Masked Trauma

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					Masked Trauma: Definition
Masked Trauma are those traumatic events, histories, and symptoms which are covered over and not evident to providers, clients, and/or significant others.

Reasons to Address Masked Trauma
1. Masked trauma occur more frequently than realized in general and psychiatric populations. 2. Trauma-related conditions are often misdiagnosed. 3. Masked trauma may remain untreated, or conversely: 4. Patients may undergo extensive treatments without addressing the underlying trauma.

Conditions of Masked Trauma
When “masked,” the Trauma factor is: • Unknown to client and/or provider • Repressed, avoided, or otherwise defended • Lacking in full PTSD symptomatology • Complicated or confounded with other disorders

Workshop Overview
1. To review the nature of trauma and PTSD. 2. To explore the “anatomy of masked trauma.” 3. To discuss how group therapists can identify and assess masked trauma. 4. To examine how therapists can best manage and treat masked trauma: the “Seven Tasks”. 5. To consider group-as-a-whole dynamics, risk management, counter-transference, and supervision. 6. Closure: Question and answer period; Debriefing of feelings; Completion of evaluation forms; and Distribution of Continuing Education Certificates.

DSM-IV Definition of “Trauma”
 exposure … involving death, injury, or a threat to ones physical integrity or that of another person  or learning about unexpected or violent death, serious harm  or threat of death or injury experienced by a family member or other close associate  And: “The person’s response to the event must involve intense fear, helplessness, or horror”

Additional “Trigger” Aspects of “Trauma”
 Van der Kolk: the traumatic exposure is inescapable.  The stressor may be single, repeated, or cumulative.  The stressor may be experienced vicariously.  The stressor leads to extreme shame, boundary violations, or loss of identity and meaning (= symbolic death of self).

PTSD Symptom Clusters
1. Re-experiencing: • intrusive recollections • distressing dreams • flashbacks • psychological distress • physiological reactivity in response to reminders of the traumatic event 2. Avoidance: • efforts to avoid thoughts or feelings related to the trauma • efforts to avoid activities or situations that arouse recollections of the trauma • amnesia for important aspects of the trauma • feelings of detachment from others • restricted range of affect • diminished interest in significant activities • sense of a foreshortened future 3. Hyperarousal: • sleep difficulties • irritability • difficulty concentrating • hypervigilance • exaggerated startle response

Cognitive-Behavioral Therapies (CBT)
•Prolonged Exposure (PE) Therapy •Stress Inoculation Training (SIT). •Cognitive Processing Therapy (CPT) •Eye Movement Desensitization and Reprocessing (EMDR)

Short-term Dynamic Psychotherapy (STDP)
•Support and strengthen healthy defenses •Restore ego functioning. •Focus on trauma-related issues. •Acknowledge trauma-related realities •Incorporate object relations, self psychological, and ego psychological principles. •Psychodynamic Tx includes “prolonged exposure” and “cognitive therapy” elements. •Work through guilt (e.g. “survivor guilt”), shame, and grief.

Short-Term Group Psychotherapy
Characteristics include: •Time limited •Ego supportive •Homogeneous group population •Highly structured to limit regression and contagion •Emphasizes the narrative of the trauma • Applicable to diverse treatment models

Masked Trauma occur when:
• PTSD is present but undisclosed • PTSD is present but misdiagnosed • Co-morbid conditions cover over traumatic responses • Complex PTSD occurs and is not recognized as trauma-based

Comorbid and Complicating Disorders to Trauma
• • • • • • • Bipolar disorder Panic attacks Substance abuse Depression Hallucinations and delusions Dissociative Disorders Psychosomatic disorders

Herman’s “Complex PTSD”
• Similar diagnostic entities proposed by others • Not yet in the DSM • Identifies long-term, pervasive consequences of severe and prolonged perpetrated trauma • “Totalitarian control” an interpersonal factor • Often masked and given other diagnoses

Herman’s “Complex PTSD” Symptom Clusters
Alterations in personality, including:

• • • • • •

Affect regulation Consciousness Self-perception Perception of the perpetrator Relations with others Systems of meaning

Additional Potential for Masked Trauma
 Inappropriate lack of emotional response to trauma  Anniversary reactions  Attachment disturbances and relationship difficulties.  Traumatic loss and  complicated bereavement.

