Self regulation for trauma iccbi
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This PPT shares some-self help tools for clients with trauma. Clients with Complex trauma, PTSD and attachments disorders usually find self-regulation extremely challenging. This presentation shares some commonly used therapy tools that can be taught to clients for use in between sessions.
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Self regulation for trauma iccbi
- 1. Use of Self-help Tools for patients with trauma Hvovi Bhagwagar Clinical Psychologist, Psychotherapist, Manashni, Dr. Reddy’s laboratories, Oberoi International School, Bipolar India, RobinAge Newspapers. ICCBI-AIIMS, March 20171
- 2. Who is a “traumatized” client? Trauma = PTSD (only) 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 2
- 3. Who is a “traumatized” client? 1.Posttraumatic Stress Disorder 2.Acute Stress Disorder 3.Adjustment Disorders 4.Reactive Attachment Disorder 5.Disinhibited Social Engagement Disorder 6.Other Specified Trauma- and Stressor-Related Disorder 7.Unspecified Trauma- and Stressor-Related Disorder DSM 5 (APA, 2013) 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 3
- 4. Is the current classification for Trauma sufficient? Or should it also include…. •Complex PTSD? •Dissociative disorders ? •Personality disorders ? 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 4
- 5. Do you agree? • Cognitive restructuring • Behavioural experiments • Desensitisation • Rational thinking • Challenging assumptions 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 5 ARE THE MOST SUITABLE SKILLS FOR TRAUMA?
- 6. Phase 1: Safety and Stabilization Phase 2: Trauma Reprocessing Phase 3: Reconnection and Integration 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 6 Tri-phasic model (Herman, 1992) endorsed by the International Society for the Study of Trauma and Dissociation (ISSTD) propose the following: Trauma Treatment from a broader perspective
- 7. 13-08-2018 7 Practical Self-regulation tools Restoring the basic housekeeping functions of the body Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017
- 8. Popular self-help strategies in trauma literature 1. Container Exercise 2. Back of Head scale 3. Sensory orientation 4. Calm Place procedure 5. Portable Soothing Kit 13-08-2018 8Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017
- 9. Container Exercise- (Recommended as the FIRST imagery to be anchored/installed) An imaginal resource to compartmentalize the distressing material in order to be present in the here and now 13-08-2018 9 The Container Exercise Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017
- 10. 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 10 Sensory Orientation
- 11. •To assess moment to moment depersonalization in the room with you. •Completely present = talking, awareness of sounds in room, engaged with you •Back of head = eyes open but caught in a memory. Not “fully present” 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 11 The “Back-of-head” Scale Jim Knipe, 2010
- 12. 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 12 Fully Back-of-the-Head Scale (BHS) present - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Dissociated - - - - - - - - - - - - - - - - - - - - - - - - - - - - Dual- Attention Zone (Co- Consciousness; that is, simultaneous awareness of safe present and traumatic past) The “Back-of-head” Scale
- 13. 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 13 The Calm Place Procedure
- 14. 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 14 Severely traumatized clients with self-harm history and suicide attempts may need regular monitoring. Not amenable to “talk therapy” Portable Soothing Kit
- 15. “I can learn effective self-soothing skills.” “I can tell my therapist the most disturbing events of my life.” “I can help my therapist in putting together a treatment plan.” “I can fearlessly and honestly confront my own ‘therapy- interfering’ behavior.” (addictions, avoidance, and other defenses) 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 15 Indicators of stabilization
- 16. Mobile Apps 1613-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017
- 17. 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 17 Self help books for clients (based on top reviews at Amazon )
- 18. H’voviBhagwagar THANKYOU 9821321132 hvovi.bhagwagar@gmail.com www.manashni.com 13-08-2018 Hvovi Bhagwagar, ICCBI AIIMS, Mar 2017 18
Editor's Notes
- My lecture today will briefly explain the need for self help tools for clients with trauma. When we see trauma as larger or more than PTSD. The need for self help skills will become more obvious.
