Vancouver Mental Health Summit Handouts by jackhirose

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November 14–16, 2023 Tuesday - Thursday 8:30am to 4:00pm PST

Richmond, BC Executive Hotel Vancouver Airport 7311 Westminster Hwy

FEATURED SPEAKERS

Alexia Rothman

Gordon Neufeld

Caroline Buzanko

Eboni Webb

Ph.D.

Live In-Person & Live Stream Conference

The VANCOUVER

Mental HEALTH SUMMIT A Conference Tailored for Mental Health and Education Professionals at All Levels and Any Professional that Applies Developmental and Behavioural Science to Practice

Psy.D.

Choose From 30 Workshop SEssions Jeff Riggenbach Ph.D.

Zachary Walsh Ph.D.

Janina Fisher Ph.D.

Jonah Paquette Ph.D.

TOPICS FOR: Counselling-Focused, School-Focused & All Professionals •• Internal Family Systems (IFS) Model

•• The Science Behind Cannabis Usage

•• Healing the Fragmented Selves of Trauma Survivors

•• The “Wow” Effect: How Awe & Wonder Make Us Happier, Healthier & More Connected

•• Fostering Flow States, Peak Experiences & Psychological Richness

•• Psychedelics-Assisted Psychotherapy Primer

•• Disarming High-Conflict Students in the Classroom

•• Fostering Well-Being

•• Addressing the Emotional Roots of Anxiety & Agitation

•• Neufeld’s Traffic Circle of Frustration

•• Sensorimotor Psychotherapy Deborah MacNamara Carissa Muth Ph.D.

Psy.D.

SPONSors

•• Fostering Resilience Through the Principles of Applied Positive Psychology •• Why Our Children’s Mental Health is Deteriorating & What Can be Done About It •• Conquering Anxiety •• CBT Strategies that Really Work with Students in the Classroom

•• Polyvagal Theory •• The Roots of Resilience & Resourcefulness •• Navigating Addictions: Practical Interventions to Promote Healing & Recovery •• Trauma-Focused DBT •• Resilience & the Stress Response •• Making Sense of Resistance & Opposition in Kids •• Healing the Healer

JACKHIROSE.COM | 1.800.456.5424 Group rates and student discounts are available. Visit our website for more information. Eligible for certification with the Hirose institute and qualifying CEU Boards.

TABLE OF CONTENTS 1

DAY ONE #1: Internal Family Systems (IFS) Model | Alexia Rothman, Ph.D.

pg. 4

#2: Healing the Fragmented Selves of Trauma Survivors | Janina Fisher, Ph.D.

pg. 33

#3: Fostering Flow States | Jonah Paquette, Psy.D.

pg. 50

#5: Addressing the Emotional Roots of Anxiety | Gordon Neufeld, Ph.D.

pg. 63

#6: Internal Family Systems (IFS) Model | Alexia Rothman, Ph.D.

pg. 4

#7: Sensorimotor Psychotherapy | Janina Fisher, Ph.D.

pg. 78

#8: Fostering Resilience & Positive Psychology | Jonah Paquette, Psy.D.

pg. 96

#10: Why Our Children's Mental Health | Gordon Neufeld, Ph.D.

pg. 109

DAY TWO #11: Internal Family Systems (IFS) Model | Alexia Rothman, Ph.D.

pg. 4

#12: Conquering Anxiety | Caroline Buzanko, Ph.D., R. Psych

pg.126

#14: The Science Behind Cannabis Usage | Zachary Walsh, Ph.D.

pg. 237

#15: The “Wow” Effect | Jonah Paquette, Psy.D.

pg. 282

#16: Internal Family Systems (IFS) Model | Alexia Rothman, Ph.D.

pg. 4

#17: Conquering Anxiety | Caroline Buzanko, Ph.D., R. Psych

pg. 126

#19: Psychedelics-Assisted Psychotherapy Primer | Zachary Walsh, Ph.D.

pg. 294

#20: Fostering Well-Being | Jonah Paquette, Psy.D.

pg. 329

DAY THREE #21: Polyvagal Theory | Alexia Rothman, Ph.D.

pg. 347

#22: Neufeld's Traffic Circle of Frustration | Gordon Neufeld, Ph.D.

pg. 366

#24: Navigating Addictions | Carissa Muth, Psy.D., CCC, R.Psych

pg. 384

#25: Trauma-Focused DBT | Eboni Webb, Psy.D., HSP

pg. 402

#26: Polyvagal Theory | Alexia Rothman, Ph.D.

pg. 347

#27: Resilience & the Stress Response | Gordon Neufeld, Ph.D.

pg. 425

#29: Navigating Addictions | Carissa Muth, Psy.D., CCC, R.Psych

pg. 384

#30: Healing the Healer | Eboni Webb, Psy.D., HSP

pg. 445

VANCOUVER MENTAL HEALTH SUMMIT - FALL 2023

208-197 Forester St, North Vancouver, BC, Canada V7H 0A6

t 604 924 0296 | tf 1 800 456 5424 | f 604 924 0239

WE ARE PLEASED TO WELCOME YOU TO A JACK HIROSE & ASSOCIATES CONFERENCE. If you have any questions or concerns throughout the day, please notify your on-site coordinator. PLEASE REMEMBER: • Wear your name badge every day • Turn off your cell phone • Hand in your evaluation forms at the end of each day • If you have pre-purchased lunch your tickets are in your name badge, please treat your tickets like cash. SCHEDULE: This schedule may vary depending on the flow of the presentation and participant questions 7:30am – 8:30am 8:30am – 10:00am 10:30am – 10:45am 11:00am – 11:45pm 11:45pm – 12:45pm 12:45pm – 2:15pm 2:15pm – 2:30pm 2:45pm – 4:00pm 4:00pm

Sign-In Morning Workshops Begin Mid-Morning Break – Refreshments Provided Workshop in Session Lunch Break Sign-In - CPA Members Only Afternoon Sessions Begin Mid-Afternoon Break – Refreshments Provided Workshop in Session Hand-In Evaluation Forms Sign-Out – CPA Members Only

CERTIFICATES: • Certificates are available digitally. To download a copy of your receipt or certificate, please visit: http://registration.jackhirose.com/certificates • Certificates are available for download on the final day of attendance for multi-day participants. Are you a member of the Canadian Psychological Association (CPA)? Please read the important CEU information below. • There is a new Policy as mandated by the Canadian Psychological Association • Please request a form from the on-site coordinator. Forms need to be filled out and submitted directly to the association by the participant. • CPA Members must take their name badge in the morning, sign in after lunch and sign out at the end of the day. • Early departure means CPA Members are no longer eligible to receive CPA credits • Certificates will be updated with CPA credits when the forms are returned to our head office for verification (please allow 2 – 4 weeks).

GUIDELINES FOR 6 F’S PRACTICE Contract FIND

FOCUS/ FLESH OUT

FEEL TOWARDS

BEFRIEND

FIND OUT (interview the part)

Collaboratively agree on a target part Encourage client to go inside/direct their focus inward. “Where do you find that part in or around your body?” “Where do you notice that part/the energy of that part?” Focus on the part (wherever/however they are experiencing it) “What do you notice about it?” “What’s it like?” Possibilities: Visual: “Do you see the part? What does it look like?” Emotional: “Are there any emotions/feelings associated with the part?” Thoughts: “What is it saying/saying to you?” Somatic: Feelings/sensations in body (describe) Situational: Is client re-experiencing an upsetting situation as this part becomes activated Clients may mention shape, color, age, etc. “How do you feel towards this part?” (if you know something about the part, insert that: “How do you feel towards the child?”) If client answers with “language of Self” (something reflecting qualities related to the 8 C’s, such as curiosity, openness, interest, compassion), proceed to befriending. If client’s answer suggests another part is blended and reacting to target part, have client ask part if it would be willing to give space to allow them (the client’s Self) to work with the target part. If not, stay with this new part (temporarily, this is the new target part until it can soften back and grant access to the original target part). Repeat with as many parts as need unblending. Establish a relationship between Self of client and target part. Extend Self-energy (however it’s manifesting in client: curiosity, interest, care, compassion, appreciation, gratitude, etc.) How does the part react? Take whatever time is needed to build some connection and trust, until part is responding well to Self’s presence. What does it want you to know? How is it trying to help/what’s its positive intention for you/its job? How old is it? If it didn’t have to protect in this way, what would it rather do in the system?

How old does it think you are? (Update if needed) What does it need? FEARS/CONCERNS “What are you afraid might happen if you didn’t [use your form of protection]?” Listen to all fears and concerns of part. *THANK PARTS for whatever they were able and willing to share.

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Internal Family Systems Therapy (IFS) Introduction to the IFS Model: Theory & Skills Practice

Alexia D. Rothman, Ph.D.

Healing Through Compassionate Connection TM

Disclaimer Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of mental health professionals. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your profession’s standards.

What is IFS?

2 3 4 5

Non-pathologizing model for understanding the organization and operation of our psychological systems Empirically validated psychotherapy Simple, relatable, comprehensive Easily integrated with other models Powerful © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

Workshop Aims

2023

and Development of the 1 Origins IFS model Support, Limitations & 2 Empirical Ongoing Research 3 IFS Theory: Principles & Assumptions

4 5 6

Origins of the Model • Richard C. Schwartz, Ph.D. • Structural family therapist, academic • Originally avoided intrapsychic work • Past not considered very important in healing process • Originally no emphasis on therapist-client relationship nor presence of the therapist • Must attend to the past © 2023 Alexia Rothman PhD

Origins of the Model

• Clients with Eating Disorders • Clients mentioning “Parts” • “Diane”

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Foundation for Self Leadership w w w. f o u n d a t i o n i f s . o r g

Non-profit activated in 2013 to advance IFS research, promote the IFS model within and beyond psychotherapy, and increase access to IFS trainings through scholarships

IFS and Rheumatoid Arthritis Shadick, N.A., Sowell, N.F., Frits, M.L., Hoffman, S.M., Hartz, S.A. Booth, F.D., et al. (2013). A randomized controlled trial of an internal family systems-based psychotherapeutic intervention on outcomes in rheumatoid arthritis: a proof-of-concept study. Journal of Rheumatology 40 (11), 1831-1841. • Brigham and Women’s Hospital Arthritis Center, Boston • IFS Group 9 months (n=39); • Group meetings (8-10 participants) biweekly 3 months; monthly until study end • 15 biweekly, 50-minute individual meetings over 36 weeks • Control Group (n=40): Mailed materials on RA symptoms & management. © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

IFS and Rheumatoid Arthritis • Evaluated at baseline, 3, 6, 9 months, and 1 year post-treatment. • Rheumatologists blinded to group assignment assessed joint swelling and tenderness in 28 joints • Disease Activity Score-28-C-reactive Protein 4 • Participant Self-Report for: • RA Disease Activity Index joint score (self-assessed joint pain) • Short Form-12 physical function score • Visual analog scale for overall pain • Mental Health Status (Beck Depression Inventory and State Trait Anxiety Inventory) • Self-Compassion (Neff Self Compassion scale): assesses selfkindness, self-judgment, common humanity, isolation, mindfulness, and overidentification. © 2023 Alexia Rothman PhD

IFS and Rheumatoid Arthritis Results 9 Months (study end), IFS Group Favored for:

21 Months (1yr post), IFS Group Sustained Improvement in:

• Self-assessed joint pain • Physical function • Self-compassion • Overall pain treatment effects • Depressive symptoms • Arthritis self-efficacy

• Self-assessed joint pain • Self-compassion • Depressive symptoms

IFS and Rheumatoid Arthritis Study Limitations • Greater attrition in IFS group (82% completed vs. 100% of controls) • Mostly due to difficulties traveling to meetings and conflicts with other commitments • Attention paid to education (control) group less intense than treatment group • 1-hour meeting and mailed educational materials vs. 15 individual and 12 group meetings) • Would ideally compare IFS with other psychotherapeutic modalities • 9-month time commitment led some people to decline participation • Insufficient diversity of sample © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Evidence‐Based Status • U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) granted evidence—based status for IFS (11/23/15). NREPP.SAMHSA.gov • “As a clinical treatment, IFS has been rated effective for improving general functioning and well-being. In addition, it has been rated promising for each of: improving phobia, panic, and generalized anxiety disorders and symptoms; physical health conditions and symptoms; personal resilience/self-concept; and depression and depressive symptoms.”

IFS for PTSD and Co‐Morbid Conditions Hodgdon, H., Anderson, F.G., Southwell, E., Hrubec, W., Schwartz, R.C. (2021). Internal family systems (IFS) treatment for PTSD and co-morbid conditions: A pilot study. Journal of Aggression, Maltreatment, and Trauma. • The Trauma Center and IFS-certified therapists • First study of IFS for adults with PTSD, co-morbid depressive symptoms, and history of at least two types of childhood trauma • 17 adults (13 completed), severe PTSD diagnosis and depressive symptoms & minimum two types of trauma exposure before age 18. • 16 weekly, 90-minute IFS therapy sessions • Four assessments: baseline, mid, post, and 1 month after treatment • Significant decrease in self-reported PTSD and depressive symptoms, maintained at 30 days post-treatment • 92% of completers no longer qualified for PTSD diagnosis • Limitations: Small sample size, no control group, limited diversity of sample © 2023 Alexia Rothman PhD

IFS for PTSD and Co‐Morbid Conditions • Phase II Study of IFS for PTSD (2-year duration, began September 2020) • Independent study at Harvard-affiliated Cambridge Health Alliance community mental health center (Massachusetts) • Program for Alleviating and Resolving Trauma and Stress (PARTS Study) • Randomized, controlled clinical trial led by Zev Schuman-Olivier, MD (Director for the center for Mindfulness and Compassion) • 60 adult participants with PTSD diagnoses • Examines efficacy of IFS vs. a nature-based stress reduction program as a treatment for PTSD and opioid use

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

IFS and Depression in College Women • Haddock, S. A., Weiler, L. M., Trump, L. J., & Henry, K. L. (2016). The efficacy of Internal Family Systems therapy in the treatment of depression among female college students: A pilot study. Journal of Marital and Family Therapy, 43(1), 131-144. • Colorado State University and University of Minnesota • Pilot study: 37 college women (32 completed), mild-to-severe depressive symptoms (BDI-II score: 14-63) • IFS (n =17) vs. Treatment as Usual (CBT or IPT; n =15) – random group assignment © 2023 Alexia Rothman PhD

IFS and Depression in College Women • Both groups experienced declines in depressive symptoms with no significant differences in magnitude or rate of change • 53% of TAU group and 0.06% of IFS group started antidepressant medication immediately before or during study • 33% of TAU group and 0% of IFS group participated in group therapy • TAU therapists more experienced than IFS therapists

IFS and Internet Addiction Sadr, M.M., Borjali, A., Eskandari, H., Delavar, A. (2023). Design and validation of a therapy program based on the internal family system model and its efficacy on internet addiction. Journal of Psychological Science, 22(121), 19-22. • Therapy program for internet addiction based on the IFS model. • Evaluated by 7 experts in clinical, behavioral addiction, and IFS fields • Validated • Participants: • 35 Iranian people aged 18-59 • Young’s Internet Addiction Test (IAT) score above 46 • Random assignment to experimental (17) and control (18) conditions • Did not meet DSM criteria for mental and developmental disorders (using SCID-5 semi-structured clinical interview) © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

IFS and Internet Addiction • Experimental group: 10 2-hour sessions over 1.5 months • Control group: no intervention until post-test • Reduction of internet addiction scores in experimental group significantly higher than in control group (P<.0001) • No difference between post-test and follow-up (2 months after intervention) scores (P<.05) • Concluded that the reduction of symptoms was likely the result of working on underlying emotions such as shame and worthlessness held by exiled parts © 2023 Alexia Rothman PhD

IFS and Internet Addiction Study Limitations • Attrition: Original sample size was 50 (25 experimental and 25 control) • Non-random selection of sample • Difficult to generalize results • Self-report tool can be influenced by participants’ biases • Online implementation of therapy due to COVID-19 pandemic • Might have influenced efficacy.

IFS & Physiology Research • How do Parts of our internal systems correlate to parts of our physical brain/nervous system? • Researchers at Northeastern University, The Justice Resource Institute’s Trauma Center, and a group of IFS-certified therapists examining physiological changes that occur during IFS therapy for therapist and client • Computerized sensors: electro-dermal and cardiovascular signals, motor movement, body temperature.

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Multiplicity of the Mind

• Not a monolithic personality • Psyche composed of multiple “Parts”

Parts • Subpersonalities • Can understand them as tiny people inside you.

EXILES • Parts that carry unresolved pain. • Vulnerable • Wounded

Types of Parts

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Exiles • Hold the feelings that are uncomfortable to feel • Pain, shame, sadness, grief, loneliness, anxiety, fear, out-ofcontrol, lost, unworthiness, guilt, humiliation, abandonment, panic, rejected, unloved • Wounded parts, very often young • Often frozen in time at original point of wounding, and continually re-experiencing the trauma • Carry memories, sensations, and emotions of traumas/painful experiences © 2023 Alexia Rothman PhD

Exiles • Protectors lock them away for their safety and the safety of the system. • Often our most innocent, open, intimacy-seeking Parts • Contain qualities like joy, liveliness, playfulness, spontaneity, creativity • Long for connection but also fearful of it. • Many seek redemption – fixate on someone like the person who wounded them © 2023 Alexia Rothman PhD

Protectors: Managers

PROACTIVE: Work to prevent exile activation • Run our day-to-day life • Intention: create stability, functioning, improvement, control environment to preserve safety • Attempt to keep us in control of situations and relationships to protect parts from hurt/ rejection and to protect system from their feelings/memories • “Never again” © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

MANAGERS IN EXTREME ROLES Striving Perfectionism Criticizing Seeking reassurance Evaluating Organizing Restricting Avoidance Guardedness

FIREFIGHTERS IN EXTREME ROLES

Protectors: Firefighters

Drug/alcohol abuse, self-harm/mutilation, bingeing, purging, starvation, sex binges, overspending, video games, TV, internet, gambling, violence, suicide attempts, lashing out, fighting, hoarding, dissociating, procrastinating, oversleeping.

• REACTIVE: Take action when exiles are activated to stifle or numb us to their feelings or distract us from them • In preferred roles, seek to balance the system: rest, soothing, novelty, pleasure, fun

Protectors: Firefighters • Impulsive • Not really concerned with consequences • Highly burdened • Can feel rejected, shamed, lonely, isolated • Often misunderstood and rejected internally and externally © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

Burdens

2023

“I’m such a loser.” “I’m pathetic.” “I’m unlovable.””

• Negative/extreme emotions, beliefs, or energies that enter system from a direct experience in life or are absorbed through the culture or family lineage.

• Arise from the meaning parts make of external events.

Assumptions about Parts

• Each has a full range of emotions • Not created by trauma, but may take on roles in response to traumatic experiences • Have a function in our system • No part operates in isolation • Take on burdens • No bad Parts – only Parts in extreme roles • Parts in roles for a reason, which we should seek to understand • Parts can transform/revert to preferred/ natural state when Exile(s) they are protecting are healed or in care of Self © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Compassion Clarity

Confidence

Curiosity

SELF

Calm

Creativity

Connection Courage

Structure of the Psyche Before Therapy Self (heart) obscured by Protectors, who determine thoughts, feelings and actions. Exiled Parts hidden behind the Curtain of Consciousness.

Structure of the Psyche after Therapy Self now the center of the psyche and all parts cooperating under its guidance. Parts in preferred, non-extreme roles can lend valuable qualities to the system.

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Diversity and Cultural Sensitivity • Well-meaning Parts may think they “know” something about a client based on group membership • Self-Energy: open, receptive space for clients’ Parts to make themselves known to the client and therapist • No assumptions, no preconceptions • Allow each part to tell its story such that the impact of any characteristics, identities, group membership, etc., can be properly appreciated and considered by both client (primarily) and therapist © 2023 Alexia Rothman PhD

SELF as Natural Leader of the System The Self is the natural leader of our systems and occupant of the Seat of Consciousness when none of our parts have taken its place.

Blending A Part can hijack the Seat of Consciousness and act as if it were you. • Feelings and energy of part obscure Self. • Think Part’s thoughts, feel its feelings, see world from its perspective. • Make decisions/act from that place © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Unblending Separating from a part so that you can relate to it or to another person from Self.

Relating to a Part when Unblended When parts unblend, can turn curiosity towards a Part and seek to understand and build a relationship with it. Allows for creation of healthy internal attachment relationships between Self and Parts

Relating to Another from Self When differentiated from Parts, can relate to the world from Self. Allows us to respond rather than react

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Technique: Unblending • Recognize and acknowledge when blended • Notice how you’re experiencing the blending; focus there • Ask directly if Part would separate and open some space for you to be WITH it • If flooding, ask it to draw most of its energy out of your body • Used frequently with any type of part to increase access to Selfenergy and open space for Self-to-Part connection © 2023 Alexia Rothman PhD

Assumptions of the IFS Model • Human beings are already healthy and whole • Mind is multiple - the nature of the human mind is to be subdivided. • Everyone has an undamaged Self • Healing entity, inner wisdom • Natural leader of our system • Inherently present – not developed because of relationship but becomes revealed and nurtured in relationship • No part operates in isolation; we are always working with multiple parts • If protection  vulnerability underneath • No bad parts • Not all parts wounded/burdened © 2023 Alexia Rothman PhD

Assumptions of the IFS Model • Parts have relationships • Protect, allied, polarized • System has wisdom about what needs to happen • Stay curious - client’s parts will lead to where you need to be. • Client and therapist in parallel process – both have parts that react. • IFS therapists work to know their own parts to be as Self-led as possible • We can only love someone else’s parts as much as we can love our own.

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Case Conceptualization in IFS • DSM - description of way Parts organize depending on genetic predispositions and life experience • Symptoms: Activity of Parts that can be negotiated with and healed • WE ARE TREATING A SYSTEM, NOT A SYMPTOM • What Parts are present, what are they doing? • How are they related (alliances, polarizations, protection) • When symptoms escalate – who is more upset than they were before? • Medication can be helpful for some clients – collaborate with client’s Parts/Self © 2023 Alexia Rothman PhD

“Personality Disorders” • PD Diagnosis can activate fearful and pessimistic parts of therapists • Most are trauma survivors • “Diagnosis” as a description of the protectors dominating the system • Different diagnoses dominated by different protectors • Symptoms reflect activity of protective parts • Interact with the system respectfully and bring hope • Help parts feel able to open space for Self to emerge © 2023 Alexia Rothman PhD

Dissociative Identity Disorder (DID) • Very dense boundaries between Parts - little to no awareness of each other or client’s Self • Therapist serves as Self for client’s system (Direct Access) until client can access Self-energy • Form relationships with each part individually, sometimes informing them about others, asking if they would be willing to get to know each other and eventually asking if they would open space for client’s Self to return • Often scary to allow Self to return • Dissociation can be conceptualized as the activity of a Part • When client dissociates, ask to talk to the part that took them out, then negotiate © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Addiction • Wounded Exile(s)  Blend  Distress  Firefighter  Temporarily keeps person distanced from Exile’s feelings, but no healing. • Critical manager often berates them for addictive behavior; fuels cycle • Most firefighters won’t stop using their methods until exile healed, but many treatments seek only to manage the symptom • Honor FF and manager, form collaborative relationships.

IFS THERAPY

Goals of IFS Therapy

• Harmony and balance in clients’ systems • Liberate parts from extreme roles • Decrease reactivity of system (more choice to respond) • Restore trust in Self and SelfLeadership • Help clients become more Self-led in the world

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Flow of the Model Over Course of Treatment • Establish some relationship between client’s parts and therapist’s Self • Shift client inside - learn to differentiate parts from Self and develop Self-to-Part relationships • Work with protectors • Healing process (exiles) • Circle back to protectors so they know exile has been healed and offer witnessing/ unburdening and chance to choose preferred roles • Integrate change into the system • RARELY A LINEAR PROCESS! • Trust wisdom of client’s system to guide direction and pace © 2023 Alexia Rothman PhD

Modalities for Working with Parts

Direct Access

SELF of THERAPIST

PARTS of CLIENT interacting with

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

In‐Sight SELF of CLIENT

PARTS of CLIENT interacting with

Externalization • Helps in differentiating strongly blended parts • Represent Parts outside the body • Sand tray figures/Objects/Dolls • Let Part pick object to represent them (if enough space internally) • Place where it feels right to Part (where does it want to be placed, where does client generally experience energy of that Part) • Access Self-Energy toward Part and Befriend • Empty Chair • Art © 2023 Alexia Rothman PhD

Possible Flow of an IFS Session • Session starts with Direct Access • Self of therapist talking to Part(s) of client • Client identifies Part they want to work with (or topic) • Begin to locate target part • Six F’s - establish a Self-to-Part relationship (In-sight if possible) • If Protector(s) steps back, work with Exile • Healing Process • Circle back to protector © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

The Six “F’S” Unblending & Relationship Building • Find • Focus • Flesh Out • Feel Toward • BeFriend • Fears

Find • GOAL: Help clients begin to notice how they’re experiencing Parts, how they are manifesting (thoughts, emotions, sensations, images) • “Can you find that Part in or around your body?” • Includes the head • “Where/how are you experiencing the Part?”

Ways Parts Can Manifest

• Emotions • Physical sensations • Images • Words • Body movements • Some show up with all of these, some just one or several • How they manifest may change

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Focus • “Focus your attention on however you’re experiencing it.” • “What do you notice about it?” “What’s it like?” • Invite them to stay present with the Part. • “What’s it like?” “Can you describe it?” • Wait and notice what arises.

Feel HOW ARE YOU FEELING TOWARD THE [PART]?

Flesh It Out • Not just a discrete step – develops over entire relationship • Help client stay present with Part and get a felt sense • “What does the part want you to know about it?” • Give client space to see if more information naturally arises • Promotes unblending • Helps client connect certain feelings/thoughts/ sensations to Part • Learn about part’s history/intentions/how it manifests/why it feels the way it does and why it does what it does, etc. © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Be‐Friend WHEN CRITICAL MASS OF SELF-ENERGY IS PRESENT: • Invite client to extend the curiosity/compassion/interest (any Self qualities) to part • See if part is aware of presence of Self • Check how part is responding to Self being present • Interview protector to learn: • Its role/job in the system • Its positive intention • What it’s afraid might happen if it stopped using its methods © 2023 Alexia Rothman PhD

Fears “What are you afraid/concerned would happen…?” [if you stopped responding/reacting in this way?] [if it allowed you to get to know another part or go to an exile]

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Protectors • Believe they know how to keep the system safe • Hesitant to stop using their form of protection • IFS has tremendous respect for Protectors • No expectation or demand for them to change until what they protect has been healed/is less vulnerable • Perceived (or actual) need for role must change first © 2023 Alexia Rothman PhD

Three Messages for Protectors

• Empathy • Honoring them, understanding why they don’t want us to go there, why they’re in this role, how hard they’ve had to work. • Control • “You’re in charge. If you don’t want us to, we will not go to the Exile.” • “If I can’t convince you that it’s safe to do it, then we’re not going to do it.” – Dick Schwartz • Hope/Possibility and vision © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Message of Possibility or Hope • Most protectors extremely exhausted • Start to bring them sense that maybe things can be different (possibility) • Here to help them: we can heal what they’re protecting so they don’t need to keep doing what they’ve had to do SELF-ENERGY CAN BE MORE POWERFUL THAN ANY PROTECTION © 2023 Alexia Rothman PhD

THE HEALING PROCESS

Differentiation Develop Self-part relationship

The Steps of Healing

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Differentiation & Relationship Establishment Once protectors allow access to Exile: • Assess Self-energy towards Exile (“How do you feel toward…?”) • Unblend from any Parts if necessary • Facilitate establishment of Self <-> Part relationship • Always allow Exile to set pace for safety and so it can be understood in the way it needs • Be aware of “push-ahead” Parts (therapist or client) © 2023 Alexia Rothman PhD

Witnessing Once client has critical mass of Self-energy and feels they can be present to whatever the Part needs them to know: • Invite Exile to tell/show their story (“Is there more?”) • Exiles communicate in different ways (words, images, sensations) • Therapist does not need to know what client is witnessing for healing to occur • When exile feels safe enough with the Self of client, it will show/tell/allow client to feel its story (witnessing) © 2023 Alexia Rothman PhD

Redo and Retrieval Once Exile feels fully witnessed: • Client’s Self enters the scene (if not already there) and is there for the Exile in the way it needed someone at that time • Does exile want client to do something with or for them before they leave scene (sometimes want to do it themselves) • Invite exile to move from past into present or a safe, comfortable place of its choosing (real or fantasy) • Convey that Part never has to go back; Self is now primary caretaker © 2023 Alexia Rothman PhD

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Unburdening • Ask Part what burdens it took on (can notice where in or around its body it’s carrying them). • If Part agrees it’s ready to release all or part of a burden, invite them to release however they choose. • Often to light, wind, fire, water, earth, higher power, etc. • Clients can use breath or body to help in release if desired.

When burden has been released, have client (Self) ask the Part:

Invitation

“What qualities would you like to invite into your body that you might need or want now or in the future?” • Client can notice what flows into them • Often qualities of Self that got obscured when Part was wounded • Reclaiming their wholeness © 2023 Alexia Rothman PhD

Integration/Appreciation • Circle back and thank and appreciate the protectors. • Invite them to see Exile is unburdened and healed so they may be comfortable releasing themselves from extreme roles • Protectors may need to be witnessed/unburdened

Internal Family Systems (IFS) Therapy Alexia D. Rothman, Ph.D.

2023

Integration/Follow‐Up • Post-unburdening follow-up between sessions can help solidify gains and reinforce new neural pathways. • Check in with unburdened Part, preferably daily, for at least 1 month. • Can be brief. • Reassure Part they remember them, see if they need anything.

If you would like to access my other IFS live and ondemand workshops and podcast episodes or be included on my e-mail list, please subscribe on my website:

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

Healing the Fragmented Selves of Trauma Survivors: A Trauma-Informed Approach Vancouver Mental Health Summit 14 November 2023

Janina Fisher, Ph.D. 1

Trauma One’s Self

Alienation from

•To survive overwhelming events, we need keep some distance from them. Maintaining any sense of self requires dissociative separation from the enormity of the trauma •Disowning “the bad child” or “wounded child” (the child who endured the abuse and humiliation) is a survival response: it preserves self-esteem, motivates us to be the “good child,” helps us go to school and do our homework •We disown the trauma by disowning these traumatized parts, too, as well as parts that are not safe in a dangerous world: parts that carry needs or anger or any feelings or behavior unacceptable in that environment Fisher, 2023

Alienation from one’s self as a survival strategy, cont. •When children can disown needs that won’t be met or feelings that are unacceptable, adaptation is easier---but at the price of altered consciousness and automatic habits of self-alienation. Our vulnerable feelings and needs feel‘bad’ or ‘not me,’ even decades later •Self-alienation and fragmentation also aid in maintaining the attachment to abusive parents that is necessary for survival when we are young. •Because an unsafe environment and attachment figures prevent internalizing a coherent sense of self, it is easier to remain split and compartmentalized Fisher, 2022

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

We remember these early experiences with our bodies •Our adaptations to early experience are encoded in the body in the form of visceral responses, emotions of fear or pleasure, habits, beliefs, even autonomic and muscle memory—all divorced from the events that shaped us in childhood.

•“Remembering” with our bodies and our emotions is adaptive in intent: it helps us to

automatically avoid whatever feels bad or threatening and to anticipate threat. The prefrontal cortex might evaluate the world as safe, but the body and nervous system become conditioned to respond to potential threat Fisher, 2023

A nervous system adapted to a dangerous world Hyperarousal-Related Symptoms: Impulsivity, risk-taking, poor judgment Hypervigilance, mistrust, resistance to treatment Anxiety, panic, terror, post-traumatic paranoia, racing thoughts Intrusive images, emotions; flashbacks and nightmares Self-destructive, suicidal, and addictive behavior

Hyperarousal

Window of Tolerance*

The prefrontal cortex shuts down

Hypoarousal-Related Symptoms: Hypoarousal Ogden and Minton (2000); Fisher, 2009 *Siegel (1999)

Flat affect, numb, feels dead or empty, “not there” Cognitive functioning slowed, “lazy” thinking Preoccupied with shame, despair and self-loathing Passive-aggressive, victim identity Sensorimotor Psychotherapy Institute

Remembering somatically: how can you tell it’s a “memory”? •When we “remember” attachment experiences implicitly, we don’t know that we are ‘remembering.’ When we feel warmth around the heart, clenching in the stomach, impulses to reach out, or feelings of suffocation, it doesn’t “feel” like memory. It feels like something being felt right “now” in response to current relationships •These non-verbal physical and emotional memory states or muscle memories do not “carry with them the internal sensation that something is being recalled. . . . We act, feel, and imagine without recognition of the influence of past experience on our present reality.” (Siegel, 1999)

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

Manifestations of self-alienation •Self-loathing, self-judgment, low self-esteem, no ability to take in mitigating information: one side attacks the other •“Terminal ambivalence:” stuck, can’t commit to a course of action, ‘self-sabotage:’ the two sides are in conflict •Numb, intellectualized, no emotion •Overwhelmed, emotional outbursts, no ability to soothe •Acting out, addicted, eating disordered, self-destructive •Paradoxical, contradictory behavior, mood shifts •Regressive or aggressive behavior without ‘ownership’ •Dissociative disorders, chronic depression and anxiety

“The concept of a single unitary ‘self’ is as misleading as the idea of a single unitary ‘brain.’ The left and right hemispheres process information in their own unique fashion and represent a conscious left brain self system and an unconscious right brain self system.” Schore, A. N. (2011). The right brain implicit self lies at the core of psychoanalysis. Psychoanalytic dialogues, 21:75-100. p. 76-77.

How does the brain self-alienate? Left Brain Slow to develop, the left brain is verbal, can reason, plan and organize. It can learn from experience and anticipate problems. The left brain is the verbal, analytical, informationgathering brain that manages right brain emotions/impulses. It assesses danger but does not sense it.

Corpus Collosum does not mature until 12+

Right Brain Dominant for the few five years of life, the right brain is the survival brain. It lacks verbal language but reads body language and facial expression to scan for danger or pleasure. It is intuitive and emotional, senses danger instead of evaluating it.

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

Primary Dissociation: even a single incident trauma leads to a divide between left and right brain selves

Pre-traumatic Personality Trauma

Apparently Normal Part of the Personality

Emotional Part of the Personality

This Left Brain part of the self “ carries on ” with daily life during and after the trauma. It minimizes the trauma: “It wasn’t that bad”

The Right Brain part of self holds both implicit memories and survival defense responses. Hypervigilance leads to preoccupation with anticipated threat

Van der Hart, Nijenhuis & Steele, 2006

Client-Friendly Language Pre-traumatic Personality

“Going On with Normal Life” Part of the Personality

Traumatized Part of the Personality

The Left Brain part of the self is driven by the instinct to “keep on keeping on ” with daily life and normal development during and after the trauma

This Right Brain part of self holds both the implicit memories and the survival responses necessary for anticipated threat Van der Hart, Nijenhuis & Steele, 1999

With chronic trauma, more splitting is necessary to defend against danger “Going On with Normal Life” Part

Traumatized Part of the Personality

Although the client appears to be one whole person, each survival defense causes a shift in personality and mood and even memory. Each part is driven by a different animal defense survival response

Van der Hart, Nijenhuis & Steele, 1999

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

Each part contributes a conflicting defensive strategy “I can’t afford to feel overwhelmed. I have to function!”

“Going on with Normal Life” Part

Emotional Part of the Personality

Fight: Protector

Flight: Distancer

Freeze: Terrified

Submit: Ashamed

Attach: Needy

Fight protects with anger hypervigilance, mistrust, resistance, selfharm and suicidality

Flight comes to the rescue by using addictive behavior to get quick relief, to ‘turn off’ the body

The terrified Freeze EP triggers other parts to respond with alarm

Shame, selfloathing, and passivity of Submit feeds helplessness, hopelessness

The Attach part uses vulnerability and desperate helpseeking to elicit protection

Van der Hart, Nijenhuis & Steele, 2006; Fisher, 2009

The parts remain ready to defend “When the traumatized individual is faced with reminders of the trauma and experiences a defensive response, the function of that

defensive response has shifted from reacting to an immediate threat to reacting to an anticipated threat. What began as a necessary defense in the face of a real threat becomes a pervasive, unrelenting reaction to the anticipation of a threat.” Ogden, Minton & Pain, 2006

Alienated parts are not experienced as ‘parts’ but as feelings •Overwhelming emotions: desperation, despair, shame and self-loathing, hopelessness and helplessness, rage

•Chronic expectation of danger: hypervigilance, fear and terror, mistrust, “post-traumatic paranoia”

•Body sensations: numbing, dizziness, tightness in the chest and jaw, nausea, constriction, sinking, quaking

•Impulses: motor restlessness, ‘hang-dog’ posture, impulses to “get out,” violence turned against the body

•Beliefs: “I hate myself,” “No one cares,” “I’m not safe here”

Fisher, 2012

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

Or parts are experienced as: •Loss of ability to communicate: client becomes mute, shut down, unwilling to speak, can’t find words •Voices: usually shaming, punitive, controlling •Constriction: withdrawal, social isolation, agoraphobia •Regressive behavior: loss of ability for well-learned skills, personal hygiene, ADLs, social engagement •Increasing preoccupation with helpers: the only safe/unsafe place becomes the office/hospital/house •Alternating dependence and counterdependence •Unchecked self-harm, suicidality and addictive behavior Fisher, 2014

“I’ve got different minds at different times—and they are not working together. . .” “Annie”

Trauma-Informed Stabilization Treatment [TIST] Mission: to create a trauma-informed therapeutic model specifically focused on stabilizing chronically suicidal and unstable patients. These were ‘chronically mentally ill’ clients who had spent years in hospitals without much change in their symptoms. • Some of these clients also were violent toward staff, and they were viewed negatively as attention-seeking, manipulative, oppositional, passive-aggressive, and noncompliant. • They were viewed as personality disordered, not as individuals who had experienced trauma

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

Trauma-Informed Stabilization Treatment [TIST], p. 2 • The premise underlying the TIST model was that this self-destructive behavior was inherently a survival strategy instinctively mobilized to regulate unbearable or unsafe affects/impulses.

• The high risk resulted from trauma-related inhibition of the prefrontal cortex in response to stress • Non-trauma-informed treatments did not have the desired results because these clients were structurally dissociated and internally conflicted: ‘do I want to be safe? Or do I want relief and a sense of control?’

What are the ingredients of TIST? • Neurobiologically-oriented understanding of trauma • Focus on reinstating prefrontal cortical activity as the prerequisite for behavior change and trauma resolution • Psychoeducational component: patients are educated in the method, not just treated with it • Re-frames and externalizes the symptoms to give client more psychological space between emotion and action • Combats shame- or paranoia-related interpretations • Use of mindfulness skills to decrease affect dysregulation • Assumption of “organicity:” the brain and body’s inherent intent is always adaptation and survival Fisher, 2023

With “whom” will we work? •In traditional talking therapies, each affect or reaction is treated as an expression of the client’s whole self. But what if we are working with just a part of a whole person? A fragment or “slice” of the client? What if there is no observing ego or witnessing self? •In trauma treatment, we should assume the presence of structurally dissociated parts so that we can be alert to their appearance in the therapy hour. By using the language of parts to differentiate a “Going On with Normal Life” Self from traumatized parts, we increase curiosity, support the ability to function, and increase the capacity for mindful internal awareness

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

Cultivation of the Normal Life Self as a witness or observer •Neuroscience research tells us restoration of frontal lobe functioning is a prerequisite for trauma treatment because traumatic threat and autonomic activation automatically cause inhibition of cortical activity. •Thus, the first priority is the cultivation of a witnessing self, a part of the self that can observe, be curious, notice patterns, and hold the “reality principle” •In Structural Dissociation theory, that self-witness is the “Going On with Normal Life” self. S/he is asked to become less disconnected or critical and more curious, observant, to be more ‘wise minded’ Fisher, 2008

Noticing ‘who I am’ moment to moment •We assume that ‘we are what we feel:’ but the repercussions of trauma complicate that assumption. What “I feel” could be a spontaneous response to the present moment, the implicit memory of a part, or a survival response. Further, what we feel gives rise to meaningmaking which affects what we feel about what we feel •Self-study: what is happening right here, right now, in this particular moment? Ask the client to avoid interpretation in favor of just noticing with curiosity. What part feels nausea? Which part feels angry? Whose words is the patient voicing? Fisher, 2014

“In order to do what you want, you have to know what you’re doing.” Feldenkreis

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

Learning parts language as a second language •Clients speak “I” fluently but not parts language, so we have to provide an intensive language class for them •The therapist becomes a ‘simultaneous translator. Each time the client says, “I feel,” the therapist translates the statement into parts language: “A part of you feels hopeless,” “the critical part thinks that’s weakness,” “a part of you wants to die.” •As in a language class, the more intensive the use of the second language, the more quickly the student learns. The habit of prefacing each feeling with “I” is automatic for most people but dangerous for some clients Fisher, 2020

“Speaking the Language” of Parts • Use of the “language of parts” increases mindfulness, helps clients tolerate vulnerable feelings more easily • “Relentless re-framing” helps clients to see the internal struggles and distress as messages from parts. When the client says, “I hate myself,” the therapist responds, “Is that a part that hates the other parts? does that part just hate their feelings? Or is it angry at you?” • “Relentless re-framing” encourages clients to pause, step back, and notice rather than react to their thoughts, feelings or impulses. When they notice mindfully, their interest, curiosity and compassion naturally increase Fisher, 2022

Don’t be afraid to be ‘relentless’! •‘Relentless’ means that we discipline ourselves to consistently use the language of parts to counteract the automatic assumption of one “I.” We have to hold the perspective that there is more than one “I” •It means that we consistently challenge habitual assumptions by re-stating them in the language of parts. When the client says, “I hate myself,” we respond, “Yes, there’s a part of you that hates herself—and is there also a part that judges her” •Just as with any foreign language, it is important to practice to become fluent. The therapist’s fluency reassures the client that it isn’t a sign of mental illness to have parts Fisher, 2010

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

Connect Symptoms to Parts In the context of client’s having cut herself, therapist tries to evoke curiosity: I hear you cut last night—what part do you think it was?

“I don’t know—I just hate myself”

Let’s think about this: was it Flight? Was it Fight?

[Looking at diagram] “Well, I guess it was Fight”

Was Fight upset about the phone call? Or just trying to protect you?

So, you want to trust people, and Fight wants you to mistrust them?

“Yeah, Fight thinks I’m a fool for trusting him”

“Of course I was upset! I can never trust anyone. But that sucks, too”

Fisher, 2006

Connect Symptoms to Parts, cont. Therapist continues to ask mindfulness questions:

Yes, if Fight had its way, you wouldn’t trust anyone, huh?

