The Western Canada Trauma Conference | HANDOUTS by jackhirose

TABLE OF CONTENTS 1

DAY ONE #1: The Complexities of Complex PTSD | Sheri Van Dijk, MSW, RSW

pg. 2

#2: Treating Personality Disorders | Jeff Riggenbach, Ph.D.

pg. 23

#3: Trauma and the Struggle to Open Up | Robert T. Muller, Ph.D.

pg. 98

#4: The Complexities of Complex PTSD (Part 2) | Sheri Van Dijk, MSW, RSW

pg. 128

#5: Trauma and Addiction | Jeff Riggenbach, Ph.D.

pg. 148

#6: Trauma and the Struggle to Open Up (Part 2) | Robert T. Muller, Ph.D.

pg. 98

DAY TWO #7: Stress and Trauma | Gordon Neufeld, Ph.D.

pg. 244

#8: Echoes of Trauma | Leanne Campbell, Ph.D., R. Psych

pg. 278

#9: Navigating Trauma & Addictions | Carissa Muth, Psy.D.

pg. 289

#10: Stress and Trauma (Part 2) | Gordon Neufeld, Ph.D.

pg. 244

#11: Echoes of Trauma (Part 2) | Leanne Campbell, Ph.D., R. Psych

pg. 278

#12: Navigating Trauma & Addictions (Part 2) | Carissa Muth, Psy.D.

pg. 289

DAY THREE #13: IFS Therapy for Trauma Treatment | Daphne Fatter, Ph.D.

pg. 351

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

pg. 381

#15: Healing the Wounded Self | Patti Ashley, Ph.D., LPC

pg. 479

#16: Polyvagal Theory | Daphne Fatter, Ph.D.

pg. 509

#17: Conquering Anxiety (Part 2) | Caroline Buzanko, Ph.D., R. Psych

pg. 381

#18: Healing the Wounded Self (Part 2) | Patti Ashley, Ph.D., LPC

pg. 479

WESTERN CANADA TRAUMA CONFERENCE - 2024

5/1/24

An Integrated Approach to Treating Complex Trauma Sheri Van Dijk, MSW, RSW EMDR Certified & Consultant

Disclosure

No individuals who have the ability to control or influence the content of this webinar have a relevant financial relationship to disclose with ineligible companies, including but not limited to members of the Planning Committee, speakers, presenters, authors, and/or content reviewers. “M any of the concepts I'm presenting today are from m y books. I do benefit financially from royalty paym ents from the sale of these products.”

Objectives By the end of this workshop participants will: § Understand some differences between PTSD, CPTSD, and BPD § Know the Triphasic approach to trauma treatment § Learn the basics of Polyvagal Theory and how to use this with clients § Have some skills to help ground and regulate clients, and to help prepare clients for trauma processing therapy

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What is Trauma? ´ Life-threatening traum a m eeting the DSM -5 Criterion A definition for PTSD requires exposure (first-hand or vicariously) to actual or threatened death, serious injury, or sexual violence (often referred to as “Big T traum a”). ´ Experiences that don’t m eet this strict definition – such as em otional or verbal abuse, or neglect – (som etim es referred to as “sm all t traum a”) m ay be perceived by an individual as equally or m ore life threatening than the Big T traum as. ´ In EM DR’s Adaptive Inform ation Processing m odel, it’s clear that if an experience underm ines an individual’s sense of self-worth or safety, inhibits their capacity to attribute or accept proper responsibility, or lim its one’s sense of control or choices in the here-and-now, then it is a traum a (Shapiro, 1997). ´ “Traum a is in the eye of the beholder”!

The Adverse Childhood Experiences (ACE) study looked at the health and social consequences of seven traum atic childhood experiences in over 17,000 adults in the US (Felitti et al, 1995)

ACEs M easured: - Parental separation, divorce, addiction, or incarceration - Household m ental illness or dom estic violence - Experiencing physical, sexual, or em otional abuse or neglect

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Adverse Childhood Experiences (ACES) ´Green et al (2010) study findings suggest that early childhood adverse experiences could be related to up to 32% of psychopathology in adults, and up to 44% in children ´ACEs also increase the risk of early mortality; individuals with six or more ACEs: § Were found to have died 20 years earlier than those with no ACEs;

§ Were at a 1.7 times higher risk of death by age 75, and 2.4 times higher risk of death by age 65.

Adverse Childhood Experiences (ACES) We need to remember that ACE scores don’t account for positive experiences in early life that can help build resilience and protect a child from the effects of trauma (e.g. having a grandparent who loves you, a teacher or coach who understands and believes in you, a trusted friend you can confide in), which may mitigate the long-term effects of early trauma § AND the initial ACEs study was composed of respondents who were predominantly white, middle-class, and welleducated. The Philadelphia ACEs (2012) project expanded on the original ACEs to look at an urban location with a racially and socio-economically diverse population, adding several events to capture a broader range of experiences… (the response rate was small, at 1784 adults, or 67%) §

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Post-Traumatic Stress Disorder (PTSD): DSM-5 vs. ICD-11 •

C-PTSD is not a diagnosis in the DSM -V-TR but has been included in the m ost recent edition of the W HO’s ICD-11.

•

DSM ’s “criterion A” for a PTSD diagnosis: The person was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, either first-hand or vicariously: •

Directly experiencing the traum atic event(s)

•

W itnessing, in person, the event(s) as it occurred to others

•

Learning that the traum atic event(s) occurred to a close fam ily m em ber or close friend. In cases of actual or threatened death of a fam ily m em ber or friend, the event(s) m ust have been violent or accidental.

•

Experiencing repeated or extrem e exposure to aversive details of the traum atic event(s) (e.g., first responders collecting hum an rem ains; police officers repeatedly exposed to details of child abuse).

*DSM criterion A is a problem right off the bat for many individuals, excluding a diagnosis of PTSD (or CPTSD if it was to be conceptualized similar to the ICD)

Post-Traumatic Stress Disorder (PTSD) The ICD-11 form ulation of PTSD requires exposure to an extrem ely threatening or horrific event or series of events; and the experience of sym ptom s in each of the following clusters: 1. Re-experiencing sym ptom s such as intrusive thoughts, flashbacks, or nightm ares. 2. Avoidance sym ptom s, such as avoiding places or situations that trigger m em ories of the traum atic event. 3. Sense of threat, such as hypervigilance and being easily startled. To be diagnosed with PTSD, the sym ptom s persist for at least several weeks and cause significant im pairm ent in personal, fam ily, social, educational, occupational or other im portant areas of functioning.

Complex PTSD In 1988, Dr. Judith Herm an of Harvard University suggested that a new diagnosis, “Com plex PTSD” (CPTSD), was needed to describe the sym ptom s of long-term traum a. To receive a diagnosis of CPTSD all the features of PTSD m ust be present; in addition, there m ust be evidence of Disturbances of Self Organization (DSO) in three additional dom ains: 1. Problem s of affect regulation (e.g. em otional reactivity such as explosive anger and violent outbursts, difficulties calm ing or soothing oneself after a stressor) 2. Persistent negative beliefs about oneself (e.g. beliefs about self as dim inished, defeated or worthless, accom panied by feelings of sham e, guilt or failure related to the traum atic event) 3. Difficulties in sustaining relationships and feeling close to others (Relationships often suffer due to difficulties trusting others and the negative self-view; the individual m ay avoid relationships or develop unhealthy relationships sim ilar to what they knew in the past)

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Complex PTSD In terms of the trauma itself: ´CPTSD usually results from multiple traumatic events, or when the exposure to trauma is prolonged (although chronic or repeated trauma is a risk factor, not a requirement, for CPTSD; and while it can be diagnosed after a single traumatic event, this is less likely); ´The stressors are typically of an interpersonal nature – that is, resulting from human mistreatment rather than acts of nature or accidents (e.g. childhood abuse, domestic violence, human trafficking, torture, kidnapping, racism, etc.)

PTSD, CPTSD and BPD as Different Disorders ´ Evidence suggests that PTSD and CPTSD are distinct from, but often co-occur with BPD (Ford & Courtois, 2021; Cloitre et al, 2014; Frost et al, 2018; Knefel et al, 2016). ´ Consistent with the idea that chronic or multiple trauma is a risk factor for CPTSD, studies have shown that childhood physical or sexual abuse, particularly within the family, is more strongly related to CPTSD than PTSD (Cloitre et al 2019); CPTSD is also associated with higher levels of psychiatric burden than PTSD, including greater depression and dissociation, and this burden increases when there is co-morbid BPD (Hyland et al, 2018; Cloitre et al, 2019)

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Com plex PTSD

Versus

BPD

- Em otion Dysregulation -

Recurrent suicidal behaviors, gestures, threats, and self-harm ing; em otional lability; extrem e, uncontrolled anger; profound em otional dyscontrol; typically underregulated

Stable, deeply negative; chronic sense of guilt, sham e, worthlessness

- Sense of Self -

Highly unstable, polarized positive and negative perceptions of self Chronic sense of em ptiness

Avoidance and detachm ent based on a fear of closeness

- Relationships -

Intense, volatile, oscillating between idealizing and disparaging; intense fear of abandonm ent and behaviors to avoid this

- Traum atic Event -

**Not required; and som e studies are showing that em otional abuse & neglect are m ore likely in BPD (Ford & Courtois, 2021)

Reactive anger; problem s calm ing self when distressed; chronic em otional num bing; substance use; often over-regulated (em otional num bing, avoidance, dissociation)

**Required

C-PTSD versus BPD

Complex PTSD: Sorting out the Language Developm ental Traum a – proposed as a new diagnosis by van der Kolk & colleagues; this refers to traum a that takes place in childhood and/or adolescence, while the brain is still developing – essentially, C-PTSD for children; often involves attachm ent traum a. - currently this is often being m is-diagnosed as pediatric Bipolar Disorder, Oppositional Defiance Disorder, Conduct Disorder, and ADD/ADHD, and therefore treated with m edications rather than addressing the traum a Relational Traum a – refers to traum a that happens within a close relationship; this can happen in relationships in children or adults; when this occurs in developm ental years it’s also referred to as Attachm ent Traum a Relational Traum a m ay lead to C-PTSD: for children, attachm ent is survival! So when attachm ent is dam aged, lost, or inadequate, the child m ay experience the world as unsafe, without explicit m em ory or experiences of “traum a” Traum atic Invalidation – can also lead to C-PTSD. W hen internal experiences are regularly invalidated by people in the environm ent; invalidation can be traum atic when it is severe, long lasting, and negatively affects your understanding of yourself and the world (Linehan, 2014). Exam ples of traum atic invalidation include em otional or verbal abuse, neglect, discrim ination, being blam ed or disbelieved when telling som eone about a traum a you experienced

International Trauma Questionnaire At present only one instrument is available that specifically assesses ICD-11 CPTSD, the International Trauma Questionnaire (Cloitre et al, 2018): International Trauma Questionnaire: ITQ (traumameasuresglobal.com)

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Triphasic Model of Treatment (Herman, 1992)

The Triphasic Approach to Treating Complex Trauma (based on Janet, 1907 & Judith Herm an, 1992)

(Keeping in mind that CPTSD is a newer diagnosis and so research is on-going regarding how best to treat it…) Stage One: Safety and Stabilization: Focus is on helping clients identify the issues that brought them to therapy, learn to manage dysregulation, develop resources, and resolve any major internal conflicts in preparation for Stage 2 (trauma resolution) ´ Develop and build the therapeutic alliance (expect this to take longer for a client with relational traum a!) ´ Identify presenting issues and concerns, including risk factors, and m edical or traum arelated sym ptom s that m ay interfere with successful treatm ent or contraindicate the use of particular interventions (such as EM DR), and that m ay need im m ediate attention (e.g. disordered eating) ´ Take a thorough history, (depending on the client’s ability to tolerate affect; not delving into details of traum a!), and identify current and past sources of resilience

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The Triphasic Approach to Treating Complex Trauma (based on Janet, 1907 & Judith Herman, 1992)

Stage One: Safety and Stabilization: History Taking: ´ Be sure to keep the client within their window of tolerance ´ Remembering that there may not be an explicit memory of the trauma, but that the body keeps the score! ´What were/are relationships like in the family of origin? ´What’s NOT being said? (e.g. a client who notes their parent was an alcoholic but then reports “childhood was great”; client might not know to report “no one was home at dinnertime so I had to make myself a sandwich when I was six”) ´e.g. From a Biosocial Theory perspective ´e.g. From an Adaptive Information Processing (AIP) perspective ´This should include screening for dissociation! e.g. The Dissociative Experiences Scale (DES and DES-T)

The Biosocial Theory (Linehan, 1993)

Pervasive emotional dysregulation is the result of two main factors: 1. A biological predisposition to emotional vulnerability (high sensitivity) AND 2. A pervasively invalidating environment (e.g. the abusive home, the poor fit, the chaotic home) § Where the individual’s internal experiences are regularly judged, punished, minimized, ignored, etc.

The Biosocial Theory (Linehan, 1993)

Consequences of the emotionally vulnerable child growing up in the invalidating environment: Ø The child doesn’t learn to label or trust private experiences, including emotions; instead, they learn to search their environment for cues on how to think, feel, and act Ø They therefore don’t learn to modulate emotional arousal; or how to respond appropriately to distress Ø “Problem Behaviors” are the result of unhealthy attempts to regulate emotions

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The Adaptive Information Processing (AIP) Model (Shapiro, 1995)

´ Usually, we’re able to heal from disturbing events we encounter; but sometimes things happen that overwhelm our ability to cope, resulting in the trauma becoming “stuck”, or remaining “unprocessed” – unable to link up with more adaptive information ´ From this perspective, we conceptualize the client’s current symptoms based on the maladaptively stored information

The Triphasic Approach to Treating Complex Trauma (based on Janet, 1907 & Judith Herman, 1992)

Stage One: Safety and Stabilization: ´Develop an initial plan for the subsequent treatment stages ´Provide psychoeducation about trauma and its effects (including the fact that talking about the trauma prematurely isn’t typically helpful and sometimes causes more harm) – we’ll come back to this with Polyvagal theory as well!

The Triphasic Approach to Treating Complex Trauma (based on Janet, 1907 & Judith Herman, 1992)

Stage One: Safety and Stabilization: Identifying Triggers “When we remember a traumatic event or are triggered by some small cue in the here and now, our bodies automatically begin to mobilize for danger, not knowing that we’re remembering threat rather than being threatened now” (Fisher, 2021, p. 96). § This is because the amygdala - the part of the brain that responds to stress and triggers our active defenses – can’t differentiate between past and present, so we feel as though the danger is happening now. § Flashbacks and dissociation are obvious signs of being triggered, but signs can also be subtler, such as: - Feeling like you’re not in control of your reaction - Having a reaction that seems more intense than what’s warranted by the situation - Having a reaction different from how you would usually react - Becoming stuck in your reaction, unable to step back and access your internal wisdom - Feeling as though you’re “not yourself”, as though another part of you has taken over

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The Triphasic Approach to Treating Complex Trauma (based on Janet, 1907 & Judith Herman, 1992) Stage One: Safety and Stabilization: § Teach skills to increase stability (externally – e.g. housing, finances, relationships; as well as internally - emotion regulation, dissociation, selfcare) § “Bottom-Up” skills to re-regulate quickly (F-TIP Skills): ´ Forward Bend (PNS) ´ “TIP” the temperature of your face (mammalian dive reflex) ***clients with anorexia and/or bulimia, who have low bp or take beta blockers cannot do this skill without first checking with their doctor!

´ Intense exercise ´ Paced Breathing (PNS) ´ Paired Breathing: Progressive Muscle Relaxation + Paced Breathing ´ (Hyperventilation technique)

Mindfulness for CPTSD (“top-down”) Stage One: Safety and Stabilization: ´ One study of an online m indfulness-based intervention dem onstrated reduced CPTSD DSO sym ptom s, particularly negative self-concept and disturbances in relationships; reduced the PTSD sym ptom of sense of threat, and prom oted positive m ental health (Dum arkaite et al, 2021) ´ Another study on m indfulness for PTSD: “findings suggest the m indfulness facet m ost relevant to PTSD m ay be nonjudging of inner experience” (Reffi et al, 2019) ´

Aliche et al (2021) found that m indfulness reduced PTSD sym ptom s associated with experiential avoidance

´ I believe everyone can benefit from m indfulness, AND we want to be cautious about how we’re introducing m indfulness to som eone with a traum a history – e.g. inform al versus form al m indfulness; caution re: focus on body or breath

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Resourcing (Top-Down & Bottom-Up) Stage One: Safety and Stabilization:

Secure (Calm, Healing, Peaceful) Place Container Protective Figure Nurturing Figure Wise Figure New Parent

The Triphasic Approach to Treating Complex Trauma (based on Janet, 1907 & Judith Herman, 1992)

Stage One: Safety and Stabilization: § For clients who are highly dissociative, Stage 1 will also include understanding how the client’s self-system is organized, obtaining on-going consent from all parts, orienting parts, and working on resolving conflicts between parts § Psychoeducation (we all have parts!); for clients with very complicated internal systems, this may be a problem itself (red flag!)

The Triphasic Approach to Treating Trauma Stage Two: Trauma Resolution: focuses on coming to terms with and resolving past, painful experiences and present triggers for that pain. Tasks include: ´ Overcoming fears of the memory, triggers, and cognitions ´ Accessing and resolving old, painful experiences ´ Accessing and resolving present triggers that connect to the painful experience ´ Depending on the treatment, an additional task in this stage may be restructuring trauma-based personal schemas (in EMDR therapy this happens naturally as a result of reprocessing dysfunctionally stored material) **Not all clients will choose or be able to engage in Stage 2 work

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Stage Two Treatments ´ Eye Movement Desensitization and Reprocessing (EMDR) ´ Deep Brain Reorienting (DBR) ´ Ego-State Therapy ´ “Four Blinks”: Four Blinks Version of Flash: An Open Approach To Traum a Reprocessing – Rapid M em ory Reconsolidation Resources (video)

´ Internal Family Systems ´ Prolonged Exposure/DBT-PE ´ DBT-PTSD ´ Cognitive Processing Therapy ´ Somatic Experiencing ´ Sensorimotor Therapy ** again, research is on-going for CPTSD

The Triphasic Approach to Treating Trauma Stage Three: Reconnection: focuses on integrating the changes within the self and in day-to-day life, consolidating gains, and (re-)connecting to a meaningful life. ´ Addressing any existential, identity, and attachment-related issues (e.g. “Who am I, now that I’m no longer defined or held back by my trauma?”) ´ Developing a more consistent sense of mastery in life and self-sufficiency through learning skills for handling “ordinary” life difficulties ´ Considering longer-term goals ´ Achieving relief of any residual symptoms ´ Concluding the therapeutic relationship (“what does it mean that we won’t be working together any longer?”, “will you be here if I need you in future?”) ´ (DBT Skills that I often use here: assertiveness, limit-setting, acceptance) It’s important to recognize that these stages of treatment don’t exist separately from one another – clients will shift back and forth between stages at times

Polyvagal Theory (Stephen Porges, 1994) Polyvagal Theory (PVT) is a popular approach to explaining how neurophysiology impacts our emotional states. It is evidence-based, but there is still debate about it. § The Autonomic Nervous System (ANS) is a system that involves various organs from the brain to the colon; the Vagus Nerve links them all together. § The job of the ANS is to keep us alive; it plays a central role in regulating emotions, behaviours, and the body’s automatic reactions to social and environmental challenges, acting outside of our conscious awareness. § Historically we’ve known the ANS to have two distinct branches: the sympathetic (SNS - “fight or flight”) and the parasympathetic (PNS - “rest and digest”). § PVT postulates that there are two branches (SNS and PNS), but three pathways: with the PNS being split between the Dorsal Vagal and the Ventral Vagal

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Polyvagal Theory (Stephen Porges, 1994) Three Organizing Principles:

1. Hierarchical: The Autonomic Nervous System (ANS) responds to external/internal stimuli through three biological pathways, in a particular order: - the ventral vagal (social engagement connection; “rest and digest”);

and

- the sympathetic nervous system (mobilization; “fight, flight/freeze”); - and the dorsal vagal (immobilization; “flop and drop”).

Polyvagal Theory (Stephen Porges, 1994) Three Organizing Principles:

2. Neuroception: -

The term coined by Stephen Porges to refer to our unconscious perception

The ANS constantly scans (6 times per second) inside your body, the environment outside your body, and what's happening between you and the people around you; it’s the filter between us and the world

Neuroception occurs deep underneath the conscious level of awareness – it’s instant and automatic.

How we neurocept is also influenced by what autonomic state we’re in; our ANS is shaped by experiences, habitual responses, and patterns; and what we neurocept leads our ANS to respond in a certain way (active or dissociative defenses)

“Are we in connection, or protection?”

(based on our senses) of safety or danger in the environment.

Polyvagal Theory (Stephen Porges, 1994) Three Organizing Principles:

3. Co-Regulation: - The process by which a nervous system is reciprocally regulated (brought back to "safety") in the presence of a safe "other" (caregiver, parent, etc). - Co-regulation is imperative to a person's ability to move into safe relationships and meaningful connections, and therefore to survival. - We influence others around us through their neurocepting the signals we send.

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Polyvagal Theory (Stephen Porges, 1994) ´ W hen a hum an neurocepts an unfam iliar or possibly dangerous stim ulus, our brain orients to the stim ulus; if it’s determ ined to be safe or non-life-threatening, we return to a state of calm . If the stim ulus is perceived to be harm ful or dangerous, a defensive response from the ANS follows (unconsciously!) ´ Active defenses are prim itive, reflexive actions that include: ´ Crying for help ´ Flight ´ Or, if escape is not possible, Fight ´ W hen active defenses are not possible, the next line of defense is im m obility: ´ the hyper-aroused freeze response (“dear in the headlights”); or ´ the hypo-aroused response of collapse/submit (“playing possum”); this submit response is the last mammalian defense prior to the onset of death, reducing ability to feel pain. In the context of day-to-day life, this shut-down can include dissociation, or collapsing into paralyzing experiences of depression, shame, or emotional and physical numbness

Ventral Vagal (Green Zone; WoT) ´ M ost recent in term s of evolutionary developm ent ´ Supports social engagem ent ´ Heart rate slows (65-70bpm resting) ´ Saliva & digestion are stim ulated ´ Facial m uscles are activated ´ Increased vocal prosody (versus m onotone) and eye contact ´ M iddle ear m uscles are turned on, allowing us to better hear sounds in the m id-range, including the hum an voice ´ “Safety is a necessary prerequisite for strong social connections”: Safety => Proxim ity => Contact => Bonds ´ Everything isn’t necessarily peaches and roses here, but we have access to our PFC!

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Green Zone

Sympathetic (Yellow Zone) ´ Heart rate increases (110bmp = amygdala hijack) ´ Pain tolerance increases ´ Middle ear muscles turn off: better to hear extreme low and higher frequency sounds (predator sounds) ´ Healthy individuals can bounce between Green & Yellow with ease (playfulness; healthy stress) ´ Clinically: client with PTSD related to her husband’s death; she’s able to recall the events of his death within her WoT (tearful, anxious), but is able to stay in or return to the present and reconnect with me.

Yellow Zone

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Dorsal Vagal (Red Zone): ´ Oldest system, associated with reptilian brain; path of last resort! ´ Supports defensive “shutdown” behaviours

immobilization

and

´ Heart rate decreases (60 and below) ´ Death feigning - DISSOCIATION ´ Understanding the Red Zone helps us to better understand Trauma ´ Clinically: client gets highjacked by a memory and dissociates into trance

Red Zone

PVT: The Story of Trauma Survivors ´ Individuals stuck in the dorsal vagal state may carry a story of loneliness, shame, depression, suicidal and selfharming thoughts and behaviors, and dissociation. ´ Stuck in the sympathetic state, individuals with unhealed trauma may carry a story of anxiety, mistrust, and difficulties managing emotions ´ When survivors are in the ventral vagal state, they’re able to let go of these stories and become more connected with and attuned to others.

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Personal Profile (Deb Dana) For each of the three zones: 1. I am…(e.g. at peace; cautious; shut-down) 2. The World is…(e.g. calm; overwhelming; terrifying) 3. What word best describes the state for you? (e.g. Chill; Defcon 1; Gone) 4. What are things you can do to help you stay in Green on your own? And with others? 5. What things can you do on your own and with others to help move you out of Yellow and Red? (it takes 20 minutes for us to move back into Green when in full fight/flight) § Name (the state) to tame it…Understanding the state reduces the shame! § Trauma isn’t psychological, it’s physiological § Anxiety is an overactive neuroceptive system

Polyvagal Theory (Stephen Porges, 1994) Ways of stimulating the Vagus Nerve: 1. (Forward Bend) 2. (Paced Breathing) 3. Stimulate the salivary glands 4. Mindfulness meditation 5. Physical exercise 6. Cold water immersion (with caution) 7. Hum, sing, chant, talk or shout, laugh, gargle (the vagus nerve is connected to the vocal chords) 8. Massage (Safe and Sound Protocol (SSP))

Polyvagal Theory (Stephen Porges, 1994) Criticisms of PVT: § The model contains vague concepts that can’t be tested as a scientific theory § It over-simplifies the complexities of human emotions and reactions, ignoring the heterogeneity of internal experiences and discounting individual temperament and personality § The evolutionary ideas are also disputed

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Diagnoses from a PVT Perspective (Ford & Courtois, 2021) ´ PTSD = freeze response (Yellow Zone): orienting response to scan the environment for stressors and for ways to avoid harm or signs of potential threat (i.e. avoidance based on intrusive re-experiencing of trauma memories) ´ CPTSD DSO Symptoms = flight response (Yellow/Red Zone): unmodulated distress (i.e. difficulty in self-calming, guilt, and sense of worthlessness); and conscious and unconscious attempts to avoid further harm (i.e. emotional numbing and relational detachment). Therefore, CPTSD might be understood as the maladaptive persistence of an initially adaptive stress response that progresses from hypervigilance (i.e., PTSD) to shut-down (i.e., DSO). ´ BPD = fight response (Yellow Zone) when executive control capabilities aren’t sufficient to sustain PTSD’s freeze/hypervigilance or CPTSD’s flight/detachment

Client Example Adam : a 47 year-old successful professional who com es to therapy with a history of feeling “angry and anxious”, reporting now he’s often just “sad”. Stage One: Safety & Stabilization Building rapport/history taking/identifying issues: -

History of invalidation from his brothers

Current invalidation from his brothers and his wife

History of CSA by an older cousin from age 10 to 12

Negative belief about him self: “I’m not good enough”

(did DES)

Biosocial Theory & AIP conceptualizations

Client Example Stage One: Safety & Stabilization Skills for external stabilization: Discuss and work on validation with partner Skills for internal stabilization: -

Em otion regulation: -

Mindfulness

Importance of self-care/work-life balance

Polyvagal Theory

Introduction to Parts – building trust in his wise self

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Client Example Stage One: Safety & Stabilization Treatm ent Plan: - Developing and enhancing em otion regulation skills and learning about the effects of traum a to prepare for Stage Two Psychoeducation: - Biosocial theory; Polyvagal Theory; Ego-State Theory Bottom -Up and Top-Down Skills: -

M indfulness

- Container

Calm Place

- Protective Figure

- W ise Figure

Client Example Stage Two: Traum a Resolution - On-going discussion of Parts EM DR: - Education -

Target selection: W e agreed there’s a core belief of “I’m not good enough” related to the sexual abuse and his relationships with his brothers

Stage Three: Reconnection -

Addressing existential, identity, and attachm ent-related issues; re-evaluation of self/goals

W hat skills does he need?

Concluding the therapeutic relationship (“what does it m ean that we won’t be working together any longer?”, “will you be here if I need you in future?”)

Polyvagal Theory (Stephen Porges, 1994) Resources: § https://www.youtube.com/watch?v=ZdIQRxwT1I0&t=2s § https://www.bing.com/videos/search?q=seth+porges+polyvagal+theory+on+y outube&view=detail&mid=BC9D971A7BED21C47BCFBC9D971A7BED21C47BCF& FORM=VIRE

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Ending In Safety Be sure to always end the session in safety, with your client grounded in the present. Kluft’s “Rule of Thirds” for therapy with clients with C-PTSD: 1. Checking in, catching up, reviewing any hom ework, m aking a plan for the session 2. Doing the deeper healing work 3. Closing the session: closure, stabilization, hom ework and planning for the upcom ing tim e between sessions

Thank You!

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Jeff Riggenbach, PhD Jeffriggenbach.com 1

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Workshop Agenda Introductory Comments PD Assessment and Recognition Evidence-Based Treatments/Integrated Approach Break Treatment • Non-Bpd Diagnosis • Emotion Regulation Groups • Individual Therapy • Schema Groups 2

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Personality Etiology

Biopsychosocial = Genes + Environment

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Etiology Trait:

An enduring pattern of perceiving, relating to, or thinking about the world and one’s self. Habit: An acquired or learned patterns of thinking and behaving

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Etiology Temperament:

Innate, genetic, or constitutional aspects of one’s personality Character:

Primarily learned, psychosocial influences on personality

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

BioSocial Model 3 Types of Invalidating Families

1) The Chaotic Family 2) The Perfect Family 3) The Normal Family

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Assessment

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

“Why Was There Ever an “Axis II?”

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Why was there ever an Axis II? DSM I =1952 Approximately 60 different disorders 5 Personality Dysfunction Subdivisions

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Why was there ever an Axis II? DSM I Personality Subdivisions 1. Personality Pattern Disturbance 2. Personality Trait Disturbance 3. Sociopathic Personality Disturbance 4. Special Symptom Reaction 5. Transient Situational Personality Disorder

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Why Was There Ever an“Axis II:”DSM Evolution DSM II = 1968 Eliminated subheadings Specific Descriptions Not based on clinical trials No distinction between normal and abnormal No specific diagnostic criteria No distinction between axis I and II 11

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Why Was There Ever an “Axis II:”DSM Evolution

DSM III = 1980 Abandoned Psychoanalytic terminology First DSM to have diagnostic criteria First to distinguish between two categories of Mental Illness (Axis I & II) Axis I: Issues of Clinical Concern Axis II: Personality Disorders

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Why Was There Ever an “Axis II:”DSM Evolution DSM III-R - 1987

DSM-IV - 1994

DSM-IV-TR - 2000

DSM 5 - 2013 - abandoned multiaxial diagnostic system 13

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Categorical vs. Dimensional Models

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Problems with Current Personality Disorder Conceptualization

1. Line between “normalcy” and pathology harder to delineate 2. Considerable overlap in diagnostic Categories

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Personality Spectrum

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Personality Disorder Diagnosis

Personality Disorder Diagnosis Assessment Technique

PDO Characteristic

Ego-Syntonic

Emphasis on assessment of signs vs. symptoms

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Personality Disorder Diagnosis PDO Characteristic 2) External Locus of Control

Assessment Technique 2) Monitor for non-responsible language

Personality Disorder Diagnosis PDO Characteristic

3) Pervasive

Assessment Technique

3) Look for patterns of behavior that are showing up in different areas

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Personality Disorder Diagnosis Assessment Technique

PDO Characteristic

4) Enduring vs. Episodic

4) Videotape vs. Snapshot

Personality Disorder Diagnosis Assessment Technique

PDO Characteristic

5) Inflexible

5) Monitor Across Contexts

www.youtube.com/watch?v=Fci iOsOj-9Y

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Treatment

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

General Strategies 1. THE THINKING OF THE THERAPIST 2. VALIDATION 3. STRUCTURE 4. CONSEQUENCES AND FOLLOW THROUGH 5. CONSISTENCY 6. RELATIONSHIP MANAGEMENT 24

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

The Thinking of the Therapist

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Validation “NOT EVERYONE IS READY TO CHANGE…BUT EVERYONE IS READY TO BE VALIDATED” - ROBERT LEAHY

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

6 Levels of Validation LEVEL 1: STAY AWAKE AND PAY ATTENTION LEVEL 2: ACCURATE REFLECTION

LEVEL 3: STATE WHAT HASN’T BEEN SAID OUT LOUD LEVEL 4: VALIDATE USING PAST HISTORY OR BIOLOGY LEVEL 5: VALIDATE BASED UPON PRESENT SITUATION LEVEL 6: RADICAL GENUINENESS 27

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Intimacy Circles

25%

50% 75%

Intimacy = “Into-me-See”

100%

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Evidence-Based Treatments

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Evidence-Based Treatments 1. Dialectical Behavior Therapy (DBT) 2. Schema-focused Therapy (SFT) 3. Systems Training for Emotional Predictability & Problem-Solving (STEPPS) 4. Mentalisation-based Treatment (MBT) 5. Transference Focused Psychotherapy (TFP) 6. Good Psychiatric Management for Borderline Personality Disorder (GPM) 7. Interpersonal Group Psychotherapy (IGP)

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Introduction to the Treatment Model

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Dialectical Behavior Therapy

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Dialectical Behaviour Therapy Marsha Linehan, 1970’s Searching for modality to treat chronically suicidal women Axis II: Personality Disorders Trained as behaviorist, found CBT to be unsuccessful due to unrelenting focus on change to be invalidating Added Validation Developed Concept of Dialectics

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

DBT’s 4 Core Skill Sets Mindfulness Emotion Regulation Skills Distress Tolerance Skills Interpersonal Effectiveness Skills

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Cognitive Behavior Therapy

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Dr. Aaron beck, 1960, Penn Based on Principle that THOUGHTS influence FEELINGS

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Based on Principle that THOUGHTS influence FEELINGS

Events

Thoughts

Feelings

Actions

Results

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

“Schema” Definitions Piaget 1926 - Structures that integrate meaning into events Beck - Cognitive structures that organize experience and behavior

Landau and goldfried - mental filters that guides the processing of information

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

3 Areas of Core Beliefs/Schemas Self Others World

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Beck’s Beliefs about Self Failure Unlovable Helpless I am defective I am a burden I am undeserving

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Beck’s Beliefs about Others Others are superior to me Others are inferior to me Others are nurturing/necessary Others are unreliable Others are out to get me

Evidence-Based Treatment of PDs CBT Tenets Beck’s Beliefs about the World The world is dangerous The world is safe The world is my playground

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Schema-Focused Therapy

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Jeff Young’s 18 “Early Maladaptive Schemas” Domain 1: Disconnection and Rejection

Abandonment Mistrust Defectiveness Emotional Deprivation Social Isolation

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Evidence-Based Treatment of PDs Schema Focused Therapy Tenets Jeff Young’s 18 “Early Maladaptive Schemas” Domain 2: Impaired Autonomy and Performance

Dependence Vulnerability Enmeshment Failure

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Jeff Young’s 18 “Early Maladaptive Schemas” Domain 3: Impaired Limits

Entitlement/Grandiosity Insufficient Self-Control

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Jeff Young’s 18 “Early Maladaptive Schemas” Domain 4: Others Directedness

Subjugation self-sacrifice Approval Seeking

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Jeff Young’s 18 “Early Maladaptive Schemas” Domain 5: Overvigilance Negativity/Pessimism Emotional Inhibition Unrelenting Standards Punitiveness

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Characteristics of Schemas

Active vs Dormant Compelling Pervasive vs Discrete

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Schema Reinforcement Processes

Maintenance Avoidance Overcompensation

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Based on Principle that THOUGHTS influence FEELINGS

Events

Thoughts

Feelings

Actions

Results

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Non-BPD Diagnosis

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Cluster A: Paranoid PD

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors Prevalence rates: - 2-3% Clinical population

Paranoid PD

- Difficult to tell in general population Gender Distribution: More common in men Heritability: Estimated .41-.59 Treatability: Poor Common Schemas: Mistrust, Punitiveness Cognitive Profile - “I am Vulnerable” - “Others are out to get you” - “The world is dangerous” Behavioral Targets: Avoiding necessary tasks, angry outbursts, attacking 54

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Cluster C: OCPD

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors Prevalence Rates

OCPD

• As high as 8% general population • 3% - 13% clinical population Gender Distribution - More common in males than females Heritability: Estimated .37 Treatability: Moderate - Good Common Schemas: Unrelenting Standards, Hypercritical Cognitive Profile • “I must be perfect” • “Others screw up a lot” • “The world must have order” Behavioral Targets: Perfectionism, Procrastination, Criticalness 56

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

OCPD General Strategies

Pay attention to detail Structure the session Utilization of intellectualization Distress tolerance Develop compassion

Cluster C: Avoidant PD

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors Prevalence Rates

Avoidant PD

• 2%-3% population • 10% clinical population Gender Distribution - Equally diagnosed in men and women Heritability: Estimated .28 Treatability: Moderate - Good Common Schemas: Failure, Defectiveness, Approval-Seeking, Social Isolation Cognitive Profile • “I am not likable” • “Others will judge me” • “The world is scary” Behavioral Targets: Isolation, avoidance 59

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Avoidant PD - General Strategies

Things will NOT accomplish Behavioral skills training Acting “as if” Hierarchy of social interactions Cognitive interventions targeting rationalizations

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Avoidant PD Hierarchy of Social Interactions

1. Checker 2. Mail Woman 3. Neighbor over fence 4. SS Teacher 5. Husband’s coworker

Cluster C: Dependent PD

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors Prevalence Rates

Dependent PD

• 1% - 8% general population • Difficult to establish in clinical population Gender Distribution - More commonly diagnosed in women than men Heritability: Estimated .27 Treatability: Moderate - Good Common Schemas: Worthless, Failure, Self-Sacrifice, Subjugation Cognitive Profile • “I am inadequate” • “Others are needed” • “The world is too vast to make it alone” Behavioral Targets: Excessive messaging, clinginess, desire for time together 63

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Dependent PD General Strategies

Develop independence Assertiveness More able to be “OK alone” Develop sense of identity not tied to ONE relationship

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Cluster B: The Erratic Type

Histrionic PD Antisocial PD Narcissistic PD

Cluster B: Histrionic PD

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Histrionic PD

Prevalence Rates • 2%-3% general population • 10% clinical population

Gender Distribution - More commonly diagnosed in women than men Heritability: Estimated .26 Treatability: Moderate Common Schemas: Defectiveness, Emotional Inhibition, Emotional Deprivation, Approval-Seeking ISC Cognitive Profile • “I am noteworthy” • “Others are my audience” • “The world is my stage!” Behavioral Targets: Flirtatious, other attention-seeking behaviors; somatic complaints 67

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Histrionic General Strategies

Be exciting! Compliment them frequently at first Role plays Psychodrama Family sculpting

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Histrionic General Strategies

Develop a more rational approach to problem solving Pros and Cons Psychoeducation Relationship insight work

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Schema Focused Work

Help them develop some sense of value that is not tied to physical appearance Help get needs met in more appropriate ways

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Cluster B: Antisocial PD

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors Prevalence Rates

Antisocial PD

• 3% - 4%% general population • 10% clinical population Gender Distribution - More commonly diagnosed in men than women Heritability: Estimated .69 Treatability: Moderate - Poor, especially if psychopathic Common Schemas: Defectiveness, Emotional Inhibition, Emotional Deprivation, Approval-Seeking ISC Cognitive Profile • “I am deserving of whatever I want” • “Others are obstacles to my gratification” • “The world is dog eat dog - you do what you have to to survive” Behavioral Targets: Rule-breaking, law-breaking behaviors, criminal activity 72

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Antisocial General Strategies

Serve as a “coach” Shoot straight Allow them to see your antisocial side (if you have it) Colombo approach Seek corroboration from outside sources As rapport develops, turn and challenge Attack rationalization

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Antisocial General Strategies Be on guard for manipulation Structure treatment so they can’t manipulate Corroborate with outside sources Set and enforce strict limits - No Wiggle room! Offer alternative ways to “get what they want” Attachment work MRT

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Cluster B: Narcissistic PD

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors Prevalence Rates

Narcissistic PD

• 1% - 6% general population • 7% - 9% clinical population Gender Distribution - More commonly diagnosed in men than women Heritability: Estimated .23 Treatability: Moderate - Moderate - Poor Common Schemas: Defectiveness, Emotional Inhibition, Emotional Deprivation, Approval-Seeking ISC Cognitive Profile • “I am more deserving than others” • “Others are less deserving than me” • “The world is a mountain to be climbed” Behavioral Targets: Physically /verbally /emotionally abusive behaviors, addictive behaviours 76

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Types of Narcissists Compensated/“Fragile” “Spoiled” High Functioning “Malignant”/Low Functioning

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Why do narcissists present for treatment?

1. Forced/others initiated 2. Addictive behavior disorder 3. Depression

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Where do narcissists come from?

1. Loneliness and Isolation 2. Insufficient limits 3. Hx of being manipulated or controlled 4. Conditional approval

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Core Schemas In Narcissism

1. Entitlement 2. Defectiveness 3. Emotional Deprivation

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Other schemas associated with narcissism

1. Unrelenting standards 2. Subjugation 3. Insufficient self-control 4. Approval-seeking

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Schema Modes in Narcissism

1. Lonely child mode 2. Self-aggrandizer mode 3. Detached self-soother mode

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Lonely Child Mode Schemas:

Defectiveness, Emotional Deprivation

Triggers: Loss of status/lack of achievement, etc Assumptions: “Since I am not CEO, I’m Nothing” “Since I have flaw, completely defective” Manifestations: Depression Goals: Identify Needs, find alternate ways of meeting needs, Emotional Connections… substitute “feeds” in interim

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Self-Aggrandizer Mode Schemas:

Entitlement, Unrelenting Standards, Subjugation, Approval-Seeking

Triggers: People, public eye Assumptions: “If I overachieve, I am superior” “If I’m admired, I’m special” “If I control others, I stay in charge” “If I’m special in some way, I’m better than others” “Since I’m special, I deserve privileges” Manifestations: Bullying, Bragging, aggressive behavior, controlling behavior, lack of empathy Goals: Limit setting/Identify Underlying Defectiveness, alternative ways to meet needs/ Making Emotional Connections

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Detached Self-Soother Mode Schemas:

Insufficient Self Control, Emotional Deprivation, Defectiveness

Triggers: Alone Assumptions: “If I _____________, I don’t have to feel” Manifestations: Substance abuse, pornography, workaholism, gambling Goals: Limit Setting, Distress Tolerance, Making Emotional Connections

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

General NPD Strategies

1. Validation 2. Limit setting 3.Utilization of leverage 4. Behavioral pattern breaking 5.Empathic confrontation 6.Development of authentic relationships

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Borderline PD

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Borderline PD Agenda: To keep from being left Primary Descriptive Trait: “Intense” Prevalence rates:

• 3-6% of General Population • 10% Outpatient • 20% Inpatient Gender Distribution: More Common in Women Heritability: Estimated .49 - .65 Prognosis: Good

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Borderline PD Common Schemas: Abandonment, Defectiveness, Approval Seeking, Vulnerable, Insufficient Self-Control Cognitive Profile ”I am worthless (bad) “Others are flawless” “Others will never understand me” “Others are evil” “The world is unfair” Behavioral Targets: Self-injurious behaviors, substance use, promiscuous sex, spending, lashing out, shutting down

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Treatment Setup

1. Individual Treatment

2. Group Treatment

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Motivational Skills

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Motivational Enhancement Therapy: Stages of Change Pre-Contemplation

Preparation

Maintenance

I———I———I———I———I Contemplation

Action

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Expressions of Concern

Standard CBT Skills

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

• Identifying and Challenging Automatic Thoughts • Perspective-taking Interventions • “Responsibility Pies” • Continuum Work - “Shades of Gray”

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Cognitive Interventions: Dealing with Your “Internal Roommate”

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Identifying and Responding to Automatic Thoughts

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

BPD - Specific Thoughts • “Because he is late coming home, he is probably leaving me” • “If I tell him everything about me on the first date I can test him to find out if he’s really interested.” • “Since she pissed me off, I have to quit. I can’t work with someone like her.”

• “Since she betrayed me once, I can never trust her again - she really isn’t even worth talking to again.”

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

BPD - Specific Thoughts

• “If I cut myself, he will not leave me” • “If I cut myself, he will not leave me” • “Since she“It’s ok to cut myself, because cutting is better than other things I could do”

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Paranoid PD

5 4 3 2

Considering Alternative Explan 1 ations

100

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

5 4 3 2 Standard CBT - Reassigning1 Blame

101

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Standard CBT Skills - Cognitive Continuum

102

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DBT Skills

103

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

DBT Skills

• Distraction Techniques • Soothing Strategies • Opposite Action • Interpersonal Effectiveness Skills

104

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

DBT Skills - Opposite Action • Anxiety • Depression • Anger • Shame

105

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Distraction Techniques

106

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

DBT Skills - Soothing Strategies Any coping skill that has a calming eﬀect

Engaging Through the 5 Senses 1. Vision 2. Hearing 3. Smell 4. Touch 5. Taste 107

Interpersonal Effectiveness Skills

108

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Interpersonal Effectiveness Skills

1. Objective Effectiveness 2. Relationship Effectiveness 3. Self-Respect Effectiveness

109

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors D

Interpersonal Effectiveness Skills

N 110

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Interpersonal Effectiveness Skills

I V

E 111

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Interpersonal Effectiveness Skills

A S

T 112

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Evidence-Based Treatment of PDs

Individual Therapy

113

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Individual Therapy • Goals - Process triggers, internalize new thinking, apply skills learned to everyday practice

Format Diary Card/Check-In

114

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Diary Cards

Improve Self-Monitoring Structure Sessions Target Behaviors Awareness of Mood States Schema Focused Skills Monitor Urges

115

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Diary Cards

116

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Individual Therapy • Goals - Process triggers, internalize new thinking, apply skills learned to everyday practice Format Diary Card/Check-In Session Acuity Protocol - Life Interfering Behaviors - Therapy Interfering Behaviors - Quality of Life Interfering Behaviors 117

Life Interfering Behaviors

118

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

CB Chain Analysis

119

Therapy Interfering Behaviors

120

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Therapy Interfering Behaviors • Unexcused Absences • Homework Non-Compliance • “I don’t know” • Disrespectful Behaviour Toward Therapist

121

Quality of Life Interfering Behaviors

122

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Integrated DBT/SFT Case Study

123

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Integrated Case Study • Mary 44 y/o female, Schizoaffective DO, BPD, OCD/BDD • Case Notes: • 6 months post Fundoplication – • Been on disability for 20 years • Lives in section 8 apt complex for mentally ill individuals

124

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Integrated Case Study

Father is successful accountant, in his 70s, not overly gentle or sensitive, but appears to be a decent man and love his daughter, but like many of his generation believes everyone should work for their $ and not take government handouts and has little understanding about mental illness

125

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Integrated Case Study

• Relationship is somewhat strained as she thinks he views her as the “bad daughter” and her sister is the “perfect sister” married to nice man who makes good living, 2 kids, regular church goers, stay at home mom, clean house, etc

126

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Integrated Case Study

Situation: continued weight loss following surgery and down to 110 lbs. Dr. recommended meeting with dietitian - made dietary recommendations including protein powder to get necessary protein without having to digest meat – powder recommended was quite expensive and pt asked her father to help her pay for it – initially he agreed, but when he heard the amount, hesitated. She leaves him a profanityladen voicemail ending in “you don’t care about my health, you don’t care about me!

127

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Integrated Case Study

Key Cognitions • “Since you impose rules/requirements, you don’t care” • “Since you won’t pay for this one, I am not willing to look for any others” • “You should pay for anything i need - since you wont you probably wish Iwas dead (never born)”

Key Schemas • “Others take advantage of you” • “Others are Controlling/Uncaring” • “I am Unlovable” • Dependent Entitlement 128

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Integrated Case Study - Data Log

129

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Schema Flashcard

130

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Schema-Focused Skills

131

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Schema - Based Interventions 1. SCHEMA PSYCHOEDUCATION AND TARGETING 2. BEHAVIOURAL PATTERN-BREAKING 3. SCHEMA CONSTRUCTION - DATA LOGS 4. OTHER SCHEMA STRATEGIES 5. MODE WORK

132

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Schema - Based Interventions 1. SCHEMA PSYCHOEDUCATION AND TARGETING Patient language Downward arrow Themes in thought logs or journaling Heightened affect

Formal Schema/Belief Inventories

133

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Schema - Based Interventions 2. BEHAVIOURAL PATTERN-BREAKING Name Mood Check Identify 1 Maladaptive Behaviour Identify Schema Targeting Identify Coping Category Identify 3 Alternate Behaviours 134

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Behavioral Pattern Breaking

135

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Schema - Based Interventions

3. Schema Modification Process 1) Identify the Maladaptive Belief 2) Identify Alternate Adaptive Belief 3) Rate Baseline Believability 4) Interventions 5) Rate Believability at Regular Intervals

136

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Schema - Based Interventions

3. Schema Reconstruction

137

Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

6/13/17

97%

I Need Others

Schema - Based Interventions - data logs

138

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Internalisation Exercises

Evidence Supporting Adaptive Belief:

Discounting ‘But’:

Add a But

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Treating Personality Disorders: Evidence-Based Strategies for Breaking Life-Long Destructive Behaviors

Internalisation Cue Card

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Let’s C o n n e c t!

