Conference Day 1 Trauma Stabilization Jamie Marich PhD LPCCS LICDCCS Founder amp Director Mindful Ohio amp The Institute for Creative Mindfulness About Your Presenter Licensed Supervising Professional Clinical Counselor ID: 563767
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2-Day Trauma Informed Treatment ConferenceDay 1: Trauma Stabilization
Jamie Marich, Ph.D., LPCC-S, LICDC-CS
Founder & Director, Mindful Ohio & The Institute for Creative MindfulnessSlide2
About Your PresenterLicensed Supervising Professional Clinical Counselor
Licensed Independent Chemical Dependency Counselor
14 years
of experience working in social services and counseling; includes three years in civilian humanitarian (Bosnia-Hercegovina)
Specialist in addictions, trauma, EMDR, dissociation, performance enhancement, grief/loss, mindfulness, and pastoral counseling
Author of
EMDR Made Simple
,
Trauma and the Twelve Steps,
and
Trauma Made Simple
(forthcoming)
Creator of the
Dancing Mindfulness
practice Slide3
What led you to this conference?Slide4
objectivesTo define trauma from several perspectives (e.g., etymological, clinical/psychological/neurobiological/diagnostic)
To explain the impact of unhealed trauma on human behavior and societal systems (e.g., the family, education, etc.)
To describe the similarities between working with trauma and addressing grief/loss and mourning
To describe the Triphasic/consensus model of trauma treatment and explain its origins
To explain the role of the therapeutic relationship and boundary setting in effective trauma treatment
To develop a plan of stabilization/affect regulation for a client impacted by trauma
To implement no fewer than five trauma-informed stabilization skills with clients presenting in human services settings
To discuss qualities of an effective trauma therapies, including the ability to assess one’s own capacity for working with trauma in clients Slide5
Defining traumaSlide6
“Once you’ve been bitten by a snake, you’re afraid even of a piece of rope.”
-Chinese ProverbSlide7
What does the word trauma mean? Slide8Slide9
Trauma comes from the Greek word meaning
wound
What do we know about physical wounds and how they heal? Slide10Slide11
Appreciating the wound metaphor is the heart of understanding emotional trauma and how to treat it.Slide12
TraumaPost-traumatic stress disorder
adverse life experiences
complex traumaSlide13Slide14
DSM-5®: Trauma & Stressor-Related Disorders
Reactive
Attachment Disorder
Disinhibited
Social Engagement Disorder
Acute
Stress Disorder
Posttraumatic
Stress Disorder
Adjustment
Disorders
Other Specified Trauma-and-Stressor Related Disorder
Unclassified Trauma-and-Stressor Related Disorder Slide15
DSM-5® Nutshell Definition of PTSDPosttraumatic
S
tress
D
isorder
(APA, 2013)
Exposure to actual or threatened a) death, b) serious injury, or c) sexual
violation:
direct experiencing, witnessing
Intrusion
symptoms
Avoidance
of stimuli associated with the
trauma
Cognitions and Mood:
negative alterations
Arousal
and reactivity
symptoms
Duration of symptoms longer than 1 month
Functional impairment due to disturbances Slide16
Trauma: “small-t”
Adverse life experiences
Not necessarily life threatening, but definitely life-altering
Examples include
g
rief/loss, divorce, verbal abuse/bullying, and just about everything else…
The trauma itself isn’t the problem—rather, does the trauma get addressed? Is the wound given a chance to heal?
If it was traumatic to the person, then it’s traumatic.
According to the adaptive information processing model, these adverse life experiences can be just as valid and just as clinically significant as PTSD-eligible traumas (Shapiro, 2014) Slide17
Complex trauma/PtSDTerm originally coined by Dr. Judith Herman in 1992
The diagnosis and related constructs (i.e., developmental trauma disorder) not accepted for DSM-5®
Many of the field’s leading trauma professional emphasis the importance of thinking beyond the DSM-5® Slide18
Complex trauma/PtSDRepetitive or
prolonged
I
nvolve
direct harm and/or neglect or abandonment by caregivers or ostensibly responsible
adults
O
ccur
at developmentally vulnerable times in the victim’s life, such as early
childhood
H
ave
great potential to compromise severely a child’s development
.