“It’s safer that way— then you don’t get hurt”

Yes, so Fight keeps trying to protect you that way

“But it backfires— because then I can’t get help”

Well, maybe you can work with Fight and help it see that you are an adult now who knows whom to trust

“I won’t reject my Fight part, though—it saved me in the orphanage”

Everyone needs a Fight part, so hold onto it—it gives us courage and backbone. But we need our Fight parts to let us decide who to trust and how to react.

“I do trust a lot of people here” Fisher, 2006

The question trauma survivors don’t know to ask . . .

“Which one of the many people who I am, the many inner voices inside of me, will dominate [today]? Who, or how, will I be? Which part of me will decide?” Hofstadter, 1986

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

How the parts dominate: “blending” [Schwartz, 2001]

•When clients become flooded with a part’s feelings and sensations and identify with or “blend” with them, the thoughts and feelings of that part feel like “me.” •Because they are not aware that they are blended and these feelings belong to the parts, clients act on them or try to suppress them, forcing parts to become more intense •If only to ensure safety, it becomes the therapist’s job to help clients identify that they are blended: “There’s a part of you here that feels utterly worthless, and you are blended with her. That doesn’t help her—or you.” Fisher, 2021

Mindful “un-blending” •Unblending is a two-step process. •First, we have to help clients begin to notice when they are“blending:” “Notice the hopelessness as a communication from a depressed part,” ”Notice the shame as the shame of that little girl…” •The therapist’s compassionate tone is essential here. . . •Then clients are asked to ‘just separate’ from the part a little: “Just stay with that feeling and notice it as a part trying to tell you how angry he is. . . When you notice the anger and you name it as ‘He is angry,’ do you feel better or worse?” Most clients report feeling better when they use the 3rd person

Building compassion, step by step •A direct approach tends to be too triggering for clients. Keep in mind that compassion and kindness were once very dangerous in their experience • Start with the basic ingredients of self-compassion: •Interest and curiosity: once clients can use the language of parts, at least with you, ask them to be ‘interested’ in the part. •Listening: could you listen to the part who’s speaking? •Interest, curiosity and listening rarely provoke resistance. •Next, we need to evoke more empathy for the part. . .

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

Building compassion, p. 2 •There are two ways to evoke empathy for the parts in distress: • Facilitate imagining them: “Imagine that little child was right here in front of you. . . You can see the fear in her eyes. . . You can see the tear marks on her cheeks. . . Notice your impulse as you see her here with you.”

• “How did this part help you survive?:” “Did it help that she was so quiet and afraid?” “Did it help he was ashamed?”

•Next, empathy builds with inner dialogue: “Ask the protector part what it’s worried about if it doesn’t harm the body?” “Ask the hopeless part what it’s worried about if you have hope?”

Building compassion, p. 3 •There are two ways to evoke empathy for the parts in distress: • Facilitate imagining them: “Imagine that little child was right here in front of you. . . You can see the fear in her eyes. . . You can see the tear marks on her cheeks. . . Notice your impulse as you see her here with you.”

• “How did this part help you survive?:” “Did it help that she was so quiet and afraid?” “Did it help he was ashamed?”

From alienation to attachment • There is a way for all wounded human beings to experience the love and comfort they didn’t get ‘then:’ by visualizing or imagining experiences, we evoke the same somatic responses as having had the experience • “Secure attachment,” “comfort,” “attunement” are all somatic: we feel warm, our bodies relax, we feel an energetic connection and sense of safety. When our wise minds begin to provide those felt sensory experiences for young child parts, old wounds begin to heal • As in all attachment relationships, this work requires what can seem like an endless and monotonous attention to the dysregulated feelings of the child parts Fisher, 2013

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

‘Rupture and repair’ of internal attachment Attunement: when the client provides the missing experience of comfort or acceptance, the felt sense of attunement is evoked in the here-and-now Sensorimotor Psychotherapy Institute

Rupture: a part is triggered by something; the client feels the emotional reaction

Repair: rather than ignore or suppress feelings, the client relates to them as a child’s feelings

Parts and reparative experiences •In treating trauma, we should not just be interested in what happened. We should also be interested in what should have happened but DID NOT. Was the child offered comfort? Safety? A safe base for exploration? Freedom from fear of abandonment? Acceptance of anger and sadness? What were the “missing experiences”? •Each part has had a different missing experience: Submit was not able to say “no” or set boundaries and still be safe and loved. Fight was not able to exercise control or defend the body against harm. Flight was trapped; Freeze couldn’t move; Cry for Help was abandoned. Fisher, 2023

Types of missing experiences, cont. •A ‘missing experience’ is always offered as an experimental trial: “Notice what happens when . . . .” •The missing experience could be a message: “What happens to those feelings of emptiness when you say to that little one, ‘Right here, right now, you are not alone’?” •It could be a gesture or movement: “Notice what happens if you place your hand over the place that feels the sadness. . .” “What happens for the depressed part if you lift your chin a bit?” •It could be visualization : “What happens when you take her hand in yours?” “When you hold her…” Fisher, 2020

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

Providing reparative or “missing experiences” for their parts •Encourage inner communication: “Ask her if she can feel you here with her now? Let her know that we are listening, and we want to understand how scared she is.” •Then, use the Four Befriending Questions to help clients frame the core fear: is it fear of annihilation? Or is it fear of abandonment? •And answer the question: “What does this part need from the Normal Life self in order to feel safer?? What is its ‘missing experience’? •The Normal Life self is then asked to meet the need: either verbally, somatically or emotionally Fisher, 2009

Building trust with parts •Building trust with the parts is based on a series of steps: • Clients must be able to notice the parts and communicate that they hear and see the part • They must show curiosity and interest by listening to the parts and trying to understand their feelings • Awareness of blending and being able to unblend builds trust • Internal communication is also a requirement for trust •This gradual building of trust leads to a sense of being able to depend on the client to create a safe world for them Fisher, 2023

Establishing relationships with parts •“How do you feel toward this part now?” is an IFS question that invites compassion and tests for mindfulness: does the client have enough mindful distance to feel curiosity or compassion for this part? •If the client responds with indifference or hostility, we can assume that s/he is “blended” (Schwartz, 2001) with a part. If the client responds, “I feel badly for her” or “I want to help him,” we know that a relationship is beginning to form. •Start by making sure client can feel the part: “Is she here with you right now?” “What tells you she’s there?”

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

Repair of internal attachment •Emphasize the togetherness of Adult and child: “What’s it like for her to feel you here with her? To feel your interest and concern?” •Encourage inner communication: “Ask her if she can feel you there with her now? Let her know that we are listening, and we want to understand how upset she is.” •Cultivate trust: “Let her know you understand: she wants to trust you but it’s hard—she’s been hurt so much. What’s it like for her to sense that you ‘get’ it?” •Find the part’s core fear: “Could you ask the hopeless part what she is worried about?”

Repair of internal attachment, p. 2 •To maximize the sense of attunement so that it can be experienced in the body, the therapist tries to help the client connect to his/her spontaneous compassion for children: “If this little girl were standing in front of you right this minute, what would you want to do? Feel it in your body. . . Reach out to her? Take her hand? Or pick her up and hold her? •“Feel what that’s like to have this little boy in your arms? To feel his hand in yours? Is it a good feeling? •“Take in the warmth of his body and the feeling of holding him safely. . . Ask him if he would feel less scared if you did this every time he got afraid? Fisher, 2013

Common Ground: ‘we are all held by a stronger, wiser person who cares’ Curious, compassionate, clear, calm, courageous, confident, committed

“ Going On with Normal Life” Part

Fight Response

Flight Response

Traumatized Part of the Personality

Freeze Response

Submit Response

Attachment Response

The Traumatized Part of the Personality becomes more compartmentalized: separate sub-states or parts evolve, reflecting the different survival strategies needed in a dangerous world

Van der Hart, Nijenhuis & Steele, 1999

Healing the Fragmented Selves of Trauma Survivors: a Trauma-Informed Approach

Vancouver Mental Health Summit 14 November 2023

For further information, please contact:

Janina Fisher, Ph.D. 511 Mississippi Street San Francisco, CA 94107 DrJJFisher@aol.com

Sensorimotor Psychotherapy Institute office@sensorimotorpsychotherapy.org www.sensorimotorpsychotherapy.org

11/6/23

Fostering Flow States, Peak Experiences, and Psychological Richness

About Me

Jonah Paquette, Psy.D. Author of Happily Even After, Awestruck, Real Happiness, and The Happiness Toolbox

• Author of Real Happiness, The Happiness Toolbox, Awestruck, and Happily Even After • International speaker and workshop trainer • Organizational Consultant • Host of The Happy Hour podcast

Co-Host of The Happy Hour Podcast www.jonahpaquette.com

What is Happiness?

What is happiness? • Hedonic Happiness • Positive emotions about the past, present, and future • A greater proportion of positive emotions versus negative emotions*

Hedonic Happiness

• Evaluative Happiness • Essentially equates to Life Satisfaction Eudaimonic Happiness

Evaluative Happiness

• Eudaimonic Happiness • A sense of meaning, purpose, and belonging

3 Interconnected Self-Transcendent States Awe

Awe and Wonder

Flow

Psychological Richness

11/6/23

Defining Awe

What is Awe?

Awe

The feeling we get in the presence of something vast that challenges our understanding of the world.

Vastness

Transcendence

• Vastness • Perceptual Vastness • Conceptual Vastness • Transcendence • Challenges our Assumptions • Accommodation of new information

Who Experiences Awe? • Personality factors • Extraversion, Openness to New Experiences

The Power of Awe

• Character Traits • Optimism, Gratitude, Creativity, Love of Learning, Appreciation of Beauty

“Something happens to you out there. You develop an instant global consciousness, a people orientation, an intense dissatisfaction with the state of the world, and a compulsion to do something about it.”

• Spirituality and Religion • Conflicting data on the link with awe

• Social Class • Inverted U-curve

-Edgar Mitchell, Apollo 14 astronaut (Yaden, 2016)

Cross-Cultural Research Why do we experience Awe?

• Universal human emotion found across all cultures • Differences in frequency of experiencing awe (Razavi, 2016)

• Emotions not only serve a purpose, but developed within our species for specific evolutionary advantages

• Comparison of US, Poland, Malaysia, Iran

• Differences in sources of awe (Bai, 2017) • US/Europe: more likely to experience awe through nature or through themselves • East Asia: more likely to experience awe through another person

• Not merely a result of social learning • But what purpose might awe serve?

11/6/23

Awe Connects Us With Others (Shiota & Keltner, 2007)

The Purposes of Awe

Awe Makes Us More Compassionate (Piff, 2015) • 60 seconds gazing up at Eucalyptus grove or at Science building • Staged “accident” would then occur • Awe condition far more likely to help • Piff: “Awe arouses altruism”

Awe Connects Us

Bai (2017): Awe resulted in greater feelings of closeness with others in the community compared to neutral or negative experiences

Awe Increases Generosity (Prade, 2016) • First study looked at how frequently people experienced various emotional states. • Participants also given 10 lottery tickets and that they’d be entered for a cash prize • Could either keep all the tickets, or share with an unknown stranger

Awe Makes Us More Curious (Smith, 2016)

• Awe linked to 40% greater generosity

11/6/23

Awe Enhances Positive Emotions (Joye, 2015) • Participants watched slideshow of either awe-inspiring nature scenes or those that were more commonplace • Both groups reported mood improvements, but awe condition led to vastly greater gains • These findings also suggest that awe itself may play a major role in nature’s healing powers

The Benefits of Awe

Awe Increases Life Satisfaction (Rudd, 2012)

Lasting Mood Boosts (Stellar, 2017) • Participants tracked mood and experiences of awe over several weeks • On average, people experienced approximately 2 instances of awe per week • Powerful awe experiences resulted in mood improvements even weeks later

• Participants asked to read an awe-inspiring story or a more neutral one • Then asked to rate their own overall life satisfaction • Reflecting on awe resulted in significantly increased life satisfaction

Awe Decreases Materialism

The Small Self (Bai, 2017)

• Awe linked to a preference for spending $ on experiences rather than material goods (Rudd, 2012) • Awe leads to a decreased emphasis on money, and prioritization of other values (Jiang, 2018)

• Awe reliably leads to a feeling of smallness relative to the world around us, a phenomenon known as ”the small self.”

11/6/23

Awe Lowers our Stress (Anderson, 2018)

Awe Changes Our Time Perspective (Rudd, 2012)

• Whitewater rafting adventure for war veterans and inner-city high schoolers • Led to dramatic decreases in stress and PTSD symptoms • Improved overall well-being, optimism, and social functioning • Awe as the “active ingredient” in nature

• The rise of “time poverty” • Experiences of awe “stretch out time” • Participants reported a sense that time had expanded • More likely to volunteer time to charity • Reduced overall stress

Awe Can Lead to Rapid Change

Awe Increases Humility (Stellar, 2018) • Individuals who reported more awe experiences rated by both self and peers as being: • Less self-absorbed • Less narcissistic • More humble • Possessing a more accurate understanding of their own strengths and weaknesses

“Awe is a lightning bolt that marks in memory those moments when the doors of perception are cleaned and we see with startling clarity what is truly important in life.” -- David Elkins

Awe and Inflammation (Stellar et al., 2015)

Our Brain and Body on Awe

Short-Term/Acute

Chronic

• Fights disease and infection • Restores us to homeostasis • Signals immune system to spring to action • Heals and repairs damaged tissue • Localized

• Persistent, low-grade • Widespread (rather than localized) • Linked to heart disease, stroke, Alzheimers, depression, and much more

11/6/23

Awe and Inflammation

Your Brain on Awe (Newberg, 2016) • Activation in areas linked to interpersonal bonding and release of oxytocin • Decreased activation of Default Mode Network (DMN) • Decreased activation in the parietal lobe • Contributes to sense of self, orients us to world around us • May explain the “out of body” experience many report during moments of awe

• Decreased activation of subgenual prefrontal cortex • Linked to anxious rumination

Awe and our Nervous System

Awe and the Brain

• Typically work in reverse of each other (like a hot and cold faucet) • Awe appears to be a rare state in which both branches are activated simultaneously

• Sixty audience members waring electroencephalogram (EEG) headgear • Able to detect unique and specific brainwave “signatures” during particular awe-inspiring moments during the performance

Awe and Goosebumps (Shurtz, 2012)

Facial expressions: widening of eyes, jaw slightly dropped, raised eyebrows common across cultures (Shiota, 2003; Campos, 2013; Anderson, 2017)

11/6/23

The Dark Side of Awe

The Impact of Negative Awe • 20% of reported awe experiences are negative • Threat-based awe (Piff, 2015) • Lower rates of positive emotions • Higher rates of anxiety and sadness • Greater activation of sympathetic nervous system

• Negative awe experiences resulted in increased compassion and altruism and a desire to help others, along with increased feelings of connection to community (Piff, 2015)

Becoming More Awestruck

Incorporating Awe in Clinical Work

Pathways to Awe

ØLink Awe to the presenting problem

ØE.g., discuss the effects of awe on mood, stress, social belonging

• Nature • Vastness • Mind-Bending • Courage & Inspiration • Timelessness

• Gratefulness • Mindful Awareness • Habit-building • Social Connection • The Arts

ØExplore past experiences the patient has had that we can see through this lens ØAssign realistic “awe homework” assignments in line with client preferences ØE.g., short visits to nature, reading about awe-inspiring people, learning about topics of interest, connecting to art ØEncourage journaling and savoring practices to accompany this

ØReview and consolidate experience in next session

11/6/23

Reflection

An Ancient Solution to a Modern Problem

•What something you often take for granted but is actually awe-inspiring? •What is one step you can take towards seeking more wonder in the week ahead?

People have never been more: • Stressed • Socially isolated • Short on time • Depressed • Materialistic • Polarized

Awe helps us to: • Relieve stress • Connect with others • Feel “time rich” • Improves mood • Connect with deeper values • Become kinder towards others

A 4th Happy Life?

• However, 10-15% of people resonate more with something else • Psychological Richness:

Hedonic Happiness

Evaluative Happiness

Eudaimonic Happiness

• A life marked by "interesting experiences in which novelty and/or complexity are accompanied by profound changes in perspective.” (Oishi, 2020)

Psychological Richness

Psychological Richness (Oishi, 2020) • An alternative to the hedonic vs. eudaimonic model • Psychometrically distinct from these as well

• 9-country cross-cultural study found that 17% (and even higher in some countries) preferred the psychological rich life over the hedonic or eudaimonic life • Characterized by variety, novelty, and interest

11/6/23

Some link to trait characteristic of Curiosity

Psychological Richness

Linked to individuals who experience both positive and negative emotions more intensely

Linked with individuals high in Openness on Big-5

Linked to lower levels of regret in surveys

Strategies to Enhance Psychological Richness

Reflection

• Learning new skills • Seek activities that yield flow states • Undo a regret • Stretch beyond your comfort zone • Become a lifelong learner • Foster curiosity • Write your obituary • Travel if able to; if not, seek small adventures • Lean into things that scare or intimidate you

What are some experiences or activity that have made you feel alive, pushed your comfort zones, or sparked your passion?

Flow and Strengths

Flow (Csikszentmihalyi)

11/6/23

Flow

Common Characteristics of Flow States

• A state of complete absorption in what one does • Moments of peak performance • Matching skills to challenge • How to Increase Flow • Activities that engage our skills and strengths • Using Signature Strengths in new ways

• Attentional focus • A proper degree of challenge • Goal oriented • Continual feedback • Sense of control

Flow and the Brain

Benefits of Flow States

• Default Mode Network changes • Neuroanatomical changes • transient hypo-frontality • temporary deactivation of the prefrontal cortex • Neurochemical Changes • Large quantities of norepinephrine, dopamine, serotonin, endorphins, anandamide • Neuroelectrical Changes • Increased alpha waves to enhance focus & concentration

• Time orientation • Feelings of peace and calm • Intrinsic motivation • Disconnection from physical needs • Single-mindedness

Highly linked to greater overall well-being and happiness levels

Enhanced productivity and focus

Improved emotion regulation

Signature Strengths

Examples of Items

• 24 Signature Strengths, 6 core virtues (Seligman & Peterson) • Character Strengths and Virtues – Classification Handbook (Peterson & Seligman) • Assessing/Testing strengths • VIA Survey • www.viacharacter.org

• Love of Learning • Do you feel an adrenaline rush from learning new things? • Kindness • Have you done good deeds for strangers on a regular basis? • Appreciation of Beauty • Does a sense of awe sweep over you as you contemplate the vastness of nature? • Creativity • Is your mind constantly challenging the status quo and looking for a better way?

11/6/23

Identifying Signature Strengths • Is it authentic? • Does it show up often? • Do others notice it? • Does using it energize me? • If unable to express it, would I feel empty?

24 Signature Strengths, 6 Core Virtue Domains

Reflection

Benefits of Incorporating Strengths

• Which of the above strengths resonate for you most? Which do you see in yourself, or have others in your life noticed in you?

• Decreased depression among those who regularly use their strengths (MacDougal, 2018) • Higher rates of overall well-being (Blanchard, 2019) and happiness levels (Schutte, 2018) • Increased levels of optimism (Uliaszek, 2020) • Buffers against pandemic related stress (Waters, 2021) • Stronger social and romantic relationships (Kashdan, 2017)

Practices for Strengths Work

Identifying and Using Signature Strengths

Identify your strengths

• Take the VIA Survey to identify core strengths • Ensure that identified strengths resonate with the individual

• Take the free VIA survey at viacharacter.org

• Identify 3-5 core “signature” strengths that are both resonant and high scoring • Choose 1 signature strength per day • Use it in a way that is outside your normal routine

You at your best • Craft a new narrative through a strength perspective

Identify ways you currently use your strengths Strengths during hard times Using Strengths in new ways

11/6/23

Strengths-Eliciting Questions (Saleeby) Support questions Example: Who are the people that you can rely on? Who has made you feel understood, supported, or encouraged? Exception questions Example: When things were going well in life, what was different? What point in your history would you like to relive, capture, or recreate? Possibility questions Example: What do you want to accomplish in your life? What are your hopes for your future or the future of your family? Esteem questions Example: What makes you proud of yourself? What positive things do people say about you? Perspective questions Example: What are your ideas about your current situation? Change questions Example: What do you think is necessary for things to change? What could you do to make that happen?

Get in Touch! Email: doctorpaquette@gmail.com Website: www.jonahpaquette.com Facebook: www.facebook.com/doctorpaquette Twitter: @doctorpaquette Instagram: @jonahpaquettepsyd Books: Happily Even After, Awestruck, Real Happiness, The Happiness Toolbox Newsletter: Three Good Things Thursday Podcast: The Happy Hour

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Addressing the emo.onal roots of

ANXIETY & AGITATION - an a%achment-based developmental approach -

The material for this seminar is exerpted from the Neufeld Ins,tute courses on Making Sense of Anxiety and the Alarm Spectrum

Gordon Neufeld, Ph.D.

Developmental & Clinical Psychologist Vancouver, Canada

ANXIETY

What is anxiety? … a vague sense of unsafety and unease, characterized by apprehension and restlessness … one’s subjective experience of an activated ALARM system

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

• triggered by where aRached • headquartered in the emo,onal or LIMBIC SYSTEM of the brain • mediated by the SYMPATHETIC branch of the autonomic nervous system

• ac,vates the ENDOCRINE and IMMUNE systems and aﬀects most every system

• mediated through special NEUROTRANSMITTERS in the nervous system

alarm system

• has high priority in func,oning, aﬀec,ng AROUSAL and hijacking ATTENTION

• begins opera,ng in the FETUS at about six months aPer concep,on

ATTACHMENT is our preeminent need so SEPARATION is our greatest threat • aRachment is about the drive towards TOGETHERNESS in all its various forms • the primary purpose of aRachment is move us to take CARE of each other – a7achment replaces survival in mammals

• it follows that facing separa,on is our greatest threat and the essence of STRESS • alarm is one of three primal emo,ons evoked to aRempt an instant FIX to the separa,on problem (the other two being frustra:on and separa:on-triggered pursuit)

facing separation

• aRachment is powerful, primal, primordial and PREEMINENT – the ﬁrst of three basic drives (play and achievement)

• the NATURE of the separa,on faced is directly derived from the nature of one’s aRachments

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Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

• alarm is a PRIMAL emo,on that can exist without any awareness or cogni,ve input or involvement • is meant to take care of us by moving us to CAUTION

• when felt, has a signiﬁcant TEMPERING eﬀect on behaviour

• once ac,vated, alarm seeks RESOLUTION in one way or another. Failure to resolve alarm results in RESIDUAL alarm.

alarm as an emotion

• alarm can DISPLACE other emo,ons as drivers of behaviour when more intense • is oPen PROVOKED by adults as a way of managing behaviour

• alarm and its eﬀect may or may not be FELT, or be felt in diﬀerent ways

• alarm is a very VULNERABLE emo,on to feel as it brings us face to face with what threatens us

• triggered by where aRached • headquartered in the emo,onal or LIMBIC SYSTEM of the brain • mediated by the SYMPATHETIC branch of the autonomic nervous system

• ac,vates the ENDOCRINE and IMMUNE systems and aﬀects most every system

alarm system

• has high priority in func,oning, aﬀec,ng AROUSAL and hijacking ATTENTION

• mediated through special NEUROTRANSMITTERS in the nervous system • begins opera,ng in the FETUS at about six months aPer concep,on

• both the separa,on and alarm must be for the alarm system to func,on properly

ABOUT FEELINGS AND ALARM 1. One can BE alarmed without FEELING alarmed. - just as one can BE sick, hurt, hungry, :red, frustrated, angry, a7ached, in love, pregnant – without feeling it at any given moment or even at all for that ma7er 2. We only FEEL alarmed if the cogni,ve brain receives the feedback coming back into the brain from the body, and interprets it as alarm. - this feedback does NOT have high priority for processing, is LESS likely when the brain is under stress or has other work to do, must be TIMELY for the links to be made, and can be defensively INHIBITED 3. The more directly one FEELS the alarm as separaFon alarm, the more likely the links will be made, se`ng the stage for alarm to be resolved. 4. Alarm can ALSO be felt vaguely as anxiety (unsafe, uneasy, apprehensive), indirectly as agitaFon or restlessness (the arousal system) or energe,cally as an adrenalin rush.

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

alarming separa:on must be correctly FELT for cau:on to be eﬀec:ve

the fu:lity of avoiding alarming separa:on must be FELT for adapta:on to occur

ALARMING SEPARATION WHERE AVOIDANCE IS FUTILE • bed,me, loss and mortality • separa,on resul,ng from going to school, moving, divorce of parents, parents working, hospitaliza,on, etc, etc • the dawning realiza,on of the inevitability of loss and losing • always being wanted, chosen and preferred by those whom we want, choose or prefer

facing separation

• being liked by everyone or avoiding rejec,on • the lack of invita,on to exist in another’s presence • the loss of aﬀec,on or signiﬁcance to another • securing the contact and closeness in an aRachment

To a7ach is to face separa:on, but we must a7ach and so facing separa:on cannot ever be truly avoided.

Adapting to Alarming Separation that Cannot be Avoided

• RESOLVES alarm, providing some REST and RELIEF from the primal emo,on

• develops the RESILIENCE to handle a world full of separa,on alarm • enables RECOVERY from alarming events and alarming aRachments

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

inner conﬂict must be FELT for alarm to be tempered

alarming separa:on must be correctly FELT for cau:on to be eﬀec:ve

the fu:lity of avoiding alarming separa:on must be FELT for adapta:on to occur

DESIRE

ALARM

to engage in an activity

to be away from home

to take part in some fun

to be laughed at

to ask one’s question

ALARM & DESIRE

to appear stupid

to stand up for a friend

to lose popularity

to wear what one prefers

to be seen as different

to share one’s story

to not be interesting

to express one’s opinion

to meet disapproval

to get attached & involved

to have to let go

to pursue a passion

to not measure up

to be oneself

to be alone

The capacity for COURAGE is developed through feeling conflicted • the capacity for registering more than one feeling at a ,me begins to develop between 5 to 7 YEARS of age. The more intense the feelings, the longer it takes.

• the prefrontal cortex takes years to become fully func,onal. The capacity for considera,on has a LENGTHY gesta,on period.

• the development of the prefrontal cortex is SPONTANEOUS but not inevitable – child must ﬁrst be full of feelings and then court the inner conﬂict

• the primary reason for the failure to develop a working prefrontal cortex (and thus the capacity to consider) is a LACK of tender feelings

• feelings of CARING & ALARM are the primary source or cause of inner conﬂict, dissonance or fric,on

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

TRAITS DERIVED FROM A WELL-FUNCTIONING ALARM SYSTEM

• REFLECTIVE

• CAREFUL

• characterized by a conﬂicted RELATIONSHIP with alarm

• CAUTIOUS • CONCERNED • CONSCIENTIOUS

• RESOLUTE – not controlled by alarm

• RESTFUL (from ﬁnding RELIEF & RESOLUTION re alarm) • RESILIENT (from having RECOVERED from alarming events and having adapted to an alarm-ﬁlled life)

A func,oning alarm system should move us … … to CAUTION if that is possible … to ‘CRY’ if that is fu,le … to take COURAGE if what alarms is in the way

cau:on that does exist is misplaced & thus ineﬀec:ve, OR not moved to cau:on at all

inner conﬂict is NOT felt and so avoidance impulses are not tempered WHEN FEELINGS ARE LACKING

the fu:lity of avoiding the alarming separa:on is NOT felt

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

LEVEL 1 – ANXIETY PROBLEMS - FLIGHT from alarming things and situaFons – involves obsessions and compulsions, which can include phobias and paranoia, as well as a preoccupa,on with staying out of trouble

LEVEL 2 – AGITATION & ATTENTION PROBLEMS - FLIGHT from apprehension and a%ending to what alarms results in signiﬁcant aRen,on deﬁcits, not being able to stay out of trouble, not being moved to cau,on, recklessness and carelessness

LEVEL 3 – ADRENALIN SEEKING PROBLEMS - FLIGHT from any sense of vulnerability whatsoever – the adrenalin rush involved in doing alarming things when devoid of a sense of vulnerability results in being aRracted to what alarms and a predisposi,on for being a trouble-maker

The Continuum of ALARM Problems alarm is displaced ANXIETY problems (obsessions & compulsions)

felt vaguely as unsafe, uneasy or apprehensive

••• • •

alarm is dysfunc:onal

alarm is perverted

AGITATION, ATTENTION, & DISCIPLINE problems

ADRENALIN SEEKING problems

felt indirectly felt only as adrenalin as agitaFon or and lacking other restlessness but vulnerable feelings lacking apprehension

• • HIGHLY ALARMED

•• •• •

The Continuum of ALARM Problems alarm is displaced

alarm is dysfunc:onal

it t s nalarm is iperverted

a g A ANXIETY AGITATION, ADRENALIN problems ATTENTION, ed SEEKING d (obsessions & DISCIPLINE problems n & compulsions) problems e ef D indirectly felt vaguely as felt only as adrenalin uasfelttagitaFon or b unsafe, uneasy and lacking other restlessness but d or apprehensive e lacking apprehension vulnerable feelings m ar l A• • • • HIGHLY ALARMED • • • • • •••

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

A Continuum of Defendedeness ANXIETY - based

The defensive inhibi,on of feelings is suﬃcient enough to interfere with linking the feelings of alarm to the separa,on faced, but NOT enough to keep from feeling nervous. The result is anxiety.

The defensive inhibi,on of feelings is significant AGITATION enough to keep from feeling nervous but NOT enough to keep from feeling agitated or restless. In addi,on, - based defensiveness in aRen,on results in a blindness to that which truly alarms. The result is agitaFon without apprehension plus significant deficits in a%enFon. ADRENALIN The defensive inhibi,on of feelings is severe enough to keep from feeling nervous, agitated or vulnerable, -based resul,ng in feeling ONLY the chemistry of alarm. The result is being a%racted to what alarms.

What is anxiety? … a vague sense of unsafety and unease, characterized by apprehension and restlessness … one’s subjective experience of an activated ALARM system … a response to facing separation where the FEELINGS that link the alarm with the separation faced are missing … a state of alarm-driven AVOIDANCE characterized by a FLIGHT from what our thinking brain has mistakenly assumed is the reason for alarm

SYMPTOMS

OF PRIMAL EMOTION

COGNITION-

BASED DERIVATIVES OF PRIMAL EMOTION

PRIMAL EMOTION

s COMPULSIONS R AGITATION hobiarestless se wo A lf-do p rry FEy n ubt io tens t . ANXIETY n u e n NERV on e d OUS ia ase ci onfusi panic parano

OBSESSIONS

mistaken assump,ons regarding what’s wrong

ALARM triggered by facing separation

TRIGGERING EXPERIENCE

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

IRRATIONAL OBSESSIONS

RESULTING COMPULSIONS

• someone or something is out to hurt me or to get me

work at avoiding the monsters and scary creatures, avoid getting conned, uncover people’s plots

• something is wrong with my health or my functioning or is going to make me sick

work at keeping things clean, at not getting sick, at avoiding germs, at avoiding contamination

• something is out of order or out of place

work at putting things in order and their place

• something is wrong with my body or with how I look

work at improving one’s appearance or at changing one’s shape

• some places or situations are dangerous or unsafe

work at avoiding that which makes one feel unsafe (ie, phobias)

• something has been left undone

work at remembering to complete one’s tasks

• one is ‘too much’ or ‘not enough’

work at editing or enhancing, diminishing or improving oneself

(mistakes regarding ‘what’s wrong’)

(to avoid or reduce alarm)

ACTIONS & ACTIVITIES THAT PROVIDE MOMENTARY RELIEF - can develop into compulsions or addicFons -

• triggering parasympathe.c ac.on (eg, sucking, ea,ng, chewing, nail-bi,ng, masturba,on [boys], physical exer,on, controlled breathing)

• drug-taking – depressants (eg - alcohol for alarm, marijuana for agita,on, myriad of an,-anxiety drugs & medica,ons) • drug-taking – s.mulants to evoke a return swing of the pendulum – caﬀeine, nico,ne, Ritalin, etc

• proximity fixes (stroking, hugging, transi,onal objects, contact comfort) • rhythmic ac.vity and pa\erning (rocking, pacing, rhythmic beat, drumming, swinging, worry beads, flickering fire, watching waves, hand wringing, etc )

• emo.onal playgrounds where alarm is de-ac,vated – eg, music, drama, art, dance, movement, stories, silliness, humour, games, cultural rituals

UNTEMPERED – inner conﬂict is NOT felt

CARELESS and RECKLESS – NOT moved to cauFon ALARM

NOT FELT DIRECTLY

... ATTENDING TO WHAT TRULY ALARMS

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

TRAITS DERIVED FROM AN AGITATION-BASED ALARM PROBLEM • restless, tense or hyperac,ve • predisposed to agita,on reduc,on &/or expression (eg, drugs, physical exer,on, frene,c ac,vi,es or s,mula,on) • impulsive & reac,ve • lacking • aRen,on apprehension deﬁcits where • can’t stay alarmed out of • lack of trouble or memory for harm’s way alarming events • overly • scaRered gregarious aRen,on & talka,ve where alarmed • doesn’t learn from mistakes and failure • predisposed to learning disabili,es

stuck in the ini,al either-or mode of aRen,on instead of progressing to the advanced this-and mode

immaturity -based

a%achment - based not properly aRached to, or engaged by, those aRemp,ng to command aRen,on

COMMON ATTENTION PROBLEMS

hypersensiFvity -based signal overload due to dysfunc,onal aRen,onal ﬁlters

ALARM-based A\en.on is hijacked by alarm, crea.ng signiﬁcant deﬁcits and concentra.on problems. A\en.on is sca\ered because of compe.ng biases – to a\end to what alarms and avoid looking at what alarms.

about alarm-based a7en:on problems • key signs are ‘highly agitated’ as IF highly alarmed but ‘without apprehension’ as if not at all alarmed • aRen,on system receives mixed messages from the brain: pay a7en:on to what alarms and don’t look at what alarms • the two primary symptoms are sca%ered a%enFon and significant a%enFonal deficits around alarming situa,ons (eg, can’t see trouble coming, can’t stay out of harm’s way, more gregarious than would be appropriate, somewhat reckless and careless, poor memory for alarming situa,ons) • typically will qualify for an a%enFon deficit diagnosis as the syndrome meets the three criteria: difficulty concentra,ng, restlessness or agita,on, and impulsiveness (only two of the three are required for the diagnosis)

Anxiety & Agita,on - Gordon Neufeld

a%racted to, & engaged by, WHAT ALARMS

Jack Hirose Seminars - Fall, 2023

UNTEMPERED – inner conﬂict is NOT felt ALARM, AGITATION & VULNERABILITY NOT FELT

... ALL VULNERABLE FEELINGS

TRAITS DERIVED FROM AN ADRENALIN-BASED ALARM PROBLEM • does alarming things (eg, risk-taking, cu`ng, burning) • seems rela,vely unaﬀected by what should alarm • FEARLESS • risk-taking

• unreﬂec,ve

• can become a troublemaker

• unconﬂicted • inconsiderate

• can lack a conscience

• unfeeling

• more able to engage in ‘cold’ cau,on

• TEARLESS – lacking in sadness and devoid of grief • adversity hardens rather than soPens

n e rv o u

s does alarming things

S SION BSES

y out A NX can’t sta ble u IET o tr f o Y

AGIT

reckless & careless

worry

O panic comp ulsio ns

CTED TMOS ATTRA LAR WHAT A

overconscien.ous N ATIO .cs

sity g curio lackin

facing separation

se ea un ut tay o y le to s unab arm’s wa ADRE of h SEEKNALINING

FEAR

LESS

tension SCATT E ATTEN RED on TION ntraF conceoblems cuang & burning r p stu% RESTL ering ESSNE hair-pulling phobias SS

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

WHY TODAY’S CHILDREN ARE MORE ALARMED TIO RA ES EP A

• not safe to depend

HA LP

CIN GM OR

• peer orienta,on

M NG MI

• failure to develop the capacity for rela,onship

• failure of adults to inspire dependence

CO BE

• premature separa,on

and less able to deal with it

• peer orienta,on

LOSING THEIR FEELINGS • loss of the safe spaces for feelings to recover • increased peer orienta,on and digital preoccupa,on • increased drugs and medica,ons

RA T ES EP A

embed in cascading care

HA LP

CIN GM

M NG MI

CO BE

reduce the separation they are facing

IO N

ADDRESSING THE CAUSES OF ALARM AS WELL AS ALARM SYSTEM DYSFUNCTION USING RELATIONAL & PLAY-BASED INTERVENTIONS

LOSING THEIR FEELINGS Safe caring relaFonships

make it safe to feel

EmoFonal Playgrounds

EVIDENCE-BASED, POWERFUL and SAFE UNIVERSAL in APPLICATION

INDIRECT and NON-INTRUSIVE

RELATIONAL & PLAY-BASED interven.ons

ADULT-FOCUSED – adults are the ones RESPONSIBLE NATURAL and INTUITIVE (given suppor,ng insight)

do NOT require PROGRAMS for execu,on do NOT require EXPERTS or specialized training

are NOT dependent upon medical DIAGNOSES or the construct of mental illness

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

The ul,mate challenge in addressing alarm problems is to reduce the separaFon being faced and restore the feelings of separa,on and alarm, to the point where the alarm system can more easily move the child … … to CAUTION if that is possible … to ‘CRY’ if that is fu,le … to take COURAGE if what alarms is in the way

Embed in Cascading Care • to give adults more CONTROL over the wounding and alarming social interac,on between children

• to ADDRESS peer orienta,on and alpha stuckness in order to reverse their impact on alarm • to create a REFUGE as well as a safe place for feelings to BOUNCE BACK

• to SHIELD a child against the impact of alarming interac,on

• to EMPOWER adults to help cul,vate a child’s rela,onship with alarm and resolve it via cau,on or sadness or courage

• taking care of younger children provides a suitable & non-alarming OUTLET for children’s own ALPHA ins,ncts

- hierarchical rela:onships with caring adults as well as younger children in need of their care and protec:on -

• NORMALIZE alarm, no maRer how exo,c the symptoms or pathologized by diagnosis • teach the LANGUAGE of alarm indirectly through reﬂec,ve mirroring • prime SADNESS if possible, indirectly and one step removed, if needed

• COME ALONGSIDE alarm, using your understanding to get to their side

• foster a RELATIONSHIP with ALARM, star,ng with accep,ng its inevitability from a place

of trusting dependence

• MODEL a healthy rela,onship with alarm including the op,ons of cau,on, ‘crying’ and courage

• lead into MIXED FEELINGS if inner conﬂict exists

• serve as TRAFFIC DIRECTOR if you can, helping to a resolu,on that is most suitable to the situa,on

Anxiety & Agita,on - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Addressing ALARM through PLAY • playfully alarming DEVELOPS the alarm system and BUILDS tolerance of alarm

• SADNESS is much easier accessed in the play mode

• play provides temporary REST and RELIEF from alarm

• play is the perfect scenario for the ‘DRAGON & TREASURE’ experience

• RE-PLAY of alarming scenarios can lead to eventual resolu.on

• obsessions and compulsions can be DEFUSED in play

• alarm can be MASTERED in play • play can provide SAFE DISCHARGE for alarm-fueled compulsions, agita.on and adrenalin-seeking

• ATTENTION problems are best addressed through play

Play Holds the Most Promise

attachment -based

• aRachment and alarm are at REST, allowing aRen,on some free ,me to play

ATTENTION PROBLEMS ALARM -based

• defensive ﬁlters are SUSPENDED in the play mode, stopping the mixed messages in alarm-based aRen,on problems

hypersensitivity based

• CURIOSITY is the best ANTIDOTE to any aRen,on problem, as it can pull the child through in their area of interest immaturity -based

• PLAY is the best CONTEXT for the aRen,on system to develop, repair, or ﬁnd ‘work-arounds’

• aRen,on is DRAWN rather than driven in play, allowing for op,mal func,oning

• play facilitates prefrontal cortex development, resolving impulsiveness and MATURING the aRen,on system

TIO RA ES EP A OR

HA LP

CIN GM

embed in cascading care

R MO NG MI

reduce the separation they are facing

CO BE

ADDRESSING THE CAUSES OF ALARM AS WELL AS ALARM SYSTEM DYSFUNCTION USING RELATIONAL & PLAY-BASED INTERVENTIONS

LOSING THEIR FEELINGS make it safe for children to feel

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Sensorimotor Psychotherapy:

Somatic Interventions in the Treatment of Trauma Vancouver Mental Health Summit 14 November 2023

Janina Fisher, Ph.D. 1

What is a “trauma” ? “Psychological trauma is the unique individual experience of an event, a series of events, or a set of enduring conditions, in which: •The individual’s ability to integrate his or her emotional experience is overwhelmed (i.e., hate the feelings, and or •The individual experiences (subjectively) a threat to life, bodily integrity, or sanity.” Saakvitne et al,

2000 Sensorimotor Psychotherapy™ Institute 2012

Nervous system dysregulation

Decreased concentration

Foreshortened future, Hopelessness

Nightmares Flashbacks

Hypervigilence Mistrust

Shame Self-loathing Social anxiety Panic attacks

Insomnia

Chronic pain Decreased interest Irritability Depression

Eating disorders Addictions

Numbing

Traumatic Event

Suicidality and self-harm

Borderline Personality Disorder

“Trauma” refers not just to the traumatic events but to the ‘living legacy’ of symptoms that result

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Threat and the brain Limbic System or Emotional Brain: perceives

Frontal Cortex:

analyzes, problem-solves, learns from experience

and reacts to threat

Threat

Reptilian Brain: controls our instinctive responses and functions Sensorimotor Psychotherapy Institute

Amygdala Fire Alarm and Emotional Memory Center

Why is it a ‘living legacy’? “Under conditions of extreme stress, there is failure of . . . memory processing, which results in an inability to integrate incoming input into a coherent autobiographical narrative, leaving the sensory elements of the experience unintegrated and unattached. These sensory elements are then prone to return. . .when. . . activated by current reminders.” Van der Kolk, Hopper & Osterman, 2001

Sensory elements without words = implicit memory •Brain scan research demonstrates that traumatic memories are encoded primarily as bodily and emotional feelings without words or pictures—detached from the event •These implicit memories do not “carry with them the internal sensation that something is being recalled. . . . we act, feel, and imagine without recognition of the influence of past experience on present reality.” (Siegel, 1999) •“Emotional memory converts the past into an expectation of the future. . . [and] makes the worst experiences in our past persist as felt realities.” (Ecker et al, 2012, p. 6) Fisher, 2015

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Triggers and triggering •The human body is self-protective: it automatically reacts to any cue indicating the possibility of danger. •The brain is biased to respond to any danger signal it has known before: times of day, days of the week. times of year, gender and age, facial expression, colors, smells or sounds, weather conditions, a tone of voice or body language, touch, even our own emotions and body sensations

•When we get triggered, we experience sudden and overwhelming feelings, sensations, and impulses that convey, “I AM in danger—right now!” not “I was in danger then” Fisher, 2015

Triggering supports a sense of threat The frontal lobes shut down or decrease activity to ensure instinctive responding

The trigger is now the threatening stimulus!