Email: Facebook: Dr. Jeff Riggenbach Author Page: clinicaltoolboxset.com Website: jeffriggenbach.com 141

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th ed). American Psychiatric Publishing. Arntz A, Jacob GA, Lee CW, et al. Effectiveness of Predominantly Group Schema Therapy and Combined Individual and Group Schema Therapy for Borderline Personality Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2022;79(4):287–299. doi:10.1001/jamapsychiatry.2022.0010. Arnst, A. et al. (2013). Responding to the Treatment Challenge of Patients with Severe BPD. Results of Three Pilot Studies of Inpatient Schema Therapy. Behavioural and Cognitive Psychotherapy, Volume 42, Issue 3, May 2014, pp 355-367. Beck, A.T. & Freeman, A. (2014). Cognitive Therapy of Personality Disorders (3rd ed.). Guilford. Beck, J. (2005). Cognitive Therapy for Challenging Problems: What to do when the Basics Don’t Work. Guilford. Behary, W.T., (2013). Challenging The Narcissist, How to Find Pathways to Empathy. Psychotherapy Networker. 7-8. Black DW. The Natural History of Antisocial Personality Disorder. The Canadian Journal of Psychiatry. 2015;60(7):309-314. doi:10.1177/070674371506000703 Blash eld R K., Intoccia V. (20000). Growth of the literature on the topic of personality disorders. Am. J. Psychiatry. 157:472-473. Caligor E., Levy K., Yeomans F. (2015). Narcissistic Personalty Disorder: Diagnosis and Clinical Challenges. Am. J. Psychiatry. K. 172 (5), 415-422. https://doi.org/10.1176/ appi.ajp.2014.14060723 Cristea I.A., Genetili C., Cotet C.D., Palomba D., Barbui C. Cuijpers P. Ef cacy of psychotherapies for borderline personality disorder: A systematic review and metaanalysis. JAMA Psychiatry. 2017;74:319-328. Doi:10.1001/ jamapsychiaty.2016.4287. Diedrich, A., Voderholzer, U. Obsessive–Compulsive Personality Disorder: a Current Review. Curr Psychiatry Rep 17, 2. https://doi.org/10.1007/s11920-014-0547-8

Farrell, J et al. (2014). The Schema Therapy Clinician’s Guide: A Complete Resource for Building and Delivering Individual, Group, and Integrated Schema Mode Treatment. Wiley-Blackwell.

Gunderson, J.G. Herpertz S. C., Skidol A.E., Torgenson S., Zanarini M.C. (2018). Borderline Personality Disorder. Nat. Rev. Dis. Primers. 4:18029. doi:10.10.1038.nrdp.2018.29. GUndersonj, a clinical guide Hunzaker, Fallin, M.B. and Valentino, L. (2019). Mapping Cultural Schemas: From Theory to Method. American Sociological Review, 84 (5), https://doi.org/ 10.1177/0003122419875638. Hare, R. (1991). Manual for Psychopathy Checklist-Revised. Multi-Health Systems. Linehan, M.M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. Guilford. Leahy, R. (2017). Cognitive Therapy Techniques: A Practitioners Guide. (2nd ed). Guildford. Lester, G. (2004), Personality Disorders in Social Work and Health Care 4th ed) Mulay, A.L., Cain, N.M. (2020). Antisocial Personality Disorder. In: Zeigler-Hill, V., Shackelford, T.K. (eds) Encyclopedia of Personality and Individual Differences. Springer, Cham. https://doi.org/10.1007/978-3-319-24612-3_569. Paris, J. (2018). Differential Diagnosis in Borderline Personality Disorder. Psychiatric Clinics of North America. 41 (4), 575-582. Riggenbach, J. (2016). The Borderline Personality Disorder Toolbox: Practical, Evidence Based Strategies for Regulating Emotion. PESI Publishing. Riggenbach, J. (2018). The Personality Disorder Toolbox: The Challenge of the Hidden Agenda. Independently Published. Riggenbach, J. (2022). Disarming High Con ict Personalities: Dealing with the Eight Most Dif cult People in Your Life Before You Burnout! Igniting Souls Publishing. Sperry, L. (2016). Handbook of DSM 5 Personality Disorders. Assessment, Case Conceptualization, and Treatment. (3rd ed). Routledtge. Tafrate, R. (2013). Forensic CBT: A Handbook for Clinical Practice. Wiley-Blackwell.

Torgensen S., Lygren S., Open PA.,Skype I., Onstage S., Edvardsen J., Tambs K., Kringlen G. (2000). A Twin Study of Personality Disorders. Comp. Psychiatry.41:416-425.

Triebwasser J., Chemerenski E., Roussas P., Sieger L. (2013). Paranoid Personality Disorder. J. Pers. Disord. 27 (6); 795-805. DOI:101521pedi201226055. Tyrer, P et al. Classi cation, Assessment, Prevalence, and Effect of Personality Disorder. (2015). The Lancet. 385 (9969), 21: 717-726. Wedig M.M., Silverman M..H., Frankenburg F.R., Reich D.B., Fitzmaurice G., Zanarini (2013). M.C. Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow up. Psycho. Med.;42:2395-2404. Weinbrecht, A., Schulze, L., Boettcher, J. et al. Avoidant Personality Disorder: a Current Review. Curr Psychiatry Rep 18, 29 (2016). https://doi.org/10.1007/s11920-016-0665-6 Young, J. (2006). Schema Therapy: A Practitioners Guide (2nd ed). Guilford.

Zanarini M.C., Laudate C.S., Frankenburg F.R., Wedig M.M., Fitzmaurice G. Reaons for self-mutilation reported by borderline patients over 16 years of prospective follow up. J.Per. Discord. 2013;27:783-794.Doi: 10.1521/pedi_2013_27_115.

2024-05-01

Relational Strategies to Treat Challenging Trauma Clients* *© 2024; all rights reserved by the author; no materials (written or oral) may be duplicated or disseminated without the author’s expressed written consent.

Robert T. Muller, Ph.D., C.Psych., Professor, Faculty of Health, York University, Fellow, International Society for Study of Trauma & Dissociation Founding Editor, The Trauma & Mental Health Report

Overview: Themes covered in workshop n How trauma shuts you down n How?

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Overview: Themes covered in workshop n What trauma therapy is: n …a path to help people open up n n

For some, opening up about the trauma For others, open up to life n Experience n Relationships n Their own bodies n Their own histories

Overview: Themes covered in workshop “You have to pass through the trauma, through the biggest pain, to continue normally…(more or less normally)…with life.”

Overview: Themes covered in workshop n What trauma therapy is: n Phase-based (Herman, 1993)

Safety Remembrance & mourning n Reconnection n n

n Paced… n

Pacing is critical

“simply telling” yields humiliation soon

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Overview: Themes covered in workshop n What trauma therapy is: n Growthful… post-traumatic growth n n

A reckoning that confronts elemental questions of life Changes to identity

n Mistake some make re post-traumatic growth: n

convincing survivors to look on “bright side”

looking for “silver lining” “Strength in face of adversity” n Such cultural narratives invalidating to survivors n n

Overview: Themes covered in workshop n What trauma therapy is: n For therapist

Meaningful work Risky work… trauma clients risk n Uncomfortable work… distressing, triggering n n

Overview: Themes covered in workshop n What trauma therapy is not: n not Cookbook approach to tx n

Many unpredictables n in path to recovery n in tx relationship

n not Infantalizing n n

Some clients seek guru Position of not knowing

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Overview: Themes covered in workshop n Why use attachment theory in trauma tx? n Trauma affects attachments

3/4 abuse survivors insecurely attached (Muller, 2001) 2/3 general pop. securely attached (van IJzendoorn)

Trauma bonding

n Children protect (even abusive) caregivers

Overview: Themes covered in workshop n Tx relationship fundamental to trauma

work…Why?

n Trauma affects relationships

n Tx relationship can make or break trauma tx n In trauma, tx rel. central…navigation is key n Case example

Overview: Themes covered in workshop n Tx relationship can make or break trauma tx n Bringing rel. into room made possible:

Safety in tx rel. Rel. repair n Corrective emotional experience n n

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Staying silent about the trauma n Family secrecy suppresses trauma stories n E.g., Craig Taylor’s play

Staying silent about the trauma n Why the silence & secrecy?? n Secrecy protects:

From the truth (dangerous) Relationships n Image to outsiders n Family’s/Institution’s narrative… stories we tell ourselves n Status quo n n

Staying silent about the trauma n Loyalty suppresses trauma stories n Family loyalty, institutional loyalty n In military…. Military sexual trauma (MST) n n

Group loyalty Secrecy about sexual abuse

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Staying silent about the trauma n Survivors suppress own trauma stories n Use self-deception n n

Rationalize… “Back then, all parents hit their kids.” Intellectualize

n Avoid trauma memories n n

“forget about it” Dissociate

n Cut-off affect, neutralize memories n

“yeah but, I wasn’t abused”… (Berger)

Staying silent about the trauma n Survivors suppress own trauma stories n Case of Annette

Staying silent about the trauma n Sometimes therapists collude in the silence n Mutual avoidance n Re-enacts “bystander” dynamic

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Staying silent about the trauma n Some survivors don’t suppress trauma stories n Secure trauma survivors

“Earned” secure Can engage in balanced, honest narrative (about traumatic past) n Secure attachment rare (1/4) in trauma n Case: “Earned Secure” n n

n AAI:

Asked if rejected as child

Opening up about the trauma: A Relational process n How do trauma stories appear in tx? n AAI, brief description n Case of Nicholas… mom as “good”

Well . . . my mother tried to abort me. Oh, the story is actually cute and funny. You see, she and I became very good friends later on. My mom said to me, “I used to jump up and down trying to get rid of you.” Well, I just thought that was really funny. Can’t you just picture that? . . . Her pregnant and jumping up and down?!

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Opening up about the trauma: A Relational process n Trauma stories appear in fragments n Notice trauma fragments

n Trauma stories told with ambivalence n In part, avoidance; in part, want to open up n Survivors only want to stay silent so long n Notice ambivalence to face trauma

Opening up about the trauma: A Relational process n Therapist discomfort with client’s trauma story n Mutual avoidance n Shuts client down n Enactment… this trauma is bigger than both of us

n Case of Nicholas

Opening up about the trauma: A Relational process n I got drawn into an enactment (mutual

avoidance) n Notice your discomfort with client’s trauma

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Opening up about the trauma: A Relational process n Starting to open up stirs dependency,

vulnerability

n When Nicholas “lost it like a baby” n Bring tx relationship into room early on

What was hard about crying just then? What was hard about crying with me? n Socializes client to tx rel. as focus of tx n n

n Ask about client hx of opening up to others? n Ask about client hx of relying on others?

How to Pace the Process of Opening up n Why do client’s rush into trauma stories? n “This secret is a burden” n “Telling will fix everything” n “If I don’t tell now, I never will” n “Therapist seems nice enough” (defenses are

down)

How to Pace the Process of Opening up n Problem: n Too much, too soon…. overwhelming, humiliating n Tx rel. isn’t ready n Case of Anaya

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How to Pace the Process of Opening up n Containment first n Confidence in tx relationship n

Is it a holding environment?

n Confidence therapist can hold my trauma

“Will my trauma overwhelm/frighten her?” “Is my trauma too powerful?” n Case of David Morris n n

How to Pace the Process of Opening up n Containment first n Confidence therapist can hold me

“Will you abandon me?” (if I push you away) “Will you punish me?” (if I push limits) n “Will you give in?” (if I cross boundaries) n n

Is therapist capable in regard to client?

How to Pace the Process of Opening up n When client’s rush into trauma stories: n Containment first n Case of Canadian pilot

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How to Pace the Process of Opening up n Containment:

Slow the process down

n Honor the telling n

Refocus from “trauma details” to telling of story n Is this the first time they’ve shared this? n What does it mean to them… having shared this (secret)? n Having shared, what are they feeling now? n If “relieved,” pay attention to varying feelings thru the week

How to Pace the Process of Opening up n Containment:

Slow the process down

n Honor the telling n

Convey awareness of story’s magnitude

Convey sense of your responsibility

n “I imagine this has had a big impact on you”

n “This is an important story you told me” n “What does it mean to you… having shared this with me ? n Conveys you’re taking story seriously

How to Pace the Process of Opening up n Containment:

Slow the process down

n Flag the topic for therapy

Unpacking the story will be part of our work “Let’s flag this as s.t. we’ll explore together” n Engage the ‘low burner’ n n

n Story is simmering, not at rolling boil just yet

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How to Pace the Process of Opening up n Containment:

Slow the process down

n Revisit the topic soon

Don’t let weeks pass (elephant in room) Bring it into the room (that session or next) n Conveys “your trauma isn’t too much for us” n n

n Back to Canadian pilot

How to Pace the Process of Opening up n When the therapist rushes into trauma stories n Back to case of David Morris

How to Pace the Process of Opening up n Rescue fantasy:

Beware the quick fix

n Managed care pulls for quick fix n Fast food culture pulls for quick fix n

“Faster is better”

n Clients pull for quick fix n

Want to feel better

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How to Pace the Process of Opening up n Rescue fantasy:

Beware the quick fix

n Therapists pull for quick fix

Hard to see people suffer Sense that stakes are high n Client: “Your my last resort” n Therapist may take charge n n

n Tells the client what to do n Disempowers client

How to Pace the Process of Opening up n Remember: n Containment before opening up n Trauma work takes time n Pace the process

Safety strategies in trauma-tx relationship n Grounding strategies great start…. but: n Help dysregulation, not safety in tx relationship n No safety in tx relationship? …..no tx!

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Safety strategies in trauma-tx relationship n Validating traumatic experiences, conveys: n “I get it, your trauma was real” n Empathic & grounding stance n Builds trust

Safety strategies in trauma-tx relationship Validating traumatic experiences n Problem:

Many don’t accept validation so readily

n “I’m no victim” identity n n

Most survivors shun “abuse” label (Berger, 1988) Case of Tony Rodgers, raped as young boy

Safety strategies in trauma-tx relationship Validating traumatic experiences n Problem:

Many don’t accept validation so readily

n Many invalidate own traumatic histories

“I was weak” “I deserved what I got” n “I should figure this out myself” n n

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Safety strategies in trauma-tx relationship Validating traumatic experiences n What to do? n View validation as a therapeutic process

Validate, yes… but don’t shove validation on clients Be attuned, go at client’s pace n Some need time to come to accept validation n n

Be transparent with trauma terminology n “Rape” “died” “sexual abuse”

Safety strategies in trauma-tx relationship Validating traumatic experiences n What else to do? n Pay attention to client’s reaction to trauma language

Float trial balloons Do they bristle? Feel relief? n Notice aloud, “Is that hard to say, ‘sexual abuse’?” n “As we discuss xyz, what are you feeling right now? n n

In time, “trauma” becomes part of survivor’s identity

Safety strategies in trauma-tx relationship n Honesty in tx relationship n Isn’t that obvious?... n Easier said than done n We get drawn into dishonest enactments n

Secret-keeping Manipulations

Dishonesty permeates trauma… & we get pulled in

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Safety strategies in trauma-tx relationship n Prioritizing basic safety needs n Hard to do trauma tx in middle of trauma n

Trauma may be ongoing

n Basic safety first n Easier said than done n n

Basic safety can take a while Can’t get someone to leave abusive partner

Safety strategies in trauma-tx relationship n Self-regulation brings safety n Working with Triggers n Case of Edmund Metatawabin

Safety strategies in trauma-tx relationship Self-regulation brings safety n Triggers n Fast connection to trauma n Highly idiosyncratic n Useful trauma language

Explains, not blames Not client “acting ridiculous” n Not client “over-reacting” n n

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Safety strategies in trauma-tx relationship Self-regulation brings safety n How to Use triggers… Help client: n …to Notice their triggers n

Journaling helps

Safety strategies in trauma-tx relationship Self-regulation brings safety n How to Use triggers… Help client: n …to Get to know their triggers

“What was going on for me just then?” “Why would I be feeling this way now?” n “What [in the other] was I reacting to?” n n

n Neediness, sadness…. bossiness, anger

“What [in the relationship] was I reacting to?

Mentalize internal experience

n Closeness, validation…. abandonment, rejection

Safety strategies in trauma-tx relationship Self-regulation brings safety n How to Use triggers: n What in the tx relationship were they reacting to? n

“I hate it when you’re so nice!”

n DANGER UP AHEAD….(manipulation, exploitation) n Empathy can be triggering

Ask yourself: “What about tx relationship triggered her?” n Ask client same question n

n Bring tx relationship into the room

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Safety strategies in trauma-tx relationship Self-regulation brings safety n Grounding techniques n Anchor to the present, reality n Activate sensory experience n Turn client’s attention to the present n

Any of the senses can be used

Navigating the Relationship in Trauma Tx n What activates your attachment system?

Private written exercise (10 minutes) n Think of a specific time you were behaviourally

out-of-control or shut down (relative to you) in a relationship context? What behaviour of the other were you responding to? What were you thinking/feeling? n What brought resolution? n n

Navigating the Relationship in Trauma Tx n Countertransference in trauma tx n Trauma raises many feelings in us n

Based on our own attachment hx

n Feeling vs. acting-on n Notice Countertransference

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Navigating the Relationship in Trauma Tx n Countertransference patterns n Re-enact trauma dynamics in tx relationship n Victim/perpetrator/rescuer-bystander dynamic n Common patterns we fall into n Something has triggered us

Navigating the Relationship in Trauma Tx Countertransference patterns n Trying to “rescue”…rescue fantasy n Therapist as “rescuer,” client as “victim” n Therapist over-identifies with client as “victim”

Navigating the Relationship in Trauma Tx Countertransference patterns n Rescue fantasy n Trying to “fix” the client n

Therapist works harder than client n Notice your affect, body, non-verbal behavior

“Telling” client what to do n “Telling” client to stop seeing abuser… Problem: n

n Disempowers client n Client leaves tx

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Navigating the Relationship in Trauma Tx Countertransference patterns n Rescue fantasy n “Indulging” the client (b/c you feel sorry for them)

“special rules” for this client Loosening time limits (when you normally don’t) n No charge for cancelation (when you normally don’t) n Emailing at all hours n Problem: weak limits feel unsafe n n

Navigating the Relationship in Trauma Tx Countertransference patterns n Rescue fantasy n Lax boundaries with client n n

Becoming client’s “friend” Lots of self-revelation n “Is my therapist capable?” n “Is my therapist more ‘messed up’ than me?”

Problem: Lax boundaries feel unsafe

Navigating the Relationship in Trauma Tx Countertransference patterns n Rescue fantasy n Feeling contempt for perpetrator

Therapist “hates” perpetrator/non-protective parent Over-identifying client as “victim” n Problem: Client may have mixed feelings toward parent n n

n Case:

“To a Safer Place”

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Navigating the Relationship in Trauma Tx Countertransference patterns n When we feel “bullied” /hurt n Therapist as “victim,” client in “perpetrator” role n Therapist feelings: n n

“afraid” of client’s aggression anxious

n What’s going on?..... Client self-protectiveness

Navigating the Relationship in Trauma Tx Countertransference patterns n When we feel “bullied” /hurt n “I’ll hurt/reject you before you can hurt/reject me”

Client feeling dependent?..... decides to drop out b/c of client fear of vulnerability n Self-protective n n

n “I’ll get angry at you before you can hurt me” n n

“I’ve had to fight for everything!” Self-protective

Navigating the Relationship in Trauma Tx Countertransference patterns n When we “bully” the client n Therapist in “perpetrator” role, client as “victim” n Happens with perfectly good clinicians n Something has been triggered in us

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Navigating the Relationship in Trauma Tx

Countertransference patterns n When we “bully” the client

n Therapist “gets tough” on client…. when feeling: n

Frustrated, anxious

Disappointed

Incompetent, “out-of-control”

n E.g., multiple suicide threats

n E.g., lack of compliance, progress

n E.g., following boundary violations

Problem: client ends up feeling hurt, like a failure n Notice your anxiety, aggression, disappointment … n

Navigating the Relationship in Trauma Tx

Countertransference patterns n When we “bully” the client

n Feeling “hate” (contempt for) client n Frustration, loss of perspective, loss of empathy n “Hate in the countertransference” Winnicott (1947) n Case

Navigating the Relationship in Trauma Tx Countertransference patterns n When we “give up” on client n Therapist in “bystander” role, client as “victim” n We become resigned, complacent n Compassion fatigue

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Navigating the Relationship in Trauma Tx Countertransference patterns n When we “give up” on client n Failing to challenge client

Don’t call out client on self-destructive behavior Lose faith in client’s ability to change n Case n n

Navigating the Relationship in Trauma Tx Countertransference patterns n When we “give up” on client n Feeling “sorry for” client

Over-validate, sympathize Therapist rationalizes: “I’m being supportive” n PROBLEM: Collusion doesn’t help n n

n No growth n Re-enacts non-protective bystander

Relationship Goes off the Rails: Enactment, Rupture, Repair n Traumatic re-enactments common in trauma tx n We act-on feelings n E.g., any of the previous examples: n n n

Rescue fantasy “Getting tough” on client Feeling “bullied” by client, etc…

n Intersection of client’s & therapist’s attachment hx n Navigating them is key

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Relationship Goes off the Rails: Enactment, Rupture, Repair n Traumatic re-enactments common in trauma tx n Case of Nigel....

1. Early in tx 2. Good tx connection (months) n

Tx relationship starts to shift (p. 148)

Relationship Goes off the Rails: Enactment, Rupture, Repair n Problem:

Enactments can lead to tx ruptures

n Why? n Enactments feel unsafe n n

Boundary violations (even small) feel dangerous Containment compromised

n Tx now crossed into using e. o. for unmet needs n

E.g., Therapist as “guru,” with trauma client

n Tx neutrality has been compromised

n Case of Nigel (p. 148)

Relationship Goes off the Rails: Enactment, Rupture, Repair n So…. n Enactments….

Inevitable in trauma tx Sneak up on you n Can lead to tx ruptures n The trick is using them in the tx n n

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Relationship Goes off the Rails: Enactment, Rupture, Repair Repairing a ruptured alliance n Why do we repair a ruptured alliance? n If not, no safety n Big opportunity for growth.

Teaches:

Relationships can be repaired n Relationships are work n Relationships aren’t doomed n

Relationship Goes off the Rails: Enactment, Rupture, Repair Repairing a ruptured alliance n How to repair a ruptured alliance n Notice the enactment n n

Adopt self-reflective stance… look inside Mentalize your experience with client n “What got activated in me? ”

“Why then?”

n “What’s going on for me that I’m doing/feeling things I normally

don’t?”

n “How did my needs activate client?”

Requires curious, nonjudgmental stance

Relationship Goes off the Rails: Enactment, Rupture, Repair Repairing a ruptured alliance n How to repair a ruptured alliance n Validate client’s experience

Validation = relational first response Listen, empathize, don’t judge n Be genuine, can’t fake it n n

n This is why you need to look inside

Ask yourself: n “How did I hurt my client?” n “How did I activate my client?”

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Relationship Goes off the Rails: Enactment, Rupture, Repair Repairing a ruptured alliance n How to repair a ruptured alliance n Validate client’s experience

Stay in here-and-now If no validation, client feels uncontained n Validation ≠ collusion n n

n Goal isn’t to agree with client n Understand client’s subjective experience

Relationship Goes off the Rails: Enactment, Rupture, Repair Repairing a ruptured alliance n How to repair a ruptured alliance n Validate client’s experience n

With Nigel….

Relationship Goes off the Rails: Enactment, Rupture, Repair Repairing a ruptured alliance n How to repair a ruptured alliance n Provide containment re the conflict n n

Why?... present moment still feels unsafe Name the conflict, frame it as “conflict” n “Conflict like this can be difficult” n “It’s hard to be in conflict”

Frame it as relational process… part of relationships n “ So how do we want to address this conflict?” n “This conflict is hard, but we can figure it out together ”

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Relationship Goes off the Rails: Enactment, Rupture, Repair

Repairing a ruptured alliance

n How to repair a ruptured alliance n Provide containment re the conflict n

Why name it as “conflict”? n Explains what’s not going on between us n This isn’t end of relationship n This isn’t betrayal, manipulation n This isn’t unbearable n It’s honest n We are having a conflict n Conflict is messy, difficult n Sitting with conflict helps client grow from conflict

Relationship Goes off the Rails: Enactment, Rupture, Repair

Repairing a ruptured alliance

n How to repair a ruptured alliance n Help client mentalize:

Unpacking conflict

Only after we look inside, validate, contain n Mentalizing: n

n Invite client to explore motivations n What triggered them? n Adopt curious stance n “I’m wondering what was going on for me/you?” n Bring in emotion n “What are you feeling right now , as we discuss this?”

Relationship Goes off the Rails: Enactment, Rupture, Repair

Repairing a ruptured alliance

n How to repair a ruptured alliance n Help client mentalize: n

Unpacking conflict

Mentalizing with Nigel n “What about what I said triggered you most?” n “After reading my email, what’d you worry I was saying to you?” n “How did it feel, to finally tell me off?”

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Relationship Goes off the Rails: Enactment, Rupture, Repair

Repairing a ruptured alliance

n How to repair a ruptured alliance n So…Unpacking conflict in trauma tx…

…is a process …takes place in the here-and-now n …always stirring n …can bring posttraumatic growth n n

Nigel cont’d

Our Online (and Free) Mental Health Magazine: The Trauma & Mental Health Report http://trauma.blog.yorku.ca/ --Google: Trauma and mental health report

2024-05-01

Book Titles: Muller, Robert T. (2018).

Trauma & the Struggle to Open Up: From Avoidance to Recovery & Growth. New York: W.W. Norton. Muller, Robert T. (2010).

Trauma & the Avoidant Client: Attachment-Based Strategies for Healing. New York: W.W. Norton. Place orders online through:

Amazon.com Amazon.ca (hardcover or kindle)

Contact: Robert T. Muller, Ph.D., C.Psych. Tel. (416) 939-6491 Email: rmuller@yorku.ca Website: www.yorku.ca/rmuller Online Magazine: The Trauma & Mental Health Report York University (Psychology)

5/1/24

An Integrated Approach to Treating Complex Trauma: Part II Sheri Van Dijk, MSW, RSW EMDR Certified & Consultant

Disclosure

Objectives By the end of this workshop, participants will understand: § Dissociation and its implications for therapy § The basics of the Theory of Structural Dissociation of the Personality § The basics of how to use a Parts approach in therapy § Skills to help ground and re-regulate clients, as well as resources to help prepare clients for trauma processing therapy

5/1/24

Dissociation: What is it? “Dissociation is the essence of trauma” (Van der Kolk, 2014) § We still lack consensus on a definition! ISSTD Definition: Involves the total or partial loss of awareness or knowledge, inner body sensation, five-sense perception, emotions, thoughts, perceptions, memories, impulses, and/or sense of self Examples: § a client reports loss of feeling in her hands after she mentioned to me in session that her hands had been badly injured when she was a child; § during assessment a client mentions they have “no memory” of their life before age 10; § a client starts describing how she worries she’s going to find her son dead from suicide, but expresses no emotion; § a client informed me that her brother, who had sexually abused her when they were growing up, was supposed to come for a visit at Christmas-time, but when I asked about this two weeks later, she had no memory of the visit.

Dissociation: What is it? § Not all dissociation is problematic, or a sign that trauma has occurred! - e.g. daydreaming, highway hypnosis, absorption in a book or movie § Dissociation becomes problematic when it occurs frequently, is activated in inappropriate circumstances, interferes with daily life functioning, or involves the symptom of identify alteration (and we need to consider the client’s perspective of this experience – culture, spiritual/religious beliefs, etc.).

Dissociation: What is it? ´ Peritraumatic dissociation (PD) is dissociation that takes place at or around the time of a distressing event; it helps us to survive (“the escape when there is no escape” – Putnam, 1997) ´ It’s an instinctive, autom atic distancing from unbearable pain; or a way of m aintaining attachm ents ´ It allows overwhelm ing experiences to be split off from and held outside of conscious awareness

´ A history of attachment trauma and/or neglect appears to increase the likelihood of PD in the face of traumatic experience; and PD predicts pathological response to trauma (Lanius et al, 2014) ´ Dissociation is greater with “betrayal trauma”, when a caregiver is an abuser, fails to protect a child from an abuser and/or has an alliance with the abuser (Courtois & Ford, 2009)

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Key Dissociative Symptoms Dissociative symptoms commonly occur in many disorders other than dissociative disorders, including PTSD/CPTSD, eating disorders, panic disorder, major depressive disorder, and borderline personality disorder 1. Depersonalization – the sense of being disconnected from, or “not in” your body, feeling as though you’re an outside observer of your own mental processes, body, or actions 2. Derealization – persistent or recurrent experiences of the world seeming unreal or dreamlike, foggy, or distant (DP/DR are more general symptoms of posttraumatic symptoms, but can also be present in more severe forms – such as dissociative disorders)

Key Dissociative Symptoms 3. Identity Confusion – feeling as though you don’t have a good sense of who you are, what your values are, what you like and dislike, and so on. 4. Identity Alteration – At its extreme, this is where a person has DID, and shifts to a different part (or self-state) that may not know where they are, how old they are, and so on. But this can also happen in less extreme ways: like feeling as though there’s a different part of you acting at times, and that part doesn’t feel like the real you. (these are the result of more fully-formed self-states resulting from traumatic experiences) 5. Amnesia – an inability to recall autobiographical information of various kinds (amnesia is highly disruptive to an individual’s sense of continuity, and ability to be present, aware, and in control; amnesia is therefore recognized as the fullest expression of pathological dissociation, and a defining characteristic of DID).

Dissociative Symptoms Paul Dell notes that, “the phenomena of pathological dissociation are recurrent, jarring, involuntary intrusions into executive (cognitive) functioning and sense of self” (2009); and developed a taxonomy of dissociative symptoms organized into three sets of criteria: 1. General posttraumatic dissociative symptoms – occur not only in dissociative disorders, but in other disorders as well, such as PTSD, panic disorder, conversion disorder, major depression, BPD: 1. General memory problems – may include day to day experiences like forgetfulness; as well as difficulties with remote memory 2. Depersonalization 3. Derealization

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Dissociative Symptoms 4. Somatoform (conversion) symptoms - bodily experiences and symptoms that have no medical basis; these may affect vision, hearing, sight, smell taste, body sensations and functions, or physical abilities, and are often a partial re-experiencing of the traumatic event 5. Trance - an altered state of consciousness that occurs spontaneously. The person loses conscious contact with what is going on around them and may not respond to attempts to gain their attention (e.g. staring into space, thinking of “nothing”, or “going away” in their own mind) 6. Flashbacks - sudden, intrusive memories, pictures, tastes or body sensations, emotions, or nightmares of traumatic events; during a flashback the individual may lose contact with the present moment

Flashbacks § DSM-5 and ICD-11 both recognize flashbacks as existing on a continuum: § at one end is total absorption in the traumatic memory, with a complete loss of awareness of the current environment; § at the other end of the continuum is a vivid, intrusive memory of the traumatic event in which the person doesn’t lose contact with their current surroundings but has a sense that the event is happening again in the here and now.

§ This helps differentiate PTSD from other conditions (e.g. major depression) in which there may be intrusive memories of distressing events, but these are experienced as belonging to the past.

Dissociative Symptoms 2. Partially-Dissociated intrusions of another self-state into executive functioning and sense of self: symptoms are registered as generated from outside of conscious intention (though not external to the person), and experienced as intrusive or disruptive (for example, hearing child voices, puzzlement about oneself, internal conflicts) 3. Full-Dissociated Actions of another self-state: the individual experiences amnesia for periods of minutes to days (or more), precipitated by distress for one or more self-states (may include time loss, where the individual discovers they can’t account for a period of time; a sense of “coming to”; fugue (suddenly discovering they’re somewhere, without memory of going); finding evidence of recent actions, etc.).

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You Might Not See It! ´ Dissociation can be difficult to observe ´ Clients might not be aware of the problems – the nature of dissociation is that it is protective! ´ Western medicine has “dissociated dissociation!” – clinicians often haven’t been trained in dissociation, what to look for, and how to screen ´ Other, “more important” treatment targets (e.g. suicidality, self-harming, eating disorders, substance abuse) might distract us from seeing dissociation or inquiring further

The Dissociative Disorders There are five dissociative disorders in the DSM-V-TR: 1. Dissociative Identity Disorder (DID) 2. Depersonalization/Derealization Disorder (DPDR) 3. Dissociative Amnesia (difficulty recalling important information about yourself and your life) 4. Unspecified Dissociative Disorder (used when the symptoms fit the general category of a dissociative disorder but are not specific enough or there’s not enough information yet to be classified as a dissociative disorder) 5. Other Specified Dissociative Disorder (OSDD) – where a person experiences dissociative symptoms but does not meet the full criteria for any other dissociative disorder; may be diagnosed when there is an identifiable cause that is not typical of other dissociative disorders. ´ There are four common presentations of OSDD: •

mixed dissociative symptoms: disturbances of identity without amnesia

•

identity disturbances due to chronic and extreme persuasion: disturbances of identity due to brainwashing, being involved with a cult, or being subjected to torture

•

dissociative reactions to stress: dissociation as a result of stressful events that last a few hours to less than one month

•

dissociative trance: an uncontrollable loss of awareness of their surroundings

The Ego State Continuum: From Differentiation to Dissociation (based on Watkins & Watkins, 1997)

Healthy, Well-adjusted Parts (Limited Internal Conflict)

Traumatized Ego States (Greater Internal Conflict)

Dissociative Parts (Severe Internal Conflict)

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Ego-State Therapy/Parts Work Ego states can develop in three ways (Watkins & Watkins, 1997): 1. Through normative, healthy differentiation (for example, as I learned and trained to be a psychotherapist, I developed my Therapist part). 2. By unconsciously internalizing certain qualities of others, such as beliefs, values, and behaviors (“Introjects”). This commonly happens with children and parents – for example, if your parents always ensured you said please and thank you as a child, as an adult you may judge people who don’t say please and thank you as impolite. Your parents’ value has been internalized as your own.

Ego-State Therapy/Parts Work Ego states can develop in three ways (Watkins & Watkins, 1997): 3. As a reaction to trauma: experiencing a traumatic event can lead to the formation of parts associated with those events: Peritraumatic Dissociation is associated with the release of endogenous opioids and endocannabinoids that alter communication between lower and higher brain structures (Lanius et al, 2014), creating isolated ego states - e.g.: a child who is verbally and emotionally abused by a male caregiver develops a part that’s triggered when they interact with male authority figures. When a trauma part is activated, you may re-experience emotions, thoughts, and physical sensations associated with the original trauma.

Theory of Structural Dissociation of the Personality When an infant/child (who, has not yet developed an integrated personality) is traumatized and receives insufficient soothing, calming, and modeling of emotion regulation, the child may not develop a healthy, integrated personality system of ego-states; instead, the personality divides on “fault-lines” – it becomes structurally dissociated.

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Theory of Structural Dissociation of the Personality

Video

W e experience the world differently from each side of the brain (Fisher, 2022)

Left Brain

Verbal language, narrative m em ory Analytical, rational, conceptual

Nonverbal language

Planning, Problem -solving

Instinctive survival/coping responses

Coping ability: carrying on with daily life, no m atter what

Em otional and sensory m em ory – and traum atic m em ory

The logical, analytical, verbal brain begins to dom inate beginning in adolescence and adulthood

Right Brain

Perception of em otion, sensation, facial expression

The survival brain is dom inant from birth until children are approxim ately age 8 or 9

The two sides begin to com m unicate after age 12 via corpus collosum

Theory of Structural Dissociation of the Personality (SDP) (van der Hart O., Nijenhuis E., and Steele, K., 2006).

´ No single model of dissociation has yet to be established as “fact”. ´ According to SDP, self-states (Parts) develop as a means of adapting to extreme or chronic stress, such as childhood abuse or neglect; these dissociative structures are based on action systems ´ The “Apparently Normal Part“ (ANP) of the personality is focused on going on with normal life (PFC) ´ “Emotional Parts“ (EP’s) are triggered by implicit or explicit reminders of traumatic events and are often characterized by intense painful emotions (Limbic System); ´ It’s important to understand that the job of the EP is to protect, even if that’s not readily apparent (e.g. a 30 year-old client has suicidal thoughts related to a 12 year-old part that started as a means of feeling in control when he lived at home with his controlling father) ´ The ANP and EP’s can interact in complex and conflicting ways, leading to difficulties with self-identity, emotion regulation, and relationships.

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SDP: Examples of Parts Fight: Cory recalls first thinking of suicide when he was 12 years old. He had a very controlling father who didn’t understand his depression, and who pushed Cory to do better in school, play more sports, take on more responsibilities, and so on, until Cory finally found escape through fantasizing about taking his life. Now Cory is 30 years old and finds himself thinking about suicide when he feels like he has no control, even though he knows he’s an adult and has choices he didn’t have as a child. Flight: Karmen recently left her marriage to an abusive and controlling partner. She had been using drugs for a long time to manage her emotions; but having finally gotten clean from these, she now finds herself alternating between restricting food and bingeing. She doesn’t want to do these things but feels like she has no control over herself. Freeze: Jhavid reports constant feelings of anxiety, and daily panic attacks. Bullied in school for being the only person of color, and growing up with three older brothers who teased him relentlessly for being more sensitive, Jhavid still feels like nowhere is safe.

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SDP: Examples of Parts Submit: Marval recalled her mother always yelling at her when she was a child, and even at age 55, she constantly feels like she’s doing something wrong. She goes out of her way to try to please others and make them like her, even when that means regularly putting aside her own needs and wants. She also has a habit of over-apologizing, constantly feeling ashamed and not good enough. Attach: Sam was seeing their new therapist, Shayne, once a week and felt very connected to him, but Sam found they had a strong need to reach out to Shayne between sessions. Sam was reaching out multiple times a day by email or text, and when Shayne told Sam he would only respond to them once a day moving forward, Sam felt very hurt and alone.

Structural Dissociation: What to Look For In Adults (From Healing the Fragm ented Selves of Traum a Survivors, Fisher, 2017)

1. Signs of internal conflict: e.g. functioning well at work but struggling in personal relationships; acting out a disorganized attachment—a desperate attach part fearing abandonment followed by a fight part pushing away those who try to get close; a client who reconnected with me to return to therapy but keeps missing or being late for appointments. 2. Treatment History: Often multiple previous treatments with little progress; past treatment may be described as “rocky” or ending badly 3. Somatic symptoms: e.g. high tolerance for pain, or an unusual pain sensitivity, headaches, eye blinking or drooping, narcoleptic symptoms, other physical symptoms with no diagnosable medical cause 4. Atypical or non-responsiveness to psychopharmacological medications

Structural Dissociation: What to Look For In Adults (From Healing the Fragm ented Selves of Traum a Survivors, Fisher, 2017)

5. Regressive behavior or thinking: e.g. body language or voice of a young child, shorter sentences, themes relating to separation, caring, and fairness; client is more likely to feel empathically failed when not well understood. 6. Patterns of indecision or “self-sabotage”: Ambivalence = conflict between parts with different objectives. 7. Memory gaps and time loss: Difficulty remembering therapy sessions, how time was spent in a day, conversations, getting lost while driving someplace familiar. 8. Patterns of self-destructive and addictive behavior: Fight and flight parts seeking to avoid pain from traumatic past. **It’s the Going On With Normal Life part that’s seeking therapy

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Red Flags for Dissociation (ISSTD, 2024) Your client may experience problematic dissociation if they: ´ Report a childhood history of abuse or neglect ´ Provide vague, inconsistent, chronological history

contradictory,

poor

´ Have multiple (three or more) prior diagnoses ´ Have concurrent psychiatric and physical symptoms ´ Notice times where they experience loss of well-rehearsed skills and knowledge

Red Flags for Dissociation (ISSTD, 2024) Your client may experience problematic dissociation if they have had times when: - They acted as if they were a child, or like a completely different person - They found objects in their possession that they don’t recall acquiring and that don’t make sense for them - They referred to themselves by a different name - They noticed distinct changes in their hand-writing - They experience rapid mood changes without apparent reason - They heard voices or “loud thoughts” (usually inside the head)

Hearing Voices § Although now recognized as a feature of PTSD (in the DSM-5 and ICD-11), the symptom of hearing thoughts as voices is rarely acknowledged; but hearing voices isn’t uncommon in PTSD and especially CPTSD (Anketell et al, 2010). In this study, hearing voices was correlated with increased dissociative symptoms. § A study by Shinn et al, 2020 concluded that hearing voices is not equivalent to having a psychotic disorder; and that instruments that assess hearing voices “apart from psychotic disorders and that capture their multidimensional nature may improve identification of voice-hearing, especially among patients with non-psychotic disorders”.

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Red Flags for Dissociation (ISSTD, 2024) Your client may experience problematic dissociation if in session you observe your client: -

“Switching” – distinct changes in voice, speech, behavior, movement, or appearance

Referring to self as “we”, or in third person (“he/she/they”)

Experiencing amnesia, DP/DR

Answering basic questions with puzzled, ambivalent, or conflicting responses

Reacting strongly to questions about dissociation

Blinking repeatedly, keeping eyes closed for no apparent reason, or exhibiting “eye rolling”

Going into trance

Struggling to track from one session to the next

Red Flags for Dissociation (ISSTD, 2024) Your client may experience problematic dissociation if in session you observe in YOURSELF: -

Feeling confused – as dissociation disrupts linear thinking and/or emotional congruity, your client may shift from one topic to another, or from one emotional state to another, and you find yourself struggling to follow what’s happening for them

Feeling sleepy – your mirror neurons may be picking up on your client’s being partially absent

Feeling like you’re in a dream – sitting with a client who’s dissociating may result in you feeling as though you’ve also drifted into an altered state of consciousness

Feeling ungrounded – you may have difficulty tracking shifts in your client, feeling unsure of what’s going on or how to intervene in an attuned way

Having a sense of not knowing the client

Red Flags for Dissociation (ISSTD, 2024) Your client may experience problematic dissociation if in session you observe in YOURSELF: -

Sensing no “emotional presence” from your client

Wondering “who came to therapy last week?” – if your client presents quite differently, with different clothing/hair style, mannerisms, vocabulary, attitude, manner of relating to you, goals for therapy, etc.

Questioning your memory – the client may have gaps in their memory for previous sessions, and may deny or be unaware of this, suggesting or leaving you questioning if you’re mis-remembering

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Ego-State Therapy/Parts Work The Adult Wise Self -

Neither the going on with normal life part nor the trauma parts are fully integrated, so we want to help our client learn to access their Adult Wise Self/Wise Mind (in IFS this is known as Self or Self Energy)

I draw on DBT’s States of Mind for this: - Emotion Mind & Reasoning Mind = Trauma Parts and going on with normal life parts - Wise Mind: Emotions + Logic + Intuition (which includes values)

Dialectical Behavior Therapy’s “States of Mind”

Core Mindfulness Skills: States of Mind Reasoning Mind (might be EP or ANP): ´Logical, practical, forward thinking

intellectual,

rational,

straight-

´No emotions involved (or very minimal) ´E.g. making a grocery list; following instructions to bake a cake; balancing your chequebook (as long as there’s no anxiety involved!)

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Core Mindfulness Skills: States of Mind Emotion Mind (EP): Ýou know you’re in emotion mind when your emotions are controlling your behaviors É.g. you’re feeling anxious so you avoid; your mood is depressed so you withdraw and isolate yourself; you feel angry and you lash out at the people around you Émotion mind also includes pleasant emotions

Core Mindfulness Skills: States of Mind Wise Mind: ´It’s not that RM and EM are bad, and we want to get rid of them; rather, we want to be able to find a balance more often: this is Wise Mind ´Wise Mind = RM + EM + Intuition ´You’re in WM when you’re thinking about the consequences of your behavior and choosing how you want to act rather than reacting. **WM is fully integrated, having access to all information in the system

Core Mindfulness Skills: States of Mind Differences between EM and WM: § Both involve an element of emotion, so clients often confuse the two § In EM, the feelings are more intense, and are controlling behavior; there’s usually an uncertainty and going back and forth between two choices § In WM, there’s a feeling of peace or calmness (“rightness”) about a decision § EM can often “trick” us into thinking it’s WM – we have to go within; this usually takes practice

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Core Mindfulness Skills: States of Mind Exercises to help clients get to Wise Mind: - “What does your Wise Mind tell you?” - Turning inward exercises – e.g. Stone flake on a lake; going down a spiral staircase within yourself - Breathing exercise: breathing in “Wise”, out “Mind”

Core Mindfulness Skills: States of Mind Often just identifying what state of mind is there can help someone take a step back if they’re in EM or RM Help increase awareness of these states by having clients notice regularly (“short cut”) Mindfulness and many of the DBT skills will help people access WM

Ego-State Therapy/Parts Work Ways of conceptualizing Self-States/Ego States/Parts: (yes, they are PART of YOU!) § Parts are “disconnected containers of implicit memory, driven by instinctive subcortical animal defense responses…a part is the child you once were at a certain age, or the child you had to be in certain situations…it’s the little You” (Fisher, 2017) § Parts are memory networks - bundles of neuronal connections that hold consistent patterns of information that belong to specific ages or situations from childhood § They’re autonomic states (e.g. “my freeze part”, or “my fight part”) § Parts are neural networks that know what to expect about the world, and therefore how to respond

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Ego-State Therapy/Parts Work Working with Parts: § It’s important for parts to know that we’re not trying to get rid of them!!! § Instead, focus is on helping the client get to know their internal system and helping the system work together more effectively (Stage One of Herman’s Model) § Brain scan research on clients with DID has demonstrated an association between the ANP and the PFC; while none of the trauma-related parts’ brain scans show cortical activity (Fisher, 2017) § Therapies: Ego-State Therapy, Stabilization Treatment

Internal

Family

Systems,

Trauma-Informed

Strategies: The Meeting Place ´ The client chooses a place they’ll be meeting with their parts; this can be based in reality, or fictional, and can be an indoor or outdoor space; have the client close their eyes if possible and imagine this place in as much detail as possible (client describes their meeting place; elicit as much details using as many senses as possible) ´ Have the client create a door in their meeting place ´ Instruct the client: “When you’re ready, unlock the door, open it up, and invite in any parts that would like to join us”. ´ Attending the Meeting Place is voluntary for parts; parts may come in but not want to participate in any way, which is fine. ´ Let the client know that parts may appear as other versions of themselves; but they may also appear as unfamiliar: they may be a gender different from the gender the client identifies with; they might be animals or inanimate objects; they may be insubstantial and so are more “felt” than “seen” ´ When the client indicates that parts have come in: “Before we start, I want to let all parts know that this is a safe place, where no one is allowed to hurt anyone else. The meeting place is a place where we’re working on getting to know one another, and increasing communication between everyone. Is everyone in agreement?” ´ You can then open up dialogue (e.g. do any of the parts have anything they’d like to share, or questions they’d like to ask?) ´ Other ways of encouraging communication with parts: collage, drawing, non-dominant hand drawing, Sand Tray

Blending With Parts § When a part takes over and is controlling thoughts, emotions, physical sensations, and body functions, the client has become blended with the part (Schwartz, 1995); they can’t tell the difference between their experience and that of the part. § Blending with a part isn’t inherently “bad” – it can be helpful when a part takes over to navigate a specific situation where that parts’ skills are required. § e.g. a parent who’s a doctor – isn’t it better for the Doctor part to take over when their child is injured, to deal with the immediate crisis, rather than having the worried Parent part in charge? § In a healthy system the part will unblend, stepping aside for the wise self to take the wheel again once that need is resolved; when this doesn’t happen in a natural and fluid way – as is often the case for individuals with CPTSD – it becomes problematic.

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How to Unblend Step One: Assume that any painful or overwhelming thoughts and emotions are communications from parts (Fisher, 2017). Step Two: Rather than referring to parts’ experiences as yours, refer to them as belonging to the part (There’s a part of me that feels angry). Notice what happens when you describe the parts’ experience – often people note a calmness, reduction in tension, or sense of relief as the part feels validated. Step Three: See if you can create some space between yourself and the part, so you still feel the parts’ feelings, but less intensely, and you’re able to feel yourself at the same time. A change in your body position (like a forward bend!), paced breathing, or looking at your hands to remind yourself of your current age can help; and continue to use parts language: That part of me is feeling… or that part of me is thinking.

How to Unblend Step Four: From your wise mind, consider what the part needs: § if this was your child, your friend, or your partner, what would you say or do for them ? § depending on the age of the part, you m ight ask, W hat do you need to help you feel less (angry, afraid, asham ed, etc.) right now? § if this is a young part, asking m ight not be appropriate – a 5 year-old can’t usually articulate what they need! So, ask yourself, If this was a 5 year-old child with m e right now, feeling afraid, what would I do or say? § then, try it: im agine yourself having that conversation with your 16 year-old self; or feel yourself hugging that 5 year-old child. § notice if the part responds: if you don’t get a positive response, you can try again – m aybe the part hears your words but doesn’t feel them ; or perhaps this part struggles to trust and it will take tim e to build a relationship with them . If the part is responsive, notice how it feels for you that the part feels soothed, reassured, a little calm er, or whatever their experience was.

Strategies: Mindful Noticing & Internal Dialogue -

What do you notice happening inside right now?

If you turn inward right now, are you able to identify what part is responding?

What does that part need? Can you check in with that part (if appropriate)? Based on what you know about__________, can you think of something that part might find helpful? (e.g. “Based on what you know about 5 year old kids, what do you think would help that young part right now?”)

