Published on October 5, 2010
TRAUMA AND ABUSE : TRAUMA AND ABUSE Report By: Ms.Cherie Lavarias- Graduate Student Faculty Dr. A. ANAND, PhD. TRAUMA : TRAUMA -a disordered psychic or behavioral state resulting from mental or emotional stress or physical injury -unresolved trauma is probably both the most important and the most misunderstood aspect of your personal history -a traumatic event can be a single incident or something that happened repeatedly or over a long period of time -outside the range of human experience and that would be markedly distressing to almost everyone. TRAUMA : TRAUMA -it is an individual’s experience of being helpless and overwhelmed by a situation that determines if it will perceived, consciously or unconsciously, as a trauma -leaves psychological scar to the victim or survivor ABUSE : ABUSE -is a term that is used to describe hurtful interpersonal behavior that is intentional or neglectful -even so called “ normal” experiences can have a debilitating effect -anyone who is regularly shamed, belittled, humiliated, intimidated, or sexually harrassed or whose efforts are met with disrespect or harsh judgement maybe a victim of emotional ABUSE : ABUSE -a common misconception is that an event must involve death or violence to have a significant impact but many survivors of physical violence say the emotional abuse has far more devastating impact -many abusive behaviors that were once socially acceptable in the home and the workplace are now recognized as physical, emotional and sexual abuse. TRAUMATIC EVENTS : TRAUMATIC EVENTS Accidents, Natural Disaster, Illness , Injury Threat or Harm to Others Threat or Harm to Self Accidents, Natural Disaster, Illness, Injury : Accidents, Natural Disaster, Illness, Injury -Accidental Physical Injury -Fire -Industrial Accident -Work Accident -Invasive medical Procedures -Motor Vehicle Accident -Property Loss Threat or harm To Others : Threat or harm To Others -Death of a Loved One -Injury or Illness of a Loved One -Threat to a Loved One -Witness to Violence -Suicide of a Loved One Threat or Harm to Self : Threat or Harm to Self -Adult Sexual Assault -gang violence -Captivity -shooting/hold-up -Childhood Sexual Abuse -Combat and Military Sexual Trauma -Communal Rejection -Cults and Entrapment -Domestic Violence -Physical Assault -Rape -Robbery -Sexual Harassment -Threat of Physical Violence -Torture -Victim of Crime TYPES OF TRAUMA : TYPES OF TRAUMA 1. Sexual Abuse ( familial and extrafamilial) 2. Physical Abuse 3. Psychological Abuse 4. Self-Abuse 5. Financial Abuse 6. Property Abuse 7. Animal Abuse and Cruelty of Animals 8. Spiritual Abuse Sexual Abuse : Sexual Abuse -Sexual abuse is insidious in many ways, it impacts in one’s life. Intimate relationships can be a challenge because of the many painful triggers for sexual abuse victims. It is not unusual for a victim of child sexual abuse to be either sexually promiscuous or sexual “anorexic”. Sexual abuse can impact one’s self and leave one with feelings of shame, guilt and creepiness around the perpetrator and anyone that triggers memories of the perpetrator. -stroking or fondling a child for sexual gratification of adult. Involving the child in making pornography Examples of Sexual Abuse : Examples of Sexual Abuse -cheating/ unfaithfulness -coercing sexual contact -Exposing partners to disease or pregnancy -Objectifying as a sexual object -pain or humiliation used for arousal -painful or unwanted touch or tickling -Rape -Staring at body parts -Suggestive comments -Using Sex to Control, Reward or Punish -Voyeurism In children: Any sexual touch, even if child complies, agrees, is aroused or initiates In children: Using a child in any way for sexual arousal, even if child is unaware. Physical Abuse : Physical Abuse -is harmful , unwanted assault on the body. It has to do more with the sense of invasion and loss of control of one’s body, than the actual harm that is done. It can be relatively mild force, or brutal and life threatening. Although the act of choking is often discounted, it can cause permanent injury, long term hoarseness and death can suddenly follow days later. Choking , like any serious assault, can be legally prosecuted as an “ attempted murder” Examples of Physical Abuse : Examples of Physical Abuse -Belting -Biting -Choking -Cutting -Hair Pulling -Hitting with Objects -Hitting Back -Kicking -Pinching -Punching -Scratching -Shoving -Slapping -Restraining -Tripping -Whipping Psychological Abuse : Psychological Abuse -it delves with the mental, emotional and verbal abuse -can be broken into two subtypes 1) Passive aggression 2) Open Aggression Passive Aggression : Passive Aggression -a type of emotional abuse that is not so easily perceived, it can be subtle, very confusing and generally hotly denied by the person acting it out. -sometimes referred to as crazymaking because it is so damaging to the victim’s sense of reality testing -For most experiences of abuse, the person acting out an abuse can be very conscious of the harm they are doing or quite unconscious! However, regardless of the intent of the person acting out the abuse, the damage occurs because the victim is experiencing a sense of helplessness to control their emotional and mental safety. The victim’s experience of intense helplessness is followed by the disruption in the brain. Psychological Abuse : Psychological Abuse Passive Agression Open Agression -blocking discussions -inconsistency -preventing problem solving -minimizing -breaking promises -trivializing -complaining -unsolicited -confusing advice -crazymaking -withholding -denying -entitlement -gossiping -ignoring -forgetting -just joking -lying -justifying -diverting -mean teasing -mind games -misleading -silent treatment -rationalizing Sarcasm/insincerity -tricking -role expectations -accusing -blaming -coercing -criticizing -disgust -hostile looks -intimidation -jugdging -name calling -ordering -punishing -Shaming -threatening -withholding basic needs -yelling -screaming Self- Abuse : Self- Abuse -trauma victims who have ben left with ongoing anxiety typically will be acting out some form of self abuse or abuse towards others. Whereas the harmful behavior may be an attempt to reduce the amount of society that the trauma is causing in the nervous system, it generally will cause even more harm in the long run. Many of these self abuse symptoms can be a true danger signs for victimization. Note: It is not the behavior itself but rather the excessive, compulsive nature of the behavior that increases the risk to one’s health and well-being Self-Abuse : Self-Abuse Poor Interpersonal Skills Risk Behaviors Clinging, needy, desperate behaviors Escalating emotions Inappropriate helplessness Ignoring one/s own needs Negative self=talk Poor boundaries Poor self care Stuffing emotions Driving under the influence of Drugs or alcohol Nicotine Promiscuity Purging Risk activities Speeding Unprotected sex Starving Excessive or compulsive behavior like spending, sex, alcohol, drugs, and gambling Financial Abuse : Financial Abuse -counterproductive to relationships that are based on mutual trust and equality Examples: -Controlling money -Secret Funds -Secret Purchases -Spending sprees w/o Agreement -Stealing from partner -Withholding money for basic needs Property Abuse : Property Abuse -is a violence that is used to express anger, and intimidate and control others. All too often, it is not recognized as abuse but it can be easily create a state of hyper-vigilance in the victims and this ongoing fear is especially damaging to child victims. Examples: -breaking -burning -destroying -hiding -smashing -stealing -throwing Animal Abuse and Cruelty of Animals : Animal Abuse and Cruelty of Animals -many stories of child abuse include the witnessing of animal abuse and cruelty Examples: -confusing -creating fear -cruelty -physical harm -pulling tail -setting on fire -torturing Spiritual Abuse : Spiritual Abuse -any kind of physical, mental, sexual abuse in the name of God -placing a curse or bad omen in the desire to harm others -toxic spirituality Toxic Spirituality : Toxic Spirituality Religious practices are toxic when they are based on shame, blame and guilt rather than support, love and trust. Spirituality becomes a source of trauma when it damages an individual’s health, self-esteem, safety, sanity, intimacy or personal effectiveness. When this type of abuse appears to be sanctioned by God, the damage permeates the very core of one’s being and therefore undermines a healthy sense of self. Clergy Abuse : Clergy Abuse When an abuser is an official in a religious institution, acting in the name of God An example of this would be a Catholic priest who sexually abuses one of his parishioners Spiritual abuse is the practice of using the name of God or any religious dogma to hurt, control and demean others. The human power desire for power is acted out under