Courtois
& Ford, 2009Slide19
ACE Study Data (CDC, 2013)
The Ten “ACEs” Measured in the Study
Emotional abuse
Physical abuse
Sexual abuse
Emotional neglect
Physical neglect
Witnessing a mother being abused
Household substance abuse
Household mental illness
Losing a parent to separation or divorce
Incarcerated household member Slide20
ACE Study Data (CDC, 2013)
Connection established between the number of adverse childhood experiences and the likelihood of these health conditions developing in young adulthood and later adulthood:
Alcoholism
and alcohol abuse
Chronic obstructive pulmonary disease (COPD)
Depression
Fetal death
Health-related quality of life
Illicit drug use
Ischemic heart disease (IHD)
Liver
diseaseSlide21
ACE Study Data (CDC, 2013)
Risk for intimate partner
violence
Multiple
sexual partners
Sexually transmitted diseases (STDs)
Smoking
Suicide attempts
Unintended pregnancies
Early initiation of smoking
Early initiation of sexual activity
Adolescent pregnancySlide22
ACE Study Data (CDC, 2013)For Further Reading
http://
acestudy.org
http://
acestoohigh.comSlide23
George Engel, M.D. (1961)
“Loss of a loved one is psychologically traumatic to the same extent that being severely wounded or burned is physiologically traumatic.”
The process of
mourning
is parallel to the process of physical healing. Slide24Slide25
A Client’s Perspective: Lily
Burana
(2009)
“PTSD means, in ‘talking over beer’ terms, that you’ve got some crossed wires in your brain due to the traumatic event. The overload of stress makes your panic button touchier than most people’s, so certain things trigger a stress reaction- or more candidly- an
over-reaction. Sometimes, the panic button gets stuck altogether and you’re in a state of constant alert, buzzing and twitchy and aggressive.”Slide26
A Client’s Perspective: Lily
Burana
(2009)
“Your
amygdala
- the instinctive flight, fight, or freeze part of your brain- reacts to a trigger before your rational mind can deter it. You can tell yourself, ‘it’s okay,’ but your wily brain is already ten steps ahead of the game, registering danger and sounding the alarm. So you might say once again, in a calm, reasoned cognitive-behavioral-therapy kind of way, ‘Brain, it’s okay…’ Slide27
A Client’s Perspective: Lily
Burana
(2009)
“But your brain yells back, ‘Bullshit kid, how dumb do you think I am? I’m not falling for that one again.’ By then, you’re hiding in the closet, hiding in a bottle, and/or hiding from life, crying, raging, or ignoring the phone and watching the counter on the answering machine go up, up, up, and up. You can’t relax, and you can’t concentrate because the demons are still pulling at your strings.”Slide28
A Client’s Perspective: Lily
Burana
(2009)
“
The long-range result is that the peace of mind you deserve in the present is held hostage by the terror of your past.” Slide29Slide30Slide31
An English teacher’s guide to trauma neurobiology
Cognitive
-behavioral, talk therapies primarily target the prefrontal regions of the brain (e.g., thinking, judgment, and willpower).
However
, when a person gets activated or triggered by traumatic memories or other visceral experiences, the prefrontal cortex is likely to shut down and the limbic brain (e.g., emotional brain) takes over.
Just talking can activate the emotional, limbic brain, but just talking isn’t very likely to calm it back down.
What
does not seem to change with traditional talk therapy is that uncomfortable experience of being triggered at a visceral
level.Slide32
Recommended reading for more depth on neuroscience
Van Der
Kolk
, B. (2014).
The body keeps the score: Brain, mind, and body in the healing of trauma.
New York, Viking. Slide33
Catalogue of Resources on the National Center for PTSD Website http://www.ptsd.va.gov/
Primary Care PTSD Screen
The PTSD Checklist
PSYCHOMETRICSSlide34
“When we honestly ask ourselves which person in our lives means
the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender
hand.”