As you (validate that part, hug that part, assure that part you’re going to continue to check in with them…) How is that part responding?

What’s it like to sense that part feeling… (e.g. reassured by your words)?

Parts often need validation, reassurance, orienting to time and place

If client really struggles: imagine you have a 5 year old sitting with you right now; would it be okay to tell them they should just get over this? What would you want to say or do for them instead? Some clients may need even more distancing (e.g. The Bonnyville Intervention)

“How do you feel towards (that part, that physical sensation, etc)?” – activates PFC “witnessing mind” and encourages a perspective of “separate from and in relationship with” (Taylor-Shore)

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Client Story: Gabrielle

Strategies: Grounding & Orienting Strategies G rounding: -

Ice pack

“Big Toes Little Toes”

Tell m e 3 things you see that are… (red, round, etc.)

Look at your hands; are these 5 year-old hands, or are they 40 year-old hands?

Having the client stand up and face the door: reach for the door handle; are you the height of a 5 year-old, or of a 40 year-old?

Can that part of you feel how long your body is? Are they able to sense that this isn’t a 5 year-old body, but a 40 year-old body?

Tell m e where you live now? And who do you live with? And where did you live when the (abuse/bad things) were happening?

Resourcing (Top-Down & Bottom-Up) Secure (Calm, Healing, Peaceful) Place Container Protective Figure Nurturing Figure Wise Figure New Parent

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Skills to Ground and Re-Regulate Clients Bottom-Up: F-TIPP Skills • Forward Bend (PNS) • “TIP” the temperature of your face (mammalian dive reflex) ***clients with anorexia and/or bulimia, who have low bp or take beta blockers cannot do this skill without first checking with their doctor! • Intense exercise • Paced Breathing (PNS) • Paired Breathing + Progressive Muscle Relaxation (PMR)

Video

Dissociative Experiences Scale (DES) Averag e D E S S cores in research G en eral A du lt Popu lation

5.4

A n xiety D isord ers

7.0

A ffective D isord ers

9.35

E atin g D isord ers

15.8

Late A d olescen ce

16.6

S ch izop h ren ia

15.4

B ord erlin e Person ality D isord er

19.2

Posttrau m atic S tress D isord er

D issociative D isord er N ot O th erw ise S p ecified

D issociative Id en tity D isord er (M PD )

http ://tra um a d issocia tion.com /d ow nloa d s/inform a tion/d issocia tive e xp e rie nce ssca le-ii.p d f

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Assessment Tools for Dissociation ´ Cambridge DPDR Scale http s://w w w .w sp ce .org /coup le s/C a m b rid g e % 20D e p e rsona liza tion% 20Sca le -cha rt-scoring % 20ve rsion.p d f

´ Multidimensional Inventory of Dissociation (MID) http s://w w w .m id -a sse ssm e nt.com /

Thank You!

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Trauma and Addiction: CBT Strategies that Work! Prepared for:

Jack Hirose and Associates Western Canadian Trauma Summit May 6, 2024

Jeﬀ Riggenbach, PhD jeﬀriggenbach.com clinicaltoolboxset.com

Trauma and Addiction: CBT Strategies that Work! Approximately 60-70% of Americans have experienced some form of trauma in their lives Estimates suggest 70-80% of Canadians will experience PTSD at some point in their lives 21.6% of Canadians met criteria for substance use disorder (2012 National Survey Estimate) 6% Americans qualify for substance use disorder (approx 21 million)

Trauma and Addiction: CBT Strategies that Work! Relationship Between Trauma and Addiction Addiction and trauma often associated with each other Trauma is risk factor for developing substance or other addictive behaviour problems Addictive behaviours are often times attempts to cope with results of traumatic experiences

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Trauma and Addiction: CBT Strategies that Work! Relationship Between Trauma and Addiction Addiction and trauma often associated with each other

People with with substance use disorders high incidence of Trauma and PTSD

Impaired driving, going to dangerous places to get substances, impaired judgment one contributing factor to increase risk of retraumatised

Trauma and Addiction: CBT Strategies that Work! Relationship Between Trauma and Addiction Some studies show as high as 50% of women in tx for substance abuse also report some form of sexual assault in their past 20% of veterans w/ ptsd also substance problems

Many clinical reports indicate 1/3 of those seeking tx for substance abuse havePTSD dx

CBT Strategies for Trauma and Addiction What they are: Trauma and PTSD

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Trauma and Addiction: CBT Strategies that Work! • 60-80% Canadians/Americans experience 1 traumatic event • 8% of lifetimeptsd • Most trauma survivors never develop ptsd symptoms and majoritywho do recover • Women 2x more likelythan men • Most recovery in 1st 3 months • When persists for 1 yr almost never remits w/o tx

Trauma and Addiction: CBT Strategies that Work! Classification - Trauma and Stressor - Related Disorders PTSD dx requires having been exposed to traumatic or stressful event that involved actual or threatened death or serious injury PTSD persists when information is processed in such a way that real past threat is perceivedas current

Trauma and Addiction: CBT Strategies that Work! ■ Becomes pathologicalwhen

1) Associations among stimuli do not accuratelyreflect the world 2) Harmless stimulus erroneously associatedwith threat meaning 3) Avoidancebehaviours are evoked by harmless stimuli 4) Excessiveand easilytriggered response elements interfere with dailyfunction

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Trauma and Addiction: CBT Strategies that Work!

Traditionally characterized as a normal response to abnormal event Much current thinking is to view this diﬀerently

Trauma and Addiction: CBT Strategies that Work!

• When someone experience as a traumatic event brain chemistry is altered • Aﬀects endocrinology, neurochemistry, brain circuitry

Trauma and Addiction: CBT Strategies that Work!

The Neurobiology of Trauma - Lower Region Lowest brain centers hold our most primitive survival reactions

Involved in activating defense\stress reactions

Reflexively respond to triggers &response produces startle response (accelerated heart rate, increase breathing, muscle tension)

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CBT for Trauma and Addiction: The Neurobiology of Trauma - The Limbic System

• Provides neural basis and emotions • Containsamgydyla & and

for memories hippocampus

CBT for Trauma and Addiction: The Neurobiology of Trauma - The Limbic System

—> In response to triggering images - Amygdala acts as a warning system by scanning the environment for danger and send the information to the hypothalamus - Hypothalamus initiates a set of actions in the endocrine system that releases with cortisol and other hormones to engage the body stress response

• Hippocampus’ role is maintaining term memory - also Context processing originates in Hippocampus

long-

CBT for Trauma and Addiction: The Neurobiology of Trauma - Prefrontal Cortex

The logical reasoning part of the brain Responsible for decision-making, rational thinking, logic, planning memory

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CBT for Trauma and Addiction: The Neurobiology of Trauma - Prefrontal Cortex

Under stress this part of the brain functions at diminished capacity - diﬃculty thinking through situations Involved with memories which are encoded diﬀerently during traumatic events - may be “gaps” in memory

Trauma and Addiction: CBT Strategies that Work! PTSD and the DSM Trigger is Exposure to actual or threatened death, serious injury, or sexual violation Examples include: Domestic, family, dating violence Community violence Sexual or physical assault Natural disaster Motor vehicle or other related accident War, refugee experiences, etc

Trauma and Addiction: CBT Strategies that Work! PTSD and the DSM Trigger is Exposure to actual or threatened death, serious injury, or violation Directly experiences traumatic event Witnesses traumatic event in person Learns that traumatic event happened to a close family member or close friend Experiences first hand repeated or extreme exposure to aversive details of traumatic event

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Trauma and Addiction: CBT Strategies that Work! PTSD and the DSM SYMPTOM CLUSTERS 1. Reliving 2. Avoiding 3. Pervasive negative changes in emotion 4. Excessive physiological arousal

CBT Strategies for Trauma and Addiction Addictions

Trauma and Addiction: CBT Strategies that Work! Addiction Biological Risk Factors Trait Impulsivity/Aggression Other Genetic factors (estimated 40-60%) Race Gender Stage of Development

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Trauma and Addiction: CBT Strategies that Work! Addiction Environmental Risk Factors Lack of Parental Supervision Peer and School Experiences Drug experimentation as children or adolescents How the drug is used Community Poverty

Trauma and Addiction: CBT Strategies that Work! Why People Use Substances To Feel Good To Not Feel at all (numb) To Forget To alleviate pain To regulate emotions To foster feelings of relaxed state or excitement

Trauma and Addiction: CBT Strategies that Work! Traditional Abuse vs. Dependence Understanding Abuse

- Usage leads to putting self in dangerous situations, jeopardizing health, neglect rest at home work or school (DSM IV)

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Trauma and Addiction: CBT Strategies that Work! Traditional Abuse vs Dependence Understanding

Concepts of physical dependence vs psychological dependence Psychological Dependence - Psych preoccupation & believe “need” to relieve negative emotions Physiological Dependence - physiological sx if stop or reduce use - Body needs it to function - Develop tolerance - Withdrawal Sx - Often need detox

Trauma and Addiction: CBT Strategies that Work! Addictive Behaviour Disorders

Substance Use Disorders Pathological Gambling

Trauma and Addiction: CBT Strategies that Work! Proposed Disorders

Compulsive Buying Disorder Internet Addiction Sexual Addiction Computer Game Addiction

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Trauma and Addiction: CBT Strategies that Work! Addictive Behaviour Disorders and DSM 1. Taking the substance in larger amounts or for longer than you meant to 2. Inability to cut back or stop in spite of repeated attempts to 3. Excessive amount of time devoted to behaviour 4. Cravings and Urges to engage in the behaviour or usage 5. Unable to meet school, work, family, or other obligations due to the behaviour or the results of the behaviour

Trauma and Addiction: CBT Strategies that Work! Addictive Behaviour Disorders and DSM 6. Continuing to engage in behaviour in spite of problematic relationships 7. Quitting social, occupational, recreational activities 8. Continuing to engage in the behaviour in even when doing so puts one in danger 9. Continuing to engage in behaviour in spite of knowing a condition of some kind will be worsened 10. Needing increasing amount to gain desired eﬀect 11. Withdrawl sx, which remit with additional use/behaviour

Trauma and Addiction: CBT Strategies that Work! Addictive Behaviour Disorders and DSM -Severity 2 or 3 = Mild Use Disorder 4 0r 5 = Moderate Use Disorder 6 or more = Sever Use Disorder

Substances: Alcohol, Cannabis, Hallucinagins, Stimulants, etc

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Trauma and Addiction: CBT Strategies that Work!

Cognitive Behavioural Therapy

Trauma and Addiction: CBT Strategies that Work! Cognitive Behavior Therapy (CBT) Aaron T. Beck, 1960, University of Pennsylvania Principle that thoughts influence feelings

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Trauma and Addiction: CBT Strategies that Work!

Cognitive Behavior Therapy (CBT)

Events

Thoughts

Feelings

Actions

Results

Trauma and Addiction: CBT Strategies that Work!

Levels of Cognition

Trauma and Addiction: CBT Strategies that Work! Identifying Core Beliefs Example Beliefs About Self • I am a failure • I am unlovable • I am worthless • I am vulnerable • I am helpless • I am a burden • I am defective

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Trauma and Addiction: CBT Strategies that Work!

Identifying Core Beliefs Example Beliefs About Others •

Others are mean

•

Others are uncaring

•

Others are self-absorbed

•

Others aren't deserving of my time

•

Others are to be taken advantage of

•

Others are unreliable

•

Others are untrustworthy

Trauma and Addiction: CBT Strategies that Work! Identifying Core Beliefs Example Beliefs About the World • The world is exciting • The world is boring • The world is scary • The world is evil • The world is a lost cause • I am defective • The world is dangerous

Cognitive Model of Addiction

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The Transtheoretical Model

Trauma and Addiction: CBT Strategies that Work! Motivational Enhancement Therapy

Stages of Change

Pre-Contemplation

Preparation

Maintenance

I—————-—I—————-——I———-————I———————I Contemplation

Action

Trauma and Addiction: CBT Strategies that Work! Gaining Insight

Expressions of Concern

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Trauma and Addiction: CBT Strategies that Work!

Cost-Benefit Analysis

Trauma and Addiction: CBT Strategies that Work!

Case Conceptualisation

Trauma and Addiction: CBT Strategies that Work! Case Conceptualisation Relevant Childhood Data Current Life Stressors Core beliefs Substance/Addiction Related Beliefs Thoughts Emotions Behaviors

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Trauma and Addiction: CBT Strategies that Work! Case Conceptualisation * Why did the pt start using? * How did recreational use lead to problem usage? * Why has pt not been able to stop on their own? * How did key beliefs and coping skills develop? * How did the pt function before substance problem?

Case Study: “Vonnie”

Trauma and Addiction: CBT Strategies that Work! Goal Setting and Treatment Planning • Problem List • Goal List • Behavioral Targets • Identify Triggers for Behaviors • Identify Cognitions associated with target behaviors

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Trauma and Addiction: CBT Strategies that Work! Conceptualisation Drives Treatment Planning

Trauma and Addiction: CBT Strategies that Work! Documentation - Acronym B I R P P

Trauma and Addiction

Conceptualisation Drives Treatment Planning

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Trauma and Addiction: CBT Strategies that Work!

Conceptualisation Drives Documentation

Trauma and Addiction: CBT Strategies that Work!

Cognitive Model of Addiction

Trauma and Addiction: CBT Strategies that Work! Cognitive Model of Addiction Interventions

• Restructure cognitions related to function of use • ID drug related beliefs • Pros & Cons • Imagery • Flashcards • Addict Letters • Cue Cards

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Trauma and Addiction: CBT Strategies that Work! Session Acuity Protocol

1. Usage or other Destructive Behaviors 2. Therapy Interfering Behaviours 3. Quality of Life Interfering Behaviours

Trauma and Addiction: CBT Strategies that Work! Relapse Prevention Questions • Did you relapse this week? • If yes, tell me what happened • On a scale of 0-10 how close did you get? • At what point during the week were you most tempted to use? What were you doing? • On a scale of 0-10 how strong was the craving at that time. • What was going through your mind at the time?

Trauma and Addiction: CBT Strategies that Work! Relapse Prevention Questions What kept you from relapsing? Anything else? How many times to you think you were tempted to use this week but didn’t? What skills did you use to resist the urges? Behavioral Skills? (what did you do?) Cognitive (what did you think?) What did you do right this week What changes do you need to implement this week?

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Trauma and Addiction: CBT Strategies that Work! Cognitive Model of Addiction

CB Chain Analysis

Trauma and Addiction: CBT Strategies that Work!

Schema Based Letter Writing

Trauma and Addiction: CBT Strategies that Work! Smart Recovery 4 Point Program

• Building and Maintaining Motivation • Coping with Urges • Managing Thoughts, Feelings, and Behaviors • Living a Balanced Life

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A Cognitive Approach to PTSD

Trauma and Addiction: CBT Strategies that Work! • PTSD persists when information is processed in such a way that real past threat is perceived as current (“fear conditioning”) ■ Cognitiveand Emotional processing is mechanism

underlying successfulreduction of symptoms

■ Goal is to help pts face traumatic memories and

situations associated with them

■ Fear is represented in memory as cognitivestructure that

is program for escaping danger

■ Structure includes 1) fear stimuliand 2) fear response

and 3) meaning associated with

Trauma and Addiction: CBT Strategies that Work! Conditions necessary for successful modification of fear structure: • Fear structure must be activated, otherwise it is not available for modifications • New information incompatible with fear structure must be incorporated • Confrontation with stimuli that are safe or low probability of harming (When this occurs, information that used to evoke anxiety no longer does)

- Requires deliberate, systematic confrontation with stimuli that are safe or low probability of harming

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Trauma and Addiction: CBT Strategies that Work! Goals

• Decrease/Eliminate flashbacks and dissociation • Move from flashback to intentional recall • Change meaning associated with • Acceptance • Benefits/Growth/Resilience • Improve overallfunctioning

Trauma and Addiction: CBT Strategies that Work! CBT for PTSD: 3 Stages of Treatment

1. Pre-Exposure Stage 2. Exposure Stage 3. Post-Exposure Stage

Trauma and Addiction: CBT Strategies that Work! CBT for PTSD: Stage 1

• Psychoeducation re PTSD • Psychoeducation re Neurobiology of Trauma • Explain Rationalefor Exposure based treatment & Obtain Consent • Teach Basic De-escalation Skills

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Trauma and Addiction: CBT Strategies that Work! CBT for PTSD: Stage 1 • Levels of Alertness Research • Avoidance • Hypervigilance/Exaggerated Startle Response • Flashbacks/dissociation • Numbness • Shame and Self-Blame • Defectiveness schemas

Trauma and Addiction: CBT Strategies that Work! CBT for PTSD: Stage 1

• Soothing • Distraction • Grounding

Trauma and Addiction: CBT Strategies that Work! CBT for PTSD: Stage 2

• 3 part summary of life 1. Post Trauma (Impact statement) 2. Pre trauma life (emphasis on positives) 3. Trauma Narrative

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Trauma and Addiction: CBT Strategies that Work! CBT for PTSD: Stage 2 - Impact Statement Views of: • Self • World • Safety • Trust • Power • Competency • Intimacy

Trauma and Addiction: CBT Strategies that Work! CBT for PTSD: Stage 2 Guidelines for Trauma Narrative

• Hand written • First person • As much detail as possible

Trauma and Addiction: CBT Strategies that Work! CBT for PTSD: Stage 3 • • • • • • • •

Residual Nightmare work Dealing with moral injury and related cognitions to guilt and shame Reclaim former self and other post-traumatic growth Silver Lining Technique Trauma taken tool and other resilience strategies Coming out of shame, relational healing, and seeking connection Values - Based Recovery Managing triggers, anger management, skills training and other quality of life improving work

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Trauma and Addiction: CBT Strategies that Work!

CBT for PTSD: Stage 3 - Nightmare Rescript

Trauma and Addiction: CBT Strategies that Work!

Moral Injury and Post-Traumatic Growth

Trauma and Addiction: CBT Strategies that Work! Moral Injury and Post-Traumatic Growth

Trauma is an event that has an eﬀect on one’s ongoing sense of threat as well as moral injury

Not just violence happening TO people; but acts they did or did not commit towards others Importance of ongoing creating a sense of safety as well as reassigning blame and redefining value and helping them see good things can come from diﬃcult situations

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Trauma and Addiction: CBT Strategies that Work! Moral Injury is associated with:

Isolation Anger Guilt and Shame Powerlessness Suicide

Trauma and Addiction: CBT Strategies that Work! Moral Injury Goals

Come out of hiding Restructure cognitions related to guilt and shame Spiritual healing Making meaningful connections Reassign meaning associated with suﬀering and promote resilience

Trauma and Addiction: CBT Strategies that Work! Moral Injury and Post-Traumatic Growth

Positive psychological changes resulting from the struggle with challenging circumstances around the crisis They say what does not kill you makes you stronger - not always the case - but with proper cognitive approach can be true May never be exactly the same afterwards, but can be healthy and happy

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Trauma and Addiction: CBT Strategies that Work!

Stage 3: The Same Silencer Tool

Trauma and Addiction: CBT Strategies that Work!

Stage 3: The Trauma Taken Tool

Trauma and Addiction: CBT Strategies that Work!

Stage 3: The Silver Lining Tool

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Trauma and Addiction: CBT Strategies that Work!

Let’s Connect!

Website: jeffriggenbach.com Email:jeff@jeffriggenbach.com Author Page: clinicaltoolboxset.com Facebook: DrJeff Riggenbach

Case Study Vonnie is a divorced 38 y/o Caucasian female. She has no children and is currently living with her new boyfriend. Her primary complaints at initial assessment are chronic depression, anxiety, and a lengthy history of substance use including benzodiazepines, methamphetamines, and alcohol. She reports that recently her mood instability had worsened due to relationship concerns that her new boyfriend might leave her as well as conflict with a coworker and she fears she may relapse “and ruin my almost 3 months sobriety.” She reports “quitting” many times for short stints of time with 11 months being her longest period of abstinence from all substances. Vonnie had maintained a professional career, holding down the same job for the past 8 years for which she made a good salary. Since her divorce 12 years ago, it was noted that she hadn’t dated a man any longer than 6 months and triggers for usage often centered around these breakups or “relational spats.” A pattern was also identified of “dating men who are in some way less than me so I didn’t have to worry about them leaving me – I could just date them until I got tired of them and them dump them – I kind of like to be in charge” she said with a smirk. Vonnie’s mother died by suicide when she was 12. She was an only child who from that age forward was raised by her “pillhead dad” who “floundered around doing odd jobs” and barely bringing home enough income to put food on the table. Vonnie recalls “one week when I was in high school, I remember we had to share a large can of beans all week.” Vonnie recalls living in fear on a daily basis wandering whether or not her father would come home that night. “After my mom left me and died, I just lived in fear of another loss. She describes a history of “on and off” relationships in high school that “often got me pretty worked up - I felt so bad I could hardly stand it.” When not during one of her dating courses, she describes feeling boredom frequently. “I was home alone a lot and didn’t have anything to do – we lived on a farm and if Dad didn’t come home, I was by myself and had no friends close – and I couldn’t text yet then”! Vonnie reports stealing her fathers’ pills as early as age 9. “They just gave me a lot of energy and a high I hadn’t felt before and some excitement for once in my life.” Although she had few friends, Vonnie reports excelling academically, graduating as the salutatorian of her class with a 3.9 GPA. “I began to realize even though I couldn’t keep a boyfriend and girls didn’t seem to like me much, that if I worked hard, I could at least be good at something…and dads Ritalin kept me going.”

Jeff Riggenbach, PhD

The Trauma Toolkit Thanks For purchasing the trauma Toolkit. I have found throughout my 15 years of doing live trainings, webinar events, and coaching programs, that many people are not interested in the “whole package” of what I am teaching or offering. Thus I decided to provide a series of toolkits that contain only the worksheets, handouts and exercises for particular symptom sets. Anyone wanting the entire package of areas addressed along with more detailed explanations needs to purchase one of the books in Toolbox series. But I wanted to make something available for those who were just interested in specific problem areas. Also these toolkits provide handouts in a format that can be printed separately and photocopied as many times as you like without copyright issues for use with your clients (which is not always the case with the formatting in some of the other books or ebooks). The contents of this booklet address the area of trauma. It should be noted these exercises are best used as part of treatment with a licensed provider. This is NOT an entire protocol for treating PTSD – but it does offer user-friendly versions of worksheets that can accompany trauma based therapy you offer your clients. I hope you find these worksheets and handouts helpful Should you need additional assistance, feel free to contact us for corresponding video teachings, webinar opportunities, or 1:1 Coaching packages at admin@jeffriggenbach.com Best, Jeff

Jeff Riggenbach, PhD President, CBT Institute of OK jeffriggenbach.com clinicaltoolboxset.com

Jeff Riggenbach, PhD

Grounding Tool I will be honest. I was taught this exercise by a client one time. It worked so well for her, I then began teaching it to others and continues to amaze me how this helps people. Grounding techniques by the way can be helpful when one is so overwhelmed by emotion that the mind attempts to “go somewhere else.” These exercises can be helpful to assist with increasing one’s awareness of the present moment. This particular tool asks people to pay attention to their surroundings with heightened focus on their senses. Specifically, identify 5 things you see, 4 things you can touch, 3 things you can hear, 2 things you can smell, and 1 thing you taste. For obvious reasons, I have heard it called the 5-4-3-2-1 exercise. Give it a try.

things you can see _______________________________________________

things you can touch _____________________________________________

things you can hear ______________________________________________

things you can smell ______________________________________________

thing you can taste _______________________________________________

___________________________________________________________________ ___________________________________________________________________

Jeff Riggenbach, PhD

Trauma Timeline Tool

Some victims of trauma have only one incident (one is too many). Others may have 10+. Use this tool to generate a list of traumatic events you have experienced. If you have less than 10, just record however many you have experienced. If you have more than 10, list the MOST difficult/painful 10.

Sequence #

Age Brief Description of Trauma

Example: Trauma #1

#10

Assaulted in the parking lot at grocery store (no specifics)

Jeff Riggenbach, PhD

Hierarchy of Traumatic Events Tool If you are watching my corresponding video teaching, (and hopefully if you are trauma provider even if you are not), you know that when doing this work it is important to pick one event at a time to process. The next step then in confronting your trauma is to look at your trauma timeline tool and pick the specific event you would like to work with. Unlike many anxiety disorders, where it can be helpful to start with the LEAST bothersome event, when doing trauma exposure work it is important to start with the MOST bothersome that a person is willing to confront. Note I did not say what they are COMFORTABLE confronting. This work is not comfortable. Anyone unwilling to experience discomfort will not do this effectively. The most important reason for this is that change generalizes down, but does not generalize up. For instance, if you identified 4 traumas in your history and you are willing to work this process with the 3rd most troublesome one, you likely will NOT have to go back and repeat this work with traumas one and two, but you would likely, at some point, need to go back through this work with trauma #4. With that in mind, identify which trauma you would like to work on first. Consult your practitioner you are working with. Give your thoughts as to why you made the choice you did. __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________

Jeff Riggenbach, PhD

“Who You’d Be Today” Tool Many people think about who they would be without having experienced trauma. In doing this work, however, it can be helpful (although again painful), to thing about HOW YOU ARE DIFFERENT TODAY AS A RESULT OF GOING THROUGH WHAT YOU DID. Consider the following areas, and use the tool to guide you to explore different areas: My trauma affected my views on each of these areas in the following way(s): 1. Trust _________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. Intimacy ______________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Vulnerability ___________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. Competence ___________________________________________________ ________________________________________________________________ ________________________________________________________________ 5. Power ________________________________________________________ ________________________________________________________________ ________________________________________________________________ Other ________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

Jeff Riggenbach, PhD

“Who I Was” Tool Use this tool to “piggy back” off of the previous one. What positives did you have BEFORE you went through the traumatic event? You may use these later J

Pre-Trauma Positives 1. 2. 3. 4. 5

Jeff Riggenbach, PhD

Trauma Taken Tool Thinking about trauma is painful. And in doing so, many are only able to see how it devastated their lives. However, people who recover from a traumatic events are able to recognize what the trauma DID take from them and genuinely grieve those losses, but also see what the trauma DID NOT take from them. Use this tool to help facilitate that process.

What the Trauma DID TAKE from Me

What the Trauma DID NOT Take from Me

I can use the strengths, areas of expertise, and giftedness the trauma did NOT take from me today to reclaim my former self in the following ways…

Jeff Riggenbach, PhD

“My Story” Telling your story is the most difficult, but the most empowering part of the “overcoming” process. Be sure you have found a safe place to do this. Then write it out, step by step, per the instructions provided in the video. Remember, leave no detail out. The share it with your “safe person” ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

Jeff Riggenbach, PhD

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

Jeff Riggenbach, PhD

Trauma Thought Log

Trauma-Related Thoughts

Rational Responses

Jeff Riggenbach, PhD

Silver Lining Tool Given a choice, nobody would choose to go through a traumatic experience. But one of the attributes of resilient people who overcome traumatic experiences is their ability to as themselves the following question: • Given that I did experience what I did, what unique opportunity, ministry, service am I now “uniquely qualified” to offer the world that I was not before going through the events related to my trauma? That “silver lining” motivates many to not only survive, but thrive! Spend some time reflecting on what your “silver lining” might be and record your thoughts in the area provided.

Jeff Riggenbach, PhD

Nightmare Rescript Tool Nightmares are essentially stories we tell ourselves during our sleep about past life events. Sometimes either changing the content of our nightmares or the meaning associated with the nightmare can curb recurring nightmares. I have had clients who were having recurring nightmares never have one again For others the result is not as dramatic, but this tool has been helpful for many people suffering from recurring nightmares.

Write out your recurring nightmare. If it is too long, write out the most troubling aspect of the nightmare. __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ How did you feel emotionally? __________________________________________________________ What bodily sensations did you notice? __________________________________________________________ __________________________________________________________ How would you like to feel instead? _______________________ How would your dream/nightmare have to change in order for you to feel those feelings? Write re-write your nightmare with this ending.

The Addictions Toolkit Thanks for purchasing the Addictions Toolkit. I have found throughout my 15 years of doing live trainings, webinar events, and coaching programs, that many people are not interested in the “whole package” of what I am teaching or offering. Thus I decided to provide a series of toolkits that contain only the worksheets, handouts and exercises for particular symptom sets. Anyone wanting the entire package of areas addressed along with more detailed explanations needs to purchase one of the books in Toolbox series. But I wanted to make something available for those who were just interested in specific problem areas. Also these toolkits provide handouts in a format that can be printed separately and photocopied as many times as you like without copyright issues for use with your clients (which is not always the case with the formatting in some of the other books or e-books). The contents of this booklet address the areas of full blown addictions as well as other bad habits. I hope you find these worksheets and handouts helpful for working with your clients. Should you need additional assistance, feel free to contact us for corresponding video teachings, webinar opportunities, or 1:1 Coaching packages at admin@jeffriggenbach.com Best, Jeff

Jeff Riggenbach, PhD President, CBT Institute of OK jeffriggenbach.com clinicaltoolboxset.com

TOOL # 1 Identification of Triggers People engage in “impulsive” and addictive behaviors for different reasons. The term “addictive” in in quotation marks because there is still some debate regarding its use. Brain scans to differ in some significant ways from people who are addicted to substances, for instance, vs people who suffer from “gambling addiction Treatment approaches however are fairly similar. They all follow an impulse control model. Some motives for engaging in addictive or other impulsive behaviors include: a quick “feel good” response, the need to stay in control, and an attempt to regulate shame based emotions Understanding these can sometimes provide insight into triggers. Use the following tool to answer questions that may guide you in identifying some of your triggers.

The last time I acted in an impulsive manner was ______________ _____________________________________________________________ _____________________________________________________________ I

did

response

time

have

acted

impulsively

include

Emotions I notice I feel before engaging in my addictive behaviors or bad habits include _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _ People I notice I am around when or just before engaging in my addictive behaviors

bad

habits

include:

My Triggers for Addictive Behaviors/Bad Habits

1. _____________________________________________________

2. _____________________________________________________

3. _____________________________________________________

4. _____________________________________________________

5. _____________________________________________________

FEELINGS IDENTIFICATION

Tool # 2 Identification of Feelings Emotions have been described by some in terms of being in discrete “feelings families” based upon different types of emotional state human beings experience. Unlike previous tools, Impulsive or addictive behaviors can be influenced by a number of different feelings families. Pick from the following emotions that commonly precipitate addictive behaviors or bad habits, or come up with your own words. Then list them on the continuum below with “1” being the least agitated and “5” being the most intense agitation for you.

Unsettled

Urge

Agitated

Powerless

Craving

Stressed

Discouraged

Shame

See below for graphic

1. ________________________________ 2. ________________________________ 3. ________________________________ 4. ________________________________ 5. ________________________________ •

It should also be noted that we can experience any of these feelings with varying ranges of intensity. When doing chain analysis, it can be helpful to rate the intensity of a feeling in response to a given situation and thoughts in the moment.

Tool # 3 Identification of Addiction-Related Thoughts The following questions are designed to help you identify your distorted thoughts specifically related to depression. Remember, these thoughts will often be related to negativity, loss, or discounting some positive aspect of self, others, or the world. When ___________________________happens, and I feel _________________________, (Trigger)

(Emotion)

What kinds of things am I often telling myself?

If I were in a cartoon, what would the bubble above my head be saying? Thought bubble?

If there were a tape recorder in my head recording my every thought, what would it be saying when someone pushed “play?” Use the tool 1.3 to log the thoughts you identify to be going along with your depression related feelings

Thoughts/Feelings Awareness Log - Example Example I felt …

...because I thought…

Vengeful

It’s OK to act spiteful because she made me mad.

Sense of urgency

I have to have that item now.

Unmotivated

It’s OK to binge, because I felt upset—food will soothe me, and nothing else will help. I can’t stand feeling this way.

Thoughts/Feelings Awareness Log I felt …

...Because I Thought…

Tool # 4 Unhealthy “Go To” Coping Skills Most people develop a set of standard “go-to” coping skills when they feel that need for a quick “feel good.” Perhaps you have heard the term autopilot, referring to just falling back on the same old skills that in some way feel comfortable but often don’t help. Usually, these behaviors “worked” in the past but no longer work in the present. Also, some may continue to work in the short term but be making problems worse in the long term. A few such examples people turn to include alcohol, drugs, promiscuous sex, spending, or shopping. Before figuring out healthy skills to use when these urges creep up, it is often useful to generate a list of what we have been trying that has not been working. In the case of this chapter, this simply means evaluating and identifying behaviors that could be addictive, impulsive, or constitute bad habits for you.

Identifying My Addictions Tool The last time I engaged in an addictive, impulsive or habitual behavior was ________ ____________________________________________________________________ I believe the behavior has become an addiction or bad habit because ___________ ____________________________________________________________________ The behavior, bad habit or addiction I will be targeting is ______________________ ____________________________________________________________________ I believe the habit or addiction first started __________________________________ I engage in the behavior ________________________________________________ (how often)

The place I usually do it is _______________________________________________ The emotions I feel frequently prior to engaging in the behavior are ______________ ____________________________________________________________________ The people in my life that have the power to trigger me to an emotional state I may be tempted to engage in these behaviors are _______________________________ ____________________________________________________________________ Other circumstances often present when I engage in the behavior include _________ ____________________________________________________________________

Tool # 5 Awareness of Consequences All unhealthy coping skills, including bad habits and addictions, “work” in the short term. We get something out of them, or we would not continue to do them. However, that is the main criteria used in this book for determining to what extent a behavior “healthy” vs “unhealthy” – the degree to which it causes long term consequences, or what the DSM calls functional impairment. As you do this tool, ask yourself how the habit has hurt you physically, emotionally, relationally, spiritually, financially, and occupationally. Glance at the example, then list all the habits or addictions you can think of that you struggle with and present or future consequences of those.

Awareness of Consequences Log – Example Autopilot Coping Skill (habit) Alcohol

Pot

Current or Past Negative Consequences $100/month I could put towards rent or education Pisses off my partner Parents threaten to cut me off Suspended from football team Affected my scholarship offers $ Grades dropped 4 straight years

Your Awareness of Consequences Log Autopilot Coping Skill (habit)

Current or Past Negative Consequences

Tool # 6 CBT Chain Analysis Here is where the rubber meets the road. This is where you get to put it all together. Now that you have the skills covered in the tools above, identify a specific situation/trigger in your life that precipitated a specific episode of engaging in your habit behavior. See if you can identify specific thoughts that you had, feelings that you experienced, choices that you made, and consequences of those choices. Use the following tool to help you follow the sequence to analyze your response in a particular episode. Also, when you identify your feelings, rate the feeling on a scale of 0-10 with zero being “none” and 10 being “extreme”. For instance if you identify “irritation” and it was as irritated as you have ever felt, your entry would look like: irritation – 10.” Once you have done enough of these, you will start to be able to identify some patterns, which can facilitate some powerful insight for recovery.

Chain Analysis Event (Trigger)

Rationalizing Thought

Feelings

Habit Behavior

Results

Tool # 7: Desired Results This one in pretty simple. When you look at the undesired consequences of choices in your usage or other habit behavior, what are some alternative outcomes you would have liked to have had? What desired results do you have for your future. Results I would like to create in my future in similar situations:

1. _____________________________________ 2. ______________________________________ 3. ______________________________________ 4. ______________________________________ 5. ______________________________________

Tool # 8: New Coping Skills Now that you know how you would like these habit trigger situations to end, how might you need to change your behavior in response to that trigger to create your desired result? This tool offers you an opportunity to brainstorm a “menu of general options” you can choose from to use to manage future cravings and urges. Write as many coping skills as you can think of here. The cards in a later tool will be situation specific.

Some coping skills I could try next time I am tempted to engage in one of my habit behaviors:

______________________________________

_______________________________________

Tool # 9: Challenging Addiction/Habit - Related Thoughts In the same way that recognizing but continuing to engage in unhealthy behaviors rarely gets us far along in recovery, recognizing distorted thoughts but not changing them also keeps us stuck. Here is your opportunity to identify specific permission giving thoughts (the excuses you tell yourself) and generate a list of challenges. This often consists of reminding yourself why the behavior is not ok. Review the example and try your own!

Thought Log - Example Permission-Giving Thoughts

Rational Responses

It’s OK to act spiteful because she upset me.

It’s not OK. I am working toward building healthy relationships. I am angry, but acting this way would only hurt me and sabotage my goals.

I have to have that item now.

I want it, but I don’t need it. We need $ for prescriptions. We can’t afford it. I can walk away.

It’s OK to binge eat because I felt upset. Food will soothe, me and nothing else will help. I can’t stand to feel this way.

It’s not OK to binge for any reason. I can now tolerate intense emotions better than before. I’ll hate myself afterward. I’ll feel fat. I’ll feel depressed. I have other skills I can use.

Thought Log Rationalization/Permission-Giving Thoughts

Rational Responses

Tool # 10 : Re-examining Urges Now that you have attempted to challenge your thoughts, reflect for a few minutes on your feelings. Ask yourself if the urges or cravings have diminished in any way? have If so, how much has the intensity changed before vs after the new thinking. Are you feeling any new feelings completely? Which rational responses seemed to have the most effect on your feelings? The least? Use to tool provided to examine the differences and then record your observations,

Automatic Thoughts

Initial Feelings

Intensity

Rational Responses

Current Feelings

Intensity

My Observations: _______________________________________ _______________________________________________________ _______________________________________________________

Tool #11: Chain Analysis with Rational Responses Finally, use the chain analysis tool with your rational responses to see the impact that your new thinking had on your feelings. Be sure to include the new feelings intensity ratings. For instance you may still be experiencing sadness, but it is important to recognize that if after your initial automatic thoughts your sadness was a “10” and after your rational responses your sadness was a “6” that the new thinking made an impact. Don’t make the mistake many depressed individuals with black and white thinking make by saying “I was sad then and I am sad now – this didn’t do anything.” See how changed thinking, feeling, and behavior affected current results and could affect future results.

Mini-Chain/Challenges EVENT

AUTOMATIC THOUGHTS

FEELINGS

ACTIONS

RESULTS

RATIONAL RESPONSES

FEELINGS

ACTIONS

RESULTS

Tool # 13: Identifying Alternate Healthy Beliefs Remember, beliefs come in pairs. I teach in my workshops and conferences that it is kind of like a sheet of paper. It inherently has a front and a back side. For each unhealthy belief you identified, you also have an alternate opposite belief. Tool #13 asks you to formulate in your own words what you would you’re your opposite belief. Then, similar to how you rated intensity of emotions above, use percentages to rate how much you believe your core belief vs how much you believe your alternate belief. These will be used in a later tool to subjectively measure your belief change as you move forward in your recovery. Be mindful that while other core beliefs may be present, an initial belief to target with addictions and bad habits is the insufficient self-control belief. Use the tool below to write out your unhealthy belief, alternate healthy belief, and baseline believability ratings for each. The next tool will help you use these as a starting place to subjectively measure your ongoing belief change. Example UNHEALTHY

HEALTHY

I Cant Control my Urges

I Can Have Self-Control

My Beliefs

Believability Ratings Example UNHEALTHY BELIEF

I Can’t Control My Urges

STRENGTH 65%

80% STRENGTH ____________%

HEALTHY BELIEF

“I Can Show Self-Control”

STRENGTH 35%

20% STRENGTH ____________%

Rating the Strength of My Beliefs

STRENGTH ____________%

Tool #14: Identifying Components of the Beliefs As has been addressed, beliefs are formulated based upon the meaning we assign to events or experiences in life. These experiences then become “evidence” to support our beliefs. “Evidence” is in quotation marks, because certain people “count” data as “evidence” that others do not. It is understandable to many people that those who live through different types of life experiences are more likely to develop different beliefs. Although every person’s life experiences are in some ways unique, another phenomenon practitioners encounter is that some clients have strikingly similar backgrounds but develop different types of beliefs. The explanation is that even though the experiences themselves may have been similar, the meaning assigned to them was quite different. Leslie Sokol with The Beck Institute of Cognitive Therapy and Research shares a visual for a belief that compares it to a table. In the same way that a table top needs legs to support it, beliefs also need supporting structures. Experiences in life serve as “evidence” to support these beliefs, based upon the meaning that is attributed to them. So the “Legs of the Evidence one uses to support a belief, in this tool, is represented by the “legs of the table.” This visual can be used in different ways. One way involves looking back at past experiences in life to examine the conclusions we came to in formulating the beliefs we currently have. A different exercise involves looking at the alternate beliefs we are aiming to construct and examining evidence as we move forward in life. Evidence log tools can be vital for recording this evidence as we increase our awareness and pay attention to it. However WHAT we log is vital and relates to how we assign meaning. For instance in a previous example, a belief combination of “worthless” vs “have value” was used. What is valuable to one person is not necessarily valuable to another. This is the reason this components of the belief tool is so important. Failing to identify what “counts” for you will lead to you logging evidence that makes no meaningful difference for you and will hinder your

process. Use the table visual to identify your components of your beliefs. These will help you know very specifically what types of experiences will be necessary to create and/or expose yourself to moving forward and what kinds of things to look for as you use your evidence logs to construct your new belief. The first part of this tool facilitates thinking historically to analyze how current beliefs might have been formed. The second part asks you to identify the “legs” as you do your work moving forward.

Historical Evidence The following questions may be helpful in reflecting back on different periods of life to uncover some of the experiences you counted as evidence to support your belief (legs to hold up your table). You may need assistance from your therapist to get the most out of this tool. The first time I ever remember feeling ______________________________[belief] was _____________________________________________________________________ __ The people in my life who influenced me to feel that way were: Family members ____________________________________________________________________________________________ ______________________________________________________________________________________________________________ Friends/Peers

_______________________________________________________________________________________________

______________________________________________________________________________________________________________ Other significant people ____________________________________________________________________________________ ______________________________________________________________________________________________________________ Experiences during my elementary school years _____________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Experiences during my junior high years ____________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Experiences during my high school years ____________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Experiences during my college/young adult years ___________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Significant experiences since then ___________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________

Use the exercise on the previous page to try to insert some of the “evidence” from your past that you have “counted” to support your unhealthy/belief. Consult the example, and then try your own historical “legs of the table” exercise. Legs of Table – Unhealthy Belief Example

Leg 1

Leg 3

Evidence that I couldn’t control my impulses: Leg 1: I couldn’t stand pain of divorce Leg 2: Felt I had to drink. Leg 3: Peer pressured to smoke pot. Leg 4: Felt need to be loved. Leg 5: Had sex at first opportunity.

Raped by cousin Leg 4

Fiance left me

Leg 2

Brother tortured me

Mom ignored me

Dad was intimidating

NO CONTROL

Leg 5

Legs of Table – Unhealthy Belief Evidence that I __________________________________(unhealthy belief)

Leg 2

Leg 4

Leg 3

Leg 5

Evidence I Could Not Control My Impulses TOOL 12 HISTORICAL EVIDENCE LOG—HEALTHY BELIEFS Leg 1: Leg 2: Leg 3: Leg 4: Leg 5:

Because of how our filters are set up, we often notice instances that support unhealthy beliefs more than we notice experiences that may support our opposite, healthy beliefs. But almost always that “evidence” exists as well. One valuable tool involves forcing ourselves to look back over those very same periods of life purposefully looking to see the evidence that supports our healthy beliefs. Many people often use family members or friends who were around them during each period of life to help them “notice” such evidence. Even if they share things they see as “counting” that you don’t think “should count” write them down anyway for now. Consider the example, and then try your own.

Legs of Table – Healthy Belief Example

Leg 1

Leg 3

Didn’ t buy extra presents

Leg 4

Only had one drink at dinner

Leg 2

Waited to lose virginity

Didn’ t drink after break up

Didn’ t yell at dad

SHOW SELF-CONTROL

Leg 5

Evidence that I can show self-control: Leg 1: Was tempted to yell at my dad when he grounded me in the 9th grade but didn’t Leg 2: Wanted to drink until I was numb when first boyfriend broke up with me but didn’t Leg 3: Had chance to lose my virginity at age 16 but decided not to and said no Leg 4: Tempted to buy extra presents for Christmas but didn’t Leg 5: Only had one margarita with Mexican food

Legs of Table – Healthy Belief

Evidence that I __________________________________(healthy belief)

Leg 2

Leg 1

Leg 4

Leg 3

Leg 1: Was tempted to yell at my dad when he grounded me in the 9th grade but didn’t Leg 2: Wanted to drink until I was numb when first boyfriend broke up with me but didn’t Leg 3: Had chance to lose my virginity at age 16 but decided not to and said no Leg 4: Tempted to buy extra presents for Christmas but didn’t Leg 5: Only had one margarita with Mexican food

Leg 5

TOOL 13 IDENTIFICATION OF COMPONENTS OF BELIEFS

Tool #15: Evidence Logs Now that you have identified your “legs of the table” for the belief you are working on, you know very specifically what to look for. Purposefully pay attention to experiences in life that support the healthy belief you are constructing. This may involve noticing evidence that was always there you didn’t notice before due to the dominant role of your old belief filtering your thinking away from it. You may also work with your practitioner on exercises that actually create new evidence that wasn’t there before. Purposefully paying attention to does not mean making it up. You have to be intellectually honest. If it legitimately isn’t there, it doesn’t count. Just remember that due to your filter you will be prone to discount things that really do support the belief, so having an open mind is vital. Use the following evidence log tool to record evidence over time that supports your new belief (with addictions and bad habits, fist on the agenda is believing that you can have self-control over your urges. Your tool allows your to rate the believability in the moment as uou log each piece to evidence to track if your belief if moving the right directions over time..

I CAN DEMONSTRATE SELF-CONTROL

YOUR ENVIRONMENT Date

Evidence

12/12

Drank no alcohol at Christmas Party

12/13

Only had one margarita with Mexican food

12/16

Stayed within budget at mall

12/20

Tempted to buy extra presents but didn’t

12/24

Chose not to eat pie at Christmas dinner

Evidence Log Unhealthy Belief: _______

Healthy Belief: _______

Starting Belief %: _______

Date

Evidence Supporting Healthy Belief

Belief %

Conclusions: _______________________________________________ __________________________________________________________

Handout 10.2 – Evidence Log

Tool # 16: Pros and Cons There are many versions of “Pros and Cons” exercises available to the public. This one was prepared by Jonathan von Breton, LCMHC, LCDP, who is a Professional Advisor to SMART Recovery and is reprinted with permission, specifically to help people work through and grow out of addictive behaviors. Complete the following exercise and answer the questions that follow. FOUR QUESTIONS ABOUT MY ADDICTION What do I think I will like about giving up my What do I enjoy about my addiction? What addiction? does it do for me? What good things might happen when I stop (Be specific.) my addiction?

What do I think I won’t like about giving up What do I hate about my addiction? What my addiction? bad things does it do to me and to others? What am I going to hate, dread or dislike (Give specific examples.) about living without my addiction?

FOUR QUESTIONS ABOUT MY ADDICTION: A COST/BENEFIT EXERCISE

These 4 questions can provide you with a lot of useful information with which to grow out of your addiction(s). The more honest and complete your answers, the more this exercise will help you. 1. What do I enjoy about my addiction? What does it do for me (be specific)? List as many things as you can that you liked about whatever you are/were addicting yourself to. 1. Where possible, find alternative ways of achieving the same goals. 2. Recognize positive thinking about the addiction as a potential relapse warning sign. 3. Realize that there are some things you liked about the addiction you will have to learn to live without. 4. List what you enjoy about your addiction so you can ask yourself if it is really worth the price. 5. Realize that you aren’t stupid; you did get something from your addiction. It just may not be working on your behalf anymore. 2. What do I hate about my addiction? What bad things does it do to me and to others (give specific examples)? List as many of the bad, undesirable results of your addiction as you can. Here it is extremely important that you use specific examples. Specific examples have much greater emotional impact and motivational force! a. Ask yourself honestly “If my addiction was a used car, would I pay this much for it?” If you wouldn’t pay this much for it, why not?

b. Review this list often, especially if you are having a lot of positive, happy thoughts about all the great things your addiction did for you and how much fun you had in pursuing it. 3. What do I think I will like about giving up my addiction? List what good things you think/fantasize will happen when you stop your addiction. 1. This provides you with a list of goals to achieve and things to look forward to as a result of your new addiction-free lifestyle. 2. This list also helps you to reality test your expectations. If they are unrealistic, they can contribute to relapse based on disappointment, depression, or self-pity.

4. What do I think I won’t like about giving up my addiction? List what you think you are going to hate, dread, or merely dislike about living without your addiction. a. This list tells you what kinds of new coping skills, behaviors, and lifestyle changes you need to develop in order to stay addiction free. b. It also serves as another relapse warning list. If all you think about is how much life sucks now that you are not doing your addiction, you are engaging in a relapse thought pattern that is just as dangerous as only focusing on what you liked about your addiction. This is not a do once and forget about it exercise. It is an ongoing project. Most people simply can’t remember all of the positive and negative aspects of addiction and recovery at any one time. Furthermore, seeing all the negative consequences of addiction listed in one place is very powerful. On the positive side, most people do not absolutely know for certain what they will like or will not like about living free of their addictions until they have done so for some time. I know of people who continued to add items to all four questions for a full 6 months.

