Meeting Biopsychosocial Needs of Individuals with Histories of Multiple Adverse Childhood

203 Pages·2017·1.5 MB·English

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LSU Master's Theses Graduate School
2016
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Christine G. Morgan
Louisiana State University and Agricultural and Mechanical College
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Morgan, Christine G., "Meeting Biopsychosocial Needs of Individuals with Histories of Multiple Adverse
Childhood Experiences" (2016). LSU Master's Theses. 1561.
https://digitalcommons.lsu.edu/gradschool_theses/1561
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MEETING BIOPSYCHOSOCIAL NEEDS OF INDIVIDUALS WITH
HISTORIES OF MULTIPLE ADVERSE CHILDHOOD EXPERIENCES

A Thesis

Submitted to the Graduate Faculty of the
Louisiana State University and
Agricultural and Mechanical College
in partial fulfillment of the
requirements for the degree of
Master of Social Work

in

The School of Social Work

by
Christine G. Morgan
B.A., Louisiana State University, 1983
M.C.D., LSU Health Science Center, 1985
M.S.W. Candidate, May 2016
© [2016/copyright]
[Christine G. Morgan]
All rights reserved

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I dedicate this work to Michael, my four children, my four parents, and the victims of the Holocaust.

Thank you Michael, my husband, for all of your love and encouragement throughout our 30 years of marriage. You
are my secure base and safe haven. I have loved every minute with you and look forward to many more years
together. Thank you for believing that I was experiencing normal reactions to abnormal events. Your persistence has
“clipped my chains” and your encouragement has helped me to “find my wings.” Come fly with me.

Thank you to my four children. I have thoroughly enjoyed watching each of you become the unique and beautiful
adult you are today. Each of you adds so much sweetness to my life. Memories of our family time are so precious to
me. I look forward to more memories as our family continues to grow. I am honored to be your mother.

I extend my gratitude posthumously to my four parents. I am eternally grateful to my foster parents for giving me
nurturance, guidance, support, and predictability. Their daily acts of care helped define parenting for me. I knew
how to be present for my children because my parents were present for me. I am also eternally grateful to my
biological parents for giving me life and providing me with two-and-a-half years of love and care. I am comforted
by music, nature, art, and reading because my biological parents shared these things with me.

The Judenplatz Memorial (Figure 1) in Vienna, Austria is dedicated to the Austrian victims of the Holocaust. The
memorial portrays a collection of books with their spines turned inward; a tribute to the many stories that will never
be known because of the annihilation of an entire race. The stories of my maternal ancestors are included in these
stone volumes; stories that are too painful to tell. I dedicate my work to all of the Holocaust victims in order to
honor the untold stories. May future generations find the strength and ability to author and share their own stories
with their children and grandchildren. May there be no more stone volumes.

Figure 1. Author’s personal photograph of Judenplatz Memorial in Vienna, Austria
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ACKNOWLEDGMENTS
I wish to acknowledge the faculty of the Louisiana State University School of Social Work for giving me
the tools to be able to contribute to my community as a social worker. I am especially grateful to my thesis
committee, Drs. Barthelemy, Yang, and Page. Dr. Juan Barthelemy introduced me to the unique needs of youth at
risk and to the concepts of risks and protective factors. I am thankful for Dr. Barthelemy’s expertise in school
psychology and encouragement during this process. Dr. Mi Youn Yang taught me about research methods, child
abuse, child abuse prevention, and child welfare practice and policy. Additionally, Dr. Yang guided me to explore
the evidence base for current treatments and the specific needs arising from each type of adversity. I thank Dr. Yang
for editing and keeping me current about local child abuse prevention. I want to express special gratitude to Dr.
Timothy Page, thesis chair and principal investigator. Dr. Page’s wise counsel helped me to accept and understand
my own complex attachment history. Through organized lectures, class discussions, and class blogs, Dr. Page taught
me about the complexities of human behavior and development across the lifespan, the subtleties of differential
diagnosis, and about direct practice with children and adolescents. I am grateful that Dr. Page introduced me to the
concept of schema-focused CBT and convinced me to focus on only four core beliefs. I also thank the experienced
clinicians who participated in the interviews for this thesis. The in-depth conversation with each clinician was
enlightening and provided me with practical guidance.
I thank my therapist who used every tool in the toolbox to empower me to find my inner wisdom. So many
of the techniques presented in this paper make sense to me because I experienced them with a safe and respectful
therapist. I certainly learned the difference between cognitively working through my issues versus allowing myself
to experientially process the memories. Of course, differentiating between being and doing and between have to and
want to has changed my life. Additionally, letting go of perfectionism and learning to forgive myself were essential
elements of my healing. I am eternally grateful that the loud sirens are now quiet whispers and that my sorrow is
mostly manageable. Most importantly, I thank my therapist for empowering my inner, healthy adult to listen to and
care for my inner, vulnerable child. As difficult as the process has been, I am glad I decided to seek help and that I
am practicing replacing my immature defense strategies with more adaptive coping behaviors.

