Trauma Informed Treatment:Trauma Informed Treatment:Applying Neuroscience Applying Neuroscience
Fairfax, VAFairfax, VAOctober 18October 18thth, 2012, 2012
Jan Beauregard, Ph.D., LPC, CSACJan Beauregard, Ph.D., LPC, CSAC
www.ipivirginia.orgwww.ipivirginia.org(703) 385 9667 Ext. 1(703) 385 9667 Ext. 1
How a Healthy Brain How a Healthy Brain Develops:Develops:• An infant is born with the brain stem fullyAn infant is born with the brain stem fully
intact and capable of primitive, subcorticalintact and capable of primitive, subcortical
reflexes like fight, flight, freeze, attachreflexes like fight, flight, freeze, attach
At 10 months, there is significantly moreAt 10 months, there is significantly more
genetic material due to interactions withgenetic material due to interactions with
the primary caregiver and the the primary caregiver and the environment environment
Schore, 2007
Brain Development:Brain Development:• At about 10 months we see that the At about 10 months we see that the
prefrontal cortex comes on line and prefrontal cortex comes on line and by age 2 the brain actually doubles by age 2 the brain actually doubles in size.in size.
• For a healthy brain to develop certain For a healthy brain to develop certain kinds of experiences are critical – kinds of experiences are critical – especially social experiences.especially social experiences.
““Cells that fire together wire together Cells that fire together wire together and those that do not DIE together.”and those that do not DIE together.”
(Porges, 2007; Siegel, 2007)
Left and Right Brain Left and Right Brain FunctioningFunctioning
Left RightLeft BrainCEO Right Brain: The
Survival Brain
Problem solver nonverbalAnalytic languageRationalConceptual perception of emotion, facialTask Master- expressionCarries on no matter sensationwhat happens instinctive Verbal/narrative survival responseMemory
Emotional/ImplicitSensory memoryimagistic
Adverse Childhood Experiences Adverse Childhood Experiences (ACE)(ACE)
Adverse Experiences: emotional, physical neglect, physical, emotional, sexual abuse, domestic violence,Mental illness, substance abuse, divorce, incarceratedFamily member, mental illness in familywww.acestudy.org/files/ACE_Score_calculator.pdfACE Score of 4 or More:2 x as likely to smoke12 x more likely to attempt suicide7 x more likely to become alcoholic10 x more likely to inject street drugs
Increased Health Risks: heart disease, obesity, liverdisease, lung cancer, asthma, autoimmune disease
Fellitti, 2003
Co-regulation With Primary Co-regulation With Primary caregivercaregiver• There are emotional and neurochemicalThere are emotional and neurochemical
effects that the mother-child diad have oneffects that the mother-child diad have on
each other:each other:
Hormones released in the mom impact theHormones released in the mom impact the
genome (oxytocin, endorphins, cortisol) and genome (oxytocin, endorphins, cortisol) and this psychobiological interaction of primary this psychobiological interaction of primary caregiver and child affects overall mental caregiver and child affects overall mental and physical health over the lifespan.and physical health over the lifespan.
Karr-Morse, 2012; Porges, 2006
Attachment Styles In ChildrenAttachment Styles In Children
•Secure – 65% Secure – 65% (UTUBE)(UTUBE)
•Avoidant/Dismissive – 20%Avoidant/Dismissive – 20%
•Preoccupied/ambivalent/anxious Preoccupied/ambivalent/anxious -5%-5%
•Disorganized/Disoriented – 10 %Disorganized/Disoriented – 10 %
(Bowlby, 1973)
Attunement has a neurocorrelate – shoving own state into the state of the infant. Parents who gain insight intotheir own attachment style will be better parents.Tatkin, 2006 – Attachment Interview for Parents (AAI)Fraley, 2011 www.web-research-design.net/cgi-bin/crq/crq.plSeigel, 2006 - Mindfulness, mirror neurons
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In Secure Attachment:In Secure Attachment:Good enough psychobiological
interactionin parent/child diad (must be
appropriate,consistent and predictable) will imprint
the right brain resulting in the development of:
TrustSelf esteemEmpathyControl of aggressionAbility to self regulate unpleasant
emotions Provide the network that fosters our
abilityto connect to others in future
relationships
Insecure Attachment – Impact on Insecure Attachment – Impact on BrainBrain
Abuse, neglect, under-stimulation and prolonged shame:• Reduces the level of dopamine• Reduces the levels of endorphins• Reduces the size of the hippocampus (8%) ***• Increases stress hormones like cortisol and noradrenalin• Results in a smaller corpus collosium (bridge)• Changes in brain grey matter and white matter•Dendritic burnout
•Elevated resting heart rate in children a consistentsign of early attachment trauma (Cozolino, 2006)
Disorganized Attachment:Disorganized Attachment:Usually at the root of symptoms we associate withthe diagnosis of BPD. A better name for this condition would be “disorganized attachment disorder.”
