Zorgzaam omgaan met traumatogene gebeurtenissen in psychotherapie

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1 Zorgzaam omgaan met traumatogene gebeurtenissen in psychotherapie Erik DE SOIR Psycholoog-Psychotherapeut DE WEG WIJZER Centrum voor Trauma & Meditatie

2 Opbouw van de workshop Ervaringsgerichte introductie - Casuïstiek 10 basisprincipes voor trauma therapie Actiepunten voor psychotrauma therapeuten Therapeutische objectieven Stadia van traumatherapie Aanbevelingen

3 10 basisprincipes voor trauma therapie 1. Veiligheid en geborgenheid zijn primordiaal Setting, omgeving (triggers), therapeut, therapieproces, methodes, veilige objecten, etc 2. Cliënt respectvol/onvoorwaardelijk aanvaarden 3. Herkennen van de rol van (tegen)overdracht en dreiging voor vicariërend trauma bij zorgverleners Hoe wordt het trauma herbeleefd in de therapie? Hoe beïnvloedt de trauma-materie de zorgverlener? 4. Werken met traumaherinneringen: containment Stabilisatie en reductie van trauma symptomen Quick trigger inventory -> controle van de omgeving

4 10 basisprincipes voor trauma therapie 5. Werken aan «somatoforme controle» stabilisatie somatische traumaherinneringen en «survival» in de directe levensomgeving vooraleer de traumagebonden feiten verder te exploreren (peritraumatische reacties) 6. Voorbereiden/anticiperen op extreme reacties gedurende therapieproces Exploring the possibilities for «quick brakes» on extreme trauma reactions Constant: angst, onzekerheid, schuld, schaamte Impact op zelfbeeld, zelfachting en beleving van zelf als een geheel

5 10 basisprincipes voor trauma therapie 7. Verschaffen van psycho-educatieve brochures of boeken met o.a. betrekking tot de impact en verwerking van psychologische trauma s Diepgaande «trauma-opleiding» om cliënt opnieuw controle te verschaffen (van brandklant tot trauma expert) Permanent werken rond vijf gebroken zekerheden: veiligheid, vertrouwen, controle, (self-)esteem & intimiteit (Rosenbloom & Williams) 8. Psychologische trauma s vernietigen de egogrenzen en sterkte Cliënten helpen (opnieuw) grenzen ontwikkelen (in de interpersoonlijke context) Cliënten verdedigingsstrategieën helpen ontwikkelen die ego-adaptief zijn, veilig en gericht op angst/kwetsbaarheid reductie

6 10 basisprincipes voor trauma therapie 9. Zelfs na aanzienlijke verbeteringen, moeten cliënten beseffen dat potentële «triggers» steeds net achter de hoek verscholen liggen Cliënten helpen leven met de nieuwe identiteit van «trauma» patiënt en met de ontwikkeling van een nieuwe levensstijl Trauma Therapy is like a roller coaster a trigger is always just around the corner 10. Aandachtig zijn voor comorbiditeit, andere gezondheidsproblemen en misdiagnosise Depressie, chronische vermoeidheid, spierziekten, migraines

7 Life After Trauma Dena Rosenbloom and Mary Beth Williams ISBN The Guilford Press 72 Spring Street New York, NY

8 THERAPY KEYWORDS TRAUMA METAPHORS RE-CO-NAISSANCE (SENSE) RE-CO-LLECTION (trauma completion) RE-COMPOSITION (the life puzzle) RE-CONSTITUTION (traumatic work) RE-CONSTRUCTION (basic beliefs) RE-COGNITION (& new cognitions) RE-AUTHOR & RE-STORY (a life)

9 Inleidende beschouwingen Traumatherapie: wat en hoe? Verschillende disciplines werken samen in een therapeutisch systeem in een eclectisch model Woorden zijn vaak onvoldoende: niet te snel op zoek gaan naar het «verhaal» «speechless terror» Cliënten moeten stapsgewijze opnieuw door hun ervaring worden geloodst re-creating & re-building their life story

10 Theoretische Modellen biological sequelae of having been exposed to traumatic events (Van der Kolk, 1984, 1994); behavioral conditioning framework (Keane, 1989a; Keane et. Al., 1985); psychodynamic perspective (Horowitz, 1986; Marmar, 1991; Weiss, 1993); informational & emotional processing (Creamer et. al., 1992; Foa & Kozak, 1986; Foa et. al., 1989; etc); schema-based model (Epstein, 1991 ; Janoff-Bulman, 1992 ; McCann & Pearlman); constructionist narrative perspective (Harvey et. al., 1990; 1991; 1992; Meichenbaum & Fitzpatrick, 1993; Meichenbaum & Fong, 1993).