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TABLE OF CONTENTS
ACKNOWLEDGMENTS ............................................................................................................................................ iv
ABSTRACT ................................................................................................................................................................ viii
PART I. BASIS FOR THE BIOPSYCHOSOCIAL TREATMENT OF COMPLEX TRAUMA .................................1
Chapter 1. Adverse Childhood Experiences ...................................................................................................................3
Prevalence of Childhood Adversity ..................................................................................................................3
Biological Factors and ACEs ...........................................................................................................................5
Social Factors and ACEs ................................................................................................................................11
Psychological Factors and ACEs ....................................................................................................................19
Differential Diagnosis: Behavioral Dysregulation, Inattention and Trauma ..................................................21
Developmental Perspective on Grief ..............................................................................................................25
Implications for Mental Health Professionals ................................................................................................29

Chapter 2. Trauma-Focused Interventions ...................................................................................................................31
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) ..........................................................................31
Promising Practices for Helping Those with a History of Complex Trauma ................................................32
Schema-Focused Cognitive Behavioral Therapy ...........................................................................................37
Components of the Building Healthy Core Beliefs Curriculum ....................................................................40

Chapter 3. Implementing Trauma-Informed Interventions ..........................................................................................47
Method ............................................................................................................................................................48
Participants .....................................................................................................................................................49
Advice from the Trauma-Informed Experts ...................................................................................................49
Discussion of Interviews ................................................................................................................................57

Chapter 4. Conclusions ................................................................................................................................................58
Understanding Complex Trauma ...................................................................................................................58
Regarding Treatment of Individuals with Histories of Complex Trauma ......................................................59
Regarding Future Directions ..........................................................................................................................63

PART II. THERAPIST MANUAL FOR THE BUILDING HEALTHY CORE BELIEFS CURRICULUM .............64
Overview for Building Healthy Core Beliefs ...............................................................................................................64
Inclusion Criteria ..........................................................................................................................................................65
Responsibility of Therapist Before Initiation of Building Healthy Core Beliefs .........................................................65
For Discussion with Parent or Guardian .......................................................................................................................65
The Past Influences the Present. .....................................................................................................................66
The Stress Response and the Development of Core Beliefs. .........................................................................66
Survival, Memory, and Triggers ....................................................................................................................66
Energy and Attention Levels ..........................................................................................................................67
Neuroplasticity ...............................................................................................................................................67
The Goals of the Building Healthy Core Beliefs Curriculum ........................................................................68
Parent Permission Form and Assessments .....................................................................................................68

Implementation of the Building Healthy Core Beliefs Curriculum ..............................................................................69
The Therapist’s Role in Stages of Change .....................................................................................................69
Assessment of Maladaptive Schemas .............................................................................................................70
Unit One Instructions .....................................................................................................................................70

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Unit Two Instructions .....................................................................................................................................74
Unit Three Instructions ...................................................................................................................................78
Unit Four Instructions .....................................................................................................................................82
Unit Five Instructions .....................................................................................................................................84
Unit Six Instructions .......................................................................................................................................86
Unit Seven Instructions ..................................................................................................................................87
Unit Eight Instructions ...................................................................................................................................88
Unit Nine Instructions ....................................................................................................................................89
Unit Ten Instructions ......................................................................................................................................90

PART III. STUDENT HANDBOOK FOR BUILDING HEALTHY CORE BELIEFS ..............................................91
Unit 1. Decision-Making, Contracts, and Coping .........................................................................................................91
Lesson 1.1. Making Decisions ........................................................................................................................93
Lesson 1.2. My Wants and My Wishes ..........................................................................................................93
Lesson 1.3. Contracts .....................................................................................................................................94
Lesson 1.4. Safety Plan ..................................................................................................................................95
Lesson 1.5. A Calm, Peaceful Spot in My Mind ............................................................................................96
Lesson 1.6. Tracking my Healthy Core Beliefs .............................................................................................97
Lesson 1.7. Coping Skills ...............................................................................................................................98
Homework Suggestions for Unit One ..........................................................................................................100

Unit 2. Beneficial and Toxic Stress and the Stress Response .....................................................................................101
Lesson 2.1. Stress is a Challenge in My Day ...............................................................................................102
Lesson 2.2. The Saber-Toothed Tiger and the Caveperson ..........................................................................102
Lesson 2.3. Recognizing and Regulating my Energy ...................................................................................103
Lesson 2.4. Relaxation .................................................................................................................................104
Lesson 2.5. Bubbles, Stress, and Emotions ..................................................................................................105
Lesson 2.6. Accepting my Bodily Sensations ..............................................................................................105
Lesson 2.7. Knowing I Can Because I Already Have ..................................................................................105
Lesson 2.8. Plan to Do Fun Things ..............................................................................................................106
Lesson 2.9. Plan Time with the People Who Matter to Me .........................................................................106
Lesson 2.10. Focused Breathing ...................................................................................................................106
Lesson 2.11. Progressive Muscle Relaxation ...............................................................................................107
Homework Suggestions for Unit Two ..........................................................................................................109

