Program

Complex trauma and personality disorder: The treatment of posttraumatic stress, attachment disturbance, and complex relational disturbance

Initially conceptualized as a relatively straightforward response to a single traumatic stressor, psychological trauma is now understood to vary dramatically in complexity according to a wide variety of variables. When trauma exposure involves early, repetitive, interpersonal maltreatment, followed by additional traumas in adulthood, the outcome may involve not only posttraumatic stress, but also dysfunctional attachment styles, affect dysregulation, overdeveloped avoidance responses (including dissociation and substance abuse), easily activated preverbal schema, conditioned cognitive-emotional responses, and a variety of other affective and behavioral outcomes often considered to be "Axis II" issues. Drawing on the latest trauma research and theory, Dr. Briere will present a nonpathologizing, developmentally-informed therapy for these complex posttraumatic presentations, especially focusing on treating "borderline personality disorder."

Outline

I.   Recent paradigm shifts in trauma field

a.       Classic Criterion A versus cumulative trauma

                                                               i.      War versus interpersonal events

b.      Intervention

                                                               i.      Short-term versus longer-term

1.      Problems with using treatment outcome studies for guidance

a.       Inclusion, exclusion, and drop-outs

                                                             ii.      Cognitive-behavioral versus relational/psychodynamic

                                                            iii.      How to incorporate the best of both worlds 

II. Complex trauma: What is it?

a.       Onset (usually involves or includes childhood trauma)

                                                               i.      Attachment disruption usual

                                                             ii.      Implicit memories more significant

b.      Duration (prolonged, usually extends to adulthood)

c.       Frequency (multiple exposures)

d.      Relational (usually interpersonal)

e.       Complexity

                                                               i.      Multiple victimization modalities

                                                             ii.      Interacting effects

f.        Social transformation: from trauma to "personality disorder"

III.      Clinical presentation

a.       Affect dysregulation: A central problem

b.      Overdeveloped avoidance strategies

                                                               i.      Behavioral, cognitive, dissociative, tension reduction behaviors, substance abuse

c.       New thinking on dissociation

1.      Dimensionality

2.      Function

3.      Relation to trauma versus attachment

d.      Chronic intrusion and hyperarousal

e.       Nonverbal/implicit memories of trauma and neglect

f.        Insecure attachment-related relational schemata that are easily triggered by interpersonal contact -- "relational gestalts"

                                                               i.      Intrinsic, nonverbal schema

1.      Proximity/Abandonment, Trust, Safety, Self as bad

                                                             ii.      "Hooked" to emotional-cognitive memories

1.      Conditioned emotional responses associated with relational schema, triggered by similar later relational stimuli

a.       e.g., separation distress associated with abandonment

2.      Associated cognitions

a. e.g. "I am bad," "He/she
doesn't love me"

b. Current "impulsivity," "out of proportion" affect, etc. as triggered early schema and associated gestalts - Relational reliving

Intense negative response (often without verbal understanding)

2.  Proximity-seeking (when abandonment) or proximity-avoidance (when danger/distrust)

3.  Tension-reduction to address overwhelming affect

4.  Often rapid return to pre-trigger mood state, if trigger is not ongoing             

IV.       Borderline Personality: Traditional and modern views: An overview

a.       Deconstructing BPD: Etiology of core symptoms from a trauma perspective

b.      A bio-psychological theory of attachment and abandonment preoccupation

c.       Phenomenology of activated relational schemas

d.      Comparing BPD to PTSD

V.         The central steps of trauma-focused treatment

a.       Exposure, activation, disparity, extinction/counterconditioning, and resolution

b.      Need for avoidance in context of affect dysregulation and flooding

c.       Two dimensions of processing

                                                               i.      Posttraumatic stress

                                                             ii.      Relational "gestalts"

VI.       New ideas

a.       Altering the triggers - cognitive effects on posttraumatic activations

b.      How new narratives and increased insight may reduce activations

VII.      Working within the Therapeutic Window in the context of complex trauma

a.       The balance between therapeutic challenge and overwhelming internal experience

                                                               i.      Posttraumatic stress

1.      Titrated exposure to trauma memories

                                                             ii.      Relational gestalts

1.      Therapeutic relationship as activator and resolver of negative relational schema

2.      Titrated exposure to relational gestalts

3.      Activating and processing relational schema and other "deep structures" in the context of the therapeutic relationship

a.       The therapist's correct emotional/relational "distance"

                                                                                                                                       i.      Geared to be neither too close (triggering feelings of intrusion) nor too distant (triggering abandonment issues)

4.      Reconsidering "transference"

VIII.    Cognitive interventions

a.       Normalization and reframing "symptoms"

b.      Cognitive "reconsideration" of trauma-specific beliefs and assumptions

                                                               i.      Using exposure processes to prompt reevaluation of cognitions

c.       Development of a coherent narrative, and the effects of insight

d.      Altering triggers

IX.       Intervening in impaired self-reference

a.       Safety and support in therapeutic relationship

b.      Exploration of self

                                                               i.      Development of self-knowledge and self-directedness

c.       Didactic/Linehan-type interventions

d.      Repetitive exposure and processing as affect regulation training

X.         The meaning, danger, and redemption of positive attachment for the relational trauma survivor