Tool # 17 - Identifying My Habits and Addictions The habit or addiction I will be targeting is ____________________________ ____________________________________________________________________ __________________________________________________________ The habit or addiction first started ____________________________________ ____________________________________________________________________ __________________________________________________________ I typically engage in the behavior ____________________________________ (How Often?)

The place I usually do the behavior Is _________________________________ The time of day I usually do the behavior is ____________________________ The emotions I usually feel before I do the behavior are __________________ ____________________________________________________________________ __________________________________________________________ The people in my life that have the power to trigger those emotions in me include _________________________________________________________ ____________________________________________________________________ __________________________________________________________ Other circumstances often present when I engage in the behavior include ____________________________________________________________________ ____________________________________________________________________ _____________________________________________________

My habit or addiction has hurt me in the following ways in each area My Physical Body ________________________________________________ ____________________________________________________________________ __________________________________________________________ My Sleep Habits _________________________________________________ ____________________________________________________________________ __________________________________________________________

My Relationships _________________________________________________ ____________________________________________________________________ __________________________________________________________ My Emotions ____________________________________________________ ____________________________________________________________________ __________________________________________________________ My Spiritual Life __________________________________________________ ____________________________________________________________________ __________________________________________________________ Medically _______________________________________________________ ____________________________________________________________________ __________________________________________________________ Financially ______________________________________________________ ____________________________________________________________________ __________________________________________________________

Tool # 18: What’s Your Why? One of the keys to overcoming addictions and bad habits is to identifying the function of the behavior. People often do things for good reasons. So identifying the reason is essential for finding replacement behaviors that can fill a similar function with less damaging consequences. Use the example below to complete your own tool to help you identify what your why is.

What’s Your Why? Tool - Example What (Habit or Addiction)

Why? (What I Get out of It) Helps me focus Gives me Energy

Adderall Smoke Pot

Helps me relax Helps me “numb out” Gives me something to do when I’m stressed

Bit fingernails

Your What’s Your Why? Tool What (Habit or Addiction)

Why? (What I Get out of It)

Tool # 19: SSS Tool (Substance Specific Strategies) As noted above, identifying function of behaviors can give us a window into what replacement behaviors may be the most effective. Certain behaviors may be helpful coping skills in general, but if they don’t help us meet the need that is behind the problem behaviors, they likely won’t work in our effort to reverse that particular habit. Use the example below to brainstorm some replacement behaviors for you to choose from to do instead of your habit behaviors that could meet your specific need with less damaging consequences.

Need (My “Why”)

1. “ I need energy to do my job”

SSS (alternate strategies that could meet that need)

Learn distress tolerance techniques Deal with my problems so intrusive thoughts don’t keep coming back Take a hot bath Read a moving story Talk about how proud I am of my daughter Listen to a funny podcast Listen to one of my go to songs Call my friend and go out to a movie

Use a distraction technique Count to 100 in my head Get on treadmill Clench my stress ball Remind myself all the reasons I will be ok

2. “I want to feel numb and not think about something bad”

3. “I need something to do when I get anxious”

5 hour energy Change my diet Increase my exercise Get blood tests to see if I need vitamins, minerals, or other supplement or medicine Start my work project even though my energy level is lower than I’d like it to be

My SSS Tool (Substance Specific Strategies) Need (My “Why”)

SSS

Tool # 20: Self-Monitoring Self-monitoring is an important tool to have whether striving to break a bad habit or addiction, managing a full blown mental illness, or working toward achieving any type of personal goal. First, monitoring is a way of increasing our awareness to our triggers, thoughts, moods, and habit behaviors. It is only after we gain awareness to the presence of these sooner that we can intentionally work to change them. Especially early in the process, many people with say things like “that’s just the way I am,” or “That’s just me.” Viewing it in this way makes it seem unchangeable (like our eye color vs like dietary habits). As we get better at developing awareness as to when these things come and go and our environment and thought processes as they do, we can change who we thought we “Just were” for the better. Secondly, monitoring is a way for us to tell if we are growing. As we get better at paying attention to certain thoughts, moods, and habit behavior we can get better at noticing if they are improving over time. Perhaps the easiest way to get started is to start with behaviors you have no desire to change. Some people start with going to the bathroom, brushing their teeth, or eating. Start by observing frequency and duration; that is, how often you do the behavior, and once you do it, how long the behavior continues. Self-monitoring does not come easily, and most people believe they are better at it than they really are. But the more you practice, the more self-aware you become. The more self-aware you become, the better insight you have into habit behaviors that you might want to change that could have a profound positive impact on your recovery and personal growth. The following tool can help you get better paying attention to a behavior that you choose to start with, even if you have no desire to change it. You will then use this skill in completing your Habit Tracker targeting actual bad habits

Behavior(s) of Focus: _____________________________________________ I will pay attention to this more in the following way ___________________ _______________________________________________________________ _______________________________________________________________

One morning practice I can implement into my daily routine that can help me shift my focus to paying attention to the behaviors I am trying to catch myself in is _____________________________________________________ _______________________________________________________________ _______________________________________________________________

How often do I notice myself doing this behavior? _____________________ _______________________________________________________________ _______________________________________________________________ Do I observe themes in specific emotions when I catch myself doing the behavior? ______________________________________________________ _______________________________________________________________ _______________________________________________________________

What can I use to help bring my attention to this when I start to do it? (a reminder on the toilet, a sticky note on the pantry door, dip my hands in a flavor I don’t like so I notice every time I start to put one in my mouth) _______________________________________________________________ _______________________________________________________________ _______________________________________________________________

A person who lives or works with me that could be a support in this by pointing out to me when they observe me engage in the behavior is _______________________________________________________________ _______________________________________________________________ _______________________________________________________________

A practical way I will use to keep track how many times I do the behavior a day is (ie little note pad in pocket, “notes” section in smartphone, use a step counter or clicker ______________________________________________ _______________________________________________________________ _______________________________________________________________ Other factors that might be important for me in improving my monitoring and increasing my awareness are _________________________________ _______________________________________________________________ _______________________________________________________________

Tool # 21: Relationship Circles and Accountability All people need people. However this can be a “catch 22.” On one hand, we need human interaction for support, encouragement, touch, fun, and a sense of connectedness. But on the other hand, relationships can be very difficult for a variety of reasons, and triggering for people who struggle with addictions or bad habits. While it is not necessary that you become “the life of the party” if that is not “you,” it is vital to have a support system to help you face overcoming your obstacles in life created by your target behaviors. Use the following tool to help you identify the relationships that you have in your life. The more you trust a person, the closer they go on your circles. The less you trust a person the further out they go. After listing people where you view them on your circles, answer the questions that follow.

Intimacy Circles

Relationship Circles Questions What changes would I like to make to my circles? ________________________________________________________________________ ________________________________________________________________________ _________________________________________________ Are there people I would like to have closer in? Further out? Who and why? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Some hurtful things I have done that have damaged one or more relationships: ___________________________________________________________________ _____________________________________________________________________ Some helpful things I have done that have helped me in maintaining relationships: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ __ Changes I could make in the way I relate to people may include: __________________________________________________________________ __________________________________________________________________ Would I like to add people to my circles who currently aren’t there? Why or why not? ________________________________________________________________________

________________________________________________________________________ ________________________________________________________________________ What are some qualities of the people I would like to add? ________________________________________________________________________ ________________________________________________________________________ _________________________________________________________ What are some “red flag” qualities of people I may be drawn to but that I have learned from experience are NOT good candidates for my circles? ________________________________________________________________________ ________________________________________________________________________ I commit to talk to the following 3 people from my “circles” to be part of my accountability team that I can call for support in times I am having a hard time managing my urges. I will put their names and number somewhere that is readily accessible and that I can find easily in times of need.

Name

Phone #

____________

_____________

____________

_____________

____________

_____________

Tool #22: Habit Tracker Here is where the rubber meets the road! Use your awareness skills to pay attention to every time you have an urge to do the behavior. , whether you did it or not. You will not catch every time – that is ok. Do the best you can. Log the date, time, what your urge was to do, what emotion you were experiencing and how strongly you felt it, if you did the habit behavior or not, and if not, on a scale of 0-10, how close you came to giving into the urge and acting. This is a royal pain to being with. But the more consistent you become with this over time, the better you will get at reversing unwanted habits. If you quit completing these, you are unlikely to succeed. Use the example to start completing your own.

Habit Tracker - Example Date

Time

4/13 0700

Urge

Emotion/Strength

Drink Alcohol

Agitation (7)

Did I Do If No, How Y/N Close? 0-10

Your Habit Tracker Date

Time

Urge

Emotion/Strength

Did I Do If No, How Y/N Close? 0-10

Tool # 23: BOB (Behavior Over Belief) As you start to develop some mastery in the use of your habit tracker closely monitoring your behaviors and urges, an additional step to integrate involves thoughts and beliefs. Most reading this are likely familiar with the term rationalization. This term has actually been used differently by different theorists over the years. A version of it even shows up on some of the cognitive distortion lists floating around out there. A cognitive term for this specific use of rationalizing is permission-giving beliefs. Every time any human being engages in a behavior that is against our moral values or in any way that we are consciously aware of not in our best interest, we do so only after giving ourselves permission to first. A general template for identifying permission-giving beliefs could be:

It’s OK to ______________________________, because ______________________________. (behavior)

(Excuse)

One common example I hear working with clients in the area of addictions is

“It’s OK to use drugs, because I think they should be legal.” They may believe this, but the reality is that the substance in question is NOT legal at this time at this place. So in helping the client examine potential pros and cons, it is important to consider potential sociological, legal, and related family consequence. Use the BOB (Behavior over belief) Tool to identify some of your permission giving beliefs that could be facilitating your bad habit or addictive behavior, aw well as to consider how you might increase your effectiveness by behaving in spite of what you believe.

BOB Tool Date 8/11

Permission - Giving Belief “Its ok to take a drink because what she said made me depressed”

Habit Behavior Tempted To Do Vodka

SSS (Alternate Behavior) Call a Friend Have a Nice Meal Sit in the Jacuzzi

Tool # 24: Burning The Bridge Once you have identified your triggers, your addictive or bad habit behaviors, and increased your awareness regarding your temptations to engage in them, the next step is getting more effective “in the moment” at not acting on your urges. The Cards we will look at in tool 25 can be helpful with this. A crucial first step is to safeguard your environment. This “bridge Burning,” as Dr. Lane Pederson Calls it, is a term that is often associated with clients with suicidality. Whether it means killing oneself, going to the casino, or using heroin, the reality is that adults can choose to do just about whatever they want to. People with addictions often have urges to do things the “rational side” of them knows is not in their best interest. So, if part of you wants to indulge while the other part of you knows its best to restrain, you are not alone. Bridge burning is simply doing anything you can that will make it less likely for you to engage in the behavior in the moment. Some safeguarding can be done preemptively. For instance, if you are in your first month without alcohol trying to break a 20-year habit, you can ensure your safety by not keeping any alcohol in the house. Other safeguarding must be done “in the moment,” which is much harder. For people who have urges to self-harm, it means making sure all objects that could be used to do so are removed. For people who are having suicidal thoughts, it might mean having high-lethality medications locked up under someone else’s supervision. If you are having an urge to binge eat and you have the food you like to binge on at the house (for some necessary reason), it may mean your leaving the house. If your urge is to spend, you could limit your access to funds. Depending on the area your unhealthy urge involves, your steps will be different. One client of mine made sure he was with other people when his urges increased because he knew he would not engage in the behavior if someone else was there. After connecting with them and participating in some form of joint activity, he noticed the urge, no matter how strong, eventually passed. Spend some time considering specific areas for which you may need to safeguard and what that might look like for you.

Areas it would be helpful for me to consider safeguarding include Specific steps I could take preemptively (ahead of time) that would make my environment safer and less tempting are ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Things I could do “in the moment” to safeguard when an urge overcomes me are ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ For me, safeguarding might include ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Use the following tool to list the specific habit behaviors you heave identified, and think of some specific ways your could “burn the bridge” that will buy you a little more time to change your mind about engaging in the behavior you are desiring to change.

Habit Behavior

Steps I Will Take to Safeguard

Tool # 25: Coping and Cue Cards The final two tools are different types of cards. The first is what is called a behavioral coping card, and the final tool is what is called cognitive cue card. To make use of the coping card, you can simply copy a habit behavior you are targeting and Identify 3 of your SSS (alternate coping skills) behaviors that you think would work in a specific situation. Since these are to be used “in the moment,” it is best to keep them succinct so as not to overwhelm yourself as you will often be using them in a time of emotional upset. Consult the following example using the client from the previous tool, and then try one yourself!

Example Coping Card The next time I feel hurt and am tempted to drink vodka, Instead I will: 1. Call a friend 2. Have a nice meal 3. Sit in the Jacuzzi

My Cue Card The next time I am tempted to _________________ I will: (Habit or addiction)

1. 2. 3.

The final card has a slightly different purpose. Unlike the coping cards, the cue cards don’t deal with any behaviors. They are more about your mindset. At least, these should pick out a rational response you used (in tool #9) related to why it is not in your best interest to engage in the habit behavior. Even more powerful yet would be to deal with your thoughts about your setback. Relapse is a part of recovery. Whether trying to stick to a certain diet or kick a meth habit, almost everyone has setbacks of some kind along the way. But the way one thinks about their failures (in this case relapse into habit behaviors) is crucial for overcoming the obstacle you are battling. Consider the following example, then try a cue card of your own. With both types of cards, use the template provided to practice, but then to transpose your answers onto actual 3x5 cards you can strategically move to places you will see them most that will benefit you “real time”.

Cue Card – Example Just because I gave in and drank the vodka doesn’t mean I am a Horrible person who will not achieve my goal. I went 11 straight days and now I had one slip. I am a valuable person that is loved by God and a few people in my support system. I am going to meet With my sponsor, tweak my relapse plan, and get back on the Horse and start riding again. I will beat this thing!

My Cue Card

Soothing Strategies

1. Take a hot bath 2. Grounding 3. Deep breathing 4. Give or receive a hug 5. Cuddle with a pt 6. Cuddle with a blanket 7. Cuddle with a pillow 8. Burn incense 9. Sing 10. Safe place imagery 11. Go to a state park 12. Sit by a quiet stream or body of water 13. Write 14. Draw 15. Color 16. Go through your photos and nd those that calm you 17. Guided meditation 18. Progressive relaxation 19. Look at a picture 20. Scented candle 21. Smell of freshly brewed coffee 22. Apply lotion 23. Smell owers 24. Get a massage 25. Drink herbal tea 26. Squeeze a stressball 27. Chew gum 28. Put on relaxing clothes 29. Stretching/Yoga 30. Meditation or prayer

Trauma and Addiction References American Psychiatric Association, DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.). American Psychiatric Publishing, Inc.. https://doi.org/10.1176/appi.books.9780890425596 Allard, C. B., Norman, S. B., Thorp, S. R., Browne, K. C., & Stein, M. B. (2018). Mid-treatment reduction in trauma-related guilt predicts PTSD and functioning following cognitive trauma therapy for survivors of intimate partner violence. Journal of Interpersonal Violence, 33(23), 3610-3629. Arntz, A., Rijkeboer, M., Chan, E., Fassbinder, E., Karaosmanoglu, A., Lee, C. W., & Panzeri, M. (2021). Towards a reformulated theory underlying schema therapy: Position paper of an international workgroup. Cognitive Therapy and Research, 45(6), 1007-1020. Beierl, E. T., Böllinghaus, I., Clark, D. M., Glucksman, E., & Ehlers, A. (2020). Cognitive paths from trauma to post-traumatic stress disorder: A prospective study of Ehlers and Clark's model in survivors of assaults or road traffic collisions. Psychological medicine, 50(13), 2172-2181. Brown, L. A., Belli, G. M., Asnaani, A., & Foa, E. B. (2019). A review of the role of negative cognitions about oneself, others, and the world in the treatment of PTSD. Cognitive Therapy and Research, 43(1), 143-173. Cockram, D. M., Drummond, P. D., & Lee, C. W. (2010). Role and treatment of early maladaptive schemas in Vietnam veterans with

PTSD. Clinical Psychology & Psychotherapy: An International Journal of Theory & Practice, 17(3), 165-182. Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., ... & Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical psychology review, 43, 128-141. Panzeri, M. (2016). Schema therapy for emotional dysregulation: Theoretical implication and clinical applications. Frontiers in psychology, 7, 1987. Ehlers, A., & Clark, D. M. (2000). A cognitive model of post-traumatic stress disorder. Behaviour research and therapy, 38(4), 319-345. Flanagan, J.C., Korte, K.J., Killeen, T.K., and Black, S.E. (2017) Concurrent Treatment of Substance Use and PTSD. Current Psychiatry Reports. 18 (8). 70. Foa, E. B., & Hembree, E. A. (2019). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences. (2nd ed.). Oxford University Press. Gallagher, M. W., & Resick, P. A. (2012). Mechanisms of change in cognitive processing therapy and prolonged exposure therapy for PTSD: Preliminary evidence for the differential effects of hopelessness and habituation. Cognitive therapy and research, 36(6), 750-755. Gillespie, K., Duffy, M., Hackmann, A., & Clark, D. M. (2002). Community based cognitive therapy in the treatment of posttraumatic stress disorder following the Omagh bomb. Behaviour Research and Therapy, 40(4), 345-357.

Giotakos, O. (2020). Neurobiology of emotional trauma. Psychiatriki, 31(2), 162-171. Hu, J., Feng, B., Zhu, Y., Wang, W., Xie, J., & Zheng, X. (2017). Gender differences in PTSD: susceptibility and resilience. In A. Alvinius (Eds.). Gender Differences in Different Contexts (pp. 21-24). Croatia. Intech. Liese, B. S., & Beck, A. T. (2022). Cognitive-behavioral therapy of addictive disorders. Guilford Publications. Marks, E. H., Franklin, A. R., & Zoellner, L. A. (2018). Can’t get it out of my mind: A systematic review of predictors of intrusive memories of distressing events. Psychological bulletin, 144(6), 584-640. McNally, R. J., & Woud, M. L. (2019). Innovations in the study of appraisals and PTSD: A commentary. Cognitive Therapy and Research, 43(1), 295-302. Murray, H., Grey, N., Warnock-Parkes, E., Kerr, A., Wild, J., Clark, D. M., & Ehlers, A. (2022). Ten misconceptions about traumafocused CBT for PTSD. The Cognitive Behaviour Therapist, 15, e33. Murray, H., & Ehlers, A. (2021). Cognitive therapy for moral injury in post-traumatic stress disorder. The Cognitive Behaviour Therapist, 14. Newman, C. F. (2019). Cognitive-behavioral therapy for alcohol and other substance use disorders: The Beck model in action. International Journal of Cognitive Therapy, 12(4), 307-326.

Peeters, N., van Passel, B., & Krans, J. (2022). The effectiveness of schema therapy for patients with anxiety disorders, OCD, or PTSD: A systematic review and research agenda. British Journal of Clinical Psychology, 61(3), 579-597. Resick, P. A., Monson, C. M., & Chard, K. M. (2016). Cognitive processing therapy for PTSD: A comprehensive manual. Guilford Publications. Riggenbach, J. (2021). The CBT Toolbox: A Workbook for Clients and Clinicians (2nd ed). PESI Publishing. Schwartz, A. (2021). The Complex PTSD Treatment Manual: An Integrative, Mind-body Approach to Trauma Recovery. Pesi publishing. Sherin, J. E., & Nemeroff, C. B. (2011). Post-traumatic stress disorder: the neurobiological impact of psychological trauma. Dialogues in clinical neuroscience, 13(3), 263-278. Udo, I., Javinsky, T. R., & Awani, T. (2022). Eye movement desensitisation and reprocessing: part 1–theory, procedure and use in PTSD. BJPsych Advances, 1-10. Watkins, L.E., Sprang, K.R., and Rothbaum, B.O. (2018). Treating PTSD: A Review Evidence-Based Psychotherapy Interventions. In Frontiers of Neuroscience. 12, 258. Yadin, E., & Foa, E. B. (2007). Cognitive Behavioral Treatments for Posttraumatic Stress Disorder. In J. Kirmayer, R. Lemelson & M. Barad (Eds.), Understanding Trauma: Integrating Biological, Clinical, and Cultural Perspectives (pp. 178-193). Cambridge University Press.

Yang, Y. S., & Bae, S. M. (2022). Association between resilience, social support, and institutional trust and post-traumatic stress disorder after natural disasters. Archives of psychiatric nursing, 37, 39-44. Young, J. E., Klosko, J. S., & Weishaar, M. E. (2006). Schema therapy: A practitioner's guide. Guilford press.

Stress & Trauma

an a$achment-based developmental perspec3ve

Gordon Neufeld, Ph.D.

Clinical & Developmental Psychologist Vancouver, Canada

A JACK HIROSE SEMINAR

Healing & Trea,ng Trauma Wounds Edmonton, Alberta May 7, 2024

Copyright 2024 Gordon Neufeld, Ph.D. All rights reserved. The handout is intended for registered par?cipants of this seminar only. Please do notduplicate this document without permission.For more informa?on regarding the Neufeld Ins?tute or Dr. Neufeld and his work, please consult the website.

www. neufeldins8tute.org

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

Stress & Trauma an a$achment-based developmental perspec3ve

Gordon Neufeld, Ph.D.

Developmental & Clinical Psychologist Vancouver, Canada

sense of safety

role of relationship grieving

tears of futility & sadness

stress Response

play & playfulness fight or flight

impact of experience & exposure

optimal functioning

emotional defense

sense of strength

vulnerable feelings

TRAUMA

nature of emotion

role of adaptation

recovery and healing

neural plasticity antecedents to bouncing back vasovagal

rest and restfulness

response

Stress & Trauma Chapter One

Chapter 1

The WISDOM ! of the ! Stress Response

THE THREAT: an evolution in understanding

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

WALTER CANNON’S FIGHT-FLIGHT RESPONSE TO THREAT • Harvard medical professor who studied the eﬀects of physical danger on lab animals and formed his thesis in 1915, published in 1932 in the book “The Wisdom of the Body” • his focus was on the situaRonal response to a threat to survival but made the mistake of isolaRng animals from their own species • studied the role of adrenalin and the sympatheRc nervous system in responding to threats to physical survival

THREAT to survival FIGHT

FlIGHT

HANS SELYE’S STRESS RESPONSE (1940’S)

• was seeking a common physiological response that could account for the behaviours that Cannon had observed as a response to threat • assumed that the FEAR system was the physiological pathway for stress, thus making the mistake that aggression came from fear • assumed that harm or survival was the essence of threat • since modified to include a third opRon – FREEZE (immobilizaRon or shutdown mediated by the vagus nerve) if flight or fight are not opRons

STRESs FlIGHT

FIGHT

about Hans Selye and the construct of STRESS • Selye was a Hungarian-Canadian endrocrinologist who worked at McGill in the 30’s and 40’s and later at the University of Montreal • popularized the construct of stress (word originates from ‘distress’ meaning coming apart) as a term for the generalized eﬀect of threat on the body • the term was borrowed from physics and engineering where it was used to describe the force exerted on a physical enRty (like a bridge) that would cause it to snap or come apart • the term became immediately and immensely popular, inﬂuencing the vocabulary and thus thinking in many languages • the term unfortunately gave the impression that stress was bad, leading to breakdown, something Selye tried in vain to correct

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

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

STRESs

threats to iden tity

on adopR

sec rets

ar yc a d e ve loss of lo d on

mov ing

ling er sib h t o n a ST LO ng bei resi d sch enRal ool

DIVORCE

E NT US RETIREME AB

CHANGE

Adversive Childhood Experiences Emotional abuse

pHysical abuse emotional neglect Mental illness of household member

sexual abuse

physical neglect

substance abuse in household

STRESs divorce incarcerated relative

mother treated violently

REDUCE DISTRESSING EVENTS

if THREAT = STRESS LOAD nd drugs aSon medica

t parariggerin sym g a resp pathe ons Sc e n ita5o d e m deep breathing g nut ni n & exeri5on l to rcise a vag

MANAGE IMPACT OF STRESS

Self-care is the logical deduction of this understanding

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

1. When kids pracRce self-care they learn to idenRfy their physical and emoRonal needs and can begin to take care of those needs. 2. PracRcing self-care at a young age allows kids to create a foundaRon that will beneﬁt them as adults. 3. PracRcing self-care allows your child to develop healthy habits that they can beneﬁt from in the future. 4. Your child will be able to become more independent and understand how to take care of themselves. 5. They will develop the skills necessary to keep themselves healthy mentally, physically and emoRonally.

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

THREAT FACING SEPARATION

= experience of separaSon

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 cRon ne reje

n not important to ... tood co n’t feel s a ing c er fe unlo eli not ma nd ved ng gerin 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

Adversive Childhood Experiences pHysical abuse

Emotional abuse

physical neglect

emotional neglect Mental illness of household member

substance abuse in household divorce incarcerated relative

Togetherness is threatened

sexual abuse

SPECTRUM OF TRAUMA

mother treated violently Togetherness IS the threat

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

THREAT – an evolution in understanding

threat is to

SURVIVAL

SEPARATION

STRESS

is the threat

itself is the threat

• address issues • reduce distressing of safety, food, events health, & shelter • manage the impact of stress

REDUCE SEPARATION via naturally developing ... ... ways to hold on when apart ... viability as a separate being ... resilience in the face of separa3on faced

If FACING SEPARATION is the THREAT, togetherness is our answer! -

and thus CASCADING CARE in the context of togetherness should become our ultimate focus

Stress & Trauma

The WISDOM ! of the ! Stress Response Chapter 1 The WISDOM Chapter Two

of the stress response

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

THE STRESS RESPONSE ACTIVATES PRIMAL EMOTIONS closure separa3on-triggered

PURSUIT

ALARM

FRUSTRATION change

cau3on

Attachment’s Emergency First Aid Team

R LA

-P

-A

UR SU IT -

- FRUSTRATION -

se on sp Re

Re Sc

EM RE OTI

Sy mp at he

e th pa ym ras Pa

sp on se

OUR MOTTO - “We promise to get emo5onal when holes appear in the fabric of your togetherness”

SP ON ON A SE L

Re Sc

Sy mp at he

Hirose Seminars - Edmonton - May 7, 2024

e th pa ym ras Pa

sp on se

Stress & Trauma - Gordon Neufeld

Re se on sp

EM RE OTI

SP ON ON A SE L

as a last resort , the parasympatheRc system can be deployed as a DEFENSIVE RESPONSE to stress

SP ON ON A SE L

se on sp

EM RE OTI

Sy mp at he

e th pa ym ras Pa

sp on se

ﬁrst response

e ez d re gue l F or aR eju 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 - a two-pronged approach al rimons p S TE oS n IVA em raRo ACTraSon, frust it) a u sep, alarm purs e (i and

de em f e n oS siv ( ie ona ely , fe l f e eli ed ng ba s) c k

- via the command centre (amygala) of limbic system

- via the brain’s sensory gaRng sytem

- to situaRonally address the separaRon problem

- to reduce felt suﬀering and improve abillty to funcRon in distressing circumstances

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

The Stress Response

animates and armours the heart al • gives the STRENGTH and primons TOUGHNESS needed to S E S T o funcRon or perform in A IV n em T stressful or wounding C o IT A U S S R • ara circumstances PU p N e s ALARM TIO A TR US FR

• while a Sme, INHt the same that wou IBITS FEELINGS performinld interfere with in stressfu g or funcRoning l circumst ances

STRESS RESPONSE = MORE EMOTION BUT LESS FEELING

• instantly CHANGES one to be able to COPE with adversity & SURVIVE distressing circumstances

• taps all available resources to enable one to PERSEVERE in the face of distress and OVERCOME stressful circumstances

LOCK, OLLOW, FAWN, IND, ANCY (family, friends, fame, fortune) devolving into

Fixes closure Fixations separa3ontriggered

PURSUIT

ALARM

FRUSTRATION

FIGHT

FlIGHT

The stress response in the ‘key’ of

impulses to

ATTACH separa3ontriggered

PURSUIT

ALARM

FRUSTRATION

impulses to

Avoid

Attack

The stress response in the ‘key’ of

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

Stress & Trauma

The WISDOM ! of the ! Chapter Three Stress Response

Chapter 1

TRAUMA REDEFINED

The Stress Response

h, lt ea l h l ia al na ent • gives the and io STRENGTH rimons t t p o po TOUGHNESS needed to S oS E m T f e funcRon or perform in o VA m n to ostressful or wounding C TI n e ti RSUIT • A araSo circumstances U P a z p i N y l se ALARteM alIO reAT u ol heTR s • while a tS b • instantly CHANGES Sme, IN t the same re a anFdRU one to be able to COPE that wouHIBITS FEELINa GnSg, with adversity & SURVIVE ni distressing circumstances performinld interfere iw g or func ct o ith in stressfu R o n n in g l c:ircum u M l f stances LE ma • taps all available resources to B i O pt enable one to PERSEVERE in the o PR RESPONSE STRESS = MORE face of distress and OVERCOME EMOTION BUT LESS FEELING stressful circumstances

animates and armours the heart

Stress Response acRvaRon of

ATTACHMENT’S EMERGENCY RESPONSE TEAM (alarm, frustraRon & pursuit) FEELINGS that would interfere with performing or funcRoning in stressful circumstances are INHIBITED

Resilience Response Feelings that have been inhibited BOUNCE BACK to enable opRmal funcRoning and the full realizaRon of potenRal

SAFETY

Stress & Trauma - Gordon Neufeld

THREAT

Hirose Seminars - Edmonton - May 7, 2024

STRESS RESPONSE

SE F A PA C I RA N G TI ON

The brain’s naturally evolved emo3onal intelligence

THREAT

STRESS RESPONSE

REMOVAL OF THREAT

S E F P A A C R I A N T G I O N

RESILIENCE RESPONSE

Recovery of feelings

The brain’s naturally evolved emo3onal intelligence

THREAT S E F P A A C R I A N T G I O N

STRESS RESPONSE

Is NOT a funcSon of reality NOR is it

REMOVAL RESILIENCE raSonal in any way; OF THREAT RESPONSE doesn’t even have

S A F E T Y

to be a conscious feeling.

Recovery of feelings

in a ain lay i ^ac depn trushing brhe pode end Sng t m enc e

The brain’s naturally evolved emo3onal intelligence

Stress & Trauma - Gordon Neufeld

THREAT

STRESS RESPONSE

S E > >> F P A A C R I A N T G I O N

Hirose Seminars - Edmonton - May 7, 2024

REMOVAL OF THREAT

RESILIENCE RESPONSE

S A F E T Y

Recovery of feelings felt >>> futility

in a ain lay i ^ac depn trushing brhe pode end Sng t m enc e

The brain’s naturally evolved emo3onal intelligence

Attachment’s Emergency First Aid Team

OUR MOTTO - “We promise to get emo5onal when holes appear in the fabric of your togetherness” “We also promise to hang around un5l fu5lity is felt”

When the ﬁxes are fuRle, they need to be FELT as such. RS

M AR AL FRUSTRATION

UI T

L ST E WA R E N RE Y VER O C RE RESILIENCE as an agribute

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

D OWN

BOUN

LET

CE B AC K

SADNESS brings RECOVERY

HELP THAT IS

HELPFUL!!

• keeping or restoring perspective • right thinking / being positive • pursuing happiness • resisting the ‘let-down’ • acquiring the ‘skills’ of resilience • pursuing calmness & tranquility

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

loss of job ne’s way losing facMORTA NEGLECT e LITY loss go n of p a ln atio e z i l g g a rent n t ibli ospi n ot s tragedy f o rejecRh s s o l on t loss of child threats y nes BUSE to iden tity di empt A ffe re nt ne ss

a traum ed ov l n isolatio u n NT TH E ME EA lo RETIR D ne NG lin ACI es F s

the nadir

Strength of DEFENSE

Strength of BECOMING - meant to be characteris5c -

- meant to be situa5onal found needed strength

OVERCAME

potenRal sRll 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 condiRons

RESILIENT

feelings recover quickly aner Rmes of stress

ADAPTIVE

transformed from inside out by adversity

can funcRon or perform in highly stressful or wounding circumstances

HARDY

doesn’t need to be sheltered from stress to preserve growth potenRal

Strength of DEFENSE

Strength of BECOMING - meant to be characteris5c potenRal sRll 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 condiRons

RESILIENT

feelings recover quickly aner Rmes of stress

ADAPTIVE

transformed from inside out by adversity

HARDY

doesn’t need to be sheltered from stress to preserve growth potenRal

fee

en de r

a ro m

f of

g lin

su lts f

m ro

can funcRon or perform in highly stressful or wounding circumstances

f lts su

lin g

found needed strength

OVERCAME

of t

- meant to be situa5onal -

Stress & Trauma - Gordon Neufeld

Stress Response acRvaRon of

ATTACHMENT’S EMERGENCY RESPONSE TEAM (alarm, frustraRon & pursuit) FEELINGS that would interfere with performing or funcRoning in stressful circumstances are INHIBITED

Hirose Seminars - Edmonton - May 7, 2024

Resilience Response Feelings that have been inhibited BOUNCE BACK to enable opRmal funcRoning and the full realizaRon of potenRal

SAFETY

as judged by the brain’s innate intelligence

sadness

ie, feelings of fuRlity re brain’s emoRonal ‘ﬁxes’

Stress Response acRvaRon of

ATTACHMENT’S EMERGENCY RESPONSE TEAM (alarm, frustraRon & pursuit) FEELINGS that would interfere with performing or funcRoning in stressful circumstances are INHIBITED

Resilience TRAUMAResponse is NOT

what happens to us Feelings but what fails to happen that have been within us in response, ie, inhibited BOUNCE the lack of a opRmal follow-up BACK to enable funcRoningresponse and the that resilience full realizaRon potenRal includesofSADNESS

SAFETY

mveantss u rotaancek strese Tsadness

as judged by the brain’s t innate intelligence bu

on stueofspfuRlity iie,s nfeelings a r re brain’s emoRonal ‘ﬁxes’

THREAT S E FP AA CR IA NT I GO N

STUCK

STRESS RESPONSE

TRAUMA

DEFENSIVELY

DEPRESS

DEFENSIVELY

DETACH

BRAIN’S INTERNAL BACKUP DEFENSES

The brain’s naturally evolved emo3onal intelligence

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

Stress & Trauma

The WISDOM ! of the ! Chapter Four Stress Response

Chapter 1

Signs of a Stuck Stress Response (ie, trauma)

Missing Key Feelings Brain’s Backup Defenses

THREAT S E F P A A C R I A N T G I O N

FIVE POINT ASSESSMENT of a STUCK STRESS RESPONSE

Resilience Response is Lacking

Stuck Primal Emo3on

Stuck Stress Response

STRESS RESPONSE

REMOVAL OF THREAT

RESILIENCE RESPONSE

S A F E T Y

Recovery of feelings felt >>> futility

DEFENSIVELY

DEPRESS

DEFENSIVELY

DETACH

in a ain lay i ^ac depn trushing brhe pode end Sng t m enc e

BRAIN’S INTERNAL BACKUP DEFENSES

Stress & Trauma - Gordon Neufeld

fe lt p lay

REST

est lt r fe

- stuck in the WORK MODE - lacking emergent or venturing forth energy - lacking curiosity

Hirose Seminars - Edmonton - May 7, 2024

LESS NES S

the vital signs of well-being felt futility

- past history of ungrieved losses

eg, sadness, sorrow, disappointment, grief

- stuck in fuRle endeavours /unable to let go / brain unable to ﬁnd work-arounds for impediments

eg, cared for, cared about, caring deeply about, etc feelings re CARE eg, sorry, remorseful, guilty about, bad about feelings of DEPENDENCE feeling eg, needy, trusjul RESPONSIBLE FEELINGS of vulnerable ATTACHMENT N IO T A that may go IT G A feelings feeling MISSING of ANGER IA ALARMED ... when personally NO A ... when facing R mistreated PA separaRon feeling FULL ADREN or EMPTY ALIN-S EEKING eg, fulﬁlled, saRated, missing, longing, agachment ‘holes’

D BORE

What BOREDOM is about

When the ‘holes’ in togetherness are NOT suﬃciently FELT, it is experienced as BOREDOM.

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

Boredom-a natural barometer for deﬁcits of feeling - can’t feel the true nature or shape of the hole that exists within -

acSv ity

food nt me n i rta

ns scree

sSm

al s git it di rsu pu

te en delin quen cy

ula So n

videog

ames

G& TIN ING T U C URN B sensing PAIN

SIGHT & HEARING

TOUCH & SMELL

3 STRESS RESPONSE

THREAT S E F P A A C R I A N T G I O N

DEFENSIVELY

DEPRESS

DEFENSIVELY

DETACH

sensing COLD

feelings of SENSATIONS that may be restricted

sensing BLADDER/BOWEL

W & ETT PRESSURE SO IN ILI G NG

REMOVAL OF THREAT

2 RESILIENCE RESPONSE

S A F E T Y

Recovery of feelings felt >>> futility

in a ain lay i ^ac depn trushing brhe pode end Sng t m enc e

BRAIN’S INTERNAL BACKUP DEFENSES

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

Impact of the STress Response - a loss of tender feeling -

insidious long-term impact

CONFUSING SIGNS OF A WORKING STRESS RESPONSE the loss of so-called ‘nega3ve’ feelings is typically misinterpreted posi3vely

no longer talks about what distresses or hurt feelings no longer feels unsafe or alarmed no longer reads rejecSon or feels its sSng 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 funcSon or perform under duress

3 STRESS RESPONSE

THREAT S E F P A A C R I A N T G I O N

DEFENSIVELY

DEPRESS

DEFENSIVELY

DETACH

REMOVAL OF THREAT

2 RESILIENCE RESPONSE

S A F E T Y

Recovery of feelings felt >>> futility

in a ain lay i ^ac depn trushing brhe pode end Sng t m enc e

BRAIN’S INTERNAL BACKUP DEFENSES

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

SIGNS OF AN ACUTE STRESS RESPONSE AFTER A DISTRESSING EVENT

lin e e f

- typically referred to in the ‘disorder approach’ as a post-traumaRc stress syndrome or disorder Blinded by:

ess SIVENESS l ut IMPUL b ALARM ion FRUSTRATION t mo e re o m PURSUIT

• diagnoses • ‘empathy’ • ‘dysregulaSon’

- 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 impaRence

- erupRons of agacking energy

- self-agack and suicidal impulses

SIGNS OF STUCK PRIMAL SEPARATION EMOTIONS

in l e fe

- clutching, clinging, possessing, hoarding, acquiring, impressing, pleasing, etc - fragmented fixes & fixaRons with pursuit as the theme – winning, placing, hunRng, chasing, agracRng, demanding, reducing, seeking, enhancing, etc - preoccupaRons with altering - preoccupaRons with concealing PURSUIT oneself in pursuit of belonging, self in pursuit of belonging, love or significance love or significance

s s e tl u n b FRUSTRATION ALARM o i ot m ee r mo

- anxiety - irraRonal obsessions - irraRonal avoidance - anxiety reducing behaviour - an agracRon to what alarms - inability to stay out of trouble - recklessness and carelessness - agenRon deﬁcits around alarm - chronic agitaRon and restlessness

- ﬁts & tantrums - hilng and ﬁghRng - obsessions with change - aggression and violence - rudeness and meanness - irritability and impaRence - erupRons of agacking energy - self-agack and suicidal impulses

THE SEPARATION COMPLEX – A LEGACY OF TRAUMA

- the telltale - the telltale (but reversable) marks of marks trauma of trauma on personality on personality -

stuck

stuck in defensive detaching and transference

stuck

ALARM

PURSUIT

stuck in defensive alpha or over-dependence

stuck

FRUSTRATION

stuck in a defensive ﬂight from feeling & vulnerability (ie, a stuck stress response)

Stress & Trauma - Gordon Neufeld

3 STRESS RESPONSE

THREAT S E F P A A C R I A N T G I O N

Hirose Seminars - Edmonton - May 7, 2024

REMOVAL OF THREAT

2 RESILIENCE RESPONSE

S A F E T Y

Recovery of feelings felt >>> futility

in a ain lay i ^ac depn trushing brhe pode end Sng t m enc e

DEFENSIVELY

DEPRESS

DEFENSIVELY

DETACH

5 BRAIN’S INTERNAL BACKUP DEFENSES

emo

tio

FEELINGS

bra nal

prefrontal cortex sensory gating system

emotions stir us up & move us

internal feedback from the body

Feelings are the mind’s READINGS of emoRonal feedback

sensing outside world

REVERSE ATTACHMENT DEPRESS EMOTION

emo

tio

FEELINGS

bra nal

prefrontal cortex DE

MO STRESS

more emotion

more feedback from the body

1 sensing trouble

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

depresssion = flaêned affect

threat to attachment can trigger a defensive depressing of emotion

e m

ot i o n

about defensive detaching If the separaSon faced is deemed unbearable, the brain can reverse direcSon of the pursuit in an automated aêmpt to reduce the threat. The aâchment drive itself cannot be reversed since it is the default and preeminent drive and only increases under threat. • can be situaRonal or pervasive, physical or emoRonal, parRal or complete • can involve DEFENSIVE TRANSFERENCE to other persons such as one’s peers and famous figures (includes fantasy agachments) • can involve the DEPERSONALIZATION of agachment (ie, detaching from persons and agaching instead to pets, groups, objects, naRons, race, ideas, possessions, poliRcs, etc, etc, etc) • depersonalizaRon can also result in fragmented pursuit – FIXES & FIXATIONS – which are highly addicRng because they cannot fulfill or deliver care

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

g in ng cli

Some common a^achment-driven where the pursuit is divorced from its relaSonal context: goin g scor g fo sin r hu ing ses PURSUING PRAISE gs/s s o mile p hoarding s T G H IN N T IN W G E N N I e T s FI U AC lau ND ATTR EH app seeking g TH FIXES & collec si n agenRon Rng FIXATIONS chaseekin g statu s clutching THE CHASE eness m g a in s ir g acqu chasing marks pursuin G PLE AM ASI ING NG x e s r fo g chasin unRng evin h i g h c a pprov a PORNOGRAPHY al placing

Stress & Trauma The WISDOM ! of the ! Chapter Five Stress Response

Chapter 1

The RECOVERY of FEELINGS

More Wounding in today’s world teach less

empathy

SAFETY

stop more bullying

reduce increased percepSons of threat

reduce more

social interacSon

increase less scripSng & supervision

Stress & Trauma - Gordon Neufeld

Resilience Response

Stress Response

Feelings that have been inhibited bounce back to enable opRmal funcRoning and the realizaRon of full potenRal

acRvaRon of

ATTACHMENT’S EMERGENCY RESPONSE TEAM alarm, frustraRon & pursuit FEELINGS that would interfere with performing or funcRoning in stressful circumstances are inhibited

Hirose Seminars - Edmonton - May 7, 2024

Provide SAFETY through

• RELATIONSHIP • PLAY

RECOVERING FEELINGS 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

- making it safe to feel -

P HI NS

O TI LA

- parent - grandparent - relaSve - teacher - coach - expert - counsellor - therapist - caregiver - case worker - volunteer

applying relaSonal and emoSonal ﬁrst-aid

ADULT

T R U - wounding S by others T - losses and I lacks N - neglect and G

(eg, parent, teacher, therapist)

We must HAVE their hearts before we can protect their hearts

rejection

CHILD

D E P E N - shaming or D put-downs abuses and E - violations N distress and C - adversity E

(or client)

ng hi c at th

nu rt ur e

Hirose Seminars - Edmonton - May 7, 2024

yt an

at ta ch m en t

Stress & Trauma - Gordon Neufeld

an d

ld ou

e id

en ga ge

v di

to caring adults and emotional playgrounds

Helping via Relationship • convey a strong CARING ALPHA presence to inspire dependence

• BRIDGE problems and all separaRons

• COLLECT to engage and invite dependence • COME ALONGSIDE emoRonal experience

RELATIONSHIP

• support EXISTING ATTACHMENTS with caring adults

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

Helping via Relationship • convey a strong CARING ALPHA presence to inspire dependence

• BRIDGE problems and all separaRons • convey TRUST in their strength to cope (vs over-protecRon)

• COLLECT to engage and invite dependence • COME ALONGSIDE emoRonal experience

• provide CARE (including food) in the context of connecRon

RELATIONSHIP

• support EXISTING ATTACHMENTS with caring adults

• matchmake to embed in CASCADING CARE

We are meant to fit together in hierarchical attachment arrangements of CASCADING CARE as opposed to contrived arrangements based on social roles, gender stereotypes, prevailing assumpRons of equality, or parRcular dynamics between parents and children or between partners of a couple or in friendship

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

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

Helping via Relationship • convey a strong CARING ALPHA presence to inspire dependence

• BRIDGE problems and all separaRons • convey TRUST in their strength to cope (vs over-protecRon)

• COLLECT to engage and invite dependence • COME ALONGSIDE emoRonal experience

• provide CARE (including food) in the context of connecRon

RELATIONSHIP

• support EXISTING ATTACHMENTS with caring adults

• matchmake to embed in CASCADING CARE

• create SAFE SPACES for feelings to bounce back

Stress & Trauma - Gordon Neufeld

SPACE FREE :

T wounding R U teaching S T problemI solving N screens & distractions G

ADULT

(eg, parent, teacher, therapist)

CHILD

Hirose Seminars - Edmonton - May 7, 2024

FREE D SPACE : E P be upset E N D feel sad E N C E

(or client)

Create timely spaces for feelings to bounce back • AFTER times of stress including separation, school, strained interactions, discipline, special performances, wounding, loss, etc • ideally BEFORE sleep or the passing of time interferes with the ability of the thinking brain to interpret emotional feedback and link to the situations that stirred one up • FREE of digital pursuit (social or videogames) and other competing activities • FREE of problem solving, judgment, correction or teaching • through RITUALS involving safe relationships and/or emotional playgrounds

Through another’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 • BE their source of WELL-BEING 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 & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

RECOVERING FEELINGS 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

- making it safe to feel -

L RE

P HI NS O I

- parent - grandparent - relaSve - teacher - coach - expert - counsellor - therapist - caregiver - case worker - volunteer

l rea

PLAY

for

NO T

T NO

wo rk

applying relaSonal and emoSonal ﬁrst-aid

expressive

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

Harness the Power of Play • to safely engage and DISTRACT in alarming situaRons

• to provide a bubble of SAFETY in a • to LIGHTEN the distressing Rmes emoRonal load • 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 emoRon

• to set the stage to access SADNESS when emoRonally ready

When drawing into play, we are transferring into the arms of NATURE itself so it can gently and wisely restore lost feelings

EmoSons are easier to feel when one step removed from real life

EmoSons are not at work, so the inhibiSon of feelings is reversed Play is safe so feelings won’t get hurt

Words or their lack, do not get in the way

EmoSons are freer to move and so more likely to be felt and idenSﬁed

Feelings of fuSlity are much easier to access

Feelings are recovered when emotions are at play

ENCOUNTERS WITH FUTILITY

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

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 crans, make music, priming the acRvity where necessary

• set the stage for made-up STORIES, so their emoRons can drive something other than nightmares • sing or hum LULLABYtype songs if possible, to harness their emoRonal and connecRve power

PLAY

• if defended against closeness, engage in PLAYFUL CONNECTION, providing brief ‘accidental’ experiences of contact that are able to disarm

• engage in the CULTURAL PLAY, ie, the dances, music, art, of their culture of origin

Inviting Instincts & Emotions to Play • provide opportuniRes to play out ALARM as well as alarming scenarios, while safely in the context of play where it is one step removed and doesn’t count for real

• give SEPARATIONTRIGGERED-PURSUIT safe expression through games or acRviRes characterized by the hunt, the chase, or the ﬁnd • provide plenty of opportunity for PRETENDING to be someone or something else

• give residual FRUSTRATION some playful expression via games of construcRon and/or destrucRon

PLAY

• give ALPHA insRncts safe expression through playing the leader, the boss, the superhero, the rescuer, the one in charge, the one giving the orders

• give DEPENDENT insRncts safe expression through playing the baby, the pet, the sick, the wounded, the one in need of care

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

... in our pursuit of happiness PRESS PAUSE

... in avoiding negaRve thoughts ... in agempRng not to be upset ... in trying to stay in perspecRve ... in agempRng to stay opRmisRc ... in trying to cheer each other up ... in pulng limits on grief and sorrow ... in denying that the glass is half empty ... in trying to change the Eeyores into Tiggers

PLAY

l rea

y ap r e th

for

NO T

T NO

wo rk

into the SADNESS whose task it is to facilitate needed endings, strengthen as required, and deliver us back to what happiness exists

expressive

Stress & Trauma - Gordon Neufeld

Hirose Seminars - Edmonton - May 7, 2024

RECOVERING FEELINGS

helper

- making it safe to feel -

L RE

P HI NS O I

RECOVERING FEELINGS - making it safe to feel -

vs adult therapeuSc techniques & methods

vs treaSng children directly

vs teaching emoSonal management vs cogniSve and raSonal approaches

vs promoSng ‘posiSve feelings’

helper

vs promoSng selfcare and stress management

P HI NS

O TI LA

vs trauma debrieﬁng & correcSng percepSons

applying relaSonal and emoSonal ﬁrst-aid

4/12/24

TRANSFORMING TRAUMA with EMOTIONALLY FOCUSED INDIVIDUAL THERAPY Dr. T. Leanne Campbell Registered Psychologist and ICEEFT Certified Trainer

4/12/24

EFT is a RELATIONAL MODEL, whether we are working with INDIVIDUALS, COUPLES OR FAMILIES “The self is a process, constantly constructed in moments of connection and disconnection with others.” S. Johnson & L. Campbell (2022)

OVERVIEW Attachment Theory, Trauma and the Attachment Perspective on the Impact of Trauma EFT: Goals, Stages and Interventions Tuning in and Finding Focus with the C.A.R.E. Model and Charting the Course for Therapy Working with Trauma through the Three-Stage Process

At the end of the workshop, participants will be able to: • Describe the the attachment perspective on trauma and its impacts • Describe the role and nature of assessment in EFIT, including the C.A.R.E. model and how the EFIT therapist charts the course of therapy based on these initial sessions • Describe the 3 stages of therapy and begin to implement the 5 moves of the EFIT Tango to shape corrective emotional experiences

4/12/24

ATTACHMENT THEORY

Attachment is Fundamentally an Interpersonal Theory Bonding with others is an essential survival strategy, a biological imperative Isolation is inherently traumatizing Focus on Emotion and the Regulation of Emotion Key factor in mental health relates to capacity to manage fear in everyday life, and in context of existential realities pertaining to death, isolation, loss and loneliness

Attachment Theory is a Developmental Theory Concerned with growth and adaptability and factors that either block or enhance adaptation under conditions of stress and/or trauma exposure

THE ATTACHMENT PERSPECTIVE ON HEALTH

• a felt sense of secure connection with self and others typified by emotional balance and cognitive flexibility “A secure connection shapes balanced, adjusted human beings who then have better relationships with loved ones and friends, which then foster ongoing mental health and adjustment and a greater ability to relate to others.” S. Johnson, 2019, p. 10

Understanding Trauma • Non-interpersonal vs. Interpersonal • Childhood Physical, Sexual, Emotional Abuse; Neglect • Developmental Trauma • Single vs. Multiple Exposures • Proximity to Event: Distant vs. Close • Shorter vs. Longer Duration • Onset: later age vs. earlier age • Minimal/No Support of Family/Caregiver vs. Less/No Support • Attachment Security with someone vs. Insecure Attachment

4/12/24

FOCUS IN EFIT ... IMPACTS OF TRAUMA AS VIEWED THROUGH THE LENS OF ATTACHMENT … • Model/View of Self and Other • Affect Regulation • Strategy (Hyperarousal, Hypoarousal, some combination of both) • Capacity (Rigid/Flexible) • ‘W indow of Tolerance’/Capacity

GOALS OF EFIT: GROWTH AND CONNECTION

HOW? GROWTH THROUGH CONNECTION • “Our sense of who we are is constructed and evolves in our most important relationships” (Johnson, 2019; Johnson & Campbell, 2022) • SPECIFIC GOALS: • To identify and unblock barriers to growth/unleash organic growth process • To offer corrective experiences that positively impact models of self and other and shape stable, lasting change • To enable clients to move into the accessibility/openness, responsiveness and full engagement that characterizes secure attachment with others • To enable clients to shape a coherent sense of a competent self that can deal with existential life issues and become a fully alive human being

A FELT SENSE OF SECURITY, WITH SELF AND OTHERS, typified by ...