Amygdala responds to the threat cue by activating emergency stress response

Triggered implicit memories take many different forms •“Feeling flashbacks” of desperation, despair, shame and selfloathing, hopelessness and helplessness, rage

•Chronic expectation of danger: hypervigilance and mistrust, fear and terror, “post-traumatic paranoia”

•“Body memories:” numbing, dizziness, tightness in the chest and jaw, nausea, constriction, sinking, quaking

•Impulses and movements: motor restlessness, ‘hang-dog’

posture, frozen states, impulses to “get out,” violence turned against the body, huddling or hunkering down

•Symptoms: vegetative symptoms of depression, anxiety disorders, somatization disorder, OCD, addictive disorders, and Borderline Personality Disorder Fisher, 2014

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Autonomic nervous system is shaped by parental attachment behavior High Activation

A R O U S A L

Window of Tolerance* feelings can be tolerated we feel safe

Low Activation Sensorimotor Psychotherapy Institute

Autonomic Adaptation to a Threatening World Hyperarousal-Related Symptoms: Impulsivity, risk-taking, poor judgment, racing thoughts Perceptual and muscular hypervigilance, post-traumatic paranoia, states of frozen terror Intrusive images, sensations, emotions; flashbacks and nightmares Self-destructive and addictive behavior

Hyperarousal Optimal Arousal Zone: feelings can be tolerated able to think and feel

Hypoarousal Ogden and Minton (2000); Fisher, 2006 *Siegel (1999)

Hypoarousal-Related Symptoms: Flat affect, numb, feels dead or empty, “not there” Cognitive functioning slowed, “lazy” Preoccupied with shame, despair and self-loathing Disabled defensive responses, victim identity

“Long-lasting responses to trauma result not simply from the experience of fear and helplessness but from how our bodies [hold and] interpret those experiences.” Yehuda, 2004

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Parts reflect the body’s defensive responses “. . . We have to understand that our body, in going into certain types of responses when we are traumatized, is acting in a very heroic way. The body is helping us, it is saving us, and our body is not failing us—it is doing something special.” Porges, 2013, p. 20 (NICABM interview)

Sensorimotor Psychotherapy •Sensorimotor Psychotherapy is a body-oriented therapy developed by Pat Ogden, Ph.D. and enriched by contributions from Alan Schore, Bessel van der Kolk, Daniel Siegel, Onno van der Hart, and Ellert Nijenhuis. •Sensorimotor work combines traditional talking therapy techniques with body-centered interventions that directly address the somatic legacy of trauma. •Using the narrative only to evoke the trauma-related bodily experience, we attend first to discovering how the body has “remembered” the trauma and then to providing the somatic experiences needed for resolution Sensorimotor Psychotherapy Institute

“Small gestures and changes in breathing are at times more significant than the family tree” (Christine Caldwell, 1997)

• Sensorimotor Psychotherapy is not focused on what happened then • The narrative is used to evoke the nonverbal implicit memories: the autonomic responses, movements, postural changes, emotions, beliefs, etc. • The therapist looks for patterns, for habits of response: too much or too little affect, movement or stillness, negative cognitions, patterns of gesture or movement • Therapist and client explore “right here, right now:” how is the client organizing internally in response to triggers? How is the memory being expressed somatically? Sensorimotor Psychotherapy Institute

Fay, 2004: Fisher, 2018

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Observing the client’s habitual patterns of response “In collaboration, therapist and client “study what is going on [for the client], not as disease or something to be rid of, but in an effort to help the client become conscious of how experience is managed and how the capacity for experience can be expanded. The whole endeavor is more fun and play rather than work and is motivated by curiosity, rather than fear.” Kurtz, 1990, p. 11 Sensorimotor Psychotherapy Institute

To stabilize, frontal lobe Inhibition must be reversed “In order for the amygdala to respond to fear reactions, the prefrontal region has to be shut down. . . . [Treatment] of pathologic fear may require that the patient learn to increase activity in the prefrontal region so that the amygdala is less free to express fear.” LeDoux, 2003

Mindfulness = noticing experience instead of talking about it •Awareness or recognition of sensation, thought, emotion, movement, external stimulus (medial prefrontal cortex)

•Detachment: noticing it but ‘not participating’ in it or getting swept away by it (medial prefrontal cortex)

•Labeling: putting neutral language to what is noticed

(e.g., “I’m having a thought—some emotion is coming up”)

•Mindfulness can be directed or directionless:

following the flow of thoughts, feelings and body experience as it unfolds or deliberately focused on an aspect of experience (e.g., the breath) Fisher, 2009

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Facilitating mindful awareness •Mindfulness in therapy depends upon the therapist becoming more mindful: slowing the pace, refraining from interpretation or direction in favor of neutral observation, helping the client begin to focus on the flow of thoughts, feelings, & body sensations •Mindful attention is present moment attention. We use “retrospective mindfulness” to bring the client into present time: “As you talk about what happened then, what do you notice happening inside you now?” •Curiosity is cultivated because of its role as an entrée into mindfulness: “Perhaps by binging and purging, you were trying to help yourself get to the wedding. . .” Fisher, 2009

Mindfulness skills •“Notice . . .” •“Be curious, not judgmental. . . “ •“Let’s just notice that reaction you’re having inside as we talk about your boy friend” •“Notice the sequence: you were home alone, bored and lonely, then you started to get agitated and feel trapped, and then you just had to get out of the house” •“What might have been the trigger? Let’s be curious—go back to the start of the day and retrace your steps” Fisher, 2004

Distinguishing thoughts, feelings, and body sensations In traditional talking treatments, we do not always clearly differentiate cognition, emotion, and body responses: For example, when we say, “I feel unsafe,” •It could reflect a cognition: “I am never safe,” “The world is not a safe place” •It could mean an emotion: “I’m feeling frightened” •It could mean bodily sensation: “My chest is tight; my heart is racing; it’s hard to take a breath” •It could mean action: “I want to hurt myself” Sensorimotor Psychotherapy Institute

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Introducing mindful attention to somatic experience Because somatic awareness can be threatening for trauma survivors, as well as helpful, we introduce attention to the body slowly and carefully and track the patient’s response: •“When you talk about feeling scared, how does that feel inside?” •“That’s the thought that goes with that scared feeling: what’s the visceral sensation that goes with it?” •“What sensations tell you that you’re scared? How does your body tell you that?”

•Throughout, attention is paid to signs that the patient is becoming more, rather than less, dysregulated Sensorimotor Psychotherapy Institute

Fisher, 2004

Increasing frontal lobe activity: offer a menu of possibilities •“When you feel the panic come up, what happens? Do you feel more tense? More jittery? Or do you want to run? •“As you feel that anger, is it more like energy? Or muscle tension? Or does it want to do something?” •“When you talk about feeling ‘nothing,’ what does ‘nothing’ feel like? Is it more like calm? Or numbing? Or like freezing? ” Ogden 2004 Sensorimotor Psychotherapy Institute

Making it even easier: ask contrasting questions •“Does that sensation feel good or bad? Is it more pleasurable or unpleasurable?” •“Does it feel like something that will hurt you from the inside or the outside?” •“When you say those words, ‘I’m a loser,’ does the shame get better or worse?” Ogden 2004; Fisher, 2005

Sensorimotor Psychotherapy Institute

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

On what should we focus? •Trauma patients generally come to treatment because of post-traumatic triggering: trauma-related stimuli have stimulated anxiety symptoms, intrusive memories, overwhelming emotions, depression, and/or suicidality •The first goal of trauma treatment is to help clients recognize the role of triggering in causing and perpetuating their symptoms in order to empower them •With greater understanding comes decreased fear and shame when these responses are triggered. With more selfawareness and a language to describe what is happening, the capacity for self-regulation in the face of triggering can potentially increase Fisher, 2008

Pierre Janet 1859-1947 “[Traumatized] patients ... are [repeatedly] continuing the action, or rather the attempt at action, which began when the thing happened, and they exhaust themselves in these everlasting recommencements.” 1919/25, p. 663

Sensorimotor Psychotherapy Institute

Introducing attention to somatic experience Because somatic awareness can be threatening for trauma survivors, as well as helpful, we introduce attention to the body slowly and carefully and track the patient’s response: •“When you talk about feeling scared, how does that feel inside?” •“That’s the thought that goes with that scared feeling: what’s the visceral sensation that goes with it?” •“What sensations tell you that you’re scared? How does your body tell you that?”

•Throughout, particular attention is paid to signs that the patient is becoming more, rather than less, dysregulated Fisher, 2004 Sensorimotor Psychotherapy Institute

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Tracking the body: what story is the body telling? As clients talk about “what happened,” the narrative telling simultaneously evokes the thoughts, emotions, physical movements and body sensations associated with the event. The therapist uses this information along with the narrative to inform the treatment: foot jiggling rigidity gestures gross motor movements

trembling holding breath head down signs of autonomic arousal

slumping of the spine hyperventilation blunted affect repeated words patterns of emotion

Sensorimotor Psychotherapy Institute

Ogden, 2000; Fisher, 2003

Keeping an “experimental attitude” Kurtz 1990; Ogden 2005 •Heightened curiosity and interest: de-investment in the outcome. We want to discover, not solve •Openness to the client’s experience, whatever it is •Mindful data collection: “Let’s see what happens if you __________. Notice what shifts—or doesn’t shift.” •Everything that happens as a result of experiments is seen as useful information and therefore grist for the therapeutic mill. What doesn’t work is of equal interest •Therefore, there are no “right” or “wrong” answers, no failures. Sensorimotor Psychotherapy Institute™

Expanding the Window of Tolerance “Our brains will continue to take in

new information and construct new realities as long as our bodies feel safe. But if we become fixated on the trauma, then our ability to take in new information is lost, and we continue to construct and re-construct the old realities.” van der Kolk, 2003 Sensorimotor Psychotherapy Institute™

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Ogden 2002

Resources

Traumatic or Triggered Experience

Resource/traumatic overwhelm imbalance 31

Human beings need resources to regulate arousal and create an autonomic sense of safety Hyperarousal

Sympathetic Arousal

Emotionally reactive, impulsive Hypervigilant, hyperdefensive Intrusive images, flashbacks, nightmares Self-destructive, risk-taking, acting out

“Window of Tolerance”* Optimal Arousal Zone

Parasympathetic Arousal Ogden and Minton (2000) *Siegel, D. (1999)

Hypoarousal Flat affect, numb, “feels dead” Cognitively dissociated or slowed Collapse, psychomotor retardation Helpless and hopeless

Ogden 2002

Resources

PostTraumatic Reactions

Restoration of balance between resources and trauma responses 33

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Teaching the skills to regulate arousal within the Window of Tolerance Interventions

Hyperarousal

Notice the triggering

•Psychoeducation •Curiosity •Reframing •Mindfulness •Differentiating body, thoughts, feelings, •Identifying triggers •Tracking patterns •Breathing or sighing •DBT skills •Somatic skills

Then regulate the arousal

Hypoarousal Ogden 2006; Fisher, 2009

Sensorimotor Psychotherapy Institute

Capitalizing on the body’s “library” of resources •When a client’s frontal lobes go “off line,” using somatic resources is often more effective because there is no requirement to “think,” only to practice movements •The body is a rich source of resources: movement, muscular tension and relaxation, breathing, balance, flexibility, alignment, musculoskeletal support •Many somatic resources support psychological capacities: eg, musculoskeletal support enhances sense of emotional support, muscular relaxation supports relaxing anxiety, bodily flexibility supports psychological flexibility Fisher, 2008

Experimenting with somatic resources for traumatic reactions Traumatic Reactions:

Resources:

Shaking, trembling

Deep breath or sigh

Numb, dazed

Grounding

Wanting to run

Lengthening the spine

Mobilized for “fight”

Slowing pace

Collapsed, helpless

Making a movement

Armoring, “on guard”

Hand on the heart

Pulling back, pushing away

Clenching/unclenching

Sensorimotor Psychotherapy Institute

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Learning to “drop the content” •When triggered, clients are often bombarded with thoughts that stimulate unresolved trauma responses, further dysregulating an already fragile nervous system •A sensorimotor skill to address triggering thoughts, images, or memories is the ability to “drop the content:” to “let go” of any distressing thoughts, images, and feelings and to choose the direction of attention •Dropping the content changes the client’s focus: from the dysregulating thoughts to the feeling of the feet on the floor, or to sensations in the body, or to a new belief, such as “I’m doing the best I can” or “I’m triggered—that’s all it is—just triggering” Sensorimotor Psychotherapy Institute

Establishing calm in the body • Restoring calm to the body is a means of sending the somatic message: “You are safe now.” • If the therapy focuses primarily on the traumatic memories or on problems caused by triggering, clients will have difficulty achieving states of bodily calm in the therapy. Any relief from‘talking about’ will be offset by the autonomic dysregulation stimulated by memory • Teaching clients the importance of learning to tolerate calm, as well as how to achieve states of calm or to restore calmness after being triggered, will help to ‘re-calibrate’ the autonomic nervous system to adjust to ‘peacetime conditions’ Fisher, 2007

Tolerating states of calm •For many trauma patients, states of calm feel threatening rather than a relief. •For torture and cult survivors, procedurally learned hyperarousal, post-traumatic paranoia, and expectations of danger are “normal” states. When calmness decreases hypervigilance, it increases the sense of danger. •For the hypoaroused client, calm states within the window of tolerance can result in increased connection to emotions and bodily experience that overwhelms rather than informs •Often the therapist has to work toward achieving “calm but alert” states before “calm and relaxed” is possible

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

Experiments for regulating hyperarousal and impulsivity The client is asked to do something: 1. Breathe: take a deep breath or sigh and breathe out 2. Ground: feel the floor under the feet, push down against the floor with the feet, feel the support of the chair 3. Orient: slowly look all the way around the room and notice selected objects, colors, familiar things 4. Lengthen the spine: gently lengthen the lower back 5. Stand up: stand up, walk around, feel legs and feet 6. Create a boundary: with hands, energetic boundary Fisher, 2008

“When neither resistance nor escape is possible, the human system of self-defense becomes overwhelmed and disorganized. Each component of the ordinary response to danger, having lost its utility, tends to persist in an altered and exaggerated state long after the actual danger is over.” Judith Herman, 1992

Being trapped in “ordinary responses to danger” • Chronic expectation of danger: still feeling unsafe, the client remains hypervigilant, isolated and avoidant, phobic of many aspects of normal life • Chronic self-destructiveness: decades after the trauma, the client is still fighting but now against her/himself • Chronic despair and self-loathing: still trapped in a submissive, helpless state, she feels degraded, defeated, and powerless to help herself • Chronically searching for rescue: though the client desperately searches for help, the ‘right’ help is never there Fisher, 2013

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

“Even when immobilization is the only survival option, the impulses to actively defend remain as urges concealed within the body long after the original trauma, often going unrecognized as manifestations of the legacy of trauma.” Ogden, Minton & Pain, in press Sensorimotor Psychotherapy Institute

“[The therapist must act as an ‘auxiliary cortex’] and affect regulator of the patient’s dysregulated states in order to provide a growth-facilitating environment for the patient’s immature affectregulating structures.” Schore, 2001

Minimizing Negative Affect and Maximizing Positive “. . . The earliest phase of [attachment formation] involves calibrating the infant-caregiver relationship in regard to maintaining a positive state for the infant. The parent’s role in regulating negative arousal during the first year is not simply to respond with comfort when the infant is disturbed, but to avert distress by maintaining the infant’s interest and engagement in a positively toned dialog with the social and physical environment.” Hennighausen & Lyons-Ruth, 2005

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

“Not only is the therapist . . . unconsciously influenced by a series of slight and, in some cases, subliminal signals, so also is the patient. Details of the therapist’s posture, gaze, tone of voice, even respiration, are [unconsciously] recorded and processed. A sophisticated therapist may use this processing in a beneficial way, potentiating a change in the patient’s state without, or in addition to, the use of words.” Meares, 2005, p. 124

Strategies for neurobiologically regulating clients •Varying voice tone and pace: soft and slow, hypnotic tone, casual tone, strong and energetic tone, playful tone

• Energy level: very “there” and energetic versus more passive •Empathy vs. challenge: how does the patient respond to empathy vs. challenge? Does s/he need limits or permission?

•Amount of information provided: noting the effect of psychoeducation or therapist self-disclosure vs. neutrality

•Titrating vs. encouraging affective expression: “too much” affect or shame-based ruminating can be dysregulating

•Speaking in ways that connect client to his/her resources: intellectual, spiritual, relational or emotional Fisher, 2008.

“The primary therapeutic attitude [that needs to be] demonstrated [by the therapist] throughout a session is one of :

P = playfulness A = acceptance C = curiosity E = empathy Hughes, 2006

Sensorimotor Psychotherapy: Somatic Interventions in the Treatment of Trauma

Vancouver Mental Health Summit November 14, 2023

“Leavening” Distress States with Positive States “Playful interactions, focused on positive affective experiences, are never forgotten . . . Shame is always met with empathy, followed by curiosity. . . . All communication is ‘embodied’ within the nonverbal. . . . All resistance is met with [playfulness, acceptance, curiosity, and empathy], rather than being confronted.” Hughes, 2006

Trauma is overcome through practice, not redemption “I believe that we learn by practice. Whether it means to learn to dance by practicing dancing or to learn to live by practicing living, the principles are the same. . . . Practice means to perform over and over again in the face of all obstacles, some act of vision, of faith, of desire. Practice is a means of inviting what is desired.” Martha Graham

For further information, please contact:

Janina Fisher, Ph.D. 511 Mississippi Street San Francisco, CA 94107 DrJJFisher@aol.com www.janinafisher.com

Sensorimotor Psychotherapy Institute www.sensorimotor.org

11/6/23

Finding Happiness, Even Now

Fostering Resilience Through the Principles of Applied Positive Psychology Jonah Paquette, Psy.D. Author of Happily Even After, Awestruck, Real Happiness, and The Happiness Toolbox Co-Host of The Happy Hour Podcast www.jonahpaquette.com

Positive Psychology Misconceptions

NOT Toxic Positivity

• Not just happy-ology • Not about ignoring pain, hardship, and heartache • Not about suppressing painful emotions • Not just positive thinking • Not only for the worried well • Not just about the surface • Not about toxic positivity

• NOT minimizing pain, hardship, heartache • NOT pressuring ourselves or others to only show positive emotions • NOT a “good vibes only” approach to life • NOT saying “everything happens for a reason” • NOT being inauthentic

Happiness: A timeless and universal question

Instead…Genuine Happiness and Well-Being

11/6/23

What is Happiness? Hedonic Happiness

Eudaimonic Happiness

Happiness: A new “problem” 7

Evaluative Happiness

What is happiness?

Barriers to Happiness

• Hedonic Happiness • Positive emotions about the past, present, and future • A greater proportion of positive emotions versus negative emotions*

• Evaluative Happiness • Essentially equates to Life Satisfaction

• Eudaimonic Happiness • A sense of meaning, purpose, and belonging

Core Habits of Well-Being After Hardship

Barriers to WellBeing

vGive Thanks vBe of Service vMake Meaning vDeep Connections vCultivate Optimism vCultivate Growth

• Hedonic Adaptation • Genetics • Our Brain’s Negativity Bias • The Relentless Pursuit of Happiness • External/Life Circumstances

vAwe and Wonder vSelf-Compassion vMindful Awareness vSavor the Good vPsychological Richness

11/6/23

Gratitude “He is a wise man who does not grieve for the things which he has not, but rejoices for that which he has.” –Epictetus

What is one thing you feel thankful for in this moment?

Gratitude

The Gratitude 2-step

“A sense of wonder, thankfulness, and appreciation for life.” – Robert Emmons

1) We recognize the presence of something good in our lives 2) We recognize that the source of this goodness lies outside of ourselves

“An antidote to negative emotions, a neutralizer of envy, avarice, hostility, worry, and irritation.” – Sonya Lyubomirsky “Gratitude is an attitude, but it is much more. Gratitude has also been depicted as an emotion, a mood, a moral virtue, a habit, a motive, a personality trait, a coping response, and even a way of life.” -Robert Emmons

Benefits of Gratitude Psychological Lower Depression, Anxiety, Stress

Other Benefits Overall health improved (Emmons,

Joy, enthusiasm, happiness, love, optimism (Emmons, 2007) Increased well-being, life satisfaction (Wood, 2010) Recovery from PTSD (Kashdan,

Better sleep (Wood, 2009) Increased immune system functioning Exercise (Emmons, 2007) Decreased physical pain

More able to forgive (Luskin, 2010) Improved perception of social support

Romantic relationships (Algoe, 2010) Social Bonds (McCullough, 2002) More forgiving (Rye, 2012)

(Seligman, 2005)

2005)

The Grateful Brain • Left Prefrontal Cortex (Zahn, 2009) • Anterior Cingulate Cortex (Fox, 2015) • Interpersonal bonding • Pregenual Anterior Cingulate Cortex (pgACC) (Wong, 2016) • Links emotional and cognitive centers of brain • Lasting differences months later • Hypothalamus • Sleep, Stress, Metabolism • Increased gray matter functioning • Ventromedial Prefrontal Cortex (reward circuitry) • Serotonin, Dopamine (Zahn, 2008)

2007)

11/6/23

Foster Connection

Practices to Cultivate Gratitude

“Happiness is love. Full stop.” –George Vaillant

• 3 Good Things • Gratitude Letter/Visit • The Hidden Helpers • How Far You’ve Come • Your Inner George Bailey • Grateful Reminiscence • The Things We Take for Granted • Thanks for where we are

Lessons from “Cyberball”

Alarming Trends • Increased loneliness across time • Influence of technology • Impact of social media • Decreased volunteerism • Fewer close friends

11/6/23

Benefits of Connection Psychological • Happiness and Well-Being

Physical • Improved physical health/immune systems

• Bi-directional relationship • Lower levels of depression and anxiety (Lyubomirsky, 2007) • Decreased anxiety (Cohen,

• Longevity (House, 1988) • On par with smoking, substance, exercise • “Blue Zone” findings (Beuttner,

• Improved sleep (Cohen, 2004)

• Sardinia, Okinawa, Loma Linda, Icaria, Nicoya

(King & Diener, 2005)

Reflections on Connection

2004)

(Pressman, 2005)

2010)

Our Brain and Body on Connection

Prioritizing Connection

• Poor Social Support linked to:

• Felt-Sense of Connection • Gratitude Letter and Visit • Loving-kindness meditation • Mental Subtraction of Relationships • Best Possible Self for Relationships • Leveraging technology for good

• Activation of the pain centers of our brain • Cingulate gyrus activation in social pain experiences • Increased activation of amygdala • Telomere shrinkage (Epel, 2009) • Cortisol dysregulation • Seeing others’ pain activates our own pain centers (Botvinick, 2005)

• Good Social Support linked to: • Decreased cardiovascular reactivity (Lepore, 1993) • Decreased blood pressure (Spitzer, 1992) • Decreased cortisol (Kiecolt-Glaser, 1984) • Improved immune system functioning (Cohen, 2003) • Slows cognitive decline (Bassuk, 1999) • Vagus nerve stimulation • Increased release of oxytocin

Strengths and Flow

Signature Strengths • 24 Signature Strengths, 6 core virtues (Seligman & Peterson) • Character Strengths and Virtues – Classification Handbook (Peterson & Seligman) • Assessing/Testing strengths • www.viacharacter.org

11/6/23

Identifying Signature Strengths • Is it authentic? • Does it show up often? • Do others notice it? • Does using it energize me? • If unable to express it, would I feel empty?

24 Signature Strengths, 6 Core Virtue Domains

Reflection

Benefits of Incorporating Strengths

• Which of the above strengths resonate for you most? Which do you see in yourself, or have others in your life noticed in you?

Practices for Strengths Work

Flow (Csikszentmihalyi)

• Identify your strengths • Take the free VIA survey at viacharacter.org

• You at your best • Craft a new narrative through a strength perspective

• Identify ways you currently use your strengths • Strengths during hard times • Using Strengths in new ways

11/6/23

Flow

Flow and the Brain

Neuroanatomical changes • transient hypo-frontality • temporary deactivation of the prefrontal cortex • Neurochemical Changes • Large quantities of norepinephrine, dopamine, serotonin, endorphins, anandamide • Neuroelectrical Changes • Increased alpha waves to enhance focus & concentration

Posttraumatic Growth

Finding Growth from Hardship

Not so rare?

Identifying New Possibilities or Purposes in Life

(Bonanno, 2005; 2012)

Strengthening and Deepening of Relationships

• Following trauma, on average: • 10-15% will experience chronic symptoms of trauma following the event (impairment) • 25% will experience symptom remission (recovery) • 60% report growth following trauma (PTG) • A cross-cultural phenomenon • PTG has been studied across numerous cultures/countries including Turkey, Germany, Japan, China, Bosnia, Australia, Israel, and others (Taku & Tedeschi, 2021) • Well established • research base has existed since the Vietnam war. • More common than we might expect: • Pietrzak, 2010: 72% of Iraq/Afghanistan war veterans with PTSD report moderate/high growth • Tsai 2015: 72% of all veterans with PTSD reported moderate/great PTG

Key Domains of Growth

Increased Compassion & Altruism Awareness and Utilization of Personal Strengths Greater Appreciation of Life Spiritual Development Enhanced Creativity

11/6/23

Posttraumatic Growth as an Intervention

Education

5 Stages of PTG as Intervention

• Compatible with previously discussed research-backed approaches for PTSD • Integrative in nature: • Elements of cognitive, narrative, behavioral, and existential approaches

Constructive Self-Disclosure Creation of Trauma Narrative Service

Savoring the Good

5 Paths to Savoring

Savoring Why • Negativity Bias • Positive experiences come and go • Using the mind to change the brain • Increased neural firing • Long-term changes

Emotion Regulation

Savoring and the Brain How • 3 A’s • Attend • Notice or Create • Amplify* • Enrich the experience • 5-10 seconds or more • Absorb • Let it sink in

Ventral Striatum • Linked to sustaining positive emotions and reward Left Prefrontal Cortex Dorsolateral Prefrontal Cortex Decreased Cortisol Increased serotonin, dopamine

11/6/23

Tips for Savoring (Fred Bryant) • Share the Experience with others (“Capitalizing”) • Memory Building • Mental Notes, Photos/Souvenirs • Self-Congratulate • Pay attention to our senses • Avoid multitasking • Absorption • Ruminate on the Good

Self-Compassion

“If your compassion does not include yourself, it is incomplete.” –Jack Kornfield

Key Concepts: • 3 components (Neff, 2011) • Mindful Awareness • Common Humanity • Self-Directed Kindness • Self-Compassion vs. Self-Esteem • “Contingent self-worth” • Unstable concept

Barriers to Self-Compassion

Benefits of Self-Compassion

• “It will make me weak” • “It’s selfish” • “I won’t achieve my goals” • “A pity party” • Others?

Psychological Lower rates of depression & anxiety (Neff, 2011) Recovery from PTSD (Thompson & Waltz, 2008)

Eating Disorders (Leary & Adams , 2007 ) Cigarette Smoking (Kelly, 2010) Greater compassion towards others

Other Alleviates chronic pain Improved lower back pain (Carson, 2005)

Chronic Acne (Kelly, 2009) Closer relationships (Germer, 2009) Increased altruism (Crocker & Canavello, 2008)

Romantic Relationships (Neff, 2011) School & Work (Neff, 2011) •

11/6/23

The Physiology of Self-Compassion

Fostering Self-Compassion

Self-Criticism

• Self-Compassion Break • Identifying Needs • How I’d treat a friend • What you admire about yourself • Give someone, or yourself, a hug • Check in with yourself • Appreciate your strengths • Drop the shoulds and comparisons

Self-Compassion

• Increased amygdala response • R Prefrontal Cortex • Cortisol increases • Adrenaline released

• L Prefrontal Cortex • Increased PNS activation • Breathing slows • Insula activation • Decreased cortisol • Increased oxytocin

Reflection •What have been some of your most aweinspiring experiences? Take a moment and identify one that comes to mind.

Embrace Awe and Wonder

•How did you feel during and after the experience? What did you notice emotionally, interpersonally, and physically?

Awe

Defining Awe

Vastness

Transcendence

The Power of Awe

• Vastness • Perceptual Vastness • Conceptual Vastness

• Transcendence • Challenges our Assumptions • Accommodation of new information

-Edgar Mitchell, Apollo 14 astronaut (Yaden, 2016)

11/6/23

The Purposes of Awe

The Benefits of Awe

Psychological Benefits of Awe • Enhances Positive Emotions (Joye, 2015) • Increases Life Satisfaction (Rudd, 2012) • Lastingly Boosts our Mood (Stellar, 2017) • The “Small Self” Effect (Bai, 2017) • Decreases Materialism (Jiang, 2018; Rudd, 2012) • Lowers Stress (Anderson, 2018) • Decreases PTSD symptoms (Anderson, 2018) • Expands our sense of time (Rudd, 2012) • Increases Humility (Stellar, 2018)

Our Brain and Body on Awe

Awe and Inflammation

Awe and Inflammation (Stellar et al., 2015)

Short-Term/Acute

Chronic

• Fights disease and infection • Restores us to homeostasis • Signals immune system to spring to action • Heals and repairs damaged tissue • Localized

• Persistent, low-grade • Widespread (rather than localized) • Linked to heart disease, stroke, Alzheimers, depression, and much more

11/6/23

Your Brain on Awe

Incorporating Awe in Clinical Work ØLink Awe to the presenting problem

ØE.g., discuss the effects of awe on mood, stress, social belonging

• Activation in areas linked to interpersonal bonding and release of oxytocin • Decreased activation of Default Mode Network (DMN) • Decreased activation in the parietal lobe

ØExplore past experiences the patient has had that we can see through this lens

• Contributes to sense of self, orients us to world around us • May explain the “out of body” experience many report during moments of awe

ØAssign realistic “awe homework” assignments in line with client preferences ØE.g., short visits to nature, reading about awe-inspiring people, learning about topics of interest, connecting to art ØEncourage journaling and savoring practices to accompany this

• Decreased activation of subgenual prefrontal cortex • Linked to anxious rumination

ØReview and consolidate experience in next session

Reflection •What something you often take for granted but is actually awe-inspiring? •What is one step you can take towards seeking more wonder in the week ahead? Becoming More Awestruck

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

Troubled & disordered a.achments and the current

Youth Mental Health Crisis

Gordon Neufeld, Ph.D.

Developmental & Clinical Psychologist Vancouver, Canada

the Youth- some Mental Health Crisis facts and figures • school-aged children suffered an approximate 40% increase in depression, anxiety, irritability and aMenNon problems over the span of the pandemic • during the pandemic, adolescent psych wards were filled, children’s help lines were overwhelmed, and self-reports of anxiety and depression were unprecedented • suicides and cuVng was increasing before the pandemic and conNnued to do so through the pandemic • some studies reported that up to 70% of children experienced harm to their mental health when isolated from their peers (in contrast to about 20% who thrived when sent home from school) • most experts assumed that being socially isolated from peers must be bad for the mental health of children and so prescribed more peer interacNon as the anNdote

making sense of the

Youth Mental Health Crisis

Youth Mental Health Crisis - G. Neufeld

THEORY:

Jack Hirose Seminars Fall, 2023

ARGUMENT for MENTAL HEALTH being ROOTED in ATTACHMENT

• togetherness is our preeminent drive and as such, has the most profound and widespread impact on emoNonal, mental and developmental processes and dynamics • togetherness replaces survival as a drive in evoluNon, as survival becomes a natural outcome of togetherness • the ‘trouble spots’ in our brain have evolved from emoNon extending the reach of insNnct - aMachment being our primary drive

EVIDENCE:

• the most consistent and widesspread ﬁnding is that those embedded in a context of caring aMachments are found to be less at risk for mental health issues and problems

mental health

Attachment NATURE’S TEMPLATE FOR GIVING AND RECEIVING ... ... signals

... care

Attachments are specifically structured for giving & receiving CARE

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

PROVIDING CARE

SEEKING CARE

dependent insNncts dependent instincts • for an invitation to exist

alpha instincts

• for contact and connection • for sameness & belonging

• for warmth & love • for recognition • for significance

seeking

• to get one’s bearings

PROVID

ING

• for safety and comfort

• for understanding • for a relational ‘home’ • for a sense of togetherness

We are meant to fit together in hierarchical attachment arrangements of CASCADING CARE

a NATURAL arrangement in harmony with the dynamics of aMachment and the principles of development

as opposed to contrived arrangements based on social roles, gender stereotypes, prevailing assumpNons of equality, or parNcular dynamics between parents and children or between partners of a couple or in friendship

Our objective should be to embed in CASCADING CARE as opposed to pushing for independence or promoNng self-care

mental health

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

NEGLECT losing face both me n paren tio ts wo bedti a rking liz ta personal injury pi s failure ho e

ol dis scho ab loneliness ilit y isola tion ATH g DE facin

ar yc a d e ve loss of lo d on

mov ing

STRESs

threats to iden tity

on adopN

sec rets

ling er sib h t o n a ST

DIVORCE

E NT US RETIREME AB

CHANGE

LO ng bei resi d sch enNal ool

of .. lacknging losing face with . can’t NEGLECTED . be w o .. bel ith ... ct by cNon ne reje

n not important to ... tood co n’t feel s a ing c er fe unlo eli not ma nd ved ng Merin u b y ... t dif g to . fe .. no re

d by ... not recognize

t isola tion g ngin belo n ot

ced repla

by ...

ed nt d i sc threats a loneliness to iden ou n tity o ... ot w ted ecial t n by . n o t sp .. ld on . n’t hoapart . B . a E c T Y R B AYED n O e T h w ON HELD NOT LIKED BY ... NOT

closure separa$on-triggered

PURSUIT

ALARM

FRUSTRATION

cau$on

change

Youth Mental Health Crisis - G. Neufeld

Stress Response

PRIMAL SEPARATION EMOTIONS ARE ACTIVATED FEELINGS that would interfere with performing or funcNoning in stressful circumstances are inhibited

Jack Hirose Seminars Fall, 2023

Resilience Response Feelings that have been inhibited bounce back to enable opNmal funcNoning and the realizaNon of full potenNal

the return of feelings requires a sense of SAFETY that is best provided by SAFE RELATIONSHIPS and EMOTIONAL PLAYGROUNDS

TIME (ideally the end of the day or end of the week at most)

Stress Response

s Resilience Response lem b ro hp

G N I L

lt aFeelings he have been lthat ainhibited t bounce n PRIMAL SEPARATION meback to enable opNmal g n EMOTIONS ARE funcNoning and the i rly realizaNon of full potenNal ACTIVATED de

un on FEELINGS that wouldiLinterfere nd or with performing co funcNoning al in stressful n circumstances Lo moare inhibited e e or ec h T

M EE

N TIO

TL U B

FE S ES

the return of feelings requires a sense of SAFETY that is best provided by SAFE RELATIONSHIPS and EMOTIONAL PLAYGROUNDS

R MO TIME (ideally the end of the day or end of the week at most)

mental health

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

EMOTION IS AT THE HEART OF THE MATTER • emoNon is in charge of managing the brain, including development, prioriNes, aMenNon, and memory • the stress response is emoNonal in nature • emoNonal processes precede and undergird mental processes – in evoluNon, in development, and in everyday funcNoning

• most problems in learning, aMenNon, and maturaNon are rooted in emoNon

EMOTION NEEDS TO MATTER TO US

• adaptaNon (including healing & recovery) is an emoNonal process • mental processes are primarily derivaNves of emoNon, rather than the other way around

• almost all troubled thinking and • emoNons need to be resolved to behaviour (including diagnoses) reduce symptoms as well as to are found to have roots in emoNon eﬀect deep and lasNng change

EMOTION IS STILL & EMATTER IS AT ISCOUNTED CLIPSED EMOTION HEART THE D OF THE W D& ON • SmostOproblems ISREA ED of managing • emoNon TILL MEN & in learning, EAS ILL Mis inPRcharge ET development, STbrain, C IL BLA and TO R the including R aMenNon, E R T MED HmaturaNon DRE IO TOare MISIN aMenNon,INand N prioriNes, FER memory F R emoNon O Erooted MO Oin RED TION BEING E D I S AL N O • theILstress L C response is • adaptaNon (including ST emoNonalDIC MB EMOTION an ATIONS NUEMOTION WITH is healing &ED recovery) MOST ME process M FRO T ERN C an emoNonal process ’ N WITH LITTLE PROTES O NEEDS TOMORE C ING DOWN M • emoNonal processes SO-CALLED EXPERTS OO LM R A G ‘C MATTER IN precede and undergird UP’ are •Nmental MAK processes MOR E CO–NC mental processes in ERNED WTO IRRED THAprimarily ITH US MAN E ‘ST derivaNves of B ING EMOTIO O evoluNon, inAG development, T emoNon, rather than the NS THAN UNDERS and in everyday funcNoning TANDING TH wayBY around STILL other ECLIPSED EM THEIR EFFECTS ON • almost all troubled thinking COGNITION & to be resolved to S STILL • emoNons need SEand IAGNO MOTION reduce symptoms behaviour E(including as well as to BEHAVIOUR E DICAL D diagnoses) F O M E L are found to Ehave RO in emoNon eﬀect deep and lasNng change THEroots ECLIPS

KEY INSIGHTS REGARDING E M O T I O N • there is PURPOSE to emoNon it is Nature’s way of moving us and taking care of us • each emoNon has specific WORK to do (ie, emoNons are Nature’s workforce) • emoNons need sufficient REST in order to do be effecNve in their work • emoNons seek RELIEF through expression but this will be thwarted if working aMachments are threatened

• emoNons need to be RESOLVED in some way or another or they will get stuck • the emoNonal system needs to DEVELOP for opNmal funcNoning but can only do so if condiNons are conducive • the emoNonal system begins in the ‘EITHER OR’ mode and is meant to mature into ‘THIS AND’ funcNoning where inner conﬂict is felt • emoNons need to be FELT for opNmal funcNoning and for children to ﬂourish

Youth Mental Health Crisis - G. Neufeld

Stress Response

Jack Hirose Seminars Fall, 2023

s Resilience Response lem b ro hp

IN EL

lt aFeelings he have been lthat

SF S E

tainhibited bounce

n eback PRIMAL SEPARATION to enable opNmal g m funcNoning and the n EMOTIONS ARE i y l r realizaNon of full potenNal ACTIVATED de n nu

o FEELINGS that wouldiLinterfere d with performing on or c l in stressful funcNoning na circumstances Lo o m are inhibited

e or ec h T

M EE

N TIO

TL U B

the return of feelings requires a sense of SAFETY that is best provided by SAFE RELATIONSHIPS and EMOTIONAL PLAYGROUNDS

R O M TIME (ideally the end of the day or end of the week at most)

The Continuum of ALARM Problems alarm is dysfunc;onal

alarm is perverted

ANXIETY problems (obsessions & compulsions)

AGITATION, ATTENTION, & DISCIPLINE problems

ADRENALIN SEEKING problems

feel unsafe but alarm not linked to the separa$on faced

driven by alarm that is not felt

devoid of feelings of alarm, fu$lity & vulnerability

alarm is displaced

including cuUng & burning ••• • •

• • HIGHLY ALARMED

•• •• •

The Continuum of Aggression Problems

EXISTENCE of attacking impulses

ERUPTIONS of attacking energy

not feeling the fu$lity of changing the frustra$ng circumstances including suicidal impulses ••• • •

VIOLATING aggression problems

devoid of feelings of alarm, fu$lity & vulnerability

• • HIGHLY FRUSTRATED • • • •

••

Youth Mental Health Crisis - G. Neufeld

Resilience Response

Stress Response

Feelings that have been inhibited bounce back to enable opNmal funcNoning and the realizaNon of full potenNal

PRIMAL SEPARATION EMOTIONS ARE ACTIVATED FEELINGS that would interfere with performing or funcNoning in stressful circumstances are inhibited

Jack Hirose Seminars Fall, 2023

the return of feelings requires a sense of SAFETY that is best provided by SAFE RELATIONSHIPS and EMOTIONAL PLAYGROUNDS

TIME (ideally the end of the day or end of the week at most)

ADULT

- wounding by others - not being held on to - losses and lacks - peer or sibling rejection

• not only serves as a SHIELD against external wounding but also as a SAFE SANCTUARY for feeling • this SAFETY is not a funcLon of reality but a funcLonal ILLUSION created by an a.achment characterized by trusLng dependence

CHILD

- shaming or put-downs - not feeling liked, wanted or valued - feeling too much to handle

ADULT

- wounding by others - not being held on to

we must HAVE their hearts before we can protect their hearts

- losses and lacks - peer or sibling rejection

CHILD

- shaming or put-downs - not feeling liked, wanted or valued - feeling too much to handle

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

mental health

T EN h)? M t l CH e a TA al h T A nt ED me R E s RD thu PEER ORIENTATION O d IS n f D g (a ALPHA COMPLEX o n c t bei a DEPERSONALIZATION p im well e l th na t iso$o a h W em on

Attachment PEER ORIENTATION

Children taking their cues from each other as to how to act, what to do, how to talk, what to wear, how to express oneself, what is valued, what is expected, what is right and what is wrong

The compeLng nature of most peer a.achments today (ie, can’t be close to both peers and adults simultaneously) pulls children out of orbit from around the adults responsible for them.

THE PROBLEMS WITH PEER ORIENTATION • does NOT serve survival as children were not meant to take care of each other • destroys the natural context for raising & educaNng children • robs adults of the power they need to parent, teach and treat • the more peers maMer, the more separaNon to be faced, resulNng in escalaNng emoLonal distress • robs children of the shielding and protecNon they need to live in an wounding world

• breeds ALPHA children, with all the problems that ensue • fuels a preoccupaNon with digital devices and social media, which further compete with family • is not conducive to feeling, as the vulnerability is too much to bear • can result in chaoNc polarizaNon & tribalizaLon which in turn can create a ‘lord of the ﬂies’ scenario

Youth Mental Health Crisis - G. Neufeld

positive polarity seeks to be with makes contact endears looks up to a.ends & listens to imitates & emulates possesses is loyal to holds dear a.empts to ﬁnd favour makes things work for seeks to ma.er to seeks to please befriends loves shares secrets with or keeps the secrets of

Jack Hirose Seminars Fall, 2023

negative polarity shies away from resists contact alienates looks down upon ignores & disregards mocks & mimics disowns opposes & betrays holds in contempt ridicules and derides spoils things for discounts as not ma.ering annoys and irritates eschews loathes keeps secrets from or creates secrets about

children are not meant to take care of each other

The PEER-ORIENTED ...

society is not structured to facilitate peer togetherness

suﬀer more separaLon ... elevaLng the separaLon-triggered emoLons of alarm, frustraLon and pursuit ...

increasing tribalizaNon renders peer interacNon unsafe

while losing the very feelings that would lead to their resoluLon.

