Sunday, June 28, 2009

Trauma Conference Part Two

On the second day of the conference, the general speakers were:
Glenn Saxe speaking on Complexity Theory
Dan Hughes speaking about the use of the body in therapy
Bessel van der Kolk on Developmental Trauma Disorder

Glenn Saxe is one of my favorite theorists and writers. His book, Saxe, Glenn; Ellis, B. Heidi; and Kaplow, Julie B. Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems Therapy Approach (2006, The Guilford Pres)s does the best job of any I have read to conceptualize a model for working both with the child themselves and with the system around the child.

At this presentation Dr. Saxe was talking about his latest fascination, complexity theory, which is the science that investigates how schools of fish or flocks of birds maintain their complex, moving patterns with out a leader or a plan. Dr. Saxe is using this theory to look at the complex patter of a traumatized child in his or her social systems, and stated that the theories will help us understand which changes will be most powerful, and where we could intervene to gain the most effect.

Daniel Hughes has long been an inspiration of mine, and was part of our beginning down the journey towards trauma informed care. His book: Hughes, Daniel. (1998). Building the bonds of attachment: Awakening love in deeply troubled children. Jason Aronson served as our guide book as we invented this new model. More recently, I have appreciated his newest books: Attachment Focused Family Therapy, (W.W. Norton & Co.; 1 edition May, 2007) and Attachment-Focused Parenting: Effective Strategies to Care for Children (Norton Professional Books, March 2009). At the conference Dr. Hughes was emphasizing the role of non-verbal communication within therapy. In fact he wondered why we call it "non-verbal" communication- 80% of our communication is what he would term "body communication". Since trauma is held in the body, it is essential that the therapist deliberately use all body communication to facilitate and deepen the therapeutic process. This includes:
Matching vitality and affect of client
Congruent with verbal communication
Awareness of other’s nonverbal meaning
Clear, nonambiguous expressions
Flowing- gradual, regulated, changes
Gaze- direct, warm, open, interested, responsive
Voice- variable, responsive, relaxed, open, animated
thoughtful, alive, empathic.
Gestures- animated, expansive, dramatic, responsive
Posture- open, moving/leaning forward

Dr. Hughes showed some wonderful videos to illustrate his points. However, he was especially prod of the picture with which he began his slide show- a lovely picture of his daughter and her daughter in attuned communication.

Bessel van der Kolk then presented on his work on establishing a new diagnostic category for the upcoming DSM V- that of Developmental Trauma Disorder. Dr. van der Kolk started by relating the history of the trauma diagnosis- noting that there is a new phrase for the effect of war on soldiers in each war, and it reflects the weapon predominated in that war (such as "shell shock"). The PTSD diagnosis was created in the aftermath of the Vietnam war, in an attempt to get funding and medical care for the veterans, and has proved effective for adults who experience trauma in adulthood.
However, there has been recognition of the profound difference between adult onset PTSD and the clinical effects of interpersonal violence on children, as well as the need to develop effective treatments for these children. It has become evident that the current diagnostic classification system is inadequate for the tens of thousands of traumatized children receiving psychiatric care for trauma-related difficulties.
PTSD is a frequent consequence of single traumatic events. Research supports that PTSD, with minor modifications, also is an adequate diagnosis to capture the effects of single incident trauma in children who live in safe and predictable caregiving systems. Even as many children with complex trauma histories exhibit some symptoms of PTSD, research shows that the diagnosis of PTSD does not adequately capture the symptoms of children who are victims of interpersonal violence in the context of inadequate caregiving systems. In fact, multiple studies show that the majority meet criteria for multiple other DSM diagnoses.

Therefore, the goal of introducing the diagnosis of Developmental Trauma Disorder is to capture the reality of the clinical presentations of children and adolescents exposed to chronic interpersonal trauma and thereby guide clinicians to develop and utilize effective interventions and for researchers to study the neurobiology and transmission of chronic interpersonal violence. Whether or not they exhibit symptoms of PTSD, children who have developed in the context of ongoing danger, maltreatment, and inadequate caregiving systems are ill-served by the current diagnostic system, as it frequently leads to no diagnosis, multiple unrelated diagnoses, an emphasis on behavioral control without recognition of interpersonal trauma and lack of safety in the etiology of symptoms, and a lack of attention to ameliorating the developmental disruptions that underlie the symptoms. Most children exhibited posttraumatic sequelae not captured by PTSD: at least 50% had significant disturbances in affect regulation; attention & concentration; negative self-image; impulse control; aggression & risk taking. These findings are in line with the voluminous epidemiological, biological and psychological research on the impact of childhood interpersonal trauma of the past two decades that has studied its effects on tens of thousands of children. Because no other diagnostic options are currently available, these symptoms currently would need to be relegated to a variety of seemingly unrelated co-morbidities, such as bipolar disorder, ADHD, PTSD, conduct disorder, phobic anxiety, reactive attachment disorder and separation anxiety.

