Treating Complex Trauma in Adolescents

Childrens Cove Conference on Child Sexual Abuse

Hyannis, MA September 13, 2013
Cheryl Lanktree, Ph.D.
USC-Adolescent Trauma Training Center
Department of Psychiatry and Behavioral Sciences
Keck School of Medicine
University of Southern California
Los Angeles, CA.
National Child Traumatic Stress Network
lanktree@usc.edu

What is Complex Trauma?

Multiple exposures to multiple types of
traumatic events and impacts immediate and
long-term
Simultaneous and/or sequential forms of
child maltreatment: emotional abuse &
neglect, child sexual abuse, physical abuse,
witnessing domestic violence, community
violence, traumatic loss---often begins in
early childhood
Insecure attachment with primary caretakers
contributes to problems in relational schemas

Exposure to traumatic events

Child sexual abuse and physical abuse
Profound neglect or parental abandonment
Emotional abuse
Sexual and physical assaults by peers
Gang or community violence
Sexual exploitation through prostitution
Trauma associated with immigration
Witnessing domestic violence
Traumatic loss of a family member or friend
Serious medical illness or injury

Simple vs. Complex Trauma

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Simple Trauma
Non-interpersonal
More likely a single
trauma exposure
Shorter duration
Traumatic exposure may be
at later age
More family support
Secure attachment with
primary caretaker(s)

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Complex Trauma
Interpersonal
Multiple exposures of
different types of trauma
Longer duration
Onset of traumatic
exposures at earlier age
Less or no support of
primary caretaker/family
Insecure attachment
Implicit and explicit
memories of trauma

Complex posttraumatic outcomes

Anxiety, depression, anger

Posttraumatic stress
Affect dysregulation
Negative relational and self schema
Identity/self-reference issues
Avoidance responses
Dissociation
Tension reduction behaviors
Self-injurious behavior, sex, bulimia, aggression, impulsive behavior

Substance abuse
Suicidality

Contextual aspects of complex trauma

exposure
Trauma intensifiers

Early onset
Extended and frequent exposure
Ubiquity
Relational context

Social marginalization
Poverty
Social discrimination
Race/ethnicity
Class
Sexual orientation

Inadequate education
Reduced access to services

Special Challenges in Working with Traumatized

Adolescents with Complex Trauma
Premature termination/limited sessions
- focus on affect regulation, building self-capacities,
increasing self-efficacy, strategies for safety and support
Issue of avoidance
- therapeutic relationship, self-capacities, safety
Multiple placements, foster family, residential treatment
- collaboration with system(s), psychoeducation
- support, addressing attachment issues, increasing emotional
attunement for youth

Integrative Treatment of Complex Trauma

(ITCT)
Development of ITCT

Clinic and school-based clients----2001-2009

Coordination and collaboration with community agencies
Multiply traumatized, socially marginalized youth and children
Focus on complex trauma and customized approach for each client
Multi-ethnic, multi-racial, bilingual, multi-disciplinary staff
Structured but flexible and individualized
Relational but also cognitive-behavioral
Intensive treatment and advocacy
No charges or fees for clients or their families

Development of Integrative Treatment of

Complex Trauma (ITCT-A)
} ITCT-A developed at Miller Childrens Abuse and Violence
Intervention Center (MCAVIC), Long Beach, CA with the
University of Southern California---SAMHSA/NCTSN and
private foundation grants 2005-2009. ITCT-C for children
aged 8-12 years.
} USC-Adolescent Trauma Training Center 2012-2016 of the
National Traumatic Stress Network (95 sites)
} Trainings, materials, website: attc.usc.edu
} ITCT-A is focused on clients 12 to 21 years.
} Evidence-based treatment model

Consultation

Community
Referral

School-based
Therapy

Individual
Group

Collateral
Referral

Screen

Assessment

Clinic-based
Therapy

Individual
Family
Group

Forensic
Interview

Hospital-based
Therapy

Individual
&/or Family

Importance of Community Collaboration,

Advocacy, and Systems Interventions
Social and economic deprivation, racism, sexism, homophobia, and
homelessness increase likelihood of trauma exposure, may intensify
effects.
Interactions with agencies, court systems can be stressful and may
require advocacy and collaboration with therapist.
Recommendations
Welcoming environment, culturally diverse staff
Culturally appropriate interventions
Advocacy for client while increasing client and familys sense of
empowerment
Therapist maintains appropriate boundaries and is mindful of
countertransference issues

MCAVIC-USC Waiting Room

Culturally Diverse Team, Client Art Create a

Welcoming Setting

Evidence Base for ITCT: Pre-Post Data

ITCT Treatment Outcome Study (Lanktree et. al.,

2012)
Results based on sample of 151clients seen in clinic and school
settings; majority seen in clinic.
Mean age 11.43 years (range: 8-17 yrs.).
48% Hispanic, 25% Black, 14% non-Hispanic White, 13% Asian
52% CSA, 27% PA, 17% CV, 31% TL, 31% DV.
62%: 2 or more types of trauma, 14%: 4 or more.
67% in treatment for 3 to 8 months (Mean=6.79 months).