- We often think trauma is synonymous with PTSD. If we gear treatment plans for PTSD alone we are missing out on the wide scope of trumatised cleints. Althought the DSM 5 now includes a section on trauma and stressor related disorders, it fails to include childhood or developmental trauma. Although the DSM includes now categories of trauma and stressor related disorders, Though treatment-outcome data with this population remain scant, there is a remarkable consensus within the professional trauma-treatment literature that therapeutic work with adult survivors of childhood trauma should be phase-oriented, multimodal, and skillfocused (Brown, Scheflin, & Hammond, 1998; Chu, 1998; Courtois, 1999). The consensus model of posttrauma treatment (Courtois, 1999) initially emphasizes stabilization,
- We often think trauma is synonymous with PTSD. If we gear treatment plans for PTSD alone we are missing out on the wide scope of trumatised cleints. Althought the DSM 5 now includes a section on trauma and stressor related disorders, there are Though treatment-outcome data with this population remain scant, there is a remarkable consensus within the professional trauma-treatment literature that therapeutic work with adult survivors of childhood trauma should be phase-oriented, multimodal, and skillfocused (Brown, Scheflin, & Hammond, 1998; Chu, 1998; Courtois, 1999). The consensus model of posttrauma treatment (Courtois, 1999) initially emphasizes stabilization,
- Current classifications of trauma-related disorders are inadequate and confusing. Often this is because theorists cannot adequately classify childhood trauma into diagnosable categories. Yet clinical reality suggests that we often see difficult clients who show little or no change and who have had long term histories of abuse and neglect. Through this presentation I hope to be able to cover all aspects of trauma related disorders including the not seen categories of developmental trauma Developmental trauma which include adverse childhood experiences that contribute to adult episodes of depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity and domestic violence. Disorders of Extreme Stress Not Otherwise Specified
- For such clients diagnosed with trauma related conditions that include neglect and abuse from an early age may not respond well to treatment plans suited for single event traumas. These top down treatment model may not be sufficient.
- As per the ISSTD trauma treatment following a phase oriented approach could lead to more desirable treatment outcomes. People affected by trauma tend to feel unsafe in their bodies and in their relationships with others. Regaining a sense of safety may take days to weeks with acutely traumatized individuals or months to years with individuals who have experienced ongoing/chronic abuse. Figuring out what areas of life need to be stabilized and how that will be accomplished will be helpful in moving toward recovery. Metaphor for creating safety: The experience of emotional overwhelm is similar to that of a shaken bottle of soda. Inside the bottle is a tremendous amount of pressure. The safest way to release the pressure is to open and close the cap in a slow, cautious and intentional manner so as to prevent an explosion. (Rothschild, 2010) 1) stabilization and symptom reduction; (2)metabolization and integration of traumatic material; and (3) personality reintegration and rehabilitation of the self is now recognized as the standard of care for traumatized individuals.
- Inorder to get along better with others, cope under duress, manage work load, multitask we need to have our lower brain calm. In other words retore the basic housekeeping functions of the body calmer The brain is built from the bottom up. It develops level by level within every child in the womb, just as it did in the course of evolution. The most primitive part, the part that is already online when we are born, is the ancient animal brain, often called the reptilian brain. . However, if your sleep is disturbed or your bowels don’t work, or if you always feel hungry, or if being touched makes you want to scream (as is often the case with traumatized children and adults), the entire organism is thrown into disequilibrium. It is amazing how many psychological problems involve difficulties with sleep, appetite, touch, digestion, and arousal. Any effective treatment for trauma has to address these basic housekeeping functions of the body. Kolk, Bessel van der. The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma (Kindle Locations 969-972). Penguin Books Ltd. Kindle Edition.
- http://www.lifemodel.org/wordhtml/trauma_02.htm Any effective treatment for trauma has to address these basic housekeeping functions of the body. The challenge of trauma treatment is not only dealing with the past but, even more, enhancing the quality of day-to-day experience. One reason that traumatic memories become dominant in PTSD is that it’s so difficult to feel truly alive right now. When you can’t be fully here, you go to the places where you did feel alive— even if those places are filled with horror and misery. Many treatment approaches for traumatic stress focus on desensitizing patients to their past, with the expectation that reexposure to their traumas will reduce emotional outbursts and flashbacks. I believe that this is based on a misunderstanding of what happens in traumatic stress. We must most of all help our patients to live fully and securely in the present. In order to do that, we need to help bring those brain structures that deserted them when they were overwhelmed by trauma back. Desensitization may make you less reactive, but if you cannot feel satisfaction in ordinary everyday things like taking a walk, cooking a meal, or playing with your kids, life will pass you by. Kolk, Bessel van der. The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma (Kindle Locations 1259-1266). Penguin Books Ltd. Kindle Edition.
