Evidence-Based Psychotherapy for Traumatized Children and Adults

Julian D. Ford University of Connecticut Department of Psychiatry Aurora Psychiatric Hospital, June 2012

Continuing Medical Education Commercial Disclosure

I, Julian D. Ford, am co-owner of Advanced Trauma Solutions, Inc., Sole Licensee for the TARGET© Treatment/Training Model I certify that the presentation will be free of commercial bias and will not promote any psychotherapy or pharmacological treatment

A Timeless Meta-Model … The 3Phase Psychotherapy Paradigm 1. Stabilization, Safety, Engagement 2. Transforming Symptoms Through Self-Reflection (Mentalization) 3. Application, Generalization, Closure Sources Pierre Janet (1923/1925) Van der Hart, Brown, & van der Kolk (1989) Judith Lewis Herman (1992) Allen, Fonagy, & Bateman (2008)

A Timeless Meta-Model … The 3Phase Psychotherapy Paradigm: Fear as the Focus Across Phases 1. Fear of External Threat - I’m not safe 2. Fear of Internal State - I’m falling apart/out of control/going crazy/helpless 3. Fear of Social Rejection/Incompetence I don’t know what to do/think - I can’t handle it - I’m damaged/unacceptable

Evolution of Psychotherapy Paradigms: Version 1.0 The Asylum Paradigm (Quarantine/Cure-Oriented) (e.g., Hospitalization, Retreat, Moral Treatment) Phase 1: Providing Sheltered/Stimulating Environment Phase 2: Increasing Prosocial Interactions/Activities Phase 3: Returning Patient to Society as a Sane Member of the Community (e.g., Clifford Beers)

Evolution of Psychotherapy Paradigms: Version 2.0 The Abreaction Paradigm (Insight-Oriented) (e.g., Psychoanalytic, Jungian, Object Relations) Phase 1: Provide Procedural Structure/Boundaries and Minimize Intrusion of External Sources of Anxiety Phase 2: Encourage Affect-Laden Expression Phase 3: Teach Patient to Bind Anxiety/Contain Affect by Internalizing Interpretations

Evolution of Psychotherapy Paradigms: Version 3.0 The Actualization Paradigm (Awareness-Oriented) (e.g., Rogerian, Self-Psychology, Gestalt, Existential) Phase 1: Provide Validation & Collaborative Alliance Phase 2: Encourage Experiencing Authentic Emotions Phase 3: Use Self-Understanding to Engage in Relationships/Life Pursuits with Authenticity

Evolution of Psychotherapy A Post-Industrial Paradigm: Version 4.0 The Algorithm Paradigm (Technique-Oriented) (e.g., Anxiety Management Training, Applied Behavior Analysis, Cognitive Behavior Therapy, Dialectical Behavior Therapy, EMDR; Interpersonal Psychotherapy, Motivational Enhancement Therapy, Prolonged Exposure, Seeking Safety)

Phase 1: Psychoeducation and Skills Training Phase 2: Confronting Fear, Craving, and Rumination Phase 3: Autonomous Application of Skills In Vivo

Evidence-informed Traumatic Stress Psychotherapies Traumatized Pre-Schoolers Lieberman’s Child-Parent Psychotherapy Eyeberg and Urquiza’s Parent-Child Interaction Therapy (PCIT)

Victimized Children and Adolescents Cohen, Deblinger & Mannarino’s Trauma-Focused Cognitive Behavior Therapy (TF-CBT) for sexual abuse and loss Stein & Jaycox’s Cognitive Behavioral Intervention for Trauma in the Schools (CBITS) Resick’s Cognitive Processing Therapy (CPT) Shapiro’s Eye Movement Desensitization/Reprocessing (EMDR) Foa’s Prolonged Exposure Therapy (PE)

Evidence-informed Traumatic Stress Psychotherapies Traumatized Adults Resick’s Cognitive Processing Therapy (CPT) Shapiro’s Eye Movement Desensitization/Reprocessing (EMDR) Foa’s Prolonged Exposure Therapy (PE) Cloitre’s Skill Training in Affect and Interpersonal Regulation with Modified Prolonged Exposure (STAIR-MPE) Hensel-Dittmann’s Narrative Exposure Therapy (NET) Smucker’s Imagery Replacement Therapy (IRT) Gerson and Schnyder’s Brief Eclectic Psychotherapy (BEP) Najavits’s Seeking Safety (SS) Ford’s Trauma Affect Regulation: Guide for Education and Therapy (TARGET)

The Next Wave in Psychotherapy’s Evolution: Transformative Models  

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Advanced Experiential Dynamic Psychotherapy Acceptance and Commitment Therapy Attachment – Regulation – Competence CPP Emotion Focused Therapy Integrated Therapy for Complex Trauma Internal Family Systems Therapy Real Life Heroes Seeking Safety Sensorimotor Psychotherapy Structured Psychotherapy for Adol. Responding to Chronic Stress STAIR TARGET Trauma Recovery and Empowerment Model

The Next Wave in the Evolution of Psychotherapy: A Transformative Paradigm (Version 5.0) The Allotropic Paradigm: Mentally Accessing Psychobiological Capacities to Transform Symptoms into Adaptive Functioning Phase 1: Modeling Reflective Self-Regulation Phase 2: Co-Regulating Extreme Affect States Phase 3: Reflective Mentalizing in Daily Life

Implications of the Transformative Paradigm for the Psychotherapy of Complex Traumatic Stress Disorders Phase 1 First Line Interventions from the Practice Guidelines Survey (Psychoeducation; Emotion Regulation) must teach how each symptom can be understood as biological and psychological survival adaptation of a still intact capacity that can be redirected to achieve self-regulation (not abandoned/unlearned or “fixed”)

Implications of the Transformative Paradigm for the Psychotherapy of Complex Traumatic Stress Disorders Phase 2 Narration of trauma-related experiences must include co-regulation of extreme affect: (A) Verbally articulated nonverbal modeling of selfregulation to provide a scaffold for the incremental experiencing of self-regulation (B) Addressing current episodes of intrusive reexperiencing/dissociation as well as past events

Implications of the Transformative Paradigm for the Psychotherapy of Complex Traumatic Stress Disorders Phase 3 Mindfulness-enhancing interventions must be a first line intervention in order to enable clients to not just cope with distress/dissociation but to incorporate reflective mentalizing in their daily lives as a relapse prevention prophylactic -including awareness of symptomatic reactions & confidence in knowing how to handle them