Case study:

Tanya

Tanya is a 15-year-old bi-racial female with African-American/

Hispanic background, referred for outpatient treatment after
disclosing sexual abuse by her step-father since age 9. He was
also physically abusive toward her mother and threatened to kill
Tanya and her siblings. Tanya has been depressed and suicidal,
cutting on herself, and engaging in substance abuse and highrisk sexual behavior.
Tanya currently lives with her mother, and describes her
relationship with her as OK, although her mother appears
disengaged from her during the intake interview, and generally
has failed to intervene in Tanyas self-endangering behaviors.

TCT-A Possible Interview Question Topics (PIQT): Areas of

complex trauma to evaluate
SafetyIs she currently safe? Fear of others?
AnxietyWorrying? Feeling something bad might
happen?
DepressionFeelings of sadness? Crying?
Hopelessness?
Anger/aggressionGetting into fights? Getting mad
easily?
Low self-esteemFeeling bad about herself? Not liking
herself?
Post-traumatic stressNightmares? Flashbacks?
Avoidance? Hyperarousal?

Areas of complex trauma to evaluate (contd.)

Attachment securityTrust of others? Worry about
abandonment?
Identity issues--Confused about what she wants? Selfconfidence?
Relationship problemsTrouble making friends?
SuicidalityThoughts about suicide? Wanting to die?
DissociationSpacing out? Watching from outside herself?
Doing things and not remembering them later?
Feeling disconnected from things or watching from a distance?
Substance abuseAlcohol/drug use? Getting into trouble
because of drug or alcohol abuse?

ITCT-A: Core aspects

Assessment-based
Assessment-Treatment Flowchart (ATF)
Focus beyond posttraumatic stress
Relational issues, identity, affect regulation
Avoidance responses, including tension reduction
behavior, substance abuse, dissociation, acting out
Centrality of therapeutic relationship: Active ingredient
Safety within therapy and environment paramount
Customization
Age, gender, culture, affect regulation capacity

ITCT-A: Core aspects

(contd.)
Focus on the client s experience
Taking him/her where he/she is
Fostering internal awareness, self-reference
Avoidance of judgmental/authoritarian therapist
behaviors
Titrated exposure and cognitive interventions
Affect regulation training and behavior control
Emotional detective work
Trigger Identification
Relaxation, mindfulness

ITCT-A Core Aspects (contd.)

Parent/family interventions: focus on improving
attachment relationships
Groups, individual sessions
Advocacy and system intervention
Beyond the traditional therapist role

Assessment-Treatment Flowchart (ATF)

Completed at intake and each 3 month period

Priority ranking (circle one for each symptom):
1 = Not currently a problem
2 = Problematic, but not an immediate treatment priority
3 = Problematic, a current treatment priority
4 = Most problematic, requires immediate attention
(S) = Suspected, requires further investigation
Available at www.johnbriere.com

Assessment-based treatment: Assessment

priority (example items)

Problem area
1. Safety environmental
2. Caretaker support issues
3. Anxiety
4. Depression
5. Anger/aggression
6. Low self-esteem
7. Posttraumatic stress
8. Attachment insecurity

Tx priority
1 2 3 4 (S)
1 2 3 4 (S)
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4 (S)
1 2 3 4 (S)
1 2 3 4 (S)

(S)
(S)
(S)

Applying ITCT-A treatment components

Problems-to-Components Grid (PCG)
Relationship Building and Support
Attachment, acceptance, compassion

Acute safety issues

Psychoeducation

Applying ITCT-A treatment components

(contd)
Distress reduction and affect regulation training
Relaxation, breath training, visualization, mindfulness
Emotion identification and discrimination
Resisting tension reduction behaviors
Trigger Identification and Intervention
Learned in sessions, before triggering event occurs
Identify triggers and triggered states
Reinterpret intrusive phenomena as just or only
Learn coping strategies (self-talk, problem-solving)

Applying ITCT-A treatment components (contd.)

Other cognitive interventions
Cognitive reconsideration/restructuring
Development of a coherent narrative

Titrated exposure
The therapeutic window, intensity control
Implicit/relational as well as specific memories

Applying ITCT-A treatment components

(contd.)
Intervening in identity issues
Reversing Other-directedness
Non-judgment, non-moralizing
Non-leading, open-ended, avoid interpretations

Family/caretaker interventions that address attachment

issues associated with attachment histories and improving
current attachment relationships
Group interventions: schools and clinics

Acute safety issues

Ongoing environmental risks
Community violence
Revictimization

Self-endangerment
Risky behaviors
Sexual acting-out
Substance abuse
Aggressive behavior
Suicidality

Survival behaviors
Prostitution
Gang involvement
Drug sales

Safety interventions

Suicide assessment and prevention

Child protection or law enforcement services
Assistance in separating from gangs
Working with prostitution issues
Safety plans
Intervening in substance abuse
Supporting safer sexual behavior
Prevention strategies for the future

