1 1COPING

WITH TRAUMA

Stress Stress is the outcome of a cognitive process in which a challenge or threat is perceived, the ability to control is assessed, in if the individual cannot cope, helplessness is registered [Benner, 1997: 32]. Lazarus in Benner [1997: 32] argued that stress consists of three processes: primary appraisal - is it a threat to oneself? secondary appraisal - potential response to threat coping - executing the response.

Seligman states that when an individual perceives no control over events, or lacks efficient coping responses, helplessness and depression will result. Problem-focused-coping has been found to be more effective: positive reinterpretation seeking support planning

Avoidance and disengagement do not solve anything: suppressing thoughts using worry or punishment to suppress memories giving up denial

Cognitive processing Cognitive bias: people with ASD exaggerate the probability of future negative events

2 Attributions: shame and anger at self and others; attribution of responsibility to others Perception of death threat in accident survivors determines future ability to recover Biology Elevated arousal becomes conditioned with fear and the traumatic experience. Cortisol is protective in the face of stress. Cortisol levels are generally lower [Benner, 1997: 35] and the hypothalamic-pituitary-adrenal axis may dysfunction. Loss The survivor of trauma may experience loss in the form of: Pain Whiplash injury traffic accidents accidental injuries injury loss of mobility or a limb loss of memory or cognitive capacity [brain injuries] separation/death of significant others destruction of social networks/relocation employment home/relocation

In summary

3 Most people do not develop PTSD after a critical incident. Most will recover [symptoms disappear within the first week] If the individual has ASD symptoms during the first week, chances are they will develop PTSD if they do not have good treatment. Relationships, problem solving and, communication skills and the ability to solve conflict may deteriorate as stress increases [Giarratano, 2004: 46]. During problem solving, attention should be given to negotiating goals, rules, routines and adaptability to stress. Keep interpersonal roles hierarchical functioning, distribution of power and subsystem boundaries stable. Tone and range of feelings, involvements/attachment/commitment, respect and regard should be monitored. ICD-10 diagnosis of Acute Stress Reaction: generalized anxiety withdrawal narrowing of attention apparent disorientation anger or verbal aggression despair or hopelessness overactivity excessive grief [Giarratano, 2004: 5-6]

Combat stress reaction restlessness/irritability psychological withdrawal constriction of affect

4 startle reactions nausea/vomiting/abdominal pains paranoid reactions psychomotor retardation/apathy sympathetic activity confusion aggressive or hostile behaviours anxiety or depression ill-concealed tearfulness [Solomon & Mikulincer in Giarratano, 2004: 6]

DSM-IV: Acute stress disorder/PTSD A

- expose to traumatic event - experienced, witnessed or confronted with event[s] that involved actual or threatened death/ serious injury, or a threat to the physical integrity of self/others - response involved intense fear, helplessness or horror examples: threat, extreme physiological strain = pain, starvation, dehydration loss isolation dehumanisation exposure to the grotesque disturbingly incongruent events

- while or after experiencing distressing event, individual has 3 or more of the following dissociative symptoms: + subjective sense of numbing, detachment or absence of emotional responsiveness [freeze] + reduction in awareness of his/her surroundings [confused, concentrate one detail] + derealisation [dream, movie, not real, time slow/stop, far away/fog] + depersonalisation [not in their body] + dissociative amnesia [inability to recall important aspect of trauma/gaps in memory]

traumatic event is persistently re-experienced [ASD=1; PTSD = 1] dreams, thoughts, recurrent images, illusions, flashbacks, a sense of reliving the experience, or distress upon exposure to reminders of traumatic event hyperarousal [ASD = 1; PTSD = 2]: marked symptoms of anxiety or increased arousal [difficulty sleeping, irritability, poor concentration, hypervigilence, exaggerated startle response, motor restlessness] [anger, irritability]

marked avoidance [ASD = 1; PTSD = 3] of stimuli that arouse recollections of the trauma [thoughts, feelings, conversations, activities, places, people] causes clinically significant distress or impairment in social, occupational or other important areas of functioning

5 G
1ASD: minimum 2 days, max 4 weeks, occurs within 4 weeks of traumatic incident PTSD: can only be diagnosed 4 weeks after traumatic incident

1not because of medication/drug of abuse or general medical condition

CBT MAP

Environment, moods, thoughts, physical reactions and behaviour are all interconnected 1ENVIRONMENT - past learning experiences - job - relationship - witness accident, assault Two Worlds Model, impact on NOW world 1PHYSICAL REACTIONS - past and present - stomach upsets - nausea arousal reduction
THOUGHTS MOODS = emotions

- re-experience - negative self-statements - negative thoughts/beliefs/images - memories - we are not safe - it was my fault - nightmares psycho-education exposure therapy cognitive restructuring 1BEHAVIOURS - increased fighting - increased crying

- anxiety - fear - anger anger management - medication - distressing emotions

6 in vivo exposure therapy before/during/after strategy

7 1Signs that you need help impaired task performance [work, care of children, getting help] poorly modulated emotions [fear, sadness, anger] negative self-perception [self-accusation, self-devaluation] inability to enjoy rewarding interaction with others/inability to be helped

Where do I begin?

Introduce some degree of order, of structure, of direction [to counter loss of control] Prioritize Get rid of the mess - raw emotion: fear/anger/irritability Break problems down into manageable units - techniques - CBT map - Before/During/After technique

1Before/During/After technique Determine situational triggers and reinforcing consequences like self-harm, bingeing and fighting. Investigate what happened immediately before a problem behaviour or situation, the result and what the individual did afterwards or what followed. BEFORE = potential triggers
What happened immediately before the problem? What were you doing? Describe the event step-by-step What did you feel? Where did this occur? Who else was there?

DURING = problem behaviour

Who did what during the situation? - complete first - keep observable - keep to facts, not judgements, list what happened - What did you do/say?

AFTER = reinforcing elements

What happened immediately after/ - short-term consequences? - long-term consequences - Summarize the result - How did you feel when it was all over?

INTERVENTIONS

INTERVENTIONS

INTERVENTIONS

8 Two-worlds model of PTSD Having PTSD is like living in two worlds at the same time: the TRAUMA world and the NOW world. The aim is to get the individual back to the NOW world. The rules may or law may be different in each of the worlds. TRAUMA WORLD
- late means dead [anger/rage/panic] - blame others for causing the reaction - mistakes equal death - sex is pain/power/dirty [sexual assault] - I am an object to be used [sexual abuse] - civilians speak rubbish [emotional distance] - If I make a mistake, someone dies - I cant let my guard down - Anyone could be the enemy

NOW WORLD
- look at facts - take responsibility, choose how you will react - nobody is perfect - what is your definition today - balanced view of self - ground yourself in now and present sensations - be a realistic human - allow yourself to experience life now - make sure you are safe

GAINING DISTANCE [Leahy in Wills, 2008: 81] Suggestion: Flowing through you like a river
- Gain distance from your worrying thoughts by saying out loud or writing down I am having the thought that and I am noticing that I am feeling ..... Let the chain of thoughts and feelings run on as long as it wants. - Get to the present by describing what is around you in concrete, non-evaluative language. - Try also to take any evaluation out of any thoughts that crop up. - Think again about the situations that evoked worrying thoughts and imagine yourself out of these situations. Imagine the situations, indeed the universe, going on without you. - Finally, imagine yourself disappearing altogether. Imagine yourself to be a grain of sand on a beach blown into the distance by a gust of wind.

Seeing negative thoughts on a white board

You may find it very helpful to write up negative thoughts on a white board, it makes it much more clear that they are negative. When you have negative thoughts again, visualize them on a white board and deal with them.

9 Hearing the therapists voice

- Remember being assertive and saying no to additional work.

The loo as a behavioural escape

- If you are in a difficult situation, go to the bathroom, wash your hands and give yourself time to calm down and solve problems constructively.

1The TRAP Model

T Trance

R Reexperiencing

A Avoidance

P Physical tension

10
- Dissociation - Treat with Targeting reexposure therapies experiencing symptoms [intrusive thoughts and images, flashbacks and nightmares using exposure therapy] - reduce reexperiencing - restructure irrational beliefs - integrate fragmented sensory and affective info to create a traumarelated narrative - reduce depression - daily event scheduling Arousal reduction= increase self[in vivo exposure] control and social - arousal reduction withdrawal strategies - increase feelings breathing control of self-efficacy, hyperventilation motivation, selfexposure esteem grounding - assist techniques family/reintegratio distraction n exercises de-condition wrong visualization associations of anger danger/ reduce management pathological fears medication - psychophysical exercise education, the role - ID and challenge of avoidance in common cognitive maintaining distortions anxiety black and white rationale for thinking Cognitive exposure catastrophizing restructuring concepts of selective attention - increase habituation, motivation generalisation, Psychoeducation - improve attention desensitisation, - empower - improve selfextinction - instill hope esteem distress scale - reduce confusion hierarchy of fears - assist family setting and Trap model monitoring in vivo Two worlds tasks reducing difficulty Crisis = graded management exposure, imaginal - manage crisis rehearsal - treatment prioritization Cognitive before/during/after restructuring Targeting avoidance

11

Grounding and distraction techniques Grounding techniques work by having the person focus upon the physical sensations in and around their bodies. They will then realize that they are safe and can relax. The following techniques may be used: Isometric exercises = tension/release exercises Self-safe hypnosis - grounding technique [flashbacks, anger, panic] Simple tips for distraction

SELF-SAFE HYPNOSIS - take your mind off thoughts - more aware of safe environment