- The amygdala responds well to imagery and symbols versus verbal instructions. PTSD can be thought of as a disorder of the present: traumatic material, including the beliefs, feelings, sensations, perceptions, and images of the stored trauma intrude in the present- and the client confuses the triggered experience with the reality of what is currently occurring. With the ability to “put away” or “set aside” some disturbing memories, thoughts, worries, and even urges/cravings individuals are able to function more fully in the present in their lives rather than having their attention “hijacked” by the past or future. The use of a container image can teach client this ability. With traumatic memories, those threatening images, sights, sounds, smells, emotions, and sensations continue to play themselves out, as if happening in the present, i.e., the memory is experienced as a present threat – continually demanding attention; full attention! It is very difficult, if not impossible, to sustain attention on routine, but necessary life tasks, when disturbing/traumatic material from the past continuously intrudes on and invades one’s present. “The container” is an imaginal resource that addresses the need to compartmentalize the distressing material, in order to be present in the here and now, attending to what one needs to.
- Better pics. This skill engages the sensory cortex, which is responsible for us UNDERSTANDING what is happening to us. Simple skill such as lable aloud 5 red objects, what sounds do you hear around you reverses the shortcut in the brain and allows the brain to process information at a more cognitive level this reducing the perception of threat. Using the five senses to stay present. Examples- Notice 3 objects you see in the room, pay attention to their details Notice 3 sounds-are they loud, soft? Touch any 3 objects closest to you-describe how they feel-smooth, rough Why presentification? Read on the brain chemistry Sensory focusing: Moving from an affective focus to a sensory focus
- Back of head scale is a quick way to assess if the client is in the “here and now” rather than being lost in thoughts. Therapist: Think of a line that goes all the way from here (therapist holds up two index fingers about 14 inches— about 35 cm— in front of the person’s face), running right from my fingers, to the back of your head. Let this point on the line (therapist moves fingers) mean that you are completely aware of being present here with me in this room, that you can easily listen to what I am saying and that you are not at all distracted by any other thoughts. Let the other place on the line, at the back of your head, mean that, even though your eyes are open, in your mind you are completely in a memory from the past. (Since even mentioning the trauma memory may, for some clients, may create some additional loss of present orientation, I usually repeat the description of the scale, using a tone of voice that is calm and matter-of-fact) The place out here (wiggle fingers) means you are completely present; the other place at the back of your head means you are in the memory. Knipe, James PhD. EMDR Toolbox: Theory and Treatment of Complex PTSD and Dissociation (Kindle Locations 4037-4043). Springer Publishing Company. Kindle Edition.
- AL notes To increase presentification. To get the adult more present in session. Esp at EOS
- Calm place is a very popular skill Traumatized client typically find everyday life situations evocative. Like standing on the street waiting for uber to arrive CPP helps them to move from a state of anxiety to state of calmness Remember: Avoiding people in the calm place as they may evoke traumatic memories Using locations that may seem comforting but may beassociated with stressful events/emotions (eg grandmother’s home, my bedroom) Ideally instrucitons such as being by the ebach/mountainside take clients to a neutral zone
- Recently attended a talk by Dr Amy Cunningham on BPD. She spoke of creating portable soothing kits. It is a valuable tool for self harm fragile cleints. Contains objects inside associated with soothing and calming and often employs the five senses Visual: Card with soothing words, pictures of god or family Touch: fur, velvet Smell: perfume bottle Taste: tic-tac lavang, elaichi Sound: bell http://www.janinafisher.com/pdfs/stabilize.pdf Carry example of a coping card Ï can stay safe and present Example of a distraction list Carry a soothing kit-elaichi lavang, tic tac, earing that tinkles, butterfly sticker,