Relationship building and support

Communicate and demonstrate safety

Non-intrusiveness
Visible positive regard
Reliability and stability
Transparency
Demarking the limits of confidentiality

Visible willingness to understand, accept, and connect

Attunement, empathy, and curiosity

Acceptance
Active relatedness (including emotional connection)
Patience

Non-authoritarianism

Distress reduction and affect regulation training

Distress reduction

Grounding
Relaxation and breath training
Visualization
Permission to time-out

Developing affect regulation capacities

Emotion identification and discrimination

Identifying and intervening in catastrophizing cognitions
Trigger identification and intervention
Resisting tension reduction behaviors
Affect regulation arising from repeated, titrated exposure
Mindfulness and meditation Teaching reduced reactivity

Cognitive interventions
Cognitive reconsideration of trauma-based assumptions,
beliefs, and expectations
Trigger identification: Using the trigger grid
Development of a coherent narrative
Normalizing and decatastrophizing
Insight and contextualization

Titrated exposure
Intensity control
The therapeutic curve

Working within the therapeutic window

Balance between exposure and affect regulation capacity

Multiple memories/trauma
Benefit of the therapeutic relationship, perceived safety
Reconsidering resistance
Both implicit and explicit material. Using a timeline, journaling.

Components of processing
Exposure, activation, disparity, counterconditioning, extinction/
resolution

Interventions for identity issues

Development of self-knowledge and self-acceptance

Self (versus other)-directedness
Utilize every opportunity for self-exploration
Focus on:
Non-judgment, non-moralizing
Non-leading, open-ended questions (versus the over-use of
interpretations)
Client (versus therapist) experience as the central domain
Empowerment (versus control or solely adjustment)

Relational processing
Exposure
Activation
Disparity
Counterconditioning
Desensitization

Attachment Behaviors and Patterns

Across the Lifespan
(Cassidy & Shaver, 2008)
Infancy

Secure

Avoidant

Resistant or
Ambivalent

Disorganized/
disoriented

ToddlerhoodPreschoolSchool Age

Secureoptimal

Defendeddisengaged

Dependentdeprived

Controllingconfused

AdolescenceAdulthood

Secure/
Autonomous

Dismissing

Preoccupied- Unresolved
entangled/
loss/traumaenmeshed
disorganized

Parenting
Style

Secure base

Dismissive/
Avoidant
Rejecting

Preoccupied/ Disorganized/
ambivalent/ Helpless
Uncertain

New ITCT-A components in revised

treatment guide
Mindfulness
Developing skill to be present-centered, observe own
thoughts and feelings, nonjudgmental, and accepting
ITCT-A has optional mindfulness/meditation training,
used for deescalation of acute states and improved
affect regulation

Mindfulness (contd.)
Moment-by-moment attention to internal/external
experience
Openness to inner experience
Sitting with distress
Observation without attachment
Letting go
Reduced identification

Mindfulness training:
Approximations of meditation

Specific time and place

Attending to breath
Notice your thoughts
Learn to let your thoughts come and go
Dont fight it, dont hold on
Metacognitive awareness
just thoughts/feelings/memories (not facts)

Newly expanded ITCT-A component--supplemental treatment guide

Substance abuse

More common in traumatized youth

Commonly associated with PTSD
Interferes with internal trauma processing
ITCT-A does not require substance-abstinence in all but most
extreme cases: Clients are taken as they are
Generally, substance abuse means
Slower, less intense exposure treatment, greater attention to
therapeutic window
More attention to affect regulation skill development
More attention to safety issues

Adaptation of ITCT-A: Storefront/School-Based

Program

Therapist Self-Care Strategies

Humor
Mindfulness
Compassion
Balance---mixed caseload, varied roles
Consultation/training/supervision/therapy
Professional and personal support
Physical and emotional well-being
Celebrate and honor your work!

ITCT resources
Multiple trainings on ITCT-C and ITCT-A
throughout the U.S.
ITCT-A Learning Community to be launched
in 2014. Webinar presentations, trainings
available at www.NCTSNet.org and http://
ATTC.USC.edu
ITCT treatment guides and forms available at:
http://attc.usc.edu and www.johnbriere.com

References
Briere, J. & Lanktree, C. (2013) Integrative treatment of complex
trauma for adolescents (ITCT-A) treatment guide (2nd. Edition).
University of Southern California Adolescent Trauma Training
Center. National Child Traumatic Stress Network.
http://www.attc.usc.edu.
Lanktree, C.B. et al. (2012). Treating multi- traumatized, sociallymarginalized children: Results of a naturalistic treatment
outcome study. Journal of Aggression, Maltreatment & Trauma,
21, 8, 813-828.
Briere, J. & Lanktree, C.B. (2012). Treating complex trauma in
adolescents and young adults. Thousand Oaks, CA: Sage.

Post-Training Evaluation for Treating Complex Trauma in

Adolescents
Cheryl Lanktree, PhD September 13, 2013
https://www.surveymonkey.com/s/CapeCodSeptember2013