the sanction of being a “ a messenger of God” NEURODEVELOPMENTAL : NEURODEVELOPMENTAL New Brain Research by Victoria Bruner First year of life: Brain undergoes extraordinary change. Early childhood experiences exert a dramatic impact-it determines how th brain works Experience after birth (rather than innate qualities) determine the wiring of the brain. Brain is very plastic-good but also creates vulnerability to Violence. If exposed to fear and stress and overwhelming experience, neurochemical response occur. Trauma increases stress hormone, CORTISOL, toxic resulting in smaller cortex/ limbic system( 20-30% smaller in abused children.) NEURODEVELOPMENTAL : NEURODEVELOPMENTAL 4. Research shows: Adults abused as children, their HIPPOCAMPUS smaller than those who did not experience abuse. This damage frontal lobe leads to inability to cope with situations. Frontal lobe damage leads to inability to cope with situations. 5. Early abandonment by mother or significant family members lower serotonin in children. 6. Regions activated by the original trauma are immediately re-activated whenever the child dreams, thinks about or is reminded of trauma. This leads to hyperactivity, anxiety, impulsive behavior NEURODEVELOPMENTAL : NEURODEVELOPMENTAL 7. Van Der Kolk, early disruption of social attachment bond causes long-standing PSYCHOBIOLOGICAL changes that reduces capacity to cope with stress, interfere with learning, interfere with motivation 8. Chronic exposure to violence can cause activation of genes linked to depression and other mental problems. ABUSED CHILDREN: Defenseless : ABUSED CHILDREN: Defenseless Child abuse is as old as human history Hammurabi Code 2100 BC and Hebrew Code of 800 BC-children considered property, infanticide acceptable Roman Times, Patria Protestae permitted fathers to sell, sacrifice, mutilate or kill offspring 16th century-German children buried alive Currently, many believe there is still a war against children VIOLENCE : VIOLENCE -it is the threatened or actual use of physical force or power against another person, against oneself or against a group of community that either results in, or has high likelihood of resulting in injury, death or deprivation Note: No one profession can address the problem of violence. But collectively, we must not accept violence as a way of life. Characteristics of Violence : Characteristics of Violence Violence repeats itself. It creates its own vicious cycle. Even in defeat, the person or nation does not forget. Parent-child relationships become entrenched in “ I’ll show you or I’ll get you back attitudes. Walls are constructed to keep children in and keep parents out.create It’s always justified by the users and abusers. Reasons are created for the violence. I hit her because she asked for it. “ My kid smart-mouthed me one too many times. I had to teach him a lesson.” Characteristics of Violence : Characteristics of Violence 3. Violence is reciprocal. It establishes a polarity. Each side of the action establishes that the other side is evil and worthy of being destroyed. 4. There is no difference in violence on either side of the conflict. Violence is violence. 5. Violence is learned behaviour that has its roots in early childhood. Factors of Abuse : Factors of Abuse -poverty -media ( TV violence and violent toys) -drugs and alcohol -stress -lack of parent education -poisonous pedagogy COMMON TRAUMA SYMPTOMS : COMMON TRAUMA SYMPTOMS Recurrent thoughts or memories of the most hurtful or terrifying events. Feeling as though the event is happening again. Recurrent nightmare Feeling detached or withdrawn from people. Unable to feel emotions. Feeling jumpy, easily startled. Difficulty concentrating. Trouble Sleeping COMMON TRAUMA SYMPTOMS : COMMON TRAUMA SYMPTOMS 9. Feeling on guard. 10. Feeling irritable or having outburst of anger. 11. Avoiding activities that remind you of the traumatic or hurtful event. 12. Inability to remember parts of the most traumatic events. 13. Less interest in daily activities. 14. Feeling as if you don’t have a future 15. Avoiding thoughts or feelings associated with the events. COMMON TRAUMA SYMPTOMS : COMMON TRAUMA SYMPTOMS 16. Sudden emotional or physical reaction when reminded of the most hurtful or traumatic event. 17. Feeling that people don’t understand what happened to you. 18. Difficulty performing work/ daily tasks. 19. Blaming yourself for things that have happened. 20. Feeling guilty for having survived. 