SIMPLE TIPS FOR DISTRACTION - helps for fears, worries, intrusive thoughts

ISOMETRIC EXERCISES - spot relaxation

12
Look around you and say: 5 things you see around you 5 things you can hear 5 things you can feel touching your body Then say: 4 things you can see 4 things you can hear 4 things you can feel Then go down to 3/2/1 thing(s) you can see/hear/feel Say them aloud/in a whisper/in your mind - observe what is happening around you - look at the people and imagine what houses they live in, what cars they drive, pets, kind of underwear they have on - look at an object close to you - try to guess how old it is, who made it, what it feels to touch/smell/taste it - look at a painting on the wall imagine who painted it, busy painting it; imagine yourself inside the painting, walking around, touching things in the painting; what would it smell like - count forward by 3/4/5 - try to recall lists (name of a food/name that starts with a/b/c/d/e/f - trace the room by describing everything you see; from corner to corner (eyes open or closed) Pick one muscle group, tense it, breathe in and count to 5, relax and breathe out. Sitting down - tense your leg muscles by raising your feet off the floor, knees bent - repeat with legs strait out in front of you - press your feet down into the floor - press your arms back into the sides of the chair press your palms down on the arms of the chair - push your shoulders/back into the chair Standing up - put your arms behind your back and clasp your hands together - stand on tiptoe - press your palms together in front of you, flexing your chest muscles - join your hands behind your back and stretch backwards - crouch down slightly, stretching your calves

Try progressive muscle relaxation [see Multiple Stressor].

1Classical conditioning Also called associative learning - when one learns to associate one thing with another, usually because they occur together [dogs + bell + food, bell + salivate]. Generalization: Fear and anxiety can also generalize to other objects [white rat, boy plays with it, no fear; white rat, boy touches it + loud noise, fear; later generalizes to similar white objects, rabbit, white cotton ball, beard of Santa Claus]. When exposed to a life threatening situation, people often experience high levels of fear. Stimuli associated with the original situation, the place, time of day, noises and smells will later elicit the same fear. Operant conditioning Also known as learning by consequences of action [consequence positive, will repeat action - reward; consequence negative, will refrain from action punishment].

13 In-vivo exposure therapy Consists of:

reciprocal inhibition: fear + opposite: relaxation systematic desensitization: stimuli presented in graded way - least frightening to most frightening imaginal desensitization: relax + visualization

in-vivo exposure: real life - exposure alone causes desensitization

Subjective units of distress scale A measure of self-reported distress levels

0
Lowe st rati ng of distr ess

5
midd le

10
High est ratin g of distr ess

Habituation

14 Anxiety levels drops [one trial] over a period of time. Desensitisation If a non-dangerous situation that has been avoided is faced, habituation will occur. If it is repeated enough times, desensitisation will occur [many trials]. No more fear. Integration of fragmented information Overwhelmingly distressing information can get split [sensory or emotional fragments] during disassociation, depersonalisation, derealisation and personality fragmentation. They persist in the form of flashbacks and memory fragments associated with the original traumatic event. That is why some people find it difficult to speak fluently about the event - it is difficult to put the experience into words. The more articulate, the less fragmented the memory is [Giarratano, 2004: 175]. Altering irrational thoughts about the event Use expose therapy if reasoning does not help.

General principles The EAS practitioner/professional assists the patient to generate a narrative [to tell the story] of the traumatic memory/event: Recount the story verbally, in detail - to integrate various aspects of the experience - until desensitisation occurs

15 Write it down in a journal/record the story on an audiotape/videotape; every time this is done, additional details are recorded Ask yourself, what does this memory make you think about you? Is this belief true? Review the script/journal/recording. Make notes of additional information. What did you feel?/What were you thinking?/What did you smell/hear/see? Rate distress. Repeat until at least a 50% reduction in distress has occurred. Progress is made when PROGRESS NEED TO IMPROVE

- whole memory - relaxation - past tense used - high sensory detail - script is written out on paper or recorded - patient or therapist reads script

- memory is broken into a graded hierarchy - no relaxation - present tense used - low sensory detail - unable to cooperate - therapist reads script

Next Continue until distress is low. Concentrate on hot spots. Challenge negative self-statements and distortions of facts. Continue in vivo exposure until habituation occurs. Use a letter writing task when loss or death is involved.

1CHALLENGING QUESTIONS

16

Below is a list of questions to be used in helping you challenge maladaptive or problematic beliefs. Answer as many questions as you can for the belief you have chosen to challenge. Belief: _____________________________________________________I dont deserve to have a family. 1. What is the evidence for and against the idea. FOR:_________________________________________________________________________ ______ AGAINST:____________________________________________________________________ ________ 2. 3. Is your belief a habit or based on facts? Are your interpretations of the situation too far removed from reality to be accurate? 4. 5. Are you thinking in all-or-none terms? Are you using words or phrases that are extreme or exaggerated [always, forever, never, need, should, must, cant, every time]? 6. Are you taking the situation out of context and only focusing on one aspect of the event? 7. 8. Is the source of information reliable? Are you confusing a low probability with a high probability?

17 9. 10. Are your judgements based on feelings rather than facts? Are you focused on irrelevant factors? [101]

[Resnick, P A; Monson, C M & Rizvi. 2008. Posttraumatic Stress Disorder in Barlow, D H. Clinical Handbook of psychological Disorders.Guilford Press: New York, pp65-122] Motivating clients Exposure therapy is like a Bunsen burner used in science class. Life stress is the fire. Traumatic memories are inside the glass container with a lid on top to keep them all in. Trauma memory work is like a tap, to let them out [distress] under controlled and safe circumstances. With the fire on high, some of the memories will spill over from time to time. Therapy improves problem solving, and that assists coping. One can also compare lancing a boil; extracting a tooth; a wet, muddy dog out in a storm, wanting to come inside the house; or the brain as a filing cabinet - trauma creates a messy filing cabinet; climbing out of hell on an aluminium ladder, the further you climb, the less the ladder burns; undigested meal - trauma work digests the memory, allowing the survivor to feel comfortable again [Giarratano, 2004, 206]. Working with traumatic nightmares Perhaps dreaming is an associative process that helps us to make sense of intense experiences in our lives. Distressing dreams often provoke people to wake up in fear. The memory has been activated, but corrective action was not incorporated. Think of your nightmare, but change the ending. many nightmares are not exact representations of the trauma. Repetitive dreams can be targeted using the following methods:

18 Use prolonged exposure to the traumatic memory itself - create a script for the nightmare Change the images/ending of the nightmare towards themes of mastery and control [overpower attacker, changes real gun into a toy gun]. Find out what is missing from the nightmare, then rehearse it with the object or skill present [speed or strength to escape, having the weapon needed] SSRIs [fluvoxamine] improves sleep quality and reduces nightmares, as it influences serotonin levels and the amygdala [REM sleep, arousal states]. EDMR [Eye Movement Desensitisation and Reprocessing] will use eye movements to target the nightmare. Sleep cycle interruption: A partner, friend or alarm clock wakes you 30 minutes before the nightmare typically occurs. Get out of bed, splash your face with water and get back into bed. The stage of sleep and the nightmare will then be disrupted. For general insomnia: use sleep hygiene methods, eliminate learned sleep-preventing associations, and restrict your sleep to specific hours every night. Use cognitive restructuring to identify and change beliefs and behaviours that interfere with sleep. COGNITIVE THERAPY Behaviours and emotions are linked to thinking

19

Actual event, external reality events people places things something happens rock hits windscreen I killed ...

beliefs thoughts interpretations

consequences emotions behaviour physiology/physical reactions

I tell myself something it is a bullet/danger I am .... I dont deserve

I feel something feels shocked and fearful swerves off road, ducks heart pounding anger, guilt

Thoughts usually come before feelings and action. An individual only responds to that which is important for him. If it is not relevant, it will be ignored or just observed. Thinking requires attributing meaning to those things we pay attention to. Interpretation of our experience creates our response [half a glass of water - half full - half empty]. Prior learning can shape our responses - learning creates automatic responses [stopping at a red light, driving a car] and habits.

Trauma and cognitive schemata Past experiences and learning form filters so that we selectively attend to information that matches our beliefs.

20 Trauma shatters beliefs about invulnerability - the world is no longer safe. This may evoke uncertainty and helplessness; disrupt inner security, trust in relationships and confidence about the future. Negative core beliefs may develop.