• Awareness of and access to vulnerabilities and needs • Capacity to assert these needs coherently and directly to key others/attachment figures • Ability to give attuned support to another • Ability to take in comfort and affirmation from supportive other/attachment figure see also Johnson, 2019, p. 33

4/12/24

THREE-STAGE PROCESS

STAGE 1: STABILIZATION STAGE 2: RESTRUCTURING – SELF AND SYSTEM STAGE 3: CONSOLIDATION/INTEGRATION

Key Therapist Interventions Reprocessing Emotion • Reflect, validate, explore (be curious) • Name, order, distill emotional processing as it occurs. Make implicit messages explicit. • Validate habitual emotion regulation strategies, stuck places, attachment longings and fears, and shifts in experiences/interactions • Ask evocative questions (unpack emotion and ways of constructing experience) • Heighten elements of experience (e.g., use repetition, images to deepen the client’s engagement) • Interpret (make small conjectures tentatively)

Key Therapist Interventions Creating New Interactions • Reflect impact of key others/key experiences • Reframe attachment meanings, interactions/within-between • Contain negative messages (e.g., shame, self-loathing, self-deprecation) • Enact present positions/patterns to make them clear • Shape interactions/encounters (request direct sharing of clear distilled messages and “slice risks thinner” as needed) • Turn new emotional experiences into new signals to key others (Discover, Distill, Disclose) • Shape encounters to heighten, highlight, and begin to consolidate new responses and their impact on views of self and other

4/12/24

STAGE 1 Stabilization • Tuning in with C.A.R.E. and Charting the Course for Therapy • Helping Clients Explore Internal (Within) and Interpersonal (Between) Patterns (Increasing awareness, flexibility, openness) • Moving Individuals into ‘frightening, alien, and unacceptable emotion’ • Shaping Less Reactivity and Numbing (Moving Clients Toward Greater Emotional Balance/Widening the ‘Window of Tolerance’)

TUNING IN AND FINDING FOCUS Assessment as a Process, Not a Checklist Assessment and Treatment Merge

• “Clinical conditions are best understood as disordered versions of what is otherwise a healthy response” (Bowlby, 1980, p. 245)

4/12/24

CONTEXT

TUNING in with C.A.R.E.

ATTACHMENT RELATIONSHIP/THERAPEUTIC ALLIANCE EMOTION

ATTACHMENT SECURITY: RISK OR PROTECTIVE FACTOR?

CASE CONCEPTUALIZATION and TREATMENT PLANNING •

Contraindications

•

Safety Considerations

•

Structuring the Process • EFIT and other Modalities (e.g., EFCT, EFFT)

•

Building an Alliance

•

Transparency provides Agency

•

’Window of Tolerance’ (Therapist and Client)

•

Therapeutic Pacing

•

Building on Momentum

•

Beyond Symptom Reduction, Kick-starting a Natural, Organic Growth Process

•

Therapeutic Outcome is not ‘Dose Dependent’

•

EFIT and other Interventions

4/12/24

STAGE 2 PROCESS – RESTRUCTURING SELF AND SYSTEM Tango interventions are pitched at a deeper level With greater capacity, individuals can move into deeper levels of experience, for longer periods

Stage 1 vs. Stage 2

Increased awareness and flexibility

More access to self (core vulnerabilities/needs, fears, longings) and greater capacity to share core vulnerabilities directly and coherently with others

Increased capacity to engage more deeply with emotion, with more coherence and for longer periods

STAGE 3

• Where were you when you started? Where are you now? And where are you going? • Shaping a new narrative that integrates the past and holds hope for the future

4/12/24

EXPECTATIONS AND OUTCOMES ... SECURE ATTACHMENT ...

• Increased ability to identify and directly and coherently express needs • Increased ability to both ACCEPT and PROVIDE attuned caring and support from/to another • Improved emotional balance, resilience and capacity to manage daily stressors, as well as major life events and trauma exposure

EXPECTATIONS AND OUTCOMES • More than symptom reduction • Template set for ongoing growth • Increased capacity, confidence and competence • Increased ability to navigate interpersonal relationships, including interpersonal conflict • Improved affect regulation strategy and capacity SECURE ATTACHMENT!

MANAGING ONGOING VULNERABILITY With attention to … • Personal Resources (& Risk Factors) • ‘Window of Tolerance’ • Social/Relationship Resources • Grief and Loss • Contextual Factors

4/12/24

SUMMARY How does EFIT meet requirements for effective trauma treatment?

• The EFIT ‘safe haven’ alliance − therapist is open responsive and engaged. I am with you, see you, hear you -• Focus on emotion. Difficulties with affect regulation are at the heart of post-traumatic problems. • EFIT is relational − lack of social support best predictor of outcome after trauma. Attachment science offers a clear map to longings, vulnerability, resilience, model of self. • EFIT is non-pathologizing − normalizes and finds the order/logic in “dysfunction.” • Extensive empirical base − outcome & follow-up − relationship & individual variables. • A tested set of interventions − the EFIT Tango gives focused direction and momentum to therapy sessions. • A clear map for the shaping of core corrective emotional experiences/identity epiphanies from emotion science and EFT process research – restructuring attachment – reshaping self & system. • EFIT is an existential model − able to shape vibrant living and resilience. Kick start an organic growth process – beyond symptom reduction.

Dr. T. Leanne Campbell

Leanne’s Contact Information

Registered Psychologist ICEEFT Certified Trainer and Supervisor CAMPBELL & FAIRWEATHER PSYCHOLOGY GROUP Phone: 250-933-4884 (Nanaimo)/778-440-4884 (Victoria) eftvancouverisland.com cfpsych.ca drleannecampbell.com

5/3/24

Navigating trauma & ad d iction s

DR. CARIS SA M U TH , R. PS YCH ( AB & BC)

Addictions “ M o m e n t a r y f r e e d o m f r o m t h e c l a i m s of t h e a g i n g , c a u t i o u s , n a g g i n g , f r i g h t e n i n g flesh.” - W i l l i a m B u r r o u g h s r o i n

EXCESSI VE HABI TS OF EVERYDAY LI FE

DYNAMI C

MU LTI FACETED

5/3/24

Addiction Myths

True or False? MO ST PEO PLE WHO GET SO BER DO WITH WITHO UT PRO FESSIO NAL HELP

5/3/24

TRUE!

83%

According to t h e NCS 2001-2003, 83% of people w h o w e r e previously d i a g n o s e d w i t h a s u b s t a n c e u s e dis o rder a c h i e v e d r e m i s s i o n for a t leas t a year. Most s t o p p e d u s i n g prior to age 3 0 a n d did n o t r e c i e v e a n y professional help.

L i f e t i m e C u m u l a t i v e P r o b a b i l i t y E s t i m a t e of R e m i s s i o n

% PROBABILITY OF REMISSION

100

70 N icotine

A lc o h o l

C annabis

C ocaine

SUBSTANCE 2 0 0 1 - 2 0 0 2 N ATIO N AL EPIDEM IO LO G IC S URVEY O N ALCO H O L AN D RELATED CO N DITIO N S ( N ES ARC)

5/3/24

Y e a r s of u s e p r i o r to r e m i s s i o n i n h a l f of all c a s e s

YEARS

0 N icotine

A lc o h o l

C annabis

C ocaine

SUBSTANCE 2 0 0 1 - 2 0 0 2 N ATIO N AL EPIDEM IO LO G IC S URVEY O N ALCO H O L AN D RELATED CO N DITIO N S ( N ES ARC)

IN COME A N D OT H ER S O CIO - ECON OMIC FA CT ORS A N D EMPLOY M EN T For nicotine- i ncome lower t ha n $20K wer e less likely to remi t t han individuals with i ncomes $70K or more

COMORBID PS Y CH IAT RIC DIA GN OS IS No association for anxiety and mood disorders Conduct disorder i ncr eased probability of remi ssi on from cannabi s and cocaine and de c r e a s e d for alcohol A PD de c r e a s e d probability of remi ssi on from alcohol or cannabis

RA CE OR ET H N IC IT Y Discrimination and lower levels of social capital s e e n in communi t i es of visible minorities de c r e a s e r at es of remission

A GE

Pr edi ct or s of Re mi s s i o n

H EA LT H GEN DER Women are mor e likely to remi t and t end to exper i ences worse physical, mental, and social c ons que nc e s from s ubs t as nce use

2001-2002 NATI ONAL EPI DEMI OLOGIC SURVEY ON ALCOHOL AND RELATED CONDI TI ONS (NESARC)

5/3/24

True or False? ADDICTIO NS ARE SIMPLY A CHO ICE

False! T h e d i s e a s e m o d e l of a d d i c t io n s h a s provided e v i d e n c e of t h e i m p a c t of s u b s t a n c e s o n t h e b rain a n d t h e c r e a t i o n of t h e addiction cycle. Cons ider ing a d d i c t i o n s a s s im p ly a c h o i c e u n d e r m i n e s t h e i m p a c t o n t h e brain.

NEUROPSYCHOPHARMACOLOGY ( 2 0 1 4 ) 39, 2 5 4 - 2 6 2 ; DO I :10 . 1 0 3 8 /NPP. 2 0 1 3 . 261

5/3/24

Dopamine •I n c r e a s e e x t r a c e l l u l a r dopam ine concentrations in t h e lim bic region •S t i m u l a n t s d i r e c t l y in c re a se d o p a m i n e in synaptic space •O t h e r s u b s t a n c e s w o r k d i r e c t l y o r i n d i r e c t l y to m o d u l a t e d o p a m i n e cell f ir in g •I n c r e a s e s m o t i v a t i o n to seek substance

True or False? ONCE AN ADDICT, ALWAYS AN ADDICT

5/3/24

ALCOHOL CENTRAL NERVOUS SYSTEM DEPRESSANT INITIAL: RELIEF OF ANXIETY, INCREASED TALKATIVENESS, FEELINGS OF CONFIDENCE AND EUPHORIA, AND ENHANCED ASSERTIVENESS

MEDICAL COMPLICATIONS SKELETAL FRAGILITY AND DAMAGE TO TISSUE SUCH AS BRAIN, LIVER, AND HEART

ALCOHOL IS A NEUROTOXIN ASSOCIATED WITH ATROPHY OF THE CEREBRAL CORTEX, REDUCED WHITE MATTER VOLUME, ENLARGED VENTRICLES, AND ATROPHY OF SUBCORTICAL STRUCTURES C O G N ITIV E D E F I C I E N C I E S WITH BOTH W HITE AND GREY MATTER ABNORMALITIES FRONTAL LOBES, LIM BIC SYSTEM, AND CEREBELLUM PARTICULARLY VULNERABLE TO C H R O N IC ALCOHOL ABUSE A LC O H O LIC DEMENTIA KORSAKOFF’ S SYNDROME

5/3/24

CANNABIS ACUTE EFFECTS: HALLUCINATORY AND REACTIVE EMOTIONAL STATES, SOME PLEASANT, SOME UNPLEASANT AND EVEN TERRIFYING; TIME DISORIENTATION; AND RECENT- TRANSIENTMEMORY LOSS LIKELY NO PERMANENT NEUROTOXIC EFFECTS IMPACT ON NEURODEVELOPMENT: CHANGES IN ADULT BRAIN CIRCUITS AFTER HEAVY CANNABIS CONSUMPTION DURING ADOLESCENCE, LEADING TO IMPAIRED EMOTIONAL AND COGNITIVE PERFORMANCE AND POTENTIALLY REPRESENTING A RISK FACTOR FOR DEVELOPING SCHIZOPHRENIA

COCAINE DISRUPTS THE FUNCTIONAL INTEGRITY OF THE BRAIN’ S REWARD CENTRES ABNORMAL METABOLISM AND HYPOPERFUSION EVEN AFTER SUSTAINED ABSTINENCE- SLOWED MENTAL PROCESSING, MEMORY IMPAIRMENTS, REDUCED MENTAL FLEXIBILITY

5/3/24

OPIATES Long- t e r m uses can sustain permanent cognitive impairmentsattention, concentration, various aspects of memory and learning, and visuospatial and visuomotor activities

METHAMPHETAMINE PARANOID PSYCHOTIC EPISODES WITH VIVID HALLUCINATIONS, BOTH AUDITORY AND VISUAL, AND VULNERABILITY TO PSYCHOTIC RELAPSES DAMAGE TO DOPAMINERGIC AND SEROTONERGIC TERMINALS COGNITIVE IMPAIRMENTSATTENTION, MEMORY, EXECUTIVE FUNCTIONS

5/3/24

Dopamine recovery

True or False? EVERYO NE WITH AN ADDICTIO N HAS TRAUMA

5/3/24

False! Individuals directly e x p o s e d to potentially t r a u m a t i c life e v e n t s a r e m o r e a t r i s k (2.5 t i m e s more likely to h a v e a n addiction)

Co-o c c u r r e n c e of PTSD ~ 25-42% Co-o c c u r r e n c e c h i ld h o o d s exual or p h y s i c a l a b u s e ~ 50%

Correlation NOT c a u s a t i o n

T r a u m a a n d S t r e s s - R e l a t e d D i s o r d e r s i n DSM-5

PO ST- T RAUMAT IC ST RE SS DISO RDE R ( PT SD)

RE ACT IVE AT TACHME NT DISO RDE R

E x p o s u r e to actual or t h r e a t e n e d death, s e r i o u s injury, or s e x u a l violence, l ea d i n g to i n t r u s i v e s y m p t o m s , avoidance, n e g a t i v e a l t e r a t i o n s i n c o g n i t i o n a n d mood, a n d h e i g h t e n e d arousal.

c a r e g i v e r s i n early c h i l d h o o d d u e to n e g l e c t or abuse.

F ailure to f o r m h e a l t h y a t t a c h m e n t s w i t h

OT HE R SPE CIFIE D T RAUMA- AND ST RE SSO R- RE LAT ED DISO RDE R ACUT E ST RE SS DISO RDE R

S y m p t o m s do n o t m e e t c r i t e r i a for o t h er

T em p o r ar y b u t s e v e r e anxiety, d i s s o ci at i v e, a n d

d i a g n o s i s i n c a t e g o r y b u t a r e d u e to a s t res s o r. P rov i d e s p e c i f i c s s u c h a s PTSD like s y m p t o m s

other s ym pt om s occurring within one m ont h after a t r a u m a t i c event.

ADJ UST ME NT DISO RDE RS E m o t i o n a l or b eh a v i o r al s y m p t o m s i n r e s p o n s e to a n i dent i fi abl e s t r es s o r , o c c u r r i n g w i t h i n t h r e e m o n t h s of t h e s t res s or.

UNSPE CIFIE D T RAUMA- AND ST RE SSO RRE LAT ED DISO RDE R Typically u s e d i n a n e m e r g e n c y r o o m w h e n a proper diagnosis cannot be obtained

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PTSD

T(t)rauma T raum a - exposure to a d istre ssin g or stressful event resulting in physiological, em otional a n d /o r psychological changes

SPE CIFIC DIAG NO ST IC CRIT ERIA SPE CIFIC DE FINIT IO N OF T RAUMAT IC EVE NT IMPACT S BRAIN FUNCT IO NING

RE SE ARCH BASE D T RE AT ME NT

DIST RE SSING EVE NT LAST ING HE ALT H IMPACT

NO SPE CIFIC EVIDE NCE BASE D T RE AT ME NT

BRO AD FRAME WO RK

GENE RIC DIST RE SSING EXPE RIE NCE

T r a u ma

76%

76 % OF CANADIANS EXPE RIE NCE T RAUMA IN T HE IR LIFE T IME

9 . 2 % OF CANADIANS EXPE RIE NCE PT SD IN T HE IR LIFE T IME

H o w p r e v a l e n t i s PTSD?

Source: Ca na dia n Psychological Association

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W h a t i s PTSD?

SEVERE PSYCHOLOGICAL TRAUMA Exposed to: death, t h r e a t e n e d death, act ual or t h r e a t e n e d ser i ous injury, or act ual or t h r e a t e n e d s e x u a l violence,

PERSISTENT REEXPERIENCING Re c u r r e n t a n d d i s t r e s s i n g recollections, flashbacks, or n i g h t m a r e s about t h e t r au mat i c event. Can be dissociation, d e p e r s o n a l i z a t i o n or derealization

NEGATIVE CHANGES IN THOUGHTS AND MOOD P e r s i s t e n t negat i ve beliefs about oneself, others, or t h e world, a n d d i s t ur b ed e mo t i o n a l state.

HYPERAROUSAL Exagger ated startle r esponse, irritability, difficulty concent r at i ng, a n d sl eep di st ur bances.

AVOIDANCE Efforts to avoid thoughts, feelings, people, places, or activities a s s o c i a t e d w i t h t h e trauma.

C o g n i t i v e b e h a v i o u r a l T h e o r y of PTSD

LEARNING T HE ORIE S F e a r c o n d i t i o n of t h e t r a u m a t i c e v e n t (i.e. m e m o r i e s ) l eads to f l a s h b a c k s a n d r e m i n d e r s of t h e e v e n t m a k e t h e m e m o r y reoccur

MALADAPT IVE CO GNIT IVE APPRAISALS Negative beliefs a b o u t t h e m s e l v e s , t h e world, a n d t h e future, l e a d i n g to d i s t o r t e d perceptions and exaggerated threat a p p r a i s a l s s u c h a s "I a m wort h l es s "

ST RE SS RE SPO NSE T HE ORY The traumatic event is compatible with c u r r e n t s c h e m a s c a u s i n g t h e e m e r g e n c e of psychological defense mechanisms.

THE CO GNITIVE MO DEL PRO VIDES A FRAMEWO RK FOR UNDERSTANDING HO W OUR THO UGHT PRO CESSES AND INTERPRETATIO NS CO NTRIBUTE TO THE DEVELO PMEN T AND MAINTENANCE OF PTSD SYMPTO MS.

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I n f o r m a t i o n P r o c e s s i n g T h e o r i e s of PTSD

FEAR NE T WO RK

CO NT INUAL ACT IVAT IO N

ME MO RY SIG NIFICANCE

C o i n ed by P e t e r Lang, fear n e t w o r k s

F e a r n e t w o r k s a r e c o n t i n u a l l y active for

T r a u m a t i c m e m o r i e s a r e u n i q u e f r o m daily

c o n t a i n t h e i n t e g r a t i o n of e m o t i o n s a n d c o g n i t i o n s w h i c h e n a b l e a survival response

t h o s e w i t h PTSD l e a d i n g to c o n t i n u a l "survival mode."

life c a u s i n g f r a g m e n t a t i o n of t h e fear network and require reintegration

INF ORMATIO N THAT IS NOT PRO CESSED PRO PERLY, CAUSES PSYCHO LOGICAL HARM

T h e o r i e s of t h e M u l t i p l e M e m o r y S y s t e m of PTSD

MULT IPLE ME MO RY SY ST EMS

DUAL RE PRE SENTAT IO N T HE ORY

FLASHBACKS

M ore m e m o r y s y s t e m s t h a n e p i s o d i c a n d

Two parallel m e m o r y s y s t e m s : co nt ext ual

Partially p r o c e s s e d s e n s o r y a n d perceptual

f u n c t i o n differently

m e m o r y a n d s e n s o r y m e m o r y . Traumatic m e m o r i e s a r e e n c o d e d pathologically i n w h i c h S-m e m i s e n h a n c e d a n d C-m e m is weakened.

i n f o r m a t i o n i s s t o r e d i n t h e S-m e m h e n c e w h y t h e retrieval of t r a u m a t i c m e m o r y is visual a n d t r i g g e r e d by s i t u a t i o n a l cues.

DISTURBANCE IN NO RMAL MEMO RY FUNCTIO NING CAUSES PTSD SYMPTO MS

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B r a i n a n d PTSD

HIPPO CAMPUS AND ME MO RY

AMY GDALA AND FE AR RE SPO NSE

PRE FRO NTAL CO RT EX AND EMOT IO NAL RE GULAT IO N

T h e h i p p o c a m p u s , a r e g i o n crucial for

T h e amygdala, r e s p o n s i b l e for

T r a u m a c a n i m p a c t t h e prefrontal

m e m o r y f o r m a t i o n a n d retrieval, c a n be affected by t r a u m a. Indi v i dual s w i t h PTSD m a y e x h i b i t d e c r e a s e d h i p p o c a m p a l volume, w h i c h c a n i m p a c t

p r o c e s s i n g fear a n d e m o t i o n a l responses, may become hyperactive in i n d i v i d u a l s w i t h PTSD. T h i s c a n lead to h e i g h t e n e d anxiety, h yp erv i g i l ance, a n d

cortex, w h i c h p l ay s a role i n e m o t i o n a l regulation, d e c i s i o n - m a k i n g , a n d i m p u l s e control. In d i v i d ual s w i t h PTSD m a y h a v e difficulty r e g u l a t i n g their

t h e i r ability to p r o c e s s a n d s t ore memories.

a n e x a g g e r a t e d s t art l e r e s p o n s e .

e m o t i o n s a n d m a n a g i n g their behaviors.

WHAT IS CPTSD?

Consi der ed a s e p a r a t e d i a g n o s i s by t h e World Health Or ganization a n d i n c l u d e d i n t h e ICD-11

Co n t ai n s all t h e s y m p t o m s of PTSD w i t h t h e u n i q u e symptomatology of d i s t u r b a n c e s of self-or gani zat i on (DSO)

Currently n ot a c c e p t e d by t h e A me r i c a n P s y ch i at r i c Association a s a s e p a r a t e disor der from PTSD

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D i s t u r b a n c e s of Self- Sel f-O r g a n i z a t i o n

AFFE CT DY SRE GULAT IO N

NE GAT IVE SE LF- CO NCE PT

DIST URBANCE S IN RE LAT IO NSHIP

I m p a i r e d ability to regul at e a n d / o r tolerate

A p e r s o n ' s overall p e r c e p t i o n a n d evaluation

Difficulty n a v i g a t i n g i n t e r p e r s o n a l

negative emotional states

of t h e m s e l v e s i s critical

r e l a t i o n s h i p s o r d e m o n s t r a t i n g p ers p ect i ve taking

Characteristics

REPE TITIVE TRAUMA

PE RSO NALITY CHANGE S

INCLUD E PTSD SYMPTO MS

P r o l o n g e d or

In fle x ib le a n d

Re-e x p e r i e n c i n g

repetitive events from w h ich escape

maladaptive features

in the present

i s d iffic u lt or impossible

H o s t i l e or mistrustful

Ongoing se n se

Avoidance of t h r e a t

attitude toward t h e world D ifficulty creating social bonds

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Developmental Impacts CPTSD i s n o t s i m p l y a m o r e s e r i o u s f o r m of PTSD. D ue to t h e prolonged n a t u r e inherent in the traum atic events, cognitive s c h e m a s a n d b r a i n d e v e l o p m e n t is i m p a c t e d i n a u n i q u e way.

Di f f e r e n t i a l D i a g n o s i s

U n s t a b l e s e n s e of self

Stable negative identity

Temper outbursts Ongoing s en s e of t h r e a t Low self-w o r t h

I m p u ls iv ity

Re- e x p e r i e n c i n g t r a u m a A ffect dysregulation

A v o i d a n c e of t r a u m a reminder

R e la tio n a l impairment

PTSD

CPTSD

BPD

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Childhood Development a n d Trauma

EARLY CHILDHO OD EXPE RIE NCE S SHAPE DE VE LOPME NT T r a u m a t i c e v e n t s d u r i n g form at i v e years can have profound and lasting impacts on m e n t a l h e a l t h a n d well-being.

SCHE MA DE VE LOPME NT

LOW- GRADE I NFLAMMATI ON

Early e x p e r i e n c e s s h a p e h o w c h i l d r e n

C h i l d h o o d a b u s e w a s a s s o c i a t e d w i t h low-

form mental representations and c o n c e p t u a l fram eworks .

grade inflammation. Chronic inflammation h as been established as the overlying m e c h a n i s m d e m o n s t r a t i n g h o w t h e i m m u n e s y s t e m c o n t r i b u t e s to d i s e a s e development.

UNDERSTANDING THE IMPLICATIO NS OF STRESS ON CHILDHO OD DEVELO PMEN T IS CRUCIAL FOR PRO VIDING APPRO PRIATE SUPPO RT AND INTERVENTIO NS.

Adverse Childhood Experiences Questionaire

10 q u e s t i o n a s s e s s m e n t of c h i l d h o o d e x p e r i e n c e s C o n n e c t e d t o i n c r e a s e d r i s k for p o o r h e a l t h o u t c o m e s i n adulthood N o t a s c r e e n i n g to o l for t r a u m a - o p e n s a c o n v e r s a t i o n a b o u t i m p a c t s of e a r l y c h i l d h o o d e x p e r i e n c e s D e b a t e d i n r e s e a r c h a s a v a l i d m e a s u r i n g tool ACEs a r e c o n s i d e r e d " c o m m o n " 67% of s a m p l e p o p u l a t i o n s c o r e d a t l e a s t o n e , 20% s c o r e d a b o v e 3 (CDC 2021)

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Childhood Trauma Questionaire

7 0 i t e m l i k h e r t s c a l e q u e s t i o n n a i r e ( S h o r t f o r m -2 8 questions) M easures em otional abuse, physical abuse, sexual abuse, e m o tio n a l neglect, a n d p h y s i c a l neglect. P e e r r e v i e w e d e v i d e n c e of v a l i d i t y a n d r e lia b ility H i g h l y s e n s i t i v e t o i d e n t i f y i n g i n d i v i d u a l s w i t h v e rifie d histories P ublished by P earso n

L a s t i n g I m p a c t s of C h i l d h o o d T r a u m a

PO OR ST RESS REPO NSE

EXE CUT IVE DY SFUNCT IO N

R e d u c e d ability to r e t u r n to

R e d u c e d ability to c o n t r o l a n d

baseline physiological and p s y c h o l o g i c a l s t a t e s after f a ci n g a c u t e s t r e s s .

coordinate thoughts and b e h a v i o u r c a u s e d by alterations in connectivity in t h e brain.

MALADAPT IVE PE RSO NALIT Y CHARACT ERIST ICS H i g h e r r i s k for a n x i e t y a n d d e p r e s s i o n a s well as n e u r o t i c i s m a n d n e g a t i v e selfassociations.

BRAIN ALT ERAT IO NS R e d u c e d m e d i c a l prefrontal c o r t e x v ol um e a n d i n c r e a s e d a m y g d a l a reactivity. .

CHILDHO OD TRAUMA CAN HAVE PRO FOUND AND LASTING IMPACTS ON BRAIN STRUCTURE, FUNCTIO N, AND EMOTIO NAL WELL-BEING, HIGHLIGHTING THE IMPO RTANCE OF EARLY INTERVENTIO N AND SUPPO RT.

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Role of Amygdala "Attentional b i a s for t r a u m a s pecif ic r e m i n d e r s , for t r a u m a e x p o s e d p ar ticip ants , reflected by a n i n c r e a s e i n f u n ctio n al activity i n visual, sensory, memory, a n d a t t e n t i o n r elated area" (Nilsen et al., 2016)

True or False? ADDICTIO NS NEEDS TO BE CO NSIDERED AS A CO MPLEX DYNAMIC BETWEEN VARIO US FACTO RS

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BIOLOG ICAL

PSYCHOLOG ICAL

Addiction cycle

Learned helplessness

Genetics

Attachment

Cas cade model

Emo tio n al regulation

I m p a c t of t r a u m a a n d development

Co-m o r b i d p s y c h i a t r i c d i a g n o s e s Conditioned behaivior Self-efficacy

True! SOCIAL

SPIR ITUAL (MEANING )

Social l e a r n i n g theory

Motivation for sobriety

Social dislocation

Salutogenesis

Social disparity

Feeling of b e i n g alive Self-a w a r n e s s

Biological

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Social

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ATTACHMENT EARLY CHILDHOOD EXPERIENCES AND INSECURE ATTACHMENTS – INTERRELATED RISK FACTORS FOR ADDICTIONS BOWLBY’S INTERNAL WORKING MODEL SELF- MEDICATION THEORY OF ADDICTIONS “SIGNIFICANT POSITIVE ASSOCIATION BETWEEN INSECURE ATTACHMENT (ANXIOUS AND AVOIDANT) AND A MORE INTENSIVE AND DYSFUNCTIONAL USE OF THE INTERNET AND SOCIAL MEDIA”

Social Learning Theory

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SOCIAL DISLOCATION Dislocation - lack of attachm ent, belonging, identity, meaning, [and] purpose

Social Disparity • Poverty • Lack of mental health resources • Housing • Increased stress

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Psychological

Addiction and ADHD • Etiology • Genetic - 0.8 heritability estimate • Environment- Risk factors smoking during pregnancy, premature birth, low birth weight

• Medications that inhibit the dopamine transporter increase synaptic dopamine levels and ameliorate the symptoms of ADHD • Reduced volume prefrontal cortex • Effects 8%-18% of children and adolescents • 60% continue to show symptoms into adulthood (4.4%)

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Addiction and ADHD • When combined with SUD, severity of impairment increases • More likely to move to another DOC after a period of sobriety • Longer duration of having a substance use disorder and a slower remission rate • Poor emotional regulation and rejection sensitive disphoria

Mood Disorders and Addiction • Major Depressive Disorder most common - 15% to SOo/o lifetime prevalence rate • MOD linked to worse outcomes in addiction treatment • Bipolar Disorder - 1o/o-3o/o • Largest strength of association between addiction and Bipolar, increase likelihood of addiction by four

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Anxiety Disorders and Addiction • High comorbid relationship between alcohol and anxiety • Overlap of symptoms between disorders makes it difficult to know rates of prevalence NESARC study - 50% of those with lifetime GAD had a lifetime comorbid SUD

Psychotic Disorders and Addiction • Transient substance-induced psychotic symptoms are not uncommon • One month of abstinence needed to make the diagnosis of a primary psychotic disorder • 47% of persons with schizophrenia have a lifetime experience of SUD

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Personality Disorders and Addiction • Usually experiences the PD as ego-syntonic and externalizes blame for their dysfunction • Onset of PD typically late adolescence or early adulthood • Treatment • Structured environment with dual focus of PD and SUD • Utilize integrated psychosocial treatments • Integrated system of care • Symptom-targeted pharmacotherapy • Psychosocial interventions

PTSD and Addiction • In civilian populations- SUD occurs in 21.6% to 43% of individual with PTSD • Self-medication theory • Treatment • Cognitive Therapy • Exposure therapy (CPT, PE, EMDR, NET)

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Conditioned Response Classical Conditioning

Operant Conditioning

Associate an involuntary response and a stimulus

Associate a voluntary behavior and a consequence

•o

••

Behavioral Economics "Behavioral economic theory predicts that the primary contextual influences on drug use are both constraints on access to drugs and the availability and value of alternative substance-free sources of reinforcement" - Correia et al., 2010

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Learned Helplessness

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

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MOTIVATION ACHIEVEMENT STRIVING

INTRINSIC MOTIVATION

COMPETENCE

FLOW

OPPONENT PROCESS

EXTERNAL REGULATION

POSITIVE AFFECT

GOAL

INTROJECTION

VALUE

PERSONAL CONTROL

POSSIBLE SELF

RELATEDNESS

Antecedent Conditions * External Events * Social Contexts

Internal Motives

Needs

Cognitions

Emotions

Energized, Goal-directed, and Persistent (Motivated) Action

Figure 1.2

Three Categories of Internal Motives Johnmarshall Reeve. Understanding Motivation and Emotion, 7th Edition (p. 3). Wiley. Kindle Edition.

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Table 14.1

The Motivational Urge (Action Tendency) Associated with 17 Emotions

Individual Emotion

Motivational Urge or Action Tendency

Fear Anger Disgust Contempt Sadness Joy Interest Pride (Authentic) Shame Guilt Embarrassment Envy (Benign) Gratitude Regret Hope Empathy Compassion

Flee; protect oneself. Overcome obstacles; right an illegitimate wrong. Reject; get rid of; get away from. Maintain the social hierarchy. Repair a loss or failure. Continue one's goal striving; play; engage in social interaction. Explore; seek; acquire new information; learn. Acquire further skill; persist at challenging tasks. Restore the self; protect the self. Make amends. Appease others; communicate blunder was unintended. Move up; improve one's position. Act prosocially; grow the relationship. Undo a poor decision or behavior. Keep engaged in the pursuit of a desired goal. Act prosocially; help the other. Reduce suffering.

Johnmarshall Reeve. Understanding Motivation and Emotion, 7th Edition (p. 3). Wiley. Kindle Edition.

Emotions

F eelin gs

B o d ily R e sp o n se s

• Subjective Experience • Phenom enological Awareness • Cognitive Interpretation

• Bodily P reparation for Action • Physiological Activation • Changes in Hormonal Activity

Distinct Patte eural (Brai Activity

S e n s e o f P urpose

E xp ressive B ehaviors

• Im p u lse to Action • Goal-Directed Motivational State • Functional Aspect to C oping

Johnmarshall Reeve. Understanding

Motivation and Emotion, 7th Edition (p. 3). Wiley. Kindle Edition.

• Social Signals and Communications • Facial Expression • Voice T o n e Significant Life Event

Figure 12.1 Four Components of Emotion

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Feelings

Bodily Responses

Aversive, Negative Feeling of Distress

Decreased Heart Rate, Low Energy Level Decreased Skin Conductance

Increased Activations In Medial

Expressive Behaviors

Sense of Purpose

Johnmarshall Reeve. Understanding Motivation and Emotion, 7th Edition (p. 3). Wiley. Kindle Edition.

Inner Eyebrows Raised, Comers of Lips Lowered, Lower Lip Pouting and Trembling

Desire to Take Whatever Action Is Necessary to Overcome or Reverse the Separation or Failure Separation from Loved One, Failure on an Important Task Figure 12.2

Four Components of Sadness

Emotional Intelligence • Ability to identify and communicate emotional experiences • Ability to connect specific mental experiences with situations and behaviors • Ability to self-regulate negative emotional states • Ability to monitor future behavior from prior feelings and emotions

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Alexithymia • Difficulty identifying feelings and distinguishing between these feelings and bodily sensations of emotional arousal • Difficulty describing feelings • Constricted imaginal processes • Externally oriented cognitive style

Stress • '½.nything which causes an alteration of psychological homeostatic processes" • Brain responses to chronic stress • Stress management and learned behaviour

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Regret/Guilt/ Self-reproach '--

Impulse Control Disorder Cycle

Compulsive Disorder Cycle

Tension/Arousal

Anxiety/Stress

Obsessions

Pleasure/Relief/ Gratification

Impulsive Acts

ADDICTION

Repetitive Behaviors

Relief of Anxiety/ . Relief of Stress

CYCLE

Kwako LE, Koob GF. Neuroclinical Framework for the Role of Stress in Addiction. Chronic Stress. 2017;1

Substance Dependence on Alcohol

STRESS RESPONSE SYSTEM

Hypothalamus

Pituitary gland

Adrenal gland

CRH - Corticotropin-releasing hormone ACTH -Adrenocorticotropic hormone

••••• • ••

• To immune system••

ttsz / Getty Images

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PERFORMANCE fatigue

exhaustiott

laid back

aN<iety/ panic/anger

JI'

ittactive

to·o little

stress

( ,.. de load)

optimuW\ st,ress

too W\uc$\

stress

(overload)

burn-olAt

STIIBSS LEVEL

Meaning

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ADDICTION AS A RESPONSE “Such w i d e s p r e a d p h e n o m e n a as depression, aggression a n d addiction are n o t u n d e r s ta n d a b le u n l e s s w e r e c o g n iz e t h e e x i s t e n t i a l v a c u u m u n d e r l y i n g them.” “When a p e r s o n can't fin d a d e e p s e n s e of m e a n in g , t h e y distract t h e m s e l v e s w i t h pleasure.” Viktor E. Frankl

RELATIONSHIPS

GOALS

TRAUMA/ PSYCHOLOGICAL SYMPTOMS/ FAMILY CONFLICT, ETC.

Alive

INTENSITY

SUBSTANCE USE DANGER CONFLICT

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Developing Meaning • Acceptance of suffering • Self- awareness • Relationships

• Intrinsic goals

•

"If there is meaning in life at alt then there must be meaning in suffering.,, -Viktor Frankl

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':..the individual is defined only by his relationship to the world and to other individuals; he exists only by transcending himself, and his freedom can be achieved only through the freedom of others. He justifies his existence by a movement which, like freedom, springs from his heart but which leads outside of himself." - Simone de Beauvoir, 1948, The Ethics OfAmbiguity, p. 156

"In order to live a meaningful life, humans need answers, i.e., a certain understanding of basic existential questions. These 'answers' do not have to be made completely explicit, as a lack of words does not necessarily indicate a lack of understanding, but one has to able to place oneself in the world and build a relatively stable identity. The founding of such an identity is only possible if one can tell a relatively coherent story about who one has been and who one intends to be." - Lars Fr. H. Svendsen, A Philosophy of Boredom

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"People have two basic concerns: One is to survive; one is to exist. The former only asks to go on living; the latter asks for meaning. The former concerns itself with how to live, the latter with why to live, the meaning of living. - Xuefu Wang, 2019, The Symbol of the Iron House: From Survivalism to Existentialism. In Existential Psychology East-West (Vol. 2), p. 7.

"Personal meaning is defined as feelings of satisfaction and fulfillment that flow from the pursuit of worthwhile activities and life goals"

- Dr. Paul Wong

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"The existential vacuum manifests itself mainly in a state of boredom. now we can understand Schopenhauer when he said that mankind was apparently doomed to vacillate eternally between the two extremes of distress and boredom. In actual fact, boredom is now causing, and certainly bringing to psychiatrists, more problems to solve than distress." - Viktor Frankl

Assessment

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Structured Interview • Background • Childhood- medical issues, traumatic events, relationship with family • Education- primary and secondary school, social connections, academic performance, any difficulties • Employment- patterns of length of employment • Psychiatric history- medications, diagnosis, treatment • Substance use history

• Current • Psychological symptoms- MSE presentation

Mini- Mental Status Exam https://cgatoolkit.ca/Uploads/ContentDocuments/MMSE.pdf

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ADHD Screening Tools • Wender Utah Rating Scale • Conners Adult ADHD Rating Scale • Adult ADHD Self- Report Scale version 1.1

PTSD Screening Tools • PCL-5 • PC-PTSD-5

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Depression Screening Tool • Patient Health Questionnaire (PHQ-9) • Beck's Depression Inventory (8D1-2)

Anxiety Screening Tool • General Anxiety Disorder (GAD-7) • Beck Anxiety Inventory (BAI)

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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

Key Factors • Impact on daily life activities • Contributing factors to compulsion to consume • Attempts to stop

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Treatment

Prochaska and DiClemente, 1983

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Inpatient Treatment • Concentrated therapeutic interventions • Behavioral monitoring • Interpersonal focus • Interdisciplinary approach • Multifaceted approach • Time removed from substance to allow for biological stabilization • Reduced exposure to stressors to reduce cravings

Post Inpatient Treatment Care

Behavioural Pattern

Stress Management

Difficult Relationships

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Ongoing Care Goals

Monitoring and testing

Community support groups

Awareness of self

Cravings and Triggers

Community Support Groups

SMART

Recovery

Recovery Dharma

Alcoholics Anonymous

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Working With Low Motivation • Resistance • Mapping effects of the issue • What does the substance provide you? • Discovering intrinsic motivation

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

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Therapeutic Interventions 2. Shifting • Creating alternative stories • Challenging schemas • CBT thought records • Amplified reflection (Motivational interviewing) • Reframing

Therapeutic Interventions 3. Developing a "New Normal" • What gets you out of bed in the morning? • What do you want to live for?

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Biological • Massage • Healthy Touch • Pharmaceutical interventions • Time for stabilization

Choice Theory • Encourage non-drug choices • Take better advantage of current resources

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Cuing Event/Stimulus ,

Activation of learned cognitive response

Craving/Emotional Response

Resumed Use (aka Relapse)

Thought Control

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

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Common Factors Catharsis Trust Positive relationship Empathy Therapeutic alliance Feedback Reframing

Lambert, 2013

Reality testing Modelling

Common Factors 1. Real relationship 2. Creation of expectations through explanation of disorder and the treatment involved 3. The enactment of health promoting actions

Wampold, 2015

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ame:

Age (Yrs):

Session#:

Sex: M/F

Date:

Please rate today's session by placing a mark on the line nearest to the desc1ip tion that best fits your expe1ience.

Session Rating Scale

Relationship

I did not feel heard, understood,

I felt heard, understood,

1------------------------------------------------I

and respected.

and respected. W e did not work on or talk about what I wanted to work on and talk about.

The therapist's approach is not a g o o d fit for

Goals and Topics

W e worked on and talked about

1------------------------------------------------I

what I wanted to work on and talk about.

Approach or Method The therapist's approach is a good fit for me.

1------------------------------------------------I

me.

There was som ething m issing in the

Overall O verall, today's session was

l-- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1

right for me.

Name: Session #:

Age (Yrs):

Sex: M/F

D a te :

W h o is filling out this form? Please check one: Self

O th e r

If other, what is your relationship to this person?

Outcome Rating Scale

Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high levels. If you are filling out this fo rm for another person, please fill out according to how you th in k h e o r she is doing. Incliviclually (Personal well-being)

l------------------------------------------------------------------------1 lnterpersonaliy (Family, close relationships)

l------------------------------------------------------------------------1 Socially (W ork, school, friendships)

1-------------------------------------------------------------------------I Overall (G eneral sense of well-being)

1-------------------------------------------------------------------------I International Center tor Clinical Excellence Source: www.centerforclinicalexcellence.com © 2000 Scott D. Miller & Barry L. Duncan

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ORS Feedback: Outcome Rating Scale

Outcome Rating Scale Measure

Score 2017-7-7

2017-7-7

2017-11-29

2018-S-14

2019-1-5

2019-1-,

lndlvidually

7.5 out or10

lnrerpersonelly

7.4 out 0110

Socially

7.3 out or 10

Overall

7.3 out ol 10

020 V

Total Score

29.5out of 40

Outcome Rating Scale

Session -

ORS Cutoff + Off Track Line

ORS At Risk O n Track Line

Off Track

O n Track

PTSD T r e a t m e n t O p t i o n s COGNITIVE PROCESSING THERAPY ( CPT) A traum a-focused cognitive behavioral therapy that h e l p s i n d i v i d u a l s m o d i f y u n h e l p f u l b e l i e f s r e l a t e d to their traum atic experience a n d develop more adaptive w a y s of c o p i n g .

MEDICATION MANAGEMENT Various m edications, s u c h a s selective serotonin r e u p t a k e i n h i b i t o r s (SSRIs) a n d s e l e c t i v e n o r e p i n e p h r i n e r e u p t a k e i n h i b i t o r s (SNRIs), c a n h e l p a l l e v i a t e s y m p t o m s of PTSD, s u c h a s a n x i e t y , depression, a n d sleep disturbances.

PROLONGED EX POSURE THERAPY ( PE)

GROUP THERAPY

A t y p e of c o g n i t i v e - b e h a v i o r a l t h e r a p y t h a t g r a d u a l l y e x p o se s individuals to m e m o r i e s a n d situ a tio n s related to th e ir t r a u m a in a safe a n d controlled environm ent, w i t h t h e g o a l of r e d u c i n g f e a r a n d a n x i e t y .

Participating in group therapy sessio n s w ith others w h o h a v e e x p e r i e n c e d t r a u m a c a n provide social support, validation, a n d o p p o rtu n ities to learn coping

EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR)

MINDF ULNESS- BASED INTERVENTIONS

Exposure a n d relaxation. Bilateral stim u la tio n h a s b e e n e v i d e n c e d to be ineffective but t r e a t m e n t still beneficial

strategies.

P r a c t i c e s s u c h a s m i n d f u l n e s s m e d i t a t i o n , yoga, a n d d eep breathing exercises c a n h elp individuals develop g r e a t e r a w a r e n e s s , a c c e p t a n c e , a n d r e g u l a t i o n of t h e i r t h o u g h t s , f e e l i n g s , a n d p h y s i c a l s e n s a t i o n s r e l a t e d to PTSD.

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Posttraumatic Growth • Move beyond happiness • Suffering as needed for growth • Resiliency • Vulnerability and flourishing • Transforming suffering to flourishing

Phased Treatment C u r r e n t G u i d e l i n e s for CPTSD r e c o m m e n d s p h a s e d t r e a t m e n t t h o u g h t h i s i s d e b a t e d

STABILIZATION (PHASE I)

PROCESSING TRAUMA MEMORIES ( PHASE II)

INTEGRATION PHASE (PHASE III)

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PHASE I

PHASE II

PHASE III

A i m e d at e n s u r i n g t h e individual's s afet y by r e d u c i n g self-

Prolonged exposure therapy

Consolidates treatment gains

EMDR

regulation problems and improving distress t o l e r a n c e a n d s o ci al competencies.

CPT

Adapt to c u r r e n t life circumstances

NET CT-PTSD

I n c r e a s e d by i n a n d t h e r a p e u t i c alliance for d r o p o u t p r o n e cl i en t s DBT- PTSD

Emotional Regulation Skills • Create emotionally safe environments • Non-judgmental approach • Teach skills o

Self-talk, taking a break, catharsis, breathing

• Normalize

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Building Self-Awareness HANDOUTS LABELING Ef u duNS • Start by sitting comfortably, eyes either closed or partially open. Take a few deep breaths, or if you prefer, bring your attention to cbc sounds around you. • Spend a few moments connecting with your anchor. When you arc taken away by an emotion, note what the emotion is. With an attitude of warmth and acceptance, label the emotion. For example, note, "worry, worry, worry." Don't obsess about gc:cc.ing the label exactly right. It doesn't need to be precise co be effective.