Suggesting that an alternative diagnosis was necessary to capture the spectrum of coherent symptoms of children exposed to interpersonal violence and disruptions in caregiving, van der Kolk (2005) proposed the creation of a Developmental Trauma Disorder diagnosis and described the broad domains of impairment and distress that characterize these children and adolescents.


A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including:
A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and
A. 2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse

B. Affective and Physiological Dysregulation. The child exhibits impaired normative developmental competencies related to arousal regulation, including at least two of the following:
B. 1. Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization
B. 2. Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds; disorganization during routine transitions)
B. 3. Diminished awareness/dissociation of sensations, emotions and bodily states
B. 4. Impaired capacity to describe emotions or bodily states

C. Attentional and Behavioral Dysregulation: The child exhibits impaired normative developmental competencies related to sustained attention, learning, or coping with stress, including at least three of the following:
C. 1. Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues
C. 2. Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking
C. 3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical movements, compulsive masturbation)
C. 4. Habitual (intentional or automatic) or reactive self-harm
C. 5. Inability to initiate or sustain goal-directed behavior

D. Self and Relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal identity and involvement in relationships, including at least three of the following:
D. 1. Intense preoccupation with safety of the caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with them after separation
D. 2. Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness
D. 3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships with adults or peers
D. 4. Reactive physical or verbal aggression toward peers, caregivers, or other adults
D. 5. Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance
D. 6. Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness to the distress of others

E. Posttraumatic Spectrum Symptoms. The child exhibits at least one symptom in at least two of the three PTSD symptom clusters B, C, & D.

F. Duration of disturbance (symptoms in DTD Criteria B, C, D, and E) at least 6 months.

G. Functional Impairment. The disturbance causes clinically significant distress or impairment in at two of the following areas of functioning:
· Scholastic: under-performance, non-attendance, disciplinary problems, drop-out, failure to complete degree/credential(s), conflict with school personnel, learning disabilities or intellectual impairment that cannot be accounted for by neurological or other factors.
· Familial: conflict, avoidance/passivity, running away, detachment and surrogate replacements, attempts to physically or emotionally hurt family members, non-fulfillment of responsibilities within the family.
· Peer Group: isolation, deviant affiliations, persistent physical or emotional conflict, avoidance/passivity, involvement in violence or unsafe acts, age-inappropriate affiliations or style of interaction.
· Legal: arrests/recidivism, detention, convictions, incarceration, violation of probation or other court orders, increasingly severe offenses, crimes against other persons, disregard or contempt for the law or for conventional moral standards.
· Health: physical illness or problems that cannot be fully accounted for physical injury or degeneration, involving the digestive, neurological (including conversion symptoms and analgesia), sexual, immune, cardiopulmonary, proprioceptive, or sensory systems, or severe headaches (including migraine) or chronic pain or fatigue.
· Vocational (for youth involved in, seeking or referred for employment, volunteer work or job training): disinterest in work/vocation, inability to get or keep jobs, persistent conflict with co-workers or supervisors, under-employment in relation to abilities, failure to achieve expectable advancements.

(Material adapted from:
Proposal To Include A Developmental Trauma Disorder Diagnosis For Children And Adolescents In Dsm-V, Bessel A. van der Kolk, MD, Robert S. Pynoos, MD, 2009)

At the conference Dr. van der Kolk discussed the complex political process that is involved in changing the DSM. The proposed new diagnosis would create sweeping changes, in that it postulates that early childhood trauma is actually at the root of other diagnosis, such as Borderline Personality Disorder. Many grants, insurance payments, and other funding streams are shaped by the DSM, and such a profound change might threaten many established programs. This change has at the time of the conference been rejected by the DSM committee. It will be fascinating to watch the process and the evolution of our understanding.

I highly recommend this trauma conference, which is held every year in Boston. It is the only conference of the many I attend which so effectively combines science, social issues, advocacy and clinical practice, and brings us the most current thinking in our field.