Negative interpretation of distressing events The following themes have been identified: CONTROL I am out of control I am helpless
RESPONSIBILITY/GUILT VULNERABILITY

I m going to die I am exposed I am not safe anywhere anymore

SELF-ESTEEM

I did not do enough I should have done more What if I had ... It is all my fault

I I I I I

am am am am am

weak gutless an animal dirty nothing

1Common cognitive distortions

21
Black and white thinking

= all or nothing thinking oversimplify = good/bad; right/wrong = magnification/exaggerating or

Catastrophising

always, never, nothing, everything, noone, everyone, total failure shows a need for control as this was lost during trauma jumping to conclusions, assuming the worst, exaggerate worst outcomes, no facts to support [bank robbery, witness - next time I will be killed]; evidence is lacking or contradictory - exaggerate importance of things - shrink things until they appear tiny

minimalisation/minimizing

Selective attention

disregard important aspects of a situation

focus on negative, ignore positive [often feel betrayed] world is unfair, you will be hurt by people feel incompetent, unlovable reinterpret, challenge a single event is a never-ending pattern of defeat focus one negative detail reject anything positive, does not count no facts to support as in mind reading or the fortune teller error - act as if prediction is a fact I feel it, so it must be true I feel it, so there must be a reason should, must, ought - expect punishment, guilt when you direct these statements to others, you feel anger, irritation, resentment

overgeneralization

mental filter disqualifying the positive jumping to conclusions

emotional reasoning

should statements

22
labelling and mislabelling

extreme form of overgeneralisation instead of describing your error, you give yourself a label - loser or another person - louse you see yourself as the cause of some external event assume people are thinking negatively when there is no definite evidence

personalisation

MIND READING

Challenge beliefs by using literal challenge best friend two worlds evidence for/against

LITERAL CHALLENGE

BEST FRIEND CHALLENGE

literally define the word you are using generate extreme examples review your statement about yourself - I am a murderer - someone who deliberately sets out to kill someone - do you fit - no premeditation - generate extreme examples using other people - review statement - gives new perspective
TWO WORLDS

Imagine best friend was in same situation, and did exactly what you did. Imagine what a third person would comment What would you say to this person about your friend? Use same standard for yourself

COGNITIVE CHALLENGE

Compare trauma world to now world Self care to prevent burnout

Use evidence for or against

Burnout is a process which becomes progressively worse because of job The ability to make decisions declines. Black and white thinking is often used by perfectionists with high standards.

23

strain, erosion of idealism and lack of achievement. Confidence diminishes.

24 Symptoms of burnout

PHYSICa L

EMOTIONA L

BEHAVIOUR

INTERPERSONA L

WORK

insomnia fatigue/ph ysical exhaustion somatic problems [headaches flu symptoms stomach upsets anxiety

irritability anger resentment anxiety depression guilt blame sense of helplessness fear it wont get better fear losing control

aggression callousness pessimism defensivenes s substance abuse indifference selfpreoccupation resistance to change rigid thinking conflict tunnel vision

withdrawal from clients and coworkers difficulty communicating inability to concentrate

poor work performan ce absente eism quitting the job misuse of work breaks high resistance to going to work every day clock watching

25 1Strategies for preventing burnout

PHYSICAL SKILL DEVELOPMENT

exercise body nurturance [massages, facials, warm baths, yoga] adequate sleep eating properly, no skipping meals or eating on the go, watch out for over/under eating schedule time for fun schedule time for vacations

assertiveness training, learning to say no look after yourself before you look after others stress management - relaxation, hypnosis, yoga cognitive restructuring - distorted thinking time management - priorities organise set realistic goals
PROFESSIONAL

INTERPERSONAL

Increase social supports - do you have people who will listen without criticising? Who can give honest feedback. Build in regular time with your loved ones, friends and children - they offer hope and joy Get help when you need it. See this as a sign of strength. Get involved with your community - social activism - domestic violence, substance abuse/misuse, child abuse - as an outlet for frustration

Balance - make time for meals, colleagues, home Boundaries/set limits Time boundaries Refrain from overworking - too many responsibilities, regular overtime, taking work home, taking calls at home Watch out for being cynical and bitter Personal boundaries Know your limits Plan for emergencies

26
PSYCHOLOGICAL

Life balance - work, hobbies, play, socialize, learning Relaxation/meditation Contact with nature Play with your pets Creative expression - write, paint, any form of art, hobbies, cooking, dancing, music Self-awareness - know when you need help Humour - reduce stress, gain perspective Make time for dreaming, thinking, wandering, exploring, planning and being in touch with your dreams [Giarratano, 2004: 260; Greenstone & Leviton, 2002: 66]]

SESSION 1. INTRODUCTION AND EDUCATION Shepherd, Street & Resick, 2007: 103-105

- explain symptoms of PTSD in terms of CBT - five-minute account of the trauma [worst one] - treatment rationale - provide overview of treatment - homework - write an impact statement

27 SESSION 2. THE MEANING OF THE EVENT - review concepts from the first session - read the impact statement; begin to ID stuck points - discuss the meaning of the impact statement - ID: Assimilation - changing memories to fit beliefs Overacommodation overgeneralizing beliefs as a result of memories Accommodation - changing beliefs to incorporate the trauma - help ID and see the connections between events, thoughts and feelings - introduce the ABC sheet - fill out the ABC sheet together - Homework - complete ABC sheets to become aware of connection between events, thoughts, feelings and behaviour - review ABC sheets, further differentiating between thoughts and feelings Label thoughts v feelings Recognise that changing thoughts can change the intensity of types of feelings Begin challenging self-blame and guilt with Socratic questions - homework - write a trauma account, with sensory details and read daily - complete ABC sheets daily

SESSION 3. ID THOUGHTS AND FEELINGS

28 SESSION 4. REMEMBERING THE TRAUMA - read the traumatic account aloud, encourage affect - ID stuck points - challenge stuck points of selfblame and other forms of assimilation using Socratic questions - homework - rewrite the trauma account; complete ABC sheets daily - read the second trauma account aloud; discuss new details that emerge - involve the client in challenging assumptions and conclusions that the client has made after processing affect, focus on self-blame and assimilation - introduce the challenging questions sheet to help ID stuck points - homework - challenge at least one stuck point a day - review challenging questions sheet to address stuck point, start with self-blame - continue cognitive therapy re stuck points - introduce the faulty thinking patterns sheet - homework - notice and record examples of faulty thinking patterns on the challenging beliefs worksheet

SESSION 5. ID STUCK POINTS

SESSION 6. CHALLENGING QUESTIONS

29 SESSION 7. FAULTY THINKING PATTERNS - review the faulty thinking patterns sheet to address trauma-related stuck points - introduce the challenging beliefs worksheet with a trauma example - introduce the first of five problem areas: safety issues related to self and others, go over the module on safety - homework - identify stuck points every day, one relating to safety, and challenge them using the challenging beliefs worksheet - review the challenging beliefs worksheet to address safety and other relevant stuck points - help the client confront faulty cognitions using the challenging beliefs worksheet and generate alternative beliefs - introduce second of five problem areas: trust issues related to self and others; use the trust module on the challenging beliefs worksheet - homework - client to identify stuck points every day, one relating to trust, and confront them using the challenging beliefs worksheet - review the challenging beliefs worksheet to challenge stuck points of trust, generate alternative beliefs - introduce the third of five problem areas - power/control issues related to self and others - homework - ID stuck points, one relating to power/control; confront them using the challenging beliefs worksheet

SESSION 8. SAFETY ISSUES

SESSION 9. TRUST ISSUES

30 SESSION 10. POWER/CONTROL ISSUES - discuss the connection between power/control and self-blame; challenge stuck points using the CBW - introduce the fourth of five problem areas - esteem issues related to self and others Review the esteem module Explore the clients self-esteem before the traumatic event - introduce the identifying assumption sheet IAS and determine which assumptions are applicable to client - homework - ID stuck points daily, one relating to esteem issues, challenge them using CBW - confront assumptions checked on IAS, using CBW - practice giving and receiving compliments daily - do a nice thing for the self at least once per day - discuss the clients reactions to giving and receiving compliments and doing nice things for oneself - help the client identify esteem issues and assumptions; challenge them using CBW - introduce the fifth of five problem areas: intimacy issues related to self and others - homework - ID stuck points, one of which relates to intimacy issues, challenge using CBW - rewrite the impact statement - continue to give and receive compliments - continue to do at least one nice thing for the self each day

SESSION 11. ESTEEM ISSUES

31 SESSION 12. INTIMACY ISSUES - help the client identify intimacy issues and assumptions, as well as any remaining stuck points; challenge using CBW - have the client read the new impact statement - involve the client in reviewing the course of treatment and his/her progress - help the client identify goals for the future and delineate strategies for meeting them - remind the client that he/she is taking over as his/her own therapist now and should continue to use the skills learned

1SOCRATIC QUESTIONS: 1What do you mean when you say x?

o o o o o o o o o o o o o o o What is the evidence that x is true? What is the evidence against x being true? What might be the worst that could happen? What leads you to think that x might happen? And if that happened, what then? If that did happen, what would you do? How would you cope? Have you been in similar situations in the past? How did you cope then? How does thinking that make you feel? Are you thinking in a biased way? Are you predicting the future or mind reading? Are you paying attention only to one aspect? What if you looked at it from a different angle? What would you say to a friend who kept on saying x to him/herself? I am stupid/I am terrible. How would that work in your body? Is there an alternative explanation? Is there any other way of seeing the situation? What are the advantages/disadvantages of thinking that? Is it helpful or unhelpful?

32
o o o o o o o o What would it mean to you to see things differently? Are you making decisions based on your feelings, or is reality telling you something different? What might you tell a friend in this situation? What would your friend say to you? Is there something else you could say to yourself that might be more helpful? What do you think you could change to make things better for you? How would you like things to be different? What would you like to do instead?

- What would have to happen to make it possible? [Wills, 2008: 60]

1ABC SHEET A. SOMETHING HAPPENS Antecedent What happened before ... I was abused I was told bad things about myself B. I TELL MYSELF SOMETHING Behaviour What happened C. I FEEL ... Consequences What happened after ... Angry at myself I feel ashamed of myself

I must be bad I am stupid and ugly

1CHALLENGING QUESTIONS SHEET [Follette & Ruzek, 2007:109] What is the evidence for/against this idea? For Against Are you confusing habit with fact? Are your interpretations of the situation too far removed from reality to be accurate? Are you thinking in all-or-none terms?

