Risky Business: Working with Compulsive and Self-endangering Behaviors in Trauma Survivors 


Survivors of trauma and early attachment disturbance are at elevated risk of a variety compulsive and self-endangering behaviors, ranging from suicidality and self-injury to substance abuse, indiscriminate sexual activities, and binge eating. Many of these difficulties are seen as symptoms of a personality disorder, behavioural addiction, or impulse control disorder. However, emerging research indicates that they are more accurately understood as coping/homeostatic responses to triggered childhood memories and inadequate emotional regulation capacities.

Calling on his upcoming book Triggered: An Integrated Approach to Trauma, Attachment Disturbance, and Risky Behavior (Guilford), John Briere presents an innovative, integrated approach to self-endangering behaviour, the compensatory avoidance model. Drawing on new research on memory reconsolidation, implicit processing, and revisions to habituation theory, this treatment system directly targets the memory/dysregulation dynamic, with interventions such as emotional regulation training; mindfulness, metacognitive awareness, and emotion surfing procedures; sequential memory processing; in vivo treatment of implicit memory activations; and harm reduction.

A new treatment component, trigger management, increases client autonomy, resilience, and problem-solving. Approaches to three risky behaviours will be presented in detail: self-injury, risky sexual behaviour, and bingeing and purging. Attendees will be provided with newly developed worksheets and assessment instruments that organize and inform the treatment process. 

Program Outline

Day 1

1. Why self-endangering behaviour

a. Traditional models

i. Borderline Personality disorder, impulse control disorder(s), and behavioural addictions

ii. Another (evidence-based) view: The Compensatory Avoidance Model (CAM)

1. Effects of childhood trauma and attachment disturbance

2. Fear structures, trauma schema, and conditioned emotional responses

3. Emotional dysregulation

4. Functions of Distress Reduction Behaviours (DRBs)

2. An overview of specific DRBs

a. Self-injury, risky sexual behaviour, bingeing and purging, reactive aggression, triggered suicidal behaviour, problem gambling, compulsive stealing, problematic internet use, compulsive buying, firesetting, hairpulling and skin picking

b. Non-DRBs that nevertheless involve maladaptive coping

3. Assessing DRB in context

a. Immediate risks and comorbidities

b. New assessment tools

i. Review of Distress Reduction Behaviors (R-DRB)

ii. Function of Distress Reduction Behaviors (F-DRB)

iii. Memories-to-Triggers Worksheet (MTW)

4. Safety, stabalization, and harm reduction

a. Environmental safety and stability

b. Safety from self-harm

c. Reducing the destabalizing effects of triggered states

i. Proactive resilience

ii. Mitigating triggered distress

d. Harm reduction strategies

5. Acceptance and mindfulness

a. Settling, metacognitive awareness, and letting go

b. Urge and emotion surfing

c. Mindfulness applications of DRBs

d. A hybrid approach

Day 2

1. Trigger Management

a. Psychoeducation on triggers

b. Identification: Direct and indirect

c. Trigger linkage

d. Intervening in triggered states

i. Actions that immediately address triggered responses

ii. Positive self-talk and metacognitive statements

iii. Counter-behaviours

iv. Pre-and post-trigger activities that decrease reactivity

2. RAINing for DRBs

a. Recognize

b. Allow

c. Investigate

d. Non-identify

3. Processing trauma-and-attachment-related memories

a. Emotional processing

i. Fear structure and trauma schema

ii. What happened to habituation and how does this change?

iii. Counter-conditioning

b. Implications of new reconsolidation research

c. Multiple memory targets: Sequential processing

d. Processing explicit versus implicit memories

i. Explicit → implicit

ii. Direct implicit

iii. In vivo processing of implicit memory

e. Steps of processing

i. Prebriefing

ii. Exposure

iii. Activation

iv. Disparity/new information

v. Counter-conditioning/extinction

vi. Debriefing/closure

4. Intervening in three forms of compensatory avoidance

a. Self-injury

b. Risky sexual behaviour

c. Food bingeing and purging


Learning Objectives

Attendees will be able to:

1. Describe the Compensatory Avoidance Model (CAM)

2. List four different distress reduction behaviours

3. Outline the central components of trigger management

4. Discuss the limitations of prolonged exposure and habituation

5. Describe two ways in which implicit processing occurs in CAM-based therapy