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Dr. John Briere


SELF TRAUMA MODEL: Different models used with acute trauma and historical trauma. People have often had multiple traumas. Similar memories activate each other when there is trauma there is lots more going on than PTSD.

– Preverbal trauma = attachment troubles as adults

– Psychological neglect = trauma = powerful psych. Impacts

– These memories are not coded in verbal memory

– Infantile Amnesia lasts to age 3

– Effective therapy requires therapist to create relationship with client. We have a culture of psych. Avoidance.

– Over 50% of folks with presenting trauma has had early childhood trauma

– Memories of past events cause present trauma to be complex.

WAR VETS: was enemy personal or not. The more you feel was out to get you the more it will affect you.

– Interpersonal trauma has greater trauma impact

– Neurobiology determines proclivity towards PTSD. They also experience trauma at a greater level than others.

– Sexual trauma is culturally perceived as shameful because of perceived violation of cultural social rules.

COMPLEX TRAUMA: (First six years of life)

Earlier it happened the more complex the outcome. Early trauma increase likelihood of adult trauma.

ATTACHMENT: Holistic process between child and adult caretaker. Most deeply learned lesson are learnt in first 3 years – nonverbal when negative influence comes child shuts down, attachment process – disrupts ability to learn things , increased use of avoidance is what the kids infers from caregivers actions and words that influences his core beliefs.

A lot of human neuro development is post birth. Develop of neurology is experience dependent. Brain is acutely affected by stress during development years. Non verbal information is not avail to us but continues to affect our present day action.

MEMORY: Implicit System

– Non verbal = sensory, motor experiential

– The “I” is not memory

– Cannot be, recalled can only be triggered

– Decreased hippocampal especially if it is fear based then it’s governed by amygdale

– Amygdale is a fast system to retrieve fear based sensations

– Flashbacks are implicit memories

– Source of the memory is confusing to your. Past seems like present.

– Contains age 1-3 memories

– Relational flashbacks to a sensory reminiscence that can’t be connected verbally. This system is more VIP than explicit system in trauma (inter personal events).

-When the feelings come the thoughts may come when the thoughts come the feeling may come

– A nightmare is the minds attempt to heal itself

– Greater the duration of abuse the more pathology

– The more you shut down your experience the greater the chronic effect of flashbacks.

– The increased different ways you’ve been hut (sex, abuse, neglect?) increase the outcome and symptomatology = increased severed reactions

– Complex Trauma = PTSD plus BDP



You don’t know you are in danger until it is too late (under estimate violence). Yet your hyper vigilance.

– Early attachment reflects sexual romantic choices

– Every survivor has a wide variety of symptomatology

– Symptomatology are adaptive responses self healing

– Affect regulation. Can you bring down traumatic emotional states (calm down) without trauma, without avoidance?

– Does your pain exceed your capacity to tolerate pain?

– Abandoned children are immediately immersed in emotional agony when not connected to attachment models

– One of the worst is neglect even more damaging than sexual abuse

– Witnessing domestic violence experience and symptoms that those who are battered

– A mother’s cry is the most dysregulative thing for a kid to hear

– Avoidance keeps you form knowing you are having bad feelings but doesn’t change the distress.

– Many behaviors seem as pathological is really maladaptive coping skills

– If pain is unmanageable they will do anything to stop it

– TRB = Tension Reduction Behaviors. External activities to deal with internal stress.

– Self mutilation/drugs make pain go away

– Bulimia is linked with sex abuse.

– Sexual tension reduction behaviors = sex addiction =

– Substance Abuse = aneastazization

– Dissociation many kinds – Dispute over continuum notion help with reducing stress – or you are overwhelmed


CHRONIC PTSD: Intrusion Avoidance Numbing Hyper arousal

Intrusion Avoidance Numbing Hyper arousal

Flashback nightmare Effortful Biological Response Sympathetic Nervous System

– Intrinsic processing”: PTSD is minds attempt to heal itself

– You have to feel bad to get well

– When you encode a memory of an event we encode the feelings of the event

– We all have a lot of material we have not conscious contact to unless it is activated

– It is not trauma memories that break us down it is the thoughts and feelings attached to it

– Source attribution error to when we respond with early material to a present day trigger

– Even though we’ve been jut by those we are attached to we will be drawn back to the one who hurts you

– Proximity seeking will happen if you sense abandonment even though you may also have proximity avoidance (danger, leave the jerk).


– Self sense is developed through interactions with others at an early age

– Other directedness is highly reinforced in dangerous environment (avoidance strategies)

– Reality is what others say it is and other people change their minds a lot.

– In abusive home there is a decrease of self/other boundaries resulting in low sense of self

– Relationality, self identity affect regulation is goal of therapy

– Assessments measure surface cognition not deeper implicit non activatible material non verbal material

– Only some therapy can be talked out early schemata can only be affected by demonstrated – words don’t reach back to non verbal issues

– Be nice to client might make client trust you less because they know how to de3al with bad guy not good ones.