33 Are you using words or phrases that are extreme or exaggerated always, forever, never, need, should, must, cant, every time? Are you taking selected examples out of context? 1Are you making excuses? I am not afraid - I just do not want to get out. Other people expect me to be perfect. I do not want to make the call because I do not have time. Is the source of information reliable? Are you thinking in terms of certainties instead of probabilities? Are you confusing a low probability with a high probability? Are your judgements based on feelings rather than facts? 1Are you focusing on irrelevant factors?

1FAULTY THINKING PATTERNS SHEET: Considering your own stuck points, find examples for each of these patterns. Write in the stuck point under the appropriate pattern and describe how it fits that pattern. Think about how that pattern affects you. Drawing conclusions when evidence is lacking or even contradictory. 1Exaggerating or minimizing the meaning of an event [you blow things way out of proportion or shrink their importance inappropriately]. 1Disregarding important aspects of a situation

34 Oversimplifying events or beliefs as good/bad or right/wrong. 1Overgeneralize from a single incident [you view a negative event as a neverending pattern] 1Mind reading - you assume people are thinking negatively of you when there is no definite evidence for this 1Emotional reasoning - you reason based on how you feel - assuming that something you feel strongly must be true

1COLUM NA Situatio n

COLUM NB Automa tic Thought s

COLUMN C Challenging your automatic thoughts

COLUMN D Faulty thinking patterns

COLUM NE Alternat ive thought s

COLUMN F De= catastrop hizing

35
1Describe the events/ thoughts or beliefs leading to the unpleasan t emotions Write the automatic thoughts that precede the emotions in Column A Rate belief in each automatic thought from 0100% Use the Challenging Question Sheet to examine your automatic thoughts from Column B Use the Faulty Thinking Patterns Sheet to examine your automatic thoughts from Column B. Jumping to conclusions exaggerate/mi nimize disregard important aspects oversimplify overgeneralize mind reading emotional reasoning What else can you say instead of what you have written in Column B? How else can you interpret the event instead of what you have written in Column B. Rate belief in alternativ e thoughts from 0100% What is the worst that could ever realistically happen?

evidence habit/fact interpretations not accurate all or none extreme/exagg erated out of context source reliable probability H/L feelings/facts

Even if that happened, what could you do?

1EMOTIO NS Specify sad, angry etc and rate the degree to which you feel each emotion from 0100%

irrelevant factors

1OUTCOME Rerate belief in automatic thoughts in Column B from 0-100% Specify and rate subsequent emotions from 0-100%

1The following 25 topics have been developed for support groups. The main aim is to create safety - safety from substances, safety from dangerous relationships [domestic violence and drug-using friends] and safety from

extreme symptoms [dissociation and self-harm]. Seeking Safety is an integrated approach for trauma, PTSD and substance use disorder.
1INTERPERSONAL TOPICS 1- asking for help - honesty - setting boundaries in relationships - healthy relationships - community resources - healing from anger - getting others to support your recovery BEHAVIOURAL TOPICS - detaching from emotional pain grounding - taking good care of yourself - red and green flags - commitment - coping with triggers - respecting your time - self-nurturing COGNITIVE TOPICS - PTSD - taking back your power - compassion - when substances control you - recovery thinking - integrating the split self - creating meaning - discovery COMBINATION TOPICS - introduction to treatment/case management - safety - the life choices game - termination

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1SESSION FORMAT CHECK-IN QUOTATION RELATE THE TOPIC TO THE CLIENTS LIVES - facilitator or clients select any of the 25 topics - connect topic to lives - 30-40 minutes - each will receive a handout - facilitator summarizes main points - each topic represents a safe coping skill - rehearse new skills CHECK-OUT

- find out how the clients are doing max 5 min per client - report on 5 questions: How are you feeling? What good coping have you done? Any substance use/unsafe behaviour? Did you complete your commitment? Community Resource update

- to help emotionally engage clients - a client reads the quotation out loud - facilitator asks, What is the main point of the quotation? and links it to the topic of the session

- reinforce progress - give facilitator feedback - few minutes - answer two questions: Name one thing you got from todays session? - What is your new commitment? - What community resource will you call?

37

1CORE ELEMENTS: TRAUMA FOCUS GROUP CHECK-IN

- members express feelings, concerns, and readiness to engage in group - members report on weekly tasks and outcomes; facilitators collect homework, shape homework compliance and performance, and problemsolve obstacles to its completion - follows session outline - majority of group time

SESSION TITLES INTRODUCTORY SESSIONS 1 2 3

INTRODUCTIONS, STRUCTURE, GROUP RULES PTSD EDUCATION COPING RESOURCES

REVIEW OF HOMEWOR K SPECIFIC TOPICS ASSIGNME NT OF HOMEWOR K 1CHECKOUT

4 5

NEGATIVE AND POSITIVE COPING PTSD AND SELF-CONTROL PRE [MILITARY] AUTOBIOGRAPHIES PRE-WARZONE MILITARY AUTOBIOGRAPHIES

- facilitators explain homework task and rationale, answer questions, and explore obstacles to completion

6-7 8

- members express reactions to sessions; facilitators calm distressed members, help plan for next week, or reinforce individual change.

TRAUMA FOCUS SESSIONS 9-10 11-22

TRAUMA SCENE ID/COPING REVIEW

TRAUMA EXPOSURE AND COGNITIVE RESTRUCTURING

RELAPSE PREVENTION AND TERMINATION 23 24 25-26 27-28 29

INTEGRATING TRAUMA: 3-WAY MIRROR IMPROVING SOCIAL SUPPORT ANGER MANAGEMENT RISK SITUATIONS AND COPING STRATEGIES BEHAVIOURAL CONTRACTING

38 30
BOOSTER SESSION S TRANSITIONING TO MONTHLY SESSIONS INTEGRATION OF TRAUMATIC EXPERIENCE AND RELAPSE PREVENTION

1OVERVIEW OF COGNITIVE-CONTEXTUAL PROGRAMME FOR PTSD Scott & Stradling, 2006: 46 SESSIO - elicit the clients account of the trauma - present the rationale for targeting N 1 the ACCOUNT of the trauma, AVOIDANCE & ALIENATION, and involvement
of significant other - set related homework

2 - review the 3 As - elaboration of worst moments, ID saboteurs eg drink/drugs, th

pain, literacy and remedial strategies. Tackling ANGER = 4 A; rationale for tackling co-morbid disorders

3 - review 4 As - engaging with traumatic material and feared situations without

being overwhelmed - review of remedial strategies - re-authoring the account of the trauma and its effects - cognitive restructuring. Yes...buts...; decatastrophising - frames of mind: ruminating on what I cant influence v concentrating on what I can influence battle mode v problem solving [define the problem; brainstorm solutions; choose a solution; experiment with a solution; review] moaning v investing processes; weaning off safety behaviours; connecting and communicating with others; investing again - communication guidelines: in stating a problem, always begin with something positive; be specific; express your feelings; admit to your role in the problem; be brief when defining problems; discuss one problem at a time; summarize what your partner has said and check with them that you have correctly understood them before making your reply; dont jump to conclusions, avoid mind reading and talk only about what you can see; be neutral rather than negative; focus on solutions; behavioural change should include give and take and compromise; any changes agreed should be very specific.

4 - review trauma and its effects; manage shifts in mood and pain

5 1- stocktaking - review mood records - introduction to faulty information

39 16-7 - stepping around prejudice against self - review of thought records and mood
management - re-assessment - mood management = monitor mood; observe thinking; objective thinking; decide what to do

18-11 outstanding issues; distillation of personal protocol to be used in the event of

relapse - emergency protocol: accept that destabilization is likely, but can be prevented from affecting your long-term quality of life; accept that destabilization will result in more vivid and frequent images of the trauma, and that old memories will have to be contextualized again by detailing in writing/audio/verbally the story of the trauma and its effects; decide to live in the land of APPROACH rather than running for cover in the land of AVOIDANCE; involve significant others as facilitators of the trauma narrative and guides in the land of approach; use communication guidelines to facilitate support; use MOOD to manage mood.

12 one month follow-up; review use of skills, fine-tuning and formal reassessment SESSIO - functioning since last session N - any issues arising out of last session FORMA - review of homework and troubleshooting difficulties T
- session specific material - integration of all teaching to date into mutually agreed homework assignments

40 1THOUGHT RECORD - ABCDE analysis [Wills, 2008: 75] A Antecede nt B Irrational Belief C
Conseque nces emotional and behaviour al

D Dispute for each IB

E Effective rational beliefs

F Feelings/ behaviou r arrived at after consideri ng effective rational belief

Less anxiety, more resistance to washing hands

Blood on money from cash point

This is dangerous

Anxiety urge to wash hands & change clothes

Am I exaggerating the danger here?

There is a small possibility of harm but I am exaggerating

41 1 ACCEPTANCE AND COMMITMENT THERAPY ACT helps the client to make room for their difficult memories, feelings and thoughts as they are directly experienced, and to include these experiences as part of a valued whole life. The aim is not to modify thoughts, feelings or physiological reactions, but to alter their functions and view them differently. These reactions are distinct from the self. You can still make decisions and do not have to control these phenomena. Make the choice to live intentionally rather than reactively. In the end, you will be working on accepting what cannot be changed and committing to things in your life that matter to you. For more information about ACT, go to www.contextualpsychology.org Experiential acceptance of emotions, sensations, memories and thoughts means tat you will stop avoiding or trying to control them. Ultimate goal - to help clients live a personally valued life. It means to have choices, to be, in accordance with personal values. Be aware of misapplied control efforts; self-as-context; be willing to experience. It is impossible to be happy all the time. Mindfulness allows us to be aware and to accept the present, the here and now, using the self as observer to put experience in perspective. Mindfulness will promote well-being. One will learn to verbalize experiences; to notice and hold thoughts and visualize thoughts as passengers on a bus - you can still carry on and choose your own direction. Creative hopelessness helps clients to see they are wasting energy trying to eliminate thoughts. Control is seen as the problem. Willingness to experience will allow more choices and alternatives.