This attachment style makes it difficult to assessincoming stimuli appropriately.
The amygdala (fire alarm for the brain) is especiallyimportant for assessing and processing a number ofemotions (fear, sadness, anger) accurately and isoveractive in traumatized individuals.
Dr. Alan Schore - Dr. Alan Schore - PsychiatristPsychiatrist
Affective Regulation in Infancy
www.utube.com/watch?V=MD5MI-EAC10
When Attachments are in When Attachments are in Peril:Peril:Education needs to begin before parenting(Psychoeducation, Adult Attachment Interview)
Treat the whole family – a parent’s understanding is critical to undo the legacy ofintergenerational trauma (Marvin, 2002)
Treatment begins with safety and containmentand affect regulation tools
Therapy (and other secure attachments) with appropriate attunement can reverse damage
Still Face Experiment: Still Face Experiment: Tronick Tronick (Utube: www.utube.com/watch?(Utube: www.utube.com/watch?v=apzxGEbZht0)v=apzxGEbZht0)This rupture in attachment could occur in
many situations. Consider a caregiver who:Has unresolved traumaIs a substance abuserHas an anxiety disorderIs depressedIs dealing with complex grief Is a victim of domestic violenceIs living with chronic stress due to unemployment or under employmentHas a serious mental illness
Teaching Tools:Teaching Tools:
Ainsworth, Mary : A Strange Situationwww.utube.com/watch?V=QTsewNrHUHU
Bowlby, John – Father of Attachment Theorywww.utube.com/watch?V= apzxGEbzht0
Porges, Stephan – Affective Neurobiologywww.utube.com/watch?v=Lpu4hKG8WOA
Fisher, J. PsychoeducationalAids for WorkingWith Psychological Trauma (Flipchart)[email protected]
Trauma Informed Therapy Trauma Informed Therapy TreatmentsTreatments::Sensorimotor Psychotherapy (Ogden)Somatic Experiencing (Levine)
Mindfulness (Siegel) and Meditation (Zinn)
DBT (Linehan) and some protocols from EMDR
ARC (Kinniburgh & Blaustein) Attachment, Self Regulation and Competency
Trauma Sensitive Yoga (Cimini, Emerson, Weintaub)
Expressive Therapies: art, music, dance
Why is the Body Important?Why is the Body Important?
Clients often relive the trauma through the body somatically because the material is inaccessible to verbal recall. If not processed from the bottom – up, the material remains unintegrated and unaltered over time leading to a variety of disruptive symptoms and poor coping tools.(Van der Kolk, 1991).
Explicit Memory – verbally accessible, factualImplicit Memory – nonverbal memory** Often results in repair to attachment system
Trauma Responses are Autonomically Trauma Responses are Autonomically DrivenDriven
“Window of Tolerance”*Optimal Arousal Zone
Hyperarousal-Related Symptoms: High activation resulting in impulsivity, risk-taking, poor judgmentChronic hypervigilance, post-traumatic paranoia, chronic dreadIntrusive emotions and images, flashbacks, nightmares, racing thoughtsObsessive thoughts and behavior, cognitive schemas focused on worthlessness and dread
Hypoarousal-Related Symptoms: Flat affect, numb, feels dead or empty, “not there”Cognitively dissociated, slowed thinking processCognitive schemas focused on hopelessnessDisabled defensive responses, victim identity
Hyperarousal
Hypoarousal
Ogden and Minton (2000); Fisher, 2006 *Siegel (1999)
Trauma Informed Treatment:
Looks at behaviors as a result of what happened instead of a symptom of what is wrong.
When the prefrontal cortex is “off line”treatment MUST begin with attentionto the body.
The first objective is to restore the feelingof safety and to help the patient/clientget back into the present moment.
