Trauma Archives - Mindful Happiness

March 11, 2017 By Admin

Object Relations Therapy for Trauma

Trauma: Object Relations Therapy

Object relations therapists, D. W. Winnicott especially, have presented a logical analysis on how to provide object-relations-oriented therapy to people suffering from the effects of psychological trauma. Such attachment-based trauma therapy provides support and healing from trauma, loss and long-term trauma-effects. The interventions below combine the best of object relations therapy, mindfulness therapy (MBSR, ACT), and cognitive-behavioral therapy. Here is the listing of therapeutic functions and interventions.

Provide support for “going-on-being” in the therapeutic alliance and the therapy itself. (Winnicott)
Unconditional positive regard is a must. (Rogers)
Recognize, work with and work through the splitting process as it activates in therapy. (Lineman)
Safely and with effective skill help to re-connect the person with safe transitional space. (Winnicott)
Carefully build and monitor the emotional “holding environment” in both alliance and therapy. (Rogers, Winnicott)
Include contextual stimuli and symbols of the traumatic experience, from very general to specific and shift slowly over time. (Briere)
Once there is a firm alliance and safety in the therapy, be more specific in exposure to traumatic experiences – monitor carefully. (Briere)
In all exposure work, best to utilize SUDs scores from 0 to 100 – larger range between numbers allows deeper investigation and specificity.
Work hard to understand and utilize body-based communications. (Ogden, Fisher, van der Kolk)
Use mindfulness attention and skills (MBSR, ACT) to remain in The Middle Way between traumatic re-exposure and the safety of “going-on-being.” (Briere, van der Kolk)
Check in with the experiences of transference and countertransference as you use images and defenses to support progress. (A. Freud)
Use multi-sensory interventions in gentle, safe, re-exposure to traumatic materials – using one step removed and cognitive processes first. (Quintiliani)
If skilled in its use, utilize the Attachment-CABs-VAKGO-IS-Rels formula for interventions. (Quintiliani – see mindfulhappiness.org for more details)
Using items #s 8-13 above, aim for development of a safe cognitive schema and narrative clarification about the traumatic event/s.
Work closely with the person to help them internalize the growth-benefits of all of the above. Take time with this process.
Be a “good object” and always return to safety over and over again – check-in and stabilizes often.
Slowly and with safety move up the hierarchy of trauma exposure process, possibly experiencing the full array of sensory experience. (Briere, Foa)
Listen, support emotionally, radically accept, validate and understand the process and the person. This is your best way to develop a “good enough” self-object via “transmuting internalization.” (Kohut) Various mindfulness and CBT skills will be used here.
Use mindfulness and good CBT to make space for acceptance and validation for post-traumatic growth. (Lineman)
Help to impact these positive changes into a “different” memory system as you expand and deepen the narrative.
Support and directly reinforce (behaviorally) the improved self – a “felt sense” of a healthier self psychologically and physically.
Place more and more safety into the transitional space, and generalize this process into therapy and life practices.
Finally, expand the person’s capacity for pleasure, joy, self-esteem, success and HAPPINESS before therapy ends.

For more information refer to Savage Scharff, J. and Scharff, D. E. (1994). Object Relations Therapy of Physical and Sexual Trauma. Northvale, NJ: J. Aronson.

Note: The ideas have been presented in this text, but I have added more current interventions and details based on new research and treatments.

Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont

Author of Mindful Happiness

New Edition of Mindful Happiness in Production…Coming soon!

January 22, 2017 By Admin Leave a Comment

A More Technical View of Mindfulness

Mindfulness: A More Technical View of

A more technical understanding of mindfulness, an understanding necessary for effective educational and clinical applications of such skills and practices, has been presented by S. A. Alper (2016). This view uses a pyramid as a symbolic metaphor for mindfulness applications. The details of this pyramid (the foundation, four sides, and a top) appear below. Before we go there, let’s do a quick review of what mindfulness is and is not.

Mindfulness is not simply relaxation (a by-product), trance state, empty mind, thinking, striving, nor is it only applied to meditation or yoga. Mindfulness is awareness in the present moment of experiencing – it is awareness of whatever comes into consciousness without trying to change it or judge it. Choiceness awareness changes over time; this is not a concentrative effort to narrow down what you pay attention to (that is concentration practice). You simply notice matter-of-factly what you are experiencing here, now. Given the dominance of various clinical conditions (depression, anxiety, trauma, substance misuse – self medicating behaviors),
mindfulness skills may be very helpful to students, clients, and patients. Over time, the practice of mindfulness reduces auto-pilot mind and body, instinctual and limbic reactivity, conditioned responses, unhelpful habits of being, unconscious/autonomic responses, and sometimes aggressiveness. Ultimately, a mindfully practiced person is a better emotionally self-regulated person – perhaps even a happier person. Self-compassion and compassionate understanding for others is part of this change process.