Self-as-context allows you to be aware that you are more than your experiences. Values provide direction in your life.

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43 The aim is to treat FEAR: F - cognitive fusion - individuals view their thinking as the truth; defusing choose to respond differently - as in CBT, learn to challenge thoughts, balance distorted perceptions/interpretations with more accurate and insightful conclusions - this needs distancing from those thoughts - defusing E - evaluation - compare, problem-solve in healthy ways A - avoidance - try not to think about something will bring the event to mind; find alternatives R - reason-giving - verbal explanations for behaviour Key issues in the approach are:
A - Accept - experience emotions/thoughts/feelings/memories/sensations but engage in safe behaviour; contact with present moment; defuse emotions - like holding a butterfly in the palm of your hand

C - Choose - what is important - values; committed action; choose to give up control T - Take Action - use self as context; I as content /I as context

The following techniques can be used to change I into context:

imagery exercises in which thoughts are allowed to flow as leaves on stream, without being bought, believed, adopted or rejected repeating thoughts rapidly - the thought loses its power and meaning use of imagery to turn thoughts into objects with shapes, sizes and colours use metaphor eg the chessboard

Let go of the struggle

let go of control; experience thoughts, feelings or memories

44

Techniques used are:

Mindfulness

Mindfulness is an ancient Buddhist practice - it is nonjudgemental awareness of thoughts and feelings - realize that you do not have to act on them; accept the experience; defused from the literal meaning - observe the thought as a thought; focus on the present moment; a transcendent sense of self; this creates clarity and acceptance [Walser & Westrup, 2007: 20]. Mindfulness can be very relaxing and can be practiced anywhere. It is not the memories that you experience that are the problem, but the function they serve. People with PTSD want to have the memories erased. This is not do-able, you are 100% acceptable as you are. 8-16 sessions will usually be held [duration: 60-90 min]. The present moment Observe what is happening right now - just listen and see. You will realise that there is lot to be aware of that has little to do with the trauma of the past or worries about the future. Try to get back your wonder and beauty about the world. You may focus on your breath or scan your body. Simply notice negative content as it shows up. Later you may focus on imagery. The past One can spend hours thinking about the past or how things should have been. Do not allow yourself to build your whole life around the trauma as your life will get smaller and you will start to function negatively or suboptimally or become lonely.

45 It is natural to experience pain or difficult emotions in the face of trauma. Suffering is all the stuff we add to it with our minds. By telling your trauma story, what do you hope to gain? History cannot be undone, but you do not have to spend so many moments in the past.

The future We can spend hours in our mind worrying about the future. Fear will come and go. Practice being present in the moment. Creating clarity See your experience for what it is. Observe the emotion/memory or thought, do not fight with it. Make choices consistent with your values. There is much more vitality in living a valued life than living a life trying to control your internal experiences. Acceptance In this moment we take the experience as it is offered, without protest or reaction. Three dominant means of coping with stressful situations have been identified: task-oriented - solve problem by modifying situation, commitment to action

46 emotion-oriented - tension or anger avoidance-oriented - distract attention away from the stressful situation [Follette & Ruzek, 2007: 154]. Make a commitment to valued action Link to your chosen values and goals Look for workable solutions

47 Session structure Open with mindfulness exercise Review homework Main topic and exercises Homework for next session

Being creative 1Things you have struggled with: PTSD, pain, anxiety, isolation, nervousness,
sadness, fear, low self-esteem, powerlessness, anger, disappointment, lack of confidence, feelings of emptiness, loneliness, memories, thinking, I am damaged, feeling unliked, feeling confused, not being forgiven, feeling crazy, thinking, Why me?

48

Positive efforts to make the above go away self-help books positive self-talk self-affirmations therapy - group/individual medications alcoholics anonymous/AA/NA/ALANON religion/spirituality talking with family and friends exercise and diet getting out of bad relationships getting a better job learning more about PTSD understanding myself better mindfulness inpatient programmes acceptance of the trauma taking legal action alternative health approaches vitamins acupuncture meditation

Negative efforts to make the above go away alcohol/drugs/misuse of prescribed medication isolation moving from relationship to relationship changing jobs frequently moving frequently running from relationships avoiding people, places and things sexual encounters driving fast being angry overeating or not eating enough throwing up cutting or other elf-injury attempting to commit suicide never going anywhere always saying no or yes pushing away people you care about being a workaholic

1To grow a lush and green forest, you have to clear out all the old burned and dead trees. You have to make space for something new to grow. If you are feeling confused and unsure, you are open to new possibilities. Discomfort is something to be felt and accepted, not avoided. Staying stuck

Imagine you fall into a hole, find a shovel and start digging. When you dig hole. You are stuck. You do not have to solve it immediately. If you keep telling the same story for 50 years, what do you think will be different? Try to find the function of the story. Giving hope to hopelessness Although the situation is hopeless, you are not! Imagine that when you fell

49

a hole, usually you dig deeper and do not get out. Stop digging. You are in a

into the hole, you were blindfolded. You are not responsible for being in the hole. You are not to blame. However, you are responsible for getting out of the hole, by trying something different. Mindfulness exercise 1: Attending to breathing - available on CD Mindfulness exercise 2: Body scan - available on CD Homework assignment 1: creative hopelessness - available on CD Homework assignment 2: practice mindfulness meditation - available on CD Moving forward Creative hopelessness helps one see all that you have tried in order to make experiences, memories, painful emotions and thoughts better or different. It is all about control of your thoughts, memories and emotions, but it does not work. Misapplied or rigidly applied control turns out to be the problem rather than the solution.

CONTROL AS THE PROBLEM SESSION FORMAT 1-2 sessions tug of war image on CD homework 1 &2 on CD control homework ! &2 on CD breathing with light imagery + just listening

50

- open with mindfulness, mindfulness exercise 1: expanded attention to breathing with light imagery, 5-10 minutes; Mindfulness exercise 2: just listening. The exercises are not about being comfortable and relaxed, they are about observing and contacting experience. - review prior session, spend about 5 minutes per individual reviewing homework and exploring responses to it. Write about your personal reflections on being in the struggle Write about the costs of being in the struggle. Record and monitor any negative experiences and report your reactions - explore the paradox of trying not to think about something: do not think about vanilla ice cream! Remember the person in the hole-metaphor. It is impossible not to think about ice cream! Focus on where you want to go, stated in positive terms, not using do not, etc. It you suppress a thought or emotion, it is bound to return. - explore the nature of paradox - imagine yourself being linked to a machine that can detect anxiety, your only job is NOT to get anxious; if you get anxious, I will give you a whack with a stick - your machine is your central nervous system; when you get anxious, most people believe they are no OK as a human being; is that your experience too? Stop controlling! - understand the costs of misapplied control; use the quicksand/Chinese finger trap or the wave metaphor - the harder you struggle, the more difficult it is to get out Quicksand - the more you struggle, the more you are pulled down - spread out in it, let as much of your body contact it the sand. Chinese finger trap - the harder you pull, the tighter the tube clamps down on your fingers - solution, push in with both fingers, so you will have more room to move Fighting the wave - if you get carried out to sea by a current, do not fight it as you may get tired and drown. Control may seem to be the solution, but at what cost? Usually narrow and inflexible lives. One may be robbed of personal relationships, golden opportunities, simple dignity or a life well lived. Remember the hole - you are not responsible for falling in, only for getting out. - examine how you learned to control: tug of war exercise = cost and benefits of control; use a rope, scarf or belt - the harder you pull, the harder the other side pull as well; this can be true for anxiety, anger, trauma memories; they cannot be erased, but are here to stay; if you drop the rope, there is no more struggle. The memories are still there, but they are not fighting against you anymore; this give you some freedom to walk around, live your life in the present moment, the memories will be in the background, and will fade with time. - explore sticking points - control is part of the problem, because it usually works; misapplied or rigidly applied control is the problem, not the solution. We can control many things - the room temperature, moving furniture around, throwing garbage away; we learn control by direct experience/by modelling; some people learn to hold back tears; dont worry, be happy - big girls/boys dont cry - disapproving looks - get over it - distraction can work, or relaxation exercises - all for the short term letting go of the struggle can bring rest and a sense of liberation - assign homework: control as the problem - moving forward Assignment 1: control as the problem - imagery exercise - give your struggle an image - observe dispassionately assignment 2: control as the problem - mindfulness exercise - focus on your senses in the present

51
Willingness

God asks no man whether he will accept life. That is not the choice. You must take it. The only question is how. Henry Ward Beecher Through acceptance and commitment therapy, one is trying to move into a position of willingness - to be willing to have the internal experiences of the moment, without attempting to alter or escape them in some way. It is a stance one takes, an active choice to have and hold whatever feelings there are rather than trying to be rid of any one feeling [Walser & Westrup, 2007: 85].