Unit 3. Emotions .........................................................................................................................................................110
Lesson 3.1. Emotions are Messages .............................................................................................................111
Lesson 3.2. Unraveling Tangled Emotions ..................................................................................................111
Lesson 3.3. Accepting Ambivalence ............................................................................................................113
Lesson 3.4. Expanding my Emotion Vocabulary .........................................................................................113
Lesson 3.5. How People Respond to Expressions of Emotions ...................................................................114
Lesson 3.6. Confusion, Disgust, Surprise, and Feeling Overwhelmed ........................................................115
Lesson 3.7. Embarrassment, Shame, Guilt, or Boredom ..............................................................................115
Lesson 3.8. Expressing Emotions .................................................................................................................117
Lesson 3.9. Empathy and Compassion .........................................................................................................117
Homework Suggestions for Unit Three ........................................................................................................119

Unit 4. Thoughts, Affirmations, and Mindfulness Meditation ...................................................................................120
Lesson 4.1. Healthy Thinking ......................................................................................................................121
Lesson 4.2. Two Opposites and Both Are True ...........................................................................................122
Lesson 4.3. Positive Self-Talk and Affirmations .........................................................................................123
Lesson 4.4. Giving Myself Credit ................................................................................................................124
Lesson 4.5. Taking One Bite at a Time and Hope ........................................................................................124
Lesson 4.6. Mindfulness ...............................................................................................................................125
Homework Suggestions for Unit Four .........................................................................................................128
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Alternative Meditation. Space Station Meditation. ......................................................................................129
Unit 5. Perspectives, Memory Packages, and Beliefs .................................................................................................131
Lesson 5.1. Perspective ................................................................................................................................133
Lesson 5.2. Memory Packages .....................................................................................................................134
Lesson 5.3. Core Beliefs ...............................................................................................................................136
Lesson 5.4. Other People Can Help Me .......................................................................................................137
Lesson 5.5. Freedom is Choosing My Own Responses ...............................................................................137
Homework Suggestions for Unit Five ..........................................................................................................139

Unit 6. I am Loved ......................................................................................................................................................140
Lesson 6.1. Defining the Statement, I am Loved ..........................................................................................141
Lesson 6.2. My Support Network .................................................................................................................142
Lesson 6.3. Conflict in Relationships ...........................................................................................................143
Lesson 6.4. Communication Basics ..............................................................................................................144
Homework Suggestions for Unit Six ............................................................................................................146

Unit 7. I am Lovable ...................................................................................................................................................146
Lesson 7.1. Defining the Statement, I am Lovable .......................................................................................148
Lesson 7.2. Many Ways to Be Smart ...........................................................................................................149
Lesson 7.3. Healthy Pride .............................................................................................................................150
Homework Suggestions for Unit Seven .......................................................................................................151

Unit 8. I am Worthy ....................................................................................................................................................152
Lesson 8.1. Defining the Statement, I am Worthy ........................................................................................153
Lesson 8.2. Using Coping Skills to Meet My Basic Needs ..........................................................................154
Homework Suggestions for Unit Eight ........................................................................................................156

Unit 9. I am Capable of Accomplishing my Goals ....................................................................................................157
Lesson 9.1. Defining the Statement, I am Capable of Achieving my Goals .................................................158
Lesson 9.2. Learning to Become More Capable of Achieving Goals ..........................................................158
Lesson 9.3. Healthy Core Belief Conflict Management Worksheet ............................................................160

Unit 10a. Review and Graduation ...............................................................................................................................163
Unit 10b. For the Parent or Guardian ..........................................................................................................................164
REFERENCES ...........................................................................................................................................................165
APPENDICES ............................................................................................................................................................176
A. ICD-10 Codes for Abuse & Neglect (APA, 2013) ..................................................................................176
B. ICD-10 Codes of Environmental Stressors (APA, 2013) ........................................................................177
C. Healthy Core Beliefs Scale ......................................................................................................................178
D. Forty-Four Coping Skills .........................................................................................................................179
E. Institutional Review Board Approval Certificate ....................................................................................181
F. Informed Consent for Clinician Interview ...............................................................................................182
G. Protocol for Interview with Trauma-informed Clinicians .......................................................................183
H. Sample Letters to Parents or Guardians ..................................................................................................185

VITA ...........................................................................................................................................................................194