-Henri
Nouwen
Slide35
Best Practices for assessing & building therapeutic alliance
Do
not
re-traumatize!
Do make use of open-ended questions
Do
consider the role of shame in addiction, trauma, and grief—
there is power in treating people with dignity
Do
not
use the “you need to” language
Do
not
attempt to talk reason when someone is in crisis
Do be genuine, see every interaction as a chance to build rapport
Do be non-judgmental
Do assure the client/student that they may not be alone in their experiences (if appropriate)
Do have closure strategies ready Slide36
Now It’s Your Turn
Write up a brief case synopsis:
An actual student or client (using a pseudonym)
A composite student or client
A “famous” example (presenting for clinical attention)
A fictitious case
Be sure to identify one of their driving negative themes (i.e., “I’m not good enough,” “I’m defective,” “I’m in danger,” etc.) Slide37Slide38
Discussion:
Your Reactions and ExperiencesSlide39
Principles of Trauma-Informed Care (SAMHSA, 2014)
Promote trauma awareness and understanding
Recognized that trauma-related symptoms and behaviors originate from adapting to traumatic experiences
View trauma in the context of individuals’ environments
Minimize the risk of retraumatization or replicating prior trauma dynamics
Create a safe environmentSlide40
Principles of Trauma-Informed Care (SAMHSA, 2014)
Identify recovery from trauma as a primary goal
Support control, choice, and autonomy
Create collaborative relationships and participation opportunities
Familiarize the client with trauma-informed services
Incorporate universal routine screenings for trauma
View trauma through a socio-cultural lens
Use a strengths-based perspective: Promote
resilienceSlide41
Principles of Trauma-Informed Care (SAMHSA, 2014)
Foster trauma-resistant skills
Demonstrate organizational and administrative commitment to trauma-informed care
Develop strategies to address secondary trauma and promote self-care
Provide hope—recovery is possibleSlide42
Read the entire SAMHSA Treatment Improvement Protocol:
Substance Abuse and Mental Health Services Administration (2014).
A treatment improvement protocol: Trauma-informed care in behavioral health services
. Washington, DC: Author.
Available online: http://
www.ncbi.nlm.nih.gov
/books/NBK207201/Slide43
Please Return by 1:00pmSlide44
From Dr. Bessel Van Der Kolk
“The purpose of trauma treatment is to help a person feel safe in his or her own body.”
-from the documentary
Trauma Treatment for the 21
st
Century
(Premier, 2012) Slide45
General Consensus Model of Trauma Treatment (ISTSS Task Force, 2012)
PHASE I: Stabilization
PHASE II: Processing of Trauma
PHASE III: ReintegrationSlide46
www.traumamadesimple.com/videosSlide47
What Types of Coping Skills W
ork
B
est???
Muscle relaxation
Breath
work
Pressure Points/Tapping
Yoga
Imagery/Multisensory Soothing
Anything
that incorporates the body in a positive, adaptive way!!! Slide48
Progressive Muscle RelaxationSlide49
Breathing Basics
”The mind controls the body, but the breath controls the mind.“
B.K.S.
IyengarSlide50
Breathing Basics
”Teaching breathing exercises to your client is like teaching a teenager when to accelerate and when to brake the car.“
Amy
WeintraubSlide51
Practicing Awareness of BreathSlide52
Breathing Basics
Diaphragmatic breathing
Complete breathing
Ujjayi breathing
Lion breathingSlide53Slide54
Breathing Basics
Clients who are easily activated may not feel comfortable closing their eyes during breath work. Reiterate that it is not necessary to close the eyes during these exercises.
Start slowly…if a client is not used to breathing deliberately, don’t overwhelm him. Starting with a few simple breaths, and encouraging repetition as a homework assignment, is fine.
Use counting or other sensory/grounding strategies if needed.
