections of the trauma,

nightmares, and occasionally flash-backs (intrusive sensory reexperiencing of aspects of the trauma)

• Sustained feelings of numbness or emotional constriction

• Attempts to avoid reminders of the trauma• Initiation of (or re-involvement in) substance abuse• Evidence of autonomic hyperarousal, such as muscle

tension, jumpiness and heightened startle responses, sleep disturbance, and irritability 

• Problems in interpersonal relationships• Mood swings• Anxiety• Depression and self-isolation

PTSD Factors

• Existence of recognizable stressor

• Reexperiencing the trauma as evident by:

1. recurrent/intrusive recollection of events in children daydreams and fantasies, usually they do not have recurrent nightmares with exact repetition of event. Do not experience sudden unexpected flashbacks.

2. recurrent dreams of events.

PTSD Factors

• Reexperiencing the trauma as evident by (cont.):

3. suddenly acting or feeling as if traumatic event were reoccurring because of an association with environmental stimulus. Primary process thinking is close to the surface, so environmental stimulus is often responsible for behavioral changes. Children do not consciously link changes in mood, affect, thinking and behavior to such things as loud noises, darkness or sudden visual or auditory stimuli which "remind" them of the traumatic event.

PTSD Factors

PTSD Factors

• Reexperiencing the trauma as evident by (cont’d.):

4. Trauma specific reenactment

PERCEPTION IS MORE BASIC AND PRIMITIVE THAN IS COGNITION.

PREVERBAL EXPERIENCE, TRAUMATIC PERCEPTION MAY REMAIN AN INDIGESTIBLE PART OF GROWING YOUNG PERSONALITY

Avoidance:

• Emotional numbing. This is a defense; children appear as if uninvolved, but do not exhibit psychic numbing. Subdued or mute behavior, unemotional third person, journalistic.

Avoidance

• Sense of foreshortened future

• Avoidance of activities that arouse recollection of traumatic event

• Repression (avoiding thoughts, affect)

Arousal: Hyperalertness

• 1. Sleep disturbance- inability to fall asleep, night terrors, nightmares

• 2. Irritability or outbursts of anger• 3. Memory impairment, trouble

concentrating• 4. Hypervigilance/ guilt• 5. Exaggerated startle response

• Regressed- go into parents bed, sleep in strange places, suck their thumbs, enuretic

Accidents, suicides and homicides are the three leading causes of death among young people in the US.

(US Bureau of Census, 1999)

Simple VS Complicated Trauma

Simple Trauma Complicated Trauma

Single Event Several Repetitive Events

Brief Duration Over Long Time

Late in Life Early in Life(after ego dev. solidified)No Man-Made Violence Man-Made Violence

Active Role Passive Role

Advance Warning Sudden, No Advanced Warning

Symptoms Time-Limited Symptoms Long Lasting; can produce

characterological change; may produce neuronal changes; both physical and psychological symptoms can be irreversible.

Resolution of symptoms Resolution of symptomscan occur simply with the usually does not occuraid of facilitative spontaneously; treatment environment usually necessary; in some

cases no resolution of symptoms, even with treatment

If treatment is needed, it's Treatment is long term, ego-brief and time-limited reparative

Trauma, Dissociation and Hypnosis

Defenses

• Denial• Suppression• Repression• Splitting• Dissociation

DissociationDistancing through :

−repression of affect (numbing)−repression of thought −repression of behavior−depersonalization (out of body)−amnesias−automatisms (e.g,sleepwalking)

Advantages of Dissociation• Need distance in order to master• Compartmentalize• Discontinuity in experience• Dissociation helps to maintain,

gain and regain control• Body may handle some of the

worst responses

Dissociation

DSM definition:A disruption in the usually integrated

functions of consciousness, memory, identity or perception of the environment.

May be sudden, gradual, transient or chronic.

Advantages of Hypnosis for the Treatment of Trauma

• Can get to original affective state. • Can train the relaxation response.• Can create endless containment

techniques through imagery utilizing trance logic phenomenon.

• Can bridge between the conscious and unconscious (accessing pictorial and sensorial memory ubiquitous to trauma).