52
SESSION
Introduce willingness = begin with a mindfulness exercise 1 - be-still mindfulness [5-10 minutes]; mindfulness exercise 2: welcome anxiety [5-10 minutes]. It is a difficult task to attempt to reconcile the reality of what you experienced - horror, fear and shame can be immensely aversive; people may feel unsafe and may feel threatened. Being willing is about letting down ones guard, guarding being a control strategy that not only does not manage to prevent pain but serves as an impediment to living fully. You are asked to feel difficult emotions, not to engage in unsafe behaviour. Being willing is about noticing the anxious feeling and letting it be there, rather than engaging in various control or avoidance strategies or trying to change or escape in some way. Hands-on exercise - ask for a volunteer - put your left hand against his/her right hand. Press against it slightly. Let the volunteer tell you something he/she struggles with - an emotion. Give it an image. Imagine the therapist being the fear/big black blob, try to push it away. As the client pushes, the therapist pushes harder. Allow the struggle for a few moments more, then give the following instructions: keep your hands against each other, but stop trying to push the other away. The therapist now moves their hands in a gentle circle, then back and forth, demonstrating increased freedom of movement. This illustrates that even though fear is still there, one is not trying to block it, it seems much more acceptable to just allow it to be, and gives you more freedom to go on with your life. Observe that you will feel more at ease and more aware of other things in the room, you are no longer focusing on the struggle. Explore cognitive defusion - the ability to recognise ones thoughts as internal phenomena, not literal truth. If you have a negative thought, I am a failure, and cannot recognise it as simply a thought - you will be in a double bind - either trying to fix yourself or accept it as true. Computer metaphor - this will help you distinguish thoughts from literal truth, and help you to see your programming - imagine yourself sitting in front of a computer, with your head stuck in it; then visualize yourself with your head facing the screen at the normal distance, with the words I am damaged goods on the screen. When your head is further removed from the screen, you can see the computer with the programmed words on it. What do you believe? Anything we experience goes into our programming. We are programmed by our parents, our families, our teachers and friends, our society, commercials. We can help ourselves by recognising our programming for what it is, programming, not necessarily truth. If you are too close to the screen, you will not realize that this is part of the programming. In the second picture, you will read the same words, but realize that the text on the screen is just programming, so one can modify your reaction, choose how you will react - make choices about your life rather than to accept programming. Taking your mind for a walk - learn to view the mind from a different perspective. Pick a partner for this exercise. One will be the person, the other will be his/her mind. Now take your mind for a walk. Your job is to walk around the room, while your mind follows. MIND: generate a constant stream of thoughts, say them out loud, one after the other. Persons may not talk to their minds, just decide which thoughts you will obey and which ones you will ignore. The lesson is that you can override your mind. You have a choice! Understand barriers to willingness - Being willing allows for greater freedom, freedom to make choices despite what one is thinking or feeling. Remember, being willing to feel an emotion, does not mean that you want the emotion, just as acceptance does not mean forgiveness. Accept the facts of what happened, and accept your feelings. Explore sticking points - moving through swamps - the burden of freedom means that we are responsible for our lives - you can choose life despite your experiences. A swamp is something you must get through you know where you want to be - at the other side - you must be willing to take one step forward - and may get muddy in the process Assign homework: willingness, 1 & 2

1Self-as-context: A distinction is drawn between ones self and the internal

phenomena [thoughts, feelings, bodily sensations] experienced at any one time. You will come into contact with your self, to recognise the continuity of consciousness, and to observe [and accept] ever-changing internal experiences. Ones observer self is then seen as the context within which other phenomena [content] comes and goes.

53 SESSION
exercises and homework on CD
- open with mindfulness: mindfulness exercise 1: recognizing mind quality mindfulness; 2: finding-thecentre mindfulness - review prior session - discuss the concept of an intact self - there is often confusion between consciousness and thoughts; or survivors state that they have no idea who they are; or lacks a whole self Playing chess - use an actual chessboard - begin to place the various pieces on the board, explaining that they represent various experiences, thoughts and feelings from your life. Ask clients to group good/bad experiences/chess pieces together. We use the chess pieces to depict the struggle between good and bad thoughts/feelings and that the game cannot be won. History is additive, this board extends endlessly in all directions. As we go through life we are continuously picking up new experiences [demonstrated by adding new pieces to the board]. They cannot just be thrown off the board - they are not so easy to get rid of. People usually want to get rid of the bad pieces - the painful memories. You can be the chess pieces, the player or the chessboard. If you are the board, you are free to go wherever you want. The board is strong and solid. The board is in contact with the pieces - it experiences the pieces - but it does not care which side is going to win! It can hold all the pieces, experience them, and yet not be them. The board is the context that holds all the pieces of experience, the traumas - yet somehow remains intact - the board is free to move despite the presence of even very difficult pieces. The self can be just an observer. Think of other experiences that were not traumatic. You will be able to think about the experience, and remember using all your senses. The observer is larger than the experience or the traumatic memory. This will enable you to view it from a different, less frightening perspective. Thoughts come and go. Trauma-related thoughts just happened to grab your attention. Cargo space - the-box-with-stuff-in-it [Hayes, 1999] - private events/thoughts/feelings/physical sensations are experienced by the self; grab a box of tissues and a wastebasket, put it in front of the client = you are the wastebasket - when something bad happens to you - [take a few tissues, crumple them up, toss them in the wastebasket] - tissues are thoughts/emotions/senses; how do you feel? [anxious, sweating, losing control] Then what? Are you distracting yourself with ..shopping, drinking? Then what? Do you feel shame or hate yourself? There are now a big pile of tissues in the basket. All pieces are linked to the first piece. Try to cover it up or hide it away. Remember the tissues are not the basket, just something in it. Remind clients that history is additive. We will always have more experiences. Thoughts and feelings are content within the self; efforts to control are ineffective and will add to the problem; there is a cost to spending ones effort and energy on attempts to make unwanted thoughts and feelings go away. Label parade - try the following labeling exercise to define self-as-context in a group or individual setting - ask for a volunteer to stand next to you, ask a peer to write a label on a post-it sticky paper and stick it to the volunteers body. Tell me something you struggle with - life sucks - write on label and attach - what comes up if your thought is life sucks - PTSD - put on label - same with something is wrong/fear/sadness/I cant get over this/depression/hate myself/I do not want to live/I hate myself even more/etc until the volunteer is covered in sticky cards. Do the same exercise, but with a different colour of labels - What do I feel good about? Divide the group into pairs - Look at each other. What do you see? Realize that there is another person behind all the labels, they are just words, you are not defined by labels. You will realize that context is not the same as content. You are more than the labels. Positive thoughts and feelings can be just as easily recalled. Some people will initially have fun when covered with labels, but as soon as you begin to identify with the labels, you may become quite upset. When covered with positive thoughts and feelings, you will feel different in a matter of minutes. Remind yourself of the difference between having a thought, and holding that thought or feeling to be true. Remember there is a self, a continuous you, who is having the experience, but who is more than or larger than those thoughts and feelings. The self is, and remains, intact - the self is context, not content - the self is not broken - you can be an observer; events come and go; consciousness is larger than experiences; the self is intact and can experience difficult thoughts and feelings; therefore one does not have to be rid of experiences to be whole. Holding too tightly to an identity - some clients will identify with being a victim - and loses the distinction between having been a victim and currently being a victim - you experienced war/an accident / a disaster - you are not the accident/disaster or war; you have many identities - mother/father; son/daughter; lover/friend - point out the costs of clinging to a specific identity - acknowledge the importance of history. Do the exercise: selfas-context: letting go of identity. Missing the point - emotions and thoughts come and go - they are not stable and ever present - do presentfocused work - awareness of body, thoughts, emotions and sensations - now - being aware of emotions/thoughts and feelings - each moment contains something different to be experienced; thoughts are transient, easily evoked, I will never change/I will always be alone v I have always survived/I have hope/I have never given up/I am brave/strong; remember there is a continuous you - explore sticking points - therapist is not one up, does not always know best - assign homework: 1 - exploring self-as-context + tracking sheet; 2 - self-as-context: letting go of identity

54 Valued living The wisest men follow their own direction. Euripides Up to now, clients have been learning to make room for their histories, how to simply experience thoughts, feelings and memories without having to use control strategies. You can live according to your own values - that will give life inherent value and vitality. We can make decisions based on how we are feeling. Live according to what is most important in your heart of hearts.

55 SESSIO N 2-3 session s exercis es and homew ork on CD

- open with mindfulness: 1 compassion mindfulness; 2 place of peace - review prior session - self-as-context; letting go of ID - help clients ID their values - consider what you care about - you choose behaviour based on values Choice making - choose simply because you can - choose between Coca-Cola and Appletizer - personal choice, taste, colour, ingredients - reasons are not causes of behaviour - it is very easy to generate reasons Providing direction and meaning making - the what-do-you-stand-for exercise [Hayes et al, 1999] - imagine your own funeral - how would you like to be remembered? What would your friends ideally say about you? How would you ideally be remembered? Here lies Mary, she was about being loving; ......To find out what you care about, dream - aim high! Think about someone you admire, who had a positive impact on your life, how you would like to be. What did you appreciate about them? This will help you articulate your values and future possibilities. Headstone exercise - draw two headstones on a whiteboard - on the first one write: Mary was about ..- making sure not to feel PTSD symptoms.. On the second one, write the same, but change the ending, Mary was about - being a loving mother. This demonstrate the difference between values and roles. - explore valued living - it is about action, about behaviour; it is not about reaching a destination, but what will guide our choices as we move through life Compass metaphor - values are like points on a compass - they point you in a direction; the choices we make will define ones life; do you want to regret your life, or do you want to make choices in the direction that gets you closer to where you want to be. Imagine 5 years from now - you are looking back over the past 5 years - what would your life look like if you made valued choices? - develop values and goals - use the worksheet to ID values and goals regarding various life domains such as family relations, employment, physical well-being, and spirituality. Watch out for anxiety - there are no right values. - examine values and trauma - survivors may have some of their values violated or overturned by life; some experience losses - personal safety, trust in others, pride; core values can be the right to be treated with respect and to be valued; some may experience pain over the unfairness of an event, anger or outrage; acknowledge that life is not fair, one can still value fairness, personal safety and the safety of others - explore sticking points - finding meaning after PTSD - life is worth living, as is - live with intention; the process is the point - why do you want your children to be happy? So they can be happy with you as provider of food, love and protection - assign homework: ID and clarify values; ID lost values; - moving forward - nothing sands in the way of a valued life: not feelings, not traumatic memories, not uncomfortable sensations or thoughts

1Committed action There is no try, there is only do, or do not. We all hold internal experiences and move in valued directions. Willingness is a choice Over the next couple of sessions, one will bring choices aligned with values to life. This implies commitment to action.

