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Trauma Processing

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2015 Oregon Counseling Association Conference presentation by Lori Daniels, PhD, LCSW about trauma processing and veterans.

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Trauma Processing

  1. 1. TRAUMA PROCESSING Revealing the Healing Lori Daniels, Ph.D., LCSW; former Counselor, Portland Vet Center
  2. 2. disclosure • All statements made are strictly the presenter’s and do not reflect the thoughts, opinions, nor policies of the Dept. of Veterans Affairs. • Acknowledgements: R. Scurfield, S. Tice, D. Smith; Readjustment Counseling Service (Vet Centers); all my clients
  3. 3. O, my good lord, why are you thus alone? For what offence have I this fortnight been A banish'd woman from my Harry's bed? Tell me, sweet lord, what is't that takes from thee Thy stomach, pleasure and thy golden sleep? Why dost thou bend thine eyes upon the earth, And start so often when thou sit'st alone? Why hast thou lost the fresh blood in thy cheeks; And given my treasures and my rights of thee To thick-eyed musing and cursed melancholy? In thy faint slumbers I by thee have watch'd, And heard thee murmur tales of iron wars; Speak terms of manage to thy bounding steed; Cry 'Courage! to the field!' And thou hast talk'd Of sallies and retires, of trenches, tents, Of palisadoes, frontiers, parapets, Of basilisks, of cannon, culverin, Of prisoners' ransom and of soldiers slain, And all the currents of a heady fight. Thy spirit within thee hath been so at war And thus hath so bestirr'd thee in thy sleep, That beads of sweat have stood upon thy brow Like bubbles in a late-disturbed stream; And in thy face strange motions have appear'd, Such as we see when men restrain their breath On some great sudden hest. O, what portents are these? Some heavy business hath my lord in hand, And I must know it, else he loves me not.Shakespeare, W. (1594); Lady Hotspur Verse Henry IV, Act II
  4. 4. Agenda: 1. What trauma survivors have encountered. 2. A model of trauma processing & PTSD 3. Preparing the client for trauma disclosure 4. Questions for data-gathering in sessions 5. Tenacious Curiosity and the Ability to Not Bail (Early) – Case examples: guilt/grief; guilt & % of responsibility; helplessness in nightmares 6. Goals of trauma processing & PTSD intervention
  5. 5. What many trauma survivor clients have encountered prior to coming into counseling – and even within counseling programs Expectations: that their story is not going to be shared (“speak no evil” AND/OR that the provider doesn’t want to hear it (“hear no evil”) = COLLUSION OF SILENCE REGARDING TRAUMATIC EVENT... Client’s minimization of trauma impact (“see no evil”)
  6. 6. TRIGGERS: subtle/ obvious Intrusive Recollections: Memories, nightmares, flashes AVOIDANCE: quest for mood shift American Psychiatric Association, DSM-V; 2013 Distorted & distressing thoughts and mood
  7. 7. TRIGGERS: subtle/ obvious Intrusive Recollections: Memories, nightmares, flashes Detachment: quest for mood shift Distorted & distressing thoughts and mood American Psychiatric Association, DSM-V; 2013
  8. 8. TRIGGERS: subtle/ obvious Intrusive Recollections: Memories, nightmares, flashes AVOIDANCE: quest for mood shift Distorted & distressing thoughts and mood American Psychiatric Association, DSM-V; 2013
  9. 9. • Cognitive Processing • Dialectical & Behavioral • Acceptance & Commitment • Eye-Movement Desensitization • Medication Mgt. • Coming in for help • Psychoeducation • Social & vocational • Medication • INTEGRATIVE INTERVENTIONS • Merging multiple methods • Includes emotional focus processing of dilemmas & conflicts BUT, what about the emotions & feelings one had during the trauma? And still has post-trauma when triggered? Distorted & distressing thoughts and mood
  10. 10. Hearing about trauma = 10
  11. 11. Trauma history is protected information. Trauma healing can occur if allowed to be revealed.
  12. 12. Trauma Processing Safe Place Strong Rapport Cognitions (distorted) Allow for emotional expression Provide feedback re: reality Eventual Goal: INTEGRATIVE METHODS
  13. 13. Trauma Processing Safe Place Strong Rapport Cognitions (distorted) Allow for emotional expression Provide feedback re: reality Eventual Goal: INTEGRATIVE METHODS Safe Place
  14. 14. SAFE PLACE  Provides a healing context  Creating a space to build trust/ where survivors can allow themselves to be vulnerable: • To disclose and process changes since traumatic event • To feel comfortable and not judged • Provide opportunity to fully express grief/loss/sadness –Clients are questioning whether they are safe with therapist.