Basic Tools: Safety & Basic Tools: Safety & ContainmentContainment• Physical/Mental Grounding (Najavitits, 2002; Physical/Mental Grounding (Najavitits, 2002;
Rothchild, 2002; Ferentz, 2000)Rothchild, 2002; Ferentz, 2000)
• Breathing techniques to engage the Breathing techniques to engage the parasympathetic nervous systemparasympathetic nervous system
• Orienting Response - client moves head as Orienting Response - client moves head as he/she describes objects in the environment he/she describes objects in the environment
• Interrupt to switch focus …pause, whatInterrupt to switch focus …pause, what
helped you through this? When did you firsthelped you through this? When did you first
realize that you were safe? (Retrospective realize that you were safe? (Retrospective Mindfulness… slow down the story)Mindfulness… slow down the story)
Pendulation – going from high activation toPendulation – going from high activation to
low activation and backlow activation and back(Beauregard, 2012)
Focusing and Calming:Focusing and Calming:• Deep breathing – Deep breathing –
exhalations longer exhalations longer One hand on heart,One hand on heart,Other below the navel Other below the navel
• Frozen lemons/limesFrozen lemons/limes• HandwarmingHandwarming• Detachment – gestures Detachment – gestures
to distance affectto distance affect• Hold feetHold feet• Something in me…..Something in me…..• Trauma sensitive yogaTrauma sensitive yoga
(Daitch, 2007; Linehan, 2000; Ogden, 2006)(Daitch, 2007; Linehan, 2000; Ogden, 2006)
Activating and Engaging:Activating and Engaging:
1. Trauma sensitive yoga:Bellows Breath, pullingPrana2. Asanas – Lum, VumRum, Yum, Hum, Om1. Movement2. Crosswalks3. Orienting Response4. Ball toss7. Tasper (EMDR)
Emerson, Porges, Weintaub)
Sensorimotor Psychotherapy & Sensorimotor Psychotherapy & SESESensorimotor Psychotherapy is a body based, bottom-up approach to processing trauma developed bysomatic pioneer Pat Ogden, Ph.D.
Somatic Experiencing (SE) is another body oriented bottom-up approach developed by Peter Levine to treating trauma.
Both programs require extensive training to useeffectively
Why Use Sensorimotor/SE?Why Use Sensorimotor/SE?
Because the body can be used to regulateBecause the body can be used to regulate
affect (breathing, movement, etc.)affect (breathing, movement, etc.)
To prevent Bottom – Up Hyjacking – To prevent Bottom – Up Hyjacking – responding to false threatsresponding to false threats
To learn new physical actions to challenge To learn new physical actions to challenge procedural learning (breathing, pushing,procedural learning (breathing, pushing,
moving)moving)
Trauma, PTSD and Trauma, PTSD and MovementMovement• Hurricane Katrina yielded the greatest Hurricane Katrina yielded the greatest
amount of PTSD (33%) more than other amount of PTSD (33%) more than other natural disastersnatural disasters
• As stress hormones got activated, the natural As stress hormones got activated, the natural response would have been to move or “do response would have been to move or “do something”something”
• Louisiana’s response was to put people in oneLouisiana’s response was to put people in onelocation and immobilize themlocation and immobilize them
After 911, The PTSD rate was documented at After 911, The PTSD rate was documented at only 6 % because people ran, moved, dug only 6 % because people ran, moved, dug others out, mobilized – completed the others out, mobilized – completed the fight/flight responsefight/flight response
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Experiment:Experiment:
• You will be shown 2 different slidesYou will be shown 2 different slides
• Notice the nonverbal cues Notice the nonverbal cues (sensations, feelings) that (sensations, feelings) that accompany each slideaccompany each slide
Sensorimotor PsychotherapySensorimotor Psychotherapy
www.sensorimotorpsychotherapy.orgwww.sensorimotorpsychotherapy.org
Pat Ogden – FounderPat Ogden – Founder
3 Levels of Training offered Nationally 3 Levels of Training offered Nationally andand
InternationallyInternationally
Mindfulness and MeditationMindfulness and MeditationMindfulness can be described as paying attention in a particular way; on purpose to the present moment, nonjudgmentally. (Kabat-Zinn, 1994)
In mindfulness we watch the the experience of the story unfold in the present moment through changes in body sensations, moment, sensory perception, emotions and thought (Ogden,2006). Mindfulness is a part of SP, SE and DBT.Posterior Cingulate – activated when mind wanders Anterior Cingulate – activated in the here and now
http://www.mindfullivingfoundation.org/meditations.html Meditations
Mindfulness QuestionsMindfulness Questions1. What do you feel in your body right now?2. Where exactly do you feel that tension?3. How big is the area of tension?4. What sensation do you feel in your legs
rightnow as you talk about ______?6. Just notice in your body what wants to
happen as you say that…7. What happens inside when you get angry?8. What inside your body tells you that you
feel safe?