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ABSTRACT
According to Felitti and colleagues (1998), a significant portion of the general population has been exposed
to adverse childhood experiences (ACEs) with subsequent and persistent, dose-related, negative consequences to
physical and mental health. Debilitating disturbances to biopsychosocial well-being are significant and frequently
lead to fatality in adulthood. After reviewing the prevalence and severity of ACEs, this thesis presents an overview
of the literature outlining the biological, social, and psychological factors contributing to the development and
progression of disease in the brain and body. Additionally, current trauma-informed interventions are summarized.
Three experienced clinicians share practical advice for implementing evidence-based, trauma-informed mental
health services. Suggestions for integrating components of empirical literature with practical advice are provided to
meet the biopsychosocial needs of those with histories of multiple adverse childhood experiences. A sample
integrated curriculum for middle school students who have been exposed to multiple adverse experiences is
included.
The strengths-based curriculum proposed in this thesis combines trauma-focused cognitive behavioral
therapy (TF-CBT), the gold standard for trauma-informed care, with principles from schema-focused cognitive
behavioral therapy (SFCBT; Young, Klosko, & Weishaar, 2003); neurobiological and mindfulness research;
motivational interviewing; existential psychology; and, attachment theory. Consistent with new recommendations
for children with complex trauma histories (Cohen, Mannarino, Kliethermes, & Murray, 2012), the proposed
Building Healthy Core Beliefs curriculum is the skill-building, phase one of a three-phase program. The skills
learned in this curriculum include: (a) recognizing, normalizing, and managing the "fight-flight-freeze" response (b)
recognizing, identifying, and managing emotions; (c) differentiating inaccurate thoughts from accurate, helpful
thoughts; (d) using positive self-talk; (e) practicing mindfulness and meditative exercises; (f) completing a program
with sequenced steps and specific tasks; (g) recognizing and celebrating accomplishments; and, (h) building healthy
core beliefs. The four healthy core beliefs promoted are: (a) I am loved; (b) I am lovable; (c) I am worthy; and, (d) I
am capable of achieving my goals. This curriculum prepares clients for the second-phase of integrated trauma-
informed care, i.e., life-scripting. Sample letters to parents or guardian are provided to maintain communication
between therapist and caregiver. Homework is designed to encourage positive parent-child interactions.
viii
PART I. BASIS FOR THE BIOPSYCHOSOCIAL TREATMENT OF COMPLEX TRAUMA
According to Felitti and colleagues (1998) and the Centers for Disease Control (U.S. Department of Health
and Human Services, 2010), more than 50% of the population has experienced childhood adversity severe enough to
affect both physical and mental health. The negative consequences of childhood adversity are extensive and extend
into adulthood. Due to the impact on development of early-onset, chronic, multiple, and/or ongoing adversity, this
type of trauma presentation is also known as complex trauma. Without effective intervention targeting root sources
of dysfunction in complex trauma, i.e., an injured stress response system, attachment disruptions, and maladaptive
core beliefs, the effects of experiencing adversity become manifested in adulthood as obesity, diabetes, cardiac
diseases, gastrointestinal difficulties, debilitating depression, and anxiety. Additionally, prolonged stress results in
progressive damage to brain structures, metabolism, and immune systems.
The prevalence of children, adolescents, and adults affected by adverse childhood experiences, the severity
and persistence of the subsequent negative health consequences, and the progressive nature of the damage are
indicative of the need for empirical research to expand the effectiveness and efficiency of population-specific,
trauma-focused psychotherapies. The purposes of this thesis are to examine the prevalence and negative effects of
adverse childhood experiences (ACEs); to review the disruptions to biological, social, and psychological
development in children and adolescents with histories of ACEs; to examine the components and scope of
effectiveness of current trauma-focused interventions; to relay practical suggestions given by experienced mental
health clinicians to implement evidence-based, trauma-informed principles into direct practice; and, to propose an
original and integrated, trauma-informed, psychotherapeutic curriculum for children and adolescents with histories
of multiple, early onset, or ongoing exposure to adverse experiences, Building Healthy Core Beliefs.
The proposed integrative trauma-informed psychotherapy curriculum for children and adolescents who
have been exposed to adversity includes enhancing current best practice, i.e., trauma-focused cognitive behavioral
therapy (TF-CBT; Cohen, Mannarino, Deblinger, 2006) with principles from neurobiological research, attachment
theory (Bowlby, 1969/1982, 1973, 1980), mindfulness (Germer, 2009; Kabat-Zinn, 2003; Neff, 2003; Neff &
Germer, 2013) motivational interviewing (Miller, 1983), existential psychology (May & Yalom, n.d.), strength-
based perspective (Saleebey, 1996), and schema therapy (SF-CBT; Young, 1990; Young, Klosko, & Weishaar,
2003). The overall objectives of the proposed, integrated, biopsychosocial treatment model are to help the
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