Now let’s get into the meaning of the pyramid, educational, and clinical practices.

The secure foundation for such practices in education and psychotherapy requires that the provider of these services and skills practice mindfulness (meditation, yoga, etc.) on their own or under the supervision of a qualified teacher. This is essential for successful applications with others. This is formal practice. In this way the helper responds mindfully not reactively. Unconditional acceptance in the present moment of experience allows trust and open-heartedness to be part of the experience with others. The foundational skills of educators and helpers allow access to and expertise on the sides of the pyramid. The sides represent nurturing, educational, and therapeutic aspects of the relationship. Teaching and doing therapy are both included here. The “doing” by the educator or helper are in the practices on each side of the pyramid. The “being” is the actual practice, itself.
One side includes the formal mindfulness meditation practices. There are many such approaches and methods used in education and psychotherapy. The best match is one that brings the provider’s experience and expertise to the recipient’s level of willingness and experience in practice. Basic breathing skills, awareness skills, basic meditation, yoga, walking meditation awareness, etc. are all helpful practices.
Another side includes specific skills, capacities, attitudes and perspectives. Jon Kabat-Zinn called these “foundational attitudes” in Mindfulness-Based Stress Reduction, and Marsha Lineman proposed similar ways of being in Dialectical Behavior Therapy. Steven Hayes referred to these attributes as mainly willing acceptance. These practices can be applied in daily life to reduce stress reactivity. Skills include attention, mindful awareness, allowing, radical acceptance, emotional regulation, disidentification, discernment, and self-care. Capacities include distress and affect tolerance, equanimity, and cognitive flexibility. Attitudes include non-judging, non-striving, trust, and letting go. Perspectives include present moment awareness, impermanence, thoughts and emotions are not you and not always truths, suffering is part of life, and ways of being happier.
Another side includes an inquiry way of knowing. This understanding is by experience only. It is not the outcome of cognitive study and executive processes. That said, one does need executive intention and motivation to initiate and continue regular self-practice. Such special inquiry, investigation, and modes of knowing are based on subjective experiences in practice. This important experience includes sensory information, the mind, emotions, and moods. Insights eventually develop that allow clear seeing and ways of being (reduced suffering, more happiness, etc.).
Another side includes the development of a way of being that is highly related to practice experience. This implies changes in how we relate to personal experiences via practice. Radical acceptance, non-striving, non-judging
are all part of these changes. Reduced negativity and criticism are good changes.
The top of the pyramid is all about how the student, client or patient is internalizing and using the specific mindfulness skills taught and practiced in the relationship with the educator or therapist. In the final
analysis, this is the most important part of the pyramid and the process. If the student, client or patient is unable to practice mindfulness skills on their own regularly, the benefits of these interventions will not be optimal. Practice! Practice! Practice! It is of utmost importance.

For more information refer to Alper, S. A. (2016). Mindfulness and Meditation In psychotherapy: An Integrative Model for Clinicians. Oakland, CA: Context Press/New Harbinger, pp. 1-50.

Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont

Author of Mindful Happiness

New Edition of Mindful Happiness in Production…Coming soon!

January 20, 2017 By Admin

Trauma Therapy Basics from Experts

Trauma Therapy: Basics from Some Expert Clinicians

For many years trauma therapist have used many approaches in their psychotherapy. Most of these approaches lack strong empirical support for outcomes, and are often the “favorites” of these therapists. One might wonder what benefits therapists derive from using approaches that are not evidence-based. If an intervention fails to support timely positive changes in people suffering from trauma, WHY would a professional use it? It is common for therapists to use psychodynamic therapy, cognitive therapy, behavior therapy, and cognitive-behavioral therapy (including dialectical behavior therapy). While it is quite true that people suffering from serious trauma requires an exceptional therapeutic alliance (psychodynamic therapy), modifications in automatic negative thoughts (cognitive therapy), changes in unhelpful behaviors, like self-medication of pain (behavior therapy, and combinations like very well executed cognitive-behavioral therapy), commonly long-term healing outcomes have been somewhat disappointing. Perhaps an experienced and skilled therapist able to develop a high quality psychodynamic clinical alliance as well as highly effective cognitive-behavioral interventions may achieve admirable outcomes; however, that specific combination of skills is not common. I am suggesting that a high quality helping alliance and successful interventions in thinking and behavior problems may be helpful for people suffering from serious trauma. However, most of these approaches (other than informed and skilled DBT) miss the mark when it comes to integrated positive impact on the mind-body system. Even in DBT (and CBT), it is common for it to be used as a form of cognitive therapy – leaving the important behavioral and body-based areas out all together. To take a new look at the traumatized mind-body, witness current successes in trauma-informed yoga and meditation for PTSD. Recent meta-analytical reviews have noted that meditation (and yoga to a lesser degree) do improve depression, anxiety, physical pain (emotional pain?), and emotion regulation. Therefore, such body-based approaches improve three (depression, anxiety, self-medication) of the common clinical conditions associated with serious trauma.