56 SESSIO N 3-4 sessions

- open with mindfulness: mindfulness exercise 1: We are all in this together [10-15 minutes]; 2 Kiss the earth with your feet - review prior session - tell the ACT story - regain values: we continue to define values and dismantle barriers; gradually one will be more active in regaining values; do not wait for a return or how others may respond; remember that skiing is a process, so is values; process [having fun] is more important than the outcome [getting to the bottom of the hill]; thoughts and feelings are transient; the mind is like a pair of rose-coloured glasses - so one evaluates and responds according to the colour of the glasses; you can take off the glasses, even for a moment; there is also a self that is experiencing the mind - ID remaining barriers: complete unfinished business; the following topics may be difficult: forgiveness, concern about right and wrong and clinging to the conceptualized self. Forgiveness means to give what went before the harm was done - so one may feel a sense of relief, lightness or peace - choose to behave in a forgiving way; non-forgiveness and self-blame can lead to years of heavy drinking, isolation or not allowing yourself to live the life you would like to live A worm stuck in a hook - in this metaphor, the client is on the hook first and the nonforgiven person is second, so that the only way for the client to get off the hook is to let the nonforgiven person off the hook first - applies to suffering and anger - anger usually harms the person who is angry, not the target. Imagine sitting in a chair, with an empty chair across from you. Close your eyes gently. Think of the person you are in the process of forgiving; imagine what it is you need to forgive. You may practice with a volunteer; you may say things you have never before expressed - being heard by a focused listener may have a freeing impact - nonforgiveness may interfere with values; right and wrong clients can get caught up in failed relationships characterized by issues of who was right and who was wrong, or may have punished others for deeds done. Punishment can take many forms, including shutting others out, giving the cold shoulder, frightening others, hiding out or behaving inappropriately through violence or yelling. Each of these tends to be strongly linked to efforts to control internal experience - not wanting to feel sad or hurt - under the anger is usually hurt feelings; people who want to be right usually find that others will keep their distance and do not want to talk; Clinging to the conceptualized self - many trauma survivors cling to an idea of who they are, linked to roles of victim/ survivor/ child/adult/employee. The following exercise will help people to get a little distance from their conceptualized self - Pair up in twos - each pair takes turns to describe at least four selves eg professional/ working self/ victim/survivor/ struggling self/ current self/ best self - describe how that self dress and look/think/feel; visualize this self - sitting lightly on your hand like a butterfly imagine this sense of self dissolving, say to this self - I let go of you, after you have focused on letting go each of these selves, notice that you are still here; would you be willing to choose what it is that you want your life to stand for? - revisit willingness - obstacles to willingness can be reason giving and emotions; unwillingness can lead to loss of vitality and engagement; choose to be willing, because it works to do so; - explore commitments - what game do you choose to play - imagine a bus with passengers monsters and good guys - it is not possible to get rid of the monsters, sometimes you have to look at them, behind the yellow line....you can still keep driving where you want to go; making a commitment to action/a value - is like choosing a road up a mountain, you can get off and stop anytime, and get back when you want; you do not have to jump off a building; maybe a chair, or a piece of paper! This nicely demonstrates how action can be taken. Do not say that you will try, just do it! - ask the willingness question - explore sticking points - assign homework - 1 & 2: committed action - moving forward

SUMMARY OF STAIR/MPE SESSIONS S T A I R = Skills training in affect and interpersonal regulation MPE = Modified prolonged exposure [Follette & Ruzec, 2007: 337]

57 SESSI ON
FOCUS AND CONTENT

SESSIO Introduction to treatment: N 1 - psychoeducation - emotion regulation, IP functioning, PTSD symptoms

- Treatment overview and goals - Practice of focused breathing

2 ID and labeling of feelings

- psychoeducation - introduction and practice of self-monitoring of feelings; triggers, intensity and coping/reaction - psychoeducation about connection between feelings/thoughts/behaviours - ID strengths/weaknesses in emotion regulation skill - practice new coping skills

3 Emotion regulation

4 Distress tolerance: - accepting feelings/distress - assessment of pros and cons of tolerating distress - ID and practice of pleasurable activities 5 Distinguishing between past trauma schemas and current goals: - IP schemas as self-fulfilling prophecies - trauma related schemas and here-and-now interpersonal goals - ID schemas in a current problematic situation 6 Alternative IP schemas - role playing; ID relevant IP situations and act out with role plays; generate alternative schemas 7 Assertiveness and control schemas - Psychoeducation and discussion of alternative schemas and behavioural responses; do role plays using assertiveness skills; generate alternative schemas 8 Flexibility in schema application - psychoeducation; do role plays using flexibility skills; generate alternative schemas; MPE 9 Introduction to imaginal exposure - develop narrative; create trauma memory hierarchy

10 Imaginal exposure to first memory

- postexposure implementation of stabilization exercise; ID labeling of feelings and schemas; contrast trauma schemas with current developing schemas

58 11-15 Continued work on imaginal exposure

- working through memory hierarchy with probes, clarifications, and greater evocative details; continue to analyze narrative ito feelings - ID progress, risk for relapse, use relapse prevention strategies

16 Wrapping up:

59 Kinchin [2007: 49-58] compares six models of debriefing:

MITCHELL 7 phases DYREGOV Norway PARKINSON 3 stages KINCHIN Emotional Decompres sion
Introduction: Diving in Debriefers introduce themselves Explain aim and purpose Explain rules and get agreement from group Stage 1: Deep water

Raphael

Armstrong

1. Introduction & rules

introduction & rules

Introduction

Introduction and rules

Introduction and rules

2. Facts -

Expectations & facts

Stage 1: Facts

What happened? What did you do? How did others treat you? How did the incident end? 3.Thoughts What did you think? What did you do? How did you treat others? How did the incident end?

What happened? What did you expect? How did others treat you? How did the incident end? Thoughts & sensory impressions What did you think in the beginning and later? What did you do and why? What sights, sounds, smells, tastes, touch sensations did you experience?

What was happening before, during and after the incident?

Initiation into disaster

What was happening before, during, after the event?

What happened before incident Level of training Positive/nega tive What learned?

ID most troubling events

focus on past reactions to stressors and coping styles

Stage 2: Feelings Sensory impressions sights, sounds, smells, touch, taste Stage 2: Emotions What feelings and emotions were generated?

Stage 2: Middle water What physical reactions were experienced?

negative/posi tive aspects and feelings

Feelings and reactions to difficult events

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4.Reactions/

Feelings How did you feel in the beginning, and later? What was the worst thing about it? How do you feel now?

Emotional reactions

Stage 2: Reactions

How did you feel at the beginning and later? What was the worst thing for you? How do you feel now?

What physical reactions? What feelings and reactions are present now? Any positive reactions? Lessons learned?
Stage 3:Future

What feelings and reactions are present now? Any positive reactions? Lessons learned? Sensory impressions? Feelings and emotions generated?

5.Symptoms

Normalisation

What physical and emotional reactions did you experience at the time & later?
6.Teaching

Normality of reactions Explain possible reactions

Normalisati on

Stage 3: Breaking the surface

Normalize

Relationshi ps with others

Coping strategies past and present

Normality of reactions Prepare for possible future reactions

Future planning & coping

Stage 3

What help do you need? What support do you need? What have you learned?