If a client has a history of respiratory difficulties, make sure to obtain a release to speak with her medical provider before proceeding. Slide55
Pressure Points
Sea of Tranquility
Letting Go/Butterfly Hug
Gates of Consciousness
Third Eye (and variations)
Karate Chop Slide56
Guided Imagery
The purpose of guided imagery as a stabilization coping exercise is to provide the client with a safe, healthy mental escape that he/she can access when needed
If you do not feel comfortable to develop your own guided imageries, there are many free scripts available online, use with caution to context
Avoid “place” guided imageries until you see how a client is going to respond Slide57
Variations Other Than Imagery
Sound
Smell
Touch/Tactile
TasteSlide58Slide59
Mindfulness
Mindfulness means paying attention in a particular way: on purpose, in the presence of the moment, and non-
judgmentally.
-Jon
Kabat-Zinn
(2011) Slide60
Mindfulness in everything…
Walking
Moving/gentle stretching
Playing
Dancing
Daily household tasksSlide61
RecommendationsSlide62
Motivational Interviewing: 4 Principles (Miller & Rollnick
, 2012)
Express Empathy
Develop
Discrepancy
Roll
with
Resistance
Support
S
elf
-efficacySlide63
Beutler, et al. (2005)On the Connection Between Therapist Traits & Client Outcomes
Effective therapists are interested in people as individuals
Have insight into their own personality characteristics
Have concern for others
Intelligent
Sensitive to the complexities of human motivation
Tolerant
Able to establish warm and effective relationships with othersSlide64
Charman (2005)
mindful
not having an agenda
having concern for others
intelligent
flexible in personality
intuitive
self-aware
knows own issues
able to take care of self
open
patient
creative Slide65
Qualities of a Good EMDR/Trauma Therapist
Marich (2012)
caring
trustworthy
intuitive
natural good common sense
connected smart
comfortable with trauma work consoling
s
killed validating
a
ccommodating gentle
magical nurturing
wonderful facilitating
Slide66
Qualities of an ineffective trauma/emdr therapist (marich, 2012)
rigid
scripted
detached
anxious
unclear
uncomfortable with trauma Slide67
Intense Affect & Abreaction
“The therapeutic process of bringing forgotten or inhibited material (i.e., experiences, memories) from the unconscious into consciousness, with concurrent emotional release and discharge of tension and anxiety.”
APA Dictionary of Psychology (2007)
Slide68
Mindfulness & self carePromoting mindfulness in psychotherapists-in-training could positively influence the therapeutic course and treatment results in patients (randomized, double-blind controlled study; Grepmair
,
Mitterlehner
,
Loew
, et al, 2007)
Health care professionals participating in a mindfulness-based stress reduction program (MBSR) were able to more fully identify their own themes of perfectionism, the automaticity of “other focus,” and their tendencies to always enter “fixer” mode; this recognition led to numerous changes along personal and professional domains (grounded theory; Irving, Park-Saltzman, Fitzpatrick, et al., 2014); a similar study that exclusively studied nurses yielded similar findings (
Frisvold
, Lindquist,
McAlpine
, 2012)Slide69
Mindfulness & Self CareIn an extensive mixed methods research study with working psychotherapists from a variety of theoretical backgrounds, Keane (2013) concluded that personal mindfulness practice can enhance key therapist abilities (e.g., attention) and qualities (e.g., empathy) that have a positive influence on therapeutic training.
Mindfulness practice
could provide a useful adjunct to psychotherapy training and be an important resource in the continuing professional development of therapists across modalities.Slide70
For Continued Development
How many of the qualities o
n these lists do I possess?
How do I handle intense affect and abreaction?
What are my personal barriers with
trauma?
What factors may inhibit me from being effective with someone struggling with
trauma?Slide71
References & ReadingAmerican Psychiatric Association. (2013).
Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, D. C.: Author.
Beutler
, L., Malik, M.,
Alimohamed
, S., Harwood, T., et al. (2005). Therapist variables. In M. Lambert (ed.).
Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change
(5th
ed
.,pp. 227–306). New York: Wiley.