Clinicians like Bessel van der Kolk remind us to pay attention to trauma-formed brain changes: the amygdala, the hippocampus, and the prefrontal area (especially medial PFC). These areas have been impacted, possibly sensitized, to trauma and its sequelae. Such changes may strongly impact the person’s future-orientation to life as less than hopeful, and cause sensitized body-based emoltionaland bodily reactions to conscious and unconscious (autonomic) traumatic cues. MRI research supports the trama-caused changes in both limbic and executive brain centers. It is believed that trauma causes changes in the neurocircuitry of the brain. Such important processes as interoception (mindfulness) and neuroception (polyvagal implications) play important roles in post-traumatic experience. The suggestion is that mindfulness, body-based interventions (meditation, yoga, body scanning, etc.) may be helpful in the experienced therapists’ hands. Recall, however, when it comes to using body-based and mindfulness-based interventions in trauma, the best therapists are also practitioners in these practices. Limbic and prefrontal interventions, NOT psychodynamic and cognitive interventions, may be highly helpful in effective trauma-informed psychotherapy.

Peter Levine reminds us that the body-based implantation of trauma may be used to slowly assist people suffering from trauma to be one with their memories without becoming powerless over them. Thus, specifically designed body movement with their associated emotional and memory components as well as verbal processing may be utilized to support recovery from even the most severe traumatic experiences. He does not forget the role the body plays in trauma and recovery from it.

Stephen Porges of Polyvagal Theory fame, notes that traumatic experience impacts the brain and the central nervous system. He notes a keen focus on the huge implications of the vagal nerve systems. It is possible to use neuroception, which functions as a risk detection system in people with trauma, to slowly help people adjust to the way their body responds to any form of traumatogenic cues – both internal and external. Utilizing adult attachment theory and process in therapy, as well as the possibility of feeling safe in social interactions, helps people with trauma move if slowly into recovery. Physical gestures, body reactions, voice quality, posture, and facial emotions – all part of post-trauma deficits – may be modified so as to assist people to enter recovery.

Pat Ogden, famous for her unique body-based and movement-based approaches, explains how habitual, conditioned body-based reactions may be modified as a new story of the body. These new experiences help to form a new better integrated story about trauma that guides the recovery process and reduces fear. She suggests that very specific forms of body movements may be most helpful here. Perhaps, the brain’s insula and thalamus have also been sensitized to reminders of traumatic experience, thus rendering their typical functions less adaptive.

Note that all of these leading trauma specialists have shifted to interventions with the body rather than typical “talk therapy” that is so often used. Yes, we do need to have important conversations with people suffering from trauma, but the real power for change comes from working with their bodily memories, reactions, and impulses along with limited verbal interactions. Inner peace, interpersonal safety, and slow readjustment to life are all part of recovery.

For more details and available clinical training refer to www.nicabm.com/holiday 2016… retrieved on December 28, 2016. See also Harrison, P. (August 13, 2014). Long-term course of PTSD revealed. www.medscape.com/viewarticle/829872…retrieved on August 14, 2014. Also refer to Buczynski, R. (October 23, 2014). PTSD, the hippocampus, and the amygdala – How trauma changes the brain. www.nicabm.com…/ptsd… Retrieved on October 24, 2014.

Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont

Author of Mindful Happiness

New Edition of Mindful Happiness in Production…Coming soon!

December 17, 2016 By Admin Leave a Comment

Supervision and Self-Care in Trauma Therapy

Today there is an ever-increasing demand for effective trauma therapy. Our American clinical history on this matter leaves much to be desired. John N. Briere and Cheryl B. Lanktree offer important suggestions on how to use clinical supervision and self-care in your clinical work with clients suffering from serious psychological trauma. Here in a nutshell is what they noted. For a more detailed review, please read the cited material on your own.