Mindfulness and MeditationMindfulness and MeditationHow long is a moment? 5-8 seconds or the amount of timeIt takes for one in and out breath.
Our minds wander 48 % of the time – the more the mindwanders the more stress increases.
A recent study showed that as little as 1 minute of mindfulness meditation a day could reduce stress, improveconcentration and reduce aggression
Alabama Prisoners – 20 % reduction in disciplinary actionfor prisoners participating in mindfulness meditation courseDocumentary Movie: The Dhamma Brotherswww.wildmind.org/blogs/news/alabama-prisoners-turn-to-meditation-forpeace
Meditation:Meditation:Thinking, thinking, thinking….return to the breath…..
Sound, sound, sound….. Return to the breath…..
Feeling, feeling, feeling…… Return to the breath…..
“Let the bird fly by….do not let it nest in your head.”
There are changes in the brain during meditation – the leftprefrontal cortex gets activated (10 – 15 % change resultsin more positive emotions) Changes in the whitematter and grey matter of the brain occur with as little as1 minute of mindfulness a day.
Trauma Sensitive YogaTrauma Sensitive Yoga• Effective in treating both anxiety, Effective in treating both anxiety,
depression and PTSD symptomsdepression and PTSD symptoms• Yoga teacher must use permissive Yoga teacher must use permissive
language and allow clients to language and allow clients to establish the boundaries they need establish the boundaries they need during the practiceduring the practice
• Give choicesGive choices
((Cimini, Emerson, Weintaub, 2004)Cimini, Emerson, Weintaub, 2004)
User Friendly LanguageUser Friendly Language
• ““If you’d like, you may open your mouth if If you’d like, you may open your mouth if it is uncomfortable to breathe through it is uncomfortable to breathe through your nose….your nose….
• ““Whatever feels comfortable right now….”Whatever feels comfortable right now….”
• ““If you wish, try to place your left hand on If you wish, try to place your left hand on the crown of your head….”the crown of your head….”
** Yoga therapist needs to contract about ** Yoga therapist needs to contract about touch with each clienttouch with each client
(Emerson, 2008)(Emerson, 2008)
Trauma Sensitive Yoga ResourcesTrauma Sensitive Yoga Resources
• Yoga Warriors – two day training with Yoga Warriors – two day training with Lucy Cimini Lucy Cimini
• David Emerson – Justice Resource CenterDavid Emerson – Justice Resource Center
Boston, MABoston, MA
Amy Weintaub – Yoga for DepressionAmy Weintaub – Yoga for Depression
Training in LifeForce YogaTraining in LifeForce Yoga
** The type of yoga and the training of the ** The type of yoga and the training of the instructor is important “trauma sensitiveinstructor is important “trauma sensitive
Yoga”Yoga”
Trauma Sensitive Yoga in Trauma Sensitive Yoga in VAVA
• Heather Hagaman, MA, RTY-200 Heather Hagaman, MA, RTY-200 Beloved Yoga, RestonBeloved Yoga, Reston
[email protected]@aol.com
Corrinne Krill, MA, RTY-200Corrinne Krill, MA, RTY-200
Sun and Moon YogaSun and Moon Yoga
Info#heartandsoulyogava.comInfo#heartandsoulyogava.com
IPI: Additional TrainingIPI: Additional Training• Tools for Transforming TraumaTools for Transforming Trauma
• Sensorimotor and Somatic TechniquesSensorimotor and Somatic Techniques
• Trauma Sensitive Yoga/Yoga WarriorsTrauma Sensitive Yoga/Yoga Warriors
• Using Ego State Therapy and ImageryUsing Ego State Therapy and Imagery
• Expressive Therapies for Trauma TreatmentExpressive Therapies for Trauma Treatment
• Using DBT in Trauma TreatmentUsing DBT in Trauma Treatment
• Treating Complex Trauma in the Substance Treating Complex Trauma in the Substance Abusing ClientAbusing Client
• Sexual Compulsivity and TraumaSexual Compulsivity and Trauma