IMPACT OF PEER ORIENTATION

CUT OFF from the care of parents and other caring adults

NOT SHIELDED by aMachments with caring adults

highly DEFENDED against the uncaring ways of peers

lacking SAFE SPACES for vulnerable feelings to return

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

INSIDIOUS IMPACT OF PEER ORIENTATION fragmented tribalization & polarization

fragmented and depersonalized pursuit creates contrived hierarchies that do not deliver care

insatiable attachment pursuit via digital devices and social media

increased alarm-based problems & vulnerability to wounding

elevated attachment frustration resulting in increased aggression including suicide

INSIDIOUS IMPACT OF PEER ORIENTATION fragmented tribalization & polarization

fragmented and depersonalized pursuit creates contrived hierarchies that do not deliver care

insatiable attachment pursuit via digital devices and social media

increased alarm-based problems & vulnerability to wounding

elevated attachment frustration resulting in increased aggression including suicide

Three Common ATtachment Disorders ... and how they impact received care and recovered feelings

1. PEER ORIENTATION 2. ALPHA COMPLEX 3. DEPERSONALIZED ATTACHMENT

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

Common manifestations of the DISPLACEMENT instinct • to take charge, to take over, to take the lead • to command aMenNon, to take centre stage • to talk louder, to talk over, to talk for another • to be ﬁrst, to be the best, to be on the top • to demand deference, to give the orders, to take command • to give the direcNons, to provide the meanings • to trump interacNon, to have the last word • to be in the know / to be the most knowledgeable

Common manifestations of the DISPLACEMENT instinct ize

m ter he ac for t r • to take charge, to take over, to take the lead ha e c ar tes o c • to command aMenNon, to take centre stage ibu wh r J ts e aadul esfor • to talk louder, to talk over, to talk h t ith another en s w h ip on the top • to be ﬁrst, to be the best, d wtoshbe me $on r o s f elato give the orders, to take command • to demand deference, ha eir r x h e t pl direcNons, • to give m the to provide the meanings or co lity a a h n p •alto trump rso interacNon, to have the last word an ir pe e th • to be in the know / to be the most knowledgeable

IMPACT OF AN ALPHA COMPLEX

- lack of dependence renders them unable to receive the care that may be there for them

their lack of dependence also renders them unable to experience aMachment as a safe sanctuary for feeling

Alpha children are highly alarmed and frustrated, without ever being able to feel the fuNlity of not being able to control their world

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

ALPHA CHILDREN ARE MORE PRONE TO ... ALARM-BASED PROBLEMS LEARNING PROBLEMS - anxiety, agitaNon, - literacy problems, & adrenalin seeking dysfuncNon due to The alpha problem has learning disabiliNes, (cannot make oneself feel safe) been totally ECLIPSED by diﬃculNes with seeking assistance misinterpreNng alpha as ATTENTION ISSUES ‘independence’, by our - cannot command COMPLIANCE their aMenNon / aversion to the construct of ISSUES elevated alarm - resistance & ‘hierarchy’, by our lack of scaMers aMenNon / opposiNonality must be the centre understanding of the nature of aMenNon & purpose of aMachment, ENTITLEMENT ISSUES and by the lack of any FRUSTRATION ISSUES - self-evident to supporNng language – - aggression, violence them that they are and self-aMack rendering the symptoms most important including suicide unexplained and resul$ng PEER ISSUES in a fu$le baJle against them - conﬂict, bullying, EATING ISSUES dominance, and - anorexia & food supremacy issues issues of all kinds

How FEELINGS develop the Alpha Caring Response

Ca rin

“neurons that FIRE together WIRE together”

nsi eR spo

bi l i ty

when devoid of feelings of caring and responsibility as well as mixed feelings, alpha can evolve into alpha perversions including bullying

the making of the bully response

highly moved to displace

Lacking feelings of caring & responsibility

the BULLY response to perceived vulnerability, neediness, threat or weakness

- to assert dominance by exploiting vulnerability -

Renders today’s children increasingly UNSAFE and highly ALARMED, whether peer-oriented or not

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

PEER ORIENTATION, the ALPHA COMPLEX and MENTAL HEALTH

- the perfect storm peer orientaNon creates CONTRIVED hierarchies devoid of care and safety

DEPENDENT peer-oriented children, having lost their adult shields, suﬀer signiﬁcant WOUNDING at the hands of their peers

increasing numbers of ALPHA peer-oriented kids who are devoid of taming feelings, evolve into BULLIES who make life unsafe for EVERYONE

the lack of received care and recovered feelings results in escalaNng and pervasive MENTAL HEALTH PROBLEMS

Three Common ATtachment Disorders ... and how they impact received care and recovered feelings

1. PEER ORIENTATION 2. ALPHA COMPLEX 3. DEPERSONALIZED ATTACHMENT

The DepersonalizaLon & FragmentaLon of Pursuit the DEPERSONALIZATION of attachment the PURSUIT of PROXIMITY with a PERSON ATTRACTING

the

ATTENTION

WINNING

the

APPROVAL

MEASURING UP

to be

VALUED

DEMANDING

to be

SPECIAL

IMPRESSING

to be

ESTEEMED

HELPING

to be

IMPORTANT

BEING NICE

to be

LIKED

BEING CHARMING

to be

LOVED

SEEKING STATUS

to be

RECOGNIZED

Sarah Matthew Genevieve Rorie Scott Ms.Kerr Kendall Sherry Uncle Jack

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

The DepersonalizaLon & FragmentaLon of Pursuit the DEPERSONALIZATION of attachment Depersonalized aMachment the PURSUIT of PROXIMITY with a PERSON Sarah is not able to deliver care Matthew ATTRACTING the ATTENTION of nor serve to recover feelings and so, like peeroforientaNon WINNING the APPROVAL Genevieve and an alpha complex, MEASURING UP to be VALUED by Rorie is dysfuncNonal and disordered.

Scott Ms.Kerr

DEMANDING

to be

SPECIAL

IMPRESSING

to be

ESTEEMED by Not only is depersonalized

HELPING

to be

BEING NICE

to be

BEING CHARMING SEEKING STATUS

aMachment fundamentally disordered, IMPORTANT to but it competes with exisNng Kendall and LIKED by potenNal aMachments that could Sherry to be LOVEDdeliver care by as well as actually safe sanctuary Uncle Jack to be provide RECOGNIZED by for feelings

mental health

CASCADING CARE vs ROLE-based, including expertbased care vs SELF-care

SAFE SANCTUARY - trus$ng dependence - end-ofday rituals

Right Relationships & Emotional Playgrounds

Youth Mental Health Crisis - G. Neufeld

Jack Hirose Seminars Fall, 2023

Allowing the popular construct of ‘mental health’, thrice removed from a working reality - a euphemised spin on mental illness which is itself an instrumental analogy vs evidence-based reality, and an indirect ‘fruit’ versus useful point of intervenNon to thus ECLIPSE its developmental ROOTS in ATTACHMENT and EMOTION

MISDIRECTING and thus EXHAUSTING our valuable resources and energy with regards to the emoNonal well-being of our beloved children and youth.

Diagnosing syndromes and vs Cutivating the Conditions Battling against Symptoms for Emotional Well-Being - crusades against bullying, meanness, discriminaNon, violence, RIGHT RELATIONSHIPS insensiNvity, injusNce, intolerance WITH CARING ADULTS - prosocial programs aimed at ... that can deliver CARE and children being nice and kind provide safe sanctuary for FEELING - discipline approaches aimed at teaching a lesson, socializaLon approaches aimed at declaring PLAYGROUNDS for huroul interacNon unacceptable, EMOTION and legal approaches punishing the violators ... so that emo;on can ﬁnd REST, - skill-based programs aMempNng working aHachments can be PROTECTED, vulnerable feelings to teach empathy, self-control, can be RECOVERED, and the emoNonal literacy, graNtude, etc CARE that has been delivered via - mental health advocacy and safe aHachments to caring literacy programs as well as selfadults can be FELT care programs

Conquering Anxiety: Concrete Strategies for Helping Anxious Clients

Dr. Caroline Buzanko, R. Psychologist www.drcarolinebuzanko.com info@korupsychology.ca

Anxiety is the most common mental health problem in children, teens & adults

Untreated anxiety is the leading predictor of depression

drcarolinebuzanko.com

70% of all mental health problems begin in childhood and adolescence

Anxiety Impairs Daily Functioning • Sleep!!! • Academics • Social interactions • Happiness and outlook • Family relationships • Doing things/going places • Nutrition • Self-care • Independence 5

Extremely Treatable

drcarolinebuzanko.com

What is anxiety?

You fight. Me flight!

Fear and worries are here to stay • Normal, protective feeling • Necessary for survival • Its ok! • Temporary in the moment • Not dangerous • Not to be eliminated or avoided • Can help motivate & energize us 9

drcarolinebuzanko.com

Worries to be expected Developmentally appropriate fears • Survival: separation, danger

Life transitions • New school or job, new relationships, teenage years, transition to adulthood

Stressful experiences • New or unfamiliar situations 10

The brain was built to protect us…

However, while society has changed so much even in the past two decades, our brain has not changed in hundreds of thousands of years…

Normal Worries

TEMPORARY

DO NOT INTERFERE WITH FUNCTIONING

STUDENTS STILL SUCCESSFUL IN ACHIEVING GOALS

drcarolinebuzanko.com

BEGINNING

MIDDLE

END 13

Worry is worry is worry

Common Vulnerabilities Among all Emotional Challenges

High levels of negative affect Tend to view their emotional experiences as negative Aversive reactions that lead to efforts to avoid and suppress them. 15

drcarolinebuzanko.com

Everyone is predisposed to anxiety.

We are Stressed

drcarolinebuzanko.com

Kids & Teens are Stressed • Teens report more stress than adults juggling all the demands imposed on them • More expectations • More homework • More deadlines • Less resources • Fewer breaks/recess • Appearances

Social disconnection and loneliness Local and world news

Identity and body Issues

Current State of the world

Social media

Worthlessness

Multiple pressures and high expectations

Far more: • Depression • Self-harm • Suicide

Helplessness

Pressure and expectations

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Self-esteem False messages to avoid rejection • So happy! • So beautiful! “Likes” worsens self-esteem • Others won’t like the “real” them.

Technostress • Hard to detach = chronic stress • Don’t receive an immediate reply to a text = anxiety and isolation • Technology-related anxiety (e.g., pressure to respond immediately) • Shame & stigma if not connected • Validation through social media

Massive-Scale Emotional contagion We begin to experience the same emotions as others without our awareness • Long-lasting moods (e.g., depression) can be transferred through social networks

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Myth of Happiness

It’s all in how we respond Based on how we perceive the demands of the situation. Anxiety makes the demands feel way bigger than what they believe they can manage. 26

Anxiety Intervention is about….

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Breaking the cycle that fuels anxiety

Traps This alone can make all the difference in the world

* Impairs healthy independence * Inhibits resilience * Disrupts their emotion regulation * Worsens anxiety * Contributes to emotional exhaustion * Can lead to aggressive behaviour

Overly Critical, Impatient, or Hostile People

* Increases risk of substance abuse and risky behaviours AND, goes against how the brain and body work, we need to learn to understand these signals! 30

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Accommodation Accommodation

Accommodations worsens anxiety long-term

Accommodation

Anxiety more impairing and severe with poorer treatment outcomes 31

What are others doing for them that they could be doing for themselves (if not for big overwhelming emotions)?

Get stuck in constant need for reassurance

Reassurance

No skills developed Minimizing 33

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Anxiety… • Wants certainty • Wants predictability • Wants comfort

Avoid traps • Others jumping in to help or continuously avoiding : • Changes brain & ingrains anxiety • Makes individuals even more vulnerable: Confidence and resilience stunted • No opportunities to experience success managing emotions and situations • No opportunities to learn (e.g., that anxiety is not dangerous)

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Medications

Individuals keep themselves stuck

Negative thought patterns Inability to manage emotions effectively Maladaptive Coping

Physically

Cognitively

AnxietyDriven, Maladaptive Response

Behaviourally 39

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Maladaptive coping strategies • Anything to avoid or reduce emotions develop and maintain challenges

Accommodations & Maladaptive Coping Strategies Become Safety Behaviours!

(Used to attempt to minimize or prevent something bad from happening)

AVOIDANCE

EXCESSIVE CHECKING

RITUALS

SEEKING REASSURANCE

SAFETY AIDS

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Others

Breaking the Cycle: Everything that Maintains Anxiety

Negative thought patterns Inability to manage emotions effectively

Maladaptive Coping

May as well figure out how to navigate them

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Remember: Emotional experiences develop and maintain challenges. Thus, the goal is to: • Change responses to emotional experiences • Create new pathways in the brain – new learning and memories • Target the problematic emotion regulation strategies people use

How they manage the experience of anxiety is related to anxiety disorder Not the actual trigger

Working with Children and Teens: Adult Focus

Connect

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For Children and teens

Adult perceptions

Worries & Stress are contagious

Be a good Role Model: No one is immune

Display vulnerability & cope out loud • Empowering • Promotes bravery, confidence, & resilience

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Be a good Role Model • Being scared & doing it anyway • Effective coping • Seeking and receiving help • Recognizing own unhelpful emotion reactions

Use mirror neurons Brain can’t tell the difference

Emotion coach Coaches avoid traps: • Reassuring • Answering questions • Reviewing the schedule • Answering every phone call or text message • Checking things

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Emotion coach Coaches validate & then ask open-ended questions. • What do you need? • What do you need to do next? • What are you going to do? • How are you going to figure that out?

Confident

Supportive

Effective Response

Coaching Cues • Confident that they can figure it out • Collaborate ideas re: how they can figure it out • Help them make predictions • I predict… (e.g., I will feel 8/10 proud when I am done.).

• Focus on learning • How did you do? • What went well? • What did you learn? • What will you do differently next time?

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Effective Coaching Cues

I know you can figure it out. Go brainstorm with _______ and make a plan. Lemme know! I look forward to hearing the positive things you will say to yourself as this gets hard. What are all the ways you can boss back this inner critic? What are other ways to deal with this problem?

I know you can stick up for yourself. What are things you can say to them?

When things go sideways

Today is your lucky day! • This means you get to try again! Yay! • Now we have all this information we can learn from… Now we know so much more • What did you notice? • What did you learn? • What needs to happen next time?

Talking will only escalate the problem 60

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Give space for regulation

Effective Communication Tips

Talk less listen more

Focus on connection & safety

Effective Emotion Coaches

• Empathy & Physical safety • Validate & acknowledge • How they are feeling • How they perceive the situation • Be present with the situation yourself • Being present is better than words

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Be prepared! Let me see if I got that. You said… Did I get it? Is there more? That makes sense…

Effective Communication Tips

• Keep the waters calm! • Reduce nagging & prompt dependency • Not personal • Thank you! • Focus on goal

Replace negativity with curiosity And control and demandingness with warmth and responsiveness

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Warning! You WILL get push back when adults start to change their response!!!

Buy-in & Tolerance • Education (especially outcomes of traps) • Awareness of traps • Pros & cons of traps • Values • Desired outcomes

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Inspire

Get Buy-in Otherwise, you get resistance

• Emotional distress directly related with hesitancy towards engaging in the work. • We MUST identify what is more important to them than feeling uncomfortable

Motivation Fluctuates – Address this Early!

Inspire

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What is Important And how is anxiety getting in the way? 73

All the things anxiety makes me avoid • Seeing friends and family • Work functions • Work • Hobbies • Trying new things • Living life!

Cost Benefit Analysis Benefit of being slave to anxiety (and not setting boundaries)

Cost of being slave to anxiety

Perceived as dedicated to work

Too upset and reactive

Comfortable: don’t need to have a hard conversation or navigate possible resistance. Open to all work-related opportunities – don’t miss out on something Better liked, more agreeable, avoid judgment Won’t fail if I try (and make things worse) Easier

Feel weak & taken advantaged of Personal relationships affected Well-being affected –on the brink of burnout Poor productivity and quality of work No time for hobbies and self-care Not sustainable Loss of self and own needs Effortful to feel overwhelm

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Remember! Short- and long-term outcomes of maladaptive vs. adaptive coping strategies Maladaptive Coping

Feel better in the moment

Worsens anxiety in the long run

Ingrains anxiety pathways

Adaptive Coping

Feel distressing in the moment

Tolerate & manage anxiety in the long run

Create new healthy pathways

I say yes so people • But I get overwhelmed with will like me and rely on too much on my plate me

I avoid speaking up for fear of judgment

• But I miss out on sharing ideas or addressing my needs

I avoid social • But I miss out seeing my functions dur to friends and nurturing those discomfort and fear of relationships rejection I work when I feel anxious

• But the work never goes away and I get no joy in other parts of life and I never learn to cope

I burnout and disrupt my work and relationships I remain silent and become a pressure cooker of distressing emotions that will come out I will lose relationships

I burnout

• Why they want to control their own life • How exhausting anxiety is • How life will be different • What they are missing out on

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Letter to your future self For when your future self gets nervous

Collaboratively create clear goals How do emotional experiences cause problems in your life

What needs to change?

Goals that promote self-efficacy – I can do it! • • • •

Boost rationale Connects strategies to what’s important to them Gives us focus Track progress 81

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Clarify expectations

What’s the problem with this goal:

To be less anxious 82

Clarify expectations • We are human! • We cannot eliminate emotions & the discomfort • We cannot change our thoughts

SMART GOALS

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Key Concern

Work-Life Balance Stress: Feeling overwhelmed by work responsibilities and struggling to maintain a healthy balance between work and personal life.

Concrete Goal 1

Specific: By September 1, establish clear boundaries between work and personal life to reduce work-life stress and promote well-being.

Set Boundaries

Measurable: Track the implementation of boundary-setting strategies over the next three months. Achievable: Identify realistic and feasible boundaries that align with my work responsibilities and personal needs. Relevant: Setting boundaries is crucial for reducing work-life stress and improving emotional well-being – the primary concerns. Time bound: Implement boundary-setting strategies immediately and continue to monitor progress for the next three months.

Necessary Steps to Achieve Goals Identify a. b. c.

Specific work-related stressors and triggers. Identify who and what needs to be addressed at work. Where boundaries need to be established.

Define & set clear boundaries a. b. c. d.

Set clear work hours Set clear break times Set clear personal time. Designate personal time for relaxation and leisure. Set realistic expectations for response times to work-related communication during non-working hours.

Communicate boundaries a. b.

Communicate the newly established boundaries with supervisors, colleagues, and family members. Articulate the reasons for setting boundaries to foster understanding and support.

Implement a. b.

Prioritize personal time for relaxation, hobbies, and spending time with loved ones. Use calendar or scheduling tools to block out specific personal time and avoid work-related intrusions.

Skill building: Time management. (start with time experiments with tasks) Practice: Assertiveness in communicating boundaries, work limitations, negotiating workload with supervisors, and saying "no" when necessary and "I" statements to express personal needs.

Seek support a. b. c. d.

To delegate tasks To manage workload effectively To be accountable for maintaining boundaries. To monitor progress.

Monitor a. b.

Effectiveness of the established boundaries in reducing work-life stress. Adjust boundaries as needed based on evolving work demands and personal priorities.

Externalize & Expose

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Anxiety likes to Overwhelm & Keep us Stuck:

Externalize You are not your worry (Or other big emotions)

Name it Some parts are helpful…But other parts are mischievous and try to make you think there is something wrong…

Mishmash of a Brain Pieced together over millennia • Some areas can communicate directly, others only indirect contact • Can hold contradicting information in different parts of the brain • No one CEO. Lots of subselves – different parts of the brain can communicate and work together easily

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At Least Seven Subselves The Best Equipped Takes over

• Self-protection • Mate attraction • Mate retention • Affiliation • Kin care • Social status • Disease avoidance

• Can argue & fight for control • No one part has complete information

At Least Seven Subselves The Best Equipped Takes over

• Can argue & fight for control • No one part has complete information

Externalize

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Saying it out loud gives us more power To take control and use helpful coping strategies To remember how it is getting in the way and what’s on the other side

Expose it • Understand emotions and how they work to take control • Yep, there’s Bob, that’s what it does. • Wow, it is really working hard to make me think the worst today! • Yeah, we knew it’d show up now. It doesn’t want me to write the test. • It wants me to avoid new things. • It really knows how to try to stress people out. 95

Understand

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Understanding Emotions

Anger • Alerts us to threats or injustices • Protect our well-being Fear • Alerts us to danger • Protects us from harm

Emotions Are Adaptive!

Joy • Positive reinforcement for doing things that promote our well-being and survival Shame • Prompts self-reflection, processing, and change • Maintains social harmony

Tell us something about reality

Sadness • Alerts us to loss, separation, or unmet needs and allows us to process the event • Promotes personal growth and deeper social connections Excitement • Propels resilience and growth • Fosters curiosity, creativity, learning, and adaptability

Emotions Help Us Navigate Situations Keep us safe or move us towards goals

No Anger

No Fear

Picked on

No Disgust

Eat pooh

Get eaten

No sadness

No Misery

No future motivation

Glutton for punishment with unattainable goals

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Thoughts, interpretations, & beliefs

90 Seconds!!!!

Environment

Physical sensations

Emotions

100

Understanding this connection makes it easier to respond differently

Feelings

Behaviours

Thoughts

101

Curiosity is a key response to emotional experiences

102

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Raise Awareness: Mindfulness Build awareness of: • What is happening in the world around us • What the feeling is • What is happening in the body • What is happening in our mind • How all of these relates to each other, and to our behaviours 103

103

Starts with Awareness: Feelings

Reaction

Interpretation / Evaluation

Awareness of Feelings Situation

104

Awareness of Feelings • Name it to tame it

105

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Core skill Mindful Awareness of Emotion (Physical Feelings)

106

Physiological

Understand Anxiety & What it does….

Motivational (response)

Emotion

Cognitive

Body language 107

107

Understand Anxiety & What it does…. Emotions (Anxiety) Manifests

Physically

108

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Physiological

• Most powerful • Usually shows up first • Triggers emotional response before we even realize it • Helps us to prepare to react to the situation

Emotion

109

Understand Anxiety & What it does…. •

When the alarm goes off, the body gets ready to fight or run

Even when it is a false alarm! The brain (and body) cannot tell the difference.

110

Our body is going to respond based on its best guess

111

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Our brain isn’t going to wait around

112

Our brain doesn’t care if its hazardous or not • Our brain will respond based on what we need to survive

113

• Released hormones • Increase heart rate • Increase blood pressure • Increase energy • Increase alertness • Slows other processes (to fight or run away) • Secretes acid into the stomach to empty it

114

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Physical Symptoms are a Problem

115

They start to worry about the physical feelings, which are distressing, which they will do anything to stop Become reactive Misinterpret as dangerous and leads to more fear, more sensations…

116

Feelings Subject to Distortion • Wrong context • Need to learn to correctly interpret our interoceptive signals • Better able to interpret signals • Can make more adaptive decisions • Boost resilience • Better emotion regulation and overall emotional functioning

117

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Feel More but can’t interpret what the feelings mean Do whatever they can to get rid of them… 118

118

… Or control what they can in their external world

119

Understand the truths! • Our bodies are intuitive and designed to protect us. • It doesn’t make sense if our body was doing something to harm us. • Trust the body to do it’s thing and get out of its way. We don’t need to add commentary. 120

120

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Hearts can beat hard all day long and stay healthy

Understand the truths!

We’d be extinct if we always fainted in danger. • Fainting happens with LOW blood pressure. • When anxious, lots of blood is flowing!

Forcing ourselves to swallow won’t help us swallow • Hum or sing

Our body will always compensate for breathing

Tension builds when we are not doing anything with the energy • Get moving: Shake!

Emotions come and, more importantly, they go

121

This is normal!!! And NOT dangerous!

122

Of course, I feel uncomfortable! I know what my body is doing. I can handle this.

Understand how stress shows up = Adaptive thinking The mystery is gone BONUS: Expecting physical sensations helps reduce signals to amygdala

123

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Accept & Unwind

124

Emotions are simply emotions! They will take over if we aren’t self-aware in the moment. Use them as a learning opportunity, get curious!

125

Mindfulness

NOT ABOUT RELAXING

NOT ABOUT CHANGING EMOTIONAL EXPERIENCES

NOT ABOUT FIGHTING OR IGNORING THEM

126

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Mindfulness

IT’S ABOUT LEANING INTO THEM & GIVING THEM SPACE 127

127

Stress is inevitable so need to learn to go with the flow & accept what we can’t change

128

Acceptance Welcoming anxiety and all it brings. And living life anyway.

129

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Anxiety/Emotion Dial

Acceptance Dial

100

130

What to Accept

Memories

Images

Bodily Sensations

Emotions

Thoughts

Automatic responses

131

Dizzy Racing

Raise Awareness

How does Worry Show up?

Tension

Feels like:

Shivers Increased heart rate Weak legs

Achy

Ringing ears

Sore

Blurred vision

Hot

Muscle tension

Cold

Shaking

Tingly

Trembling

Numb

Chest pain

Sharp

Headaches

Breathless

Burning skin/sweating

Shivering

Blushing

Sweating

Changes in breathing

Trouble swallowing

Stomach-ache/ Nausea

Tired

Relaxed

132

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Change Relationship with Emotions From judgmental and critical stance in which they try to avoid, minimize, or eliminate

133

To an accepting & nonjudgmental stance in which they lean in 134

134

Can’t just talk about it. Practicing Emotional Awareness Key!

135

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Focus on Physical Sensations Be with it • Observe it vs. think about it • Breathe into it • Expand it • Allow it to be there Sensations might change but they might not. It doesn’t matter! 136

136

137

138

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139

Guided Meditation Focusing on Emotions

140

Guided Meditation

140

• Ground in the here and now • Environment • Body in the room • Feeling • Physical sensations • Thoughts • Bring awareness back to room

141

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Staying Present

• Ground • Check-in • Physical sensations • Thoughts • Behaviours or urges

• What is happening around me right now? • What are the facts of this moment? • Is my internal experience consistent with what is happening externally right now? (or stuck in the past or future) 142

142

Grounding Strategies Quickly shift attention to the present moment: Individualize!

Stretch

5 Senses

Tense and release

Body Scan

Details on something

Feet on floor

143

• Note the urge to breath begins and ends in your body. • Locate where the urge starts from. • Allow the feeling to come but keep holding your breath. • Notice the thoughts that come up. • Are they trying to get you to breathe? Who is in control?

• Notice the feelings that come up • Thank everything that comes up and keep holding your breath • Survey the rest of your body. Notice everything else is working. • Think of what you can do to help with acceptance vs. avoid. • E.g., Imagining water rushing in.

Here we go….

144

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Mood Induction Practice • Observe reactions, whatever comes up physiologically, in an objective and nonjudgmental way • Third party reporter • It makes sense I feel______________________ • Focus on the PRESENT MOMENT • Grounding techniques

• Debrief at the end about all the reactions that happened, in an objective and nonjudgmental way

145

146

Nonjudgmental Awareness of the NOW is Foundational • Without mindful awareness of emotions, can’t move on with any of the other work to strengthen more adaptive responses • Therefore, need LOTS of practice and experiences 147

147

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Worry Likes to Keep us Stuck! Negatively influences affect, thoughts, behaviours

Thoughts of Past or Future

Keeping thinking of past or future

Negatively influences affect, thoughts, behaviours

At the expense of valuable information now

148

• Need to stay here and attend to the current context • To keep prefrontal cortex online • To attend to corrective information • To learn! Versus getting sucked into worries, which intensifies the emotional experience and keeps us stuck

149

When we: Understand anxiety is & what it does… • • • •

Can’t turn the alarm off We can’t get rid of worry We can’t get rid of the feelings The discomfort might still be there

…& Label emotions and experiences…

150

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…It becomes easier to: • Be ready for worry when emotions shows up • Tolerate it • Change our interpretation of them • Dampen amygdala’s false alarm • Keep the prefrontal cortex online • Learn that we have control over our responses • Avoid getting sucked in – it’s just a piece of information • Take control of how we respond & • Make adaptive decisions

151

Daily Practice! Focus on awareness • Track ABC’s of emotion • Practice guided meditation to objectively observe whatever comes up in the present moment Physical sensations Thoughts Behavioural urges 152

152

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Anxiety is not in the situation but the feelings we have and how we perceive those feelings

Understand Anxiety & What it does…. Emotions (Anxiety) Manifests

Cognitively

Emotion

Cognitive

• Evaluate the situation that led to our emotion (and accompanying feelings) • Avoid getting caught in the content!

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How Anxiety Manifests: Thoughts • Unrealistic, extreme • What if’s… • The world is dangerous • Catastrophic thinking

Thoughts Brain built for survival – its job is NOT to be happy • Negativity bias (primed to see non-existent danger) • Uncertainty misinterpreted • See events as threats • Becomes ingrained

The brain cannot tell the difference between what it actually sees and what it imagines

Expecting something bad to happen keeps us stuck worrying ourselves with our own thoughts 6

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Emotions are simply emotions! We can experience different emotions despite the exact same circumstances. How we interpret them causes suffering. They will take over if we aren’t self-aware in the moment. Use them as a learning opportunity, get curious!

Different hormones released to prepare for what's to come. How does our body know? • Depends largely on our evaluation of the situation.

Threat vs. Challenge Response Not good or bad, different purposes Threat response: Goal is survival in situations we aren’t equipped to handle • Rush of cortisol to defend and protect Challenge response: Opportunity for growth where we tackle hard but manageable situations • More testosterone and adrenaline to help us achieve our goal

Our thoughts are not always trustworthy!

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Stretch Make a list of things you or others have believed that you do not believe anymore

Organize information automatically to see the whole

Thoughts Influence

What would a co-worker 1. Feel? 2. Do? If they sees these people at the water cooler and thinks:

“Oh, it must be lunch time! I am so excited to meet up with my friend!!”

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Emotions can also Influence How We Think

What would an overwhelmed co-worker 1. Think? 2. Do? If they sees these people at the water cooler and feels overwhelmed with work, stressed too much on their plate they don’t even have time to go to the bathroom 13

Not about the trigger: It’s just an Illusion

Just for Fun… Mechanics of vision: The eye is like a camera • Light bounces off objects • Enters our eyes • Focused on the retina by the lens • Retinal image (2-D) 15

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Terminator Fallacy: No brain accessing 2-D image Retinal image (2-D) sent to the brain to interpret the information

Surprise! • Information from our eyes and ears only loosely connected to what we experience • Fragmented • Ambiguous • Lots of effort to change them into 3-D

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Brain Shortcuts: Importance of Context • Turkey mothers • Good mothers • All mothering is triggered by “cheepcheep” • Smell, touch, appearance minor roles

Automatic Negative I made a in Thoughts mistake the document (ANTS)

I am in trouble

My boss wants to see me I spoke out of line

Someone complained

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Lead to spiralling

I made a mistake

They realize I am incompetent

I am going to be fired

My family is going to reject me

Homeless

Wrong 99% of the time The first draft

We can't control our thoughts – only our response to them

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Sit with, accept, & acknowledge worries

Focus on raising awareness to thoughts Recognizing them

Acknowledging them

Disentangling from them

Accepting them

vs. trying to change thoughts 26

Core skill Mindful Awareness of Emotion (Thoughts)

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Defusion

•Noticing thoughts vs. getting caught in thoughts

Look at thoughts, not from them

Past

Future Present

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Detach Distancing • “I notice I’m having the thought that….” • Use third person language Train, balloons, bubbles clouds, or leaves on the river

Thank them • Genuinely • Sarcastically

Detach War of the Worlds

Objectify • What colour? How big? What shape? What texture? How would it move if it could? Name that Story

Identify the Adaptive nature of the story

Guided Meditation Focusing on Physical Sensations & Thoughts that Arise

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The Problem with Language

Make fun of worried thoughts 35

Sing it Draw cartoons Literalization Mute it Say it really fast Say it in slow motion Mimic it Exaggerate it

Dismiss Worried Thoughts Dismiss Worried Thoughts

Demand more from worried thoughts

Roll my eyes

You’re so boring!

Is that all you got?

Is that the best you can come up with?

Big deal

So what?

Don’t you have something scarier?

Can’t you give me more? 36

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Acknowledge & Detach!

• Yep, that’s your story you’re trying to tell. • Nice first draft. Nice conspiracy. • This is normal. • This is not an emergency. • You’re annoying.

Create a Bingo Card of Strategies Past/Present/Future

Distancing

Train, balloons, bubbles clouds, or leaves on the river

Thank them

War of the Worlds

Objectify

Name that Story

Repetition

Humour

Paradox

Body Scan

Literalization

Get sucked in with one interpretation • Brain Shortcuts: Cuts out information to maximize brain resources • Helpful at times (e.g., repetitive stimuli) • Unhelpful when emotions kick in: Miss other possibilities • Become rigid and stuck

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Core skill Cognitive Flexibility

These are only guesses!!!!

I made a mistake in the document

I am in trouble

My boss wants to see me I spoke out of line

Someone complained

Overestimation

ANTS Involve:

• Believe something bad is for sure going to happen Catastrophizing • Worse case scenario • Completely awful • Completely unmanageable

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Overestimation • About the likelihood of something happening Catastrophizing • About the importance of the event

Catastrophic: Crisis!

Remember! To be done PROACTIVELY • (Way harder in the heat of big emotions) • Our emotional state influences how we interpret information

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Cognitive Flexibility • Lean into strong emotions • Respond in adaptive ways

Cognitive Flexibility • Thinking traps NOT good or bad • They DO limit our flexibility • Get curious • To change our relationship and response to emotion-provoking situations vs. trying to eliminate, replace, or fix thinking patterns

Detach. Then edit the first draft.

I made a mistake in the document

What are other possibilities?

I am in trouble

My boss wants to see me I spoke out of line

Someone complained

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Possibility 1

Possibility 4

Possibility 2

Situation

Possibility 3

Cognitive Flexibility: Co-Existence (with other possibilities based on the NOW) I am in trouble & I won’t be able to cope

I am getting promoted

Boss responding to my earlier request

Boss had a question about my time off request

Boss wants to explain the new project 50

Break into Parts Ex: Perfectionism

Helpful parts of perfectionism

Unhelpful parts of perfectionism

Helps us prepare

Become paralyzed

Helps us strive for excellence

Procrastinate & create more stress Stifles learning and growth Narrows our world Makes us perform worse

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Cognitive Flexibility: Get Critical Worry wants us to think the very worst. Build awareness and critical thinking to: • Get unstuck from rumination • Differentiate helpful vs. unhelpful parts of worry • Decide whether they should buy into it

Alternative explanations

• To generate alternative explanations

Is there any shred of usefulness in this thought? What would I get for buying into this story?

Enhance Cognitive Flexibility with Helpful Questions Create a checklist

How would my friend interpret this? Grandma? Pet?

Am I going to follow my thoughts or my experience? What advice would I give to someone else? What have I not considered? What evidence is there for and against this thought? How much do I believe this is true? What do I know for sure? If I were in a sitcom, what would be funny about this situation?

Ability to cope

• To acknowledge their ability to cope

What little change will help? How would my successful future self-handle this situation? What is going positively in my life that will help me cope? How have I coped with emotional experienced in the past? What aspect of this situation is easy to target? If this was true, would I still survive? If this was true, what are five possibilities re: where I will be in a year from now? If this was true, what have I learned?

Hypothesis Testing Lots of experiments and experiences needed! • How sure? (1-10)? • Was the hypothesis right? • What did you learn?

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• • •

What I know

What I don’t know

My boss • wants to • speak with me I am going to • his office I am meeting • at 10

If I am in trouble What the meeting is about If the meeting is about my work If the meeting is about my vacation request If I am the only one How long it will be if I will still have a job after this

• • •

Columbo Approach • Guide them to create discrepancies • Can you read everyone’s minds? • All the time? • With everything? Or certain things? • Examples?

Columbo

Does that mean you suck?

All the time? Some of the time? With all things? Some things?

What is and is not true of human nature? 57

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Practice Cognitive Flexibility • Paradox & Humour • Yes, And • Story re-write • Can try visualization • Externalization of voices • Play devil’s advocate • Counterarguments

Adults

Unexpected event of the day & how you handled it 59

Problem Solving: Get Unstuck • Identify the problem • Brainstorm as many ideas as possible • Write them out • No judgment! • Weigh pros and cons • Implement the plan • Evaluate 60

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No idea how it will work out. But, I am going to use what I’ve got to get through.

WHAT STRENGTHS DO I HAVE?

WHAT RESOURCES ARE AVAILABLE?

Practice!

• Start with emotion free problems • Move toward emotionally charged problems

Practice Identifying Potential ANTS Proactively & Problem Solving

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Write it out! • I want to ask for the promotion to ensure my boss knows I am interested • I want to be on set, so I am willing to feel nervous and go to the audition

What story DO you want to buy into?!

• I want to take this opportunity to share my work and move forward in my career, so I am willing to do the presentation even if I feel like I am going to puke

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Emotion

Body language 1

What it looks like • Our body communicates how we are feeling • How would others know when I am feeling anxious by looking at me?

Motivational (behavioural response)

Emotion

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Emotions Lead to Behavioural responses to respond quickly to our environment Anger

Assert, defend

Fear

Flee, freeze

Shame

Avoid

Sadness

Support, withdrawal

Joy

Connect, engage

Excitement

Attend, explore

Understand Anxiety & What it does…. Emotions (Anxiety) Manifests

Behaviourally

Thoughts about the situation & their belief of how they can manage lead to patterns of behaviours

I can’t handle it!

Behaviours: Internalizing • Withdrawn/isolated • Shy • Sad/irritable • Head/stomach-aches • Eating issues (under- or over-eating; food intolerances) • Sleep problems/Fatigue • Low self-esteem and confidence • Rejection • Repetitive behaviours/obsession • Difficulties concentrating, fidgety • Avoidance • Disorganized • Cry

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• Easily triggered • Disrespectful

Behaviours: Externalizing

• Oppositional and defiant • Difficulty transitioning • Aggression/intimidation • Difficulties concentrating • Lies or steals • Temper outbursts • Restless/fidgety • Interrupts/Intrudes • Impulsive • Give up easily • Argumentative • Yell • Repetitive questions • Seek constant approval 7

• Substance use

We learn to avoid Helpful

• Avoid danger Excessive

Becomes a problematic learned behaviour that’s hard to break

Unhelpful Never learn anything new

Incongruent with the context Gets in the way of what’s important to us Based on short-term gratification vs. long-term consequences

That things aren’t as dangerous as we thought That feelings pass That we can cope

Maladaptive • Counterproductive or harmful in the long run • Worsen emotional distress • Hinder problem-solving • Damage relationships • Negative consequences for one's overall wellbeing and functioning

Adaptive • Promote well-being • Positive interactions with self and others • Effective problem-solving • Healthy, constructive coping • Align with long-term goals and values • Promotes emotional and psychological health • Sustainable

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Thoughts & Feelings lead to (avoidant) behaviours People will think I’m stupid

• I avoid speaking up in meetings

I feel like I will vomit

• I avoid going out

Everything must be done perfectly

• I avoid doing anything I can’t do perfectly

I am going to be in a car accident

• I avoid driving

People will think I am boring • I avoid hanging out with friends 10

Emotional Behaviours Function: To reduce the intensity of the emotion

Overt Avoidance

Avoid situations, people, things

Subtle Avoidance

Avoid full experience of emotions

Cognitive Avoidance

Avoid distressing thoughts

Safety Behaviours/signals

Used to feel as safe as possible 11

With avoidance, they never learn!

Biased Thoughts

Safety behaviours

Never learn thoughts are biased and bad things might not happen

Never learn they can cope on their own

Anxiety strengthened Worried thoughts seem believable

Hinders their ability to face challenges

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MUST DO THINGS DIFFERENTLY! Becomes a disorder when we do what anxiety wants.

Core skills • Identifying and modifying unhelpful emotiondriven behaviours • •

Increasing awareness and tolerance of physical sensations Integration of all the skills through emotion exposure to master adaptive responses

Unhelpful: I avoid speaking up in People will think • meetings I’m stupid: • Helpful:

What am I going to do next?

(The Opposite of What Anxiety Wants)

I feel like I will vomit

• Unhelpful: I avoid going out • Helpful:

Everything must • Unhelpful: I avoid doing anything I can’t do perfectly be done • Helpful: perfectly I am going to be • Unhelpful: I avoid driving • Helpful: in a car accident Unhelpful: I avoid hanging out People will think • with friends I am boring • Helpful:

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Core skills • Identifying and modifying unhelpful emotion-driven behaviours

• Increasing awareness and tolerance of physical sensations

Integrate Skills through Emotion Exposure Integrate skills to master adaptive responses • Talking not enough to change the brain! Must practice skills • Provoke strong emotions - MUST show up for learning to happen

Become so good at managing ANY emotion that comes up. Learn to respond differently through LOTS OF EXPERIENCES Anxiety Shame Guilt Rejection Disappointment Frustration Self-doubt

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Emotion Exposures Interoceptive

• Elicit distressing physical sensations

Situationalbased

• Face situations that provoke intense emotional reactions

Imaginal

• Confront distressing thoughts or emotions.

Combine for maximal benefits

All exposures • Based on something actionable • Targets distress • Ensures they learn something new firsthand

Exposure to LEARN Anxiety is safe, tolerable, & temporary When I don’t do anything to try to make myself feel better, the amygdala learns: This is not dangerous! (And stops sending the false alarm.)

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Exposure to LEARN Despite feeling anxious, I still did it • And… I can still live life and do anything, even while feeling anxious!

Exposure TO LEARN • Something about the specific issue (based on their prediction) • Did the feared outcome happen? • No • Less likely • Less severe and/or • Not as dangerous as I thought • Yes…

Exposure TO LEARN …No matter what happens, I can handle it

• On my own • Others and safety behaviours are not needed to tolerate anxiety or to stay safe

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Interoceptive Exposures

Physical Symptoms are a Natural Response

• But often misinterpreted as dangerous, which creates a positive feedback loop • Often motivated to avoid these

Critical to address for EVERYONE • Not just panic disorder • OCD • Social anxiety • Phobia • Performance anxiety • Perfectionism • Sadness • Stress

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Interoceptive Exposure: Lean In! • Confront worrisome body sensations • Evoke things they worry about • Learning: The uncomfortable physical sensations are tolerable, temporary, and not dangerous.

