2-Day Trauma Informed Treatment - PowerPoint Presentation

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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? Slide8
Slide9

Trauma comes from the Greek word meaning

wound

What do we know about physical wounds and how they heal? Slide10
Slide11

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 traumaSlide13
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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. Slide24
Slide25

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.” Slide29
Slide30
Slide31

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.) Slide37
Slide38

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 breathingSlide53
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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

TasteSlide58
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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