Hypnosisan altered state of consciousness

Changes in consciousness reported by those in hypnotic state include:

•narrowed focus of attention•dissociation: numbing, out of body,

“spacey”•altered sense of time•altered sensory perceptions

(Ref: Cardena, 2000)

Grounding

Sensory and cognitive awareness

• Keep a person in the present• Reorient to reality, here and now• Can prevent unhealthy dissociating• Regain mental focus

Grounding Techniques

• Self talk• Directed imagination (all the

senses)• Energy toning• Acting “as if” principles

• Safe place imagery

• Become absorbed in activity.

• Write in your journal.

• Breathing exercises. Relaxation exercises.

• Visualize a "STOP" sign

• Use positive affirmations.

• Transfer your feeling/memory into a safe "container" either through visualization or by creating an actual box where you can write the feeling/memory on a piece of paper and slip it into the box leaving it to be dealt with together with your therapist.

• Identify cognitive distortions and replace with counter statements.

• Dance.

• Repeat a grounding phrase: "I'm here right now."

• Hold a safe object (smooth stone, stuffed animal, watch, ring, cup or mug, etc.).

•Pray (e.g. Serenity Prayer). Exercise.

• Draw.

• Find a safe person.

• Listen to a tape of your therapist.

• Listen to a tape of self-affirmations.

Change sensory experience/input:

• Sight: allow yourself to see through your eyes, look at a

picture, read a book • Touch:

allow yourself to feel the chair you are sitting on, touch ice, hold a smooth stone

• Sound: talk to someone, listen to music, TV

• Taste: eat something

• Smell: perfume, favorite scent

Consequences of Trauma

• persistent fear state• disorder of memory • dysregulation of affect• avoidance of intimacy

Symptom Checklist

Defenses Behavior

• Depression • Repression • Regression

• Re -experiencing • Avoidance• Arousal

Trauma Models

Fight FlightFreeze

Perry- Neurophysiological equivalents in children

• Fight- cry to alert an adult, regressive tantrums

• Flight- often not possible, so dissociate

• Freeze-when an event is perceived as inevitable, seen as oppositional defiant.

Table 1: The Continuum of Adaptive Responses to Threat Bruce Perry, MD, PhD

• Hans Selye General Adaptation Syndrome:

(Psychobiological model)• Anne Burgess

Information Processing of Trauma• Pierre Janet

Stabilization, Exploration, Integration

• Judith HermanSafety, Remembrance and Mourning, Reconnection

• FrancineShapiroEMDR- Eye Movement Desensitization and Reprocessing

• Sandra BloomSAGE- Creating Sanctuary:Safety, Affect Management, Grieving and Emancipation

• Roger FallotTREM- Trauma, Recovery and Empowerment

Hypnotic Model for Treatment

Stabilization/Rapport & Trust Building

Uncovering

Working Through

Kinds of Interventions• Play therapy-symbolic

Houses, toys, costumes, puppets• Hypnosis/Hypnoidal* techniques

Imagery/relaxation Storytelling Role playing/ Playback theater

• EMDR • Sandplay• Art Therapy• Board games• Electronic Techniques

Lap top writing Biofeedback games

*Differ from formal hypnosis in that they utilize the naturally occurring trance state and relaxation response.

Play’s therapeutic factors:

• visualize or use fantasy• communicate • form attachments • enhance relationships • learn through metaphoric teaching• develop competence through mastery • think creatively• achieve catharsis or abreaction • develop positive emotion• helping children overcome resistance• master developmental fears • role-play • develop game play (which helps with

socialization)

Play as hypnosis• Children prefer action to talking• A function of play, at a biological level is to relax

and release tension• Most forms of play for children produce trance

state narrowed focus of attention, dissociation, absorption, imaginative involvement

• At an intrapersonal level, play may provide for mastery of conflicts through the use of symbolism and wish fulfillment

• Therapeutic play- the use of “alone play” with the therapist, using 1) art medium, toys or drama, 2) storytelling through activity and 3) make believe. (Sandplay uses all three).

Hypnotic suggestions and play

Pair play trance state and hypnoidal suggestion

• Just as do in formal trance induction with adults, this is more suitable with children where imagination and imaginative involvement is more present.