Interoceptive Exposure Ultimate goal: Tolerate the physical sensations • Without being scared of them (and therefore making them worse) • Without needing to engage in emotion-driven behaviours to reduce, avoid, or eliminate the feelings • New learning: I am not • Having a heart attack • Lose complete control • Suffocating • Dying

Interoceptive Exposure Be prepared! We need their confidence in this process

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Hyperventilate/fast breathing (dizziness)

Breathe through a straw really fast (breathlessness) • Hold your nose!

Jumping jacks, run on the spot or up and down stairs (increased heart rate)

Spin in place (dizziness, nausea)

Shake head fast side to side or drawing a circle with your nose (dizziness)

Stare at hands for 2-3 min. (unreality)

Wear something tight around neck (tightness in throat)

Stare at ceiling light for 1 min. and then try to read something (blurred vision)

Get them to do whatever causes the feelings

Find the most distressing exercises and use those to elicit symptoms

Try a series of exercises and record the data

Length of time

The physical sensations that come up The intensity of those sensations

The level of distress experienced (we want to repeat the ones that are most distressing) 32

• Pick one of the moderate+ distressing exercise and repeat it • Evoke sensations as intensely as possible • Sustain sensations beyond feared outcome limits • Repeat – especially with any “yeah but’s” • No distraction nor avoidance

• Record • Length of time & number of repetitions • Sensations • Intensity • Level of distress

• Assign for homework! 33

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Increase flexibility with response to physical sensations Intensifies Feelings & Beliefs

Physical sensation

ANTS: Something bad!

Interpret as threat 34

Situational Emotion Exposures

Tolerating Uncertainty

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Avoiding Rejection Ingrained in the Brain Why?

It Meant Survival Feel Rection SO intensely

“Anyone who isn't embarrassed of who they were last year probably isn't learning enough.”

Alain de Botton “The way to greater confidence is not to reassure ourselves of our own dignity; it’s to come to peace with our inevitable ridiculousness.”

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Practice! Being Ridiculous

Rejection Practice Ask a store to stay open an extra 30 minutes for me Ask a stranger to take a selfie with me Ask for a bite of a stranger’s food at a restaurant Ask to make an announcement over the loudspeaker at a grocery store Ask a stranger for $50 Ask someone for their car Ask for a 50% discount at a store 41

Set up the situation & collaborate a specific plan Address obstacles Address safety behaviours

Setting up Exposure

Honesty & Remind them how anxiety works Rationale and buy-in Test it out! Validate & normalize Debrief & Evaluate Reinforce Keep going

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Setting up Exposure

Set up the situation: Collaborate

Together create a menu

They get to choose what they want to do

Choose a wide variety of things, including the specific issue they come in with

Several things can make it easier or harder, such as:

Remind them the focus is on the process rather than the list, but we will practice through the list

Does NOT need to be easiest first

• Distance, Time, People

You are the expert and I need your expertise! We will put our expert heads together to figure out the best plan.

Create a Menu of Feared Situations & Internal/External Stimuli Match situations, thoughts, and physiological experiences

Make it worthwhile: Include the hardest, scariest things they think are valid and need to be avoided

What do they have to learn? What do they have to do to learn?

No more than 10

Remember: Focus on PROCESS vs. outcome, LEARNING vs. anxiety reduction

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Feared Situations & Internal/External Stimuli Antecedents (Triggers to anxiety) Snakes Feeling nausea Trying something new Initiating an interaction Presentations Being with unfamiliar people Intrusive thoughts re: break-ins Intrusive thoughts re: house setting on fire

Reasonable Risk Not absolutely risk-free but something people do everyday • Say something stupid • Do something embarrassing • Make a mistake • Sweat in front of others • Wear something atrocious • Ask a crush out • Forget to lock the door • Go to the toilet in public • Walk outside on a really windy day 47

Rate it Antecedents (Triggers to anxiety)

Predicted Awfulness

Walking by the snake cage

Standing by the snake cage for 30 seconds

Standing by the snake cage for 2 minutes

Opening the snake cage

Putting my hand in the snake cage for 30 seconds

100

Holding my hand in the snake cage for 2 minutes

100

Touching the snake

100

Holding the snake for 30 seconds

100

Holding the snake for 5 minutes

100

Actual Awfulness

Later

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• Slows the process & impedes fear extinction • Reinforce the big deal • Reinforce the anxiety story • Life doesn’t happen in a linear way • Random approach focusing on

what they are most motivated to work on will enhance the process

Setting up Exposure:

Collaborate a specific plan

• Step-by-step plan: • I will enter the room and go straight to the snake cage • I will stand facing the cage straight on and look at the snake • Once I am at the cage, Cindy will start the timer for 30 seconds • Cindy will stand by the door with no one else around • When the alarm is done, I will leave the room with Cindy • Cindy is only going to look at the timer. She is not going to say anything except, “Time is up”

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I throw up

Setting up Exposure:

Address Obstacles

• I will: bring a paper towel with me to wipe it up • Cindy will: • Keep looking at the timer and not say anything except time is up • Help me clean it up when the exposure is over

Worry makes me feel overwhelmed • I will: • Bring in my coping cards to talk back • Go to the snake cage anyway • Cindy will: keep looking at the timer and not say anything except time is up

The Problem with Safety Behaviours Worsens anxiety • No learning happens: believe the behaviour prevented catastrophe • Still trying to control anxiety (so never confront fears) • Effortful and exhausting (which causes more anxiety and dysregulation)

Passive avoidance • Purposely avoiding situations based on predictions • Need to know: what they avoid, why they avoid, and how they avoid

Safety behaviours: Can be obvious or subtle

Excessive checking • Reassurance seeking • Ensuring certainty of safety • Preventative behaviours – solidify the belief that these are what saves them Overt compulsions • Reduce anxiety or danger/ Prevent feared outcomes • Negatively reinforced • Need to know: what the rituals are, triggers, function, what will happen if they don’t, and how they feel after Covert (mental) compulsions • Quick attempts to reduce anxiety • Relaxation, distraction, positive affirmations Safety signals • Make people feel safer

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Safety Behaviours Sitting strategically (e.g., near exits)

Having someone with you

Carrying a safety object

Never letting heart rate get too high

Having phone charged and on at all times

Medications

Reassurance seeking

Checking google all the time

Having water available at all times

Not eating before leaving the house

Not going to work or school

Asking forgiveness

Praying

Anxiety will be at its highest when you do something different the first time without safety behaviours

Setting up Exposure

Honesty! You’re going to feel uncomfortable MUST Activate to generate

Develop new, competing brain circuits

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Setting up Exposure:

Honesty!

Anxiety is • Normal (of course you are going to be scared!) • Safe (it’s meant to protect you!) • Temporary (let’s see how long this feeling lasts) AND Anxiety is uncomfortable & this is what it does…

Setting up Exposure:

Honesty!

• We have no idea what is going to happen • You will handle it

We MUST have buy-in We can never make anyone (even kids) do anything – especially distressing things they don’t want to do 60

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Setting up Exposure

Rationale & Buy-In Collaborate • What is important to them • Why are we doing this? How will it be helpful for you? • How does worry get in the way of your life?

• New learning • To manage emotions • I can handle it!

Real Bravery in not Fearlessness.

Bravery is acknowledging when something is hard and not pretending it isn’t • With an honest appraisal, we can respond productively

Speed of recovery directly relates to your willingness to feel anxiety

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Building Tolerance

If I am uncomfortable Then I know I am on the right track

Anxiety Dial

Willingness Dial

100

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Setting up Exposure:

Test it out

This is the only way to create new experiences that contradict with old worries

Use Adaptive Coping Skills When they’re in it, focus on sticking with it vs. what ifs and avoidance

What does it sound like?

Maintain mindfulness – Notice and ride the wave

What does it feel like? What does it want me to do?

When the gremlin shows up, it is going to:

I am going to:

Tell me

Say

Make me feel

Notice

Want me to do

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Coping Cards

What worry says: 1. 2. 3

What I am going to say back: 1. 2. 3 70

AVOID False Fear Blockers Anything to make them feel better in the moment • Taking deep breaths • Relaxation • Distraction

What to do instead…

Calming strategies

Stay present with what is, tolerate, and notice what happens. Amygdala learns by feeling the discomfort and seeing that nothing needs to happen for it to go away (and can handle it).

drcarolinebuzanko.com

What to do instead…

Reassure

Support Confidence

Setting up Exposure:

Validate & Normalize

No matter what! • Stick to the plan until you surpass the feared outcome handle ANYTHING • Must learn they can go further than the worry made them believe they can

Setting up Exposure:

Debrief & Evaluate

Learning happens here to disconfirm conspiracy 75

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Getting unstuck

Face Fear

Without the worst thing happening

Without safety behaviours

Or, if it does, they can handle It

Evaluate Antecedents (Triggers to anxiety)

Predicted Awfulness

Actual Awfulness

Standing by the snake cage for 30 seconds I predict this will happen

What really happened?

I will throw up

Felt nausea but didn’t throw up

The snake will be let loose

The snake was in its cage

The snake will bite me

The snake did not have any contact

I will cry

I was brave and walked out with a smile

Later

No matter how awful or what happened, • It passed &

I HANDLED IT!!!!

Maximize Learning: Combine Interoceptive and Situational Exposures

• Teenager who was terrified she’d hurt someone if she felt panicky (lots of nightmares)

Elicit the physiological response (e.g., of panic, turning red, getting sweaty)

• Teenager terrified of having a panic attack while driving and getting into an accident

Put them into the situation • In a room alone with a friend • In a car driving • In a presentation in front of others

• Woman terrified of turning red or getting sweaty in front of others

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An environment which emphasizes safety, trust, and belonging while showing confidence

Important Foundations

Integrate all the skills to handle challenges

Set goals – what am I going to do and why is it important?

Get curious and keep the prefrontal cortex online

Recognize and name their emotions

Understand and identify what is happening in the body and mind

Accept and tolerate the discomfort in the body and mind

Detach, boss back, and problem solve 79

Predictions are important for learning! Set up as experiments to ensure learning

I predict this will happen if I hold a snake Test Predictions & Collect Data

I will throw up

Predict what will happen

The distraction will let the snake loose The snake will bite me I will die 81

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When the gremlin shows up, it is going to:

Tell me Make me feel Want me to do

Predict: What will I Learn?

Ending Exposure Session Did you survive? Yes How manageable was it?

Did the feared outcome happen? No

How tolerable was the distress waiting for It to happen?

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Worry is strong & makes us forget • Negative, worrisome events create strong memories • Keeping track is essential to create memory bridges

Hard

Working on It

Success!

Keep Going! What can we do to tweak the exposure to be even more effective & next targets 87

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What I couldn’t do because of worry: • Go to school • See friends • Ask for help

Moving on

What I can do now: • Go to school on my own • Stay at a friend’s house on my own • Put my hand up in class • Ride the bus

Where I am going next: • Sleepover • Summer camp • Corner store with a friend

Create new ingrained habits

Even the most skilled of us revert to old ingrained habits when the situation is new and/or overwhelming 89

When exposure is done • Lots of opportunities • Can do it on their own without safety behaviours • NOT about their subjective distress!!!!

Willingness to face anxiety provoking experiences!!!

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Committed action Daily Doses of Stress Inoculation to Maximize Success

Lifestyle Focus Opportunists: Choosing to be anxious now for more success later

Resilience is About: Creating the Right World with the Right Opportunities & Experiences

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Do something hard & take risks! Every day.

Goal:

Willingness Action Plan

Big why:

The steps I need to take are:

The discomfort I am willing to have to achieve this goal:

I will take the first step on (date) at (time)

Thoughts Feelings Sensations Urges I can remind myself that:

Recovery is when:

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BONUS (if time) Exposure Obstacles & Traps

Common Obstacles: • Lack of understanding about anxiety and what maintains it • Unclear rationale • Rationale irrelevant or weak • Fusion to unhelpful thoughts (e.g., justifications) • Excessive (e.g., too big, skills or resources lacking) • Individual is not involved in selecting and planning • Exposures aren’t worrying – too easy • Something still makes them feel safe (yeah but…) • Practice sessions too narrow

Common Obstacles: • Implemented incorrectly • Focus too much on convincing or reframing • No learning happening • Poor relationship • Depression • Failing to address others’ accommodations • Failing to address safety behaviours • Unintentionally reassuring or accommodating ourselves • Working harder than the individual • Stuck in trying to convince them

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Us! We need to get over our own discomfort They MUST get uncomfortable

100

Habituation Sending the wrong messages • Anxiety is bad (because it must be reduced) • Something is wrong with me (because the only way I will be fixed is if I don’t feel anxious) • Misinterpret inevitable and normal unexpected anxiety becomes signs of failure • Hopelessness • Anxiety is controllable • Exposure can become another safety signal

101

What to do instead…

Habituation

Focus on learning: Feared outcome beliefs contradicted ? Did you handle it?

102

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What to do instead…

Eliminate anxiety & fearful associations

Create new learning patterns that compete with old ones

103

Learned Fear Generalizes Easily •Safety learning affected by context • People • Place • Time • Access to safety signals • Intensity of arousal

104

If Stuck on Safety Behaviours

• We want to let go of these as quick as possible. • Use only to build momentum and success if absolutely needed • Do a cost benefit analysis (e.g., short-term gain for long-term pain)

105

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What to do instead…

Conditional Safety Learning

Learn non-danger-based associations across contexts with different people and everywhere anxiety can show up

106

If something bad DOES happen What did you learn!!!??? • Yay! • Importance of keeping going

107

When Anxiety Overwhelms During a Meltdown

After a meltdown

• Remain calm and neutral • Create safety

• Acknowledge and praise • Validate and empathize • If calm

• May need to disengage but remain close for support

• Work through it • Lessons learned • Function of emotion • Rewind and do over

108

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https://bit.ly/POTYpodcast

https://bit.ly/overpoweringemotions

109

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2023-11-09

Cannabis & Mental Health Primer Webinar Zach Walsh

Disclosure u

My research has received financial support from Tilray and Doja in the form of funding to sponsor a clinical trial for which I am principal investigator.

Former director of clinical research for Indigenous Bloom as an advisory board member.

Potential for conflict(s) of interest:

Zach Walsh has received research support from Tilray & Doja.

Tilray & Doja are licensed producers of cannabis for medical purposes.

I hold shares in Indigenous Bloom.

Indigenous Bloom is an Indigenous operated cannabis company.

Other funders of this research:

Overview - Me u

Clinical psychologists (#2011)

Trained in addictions treatment u

University of Chicago

Brown University – Center for Alcohol and Addiction Treatment

Professor – UBC

Lead - Therapeutic Recreational & Problematic Substance Use lab

Published and presented widely on cannabis use and mental health u

HOC

Senate

BC Supreme Court

Uruguay and Costa Rica

PI – Canada’s 1 st clinical trial of cannabis to treat mental health d/o

Advisory boards of MAPS Canada & Clinical team for MDMA for PTSD trials

CIHR & SSHRC funded studies of cannabis use in young adults

2023-11-09

Overview - Today PART 1 u History u

3000 BCE to C-45

The plant u

Cannabinoids

Terpenes

Strains/Chemovars

Modes of Administration

u THC-CBD…

u Entourage effect

u Indica / Sativa

Overview - Today PART 2 u Cannabinoids in humans u

The Endocannabinoid System u Endocannabinoid deficits u Endocannabinoid care

Cannabinoid pharmacology

Medical Cannabis use u

Patient reports

Cannabis for pain and anxiety

Substitution u Benzodiazapines u Opioids u Alcohol

Overview - Today PART 3 u

Cannabinoids and Mental Health u

Anxiety

Depression

Psychosis

Risk

PTSD

2023-11-09

Overview - Today PART 4 u

Problems u

Withdrawal

Disorder

Assessment

Treatment

Safe use

Driving

Special populations u

Youth

Older adults

Cannabinoids u

Endocannabinoids u

Naturally occurring in animals

Anandamide

2-AG

Phytocannabinoids u

From plants

THC, CBD and many others

Synthetic u

K9, Spice

2023-11-09

History - China u

Shen-Nung (c.2700 B.C.)

Sehng na

History - India u

Ganja

Bhang

Holi

The Vedas call cannabis a source of happiness, joy-giver, liberator that was compassionately given to humans to help us attain delight and lose fear (Abel, 1980).

History - Europe u

William Brooke O'Shaughnessy u

Introduced medical use of cannabis to Europe

From India - 1841

2023-11-09

HISTORICAL MAP

History - Prohibition “Marihuana is a short cut to the insane asylum. Smoke marihuana cigarettes for a month and what was once your brain will be nothing but a storehouse of horrid specters. Hasheesh makes a murderer who kills for the love of killing out of the mildest mannered man who ever laughed at the idea that any habit could ever get him…” Harry Aslinger, 1937 1st Commissioner of the Federal Bureau of Narcotics

History - Canada u

Canada – Janey Canuck – The Black Candle (1922)

2023-11-09

Canada - Recent

Background – Medical Cannabis in Canada u

Parker (2000) - constitutional right to choose cannabis as medicine without fear of criminal sanction

In 2001, the Marihuana Medical Access Regulations (MMAR) u

Access u Health Canada – Prairie PPS

u Private production license

u Designated grower (1:1…2:1)

2023-11-09

MMPR MARIHUANA FOR MEDICAL PURPOSES REGULATIONS u

Simplified/decentralized application process

Multiple Licensed Producers Increased quality & strain choice

Research funding & materials

No self-production or storefronts Allard

u 2016 ACCESS TO CANNABIS FOR MEDICINAL PURPOSES

REGULATIONS (ACMPR)

C-45: THE CANNABIS ACT Sale -provincial gov’t

•

online (mail) and retail stores;

•

public/private models

•

Minimum age of 18 (provinces can adjust)

•

Adults – •

up to 30 grams –

•

4 plants per household

Youth (12-17) –

•

decriminalized for 5 grams or less

• •

Providing cannabis to minors – 14 year max

•

Limits on advertising and branding

•

Outside of regulated framework •

•

45+ new penalties

UP FOR REVIEW 2023 (THOUGHTS?)

Cannabinoids u

The Cannabinoids u

Delta-9-tetrahydrocannabinol (∆9 -THC)

Cannabinoids

5-25% “superweed?”

u Over 100 Cannabinoids u

Cannabinol and Cannabidiol (CBD)

THCA, THC, CBDA, CBD, CBGA, CBG, CBN

Some on plant ratios of 2:1, >20:1, u Terpenes

u Entourage effect of herbal cannabis u Whole plant – coevolution with humans? Synthetic Cannabinoids u Sativex - extract u Dronabinol (Marinol)-Levonantradol (30x THC) u Spice / K2

Rimonabant – antagonist

2023-11-09

Pharmacology of THC u

THC functions by binding to the Cannabinoid Receptor (CB 1). u The presence of this receptor indicates that there is a

naturally occur (endogenous) ligand, Anandimide, as well as other related compounds.

The response can affect the hippocampus and hypothalamus u Hippocampus –involved in motivation and emotion as

part of the limbic system; has a central role in the formation of memories.

u Hypothalamus –regulating sleep cycles, body

temperature, appetite, etc., and that acts as an endocrine gland by producing hormones, including the releasing factors that control the hormonal secretions of the pituitary gland.

CBD u Well Documented: u Anti-epileptic u Potential: u Analgesic (acute and chronic pain) u Antipsychotic u Anxiolytic u Anti-cancer u Anti-inflammatory 23

CBD u CBD does not activate CB1 or CB2 receptors u Does not mimic endocannabinoids. u Interacts indirectly with the

endocannabinoid system

Agonist u

5 HT 1A (anxiolytic; antidepressant)

Adenosine (anxiolytic)

TRPV1 - (analgesic)

Mu and delta opiate – (analgesic)

2023-11-09

Terpenes u

Biologically active cannabis constituents with pharmacologic effects.

> 200 in the cannabis plant.

Most are “Generally Recognized as Safe” as food additives.

How to optimize terpene absorption?

Terpenes

Entourage?

2023-11-09

strains u

Indica/ sativa

leafly

2023-11-09

CBD vs

Lewis, Russo & Smith, 2018

Edibles u

Special consideration

Concentrates

2023-11-09

Concentrates

Modes of use u

Absorption u

Oral Administration u Highly Lipid Soluble u

Will hardly dissolve in water

Bake in food

Oral dose must be doubled or tripled to have same effect as inhalation

First pass metabolism

Peak effects: 1 to 3 hrs after ingestion

Inhalation u Depth of Inhalation u

Vs duration

10-25% cannabinoids

Peak effects: 15 to 60 minutes

2023-11-09

Modes Distribution u The time course for

intensity of a subjective “high” after consuming various doses of THC via different routes of administration

Part 2 - Cannabis, the Brain & Mental Health

Neurological Effects of THC Endocannabinoid Synaptic Transmission

u 1.

Transmission of neurotransmitter into the post-synaptic neuron.

Production of endocannabinoids in the post-synaptic neuron.

The endocannabinoid (e.g. anadamide, 2AG) is released into the synaptic cleft.

In the synaptic cleft the endocannabinoid binds to the cannabinoid receptor of the pre-synaptic neuron. u

This in turn modulates neurotransmission pre-synapticly

Post-Synaptic Neuron à Pre-Synaptic Neuron (Retrograde Transmission)

This mechanism is reverse of what is typically seen u

Pre-Synaptic Neuron à Post-Synaptic Neuron (Normal Transmission)

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Neuropharmacology Receptors – 2 discovered 1990 u Likely many more u Second Messenger System

u Endocannabinoids u Anandamide u 2-arachidonylglycerol (2-AG) u THC > duration & effect

u Presynaptic Neuromodulators u From post to pre synaptic u Effects depend on nature of pre u Depolarization-induced suppression of inhibition u Depolarization-induced suppression of excitation

u Stress Recovery u Relax, eat, sleep,forget & protect

Effects on Behavior of Humans u Subjective Effects uBipolar / contradictory u Mood Changes and Getting High uMood swings uSocial effects u Perception uLoss of sensitivity to pain uTime distortion McKim, 2017

2023-11-09

Effects on Behavior of Humans u Memory u No effect on the ability to recall material already well

learned or on recognition memory u Does disrupt the ability to recall words or narrative material u Short term memory u Temporal disintegration

u Attention u Easily distracted

u Creativity u Appreciation u No evidence that creativity is enhanced

McKim, 2017

u Setting? (NCAP)

Effects on Behavior of Humans u Performance u Varied results u Level of use u Features of task u Ability vs attention/ motivation

u Performance Screening Tests u Standardized Field Sobriety Tests u Gaze nystagmus, Walk and turn test, One-leg stand u 56% of high THC group identified vs 2.5% placebo

McKim, 2017

Cannabis for Therapeutic Purposes u Risks and benefits u Cannabis is: u

“…one of the safest therapeutically active substances known to man” US Drug Enforcement Administration Judge Francis Young -1988

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Conditions in Clinical Practice Rank order - Hergenrather 2016 u

Pain (acute pain, chronic inflammatory, neuropathic) Mental disorders (all kinds)

Cancers

Gastrointestinal disorders

Insomnia Migraine headaches

Harm reduction, alternative to opioids . . . Spastic disorders

Autoimmune disorders

Neurodegenerative disorders

Glaucoma Skin diseases

u u u

Epilepsy, Autism, Tourettes, ADD, Dystonia, Dementia AIDS and other infections

Cannabis for Therapeutic Purposes

Cannabis & Mental Health Cannabis Access for Medical Purposes Study (CAMPS)

N=628

Sleep

85% 82% 78% 66% 56% 49%

Pain Anxiety Depression Appetite/ Weight Nausea

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“…the use of prescription drugs … fell significantly, once a medical marijuana law was implemented. National reductions in Medicare program and enrollee spending when states implemented medical marijuana laws were estimated to be $165.2 million per year”

2023-11-09

Substituting Cannabis

Cannabis, Pain, & Anxiety

“I saw in it (cannabis)a means of effectively combating the fixed ideas of depressives, disrupting the chain of their ideas, of unfocusing their attention … Jacques-Joseph Moreau (1845)

Substituting cannabis for alcohol

UBC students (n=253)

When using cannabis Don’t drink as quickly Don’t drink as much Don’t desire alcohol Crave alcohol

71% 53% 34% 0%

Walsh, Crosby & Lucas, in prep

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Overview - Anxiety •Anxiety disorders - Overview •Cannabis and general anxiety •Cannabis and social anxiety disorder •Cannabis substitution for benzodiazepines •CBD •Summary / conclusions

Generalized Anxiety Disorder Associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months); u

1. Restlessness or feeling keyed up or on edge.

2. Being easily fatigued.

3. Difficulty concentrating or mind going blank.

4. Irritability.

5. Muscle tension.

6. Sleep disturbance.

(American Psychiatric Association, 2013)

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Human studies – Medical

888/2032 (43.7%) reported authorization to treat anxiety symptoms 46% Generalized Anxiety Disorder 42% Social Anxiety Disorder 26% Panic Disorder/Agoraphobia 26% Major Depressive Disorder 63% met screening criteria for ≥1 disorder

92% - Cannabis improved symptoms 1 2 3 4 5 6 7 8

Anxiety Irritability Sleep onset Anxiety attack Low mood Muscle tension Restlessness Sleep interruption

Human studies – Harms?

NESARC focusing on social anxiety, panic disorder, generalized anxiety disorder, and specific phobias (N = 3,723).

Large longitudinal epidemiological study National Epidemiological Study of Alcohol and Related Conditions(NESARC) 3yrs & >30, 000 participants Cannabis use was not associated with development of any anxiety disorder

Compared cannabis users and non users in rates of remission, suicidality, general functioning, and quality of life With control factors in analyses - no differences in outcome. “poorer outcome of anxiety disorders among cannabis users may be attributed mainly to differences in baseline factors and not cannabis use.”

Individuals with baseline panic disorder were more prone to initiate cannabis use at follow-up – medical?

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Human studies – SAD

• Socially anxious > cannabis use to relieve symptoms than individuals with other anxiety d/o

• 300mg CBD/ day – 4 weeks • 18-19 y/o w/ SAD and Avoidant PD • (N= 17 CBD v 20 placebo)

• Nonmedical cannabis use among the socially anxious may be associated with cannabis-related problems • SAD typically precedes the development of problematic cannabis use

• Significant reductions in anxiety in the CBD group

• CBD use is associated with: • decreased subjective anxiety among SAD patients • decreased cognitive impairment and anxiety in a simulated public speaking task

“many of the participants treated with CBD became positive in their attitude toward seeking treatment.”

Cannabis – benzodiazepine substitution

•

Benzodiazepines using patients (n = 146) from a cannabis clinic

•

30% discontinued benzodiazepines after 2-month

•

45% after 4 & 6 months

• Dispensary members (n = 1513) survey • 72% decreased use of benzodiazepines • Over half decreased “a lot” • 77% reduced opioids • 38% antidepressants

Cannabis & Anxiety – Summary u

Anxiety is among the most frequently cited reasons for using medical cannabis

Patients report relief of symptoms including irritability, agitation, sleep

Cannabis use does not appear to lead to development of anxiety d/o

Cannabis use does not appear to worsen outcomes among those with anxiety d/o

Cannabis is being used as a substitute for benzodiazepines

Preliminary evidence suggests that CBD isolate has anxiolytic effects independent of THC or herbal cannabis

No RCT has examined the effectiveness of cannabis versus placebo

BUT anxiety can be a symptom of cannabis overdose and withdrawal

Comparative efficacy trials required

2023-11-09

Major Depressive Disorder u

7% - prevalence

Negative Affect is a well-established risk factor – u

Traits/ personality

Refractory?

Among largest contributors to non-fatal health loss

Annual cost >200B$ in US

High comorbidity u Anxiety u Substance use – including cannabis

Extant treatments – behavioral therapy and pharmacotherapy

High proportion of US adults prescribed antidepressants u adverse effects

“Our results show that the harmful effects of SSRIs versus placebo for major depressive disorder seem to outweigh any potentially small beneficial effects.”

u questionable effectiveness

Major Depression u

1. Depressed mood most of the day, nearly every day*

2. Diminished interest or pleasure in all, or almost all, activities*

3. Significant weight loss when not dieting or weight gain

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation

6. Fatigue or loss of energy

7. Feelings of worthlessness or excessive or inappropriate guilt

8. Diminished ability to think or concentrate, or indecisiveness

9. Recurrent thoughts of death / suicidal ideation (American Psychiatric Association, 2013)

Cannabis & Depression - Mood

• Healthy adults (n=91) – pre, 1h, 24h, 48h • smoked 12.5% THC cannabis vs placebo • 1h - Increased Arousal and Positive Mood, Friendliness, Elation, Confusion • 24h - Increases in Friendliness and Elation for 24 h. • No evidence of residual cognitive impairment.

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Cannabis & Depression

Cannabis Access for Medical Purposes Study (CAMPS)

Sleep Pain Anxiety Depression Appetite/ Weight Nausea

N=628

85% 82% 78% 66% 56% 49%

Cannabis & Bipolar Disorder • Anecdotal reports suggest that some individuals use cannabis to effectively treat symptoms of bipolar disorder (BD) • Narrative review suggested potential for managing manic and depressive symptoms • Evidence of improved neurocognitive functioning in BD patients who use cannabis • Reviews concluded that non-medical cannabis use among those with BD may: • prolong or worsen manic states • increased odds of suicide attempts • earlier age of BD onset • psychosis • more severe course of illness

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Cannabis & Bipolar Disorder

• 35 studies (n=51,756; female: 60%), • 24% cannabis use among Bipolar D/O • Cannabis users were younger at first episode • More lifetime suicide attempts • More lifetime psychotic symptoms • No differences in: • rapid cycling • comorbid anxiety disorders

• Compared Bipolar to Major Depression • BPD > frequency and quantity cannabis • BPD> criteria for CUDs • No differences in associations: • rates of other co-morbid psychiatric d/o • treatment utilization • suicidality

Cannabis and Depression Summary u

Endocannabinoid system implicated in depression

Mood improvement is a frequently cited motive among medical cannabis users

Cannabis produces short term improvements in mood

Evidence is mixed with regard to reduction in motivation

Cannabis use is prevalent among those with bipolar depression

Similar outcomes to major depression

Some additional cautions regarding psychosis risk

Cannabis may be particularly helpful for relieving negative mood in the context of chronic pain

Severity

Withdrawal

2023-11-09

Cannabis Anxiolytics & Antidepressants

• Extant treatment evidence is a few small, primarily single-dose studies. • Not whole plant

“...it may be difficult to objectively place cannabis in the armamentarium of psychopharmacological treatments until further research is conducted and treatment guidelines developed”

Cannabis and sleep - preclinical

• Endocannabinoids are important in sleep and sleep neurophysiology • Sleep patterns clearly altered by cannabinoid drugs • Cannabis /THC • decreased sleep onset latency, • decreased waking after sleep onset • increased slow-wave sleep and decreased REM sleep

Cannabis and sleep

Cannabis Access for Medical Purposes Study (CAMPS)

Sleep Pain Anxiety Depression Appetite/ Weight Nausea

N=628

Licensed producer survey

85% 82% 78% 66% 56% 49%

Pain Stress Insomnia Depression Headache

N=271

73% 60% 57% 46% 32%

2023-11-09

Cannabis and sleep

• Patients may decrease their use of pharmaceutical sleep medication • Relatively rapid tolerance with regular use • Withdrawal/ cessation associated with: • Decreases in total sleep time • Decreased sleep efficiency • Increased Latency to sleep onset • Increased wake after sleep

Cannabis and sleep

• Studies are flawed • Cannabis use associated with decrease in slow wave sleep & increase in stage 2 • No effect on total sleep time. • Reduced disturbance & better sleep quality with a medical condition (e.g. pain, spasticity, PTSD) • Secondary effects of cannabinoids • More research needed on dose

Cannabis & nightmares

Cross sectional / retrospective Reduced PTSD symptoms Improved sleep & nightmares Discontinuation of meds (e.g. opioids, benzos)

Small trial from PTSD clinic (n=10) Reduced nightmares

Dispensary sample n = 163 – 81 insomnia & 14 nightmare Reported “sativa” preference for reduced nightmares Higher CBD preference for insomnia

General clinical improvement

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Cannabis and sleep – Summary • Clear role for endocannabinoid system in sleep • Use for sleep disturbance is common among medical users • May be most effective for sleep in the context of other symptoms • Pain, PTSD • Cannabis withdrawal involves sleep disturbance • Nabilone reduces nightmares • Preliminary evidence of high-CBD cannabis preference for insomnia • More research needed

Cannabis and madness "The deleterious, even vicious, qualities of the drug render it highly dangerous to the mind and body upon which it operates to destroy the will, cause one to lose the power of connected thought, producing imaginary delectable situations and gradually weakening the physical powers. Its use frequently leads to insanity." Harry Anslinger, 1937 1st Commissioner of the Federal Bureau of Narcotics

Cannabis and madness

https://www.drugpolicy.org/resource/letter-scholars-andclinicians-who-oppose-junk-science-about-marijuana

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Clinical

1 - Does the prevalence of psychotic disorders differ according to cannabis use? 2- Do cannabis users have earlier onsets of psychotic illnesses? 3- Differences between cannabis users and non-users with psychotic illnesses? 4- Biological n link use of & and thethe development of psychosis?review 113,802 Largest meta-analyses = between 66,816 cannabis participants and largest systematic participants (American Psychiatric Association, 2013)

Clinical

1 - Does the prevalence of psychotic disorders differ according to cannabis use? YES - Dose-dependent 2- Do cannabis users have earlier onsets of psychotic illnesses? YES - 2-3 years earlier 3- Differences between cannabis users and non-users with psychotic illnesses? MIXED – may worsen positive symptoms, relapse, hospitalizations – NOT duration, suicidality 4- Biological link between cannabis use of and the development of psychosis? NO clear relationship

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Clinical

• Danish survey >3m ; 200k SUD, 20k Schz • Any SUD increased risk of developing schizophrenia [hazard ratio (HR) 6.04 (CI) 5.84–6.26]. •

Cannabis (HR 5.20, 95% CI 4.86–5.57)

•

Alcohol (HR 3.38, 95% CI 3.24–3.53)

•

Hallucinogens (HR 1.86, 95% CI 1.43–2.41),

•

Sedatives (HR 1.68, 95% CI 1.49–1.90)

•

Other substances (HR 2.85, 95% CI 2.58–3.15)

• Associations between “almost any type” of SUD and schizophrenia

Clinical – Causal versus co-occuring

• > 100 papers/ year 2012-2015 versus < 10/yr 1990s • Current /prior cannabis associated with 1st episode psychosis/ schizophrenia • Cannabis use is part of a cluster of “general deviant behavior” • Schizophrenia is linked to diverse array of variables “Future research studies that focus exclusively on the cannabispsychosis association will therefore be of little value in our quest to better understand psychosis and how and why it occurs.”

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CBD & Psychosis

• Large dose of single molecule isolate •

CBD 1000 mg/day (N=43) /placebo (N=45)

One time/ single dose of CBD (600 mg)

FMRI indicated CBD attenuated acute dysfunction in mediotemporal and prefrontal activation & mediotemporalstriatal function during experimental task

Psychosis patients w/ CBD (13) were intermediate between controls (19) and placebo

Trend-level symptom reduction in psychosis patients at 5.5hrs.

• At 6 weeks the CBD group had: • Lower positive symptoms • Higher rate of improvement • Well tolerated / no difference in adverse events

Schizophrenia – Summary • Exaggerated and lurid depictions of the association between cannabis and psychosis are an enduring aspect of cannabis related-stigma from the early days of prohibition to the current backlash against progressive cannabis policy • The etiology of both psychotic disorders and substance use is complex and multidetermined •

The ECS likely has a role

• Individuals with psychotic disorders are more likely to use cannabis •

This use often precedes formal diagnosis of psychosis

• Individuals with psychotic disorders who use cannabis demonstrate earlier onset and worse course of treatment • The preponderance of evidence suggests shared vulnerabilities rather than a casual relationship • CBD may have anti-psychotic effects

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History – PTSD & Cannabis • Patient/combat veterans have taken a leading role in advocacy • CNN WEEDS 3 Documentary – 2015 • US VA – will not recommend • Canada – Vets only group to get federal coverage for cannabis • Advocacy continues – several groups e.g Veterans for Medical Cannabis Access

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Preclinical - summary

“…deficiencies in eCB signaling can result in: u

hyperactivity of the amygdala

hypoactivity of the mPFC

impaired regulation of the stress response elevated levels of basal and stress-induced anxiety

u u u

increased retrieval and impaired extinction of emotionally aversive memories increased propensity to develop a state of inflammation.”

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PTSD Symptoms I CRITERION A – Experience traumatic event CRITERION B - Intrusion Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the event(s) occurred:

Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)

Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event.

Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the event(s) were recurring.

Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Marked physiological reaction to external or internal cues that symbolize or resemble an aspect of the traumatic event(s).

CRITERION C - Avoidance Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing, memories, thoughts, or feelings about or closely associated with the traumatic event(s). (American Psychiatric Association, 2013)

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PTSD Symptoms - II

D -Negative Alterations in Cognition & Mood

Inability to remember an important aspect of the traumatic event

Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world

Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that leads the individual to blame self or others.

Persistent negative emotional state .

Marked diminished interest or participation in significant activities.

Feelings of detachment or estrangement from others.

Persistent inability to experience positive emotions (e.g., happiness, satisfaction, or loving feelings).

E – Arousal & Reactivity 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g. problems falling or staying asleep or restless sleep).

(American Psychiatric Association, 2013)

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Human studies -II

• Small open label trial from PTSD clinic (n=10) • Reduced symptom severity • Improved sleep & nightmares • Reduced hyperarousal

• Cross sectional / retrospective • Recruited from cannabis clinic • Notable reductions in: • re-experiencing • avoidance • hyperarousal

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Recent updates I

Elevated hyperarousal symptoms are associated with anxietyrelated cannabis use

Higher hyperarousal patients reported greater anxiolytic effects relative to those with more avoidance and reexperiencing symptoms

Consistent with a negative reinforcements model of PTSD and cannabis use

• Large prospective study in VA • PTSD associated with later development of problematic cannabis use • Cannabis use associated with greater intrusion symptoms at 6 months • “Coping-oriented pattern of heightened avoidance of negative emotional states via cannabis use” • Limitations – • •

No query of medical use No reporting of other symptom groups

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Recent updates II

Baseline cannabis use was unrelated to endpoint (12-wk) PTSD or SUD.

Higher cannabis use was associated with higher PTSD symptom severity early in treatment, but lower PTSD symptom severity later in treatment.

As cannabis use increased primary substance use decreased and vice versa.

u Cannabis use may be synergistic with CBT to reduce PTSD symptoms.

u Substitution?

• Higher levels of cannabis use among those with PTSD. • PTSD was associated with depression and suicidality among non-cannabis users • PTSD was not associated with these outcomes among cannabis users

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Recent updates III

• 404 medical cannabis self-identified with PTSD were tracked with app • >90% session resulted in acute reductions of over 50% in: • • • •

Intrusive thoughts Flashbacks Irritability Anxiety

• PTSD symptoms did not change over time • Doses increased over time • Tolerance?

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Recent updates IV

110

PTSD SUMMARY u

Extant treatments are inadequate for many and consequences are severe

Preclinical research has identified an etiological role for the ECS

u u

Substantial anecdote, advocacy and cross-sectional evidence in favour Nabilone reduced nightmares and improves sleep

Longitudinal evidence is mixed – and methodologically limited

Some evidence for negative reinforcement/ exacerbation of avoidance

Some evidence for reduced anxiety, depression and suicidal ideation

Evidence for acute symptom improvement with no long term gains

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113

Cannabis – Young adults

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Cannabis – Older adults

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Problems - Respiratory

lungs

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Problems- Withdrawal

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Problems- Withdrawal

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Treatment considerations u

Harm reduction

Use of CBD to reduce withdrawal

Edibles

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Overdose Green out u

Canadian Institute of Health Information

2017-2018 -2,266 ER visits (>25, 000 for other substances)

Mostly from edibles

Symptoms:

u Dabbing

Paranoia

Anxiety

Lethargy

Extreme dry mouth

Burning eyes

Shortness of breath

Increased heart rate

Shaking / trembling

Chills / sweats

Disorientation / lack of focus

Nausea

https://www.theleafnews.com/news/leaflet-Cannabis-overdoses-in-emergency-rooms-492201931.html

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Cannabis & Driving u

Influence upon performance is short-lived u Peak acute effects … obtained within 10 to 30 minutes

2004. Drugs and Human Performance Facts Sheets)

(NHTSA.

u “impairment from cannabis typically clears 3-4 hours after use. …a

minimum wait period before driving.” (Fischer et al., 2011. Lower risk cannabis use guidelines for Canada)

Experienced users become tolerant u “Experienced smokers who drive on a set course show almost no

functional impairment under the influence of marijuana.”(Sewell et al., 2009. The effect of cannabis compared with alcohol on driving)

u “Patients … develop tolerance to the impairment of psychomotor

performance, so that they can drive vehicles safely.” (Grotenhermen and Mueller Vahl. 2012. The therapeutic potential of cannabis and cannabinoids)

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Driving with two or more passengers (OR = 2.2) (McEvoy et al., 2007)

Exceeding the speed limit by 3+ mph (OR = 1.89) (Kloeden et al., 2002)

Using a mobile phone (OR = 4.1) (Redelmeier and Tibshirani, 1997)

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February, 2017

“Medical marijuana laws were associated with immediate reductions in traffic fatalities in those aged 15 to 44 years …Dispensaries were also associated with traffic fatality reductions in those aged 25 to 44 years.”

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Cannabis – Young adults www.cssdp.org/youthtoolkit 1. 10 Principles for Approaching Cannabis Education with Young People 2. Pull Away Curriculum a. Cannabis 101 b. Why Youth Use and Don’t Use Cannabis c. Harm Reduction d. Legislative Overview e. Literature Review of Health Harms (as of Dec 2017)

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Mindful Cannabis Use

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Jeffrey Y. Hergenrather, MD General practice physician Solo private practice Cannabis consultations since 1997 Sebastopol, California President and founding member of The Society of Cannabis Clinicians

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2023-11-09

Treatment plan Dosing range: Titrate for desired effect (low and slow) Micro-dosing 1 ug/kg/day Average dosing: “High dose” 1-20 mg/kg/day

Frequency of dosing

• Episodic or as needed • Daily administration: morning, evening or bedtime • Multiple or frequent administrations daily • Holidays

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Treatment Plan Method of Admininistration (MOA): ☐

Oral tincture, infusion, or spray, alcohol or oil based

☐

Full extract cannabis oil, FECO

☐

Other ingested flowers, products, or concentrates

☐ ☐

Vapor or smoke Suppositories

☐

Topical

Cannabinoid ratio: Preferred ratio of principle cannabinoids, THC:CBD. ☐ ☐

High CBD strain: CBD:THC (30:1 <-> 10:1) , (ACDC, Charlotte’s Web, and others) Balanced: 6:1<-> 1:1 <-> 1:2 THC:CBD, nominally 1:1

☐ ☐

High THC strain: (THC:CBD ~ 100:1 <-> 50:1) Other: e.g. consider a High CBD tincture in the AM before breakfast and a balanced THC:CBD tincture at bedtime

Frequency: Frequency varies depending therapeutic goal, variations in the rate of hepatic metabolism, and MOA. ☐ ☐

Once daily Twice daily, AM before breakfast or PM, and bedtime

☐

Three times daily, every 8 hours ~ AM before breakfast, PM, and bedtime

☐

Other ___________

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Developing the Treatment Plan Suggested Dose: Wide range in dosing depending on tolerance and individual differences. Generally dosing is increased by slow titration to effective dose. ☐

2 1/2 mg to 5 mg per dose

☐

5 - 10 mg per dose

☐

10 - 20 mg per dose

☐

20 - 40 mg per dose

☐

~ 50 mg per dose

☐

Other: e.g. Increase dose gradually and speadily..