Gives info about possible reactions Support personal, org, group, external Aftermath: court cases, inquests, inquiries, funerals

Info about future reactions Coping strategies Snakes and ladders model of recovery Support: personal, group, org, external Aftermath: court cases, inquests, inquiries, funerals

Feelings of victims

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7.Re-entry

What support is needed? What support is available? Any questions Info and leaflets Remain available after debriefing Follow-up essential; referral as necessary Time: min 2 hours

Disengagemen t

Endings

Any questions? Issue info/leaflet s Follow-up and referral Be available after session

Final statements Referrals Refreshme nts

Endings: Treading water

Disengagemen t

Final statements Referrals Further info Refreshme nts

Focus on leaving the disaster and returning home

Time: 1 hours

Time: min 3 hours

62 DUAL ATTENTION THEORY 1 Brewin and Turnbull states that there are two different memory systems: VAM verbal accessible memory, can communicate info through language and speech - hippocampus/cortex SAM sensory/situationally accessible memory, perception-based info based on senses - amygdala Incoming sensory goes to THALAMUS then to HIPPOCAMPUS HYPOTHALAMUS = controls - recent conscious memories, long fight/flight response term memories - part of cortex - executive control - current sense of self - locate event in time and space - compare previous experiences - corrective info to AMYGDALA - trauma encoded here - worried about what did happen [Scott & Stradling, 2006: 29-34] CONTROLLED DEMAND: - ANTERIOR CINGULATE + - DORSOLATERAL FRONTAL CORTEX - cope by dissociation - distance, slow motion, spectator view

at same time to AM = brains emotional alarm system - emotional respons - within seconds - react before think - freezes trauma, fla - fast response - react to stimuli, do - non-conscious res - trauma encoded h - troubled more by w happened

63 Counselling will therefore focus on three parts [Scott & Stradling, 2006: 49-50]: The brains alarm: the amygdala There is an alarm deep inside the brain called the amygdala. The normal setting of the alarm is on the left, the dotted line - safe place. When something extreme happens, it moves over to the right - war zone. In PTSD the alarm can be triggered by very trivial things. You may get angry because the alarm goes off so easily, but you can only stop it with practice by collecting info daily that you are not in a real war zone, it just feels like it. Gradually you have to go places you have been avoiding. The story of the trauma The drama of the trauma is written by the brains hippocampus and possibly the pre-frontal cortex. This system is aware of how serious the alarm/amygdala is and can send a corrective message. The hippocampus updates the trauma story as it gains more access to initially forgotten info. Talking and writing about the incident will help you integrate information from different parts of the brain. Gradually you will be able to take charge of the memory.

The bubble and em

People who have had very become very concerned a emotional flatness, as a re producing opiates during t may feel like lemonade wi return gradually and often engage in increasing dose also feel in a bubble. You connect with others, becau different, and they cannot have not been through the behaviour means graduall feeling of flatness and disc will feel like a robot going fake it till you make it - as command system - anterio dorsolateral frontal cortex hippocampus and amygda the fear will still be there, b over time. Initially it will ta the bubble and reconnect yourself for being in the bu responsible for the problem solution. Memories are on more you avoid them or pu they spring back. Learn to with distressing emotions, a few seconds each day. S emotion while you realize that it is part of a backgrou You can also visualize the robot - red [stop to think if on facts], amber, green [ta

DEALING WITH PAIN 1 Pain is often a consequence of trauma and often reminds one of the incident. Pain is linked to tissue damage, but also thinking and emotional states. Remember that pain free days may be the ideal, so do not wait for them before doing something. Negative beliefs may also block people from being who they were before the trauma, :I need to wait for a pain free day before doing anything/I cant, so why try.

64 Pain Management programmes are usually presented at major hospitals and involves attendance of 8 half-days a week with a follow-up at 6 weeks and 6 months. CBT pain management has 7 components:
education and socialisation into therapy relaxation exercise and fitness behavioural contingency management attention management cognitive restructuring social and family management

Education and socialisation The neuromatrix theory of pain [Melzac in Scott & Stradling, 2006: 129] proposes that the brain has a neural network that integrates information from multiple sources to produce the sensation of pain - inputs include sensory information and inputs from the bodys stress regulation systems. Remember, the experience of pain is more than just tissue damage. Thinking and emotion will also play a role: If you have a bit of a headache and you get the news that you have won the lottery, what happens to the headache? If you just had an argument, you are in a bad mood, how does your headache feel now? Most often you will find that the sensation of pain is heightened by a worsening mood. Monitoring pain Pain should be monitored so that you can learn what factors increase/decrease pain and adjust coping strategies accordingly. Keep a log/diary of your pain, at minimum: morning/afternoon/evening, noting the pain intensity, mood, activities, thoughts. See if you can disconfirm negative predictions. Cognitive restructuring and attention control A flare up of pain can result in a downturn in mood [M], observe [O] your thinking when the pain is really bad, try to practice objective thinking [O] and decide on a pain management strategy [D] with detached mindfulness. Lower back pain may be treated by increasing activity levels, as simple as going shopping. Stop all or nothing thinking - accept some pain, do not expect to be pain free every day. Do not alternate periods of inactivity with blitzing - attempting to do tasks at the speed and for the duration as you did before the injury, as that may result in you being immobile and demoralized for days. Accept the pain with detached mindfulness. Try not to magnify pain, do not think too much about it as it may render you helpless. Try to get involved in tasks that capture your attention. Dare yourself to try various activities. Remember that others cannot read your mind, tell them how you are feeling.

65 Prepare before you try to switch your focus of attention from the pain to something external - a computer game or imagine the pain filling various coloured balloons floating away with your pain. You may also use the signal breath technique of Hanson and Gerber. Take a deep breath that is held for a few moments and then released slowly. At the moment the breath is released, tell yourself to relax/let go of the pain. Scan your body quickly, especially neck, jaw, feet, hands and shoulders - release areas of excessive muscle tension as the breath is being exhaled. This may not reduce pain significantly, but it makes you more aware of your senses. Prevent preoccupation with pain Accept the pain as part of your life if you cannot be pain free every day as this state is highly unlikely. You can still make a difference and influence the pain, even if it is not possible to completely eliminate it. Refuse to see the experience of pain as a sign of weakness. Use the following coping self-statement, There is likely to be pain today, but sometimes it is not as bad as others and there are better and worse ways of playing it. It does not stay this bad for more than .... days/minutes. Try to invest in various activities and pastimes, otherwise there will be no return. Anger at the injustice of pain is normal. Try to separate acceptance of pain from anger at the perpetrator. Communicating about pain Even when people care, they cannot read your mind. You have to tell them how much pain you are experiencing. Prevent family from having unrealistic expectations by telling them the truth about your pain. You are not moaning, just realistic. Use KISS - Keep It Simple Stupid! Own up to what you can/cannot usually do and simply re-iterate this at appropriate times. Relatives and friends can be very valuable in keeping you active at the appropriate pace and in making sure you continue to invest in life. PHASES OF PTSD RECOVERY Williams gives the phases as: Stressor, Immobilization, Denial, Anxiety/Anger, Guilt, Depression, Testing and Acceptance. Horowitz gives it as Event, Outcry, Denial, Intrusion, Working through and Completion. Like a physical wound, which leaves some scar tissue, victims of trauma incorporate the event into their life experience with psychological scarring. So, even with full recovery, they are never likely to return to how they were before the event. The snakes and ladders model of recovery

66 PTSD sufferers find themselves playing a game of emotional snakes and ladders. The game board represents the road to recovery, divided into 100 squares. A series of ladders helps the person on the way to recovery, but between ladders are snakes, which may take the survivor back towards the start of the game, and to re-experience previous anguish and turmoil [Kinchin, 2007: 95]. The traumatic event takes place on square 1, recovery begins. Some people recover in less than four weeks, some never finish the game and never finish exactly on square 100. They may give up. Recovery is not smooth or predictable. Examples of snakes and ladders which might affect a persons recovery: SNAKES - panic attacks - depression - triggers: sounds/smells/specific situation - alcohol, drugs, medication as an initial crutch may become a dependency - adverse publicity may increase guilt - anniversaries, especially the first, can be a milestone or a hurdle - non-acceptance of PTSD - unrealistic goals LADDERS - good medication, antidepressants - therapy/counselling or any kind of helpful support - relaxation techniques - trauma bond/you are not alone/people with similar experiences - individual or group support - emphatic counsellor/therapist - reaching the top 9 nine squares is good enough for recovery - realistic goals - time can be a great healer

Advice from Aileen Quinton:

claim the right to experience and express your own feelings allow yourself to be sad or to cry take every opportunity to talk if this is helpful the situation is abnormal, to feel trauma is normal make contact with others in similar situations be encouraged to progress in an individual way, at your own pace; take breathing spaces after achieving goals or accept temporary regression of progress if necessary do not push yourself too fast just to please others be empowered to make your own decisions

67 EMOTIONAL DECOMPRESSION PROMPT CARDS 1 The following seven cards may be used by debriefers [Kinchin, 2007: 127-130]: Introduction No telephones, disturbances, outsiders Introduce self, confidentiality clauses No notes will be taken, except attendance register Dont share this with others, except partners May feel a little worse immediately after the debriefing, this is normal and will soon pass facts Expectations immediately prior to the event Before ... During ... After ... What did you think would happen? How prepared were you? What could have happened? Aim To clarify the event and make sense of what you recall. To share your recollections with others. To feel more comfortable with what you may have witnessed

Feelings First thoughts: sensory impressions before, during, after Emotional reactions. After, just how did you feel? How do you feel now? Look out for people who may appear to have difficulties Individual vulnerability in situations, feelings afterwards, at home, later that night, right now! Future Look at support networks Sharing emotions and feelings Important that others understand the impact on YOU Warning of other events ahead: COURT FUNERALS Teaching on PTSD

Normalising These feelings are actually normal elaborate Enforce the normal in all of this Coping mechanisms Not everyone will react in the same way Intrusive images will diminish over time Dont actually need to react to be normal, but it is very normal to react

68 Disengagement Allow time for questions Make sure there are sufficient drinks and biscuits! Give information on self-referral and PTSD and other useful information Thank people for attending Make sure YOU stay behind and are able to meet individual needs 1 Sources for further reading: Benner, M P. 1997. Mental health and psychiatric nursing. Springhouse Corp: Pennsylvania. Giarratano, L. 2004. Clinical skills for managing acute psychological trauma. Effective early interventions for treating acute stress disorder. TalominBooks: Mascot, NSW, Australia.

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