Centers for Disease Control. (2013). Major findings, In
Adverse Childhood Experiences (ACEs) Study
. Updated January 18, 2013, Retrieved from http://
www.cdc.gov
/ace/
findings.html
Charman
, D. (2005). What makes for a “good” therapist? A review.
Psychotherapy in Australia, 11
(3), 68–72. Courtis, C. A., & Ford, J. D. (2009). Treating complex traumatic stress disorders: An evidence-based guide. New York: The Guilford Press.Engel, G. L. (1961). Is grief a disease?: A challenge for medical research. Psychosomatic Medicine, 23, 18–22. Frisvold, M. H., Lindquist, R., & McAlpine, C. P. (2012). Living life in balance at midlife: Lessons learned from mindfulness. Western Journal of Nursing Research, 34, 265-278.Grepmair, L., Mitterlehner, F., Loew, T., Bachler, E., Rother, W., & Nickel, M. (2007). Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: A randomized, double-blind controlled study. Psychotherapy and Psychosomatics, 76, 332-338
.
Herman
, J. (1992).
Trauma and recovery
. New York: Basic Books.
Irving, J.A., Park-Saltzman, J., Fitzpatrick, M.,
Dobkin
, P.L., Chen, A., & Hutchinson, T. (2014). Experiences of health care professionals enrolled in mindfulness-based medical practice: A grounded theory model.
Mindfulness, 5
, 60-71.
ISTSS Task Force:
Cloitre
, M.,
Courtois
, C. A., Ford, J. D., Green, B. L., Alexander, P.,
Briere
, J., … van der Hart, O. (2012).
The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults
. . Retrieved from
http://www.istss.org/AM/Template.cfm?Section=ISTSS_Complex_PTSD_Treatment_Guidelines&Template=/CM/ContentDisplay.cfm&ContentID=5185
.
Kabat-Zinn
, J. (2011).
Mindfulness for beginners
. Boulder, CO:
SoundsTrue
Books. Slide72
References & readingKeane, A. (2013). The influence of therapist mindfulness practice on psychotherapeutic work: A mixed-methods study.
Mindfulness
. DOI: 10.1007/s12671-013-0223-9.
Kilpatrick, D.,
Resnick
, H.S.,
Milanak
, S.E., et al. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5® criteria.
Journal of Traumatic Stress, 26(
5), 537-547
.
Marich, J. (2012). What makes a good EMDR therapist?: Exploratory clients from client-centered inquiry.
Journal of Humanistic Psychology, 52
(4), 401–422
.
Miller, W., &
Rollnick
, S. (2012).
Motivational interviewing: Helping people change. (3
rd
edition).
New York: The Guilford Press. Pease Bannit, S. (2012). The trauma toolkit: Healing PTSD from the inside out. Wheaton, IL: Quest Books. Reiger, D.A., Narrow, W.E., Clarke, D.E., et al. (2013). DSM-5® field trials in the United States and Canada, Part II: Test-Retest reliability of selected categorical diagnoses.Resick, P.A., Bovin, M.J., Calloway, A.L, et al. (2012). A critical evaluation of the complex PTSD literature: Implications for DSM-5®. Journal of Traumatic Stress, 25(3), 241-251 Shapiro, F. (2014). The Role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: Addressing the psychological and physical symptoms stemming from adverse life experiences. Permanente Journal, 18(1), 71-77.Substance Abuse and Mental Health Services Administration (2014). A treatment improvement protocol: Trauma-informed care in behavioral health services. Washington, DC: Author. Van Der
Kolk
, B. (2014).
The body keeps the score: Brain, mind, and body in the healing of trauma.
New York, Viking.
Weintraub
, A. (2012).
Yoga skills for therapists: Effective practices for mood management
. New York: W. W. Norton. Slide73
To contact today’s presenter:
Jamie
Marich, Ph.D
., LPCC-S,
LICDC-CS
Mindful Ohio
jamie@jamiemarich.com
www.mindfulohio.com
www.jamiemarich.com
www.drjamiemarich.com
www.dancingmindfulness.com
www.TraumaTwelve.com
www.TraumaMadeSimple.com
Phone: 330-881-2944