RELATED TO THE CASE STUDY BELOX ANSWER THE QUESTIONS 1 THROUGH 9 IN 2 PAGES
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DUE DATE DECEMBER 13, 2023
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Ms. H, an attractive, petite, 42-year-old full-time housewife came to psychotherapy initially for severe bulimia, vomiting as many as 40 times each day for the past year. She had previously been diagnosed with PTSD, anorexia nervosa, DDNOS, dependent personality disorder, panic anxiety, major depressive disorder, and polysubstance dependence. In the past, Ms. H self-medicated with alcohol, Vicodin, Xanax, and OxyContin. The Vicodin and OxyContin were taken to relieve her long-standing severe back pain. She was hospitalized twice for polysubstance abuse, and medications taken after hospitalization included Paxil (60 mg each day) and Depakote (250 mg twice daily). Ms. H was physically and emotionally abused as a child by a sadistic father and a neglectful, narcissistic mother. At intake, in addition to the bulimia, she reported depressive symptoms, trouble concentrating, anxiety, and periods of depersonalization and feeling dizzy and confused. She forgot periods of time; for example, she found herself in the grocery store and could not remember how she got there. This occurred particularly when she was stressed and anxious. She denied self-harm and suicide ideation. She had been married for 22 years and reported long-standing marital difficulties.
The history of childhood trauma and her tumultuous psychiatric history indicated that a long period of stabilization most likely would be needed. The APPN explained to Ms. H about her RZ and how it would be helpful to learn some strategies so she could stay regulated and in her RZ. The APPN worked with Ms. H once a week initially and, after several months, began twice-weekly psychotherapy, which continued over the next 5 years. Within 6 months of beginning treatment, her bulimia subsided. Much of the content of beginning sessions focused on building in resources and later on the abuse she suffered from her husband, which was ongoing and included emotional, sexual, and physical abuse. Ms. H initially appeared frightened and confused, especially when asked about her feelings. The therapist supported and validated Ms. H and told her that she was being abused as she vacillated between thinking that she deserved such punishment to feeling anger at her husband. She had idealized her husband, and as she began to see him more realistically, she also began to see herself in a different light, and her self-esteem increased. She began to assert herself more, and her marital relationship further deteriorated because her abusive husband was enraged that he was losing control of her. Plans for her safety were made, and 2 years after starting therapy, she filed for divorce and moved out of their house. This represented a significant turning point because stabilization was not possible previously as long as she was not safe. Her medication was changed to 20 mg of Prozac, and she found a full-time job shortly after the divorce. Over the course of treatment, various stabilization strategies were gradually integrated, which helped to widen her RZ so she could stay regulated. These included safe/calm place, container, circle of strength, rating negative feelings, basic self-care, yoga, progressive muscle relaxation, journaling, grounding, cognitive restructuring, walking, and deep breathing, in addition to other soothing activities. All were new to Ms. H; she had never practiced any of these before therapy.
Through mindfulness, Ms. H learned to manage her dissociative symptoms, and these periods decreased dramatically as she was able to stay in the present, understand the triggers, and talk about some of her traumatic experiences. Her back pain all but disappeared as she became aware that the triggers for these episodes were linked to feelings of anger. Her identification of her feelings in the present, the ability to experience these feelings, and understanding the meaning of her symptoms were crucial to her development of affect-regulation skills. Along with the deepening of her identity apart from her husband, her sense of humor and keen intelligence emerged. Some of her early childhood trauma was processed with EMDR therapy, but much of the work in psychotherapy focused on increasing resources, psychoeducation, and support, with the therapist bearing witness to her struggle and courage. Her healing reflected the return and expansion of her full consciousness through the integration of adaptive memory networks with dissociated neural networks. This was accomplished by creating positive experiences through the therapeutic relationship, learning and practicing specific resources, and weaving a narrative that connected her old and new memory experiences into a coherent tapestry reflecting a stronger, more resilient sense of self.