  15. 15. Trauma Processing Safe Place Strong Rapport Cognitions (distorted) Allow for emotional expression Provide feedback re: reality Eventual Goal: INTEGRATIVE METHODS
  16. 16. Trauma Processing Safe Place Strong Rapport Cognitions (distorted) Allow for emotional expression Provide feedback re: reality Eventual Goal: INTEGRATIVE METHODS Strong Rapport
  17. 17. A bit about RAPPORT... • How can a therapist “soften” the tension? – Know that clients are watching closely (for reasons to discontinue; “Is this provider wanting to help me? Able to help me?”) – Informal vs. formal approach: first name vs. Mr., Mrs., Dr., etc. • Depends on program, care provider context – Standardized assessments vs. open interview (first impressions) – Flexibility with first few appointments: interaction
  18. 18. • Part of rapport-building: – Friendly, non-judgmental tone, welcoming to your office, explanation of how 1st interview, and subsequent conversations will “look” – Ask early: “What kind of things are you looking to work on through (me/us/______(name of agency)?” – Listen closely to specific problem areas – Share that you’re listening for whether you/program will “match” with the needs stated by the client – Ask at the end of interview if the client has any questions; ask also if they feel like they’d like to come back – Offer to share with them during next visit about what PTSD diagnoses looks like, and the therapy role within PTSD.
  19. 19. Trauma Processing Safe Place Strong Rapport Cognitions (distorted) Allow for emotional expression Provide feedback re: reality Eventual Goal: INTEGRATIVE METHODS
  20. 20. Remembering and telling the truth about terrible events are prerequisites both for the restoration of the social order and for the healing of individual victims. Herman (1992)
  21. 21. Without thorough assessment and rapport building: PROTECTED INFORMATION regarding a traumatic incident may never be disclosed by a client to their provider.
  22. 22. Setting the foundation for trauma processing • Education about PTSD diagnoses • Share about the goal of therapy and counselor’s role – Discuss compressed/overly controlled emotions • Consistency and no surprises.
  23. 23. Trauma Processing Safe Place Strong Rapport Cognitions (distorted) Allow for emotional expression Provide feedback re: reality Eventual Goal: INTEGRATIVE METHODS
  24. 24. Trauma Processing Safe Place Strong Rapport Cognitions (distorted) Allow for emotional expression Provide feedback re: reality Eventual Goal: INTEGRATIVE METHODS Trauma Processing
  25. 25. Hearing about trauma = 25
  26. 26. One approach does not appear to fit for all clients
  27. 27. What is there to process? GUILT Helpless GRIE F
  28. 28. Dilemmas After Trauma • Unpredictability of life and death • Unexpected Losses (multiple levels of grief) • Moral Complexities (incl. guilt) • Feelings of low self-worth Boehnlein, JK (2000). Psychiatry and Religion: The Convergence of Mind and Spirit. Washington, DC: American Psychiatric Press
  29. 29. Preparing the client for trauma disclosure • Provide basic information (use visual diagram) to share about PTSD symptoms: fill out specifics together • Explain how you plan to intervene with current pattern – “Why I do what I do.” • Share diagram of emotions and truncated feelings – “Why I do what I do... Toward feelings.” • Watch their responses, reassess their understanding, are they on-board? Have they had this before? Validate discomfort. Clarify their goals for therapy. Reassure that doing heavy work too soon will not occur, but avoidance won’t either.
  30. 30. TRAUMATIC EVENT OCCURS  No resources to help survivor put that experience (share, feel)- left to own methods of coping YEARS LATER  Survivor is probably experiencing increased trauma reactions due to TRIGGERS NOT BEING IDENTIFIED TRAUMA TRIGGERS: Thoughts about self, danger, old- script; EMOTIONS.