Mindfulness

• Sec where you find chis emotion an your body. Allow yourself to simpl)' be with it. • Notice the attitude you bring to this practice. Arc you yelling at yourself when you notice "anger, anger, anger"? Arc you telling yourself chat you're a bad person for having this emotion? Sec if you can label with kindness, warmth, and acceptance. • If the emotion becomes too intense aucl you start to gee overwhdmecl or lost in it, simply return to your anchor. • There is no need to hold on to or analyze the emotion. Let it rise and fall away. No need to go into che history or story bch.ind the emotion either. Label it and let it go. • Label the emotions with as much warmth and kindness as possible. If you feel that negative emotions don't deserve kindness, label chis as w d l . Be open to pleasant emotions and labd chem too. • Continue to alternate between labding che emotions and grounding with your anchor. When you're ready, rake a few deep breaths, wiggle your fingers and toes, screech, and open yo1u eyes if they have been closed. Try to continue to be aware of your emotional reactions as you move into your next activity.

Building Self-Awareness Peak Performance

Stress Curve

Increased Attention / Interest

Q) (.)

rCo

Healthy Focus

Fatigue

Excessive Demand / Stress

Motivated / Energised

L..

Q_ '+--

...... ro

a: : : ,

Decreased or Impaired Performance

Overwhelmed &Impaired Performance

Healthy Tension

Inactive/ Bored Optimum

Overload

Stress / Arousal

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Thought Record Sheet - 7 column Situation I Trigger

Feelings Emotions (Pate 0-100%) Bodv sensations

Whal emotion did I feel al Ilia/ lime? Wha/e/3=? Ho ,4,• miensewas .if? 1

W11aI happened? W11ere? v\l/1en? v\1110 w,lh? How?

Whal didI no/ice1n myb:xfv"? Whe,ed,d I feel ,t·1

,v,,w 1.9etselfhelp.co.11k

Unhelpful Thoughts/ Images

v\11a/ wen/ throughmy mind? v\1)&/ d,surted me? \,\,1;al did /ho&? houghl&'iinage&'me,rories mean lo me, 01My about roo or /he s/ual1on? Whal amI rel'f->Ondmg /o? What 'bvllon' 1s /his pressmg for me? Whal would bethe won;/ thing atout that, or /hat could happen?

Facts that support the unhelpful thought

Facts thatprovide evidence against tne unhelpful thought

\!\Ilia/ facts doI have lhal /heunhepfu/lhough 's a,e NOTlolaDy /we? is ,I pos&bie Iha/ Ihis ,s opimon, rather /lienfact? What have others said a!x,ul /his? © C aro l Vivvcn 2 0 1 0 , p erm issio n to u se fo r theatPJ'purposes Whf,t are the facts? Whal facts do I hffl'e Iha/ /he vnhelpfu! ihoughVs are lo/al.It /rue?

Alternative, more realistic and balanced perspective

STOPPI Ta.<,ea L"realh vVhal would romeone else tay aoou/ lh,s si/ua/1on? Whars lhE>b,gge, picture>? is /here anolherwayof seeing.I? Whal advicewouki I give oomeone e.Cse? Is rr.y reaction1i, proponion lo /he adual event? Is /his ,ea/J;as 11npoitanl es,/seems?

Outcome Re-rate emotion

v\l/1at amI feefog /)OW?(0-101)"/i,) Whal couldI do differen//y? \¼al would be roore effective? Do what wo,/,,sl Ad wise.i_;. 'Nhal w1/i bemos/ helpful lo, meor /he sKuat1on? Whal w11//he con!'£quences be? \.'l'l ·w .get.(19

References DE JONGH, A. D., RESICK, P. A., ZOELLNER, L. A., VAN M IN N E N , A., LEE, C. W., M ONSON, C. M ., ... & BICANIC, I. A. ( 2 0 1 6 ) . CRITICAL ANALY SIS OF THE CURRENT TREATMENT GUIDELINES FOR COMPLEX PTSD IN ADULTS. DEPRESSION AND ANXIETY, 3 3 ( 5 ) , 3 5 9 369. JOWETT, S., KARATZIAS, T., SHEVLIN, M ., & ALBERT, I. ( 2 0 2 0 ) . DIFFERENTIATING S Y M P T O M PROFILES OF IC D - 11 PTSD, COMPLEX PTSD, AND BORDERLINE PERSONALITY DISORDER: A LATENT CLASS ANALY SIS IN A MULTIP LY TRAUMATIZED SAMPLE. PERSONALITY DISORDERS: THEORY, RESEARCH, AND TREATMENT , 11 (1), 36.

REED, G. M ., FIRST, M . B., BILLIEUX, J., CLOITRE, M ., BRIKEN, P., ACHAB, S., ... & BRYANT, R. A. ( 2 0 2 2 ) . EMERGING EXPERIENCE WITH SELECTED NEW CATEGORIES IN THE IC D - 1 1 : COMPLEX PTSD, PROLONGED GRIEF DISORDER, GAMING DISORDER, AND COMPULSIVE SEXUAL BEHAVIOUR DISORDER. WORLD PSYCHIATRY , 21 (2), 1 8 9 - 2 1 3 .

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References LOPEZ-QUINTERO, C. , DE LOS COBOS, J. P., HASIN, D. S., OKUDA, M., WANG, S., GRANT, B. F., & BLANC O, C. ( 2011). PROBABILITY AND PREDIC TORS OF TRANSITION FROM FIRST USE TO DEPENDENC E ON NIC OTINE, ALC OHOL, CANNABIS, AND COCAINE: RESU LTS OF THE NATIONAL EPIDEMIOLOGIC SU RV EY ON ALC OHOL AND RELATED CONDITIONS ( NESARC ) . DRUG AND ALC OHOL DEPENDENC E, 115( 1-2), 120-130. WISE, R., KOOB, G. THE DEV ELOPMENT AND MAINTENANC E OF DRUG ADDIC TION. NEU ROPSYC HOPHARMAC OL 39, 254–26 2 ( 2014). HTTPS: // DOI. ORG/ 10. 1038 / NPP. 2013. 26 1 LEV IN, Y., BAR-OR, R. L., FORER, R., V ASERMAN, M., KOR, A., & LEV-RAN, S. ( 2021). THE ASSOC IATION BETWEEN TYPE OF TRAU MA, LEV EL OF EXPOSU RE AND ADDIC TION. ADDIC TIV E BEHAV IORS, 118 , 106 889. FARRUGIA, P. L., MILLS, K. L., BARRETT, E., BAC K, S. E., TEESSON, M., BAKER, A., SANNIBALE, C. , HOPWOOD, S., ROSENFELD, J., MERZ, S., & BRADY, K. T. ( 2011). CHILDHOOD TRAU MA AMONG INDIV IDU ALS WITH CO-MORBID SU BSTANC E USE AND POST TRAU MATIC STRESS DISORDER. MENTAL HEALTH AND SU BSTANC E USE : DUAL DIAGNOSIS, 4( 4), 314–326 . HTTPS: // DOI. ORG/ 10. 1080/ 17523281. 2011. 59846 2 WANG, MING & LIU , JING & SU N, QIWU & ZHU , WENZHEN. ( 2019). MEC HANISMS OF THE FORMATION AND INV OLU NTARY REPETITION OF TRAU MA-RELATED FLASHBAC K: A REV IEW OF MAJOR THEORIES OF PTSD. INTERNATIONAL JOU RNAL OF MENTAL HEALTH PROMOTION. 21. 8 1 - 97. 10. 326 04/ IJMHP. 2019. 011010. WONG KE, WADE TJ, MOORE J, MARC ELLU S A, MOLNAR DS, O'LEARY DD, MAC NEIL AJ. EXAMINING THE RELATIONSHIPS BETWEEN ADV ERSE CHILDHOOD EXPERIENC ES ( AC ES), CORTISOL, AND INFLAMMATION AMONG YOU NG ADU LTS. BRAIN BEHAV IMMU N HEALTH. 2022 SEP 20;25: 100516 . DOI: 10. 1016 / J. BBIH. 2022. 100516 . PMID: 36 177305; PMC ID: PMC 9513107. JOHN D. MC LENNAN, HARRIET L. MAC MILLAN, TRAC IE O. AFIFI, QU ESTIONING THE USE OF ADV ERSE CHILDHOOD EXPERIENC ES ( AC ES) QU ESTIONNAIRES, CHILD ABUSE & NEGLECT, V OLUME 101, 2020, 104331 HU ANG, Z., BAI, H., YANG, Z., ZHANG, J., WANG, P., WANG, X., & ZHANG, L. ( 2024). BRIDGING CHILDHOOD TO ADU LTHOOD: THE IMPAC T OF EARLY LIFE STRESS ON AC UTE STRESS RESPONSES. FRONTIERS IN PSYC HIATRY, 15, 13916 53. SILV EIRA, S., SHAH, R., NOONER, K. B., NAGEL, B. J., TAPERT, S. F., DE BELLIS, M. D., & MISHRA, J. ( 2020). IMPAC T OF CHILDHOOD TRAU MA ON EXEC UTIV E FU NC TION IN ADOLESC ENC E-MEDIATING FU NC TIONAL BRAIN NETWORKS AND PREDIC TION OF HIGH-RISK DRINKING. BIOLOGIC AL PSYC HIATRY. COGNITIV E NEU ROSC IENC E AND NEU ROIMAGING, 5( 5), 499–509. HTTPS: // DOI. ORG/ 10. 1016 / J. BPSC . 2020. 01. 011 KUZMINSKAITE, E., PENNINX, B. W., V AN HARMELEN, A. L., ELZINGA, B. M., HOV ENS, J. G., & V INKERS, C. H. ( 2021). CHILDHOOD TRAU MA IN ADU LT DEPRESSIV E AND ANXIETY DISORDERS: AN INTEGRATED REV IEW ON PSYC HOLOGIC AL AND BIOLOGIC AL MEC HANISMS IN THE NESDA COHORT. JOU RNAL OF AFFEC TIV E DISORDERS, 283, 179-191.

References BEGEMA NN, M. J . , SC HUTTE , M. J . , VA N DELLE N, E. , A BRA MOVI C, L. , BOKS, M. P., VA N HA REN, N. E. , . . . & SOMME R, I . E. (2 0 2 3 ). CHI LD HOOD TRA UMA I S A SSOC I ATE D WI TH REDUCED FRONTA L GRA Y MATTE R VOLUME : A LA RGE TRA NSD I A GNOSTI C STRUC TURA L MRI STUD Y. PSYCHOLOGICAL ME DICINE , 53 (3 ), 7 4 1 -7 4 9 .

NI LSE N, A . S. , BLI X, I . , LEKNE S, S. , EKEBERG, Ø. , SKOGSTA D, L. , END ESTA D, T. , ØSTBE RG, B. C. , & HE I R, T. (2 0 1 ). BRA I N A CTI VI TY I N RESPONSE TO TRA UMA -SPE CI FI C, NE GATI VE, A ND NE UTRA L STI MULI . A FMRI STUD Y OF RECENT ROA D TRA FFI C A CCI DENT SURVI VORS. FRONTIE RS IN PSYCHOLOGY , 7 , 1 1 7 3 . HTTPS://D OI . ORG/1 0 . 3 3 9 /F PSYG. 2 0 1 . 0 1 1 7 3

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Resources Presentati•on PDF

Family Videos

Family Resources

Thank you! Questions?

5/2/24

Internal Family Systems Therapy for Trauma Treatment BY DAPHNE FATTER, PH.D. (SHE/HER) LICENSED PSYCHOLOGIST, CERTIFIED IFS THERAPIST IFS CLINICAL CONSULTANT

Learning Objectives 1.

Describe qualities of Self in Internal Family Systems (IFS).

Identify qualities of the three types of parts in an individual’s system.

Report on two specific IFS techniques necessary for using IFS in trauma treatment.

Explain ways to get started using IFS with clients.

Become familiar with your own parts activated through experiential practices of IFS during workshop.

Internal Family Systems: Foundational Principles 1.

The psyche is innately divided into sub-personalities, called parts. A Systems approach can be applied in individual therapy to an individual’s system. Every person has a Self. • Self is non-judgmental loving essence that is unharmed by trauma. • An individual’s internal system can be and should be led by Self.

All Parts are Welcome.

(Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021)

3 3

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What is Self? 8 C’s: Curiosity

5 P’s: Presence

Calm Compassion

Perspective Persistence

Courage Creativity

Playfulness Patience

What are Parts?

(Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021) oParts all have positive intentions oParts have inherent gifts and value for the system. o Full range of feelings and expressions o Internalized beliefs about self, others and the world o Have their own worldview, cognitive schemas & thought patterns o Can express themselves through body sensations/somatic symptoms There are no ‘bad’ parts = we don’t get rid of parts, we have them for life. COPYRIGHT © 2023 DAPHNE FATTER, PH.D.

Intrapersonally: Repairs Internal Ruptures between Parts & Self

In IFS, the therapist guides the client to Befriend their parts from Self: • Parts restore trust in Self, connection and on-going relationship. • Self provides updated and current information. • Self Witnesses parts stories. • Help them out of where they are unstuck in past. • Release their burdens (emotions and beliefs they carry). • This transforms parts to their naturally valuable states. (Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021) COPYRIGHT © 2023 DAPHNE FATTER, PH.D.

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Internal Family Systems Provides a Paradigm Shift When Parts Unburden & Transform: ◦Internal system can re-organize so that Self is leader in system. Non-pathological model. All parts have positive intentions for system. Mental Health Symptoms = Parts stuck in extreme roles with positive intentions for system. (Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021)

Internal Family Systems Provides a Paradigm Shift “We don’t overcome, we get into relationship with.” Dr. Richard Schwartz “We do therapy with a system, not with a symptom.” Cece Sykes (2023) Applying an IFS lens, looking at a constellation of parts and helping client move into relationship with them.

Goals of Internal Family Systems Therapy

Anderson et al., 2017;Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021

1. Liberate parts so their natural states can be restored. 2. Restore trust in Self and Selfleadership. 3. To attain balance and harmony within the internal system. 4. Become more Self-led in relationships and in life.

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What is a Burden? Anderson et al., 2017; Schwartz & Sweezy, 2020; Schwartz,1995

Burdens are: • Negative internalized beliefs about oneself, others and the world. • Intense trauma-related feelings • Distressing physical sensations or physiological dysregulation Adaptive Parts

LIFE Happens

Burdened Parts

How do Parts Become Burdened? Anderson et al., 2017; Schwartz & Sweezy, 2020; Schwartz,1995

•Parts can get stuck in extreme roles due to experiencing adverse life experiences, relational wounding, or trauma. •Parts are “forced out of their naturally valuable states and they become stuck in roles they don’t even like, but feel like are necessary to keep you alive” (Schwartz, 2014). •Legacy burdens: Intergenerational trauma passed on through our parents and ancestors in the form of:

◦ Ways we respond to stress, our protective system, belief systems and survival strategies. ◦ Collective Legacy Burdens: https://www.youtube.com/watch?v=h2Nm2lxZ1CU

5. Why is Unburdening Healing? - Unburdening exiled parts facilitates a sense of freedom from their past – helping them return/transform to their naturally valuable state.

1. Parts can be in Healthy Roles - Naturally have gifts for our system & good intentions -Contribute to our well-being and functioning. 2. How Do Parts Become Burdened? Life Happens = Wounding = Burdens - Adversity of Life - Relational Injuries - Trauma - Legacy Burdens

- Once burdens of exiles are healed, then protective parts are free to change their roles. - Gives space in system for Self-leadership.

4. IFS offers Roadmap to Unburdening: Self must become conscious of and in loving relationship with exiled vulnerable parts to help release burdens they carry.

3. What Happens When Parts Become Burdened? - Parts become burdened and move in extreme roles. - Burdens of exiled parts DRIVE protector roles

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Three Types of Parts Anderson et al., 2017; Schwartz & Sweezy, 2020; Schwartz,1995

1. Exiles: An injured vulnerable part that holds feelings, beliefs, sensations of relational injury or trauma.

Protector

Protective Parts: Protect Exiles 2. Managers: Proactively try to prevent exiles from getting activated.

Exile

3. Firefighters: Reactively try to get rid of emotional pain of exile.

Exiles

Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schw artz, Schwartz, & Galperin, 2009; Schwartz,1995; Schwartz, 2021

• Parts that experienced attachment/relational injuries and traumas • Hold burdens of shock, betrayal, and pain from trauma. • Exiles can be ‘frozen’ in time at any age. • Can become isolated from system in order to protect person from pain of trauma. • Exiles can be ANY age.

How Do You Know Its an Exile? Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021

o Frozen in time (usually at the time of the trauma) o May believe trauma is happening in present. o May be stuck in an actual traumatic memory o e.g. client sees a memory, has a flashback of scene

o Part is intensely emotional or overwhelmed, or scared o Typically there is a raw “charge” to exiles indicative of unmetabolized traumatic memory.

o Somatically shows up with full range of body discomfort: o e.g. shakiness, agitation, acute pain, sense of doom, free-floating anxiety.

o Has negative internalized belief that is trauma-related about self, world, and others.

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Manager Parts

Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021

oManagers help protect the system by trying to prevent exiles from getting activated. o They may be in extreme roles and states in their efforts to prevent exiles from getting activated.

Adaptive Parts can become Manager Parts

Common Manager Parts within Mental Health Providers Social Justice Part Senses intense urgency to make the world a better place. May over-extend and be exhausted.

Loyal Caregiver or Rescuer May over-extend support; nurture client in over-extending way; May overidentifying with client’s pain.

Analyzer or intellectualizing manager

Optimist Manager

Burnout “Fix it” Managers

Critical Manager

Self-reliant Manager

May analyze the case, track parts of client without connecting to client. Can be a figuring out part.

Cheerleader or motivator of client’s system. Needs to make it okay. May serve as hope merchant.

Can get frustrated if the client isn’t getting better or when client is overwhelmed. Have difficulty tolerating client’s pain. May also show up as advice giving parts or over-functioning parts.

May criticize you as the therapist eliciting imposter syndrome.

“I’m the only one that can do this”.

No one else will do it or do it like me, so I’ll take this on.

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Firefighter Parts Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021

oWhen exiles get activated, Firefighters come in to distract or numb feelings in any way possible regardless of collateral damage. o Firefighter parts takes over system and keeps system occupied until activating exile isn’t felt.

Adaptive Parts can become Firefighter Parts

What Firefighters parts show up for you as a therapist? o What do you do, feel, say, think when you have reached your stress limit? o What does burnout look like and feel like for you? o What happens for you when you are experiencing vicarious trauma? o What are your signs of countertransference? COPYRIGHT © 2023 DAPHNE FATTER, PH.D.

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Managers vs Firefighters Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021

Primary difference between manager and firefighter is the internal sequence of when they operate.

Spectrum of Complexity of Systems Protector Protector

Protector

Exile

Protector

Exile

The more traumatic experiences the client has experienced = The more complex the client’s system. The more burdened parts are = The more extreme roles parts are in.

Imbalanced System in which a Part is Leader 1. Initially, You may hear 2 Parts in Session…

2. In IFS, you will become aware of protective parts in polarizations (2 protectors in disagreement about how to manage an exile).

• Self-Criticism Self • Suicidal Ideation

Manager: Inner Critic

Power Struggle

Firefighter: Suicidal Ideation

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Move to a System in which Self is Leader 3. Over Time, in IFS, Protective System trusts Self, and Self gets permission to work with exile.

4. In IFS, Self forms a relationship with exiled parts in addition to protective parts. So these parts can unburden and transform into their preferred roles, with Self as the leader.

Self

Manager: Inner Critic

Self

Firefighter:

Manager: Ability to focus on Goals

Suicidal Ideation Exile: Child Part “I’m Worthless”

Child Part: Wants to be Spontaneous & Creative

Firefighter transforms to Part that can see possibilities

Clinical Vignette: Anxiety 28 year old South Asian Canadian cis-gender heterosexual single male who is a professional musician. His presenting symptoms include worsening anxiety, rumination, avoiding practicing, beating himself up/inner criticism, and panic attacks during professional auditions. He manages his anxiety by smoking marijuana, which is not helping as much now. What does applying an IFS lens look like?

Clinical Vignette: Depression 54 year old Latinx Canadian cis-gender lesbian in longterm marriage reports history of chronic depression. Her presenting symptoms include sleeping during the day, apathy, difficulty finding motivation to work, and feeling like “what’s the point”? What does applying an IFS lens look like?

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IFS, Cultural Identities and Intersectionality Racial Identities Social Class, Immigration Status

Sexual Orientation

Gender Identity & Gender Expression

Cultural Identities & Ethnicities, Nationality

(Dis)Ability Status, & Health Status

Spirituality & Religion

Intersectionality: refers to the way in which a person with multiple marginalized identities, experience a compounding impact of trauma and oppression (See Crenshaw, 1989, 1991, 2005). COPYRIGHT © 2023 DAPHNE FATTER, PH.D.

Systems We Live In & Have to Navigate including Dominant Cultures Are there parts I have to cut off from in order to provide therapy? (because professional environment and world isn’t safe): ◦ Numbing parts to protect oneself to survive ◦ “Push through” parts ◦ Aspects of Identity (visible and invisible) Parts that have to code switch: ◦ Vigilant parts – can I be me here? ◦ Language switching ◦ Bi-cultural; Multi-cultural IFS framework: All parts are welcome & what do parts of me need from me right now?

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1. Identify a Target Part: Get Contract and Separate Part from Self. 2. Befriending Protective System - (The Gatekeepers: Managers & Firefighters) • Developing trusting relationship between Self and Protective System. • Getting to know fears and concerns of protectors. • Getting Permission to work with an Exile

Steps of IFS Therapy Anderson et al., 2017; Early, 2009; Schwartz & Sweezy, 2020; Schwartz,1995

3. Befriending Exile: Developing trusting relationship between Self and Exile. • Accessing Exile. • Getting to know Exile and developing relationship between Self & Exile. 4. Witnessing: Adult Self is witnessing exile’s story, traumatic experiences, fears, memories; re-parenting is happening here. 5. Retrieval (optional): Take Exile out of traumatic memories to help stabilize part. Bring it to present time or to safe place. • This step can happen before or after witnessing, or before or after unburdening. 6. Unburdening Exiles: releasing extreme beliefs, feelings, pain. 7. Invitation: Inviting in positive qualities that part wants or needs now or in the future. 8. Integration: Introduce Transformed exile to protectors. Ask exile new role in system. Ask protectors or any other parts their response to unburdening. Protectors may need to unburden and move into their preferred role in system. 9. Appreciation/Closure: Appreciate all parts who showed up! COPYRIGHT © 2023 DAPHNE FATTER, PH.D.

Tips Experiential client-centered therapy: • Process is not linear • Follow the client’s system – Client’s system leads you (river analogy). • Important to stay connected to client • Focus on Self- to – Part relationship • Slower is faster • Therapist tracks their own parts. If you get lost in session: • Ask client – “What do you notice now”? • Ask client – “How do you feel towards the part now?” (check for Self energy)

1. Identify a Target Part Anderson et al., 2017; Early, 2009; Schwartz & Sweezy, 2020; Schwartz,1995

Technique #1 to Identify Target Part & Get Contract: Empathetic Listening & Reflecting back Using Parts Language Step 1: Naming feelings/experiences of client’s story with parts language:

• “Sounds like a part of you feels sad and a part of you feels angry, am I getting that right?” • “Seems like a part of you wants to be in therapy and a part of you wants you to figure this out on your own, am I getting that right?”

Step 2: Getting Permission/Contract:

• “ Would it be okay to focus on these parts” “Which one would you like to focus on first?”

• “Would you like to work on this today” “Which part has the most energy/charge?”

Step 3: Separate Part from Self: “Let’s invite in curiosity about this part, How do you notice this part? Where

do you notice it in your body? Is it a feeling or do you have an image for this part of you?” How do you feel towards this part?

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1. Identify a Target Part Anderson et al., 2017; Early, 2009; Schwartz & Sweezy, 2020; Schwartz,1995

Technique# 2 to Identify Target Part & Get Contract: Pause Story-Telling:

• “Is it okay if we pause for a moment. I’m curious what you are noticing inside as you tell me this.” Asking clients to check inside to notice what they are feeling/body sensations. Step 1: Reflect back -- Naming feelings/experiences of client’s present moment experience with parts language: • “You have tension in your throat and a part of you feels sad.” Step 2: Getting Permission/Contract: “is it okay for us to focus on your experience right now? • We can invite in some curiosity about what that tension in your throat and that sadness wants you to know – would you like to focus on this today? ” Step 3: Separate Part from Self: • “Let’s invite in curiosity about this part, which part feels closer to you right now? How do you notice this part? Where do you notice it in your body? Is it a feeling or do you have an image for this part of you? How do you feel towards this part?”

1. Identify a Target Part Anderson et al., 2017; Early, 2009; Reed, 2019; Schwartz & Sweezy, 2020; Schwartz,1995

Technique# 3 to Identify Target Part & Get Contract: Externalize Parts Use white board to draw parts, Art Therapy, Use pillows/props, sand tray, journaling. Step 1: Reflect back -- Naming feelings/experiences of client’s present moment experience with parts language drawn on white board: •

“Sounds like you have…..and another part that…,am I getting that right?

Step 2: Getting Permission/Contract: •

“What part would you like to focus on today?” “Which part feels the biggest here? Would it be okay with we work with it?”

Step 3: Separate Part from Self: •

“Let’s invite in curiosity about this part, which part feels closer to you right now? How do you notice this part? Where do you notice it in your body? Is it a feeling or do you have an image for this part of you? How do you feel towards this part?”

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Externalizing Parts Helps parts be known and also creates physical distance between client & Parts. (Anderson, Sweezy, & Schwartz, 2017).

1. Identify a Target Part Anderson et al., 2017; Early, 2009; Schwartz & Sweezy, 2020; Schwartz,1995

Technique# 4 to Identify Target Part & Get Contract: Contract with client regarding focusing on presenting problem

Step 1: Reflect back Presenting Problem – “You started therapy to decrease your anxiety, is this still what you want to focus on?” Step 2: Getting Permission/Contract: “Would it be okay if we focus on this part of you that feels anxious?” • • • •

How does that show up for you? What is your experience of that? What does that look like? What does that feel like? Are you feeling any of that now? Is it okay if we focus on that?

Step 3: Separate Part from Self: “Let’s invite in curiosity about this part, How do you feel towards this part of you? How do you relate to that part of you?”

Vision Statement: “I am more organized and feel rested.”

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Vision Statement: “I am more accepting of myself”.

Guided Exercise Adapted from ‘Greater than the Sum of our Parts’ Schwartz (2018). 1. Ask client to create vision statement (e.g. “I am..”). 2. Ask client to read it aloud, what parts do they notice (e.g. “What fears or concerns do parts have about vision?”) How these parts want to be represented on the page? Ask client to draw it on a page. 3. If one vulnerable part could get our help that would have the biggest impact in changing the system toward this vision, what part would that be? How does this part want to be represented on the page? 4. You now have a parts map! Start befriending protectors first.

2 Ways to Integrate IFS with a New Client 1. Asking about fears and concerns about starting therapy during the intake. 2. Connecting the presenting problem and treatment plan using parts language to shift into befriending.

42 42

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During Intake: Integrate IFS into your Intake Process ◦ What fears and concerns do you have about starting therapy? ◦ Is it okay if we explore this to give you a sense of what IFS therapy is like? ◦ Where are you noticing the part that has fears and concerns right now in or around your body? ◦ Let it know you are here with it – how do you feel towards it. ◦ Befriend this part (Self to Part relationship) ◦ Then check in with client about what that was like for them?

Continuum of Blending Adapted from Reed, 2019

Blending: Parts are merging with the client’s Self. o Intimate way for parts to share information

Parts-Driven

Self

(Not Conscious)

Blended (Conscious)

Self-led (In-Relationship)

Ways to Separate Part from Self Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021

Ask the part to give you some space so you can get to know it? ◦ “Okay let the part know that you are feeling it, seeing it, sensing it.” ◦ “How would it be If we could help that part? Ask the part what would happen if it would be willing to give you some space? Ask it to relax back, or step back so that you can really be with it? What does it need from you to step back?” If part doesn’t separate, ask, what is it afraid would happen if it did separate? ◦ Reassure it that you understand its fears and that you can be with it easier, if it gives you some space.

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2. Befriending Protective System (The Gatekeepers: Managers & Firefighters) Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021

What happens during this step? Transition to In-sight =THIS IS ALL EXPERIENTIAL • Assess that Self is ‘online?’ • Developing trusting relationship between Self and Protective System. • Getting to know fears and concerns of protectors. • Getting Permission to work with an Exile

Using 6F’s to Befriend Managers & Firefighters in Client’s system (Anderson et al., 2017 Anderson, 2021; Schwartz, 1995; Schwartz & Sweezy, 2020; Schwartz, 2021)

Find: "Where do you notice this part in or around your body?"

Focus: "Give your attention to this part."

Flesh it out: "How are you experiencing it right now?" (image, felt sense?)

"How do you Feel Towards this part?" (Checking for Self Energy)

Fears: "What are this part's Fears and Concerns?"

BeFriend part: "How is it trying to help you?"

Goals of Befriending Protectors: Getting to know client’s protective system & Addressing fears/concerns experientially, getting internal consent to work with exile, widening window of tolerance (through Self to part relationship). COPYRIGHT © 2023 DAPHNE FATTER, PH.D.

2. Befriending Protective System Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021

Guide the client to have bi-directional communication with client’s Self and part. Getting to know fears and concerns of protectors of target part: • What are the fears of the part? What is it concerned about? • What is the part’s job? • How long have you been doing your job? • What are you afraid would happen if you didn’t do your job? Developing Trust in Self to Part relationship: • “Does that make sense to you? Let it know you get that. How is it responding to you really getting it”. • “Can it hear you understanding it right now? How is it responding to being heard by you?” • “Can you let it know you can see it? How is it responding to being seen by you?” Is it okay with the part for you to just be with it? Make eye contact with it?”

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2. Befriending Protective System Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021

Ask the protector for permission to work with exile: • Once know role of protector, Have Self share appreciation for it and understanding. • Contract with protectors about intentions of helping exiles – do this to help prevent back lash in system. • “Is it okay if I focus on this young part? You are welcome to stay on the sidelines and watch. If you have any concerns as we help this part, let me know” • “You have been around since I was 9, is it okay if I work with the 9 year old who lived through that. I can help that part release pain from that” • If protector wont give permission, ask what is it afraid would happen if you contacted the exile? • Exiles tend to show up spontaneously.

3. Befriending Exile (Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021)

Assess that Self is online: Want Self to Part Connection for Healing Steps: • (If Self is not online, separate parts from self until you get 8 C’s) • “How do you feel towards the part? (curious, compassionate,…). • Can you let the part know that in whatever way it can take it in?” • “Is your heart open to this part? Can you share that with the part? • “How old is this part? Does it know who you are?” Make sure exile can sense client’s Self is present and see how it is responding to you being with it and your compassion. • This is a process of re-parenting. Important that exile really ‘takes in’ positive presence and caring from client’s Self. • If Bi-lingual client – be aware that exiles may only respond to native language of client.

Therapist’s Job: be patient, make sure you are in Self, continue to help client tease out parts (protectors and exile) until Self of client is connecting with exile. 50 COPYRIGHT © 2023 DAPHNE FATTER, PH.D.

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Guided experiential • Adapted from Schwartz, 2001.

4. Witnessing Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021

Client’s Self is witnessing exile’s story, traumatic experiences, fears, memories: • Part shows anything it wants Self to know from past. • These can be specific traumatic memories, and can include specific scenes, feelings and body sensations. Ask: “Does the part want to show you what it was like to be it? • “Does the part want to show you an image or memory of when it felt this way in childhood?” • “Where is this part in time and space?” (elicits if part is stuck in specific memory). “Ask the part if it wants you to be with it in memory” (or if part is stuck in specific memory): • “Enter the scene to be with the part in whatever what it needed at that time”. • “ What didn’t happen that needed to happen? Can you be there in just the way that it needed?” • “Is there anything that it wants you to say or do?” (REPAIRATIVE) Check with part to see how it is responding to Self being with it. COPYRIGHT © 2023 DAPHNE FATTER, PH.D.

5. Retrieval (optional)

Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz,2021

Signs retrieval is needed: •It is hard for exile to go into witnessing stage à if scene/memory is too distressing for part, part may need to leave scene before it can show Self of client specific memories. •It is hard for exile to unburden. How to retrieve: •Ask, “Does part want to come be with you in present time?” •“Would the part like to leave that scene? Where would it like to go” •“Does part want to go somewhere else, be with you in present, go to a safe place to be with you?” When Self of client and/or therapist enter the scene to be with that part, ask what part needs to leave that scene.

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6. Unburdening Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz,2021

What happens at this step: Release beliefs, feelings and pain in exile. “Ask the part if it wants to release or unload any belief or burden that its carrying”. “If it feels ready, ask it how it would like to release the burden” ◦ (Fire, Earth, Wind, Light, Water, Higher Power, etc.) ◦ “Take your time and let me know when that feels complete.” If Exile doesn’t feel ready, ask “What is it afraid would happen if it let it go?” “What does the part need in order to release the burden?” 3-4 weeks after unburdening, physiological and emotional changes are consolidated (Anderson et al., 2017)

7. Invitation

Anderson et al., 2017; Anderson; 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021

What happens at this step: Inviting in positive qualities that were lost or that part needs now Ask: “What positive qualities would the part like to invite in that were lost or that it needs now or in the future?” “How would the part like to invite that in? “Take Your time and let me know when that feels complete.” (examples: spontaneity, joy, playfulness, etc.)

8. Integration

Anderson et al., 2017;Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995; Schwartz, 2021

What happens at this step: Introduce transformed exile to whole system.

Ask: “What new role would this transformed part like now?” “Check in with your protectors or any other parts to see their response to this part now. Can they take in that this part transformed?” Protectors may need unburdening and can ask them their preferred role in the system.

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9. Appreciation

Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz,1995l Schwartz, 2021

What happens at this step: Share appreciation for all the parts for showing up: •“Thank all your protectors that gave you space and permission to work with the exile.” •“Are there any other parts that need to be named before ending session”

Sometimes, you run out of time to do this, so client may need to do this on their own in between sessions.

Why Is IFS Effective? (Anderson, 2021; Ecker, Ticic, & Hulley, 2012).

IFS supports people through the neurological process of memory reconsolidation. Memory Reconsolidation refers to brain’s natural ability: ◦ Pause a patterned response to a stimulus ◦ Make the pattern response susceptible to edit & update to having a new kind of experience According to memory consolidation research, brain’s rules for “unlearning and erasing a target learning” (p. 26): 1. Reactivation (re-triggering target knowledge from original learning 2. Mismatch/unlock synapses– create an experience that is sig different with the target learning’s model 3. Experiential new learning

IFS within 3-Phase Trauma Recovery Model (Twombly, 2013;Twombly, 2023)

3 Phase Model: Phase I: Stabilization

IFS model: 1:Befriending Protective System & Getting Permission to work with Exiles.

◦ Skill building and self-care. ◦ Increasing window of tolerance.

Phase II: Trauma Processing & Grieving

2. Befriending Exiles & Witness & Unburdening.

Phase III: Present Day Life

3. Integration: Moving towards Self-led System.

(Courtois & Ford, 2016)

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Clinical Vignette: PTSD Symptoms through an IFS Lens HYPERAROUSAL:

HYP0AROUSAL:

o Anxious or Panicky Parts o Emotional Numb – who is doing Aggression/Rageful/Agitated the numbing? Parts that are o Parts that are giving system emotionally shut down. Dissociation – foggy, dizziness, Intrusive/ruminative thoughts oBlank, Paralyzed, Can’t Speak, o Flashbacks (emotional, Fainting, Amnesic Parts, somatic or visual in nature) – “Plexiglass” Potentially Exiles o Depersonalization (“Is this real?”) o Insomnia – What Parts are o Over compliance keeping a client up at night? o Withdrawal; Detachment oHypervigilant parts

Approaches to Emotion Regulation in IFS (Anderson et al., 2017; Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz, 2021)

Contracting with parts Befriending Protectors to get permission to work with exiles. Contract and ask the exile to not overwhelm the system

Using IFS for Complex Trauma Anderson, 2021; Fisher, 2017; Reed, 2019; Schwartz & Sweezy, 2020; Schwartz, 2021

Longer time to Help Client Access Self Energy:

• Therapist is in relationship with parts until client can learn to be in relationship with their own parts. • More likely doing Direct Access with parts until protectors give space for Self.

Longer time in Befriending Managers & Contracting with Protective System. Internal battle between protector parts that say ‘this will never happen again’ and exiles parts that say ‘never forget.’ Therapist serves as Self in the client’s system

Therapist as Guide/Directive Stance

Therapist as Witness to Client’s process

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Direct Access

Anderson, 2021; Schwartz & Sweezy, 2020; Schwartz, 2021

Therapists speaks directly to a part in client. Ask client to ‘blend’ with the part and speak directly from the part: 1. How do you protect ____(client’s name)? 2. What are you afraid will happen if you do not do your job? 3. How long have you been doing this job? How do you feel about the job you are doing? 4. Are there other ways you protect ____? 5. How old do you think ____ is now? 6. If you didn’t have to do this job, is there something else you would rather be doing? OR – does your role come at some cost or have a downside? What difference would it make if you could have another job for ____? 7. How do you feel towards _____?

IFS is an Evidenced-Based Practice Since 2015, IFS has been registered as an official evidenced-based practice via the US Department of Health and Human Service’s Substance Abuse and Mental Health Administration (SAMHA) registry of evidenced-based practices: IFS has been rated promising for each of: •Improving phobia; panic, •Generalized anxiety disorders and symptoms; PTSD (Hodgdon, et al, 2021) •Physical health conditions and symptoms (e.g. Shadick et al., 2013) •Personal resilience/self-concept •Depression and depressive symptoms • (e.g. Haddock, Weiler, Trump & Henry, 2017; Shadick et al., 2013)

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Applications of IFS Model Anderson et al., 2017; Schwartz & Sweezy, 2020; Schwartz,1995

Is considered its own theoretical orientation and can be applied to any clinical issue or diagnoses. •Individual Therapy, Group Therapy, Couples Therapy & Family Therapy •Children, Adolescents & Adults For Therapists: • Means to process countertransference and vicarious trauma reactions. • Help prevent burnout and compassion fatigue.

Game Time!

You (the therapist) are noticing feeling impatient towards your client. You are ready for them to get better and they would, if only they stopped using cocaine. You have empathy for them, but you feel like the client NEEDS to get on board with addiction treatment.

Game Time!

Are you (the therapist) in Self Energy?

Yes

No 68

Therapeutic Relationship & IFS Therapy Adapted from Reed, 2019

Interaction between Client’s Parts and Therapist’s Parts

Therapist Self

Therapist’s Exiles

Client Self Therapist Protectors

Client’s Protectors

Client’s Exiles

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Limitations of Model Limitations: Mainly Case Studies. •3 published empirical studies had control groups, but limited sample size. Abreactions: no research data yet. Side Effects: no research data yet. This is an experiential type of therapy – clients have to be willing and interested to focus internally to connect with their parts. When not to use IFS: crisis counseling, when clients need IOP, have immediate case management needs (housing, SI, etc.)

Questions?

Daphne Fatter, Ph.D. Licensed Psychologist daphnefatterphd@gmail.com www.daphnefatterphd.com

For Additional Training in IFS IFS Institute: https://ifs-institute.com/ • Free Community Webinar Series • Training section, Level 1 Training • IFS Online: IFS Online Circle

•https://ifsca.ca/courses/stepping-stones/ •Podcast: IFS Talks: https://internalfamilysystems.pt/ifs-talks

• The One Inside: An Internal Family Systems Podcast: https://theoneinside.libsyn.com/

•You Tube Channel: IFSCA by Derek Scott & You Tube videos by IFS Institute Starter Resources for Adult Clients or Therapists: Sounds true Audio: greater-than-the-sum-of-our-parts •Parts Work: An Illustrated Guide to Your Inner Life, by Tom Holmes, Ph.D. •No Bad Parts by Dr. Richard Schwartz, Ph.D.

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IFS & Trauma: Case Studies • Anderson, F., Sweezy, M., & Schwartz, R. (2017). Internal family systems skills training manual: Trauma-informed treatment for anxiety, depression, PTSD, & substance abuse. Eau Clair, WI: PESI. • Anderson, F., & Sweezy, M. (2016). What IFS offers to the treatment of trauma. In M. Sweezy & E. Zeskind (Eds.), Internal family systems therapy: Innovations and elaborations in internal family systems therapy (pp. 133-147). New York, NY: Routledge. • Goulding, R., & Schwartz, R. (2005). The mosaic mind: Empowering the tormented selves of child abuse survivors. New York, NY: W.W. Norton & Company. • Jones, E. R.; Lauricella, D., D’Aniello, C., Smith, M. & Romney, J. (2021) Integrating Internal Family Systems and Solutions Focused Brief Therapy to Treat Survivors of Sexual Trauma. Contemporary Family Therapy 40. • Lucero, Rebecca & Jones, Adam & Hunsaker, Jacob. (2017). Using Internal Family Systems Theory in the Treatment of Combat Veterans with Post-Traumatic Stress Disorder and Their Families. Contemporary Family Therapy. 40. 10.1007/s10591-017-9424-z. • Miller, B. J., Cardona, J. & Hardin, M. (2007) The Use of Narrative Therapy and Internal Family Systems with Survivors of Childhood Sexual Abuse, Journal of Feminist Family Therapy, 18:4, 127, DOI: 10.1300/J086v18n04_01

IFS & Trauma: Case Studies •Schwartz, R. C., Schwartz, M. F., & Galperin, L. (2009). Internal Family Systems Therapy. In C. A. Courtois & J. D. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp. 82–104). New York: Guilford Press. •Sweezy, M. (2011). Treating trauma after dialectical behavioral therapy. Journal of Psychotherapy Integration, 21(1), 90-102. •van der Kolk, B. (2014) The body keeps the score: Brain, mind, and body in the healing of trauma. New York, NY: Penguin. •Wilkins, E. (2007) Using an IFS Informed Intervention to Treat African American Families Surviving Sexual Abuse, Journal of Feminist Family Therapy, 19:3, 3753, DOI: 10.1300/J086v19n03_03

IFS & Dissociative Identity Disorder • Theoretical article on applying IFS with DID: Twornbly, J. H. (2013). Integrating IFS with phaseoriented treatment of clients with dissociative disordered clients. Internal Family Systems Therapy: New Dimensions, 72. doi: 10.1037/e608922012-134. • Pais, S. (2009). A systematic approach to the treatment of dissociative identity disorder. Journal of Family Psychotherapy, 20(1), 72-88

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IFS & Eating Disorders • Grabowski, A. (2017). An internal family systems guide to recovery from eating disorders: Healing part by part. New York, NY: Routledge. • Lester, J (2017). Self-governance, psychotherapy, and the subject of managed care: internal family systems therapy and the multiple self in a U.S. eating disorders treatment center, American Ethnologist, 44 (1), 23-35 • Catanzaro, J. (2016). IFS and eating disorders: Healing the parts who hide in plain sight. In E. Zeskind & M. Sweezy (Eds.), Innovations and elaborations in internal family systems therapy (pp. 10-28). New York, NY: Routledge

IFS & Addictions • Grabowski, A. (2017). An internal family systems guide to recovery from eating disorders: Healing part by part. New York, NY: Routledge. • Lester, J (2017). Self-governance, psychotherapy, and the subject of managed care: internal family systems therapy and the multiple self in a U.S. eating disorders treatment center, American Ethnologist, 44 (1), 23-35 • Catanzaro, J. (2016). IFS and eating disorders: Healing the parts who hide in plain sight. In E. Zeskind & M. Sweezy (Eds.), Innovations and elaborations in internal family systems therapy (pp. 10-28). New York, NY: Routledge

Specific Case Studies • Shame: • Sweezy, M. (2011). The teenager’s confession: regulating shame in internal family systems therapy. American Journal of Psychotherapy, 65(2), 179-188. • Sweezy, M. (2013). Emotional cannibalism: shame in action. In E. Zeskind & M. Sweezy (Eds.), Internal family systems therapy: New dimensions (pp. 24-24). New York, NY: Routledge

• Racial Identity Development: (case study of applying IFS to group) • Cooper, B. A. (1999). The use of internal family systems therapy to treat issues of biracial identity development (Unpublished doctoral dissertation). United States International University, San Diego, CA.

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Theory & Case Studies: IFS in Children •Krause, P. (2013). IFS with children and adolescents. M. Sweezy & E. Zeskind (Eds.), Internal family systems therapy: New dimensions (pp. 35-54). New York, NY: Routledge. •Mones, A. (2014). Transforming troubled children, teens, and their families. An internal family systems model for healing. New York, NY: Routledge. •Spiegel, Lisa (2017). Internal family systems with children. Oak Park, IL: Center for Self Leadership. •Wark, L, Thomas, M & Peterson, S (2001). Internal family systems therapy for children in family therapy, Journal of Marital & Family Therapy, 27 (2), 189-200. PARENTING: Neustadt, P. (2016). From reactive to Self-led parenting: IFS therapy for parents. M. Sweezy & E. Zeskind (Eds.), Internal family systems therapy: Innovations and elaborations in internal family systems therapy (pp. 29-48). New York, NY: Routledge.

Integrating IFS & Spirituality •Cook, A., & Miller, K. (2018). Boundaries for your soul: How to turn your overwhelming thoughts and feelings into your greatest allies. Nashville, TN: Nelson. •Holmes, T. (1994). Spirituality in Systemic Practice: An Internal Family Systems Perspective. The Journal of Systemic Therapies, 13(3), 26-35. •Riemersma, J. (2020) Altogether You: Experiencing personal and spiritual transformation with Internal Family Systems therapy. •Schwartz, R., & Falconer, R. (2017). Many minds, one Self: Evidence for a radical shift in paradigm. Oak Park, IL: Trailheads Publications. •Steege, M. (2010). The spirit-led life: A Christian encounter with internal family systems. Scotts Valley, CA: Create Space Independent Publishing Platform.

IFS & Use with Native American Populations McVicker, Suzan A. M. (2014). Internal family systems (IFS) in Indian country: perspectives and practice on harmony and balance, Journal of Indigenous Research: Vol. 3 (1)Available at: https://digitalcommons.usu.edu/kicjir/vol3/iss1/6

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IFS with Couples: Intimacy from the Inside Out •Barbera, M. (2016). Bring yourself to love: How couples can turn disconnection into intimacy. Providence, RI: Dos Monos. •Herbine-Blank, T. (2013). Self in relationship: An introduction to IFS couple therapy. In E. Zeskind & M. Sweezy (Eds.), Internal family systems therapy: New dimensions (pp. 55-71). New York, NY: Routledge. •Herbine-Blank, T., Kerpelman, D., & Sweezy, M. (2015). Intimacy from inside out: Courage and compassion in couple therapy. New York: Routledge. •Prouty, A. & Protinsky, H. O. (2008). Feminist-Informed Internal Family Systems Therapy with Couples. Journal of Couple & Relationship Therapy, 1:3, 21-36, DOI: 10.1300/J398v01n03_02 Specific Training for use with Couples: https://www.toniherbineblank.com/

IFS with Therapists in Training •Mojta, C., Falconier, M. K., & Huebner, A. J. (2014). Fostering self-awareness in novice therapists using internal family systems therapy. The American Journal of Family Therapy, 42(1), 67-78. •Redfern, E. E. (Ed). (2023) Internal Family Systems Therapy: Supervision and consultation. Routledge. •Reed, D. (2019) – Internal Family Systems Informed Supervision (Grounded Theory approach using surveys). •Ehrmann, L., Krause, P., Le Doze, F., & Hakim, T. (2014). The IFS Adherence Scale – used for research and clinical use.

Integration of IFS & Other Models J. Riemersma (Ed.), (2023). Altogether Us: Integrating the IFS Model with Key Modalities, Communities, and Trends. Integrating IFS with EMDR:

• Fatter, D. (2023). IFS and EMDR: Transforming Traumatic Memories and Providing Relational Repair with Self. In J. Riemersma (Ed.), Altogether Us: Integrating the IFS Model with Key Modalities, Communities, and Trends. • Twornbly, J. H., & Schwartz, R. C. (2008). The integration of the internal family systems model and EMDR. In C. Forgash & M. Copeley (Eds.), Healing the heart of trauma and dissociation with EMDR and ego state therapy (pp. 295–311). New York: Springer Publishing Company.

Integrating IFS with Sandtray: • Turns, B., Springer, P., Eddy, B. P. & Sibley, D. S. (2021) “Your Exile is Showing”: Integrating Sandtray with Internal Family Systems Therapy. The American Journal of Family Therapy 49:1, 74-90. Integrating IFS with Somatic Psychology: • McConnell, S. (2013). Embodying the internal family. In E. Zeskind & M. Sweezy (Eds.), Internal family systems therapy: New dimensions (pp. 90-106). New York, NY: Routledge. • McConnell, S. (2020). Somatic Internal Family Systems Therapy: Awareness, Breath, Resonance, Movement and Touch in Practice. Integrating IFS with Art Therapy: • Majie Lavergne (2004) Art Therapy and Internal Family Systems Therapy, Canadian Art Therapy Association Journal, 17:1, 17-36, DOI: 10.1080/08322473.2004.11432257

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References Anderson, F. G., Sweezy, M., & Schwartz, R. C. (2017). Internal Family Systems Skills Training Manual: Trauma-informed treatment for anxiety, depression, PTSD & substance abuse. PESI Publishing & Media. Anderson, F. G. (2021). Transcending trauma: healing complex PTSD with internal family systems therapy. PESI Publishing & Media. Center for Self Leadership. (2019). IFS, An evidence based practice. Retrieved from https://selfleadership.org/evidence-basedpractice.html Dubin, R., & Stewart, S. (2017). Checklist for noticing blending. Unpublished manuscript, unavailable on a website or archive. Earley, J. (2009). Self-Therapy. Larkspur, CA: Pattern System Books. Ecker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. New York, NY: Routledge Ehrmann, L., Krause, P., Le Doze, F., & Hakim, T. (2014). The IFS Adherence Scale [Measurement Instrument]. Retrieved from https://www.foundationifs.org/research/adherence-scale Fisher, J. (2017). Healing the fragmented selves of trauma survivors: Overcoming internal self-alienation. Routledge: New York, NY. Foundation for Self Leadership - 2019. Retrieved from website: https://foundationifs.org/news/outlook/outlook-november2016#Research-News Haddock, S. A., Weiler, L. M., Trump, L. J., & Henry, K. L. (2017). 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), 131144. https://doi.org/10.1111/jmft.2017 COPYRIGHT © 2023 DAPHNE FATTER, PH.D.