POST-MASTER’S TRAUMA TRAINING AND CERTIFICATION REQUIREMENTS
The APPN who wishes to attain competency treating traumatized patients should pursue additional training and ongoing supervision. Working with dissociative patients requires a high level of clinical expertise to do so successfully. The International Society for the Study of Dissociation (ISSD) offers post-master’s training in the treatment of DDs but not certification. The program consists of nine monthly or biweekly sessions of 2.5 hours, which are held in many major cities listed on the website (www.issd.org). The sessions are designed to focus on readings and clinical situations. A distance-learning module is also available, along with advanced coursework.
In addition, integrative trauma psychotherapy programs are offered in large cities in the United States. An Integrative Trauma Psychotherapy Certificate Program is offered at Fairfield University and includes Basic Training in EMDR and the Trauma Resilience Model (TRM), a somatic therapy described in Chapter 11. See fairfield.edu/resiliencetraining.
CONCLUDING COMMENTS
Stabilization and safety are always the first order of business for any psychotherapy. This ensures that the processing needed to integrate the dissociated memory networks will not destabilize the patient. Enhancing resources ensures that positive adaptive memory networks exist for the eventual linking of dysfunctional material so that integration can occur. Strategies for stabilization are basic tools that all APPNs need to know to work with patients who present for psychotherapy. These skills build on the stress management techniques that registered nurses are familiar with. This foundation is deepened by understanding how and when to tailor specific stabilization strategies. Competency in stage 1 (stabilization) reflects the beginning-level skills needed for APPN practice.
There is a wide spectrum of trauma responses, and stabilization is needed before processing trauma. The limiting diagnosis of PTSD does not capture the complexity of traumatic experiences and their sequelae. Neurophysiological research demonstrates the importance of even subtle negative life events on the developing brain when a state of helplessness occurs (see Chapter 2). The physiological changes that occur and the perpetuation of those changes over time are determined by the meaning of life events in relation to past trauma (Shapiro, 2018). The learned associated responses embedded in memory networks are modified in the safety of the therapeutic relationship. Managing arousal and altering procedural memories begin the work of healing trauma.
The patients of severe childhood trauma are chronically disenfranchised and re-create betrayal and abandonment scenarios wherever they go, especially in the psychotherapeutic relationship as early attachment schemas are reactivated. Most complex child-onset trauma requires painstaking work as resources are increased and a narrative is woven about the nuances of the meaning of the events as the trauma is processed. Individuals who are survivors of childhood abuse present treatment challenges and the complexity and severity of symptoms can seem insurmountable to even the most experienced psychotherapist. However, healing occurs in this relationship with patience, caring, and skill. Novice APPN psychotherapists who continue to train and obtain supervision to develop skill in trauma treatment will be richly rewarded in their work. The APPN’s presence bears witness with empathic resonance, creating the atmosphere needed for the most vulnerable of patients to be whole again. Those of us who work with this population marvel at the remarkable capacity for endurance, compassion, depth of character, and resilience of the human spirit. The honor of assisting in the growth of another person changes the patient and the therapist. In the healing journey with another, we heal ourselves.
DISCUSSION QUESTIONS
1.
Discuss the spectrum of trauma-related diagnoses with respect to specific symptoms that overlap. Pick one trauma-related DSM diagnosis and identify what might be some, and differential diagnoses.
2.
Identify goals of treatment for trauma.
3.
What happens physiologically during dissociation, and what would you observe in the patient who dissociated during a session?
4.
Fill out the DES, which is included in Chapter 3 on yourself and score it. Keep track with a log of all the times you notice yourself dissociating over the course of the next week.
5.
How would you know whether a person was stabilized and ready to go on to processing?
6.
Discuss why a person who has been traumatized as a child most likely has pervasive feelings of guilt.
7.
Develop a comprehensive plan of all the potential issues and strategies that you need to teach a patient who has flashbacks.
8.
Explain why mindfulness underlies all stabilization, why you should develop this skill, and how you plan to do so.
9.
Practice the progressive muscle relaxation exercise and the safe/calm place exercise in Appendices 13.2 and 1.7 with a friend or family member. Ask for feedback so that you can improve.