Target dose: (SPECIAL CONDITIONS) ☐

Minimum target dose: _____ mg / day, (or mg/dose)

☐

Maximum target dose: _____mg / day, (or mg/dose)

Tolerance (a reminder): Develops with a steady, at least daily, dosing with induction of auto-regulation of cannabinoid CB1 receptor population (internalization of CB1 receptors). From onset tolerance develops in ~ 1-2 weeks, Footnotes: 1. All products are considered to be organically grown and produced. 2. Products have accurately measured cannabinoid content and terpenes when available. 3.. Hold dose if too sleepy 4. Drug-Drug interactions: For nearly all conventional pharmaceuticals there is no significant drug-drug interactions with cannabis/cannabinoids. Clobazam and other anti-epileptics drugs metabolized by the hepatic CYP 2C19 and CYP 3A4 families, with concurrent high doses of cannabis concentrates (> 1 mg/kg/day) should be monitored for safe and effective blood levels of these anti-epileptic medications.

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Treatment Plan - Precautions • Anxiety and panic in the neophyte or THC sensitive • Syncope and/or fall risk especially with high dose “dabs” • Smoking > bronchitis ~ No COPD, emphysema, or cancers • Habit Forming ~ Not addictive, minor withdrawal • Drug Drug interaction: CYP450 2C and 3A families • Association with schizophrenia and psychosis • Association with the hyperemesis syndrome

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THANKS

http://blogs.ubc.ca/walshlab/

ZACHARY.WALSH@UBC.CA

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11/6/23

The “Wow” Effect How the New Science of Awe Can Make Us Happier, Healthier, and More Connected

About Me

• Author of Happily Even After, Real Happiness, The Happiness Toolbox, and Awestruck • International speaker and workshop trainer

Jonah Paquette, Psy.D. Author of Happily Even After, Real Happiness, The Happiness Toolbox, and Awestruck

www.jonahpaquette.com

An unusual day… • Record number of sick days • State populations tripled • Record-breaking marriage proposals • Same distinct #hashtag • Unusual Fashion Choices • Strange Behaviors

What do you feel when you… Gaze up at the Milky Way? See a beautiful sunrise or sunset? Witness an act of great compassion or courage? Watch a child learn to walk? See a mind-blowing work of art? Attend an incredible performance?

11/6/23

What is Awe? The feeling we get in the presence of something vast that challenges our understanding of the world.

What is Awe?

Awe

Defining Awe

Vastness

Transcendence

The Power of Awe

• Vastness • Perceptual Vastness • Conceptual Vastness

• Transcendence • Challenges our Assumptions • Accommodation of new information

-Edgar Mitchell, Apollo 14 astronaut (Yaden, 2016)

Who Experiences Awe?

Cross-Cultural Research

• Personality factors

• Universal human emotion found across all cultures • Differences in frequency of experiencing awe (Razavi, 2016)

• Extraversion, Openness to New Experiences

• Character Traits

• Comparison of US, Poland, Malaysia, Iran

• Optimism, Gratitude, Creativity, Love of Learning, Appreciation of Beauty

• Differences in sources of awe (Bai, 2017) • US/Europe: more likely to experience awe through nature or through themselves • East Asia: more likely to experience awe through another person

• Spirituality and Religion • No differences found overall, though sources of awe may differ

• Social Class • Slight link to lower-SES individuals

11/6/23

Challenges to Awe

Why do we experience Awe? • Emotions not only serve a purpose, but developed within our species for specific evolutionary advantages

• Technology • Rise of Urban Living • Increasing length of workday • Rising levels of stress

• Not merely a result of social learning

• Constant worry and rumination • Increased materialism • Changing attention spans

• But what purpose might awe serve?

• Decreased attendance for concerts, museums, and live performances

Awe Connects Us With Others (Shiota & Keltner, 2007)

The Purposes of Awe

Awe Connects Us

Bai (2017): Awe resulted in greater feelings of closeness with others in the community compared to neutral or negative experiences

11/6/23

Awe Increases Generosity (Prade, 2016)

Awe Increases Generosity (Rudd, 2012) • Brief writing exercise • Happy memory or awe-inspiring memory

• First study looked at how frequently people experienced various emotional states. • Participants also given 10 lottery tickets and that they’d be entered for a cash prize • Could either keep all the tickets, or share with an unknown stranger

• Awe condition • Higher levels of patience • Greater willingness to donate time or money to a good cause

• Awe linked to 40% greater generosity

Awe Increases Generosity (Prade, 2016) • Follow-up study compared people reflecting on awe-inspiring experiences to neutral experiences • Then asked to imagine winning the lottery • Reflecting on awe resulted in significantly increased generosity and sharing of the potential prize money

Awe Makes Us More Curious (Smith, 2016)

The Benefits of Awe

11/6/23

Awe Increases Life Satisfaction (Rudd, 2012)

Lasting Mood Boosts (Stellar, 2017)

• Participants tracked mood and experiences of awe over several weeks • On average, people experienced approximately 2 instances of awe per week • Powerful awe experiences resulted in mood improvements even weeks later

Awe Decreases Materialism

The Small Self (Bai, 2017)

• Awe linked to a preference for spending $ on experiences rather than material goods (Rudd, 2012) • Awe leads to a decreased emphasis on money, and prioritization of other values (Jiang, 2018)

• Awe reliably leads to a feeling of smallness relative to the world around us, a phenomenon known as ”the small self.”

Awe Lowers our Stress (Anderson, 2018)

Awe Changes Our Time Perspective (Rudd, 2012)

11/6/23

Awe Increases Humility (Stellar, 2018) • Individuals who reported more awe experiences rated by both self and peers as being:

Our Brain and Body on Awe

• Less self-absorbed • Less narcissistic • More humble • Possessing a more accurate understanding of their own strengths and weaknesses

Awe and Inflammation

Awe and Inflammation (Stellar et al., 2015) Short-Term/Acute

Chronic

• Fights disease and infection • Restores us to homeostasis • Signals immune system to spring to action • Heals and repairs damaged tissue • Localized

• Persistent, low-grade • Widespread (rather than localized) • Linked to heart disease, stroke, Alzheimers, depression, and much more

Your Brain on Awe (Newberg, 2016)

Awe and the Brain

• Activation in areas linked to interpersonal bonding and release of oxytocin • Decreased activation in the parietal lobe

• Sixty audience members waring electroencephalogram (EEG) headgear • Able to detect unique and specific brainwave “signatures” during particular awe-inspiring moments during the performance

• Contributes to sense of self, orients us to world around us • May explain the “out of body” experience many report during moments of awe

• Decreased activation of subgenual prefrontal cortex • Linked to anxious rumination

11/6/23

Awe and our Nervous System • Typically work in reverse of each other (like a hot and cold faucet) • Awe appears to be a rare state in which both branches are activated simultaneously

Awe and Goosebumps (Shurtz, 2012)

Verbal and Nonverbal expressions of awe Vocal bursts: listeners able to identify “awe vocalizations” compared to other emotions (Simon-Thomas et al, 2009) Similar verbal expressions across both Western and non-western cultures (Cordaro, 2016) Facial expressions: widening of eyes, jaw slightly dropped, raised eyebrows common across cultures (Shiota, 2003; Campos, 2013; Anderson, 2017)

The Dark Side of Awe

11/6/23

Negative Awe and Altruism Negative awe experiences resulted in increased altruism and a desire to help others (Piff, 2015)

Becoming More Awestruck

Awe through Vastness

Awe through Nature “There stood Mount Hood in all the glory of the alpenglow, looming immensely high, beaming with intelligence, and so impressive that one was overawed as if suddenly brought before some superior being newly arrived from the sky.”

“Look up at the stars and not down at your feet. Try to make sense of what you see, and wonder about what makes the universe exist. Be curious.”

– John Muir

– Stephen Hawking

Mind-Bending Awe

Awe through Courage & Inspiration

“The feeling of awed wonder that science can give us is one of the highest experiences of which the human psyche is capable.” – Richard Dawkins

“Awe is the best of man.” – Goethe

11/6/23

“Gratitude bestows reverence, allowing us to encounter everyday epiphanies, those transcendent moments of awe that change forever how we experience life and the world.” – John Milton

Awe through Timelessness “If spring came but once a century instead of once a year, or burst forth with the sound of an earthquake and not in silence, what wonder and expectation there would be in all hearts to behold the miraculous change.”

Awe from Gratefulness

– Henry Wadsworth Longfellow

Awe in the Present Moment

“The moment one gives close attention to anything, even a blade of grass, it becomes a mysterious, awesome, indescribably magnificent world in itself.” – Henry Miller

“Dwell on the beauty of life. Watch the stars, and see yourself running with them.” – Marcus Aurelius

Awe through Habit

Awe through Social Connection “The most beautiful thing we can experience is the mysterious. It is the source of all true art and science. He to whom this emotion is a stranger, who can no longer and stand rapt in awe, is as good as dead: his eyes are closed.”

Awe through Creativity & The Arts

–Albert Einstein

“Beauty will save the world.” – Fyodor Dostoevsky

11/6/23

An Ancient Solution to a Modern Problem People have never been more: • Stressed • Socially isolated • Short on time • Depressed • Materialistic • Polarized

Awe helps us to: • Relieve stress • Connect with others • Feel “time rich” • Improves mood • Connect with deeper values • Become kinder towards others

Psychological Richness

A 4th Happy Life?

Psychological Richness (Oishi, 2020)

• However, 10-15% of people resonate more with something else

• An alternative to the hedonic vs. eudaimonic model • Psychometrically distinct from these as well

• Psychological Richness: Hedonic Happiness

Evaluative Happiness

Eudaimonic Happiness

• A life marked by "interesting experiences in which novelty and/or complexity are accompanied by profound changes in perspective.” (Oishi, 2020)

11/6/23

Reflection

Some link to trait characteristic of Curiosity

Psychological Richness

What are some experiences or activity that have made you feel alive, pushed your comfort zones, or sparked your passion?

Linked to individuals who experience both positive and negative emotions more intensely

Linked with individuals high in Openness on Big-5

Linked to lower levels of regret in surveys

Strategies to Enhance Psychological Richness

Get in Touch!

Email: doctorpaquette@gmail.com Website: www.jonahpaquette.com Facebook: www.facebook.com/doctorpaquette Twitter: @doctorpaquette Instagram: @jonahpaquettepsyd Books: Happily Even After, Awestruck, Real Happiness, The Happiness Toolbox Newsletter: Three Good Things Thursday Podcast: The Happy Hour

2023-11-09

Psychedelics & Psychedelic-Assisted Psychotherapy Primer 11-15-2023 – Richmond 12:45-4:00

Zach Walsh, PhD., R.Psych.

Disclosure ¢

Have conducted paid clinical work for MAPS. Member of advisory boards for Numinus, Mycomedica Life Sciences, EntheoTech and MAPS Canada. All of which are developing psychedelic psychotherapy options in Canada.

Advisor to Quantified Citizen

Funders of my research:

O VERVIEW - M E ¢ Clinical psychologists (#2011) ¢ Trained in addictions treatment

University of Chicago Brown University – Center for Alcohol and Addiction Treatment

¢ Professor– UBC ¢ Lead - Therapeutic Recreational & Therapeutic

Substance Use lab

¢ Published and presented widely on psychedelic use

and mental health

¢ Clinical team for MDMA for PTSD trials ¢ PI – Canada’s 1st clinical trial of cannabis to treat

mental health d/o

¢ Advisory boards of MAPS Canada ¢ CIHR & SSHRC funded studies of substance use

2023-11-09

O VERVIEW – T ODAY 12:45 -1:15 ¢ Introduction to the psychedelic “renaissance”

Current regulatory status The past 5 years The next 5 years ¢ Psychedelic History

Indigenous technologies Mainstream psychiatry Criminalization Renaissance

O VERVIEW - T ODAY 1:15 - 1:45 ¢ Categories and terminology ¢ Classic psychedelics

Psilocybin ¢

LSD, Ayahuasca, DMT, Mescaline, Peyote

¢ MDMA – Empathogen

Neurophysiological effects ¢ Ketamine – Dissociative

Effects & mechanisms

O VERVIEW - T ODAY 1:45 – 2:30 ¢ Mechanisms Neurophysiology Mystical Behavioral ¢ Conditions and evidence Psilocybin ¢ End of life anxiety ¢ Depression ¢ Substance use MDMA ¢ PTSD

¢ Relationships Ketamine ¢ Treatment Resistant Depression ¢ Suicidality ¢ Substance use

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O VERVIEW - T ODAY 2:45 – 3:30 ¢ Special topic

Psychedelics and antisocial behavior Mindfulness-based intervention

¢ Approaches to psychedelic psychotherapy

Psycholytic/ dynamic Non-directive/ humanistic Third wave behaviorist/ mindfulness Ketamine assisted psychotherapy

¢ Sample protocol

Preparation

Creating Optimal Set and Setting

Integration

Psychoeducation, grounding & intention. Role of Ritual & Ceremony

O VERVIEW - T ODAY 3:30 – 4:00 PM ¢ Microdosing

Risks Safety

Misuse Acute phase

Equity & culturally safe care Trauma and violence informed care

Ethical Considerations

O VERVIEW - T ODAY This is not a training in psychedelic psychotherapy – Its an introduction to the field

2023-11-09

INTRO P SYCHEDELIC R ENAISSANCE

INTRO P SYCHEDELIC R ENAISSANCE Current regs Compassionate psygen

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INTRO P SYCHEDELIC R ENAISSANCE

2023-11-09

INTRO P SYCHEDELIC R ENAISSANCE Current regs ketamine

INTRO P SYCHEDELIC R ENAISSANCE Current decrim Van, Cal, Denver, Oregon

INTRO P SYCHEDELIC R ENAISSANCE Next 5 - psilocybin

2023-11-09

INTRO P SYCHEDELIC R ENAISSANCE

https://globalnews.ca/video/rd/f5f41a86-cb0c-11eb-873b-0242ac110007/?jwsource=cl

PSYCHEDELIC HISTORY – INDIGENOUS TECHNOLOGY

1955

2023-11-09

PSYCHEDELIC HISTORY – INDIGENOUS TECHNOLOGY ¢

Mazatec people in what is now Mexico have a long tradition of use of psilocybin mushrooms María Sabina died in 1985, at the age of 91 in extreme poverty because she only received things that her patients brought her in exchange for services. He (Bernardino García Martínez) asked: “that the name of my greatgrandmother be given the attention it deserves, a true museum worthy of her; the paving of the road that leads to her house which is now totally abandoned ”

“The first ever documented recreational use of psilocybin mushrooms growing outside Mexico occurred in Vancouver. In 1965 RCMP confiscated Psilocybe semilanceata or Liberty Cap mushrooms from students at UBC. Evidently this mushroom had been recognized as being related to species encountered by magic mushroom tourists in Mexico.”

P EYOTE

Native American Church Quanah Parker

2023-11-09

¢ History of LSD Ergot Fungus ¢ Ergotism ¢ St. Anthony’s Fire (Middle Ages) Albert Hoffman ¢ Synthesized lysergic acid compounds ¢ Tested LSD-25 (1943) Studied for Potential Use ¢ Mental disorders, alcoholism, psychotic behavior, personal insight Timothy Leary (1960s) ¢ Turn on, Tune in, Drop out

CATEGORIES AND TERMINOLOGY ¢

Psychedelics Hallucinogens Empathogenics Psychotomimetrics Entheogens Club drugs

The word “hallucinate” comes from Latin words meaning “to wander in the mind.” ¨ Psychedelic means “mind manifesting”. ¨

2023-11-09

CATEGORIES AND TERMINOLOGY The following is a list of some organisms known to contain hallucinogens ¢ Plant Psychedelics ¢

¢ ¢

Ayahuasca (combination of plants containing DMT & harmaline) Morning Glory (seeds contain LSA)

Dissociatives Iboga (Tabernanthe iboga) (contains ibogaine) Salvia divinorum (contains salvinorin A) ¢ Datura (contains scopolamine) ¢ ¢

Cacti psychedelics ¢ ¢

Peyote (Lophophora williamsii) (contains mescaline) San Pedro (Trichocereus pachanoi) (contains mescaline)

CATEGORIES AND TERMINOLOGY ¢

Fungi Psychedelics

Psilocybe mushrooms (contain psilocybin and psilocin)

Ergot fungus

Dissociatives ¢

Fly Agaric mushroom (Amanita muscaria) (contains muscimol)

Animals ¢

Psychoactive psychedelic toads (Bufo alvarius) (contain 5-MeO-DMT and bufotenine)

Categories and terminology

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CATEGORIES AND TERMINOLOGY

Categories and terminology INDOLAMINE/SEROTONIN PSYCHEDELICS ¢ LSD, psilocybin, DMT ¢ Actions on serotonin receptors is unclear – 5HT2a ¢ Likely a “mixed bag” of serotonin actions. ¢ Visual distortions and psychic effects predominate

changes in mood thought disruption altered time perception depersonalization hallucinations suggestibility

Categories and terminology ¢

DMT: Short-acting, LSD-like, binds to serotonin-2 receptors.

Must be smoked or sniffed (inactive orally). Metabolized by MAO enzyme.

Primary active ingredient in Ayahuasca

Mixed with MAO ‘I”(inhibitor) Harmaline?

2023-11-09

CATEGORIES AND TERMINOLOGY LSD ¢ Dosage and Sources

Hits 1970s: 100 micrograms Gel tab Window pane ¢ Microdots ¢ ¢ ¢

Pharmacokinetics

Usually taken orally ¢

Effects begin between 30-90 min. after ingestion ¢ Half-life: 110 minutes in humans ¢ Metabolized in the liver

CATEGORIES AND TERMINOLOGY P SILOCYBIN ¢ 1/200 as potent as LSD; lasts 6–10 hours ¢ Well absorbed orally (eaten raw). ¢ Found in several mushroom species, which differ greatly

in the concentration of the active ingredient.

¢ Most varieties found in southern U.S., Mexico, Central

America.

¢ Mostly Cubenses – self produced

Discriminative Stimulus Properties

Nonhumans readily learn to discriminate from saline. Blocked by seratonin agonists.

Tolerance

Tolerance develops rapidly ¢

If taken repeatedly, its effects disappear within 2 or 3 days. ¢ No amount of the drug will be effective ¢ ¢

Tolerance dissipates quickly Cross tolerance with other serotonin hallucinogens

2023-11-09

MDMA ¢ Ecstasy and Synthetic Mescaline-Like Drugs Combo of catecholamine-like & stimulants MDMA ¢

3,4-Methylenedioxymethamphetamine

White or colored tablets (100 mg)

¢ Originally synthesized by the Merck drug company ¢

Patented in 1914

¢ No use until the 1960s ¢ ¢

Given to patients to enhance intimacy and communication Designer drugs Minor molecular changes evade laws Most dissapeared (DMA, DOM, DOET)

¢ Reclassified in 1985

MDMA

phenethylamines

tryptamines

phenethylamines

MDMA ¢

Pharmacokinetics

Orally ¢ ¢

Peak level in 2 hrs Metabolized to MDA ¢ Half-life: about 8 hrs

40 hours for full elimination

Used socially Wakefulness Endurance ¢ Energy ¢ Euphoria ¢ Sensory perception ¢ Extroversion ¢ ¢

2023-11-09

MDMA ¢

Neurophysiology

Increase transmission at synapses that use serotonin, norepinephrine, and dopamine ¢

Causes the release and blocks reuptake

Discriminative Stimulus Properties

Increased serotonin activity Enhances stimulus properties of LSD

MDMA ¢

Behavior and Performance

A dose of 75 to 100 mg induces a non-hallucinogenic empathogenic state ¢

Increased muscular tension ¢ Bruxism – teeth grinding Increase in body temperature, stiffness, loss of appetite, headache, nausea, blurred vision, and insomnia, ¢ Dehydration? Days after – ¢ difficulty in concentration, fatigue, and depression

MDMA ¢

Self-Administration

Nonhumans ¢ ¢

Readily self-administered by primates Blocked by blocking 5-HT(2a) receptors ¢ Unlike stimulants

Human Epidemiology Increase in the number of users throughout the 1990s Increase in number of mentions in emergency room admissions between 1994 and 1999 ¢ Use began to drop around 2000 ¢ ¢

2023-11-09

DISSOCIATIVES ¢ Dissociative Anesthetics Phencyclidine (PCP) ¢ Synthetic drug developed in 1963 ¢ ¢

Dissociative anesthetic Withdrawn from the marked due to delirium, disorientation, agitation (emergence delirium) Sernylan Crystal, angel dust, hob, horse tanks

Ketamine ¢ Developed to replace PCP ¢ Veterinary use ¢ Liquid is colorless and tasteless ¢ Swallowed or injected Converted to powder, snorted

KETAMINE ¢ Pharmacokinetics and Dose ¢ Ketamine can be snorted, injected, or taken orally. ¢

Oral administration is slowly absorbed. Typically used intranasally in recreational context IV or IM medical Effects last from 35 to 40 minutes Typical oral dose is 175 mg; intranasal dose is 50 mg

KETAMINE ¢ Neurophysiology

Block NMDA receptors for glutamate Act as reinforcers Endogenous analog unknown

¢ Behavior and Performance Amnesia ¢

NMDA

Relaxation, warmth, numbness Euphoric feeling, distortions in body image, floating

in space

Mood changes

2023-11-09

KETAMINE ¢

Self-Administration

Nonhumans

PCP: monkeys, dogs, baboons, and rats ¢ Reinforcement not blocked by DA receptors ¢ Ketamine: rats and monkeys ¢

Human Epidemiology ¢

Patterns of use are similar to LSD. ¢ But, unlike LSD, some occasional users may become chronic users.

Popular in select areas

MECHANISMS

M YSTICAL E XPERIENCE ¢

Marsh Chapel Experiment / Good Friday Experiment

"the most powerful cosmic homecoming I have ever experienced“ Huston Smith

In a 25-year follow-up to the experiment in 1986, all of the subjects given psilocybin except for one described their experience as having elements of "a genuine mystical nature and characterized it as one of the high points of their spiritual life”

"[psychedelic] mushroom use may constitute one technology for evoking revelatory experiences that are similar, if not identical, to those that occur through so-called spontaneous alterations of brain chemistry."[ William A. Richards

2023-11-09

Participants were 36 hallucinogen-naïve adults reporting regular participation in religious/ spiritual activities. ¢ At the 14-month follow-up, ¢

58% and 67%, respectively, of volunteers rated the psilocybin-occasioned experience as being among the five most personally meaningful and among the five most spiritually significant experiences of their lives; 64% indicated that the experience increased well-being or life satisfaction; a central role of the mystical experience assessed on the session day in the high ratings of personal meaning and spiritual significance at follow-up.

¢ Arrest for intimate partner violence ¢ 302 male inmates – Illinois County Jail ¢ With substance use disorders ¢ Any hallucinogen use/ hallucinogen d/o ¢

Prevalence 44%/ 7%

2023-11-09

EVIDENCE – 2ND WAVE Psychedelic associated with reduced

partner violence perpetration among men 11 10 9 8 7 6 5 4 3 2 1 0

Psychedeli c Use Yes

2023-11-09

Protective effect mediated by better emotion regulation

+ _ !"#$%#&'()*+,-#$.'*/#0'1#"#),,23#

!40,(#"5%#*6+,/7#"#$&8('12,-9,#%:#,%'/;'(+3<=>

CONDITIONS & EVIDENCE

2023-11-09

C ONDITIONS & E VIDENCE

In controlled studies, the most effective smoking cessation medications typically demonstrate less than 31% abstinence at 12 months posttreatment, whereas the present study found 60% abstinence more than a year after psilocybin administration. However, the current findings are limited by the small sample, open-label design, and lack of control condition.

2023-11-09

KETAMINE

John C Lilly

KETAMINE

2023-11-09

“It was peaceful. It was calming and I just sat back and... you know, I didn’t lose sense of who I was. I always knew who I was, and I had confidence that this would be temporary.” “So it was a sort of mixture of extreme comfort for want of a better word with a sort of paranoia where one’s brain is saying, if you guys in the room will leave the room, I’m stuck here for the rest of my life, sort of thing.” “It was a sense of completeness sense of, I suppose in a way finality, a source of finish. But also, a sense of enormous growth and a feeling of oneness with other entities, other living beings in particular, but also the world and universe as a whole.” “It helped family wise, relationship wise in every, every single avenue of my life. It’s changed it...doing the ketamine and seeing this other dimension enforced my belief of another life and I now live every single day to the max. When I go for a walk, I’m very observant of my world around me. I take pleasures in life rather than pleasures of...drink...So...it’s still with me and I hope it’ll stay with me for forever.”

Rationale for this approach • Ketamine has been shown to reduce cravings and act on psychological mechanisms to increase motivation to quit • Therapy aimed at enhancing motivation may take advantage of these shifts induced by ketamine to deepen commitment and strengthen motivation for change • Mirrors other psychedelic work in which psychoactive effects facilitate re-evaluation of meaning and personal values while also restructuring commitments and behaviours • Session timing takes advantage of window of heightened neuroplasticity as a potent period for the initiation and reinforcement of new behaviour

66 (D akw ar et al., 2014; D akw ar et al., 2020)

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C ONDITIONS & E VIDENCE ¢

Ayahuasca Brasil

Santo Daime Shipibo

2023-11-09

Psychoanalytic/Psycholytic - talk therapy w/ low to moderate dose access to unconscious ego-loosening regression to earlier developmental stages lowered defense mechanisms

Humanistic/existential psychedelic therapy higher dose non-directive preparation / integration

Current model - psychedelic with motivational enhancement CBT

Behaviorist?

Accentuated mindfulness and emotional regulation might underlie some of the beneficial effects of psychedelic experiences The practice and development of mindfulness and emotion regulation are key components of Third Wave Behavior Therapies. Do adjunctive Third Wave therapies have potential to enhance the positive effects of psychedelic therapy?

C ROSS CUTTING ISSUES – S ET & S ETTING ¢

Set and setting important across approaches Music Atmosphere Rapport Preparation Integration

2023-11-09

S AMPLE PROTOCOL

2023-11-09

PSYCHEDELIC M ICRODOSING ¢ What is microdosing? Successive self-administration Within a limited time window Doses that do not impair normal functioning and are

predominantly sub-sensorium

¢ What is being microdosed? Predominantly psilocybin and LSD, but others have

been noted in observational research

¢ How much?

Typical: 5 - 20 µg of LSD /0.1 to 0.3g of dried psilocybin Several times a week with microdose days

alternating with non-microdose days.

(Cameron et al., 2020;; Hutten et al., 2019a; Hutten et al., 2019b; Lea et al., 2020a; Lea et al., 2020b; Polito & Stevenson, 2019; Rosenbaum et al., 2020; Kuypers et al., 2019)

STACKING ¢ Growing interest has focused on

combining microdoses of primarily psilocybin-containing mushrooms with other substances such as: Lions Mane mushrooms (Hericium erinaceus) Niacin Cacao Chocolate Syrian rue (Peganum harmala)

¢ Reviewed 14 experimental studies of LSD

and psilocybin microdosing ¢ Findings show subtle positive effects on

cognitive processes time perception, convergent and divergent thinking brain regions involved in affective processes

2023-11-09

Psilocybin

(n = 3486)

Frequency

23.0% (800) 72.4% (2520) 54.7% (1890)

5 or more times per week** 1-4 times per week** Combination/ stacking*

No concerns (2665) Mental health concerns (1261) Enhance mindfulness

82.0% (2184)

84.9% (1070)

Improve mood** Enhance creativity

70.6% (1882) 75.3% (2006)

87.3% (1104) 72.2% (911)

Enhance learning**

60.0% (1599)

54.6% (688)

Decrease anxiety**

47.0% (1252)

78.0% (984)

Improve sleep** Decrease substance use**

25.4% (678) 18.3% (489)

33.1% (418) 41.5% (523)

2023-11-09

Mental health (DASS) – Longitudinal Psilocybin Microdosers (n = 953) vs Non-Microdosers (n = 180)

Stress**: Microdosers Non-microdosers Depression**: Microdosers Non-microdosers Anxiety**: Microdosers Non-microdosers Baseline

Month-1

** = p < 0.01

2023-11-09

Mood (PANAS) - Longitudinal Psilocybin Microdosers (n = 953) vs Non-Microdosers (n = 180) Positive Mood

Negative mood

Positive mood**: Microdosers Non-microdosers Negative mood**: Microdosers Non-microdosers

Baseline Month-1 ** = p < 0.01

HARMS & RISKS ¢

Withdrawal

Self-Administration

No withdrawal symptoms Nonhumans ¢

Not self-administered by nonhumans ¢ Adverse effects ¢ Work to avoid Exception is Hawaiian dogs eat shrooms & mongoose eat trippy toads DMT with monkeys with a history of administering MDMA

Humans ¢

Ancient - No continuous consumption

HARMS & RISKS ¢

Harmful Effects Acute psychotic reaction or “freak out” Flashbacks & trailing phenomena ? No recorded death from overdose

Bad Trips?

Difficult – In & Through Re-traumatization?

Importance of Set & Setting

2023-11-09

MDMA ¢ Withdrawal Hangover effects ¢ Harmful Effects of Ecstasy Depletion in serotonin (reversible?) ¢ Sleep disorders, depression, persistent anxiety, impulsiveness, hostility, and selective impairment of memory and attention ¢ Most effects dissipate after about 6 months once drug is stopped ¢ Heat regulation: increase in body temperature may lead to heatstroke, muscle tissue damage, kidney failure, seizures ¢ Electrolyte imbalances

Quality control ¢

Impure

HALLUCINOGENS - DISSOCIATIVES ¢ Harmful Effects Disorientation, agitation, hyperactivity Long term heave use – severe bladder

problems

ETHICAL CONSIDERATIONS

Equity

2023-11-09

ETHICAL CONSIDERATIONS

Trust and respect are the keys to building a strong rapport. It is important to understand throughout our history with non-native people that our relationships were typically fraught with deceit and mistrust. As a result, our natural tendency and response to someone offering to help us is skepticism. Therapist and practitioners will need to exercise patience and over time for the relationship will – flourish. – Native American individuals are private by nature and do not typically disclose their personal lives. Growing up in a small community on the reservation where everyone knows each other and should not be taken too lightly. There is often reluctance for a native individual living in a small community to share their personal lives openly, especially with a stranger. There may be fear from the native client’s perspective that others in the community will know their business. Therefore, it is important that precautionary measures are taken to ensure each individual’s privacy outside of the clinical and therapeutic settings is maintained.

Therapeutic models that allow for Native American traditional practitioners to be a part of treatment plan processes have proven to be beneficial (e.g., Pouchly, 2012). In addition, allowing native clients to use health practices (such as sweat lodge or talking circles) can improve the treatment outcomes.

The concepts of mental illness and associated disorders have a different causation and remedies in Native American cultures, and this understanding should be included in the treatment plan as much as possible (Duran, Duran, Heart, & Horse-Davis, 1998).

Spirituality is not separated from our physical, emotional, and mental bodies. Hence, the treatment plan should be culturally specific(Bassett, 2012). Educating ourselves about the Native American culture(s) for which we will be providing care is fundamental to establishing rapport with clients and cos, and languages (Bureau of Indian Affairs, 2019).

ETHICAL CONSIDERATIONS

¢ •

•

Trauma-informed care seeks to: Realize the widespread impact of trauma and understand paths for recovery; Recognize the signs and symptoms of trauma in patients, families, and staff; Integrate knowledge about trauma into policies, procedures, and practices; and Actively avoid retraumatization.

https://youtu.be/8wxnzVib2p4

Start Within

Study the Traditions

I pledge to ground my work in the field with work on myself, and to treat personal growth as a lifelong process. I pledge to grow my knowledge of the history of psychedelics and their many traditions of use, in a goodfaith effort to appreciate both the potential of these substances and the conflict and complexity surrounding them.

Build Trust

Consider the Gravity

Focus on Process

I pledge to invest in building trust in my relationships across the psychedelic field, and repair trust where possible. I pledge to consider the implications of the choices that I make, understanding the potential consequences of unethical behavior to individuals, communities, and the psychedelic field at large. I pledge to make the process as important as the outcome, letting the future I hope to see guide the approach I take in getting there.

Create Equality & Justice

Pay it Forward

I pledge to actively take steps to make the world more equitable and just. I pledge to support the flourishing of the psychedelic field and the communities in which I work, and to give back should my work lead to personal gain.

2023-11-09

ETHICAL CONSIDERATIONS

It is important to be clear that a harm reduction approach to psychedelic use does not permit therapists to legally attend or facilitate dosing sessions ¢ Harm reduction sessions before psychedelic use are oriented more toward helping clients make informed choices about psychedelic use and focus more heavily on safety and education. Clients who seek professional guidance in relation to psychedelics often have little experience or knowledge with these substances and are unsure whether psychedelic use is a good idea for them. In a harm reduction approach, the therapist does not advocate for or against the use of psychedelics, but instead focuses on the client’s goals and welfare and attempts to help the client determine for themselves what behaviors will lead them toward the life they desire. ¢

ETHICAL CONSIDERATIONS

First, clinicians can provide resources, ask clients to do their own research, and provide space for clients to synthesize information they encounter. Clinicians can play a role in encouraging clients to critically evaluate. ¢ Second, clinicians can directly educate. ¢ One common topic about which clients seek information is the potential interactions between psychedelics and medications they are currently taking. Coach clients to bring such questions directly to their medical provider or assist clients in obtaining a psychedelic- friendly provider that would be willing to provide relevant information. ¢ If clients decide to pursue psychedelic use, clinicians can be helpful in promoting safety by helping clients plans ¢

Will they have support from someone

safe, familiar environment Drug checking ¢ Clinicians can collaborate with clients to develop a set of questions to ask guides.

ETHICAL CONSIDERATIONS

Risk

Licensing boards

Due to the novelty of psychedelic therapy, less familiarity with harm reduction principles, and stigma against drug use, it is possible that any given licensing board may disapprove of therapists who are not explicitly trying to prevent people from using prohibited substances. ¢ Because licensing boards may receive complaints from clients, other clinicians, or general members of the public, there are multiple ways that they may become aware of a clinician’s actions. ¢ Adverse reaction could lead another clinician to complain – failure to protect ¢

If a therapist refers a client to an underground guide, this could implicate one in racketeering, conspiracy to commit a crime, or aiding and abetting unlawful acts.

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¢ Safety

We ensure that a person is an eligible candidate for treatment before enrolling them, both medically and psychologically. An eligible candidate has the resources necessary to engage in treatment, ideally including supportive people in their life and a stable and safe living environment. We conduct thorough and comprehensive preliminary screening and preparation. Prior to initiating treatment, we provide participants with clear information about our availability, backup support, and emergency contacts. We take measures to prevent physical and psychological harm. We ask participants not to leave during medicine sessions. We inform participants that we will take precautions to ensure their safety, such as preventing falls or injuries.

¢ ¢

Confidentiality & Privacy Transparency

We respect participants’ autonomy and informed choice. We include our participants in treatment decisions

Therapeutic Alliance & Trust

We aspire to create and maintain therapeutic alliances built on trust, safety, and clear agreements, so that participants can engage in inner explorations. We respect the inner healing intelligence of our participants to guide their experience. We understand that the healing process is deeply personal; each participant has different needs for support.

Use of Touch

When using touch as part of our practice, we commit to obtaining consent and offering touch only for therapeutic purposes. We only offer techniques, such as touch, if they fall within our scope of practice and competence. When touch is part of our practice, we discuss consent for touch during intake, detailing the purpose of therapeutic touch, how and when touch might be used and where on the body, the potential risks and benefits of therapeutic touch, and that there will be no sexual touch. We obtain consent for touch prior to the participant ingesting medicine, as well as in the therapeutic moment. Aside from protecting a person’s body from imminent harm, such as catching them from falling, the use of touch is always optional, according to the consent of the participant. We discuss in advance simple and specific words and gestures the participant is willing to use to communicate about touch during therapy sessions. For example, participants may use the word “stop,” or a hand gesture indicating stop, and touch will stop.

Sexual Boundaries

We do not initiate, respond to, or allow any sexual touch with participants.

2023-11-09

Diversity We respect the value of diversity, as it is expressed in the various identities and experiences of our participants Special Considerations for Non-Ordinary States of Consciousness Participants in non-ordinary states of consciousness may be especially open to suggestion, manipulation, and exploitation; therefore, we acknowledge the need for increased attention to safety and issues of consent. We examine our own actions and do not engage in coercive behavior. In working with non-ordinary states that can evoke unconscious material for both the participant and therapy provider, we acknowledge the potential for stronger, more subtle, and more complicated transference and countertransference, and, with that in mind, we practice self-awareness and self-examination, and seek supervision as needed. We respect the spiritual autonomy of our participants. We practice vigilance in not letting our own attitudes or beliefs discount or pathologize our participants’ unique experiences. We hold and cultivate an expanded paradigm, which includes the experiences people have in extraordinary states. We protect our participants’ health and safety through careful preparation and orientation to the therapy, as well as thorough integration. We support participants who may experience crisis or spiritual emergency related to psychedelic experiences with appropriate medical and psychological care, engaging the support of outside resources as needed.

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Finance Competence ¢ Relationship to Colleagues and the Profession ¢ Relationship to Self ¢ ¢

• We subscribe to the value of humility, out of respect for the transformative power of the experiences we have the privilege to witness and support, and out of respect for human dignity

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THANKS

http://blogs.ubc.ca/walshlab/

ZACHARY.WALSH@UBC.CA

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11/6/23

Fostering WellBeing: A StrengthBased Approach to Change

About Me

Jonah Paquette, Psy.D. Author of Happily Even After, Awestruck, Real Happiness, and The Happiness Toolbox

• Author of Real Happiness, The Happiness Toolbox, Awestruck, and Happily Even After • International speaker and workshop trainer • Organizational Consultant • Host of The Happy Hour podcast

Co-Host of The Happy Hour Podcast www.jonahpaquette.com

What we’ll cover

What is happiness?

Why happiness?

Key brain regions and systems

How to become happier

Can we increase happiness?

Tools for clinical change

Happiness: A timeless and universal question

• Practical, EvidenceBased, Easy to Integrate

What is Happiness? Hedonic Happiness

Eudaimonic Happiness

Happiness: A new “problem” 5

Evaluative Happiness

11/6/23

What is happiness?

Measuring Happiness

• Hedonic Happiness

• Authentic Happiness Inventory • General Happiness Scale • Satisfaction with Life Scale • Subjective Happiness Scale • Optimism Scale • Gratitude Survey

• Positive emotions about the past, present, and future • A greater proportion of positive emotions versus negative emotions*

• Evaluative Happiness

• Grit Scale • VIA Strengths Test, Brief Strengths Test • PERMA Questionnaire • Meaning in Life Questionnaire • Compassionate Love Survey

• Essentially equates to Life Satisfaction

*Free through www.authentichappiness.org

• Eudaimonic Happiness • A sense of meaning, purpose, and belonging

Subjective Happiness Scale (Lyubomirsky)

Satisfaction with Life Scale (Diener)

Why Happiness?

The Nun Study (Danner, 2001)

What do nuns, baseball players, and yearbook photos have in common?

“God started my life off well by bestowing me grace of inestimable value…The past year which I spent as a candidate studying at Notre Dame has been a very happy one. Now I look forward with eager joy to receiving the Holy Habit of our Lady and to a life of union with Love Devine.” –Cecilia O’Payne

“I was born on September 26, 1909, the eldest of 7 children, 5 girls and 2 boys. My candidate year was spent in the motherhouse, teaching chemistry and 2 nd year Latin at Notre Dame Institute. With God’s grace, I intend to do my best for our Order, for the spread of religion and for my personal sanctification.” –Marguerite Donnelly

11/6/23

The Yearbook Study (Harker & Keltner, 2001)

A Happy Nun is a Healthy Nun!

The Baseball Card Study (Abel & Kruger, 2010)

It’s Good to be Happy • Psychological: Increased life satisfaction, lower rates of depression and anxiety, increased frequency of positive emotional states, increased resiliency, openness to new experiences • Physical: Increased longevity, improved physical health, stronger immune system, decreased inflammation, improved coping with chronic illness • Life: Higher income, stronger marriages, closer relationships, improved job performance

Mental Health Abstracts, 1968-2000

Happiness: Can we really increase it? “I don’t have one minute’s regret. It was a glorious experience.” – Moreese Bickham

Ratio of Abstracts

“It was the worst thing that ever happened to me.” – Billy Bob Harrell, Jr. Pos itive Ne ga tive

11/6/23

Happiness Forecasting

12 months later (Gilbert, 2006)

Barriers to Happiness

Barrier #1: Hedonic Adaptation

“People are exposed to many messages that encourage them to believe that a change of weight, scent, hair color (or coverage), car, clothes, or many other aspects will produce a marked improvement in their happiness. Our research suggests a moral, and a warning: Nothing that you focus on will make as much difference as you think.” – Daniel Kahneman, Ph.D.

11/6/23

Barrier #2: Genetics

The “Negativity Bias” • Greater focus on negative experiences • Learn faster from pain than pleasure • Hard to “undo” these effects • Negative experiences stored longer in memory • Great for survival, but…

Barrier #3: A “Negative” Brain

“Most good experiences are wasted on the brain.” – Rick Hanson

Barrier #4: The Way We Pursue Happiness

Barrier #5: Societal Factors and Social Inequality

11/6/23

Well-Being Principle: Gratitude

Core Habits of Well-Being vGratitude vCompassion vCultivating Strengths vMeaning vConnection vOptimism vFostering Resilience vPsychological Richness

“He is a wise man who does not grieve for the things which he has not, but rejoices for that which he has.” –Epictetus

vAwe vSelf-Compassion vHealth & Wellness vForgiveness vMindfulness vSavoring vNature

Gratitude “A sense of wonder, thankfulness, and appreciation for life.” – Robert Emmons

What is one thing you feel thankful for in this moment?