References Hodgdon, H.G., Anderson, F. G., Southwell, E., Hrubec, W. & Schwartz R.C. (2021) Internal Family Systems (IFS) Therapy for Posttraumatic Stress Disorder (PTSD) among Survivors of Multiple Childhood Trauma: A Pilot Effectiveness Study. Journal of Aggression, Maltreatment & Trauma, 1-22. DOI: 10.1080/10926771.2021.2013375 Reed, D. (2019). Internal Family Systems Informed Supervision: A Grounded Theory Inquiry. (Unpublished Doctoral Dissertation). St. Mary’s University, San Antonio, Texas. Schwartz, R. C. (1995), Internal Family Systems Therapy. New York: Guildford Press. Schwartz, R. C. (2001). Introduction to the Internal Family Systems Model. Trailheads Publications. Oak Park, IL. Schwartz, R. C. (2014), Introduction to Internal Family Systems Video. Center for Self-Leadership website.

References Schwartz, R. C. (2018), Greater than the Sum of its Parts: Discovering Your True Self Through Internal Family Systems Therapy. Sounds True. Schwartz, R. C. & Sweezy, M. (2020). Internal Family Systems (2nd Ed.). The Guilford Press. New York: NY. Schwartz, R. C. (2021). No bad parts: Healing trauma and restoring wholeness with the internal family systems model. Sounds true. Schwartz, R. C., Schwartz, M. F., & Galperin, L. (2009). Internal Family Systems Therapy. In, Treating Complex Traumatic Stress Disorders:: Scientific Foundations and Therapeutic Models by, Courtois, C. A. & Ford, J. D., pp. 353-370. Shadick, NA, Sowell, NF, Frits, ML, Hoffman, SM, Hartz, SA, Booth, FD, Sweezy, M, Rogers, PR, Dubin, RL, Atkinson, JC, Friedman, AL, Augusto, F, Iannaccone, CK, Fossel, AH, Quinn, G, Cui, J, Losina, E & Schwartz, RC (2013). A randomized controlled trial of an internal family systems-based psychotherapeutic intervention on outcomes in rheumatoid arthritis: a proof-of-concept study, The Journal of Rheumatology 40 (11) 1831-1841; DOI: https://doi.org/10.3899/jrheum.121465 Watkins, J. G., & Watkins, H. H. (1979). Ego states and hidden observers. Journal of Altered States of Consciousness, 5, 318. Watkins, J. G., & Watkins, H. H. (1997). Ego states: Theory and therapy. New York: Norton.

Conquering Anxiety: Concrete Strategies for Helping Your Anxious Adult Clients

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

Anxiety is the most common mental health problem

Untreated anxiety is the leading predictor of depression

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Anxiety Impairs Daily Functioning • Sleep!!! • Work Performance • Social interactions • Happiness and outlook • Family relationships • Doing things/going places • Nutrition • Self-care • Independence 4

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 5

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…

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Society is now created in a way that makes that brain meant to protect us to actually harm us

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 8

Normal Worries

TEMPORARY

DO NOT INTERFERE WITH FUNCTIONING

STILL SUCCESSFUL IN ACHIEVING GOALS

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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. 10

Different parts of the brain that activates worries need different strategies

Amygdala Pathway: Physiological

Amygdala Based Memories: Emotional Memories

• Oldest, quickest, strongest • Talking will escalate the problem

• Out of awareness • Remembered very differently from conscious memories 12

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Cortex Pathway: Thinking

Ruminate Talk to self Try to problem solve

Visual images Imaginative worries

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

Expecting something bad to happen People continue to worry themselves with their own thoughts

Anxiety-Based Schemas The world is a scary place and I am vulnerable

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Everyone is predisposed to anxiety.

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. 18

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We are Stressed

Social disconnection and loneliness Local and world news

Social media

Identity and body Issues

Current State of the world

Worthlessness

Multiple pressures and high expectations

Far more: • Depression • Self-harm • Suicide

Helplessness

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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

Accommodation Behaviours Participation

• Assist in checking behaviours • Assist in avoidance • Reassure

Modification

• Prevent anxiety provoking situations 27

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Accommodation Accommodation

Accommodations worsens anxiety long-term

Accommodation

Anxiety more impairing and severe with poorer treatment outcomes 28

Medications 29

Get stuck in constant need for reassurance

Reassurance

No skills developed Minimizing 30

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Anxiety… • Wants certainty • Wants predictability • Wants comfort

Brain in high stress state = amygdala kicks in and becomes a stop sign for information and any rational thinking

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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Individuals keep themselves stuck

Negative thought patterns Inability to manage emotions effectively Maladaptive Coping

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

Remember: How we respond to 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

NOT to eliminate or reduce the intensity of emotional experiences – Impossible! 39

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What’s the # 1 thing they need to learn?

How to effectively experience anxiety (with less distress and avoidance) 41

Mindful emotion awareness Increasing awareness and tolerance of physical sensations

Core skills

Challenging automatic thoughts and increasing cognitive flexibility. Identifying and modifying problematic emotional behaviours. Integration of above skills through emotion exposure to master adaptive responses

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Address external maintaining variables

Outline rationale & personal reasons for making changes

Set goals, address barriers, and maintain motivation

Externalize challenges

Skill building: Raising awareness & relating to emotions in an accepting way

Explore emotions

Target different parts of emotions: Affect

Target different parts of emotions: Thoughts

Target different parts of emotions: Emotional behaviours

Emotion exposures

Have a Structure!

Not just the individual

Reassuring Suzie in the morning Pros

Cons

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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

Talking will only escalate the problem 48

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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

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

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Suzie’s Mom Learned reasonable vs. excessive Modelled her own emotion regulation Practiced validation • Acknowledging fear • Acknowledging the physical sensations Collaboratively created a plan on new ways for mom to respond • Asking open-ended question in response to Suzie’s questions (e.g., what do you think?) • Responding to one call or text a day when there are no classes • Specific guidelines when a doctor’s visit is warranted • Do opposite of what anxiety wants!

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

Biggest Barrier to Success?

Motivation for Change

Inspire

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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

Address Resistance Early: Outcomes

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Suzie’s Cost Benefit Analysis Benefit of anxiety Protection – alert to potential dangers Makes me feel safer and more prepared Better liked Prevent judgment Responsible & taking good care of my health Easier & more comfortable

Cost of anxiety Too upset and reactive Social isolation Personal relationships affected Academics affected No time for hobbies and self-care Time consuming! Not sustainable Chronic physical symptoms Loss of self Effortful to feel overwhelm No joy in life

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

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

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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 62

Clarify expectations

What’s the problem with this goal:

To be less anxious 63

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

SMART GOALS

Key Concern

Unable to leave the house without very specific criteria being met. Leads to everyone arguing, feeling overwhelmed, and late.

Concrete Goal 1

Specific: By October 22, Suzie will leave the house to go to school on her own. She will use her skills instead of asking for reassurance. Leaving the house despite the unknown. Measurable: Track the number of times Suzie asks for reassurance. Track her use of strategies. Achievable: Identify realistic and feasible strategies that will work for Suzie’s personal needs and leave enough time to get ready. Relevant: Learning to cope is crucial to break the dependency traps that are maintaining anxiety. This will improve Suzie’s emotional well-being – (the primary concerns), as well as her relationship with her mother and morning. Time bound: Implement strategies immediately and continue to monitor until our next appointment.

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Necessary Steps to Achieve Goals Skill building:  Awareness  Acceptance (of discomfort)  Detach Practice  Leaning in

Monitor  Effectiveness of the established plan  Obstacles  Adjust as needed

Address barriers to success Individual Barriers

• Willingness, commitment, and consistency • Irrational thoughts and negative mindset • Self-concept and self-efficacy • Avoidance

Familial Barriers

• Mother's Anxiety • Unintentionally reinforcing avoidance behaviours • Poor modelling • Codependency • Family beliefs and attitudes • Parenting style

External Barriers

• Social pressures and dynamics • School stressors • Social media influences • Time constraints • Therapeutic alliance

Address Resistance Early: Process

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Anxiety likes to Overwhelm & Keep us Stuck:

Externalize

Mishmash of a Brain Pieced together over millennia • No one CEO. Lots of sub selves. • Different parts of the brain can communicate and work together easily • Others only have indirect contact • Can hold contradicting information in different parts of the brain

At Least Seven Subselves The Best Equipped Takes over Self-protection Mate attraction Mate retention Affiliation Kin care Social status Disease avoidance

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Argue & fight for control when it feels it is best suited for the job

Inner Dialogue • A lot of back and forth • Integrative – working through a scenario • Confrontational – competing to win • Different parts of the brain activated depending on the selftalk • How we talk to ourselves influences our behaviours 73

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

Name it to tame it

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November

Rigid Rick

Missing out on • Seeing friends

All-or-nothing Allie

• Learning opportunities • Wasting time she could be doing other things

Avoidant Alison

• Positive relationship with mother

Self-Critical Carla Catastrophic Cam Perfectionist Pete Fortunetelling Fran Mind reading Mandy Negative Nellie

No one part has complete information: It fills in the gaps

Address external maintaining variables

Outline rationale & personal reasons for making changes

Set goals, address barriers, and maintain motivation

Externalize challenges

building:Raising Skill Skill building: Raising awareness awareness & relating & relating to toemotions emotions in anin an accepting way accepting way

Explore emotions

Target different parts of emotions: Affect

Target different parts of emotions: Thoughts

Target different parts of emotions: Emotional behaviours

Emotion exposures

drcarolinebuzanko.com

Have a Structure!

Core Skill: Mindful Awareness of Emotion

Establish a Framework

Physical Feelings • Prepares to take action

AnxietyDriven, Maladaptive Response

Emotion

Behaviours

Thoughts

• Nonverbals • Compelled to take action

• Focus on perceived threats 79

Physiological

Understand Anxiety & What it does Understanding this connection makes it easier to respond differently

90 Seconds!!!!

Motivational (response)

Emotion

Cognitive

Body language 80

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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 82

Mindfulness is Key

NOT ABOUT RELAXING

NOT ABOUT CHANGING EMOTIONAL EXPERIENCES

NOT ABOUT FIGHTING OR IGNORING THEM

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

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At the expense of valuable information now

• 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

Mindfulness

IT’S ABOUT LEANING INTO THEM & GIVING THEM SPACE 86

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

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

Anxiety/Emotion Dial

Acceptance Dial

100

What to Accept

Memories

Images

Bodily Sensations

Feelings

Thoughts

Automatic responses

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

To an accepting & nonjudgmental stance in which they lean in 92

Curiosity is a key response to emotional experiences

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Starts with Awareness & Acceptance: Affect

Awareness & Modification of Reaction

Awareness of Interpretation & Flexibility

Awareness of & Feelings of Acceptance Affect Situation

Understanding emotions is key to accept & tolerate them!

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

Physically

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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

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.

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

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…What it feels like…

100

• 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

Physical Symptoms are a Problem

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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…

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

104

Feel More but can’t interpret what the feelings mean Do whatever they can to get rid of them… 105

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… Or control what they can in their external world

106

Of course you feel that way!

Validate & Normalize Feelings

No wonder - your adrenal glands sent out all that stuff that’s really uncomfortable.

Quick Tip 108

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Understanding the FUNCTION of emotions also critical to accept & tolerate them!

109

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

110

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

No Anger

No Fear

Picked on

No Disgust

Eat pooh

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Get eaten

No sadness

No Misery

Glutton for punishment with unattainable goals

No future motivation

Unable to process loss

Understand Function of Emotions

Disappointment

MUST have physical reactions to alert us to what is happening • Cannot change reactions without this understanding

Hurt

Fear 112

113

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.

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

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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

This is normal!!! And NOT dangerous!

115

When uncomfortable, EVERYONE’s brain wants us to quit.

116

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

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I understand what my body is doing I can handle what my body does

Self-Coach

I can handle discomfort I know what I can do now

Essential to Reconnect Physiologically Diz z y

Racing

Tens ion

Achy

Sore

H ot

Cold

Tingly

Relaxed

Trembling

N umb

Sharp

N aus ea

Breathles s

Shivering

Sweating

119

Trouble s wallowing

Tired

Dizzy

Shivers

Racing

Increased heart rate

Tension

Weak legs Ringing ears

Achy Sore Hot Cold Tingly Numb

Identify& describe TWO places anxiety shows up. Stronger on left or right?

Blurred vision Muscle tension Shaking Trembling Chest pain

Sharp

Headaches

Breathless

Burning skin/sweating

Shivering

Blushing

Sweating

Changes in breathing

Trouble swallowing

Stomach-ache/ Nausea

Tired

Relaxed

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120

When we label the different parts of emotions and our experiences, we: • Change our interpretation of them • Change how our body responds • Dampen amygdala’s false alarm • Turn on prefrontal cortex • Make adaptive decisions • Learn that we have control over our responses • I know what you are & I know how to handle you

• Avoid getting sucked in – it’s just a piece of information 121

Can’t just talk about it. Practicing Emotional Awareness Key! 122

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

123

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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!

124

Nonjudgmental Awareness of the NOW is Foundational

• Without mindful awareness and acceptance of emotions, can’t move on with any of the other work to strengthen more adaptive responses • Therefore, need LOTS of practice and experiences with uncomfortable feelings

125

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! 126

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Learning? • It might change • It’s temporary if you sit long enough with it • Staying curious keeps our prefrontal cortex on

127

Anxiety is not in the situation but the feelings we have and

how we perceive those feelings

Same mindful acceptance applies with thoughts

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

Cognitively

129

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Brain built for survival – its job is NOT to be happy

Emotion

Cognitive

• Negativity bias (primed to see non-existent danger) • Uncertainty misinterpreted • See events as threats • Becomes ingrained

130

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

• Avoid getting caught in the content!

131

Mindful Awareness & Acceptance of Thoughts • Infinite amount of thoughts • (4.617 x 10^61 potential thoughts= four hundred sixty-one duodecillion and seven hundred decillion)

132

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• Constant stream • Unaware of most of them • Even when they affect how we feel • Easy to get stuck on one • If sensitive, the bizarre ones will always stand out

We can't control our thoughts – only our response to them Be aware and accept it for what it is: A random thought

134

Success at controlling obsessions _________________________________ 1 10 Effort in trying to control obsessions _________________________________ 1 10 Back & forth battle where obsessions typically always win…

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Core skill Mindful Awareness & Acceptance of Emotion:

Thoughts

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

Defusion

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•Noticing thoughts vs. getting caught in thoughts

Past

Future Present

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!

140

Our emotional state influences how we interpret information

141

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Did you know? Fear and excitement feel the same in the body? But how we think about it makes all the difference in the world….

Threat vs. Challenge Response Not good or bad, different purposes Different hormones released to prepare for what's to come. How does our body know?

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

143

Our thoughts are not always trustworthy!

144

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

145

Information from our eyes and ears only loosely connected to what we experience Mechanics of vision: The eye is like a camera • Light bounces off objects

Retinal image (2-D) sent to the brain to interpret the information • Information • Fragmented • Ambiguous • Takes a lot of effort to change them into 3-D

• Enters our eyes • Focused on the retina by the lens • Retinal image (2-D)

146

Knowledge Influences Sensory Information (e.g., all faces are always convex) Our knowledge/ experience misleads us into seeing the mask as convex

147

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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

The first draft

149

The first draft

These are only guesses!!

Wrong 99% of the time 150

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Overestimation

ANTS Involve:

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

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

Lead to spiralling

I made a mistake

They realize I am incompetent

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I am going to be fired

My family is going to reject me

Homeless

First interpretation: Little effort at all • Second interpretation: Takes more work

Brain Shortcuts With these shortcuts it is really easy to get stuck with ONE interpretation (the automatic conspiracy END OF THE WORLD)

• 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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Cognitive Flexibility

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Zoom Out! • When we are too close, we get drawn into the emotions of the experience and spiral to the easy way out. • When we can create space, we can respond in helpful ways

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Get Unstuck: Detach Distancing • “___ is noticing ____ is having the thought that….” • Use third person language Train, balloons, bubbles clouds, or leaves on the river Thank them Objectify

• What colour? How big? What shape? What texture? How would it move if it could?

Name that Story

• The worst thing about me is _________________ • I am so anxious I think I will just _________________

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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? 160

• 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.

161

ANTS are only guesses!!!!

I made a mistake in the document

I am in trouble

My boss wants to see me

(Automatic ones that tend to prepare us for the worst)

I spoke out of line

Someone complained

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Overestimation

ANTS Involve:

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

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

Overestimation

NOT good or bad BUT they

DO limit our flexibility

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

Cognitive Flexibility • Lean into strong emotions • Keep our prefrontal cortex online by GETTING CURIOUS • Break anxiety maintaining cycles: Change relationship and response to emotion-provoking situations

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Cognitive Flexibility: Get Unstuck from Thinking Traps Goal is to increase flexibility in appraising situations  NOT to eliminate, replace, or fix thinking – this IS one possible way to look at the situation

• Respond in adaptive ways •

167

Detach. Then edit. Yes, these are possibilities.

I made a mistake in the document

AND, 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 is responding to my earlier request

Boss had a question about my time off request

Boss wants to explain the new project 170

Enhance Cognitive Flexibility with Helpful Open-Ended Questions Create a checklist • To generate alternative explanations

Alternative explanations

How would my friend interpret this? Grandma? Pet? Is there any shred of usefulness in this thought? What would I get for buying into this story? 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?

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

172

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?

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

175

Perfectionism is the most serious thinking trap & root of depression Focus on core concepts • Unrealistic expectations • Rumination • Need for approval • Concern about mistakes • Doubts about actions • Additional traps like circumstantial thinking , quality/quantity 176

Break into Parts

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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Break into parts

• You never do anything right • No one likes you • Everything you do sucks • You always fail and will continue to fail

• Good and not so good • This part is hard • I will focus on one step at a time

Perfectionism Guesses

178

All or nothing: I can’t do anything Leading meetings: easy

I can’t write I can brainstorm

I can follow a template

I can edit

Supervision meetings: Easy

Client work: Easy 179

Build Procedural Thinking! • Strive for excellence, but address unrealistic standards • Emotions related to expectations • Focus on what’s next (vs. circumstances, rumination, should’s)

What’s next? What’s next? What’s next?

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Mental Association Pair a difficult situation with an action that has never failed

181

The Importance of Mistakes  Talk about your own mistakes  Talk about others’ experiences

Common characteristic of TOP, most successful CEO’s: Embrace their mistakes as learning opportunities of how to be even better

They look forward to failures

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Embracing mistakes: Mistake of the Day! What was this experience like? What did you learn from this mistake What will you do the next time you are in this situation? What advice can you tell others based on this?

Forging ahead • Avoid getting stuck • What’s next? • Think of the hows • How will I fix this mistake? • How will I move on? • How will I handle ______________?

MacGyver It Up!

• 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?

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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 187

What story DO you want to buy into?! 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 • 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 188

Practice!

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

189

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Daily Practice! Focus on awareness • Track • Physical sensations • Thoughts • Behavioural urges

190

Daily Practice! Focus on Acceptance Stress is inevitable so need to learn to go with the flow & accept what we can’t change • Practice getting uncomfortable on purpose! • Be present with any unpleasant feelings, physical sensations, or Focus on the physical sensations thoughts

Core skills  Identifying and modifying unhelpful emotion-driven behaviours

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

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

Behaviourally

194

Remember, emotions lead to behavioural responses to respond quickly to our environment

Anger

Assert, Flee, ThoughtsFear about the situation defend freeze

Shame

Avoid

& their belief of how they can manage also lead to patterns of behaviours

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Sadness

Support, withdrawal

Joy

Excitement

Connect, engage

Attend, explore

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

• 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 197

• Substance use

Maladaptive Behaviours • 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 Behaviours • 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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When someone avoids things they don’t feel comfortable with, they lose the chance to practice and grow

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 200

With avoidance, they never learn! Biased Thoughts

Safety behaviours

Never learn thoughts are biased and bad things might not happen or be as bad as thought.

Never learn they can cope on their own

Anxiety strengthened Worried thoughts seem believable

Hinders their ability to face challenges

201

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Emotional (Avoidant) 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 202

Emotional Discomfort

Brain is rewarded

Important!

Avoid

Feel better in the moment

MUST understand how their behaviours are maintaining, or even worsening, their emotional discomfort  The behaviour is reinforced in the moment, increasing the likelihood of using this strategy again in the future

203

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

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• But I end up missing school I ensure I look perfect to feel safe • But I fight with my mom against potential embarrassment.

I skip social functions to avoid rejection

• But I miss out seeing my friends and nurturing those relationships

I constantly check • But I miss out on things my health to stay in • Time consuming control and catch • Always worried and no anything early time for hobbies

I fail school Homelife is tense

I will lose relationships and become isolated.

I disrupt relationships, lose self, become depressed

90% of what people learn is from what they experience

206

Don’t underestimate the power of the anxious emotional brain! • Change is neurological – we need to change the brain • Behaviours affect emotions more effectively than thought or talking • Brain is changed through EXPERIENCES • Can’t think or talk our way to change • Focus on strength (behaviours) rather than weakness (thoughts)! 207

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MUST DO THINGS DIFFERENTLY! Emotions become a disorder when we do what anxiety wants (i.e., feel better in the moment)

Speed of recovery directly relates to your willingness to feel anxiety

209

Resilience Ability to adapt well to adversity, trauma, tragedy, threats, or even significant sources of stress.

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What am I going to do next? (The Opposite of What Anxiety Wants)

Avoid judgment

Avoid rejection

Ensure Healthy

• Harassing mom to ensure I look perfect

Face uncertainty of possible judgment

• Leave without asking mom

• Skip social functions

Face uncertainty of possible rejection

• Go to social functions

• Waste time constantly checking • Fighting with mom

Face uncertainty of my health status

• Paint instead of checking Dr. Google

Core skills Integration of all the skills through emotion exposure to

master adaptive responses

Integrate Skills through Emotion Exposure Integrate skills to master adaptive responses • Talking not enough to change the brain! • Doing makes stronger memories • Doing gives us experience • Quicker progress • Provoke STRONG EMOTIONS - MUST show up for learning to happen

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Worry is… Emotional exposures because the primary focus is not the specific situation, image, or activity but the emotion itself.

Emotion Exposures Interoceptive

• Elicit distressing physical sensations

situations that provoke Situational-based • Face intense emotional reactions

Imaginal

• Confront distressing thoughts or emotions.

215

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

216

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Goals for ALL Exposures PROCESS vs. OUTCOME • Based on something actionable • Targets distress

• Ensures they learn something new firsthand vs. anxiety reduction

Exposure to LEARN

Anxiety is safe, tolerable, & temporary • Safety behaviours are not needed to tolerate anxiety or to stay safe • The amygdala will learn: This is not dangerous! (And stops sending the false alarm.)

Exposure to LEARN

Despite feeling anxious, I still did it • And… I can still live life and do anything, even while feeling anxious!

219

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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 …But, 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

Getting unstuck

Face Fear

Without the worst thing happening

Without safety behaviours

Or, if it does, they can handle It

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Interoceptive Exposure: Critical to address for EVERYONE • Not just panic disorder • OCD • Social anxiety • Phobia • Performance anxiety • Perfectionism • Sadness • Stress

Physical Symptoms are a Natural Response

• But often misinterpreted as dangerous, which creates a positive feedback loop • Often motivated to avoid these

Interoceptive Exposure: Lean Into Discomfort! • Confront worrisome body sensations • Evoke things they worry about

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

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Interoceptive Exposure Learning: The uncomfortable physical sensations are tolerable, temporary, and not dangerous. • I am not • Having a heart attack • Losing complete control • Suffocating • Dying

Be Prepared! 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 side to side or draw 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

Collaboratively choose a moderate & distressing exercise • 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 • Physical sensations • Intensity of sensations • Level of distress

• Assign for homework!

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228

Increase flexibility with response to physical sensations Intensifies Feelings & Beliefs

Physical sensation

ANTS: Something bad!

Interpret as threat 229

Context Influences Interpretation Feelings subside

Physical sensation

This is normal 230

Tolerating Uncertainty • Life is full of uncertainty: we can never know what is going to happen from one moment to the next • Brain will do whatever it can to avoid uncertainty • Build tolerance by going into the unknown!

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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

Avoiding Rejection Ingrained in the Brain Why?

233

It Meant Survival Feel it intensely 234

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Alain de Botton “Anyone who isn't embarrassed of who they were last year probably isn't learning enough.” “The way to greater confidence is not to reassure ourselves of our own dignity; it’s to come to peace with“ our inevitable ridiculousness.”

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 236

Setting up Exposure Set up the situation & collaborate a specific plan Address obstacles Address safety behaviours 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: COLLABORATIVELY Create a Menu of Feared Situations & Internal/External Stimuli Have a variety and 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. trigger or outcome, LEARNING vs. anxiety reduction

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 someone out • Forget to lock the door • Go to the toilet in public

• Walk outside on a really windy day 239

You are the expert and I need your expertise! We will put our expert heads together to figure out the best plan.

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Brainstorm & Rate

Antecedents (Triggers to anxiety)

Predicted Awfulness

Making eye contact with a co-worker and smiling

Needing to ask the co-worker a work-related question

Sending an email

Walking past the co-worker's desk and smiling

Walking past the co-worker's desk and saying Hi

Being in a small group meeting with a co-worker and making a comment

100

Asking a co-worker for personal assistance

100

Stopping at a co-worker’s desk to chat

100

Asking a co-worker to go to lunch

100

Collaborate

Actual Awfulness

Later

They get to choose what they want to do Several things can make it easier or harder (e.g., distance, time, people) Does NOT need to be easiest first MUST surpass the identified point at which the feared outcome is expected

242

Setting up Exposure:

Collaborate a specific plan

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Step-by-step plan On Monday morning at 10:00, I will: • Mindfully walk (focusing on my feet movement) in the direction of M’s desk. • I will maintain a natural pace and posture with my eyes up • When I reach the intersection of desk, I will look at M and smile • As I reach the corner of M’s desk, I will say “Hi” clearly and audibly • I will continue walking past the desk to the photocopier to photocopy a document • I will return to my desk to note how I felt before, during, and after the exposure and rate the awfulness.

Intense Anxiety or Panic Before the Attempt

Setting up Exposure:

Address Obstacles

• Drop into the body and review my goal and coping cards • Identify the first step and go anyway M is not at their desk • Practice walking past the desk • Try again when M is back • Do the exposure at the next alternate time I get called into a meeting • Do the exposure at the next alternate time

No Safety Behaviours Allowed! (It’s only an illusion of safety anyway)

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The Problem with Safety Behaviours Habits that maintain & 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)

Safety Behaviours

Any strategy to control, avoid, or reduce anxiety 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

248

AVOID False Fear Blockers Anything to make them feel better in the moment • Taking deep breaths • Relaxation • Distraction

249

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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).

Predictions are important for learning! Set up as experiments to ensure learning

251

Predict to Maximize Learning! Antecedents (Triggers to anxiety)

Predicted Awfulness

Walking by M’s desk and saying Hi I predict this will happen

Actual Awfulness

Later

90 What really happened?

I will turn bright red I will stare like a deer in headlights I will say something nonsensical or stupid

Need to disconfirm their fear story to the fullest extent possible

M will look at me in disgust Everyone will hate me I will die from embarrassment

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Setting up Exposure

Honesty!

You’re going to feel uncomfortable Anxiety will be at its highest when you do something different the first time without safety behaviours

253

Setting up Exposure

You’re going to feel uncomfortable MUST Activate to generate

Develop new, competing brain circuits

Setting up Exposure: Remind how anxiety works Anxiety is • Uncomfortable & this is what it does… • 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)

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Setting up Exposure:

Honesty!

• We have no idea what is going to happen • I know you will handle it

256

Setting up Exposure:

Rationale

Remember!

We can never make anyone do anything – especially distressing things - if they don’t want to do

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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!

BUT…Fake it ‘til you make it doesn’t work (Masking is exhausting and too hard in the face of a real challenge) 260

Real Bravery is NOT Fearlessness.

Bravery is acknowledging when something is hard (not pretending it isn’t) • With an honest appraisal, we can respond productively

261

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Remember! Speed of recovery directly relates to your willingness to feel anxiety

262

If I am uncomfortable Then I know I am on the right track

Setting up Exposure:

Test it out

This is the only way to create new experiences that contradict with old worries

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When the gremlin shows up, it is going to:

I am going to:

Tell me

Say

Make me feel

Notice

Want me to

For Suzie’s mom:

Reassure

Suzie’s Flowchart

Support Confidence

Acknowledge & Name it

Where & how does it show up

What story is it telling

Whatever

Thank it

266

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

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Setting up Exposure: Debrief & Evaluate

Learning happens here to disconfirm conspiracy 268

Evaluate to Maximize Learning! Antecedents (Triggers to anxiety)

Predicted Awfulness

Walking by M’s desk and saying Hi

I predict this will happen

What really happened?

I will turn bright red

Feel like I turned red (but don’t know for sure)

I will stare like a deer in headlights

I smiled

I will say something nonsensical or stupid

I said Hi

M will look at me in disgust

M smiled and said hi back

Everyone will hate me

No one has treated me any differently

I will die from embarrassment

I am still alive

Actual Awfulness

Later 0

Disconfirm their fear story to the fullest extent possible but,

No matter how awful or what happened, it passed &

I HANDLED IT!!!!

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 270

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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?

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!!!

Worry is strong • Negative, worrisome events create strong memories

273

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Worry makes us forget

274

Keeping track is essential to create memory bridges

Hard

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Working on It

Success!

Even the most skilled of us revert to old ingrained habits when the situation is new and/or overwhelming

Create new ingrained habits

277

Keep Going! What can we do to tweak the exposure to be even more effective & next targets

278

What I couldn’t do because of worry: • Look at or talk to co-workers • Look at or talk to unfamiliar people

Moving on

What I can do now: • Say hi to co-workers • Go to lunch with co-workers • Ask co-workers to go for coffee • Smile and say hi to strangers

Where I am going next: • Ask someone to hang out on the weekend • Ask someone out on a date

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Committed action Daily Doses of Stress Inoculation to Maximize Success

280

Lifestyle Focus Opportunists: Choosing to be anxious now for more success later

Goal:

Willingness Action Plan

Big why:

The steps I need to take are:

The discomfort I am willing to have to achieve this goal:

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I will take the first step on (date) at (time)

Thoughts Feelings Sensations Urges I can remind myself that:

Recovery is when: You’re not worried about worries

END

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 therapeutic 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

286

Focusing on 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

What to do instead…

Habituation

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Focus on learning: Feared outcome beliefs contradicted ? Did you handle it?

What to do instead…

Eliminate anxiety & fearful associations

Create new learning patterns that compete with old ones

What to do instead…

Conditional Safety Learning

https://parentsoftheyear. com

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Learn non-danger-based associations across contexts with different people and everywhere anxiety can show up

https://bit.ly/overpoweringemotionspodcast

4/24/24

Healing the Wounded Self

P A T T I A S H L E Y, P H D , L P C WE S T E R N C A N A D A T R A U M A C O N F E R E N C E MAY 8 , 2 0 2 4

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Part One: Objectives •

Develop an understanding of the neurobiology of trauma and shame.

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Explore attachment theory, and subsequent adult attachment styles.

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Recognize how early relationships set the stage for adult relationships.

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Identify non-verbal, sensory, and implicit cues related to trauma treatment.

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Recognize the sensory aspects of trauma and develop fine-tuned co-regulation skills.

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Utilize techniques that facilitate healing body memories of trauma and shame.

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The Neurobiology of Trauma, Attachment, and Early Childhood Influences

What is Trauma?

Any unresolved autonomic nervous system response to an event. It is not the event itself. Levine (2010)

“Trauma is not what happens to you but what happens inside you.”Mate (2022 p.20)

Trauma-Informed Approach • Introduced in 2001 • Integrating aftereffects of trauma on mental health • “What happened to you?” Perry & Winfrey (2021) & Dolezal, L., Gibson M. (2022)

“We now know that the neurochemistry of sustained stress and traumatic experiences distorts our perception and cognition in ways that support our immediate survival.” Cozolino (2020, p. 132)

Perry & Winfrey (2021) & Dolezal, L., Gibson M. (2022)

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Degrees of Trauma •

Big traumas (natural disasters, sexual assault, situations that involve threatened or actual injury, etc.)

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Little traumas (divorce, job loss, emotional abuse, etc.)

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Sanctioned mini-traumas (some traditional parenting practices)

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Secondary traumas (an indirect experience of a traumatic event)

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Intrauterine and birth traumas (fetus, pregnancy, mother, instrumentation during delivery, etc.)

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Medical procedure traumas (negative experiences within a medical setting )

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Intergenerational traumas (passed done from ancestors) Fitzgerald et.al. (2020)

Disturbed Executive Functioning • The hyperarousal of the amygdala inhibits executive systems vital to

navigating the world • Parietal-frontal executive system--abstract thinking, problem solving, and

intelligence • Broca’s area in the left frontal lobe--systems of expressive language

Cozolino (2020)

The ANS & Polyvagal Theory •

The autonomic nervous system (ANS) is the neural platform beneath every experience.

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Stephen Porges’ polyvagal theory expanded on prior understanding of the ANS. Porges (2011)

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The Vagus Nerve • Largest of the twelve cranial nerves and is sometimes referred to as the “wanderer,” as it extends from the brainstem into the chest and abdomen • Influences the throat, lungs, heart, digestion, and elimination • Provides sensory input from our visceral organs to our brain about how our body is feeling • Conveys information to the nervous system about safety, or lack thereof, in surroundings

Rosenberg (2017)

Polyvagal TheoryThree Organizing Principles 1. ANS Hierarchy: dorsal vagal; sympathetic; ventral vagal

2. Neuroception: subconscious system for detecting threats and safety in the environment; detection without awareness; precedes perception 3. Co-Regulation: loss of coregulation results in a neuroception of threat; misattunement violates neural expectancies regarding social connection Porges (2017) & Levine (2010) & Dana (2018)

Emotional Safety •

Co-regulation is the requirement for feeling safe.

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Every action is a reaction seeking safety and survival. Porges (2012)

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Social Engagement System and Connection • Ventral vagal state promotes connection • ANS functioning well--openness, positive expectations, and

trust • ANS unsafe--hard to access rational thought, energy moves

into defensive, instinctual responses Porges (2011)

Body memories • Nervous system may react as if happening now • Happens faster than mind able to process • Unable to distinguish if memory or current • Prefrontal cortex (time-keeper) goes off-line • Can trigger painful emotions and sensations • Gut-wrenching and heart-breaking sensations • The body always wins • Posture, gait, movement, and body language can give clues • Somatic memories often override cognitive thought processes van der Kolk (2014)

Reenactments • Individuals may reenact past traumas to master them • Conscious awareness is key to change • Energetic discharge • Renegotiation • Patience and attention • Unconscious repetitions van der Kolk (2014) & Levy (1998)

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The key feature of trauma is loss of social connection. Cozolino (2020)

Connection is why we're here. We are hardwired to connect with others, it's what gives purpose and meaning to our lives, and without it there is suffering. Brown (2015)

Attachment Theory and Trauma

Co-Regulation in Infancy

Synchrony

Serve and Return

Attunement

Rupture and Repair

Brazelton & Cramer (1990)

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THE Crucial FIRST 3 YEARS

Permission granted by Center on the Developing Child at Harvard University http://developingchild.harvard.edu.

Poisonous Pedagogy

Alice Miller, Swiss psychoanalyst researched Eighteenth Century child-rearing texts Shame-based systems

Goal was to “break the will” of the child Needed to happen before child was old enough to remember Miller (1983)

Some Not-Enough Messages • You’ll never amount to anything. • You should be ashamed of yourself. • Stop crying before I give you something to cry about. • Get over yourself and be happy. • Stop that attitude. • You need to respect me.

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Identifying Developmental Traumas

THE FIRST SIX YEARS

Theta waves– relaxation, meditation, receptive

to information beyond normal conscious awareness. This low frequency state is likened to hypnosis and is highly programable. 4 / 2 4 / 2 4

Laibow (1999 )

“The fundamental behaviors, beliefs, and attitudes we observe in our parents become ‘hardwired’ as synaptic pathways in our subconscious mind.” Lipton (2005)

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Adverse Childhood Experiences (ACES) •

CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study 1995-1997

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Traumatic events that occur in childhood can influence physical and mental health long-term

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These events might include violence, abuse, and a family with mental health or substance use problems

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Can change brain development and affect how the body responds to stress

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Linked to chronic health problems, mental illness, and substance misuse in adulthood

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Childhood adversity in 45% of childhood mental health disorders and 30% of adult MHD Felitti, et.al (1998) & Perry & Winfrey (2021)

Therapeutic Empathy, Emotional Literacy, Agency, & Co-Regulation

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Going Beyond Trauma-Informed • Shame–sensitive practice is essential in trauma-informed work • Shame is key emotional after-effect of trauma • Trauma-informed approaches often fail to adequately address shame • Effectively addressing the post-traumatic state requires a clear understanding of

shame

• Shame can be barrier to successful engagement in treatment Dolezal & Gibson (2022)

What is Shame?

“The intensely painful feeling or experience of believing that we are flawed and therefore unworthy of love and belonging.” Brown (2010a, p.39)

Core Shame A primary affect induced from ruptures in the interpersonal bridges that becomes a core part of one’s identity. Kaufman (1992)

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Beginning with Shame “Like a wound made from the inside by an unseen hand, shame disrupts the natural functioning of the self. If we are to understand and eventually heal what ails the self, then we must begin with shame….” Kaufman (1989, p.5)

Shame Identity

Guilt is “I did something bad.” Shame is “I am bad.” bad a failure

flawed

I am… unworthy of love

a fraud never good enough

Person-Centered Therapy “To sense a client’s anger, fear, or confusion as if it were your own, yet without your own anger, fear or confusion getting bound up in it, is the condition we are endeavoring to describe…When the client’s world is this clear to the therapist, and he moves about in it freely, then he can both communicate his understanding of what is clearly known to the client and can also voice meanings in the client’s experience of which the client is scarcely aware.” Rogers (1957) p. 284

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Empathy is a Right Brain Activity The principal agent of change is the therapist’s capacity for empathy. Siegel (2010)

“Our shamed clients need changes in how their right brains work for them, but they cannot make these changes on their own. They need to be in sustained connection with at least one other person who is close enough to become someone who can regulate—rather than dysregulate—their right brain affective experience.” DeYoung (2015) p. 87

If Empathy Could Speak…

Mirror neurons •

the root of empathy

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fire in the prefrontal cortex in response to another person’s experience

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automatic during intentional acts

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resonates with feelings and all sensory channels Siegel (2010)

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Four Characteristics of Empathy Perspective Taking Staying out of Judgment Recognizing Emotion

Communicating Emotion Wiseman (1996)

The Four Therapeutic “R” s + ONE MORE • Recognizing the autonomic state the client is in • Respecting the adaptive survival response • Regulating or co-regulating with the client into a ventral vagal state • Re-storying

Repetition, repetition, repetition…………………….. Porges (2009) & Ashley (2020)

Therapeutic Empathy: Four Skills At Once 1.

To share the shame and humiliation of the client

To take on our own perspective while regulating affect when feeling with client.

To bear and contain the experience of being seen, even if as abuser

To co-create a new relational experience where both therapist and patient collaborate and co-construct selfcompassion Knox (2013)

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Therapist Self-Assessment Stepping into the right-brain experience of our clients may present some challenges. These can include feeling vulnerable; feeling like a fraud; agitation; frustration; worrying about outcomes; sustaining connection when stressed; holding space for whatever comes up; making mistakes; etc. Here are some thought questions for you to explore. 1. Empathy to me feels like... 2. When my client is getting dysregulated I feel my body... 3. Some clues that my client has triggered my own shame is... 4. It is difficult for me to notice my own shame because... 5. What helps me self-regulate is...

Emotional Literacy & Agency • All feelings are okay • All behavior isn’t! • Tolerating Discomfort

Paradox

• Holding the tension of the opposites • Tolerating pain & discomfort • What we resist persists “Some of you say - joy is greater than sorrow, and others say - nay, sorrow is the greater.’ But I say unto you, they are inseparable.” Gibran (1923)

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Six Ways To Express Anger

Turn it inward

Lash-out

Nonproductive outlet

Productive outlet

Talk about it

Problemsolve Kersey (1983)

Part Two Objectives •

Practice acute right-brain relational attunement with clients.

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Learn somatic and relational tools that foster compassion & empathy. Discover evidence-based tools and techniques to treat shame and trauma.

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Utilize mindfulness and meditation to calm nervous system responses.

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Excavate old narratives and rescript more authentic safety stories.

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The Art & Architecture of Reconstructing The Authentic Self Creating container (foundation) Building relationship (frame) Bridging heart & head (wiring) Witnessing & guiding (plumbing) Tools & techniques (lighting) Working with secrets (closets & cabinets) Creativity (décor & art) Barriers to relational presence (fences)

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Genograms & Time-Lines

Tools & Techniques (Lighting)

Journaling, Poetry, & Letter-writing Yoga, Movement, Ritual, & Dance Laughter & Play Common Treatment Models Creative arts, Mandalas, & Coloring Mythology, Archetypes, & Stories Dream-work & Visualization Meditation & Mindfulness Nature & Animals Prosody in Sound & Music

Genograms, Time-lines, & Re-storying

Genograms look at patterns

Depersonalizes shame

Time-lines identify shame developmentally

Re-storying ancestral shame scripts

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Re-Storying OLD STORY

NEW STORY

“I am a burden.”

“I am a blessing”

Easier to know what we don’t want then what we do want. Find opposite. Look up antonyms.

Excavation Exercise: Deep SEA Dive • Situation • Emotion • Aspired Action

Connecting the Dots to Early Trauma & Shame Feeling

Embodying new story

Body sensation

Naming new story

Early memory of feeling

Core shame story

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If I were to embody my affirmation, it might: Look like ___________________________________________________

Come to Your Senses

Sound like ___________________________________________________

Smell like ___________________________________________________

Taste like ___________________________________________________

Feel like ___________________________________________________

Patience With The Process Do the math--How many negative self-talk messages a day X 365 days X how many years on the planet ________________________ = the hundreds of thousands of messages that need to be rewritten in the body memory!

My Three-Act Day • Affirm • Connect • Trust

3x/Day

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Not for everyone

Journaling

Bring journal to session (if client is interested) Homework assignments Old story/new story Journal prompts Getting power back through writing

Letters to and from “little me”

Letter Writing

Letters NOT to send Thank-you notes to SELF

Yoga, Movement, & Dance Yoga and mindfulness have comparable effectiveness in reducing trauma-related symptoms.

Taylor et al (2020) & Esfeld et al (2021)

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Fear Melters with Rebecca Folsom Freeze- Shake Flea- Sumo Stance Fight- Ooze Faint- Love Scoops Hendricks (2016)

Laughter & Play )

Brown (2010b

Song Courtesy of Cheryl Wheeler

I AM A NUFF

Drawing by Laura Martinez

EMDR, EFT, ACT, Psychedelics, Brain-Spotting & IFS

All helpful in somatic reprogramming What will help clients use tools on their on?

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Treatment Strategies that Influence Right Brain Neuroplasticity and Epigenetics

Neuroplasticity & Epigenetics Neuroplasticity- The nervous system can change its activity in response to stimuli by reorganizing its structure, functions, or connections. Epigenetics- The new biology that reveals how environment and perception control genetic activity. Mateos-Aparicio P. & Rodríguez-Moreno A. (2019) & Gustafson C. (2017)

Creative Arts Expression •Might be shaming for some clients •Find client’s interest/medium •Drawing/painting/other… •Bring to session or suggest for homework •Great for groupwork •Collage/vision boards/paradox boxes

“Often the hands know how to solve a riddle with which the intellect has wrestled in vain.” Carl Jung

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Mandalas & Coloring Books

Metaphor & Archetypes • Working with metaphor and stories • We are wired for story • Archetypes activate the right brain

Dreamwork, Imagination, & Visualization

•Making the unconscious conscious •Projective dreamwork •In my imagined version of this dream… •Imagination as compassion •Guided imagery & visualization

“All dreams come in the service of health and wholeness.” Taylor (2009)

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Meditation & Mindfulness • Calms nervous system • Breathing (or sighing)

“Moment to moment nonjudgmental awareness.”

• Heart-Brain Coherence

Kabat-Zinn (1997)

• Mindfulness & Meditation Apps • Mindful moments • Daily practice Deits-Lebehn, et al (2023) Childre, et al (2000) Gundel, et al (2018) & Keng, et al (2017)

Nature & Animals “We find ourselves in the quiet moments when the earth pauses, and we are still.” unknown

Prosodic sound most effective sensory healing modality Strongest trigger of neuroception

Prosody, Poetry, Music, & Sound Music or poetry during and after session Guided imagery/meditation with music

Drumming, toning, chanting, chimes, bowls, gong bath, etc. Listening to client's music Porges (2011)

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The Guest House By Rumi

This being human is a guest house. Every morning a new arrival. A joy, a depression, a meanness, some momentary awareness comes as an unexpected visitor. Welcome and entertain them all! Even if they’re a crowd of sorrows, who violently sweep your house empty of its furniture, still, treat each guest honorably. They may be clearing you out for some new delight. The dark thought, the shame, the malice, meet them at the door laughing, and invite them in. Be grateful for whoever comes, because each has been sent as a guide from beyond. Jalāl & Barks (1997)

Find Your Brave Song What song helps you feel strong?

How does it inspire you?

Play it often

Feel your courage

Let’s be Too Much Courtesy of Rebecca Folsom

Grief, Trauma, and Shame in the Brain •

ANS activated

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Emotionally dysregulated

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“Widow’s fog”

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Shame related to emotions not expressed

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Telling the story at least 100 times

Who is safe to trust with story?

Enlightened Witnesses

The trouble with friends & family

Therapists, spiritual counselors, support groups, etc.

Rhythm, Routine, & Ritual

Circadian Rhythms Daily Routines Rituals

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Questions?

Excavation Exercise: Take a Deep-SEA Dive “True wisdom is like an ocean; the deeper you go the greater the treasures you'll find.” Matshona Dhliwayo

Many of us were raised in families where the free expression of feelings was not the norm. We were taught things such as stop crying, don’t be angry, just get over it, etc. As a result, when something triggers us, it can be difficult to uncover the true feelings associated with that event. This exercise helps you get to the heart of the matter and excavate the deep feelings you are experiencing to see clearly what it is you truly desire. In order to excavate the deeper feelings associated with an event, I recommend taking a deep dive into the SEA: situation, emotion, and aspiration. The next time you are feeling stressed or emotional about something that is happening, take a minute to write about the situation, the emotion and the aspiration related to it. The SEA format helps you to see some of the lost and forgotten parts of yourself, and bring them to the surface. It is designed to help you excavate the treasure buried deep in your heart. It is a self-awareness exercise that only secondarily may be used to actually repair the situation with the other. The repair with the other may or may not come at a later time, and is not the intention of this exercise. This is for YOU to find YOU! Give yourself permission to dig deep to find what your heart truly desires. Remnants of your authentic self are hidden in the rubble. Here lies the treasure! In the SEA we define the situation in observable, repeatable and countable terms; search for the underlying emotions; and then think of what might have felt better instead and what your true aspiration is in this situation. Here is an example of the three parts of the SEA:

1) Situation: Define what happened in observable, repeatable and countable terms, such as when you yelled at me for not taking out the garbage. Do not write something vague and undefinable like, when you are grumpy. 2) Emotion: Search for the underlying emotions associated with the behavior, using the Feeling Words handout on the next page if you need it. Try to find words besides angry, frustrated, or sad. Although these are certainly appropriate, there are usually deeper feelings underneath, such as attacked, unloved, and unappreciated. 3) Aspiration: Think of what might have felt better instead, and what you truly desire. Write about it as such- it would mean a lot to me if we could negotiate household chores without yelling and arguing. This written excavation exercise might look like something this-- When you yell at me for not taking out the garbage, I feel attacked and unloved. It would mean a lot to me if we could negotiate household chores without yelling or arguing so much. Each time you recognize a deeper feeling and an aspiration, you discover what you have hidden away. For instance in the above example the feeling of being attacked and unloved may be something that had happened before that wasn’t identified as such, until diving into the feeling word sheet in the SEA. The aspiration may have been hidden because it didn’t feel obtainable. Even though it may be out of reach, it is important to allow yourself to SEE it. Bringing the hidden treasure to the surface and seeing the parts of yourself you previously denied helps set the stage for transformation and change. Be patient with the process. Simply observe the gems you are excavating for now. Breathe into what it is you truly desire, knowing that it is okay to be YOU!