21. Hopelessness 22. Feeling ashamed of the hurtful or traumatic events. COMMON TRAUMA SYMPTOMS : COMMON TRAUMA SYMPTOMS 23. Spending time thinking about why these things happened to you. 24. Feeling as if you are going crazy. 25. Feeling that you are the only one who suffered these events. 26. Feelings that others are hostile toward you. 27. Feeling that you have no one to rely on. 28. Finding out or being told by others that you have done something that you cannot remember. 29. Feeling as if you are split into two people and one of you is watching the other is doing. 30. Feeling someone you trusted betrayed you. POST-TRAUMATIC STRESS DISORDER (PTSD) : POST-TRAUMATIC STRESS DISORDER (PTSD) Mental disorder resulting from exposure to an extreme traumatic stressors Characteristics Exposure The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone eg., serious threat to one’s life or physical integrity, serious threat or harm to one’s children, sudden destruction of one’s home or seeing another person who has recently been, seriously injured or killed as the result of an accident or physical violence. PTSD : PTSD B. The traumatic event is PERSISTENTLY EXPERIENCED in at least one of the following ways: Recurrent and intrusive distressing recollections of the event Recurrent distressing dreams of the event Sudden acting or feeling as if the traumatic event were recurring ( hallucinations, dissociative, flashback) Intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event including anniversaries of the trauma. PTSD : PTSD C. PERSISTENT AVOIDANCE OF STIMULI ASSOCIATED WITH THE TRAUMA OR NUMBING -At least 3 of the following > efforts to avoid thoughts or feeling associated with the trauma >efforts to avoid activities or situations that arouse recollections of the trauma >inability to recall an important aspect of the trauma (psychogenic amnesia) >markedly diminished interest ( language skills, toilet training) >feeling of detachment or estrangement from others >range of affect , unable to have loving skills >sense of foreshortened future PTSD : PTSD D. PERSISTENT SYMPTOMS OF INCREASED AROUSAL (not present before the trauma) At least 2 of the following: >difficulty falling or staying asleep >irritability or outburst anger >difficulty concentrating >hyper-vigilance >exaggerated startle response >physiologic reactivity upon exposure to events that symbolizes or resemble an aspect of the traumatic event( woman who was raped in an elevator breaks out in a sweat when entering any elevator) PTSD : PTSD E.-symptoms in persistently experience, persistent avoidance of stimuli, persistent system of increased arousal of at least one month. -Specify delayed onset if the onset of symptoms was at least six months after the trauma TRAUMATIC STRESS REACTIONS : TRAUMATIC STRESS REACTIONS Emotional Effects Cognitive Effects Shock Terror Irritability Blame Anger Guilt Grief or sadness Emotional numbing Helplessness Loss of pleasure Difficulty feeling happy/ loving Impaired concentration Impaired decision making ability Memory impairment Disbelief Confusion Nightmares Decreased self esteem/ self-efficacy Intrusive thoughts/memory dissociation TRAUMATIC STRESS REACTIONS : TRAUMATIC STRESS REACTIONS Physical effects Interpersonal Effects Fatigue, exhaustion Insomnia Cardiovascular strain Startle response Headaches Gastrointestinal pain Startle response Hyperarousal Increased physical pain Reduced immune response Decreased libido Increased relational conflict Social withdrawal Reduced relational intimacy Alienation Impaired work performance Decreased satisfaction Externalization of blame Feeling abandoned/rejected Overprotectiveness distrust PROBLEMATIC STRESS RESPONSE : PROBLEMATIC STRESS RESPONSE Severe Dissociation- feeling as if you or the world is “unreal” not feeling connected to one’s own body, losing one’s sense of identity or taking on a new identity, amnesia. Severe Intrusive Re-experiencing-flashbacks, terrifying screen memories or nightmares repetitive automatic re-enactment Extreme Avoidance-agoraphobic like social or vocational withdrawal, compulsive avoidance Severe Hyperarousal-panic episodes, terrifying nightmares, difficulty controlling violent impulses, inability to concentrate PROBLEMATIC STRESS RESPONSE : PROBLEMATIC STRESS RESPONSE Debilitating Anxiety-ruminative worry, severe phobias, unshakeable obsessions, paralyzing nervousness, fear of losing control/going crazy Severe Depression-lack