Supervision and self-care include the following:

Supervisors work on emotional reactions common in trauma therapy;
Guidance and working through unhelpful thoughts, feelings and behaviors;
Use of clinical documentation as a metaphor for structure and true liability protection;
Problematic boundary issues;
Obtaining social-emotional support from others, especially a clinical team;
Participating in personal psychotherapy as needed;
Using mindfulness skills (especially T. Brach’s 2013 RAIN process) in trauma work – both with clients and as self-care;
As a reminder RAIN includes Recognition, Acceptance, Investigation, and Non-Identification when dealing with highly stressful immediate experiences;
Maintaining a personal practice of effective self-care in your work and in your life outside of work.

In addition, they note specific and repeated clinical interactions that help clients but may also deplete emotional and energetic resilience in therapists. These include attention to:

Caretaker issues – supports, emotions, energy;
General environmental and relational safety;
Specific risks regarding dangerous behaviors;
Anxiety, depression, grief, anger and other emotionally dysregulating conditions;
Poor sell-concept, low self-esteem, and various self-identity problems;
Various acting out and acting in situations;
Suicidal and self-harm risks and behaviors;
Consequences of various attachment problems and deficits;
Social, school, and family adjustment conditions;
Various somatization complaints; and,
Psychosexual preoccupation, stress, and behaviors.

It is quite obvious that while working with these serious conditions and symptoms, trauma therapists would remain at considerably high risk for vicarious traumatization. Thus, the need to maintain regular effective clinical supervision and good self-care practices are of utmost importance to psychological survival of the therapist.

For more information refer to Lanktree, C. B. and Briere, J. N. (2017). Treating Complex Trauma in Children and Their Families: An Integrative Approach. Los Angeles,CA: SAGE Publications, pp. 220-246.

By Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont

Author of Mindful Happiness

New Edition of Mindful Happiness in Production…Coming soon!

November 7, 2016 By Admin Leave a Comment

Trauma Informed Care – The Avoidance Process

Trauma Informed Care – Avoidance Process

Although more and more clinicians are learning about and using principles/practices of Trauma Informed Care, too few understand the behavioral dynamics of negative reinforcement in the avoidance of trauma-related cues (people, places, things, internal sensations, emotions and images). This post will give a very brief description of negative reinforcement via habitual avoidance. Psychologist B. F. Skinner in his explanation of operant conditioning explained negative reinforcement as a behavioral response being strengthened by avoiding or removing a negative (in this case emotional) consequence or aversive stimulus. Behaviors are negatively reinforced when they enhance escape from aversive stimuli. Here the behavior of avoidance is reinforced; such conditioning leads to habitual avoidance of trauma-related cues and stimuli. This conditioned behavior is adaptive in that it reduces painful emotional suffering. In a sense, it is a form of emotional self-medication: short-term emotional relief by avoidance behavior but long-term suffering continues. The removal of a punishing experience is a highly reinforced, conditioned outcome. Therefore, a person suffering from psychological trauma learns that avoiding trauma-related stimuli leads to less suffering. Thus avoiding traumatic stimuli reduces emotional suffering activated by those same stimuli. Avoidance is learned as an adaptive coping response to traumatic fear of suffering on-going traumatic symptoms and reactions. In behavioral chain analysis, the person suffering from trauma learns avoidance improves their emotion state because it reduces consequential emotional suffering. The positive consequence is often immediate, making the reinforced conditioning stronger; habit formation occurs quickly. The behavior becomes stronger over time. As avoidance becomes habitual, the person cannot benefit from successive approximations – the slow, safe. steady approach behaviors related to facing and being with traumatic cues and stimuli. Longer-term, slow and safe exposure to these traumatic cues and stimuli improves emotional coping as it reduces negative physiological and emotional reactivity. The consequence of learning the avoidance cycle implies little progress will occur in recovering from powerful traumatic experience/s.

In the current scientific treatment of trauma, slowly weakening the habit of the learned avoidance cycle helps the person to approach and cope with traumatic cues and stimuli with less emotional reactivity and fear. Therapeutically supported cognitive restructuring, slow and safe behavioral exposure to cues and stimuli, and the application of mind body coping skills (use of the therapeutic alliance, supportive self-talk, cognitive and behavioral rehearsal, breathing retraining, mindfulness, meditation/yoga, etc.) will eventually improve coping, emotion regulation, and recovery process. People suffering from trauma can get well, but only if their therapists and medical providers understand how to treat psychological trauma. It is not just prescribing another medication. Co-occurring conditions (depression, other forms of anxiety, substance abuse) often mean that the treatment of trauma is NOT unidimensional in nature.

For more information refer to Skinner, B. F. (1953). Science of Human Behavior. New York: Macmillan. See also Kanazawa, S. (2010). Common misconceptions about science: Negative Reinforcement. Psychology Today. Retrieved 9-20-16.

By Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont

Author of Mindful Happiness