Masked Trauma Detection and Assessment
 Developmental and family history  Specific inquiry about physical, emotional, and/or sexual abuse  Ask about periods of amnesia, or significant gaps in memories  PTSD symptom checklist

Masked Trauma Observations
Observe and Note:  Dissociation and trancelike states  Labile emotionality  Countertransference feelings

General Screening Criteria for Group Therapy:
2. 3. Matching Patient and Group Availability of community and treatment supports Current ego strength and resilience The group’s experience and capacity to identify with the patient, his/her trauma, and treatment needs Patient safety and risk factors Confidentiality issues

4. 5.

Observing Behavior in the Group
for Signs of Masked Trauma

•Seductive behaviors and overly erotized fantasies •Labile emotions versus numbing •Excessive attempts to control others’ behavior •Boundary violations •Difficulty forming affiliative bonds

Indications of Difficulty Bonding
(Further signs of Masked Trauma)

 Severe mistrust  Emotional withdrawal  Becoming depressed, anxious, or avoidant when experiencing intimacy and closeness  Scapegoat role  Extreme clinging and overdependence o the therapist

Holistic-Organismic Approach
(Wilson, Freeman, and Lindy)

 Trauma and “Allostasis”  Whole self emphasis: biological, psychological, social, spiritual  Multiple levels of treatment: symptomatic relief, personality change, social readjustment, etc.  Multi-modal treatment: Individual, family, and group therapy; medication management; community supports

“The Seven Tasks”
of Treating Masked Trauma in Groups

I. Unmasking the Trauma II. Developing the Group III. Healing the Wounded Self IV. Managing Trauma Responses in Group V. Managing the Group-as-a-Whole VI. Risk Management VII. Therapist Self-Management

“Discovery and Un-covery”
of Masked Trauma in Groups

A group member may experience especially intense emotions or difficult interactions. • Exploring the sources of these feelings and conflicts may lead to memories of trauma. • In an atmosphere of empathy and support, these experiences may be further elaborated in detail. • The therapist should inquire whether the other members of the group “resonate” with these experiences, so that the individual becomes a “voice

Facilitating and Restoring Trust
in the face of trauma  The leader role models “merited trust” through: >consistently ethical behaviors >maintaining group boundaries >staying in role.  The leader contains and interprets the intense traumatic affects and reenactments that occur.  The group establishes norms and rules that promote the safety and dignity of each member.  The leader facilitates empathic

The Group as a Holding Environment
• “Holding” (Winnicott) = mother as safe, secure context for “going on being” • “Mother group” (Scheidlinger) provides such a context • Homogeneous groups require: Protective rules and structure Strong mutual identifications • Heterogeneous groups require: merited idealization of the therapist a history of working through difficult issues and emotions

Group Steps to Healing
 Witnessing the trauma  Re-integrating dissociated parts of the self  Reworking interpersonal relations  Resolving grief and loss  Re-writing the “relational biography” and narrative

The Group-as-aWhole
• • • and Trauma Splitting and Projective Identification Contagion Basic Assumptions (Bion) Dependency Fight/Flight Pairing The Fourth Basic Assumption (Hopper):
Incohesion: Aggregation/Massification


Risk Factors
Associated with Masked Trauma
• • • • Suicide Homicide Abuse Lowered Levels of Functioning • Substance Abuse

Approaches to Understanding


Psychodynamic:  CT as an unconscious reaction that interferes with treatment  The therapist must resolve the CT so as to reduce its impact  Intersubjective-relational:  CT as inevitable and a potentially useful tool in treatment  CT is an ongoing part of the therapist/patient relationship  The therapist strives to understand the mutual relationship  The therapist may sometimes self-disclose CT feelings

Confidentiality Issues
• • • Group members not legally bound to confidentiality In some cases, group therapists may yield legally binding confidentiality Some patient disclosures are best made in individual sessions Traumatic material can often be worked through without disclosing potentially damaging details Confidentiality is best preserved in the group through a strong therapeutic alliance and ethical group norms.

• •

Medication Management
•Helpful but not sufficient in treating PTSD •PTSD is a biochemically complex phenomenon •Meds alleviate anxiety, insomnia, and depression •Can aid in overcoming helplessness •Risk of substance dependence in some cases •Assess for comorbid disorders •Psychiatrist to establish empathy and rapport •Medication without relationship can re-traumatize

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Description: MASKED TRAUMA