  31. 31. Despondent Despair Helpless Grief Sadness Depressed Low Disappointed Fear Loneliness Hurt, Solemn Anger Irritated Agitated Frustrated Numb "Okay" "Fine" No Feeling Satisfied Confident Optimistic Excited Thrilled Enthusiastic Ecstatic Joyful Acceptable range VICE GRIP ON EMOTIONS AFTER TRAUMATIC EVENTS © Daniels, 2012
  32. 32. Where the rubber meets the road • Once you have safe place, rapport, and context, how to distill out underlying issues • Listen: very closely to language used by client while sharing • Watch: affect as client shares • Use: Probing, summary, reflecting, neutral affect, supportive body- language
  33. 33. QUESTIONS TO ASK THE CLIENT (assessing for context): • “How long have you had ____(symptom)?” • “How often do you have these thoughts?” (frequency) • “When was the first time you felt like this in your life?” (duration) • “How old were you when ___(incident) occurred?” • “What emotions (feelings) are you experiencing right now as you are sharing this?” Where the rubber meets the road
  34. 34. QUESTIONS TO ASK THE CLIENT (assessing for current response pattern): • “What do you usually do when ___(memory) arises?” • “Does ___ (behavior) work?” What effect does that have for you? What function?” • “What emotions are you trying to change?” • “Have you ever allowed yourself to feel the emotions connected to your trauma?” (If so, what was that like?) Where the rubber meets the road
  35. 35. SIMULTANEOUSLY, QUESTIONS TO ASK YOURSELF: (gathering data via “watching” and “listening”) • “What is their affect/body- posture/gaze?” • “Do I hear statements suggesting loss, guilt, unresolved grief?” • “What statements of ‘I am’ can I infer from what I’m hearing?” • “How old would I guess the client is as they are talking with me now? (how they present themselves)?” Where the rubber meets the road
  36. 36. QUESTIONS/STATEMENTS TO THE CLIENT: • “What emotions are you aware of right now? Where in your body are your feeling them?” • “I notice that you are hunched over and looking down... What’s going on?” (wait wait wait for the answer) • Combining assessment and observing: more information. Where the rubber meets the road
  37. 37. So many options: clinical intuition
  38. 38. So many options: clinical intuition Watch/Listen: • Body posture, eyes • Statement about self • Specifics about traumatic incident – Decisions made – Full context of situation – Use of outcome to flavor decisions made during crisis Therapist options: (just like they taught us in school – just mix it up) • Summary • Reflection • Deeper level questions • Extra information/educ • Focus on emotions • Listen... listen, watch, wait, listen more. – The whole time thinking
  39. 39. Tenacious curiosity + don’t bail too early. What is the narrative I’m hearing? How is this being shared? First time? Details? Context? Triggers? Resistance: verbal, emotional? Emotions: Fear? Guilt? Grief? Helpless? How to get “unstuck?” TRAUMA STORY REVEALED More details shared Context assessed Emotions identified “I -- statements” identified
  40. 40. Case: Mr. B - VN Vet (processing guilt and grief) • Benjamin is a war veteran (65 y.o.) from VN; helicopter door- gunner; guilt about not retrieving the body of his friend (who was KIA during training mission in dangerous area). – His narrative: “I should have gotten him... I have not allowed myself to grieve him yet b/c we didn’t get his body... I’m still angry about it... The Capt. Should have let me go – I’ve been on dangerous missions before... “ “What kind of person am I to leave someone behind?... Who did I become?” – Prior to processing – a lot more information gathered (tenacious curiosity – full picture); all aspects of what he recalled were explored and assessed • Example: He shared that he had been part of intelligence meetings, which were often accurate; his commander left for several minutes before telling the vet “no” about going to get his friend; reasoning for not being allowed to go changed (wider perspective). – Processing using all information he provided
  41. 41. Case: Ms. M - VN Vet female w/MST (processing guilt) • Marianne (63 y.o.) states that her decision to sign-up her ex- boyfriend on a helicopter for a base air-show resulted in him being killed – Her narrative: “I got him killed...and I’ve never forgiven myself for that “ – Prior to processing – more information gathered (tenacious curiosity – full picture) – Percentages of Responsibility questions asked • “What have you been saying about yourself given this incident?” “How often have you told people that you feel this way?” “How has this effected your life?” • (Gestalt) “Choose three people in this room and tell them how you’ve been holding yourself responsible all these years and the impact it’s had on your life”. • Diagram produced: Processing using all information she provided
  42. 42. Diagram: before & after processing degrees of responsibility “I’m 100% responsible, he’s dead because of me.” Veteran who was isolated after the tragedy; told that she was at fault by officers. “I wasn’t the only one making decisions that day that caused him to get killed.” The officers who arranged the air show The politicians who visited The helicopter mechanics The other pilot of the other helicopter The ex-boyfriend who coerced the vet to put him on the manifest The Veteran The designers of the Cobra
  43. 43. Case study: (processing disempowerment, helplessness) Mr. L, MST client with recurrent, traumatically-based nightmares, and lots of triggers • Larry (61 y.o.), former Air Force, was on special duty at another base; took a nap in the barracks and was assaulted by another service-member who came into the room while he slept. Was threatened 2-3x during assault. – His narrative: “I didn’t move… and then I didn’t tell anyone what happened… there was no one to tell…and I really thought he was going to kill me…” – Prior to processing: identified more triggers (wood smells, larger men, being visible, feelings of out of control – Original target symptom: recurrent nightmare 3x/week – Client completed CPT and PE at VAMC prior to Vet Ctr. – Nightmare therapy, action (Wii) therapy, sandplay with new nightmare
  44. 44. Case study: (processing disempowerment, helplessness) Mr. L, MST client with recurrent, traumatically-based nightmares, and lots of triggers
  45. 45. Emotionally processing traumatic events: Goals • Increased understanding of one’s own unique PTSD symptoms & triggers • Reduction of hyperarousal & reexperiencing symptoms • Reduction of distorted beliefs • Gain insight • Reduction of dysfunctional coping • Permission to have all emotions • Increased self-worth • Ability to control PTSD response (automatic) toward reduced time/intensity of reaction.
  46. 46. NATIONAL CENTER FOR PTSD PILOTS Database www.ptsd.va.gov

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