Tuesday, June 16, 2009

Steve Brown on Workshop at Trauma Conference

I attended a workshop entitled "Divided Mind, Divided Body: Interventions for Working with Dissociated Parts in Traumatized Individuals" by Kathy Steele, MN, CS and Pat Ogden, Ph.D. The workshop was about doing therapy with dissociative survivor clients integrating talk therapy and a body-oriented therapy called sensorimotor psychotherapy. While the workshop was about adult clients, there were a few themes relevant children. First, the workshop talked about an important factor worsening the impact of trauma, and often leading to dissociation, is the inability of the body to act -- being frozen during traumatic experiences. When unable to fight or flee, the body freezes -- but freeze mode is like having your foot full force on the gas and the brake at the same time. Therefore, in addition to emotional, cognitive manifestations of trauma, people have enduring somatic effects in their body from these childhood experiences -- patterns of how trauma shows itself and lives in the body. Part of the idea of sensorimotor psychotherapy (totally oversimplified) is that people are made aware of and asked to tune into their bodily sensations and take action with their body that was kind of action they would have wished to do at the time of the traumas.

Second, is the idea of every persons "window of tolerance." All of us have a "window of tolerance" of arousal or feelings we can tolerate or manage. Above this window of tolerance is is hyperarousal (often associated with body's danger response) and below the window is hypoarousal (numbness, deadness, etc). Traumatized children and adults have narrow windows of tolerance and quickly go out of the window, sometimes rollercoasting between hyper and hypoarousal. Our job is to help them and teach them to get back into the window. Much of the therapist job is to urge clients toward the "edge of the window" so they feel some affect, but not push them out of the window when they feel out-of-control. This is the true art of being a trauma therapist, walking this fine line. Body oriented therapies often talk about the "pendulation" of the the body's physiology. In normal development, infacts and children experience stress and are comforted by attachment figures -- the arousal up and comes down, up and down. Children learn to regulate their own stress over time. In unhealthy development, a child is stress and not soothed so the bodies smooth pendulation up and down never happens -- they get stuck in hyperarousal or hypoarousal mode -- and don't know how to return their body within window of tolerance. In our moment to moment attuned interactions with traumatized kids we are reteaching them and their bodies this pendulation.

Monday, June 15, 2009

20th Annual International Trauma Conference

20th Annual International Trauma Conference

June 4-6, 2009

Boston, Mass

I have just returned from the 20th Annual International Trauma Conference in Boston, Mass. This conference is put on by Bessel van der Kolk and the Trauma Center at Justice Resource Institute ( It is such an exciting and inspiring conference, because it blends science and clinical expertise is a way that is unique in my experience, as well as containing an advocacy, social and moral component.

I attended a day long pre-conference work shop entitled: Reorganizing the Disorganized Brain, with Ruth Lanius, MD, PhD, Eric Vermetten, MD, PhD., John Gruzelier, MD. , Rachel Yehuda, PhD., James Hopper, PhD., Laurence M. Hirshberg, PhD., Alexander McFarlane, MB BS, (Hons), MD, and Bessel A. van der Kolk, MD. This workshop examined how trauma affects brain regions that support intense emotions while decreasing (a) activation in the CNS regions involved in the integration of sensory input with motor output, (b) the inhibition of emotional expression, (c) the organization of self-experience, and (d) the translation of experience into communicable language.

The first speaker was Ruth Lanius. She uses fMRI to study the brains of trauma victims and discover the effects on various parts of the brain. In this presentation Dr. Lanius was focusing on the default state of the brain, which is how the brain looks when we are not doing anything in particular. She has discovered that the parts of the brain that are related to self reflection, creating a self narrative, and self awareness are almost non-functional in the default states of trauma survivors, while being very active in those of the control groups. Therefore, biologically trauma survivors are less able to be self aware and notice and name their emotions. They develop a post traumatic alexithymia. Alexithymia is a psychological construct that refers to difficulties identifying and labeling emotional states. Alexithymic individuals with PTSD may experience intense emotional-physiological states (e.g., fear, anger, and dysphoria) that are poorly integrated with, and modulated by, higher-order verbal cognitive processing. Therefore these individuals may report that they either do not know what they feel, or cannot feel anything at all.