– If your current situation is reminiscent of a past event you may be triggered to early activatible reactions and maybe not be able to reason with this reaction especially if the previous event is preverbal.

– The more you work on issues the less triggering the past will be.

– You must have painful feeling to have it reinforced in order to get through it to healing.

– Lots of pain and decreased affect regulation temps person to go to avoidance mechanisms like drugs dissociation promiscuity etc.

– Therapists are specialist in avoidance in order to remain high functioning we are drawn to triggers because of our own lived injustices.

– Titrated exposure will require us controlling the amount of traumatic material the client experience so he is not overwhelmed.

– One person’s trauma is another person’s non-trauma.

– What do you get when you process a traumatic memory – A memory that does not overwhelm you anymore?

– We don’t have to go back and figure out the memory just have you proves in safety.

– People recover on their own if conditions are safe and loving. People are the context in which recover.

– With poor affect regulation flashbacks and nightmares may exceed your capacity and re-traumatize individual.

– If pain does not exceed your capacity to handle pain, you’; recover.

– Treatment is desensitizing traumatic activation and increases your ability to handle them.

– Many trauma symptoms can be misinterpreted as DSM labels.

– Trauma will increase likelihood of exp-genetic predispositions to other psych disorders.

– Disassociation can look like a seizure.

– Beta blockers care used by some to reduce PTSD responses but the data isn’t at a level that can/should be used clinically.

– Date rape drug blockers explicit memory but not impliert memory. – Client can’t talk about the experience but have flashbacks.

– Ex-combats may “walk the perimeter” which means lacing around inside/outside of house looking for danger.


1. EXPOSURE = exposure to memory of traumatic event because i.e., you see something that reminds you of event causing you to remember trauma either affect or memory of event which may trigger a bunch of other events.

2. ACTIVATION is your triggered response that activation.

3. DISPARITY = lack of agreement between two things – feel terror but your safe, feel danger but there is no danger. Chronic trauma is its own guarantee of chronic trauma. A little bit of avoidance is a good thing when processing trauma.

4. COUNTER CONDITIONING = If you can feel good when you are feeling bad you feel better by associating a bad feeling with a good one. We have biological reward systems for safe attachments thru dopamine production and pleasure releasing.

5. EXTINTION/RESOLUTION = Over and over again your exposed to distress while re-examining matter = decreased in distressing emotional response

– Hypnosis capitalizes on suggestivability.

– Physical and emotional pain both show up in MRI in same area of brain therefore the numbing out is the brain producing neuro-chemicals to numb pain.

– People who are triggered can’t differentiate a positive response from a negative response.

– Shame can keep you from recovering when you have been a victim but have also victimized others i.e., atrocities

– You need avoidance to survive work with client’s natural healing system

– Drug use may be persons only means of survival may be life saving

– Alcohol/Drugs are the side effect of the problem not the problem.

– Use the narrative track to expose self to painful material with out over activating exposure control

– Therapeutic relationship can bring up implicit memories as you bond with therapist as attachment object.

THERAPEUTIC WINDOW = Sufficient exposure and activation of memories where work can be done in safety with min activation

– You can only feel better by experiencing pain over and over again until it doesn’t hurt anymore.


– Clients don’t burn out systems do

– As you talk about memories you trigger more memories

– What does the therapist do with client statements? Silence, questions, reflection, interpretation analysis.

– Each of these response modes elicit different responses

1. Open ended?

2. Close ended questions?

3. Reflection and if silence are the best in this order.

– Avoid interventions that make you and therapist too special

– Clients super sensitive to abandonment and reflection

QUESTIONS: Facilitate exploration.

– People who don’t have a sense of self just have difficulty accessing what they do know.

– Therapist must not make interpretation

– Ask a question the answer to which can only be given by a person at the level of processing that you want them to be at.



Processing – Activation is the details. There can be good process without content with client trying to titrate emotions.

– You have to have empathic attunement to avoidance (defenses)

– Lesser detail reduces activation. Greater detail increases activation

– Try not to break the narrative in therapy rather to use questions to keep them in therapeutic window

– Let client do real time processing. If client is too cognitive go to emotional questions and vise versa.

– How do you ask a question of lesser detail to reduce emotionality?

– Hot spot processing with laser like on one issue only when general processing isn’t working on a particular issue. Talk about past in present tense. This is only done late in process.

– We use the explicit memory to trigger inexplicit memory experience.

– As therapist don’t dominate the session

– Therapist should not be too close (intrusion) or too distant (abandonment)

– Explore cognitive distortions until it becomes obvious to client

– The more you have a coherent narrative the more you can process with decreased chaos.



– Give client a language for feelings

– Don’t label stuff for client

– When are you done therapy? When there is nothing else to do.