11 Healing Stories Construct Therapist Assimilate and liquidate traumatic experience Janet Metabolised psychologically Wilson Fabricate a new meaning McCann & Pearlman Develop a healing theory Figley Re-author or re-story a life Epstein & White Restructure and conclude the trauma story Herman Engage in narrative repair Shafer Rebuild shattered assumptions Janoff-Bulman Co-construct a better and healthier life story Spence Orient into a new life narrative construct new selves Goncalves

12 «Stories» of people who actively «coped» with traumatic events (Meichenbaum, 1994) sharing one s trauma with others the nature of social comparison processes the nature and incidence of ruminations the amount and content of efforts at cognitively undoing traumatic events the absence of being able to find closure and the tendency to continue search for meaning the degree to which the individual sees oneself as blameworthy and lacking in personal control the nature of the metaphorical thinking one engages in...

13 Stages of Recovery DE SOIR, 1997, 1998 Different Stages of Restoring the Trauma Puzzle: Stage of Recoil and Physical Recovery; Stage of Early Exploration and Completion on Sensori-Motor, Cognitive and Emotional Levels; Stage of Narrative Working Through; Stage of Meaning and Sensegiving

14 Stages of Trauma Recovery Erik DE SOIR, 1999, 2000 Broken Vase Therapy Creative Arts Protocol re-co-naissance re-co-llect re-co-nstitute re-form re-frame

15 The Trauma Labyrinth The Odessey with a Guide Through the Deep Dark Valley of Evil La Descente en Enfer Exploration of the Black Hole of Deep Emotions

16 Trauma Therapy Stages I. STABILISATION, EDUCATION, CONTAINMENT Intake & Introduction: Rules, Setting, Mandate Establishment of a secure, safe and workable therapeutic relationship & alliance Assessment of the client s complaints & current trauma symptoms (diagnostic evaluation) Assessment of the expectations & goals prior-to the start up of therapy process Explanation of the therapy stages & methods

17 The Window of Tolerance Arousal Model High Arousal A R O U S A L Optimum Arousal Zone Arousal Capacity: window of tolerance Low Arousal

18 Stage 1 - Stabilisation, education, containment of symptomatology Work toward relief and understanding of trauma symptoms and somatic responses Supportive and safe environment (client/therapist relation) No obligation to verbalize or search for the story Comprehensive education on survival mechanisms and bodily reactions : a trigger is always just around the corner Working on stabilisation of reptilian brain responses Resourcing the body by education on sensorimotor processing and self-regulation Impulses, postural changes, orienting responses, physical defensive responses, and ANS arousal

19 The Use of Creative Arts in Psychotrauma Therapy Trauma Therapy Stages II. RENEGOTIATION, REORGANISATION & 3-LEVEL INTEGRATION Narrative Exploration/Confrontation Explore client s clinical picture CAVE: comorbidity or coexisting disorders CAVE: repeated victimisation/traumatisation Explore client s narrative capabities Help client retell his/her story (events) Identify blocking mechanisms between cognitive, emotional & sensori-motor levels «Somatoform Take Over»

20 Stage 2 - Renegociation, reorganization, integration Re-connecting client with lost basic orientation & defense responses in current life situations RED Alert : Resource-Empower-Deactivate Alert Building toward physical, psychic, emotional and spiritual resiliency Necessary to explore trauma-related facts Work through trauma-related facts without reliving the trauma or losing the grip Cf. Mastery techniques in first stage Re-structuring, re-framing, re-authoring RER : Respect Empower - Resource

21 Multimodal Approach Safegarding the link between various levels Emotions Metaphors Behaviour Information treatment Diseases Images Sensations Thoughts Kinesthesia Somatic symptoms

22 Multidisciplinarity Doctors, Nurses, a.o. Medical Staff Psychologists/Psychiatrists Osteopathy/Kinesiology/Rheumatology Family Members, Friends, Colleagues Trauma Buddies (Most Significant Others) The therapist must not be the only resource for the trauma client

23 The Use of Creative Arts in Psychotrauma Therapy Trauma Therapy Stages III. EXPANSION & INTEGRATION in LIFE Metaphoric & Artistic Elaboration Start Up Creative Arts Work Protocol Broken Vase Protocol (Narrative) Connection & Healing Sensegiving & Further Recovery Follow-Up Session Working with «trauma buddies» Termination Ritual

24 Stage 3. Expansion, integration, sensegiving Starting point: newly connected body/mind Éveil sensoriel (sensory awakening) Awareness and mindfullness Emotional stability, new life assumptions Expansion: re-investing energy in pleasant normal (positive) life experiences Sensegiving: re-connecting with spirituality Integration in personal life cycle & story

25 Q U E S T I O N S Erik.De.Soir@telenet.be