This ability to self reflect, this part of the brain, is developed through attuned relationships with loving care givers. What cannot be communicated to another cannot be communicated to the self. In order to develop self reflection and self awareness, some one must reflect on the child and be aware of them- tell them their story. This is what our children either have not had or have had in fragments.

Eric Vermetten, MD, PhD is a military doctor from the Netherlands. He works primarily with veterans who return from deployments in Iraq and Afghanistan. He reported on the good results his team is finding from neurofeedback.

James Hopper, PhD is a delightful presenter. He spoke of the Buddhist concept of the mind, and how that integrates with what modern biological science is discovering. He described how trauma gets in the way of being able to experience (and enjoy) the present moment. This of course interferes with the experience of pleasure and the richness of life, but also with the development of a narrative and self awareness.

The rest of the day was given to explaining what neurofeedback is, and the amazing results that are happening in 20-30 half hour sessions. I would love to add neurofeedback to our treatment- is any one doing it? I know that Kevin Creeden does it at his place.

The actual conference began on Friday. The first speaker was Rachel Yehuda, PhD who spoke on Mothers, DNA and the Transmission of Trauma. She is my new heroine. She is a bio chemist, very smart and rigorous in her work. And she is funny, irreverent, caring and always questioning. She started by saying she has more questions than answers- but a later speaker said she was lying. Her specialty is the blood chemistry and genetics, and the effects of trauma.

Rachel taught us a lot about the complexity of blood chemistry. One point she made is that cortisol is the substance in the blood which is responsible for stopping the human danger response. People who suffer from trauma have low cortisol, so PTSD can be thought of as a failure to effectively end the danger response.

But the main point Dr. Yehunda was communicating was that the chemicals that are in our bodies can actually interact with our genes and change them, through a mechanism she explained. So in this way trauma can be transmitted through the generations.

The next speaker was Alexander McFarlane, MB, BS (Hons) MD, who spoke on Integrating Past and Present: PTSD as an Information Processing Disorder. Dr. McFarlane, who is from Australia, discussed the fact that although we often realize the presence of flashbacks and dissociation in traumatized individuals, in fact the damage to thought processing is much more profound. Through careful fMRI studies Dr.McFarlane showed a large difference in the amount of processing going on in the brains of trauma survivors. In short, it’s not just that these kids are having flashbacks and dissociating, even doing their math is much harder for them.

Harry Spence, JD was the Commissioner of the Child Welfare agency in Massachusetts, and is no longer. He said he could speak more eloquently about the system now that he was not in charge of it. One important point he made was that the system was strongly influenced by the high profile case- the child death that makes headlines in the paper. In such situations there is tremendous pressure to scapegoat a social worker. At times this has been done, and the social workers are very aware of this possibility. So, Dr. Spence made the comparison between the experience of the workers and the families they serve- both are demoralized, under-resourced, distrust authority, and are overwhelmed. Another excellent point was that trauma work demands work in teams- and child welfare workers do not have any access to a team. Furthermore, the system almost prohibits workers from examining their own reactions to the work- silence is demanded from the workers. There is no culture of self examination. Young people are making life altering decisions about children and families with little team support, little self awareness, and emotional distress.

Dr. Spence spoke of the moral endeavors that all our organizations are engaged in. He said that workers join organizations- child welfare, the military, education- with the goal of doing good. All too often, however, they feel betrayed by their leaders. The compromises that are made erode the purity of purpose. When the workers are blamed or treated badly they become less connected to their moral purpose. Their moral universe shrinks- not it is just their unit, or their best friend and themselves that are doing good. They adopt a "who cares, it’s not my job" attitude towards the larger organization.

Dr. Spence called on all leaders and administrators of organizations to keep and enhance the moral commitment of their workers, by highlighting the moral victories of the organization, the ways in which the organization does good and changes the world.

In the afternoon I attended a workshop by Jane Koomar, PhD, OTR/L, FAOTA; Elizabeth Warner, PsyD; and Anne Westcott, LICSW. They were describing a program in which they integrated sensory intervention techniques into the therapy room. They used large balls, weighted blankets, rhythmic activities, and other sensory techniques to help the child regulate their body. Both in individual and family therapy this resulted in the child being much more open and available for both connection and discussion. Their video tapes were moving. This is something we could all do in our treatment centers without too much difficulty.

I will write about the second day next time, plus Steve Brown has written up the workshop he went to on Dissociation, which I will also post here.

As usual, all comments welcome. Did any one else attend the conference? Add your impressions by clicking on the word "comment" below.