The Gratitude 2-step

Benefits of Gratitude

1) We recognize the presence of something good in our lives 2) We recognize that the source of this goodness lies outside of ourselves

Psychological Lower Depression, Anxiety, Stress

Other Benefits Overall health improved (Emmons,

Joy, enthusiasm, happiness, love, optimism (Emmons, 2007) Increased well-being, life satisfaction (Wood, 2010) Recovery from PTSD (Kashdan,

Better sleep (Wood, 2009) Increased immune system functioning Exercise (Emmons, 2007) Decreased physical pain

More able to forgive (Luskin, 2010) Improved perception of social support

Romantic relationships (Algoe, 2010) Social Bonds (McCullough, 2002) More forgiving (Rye, 2012)

(Seligman, 2005)

2005)

2007)

11/6/23

The Grateful Brain

Practices to Cultivate Gratitude

• Left Prefrontal Cortex (Zahn, 2009) • Anterior Cingulate Cortex (Fox, 2015) • Interpersonal bonding • Pregenual Anterior Cingulate Cortex (pgACC) (Wong, 2016) • Links emotional and cognitive centers of brain • Lasting differences months later • Hypothalamus • Sleep, Stress, Metabolism • Increased gray matter functioning • Ventromedial Prefrontal Cortex (reward circuitry) • Serotonin, Dopamine (Zahn, 2008)

Well-Being Principle: Strengths and Flow

Examples of Items • Love of Learning • Do you feel an adrenaline rush from learning new things? • Kindness • Have you done good deeds for strangers on a regular basis? • Appreciation of Beauty • Does a sense of awe sweep over you as you contemplate the vastness of nature? • Creativity • Is your mind constantly challenging the status quo and looking for a better way?

24 Signature Strengths, 6 Core Virtue Domains

11/6/23

Identifying Signature Strengths

Reflection • Which of the above strengths resonate for you most? Which do you see in yourself, or have others in your life noticed in you?

• Is it authentic? • Does it show up often? • Do others notice it? • Does using it energize me? • If unable to express it, would I feel empty?

Benefits of Incorporating Strengths

Practices for Strengths Work

Identify your strengths • Take the free VIA survey at viacharacter.org

You at your best • Craft a new narrative through a strength perspective

Identify ways you currently use your strengths Strengths during hard times Using Strengths in new ways

Identifying and Using Signature Strengths

Flow (Csikszentmihalyi)

• Take the VIA Survey to identify core strengths • Ensure that identified strengths resonate with the individual

• Identify 3-5 core “signature” strengths that are both resonant and high scoring • Choose 1 signature strength per day • Use it in a way that is outside your normal routine

11/6/23

Flow

Flow and the Brain

Well-Being Principle: Connection

Strengths-Eliciting Questions (Saleeby)

“Happiness is love. Full stop.” –George Vaillant

Support questions Example: Who are the people that you can rely on? Who has made you feel understood, supported, or encouraged? Exception questions Example: When things were going well in life, what was different? What point in your history would you like to relive, capture, or recreate? Possibility questions Example: What do you want to accomplish in your life? What are your hopes for your future or the future of your family? Esteem questions Example: What makes you proud of yourself? What positive things do people say about you? Perspective questions Example: What are your ideas about your current situation? Change questions Example: What do you think is necessary for things to change? What could you do to make that happen?

Lessons from “Cyberball”

11/6/23

Benefits of Connection Psychological • Happiness and Well-Being

Physical • Improved physical health/immune systems

• Bi-directional relationship • Lower levels of depression and anxiety (Lyubomirsky, 2007) • Decreased anxiety (Cohen,

• Longevity (House, 1988) • On par with smoking, substance, exercise • “Blue Zone” findings (Beuttner,

• Improved sleep (Cohen, 2004)

• Sardinia, Okinawa, Loma Linda, Icaria, Nicoya

(King & Diener, 2005)

2004)

2010)

Well-Being Principle: Self-Compassion

Our Brain and Body on Connection • Poor Social Support linked to: • Activation of the pain centers of our brain • Cingulate gyrus activation in social pain experiences • Increased activation of amygdala • Telomere shrinkage (Epel, 2009) • Cortisol dysregulation • Seeing others’ pain activates our own pain centers (Botvinick, 2005)

“If your compassion does not include yourself, it is incomplete.” –Jack Kornfield

(Pressman, 2005)

Self-Compassion

Barriers to Self-Compassion

Key Concepts: • 3 components (Neff, 2011) • Self-Kindness • Mindfulness • Shared Humanity • Self-Compassion vs. Self-Esteem • “Contingent self-worth” • Unstable concept

• “It will make me weak” • “It’s selfish” • “I won’t achieve my goals” • “A pity party” • Others?

11/6/23

Benefits of Self-Compassion Psychological Lower rates of depression & anxiety (Neff, 2011) Recovery from PTSD (Thompson & Waltz, 2008)

Eating Disorders (Leary & Adams , 2007 ) Cigarette Smoking (Kelly, 2010) Greater compassion towards others

The Physiology of Self-Compassion

Other Alleviates chronic pain Improved lower back pain (Carson,

Self-Criticism

Self-Compassion

• Increased amygdala response • R Prefrontal Cortex • Cortisol increases • Adrenaline released

2005)

Chronic Acne (Kelly, 2009) Closer relationships (Germer, 2009) Increased altruism (Crocker & Canavello, 2008)

Romantic Relationships (Neff, 2011) School & Work (Neff, 2011)

• L Prefrontal Cortex • Increased PNS activation • Breathing slows • Insula activation • Decreased cortisol • Increased oxytocin

•

Self-Compassion Practices

Benefits of Loving-Kindness

• Self-Compassion Break • Compassionate Touch • A letter of Self-Compassion • Identifying Needs • How I’d treat a friend • Self-Appreciation • Lovingkindness meditation

• Increased positive emotions

(Frederickson, 2008)

• Increased Vagal Tone (Kok, 2013)

• PTSD symptoms (Kearney, 2013) • Increased gray matter (Leung, 2013)

• Prosocial behaviors increased

• Reduced Migraines (Tonelli, 2014) (Leiberg, 2011) • Improves lower-back pain • Increased empathy (Klimecki, (Carson, 2005)

2013)

A 4th Happy Life?

• However, 10-15% of people resonate more with something else • Psychological Richness:

Hedonic Happiness

Evaluative Happiness

Eudaimonic Happiness

• A life marked by "interesting experiences in which novelty and/or complexity are accompanied by profound changes in perspective.” (Oishi, 2020)

Well-Being Principle: Psychological Richness

11/6/23

Psychological Richness (Oishi, 2020) • An alternative to the hedonic vs. eudaimonic model • Psychometrically distinct from these as well

Some link to trait characteristic of Curiosity

Psychological Richness

Linked to individuals who experience both positive and negative emotions more intensely

Linked with individuals high in Openness on Big-5

Linked to lower levels of regret in surveys

Strategies to Enhance Psychological Richness

Reflection

What are some experiences or activity that have made you feel alive, pushed your comfort zones, or sparked your passion?

11/6/23

“Life is not primarily a quest for pleasure, as Freud believed, or a quest for power, as Alfred Adler taught, but a quest for meaning. The greatest task for any person is to find meaning in his or her own life.” – Viktor Frankl

Well-Being Principle: Meaning & Purpose

Reflection What are some aspects of your life that tap into something larger than yourself? What helps you feel connected to something greater than yourself?

Meaning

Benefits and Importance of Meaning

• A sense of connection to something bigger than ourselves, or to have a sense that our life is linked to a greater purpose and has greater significance beyond our day-to-day struggles

• Higher levels of happiness (Huo, 2019) • Increase life satisfaction (Ivtzan, Lomas, & Hefferon, 2016) • Lower levels of depression (Steger, 2009) • Lower risk of substance use disorders (Csabonyi, 2020)

• Meaning in life “may be defined as the extent to which a person experiences his or her life as having purpose, significance, and coherence.” (Laura King, psychologist and positive psychology expert).

• Greater resilience to adversity (Schaefer, 2018) • Health seeking behaviors (Kim, 2014) • Cognitive functioning across lifespan (Lewis, 2016) • Better physical health and lower risk of chronic illness (Steptoe, 2012) • Successful aging (Hedberg, 2010)

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Impact of lack of meaning on psychopathology

Reflection

Consider how a person’s lack of meaning may tie into: • Depression • Anxiety Disorders • Substance use issues • Anger • Work-related stress/job dissatisfaction • Relationship conflict

Consider the role of meaning (or lack thereof) in a person’s life, and how this might be playing out with some of your clients struggling with depression, addiction, anxiety, relationship conflict, or other forms of ”traditional” psychopathology.

Rather than view psychopathology as a maladaptive set of symptoms to be managed or cured, consider how they might partially represent a reaction to existential concerns or a perceived lack of meaning.

“Purpose Anxiety” (Rainey, 2014) • The experience of negative emotions stemming from a perceived lack of purpose, or a perceived lack of success in seeking meaning and purpose • Some evidence of increased purpose anxiety in recent years • Increased social comparison due to social media • Longer lifespans • Shifting social norms and decreased social cohesion • Changes in religiosity • Greater fulfillment of basic needs

• Possible signs: frequent job changes, frequent relationship changes, struggles with social comparison

Reflection Questions (van Deurzen, 2016)

Practices

• What do I intend to do before I die? How can I take meaningful steps towards this? • How do I get along with my friends, family, and those closest to me? Am I satisfied with these, or are there changes I’d like to see happen? • What do I owe myself in life, and how do I get it? • What are my moral values, and how do I live up to them?

• The unlikelihood of existence • The last time • Ripple Effects • Growth following hardship • Being of service • Fostering connetion • De-reflection

11/6/23

Well-Being Principle: Mindful Awareness

“The present moment is filled with joy and happiness. If you are attentive, you will see it.” –Thich Nhat Hanh

• Mindfulness vs. Mindlessness • The toll of a wandering mind (Killington & Gilbert, 2010)

• Barriers to Mindfulness • Modern Culture • What mindfulness is not • A way of being in the world

What is Mindfulness?

Benefits of Mindfulness Psychological • Depression (Keng, 2011) • Reduced stress & anxiety (Hofmann et al., 2010; Bowden, 2010)

• Buffers against future depressive episodes (Williams & Penman, 2011) • Happiness, Well-Being (Shapiro, 2008) • Problem-solving, attention & focus (Moore, 2012)

• Enhanced cognitive ability (Xion & Doraiswamy, 2009)

Life/Relationships ØImproved job performance & retention (Dane, 2013) ØLess aggression, improved behavior in schools for students

Physical • Fewer doctor’s visits, fewer hospital days (Williams & Penman, 2011) • Immune system (Davidson & Kabat-Zinn,

ØLower BP for teachers (Flook, 2013)

2003)

• HIV (Creswell, 2009) • Chronic Pain • Reduced insomnia (Bowden, 2012) • Improved heart rate variability (Miu,

ØIncreased altruism (Condon, 2013)

2009)

Benefits of Mindfulness

• Disordered Eating • Decreased negative emotions (Erisman, 2010)

ØIncreased empathy (Fulton, 2005; Zhapiro & Izett, 2008) ØIncreased compassion for others’ suffering (Weng, 2013)

11/6/23

Everyday Mindfulness

• Left PFC (Davidson, 2003) • Activation of memory and learning centers (Holzel, 2011)

• Choose 1 “autopilot” activity per day • Cultivate present moment, nonjudgmental awareness • Examples include: • Eating • Walking • Showering • Cleaning Dishes • Gardening • Others?

• Decreased amygdala response (Davis, 2008; Lieberman, 2007)

• Increased left hippocampal volume • Offsets cortical thinning (Lazar, 2005

• Structural changes can occur in as little as 12-16 weeks

Mindfulness and the Brain

Well-Being Principle: Savoring

5 Paths to Savoring

Savoring Why • Negativity Bias • Positive experiences come and go • Using the mind to change the brain • Increased neural firing • Long-term changes

Savoring and the Brain How • 3 A’s • Attend • Notice or Create • Amplify* • Enrich the experience • 5-10 seconds or more • Absorb • Let it sink in

Ventral Striatum • Linked to sustaining positive emotions and reward Left Prefrontal Cortex Dorsolateral Prefrontal Cortex Decreased Cortisol Increased serotonin, dopamine

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IFS & POLYVAGAL THEORY H e a l i n g T h ro u g h C o m p a s s i o n a t e C o n n e c t i o n TM

OBJECTIVES How can understanding PVT help us implement IFS more safely and effectively?

2 Basic principles of IFS and PVT 3 4 5 6

Impact of therapist’s internal state on clinical work; Using this awareness to facilitate client regulation and healing. IFS strategies to shift clients’ nervous systems towards regulation and healing

IFS and Polyvagal Theory

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• Developed over 40 years ago • Non-pathologizing model of the organization and operation of the psyche

Internal Family Systems Therapy

• Empirically validated psychotherapy • Can facilitate healing and transformative change

Compassion Clarity

Confidence

Curiosity

SELF

Connection

Calm

Parts • Subpersonalities • Can understand them as tiny people inside you.

IFS and Polyvagal Theory

2023

EXILES

Types of Parts

• Parts that carry unresolved pain. • Vulnerable • Wounded PROTECTORS • Parts that manage our interactions with the world and defend against underlying pain. • Managers: PROACTIVE • Firefighters: REACTIVE © 2023 Alexia Rothman PhD

Assumptions of the IFS Model

Multiplicity is the natural state of the mind • Trauma does not create parts but can force them to take on extreme roles, burdens Everyone has an undamaged Self • Constraint-release model No bad parts • Can be wounded, burdened, in extreme roles, trapped in trauma time • Can be unburdened, released from extreme roles No part operates in isolation • This is an internal system © 2023 Alexia Rothman PhD

IFS & Polyvagal Theory

IFS and Polyvagal Theory

2023

Polyvagal Theory Stephen W. Porges, Ph.D. • Developed in the 1990s • Adapted for use in therapy by Deb Dana, LCSW “Polyvagal Theory is the science of feeling safe enough to fall in love with life and take the risks of living.” -Deb Dana © 2023 Alexia Rothman PhD

This Photo by Unknown Author is licensed under CC BY-SA

What Really Brings Clients to Therapy? Difficulty Regulating their Nervous System Symptoms

SYMPTOMS Depression Anxiety Irritability/Anger Sleep Disturbance Attention/Concentration Intrusive Thoughts Obsessions/Compulsions Nightmares/Flashbacks Hallucinations/Delusions

INTERPERSONAL RELATIONSHIPS Conflict in personal/ professional relationships Difficulty forming/keeping healthy relationships Social Anxiety Boundaries Isolation/Loneliness Aggression

ADDICTION

OTHER

Stress Self-Esteem Procrastination/Avoidance Relationship with food Personal Hygiene Self-Care Addictive Processes: gambling, internet, Change in life circumstances pornography, overexercising, Grief/Loss overwork, overspending Career-Related Issues

Drugs

Alcohol

Why consider the nervous system? Dysregulation of the nervous system and associated suffering brings clients for treatment. Can’t think our way out of trauma/survival responses PVT: How the ANS operates and can be reshaped. IFS: Relational, experiential therapy for healing and transformation. © 2023 Alexia Rothman PhD

IFS and Polyvagal Theory

2023

Significant individual differences in outcomes to traumatic experiences. “…it is not trauma as an event that is the primary determinant of outcome.” “…it is the re-tuning of the neural regulation of the autonomic nervous system to support threat reactions that is the primary determinant of outcome.”

Trauma D r. S t e p h e n Po r g e s

Polyvagal Theory

Internal Family Systems Therapy

• Not a psychotherapy; can underlie any therapeutic modality • Structure and operation of ANS • Non-shaming, non-pathologizing • Helps us design & implement safe, effective therapeutic interventions • Hope and possibility • Can reshape nervous system towards flexibility and resilience • Don’t have to remain stuck in survival responses

• Empirically validated psychotherapeutic modality • Organization and functioning of the psyche • Non-shaming, non-pathologizing • Compassionate, relational way to interact with internal systems • Hope and possibility • Can heal and unburden wounded and traumatized parts • Bring/Restore Harmony and Balance to Internal system © 2023 Alexia Rothman PhD

The Autonomic Nervous System

Parasympathetic

Sympathetic

Ventral Vagal

IFS and Polyvagal Theory

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Parasympathetic Nervous System Two Bi-Directional Pathways via the Vagus Nerve DORSAL VAGAL

VENTRAL VAGAL

• Travels from brainstem down, primarily receiving information from and regulating organs below the diaphragm, including the digestive system

The Autonomic Nervous System

Parasympathetic

Sympathetic (Mobilization/Action)

Ventral Vagal (Connection)

Dorsal Vagal (Shutdown)

Neuroception

IFS and Polyvagal Theory

2023

HIERARCHY Three Predictable Pathways of Response VENTRAL

• Feel safe and connected • Able to engage with life: self, others, the world, spirit • Can send and receive cues of safety • Perspective, possibility, hope • Associated with physical health and well-being • Sense of impending danger • Hypervigilant/alarmed/uneasy

SYMPATHETIC • May misread/not notice signs of safety but more easily notice signs of danger • Disrupted connection from ourselves, others, world, spirit (me vs. you, us vs. Survival them)

DORSAL Survival

• Do not feel connected at all • Shut down, no energy, don’t care • Hopeless • Feel unsafe and surrounded by unsafe people

Release of adrenaline & cortisol

Sympathetic Survival State (Mobilization/Action)

Dorsal Vagal Survival State (Immobilization)

Oldest pathway

Extreme danger feel trapped, can’t escape, life threat

Immobilization, collapse, shut down, numb, not present

Takes us out of connection and awareness

Drained, hopeless, give up

IFS and Polyvagal Theory

Parts and the Nervous System

2023

1 Parts are not states 2 Parts can live in states can make strategic use of 3 Parts survival states can make strategic use of 4 Parts regulated states can be affected by and 5 Parts react to states “have their own nervous 6 Parts systems” © 2023 Alexia Rothman PhD

Newest pathway

Unique to mammals

Supports being in safe engagement with others

Responds to cues of safety

Feel safe, connected, calm, social

Our Self-energy can facilitate client’s returning to this state

Ventral Vagal Pathway

Safety & Connection

Self / Self‐Energy E m e r g e n t Q u a l i t y o f Ve n t r a l ? Qualities that emerge/become accessible when parts open space (8 C’s) are also emergent qualities of VV activation. • Curiosity, compassion • Deb Dana: “We have a home in ventral.” • IFS: “This is who I really am. This is my Self.” IFS is a constraint-release model • Self present/undamaged in everyone but may be obscured by energy and burdens of parts • Help clients access Self through unblending and healing/unburdening • PVT (Deb): “Ventral is where our nervous system longs to be. Our job is to uncover the pathways that take us back there.” © 2023 Alexia Rothman PhD

IFS and Polyvagal Theory

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Ventral Vagal Activation

Self‐Energy • 8 C’s: Curiosity, Compassion, Connectedness, Clarity, Courage, Calm, Creativity, Confidence • 5 P’s: Presence, Patience, Persistence, Perspective, Playfulness • Openness/spaciousness in chest • Open-heartedness • Energy running down arms into hands • Sense of connection to all around you • Clear mind • Sense of ease in the body • Sense of being completely present Source: IFS Training Manual: IFS Institute

• Curiosity, Compassion • Grounded in realism but aware of possibility and options • Can reach out for & offer support • Feel safe • Able to communicate effectively • Able to adapt more easily to changes (go with the flow) • Open for connection to Self, others, the world, and spirit © 2023 Alexia Rothman PhD

Trauma Disrupts Connection What happens to us when we aren’t treated as we should be?

Consistent, Reliable, Safe Co‐Regulation

IFS Translation Polyvagal Theory • Effective co-regulation leads to effective self- • Consistent co-regulation with Self-led others helps regulation prevent parts from taking • Ample opportunities to on burdens and being exiled exercise circuits of connection • Protectors do not have to • Well-tuned vagal brake step into extreme roles, as the presence of Self • Able to safely engage (ours and that of cowith others in a regulating other) is rewarding and regulating available to the system. way • Able to engage with the • Can connect with our parts, others, the world world and spirit. • Connection to spirit © 2023 Alexia Rothman PhD

IFS and Polyvagal Theory

Absent or Unpredictable Co‐Regulation

2023

Polyvagal Theory

IFS Translation

• More difficult to selfregulate • Missed opportunities to exercise circuits of connection • Poorly tuned vagal brake • Self-regulate for survival • Disrupted connection to self, others, the world, and spirit

• Wounded parts more likely to take on burdens and be exiled • Protectors more likely to take on extreme roles. • Very difficult for protectors to trust Self, so they run our lives. • Disconnection from Self/parts, others, the world, and spirit. © 2023 Alexia Rothman PhD

Presence of the Therapist

“I’ve found that the most important variable in how quickly clients can access their Selves is the degree to which I’m Self-led. When I can be deeply present to my clients from the core of my being…clients respond as if the resonance of my Self were a tuning fork that awakens their own.” - Dick Schwartz

Presence of the Therapist

“I have…learned that my relationship with clients is terribly important to our success… because my ability to be in Self helps their protective parts relax so their Selves can flow in.” -Dick Schwartz

IFS and Polyvagal Theory

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Co‐Regulation Self begets Self • Ask our parts for the space to allow us to access at least a “critical mass” of Self-energy • Our regulated presence (our Selfenergy) facilitates others accessing their own © 2023 Alexia Rothman PhD

Exercising the Circuits of Connection

Co‐Regulation in IFS Therapy

Consistent, co-regulating presence of therapist’s Self Lending our Self-energy to client’s system to facilitate access to their own

In the moment, helps make deep work safer and possible Critical mass of Self allows us to be compassionately and effectively present WITH our parts Long-term, helps shift client’s nervous system towards flexibility and resilience Increases access to Self and ability to return to being Self-led when parts are activated

IFS & PVT Integration Session

1 2 3 4 5

Cisgender, heterosexual, white male, mid-50’s, educated professional Complete isolation during pandemic, no therapy for 2 years Chronically stuck in either dorsal or sympathetic survival states Between jobs, no money, nightly alcohol use high Requested emergency session – overwhelm, hopelessness, passive suicidal ideation © 2023 Alexia Rothman PhD

IFS and Polyvagal Theory

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Video Segment 1 Direct Access • Overwhelmed part • Co-regulation with therapist Initiating In-Sight • Noticing Hulk • Protector associated with Sympathetic survival state of “fight” Direct Access • Concerned part comparing Hulk to Arnie © 2023 Alexia Rothman PhD

Internal Co‐Regulation

Self-to-Part connection with protector or exile Regulated Self can be with dysregulated part Co-regulation with Self helps shift part from survival state Exercises circuits of connection Effective self-regulation skill Opens opportunity for healing

Benefits of Internal Co‐Regulation

1 Don’t have to rely on external people 2 Available all the time have to achieve complete 3 Don’t regulation Self as natural leader of 4 Reinforces system and resource 5 Non-exiling form of self-regulation

IFS and Polyvagal Theory

2023

Video Segment 2 Internal Co‐Regulation

Feel Toward • Young parts terrified Fleshing Out • Doesn’t care about anything, won’t back down Internal Co-Regulation • Accessing compassion toward boys • Connecting with boy – touch, compassionate energy • Seeing part through eyes of Self • Being there for part in way he needs - instinctive © 2023 Alexia Rothman PhD

Critical Mass of Self Anchor in Ventral May have to start with therapist’s Self Can go to Sympathetic or Dorsal while anchored in Ventral New experience: parts in extreme roles/states connected to Self Makes even the deepest work safe and possible Makes the work effective, rather than damaging or retraumatizing © 2023 Alexia Rothman PhD

HOW ARE YOU FEELING TOWARD THE [PART]?

IFS and Polyvagal Theory

Video Segment 3

2023

Getting Permission • Checking with concerned parts • Parts are whole beings • Physiological shift beginning Fleshing Out Part • Understanding Hulk also has a preferred/regulated state (doctor) • Seeing part through eyes of Self (and part calming) • Adolescent protector Internal Co-Regulation with Protector • Sitting on park swing • Physiological shift continues – releasing tension in body • Exile positively impacted

Video Segment 4 Self-to-Part Relationship with Protector • Learning Hulk’s fears and needs • Protector needs Self to assume natural leadership role • Protectors don’t want to have to be extreme Mapping Relevant Clusters of Parts • Web of relationships target part is embedded in • Make note of parts in cluster for future work • May be needed for part to truly release from role • Gym Guy, Doctor Part, CFO, Aggressive part Encourage Reconnection to Target Part • “By tending to some other parts, you’re really tending to me.”

Gym Guy

Doctor

CFO

Aggressive Part

IFS and Polyvagal Theory

2023

WORK PROCEEDS MORE SMOOTHLY AND WITH LESS RESISTANCE IF YOU

IFS – Access at Least a Critical Mass of Self • Prioritize Self-to-Part relationship • Information/content less important than connection • Make sure connection established in both directions • Work unfolds more smoothly and with less resistance • Circle back to this step whenever needed

PVT – Anchor in Ventral Before Visiting Survival States

Slower can be Faster

• Stories emerge from states • Enter process at state rather than fight against it • Micromoments of regulation help survival relax • Stories, feelings, behaviors begin to shift organically © 2023 Alexia Rothman PhD

Video Segment 5

Fleshing out Protector • Hulk is a protector – WSG somehow related • Seen through eyes of Hulk, WSG a “madman” • Getting permission from Hulk to go to WSG Internal Co-Regulation with Protector in Dorsal • Wall Street Guy – frustrated, disillusioned, hopeless, expensive suit tattered, stained, moth-eaten, cobwebs • Unblend parts reacting to him; check HFT • Has been a powerhouse protector; now in dorsal despair • Scares other parts to see him like this – blend and need differentiation from Self © 2023 Alexia Rothman PhD

Video Segment 6 Internal Co-Regulation with Protector in Dorsal • Much harder to come up out of dorsal than down out of sympathetic • Parts tempted to fix/change/convince need to soften back • Self can effectively hold space, validate, extend compassion • Attached to old dreams/aspirations, anger/drive 6th F: Fear of Protector • If he lets go of the old dreams, other parts might settle and client will be unsafe. Also doesn’t know how else to be. • Role: Keeps system financially safe and socially respectable. © 2023 Alexia Rothman PhD

IFS and Polyvagal Theory

2023

Video Segment 6

Progress • WSG was talking through Hulk - now has established Self-to-Part connection & willing to continue • Circle back to other parts: Hulk calm and relaxed, exile doing well • Physical symptoms completely gone • Can move through world more safely (in a regulated state, not a place of threat/protection) © 2023 Alexia Rothman PhD

The Vagal Brake

1 2 3 4 5

Ventral vagal circuit to the pacemaker of the heart – medulla (in brainstem) to sinoatrial node of heart Speeds up and slows down heartrate Allows access to more sympathetic energy Not a survival response – still regulated by ventral, feel safe Can respond rather than react – do what is needed in the moment © 2023 Alexia Rothman PhD

Keeps us between sympathetic and ventral (regulated sympathetic)

The Vagal Brake Becoming Active Operators of our Nervous Systems

Vagal brake may not work as efficiently if consistent co‐ regulation opportunities were not available in childhood.

Vagal Brake releases somewhat to allow in some sympathetic energy to meet the demands of the moment/task. Vagal Brake engages, heart rate slows Vagal Brake Disengages (Releases Completely) HPA axis engaged – cortisol & adrenaline Enter Sympathetic Survival State

IFS and Polyvagal Theory

2023

IFS PERSONAL TRAINING FOR THE NERVOUS SYSTEM Repeated Opportunities for Neural Exercise

• Increase access to Self‐Energy through: • Unblending (Anchor in Ventral) • Befriending (Glimmer to Glow) • Healing of Exiles (Retrieving wounded from existing in survival states) • Helping protectors shift into preferred roles (Releasing protective parts from being in or using survival energy) • Tone the Vagal Brake/Improving its Efficiency • Helps us access mobilizing energy when needed • Help us decrease sympathetic activation when not needed • Makes it easier to find our way home (Self/Ventral) • Appropriate amount of challenge for the nervous system © 2023 Alexia Rothman PhD

IFS & PVT Integration Session

Using pure IFS techniques in a Polyvagal-Informed way

Befriending parts that strategically activate sympathetic and dorsal survival states for protection

Seamless integration method (no explicit psychoeducation about the nervous system)

has NO previous 4 Client knowledge of Polyvagal Theory 5 Internal Psychoeducation

Three Essential Elements

CHOICE

Needed by nervous system in interactions Deb Dana

CONTEXT

IFS and Polyvagal Theory

2023

“Befriending is learning to tune in and turn toward autonomic state and story with curiosity and self-compassion.” – Deb Dana

Befriending Glimmer to Glow

• Extending curiosity/compassion to target part • How is part responding? • Establishing bi-directional connection • Inviting part to share • How is client reacting to part’s sharing? • If more Self-energy  extend to part • Appreciation, gratitude, compassion • Honoring part for its intention and service (protector) • Allowing part to take in presence of Self and not being alone anymore © 2023 Alexia Rothman PhD

How Can PVT Help us Implement IFS More Safely and Effectively?

1 2 3 4

Deeper understanding of why and how our Self-led presence facilitates healing Deeper understanding of why we respect protectors

Appropriate level of challenge for nervous system; Repeatedly exercising and toning Vagal Brake

More safely  More effectively

Pacing, Timing, Choice of Interventions

If you would like to access other IFS live and ondemand workshops and podcast episodes, including my interview with Deb Dana on IFS and Polyvagal Theory Please subscribe on my website:

DrAlexiaRothman.com My cat, Tamino 

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

ag a r gre ev ssi olu on 8o , d na ep ry res ap sio pro n a ac nd h t su o NEUFELD’S TRAFFIC CIRCLE MODEL OF icide

frustration

Gordon Neufeld, Ph.D.

Clinical & Developmental Psychologist Vancouver, Canada

THE UNTOLD STORY OF FRUSTRATION

Becoming Acquainted - is one of Nature’s most powerful and primordial instruments of CARE

- is BLIND and IMPULSIVE if not felt, which can be most (if not all) of the 'me

- comes into existence when things aren’t working, and s'cks around seeking for resolu'on of some kind

- is typically perceived as a NEGATIVE and unnecessary emo'on and therefore not always invited to exist

- serves ATTACHMENT ﬁrst and foremost as aRachment is what most needs to work

- is rou'nely VILLIFIED for the way it expresses itself when its purposes are thwarted - has many and diverse OFFSPRING involving cogni'on & behaviour, which oOen tend to camouﬂage its existence

- has a MIND of its OWN, bent on eﬀec$ng change when sensing disas'sfac'on, but not at all inclined to consult with higher mental processes

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Becoming Acquainted S SU UM IMP ICID U A T FRU GUILT LSES L TR AN

STR A DEPBASEDTIONRES SIO ELFENS T SIV EN SES EM OB PROV ANGE R IMV

IOLENC E ION G G A RESS SELF CK A ATT

EMOTIONAL FIXES FOR ATTACHMENT DISTRESS

Fixes &closure Fixations separa$ontriggered

PURSUIT

FRUSTRATION

ALARM

change

cau$on

FIGHT

FlIGHT

Attachment’s Emergency First Aid Team

-P

R LA

-A

UR SU IT -

- FRUSTRATION -

OUR MOTTO - “We promise to get emo.onal when holes appear in the fabric of your togetherness”

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

EMOTIONAL FIXES FOR ATTACHMENT DISTRESS closure

COMMON MISTAKE Displacing frustra8on to another 8me and place by responses that intensify either ALARM or PURSUIT.

separa$ontriggered

PURSUIT

FRUSTRATION

ALARM

change

cau$on

e ms irritability eng s antru elf-p t rev ds self-blame unis hme nt BEHAVIORAL hos8 sults AGGRESSION lity in DERIVATIVES OF m impa8ence s g a c r g FRUSTRATION a s fyin n 8 h VIOLE iVn self-a jus8 NCE ﬁgh g Tack COGNITION-

foul

BASED DERIVATIVES OF FRUSTRATION

(ie, secondary emo8on)

wor

ANGER

PRIMAL EMOTION

GUILT

SHAME

judgements regarding whose fault

FRUSTRATION triggered by thwarted proximity

CHALLENGE to see through the distrac8ng deriva8ves of frustra8on to the emo8on itself and its typical roots in aTachment distress

PRIMARY CAUSE OF FRUSTRATION

- experienced only by humans

- experienced by all mammals

- triggered by perceived injus'ce

- evoked by something not working

- a SECONDARY emo'on involving - a PRIMAL emo'on that can exist without thinking or feeling cogni'on and consciousness - triggers impulses to assign blame - triggers impulses to eﬀect change, and if thwarted in this work and and seek jus'ce (eg, get even, the fu'lity not felt, in aRacking exact revenge, seek an apology) energy and impulses - focusing on anger including confron'ng it, interferes with resolving underlying frustra'on

- focusing on frustra'on, even if anger exists, best sets the stage for healthy resolu'on

Anger eclipses and camouflages frustration and distracts from its resolution

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

frustration A STORY OF ALTERNATE OUTCOMES

• demanding & commanding • bossing and controlling

OTHERS

• exposing one’s neediness • advising and confron'ng • construc'ng & problem solving • planning and scheming • orchestra'ng & organizing

THINGS

• controlling and manipula'ng

• improving one’s self • adjus'ng & accommoda'ng

SELF

• trying harder to make things work • sacriﬁcing self to make things work

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

frustration A STORY OF ALTERNATE OUTCOMES

• holding on to good experiences

• geYng one’s way all the 'me

• altering 'me or reality or the past

• keeping siblings from being born or sending them back

• altering circumstances or another’s character or decisions

• choosing one’s parents or keeping them together • making things work that won’t

• keeping bad things from happening, including loss and dying

• altering the ‘givens’ • avoiding upset

• defying the laws of nature

for spontaneous transforma$on to happen, fu$lity has to be truly FELT, not just known

The Singular Work of Sadness • RELIEF from the emo'onal pressure of stuck & stale frustra'on • emo'onal RESET and RENEWAL as frustra'on is RESOLVED • emo'onal REST from fu'le work, rendering discipline eﬀec've and enabling healing and leYng go

• RECOVERY of the capacity for fulﬁllment and happiness as well as the spontaneous realiza'on of poten'al • develops RESILIENCE as strength results from facing and feeling fu'lity • RESTORES hope and perspec've

drives the transforming process of ADAPTATION

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Attachment’s Emergency First Aid Team

OUR MOTTO - “We promise to get emo.onal when holes appear in the fabric of your togetherness” “We also promise to hang around un.l fu.lity is felt”

The Work & Wisdom of Frustration • how Nature ensures our ongoing personal EVOLUTION, developing us as agents of change and transforming us when that change is not possible, thus con'nually moving us towards a more sa'sfying state of being • how Nature takes CARE of us, regardless of the situa'on or circumstances we are born to, and regardless of what happens along the way • could be considered the core work of THERAPY, that is, to facilitate the work of frustra'on

moved to make things WORK

frustration or to REST from fu'le endeavours and be CHANGED instead

frustration A STORY OF ALTERNATE OUTCOMES

Frustra'on Traﬃc Circle - Gordon Neufeld

hitting & fighting fits & tantrums

Jack Hirose Seminars - Fall, 2023

acting mean & rude hostility attacking gestures foul moods & cutting words

selfattack

self-deprecation irritability & impatience

suicidal ideation violent fantasies vicarious attacks

putdowns & shaming biting, throwing, screaming

ignoring, shunning, ostracizing

sarcasm & insults

ERUPTIONS OF FRUSTRATION-FUELED ATTACKING ENERGY ie, the face of frustra'on when thwarted in its purposes

- a messy construct that interferes with insight as to its varied emo'onal roots

- if frustra'on-fueled, results from aRacking impulses that have been displaced to the self

- most of what is referred to as - self-aRack can take many forms – self-harm (ie, burning, cuYng, self-derision, self-hatred, selfhair-pulling) is rooted in being depreca'on, self-nega'ng, selfso defended against the primal hiYng, AND also includes most emo'on of alarm that engaging suicidal idea'on and impulses in alarming behaviour evokes an adrenalin rush without any - some other mo'va'ons for suicide are PURSUIT (eg, to join a loved one, corresponding sense of increase one’s status), ALARM (prevulnerability. This kind of selfharm can also evoke the body’s empt a terrifying scenario), or as a DEFENSE against an unbearable defenses against pain. experience The current construct of self-harm tends to eclipse and camouﬂage its varied emo8onal roots in alarm, frustra8on and pursuit

highly frustrated

frustration aNacking impulses are UNtempered

THE ANTECEDENTS OF AGGRESSION

FUTILITY is encountered but NOT FELT

A T T A C K

COMMON MISTAKE Imposing consequences to frustra8on-fueled behaviour that fuel its antecedents

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

TRAVERSING

THE TRAFFIC CIRCLE OF MODEL OF

frustration EXAMINING THE ROLES OF ... • MATURATION in influencing outcomes • ATTACHMENT, especially in the depression and displacement of aRacking impulses • FEELING in influencing outcomes • EMOTIONAL PLAY in influencing outcomes

frustration THE

MATURITY FACTOR

lacking a developed capacity to hold on when apart

frustration

lacking a rela$onship with frustra$on lacking ability to eﬀect change

THE IMMATURITY FACTOR IN AGGRESSION

lacking an opera$onal prefrontal cortex A and thus mixed T feelings

T A C K

lacking cogni$ve support for fu$lity

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Neufeld’s Five-Step Model of Emotional Maturation

reﬂec$ng

mixing

feeling

naming COMMON MISTAKE Not retrea8ng far enough developmentally in order to get at the root of the emo8onal immaturity

expressing

lacking rela$onship with frustra$on

frustration

lacking an d opera$onal an cortex prefrontal n tmixed A o thus iand en at feelings

lacking ability to eﬀect change

m ur ch at tta IMMATURITY lm a FACTOR na t of o i ot en m pm e lo t or eve p lacking d p cogni$ve support Su tfor hefu$lity THE

T T A C K

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

frustration unable to change that which counts

develops a working prefrontal cortex THE MATURATION FACTOR IN DEPRESSION

failing to access the sadness that fu$lity should evoke

frustration expression of foul frustra$on blocked A by mixed feelings

unable to change that which counts DEPRESSION AS A TRAFFIC JAM

T T A C K

failing to access the sadness that fu$lity should evoke

frustration THE

ATTACHMENT FACTOR

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

THWARTED

PROXIMITY frustration where aNached aNacking impulses are untempered THE ATTACHMENT FACTOR IN AGGRESSION

aNempts at togetherness are fu$le

A T T A C K

access to sadness is foiled by lack of safe & comfor$ng aNachment

THWARTED

PROXIMITY frustration where aNached

A T T A C K

THE ATTACHMENT FACTOR IN DISPLACEMENT

DISPLACED to reduce the threat to working aTachments (can also be displaced to SELF, fueling suicidal impulses & idea8on)

the brain defensively DEPRESSES frustra$on for the sake of aNachment

THWARTED

PROXIMITY frustration where aNached

THE ATTACHMENT FACTOR IN DEPRESSION

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

e ms irritability eng self tantru -pun rev ds self-blame i shm hos s ent 8lit insult AGGRESSION y arcasm impa8ence fying g s n VIOLE 8 hiVn self-a s8 j h NCE ﬁg Tack u g

foul

wor

ANGER

GUILT

SHAME

judgements regarding whose fault

FRUSTRATION triggered by thwarted proximity

depression = ﬂa<ened aﬀect

The Wisdom of Depression Although inherently biased to express ourselves, when this expression threatens attachment the human brain is wisely programmed to sacrifice emotional expression for the sake of togetherness. This core internal defense results in the brain being divided against itself and comes at a great cost to energy and functioning.

frustration ng ei

d ce fa

THE b THE ANTECEDENTS n ATTACHMENT OF io t FACTOR AGGRESSION a

e uc d Re

e th

r pa se

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

frustration THE

FEELING FACTOR

Giving the Brain the Feedback it Needs To facilitate the work of frustra.on, scenarios must end in one of two feelings - ﬂip sides of the same emo.onal coin & derived from the same La.n word ‘sate’ meaning ‘enough’ or ‘turning point’.

Today’s society lacks the wisdom to take scenarios to their emo.onal endpoints , believing instead in the‘mind’ as the answer.

anger

F RU S T R AT I O N

Accessing sadness is much easier via frustration

shame

guilt

futility

Frustra'on Traﬃc Circle - Gordon Neufeld

cannot manage frustra$on that is not FELT

Jack Hirose Seminars - Fall, 2023

frustration lack of mixed FEELINGS leaves aNacking impulses A UNtempered

without FEELINGS, aNempts to eﬀect change will be uninformed

T T A C K

FEELING AND AGGRESSION the fu$lity encountered must be FELT for frustra$on to end and adapta$on to occur

frustration a lack of feeling restricts release through symbolic expression

a lack of feeling restricts informed aNempts at change

FEELING AND DEPRESSION

a lack of feeling restricts release through sadness

frustration THE ry FEELING ua FACTOR t c

de vi o r

fe sa

gs lin e e rf o f

n sa

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

frustration THE

PLAY

FACTOR

frustration lacking the kind of play that builds the prefrontal cortex A

lacking playful problem solving and construc$on

THE PLAY FACTOR IN AGGRESSION lacking playful aNacking and destruc$on

lacking playful access to sadness

T T A C K

frustration lack of construc$on play and ‘making things work’ play restricts release

THE PLAY FACTOR IN DEPRESSION

lack of emo$onal play that accesses sadness restricts release

lack of destruc$on play and playful aNacking restricts release

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

frustration

c In

e as e r

c ac

s es

s nd u o gr ay l p al THE n PLAYtio o FACTOR em o t

Taking FRUSTRATION out to play

Inviting FRUSTRATION to PLAY frustra8on-fuelled energy and impulses to make things or to make things work • construc.ng and craJs • organizing and orchestra.ng • designing and engineering • developing models, sets and scenarios

frustra8on-fuelled energy and impulses to aTack or destroy • destroying & demolishing in play • play ﬁgh.ng & mock aggression • hiHng and throwing in play • kicking and screaming in play • war games, a<acking games • sword play, insult games • playful sarcasm and wit • a<acking energy in stories, art, music, dance and wri.ng

Frustra'on Traﬃc Circle - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

... pressing down on irrita'on or aggression ... trying hard not to get frustrated ... trying to make everything work ... aRemp'ng to keep posi've ... controlling one’s thoughts ... aRempts at self-control ... trying to calm down ... striving for success ... ﬁgh'ng depression

invite into play the underlying FRUSTRATION

Accessing sadness is usually easier in the play mode • renders defenses unnecessary, thus making it easier to feel

• plays directly to our emotions as in melancholy music, poetry, or a sad story

• provides something to cry about that is one step removed and thus not too much to bear

• can remove the impediments to tears such as selfconsciousness, shame, and social sanctions

• can set the stage with fantasies that reveal the futility

• contains the sadness to the parameters of play, rendering it more bearable

• shifts the locus from the HEAD to HEART, from thinking to feeling, from doing to being

• provides safe release for stuck emotion, thus making it easier to fall into our tears in the wake of intense expression

To create a story of frustration with good outcomes ... • accept that it exists and needs some space to work and to be expressed • call it by name, reframing as needed • make frustra$on the focus, not fault or resul$ng behaviour • come alongside frustra$on & its work • support outcomes that are incompa$ble with aggression, depression & suicide ... cultivate a healthy relationship with frustration

2023-11-06

Navigating Addictions: Practical Interventions to Promote Healing & Recovery (Part 1)

Dr. Carissa Muth, R.Psych (AB and BC)

Defining Addictions DSM-5 - Substances and Gambling Criteria (at least 2 in 12 months) • Larger amounts or over longer period of time than intended • Persistent desire or unsuccessful efforts to cut down or control use • A great deal of time is spent in activities necessary to obtain substance • Craving or strong urge to use • Failure to fulfill major role obligations

• Continued use despite persistent social or interpersonal problems • Important activities given up because of use • Recurrent use in situations in which is it physically dangerous • Continued use despite knowledge of having recurrent problems • Tolerance • Withdrawal

Defining Addictions • Excessive habits of everyday life • Dynamic • View behaviour as ego syntonic when it is not • Not strictly due to neuroadaptation

2023-11-06

Model of Addictions •

Earliest models of addictions (1812, 1891) Explain addiction as excessive behaviour patterns from a moral turpitude that requires values conversion and piety.