of pleasure in life, worthlessness, self-blame, dependency Problematic Substance –abuse or dependency, self-medication Psychotic symptoms-delusions, hallucinations, bizarre thoughts or images CHARACTERISTICS OF TRAUMATIC : CHARACTERISTICS OF TRAUMATIC 1. Life threatening 2. Unpredictable 3. Uncontrollable 4. Meaningless STAGES OF TRAUMA : STAGES OF TRAUMA Sudden Occurrence of Traumatic Event Physical Sequelae Shock or Disbelief Destabilization Psychological/Psychosomatic Sequelae Coping/ Normalizing Recovery/ Expressive Theraphy TREATMENT PROCESS : TREATMENT PROCESS Communication, in which the child learns how to delineate and express feelings. Sorting out where he/she explores his understanding of what happened to him Education where he/she learns to understand the specific elements of the traumatized experience Perspectives where the child ‘s experience is accepted as something that has happened to him, without the need for exaggeration or minimization of the impact Treatment Preparations : Treatment Preparations Conduct a comprehensive evaluation of the child and family Make a differential diagnosis Develop a specific TX plan with clearly stated objectives, including the possibility of additional TX at later time. Treat the child and caregiver as respected partners in TX who will actively assist in the planning and implementation of therapeutic work. The additional involvement of teachers, extended family among others maybe desirable. Develop a strong relationship with the child TREATMENT PREPARATIONS : TREATMENT PREPARATIONS 6. Use a combination of directive and non-directive techniques to assist the child in reviewing traumatic events and working conflicts and behaviors related to the events. 7. End initial TX when objectives are met, not necessarily when all loose ends are tied up. 8. Make termination of course TX” open door” that is make yourself available for consultation to child and or parents on as needed basis, so that the child may return for check ups and additional clinical help. 9. Identify signs for the child and parents to look for, which would indicate that a clinical booster might be useful. ASPECTS CRITICAL TO TREATMENT PROCESS : ASPECTS CRITICAL TO TREATMENT PROCESS The child needs to acknowledge and explore his pain while in therapy, in order to integrate his experience. A serialized course of treatment, rather than one uninterrupted period of therapy is often indicated. The needs of the child usually cannot be effectively met by a clinician working alone, without the supports of others involved with the child. The caregiver must be considered part of the treatment team and their active participation is needed. A direct, active treatment approach is needed to elicit material from the child that is unlikely to emerge spontaneously and to demonstrate that the issues need not be shameful and can be dealt with directly. The clinical course must include attention to the physical, cognitive, emotional and spiritual parts of the child since the damage usually affects all these areas. Insights : Insights As therapists, we need to be sensitive and have a vast understanding of the client’s traumatic experience as well as his/her personality structure and functioning. We need to be aware of their strengths and weaknesses, as well as our own. We need not be aware but also we must learn to accept it to be able for us to help our client in accepting what had happened to them. Acceptance is a very important part of treatment and it is actually the first step, while avoidance or resistance is far from healing. Insights : Insights A therapist without preparation and knowledge of the treatment guidelines and aspects critical to treatment process is like a soldier going to a battle without his riffle. In this , the therapy will not be successful and the goals of treatment cannot be achieved. It may be possible that instead of treating and helping the client resolve his/her conflict or issue, the therapist may worsen the situation and add confusion to the client and it is also possible that the therapist ends up as a victim of his/her own carelessness. TRAUMA MANAGEMENT : TRAUMA MANAGEMENT Address immediate needs/crisis/medical needs Assure victims/ survivors that they are safe Debriefing: relieving/retelling of story/ encourage narrative expressions Stabilize somatic or psychological symptoms Counseling -education about the impact of trauma, about adaptive and maladaptive coping responses -validate the nature of reactions and symptoms eg. “Okey, I believe to what you are saying, it’s normal. I understand you, it’s painful, but if you will try to...” TRAUMA MANAGEMENT : TRAUMA MANAGEMENT 6. Normalization/Recovery -restore functioning: reinvest new/ meaningful relationships -restore activities/ exercise -teach coping strategies OTHER THERAPY : OTHER THERAPY Critical Incident Stress Debriefing -catastrophic phenomenon which makes it almost impossible for human being to cope -allowing the person discuss to discuss what happened, the experience itself, the feeling level ff. the critical incident CISD-allowing the survivor to relive/ tell the critical event express how they feel about the incident (during and after) and providing emotional support to the survivor. OTHER THERAPY : OTHER THERAPY 1. Assessment Procedures . Drawing and Writing Exercises for Children –drawings can be used both in standardized(House Tree Person Test, Kinetic Drawing System) and non –standardized (to obtain an estimate of a child or adolescents cognitive and level of maturity) 3 types: free-drawing , self-portrait, family Art Therapy Program ( the creative process can be a means both of reconciling emotional conflicts and of fostering self-awareness...) OTHER THERAPY : OTHER THERAPY B. Clinical Interview 1. The Diagnostic Interview for Children and Adolescents-this is highly structured diagnostic interview that can be used with children 6 years or older. It covers a wide range of childhood symptoms in terms of frequency and duration. 2. The Interview Schedule for Children-semi structured interview for children ages 8 to 17. It is a symptom oriented interview that focuses primarily on depression, although it assess other diagnostic criteria. 3. The Diagnostic Interview Schedule for Children-highly structured interview for children and adolescent ages 6-18. It provides natural form of communication and an expression of creativity linked to learning, coping and self-realization OTHER THERAPY : OTHER THERAPY 2. Counseling Approaches Play therapy-provides natural form of communication and an expression of creativity linked to learning , coping and self-realization. Play therapy is the window through which we view the child’s world. It is the most important language in speaking with and listening to the traumatized child. Youth conflict resolution-the youth takes an active role in the process by learning how to mange his/her own conflicts. It’s main goal is to foster problem solving skills, coping and resiliency characteristics that can be used to overcome conflict and foster optimal development. Steps for Conflict resolution Problem Solving : Steps for Conflict resolution Problem Solving Take a positive approach. 2. Listen appropriately Become aware of choices Create solutions that promote friendship 5. Follow-up OTHER THERAPY : OTHER THERAPY Storytelling -narrative approaches to counseling attempt to simplify and expose counseling by focusing on the client’s own language as opposed to psychological jargon. In this process, the counselor and client work together to create new narratives ( alternative stories) as a means of enhancing the client’s well being. -creative characters, used for children with emotional problems and defensive maneuver. -role playing help alleviate a child’s difficulty in affective, cognitive or behavioral areas that impedes developmental adaptation. Through storytelling... : Through storytelling... People organize information in terms of stories about themselves. Negative, stressful life events affect people’s belief systems, thereby altering the nature of their stories. How people rescript their stories ( that is engage in narrative repair) will influence how well they cope with stress... OTHER THERAPY : OTHER THERAPY IRCT-International Rehabilitation Council of Torture Victims Denmark (physiotherapy/pyschotherapy) Management of Rape Trauma ( SWAMY MODEL) Reality Therapy by Glasser- process by which the psychiatrist guides the patients so that they can face reality and fulfill their needs. EMDR-Eye Movement Desensitization and Reprocessing (8 phase of treatment-dependent to profile of client) Neuro-Linguistic Programming – I see what you mean, I hear whatyou’re saying, I don’t feel like I understand. Gestalt Theraphy-that people must find their own way in life and accept personal responsibility to achieve maturity. “ PRAY FOR GUIDANCE” : “ PRAY FOR GUIDANCE” THANK YOU VERY MUCH!!!!!