Excavation Exercise: Your Deep-SEA Dive You can make copies of this worksheet use when you want to excavate your feelings and desires, or you can write the exercise in your journal when something emotional comes up. Situation: Define the situation in observable, repeatable and countable terms. When ……. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Emotions: Search for the underlying feelings associated with the behavior. Use the feeling words sheet if helpful. Try to find other feeling words besides angry, frustrated and/or sad. Even though they are certainly appropriate, there are usually deeper feelings underneath those more easily recognized ones. I feel……. ______________________________________________________________________________ Aspiration: Think of what might have felt better instead of the above behavior. It would mean a lot to me if…….. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Excavation Exercise: The Deep-SEA Dive (Feeling Sheet) Angry, sad and frustrated are easier to identify emotions. Look at this list to dig a little deeper for what might other feelings might be below the surface. ABANDONED ABUSED ACCOMPLISHED ADVENTURESOME ALERT ALONE ANGRY ANNOYED ANXIOUS APPRECIATED ARTISTIC ASHAMED ATHELETIC AWKWARD BABIED BEAUTIFUL BETRAYED BORED BRAVE BROKE CALM CAPTIVE CENTERED CHALLENGED CLUMSY CLUTTERED COMMANDED CONFUSED CONNECTED CONTENT COURAGEOUS CURIOUS DEPLETED DEPRESSED DIRECTED DISCONNECTED DISLIKE DISMISSED DISORGANIZED DISSATISFIED DRAINED EDGY

ELATED EMBARRASSED EMPTY ENERGETIC ENGAGED ENTHUSIASTIC EXCITED EXCLUDED FABULOUS FLATTERED FORGETFUL FRUSTRATED FULFILLED FULL FUNNY GASLIGHTED HAPPY HELPFUL HELPLESS HORRIFIED HUMILIATED HURT INCLUDED INCONVENIENCED INTERESTED INVOLVED IRRITATED INSIGNIFIGANT INVISIBLE ISOLATED KNOWLEDGABLE LAZY LETHARGIC LIGHTHEADED LONELY LOVED MISERABLE MISUNDERSTOOD MORTIFIED NEEDED NEEDY NEGATIVE

NERVOUS OFFENDED ORGANIZED OUT-OF-CONTROL OVERWHELMED OWNED PATIENT PEACEFUL PENSIVE PITIFUL PLAYFUL PLEASED POOR POSITIVE PRAISED PREPARED PRESENT PRESSURED PRETTY PROUD PUSHED PUT-UPON RAILROADED RELAXED RESTLESS RICH ROMANTIC RUSHED SABOTAGED SAD SATISFIED SCARED SCOLDED SHAKY SHOCKED SICK SILLY SKINNY SMOTHERED SPECTACULAR STRESSED STRONG

SURPRISED SWEET TALENTED TALL THIRSTY THOUGHTFUL TIRED TONGUE-TIED TRUSTING UGLY UNACCEPTED UNAPPRECIATED UNDERUTILIZED UNGRATEFUL UNHAPPY UNLIKED UNLOVED UNPREPARED USED USELESS OTHERS: __________________ __________________ __________________ __________________ __________________ _________________

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POLYVAGAL THEORY & TRAUMA-INFORMED STABILIZATION TOOLS DAPHNE FATTER, PH.D. (SHE/HER) LICENSED PSYCHOLOGIST

LEARNING OBJECTIVES

1. Describe at least one aspect of how traumatic stress impacts the brain. 2. Understand Polyvagal theory and how it applies to effective trauma treatment. 3. Identify several signs of when clients are in a state of hyper-arousal or hypo-arousal. 4. Apply at least one trauma-informed intervention to use when clients are in hyper-arousal and one intervention when clients are in hypo-arousal. 5. Differentiate treatment goals for each stage of the three-phase model for trauma recovery.

TRIUNE BRAIN (MACLEAN, 1990)

We have 3 brains in one brain that have progressed across evolution: • Brain Stem (Reptilian) • Limbic System (Emotional Brain) • Pre-Frontal Cortex (Neo-cortex)

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PTSD BRAIN: BRAIN STEM

ØBrain Stem (reptilian brain): awake/sleep/hunger/breathe becomes impaired: • Breathing becomes fast and shallow. • The pons within the brainstem serves as a major relay center between the brain and the bladder (Malykhina, 2017). • Impaired ability to modulate physiological arousal. • Difficulty being aware of internal sensations and perceptions. • Difficulty self-soothing and self-regulating due to higher level of sympathetic nervous system activation and lower heart rate variability (marker of flexibility in ANS). (Courtois & Ford, 2009; 2016; van der Kolk, et al., 1996; van der Kolk, 2006; van der Kolk, 2014)

PTSD BRAIN: LIMBIC SYSTEM

Limbic system: determines how you see things/what is our “reality” • Am I Safe, Approach/Avoid, Pleasure

ØAmygdala: “smoke detector” of brain: • Keeps firing when re-interpreting both minor stressful experiences and neutral stimuli as dangerous and in need of flight/fight or flop/faint response. • Difficulty figuring out what things mean. • Brain is set to interpret things into danger, fear, fright and disruption. • Hyperstimulated by body sensations, sounds, images and trauma reminders.

ØHippocampus (organize storage and retrieval of memories – short-term to long-term): • Information-processing process gets hijacked, so memories are not encoded with context. (Courtois & Ford, 2009; 2016; van der Kolk, et al., 1996; van der Kolk, 2006; van der Kolk, 2014)

PTSD BRAIN: FRONTAL LOBE

ØFrontal Lobe: Executive functioning, ability to communicate, problem solve. • Have difficulty filtering out irrelevant information. • Have difficulty keeping attention in present moment; Difficulty concentrating. • Difficulty retaining information learned à Potential Learning Difficulties. • The above symptoms particularly overlap with ADHD which is a differential diagnosis. • Have a hard time taking in neutral current information: • Difficult to learn from experience. Impaired capacity to communicate experience in words. • Hard to take in new information into brain. • Blood flow to left prefrontal lobe can decrease à less ability to connect to language. • Blood flow to right prefrontal lobe can increase à increased irritability, anger, sadness. (Courtois & Ford, 2009; 2016; van der Kolk, et al., 1996; van der Kolk, 2006; van der Kolk, 2014)

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IMPACT OF TRAUMATIC STRESS ON BRAIN: INFORMATION PROCESSING In normal processing of experiences à information comes in and gets effectively ‘metabolized’ • through our senses, limbic system (where it is interpreted) • then connected with our pre-frontal cortex (executive functioning and where we can assimilate new experiences into existing memory networks and help us problem solve and guide future choices).

When trauma occurs à connection to pre-frontal cortex doesn’t happen appropriately. • Memory of trauma is stored in brain as highly charged raw sensorimotor data frozen in time. (Courtois & Ford, 2009; 2016; van der Kolk, et al., 1996; 1998; 2006; van der Kolk, 2014)

TRAUMA’S IMPACT ON EXPLICIT MEMORY • EXPLICIT MEMORY: Can be intentionally & consciously recalled. • Semantic (Facts & General knowledge): • Trauma can prevent information from different parts of the brain from combining to form semantic memory. (Brown et al., 2014; Samuelson, 2011) • Episodic (Autobiographical Memory): ØThe sequence of traumatic events can be fragmented (Jelinek, et al., 2009) ØLess likely to be able to verbalize (Petzold et al., 2022)

TRAUMA’S IMPACT ON IMPLICIT MEMORY • IMPLICIT MEMORY: Can’t be recalled consciously (van der Kolk, 2014). • Procedural (how to do a common task; previously learned motor memories) Trauma -> can change patterns of procedural memory. • Emotional (memory of emotions during an experience) (Durand et al., 2019) Trauma-> may experience painful feelings when triggered, without context.

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IMPACT OF TRAUMATIC STRESS ON OUR WINDOW OF TOLERANCE

• “W indow of Tolerance” – coined by Dr. Dan Siegel (1999) to describe brain/body’s processes of emotional regulation. • Being in the window of tolerance: •

C an be present, attending to our ow n internal needs and dem ands of environm ent.

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C an still connect w ith others in m eaningful w ay.

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A dapt to w hat is happening in present m om ent w ith attentiveness and calm ness.

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If stress occurs, can m anage , continue to breathe , positive self-talk,, etc.

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C an “ride the w ave” of stress. Let things “roll off your back.”

• Being outside of the window of tolerance: Hyperarousal (upper limit) and Hypoarousal (lower limit) • Traum atic stress im pacts one’s window of tolerance. (Corrigan & Fisher, & Nutt., 2011; Courtois & Ford, 2009; 2016; Siegel, 1999)

INDICATORS THAT A CLIENT HAS UNPROCESSED TRAUMA • PTSD: (Pless Kaiser et al,, 2019). Ønot a static condition Ønot experienced in the same way by people with PTSD • E.g. PTSD may be chronic and long-lasting for some people; while others may experience fluctuating PTSD symptoms across the lifespan (Chopra et al., 2016). ØJumps time periods during intake or history taking. ØHas difficulty verbally describing trauma history (Petzold & Bunzeck, 2022) ØTrouble remembering aspects of everyday life (Pitts et al., 2022). ØFear-related thoughts, feelings and behaviors (Bremner, 2006) Copyright © 2023 Daphne Fatter, Ph.D.

HOW UNDERSTANDING THE NEUROBIOLOGY INFORMS TREATMENT PLANS • Neuroscience research supports that effective trauma recovery treatment includes: • Learning to tolerate feelings and sensations. • Learning to modulate arousal. • Helping brain learning to be flexible by adapting to situation in present – ability to take in new information and learn from it. • Learning to tolerate attending to internal experience. • Take Away: Organize your treatment plan around arousal regulation. • Informs Three Phase Model for Trauma Recovery Copyright © 2023 Daphne Fatter, Ph.D.

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CREATING TREATMENT PLANS FOCUSED ON AROUSAL REGULATION ØPTSD & the Nervous System ØReading Your Client’s Signals: Ø Signs Your Client is in Hyperarousal & Interventions that Help Ø Signs Your Client is in Hypoarousal & Interventions that Help

ØPolyvagal Theory ØEmotional Attunement in Therapeutic Relationship

OVERARO USED => Fight/Flight response

W IN DOW O F TO LERAN CE

UN DERARO USED =>Freeze/Im m obilization response

Adapted from Corrigan & Fisher, & Nutt., 2011

3 States of Autonom ic Arousal • • • • •

Social Engagem ent => Cue to Calm /Safe & Social State=> VEN TRAL VAGAL Optimal regulation: Emotions can be tolerated New information can be integrated/Learning Sense of self-control and balance Clarity; social communication Can “ride the wave” of stress

• • • • • •

HYPERARO USED => Fight/Flight Response => SYMPATHETIC Anxiety, Panic Emotionally overwhelmed/dysregulated (Crying uncontrollable; Aggression/Rage) Cognitive processes can be diminished or disorganized Flooding, Intrusive/ruminative thoughts, Hypervigilance Flashbacks (emotional, somatic, visual, or sensory in nature) Insomnia; More physical sensations (chronic pain, shaking/irritability)

• •

Blended States => SYMPATHETIC & DO RSAL VAGAL Fawn: “please and appease” attachment figure who is also a threat. Freeze: high-arousal; physiological stuckness; charge that is trapped.

• • • •

HYPOARO USED => Flop/Subm it/Collapse Shutdown/Im m obilization Response => DO RSAL VAGAL Emotional numbing-“I feel nothing”; Dissociation; Depersonalization (“Is this real?”) Shut down both emotionally and cognitively (Can’t think; Can’t feel; memory impaired); blank stare. Less physical movement; Lack of sensation; dizzy; fainting; collapse; flaccid and loose muscles, decreased heart rate. Relationally overcompliance from numbness/Submit; W ithdrawal; Detachment

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SIGNS OF HYPERAROUSAL = Fight/Flight Sympathetic Activation

1Porges, 2016 2Corrigan & Fisher, & Nutt., 2011; Courtois & Ford, 2009; 2016; Siegel, 1999 3 Levine, 2018; 4Ogden & Minton, 2000

Cognitive Signs

Emotional Signs

Lower cognitive functioning 1,4, Poor Judgement 4 Lowered awareness of others 1, Trauma-related fears/paranoia 4, Obsessive thoughts 2, Racing thoughts 2,4 Anxiety Panic/Fear/Emotional Overwhelm 2, Intrusive imagery, emotions, sensations (flashbacks) 2, 4, Aggression 2 and/or irritability 2, Emotional Reactivity 2, Anger/Rage 2, Feeling unsafe 2

Physical Signs

Pain 2, Physical Tension 2, Shaking 2

Behavioral Signs

Hypervigilance 1 , Avoidance 1, Oppositional Behaviors 1(kids), Social W ithdrawal1, Traumatic Nightmares 4, Impulsive & Compulsive behaviors,2,4 (e.g. Self-harm, substance abuse, disordered eating), Risktaking 4, Rapid chest breathing,3 Suspicious glances 3 Aggressive Outbursts 2, Dilated pupils 3, “edgy” 3, Visible Shaking 2

Medical Signs

Hyperacusis (sound sensitivity) 1, Hypertension 1, Gut problems 1

SIGNS OF HYPOAROUSAL = Dorsal Vagal Parasympathetic Activation

1Porges, 2016 2Corrigan & Fisher, & Nutt., 2011; Courtois & Ford, 2009; 2016; Siegel, 1999. 3 Levine, 2018 4Levine, 2010; 5Ogden & Minton, 2000

Cognitive Signs

Lower cognitive functioning 1,5 “Can’t think” 2,5

Emotional Signs

Emotional numbness 2,5, “feeling nothing” 2, Flat affect 2,5, Feeling disconnected 2, Dissociative states 1,2 Feeling “dead” 2,5, Depersonalization (“Is this real? Am I real?”) 2, Preoccupied with self-loathing, shame, despair 5, Pervasive hopelessness 2

Physical Signs

Immobilization 1,2, Collapse 1, Numbness 2, Lack of feeling or body sensations 2, Noticeably Pale 1, Little or no energy/Exhaustion 2

Behavioral Signs

“Spaced out” 3, Frozen/flat face,3 Avoidance of eye contact,3 “Passive 2, Can’t say “no” 2, Can’t defend oneself2, Social W ithdrawal2,

Medical Signs

Hypotension 1, Vasovagal syncope (fainting due to stressful trigger) 1, Chronic Fatigue 3,4, Migranes 4, GI3,4 & urinary problems,3 cardiac arrhythimias 3, episodes of dizziness 3, autoimmune disorders, 3 Fibromyalgia 1

Clinical Challenges of Identifying Hypoarousal: • Much harder to detect in higher functioning clients. • Use your own body as a resource. • Is a hypoaroused client stable or is client care taking/displaying protector part? • Watch for dissociation and/or depersonalization when client’s reports being numb. Copyright © 2023 Daphne Fatter, Ph.D.

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1Porges, 2016

Signs of Optimal StateWindow of Tolerance

Corrigan & Fisher, & Nutt., 2011; Courtois & Ford, 2009; 2016; Siegel, 1999. 3 Levine, 2018; 4 O gden & M inton, 2000

Cognitive Signs

Optimal cognitive functioning2 Can think & Feel at the same time2,4 Can take in new information; can learn1 Able to maintain present moment awareness

Emotional Signs

Able to tolerate feelings2 Feeling safe2 Experience empathy2 Notice cues of others and oneself1 Able to regulate emotions1

Physical Signs

More likely to be abdominally breathing3

Behavioral Signs

Voice is melodic1 Social communication1 Reactions are adaptive and can fit the situation at hand2

Polyvagal Theory – Evolution of Autonomic Nervous System

“Path of Last Resort” Dorsal Vagal System Primitive Parasympathetic • • •

•

“O n the Move”

“Safe & Social”

Sympathetic Nervous System

Life Threat Immobilization Conserve metabolic resources Shut Down

• • •

Ventral Vagal System Newest Parasympathetic • •

Danger Mobilization Fight/Flight

•

Safety Cooperative behavior; Can socially engage Calm & can cue others to calm

Adapted from Dana & Grant, 2018; Porges, 1995; Porges, 2018; Levine, 2018

HOW DOES POLYVAGAL THEORY INFORM TRAUMA RECOVERY? • Autonomic states are hierarchically organized. • Newer circuits have capacity to down regulate and inhibit defensive behaviors. W hen newer circuits don’t work, use older and older circuits. • Neuroception (automatic surveillance)– how the nervous system detects safety.

• We are wired to connect: Engage the social engagement system to help inhibit other autonomic states. • Clinicians can teach their clients signs of which of the three autonomic states they are in. • Coping skills can be identified to help client move to the “Safe and social” calm state. (Dana & Grant, 2018; Porges, 2018)

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THERAPEUTIC RELATIONSHIP AS MECHANISM OF CHANGE

• Polyvagal theory validates importance of therapist’s ability to be •

present to clients à Develop working alliance à help client’s feel safe and secure in relationship (Geller, 2018).

• Research shows that therapeutic relationship as most consistent predictor of change (Geller, 2018; Norcross, 2011) and serve as both a mediator and/or moderator of change (Vilkin, Sullivan, & Goldfried, 2022). • The therapeutic alliance can be a moderator in couples therapy & crucial for the couple’s relationship satisfaction (Wiggins, 2022). • Consistently be attuned and offer secure attachment base in therapeutic relationship.

THERAPIST’S ROLE • Co-regulation: bidirectional linkage of fluctuating emotions between client and therapist, contributing to emotional stability of both (Butler & Randall, 2013; Geller, 2018).

• Therapist is co-regulator of emotion (physically and emotionally attuned) • Synchronization leads to neuronal growth. • Neuronal growth à new neural pathways are stimulated which help brain development, esp. in left side (verbal) and prefrontal cortex (judgement, executive functioning) (Courtois & Ford, 2016).

WHAT SUPPORTS EMOTIONALLY ATTUNEMENT? • Be mirror for client’s emotions by naming them. • Respond to emotional content rather than non-verbal body language, but name or notice the non-verbal language. • Use what you notice in your body as information, which can be particularly helpful if client is dissociative. • Notice and name moment by moment.

• Non-Verbally: • Your Voice Matters -> Prosody (rhythm and melody) in voice • Soft facial expression • Open & forward leaning body posture • Soft & direct eye contact • Attention on client • (Geller, 2018)

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TRAUMA-INFORMED STABILIZATION TOOLS FOR HYPER-AROUSAL & HYPO-AROUSAL STATES

All of these can be used throughout trauma treatment, especially during Phase 1: Stabilization

26 Practical Inter ventions to H elp M anage H yperarousal A nxiety, Panic, Fear

Em otional D ysregulation/U ncontrollably C rying

Som atic Sym ptom s: shaking, tension, pain

A ggression/Rage

Im pulsivity/C om pulsive/Reckless Behavior

•

“Butterfly H ug” (Korn & Leeds, 2002)

• • • • •

C old Stim ulus to face (Richer et al., 2022) Bring attention to feet and hands (Levine , 2018) H eart Rate Variability Training (e .g. Tan et al., 2011) C ounting breaths (backw ards) Exercise (Zschucke et al., 2015).

•

Slow Breathing w ith Long Exhalations (G eller, 2018)

• • •

Square Breathing D eep Breathing w ith a Sigh (M oore , 2005) C ontainm ent Skills/Im agery (EM D R Intervention) (Shapiro, Kaslow, & M axfield, 2007).

•

Progressive M uscle Relaxation

• •

M icrom ovem ents/running in slow m otion (Levine , 2010) G uided Im agery

• •

Pushing A gainst Wall Exercise (Zschucke et al., 2015).

•

Safety plan as needed

•

Safety Plan

•

Pro/C on List

BUTTERFLY HUG (ARTIGAS ET AL., 2000; BOEL, 1999, ARTIGAS & JARERO, 2010; JARERO & URIBE, 2014; JARERO & ARTIGAS, 2022; KORN & LEEDS, 2002)

• Originally developed by Lucina Artigas during working with survivors of Hurricane Pauline in Acapulco, Mexico in 1998. • Self-administered bi-lateral stimulation (BLS): • Like eye movements or tapping, can be used during Standard EMDR Protocol for trauma processing for individual or group work. • Can be used with children, teens and adults (can practice as a family). • Because, self-administered, can help with sense of safety. • Helps clinicians prevent secondary traumatization (Jarero & Uribe, 2014). • Culturally well received (from Melville, 2003 who has taught EMDR in 63 countries ) vs other forms of BLS that could be interpreted as hypnosis, shamanic ritual, witchcraft or a spell.

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OPTIONAL PRACTICE TIME!

I W ILL DEMONSTRATE THIS FOR ABOUT 30 SECONDS OR LESS.

RESOURCE TAPPING: WHAT IS IT AND WHEN TO USE IT

(PA RN ELL, 2008)

What is Resource Tapping?

Ø Slow tapping only (fast tapping is for EMDR Trauma Processing) •

If person feels m ore anxious during it, they m ay be tapping too fast or doing it too long.

Ø For self-soothing: 6-12 taps or 1-2 minutes should be helpful. •

O nly keep tapping longer as long as its feeling relaxing to client.

• When to Use it: Ø Feeling good (even if its just moments) or calm. Tap to strengthen this feeling. • To strengthen positive resources client already has access to and/or is within the client. Ø Feeling anxious. Tap slowly to feel calmer. Ø BLS when paired with positive imagery can increase relaxation & positive affect (Amano, & Toichi, 2016) and naturally elicits relaxation (Girianto et al., 2021). • What this is not: This is not trauma processing. •

We don’t allow for free-flow ing processing/state of consciousness processing. This is short!

SLOW TAPPING TO STRENGTHEN SENSE OF SAFETY (A DA PTED FRO M PA RN ELL, 2008)

• Can be visualizing place real or imagined that feels safe and peaceful. • “Experience this place as though you were there now, notice what you see there, what sounds you hear, what do you smell, what sensations do you feel in your body? Notice what it feels like to be there - allow yourself to absorbed the feelings of peacefulness, being at ease, immerse yourself in serenity” Parnell, 2008, p. 46. • “W hen you can sense the peacefulness of this special place, then begin to tap”. • “You can return to this place anytime you wish – this place is always available to you” • Is there a cue word to help you return to this place?

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SLOW TAPPING TO STRENGTHEN SENSE OF SAFETY

(A DA PTED FRO M PA RN ELL, 2008 & DA N A , 2018)

• Ventral Vagal (Social Engagement System) responds to contextual cues of safety which will override fight/flight and flop/faint nervous system responses to threat/danger. • Prosody in therapist’s voice; Can use sense of connection to other people in home. • Can be present moment focused if they are feeling safe in home: • “Notice cues in the room you are in that remind you that you are safe in this moment. • W hat are cues of safety in your body? In your environment? (sound, smells, people, familiarity). • As you invite in these reminders that you are safe in this moment, notice how you feel inside. • If you are feeling calm, nod your head, and being to tap to strengthen this feeling of calm.”

SLOW TAPPING & RELATIONAL RESOURCES

(ADAPTED FROM PARNELL, 2008) • Resource Team: Real or imagined, animals, figures from history, movies or from books • Protective Figure • Nurturing Figure • W ise Figure/Inner W isdom Figure • Can use figure one at a time or all together à Tap to strengthen. • “W hat do you feel in your body when you are with this protective figure?” (if feels positive, tap) • Can ‘tap in’ one protective figure at a time… You can imagine being supported by your team of protective figures.”

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SLOW TAPPING TO CONNECT TO RELATIONAL RESOURCES

(ADAPTED FROM PARNELL, 2008) • Connect to Nature: • Either being in nature, looking at picture of nature or visualizing being in nature. • Connect to Animals: • Either pets in their home, favorite animals – imagine being with them or petting them. • Spiritual Resources: • Being with spiritual guide, angel, saint, religious figure, Diety, animal spirit, ancestors. • Being in a spiritual sanctuary.

SQUARE BREATHING • Inhale for 4 counts. • Hold for 4 counts. • Exhale for 4 counts. • Hold for 4 counts. • (Can also rectangle breathing elongating inhale and exhale).

DEEP BREATHING WITH A SIGH MOORE, 2005

1. Inhale 2. Hold breathe for a few seconds (e.g. hold to silent count of four)

3. Exhale, slowly release the breath with a big sigh. (Sigh needs to be audible)

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EMOTION FREEDOM TECHNIQUE (EFT)

ØMethod of tapping a sequence of acupressure points while saying a statement. ØBased on bioenergetics & Neurolinguistic Programing (NLP) & cognitive therapy. • Research shows that EFT: • Lowers cortisol (Church et al., 2012). • Lowers PTSD, anxiety & depression symptoms (Bach et al., 2019). • Lowers food cravings (Bach et al., 2019; Stapelton et al., 2016) • Lowers physical pain (Bach et al., 2019) • Guidelines for PTSD recommend five treatment sessions for subclinical PTSD and 10 sessions for clinical PTSD (see Church et al. 2018)

EFT PRACTICE

SEE C H U RC H ET A L. 2013 FO R M A N UA L

A “Setup Statement” that “consists of a reference to the traumatic event or related feelings combined with a self-acceptance statement and acupoint tapping” (Church et al., 2018, p.146; See Church et al. 2013 for manual)

Tap on the Side of Hand point for several minutes.

For example: Say out loud while tapping: 1. “Even though I vividly recall the horror of the bomb blast, I deeply and completely accept myself” (Church et al., 2018, p. 146). 2. “Even though I'm feeling anxiety, I can accept that I am safe in this moment“. 3. “Even though I know I’ve had negative experiences happen to me in the past, in this moment, I am safe”. 4. “Even though I am noticing some stress and discomfort in my body, I can accept that this is how I am feeling right now”. 5. “Even though there is a lot of uncertainty, in this moment I can accept that I am okay”. 6.

After Setup Statement & Tapping on Side of Hand, then gently tap with two fingers on the eight or more acupoints; use SUDS (110 scale as needed) (Church et al., 2013; Church et al., 2018).

Practical Interventions to Help Manage Hypoarousal Emotional Numbness, Dissociation, Depersonalization, Shut down

•

“Vooo Breath” (Levine, 2018, p.19; Levine, 2010): • •

Sense of Immobility

“Take in full breath..extend “voo” (like ‘ou’ in you)..as you exhale” Add visualization of foghorn guiding in ships in fog to safe harbor home.

• • • • • •

Weighted Blanket Engaging rhythmic activity (rolling ball, drumming) Gentle Sensory Input (sounds, smells, etc.) Singing and Chanting (Levine, 2018) Running in place (Levine, 2010) Mindfulness in form of internal tracking is counterproductive (Levine, 2018), but connecting to environment in present-moment way is helpful.

•

Exercise, Dance & Rhythmic Movement

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SOMATIC INTERVENTIONS

• Co-regulation & Self-Regulation & Orienting:

ØThrowing a ball. ØRocking. ØTouching one’s own face. ØBody as Container.

BODY AS CONTAINER (LEVINE, 2018)

Take right hand, put it under left arm (on side of heart).

Take the left hand on the right shoulder.

Notice what goes on inside the body (client becomes aware that body is container for our feelings)

Keep doing this until notice energy shift.

Especially helpful for dissociation symptoms

“HANDS TO FOREHEAD & CHEST, THEN CHEST & BELLY”

(LEVINE, 2018)

Put one hand on your forehead and the other hand on your chest.

Can do this with eyes open or closed.

Feel what goes on between the hands – keep there until they notice an energy shift.

Then take hand from forehand (keeping other hand on chest), and place hand on belly (bellow belly button).

Keep the hands here until notice energy shift and feeling calm.

Especially helpful for dissociation symptoms

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43 • Proprioception: Ability to sense body in environment. • Vestibular: Ability to have sense of balance and spatial orientation in order to coordinate movement with balance. • Moore, 2005

Sense/Input

Calm ing for Hyperarousal

Sm ell

44 Taste

O ral M otor

Vision H earing/Sound

Alerting/Energizing for Hypoarousal

Vanilla candles; lavender

Strong scent candles (lem on)

M ild, sweet: hard candy, lollipop, apple

Pepperm int, lem on drop, sourballs

juice , grapes

Lem onade , pickles

Sucking & C hew y: gum , licorice , dried

C runchy & Blow ing: popcorn, pretzels,

fruit, thick liquid thru straw, gum my bears, hard candy, bagel

raw veggies, w histling, blow ing bubbles, blow ing pinw heel/w ind instrum ent.

Soft colors, pictures of loved ones that

C om plex visual im ages, video gam e , bright

are calm ing, w atching fish in aquarium

colors

Soft, slow m usic, hum m ing, repetitive

Q uick-paced/loud m usic, w histling

sound (ocean w aves) Touch/D eep Pressure Touch

Vestibular Input

Proprioception

D eep Pressure: strong hugs

Light touch: Weighted blanket

Weighted blanket, squeezing stress ball U se of hand lotions, D eep m assage

Sitting w ith pet on lap H and/foot m assage , w alking barefoot

Rocking in chair/ sw inging gently

Fast D ancing

slow dancing, w alking, slow head rolls

Jogging, Sw inging

Slow rhythm ic m ovem ents or heavy,

Q uick changes, lots of

sustained resistance: Yoga, weight lifting Pushing hands together/against a w all Lifting, carrying, chair push ups

m ovem ent/changing activities: tram poline jum ping, Jogging Kickboxing, aerobic exercise , Jum ping Rope , Stepper m achine

CREATE A SENSORY TOOK KIT FROM ITEMS IN YOUR HOME •

The sm ell of ___ m akes m e calm er.

•

(e .g. pepperm int/lavender)

•

The sound of ____m akes m e calm er.

•

(e .g. ocean w aves).

•

The taste of _____m akes m e calm er.

•

(e .g. w arm tea).

•

The touch/feel of_____m akes m e calm er

•

(e .g. w arm w ater on my face).

•

The picture/color of_____m akes m e calm er.

•

(e .g. im ages of nature)

(A dapted from M oore , 2005)

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SELF-COMPASSION & MINDFULNESS ØResearch shows that self-compassion may be a useful intervention for CPTSD treatment, particularly for emotion dysregulation and negative self-concept symptoms (Karatzias et al., 2019). ØSelf-compassion and mindfulness are both skills that can be learned practiced (Neff, 2023). ØMindful Self-Compassion (See Germer & Neff, 2019; Neff, 2023 for review) ØMindfulness-based interventions lower PTSD symptoms, esp. when participants do longer mindfulness training (Hopwood & Schutte, 2017).

LIMITATIONS OF THE RESEARCH & POTENTIAL RISKS

47 •

Potential R isks:

•

No know n risks for any of these acute interventions for clients.

•

Som e m indfulness interventions m ay elicit traum a response of negative reactions in PTSD clients (See H opw ood & Schutte, 2017).

•

Lim itations:

•

EFT is less effective for purely physical phenom enon w ithout an em otional com ponent (e .g. pure physical injury) (C hurch et al., 2018).

•

Research is needed to com pare effectiveness of m indfulness-based approaches w ith first-line psychotherapies for PTSD (e .g. PE and C PT) (Boyd et al., 2008).

•

Research is needed on how sociocultural factors, m arginalization, power inequality, and other social factors m ay interact selfcom passion’s developm ent and application (N eff, 2023).

USING THE THREE PHASE MODEL IN TRAUMA RECOVERY • Phase I: Stabilization • Skill building and self-care. • Increasing window of tolerance. • Phase II: Traum a Processing & Grieving • Phase III: Present Day Life • Now what? W ho am I besides a trauma survivor? Relationships, career, moving on (Courtois & Ford, 2016 developed from -> van der Hart, Brown, & van der Kolk,1989; Herman, 1992b -> developed from Janet 1889/1973’s model).

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BENEFITS, RISKS, LIMITATIONS

49 •

Research supports the effectiveness of phase-oriented models for PTSD treatment (Corrigan, et al., 2020; Coventry, et al., 2020; Dyer & Corrigan, 2021).

•

Pacing is KEY in attempt to control intensity.

• While research supports single-phase models (e.g. CBT for PTSD or CPT for PTSD), research supports clinicians consider more blended practices when treating Complex PTSD (Dyer & Corrigan, 2021)à Use Phase Oriented Treatment within the therapeutic model you are using. •

Length of stabilization stages varies based on skills acquired rather than tim e .

•

Phases are fluid and dynamic àMovement between stages throughout therapy.

• “One step forward, two steps back” is the norm: Relearn skills, rather than “failure”. (Courtois & Ford, 2016)

CLINICAL CONSIDERATIONS WITH PHASEORIENTED TRAUMA TREATMENT APPROACH

• Co-Morbidity • Suicidality and self-injurious behavior • Important to provide psychoeducation that clients move back and forth between stages. • Client regression is normal and discuss what it means to client. (Courtois & Ford, 2016)

STABILIZATION PHASE & TREATMENT PLAN FOR PTSD

51 1.

Psychoeducation about PTSD: Impact of trauma.

Addressing client’s current symptoms in context of PTSD (and any other dx): • Flashbacks, rumination, intrusive thoughts, angry outbursts, irritability, generalized anxiety, insomnia. • Numbing, detachment, loss of interest in life, trauma-related fears, avoidance, concentration issues.

Getting to Know the Landscape: Identifying trauma-related internalized negative beliefs, feelings and sensorimotor reactions. (Courtois & Ford, 2016)

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STABILIZATION PHASE & TREATMENT PLAN FOR PTSD

52 4.

Identify Current Triggers (environmental/external, relational, internal, times of year): • Identify relationship between triggers à symptoms of PTSD à any harmful coping behaviors. • E.g. Identify sources of guilt, grief/loss and triggers for isolation and self-harm behavior. • Identify sequence of client’s internal emotional process of activation when triggered by relational trauma trigger. • E.g. someone who is warm/nurturing à Panic/anxiety à dizzy/dissociation or “I’ve got to run. • Plan for known future/upcoming triggers or stressful situations (e.g. holidays, anniversaries). (Courtois & Ford, 2016)

STABILIZATION PHASE & TREATMENT PLAN FOR PTSD

5. Learning coping skills, self-soothing skills, emotion regulation skills & stress management skills. • Using senses to help client feel more connected to body and aware of physical experience in addition to using breath, progressive muscle relaxation or guided imagery.

Attending to client’s physical needs: (Sleep hygiene, eating regularly, exercise, self-care).

Addressing safety needs: create safety plan for any self-harm concerns (history gathering).

Increasing Containment Skills: routine, structure in daily life for sense of predictability.

Increasing Affect Tolerance: Decreasing affect dysregulation. (Courtois & Ford, 2016)

“Safe & Social”

Ladder Map Exercise: 1. Choose colors for each autonomic state. E.g. “W hat color are you drawn to as you prepare to map danger, life threat and safety?”

“On the Move”

2. For each state, It looks like… .it sounds like… I think… I say… .I do… . My sleep is.. My eating is… … My overall functioning is… . Other people notice that… . 3. For each state, complete the two sentences: “I am… … .” “The world is… … ”

“Shut Down”

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TITRATION & PENDULATION

55 •

Titration: Bite-sized pieces w hen talking about triggers.

•

Pendulation:Titrating toe dipping in w ater, then back off and regulating. This is rhythm that can happen prior to traum a processing (Levine , 2010).

•

Practical things to do in session: •

A rt therapy/coloring w hile talking/having topics that help engage client (e .g. pets, children)

•

H elp client begin to internally track w hen getting activated,

•

Practice asking to change topics/N otify others in relationship w hat’s happening for them .

•

H ave positive reinforcem ent that pacing for client’s nervous system is respected.

Once client can better identify what state they are in then ask (Dana & Grant, 2018): •

W hat can you do alone or w ith others to help you m ove out of H yper or H ypo arousal?

•

W hat can you do alone or w ith others to keep you in the Safe & Social state?

PHASE ONE: STABILIZATION WHAT HAPPENS IN THERAPY?

ØIncreasing window of tolerance for emotions: • E.g. Use skills-based approaches (Coventry, et al., 2020).

ØStrengthening support system (who can distract them, who can help soothe them) ØSymptom Reduction (no processing of traumatic memories) ØDecrease alteration in consciousness (e.g. decrease dissociative sx) ØDevelop ego strength (Courtois & Ford, 2016)

PRACTICES FOR STABILIZATION • Routine: • Go to bed and wake up same time everyday. • Eat at same time everyday. • Sleep Hygiene/routine •

Connection to others – in person is best, seeing face/hearing voice, rather than text or email.

• Limit Media Exposure (Garfin, et al., 2015; Garfin, et al., 2018; Garfin et al., 2020).

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THREE PHASES IN TRAUMA RECOVERY • Phase I: Stabilization • Skill building and self-care. • Increasing window of tolerance. • Phase II:Trauma Processing & Grieving • Phase III: Present Day Life • Now what? Who am I besides a trauma survivor? Relationships, career, moving on (Courtois & Ford, 2016 developed from -> van der Hart, Brown, & van der Kolk,1989; Herman, 1992b -> developed from Janet 1889/1973’s model).

PHASE TWO: TRAUMA PROCESSING OF TRAUMATIC MEMORIES

Objective/ Focus of Treatment Plan: (Explore Traumatic Memories): 1.

Integrate traumatic memories into coherent life narrative à Improve self-perception + Improve ability to be in relationships with others.

Cognitive restructuring internalized negative beliefs about self in relation to trauma (e.g. “It’s my fault”) that are impacting client’s current life and functioning.

Decrease negative affect and sensorimotor reactions associated with trauma memories. (Courtois & Ford, 2016)

PHASE TWO: TRAUMA PROCESSING OF TRAUMATIC MEMORIES

Objective/ Focus of Treatment Plan: 4. Grieving and putting client’s lived experience of traumatic experiences into words. 5. Decreasing guilt (e.g. what guilt belongs to client vs doesn’t belong to client). Evidence supports effectiveness of trauma processing for simple PTSD, but evidence is less clear for complex trauma and/or Unspecified Dissociative Disorder. (Courtois & Ford, 2016)

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PHASE THREE: PRESENT DAY LIFE

2 Main Treatment Goals: • Apply Therapeutic gains to daily life and future: • Who am I now? What do I want now in my life? • Practical, emphasis on what choices does client have • Prepare for ending treatment. (Courtois & Ford, 2016)

PHASE THREE: PRESENT DAY TREATMENT PLAN FOR PTSD

Increase connection with trustworthy peers.

Identify meaningful work.

Increase comfort in one’s body and possibility to experience pleasure in one’s body.

Identify and increase pleasurable activities (Can client take pleasure in?)

Focus on quality of relationships

Develop sense of self other than trauma survivor or victim. (Courtois & Ford, 2016)

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EVIDENCED-BASED ADJUNCTIVE THERAPIES FOR STABILIZATION PHASE

•Yoga •Heart-Rate Variability Training

YOGA AS ADJUNCTIVE THERAPY • Current Research on Exercise: • Rosenbaum, et al., 2015 in meta-analysis of 4 studies showed physical activity helpful as adjunctive therapy for PTSD. • Heissel et al., 2023 found that exercise (of moderate intensity & aerobic) – is an evidenced based treatment for depression along with medication and therapy.

PRELIMINARY RESEARCH ON YOGA & PTSD Overall, research on yoga and PTSD shows that that yoga (see Nguyen-Feng et al, 2020 for review): • Decreased PTSD and depressive symptoms • Decreased emotional distress • Increased body attunement • Increased self-compassion (Clark et al., 2014); Rhodes, 2015). • Increased meaning in one’s life (Clark et al., 2014; Rhodes, 2015).

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RESEARCH ON YOGA WITH PTSD POPULATION

• Yoga research thus far suggests that physical and interoceptive aspects of yoga contribute to decrease in PTSD symptomology rather than social aspect of group (Emerson et al., 2009; van der Kolk et al., 2014). • 60 women with treatment resistant PTSD from chronic trauma did 10 sessions of yoga and had statistically significant decreases in PTSD, dissociative symptoms, self-injury, and depressive symptoms compared with control. (van der Kolk et al., 2014). • This study has been replicated with sig decrease in PTSD (Nguyen-Feng et al, 2020).

• Yoga contributes to decrease in PTSD in female veterans with MST (Kelly et al., 2021). • Frequency of yoga practice significantly predicted more decrease in depression severity, PTSD severity and greater chance of PTSD diagnosis – 1.5 year follow up (Rhodes et al., 2016).

BIOFEEDBACK -- HEART RATE VARIABILITY

WHAT IS HEART RATE VARIABILITY? • Measure of the beat-to-beat changes in the heart rate. • Important indicator of both physiological resiliency & behavioral flexibility • HRV Training helps teach how to down-regulate the autonomic nervous system. ( Gilman, 2011; McCraty, 2015) • W hy its helpful: • Research shows that daily biofeedback sessions à increase the amplitude of heart rate oscillations à improve emotional well being. • Links Between HRV and Brain Regions Involved in Emotion Regulation • (See Mather & Thayer, 2018 for review) •

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QUICK COHERENCE TECHNIQUE

1) Heart Focus: Focus your attention to the center of your chest. Can place your hand on your chest.

2) Heart-Focused Breathing: Imagine your breath flowing in and out of your heart space. Continue until your breathing feels smooth and balanced.

3) Heart Feeling: Recall a positive feeling. Can be remembering a time in which you felt peaceful and calm or can be feeling of gratefulness for someone or for experiences. Bring positive feelings to your heart space as you breathe from your heart. (Adapted from Gilman, 2011)

RESEARCH ON HRV BIOFEEDBACK Research has shown that HRV training for people with PTSD can help: • Increase psychophysiological coherence. • Improve cognitive functioning. • Increase HRV. • Reduce PTSD symptoms. (Ginsberg et al., 2010; McCraty, 2015; Tan et al., 2011) • Decreased PTSD symptoms (Schuman, et al., 2019; Schuman et al., 2023) compared to diaphragmic breathing alone (Schuman, et al., 2019).

Limitations: • Need for enhanced methodological guidelines in research on HRV(Lalanza et al.,2023). • Adherence can go down over time (Schuman et al., 2023).

IMPLEMENTING HRV TRAINING • Introducing it to clients: “Biofeedback is way to learn how to breathe so that your heart sends a message to brain to relax”. • Practice during non-stressful times and stressful times. Practice with eyes closed or eyes open • If clients have difficulty connecting to positive emotion, start small (e.g. feelings towards pet, client getting to session, etc.) • Great way to end session, so clients are in state of coherence as they transition into the rest of their day.

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PROMISING APPROACHES FOR PTSD

Safe & Sound Protocol (Porges, 2018): Resource: https://integratedlistening.com/products/ssp-safe-sound-protocol/

Neurofeedback (Chiba, et al., 2019; Fragedakis & Toriello, 2014; Gapen et al., 2016; Huang-Storms, L., et al., 2007; Mills, 2012; Nicholson et al., 2020; See Panisch et al., 2020 for review; Zweerings et al., 2020)

Transcranial magnetic stimulation (See Petrosino et al., 2021 for review)

Psychedelic-Assisted Psychotherapy: 1. Ketamine is the only psychedelic substance (other than cannabis) currently permitted for therapeutic use in Canada, with clinics operating in Toronto and other Canadian cities.

• Current Research https://maps.org/

74 QUESTIONS?

• Daphne Fatter, Ph.D. • Licensed Psychologist • daphnefatterphd@gmail.com • www.daphnefatterphd.com

MY FAVORITE FREE PHONE APPS • “PTSD Coach” Phone Application

• “STAIR Coach” Phone Application • “Insight Timer” Phone Application • “PTSD Family Coach” (for family members)

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TRAUMA SENSITIVE YOGA RESOURCES Trauma Sensitive Yoga: https://www.traumasensitiveyoga.com Restorative Yoga for Ethnic and Race-Based Stress and Trauma (2020) by Gail Parker, Ph.D. • https://www.blackmindsinmeditation.com/ (Daphne Fuller) • https://liberatemeditation.com/ (Meditation App Honoring the Black Experience) • https://www.theshineapp.com/ (Meditation App Focused on Healing Racial Battle Fatigue) 76

TO GET TRAINING TO BECOME A SSP PROVIDER

Integrated Listening Systems: https://integratedlistening.com/

HEART RATE VARIABILITY & NEUROFEEDBACK RESOURCES

Note: there are many devices for HRV training: HRV Professional Training: http://www.heartmath.org •

Inner Balance - phone app plus sensor.

• To find a certified HRV or neurofeedback practitioner: http://www.bcia.org/ For Training, research and education on neurofeedback: • EEG SPECTRUM INTERNATIONAL: http://www.eegspectrum.com/ • The Neurodevelopment Center: https://www.neurodevelopmentcenter.com/

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CLINICAL RESOURCES

• International Society for Traumatic Stress Studies: www.istss.org • International Society for the Study of Trauma and Dissociation: • www.isst-d.org/ • PTSD Association of Canada: https://www.ptsdassociation.com/

• Canadian Mental Health Association: https://cmha.ca/brochure/posttraumatic-stress-disorder-ptsd/

REFERENCES • Artigas, L., Jarero, I., Mauer, M., López Cano, T., & Alcalá, N. (2000, September). EMDR and Traumatic Stress after Natural Disasters: Integrative Treatment Protocol and the Butterfly Hug. Poster presented at the EMDRIA Conference, Toronto, Ontario, Canada. • Artigas, L. and Jarero, I. N. (2010). The butterfly hug. In Luber, M (Ed.), Eye Movement Desensitization and Reprocessing (EMDR) Scripted Protocols: Special Populations (pp1-8). Springer Publications. • Atkinson, N.L. & Permuth-Levine, R. (2009). Benefits, barriers, and cues to action of yoga practice: A focus group approach. American Journal of Health Behavior, 33(1), 3-14. • Boel, J. (1999). The Butterfly Hug. EMDRIA Newsletter,4(4),11-13. • Butler, E. A. & Randall, A. K. (2013). Emotional coregulation in close relationships. Emotion Review, 5(2), 202-210.

REFERENCES • Chiba, T., Kanazawa, T., Koizumi, A., Ide, K., Taschereau-Dumouchel,V., Boku, S., Hishimoto, A., Shirakawa, M., Sora, I., Lau, H.,Yoneda, H., & Kawato, M. (2019). Current status of neurofeedback for post-traumatic stress disorder: A systematic review and the possibility of decoded neurofeedback. Frontiers in Human Neuroscience, 13, Article 233. https://doi.org/10.3389/fnhum.2019.00233

• Clark, C.J., Lewis-Dmello, A., Anders, D. Parsons, A., Nguyen-Feng,V., Henn, L. & Emerson, D. (August 2014). Trauma-Sensitive Yoga as an Adjunct Mental Health Treatment in Group Therapy for Survivors of Domestic Violence: A Feasibility Study. Complementary Therapies in Clinical Practice, 20, (3),152–158. • Corrigan, Frank & J Fisher, J & Nutt, David. (2011). Autonomic dysregulation and the Window of Tolerance Model of the effects of complex emotional trauma. Journal of psychopharmacology (Oxford, England). 25. 17-25. 10.1177/0269881109354930.

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REFERENCES • Dana, D. (2018). The polyvagal theory in therapy: Engaging the rhythm of regulation. New York: W. W. Norton. • Dana, D. & Grant, D. (2018). The polyvagal playlab: helping therapists bring polyvagal theory to their clients. In Clinical applications of the polyvagal theory: The emergence of polyvagal-informed therapies. (Porges, S.W. & Dana, D. (Eds.)), pp. 185-206. • Dyer, K. F. W., & Corrigan, J.-P. (2021). Psychological treatments for complex PTSD: A commentary on the clinical and empirical impasse dividing unimodal and phase-oriented therapy positions. Psychological Trauma: Theory, Research, Practice, and Policy, 13(8), 869–876. https://doi.org/10.1037/tra0001080 • Emerson, D., Sharma, R., Chaudry, R. & Turner, J. (2009). Yoga Therapy in Practice: Trauma-Sensitive Yoga: Principles, Practice, and Research. International Journal of Yoga Therapy, 19, 123-128.

REFERENCES • Fragedakis, T. M., & Toriello, P. (2014). The development and experience of combat-related PTSD: A demand for neurofeedback as an effective form of treatment. Journal of Counseling and Development, 92(4), 481-488. doi: http://dx.doi.org/10.1002/j.1556-6676.2014.00174.x • Gallegos, A.M., Crean, H.F., Pigeon, W.R., Heffner, K.L. (2017). Meditation and yoga for posttraumatic stress disorder: A meta-analytic review of randomized controlled trials. Clin Psychol Rev. 2017 Dec;58:115-124. doi: 10.1016/j.cpr.2017.10.004. PMID: 29100863; PMCID: PMC5939561. • Gapen, M., van der Kolk, B. A. Hamlin, E. Hirshberg, L., Suvak, & Spinazzola, J. A. (2016). A Pilot Study of Neurofeedback for Chronic PTSD Applied Psychophysiology and Biofeedback, 1-11. • Garfin, D. R., Holman, E. A., & Silver, R. C. (2015). Cumulative exposure to prior collective trauma and acute stress responses to the Boston marathon bombings. Psychological Science, 26, 675–683.

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