•

Alcoholics Anonymous Disease or illness model that consider excessive behaviour as a chronic, fundamental disorder for which there is no cure other than abstinence.

•

Biological Model Person has no control, shifts in the reward cycle.

•

Psychodynamic Addiction as adaptive response, keep people from regressing to a more primitive state, self-medication.

History of SUD Opium used medically and spiritually by Greeks

Opium becomes widespread in

Bowrey notes firsthand account

Europe, Middle East, and North

of Cannabis used in Western

Africa

World

10,000

2,000

700

1600s

1700s

1900

Medical marijuana used by

Agapios writes excess alcohol

United States attempts to reduce

Chinese Emperor, Shen

harmful and causes medical

drug trade with opium traffic

Neng

issues

History of SUD Addict begins to be commonly used

APA first classifies Alcoholism and Drug USA Prohibition

to describe someone with an

Addiction under Sociopathic Personality

addiction

1900

Disturbances in DSM-I

1900

Racial stereotypes surrounding marijuana use are prominent

1920 -1935

1935

1952

Alcoholics Anonymous founded

2023-11-06

Biopsychosocial Model • Considers the complexity of addictions • Constellation of factors rather than one cause for addictions • Biological • Psychological • Social

Etiology - BIOLOGICAL 40-60% Biological Factors Epigenetics Cascade Model

Photo Credit: National Institute of Health

2023-11-06

Etiology - SOCIAL

Attachment

Loneliness

Social Learning Theory

Etiology - PSYCHOLOGICAL Comorbidity Emotional Regulation Development

Adverse Childhood Experience (ACE) Study • Higher ACE Score = Great risk of addiction • Higher ACE Score = Lower resilience • Resilience mitigates drug use • Building resilience

2023-11-06

Adverse Childhood Experience (ACE) Questionnaire

Schemas • Patterns of thinking and behavior that are used to interpret • Maximum neurons at 3 years old • Pruning for efficiency • Chronic stress causes excess pruning • Self-protection and survival • Narrative therapy and challenging schemas

Desensitization • Maladaptive cognitive appraisals • Every act of recall is also potentially an act of modification • Learning safety • Prolonged Exposure Therapy

2023-11-06

Meaning Boredom

Escape

Passion

Addiction as a Response “Such widespread phenomena as depression, aggression and addiction are not understandable unless we recognize the existential vacuum underlying them.” “When a person can't find a deep sense of meaning, they distract themselves with pleasure.” — Viktor E. Frankl

RELATIONSHIPS

TRAUMA/ PSYCHOLOGICAL SYMPTOMS/ FAMILY CONFLICT, ETC.

GOALS

------------------------------------------------

Alive INTENSITY

SUBSTANCE USE DANGER CONFLICT

2023-11-06

Developing Meaning • Self- awareness • Acceptance of suffering • Relationships • Intrinsic goals

Assessment • Gold Standard

• Distinguish overwhelming impulses versus and unwillingness to resist those impulses

Psychometric Tools • AUDIT Alcohol screening tool, identify potential hazardous use, 10 questions • CIWA Assess severity of alcohol withdrawal • SCID-5 Structured clinical interview for DSM-5 assessment

2023-11-06

Navigating Addictions: Practical Interventions to Promote Healing & Recovery (Part 2)

Dr. Carissa Muth, R.Psych (AB and BC)

Defining Addictions • Excessive habits of everyday life • Dynamic • Interaction of psychological, social, biological, and existential components

Barriers to Treatment • Stigma • Low self-efficacy • Cost • Logistical limitations • Pre-contemplative

2023-11-06

Prochaska and DiClemente, 1983

Inpatient Treatment

Detox

“Pink Cloud”

Stabilization

Dopamine Receptors After Cocaine Addiction

2023-11-06

Post Inpatient Treatment Care

Behavioural Pattern

Stress Management

Difficult Relationships

Community Support Groups

SMART Recovery

Recovery Dharma

Alcoholics Anonymous

Working With Low Motivation • Complexity of motivation • Resistance • Mapping effects of the issue • What does the substance provide you?

2023-11-06

Boundaries

Unhealthy Means of Survival

Not Showing up for Appointments

Family Involvement

Therapeutic Interventions 1. Understanding • What does the substance provide? • How does the client understand their substance use? • Identifying thought distortions Goal: understand the client’s narrative, cognitive schemas, and relationship with their substance

Feedback-Informed Treatment • Evidenced based approach to assess and adapt to client’s feedback in real time in order to improve session outcomes • Based on common factor model of psychotherapy

2023-11-06

Session Rating Scale

Outcome Rating Scale

2023-11-06

Therapeutic Interventions 2. Shifting • Creating alternative stories • Challenging schemas • CBT thought records • Amplified reflection (Motivational interviewing) • Reframing

C B T M odel A pplied to A ddictive B ehaviours

2023-11-06

Therapeutic Interventions 3. Developing a “New Normal” • What gets you out of bed in the morning? • What do you want to live for?

Exploring Meaning Three types of values whereby one can discover meaning: • Creative What the person gives to the world • Experiential What the person receives from the world • Attitudinal Adopting the right attitude of acceptance and taking a stand towards unavoidable suffering

2023-11-06

ACTIVITY

BEAUTY ACCEPTANCE

• Activities that are intrinsically valuable and interesting • Activities that are instrumental in obtaining significant goals • Activities that are self- transcended and directed at serving others Beauty, truth and love joy and wonder Acceptance in suffering

Thank you! Questions?

11/3/23

TRAUMA-FOCUSED DBT

Rudyard Kipling “Often and often afterwards, the beloved Aunt would ask me why I had never told anyone how I was being treated. Children tell little more than animals, for what comes to them they accept as eternally established.”

TARGETING THE DBT BIOSOCIAL MODEL Eboni Webb, PsyD, HSP

11/3/23

• Understand DBT in the context of the biosocial model regarding

pervasive emotional dysregulation disorders • Understand the impact of trauma on the developing mind • Develop a conceptualization plan that focuses on key biological

and attachment factors within the framework of DBT

LEARNING OBJECTIVES Targeting the Biosocial M odel

The Biosocial Model of Emotional Dysregulation

BORDERLINE PERSONALIT Y DISORDER

Key Characteristics

Attachment Disturbances

Pattern of Impulsivity

Instability in interpersonal relationships

Instability in life

Hypersensitive to abandonment

Unstable self-image and emotions

Pattern of undermining success in relationships

11/3/23

OVERVIEW •

Clients suffer from emotional vulnerabilities

•

Emotional vulnerabilities can come from many sources (e.g., attachment issues, loss, trauma), but is often assumed to be biological

•

Chronic and consistent invalidation exacerbates emotional vulnerabilities

•

An ongoing, reciprocal relationship exists between emotional vulnerabilities and environments

THE BIOSOCIAL MODEL

•

Em otional vulnerabilities are characterized by: -

Em otional sensitivity

Em otional reactivity

Slow return to em otional baseline

•

Over tim e em otions get sensitized, leading to a “kindling” effect

•

This em otionality (and associated invalidation) is associated with m any problem s (disorders)

•

Em otionality leads to escape and avoidance that leads to chronicity

11/3/23

Targeting the Biosocial M odel

HYPOTHALAMIC PITUITARY ADRENAL AXIS Open pathway for first 6 months of life

Excessive Cortisol Effects • Neurotoxic to the Hypothalamus • Neuron Death • Clogging of the corpus callosum connecting the left and right hemispheres • Suppression of the immune system

11/3/23

AMYGDALA: FIGHT, FLIGHT, AND FREEZE Features • Reactionary • Triggers Sensory System (Smell and Touch are the most direct pathways) • Controls autonomic responses

WHAT HAPPENS DURING A STRESS RESPONSE?

Blood Flow Decreases • Frontal Lobe • Nondominant Hemisphere

Sensory System Activates • Hypervigilance • Heightened 5 senses

Blood Flow Increases • Heart • Extremities • Decreases to Gut • Digestive Issues

•

Abuse and neglect

•

Open rejection of thoughts, feelings, and behaviors

•

Making “normal” responses “abnormal”

•

Failing to communicate how experience “makes sense”

COMMON T YPES OF INVALIDATION Targeting the Biosocial M odel

•

Expecting behaviors that one cannot perform (e.g., due to developmental level, emotionality, or behavioral deficits

11/3/23

Types of Dysregulation

Dysregulation: Learned Behavior

Invalidating Environment

Cortisol Release

Distress Cues Dysregulation

Cortisol=Automatic (Uncomfortable) reaction

11/3/23

EMOTIONAL DYSREGULATION

Emotional Arousal

Coping-Avoidance Escape Behaviors Heightened Reactivity Innate Sensitivity Time

Hormonal Counter to Cortisol Architect of Regulation

Oxytocin

How Problematic Auto-Regulation is Learned

Oxytocin

Cortisol

SelfSoothe

Stress

Behavior

11/3/23

TREATMENT TARGETS TO INCREASE OXY TOCIN WITHOUT PROBLEM BEHAVIORS • Hugs

• Make positive eye• Build Positive Experiences

contact

• Sing in a choir

• Self-Soothe

• Breath work

• Give a back rub/foot

rub

• IMPROVE the Moment

• Listen without

• Nonjudgmental Stance

• Positive touch

• Stroke a dog or cat • Perform a generous act • Pray

• DISTRACT

judgment

• Hold a baby

• Mindful Breathing

• Proximity

• GIVE

• Laugh/Dance

Social Engagement System ▫ ▫ ▫ ▫ ▫

Eye-gazing Language Prosody Touch Proximity

Biosocial Theory Coherently Guides Treatment Targets and Strategies

Validation is a primary intervention to: Reduce acute em otionality

Provide gentle exposure to em otions

Provide a corrective validating environm ent (and new learning)

Create a bridge to learning selfvalidation

Open the client up to change interventions

Emotion regulation is taught to: Understand how em otion happen

Reduce vulnerability to intense em otions

Increase opportunities for positive em otions

Assist in stepping out of ineffective m oodcongruent behaviors

Biosocial Theory Coherently Guides Treatment Targets and Strategies

11/3/23

Mindfulness (non-judgment and acceptance) is taught to: • Reduce amplifying emotions • Reduce escape and avoidance of emotions • Create qualitatively different and effective experience of emotions

Distress Tolerance is taught to: • Provide healthy ways of coping with emotions when needed

Use the theory to conceptualize the purpose of the interventions used

HEALTHY ATTACHMENT

From Bowlby and Beyond

ATTACHMENT GOAL SECURE AND AUTHORI TATI VE PARENTI NG PRODUCES AUTONOMOUS AND I NTERDEPENDENT ADULT S

11/3/23

ATTACHMENT RULE AT TAC H M E N T I S N OT F I X E D O R A B S O LU T E . G ROW T H A N D CHANGE ARE D R I V E N BY O N E ’ S SEASON OF LIFE.

DEFINITION: ATTACHMENT

SelfConcept

Affect Regulation

Cognition

Behavioral Regulation

“A N I N - B O R N S Y S T E M I N T H E B R A I N T H AT E VO LV E S I N WA Y S T H AT I N F L U E N C E A N D O R G A N I Z E M O T I VAT I O N A L , E M O T I O N A L A N D M E M O RY P ROC ES S ES WI T H RES P EC T TO SIGNIFICANT CAREGIVING F I G U R E S . ” ( B OW L B Y )

How do we live and thrive as humans? (Bowlby to Ainsworth)

Secure Base

Safe Harbor

Proximity Maintenance

Seeking, m onitoring, and attempting to

Fleeing to an attachm ent figure when in

Attunem ent, presence, accountability,

m aintain connection to a protective attachm ent figure.

situations of danger or alarm

direction, protection, correction, and connection.

11/3/23

A I N S WO RT H & M A I N AND AT TAC H M E N T

Avoidant

Ambivalent

Secure

THE STRANGE SITUATION SECURE ATTACHMENT oReunion behaviors are more insightful than separation behaviors. oImmediate reassurance from the return of their secure base (distress is natural and expected at separation). oReconnection prompts return to independent exploration and play. oChild Behaviors: Flexibility and resilience oSecure Parent = Sensitivity, attunement, acceptance, cooperation and emotional availability

THE STRANGE SITUATION AVOIDANT ATTACHMENT oReunion behaviors are more insightful than separation behaviors. oApparent lack of distress should not be mistaken for calm. Superficial indifference is a trauma defense. oReconnection displays active rejection of bids for connection by parent resulting in limp physical connection. oParent Behaviors: W ithdraw and Rebuff oAvoidant Parent = Inhibited emotionality, aversion to physical contact, and brusqueness

11/3/23

THE STRANGE SITUATION AMBIVALENT ATTACHMENT oReunion behaviors are more insightful than separation behaviors. Looking for their absent parent even when the parent is present. oTwo presentations: Angry or Passive oReconnection displays overt bids for connection and expressions of rejection (e.g. full-blown tantrums, leaning away, etc.) to implicit bids for solace displayed in helplessness and misery. Lack of exploration. Parent Behaviors: Unpredictable and Intermittently available oAmbivalent Parent = Insensitive signaling, neither verbal or physically rejecting while discouraging autonomy

AINSWORTH & MAIN INFANT TO ADULT

Secure/Autonomous

Preoccupied

Dismissing

Disorganized

ADULT STATE OF MIND WHAT TO LOOK FOR

My parents did the best they could, but they did make mistakes.

My parents just didn’t get me, but I don’t know I guess they tried but they were always trying… .

oSecure: Values attachment, objective, collaborative, consistent even in unfavorable experiences. oDismissing: Inconsistent, high efforts to normalize experiences and relationships, overly generalized and unsupportive or contradictory evidence. oPreoccupied: Fixated on past grievances often appearing angry, passive or fearful. Long winded and still vague in descriptions.

I h a d v e ry

I can’t believe my

e x ce lle n t p a re n ts. V e ry

mother treats me this way after all these years, my kids have it so

n o rm a l ch ild h o o d .

good.

oDisorganized: Lapses in reasoning and coherent discourse especially when discussing trauma, loss, or abuse. Time is fluid.

11/3/23

S T E P S T O A DA P TAT I O N : L E A R N I N G H OW T O F I T I N YO U R FA M I LY S Y S T E M Intersubjectivity (Trevathen, 1980) Wounding

Intention

Attunement

Communication

Action

Repair

Trauma Mirror Neurons (Gallese, 2007)

Dem ocratic-Authoritative Parenting

Abusing-Authoritarian Parenting

High nurturance, expectations, and control Moderate com m unication

High expectations and control Low nurturance and com m unication

Neglecting-Uninvolved Parenting

Indulgent-Perm issive Parenting

Low nurturance, expectations, control and com m unication

com m unication, low expectations, and control

High nurturance, m oderate

11/3/23

Family Dialectical Dilemmas Excessive Leniency Fostering Dependence

Pathologizing Normal Behaviors

Limits Presence

Forcing Autonomy

Normalizing Problem Behaviors

Authoritarian Control

SEC U RE C onsistency

B ASE

C onnection

Protection

Parents Inspection

Healthy Attachment

PROX IM ITY M AIN TEN AN C E

SAFE H ARBO R

Em otional Safety

Community

Family

D irection

Body

Social

Mind

ATTACHMENT AND TRAUMA Eboni Webb, PsyD, HSP

11/3/23

What is Trauma?

• Divorce • Prolonged separation from parents and/or siblings • Frequent moves • School transitions • Bullying (Cyber, physical, etc.)

• In utero assaults • Delivery difficulties • Health of both parents during conception • Mental Illness • Abandonment via adoption • Learning difficulties

• Identity disturbances • Racial issues • Inside threats • Sexual assaults • Accidents (falls, vehicle, etc.)

th is y is ? Wh in g pen hap

Wha t can I lear n from this ?

How do I fix th is ?

Prefrontal Cortex Observing Thinking Decision-Making Mid Brain Emotional Center

W il lI su rv iv t h is e ?

Memory

Lower Brain Survival defenses Automatic processes

11/3/23

The vagus nerve is the largest nerve in the body and controls our body’s ability to detect danger, sense safety, experience rest/relaxation, and connect socially. It is refined through connection from birth and innervation of touch. The Polyvagal Theory (Porges, 2011)

Safe

Danger!

Life Threat

11/3/23

Attachment vs. Developmental Trauma 46

Parent Attachment Style & Adoption

Parent Attachment Style

Autonomous/Free (Authoritative) Dismissing (Authoritarian/Uninvolved) Entangled (Permissive/Anxious) Unresolved (Authoritarian/Neglecting)

% of Low-Risk Adoption

% of Troubled Adoptions (e.g. trauma, abuse, illness)

Avoidant

20%

42%

Ambivalent

20%

42%

Childhood Attachment Type

American Population %

Secure

15%

Disorganized

1-2%

TCU Institute of Child Development . (Producer). (n.d.). Attachment Dance [DVD]. Available from TCU.

Unraveling the Trauma Bond

11/3/23

Child Dialectical Dilemmas Increasing Choices Acceptance of Change

Supervising Connected Authoritative

Giving Permission

Validating Stability Keeping their world small

EMOTIONALLY REGULATED

“

We cannot selectively numb emotions, when we numb the painful emotions, we also numb the positive emotions. Brene Brown 51

11/3/23

Types of Dysregulation

FROM A TRAUMA STATE TO A CLEAR STATE OF MIND……. Sex

Alcohol

SelfHarm IT DIDN’T REALLY HAPPEN

Work Drugs 53

Eating Disorders

A I

U I

NEW SELF

HOPE

L T

IT REALLY HAPPENED

IT REALLY HAPPENED TO ME

N G

S H A

E R

M E

VOICE

HEAL

BODY CENTERED AND GROUNDED

11/3/23

Repairing the Trauma Bond

Adolescent Dialectical Dilemmas Skill Enhancement

Trust

Transparency Empathic Relational

Suspicion

Privacy Self Acceptance

RESET SURVIVAL DEFENSES

11/3/23

HYPERAROUSAL

Window of Tolerance Sensorimotor Psychotherapy Institute®/Sensorimotor Psychotherapy founder, “Pat Ogden

HYPOAROUSAL

ORGANIZED STORYTELLING

From Organization to Disorganization Organized Storytelling

Disorganized Storytelling

11/3/23

How Do We Create Our Stories? ╺

╺

Thoughts Emotions Sensations Urges Movements

How the Brain Organizes Our Experiences

Sensations

Thoughts

Emotions

Urges

Movements

What Does Earned Security Look Like? 63

11/3/23

Survivors

SECURE BASE

Sponsor

G roup

Safe Housing

Therapist C oaches

PROXIMITY MAINTENANCE

SAFE HARBOR

HEALING

Physician

C ase

Therapy

Family

M anagem ent

Body

HOLISTIC THERAPY

Mind

Questions?

THANK-YOU •

Eboni Webb PsyD, HSP ewebb@webbjamconsulting.com 615-589-1018

The Village of Kairos 1451 Elm Hill Pike, Suite 250 Nashville, TN 37210 367 Riverside Drive, Suite 104 Franklin, TN 37064

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

R AU S S E MA R T S and resilience Gordon Neufeld, Ph.D.

Developmental & Clinical Psychologist Vancouver, Canada

sense of safety

optimal functioning

role of relationship The Story of Resilience

sense of strength

Theemotional WISDOM ! tears of grieving defense futility stress of the ! vulnerable & sadness Response feelings Chapter One Stress Response impact1 Chapter of

TRAUMA

experience &

play & Theexposure hidden and playfulness nature

surprising WISDOM! of emotion of the Stress Response

fight or flight

rest and restfulness

recovery and healing

role of adaptation

neural plasticity antecedents to bouncing back vasovagal

response

The Story of Resilience Chapter One

Chapter 1

The WISDOM ! of the ! Stress Response

The hidden and surprising WISDOM! of the Stress Response

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

STRESS

NEGLECT losing face both me n paren tio ts wo bedti a rking liz ta personal injury pi s failure ho e

ol dis scho ab loneliness ilit y isola tion ATH g DE facin

mov ing

STRESs

threats to iden tity

sec rets

CHANGE

adopI

yc da

e loss of loved on

er anoth

DIVORCE

E NT US RETIREME AB

g siblin

ST LO ng i e b resi d sch enIal ool

Adversive Childhood Experiences pHysical abuse emotional neglect Mental illness of household member

Emotional abuse

physical neglect

STRESs divorce incarcerated relative

sexual abuse

substance abuse in household

mother treated violently

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

STRESs FACING SEPARATION

= experience of separa9on

SEPARATION

is thus the greatest threat

ATTACHMENT = SURVIVAL and is thus our preeminent drive

of .. lacknging losing face with . can’t NEGLECTED . be w o .. bel ith ... ct by cIon ne reje

n not important to ... tood co n’t feel s a ing c er fe unlo eli not ma nd ved ng Verin u b y ... t dif g to . fe .. no re

d by ... not recognize

t isola tion g ngin belo n ot

ced repla

by ...

ed loneliness nt d i sc threats . a .. to o t id ou n entity ecial tw ted n o t sp no by . n .. old o BETRAY .. ED can’t hn apart BY . O e T h w ON HELD NOT LIKED BY ... NOT

closure separa6on-triggered

PURSUIT

ALARM

FRUSTRATION

cau6on

change

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Attachment’s Emergency First Aid Team

-P

R LA

-A

UR SU IT -

- FRUSTRATION -

OUR MOTTO - “We promise to get emo.onal when holes appear in the fabric of your togetherness”

LOCK, OLLOW, FAWN, IND, ANCY (family, friends, fame, fortune) devolving into

Fixes & Fixations separa6ontriggered

PURSUIT

ALARM

FRUSTRATION

FIGHT

FlIGHT

se on sp Re

Re 9c

EM RE OTI

Sy mp at he

e th pa ym ras Pa

sp on se

The stress response in the ‘key’ of

SP ON ON A SE L

ﬁrst response

se on sp

Re SP ON ON A SE L

Sy mp at he

as a last resort , the parasympatheIc system can be deployed as a DEFENSIVE RESPONSE to stress

EM RE OTI

Jack Hirose Seminars - Fall, 2023

e th pa ym ras Pa

sp on se

Stress & Resilience - Gordon Neufeld

e ez d re gue l F or aI e[u int y, F rg Fa ogg , Fo F ble e Fe if trapped or thwarted, can trigger if trapped or thwarted, can trigger

a reverse thependulum pendulum a reverseswing swing of of the

The Stress Response armours the heart

al rim ons p s ate mo9 c9v n e • a ra9o a sep

• while a 9me, INHt the same that wou IBITS FEELINGS performinld interfere with in stressfu g or funcIoning l circumst ances

STRESS RESPONSE = MORE EMOTION BUT LESS FEELING

• gives us the STRENGTH and TOUGHNESS needed to funcIon or perform in stressful or wounding circumstances (also referred to as HARDINESS) • CHANGES us instantly so that we can COPE with adversity and SURVIVE distressing circumstances • summons up all our resources so we can PERSEVERE in the face of distress and OVERCOME stressful circumstances

The Story of Resilience

The WISDOM ! The WISDOM ! of the ! of the Chapter Two! Stress Response Chapter 1 Stress Response

The Resilience Response as Nature’s Answer to the Stress Response

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

The Stress Response

, th al e l h ial • gives us theoSTRENGTH and na ent l a i TOUGHNESS rim ons ot pot needed to p s m funcIon or perform in 9 e of ate mo or wounding n to stressful c9v9on e ocircumstances i a (also • ra at a referred to as y liz sep el ea HARDINESS) t r u ol he • while a bs d t a t th e same re an 9me, IN • CHANGES us instantly so that we can COPE with that wouHIBITS FEELINaGiSng, ld adversity and SURVIVE performin interfere w on distressing circumstances g or func cti ith in stressfu nIoning u : lM circulm f E a stances • summons up all our resources BL tim O so we can PERSEVERE in the PR op STRESS RESPONSE = MORE face of distress and OVERCOME EMOTION BUT LESS FEELING stressful circumstances

armours the heart

Stress Response

PRIMAL SEPARATION EMOTIONS ARE ACTIVATED FEELINGS that would interfere with performing or funcIoning in stressful circumstances are inhibited

Resilience Response Feelings that have been inhibited bounce back to enable opImal funcIoning and the realizaIon of full potenIal

SAFETY is required for feelings to be recovered

TIME (ideally the end of the day or end of the week at most)

Stress Response

Resilience Response

PRIMAL SEPARATION EMOTIONS ARE ACTIVATED

Feelings that have been inhibited bounce The issue is not the back to enable opImal stress response funcIoning and the but a missing realizaIon of fullresilience potenIal

FEELINGS that would interfere with performing or funcIoning in stressful circumstances are inhibited

response that results in the stress response working unIl return of feelings exhausted. requires SAFE SANCTUARY

TIME (ideally the end of the day or end of the week at most)

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Attachment’s Emergency First Aid Team

OUR MOTTO - “We promise to get emo.onal when holes appear in the fabric of your togetherness” “We also promise to hang around un.l fu.lity is felt”

What is missing in the stress response?

faint or freeze

or k w c devoloves lo floolinto f

FIX

O ATI

FIX FIG

G FlI

faw fan n or cy

M AR AL FRUSTRATION

UI T

xes he ﬁ , t n e e Wh re fuIl d to a nee ch. u they LT as s E F be

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

The WISDOM & WORK of Sadness

RECOVERY

REST

RESILIENCE

D OWN

BOUN

LET

CE B AC

SADNESS brings RECOVERY and turns STRESS into STRENGTH

loss of job ne’s way losing facMORTA NEGLECT e o LITY loss ng ion t d a e z i g tal ing tragedy of parent ospi n ot f sibl o rejecIh s s lo on loss of child est threats to iden pty n ABUSE ti m ty dif e f er en tn es s

a traum ed v o l isolatio un n H ENT AT REM I T E lo R DE G ne N lin ACI es F s

the nadir

Stress & Resilience - Gordon Neufeld

HELP THAT IS

Jack Hirose Seminars - Fall, 2023

HELPFUL!!

• keeping or restoring perspective • right thinking / being positive • pursuing happiness • resisting the ‘let-down’ • acquiring the ‘skills’ of resilience • pursuing calmness & tranquility

Strength of DEFENSE

Strength of BECOMING - meant to be characteris.c -

- meant to be situa.onal found needed strength

OVERCAME

potenIal sIll unfolding

persisted despite distress

PERSEVERED

growth force persists

came through distress seemingly ‘unscathed’

SURVIVED

heart was mended and spirits were revived

changed to withstand or cope with adversive or distressing condiIons

RESILIENT

feelings recover quickly ager Imes of stress

ADAPTIVE

transformed from inside out by adversity

can funcIon or perform in highly stressful or wounding circumstances

HARDY

doesn’t need to be sheltered from stress to preserve growth potenIal

Strength of DEFENSE

Strength of BECOMING - meant to be characteris.c potenIal sIll unfolding

persisted despite distress

PERSEVERED

growth force persists

came through distress seemingly ‘unscathed’

SURVIVED

heart was mended and spirits were revived

changed to withstand or cope with adversive or distressing condiIons

RESILIENT

feelings recover quickly ager Imes of stress

ADAPTIVE

transformed from inside out by adversity

HARDY

doesn’t need to be sheltered from stress to preserve growth potenIal

fee

en de r

a ro m

f of

g lin

su lts f

m ro

can funcIon or perform in highly stressful or wounding circumstances

f lts su

lin g

found needed strength

OVERCAME

of t

- meant to be situa.onal -

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

The Story of Resilience

The WISDOM ! of the ! Chapter Three Stress Response

Chapter 1

The Truth about Trauma

The truth about trauma is that is NOT in the nature of an event, no maVer how distressing the event may be. Trauma is not what happens TO us, but what fails to happen IN us as a response.

Stress Response

PRIMAL SEPARATION EMOTIONS ARE ACTIVATED FEELINGS that would interfere with performing or funcIoning in stressful circumstances are inhibited

Resilience Response Feelings that have been inhibited bounce back to enable opImal funcIoning and the realizaIon of full potenIal

SAFETY is required for feelings to be recovered

TIME (ideally the end of the day or end of the week at most)

Stress & Resilience - Gordon Neufeld

Resilience Response

Stress Response becomes PRIMAL SEPARATION EMOTIONS ARE ACTIVATED FEELINGS that would interfere with performing or funcIoning in stressful circumstances are inhibited

Jack Hirose Seminars - Fall, 2023

Feelings that have been inhibited bounce back to enable opImal funcIoning and the Whenoffeelings realizaIon full potenIal

fail to bounce back, an acute stress response turns into TRAUMA return of feelings SAFE Traumarequires = stuck stress response SANCTUARY

TIME (ideally the end of the day or end of the week at most)

a stuck stress response

TRAUMA a missing resilience response

an emo6onal emergency response that has failed to come to an end

SIGNS OF POST TRAUMATIC STRESS SYNDROME

in l e fe

ess l IMPULSIVENESS ut b ion FRUSTRATION ALARM t mo e re o m PURSUIT

- elevated startle response - ﬂashbacks and nightmares - avoidance of whatever alarms - intrusive thoughts & memories - unable to focus and concentrate - hyper-arousal and hyper-vigilence

- irritability and impaIence

- erupIons of aVacking energy

- self-aVack and suicidal impulses

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

SIGNS OF UNRESOLVED & RESIDUAL PRIMAL EMOTION

lin e e f

- clutching, clinging, possessing, hoarding, acquiring, impressing, pleasing, etc - fragmented fixes & fixaIons with pursuit as the theme – winning, placing, hunIng, chasing, aVracIng, demanding, reducing, seeking, enhancing, etc - preoccupaIons with altering - preoccupaIons with concealing self in pursuit of belonging, of belonging, PURSUIT oneself in pursuit love or significance love or significance

ess l ut b ion FRUSTRATION ALARM t mo e re o m

- ANXIETY - irraIonal obsessions - irraIonal avoidance - anxiety reducing behaviour - an aVracIon to what alarms - inability to stay out of trouble - recklessness and carelessness - aVenIon deﬁcits around alarm - chronic agitaIon and restlessness

- ﬁts & tantrums - hidng and ﬁghIng - obsessions with change - aggression and violence - rudeness and meanness - irritability and impaIence - erupIons of aVacking energy - self-aVack and suicidal impulses

Signs of a Stuck Stress Response UNRESOLVED alarm, frustraIon & pursuit

Missing the VITAL SIGNS of well-being

RED FLAGS for lost feeling

ful nes

s lne

vital signs of well-being

pl ay

- rest is the state from which all growth and recovery happens

stfu re

- the play mode is about opImizing and so is only acIvated when the preeminent aVachment drive is at rest

Missing the ‘Vital Signs’ of Well-Being

‘feelingfulness’

Feelings are ‘feedback’ which, despite their role in the unfolding of potenIal, are somewhat luxurious & ‘advanced’. Given how readily they are sacriﬁced by a distressed brain, they are a key indicator of emoIonal health & well-being.

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Feelings more likely to be defensively inhibited feelings of MISSING (longing, loss, empIness, loneliness, lack of invitaIon)

feeling RESPONSIBLE (sorry, remorseful, guilty about, bad about, responsible for)

feelings of CARING (caring for, caring about, love, compassion)

feelings of (fulﬁlled) DEPENDENCE (needy, vulnerable, cared for, saIated by, trusIng in)

feelings of FUTILITY (sadness, disappointment, grief, melancholy, sorrow)

feelings of ALARM (unsafe, nervous, apprehensive, cauIous, concerned, careful)

As a result ...

feeling CONFLICTED

RED FLAGS for LOST FEELING NO RECOVERY of lost feelings over Ime FUTILITY is not felt (the ‘canary’ of emoIonal distress) a proneness to BOREDOM

What BOREDOM is about

When the ‘holes’ in togetherness are NOT suﬃciently FELT, it is experienced as BOREDOM.

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Boredom-a natural barometer for deﬁcits of feeling - can’t feel the true nature or shape of the hole that exists within -

ac9v ity

food nt me n i rta

s9m

ula 9o n

al s git it di rsu pu

te en delin quen cy

ns scree

videog

ames

EARLY SIGNS OF A STUCK STRESS RESPONSE no longer talks about what distresses or hurt feelings no longer feels unsafe or alarmed no longer reads rejec9on or feels its s9ng no longer given to sadness and disappointment no longer feels as needy, empty, lonely or dependent no longer is as visibly aﬀected by loss and lack be^er able to func9on or perform under duress

RED FLAGS for LOST FEELING NO RECOVERY of lost feelings over Ime FUTILITY is not felt (the ‘canary’ of emoIonal distress) a proneness to BOREDOM ADDITIONAL RED FLAGS a diminished sensorium (especially pain & bladder pressure for youngsters and even youth) a urgent and persistent flight from feeling flaVened affect (per ‘classical’ definiIon of depression)

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

The Story of Resilience

The WISDOM ! of the ! Chapter Four Stress Response

Chapter 1

How to Resuscitate the Resilience Response

Stress Response

Triggers Primal Separa9on Emo9ons FEELINGS that would interfere with performing or funcIoning in stressful circumstances are inhibited

Resilience Response Feelings that have been inhibited bounce back to enable opImal funcIoning and the realizaIon of full potenIal

Provide SAFE SANCTUARY for FEELING

TIME (ideally the end of the day or end of the week at most)

SAFETY It is NOT the existence of SAFETY that is required for feelings to return but rather the experience of safety that is conducive to feeling.

TWO SAFE SANCTUARIES for FEELING • SAFE RELATIONSHIP - when CLOSE to a person ATTACHED to in a trusIng DEPENDENT mode • when in the PLAY MODE and in par9cular when emo9ons are at play

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Where the helper can be ANYONE but preferably a caring adult to whom the child or adult is a^ached or will a^ach

helper

Resuscitating the Resilience Response - applying rela9onal and emo9onal ﬁrst-aid -

P HI NS

O TI LA

- parent - grandparent - rela9ve - teacher - coach - expert - counsellor - therapist - caregiver - case worker - volunteer

- helping the troubled OR helping in troubled 9mes helping the traumatized to get unstuck

Relational First Aid & Treatment • convey a strong caring ALPHA PRESENCE

• BRIDGE separaIons with other forms of connecIon • BRIDGE troubling symptoms with connecIon

• COLLECT to engage and invite dependence • COME ALONGSIDE emoIonal experience

RELATIONSHIP

• support EXISTING ATTACHMENTS with caring adults

• NURTURE (including food) in the context of connecIon

• matchmake to embed in CASCADING CARE and shielding aVachments

• ritualize some SAFE SPACES for feelings to bounce back

Through the other’s attachment to us, we can BE their ANSWER even when there are no answers: • BE their HOME

• BE their place of REST • BE their sanctuary of SAFETY • BE their SHIELD in a wounding world • BE their REASON for holding on The answer is in BEING - not in DOING or SAYING or KNOWING the right things – when empowered by the other’s attachment to us.

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Employing PLAY as emotional first aid ...

PLAY

l rea

PLAY

for

NO T

T NO

wo rk

as well as for ongoing recovery & healing

expressive

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

Harness the Healing Power of Play • to LIGHTEN the emoIonal load

• to safely engage and DISTRACT in alarming situaIons

• to aid the RECOVERY of feelings so that the stress response does not get stuck

• to give the brain a chance to REST and RECOVER PLAY • to provide for SAFE EXPRESSION of primal emoIon

• to set the stage to access healing SADNESS when emoIonally ready

When drawing the child into play, we are transferring the child into the arms of NATURE so it can gently and wisely take care of the child

Emo9ons are easier to feel when one step removed from real life

Emo9ons are not at work, so the inhibi9on of feelings is reversed Play is safe so feelings won’t get hurt

Words or their lack, do not get in the way

Emo9ons are freer to move and so more likely to be felt and iden9ﬁed

Feelings of fu9lity are much easier to access

Emotional playgrounds help in the recovery of feelings

Suggestions for Harnessing Play • engage in play by giving play signals, like a bit of silliness, singing, wearing a playful cape • playfully engage in games, puzzles, stories, music, movement, drama, theatre, etc • provide materials to draw, paint, construct, make crags, make music, priming the acIvity where necessary

• take turns telling made-up stories, so their emoIons can drive something other than nightmares

PLAY

• sing or hum lullabytype songs if possible, to harness their emoIonal and connecIve power

• engage in playful connecIon, providing brief experiences of contact and togetherness that are able to disarm

• engage in the cultural play, ie, the dances, music, art of their culture of origin

Stress & Resilience - Gordon Neufeld

Jack Hirose Seminars - Fall, 2023

... in our pursuit of happiness PRESS PAUSE

... in avoiding negaIve thoughts ... in aVempIng not to be upset ... in trying to stay in perspecIve ... in aVempIng to stay opImisIc ... in trying to cheer each other up ... in pudng limits on grief and sorrow ... in denying that the glass is half empty ... in trying to change the Eeyores into Tiggers

into the SADNESS whose task it is to facilitate needed endings, strengthen as required, and deliver us back to what happiness exists

S T R E P O T E N T I A L G T H

UND ING

g 9n len S

S re un TRE S

trag e

unb sepaearable ra9o n

sadness

ty rtain unce

feelings

sing distresstances circum loss & lack

t toghreate eth ne ern d ess M

ALAR

chaos

recover the resilience response

helper

Resuscitating the Resilience Response

L RE

P HI NS O I

11/3/23

Healing the Healer Self-Care as an Act of Resilience Eboni Webb, PsyD

LET’S TAKE A MINDFUL MOMENT Take a moment to reflect on one of your current clients and their family system. Close your eyes and allow your body to become aware of the hope you hold for them. Breathe and write down your thoughts and body observations. Now, close your eyes and allow your body to become aware of the fear you hold for them. Breathe and write down your observations. Finally, when cued, go back to your body stance of hope for the family you serve.

Let’s Examine Your Hopes and Fears

Cortisol Fatigue • “In the brains of people who have been abused, the genes responsible for clearing cortisol were 40% less active” • (Morse &Wiley, 2012)

11/3/23

EMOTIONALLY REGULATED

11/3/23

SELF-CARE STRATEGIES TO REDUCE CORTISOL RESPONSE Activities

Regular massages

Prayer

Hydration

Balanced sleep

Proper Nutrition

Positive touch

Proximity

Laugh/Dance

LET’S WAKE UP YOUR BODY 32

PL.E.A.S.E.D SKILLS • Physical health •

List resources and barriers (each area)

•

Eat three healthy, balanced meals

•

Avoid mood altering drugs

•

Sleep between 7 to 10 hours

• •

Exercise at least 20 minutes Daily

• Address Barriers • Develop a plan/track on diary card

11/3/23

Build Positive Experience • Must be planned/scheduled • Must include mindfulness skills • Address distractions that interfere with BPEs • Address judgments that interfere with BPEs (e.g., not deserving, etc.) • Address concerns about expectations

Build Positive Experience • Short term • Do pleasant things that are possible now • Long term • Invest in relationships (Attend to Relationships-A2R) • Invest in your goals • Build a satisfying life • Take one step at a time

Build Mastery • Engage in activities of daily living • Accomplish tasks that need to be done • Take steps toward a challenging goal • Build a sense of control, confidence, and competence • Give yourself credit!

11/3/23

SIMON SAYS DANCE BREAK 37

SOMATIC AND EXPRESSIVE ART INTERVENTIONS

Exercises

scover Let’s Di racter a Your Ch s! ie g Strate

11/3/23

What are Character Strategies?

Sensitive-Emotional

Strengths

Limitations

Sensitive-Withdrawn

Strengths

Limitations

11/3/23

Dependent-Endearing

Strengths

Limitations

Self-Reliant

Strengths

Limitations

Tough Generous

Strengths

Limitations

11/3/23

Charming Manipulative

Strengths

Limitations

Burdened-Enduring

Strengths

Limitations

Industrious Overfocused

Strengths

Limitations

11/3/23

Expressive-Clinging

Strengths

Limitations

Organizing Our Experiences Through Examining Our Barriers

Nourishment

Reaction

Completion

Response

Satiation

Insight Stimulus

Connection

RESOURCING OUR STRATEGIES

11/3/23

Sensitive-Emotional Body

Breathwor k

Sensitive-Withdrawn Body

Boundarie s

DependentEndearing

Body

Taking Over

11/3/23

Self-Reliant Body

Cooperatio n

Tough Generous Body

Groundin g

Charming Manipulative

Body

Screenin g

11/3/23

Burdened Enduring Body

Definitio n

Body

Industrious Overfocused Pleasure

Body

Expressive Clinging Presence

11/3/23

Nourishment (DE, SR, TG)

Reaction Response (BE/CM)

Insight Stimulus (SW, SE, EC)

Completion Satiation (IO, EC)

Rest Digest Reflection

Working Through Our Strategies’ Barriers

Thank-You for Attending! • Eboni Webb, PsyD, HSP, Consultant • Office Locations • Nashville: 1451 Elm Hill Pike, Suite 250 • Franklin: 367 Riverside Drive, Suites 220, 250 • To Schedule a Consultation • Call 615-613-7639 • www.webbjamconsulting.com • ewebb@webbjamconsulting.com