• Sensitivity to timing of suggestion, although can be used at any phase of treatment.

• The attachment of words to action (know the power of negative suggestions)

Similarities between hypnoidal play and formal hypnosis

• Resolve problems at an unconscious level: Both hypnosis and play reach into the sub and unconscious, retrieving those aspects of the self, hidden from the client.

• A meditative, focused, absorbed state• Frequently feel time distortion • Dissociation• Accesses original affect• Simultaneous use of both lobes of the brain

Characteristics of Post-traumatic Play

• Compulsive Repetition• Unconscious link between the play

and the real event• Literalness of Play• Failure to relieve anxiety• Depiction of danger• Lack of spontaneity and enjoyment

Interventions for Unhealthy Play

• Physical Movement - ask child to stand up, take a deep breath, move arms and legs. This can be a pattern interruption to rigid emotional and behavioral constriction.

• Verbal statement about the play that may encourage child to disengage, to observe (non interpretive), rather than to be in it.

• Interrupting the sequence of play by asking the child to take specific roles and describe perceptions, thoughts, or feelings. This pretend play is usually normative play for children and may move child out of constricted behavior.

Interventions for Unhealthy Play (cont’d)• Manipulating the toys asking “what would

happen if” to elicit the child’s creative imagination and to consider new options.

• Encouraging child to differentiate between traumatic material and current reality in terms of environmental changes and new coping strategies.

• Videotaping- allows child to be removed from toys and play which may be too real or intrusive. May not be able to use toys as symbolic and instead view them as realistic objects.

Importance of affect

• Emotional interactions are the foundation of cognition and most of the child’s intellectual abilities, including creativity and abstract thinking skills.

What is attachment?:

• An attachment is a reciprocal, enduring emotional and physical affiliation between a child and a caregiver. (B. James)

Attachment vs. Trauma-bond relationships

Attachment Trauma-bond• Love Terror• Takes time Instantaneous• Reciprocity and caring Domination and fear• Person is experienced as essential same

for survival• Proximity→safety(pleasure) Proximity →conflict

(alarm/numbing)

• Separate person dependent Not separate person, extension of

other’s needs• Self-mastery Mastery by others• Autonomy-individuation Obedient to will of

other

Attachment vs. Trauma-bond relationships

• Goals of attachment behavior: safety, exploration, avoidance of danger, and affiliation.

• Goals of trauma-bond behavior: objective of adult’s wellbeing, regulation of intensity of feeling, limited interaction, and safety

Children’s Experiences of War in Bosnia-Herzegovina• Approximately 16,855 children were killed,

died due to hunger or cold, or were missing because of 1992-1995 war in Bosnia

• Over 34,000 children were wounded• War crimes against children included:

• Forced displacement• Rape• Forced prostitution• Torture• Using children as human shields• Taking children as hostages• Killing children in mass murders• Other forms of persecution• Severe abuse

(Commission for Gathering Facts on war Crimes 1996 report)

War Trauma

Children face conflicts related to:• Protection and attachment• Aggression, power, retaliation and the

redressing of wrongs• Fragmentation and incoherence related

to loss in the moral as well as physical, relational and social order(S. Rafman 2002)

Clinical themes

• Good and evil• Trust and betrayal• Protection and aggression• Death as consequence of wrong

choice(S. Rafman 2002)

Type and Frequency of PTSD Symptoms

1. Being upset when reminded of war experiences (92%)*

2. Having intrusive memories (89%)*3. Being watchful or on guard (84%)*4. Avoiding thoughts of the war (81%)*5. Having nightmares (76%)6. Feeling cut off from others (76%)*7. Increased startle response (71%)*8. Decreased concentration (68%)*

Type and Frequency of PTSD Symptoms

9. Feeling numb (61%) *10. Having sleep disturbance ((61%)*11. Reactivity to war reminders (61%)*12. Decreased interest (58%)13. Flashbacks (58%)*14. Avoiding war reminders (55%)*15. Irritability (53%)*16. Feeling future is unclear (50%)*

17. Amnesia (16%)From Weine & Pavkovic (1995). Items with a star (*) were reported by the Philadelphia group.